[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3502 Introduced in House (IH)]

<DOC>






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 Tennessee, 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. Cardenas, 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 Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Protecting People 
From Surprise Medical Bills Act''.
    (b) Table of Contents.--The table of contents for this Act is as 
follows:

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.

    (a) Emergency Services Performed by Nonparticipating Providers.--
Section 2719A of the Public Health Service Act (42 U.S.C. 300gg-19a) is 
amended--
            (1) in subsection (b)--
                    (A) in paragraph (1)--
                            (i) in the matter preceding subparagraph 
                        (A)--
                                    (I) by striking ``offering group or 
                                individual health insurance issuer'' 
                                and inserting ``offering group or 
                                individual health insurance coverage''; 
                                and
                                    (II) by striking ``paragraph 
                                (2)(B)'' and inserting ``paragraph 
                                (2)'';
                            (ii) in subparagraph (B), by inserting ``or 
                        a participating emergency facility, as 
                        applicable,'' after ``participating provider''; 
                        and
                            (iii) in subparagraph (C)--
                                    (I) in the matter preceding clause 
                                (i), by inserting ``by a 
                                nonparticipating provider or a 
                                nonparticipating emergency facility'' 
                                after ``enrollee'';
                                    (II) by striking clause (i);
                                    (III) by striking ``(ii)(I) such 
                                services'' and inserting ``(i) such 
                                services'';
                                    (IV) by striking ``where the 
                                provider of services does not have a 
                                contractual relationship with the plan 
                                for the providing of services'';
                                    (V) by striking ``emergency 
                                department services received from 
                                providers who do have such a 
                                contractual relationship with the plan; 
                                and'' and inserting ``emergency 
                                services received from participating 
                                providers and participating emergency 
                                facilities with respect to such 
                                plan;'';
                                    (VI) by striking ``(ii) if such 
                                services'' and all that follows through 
                                ``were provided in-network'' and 
                                inserting the following:
                            ``(ii) the cost-sharing requirement 
                        (expressed as a copayment amount, coinsurance 
                        rate, or deductible) is not greater than the 
                        requirement that would apply if such services 
                        were provided by a participating provider or a 
                        participating emergency facility;''; and
                                    (VII) by adding at the end the 
                                following new clauses:
                            ``(iii) the group health plan or health 
                        insurance issuer offering group or individual 
                        health insurance coverage pays to such provider 
                        or facility, respectively, subject to 
                        subsection (f), the amount by which the 
                        commercially reasonable rate, as determined by 
                        the plan or issuer, for such services exceeds 
                        the cost-sharing amount for such services (as 
                        determined in accordance with clause (ii) and, 
                        if applicable, any amount to reconcile the 
                        difference between such rate so paid and the 
                        specified rate determined under subsection 
                        (f)(1)) for such services; and
                            ``(iv) there shall be counted toward any 
                        deductible or out-of-pocket maximums applied 
                        under the plan any cost-sharing payments made 
                        by the participant, beneficiary, or enrollee 
                        with respect to such emergency services so 
                        furnished in the same manner as if such cost-
                        sharing payments were with respect to emergency 
                        services furnished by a participating provider 
                        and a participating emergency facility.''; and
                    (B) in paragraph (2)--
                            (i) in the matter preceding subparagraph 
                        (A), by inserting ``and subsection (e)'' after 
                        ``this subsection'';
                            (ii) by redesignating subparagraph (C) as 
                        subparagraph (H); and
                            (iii) by inserting after subparagraph (C) 
                        the following subparagraphs:
                    ``(D) Nonparticipating emergency facility; 
                participating emergency facility.--
                            ``(i) Nonparticipating emergency 
                        facility.--The term `nonparticipating emergency 
                        facility' means, with respect to an item or 
                        service and a group health plan or health 
                        insurance coverage offered by a health 
                        insurance issuer, an emergency department of a 
                        hospital or an independent freestanding 
                        emergency department, that does not have a 
                        contractual relationship with the plan or 
                        coverage for furnishing such item or service.
                            ``(ii) Participating emergency facility.--
                        The term `participating emergency facility' 
                        means, with respect to an item or service and a 
                        group health plan or health insurance coverage 
