[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 1531 Introduced in Senate (IS)]
<DOC>
116th CONGRESS
1st Session
S. 1531
To amend the Public Health Service Act to provide protections for
health insurance consumers from surprise billing.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
May 16, 2019
Mr. Cassidy (for himself, Mr. Bennet, Mr. Young, Ms. Hassan, Ms.
Murkowski, Mr. Carper, Mr. Sullivan, Mr. Brown, Mr. Cramer, Mr. Cardin,
Mr. Kennedy, and Mr. Casey) introduced the following bill; which was
read twice and referred to the Committee on Health, Education, Labor,
and Pensions
_______________________________________________________________________
A BILL
To amend the Public Health Service Act to provide protections for
health insurance consumers from surprise billing.
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 ``Stopping The Outrageous Practice of
Surprise Medical Bills Act of 2019'' or the ``STOP Surprise Medical
Bills Act of 2019''.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) Consumers frequently struggle to determine when and how
much they will pay for a medical service or procedure. A
majority of consumers say health care providers rarely, if
ever, discuss costs of recommended treatments and whether these
treatments are covered by health insurance. Almost 70 percent
of patients who receive bills from out-of-network providers did
not realize the provider was out-of-network at the time of
treatment. Patients using in-network facilities still receive
claims from out-of- network providers at high rates, over 15
percent of inpatient admissions and 5 percent of outpatient
service days. Even when patients try to schedule an in-network
procedure at an in-network hospital and try to ensure that all
providers who administer treatment will be in-network, they may
be sent a balance bill by an out-of-network provider after
receiving care. If providers accepted the same health plans as
the facilities at which they practice and administer care, out-
of-network surprise medical bills would not be a complication
for consumers scheduling elective procedures.
(2) Surprise medical bills affect a sizeable portion of the
insured population. Approximately 30 percent of individuals
covered by private health insurance have received a surprise
medical bill within the past year. Almost 20 percent of
inpatient admissions by enrollees in large employer plans
include at least 1 claim from an out-of-network provider, while
8 percent of outpatient service days include an out-of-network
claim.
(3) Surprise medical bills are an issue of particular
concern to consumers. A majority of Americans feel that
softening the impact of surprise medical bills should be a
priority for the current Congress. Eighty-six percent of
Americans think it is important to protect individuals from
surprise medical bills.
(4) Surprise medical bills for emergency care are
frequently unavoidable due to the emergent and serious nature
of the patient's condition at the time of treatment. One in 5
cases of inpatient hospital admissions that originate within
the emergency department result in a surprise medical bill. For
inpatient admissions, those that include an emergency room
claim are much more likely to include a claim from an out-of-
network provider than admissions without an emergency room
claim. This is true whether or not enrollees use in-network
facilities. Most cases of surprise medical billing occur when
privately insured individuals involuntarily see out-of-network
providers during medical emergencies.
(5) The financial implications of surprise medical bills
can be devastating for American consumers and can prevent them
from seeking timely follow-up care or from accessing necessary
services. Approximately 20 percent of insured Americans
struggle to pay their medical bills. Almost a third of
consumers who report they are struggling to pay a medical bill
also report this bill was due to charges from an out-of-network
provider that were not covered or were only partially covered
by their insurer. Consumers with outstanding medical bills
report delaying or skipping needed health care at rates 2 to 3
times higher than consumers without outstanding bills. Over 60
percent of consumers with outstanding medical bills report
difficulties paying other bills (including necessities such as
food, heat, or housing costs) as a result of their medical
bills.
SEC. 3. PROHIBITION ON SURPRISE BALANCE BILLING AND INDEPENDENT DISPUTE
RESOLUTION WITH RESPECT TO OUT-OF-NETWORK HEALTH CARE
SERVICES.
(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. GENERAL PROHIBITION ON SURPRISE BALANCE BILLING.
