[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3630 Introduced in House (IH)]
<DOC>
116th CONGRESS
1st Session
H. R. 3630
To amend title XXVII of the Public Health Service Act to protect health
care consumers from surprise billing practices, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 9, 2019
Mr. Pallone (for himself and Mr. Walden) introduced the following bill;
which was referred to the Committee on Energy and Commerce, and in
addition to the Committee on 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 title XXVII of the Public Health Service 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.
This Act may be cited as the ``No Surprises Act''.
SEC. 2. PREVENTING SURPRISE MEDICAL BILLS.
(a) Coverage of Emergency Services.--Section 2719A(b) of the Public
Health Service Act (42 U.S.C. 300gg-19a(b)) is amended--
(1) in paragraph (1)--
(A) in the matter preceding subparagraph (A)--
(i) by striking ``a group health plan, or a
health insurance issuer offering group or
individual health insurance issuer,'' and
inserting ``a health plan (as defined in
subsection (e)(2)(A))'';
(ii) by inserting ``or, for plan year 2021
or a subsequent plan year, with respect to
emergency services in an independent
freestanding emergency department (as defined
in paragraph (3)(D))'' after ``emergency
department of a hospital'';
(iii) by striking ``the plan or issuer''
and inserting ``the plan''; and
(iv) by striking ``paragraph (2)(B)'' and
inserting ``paragraph (3)(C)'';
(B) in subparagraph (B), by inserting ``or a
participating emergency facility, as applicable,''
after ``participating provider''; and
(C) 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 or coinsurance
rate) 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) such requirement is calculated as
if the total amount that would have been
charged for such services by such participating
provider or participating emergency facility
were equal to--
``(I) in the case of such services
furnished in a State described in
paragraph (3)(H)(ii), the median
contracted rate (as defined in
paragraph (3)(E)(i)) for such services;
and
``(II) in the case of such services
furnished in a State described in
paragraph (3)(H)(i), the lesser of--
``(aa) the amount
determined by such State for
such services in accordance
with the method described in
such paragraph; and
``(bb) the median
contracted rate (as so defined)
for such services;
``(iv) the health plan pays to such
provider or facility, respectively, the amount
by which the recognized amount (as defined in
paragraph (3)(H)) for such services exceeds the
cost-sharing amount for such services (as
determined in accordance with clauses (ii) and
(iii)); and
``(v) any cost-sharing payments made by the
participant, beneficiary, or enrollee with
respect to such emergency services so furnished
shall be counted toward any in-network
deductible or out-of-pocket maximums applied
under the plan 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'';
(2) by redesignating paragraph (2) as paragraph (3);
(3) by inserting after paragraph (1) the following new
paragraph:
``(2) Audit process for median contracted rates.--Not later
than July 1, 2020, the Secretary shall, in consultation with
appropriate State agencies, establish through rulemaking a
process under which sponsors and issuers of health plans are
audited to ensure that such sponsors and issuers are in
compliance with the requirement of applying a median contracted
rate under this section that satisfies the definition under
paragraph (3)(E).''; and
(4) in paragraph (3), as redesignated by paragraph (2) of
this subsection--
(A) in the matter preceding subparagraph (A), by
inserting ``and subsections (e) and (f)'' after ``this
subsection'';
(B) by redesignating subparagraphs (A) through (C)
as subparagraphs (B) through (D), respectively;
(C) by inserting before subparagraph (B), as
redesignated by subparagraph (B) of this paragraph, the
following new subparagraph:
``(A) Emergency department of a hospital.--The term
`emergency department of a hospital' includes a
hospital outpatient department that provides emergency
services.'';
(D) by amending subparagraph (C), as redesignated
by subparagraph (B) of this paragraph, to read as
follows:
``(C) Emergency services.--
``(i) In general.--The term `emergency
services', with respect to an emergency medical
condition means--
``(I) a medical screening
examination (as required under section
1867 of the Social Security Act, or as
would be required under such section if
such section applied to an independent
freestanding emergency department) that
is within the capability of the
emergency department of a hospital or
of an independent freestanding
emergency department, as applicable,
including ancillary services routinely
available to the emergency department
to evaluate such emergency medical
condition; and
``(II) within the capabilities of
the staff and facilities available at
the hospital or the independent
freestanding emergency department, as
applicable, such further medical
examination and treatment as are
required under section 1867 of such
Act, or as would be required under such
section if such section applied to an
independent freestanding emergency
department, to stabilize the patient.
