STOP Surprise Medical Bills Act of 2019

II 116TH CONGRESS 1ST SESSION S. 1531 To amend the Public Health Service Act to provide protections for health insurance consumers from surprise billing. IN THE SENATE OF THE UNITED STATES MAY 16, 2019 Mr. CASSIDY (for himself, Mr. BENNET, Mr. YOUNG, Ms. HASSAN, Ms. MUR- KOWSKI, Mr. CARPER, Mr. SULLIVAN, Mr. BROWN, Mr. CRAMER, Mr. CARDIN, Mr. KENNEDY, and Mr. CASEY) introduced the following bill; which was read twice and referred to the Committee on Health, Edu- cation, Labor, and Pensions A BILL To amend the Public Health Service Act to provide protec- tions for health insurance consumers from surprise bill- ing. 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 ‘‘Stopping The Out- 4 rageous Practice of Surprise Medical Bills Act of 2019’’ 5 or the ‘‘STOP Surprise Medical Bills Act of 2019’’. 6 SEC. 2. FINDINGS. 7 Congress makes the following findings: 8 VerDate Sep 11 2014 18:57 May 31, 2019 Jkt 034408 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S1531.IS S1531 pbinns on DSK79D2C42PROD with BILLS 2 •S 1531 IS (1) Consumers frequently struggle to determine 1 when and how much they will pay for a medical 2 service or procedure. A majority of consumers say 3 health care providers rarely, if ever, discuss costs of 4 recommended treatments and whether these treat- 5 ments are covered by health insurance. Almost 70 6 percent of patients who receive bills from out-of-net- 7 work providers did not realize the provider was out- 8 of-network at the time of treatment. Patients using 9 in-network facilities still receive claims from out-of- 10 network providers at high rates, over 15 percent of 11 inpatient admissions and 5 percent of outpatient 12 service days. Even when patients try to schedule an 13 in-network procedure at an in-network hospital and 14 try to ensure that all providers who administer 15 treatment will be in-network, they may be sent a 16 balance bill by an out-of-network provider after re- 17 ceiving care. If providers accepted the same health 18 plans as the facilities at which they practice and ad- 19 minister care, out-of-network surprise medical bills 20 would not be a complication for consumers sched- 21 uling elective procedures. 22 (2) Surprise medical bills affect a sizeable por- 23 tion of the insured population. Approximately 30 24 percent of individuals covered by private health in- 25 VerDate Sep 11 2014 18:57 May 31, 2019 Jkt 034408 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S1531.IS S1531 pbinns on DSK79D2C42PROD with BILLS 3 •S 1531 IS surance have received a surprise medical bill within 1 the past year. Almost 20 percent of inpatient admis- 2 sions by enrollees in large employer plans include at 3 least 1 claim from an out-of-network provider, while 4 8 percent of outpatient service days include an out- 5 of-network claim. 6 (3) Surprise medical bills are an issue of par- 7 ticular concern to consumers. A majority of Ameri- 8 cans feel that softening the impact of surprise med- 9 ical bills should be a priority for the current Con- 10 gress. Eighty-six percent of Americans think it is 11 important to protect individuals from surprise med- 12 ical bills. 13 (4) Surprise medical bills for emergency care 14 are frequently unavoidable due to the emergent and 15 serious nature of the patient’s condition at the time 16 of treatment. One in 5 cases of inpatient hospital 17 admissions that originate within the emergency de- 18 partment result in a surprise medical bill. For inpa- 19 tient admissions, those that include an emergency 20 room claim are much more likely to include a claim 21 from an out-of-network provider than admissions 22 without an emergency room claim. This is true 23 whether or not enrollees use in-network facilities. 24 Most cases of surprise medical billing occur when 25 VerDate Sep 11 2014 18:57 May 31, 2019 Jkt 034408 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1531.IS S1531 pbinns on DSK79D2C42PROD with BILLS 4 •S 1531 IS privately insured individuals involuntarily see out-of- 1 network providers during medical emergencies. 2 (5) The financial implications of surprise med- 3 ical bills can be devastating for American consumers 4 and can prevent them from seeking timely follow-up 5 care or from accessing necessary services. Approxi- 6 mately 20 percent of insured Americans struggle to 7 pay their medical bills. Almost a third of consumers 8 who report they are struggling to pay a medical bill 9 also report this bill was due to charges from an out- 10 of-network provider that were not covered or were 11 only partially covered by their insurer. Consumers 12 with outstanding medical bills report delaying or 13 skipping needed health care at rates 2 to 3 times 14 higher than consumers without outstanding bills. 15 Over 60 percent of consumers with outstanding 16 medical bills report difficulties paying other bills (in- 17 cluding necessities such as food, heat, or housing 18 costs) as a result of their medical bills. 