[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[S. 3592 Introduced in Senate (IS)]

<DOC>






115th CONGRESS
  2d Session
                                S. 3592

  To amend the Public Health Service Act to prevent surprise medical 
               billing practices, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                            October 11, 2018

  Ms. Hassan (for herself and Mrs. Shaheen) introduced the following 
  bill; which was read twice and referred to the Committee on Health, 
                     Education, Labor, and Pensions

_______________________________________________________________________

                                 A BILL


 
  To amend the Public Health Service Act to prevent surprise medical 
               billing practices, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``No More Surprise Medical Bills Act 
of 2018''.

SEC. 2. PREVENTING SURPRISE BILLING PRACTICES.

    (a) In General.--
            (1) Prohibition.--Subpart II of part A of title XXVII of 
        the Public Health Service Act (42 U.S.C. 300gg-11 et seq.) is 
        amended by adding at the end the following:

``SEC. 2729. PREVENTING SURPRISE BILLING PRACTICES.

    ``(a) Definitions.--In this section:
            ``(1) Health care provider.--The term `health care 
        provider' means--
                    ``(A) a hospital (as defined in section 1861(e) of 
                the Social Security Act);
                    ``(B) a critical access hospital (as defined in 
                section 1861(mm) of such Act);
                    ``(C) an ambulatory surgical center as described in 
                section 1833(i)(1)(A) of such Act; or
                    ``(D) a provider of services or supplier furnishing 
                services at such hospital, critical access hospital, or 
                ambulatory surgical center.
            ``(2) In-network health care provider.--The term `in-
        network health care provider', with respect to a group health 
        plan or health insurance coverage offered in the group market, 
        means a health care provider that is within the health care 
        provider network of the plan or coverage or is otherwise a 
        participating provider of services or supplier with respect to 
        such plan or coverage.
            ``(3) Out-of-network health care provider.--The term `out-
        of-network health care provider', with respect to a group 
        health plan or health insurance coverage offered in the group 
        market, means a health care provider that is not within the 
        health care provider network of the plan or coverage or is not 
        otherwise a participating provider of services or supplier with 
        respect to such plan or coverage.
    ``(b) Requirement for Notice and Consent.--
            ``(1) Notice.--A health care provider, in the case of an 
        individual enrolled in a group health plan or health insurance 
        coverage offered in the group market, who seeks to be furnished 
        items or services or is to be furnished items or services by 
        the provider, shall--
                    ``(A)(i) provide to the individual (or to a 
                representative of the individual), on the date on which 
                the individual makes an appointment to be furnished 
                such items or services, if applicable, and on the date 
                on which the individual is furnished such items and 
                services--
                            ``(I) an oral explanation of the written 
                        notification described in subclause (II) and 
                        such documentation of the provision of such 
                        explanation, as the Secretary determines 
                        appropriate; and
                            ``(II) a written notice specified by the 
                        Secretary through rulemaking that--
                                    ``(aa) contains the information 
                                required under paragraph (2); and
                                    ``(bb) is signed and dated by the 
                                individual; and
                    ``(ii) retain, for a period specified through 
                rulemaking by the Secretary, a copy of the 
                documentation described in clause (i)(I) and the 
                written notice described in clause (i)(II); and
                    ``(B) in the case that such provider is an out-of-
                network health care provider, obtain from the 
                individual the consent described in paragraph (3).
            ``(2) Information included in notice.--The notice described 
        in paragraph (1)(A) shall include, with respect to the 
        individual described in such paragraph, a notification of each 
        of the following:
                    ``(A) Whether the health care provider is an out-
                of-network health care provider with respect to the 
                group health plan, or health insurance coverage offered 
                in the group market, of such individual.
                    ``(B) If the health care provider is such an out-
                of-network health care provider, the estimated amount 
                that such provider will charge the individual for such 
                items and services in excess of any cost sharing 
                obligations that the individual would otherwise have 
                under such plan or coverage for such items and services 
                if the health care provider were an in-network health 
                care provider with respect to the plan or coverage of 
                such individual.
                    ``(C) In the case of a health care provider that is 
                a hospital, critical access hospital, or ambulatory 
                surgical center as described in subparagraph (A), (B), 
                or (C) of subsection (a)(1), respectively--
                            ``(i) whether any of the providers of 
                        services or suppliers furnishing items or 
                        services at such hospital, critical access 
                        hospital, or ambulatory surgical center who 
                        will furnish the items or services to the 
                        individual are out-of-network health care 