``(ii) Inclusion of poststabilization
services.--For purposes of this subsection and
section 2799, in the case of an individual
enrolled in a health plan who is furnished
services described in clause (i) by a provider
or facility to stabilize such individual with
respect to an emergency medical condition, the
term `emergency services' shall include such
items and services in addition to those
described in clause (i) that such a provider or
facility determines are needed to be furnished
to such individual during the visit in which
such individual is so stabilized after such
stabilization, unless each of the following
conditions are met:
``(I) Such a provider or facility
determines such individual is able to
travel using nonmedical transportation
or nonemergency medical transportation.
``(II) Such provider furnishing
such additional items and services is
in compliance with section 2799A(d)
with respect to such items and
services.'';
(E) by redesignating subparagraph (D), as
redesignated by subparagraph (B) of this paragraph, as
subparagraph (I); and
(F) by inserting after subparagraph (C), as
redesignated by subparagraph (B) of this paragraph, the
following new subparagraphs:
``(D) Independent freestanding emergency
department.--The term `independent freestanding
emergency department' means a facility that--
``(i) is geographically separate and
distinct and licensed separately from a
hospital under applicable State law; and
``(ii) provides emergency services.
``(E) Median contracted rate.--
``(i) In general.--The term `median
contracted rate' means, with respect to an item
or service and a health plan (as defined in
subsection (e)(2)(A))--
``(I) for 2021, the median of the
negotiated rates recognized by the
sponsor or issuer of such plan
(determined with respect to all such
plans of such sponsor or such issuer)
as the total maximum payment (including
the cost-sharing amount imposed for
such services (as determined in
accordance with paragraph (1)(C)(ii) or
subsection (e)(1)(A), as applicable)
and the amount to be paid by the plan
or issuer) under such plans in 2019 for
the same or a similar item or service
that is provided by a provider in the
same or similar specialty and provided
in the geographic region in which the
item or service is furnished,
consistent with the methodology
established by the Secretary under
section 2(e) of the No Surprises Act,
increased by the percentage increase in
the consumer price index for all urban
consumers (United States city average)
over 2019 and 2020; and
``(II) for 2022 and each subsequent
year, the median contracted rate for
the previous year, increased by the
percentage increase in the consumer
price index for all urban consumers
(United States city average) over such
previous year.
``(ii) Special rule; rule of
construction.--
``(I) Certain insurers.--The
Secretary shall provide pursuant to
rulemaking described in clause (ii)
that--
``(aa) if the sponsor or
issuer of a health plan does
not have sufficient information
to calculate a median
contracted rate for an item or
service or provider type, or
amount of, claims for items or
services (as determined by the
Secretary) provided in a
particular geographic area
(other than in a case described
in item (bb)), such sponsor or
issuer shall demonstrate that
such sponsor or issuer will use
any database free of conflicts
of interest that has sufficient
information reflecting allowed
amounts paid to individual
health care providers for
relevant services provided in
the applicable geographic
region (such as All Payer
Claims Databases (as defined in
section 4(d) of the No
Surprises Act) of States), and
that such sponsor or issuer
will use any such database to
determine a median contracted
rate and cover the cost of
accessing any such database;
and
``(bb) in the case of a
sponsor or issuer offering a
health plan in a geographic
region that did not offer any
health plan in such region
during 2019, such sponsor or
issuer shall use a methodology
established by the Secretary
for determining the median
contracted rate for items and
services covered by such plan
for the first year in which
such plan is offered in such
region, and that, for each
succeeding year, the median
contracted rate for such items
and services under such plan
shall be the median contracted
rate for such items and
services under such plan for
the previous year, increased by
the percentage increase in the
consumer price index for all
urban consumers (United States
city average) over such
previous year.
``(II) Rule of construction.--
Nothing in this subparagraph shall
prevent the sponsor or issuer of a
health plan from establishing separate
calculations of a median contracted
rate under this subparagraph for items
and services delivered in non-hospital
facilities, including independent
freestanding emergency departments.
``(F) 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 health plan, an emergency
department of a hospital, or an independent
freestanding emergency department, that does
not have a contractual relationship with the
plan (or, if applicable, issuer offering the
plan) for furnishing such item or service under
the plan.
``(ii) Participating emergency facility.--
The term `participating emergency facility'
means, with respect to an item or service and a
health plan, an emergency department of a
hospital, or an independent freestanding
emergency department, that has a contractual
relationship with the plan (or, if applicable,
issuer offering the plan) for furnishing such
item or service under the plan.
