PRINTER'S NO. 1128
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
822
Session of
2019
INTRODUCED BY SCHWANK AND COSTA, AUGUST 7, 2019
REFERRED TO BANKING AND INSURANCE, AUGUST 7, 2019
AN ACT
Providing for the protection of consumers of health care
coverage against surprise balance bills for emergency
services and certain covered health care services.
TABLE OF CONTENTS
Chapter 1. Preliminary Provisions
Section 101. Short title.
Section 102. Definitions.
Chapter 3. Balance Billing and Payment
Section 301. Applicability.
Section 302. In-network facility notice.
Section 303. Hold harmless.
Section 304. Direct dispute resolution.
Section 305. Arbitrated dispute resolution.
Chapter 5. Miscellaneous Provisions
Section 501. Communications to consumers.
Section 502. Records and confidentiality.
Section 503. Enforcement.
Section 504. Private cause of action.
Section 505. Regulations.
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Section 506. 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 Health
Insurance 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 that seeks to collect from the insured 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 and copies thereof in the possession or control of
the department, the Department of Health, the Department of
State, the Office of Attorney General, any resolution
organization assigned to a dispute under section 305 or other
person, that is produced by, obtained by or disclosed to any of
them in the course of a dispute resolution under this act.
"Confidential proprietary information." Commercial or
financial information:
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(1) that is privileged or confidential; and
(2) the disclosure of which 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 pursuant to 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. ยง 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 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, with respect to a
pregnant woman, the health of the insured or her unborn child.
The term includes:
(1) Emergency medical services, including emergency
medical services as defined in 35 Pa.C.S. ยง 8103, rendered by
an EMS agency.
(2) A health care service that a provider determines is
necessary to evaluate and, if necessary, stabilize the
condition of an insured so that the insured may be
transported without suffering detrimental consequences or
aggravating the insured's condition.
(3) If an insured is admitted, a health care service
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rendered prior to transfer or discharge.
"Facility." A facility that provides a health care service,
including:
(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 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:
(1) A health service doctor, as that term is defined in
40 Pa.C.S. ยง 6302 (relating to definitions).
(2) An individual accredited or certified to provide
behavioral health services.
(3) A practice group.
(4) A licensed individual to whom a facility has granted
clinical privileges and who provides health care services to
patients of the facility under the clinical privileges.
(5) A licensed individual who provides health care
services to a patient, or in conjunction with services
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provided to that patient in a facility.
"Health care service." The term includes the following:
(1) 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) Types of services:
(i) An emergency service.
(ii) A behavioral health care service.
(iii) A service provided in conjunction with the
service sought by an insured in or from a provider,
including, but not limited to, radiology, pathology,
anesthesiology, neonatology, hospitalist 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 one or more of the
following:
(1) The past, present or future 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.
"Health insurance policy." A policy, subscriber contract,
certificate or plan issued by an insurer that provides medical
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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 TRICARE policy, including a Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS)
supplement policy.
(7) A fixed indemnity policy.
(8) A dental only policy.
(9) A vision only policy.
(10) A workers' compensation policy.
(11) An automobile medical payment policy under 75
Pa.C.S. (relating to vehicles).
(12) Any other similar policy providing for limited
benefits.
"In-network provider." A provider that contracts with an
insurer to provide health care services to an insured under a
health care plan.
"Insurance fraud." As defined in 18 Pa.C.S. ยง 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. An authorized
representative may act on behalf of an insured.
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"Insurer." An entity licensed by the department with
accident and health authority to issue a policy, subscriber
contract, certificate or plan that provides medical or health
care coverage 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, including section 630 and
Article XXIV thereof.
(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(3) 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) there is a reasonable basis to believe could be used
to identify an individual.
"Out-of-network provider." A provider that does not contract
with an insurer to provide health care services to an insured
under the insured's health care plan.
"Practice group." Two or more health care practitioners,
legally organized in a business form 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 that satisfies one of the following
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criteria:
(1) in which each practitioner who is a member of the
group provides substantially the full range of services that
the 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;
(2) for which substantially all of the services of the
practitioners who are members of the group are provided
through the group and are billed in the name of the group
practice, and amounts so received are treated as receipts of
the group; or
(3) in which the overhead expenses of, and the income
from, the group are distributed in accordance with methods
previously determined by members of the group.
