,,ii #aaeth ,,congress #b;d ,session ,s4 #ceib ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,october #aa1 #bjah ,ms4 ,hassan 7for herself and ,mrs4 ,shaheen7 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 prevent surprise medical billing practices1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,no ,more ,surprise ,medical ,bills ,act of #bjah4 #b4 ,preventing surprise billing practices 7a7 ,in general 7#a7 ,prohibition ,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 ,preventing surprise billing practices 7a7 ,definitions ,in this section3 7#a7 ,health care provider ,the term health care provider means-- 7,a7 a hospital 7as defined in section #ahfa7;e7 of the ,social ,security ,act72 7,b7 a critical access hospital 7as defined in section #ahfa7mm7 of such ,act72 7,c7 an ambulatory surgical center as described in section #ahcc7;i77#a77;,a7 of such ,act2 or 7,d7 a provider of services or supplier furnishing services at such hospital1 critical access hospital1 or ambulatory surgical center4 7#b7 ,in-network health care provider ,the term in-network health care provider1 with respect to a group health plan or health insurance coverage offered in the group market1 means a health care provider that is within the health care provider network of the plan or coverage or is otherwise a participating provider of services or supplier with respect to such plan or coverage4 7#c7 ,out-of-network health care provider ,the term out-of-network health care provider1 with respect to a group health plan or health insurance coverage offered in the group market1 means a health care provider that is not within the health care provider network of the plan or coverage or is not otherwise a participating provider of services or supplier with respect to such plan or coverage4 7b7 ,requirement for notice and consent 7#a7 ,notice ,a health care provider1 in the case of an individual enrolled in a group health plan or health insurance coverage offered in the group market1 who seeks to be furnished items or services or is to be furnished items or services by the provider1 shall-- 7,a7 7i7 provide to the individual 7or to a representative of the individual71 on the date on which the individual makes an appointment to be furnished such items or services1 if applicable1 and on the date on which the individual is furnished such items and services-- 7,i7 an oral explanation of the written notification described in subclause 7,,ii7 and such documentation of the provision of such explanation1 as the ,secretary determines appropriate2 and 7,,ii7 a written notice specified by the ,secretary through rulemaking that-- 7aa7 contains the information required under paragraph 7#b72 and 7bb7 is signed and dated by the individual2 and 7ii7 retain1 for a period specified through rulemaking by the ,secretary1 a copy of the documentation described in clause 7i77,i7 and the written notice described in clause 7i77,,ii72 and 7,b7 in the case that such provider is an out-of-network health care provider1 obtain from the individual the consent described in paragraph 7#c74 7#b7 ,information included in notice ,the notice described in paragraph 7#a77;,a7 shall include1 with respect to the individual described in such paragraph1 a notification of each of the following3 7,a7 ,whether the health care provider is an out-of-network health care provider with respect to the group health plan1 or health insurance coverage offered in the group market1 of such individual4 7,b7 ,if the health care provider is such an out-of-network health care provider1 the estimated amount that such provider will charge the individual for such items and services in excess of any cost sharing obligations that the individual would otherwise have under such plan or coverage for such items and services if the health care provider were an in-network health care provider with respect to the plan or coverage of such individual4 7,c7 ,in the case of a health care provider that is a hospital1 critical access hospital1 or ambulatory surgical center as described in subparagraph 7,a71 7,b71 or 7,c7 of subsection 7a77#a71 respectively-- 7i7 whether any of the providers of services or suppliers furnishing items or services at such hospital1 critical access hospital1 or ambulatory surgical center who will furnish the items or services to the individual are out-of-network health care providers with respect to the group health plan1 or health insurance coverage offered in the group market1 of such individual2 and 7ii7 if any such providers of services or suppliers are such out-of-network health care providers1 the estimated amount that such providers or suppliers will charge the individual