Pennsylvania has several state-specific mandated health insurance related regulations. These include mandated policy benefits for health and long-term care, and regulations for producers and insurance companies selling policies in Pennsylvania. Regulations benefit the consumer and require insurers and producers to maintain fair practices. Pennsylvania regulation includes specified penalties for insurers and producers who do not comply with the mandates and laws.
Pennsylvania Mandated Benefits
Pennsylvania has more than 10 mandated benefits required to be included in all Pennsylvania-issued individual and group health insurance policies. Several of the mandates are women's health related, such as requirements for postpartum coverage, annual gynecological exams and mammograms. Others are substance abuse and mental illness related, stipulating minimum benefits for each. Lastly, several regulated mandates involve children. Pennsylvania requires health insurance policies to cover childhood immunizations and require coverage for adopted, newborn and physically and mentally handicapped children.
Pennsylvania Long-term Policy Regulations
In Pennsylvania, long-term care policies have many regulations and required provisions. These regulations provide fairness to Pennsylvania residents and must be included with each sold policy, individual or group. Policies must include an outline of coverage, a free look period of 30 days in which the policy holder can return the policy for a full refund. Policies also must contain a portability clause, inflation protection and provisions covering pre-existing conditions. Agents and insurers must provide a "shopper's guide" prior to application and cannot exceed certain commission levels. Insures not following regulations are subject to civil penalties up to $10,000, as of 2011.
Health Insurance Producer Regulations
A governor-appointed commission, that oversees producer regulations, heads the Pennsylvania Insurance Department. Health insurance producers, agents and brokers are subject to many licensing laws and regulations. Producers must be 18 years of age, complete a pre-licensing course and pass an exam. Producers have a fiduciary responsibility to handle funds properly and cannot engage in unfair insurance practices as defined by the Pennsylvania Insurance Department. Pennsylvania also defines unfair discrimination and requires each insurer in Pennsylvania to pay an annual assessment fee into the Insurance Fraud Prevention Trust Fund each April 1.
Other Department of Insurance Regulations
The Department of Insurance requires health insurance producers to report action taken against them in other states, criminal charges and notification of change of address or name to the Commissioner within 30 days of occurring. Insurers must file their premium rates and policy forms with the Commissioner within 30 days of initial occurrence or changes. The commission has 10 days to approve rates or hold a hearing after receiving the information. The commission must approve or disapprove changes to a form within 30 days. Additionally, the commission will examine each insurer at least every five years to ensure regulation compliance.
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