``(a) Surprise Medical Bill.--In this title, the term `surprise
medical bill' means a balance bill, as described in subsection (b),
that an enrollee receives for services provided to the enrollee where
such services were--
``(1) emergency services provided by an out-of-network
health care professional or at an out-of-network facility;
``(2) health care services that were provided--
``(A) at an in-network facility (including the use
of equipment, devices, telemedicine services, or other
treatments or services); and
``(B) by an out-of-network health care
professional; or
``(3) additional health care services required in the case
of an enrollee who initially enters a hospital through the
emergency room for emergency services, and then receives
nonemergency services from an out-of-network health care
professional or at an out-of-network hospital or facility after
the enrollee has been stabilized (as defined in section
2719A(b)(2)(C)), as determined by the treating physician.
Paragraph (3) shall not apply in the case of an enrollee who is
stabilized and able to travel in nonmedical transport, and the enrollee
(or designee of the enrollee where the enrollee is not able to
comprehend the information to be provided or make related decisions)
has been provided with clear, written notification that the
professional or facility is an out-of-network health care professional
or facility, has been given a cost estimate for services provided by
the out-of-network professional or facility, and has assumed, in
writing, full responsibility for out-of-pocket costs associated with
such out-of-network care.
``(b) Balance Bill.--In subsection (a), the term `balance bill'
refers to a claim for payment for services provided to an enrollee that
is in an amount equal to the difference between the actual amount
charged with respect to services or care described in subsection (a)
and the expected in-network cost-sharing required by the enrollee under
the plan or coverage involved.
``(c) Prohibition on Balance Billing.--
``(1) Prohibition.--
``(A) In general.--A group health plan, a health
insurance issuer in connection with group or individual
health insurance coverage, or a health care provider
shall not engage in balance billing practices
prohibited under this section.
``(B) Application of provisions.--Subparagraph (A)
shall apply--
``(i) to all services provided at
hospitals, emergency rooms, State-accredited
free-standing emergency departments, hospital
outpatient departments, and ambulatory surgery
centers; and
``(ii) with respect to subsection (a)(2),
to the health care provider's offices and
related services (including laboratory and
imaging services ordered by an in-network
provider and provided by an out-of-network
provider or laboratory).
``(2) Enrollee liability.--With respect to the services and
care described in subsection (a), an enrollee shall only be
liable for the in-network cost-sharing amount provided for in
their plan or coverage. For purposes of this section, such
payments by the enrollee shall count toward the in-network
deductible under the plan or coverage as well as toward the
enrollee's out-of-pocket maximum limitation.
``(3) Penalty.--Violations of this section shall subject
the violator to a civil monetary penalty as provided for in
this title. Such provisions shall not apply to a health care
provider, group health plan, or health insurance issuer that
unknowingly balance bills an enrollee and reimburses such
enrollee within 30 calendar days of such billing.
``SEC. 2729B. OUT-OF-NETWORK BILLING.
``(a) Prohibition.--
``(1) In general.--An enrollee may not be billed in excess
of the in-network cost-sharing amount for services or care
provided under section 2729A (a surprise medical bill
situation).
``(2) Automatic payment.--
``(A) In general.--A group health plan, or health
insurance issuer in connection with group or individual
health insurance coverage, shall pay the median in-
network rate under the plan or coverage, less the
applicable enrollee in-network cost-sharing, directly
to the health care provider as provided for in this
section.
``(B) Request for alternative rate.--Upon payment
under subparagraph (A), the plan or issuer shall
provide to the health care provider information about
how the provider may initiate independent dispute
resolution under such subsection with respect to such
payment. The plan, issuer, or provider may negotiate an
alternative amount or initiate independent dispute
resolution under subsection (b) during the 30-day
period beginning on the date on which the automatic
payment is made under this subsection.
``(b) Establishment of IDR Process; Certification of Entities.--
``(1) Establishment.--Not later than 1 year after the date
of enactment of this section, the Secretary, in consultation
with the Secretary of Labor, shall establish a process for
resolving payment disputes between group health plans, or
health insurance issuers offering health insurance coverage in
the group market, and out-of-network health care providers in
surprise medical bill situations in accordance with this
section (referred to in this section as the `IDR process').
``(2) Certification of 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.
``(3) IDR entity.--Under the process established under
paragraph (1), the parties in the independent dispute
resolution process shall jointly agree upon an independent
dispute resolution entity. In the event that parties cannot
agree, one will be selected at random jointly by the Department
of Health and Human Services and the Department of Labor.
