Insurance Commissioner Reminds Pa. of Increased Consumer Protections from Unexpected Medical Bills

Pennsylvania Insurance Commissioner Jessica Altman reminded Pennsylvanians that the federal No Surprises Act legislation is now in effect and patients are protected from receiving surprise medical bills.

A surprise bill is an unexpected medical bill that a patient receives when they unknowingly or unintentionally obtain health care from a provider that is outside their plan’s provider network. Surprise bills can happen in emergency situations, but can also occur in a non-emergency situation, when an out-of-network ancillary provider such as an anesthesiologist or radiologist provides care at an in-network facility.

The No Surprises Act went into effect Jan. 1. The new legislation protects patients from surprise bills by requiring that emergency services are billed as in-network, without needing prior approval, and certain non-emergency services at an in-network facility provided by out-of-network ancillary providers are also covered as in-network. In both situations, patients are responsible for no more than their in-network cost-sharing (like a deductible or co-pay) for the service. Patients should no longer be receiving surprise balance bills for more than this amount.

In addition, the No Surprises Act bans certain other out-of-network charges and balance billing without advance notice. Health care providers and facilities are required to provide consumers with a plain-language consumer notice explaining that patient consent is required to get care on an out-of-network basis before that provider can bill the consumer.

In December, Governor Tom Wolf signed an Executive Order designating the Pennsylvania Insurance Department as the lead agency to coordinate implementation of the No Surprises Act in the commonwealth. The Executive Order also directed Pennsylvania state agencies to provide assistance and encouraged interagency cooperation in implementing the new federal legislation.

The No Surprises Act protects individuals with coverage through their employer, Pennie (Pennsylvania’s state-based Marketplace), or directly through an individual market health insurance company. Other types of coverage, such as Medicare and Medical Assistance, already has protections from balance billing in place prior to Jan. 1.

Patients who receive a surprise medical bill for services provided on or after Jan. 1, 2022, should submit a bill review request to the Insurance Department at http://www.insurance.pa.gov/NoSurprises. When possible, consumers should contact the Department before paying a bill they believe may be a surprise bill or otherwise sent in error. The department’s dedicated consumer complaints team will verify the type of coverage the patient has and will reach out directly to the provider regarding the bill in question with the primary goal of ensuring the protections of the No Surprises Act are being met. Depending on the nature of the complaint, the department may have to work with the federal government or another commonwealth agency to help resolve the issue for the patient. Patients can also seek assistance from their health plan.

The Pennsylvania Insurance Department encourages patients to contact the department before paying a bill they believe has been sent in error or appears to not be consistent with the No Surprises Act. In addition to the website, the department can also be reached at (877) 881-6388.