reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 147 - ANNUAL FINANCIAL REPORTING REQUIREMENTS › Section 147.3a - Requirements for audit committees

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				Every insurer required to file an annual audited financial report under this
				chapter shall establish an audit committee.
(b) An ultimate controlling person may
				designate an audit committee of a controlling person to be the audit committee
				for one or more controlled insurers. The designation must:
(1) Be in writing.
(2) Identify the ultimate controlling
				person.
(3) Explain the basis for
				the designation in sufficient detail for the Department to determine compliance
				with this chapter.
(4) Be provided
				by the ultimate controlling person or the insurer to the Department and the
				chief insurance regulatory official of each other state in which the controlled
				insurers are domiciled no later than April 1 of the year in which the insurer's
				audited financial report is required to be filed under this chapter.
(5) Be effective upon receipt by the
				Department and remain in effect unless modified or rescinded by subsequent
				notice provided by the ultimate controlling person or the insurer as required
				under paragraph (4).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 147 - ANNUAL FINANCIAL REPORTING REQUIREMENTS › Section 147.4 - Contents of annual audited financial report

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The annual audited financial report shall
				reflect the financial condition of the insurer as of the end of the most recent
				calendar year and the results of its operations, cash flows and changes in
				capital and surplus for the year then ended in conformity with statutory
				accounting practices prescribed, or otherwise permitted, by the Department.
				Statutory accounting practices are those practices and procedures prescribed by
				the Accounting Practices and Procedures Manuals published by the National
				Association of Insurance Commissioners, or as otherwise prescribed or provided
				by specific statutes, regulations, orders or rulings of the Commonwealth or the
				Department.
(b) The annual audited
				financial report must, at a minimum, include the following:
(1) Financial statements that present in a
				comparable manner, as of the end of the current and the preceding calendar
				year, the financial condition of the insurer, including the following:
(i) Statement of admitted assets,
				liabilities, capital and surplus.
(ii) Statement of operations.
(iii) Statement of cash flows.
(iv) Statement of changes in capital and
				surplus.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 147 - ANNUAL FINANCIAL REPORTING REQUIREMENTS › Section 147.6 - Recognition, qualification and responsibilities of an independent certified public accountant

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An
				annual audited financial report must be prepared by a qualified independent
				certified public accountant recognized by the Commissioner.
(b) Except for insurers organized in Canada
				or the United Kingdom of Great Britain and Northern Ireland, the Commissioner
				will not recognize a person or firm as a qualified independent certified public
				accountant nor accept an annual audited financial report prepared in whole or
				in part by the person or firm under any of the following conditions:
(1) The person is not licensed, or the firm
				is not registered, to practice and is not in good standing under the laws of
				the Commonwealth or of a state with licensing requirements similar to the
				Commonwealth.
(2) The person or
				firm is not in good standing with the American Institute of Certified Public
				Accountants, Inc. and, if applicable, the Public Company Accounting Oversight
				Board.
(3) The person or firm is
				not in good standing in all states in which the person is licensed, or the firm
				is registered, to practice.
(4) The
				person or firm has entered into an agreement of indemnity, or other release
				from liability, that would shift, transfer, or limit in any manner the
				potential liability of the person or firm for failure, whether by omission or
				commission, to adhere to applicable auditing or professional standards, whether
				or not the failure would result in whole or in part from misrepresentations
				made by the insurer or its representatives.
(5) The person or firm employed a partner or
				senior manager who was involved in an audit of the insurer during the 1 year
				period preceding the date that the most current annual audited financial report
				is due and who currently serves as a member of the board of directors,
				president, chief executive officer, controller, chief financial officer, chief
				accounting officer, or in any equivalent position for the insurer.
(6) The person or firm provides to the
				insurer contemporaneously with the audit any of the following non-audit
				services:
(i) Bookkeeping or other services
				relating to the insurer's accounting records or financial statements.
(ii) Financial information systems design and
				implementation.
(iii) Appraisal or
				valuation services, fairness opinions or contribution-in-kind
				reports.
(iv) Actuarial advisory
				services.
(v) Internal audit
				outsourcing services.
(vi)
				Management functions or human resource services.
(vii) Broker or dealer, investment adviser or
				investment banking services.
(viii)
				Legal or expert services unrelated to the audit.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 147 - ANNUAL FINANCIAL REPORTING REQUIREMENTS › Section 147.6a - Letter of qualifications of independent certified public accountant