``(c) Applicable Claims.--
``(1) In general.--The IDR process shall be with respect to
one or more Current Procedural Terminology (`CPT') codes.
``(2) Batching of claims.--Health care facilities and
providers and group health plans or health insurance issuers
may batch claims if such claims--
``(A) involve identical plan or issuer and provider
or facility parties;
``(B) involve claims with the same or related
current procedural terminology codes relevant to a
particular procedure; and
``(C) involve claims that occur within 30 days of
each other.
``(d) Independent Dispute Resolution Process.--
``(1) Timing.--An independent dispute resolution entity
that receives a request under this section shall, not later
than 30 days after receiving such request, determine the amount
the group health plan, or health insurance issuer offering
health insurance coverage in the group market, is required to
pay the out-of-network health care provider. Such amount shall
be--
``(A) the amount determined by the parties through
a settlement under paragraph (2); or
``(B) the amount determined reasonable by the
entity in accordance with paragraph (3).
``(2) Settlement.--
``(A) In general.--If the independent dispute
resolution entity determines, based on the amounts
indicated in the request under this section, that a
settlement between the group health plan, or health
insurance issuer offering health insurance coverage in
the group market, and the out-of-network health care
provider is likely, the independent dispute resolution
entity may direct the parties to attempt, for a period
not to exceed 10 days, a good faith negotiation for a
settlement.
``(B) Timing.--The period for a settlement
described in subparagraph (A) shall accrue towards the
30-day period required under paragraph (1).
``(3) Determination of amount.--
``(A) Final offers.--In the absence of a settlement
under paragraph (2), the group health plan, or health
insurance issuer offering health insurance coverage in
the group market, and the out-of-network health care
provider shall each submit to the independent dispute
resolution entity their final offer. Such entity shall
determine which of the 2 amounts is more reasonable
based on the factors described in subparagraph (D).
``(B) Final decisions.--The amount that is
determined to be the more reasonable amount under
subparagraph (A) shall be the final decision of the
independent dispute resolution entity as to the amount
the group health plan, or health insurance issuer
offering health insurance coverage in the group market,
is required to pay the out-of-network health care
provider.
``(C) Service units.--A final determination under
subparagraph (B) may include the resolution of disputes
for multiple items or services, if such determination
is in regard to items or services that are eligible for
independent dispute resolution under subsection (c)(2).
``(D) Factors.--In determining which final offer to
select as the more reasonable amount under subparagraph
(A), the independent dispute resolution entity shall
consider relevant factors including--
``(i) 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); and
``(ii) other factors that may be submitted
at the discretion of either party, which may
include--
``(I) the level of training,
education, experience, and quality and
outcomes measurements of the out-of-
network health care provider;
``(II) the circumstances and
complexity of the particular dispute,
including the time and place of the
service;
``(III) the market share held by
the out-of-network health care provider
or that of the plan or issuer;
``(IV) demonstration of good faith
efforts (or lack of good faith efforts)
made by the out-of-network provider or
the plan to contract and prior
negotiated rates, if applicable; and
``(V) other relevant economic
aspects of provider reimbursement for
the same specialty within the same
geographic area.
``(E) Effect of determination.--A final
determination of an independent dispute resolution
entity under subparagraph (B)--
``(i) shall be binding; and
``(ii) 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.
``(4) Privacy laws.--An independent dispute resolution
entity shall, in conducting an independent dispute resolution
process under this subsection, comply with all applicable
Federal and State privacy laws.
``(5) Public availability.--The reasonable amount
determined by an independent dispute resolution entity under
this subsection with respect to any claim shall not be
confidential, except that information submitted to the
independent dispute entity shall be kept confidential.
Independent dispute entities may consider past decisions
awarded by independent dispute entities during the independent
dispute resolution process.
``(6) Costs of independent dispute resolution process.--The
nonprevailing party shall be responsible for paying all fees
charged by the independent dispute resolution entity. If the
parties reach a settlement prior to completion of the
independent dispute resolution process, the costs of the
independent dispute resolution process shall be divided equally
between the parties.
