[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4223 Introduced in House (IH)]
<DOC>
116th CONGRESS
1st Session
H. R. 4223
To amend the Employee Retirement Income Security Act of 1974 to protect
patients from surprise medical bills.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
August 30, 2019
Mr. Spano introduced the following bill; which was referred to the
Committee on Education and Labor
_______________________________________________________________________
A BILL
To amend the Employee Retirement Income Security Act of 1974 to protect
patients from surprise medical bills.
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 ``Protecting Patients from Surprise
Medical Bills Act''.
SEC. 2. PROHIBITION ON SURPRISE MEDICAL BILLING.
Subpart B of part 7 of title I of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at
the end the following:
``SEC. 716. PROHIBITION ON SURPRISE MEDICAL BILLING.
``(a) Definitions.--In this section:
``(1) Balance bill.--The term `balance bill' means the
collection or attempted collection from a participant or
beneficiary of any amount in excess of the applicable
copayments, coinsurance, or deductible for services covered
under the participant or beneficiary's group health plan.
``(2) Emergency medical condition.--The term `emergency
medical condition' means the condition described in section
2719A(b)(2)(A) of the Public Health Service Act.
``(3) Emergency services.--The term `emergency services'
means the services described in section 2719A(b)(2)(B) of the
Public Health Service Act.
``(4) Emergency services provider.--The term `emergency
services provider' means a facility or facility-based provider
that bills a participant or beneficiary for emergency services.
``(5) Facility.--The term `facility' means an entity
providing health care services, as licensed or authorized by a
State.
``(6) Facility-based provider.--The term `facility-based
provider' means a physician, health care professional, or
entity that has entered into an agreement with a facility to
provide health care services to patients of that facility.
``(b) Emergency Services.--
``(1) Prohibition on balance billing.--A self-insured group
health plan shall be solely liable for making payments to an
emergency services provider for emergency services covered
under the plan that are provided to a participant or
beneficiary, and such participant or beneficiary shall not be
liable to the emergency services provider for any amount for
such services other than the applicable copayment, coinsurance,
or deductible amount required under the plan for covered
emergency services. Emergency service providers shall not
balance bill a participant or beneficiary under a self-insured
group health plan for any covered emergency services provided
to such participant or beneficiary.
``(2) Cost sharing limitation and prior authorization.--If
a self-insured group health plan provides coverage for any
benefits with respect to emergency services, such coverage
shall be in accordance with the provisions of section 2719A(b)
of the Public Health Service Act and--
``(A) if such services are provided by an out-of-
network provider, the cost-sharing requirements
(including any deductible amount and the out-of-pocket
limit) applicable to such services shall be the same as
the cost-sharing requirement that would apply if such
services were provided by an in-network provider;
``(B) prior authorization shall not be required for
pre-hospital transport or treatment; and
``(C) payment by the plan shall be made directly to
the emergency services provider.
``(c) Covered Non-Emergency Services.--Facility-based providers
shall not balance bill a patient for covered non-emergency services if
the services are provided at an in-network facility and the participant
or beneficiary did not have the ability or opportunity to select to
receive such services from an in-network provider.
``(d) Reimbursements for Out-of-Network Payments.--A self-insured
group health plan shall reimburse a health care provider for out-of-
network emergency and non-emergency services described in subsections
(b) and (c) based on one of the following payment methodologies:
``(1) The amount of the claim made by the provider for such
services.
``(2) The usual and customary amount charged by the
provider for similar services in the community where the
services were provided.
``(3) The amount mutually agreed to by the plan and the
provider during the 60-day period after the date on which the
claim is submitted.
``(e) Voluntary Binding Arbitration.--
``(1) In general.--If a self-insured group health plan and
health care provider are unable to resolve a dispute with
respect to billing for services described in subsection (b) or
(c), such provider may voluntarily initiate binding arbitration
with such plan under this subsection. The Secretary shall
establish by rule methods of aggregation for claim disputes
submitted to voluntary binding arbitration under this
subsection.
``(2) Arbitration organizations.--
``(A) In general.--The Secretary shall enter into
contracts with outside organizations to conduct timely,
voluntary binding arbitration proceedings under this
subsection. To be eligible for such a contract, an
organization shall have at least 5 years of experience
serving as a neutral party in complex dispute
resolution proceedings.
``(B) Limitation.--An organization shall not be
eligible to enter into a contract under subparagraph
(A) if the organization has been employed by, consulted
for, or otherwise had a business relationship (other
than the receipt of arbitration fees) with a health
plan, health insurance issuer, facility, or health care
professional during the 3-year period immediately
preceding the effective date of the contract with the
Secretary or during the term of such contract.
``(C) Arbitrator.--An arbitrator may not be
assigned by an organization to resolve a dispute under
this paragraph if the arbitrator has been employed by,
consulted for, or otherwise had a business relationship
(other than the receipt of arbitration fees) with a
health plan, health insurance issuer, facility, or
health care professional during the 3-year period
immediately preceding the request for arbitration.
``(3) Eligibility.--To be eligible for voluntary binding
arbitration under this subsection the claim involved shall--
``(A) in the case of a claim relating to facility
health care services, be not less than $3,000; and
``(B) in the case of a claim relating to
professional services, be not less than $500.
Such amounts shall be adjusted by the Secretary each year by
the percentage increase in the consumer price index.
``(4) Procedures.--The following procedures shall apply
during a voluntary arbitration proceeding under this
subsection:
``(A) The plan or provider involved may make an
offer to settle the disputed claim. The party to whom
such an offer is directed shall respond to such offer
within 15 days after receipt of the offer.
``(B) If the party receiving an offer to settle
under paragraph (A) does not accept such offer, and the
arbitrator issues a final order with respect to the
disputed claim that is more than 90 percent or less
than 110 percent of the offer amount, the party
receiving the offer is deemed a non-prevailing party
for purpose of paragraph (5).
``(C) A final order under this paragraph is subject
to judicial review under this Act.
``(D) All parties to a dispute that is subject to
arbitration under this subsection may agree to settle
claim at any time, for any amount, regardless of
whether an offer to settle was made or rejected.
``(5) Review costs.--
``(A) In general.--The entity that does not prevail
under an arbitrator's final order under voluntary
binding arbitration under this subsection shall pay the
review costs.
``(B) Apportionment of costs.--In the case that
both parties to voluntary binding arbitration under
this subsection prevail in part, the review costs shall
be apportioned among the parties in proportion to the
final judgment. The apportionment shall be based on the
disputed claim amount.
``(C) Failure to pay.--If a party to voluntary
binding arbitration under this subsection fails to pay
any amount of the ordered review costs within 35 days
after the arbitrator's final order, the party shall be
subject to a penalty of $500 for each day that such
amount is not paid.
``(f) Network Transparency.--A self-insured group health plan
shall--
``(1) not later than 1 year after the date of enactment of
this section, publish on their internet website a list of
network providers, and update such list on a monthly basis; and
``(2) not later than 1 year after the date of enactment of
this section, and annually thereafter, provide an annual
notification to participants and beneficiaries concerning the
potential for balance billing when using out-of-network
providers.''.
<all>