Current through Register Vol. 54, No. 28, July 13, 2024
The independent certified public accountant shall furnish the
				  insurer for inclusion in the filing of the annual audited financial report a
				  letter of qualifications that includes the following:
(1) A statement that the certified public
				accountant is independent from the insurer and conforms to the standards of the
				profession as contained in the Code of Professional Ethics and pronouncements
				of the American Institute of Certified Public Accountants, Inc. and The C.P.A.
				Law (63 P.S. §§
										9.1-9.16(b)) or similar
				laws.
(2) A general description of
				the independent certified public accountant's background and
				experience.
(3) A specific
				description of the insurer auditing experience of partners, senior managers,
				in-charge auditors or other key staff persons assigned to the engagement and a
				statement as to whether each staff person is an independent certified public
				accountant. This provision does not prohibit the independent certified public
				accountant from utilizing staff as the independent certified public accountant
				deems appropriate when consistent with the standards prescribed by generally
				accepted auditing standards.
(4) A
				statement that the independent certified public accountant understands that the
				annual audited financial report that the independent certified public
				accountant's opinion thereon will be filed in compliance with this chapter and
				that the Commissioner will be relying on this information in the monitoring and
				regulation of the financial position of insurers.
(5) A statement that the independent
				certified public accountant consents to the requirements of §
									147.11 (relating to definitions,
				availability and maintenance of independent certified public accountant
				workpapers) and that the independent certified public accountant consents and
				agrees to make available for review by the Commissioner, the Commissioner's
				designee or Department examiners, the workpapers, as defined in §
				147.11.
(6) Representation that the
				independent certified public accountant is properly licensed by an appropriate
				state licensing authority and is a member in good standing in the American
				Institute of Certified Public Accountants, Inc.
(7) Representation that the independent
				certified public accountant is in compliance with §
									147.6 (relating to recognition,
				qualification and responsibilities of an independent certified public
				accountant).
The section cited in 31 Pa. Code §
											147.6 (relating to recognition,
					 qualification and responsibilities of an independent certified public
					 accountant).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 147 - ANNUAL FINANCIAL REPORTING REQUIREMENTS › Section 147.6b - Conduct of insurer relating to audits

Current through Register Vol. 54, No. 28, July 13, 2024
(a) When communicating with any accountant
				relating to an audit, review or communication required under this chapter, an
				officer or director of an insurer may not directly or indirectly:
(1) Make or cause to be made a materially
				false or misleading statement.
(2)
				Omit or cause another person to omit any material fact necessary to make
				statements made, in light of the circumstances under which the statements are
				made, not misleading.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 147 - ANNUAL FINANCIAL REPORTING REQUIREMENTS › Section 147.8 - Scope of audit and report of independent certified public accountant

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The annual
				financial statements filed by an insurer with the Department shall be audited
				by an independent certified public accountant. The audit of the financial
				statements of the insurer shall be conducted in accordance with generally
				accepted auditing standards.
(b)
				The scope of the audit and data testing procedures shall be conducted as
				required by the appropriate
Annual Statement Instructions
adopted by the NAIC. Consideration shall also be given to other procedures in
				the
Financial Condition Examiner's Handbook
adopted by the
				NAIC. The independent certified public accountant shall obtain an understanding
				of internal control sufficient to plan the audit in accordance with AU Section
				319 of the Porfessional Standards of the American Institute of Certified Public
				Accountants,
Consideration of Internal Control in a Financial Statement
				Audit
(AU 319). To the extent required by AU 319 and as part of the
				independent certified public accountant's professional requirements defined in
				Statement on Auditing Standards (SAS) No. 102,
Defining Professional
				Requirements in Statements on Auditing Standards
or its replacement,
				the independent certified public accountant shall consider the most recently
				available Management's Report of Internal Control over Financial Reporting, as
				required under §
									147.9b, in planning and performing
				the audit of an insurer's statutory financial statements.
(c) Subsection (b) does not apply to
				continuing care providers.
(d) The
				Commissioner may prescribe that additional auditing procedures be observed by
				the independent certified public accountant in the audit of the financial
				statements of insurers under this chapter.
The provisions of this §
											147.8 amended under the authority
					 of sections 206, 506, 1501 and 1502 of The Administrative Code of 1929
					 (71
					 P.S. §§
												66,
					 186,
					 411 and
					 412); sections 320, 630, 1007
					 and 2452 of The Insurance Company Law of 1921 (40 P.S. §§
												443,
					 764a,
					 967 and
					 991.2452); sections 205 and
					 206 of The Pennsylvania Fair Plan Act (40 P.S. §§
												1600.205 and
					 1600.206); section 731 of the
					 Medical Care Availability and Reduction of Error (MCARE) Act (40 P.S. §
												1303.731);
					 40 Pa.C.S. §§
												6125,
					 6331 and
					 6701; sections 11 and 14
					 of the Health Maintenance Organization Act (40 P.S. §§
												1561 and
					 1564); and sections 7 and 25
					 of the Continuing-Care Provider Registration and Disclosure Act (40 P.S.
					 §§
												3207 and
					 3225).
This section cited in 31 Pa. Code §
											147.12 (relating to
					 examinations).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 147 - ANNUAL FINANCIAL REPORTING REQUIREMENTS › Section 147.8a - Internal audit function requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Exemption
. An insurer is
				exempt from the requirements of this section if:
(1) The insurer meets the following
				requirements:
(i) Has annual direct written
				and unaffiliated assumed premium, including international direct and assumed
				premium excluding premiums reinsured with the Federal Crop Insurance
				Corporation and Federal Flood Program, less than $500 million.
(ii) If the insurer is a member of a group of
				insurers, the group has annual direct written and unaffiliated assumed premium
				including international direct and assumed premium, excluding premiums
				reinsured with the Federal Crop Insurance Corporation and Federal Flood
				Program, less than $1 billion.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 147 - ANNUAL FINANCIAL REPORTING REQUIREMENTS › Section 147.9 - Notification of adverse financial condition

