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PRINTER'S NO. 2033
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
1553
Session of
2017
INTRODUCED BY BAKER, PICKETT, FRANKEL, DIAMOND, CALTAGIRONE,
V. BROWN, IRVIN, JAMES, MILLARD, DeLUCA, DRISCOLL,
SCHLOSSBERG, KAUFER, KINSEY, D. COSTA, M. QUINN, SIMMONS,
FABRIZIO, WARREN, WARD, PASHINSKI, ROAE, ENGLISH, EVERETT,
RADER, BIZZARRO, GABLER, WHEELAND, ZIMMERMAN, CORR AND
MARSHALL, JUNE 16, 2017
REFERRED TO COMMITTEE ON HEALTH, JUNE 16, 2017
AN ACT
Providing for the protection of consumers of health care
coverage against surprise balance bills for emergency health
care services or for other covered health care services when
health care services are sought from in-network facilities.
TABLE OF CONTENTS
Chapter 1. Preliminary Provisions
Section 101. Short title.
Section 102. Definitions.
Chapter 3. Balance Billing and Payment
Section 301. Duty of facilities to provide written disclosure.
Section 302. Surprise balance bills.
Section 303. Direct dispute resolution.
Section 304. Independent dispute resolution.
Section 305. Applicability.
Chapter 5. Insurers
Section 501. Communications to consumers.
Section 502. Records and confidentiality.
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Section 503. Enforcement.
Section 504. Private cause of action.
Chapter 7. Miscellaneous Provisions
Section 701. Regulations.
Section 702. Effective date.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
CHAPTER 1
PRELIMINARY PROVISIONS
Section 101. Short title.
This act shall be known and may be cited as the Surprise
Balance Bill Protection Act.
Section 102. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Balance bill." A bill for a covered service provided to an
insured who has coverage through a health care plan in order to
collect the difference between an out-of-network provider's fee
for a covered service received by the insured from the out-of-
network provider and the reimbursement received by the out-of-
network provider from the insured's health care plan.
"Commissioner." The Insurance Commissioner of the
Commonwealth.
"Confidential information." Nonpublic personal health
information, trade secret or confidential proprietary
information which is produced by, obtained by or disclosed to
the department, the Department of Health, the Department of
State, the Office of Attorney General, a resolution organization
assigned to a dispute under Chapter 3 or any other person in the
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course of a dispute resolution under this act.
"Confidential proprietary information." Commercial or
financial information that:
(1) is privileged or confidential; and
(2) if disclosed, would cause substantial harm to the
competitive position of the person that submitted the
information.
"Cost-sharing." A copayment, coinsurance, deductible or
similar charge. The term does not include premiums, balance
billing amounts or the cost of noncovered services.
"Covered service." A health care service reimbursable by an
insurer under a health care plan.
"Department." The Insurance Department of the Commonwealth.
"Emergency medical services agency" or "EMS agency." As
defined in 35 Pa.C.S. § 8103 (relating to definitions).
"Emergency service." A health care service provided to an
insured after the sudden onset of a medical condition that
manifests itself by acute symptoms of sufficient severity or
severe pain such that a prudent layperson who possesses an
average knowledge of health and medicine could reasonably expect
the absence of immediate medical attention to result in
detrimental consequences to the health of the insured or, in the
case of a pregnant woman, the health of the insured or her
unborn child. The term includes the following:
(1) Emergency medical services as defined in 35 Pa.C.S.
§ 8103.
(2) A health care service that a provider determines is
necessary to evaluate and, if necessary, stabilize the
condition of the insured so that the insured may be
transported without suffering detrimental consequences or
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aggravating the insured's condition.
(3) If the insured is admitted into a facility, a health
care service rendered prior to transfer or discharge.
"Facility." A facility providing a health care service,
including any of the following:
(1) A general, special, psychiatric or rehabilitation
hospital.
(2) An ambulatory surgical facility.
(3) A cancer treatment center.
(4) A birth center.
(5) An inpatient, outpatient or residential drug and
alcohol treatment facility.
(6) A laboratory, diagnostic or other outpatient medical
service or testing facility.
(7) A physician's office or clinic.
"Health care plan." A package of coverage benefits with a
particular cost-sharing structure, network and service area that
is purchased through a health insurance policy.
