HB 2212 — An Act amending Title 40 (Insurance) of the Pennsylvania Consolidated Statutes, in regulation of insurers and related persons generally, providing for nondiscrimination by payers in health care benefit plans.

PRINTER'S NO.   2906

                     THE GENERAL ASSEMBLY OF PENNSYLVANIA



                         HOUSE BILL
                         No. 2212
                                               Session of
                                                 2026

     INTRODUCED BY MALAGARI, GIRAL, HILL-EVANS, FREEMAN, SANCHEZ,
        McANDREW, MAYES, D. WILLIAMS, HADDOCK, CEPEDA-FREYTIZ,
        CIRESI, GALLAGHER AND MADDEN, FEBRUARY 10, 2026

     REFERRED TO COMMITTEE ON INSURANCE, FEBRUARY 11, 2026


                                    AN ACT
 1   Amending Title 40 (Insurance) of the Pennsylvania Consolidated
 2      Statutes, in regulation of insurers and related persons
 3      generally, providing for nondiscrimination by payers in
 4      health care benefit plans.
 5      The General Assembly of the Commonwealth of Pennsylvania
 6   hereby enacts as follows:
 7      Section 1.    Title 40 of the Pennsylvania Consolidated
 8   Statutes is amended by adding a chapter to read:
 9                                CHAPTER 46
10                        NONDISCRIMINATION BY PAYERS
11                       IN HEALTH CARE BENEFIT PLANS
12   Sec.
13   4601.   Definitions.
14   4602.   Discrimination against willing facility prohibited.
15   4603.   Applicability.
16   4604.   Retaliation prohibited.
17   § 4601.   Definitions.
18      The following words and phrases when used in this chapter
 1   shall have the meanings given to them in this section unless the
 2   context clearly indicates otherwise:
 3      "Ambulatory surgical facility."        The term shall have the same
 4   meaning as defined under section 802.1 of the act of July 19,
 5   1979 (P.L.130, No.48), known as the Health Care Facilities Act.
 6      "Arbitrator."   An independent and impartial third party
 7   accredited by a national or international organization that
 8   specializes in dispute management with subject matter expertise
 9   in health care.
10      "Baseball-style arbitration."        A method by which an
11   arbitrator selects either the figure submitted by the health
12   care benefit plan or the figure submitted by the out-of-network
13   facility.
14      "CPT."    The Current Procedural Terminology 2024 code set as
15   published by the American Medical Association.
16      "DRG."    The Diagnosis Related Group classification system
17   that uses patient discharge information to classify patients
18   into clinically meaningful groups.
19      "Facility."    A physician-owned hospital or physician-owned
20   ambulatory surgical facility.
21      "Health care benefit plan."     An insurance policy, contract or
22   plan that provides health care to participants or beneficiaries
23   directly or through insurance, reimbursement or otherwise.
24      "Health care payer."   An individual or entity that is
25   responsible for providing or paying for all or part of the cost
26   of health care services covered by a health care benefit plan.
27   The term includes an entity subject to at least one of the
28   following:
29          (1)    Chapter 61 (relating to hospital plan corporations)
30      or 63 (relating to professional health services plan

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 1      corporations).
 2             (2)   The act of May 17, 1921 (P.L.682, No.284), known as
 3      The Insurance Company Law of 1921, including either of the
 4      following:
 5                   (i)    A preferred provider organization subject to
 6             section 630 of The Insurance Company Law of 1921.
 7                   (ii)    A fraternal benefit society subject to Article
 8             XXIV of The Insurance Company Law of 1921.
 9             (3)   The act of December 29, 1972 (P.L.1701, No.364),
10      known as the Health Maintenance Organization Act.
11             (4)   An agreement by a self-insured employer or self-
12      insured multiple employer trust to provide health care
13      benefits to employees and the employees' dependents.
14      "Highest in-network rate."        The highest rate for a service or
15   fee that is determined by identifying the contracted rates of
16   all plans of a health care payer or administering entity, if
17   applicable, or all coverage offered by the health care payer in
18   the same individual marketplace rating area as defined by the
19   department for the same or similar item or service that is
20   provided by a facility in the same or similar specialty or
21   facility type and provided in the geographic region in which the
22   item or service is furnished.
23      "Hospital."         The term shall have the same meaning as defined
24   under section 802.1 of the Health Care Facilities Act.
25      "Out-of-network facility."        A facility that has not
26   contracted with a health care payer to provide health care
27   services to insureds covered by a health care payer.
28   § 4602.    Discrimination against willing facility prohibited.
29      (a)    Prohibition.--A health care payer shall reimburse a
30   facility willing to provide health care services. A health care