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An insurer required by this chapter to
				file an annual audited financial report shall require the independent certified
				public accountant to report, in writing, within 5 business days to the board of
				directors or audit committee of the insurer, any of the following:
(1) A determination by the independent
				certified public accountant that the insurer has materially misstated its
				financial condition as reported to the Commissioner as of the balance sheet
				date currently being audited.
(2) A
				determination by the independent certified public accountant that the insurer
				does not meet its capital and surplus requirement, or that the continuing care
				provider does not meet its liquid reserve requirement, under laws and
				regulations relating to the insurer or continuing care provider as of the
				balance sheet date currently being audited.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 147 - ANNUAL FINANCIAL REPORTING REQUIREMENTS › Section 147.9a - Establishment and communication of internal control over financial reporting

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An insurer or
				insurer group shall establish internal control over financial reporting
				policies and procedures designed to provide reasonable assurance that:
(1) The financial statements of the insurer
				or insurer group as required under §
										147.4(b) and (c)
				(relating to contents of annual audited financial report) are
				reliable.
(2) Records are created
				and maintained to accurately and fairly reflect dispositions of assets and
				other transactions.
(3)
				Transactions are recorded as needed to prepare financial statements.
(4) Receipts and expenditures are made only
				as authorized by the management or board of directors of the insurer or insurer
				group.
(5) Unauthorized
				acquisition, use or disposition of assets that could have a material effect on
				the financial statements of the insurer or insurer group are prevented or
				detected in a timely manner.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 147 - ANNUAL FINANCIAL REPORTING REQUIREMENTS › Section 147.14 - Penalties

Current through Register Vol. 54, No. 28, July 13, 2024
Failure to file the annual audited financial report and
				  additional statements, letters or reports required by this chapter or failure
				  to comply with §
									147.11 (relating to definition,
				  availability and maintenance of independent certified public accountant
				  workpapers) will subject the insurer to the penalties provided by
				  law.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 148a - SAFEGUARDING INSURER SECURITIES › Section 148a.1 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
				  have the following meanings, unless the context clearly indicates otherwise:
Agent
-
(i) A National bank, state bank or trust
				company that does any of the following:
(A)
				Maintains an account in its name in a clearing corporation.
(B) Is a member of the Federal Reserve System
				through which a custodian participates in a clearing corporation or the Federal
				Reserve book-entry system.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 148a - SAFEGUARDING INSURER SECURITIES › Section 148a.2 - Permissible methods of holding securities

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An insurer may hold its securities in
				definitive certificates.
(b) An
				insurer may provide for its securities to be held by a custodian under a
				custodial agreement as required under §
									148a.3 (relating to requirements
				for custodial agreements). Securities held under a custodial agreement shall be
				held by:
(1) The custodian.
(2) The custodian's agent.
(3) A clearing corporation.
(4) The Federal Reserve book-entry
				system.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 148a - SAFEGUARDING INSURER SECURITIES › Section 148a.3 - Requirements for custodial agreements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An agreement between an insurer and a
				custodian providing for the custody of the insurer's securities under §
									148a.2(b)
				(relating to permissible methods of holding securities) shall be:
(1) In writing.
(2) Authorized by a resolution of either the
				insurer's board of directors or an authorized committee of its board of
				directors.
(3) Signed by at least
				one officer of the insurer and one officer of the
				custodian.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 148a - SAFEGUARDING INSURER SECURITIES › Section 148a.4 - Requirements for investment company securities

