40 Pa.C.S. § 4522 — PA Code / Title 40 / Chapter 45 / Section 4522
Penalties.
Status: in_force

Upon the determination, after notice and hearing, that this chapter has been violated, the commissioner may impose the following penalties:

(1) Suspension or revocation of the licensee's license, authorization to operate or registration.

(2) Refusal to issue or renew a license, authorization to operate or registration.

(3) A cease and desist order.

(4) For each violation of this chapter that a licensee knew or reasonably should have known was a violation, a penalty of not more than $5,000, not to exceed an aggregate penalty of $100,000 in a single calendar year.

(5) For each violation of this chapter that a licensee did not know nor reasonably should have known was a violation, a penalty of not more than $1,000, not to exceed an aggregate penalty of $20,000 in a single calendar year.
40 Pa.C.S. § 4701 — PA Code / Title 40 / Chapter 47 / Section 4701
Purpose and scope of chapter.
Status: in_force

(a) Purpose.--The purpose of this chapter is to create a comprehensive legal framework for the sale, solicitation and negotiation of pet insurance policies in this Commonwealth.

(b) Applicability.--This chapter applies to a pet insurance policy that is:

(1) sold, solicited or negotiated in this Commonwealth and issued to a resident of this Commonwealth; or

(2) delivered or issued for delivery in this Commonwealth.
40 Pa.C.S. § 5106 — PA Code / Title 40 / Chapter 51 / Section 5106
Regulations.
Status: in_force

The department may promulgate regulations, as necessary, to implement, administer and enforce this chapter.
40 Pa.C.S. § 5007 — PA Code / Title 40 / Chapter 50 / Section 5007
Prior consent for electronic delivery of insurance notices or documents.
Status: in_force

If an insurer has a documented record from a covered person indicating approval by the covered person for a notice or document to be delivered by electronic means from the insurer before the effective date of this section and the insurer intends to deliver by electronic means an additional notice or document under this chapter, prior to providing the additional notice or document for delivery by electronic means, the insurer shall comply with sections 5003 (relating to electronic delivery of insurance notices or documents) and 5004 (relating to changes in hardware or software requirements) and provide the covered person with a statement that describes the following:

(1) A list of each notice or document that will be delivered by electronic means that was not previously delivered by electronic means.

(2) The covered person's right to opt out of delivery by electronic means without imposition of a condition or consequence that was not previously disclosed to the covered person.
40 Pa.C.S. § 5105 — PA Code / Title 40 / Chapter 51 / Section 5105
Penalties.
Status: in_force

A violation of this chapter shall be deemed and defined by the commissioner to be an unfair method of competition and an unfair or deceptive act or practice in accordance with the act of July 22, 1974 (P.L.589, No.205), known as the Unfair Insurance Practices Act.
40 Pa.C.S. § 6329 — PA Code / Title 40 / Chapter 63 / Section 6329
Rates and contracts.
Status: in_force

(a) General rule.--All rates charged subscribers or groups of subscribers by any professional health service corporation, and the form and content of all contracts between any such corporation and its subscribers or groups of subscribers, all methods and rates of payment by such corporation to health service doctors serving its subscribers, all acquisition costs in procuring subscribers, the reserves to be maintained by such corporation, and all contracts entered into by any such corporation and extending over a period of more than one year or calling for the expenditure by the corporation of any amount in excess of 20% of its reserves, shall be approved by the department before they become effective.

(b) Procedure.--Every application for such approval shall be made to the department in writing and shall be subject to the provisions of subsections (c) through (f) of section 6102 of this title (relating to certification of hospital plan corporations), except that the department may substitute publication in the Pennsylvania Bulletin of notice of reasonable

opportunity to submit written comments for publication of opportunity for hearing in any case where the right to an oral hearing is not conferred by the Constitution of the United States or the Constitution of Pennsylvania. Within 60 days after the filing of the application the department shall approve or refuse such application. 1996 Partial Repeal. Section 14 of Act 159 of 1996, known as the Accident and Health Filing Reform Act, provided that subsec. (a) is repealed insofar as it provides for the approval of rates and contracts. References in Text. Section 14 of Act 159 of 1996, known as the Accident and Health Filing Reform Act, was renumbered 5101 by the act of December 22, 2011, P.L.614, No.134.
40 Pa.C.S. § 3906 — PA Code / Title 40 / Chapter 39 / Section 3906
Third-party consultants.
Status: in_force

(a) Assistance with review.--The department may retain, at the insurer or insurance group's expense, third-party consultants, including attorneys, actuaries, accountants and other experts not otherwise a part of the department's staff as may be reasonably necessary to assist the department in reviewing the CGAD, CGAD-related information or the insurer's or insurance group's compliance with this chapter. Before retaining a third-party consultant, the department shall consider all of the following:

(1) The complexity of the corporate governance structure of the insurer or insurance group.

(2) Whether subject matter expertise to effectively review the report is available within the department.

(b) Advisory capacity.--A person retained under subsection

(a) shall be under the direction and control of the department and shall act in a purely advisory capacity.

(c) Confidentiality.--Each third-party consultant shall be subject to the same confidentiality standards and requirements as the department.

(d) Verification.--As part of the retention process, a third-party consultant shall verify to the department, with notice to the insurer or insurance group, that it:

(1) is free of a conflict of interest;

(2) will comply with the confidentiality standards and requirements of this chapter; and

(3) has internal procedures in place to monitor compliance with this section.

(e) Written consent.--A retention agreement with a third-party consultant shall expressly require the written consent of the insurer or insurance group prior to making information provided under this chapter public. Cross References. Section 3906 is referred to in section 3907 of this title.
40 Pa.C.S. § 5013 — PA Code / Title 40 / Chapter 50 / Section 5013
Violations.
Status: in_force

Failure to comply with the requirements of this chapter shall be deemed an unfair insurance practice under the act of July 22, 1974 (P.L.589, No.205), known as the Unfair Insurance Practices Act.
40 Pa.C.S. § 3706 — PA Code / Title 40 / Chapter 37 / Section 3706
Regulations.
Status: in_force

The commissioner may promulgate rules and regulations to administer the provisions of this chapter.
40 Pa.C.S. § 7105 — PA Code / Title 40 / Chapter 71 / Section 7105
Regulations.
Status: in_force

The department may promulgate regulations, as necessary, to implement, administer and enforce this chapter.
40 Pa.C.S. § 6304 — PA Code / Title 40 / Chapter 63 / Section 6304
Certification of professional health service corporations.
Status: in_force

(a) General rule.--A corporation not-for-profit incorporated for the purpose of establishing, maintaining and operating a nonprofit professional health service plan, nonprofit dental service plan or nonprofit optometric service plan shall not commence business until it shall have received from the department a certificate of authority authorizing the corporation to establish, maintain and operate a nonprofit professional health service plan, a nonprofit dental service plan or a nonprofit optometric service plan, as the case may be.

(b) Exemptions.--The provisions of subsection (a) of this section shall not apply to any nonprofit corporation incorporated with the approval of the department under the former provisions of section 219 or 220 of the Nonprofit Corporation Law of 1933. For the purposes of this chapter such a corporation shall be deemed to be a holder of a certificate of authority issued under this section as:

(1) an optometric service corporation, if incorporated under the former provisions of section 219 of the Nonprofit Corporation Law of 1933 for the primary purpose of providing a nonprofit optometric service plan;

(2) a general medical service corporation, if incorporated under the former provisions of section 219 of the Nonprofit Corporation Law of 1933 for any other purpose; or

(3) a dental service corporation, if incorporated under the former provisions of section 220 of the Nonprofit Corporation Law of 1933.

(c) Form of application.--Every application for a certificate of authority under this section shall be made to the Insurance Department in writing and shall be in such form and contain such information as the regulations of the Department of Health and the Insurance Department may require. The Insurance Department shall forward the application to the Department of Health for action thereon and report to the Insurance Department.

(d) Standards for issuance of certificate.--A certificate of authority shall be issued by order of the Insurance Department only if and when the Department of Health and the Insurance Department shall severally find and determine that the application complies with the provisions of this chapter and the regulations of the Department of Health and the Insurance Department thereunder.

(e) Procedure.--The proceedings before the Department of Health and the Insurance Department shall be subject to the provisions of section 6102(e) of this title (relating to procedure before department) and the term department in such section shall be deemed to be a reference also to the Department of Health. Each department shall make a thorough investigation of the applicant and the area in and the plan under which it proposes to operate.

(f) Judicial review.--The final orders of the Department of Health and the Insurance Department upon an application for a certificate of authority under this section shall be deemed to be a single order for the purposes of judicial review and to have been issued on the date the Insurance Department issues its final order after having considered the final action of the Department of Health upon the application. Such order, and all other orders of each department, shall be subject to judicial review in the manner and within the time provided by law. Cross References. Section 6304 is referred to in section 6322 of this title.
40 Pa.C.S. § 4902 — PA Code / Title 40 / Chapter 49 / Section 4902
Payment.
Status: in_force

(a) Payment.--A health insurer or its contracted vendor may not restrict the method of payment to a participating health care provider so that the exclusive payment method is a credit card payment.

(b) Changing payment.--If initiating or changing payments to a participating health care provider using electronic funds transfer payments, including credit card payments, a health insurer or its contracted vendor shall:

(1) Advise the health care provider of all available payment methods.

(2) Notify the health care provider that fees imposed by the health insurer or its contracted vendor may apply to electronic funds transfer payments, including credit card payments, and provide instructions and contact information so that the health care provider may obtain the exact amount of the fees. Fees charged by a financial institution or merchant servicer chosen by the health care provider shall not be included for the purposes of this paragraph.

(3) Provide clear instructions to the health care provider for the process of selecting a payment method.

(4) Not charge a fee solely to transmit the payment to the health care provider, unless the health care provider has consented to the fee.

(c) Waiver prohibited.--The provisions of this section may not be waived by contract, and any contractual clause in conflict with the provisions of this section or that purport to waive any requirements of this section are void.
40 Pa.C.S. § 9301 — PA Code / Title 40 / Chapter 93 / Section 9301
Scope of chapter.
Status: in_force

This chapter relates to the Pennsylvania Health Insurance Exchange Authority.
40 Pa.C.S. § 4521 — PA Code / Title 40 / Chapter 45 / Section 4521
Power to examine licensees.
Status: in_force

(a) Insurers.--The commissioner shall have the powers provided under Article IX of the act of May 17, 1921 (P.L.789, No.285), known as The Insurance Department Act of 1921, to examine and investigate an insurer to determine whether the insurer has been or is engaged in conduct in violation of section 4512 (relating to risk assessment), 4513 (relating to information security program), 4514 (relating to corporate oversight), 4515 (relating to oversight of third-party service provider arrangements) or 4516 (relating to certification).

(b) Licensees other than insurers.--

(1) The commissioner shall have the power to examine and investigate a licensee not subject to Article IX of The Insurance Department Act of 1921 to determine whether the licensee has engaged in conduct in violation of this chapter.

(2) Each licensee subject to examination in accordance with paragraph (1) shall keep all books, records, accounts, papers, documents and any computer or other recordings relating to compliance with this chapter in the manner and time periods as the department, in its discretion, may require in order that the department's authorized representatives may verify and ascertain whether the company or person has complied with the requirements of this chapter.

(3) Each licensee subject to examination in accordance with paragraph (1) from whom information is sought and the officers, directors, employees and agents of the licensee shall provide to the examiners timely, convenient and free access at all reasonable hours at the licensee's offices to all books, records, accounts, papers, documents and any computer or other recordings relating to the property,

assets, business and affairs of the licensee being examined. The following apply:

(i) The officers, directors, employees and agents of the licensee shall facilitate the examination and aid in the examination insofar as it is in their power to do so.

(ii) The refusal of a licensee by its officers, directors, employees or agents to submit to examination or to comply with any reasonable written request of the examiners shall be grounds for suspension, revocation, refusal or nonrenewal of any license or authority held by the licensee to engage in an insurance or other business subject to the department's jurisdiction.

(iii) A proceeding for suspension, revocation, refusal or nonrenewal of any license or authority shall be conducted in accordance with 2 Pa.C.S. (relating to administrative law and procedure).

(c) Authorized actions by commissioner.--Notwithstanding and in addition to the powers specified under this section, whenever the commissioner has reason to believe that a licensee has been or is engaged in conduct in this Commonwealth that violates this chapter, the commissioner may take an action that is necessary or appropriate to enforce the provisions of this chapter.
40 Pa.C.S. § 4514 — PA Code / Title 40 / Chapter 45 / Section 4514
Corporate oversight.
Status: in_force

(a) Duties.--If a licensee has a board of directors, the board or an appropriate committee of the board shall, at a minimum:

(1) Require the licensee's executive management or delegates to develop, implement and maintain the licensee's information security program.

(2) Require the licensee's executive management or delegates to report in writing at least annually, the following information:

(i) The overall status of the information security program and the licensee's compliance with this chapter.

(ii) Material matters related to the information security program, addressing issues such as:

(A) Risk assessment, risk management and control decisions.

(B) Third-party service provider arrangements.

(C) The results of testing.

(D) Cybersecurity events.

(E) Any violation of this chapter and management's responses to the violation.

(F) Recommendations for changes in the information security program.

(b) Delegation.--If the executive management of a licensee delegates any of its responsibilities under this section or section 4512 (relating to risk assessment), 4513 (relating to information security program) or 4515 (relating to oversight of third-party service provider arrangements), the executive management shall oversee the development, implementation and maintenance of the licensee's information security program prepared by the delegated entity, which shall provide a written report to the executive management in accordance with the reporting requirements of this chapter. Cross References. Section 4514 is referred to in sections 4516, 4521, 4532, 4536 of this title.
40 Pa.C.S. § 4502 — PA Code / Title 40 / Chapter 45 / Section 4502
Definitions.
Status: in_force

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Authorized individual." An individual known to and screened by a licensee and determined to be necessary and appropriate to have access to the nonpublic information held by the licensee and its information systems.

"Commissioner." The Insurance Commissioner of the Commonwealth.

"Consumer." An individual, including an applicant, policyholder, insured, beneficiary, claimant or certificate holder, who is a resident of this Commonwealth and whose nonpublic information is in a licensee's possession, custody or control.

"Cybersecurity event." As follows:

(1) An event resulting in unauthorized access to, disruption of or misuse of an information system or nonpublic information stored on the information system.

(2) The term does not include:

(i) The unauthorized acquisition of encrypted nonpublic information if the encryption, process or key is not also acquired, released or used without authorization.

(ii) An event in which the licensee has determined that the nonpublic information accessed by an unauthorized person has not been used or released and has been returned or destroyed.

"Department." The Insurance Department of the Commonwealth.

"Encrypted." The transformation of data into a form that has a low probability of assignment of meaning without the use of a protective process or key.

"Information security program." The administrative, technical and physical safeguards that a licensee uses to access, collect, distribute, process, protect, store, use, transmit, dispose of or otherwise handle nonpublic information.

"Information system." Any of the following:

(1) A discrete set of information resources that is stored in an electronic system and is organized for the collection, processing, maintenance, use, sharing, dissemination or disposition of electronic nonpublic information.

(2) Any specialized system such as an industrial or process control system, telephone switching and private branch exchange system or an environmental control system.

"Insurer." An insurance company, association, exchange, interinsurance exchange, health maintenance organization, preferred provider organization, professional health services plan corporation subject to Chapter 63 (relating to professional health services plan corporations), a hospital plan corporation subject to Chapter 61 (relating to hospital plan corporations), fraternal benefit society, beneficial association, Lloyd's insurer or health plan corporation.

"Licensee." As follows:

(1) A person that is or is required to be licensed, authorized to operate or registered under the insurance laws of this Commonwealth.

(2) The term does not include:

(i) A purchasing group or risk retention group as defined in section 1502 of the act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, that is chartered and licensed in a state other than this Commonwealth.

(ii) A person that is acting as an assuming insurer that is domiciled in another state or jurisdiction.

"Multifactor authentication." Authentication through verification of at least two of the following types of authentication factors:

(1) Knowledge factors, such as a password.

(2) Possession factors, such as a token or text message on a mobile telephone.

(3) Inherence factors, such as a biometric characteristic.

"Nonpublic information." Information that is stored or maintained in an electronic system, is not publicly available information and is any of the following:

(1) Business-related information of a licensee that would cause a materially adverse impact to the business, operations or security of the licensee if the information is tampered with, accessed, used or subject to unauthorized disclosure.

(2) Information concerning a consumer that because of a name, number, personal mark or other identifier, can be used to identify the consumer, in combination with any one or more of the following data elements:

(i) Social Security number.

(ii) Driver's license number or nondriver identification card number.

(iii) Financial account number, credit card number or debit card number.

(iv) A security code, access code or password that would permit access to a consumer's financial account.

(v) Biometric records.

(3) Information or data, except age or gender, in any form or medium created by or derived from a health care provider or a consumer that can be used to identify a particular consumer and that relates to any of the following:

(i) The past, present or future physical, mental or behavioral health or condition of a consumer or a member of the consumer's family.

(ii) The provision of health care to any consumer.

(iii) Payment for the provision of health care to any consumer.

"Person." An individual or nongovernmental entity, including a nongovernmental partnership, corporation, branch, agency or association.

"Publicly available information." Information that a licensee has a reasonable basis to believe is lawfully made available to the general public from any of the following:

(1) Federal, State or local government records.

(2) Widely distributed media.

(3) Disclosures to the general public that are required to be made in accordance with Federal, State or local law.

"Risk assessment." The assessment that each licensee is required to conduct under section 4512 (relating to risk assessment).

"Third-party service provider." As follows:

(1) A person that contracts with a licensee to maintain, process or store, or is otherwise permitted to access, nonpublic information through its provision of services to the licensee.

(2) The term does not include a licensee.
40 Pa.C.S. § 5003 — PA Code / Title 40 / Chapter 50 / Section 5003
Electronic delivery of insurance notices or documents.
Status: in_force

(a) Transactions.--Subject to the requirements of this section, an insurer may deliver by electronic means a notice to a covered person or any document required by Federal or State law in a transaction with the insurer or deliver in a manner that serves as evidence of insurance coverage in accordance with the act of December 16, 1999 (P.L.971, No.69), known as the Electronic Transactions Act.

(b) Effect of delivery.--The delivery of a notice or document in accordance with this section shall be considered the equivalent to and having the same effect as a delivery method required by Federal or State law, including delivery by first class mail, first class mail with postage prepaid, certified mail, certificate of mail or certificate mailing.

(c) Consent from covered persons.--Notwithstanding subsection (d), an insurer may deliver by electronic means a notice or document to a covered person in accordance with this section if all of the following apply:

(1) The covered person has affirmatively consented electronically or confirmed consent electronically in a manner that reasonably demonstrates that the covered person can access information in the electronic form that will be used for a notice or document delivered by electronic means, and the covered person has not withdrawn the consent.

(2) Before the covered person gives the consent required under paragraph (1), the insurer provides the covered person with a clear and conspicuous statement informing the covered person of all of the following:

(i) The hardware and software requirements for access to and retention of a notice or document delivered by electronic means.

(ii) The types of notices and documents for which the covered person may consent to receive by delivery by electronic means.

