SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘No Surprises Act En-
forcement 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 (42 U.S.C. 300gg–22(b)(2)(C)) is 
amended— 
(1) in clause (i), by inserting ‘‘(or, in the case 
of such a failure with respect to a provision specified 
in clause (iv), $10,000 for each failure)’’ after 
‘‘$100 for each day’’; and 
(2) by adding at the end the following new 
clause: 
‘‘(iv) PROVISIONS
SPECIFIED.—For 
purposes of clause (i), the provisions speci-
fied in this clause are the following: 
‘‘(I) Subparagraphs (A) and (B) 
of section 2799A–1(a)(1). 
‘‘(II) Clauses (i), (ii), (iii), and 
(v) of section 2799A–1(a)(1)(C). 
‘‘(III) Subparagraphs (A), (B), 
and (E) of section 2799A–1(b)(1). 
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‘‘(IV) Paragraphs (1) and (2) of 
section 2799A–2(a).’’. 
(b) ERISA.—Section 502 of the Employee Retire-
ment Income Security Act of 1974 (29 U.S.C. 1131) is 
amended— 
(1) in subsection (a)(6), by striking ‘‘or (9)’’ 
and inserting ‘‘(9), or (12)’’; 
(2) in subsection (b)(3)— 
(A) by inserting ‘‘, (c)(12),’’ after ‘‘sub-
sections (c)(9)’’; and 
(B) by inserting ‘‘or (c)(12)’’ after ‘‘under 
subsection (c)(9)’’; and 
(3) in subsection (c), by adding at the end the 
following new paragraph: 
‘‘(12) 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 for each individual with respect to which such 
plan or coverage fails to comply with one of the following 
provisions: 
‘‘(A) Subparagraphs (A) and (B) of section 
716(a)(1). 
‘‘(B) Clauses (i), (ii), (iii), and (v) of section 
716(a)(1)(C). 
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‘‘(C) Subparagraphs (A), (B), and (E) of sec-
tion 716(b)(1). 
‘‘(D) Paragraphs (1) and (2) of section 
717(a).’’. 
(c) IRC.—Section 4980D(b) of the Internal Revenue 
Code of 1986 is amended— 
(1) in paragraph (1), by inserting ‘‘(or, in the 
case of such a failure with respect to a provision 
specified in paragraph (4), $10,000 for each fail-
ure)’’ after ‘‘$100 for each day in the noncompliance 
period’’; and 
(2) by adding at the end the following new 
paragraph: 
‘‘(4) PROVISIONS SPECIFIED.—For purposes of 
paragraph (1), the provisions specified in this para-
graph are the following: 
‘‘(A) Subparagraphs (A) and (B) of section 
9816(a)(1). 
‘‘(B) Clauses (i), (ii), (iii), and (v) of sec-
tion 9816(a)(1)(C). 
‘‘(C) Subparagraphs (A), (B), and (E) of 
section 9816(b)(1). 
‘‘(D) Paragraphs (1) and (2) of section 
9817(a).’’. 
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SEC. 3. ADDITIONAL PENALTIES FOR LATE PAYMENT OR 
NON-PAYMENT AFTER IDR ENTITY PAYMENT 
DETERMINATION. 
