SB 51 — An Act providing for individual and group health care insurance coverage protections and for core health benefits; imposing penalties; and providing for applicability and for regulations.

PRINTER'S NO.   98

                     THE GENERAL ASSEMBLY OF PENNSYLVANIA



                        SENATE BILL
                        No. 51
                                                 Session of
                                                   2025

     INTRODUCED BY HUGHES, KEARNEY, BOSCOLA, CAPPELLETTI, COLLETT,
        COMITTA, COSTA, FLYNN, FONTANA, HAYWOOD, KANE, KIM, MILLER,
        MUTH, PISCIOTTANO, SANTARSIERO, SAVAL, SCHWANK, STREET,
        TARTAGLIONE, A. WILLIAMS AND L. WILLIAMS, JANUARY 22, 2025

     REFERRED TO BANKING AND INSURANCE, JANUARY 22, 2025


                                     AN ACT
 1   Providing for individual and group health care insurance
 2      coverage protections and for core health benefits; imposing
 3      penalties; and providing for applicability and for
 4      regulations.
 5      The General Assembly of the Commonwealth of Pennsylvania
 6   hereby enacts as follows:
 7   Section 1.   Short title.
 8      This act shall be known and may be cited as the Health
 9   Insurance Core Benefits Coverage Act.
10   Section 2.   Definitions.
11      The following words and phrases when used in this act shall
12   have the meanings given to them in this section unless the
13   context clearly indicates otherwise:
14      "Commissioner."     The Insurance Commissioner of the
15   Commonwealth.
16      "Department."     The Insurance Department of the Commonwealth.
17      "Group health insurance policy."      A policy, subscriber
18   contract, certificate or plan issued by an insurer that provides
 1   medical or health care coverage on an annual basis to
 2   individuals who obtain health insurance coverage through a
 3   group.
 4      "Health insurance policy."     A policy, subscriber contract,
 5   certificate or plan issued by an insurer that provides medical
 6   or health care coverage. The term does not include any of the
 7   following:
 8            (1)    An accident only policy.
 9            (2)    A credit only policy.
10            (3)    A long-term care or disability income policy.
11            (4)    A specified disease policy.
12            (5)    A Medicare supplement policy.
13            (6)    A fixed indemnity policy.
14            (7)    A dental only policy.
15            (8)    A vision only policy.
16            (9)    A workers' compensation policy.
17            (10)    An automobile medical payment policy.
18            (11)    A policy under which benefits are provided by the
19      Federal Government to active or former military personnel and
20      their dependents.
21            (12)    Any other similar policies providing for limited
22      benefits.
23      "Individual health insurance policy."        A policy, subscriber
24   contract, certificate or plan issued by an insurer that provides
25   medical or health care coverage on an annual basis to an
26   individual other than in connection with a group.
27      "Insurer."     An entity that offers, issues or renews an
28   individual or group health insurance policy, contract or plan
29   that provides medical or health care coverage by a health care
30   facility or licensed health care provider and that is governed

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 1   under any of the following:
 2            (1)    The act of May 17, 1921 (P.L.682, No.284), known as
 3      The Insurance Company Law of 1921, including section 630 and
 4      Article XXIV thereof.
 5            (2)    The act of December 29, 1972 (P.L.1701, No.364),
 6      known as the Health Maintenance Organization Act.
 7            (3)    40 Pa.C.S. Ch. 61 (relating to hospital plan
 8      corporations).
 9            (4)    40 Pa.C.S. Ch. 63 (relating to professional health
10      services plan corporations).
11   Section 3.      Core health benefits.
12      (a)   Benefits.--Except as otherwise provided in this section,
13   an insurer offering, issuing or renewing an individual health
14   insurance policy or group health insurance policy shall include
15   health benefits in at least the following general categories and
16   the items and services covered within the categories:
17            (1)    Ambulatory patient services.
18            (2)    Emergency services.
19            (3)    Hospitalization.
20            (4)    Maternity and newborn care.
21            (5)    Mental health and substance use disorder services,
22      including behavioral health treatment.
23            (6)    Prescription drugs.
24            (7)    Rehabilitative and habilitative services and
25      devices.
26            (8)    Laboratory services.
27            (9)    Preventive and wellness services and chronic disease
28      management.
29            (10)    Pediatric services, including oral and vision care.
30      (b)   Comprehensiveness.--