``(7) Payment.--Group health plans and health insurance
issuers with respect to group health coverage shall pay
directly to the health care provider amounts determined by the
independent dispute resolution entity within 30 days of the
date on which the entity makes a determination with respect to
such amount. A plan or issuer that fails to comply with this
paragraph shall be subject to the penalties described in
section 2729A(c)(3).''.
(b) Emergency Services.--Section 2719A(b)(1)(C)(ii)(II) of the
Public Health Service Act (42 U.S.C. 300gg-19a(b)(1)(C)(ii)(II)) is
amended by inserting ``, deductible amount,'' after ``copayment
amount''.
SEC. 4. NOTIFICATION OF NEW INSURANCE PRODUCTS TO IN-NETWORK PROVIDERS.
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. 2729C. NOTIFICATION OF NEW INSURANCE PRODUCTS TO IN-NETWORK
PROVIDERS.
``If a health care provider has a contract to provide in-network
services to enrollees in a group health plan or health insurance
coverage offered by a health insurance issuer, the plan or issuer shall
notify the in-network provider within 7 days of offering any new
insurance product for which the in-network provider would be eligible
to enroll as an in-network provider.''.
SEC. 5. TRANSPARENCY REGARDING IN-NETWORK AND OUT-OF-NETWORK
DEDUCTIBLES.
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 4, is further
amended by adding at the end the following:
``SEC. 2729D. 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).''.
SEC. 6. ENSURING ENROLLEE ACCESS TO COST-SHARING INFORMATION.
(a) In General.--Subpart II of part A of title XXVII of the Public
Health Service Act (42 U.S.C. 300gg-11 et seq.), as amended by section
5, is further amended by adding at the end the following:
``SEC. 2729E. PROVISION OF COST-SHARING INFORMATION.
``(a) Cost-Sharing Disclosure for Medical Services.--
``(1) Provider disclosures.--A group health plan or a
health insurance issuer offering group or individual health
insurance coverage shall not contract with a health care
provider with respect to the plan or coverage unless the
provider agrees to provide an enrollee in the plan or coverage,
at the time of scheduling an elective health care service, or
not later than 48 hours of the enrollee requesting such
information, the expected enrollee cost-sharing for the
provision of a particular health care service involved
(including any service that is reasonably expected to be
provided in conjunction with such specific service, such as
expected cost-sharing of laboratory services).
``(2) Insurer disclosures.--A group health plan or a health
insurance issuer offering group or individual health insurance
coverage shall provide an enrollee in the plan or coverage with
a good faith estimate of the enrollee's cost-sharing (including
deductibles, copayments, and coinsurance) for which the
enrollee would be responsible for paying with respect to a
specific elective health care service (including any service
that is reasonably expected to be provided in conjunction with
such specific service such as expected cost-sharing of
laboratory services), not later than 48 hours after receiving a
request for such information by an enrollee.
``(b) Electronically Available Price Information.--A group health
plan or a health insurance issuer offering group or individual health
insurance coverage shall provide to enrollees the out-of-pocket costs
and benefits information at all sites of care and for all providers
included in the plan network. Such information shall be made available
to enrollees through an internet website or an application. Information
about the availability of such price information through such means
shall be provided to each enrollee upon enrollment, or renewal, in the
health plan or health insurance coverage.''.
(b) Effective Dates.--
(1) Cost-sharing disclosures.--Subsection (a)(1) of section
2729E of the Public Health Service Act, as added by subsection
(a), shall apply with respect to plan years beginning on or
after January 1, 2020.
(2) Availability of information.--Subsection (b) of section
2729E of the Public Health Service Act, as added by subsection
(a), shall apply with respect to plan years beginning on or
after January 1, 2021.
SEC. 7. MEDICAL LOSS RATIO.
Section 2718(a)(1) of the Public Health Service Act (42 U.S.C.
300gg-18(a)(1)) is amended by inserting before the period the
following: ``(including, in the case of group health plans, the amount
of independent dispute process expenses incurred by the plan)''.