``(G) Nonparticipating providers; participating
providers.--
``(i) Nonparticipating provider.--The term
`nonparticipating provider' means, with respect
to an item or service and a health plan, a
physician or other health care provider who is
acting within the scope of practice of that
provider's license or certification under
applicable State law and who does not have a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for
furnishing such item or service under the plan.
``(ii) Participating provider.--The term
`participating provider' means, with respect to
an item or service and a health plan, a
physician or other health care provider who is
acting within the scope of practice of that
provider's license or certification under
applicable State law and who has a contractual
relationship with the plan (or, if applicable,
issuer offering the plan) for furnishing such
item or service under the plan.
``(H) Recognized amount.--The term `recognized
amount' means, with respect to an item or service--
``(i) in the case of such item or service
furnished in a State that has in effect a State
law that provides for a method for determining
the amount of payment that is required to be
covered by a health plan regulated by such
State in the case of a participant,
beneficiary, or enrollee covered under such
plan and receiving such item or service from a
nonparticipating provider or facility, not more
than the amount determined in accordance with
such law plus the cost-sharing amount imposed
under the plan for such item or service (as
determined in accordance with paragraph
(1)(C)(ii) or subsection (e)(1)(A), as
applicable); or
``(ii) in the case of such item or service
furnished in a State that does not have in
effect such a law, an amount that is at least
the median contracted rate (as defined in
subparagraph (E)(i) and determined in
accordance with rulemaking described in
subparagraph (E)(ii)) for such item or
service.''.
(b) Coverage of 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) Coverage of Non-Emergency Services Performed by
Nonparticipating Providers at Certain Participating Facilities.--
``(1) In general.--Subject to paragraph (3), 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)(3)(G)(i)) during a visit (as defined by the
Secretary in accordance with paragraph (2)(C)) at a
participating health care facility (as defined in paragraph
(2)(B)), 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 (as defined in
subsection (b)(3)(G)(ii));
``(B) shall calculate such cost-sharing amount as
if the amount that would have been charged for such
items and services by such participating provider were
equal to--
``(i) in the case of such items and
services furnished in a State described in
subsection (b)(3)(H)(ii), the median contracted
rate (as defined in subsection (b)(3)(E)(i))
for such items and services; and
``(ii) in the case of such items and
services furnished in a State described in
subsection (b)(3)(H)(i), the lesser of--
``(I) the amount determined by such
State for such items and services in
accordance with the method described in
such subsection; and
``(II) the median contracted rate
(as so defined) for such items and
services;
``(C) shall pay to such provider furnishing such
items and services to such participant, beneficiary, or
enrollee the amount by which the recognized amount (as
defined in subsection (b)(3)(H)) for such items and
services exceeds the cost-sharing amount imposed under
the plan for such items and services (as determined in
accordance with subparagraphs (A) and (B)); and
``(D) shall count toward any in-network 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 (b):
``(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 and includes a grandfathered health plan (as
defined in section 1251(e) of the Patient Protection
and Affordable Care Act).
``(B) Participating health care facility.--
``(i) In general.--The term `participating
health care facility' means, with respect to an
item or service and a health plan, a health
care facility described in clause (ii) that has
a contractual relationship with the plan (or,
if applicable, issuer offering the plan) 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 facility or
imaging center.
``(C) During a visit.--The term `during a visit'
shall, with respect to items and services furnished to
an individual at a participating health care facility,
include equipment and devices, telemedicine services,
imaging services, laboratory services, and such other
items and services as the Secretary may specify,
regardless of whether or not the provider furnishing
such items or services is at the facility.
``(3) Exception.--Paragraph (1) shall not apply to a health
plan 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)(3)(G)(i)) during a visit (as defined
by the Secretary in accordance with paragraph (2)(C)) at a
participating health care facility (as defined in paragraph
(2)(B)) if such provider is in compliance with section 2799A(d)
with respect to such items and services.''.
(c) Provider Directory Requirements; Disclosure on Patient
Protections.--Section 2719A of the Public Health Service Act, as
amended by subsection (b), is further amended by adding at the end the
following new subsections:
``(f) Provider Directory Information Requirements.--
``(1) In general.--Not later than 1 year after the date of
the enactment of this subsection, each group health plan and
health insurance issuer offering group or individual health
insurance coverage shall--
``(A) establish the verification process described
in paragraph (2);
``(B) establish the response protocol described in
paragraph (3);
``(C) establish the database described in paragraph
(4); and
``(D) include in any print directory containing
provider directory information with respect to such
plan or such coverage the information described in
paragraph (5).