for such items and services in excess of any cost sharing obligations that the individual would otherwise have for such items and services if the providers or suppliers were in-network health care providers with respect to the plan or coverage of such individual4 7#c7 ,consent described ,for purposes of paragraph 7#a77;,b71 the consent described in this paragraph1 with respect to an individual enrolled in a group health plan1 or health insurance coverage offered in the group market1 who is to be furnished items or services by an out-of-network health care provider1 is a document specified by the ,secretary through rulemaking that is signed by the individual 7or by a representative of the individual7 not less than #bd hours prior to the individual being furnished such items or services by such health care provider1 and that-- 7,a7 acknowledges that the individual has been-- 7i7 provided with a written estimate and an oral explanation of the charge that the individual will be assessed for the items or services anticipated to be furnished to the individual by such out-of-network health care provider2 and 7ii7 informed that the payment of such charge by the individual will not accrue toward meeting any limitation that the group health plan1 or health insurance coverage offered in the group market1 places on cost-sharing2 and 7,b7 documents the consent of the individual to-- 7i7 be furnished with such items or services by such out-of-network health care provider2 and 7ii7 in the case that the individual is so furnished such items or services1 be charged an amount approximate to the estimated charge described in subparagraph 7,a77i7 with respect to such items or services4 7c7 ,limitations on balance billing in surprise billing situations 7#a7 ,in case of noncompliance with notice and consent requirements ,in the case of an individual enrolled in a group health plan1 or health insurance coverage offered in the group market1 who is furnished items or services by an out-of-network health care provider with respect to such plan or coverage1 if the out-of-network health care provider does not comply with the requirements of subsection 7b7 with respect to the furnishing of such items or services to such individual1 the out-of-network health care provider 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 an in-network health care provider with respect to such plan or coverage4 7#b7 ,in case of same-day emergency services ,in the case of an individual enrolled in a group health plan or health insurance coverage offered in the group market who is furnished items or services by a health care provider that is an out-of-network health care provider with respect to such plan or coverage on the same date on which the individual makes an appointment for such items or services 7or otherwise presents at the hospital1 critical access hospital1 or ambulatory surgical center for such services such as in the case of items and services furnished with respect to an emergency medical condition1 as defined in section #ahfg7;e771 the out-of-network health care provider 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 an in-network health care provider with respect to such plan or coverage4 4 7#b7 ,effective ,date ,the amendment made by paragraph 7#a7 shall take effect beginning #b years after the date of the enactment of this ,act4 7b7 ,condition of ,participation in ,medicare 7#a7 ,in general ,section #ahff7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7a77#a77 is amended-- 7,a7 in subparagraph 7,x71 by striking and at the end2 7,b7 in subparagraph 7,y71 by striking at the end the period and inserting 1 and2 and 7,c7 by inserting after such subparagraph 7,y7 the following new subparagraph3 7,z7 in the case of a hospital1 a critical access hospital1 or an ambulatory surgical center described in section #ahcc7;i77#a77;,a71 to adopt and enforce a policy to ensure compliance with the requirements of subsections 7b7 and 7c7 of section #bgbi of the ,public ,health ,service ,act and to meet the requirements of such subsections 7relating to the prevention of surprise billing practices72 4 7#b7 ,effective ,date ,the amendments made by paragraph 7#a7 shall apply with respect to agreements under such section #ahff7;a77#a7 that are filed with the ,secretary of ,health and ,human ,services on a date that is not less than #b years after the date of the enactment of this ,act4 #c4 ,payments made by insured individuals in surprise billing situations included in cost-sharing limitations 7a7 ,in general ,section #bgjg of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#f7 is amended by adding at the end the following3 7e7 ,surprise billing situations ,notwithstanding section #acjb7;c77#c77;,b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #ahjbb7;c77#c77;,b771 any group health plan or health insurance issuer offering health insurance coverage in the group market shall ensure that any amount paid by an individual enrolled in such plan or coverage in a surprise billing situation1 as defined in section #bgcj7;a71 accrues towards meeting any annual limitation on cost-sharing under the plan or coverage4 4 7b7 ,effective date ,the amendments made by subsection 7a7 shall apply with respect to any plan year beginning not earlier than #b years after the date of enactment of this ,act4 #d4 ,resolving payment disputes in surprise billing situations ,subpart ,,ii of part ,a of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aa et seq471 as amended by section #b7;a71 is further amended by adding at the end the following3 #bgcj4 ,resolving payment disputes in surprise billing situations 7a7 ,definitions ,in this section3 7#a7 ,health care provider2 in-network health care provider2 out-of-network health care provider ,the terms health care provider1 in-network health care provider1 and out-of-network health care provider have the meanings given such terms in section #bgbi7;a74 7#b7 ,independent dispute resolution entity ,the term independent dispute resolution entity means an entity certified by the ,secretary1 in consultation with the ,secretary of ,labor1 under subsection 7b77#b7 to conduct an independent dispute resolution process under subsection 7d74 7#c7 ,surprise billing situation ,the term surprise billing situation means-- 7,a7 a situation in which an individual who is enrolled in a group health plan1 or health insurance coverage offered in the group market1 is furnished items or services by an out-of-network health care provider and such provider does not comply with the requirements of section #bgbi7;b7 with respect to the furnishing of such items or services to such individual2 or 7,b7 a situation in which an individual who is enrolled in a group health plan1 or health insurance coverage offered in the group market1 is furnished items or services by an out-of-network health care provider on the same date on which the individual makes an appointment for such items or services 7or otherwise presents at the hospital1 critical access hospital1 or ambulatory surgical center for such services such as in the case of items and services furnished with respect to an emergency medical condition1 as defined in section #ahfg7;e774 7b7 ,establishment of independent dispute resolution process 7#a7 ,establishment ,not later than #b years after the date of enactment of this section1 the ,secretary1 in consultation with the ,secretary of ,labor1 shall establish a process for resolving payment disputes between group health plans1 or health insurance issuers offering health insurance coverage in the group market1 and out-of-network health care providers in surprise billing situations in accordance with this section4 7#b7 ,certification of independent dispute resolution entities 7,a7 ,in general ,the ,secretary1 in consultation with the ,secretary of ,labor1 shall establish a process through rulemaking to certify entities as independent dispute resolution entities to conduct independent dispute resolution processes under subsection 7d74 7,b7 ,requirements ,to be eligible for certification under this paragraph1 an entity shall-- 7i7 have experience in health care billing1 health care pricing1 and arbitration2 and 7ii7 not have any conflict of interest1 as determined in accordance with subparagraph 7,c74 7,c7 ,conflict of interest ,the ,secretary1 in consultation with the ,secretary of ,labor1 shall determine1 through rulemaking1 the criteria for a conflict of interest for purposes of subparagraph 7,b77ii71 which shall include-- 7i7 having any material arrangement1 financial or otherwise1 that could bias the entity1 or an employee of the entity working on a particular dispute2 or 7ii7 owning or controlling1 being owned by or controlled by1 or being under common control of-- 7,i7 any pharmaceutical company1 disease group1 or public advocacy group2 7,,ii7 any national1 ,state1 or local society or association of hospitals1 physicians1 or other providers of health care services2 or 7,,iii7 any national1 ,state1 or local association of health care plans4 7c7 ,pre-,independent dispute resolution process 7#a7 ,requirement to pay out-of-network health care providers 7,a7 ,requirement on plan ,the process established by the ,secretary1 in consultation with the ,secretary of ,labor1 under this section shall require that a group health plan1 or health insurance issuer offering health