,,ii  #aaf? ,,congress  #a/ ,session    
,s4 #ifg  ,,9 ,,! ,,s5ate ,,( ,,!       
,,unit$ ,,/ates  ,april #a1 #bjai,mrs4  
,%ahe5 7= h]self1 ,ms4 ,baldw91 & ,mr4  
,m]kley7 introduc$ ! foll[+ bill2 :i* 0 
read twice & ref]r$ to ! ,committee on  
,heal?1 ,education1 ,labor1 & ,p5sions  
,a ,,bill  ,to am5d ! ,public ,heal?    
,s]vice ,act to e/abli% limitations on  
co/-%>+ = out-(-network s]vices 9 !     
individual m>ket1 to prohibit balance   
bill+ = su* s]vices1 & = o!r purposes4  
#a4 ,%ort title ,?is ,act may be cit$ z 
! ,r$uc+ ,co/s = ,out-(-,network        
,s]vices ,act ( #bjai4  #b4 ,limitations
 on co/-%>+ = out-(-network s]vices  7a7
 ,9 g5]al ,subp>t #b ( "p ,b ( title    
,,xxvii ( ! ,public ,heal? ,s]vice ,act 
7#db ,u4,s4,c4 #cjj;gg-#ea et seq47 is  
am5d$ by add+ at ! end ! foll[+3  #bged4
 ,limitations on co/-%>+ = out-(-network
 s]vices  7a7 ,heal? insurance issu]    
requirem5t ,a heal? insurance issu] (f]+
 heal? insurance cov]age1 9 ! individual
 m>ket 9 a ,/ate1 t (f]s b5efits )      

respect to a heal? c>e s]vice provid$ 9 
! ,/ate by a p>ticipat+ provid] %all    
ensure t ! co/-%>+ requirem5t ) respect 
to su* s]vice provid$ 9 ! ,/ate by a    
nonp>ticipat+ provid] does n exce$ !    
rate select$ by ! applicable ,/ate      
au?ority "u subsection 7c77#a7 = su*    
s]vice4  7b7 ,limitation on *>ges by    
heal? c>e provid]s  7#a7 ,9 g5]al ,a    
heal? c>e provid] may n *>ge a pati5t = 
a heal? c>e s]vice at a rate 9 excess ( 
! foll[+3  7,a7 ,9 ! case ( a pati5t :o 
is enroll$ 9 heal? insurance cov]age 9 !
 individual m>ket t does n provide      
out-(-network b5efits = su* s]vice1 !   
heal? c>e provid] may *>ge su* pati5t no
 m ?an ! rate select$ by ! applicable   
,/ate au?ority "u subsection 7c77#a74   
7,b7 ,9 ! case ( a pati5t enroll$ 9     
heal? insurance cov]age 9 ! individual  
m>ket t provides out-(-network b5efits =
 su* s]vice1 ! heal? c>e provid] may    
*>ge su* pati5t no m ?an--  7i7 ! rate  
select$ by ! applicable ,/ate au?ority  
"u subsection 7c77#a72 m9us  7ii7 ! sum 

(--  7,i7 ! paym5t made by ! heal?      
insurance issu] to ! heal? c>e provid]  
pursuant to su* cov]age2 &  7,,ii7 !    
out-(-network co/-%>+ am\nt requir$ "u  
su* cov]age4  7,c7 ,9 ! case ( an       
un9sur$ individual1 ! heal? c>e provid] 
may *>ge su* pati5t no m ?an ! l[] (--  
7i7 ! rate select$ by ! applicable ,/ate
 au?ority "u subsection 7c77#b72 or     
7ii7 ! rate o!rwise all[$ to be *>g$ to 
su* an individual = su* a s]vice "u an  
applicable law 9 ! ,/ate4  7#b7         
,en=cem5t ,a heal? c>e provid] t        
violates ! requirem5t "u p>agraph 7#a7  
%all be subject to ! same civil monet>y 
p5alties describ$ 9 p>agraph 7#a7 (     
section #ibb7;f71 includ+ ! provisions  
describ$ 9 p>agraph 7#b7 ( su* section1 
z a p]son :o commits a violation        
describ$ 9 p>agraph 7#a7 ( su* section4 
7c7 ,rate  7#a7 ,individuals enroll$ 9  
heal? insurance cov]age ,an applicable  
,/ate au?ority %all select = ! ,/ate z  
applicable = purposes ( subsection 7a7 &
 subp>agraphs 7,a7 & 7,b7 ( subsection  

7b77#a7 "o ( ! foll[+ z a maximum rate =
 a heal? c>e s]vice = individuals       
enroll$ 9 heal? insurance cov]age 9 !   
individual m>ket 9 ! ,/ate3  7,a7 #abe  
p]c5t 7or1 9 a case describ$ 9 p>agraph 
7#c7 & at ! discretion ( ! applicable   
,/ate au?ority1 #bjj p]c5t7 ( ! all[$   
*>ges det]m9$ = ! item or s]vice "u !   
orig9al ,m$ic>e fee-=-s]vice program "u 
p>ts ,a & ,b ( title ,,xviii ( ! ,social
 ,security ,act4  7,b7 ,! #hj? p]c5tile 
( usual1 cu/om>y1 & reasonable *>ge     
rates = ! s]vice = ! geographic area1 z 
det]m9$ by a database ( usual1 cu/om>y1 
& reasonable *>ges select$ by !         
applicable ,/ate au?ority & approv$ z   
appropriate by ! ,secret>y4  7,c7 #ajj  
p]c5t ( ! all[$ *>ges = ! s]vice if !   
s]vice 7 provid$ by a p>ticipat+        
provid]1 :i* %all be det]m9$ bas$ ^u !  
av]age actual all[$ rate "u ! cov]age = 
all p>ticipat+ provid]s = su* s]vice 9 !
 heal? insurance issu]'s p>ticipat+     
provid] network4  7#b7 ,un9sur$         
individuals ,an applicable ,/ate        