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 1   payer shall not discriminate against a facility delivering
 2   health care services who:
 3            (1)   Agrees to accept either the health care payer's
 4      highest in-network rate or a baseball-style arbitration and
 5      obtains and maintains Center for Medicare and Medicaid
 6      Services accreditation status.
 7            (2)   Can perform the procedure at an earlier date than
 8      the nearest in-network facility.
 9            (3)   Meets at least one of the following quality metrics:
10                  (i)    A hospital facility achieves a Hospital Consumer
11            Assessment of Healthcare Providers and Systems, or
12            successor rating system, patient satisfaction survey
13            rating of at least four stars.
14                  (ii)   An ambulatory surgical facility achieves an
15            Outpatient and Ambulatory Surgery Consumer Assessment of
16            Healthcare Providers and Systems, or successor rating
17            system, patient satisfaction survey rating of at least
18            four stars.
19            (4)   Is owned, at least in part, by physicians practicing
20      at the out-of-network facility and who are in-network with
21      the health care payer.
22      (b)   Arbitrator selection.--In determining whether the
23   arbitrator shall select the amount submitted by the health care
24   payer or the out-of-network facility for the health care service
25   rendered at an out-of-network facility, the arbitrator shall
26   select either the health care payer's or the facility's best and
27   final proposal for a payment amount without change based on
28   which of the amounts is most consistent with the criteria
29   specified under subsection (c).
30      (c)   Criteria.--The determination of the arbitrator in

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 1   selecting either the health care payer's or out-of-network
 2   facility's payment amount shall be based exclusively on the
 3   following:
 4          (1)     Whether there is a gross disparity between the out-
 5      of-network facility's proposal for a reasonable payment
 6      amount for the health care service or CPT or DRG code in
 7      dispute as compared to the payment received by the out-of-
 8      network facility for the same health care service, CPT or DRG
 9      code from other health care payers in which the out-of-
10      network facility is under contract.
11          (2)     Whether there is a gross disparity in the amount
12      proposed by the health care payer to the out-of-network
13      facility as compared to the amount paid by the health care
14      payer to the out-of-network facility as compared to the
15      amount paid to the other facilities in the same specialty for
16      the same health care service or CPT or DRG code and in the
17      same geographic area that is under contract with the health
18      care payer.
19          (3)     The level of training, education, experience,
20      quality and outcome measurements of the out-of-network
21      facility.
22          (4)     Other relevant economic aspects of the health care
23      payer and the out-of-network facility payments as adduced by
24      either party in arbitration.
25          (5)     The circumstances and complexity of the particular
26      case, including the patient's medical history and the time
27      and cost of the health care service.
28          (6)     Any final judgment of an award rendered by the
29      arbitrator between the health care payer and the out-of-
30      network facility for the same health care service, CPT or DRG

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 1      code within the prior year.
 2      (d)    Bundling.--The parties in arbitration may bundle a
 3   single health care service type, CPT or DRG code in multiple
 4   cases between the same health care payer and the out-of-network
 5   facility.
 6      (e)    Fees.--The arbitration fees shall be paid by the losing
 7   party in the arbitration dispute, except if the arbitration
 8   dispute is resolved as a result of a negotiation between the
 9   parties after the initiation of the arbitration process, and the
10   arbitration fees shall be shared equally by the parties.
11   § 4603.    Applicability.
12      (a)    Construction.--This chapter shall not be construed to
13   prohibit a health care payer from negotiating and paying rates
14   higher than the health care payer's standard payment levels to
15   one or more facilities.
16      (b)    Application.--This chapter:
17             (1)   Shall apply to health care benefit plans that
18      compensate facilities on a fee-for-service basis, per diem or
19      other nonrisk basis.
20             (2)   May not apply to health care benefit plans regarding
21      products that compensate facilities on a capitated basis or
22      under which facilities accept significant financial risk in a
23      formal arrangement approved by Federal or State authorities.
24   § 4604.    Retaliation prohibited.
25      It shall be unlawful for a health care payer to terminate,
26   threaten or otherwise retaliate against an in-network physician
27   with ownership of an out-of-network facility for exercising
28   rights under this chapter.
29      Section 2.     This act shall take effect in 60 days.



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