                        offered by a health insurance issuer, an 
                        emergency department of a hospital or an 
                        independent freestanding emergency department, 
                        that has a contractual relationship with the 
                        plan or coverage for furnishing such item or 
                        service.
                    ``(E) Nonparticipating providers; participating 
                providers.--
                            ``(i) Nonparticipating provider.--The term 
                        `nonparticipating provider' means, with respect 
                        to an item or service and a group health plan 
                        or health insurance coverage offered by a 
                        health insurance issuer, a physician or other 
                        health professional who is licensed by the 
                        State involved to furnish such item or service 
                        and who does not have a contractual 
                        relationship with the plan or coverage for 
                        furnishing such item or service.
                            ``(ii) Participating provider.--The term 
                        `participating provider' means, with respect to 
                        an item or service and a group health plan or 
                        health insurance coverage offered by a health 
                        insurance issuer, a physician or other health 
                        professional who is licensed by the State 
                        involved to furnish such item or service and 
                        who has a contractual relationship with the 
                        plan or coverage for furnishing such item or 
                        service.''.
    (b) Non-Emergency Services Performed by Nonparticipating Providers 
at Certain Participating Facilities.--Section 2719A of the Public 
Health Service Act (42 U.S.C. 300gg-19a) is amended by adding at the 
end the following new subsection:
    ``(e) Non-Emergency Services Performed by Nonparticipating 
Providers at Certain Participating Facilities.--
            ``(1) In general.--In the case of items or services (other 
        than emergency services to which subsection (b) applies) 
        furnished to a participant, beneficiary, or enrollee of a 
        health plan (as defined in paragraph (2)(A)) by a 
        nonparticipating provider (as defined in subsection (b)(2)(G)) 
        during a visit at a participating health care facility (as 
        defined in paragraph (2)(B)) (including imaging or laboratory 
        services so furnished by a nonparticipating provider when 
        ordered by a participating provider or after-emergency care 
        furnished by a nonparticipating provider in the case that the 
        participant, beneficiary, or enrollee cannot travel without 
        medical transport), with respect to such plan, the plan--
                    ``(A) shall not impose on such participant, 
                beneficiary, or enrollee a cost-sharing amount 
                (expressed as a copayment amount or coinsurance rate) 
                for such items and services so furnished that is 
                greater than the cost-sharing amount that would apply 
                under such plan had such items or services been 
                furnished by a participating provider;
                    ``(B) shall pay to such provider furnishing such 
                items and services to such participant, beneficiary, or 
                enrollee, subject to subsection (f), the amount by 
                which the commercially reasonable rate, as determined 
                by the plan or issuer, for such services exceeds the 
                cost-sharing amount imposed for such services (as 
                determined in accordance with subparagraph (A)) and, if 
                applicable, any amount to reconcile the difference 
                between such rate so paid and the specified rate 
                (determined under subsection (f)(1)) for such services; 
                and
                    ``(C) shall count toward any deductible or out-of-
                pocket maximums applied under the plan any cost-sharing 
                payments made by the participant, beneficiary, or 
                enrollee with respect to such items and services so 
                furnished in the same manner as if such cost-sharing 
                payments were with respect to items and services 
                furnished by a participating provider.
            ``(2) Definitions.--In this subsection and subsection (f):
                    ``(A) Health plan.--The term `health plan' means a 
                group health plan and health insurance coverage offered 
                by a heath insurance issuer in the group or individual 
                market.
                    ``(B) Participating health care facility.--
                            ``(i) In general.--The term `participating 
                        health care facility' means, with respect to an 
                        item or service and a group health plan or 
                        health insurance coverage offered by a health 
                        insurance issuer, a health care facility 
                        described in clause (ii) that has a contractual 
                        relationship with the plan or coverage for 
                        furnishing such item or service.
                            ``(ii) Health care facility described.--A 
                        health care facility described in this clause 
                        is each of the following:
                                    ``(I) A hospital (as defined in 
                                1861(e) of the Social Security Act).
                                    ``(II) A critical access hospital 
                                (as defined in section 1861(mm) of such 
                                Act).
                                    ``(III) An ambulatory surgical 
                                center (as defined in section 
                                1833(i)(1)(A) of such Act).
                                    ``(IV) A laboratory.
                                    ``(V) A radiology or imaging 
                                center.
                                    ``(VI) Any other facility that 
                                provides services that are covered 
                                under a group health plan or health 
                                insurance coverage.
                                    ``(VII) Any other facility 
                                specified by the Secretary.''.
    (c) Negotiation and Arbitration Process for Determining Prices.--
Section 2719A of the Public Health Service Act (42 U.S.C. 300gg-19a), 
as amended by subsection (b), is further amended by adding at the end 