Current through Register Vol. 54, No. 28, July 13, 2024
An insurer's investment company securities may be held by the
				  investment company that issued the investment company securities if the
				  investment company:
(1) Provides the
				insurer with written reports on at least a monthly basis of the insurer's
				investment, including written confirmations of all transfers of investments to
				or from the insurer's account. The reports and confirmations may be transmitted
				in electronic or paper form.
(2)
				Maintains records and information sufficient to enable the insurer to:
(i) Comply with accounting and reporting
				requirements for financial statements and supporting schedules filed with the
				Department, to the extent that information maintained by the investment company
				is relied upon by the insurer to prepare its financial statements.
(ii) Provide information required in a
				financial examination of the insurer under Article IX of The Insurance
				Department Act of 1921 (40 P. S. §§
											323.1-323.8) or an audit, including the
				identifying numbers assigned to the securities by the Committee on Uniform
				Securities Identification Procedures (CUSIP).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 148a - SAFEGUARDING INSURER SECURITIES › Section 148a.5 - Penalty and existing custodial agreements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Failure to comply with this chapter will
				result in the treatment of an insurer's securities or investment company
				securities as nonadmitted assets for purposes of financial reports filed with
				the Department.
(b) With respect to
				custody agreements entered into prior to November 2, 2002, and in compliance
				with laws or regulations in existence immediately preceding November 2, 2002,
				insurers have until November 3, 2003, to achieve compliance with this
				chapter.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 150 - UNIFORM HEALTH INSURANCE CLAIM FORM-STATEMENT OF POLICY › Section 150.1 - HCFA 1500 and UB 82 Health Insurance Claim Forms

Current through Register Vol. 54, No. 28, July 13, 2024
Article XII of The Insurance Company Law of 1921
				  (40
				  P. S. §§
										991.1201-991.1205) directs
				  the Insurance Department to develop a uniform health insurance claim form.
				  Effective November 1, 1993, the Department of Public Welfare's health care
				  coverage program and all insurers, as defined in section 1201 of The Insurance
				  Company Law of 1921 (40 P. S. §
										992.1201),
				  shall accept from Pennsylvania health care providers the HCFA 1500 and UB 82
				  forms, or their successors, as required for use in the Federal Medicare
				  Program, for services performed in this Commonwealth for which providers are
				  required to submit a claim form for reimbursement.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 150 - UNIFORM HEALTH INSURANCE CLAIM FORM-STATEMENT OF POLICY › Section 150.2 - Additional information requests

Current through Register Vol. 54, No. 28, July 13, 2024
As required by Article XII of The Insurance Company Law of
				  1921 (40 P. S. §§
										991.1201-991.1205), the uniform health
				  insurance claim form shall contain blank spaces for additional information
				  requests. An insurer or the Department of Public Welfare may request Insurance
				  Departmental approval of additional information to be printed in the blank
				  spaces on the uniform health insurance claim form, and on subsequent pages, if
				  necessary. The requests will be published in the
Pennsylvania
				  Bulletin
for public comment. The Insurance Department will review the
				  requests in accordance with the procedures under 2 Pa.C.S. (relating to
				  administrative law and procedure). The requests will be deemed approved by the
				  Insurance Department if not disapproved within 60 days after receipt of the
				  request.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 150 - UNIFORM HEALTH INSURANCE CLAIM FORM-STATEMENT OF POLICY › Section 150.3 - Exceptions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				requirements of Article XII of The Insurance Company Law of 1921 (40 P. S.
				§§
										991.1201-991.1205) do not extend
				to items such as logos, letterhead, color of paper or ink type.
(b) The requirements of Article XII of The
				Insurance Company Law of 1921 also do not extend to claims related to
				pharmaceutical services.
(c) In the
				case of vision, dental and supplemental major medical claims, utilization of
				the uniform health insurance claim form shall be at the discretion of the
				individual insurer.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 150 - UNIFORM HEALTH INSURANCE CLAIM FORM-STATEMENT OF POLICY › Section 150.4 - Electronic billing

Current through Register Vol. 54, No. 28, July 13, 2024
When a health care provider and an insurer agree to submit
				  and accept claims on an electronic basis, the agreement shall be deemed to
				  constitute compliance with Article XII of The Insurance Company Law of 1921
				  (40
				  P. S. §§
										991.1201-991.1205).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 150 - UNIFORM HEALTH INSURANCE CLAIM FORM-STATEMENT OF POLICY › Section 150.5 - Request for extension of time

