,i #aafth ,,congress #ast ,session ,h4 ,r4 #cghd ,,in ,,the ,,house ,,of ,,representatives ,july #af1 #bjai,mr4 ,neguse introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce ,a ,,bill ,to amend title ,,xxvii of the ,public ,health ,service ,act and title ,,xi of the ,social ,security ,act to prohibit surprise billing with respect to air ambulance services4 #a4 ,short title ,this ,act may be cited as the ,air ,ambulance ,affordability ,act of #bjai4 #b4 ,prohibiting surprise billing with respect to air ambulance services 7a7 ,air ambulance services 7#a7 ,in general ,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 subsections3 7e7 ,air ambulance services 7#a7 ,in general ,subject to paragraph 7#b71 in the case of air ambulance services furnished to a participant1 beneficiary1 or enrollee of a health plan 7as defined in paragraph 7#c77;,a77 by a nonparticipating provider 7as defined in paragraph 7#c77;,c771 the plan-- 7,a7 shall not impose on such participant1 beneficiary1 or enrollee a cost-sharing amount 7expressed as a copayment amount or coinsurance rate7 for such services so furnished that is greater than the cost-sharing amount that would apply under such plan had such services been furnished by a participating provider2 7,b7 shall calculate such cost-sharing amount as if the negotiated rate that would have been charged by such participating provider for such services were equal to the amount determined in accordance with subsection 7f7 for such services 7or1 in the case of such services furnished in a ,state described in paragraph 7#c77;,e77i71 the amount determined by such ,state for such services in accordance with the method described in such paragraph72 7,c7 shall pay to such provider furnishing such services to such participant1 beneficiary1 or enrollee the amount by which the recognized amount 7as defined in paragraph 7#c77;,e77 for such services exceeds the cost-sharing amount imposed for such services 7as determined in accordance with subparagraphs 7,a7 and 7,b772 and 7,d7 shall count toward any deductible or out-of-pocket maximums applied under the plan any cost-sharing payments made by the participant1 beneficiary1 or enrollee with respect to such services so furnished in the same manner as if such cost-sharing payments were with respect to services furnished by a participating provider4 7#b7 ,exception for certain services ,the provisions of paragraph 7#a7 shall not apply in the case of air ambulance services that-- 7,a7 are not furnished with respect to an individual with an emergency medical condition 7as defined in subsection 7b77#b77;,a772 and 7,b7 are furnished by a provider that is in compliance with the requirement of section #aabh;,a7t77#c7 of the ,social ,security ,act with respect to such services4 7#c7 ,definitions ,in this subsection and subsection 7f73 7,a7 ,health plan ,the term health plan means a group health plan and health insurance coverage offered by a heath insurance issuer in the group or individual market4 7,b7 ,provider ,the term provider means a provider of services or a supplier 7as such terms are defined in section #ahfa of the ,social ,security ,act74 7,c7 ,nonparticipating provider ,the term nonparticipating provider means1 with respect to air ambulance services and a group health plan or health insurance coverage offered by a health insurance issuer1 a provider or supplier of such services that is licensed by the ,state involved to furnish such services and that does not have a contractual relationship with the plan or coverage for furnishing such services4 7,d7 ,participating provider ,the term participating provider means1 with respect to air ambulance services and a group health plan or health insurance coverage offered by a health insurance issuer1 a provider or supplier of such services that is licensed by the ,state involved to furnish such services and that has a contractual relationship with the plan or coverage for services4 7,e7 ,recognized amount ,the term recognized amount means1 with respect to air ambulance services-- 7i7 in the case of such services furnished in a ,state that has in effect a ,state law that provides for a method for determining the amount of payment that is required to be covered by a health plan or health insurance issuer offering group or individual health insurance coverage regulated by such ,state in the case of a participant1 beneficiary1 or enrollee covered under such plan or coverage and receiving such services from a nonparticipating provider1 not more than the amount determined in accordance with such law plus the cost-sharing amount imposed for such services 7as determined in accordance with paragraph 7#a772 or 7ii7 in the case of such services furnished in a ,state that does not have in effect such a law1 an amount determined in accordance with the independent dispute resolution process established under subsection 7f74 7f7 ,independent dispute resolution process 7#a7 ,establishment 7,a7 ,in general ,not later than #a year after the date of the enactment of this subsection1 the ,secretary1 in consultation with the ,secretary of ,labor1 shall establish by regulation an independent dispute resolution process 7referred to in this subsection as the ,,idr process7 under which entities certified under paragraph 7#b7 7in this subsection referred to as certified ,,idr entities7 resolve specified claims of nonparticipating providers