Affordable Quality Healthcare
Universal, Affordable Health Coverage With A Cap On Out-Of-Pocket Expenses
Policy Library

Reduce Healthcare Costs — Stop Surprise Billing

Over 50% of Americans report having been surprised by healthcare bills. Surprise bills leave people with thousands of dollars of bills for emergency services that were beyond their control or routine services they could have received at much lower cost without unknowingly incurring out-of-network fees. And these bills often come at the worst time, when people are ill or in recovery. The “Stop Surprise Bills Act” protects patients and lowers costs by requiring notice to patients before an out-of-network charge is incurred and prohibiting out-of-network fees for emergency services.

The National Landscape

Passed in:

California, Connecticut, Florida, Illinois, Maryland, New York, New Jersey

In The News

“Vox’s database shows that patients are especially vulnerable to these surprise bills when out-of-network doctors work at in-network hospitals.”
“[Drew] Calver believed he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him. And then the bills came.”

Partners

  • Consumers
  • Patient advocates
  • Senior citizen advocates
  • Small businesses and business associations
  • Others who pay for healthcare

Opposition

  • Healthcare providers who don’t take insurance
Call us for real-time support using this library, problem-solving tips, and follow-up from our team of national experts:
The State Line
1-833-
STATES-1

FAQ

Who does this help?
Ending surprise bills helps families, the elderly, and others who receive medical care. It helps everyone who unexpectedly receive bills that should reasonably have been covered by their insurance. By reducing healthcare costs overall, it also helps small businesses, unions and others who shoulder healthcare costs.
Is this high-cost to the state?
No. Stopping surprise billing improves practices between doctors, hospitals and insurance companies. It protects patients and brings down costs without taxpayer expense.
Print

Model Policy

SECTION 1 (TITLE):
This act shall be known as the Stop Surprise Bills Act.

SECTION 2 (PURPOSE):
This act prevents “surprise bills” in which patients are charged after-the-fact for unknowingly receiving out-of-network care.

SECTION 3 (PROVISIONS):

(a) It is the goal of STATE to protect patients from “surprise bills” in which they are charged for unknowing receipt of out-of-network services, either because of emergency treatment or because out-of-network providers participated in or provided routine or scheduled care without the patient affirmatively choosing to receive out-of-network care.

(b) No health carrier shall require prior authorization for rendering emergency services, including laboratory tests and services, to an insured.

(c) No health carrier shall impose, for emergency services, including laboratory tests and 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 healthcare provider.

(d) (1) If emergency services, including laboratory tests and 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: (i) The amount the insured's health care plan would pay for such services if rendered by an in-network health care provider; (ii) the usual, customary and reasonable rate for such services, or (iii) the amount Medicare would reimburse for such services. As used in this subparagraph, "usual, customary and reasonable rate" means the eightieth percentile of all charges for the particular health care service performed by a health care provider in the same or similar specialty and provided in the same geographical area, as reported in a benchmarking database maintained by a nonprofit organization specified by the Insurance Commissioner. Such organization shall not be affiliated with any health carrier.(B) Nothing in this subdivision shall be construed to prohibit such health carrier and out-of-network health care provider from agreeing to a greater reimbursement amount.

(e) "Surprise bill" means a bill for health care services including laboratory services and tests, other than emergency services, received by an insured for services rendered by an out-of-network healthcare 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. (2) "Surprise bill" 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.

(f) With respect to a surprise bill: (1) An insured shall only be required to pay the applicable coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed for such health care services if such services were rendered by an in-network health care provider; and (2) A health carrier shall reimburse the out-of-network health care provider or insured, as applicable, for health care services rendered at the in-network rate under the insured's health care plan as payment in full, unless such health carrier and health care provider agree otherwise.

(g) If health care services, including laboratory tests and services, were rendered to an insured by an out-of-network health care provider and the health carrier failed to inform such insured, the health carrier shall not impose 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 services were rendered by an in-network healthcare provider.

(h) It shall be an unfair trade practice in violation of the [general business laws of STATE] for any health care provider, including laboratory, to request payment by an insured other than the applicable coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed for such health care services if such services were rendered by an in-network healthcare provider for (1) emergency services covered under a health care plan and rendered by an out-of-network health care provider, or (2) a surprise bill, as defined in this act.

(i) Within 1 year of the effective date of this law, the Department of [Health/Insurance] shall report to the Governor, Legislature, and on its website on the efficacy of dispute resolution practices between providers, including physicians, laboratories, and hospitals, and insurance companies, and make recommendations as to any changes that should be made based on best practices from surprise billing laws in other states.