reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter F - COVERAGE FOR NEWBORN CHILDREN › Section 89.203 - Forms which must provide newborn coverage

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Forms providing benefits on an expense
				  incurred or service basis shall extend the benefits to newborn
				  children.
(b) Where a form provides
				  both expense incurred or service benefits and indemnity benefits, for the
				  purposes of implementation of Act 81 and this subchapter, the policy shall be
				  considered an expense incurred or service benefit policy, and benefits
				  thereunder shall be extended to newborn children. Accidental death or
				  accidental death and dismemberment or disability income benefits need not be
				  extended to newborn children, even though the form provides some expense
				  incurred benefits.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter F - COVERAGE FOR NEWBORN CHILDREN › Section 89.204 - Inapplicability of preexisting condition limitation or waiting period limitation

Current through Register Vol. 54, No. 28, July 13, 2024
A form may not deny a claim for newborn coverage on the
					 basis that the cause of the claim was a sickness or injury which existed on or
					 prior to the effective date of the coverage or date of birth of the newborn. A
					 form may not provide for a waiting period between the date of birth and
					 provision of coverage for a newborn child, unless the waiting period is
					 applicable to all insureds under the form, that is, the form provides coverage
					 from the fourth day of hospitalization due to sickness, provided however, that
					 upon newly issued forms a company, in order to prevent adverse selection
					 against it by persons who may seek to buy coverage solely to have a newborn
					 covered, may impose a limitation that the newborn child shall have been
					 conceived on or after the effective date of coverage of the
					 form.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter F - COVERAGE FOR NEWBORN CHILDREN › Section 89.205 - Compliance procedure

Current through Register Vol. 54, No. 28, July 13, 2024
Forms issued or renewed on or after November 29, 1975,
					 shall provide at least the coverage specified in Act 81 as interpreted by this
					 subchapter, either by amendatory rider or endorsement or appropriate revision
					 of the form itself.
(1) The form
				  provision shall provide that the newborn child coverage is included
				  automatically for each newborn child for 31 days after birth and that the
				  insured or subscriber shall have the right upon application if such is required
				  by the insurer within the 31 day period to continue coverage beyond the 31 day
				  period if the form provides for coverage of dependents.
(2) If the form does not provide for coverage
				  of dependents, the insured or subscriber shall have the right, upon application
				  within 31 days of the birth of the newborn, to convert to a form which shall
				  provide substantially similar benefits, or to add an appropriate coverage rider
				  to the existing form.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter F - COVERAGE FOR NEWBORN CHILDREN › Section 89.206 - Filing procedure

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  Insurers subject to Act 81 and this subchapter shall submit for review and
				  approval compliance riders or endorsements to affected, currently approved and
				  in-use forms.
(b) Prior to January
				  1, 1977, required changes in forms submitted for review and approval may
				  contain required Act 81 amendments by an amendatory rider, or the changes may
				  be incorporated into the text of the new or revised policy submission. After
				  that date, contracts submitted for review and approval shall contain Act 81
				  compliance provisions within the text of the form itself. A form submission
				  made prior to January 1, 1977, should specify within its submission letter how
				  Act 81 has been or will be complied with in the form so submitted.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter F - COVERAGE FOR NEWBORN CHILDREN › Section 89.207 - Rates

Current through Register Vol. 54, No. 28, July 13, 2024
A necessary and appropriate change in currently approved
					 premium rates required by the 31 day newborn coverage period extension shall be
					 submitted for review and approval in accordance with applicable statutory
					 authority.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter F - COVERAGE FOR NEWBORN CHILDREN › Section 89.208 - Deferred claims

Current through Register Vol. 54, No. 28, July 13, 2024
Coverage for claims incurred during the 31 day newborn
					 coverage period, extending beyond the period in those cases wherein no valid
					 application for continuation of coverage is made on behalf of the newborn,
					 shall be covered in accordance with the termination provisions otherwise
					 applicable to other covered members.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter F - COVERAGE FOR NEWBORN CHILDREN › Section 89.209 - Retroactive compliance provisions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An insurer shall provide affected
				  insureds with a compliance rider, which shall be retroactively effective to
				  November 29, 1975, or a later form renewal date that may be
				  applicable.
(b) An insurer shall
				  retroactively evaluate claims arising on or after November 29, 1975, for
				  applicability of Act 81 and this subchapter in claims settlement.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter G - PREEXISTING CONDITION EXCLUSION IN GROUP CONTRACTS › Section 89.401 - Scope

