An Act amending Title 40 (Insurance) of the Pennsylvania Consolidated Statutes, providing for school-based services; and, in telemedicine, further providing for insurance coverage of telemedicine.

PRINTER'S NO. 1897
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No. 1445
Session of
2025
INTRODUCED BY WARREN, BRENNAN, MALAGARI, HILL-EVANS, SANCHEZ,
VITALI, PIELLI, HOHENSTEIN, SCHLOSSBERG, NEILSON, MERSKI AND
D. WILLIAMS, JUNE 10, 2025
REFERRED TO COMMITTEE ON INSURANCE, JUNE 10, 2025
AN ACT
Amending Title 40 (Insurance) of the Pennsylvania Consolidated
Statutes, providing for school-based services; and, in
telemedicine, further providing for insurance coverage of
telemedicine.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Title 40 of the Pennsylvania Consolidated
Statutes is amended by adding a chapter to read:
CHAPTER 44
SCHOOL-BASED SERVICES
Sec.
4401. Legislative findings and intent.
4402. Definitions.
4403. Insurance coverage for health care service in school
setting.
4404. Permitted exclusions.
4405. Coordination of benefits.
4406. Construction.
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4407. Regulations.
4408. Penalties.
4409. Administrative procedures.
§ 4401. Legislative findings and intent.
(a) Legislative findings.--The General Assembly finds and
declares as follows:
(1) Health care services, including mental health
services, may be available to students in a school setting.
(2) Educational opportunities for students will be
maximized if students are able to access health care services
without leaving their school setting.
(b) Intent.--The intent of this chapter is to maximize
educational opportunities for students by establishing
limitations on when health insurance coverage for health care
services provided in a school setting may be excluded or denied.
§ 4402. Definitions.
The following words and phrases when used in this chapter
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Administrative policy." A written document or collection of
documents reflecting the terms of the contractual or operating
relationship between an insurer and a health care provider.
"Clinical review criteria." The set of written screening
procedures, decision abstracts, clinical protocols and practice
guidelines used by an insurer to determine the necessity and
appropriateness of health care services.
"Commissioner." The Insurance Commissioner of the
Commonwealth.
"Covered person." A policyholder, subscriber or other
individual who is entitled to receive health care services under
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a health insurance policy.
"Habilitative speech therapy." Speech therapy that helps an
individual to keep, learn or improve skills and function for
daily living.
"Health care provider." A person that is licensed,
certified, registered or otherwise permitted by law or
regulation to provide health care services under the laws of
this Commonwealth.
"Health care service." A treatment, procedure, medical
supply or other service prescribed or otherwise provided or
proposed to be provided by a health care provider to a covered
person for any of the following:
(1) mental health;
(2) behavioral health; or
(3) speech therapy.
"Health insurance policy." As follows:
(1) A policy, subscriber contract, certificate or plan
issued by an insurer that provides medical or health care
coverage.
(2) The term does not include:
(i) An accident only policy.
(ii) A credit only policy.
(iii) A long-term care or disability income policy.
(iv) A specified disease policy.
(v) A Medicare supplement policy.
(vi) A policy under which benefits are provided by
the Federal Government to active or former military
personnel and their dependents, including a Tricare
policy or a Civilian Health And Medical Program of the
Uniformed Services (CHAMPUS) supplement policy.
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(vii) A fixed indemnity policy.
(viii) A hospital indemnity policy.
(ix) A dental only policy.
(x) A vision only policy.
(xi) A workers' compensation policy.
(xii) An automobile medical payment policy under 75
Pa.C.S. (relating to vehicles).
(xiii) A homeowner's insurance policy.
(xiv) Any other similar policies providing for
limited benefits.
"Insurer." An entity licensed by the department that offers,
issues or renews an individual or group health insurance policy
that is offered or governed under any of the following:
(1) The act of May 17, 1921 (P.L.682, No.284), known as
The Insurance Company Law of 1921, including section 630 and
Article XXIV thereof.
(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(3) Chapter 61 (relating to hospital plan corporations)
or 63 (relating to professional health services plan
corporations).
"Medical policy." A written document adopted, maintained and
applied by an insurer that combines the clinical review criteria
and any additional administrative policy, as applicable,
necessary to articulate the insurer's standards for coverage of
a given health care service or set of health care services under
the terms of a health insurance policy.
"Participating network provider." A health care provider
that has entered into a contractual or operating relationship
with an insurer to participate in one or more designated
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networks of the insurer and to provide health care services to
covered persons under the terms of the insurer's administrative
policy.
"Rehabilitative speech therapy." Speech therapy that helps
an individual restore or improve skills and functioning for
daily living that have been lost or impaired.
"School entity." As follows:
(1) A public school, including a charter school or cyber
charter school, private school, nonpublic school,
intermediate unit or area career and technical school.
(2) The term does not include a postsecondary
educational institution.
"School entity facility." A school entity building, whether
permanent or temporary, including a mobile unit.
"Speech therapy." Therapeutic care provided to an individual
for treatment administered by a licensed speech-language
pathologist. The term includes both habilitative speech therapy
and rehabilitative speech therapy.
§ 4403. Insurance coverage for health care service in school
setting.
(a) Prohibition.--A health insurance policy offered, issued
or renewed in this Commonwealth may not exclude coverage for a
medically necessary health care service because the health care
service is provided in a school setting, whether through an
explicit school setting exclusion or a general place of service
exclusion.
