Pennsylvania Introduces Legislation to Limit Surprise Balance Bills

Pennsylvania House Health and Insurance Committee Chairs Matt Baker and Tina Pickett have introduced legislation to protect health care consumers from surprise balance bills in a move Pennsylvania Insurance Commissioner Teresa Miller has praised.

“When patients receive medical care, they and their families should be focusing on getting better, and not worrying about whether a big medical bill will be arriving in the next day’s mail,” Commissioner Miller said in a statement. “This legislation will go a long way toward making that happen in Pennsylvania.”

Surprise balance bills happen when consumers make an effort to use providers and facilities in their insurance network, but receive a service from an out-of-network provider or facility during treatment, and then get a balance bill for this service, Miller explained.

The new legislation, HB 1553, has 31 sponsors, including Health and Insurance Committee Minority Chairs Tony DeLuca-D/Berks County and Florindo Fabrizio-D/Erie County. It would protect consumers from surprise balance bills when the consumer makes an effort to use in-network providers and facilities, but during the course of medical care, receives a service from an out-of-network provider or facility.

The legislation would require insurers and providers or facilities to work out payment for out-of-network services, with consumers being responsible only for payments equal to any cost-sharing they have for in-network services.

If the insurer and provider or facility cannot reach agreement on payment for out-of-network services, the matter would be submitted to arbitration, with each side submitting its last best offer. In what is known as “baseball arbitration,” the arbitrator would then choose one of the offers, and this decision would be binding on both parties. The consumer would not be involved in this process.

Miller emphasized this legislation would apply to emergency room care. She noted in emergency situations, consumers often have no choice as to which provider or facility delivers care and have no say in whether the care is in-network.

Similar legislation, SB 678, has been introduced in the Senate by Senator Judith Schwank-D/Berks County, Insurance Committee Chair Don White and Minority Leader Jay Costa, and seven other co-sponsors.

“It’s very important to get the patient out of this equation,” Sen. Schwank said in a statement. “Somebody who has done everything reasonable to make sure they are within their network should not face hidden, and often expensive, bills because of struggles between providers and insurers. Too often that’s what is happening now.”