Current through Register Vol. 54, No. 28, July 13, 2024
This subchapter applies to:
(1) Policies of group accident, group
				  sickness or group accident and sickness insurance policies, as defined in
				  section 621.2 of the act (40 P. S. §
											756.2), issued or issued for delivery in this
				  Commonwealth.
(2) Policies of
				  blanket accident and sickness insurance, as defined in section 621.3 of the act
				  (40
				  P. S. §
											756.3) issued or issued for
				  delivery in this Commonwealth.
(3)
				  Group master agreements issued by a hospital plan corporation subject to the
				  prior approval of the Department under
				  40 Pa.C.S. §
											6124
				  (relating to rates and contracts).
(4) Group master agreements issued by a
				  professional health services plan corporation subject to the prior approval of
				  the Department under
				  40 Pa.C.S. §
											6329
				  (relating to rates and contracts).
(5) Blanket or group student accident
				  sickness insurance and group mortgage disability insurance policies subject to
				  the prior approval of the Department under section 621.2 of the act
				  (40
				  P. S. §
											756.2) issued or issued for
				  delivery in this Commonwealth.
This section cited in 31 Pa. Code §
												89.407 (relating to effective
						date).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter G - PREEXISTING CONDITION EXCLUSION IN GROUP CONTRACTS › Section 89.402 - Approval

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A preexisting
				  condition limitation will not be approved for use with a policy or contract
				  which is more restrictive than the following definition: A preexisting
				  condition is a disease or physical condition for which medical advice or
				  treatment has been received within 90 days immediately prior to becoming
				  covered under the group contract. The condition shall be covered after the
				  individual has been covered for more than 12 months under the group
				  contract.
(b) Long-term disability
				  benefit provisions may require that the total disability resulting from a
				  preexisting condition commence after the individual has been covered for more
				  than 12 months under the group contract.
This section cited in 31 Pa. Code §
												89.404 (relating to preexisting
						condition).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter G - PREEXISTING CONDITION EXCLUSION IN GROUP CONTRACTS › Section 89.403 - Disclosure

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A disclosure
				  statement substantially similar to the following shall be given in writing to a
				  group member at the time of the enrollment under the group contract.
NOTICE
If you or any dependents have received medical care or
					 advice within the past 90 days for a disease or physical condition, you, he or
					 she will not be covered for such disease or physical condition until you, he or
					 she has been covered for one year under this contract. This exclusion, however,
					 only applies to a disease or physical condition for which medical care or
					 advice has been received in the past 90 days.
(b) The statement set forth in subsection (a)
				  shall be printed in bold face type.
The provisions of this §
												89.403 issued under The Insurance
						Company Law of 1921 (40 P. S. §§
													1-321);
						The Insurance Company Law of 1921 (40 P. S. §§
													341-991); sections 206, 506, 1501 and 1502 of
						The Administrative Code of 1929 (71 P. S. §§
													66,
						186,
						411 and
						412); and
						40 Pa.C.S. §§
													6124 and
						6329.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter G - PREEXISTING CONDITION EXCLUSION IN GROUP CONTRACTS › Section 89.404 - Preexisting condition

Current through Register Vol. 54, No. 28, July 13, 2024
A preexisting condition limitation defined other than as
					 set forth in §
										89.402 (relating to approval)
					 shall substantially conform to the standards set forth in this subchapter. The
					 preexisting condition limitation would be considered for approval by the
					 Department only upon appropriate justification by the submitting company
					 proposing to use it.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter G - PREEXISTING CONDITION EXCLUSION IN GROUP CONTRACTS › Section 89.405 - Exclusion

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Every group
				  contract issued to a policyholder to replace another group contract shall only
				  exclude a preexisting condition excluded by the other group policy.
(b) The provisions of subsection (a) applies
				  to those individuals covered under the group policy being replaced.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter G - PREEXISTING CONDITION EXCLUSION IN GROUP CONTRACTS › Section 89.406 - Acceptability

Current through Register Vol. 54, No. 28, July 13, 2024
A preexisting condition exclusion will not be acceptable in
					 blanket or group student accident and sickness insurance and group mortgage
					 disability insurance.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter G - PREEXISTING CONDITION EXCLUSION IN GROUP CONTRACTS › Section 89.407 - Effective date

Current through Register Vol. 54, No. 28, July 13, 2024
This subchapter applies to policies and agreements set
					 forth in §
										89.401 (relating to scope) issued,
					 renewed, substantially altered or amended, on or after November 23,
					 1979.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter H - STATEMENTS OF POLICY › GENERALLY › Section 89.451 - Insurance coverage

