PRINTER'S NO. 1330
No. 1094 Session of 1999
INTRODUCED BY SCHWARTZ, KUKOVICH, EARLL, HUGHES, KITCHEN AND
DENT, SEPTEMBER 24, 1999
REFERRED TO BANKING AND INSURANCE, SEPTEMBER 24, 1999
AN ACT
1 To ensure equitable coverage of prescription contraceptive drugs
2 and devices and the medical and counseling services necessary
3 for their effective use.
4 The General Assembly of the Commonwealth of Pennsylvania
5 hereby enacts as follows:
6 Section 1. Short title.
7 This act shall be known and may be cited as the Prescription
8 Contraception Equity Act.
9 Section 2. Findings.
10 The General Assembly finds and declares as follows:
11 (1) Each year, approximately 3,600,000 women face an
12 unintended pregnancy, representing nearly half of all
13 pregnancies in the United States.
14 (2) By reducing rates of unintended pregnancy,
15 contraception improves women's health and well-being, reduces
16 infant morbidity and mortality and reduces the need for
17 abortion.
18 (3) The cost of adding insurance coverage for all FDA-
1 approved contraception and related medical and counseling
2 services is estimated at $1.78 per employee per month.
3 (4) To defray their medical expenses, most women in the
4 United States, including two-thirds of women of childbearing
5 age, rely on some form of private, employment-related
6 insurance which they receive through either their own
7 employer or a family member's employer.
8 (5) Although 97% of typical fee-for-service insurance
9 policies written for large groups or preferred provider
10 organizations cover prescription drugs and 92% of these
11 policies cover prescription medical devices, including drugs
12 and devices used exclusively by men, 49% of these policies
13 cover no reversible method of contraception at all. Moreover,
14 only 15% of these policies cover all five methods of FDA-
15 approved contraception.
16 (6) Although the vast majority of typical fee-for-
17 service insurance policies written for large groups or
18 preferred provider organizations cover outpatient medical and
19 counseling services, the majority of these policies fail to
20 cover outpatient medical and counseling services necessary
21 for the effective use of contraception.
22 (7) Health insurance policies that fail to cover
23 prescription contraception and related medical and counseling
24 services discriminate against women and place effective forms
25 of contraception beyond the financial reach of many families.
26 Women of reproductive age spend 68% more than men on out-of-
27 pocket health care costs. Contraceptive drugs, devices and
28 related medical and counseling services account for much of
29 this difference.
30 (8) This act affects the business of insurance. The
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1 requirements of this act govern entities within the insurance
2 industry that provide health insurance policies as defined by
3 this act. The provisions of this act transfer and spread an
4 insured's risk and are an integral part of the policy
5 relationship between the insurer and the insured.
6 Section 3. Definitions.
7 The following words and phrases when used in this act shall
8 have the meanings given to them in this section unless the
9 context clearly indicates otherwise:
10 "Commissioner." The Insurance Commissioner of the
11 Commonwealth.
12 "Health insurance policy." A policy, agreement, contract,
13 certificate, indemnity plan, suretyship or annuity issued,
14 proposed for issuance or intended for issuance by an insurer,
15 including endorsements, supplements or riders to an insurance
16 policy, contract or plan, that provides health coverage to an
17 insured and that is issued, delivered, amended or renewed in
18 this Commonwealth on or after the effective date of this act.
19 The term does not include short-term travel or accident-only
20 policies, workers' compensation or short-term nonrenewable
21 policies of not more than six months' duration. A policy located
22 or documented outside this Commonwealth is subject to the
23 requirements of this act if it receives, processes, adjudicates,
24 pays or denies claims for drugs, devices or medical or
25 counseling services submitted on behalf of an insured who
26 resides in or receives drugs, devices or services in this
27 Commonwealth.
28 "Insured." A party named on a health insurance policy,
29 including an individual, corporation, partnership, association,
30 unincorporated organization or any similar entity, as the person
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1 with legal rights to the coverage provided by the health
2 insurance policy. For group insurance, the term includes a
3 person who is a beneficiary covered by a group health insurance
4 policy.
