,i  #aaeth ,,congress  #ast ,session    
,h4 ,r4 #chgg  ,,in ,,the ,,house ,,of  
,,representatives  ,september #bh1      
#bjag,ms4 ,michelle ,lujan ,grisham of  
,new ,mexico introduced the following   
bill2 which was referred to the         
,committee on ,energy and ,commerce1 and
 in addition to the ,committee on ,ways 
and ,means1 for a period to be          
subsequently determined by the ,speaker1
 in each case for consideration of such 
provisions as fall within the           
jurisdiction of the committee concerned 
,a ,,bill  ,to amend title ,,xviii of   
the ,social ,security ,act to protect   
health care consumers from surprise     
billing practices1 and for other        
purposes4  #a4 ,short title ,this ,act  
may be cited as the ,fair ,billing ,act 
of #bjag4  #b4 ,protecting health care  
consumers from surprise billing         
practices  7a7 ,providers ,section #ahff
 of the ,social ,security ,act 7#db     
,u4,s4,c4 #acie;cc7 is amended--  7#a7  
in subsection 7a77#a7-- 7,a7 in         

subparagraph 7,x71 by striking and at   
the end2  7,b7 in subparagraph 7,y71 by 
striking the period at the end and      
inserting 1 and2 and  7,c7 by inserting 
after subparagraph 7,y7 the following   
new subparagraph3  7,z7 in the case of a
 hospital or critical access hospital1  
to meet the requirements of paragraphs  
7#a71 7#b71 and 7#c7 of subsection 7l74 
2 and  7#b7 by adding at the end the    
following new subsection3  7l7 ,no      
surprise billing at in-,network         
facilities2 emergency services2 external
 review of certain payments  7#a7 ,no   
surprise billing at in-network          
facilities  7,a7 ,in general ,subject to
 subparagraph 7,b71 in the case of an   
individual with benefits under a health 
care plan who is furnished items or     
services at a relevant facility         
7including items or services furnished  
by a provider of services or supplier at
 such facility7 that is within the      
health care provider network or         
otherwise a participating provider of   

services or supplier with respect to the
 health care plan of such individual1   
the relevant facility 7or the provider  
of services or supplier7 may not hold   
the individual liable for more than the 
amount that the individual would have   
been required to pay in cost sharing if 
such items or services had been         
furnished by a relevant facility 7or1 as
 applicable1 by a provider of services  
or supplier7 that is within the health  
care provider network or otherwise a    
participating provider of services or   
supplier with respect to the health care
 plan of such individual4  7,b7         
,exception for notification and written 
consent ,subparagraph 7,a7 shall not    
apply in the case of a relevant facility
 7or provider of services or supplier at
 such facility7 that1 not later than #gb
 hours before furnishing items or       
services to an individual 7or1 in the   
case where such items or services are   
scheduled to be furnished less than #gb 
hours from the time of scheduling1 #bd  

hours before furnishing such items or   
services71 notifies such individual of  
an estimate of the individual's         
anticipated total out-of-pocket cost of 
care for such items and services and    
obtains written consent from such       
individual4  7#b7 ,emergency services   
,in the case of an individual with      
benefits under a health care plan who is
 furnished items or services with       
respect to an emergency medical         
condition at a hospital or critical     
access hospital 7including items or     
services furnished by a provider of     
services or a supplier at the hospital  
or critical access hospital71 the       
hospital or critical access hospital 7or
 the provider of services or supplier7  
may not charge the individual more than 
the amount that the individual would    
have been required to pay in cost       
sharing if such items or services had   
been furnished by a hospital or critical
 access hospital 7or by a provider of   
services or supplier7 within such       

network or otherwise a participating    
provider of services4  7#c7 ,review     
process ,a relevant facility shall      
participate in any review process       
requested1 and comply with any          
determination made1 under section #c of 
the ,fair ,billing ,act of #bjag4  7#d7 
,definitions ,in this subsection3 7,a7  
,emergency medical condition ,the term  
emergency medical condition has the     
meaning given such term in section      
#ahfg7;e74  7,b7 ,health care plan ,the 
term health care plan means-- 7i7 a     
group health plan2  7ii7 group health   
insurance coverage2  7iii7 individual   
health insurance coverage2 or  7iv7 a   
,federal health care program 7as defined
 in section #aabh;,b7f774  7,c7 ,public 
,health ,service ,act terms ,the terms  
group health plan1 group health         
insurance coverage1 and individual      
health insurance coverage have the      
meanings given those terms1             
respectively1 under section #bgia of the
 ,public ,health ,service ,act 7#db     

,u4,s4,c4 #cjj;gg-#ia74  7,d7 ,relevant 
facility ,the term relevant facility    
means a hospital or critical access     
hospital4  4  7b7 ,insurers ,section    
#bgai;,a of the ,public ,health ,service
 ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is  
amended by adding at the end the        
following new subsection3  7e7 ,payment 
review process ,a group health plan or a
 health insurance issuer offering group 
or individual health insurance shall    
participate in any review process       
requested1 and comply with any          
determination made1 under section #c of 
the ,fair ,billing ,act of #bjag4  4    
7c7 ,effective date ,the amendments made
 by this section shall apply with       
respect to items or services furnished  
on or after the date that is one year   
after the date of the enactment of this 
,act4  #c4 ,review process for surprise 
billing practices  7a7 ,state election  
,each ,state may elect1 at such time and
 in such manner as the ,secretary of    
,health and ,human ,services 7the       