Current through Register Vol. 54, No. 28, July 13, 2024
The act of December 23, 1981 (P. L. 583, No. 168)
						(40
						P. S. §§
												3001-3003) requires that
						the services of licensed midwives be covered on the same basis as the services
						of licensed physicians or osteopaths for those areas of practice for which
						midwives may be licensed. Effective February 6, 1982, no policy form,
						subscriber agreement or certificate will be approved by the Insurance
						Department unless it complies with the act of December 23, 1981 (P. L. 583, No.
						168) (40 P. S. §§
												3001-3003).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter H - STATEMENTS OF POLICY › GENERALLY › Section 89.461 - Fraternal benefit societies

Current through Register Vol. 54, No. 28, July 13, 2024
Section 3101 (d) of 20 Pa.C.S. (relating to payments to
						family and funeral directors) was amended to allow for direct payment to
						certain statutorily determined recipients of an insurance contract for an
						amount of $11,000 or less where an appointed personal representative of the
						decedent has failed to make written demand for payment within 60 days following
						the death of the insured. The Department construes the insurance contracts
						specified in
						20 Pa.C.S. §
												3101(d) to include insurance
						contracts offered by fraternal benefit societies which are regulated by the
						Department under the Fraternal Benefit Societies Code (40 P. S.
						§§
												1141-101-1141-1001).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter H - STATEMENTS OF POLICY › STOP-LOSS POLICIES › Section 89.471 - Licensed accident and health insurers may write stop-loss coverage

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Section 202 of
					 the act (40 P. S. §
												382), defines
					 group accident and health coverages that may be written by licensed accident
					 and health companies. In an effort to increase health insurance options
					 available to employers, stop-loss; that is, excess loss, coverage may be
					 written by Pennsylvania licensed accident and health companies, if, before
					 doing so, the Department has determined that the policy serves the interests of
					 the public, and has approved the policy.
(b) This coverage may still be written by
					 property and casualty insurers, if they also have the authority to write
					 accident and health insurance. Current, approved policies written by property
					 and casualty insurers may continue in force.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter H - STATEMENTS OF POLICY › STOP-LOSS POLICIES › Section 89.472 - Filing requirements for stop-loss policies

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Section 354 of the act (40 P. S. §
												477b), authorizes the Department to review
					 and approve accident and health policies filed by companies. A stop-loss policy
					 submitted to the Department for approval shall satisfy the following
					 conditions:
(1) The stop-loss policy shall be
					 issued to, and insure, the sponsor of the plan, or the plan itself, not the
					 employes, members or participants.
(2) Payments by the insurer shall be made to
					 the sponsor of the plan or the plan itself, not the employes, members,
					 participants or providers.
(3) The
					 individual stop-loss amount; that is, retention or attachment point per
					 claimant, shall be at least $10,000; the aggregate stop-loss amount for the
					 plan shall be, at a minimum, $100,000 per calendar year.
(4) The stop-loss policy shall contain a
					 provision that the plan's or the plan sponsor's bankruptcy or insolvency will
					 not relieve the stop-loss carrier from its obligation to pay claims under the
					 stop-loss policy.
(5) In addition
					 to the stop-loss policy filed with the Department for approval, filings shall
					 contain a separate document certifying that each of the four requirements
					 listed in paragraphs (1)-(4) have been met.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter H - STATEMENTS OF POLICY › STOP-LOSS POLICIES › Section 89.473 - Ascertaining the legitimacy of the underlying plan

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Legitimacy of underlying
					 plan.
Insurance companies writing stop-loss coverage shall exercise
					 due diligence in ascertaining the legitimacy of the underlying plan before
					 issuing coverage. This includes ensuring that:
(1) The underlying plan is a legitimate
					 self-funded plan and not a self-insured or partially insured multiple employer
					 welfare arrangement.
(2) The plan
					 is not structured in a manner that is prohibited by this subsection.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter H - STATEMENTS OF POLICY › STOP-LOSS POLICIES › Section 89.474 - Prohibited activities

