Pennsylvania medical-plan questions focus on mandated benefits and on the managed care consumer protections in Article XXI of the Insurance Company Law (Act 68 of 1998). Also tested: newborn, adopted-child and dependent coverage, which includes the Pennsylvania rule that lets young adults stay on a group plan through age 29. The general material (indemnity vs. managed care, HMOs and PPOs, cost sharing, HDHPs and HSAs, the ACA) is in the national Medical Plans guide.

Children and dependents

Newborns (40 P.S. 753.1-753.4, Act 81 of 1975)

• A policy that covers dependents must cover a newborn from the moment of birth. Coverage includes sickness, injury, congenital defects and prematurity.
• The parent must notify the insurer within 31 days to continue coverage beyond that period.

Adopted children (40 P.S. 775.1)

• Covered on the same basis as natural children, including children placed for adoption.

Young adults to 29 (Insurance Company Law 617.1, Act 4 of 2009)

• Group insurers must make coverage available, at the employee's expense, for an unmarried child with no dependents who lives in Pennsylvania or is a full-time student and has no other coverage, through age 29.
• This is separate from the ACA rule that covers children to age 26.

Disabled children (40 P.S. 752(A)(9))

• Coverage continues past the limiting age for an unmarried child who is incapable of self-support because of disability.
• Proof of incapacity is due within 31 days of the child reaching the limiting age.

Immunizations

• Policies covering children must include childhood immunizations (40 P.S. 3503).

Mandated benefits

Breast imaging (Insurance Company Law 632.1, as amended by Act 52 of 2025)

• Mammograms for covered persons 40 and older with no cost sharing.
• Supplemental breast MRI or ultrasound and diagnostic exams, also without cost sharing, for a covered person with at least average breast cancer risk.

Mastectomy (40 P.S. 764d)

• Covers the inpatient stay the attending physician decides is needed.
• If the patient is discharged within 48 hours of admission, a physician-ordered home health visit within 48 hours is covered.
• Prostheses, lymphedema treatment and reconstructive surgery are covered.

Maternity (40 P.S. 1583)

• At least 48 hours in the hospital after a vaginal delivery and 96 hours after a cesarean.

Women's health (40 P.S. 1574)

• An annual gynecological exam and routine Pap smear.

Cancer treatment

• Chemotherapy and hormone treatment: covered in any medically appropriate setting (40 P.S. 764b).
• Oral chemotherapy: covered on terms no less favorable than IV or injected chemotherapy (Insurance Company Law 631.1, Act 73 of 2016).

Colorectal screening (40 P.S. 764i)

• Large groups only (51 or more employees).
• For people 50 and older without symptoms, a colonoscopy at least once every 10 years.

Diabetes (40 P.S. 764e)

• Equipment, supplies and self-management education for all types, including gestational and non-insulin-using diabetes.

Autism spectrum disorders (40 P.S. 764h)

• Diagnosis and treatment for covered plans.

Serious mental illness (40 P.S. 764g)

• Groups of 50 or more.
• At least 30 inpatient and 60 outpatient days a year. Inpatient days can be converted to outpatient days at one for two.

Alcohol and drug abuse (40 P.S. 908-1 to 908-8)

• Group policies must cover treatment of alcohol and other drug abuse and dependency.

Mental health parity (40 P.S. 908-11 to 908-16)

• Mental health benefits can't have more restrictive limits than medical benefits.

No such mandate: Pennsylvania has no prostate-screening or bone-density mandate.

Managed care protections (40 P.S. 991.2101 et seq.)

• Emergency services: covered on a prudent layperson standard. An emergency provider may evaluate and stabilize without prior authorization (991.2116).
• OB-GYN: women may see a network OB-GYN without a referral (991.2111(7)).
• Standing referrals: an enrollee with a life-threatening, degenerative or disabling condition may request a standing referral to a specialist, or a specialist as coordinator of care (991.2111(6)).
• Continuity of care (991.2117):
  • When a provider leaves the network, the plan provides a transition period.
  • A new enrollee in the second or third trimester of pregnancy may keep a nonparticipating provider through postpartum care.
• Grievances: enrollees get internal grievance rights and independent external review of denials (991.2111; Act 146 of 2022).
• Gag clauses: plans may not penalize providers for discussing treatment options with patients (991.2113).
• Incentives: plans may not pay providers to give less than medically necessary care (991.2112).

Guaranty protection

• The Pennsylvania Life and Health Insurance Guaranty Association covers health benefit plans up to $500,000 per individual (40 P.S. 991.1703).

Common exam traps

• Dependents through age 29 under Pennsylvania's Act 4 is a separate rule from the ACA's age 26. It is made available at the employee's expense, with conditions.
• Newborn notice: 31 days. Coverage still starts at birth and includes congenital defects.
• Mammograms at 40 and older have no cost sharing (Act 52 of 2025).
• Colorectal and serious mental illness mandates apply to large groups (51+ and 50+), not individual policies.
• Mental illness minimum: 30 inpatient and 60 outpatient days.
• No prostate or bone-density mandate in Pennsylvania.