Current through Register Vol. 54, No. 28, July 13, 2024
The Insurance Department may consider a request from the
				  Department of Public Welfare for an extension in meeting the implementation
				  deadline under section 1202(b) of The Insurance Company Law of 1921
				  (40
				  P. S. §
										991.1202(b)). A
				  request by the Department of Public Welfare and the Insurance Department's
				  subsequent ruling will be published in the
Pennsylvania
				  Bulletin
.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 151 - CONTINUING CARE PROVIDERS › Section 151.1 - Purpose

Current through Register Vol. 54, No. 28, July 13, 2024
The purpose of this chapter is to implement the Continuing
				  Care Provider Registration and Disclosure Act (40 P. S. §§
										3201-3225).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 151 - CONTINUING CARE PROVIDERS › Section 151.3 - Certificates of authority

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				provider shall apply for, and obtain, a certificate of authority for each
				separate facility operated by the provider in this Commonwealth.
(b) A certificate of authority authorizes and
				empowers only the provider named therein to conduct the business of continuing
				care, and may not be transferable.
(c) Each applicant shall file an application
				for a certificate of authority on a prescribed form, which may be obtained from
				the Department.
(d) Each
				application for a certificate of authority shall be accompanied by the
				documents referenced in the following:
(1)
				Section 151.4 (relating to statement in
				support of application).
(2)
				Section 151.7 (relating to disclosure
				statements).
(3) Section
				151.8 (relating to resident's
				agreement).
(4) Section 151.14
				(relating to fees).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 151 - CONTINUING CARE PROVIDERS › Section 151.5 - Issuance of certificates of authority

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the Commissioner determines that all
				of the statutory and regulatory requirements for the issuance of a certificate
				of authority have been met, a certificate of authority shall be issued within
				the time prescribed by section 4(c) of the act (40 P. S. §
										3204(c)), or an extension
				thereof under section 4(d) of the act (40 P. S. §
										3204(d)).
(b) The certificate of authority shall
				certify that the provider named therein has complied with the act, and
				authorize and empower the provider to transact the business of continuing care
				in compliance with the statutes of the Commonwealth and this title.
(c) If the Commissioner determines that the
				statutory or regulatory requirements have not been met, an order rejecting the
				application for a certificate of authority will be issued under section 4(d) of
				the act (40 P. S. §
										3204(d)). Orders denying an
				application for a certificate of authority shall not become final and
				appealable until after an administrative hearing conforming to
				2
				Pa.C.S. §§
										501-508 (relating to
				practice and procedure of Commonwealth agencies) has been held. Final orders
				entered after a hearing upon an applicant's petition for reconsideration of the
				denial shall be adjudications within the meaning of
				2
				Pa.C.S. §
										101 (relating to
				definitions).
(d) If the
				Commissioner determines that the issuance of a temporary certificate of
				authority is authorized under section 4(e) of the act (40 P. S. §
										3204(e)), a temporary
				certificate of authority will be issued authorizing and empowering the provider
				to transact the business of continuing care in compliance with the statutes of
				the Commonwealth and this title for a stated period of time, which shall not
				exceed 2 years from the date of issuance of the temporary certificate of
				authority.
(e) Upon petition of a
				provider, if the Commission determines that an extension of a temporary
				certificate of authority is authorized under section 4(f) of the act
				(40
				P. S. §
										3204(f)), an
				extended temporary certificate of authority shall be issued authorizing and
				empowering the provider to transact the business of continuing care in
				compliance with the statutes of the Commonwealth and this title for a stated
				period of time, which shall not exceed 3 years from the date of issuance of the
				extended temporary certificate of authority.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 151 - CONTINUING CARE PROVIDERS › Section 151.6 - Transfers of ownership

