I 116TH CONGRESS 1ST SESSION H. R. 3502 To amend the Public Health Service Act and title XI of the Social Security Act to protect health care consumers from surprise billing practices, and for other purposes. IN THE HOUSE OF REPRESENTATIVES JUNE 26, 2019 Mr. RUIZ (for himself, Mr. BUCSHON, Mr. MORELLE, Mr. BERA, Mr. WENSTRUP, Ms. SHALALA, Mr. TAYLOR, Mr. DAVID P. ROE of Ten- nessee, Mr. BANKS, Mr. HIGGINS of New York, Mr. GRIJALVA, Mr. CISNEROS, Mr. SOTO, Mr. HARRIS, Mr. HUDSON, Ms. SCHRIER, Mr. MARSHALL, Mr. DUNN, Mr. STIVERS, Mr. DESJARLAIS, Mr. BURCHETT, Mr. RIGGLEMAN, Mr. WATKINS, Mr. JOYCE of Pennsylvania, Mr. SMUCKER, Ms. STEFANIK, Mr. THOMPSON of Pennsylvania, Mr. WRIGHT, Mr. NORCROSS, Mrs. LOWEY, Mr. CA´RDENAS, Mr. DESAULNIER, and Ms. KELLY of Illinois) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Oversight and Reform, and Education and Labor, for a period to be subsequently 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 the Public Health Service Act and title XI of the Social Security Act to protect health care consumers from 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 VerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\H3502.IH H3502 khammond on DSKBBV9HB2PROD with BILLS 2 •HR 3502 IH SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 1 (a) SHORT TITLE.—This Act may be cited as the 2 ‘‘Protecting People From Surprise Medical Bills Act’’. 3 (b) TABLE OF CONTENTS.—The table of contents for 4 this Act is as follows: 5 Sec. 1. Short title; table of contents. Sec. 2. Preventing surprise medical bills. Sec. 3. Transparency regarding in-network and out-of-network deductibles. Sec. 4. Transparency for in-network patients. Sec. 5. Reporting requirements. Sec. 6. Billing statute of limitations. Sec. 7. Application. Sec. 8. Studies by Secretaries of Health and Human Services and of Labor. Sec. 9. Regulations. SEC. 2. PREVENTING SURPRISE MEDICAL BILLS. 6 (a) EMERGENCY SERVICES PERFORMED BY NON- 7 PARTICIPATING PROVIDERS.—Section 2719A of the Pub- 8 lic Health Service Act (42 U.S.C. 300gg–19a) is amend- 9 ed— 10 (1) in subsection (b)— 11 (A) in paragraph (1)— 12 (i) in the matter preceding subpara- 13 graph (A)— 14 (I) by striking ‘‘offering group or 15 individual health insurance issuer’’ 16 and inserting ‘‘offering group or indi- 17 vidual health insurance coverage’’; 18 and 19 VerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H3502.IH H3502 khammond on DSKBBV9HB2PROD with BILLS 3 •HR 3502 IH (II) by striking ‘‘paragraph 1 (2)(B)’’ and inserting ‘‘paragraph 2 (2)’’; 3 (ii) in subparagraph (B), by inserting 4 ‘‘or a participating emergency facility, as 5 applicable,’’ after ‘‘participating provider’’; 6 and 7 (iii) in subparagraph (C)— 8 (I) in the matter preceding clause 9 (i), by inserting ‘‘by a nonpartici- 10 pating provider or a nonparticipating 11 emergency facility’’ after ‘‘enrollee’’; 12 (II) by striking clause (i); 13 (III) by striking ‘‘(ii)(I) such 14 services’’ and inserting ‘‘(i) such serv- 15 ices’’; 16 (IV) by striking ‘‘where the pro- 17 vider of services does not have a con- 18 tractual relationship with the plan for 19 the providing of services’’; 20 (V) by striking ‘‘emergency de- 21 partment services received from pro- 22 viders who do have such a contractual 23 relationship with the plan; and’’ and 24 inserting ‘‘emergency services received 25 VerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H3502.IH H3502 khammond on DSKBBV9HB2PROD with BILLS 4 •HR 3502 IH from participating providers and par- 1 ticipating emergency facilities with re- 2 spect to such plan;’’; 3 (VI) by striking ‘‘(II) if such serv- 4 ices’’ and all that follows through 5 ‘‘were provided in-network’’ and in- 6 serting the following: 7 ‘‘(ii) the cost-sharing requirement (ex- 8 pressed as a copayment amount, coinsur- 9 ance rate, or deductible) is not greater 10 than the requirement that would apply if 11 such services were provided by a partici- 12 pating provider or a participating emer- 13 gency facility;’’; and 14 (VII) by adding at the end the 15 following new clauses: 16 ‘‘(iii) the group health plan or health 17 insurance issuer offering group or indi- 18 vidual health insurance coverage pays to 19 such provider or facility, respectively, sub- 20 ject to subsection (f), the amount by which 21 the commercially reasonable rate, as deter- 22 mined by the plan or issuer, for such serv- 23 ices exceeds the cost-sharing amount for 24 such services (as determined in accordance 25 VerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H3502.IH H3502 khammond on DSKBBV9HB2PROD with BILLS 5 •HR 3502 IH with clause (ii) and, if applicable, any 1 amount to reconcile the