                        providers with respect to the group health 
                        plan, or health insurance coverage offered in 
                        the group market, of such individual; and
                            ``(ii) if any such providers of services or 
                        suppliers are such out-of-network health care 
                        providers, the estimated amount that such 
                        providers or suppliers will charge the 
                        individual for such items and services in 
                        excess of any cost sharing obligations that the 
                        individual would otherwise have for such items 
                        and services if the providers or suppliers were 
                        in-network health care providers with respect 
                        to the plan or coverage of such individual.
            ``(3) Consent described.--For purposes of paragraph (1)(B), 
        the consent described in this paragraph, with respect to an 
        individual enrolled in a group health plan, or health insurance 
        coverage offered in the group market, who is to be furnished 
        items or services by an out-of-network health care provider, is 
        a document specified by the Secretary through rulemaking that 
        is signed by the individual (or by a representative of the 
        individual) not less than 24 hours prior to the individual 
        being furnished such items or services by such health care 
        provider, and that--
                    ``(A) acknowledges that the individual has been--
                            ``(i) provided with a written estimate and 
                        an oral explanation of the charge that the 
                        individual will be assessed for the items or 
                        services anticipated to be furnished to the 
                        individual by such out-of-network health care 
                        provider; and
                            ``(ii) informed that the payment of such 
                        charge by the individual will not accrue toward 
                        meeting any limitation that the group health 
                        plan, or health insurance coverage offered in 
                        the group market, places on cost-sharing; and
                    ``(B) documents the consent of the individual to--
                            ``(i) be furnished with such items or 
                        services by such out-of-network health care 
                        provider; and
                            ``(ii) in the case that the individual is 
                        so furnished such items or services, be charged 
                        an amount approximate to the estimated charge 
                        described in subparagraph (A)(i) with respect 
                        to such items or services.
    ``(c) Limitations on Balance Billing in Surprise Billing 
Situations.--
            ``(1) In case of noncompliance with notice and consent 
        requirements.--In the case of an individual enrolled in a group 
        health plan, or health insurance coverage offered in the group 
        market, who is furnished items or services by an out-of-network 
        health care provider with respect to such plan or coverage, if 
        the out-of-network health care provider does not comply with 
        the requirements of subsection (b) with respect to the 
        furnishing of such items or services to such individual, the 
        out-of-network health care provider may not charge the 
        individual more than the amount that the individual would have 
        been required to pay in cost sharing if such items or services 
        had been furnished by an in-network health care provider with 
        respect to such plan or coverage.
            ``(2) In case of same-day emergency services.--In the case 
        of an individual enrolled in a group health plan or health 
        insurance coverage offered in the group market who is furnished 
        items or services by a health care provider that is an out-of-
        network health care provider with respect to such plan or 
        coverage on the same date on which the individual makes an 
        appointment for such items or services (or otherwise presents 
        at the hospital, critical access hospital, or ambulatory 
        surgical center for such services such as in the case of items 
        and services furnished with respect to an emergency medical 
        condition, as defined in section 1867(e)), the out-of-network 
        health care provider may not charge the individual more than 
        the amount that the individual would have been required to pay 
        in cost sharing if such items or services had been furnished by 
        an in-network health care provider with respect to such plan or 
        coverage.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect beginning 2 years after the date of the 
        enactment of this Act.
    (b) Condition of Participation in Medicare.--
            (1) In general.--Section 1866(a)(1) of the Social Security 
        Act (42 U.S.C. 1395cc(a)(1)) is amended--
                    (A) in subparagraph (X), by striking ``and'' at the 
                end;
                    (B) in subparagraph (Y), by striking at the end the 
                period and inserting ``, and''; and
                    (C) by inserting after such subparagraph (Y) the 
                following new subparagraph:
                    ``(Z) in the case of a hospital, a critical access 
                hospital, or an ambulatory surgical center described in 
                section 1833(i)(1)(A), to adopt and enforce a policy to 
                ensure compliance with the requirements of subsections 
                (b) and (c) of section 2729 of the Public Health 
                Service Act and to meet the requirements of such 
                subsections (relating to the prevention of surprise 
                billing practices);''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply with respect to agreements under such section 
        1866(a)(1) that are filed with the Secretary of Health and 
        Human Services on a date that is not less than 2 years after 
        the date of the enactment of this Act.