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Transfer of ownership of a facility.
(1) A provider intending to undertake a
				transfer of ownership of a facility shall notify the Department at least 30
				days in advance of the proposed settlement date.
(2) A notice of intention to transfer
				ownership of a facility may be in the form of a letter, addressed to the
				Department, and shall contain the following information:
(i) Name and address of the licensed provider
				from whom ownership will be transferred.
(ii) Name and address of the person intending
				to acquire the ownership interest.
(iii) Name and address of a facility whose
				ownership is being transferred.
(iv) Proposed settlement date.
(3) No transfer of ownership of a
				facility shall be consummated until the person to whom ownership is being
				transferred obtains a certificate of authority.
(4) When a person to whom ownership is being
				transferred files an application for a certificate of authority, in addition to
				the information specified in §
										151.3(d)
				(relating to certificates of authority), the person shall file a statement
				containing the following information:
(i) The
				terms and conditions of the transfer of ownership.
(ii) The source of funds to be used to
				finance the transfer of ownership and, if the funds are to be borrowed, the
				name of a lender and a summary of the terms and conditions of the loan
				transactions.
(iii) The plans,
				arrangements, understandings and intentions of the transferee for the future
				business and management of the facility, including plans as to the sale of
				assets or material change in business, corporate structure or
				management.
(5) A
				certificate of authority will not be issued under this subsection unless the
				transferee has agreed in writing to assume the contractual obligations imposed
				on the current provider by its existing resident
				agreements.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 151 - CONTINUING CARE PROVIDERS › Section 151.7 - Disclosure statements

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				Disclosure statements shall contain the information required by section 7 of
				the act (40 P. S. §
										3207) and the
				information required by this section.
(b) The first page of the disclosure
				statement shall be a cover page, which shall contain the information required
				by section 7(a)(12) of the act (40 P. S. §
										3207(a)(12)).
(c) The disclosure statement shall include a
				page containing a summary of the information presented in the statement, as
				outlined in paragraphs (1)-(8):
(1) The name
				and address of the facility.
(2)
				The name and address of the licensed provider.
(3) The name, location and telephone number
				of the person to be contacted to discuss admissions.
(4) A description of the physical property of
				the facility, including the following facts:
(i) A designation of the facility as urban,
				suburban or rural.
(ii) The number
				of acres occupied by the facility.
(iii) A specification of the type of
				residential units available-such as high-rise apartments, single level
				buildings, two-story townhouses, and the like.
(5) A specification of the minimum age for
				admission, including exceptions for spouses/companions.
(6) A disclosure of the provider's or
				facility's affiliation with religious, fraternal, charitable or other nonprofit
				organizations with an identification of the affiliated organizations.
(7) A statement of the current resident
				population.
(8) A sample of the
				fees charged to residents based upon occupancy of a one bedroom unit by one and
				two persons, including entrance and periodic fees. The information summary
				shall be provided in numbered paragraph form, as specified in this subsection,
				so that consumers can easily compare the disclosure statements of several
				facilities. Additionally, the summary data will be used by the Department in
				compiling information for its publication of a consumer's guide to continuing
				care facilities and its annual directory of continuing care
				facilities.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 151 - CONTINUING CARE PROVIDERS › Section 151.8 - Resident's agreement

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Each
				resident's agreement shall contain the information required by section 14 of
				the act (40 P. S. §
										3214) and the
				information required by this section.
(b) A valid and binding resident's agreement
				shall be signed by the provider and each resident who will be admitted to the
				facility. An authorized representative may sign the resident's agreement on
				behalf of either party.
(c) If the
				resident has agreed to purchase, at an additional price, optional products or
				services beyond those included in the entrance and periodic fees, a separate
				page shall be attached specifying the product or service purchased, and the
				cost of each including installation charge. The page shall be executed by the
				parties identified in subsection (b).
(d) Each resident's agreement shall contain a
				provision whereby the provider agrees that the resident shall not be liable to
				a health care provider for services rendered under a resident's agreement. In
				the event a health care provider seeks payment from the resident, the
				continuing care provider shall assume liability for payment of the health care
				services rendered, if the health care services rendered are services which a
				provider agreed to furnish to a resident in consideration of the resident's
				payment of entrance and periodic fees. Health care providers shall include
				persons rendering services to a resident as employes of the provider or
				facility, on a fee-for-service basis, or otherwise.
(e) Amendments to the resident's agreement
				may be filed with the Department at any time. The filing should be accompanied
				by a cover letter briefly outlining the sections of the resident's agreement
				amended.
(f) The resident's
				agreement shall be distributed as follows:
(1)
				A copy of the current resident's agreement shall be attached as an appendix to
				each disclosure statement or amended disclosure statement filed with the
				Department.
(2) A copy of the
				current resident's agreement shall be attached to each disclosure statement
				given to a prospective resident, unless the individual previously received a
				disclosure statement with a resident's agreement attached thereto, and the
				resident's agreement has not been amended subsequent to that time.
(3) A copy of the current resident's
				agreement need not be given to current residents.
(4) If a resident's agreement is not attached
				to the disclosure statement, as authorized under paragraphs (2) and (3), a
				separate page shall be attached stating that a copy of the resident's agreement
				was omitted.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 151 - CONTINUING CARE PROVIDERS › Section 151.9 - Standards for disclosure statement and resident's agreement