"Health care practitioner." An individual who is authorized
to practice some component of the healing arts by a license,
permit, certificate or registration issued by a Commonwealth
licensing agency or board. The term includes all of the
following:
(1) A health service doctor as defined in 40 Pa.C.S. §
6302 (relating to definitions).
(2) An individual accredited or certified to provide
behavioral health services.
(3) A practice group.
(4) A licensed individual who provides health care
services to patients of a facility under clinical privileges
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granted by the facility.
(5) A licensed individual who provides health care
services to patients in, or in conjunction with, services
provided to patients in a facility.
"Health care service." As follows:
(1) All of the following categories of services:
(i) A covered treatment.
(ii) An admission.
(iii) A procedure.
(iv) Medical supplies and equipment.
(v) Other services prescribed or otherwise provided
or proposed to be provided by a provider to an insured
under a health care plan.
(2) All of the following types of services:
(i) An emergency service.
(ii) A behavioral health care service.
(iii) A health care service provided in conjunction
with any other health care service sought by an insured
in or from a provider, including, but not limited to,
radiology, pathology, anesthesiology, neonatology,
hospital services and diagnostic interpretation.
"Health information." Information or data, whether oral or
recorded in any form or medium, created by or derived from a
provider or an insured that relates to any of the following:
(1) The physical, mental or behavioral health or
condition of an individual.
(2) The provision of a health care service to an
individual.
(3) Payment for the provision of a health care service
to an individual.
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"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 credit only policy.
(3) A long-term care or disability income policy
(4) A specified disease policy.
(5) A Medicare supplement policy.
(6) A fixed indemnity policy.
(7) A dental only policy.
(8) A vision only policy.
(9) A workers' compensation policy.
(10) An automobile medical payment policy.
(11) Any other similar policies providing for limited
benefits.
"In-network provider." A provider who contracts with an
insurer to provide health care services to an insured under a
health care plan.
"Insurance fraud." An offense under 18 Pa.C.S. § 4117
(relating to insurance fraud).
"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 care plan. The term includes a
policyholder, certificate holder, subscriber, member, dependent
or other individual who is eligible to receive health care
services through a health care plan.
"Insurer." An entity licensed by the department with the
authority to issue a policy, subscriber contract, certificate or
plan that provides medical or health care coverage and is
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offered or governed under any of the following:
(1) The act of May 17, 1921 (P.L.682, No.284), known as
The Insurance Company Law of 1921.
(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(3) The provisions of 40 Pa.C.S. Ch. 61 (relating to
hospital plan corporations) or 63 (relating to professional
health services plan corporations).
"Network." The health care providers designated by an
insurer to provide health care services to insureds in a health
care plan.
"Nonpublic personal health information." Health information
that:
(1) identifies an individual who is the subject of the
information; or
(2) can provide a reasonable basis to identify an
individual.
"Out-of-network provider." A provider who does not contract
with an insurer to provide health care services to an insured
under the insured's health care plan.
"Practice group." Any of the following:
(1) Two or more health care practitioners legally
organized in an entity recognized by the Commonwealth,
including a partnership, professional corporation, limited
liability company formed to render health care services,
medical foundation, not-for-profit corporation, faculty
practice plan or other similar entity, if any of the
following are satisfied:
(i) Each health care practitioner provides a
substantial amount of the same range of services that
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each health care practitioner routinely provides,
including, but not limited to, medical care,
consultation, diagnosis or treatment, through the joint
use of shared office space, facilities, equipment or
personnel.
(ii) The entity provides a substantial amount of its
services through the entity, services are billed in the
name of the entity and payments are treated as receipts
to the entity.
(iii) The entity's overhead expenses and the income
are assessed or distributed in accordance with methods
previously determined by members of the entity.
(2) An entity in which the entity's shareholders,
partners or owners include single-practitioner professional
corporations, limited liability companies formed to render
professional services or other entities in which beneficial
owners are individual health care practitioners.
"Provider." A facility, health care practitioner,
institution or organization, whether for profit or nonprofit,
which has the primary purpose of providing health care services
and is licensed or otherwise authorized to practice in this
Commonwealth.
"Record custodian." The department, the Department of
Health, the Department of State, a resolution organization
assigned to a dispute under section 304 or a person who
possesses or controls confidential information.
"Resolution organization." A qualified independent third-
party claim dispute resolution entity selected by and contracted
with the department.
"Service area." The geographic area where a health care plan
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is offered.