the following new subsection:
    ``(f) Negotiation and Arbitration Process.--
            ``(1) Specified amount.--For purposes of subsections (b) 
        and (e) and this subsection, the specified amount determined 
        under this subsection, with respect to a health plan and 
        nonparticipating provider for an item or service, is--
                    ``(A) in the case the plan and provider enter into 
                negotiations pursuant to paragraph (2) and such 
                negotiations are successful, the amount determined for 
                such item or service pursuant to such negotiations; or
                    ``(B) in the case the plans and provider enter into 
                such negotiations but such negotiations are not 
                successful, the reasonable amount determined for such 
                item or service pursuant to the independent dispute 
                resolution process under paragraph (3).
            ``(2) Negotiations.--For purposes of subsections 
        (b)(1)(C)(iii) and (e)(1)(B), in the case of a payment of a 
        commercially reasonable rate made by a health plan to a 
        nonparticipating provider pursuant to such respective 
        subsection for an item or service, the provider and plan may, 
        not later than 30 days after the date of such payment, 
        negotiate an amount of payment (other than the commercially 
        reasonable rate specified in such subsection) to be made for 
        such item or service.
            ``(3) Independent dispute resolution.--
                    ``(A) In general.--If, by the end of such 30-day 
                period specified in paragraph (2), the plan and 
                provider have not determined a negotiated amount for 
                the payment involved, the plan or provider may initiate 
                an independent dispute resolution process under this 
                paragraph to determine the amount of payment.
                    ``(B) Establishment of idr.--
                            ``(i) In general.--Not later than January 
                        1, 2021, the Secretary, in consultation with 
                        the Secretary of Labor, shall establish a 
                        process for resolving payment disputes between 
                        health plans and nonparticipating providers for 
                        purposes of determining amounts of payments to 
                        be made by the plans to the providers pursuant 
                        to subsections (b) and (e) (referred to in this 
                        section as the `IDR process').
                            ``(ii) Entities.--An entity wishing to 
                        participate in the IDR process under this 
                        subsection shall request certification from the 
                        Secretary. The Secretary, in consultation with 
                        the Secretary of Labor, shall determine 
                        eligibility of applicant entities, taking into 
                        consideration whether the entity is unbiased 
                        and unaffiliated with health plans and 
                        providers and free of conflicts of interest, in 
                        accordance with the Secretary's rulemaking on 
                        determining criteria for conflicts of interest.
                            ``(iii) Applicable claims.--
                                    ``(I) In general.--The IDR process 
                                shall be with respect to one or more 
                                Current Procedural Terminology (`CPT') 
                                codes.
                                    ``(II) Batching of claims.--Claims 
                                may be batched if such claims--
                                            ``(aa) involve identical 
                                        plan or issuer and provider or 
                                        facility parties;
                                            ``(bb) involve claims with 
                                        the same or related current 
                                        procedural terminology codes 
                                        relevant to a particular 
                                        procedure; and
                                            ``(cc) involve claims that 
                                        occur within 60 days of each 
                                        other.
                    ``(C) Independent dispute resolution process.--
                            ``(i) Timing.--In the case of an IDR entity 
                        that receives a request under this paragraph, 
                        with respect to a payment amount to be paid by 
                        a health plan to a nonparticipating provider--
                                    ``(I) the plan and provider may, 
                                during the 30-day period following the 
                                date of receipt of such request, submit 
                                any information or supporting 
                                documentation to the IDR entity; and
                                    ``(II) the IDR entity shall, not 
                                later than 60 days after receiving such 
                                request, determine such amount.
                            ``(ii) Determination of amount.--
                                    ``(I) In general.--The amount 
                                determined by the IDR entity under 
                                clause (i), with respect to a payment 
                                amount to be paid by a health plan to a 
                                nonparticipating provider for an item 
                                or service shall be--
                                            ``(aa) the initial charge 
                                        for the item or service made by 
                                        the provider or the 
                                        commercially reasonable rate 
                                        paid by the plan for the item 
                                        or service under subsections 
                                        (b)(1)(C)(iii) or (e)(1)(B), 
                                        respectively, whichever is 
                                        determined reasonable by the 
                                        entity based on the factors 
                                        described in subclause (III); 
                                        or
                                            ``(bb) in the case neither 
                                        such charge or such rate is 
