S. 2420

119th CONGRESS 1st Session

To amend title XXVII of the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code of 1986 to increase penalties for group health plans, health insurance issuers, and nonparticipating providers or facilities for practices that violate balance billing requirements, and for other purposes.

IN THE SENATE OF THE UNITED STATES · July 23, 2025 · Sponsor: Mr. Marshall · Committee: Committee on Health, Education, Labor, and Pensions

Table of contents

• S. 2420
  • SEC. 1. Short title
  • SEC. 2. Increasing penalties for group health plans and health insurance issuers for practices that violate balance billing requirements
  • SEC. 3. Additional penalties for late payment or non-payment after IDR entity payment determination
  • SEC. 4. Transparency reporting requirements

SEC. 1. Short title

• This Act may be cited as the No Surprises Act Enforcement Act.

SEC. 2. Increasing penalties for group health plans and health insurance issuers for practices that violate balance billing requirements

• (a) PHSA
  • Section 2723(b)(2)(C) of the Public Health Service Act () is amended— 42 U.S.C. 300gg–22(b)(2)(C)
    • in clause (i), by inserting after ; and
      • (iv) For purposes of clause (i), the provisions specified in this clause are the following:
      • Subparagraphs (A) and (B) of section 2799A–1(a)(1).
      • Clauses (i), (ii), (iii), and (v) of section 2799A–1(a)(1)(C).
      • Subparagraphs (A), (B), and (E) of section 2799A–1(b)(1).
      • Paragraphs (1) and (2) of section 2799A–2(a).
    • by adding at the end the following new clause:
• (b) ERISA
  • Section 502 of the Employee Retirement Income Security Act of 1974 () is amended— 29 U.S.C. 1131
    • in subsection (a)(6), by striking or (9)and inserting (9), or (12);
    • in subsection (b)(3)—
      • by inserting after ; and
        • The Secretary may assess a civil penalty against any group health plan or health insurance issuer offering group health insurance coverage of not more than $10,000 per violation for each individual with respect to which such plan or coverage fails to comply with one of the following provisions:
          • Subparagraphs (A) and (B) of section 716(a)(1).
          • Clauses (i), (ii), (iii), and (v) of section 716(a)(1)(C).
          • Subparagraphs (A), (B), and (E) of section 716(b)(1).
          • Paragraphs (1) and (2) of section 717(a).
    • in subsection (c), by adding at the end the following new paragraph:
• (c) IRC
  • of the Internal Revenue Code of 1986 is amended— Section 4980D(b)
    • in paragraph (1), by inserting after ; and
      • (4) Provisions specified
        • For purposes of paragraph (1), the provisions specified in this paragraph are the following:
          • Subparagraphs (A) and (B) of section 9816(a)(1).
          • Clauses (i), (ii), (iii), and (v) of section 9816(a)(1)(C).
          • Subparagraphs (A), (B), and (E) of section 9816(b)(1).
          • Paragraphs (1) and (2) of section 9817(a).
    • by adding at the end the following new paragraph:

SEC. 3. Additional penalties for late payment or non-payment after IDR entity payment determination

