Title 40, INSURANCE

(a) Plan of conversion.--The following shall apply: (1) A plan of conversion may not become effective unless the reciprocal insurer seeking to convert to a stock company has adopted: (i) by the affirmative vote of not less than two-thirds of the subscribers' advisory committee or…

(a) Contents.--The following provisions shall be included in a plan of conversion: (1) The reasons for proposed conversion. (2) The effect of conversion on existing policies, including a provision that the policies in force on the effective date of conversion continue to remain i…

(a) Subscription rights.--The plan may provide that the directors and officers of the attorney and the reciprocal insurer shall receive, without payment, nontransferable subscription rights to purchase capital stock of the stock company or the stock of another corporation that is…

A plan of conversion may be adopted that does not rely in whole or in part upon issuing nontransferable subscription rights to subscribers to purchase stock of the stock company if the commissioner finds that the plan does not prejudice the interests of the subscribers, is fair a…

A plan is effective when the following have been completed: (1) The commissioner has approved the plan. (2) The eligible subscribers have approved the plan. (3) If the stock company becomes successor to the reciprocal insurer by merger, the eligible subscribers have approved the …

(a) Notice.--A subscriber shall be sent a written notice regarding the plan upon issuance of a policy if the subscriber's policy is issued after the later of: (1) the date the proposed plan has been adopted; or (2) if different, the record date for establishing subscribers eligib…

On the effective date of the conversion, the corporate existence of the reciprocal insurer continues in the stock company. On the effective date of the conversion, the assets, rights, franchises and interests of the reciprocal insurer in and to every species of real, personal and…

(a) Compensation.--A director, officer, agent or employee of the attorney or reciprocal insurer may not receive a fee, commission or other valuable consideration, other than his usual regular salary or compensation, for aiding, promoting or assisting in a conversion under this ch…

If the reciprocal insurer complies substantially and in good faith with the notice requirements of this chapter, the reciprocal insurer's failure to send a subscriber the required notice does not impair the validity of an action taken under this chapter.

An action challenging the validity of or arising out of acts taken or proposed to be taken under this chapter shall be commenced no later than 30 days after the later of the approval of the plan by the commissioner or the deemed approval of the plan by a vote of the eligible subs…

(a) Waiver of requirements.--If a reciprocal insurer seeking to convert is insolvent or is in hazardous financial condition according to information supplied in its most recent annual or quarterly statement filed with the department or as determined by a financial examination per…

The commissioner may promulgate rules and regulations to administer and enforce this chapter.

(a) Control of stock company.--A reciprocal insurer may not convert under this chapter if, as a direct result of the conversion, a person or the person's affiliates acquire control of the stock company, unless that person and the person's affiliates comply with the provisions of …

The commissioner may waive the minimum surplus requirement of a stock company in connection with the initial licensing of a stock company that will be the successor to a reciprocal insurer. The stock company may not engage in the business of insurance as a stock company until the…

By endorsement or rider approved by the commissioner and sent to the policyholder, a reciprocal insurer may simultaneously with or after the adoption of a plan of conversion amend an outstanding insurance policy for the purpose of extinguishing a right of the holder of the policy…

Except as otherwise specifically provided in section 3503 (relating to contents of plan of conversion), from the date a plan of conversion is adopted until the effective date of the plan of conversion, a person may not directly or indirectly offer to acquire, make an announcement…

The purpose of this chapter is to require the complete and proper disclosure, transparency and accountability relating to a method of payment for life insurance death benefits regulated by the Insurance Department.

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: "Beneficiary." A person designated to receive the proceeds from a life insurance policy or retained asset account. "Comm…

(a) Comparison.--An insurer shall implement procedures for performing a comparison of its insureds' in-force life insurance policies, contracts and retained asset accounts against the same death master file, on at least a semiannual basis, by using the full death master file once…

This chapter shall not apply to all of the following: (1) An annuity contract that does not require the insurer to pay benefits to the beneficiary of the policy. (2) A policy that provides a death benefit under the Employee Retirement Income Security Act of 1974 (Public Law 93-40…

(a) Actions.--Upon a determination by hearing that an insurer has violated this chapter, the commissioner may pursue one or more of the following courses of action: (1) issue an order requiring the insurer to cease and desist from engaging in the violation or suspend, revoke or r…

The commissioner may promulgate rules and regulations to administer the provisions of this chapter.

This chapter shall not apply to reimbursements made as part of an annual contracted reconciliation of a risk-sharing arrangement under an administrative service provider contract.

