II 

118TH CONGRESS 

2D SESSION S. 5535 

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 and health 

insurance issuers for practices that violate balance billing requirements, 

and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

DECEMBER 16, 2024 

Mr. MARSHALL (for himself and Mr. BENNET) introduced the following bill; 

which was read twice and referred to the Committee on Health, Education, Labor, and Pensions 

A BILL 

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 and health insurance issuers 

for practices that violate balance billing requirements, 

and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘No Surprises Act En5 forcement Act’’. 


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1 SEC. 2. INCREASING PENALTIES FOR GROUP HEALTH 

2 PLANS AND HEALTH INSURANCE ISSUERS 

3 FOR PRACTICES THAT VIOLATE BALANCE 

4 BILLING REQUIREMENTS. 

5 (a) PHSA.—Section 2723(b)(2)(C) of the Public 

6 Health Service Act (42 U.S.C. 300gg–22(b)(2)(C)) is 

7 amended— 

8 (1) in clause (i), by inserting ‘‘(or, in the case 

9 of such a failure with respect to a provision specified 

10 in clause (iv), $10,000 per failure)’’ after ‘‘$100’’; 

11 and 

12 (2) by adding at the end the following new 

13 clause: 

14 ‘‘(iv) PROVISIONS SPECIFIED.—For 

15 purposes of clause (i), the provisions speci16 fied in this clause are the following: 

17 ‘‘(I) Subparagraphs (A) and (B) 

18 of section 2799A–1(a)(1). 

19 ‘‘(II) Clauses (i), (ii), (iii), and 

20 (v) of section 2799A–1(a)(1)(C). 

21 ‘‘(III) Subparagraphs (A), (B), 

22 and (E) of section 2799A–1(b)(1). 

23 ‘‘(IV) Paragraphs (1) and (2) of 

24 section 2799A–2(a).’’. 


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1 (b) ERISA.—Section 502 of the Employee Retire2 ment Income Security Act of 1974 (29 U.S.C. 1131) is 

3 amended— 

4 (1) in subsection (a)(6), by striking ‘‘or (9)’’ 

5 and inserting ‘‘(9), or (12)’’; 

6 (2) in subsection (b)(3)— 

7 (A) by inserting ‘‘, (c)(12),’’ after ‘‘sub8 sections (c)(9)’’; and 

9 (B) by inserting ‘‘or (c)(12)’’ after ‘‘under 

10 subsection (c)(9)’’; and 

11 (3) in subsection (c), by adding at the end the 

12 following new paragraph: 

13 ‘‘(12) The Secretary may assess a civil penalty 

14 against any group health plan or health insurance issuer 

15 offering group health insurance coverage of not more than 

16 $10,000 for each violation for each individual with respect 

17 to which such plan or coverage fails to comply with one 

18 of the following provisions: 

19 ‘‘(A) Subparagraphs (A) and (B) of section 

20 716(a)(1). 

21 ‘‘(B) Clauses (i), (ii), (iii), and (v) of section 

22 716(a)(1)(C). 

23 ‘‘(C) Subparagraphs (A), (B), and (E) of sec24 tion 716(b)(1). 


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1 ‘‘(D) Paragraphs (1) and (2) of section 

2 717(a).’’. 

3 (c) IRC.—Section 4980D(b) of the Internal Revenue 

4 Code of 1986 is amended— 

5 (1) in paragraph (1), by inserting ‘‘(or, in the 

6 case of such a failure with respect to a provision 

7 specified in paragraph (4), $10,000 per failure)’’ 

8 after ‘‘$100’’; and 

9 (2) by adding at the end the following new 

10 paragraph: 

11 ‘‘(4) PROVISIONS SPECIFIED.—For purposes of 

12 paragraph (1), the provisions specified in this para13 graph are the following: 

14 ‘‘(A) Subparagraphs (A) and (B) of section 

15 9816(a)(1). 

16 ‘‘(B) Clauses (i), (ii), (iii), and (v) of sec17 tion 9816(a)(1)(C). 

18 ‘‘(C) Subparagraphs (A), (B), and (E) of 

19 section 9816(b)(1). 

20 ‘‘(D) Paragraphs (1) and (2) of section 

21 9817(a).’’. 