(a) PHSA.— 
(1) EMERGENCY
AND
NONEMERGENCY
SERV-
ICES.—Section 2799A–1(c)(6) of the Public Health 
Service Act (42 U.S.C. 300gg–111(c)(6)) is amend-
ed— 
(A) in the paragraph heading, by inserting 
‘‘; PENALTY FOR LATE PAYMENT OR NON-PAY-
MENT’’ after ‘‘PAYMENT’’; 
(B) by striking ‘‘The total plan’’ and in-
serting the following: 
‘‘(A) TIMING
OF
PAYMENT.—The total 
plan’’; 
(C) in subparagraph (A), as so inserted, by 
adding at the end the following new sentence: 
‘‘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 re-
quired to be paid by the individual receiving 
such item or service, the nonparticipating pro-
vider or facility furnishing such item or service 
shall pay to such plan or coverage the dif-
ference between such determination and such 
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sum not later than 30 days after the date on 
which such determination is made.’’; and 
(D) by adding at the end the following new 
subparagraphs: 
‘‘(B) NOTIFICATION.—In the case of a 
plan or coverage, or a nonparticipating provider 
or facility, required to make a payment pursu-
ant to a determination described in subpara-
graph (A), such plan or coverage or nonpartici-
pating 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 GENERAL.—In the case of a 
plan or coverage, or a nonparticipating 
provider or facility, that has not made the 
required payment described in subpara-
graph (A) with respect to an item or serv-
ice in the time period described in such 
subparagraph, in addition to making such 
payment, such plan or coverage or non-
participating provider or facility shall also 
pay to the nonparticipating provider or fa-
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cility or plan or coverage (as applicable) an 
amount that is three times the difference 
between— 
‘‘(I) the initial payment (or, in 
the case of a notice of denial of pay-
ment, $0) described in subsection 
(a)(1)(C)(iv)(I) or (b)(1)(C), as appli-
cable; and 
‘‘(II) 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 in-
dividual receiving such item or serv-
ice). 
‘‘(ii) INTEREST.—Any amount owed 
under clause (i) shall be subject to interest 
in a manner specified by the Secretary.’’. 
(2) 
AIR
AMBULANCE
SERVICES.—Section 
2799A–2(b)(6) of the Public Health Service Act (42 
U.S.C. 300gg–112(b)(6)) is amended— 
(A) in the paragraph heading, by inserting 
‘‘; PENALTY FOR LATE PAYMENT OR NON-PAY-
MENT’’ after ‘‘PAYMENT’’; 
(B) by striking ‘‘The total plan’’ and in-
serting the following: 
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‘‘(A) TIMING
OF
PAYMENT.—The total 
plan’’; 
(C) in subparagraph (A), as so inserted, by 
adding at the end the following new sentence: 
‘‘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 re-
quired to be paid by the individual receiving 
such item or service, the nonparticipating pro-
vider or facility furnishing such item or service 
shall pay to such plan or coverage the dif-
ference between such determination and such 
sum not later than 30 days after the date on 
which such determination is made.’’; and 
(D) by adding at the end the following new 
subparagraphs: 
‘‘(B) NOTIFICATION.—In the case of a 
plan or coverage, or a nonparticipating provider 
or facility, required to make a payment pursu-
ant to a determination described in subpara-
graph (A), such plan or coverage or nonpartici-
pating 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. 
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‘‘(C) PENALTY
FOR
LATE
PAYMENT
OR 
NON-PAYMENT.— 
‘‘(i) IN GENERAL.—In the case of a 
plan or coverage, or a nonparticipating 
provider or facility, that has not made the 
required payment described in subpara-
graph (A) with respect to an item or serv-
ice in the time period described in such 
subparagraph, in addition to making such 
payment, such plan or coverage or non-
participating provider or facility shall also 
pay to the nonparticipating provider or fa-
cility or plan or coverage (as applicable) an 
amount that is three times the difference 
between— 
‘‘(I) the initial payment (or, in 
the case of a notice of denial of pay-
ment, $0) described in subsection 
(a)(3)(A); and 
‘‘(II) 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 in-
dividual receiving such item or serv-
ice). 
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‘‘(ii) INTEREST.—Any amount owed 
under clause (i) shall be subject to interest 
in a manner specified by the Secretary.’’. 
(b) ERISA.— 
(1) EMERGENCY
AND
NONEMERGENCY
SERV-
ICES.—Section 716(c)(6) of the Employee Retire-
ment Income Security Act of 1974 (29 U.S.C. 
