S 2420
No Surprises Act Enforcement Act
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Bill overview
The No Surprises Act Enforcement Act aims to strengthen penalties for group health plans, health insurance issuers, and nonparticipating providers regarding balance billing violations. Specifically, it increases financial penalties for non-compliance, enhances transparency reporting requirements, and clarifies enforcement procedures related to late payments or non-payments. The bill seeks to ensure that patients are not unexpectedly billed for out-of-network care and to hold accountable those who violate the No Surprises Act.
Key provisions
- Increases financial penalties for group health plans and issuers for balance billing violations to $10,000 per violation.
- Raises penalties for late payment or non-payment of medical bills to three times the initial payment amount.
- Requires annual reporting to Congress on audits and enforcement actions related to the No Surprises Act.
- Expands the scope of reporting to include details on complaints, penalties issued, and common violations.
- Clarifies the timing and notification requirements for payment determinations.
- Modifies the Public Health Service Act and ERISA to align with the increased penalty amounts.
- Updates the Internal Revenue Code to reflect the enhanced penalties.
- Introduces transparency reporting requirements regarding audits and enforcement actions.
Who is affected
- Group health plans
- Health insurance issuers
- Nonparticipating providers and facilities
- Patients and consumers
- Healthcare providers
Sponsors
Official sponsors from legislative records.
Primary sponsor
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119th CONGRESS — 1st Session
S. 2420
IN THE SENATE OF THE UNITED STATES
A BILL
To amend title XXVII of the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code of 1986 to increase penalties for group health plans, health insurance issuers, and nonparticipating providers or facilities for practices that violate balance billing requirements, and for other purposes.
This Act may be cited as the No Surprises Act Enforcement Act
.
in clause (i), by inserting (or, in the case of such a failure with respect to a provision specified in clause (iv), $10,000 per violation)
after $100
; and
by adding at the end the following new clause:
Subparagraphs (A) and (B) of section 2799A–1(a)(1).
Clauses (i), (ii), (iii), and (v) of section 2799A–1(a)(1)(C).
Subparagraphs (A), (B), and (E) of section 2799A–1(b)(1).
Paragraphs (1) and (2) of section 2799A–2(a).
in subsection (a)(6), by striking or (9)
and inserting (9), or (12)
;
in subsection (b)(3)—
by inserting , (c)(12),
after subsections (c)(9)
; and
by inserting or (c)(12)
after under subsection (c)(9)
; and
in subsection (c), by adding at the end the following new paragraph:
Subparagraphs (A) and (B) of section 716(a)(1).
Clauses (i), (ii), (iii), and (v) of section 716(a)(1)(C).
Subparagraphs (A), (B), and (E) of section 716(b)(1).
Paragraphs (1) and (2) of section 717(a).
(or, in the case of such a failure with respect to a provision specified in paragraph (4), $10,000)after
$100; and
by adding at the end the following new paragraph:
Subparagraphs (A) and (B) of section 9816(a)(1).
Clauses (i), (ii), (iii), and (v) of section 9816(a)(1)(C).
Subparagraphs (A), (B), and (E) of section 9816(b)(1).
Paragraphs (1) and (2) of section 9817(a).
Section 2799A–1(c)(6) of the Public Health Service Act (42 U.S.C. 300gg–111(c)(6)) is amended—
; penalty for late payment or non-paymentafter
payment;
by striking The total plan
and inserting the following:
in subparagraph (A), as so inserted, by adding at the end the following new sentence: In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan or coverage the difference between such determination and such sum not later than 30 days after the date on which such determination is made.
; and
by adding at the end the following new subparagraphs:
In the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between—
the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(1)(C)(iv)(I) or (b)(1)(C), as applicable; and
the out-of-network rate (as defined in subsection (a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service).
A late payment penalty under clause (i) shall also be subject to interest in a manner specified by the Secretary.
Section 2799A–2(b)(6) of the Public Health Service Act (42 U.S.C. 300gg–112(b)(6)) is amended—
in the paragraph heading, by inserting ; penalty for late payment or non-payment
after payment
;
by striking The total plan
and inserting the following:
in subparagraph (A), as so inserted, by adding at the end the following new sentence: In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan or coverage the difference between such determination and such sum not later than 30 days after the date on which such determination is made.
; and
by adding at the end the following new subparagraphs:
the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(3)(A); and
the out-of-network rate (as defined in section 2799–1(a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service).
A late payment penalty under clause (i) shall also be subject to interest in a manner specified by the Secretary.
Section 716(c)(6) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185e(c)(6)) is amended—
; penalty for late payment or non-paymentafter
payment;
by striking The total plan
and inserting the following:
in subparagraph (A), as so inserted, by adding at the end the following new sentence: In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan or coverage the difference between such determination and such sum not later than 30 days after the date on which such determination is made.