or health plans1 taking into account the factors described in subparagraph 7,c74 ,such process shall prohibit such an entity from participating in the resolution of such a claim if such entity has a conflict of interest with respect to such provider1 facility1 or the health plan involved4 7,b7 ,specified claim ,for purposes of subparagraph 7,a71 the term specified claim means a claim by a nonparticipating provider or health plan that1 with respect to air ambulance services furnished by such provider for which a health plan is required to make payment pursuant to subsection 7e77#a71 is made under the ,,idr process not later than #cj days after the services are furnished4 7,c7 ,factors ,the factors described in this subparagraph include-- 7i7 commercially reasonable rates for comparable services furnished in the same geographic area 7which shall take into consideration in-network rates for that geographic area and not charges72 and 7ii7 other factors that may be submitted at the discretion of either party1 which may include-- 7,i7 the level of training1 education1 experience1 and quality and outcomes measurements of the provider2 7,,ii7 the circumstances and complexity of the particular dispute1 including the time and place of the service2 7,,iii7 the market share held by the provider or that of the plan2 7,,iv7 demonstration of good faith efforts 7or lack of good faith efforts7 made by the provider or the plan to contract for negotiated rates1 if applicable2 and 7,v7 other relevant economic aspects of provider reimbursement for the same specialty within the same geographic area4 7#b7 ,certification of entities 7,a7 ,process of certification ,as part of the regulation described in paragraph 7#a71 the ,secretary1 in consultation with the ,secretary of ,labor1 shall establish a certification process under which eligible entities may be certified to carry out the ,,idr process4 7,b7 ,eligibility ,for purposes of subparagraph 7,a71 an eligible entity is an entity that is a nongovernmental entity 7such as the ,american ,arbitration ,association74 7#c7 ,selection of certified ,,idr entity for a specified claim ,with respect to the resolution of a specified claim under the ,,idr process1 the health plan and the nonparticipating provider involved shall agree on a certified ,,idr entity to resolve such claim4 ,in the case that such plan and such provider cannot so agree1 such an entity shall be selected by the ,secretary at random4 7#d7 ,payment determination 7,a7 ,timing ,a certified ,,idr entity that receives a request from a nonparticipating provider or health plan under this subsection shall1 not later than #cj days after receiving such request1 determine the amount the health plan is required to pay such provider or facility for services described in paragraph 7#a71 in accordance with subparagraph 7,c71 in the case that a settlement described in subparagraph 7,b7 is not reached4 7,b7 ,settlement 7i7 ,in general ,if such entity determines that a settlement between the health plan and the provider is likely1 the entity may direct the parties to attempt1 for a period not to exceed #aj days1 a good faith negotiation for a settlement4 7ii7 ,timing ,the period for a settlement described in clause 7i7 shall accrue towards the #cj-;day period required under subparagraph 7,a74 7,c7 ,determination of amount 7i7 ,decisions ,the health plan and the nonparticipating provider shall each submit to the certified ,,idr entity a final offer of payment with respect to services which are the subject of the specified claim4 ,such entity shall select the offer that such entity determines is the most reasonable based on the factors described in paragraph 7#a77;,c74 7ii7 ,effect of decision ,a decision of a certified ,,idr entity under clause 7ii7-- 7,i7 shall be binding2 and 7,,ii7 shall not be subject to judicial review1 except in a case described in any of paragraphs 7#a7 through 7#d7 of section #aj7;a7 of title #i1 ,united ,states ,code1 as determined by the ,secretary in consultation with the ,secretary of ,labor4 7iii7 ,costs of independent dispute resolution process ,the party whose calculation is not chosen under subparagraph 7,b77ii7 shall be responsible for paying all fees charged by the certified ,,idr entity4 ,if the parties reach a settlement prior to completion of the ,,idr process1 the costs of such process shall be divided equally between the parties1 unless the parties otherwise agree4 7iv7 ,payment ,not later than #cj days after a decision described in clause 7i7 is made1 the health plan shall pay to the provider or supplier of the services with respect to which the specified claim is made the amount determined under this subsection4 7v7 ,public availability ,the certified ,,idr entity shall make each final offer selected under clause 7i7 available to the public4 ,any information submitted to the entity by the health plan1 provider1 or facility1 other than such final offer1 may not be disclosed by the entity4 4 7#b7 ,effective date ,the amendments made by this subsection shall apply with respect to plan years beginning on or after ,january #a1 #bjba4 7b7 ,preventing certain cases of balance billing ,section #aabh;,a of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;a7 is amended by adding at the end the following new subsections3 7t7 7#a7 ,subject to paragraph 7#b71 in the case of an individual with benefits under a health plan or