"Surprise balance bill." A balance bill for any of the
following:
(1) A covered emergency service provided to an insured
by an out-of-network provider, not including a bill for an
emergency medical service for which an emergency medical
services agency may register with the Department of Health
for direct reimbursement under section 635.7 of The Insurance
Company Law of 1921.
(2) A covered service provided to an insured by an out-
of-network provider at an in-network facility in
circumstances when the insured did not know the provider was
out-of-network or did not choose to receive the service from
the out-of-network provider by having requested to receive
the service from an in-network provider.
(3) A covered service provided to an insured by an out-
of-network provider, in conjunction with a health care
service for which the insured presented for care to an in-
network provider, in circumstances when the insured did not
know the provider was out-of-network or did not choose to
receive the service from the out-of-network provider by
having requested to receive the service from an in-network
provider.
"Trade secret." Information that:
(1) derives independent economic value, actual or
potential, from not being generally known to and not being
readily ascertainable by proper means by other persons who
can obtain economic value from disclosure or use of the
information; and
(2) is the subject of efforts that are reasonable under
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the circumstances to maintain the secrecy of the information.
CHAPTER 3
BALANCE BILLING AND PAYMENT
Section 301. Duty of facilities to provide written disclosure.
(a) Disclosure.--Whenever an in-network facility schedules a
health care service or seeks prior authorization from an insurer
for the provision of a health care service to an insured that is
expected to include the provision of a health care service by an
out-of-network provider, but not earlier than 10 business days
prior to admission or date of service, the facility shall
provide the insured with an out-of-network service written
disclosure. Nothing in this act shall prohibit an insurer from
appropriately utilizing reasonable medical management
techniques.
(b) Provisions.--The out-of-network service written
disclosure under subsection (a) shall include the following:
(1) One or more named out-of-network providers that are
expected to be called upon to render a health care service to
the insured during the course of treatment.
(2) The out-of-network providers may not have a contract
with the insurer and is therefore considered to be out-of-
network.
(3) A health care service rendered by the named provider
will be provided on an out-of-network basis.
(4) A description of the range of the charges for the
out-of-network health care service.
(5) The manner in which the insured may obtain from the
insurer an identification of in-network providers who may
render the health care service and on how the insured may
request and receive the health care service from an in-
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network provider.
(6) The insured may rely on the rights and remedies that
may be available under Federal or State law, contact the
insurer for additional assistance or agree to accept and pay
the charges for the health care service by the out-of-network
provider on an out-of-network basis.
Section 302. Surprise balance bills.
(a) Prohibition.--The following apply:
(1) An out-of-network provider which renders a health
care service to an insured may not surprise balance bill the
insured for any amount in excess of the cost-sharing amounts
that would have been imposed if the health care service had
been rendered by an in-network provider. Upon request, the
insurer shall furnish to the out-of-network provider a
statement of the applicable in-network cost-sharing amounts
owed by the insured to the provider. The insured shall be
responsible for no more than the cost-sharing amounts that
would have been due if the service had been rendered by an
in-network provider.
(2) An out-of-network provider may not advance a
surprise balance bill to collections.
(b) Assignment of benefits.--The following apply:
(1) An out-of-network provider of a health care service
which does not surprise balance bill an insured shall be
deemed to have received an assignment of benefits from the
insured and any reimbursement paid by the insurer shall be
paid directly to the out-of-network provider.
(2) If an insured receives a surprise balance bill, the
insured may submit to the insurer a surprise balance bill
form as specified under subsection (c) for the purpose of
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declaring the bill to be a surprise balance bill. Submission
of the surprise balance bill form to the insurer by the
insured shall effect an assignment of the insured's benefits
to the out-of-network provider. An insured who submits a
surprise balance bill form to the insurer, except in the case
of insurance fraud, shall be held harmless from all costs
except the in-network cost-sharing amount that would
otherwise have been due.
(c) Form.--The following apply:
(1) The department shall specify the content and format
of the surprise balance bill form. A draft of the surprise
balance bill form and any substantive revisions of the draft
shall be published on the department's publicly accessible
Internet website and in the Pennsylvania Bulletin for a 30-
day comment period prior to the final form being
published. The final form and any substantive revisions of
the final form shall be published on the department's
publicly accessible Internet website and in the Pennsylvania
Bulletin. Upon request, the department shall make the
surprise balance bill form available in hard copy. The
surprise balance bill form shall include the following:
(i) A description of a surprise balance bill.
