Lower Health Care Costs Act

II Calendar No. 133 116TH CONGRESS 1ST SESSION S. 1895 To lower health care costs. IN THE SENATE OF THE UNITED STATES JUNE 19, 2019 Mr. ALEXANDER (for himself and Mrs. MURRAY) introduced the following bill; which was read twice and referred to the Committee on Health, Edu- cation, Labor, and Pensions JULY 8, 2019 Reported by Mr. ALEXANDER, with an amendment [Strike out all after the enacting clause and insert the part printed in italic] A BILL To lower health care costs. 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; TABLE OF CONTENTS. 3 (a) SHORT TITLE.—This Act may be cited as the 4 ‘‘Lower Health Care Costs Act’’. 5 (b) TABLE OF CONTENTS.—The table of contents for 6 this Act is as follows: 7 Sec. 1. Short title; table of contents. VerDate Sep 11 2014 23:21 Jul 08, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6411 E:\BILLS\S1895.RS S1895 dlhill on DSKBBY8HB2PROD with BILLS 2 •S 1895 RS TITLE I—ENDING SURPRISE MEDICAL BILLS Sec. 101. Protecting patients against out-of-network deductibles in emergencies. Sec. 102. Protection against surprise bills. Sec. 103. Benchmark for payment. Sec. 104. Effective date. Sec. 105. Ending surprise air ambulance bills. Sec. 106. Report. TITLE II—REDUCING THE PRICES OF PRESCRIPTION DRUGS Sec. 201. Biological product patent transparency. Sec. 202. Orange book modernization. Sec. 203. Ensuring timely access to generics. Sec. 204. Protecting access to biological products. Sec. 205. Preventing blocking of generic drugs. Sec. 206. Education on biological products. Sec. 207. Biological product innovation. Sec. 208. Clarifying the meaning of new chemical entity. Sec. 209. Streamlining the transition of biological products. Sec. 210. Orphan drug clarification. Sec. 211. Prompt approval of drugs related to safety information. Sec. 212. Conditions of use for biosimilar biological products. Sec. 213. Modernizing the labeling of certain generic drugs. TITLE III—IMPROVING TRANSPARENCY IN HEALTH CARE Sec. 301. Increasing transparency by removing gag clauses on price and quality information. Sec. 302. Banning anticompetitive terms in facility and insurance contracts that limit access to higher quality, lower cost care. Sec. 303. Designation of a nongovernmental, nonprofit transparency organiza- tion to lower Americans’ health care costs. Sec. 304. Protecting patients and improving the accuracy of provider directory information. Sec. 305. Timely bills for patients. Sec. 306. Health plan oversight of pharmacy benefit manager services. Sec. 307. Government Accountability Office study on profit- and revenue-shar- ing in health care. Sec. 308. Disclosure of direct and indirect compensation for brokers and con- sultants to employer-sponsored health plans and enrollees in plans on the individual market. Sec. 309. Ensuring enrollee access to cost-sharing information. Sec. 310. Strengthening parity in mental health and substance use disorder benefits. Sec. 311. Technical amendments. Sec. 312. Third-party administrators. TITLE IV—IMPROVING PUBLIC HEALTH Sec. 401. Improving awareness of disease prevention. Sec. 402. Grants to address vaccine-preventable diseases. Sec. 403. Guide on evidence-based strategies for public health department obe- sity prevention programs. Sec. 404. Expanding capacity for health outcomes. Sec. 405. Public health data system modernization. Sec. 406. Innovation for maternal health. VerDate Sep 11 2014 23:21 Jul 08, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6411 E:\BILLS\S1895.RS S1895 dlhill on DSKBBY8HB2PROD with BILLS 3 •S 1895 RS Sec. 407. Training for health care providers. Sec. 408. Study on training to reduce and prevent discrimination. Sec. 