This bill amends Title XXVII of the Public Health Service Act to protect people who experience a miscarriage or stillbirth from unexpectedly large out-of-pocket bills for prenatal services that were included in a bundled payment for birth-related care. It targets situations where the insurer would have paid a bundled amount for delivery and associated prenatal care but, because the pregnancy ends before delivery, the bundle is not paid and the carrier bills the patient separately.
The change matters because many modern payment arrangements bundle prenatal and delivery services. When a bundle falls away after pregnancy loss, patients can face retroactive cost-sharing for earlier prenatal care; the bill prevents carriers from imposing cost-sharing on those prior prenatal services that exceeds what the patient would have paid under the full bundled payment scenario.
That shifts financial risk and creates operational requirements for plans, administrators, and provider billing systems.
At a Glance
What It Does
The bill adds a new Section 2730 to Title XXVII that forbids plans and carriers from charging more in patient cost-sharing for prenatal services furnished before a miscarriage or stillbirth than the cost-sharing that would have applied to the whole bundled birth payment if delivery had occurred. The text explicitly covers deductibles, coinsurance, and copayments.
Who It Affects
Applies to group health plans and to group and individual health insurance coverage regulated under Title XXVII — which encompasses both insured market plans and many employer-sponsored products. Providers, plan sponsors (including self-funded employers), third-party administrators, and state and federal regulators will see operational impacts.
Why It Matters
This fills a narrow but recurring gap in bundled-payment workflows that can produce steep retrospective patient bills after pregnancy loss. For compliance officers and revenue-cycle managers, it creates a new rule that will require claim re-pricing, revised provider contracts, and updated member communications.
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What This Bill Actually Does
The bill inserts a single, targeted protection into federal insurance rules: when a health plan structures birth-related care as a bundled payment that includes prenatal services, and that bundle ultimately is not paid because the pregnancy ends in a miscarriage or stillbirth, the plan cannot hold the patient responsible for more cost-sharing for the prenatal services already delivered than they would have owed under the prospective bundle. That is, plans must not retroactively bill patients an amount larger than the bundle’s patient cost-share would have been.
Operationally, the rule applies at the time claims are adjudicated: insurers will need to detect when a pregnancy has ended before delivery, identify prenatal services furnished prior to that event, and ensure patient liability for those services is capped at the bundle-equivalent amount. The statute names common examples (imaging tests, office visits) to make clear it covers routine prenatal care, and it lists common forms of cost-sharing — deductibles, coinsurance, and copays — as within the prohibition.Because the protection ties patient liability to a hypothetical bundled charge that never paid out, plans and providers must reconcile three moving parts: the contractual terms of any provider bundled-pay arrangement, the claims history of prenatal services for the individual, and the member’s expected share under the bundle.
That reconciliation will require claim reprocessing rules, system flags to identify pregnancy loss events, and likely changes to provider contracts that currently assume the bundle will always be applied at delivery.The bill takes effect for plan years beginning on or after January 1, 2027, giving plans and administrators time to update systems and agreements. It does not create specific new payment to providers or designate an enforcement mechanism beyond the underlying Title XXVII framework; enforcement pathways will rely on existing authorities that apply to covered plans and policies.
The Five Things You Need to Know
The bill adds Section 2730 to Title XXVII of the Public Health Service Act to address prenatal cost-sharing when a bundled birth payment is not made due to miscarriage or stillbirth.
It applies to both group health plans and to group or individual health insurance coverage governed by Title XXVII.
The prohibition covers patient cost-sharing forms specifically listed in the text: deductibles, coinsurance, and copayments.
The cap applies only to prenatal services furnished prior to the miscarriage or stillbirth and limits liability to the amount that would have applied to the full bundled payment had delivery occurred.
The amendment is effective for plan years beginning on or after January 1, 2027.
Section-by-Section Breakdown
Every bill we cover gets an analysis of its key sections.
Short title
Sets the Act's short title as the "Caring for Grieving Families Act of 2025." This is a formal label only; it creates no substantive rights or duties beyond naming the legislation.
Adds Section 2730 — caps cost-sharing for prenatal services when a birth bundle isn't paid
The core operative language appears here. It identifies the covered plans (group health plans and group/individual insurance under Title XXVII) and creates a rule triggered when a plan has bundled items and services relating to birth that include prenatal services, but the bundled payment is not paid because of a miscarriage or stillbirth. The provision requires plans to ensure that any cost sharing imposed on prenatal services furnished prior to that loss does not exceed the amount the patient would have owed under the bundle. That will force plans to build logic that compares actual patient charges to the hypothetical bundle-based patient share and to adjust bills and claims accordingly.
Effective date
The amendment applies to plan years starting on or after January 1, 2027. This gives carriers and plan administrators a runway to modify claims systems, update provider contracts, and reconfigure member billing processes before the rule becomes applicable.
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Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Individuals who experience miscarriage or stillbirth — the direct beneficiaries: they face lower or capped out-of-pocket bills for prenatal imaging, visits, and other services delivered before the loss, reducing financial and administrative burdens during a period of grief.
- Patients enrolled in plans that use bundled payment models — by increasing predictability of financial exposure when care pathways change midstream, the bill reduces the risk of retrospective surprise bills tied to pregnancy loss.
- Providers and hospital billing offices — fewer patient-balance disputes and less bad-debt collection when carriers bear the residual financial responsibility instead of shifting it to grieving patients; this can simplify revenue-cycle interactions in cases of pregnancy loss.
Who Bears the Cost
- Health insurers and carriers (and self‑funded plan sponsors) — they shoulder the residual payment responsibility when a bundle is not paid, and they must absorb claims that otherwise would have been recouped from patients.
- Third‑party administrators and plan administrators — they face increased administrative costs to detect pregnancy-loss events, reprice claims to a bundle-equivalent patient share, and reprocess prior payments or member bills.
- Providers and institutions with bundled contracts — they may need to renegotiate bundled arrangements or accept different payment flows if plans refuse to pay the full bundle when delivery does not occur, shifting contractual risk among providers and payers.
- State regulators and compliance teams — they will need to incorporate the new rule into oversight frameworks, complaints handling, and guidance without additional funding, increasing regulatory workload.
Key Issues
The Core Tension
The central dilemma is protecting grieving patients from retrospective, potentially large out-of-pocket bills versus imposing additional financial and administrative burdens on payers and provider networks that must absorb or reconcile costs when a bundle disappears; the bill solves the patient-protection problem but forces stakeholders to reallocate risk and redesign claims and contract workflows, with no single clear mechanism to do that seamlessly.
The bill is concise and targeted, but that concision creates practical ambiguity. It ties patient liability to a hypothetical bundled-charge scenario that never materialized, leaving unclear how plans must calculate the relevant "would have been" patient share when bundles vary by provider contract, capitated arrangements, or negotiated discounts.
Plans and providers will dispute whether a particular prenatal service was part of the bundle and whether the plan’s accounting of the hypothetical bundle is reasonable. Those disputes implicate claims-adjudication rules, provider contracts, and coding practices.
Another uncertainty is enforcement and ERISA interaction. The amendment sits in Title XXVII, which governs insurance market rules, but many employer-sponsored plans are self-funded and administered under ERISA; how state regulators and the Department of Health and Human Services will coordinate enforcement across insured and self-funded arrangements is not spelled out.
The statute also does not create a specific private right of action, penalty scheme, or administrative remedy, leaving enforcement to existing authorities and litigation to clarify scope. Finally, the policy shifts economic risk from patients to payers (and ultimately to plan sponsors/premiums), creating trade-offs between immediate patient protection and potential long-run cost implications for covered populations and provider contracting behavior.
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