Overview
Pennsylvania is a leader in antitrust enforcement of its healthcare provider market with a robust set of review protocol for nonprofit hospital transactions. The state attorney general has oversight authority which requires notice of all nonprofit health entity transactions with review and based on consideration of public interest and antitrust implications. Additionally, the AG may challenge transactions in court and maintain post-merger oversight. Pursuant to this authority, the AG has been active in legal challenges against proposed mergers in the state. One of the landmark enforcement cases is a joint lawsuit with the FTC against Penn State Hershey Medical Center and Pinnacle Health System, in which the 3rd Circuit reversed a lower court decision and blocked the merger of the two largest hospitals systems in the Harrisburg area. A number of other mergers and acquisitions were either abandoned or saw condition imposed on the deals to alleviate anticompetitive concerns upon the AG’s review and challenge.
By comparison, Pennsylvania’s efforts in other healthcare initiatives such as price transparency have lagged. The legislature has yet to mandate the implementation of an all-payer claims database. In terms of surprise and balance billing prohibitions, Pennsylvania law provides only protections against out-of-network services in emergency situations.
In 2020, Pennsylvania received federal approval of a Section 1332 State Innovation Waiver to run a state-based reinsurance program, which would partially reimburse insurers for certain high-cost claims for consumers in the individual health insurance market. The state all rolled out a state-based insurance exchange, named Pennie, designed to save money and give the state more control over its exchange compared to utilizing the federal exchange.
See below for an overview of existing Pennsylvania state mandates. Click on citation tab for detailed information of specific statutes (click link to download statute text).
State Action
Latest Legislative Session: 1/3/2023 - 11/17/2023 (2023-2024 term). *Current session bill updates are ongoing. Check back weekly for updates.
HB 1013 (See companion bill SB 50) – Pennsylvania
Introduced: 2019 Status: Inactive / Dead
An insurer offering, issuing or renewing an individual or group health insurance policy may not require an individual to pay a premium rate that is greater than the premium rate for a similarly situated individual …
HB 1042 – Pennsylvania
Introduced: 2019 Status: Inactive / Dead
The Prescription Drug Pricing Task Force is established to study the pricing of prescription drugs and issue a report under this act.
HB 1091 – Pennsylvania
Introduced: 2019 Status: Inactive / Dead
An Act making appropriations from the General Fund to the Health Care Cost Containment Council for the fiscal year beginning July 1, 2019, and for the payment of bills incurred and remaining unpaid at the …
HB 1194 – Pennsylvania
Introduced: 2019 Status: Inactive / Dead
An Act amending the act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, in quality healthcare accountability and protection, further providing for definitions, for responsibilities of managed care plans, …
HB 1204 – Pennsylvania
Introduced: 2019 Status: Inactive / Dead
An Act amending the act of July 19, 1979 (P.L.130, No.48), known as the Health Care Facilities Act, in preliminary provisions, reenacting and amending provisions relating to definitions; in powers and duties of the department, …
40 Pa. Stat. and Cons. Stat. Ann. §§ 3041 & 3042: Insurance Reimbursement for Hospital Emergency Facility Services – Pennsylvania
Introduced: Status: Enacted
States that an insurer shall reimburse an insured or provider for medically necessary services that are provided in a hospital emergency facility due to a medical emergency
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40 Pa. Stat. and Cons. Stat. Ann. §§ 3101 through 3111: Medicare Supplement Insurance Act – Pennsylvania
Introduced: Status: Enacted
Governs Medicare supplement insurance policies including provisions regarding prohibited policy provisions, minimum benefit standards, loss ratio standards, required disclosure provisions, and requirements for replacement.
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40 Pa. Stat. and Cons. Stat. Ann. §§ 323.1 through 323.8: The Insurance Department Act of 1921 — Examinations – Pennsylvania
Introduced: Status: Enacted
The purpose of this article is to provide an effective and efficient system for examining the activities, operations, financial condition and affairs of all persons transacting the business of insurance in this Commonwealth and all …
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40 Pa. Stat. and Cons. Stat. Ann. §§ 3801.101 through 3801.315: Accident and Health Filing Reform Act — Federal Compliance – Pennsylvania
Introduced: Status: Enacted
Requires that each insurer shall file with the department rates for individual accident, small group accident and health insurance policies which it proposes to issue on am individual or group basis in this Commonwealth for …
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40 Pa. Stat. and Cons. Stat. Ann. §§ 3801.501 through 3801.514: Accident and Health Filing Reform Act — Commonwealth Exclusivity – Pennsylvania
Introduced: Status: Enacted
Each insurer, HMO, hospital plan corporation, professional health services plan corporation shall file with the department rates for accident and health insurance policies which it proposes to use in this Commonwealth for the department to …
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Ross v. University of Pittsburgh Medical Center – Pennsylvania
District Court: US District Court for the Western District of Pennsylvania Status: Pending
On January 18, 2024, Victoria Ross, a former University of Pittsburgh Medical Center (UPMC) nurse, filed an antitrust class action suit in the US District …
SEIU Healthcare Pennsylvania & Strategic Organizing Center v. University of Pittsburgh Medical Center – Pennsylvania
District Court: Status: Pending
On May 18, 2023, Strategic Organizing Center (SOC)—which is a coalition of labor unions Service Employees International Union (SEIU), Communications Workers of America, and United …
United States v. Geisinger Health and Evangelical Community Hospital – Pennsylvania
District Court: Middle District of Pennsylvania Status: Decided
In August 2020, the DOJ filed suit in the district court of Pennsylvania, challenging agreements that include Geisinger Health System’s bid to acquire 30% ownership …
Federal Trade Commission and Commonwealth of Pennsylvania v. Thomas Jefferson University and Albert Einstein Healthcare Network – Pennsylvania
District Court: Eastern District of Pennsylvania Status: Decided
The FTC and the Pennsylvania AG filed a lawsuit in the Eastern District of Pennsylvania to block the nearly $600 million merger deal between Jefferson …
Pennsylvania Professional Liability Joint Underwriting Association v. Wolf – Pennsylvania
District Court: U.S. District Court, M.D. Pennsylvania Status: Decided
Additional Resources
STATE BUDGET
Pennsylvania’s budget operates on a twelve month cycle beginning July 1 and ending June 30 of the following calendar year, which is enacted during its regular legislative session in the previous year.
REGULATION & ENFORCEMENT
- In October 2013, Attorney General Kathleen G. Kane announced that her office had reached an agreement with Geisinger Health System Foundation over antitrust concerns that the acquisition of Lewistown Hospital and its employed physician group may have substantially lessened or eliminated competition in the region. The eight-year agreement placed several conditions on the merger.
- Pennsylvania was one of 16 states to file an amicus brief supporting the FTC’s winning position in the Ninth Circuit appeal of St. Luke’s Health Care Sys. v. FTC, No. 14-35173 (March 7, 2014), decided February 10, 2015. The States’ brief stated that the acceleration of health care costs due to the growth of large health care provider systems had become a matter of grave concern for the states.
- Enforcement Actions, Market Conduct Actions and Market Surveillance reports conducted by the Department of Insurance can be found here.