                                        determined by the entity to be 
                                        reasonable, the final offer 
                                        submitted under subclause (II) 
                                        that is determined more 
                                        reasonable in accordance with 
                                        such subclause.
                                    ``(II) Final offers.--For purposes 
                                of subclause (I)(bb), the health plan 
                                and the nonparticipating provider party 
                                to the independent dispute resolution 
                                under this paragraph shall each submit 
                                to the IDR entity their final offer for 
                                an amount for the payment that is 
                                subject to the dispute not later than 
                                30 days after the IDR entity determines 
                                under such subclause that neither the 
                                charge or rate described in subclause 
                                (I)(aa) were reasonable. Not later than 
                                60 days after such date of such 
                                determination, such entity shall 
                                determine which of the 2 final offers 
                                is more reasonable based on the factors 
                                described in subclause (III).
                                    ``(III) Factors.--For purposes of 
                                subclauses (I) and (II), the factors 
                                described in this subclause include, as 
                                relevant--
                                            ``(aa) commercially 
                                        reasonable rates for comparable 
                                        services or items in the same 
                                        geographic area (which shall 
                                        take into consideration in-
                                        network rates for that 
                                        geographic area and not 
                                        charges);
                                            ``(bb) the usual and 
                                        customary cost of the item or 
                                        service involved, determined as 
                                        the 80th percentile of charges 
                                        for comparable items and 
                                        services for the specialty 
                                        involved in the geographical 
                                        area in which the item or 
                                        service was furnished, as 
                                        determined through reference to 
                                        a medical claims database;
                                            ``(cc) other factors that 
                                        may be submitted at the 
                                        discretion of either party, 
                                        which may include--
                                            ``(dd) the level of 
                                        training, education, 
                                        experience, and quality and 
                                        outcomes measurements of the 
                                        nonparticipating provider;
                                            ``(ee) the circumstances 
                                        and complexity of the 
                                        particular dispute, including 
                                        the time and place of the 
                                        service;
                                            ``(ff) the provider's 
                                        quality and outcome metrics;
                                            ``(gg) the provider's usual 
                                        charge for comparable services 
                                        with regard to patients in 
                                        health care plans in which the 
                                        provider is not participating;
                                            ``(hh) the individual 
                                        patient characteristics; and
                                            ``(ii) other relevant 
                                        economic and clinical factors.
                                    ``(IV) Final decisions.--The amount 
                                that is determined to be the more 
                                reasonable amount under item (aa) or 
                                (bb) of subclause (I), as applicable, 
                                shall be the final decision of the IDR 
                                entity as to the amount the health plan 
                                is required to pay the provider.
                                    ``(V) Effect of determination.--A 
                                final determination of an IDR entity 
                                under subclause (IV)--
                                            ``(aa) shall be binding; 
                                        and
                                            ``(bb) 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, and cases in which 
                                        information submitted by one 
                                        party was determined to be 
                                        fraudulent.
                            ``(iii) Privacy laws.--An IDR entity shall, 
                        in conducting an independent dispute resolution 
                        process under this paragraph, comply with all 
                        applicable Federal and State privacy laws.
                            ``(iv) Public availability.--The reasonable 
                        amount determined by an IDR entity under this 
                        paragraph with respect to any claim shall not 
                        be confidential, except that information 
                        submitted to the IDR entity shall be kept 
                        confidential. IDR entities may consider past 
                        decisions awarded by independent dispute 
                        entities during the independent dispute 
                        resolution process.
                            ``(v) Costs of independent dispute 
                        resolution process.--The nonprevailing party 