5 "Insurer." An individual, corporation, association,
6 partnership, reciprocal exchange, interinsurer, Lloyds insurer,
7 fraternal benefit society and any other legal entity engaged in
8 the business of insurance, including agents, brokers, adjusters
9 and third-party administrators. The term also includes a person
10 who contracts on a risk-assuming basis to provide, deliver,
11 arrange for, pay for or reimburse any of the cost of health care
12 services, including, but not limited to, health plan
13 corporations as defined in 40 Pa.C.S. Chs. 61 (relating to
14 hospital plan corporations) and 63 (relating to professional
15 health services plan corporations), beneficial societies as
16 defined in 40 Pa.C.S. Ch. 67 (relating to beneficial societies),
17 fraternal benefit societies as defined in the act of December
18 14, 1992 (P.L.835, No.134), known as the Fraternal Benefit
19 Societies Code, health maintenance organizations as defined in
20 the act of December 29, 1972 (P.L.1701, No.364), known as the
21 Health Maintenance Organization Act, and preferred provider
22 organizations as defined in section 630 of the act of May 17,
23 1921 (P.L.682, No.284), known as The Insurance Company Law of
24 1921, and 31 Pa. Code § 152.2 (relating to definitions).
25 "Limitation." Any of the following:
26 (1) Any copayment, deductible or other cost-sharing
27 mechanism, or premium differential, rules or regulations that
28 establish the type of professionals that may prescribe
29 prescription drugs or devices, utilization review provisions
30 and limits on the volume of prescription drugs or devices
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1 that may be obtained on the basis of a single consultation
2 with a professional.
3 (2) Requirements or procedures relating to timing of
4 payments or reimbursement by insurers
5 (3) Requirements relating to second opinions or
6 preauthorizations prior to coverage.
7 "Outpatient medical or counseling services necessary for the
8 effective use of contraception." The term includes, but is not
9 limited to, examinations, procedures and medical and counseling
10 services provided on an outpatient basis, and services for
11 initial and periodic comprehensive physical examinations,
12 medical, laboratory and radiology services warranted by the
13 initial and periodic examinations or by the history, physical
14 findings or risk factors, including medical services necessary
15 for the insertion and removal of any contraceptive drug or
16 device and individual or group family planning counseling.
17 Coverage for the comprehensive health exam shall be consistent
18 with the recommendations of the appropriate medical specialty
19 organizations and shall be made under terms and conditions
20 applicable to other coverage.
21 "Prescription contraceptive drug or device approved by the
22 Food and Drug Administration." Any regime of a prescription
23 contraceptive drug and any regime of a prescription
24 contraceptive device approved by the Food and Drug
25 Administration, as well as any generic equivalent approved as
26 substitutable by the Food and Drug Administration.
27 Section 4. Requirements for coverage.
28 A health insurance policy shall not:
29 (1) Exclude or restrict coverage for any prescription
30 contraceptive drug approved by the Food and Drug
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1 Administration, if the policy provides coverage for other
2 prescription drugs.
3 (2) Exclude or restrict coverage for a prescription
4 contraceptive device approved by the Food and Drug
5 Administration, if the policy provides coverage for other
6 prescription devices.
7 (3) Exclude or restrict coverage for outpatient medical
8 or counseling services necessary for the effective use of
9 contraception, if the policy provides coverage for other
10 outpatient medical or counseling services.
11 (4) Deny to any individual eligibility or continued
12 eligibility to enroll or to renew coverage under the terms of
13 the policy because of the individual's past, present or
14 future use of contraceptive drugs, devices or medical or
15 counseling services that are required by this act.
16 (5) Provide monetary payments or rebates to an insured
17 to encourage the insured to accept less than the minimum
18 coverage required by this act.
19 (6) Penalize or otherwise reduce or limit the
20 reimbursement of a health care professional because that
21 professional has in the past or will in the future prescribe
22 contraceptive drugs or devices, or provide medical or
23 counseling services that are required by this act.