Current through Register Vol. 54, No. 28, July 13, 2024
An individual or entity, including third-party
						administrators, that places stop-loss coverage through an insurer or other
						entity not licensed to issue stop-loss coverage in this Commonwealth may be
						found to be in violation of provisions of The Insurance Department Act of one
						thousand nine hundred and twenty-one (40 P. S. §§
												1-297.4) that prohibit unlicensed agent
						activity. Stop-loss coverage may only be issued by licensed Pennsylvania
						insurers through their licensed agents or brokers. Other entities who receive,
						or attempt to receive, a fee, commission or other compensation in connection
						with the issuance of stop-loss coverage may be found to be in violation of
						provisions of The Insurance Department Act of one thousand nine hundred and
						twenty-one that prohibit unlicensed insurance activity. Further, stop-loss
						coverage may only be issued to valid single employer self-funded ERISA
						qualified plans, unless the Commissioner determines that other plans may be
						eligible for the coverage.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter I - ALCOHOL ABUSE AND DEPENDENCY BENEFITS › GENERAL › Section 89.601 - Applicability

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This subchapter
					 implements Article VI-A of the act (40 P. S. §§
												908-1-908-8) relating to mandatory benefits
					 for the treatment of alcohol abuse and dependency.
(b) This subchapter applies to group health
					 or sickness or accident insurance policies providing hospital or
					 medical/surgical coverage and group subscriber contracts for certificates
					 issued by an entity subject to the act, 40 Pa.C.S. Chapters 61 and 63 (relating
					 to hospital plan corporations; and professional health services plan
					 corporations), the Health Maintenance Orgnization Act (40 P. S.
					 §§
												1551-1567) or the Fraternal
					 Benefit Society Code (40 P. S. §§
												1141.101-1141.905).
(c) Every entity that issues the policies,
					 contracts or certificates described in subsection (b) shall submit forms of the
					 contracts in compliance with this subchapter to the Department by May 25, 1988.
					 The obligation to provide alcohol abuse and dependency benefits applies to
					 policies, contracts and certificates issued or renewed on or after December 8,
					 1986. A policy, contract or certificate is considered renewed on the date of
					 its renewal or, if the contract had no fixed term as of December 8, 1986, on
					 the first anniversary date on or after December 8, 1986.
The provisions of this §
													89.601 issued under sections 206,
						  506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
						  §§
														66,
						  186,
						  411 and
						  412); and The Insurance
						  Company Law of 1921 (40 P. S. §§
														341-391).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter I - ALCOHOL ABUSE AND DEPENDENCY BENEFITS › POLICY REQUIREMENTS › Section 89.611 - Deductibles and copayments

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Definition.
A course of treatment shall be considered to be
					 the full range of detoxification, treatment and supportive services carried out
					 specifically to alleviate the dysfunction of the insured or
					 subscriber.
(b)
First
					 instance or course of treatment.
In the first instance or course of
					 treatment for alcohol abuse and dependency, no deductible or copayment may be
					 less favorable than those applied to similar classes or categories of treatment
					 for other conditions of physical illness or injury.
(c)
Second and subsequent courses of
					 treatment.
For the second and subsequent courses of treatment for
					 alcohol abuse and dependency, the total proportion of payment after the
					 deductibles and copayments may not be less than 50% of the allowance for
					 similar classes or categories of treatment for other conditions of physical
					 illness or injury.
The provisions of this §
													89.611 issued under sections 206,
						  506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
						  §§
														66,
						  186,
						  411 and
						  412); and The Insurance
						  Company Law of 1921 (40 P. S. §§
														341-391).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter I - ALCOHOL ABUSE AND DEPENDENCY BENEFITS › POLICY REQUIREMENTS › Section 89.612 - Minimum covered services

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Nonhospital, residential alcohol treatment services which are included as a
					 covered benefit under Article VI-A of the act (40 P. S. §§
												908-1-908-8) shall be covered for a minimum
					 of 30 days per year. The minimum of 30 days per year may not be exchanged for
					 outpatient alcohol treatment services.
(b) Outpatient alcohol treatment services
					 which are included as a covered benefit under Article VI-A of the act shall be
					 covered for a minimum of 30 outpatient, full-session visits or equivalent
					 partial visits per year. The minimum 30 sessions per year may not be exchanged
					 for nonhospital residential alcohol treatment services.
(c) Thirty outpatient, full-session visits or
					 equivalent partial visits, which may be exchanged on a two-for-one basis for up
					 to 15 nonhospital, residential alcohol treatment days, shall be available in
					 addition to the minimum required in subsections (a) and (b).
(d) Treatment services provided in
					 subsections (a)-(c) may be subject to a lifetime limit, for a covered
					 individual, of 90 days of nonhospital, residential alcohol treatment services
					 and 120 outpatient, full-session visits or equivalent partial visits.
The provisions of this §
													89.612 issued under sections 206,
						  506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
						  §§
														66,
						  186,
						  411 and
						  412); and The Insurance
						  Company Law of 1921 (40 P. S. §§
														341-391).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter I - ALCOHOL ABUSE AND DEPENDENCY BENEFITS › COVERAGE FOR TREATMENT SERVICES › Section 89.621 - Inpatient detoxification services