                        shall be responsible for paying all fees 
                        charged by the IDR entity. If the parties reach 
                        a settlement prior to completion of the IDR 
                        process, the costs of the independent dispute 
                        resolution process shall be divided equally 
                        between the parties.
                            ``(vi) Payment.--Any difference between--
                                    ``(I) the amount determined to be 
                                paid by one party of the dispute 
                                resolution to another pursuant to this 
                                paragraph; and
                                    ``(II) the amounts already paid 
                                under subsection (b) or (e) before 
                                entering into the process under this 
                                paragraph,
                        shall be paid not later than 15 days after the 
                        date on which the entity makes a determination 
                        with respect to such amount.
                    ``(D) Publication.--The Secretary shall publish 
                aggregated results of the independent dispute 
                resolution by geographic region in order to give more 
                guidance to providers and health plans.''.
    (d) Preventing Certain Cases of Balance Billing.--Section 1128A of 
the Social Security Act (42 U.S.C. 1320a-7a) is amended by adding at 
the end the following new subsections:
    ``(t)(1) Subject to paragraph (3), in the case of an individual 
with benefits under a health plan or health insurance coverage offered 
in the group or individual market who is furnished on or after January 
1, 2021, emergency services with respect to an emergency medical 
condition during a visit at an emergency department of a hospital--
            ``(A) if the emergency department of a hospital holds the 
        individual liable for a payment amount for such emergency 
        services so furnished that is more than the cost-sharing amount 
        for such services (as determined in accordance with section 
        2719A(b)(1)(C)(ii) of the Public Health Service Act); or
            ``(B) if any health care provider holds such individual 
        liable for a payment amount for an emergency service furnished 
        to such individual by such provider with respect to such 
        emergency medical condition and visit for which the individual 
        receives emergency services at the hospital or emergency 
        department that is more than the cost-sharing amount for such 
        services furnished by the provider (as determined in accordance 
        with section 2719A(b)(1)(C)(ii) of the Public Health Service 
        Act),
the hospital, emergency department or health care provider, 
respectively, shall be subject, in addition to any other penalties that 
may be prescribed by law, to a civil money penalty of not more than an 
amount determined appropriate by the Secretary for each specified 
claim.
    ``(2) The provisions of subsections (c), (d), (e), (g), (h), (k), 
and (l) shall apply to a civil money penalty or assessment under 
paragraph (1) or subsection (u) in the same manner as such provisions 
apply to a penalty, assessment, or proceeding under subsection (a).
    ``(3) Paragraph (1) shall not apply to an emergency department of a 
hospital or a provider, with respect to items or services furnished to 
a participant, beneficiary, or enrollee of a health plan or health 
insurance coverage offered by a health insurance issuer, if the 
emergency department of the hospital or the provider, respectively, 
reimburses such participant, beneficiary, or enrollee any amount for 
such an item or service that is more than the cost-sharing amount for 
such item or service (as determined in accordance with section 
2719A(e)(1)(A)) not later than 30 days after the date the emergency 
department of the hospital or provider, respectively, knew or should 
have known such excess payment was in violation of this subsection.
    ``(4) In this subsection and subsection (u):
            ``(A) The terms `emergency medical condition' and 
        `emergency services' have the meanings given such terms, 
        respectively, in section 2719A(b)(2) of the Public Health 
        Service Act.
            ``(B) The terms `group health plan', `health insurance 
        issuer', and `health insurance coverage' have the meanings 
        given such terms, respectively, in section 2791 of the Public 
        Health Service Act.
    ``(u)(1) Subject to paragraph (2), in the case of an individual 
with benefits under a health plan or health insurance coverage offered 
in the group or individual market who is furnished on or after January 
1, 2021, items or services (other than emergency services to which 
subsection (t) applies) during an episode of care (as defined by the 
Secretary) at a participating health care facility by a 
nonparticipating provider (including imaging or laboratory services so 
furnished by a nonparticipating provider when ordered by a 
participating provider or after-emergency care furnished by a 
nonparticipating provider in the case that the participant, 
beneficiary, or enrollee cannot travel without medical transport), if 
such nonparticipating provider holds such individual liable for a 
payment amount for such an item or service furnished by such provider 
that is more than the cost-sharing amount for such item or service (as 
determined in accordance with section 2719A(e)(1)(A) of the Public 
Health Service Act), such provider shall be subject, in addition to any 
other penalties that may be prescribed by law, to a civil money penalty 
of not more than an amount determined appropriate by the Secretary for 
each specified claim.
    ``(2) Paragraph (1) shall not apply to a nonparticipating provider, 
with respect to items or services furnished by the provider to a 
participant, beneficiary, or enrollee of a health plan or health 
insurance coverage offered by a health insurance issuer, if the 
provider reimburses such participant, beneficiary, or enrollee any 
amount for such an item or service that is more than the cost-sharing 
amount for such item or service (as determined in accordance with 
section 2719A(e)(1)(A)) not later than 30 days after the date the 
provider knew or should have known such excess payment was in violation 
of this subsection.
    ``(3) For purposes of this subsection, the terms `nonparticipating 
provider' and `participating health care facility' have such meanings 
given such terms under subsections (b)(2) and (e)(2), respectively, of 
section 2719A of the Public Health Service Act.''.
    (e) Effective Date.--The amendments made by this section shall 
apply with respect to plan years beginning on or after January 1, 2021.

