{ "id": "R46116", "type": "CRS Report", "typeId": "REPORTS", "number": "R46116", "active": true, "source": "EveryCRSReport.com, CRSReports.Congress.gov", "versions": [ { "source": "EveryCRSReport.com", "id": 611426, "date": "2019-12-12", "retrieved": "2019-12-20T16:36:57.809074", "title": "Surprise Billing in Private Health Insurance: Overview and Federal Policy Considerations", "summary": "In response to individuals receiving large, unexpected medical bills for out-of-network care, Congress has recently been considering legislation to address surprise billing. As the term is currently being discussed, surprise billing typically refers to situations where consumers are unknowingly, and potentially unavoidably, treated by providers outside of the consumers\u2019 health insurance plan networks and, as a result, unexpectedly receive larger bills than they would have received if the providers had been in the plan networks. In the 116th Congress, federal proposals have sought to address surprise billing in the context of two types of situations: (1) where an individual receives emergency services from an out-of-network provider and (2) where an individual receives services from an out-of-network provider that is working at an in-network facility.\nAlthough no federal requirements directly address surprise billing, at least half of the states have implemented policies to address surprise billing in some capacity. However, the state laws are limited in application, as certain types of plans, such as self-funded plans offered by employers, are exempt from state insurance regulation. State policies to address surprise billing vary in terms of the types of consumer financial protections provided (e.g., consumer balance billing limitations) and the related requirements on insurers and providers to establish such protections. Among states that offer similar types of consumer protections, policies may vary in their application and may differ according to the types of situations addressed (e.g., emergency services, out-of-network care at an in-network facility), the types of plans addressed (e.g., HMO, PPO), and the methods used to determine insurer payments to providers for such services (e.g., benchmark, arbitration). \nSimilar to many state laws, recent federal legislative proposals related to surprise billing typically seek to address the financial relationships between insurers, providers, and consumers. They do so by establishing new requirements on insurers, providers, or both to create a degree of consumer protection related to reducing patient financial responsibilities with respect to some types of out-of-network care.\nIn addition to including language that limits consumer cost sharing in surprise billing situations, the federal proposals typically include language that specifies the methods by which insurers determine payment to providers for the services being addressed in the bill (since solely reducing consumer financial liability in such situations would reduce the total amount providers receive for their services). When combined with balance billing prohibitions, this type of requirement effectively results in what the insurer and provider recognize as the total payment for out-of-network care. \nTo date, federal proposals are largely aligned in how they would address consumer protections in surprise billing situations. However, the proposals differ in how they would address total payment for specified services furnished by out-of-network providers.\nFederal proposals generally have focused on at least one of two methods to determine insurers\u2019 financial responsibility: (1) selecting a benchmark provider payment rate that serves as the basis for determining specific amounts that insurers must pay providers, net of consumer cost sharing or (2) establishing an alternative dispute resolution process, such as arbitration, with provider payment determined by a neutral third party. \nThis report discusses selected policy issues that Congress may want to consider as it assesses surprise billing proposals. The report concludes by providing an overview of how surprise billing proposals may affect some combination of insurers, providers, and consumers. An Appendix table compares two federal proposals that have gone through committee markup procedures: Title I of S. 1895 (Alexander), which went through a Senate Committee on Health, Education, Labor, and Pensions (HELP) markup session on June 26, 2019, and Title IV of the amendment in the nature of a substitute (ANS) to H.R. 2328, which went through a markup session held by the House Committee on Energy and Commerce on July 17, 2019.", "type": "CRS Report", "typeId": "REPORTS", "active": true, "formats": [ { "format": "HTML", "encoding": "utf-8", "url": "https://www.crs.gov/Reports/R46116", "sha1": "d83eaface8255afb89b4b91a6a21f3cdf94c1d49", "filename": "files/20191212_R46116_d83eaface8255afb89b4b91a6a21f3cdf94c1d49.html", "images": { "/products/Getimages/?directory=R/html/R46116_files&id=/0.png": "files/20191212_R46116_images_5dcda4e73dc55f80182436c8f9ba9cd212b34751.png" } }, { "format": "PDF", "encoding": null, "url": "https://www.crs.gov/Reports/pdf/R46116", "sha1": "5bb3f7280b50d132f922a9cdaf0d80dbcb516147", "filename": "files/20191212_R46116_5bb3f7280b50d132f922a9cdaf0d80dbcb516147.pdf", "images": {} } ], "topics": [ { "source": "IBCList", "id": 4790, "name": "Private Health Insurance" } ] }, { "summary": null, "sourceLink": "https://crsreports.congress.gov/product/details?prodcode=R46116", "source_dir": "crsreports.congress.gov", "type": "CRS Report", "formats": [ { "sha1": "31ce312c5130f035526f8491c4cc938ad5b73be6", "format": "PDF", "url": "https://crsreports.congress.gov/product/pdf/R/R46116/1", "filename": "files/2019-11-25_R46116_31ce312c5130f035526f8491c4cc938ad5b73be6.pdf" }, { "format": "HTML", "filename": "files/2019-11-25_R46116_31ce312c5130f035526f8491c4cc938ad5b73be6.html" } ], "title": "Surprise Billing in Private Health Insurance: Overview and Federal Policy Considerations", "source": "CRSReports.Congress.gov", "retrieved": "2020-09-07T12:24:48.818662", "date": "2019-11-25", "typeId": "R", "id": "R46116_1_2019-11-25", "active": true } ], "topics": [ "Domestic Social Policy", "Health Policy" ] }