``(2) Verification process.--The verification process
described in this paragraph is, with respect to a group health
plan or a health insurance issuer offering group or individual
health insurance coverage, a process under which--
``(A) not less frequently than once every 90 days,
such plan or such issuer (as applicable) verifies and
updates the provider directory information included on
the database described in paragraph (4) of such plan or
issuer of each health care provider and health care
facility included in such database; and
``(B) such plan or such issuer removes any such
provider or facility with respect to which such plan or
such issuer has been unable to verify such information
during any 6-month period.
``(3) Response protocol.--The response protocol described
in this paragraph is, in the case of an individual enrolled
under a group health plan or group or individual health
insurance coverage offered by a health insurance issuer who
requests information on whether a health care provider or
health care facility has a contractual relationship to furnish
items and services under such plan or such coverage, a protocol
under which such plan or such issuer (as applicable), in the
case such request is made through a telephone call--
``(A) responds to such individual as soon as
practicable and in no case later than 1 business day
after such call is received through a written
electronic communication; and
``(B) retains such communication in such
individual's file for at least 2 years following such
response.
``(4) Database.--The database described in this paragraph
is, with respect to a group health plan or health insurance
issuer offering group or individual health insurance coverage,
a database on the public website of such plan or issuer that
contains--
``(A) a list of each health care provider and
health care facility with which such plan or such
issuer has a contractual relationship for furnishing
items and services under such plan or such coverage;
and
``(B) provider directory information with respect
to each such provider and facility.
``(5) Information.--The information described in this
paragraph is, with respect to a print directory containing
provider directory information with respect to a group health
plan or individual or group health insurance coverage offered
by a health insurance issuer, a notification that such
information contained in such directory was accurate as of the
date of publication of such directory and that an individual
enrolled under such plan or such coverage should consult the
database described in paragraph (4) with respect to such plan
or such coverage or contact such plan or the issuer of such
coverage to obtain the most current provider directory
information with respect to such plan or such coverage.
``(6) Definition.--For purposes of this subsection, the
term `provider directory information' includes, with respect to
a group health plan and a health insurance issuer offering
group or individual health insurance coverage, the name,
address, specialty, and telephone number of each health care
provider or health care facility with which such plan or such
issuer has a contractual relationship for furnishing items and
services under such plan or such coverage.
``(g) Disclosure on Patient Protections.--Each group health plan
and health insurance issuer offering group or individual health
insurance coverage shall make publicly available, and (if applicable)
post on a public website of such plan or issuer--
``(1) information in plain language on--
``(A) the requirements and prohibitions applied
under sections 2799 and 2799A (relating to prohibitions
on balance billing in certain circumstances);
``(B) if provided for under applicable State law,
any other requirements on providers and facilities
regarding the amounts such providers and facilities
may, with respect to an item or service, charge a
participant, beneficiary, or enrollee of such plan or
coverage with respect to which such a provider or
facility does not have a contractual relationship for
furnishing such item or service under the plan or
coverage after receiving payment from the plan or
coverage for such item or service and any applicable
cost-sharing payment from such participant,
beneficiary, or enrollee; and
``(C) the requirements applied under subsections
(b) and (e); and
``(2) information on contacting appropriate State and
Federal agencies in the case that an individual believes that
such a provider or facility has violated any requirement
described in paragraph (1) with respect to such individual.''.
(d) Preventing Certain Cases of Balance Billing.--Title XXVII of
the Public Health Service Act is amended by adding at the end the
following new part:
``PART D--PREVENTING CERTAIN CASES OF BALANCE BILLING
``SEC. 2799. BALANCE BILLING IN CASES OF EMERGENCY SERVICES.
``(a) In General.--In the case of a participant, beneficiary, or
enrollee with benefits under a health plan 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 or an independent freestanding emergency department--
``(1) the emergency department of a hospital or independent
freestanding emergency department shall not hold the
participant, beneficiary, or enrollee 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)); and
``(2) a health care provider shall not hold such
participant, beneficiary, or enrollee 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)).
``(b) Definitions.--In this section:
``(1) The terms `emergency department of a hospital',
`emergency medical condition', `emergency services', and
`independent freestanding emergency department' have the
meanings given such terms, respectively, in section
2719A(b)(3).
``(2) The term `health plan' has the meaning given such
term in section 2719A(e).
``(3) The term `during a visit' shall have such meaning as
applied to such term for purposes of section 2719A(e).