22 SEC. 3. ADDITIONAL PENALTIES FOR LATE PAYMENT OR 

23 NON-PAYMENT AFTER IDR ENTITY PAYMENT 

24 DETERMINATION. 

25 (a) PHSA.— 


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1 (1) EMERGENCY AND NONEMERGENCY SERV2 ICES.—Section 2799A–1(c)(6) of the Public Health 

3 Service Act (42 U.S.C. 300gg–111(c)(6)) is amend4 ed— 

5 (A) in the paragraph heading, by inserting 

6 ‘‘; PENALTY FOR LATE PAYMENT OR NON-PAY7 MENT’’ after ‘‘PAYMENT’’; 

8 (B) by striking ‘‘The total plan’’ and in9 serting the following: 

10 ‘‘(A) TIMING OF PAYMENT.—The total 

11 plan’’; and 

12 (C) by adding at the end the following new 

13 subparagraphs: 

14 ‘‘(B) NOTIFICATION.—In the case of a 

15 plan or coverage required to make a payment 

16 pursuant to a determination described in sub17 paragraph (A), such plan or coverage shall sub18 mit to the Secretary a notification of such pay19 ment as of the date such payment is made in 

20 a manner specified by the Secretary. 

21 ‘‘(C) PENALTY FOR LATE PAYMENT OR

22 NON-PAYMENT.— 

23 ‘‘(i) IN GENERAL.—In the case of a 

24 plan or coverage that has not made the re25 quired payment described in subparagraph 


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1 (A) with respect to an item or service in 

2 the time period described in such subpara3 graph, in addition to making such pay4 ment, such plan or coverage shall also pay 

5 to the nonparticipating provider or facility 

6 an amount that is three times the dif7 ference between— 

8 ‘‘(I) the initial payment (or, in 

9 the case of a notice of denial of pay10 ment, $0) described in subsection 

11 (a)(1)(C)(iv)(I) or (b)(1)(C), as appli12 cable; and 

13 ‘‘(II) the out-of-network rate (as 

14 defined in subsection (a)(3)(K)) for 

15 such item or service (less any cost 

16 sharing required to be paid by the in17 dividual receiving such item or serv18 ice). 

19 ‘‘(ii) INTEREST.—Such late payment 

20 or non-payment (as applicable) shall also 

21 be subject to interest in a manner specified 

22 by the Secretary.’’. 

23 (2) AIR AMBULANCE SERVICES.—Section 

24 2799A–2(b)(6) of the Public Health Service Act (42 

25 U.S.C. 300gg–112(b)(6)) is amended— 


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1 (A) in the paragraph heading, by inserting 

2 ‘‘; PENALTY FOR LATE PAYMENT OR NON-PAY3 MENT’’ after ‘‘PAYMENT’’; 

4 (B) by striking ‘‘The total plan’’ and in5 serting the following: 

6 ‘‘(A) TIMING OF PAYMENT.—The total 

7 plan’’; and 

8 (C) by adding at the end the following new 

9 subparagraphs: 

10 ‘‘(B) NOTIFICATION.—In the case of a 

11 plan or coverage required to make a payment 

12 pursuant to a determination described in sub13 paragraph (A), such plan or coverage shall sub14 mit to the Secretary a notification of such pay15 ment as of the date such payment is made in 

16 a manner specified by the Secretary. 

17 ‘‘(C) PENALTY FOR LATE PAYMENT OR

18 NON-PAYMENT.— 

19 ‘‘(i) IN GENERAL.—In the case of a 

20 plan or coverage that has not made the re21 quired payment described in subparagraph 

22 (A) with respect to an item or service in 

23 the time period described in such subpara24 graph, in addition to making such pay25 ment, such plan or coverage shall also pay 


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1 to the nonparticipating provider an amount 

2 that is three times the difference be3 tween— 

4 ‘‘(I) the initial payment (or, in 

5 the case of a notice of denial of pay6 ment, $0) described in subsection 

7 (a)(3)(A); and 

8 ‘‘(II) the out-of-network rate (as 

9 defined in section 2799–1(a)(3)(K)) 

10 for such item or service (less any cost 

11 sharing required to be paid by the in12 dividual receiving such item or serv13 ice). 

14 ‘‘(ii) INTEREST.—Such late payment 

15 or non-payment (as applicable) shall also 

16 be subject to interest in a manner specified 

17 by the Secretary.’’. 

18 (b) ERISA.— 

19 (1) EMERGENCY AND NONEMERGENCY SERV20 ICES.—Section 716(c)(6) of the Employee Retire21 ment Income Security Act of 1974 (29 U.S.C. 

