Pennsylvania Statutes Title 40 P.S. Insurance § 908-13. Definitions

(a) General rule.--The following words and phrases when used in this article shall have the meanings given to them in this section unless the context clearly indicates otherwise:

“Commissioner.” The Insurance Commissioner of the Commonwealth.

“Department.” The Insurance Department of the Commonwealth.

“Federal acts.”The Federal laws known as the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343, 122 Stat. 3881), the Genetic Information Nondiscrimination Act of 2008 (Public Law 110-233, 122 Stat. 881) and Michelle's Law (Public Law 110-381, 122 Stat. 4081), collectively contained in the Public Health Service Act (58 Stat. 682, 42 U.S.C. § 201 et seq.).

“Fraternal benefit society.”An entity holding a current certificate of authority under Article XXIV.  1

“Health insurance policy.”A policy, subscriber contract, certificate or plan issued by an insurer that provides medical or health care coverage. The term does not include any of the following:

(1) An accident only policy.

(2) A fixed indemnity policy.

(3) A limited benefit policy.

(4) A credit only policy.

(5) A dental only policy.

(6) A vision only policy.

(7) A specified disease policy.

(8) A Medicare supplement policy.

(9) A policy under which benefits are provided by the Federal Government to active or former military personnel and their dependents.

(10) A long-term care or disability income policy.

(11) A workers' compensation policy.

(12) An automobile medical payment policy.

“Health maintenance organization.”An entity holding a current certificate of authority under the act of December 29, 1972 (P.L. 1701, No. 364),  2 known as the Health Maintenance Organization Act.

“Hospital plan corporation.”An entity holding a current certificate of authority organized and operated under 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations).

“Insured.” A person on whose behalf an insurer is obligated to pay covered health care expense benefits or provide health care services under a health insurance policy. The term includes a policyholder, subscriber, certificate holder, member, dependent or other individual who is eligible to receive health care services through a health insurance policy.

“Insurer.” A foreign or domestic insurance company, association or exchange, health maintenance organization, hospital plan corporation, professional health services plan corporation, fraternal benefit society or risk-assuming preferred provider organization. The term shall not include a group health plan as defined in section 2791 of the Public Health Service Act (58 Stat. 682, 42 U.S.C. § 300gg-91).

“MH/SUD.” Mental health and substance use disorder.

“MH/SUD parity Federal guidance.”Federal guidance issued pursuant to or in conjunction with MHPAEA and the MH/SUD parity Federal regulations.

“MH/SUD parity Federal regulations.”Regulations promulgated by the Federal Government to implement MHPAEA, including 45 CFR 146.136 (relating to parity in mental health and substance use disorder benefits), 147.160 (relating to parity in mental health and substance use disorder benefits) and Pt. 156 (relating to health insurance issuer standards under the Affordable Care Act, including standards related to exchanges), as amended.

“MHPAEA.” The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (Public Law 110-343, 122 Stat. 3881), originally enacted as section 2705 of the Public Health Service Act (58 Stat. 682, 42 U.S.C. § 300gg-5), as renumbered and amended by the Patient Protection and Affordable Care Act (Public Law 111-148, 124 Stat. 119), together with the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152, 124 Stat. 1029), as section 2726 of the Public Health Service Act (42 U.S.C. § 300gg-26), as further amended by the enhanced compliance with the MH/SUD coverage requirements under § 13001 of the 21st Century Cures Act (Public Law 114-255, 42 U.S.C. § 300gg-26(a)(6) and (7)), as amended.

“Preferred provider organization.”An entity holding a current certificate of authority under section 630.  3

“Professional health services plan corporation.”An entity holding a current certificate of authority under 40 Pa.C.S. Ch. 63 (relating to professional health services plan corporations). This term shall not include dental service corporations or optometric service corporations, as those terms are defined under 40 Pa.C.S. § 6302(a) (relating to definitions).

“Treatment limitation.”A limit on the scope of a benefit or duration of treatment for a covered service.

(b) Federal law.--The words, terms and definitions found in the Federal acts, including those in section 2791 of the Public Health Service Act (58 Stat. 682, 42 U.S.C. 300gg-91), are adopted for purposes of implementing this article, except as noted in this subsection. The term “health insurance issuer” under section 2791(b)(2) of the Public Health Service Act shall have the meaning provided under “insurer” in subsection (a).