409. Perinatal quality collaboratives. Sec. 410. Integrated services for pregnant and postpartum women. Sec. 411. Extension for community health centers, the National Health Service Corps, and teaching health centers that operate GME pro- grams. Sec. 412. Other programs. TITLE V—IMPROVING THE EXCHANGE OF HEALTH INFORMATION Sec. 501. Requirement to provide health claims, network, and cost information. Sec. 502. Recognition of security practices. Sec. 503. GAO study on the privacy and security risks of electronic trans- mission of individually identifiable health information to and from entities not covered by the Health Insurance Portability and Accountability Act. Sec. 504. Technical corrections. TITLE I—ENDING SURPRISE 1 MEDICAL BILLS 2 SEC. 101. PROTECTING PATIENTS AGAINST OUT-OF-NET- 3 WORK DEDUCTIBLES IN EMERGENCIES. 4 Section 2719A(b) of the Public Health Service Act 5 (42 U.S.C. 300gg–19a) is amended— 6 (1) in paragraph (1)— 7 (A) in the matter preceding subparagraph 8 (A), by inserting ‘‘or a freestanding emergency 9 room’’ after ‘‘hospital’’; and 10 (B) in subparagraph (C)— 11 (i) in clause (ii)(I), by inserting ‘‘or 12 emergency room’’ after ‘‘emergency depart- 13 ment’’; and 14 (ii) in subparagraph (C)(ii)(II), by 15 adding, ‘‘a deductible,’’ after ‘‘(expressed 16 as’’; and 17 VerDate Sep 11 2014 23:21 Jul 08, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6401 E:\BILLS\S1895.RS S1895 dlhill on DSKBBY8HB2PROD with BILLS 4 •S 1895 RS (2) in paragraph (2)(B)— 1 (A) in clause (i)— 2 (i) by inserting ‘‘or freestanding emer- 3 gency room’’ after ‘‘hospital’’; and 4 (ii) by inserting ‘‘or emergency room’’ 5 after ‘‘emergency department’’; and 6 (B) in clause (ii), by inserting ‘‘or emer- 7 gency room’’ after ‘‘hospital’’. 8 SEC. 102. PROTECTION AGAINST SURPRISE BILLS. 9 (a) PHSA.—Section 2719A of the Public Health 10 Service Act (42 U.S.C. 300gg–19a) is amended by adding 11 at the end the following: 12 ‘‘(e) COVERAGE OF CERTAIN OUT-OF-NETWORK 13 SERVICES.— 14 ‘‘(1) IN GENERAL.—Subject to subsection (h), 15 in the case of an enrollee in a group health plan or 16 group or individual health insurance coverage who 17 receives out-of-network, ancillary, non-emergency 18 services at an in-network facility, including any re- 19 ferrals for diagnostic services— 20 ‘‘(A) the cost-sharing requirement (ex- 21 pressed as a copayment amount, coinsurance 22 rate, or deductible) with respect to such services 23 shall be the same requirement that would apply 24 if such services were provided by an in-network 25 VerDate Sep 11 2014 23:21 Jul 08, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6401 E:\BILLS\S1895.RS S1895 dlhill on DSKBBY8HB2PROD with BILLS 5 •S 1895 RS practitioner, and any coinsurance or deductible 1 shall be based on in-network rates; and 2 ‘‘(B) such cost-sharing amounts shall be 3 counted towards the in-network deductible and 4 in-network out-of-pocket maximum amount 5 under the plan or coverage for the plan year. 6 ‘‘(2) DEFINITION.—For purposes of this sub- 7 section, the term ‘facility’ has the meaning given the 8 term ‘health care facility’ in section 2729A(c). 9 ‘‘(f) COVERAGE OF OUT-OF-NETWORK SERVICES FOR 10 ENROLLEES ADMITTED AFTER EMERGENCY SERVICES.— 11 ‘‘(1) NOTICE AND CONSENT.