An Act providing for health care insurance coverage protections; imposing duties on the Insurance Department and the Insurance Commissioner; and imposing penalties.

PRINTER'S NO. 528
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No. 535
Session of
2025
INTRODUCED BY FRANKEL, VENKAT, MERSKI, HOHENSTEIN, PIELLI, HILL-
EVANS, HOWARD, KHAN, BENHAM, SANCHEZ, GIRAL, DEASY, HADDOCK,
MAYES, BOYD, CURRY, CERRATO AND WARREN, FEBRUARY 10, 2025
REFERRED TO COMMITTEE ON INSURANCE, FEBRUARY 10, 2025
AN ACT
Providing for health care insurance coverage protections;
imposing duties on the Insurance Department and the Insurance
Commissioner; and imposing 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 Protection Against Limitations 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.
"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.
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"Group health insurance policy." A policy, subscriber
contract, certificate or plan issued by an insurer that provides
medical or health care coverage on an annual basis to
individuals who obtain health insurance coverage through a
group.
"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 policies providing for limited
benefits.
"Individual health insurance policy." A policy, subscriber
contract, certificate or plan issued by an insurer that provides
medical or health care coverage on an annual basis to an
individual other than in connection with a group.
"In-network provider." A provider who contracts with an
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insurer to provide health care services to an enrollee under a
health insurance policy.
"Insurer." An entity that offers, issues or renews an
individual or group 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 The Insurance Company Law of 1921.
(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.
Section 3. Limitation on annual and lifetime limits.
(a) Limits generally prohibited.--Except as otherwise
provided in this section, an insurer offering, issuing or
renewing an individual or group health insurance policy may not
establish, on either an annual or lifetime basis, a limit on the
dollar value of any core benefit for an enrollee, whether
provided by an in-network or out-of-network provider.
(b) Core benefit.--For purposes of this section, a core
benefit shall include a benefit for which no annual or lifetime
per enrollee limit was permitted to be included in an individual
or small group policy first offered or issued in this
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Commonwealth in plan year 2025.
(c) No coverage requirement.--This section shall not be
construed to require coverage of any specific benefit.
Section 4. Regulations.
(a) Authority to promulgate.--The department may promulgate
regulations as may be necessary and appropriate to carry out the
provisions of this act.
(b) (Reserved).
Section 5. 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
violation of this act.
(b) Limitation.--
(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 section are in addition to any other remedies or
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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 6. Notice.
The commissioner shall transmit notice to the Legislative
Reference Bureau for publication in the next available issue of
the Pennsylvania Bulletin if any of the following occurs:
(1) The Congress of the United States repeals 42 U.S.C.
§ 300gg-11 (relating to no lifetime or annual limits), in
whole or in part.
(2) A court of the United States abrogates, vacates or
invalidates 42 U.S.C. § 300gg-11, in whole or in part, or a
regulation implementing 42 U.S.C. § 300gg-11, in whole or in
part.
(3) The executive branch of the United States refuses to
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enforce or repeals a regulation implementing 42 U.S.C. §
300gg-11, in whole or in part.
Section 7. 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-11
(relating to no lifetime or annual limits) that are impacted by
the occurrence of any of the events described in section 6.
Section 8. Repeals.
All acts and parts of acts are repealed insofar as they are
inconsistent with this act.
Section 9. Effective date.
This act shall take effect as follows:
(1) The following shall take effect immediately:
Section 6.
Section 7.
This section.
(2) The remainder of this act shall take effect upon
publication of the notice in section 6.
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