``SEC. 2799A. BALANCE BILLING IN CASES OF NON-EMERGENCY SERVICES
PERFORMED BY NONPARTICIPATING PROVIDERS AT CERTAIN
PARTICIPATING FACILITIES.
``(a) In General.--Subject to subsection (b), in the case of a
participant, beneficiary, or enrollee with benefits under a health plan
(as defined in section 2799(b)) who is furnished on or after January 1,
2021, items or services (other than emergency services to which section
2799 applies) at a participating health care facility by a
nonparticipating provider, such provider shall not hold such
participant, beneficiary, or enrollee liable for a payment amount for
such an item or service furnished by such provider during a visit at
such facility that is more than the cost-sharing amount for such item
or service (as determined in accordance with subparagraphs (A) and (B)
of section 2719A(e)(1)).
``(b) Exception.--
``(1) In general.--Subsection (a) shall not apply to a
nonparticipating provider (other than a specified provider at a
participating health care facility), with respect to items or
services furnished by the provider to a participant,
beneficiary, or enrollee of a health plan, if the provider is
in compliance with the notice and consent requirements of
subsection (d).
``(2) Specified provider defined.--For purposes of
paragraph (1), the term `specified provider', with respect to a
participating health care facility--
``(A) means a facility-based provider, including
emergency medicine providers, anesthesiologists,
pathologists, radiologists, neonatologists, assistant
surgeons, hospitalists, intensivists, or other
providers as determined by the Secretary; and
``(B) includes, with respect to an item or service,
a nonparticipating provider if there is no
participating provider at such facility who can furnish
such item or service.
``(c) Clarification.--In the case of a nonparticipating provider
(other than a specified provider at a participating health care
facility) that complies with the notice and consent requirements of
subsection (d) with respect to an item or service (referred to in this
subsection as a `covered item or service'), such notice and consent
requirements may not be construed as applying with respect to any item
or service that is furnished as a result of unforeseen medical needs
that arise at the time such covered item or service is furnished.
``(d) Compliance With Notice and Consent Requirements.--
``(1) In general.--A nonparticipating provider or
nonparticipating facility is in compliance with this
subsection, with respect to items or services furnished by the
provider or facility to a participant, beneficiary, or enrollee
of a health plan, if the provider (or, if applicable, the
participating health care facility on behalf of such provider)
or nonparticipating facility--
``(A) provides to the participant, beneficiary, or
enrollee (or to an authorized representative of the
participant, beneficiary, or enrollee), on the date on
which the participant, beneficiary, or enrollee makes
an appointment to be furnished such items or services,
if applicable, and on the date on which the individual
is furnished such items or services--
``(i) an oral explanation of the written
notice described in clause (ii); and
``(ii) a written notice specified, not
later than July 1, 2020, by the Secretary
through guidance (which shall be updated as
determined necessary by the Secretary) that--
``(I) contains the information
required under paragraph (2); and
``(II) is signed and dated by the
participant, beneficiary, or enrollee
(or by an authorized representative of
the participant, beneficiary, or
enrollee) and, with respect to items or
services to be furnished by such a
provider that are not poststabilization
services described in section
2719A(b)(3)(C)(ii), is so signed and
dated not less than 72 hours prior to
the participant, beneficiary, or
enrollee being furnished such items or
services by such provider; and
``(B) obtains from the participant, beneficiary, or
enrollee (or from such an authorized representative)
the consent described in paragraph (3).
``(2) Information required under written notice.--For
purposes of paragraph (1)(A)(ii)(I), the information described
in this paragraph, with respect to a nonparticipating provider
or nonparticipating facility and a participant, beneficiary, or
enrollee of a health plan, is each of the following:
``(A) Notification, as applicable, that the health
care provider is a nonparticipating provider with
respect to the health plan or the health care facility
is a nonparticipating facility with respect to the
health plan.
``(B) Notification of the estimated amount that
such provider or facility may charge the participant,
beneficiary, or enrollee for such items and services
involved.
``(C) In the case of a nonparticipating facility, a
list of any participating providers at the facility who
are able to furnish such items and services involved
and notification that the participant, beneficiary, or
enrollee may be referred, at their option, to such a
participating provider.
