reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67 - CATASTROPHIC LOSS BENEFITS CONTINUATION FUND › Subchapter C - SURCHARGE DISCLOSURE PLAN › Section 67.33 - Assessment of premium surcharge

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Circumstances where a premium surcharge can be assessed on a named
				  insured.
(1) Insurers may assess a
				  premium surcharge on policies where payment for at-fault accidents exceeds
				  their approved dollar threshold. An at-fault accident is one where the insured
				  was at fault in causing or contributing to the accident, and the claim
				  resulting from that accident was paid in part or in whole by the
				  insurer.
(2) Insurers may assess a
				  premium surcharge on policies where an insured has been convicted of at least
				  two violations of an offense enumerated in
				  75 Pa.C.S. §
												1535
				  (relating to schedule of convictions and points).
(i) To impose a surcharge the two violations
				  must have occurred in a period of time no more than 36 months in
				  duration.
(ii) To impose a
				  surcharge the accumulation of two violations must have been committed by one
				  individual insured in the household covered by the policy.
(3) Where an insurer imposes a surcharge for
				  an at-fault accident, the amount of the surcharge may be increased if the same
				  accident also resulted in two
				  75 Pa.C.S. §
												1535
				  convictions.
(4) Offenses that
				  occur while operating a motor vehicle other than those listed in
				  75 Pa.C.S. §
												1535 may
				  be used in a premium surcharge plan.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67 - CATASTROPHIC LOSS BENEFITS CONTINUATION FUND › Subchapter C - SURCHARGE DISCLOSURE PLAN › Section 67.34 - Contents of the surcharge disclosure plan

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A surcharge disclosure plan shall
				  describe the circumstances and conditions when a surcharge would be applied,
				  the estimated increase of the surcharge per policy period per policyholder and
				  the number of years a surcharge will be in effect. The estimated increase of
				  the surcharge may be stated as a percent or dollar amount of premium increase.
				  The estimated increase may also be stated as a percentage of the base premium
				  if the insurer describes the manner in which the prospective or named insured's
				  premium relates to the base premium.
(b) The insurer shall disclose the approved
				  dollar threshold in the surcharge disclosure plan.
(c) The insurer shall disclose in the
				  surcharge disclosure plan whether the insurer will assess a premium surcharge
				  due to the payment of an at-fault accident by another insurer.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67 - CATASTROPHIC LOSS BENEFITS CONTINUATION FUND › Subchapter C - SURCHARGE DISCLOSURE PLAN › Section 67.35 - Distribution of the surcharge disclosure plan

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Prospective insured.
Beginning on October 1, 1984, the insurer shall give the surcharge disclosure
				  plan to each prospective insured at the time application is made for motor
				  vehicle insurance coverage.
(b)
Named insured.
Beginning on October 1, 1984, the insurer shall
				  deliver the surcharge disclosure plan to each named insured at least once every
				  year.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67 - CATASTROPHIC LOSS BENEFITS CONTINUATION FUND › Subchapter D - STATEMENTS OF POLICY › Section 67.41 - Eligibility guidelines for the Catastrophic Loss Trust Fund for accidents on and after June 1, 1989

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Section
				  1798.2(a) of the
				  act (relating to transition), added by the act of April 26, 1989 (P. L. ___,
				  No. 4) (Act 4), continues the Catastrophic Loss Trust (CAT) Fund eligibility
				  for certain individuals suffering catastrophic losses after June 1, 1989. The
				  Department will be guided by this section in making eligibility determinations
				  for accidents occurring on or after 12:01 a.m., June 1, 1989.
(b) Natural persons who suffer catastrophic
				  losses on or after 12:01 a.m., June 1, 1989, may be eligible for benefits from
				  the CAT Fund if the following apply:
(1) They
				  are injured in an accident arising out of the maintenance or use of a motor
				  vehicle.
(2) The accident giving
				  rise to the claim for CAT Fund benefits occurred during the registration year
				  for which the CAT Fund charge had been paid on one or more of the motor
				  vehicles involved in the accident.
(3) They otherwise are "eligible claimants"
				  as defined in
				  75 Pa.C.S. §
												1761
				  (repealed).
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67 - CATASTROPHIC LOSS BENEFITS CONTINUATION FUND › Subchapter D - STATEMENTS OF POLICY › Section 67.43 - Coordination of benefits between the Catastrophic Loss Trust Fund and Extraordinary Medical Benefit Coverage