health insurance coverage offered in the group or individual market who is furnished on or after ,january #a1 #bjba1 air ambulance services by a nonparticipating provider 7as defined in section #bgai;,a7e77#c7 of the ,public ,health ,service ,act71 if such provider holds the individual liable for a payment amount for such services so furnished that is more than the cost-sharing amount for such services 7as determined in accordance with section #bgai;,a7e77#a7 of the ,public ,health ,service ,act71 such provider shall be subject1 in addition to any other penalties that may be prescribed by law1 to a civil money penalty of not more than an amount determined appropriate by the ,secretary for each specified claim4 7#b7 ,paragraph 7#a7 shall not apply to a nonparticipating provider1 with respect to air ambulance services furnished by the provider to a participant1 beneficiary1 or enrollee of a health plan or health insurance coverage offered by a health insurance issuer1 if-- 7,a7 such services are not furnished with respect to an individual with an emergency medical condition 7as defined in section #bgai;,a7e77#c7 of the ,public ,health ,service ,act72 and 7,b7 the provider is in compliance with the requirement of paragraph 7#c74 7#c7 7,a7 ,for purposes of paragraph 7#b7 and section #bgai;,a7e77#b7 of the ,public ,health ,service ,act1 a nonparticipating provider is in compliance with this paragraph1 with respect to air ambulance services furnished by the provider to a participant1 beneficiary1 or enrollee of a health plan or health insurance coverage offered by a health insurance issuer1 if the provider-- 7i7 7,i7 provides to the participant1 beneficiary1 or enrollee 7or to a representative of the participant1 beneficiary1 or enrollee71 on the date on which the participant1 beneficiary1 or enrollee schedules such services1 if applicable1 and on the date on which the individual is furnished such services-- 7aa7 an oral explanation of the written notice described in item 7bb7 and such documentation of the provision of such explanation1 as the ,secretary determines appropriate2 and 7bb7 a written notice specified1 not later than ,july #a1 #bjbj1 by the ,secretary through rulemaking that-- 7,,aa7 contains the information required under subparagraph 7,b72 and 7,,bb7 is signed and dated by the participant1 beneficiary1 or enrollee2 and 7,,ii7 retains1 for a period specified through rulemaking by the ,secretary1 a copy of the documentation described in subclause 7,i77aa7 and the written notice described in subclause 7,i77bb72 and 7ii7 obtains from the participant1 beneficiary1 or enrollee 7or representative7 the consent described in subparagraph 7,c74 7,b7 ,for purposes of subparagraph 7,a77i71 the information described in this subparagraph1 with respect to a nonparticipating provider and a participant1 beneficiary1 or enrollee of a health plan or health insurance coverage offered by a health insurance issuer1 is a notification of each of the following3 7i7 ,that the health care provider is a nonparticipating provider with respect to the group health plan or health insurance coverage4 7ii7 ,the estimated amount that such provider will charge the participant1 beneficiary1 or enrollee for such services involved4 7,c7 ,for purposes of subparagraph 7,a77ii71 the consent described in this subparagraph1 with respect to a participant1 beneficiary1 or enrollee of a group health plan or health insurance coverage offered by a health insurance issuer1 who is to be furnished air ambulance services by a nonparticipating provider1 is a document specified by the ,secretary through rulemaking that-- 7i7 is signed by the participant1 beneficiary1 or enrollee 7or by a representative of the participant1 beneficiary1 or enrollee7 not less than #bd hours prior to the participant1 beneficiary1 or enrollee being furnished such services by such provider2 7ii7 acknowledges that the participant1 beneficiary1 or enrollee has been-- 7,i7 provided with a written estimate and an oral explanation of the charge that the participant1 beneficiary1 or enrollee will be assessed for the services anticipated to be furnished to the participant1 beneficiary1 or enrollee by such nonparticipating provider2 and 7,,ii7 informed that the payment of such charge by the participant1 beneficiary1 or enrollee will not accrue toward meeting any limitation that the group health plan or health insurance coverage places on cost-sharing2 and 7iii7 documents the consent of the participant1 beneficiary1 or enrollee to-- 7,i7 be furnished with such services by such nonparticipating provider2 and 7,,ii7 in the case that the individual is so furnished such services1 be charged an amount that may be greater than the amount that would otherwise be changed the individual if furnished by a participating provider 7as defined in section #bgai;,a7e77#c7 of the ,public ,health ,service ,act7 with respect to such services and plan or coverage4 7#d7 ,the provisions of subsections 7c71 7d71 7e71 7g71 7h71 7k71 and 7l7 shall apply to a civil money penalty or assessment under paragraph 7#a7 in the same manner as such provisions apply to a penalty1 assessment1 or proceeding under subsection 7a74 7#e7 ,in this subsection1 the terms group health plan1 health insurance issuer1 and health insurance coverage have the meanings given such terms1 respectively1 in section #bgia of the ,public ,health ,service ,act 4