SEC. 8. TRANSPARENCY REQUIREMENTS ON HOSPITALS.
Section 2718 of the Public Health Service Act (42 U.S.C. 300gg-18)
is amended by adding at the end the following:
``(f) Transparency Requirements on Hospitals.--
``(1) Requirements for hospitals and physician groups.--
Each hospital operating within the United States shall for each
year disclose on its internet website and in printed materials,
any financial relationship or profit-sharing agreement the
hospital maintains with a physician group.
``(2) Required information.--
``(A) In general.--Each hospital operating within
the United States shall include ancillary services
provided by individuals such as phlebotomists,
laboratory technicians, and echocardiogram technicians
within each hospital bill that is provided to patients.
``(B) Study.--Not later than 1 year after the date
of enactment of this Act, the Secretary shall conduct a
study on the feasibility of hospitals and hospital-
based provider groups providing to patients a single,
unified bill for all services provided within an
episode of care.''.
SEC. 9. TRANSPARENCY REQUIREMENTS ON INSURANCE.
(a) Group Health Plan Reporting.--Part C of title XXVII of the
Public Health Service Act (42 U.S.C. 300gg-91 et seq.) is amended by
adding at the end the following:
``SEC. 2795. TRANSPARENCY REQUIREMENTS FOR GROUP HEALTH PLANS.
``(a) In General.--Each group health plan and health insurance
issuer offering group or individual health insurance coverage shall
annually report to the Secretary of Health and Human Services 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, including applicable cost-sharing amounts, to
the enrollee for the services, and the difference between the
billed charge and the amount the plan pays, adjusted by any
balance billing limitation through State and Federal regulatory
and statutory requirements that might apply;
``(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. 10. APPLICABILITY TO STATES WITH SURPRISE BILLING LAWS.
(a) General Application.--
(1) In general.--Nothing in this Act, or the amendments
made by this Act, shall be construed to prohibit a State from
enacting patient protections that are greater than those
provided for in such amendments.
(2) Application to all plans.--In the case of a group
health plan, individual health plan, and non-Federal
governmental health plan offered in a State that has not
enacted a law to determine the payment resolution between
enrollees and health care facilities or professionals relating
to surprise medical bills, the procedures applicable to self-
insured group health plans for the resolution of surprise
medical bills under this Act (including the amendments made by
this Act), shall apply to determine compensation with respect
to a surprise medical bill, until such time as the State enacts
a law providing for such a resolution methodology.
(b) Provisions Applicable to ERISA.--Section 715 of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1185d) is amended by
adding at the end the following:
``(c) Prohibitions on Balance Billing.--
``(1) Fully insured plans.--In the case of a fully insured
group health plan--
``(A) a State may establish procedures for
determining the appropriate compensation applicable to
surprise medical bills between a participant or
beneficiary and a health care facility or professional
so long as the methodology used relies on the
definition of `surprise medical bill' and the
prohibitions contained in section 2729A of the Public
Health Service Act; and
``(B) a State may enact laws relating to rate-
setting, independent dispute resolution, an in-network
guarantee, or an alternative methodology that complies
with paragraph (1).
``(2) Self-insured plans.--In the case of a self-insured
group health plan, the resolution methodology provided for
under section 2729A of the Public Health Service Act, shall be
used to determine compensation with respect to a surprise
medical bill.''.
(c) FEHBP.--In the case of a health plan under chapter 89 of title
5, United States Code, the resolution methodology provided for under
this Act (including the amendments made by this Act), shall be used to
determine compensation with respect to a surprise medical bill.
SEC. 11. BALANCE BILLING STUDY.
(a) In General.--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 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 out-of-
network health care services;
(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) the impact of connecting reimbursement to different
claims databases;
(5) the number of bills that go to the independent dispute
resolution process; and
(6) the administrative cost of the independent dispute
resolution process and estimated impact on health insurance
premiums and deductibles.
(b) Information Requirements.--The information provided in the
report under subsection (a) shall be--
(1) disaggregated by State and according to the fully
insured and the self-insured markets; and
(2) with respect to paragraphs (1) through (3) of such
subsection, made available to the public electronically in a
searchable database.
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