(ii) A description of the assignment of benefits
affected by submission of the surprise balance bill form.
(iii) A description of the hold harmless protection
affected by submission of the surprise balance bill form.
(iv) An explanation of the purpose of submitting the
surprise balance bill form and the surprise balance bill
to the insurer.
(v) An explanation of what constitutes insurance
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fraud in the context of submitting the surprise balance
bill form, including the criminal and civil penalties for
insurance fraud under the laws of this Commonwealth.
(2) An insurer shall make available on the insurer's
publicly accessible Internet website and include in the
insured's health insurance policy form information on how to
access and submit a surprise balance bill form.
(3) When an insured receives a health care service that
may be subject to a surprise balance bill, a provider or
insurer associated with the service shall make a good faith
effort to notify the insured of the protections specified
under this act, including all of the following:
(i) The surprise balance bill form as specified
under this subsection.
(ii) The method to submit the surprise balance bill
to the insurer. This may include referencing the
availability of the surprise balance bill form on a
provider bill, explanation of benefits or the insurer's
Internet website or making the surprise balance bill form
available in hard copy.
(d) Overpayment.--If the insured pays an out-of-network
provider more than the in-network cost-sharing amount, all of
the following apply:
(1) The provider shall refund to the insured within 30
business days of receipt any amount paid in excess of the in-
network cost-sharing amount.
(2) If an out-of-network provider has not made a full
refund of any amount paid in excess of the in-network cost-
sharing amount to the insured within 30 business days of
receipt, interest shall accrue at the rate of 10% per annum
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beginning with the first calendar day after the 30-business
day period. A violation of this paragraph shall be a
violation of the act of December 17, 1968 (P.L.1224, No.387),
known as the Unfair Trade Practices and Consumer Protection
Law.
(e) Cost-sharing amount.--An insurer shall count each
payment that an insured makes to satisfy a surprise balance bill
toward an insured's in-network deductible and maximum out-of-
pocket cost-sharing amount.
(f) Applicability.--The following apply:
(1) For a health insurance policy which requires rates
or forms be filed with the Federal Government or the
department, this section shall apply to any policy for which
a form or rate is first permitted to be used within 180 days
of the effective date of this subsection.
(2) For a health insurance policy which does not require
rates or forms to be filed with the Federal Government or the
department, this section shall apply to any policy issued or
renewed on or after 180 days from the effective date of this
subsection.
Section 303. Direct dispute resolution.
(a) Mutual agreement.--The following apply:
(1) Nothing in this section shall prevent an insurer and
an out-of-network provider from mutually agreeing to a
payment amount for a health care service which is different
from the requirements under this section.
(2) Nothing in this section shall prevent an insurer
from addressing the availability and use of in-network
providers in the insurer's contracts with in-network
facilities and in-network providers who make referrals to
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other providers.
(b) Health care service payments.--If an insurer receives a
surprise balance bill form and bill from an insured, or if an
out-of-network provider submits to an insurer a bill for a
health care service covered by this act, the following apply:
(1) The insurer shall pay, in accordance with the prompt
payment requirements under section 2166 of the act of May 17,
1921 (P.L.682, No.284), known as The Insurance Company Law of
1921, the out-of-network amount due under the health
insurance policy or as required by Federal law.
(2) Payment under paragraph (1) shall be made directly
to the provider in accordance with section 302(b).
(3) The insurer and provider may reach agreement as to
an additional amount to be paid for the provider's services,
payment of which, in addition to the applicable in-network
cost-sharing amount owed by the insured, shall constitute
payment in full to the provider for the health care service
rendered.
(4) If the provider and insurer do not reach an
agreement on a payment amount within 60 calendar days after
the insurer receives the bill for the health care service,
the provider or insurer may submit the dispute for
independent dispute resolution under section 304. The
provider or insurer may aggregate claims from the provider to
the insurer that are submitted for independent dispute
resolution, including all claims pertaining to an insured
from a single encounter.
Section 304. Independent dispute resolution.
(a) Arbitration.--The following apply:
(1) An independent dispute resolution process for the
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purpose of arbitrating disputes between an insurer and a
provider for payment for an out-of-network service covered by
this act shall be administered in accordance with this
section. The independent dispute resolution process shall
permit private negotiations. Nothing in this section shall be
construed to preclude an insurer and a provider from reaching
a resolution of their dispute before the arbitrator issues a
final award.