(iii) The right of the covered person to withdraw consent to having a notice or document delivered by electronic means at any time and the conditions or consequences imposed in the event consent is withdrawn.

(iv) The procedures necessary for the covered person to withdraw consent to having a notice or document delivered by electronic means, which shall be no more burdensome than the procedures required to provide consent under paragraph (1), and the manner in which the covered person can update the covered person's email address for the purposes of this subsection.

(v) The right of a covered person to have a notice or document delivered by the insurer upon request in paper form.

(vi) The right of a covered person to request that personal health information be treated and communicated confidentially and the process by which a covered person may receive confidential communication of personal health information delivered by electronic means.

(d) Consent from plan sponsors.--A plan sponsor may, on behalf of each covered person, provide consent to the delivery by electronic means of communications related to the plan from an insurer.

(e) Duties of plan sponsors.--Before consenting on behalf of a covered person under subsection (d), a plan sponsor shall have the following duties:

(1) To the extent applicable, confirm that the covered person routinely uses electronic communications and is able to access and retain electronic communications that may be delivered by an insurer to an email address used by the covered person.

(2) Inform the covered person no less than 30 days prior that consent will be provided as authorized under subsection

(d) and a notice or document related to the health benefit plan may be delivered by electronic means unless the covered person affirmatively opts out of delivery by electronic means prior to the expiration of the 30-day period.

(f) Duties of insurers for health benefit plans.--At least 30 days before providing delivery by electronic means of a notice or document related to a health benefit plan, an insurer for the plan shall have the following duties:

(1) Verify that the plan sponsor has met its duties under subsection (e).

(2) Provide a clear and conspicuous statement informing a covered person enrolled in the plan of all of the following:

(i) The types of notices and documents that may be delivered by electronic means to the covered person.

(ii) The right of the covered person to opt out of having a notice or document delivered by electronic means at any time without charge.

(iii) The procedures necessary for the covered person to opt out of having a notice or document delivered by electronic means and the manner in which the covered person can update the covered person's email address for the purposes of this subsection.

(iv) The right of the covered person to have a notice or document delivered by the insurer upon request in paper form without charge.

(v) The right of a covered person to request that personal health information be treated and communicated confidentially and the process by which a covered person may receive the confidential communication of personal health information delivered by electronic means.

(3) Provide an opportunity for a covered person enrolled in the plan to opt out of delivery by electronic means.

(4) Comply with the applicable provisions of this chapter, the Electronic Transactions Act, 45 CFR 164.530(c) (relating to administrative requirements) and other applicable provisions of Federal law regarding technical safeguards such as encryption. Cross References. Section 5003 is referred to in sections 5004, 5007 of this title.
40 Pa.C.S. § 3 — PA Code / Title 40 / Chapter 3 / Section 3
Effective date and retroactivity.
Status: in_force

This act shall take effect immediately and shall be retroactive to the extent provided in section 2 of this act.
40 Pa.C.S. § 5101 — PA Code / Title 40 / Chapter 51 / Section 5101
Definitions.
Status: in_force

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Commissioner." The Insurance Commissioner of the Commonwealth.

"Customer." A policyholder, potential policyholder, certificate holder, potential certificate holder, insured, potential insured or applicant.

"Insurance policy." A certificate, excluding a certificate of liability insurance, or contract of insurance, indemnity, health care, suretyship, title insurance or annuity issued, proposed for issuance or intended for issuance by an insurance producer or insurer.

"Insurance producer." A person licensed or approved by the department to sell, solicit or negotiate insurance policies.

"Insurer." Any of the following that is licensed or approved by the department:

(1) An insurance company, association or exchange.

(2) A reciprocal or interinsurance exchange.

(3) A health maintenance organization.

(4) A preferred provider organization.

(5) A professional health services plan corporation subject to Chapter 63 (relating to professional health services plan corporations).

(6) A hospital plan corporation subject to Chapter 61 (relating to hospital plan corporations).

(7) A fraternal benefits society.

(8) A beneficial association.

(9) A Lloyd's insurer.

(10) An eligible surplus lines insurer.
40 Pa.C.S. § 7114 — PA Code / Title 40 / Chapter 71 / Section 7114
Actuarial opinion of reserves on or after operative date of valuation manual.
Status: in_force

(a) Applicability.--This section shall apply to an actuarial opinion prepared on or after the operative date of the valuation manual.

(b) Compliance with valuation manual.--The actuarial opinion under this section must comply with the requirements set forth in the valuation manual.

(c) Annual submission and purpose.--Each company with outstanding life insurance contracts, accident and health insurance contracts or deposit-type contracts in this Commonwealth shall annually submit the opinion of the appointed actuary as to whether the reserves and related actuarial items held in support of the company's policies and contracts:

(1) are computed appropriately;

(2) are based on assumptions that satisfy contractual provisions;

(3) are consistent with prior reported amounts; and

(4) comply with the applicable laws of this Commonwealth.

(d) Opinion regarding company obligations.--The following shall apply regarding the opinion of the appointed actuary and the company's obligations:

(1) Except as exempted in the valuation manual, each company with outstanding life insurance contracts, accident and health insurance contracts or deposit-type contracts in this Commonwealth shall include in the actuarial opinion required under this section an opinion by the same appointed actuary as to whether the reserves and related actuarial items held in support of the company's policies and contracts specified in the valuation manual, when considered in light of the assets held by the company with respect to the

reserves and related actuarial items, including, but not limited to, the investment earnings on the assets and the considerations anticipated to be received and retained under the policies and contracts, make adequate provision for the company's obligations under the policies and contracts, including, but not limited to, the benefits under and expenses associated with the policies and contracts.

(2) A memorandum, in form and substance as specified in the valuation manual and as acceptable to the commissioner, shall be prepared to support each actuarial opinion.

(3) If a company fails to provide a supporting memorandum at the request of the commissioner within a period specified in the valuation manual or if the commissioner determines that the supporting memorandum provided by the company fails to meet the standards prescribed by the valuation manual or is otherwise unacceptable to the commissioner, the commissioner may engage a qualified actuary at the expense of the company to review the opinion and the basis for the opinion and prepare the supporting memorandum required by the commissioner.

(e) Requirements.--Each actuarial opinion under this section shall be governed by the following:

(1) The opinion shall be in form and substance as specified in the valuation manual and acceptable to the commissioner.

(2) The opinion shall be submitted with the annual statement reflecting the valuation of the reserve liabilities for each year ending on or after the operative date of the valuation manual.

(3) The opinion shall apply to all policies and contracts subject to subsection (d), plus other actuarial liabilities as may be specified in the valuation manual.

(4) The opinion shall be based on standards adopted from time to time by the Actuarial Standards Board, or its successor, and on any additional standards as prescribed in the valuation manual.

(5) In the case of an opinion required to be submitted by a foreign or alien company, the commissioner may accept the opinion filed by that company with the insurance supervisory official of another state if the commissioner determines that the opinion reasonably meets the requirements applicable to a company domiciled in this Commonwealth.

(6) Except in cases of fraud or willful misconduct, an appointed actuary shall not be liable for damages to any person, other than the company and the commissioner, for any act, error, omission, decision or conduct with respect to the actuarial opinion.

(7) Disciplinary action by the commissioner against the company or the appointed actuary shall be prescribed by regulation.

(8) The confidentiality provisions under Subchapter C (relating to confidentiality) shall apply. Cross References. Section 7114 is referred to in sections 7102, 7120, 7121, 7131, 7137 of this title.
40 Pa.C.S. § 3705 — PA Code / Title 40 / Chapter 37 / Section 3705
Enforcement.
Status: in_force

(a) Actions.--Upon a determination by hearing that an insurer has violated this chapter, the commissioner may pursue one or more of the following courses of action:

(1) issue an order requiring the insurer to cease and desist from engaging in the violation or suspend, revoke or refuse to issue the certificate of qualification or license of the offending insurer.

(2) impose a civil penalty of not more than $5,000 for each violation.

(b) Additional remedies or penalties.--The enforcement remedies imposed under this section shall be in addition to any other remedies or penalties imposed by statute.

(c) Administrative procedure.--An action or adjudication of the commissioner under this section shall be preceded by a hearing in accordance with 2 Pa.C.S. Ch. 5 Subch. A (relating to practice and procedure of Commonwealth agencies) and shall be subject to review and appeal in accordance with 2 Pa.C.S. Ch. 7 Subch. A (relating to judicial review of Commonwealth agency action).
40 Pa.C.S. § 3517 — PA Code / Title 40 / Chapter 35 / Section 3517
Prohibition on acquisitions of control.
Status: in_force

Except as otherwise specifically provided in section 3503 (relating to contents of plan of conversion), from the date a plan of conversion is adopted until the effective date of the plan of conversion, a person may not directly or indirectly offer to acquire, make an announcement to acquire or acquire in any manner, including making a filing with the department for acquisition under a statute or regulation of this Commonwealth, the beneficial ownership of 10% or more of a class of a voting security of the attorney or the stock company that will be the successor of the reciprocal insurer or of a person that controls the voting securities of the attorney or the stock company that will be the successor of the reciprocal insurer.
40 Pa.C.S. § 9313 — PA Code / Title 40 / Chapter 93 / Section 9313
Federal guidance.
Status: in_force

Until the exchange authority promulgates regulations, the exchange authority shall operate the exchange pursuant to:

(1) any applicable Federal rules, regulations or guidance; or

(2) interim State guidelines consistent with this chapter.
40 Pa.C.S. § 3910 — PA Code / Title 40 / Chapter 39 / Section 3910
Construction.
Status: in_force

Nothing in this chapter shall be construed to prescribe or impose corporate governance standards and internal procedures in addition to those required under applicable State corporate law. Notwithstanding the foregoing, nothing in this chapter shall be construed to limit the commissioner's authority or the rights or obligations of third parties under Article IX of the act of May 17, 1921 (P.L.789, No.285), known as The Insurance Department Act of 1921.
40 Pa.C.S. § 5005 — PA Code / Title 40 / Chapter 50 / Section 5005
Affect, validity and enforceability of insurance notices or documents.
Status: in_force

(a) Content of notices or documents.--Nothing in this chapter shall be construed to affect requirements related to content of an insurance notice or document or the timing related to the notice or document required under any other provision of Federal or State law.

(b) Confirmation receipts.--If any other applicable Federal or State law requires confirmation of the receipt of a notice or document from a covered person or plan sponsor of a health benefit plan, an insurer shall only deliver by electronic means a notice or document if the method for delivery provides for an active confirmation receipt by the covered person or plan sponsor.

(c) Prior consent.--This chapter shall not apply to a notice or document delivered by electronic means by an insurer before the effective date of this subsection to a covered person who, prior to the effective date of this subsection, provided consent to the insurer to receive a notice or document delivered by electronic means from the insurer.

(d) Validity or enforceability.--The validity or enforceability of a contract or policy of an insurer executed by a covered person shall not be denied solely because of the failure of the insurer to obtain electronic consent or confirmation of consent of the covered person in accordance with this chapter if the notice or document is delivered in paper form.
40 Pa.C.S. § 7121 — PA Code / Title 40 / Chapter 71 / Section 7121
Optional reserve calculation.
Status: in_force

(a) Issuance prior to May 17, 1921.--Reserves for policies and contracts issued prior to May 17, 1921, may be calculated, at the option of the company, according to any standards that produce greater aggregate reserves for all these policies and contracts than the minimum reserves required by law.

(b) Issuance on or after May 17, 1921.--Reserves for any category of policies, contracts or benefits established by the commissioner, issued on or after May 17, 1921, may be calculated, at the option of the company, according to any standards that produce greater aggregate reserves for the category than those calculated according to the minimum standard provided under this chapter, but the rate or rates of interest used for policies and contracts, other than annuity and pure endowment contracts, shall not be greater than the corresponding rate or rates of interest used in calculating any nonforfeiture benefits provided in the policies or contracts.

(c) Adoption of alternative standards.--The following shall apply:

(1) Subject to paragraph (2), a company that adopts at any time a standard of valuation producing greater aggregate reserves than those calculated according to the minimum standard provided under this chapter may adopt a lower standard of valuation with the approval of the commissioner, but not lower than the minimum provided in this chapter.

(2) For the purposes of this section, the holding of additional reserves previously determined by the appointed actuary to be necessary to render the opinion required by section 7113 (relating to actuarial opinion of reserves prior to operative date of valuation manual) or 7114 (relating to actuarial opinion of reserves on or after operative date of valuation manual) shall not be deemed to be the adoption of a higher standard of valuation. Cross References. Section 7121 is referred to in section 7103 of this title.
40 Pa.C.S. § 4804 — PA Code / Title 40 / Chapter 48 / Section 4804
Medical assistance and children's health insurance program coverage.
Status: in_force

(a) MA or CHIP managed care plan payment.--

(1) MA or CHIP managed care plan payments shall be made on behalf of enrollees for medically necessary health care services provided through telemedicine, if all of the following apply:

(i) The health care service would be covered through an in-person encounter.

(ii) The provision of the health care service through telemedicine is consistent with Federal law and regulations, the laws of this Commonwealth, applicable regulations and guidance.

(iii) Federal approval, if necessary for the provision of the health care service through telemedicine, has been received by the Department of Human Services.

(2) The MA or CHIP managed care plan shall pay a participating network provider for covered health care services delivered through telemedicine in accordance with the terms and conditions of both:

(i) the contract negotiated between the MA or CHIP managed care plan and the participating network provider; and

(ii) the agreement with the Department of Human Services.

(b) Applicability.--

(1) Subsection (a) does not apply if the telemedicine-enabling device, technology or service fails to comply with the Health Insurance Portability and Accountability Act of 1996, the Health Information Technology for Economic and Clinical Health Act or other applicable statute, regulation or guidance from the Federal Government or the Department of Human Services.

(2) This section shall apply to MA and CHIP managed care plans beginning on or after January 1, 2026.

(c) Construction.--This section may not be construed to:

(1) Prohibit a MA or CHIP managed care plan from making payments on behalf of enrollees to other health care providers for covered health care services provided through telemedicine.

(2) Require a MA or CHIP managed care plan to pay for a health care service if the delivery of the health care service through telemedicine would be inconsistent with the standard of care.
40 Pa.C.S. § 9101 — PA Code / Title 40 / Chapter 91 / Section 9101
Scope of part.
Status: in_force

This part relates to health insurance markets oversight.
40 Pa.C.S. § 7117 — PA Code / Title 40 / Chapter 71 / Section 7117
Computation of minimum standard by calendar year of issue.
Status: in_force

(a) Applicability.--The interest rates used in determining the minimum standard for the valuation of the following shall be the calendar year statutory valuation interest rates as defined in this section:

(1) Life insurance policies issued in a particular calendar year on or after the operative date of section 410A(e) of The Insurance Company Law of 1921.

(2) Individual annuity and pure endowment contracts issued in a particular calendar year on or after January 1, 1981.

(3) Annuities and pure endowments purchased in a particular calendar year on or after January 1, 1981, under group annuity and pure endowment contracts.

(4) The net increase, if any, in a particular calendar year after January 1, 1981, in amounts held under guaranteed interest contracts.

(b) Calendar year statutory valuation interest rates.--The following shall apply:

(1) Subject to paragraph (2), the calendar year statutory valuation interest rates, I, shall be determined as follows and the results rounded to the nearest 0.25%:

(i) For life insurance: I = .03 + W(R1 - .03) + W/2(R2 - .09).

Where R1 is the lesser of R and .09, R2 is the greater of R and .09, R is the reference interest rate defined in this section and W is the weighting factor defined in this section.

(ii) For single premium immediate annuities and for annuity benefits involving life contingencies arising from other annuities with cash settlement options and from guaranteed interest contracts with cash settlement options: I = .03 + W(R1 - .03). Where R1 is the lesser of R and .09, R2 is the greater of R and .09, R is the reference interest rate defined in this section and W is the weighting factor defined in this section.

(iii) For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on an issue year basis, except as stated in subparagraph (ii):

(A) The formula for life insurance stated in subparagraph (i) shall apply to annuities and guaranteed interest contracts with guarantee durations in excess of 10 years.

(B) The formula for single premium immediate annuities stated in subparagraph (ii) shall apply to annuities and guaranteed interest contracts with guarantee duration of 10 years or less.

(iv) For other annuities with no cash settlement options and for guaranteed interest contracts with no cash settlement options, the formula for single premium immediate annuities stated in subparagraph (ii) shall apply.

(v) For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on a change in fund basis, the formula for single premium immediate annuities stated in subparagraph (ii) shall apply.

(2) The following shall apply:

(i) If the calendar year statutory valuation interest rate for a life insurance policy issued in any calendar year determined without reference to this subparagraph differs from the corresponding actual rate for similar policies issued in the immediately preceding calendar year by less than 0.5%, the calendar year statutory valuation interest rate for the life insurance policies shall be equal to the corresponding actual rate for the immediately preceding calendar year.

(ii) For purposes of applying subparagraph (i), the calendar year statutory valuation interest rate for life insurance policies issued in a calendar year shall be determined for 1980, using the reference interest rate defined in 1979, and shall be determined for each subsequent calendar year regardless of the operative date of section 410A(e) of The Insurance Company Law of 1921.

(c) Weighting factors.--The weighting factors referred to in subsection (b) shall be as follows:

(1) For life insurance, the guarantee duration shall be the maximum number of years the life insurance can remain in force on a basis guaranteed in the policy or under options to convert to plans of life insurance with premium rates or nonforfeiture values, or both, which are guaranteed in the

original policy. Weighting factors for life insurance shall be as provided in the following table: Weighting Guarantee Duration Factors (Years) .50 10 or less .45 More than 10, but not more than 20 .35 More than 20

(2) Weighting factors for single premium immediate annuities and for annuity benefits involving life contingencies arising from other annuities with cash settlement options and guaranteed interest contracts with cash settlement options shall be .80.

(3) Weighting factors for other annuities and for guaranteed interest contracts, except as stated in paragraph

(2), shall be as specified in subparagraphs (i), (ii) and

(iii), according to the rules and definitions in subparagraphs (iv), (v) and (vi):

(i) For annuities and guaranteed interest contracts valued on an issue year basis, the following table shall apply: Weighting Factor for Plan Type Guarantee Duration (Years) C B A .50 .60 .80 5 or less .50 .60 .75 More than 5, but not more than 10 .45 .50 .65 More than 10, but not more than 20 .35 .35 .45 More than 20

(ii) For annuities and guaranteed interest contracts valued on a change in fund basis, the factors shown in subparagraph (i) shall be increased by .15 for plan type A, .25 for plan type B and .05 for plan type C.

(iii) For annuities and guaranteed interest contracts valued on an issue year basis, other than those with no cash settlement options, that do not guarantee interest on considerations received more than one year after issue or purchase and for annuities and guaranteed interest contracts valued on a change in fund basis that do not guarantee interest rates on considerations received more than 12 months beyond the valuation date, the factors shown in subparagraph (i) or derived in subparagraph (ii) shall be increased by .05 for plan types A, B and C.

