On March 12, 2022, the Department of Insurance published Notice 2022-04. The notice relates to an annual adjustment to the maximum benefit amount for coverage of autism spectrum disorders. According to the notice, for plans/policies issued or renewed in 2023, the maximum benefit is $45,808 (up from $42,811 for plans/policies issued or renewed in 2022). Employers with questions on the maximum benefit should work with their carriers.

Notice 2022-04 »

On March 13, 2021, the Department of Insurance published Notice 2021-03. The notice relates to an annual adjustment to the maximum benefit amount for coverage of autism spectrum disorders. According to the notice, for plans/policies issued or renewed in 2022, the maximum benefit is $42,811 (up from $42,220 for plans/policies issued or renewed in 2021). Employers with questions on the maximum benefit should work with their carriers.

Notice 2021-03 »

On March 6, 2021, the Insurance Department issued Notice 2021-03 reminding insurers of their obligation to provide certain coverage related to COVID-19. The notice also serves as a good reminder for employer plan sponsors of the coverage available under a group health insurance policy issued in Pennsylvania.

• As required by the FFCRA and CARES Act, insurers must provide coverage for COVID-19 testing without cost sharing for the insured when recommended by a health care provider as medically appropriate.
• As required by the CARES Act, insurers must provide coverage for the approved COVID-19 vaccinations without cost sharing for the insured without regard to the network participation status of the health care provider.
• The Insurance Department encourages insurers to be flexible with their telehealth coverage and policies through the end of the public health emergency and communicate any policy changes to insureds 60 days in advance.

Employers with plans issued by the state should be aware of this development.

Notice 2021-03 »

The COVID-19 Emergency Paid Sick Leave Act is a temporary ordinance signed into law on December 9, 2020, and is effective immediately. It will remain in effect until the public health emergency ends. Employers with 50 or more total employees must provide eligible employees with 80 hours of paid COVID-19 sick leave. Eligible employees are those who perform at least 51% of their work in Pittsburgh, including telework. It also includes those that normally work in Pittsburgh, but are teleworking from another location during the pandemic.

Qualified reasons for leave are as follows:

• If a healthcare provider or public health authority or employer determines that an employee would be a health risk to others due to exposure to COVID-19, or due to that employee exhibiting symptoms of COVID-19.
• If an employee must care for a family member due to that family member being determined as a health risk to others due to exposure to COVID-19, or due to that family member showing symptoms of COVID-19.
• If an employee needs to quarantine due to being diagnosed with COVID-19, showing symptoms of COVID-19, or needs to seek diagnosis or other care for COVID-19.
• If an employee must care for a family member who needs to quarantine or otherwise seek treatment/diagnosis under item iii) above.

There is no specific notice requirement, but the best practice would be for employers to inform employees of the availability of this paid leave.

Pittsburgh COVID-19 Emergency Paid Sick Leave FAQs »

HB 427 requires policies issued or renewed on or after October 9, 2020, which provide coverage for the treatment of stage four advanced metastatic cancer to provide coverage for prescription drugs related to the treatment of such cancer. Specifically, the insurer may not require an insured to first fail to successfully respond to a different drug or prove a history of failure with a different drug before providing coverage for a covered drug if it is approved by the FDA is consistent with the best clinical practices for the treatment of stage four advanced metastatic cancer or a related severe adverse health condition.

Employers should be aware of this insurance mandate.

HB427 »

On March 20, 2020, the City of Philadelphia announced expansions to its paid sick leave law relating to COVID-19. Specifically, during the COVID-19 risk, covered employees can use accrued paid sick leave time for mandated business closures, caring for children during school or childcare closures, official or self-quarantine, and illness and treatment of an illness for an individual and their family member. In addition, employees are not required to provide a note from a medical professional in order to use consecutive paid sick leave during the COVID-19 risk.

Employers with Philadelphia employees should review the announcement and work with outside counsel in updating their leave policies to reflect the ability of employees to use accrued paid sick leave for the above COVID-19 reasons

Announcement »
Updated FAQs »
Updated Guidelines »

On March 19, 2020, the Insurance Department published Notice 2020-4. The bulletin encourages carriers to assist employers (and other policyholders) who have been negatively impacted by the COVID-19 pandemic by relaxing due dates for premium payments, extending grace periods, waiving late fees and penalties and allowing payment plans for premium payments to otherwise avoid a lapse in coverage. The bulletin directs carriers to consider cancellation or nonrenewal of policies only after exhausting other efforts to work with employers (and other policyholders) to continue coverage.

Employers with fully insured plans in Pennsylvania that may need assistance with premium payments should contact and discuss the issue with their carrier.

Notice 2020-4 »

On March 7, 2020, the Department of Insurance published Notice Number 2020-02. The notice relates to an annual adjustment to the maximum benefit amount for coverage of autism spectrum disorder. According to the notice, for plans/policies issued or renewed in 2021 the maximum benefit is $42,220 (up from $41,271 for plans/policies issued or renewed in 2020). Employers with questions on the maximum benefit should work with their carriers.

Notice Number 2020-02 »

On March 10, 2020, the Department of Insurance published Notice Number 2020-03. The new bulletin relates to health insurance coverage of coronavirus (COVID-19). According to the bulletin, the Department expects medically prescribed diagnostic testing for COVID-19 to be covered without prior authorization requirements that might ordinarily apply to diagnostic testing. The Department also urges health insurers to waive any cost sharing for COVID-19 laboratory tests, in-network provider office visits, in-network urgent care center visits and emergency care services (when related to COVID-19).

In addition, with regard to prescription drugs, carriers are encouraged to make expedited formulary exceptions and to permit the temporary use of out-of-network pharmacies (at in-network cost sharing) in the event of medication shortages at in-network pharmacies. The Department also encourages insurers to cover refills even when the scheduled refill date has not been reached (although that recommendation does not apply to opioids).

Notice Number 2020-03 applies directly to carriers, but is an important reminder on coverage of COVID-19-relates services and items.

Notice Number 2020-03 »

As reported in the August 6, 2020, edition of Compliance Corner, the Supreme Court of Pennsylvania Western District overturned the lower court’s decision in Pennsylvania Restaurant & Lodging Association v. City of Pittsburgh, ruling that the city’s paid sick leave ordinance is permissible under state law as it falls under the health and prevention of disease exception. The City of Pittsburgh Law Department has announced that the ordinance becomes effective March 15, 2020.

The law requires employers doing business in the city of Pittsburgh to provide paid sick leave to employees to care for an ill family member, for their own preventive care or illness, or in the event of declared public health emergency. Employees will accrue one hour for every 35 hours worked.

Employers with 15 or more employees must provide up to a maximum accrual of 40 hours in a calendar year. Employers with fewer employees must provide up to a maximum accrual of 24 hours in a calendar year. Additionally, the smaller employers are only required to provide unpaid leave the first year following the effective date. Employer size is determined by counting all employees (full-time and part-time) both inside and outside Pittsburgh, excluding owners.

The city has posted proposed guidelines and an employee notice, on which they request comments.

City of Pittsburgh Paid Sick Leave website »