``(3) Consent described.--For purposes of paragraph (1)(B),
the consent described in this paragraph, with respect to a
participant, beneficiary, or enrollee of a health plan who is
to be furnished items or services by a nonparticipating
provider or nonparticipating facility, is a document specified
by the Secretary through rulemaking that--
``(A) is signed by the participant, beneficiary, or
enrollee (or by an authorized representative of the
participant, beneficiary, or enrollee) and, with
respect to items or services to be furnished by such a
provider or facility that are not poststabilization
services described in section 2719A(b)(3)(C)(ii), is so
signed not less than 72 hours prior to the participant,
beneficiary, or enrollee being furnished such items or
services by such provider or facility;
``(B) acknowledges that the participant,
beneficiary, or enrollee has been--
``(i) provided with a written estimate and
an oral explanation of the charge that the
participant, beneficiary, or enrollee will be
assessed for the items or services anticipated
to be furnished to the participant,
beneficiary, or enrollee by such provider or
facility; and
``(ii) informed that the payment of such
charge by the participant, beneficiary, or
enrollee may not accrue toward meeting any
limitation that the health plan places on cost-
sharing; and
``(C) documents the consent of the participant,
beneficiary, or enrollee to--
``(i) be furnished with such items or
services by such provider or facility; and
``(ii) in the case that the individual is
so furnished such items or services, be charged
an amount that may be greater than the amount
that would otherwise be charged the individual
if furnished by a participating provider or
participating facility with respect to such
items or services and plan.
``(e) Retention of Certain Documents.--A nonparticipating provider
(or, in the case of a nonparticipating provider at a participating
health care facility, such facility) or nonparticipating facility that
obtains from a participant, beneficiary, or enrollee of a health plan
(or an authorized representative of such participant, beneficiary, or
enrollee) a written notice in accordance with subsection (c)(1)(ii),
with respect to furnishing an item or service to such participant,
beneficiary, or enrollee, shall retain such notice for at least a 2-
year period after the date on which such item or service is so
furnished.
``(f) Definitions.--In this section:
``(1) The terms `nonparticipating provider' and
`participating provider' have the meanings given such terms,
respectively, in subsection (b)(3) of section 2719A.
``(2) The terms `participating health care facility' and
`health plan' have the meanings given such terms, respectively,
in subsection (e)(2) of section 2719A.
``(3) The term `nonparticipating facility' means--
``(A) with respect to emergency services (as
defined in section 2719A(b)(3)(C)(i)) and a health
plan, an emergency department of a hospital, or an
independent freestanding emergency department, that
does not have a contractual relationship with the plan
(or, if applicable, issuer offering the plan) for
furnishing such services under the plan; and
``(B) with respect to poststabilization services
described in section 2719A(b)(3)(C)(ii) and a health
plan, an emergency department of a hospital (or other
department of such hospital), or an independent
freestanding emergency department, that does not have a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for furnishing
such services under the plan.
``(4) The term `participating facility' means--
``(A) with respect to emergency services (as
defined in section 2719A(b)(3)(C)(i)) and a health
plan, an emergency department of a hospital, or an
independent freestanding emergency department, that has
a contractual relationship with the plan (or, if
applicable, issuer offering the plan) for furnishing
such services under the plan; and
``(B) with respect to poststabilization services
described in section 2719A(b)(3)(C)(ii) and a health
plan, an emergency department of a hospital (or other
department of such hospital), or an independent
freestanding emergency department, that has a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for furnishing
such services under the plan.
``SEC. 2799B. PROVIDER REQUIREMENTS WITH RESPECT TO PROVIDER DIRECTORY
INFORMATION.
``Not later than 1 year after the date of the enactment of this
section, each health care provider and health care facility shall
establish a process under which such provider or facility transmits, to
each health insurance issuer offering group or individual health
insurance coverage and group health plan with which such provider or
facility has in effect a contractual relationship for furnishing items
and services under such coverage or such plan, provider directory
information (as defined in section 2719A(f)(6)) with respect to such
provider or facility, as applicable. Such provider or facility shall so
transmit such information to such issuer offering such coverage or such
group health plan--
``(1) when the provider or facility enters into such a
relationship with respect to such coverage offered by such
issuer or with respect to such plan;
``(2) when the provider or facility terminates such
relationship with respect to such coverage offered by such
issuer or with respect to such plan;
``(3) when there are any other material changes to such
provider directory information of the provider or facility with
respect to such coverage offered by such issuer or with respect
to such plan; and
``(4) at any other time determined appropriate by the
provider, facility, or the Secretary.
``SEC. 2799C. PROVIDER REQUIREMENT WITH RESPECT TO PUBLIC PROVISION OF
INFORMATION.