(iv) For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, the guarantee duration is the number of years for which the contract guarantees interest rates in excess of the calendar year statutory valuation interest rate for life insurance policies with guarantee duration in excess of 20 years. For other annuities with no cash settlement options and for guaranteed interest contracts with no cash settlement options, the guarantee duration is the number of years from the date of issue or date of purchase to the date annuity benefits are scheduled to commence.

(v) Each plan type referenced in this paragraph shall be defined as follows:

(A)

"Plan type A." A plan in which at any time the policyholder may withdraw funds only:

(I) with an adjustment to reflect changes in interest rates or asset values since receipt of the funds by the insurance company;

(II) without an adjustment but in installments over five years or more; (III) as an immediate life annuity; or (IV) no withdrawal permitted.

(B)

"Plan type B." A plan in which, before expiration of the interest rate guarantee, the policyholder may withdraw funds only:

(I) with an adjustment to reflect changes in interest rates or asset values since receipt of the funds by the insurance company; (II) without an adjustment but in installments over five years or more; or (III) no withdrawal permitted. At the end of interest rate guarantee, funds may be withdrawn without an adjustment in a single sum or installments over less than five years.

(C)

"Plan type C." A plan in which the policyholder may withdraw funds before expiration of interest rate guarantee in a single sum or installments over less than five years either:

(I) without adjustment to reflect changes in interest rates or asset values since receipt of the funds by the insurance company; or (II) subject only to a fixed surrender charge stipulated in the contract as a percentage of the fund.

(vi) The following shall apply:

(A) A company may elect to value guaranteed interest contracts with cash settlement options and annuities with cash settlement options on either an issue year basis or on a change in fund basis.

(B) Guaranteed interest contracts with no cash settlement options and other annuities with no cash settlement options shall be valued on an issue year basis.

(C) As used in this section:

(I) An issue year basis of valuation shall refer to a valuation basis under which the interest rate used to determine the minimum valuation standard for the entire duration of the annuity or guaranteed interest contract is the calendar year valuation interest rate for the year of issue or year of purchase of the annuity or guaranteed interest contract. (II) A change in fund basis of valuation shall refer to a valuation basis under which the interest rate used to determine the minimum valuation standard applicable to each change in the fund held under the annuity or guaranteed interest contract is the calendar year valuation interest rate for the year of the change in the fund.

(d) Reference interest rate.--The reference interest rate referred to in subsection (b) shall be defined as follows:

(1) For life insurance, the lesser of the average over a period of 36 months and the average over a period of 12 months, ending on June 30 of the calendar year preceding the year of issue, of the monthly average of the composite yield on seasoned corporate bonds, as published by Moody's Investors Service, Inc.

(2) For single premium immediate annuities and for annuity benefits involving life contingencies arising from

other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, the average over a period of 12 months, ending on June 30 of the calendar year of issue or year of purchase, of the monthly average of the composite yield on seasoned corporate bonds, as published by Moody's Investors Service, Inc.

(3) For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on a year of issue basis, except as stated in paragraph (2), with guarantee duration in excess of 10 years, the lesser of the average over a period of 36 months and the average over a period of 12 months, ending on June 30 of the calendar year of issue or purchase, of the monthly average of the composite yield on seasoned corporate bonds, as published by Moody's Investors Service, Inc.

(4) For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on a year of issue basis, except as stated in paragraph (2), with guarantee duration of 10 years or less, the average over a period of 12 months, ending on June 30 of the calendar year of issue or purchase, of the monthly average of the composite yield on seasoned corporate bonds, as published by Moody's Investors Service, Inc.

(5) For other annuities with no cash settlement options and for guaranteed interest contracts with no cash settlement options, the average over a period of 12 months, ending on June 30 of the calendar year of issue or purchase, of the monthly average of the composite yield on seasoned corporate bonds, as published by Moody's Investors Service, Inc.

(6) For other annuities with cash settlement options and guaranteed interest contracts with cash settlement options, valued on a change in fund basis, except as stated in paragraph (2), the average over a period of 12 months, ending on June 30 of the calendar year of the change in the fund, of the monthly average of the composite yield on seasoned corporate bonds, as published by Moody's Investors Service, Inc.

(e) Alternative method to determine reference interest rate.--If the monthly average of the composite yield on seasoned corporate bonds is no longer published by Moody's Investors Service, Inc. or if NAIC determines that the monthly average of the composite yield on seasoned corporate bonds as published by Moody's Investors Service, Inc. is no longer appropriate for the determination of the reference interest rate, then an alternative method for determination of the reference interest rate adopted by NAIC and approved by regulation may be substituted. Cross References. Section 7117 is referred to in sections 7103, 7111, 7115, 7116, 7118, 7122, 7151 of this title.
40 Pa.C.S. § 3701 — PA Code / Title 40 / Chapter 37 / Section 3701
Purpose of chapter.
Status: in_force

The purpose of this chapter is to require the complete and proper disclosure, transparency and accountability relating to a method of payment for life insurance death benefits regulated by the Insurance Department.
40 Pa.C.S. § 6125 — PA Code / Title 40 / Chapter 61 / Section 6125
Reports and examinations.
Status: in_force

(a) Annual report.--Every hospital plan corporation shall on or before March 1 of each year, file with the department a statement, verified by at least two of the principal officers of the corporation showing its condition at the end of the preceding calendar year. Such statement shall be in such form, and shall contain such matters, as the department shall prescribe.

(b) Examination.--Every hospital plan corporation shall be subject to examination not less frequently than every three years by the department and its agents, who shall have free access to all the books, records, papers and documents that relate to the business of the corporation, and the power to examine the officers, agents, employees and subscribers to the nonprofit hospital plan of the corporation, under oath, in relation to the affairs, transactions and financial condition of the corporation. Such examinations shall be made at such times as the department shall deem necessary.
40 Pa.C.S. § 5008 — PA Code / Title 40 / Chapter 50 / Section 5008
Alternative methods of delivery.
Status: in_force

(a) Alternative methods.--An insurer shall deliver a notice or document to a covered person by any other method that was authorized by Federal or State law before the effective date of this subsection other than delivery by electronic means if either of the following occurs:

(1) The insurer attempts to deliver the notice or document by electronic means and has a reasonable basis for

believing that the notice or document has not been received by the covered person.

(2) The insurer becomes aware that the email address provided by the covered person to the insurer is no longer valid.

(b) Confidentiality.--Nothing in this chapter shall be construed to preclude the ability of a covered person to request confidential communication of the covered person's protected health information as permitted by the Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191, 110 Stat. 1936).

(c) Construction.--Nothing in this chapter shall be construed to preclude the ability of an insurer to deliver a notice or document to a covered person by any method authorized by Federal or State law.
40 Pa.C.S. § 4705 — PA Code / Title 40 / Chapter 47 / Section 4705
Policy disclosures.
Status: in_force

(a) Information.--A pet insurer shall clearly and conspicuously disclose, in accordance with subsection (b), the following information to an insured or a prospective insured in a pet insurance policy:

(1) Whether the pet insurance policy excludes coverage due to any of the following:

(i) A preexisting condition.

(ii) A hereditary disorder.

(iii) A congenital anomaly or disorder.

(iv) A chronic condition.

(2) If the pet insurance policy includes any other exclusions, the following statement: "Other exclusions may apply. Please refer to the exclusions section of the policy for more information."

(3) Any limitation of coverage through a waiting period or affiliation period.

(4) Any deductible or coinsurance.

(5) The annual or lifetime policy limit of the pet insurance policy, if any.

(6) Whether the pet insurer will reduce coverage or increase premiums based on the insured's claim history, the age of the covered pet or a change in the geographic location of the insured.

(7) The name of the underwriting company if it differs from the brand name used to market and sell the product.

(8) A summary description of the basis or formula on which the pet insurer determines claim payments under the pet insurance policy.

(9) If a pet insurer uses a benefit schedule to determine claim payment under the pet insurance policy:

(i) The applicable benefit schedule in the pet insurance policy.

(ii) All benefit schedules used by the pet insurer under its pet insurance policies.

(10) If a pet insurer determines claim payments under a pet insurance policy based on usual and customary fees, or any other reimbursement limitation based on prevailing veterinary service provider charges:

(i) The usual and customary fee limitation provision in the pet insurance policy that clearly describes the pet insurer's basis for determining usual and customary fees and how that basis is applied in calculating claim payments.

(ii) The pet insurer's basis for determining usual and customary fees.

(11) If any medical examination by a veterinarian is required to effectuate coverage, the required aspects of the examination and a statement that the examination documentation may result in a preexisting condition exclusion.

(12) Clear and prominent disclosure of waiting periods, if any, and requirements applicable to them.

(b) Methods of disclosure.--

(1) A pet insurer shall prepare a separate document in at least 12-point type that contains the information specified under subsection (a) and in section 4704 (relating to right to examine and return pet insurance policy), which shall be titled "Insurer Disclosure of Important Policy Provisions." The following apply:

(i) The pet insurer shall post the document through a clear and conspicuous link on the main page of the publicly accessible Internet website of the pet insurer or pet insurer's program administrator.

(ii) The pet insurer shall provide the insured a copy of the document upon issuance or delivery of the pet insurance policy.

(2) A pet insurer shall disclose the information required under subsection (a)(8), (9) and (10) in the language of the pet insurance policy itself.

(3) A pet insurer shall disclose the information required under subsection (a)(8), (11) and (12) prior to the issuance of the pet insurance policy.

(4) The information specified under subsection (a)(8),

(9) and (10) shall be posted through a clear and conspicuous link on the main page of the publicly accessible Internet website of the pet insurer or pet insurer's program administrator.

(c) Additional information.--At the time that a pet insurance policy is issued or delivered to an insured, the pet insurer shall include a written disclosure with the following information, printed in 12-point boldface type:

(1) The department's mailing address, toll-free telephone number and website address.

(2) The address and customer service telephone number of the pet insurer or the agent or broker of record.

(3) If the pet insurance policy was issued or delivered by an agent or broker, a statement advising the insured to contact the broker or agent for assistance.

(d) Other requirements.--The disclosures required in this section shall be in addition to any other disclosure requirements required by law or regulation. Cross References. Section 4705 is referred to in section 4706 of this title.
40 Pa.C.S. § 3302 — PA Code / Title 40 / Chapter 33 / Section 3302
Opt-out for abortion.
Status: in_force

(a) Prohibition.--The Commonwealth of Pennsylvania hereby elects pursuant to the authority granted the states under section 1303(a) of the Patient Protection and Affordable Care Act (Public Law 111-148, 42 U.S.C. § 18023(a)) to prohibit certain abortion coverage in qualified health plans offered through the health insurance exchange under subsection (b).

(b) Included coverage prohibition.--No qualified health plan offered in this Commonwealth through the health insurance exchange shall include coverage for the performance of any abortion unless the reason the abortion is performed is one for which the expenditure of public funds would be permitted under 18 Pa.C.S. § 3215(c) (relating to publicly owned facilities; public officials and public funds).

(c) Excluded coverage prohibited.--No qualified health plan offered in this Commonwealth through a health insurance exchange shall exclude coverage for:

(1) Treatment of any postabortion complication.

(2) Treatment of any miscarriage or any complication related to a miscarriage.

(d) Option.--Nothing in this section shall prohibit an individual from purchasing optional supplemental abortion coverage provided the individual pays a separate premium for the coverage and obtains the coverage outside of the health insurance exchange.
40 Pa.C.S. § 4512 — PA Code / Title 40 / Chapter 45 / Section 4512
Risk assessment.
Status: in_force

A licensee shall conduct a risk assessment, which must:

(1) Identify reasonably foreseeable internal or external threats that could result in unauthorized access, transmission, disclosure, misuse, alteration or destruction of nonpublic information, including the security of information systems and nonpublic information that are accessible to, or held by, third-party service providers.

(2) Assess the likelihood and potential damage of threats, taking into consideration the sensitivity of the nonpublic information.

(3) Assess the sufficiency of policies, procedures, information systems and other safeguards in place to manage threats in each relevant area of the licensee's operations, including:

(i) Employee training and management.

(ii) Information systems, including network and software design and information classification,

governance, processing, storage, transmission and disposal.

(iii) Detection, prevention and response to attacks, intrusions or other system failures.

(4) Implement information safeguards to manage the threats identified in its ongoing assessment.

(5) At least annually, assess the effectiveness of the safeguards' key controls, systems and procedures. Cross References. Section 4512 is referred to in sections 4502, 4514, 4516, 4521, 4532, 4536 of this title.
40 Pa.C.S. § 9514 — PA Code / Title 40 / Chapter 95 / Section 9514
Immunity.
Status: in_force

(a) General rule.--Except as provided in subsection (b), the department, a Commonwealth agency or person or entity under contract with the department for the reinsurance program, or an authorized representative, agent or employee of any of them, may not be subject to civil or criminal liability and no cause of action of any nature shall arise for any action taken or not taken, including any discretionary decision or failure to make a discretionary decision, when the action or inaction is done in good faith and in the performance of the powers and duties under this chapter, or for the reasonable and good faith use of any information pertaining to the reinsurance program.

(b) Exception.--This section shall not prohibit legal actions against the reinsurance program to enforce the reinsurance program's statutory or contractual duties or obligations. Cross References. Section 9514 is referred to in section 9505 of this title.
40 Pa.C.S. § 3909 — PA Code / Title 40 / Chapter 39 / Section 3909
Rules and regulations.
Status: in_force

The department may promulgate rules and regulations and issue orders necessary to administer and enforce this chapter.
40 Pa.C.S. § 3506 — PA Code / Title 40 / Chapter 35 / Section 3506
Effective date of plan.
Status: in_force

A plan is effective when the following have been completed:

(1) The commissioner has approved the plan.

(2) The eligible subscribers have approved the plan.

(3) If the stock company becomes successor to the reciprocal insurer by merger, the eligible subscribers have approved the merger of the reciprocal insurer with and into the stock company and the articles of merger have been filed with the Secretary of the Commonwealth.
40 Pa.C.S. § 6302 — PA Code / Title 40 / Chapter 63 / Section 6302
Definitions.
Status: in_force

(a) General rule.--The following words and phrases when used in this chapter shall have, unless the context clearly indicates otherwise, the meanings given to them in this section:

"Ancillary health services." The general and usual services rendered and care administered by ancillary health service providers as defined herein.

"Ancillary health service providers." The following persons duly licensed or certified under the laws of this Commonwealth to provide ancillary health services: Clinical laboratory permittees as defined in the act of September 26, 1951 (P.L.1539, No.389), known as The Clinical Laboratory Act.

"Chiropractic services." The general and usual services rendered and care administered by doctors of chiropractic, as defined in the act of August 10, 1951 (P.L.1182, No.264), known as the Chiropractic Registration Act of 1951.

"Clinical social work services." The general and usual services rendered and care administered by licensed clinical social workers, as defined by the "practice of clinical social work" in the act of July 9, 1987 (P.L.220, No.39), known as the Social Workers, Marriage and Family Therapists and Professional Counselors Act.

"Dental service corporation." A corporation not-for-profit engaged in the business of maintaining and operating a nonprofit dental service plan.

"Dental services." The general and usual services rendered and care administered by doctors of dental surgery, as defined in the act of May 1, 1933 (P.L.216, No.76), known as The Dental Law.

"Department of Health." The Department of Health of the Commonwealth.

"General medical service corporation." A corporation not-for-profit engaged in the business of maintaining and operating a nonprofit professional health service plan.

"Health care facility." As defined in the act of July 19, 1979 (P.L.130, No.48), known as the Health Care Facilities Act.

"Health service doctor." Any health care professional duly licensed or certified under Commonwealth statute regulating a particular branch of health care practice, including, but not limited to, doctor of dental surgery, doctor of medicine, doctor of optometry, doctor of osteopathy, doctor of podiatry, doctor of chiropractic, licensed physical therapist, licensed clinical social worker, licensed occupational therapist, licensed marriage and family therapist, licensed professional counselor, certified registered nurse anesthetist, certified registered nurse practitioner, certified enterostomal therapy nurse, certified community health nurse, certified psychiatric mental health nurse, certified clinical nurse specialist, licensed psychologist, licensed speech-language pathologist, licensed audiologist or licensed teacher of persons who are hearing impaired.

"Income." Net income from gains, profits and net income derived from professions, vocations, trades, businesses, commerce or sales, or dealings in property, whether real or personal, growing out of the ownership or use of or interest in such property, also from interest, rent, dividends, securities, or the transaction of any business carried on for gain or profit, or gains or profits and income derived from any source whatever and income derived from salaries, wages or compensation for personal service of whatever kind and in whatever form paid.

"Licensed marriage and family therapy services." The general and usual services rendered and care administered by persons licensed pursuant to 49 Pa. Code Ch. 48 (relating to State Board of Social Workers, Marriage and Family Therapists and Professional Counselors-Licensure of Marriage and Family Therapists).

"Licensed professional counseling services." The general and usual services rendered and care administered by persons licensed pursuant to 49 Pa. Code Ch. 49 (relating to State Board of Social Workers, Marriage and Family Therapists and Professional Counselors-Licensure of Professional Counselors).

"Low income." Low income as set forth in section 6325 (relating to income status and effect).

"Medical services." The general and usual services rendered and care administered by doctors of medicine, as defined in the act of December 20, 1985 (P.L.457, No.112), known as the Medical Practice Act of 1985.

"Nonprofit dental service plan." A plan whereby for prepayment, periodical or lump sum payment dental services only may be provided to persons of low income or over-income and their dependents.

"Nonprofit optometric service plan." A plan whereby for prepayment, periodical or lump sum payment optometric services only may be provided to persons of low income and over-income and their dependents.

"Nonprofit professional health service plan." A plan whereby for prepayment, periodical or lump sum payment professional health services may be provided to persons of low income or over-income and their dependents. The term does not include a plan which is primarily a nonprofit dental service plan or a nonprofit optometric service plan.

"Occupational therapy services." The general and usual services rendered and care administered by licensed occupational therapists, as defined by "occupational therapy" in the act of June 15, 1982 (P.L.502, No.140), known as the Occupational Therapy Practice Act.

"Optometric service corporation." A corporation not-for-profit engaged in the business of maintaining and operating a nonprofit optometric service plan.

"Optometric services." The general and usual services rendered and care administered by doctors of optometry, as defined in the act of June 6, 1980 (P.L.197, No.57), known as the Optometric Practice and Licensure Act.

"Osteopathic services." The general and usual services rendered and care administered by doctors of osteopathy, as defined in the act of October 5, 1978 (P.L.1109, No.261), known as the Osteopathic Medical Practice Act.

"Over-income." Over-income as set forth in section 6325 (relating to income status and effect).

"Person with dependents." Any person who furnishes other persons with their chief support, whether or not such dependent person is related to or living with him.

"Physical therapy services." The general and usual services rendered and care administered by licensed physical therapists, as defined as "physical therapy" in the act of October 10, 1975 (P.L.383, No.110), known as the Physical Therapy Practice Act.

"Podiatry services." The general and usual services rendered and care administered by doctors of podiatry, as defined in the act of March 2, 1956 (1955 P.L.1206, No.375), known as the Podiatry Practice Act.

"Professional health service corporation." A dental service corporation, a general medical service corporation, or an optometric service corporation.

"Professional health services." Professional services provided by a duly licensed health service doctor, provided that the services are medically necessary.

