This bill matters because surprise medical bills have been a major financial stressor for many Americans, often for services they didn't choose, like an out-of-network anesthesiologist during an in-network surgery. The original No Surprises Act aimed to stop these bills, but enforcement can be challenging. By significantly increasing the penalties for health plans and insurers that violate these protections, this bill makes it more costly for them to break the rules, hopefully deterring illegal billing practices.
If this bill becomes law, it could mean fewer surprise bills for patients and quicker resolution of payment disagreements between providers and insurers. This could lead to more stable out-of-pocket costs for consumers and reduce the burden of navigating complex billing issues. If it doesn't pass, health plans and providers would continue to face the current, lower penalties, potentially leading to less incentive for strict compliance with the existing No Surprises Act protections.
KEY PROVISIONS
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PROVISION 01
Increases penalties for group health plans and health insurance issuers from $100 per day to $10,000 per failure for specific balance billing violations under the Public Health Service Act and Internal Revenue Code.
This significantly raises the financial stakes for non-compliance, aiming to deter health plans and insurers from violating surprise billing protections.
PROVISION 02
Establishes a new civil penalty under ERISA of up to $10,000 for each individual affected by a group health plan's or issuer's failure to comply with certain balance billing requirements.
This adds another layer of financial accountability for plans and issuers specifically related to employer-sponsored health coverage.
PROVISION 03
Imposes an additional penalty for late or non-payment after an Independent Dispute Resolution (IDR) entity makes a payment determination.
This provision aims to speed up the resolution of payment disputes between providers and insurers, reducing delays that can impact patients or providers.
PROVISION 04
The new penalty for late or non-payment after IDR is three times the difference between the initial payment (or denial) and the final out-of-network rate determined by the IDR, plus interest.
This substantial penalty provides a strong incentive for all parties to comply with IDR decisions promptly.
PROVISION 05
Requires plans, coverage, or nonparticipating providers/facilities to notify the Secretary of payment once an IDR determination is made and payment is completed.
This provision helps ensure transparency and accountability in the IDR payment process.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
This bill matters because surprise medical bills have been a major financial stressor for many Americans, often for services they didn't choose, like an out-of-network anesthesiologist during an in-network surgery. The original No Surprises Act aimed to stop these bills, but enforcement can be challenging. By significantly increasing the penalties for health plans and insurers that violate these protections, this bill makes it more costly for them to break the rules, hopefully deterring illegal billing practices.
If this bill becomes law, it could mean fewer surprise bills for patients and quicker resolution of payment disagreements between providers and insurers. This could lead to more stable out-of-pocket costs for consumers and reduce the burden of navigating complex billing issues. If it doesn't pass, health plans and providers would continue to face the current, lower penalties, potentially leading to less incentive for strict compliance with the existing No Surprises Act protections.
KEY PROVISIONS
AI-extracted
high
Increases penalties for group health plans and health insurance issuers from $100 per day to $10,000 per failure for specific balance billing violations under the Public Health Service Act and Internal Revenue Code.
This significantly raises the financial stakes for non-compliance, aiming to deter health plans and insurers from violating surprise billing protections.
high
Establishes a new civil penalty under ERISA of up to $10,000 for each individual affected by a group health plan's or issuer's failure to comply with certain balance billing requirements.
This adds another layer of financial accountability for plans and issuers specifically related to employer-sponsored health coverage.
med
Imposes an additional penalty for late or non-payment after an Independent Dispute Resolution (IDR) entity makes a payment determination.
This provision aims to speed up the resolution of payment disputes between providers and insurers, reducing delays that can impact patients or providers.
high
The new penalty for late or non-payment after IDR is three times the difference between the initial payment (or denial) and the final out-of-network rate determined by the IDR, plus interest.
This substantial penalty provides a strong incentive for all parties to comply with IDR decisions promptly.
low
Requires plans, coverage, or nonparticipating providers/facilities to notify the Secretary of payment once an IDR determination is made and payment is completed.
This provision helps ensure transparency and accountability in the IDR payment process.
Group health plans or health insurance issuers offering group health insurance coverage for specific balance billing violations under ERISA
administrative
Three times the difference between the initial payment (or $0 if denied) and the out-of-network rate, plus interest
Plan or coverage, or a nonparticipating provider or facility, that has not made the required payment after an Independent Dispute Resolution determination within 30 days
GLOSSARY
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Balance Billing
When a healthcare provider bills a patient for the difference between what the provider charges and what the patient's insurance pays, even after the insurance has paid its share. The No Surprises Act generally bans this for emergency and certain non-emergency services.
Group Health Plan
A health plan that provides medical care benefits to employees and their dependents through an employer or employee organization, such as a union.
Health Insurance Issuer
A health insurance company that offers group health insurance coverage or individual health insurance coverage.
No Surprises Act
A federal law passed in 2020 that protects people from unexpected medical bills from out-of-network providers and facilities during emergencies or when getting scheduled care at in-network facilities.
Independent Dispute Resolution (IDR)
A process established by the No Surprises Act where an independent third party reviews payment disputes between health insurance companies and out-of-network healthcare providers to decide a fair payment amount.
Nonparticipating Provider or Facility
A healthcare provider (like a doctor) or a healthcare facility (like a hospital) that does not have a contract with a patient's health insurance plan.
ACTION TIMELINE
2 EVENTS
JUL 23, 25
Introduced in House
INTROREFERRAL
JUL 23, 25
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
The total amount a health plan or coverage will pay for an item or service provided by an out-of-network provider or facility, as determined through negotiation or the Independent Dispute Resolution (IDR) process.
ERISA
The Employee Retirement Income Security Act of 1974, a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans.