``Each health care provider and health care facility shall make
publicly available, and (if applicable) post on a public website of
such provider or facility--
``(1) information in plain language on--
``(A) the requirements and prohibitions of such
provider or facility under sections 2799 and 2799A
(relating to prohibitions on balance billing in certain
circumstances); and
``(B) if provided for under applicable State law,
any other requirements on such provider or facility
regarding the amounts such provider or facility may,
with respect to an item or service, charge a
participant, beneficiary, or enrollee of a health plan
(as defined in section 2719A(e)(2)) with respect to
which such provider or facility does not have a
contractual relationship for furnishing such item or
service under the plan after receiving payment from the
plan for such item or service and any applicable cost-
sharing payment from such participant, beneficiary, or
enrollee; and
``(2) information on contacting appropriate State and
Federal agencies in the case that an individual believes that
such provider or facility has violated any requirement
described in paragraph (1) with respect to such individual.
``SEC. 2799D. ENFORCEMENT.
``(a) State Enforcement.--
``(1) State authority.--Each State may require a provider
or health care facility subject to the requirements of sections
2799, 2799A, 2799B, or 2799C to satisfy such requirements
applicable to the provider or facility.
``(2) Failure to implement requirements.--In the case of a
State that fails to substantially enforce the requirements set
forth in this part with respect to applicable providers and
facilities in the State, the Secretary shall enforce the
requirements of this part under subsection (b) insofar as they
relate to actions prohibited under this part occurring in such
State.
``(b) Secretarial Enforcement Authority.--
``(1) In general.--If a provider or facility is found to be
in violation of this part by the Secretary, the Secretary may
apply a civil monetary penalty with respect to such provider or
facility in an amount not to exceed $10,000 per violation. The
provisions of subsections (c), (d), (e), (g), (h), (k), and (l)
of section 1128A of the Social Security Act shall apply to a
civil monetary penalty or assessment under this subsection in
the same manner as such provisions apply to a penalty,
assessment, or proceeding under subsection (a) of such section.
``(2) Limitation.--The provisions of paragraph (1) shall
apply to enforcement of a provision (or provisions) of this
part only as provided under subsection (a)(2).
``(3) Complaint process.--The Secretary shall, through
rulemaking, establish a process to receive consumer complaints
of violations of this part and resolve such complaints within
60 days of receipt of such complaints.
``(4) Exception.--The Secretary shall waive the penalties
described under paragraph (1) with respect to a facility or
provider who does not knowingly violate, and should not have
reasonably known it violated, a provision of this part with
respect to a participant, beneficiary, or enrollee, if such
facility or practitioner, within 30 days of the violation,
withdraws the bill that was in violation of such provision, and
reimburses the health plan or enrollee, as applicable, in an
amount equal to the difference between the amount billed and
the amount allowed to be billed under the provision, plus
interest, at an interest rate determined by the Secretary.
``(5) Hardship exemption.--The Secretary may establish a
hardship exemption to the penalties under this subsection.
``(c) Continued Applicability of State Law.--This part shall not be
construed to supersede any provision of State law which establishes,
implements, or continues in effect any requirement or prohibition
except to the extent that such requirement or prohibition prevents the
application of a requirement or prohibition of this part.''.
(e) Rulemaking for Median Contracted Rates.--Not later than July 1,
2020, the Secretary of Health and Human Services, jointly with the
Secretary of Labor, shall establish through rulemaking the methodology
the sponsor or issuer of a health plan (as defined in subsection (e) of
section 2719A of the Public Health Service Act (42 U.S.C. 300gg-19a),
as added by subsection (b) of this section) shall use to determine the
median contracted rate (as defined in section 2719A(b) of such Act, as
amended by subsection (a) of this section), the information such
sponsor or issuer shall share with the nonparticipating provider (as
defined in such section) involved when making such a determination, and
the geographic regions applied for purposes of this subparagraph (E) of
section 2719A(b)(3), as amended by subsection (a) of this section.
(f) Effective Date.--The amendments made by subsections (a) and (b)
shall apply with respect to plan years beginning on or after January 1,
2021.
SEC. 3. GOVERNMENT ACCOUNTABILITY OFFICE STUDY ON PROFIT- AND REVENUE-
SHARING IN HEALTH CARE.