,secretary7 shall prescribe1 to         
establish a review process described in 
subsection 7c7 to be available at the   
request of a health care plan or        
provider of services or supplier4  7b7  
,failure ,to establish an external      
review process or implement standards   
,in the case of a ,state that does not  
elect under subsection 7a7 to establish 
a review process described in subsection
 7c71 the ,secretary shall make         
available within the ,state such a      
review process to be available at the   
request of a health care plan or        
provider of services or supplier4  7c7  
,review process ,in the case of payment 
from a health care plan to a provider of
 services or supplier for items or      
services furnished by such provider or  
supplier to an individual with benefits 
under such plan in a case in which      
section #ahff7l77#a77;,a7 or subsection 
7l77#b7 of such section applies and such
 plan or such provider or supplier      
requests a review of such payment1 a    

review process described in this        
subsection is a process by which an     
independent health care expert          
determines the amount of the payment to 
be made by such plan to such provider or
 supplier using the methodology         
described in subsection 7d7 and notifies
 the individual furnished such items or 
services of such determination within   
#cj days of making such determination4  
7d7 ,methodology ,in the case of payment
 from a health care plan to a provider  
of services or supplier for items or    
services furnished by such provider or  
supplier to an individual with benefits 
under such plan1 the methodology        
described in this subsection consists of
 an independent health care expert      
determining an amount to be paid by the 
plan to the provider or supplier by     
selecting one of the following amounts3 
7#a7 ,the lesser of-- 7,a7 an amount    
proposed by the provider of services or 
supplier that furnished such items or   
services2 and  7,b7 an amount that is   

equal to the #hjth percentile of the    
amount paid for such items and services1
 as reported by a national all-payer    
claims database or1 if available1 a     
,state or regional all-payer claims     
database1 as determined by the          
independent health care expert4  7#b7   
,the greater of-- 7,a7 an amount        
proposed by the health plan providing   
health benefits coverage to such        
individual with respect to such items   
and services2 and  7,b7 #a4be multiplied
 by the ,medicare fee schedule for such 
items and services 7or1 if such items   
and services are not covered under      
,medicare1 an amount determined by the  
,secretary74  7e7 ,reconsideration ,an  
individual furnished items or services  
by a provider of services or supplier   
for which payment is determined in      
accordance with the review process      
described in subsection 7c7 may1 within 
#cj days of receiving notification of   
such determination1 file a written      
request for a reconsideration of such   

determination with the independent      
health care expert making such          
determination4 ,such expert shall1      
within #cj days of receiving such       
request1 determine whether such         
determination should be revised and     
notify such individual of any change to 
such determination4  7f7 ,cost-,sharing 
clarification ,any cost sharing         
7including any copayment or coinsurance7
 that an individual may be responsible  
for after a determination is made under 
subsection 7c7 shall count towards such 
individual's annual deductible with     
respect to the health care plan of such 
individual4  7g7 ,definitions ,in this  
section3 7#a7 ,health care plan ,the    
term health care plan has the meaning   
given such term in section #ahff7l77#d7 
of the ,social ,security ,act 7#db      
,u4,s4,c4 #acie;cc7l77#d774  7#b7       
,independent health care expert defined 
,the term independent health care expert
 means an individual who is1 with       
respect to a payment for items and      

services-- 7,a7 an expert in health care
 billing2  7,b7 free of conflicts of    
interest with respect to such payment2  
and  7,c7 appointed by a ,state or the  
,secretary to make determinations under 
the external review process described in
 subsection 7c74  7#c7 ,provider of     
services ,the term provider of services 
has the meaning given such term in      
section #ahfa of the ,social ,security  
,act 7#db ,u4,s4,c4 #aciex74  7#d7      
,state ,the term ,state has the meaning 
given such term in section #baj of the  
,social ,security ,act 7#db ,u4,s4,c4   
#daj74  7#e7 ,supplier ,the term        
supplier has the meaning given such term
 in section #ahfa of the ,social        
,security ,act 7#db ,u4,s4,c4 #aciex74  
7h7 ,grants to ,states  7#a7 ,in general
 ,the ,secretary of ,health and ,human  
,services shall provide grants1 not     
later than #ij days after the date of   
the enactment of this ,act1 to eligible 
,states to establish and implement a    
review process described in subsection  

7a74  7#b7 ,eligible ,state ,for        
purposes of this subsection1 the term   
eligible ,state means a ,state that has 
elected under subsection 7a7 to         
establish a review process and that has 
submitted an application to the         
,secretary at such time1 in such manner1
 and containing such information as the 
,secretary may require4  7#c7           
,authorization of appropriations ,there 
is authorized to be appropriated to the 
,secretary of ,health and ,human        
,services #d1jjj1jjj1jjj to award grants
 under this subsection4  7i7 ,effective 
date ,this section shall apply with     
respect to items or services furnished  
on or after the date that is one year   
after the date of the enactment of this 
,act4