22 1185e(c)(6)) is amended— 

23 (A) in the paragraph heading, by inserting 

24 ‘‘; PENALTY FOR LATE PAYMENT OR NON-PAY25 MENT’’ after ‘‘PAYMENT’’; 


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1 (B) by striking ‘‘The total plan’’ and in2 serting the following: 

3 ‘‘(A) TIMING OF PAYMENT.—The total 

4 plan’’; and 

5 (C) by adding at the end the following new 

6 subparagraphs: 

7 ‘‘(B) NOTIFICATION.—In the case of a 

8 plan or coverage required to make a payment 

9 pursuant to a determination described in sub10 paragraph (A), such plan or coverage shall sub11 mit to the Secretary a notification of such pay12 ment as of the date such payment is made in 

13 a manner specified by the Secretary. 

14 ‘‘(C) PENALTY FOR LATE PAYMENT OR

15 NON-PAYMENT.— 

16 ‘‘(i) IN GENERAL.—In the case of a 

17 plan or coverage that has not made the re18 quired payment described in subparagraph 

19 (A) with respect to an item or service in 

20 the time period described in such subpara21 graph, in addition to making such pay22 ment, such plan or coverage shall also pay 

23 to the nonparticipating provider or facility 

24 an amount that is three times the dif25 ference between— 


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1 ‘‘(I) the initial payment (or, in 

2 the case of a notice of denial of pay3 ment, $0) described in subsection 

4 (a)(1)(C)(iv)(I) or (b)(1)(C), as appli5 cable; and 

6 ‘‘(II) the out-of-network rate (as 

7 defined in subsection (a)(3)(K)) for 

8 such item or service (less any cost 

9 sharing required to be paid by the in10 dividual receiving such item or serv11 ice). 

12 ‘‘(ii) INTEREST.—Such late payment 

13 or non-payment (as applicable) shall also 

14 be subject to interest in a manner specified 

15 by the Secretary.’’. 

16 (2) AIR AMBULANCE SERVICES.—Section 

17 717(b)(6) of the Employee Retirement Income Secu18 rity Act of 1974 (29 U.S.C. 1185f(b)(6)) is amend19 ed— 

20 (A) in the paragraph heading, by inserting 

21 ‘‘; PENALTY FOR LATE PAYMENT OR NON-PAY22 MENT’’ after ‘‘PAYMENT’’; 

23 (B) by striking ‘‘The total plan’’ and in24 serting the following: 


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1 ‘‘(A) TIMING OF PAYMENT.—The total 

2 plan’’; and 

3 (C) by adding at the end the following new 

4 subparagraphs: 

5 ‘‘(B) NOTIFICATION.—In the case of a 

6 plan or coverage required to make a payment 

7 pursuant to a determination described in sub8 paragraph (A), such plan or coverage shall sub9 mit to the Secretary a notification of such pay10 ment as of the date such payment is made in 

11 a manner specified by the Secretary. 

12 ‘‘(C) PENALTY FOR LATE PAYMENT OR

13 NON-PAYMENT.— 

14 ‘‘(i) IN GENERAL.—In the case of a 

15 plan or coverage that has not made the re16 quired payment described in subparagraph 

17 (A) with respect to an item or service in 

18 the time period described in such subpara19 graph, in addition to making such pay20 ment, such plan or coverage shall also pay 

21 to the nonparticipating provider an amount 

22 that is three times the difference be23 tween— 

24 ‘‘(I) the initial payment (or, in 

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1 ment, $0) described in subsection 

2 (a)(3)(A); and 

3 ‘‘(II) the out-of-network rate (as 

4 defined in section 716(a)(3)(K)) for 

5 such item or service (less any cost 

6 sharing required to be paid by the in7 dividual receiving such item or serv8 ice). 

9 ‘‘(ii) INTEREST.—Such late payment 

10 or non-payment (as applicable) shall also 

11 be subject to interest in a manner specified 

12 by the Secretary.’’. 

13 (c) IRC.— 

14 (1) EMERGENCY AND NONEMERGENCY SERV15 ICES.—Section 9816(c)(6) of the Internal Revenue 

16 Code of 1986 is amended— 

17 (A) in the paragraph heading, by inserting 

18 ‘‘; PENALTY FOR LATE PAYMENT OR NON-PAY19 MENT’’ after ‘‘PAYMENT’’; 

20 (B) by striking ‘‘The total plan’’ and in21 serting the following: 

22 ‘‘(A) TIMING OF PAYMENT.—The total 

23 plan’’; and 

24 (C) by adding at the end the following new 

25 subparagraphs: 


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1 ‘‘(B) NOTIFICATION.—In the case of a 

2 plan required to make a payment pursuant to 

3 a determination described in subparagraph (A), 

4 such plan shall submit to the Secretary a notifi5 cation of such payment as of the date such pay6 ment is made in a manner specified by the Sec7 retary. 