SEC. 3. PAYMENTS MADE BY INSURED INDIVIDUALS IN SURPRISE BILLING 
              SITUATIONS INCLUDED IN COST-SHARING LIMITATIONS.

    (a) In General.--Section 2707 of the Public Health Service Act (42 
U.S.C. 300gg-6) is amended by adding at the end the following:
    ``(e) Surprise Billing Situations.--Notwithstanding section 
1302(c)(3)(B) of the Patient Protection and Affordable Care Act (42 
U.S.C. 18022(c)(3)(B)), any group health plan or health insurance 
issuer offering health insurance coverage in the group market shall 
ensure that any amount paid by an individual enrolled in such plan or 
coverage in a surprise billing situation, as defined in section 
2730(a), accrues towards meeting any annual limitation on cost-sharing 
under the plan or coverage.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply with respect to any plan year beginning not earlier than 2 years 
after the date of enactment of this Act.

SEC. 4. RESOLVING PAYMENT DISPUTES IN SURPRISE BILLING SITUATIONS.

    Subpart II of part A of title XXVII of the Public Health Service 
Act (42 U.S.C. 300gg-11 et seq.), as amended by section 2(a), is 
further amended by adding at the end the following:

``SEC. 2730. RESOLVING PAYMENT DISPUTES IN SURPRISE BILLING SITUATIONS.