Current through Register Vol. 54, No. 28, July 13, 2024
An individual eligible for CAT Fund benefits under §
										67.41 (relating to eligibility
					 guidelines for the Catastrophic Loss Trust Fund for accidents on and after June
					 1, 1989) may also be insured for EMB coverage. In these instances, the EMB
					 carrier is primary and the CAT Fund secondary. No duplicate recovery may be
					 available. The total lifetime aggregate to one individual under both EMB
					 coverage and the CAT Fund may not exceed $1 million dollars.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67 - CATASTROPHIC LOSS BENEFITS CONTINUATION FUND › Subchapter D - STATEMENTS OF POLICY › Section 67.44 - EMB coverage provided by nonautomobile insurers

Current through Register Vol. 54, No. 28, July 13, 2024
Section 1715 (e) of the act (relating to availability of
					 adequate limits), added by the act of April 26, 1989 (P.L. ______ , No. 4)
					 authorizes insureds to obtain EMB coverage through nonautomobile insurers and
					 other arrangements. The Department interprets this provision as authorizing
					 commercial accident and health insurers, Professional Health Service Plan
					 Corporations, and Hospital Plan Corporations to offer EMB coverage as defined
					 in the act, as either a freestanding policy or a part of another policy. An
					 insurer, Health Maintenance Organization, Preferred Provider Organization,
					 Professional Health Service Plan Corporation or Hospital Plan Corporation shall
					 obtain the approval of the Department prior to offering this coverage.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67 - CATASTROPHIC LOSS BENEFITS CONTINUATION FUND › Subchapter D - STATEMENTS OF POLICY › Section 67.45 - Nondiscrimination in availability of approved EMB coverage

Current through Register Vol. 54, No. 28, July 13, 2024
Insurers shall make available to an applicant or
					 policyholder all levels of extraordinary medical benefit coverage approved for
					 use by the Department.
This section cited in 31 Pa. Code §
												67.42 (relating to phase-in
						extraordinary medical benefit
						coverage).
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67 - CATASTROPHIC LOSS BENEFITS CONTINUATION FUND › Subchapter D - STATEMENTS OF POLICY › Appendix A

Current through Register Vol. 54, No. 28, July 13, 2024
Click to view
					 image
This section cited in 31 Pa. Code §
												67.42 (relating to phase-in
						extraordinary medical benefit
						coverage).
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67 - CATASTROPHIC LOSS BENEFITS CONTINUATION FUND › Subchapter D - STATEMENTS OF POLICY › Appendix B › Section 1762 - Funding [Repealed]

Current through Register Vol. 54, No. 28, July 13, 2024
The Catastrophic Loss Trust Fund shall be funded by
						levying an initial charge of $5 upon all motor vehicles required to be
						registered under Chapter 13 (relating to registration of vehicles) except
						trailers, recreational vehicles not intended for highway use, motorcycles,
						motor-driven cycles, motorized pedalcycles or like type vehicles. This charge
						shall be remitted to an insurance company or other party as may be designated
						by the Insurance Department. Upon receipt of the charge, the insurance company
						or other designated party shall remit it to the Insurance Department for
						deposit in the trust fund. The Catastrophic Loss Trust Fund Board shall by
						regulation determine by January 1 of each calendar year the amount of the fund
						charge for each registration year subsequent to the initial registration year
						and shall notify the Insurance Department which shall notify the insurance
						companies or other designated parties to collect the charge.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67 - CATASTROPHIC LOSS BENEFITS CONTINUATION FUND › Subchapter D - STATEMENTS OF POLICY › Appendix B › Section 1766 - Definitions [Repealed]

