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TAM18B37 Discussion draft S.L.C.

S. ll
115TH CONGRESS
2D SESSION

To prohibit surprise medical billing of patients.

IN THE SENATE OF THE UNITED STATES
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Mr. CASSIDY introduced the following bill; which was read twice and referred
to the Committee on llllllllll

A BILL
To prohibit surprise medical billing of patients.

1 Be it enacted by the Senate and House of Representa-
2 tives of the United States of America in Congress assembled,
3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Protecting Patients
5 from Surprise Medical Bills Act’’.
6 SEC. 2. STOPPING SURPRISE MEDICAL BILLS.

7 (a) IN GENERAL.—Section 2719A of the Public
8 Health Service Act (42 U.S.C. 300gg–19a) is amended—
9 (1) in subsection (b), by adding at the end the
10 following:
11 ‘‘(3) RESOLUTION OF PROVIDER BILLING.—Any

12 difference between the amount billed with respect to
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1 emergency services provided by an out-of-network
2 provider and the cost-sharing amount under para-
3 graph (1)(C)(ii)(II) shall be paid by the health plan
4 or health insurance issuer. The provider may not
5 balance bill the patient for amounts beyond the cost-
6 sharing amount allowed under this subsection.
7 ‘‘(4) COST-SHARING AMOUNT TO BE PAID BY

8 PLAN OR ISSUER.—

9 ‘‘(A) IN GENERAL.—The amount of any
10 cost-sharing or coinsurance applied with respect
11 to an enrollee under paragraph (1)(C)(ii)(II)
12 for emergency services provided by an out-of-
13 network provider shall not exceed the cost-shar-
14 ing requirement imposed with respect to the en-
15 rollee if the services were provided in-network.
16 ‘‘(B) EXCESS AMOUNTS.—A health plan or
17 health insurance issuer shall pay to an out-of-
18 network provider that provides emergency serv-
19 ices to an enrollee, the excess of the amount the
20 out-of-network provider charges for such serv-
21 ices above the amount the enrollee is required
22 to pay under subparagraph (A), as determined
23 in accordance with this subparagraph. The
24 amount the plan or issuer is required to pay
25 under this subparagraph shall be—
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1 ‘‘(i) an amount determined, and pay-
2 able in such manner, in accordance with
3 the law of the applicable State, county,
4 parish, or tribal government; or
5 ‘‘(ii) in the case of State for which the
6 applicable State law does not provide for
7 determining such amount and manner of
8 such payment, in such amount that is at
9 least equal to the greater of the amount
10 determined under clause (i) or (ii) of sub-
11 paragraph (C), less the cost-sharing
12 amount under subparagraph (A).
13 ‘‘(C) AMOUNTS DETERMINED.—The

14 amounts determined under this subparagraph
15 are as follows with respect to the service in-
16 volved:
17 ‘‘(i) AVERAGE AMOUNT.—The average
18 amount for the service involved as deter-
19 mined under this clause shall be equal to
20 the median in-network amount negotiated
21 by health plans and health insurance
22 issuers for the service provided by a pro-
23 vider in the same or similar specialty and
24 provided in the same geographical area (as
25 determined by the insurance commissioner
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1 of the applicable State or, if such State
2 does not determine a geographic area, as
3 determined by the Secretary).
4 ‘‘(ii) USUAL, CUSTOMARY, AND REA-

5 SONABLE RATE.—The usual, customary,
6 and reasonable rate for the service involved
7 as determined under this clause, with re-
8 spect to any calendar year, shall be equal
9 to 125 percent of the average allowed
10 amount for all private health plans and
11 health insurance issuers for the service
12 provided by a provider in the same or simi-
13 lar specialty and provided in the same geo-
14 graphical area (as determined by the insur-
15 ance commissioner of the applicable State
16 using a database selected by such State,
17 or, if such State does not select a data-
18 base, selected by the Secretary) for the ap-
19 plicable calendar year or the most recent
20 calendar year that is available, as reported
21 in a statistically significant benchmarking
22 database maintained by a nonprofit organi-
23 zation specified by the insurance commis-
24 sioner or the applicable State, so long as
25 such organization involved is not affiliated
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1 with any plan or issuer and is transparent
2 with the plan, issuer, provider, and insur-
3 ance commissioner of the applicable State
4 as to how the average amount negotiated is
5 determined.
6 ‘‘(5) SUBSEQUENT NON-EMERGENCY SERV-

7 ICES.—In the case of an enrollee who receives emer-
8 gency services from a nonparticipating health care
9 provider or facility as described in this subsection,
10 for whom additional health care services after the
11 enrollee has been stabilized that are not emergency
12 services, the health care facility or hospital shall no-
13 tify, in writing, prior to providing additional serv-
14 ices, the enrollee or the enrollee’s designee that the
15 provider or facility is a nonparticipating health care
16 provider. Such notice shall include—
17 ‘‘(A) information about the potential for
18 higher cost-sharing if such enrollee receives
19 services at the out-of-network facility;
20 ‘‘(B) a written acknowledgement of such
21 notice that the patient is required to sign and
22 return to the hospital or health care facility in
23 advance of the additional services; and
24 ‘‘(C) the option to transfer to an in-net-
25 work facility.’’; and
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1 (2) by adding at the end the following:
2 ‘‘(e) NON-EMERGENCY SERVICES PERFORMED BY AN

3 OUT-OF-NETWORK PROVIDER AT AN IN-NETWORK FACIL-
4 ITY.—

5 ‘‘(1) IN GENERAL.—Notwithstanding subsection
6 (b), a group health plan or health insurance issuer
7 with respect to group or individual health insurance
8 coverage shall not impose cost-sharing on an en-
9 rollee, with respect to services provided by an out-
10 of-network provider at an in-network facility for
11 non-emergency services, that is greater than the
12 cost-sharing that would apply under such plan or
13 coverage had such services been provided by an in-
14 network provider at such facility.
15 ‘‘(2) RESOLUTION OF PROVIDER BILLING.—Any

16 difference between the amount billed with respect to
17 services provided by an out-of-network provider de-
18 scribed in paragraph (1) and the cost-sharing
19 amount under paragraph (1) shall be paid by the
20 health plan or health insurance issuer—
21 ‘‘(A) in such amount and in such manner
22 as determined in accordance with the law of the
23 applicable State, county, or parish; or
24 ‘‘(B) in the case of State for which the ap-
25 plicable State law does not provide for deter-
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1 mining such amount and manner of such pay-
2 ment, in an amount that is at least equal to the
3 greatest of the amounts specified in subsection
4 (b)(4)(C) (which are adjusted for in-network
5 cost-sharing requirements), less the cost-shar-
6 ing amount under paragraph (1).
7 The provider may not balance bill the patient for
8 amounts beyond the cost-sharing amount allowed
9 under this subsection.’’.
10 (b) APPLICATION.—The amendments made by sub-
11 section (a) shall apply with respect to plan years beginning
12 on or after January 1, 2020.
13 SEC. 3. HHS STUDY ON IMPACT OF THIS ACT.

14 The Secretary of Health and Human Services shall—
15 (1) conduct a comprehensive study on the im-
16 pacts of this Act (including the amendments made
17 by this Act), including the impacts on patient cost-
18 sharing, access to care, quality of care, insurance
19 premiums, health care costs, emergency care use,
20 network adequacy, and access to new and improved
21 drugs and technology; and
22 (2) not later than December 31, 2025, issue a
23 publicly available report based on such study that in-
24 cludes recommendations to Congress regarding po-
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1 tential changes to the law with respect to the issues
2 described in paragraph (1).