"Psychological services." The general and usual services rendered and care administered by licensed psychologists as defined as the "practice of psychology" in the act of March 23, 1972 (P.L.136, No.52), known as the Professional Psychologists Practice Act. "Speech-language pathology services," "audiology services" and "services of teachers of persons who are hearing impaired." The general and usual services rendered and care administered by licensed speech-language pathologists, licensed teachers of persons who are hearing impaired or licensed audiologists, as defined in the act of December 21, 1984 (P.L.1253, No.238), known as the Speech-Language and Hearing Licensure Act.

"Subscribers of low income." Persons of low income who subscribe to a nonprofit professional health service plan, a nonprofit dental service plan or a nonprofit optometric service plan.

"Subscribers of over-income." Persons of over-income who subscribe to a nonprofit professional health service plan, a nonprofit dental service plan or a nonprofit optometric service plan.

(b) Rule of construction.--The definitions specified in subsection (a) are for the purposes of this chapter only and not for the purpose of defining dental practice, medical practice, optometric practice, osteopathic practice, podiatry practice, chiropractic practice, physical therapy practice, psychological practice, speech-language pathology practice, audiology practice or the practice of teaching persons who are hearing impaired as such. (Oct. 10, 1980, P.L.801, No.151, eff. 90 days; Mar. 30, 1982, P.L.220, No.70, eff. imd.; Nov. 17, 1982, P.L.681, No.193, eff. 60 days; Apr. 20, 1988, P.L.363, No.57, eff. 60 days; Apr. 21, 1994, P.L.124, No.14, eff. 60 days; Oct. 9, 2008, P.L.1393, No.108, eff. 120 days) 2008 Amendment. Act 108 amended the defs. of "health service doctor" and "professional health services" and added the defs. of "clinical social work services," "licensed marriage and family therapy services," "licensed professional counseling services" and "occupational therapy services." References in Text. The act of August 10, 1951, P.L.1182, No.264, known as the Chiropractic Registration Act of 1951, referred to in the def. of "chiropractic services," was repealed by the act of December 16, 1986, P.L.1646, No.188, known as the Chiropractic Practice Act. Cross References. Section 6302 is referred to in section 102 of Title 15 (Corporations and Unincorporated Associations).
40 Pa.C.S. § 4703 — PA Code / Title 40 / Chapter 47 / Section 4703
Use of definitions in pet insurance policy.
Status: in_force

(a) Terms.--If a pet insurer uses any of the terms in section 4702 (relating to definitions) in a pet insurance policy, the definition under section 4702 shall apply and the pet insurer shall include the definition of the term in the pet insurance policy.

(b) Website.--A pet insurer shall make each definition described in subsection (a) available through a clear and conspicuous link on the main page of the publicly accessible Internet website of the pet insurer or pet insurer's program administrator.

(c) Construction.--Nothing in this chapter shall:

(1) prohibit or limit the types of exclusions that a pet insurer may use in a pet insurance policy; or

(2) require a pet insurer to have any of the limitations or exclusions described in this chapter.
40 Pa.C.S. § 4901 — PA Code / Title 40 / Chapter 49 / Section 4901
Definitions.
Status: in_force

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Commissioner." The Insurance Commissioner of the Commonwealth.

"Covered person." A policyholder, subscriber or other individual who is entitled to receive health care services under a health insurance policy.

"Credit card payment." A type of electronic funds transfer in which a health insurer or its contracted vendor issues a single-use series of numbers associated with the payment of covered health care services performed by a health care provider and chargeable at a predetermined rate for which the health

care provider is responsible for processing the payment by a credit card terminal or Internet portal. The term includes virtual or online credit card payments for which no physical card is presented to the health care provider and the single-use credit card expires upon payment processing.

"Dental insurance policy." An insurance policy that pays or provides dental expense benefits for covered dental services and is delivered or issued for delivery by or through a dental insurer. The term includes coverage for dental benefits issued either on a stand-alone basis or integrated, or otherwise incorporated into the terms and coverage of a health insurance policy.

"Dental insurer." An entity that offers, issues or renews a dental insurance policy that covers dental services provided by a dentist and that is governed under any of the following:

(1) The act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, including section 630 and Article XXIV.

(2) The act of December 29, 1972 (P.L.1701, No.364), known as the Health Maintenance Organization Act.

(3)
40 Pa.C.S. § 7125 — PA Code / Title 40 / Chapter 71 / Section 7125
Valuation manual for policies issued on or after operative date of valuation manual.
Status: in_force

(a) Standard in valuation manual.--Except as provided in subsection (c) or (e), for policies issued on or after the operative date of the valuation manual, the standard prescribed in the valuation manual shall be the minimum standard of valuation required under section 7112 (relating to reserve valuation for policies and contracts issued on or after operative date of valuation manual).

(b) Specific information in valuation manual.--The valuation manual shall specify:

(1) Minimum valuation standards for and definitions of the policies or contracts subject to section 7112, which shall be:

(i) The commissioners reserve valuation method for life insurance contracts other than annuity contracts.

(ii) The commissioners annuity reserve valuation method for annuity contracts.

(iii) Minimum reserves for all other policies or contracts.

(2) Which policies or contracts or types of policies or contracts are subject to the requirements of a principle-based valuation in section 7126(a) (relating to requirements of principle-based valuation) and the minimum valuation standards consistent with those requirements.

(3) For policies and contracts subject to a principle-based valuation under section 7126:

(i) Requirements for the format of reports to the commissioner under section 7126(b)(3), including information necessary to determine if the valuation is appropriate and in compliance with this chapter.

(ii) Assumptions prescribed for risks over which the company does not have significant control or influence.

(iii) Procedures for corporate governance and oversight of the actuarial function and a process for appropriate waiver or modification of those procedures.

(4) For policies not subject to a principle-based valuation under section 7126, the minimum valuation standard, which shall:

(i) be consistent with the minimum standard of valuation prior to the operative date of the valuation manual; or

(ii) develop reserves that quantify the benefits, guarantees and the funding associated with the contracts and their risks at a level of conservatism that reflects conditions that include unfavorable events having a reasonable probability of occurring.

(5) Other requirements, including those relating to reserve methods, models for measuring risk, generation of economic scenarios, assumptions, margins, use of company experience, risk measurement, disclosure, certifications, reports, actuarial opinions and memorandums, transition rules and internal controls.

(6) The data and form of the data required under section 7127 (relating to experience reporting for policies in force on or after operative date of valuation manual) and with whom the data must be submitted. The valuation manual may specify other requirements, including data analyses and reporting of analyses.

(c) Absent or noncompliant valuation requirement.--In the absence of a specific valuation requirement or if a specific valuation requirement in the valuation manual is not, in the opinion of the commissioner, in compliance with this chapter, the company shall, with respect to those requirements, comply with minimum valuation standards prescribed by the commissioner by regulation.

(d) Actuarial examination and review.--The following shall apply:

(1) The commissioner may engage a qualified actuary, at the expense of a company, to:

(i) perform an actuarial examination of the company and opine on the appropriateness of any reserve assumption or method used by the company; or

(ii) review and opine on the company's compliance with any requirement under this chapter.

(2) The commissioner may rely on the opinion regarding provisions contained in this chapter of a qualified actuary engaged by the commissioner of another state, district or territory of the United States.

(3) As used in this subsection, the term "engage" shall include employment and contracting.

(e) Change, adjustment and disciplinary action.--The commissioner may require a company to change any assumption or method or adjust company reserves if, in the opinion of the commissioner, the change or adjustment is necessary to comply with the requirements of the valuation manual or this chapter. The commissioner may take disciplinary action as permitted by law. Cross References. Section 7125 is referred to in sections 7103, 7112, 7131, 7141 of this title.
40 Pa.C.S. § 4803 — PA Code / Title 40 / Chapter 48 / Section 4803
Insurance coverage of telemedicine.
Status: in_force

(a) General rule.--

(1) A health insurance policy offered, issued or renewed in this Commonwealth shall provide coverage for medically necessary health care services provided through telemedicine and delivered by a participating network provider who

provides a covered health care service through telemedicine consistent with the insurer's medical policies. A health insurance policy may not exclude a health care service from coverage solely because the health care service is provided through telemedicine.

(2) Subject to paragraph (1), an insurer shall pay or reimburse a participating network provider for covered health care services delivered through telemedicine and pursuant to a health insurance policy in accordance with the terms and conditions of the contract as negotiated between the insurer and the participating network provider. A contract that includes payment or reimbursement for covered health care services delivered through telemedicine may not prohibit payment or reimbursement solely because a health care service is provided by telemedicine. Payment or reimbursement may not be conditioned upon the use of an exclusive or proprietary telemedicine technology or vendor.

(b) Applicability.--

(1) Subsection (a) does not apply if the telemedicine-enabling device, technology or service fails to comply with the Health Insurance Portability and Accountability Act of 1996, the Health Information Technology for Economic and Clinical Health Act or other applicable statute, regulation or guidance.

(2) For a health insurance policy for which either rates or forms are required to be filed with the Federal Government or the department, this section shall apply to a policy for which a form or rate is first filed on or after 180 days after the effective date of this paragraph.

(3) For a health insurance policy for which neither rates nor forms are required to be filed with the Federal Government or the department, this section shall apply to a policy issued or renewed on or after 180 days after the effective date of this paragraph.

(c) Construction.--This section may not be construed to:

(1) Prohibit an insurer from paying or reimbursing other health care providers for covered health care services provided through telemedicine.

(2) Require an insurer to pay or reimburse an out-of-network health care provider for health care services provided through telemedicine.

(3) Require an insurer to pay or reimburse a participating network provider if the provision of the health care service through telemedicine would be inconsistent with the standard of care.
40 Pa.C.S. § 6305 — PA Code / Title 40 / Chapter 63 / Section 6305
Initial reserves.
Status: in_force

No professional health service corporation shall receive a certificate of authority under this chapter unless it has set up a minimum reserve of $25,000 for the exclusive purpose of meeting the contractual obligations of its subscribers. All or any part of such $25,000 may be in the form of borrowed money to be repaid in whole or in part from surplus. Money borrowed to satisfy the requirements of this section may be repaid only

when authorized by two-thirds of the board of directors of such corporation in office and the Insurance Department.
40 Pa.C.S. § 3512 — PA Code / Title 40 / Chapter 35 / Section 3512
Reciprocal insurer insolvent or in hazardous financial condition.
Status: in_force

(a) Waiver of requirements.--If a reciprocal insurer seeking to convert is insolvent or is in hazardous financial condition according to information supplied in its most recent annual or quarterly statement filed with the department or as determined by a financial examination performed by the department under
40 Pa.C.S. § 3510 — PA Code / Title 40 / Chapter 35 / Section 3510
Failure to give notice.
Status: in_force

If the reciprocal insurer complies substantially and in good faith with the notice requirements of this chapter, the reciprocal insurer's failure to send a subscriber the required notice does not impair the validity of an action taken under this chapter.
40 Pa.C.S. § 6307 — PA Code / Title 40 / Chapter 63 / Section 6307
Exemptions applicable to certificated professional health service corporations.
Status: in_force

(a) General insurance laws.--A professional health service corporation shall be subject to regulation and supervision by the Department of Health and the Insurance Department under this chapter. A professional health service corporation holding a certificate of authority under this chapter shall not be subject to the laws of this Commonwealth now in force relating to the business of insurance, and no statute hereafter enacted relating to the business of insurance shall apply to such a corporation unless such statute shall specifically refer and apply to a corporation subject to this chapter.

(b) Tax laws.--Every professional health service corporation holding a certificate of authority under this chapter is hereby declared to be a charitable and benevolent institution, and all its income, funds, investments and property shall be exempt from all taxation by the Commonwealth or its political subdivisions.
40 Pa.C.S. § 6101 — PA Code / Title 40 / Chapter 61 / Section 6101
Definitions.
Status: in_force

The following words and phrases when used in this chapter shall have, unless the context clearly indicates otherwise, the meanings given to them in this section:

"Hospital plan corporation." A corporation not-for-profit engaged in the business of maintaining and operating a nonprofit hospital plan.

"Nonprofit hospital plan." A plan whereby for prepayment, periodical or lump sum payment hospitalization or related health benefits may be provided to subscribers to such plan.

Cross References. Section 6101 is referred to in section 6301 of this title; section 102 of Title 15 (Corporations and Unincorporated Associations).
40 Pa.C.S. § 6127 — PA Code / Title 40 / Chapter 61 / Section 6127
Dissolution or liquidation.
Status: in_force

No hospital plan corporation shall be dissolved under the provisions of Title 15 (relating to corporations and unincorporated associations) or under any other provision of law except with the prior approval of the department. Articles of dissolution for a hospital plan corporation filed in the Department of State, whether pursuant to a decree of court liquidating the corporation or otherwise, shall not be effective unless and until approved by the Insurance Department. Any dissolution or liquidation of a hospital plan corporation shall be under the supervision of the department, which shall have all powers with respect thereto granted to it under laws of this Commonwealth governing the dissolution or liquidation of insurance companies.
40 Pa.C.S. § 9103 — PA Code / Title 40 / Chapter 91 / Section 9103
Definitions.
Status: in_force

Subject to additional definitions contained in subsequent provisions of this part which are applicable to specific

provisions of this part, the following words and phrases when used in this part shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Affordable Care Act." The Patient Protection and Affordable Care Act (Public Law 111-148, 124 Stat. 119), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152, 124 Stat. 1029).

"Attachment point." The threshold amount for claims costs incurred by an eligible insurer for an enrolled individual's covered benefits in a benefit year, above which the claims costs for benefits are eligible for reinsurance payments under this part.

"Benefit year." The calendar year during which an eligible insurer provides coverage through a health care plan.

"Board." The governing body of the exchange authority.

"Children's Health Insurance Program." The children's health insurance program under Article XXIII-A of the act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921.

"Coinsurance rate." The percentage rate at which the reinsurance program will reimburse an eligible insurer for claims incurred for an enrollee's covered benefits in a benefit year above the attachment point and below the reinsurance cap.

"Commissioner." The Insurance Commissioner of the Commonwealth.

"Department." The Insurance Department of the Commonwealth.

"Eligible insurer." An insurer offering reinsurance-eligible health care plans to consumers in this Commonwealth.

"Enrollee." A policyholder, certificate holder, subscriber, covered person or other individual who is enrolled to receive health care services pursuant to a health insurance policy.

"Exchange." A health insurance exchange as contemplated by the Affordable Care Act, established or operating in this Commonwealth, that facilitates or assists in facilitating enrollment in qualified plans.

"Exchange assister." The term has the meaning given to it in section 2 of the act of June 19, 2015 (P.L.25, No.7), known as the Navigator and Exchange Assister Accessibility and Regulation Act.

"Exchange authority." The Pennsylvania Health Insurance Exchange Authority established under section 9302(a) (relating to Pennsylvania Health Insurance Exchange Authority).

"Exchange fund." The Pennsylvania Health Insurance Exchange Fund established under section 9312 (relating to exchange fund).

"Federal acts." The Affordable Care Act and any amendments thereto, and related provisions of the Public Health Service Act (58 Stat. 682, 42 U.S.C. § 201 et seq.).

"Government program." A program of government sponsored or subsidized health care coverage, including:

(1) A premium tax credit or cost-sharing subsidy under the Federal acts.

(2) Coverage under Medicare Parts A and B or Medicare Advantage Part C under Title XVIII of the Social Security Act (49 Stat. 620, 42 U.S.C. § 1395 et seq.).

(3) A TRICARE or other health care plan provided through the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) as defined under 10 U.S.C. § 1072 (relating to definitions).

(4) A health care plan provided through the Federal Employees Health Benefits Program established under 5 U.S.C. Ch. 89 (relating to health insurance).

(5) The Commonwealth's medical assistance program established under the act of June 13, 1967 (P.L.31, No.21), known as the Human Services Code.

(6) The Children's Health Insurance Program.

(7) Health care coverage provided by the Commonwealth, a county, a city, or other State or local governmental entity or an agency, subdivision or department of a governmental entity, including:

(i) a corporation or other arrangement organized by the entity for the provision of health care coverage and subject to control by the entity or an instrumentality of one or more of them;

(ii) the Pennsylvania Employee Benefit Trust Fund for active and retired employees; and

(iii) benefit programs administered by the Department of Corrections.

"Grandfathered health care plan." Individual or group health insurance coverage in which an individual was enrolled prior to the date of enactment of the Affordable Care Act, or as otherwise specified in section 1251 of the Affordable Care Act (Public Law 111-148, 42 U.S.C. § 18011).

"Health care plan." A package of coverage benefits with a particular cost-sharing structure, network and service area that is purchased through a health insurance policy.

"Health insurance policy." A policy, subscriber contract, certificate or plan issued by an insurer that provides hospital or medical/surgical health care coverage. The term does not include any of the following:

(1) An accident only policy.

(2) A credit only policy.

(3) A long-term care or disability income policy.

(4) A specified disease policy.

(5) A Medicare supplement policy.

(6) A fixed indemnity policy.

(7) An adult-only dental only policy.

(8) A vision only policy.

(9) A workers' compensation policy.

(10) An automobile medical payment policy.

(11) A policy under which benefits are provided by the Federal Government to active or former military personnel and their dependents.

(12) Any other similar policies providing for limited benefits.

"Hospital plan corporation." An entity organized and operating under Chapter 61 (relating to hospital plan corporations).

"Individual market." The market for health insurance coverage offered to individuals other than in connection with a group.

"Innovation waiver." A waiver applied for pursuant to section 1332 of the Affordable Care Act (Public Law 111-148, 42 U.S.C. § 18052).

"Insurance producer." The term has the meaning given to it in section 601-A of the act of May 17, 1921 (P.L.789, No.285), known as The Insurance Department Act of 1921.

"Insurer." An entity that offers, issues or renews an individual or group health, accident or sickness insurance policy, contract or plan, and that is governed under any of the following:

(1)
40 Pa.C.S. § 7124 — PA Code / Title 40 / Chapter 71 / Section 7124
Minimum standard for accident and health insurance contracts.
Status: in_force

(a) Annual valuation of reserve liabilities.--On an annual basis as of the December 31 of the preceding year, the commissioner shall value or cause to be valued, or require the insurer to value or cause to be valued the reserve liabilities of each company doing business in this Commonwealth, with respect to all the accident and health insurance contracts of the company.

(b) Issuances after operative date of valuation manual.--For accident and health insurance contracts issued on or after the operative date of the valuation manual, the standard prescribed in the valuation manual shall be the minimum standard of valuation required under section 7112 (relating to reserve valuation for policies and contracts issued on or after operative date of valuation manual).

(c) Issuances prior to operative date of valuation manual.--For accident and health insurance contracts issued on or after May 17, 1921, and prior to the operative date of the valuation manual, the following shall apply:

(1) The minimum standard of valuation shall be the standard adopted by the commissioner by regulation.

(2) The company shall maintain a claim reserve for incurred but unpaid claims and an active life reserve that shall:

(i) place a sound value on its liabilities under these contracts; and

(ii) be not less than the reserve according to appropriate standards as prescribed by regulation.

(3) The active life reserve shall not be less in the aggregate than the pro rata gross unearned premiums for the contracts.