An entity that does not otherwise meet this definition shall be
considered a practice group even if its shareholders, partners
or owners of the practice group include single-practitioner
professional corporations, limited liability companies formed to
render professional services or other entities in which
beneficial owners are individual practitioners.
"Provider." An individual, facility, institution,
organization or other person, whether for profit or nonprofit,
whose primary purpose is to provide health care services and is
licensed or otherwise authorized to practice in this
Commonwealth. The term includes a facility and health care
practitioner.
"Record custodian." The department, the Department of
Health, the Department of State, a resolution organization
assigned to a dispute under section 305 or other person who
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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 in which a health care
plan is offered.
"Surprise bill." A balance bill as provided in section 301.
"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 its disclosure or use.
(2) Is the subject of efforts that are reasonable under
the circumstances to maintain secrecy of the information.
CHAPTER 3
BALANCE BILLING AND PAYMENT
Section 301. Applicability.
(a) General rule.--This act applies to a balance bill for
one or more of the following:
(1) A covered emergency service provided to an insured
by an out-of-network provider except that this act does not
apply to a bill for an emergency medical service for which an
emergency medical services agency may register with the
Department of Health for direct reimbursement pursuant to
section 635.7 of the act of May 17, 1921 (P.L.682, No.284),
known as 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, when the
insured did not know the provider was an out-of-network
provider or did not choose to receive the service from the
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out-of-network provider, and 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, when the insured did not know the provider
was an out-of-network provider or did not choose to receive
the service from the out-of-network provider, and requested
to receive the service from an in-network provider.
(b) Exceptions.--This act does not apply to:
(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 from an in-network
provider.
(2) A health care service for which an entity, other
than an insurer under a health insurance policy, is
responsible.
(c) Construction.--Nothing in this act shall be construed to
prohibit an insurer from appropriately utilizing reasonable
medical management techniques.
Section 302. In-network facility notice.
(a) Written disclosure required.--At the time 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 in
any event not less than 10 business days prior to admission or
date of service, the in-network facility shall provide the
insured with an out-of-network service written disclosure.
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(b) Contents of written disclosure.--The out-of-network
service written disclosure shall include the following:
(1) A statement that one or more certain named out-of-
network providers are expected to be called upon to render a
health care service to the insured during the course of
treatment.
(2) A statement that the named out-of-network provider
may not have a contract with the insurer and is therefore
considered to be an out-of-network provider.
(3) A statement that 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 provider's health care service.
(5) Directions on how the insured may obtain from the
insurer an identification of in-network providers who may
render the health care service and how the insured may
request and receive the health care service from an in-
network provider.
(6) Notification that the insured may rely on the rights
and remedies that may be available under this act or other
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 303. Hold harmless.
(a) Out-of-network providers and insurers.--
(1) An out-of-network provider that renders a health
care service covered by this act to an insured may not
surprise bill the insured for any amount in excess of the
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cost-sharing amounts that would have been imposed if the
health care service had been rendered by an in-network
provider.
(2) The insurer shall furnish to the out-of-network
provider upon request a statement of the applicable in-
network provider cost-sharing amounts owed by the insured to
the provider.
(3) The insured shall be responsible for no more than
the cost-sharing amounts that would have been due if the
health care service had been rendered by an in-network
provider.
(b) Collections.--An out-of-network provider may not advance
a surprise bill to collection.
(c) Assignment of benefits.--
(1) An out-of-network provider of a health care service
covered by this act that does not surprise 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) (i) If an insured receives a surprise bill, the
insured may submit to the insurer a surprise bill form,
as described in subsection (d), to declare the bill a
surprise bill. Submission of the surprise bill form to
the insurer by the insured shall effect an assignment of
the insured's benefits to the out-of-network provider.
(ii) An insured who submits a surprise bill form to
the insurer, except in the case of insurance fraud, shall
be held harmless from all costs except the in-network
provider cost-sharing amount that would otherwise have
been due.
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(d) Surprise bill form.--
(1) The department shall specify the content and format
of a surprise bill form. A draft shall be published for a 30-
day comment period prior to the final form being published.