SEC. 3. TRANSPARENCY REGARDING IN-NETWORK AND OUT-OF-NETWORK 
              DEDUCTIBLES.

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

``SEC. 2729A. TRANSPARENCY REGARDING IN-NETWORK AND OUT-OF-NETWORK 
              DEDUCTIBLES.

    ``(a) In General.--A group health plan or a health insurance issuer 
offering group or individual health insurance coverage and providing or 
covering any benefit with respect to items or services shall include, 
in clear writing, on any plan or insurance identification card issued 
to enrollees in the plan or coverage the amount of the in-network and 
out-of-network deductibles and the out-of-pocket maximum limitation 
that apply to such plan or coverage.
    ``(b) Guidance.--The Secretary, in consultation with the Secretary 
of Labor, shall issue guidance to implement subsection (a).''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply with respect to plan years beginning on or after the date that is 
one year after the date of the enactment of this Act.

SEC. 4. TRANSPARENCY FOR IN-NETWORK PATIENTS.

    Subpart II of part A of title XXVII of the Public Health Service 
Act (42 U.S.C. 300gg et seq.), as amended by section 3, is further 
amended by adding at the end the following:

``SEC. 2729B. TRANSPARENCY FOR IN-NETWORK PATIENTS.

    ``(a) Standards.--Not later than January 1, 2021, the Secretary 
shall, through rulemaking, establish transparency standards to provide 
better information to individuals who are enrolled in group health 
plans or health insurance coverage offered in the individual or group 
market (as such terms are defined in section 2791 of the Public Health 
Service Act (42 U.S.C. 300gg-91)) about which health care providers are 
participating in the network of the plan or coverage in which such an 
individual is enrolled. Such standards shall at a minimum provide for 
the following:
            ``(1) Such plans and coverage offer provider directories 
        online and in print.
            ``(2) Annual audits of such provider directories, as 
        specified by the Secretary.
            ``(3) Monthly updates of such online directories.
    ``(b) Guidance.--Beginning January 1, 2022, a group health plan or 
a health insurance issuer offering group or individual health insurance 
coverage shall be in compliance with the standards established pursuant 
to subsection (a).''.

SEC. 5. REPORTING REQUIREMENTS.

    Subpart II of part A of title XXVII of the Public Health Service 
Act (42 U.S.C. 300gg et seq.), as amended by sections 3 and 4, is 
further amended by adding at the end the following:

``SEC. 2729C. TRANSPARENCY REQUIREMENTS.

    ``(a) In General.--Each group health plan and health insurance 
issuer offering group or individual health insurance coverage shall 
annually report (beginning for plan year 2021) to the Secretary and the 
Secretary of Labor, with respect to the applicable plan or coverage for 
the applicable plan year--
            ``(1) the total claims that were submitted by in-network 
        health care providers with respect to enrollees under the plan 
        or coverage, and the number of such claims that were paid and 
        the number of such claims that were denied;
            ``(2) the total claims that were submitted by out-of-
        network health care providers with respect to enrollees under 
        the plan or coverage, and the number of such claims that were 
        paid and the number of such claims that were denied;
            ``(3) with respect to each out-of-network claim, the out-
        of-pocket costs to the enrollee for the services;
            ``(4) the number of out-of-network claims reported under 
        paragraph (2) that are for emergency services; and
            ``(5) the number of out-of-network claims reported under 
        paragraph (2) that relate to care at in-network hospitals or 
        facilities provided by out-of-network providers.
    ``(b) Clarification.--The information required to be submitted 
under this section shall be in addition to the information required to 
be submitted under section 2715A.''.