(a) Study.--Not later than 1 year after the date of enactment of
this Act, the Comptroller General of the United States shall conduct a
study to--
(1) describe what is known about profit- and revenue-
sharing relationships in the commercial health care markets,
including those relationships that--
(A) involve one or more--
(i) physician groups that practice within a
hospital included in the profit- or revenue-
sharing relationship, or refer patients to such
hospital;
(ii) laboratory, radiology, or pharmacy
services that are delivered to privately
insured patients of such hospital;
(iii) surgical services;
(iv) hospitals or group purchasing
organizations; or
(v) rehabilitation or physical therapy
facilities or services; and
(B) include revenue- or profit-sharing whether
through a joint venture, management or professional
services agreement, or other form of gain-sharing
contract;
(2) describe Federal oversight of such relationships,
including authorities of the Department of Health and Human
Services and the Federal Trade Commission to review such
relationships and their potential to increase costs for
patients, and identify limitations in such oversight; and
(3) as appropriate, make recommendations to improve Federal
oversight of such relationships.
(b) Report.--Not later than 1 year after the date of enactment of
this Act, the Comptroller General of the United States shall prepare
and submit a report on the study conducted under subsection (a) to the
Committee on Health, Education, Labor, and Pensions of the Senate and
the Committee on Education and Labor and Committee on Energy and
Commerce of the House of Representatives.
SEC. 4. STATE ALL PAYER CLAIMS DATABASES.
(a) In General.--The Secretary of Health and Human Services shall
make one-time grants to eligible States for the purposes described in
subsection (b).
(b) Uses.--A State may use a grant received under subsection (a)
for one of the following purposes:
(1) To establish an All Payer Claims Database for the
State.
(2) To maintain an existing All Payer Claims Databases for
the State.
(c) Eligibility.--To be eligible to receive a grant under
subsection (a), a State shall submit to the Secretary an application at
such time, in such manner, and containing such information as the
Secretary specifies. Such information shall include, with respect to an
All Payer Claims Database for the State, at least specifics on how the
State will ensure uniform data collection through the database and the
security of such data submitted to and maintained in the database.
(d) All Payer Claims Database.--For purposes of this section, the
term ``All Payer Claims Database'' means, with respect to a State, a
State database that may include medical claims, pharmacy claims, dental
claims, and eligibility and provider files, which are collected from
private and public payers.
(e) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated $50,000,000, to remain
available until expended.
SEC. 5. SIMPLIFYING EMERGENCY AIR AMBULANCE BILLING.
(a) In General.--Providers of emergency air medical services shall
submit to a group health plan or health insurance issuer offering group
or individual health insurance coverage, together with an electronic
claims transaction with respect to an enrollee in such plan or
coverage, a description of charges for such services that are separated
by--
(1) the cost of air travel; and
(2) the cost of emergency medical services and supplies.
(b) Rulemaking.--Not later than 1 year after the date of the
enactment of this Act, the Secretary of Health and Human Services shall
determine the form and manner for submitting the description of charges
in subsection (a) through notice and comment rulemaking.
(c) Civil Monetary Penalties.--
(1) In general.--A provider of emergency air medical
services who violates the requirement of subsection (a) shall
be subject to a civil monetary penalty of not more than $10,000
for each act constituting such violation.
(2) Procedure.--The provisions of section 1128A of the
Social Security Act (42 U.S.C. 1320a-7a), other than
subsections (a) and (b) and the first sentence of subsection
(c)(1) of such section, shall apply to civil money penalties
under this subsection in the same manner as such provisions
apply to a penalty or proceeding under section 1128A of the
Social Security Act.
(d) Definitions.--In this section, the terms ``group health plan'',
``health insurance coverage'', and ``health insurance issuer'' have the
meanings given such terms in section 2791 of the Public Health Service
Act (42 U.S.C. 300gg-91).
(e) Effective Date.--The requirement under subsection (a) shall
take effect 6 months after the rules described in subsection (b) are
finalized.
SEC. 6. REPORT BY SECRETARY OF LABOR.
Not later than one year after the date of the enactment of this
Act, and annually thereafter for each of the following 5 years, the
Secretary of Labor shall--
(1) conduct a study of--
(A) the effects of the provisions of, including
amendments made by, this Act on premiums and out-of-
pocket costs in group health plans, including out-of-
pocket costs that are permitted by reason of compliance
with section 2799A(d) of the Public Health Service Act,
as added by section 2(d);
(B) the adequacy of provider networks in group
health plans; and
(C) such other effects of such provisions, and
amendments, as the Secretary deems relevant; and
(2) submit a report on such study to the Committee on
Health, Education, Labor, and Pensions of the Senate and the
Committee on Education and Labor and the Committee on Energy
and Commerce of the House of Representatives.
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