PRINTER'S NO. 779
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.755
Session of
2025
INTRODUCED BY WARREN, PIELLI, VENKAT, OTTEN, SANCHEZ, KHAN,
PROKOPIAK, GIRAL, FREEMAN, HANBIDGE, HOHENSTEIN, DONAHUE,
GALLAGHER, SCHLOSSBERG, HOWARD, SHUSTERMAN, DALEY, DEASY,
FIEDLER, MADDEN AND MALAGARI, MARCH 3, 2025
REFERRED TO COMMITTEE ON INSURANCE, MARCH 3, 2025
AN ACT
Providing for health care insurance preventive services coverage
protections; conferring authority on the Insurance Department
and the Insurance Commissioner; and providing for
regulations, for enforcement and for penalties.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be known and may be cited as the Health
Insurance Preventive Services Coverage Act.
Section 2. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Commissioner." The Insurance Commissioner of the
Commonwealth.
"Cost sharing." The share of health care costs covered by an
insurance policy that an enrollee pays out-of-pocket. The term
includes deductibles, coinsurance, copayments and similar
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18 charges. The term does not include a premium, a balance billed
amount from an out-of-network provider or the cost of a
noncovered service.
"Department." The Insurance Department of the Commonwealth.
"Enrollee." A policyholder, subscriber, covered person or
other individual who is entitled to receive health care services
under a health insurance policy.
"Grandfathered health care plan." Individual or group health
insurance coverage in which an individual was enrolled prior to
March 23, 2010, or as specified in 42 U.S.C. § 18011 (relating
to preservation of right to maintain existing coverage).
"Health insurance policy." A policy, subscriber contract,
certificate or plan issued by an insurer that provides medical
or health care coverage. The term does not include any of the
following:
(1) An accident only policy.
(2) A credit only policy.
(3) A long-term care or disability income policy.
(4) A specified disease policy.
(5) A Medicare supplement policy.
(6) A fixed indemnity policy.
(7) A dental only policy.
(8) A vision only policy.
(9) A workers' compensation policy.
(10) An automobile medical payment policy.
(11) A policy under which benefits are provided by the
Federal Government to active or former military personnel and
their dependents.
(12) A hospital indemnity policy.
(13) Any other similar policy providing for limited
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30 benefits.
"Insurer." An entity that offers, issues or renews a health
insurance policy that provides medical or health care coverage
by a health care facility or licensed health care provider and
that is governed under any of the following:
(1) The act of May 17, 1921 (P.L.682, No.284), known as
The Insurance Company Law of 1921, including section 630 and
Article XXIV of that act.
(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations).
(4) 40 Pa.C.S. Ch. 63 (relating to professional health
services plan corporations).
"Out-of-network provider." A provider who does not contract
with an insurer to provide health care services to an enrollee
under a health insurance policy.
"Preventive service." A health care service that is on the
preventive services list.
"Preventive services list." A list of health care services
compiled by the department that includes:
(1) Health care services required to be covered by an
individual health insurance policy approved to be offered or
issued in this Commonwealth on January 1, 2025, as a
preventive service in accordance with 42 U.S.C. § 300gg-13
(relating to coverage of preventive health services), other
than any health care service exempted by the department under
the modification process under section 4.
(2) Health care services added by the department under
the modification process under section 4.
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30 Section 3. Preventive services coverage requirement.
An insurer offering, issuing or renewing a health insurance
policy other than a grandfathered health care plan shall provide
coverage and may not impose any cost-sharing requirements for
services on the preventive services list.
Section 4. Modification of preventive services list.
(a) Additions and exemptions.--T he department may add or
exempt one or more preventive services from the preventive
services list in accordance with the requirements of this
section.
(b) Notice and comment requirements.--Prior to adopting an
addition to or exemption from the preventive services list, the
department shall:
(1) Transmit a notice to the Legislative Reference
Bureau for publication in the next available issue of the
Pennsylvania Bulletin requesting public comments. The public
comment period shall be for not less than 15 business days
following the date of publication.