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 1            (1)   An individual health insurance policy or group
 2      health insurance policy shall cover health benefits at least
 3      as comprehensive as the health benefits required to be
 4      covered in an individual health insurance policy or a small
 5      group policy first offered or issued in this Commonwealth in
 6      2018.
 7            (2)   A large group health insurance policy also shall
 8      cover health benefits required to be covered in a large group
 9      policy first offered or issued in this Commonwealth in 2018.
10      (c)   Modifications.--The department may add a health benefit
11   or exempt a health benefit required to be covered under this
12   section through a regulation promulgated under section 4. In
13   determining whether to add a health benefit or exempt a health
14   benefit required to be covered under this section, the
15   department shall consider all of the following:
16            (1)   The balance of the health benefits in the categories
17      specified under subsection (a) and whether the health
18      benefits are not unduly weighted toward any category.
19            (2)   The health care needs of the diverse segments of the
20      population, including women, children, individuals with
21      disabilities and other diverse groups.
22            (3)   The potential for discrimination against individuals
23      because of their age or expected length of life, present or
24      predicted disability, degree of medical dependency, quality
25      of life or other health conditions.
26            (4)   The accessibility of the health benefits, including
27      the cost of the health benefits.
28            (5)   Changes in medical evidence or scientific
29      advancement.
30      (d)   Management techniques.--Nothing in this section shall be

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 1   construed to prevent an insurer from appropriately utilizing
 2   reasonable medical management techniques.
 3   Section 4.      Regulations.
 4      (a)   Authority to promulgate.--The department may promulgate
 5   regulations as may be necessary and appropriate to carry out the
 6   provisions of this act.
 7      (b)   Temporary regulations.--
 8            (1)    In order to facilitate the prompt implementation of
 9      this act, the department may issue temporary regulations,
10      which shall expire no later than two years following
11      publication of the temporary regulations in the Pennsylvania
12      Bulletin. The temporary regulations shall be exempt from the
13      following:
14                   (i)    Section 612 of the act of April 9, 1929
15            (P.L.177, No.175), known as The Administrative Code of
16            1929.
17                   (ii)    Sections 201, 202, 203, 204 and 205 of the act
18            of July 31, 1968 (P.L.769, No.240), referred to as the
19            Commonwealth Documents Law.
20                   (iii)    Section 204(b) of the act of October 15, 1980
21            (P.L.950, No.164), known as the Commonwealth Attorneys
22            Act.
23                   (iv)    The act of June 25, 1982 (P.L.633, No.181),
24            known as the Regulatory Review Act.
25            (2)    The authority of the department to issue temporary
26      regulations under this subsection shall expire two years from
27      the effective date of this section. Regulations adopted after
28      the two-year period shall be promulgated as provided by
29      statute.
30   Section 5.      Enforcement.

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 1      (a)   Penalties.--Upon satisfactory evidence of a violation of
 2   any section of this act by an insurer or any other person, one
 3   or more of the following penalties may be imposed at the
 4   commissioner's discretion:
 5            (1)   Suspension or revocation of the license of the
 6      offending insurer or other person.
 7            (2)   Refusal, for a period not to exceed one year, to
 8      issue a new license to the offending insurer or other person.
 9            (3)   A fine of not more than $5,000 for each violation of
10      this act.
11            (4)   A fine of not more than $10,000 for each willful
12      violation of this act.
13      (b)   Limitations.--
14            (1)   Fines imposed against an individual insurer under
15      this act may not exceed $500,000 in the aggregate during a
16      single calendar year.
17            (2)   Fines imposed against any other person under this
18      act may not exceed $100,000 in the aggregate during a single
19      calendar year.
20      (c)   Additional remedies.--The enforcement remedies imposed
21   under this section are in addition to any other remedies or
22   penalties that may be imposed under any other applicable law of
23   this Commonwealth, including:
24            (1)   The act of July 22, 1974 (P.L.589, No.205), known as
25      the Unfair Insurance Practices Act. Violations of this act
26      shall be deemed to be an unfair method of competition and an
27      unfair or deceptive act or practice under the Unfair
28      Insurance Practices Act.
29            (2)   The act of December 18, 1996 (P.L.1066, No.159),
30      known as the Accident and Health Filing Reform Act.

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 1            (3)   The act of June 25, 1997 (P.L.295, No.29), known as
 2      the Pennsylvania Health Care Insurance Portability Act.
 3      (d)   Administrative procedure.--The administrative provisions
 4   of this section shall be subject to 2 Pa.C.S. Ch. 5 Subch. A
 5   (relating to practice and procedure of Commonwealth agencies).
 6   A party against whom penalties are assessed in an administrative
 7   action may appeal to Commonwealth Court as provided in 2 Pa.C.S.
 8   Ch. 7 Subch. A (relating to judicial review of Commonwealth
 9   agency action).
10   Section 6.     Applicability.
11      This act shall apply as follows:
12            (1)   For health insurance policies for which either rates
13      or forms are required to be filed with the department, this
14      act shall apply to any policy for which a form or rate is
15      first filed on or after the effective date of this section.
16            (2)   For health insurance policies for which neither
17      rates nor forms are required to be filed with the department,
18      this act shall apply to any policy issued or renewed on or
19      after 180 days after the effective date of this section.
20   Section 7.     Repeals.
21      All acts and parts of acts are repealed insofar as they are
22   inconsistent with this act.
23   Section 8.     Effective date.
24      This act shall take effect immediately.




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