Protecting Patients from Surprise Medical Bills Act

Protecting Patients from Surprise Medical Bills Act

This bill prohibits balance billing the holder of a self-insured group health plan (plans in which an employer pays claims to providers for health benefits offered to employees) for emergency and specified nonemergency services. Balance billing is the practice of charging a plan holder for the difference between a provider's rate for a service and the in-network rate.

First, the bill requires self-insured group health plans that cover emergency services to comply with the requirements for other types of group health plans. This includes the requirement to bill a plan holder no more than the in-network cost-sharing amount for covered emergency services, even if the provider is out-of-network. Second, the bill prohibits emergency services providers from billing a self-insured group plan holder for any remaining balance for covered services not paid to the provider by the employer.

Further, unless a plan holder has the option to select an in-network provider, an out-of-network provider of covered, nonemergency services is prohibited from billing plan holders for the difference in rates for such services when provided at an in-network facility.

Employers must pay out-of-network providers for services subject to the requirements of this bill (1) the amount the provider claims, (2) the usual and customary amount for such services in that community, or (3) an amount agreed to within 60 days of when the claim is submitted. Otherwise the parties may enter voluntary binding arbitration.

Written by the nonpartisan Congressional Research Service. All summary versions on Congress.gov