au?ority %all select = ! ,/ate z        
applicable = purposes ( subsection      
7b77#a77;,c7 "o ( ! foll[+ z a maximum  
rate = a heal? c>e s]vice = un9sur$     
individuals3  7,a7 ,! rate describ$ 9   
subp>agraph 7,a7 ( p>agraph 7#a74  7,b7 
,! rate describ$ 9 subp>agraph 7,b7 (   
p>agraph 7#a74  7#c7 ,s]vices provid$ 9 
rural areas ,a case describ$ 9 ?is      
p>agraph is a case 9 :i* ! item or      
s]vice is furni%$ by a provid] ( s]vices
 7z def9$ 9 subsection 7u7 ( section    
#ahfa ( ! ,social ,security ,act7 or    
suppli] 7z def9$ 9 subsection 7d7 ( su* 
section7 9 a rural area 7z def9$ 9      
section #ahhf7;d77#b77;,d7 ( su* ,act74 
7#d7 ,default rate ,9 ! case 9 :i* an   
applicable ,/ate au?ority does n select 
a rate "u p>agraph 7#a7 or 7#b7 = a     
s]vice1 ! maximum rate applicable 9 !   
,/ate = ! s]vice = purposes (           
subsections 7a7 & 7b7 %all--  7,a7 be ! 
rate describ$ 9 subp>agraph 7,a7 (      
p>agraph 7#a71 if ! s]vice is cov]$ "u !
 orig9al ,m$ic>e fee-=-s]vice program "u

 p>ts ,a & ,b ( title ,,xviii ( !       
,social ,security ,act2 or  7,b7 be a   
rate e/abli%$ by ! ,secret>y1 if !      
s]vice is n cov]$ "u su* program4  7#e7 
,cl>ification ,9 select+ a rate "u      
p>agraph 7#a7 or 7#b7 = a heal? c>e     
s]vice1 ! applicable ,/ate may select a 
rate t diff]s f ! rate select$ "u su*   
p>agraph = a diff]5t heal? c>e s]vice4  
7d7 ,def9itions ,= purposes ( ?is       
section3 7#a7 ,heal? c>e provid] ,! t]m 
heal? c>e provid] includes a hospital 7z
 def9$ 9 section #ahfa7;e7 ( ! ,social  
,security ,act71 a critical access      
hospital 7z def9$ 9 section #ahfa7mm7 ( 
su* ,act71 a physician 7z def9$ 9       
section #ahfa7r7 ( su* ,act71 & o!r     
provid]s z det]m9$ by ! ,secret>y4  7#b7
 ,un9sur$ individual ,! t]m un9sur$     
individual1 ) respect to an individual  
receiv+ a heal? c>e s]vice1 means an    
individual :o1 at ! "t at :i* ! s]vice 0
 furni%$1 0 n enroll$ 9 a plan t        
provides m$ical c>e b5efits1 includ+ any
 ,f$]al heal? b5efit program1 z det]m9$ 

by ! ,secret>y4  #bgee4 ,reports to     
,congress on network adequacy  ,n lat]  
?an ,janu>y #a1 #bjbb1 & e ye> !reaft]1 
! ,secret>y %all prep>e & submit to !   
,committee on ,heal?1 ,education1       
,labor1 & ,p5sions ( ! ,s5ate & !       
,committee on ,en]gy & ,comm]ce ( !     
,h\se ( ,repres5tatives a report on--   
7#a7 h[ ,/ate network adequacy laws1    
section #bgjb7;c71 & any o!r network    
adequacy requirem5ts = qualifi$ heal?   
plans "u ! ,pati5t ,protection &        
,af=dable ,c>e ,act ensure t provid]    
networks are broad en\gh to meet ! ne$s 
( enroll$ pati5ts2  7#b7 ! impact (     
section #bged on network adequacy2 &    
7#c7 any recomm5dations = ,congress1 z  
necess>y1 on h[ to improve network      
adequacy4  4  7b7 ,effective date       
,section #bged ( ! ,public ,heal?       
,s]vice ,act1 z add$ by subsection 7a71 
%all take effect on ,janu>y #a1 #bjba4  
#c4 ,grants = gr\p m>ket  7a7 ,9 g5]al  
,! ,secret>y ( ,heal? & ,human ,s]vices 
%all aw>d grants to ,/ates = ! purpose (

 /udy+ ! pot5tial = impos+ limitations  
on *>ges = heal? c>e s]vices provid$ to 
individuals enroll$ 9 gr\p heal? plans  
or gr\p heal? insurance cov]age t are   
simil> to ! limitations t apply "u      
section #bged ( ! ,public ,heal? ,s]vice
 ,act1 z add$ by section #b4  7b7       
,au?orization ( appropriations ,!re are 
au?oriz$ to be appropriat$ su* sums z   
may be necess>y to c>ry out ?is section4
  7c7 ,def9itions ,9 ?is section1 ! t]ms
 gr\p heal? plan & gr\p heal? insurance 
cov]age h ! mean+s giv5 su* t]ms 9      
section #bgia ( ! ,public ,heal? ,s]vice
 ,act 7#db ,u4,s4,c4 #cjj;gg-#ia74