1185e(c)(6)) is amended— 
(A) in the paragraph heading, by inserting 
‘‘; PENALTY FOR LATE PAYMENT OR NON-PAY-
MENT’’ after ‘‘PAYMENT’’; 
(B) by striking ‘‘The total plan’’ and in-
serting the following: 
‘‘(A) TIMING
OF
PAYMENT.—The total 
plan’’; 
(C) in subparagraph (A), as so inserted, by 
adding at the end the following new sentence: 
‘‘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 re-
quired to be paid by the individual receiving 
such item or service, the nonparticipating pro-
vider or facility furnishing such item or service 
shall pay to such plan or coverage the dif-
ference between such determination and such 
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sum not later than 30 days after the date on 
which such determination is made.’’; and 
(D) by adding at the end the following new 
subparagraphs: 
‘‘(B) NOTIFICATION.—In the case of a 
plan or coverage, or a nonparticipating provider 
or facility, required to make a payment pursu-
ant to a determination described in subpara-
graph (A), such plan or coverage or nonpartici-
pating 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 GENERAL.—In the case of a 
plan or coverage, or a nonparticipating 
provider or facility, that has not made the 
required payment described in subpara-
graph (A) with respect to an item or serv-
ice in the time period described in such 
subparagraph, in addition to making such 
payment, such plan or coverage or non-
participating provider or facility shall also 
pay to the nonparticipating provider or fa-
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cility or plan or coverage (as applicable) an 
amount that is three times the difference 
between— 
‘‘(I) the initial payment (or, in 
the case of a notice of denial of pay-
ment, $0) described in subsection 
(a)(1)(C)(iv)(I) or (b)(1)(C), as appli-
cable; and 
‘‘(II) 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 in-
dividual receiving such item or serv-
ice). 
‘‘(ii) INTEREST.—Any amount owed 
under clause (i) shall be subject to interest 
in a manner specified by the Secretary.’’. 
(2) 
AIR
AMBULANCE
SERVICES.—Section 
717(b)(6) of the Employee Retirement Income Secu-
rity Act of 1974 (29 U.S.C. 1185f(b)(6)) is amend-
ed— 
(A) in the paragraph heading, by inserting 
‘‘; PENALTY FOR LATE PAYMENT OR NON-PAY-
MENT’’ after ‘‘PAYMENT’’; 
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(B) by striking ‘‘The total plan’’ and in-
serting the following: 
‘‘(A) TIMING
OF
PAYMENT.—The total 
plan’’; 
(C) in subparagraph (A), as so inserted, by 
adding at the end the following new sentence: 
‘‘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 re-
quired to be paid by the individual receiving 
such item or service, the nonparticipating pro-
vider or facility furnishing such item or service 
shall pay to such plan or coverage the dif-
ference between such determination and such 
sum not later than 30 days after the date on 
which such determination is made.’’; and 
(D) by adding at the end the following new 
subparagraphs: 
‘‘(B) NOTIFICATION.—In the case of a 
plan or coverage, or a nonparticipating provider 
or facility, required to make a payment pursu-
ant to a determination described in subpara-
graph (A), such plan or coverage or nonpartici-
pating provider or facility shall submit to the 
Secretary a notification of such payment as of 
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the date such payment is made in a manner 
specified by the Secretary. 
‘‘(C) PENALTY
FOR
LATE
PAYMENT
OR 
NON-PAYMENT.— 
‘‘(i) IN GENERAL.—In the case of a 
plan or coverage, or a nonparticipating 
provider or facility, that has not made the 
required payment described in subpara-
graph (A) with respect to an item or serv-
ice in the time period described in such 
subparagraph, in addition to making such 
payment, such plan or coverage or non-
participating provider or facility shall also 
pay to the nonparticipating provider or fa-
cility or plan or coverage (as applicable) an 
amount that is three times the difference 
between— 
‘‘(I) the initial payment (or, in 
the case of a notice of denial of pay-
ment, $0) described in subsection 
(a)(3)(A); and 
‘‘(II) 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 in-
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