; and
by adding at the end the following new subparagraphs:
the out-of-network rate (as defined in subsection (a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service).
A late payment penalty under clause (i) shall also be subject to interest in a manner specified by the Secretary.
; penalty for late payment or non-paymentafter
payment;
by striking The total plan
and inserting the following:
in subparagraph (A), as so inserted, by adding at the end the following new sentence: In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan or coverage the difference between such determination and such sum not later than 30 days after the date on which such determination is made.
; and
by adding at the end the following new subparagraphs:
the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(3)(A); and
the out-of-network rate (as defined in section 716(a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service).
A late payment penalty under clause (i) shall also be subject to interest in a manner specified by the Secretary.
Section 9816(c)(6) of the Internal Revenue Code of 1986 is amended—
; penalty for late payment or non-paymentafter
payment;
by striking The total plan
and inserting the following:
in subparagraph (A), as so inserted, by adding at the end the following new sentence: In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan the difference between such determination and such sum not later than 30 days after the date on which such determination is made.
; and
by adding at the end the following new subparagraphs:
the out-of-network rate (as defined in subsection (a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service).
A late payment penalty under clause (i) shall also be subject to interest in a manner specified by the Secretary.
; penalty for late payment or non-paymentafter
payment;
by striking The total plan
and inserting the following:
in subparagraph (A), as so inserted, by adding at the end the following new sentence: In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan the difference between such determination and such sum not later than 30 days after the date on which such determination is made.
; and
by adding at the end the following new subparagraphs:
the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(3)(A); and
the out-of-network rate (as defined in section 9816(a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service).
A late payment penalty under clause (i) shall also be subject to interest in a manner specified by the Secretary.
No Surprises Act Enforcement Act
is enacted, the Secretary shall annually submit to Congress a report on the number of plans and issuers with respect to which audits were conducted during such year pursuant to this subparagraph.With respect to the first calendar year following the date of the enactment of the
No Surprises Act Enforcement Act
, not later than February 1 of such year, and every 6 months thereafter, the Secretary, in coordination with the Secretary of Labor and the Secretary of the Treasury, shall submit to the Committee on Ways and Means, the Committee on Energy and Commerce, and the Committee on Education and the Workforce of the House of Representatives, and the Committee on Finance and the Committee on Health, Education, Labor and Pensions of the Senate, a report on any audits conducted pursuant to this subparagraph during the applicable reporting period, and any enforcement actions taken during such period in accordance with the provisions of this part, including—the total number of audits conducted under this subparagraph;
the number of audits conducted pursuant to clause (ii)(I);
the number of complaints submitted by providers and by participants, beneficiaries, and enrollees with respect to a violation of this part;
any enforcement actions taken as a result of a complaint submitted by a provider or by a participant, a beneficiary, or an enrollee, with respect to the provisions of this part;
the total number of, and the aggregate dollar amount of, any civil monetary penalties issued in accordance with this part;
a summary of any non-monetary corrective action taken against a group health plan or health insurance issuer offering group or individual health insurance coverage for a violation of this part; and
a description of the 3 most commonly reported violations of this part.
For purposes of this subclause, the term applicable reporting period
means the 6 month period prior to each report submitted under item (aa).
No Surprises Act Enforcement Act
is enacted, the Secretary shall annually submit to Congress a report on the number of plans with respect to which audits were conducted during such year pursuant to this subparagraph.No Surprises Act Enforcement Act
, not later than February 1 of such year, and every 6 months thereafter, the Secretary, in coordination with the Secretary of Labor and the Secretary of Health and Human Services, shall submit to the Committee on Ways and Means, the Committee on Energy and Commerce, and the Committee on Education and Workforce of the House of Representatives, and the Committee on Finance and the Committee on Health, Education, Labor and Pensions of the Senate, a report on audits performed pursuant to this subparagraph during the applicable reporting period, and any enforcement actions taken during such period in accordance with the provisions of an applicable section, including—the total number of audits conducted under this subparagraph;
the number of audits conducted pursuant to clause (ii)(I);
the number of complaints submitted by providers and by participants and beneficiaries with respect to a violation of an applicable section;
any enforcement actions taken pursuant to a violation of an applicable section;
the total number of, and the aggregate dollar amount of, any civil monetary penalties issued in accordance with an applicable section;
a summary of any non-monetary corrective action taken against a group health plan for a violation of an applicable section; and
a description of the 3 most commonly reported violations of an applicable section.
In this subclause:
The term applicable reporting period
means the 6 month period prior to each report submitted under item (aa).
The term applicable section
means this section and each of sections 9817 through 9825.