Publication shall be on the department's publicly accessible
Internet website and in the Pennsylvania Bulletin.
Substantive revisions of the form shall also be subject to
the comment period and publication requirement. The form
shall at least:
(i) Describe what is a surprise bill.
(ii) Describe the assignment of benefits effected by
submission of the form.
(iii) Describe the hold harmless protection effected
by submission of the form.
(iv) Explain the need to submit the form and the
surprise bill to the insurer.
(v) Caution the insured regarding what is insurance
fraud in the context of submitting the form, including
that insurance fraud is punishable as a felony crime, may
require payment of restitution and may subject a person
who has committed insurance fraud to a civil action.
(2) The department shall make the surprise bill form
available on the department's publicly accessible Internet
website and in hard copy upon request.
(3) An insurer shall make available on the department's
publicly accessible Internet website and include in the
insured's health insurance policy form information on how to
access and submit a surprise bill form.
(4) When an insured receives a health care service that
may be subject to a surprise bill, each provider and insurer
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associated with the health care service shall make a good
faith effort to notify the insured of the protections
afforded by this act, the surprise bill form and the means
for submitting the surprise bill form to the insurer. The
notification may include referencing the availability of the
surprise bill form on a provider bill or an explanation of
benefits, making the surprise bill form available on a
publicly accessible Internet website and making the surprise
bill form available to the insured in hard copy.
(e) Overpayment.--If the insured pays an out-of-network
provider more than the in-network cost-sharing amount:
(1) The provider shall refund to the insured, within 30
business days of receipt of payment, any amount paid in
excess of the in-network provider 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
provider cost-sharing amount to the insured within 30
business days of receipt of payment, interest shall accrue at
the rate of 10% per annum beginning with the first calendar
day after the 30-business day period.
(3) A violation of this subsection shall be considered 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) Credit against maximum out-of-pocket cost-sharing
amount.--An insurer shall count toward an insured's in-network
provider deductible and maximum out-of-pocket cost-sharing
amount each payment that an insured makes to satisfy a surprise
balance bill subject to this act.
Section 304. Direct dispute resolution.
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(a) Construction.--Nothing in this act shall be construed
to:
(1) Prevent an insurer and an out-of-network provider
from mutually agreeing to a payment amount for a health care
service covered by this act outside of the mechanism provided
in this section.
(2) Prevent an insurer from addressing the availability
and use of in-network providers in the insurer's contracts
with in-network provider facilities and in-network providers
that make referrals to other providers.
(b) Payment for health care service.--If an insurer receives
a surprise 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:
(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 provider 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 according to the assignment of benefits
provision under section 303(c).
(3) The insurer and provider may reach agreement as to
an additional amount to be paid for the provider's health
care services, payment of which, in addition to the
applicable in-network provider 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 agreement
on a payment amount, either through the negotiation process
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specified in this subsection or otherwise, within 60 calendar
days after the insurer receives the bill for the health care
service, either party may submit the dispute for formal
dispute resolution under this section. Either party may
aggregate claims from the provider to the insurer that are
submitted for formal dispute resolution to include all claims
pertaining to an insured from a single encounter.
Section 305. Arbitrated dispute resolution.
(a) Process established.--
(1) (i) An independent dispute resolution process for
the purpose of arbitrating disputes between an insurer
and a provider for payment for an out-of-network service
covered by this act is established. Private negotiations
are permitted.
(ii) Nothing in this section shall be construed to
preclude the parties from reaching a resolution of their
dispute before the arbitrator issues a final award.
(2) (i) The dispute resolution process shall use the
American Arbitration Association or, if the American
Arbitration Association ceases to exist or ceases to be
qualified or becomes unable to perform arbitrations in
connection with section 304, a similarly qualified
organization specified by the department, as the
resolution organization.
(ii) Except as otherwise provided in this section,
the arbitration shall follow the desk/telephonic track
procedures of the American Arbitration Association
Healthcare Payor Provider Arbitration Rules and Mediation
Procedures, with fees calculated under the Standard Fee
Schedule and based on the monetary amount in dispute
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between the out-of-network provider's initial bill and
the insurer's initial out-of-network payment.