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
General rule
.-Subject to the limitations set forth in
					 subsection (b), the Catastrophic Loss Trust Fund shall provide catastrophic
					 loss benefits to eligible claimants only for the payment of expenses for
					 medical treatment and rehabilitative services in excess of $100,000. No payment
					 shall be made by the fund for the first $100,000 of expense for medical
					 treatment and rehabilitative services incurred by an eligible
					 claimant.
(b)
Maximum
					 benefit
.-The maximum catastrophic loss benefit which shall be paid by
					 the fund on behalf of any one eligible claimant shall be $50,000 per year and
					 $1,000,000 lifetime aggregate. During the first 18 months of eligibility, the
					 administrator may approve payments on behalf of a claimant without regard to
					 the $50,000 per year limit but subject to the $1,000,000 lifetime
					 aggregate.
(c)
Effect of
					 other benefits
.-Except for workers' compensation, catastrophic loss
					 benefits paid or payable by the fund shall be primary to any other available
					 source of accident or health benefits including any program, group contract or
					 other private or public source of benefits unless the law authorizing or
					 providing those benefits makes the benefits primary to the benefits provided
					 under this subchapter.
(d)
Structured settlements
.-The administrator may enter into
					 structured settlements to pay benefits under this subchapter. Where it appears
					 the settlement will be both cost effective to the fund and in the best interest
					 of the claimant, the restrictions in subsection (b) shall not apply to this
					 subsection, but in no event shall the cost of the structured settlement exceed
					 the present value of the future annual payments up to the maximum lifetime
					 aggregate benefit remaining calculated at 6% simple interest.
(e)
Preclusion of pleading, proving
					 and recovering benefits
.-In any action for damages against a
					 tortfeasor arising out of the maintenance or use of a motor vehicle, a person
					 who is eligible to receive catastrophic loss benefits shall be precluded from
					 pleading, introducing into evidence or recovering the amount of medical and
					 rehabilitative expenses for which catastrophic loss benefits were paid or are
					 payable. This preclusion applies only to catastrophic loss benefits.
(f)
Subrogation
.-There shall
					 be no subrogation or reimbursement from a claimant's tort recovery with respect
					 to catastrophic loss benefits.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67a - PENNSYLVANIA ASSIGNED RISK PLAN CONSUMER PROTECTIONS › Section 67a.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 meaning unless the context clearly indicates
				  otherwise:
Assigned Risk Plan
-As defined in
				  75 Pa.C.S. §
										1702
				  (relating to definitions).
Department
-The Insurance Department of the
				  Commonwealth.
Producer
-An agent or broker, certified or
				  licensed, by the Insurance Department to conduct business and certified by the
				  Assigned Risk Plan.
Producer of record
-The agent or broker,
				  certified or licensed, by the Department to conduct business, certified by the
				  Assigned Risk Plan and whose signature appears on the application for
				  insurance.
Voluntary market
-The ordinary market where a
				  person obtains insurance without the assistance from government and through an
				  insurer of the consumer's own selection.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67a - PENNSYLVANIA ASSIGNED RISK PLAN CONSUMER PROTECTIONS › Section 67a.2 - Consumer protections

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				producer may submit an application to the Assigned Risk Plan and may deliver
				the policy of the company to which the risk is assigned.
(b) A producer may submit an application to
				the Assigned Risk Plan only after having been unable to obtain coverage for the
				applicant, in the voluntary market, within the time frame established by the
				Assigned Risk Plan rules.
(c) Upon
				completion of the original application, premium moneys from the applicant to
				the producer of record shall be in the form of a money order, cashier's check,
				certified check, personal check or other method approved by the Insurance
				Commissioner, made payable to the "Pennsylvania Assigned Risk Plan." The
				producer of record may not accept cash.
(d) Upon receipt of the premium moneys for an
				original application, the producer of record shall issue a receipt showing the
				amount received, and the date and time that the money was received. The receipt
				shall also contain the applicant's name and address, the signature of the
				producer of record and a statement indicating that it was received for the
				Pennsylvania Assigned Risk Plan. The electronic mail reference number shall be
				included, if applicable.
(e) A
				producer of record shall maintain appropriate records of original applications,
				including the electronic mail reference number, noting the date and time of
				coverage. The producer of record shall make available for inspection these
				records to the Assigned Risk Plan, a representative of the assigned company or
				the Department.
(f) If the
				applicant produces reasonable documentation of payment of the required premium
				to the producer of record in accordance with subsection (c) and a completed
				application for insurance under the Assigned Risk Plan, payment to the producer
				of record shall be deemed payment to the Assigned Risk Plan in accordance with
				the Assigned Risk Plan rules. Coverage shall be effective as of the date and
				time specified in the application in accordance with the Assigned Risk Plan
				rules. See
				75 Pa.C.S. §
										1742(4) (relating to scope
				of plan).
(g) A producer may not
				charge referral fees or other fees for placing or servicing any coverage in the
				Assigned Risk Plan. A producer's remuneration shall be limited to the method of
				compensation established by the Assigned Risk Plan rules.
(h) Producers shall comply with the Assigned
				Risk Plan rules. Violation of the Assigned Risk Plan rules may be construed to
				be a violation of section 604 of The Insurance Department Act of 1921
				(40
				P. S. §
										234).
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67b - MANDATORY OFFER TO WRITE NONSURCHARGED PRIVATE PASSENGER NONFLEET RISKS › Section 67b.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:
Assigned Risk Plan
-As defined in section 7
				  of the Motor Vehicle Financial Responsibility Law,
				  75 Pa.C.S. §
										1702
				  (relating to definitions).
Commissioner
-The Insurance Commissioner of
				  the Commonwealth.
Department
-The Insurance Department of the
				  Commonwealth.
Governing committee
-The governing body that
				  administers the Plan.
Nonfleet
-Four or fewer motor vehicles of any
				  type.
Plan
-Assigned Risk Plan.
Producer
-An agent or broker, certified or
				  licensed, by the Department to conduct business and certified by the Plan.
Producer of record
-The agent or broker,
				  certified or licensed, by the Department to conduct business, certified by the
				  Plan and whose signature appears on the application for insurance.
Risk
-Refers to private passenger nonfleet
				  vehicles.
Take-out
-An offer from the assigned company
				  to write voluntary market coverage for a private passenger nonfleet automobile
				  risk insured by the Plan.
Take-out notice
-A notice from the assigned
				  company offering voluntary market coverage to a private passenger nonfleet
				  automobile risk insured by the Plan.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67b - MANDATORY OFFER TO WRITE NONSURCHARGED PRIVATE PASSENGER NONFLEET RISKS › Section 67b.2 - Eligibility