19 VerDate Sep 11 2014 18:57 May 31, 2019 Jkt 034408 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1531.IS S1531 pbinns on DSK79D2C42PROD with BILLS 5 •S 1531 IS SEC. 3. PROHIBITION ON SURPRISE BALANCE BILLING AND 1 INDEPENDENT DISPUTE RESOLUTION WITH 2 RESPECT TO OUT-OF-NETWORK HEALTH 3 CARE SERVICES. 4 (a) IN GENERAL.—Subpart II of part A of title 5 XXVII of the Public Health Service Act (42 U.S.C. 300gg 6 et seq.) is amended by adding at the end the following: 7 ‘‘SEC. 2729A. GENERAL PROHIBITION ON SURPRISE BAL- 8 ANCE BILLING. 9 ‘‘(a) SURPRISE MEDICAL BILL.—In this title, the 10 term ‘surprise medical bill’ means a balance bill, as de- 11 scribed in subsection (b), that an enrollee receives for serv- 12 ices provided to the enrollee where such services were— 13 ‘‘(1) emergency services provided by an out-of- 14 network health care professional or at an out-of-net- 15 work facility; 16 ‘‘(2) health care services that were provided— 17 ‘‘(A) at an in-network facility (including 18 the use of equipment, devices, telemedicine serv- 19 ices, or other treatments or services); and 20 ‘‘(B) by an out-of-network health care pro- 21 fessional; or 22 ‘‘(3) additional health care services required in 23 the case of an enrollee who initially enters a hospital 24 through the emergency room for emergency services, 25 and then receives nonemergency services from an 26 VerDate Sep 11 2014 18:57 May 31, 2019 Jkt 034408 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S1531.IS S1531 pbinns on DSK79D2C42PROD with BILLS 6 •S 1531 IS out-of-network health care professional or at an out- 1 of-network hospital or facility after the enrollee has 2 been stabilized (as defined in section 3 2719A(b)(2)(C)), as determined by the treating phy- 4 sician. 5 Paragraph (3) shall not apply in the case of an enrollee 6 who is stabilized and able to travel in nonmedical trans- 7 port, and the enrollee (or designee of the enrollee where 8 the enrollee is not able to comprehend the information to 9 be provided or make related decisions) has been provided 10 with clear, written notification that the professional or fa- 11 cility is an out-of-network health care professional or facil- 12 ity, has been given a cost estimate for services provided 13 by the out-of-network professional or facility, and has as- 14 sumed, in writing, full responsibility for out-of-pocket 15 costs associated with such out-of-network care. 16 ‘‘(b) BALANCE BILL.—In subsection (a), the term 17 ‘balance bill’ refers to a claim for payment for services 18 provided to an enrollee that is in an amount equal to the 19 difference between the actual amount charged with respect 20 to services or care described in subsection (a) and the ex- 21 pected in-network cost-sharing required by the enrollee 22 under the plan or coverage involved. 23 ‘‘(c) PROHIBITION ON BALANCE BILLING.— 24 ‘‘(1) PROHIBITION.— 25 VerDate Sep 11 2014 18:57 May 31, 2019 Jkt 034408 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S1531.IS S1531 pbinns on DSK79D2C42PROD with BILLS 7 •S 1531 IS ‘‘(A) IN GENERAL.—A group health plan, 1 a health insurance issuer in connection with 2 group or individual health insurance coverage, 3 or a health care provider shall not engage in 4 balance billing practices prohibited under this 5 section. 6 ‘‘(B) APPLICATION OF PROVISIONS.—Sub- 7 paragraph (A) shall apply— 8 ‘‘(i) to all services provided at hos- 9 pitals, emergency rooms, State-accredited 10 free-standing emergency departments, hos- 11 pital outpatient departments, and ambula- 12 tory surgery centers; and 13 ‘‘(ii) with respect to subsection (a)(2), 14 to the health care provider’s offices and re- 15 lated services (including laboratory and im- 16 aging services ordered by an in-network 17 provider and provided by an out-of-network 18 provider or laboratory). 19 ‘‘(2) ENROLLEE LIABILITY.—With respect to 20 the services and care described in subsection (a), an 21 enrollee shall only be liable for the in-network cost- 22 sharing amount provided for in their plan or cov- 23 erage. For purposes of this section, such payments 24 by the enrollee shall count toward the in-network de- 25 VerDate Sep 11 2014 18:57 May 31, 2019 Jkt 034408 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1531.IS S1531 pbinns on DSK79D2C42PROD with BILLS 8 •S 1531 IS ductible under the plan or coverage as well as to- 1 ward the enrollee’s out-of-pocket maximum limita- 2 tion. 3 ‘‘(3) PENALTY.—Violations of this section shall 4 subject the violator to a civil monetary penalty as 5 provided for in this title. Such provisions shall not 6 apply to a health care provider, group health plan, 7 or health insurance issuer that unknowingly balance 8 bills an enrollee and reimburses such enrollee within 9 30 calendar days of such billing. 10 ‘‘SEC. 2729B. OUT-OF-NETWORK BILLING. 11 ‘‘(a) PROHIBITION.