    ``(a) Definitions.--In this section:
            ``(1) Health care provider; in-network health care 
        provider; out-of-network health care provider.--The terms 
        `health care provider', `in-network health care provider', and 
        `out-of-network health care provider' have the meanings given 
        such terms in section 2729(a).
            ``(2) Independent dispute resolution entity.--The term 
        `independent dispute resolution entity' means an entity 
        certified by the Secretary, in consultation with the Secretary 
        of Labor, under subsection (b)(2) to conduct an independent 
        dispute resolution process under subsection (d).
            ``(3) Surprise billing situation.--The term `surprise 
        billing situation' means--
                    ``(A) a situation in which an individual who is 
                enrolled in a group health plan, or health insurance 
                coverage offered in the group market, is furnished 
                items or services by an out-of-network health care 
                provider and such provider does not comply with the 
                requirements of section 2729(b) with respect to the 
                furnishing of such items or services to such 
                individual; or
                    ``(B) a situation in which an individual who is 
                enrolled in a group health plan, or health insurance 
                coverage offered in the group market, is furnished 
                items or services by an out-of-network health care 
                provider on the same date on which the individual makes 
                an appointment for such items or services (or otherwise 
                presents at the hospital, critical access hospital, or 
                ambulatory surgical center for such services such as in 
                the case of items and services furnished with respect 
                to an emergency medical condition, as defined in 
                section 1867(e)).
    ``(b) Establishment of Independent Dispute Resolution Process.--
            ``(1) Establishment.--Not later than 2 years after the date 
        of enactment of this section, the Secretary, in consultation 
        with the Secretary of Labor, shall establish a process for 
        resolving payment disputes between group health plans, or 
        health insurance issuers offering health insurance coverage in 
        the group market, and out-of-network health care providers in 
        surprise billing situations in accordance with this section.
            ``(2) Certification of independent dispute resolution 
        entities.--
                    ``(A) In general.--The Secretary, in consultation 
                with the Secretary of Labor, shall establish a process 
                through rulemaking to certify entities as independent 
                dispute resolution entities to conduct independent 
                dispute resolution processes under subsection (d).
                    ``(B) Requirements.--To be eligible for 
                certification under this paragraph, an entity shall--
                            ``(i) have experience in health care 
                        billing, health care pricing, and arbitration; 
                        and
                            ``(ii) not have any conflict of interest, 
                        as determined in accordance with subparagraph 
                        (C).
                    ``(C) Conflict of interest.--The Secretary, in 
                consultation with the Secretary of Labor, shall 
                determine, through rulemaking, the criteria for a 
                conflict of interest for purposes of subparagraph 
                (B)(ii), which shall include--
                            ``(i) having any material arrangement, 
                        financial or otherwise, that could bias the 
                        entity, or an employee of the entity working on 
                        a particular dispute; or
                            ``(ii) owning or controlling, being owned 
                        by or controlled by, or being under common 
                        control of--
                                    ``(I) any pharmaceutical company, 
                                disease group, or public advocacy 
                                group;
                                    ``(II) any national, State, or 
                                local society or association of 
                                hospitals, physicians, or other 
                                providers of health care services; or
                                    ``(III) any national, State, or 
                                local association of health care plans.
    ``(c) Pre-Independent Dispute Resolution Process.--
            ``(1) Requirement to pay out-of-network health care 
        providers.--
                    ``(A) Requirement on plan.--The process established 
                by the Secretary, in consultation with the Secretary of 
                Labor, under this section shall require that a group 
                health plan, or health insurance issuer offering health 
                insurance coverage in the group market, that receives a 
                bill from an out-of-network health care provider for 
                items or services furnished to an individual enrolled 
                in the plan or coverage in a surprise billing 
                situation, not later than 30 days after receiving such 
                bill--
                            ``(i) pay the out-of-network health care 
                        provider the amount in the bill; or
                            ``(ii) attempt to negotiate with the out-
                        of-network health care provider an alternative 
                        amount for the plan or issuer to pay the 
                        provider.
                    ``(B) Pre-independent dispute resolution 
                negotiations.--If, not later than 30 days after the 
                date on which negotiations begin under subparagraph 
                (A)(ii), an out-of-network health care provider and 
                group health plan, or health insurance issuer offering 
                health insurance coverage in the group market, 