(3) An arbitrator appointed to administer a dispute
shall be impartial and independent of the parties and shall
perform the arbitrator's duties with diligence and in good
faith.
(4) If either an insurer or an out-of-network provider
submits the dispute for resolution, the other party shall
also participate in the process as provided in this section.
(5) The award obtained through the resolution process
shall be binding on both parties and not appealable. The
award shall be binding on the insurer and provider for any
disputes between them involving the same claim code stated in
the demand for arbitration for a period of one year from the
date of the award.
(6) A payment made by an insurer to a provider under an
award obtained through the resolution process specified in
this section, in addition to the applicable cost-sharing owed
by the insured who received the health care service that is
the subject of the resolution process, shall constitute
payment in full for the health care service rendered.
(b) Binding resolution process.--
(1) The party initiating the 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 and shall transmit the demand in accordance with the
resolution organization's procedures.
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(2) Within 14 calendar days after notice of the filing
of the demand is sent by the resolution organization, the
parties named in the demand shall each submit their best and
final offer for the amount in dispute with supporting
documents to each other and the resolution organization.
(3) An arbitrator shall be selected in accordance with
the process established by the resolution organization,
subject to the following:
(i) During the 14-calendar-day period after the
notice of filing is sent, the parties may negotiate a
settlement. If a settlement is reached, both parties
shall advise in writing the resolution organization and
the department.
(ii) If, during the 14-calendar-day period, the
parties do not notify in writing the resolution
organization that a settlement was reached, an arbitrator
shall be appointed in accordance with the procedures of
the resolution organization.
(iii) Upon appointment of the arbitrator, the
resolution organization shall require the parties to
deposit sums of money as the resolution organization
deems necessary to cover the expense of arbitration,
including the arbitrator's fees, if any, 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 between the
parties.
(4) After the arbitrator is appointed, the resolution
organization shall transmit to the arbitrator the parties'
previously submitted best and final offers with supporting
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documents.
(5) In making an award under this subsection, the
arbitrator may consider:
(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 plan.
(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 a 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
in networks and the propensity of the insurer to include
providers in networks.
(vii) Payments made in prior surprise 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 award 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.
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(7) The arbitrator shall issue a final binding award in
writing. The award shall include the final offers from each
party and the claim code, and shall be issued within 30 days
after the arbitrator has received the parties' best and final
offer and supporting documents. Electronic copies of the
final award shall be provided to both parties and the
department.
(c) Cost allocations.--
(1) In the final award, the arbitrator shall apportion
the administrative fees, arbitrator compensation and expenses
to the nonprevailing party.
(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
Company Law of 1921.
(ii) Be subject to a penalty of $100 per day until
all payments are made in full.
(d) Resolution organization records.--A resolution
organization shall comply with the following:
(1) Maintain for 18 months after a case is closed, by
calendar year, all in an easily accessible and retrievable
format, the following:
(i) The written demand filed by the initiating party
establishing the date the resolution organization
receives a request for dispute resolution.
(ii) Complete materials received from both parties.
(iii) The award.
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(iv) The date the award was communicated to the
parties.
(2) Document measures taken to appropriately safeguard
the confidentiality of the records and prevent unauthorized
use and disclosures under applicable Federal and State law.
(3) Report annually to the department in the aggregate:
(i) The total number of demands for arbitrations
received under this section.
(ii) The total number of arbitrations concluded.
(iii) The breakdown of disposition for arbitrations
concluded, including arbitrations withdrawn due to
settlement and the awards made.
(4) Protect from disclosure, except as provided in
section 502, information specifically identifying the insured
who received the health care services that were the subject
of an arbitration decision. This information shall be
protected and remain confidential in compliance with all
applicable Federal and State laws and regulations and shall
be confidential as nonpublic personal health information.
(5) Report immediately to the department a change in its
status which would cause it to cease performing or being
qualified to perform arbitrations under this act.
CHAPTER 5
MISCELLANEOUS PROVISIONS
Section 501. Communications to consumers.
(a) Departmental notice.--The department shall provide a
notice on its publicly accessible Internet website containing
information for consumers of health care coverage relating to
the protections provided by this act and information regarding
the process by which consumers may report and file complaints
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with the department or another appropriate regulatory agency
relating to surprise bills.
