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​Proposed Solution to Protect Consumers from Surprise Balance Billing

Insurance Commissioner Seeks Public Comments and Feedback 

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.

At the 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 complicated situations.

  • The 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

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.