(2) Post the notice on the department's publicly
accessible Internet website.
(3) Electronically send the notice to the chairperson
and minority chairperson of the Banking and Insurance
Committee of the Senate and the chairperson and minority
chairperson of the Insurance Committee of the House of
Representatives.
(c) Evaluation standards.--
(1) The department may add a service to the preventive
service list if the department finds that the service is
then-currently:
(i) An evidence-based item or service that has in
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30 effect a rating of "A" or "B" by the United States
Preventive Services Task Force.
(ii) A recommended immunization by the Advisory
Committee on Immunization Practices of the Centers for
Disease Control and Prevention.
(iii) A preventive care or screening for women,
infants, children or adolescents provided for in the
comprehensive guidelines supported by the United States
Health Resources and Services Administration.
(2) The department may exempt a service from the
preventive services list if the service no longer meets the
requirements of paragraph (1).
(3) In addition to the requirements of paragraphs (1)
and (2), prior to adopting an addition or exemption of a
service from the preventive services list, the department
shall consider:
(i) Each public comment received in response to the
notice under subsection (b).
(ii) The potential escalation of the cost of health
care services.
(iii) The accessibility and cost of the preventive
service and of health care services likely to be avoided
by the preventive service.
(iv) Changes in medical evidence or scientific
advancement.
(v) The potential for discrimination against
individuals by reason of:
(A) Health status-related factors listed under
42 U.S.C. § 300gg-4 (relating to prohibiting
discrimination against individual participants and
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30 beneficiaries based on health status).
(B) The factors specified in section 5(a)(7)
(iii) of the act of July 22, 1974 (P.L.589, No.205),
known as the Unfair Insurance Practices Act.
(C) The expected length of life, present or
predicted disability, degree of medical dependency or
quality of life.
(d) Maintenance of list.--Each time a benefit is added or
exempted from the preventive services list, the department shall
transmit notice of the addition or exemption to the Legislative
Reference Bureau for publication in the next available issue of
the Pennsylvania Bulletin and shall post and transmit the notice
in the same manner as the preliminary notice under subsection
(b)(2) and (3). The department shall maintain a current
preventive services list on the department's publicly accessible
Internet website.
(e) Applicability.--An addition or exemption under
subsection (a) shall apply as follows:
(1) For a health insurance policy for which either rates
or forms are required to be filed with the department, to a
policy for which a form or rate is first filed on or after
the notice.
(2) For a health insurance policy for which neither
rates nor forms are required to be filed with the department,
to a policy issued or renewed 180 days after the publication
of the notice.
(3) For an exemption of a service on the grounds of a
potential danger to patients, on a case-by-case basis, at a
time established by the department within the time provided
in paragraphs (1) and (2).
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30 (f) Administrative procedure.--An addition or exemption by
the department is appealable to the commissioner under 1 Pa.
Code 35.20 (relating to appeals from actions of the staff) and
shall be subject to 2 Pa.C.S. Ch. 5 Subch. A (relating to
practice and procedure of Commonwealth agencies). A party may
appeal the commissioner's adjudication to Commonwealth Court as
provided in 2 Pa.C.S. Ch. 7 Subch. A (relating to judicial
review of Commonwealth agency action).
Section 5. Construction.
(a) Construction.--Nothing in this act shall be construed to
prohibit an insurer from:
(1) Providing coverage for preventive services in
addition to those on the preventive services list.
(2) Denying coverage for preventive services not on the
preventive services list.
(3) Using value-based insurance designs.
(4) Using reasonable medical management techniques to
determine the frequency, method, treatment or setting for a
preventive service, based on relevant clinical evidence, to
the extent not specified in the relevant recommendation or
guideline.
(5) Diminish any other law that limits cost sharing for
a health care service.
(b) Insurers.--For an insurer that uses a network of
providers to provide services under a health insurance policy:
(1) Subject to paragraph (2), nothing in this act shall
be construed to:
(i) Require the insurer to provide coverage for
services on the preventive services list that are
delivered by an out-of-network provider.