(b) Provider communications.--
(1) A provider that provides health care services 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 provider rates shall post a sign containing the
following information in a prominent place or an appropriate
written or electronic communication.
(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 shall 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.--
(1) An insurer shall provide a written notice to an
insured of the protections provided to insureds 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:
(i) Post the notice on its publicly accessible
Internet website and make it available upon request
within 90 days of the effective date of this section.
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(ii) Include the notice with an explanation of
benefits for claims submitted beginning not more than 90
days after the effective date of this section.
(2) The department may by notice 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 shall 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
confidential information. A record containing confidential
information shall be:
(1) Confidential and privileged.
(2) Not subject to the act of February 14, 2008 (P.L.6,
No.3), known as the Right-to-Know Law.
(3) Not subject to subpoena.
(4) Not subject to discovery nor admissible as evidence
in a private civil action.
(b) Exceptions.--A record custodian may disclose
confidential information to the department, the Department of
Health, the Department of State, a resolution organization or
the Office of Attorney General to facilitate the fulfillment of
a duty or obligation under this act. A duty or obligation that
requires the use of confidential information includes:
(1) Arbitration of a disputed claim.
(2) Resolution of a consumer complaint.
(3) Investigation and enforcement of an alleged
violation of this act.
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(c) Departmental analysis and disclosure of confidential
information.--Nothing in this act shall be construed to prevent
the department from using confidential information for internal
analysis or from disclosing aggregated confidential information
in a way that the identity of the subject of the information
cannot be ascertained.
(d) No waiver of privilege or confidentiality.--The sharing
of confidential information with or by the department, the
Department of Health, the Department of State, a resolution
organization or the Office of Attorney General as authorized by
this act shall not constitute a waiver of an applicable
privilege or claim of confidentiality.
Section 503. Enforcement.
(a) General authority.--
(1) The department, the Department of Health, the
Department of State and the Office of Attorney General shall
have authority to enforce this act and may investigate
potential violations of 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
their regulatory duties under any other law.
(3) Except as otherwise specified, fines collected under
this act shall be deposited in the General Fund.
(b) Departmental authority.--
(1) Upon satisfactory evidence of a violation of this
act by an insurer, the commissioner may impose any of the
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penalties under 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 section
are in addition to other remedies or penalties that may be
imposed under an applicable statute, 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 and defined 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) Department of State.--
(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 provisions of the professional licensure
statute under which the health care practitioner is licensed.
(2) Penalties collected under this section shall be
deposited in the fund specified in the professional licensure
statute under which the disciplinary action is taken.
(d) Department of Health.--
(1) A violation of a provision of section 302, 303(d)(4)
or 501(b) by an EMS agency shall constitute a violation of
and may be subject to the penalties under 35 Pa.C.S. ยง 8156
(relating to penalties).
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(2) A violation of a provision of section 302, 303(d)(4)
or 501(b) by a facility shall constitute a violation of and
may be subject to the penalties under the act of July 19,
1979 (P.L.130, No.48), known as the Health Care Facilities
Act.
(3) Penalties collected under this section shall be
deposited in the General Fund.
(e) Office of Attorney General.--A violation of this act
shall be deemed a violation of and may be subject to the
penalties under the act of December 17, 1968 (P.L.1224, No.387),
known as the Unfair Trade Practices and Consumer Protection Law.
(f) Administrative practice and 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 the
Commonwealth Court as provided in 2 Pa.C.S. Ch. 7 Subch. A
(relating to judicial review of Commonwealth agency action).
(g) Remedies cumulative.--The enforcement remedies imposed
under this section are in addition to any other remedies or
penalties that may be imposed under any other applicable
statute.
(h) Duplicative penalties prohibited.--Two or more
authorities may not impose a penalty on the same insurer or
provider for the same violation. An authority that imposes a
penalty under this act will 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
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as permitted under the act of December 17, 1968 (P.L.1224,
No.387), known as the Unfair Trade Practices and Consumer
Protection Law.
Section 505. Regulations.
The department, the Department of Health and the Department
of State may each promulgate regulations as may be necessary and
appropriate to implement this act.
Section 506. Effective date.
This act shall take effect in six months.
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