— 12 ‘‘(1) IN GENERAL.—An enrollee may not be 13 billed in excess of the in-network cost-sharing 14 amount for services or care provided under section 15 2729A (a surprise medical bill situation). 16 ‘‘(2) AUTOMATIC PAYMENT.— 17 ‘‘(A) IN GENERAL.—A group health plan, 18 or health insurance issuer in connection with 19 group or individual health insurance coverage, 20 shall pay the median in-network rate under the 21 plan or coverage, less the applicable enrollee in- 22 network cost-sharing, directly to the health care 23 provider as provided for in this section. 24 VerDate Sep 11 2014 18:57 May 31, 2019 Jkt 034408 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1531.IS S1531 pbinns on DSK79D2C42PROD with BILLS 9 •S 1531 IS ‘‘(B) REQUEST FOR ALTERNATIVE RATE.— 1 Upon payment under subparagraph (A), the 2 plan or issuer shall provide to the health care 3 provider information about how the provider 4 may initiate independent dispute resolution 5 under such subsection with respect to such pay- 6 ment. The plan, issuer, or provider may nego- 7 tiate an alternative amount or initiate inde- 8 pendent dispute resolution under subsection (b) 9 during the 30-day period beginning on the date 10 on which the automatic payment is made under 11 this subsection. 12 ‘‘(b) ESTABLISHMENT OF IDR PROCESS; CERTIFI- 13 CATION OF ENTITIES.— 14 ‘‘(1) ESTABLISHMENT.—Not later than 1 year 15 after the date of enactment of this section, the Sec- 16 retary, in consultation with the Secretary of Labor, 17 shall establish a process for resolving payment dis- 18 putes between group health plans, or health insur- 19 ance issuers offering health insurance coverage in 20 the group market, and out-of-network health care 21 providers in surprise medical bill situations in ac- 22 cordance with this section (referred to in this section 23 as the ‘IDR process’). 24 VerDate Sep 11 2014 18:57 May 31, 2019 Jkt 034408 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1531.IS S1531 pbinns on DSK79D2C42PROD with BILLS 10 •S 1531 IS ‘‘(2) CERTIFICATION OF ENTITIES.—An entity 1 wishing to participate in the IDR process under this 2 subsection shall request certification from the Sec- 3 retary. The Secretary, in consultation with the Sec- 4 retary of Labor, shall determine eligibility of appli- 5 cant entities, taking into consideration whether the 6 entity is unbiased and unaffiliated with health plans 7 and providers and free of conflicts of interest, in ac- 8 cordance with the Secretary’s rulemaking on deter- 9 mining criteria for conflicts of interest. 10 ‘‘(3) IDR ENTITY.—Under the process estab- 11 lished under paragraph (1), the parties in the inde- 12 pendent dispute resolution process shall jointly agree 13 upon an independent dispute resolution entity. In 14 the event that parties cannot agree, one will be se- 15 lected at random jointly by the Department of 16 Health and Human Services and the Department of 17 Labor. 18 ‘‘(c) APPLICABLE CLAIMS.— 19 ‘‘(1) IN GENERAL.—The IDR process shall be 20 with respect to one or more Current Procedural Ter- 21 minology (‘CPT’) codes. 22 ‘‘(2) BATCHING OF CLAIMS.—Health care facili- 23 ties and providers and group health plans or health 24 insurance issuers may batch claims if such claims— 25 VerDate Sep 11 2014 18:57 May 31, 2019 Jkt 034408 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S1531.IS S1531 pbinns on DSK79D2C42PROD with BILLS 11 •S 1531 IS ‘‘(A) involve identical plan or issuer and 1 provider or facility parties; 2 ‘‘(B) involve claims with the same or re- 3 lated current procedural terminology codes rel- 4 evant to a particular procedure; and 5 ‘‘(C) involve claims that occur within 30 6 days of each other. 7 ‘‘(d) INDEPENDENT DISPUTE RESOLUTION PROC- 8 ESS.— 9 ‘‘(1) TIMING.—An independent dispute resolu- 10 tion entity that receives a request under this section 11 shall, not later than 30 days after receiving such re- 12 quest, determine the amount the group health plan, 13 or health insurance issuer offering health insurance 14 coverage in the group market, is required to pay the 15 out-of-network health care provider. Such amount 16 shall be— 17 ‘‘(A) the amount determined by the parties 18 through a settlement under paragraph (2); or 19 ‘‘(B) the amount determined reasonable by 20 the entity in accordance with paragraph (3). 21 ‘‘(2) SETTLEMENT.— 22 ‘‘(A) IN GENERAL.—If the independent 23 dispute resolution entity determines, based on 24 the amounts indicated in the request under this 25 VerDate Sep 11 2014 18:57 May 31, 2019 Jkt 034408 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S1531.IS S1531 pbinns on DSK79D2C42PROD with BILLS 12 •S 1531 IS section, that a settlement between the group 1 health plan, or health insurance issuer offering 2 health insurance coverage in the group market, 3 and the out-of-network health care provider is 4 l [Text truncated for display. Full text available on Congress.gov.]