Current through Register Vol. 54, No. 28, July 13, 2024
A private passenger nonfleet automobile risk is eligible for
				  take-out if during the 3 successive years prior to the expiration of the
				  policy, the named insured and any other person who usually operates the
				  automobile meet the following requirements:
(1) Have been licensed to operate an
				automobile for at least 2 years.
(2) Have not been involved in accidents or
				convictions for which points are required to be assessed in accordance with the
				rules of the Plan.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67b - MANDATORY OFFER TO WRITE NONSURCHARGED PRIVATE PASSENGER NONFLEET RISKS › Section 67b.3 - Take-out notice

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The assigned
				company shall mail a take-out notice to all eligible private passenger nonfleet
				automobile risks.
(b) The take-out
				notice must offer to write the same coverages afforded by the Plan policy the
				assigned company is offering to replace for 1 year.
(c) An insured accepting take-out from the
				assigned company is not required to select the kinds and amounts of coverage
				specified in the take-out notice, but may select other kinds and amounts.
				However, the kinds and amounts of coverage selected by the insured shall be
				sufficient to maintain financial responsibility under
				75 Pa.C.S. §
										1702
				(relating to definitions).
(d) The
				take-out notice shall inform the insured that acceptance of take-out is not
				mandatory, and that the insured may shop for coverage in the voluntary market
				or remain in the Plan under §
									67b.6 (relating to right of
				insured to reapply to Plan).
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67b - MANDATORY OFFER TO WRITE NONSURCHARGED PRIVATE PASSENGER NONFLEET RISKS › Section 67b.4 - Notification

Current through Register Vol. 54, No. 28, July 13, 2024
The assigned company shall mail a take-out notice to each
				  insured eligible for take-out and the producer of record at least 45 days, but
				  no more than 60 days, prior to the expiration of the Plan policy to be
				  replaced. The take-out notice shall contain a provisional premium quotation for
				  the voluntary market coverage being offered. If the assigned company complies
				  with this section and the insured accepts take-out, the Plan shall give credit
				  to the assigned company, at the expiration date of the Plan policy, for writing
				  a voluntary market policy for risk previously insured by the
				  Plan.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67b - MANDATORY OFFER TO WRITE NONSURCHARGED PRIVATE PASSENGER NONFLEET RISKS › Section 67b.5 - Company obligations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the
				insured does not accept take-out and obtains replacement coverage in the
				voluntary market from another company, the assigned company shall have no
				further obligation to the insured or the producer of record, except that the
				assigned company shall issue a notice of termination of the Plan policy which
				is required by the rules of the Plan.
(b) If the insured accepts take-out, the
				assigned company shall be required to issue voluntary market coverage for 1
				year.
(c) Thereafter, the company
				issuing the policy shall be obligated to renew coverage from year to year,
				unless the company is permitted to nonrenew the coverage under the act of June
				17, 1998 (P. L. 484, No. 68) (40 P. S. §§
										991.2001-991.2013).
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67b - MANDATORY OFFER TO WRITE NONSURCHARGED PRIVATE PASSENGER NONFLEET RISKS › Section 67b.6 - Right of insured to reapply to Plan

Current through Register Vol. 54, No. 28, July 13, 2024
This chapter will not render the insured ineligible for
				  coverage in the Plan. The insured may, at the insured's option, continue the
				  insured's policy with the assigned company as a Plan risk or, if the 3-year
				  assignment period has expired, the insured may reapply to the Plan for
				  assignment to another company.
This section cited in 31 Pa. Code §
											67b.3 (relating to take-out
					 notice).
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 67b - MANDATORY OFFER TO WRITE NONSURCHARGED PRIVATE PASSENGER NONFLEET RISKS › Section 67b.7 - Failure to comply

Current through Register Vol. 54, No. 28, July 13, 2024
If the governing committee finds that a company, without good
				  cause, is not complying with this chapter, it shall notify the
				  Commissioner.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PRELIMINARY PROVISIONS › Section 69.1 - Purpose

Current through Register Vol. 54, No. 28, July 13, 2024
This chapter implements section 18 of Act 6 relating to
						insurer payments for medical treatment provided to injured persons covered by
						automobile insurance policies.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PRELIMINARY PROVISIONS › Section 69.2 - Applicability