8 ‘‘(C) PENALTY FOR LATE PAYMENT OR

9 NON-PAYMENT.— 

10 ‘‘(i) IN GENERAL.—In the case of a 

11 plan that has not made the required pay12 ment described in subparagraph (A) with 

13 respect to an item or service in the time 

14 period described in such subparagraph, in 

15 addition to making such payment, such 

16 plan shall also pay to the nonparticipating 

17 provider or facility an amount that is three 

18 times the difference between— 

19 ‘‘(I) the initial payment (or, in 

20 the case of a notice of denial of pay21 ment, $0) described in subsection 

22 (a)(1)(C)(iv)(I) or (b)(1)(C), as appli23 cable; and 

24 ‘‘(II) the out-of-network rate (as 

25 defined in subsection (a)(3)(K)) for 


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1 such item or service (less any cost 

2 sharing required to be paid by the in3 dividual receiving such item or serv4 ice). 

5 ‘‘(ii) INTEREST.—Such late payment 

6 or non-payment (as applicable) shall also 

7 be subject to interest in a manner specified 

8 by the Secretary.’’. 

9 (2) AIR AMBULANCE SERVICES.—Section 

10 9817(b)(6) of the Internal Revenue Code of 1986 is 

11 amended— 

12 (A) in the paragraph heading, by inserting 

13 ‘‘; PENALTY FOR LATE PAYMENT OR NON-PAY14 MENT’’ after ‘‘PAYMENT’’; 

15 (B) by striking ‘‘The total plan’’ and in16 serting the following: 

17 ‘‘(A) TIMING OF PAYMENT.—The total 

18 plan’’; and 

19 (C) by adding at the end the following new 

20 subparagraphs: 

21 ‘‘(B) NOTIFICATION.—In the case of a 

22 plan required to make a payment pursuant to 

23 a determination described in subparagraph (A), 

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1 ment is made in a manner specified by the Sec2 retary. 

3 ‘‘(C) PENALTY FOR LATE PAYMENT OR

4 NON-PAYMENT.— 

5 ‘‘(i) IN GENERAL.—In the case of a 

6 plan that has not made the required pay7 ment described in subparagraph (A) with 

8 respect to an item or service in the time 

9 period described in such subparagraph, in 

10 addition to making such payment, such 

11 plan shall also pay to the nonparticipating 

12 provider an amount that is three times the 

13 difference between— 

14 ‘‘(I) the initial payment (or, in 

15 the case of a notice of denial of pay16 ment, $0) described in subsection 

17 (a)(3)(A); and 

18 ‘‘(II) the out-of-network rate (as 

19 defined in section 9816(a)(3)(K)) for 

20 such item or service (less any cost 

21 sharing required to be paid by the in22 dividual receiving such item or serv23 ice). 

24 ‘‘(ii) INTEREST.—Such late payment 

25 or non-payment (as applicable) shall also 


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1 be subject to interest in a manner specified 

2 by the Secretary.’’. 

3 SEC. 4. TRANSPARENCY REPORTING REQUIREMENTS. 

4 (a) PHSA.—Section 2799A–1(a)(2)(A)(iii) of the 

5 Public Health Service Act (42 U.S.C. 300gg– 

6 111(a)(2)(A)(iii)) is amended to read as follows: 

7 ‘‘(iii) REPORTING.— 

8 ‘‘(I) INITIAL REPORTING.—Be9 ginning for 2022 and ending on De10 cember 31 of the calendar year in 

11 which the No Surprises Act Enforce12 ment Act is enacted, the Secretary 

13 shall annually submit to Congress a 

14 report on the number of plans and 

15 issuers with respect to which audits 

16 were conducted during such year pur17 suant to this subparagraph. 

18 ‘‘(II) SUBSEQUENT REPORT19 ING.— 

20 ‘‘(aa) IN GENERAL.—With 

21 respect to the first calendar year 

22 following the date of the enact23 ment of the No Surprises Act 

24 Enforcement Act, not later than 

25 February 1 of such year, and 


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1 every 6 months thereafter, the 

2 Secretary, in coordination with 

3 the Secretary of Labor and the 

4 Secretary of the Treasury, shall 

5 submit to the Committee on 

6 Ways and Means, the Committee 

7 on Energy and Commerce, and 

8 the Committee on Education and 

9 the Workforce of the House of 

10 Representatives, and the Com11 mittee on Finance and the Com12 mittee on Health, Education, 

13 Labor and Pensions of the Sen14 ate, a report on any audits con15 ducted pursuant to this subpara16 graph during the applicable re17 porting period, and any enforce18 ment actions taken during such 