Current through Register Vol. 54, No. 28, July 13, 2024
Inpatient detoxification services which are included as a
						covered benefit under Article VI-A of the act (40 P. S. §§
												908-1-908-8) shall be provided in a facility
						which meets Department of Health minimum drug and alcohol standards for
						client-to-staff ratios and staff qualifications and which is one of the
						following:
(1) A hospital licensed
					 under 28 Pa. Code Chapter 157 (relating to drug and alcohol services) and
					 complying with §§
											157.21-157.25 (relating to inpatient
					 hospital activities-detoxification).
(2) A psychiatric hospital licensed under 28
					 Pa. Code Chapter 709 Subchapter K (relating to standards for inpatient hospital
					 drug and alcohol activities offered in a freestanding psychiatric hospital) and
					 complying with §
											709.122 (relating to
					 detoxification).
(3) A freestanding
					 treatment facility licensed under 28 Pa. Code Chapter 709 (relating to
					 standards for licensure of freestanding treatment facilities) and complying
					 with 28 Pa. Code Chapter 709, Subchapter F (relating to standards for inpatient
					 nonhospital activities-short-term detoxification) and which has a written
					 affiliation agreement with a hospital for emergency, medical and psychiatric or
					 psychological support services.
(4)
					 A health care facility issued a certificate of compliance under 28 Pa. Code
					 Chapter 711 (relating to standards for certification of treatment activities
					 which are a part of a health care facility) and complying with 28 Pa. Code
					 Chapter 711, Subchapter E (relating to standards for inpatient nonhospital
					 activities-short-term detoxification) and which has a written affiliation
					 agreement with a hospital for emergency, medical and psychiatric or
					 psychological support services.
The provisions of this §
													89.621 issued under sections 206,
						  506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
						  §§
														66,
						  186,
						  411 and
						  412); and The Insurance
						  Company Law of 1921 (40 P. S. §§
														341-391).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter I - ALCOHOL ABUSE AND DEPENDENCY BENEFITS › COVERAGE FOR TREATMENT SERVICES › Section 89.622 - Nonhospital, residential treatment and rehabilitation services

Current through Register Vol. 54, No. 28, July 13, 2024
Nonhospital, residential treatment and rehabilitation
						services which are included as a covered benefit under Article VI-A of the act
						(40
						P. S. §§
												908-1-908-8) shall be
						provided in a facility which meets Department of Health minimum drug and
						alcohol standards for client-to-staff ratios and staff qualifications and which
						is one of the following:
(1) A
					 freestanding treatment facility licensed under 28 Pa. Code Chapter 709
					 (relating to standards for licensure of freestanding treatment facilities) and
					 complying with 28 Pa. Code Chapter 709, Subchapter E (relating to standards for
					 inpatient nonhospital activities-residential treatment and
					 rehabilitation).
(2) A health care
					 facility issued a certificate of compliance under 28 Pa. Code Chapter 711
					 (relating to standards for certification of treatment activities which are a
					 part of a health care facility) and complying with 28 Pa. Code Chapter 711,
					 Subchapter D (relating to standards for inpatient nonhospital
					 activities-residential treatment and rehabilitation).
The provisions of this §
													89.622 issued under sections 206,
						  506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
						  §§
														66,
						  186,
						  411 and
						  412); and The Insurance
						  Company Law of 1921 (40 P. S. §§
														341-391).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter I - ALCOHOL ABUSE AND DEPENDENCY BENEFITS › COVERAGE FOR TREATMENT SERVICES › Section 89.623 - Outpatient services

Current through Register Vol. 54, No. 28, July 13, 2024
Outpatient alcohol services which are included as a
						covered benefit under Article VI-A of the act (40 P. S. §§
												908-1-908-8) shall be provided in a facility
						which is one of the following:
(1) A
					 freestanding treatment facility licensed under 28 Pa. Code Chapter 709
					 (relating to standards for licensure of freestanding treatment facilities) and
					 complying with Chapter 709 Subchapter I (relating to standards for outpatient
					 activities).
(2) A psychiatric
					 hospital licensed under 28 Pa. Code Chapter 709.
(3) A health care facility issued a
					 certificate of compliance under 28 Pa. Code Chapter 711 (relating to standards
					 for certification of treatment activities which are a part of a health care
					 facility) and complying with 28 Pa. Code Chapter 711, Subchapter H (relating to
					 standards for outpatient activities).
The provisions of this §
													89.623 issued under sections 206,
						  506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
						  §§
														66,
						  186,
						  411 and
						  412); and The Insurance
						  Company Law of 1921 (40 P. S. §§
														341-391).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.770 - Purpose