—Subject to sub- 12 section (h), in the case of an enrollee in a group 13 health plan or group or individual health insurance 14 coverage who receives emergency services, or mater- 15 nal care for a woman in labor, in the emergency de- 16 partment of an out-of-network facility and has been 17 stabilized (within the meaning of subsection 18 (b)(2)(C)), if the patient is subsequently admitted to 19 the out-of-network facility for care, the cost-sharing 20 requirement (expressed as a copayment amount, co- 21 insurance rate, or deductible) with respect to any 22 out-of-network services is the same requirement that 23 would apply if such services were provided by a par- 24 ticipating provider, unless the enrollee, once stable 25 VerDate Sep 11 2014 23:21 Jul 08, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6401 E:\BILLS\S1895.RS S1895 dlhill on DSKBBY8HB2PROD with BILLS 6 •S 1895 RS and in a condition to receive such information, in- 1 cluding having sufficient mental capacity— 2 ‘‘(A) has been provided by the facility, 3 prior to the provision of any post-stabilization, 4 out-of-network service at such facility, with— 5 ‘‘(i) paper and electronic notification 6 that the practitioner or facility is an out- 7 of-network health care provider and the 8 out-of-network rate of the provider, as ap- 9 plicable, and the option to affirmatively 10 consent to receiving services from such 11 practitioner or facility; and 12 ‘‘(ii) the estimated amount that such 13 provider may charge the participant, bene- 14 ficiary, or enrollee for such items and serv- 15 ices involved; 16 ‘‘(B) has been provided by the plan or cov- 17 erage, prior to the provision of any post-sta- 18 bilization, out-of-network service at such facil- 19 ity, with— 20 ‘‘(i) paper and electronic notification 21 that the practitioner or facility is an out- 22 of-network health care provider and the 23 out-of-network rate of the provider, as ap- 24 plicable, and the option to affirmatively 25 VerDate Sep 11 2014 23:21 Jul 08, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6401 E:\BILLS\S1895.RS S1895 dlhill on DSKBBY8HB2PROD with BILLS 7 •S 1895 RS consent to receiving services from such 1 practitioner or facility; 2 ‘‘(ii) a list of in-network practitioners 3 or facilities that could provide the same 4 services, and an option for a referral to 5 such providers; and 6 ‘‘(iii) information about whether prior 7 authorization or other care management 8 limitations may be required in advance of 9 receiving in-network care at the facility; 10 and 11 ‘‘(C) has acknowledged that the out-of-net- 12 work treatment may not be covered or may be 13 covered at an out-of-network cost-sharing 14 amount, requiring higher cost-sharing obliga- 15 tions of the enrollee than if the service were 16 provided at an in-network facility, and has as- 17 sumed, in writing, full responsibility of out-of- 18 pocket costs associated with services furnished 19 after the enrollee has been stabilized, from the 20 out-of-network practitioner or facility, as appli- 21 cable. 22 ‘‘(2) REQUIREMENTS OF NOTICE.—The notice 23 under paragraph (1) shall be in a format determined 24 by the Secretary to give a reasonable layperson clear 25 VerDate Sep 11 2014 23:21 Jul 08, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6401 E:\BILLS\S1895.RS S1895 dlhill on DSKBBY8HB2PROD with BILLS 8 •S 1895 RS comprehension of the terms of the agreement, in- 1 cluding all possible financial responsibilities, includ- 2 ing the requirements that the notice— 3 ‘‘(A) does not exceed one page in length; 4 ‘‘(B) is readily identifiable for its purpose 5 and as a contract of consent; 6 ‘‘(C) clearly states that consent is optional; 7 ‘‘(D) includes an estimate of the amount 8 that such provider will charge the participant, 9 beneficiary, or enrollee for such items and serv- 10 ices involved; and 11 ‘‘(E) be available in the 15 most common 12 languages in the facility’s geographic area, with 13 the facility making a good faith effort to pro- 14 vide oral notice in the enrollee’s primary lan- 15 guage if it is not one of such 15 languages. 