This bill expands restrictions on charging health care plan holders out-of-network rates for certain services. First, the bill requires insurers offering plans that cover emergency services to bill plan holders no more than the median in-network rate for a particular emergency service, even if the service provider is out of network. The bill further prohibits insurers from billing plan holders more than the median in-network rate for nonemergency services provided by out-of-network providers at in-network facilities.
Out-of-network providers may not bill plan holders for the difference between the in-network and out-of-network rates for emergency services. The bill further prohibits out-of-network providers from billing plan holders for the difference in rates for nonemergency services provided at an in-network facility unless the provider complies with specified notice and consent requirements. Even when complying with these requirements, an out-of-network provider may not charge plan holders for the difference in rates for such nonemergency services if the provider is based at the in-network facility and is the only provider available to deliver the particular treatment or service at the facility.
States will be primarily responsible for enforcement with the federal government maintaining oversight. By 7/1/2021 the Secretary of Health and Human Services is required to establish a complaint process for violations of surprise billing protections by health care providers and facilities for consumers. Violations of this act by providers could result in fines as high as $10,000.00.
Providers will need to implement procedures and systems (analysis) to track payer payment negotiations/efforts in order to preserve arbitration rights. The establishment of a reliable system/analysis is essential to receiving fair payment for services rendered and not leaving money on the table.
H.R. 3630 | No Surprises Act
Introduced in House (07/09/2019)
Enacted by Congress and signed by President (12/27/2020)
Effective Date (1/1/2022)