,,ii  #aafth ,,congress  #ast ,session  
,s4 #ifg  ,,in ,,the ,,senate ,,of ,,the
 ,,united ,,states  ,april #a1          
#bjai,mrs4 ,shaheen 7for herself1 ,ms4  
,baldwin1 and ,mr4 ,merkley7 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 services in the      
individual market1 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     
#bjai4  #b4 ,limitations on cost-sharing
 for out-of-network services  7a7 ,in   
general ,subpart #b of part ,b of title 
,,xxvii of the ,public ,health ,service 
,act 7#db ,u4,s4,c4 #cjj;gg-#ea et seq47
 is amended by adding at the end the    
following3  #bged4 ,limitations on      
cost-sharing for out-of-network services

  7a7 ,health insurance issuer          
requirement ,a health insurance issuer  
offering health insurance coverage1 in  
the individual market in a ,state1 that 
offers benefits with respect to a health
 care service provided in the ,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 a health care service at a  
rate in excess of the following3  7,a7  
,in the case of a patient who is        
enrolled in health insurance coverage in
 the individual market that does not    
provide out-of-network benefits for such
 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 health insurance coverage in the     
individual market that provides         
out-of-network benefits for such        
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 by the health insurance
 issuer 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 an  
applicable law in the ,state4  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   
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 a   
health care service for individuals     
enrolled in health insurance coverage in
 the individual market in the ,state3   
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 ,the #hjth        
percentile of usual1 customary1 and     
reasonable charge rates for the service 
for the geographic area1 as determined  
by a database of usual1 customary1 and  
reasonable charges selected 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
 average actual allowed rate under the  
coverage for all participating providers
 for such service in the health         
insurance issuer's participating        
provider network4  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 a health care service  
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  #bgee4 ,reports to         
,congress on network adequacy  ,not     
later than ,january #a1 #bjbb1 and every
 year thereafter1 the ,secretary shall  
prepare and submit to the ,committee on 
,health1 ,education1 ,labor1 and        
,pensions of the ,senate and the        
,committee on ,energy and ,commerce of  
the ,house of ,representatives a report 
on--  7#a7 how ,state network adequacy  
laws1 section #bgjb7;c71 and any other  
network adequacy requirements for       
qualified health plans under the        
,patient ,protection and ,affordable    
,care ,act ensure that provider networks
 are broad enough to meet the needs of  
enrolled patients2  7#b7 the impact of  
section #bged on network adequacy2 and  
7#c7 any recommendations for ,congress1 
as necessary1 on how to improve network 
adequacy4  4  7b7 ,effective date       
,section #bged of the ,public ,health   

,service ,act1 as added by subsection   
7a71 shall take effect on ,january #a1  
#bjba4  #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 that are      
similar to the limitations that apply   
under section #bged 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 plan and group health
 insurance coverage have the meanings   
given such terms in section #bgia of the
 ,public ,health ,service ,act 7#db     
,u4,s4,c4 #cjj;gg-#ia74