(2) The independent dispute resolution process shall be
conducted by a resolution organization with the procedures as
of the effective date of this section of the American
Arbitration Association
or similarly qualified organization
as specified by the department. Except as otherwise set forth
in this section, the independent dispute resolution process
shall be in accordance with the procedures of the American
Arbitration Association
Healthcare Payor Provider Arbitration
Rules, Desk/Telephonic Track, with fees calculated pursuant
to the standard fee schedule and based on the monetary amount
in dispute between the out-of-network provider's initial bill
and the insurer's initial out-of-network payment.
(3) An arbitrator appointed to administer the
independent dispute resolution process shall be impartial and
independent of the parties and shall perform the arbitrator's
duties with diligence and in good faith.
(4) The award obtained through the independent dispute
resolution process shall be binding on insurer and provider
involving the same claim code put forth in the demand for
arbitration for a period of one year from the date of the
award and shall not be appealable.
(5) A payment made by an insurer to a provider for an
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award obtained through the independent dispute resolution
process set forth under this subsection, in addition to the
applicable cost-sharing owed by the insured who received the
health care service that is the subject of the independent
dispute resolution process, shall constitute payment in full
for the health care service rendered.
(6) If an insurer or out-of-network provider submits the
dispute for resolution, the insurer or out-of-network
provider shall also participate in the process as described
in this section.
(b) Process.--The following apply:
(1) The party initiating the independent dispute
resolution process shall file a demand for arbitration and
the applicable administrative filing fee with the resolution
organization and simultaneously send a copy of the demand to
the department and the other party. The initiating party
shall include on the demand the claim code, claim amount and
complete contact information for both parties. The demand
shall be transmitted in accordance with the resolution
organization's procedures.
(2) Within 14 days after notice of the filing of the
demand is sent under paragraph (1), the parties named in the
demand shall submit their best and final offer for the amount
in dispute with any supporting documents to each other and
the resolution organization. The parties may negotiate a
settlement within the 14-day period after notice of the
filing is sent. If a settlement is reached, both parties
shall advise the resolution organization and the department
in writing. If the parties do not notify in writing the
resolution organization that a settlement was reached during
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the 14-day period after notice of the filing is sent, an
arbitrator shall be appointed in accordance with the
procedures of the resolution organization.
(3) Upon appointment of the arbitrator, the resolution
organization shall require the parties to deposit the funds
it deems necessary to cover the expense of arbitration,
including arbitrator's fee, if any, and shall render an
accounting to the parties and return any unexpended balance
at the conclusion of the case. The deposit for arbitrator's
fees shall be split evenly.
(4) After the arbitrator is appointed, the resolution
organization shall transmit the parties' previously submitted
best and final offers with any supporting documents to the
arbitrator.
(5) In making an award under this subsection, the
arbitrator may consider any of the following:
(i) The level of training, education and experience
of the provider.
(ii) The provider's usual charge for comparable
health care services provided in-network and out-of-
network with respect to any health care plans.
(iii) The insurer's usual payment for comparable
health care services provided in-network and out-of-
network in the service area.
(iv) The payment for comparable health care services
provided in the service area by any recognized standard,
including Medicare or a median index.
(v) The availability of the health care service for
the insured from in-network providers.
(vi) The propensity of the provider to be included
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in networks and the propensity of the insurer to include
providers in networks.
(vii) Payments made in prior surprise balance bill
disputes between the provider and the insurer.
(viii) The circumstances and complexity of the
particular case, including the time and place of the
health care service.
(ix) Any final awards between the insurer and
provider for the same claim code from a period of one
year prior.
(6) The arbitrator's award shall be one of the two
amounts submitted by the parties as their best and final
offers and shall be binding on both parties.
(7) The arbitrator shall issue a final binding award in
writing, which shall include the final offers from each party
and the claim code. The final binding award shall be issued
within 30 days after the arbitrator receives the parties'
best and final offer and any supporting documents. Electronic
copies of the final award shall be provided to both parties
and the department.
(c) Cost allocations.--The following apply:
(1) In the final award, the arbitrator shall apportion
the administrative fees, arbitrator compensation and expenses
between the parties.
(2) A party that fails to pay all amounts due to the
other party within 30 days of receiving the final award
shall:
(i) pay interest to the prevailing party, calculated
and paid in accordance with section 2166 of the act of
May 17, 1921 (P.L.682, No.284), known as The Insurance
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Company Law of 1921; and
(ii) be subject to a penalty of $100 per day, which
the department shall transmit to the State Treasurer for
deposit into the General Fund, until all payments are
made in full.