(d) Foreign or alien insurers.--For a foreign or alien insurer, the commissioner may accept a like valuation of the insurance supervising official of the state, province or foreign country in which that insurer is domiciled, if that valuation is made upon a basis and according to standards producing an aggregate reserve not less than contained in this chapter.

(e) Applicability.--This section shall not apply to total and permanent disability benefits supplementary to life insurance or annuity policies or contracts. Cross References. Section 7124 is referred to in sections 7103, 7112, 7115, 7118 of this title.
40 Pa.C.S. § 6322 — PA Code / Title 40 / Chapter 63 / Section 6322
Scope of service.
Status: in_force

(a) Territory of service.--The certificate of authority of a professional health service corporation shall define the limits of the area in which it may operate. If the corporation is deemed to be a holder of a certificate of authority under section 6304(b) of this title (relating to exemptions), the articles of incorporation of the corporation on the effective date of this chapter, regardless of any subsequent amendment to such articles, shall be deemed to be its initial certificate of authority for the purposes of this section.

(b) Classes and kinds of services.--The certificate of authority, bylaws, or resolutions of the board of directors of a professional health service corporation may limit the professional health services that will be provided for its subscribers, and may divide such professional health services

as it elects to provide into classes or kinds, and it may enter into contracts with its subscribers or groups of subscribers to secure professional health services of any kind or class so delimited. A general medical services corporation shall make available to its subscribers or groups of subscribers, upon request of any individual for his individual subscriptions or any group for its group subscriptions, contracts which provide coverage for professional health services with appropriate premiums.

(c) Services provided only by licensed persons.--A professional health service corporation shall not provide professional health services for its subscribers otherwise than through health service doctors, duly licensed to practice in their respective fields under the laws of this Commonwealth.

(d) Services provided only to domiciliaries.--A professional health service corporation shall provide professional health services only to persons domiciled within this Commonwealth. If a subscriber, regularly domiciled within this Commonwealth and entitled to professional health services, or any of his dependents so entitled, necessarily employs professional health services within the meaning of this chapter, while absent from this Commonwealth, a professional health service corporation to which he is a subscriber may, in its discretion, and if satisfied as to the necessity for such services and satisfied that it was such as the subscriber would have been entitled to under similar circumstances in this Commonwealth, pay to the persons who rendered the services such fees and charges as would have been payable if the services had been rendered in this Commonwealth. A professional health service corporation organized under the laws of, and operating near the boundaries of, this Commonwealth may, with the consent of the proper officers of and as authorized by the laws of the adjacent state, provide professional health services therein; but all operations of any such corporation, whether within or without this Commonwealth, shall remain at all times subject to the provisions of this chapter.

(e) Liability of corporation limited.--All professional health services provided by or on behalf of a professional health service corporation shall be in accordance with the best professional health service practice in the community at the time, but the corporation providing such services shall not be liable for injuries resulting from negligence, misfeasance, malfeasance, nonfeasance, or malpractice, on the part of any officer or employee or on the part of any health service doctor in the course of rendering professional health services to subscribers, and the corporation may so provide in its contracts with subscribers.

(f) Legislative amendment of stated purposes of existing corporations.--The stated purposes of all existing general medical service corporations are hereby amended so as to include the furnishing of osteopathic, dental, optometric, podiatry, chiropractic, physical therapy, clinical social work, occupational therapy, psychological, speech-language pathology and audiology services and the services of teachers of persons who are hearing impaired through doctors of osteopathy, dentistry, optometry, podiatry and chiropractic and through licensed physical therapists, licensed clinical social workers, licensed marriage and family therapists, licensed occupational therapists, licensed professional counselors, psychologists, speech-language pathologists, audiologists and teachers of persons who are hearing impaired, respectively.

(Oct. 10, 1980, P.L.801, No.151, eff. 90 days; Mar. 30, 1982, P.L.220, No.70, eff. imd.; Apr. 20, 1988, P.L.363, No.57, eff. 60 days; Apr. 21, 1994, P.L.124, No.14, eff. 60 days; Oct. 9, 2008, P.L.1393, No.108, eff. 120 days) 2008 Amendment. Act 108 amended subsec. (f). 1980 Amendment. Act 151 amended subsecs. (b) and (f). Cross References. Section 6322 is referred to in section 6324 of this title.
40 Pa.C.S. § 6331 — PA Code / Title 40 / Chapter 63 / Section 6331
Reports and examinations.
Status: in_force

(a) Annual report.--Every professional health service corporation shall, on or before March 1 of each year, file with the department a statement, verified by at least two of the principal officers of the corporation, summarizing its financial activities during the preceding calendar year, and showing its financial condition at the end of that year. Such statement shall be in such form, and shall contain such matters, as the department shall prescribe.

(b) Examination and special reports.--Every professional health service corporation shall be subject to examination not less frequently than once in every three years by the department and its agents, who shall have free access to all the books, records, papers and documents that relate to the business of the corporation, and the power to examine the officers, agents, employees, and subscribers for the professional health services of the corporation, and all health service doctors registered with the corporation, and all other persons having or having had substantial part in the work of the corporation, in relation to its affairs, transactions, and financial condition. Such examination shall be made at such times as the department shall deem necessary. The department may, at any time, without making such examination, call on any such corporation for a written report, authenticated by at least two of its principal officers, concerning the financial affairs and status of the corporation.
40 Pa.C.S. § 4517 — PA Code / Title 40 / Chapter 45 / Section 4517
Investigation of cybersecurity event.
Status: in_force

(a) Requirement.--If a licensee discovers that a cybersecurity event has or may have occurred regarding the licensee, the licensee or an outside vendor or service provider designated to act on behalf of the licensee shall conduct a prompt investigation.

(b) Determination.--During an investigation under this section, the licensee or an outside vendor or service provider designated to act on behalf of the licensee shall, at a minimum, do as much of the following as possible:

(1) Determine whether a cybersecurity event has occurred.

(2) Assess the nature and scope of the cybersecurity event.

(3) Identify any nonpublic information that may have been involved in the cybersecurity event.

(4) Perform or oversee reasonable measures to restore the security of the information systems compromised in the cybersecurity event in order to prevent further unauthorized acquisition, release or use of nonpublic information in the licensee's possession, custody or control.

(c) Third-party service provider.--If the licensee learns that a cybersecurity event has or may have occurred in a system maintained by a third-party service provider, the licensee shall complete the steps specified in subsection (b) or confirm and document that the third-party service provider has completed those steps.

(d) Records.--A licensee shall maintain records concerning all cybersecurity events for a period of at least five years from the date of the cybersecurity event and shall produce those records upon demand of the commissioner.

Cross References. Section 4517 is referred to in section 4535 of this title.
40 Pa.C.S. § 3911 — PA Code / Title 40 / Chapter 39 / Section 3911
Severability.
Status: in_force

(a) General rule.--Except as provided in subsection (b):

(1) The provisions of this chapter are severable.

(2) If a provision of this chapter or its application to a person or circumstance is held invalid, the invalidity does not affect other provisions or applications of this chapter that can be given effect without the invalid provision or application.

(b) Exception.--If the addition of section 3907 (relating to confidentiality) is held invalid, independent of its application to a person or circumstance, the remaining provisions or applications of this chapter are void.
40 Pa.C.S. § 9701 — PA Code / Title 40 / Chapter 97 / Section 9701
Regulations.
Status: in_force

(a) Authority to promulgate.--The department and the exchange authority may promulgate regulations as may be necessary and appropriate to carry out the provisions of this part.

(b) Omission of proposed rulemaking.--The General Assembly finds and declares as follows:

(1) This part is essential to:

(i) the provision of health care for the citizens of this Commonwealth; and

(ii) the financial viability of the health care system in this Commonwealth.

(2) The finding and declaration under paragraph (1) constitutes good cause for the omission of notice of proposed rulemaking under section 204(3) of the act of July 31, 1968 (P.L.769, No.240), referred to as the Commonwealth Documents Law.
40 Pa.C.S. § 6126 — PA Code / Title 40 / Chapter 61 / Section 6126
Solicitors and agents.
Status: in_force

Solicitors and agents for every hospital plan corporation shall meet the prerequisites provided by law for agents of insurance companies.
40 Pa.C.S. § 6326 — PA Code / Title 40 / Chapter 63 / Section 6326
Specifically authorized contract provisions.
Status: in_force

A professional health service corporation may, as a condition precedent to entering into a contract with an applicant or group of applicants for professional health service, require any of the following:

(1) A physical examination of the applicant and of each of his dependents, if any, and proof of his or their substantial freedom from any disease or condition requiring immediate professional health service or likely to require it within the next 12 months, before a contract becomes effective.

(2) A waiting period after a contract is entered into and before the subscriber is entitled to professional health service.

(3) An agreement that the subscriber or someone on his behalf shall pay the stated fee or fees for professional health services in the case of any given illness or injury or other condition requiring professional health service, before becoming entitled to treatment under the terms of the contract.

(4) An agreement that, as a condition precedent to payment by the corporation for professional health services performed for the subscriber, the subscriber or someone on his behalf will submit to the corporation such information as is reasonably necessary to enable it to determine the amount of such payment, which information shall be submitted in the form and verified in the manner prescribed by the corporation.

(5) An agreement that any rights of the subscriber to receive services or payments under his contract with the corporation are personal to the subscriber and may not be assigned.
40 Pa.C.S. § 9309 — PA Code / Title 40 / Chapter 93 / Section 9309
Nonliability.
Status: in_force

(a) General rule.--Except as provided under subsection (b), there shall be no liability on the part of and no cause of action of any nature may arise against the exchange authority, board or advisory council or members thereof, the commissioner, the department, an insurer, insurance producer or an exchange

assister or an authorized representative, agent or employee thereof, for the use of information furnished pertaining to:

(1) An application for, inquiry concerning or enrollment or disenrollment in a health insurance policy or government program, including an inquiry regarding eligibility for enrollment or eligibility for a government program, relevant to health insurance available through an exchange or health care coverage or other benefits through a government program.

(2) A charge, assessment or fee imposed on or received from a person or entity relevant to the exchange.

(b) Limitation.--Subsection (a) shall apply only insofar as the person or entity is acting within the scope of the person's or entity's duties and responsibilities under this chapter.
40 Pa.C.S. § 5002 — PA Code / Title 40 / Chapter 50 / Section 5002
Definitions.
Status: in_force

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Covered person." An individual who is entitled to receive health care services under a health benefit plan.

"Deliver by electronic means." Any of the following:

(1) The delivery to an email address at which a covered person has consented to receive a notice or document from an insurer.

(2) A post on an electronic network or website accessible via the Internet, mobile device or application, tablet or any other electronic device, administered by an insurer, including a separate notice of the post by delivery to an email address at which a covered person has consented to receive a notice or document or by any other delivery method that has been consented by the covered person, which contains the Internet address at which the notice or document is posted. For purposes of this definition, delivery shall be effective upon the post or actual delivery of the separate notice of the post as specified under this paragraph.

"ERISA." Employee Retirement Income Security Act of 1974 (Public Law 93-406, 88 Stat. 829).

"Health benefit plan." A policy, contract, certificate or agreement entered into, offered by or issued by an insurer to provide, deliver or arrange for, pay for or reimburse any of the costs of health care services, including a vision or dental benefit plan.

"Insurer." An entity licensed by the department with authority to issue a health benefit plan that is governed under any of the following:

(1) The act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, including section 630 and Article XXIV.

(2) The act of December 29, 1972 (P.L.1701, No.364), known as the Health Maintenance Organization Act.

(3)
40 Pa.C.S. § 6325 — PA Code / Title 40 / Chapter 63 / Section 6325
Income status; effect.
Status: in_force

(a) Income standards.--

(1) Every professional health service corporation shall from time to time, by action of its members, fix the requisites for persons of low income eligible for the benefits of and under this chapter, such requisites to afford due consideration to the marital status and to the number of dependents of the persons involved and such requisites to be consistent with the declaration contained in section 6303(a) of this title (relating to declaration of necessity). Any requisites thus fixed shall be subject to the approval of the department.

(2) All persons not meeting the requisites for persons of low income as thus fixed shall be persons of over-income.

(b) Determination of status.--

(1) The professional health service corporation shall determine whether an applicant for subscription is in receipt of a low income or over-income within the meaning of this chapter and after the application has been approved, the subscriber shall be deemed to be of low income or over-income until his status has been redetermined by the corporation, which redetermination may be made at any time.

(2) The professional health service corporation, in determining the income status of any applicant or subscriber, may, through its officers and agents, examine under oath any applicant or subscriber claiming a low income status and any other person consenting thereto who is believed to have material knowledge concerning the income status of the applicant or subscriber. The determination of the corporation shall be final.

(c) Effect of status.--Every person of low income and every person of over-income, residing in the area served by a professional health service corporation, shall be entitled, upon complying with regulations adopted by that corporation and the payment of such initiation and other fees as are authorized by the department, to the services of any health service doctor registered with the corporation, under such terms and conditions as are customary in professional health services in the community, but only within the limits of services for which such health service doctors are registered. A professional health service corporation may for cause refuse to enter into contractual relations with an applicant and may, for cause, after due notice and opportunity for hearing, rescind any contract that it has entered into with any subscriber and refund any unearned portion of any fees paid and may, on default in payment of the agreed dues, fees, payments or any charges by subscriber or someone on his behalf, discontinue coverage without notice and opportunity for hearing, after having notified a subscriber of his default, and having allowed him two days to procure such coverages. Any payment made by the corporation to health service doctors for services rendered to subscribers of over-income shall be a payment only to the extent agreed upon between the corporation and the health service doctors on account of any greater sum which may be due the health service doctors for rendering such services.

(d) Prohibited contracts.--No contract by or on behalf of any professional health service corporation shall provide for any periodic payment or any other payment by that corporation to a subscriber which is not related to the value of the service provided to such subscriber on account of illness or injury, nor be in any way related to the payment of any such benefit by any other entity. Cross References. Section 6325 is referred to in section 6302 of this title.
40 Pa.C.S. § 7120 — PA Code / Title 40 / Chapter 71 / Section 7120
Minimum reserves.
Status: in_force

(a) Amount calculated.--A company's aggregate reserves for all life insurance policies, excluding disability and accidental death benefits, issued on or after May 17, 1921, shall not be less than the aggregate reserves calculated by using the mortality table or tables and rate or rates of interest used in calculating nonforfeiture benefits for the policies and in accordance with the methods set forth in:

(1) Section 7118 (relating to reserve valuation method for life insurance and endowment benefits).

(2) Section 7119 (relating to reserve valuation method for annuity and pure endowment benefits).

(3) Section 7122 (relating to reserve calculation for valuation net premium exceeding gross premium charged).

(4) Section 7123 (relating to reserve calculation for indeterminate premium plans).

(b) Amount necessary to render actuarial opinion.--The aggregate reserves for all policies, contracts and benefits shall not be less than the aggregate reserves determined by the appointed actuary to be necessary to render the opinion required by section 7113 (relating to actuarial opinion of reserves prior to operative date of valuation manual) or 7114 (relating to actuarial opinion of reserves on or after operative date of valuation manual). Cross References. Section 7120 is referred to in section 7103 of this title.
40 Pa.C.S. § 4005 — PA Code / Title 40 / Chapter 40 / Section 4005
Application of chapter.
Status: in_force

(a) Prescription drugs.--This chapter does not apply to prescription drugs that are:

(1) unit-of-use packaging for which medication synchronization is not possible; or

(2) controlled substances classified in Schedule II under section 4(2) of the act of April 14, 1972 (P.L.233, No.64), known as The Controlled Substance, Drug, Device and Cosmetic Act.

(b) Health insurance policies.--This chapter shall apply to health insurance policies as follows:

(1) For a health insurance policy for which either rates or forms are required to be filed with the Federal Government or the Insurance Department, this chapter shall apply to a health insurance policy for which a form or rate is first permitted to be used on or after the effective date of this section.

(2) For a health insurance policy for which neither rates nor forms are required to be filed with the Federal Government or the Insurance Department, this chapter shall apply to a health insurance policy issued or renewed on or after the effective date of this section.
40 Pa.C.S. § 5104 — PA Code / Title 40 / Chapter 51 / Section 5104
Pilot or testing program.
Status: in_force

If an insurer or insurance producer does not have sufficient evidence but has a good faith belief that the product or service meets the criteria specified under section 5102(b)(5)(ii) (relating to rebates and inducements), the insurer or insurance producer may provide the product or service to consumers in a manner that is not unfairly discriminatory as part of a pilot or testing program for no more than one year. The following apply:

(1) The insurer or insurance producer shall notify the department of the pilot or testing program prior to launching the pilot or testing program.

(2) The insurer or insurance producer may proceed with the pilot or testing program unless the department objects within 21 business days of the submission of a description of the pilot or testing program to the department.
40 Pa.C.S. § 3904 — PA Code / Title 40 / Chapter 39 / Section 3904
Contents of CGAD.
Status: in_force

(a) Contents.--The CGAD must contain the material information necessary to permit the department to gain an understanding of the insurer's or insurance group's corporate governance structure, policies and practices. The commissioner

shall consider premium volume, licensing status in other states and corporate complexity and scale when evaluating the comprehensiveness of a company's CGAD.

(b) Discretion.--The insurer or insurance group shall have discretion over the contents of the CGAD if the CGAD includes all of the following information:

(1) A description of the insurer's or insurance group's corporate governance framework, including all of the following:

(i) The board and committees of the board that are ultimately responsible for oversight of the filing entity.

(ii) The level or levels at which board or committee oversight occurs, such as the ultimate controlling parent level, an intermediate holding company level or the individual legal entity level or some combination of these levels.

(iii) The rationale for the current board size and structure.

(iv) The duties of the board and each of its significant committees.

(v) The method of board and committee governance, such as bylaws, charters or informal mandates.

(vi) The structure of the board's leadership.

(vii) A discussion of the roles of the chief executive officer and chairman of the board or their functional counterparts within the organization.

(2) Policies and practices of the board of directors or the most senior governing entity and significant committees of the board or entity, including a discussion of the following factors:

(i) The way in which the qualifications, expertise and experience of each board member meet the needs of the filing entity.

(ii) The method for maintaining an appropriate amount of independence on the board and its significant committees.

(iii) The number of meetings held by the board and its significant committees over the past year as well as information on board member attendance.

(iv) The way in which the filing entity identifies, nominates and elects members to the board and its committees. Factors discussed may include whether a nominating committee exists, whether term limits are placed on directors, how the election and reelection processes function and whether a board diversity policy is in place and, if so, how it functions.

(v) The processes in place for the board to evaluate its performance and the performance of its committees, as well as any recent measures taken to improve performance, including any board or committee training programs.

(3) Policies and practices for directing senior management, including a description of any processes, practices or suitability standards used to determine whether officers and key persons in control functions have the appropriate background, experience and integrity to fulfill their prospective roles. The description shall identify:

(i) The following:

(A) The specific positions for which suitability standards have been developed and a description of the standards employed.

(B) Procedures in place to monitor any changes in an officer's or key person's suitability, as outlined by the filing entity's standards and procedures to monitor and evaluate such changes.

