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(a) Notwithstanding any other provision of law and except as provided in this section, any person or other entity which provides benefits in this Commonwealth for medical, surgical, chiropractic, physical therapy, speech pathology, audiology, professional mental health, dental, hospital or optometric expenses, whether the benefits are provided by direct payment, reimbursement or otherwise, shall comply with the requirements of section 208, 1 unless the person or other entity shows that while providing those services it is subject to the jurisdiction of another agency of the Commonwealth, any subdivisions thereof, or the Federal Government with respect to financial solvency.
(b) A person or entity may show that it is subject to the jurisdiction of another agency of the Commonwealth, or any subdivision thereof, or of the Federal Government by providing to the Insurance Commissioner the appropriate certificate, license or other document issued by the other governmental agency which permits or qualifies it to provide those services. Such certificate, license or other document may constitute evidence that a person or entity is subject to the jurisdiction of another agency of the Commonwealth, or any subdivision thereof, or of the Federal Government, but such evidence is subject to rebuttal. A Department of Labor letter concerning an entity's purported status under the Employee Retirement Income Security Act of 1974 (Public Law 93-406, 29 U.S.C. § 1001 et seq.) is not a certificate, license or other document within the meaning of this section which permits or qualifies an entity to provide services.
(c) Any person or entity which is unable to show under subsection (b) that it is subject to the jurisdiction of another agency of the Commonwealth, or any subdivision thereof, or the Federal Government shall submit to an examination by the Insurance Commissioner to determine the organization and solvency of the person or the entity and to determine whether or not such person or entity complies with the applicable provisions of law. The person or entity examined shall be responsible for the Insurance Department's examination expenses to the same extent as a licensed insurance company would be responsible if the person or entity is found to be subject to the requirements of section 208.
(d) Any person or entity unable to show that it is subject to the jurisdiction of another agency of the Commonwealth, or any subdivision thereof, or of the Federal Government shall be subject to all appropriate provisions of law regarding the conduct of its business.
(e) Any person, entity, agent or administrator which advertises, sells, transacts or administers in this Commonwealth the benefits described in subsection (a) and which is required to submit to an examination by the Insurance Commissioner under subsection (c) shall, if said benefits are not fully insured or otherwise fully covered by any insurer licensed to do the business of insurance in this Commonwealth, nonprofit hospital service plan or nonprofit health care plan, give notice to every purchaser, prospective purchaser and covered person of such lack of insurance or other coverage and lack of State insurance insolvency guaranty funds protection.
(f) Any administrator which advertises or administers in this Commonwealth the benefits described in subsection (a) and which is required to submit to an examination by the Insurance Commissioner under subsection (c) shall give notice to any person or agent, as described in subsection (e), of the elements of the coverage, including, but not limited to, the amount of “stop-loss” insurance in effect and lack of State insurance insolvency guaranty funds protection.
(g) The notice described in subsections (e) and (f) shall be in ten-point type on any solicitation, application, description of benefits, renewal form or any other form provided to any person covered by a person or entity described in subsection (a).
(h) Upon satisfactory evidence of the violation of any of the provisions of this section, the Insurance Commissioner may in his discretion pursue any one or more of the following courses of action, regardless of whether such person, entity, agent, solicitor, broker or company is licensed or not licensed by the Insurance Commissioner:
(1) Suspend or revoke or refuse to renew the license of such offending party or parties.
(2) Impose a civil penalty of not more than one thousand dollars ($1,000) for each and every act in violation of any of said sections by said party or parties.
Cite this article: FindLaw.com - Pennsylvania Statutes Title 40 P.S. Insurance § 61. Jurisdiction over providers of health care benefits - last updated January 01, 2019 | https://codes.findlaw.com/pa/title-40-ps-insurance/pa-st-sect-40-61.html
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