                described in subparagraph (A) have not agreed upon an 
                alternative amount for the plan or issuer to pay the 
                provider, the plan or issuer shall--
                            ``(i) pay the provider the amount the plan 
                        or issuer determines reasonable for the 
                        services (less the cost-sharing amount paid by 
                        the individual enrolled in the plan or 
                        coverage); and
                            ``(ii) provide information to the provider 
                        on how the provider may initiate an independent 
                        dispute resolution process under paragraph (2).
            ``(2) Initiating an independent dispute resolution 
        process.--
                    ``(A) In general.--If, after a good faith attempt 
                to negotiate under paragraph (1)(A)(ii), the out-of-
                network health care provider and group health plan, or 
                health insurance issuer offering health insurance 
                coverage in the group market, described in paragraph 
                (1)(A) are unable to reach an agreement on an amount 
                for the plan or issuer to pay the provider, any party 
                to the dispute may, not later than 30 days of being 
                unable to come to an agreement, as determined by the 
                Secretary, in consultation with the Secretary of Labor, 
                initiate an independent dispute resolution process 
                under subsection (d) by submitting a request for such 
                process to the Secretary, and the Secretary of Labor, 
                or directly to an independent dispute resolution 
                entity, in accordance with the process established by 
                the Secretary, in consultation with the Secretary of 
                Labor, under this section.
                    ``(B) Request.--A request submitted under 
                subparagraph (A) shall indicate--
                            ``(i) the amount the out-of-network health 
                        care provider requested in the bill described 
                        in subparagraph (A) of paragraph (1) or after 
                        attempted negotiations in accordance with such 
                        paragraph; and
                            ``(ii) the amount the group health plan, or 
                        health insurance issuer offering health 
                        insurance coverage in the group market, paid 
                        the out-of-network health care provider in 
                        accordance with paragraph (1)(B) after such 
                        negotiations.
                    ``(C) Notice to other party.--A party initiating an 
                independent dispute resolution process under 
                subparagraph (A) shall, not later than 10 days after 
                submitting a request under such subparagraph, notify 
                the other party that such request has been submitted.
    ``(d) Independent Dispute Resolution Process.--
            ``(1) In general.--The Secretary, in consultation with the 
        Secretary of Labor, shall establish procedures for independent 
        dispute resolution entities to conduct independent dispute 
        resolution processes under this subsection to resolve payment 
        disputes between group health plans, or health insurance 
        issuers offering health insurance coverage in the group market, 
        and out-of-network health care providers.
            ``(2) Timing.--An independent dispute resolution entity 
        that receives a request under subsection (c)(2)(A) shall, not 
        later than 30 days after receiving such request, determine the 
        amount the group health plan, or health insurance issuer 
        offering health insurance coverage in the group market, is 
        required to pay the out-of-network health care provider. Such 
        amount shall be--
                    ``(A) the amount determined by the parties through 
                a settlement under paragraph (3); or
                    ``(B) the amount determined reasonable by the 
                entity in accordance with paragraph (4).
            ``(3) Settlement.--
                    ``(A) In general.--If the independent dispute 
                resolution entity determines, based on the amounts 
                indicated in the request under subsection (c)(2)(B), 
                that a settlement between the group health plan, or 
                health insurance issuer offering health insurance 
                coverage in the group market, and out-of-network health 
                care provider is likely or that the amounts provided in 
                such subsection each represent unreasonable extremes, 
                the independent dispute resolution entity may direct 
                the parties to attempt, for a period not to exceed 10 
                days, a good faith negotiation for a settlement.
                    ``(B) Timing.--The period for a settlement 
                described in subparagraph (A) shall accrue towards the 
                30-day period required under paragraph (2).
            ``(4) Determination of amount.--
                    ``(A) Final offers.--In the absence of a settlement 
                under paragraph (3), the group health plan, or health 
                insurance issuer offering health insurance coverage in 
                the group market, and out-of-network health care 
                provider shall each submit to the independent dispute 
                resolution entity an amount as a final offer. Such 
                entity shall determine which of those 2 amounts is more 
                reasonable based on the factors described in 
                subparagraph (D).
                    ``(B) Final decisions.--The amount that is 
                determined to be the more reasonable amount under 
                subparagraph (A) shall be the final decision of the 
                independent dispute resolution entity as to the amount 
                the group health plan, or health insurance issuer 
                offering health insurance coverage in the group market, 