SEC. 6. BILLING STATUTE OF LIMITATIONS.

    Notwithstanding any other provision of law, a health care provider 
may not seek reimbursement from an individual for a service furnished 
by such provider to such individual more than a year after such date of 
service. Any provider that bills an individual in violation of the 
previous sentence shall be subject to a civil monetary penalty in such 
amount as specified by the Secretary of Health and Human Services.

SEC. 7. APPLICATION.

    (a) Non-Application in Cases of States With Certain Balance Billing 
Laws.--Section 2719A of the Public Health Service Act (42 U.S.C. 300gg-
19a) is amended by adding at the end the following new subsection:
    ``(g) In any case in which a State has in effect a law or 
regulation that prohibits balance billing or otherwise provides an 
alternate method for resolving a dispute between a health plan and 
provider for determining compensation for services described in 
subsections (b), (e), or (f), the provisions of such law and not the 
provisions of this Act shall apply to health plans (except self-insured 
group health plans that are not subject to State insurance regulation), 
health care providers, and individuals in such State so long as such 
law does not require an individual to pay more in cost-sharing than the 
amount that would otherwise be required of such individual under this 
section.''.
    (b) Application to FEHB.--
            (1) In general.--Section 8902 of title 5, United States 
        Code, is amended by adding at the end the following new 
        subsection:
    ``(p) Each contract under this chapter shall require the carrier to 
comply with requirements described in the provisions of subsections 
(b), (e), and (f) of section 2719A of the Public Health Service Act and 
sections 2729A and 2729B of such Act in the same manner as those 
provisions apply to a groups health plan or health insurance issuer 
offering health insurance coverage, as described in such sections.''.
            (2) Effective date.--The amendment made by this subsection 
        shall apply with respect to contracts entered into or renewed 
        for contract years beginning at least one year after the date 
        of enactment of this Act.

SEC. 8. STUDIES BY SECRETARIES OF HEALTH AND HUMAN SERVICES AND OF 
              LABOR.

    (a) Impact Study.--Not later than 3 years after the date of 
enactment of this Act, the Secretary of Health and Human Services, in 
consultation with the Secretary of Labor, shall conduct a study of the 
effects of this Act (including the amendments made by this Act), and 
submit to Congress (and make public) a report on the findings of such 
study, which shall include information and analysis on--
            (1) the financial impact on patient responsibility for 
        health care spending and overall health care spending;
            (2) the incidence and prevalence of the delivery of 
        unanticipated out-of-network health care services, in the cases 
        of emergency services and in the cases of care at in-network 
        hospitals or facilities provided by out-of-network providers;
            (3) the adequacy of provider networks offered by health 
        plans and health insurance issuers (as such terms are defined 
        in section 2791 of the Public Health Service Act (42 U.S.C. 
        300gg-91));
            (4) a comparison of the different claims databases used and 
        the impact of using such databases on reimbursement rates;
            (5) the number of bills that are settled through 
        negotiations pursuant to subsection (f)(2) of section 2719A of 
        the Public Health Service Act (42 U.S.C. 300gg-19a), as added 
        by section 2, and the number of bills that go to the 
        independent dispute resolution process under subsection (f)(3) 
        of such section, as so added;
            (6) the administrative cost of such independent dispute 
        resolution process; and
            (7) the estimated impact of such independent dispute 
        resolution process on health insurance premiums and 
        deductibles.
    (b) Billing Feasibility Study.--Not later than 3 years after the 
date of the enactment of this Act, the Secretary of Health and Human 
Services shall conduct, and submit to Congress (and make public), a 
feasibility study on the provision of a single bill for all services 
provided for a single episode of care, as defined by the Secretary.

SEC. 9. REGULATIONS.

    Not later than one year after the date of the enactment of this 
Act, the Secretary of Labor and the Secretary of Health and Human 
Services shall promulgate regulations pertaining to carry out the 
provisions (including amendments made by) this Act.
                                 <all>