16 ‘‘(g) PROHIBITION ON BILLING MORE THAN AN IN- 17 NETWORK RATE UNDER CERTAIN CIRCUMSTANCES.— 18 ‘‘(1) IN GENERAL.—A facility or practitioner 19 furnishing— 20 ‘‘(A) emergency services, as defined in sub- 21 section (b)(2), regardless of the State in which 22 the patient resides; 23 ‘‘(B) services at an in-network facility de- 24 scribed in subsection (e); or 25 VerDate Sep 11 2014 23:21 Jul 08, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6401 E:\BILLS\S1895.RS S1895 dlhill on DSKBBY8HB2PROD with BILLS 9 •S 1895 RS ‘‘(C) out-of-network services furnished 1 after the enrollee has been stabilized (within the 2 meaning of subsection (b)(2)(C)), where the no- 3 tice and option for referral required under sub- 4 section (f)(1) have not been provided to the en- 5 rollee and the assumption of responsibility for 6 out-of-pocket costs under subsection (f)(2) has 7 not been obtained, 8 may not bill an enrollee in a group health plan or 9 group or individual health insurance coverage for 10 amounts beyond the cost-sharing amount that would 11 apply under subsection (b)(1)(C)(ii)(II), (e), or (f), 12 as applicable. 13 ‘‘(2) NOTICE.—A facility furnishing services de- 14 scribed in paragraph (1) shall provide enrollees in a 15 group health plan or group or individual health in- 16 surance coverage with a one-page notice, in 16-point 17 font, upon intake at the emergency room or being 18 admitted at the facility of the prohibition on balance 19 billing under paragraph (1) and who to contact for 20 recourse if they are sent a balance bill in violation 21 of such paragraph. The facility shall be responsible 22 for obtaining the signature from the enrollee on such 23 notice. The Secretary shall issue regulations within 24 6 months of the date of enactment of the Lower 25 VerDate Sep 11 2014 23:21 Jul 08, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6401 E:\BILLS\S1895.RS S1895 dlhill on DSKBBY8HB2PROD with BILLS 10 •S 1895 RS Health Care Costs Act on the requirements for the 1 notice under this paragraph. 2 ‘‘(3) ENFORCEMENT.— 3 ‘‘(A) IN GENERAL.—Subject to subpara- 4 graph (B), a facility or practitioner that vio- 5 lates a requirement under paragraph (1) shall 6 be subject to a civil monetary penalty of not 7 more than $10,000 for each act constituting 8 such violation. 9 ‘‘(B) PROCEDURE.—The provisions of sec- 10 tion 1128A of the Social Security Act, other 11 than subsections (a) and (b) and the first sen- 12 tence of subsection (c)(1) of such section, shall 13 apply to civil money penalties under this sub- 14 section in the same manner as such provisions 15 apply to a penalty or proceeding under section 16 1128A of the Social Security Act. 17 ‘‘(C) SAFE HARBOR.—The Secretary shall 18 waive the penalties described under subpara- 19 graph (A) with respect to a facility or, practi- 20 tioner who unknowingly violates paragraph (1) 21 with respect to an enrollee, if such facility or 22 practitioner, within 30 days of the violation, 23 withdraws the bill that was in violation of para- 24 graph (1), and, as applicable, reimburses the 25 VerDate Sep 11 2014 23:21 Jul 08, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6401 E:\BILLS\S1895.RS S1895 dlhill on DSKBBY8HB2PROD with BILLS 11 •S 1895 RS group health plan, health insurance issuer, or 1 enrollee, as applicable, in an amount equal to 2 the amount billed in violation of paragraph (1), 3 plus interest, at an interest rate determined by 4 the Secretary. 5 ‘‘(h) MAINTAINING STATE SURPRISE BILLING PRO- 6 TECTIONS.— 7 ‘‘(1) IN GENERAL.—Notwithstanding section 8 514 of the Employee Retirement Income Security 9 Act of 19 [Text truncated for display. Full text available on Congress.gov.]