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Drafting.
Disclosure
				statements and resident's agreements shall be drafted in consideration of the
				amount and nature of the information to be relayed to prospective
				residents.
(b)
Readability.
Documents given to residents and prospective residents, including
				disclosure statements and resident's agreements, shall be drafted in accordance
				with the following standards:
(1) The language
				used shall be readable by a person of average intelligence and
				education.
(2) Information
				presented should be conveyed in a logical sequence and in a clear and direct
				fashion.
(3) Complex and compound
				sentences should be avoided.
(4)
				Words should convey their commonly understood meanings.
(5) Definitions shall be included for words
				or terms which cannot properly be explained or qualified in the text.
(6) Frequent section headings should be used
				to permit ease in locating provisions.
(7) Documents shall be printed in easily
				legible typeface. A sample of typefaces which meet minimum standards of
				legibility may be found in §
										64.9 (relating to
				legibility).
(8) Documents shall be
				printed in type-size easily legible to the audience to whom the literature is
				directed. Upright type at least as large as 10-point type should be
				used.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 151 - CONTINUING CARE PROVIDERS › Section 151.10 - Investments

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Funds of a
				provider which are permitted or required to be invested under the act shall be
				invested in good faith and with the degree of care that an ordinarily prudent
				individual in a like position would exercise under similar circumstances.
(1) Funds which are required to be invested
				shall include the entrance fees maintained in an escrow account, under section
				12 of the act (40 P. S. §
											3212).
(2) Funds which are permitted to be invested
				shall include liquid reserves established under section 9 of the act
				(40
				P. S. §
											3209), and reserve fund escrow
				accounts established under section 10 of the act (40 P. S. §
											3210).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 151 - CONTINUING CARE PROVIDERS › Section 151.11 - Annual statements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) At the
				time the annual disclosure statement is filed, each provider shall submit to
				the Department an annual statement detailing its financial status as of the
				close of business on the last day of the provider's fiscal year.
(b) Providers holding one or more
				certificates of authority to operate facilities organized as separate and
				distinct legal entities from the provider shall file an annual statement for
				each separate facility.
(c) Annual
				statements shall be filed on a prescribed form, which is available from the
				Department.
(d) Providers may be
				requested to submit additional information to the Department to supplement
				their annual statement.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 151 - CONTINUING CARE PROVIDERS › Section 151.12 - Reports of examination

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Upon
				completion of a financial examination of a provider as authorized by section 19
				of the act (40 P. S. §
										3219), a
				report of the examination will be prepared.
(b) The report of examination shall be
				submitted to the provider examined, who shall have the privilege of objecting
				to the report within 30 days from the receipt thereof.
(c) Objections to a report of examination
				shall be made in compliance with the requirements of § 58.2
				(reserved).
(d) In the event the
				examined provider raises an objection, the Commissioner will grant a hearing
				and issue a final adjudication before making the report available for public
				inspection. Prior to the final adjudication, a report of examination shall not
				be a public document available under the act of June 21, 1957 (P. L. 390, No.
				212) (65 P. S. §§
										66.1-66.4)
(e) The procedures set forth in §
									58.3 (relating to hearing
				procedure) will be followed for all hearings granted to consider objections to
				a report of examination.
(f) Upon
				acceptance of a report of examination by the provider examined, or upon
				issuance of an adjudication after a hearing has been held to consider
				objections, the Commissioner, if he deems it in the interest of the public to
				do so, may publish all or any portion of the report in a manner he deems
				appropriate.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 151 - CONTINUING CARE PROVIDERS › Section 151.13 - Rehabilitation and liquidation

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				Whenever the Commissioner has been appointed the rehabilitator of, or has been
				authorized to appoint a trustee to rehabilitate, a provider or facility under
				section 16 of the act (40 P. S. §
										3216), the rehabilitation shall be conducted
				in compliance with the act and pertinent standards and procedures contained in
				Article V.
(b) Whenever the
				Commissioner has been appointed the liquidator of, or has been authorized to
				appoint a trustee to liquidate, a provider or facility under section 16 of the
				act (40 P. S. §
										3216), the
				liquidation shall be conducted in compliance with the act and pertinent
				standards and procedures contained in Article V.
(c) In applying Article V standards and
				procedures to a rehabilitation or liquidation under the act, the following
				phrases in Article V shall have the following meanings:
(1) A reference to insurer in Article V shall
				be deemed a reference to the provider or facility for whom a rehabilitator or
				liquidator has been appointed.
(2)
				A reference to policyholder, certificate holder or insured in Article V shall
				be deemed a reference to a resident, or prospective resident who has
				transferred money or other property to a provider.
(3) A reference to a policy or coverage in
				Article V shall be deemed a reference to a resident's agreement.
(4) A reference to a premium in Article V
				shall be deemed a reference to the entrance fee, periodic fees or other charges
				payable by a resident or prospective resident to a provider.
(5) If the provisions of Article V are
				determined to be in conflict with the act, the requirements of the act shall
				control.
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 151 - CONTINUING CARE PROVIDERS › Section 151.14 - Fees