Current through Register Vol. 54, No. 28, July 13, 2024
This chapter applies to medical payments made by insurers
						under automobile insurance policies issued under the MVFRL. This chapter
						applies to insurer payments to providers for services rendered on and after
						November 30, 1991.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › COVERED SERVICES › Section 69.11 - Payment limitation applicability

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The payment limitations of Act 6 apply to
					 a provider rendering services to an injured person whose medical costs are
					 covered by automobile insurance issued under the MVFRL. The payment limitations
					 of Act 6 also apply to providers not currently participating in
					 Medicare.
(b) The payment
					 limitations of Act 6 apply in cases when care is rendered by a Pennsylvania
					 licensed provider to a Pennsylvania resident covered by automobile insurance
					 for injuries arising out of the maintenance or use of a motor vehicle,
					 irrespective of where the injuries occurred or where the care is
					 rendered.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › COVERED SERVICES › Section 69.12 - Exemption from payment limitations

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Acute care treatment and services for life-threatening or urgent injuries, and
					 services for burn injury patients rendered by providers during transport to and
					 while at a trauma center or a burn facility, shall be paid at the usual and
					 customary charge when the insured's condition meets the definition of urgent or
					 life-threatening injury, based upon information available at the time of the
					 insured's assessment. When the initial assessment at the trauma center
					 determines that the insured's injuries are not urgent or life-threatening, the
					 exemption shall apply only to the initial assessment and the transportation to
					 the facility. A decision by ambulance personnel that an injury is urgent or
					 lifethreatening shall be presumptive of the reasonableness and necessity of the
					 transport to a trauma center or burn facility unless there is clear evidence of
					 a violation of the American College of Surgeons' Triage Guidelines.
(b) A provider may seek a determination that
					 a Medicare reimbursement allowance under the Medicare Program is unreasonable
					 by applying to the Department for a deviation from the Medicare reimbursement
					 allowance. The application shall be provider specific and shall be for the
					 specific Medicare reimbursement allowance that is believed to be unreasonable.
					 The application for a different Medicare reimbursement allowance will be
					 subject to a formal adjudicatory hearing in accordance with
					 2
					 Pa.C.S. §§
												501-508 and
					 701-704 (relating to the
					 Administrative Agency Law).
This section cited in 31 Pa. Code §
													69.42 (relating to payments under
						  the act); and 31 Pa. Code §
													69.43 (relating to insurer payment
						  requirements).
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PROVIDER BILLING › Section 69.21 - Allowable payment amounts

Current through Register Vol. 54, No. 28, July 13, 2024
The provider may not require payment in excess of the
						Medicare payment pertaining to the applicable specialty under Medicare for
						comparable services at the time services were rendered, or the provider's usual
						and customary charge, whichever is less. An insurer shall use the Medicare
						payment applicable in this Commonwealth to determine the appropriate payment.
						The applicable Medicare payment shall be utilized even when a service is not a
						reimbursed service under Medicare. If no Medicare payment has been calculated,
						payment shall be 80% of the provider's usual and customary
						charge.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PROVIDER BILLING › Section 69.23 - Applicable Medicare payment and codes

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The applicable Medicare fee schedule
					 shall include fees associated with all permissible procedure codes. If the
					 Medicare fee schedule also includes a larger grouping of procedure codes and
					 corresponding charges than are specifically reimbursed by Medicare, a provider
					 may use these codes, and corresponding charges shall be paid by insurers. If a
					 Medicare code exists for application to a specific provider specialty, that
					 code shall be used.
(b) Medicare
					 payments are updated periodically by HCFA and the carrier and intermediaries.
					 Insurers and providers shall utilize the latest Medicare payments as updated
					 and provided by HCFA. Medicare payments shall be utilized by insurers and
					 providers within 30 days of their effective date or date of official
					 publication by HCFA, whichever occurs later.
(c) Medicare procedure codes are updated
					 periodically by HCFA and the carrier and intermediaries. The updated Medicare
					 procedure codes shall be utilized by insurers and providers within 30 days of
					 their effective date or date of official publication by HCFA, whichever occurs
					 later.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PROVIDER BILLING › Section 69.24 - Unbundling

Current through Register Vol. 54, No. 28, July 13, 2024
A provider may not fragment or unbundle charges imposed
						for specific care except as consistent with the Medicare Program. Changes to a
						provider's codes by an insurer shall be made only as consistent with the
						Medicare Program and when the insurer has sufficient information to make the
						changes and following consultation with the provider. An insurer shall
						substantiate the reasons for coding changes to the provider in
						writing.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PROVIDER BILLING › Section 69.25 - Required billing information