(ii) The filing entity's code of business conduct and ethics, including a discussion of compliance with laws, rules and regulations, and proactive reporting of any illegal or unethical behavior.

(iii) The filing entity's plans for senior management succession.

(iv) The filing entity's processes for performance evaluation, compensation and corrective action to ensure effective senior management throughout the organization, including a description of the general objectives of significant compensation programs and what the programs are designed to reward. The description shall include sufficient detail to allow the department to understand how the organization ensures that compensation programs neither encourage nor reward excessive risk-taking. Elements to be discussed may include any of the following:

(A) The board's role in overseeing management compensation programs and practices.

(B) The various elements of compensation awarded in the filing entity's compensation programs.

(C) The method by which the filing entity determines and calculates the amount of each element of compensation paid.

(D) The way in which compensation programs are related to both company and individual performance over time.

(E) Whether compensation programs include risk adjustments and, if so, how those adjustments are incorporated into the programs for employees at different levels.

(F) Any clawback provisions built into the programs to recover awards or payments if the performance measures upon which they are based are restated or otherwise adjusted.

(G) Any other factors relevant in understanding how the filing entity monitors its compensation policies to determine whether its risk management objectives are met by incentivizing its employees.

(4) A description of the processes by which the board, its committees and senior management ensure an appropriate amount of oversight over critical risk areas impacting the insurer or insurance group's business activities, including a discussion of the following:

(i) The way in which oversight and management responsibilities are delegated among the board, its committees and senior management.

(ii) The way in which the board remains informed of the filing entity's strategic plans, the associated risks and steps that senior management is taking to monitor and manage those risks.

(iii) The way in which reporting responsibilities are organized for each critical risk area. The description should allow the department to understand the frequency at which information on each critical risk area is reported to and reviewed by senior management and the board. This description may include the following critical risk areas of the insurer:

(A) Risk management processes.

(B) Actuarial function.

(C) Investment decision-making processes.

(D) Reinsurance decision-making processes.

(E) Business strategy.

(F) Finance decision-making processes.

(G) Compliance function.

(H) Financial reporting.

(I) Internal auditing.

(J) Market conduct decision-making processes.

(5) Any other information as specified by regulation.

(c) Additional information.--The department may request additional information regarding the items provided under subsection (b) that are material and necessary to provide a clear understanding of the corporate governance policies, the reporting or information system or the controls implementing those policies. An insurer or insurance group shall maintain and make available supporting information upon examination or upon the request of the department.

(d) Permissible levels of reporting.--

(1) For purposes of completing the CGAD, the insurer or insurance group may provide information regarding corporate governance at the ultimate controlling parent level, an intermediate holding company level or the individual legal entity level, or some combination thereof, depending upon how the insurer or insurance group has structured its system of corporate governance. When determining which level to choose, the insurer or insurance group shall consider the level at which any of the following occurs:

(i) The insurer's or insurance group's risk appetite is determined.

(ii) Earnings, capital, liquidity, operations and reputation of the insurer or insurance group are overseen collectively and at which the supervision of those factors are coordinated and exercised.

(iii) Legal liability for failure of general corporate governance duties would be placed.

(2) An insurer or insurance group that determines the level of reporting based on any of the criteria under paragraph (1) shall indicate which of the criteria was used to determine the level of reporting and explain any subsequent changes in level of reporting.

(e) Attestation.--The CGAD must include a signature of the insurer or insurance group's chief executive officer or corporate secretary attesting to the best of that individual's belief and knowledge that the insurer or insurance group has implemented the corporate governance practices and that a copy of the disclosure has been provided to the insurer or insurance group's board of directors or the appropriate committee of the board.
40 Pa.C.S. § 7127 — PA Code / Title 40 / Chapter 71 / Section 7127
Experience reporting for policies in force on or after operative date of valuation manual.
Status: in_force

A company shall submit to the commissioner, or the commissioner's designee or agent, mortality, morbidity, policyholder behavior or expense experience and other data as prescribed in the valuation manual. Cross References. Section 7127 is referred to in sections 7102, 7125 of this title.
40 Pa.C.S. § 3806 — PA Code / Title 40 / Chapter 38 / Section 3806
Tolling.
Status: in_force

An insurer may request medical or billing records in writing from a health care provider under section 3803 (relating to retroactive denial of reimbursement). The health care provider shall provide the necessary records to the insurer within 60 days of the request. The period of time in which the health care provider is gathering the requested documentation shall be added to the 24-month period.
40 Pa.C.S. § 6122 — PA Code / Title 40 / Chapter 61 / Section 6122
Action as agent under Federal and other programs.
Status: in_force

(a) General rule.--Any hospital plan corporation may, with the approval of the department, act as a contracting agency or organization under section 1841 of Title XVIII of the Federal Social Security Act, as amended or supplemented, with power to perform all the services which may be required of a contracting

agency or organization thereunder and may perform administrative services similar or related to those which may be required of an agency or organization thereunder in connection with a Federal, State or local governmental health care program and may perform administrative services similar or related to those which may be required of such an agency or organization in connection with or associated with nongovernmental organizations, individuals, groups and agencies in the health care field.

(b) Legislative amendment of stated purposes of existing corporations.--The stated purposes of all existing hospital plan corporations are hereby amended so as to include the performance of the activities authorized by subsection (a) of this section.
40 Pa.C.S. § 9303 — PA Code / Title 40 / Chapter 93 / Section 9303
Advisory council.
Status: in_force

(a) Establishment.--An advisory council is created to advise the exchange authority under section 9304(g) (relating to meetings and operation).

(b) Composition.--The advisory council shall consist of the following members, who may not be in the employ of the Commonwealth:

(1) Four consumer representatives which include two representatives appointed by the Governor at least one of whom shall be a registered insurance exchange navigator or assister, one appointed by the President pro tempore of the Senate and one appointed by the Speaker of the House of Representatives.

(2) One representative selected by the Hospital and Healthsystem Association of Pennsylvania.

(3) One representative selected by the Pennsylvania Medical Society.

(4) One representative selected by the Pennsylvania Chamber of Business and Industry from a small group employer.

(5) One representative selected by the Pennsylvania Association of Health Underwriters.
40 Pa.C.S. § 6309 — PA Code / Title 40 / Chapter 63 / Section 6309
Penalties.
Status: in_force

Any person who violates any provision of this chapter or of any regulation or order of the Department of Health or of the Insurance Department made pursuant thereto, any person who hinders or prevents the Department of Health or the Insurance Department in the discharge of any duty imposed on it by this chapter, any person who fraudulently procures or attempts to procure any benefit from any professional health service corporation holding a certificate of authority under this chapter, and any person who willfully makes any false statement in any proceeding or report under this chapter, shall be guilty

of a misdemeanor, and, upon conviction thereof, shall be sentenced to pay a fine of not more than $3,000 or to be imprisoned for not more than six months, or both, in the discretion of the court. Any act or default by any corporation, association, or common law trust, in violation of any provision of this chapter or of any regulation or order of either department made pursuant thereto, shall be deemed to be the act or default of the officers or directors who participated in authorizing or effecting such act or default or who knowingly permitted it.
40 Pa.C.S. § 3301 — PA Code / Title 40 / Chapter 33 / Section 3301
Definitions.
Status: in_force

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Abortion." The term shall have the same meaning given to it in 18 Pa.C.S. § 3203 (relating to definitions).

"Complication." The term shall have the same meaning given to it in 18 Pa.C.S. § 3203 (relating to definitions).

"Health insurance exchange." The term shall mean an insurance system established to comply with section 1311(b) or 1321(c) of the Patient Protection and Affordable Care Act (Public Law 111-148, 42 U.S.C. § 18031(b) or 18041(c)).
40 Pa.C.S. § 7111 — PA Code / Title 40 / Chapter 71 / Section 7111
Reserve valuation for policies and contracts issued prior to operative date of valuation manual.
Status: in_force

(a) Applicability.--This section shall apply to each policy or contract issued prior to the operative date of the valuation manual.

(b) Annual valuation.--The commissioner shall annually value, or cause to be valued, the reserve liabilities for all outstanding life insurance policies and annuity and pure endowment contracts of each company doing business in this Commonwealth. The commissioner may certify the amount of reserves.

(c) Calculation.--In calculating reserves, the commissioner may use group methods and approximate averages for fractions of a year or otherwise.

(d) Other jurisdictions.--In lieu of the valuation of the reserves required of a foreign or alien company, the commissioner may accept a valuation made, or caused to be made, by the insurance supervisory official of any state or other jurisdiction when the valuation complies with the minimum standard provided in this chapter.

(e) Minimum standard.--The minimum standard for the valuation of policies and contracts issued prior to the operative date of section 410A of The Insurance Company Law of 1921 shall be as follows:

(1) The net value of all outstanding policies of life insurance, issued by the company prior to January 1, 1890, shall be computed upon the basis of the American experience table of mortality, with interest at not less than 4.5% and not more than 6% per year.

(2) The net value of all outstanding policies, issued between January 1, 1890, and January 1, 1903, shall be computed on the combined experience or actuaries' table of mortality, with interest at 4% per year.

(3) The net value of all outstanding policies of life insurance, issued on and after January 1, 1903, shall be computed on the American experience table of mortality, with interest at 3.5% per year, but a company may value its group term insurance policies, under which premium rates are not guaranteed for a period in excess of five years, according to the American men ultimate table of mortality, with interest at 3.5% per year.

(4) The net value of all policies of life insurance, issued on and after January 1, 1921, where the premiums are payable monthly or more frequently, shall be computed according to the American experience table of mortality, with interest at 3.5% per year, but a company may voluntarily value its industrial policies according to the standard industrial mortality table, with interest at 3.5% per year.

(5) The net value of a policy at any time shall be taken to be the single net premium which will, at that time, affect the insurance, less the value at that time of the future net premiums called for by the table of mortality and rate of interest designated.

(6) Except as otherwise provided in sections 7116(a) (relating to computation of minimum standard for annuities) and 7117(a) (relating to computation of minimum standard by calendar year of issue) for group annuity and pure endowment contracts, the legal minimum standard for valuation of annuities issued after January 1, 1912, shall be computed according to McClintock's table of mortality among annuitants, with interest at 3.5% per year, but the following shall apply:

(i) For annuities and pure endowments purchased under group annuity and pure endowment contracts, the legal minimum standard may, at the option of the company, be computed according to the 1971 Group Annuity Mortality Table or any modification of this table approved by the commissioner, with interest at 5% per year.

(ii) Annuities deferred 10 or more years, and written in connection with life or term insurance, shall be valued upon the same mortality table from which the consideration or premiums were computed, with interest at not more than 3.5% per year.

(7) At any time and under any of its policies of life insurance, a company may elect to reserve on the following, with its obligations under these policies to be valued accordingly:

(i) the American experience table of mortality with a lower rate of interest, but at a rate not less than 2% per year; or

(ii) the American men ultimate table of mortality, with any modification and extension below 20 years of age as may be approved by the commissioner, with interest at a rate not less than 2% nor more than 3.5% per year.

(8) On or after the operative date of section 410A of The Insurance Company Law of 1921, reserves for any policies or contracts may be calculated, at the option of the company, according to any standard which produces greater aggregate reserves for all these policies or contracts than the standard in use by the company immediately prior to the exercise of the option.

(9) With the approval of the commissioner, a company that adopts a standard under paragraph (8) may adopt a lower standard of valuation for any policies or contracts if that lower standard is not lower than:

(i) the minimum reserves provided under this section;

(ii) the standard specified in the policies or contracts; or

(iii) the standard used by the company for the determination of the nonforfeiture values of the policies or contracts.
40 Pa.C.S. § 4004 — PA Code / Title 40 / Chapter 40 / Section 4004
Certain payment structures prohibited.
Status: in_force

(a) Prorated dispensing fees.--A health insurance plan providing prescription drug coverage may not use payment structures incorporating prorated dispensing fees.

(b) Full payment.--Dispensing fees for a partial supply or refilled prescriptions shall be paid in full for each maintenance medication dispensed, regardless of any prorated copay for the beneficiary or fee paid for alignment services.
40 Pa.C.S. § 3516 — PA Code / Title 40 / Chapter 35 / Section 3516
Amendment of policies.
Status: in_force

By endorsement or rider approved by the commissioner and sent to the policyholder, a reciprocal insurer may simultaneously with or after the adoption of a plan of conversion amend an outstanding insurance policy for the purpose of extinguishing a right of the holder of the policy to share in the surplus of the reciprocal insurer. This amendment shall be void if the plan of conversion is not submitted to the commissioner or, if submitted, is disapproved by the commissioner or, if approved by the commissioner, is not approved by the eligible subscribers on or before the first anniversary of its approval by the commissioner.
40 Pa.C.S. § 3504 — PA Code / Title 40 / Chapter 35 / Section 3504
Optional provisions of plan of conversion.
Status: in_force

(a) Subscription rights.--The plan may provide that the directors and officers of the attorney and the reciprocal insurer shall receive, without payment, nontransferable subscription rights to purchase capital stock of the stock company or the stock of another corporation that is participating in the conversion plan, as provided in section 3503(a)(3)(ii) (relating to contents of plan of conversion). The subscription rights shall be allocated among the directors and officers by a fair and equitable formula and shall be subordinate to the subscription rights of eligible subscribers. This chapter may not require the subordination of subscription rights received by directors and officers in their capacity as eligible subscribers.

(b) Maximum share purchase by directors and officers.--The aggregate total number of shares that may be purchased by directors and officers of the attorney and the reciprocal insurer in their capacity under subsection (a) and in their capacity as eligible subscribers under section 3503(a)(3) may not exceed 35% of the total number of shares to be issued if total assets of the reciprocal insurer are less than $50,000,000 or 25% of the total number of shares to be issued if total assets of the reciprocal insurer are more than $500,000,000. For reciprocal companies with total assets of or between $50,000,000 and $500,000,000, the percentage of the total number of shares that may be purchased shall be interpolated.

(c) Liquidation account.--The plan may provide for the creation of a liquidation account for the benefit of subscribers in the event of voluntary liquidation subsequent to conversion in an amount equal to the surplus of the reciprocal insurer, exclusive of the principal amount of a surplus note, on the last day of the quarter immediately preceding the date of adoption of the plan. Cross References. Section 3504 is referred to in sections 3502, 3503 of this title.
40 Pa.C.S. § 3703 — PA Code / Title 40 / Chapter 37 / Section 3703
Death master file comparison.
Status: in_force

(a) Comparison.--An insurer shall implement procedures for performing a comparison of its insureds' in-force life insurance policies, contracts and retained asset accounts against the same death master file, on at least a semiannual basis, by using the full death master file once and thereafter using the death master file update files for future comparison to identify potential matches of its insureds. For a potential match identified as a result of a death master file match, all of the following shall apply:

(1) Within 90 days of a death master file match the insurer shall:

(i) complete a good faith effort to confirm the death of the insured or retained asset account holder against other available records and information. The effort shall be documented by the insurer; and

(ii) determine whether benefits are due in accordance with the applicable policy or contract, and if benefits are due:

(A) use good faith efforts to locate the beneficiary or beneficiaries, which shall be documented by the insurer; and

(B) provide the appropriate claims forms or instructions to the beneficiary or beneficiaries to make a claim, including instructions on the need to provide an official death certificate, if applicable under the policy or contract.

(2) The insurer shall implement procedures to account for:

(i) common nicknames, initials used in lieu of a first or middle name, use of a middle name, compound first and middle names and interchanged first and middle names;

(ii) compound last names, maiden or married names and hyphens, blank spaces or apostrophes in last names;

(iii) transposition of the month and date portions of the date of birth; and

(iv) incomplete Social Security numbers.

(3) To the extent permitted by law, the insurer may disclose minimum necessary personal information about the insured or beneficiary to a person who the insurer reasonably believes may be able to assist the insurer with locating the beneficiary or a person otherwise entitled to payment of the claims proceeds.

(b) Costs.--An insurer or its service provider may not charge an insured, a retained asset account holder, a beneficiary or other authorized representative for costs associated with a search or verification conducted in accordance with subsection (a).

(c) Payment.--

(1) The benefits from a policy, contract or retained asset account, plus applicable accrued contractual interest, shall first be paid to the designated beneficiaries or owners.

(2) If the beneficiary cannot be found, the benefits shall escheat to the Commonwealth as unclaimed property pursuant to Article XIII.1 of the act of April 9, 1929 (P.L.343, No.176), known as The Fiscal Code, and, notwithstanding the provisions of section 1301.4(a)1 of The Fiscal Code, shall be due and reportable to the Commonwealth three years after knowledge of death of the insured.

(d) Group life insurance.--An insurer shall confirm the possible death of an insured if the insurer maintains at least the following information regarding those covered under a policy or certificate:

(1) Social Security number or name and date of birth;

(2) beneficiary designation information;

(3) coverage eligibility;

(4) benefit amount; and

(5) premium payment status.

(e) Exceptions and exemptions.--At the written request of an insurer, the commissioner may make an order to:

(1) limit the insurer's death master file comparisons required under this section to the insurer's electronic searchable files or approve a plan and timeline for conversion of the insurer's files to searchable electronic files, upon a demonstration of hardship by the insurer;

(2) exempt the insurer from the death master file comparisons required under this section or permit the insurer to perform the comparisons less frequently than annually, upon a demonstration of hardship by the insurer; or

(3) phase in compliance with this section according to a plan and timeline submitted by the insured and approved by the commissioner. Cross References. Section 3703 is referred to in section 3702 of this title.
40 Pa.C.S. § 6105 — PA Code / Title 40 / Chapter 61 / Section 6105
Penalties.
Status: in_force

Any person who violates any of the provisions of this chapter, or any regulation or order of the department made pursuant thereto, any person who hinders or prevents the department in the discharge of any duty imposed on it by this chapter, any person who fraudulently procures or attempts to procure any benefit from any hospital plan corporation holding a certificate of authority under this chapter, and any person who willfully makes any false statement in any proceeding or report under this chapter, shall be guilty of a misdemeanor, and, upon conviction thereof, shall be sentenced to pay a fine of not more than $3,000 or to be imprisoned for not more than six months, or both, in the discretion of the court. Any act or default by any corporation, association, or common law trust, in violation of any provision of this chapter or of any regulation or order of the department made pursuant thereto, shall be deemed to be the act or default of the officers or directors who participated in authorizing or effecting such act or default or who knowingly permitted it.
40 Pa.C.S. § 3501 — PA Code / Title 40 / Chapter 35 / Section 3501
Definitions.
Status: in_force

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Attorney." The person that manages and acts as the attorney-in-fact for the reciprocal insurer.

"Commissioner." The Insurance Commissioner of the Commonwealth.

"Department." The Insurance Department of the Commonwealth.

"Eligible subscriber." A subscriber of a reciprocal insurer whose policy is in force on at least one of the following dates:

(1) the date the reciprocal insurer or its attorney adopts a plan of conversion; or

(2) if a different date, on the record date for establishing subscribers eligible to vote on the plan of conversion.

"Participating policy." A policy that grants a holder the right to receive dividends if, as and when declared by the reciprocal insurer.

