The public comment period is now closed. Submitted comments from consumers and stakeholders are available to read online.
On October 1, 2015, the Pennsylvania Insurance Department
held a public hearing on the issue of surprise balance billing. Surprise
balance billing occurs when a consumer receives emergency care or a service that
they expect, and often plan, to be in their health insurance plan’s network,
but a portion of their care is performed by an out-of-network provider or
facility. In these cases, consumers can be billed for a large portion or even
the entire bill for that out-of-network care. These unexpected and sometimes
significant bills are troubling and can be unaffordable for consumers, who may
have done everything right when choosing to receive care in-network.
hearing, the Department heard testimony from many stakeholders, including
consumers who have been affected by balance billing, providers, hospitals,
insurance companies, and academic experts. The Department was pleased to see a
general consensus that this is a problem that should be addressed and that
consumers should be protected in these situations. Since the hearing, the
Department has carefully reviewed this testimony and researched actions taken
by other states to address balance billing in order to propose a potential
solution for interested parties to comment upon. The Department’s primary goal
for this proposed solution is to protect consumers from receiving these
unexpected bills, while minimizing burden on the stakeholders involved in these
Department believes the proposed solution meets these goals, but welcomes
comments from any interested stakeholder on the following: The Department seeks comment on whether this is
the best solution or if an alternative solution, whether legislative or
otherwise, could better achieve the stated goals.
- The Department seeks comment on whether there
are changes to the proposed solution that would either further benefit consumers
or minimize burden on stakeholders.
- In some cases, the Department explicitly
outlined options or intentionally left placeholders in place of numbers,
denoted with an XXX, within the draft. The Department specifically seeks
comment on which of the provided options should be pursued and what the
appropriate numbers are to replace these placeholders.
In addition to comments on this proposed solution as
presented, the Department seeks comment on whether surprise bills that result
from differing network tiers is an analogous situation for consumers and
therefore falls within the scope of what is intended to be addressed within the
draft. While the Department recognizes this issue was not articulated at the
public hearing, a review of consumer complaints the Department has received
demonstrates that, in addition to surprise bills from out-of-network providers,
consumers also receive unexpected bills due to unintentional utilization of a
higher tier provider. The Department specifically requests comment on the
situation where a consumer seeks care from a lower tier provider, but a portion
of their care is performed by a higher tier provider, making the consumer
responsible for the higher level of cost-sharing associated with that tier. An
example of this would be a consumer delivering their child with a first tier
OBGYN, but the newborn is unexpectedly seen by a second tier neonatologist and
the consumer must pay higher cost-sharing for those neonatology services,
resulting in a surprise bill.
The Department thanks all interested parties for taking the
time to review the proposed solution and for assisting the Commonwealth in this
important initiative to protect consumers.
Please send comments on the proposed solution no later than February 29, 2016. Note that all comments will be publicly posted
on the Department’s website. Comments or
questions may be sent to firstname.lastname@example.org.
You can read the proposed solution in full here. We appreciate your time and consideration as we work towards a solution on this important issue.