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In
					 submitting a request for payment to an insurer, a provider may state the full
					 charge for services rendered. To the extent possible, a Part A provider shall
					 submit DRG payment information including estimated pass-throughs and outliers
					 as calculated by the intermediary and shall utilize Form UB82 or the form
					 currently in use by Medicare. If Form UB82 is used, the intermediary assigned
					 provider number shall be shown on the form. To the extent possible, a Part B
					 provider shall utilize Medicare procedure codes for the service rendered and
					 shall utilize Form HCFA-1500 or the form currently in use by Medicare. Provider
					 specialty codes shall be provided, if known. Failure to use Forms UB82 and
					 HCFA-1500 or Medicare procedure codes does not preclude payment by an insurer
					 if the provider submits a complete narrative describing the services rendered
					 for which payment is requested, including complete information on the insured
					 and provider. When applicable, complete information on the primary or secondary
					 diagnosis shall also be submitted.
(b) Insurer processing of provider bills
					 under this section is subject to the Unfair Insurance Practices Act
					 (40
					 P. S. §§
												1171.1-1171.15).
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PROVIDER BILLING › Section 69.26 - Complaint submissions to the Department by providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Before submitting a complaint to the
					 Department, a provider shall first attempt to resolve the complaint in writing
					 with the affected insurer and show evidence that the attempt at resolution
					 failed. An insurer shall respond to complaint correspondence from a provider
					 within 30 days of receipt.
(b) In
					 submitting an unresolved complaint to the Department, a provider shall include
					 the following information for each insured person:
(1) The name of the insured.
(2) The name of the provider.
(3) The name of the insurer.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › INSURER CLAIMS PROCESSING › Section 69.41 - Medicare data

Current through Register Vol. 54, No. 28, July 13, 2024
An insurer may obtain data on Medicare procedure codes
						and Medicare payments from the carrier and intermediaries at a cost for
						preparation and distribution of the data. A request for services beyond
						providing this data from the carrier and intermediaries is a matter of private
						negotiation.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › INSURER CLAIMS PROCESSING › Section 69.42 - Payments under the act

Current through Register Vol. 54, No. 28, July 13, 2024
An insurer shall make payments to providers in accordance
						with the Medicare Program as applied in this Commonwealth by the carrier and
						intermediaries. Care covered under the Medicare Program shall be reimbursed at
						110% of the Medicare payment or a different allowance as may be determined
						under §
											69.12(b)
						(relating to exemption from payment limitations). Medicare co-insurance and
						deductibles may not be excluded in payments made by the
						insurer.
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PEER REVIEW › Section 69.51 - Authority

Current through Register Vol. 54, No. 28, July 13, 2024
A PRO has the authority to evaluate the reasonableness
						and medical necessity of care, and the professional standards of performance
						including the appropriateness of the setting where the care is rendered, and
						the appropriateness of the delivery of the care rendered.
This section cited in 31 Pa. Code §
													69.55 (relating to criteria for
						  Department approval of a PRO).
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PEER REVIEW › Section 69.53 - PRO standards for operation

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
					 PRO shall contract, in writing, jointly or separately with an insurer for the
					 provision of peer review services as authorized by Act 6 and this
					 chapter.
(b) A PRO may not mediate
					 disputes over appropriate charges, costs or payments, and may not engage in
					 administration of claims for insurers. A PRO engaging in claims administration
					 shall establish a separate company to perform peer review services.
(c) A PRO shall reimburse providers the cost
					 for copying of records at the current rate HCFA reimburses its contracted
					 PRO.
(d) Written notice of
					 determinations shall be mailed to the insurer within 3 working days of
					 conclusion of a PRO's review.
(e) A
					 PRO shall apply National, or when appropriate, regional norms in conducting
					 determinations. If National and regional norms do not exist, a PRO shall
					 establish written criteria to be used in conducting its reviews based upon
					 typical patterns of practice in the PRO's geographic area of
					 operation.
(f) A PRO shall maintain
					 reasonable security and confidentiality practices to prevent unauthorized
					 access to PRO records and information including training of employes in
					 procedures to protect the confidentiality of information.
This section cited in 31 Pa. Code §
													69.55 (relating to criteria for
						  Department approval of a PRO).
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PEER REVIEW › Section 69.54 - PRO reporting responsibility

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
					 PRO shall submit an annual report to the Commissioner. The report shall
					 include, at a minimum:
(1) The number of
					 determinations performed.
(2) The
					 results of initial determinations delineated by the provider and
					 insurer.
(3) The number of
					 reconsiderations requested.
(4) The
					 number of initial determinations overturned.
(5) The number of determinations where the
					 review period was tolled under §
												69.52(d) and (l)
					 (relating to peer review procedures).
Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PEER REVIEW › Section 69.55 - Criteria for Department approval of a PRO