Current through Register Vol. 54, No. 28, July 13, 2024
This subchapter provides for the following:
(1) The reasonable standardization of
				  coverage and simplification of terms and benefits of Medicare supplement
				  policies.
(2) The facilitation of
				  public understanding and comparison of the policies.
(3) The elimination of provisions contained
				  in the policies which may be misleading or confusing in connection with the
				  purchase of the policies or with the settlement of claims.
(4) Full disclosures in the sale of accident
				  and sickness insurance coverages to persons eligible for Medicare.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.771 - Applicability and scope

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except
				  as otherwise specifically provided in §§
										89.775,
				  89.779, 89.780, 89.783 and 89.788,
				  this subchapter applies to:
(1) Medicare
				  supplement policies delivered or issued for delivery in this Commonwealth on or
				  after July 30, 1992.
(2)
				  Certificates issued under group Medicare supplement policies which certificates
				  have been delivered or issued for delivery in this
				  Commonwealth.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.773 - Policy definitions and terms

Current through Register Vol. 54, No. 28, July 13, 2024
A policy or certificate may not be advertised, solicited or
					 issued for delivery in this Commonwealth as a Medicare supplement policy or
					 certificate, unless the policy or certificate contains definitions or terms
					 which conform to the requirements of this section.
(1) The terms "accident," "accidental injury"
				  or "accidental means" shall be defined to employ "result" language and may not
				  include words which establish an accidental means test or use words, such as
				  "external, violent, visible wounds" or similar words of description or
				  characterization.
(i) The definition may not
				  be more restrictive than the following: "Injury or injuries for which benefits
				  are provided means accidental bodily injury sustained by the insured person
				  which is the direct result of an accident, independent of disease or bodily
				  infirmity or any other cause, and occurs while insurance coverage is in
				  force."
(ii) The definition may
				  provide that injuries may not include injuries for which benefits are provided
				  or available under workers' compensation, employer's liability or similar law
				  or motor vehicle no-fault plan, unless prohibited by law.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.774 - Exclusions and limitations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except
				  for permitted preexisting condition clauses as described in §§
										89.775(1)(i),
				  89.776(1)(i) and
				  89.776a(1)(i)
				  (relating to minimum benefit standards for policies or certificates issued for
				  delivery prior to July 30, 1992; benefit standards for policies or certificates
				  issued or delivered on or after July 30, 1992 and prior to June 1, 2010; and
				  benefit standards for policies or certificates issued or delivered on or after
				  June 1, 2010), a policy or certificate may not be advertised, solicited or
				  issued for delivery in this Commonwealth as a Medicare supplement policy if the
				  policy or certificate contains limitations or exclusions on coverage that are
				  more restrictive than those of Medicare.
(b) A Medicare supplement policy or
				  certificate may not use waivers to exclude, limit or reduce coverage or
				  benefits for specifically named or described preexisting diseases or physical
				  conditions.
(c) A Medicare
				  supplement policy or certificate in force in this Commonwealth may not contain
				  benefits which duplicate benefits provided by Medicare.
(d) The following applies to issuance and
				  renewal limitations of Medicare supplement policies:
(1) Subject to §§
											89.775(1)(iv), (v) and
				  (vii) and
				  89.776(1)(iv) and
				  (v) (relating to minimum benefit standards
				  for policies or certificates issued for delivery prior to July 30, 1992; and
				  benefits standards for policies or certificates issued or delivered on or after
				  July 30, 1992, and prior to June 1, 2010), a Medicare supplement policy with
				  benefits for outpatient prescription drugs in existence prior to January 1,
				  2006, shall be renewed for current policyholders who do not enroll in Part D at
				  the option of the policyholder.
(2)
				  A Medicare supplement policy with benefits for outpatient prescription drugs
				  may not be issued after December 31, 2005.
(3) After December 31, 2005, a Medicare
				  supplement policy with benefits for outpatient prescription drugs may not be
				  renewed after the policyholder enrolls in Medicare Part D unless the following
				  conditions apply:
(i) The policy is modified
				  to eliminate outpatient prescription coverage for expenses of outpatient
				  prescription drugs incurred after the effective date of the individual's
				  coverage under a Part D plan.
(ii)
				  Premiums are adjusted to reflect the elimination of outpatient prescription
				  drug coverage at the time of Medicare Part D enrollment, accounting for any
				  claims paid, if applicable.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.777b - Standard Medicare supplement benefit plans for 2010 Standardized Medicare supplement benefit plan policies or certificates issued or delivered on or after June 1, 2010

