H1553B2033A05207 AJB:CDM 12/11/17 #90 A05207
AMENDMENTS TO HOUSE BILL NO. 1553
Sponsor: REPRESENTATIVE BAKER
Printer's No. 2033
Amend Bill, page 1, line 4, by striking out "facilities" and
inserting
providers
Amend Bill, page 1, line 15, by striking out "Insurers" and
inserting
Communications, Records and Enforcement
Amend Bill, page 5, line 21, by striking out "hospital" and
inserting
hospitalist
Amend Bill, page 5, line 25, by inserting after "The "
past, present or future
Amend Bill, page 6, by inserting between lines 14 and 15
(11) A policy under which benefits are provided by the
Federal Government to active or former military personnel and
their dependents.
Amend Bill, page 6, line 15, by striking out "(11)" and
inserting
(12)
Amend Bill, page 6, line 27, by inserting after "plan. "
Nothing in this definition shall be construed to prohibit an
authorized representative from acting on behalf of an insured.
Amend Bill, page 6, line 28, by striking out "the" where it
occurs the second time and inserting
accident and health
Amend Bill, page 7, line 3, by striking out the period after
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"1921" and inserting
, including section 630 and Article XXIV of The Insurance
Company Law of 1921.
Amend Bill, page 7, line 16, by striking out "can provide a
reasonable basis" and inserting
an individual would reasonably believe could be used
Amend Bill, page 7, lines 29 and 30, by striking out "a
substantial amount of the same" and inserting
substantially the full
Amend Bill, page 8, line 6, by striking out "entity provides
a substantial amount of its" and inserting
health care practitioners provide a substantial
amount of their
Amend Bill, page 8, line 9, by striking out "to" and
inserting
of
Amend Bill, page 8, line 10, by inserting after "the"
entity's
Amend Bill, page 9, lines 2 through 23, by striking out all
of said lines and inserting
"Surprise balance bill." As follows:
(1) A balance bill for any of the following:
(i) 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 has registered with the
Department of Health for direct reimbursement under
section 635.7 of the Insurance Company Law of 1921.
(ii) 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 out-of-network
or did not choose to receive the service from the out-of-
network provider.
(iii) 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 out-of-network or did not choose to receive
the service from the out-of-network provider.
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(iv) A covered service provided to an insured by an
out-of-network provider at an in-network facility when
the insured did not have the ability to make an informed
choice of the provider of the health care service.
(2) The term does not include any of the following:
(i) 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
rather than an in-network provider.
(ii) A health care service for which an entity,
other than an insurer under a health insurance policy, is
responsible.
(3) Nothing in this definition shall be construed to
prohibit an insurer from appropriately utilizing reasonable
medical management techniques.
Amend Bill, page 10, by inserting between lines 1 and 2
"Usual, customary and reasonable rate." The seventy-fifth
percentile of all charged amounts for a particular health care
service performed by a provider which is in the same or similar
specialty and provided in the same geographic area as reported
in a benchmarking database maintained by a nonprofit
organization designated by the commissioner and not affiliated
with an insurer or provider.
Amend Bill, page 10, lines 9 and 10, by striking out ", but
not earlier than 10 business days prior to admission or date of
service" and inserting
and there are 10 business days between the date when the
health care service is scheduled and the date when the health
care service is scheduled to be provided
Amend Bill, page 10, lines 12 through 14, by striking out
"Nothing in this act shall prohibit an insurer from" in line 12
and all of lines 13 and 14 and inserting
Notice provided less than 10 business days before the date
when the health care service will be provided shall not be
considered fair notice to allow the insured to make an informed
choice to receive a health care service from an out-of-network
provider.
Amend Bill, page 10, line 20, by striking out "providers" and
inserting
provider
Amend Bill, page 11, line 10, by inserting after "service"
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covered by this act
Amend Bill, page 11, line 22, by striking out "Assignment of
benefits" and inserting
Form submission
Amend Bill, page 11, lines 23 through 28, by striking out all
of lines 23 through 27 and "(2)" in line 28
Amend Bill, page 12, lines 1 through 4, by striking out
"Submission" in line 1, all of lines 2 and 3 and "to the out-of-
network provider." in line 4
Amend Bill, page 12, lines 23 through 25, by striking out all
of lines 23 and 24 and "(iii)" in line 25 and inserting
(ii)
Amend Bill, page 12, line 26, by striking out "affected" and
inserting
effected
Amend Bill, page 12, line 27, by striking out "(iv)" and
inserting
(iii)
Amend Bill, page 12, line 30, by striking out "(v)" and
inserting
(iv)
Amend Bill, page 13, line 24, by inserting after "The "
out-of-network
Amend Bill, page 14, line 2, by striking out "paragraph" and
inserting
section
Amend Bill, page 15, by inserting between lines 1 and 2
(3) Nothing in this section shall supersede existing
agreements between insurers and providers in instances of
surprise balance billing.