difference between 2 such rate so paid and the specified rate de- 3 termined under subsection (f)(1)) for such 4 services; and 5 ‘‘(iv) there shall be counted toward 6 any deductible or out-of-pocket maximums 7 applied under the plan any cost-sharing 8 payments made by the participant, bene- 9 ficiary, or enrollee with respect to such 10 emergency services so furnished in the 11 same manner as if such cost-sharing pay- 12 ments were with respect to emergency 13 services furnished by a participating pro- 14 vider and a participating emergency facil- 15 ity.’’; and 16 (B) in paragraph (2)— 17 (i) in the matter preceding subpara- 18 graph (A), by inserting ‘‘and subsection 19 (e)’’ after ‘‘this subsection’’; 20 (ii) by redesignating subparagraph 21 (C) as subparagraph (H); and 22 (iii) by inserting after subparagraph 23 (C) the following subparagraphs: 24 VerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H3502.IH H3502 khammond on DSKBBV9HB2PROD with BILLS 6 •HR 3502 IH ‘‘(D) NONPARTICIPATING EMERGENCY FA- 1 CILITY; PARTICIPATING EMERGENCY FACIL- 2 ITY.— 3 ‘‘(i) NONPARTICIPATING EMERGENCY 4 FACILITY.—The term ‘nonparticipating 5 emergency facility’ means, with respect to 6 an item or service and a group health plan 7 or health insurance coverage offered by a 8 health insurance issuer, an emergency de- 9 partment of a hospital or an independent 10 freestanding emergency department, that 11 does not have a contractual relationship 12 with the plan or coverage for furnishing 13 such item or service. 14 ‘‘(ii) PARTICIPATING EMERGENCY FA- 15 CILITY.—The term ‘participating emer- 16 gency facility’ means, with respect to an 17 item or service and a group health plan or 18 health insurance coverage offered by a 19 health insurance issuer, an emergency de- 20 partment of a hospital or an independent 21 freestanding emergency department, that 22 has a contractual relationship with the 23 plan or coverage for furnishing such item 24 or service. 25 VerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H3502.IH H3502 khammond on DSKBBV9HB2PROD with BILLS 7 •HR 3502 IH ‘‘(E) NONPARTICIPATING PROVIDERS; PAR- 1 TICIPATING PROVIDERS.— 2 ‘‘(i) NONPARTICIPATING PROVIDER.— 3 The term ‘nonparticipating provider’ 4 means, with respect to an item or service 5 and a group health plan or health insur- 6 ance coverage offered by a health insur- 7 ance issuer, a physician or other health 8 professional who is licensed by the State 9 involved to furnish such item or service 10 and who does not have a contractual rela- 11 tionship with the plan or coverage for fur- 12 nishing such item or service. 13 ‘‘(ii) PARTICIPATING PROVIDER.—The 14 term ‘participating provider’ means, with 15 respect to an item or service and a group 16 health plan or health insurance coverage 17 offered by a health insurance issuer, a phy- 18 sician or other health professional who is 19 licensed by the State involved to furnish 20 such item or service and who has a con- 21 tractual relationship with the plan or cov- 22 erage for furnishing such item or service.’’. 23 (b) NON-EMERGENCY SERVICES PERFORMED BY 24 NONPARTICIPATING PROVIDERS AT CERTAIN PARTICI- 25 VerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H3502.IH H3502 khammond on DSKBBV9HB2PROD with BILLS 8 •HR 3502 IH PATING FACILITIES.—Section 2719A of the Public Health 1 Service Act (42 U.S.C. 300gg–19a) is amended by adding 2 at the end the following new subsection: 3 ‘‘(e) NON-EMERGENCY SERVICES PERFORMED BY 4 NONPARTICIPATING PROVIDERS AT CERTAIN PARTICI- 5 PATING FACILITIES.— 6 ‘‘(1) IN GENERAL.—In the case of items or 7 services (other than emergency services to which 8 subsection (b) applies) furnished to a participant, 9 beneficiary, or enrollee of a health plan (as defined 10 in paragraph (2)(A)) by a nonparticipating provider 11 (as defined in subsection (b)(2)(G)) during a visit at 12 a participating health care facility (as defined in 13 paragraph (2)(B)) (including imaging or laboratory 14 services so furnished by a nonparticipating provider 15 when ordered by a participating provider or after- 16 emergency care furnished by a nonparticipating pro- 17 vider in the case that the participant, beneficiary, or 18 enrollee cannot travel without medical transport), 19 with respect to such plan, the plan— 20 ‘‘(A) shall not impose on such participant, 21 beneficiary, or enrollee a cost-sharing amount 22 (expressed as a copayment amount or coinsur- 23 ance rate) for such items and services so fur- 24 nished that is greater than the cost-sharing 25 VerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H3502.IH H3502 khammond on DSKBBV9HB2PROD with BILLS 9 •HR 3502 IH amount that would