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A PRO shall apply in writing to the
					 Commissioner for approval to contract with an insurer to provide peer review
					 services in accordance with the act and this chapter. If the application is
					 disapproved, the PRO may appeal the disapproval to the Commissioner. If the
					 Commissioner determines that reasonable grounds exist to review the
					 disapproval, the Commissioner may schedule a hearing to review the
					 determination. The hearing shall be conducted in accordance with
					 2
					 Pa.C.S. §§
												501-508 and
					 701-704 (relating to the
					 Administrative Agency Law).
(b) A
					 PRO applicant shall include in its written application the following
					 information:
(1) A Certification of
					 Independence. A PRO may not be owned by a Pennsylvania-licensed insurer. While
					 a PRO may be organized by one or more insurers, that PRO may not review the
					 claims of those insurers, may not be a subsidiary or affiliate of those
					 insurers' corporate structure and none of the PRO's officers or directors may
					 have a direct financial interest in the insurers. PRO personnel may not review
					 services provided to an insured by an institution or agency in which they have
					 financial interest.
(2) A
					 description of previous experience as a PRO and the length of time in
					 operation.
(3) A certification that
					 reviews are conducted by medical personnel licensed in this
					 Commonwealth.
(4) A compensation
					 policy. A PRO shall charge for its service on a flat fee or hourly rate basis.
					 A PRO may not charge for services on a percentage or contingency fee
					 basis.
(5) A quality assessment of
					 the PRO's review services, including examples of the PRO's review
					 procedures.
(6) A policy statement
					 on the preservation of the confidentiality of medical records.
(7) A certification that the PRO will operate
					 and provide services in accordance with §§
												69.51 -69.54 and this
					 section.
Pennsylvania Code › Title 31 - INSURANCE › Part III - Credit Insurance › Chapter 73 - CREDIT LIFE INSURANCE AND CREDIT ACCIDENT AND HEALTH INSURANCE › Section 73.101 - Purpose

Current through Register Vol. 54, No. 28, July 13, 2024
The purpose of this chapter is to interpret and implement the
				  act and section 641 of The Insurance Department Act of 1921 (40 P. S. §
										281). This chapter is intended to protect the
				  interests of debtors and the public in this Commonwealth by providing a system
				  of rate, contract form and operating standards for the transaction of credit
				  life, credit accident and health and credit unemployment insurance. This
				  chapter is not intended to prohibit or discourage reasonable
				  competition.
Pennsylvania Code › Title 31 - INSURANCE › Part III - Credit Insurance › Chapter 73 - CREDIT LIFE INSURANCE AND CREDIT ACCIDENT AND HEALTH INSURANCE › Section 73.102 - Applicability

Current through Register Vol. 54, No. 28, July 13, 2024
This chapter applies to the following:
(1) An individual or group credit insurance
				policy.
(2) Certificates issued
				under a group credit insurance policy and applications or other forms used in
				connection with the policy or certificate.
(3) A premium rate charged for credit
				insurance.
(4) Practices followed
				in providing credit insurance.
Pennsylvania Code › Title 31 - INSURANCE › Part III - Credit Insurance › Chapter 73 - CREDIT LIFE INSURANCE AND CREDIT ACCIDENT AND HEALTH INSURANCE › Section 73.104 - Life insurance and life insurance with TPD benefit

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Life benefit plan
. The
				prima facie premium rate standards referenced in §
									73.106 (relating to life insurance
				rate standards) apply to a plan of credit life insurance benefits, if the plan
				provides the features in paragraphs (1)-(3) and, if applicable, paragraph (4).
				This plan shall be described in a group policy and group certificate or in an
				individual policy.
(1) Single life coverage
				or joint life coverage for all eligible debtors.
(2) A benefit payable upon death or upon TPD,
				if TPD coverage applies, subject to any maximum dollar amount of coverage
				specified in the group policy and group certificate or individual policy, equal
				to any of the following:
(i) The actual gross
				or net unpaid indebtedness at the time of death or commencement of TPD, in the
				case of a closed end loan for a group policy of credit life insurance or credit
				life insurance with a TPD benefit.
(ii) The greater of the scheduled gross or
				net unpaid indebtedness, or the actual gross or net unpaid indebtedness, at the
				time of death or commencement of TPD, in the case of a closed end loan for an
				individual policy of credit life insurance or credit life insurance with a TPD
				benefit.
(iii) The actual net
				unpaid indebtedness at the time of death or commencement of TPD, in the case of
				an open end loan .
(3) A
				coverage period equal to the lesser of the following:
(i) The term of the indebtedness remaining at
				the time coverage is elected.
(ii)
				The term of the indebtedness remaining at the time coverage is elected to the
				time the insured debtor attains an age at which the group policy and group
				certificate or individual policy provides for coverage to terminate.
(iii) The term of the indebtedness remaining
				at the time coverage is elected until truncated coverage terminates.
(4) If TPD coverage is provided, a
				definition of TPD requiring that the debtor be totally and permanently and
				continuously unable to engage in any occupation, employment or activity for
				compensation or profit, for which the debtor is suited by education, training
				or experience, according to the certification of a physician or podiatrist. The
				physician or podiatrist's certification may be waived by the insurer if the
				debtor has suffered the permanent loss of sight of both eyes, or the severance
				of both hands, both feet or of one hand and one foot.
Pennsylvania Code › Title 31 - INSURANCE › Part III - Credit Insurance › Chapter 73 - CREDIT LIFE INSURANCE AND CREDIT ACCIDENT AND HEALTH INSURANCE › Section 73.105 - Life insurance and life insurance with TPD benefit requirements

