35 Pa. Stat. § 5701.1302

Current through Pa Acts 2024-35, 2024-56

Section 5701.1302 - 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:

"Benefit package." Insurance coverage which provides the benefits set forth in section 1303(f)(2) for eligible adults.

"Contractor." An insurer or other entity or its subsidiaries operating under 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63 (relating to professional health services plan corporations), or both.

"Department." The Insurance Department of the Commonwealth.

"Eligible adult." A low-income adult who meets all of the following:

(1) Legally resides within the United States.

(2) Has been domiciled in this Commonwealth for at least 90 days prior to enrollment.

(3) Is not covered by a health insurance plan, a self-insurance plan or a self-funded plan.

(4) Has not been covered by a health insurance plan, a self-insurance plan or a self-funded plan during the three months immediately preceding the determination of eligibility except when one of the following apply:

(i) The low-income adult is eligible to receive benefits pursuant to the act of December 5, 1936 (2nd Sp.Sess., 1937 P.L. 2897, No. 1), known as the Unemployment Compensation Law.

(ii) The low-income adult was covered under one of the above plans but at the time of application for coverage is no longer employed and is ineligible to receive benefits pursuant to the Unemployment Compensation Law.

(iii) The low-income adult is the spouse of a person who meets either of the exceptions set forth in subparagraph (i) or (ii) and both the eligible adult and the spouse are low income and applying for coverage.

(5) Is ineligible for medical assistance or Medicare.

"Hospital." A hospital as defined and licensed under the act of July 19, 1979 (P.L. 130, No. 48) , known as the Health Care Facilities Act.

"Insurer." An insurance company, association, reciprocal, health maintenance organization, fraternal benefit society or a risk-bearing preferred provider organization that offers health care benefits and is subject to regulation under the act of May 17, 1921 (P.L. 682, No. 284), known as The Insurance Company Law of 1921, or the act of December 29, 1972 (P.L. 1701, No. 364), known as the Health Maintenance Organization Act.

"Low-income adult." An individual who is at least 19 years of age but less than 65 years of age and whose household income is less than 200% of the Federal poverty level at the time of eligibility determination.

"Medical assistance." The State program of medical assistance established under the act of June 13, 1967 (P.L. 31, No. 21), known as the Public Welfare Code.

"Medicare." The Federal program established under Title XVIII of the Social Security Act (49 Stat. 620, 42 U.S.C.§ 1395 et seq.).

"Offeror." An insurer that submits a proposal in response to the department's request for proposals issued pursuant to section 1303(f).

"Preexisting condition." A disease or physical condition for which medical advice or treatment has been received prior to the effective date of coverage.

"Program." The adult basic coverage insurance program established in section 1303.

35 P.S. § 5701.1302

2001, June 26, P.L. 755, No. 77, § 1302, effective 7/1/2001.