insurance coverage in the group market1 that receives a bill from an out-of-network health care provider for items or services furnished to an individual enrolled in the plan or coverage in a surprise billing situation1 not later than #cj days after receiving such bill-- 7i7 pay the out-of-network health care provider the amount in the bill2 or 7ii7 attempt to negotiate with the out-of-network health care provider an alternative amount for the plan or issuer to pay the provider4 7,b7 ,pre-independent dispute resolution negotiations ,if1 not later than #cj days after the date on which negotiations begin under subparagraph 7,a77ii71 an out-of-network health care provider and group health plan1 or health insurance issuer offering health insurance coverage in the group market1 described in subparagraph 7,a7 have not agreed upon an alternative amount for the plan or issuer to pay the provider1 the plan or issuer shall-- 7i7 pay the provider the amount the plan or issuer determines reasonable for the services 7less the cost-sharing amount paid by the individual enrolled in the plan or coverage72 and 7ii7 provide information to the provider on how the provider may initiate an independent dispute resolution process under paragraph 7#b74 7#b7 ,initiating an independent dispute resolution process 7,a7 ,in general ,if1 after a good faith attempt to negotiate under paragraph 7#a77;,a77ii71 the out-of-network health care provider and group health plan1 or health insurance issuer offering health insurance coverage in the group market1 described in paragraph 7#a77;,a7 are unable to reach an agreement on an amount for the plan or issuer to pay the provider1 any party to the dispute may1 not later than #cj days of being unable to come to an agreement1 as determined by the ,secretary1 in consultation with the ,secretary of ,labor1 initiate an independent dispute resolution process under subsection 7d7 by submitting a request for such process to the ,secretary1 and the ,secretary of ,labor1 or directly to an independent dispute resolution entity1 in accordance with the process established by the ,secretary1 in consultation with the ,secretary of ,labor1 under this section4 7,b7 ,request ,a request submitted under subparagraph 7,a7 shall indicate-- 7i7 the amount the out-of-network health care provider requested in the bill described in subparagraph 7,a7 of paragraph 7#a7 or after attempted negotiations in accordance with such paragraph2 and 7ii7 the amount the group health plan1 or health insurance issuer offering health insurance coverage in the group market1 paid the out-of-network health care provider in accordance with paragraph 7#a77;,b7 after such negotiations4 7,c7 ,notice to other party ,a party initiating an independent dispute resolution process under subparagraph 7,a7 shall1 not later than #aj days after submitting a request under such subparagraph1 notify the other party that such request has been submitted4 7d7 ,independent dispute resolution process 7#a7 ,in general ,the ,secretary1 in consultation with the ,secretary of ,labor1 shall establish procedures for independent dispute resolution entities to conduct independent dispute resolution processes under this subsection to resolve payment disputes between group health plans1 or health insurance issuers offering health insurance coverage in the group market1 and out-of-network health care providers4 7#b7 ,timing ,an independent dispute resolution entity that receives a request under subsection 7c77#b77;,a7 shall1 not later than #cj days after receiving such request1 determine the amount the group health plan1 or health insurance issuer offering health insurance coverage in the group market1 is required to pay the out-of-network health care provider4 ,such amount shall be-- 7,a7 the amount determined by the parties through a settlement under paragraph 7#c72 or 7,b7 the amount determined reasonable by the entity in accordance with paragraph 7#d74 7#c7 ,settlement 7,a7 ,in general ,if the independent dispute resolution entity determines1 based on the amounts indicated in the request under subsection 7c77#b77;,b71 that a settlement between the group health plan1 or health insurance issuer offering health insurance coverage in the group market1 and out-of-network health care provider is likely or that the amounts provided in such subsection each represent unreasonable extremes1 the independent dispute resolution entity may direct the parties to attempt1 for a period not to exceed #aj days1 a good faith negotiation for a settlement4 7,b7 ,timing ,the period for a settlement described in subparagraph 7,a7 shall accrue towards the #cj-;day period required under paragraph 7#b74 