End Surprise Billing Act of 2019

I 116TH CONGRESS 1ST SESSION H. R. 861 To amend title XVIII of the Social Security Act to prevent surprise billing practices, and for other purposes. IN THE HOUSE OF REPRESENTATIVES JANUARY 30, 2019 Mr. DOGGETT (for himself, Mr. CARTWRIGHT, Ms. JUDY CHU of California, Mr. CICILLINE, Mr. COHEN, Mr. COURTNEY, Mr. DANNY K. DAVIS of Illinois, Ms. DELAURO, Mr. GRIJALVA, Ms. HILL of California, Ms. JAYAPAL, Ms. KAPTUR, Ms. KELLY of Illinois, Mr. KHANNA, Ms. KUSTER of New Hampshire, Ms. LEE of California, Mr. LEWIS, Ms. MOORE, Ms. NORTON, Ms. PINGREE, Mr. POCAN, Ms. VELA´ZQUEZ, Ms. SCHAKOWSKY, Mr. LIPINSKI, Ms. DEGETTE, Mr. ESPAILLAT, Mr. WELCH, Ms. PORTER, and Mr. LANGEVIN) introduced the following bill; which was referred to the Committee on Ways and Means, and in addi- tion to the Committee on Energy and Commerce, for a period to be sub- sequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to prevent surprise billing practices, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘End Surprise Billing 4 Act of 2019’’. 5 VerDate Sep 11 2014 02:42 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H861.IH H861 kjohnson on DSK79L0C42 with BILLS 2 •HR 861 IH SEC. 2. PREVENTING SURPRISE BILLING PRACTICES. 1 (a) CONDITION OF PARTICIPATION IN MEDICARE.— 2 Section 1866 of the Social Security Act (42 U.S.C. 3 1395cc) is amended— 4 (1) in subsection (a)(1)— 5 (A) in subparagraph (X), by striking 6 ‘‘and’’ at the end; 7 (B) in subparagraph (Y), by striking at 8 the end the period and inserting ‘‘, and’’; and 9 (C) by inserting after such subparagraph 10 (Y) the following new subparagraph: 11 ‘‘(Z) in the case of a hospital or critical ac- 12 cess hospital, to adopt and enforce a policy to 13 ensure compliance with the requirements of 14 paragraphs (1) and (4) of subsection (l) and to 15 meet the requirements of such paragraphs (re- 16 lating to the prevention of surprise billing prac- 17 tices).’’; and 18 (2) by adding at the end the following new sub- 19 section: 20 ‘‘(l) REQUIREMENT FOR PURPOSES OF PREVENTING 21 SURPRISE BILLING.— 22 ‘‘(1) IN GENERAL.—For purposes of subsection 23 (a)(1)(Z), the requirements described in this para- 24 graph are, with respect to a hospital or critical ac- 25 cess hospital, in the case of an individual with health 26 VerDate Sep 11 2014 02:42 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H861.IH H861 kjohnson on DSK79L0C42 with BILLS 3 •HR 861 IH benefits coverage, including benefits under a group 1 health plan or health insurance coverage offered in 2 the group or individual market (as such terms are 3 defined in section 2791 of the Public Health Service 4 Act) or under this title, title XIX, title XXI, or an- 5 other government-sponsored health plan or program, 6 who seeks to be furnished items or services or is to 7 be furnished items or services by the hospital or crit- 8 ical access hospital (including by a provider of serv- 9 ices or supplier that furnishes items or services at 10 the hospital or critical access hospital), that the hos- 11 pital or critical access hospital— 12 ‘‘(A)(i) provides to the individual (or to a 13 representative of the individual), on the date on 14 which the individual makes an appointment to 15 be furnished such items or services, if applica- 16 ble, and on the date on which the individual is 17 furnished such items and services, a written no- 18 tice specified by the Secretary through rule- 19 making that— 20 ‘‘(I) contains the information required 21 under paragraph (2); and 22 ‘‘(II) is signed and dated by the indi- 23 vidual; and 24 VerDate Sep 11 2014 02:42 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H861.IH H861 kjohnson on DSK79L0C42 with BILLS 4 •HR 861 IH ‘‘(ii) retains a copy of each such notice for 1 a period specified through rulemaking by the 2 Secretary; and 3 ‘‘(B) in the case that such hospital or crit- 4 ical access hospital (or provider of services or 5 supplier furnishing services at such hospital or 6 critical access hospital) is not within the health 7 care provider network or otherwise a partici- 8 pating provider of services or supplier with re- 9 spect to such health benefits coverage of such 10 individual, obtains from the individual the con- 11 sent described in paragraph (3). 