                is required to pay the out-of-network health care 
                provider.
                    ``(C) Service units.--A final offer submitted under 
                subparagraph (A) shall be made per service unit, as 
                defined by the Secretary, in consultation with the 
                Secretary of Labor, through regulations. A final 
                decision under subparagraph (B) may include the 
                resolution of disputes for multiple items or services 
                for a single patient, such as for instances in which 
                multiple specialists are involved.
                    ``(D) Factors.--In determining which final offer to 
                select as the more reasonable amount under subparagraph 
                (A), the independent dispute resolution entity shall 
                consider relevant factors including--
                            ``(i) the average in-network payment rate 
                        for comparable items or services in the same 
                        geographic region, including as calculated by 
                        an independent database or an all-payer claims 
                        database;
                            ``(ii) the level of training, education, 
                        and experience of the out-of-network health 
                        care provider;
                            ``(iii) the circumstances and complexity of 
                        the particular dispute, including the time and 
                        place of the service; and
                            ``(iv) the payment rate determined for the 
                        item or service under the original Medicare 
                        fee-for-service program under parts A and B of 
                        title XVIII of the Social Security Act.
            ``(5) Effect of decision.--A final decision of an 
        independent dispute resolution entity under paragraph (4)(B)--
                    ``(A) shall be binding; and
                    ``(B) shall not be subject to judicial review, 
                except in cases comparable to those described in 
                section 10(a) of title 9, United States Code, as 
                determined by the Secretary in consultation with the 
                Secretary of Labor.
            ``(6) Privacy laws.--An independent dispute resolution 
        entity shall, in conducting an independent dispute resolution 
        process under this subsection, comply with all applicable 
        Federal and State privacy laws.
    ``(e) Responsibility To Pay Costs.--The costs for an independent 
dispute resolution process under subsection (d) shall be paid for in 
accordance with the following:
            ``(1) In a case in which the independent dispute resolution 
        entity determines that the amount in the final offer submitted 
        under subsection (d)(4)(A) by the out-of-network health care 
        provider is the more reasonable amount, the group health plan, 
        or health insurance issuer offering health insurance coverage 
        in the group market, shall pay all costs of the independent 
        dispute resolution process.
            ``(2) In a case in which the independent dispute resolution 
        entity determines that the amount in the final offer submitted 
        under subsection (d)(4)(A) by the group health plan, or health 
        insurance issuer offering health insurance coverage in the 
        group market, is the more reasonable amount, the out-of-network 
        health care provider shall pay all costs of the independent 
        dispute resolution process.
            ``(3) In a case in which a settlement is reached under 
        subsection (d)(3), the group health plan, or health insurance 
        issuer offering health insurance coverage in the group market, 
        and the out-of-network health care provider shall each pay half 
        of the costs of the independent dispute resolution process.
    ``(f) Reports.--
            ``(1) Entity reports.--Not later than 4 years after the 
        date of enactment of this section, and each year thereafter, 
        each independent dispute resolution entity shall submit to the 
        Secretary, and the Secretary of Labor, a report on all 
        independent dispute resolution processes conducted by the 
        entity under subsection (d) for the period of the report. Each 
        such report shall contain information determined appropriate by 
        the Secretary, in consultation with the Secretary of Labor, in 
        order to prepare the report required under paragraph (2).
            ``(2) Reports by secretaries.--
                    ``(A) In general.--Not later than 5 years after the 
                date of enactment of this section, and each year 
                thereafter, the Secretary, in consultation with the 
                Secretary of Labor, shall based on the reports 
                submitted under paragraph (1) prepare a report, 
                disaggregated by State, that contains each of the 
                following for the period of the report:
                            ``(i) The total number of independent 
                        dispute resolution processes initiated under 
                        subsection (c)(2)(A), including an indication 
                        of the number of instances in which--
                                    ``(I) the amount in the final offer 
                                under subsection (d)(4)(A) made by the 
                                group health plan, or health insurance 
                                issuer offering health insurance 
                                coverage in the group market, was 
                                determined to be more reasonable than 
                                the amount in the final offer under 
                                such subsection made by the out-of-
                                network health care provider;
                                    ``(II) the amount in the final 
                                offer under subsection (d)(4)(A) made 
                                by the out-of-network health care 
                                provider was determined to be more 
                                reasonable than the amount in the final 