7#d7 ,determination of amount 7,a7 ,final offers ,in the absence of a settlement under paragraph 7#c71 the group health plan1 or health insurance issuer offering health insurance coverage in the group market1 and out-of-network health care provider shall each submit to the independent dispute resolution entity an amount as a final offer4 ,such entity shall determine which of those #b amounts is more reasonable based on the factors described in subparagraph 7,d74 7,b7 ,final decisions ,the amount that is determined to be the more reasonable amount under subparagraph 7,a7 shall be the final decision of the independent dispute resolution entity as to the amount the group health plan1 or health insurance issuer offering health insurance coverage in the group market1 is required to pay the out-of-network health care provider4 7,c7 ,service units ,a final offer submitted under subparagraph 7,a7 shall be made per service unit1 as defined by the ,secretary1 in consultation with the ,secretary of ,labor1 through regulations4 ,a final decision under subparagraph 7,b7 may include the resolution of disputes for multiple items or services for a single patient1 such as for instances in which multiple specialists are involved4 7,d7 ,factors ,in determining which final offer to select as the more reasonable amount under subparagraph 7,a71 the independent dispute resolution entity shall consider relevant factors including-- 7i7 the average in-network payment rate for comparable items or services in the same geographic region1 including as calculated by an independent database or an all-payer claims database2 7ii7 the level of training1 education1 and experience of the out-of-network health care provider2 7iii7 the circumstances and complexity of the particular dispute1 including the time and place of the service2 and 7iv7 the payment rate 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#e7 ,effect of decision ,a final decision of an independent dispute resolution entity under paragraph 7#d77;,b7-- 7,a7 shall be binding2 and 7,b7 shall not be subject to judicial review1 except in cases comparable to those described in section #aj7;a7 of title #i1 ,united ,states ,code1 as determined by the ,secretary in consultation with the ,secretary of ,labor4 7#f7 ,privacy laws ,an independent dispute resolution entity shall1 in conducting an independent dispute resolution process under this subsection1 comply with all applicable ,federal and ,state privacy laws4 7e7 ,responsibility ,to pay costs ,the costs for an independent dispute resolution process under subsection 7d7 shall be paid for in accordance with the following3 7#a7 ,in a case in which the independent dispute resolution entity determines that the amount in the final offer submitted under subsection 7d77#d77;,a7 by the out-of-network health care provider is the more reasonable amount1 the group health plan1 or health insurance issuer offering health insurance coverage in the group market1 shall pay all costs of the independent dispute resolution process4 7#b7 ,in a case in which the independent dispute resolution entity determines that the amount in the final offer submitted under subsection 7d77#d77;,a7 by the group health plan1 or health insurance issuer offering health insurance coverage in the group market1 is the more reasonable amount1 the out-of-network health care provider shall pay all costs of the independent dispute resolution process4 7#c7 ,in a case in which a settlement is reached under subsection 7d77#c71 the group health plan1 or health insurance issuer offering health insurance coverage in the group market1 and the out-of-network health care provider shall each pay half of the costs of the independent dispute resolution process4 7f7 ,reports 7#a7 ,entity reports ,not later than #d years after the date of enactment of this section1 and each year thereafter1 each independent dispute resolution entity shall submit to the ,secretary1 and the ,secretary of ,labor1 a report on all independent dispute resolution processes conducted by the entity under subsection 7d7 for the period of the report4 ,each such report shall contain information determined appropriate by the ,secretary1 in consultation with the ,secretary of ,labor1 in order to prepare the report required under paragraph 7#b74 7#b7 ,reports by ,secretaries 7,a7 ,in general ,not later than #e years after the date of enactment of this section1 and each year thereafter1 the ,secretary1 in consultation with the ,secretary of ,labor1 shall based on the reports submitted under paragraph 7#a7 prepare a report1 disaggregated by ,state1 that contains each of the following for the period of the report3 7i7 ,the total number