• (a) PHSA
  • (1) Emergency and nonemergency services
    • Section 2799A–1(c)(6) of the Public Health Service Act () is amended— 42 U.S.C. 300gg–111(c)(6)
      • in the paragraph heading, by inserting after ;
      • by striking and inserting the following:
        • (A) Timing of payment
          • The total plan
      • in subparagraph (A), as so inserted, by adding at the end the following new sentence: ; and In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan or coverage the difference between such determination and such sum not later than 30 days after the date on which such determination is made.
        • (B) Notification
          • In the case of a plan or coverage, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or coverage or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary.
        • (C) Penalty for late payment or non-payment
          • (i) In the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between—
          • the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(1)(C)(iv)(I) or (b)(1)(C), as applicable; and
          • the out-of-network rate (as defined in subsection (a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service).
          • (ii) A late payment penalty under clause (i) shall also be subject to interest in a manner specified by the Secretary.
      • by adding at the end the following new subparagraphs:
  • (2) Air ambulance services
    • Section 2799A–2(b)(6) of the Public Health Service Act () is amended— 42 U.S.C. 300gg–112(b)(6)
      • in the paragraph heading, by inserting after ;
      • by striking and inserting the following:
        • (A) Timing of payment
          • The total plan
      • in subparagraph (A), as so inserted, by adding at the end the following new sentence: ; and In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan or coverage the difference between such determination and such sum not later than 30 days after the date on which such determination is made.
        • (B) Notification
          • In the case of a plan or coverage, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or coverage or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary.
        • (C) Penalty for late payment or non-payment
          • (i) In the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between—
          • the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(3)(A); and
          • the out-of-network rate (as defined in section 2799–1(a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service).
          • (ii) A late payment penalty under clause (i) shall also be subject to interest in a manner specified by the Secretary.
      • by adding at the end the following new subparagraphs:
• (b) ERISA
  • (1) Emergency and nonemergency services
    • Section 716(c)(6) of the Employee Retirement Income Security Act of 1974 () is amended— 29 U.S.C. 1185e(c)(6)
      • in the paragraph heading, by inserting after ;
      • by striking and inserting the following:
        • (A) Timing of payment
          • The total plan
      • in subparagraph (A), as so inserted, by adding at the end the following new sentence: ; and In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan or coverage the difference between such determination and such sum not later than 30 days after the date on which such determination is made.
        • (B) Notification
          • In the case of a plan or coverage, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or coverage or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary.
        • (C) Penalty for late payment or non-payment
          • (i) In the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between—
          • the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(1)(C)(iv)(I) or (b)(1)(C), as applicable; and
          • the out-of-network rate (as defined in subsection (a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service).
          • (ii) A late payment penalty under clause (i) shall also be subject to interest in a manner specified by the Secretary.
      • by adding at the end the following new subparagraphs:
  • (2) Air ambulance services
    • Section 717(b)(6) of the Employee Retirement Income Security Act of 1974 () is amended— 29 U.S.C. 1185f(b)(6)
      • in the paragraph heading, by inserting after ;
      • by striking and inserting the following:
        • (A) Timing of payment
          • The total plan
      • in subparagraph (A), as so inserted, by adding at the end the following new sentence: ; and In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan or coverage the difference between such determination and such sum not later than 30 days after the date on which such determination is made.
        • (B) Notification
          • In the case of a plan or coverage, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or coverage or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary.
        • (C) Penalty for late payment or non-payment
          • (i) In the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between—
          • the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(3)(A); and
          • the out-of-network rate (as defined in section 716(a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service).
          • (ii) A late payment penalty under clause (i) shall also be subject to interest in a manner specified by the Secretary.
      • by adding at the end the following new subparagraphs:
• (c) IRC
  • (1) Emergency and nonemergency services
    • of the Internal Revenue Code of 1986 is amended— Section 9816(c)(6)
      • in the paragraph heading, by inserting after ;
      • by striking and inserting the following:
        • (A) Timing of payment
          • The total plan
      • in subparagraph (A), as so inserted, by adding at the end the following new sentence: ; and In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan the difference between such determination and such sum not later than 30 days after the date on which such determination is made.
        • (B) Notification
          • In the case of a plan, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary.
        • (C) Penalty for late payment or non-payment
          • (i) In the case of a plan, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan (as applicable) an amount that is three times the difference between—
          • the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(1)(C)(iv)(I) or (b)(1)(C), as applicable; and
          • the out-of-network rate (as defined in subsection (a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service).
          • (ii) A late payment penalty under clause (i) shall also be subject to interest in a manner specified by the Secretary.
      • by adding at the end the following new subparagraphs:
  • (2) Air ambulance services
    • of the Internal Revenue Code of 1986 is amended— Section 9817(b)(6)
      • in the paragraph heading, by inserting after ;
      • by striking and inserting the following:
        • (A) Timing of payment
          • The total plan
      • in subparagraph (A), as so inserted, by adding at the end the following new sentence: ; and In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan the difference between such determination and such sum not later than 30 days after the date on which such determination is made.
        • (B) Notification
          • In the case of a plan, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary.
        • (C) Penalty for late payment or non-payment
          • (i) In the case of a plan, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan (as applicable) an amount that is three times the difference between—
          • the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(3)(A); and
          • the out-of-network rate (as defined in section 9816(a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service).
          • (ii) A late payment penalty under clause (i) shall also be subject to interest in a manner specified by the Secretary.
      • by adding at the end the following new subparagraphs:

SEC. 4. Transparency reporting requirements

• (a) PHSA
  • Section 2799A–1(a)(2)(A)(iii) of the Public Health Service Act () is amended to read as follows: 42 U.S.C. 300gg–111(a)(2)(A)(iii)
    • (iii) Reporting
      • Beginning for 2022 and ending on December 31 of the calendar year in which the is enacted, the Secretary shall annually submit to Congress a report on the number of plans and issuers with respect to which audits were conducted during such year pursuant to this subparagraph.
      • With respect to the first calendar year following the date of the enactment of the , not later than February 1 of such year, and every 6 months thereafter, the Secretary, in coordination with the Secretary of Labor and the Secretary of the Treasury, shall submit to the Committee on Ways and Means, the Committee on Energy and Commerce, and the Committee on Education and the Workforce of the House of Representatives, and the Committee on Finance and the Committee on Health, Education, Labor and Pensions of the Senate, a report on any audits conducted pursuant to this subparagraph during the applicable reporting period, and any enforcement actions taken during such period in accordance with the provisions of this part, including—
      • the total number of audits conducted under this subparagraph;
      • the number of audits conducted pursuant to clause (ii)(I);
      • the number of complaints submitted by providers and by participants, beneficiaries, and enrollees with respect to a violation of this part;
      • any enforcement actions taken as a result of a complaint submitted by a provider or by a participant, a beneficiary, or an enrollee, with respect to the provisions of this part;
      • the total number of, and the aggregate dollar amount of, any civil monetary penalties issued in accordance with this part;
      • a summary of any non-monetary corrective action taken against a group health plan or health insurance issuer offering group or individual health insurance coverage for a violation of this part; and
      • a description of the 3 most commonly reported violations of this part.
      • For purposes of this subclause, the term means the 6 month period prior to each report submitted under item (aa). applicable reporting period
• (b) IRC
  • of the Internal Revenue Code of 1986 is amended to read as follows: Section 9816(a)(2)(A)(iii)
    • (iii) Reporting
      • Beginning for 2022 and ending on December 31 of the calendar year in which the is enacted, the Secretary shall annually submit to Congress a report on the number of plans with respect to which audits were conducted during such year pursuant to this subparagraph.
      • With respect to the first calendar year following the date of the enactment of the , not later than February 1 of such year, and every 6 months thereafter, the Secretary, in coordination with the Secretary of Labor and the Secretary of Health and Human Services, shall submit to the Committee on Ways and Means, the Committee on Energy and Commerce, and the Committee on Education and Workforce of the House of Representatives, and the Committee on Finance and the Committee on Health, Education, Labor and Pensions of the Senate, a report on audits performed pursuant to this subparagraph during the applicable reporting period, and any enforcement actions taken during such period in accordance with the provisions of an applicable section, including—
      • the total number of audits conducted under this subparagraph;
      • the number of audits conducted pursuant to clause (ii)(I);
      • the number of complaints submitted by providers and by participants and beneficiaries with respect to a violation of an applicable section;
      • any enforcement actions taken pursuant to a violation of an applicable section;
      • the total number of, and the aggregate dollar amount of, any civil monetary penalties issued in accordance with an applicable section;
      • a summary of any non-monetary corrective action taken against a group health plan for a violation of an applicable section; and
      • a description of the 3 most commonly reported violations of an applicable section.
      • In this subclause:
      • The term means the 6 month period prior to each report submitted under item (aa). applicable reporting period
      • The term means this section and each of sections 9817 through 9825. applicable section