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| PRIOR PRINTER'S NO. 1956 | PRINTER'S NO. 2505 |
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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| SENATE BILL |
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| INTRODUCED BY McILHINNEY, RAFFERTY, BOSCOLA, WAUGH, ALLOWAY, COSTA, KASUNIC, D. WHITE, GORDNER, ROBBINS, WOZNIAK, ERICKSON, BROWNE, FARNESE, MENSCH AND ARGALL, FEBRUARY 13, 2012 |
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| SENATOR D. WHITE, BANKING AND INSURANCE, AS AMENDED, OCTOBER 17, 2012 |
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| AN ACT |
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1 | Limiting copayments and coinsurances for insured medical |
2 | services. |
3 | The General Assembly of the Commonwealth of Pennsylvania |
4 | hereby enacts as follows: |
5 | Section 1. Short title. |
6 | This act shall be known and may be cited as the Fairness in |
7 | Copayment Act. |
8 | Section 2. Declaration of intent. |
9 | The general purpose of this act shall be to limit the | <-- |
10 | imposition of copayments and coinsurances for nonphysician |
11 | services to no more than an insured's primary care physician |
12 | copayment amount or up to 30% of the total reimbursement to the |
13 | provider of service, whichever is less. The general purpose of | <-- |
14 | this act shall be to provide fairness for persons seeking |
15 | appropriate and necessary medical care who are sharing the cost |
16 | of the care pursuant to a health insurance policy by limiting |
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1 | the imposition of copayments and coinsurances for nonphysician |
2 | services to not more than the cost of the copayment or |
3 | coinsurance for an insured's primary care physician office |
4 | visit. |
5 | Section 3. Definitions. |
6 | The following words and phrases when used in this act shall |
7 | have the meanings given to them in this section unless the |
8 | context clearly indicates otherwise: |
9 | "Coinsurance." A percentage of the contractual fee schedule |
10 | of the provider that a covered person must pay for covered |
11 | services and supplies rendered by the provider under a health |
12 | benefit plan insurance policy. | <-- |
13 | "Copayment." The specified dollar amount a covered person |
14 | must pay for covered services rendered by a provider under a |
15 | health benefit plan. |
16 | "Health insurance policy." An individual or group health | <-- |
17 | "Health insurance policy." As follows: | <-- |
18 | (1) An individual or group health insurance policy, |
19 | contract or plan which provides medical or health care |
20 | coverage by a health care facility or licensed health care |
21 | provider on an expense-incurred service or prepaid basis and |
22 | which is offered by or is governed under any of the |
23 | following: |
24 | (1) Section 630 of the act of May 17, 1921 (P.L.682, | <-- |
25 | (i) Section 630 of the act of May 17, 1921 (P.L.682, | <-- |
26 | No.284), known as The Insurance Company Law of 1921. |
27 | (2) The act of December 29, 1972 (P.L.1701, No.364), | <-- |
28 | (ii) The act of December 29, 1972 (P.L.1701, | <-- |
29 | No.364), known as the Health Maintenance Organization |
30 | Act. |
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1 | (3) 40 Pa.C.S. Ch. 61 (relating to hospital plan | <-- |
2 | (iii) 40 Pa.C.S. Ch. 61 (relating to hospital plan | <-- |
3 | corporations). |
4 | (4) 40 Pa.C.S. Ch. 63 (relating to professional health | <-- |
5 | (iv) 40 Pa.C.S. Ch. 63 (relating to professional | <-- |
6 | health services plan corporations). |
7 | (5) 40 Pa.C.S. Ch. 67 (relating to beneficial | <-- |
8 | (v) 40 Pa.C.S. Ch. 67 (relating to beneficial | <-- |
9 | societies). |
10 | (2) The term does not include accident only, fixed | <-- |
11 | indemnity, limited benefit, credit, dental, vision, specified |
12 | disease, Medicare supplement, Civilian Health and Medical |
13 | Program of the Uniformed Services (CHAMPUS) supplement, long- |
14 | term care or disability income, workers' compensation or |
15 | automobile medical payment insurance. |
16 | "Physician." In connection with the application and use in |
17 | this act, the term shall be as defined under section 2 of the |
18 | act of December 20, 1985 (P.L.457, No.112), known as the Medical |
19 | Practice Act of 1985. |
20 | Section 4. Limits on copayments. |
21 | A health insurance policy which is delivered, issued for |
22 | delivery, renewed, extended or modified in this Commonwealth by |
23 | a health care insurer shall not impose a copayment or |
24 | coinsurance that exceeds an insured's primary care physician |
25 | copayment amount or up to 30% of the total reimbursement to the | <-- |
26 | provider of service, whichever is less. In no event may an |
27 | insured be subjected to more than one copayment per day for |
28 | services provided by one provider or be charged for more than |
29 | one visit per day for services provided by one provider. office | <-- |
30 | visit copayment or coinsurance amount. An insured may not be |
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1 | subjected to more than one copayment or coinsurance amount per |
2 | visit for outpatient medical services provided by one provider |
3 | or deplete more than one visit for outpatient medical services |
4 | provided by one provider. |
5 | Section 5. Applicability. |
6 | This act shall apply to: |
7 | (1) Insurance policies. |
8 | (2) Subscriber contracts and group certificates issued |
9 | under any group master policy delivered or issued for |
10 | delivery on or after the effective date of this act. |
11 | (3) Renewals of contracts on a renewal date which is on |
12 | or after the effective date of this act. |
13 | Section 6. Effective date. |
14 | This act shall take effect in 60 days. |
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