24 (7) Provide monetary or other incentives to a health
25 care professional to withhold from an insured contraceptive
26 drugs or devices or medical or counseling services that are
27 required by this act.
28 Section 5. Construction.
29 Nothing in this act shall be construed as:
30 (1) Preventing a health insurance policy from imposing a
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1 limitation in relation to:
2 (i) Coverage for prescription contraceptive drugs,
3 provided that the limitation for this coverage is not
4 greater than or different from limitations imposed under
5 general terms and conditions applicable to all other
6 prescription drugs covered under the policy.
7 (ii) Coverage for prescription contraceptive
8 devices, provided that the limitation for this coverage
9 is not greater than or different from limitations imposed
10 under general terms and conditions applicable to all
11 other prescription devices covered under the policy.
12 (iii) Coverage for outpatient medical or counseling
13 services necessary for the effective use of
14 contraception, provided that the limitation for this
15 coverage is not greater than or different from
16 limitations imposed under general terms and conditions
17 applicable to all other outpatient medical or counseling
18 services covered under the policy.
19 (2) Requiring a health insurance policy to cover
20 experimental prescription contraceptive drugs or devices or
21 experimental outpatient medical or counseling services
22 necessary for the effective use of contraception, except to
23 the extent that the policy provides coverage for other
24 experimental prescription drugs or devices or experimental
25 outpatient medical or counseling services.
26 (3) Requiring coverage for prescription contraceptive
27 drugs, devices or medical or counseling services required by
28 this act in any policy that does not otherwise provide
29 coverage for prescription drugs or devices or outpatient
30 medical or counseling services.
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1 Section 6. Enforcement.
2 (a) Action by applicant.--An applicant or an insured who
3 believes that he has been adversely affected by an act or
4 practice of an insurer in violation of this act may:
5 (1) file a complaint with the commissioner, who shall
6 handle the complaint consistent with 2 Pa.C.S. Ch. 5 Subch. A
7 (relating to practice and procedure of Commonwealth agencies)
8 and Ch. 7 Subch. A (relating to judicial review of
9 Commonwealth agency action) and address any violation through
10 means appropriate to the nature and extent of the violation,
11 which may include cease-and-desist orders, injunctive relief,
12 restitution, suspension or revocation of certificates of
13 authority or licenses, civil penalties and reimbursement of
14 costs and reasonable attorney fees incurred by the aggrieved
15 individual in bringing the complaint, or any combination of
16 these; or
17 (2) file a civil action against the insurer in a court
18 of original jurisdiction, which, upon proof of the act's
19 violation by a preponderance of the evidence, shall award
20 appropriate relief, including, but not limited to, temporary,
21 preliminary or permanent injunctive relief, compensatory and
22 punitive damages, as well as the costs of suit and reasonable
23 attorney fees for the aggrieved individual's attorneys and
24 expert witnesses. The aggrieved individual may elect, at any
25 time prior to the rendering of final judgment, to recover in
26 lieu of actual damages an award of statutory damages in the
27 amount of $5,000 for each violation.
28 (b) Civil action.--
29 (1) If an aggrieved individual elects to file a
30 complaint with the commissioner pursuant to subsection
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1 (a)(1), that individual's right of action in a court of
2 original jurisdiction shall not be foreclosed.
3 (2) If the commissioner has not secured a resolution of
4 the complaint acceptable to the complainant within 180 days
5 after the filing of the complaint, the complainant may file a
6 civil action pursuant to subsection (a)(2). Upon the filing
7 of a civil action, all proceedings before the commissioner
8 shall terminate.
9 Section 7. Notice of change.
10 The enactment of this act shall be treated as a material
11 notification of a change in the terms of a health insurance
12 policy.
13 Section 8. Severability.
14 The provisions of this act are severable. If any provision of
15 this act or its application to any person or circumstance is
16 held invalid, the invalidity shall not affect other provisions
17 or applications of this act which can be given effect without
18 the invalid provision or application.
19 Section 9. Effective date.
20 This act shall take effect in 60 days.
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