(d) Resolution organization records.--A resolution
organization shall comply with all of the following:
(1) Maintaining, in an easily accessible and retrievable
format and delineated by year, records of the following:
(i) The written demand filed by the initiating party
establishing the date the resolution organization
receives a request for an independent dispute resolution.
(ii) Complete materials received from both parties.
(iii) The award.
(iv) The date the award was communicated to parties.
(2) Documenting measures taken to appropriately
safeguard the confidentiality of the records and prevent
unauthorized use and disclosures under applicable Federal and
State law.
(3) Reporting annually to the department in the
aggregate:
(i) The total number of demands for arbitrations
received by the resolution organization.
(ii) The total number of arbitrations concluded.
(iii) The method of disposition for arbitrations
concluded, including arbitrations withdrawn due to
settlement and the awards made.
(4) Protecting from disclosure, except as set forth in
section 502, any information specifically identifying the
insured who received the health care services that were the
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subject of an arbitration decision. The information shall be
protected and remain confidential in compliance with all
applicable Federal and State laws and regulations.
(5) Reporting immediately to the department a change in
the resolution organization's status which would cause the
resolution organization to cease performing or being
qualified to perform arbitrations in accordance with this
act.
Section 305. Applicability.
This chapter shall not apply to any of the following:
(1) A balance bill for a health care service rendered by
an out-of-network provider when an in-network provider is
available and the insured has elected to receive the service
from an out-of-network provider instead of an in-network
provider.
(2) A health care service for which an entity, other
than an insurer specified under a health insurance policy, is
responsible.
CHAPTER 5
INSURERS
Section 501. Communications to consumers.
(a) Departmental notice.--The department shall provide a
notice on the department's publicly accessible Internet website
containing the following:
(1) Information for consumers of health care coverage
specifying the protections provided under this act.
(2) Information regarding the process by which consumers
may report and file complaints with the department or another
appropriate regulatory agency relating to surprise balance
bills.
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(b) Provider communications.--The following apply:
(1) A sign which sets forth the following shall be
posted in a prominent place or be included in an appropriate
written or electronic communication by a provider and a
facility in which health care services are rendered to
patients covered by a health care plan who may not be covered
at in-network rates:
(i) The rights of insureds under this act.
(ii) The identification of the department as the
proper Commonwealth agency to receive complaints relating
to surprise balance bills prohibited under this act.
(iii) Contact information for the department.
(2) The department may specify the form and content of
the notice required under paragraph (1).
(3) A communication detailing the cost of a health care
service covered by this act must clearly state that an
insured will only be responsible for payment of the
applicable cost-sharing amounts under the insured's health
care plan.
(c) Insurer communications.--The following apply:
(1) An insurer shall provide a written notice to each
insured of the protections provided under this act. The
notice shall include information regarding how an insured may
contact the department to report and dispute a surprise
balance bill. The insurer shall post the notice on the
insurer's publicly accessible Internet website and make it
available upon request within 90 days of the effective date
of this section. The notice shall include an explanation of
benefits for any claim submitted beginning not more than 90
days after the effective date of this section.
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(2) The department may specify the form and content of
the notice required under paragraph (1).
(3) A communication detailing the cost of a health care
service covered by this act must clearly state that an
insured will only be responsible for payment of the
applicable cost-sharing amounts under the insured's health
care plan.
Section 502. Records and confidentiality.
(a) General rule.--A record custodian may not disclose
information which is confidential and privileged and not subject
to any of the following:
(1) The act of February 14, 2008 (P.L.6, No.3), known as
the Right-to-Know Law.
(2) A subpoena.
(3) A discovery or admissible evidence in any private
civil action.
(b) Exception.--A record custodian may disclose information
which meets the criteria under subsection (a) to the department,
the Department of Health, the Department of State, the Office of
Attorney General or a resolution organization to facilitate the
fulfillment of a duty or obligation, including any of the
following:
(1) Arbitration of a disputed claim.
(2) Resolution of a consumer complaint.
(3) Investigation and enforcement of an alleged
violation of this act.
(c) Construction.--Nothing in this section shall be
construed to prevent the department from using information which
meets the criteria under subsection (a) for internal analysis,
or from disclosing the information in a manner that the identity
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of the subject of the information cannot be ascertained.
