,,ii  #aaeth ,,congress  #b;d ,session  
,s4 #ceda  ,,in ,,the ,,senate ,,of     
,,the ,,united ,,states  ,october #c    
7legislative day1 ,september #bh71 #bjah
 ,mrs4 ,shaheen 7for herself1 ,mrs4     
,mc,caskill1 ,ms4 ,baldwin1 and ,ms4    
,hassan7 introduced the following bill2 
which was read twice and referred to the
 ,committee on ,health1 ,education1     
,labor1 and ,pensions  ,a ,,bill  ,to   
amend the ,public ,health ,service ,act 
to establish limitations on cost-sharing
 for out-of-network services1 to        
prohibit balance billing for such       
services1 and for other purposes4  #a4  
,short title  ,this ,act may be cited as
 the ,reducing ,costs for               
,out-of-,network ,services ,act of      
#bjah4  #b4 ,limitations on cost-sharing
 for out-of-network services  7a7 ,in   
general ,subpart ,,ii of part ,a of     
title ,,xxvii of the ,public ,health    
,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aa
 et seq47 is amended by adding at the   
end the following3  #bgbi4 ,limitations 

on cost-sharing for out-of-network      
services  7a7 ,health insurance issuer  
requirement ,a health insurance issuer  
offering individual health insurance    
coverage that offers benefits with      
respect to a health care service        
provided in a ,state by a participating 
provider shall ensure that the          
cost-sharing requirement with respect to
 such service provided in the ,state by 
a nonparticipating provider does not    
exceed the rate selected by the         
applicable ,state authority under       
subsection 7c77#a7 for such service4    
7b7 ,limitation on charges by health    
care providers  7#a7 ,in general ,a     
health care provider may not charge a   
patient for health care services in     
excess of the following3  7,a7 ,in the  
case of a patient who is enrolled in    
individual health insurance coverage    
that does not provide out-of-network    
benefits for a given service1 the health
 care provider may charge such patient  
no more than the rate selected by the   

applicable ,state authority under       
subsection 7c77#a74  7,b7 ,in the case  
of a patient enrolled in individual     
health insurance coverage that provides 
out-of-network benefits for a given     
service1 the health care provider may   
charge such patient no more than--  7i7 
the rate selected by the applicable     
,state authority under subsection       
7c77#a72 minus  7ii7 the sum of--  7,i7 
the payment made to the health care     
provider pursuant to such coverage2 and 
7,,ii7 the out-of-network cost-sharing  
amount required under such coverage4    
7,c7 ,in the case of an uninsured       
individual1 the health care provider may
 charge such patient no more than the   
lower of--  7i7 the rate selected by the
 applicable ,state authority under      
subsection 7c77#b72 or  7ii7 the rate   
otherwise allowed to be charged to such 
an individual for such a service under  
,state law4  7#b7 ,enforcement ,a health
 care provider that violates the        
requirement under paragraph 7#a7 shall  

be subject to the same civil monetary   
penalties described in paragraph 7#a7 of
 section #ibb7;f71 including the        
provisions described in paragraph 7#b7  
of such section1 as a person who commits
 a violation described in paragraph 7#a7
 of such section4  7c7 ,rate  7#a7      
,individuals enrolled in individual     
health insurance coverage ,an applicable
 ,state authority shall select for the  
,state as applicable for purposes of    
subsection 7a7 and subparagraphs 7,a7   
and 7,b7 of subsection 7b77#a7 one of   
the following as a maximum rate for     
health care services for individuals    
enrolled in individual health insurance 
coverage3  7,a7 #abe percent 7or1 in a  
case described in paragraph 7#c7 and at 
the discretion of the applicable ,state 
authority1 #bjj percent7 of the allowed 
charges determined for the item or      
service under the original ,medicare    
fee-for-service program under parts ,a  
and ,b of title ,,xviii of the ,social  
,security ,act4  7,b7 #hj percent of the

 usual1 customary1 and reasonable charge
 for the service1 as determined by a    
database of usual1 customary1 and       
reasonable charges chosen by the        
applicable ,state authority and approved
 as appropriate by the ,secretary4  7,c7
 #ajj percent of the allowed charges for
 the service if the service were        
provided by a participating provider1   
which shall be determined based upon the
 actual allowed rate under the coverage4
  7#b7 ,uninsured individuals ,an       
applicable ,state authority shall select
 for the ,state as applicable for       
purposes of subsection 7b77#a77;,c7 one 
of the following as a maximum rate for  
health care services for uninsured      
individuals3  7,a7 ,the rate described  
in subparagraph 7,a7 of paragraph 7#a74 
7,b7 ,the rate described in subparagraph
 7,b7 of paragraph 7#a74  7#c7 ,services
 provided in rural areas ,a case        
described in this paragraph is a case in
 which the item or service is furnished 
by a provider of services 7as defined in

 subsection 7u7 of section #ahfa of the 
,social ,security ,act7 or supplier 7as 
defined in subsection 7d7 of such       
section7 in a rural area 7as defined in 
section #ahhf7;d77#b77;,d7 of such      
,act74  7#d7 ,default rate ,in the case 
in which an applicable ,state authority 
does not select a rate under paragraph  
7#a7 or 7#b7 for a service1 the maximum 
rate applicable in the ,state for the   
service for purposes of subsections 7a7 
and 7b7 shall--  7,a7 be the rate       
described in subparagraph 7,a7 of       
paragraph 7#a71 if the service is       
covered under the original ,medicare    
fee-for-service program under parts ,a  
and ,b of title ,,xviii of the ,social  
,security ,act2 or  7,b7 be a rate      
established by the ,secretary1 if the   
service is not covered under such       
program4  7#e7 ,clarification ,in       
selecting a rate under paragraph 7#a7 or
 7#b7 for a health care service1 the    
applicable ,state may select a rate that
 differs from the rate selected under   

such paragraph for a different health   
care service4  7d7 ,definitions ,for    
purposes of this section3 7#a7 ,health  
care provider ,the term health care     
provider includes a hospital 7as defined
 in section #ahfa7;e7 of the ,social    
,security ,act71 a critical access      
hospital 7as defined in section         
#ahfa7mm7 of such ,act71 a physician 7as
 defined in section #ahfa7r7 of such    
,act71 and other providers as determined
 by the ,secretary4  7#b7 ,uninsured    
individual ,the term uninsured          
individual1 with respect to an          
individual receiving a health care      
service1 means an individual who1 at the
 time at which the service was          
furnished1 was not enrolled in a plan   
that provides medical care benefits1    
including any ,federal health benefit   
program1 as determined by the           
,secretary4  4  7b7 ,effective date     
,section #bgbi of the ,public ,health   
,service ,act1 as added by subsection   
7a71 shall take effect on ,january #a1  

#bjbj4  #c4 ,grants for group market    
7a7 ,in general ,the ,secretary of      
,health and ,human ,services shall award
 grants to ,states for the purpose of   
studying the potential for imposing     
limitations on charges for health care  
services provided to individuals        
enrolled in group health plans or group 
health insurance coverage offered by a  
health insurance issuer that are similar
 to the limitations that apply under    
section #bgbi of the ,public ,health    
,service ,act1 as added by section #b4  
7b7 ,authorization of appropriations    
,there are authorized to be appropriated
 such sums as may be necessary to carry 
out this section4  7c7 ,definitions ,in 
this section1 the terms group health    
plan1 group health insurance coverage1  
and health insurance issuer have the    
meanings given such terms in section    
#bgia of the ,public ,health ,service   
,act 7#db ,u4,s4,c4 #cjj;gg-#ia74