12 ‘‘(2) INFORMATION INCLUDED IN NOTICE.— 13 The notice described in paragraph (1)(A) shall in- 14 clude, with respect to an individual with health bene- 15 fits coverage described in paragraph (1) who seeks 16 to be furnished items or services or is to be fur- 17 nished items or services by a hospital or critical ac- 18 cess hospital (including by a provider of services or 19 supplier that furnishes items or services at the hos- 20 pital or critical access hospital), a notification of 21 each of the following: 22 ‘‘(A) Whether the hospital or critical ac- 23 cess hospital is not within the health care pro- 24 vider network or otherwise a participating pro- 25 VerDate Sep 11 2014 02:42 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H861.IH H861 kjohnson on DSK79L0C42 with BILLS 5 •HR 861 IH vider of services or supplier with respect to such 1 health benefits coverage of such individual. 2 ‘‘(B) If the hospital or critical access hos- 3 pital is not within such network or otherwise 4 such a participating provider or supplier, the 5 estimated amount that the hospital or critical 6 access hospital will charge the individual for 7 such items and services in excess of any cost 8 sharing obligations that the individual would 9 otherwise have under such health benefits cov- 10 erage for such items and services if the hospital 11 or critical access hospital were within such net- 12 work or otherwise participating in such cov- 13 erage. 14 ‘‘(C) Whether any of the providers of serv- 15 ices or suppliers furnishing items or services at 16 the hospital or critical access hospital who will 17 furnish the items or services to the individual 18 are not within the health care provider network 19 or otherwise a participating provider of services 20 or supplier with respect to such health benefits 21 coverage of such individual. 22 ‘‘(D) If any of such providers of services or 23 suppliers are not within such network or other- 24 wise such a participating provider or supplier, 25 VerDate Sep 11 2014 02:42 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H861.IH H861 kjohnson on DSK79L0C42 with BILLS 6 •HR 861 IH the estimated amount that such providers of 1 services or suppliers will charge the individual 2 for such items and services in excess of any cost 3 sharing obligations that the individual would 4 otherwise have for such items and services if 5 the providers of services or suppliers were with- 6 in the such network or otherwise participating 7 in such coverage. 8 ‘‘(3) CONSENT DESCRIBED.—For purposes of 9 paragraph (1)(B), the consent described in this 10 paragraph, with respect to an individual with health 11 benefits coverage described in paragraph (1) who is 12 to be furnished items or services by a hospital or 13 critical access hospital (or provider of services or 14 supplier furnishing services at such hospital or crit- 15 ical access hospital) that is not within the health 16 care provider network or otherwise a participating 17 provider of services or supplier with respect to such 18 health benefits coverage of such individual, is a doc- 19 ument specified by the Secretary through rule- 20 making that is signed by the individual (or by a rep- 21 resentative of the individual) not less than 24 hours 22 prior to the individual being furnished such items or 23 services by such hospital, critical access hospital, 24 VerDate Sep 11 2014 02:42 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H861.IH H861 kjohnson on DSK79L0C42 with BILLS 7 •HR 861 IH provider of services, or supplier, respectively, and 1 that— 2 ‘‘(A) acknowledges that the individual has 3 been— 4 ‘‘(i) provided with a written estimate 5 of the charge that the individual will be as- 6 sessed for the items or services anticipated 7 to be furnished to the individual by the 8 hospital, critical access hospital, provider 9 of services, or supplier that is not within 10 such network or otherwise such a partici- 11 pating provider of services or supplier; and 12 ‘‘(ii) informed that the payment of 13 such charge by the individual will not ac- 14 crue toward any limitation that the health 15 benefits coverage places upon the annual 16 out-of-pocket expenses to be paid by the 17 individual or upon the in-network deduct- 