of independent dispute resolution processes initiated under subsection 7c77#b77;,a71 including an indication of the number of instances in which-- 7,i7 the amount in the final offer under subsection 7d77#d77;,a7 made by the group health plan1 or health insurance issuer offering health insurance coverage in the group market1 was determined to be more reasonable than the amount in the final offer under such subsection made by the out-of-network health care provider2 7,,ii7 the amount in the final offer under subsection 7d77#d77;,a7 made by the out-of-network health care provider was determined to be more reasonable than the amount in the final offer under such subsection made by the group health plan1 or health insurance issuer offering health insurance coverage in the group market2 and 7,,iii7 a settlement was reached under subsection 7d77#c74 7ii7 ,the number of requests made for an independent dispute resolution process under subsection 7c77#b77;,a7 that were determined to be ineligible for such process and the reason for such determination4 7iii7 ,the number of independent dispute resolution processes conducted under subsection 7d7 that-- 7,i7 were based on a situation described in subsection 7a77#c77;,a72 and 7,,ii7 were based on a situation described in subsection 7a77#c77;,b74 7iv7 ,the total number of final decisions rendered by independent dispute resolution entities under subsection 7d77#d77;,b74 7v7 ,for each independent dispute resolution process conducted under subsection 7d7-- 7,i7 the type of coverage of the plan or issuer involved1 such as whether the plan or issuer is a health maintenance organization or preferred provider organization2 7,,ii7 the specialty of the out-of-network health care provider1 and specific types of services1 involved2 and 7,,iii7 the dollar amount of the final decision under subsection 7d77#d77;,b74 7vi7 ,any additional information the ,secretary1 in consultation with the ,secretary of ,labor1 determines necessary4 7,b7 ,public access ,the ,secretary1 in consultation with the ,secretary of ,labor1 shall1 each year1 publish the report prepared under subparagraph 7,a7 and make such report available to the public4 7,c7 ,privacy ,in carrying out this paragraph1 the ,secretary1 in consultation with the ,secretary of ,labor1 shall comply with all applicable ,federal and ,state privacy laws4 7g7 ,applicability of ,state law 7#a7 ,in general ,notwithstanding any other provision in this section1 the process established by the ,secretary1 in consultation with the ,secretary of ,labor1 under this section shall not apply with respect to any surprise billing situation involving a group health plan 7other than a self-insured plan71 or health insurance issuer offering health insurance coverage in the group market1 in a ,state that has in effect a ,state law that applies to the dispute involved and meets the requirements under paragraph 7#b74 7#b7 ,requirements 7,a7 ,in general ,the requirements under this paragraph are that the ,state law provides1 in a surprise billing situation1 for-- 7i7 a dispute resolution process meeting the requirements under subparagraph 7,b72 or 7ii7 a payment standard that meets the requirements under subparagraph 7,c74 7,b7 ,dispute resolution process ,the requirements for a dispute resolution process under this subparagraph are that the entity conducting the process-- 7i7 be an independent entity whereby the entity shall not represent the interests of any party to the dispute and shall be free of any conflict of interest2 and 7ii7 report to the public on the results of the process4 7,c7 ,payment standard ,the requirements for a payment standard under this paragraph are that the group health plan1 or health insurance issuer offering health insurance coverage in the group market1 pay the out-of-network health care provider in the surprise billing situation an amount at a rate-- 7i7 that does not exceed #abe percent of the allowed charges for items or services under the original ,medicare fee-for-service program under parts ,a and ,b of title ,,xxviii of the ,social ,security ,act2 or 7ii7 that does not exceed a payment standard comparable to the standard described in clause 7i71 as determined by the ,secretary1 in consultation with the ,secretary of ,labor4 7#c7 ,clarification for self-insured group health plans ,with respect to any payment dispute in a surprise billing situation involving a self-insured group health plan-- 7,a7 the process established by the ,secretary1 in consultation with the ,secretary of ,labor1 under this section shall apply2 and 7,b7 any ,state law that meets the requirements under paragraph 7#b71 and may otherwise apply1 shall not apply4 4