apply under such plan had 1 such items or services been furnished by a par- 2 ticipating provider; 3 ‘‘(B) shall pay to such provider furnishing 4 such items and services to such participant, 5 beneficiary, or enrollee, subject to subsection 6 (f), the amount by which the commercially rea- 7 sonable rate, as determined by the plan or 8 issuer, for such services exceeds the cost-shar- 9 ing amount imposed for such services (as deter- 10 mined in accordance with subparagraph (A)) 11 and, if applicable, any amount to reconcile the 12 difference between such rate so paid and the 13 specified rate (determined under subsection 14 (f)(1)) for such services; and 15 ‘‘(C) shall count toward any deductible or 16 out-of-pocket maximums applied under the plan 17 any cost-sharing payments made by the partici- 18 pant, beneficiary, or enrollee with respect to 19 such items and services so furnished in the 20 same manner as if such cost-sharing payments 21 were with respect to items and services fur- 22 nished by a participating provider. 23 ‘‘(2) DEFINITIONS.—In this subsection and 24 subsection (f): 25 VerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H3502.IH H3502 khammond on DSKBBV9HB2PROD with BILLS 10 •HR 3502 IH ‘‘(A) HEALTH PLAN.—The term ‘health 1 plan’ means a group health plan and health in- 2 surance coverage offered by a heath insurance 3 issuer in the group or individual market. 4 ‘‘(B) PARTICIPATING HEALTH CARE FACIL- 5 ITY.— 6 ‘‘(i) IN GENERAL.—The term ‘partici- 7 pating health care facility’ means, with re- 8 spect to an item or service and a group 9 health plan or health insurance coverage 10 offered by a health insurance issuer, a 11 health care facility described in clause (ii) 12 that has a contractual relationship with 13 the plan or coverage for furnishing such 14 item or service. 15 ‘‘(ii) HEALTH CARE FACILITY DE- 16 SCRIBED.—A health care facility described 17 in this clause is each of the following: 18 ‘‘(I) A hospital (as defined in 19 1861(e) of the Social Security Act). 20 ‘‘(II) A critical access hospital 21 (as defined in section 1861(mm) of 22 such Act). 23 VerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H3502.IH H3502 khammond on DSKBBV9HB2PROD with BILLS 11 •HR 3502 IH ‘‘(III) An ambulatory surgical 1 center (as defined in section 2 1833(i)(1)(A) of such Act). 3 ‘‘(IV) A laboratory. 4 ‘‘(V) A radiology or imaging cen- 5 ter. 6 ‘‘(VI) Any other facility that pro- 7 vides services that are covered under 8 a group health plan or health insur- 9 ance coverage. 10 ‘‘(VII) Any other facility speci- 11 fied by the Secretary.’’. 12 (c) NEGOTIATION AND ARBITRATION PROCESS FOR 13 DETERMINING PRICES.—Section 2719A of the Public 14 Health Service Act (42 U.S.C. 300gg–19a), as amended 15 by subsection (b), is further amended by adding at the 16 end the following new subsection: 17 ‘‘(f) NEGOTIATION AND ARBITRATION PROCESS.— 18 ‘‘(1) SPECIFIED AMOUNT.—For purposes of 19 subsections (b) and (e) and this subsection, the spec- 20 ified amount determined under this subsection, with 21 respect to a health plan and nonparticipating pro- 22 vider for an item or service, is— 23 ‘‘(A) in the case the plan and provider 24 enter into negotiations pursuant to paragraph 25 VerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H3502.IH H3502 khammond on DSKBBV9HB2PROD with BILLS 12 •HR 3502 IH (2) and such negotiations are successful, the 1 amount determined for such item or service 2 pursuant to such negotiations; or 3 ‘‘(B) in the case the plans and provider 4 enter into such negotiations but such negotia- 5 tions are not successful, the reasonable amount 6 determined for such item or service pursuant to 7 the independent dispute resolution process 8 under paragraph (3). 9 ‘‘(2) NEGOTIATIONS.—For purposes of sub- 10 sections (b)(1)(C)(iii) and (e)(1)(B), in the case of 11 a payment of a commercially reasonable rate made 12 by a health plan to a nonparticipating provider pur- 13 suant to such respective subsection for an item or 14 service, the provider and plan may, not later than 30 15 days after the date of such payment, negotiate an 16 amount of payment (other than the commercially 17 reasonable rate specified in such subsection) to be 18 made for such item or service. 19 ‘‘(3) INDEPENDENT DISPUTE RESOLUTION.— 20 ‘‘(A) IN GENERAL.—If, by the end of such 21 30-day period specified in paragraph (2), the 22 plan and provider have not determined a nego- 23 tiated amount for the payment involved, the 24 plan or provider may initiate an independent 25 VerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 0001 [Text truncated for display. 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