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30 (ii) Preclude the insurer from imposing cost-sharing
requirements for services on the preventive services list
that are delivered by an out-of-network provider.
(2) If an insurer does not have in its network a
provider who can provide an item or service on the preventive
services list, the insurer shall cover the item or service
when performed by an out-of-network provider and may not
impose cost-sharing with respect to the item or service.
(c) Health insurance policies.--Nothing in this act shall
require a health insurance policy to cover a preventive service
if the enrollee is exempt by the exercise of its constitutional
protections of religious freedom under the act of December 9,
2002 (P.L.1701, No.214), known as the Religious Freedom
Protection Act, or 42 U.S.C. Ch. 21B (relating to religious
freedom restoration).
Section 6. Regulations.
The department may promulgate regulations as may be necessary
and appropriate to carry out the provisions of this act.
Section 7. Enforcement.
(a) Penalties.--Upon satisfactory evidence of the violation
of any section of this act by an insurer or any other person,
one or more of the following penalties may be imposed at the
commissioner's discretion:
(1) Suspension or revocation of the license of the
offending insurer or other person.
(2) Refusal, for a period not to exceed one year, to
issue a new license to the offending insurer or other person.
(3) A fine of not more than $5,000 for each violation of
this act.
(4) A fine of not more than $10,000 for each willful
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30 violation of this act.
(b) Limitations.--
(1) Fines imposed against an individual insurer under
this act may not exceed $500,000 in the aggregate during a
single calendar year.
(2) Fines imposed against any other person under this
act may not exceed $100,000 in the aggregate during a single
calendar year.
(c) Additional remedies.--The enforcement remedies imposed
under this subsection are in addition to any other remedies or
penalties that may be imposed under any other applicable law of
this Commonwealth, including:
(1) The act of July 22, 1974 (P.L.589, No.205), known as
the Unfair Insurance Practices Act. Violations of this act
shall be deemed to be an unfair method of competition and an
unfair or deceptive act or practice under the Unfair
Insurance Practices Act.
(2) The act of December 18, 1996 (P.L.1066, No.159),
known as the Accident and Health Filing Reform Act.
(3) The act of June 25, 1997 (P.L.295, No.29), known as
the Pennsylvania Health Care Insurance Portability Act.
(d) Administrative procedure.--The administrative provisions
of this section shall be subject to 2 Pa.C.S. Ch. 5 Subch. A
(relating to practice and procedure of Commonwealth agencies). A
party against whom penalties are assessed in an administrative
action may appeal to Commonwealth Court as provided in 2 Pa.C.S.
Ch. 7 Subch. A (relating to judicial review of Commonwealth
agency action).
Section 8. Repeals.
All acts and parts of acts are repealed insofar as they are
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30 inconsistent with this act.
Section 9. Implementation notice.
The commissioner shall transmit notice to the Legislative
Reference Bureau for publication in the next available issue of
the Pennsylvania Bulletin i f any of the following occur:
(1) The Congress of the United States repeals, in whole
or in part, 42 U.S.C. § 300gg-13 (relating to coverage of
preventive health services).
(2) A court of the United States with competent
jurisdiction abrogates, vacates or invalidates, in whole or
in part, 42 U.S.C. § 300gg-13.
(3) The executive branch of the United States refuses to
enforce, or repeals a regulation implementing, in whole or in
part, 42 U.S.C. § 300gg-13.
Section 10. Implementation.
The implementation of this act shall be limited to the
provisions necessary to achieve a substitute coverage
requirement for the portion or portions of 42 U.S.C. § 300gg-13
(relating to coverage of preventive health services) that are
impacted by the occurrence of any of the events described in
section 9.
Section 11. Effective date.
This act shall take effect as follows:
(1) The following shall take effect immediately:
Section 9.
Section 10.
This section.
(2) The remainder of this act shall take effect upon
publication of the implementation notice in section 9.
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