(d) Waiver prohibited.--The sharing of information which
meets the criteria under subsection (a) by the department, the
Department of Health, the Department of State, the Office of
Attorney General or a resolution organization as authorized by
subsection (b) does not constitute a waiver of any applicable
privilege or claim of confidentiality.
Section 503. Enforcement.
(a) Authority.--The following apply:
(1) The department, the Department of Health, the
Department of State and the Office of Attorney General shall
have authority to enforce this act. The appropriate
Commonwealth agency may investigate potential violations
under this act based upon information received from insureds,
insurers, providers and other sources in order to ensure
compliance with this act.
(2) Nothing in this act shall be construed to limit the
ability of the department, the Department of Health, the
Department of State or the Office of Attorney General from
using information received under this act in the course of
its duties under any other law of the Commonwealth.
(b) Insurer violations.--The following apply:
(1) Upon satisfactory evidence of a violation of this
act by an insurer, the commissioner may, in the
commissioner's discretion, impose any of the penalties set
forth in section 5 of the act of June 25, 1997 (P.L.295,
No.29), known as the Pennsylvania Health Care Insurance
Portability Act.
(2) The enforcement remedies imposed under this
subsection are in addition to any other remedies or penalties
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that may be imposed under any other applicable law of this
Commonwealth, including the act of July 22, 1974 (P.L.589,
No.205), known as the Unfair Insurance Practices Act.
Violations of this act by an insurer shall be deemed to be an
unfair method of competition and an unfair or deceptive act
or practice under the Unfair Insurance Practices Act.
(3) Upon receipt or discovery of evidence of a potential
violation of this act by a provider, the department may refer
the matter to the Department of Health, the Department of
State or the Office of Attorney General, as may be
appropriate.
(c) Health care practitioner violations.--The following
apply:
(1) A violation of a provision of this act by a health
care practitioner shall constitute unprofessional conduct and
subject the health care practitioner to disciplinary action
under the applicable law of this Commonwealth relating to
professional licensure under which the individual is
licensed.
(2) Money collected under this section shall be
deposited into the fund specified under the applicable law of
this Commonwealth relating to professional licensure under
which the disciplinary action is taken.
(d) EMS agency and facility violations.--The following
apply:
(1) A violation of section 302 or section 501(b) by an
EMS agency shall constitute a violation of 35 Pa.C.S. Ch. 81
(relating to emergency medical services system).
(2) A violation of section 302 or section 501(b) by a
facility shall constitute a violation of the act of July 19,
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1979 (P.L.130, No.48), known as the Health Care Facilities
Act.
(3) Money collected under this subsection shall be
deposited into the General Fund.
(e) Unfair trade practices.--A violation of this act shall
be deemed a violation of the act of December 17, 1968 (P.L.1224,
No.387), known as the Unfair Trade Practices and Consumer
Protection Law.
(f) Administrative procedure.--The administrative provisions
of this section shall be subject to 2 Pa.C.S. Ch. 5 Subch. A
(relating to practice and procedure of Commonwealth agencies). A
party against whom penalties are assessed in an administrative
action may appeal to Commonwealth Court as provided in 2 Pa.C.S.
Ch. 7 Subch. A (relating to judicial review of Commonwealth
agency action).
(g) Enforcement remedies.--The enforcement remedies imposed
under this section shall be in addition to any other remedies or
penalties that may be imposed under the laws of this
Commonwealth.
(h) Duplicative penalties.--Two or more Commonwealth
agencies may not impose a penalty on the same insurer or
provider for the same violation. A Commonwealth agency that
imposes a penalty under this act shall notify the department of
the imposition of the penalty.
Section 504. Private cause of action.
Nothing in this act shall be construed to create or imply a
private cause of action for a violation of this act other than
as permitted under the act of December 17, 1968 (P.L.1224,
No.387), known as the Unfair Trade Practices and Consumer
Protection Law.
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CHAPTER 7
MISCELLANEOUS PROVISIONS
Section 701. Regulations.
The department, the Department of Health and the Department
of State may promulgate regulations as may be necessary to
implement and enforce this act.
Section 702. Effective date.
This act shall take effect as follows:
(1) The following provisions shall take effect
immediately:
(i) This section.
(ii) Section 302(f).
(2) The remainder of this act shall take effect in 180
days.
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