"Person." An individual, a corporation, a limited liability company, a partnership, an association, a joint stock company, a trust, an unincorporated organization, a similar entity or a combination of the foregoing acting in concert. "Plan of conversion" or "plan." A plan adopted under this chapter to convert the reciprocal insurer into a stock company by the subscribers' advisory committee or an equivalent governing body of the reciprocal insurer or, in the absence of a governing body, by the board of directors or governing body of the attorney for the reciprocal insurer.

"Policy." An insurance policy issued by the reciprocal insurer.

"Reciprocal insurer." A Pennsylvania-domiciled reciprocal and inter-insurance exchange, as established in Article X of the act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, that is authorized to write medical professional liability insurance and at least 50% of its direct written premium in the calendar year preceding adoption of the plan of conversion consisted of medical professional liability insurance.

"Stock company." An insurance company that:

(1) meets the requirements for admission to do business as a domestic Pennsylvania insurer;

(2) is formed at the direction of the reciprocal insurer or attorney; and

(3) shall be the successor of the reciprocal insurer by the merger of the reciprocal insurer with and into the stock company or by another means approved by the commissioner.
40 Pa.C.S. § 5009 — PA Code / Title 40 / Chapter 50 / Section 5009
Limitation on civil liability.
Status: in_force

An insurer or plan sponsor shall not be civilly liable under this chapter.
40 Pa.C.S. § 4304 — PA Code / Title 40 / Chapter 43 / Section 4304
Regulations.
Status: in_force

The department may promulgate regulations necessary to implement this chapter.
40 Pa.C.S. § 6303 — PA Code / Title 40 / Chapter 63 / Section 6303
Statement of legislative findings and policy.
Status: in_force

(a) Declaration of necessity.--It is hereby declared that adequate professional health services are essential for the maintenance of the physical and mental health of the residents of this Commonwealth, and that it is necessary that provision be made for adequate professional health services to persons of low income who are unable to provide such services for themselves or their dependents without depriving themselves or their dependents of such necessaries of life as food, clothing and shelter.

(b) Construction of chapter.--It is hereby declared to be the purpose and intent of this chapter and the policy of the General Assembly to authorize qualified persons to provide adequate professional health services for residents of this Commonwealth who are unable to provide such services for themselves or their dependents at their own cost without depriving themselves or their dependents of such necessaries of life as food, clothing and shelter, and provide persons of over-income with the limited professional health services benefits set forth in this chapter. Cross References. Section 6303 is referred to in section 6325 of this title.
40 Pa.C.S. § 7101 — PA Code / Title 40 / Chapter 71 / Section 7101
Scope of chapter.
Status: in_force

This chapter relates to standards for the valuation of reserve liabilities for life insurance, accident and health insurance and deposit-type contracts depending on their date of issuance.
40 Pa.C.S. § 4002 — PA Code / Title 40 / Chapter 40 / Section 4002
Prorated daily cost-sharing rate.
Status: in_force

A health insurance policy shall permit and apply a prorated daily cost-sharing rate to maintenance medications that are dispensed by a pharmacy as a partial supply if the pharmacist or prescriber determines the fill or refill to be in the best interest of the patient and the patient requests or agrees to a partial supply for the purpose of medication synchronization. The fill or refill under this section shall be limited to three times per year for each maintenance medication for a covered individual. For each clinically necessary synchronization thereafter, approval may be required at the discretion of the health insurance policy.
40 Pa.C.S. § 6103 — PA Code / Title 40 / Chapter 61 / Section 6103
Exemptions applicable to certified hospital plan corporations.
Status: in_force

(a) General insurance laws.--A hospital plan corporation holding a certificate of authority under this chapter shall not be subject to the laws of this Commonwealth now in force relating to the business of insurance, and no statute hereafter enacted relating to the business of insurance shall apply to such a corporation unless such statute shall specifically refer and apply to a corporation subject to this chapter.

(b) Tax laws.--Every hospital plan corporation holding a certificate of authority under this chapter is hereby declared to be a charitable and benevolent institution, and all its funds and investments shall be exempt from taxation by the Commonwealth and its political subdivisions.
40 Pa.C.S. § 6332 — PA Code / Title 40 / Chapter 63 / Section 6332
Regulation by Department of Health.
Status: in_force

(a) Annual reports.--Every professional health service corporation shall, on or before March 1 of each year, file with the Department of Health a report of its activities, other than its financial activities, during the preceding calendar year. Every such report shall be verified by at least two of the principal officers of the corporation and shall be in such form, and shall contain such matter, as the Department of Health shall prescribe. The Department of Health is hereby authorized to inquire into the activities of every professional health service corporation and to determine whether the corporation is providing adequate professional health services to its subscribers in accordance with the best professional health service practice in the community.

(b) Examination and special reports.--The Department of Health and its agents shall have free access to all the books, records, papers and documents that relate to the business of the corporation, other than financial, and the power to examine the officers, agents, employees, and subscribers for the professional health services of the corporation, and all health service doctors registered with the corporation, and all other persons having or having had substantial part in the work of the corporation, in relation to its affairs, transactions, and condition of the corporation, other than financial. Such examinations shall be made at such times as the Department of Health shall deem necessary. The Department of Health may, at any time, without making such examination, call on any such corporation for a written report, authenticated by at least two of its principal officers, concerning the affairs of the corporation other than its financial affairs.

(c) Extension or improvement of service pursuant to order.--In the event the Department of Health finds that a professional health service corporation does not provide adequate professional health services to its subscribers in accordance with the best professional health service practice in the community, the Department of Health may notify the corporation of its findings and order the corporation, in specific terms, to extend or improve the professional health services furnished by the corporation. Such order shall be entered after notice and opportunity for hearing and shall be subject to judicial review in the manner and within the time provided by law.
40 Pa.C.S. § 7136 — PA Code / Title 40 / Chapter 71 / Section 7136
No waiver of privilege or confidentiality.
Status: in_force

(a) Sharing of information by department.--The sharing of confidential information with or by the department as authorized by section 7134 (relating to use of confidential information by department) shall not constitute a waiver of any applicable privilege or claim of confidentiality in the documents, materials or information.

(b) Privilege established in other jurisdictions.--A privilege established under the law of any state or jurisdiction that is substantially similar to the privilege established under this subchapter shall be available and enforced in any proceeding in, and in any court of, this Commonwealth.
40 Pa.C.S. § 3903 — PA Code / Title 40 / Chapter 39 / Section 3903
Submittal of CGAD.
Status: in_force

(a) General rule.--

(1) Beginning January 1, 2020, a domestic insurer or an insurance group of which this Commonwealth is the lead state shall submit to the department a CGAD no later than June 1 of each calendar year.

(2) If a domestic insurer is a member of an insurance group of which this Commonwealth is not the lead state, the insurer shall submit the report required by this section to the commissioner of the lead state for the insurance group in accordance with the laws of the lead state.

(b) Exception.--An insurer or insurance group not required to submit a CGAD to the department under subsection (a) shall submit a copy of the most current version of its CGAD to the department upon the commissioner's request.

(c) Amendments.--Each year following the initial filing of the CGAD, the filing entity shall file an amended version of the previously filed CGAD indicating where changes have been made. If no changes were made in the information or activities reported by the filing entity, the filing should so state.

(d) Format.--The filing entity may exercise discretion regarding the appropriate format for providing the information required in this chapter and may customize the CGAD to provide the most relevant information necessary to permit the department to understand the corporate governance structure, policies and practices utilized by the filing entity. The department shall include a sample template on its publicly accessible Internet website.
40 Pa.C.S. § 6328 — PA Code / Title 40 / Chapter 63 / Section 6328
Board of directors.
Status: in_force

(a) Professional health service corporations generally.--The business of every professional health service corporation, except a general medical service corporation, shall be managed by a board of directors of at least nine persons, all of whom shall be residents of this Commonwealth.

(b) General medical service corporation.--

(1) A general medical service corporation shall be managed by a board of not less than 21, nor more than 36

members, all of whom shall be residents of this Commonwealth, and at no time shall the board be less than 50% subscribers who have coverage under a contract issued by the corporation, and who are generally representative of broad segments of subscribers covered under contracts issued by such corporation, whose background and experience indicate that they are qualified to act in the interests of such subscribers and who or whose spouse does not derive substantial income from the delivery or administration of health care.

(2) The bylaws of every general medical service corporation shall provide appropriate procedures for the nomination and election or appointment of the directors of the corporation and the nomination and election or appointment of committees of the board in such a manner that the interests of the subscribers of the corporation will be justly and reasonably represented.

(3) All directors of the corporation shall be members of the corporation.

(4) A health service doctor, who provides professional health services for the corporation's subscribers, may be a director but in no event shall be counted among the directors who represent subscribers.

(5) Every general medical service corporation shall within six months of the effective date of this act submit for review by the Insurance Commissioner and the Secretary of Health bylaws meeting the standards of this section. Whenever a general medical service corporation changes its bylaws, said change shall be submitted within 30 days to the commissioner and secretary for their review to determine whether such changes meet statutory standards of this section.

(6) In the event that the Insurance Commissioner or the Secretary of Health find, after notice to the corporation and hearing, that a general medical service corporation has not met the requirements of this section, the commissioner or secretary shall notify the corporation of the findings and order the corporation, in specific terms, to meet the requirements of this section. Such findings and order shall be subject to judicial review in the manner and within the time provided by law. (Apr. 28, 1978, P.L.202, No.53, eff. 60 days; Oct. 4, 1978, P.L.1001, No.211, eff. imd.)
40 Pa.C.S. § 3505 — PA Code / Title 40 / Chapter 35 / Section 3505
Alternative plan of conversion.
Status: in_force

A plan of conversion may be adopted that does not rely in whole or in part upon issuing nontransferable subscription rights to subscribers to purchase stock of the stock company if the commissioner finds that the plan does not prejudice the interests of the subscribers, is fair and equitable and is not

inconsistent with the purpose and intent of this chapter. An alternative plan may:

(1) Include the acquisition or merger of the stock company or a corporation participating in the conversion plan under section 3503(a)(3)(ii) (relating to contents of plan of conversion) by or into a domestic or foreign stock company.

(2) Provide for issuing stock, cash or other consideration to subscribers instead of subscription rights.

(3) Set forth another plan containing any other provisions approved by the commissioner.
40 Pa.C.S. § 4501 — PA Code / Title 40 / Chapter 45 / Section 4501
Scope of chapter.
Status: in_force

This chapter relates to insurance data security.
40 Pa.C.S. § 7133 — PA Code / Title 40 / Chapter 71 / Section 7133
Private civil actions.
Status: in_force

The commissioner, department or any person who receives documents, materials or other information while acting under the authority of the commissioner or department or with whom the documents, materials or other information are shared under this chapter may not be permitted or required to testify in any private civil action concerning any confidential information covered under this subchapter.
40 Pa.C.S. § 6330 — PA Code / Title 40 / Chapter 63 / Section 6330
Investment of funds.
Status: in_force

Any statute to the contrary notwithstanding, funds of any professional health service corporation, equal to its reserves, shall be invested in compliance with the requirements of law for the investment of the capital and reserves of life insurance companies. The funds of any such corporation, equal to its surplus, shall be invested in compliance with the requirements of law for the investment of the surplus of life insurance companies.
40 Pa.C.S. § 7118 — PA Code / Title 40 / Chapter 71 / Section 7118
Reserve valuation method for life insurance and endowment benefits.
Status: in_force

(a) Uniform insurance amount and premiums.--Except as otherwise provided in sections 7119 (relating to reserve valuation method for annuity and pure endowment benefits), 7122 (relating to reserve calculation for valuation net premium exceeding gross premium charged) and 7124 (relating to minimum standard for accident and health insurance contracts), for the life insurance and endowment benefits of policies providing for a uniform amount of insurance and requiring the payment of uniform premiums, reserves according to the commissioners reserve valuation method shall be the excess, if any, of the

present value, at the date of valuation, of the future guaranteed benefits provided for by those policies, over the then present value of any future modified net premiums therefor. The modified net premiums for a policy shall be the uniform percentage of the respective gross premiums for the benefits so that the present value, at the date of issue of the policy, of all modified net premiums shall be equal to the sum of the then present value of the benefits provided for by the policy and the excess of paragraph (1) over paragraph (2), as follows:

(1) A net level annual premium equal to the present value, at the date of issue, of the benefits provided for after the first policy year, divided by the present value, at the date of issue, of an annuity of one per year payable on the first and each subsequent anniversary of the policy on which a premium falls due. However, the net level annual premium shall not exceed the net level annual premium on the 19-year premium whole life plan for insurance of the same amount at an age one year greater than the age at issue of the policy.

(2) A net one-year term premium for the benefits provided for in the first policy year.

(b) First-year excess.--For a life insurance policy issued on or after January 1, 1985, for which the gross premium in the first policy year exceeds that of the second year and for which no comparable additional benefit is provided in the first year for the excess and which provides an endowment benefit or a cash surrender value or a combination in an amount greater than the excess premium, reserves according to the commissioners reserve valuation method as of any policy anniversary occurring on or before the assumed ending date defined under this subsection as the first policy anniversary on which the sum of any endowment benefit and any cash surrender value then available is greater than the excess premium shall, except as otherwise provided in section 7122, be the greater of the reserve as of the policy anniversary calculated as described in subsection (a) and the reserve as of the policy anniversary calculated as described in subsection (a), but with:

(1) The value defined in subsection (a) being reduced by 15% of the amount of this excess first year premium.

(2) All present values of benefits and premiums being determined without reference to premiums or benefits provided for by the policy after the assumed ending date.

(3) The policy being assumed to mature on that date as an endowment.

(4) The cash surrender value provided on that date being considered as an endowment benefit. In making the comparison under this subsection, the mortality and interest bases stated in sections 7115 (relating to computation of minimum standard) and 7117 (relating to computation of minimum standard by calendar year of issue) shall be used.

(c) Consistent method.--Reserves according to the commissioners reserve valuation method shall be calculated by a method consistent with the principles of this section, except that any extra premiums charged because of impairments or special hazards shall be disregarded in the determination of modified net premiums, for:

(1) Life insurance policies providing for a varying amount of insurance or requiring the payment of varying premiums.

(2) Group annuity and pure endowment contracts purchased under a retirement plan or plan of deferred compensation,

established or maintained by an employer, including a partnership or sole proprietorship, or by an employee organization, or by both, other than a plan providing individual retirement accounts or individual retirement annuities under section 408 of the Internal Revenue Code of 1986 (Public Law 99-514, 26 U.S.C. § 408).

(3) Disability and accidental death benefits in all policies and contracts.

(4) All other benefits, except life insurance and endowment benefits in life insurance policies and benefits provided by all other annuity and pure endowment contracts. Cross References. Section 7118 is referred to in sections 7103, 7115, 7116, 7120, 7122, 7123 of this title.
40 Pa.C.S. § 7142 — PA Code / Title 40 / Chapter 71 / Section 7142
Small company exemption (Repealed).
Status: repealed

2023 Repeal. Section 7142 was repealed June 14, 2023, P.L.4, No.2, effective immediately.
40 Pa.C.S. § 7134 — PA Code / Title 40 / Chapter 71 / Section 7134
Use of confidential information by department.
Status: in_force

To assist in the performance of its duties, the department may:

(1) Use confidential information in the furtherance of any regulatory or legal action brought against a company as a part of the department's official duties.

(2) Share confidential information with regulatory or law enforcement officials of this Commonwealth or other jurisdictions, IAIS, NAIC and its affiliates and subsidiaries, group-wide supervisors and members of a supervisory college under section 1406.1 of The Insurance Company Law of 1921, if prior to receiving the confidential information the recipient agrees, and has the legal authority to agree, to maintain the confidential and privileged status of the confidential information in the same manner and to the same extent as required for the commissioner.

(3) Receive, and shall maintain as confidential, any confidential information from the Actuarial Board for Counseling and Discipline or its successor, from NAIC and its affiliates and subsidiaries and from regulatory and law enforcement officials of this Commonwealth or other

jurisdictions with the understanding that the documents, materials or other information received are confidential by law in those jurisdictions and shall be given the same confidential treatment provided by this subchapter. Cross References. Section 7134 is referred to in section 7136 of this title.
40 Pa.C.S. § 4801 — PA Code / Title 40 / Chapter 48 / Section 4801
Scope of chapter.
Status: in_force

This chapter relates to telemedicine.
40 Pa.C.S. § 3902 — PA Code / Title 40 / Chapter 39 / Section 3902
Definitions.
Status: in_force

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Board." The board of directors of the filing entity.

"CGAD-related information." The CGAD or any documents, materials or other information, including proprietary and trade secret information or documents, related to an insurer or insurance group's CGAD.

"Commissioner." The Insurance Commissioner of the Commonwealth.

"Corporate governance annual disclosure" or "CGAD." The confidential report filed by the insurer or insurance group in accordance with the requirements of this chapter.

"Department." The Insurance Department of the Commonwealth.

"Insurance Company Law." The act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921.

"Insurance group." The insurers and affiliates included within an insurance holding company system as defined in section 1401 of the Insurance Company Law.

"Insurer." A fraternal benefit society, a health maintenance organization, a preferred provider organization, a company, an association, an exchange, a hospital plan corporation as defined in and subject to Chapter 61 (relating to hospital plan corporations) or a professional health services plan corporation subject to Chapter 63 (relating to professional health services plan corporations) authorized by the commissioner to transact the business of insurance in this Commonwealth.

"Lead state." The state responsible for coordination and communication among state regulators regarding oversight of an insurance group, as determined by the department in consultation with other regulators with domestic insurers in the insurance group.

"NAIC." The National Association of Insurance Commissioners or successor organization and its affiliates and subsidiaries.

"Senior management." A corporate officer or other high-level management official responsible for reporting information to the board of directors at regular intervals, providing information to shareholders or providing information to regulators.
40 Pa.C.S. § 4709 — PA Code / Title 40 / Chapter 47 / Section 4709
Insurance producer training.
Status: in_force

(a) Prohibitions.--An insurance producer may not sell, solicit or negotiate a pet insurance policy or related product unless the insurance producer is appropriately licensed in this Commonwealth and has completed the training requirements of subsection (c).

(b) Requirement.--A pet insurer shall ensure that its insurance producers are trained under subsection (c) and have

been appropriately trained on the coverages and conditions of its pet insurance policies and related products.

(c) Training requirements.--The training required under this section shall include the following topics:

(1) Pets' preexisting conditions and waiting periods.

(2) The differences between pet insurance and noninsurance wellness programs.

(3) Pets' hereditary disorders, congenital anomalies or disorders and chronic conditions and how pet insurance policies interact with these conditions or disorders.

(4) Rating, underwriting, renewal and other related administrative topics.