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: "Abuse." Incidents or practices of providers, physicians or suppliers of services and equipment which are inconsistent w…

(a) General rule.--Except as provided in section 3804 (relating to exceptions to retroactive denial of reimbursement), an insurer may not retroactively deny reimbursement as a result of an overpayment determination more than 24 months after the date the insurer initially paid the…

The provisions of section 3803 (relating to retroactive denial of reimbursement) do not apply if an insurer retroactively denies reimbursement to a health care provider because any of the following apply: (1) The information submitted to the insurer constitutes fraud, waste or ab…

If an insurer retroactively denies reimbursement for services as a result of coordination of benefits under the provisions of section 3804(4) (relating to exceptions to retroactive denial of reimbursement), the health care provider shall have 12 months from the date of the denial…

An insurer may request medical or billing records in writing from a health care provider under section 3803 (relating to retroactive denial of reimbursement). The health care provider shall provide the necessary records to the insurer within 60 days of the request. The period of …

(a) Purposes.--The purposes of this chapter are to: (1) Provide the commissioner a summary of an insurer or insurance group's corporate governance structure, policies and practices to permit the commissioner to gain and maintain an understanding of the insurer or insurance group'…

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: "Board." The board of directors of the filing entity. "CGAD-related information." The CGAD or any documents, materials o…

(a) General rule.-- (1) Beginning January 1, 2020, a domestic insurer or an insurance group of which this Commonwealth is the lead state shall submit to the department a CGAD no later than June 1 of each calendar year. (2) If a domestic insurer is a member of an insurance group o…

(a) Contents.--The CGAD must contain the material information necessary to permit the department to gain an understanding of the insurer's or insurance group's corporate governance structure, policies and practices. The commissioner shall consider premium volume, licensing status…

(a) Procedures for review.--The review of the CGAD and any additional requests for information shall be made by or through the lead state or, in the case of an insurer that is not part of an insurance group, the department. (b) Duplicative filings.--An insurer or insurance group …

(a) Assistance with review.--The department may retain, at the insurer or insurance group's expense, third-party consultants, including attorneys, actuaries, accountants and other experts not otherwise a part of the department's staff as may be reasonably necessary to assist the …

(a) General rule.--The CGAD-related information in the possession or control of the department that is produced by, obtained by or disclosed to the department or any other person under this chapter shall be privileged and given confidential treatment and shall not be: (1) subject…

An insurer or insurance group that fails to timely file a CGAD as required under this chapter or by regulation shall be required, after notice and hearing, to pay a penalty of $200 for each day's delay. The maximum penalty under this section shall be $25,000 per year.

The department may promulgate rules and regulations and issue orders necessary to administer and enforce this chapter.

Nothing in this chapter shall be construed to prescribe or impose corporate governance standards and internal procedures in addition to those required under applicable State corporate law. Notwithstanding the foregoing, nothing in this chapter shall be construed to limit the comm…

(a) General rule.--Except as provided in subsection (b): (1) The provisions of this chapter are severable. (2) If a provision of this chapter or its application to a person or circumstance is held invalid, the invalidity does not affect other provisions or applications of this ch…

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: "Health insurance policy." An individual or group policy, subscriber contract, certificate or plan issued by an insurer …

A health insurance policy shall permit and apply a prorated daily cost-sharing rate to maintenance medications that are dispensed by a pharmacy as a partial supply if the pharmacist or prescriber determines the fill or refill to be in the best interest of the patient and the pati…

(a) Partial supply.--A health insurance policy providing prescription drug coverage may not deny coverage for the dispensing of a maintenance medication that is dispensed by a network pharmacy on the basis that the dispensing is for a partial supply if the prescriber or pharmacis…

(a) Prorated dispensing fees.--A health insurance plan providing prescription drug coverage may not use payment structures incorporating prorated dispensing fees. (b) Full payment.--Dispensing fees for a partial supply or refilled prescriptions shall be paid in full for each main…

(a) Prescription drugs.--This chapter does not apply to prescription drugs that are: (1) unit-of-use packaging for which medication synchronization is not possible; or (2) controlled substances classified in Schedule II under section 4(2) of the act of April 14, 1972 (P.L.233, No…

This chapter relates to an attestation of compliance with Federal and State insurance laws regarding mental health and substance use disorder benefits.

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: "Health insurance policy." As follows: (1) An insurance policy, subscriber contract, certificate or plan that provides m…