Sec. 121. No surprise billing

850 words·~4 min read·/bill/116/hr/2452/ih/section-121

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

For purposes of this section the term surprise bill — means a bill for health care services, other than emergency services, received by an insured for services rendered by an out-of-network health care provider, where such services were rendered by such out-of-network provider at an in-network facility, during a service or procedure performed by an in-network provider or during a service or procedure previously approved or authorized by the health carrier and the insured did not knowingly elect to obtain such services from such out-of-network provider; and does not include a bill for health care services received by an insured when an in-network health care provider was available to render such services and the insured knowingly elected to obtain such services from another health care provider who was out-of-network.

No non-participating health care provider shall require prior authorization for rendering emergency services to an insured. No health carrier shall impose, for emergency services rendered to an insured by an out-of-network health care provider, a coinsurance, copayment, deductible or other out-of-pocket expense that is greater than the coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed if such emergency services were rendered by an in-network health care provider.

If emergency services were rendered to an insured by an out-of-network health care provider, such health care provider may bill the health carrier directly and the health carrier shall reimburse such health care provider the greatest of the following amounts: The amount payable under Medicare for America for such services if rendered by a health care provider participating in Medicare for America. The arbitrated amount between the qualifying health plan and the non-participating provider.

Nothing in this section shall be construed to prohibit the qualifying health plan and the non-participating health care provider from agreeing to a greater reimbursement amount. With respect to a surprise bill, the following applies: An individual enrolled in the qualifying health plan shall only be required to pay the applicable coinsurance that would be imposed for such health care services if such services were rendered by a participating health care provider. The qualifying health plan shall reimburse the non-participating health care provider or individual enrolled in such health plan, as applicable, for health care services rendered at the qualifying health plane rate as payment in full, unless the health plan and the non-participating health care provider agree otherwise.

If health care services were rendered to an individual enrolled in qualifying health coverage by a non-participating health care provider and the qualifying health plan failed to inform such enrollee, if such enrollee was required to be informed, of the network status of such non-participating health care provider, the qualifying health plan shall not impose coinsurance expense that is greater than the maximum out-of-pocket expense that would be imposed if such services were rendered by a qualifying health care provider.

A health care provider not participating in Medicare for America may not require prior authorization for rendering emergency services to an individual enrolled under Medicare for America. A health care provider not participating in Medicare for America may not impose, for emergency services rendered to an individual enrolled in Medicare for America, a coinsurance, copayment, or other out-of-pocket expense that is greater than the coinsurance or maximum out-of-pocket expense that would be imposed if such emergency services were rendered by a Medicare for America participating provider.

If emergency services are rendered to an individual enrolled in Medicare for America by a health care provider not participating in Medicare for America, such health care provider may bill Medicare for America directly and Medicare for America shall reimburse such health care provider the greatest of the following amounts: The amount payable under Medicare for America for such services if rendered by a health care provider participating in Medicare for America. The arbitrated amount between the Secretary of Health and Human Services and the provider, determined by an arbitration process established by the Secretary.

With respect to a surprise bill, the following applies: An individual enrolled in qualifying coverage (as defined in section 2202(b)(4)(B) of the Social Security Act) shall only be required to pay the applicable coinsurance that would be imposed for such health care services if such services were rendered by a health care provider participating in Medicare for America. The Secretary of Health and Human Services shall reimburse the non-participating health care provider or individual enrolled in such health plan, as applicable, for health care services rendered at rate payable under Medicare for America as payment in full, unless the Secretary and the non-participating health care provider agree otherwise.

If health care services were rendered to an individual enrolled in Medicare for America by a health care provider not participating in Medicare for America and the Secretary of Health and Human Services failed to inform such enrollee, if such enrollee was required to be informed, of the network status of such non-participating health care provider, the Secretary shall not impose a coinsurance expense that is greater than the maximum out-of-pocket expense that would be imposed if such services were rendered by a provider participating in Medicare for America.