(b) School setting.--A health care service is provided in a
school setting if it is provided in a school entity facility by
a health care provider that is:
(1) an employee of the school entity;
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(2) a contractor of the school entity; or
(3) otherwise authorized by the school entity to provide
the health care service in the school entity facility.
§ 4404. Permitted exclusions.
Notwithstanding section 4403, an insurer may exclude coverage
for a health care service provided to a covered person in a
school setting for any of the following reasons:
(1) The health care service is provided by an individual
who:
(i) is not a health care provider; or
(ii) is practicing outside of the individual's scope
of practice.
(2) The health care service is not medically necessary
under the terms of the insurer's medical policies.
(3) The provision of the health care service does not
comply with the insurer's administrative policies.
(4) A school entity or government entity, as defined in
2 Pa.C.S. § 101 (relating to definitions), is obligated under
Federal or State law to provide the health care service in
accordance with an individualized education program or
section 504 of the Rehabilitation Act of 1973 (Public Law 93-
122, 29 U.S.C. § 794).
§ 4405. Coordination of benefits.
(a) Coordination.--Consistent with Federal or State law and
upon consent of the parent or guardian, if a covered person has
an individualized education program or a section 504 plan, an
insurer may coordinate a medically necessary health care service
provided in a school setting with any service included in an
individualized education program or section 504 plan.
(b) Claim.--A health care provider may not submit a claim to
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an insurer for a health care service that is provided to a
covered person as part of an individualized education program or
a section 504 plan.
(c) Costs and reimbursements.--A school entity may not shift
costs onto or otherwise seek reimbursement from an insurer for
health care services that a school entity is required to provide
as part of free appropriate public education under the
Individuals with Disabilities Education Act (Public Law 91-230,
20 U.S.C. § 1400 et seq.).
§ 4406. Construction.
This chapter may not be construed to limit the application of
a health insurance policy's terms and conditions, including:
(1) Prohibiting an insurer from paying or reimbursing
health care providers for other covered health care services
provided in a school setting.
(2) Prohibiting an insurer from imposing cost-sharing
that is consistent with the terms and conditions of the
health insurance policy.
(3) Requiring an insurer to cover a health care service
provided in a school setting by an out-of-network provider
unless otherwise required by network adequacy standards.
(4) Requiring an insurer to pay or reimburse a
participating network provider if the provision of the health
care service in a school setting would be inconsistent with
the standard of care.
(5) Requiring an insurer to pay or reimburse a health
care provider for a health care service for which the health
care provider receives or is entitled to receive compensation
from a school entity as part of an employment arrangement or
contract.
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§ 4407. Regulations.
The department may promulgate regulations as necessary and
appropriate to carry out the provisions of this chapter.
§ 4408. Penalties.
(a) Authority of commissioner.--Subject to subsection (b),
upon satisfactory evidence of a violation of this chapter by an
insurer, the commissioner may, in the commissioner's discretion,
pursue any of the following courses of action:
(1) Suspend, revoke or refuse to renew the license of
the offending person.
(2) Enter a cease and desist order.
(3) Impose a civil penalty of not more than $5,000 for
each action in violation of this chapter.
(4) Impose a civil penalty of not more than $10,000 for
each action in willful violation of this chapter.
(b) Limitation.--Penalties imposed against an insurer under
this section may not exceed $500,000 in the aggregate during a
single calendar year.
(c) Nonexclusive remedies.--
(1) The enforcement remedies imposed under this chapter
are in addition to any other remedies or penalties that may
be imposed under any other applicable law of this
Commonwealth, including the act of July 22, 1974 (P.L.589,
No.205), known as the Unfair Insurance Practices Act.
(2) A violation of this chapter by an insurer shall be
deemed to be an unfair method of competition and an unfair or
deceptive act or practice under the Unfair Insurance
Practices Act.
§ 4409. Administrative procedures.
(a) Procedures generally.--The administrative provisions of
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this chapter shall be subject to 2 Pa.C.S. Ch. 5 Subch. A
(relating to practice and procedure of Commonwealth agencies).
(b) Appeals.--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 2. Section 4803(a)(1) of Title 40, added July 3,
2024 (P.L.516, No.42), is amended and subsection (c) is amended
by adding a paragraph to read:
§ 4803. Insurance coverage of telemedicine.
(a) General rule.--
(1) A health insurance policy offered, issued or renewed
in this Commonwealth shall provide coverage for medically
necessary health care services provided through telemedicine
and delivered by a participating network provider who
provides a covered health care service through telemedicine
consistent with the insurer's medical policies. A health
insurance policy may not exclude a health care service from
coverage solely because the health care service is provided
through telemedicine, whether explicitly or through a place
of service exclusion.
* * *
(c) Construction.--This section may not be construed to:
* * *
(4) Require an insurer to pay or reimburse for a health
care service that is required by Federal or State law to be
provided by a school entity, including a health care service
provided in accordance with an individualized education
program or section 504 of the Rehabilitation Act of 1973
(Public Law 93-122, 29 U.S.C. § 794).
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Section 3. This act shall apply as follows:
(1) For health insurance policies for which either rates
or forms are required to be filed with the Federal Government
or the Insurance Department, this act shall apply to any
policy for which a form or rate is first filed on or after
the effective date of this section.
(2) For health insurance policies for which neither
rates nor forms are required to be filed with the Federal
Government or the Insurance Department, this act shall apply
to any policy issued or renewed on or after 180 days after
the effective date of this section.
Section 4. This act shall take effect immediately.
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