Current through Register Vol. 54, No. 28, July 13, 2024
A plan of credit life insurance or credit life insurance with
				  TPD benefit and a group policy and group certificate or an individual policy
				  describing the plan, shall comply with the following:
(1)
Joint coverage
.
(i) If joint life coverage with or without
				TPD benefit is provided, a group certificate or individual policy providing
				joint life coverage with or without TPD coverage shall be issued. Insurers
				shall not issue two single life coverage group certificates or two single life
				individual policies.
(ii) The
				benefit payable in the case of simultaneous death or TPD of both insureds shall
				not exceed the benefit that would be payable if coverage were provided on only
				one debtor.
(iii) The group policy
				and group certificate or individual policy shall make provision for whom any
				excess benefit will be paid in the event of the simultaneous death of the joint
				insureds.
Pennsylvania Code › Title 31 - INSURANCE › Part III - Credit Insurance › Chapter 73 - CREDIT LIFE INSURANCE AND CREDIT ACCIDENT AND HEALTH INSURANCE › Section 73.106 - Life insurance rate standards

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Prima facie rates
. Premium rates for credit life insurance and
				credit life insurance with TPD benefit, as described in §
									73.104(a)
				(relating to life insurance and life insurance with TPD benefit), may not
				exceed the prima facie premium rates referenced in this section and published
				in the
Pennsylvania Bulletin
, unless higher premium rates are
				approved under §
									73.122 (relating to deviated
				rates). Premium rates for benefits that differ from those benefits described in
				§
									73.104(a) may not
				exceed premium rates that are actuarially consistent with the prima facie
				premium rates referenced in this section and published in the
Pennsylvania Bulletin
.
(b)
Symbols
. The symbols
				used in this section shall have the following meanings.
(1) Et = amount at
				risk in month t per $1 of initial insured indebtedness.
(2) i = 4.5%, consisting of an interest
				discount of 4% and a mortality discount of .5%.
(3) LSPn = single
				premium prima facie premium rate per $100 of a level amount of insured
				indebtedness.
(4) n = coverage
				period in months.
(5)
				Op = monthly outstanding balance prima facie premium
				rate per $1,000 of outstanding balance.
(6) SPn = single
				premium prima facie premium rate per $100 of initial insured gross
				indebtedness, as defined in §
										73.103 (relating to definitions),
				repayable in n equal monthly installments.
(7) NSPn = single
				premium prima facie premium rate per $100 of initial insured net indebtedness,
				as defined in § 73.103, repayable in n equal monthly
				installments.
Pennsylvania Code › Title 31 - INSURANCE › Part III - Credit Insurance › Chapter 73 - CREDIT LIFE INSURANCE AND CREDIT ACCIDENT AND HEALTH INSURANCE › Section 73.108 - A and H insurance requirements

Current through Register Vol. 54, No. 28, July 13, 2024
A plan of credit A and H insurance and a group policy and
				  group certificate or an individual policy describing such plan, shall comply
				  with the following:
(1)
Joint
				coverage basis
. If joint A and H coverage is provided, it shall be
				provided either on the basis of each debtor being insured for 100% of the
				monthly disability payment, or on the basis of each debtor being insured for a
				specified portion of the amount of the monthly disability payment, with the
				total of the portions equal to 100% of the monthly disability
				payment.
(2)
Joint
				contract
.
(i) If joint A and H
				coverage is provided, a group certificate or individual policy providing joint
				A and H coverage shall be issued. Insurers may not issue two single A and H
				coverage group certificates or two single individual polices.
(ii) The benefit payable in the case of
				simultaneous disability of both insureds may not exceed the benefit that would
				be payable if coverage were provided on only one debtor.