Providing for patient access to clear health care information; and requiring plain-language summaries of coverage, prior authorization and appeal rights.
SB1289, titled the Patient Right-to-Understand Act, would require health care entities in Pennsylvania to give patients plain-language summaries of key insurance and billing information. The required summary would cover coverage basics such as deductibles, copayments, coinsurance, facility and professional fees, and network restrictions, as well as prior authorization requirements, appeal rights, and expected out-of-pocket costs for nonemergent services based on a good-faith estimate. The bill also requires that the summary be provided electronically at enrollment or renewal and upon request, and that it be concise, standardized, and no more than two pages long.
The bill further requires a plain-language statement distinguishing what is covered by insurance from medical care decisions made solely between a patient and a practitioner. It also directs health care entities to disclose legally available care and payment options, including cash-pay pricing, health savings accounts, employer-funded spending accounts, and out-of-network options, without requiring patients to endorse any option in order to receive the disclosure. The act is intended to improve transparency, patient understanding, and informed decision-making in the health care marketplace.
SB1289 would impose new disclosure obligations on insurers, managed care organizations, hospitals, health systems, medical practices, and third-party administrators that submit claims for reimbursement in Pennsylvania. It would not apply to certain direct-pay practices that do not submit insurance claims. The bill would also create an enforcement mechanism by barring debt collection against a patient disputing care or financial obligations if the health care entity fails to provide the required summaries and a Department of Health compliance certificate. The Department of Health would be responsible for adopting the compliance certificate referenced in the bill.
The bill text reflects a strongly pro-consumer and transparency-oriented approach, emphasizing patient empowerment, clearer communication, and easier comparison of costs and coverage. Although there is no committee transcript or recorded vote history available in the provided materials, the introduced sponsors and the framing of the legislation suggest support for simplifying health care information and reducing confusion around insurance and billing. No formal opposition is documented in the supplied record.
The main potential points of contention are the scope of the disclosure mandate, the administrative burden on health care entities, and the enforcement provision tying compliance to debt collection rights. Providers, insurers, and administrators may object to the cost and operational complexity of producing standardized plain-language summaries, especially the requirement to estimate out-of-pocket costs and explain prior authorization and appeal processes. Another possible issue is the bill’s distinction between insurance coverage and medical decision-making, which could raise questions about how broadly the disclosure duties reach and whether they interfere with existing billing, utilization review, or payment practices.