United StatesHealth plans would use a federal formula for certain surprise bills
Health plans would have 30 days after providers send surprise medical bills to pay their share when the federal payment formula applies.
What it does
For certain surprise bills for care from 2028 onward, health plans would pay using a federal formula within 30 days after providers send bills. Federal dispute reviews would cover only earlier care.
For comparable care in the same specialty and geographic area, the 2028 formula would generally use a plan’s middle 2019 contract price, adjusted for inflation. Later amounts would also track inflation.
Coverage not offered in 2019 would use a federal method from 2028. Plans first gaining enough price data in 2028 or later would use that year’s starting rates without an initial inflation increase.
Federal officials would set payment calculation rules within 180 days after the bill becomes law. Courts could not review the calculation method.
Starting in 2028, federal officials would audit claims from at least 25 health plans or insurers each year and publish the findings.
Argument forA 30-day payment deadline could help medical providers plan their finances when their bills fall under the federal payment formula.
Argument againstProviders disputing the payment formula could lack a court remedy because judges would be barred from reviewing the calculation method.
More detail
Health plans would pay their share within 30 days after providers send bills. This would cover certain surprise medical bills under group and individual coverage, including air ambulance bills. The 30-day deadline would apply when the federal formula sets the payment rate. The formula would apply to covered care on or after January 1, 2028. Federal dispute reviews would cover care through December 31, 2027.
Plans would include patients’ shares and expected payment adjustments in contract prices. Each plan would use its own prices for comparable care in the same specialty and geographic area. The usual calculation would count only providers who delivered that care in the plan year containing January 31, 2019. The 2028 calculation would adjust January 31, 2019, prices for inflation over 2019–2027. Yearly inflation adjustments would follow from 2029.
Federal rules would set starting rates for coverage not offered in 2019. These exceptions would cover group and individual health coverage. Coverage not offered in 2019 would then receive yearly inflation adjustments. Plans first gaining enough rate data in 2028 or later would use prices from that year’s first day, without the initial inflation increase. The special rules for coverage not offered in 2019 would apply from 2028.
Federal officials would set the payment calculation rules. The rules would cover group health plans and insurers offering group or individual coverage. Courts could not review the method used to calculate payment amounts. Officials could use a faster rulemaking process. Officials would have 180 days after the bill becomes law to prepare rules for care provided in 2028 and later.
Federal officials would audit sampled claims and publish their findings. The sample rules would cover group health plans and insurers offering group or individual coverage. Each annual sample would draw from at least 25 plans or insurers. The sample requirement and public reporting would apply beginning with 2028.
Where do you stand?
Choose your position
Tell your reps
Take a position to see your representatives and ways to contact them.
Where it stands
- Introduced
- Passed House
- Passed Senate
- To President
- Became Law
Looking ahead
No hearings or votes scheduled.
History
- 2026
- Oct 9Introduced in HouseLatest
- Oct 9Referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.Introduced
Healthcare