This bill matters because surprise medical bills remain a major financial stressor for many Americans, even with the No Surprises Act in place. While the original act made these bills illegal in many situations, this new bill focuses on making sure those rules are actually followed by significantly increasing the consequences for breaking them. If this bill becomes law, health plans, insurers, and out-of-network providers would have a much stronger financial incentive to comply with the rules, potentially leading to fewer surprise bills for patients and faster resolution of payment disputes.
Without this bill, the current penalties might not be enough to deter all violations, leaving some patients vulnerable to unexpected costs. By increasing the fines and adding penalties for late payments after an arbitration decision, it aims to reinforce patient protections and ensure that the spirit of the No Surprises Act is upheld, making the healthcare billing process more predictable for consumers.
KEY PROVISIONS
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PROVISION 01
Increases existing penalties for health plans and insurers from $100 to $10,000 per violation for failing to follow specific balance billing requirements of the No Surprises Act.
This provision significantly raises the financial risk for health plans and insurers that violate balance billing rules, aiming to deter non-compliance and protect consumers from unexpected costs.
PROVISION 02
Establishes new penalties for health plans, insurers, and non-participating providers or facilities that fail to make payments within 30 days after an Independent Dispute Resolution (IDR) entity determines the final payment amount.
This addresses a potential loophole where parties might delay or avoid payment even after a ruling, ensuring that IDR decisions lead to timely financial resolution.
PROVISION 03
The new penalty for late or non-payment after an IDR decision is three times the difference between the initial payment (or $0 if no payment) and the determined out-of-network rate, plus interest.
This substantial penalty is designed to strongly incentivize prompt compliance with IDR outcomes, preventing prolonged payment disputes and ensuring fair compensation.
PROVISION 04
Requires plans, coverage, or non-participating providers/facilities to notify the Secretary of the payment made pursuant to an IDR determination.
This provision adds transparency and allows for better oversight of compliance with IDR decisions and overall No Surprises Act enforcement.
This bill matters because surprise medical bills remain a major financial stressor for many Americans, even with the No Surprises Act in place. While the original act made these bills illegal in many situations, this new bill focuses on making sure those rules are actually followed by significantly increasing the consequences for breaking them. If this bill becomes law, health plans, insurers, and out-of-network providers would have a much stronger financial incentive to comply with the rules, potentially leading to fewer surprise bills for patients and faster resolution of payment disputes.
Without this bill, the current penalties might not be enough to deter all violations, leaving some patients vulnerable to unexpected costs. By increasing the fines and adding penalties for late payments after an arbitration decision, it aims to reinforce patient protections and ensure that the spirit of the No Surprises Act is upheld, making the healthcare billing process more predictable for consumers.
KEY PROVISIONS
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high
Increases existing penalties for health plans and insurers from $100 to $10,000 per violation for failing to follow specific balance billing requirements of the No Surprises Act.
This provision significantly raises the financial risk for health plans and insurers that violate balance billing rules, aiming to deter non-compliance and protect consumers from unexpected costs.
high
Establishes new penalties for health plans, insurers, and non-participating providers or facilities that fail to make payments within 30 days after an Independent Dispute Resolution (IDR) entity determines the final payment amount.
This addresses a potential loophole where parties might delay or avoid payment even after a ruling, ensuring that IDR decisions lead to timely financial resolution.
high
The new penalty for late or non-payment after an IDR decision is three times the difference between the initial payment (or $0 if no payment) and the determined out-of-network rate, plus interest.
This substantial penalty is designed to strongly incentivize prompt compliance with IDR outcomes, preventing prolonged payment disputes and ensuring fair compensation.
med
Requires plans, coverage, or non-participating providers/facilities to notify the Secretary of the payment made pursuant to an IDR determination.
This provision adds transparency and allows for better oversight of compliance with IDR decisions and overall No Surprises Act enforcement.
not later than 30 days after the date on which such determination is made.
Payment must be made by the required party (plan, coverage, or nonparticipating provider/facility) to the other party after an Independent Dispute Resolution (IDR) determination.
Group health plans and health insurance issuers for violating specific balance billing requirements.
civil
Three times the difference between the initial payment (or $0 if denied) and the out-of-network rate (less cost sharing), plus interest.
Group health plans, health insurance issuers, or nonparticipating providers/facilities for not making required payments within 30 days after an Independent Dispute Resolution (IDR) determination.
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 plan pays. The No Surprises Act generally makes this illegal for emergency services and certain non-emergency services provided by out-of-network providers at in-network facilities.
Group health plan
A health plan that provides medical care to employees and their families, typically offered by an employer or employee organization.
Health insurance issuer
A health insurance company that offers and sells health insurance policies.
Nonparticipating provider or facility
A doctor, hospital, or other healthcare facility that does not have a contract with a patient's health insurance plan. These are also known as 'out-of-network' providers.
Independent Dispute Resolution (IDR)
A process established by the No Surprises Act where an independent arbiter reviews payment disputes between health plans/insurers and out-of-network providers/facilities, deciding the final payment amount for a service.
Public Health Service Act (PHSA)
A federal law that gives the government broad authority to improve the nation's public health. It includes provisions related to health insurance market reforms, including aspects of the No Surprises Act.
ACTION TIMELINE
2 EVENTS
JUL 23, 25
Introduced in Senate
INTROREFERRAL
JUL 23, 25
Read twice and referred to the Committee on Health, Education, Labor, and Pensions.
Employee Retirement Income Security Act of 1974 (ERISA)
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.
Internal Revenue Code of 1986 (IRC)
The body of tax law for the United States, which includes provisions related to health insurance and employer-sponsored health plans.
