States Lead on Surprise Medical Billing Protections, Congress Poised to Follow

*Updated Oct. 4, 2019

States are at the forefront of protecting consumers from surprise medical balance billing, which occurs when consumers are billed for the balance of services they unexpectedly receive from an out-of-network provider or facility. More than half of all states have enacted some level of protections and Congress is now considering proposals to address surprise balance bills.

Several bills have been introduced in the House and Senate, and each differs in defining which insurer market is targeted, how reimbursements are handled, and the exact circumstances in which consumers are protected. All of the bills include potentially significant roles for states by:

  • Defaulting to state laws, if they exist, in lieu of federal laws;
  • Proposing that states establish and/or calculate reimbursement rates; and/or
  • Appropriating funds for creation of state all-claims databases.

These proposals also have important implications for state insurance markets. For example, establishing limits on how much a provider can “balance bill” a consumer or insurer may trigger cost shifting to other payers. These changes may also alter negotiating dynamics between insurers and providers, leading to changes in network composition for some insurance plans.

State and federal officials may also wish to consider how best to coordinate implementation of these new policies, including what infrastructure is needed to perform and share required cost calculations. In addition, state and federal officials may also wish to consider how to coordinate the notice and disclosure requirements they impose on providers and insurers to reduce administrative burden and potential consumer confusion in the event of redundant policies.

  • A detailed summary of current congressional proposals is featured below.
  • Read or download a chart containing this information with notations here

As federal proposals evolve, the National Academy for State Health Policy (NASHP) will continue to evaluate and share implications for states.