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Applicability
. The following standards apply to 2010
				  Standardized Medicare supplement benefit plan policies or certificates. A
				  policy or certificate may not be advertised, solicited, delivered or issued for
				  delivery in this Commonwealth as a Medicare supplement policy or certificate
				  unless it complies with these benefit plan standards. Benefit plan standards
				  applicable to Medicare supplement policies and certificates issued before June
				  1, 2010, remain subject to the requirements of §
										89.777 (relating to Standard
				  Medicare supplement benefit plans for 1990 Standardized Medicare supplement
				  benefit plan policies or certificates issued or delivered on or after July 30,
				  1992 and prior to June 1, 2010).
(b)
Basic (core) and additional
				  benefits
.
(1) An issuer shall make
				  available to each prospective policyholder and certificateholder a policy form
				  or certificate form containing only the basic (core) benefits, as defined in
				  §
											89.776a(2)
				  (relating to benefit standards for policies or certificates issued or delivered
				  on or after June 1, 2010). An issuer shall also offer a policy or certificate
				  to prospective insureds meeting the Plan B benefit plan.
(2) If an issuer makes available any of the
				  additional benefits described in §
											89.776a(3), or
				  offers standardized benefit Plans K or L (as described in subsections (f)(8)
				  and (9)), the issuer shall make available to each prospective policyholder and
				  certificate holder, in addition to a policy form or certificate form with only
				  the basic (core) benefits as described in paragraph (1) a policy form or
				  certificate form containing either standardized benefit Plan C as described in
				  subsection (f)(3) or standardized benefit Plan F (as described in subsection
				  (f)(5)).
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.777c - Standard Medicare supplement benefit plans for 2020 Standardized Medicare supplement benefit plans issued or delivered to individuals newly eligible for Medicare on or after January 1, 2020

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Applicability.
(1) Except as provided in subsection (d),
				  this section applies to a 2020 Standardized Medicare supplement plan issued or
				  delivered to an individual newly eligible for Medicare on or after January 1,
				  2020, by reason of:
(i) Attainment of 65
				  years of age on or after January 1, 2020.
(ii) Entitlement to Medicare Part A benefits
				  under section 226(b) or 226A of the Social Security Act (42 U.S.C.A. §§
													426(b) and
				  426-1) on or after January 1,
				  2020.
(iii) Entitlement to benefits
				  under section 226(a) of the Social Security Act on or after January 1,
				  2020.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.778 - Open enrollment

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Prohibitions regarding denial, issuance and pricing of Medicare
				  supplement policies or certificates.
(1) An issuer may not deny or condition the
				  issuance or effectiveness of a Medicare supplement policy or certificate
				  available for sale in this Commonwealth, nor discriminate in the pricing of a
				  policy or certificate because of the health status, claims experience, receipt
				  of health care or medical condition of an applicant in the case of an
				  application for a policy or certificate that is submitted prior to or during
				  the 6-month period beginning with the first day of the first month in which
				  either of the following occurs:
(i) An
				  individual enrolled for benefits under Medicare Part B.
(ii) An applicant who is retroactively
				  enrolled in Medicare Part B due to a retroactive eligibility decision made by
				  the Social Security Administration received notice of retroactive eligibility
				  to enroll.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.779 - Standards for claims payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An
				  issuer shall comply with section 1882(c)(3) of the Social Security Act
				  (42 U.S.C.A. §
											1395ss(c)(3) (as enacted by
				  section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA)
				  1987, the act of December 22, 1987 (Pub.L. No. 100, 101 Stat. 1330) by:
(1) Accepting a notice from a Medicare
				  carrier on dually assigned claims submitted by participating physicians and
				  suppliers as a claim for benefits in place of another claim form otherwise
				  required and making a payment determination on the basis of the information
				  contained in that notice.
(2)
				  Notifying the participating physician or supplier and the beneficiary of the
				  payment determination.
(3) Paying
				  the participating physician or supplier directly.
(4) Furnishing, at the time of enrollment,
				  each enrollee with a card listing the policy name, number and a central mailing
				  address to which notices from a Medicare carrier may be sent.
(5) Paying user fees for claim notices that
				  are transmitted electronically or otherwise.
(6) Providing to the Secretary of Health and
				  Human Services, at least annually, a central mailing address to which all
				  claims may be sent by Medicare carriers.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.780 - Loss ratio standards and refund or credit of premium