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Upon each
				application for a certificate of authority, the applicant shall pay a fee of
				$750 to the Commonwealth.
(b) Upon
				each petition for an extension of a temporary certificate of authority, the
				applicant shall pay a fee of $100 to the Commonwealth.
(c) Upon each filing of an annual disclosure
				statement as required by section 7(b) of the act (40 P. S. §
										3207(b)), the provider shall
				pay a fee of $750 to the Commonwealth. This fee is not applicable to disclosure
				statements accompanying an application for a certificate of
				authority.
(d) A fee may not be
				charged for an amendment to an application for a certificate of authority, or
				for an amendment to or update of a disclosure statement or resident's
				agreement.
(e) Providers shall be
				subject to the fees set forth in The Administrative Code of 1929 (71 P. S.
				§§
										51-732), including but not
				limited to, the fees contained in section 612-A of The Administrative Code of
				1929 (71 P. S. §
										240.12A).
(f) Whenever an investigation, examination or
				rehabilitation is undertaken as authorized by the act, or as otherwise
				authorized by statute, the provider shall be assessed the expenses incurred by
				the Department, including compensation of Department employes or consultants,
				agents or trustees acting on behalf of the Department, and the expenses of
				these persons for travel, lodging and food, which amounts shall be assessed
				under 4 Pa. Code Chapter 40 (relating to travel and subsistence).
(g) Fees specified in this section shall be
				assessed and billed to providers in accordance with established Department
				procedures and this title.
The provisions of this § 151.14 amended under
					 45 Pa.C.S. §§
												502,
					 503,
					 729-731; and sections 206,
					 506, 1501 and 1502 of The Administrative Code of 1929 (71 P. S.
					 §§
												66,
					 186,
					 411 and
					 412).
This section cited in 31 Pa. Code §
											151.3 (relating to certificates of
					 authority).
Pennsylvania Code › Title 31 - INSURANCE › Part VIII - Miscellaneous Provisions › Chapter 152 - PREFERRED PROVIDER ORGANIZATIONS › GENERAL › Section 152.4 - Scope of Department of Health review of a preferred provider organization

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department of Health will review the applications of preferred provider
				  organizations which assume financial risk and which utilize arrangements or
				  provisions which may lead to undertreatment or poor quality care.
(1) Arrangements or provisions which may lead
				  to undertreatment or poor quality care include, but are not limited to, the
				  following:
(i) Contractual arrangements with
				  physicians or providers in which the physicians or providers agree to arrange,
				  pay for or provide health care services for a fixed payment set and received in
				  advance of health care services, sometimes referred to as capitation
				  reimbursement arrangements.
(ii)
				  Contractual arrangements with physicians or providers in which a type of
				  financial incentive structure is employed which conditions the provider's
				  payment for service, or a portion thereof, upon gains or losses experienced by
				  an insurer or purchaser resulting from preferred provider arrangements or which
				  allows a provider to share in the gains or losses, sometimes referred to as fee
				  withholding risk pool arrangements.
(iii) Health benefit plans under which the
				  reimbursement received by an enrollee for a health care service rendered by a
				  nonpreferred provider is less than 80% of the payment which a preferred
				  provider would receive from the preferred provider organization for the same
				  health care service.
(iv) Health
				  benefit plans under which an enrollee who receives a health care service from a
				  nonpreferred provider is liable for payment of more than 20% of the payment
				  which a preferred provider would receive from the preferred provider
				  organization for the same health care service. For the purpose of calculating
				  this percentage, cost-sharing amounts shall be excluded if cost-sharing is
				  applied by the preferred provider arrangement regardless of whether a health
				  care service is rendered by a preferred or a nonpreferred provider.
(v) Health benefit plans under which coverage
				  for health care services is provided only when the services are rendered by a
				  preferred physician or provider participating in the preferred provider
				  arrangement.