Amend Bill, page 15, line 2, by striking out all of said line
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and inserting
(b) Health care service payments.--
(1) If an insurer receives a
Amend Bill, page 15, line 3, by striking out "and bill from
an insured"
Amend Bill, page 15, line 4, by striking out "bill" and
inserting
claim
Amend Bill, page 15, line 6, by striking out all of said line
and inserting
(2) Payment under paragraph (1) shall be in accordance
with the following:
(i) If the claim by the out-of-network provider in
excess of $500, either party may initiate the independent
dispute resolution process under section 304.
(ii) If the claim by the out-of-network provider is
$500 or less, the insurer shall reimburse the out-of-
network provider the greater of:
(A) the amount that would have been paid for the
claim under the insured's health insurance policy had
the service which is the subject of the claim been
rendered by an in-network provider; or
(B) the usual, customary and reasonable rate for
the out-of-network provider's services.
(iii) The insurer shall pay, in accordance with the
prompt
Amend Bill, page 15, line 11, by striking out all of said
line and inserting
(iv) Payment under subparagraph (i) shall be made
directly
Amend Bill, page 15, line 13, by striking out all of said
line and inserting
(v) The insurer and out-of-network provider may
reach an agreement as to
Amend Bill, page 15, line 14, by inserting after "the"
out-of-network
Amend Bill, page 15, line 17, by inserting after "the" where
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it occurs the first time
out-of-network
Amend Bill, page 15, line 19, by striking out all of said
line and inserting
(vi) If the out-of-network provider and insurer do
not reach an
Amend Bill, page 15, line 22, by inserting after "the " where
it occurs the first time
out-of-network
Amend Bill, page 15, line 23, by inserting after "The "
out-of-network
Amend Bill, page 15, line 24, by inserting after "the "
out-of-network
Amend Bill, page 15, line 26, by striking out ", including"
and inserting
to include
Amend Bill, page 16, line 26, by striking out "insurer and
provider" and inserting
the insurer and provider for any dispute
Amend Bill, page 17, line 7, by striking out "the" and
inserting
a
Amend Bill, page 17, line 23, by inserting after "shall"
each
Amend Bill, page 19, line 18, by striking out "offer" and
inserting
offers
Amend Bill, page 19, line 24, by striking out "between the
parties" and inserting
to the prevailing party
Amend Bill, page 20, line 7, by striking out "comply with all
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of the following"
Amend Bill, page 20, line 8, by striking out "Maintaining"
and inserting
Maintain
Amend Bill, page 20, line 16, by striking out "Documenting"
and inserting
Document
Amend Bill, page 20, line 20, by striking out "Reporting" and
inserting
Report
Amend Bill, page 20, line 28, by striking out "Protecting"
and inserting
Protect
Amend Bill, page 21, line 3, by striking out the period after
"regulations" and inserting
and shall be confidential as nonpublic personal health
information.
Amend Bill, page 21, line 4, by striking out "Reporting" and
inserting
Report
Amend Bill, page 21, lines 10 through 18, by striking out all
of said lines and inserting
This chapter applies to surprise balance bills. Nothing in
this act shall prohibit an insurer from appropriately utilizing
prior authorization or other reasonable medical management
techniques.
Amend Bill, page 21, line 20, by striking out all of said
line and inserting
COMMUNICATIONS, RECORDS AND ENFORCEMENT
Amend Bill, page 23, line 10, by striking out all of said
line and inserting
confidential information. Confidential information under
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this section shall not be subject
Amend Bill, page 23, line 15, by striking out "A discovery or
admissible evidence" and inserting
Discovery or admissible evidence
Amend Bill, page 23, line 17, by inserting after "disclose"
confidential
Amend Bill, page 23, line 18, by striking out "which meets
the criteria under subsection (a)"
Amend Bill, page 23, lines 28 and 29, by striking out
"information which meets the criteria under subsection (a)" and
inserting
confidential information
Amend Bill, page 23, line 30, by inserting after "the" where
it occurs the first time
aggregated
Amend Bill, page 24, lines 2 and 3, by striking out
"information which meets the criteria under subsection (a)" and
inserting
confidential information
Amend Bill, page 25, line 27, by inserting after "of"
and may be subject to the penalties provided for in
Amend Bill, page 25, line 30, by inserting after "of" where
it occurs the first time
and may be subject to the penalties provided for in
Amend Bill, page 26, line 6, by inserting after "of" where it
occurs the first time
and may be subject to the penalties provided for in
Amend Bill, page 27, line 5, by inserting after "may" where
it occurs the first time
each
Amend Bill, page 27, by inserting between lines 6 and 7
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Section 702. Publication of benchmarking databases.
(a) Databases.--The department shall compile and maintain a
list of benchmarking databases maintained by nonprofit
organizations not affiliated with an insurer or provider.
(b) Publication.--The department shall publish the list of
benchmarking databases on the department's publicly accessible
Internet website and annually in the Pennsylvania Bulletin on or
before July 1.
Amend Bill, page 27, line 7, by striking out "702" and
inserting
703
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