18 ible to be paid by the individual; and 19 ‘‘(B) documents the consent of the indi- 20 vidual to— 21 ‘‘(i) be furnished with such items or 22 services by such hospital, critical access 23 hospital, provider of services, or supplier, 24 as applicable; and 25 VerDate Sep 11 2014 02:42 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H861.IH H861 kjohnson on DSK79L0C42 with BILLS 8 •HR 861 IH ‘‘(ii) in the case that the individual is 1 so furnished such items or services, be 2 charged an amount approximate to the es- 3 timated charge described in subparagraph 4 (A)(i) with respect to such items or serv- 5 ices. 6 ‘‘(4) LIMITATIONS ON PAYMENT BY INDI- 7 VIDUAL.—For purposes of subsection (a)(1)(Z), the 8 requirements under this paragraph are the following: 9 ‘‘(A) IN CASE OF NONCOMPLIANCE BY 10 HOSPITALS AND CRITICAL ACCESS HOS- 11 PITALS.—In the case of an individual with 12 health benefits coverage described in paragraph 13 (1) who is furnished items or services by a hos- 14 pital or critical access hospital (or provider of 15 services or supplier furnishing services at such 16 hospital or critical access hospital) that is not 17 within the health care provider network or oth- 18 erwise a participating provider of services or 19 supplier with respect to such health benefits 20 coverage of such individual, if the hospital or 21 critical access hospital does not comply with the 22 requirements of paragraph (1) with respect to 23 the furnishing of such items or services to such 24 individual, the hospital or critical access hos- 25 VerDate Sep 11 2014 02:42 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H861.IH H861 kjohnson on DSK79L0C42 with BILLS 9 •HR 861 IH pital (or, as applicable, the provider of services 1 or supplier furnishing such items or services to 2 such individual) may not charge the individual 3 more than the amount that the individual would 4 have been required to pay in cost sharing if 5 such items or services had been furnished by a 6 hospital or critical access hospital, as applicable 7 (or by a provider of services or supplier, as ap- 8 plicable) that is within such network or that is 9 otherwise such a participating provider of serv- 10 ices or supplier. 11 ‘‘(B) IN CASE OF SAME-DAY EMERGENCY 12 SERVICES.—In the case of an individual with 13 health benefits coverage described in paragraph 14 (1) who is furnished items or services by a hos- 15 pital or critical access hospital (or provider of 16 services or supplier furnishing services at such 17 hospital or critical access hospital) that is not 18 within the health care provider network or oth- 19 erwise a participating provider of services or 20 supplier with respect to such health benefits 21 coverage of such individual on the same date on 22 which the individual makes an appointment for 23 such items or services (or otherwise presents at 24 the hospital or critical access hospital for such 25 VerDate Sep 11 2014 02:42 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H861.IH H861 kjohnson on DSK79L0C42 with BILLS 10 •HR 861 IH services such as in the case of items and serv- 1 ices furnished with respect to an emergency 2 medical condition, as defined in section 3 1867(e)), the hospital or critical access hospital 4 (or, as applicable, the provider of services or 5 supplier furnishing such items or services to 6 such individual) may not charge the individual 7 more than the amount that the individual would 8 have been required to pay in cost sharing if 9 such items or services had been furnished by a 10 hospital or critical access hospital, as applicable 11 (or by a provider of services or supplier, as ap- 12 plicable) that is within such network or that is 13 otherwise such a participating provider of serv- 14 ices or supplier.’’. 15 (b) EFFECTIVE DATE.—The amendments made by 16 subsection (a) shall apply with respect to agreements 17 under section 1866(a)(1) of the Social Security Act (42 18 U.S.C. 1395cc(a)(1)) that are filed with the Secretary of 19 Health and Human Services on a date that is not less 20 than 12 months after the date of the enactment of this 21 Act. 22 Æ VerDate Sep 11 2014 02:42 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6301 E:\BILLS\H861.IH H861 kjohnson on DSK79L0C42 with BILLS