(d) Training in other states.--The satisfaction of the training requirements of another state that are substantially similar to the provisions of subsection (c) shall be deemed to satisfy the training requirements in this Commonwealth.
40 Pa.C.S. § 9511 — PA Code / Title 40 / Chapter 95 / Section 9511
Procurements within one year.
Status: in_force

Notwithstanding any other provision of law and for the limited purpose of fulfilling the requirements under this chapter, procurement of contracts and agreements for the implementation and operation of the reinsurance program initiated within one year of the effective date of this section shall not be subject to the provisions of 62 Pa.C.S. (relating to procurement). No contract or agreement entered into under this section may exceed a term of five years.
40 Pa.C.S. § 6701 — PA Code / Title 40 / Chapter 67 / Section 6701
Regulation.
Status: in_force

All beneficial societies or associations not subject to regulation under Chapter 65 of this title (relating to fraternal benefit societies), transacting any class of insurance, shall file with the department copies of their charter, constitution, and laws and annually make a report in such form as the department may require, showing their condition and standing at the end of the preceding calendar year, and of their transactions for such year, and the department may at any time make an examination of the books and accounts of any such society. References in Text.
40 Pa.C.S. § 5103 — PA Code / Title 40 / Chapter 51 / Section 5103
Advertisements.
Status: in_force

An insurer or insurance producer, or a representative of an insurer or insurance producer, may not offer or provide insurance as an inducement to the purchase of another policy or otherwise use the words "free," "no cost" or words of similar import in an advertisement.
40 Pa.C.S. § 4702 — PA Code / Title 40 / Chapter 47 / Section 4702
Definitions.
Status: in_force

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Chronic condition." A condition that can be treated or managed, but not cured.

"Commissioner." The Insurance Commissioner of the Commonwealth.

"Congenital anomaly or disorder." A condition that is present from birth, whether inherited or caused by the environment, which may cause or contribute to illness or disease.

"Hereditary disorder." An abnormality that is genetically transmitted from parent to offspring and may cause illness or disease.

"Insurance producer." As defined in section 601-A of the act of May 17, 1921 (P.L.789, No.285), known as The Insurance Department Act of 1921.

"Insured." A person on whose behalf a pet insurer is obligated to pay or reimburse covered veterinary expenses under a pet insurance policy.

"Orthopedic condition." As follows:

(1) A condition affecting the bones, skeletal muscle, cartilage, tendons, ligaments or joints.

(2) The term includes elbow dysplasia, hip dysplasia, intervertebral disc degeneration, patellar luxation and ruptured cranial cruciate ligaments.

(3) The term does not include cancer or a metabolic, hemopoietic or autoimmune disease.

"Pet insurance policy." A property insurance policy, certificate or rider that provides coverage for accidents and illnesses of pets.

"Pet insurer." An insurer that issues a pet insurance policy.

"Practice of veterinary medicine." As defined in section 3 of the act of December 27, 1974 (P.L.995, No.326), known as the Veterinary Medicine Practice Act.

"Preexisting condition." A condition for which any of the following apply regarding a pet prior to the effective date of a pet insurance policy for the pet or during any waiting period:

(1) A veterinarian provided medical advice regarding the pet.

(2) The pet received previous treatment.

(3) Based on information from verifiable sources, the pet had signs or symptoms directly related to the condition for which a claim is being made.

"Renewal." As defined in section 3 of the act of July 22, 1974 (P.L.589, No.205), known as the Unfair Insurance Practices Act.

"Veterinarian." An individual who holds a valid license to engage in the practice of veterinary medicine from the appropriate licensing entity of the jurisdiction in which the individual engages in the practice of veterinary medicine.

"Veterinary expenses." The costs associated with medical advice, diagnosis, care or treatment provided by a veterinarian, including the cost of drugs prescribed by a veterinarian.

"Waiting period." As follows:

(1) The period of time specified in a pet insurance policy that is required to transpire before some or all of the coverage in the policy can begin.

(2) A waiting period may not be applied to a renewal of existing coverage.

"Wellness program." As follows:

(1) A subscription or reimbursement-based program that is separate from a pet insurance policy that provides goods and services to promote the general health, safety or well-being of the pet.

(2) A wellness program does not assume or transfer any risk of loss. Cross References. Section 4702 is referred to in section 4703 of this title.
40 Pa.C.S. § 4302 — PA Code / Title 40 / Chapter 43 / Section 4302
Definitions.
Status: in_force

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Health insurance policy." As follows:

(1) An insurance policy, subscriber contract, certificate or plan that provides medical or health care coverage, including emergency services.

(2) The term does not include any of the following types of policies:

(i) Accident only.

(ii) Fixed indemnity.

(iii) Credit.

(iv) Dental only.

(v) Vision only.

(vi) Specified disease.

(vii) Medicare supplement.

(viii) Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement.

(ix) Long-term care.

(x) Disability income.

(xi) Workers' compensation.

(xii) Automobile medical payment insurance.

"Insurer." An entity licensed by the department with accident and health authority to issue a health insurance policy that is offered or governed under any of the following:

(1) The act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, including section 630 and Article XXIV of that act.

(2) The act of December 29, 1972 (P.L.1701, No.364), known as the Health Maintenance Organization Act.

(3)
40 Pa.C.S. § 9512 — PA Code / Title 40 / Chapter 95 / Section 9512
Access to information and records.
Status: in_force

(a) Reports and access.--An insurer shall, without charge, report information and provide access to and furnish records as the department requests in order for the department to:

(1) Prepare the State innovation waiver application submitted under section 9501(a) (relating to application).

(2) Determine reinsurance parameters under section 9504 (relating to reinsurance parameters).

(3) Determine the reinsurance payments due to each insurer.

(4) Monitor costs and revenues associated with the reinsurance program.

(5) Administer the reinsurance program.

(6) Assure compliance with applicable Federal and State law.

(b) Time period.--The information and records requested under subsection (a) shall be provided to the department within 30 days of receipt by an insurer of the written request, unless required at an earlier date for department compliance with a request from a Federal or other State agency.

(c) Use.--Information and records provided to the department under subsection (a) may only be used for the purposes specified in subsection (a).

(d) Exemptions.--Any instructions, forms or reports issued by the department and required to be completed by an insurer under this section shall not be subject to:

(1) The act of July 31, 1968 (P.L.769, No.240), referred to as the Commonwealth Documents Law.

(2) The act of October 15, 1980 (P.L.950, No.164), known as the Commonwealth Attorneys Act.

(3) The act of June 25, 1982 (P.L.633, No.181), known as the Regulatory Review Act.
40 Pa.C.S. § 4706 — PA Code / Title 40 / Chapter 47 / Section 4706
Policy conditions.
Status: in_force

(a) Preexisting conditions.--

(1) A pet insurer may issue pet insurance policies that exclude coverage on the basis of one or more preexisting conditions if the pet insurer follows the disclosure requirements of section 4705 (relating to policy disclosures).

(2) A pet insurer has the burden of proving that the preexisting condition exclusion under paragraph (1) applies to the condition for which a claim is being made.

(3) A condition for which coverage is afforded on a pet insurance policy may not be considered a preexisting condition upon any renewal of the pet insurance policy.

(b) Waiting periods.--

(1) A waiting period under a pet insurance policy for an accident is prohibited.

(2) A waiting period under a pet insurance policy for an illness or orthopedic condition not resulting from an accident is permitted in accordance with the following:

(i) The waiting period may not exceed 30 days.

(ii) The waiting period, and the requirements applicable to any waiting period, must be clearly and prominently disclosed to a prospective insured prior to the purchase of the pet insurance policy.

(iii) The pet insurance policy must contain a provision that allows for the waiver of a waiting period upon completion of a medical examination in accordance with the following:

(A) The pet insurer may require the medical examination to be conducted by a veterinarian.

(B) The medical examination shall be paid for by the insured, unless the pet insurance policy specifies that the pet insurer will pay for the medical examination.

(C) The pet insurer may specify elements to be included as part of the medical examination and require documentation regarding the medical examination, provided that the specifications do not unreasonably restrict the waiver.

(c) Examination not required upon renewal.--A pet insurer may not require a veterinary examination of a pet covered under a pet insurance policy when the insured seeks a renewal of the pet insurance policy.

(d) Wellness benefits.--

(1) If a pet insurer includes any prescriptive, wellness or noninsurance benefits in the pet insurance policy form, those benefits become part of the policy contract and must follow all applicable insurance laws and regulations.

(2) An insured's eligibility to purchase a pet insurance policy may not be based on participation, or lack of participation, in a separate wellness program.

(e) Acceptance.--A pet insurer shall accept a claim submitted by an insured electronically or through physical mail.
40 Pa.C.S. § 7122 — PA Code / Title 40 / Chapter 71 / Section 7122
Reserve calculation for valuation net premium exceeding gross premium charged.
Status: in_force

(a) Calculation of minimum reserve.--The following shall apply:

(1) If in any contract year the gross premium charged by a company on a policy or contract is less than the valuation net premium for the policy or contract calculated by the method used in calculating the reserve but using the minimum valuation standards of mortality and rate of interest, the minimum reserve required for the policy or contract shall be the greater of:

(i) The reserve calculated according to the mortality table, rate of interest and method actually used for the policy or contract.

(ii) The reserve calculated by the method actually used for the policy or contract but using the minimum valuation standards of mortality and rate of interest and replacing the valuation net premium by the actual gross premium in each contract year for which the valuation net premium exceeds the actual gross premium.

(2) The minimum valuation standards of mortality and rate of interest referred to in this subsection are those standards stated in sections 7115 (relating to computation of minimum standard) and 7117 (relating to computation of minimum standard by calendar year of issue).

(b) How to apply this section for certain policies.--The following shall apply:

(1) For a life insurance policy issued on or after January 1, 1985, for which the gross premium in the first policy year exceeds that of the second year and for which no comparable additional benefit is provided in the first year for the excess and which provides an endowment benefit or a cash surrender value or a combination in an amount greater than the excess premium, the provisions of this section shall be applied as if the method actually used in calculating the reserve for the policy were the method described in section 7118 (relating to reserve valuation method for life insurance and endowment benefits), ignoring section 7118(b).

(2) The minimum reserve at each policy anniversary of the policy under paragraph (1) shall be the greater of the minimum reserve calculated in accordance with section 7118, including section 7118(b), and the minimum reserve calculated in accordance with this section. Cross References. Section 7122 is referred to in sections 7103, 7115, 7118, 7120, 7123 of this title.
40 Pa.C.S. § 7112 — PA Code / Title 40 / Chapter 71 / Section 7112
Reserve valuation for policies and contracts issued on or after operative date of valuation manual.
Status: in_force

(a) Applicability.--This section shall apply to each policy or contract issued on or after the operative date of the valuation manual.

(b) Annual valuation.--The commissioner shall annually value, or cause to be valued, the reserve liabilities for all outstanding life insurance contracts, annuity and pure endowment contracts, accident and health contracts and deposit-type contracts of each company doing business in this Commonwealth. The commissioner may certify the amount of reserves.

(c) Other jurisdictions.--In lieu of the valuation of the reserves required of a foreign or alien company, the commissioner may accept a valuation made, or caused to be made, by the insurance supervisory official of any state or other jurisdiction when the valuation complies with the minimum standard provided in this chapter.

(d) Applicable standards.--The following provisions shall govern a policy or contract under this section:

(1) Section 7124(a), (b), (d) and (e) (relating to minimum standard for accident and health insurance contracts).

(2) Section 7125 (relating to valuation manual for policies issued on or after operative date of valuation manual).

(3) Section 7126 (relating to requirements of principle-based valuation). Cross References. Section 7112 is referred to in sections 7124, 7125 of this title.
40 Pa.C.S. § 3804 — PA Code / Title 40 / Chapter 38 / Section 3804
Exceptions to retroactive denial of reimbursement.
Status: in_force

The provisions of section 3803 (relating to retroactive denial of reimbursement) do not apply if an insurer retroactively denies reimbursement to a health care provider because any of the following apply:

(1) The information submitted to the insurer constitutes fraud, waste or abuse as defined in this chapter.

(2) The claim submitted to the insurer was a duplicate claim.

(3) Denial was required by a Federal or State government plan.

(4) Services were subject to coordination of benefits with another insurer, the medical assistance program or the Medicare program. Cross References. Section 3804 is referred to in sections 3803, 3805 of this title.
40 Pa.C.S. § 9304 — PA Code / Title 40 / Chapter 93 / Section 9304
Meetings and operation.
Status: in_force

(a) Chairperson.--The members of the advisory council shall annually elect a chairperson from among its membership.

(b) Terms of members.--Each member's term shall be four years, not to exceed more than two full consecutive four-year terms, except that:

(1) Initial appointments shall be staggered to ensure less than 50% of the membership expire each year.

(2) A member's term shall continue until the member's successor is appointed.

(c) Meetings.--All meetings of the advisory council shall be conducted in accordance with 65 Pa.C.S. Ch. 7 (relating to open meetings), except as provided in this section. Meetings must be held in accordance with the following:

(1) The advisory council shall meet at least twice per year, with each meeting held prior to a meeting of the board. Additional meetings may be held upon reasonable notice at times and locations selected by the board. The council shall meet at the call of the chairperson or upon written request of three members of the council.

(2) The executive director of the exchange authority, or a designee, shall attend each meeting of the advisory council.

(3) Meeting dates shall be set by a majority vote of members of the advisory council or by call of the chairperson upon seven days' notice to all members.

(4) The advisory council shall post notice of the council's meetings on the exchange authority's publicly accessible Internet website at least five days prior to each meeting. The notice must specify the date, time and place

of the meeting and shall state that the council's meetings are open to the general public.

(5) All action taken by the advisory council shall be taken in open public session and may not be taken except upon a majority vote of the members present at a meeting at which a quorum is present.

(d) Compensation.--The members of the advisory council shall not be entitled to any compensation for their services as members, except that, subject to the availability of money, the members of the advisory council shall be entitled to reimbursement for actual and necessary travel expenses. The expenses shall be paid for by the exchange fund.

(e) Vacancies.--Vacancies in appointed positions shall be filled in the same manner as the original appointment. Members shall serve until their successors are appointed and qualified.

(f) Quorum.--A majority of the advisory council members shall constitute a quorum and a quorum may act for the advisory council in all matters.

(g) Duties.--Upon request by the exchange authority, the advisory council shall advise the exchange authority on the following administrative and operational decisions:

(1) Initial operational decisions.

(2) Ongoing financing decisions.

(3) Other decisions as the exchange authority may deem appropriate. Cross References. Section 9304 is referred to in sections 9303, 9305 of this title.
40 Pa.C.S. § 6123 — PA Code / Title 40 / Chapter 61 / Section 6123
Investment of funds.
Status: in_force

Any statute to the contrary notwithstanding, funds of any hospital plan corporation, equal to its reserves, shall be invested in compliance with the requirements of law for the investment of the capital and reserves of life insurance companies. The funds of any such corporation, equal to its surplus, shall be invested in compliance with the requirements of law for the investment of the surplus of life insurance companies.
40 Pa.C.S. § 4904 — PA Code / Title 40 / Chapter 49 / Section 4904
Enforcement.
Status: in_force

(a) Penalties.--Upon satisfactory evidence of the violation of this chapter by a health insurer or any other person, one or more of the following penalties may be imposed at the commissioner's discretion:

(1) A fine of not more than $5,000 for each violation of this chapter.

(2) A fine of not more than $10,000 for each willful violation of this chapter.

(b) Limitations.--

(1) Fines imposed against an individual insurer under this chapter may not exceed $500,000 in the aggregate during a single calendar year.

(2) Fines imposed against any other person under this chapter may not exceed $100,000 in the aggregate during a single calendar year.

(c) Additional remedies.--The enforcement remedies imposed under this section are in addition to any other remedies or penalties that may be imposed under any other applicable law of this Commonwealth, including:

(1) The act of July 22, 1974 (P.L.589, No.205), known as the Unfair Insurance Practices Act. Violations of this chapter shall be deemed to be an unfair method of competition and an unfair or deceptive act or practice under that act.

(2) The act of December 18, 1996 (P.L.1066, No.159), known as the Accident and Health Filing Reform Act.

(3) The act of June 25, 1997 (P.L.295, No.29), known as the Pennsylvania Health Care Insurance Portability Act.

(d) Administrative procedure.--The administrative provisions of this section shall be subject to 2 Pa.C.S. Ch. 5 Subch. A (relating to practice and procedure of Commonwealth agencies). A party against whom penalties are assessed in an administrative action may appeal to Commonwealth Court as provided in 2 Pa.C.S. Ch. 7 Subch. A (relating to judicial review of Commonwealth agency action).
40 Pa.C.S. § 4711 — PA Code / Title 40 / Chapter 47 / Section 4711
Rules and regulations.
Status: in_force

The commissioner may promulgate rules and regulations to administer and enforce this chapter.
40 Pa.C.S. § 4802 — PA Code / Title 40 / Chapter 48 / Section 4802
Definitions.
Status: in_force

The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise:

"Agreement with the Department of Human Services." As follows:

(1) An agreement between an MA or CHIP managed care plan and the Department of Human Services to manage the purchase and provision of services.

(2) The term includes a county or multicounty agreement with the Department of Human Services for behavioral health services.

"Asynchronous interaction." An exchange of information between a patient and a health care provider that does not occur in real time, including the secure collection and transmission of a patient's medical information, clinical data, clinical images, laboratory results and self-reported medical history. "Children's Health Insurance Program" or "CHIP." The Children's Health Insurance Program under Article XXIII-A of the act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921.

"Enrollee." An individual who is entitled to receive health care services under an agreement with the Department of Human Services.

"Health care facility." As follows:

(1) An entity that is licensed to provide a health care service under Article X of the act of June 13, 1967 (P.L.31, No.21), known as the Human Services Code, or the act of July 19, 1979 (P.L.130, No.48), known as the Health Care Facilities Act.

(2) A federally qualified health center as defined in 42 U.S.C. § 1395x(aa)(4) (relating to definitions).

(3) A rural health clinic as defined in 42 U.S.C. § 1395xx(aa)(2).

"Health care provider." A health care facility, medical equipment supplier or person that is licensed, certified or otherwise regulated to provide health care services under the laws of this Commonwealth or another state.

"Health care service." Any treatment, admission, procedure, medical supplies and equipment or other services, including behavioral health, prescribed or otherwise provided or proposed to be provided by a health care provider to a patient for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease. "Health Information Technology for Economic and Clinical Health Act." The Health Information Technology for Economic and Clinical Health Act (Public Law 111-5, 123 Stat. 226-279 and 467-496).

"Health insurance policy." As follows:

(1) A policy, subscriber contract, certificate or plan issued by an insurer that provides medical or health care coverage.

(2) The term includes a dental only and a vision only policy.

(3) The term does not include:

(i) An accident only policy.

(ii) A credit only policy.

(iii) A long-term care or disability income policy.

(iv) A specified disease policy.

(v) A Medicare supplement policy.

(vi) A TRICARE policy, including a Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) supplement policy.

(vii) A fixed indemnity policy.

(viii) A hospital indemnity policy.

(ix) A worker's compensation policy.

(x) An automobile medical payment policy under 75 Pa.C.S. (relating to vehicles).

(xi) A homeowner's insurance policy.

(xii) Any other similar policies providing for limited benefits. "Health Insurance Portability and Accountability Act of 1996." The Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191, 110 Stat. 1936).

"Insurer." An entity licensed by the department that offers, issues or renews a health insurance policy and is governed under any of the following:

(1) The Insurance Company Law of 1921, including section 630 and Article XXIV of that act.

(2) The act of December 29, 1972 (P.L.1701, No.364), known as the Health Maintenance Organization Act.

(3)