Fact Sheet: Surprise Billing Legislation

The Issue

The Senate and House are both considering legislation to address surprise medical bills that patients may incur as a result of unexpected gaps in insurance coverage or medical emergencies. Below are brief summaries of the proposals under consideration. Additional resources are available online.

Senate Legislation

The Senate Committee on Health, Education, Labor and Pensions (HELP) June 26, 2019 passed the Lower Health Care Costs Act of 2019 (S. 1895) − legislation focused on reducing health care costs. Facilities and practitioners would be barred from sending patients “balance” bills for more than the in-network cost-sharing amount. The bill would require the health plan to pay the practitioner and/or the facility based on the median in-network contracted rate for services in the geographic area. The legislation also includes very concerning provisions related to price transparency and provider/health plan contracting.

House Legislation

The Energy and Commerce Committee July 17, 2019 approved legislation to address surprise medical bills. The legislation, H.R. 2328, includes the text of the No Surprises Act that would prohibit balance billing for out-of-network emergency services and certain out-of-network ancillary and post-stabilization services, and set reimbursement for out-of- network providers at the median in-network contracted rate for services in the geographic area. The legislation also includes a voluntary arbitration process for hospital and physician claims with median in-network reimbursement of $1,250 or more.

The Education and Labor Committee Feb. 11 approved the Ban Surprise Billing Act (H.R. 5800), legislation to address surprise medical bills. The bill relies on a median in-network rate to resolve out-of-network payments. For amounts paid above $750 (or $25,000 for air ambulance services), the legislation allows for an independent dispute resolution process to determine the final payment.

The Ways and Means Committee Feb. 12 approved the Consumer Protections Against Surprise Medical Bills Act (H.R. 5826), AHA-supported legislation to address surprise medical bills. The bill prohibits providers from balance billing patients for emergency services or medical care the patient reasonably could have expected to be in-network, and from charging patients more than the in-network cost-sharing amount. Rather than rely on a benchmark payment rate to determine out-of-network reimbursement, the legislation provides a period for health plans and providers to negotiate out-of-network reimbursement, followed by a mediated dispute resolution process if necessary.

Senate HELP Committee and Energy and Commerce Committee Agreement

Leaders from the Senate HELP Committee and House Energy and Commerce Committee Dec. 8, 2019 announced an agreement on legislation to address surprise medical billing. While legislative language has not been released, a summary of the proposal includes both a benchmark rate and an independent dispute resolution process for claims over $750.

AHA Position

Once the patient is protected, providers and insurers should be permitted to negotiate payment rates for services provided. We strongly oppose approaches that would impose arbitrary rates on providers as it would compromise patient access to care and create a disincentive for insurers to maintain adequate provider networks, particularly in rural America.