Protecting People From Surprise Medical Bills Act
Congressman Ruiz, M.D. & Congressman Roe, M.D.
Section by Section
Section 1:
Title
“Protecting People From Surprise Medical Bills Act”
Section 2:
Prohibition on Surprise Balance Billing
Out-of-network (OON) providers will no longer be permitted to balance bill a patient for
unanticipated out-of-network care, which includes the following situations:
- Emergency care in both in-network and out-of-network facilities
- Scheduled anticipated care with unanticipated out-of-network providers
- Out-of-network after-emergency care when a patient cannot travel without medical transport
- Out-of-network imaging or lab services when ordered by an in-network provider
The patient shall not be liable to pay the insurer any amount in excess of the applicable in-network cost-sharing amount and deductible, and the insurer or provider shall not bill any such
excess payment.
Entities who violate the ban and balance bill a patient will be subject to civil monetary damages
if the patient has not been reimbursed the amount that they were balanced billed within 30 days
of the entity being made aware of the error.
Initial payment
The plan/issuer will pay the provider a commercially reasonable rate within 30 days.
Direct Negotiation
If either party is dissatisfied with that amount, they will have 30 days to privately settle on a
payment amount.
Establishment of Independent Dispute Resolution (IDR) Process
If no agreement between the parties is met, either party may trigger the independent dispute
resolution (IDR) process described below.
The Secretaries of HHS and Labor shall establish an IDR process for resolving disputes between
health plans and out-of-network providers for emergency services or unanticipated care rendered
to enrollees.
The patient will be completely out of the process and will only be billed for their in-network
cost-sharing rates
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