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Loss ratio standards.
(1) A Medicare Supplement policy form or
				  certificate form may not be delivered or issued for delivery unless the policy
				  form or certificate form can be expected, as estimated for the entire period
				  for which rates are computed to return to policyholders and certificateholders
				  in the form of aggregate benefits, a percentage of the aggregate amount of
				  premiums earned as listed in this paragraph. The amount returned to
				  policyholders and certificateholders shall be calculated on the basis of
				  incurred claims experience or incurred health care expenses when coverage is
				  provided by a health maintenance organization on a service rather than
				  reimbursement basis, and on earned premiums for the period. The calculation
				  shall be made in accordance with accepted actuarial principles and practices.
				  This does not include anticipated refunds or credits provided under the policy
				  form or certificate form. The amount returned as benefits shall be equal to:
(i) At least 75% of the aggregate amount of
				  premiums earned in the case of group policies.
(ii) At least 65% of the aggregate amount of
				  premiums earned in the case of individual policies.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.781 - Filing and approval of policies and certificates and premium rates

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Approval of policy or certificate
. An issuer may not deliver
				  or issue for delivery a policy or certificate to a resident of this
				  Commonwealth, unless the policy form or certificate form has been filed with
				  and approved by the Commissioner in accordance with filing requirements and
				  procedures prescribed by the Commissioner.
(b) An issuer shall file any riders or
				  amendments to policy or certificate forms to delete outpatient prescription
				  drug benefits as required by the Medicare Prescription Drug, Improvement, and
				  Modernization Act of 2003, the act of December 8, 2003 (Pub. L. No.
				  108-173, 117 Stat. 2066), only with the
				  commissioner in the state in which the policy or certificate was
				  issued.
(c)
Filing of
				  rating schedule and supporting documentation
. An issuer may not use or
				  change premium rates for a Medicare supplement policy or certificate unless the
				  rates, rating schedule and supporting documentation have been filed with and
				  approved by the Commissioner in accordance with the filing requirements and
				  procedures prescribed by the Commissioner.
(d)
Exceptions
.
(1) Except as provided in paragraph (2), an
				  issuer may not file for approval more than one form of a policy or certificate
				  of each type for each standard Medicare supplement benefit plan.
(2) An issuer may offer, with the approval of
				  the Commissioner, up to three additional policy forms or certificate forms of
				  the same type for the same standard Medicare supplement benefit plan. These
				  additional forms may include one or more of the following three variations.
				  Forms with only these variations will be regarded as new policy forms under
				  each type:
(i) The inclusion of new or
				  innovative benefits.
(ii) The
				  addition of either direct response or producer marketing methods.
(iii) The addition of either guaranteed issue
				  or underwritten coverage.
(3) For the purpose of this section, a "type"
				  means an individual policy, a group policy, an individual Medicare Select
				  Policy or a group Medicare Select Policy.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.782 - Permitted compensation arrangements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An issuer or other entity may provide a
				  commission or other compensation to a producer or other representative for the
				  sale of a Medicare supplement policy or certificate only if the 1st-year
				  commission or other 1st- year compensation is no more than 200% of the
				  commission or other compensation paid for selling or servicing the policy or
				  certificate in the 2nd year or period.
(b) The commission or other compensation
				  provided in subsequent (renewal) years shall be the same as that provided in
				  the 2nd year or period and shall be provided for no fewer than 5 renewal
				  years.
(c) An issuer or other
				  entity may not provide compensation to its producers or its other
				  representatives and a producer may not receive compensation greater than the
				  renewal compensation payable by the replacing issuer on renewal policies or
				  certificates if an existing policy or certificate is replaced.
(d) For purposes of this section,
				  compensation includes pecuniary or nonpecuniary remuneration of any kind
				  relating to the sale or renewal of the policy or certificate, including
				  bonuses, gifts, prizes, awards and finders fees.
Pennsylvania Code › Title 31 - INSURANCE › Part IV - Life Insurance › Chapter 89 - APPROVAL OF LIFE, ACCIDENT AND HEALTH INSURANCE › Subchapter K - MEDICARE SUPPLEMENT INSURANCE MINIMUM STANDARDS › Section 89.785 - Filing requirements for advertising

Current through Register Vol. 54, No. 28, July 13, 2024
An issuer shall provide a copy of any Medicare supplement
					 advertisement intended for use in this Commonwealth whether through written,
					 radio or television medium to the Commissioner for review or approval by the
					 Commissioner to the extent it may be required under State
					 law.