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1 1 (April 15, 2019)

handle is hein.crs/govziw0001 and id is 1 raw text is: Congressional_ ~.Research Service Balance Billing: Current Legal Landscape and Proposed Federal Solutions April 15, 2019 As several recent reports have publicized, some patients covered by private health insurance continue to receive surprise-and often surprisingly high-medical bills resulting from treatment by out-of-network providers. Through a practice known as balance billing, an out-of-network provider bills the patient for charges that exceed her health insurance plan's payment for a covered service. These bills are often surprising to the patients because they had received out-of-network care involuntarily or unknowingly- some were receiving emergency care and therefore had no choice in providers, while others unknowingly received care from such providers at an in-network facility. Several states have enacted legislation that would prohibit providers from balance billing the patients while also addressing the key underlying question-who should pay for the care provided and how much to pay. A number of proposals introduced in the 115th Congress aimed to address the issue at the federal level and additional proposals may be forthcoming in the 116th Congress. This Sidebar provides an overview of balance billing, the relevant state and federal laws that currently govern this practice, and relevant federal legislation that has been proposed so far. The Sidebar concludes by highlighting several legal issues for Congress's consideration as it continues to study this issue. Overview of Balance Billing Typically, a patient with private insurance receives care from in-network health care providers who have contracted with the health plan and accepted the plan's negotiated payment rate. As part of the contract, the provider agrees not to charge the plan or the patient more than the negotiated rate. The plan, in turn, pays the negotiated rate with the patient contributing to a cost-sharing amount (usually in the form of coinsurance or a co-payment) for the specific health care services received. In contrast, an out-of-network provider has no contract with the health plan and thus no negotiated payment rate. When an out-of- network provider treats a patient, the health plan may pay only an amount it determines is fair or may not pay any charges if the plan does not offer out-of-network benefits. When this occurs, the out-of-network provider may balance bill the consumer by billing her for the difference between what her health plan paid and what the provider charged. From the perspective of the patients, balance bills can be seen as unfair because, as noted above, they may have received out-of-network care involuntarily or unknowingly. From the perspective of the providers, Congressional Research Service https://crsreports.congress.gov LSB10284 CRS Legal Sidebar Prepared for Members and Committees of Congress

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