19 period in accordance with the 

20 provisions of this part, includ21 ing— 

22 ‘‘(AA) the total number 

23 of audits conducted under 

24 this subparagraph; 


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1 ‘‘(BB) the number of 

2 audits conducted pursuant 

3 to clause (ii)(I); 

4 ‘‘(CC) the number of 

5 complaints submitted by 

6 providers and by partici7 pants, beneficiaries, and en8 rollees with respect to a vio9 lation of this part; 

10 ‘‘(DD) any enforcement 

11 actions taken as a result of 

12 a complaint submitted by a 

13 provider or by a participant, 

14 a beneficiary, or an enrollee, 

15 with respect to the provi16 sions of this part; 

17 ‘‘(EE) the total number 

18 of, and the aggregate dollar 

19 amount of, any civil mone20 tary penalties issued in ac21 cordance with this part; 

22 ‘‘(FF) a summary of 

23 any non-monetary corrective 

24 action taken against a group 

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1 ance issuer offering group or 

2 individual health insurance 

3 coverage for a violation of 

4 this part; and 

5 ‘‘(GG) a description of 

6 the 3 most commonly re7 ported violations of this 

8 part. 

9 ‘‘(bb) APPLICABLE REPORT10 ING PERIOD.—For purposes of 

11 this subclause, the term ‘applica12 ble reporting period’ means the 6 

13 month period prior to each report 

14 submitted under item (aa).’’. 

15 (b) IRC.—Section 9816(a)(2)(A)(iii) of the Internal 

16 Revenue Code of 1986 is amended to read as follows: 

17 ‘‘(iii) REPORTING.— 

18 ‘‘(I) INITIAL REPORTING.—Be19 ginning for 2022 and ending on De20 cember 31 of the calendar year in 

21 which the No Surprises Act Enforce22 ment Act is enacted, the Secretary 

23 shall annually submit to Congress a 

24 report on the number of plans with 

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1 ducted during such year pursuant to 

2 this subparagraph. 

3 ‘‘(II) SUBSEQUENT REPORT4 ING.— 

5 ‘‘(aa) IN GENERAL.—With 

6 respect to the first calendar year 

7 following the date of the enact8 ment of the No Surprises Act 

9 Enforcement Act, not later than 

10 February 1 of such year, and 

11 every 6 months thereafter, the 

12 Secretary, in coordination with 

13 the Secretary of Labor and the 

14 Secretary of Health and Human 

15 Services, shall submit to the 

16 Committee on Ways and Means, 

17 the Committee on Energy and 

18 Commerce, and the Committee 

19 on Education and the Workforce 

20 of the House of Representatives, 

21 and the Committee on Finance 

22 and the Committee on Health, 

23 Education, Labor and Pensions 

24 of the Senate, a report on audits 

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1 paragraph during the applicable 

2 reporting period, and any en3 forcement actions taken during 

4 such period in accordance with 

5 the provisions of an applicable 

6 section, including— 

7 ‘‘(AA) the total number 

8 of audits conducted under 

9 this subparagraph; 

10 ‘‘(BB) the number of 

11 audits conducted pursuant 

12 to clause (ii)(I); 

13 ‘‘(CC) the number of 

14 complaints submitted by 

15 providers and by partici16 pants and beneficiaries with 

17 respect to a violation of an 

18 applicable section; 

19 ‘‘(DD) any enforcement 

20 actions taken pursuant to a 

21 violation of an applicable 

22 section; 

23 ‘‘(EE) the total number 

24 of, and the aggregate dollar 

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1 tary penalties issued in ac2 cordance with an applicable 

3 section; 

4 ‘‘(FF) a summary of 

5 any non-monetary corrective 

6 action taken against a group 

7 health plan for a violation of 

8 an applicable section; and 

9 ‘‘(GG) a description of 

10 the 3 most commonly re11 ported violations of an appli12 cable section. 

13 ‘‘(bb) DEFINITIONS.—In 

14 this subclause: 

15 ‘‘(AA) APPLICABLE RE16 PORTING PERIOD.—The 

17 term ‘applicable reporting 

18 period’ means the 6 month 

19 period prior to each report 

20 submitted under item (aa). 

21 ‘‘(BB) APPLICABLE

22 SECTION.—The term ‘appli23 cable section’ means this 


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1 section and each of sections 

2 9817 through 9825.’’. 

Æ 


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