                                offer under such subsection made by the 
                                group health plan, or health insurance 
                                issuer offering health insurance 
                                coverage in the group market; and
                                    ``(III) a settlement was reached 
                                under subsection (d)(3).
                            ``(ii) The number of requests made for an 
                        independent dispute resolution process under 
                        subsection (c)(2)(A) that were determined to be 
                        ineligible for such process and the reason for 
                        such determination.
                            ``(iii) The number of independent dispute 
                        resolution processes conducted under subsection 
                        (d) that--
                                    ``(I) were based on a situation 
                                described in subsection (a)(3)(A); and
                                    ``(II) were based on a situation 
                                described in subsection (a)(3)(B).
                            ``(iv) The total number of final decisions 
                        rendered by independent dispute resolution 
                        entities under subsection (d)(4)(B).
                            ``(v) For each independent dispute 
                        resolution process conducted under subsection 
                        (d)--
                                    ``(I) the type of coverage of the 
                                plan or issuer involved, such as 
                                whether the plan or issuer is a health 
                                maintenance organization or preferred 
                                provider organization;
                                    ``(II) the specialty of the out-of-
                                network health care provider, and 
                                specific types of services, involved; 
                                and
                                    ``(III) the dollar amount of the 
                                final decision under subsection 
                                (d)(4)(B).
                            ``(vi) Any additional information the 
                        Secretary, in consultation with the Secretary 
                        of Labor, determines necessary.
                    ``(B) Public access.--The Secretary, in 
                consultation with the Secretary of Labor, shall, each 
                year, publish the report prepared under subparagraph 
                (A) and make such report available to the public.
                    ``(C) Privacy.--In carrying out this paragraph, the 
                Secretary, in consultation with the Secretary of Labor, 
                shall comply with all applicable Federal and State 
                privacy laws.
    ``(g) Applicability of State Law.--
            ``(1) In general.--Notwithstanding any other provision in 
        this section, the process established by the Secretary, in 
        consultation with the Secretary of Labor, under this section 
        shall not apply with respect to any surprise billing situation 
        involving a group health plan (other than a self-insured plan), 
        or health insurance issuer offering health insurance coverage 
        in the group market, in a State that has in effect a State law 
        that applies to the dispute involved and meets the requirements 
        under paragraph (2).
            ``(2) Requirements.--
                    ``(A) In general.--The requirements under this 
                paragraph are that the State law provides, in a 
                surprise billing situation, for--
                            ``(i) a dispute resolution process meeting 
                        the requirements under subparagraph (B); or
                            ``(ii) a payment standard that meets the 
                        requirements under subparagraph (C).
                    ``(B) Dispute resolution process.--The requirements 
                for a dispute resolution process under this 
                subparagraph are that the entity conducting the 
                process--
                            ``(i) be an independent entity whereby the 
                        entity shall not represent the interests of any 
                        party to the dispute and shall be free of any 
                        conflict of interest; and
                            ``(ii) report to the public on the results 
                        of the process.
                    ``(C) Payment standard.--The requirements for a 
                payment standard under this paragraph are that the 
                group health plan, or health insurance issuer offering 
                health insurance coverage in the group market, pay the 
                out-of-network health care provider in the surprise 
                billing situation an amount at a rate--
                            ``(i) that does not exceed 125 percent of 
                        the allowed charges for items or services under 
                        the original Medicare fee-for-service program 
                        under parts A and B of title XXVIII of the 
                        Social Security Act; or
                            ``(ii) that does not exceed a payment 
                        standard comparable to the standard described 
                        in clause (i), as determined by the Secretary, 
                        in consultation with the Secretary of Labor.
            ``(3) Clarification for self-insured group health plans.--
        With respect to any payment dispute in a surprise billing 
        situation involving a self-insured group health plan--
                    ``(A) the process established by the Secretary, in 
                consultation with the Secretary of Labor, under this 
                section shall apply; and
                    ``(B) any State law that meets the requirements 
                under paragraph (2), and may otherwise apply, shall not 
                apply.''.
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