End Surprise Billing Act of 2015

Summary: End Surprise Billing Act of 2015 This bill amends title XVIII (Medicare) of the Social Security Act to require a critical access hospital or other hospital to comply, as a condition of participation in Medicare, with certain requirements related to billing for out-of-network services. With respect to an individual who has health benefits coverage and is seeking services, a hospital must provide notice as to: (1) whether the hospital, or any of the providers furnishing services to the individual at the hospital, is not within the health care provider network or otherwise a participating provider with respect to the individual's health care coverage; and (2) if so, the estimated out-of-pocket costs of the services to the individual. At least 24 hours prior to providing those services, the hospital must document that the individual: (1) has been provided with the required notice, and (2) consents to be furnished with the services and charged an amount approximate to the estimate provided. Otherwise, the hospital may not charge the individual more than the individual would have been required to pay if the services had been furnished by an in-network or participating provider. With respect to such an individual who is seeking same-day emergency services, a hospital may not charge more than the individual would be required to pay for such services furnished by an in-network or participating provider.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``End Surprise Billing Act of 2015''.

SEC. 2. PREVENTING SURPRISE BILLING PRACTICES.

    (a) Condition of Participation in Medicare.--Section 1866 of the 
Social Security Act (42 U.S.C. 1395cc) is amended--
            (1) in subsection (a)(1)--
                    (A) in subparagraph (X), by striking ``and'' at the 
                end;
                    (B) in subparagraph (Y), by striking at the end the 
                period and inserting ``, and''; and
                    (C) by inserting after such subparagraph (Y) the 
                following new subparagraph:
                    ``(Z) in the case of a hospital or critical access 
                hospital, to adopt and enforce a policy to ensure 
                compliance with the requirements of paragraphs (1) and 
                (4) of subsection (l) and to meet the requirements of 
                such paragraphs (relating to the prevention of surprise 
                billing practices).''; and
            (2) by adding at the end the following new subsection:
    ``(l) Requirement for Purposes of Preventing Surprise Billing.--
            ``(1) In general.--For purposes of subsection (a)(1)(Z), 
        the requirements described in this paragraph are, with respect 
        to a hospital or critical access hospital, in the case of an 
        individual with health benefits coverage, including benefits 
        under a group health plan or health insurance coverage offered 
        in the group or individual market (as such terms are defined in 
        section 2791 of the Public Health Service Act) or under this 
        title, title XIX, title XXI, or another government-sponsored 
        health plan or program, who seeks to be furnished items or 
        services or is to be furnished items or services by the 
        hospital or critical access hospital (including by a provider 
        of services or supplier that furnishes items or services at the 
        hospital or critical access hospital), that the hospital or 
        critical access hospital--
                    ``(A)(i) provides to the individual (or to a 
                representative of the individual), on the date on which 
                the individual makes an appointment to be furnished 
                such items or services, if applicable, and on the date 
                on which the individual is furnished such items and 
                services, a written notice specified by the Secretary 
                through rulemaking that--
                            ``(I) contains the information required 
                        under paragraph (2); and
                            ``(II) is signed and dated by the 
                        individual; and
                    ``(ii) retains a copy of each such notice for a 
                period specified through rulemaking by the Secretary; 
                and
                    ``(B) in the case that such hospital or critical 
                access hospital (or provider of services or supplier 
                furnishing services at such hospital or critical access 
                hospital) is not within the health care provider 
                network or otherwise a participating provider of 
                services or supplier with respect to such health 
                benefits coverage of such individual, obtains from the 
                individual the consent described in paragraph (3).
            ``(2) Information included in notice.--The notice described 
        in paragraph (1)(A) shall include, with respect to an 
        individual with health benefits coverage described in paragraph 
        (1) who seeks to be furnished items or services or is to be 
        furnished items or services by a hospital or critical access 
        hospital (including by a provider of services or supplier that 
        furnishes items or services at the hospital or critical access 
        hospital), a notification of each of the following:
                    ``(A) Whether the hospital or critical access 
                hospital is not within the health care provider network 
                or otherwise a participating provider of services or 
                supplier with respect to such health benefits coverage 
                of such individual.
                    ``(B) If the hospital or critical access hospital 
                is not within such network or otherwise such a 
                participating provider or supplier, the estimated 
                amount that the hospital or critical access hospital 
                will charge the individual for such items and services 
                in excess of any cost sharing obligations that the 
                individual would otherwise have under such health 
                benefits coverage for such items and services if the 
                hospital or critical access hospital were within such 
                network or otherwise participating in such coverage.
                    ``(C) Whether any of the providers of services or 
                suppliers furnishing items or services at the hospital 
                or critical access hospital who will furnish the items 
                or services to the individual are not within the health 
                care provider network or otherwise a participating 
                provider of services or supplier with respect to such 
                health benefits coverage of such individual.
                    ``(D) If any of such providers of services or 
                suppliers are not within such network or otherwise such 
                a participating provider or supplier, the estimated 
                amount that such providers of services 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 of services or suppliers were 
                within the such network or otherwise participating in 
                such coverage.
            ``(3) Consent described.--For purposes of paragraph (1)(B), 
        the consent described in this paragraph, with respect to an 
        individual with health benefits coverage described in paragraph 
        (1) who is to be furnished items or services by a hospital or 
        critical access hospital (or provider of services or supplier 
        furnishing services at such hospital or critical access 
        hospital) that is not within the health care provider network 
        or otherwise a participating provider of services or supplier 
        with respect to such health benefits coverage of such 
        individual, is a document specified by the Secretary through 
        rulemaking that is signed by the individual (or by a 
        representative of the individual) not less than 24 hours prior 
        to the individual being furnished such items or services by 
        such hospital, critical access hospital, provider of services, 
        or supplier, respectively, and that--
                    ``(A) acknowledges that the individual has been--
                            ``(i) provided with a written estimate of 
                        the charge that the individual will be assessed 
                        for the items or services anticipated to be 
                        furnished to the individual by the hospital, 
                        critical access hospital, provider of services, 
                        or supplier that is not within such network or 
                        otherwise such a participating provider of 
                        services or supplier; and
                            ``(ii) informed that the payment of such 
                        charge by the individual will not accrue toward 
                        any limitation that the health benefits 
                        coverage places upon the annual out-of-pocket 
                        expenses to be paid by the individual or upon 
                        the in-network deductible to be paid by the 
                        individual; and
                    ``(B) documents the consent of the individual to--
                            ``(i) be furnished with such items or 
                        services by such hospital, critical access 
                        hospital, provider of services, or supplier, as 
                        applicable; and
                            ``(ii) in the case that the individual is 
                        so furnished such items or services, be charged 
                        an amount approximate to the estimated charge 
                        described in subparagraph (A)(i) with respect 
                        to such items or services.
            ``(4) Limitations on payment by individual.--For purposes 
        of subsection (a)(1)(Z), the requirements under this paragraph 
        are the following:
                    ``(A) In case of noncompliance by hospitals and 
                critical access hospitals.--In the case of an 
                individual with health benefits coverage described in 
                paragraph (1) who is furnished items or services by a 
                hospital or critical access hospital (or provider of 
                services or supplier furnishing services at such 
                hospital or critical access hospital) that is not 
                within the health care provider network or otherwise a 
                participating provider of services or supplier with 
                respect to such health benefits coverage of such 
                individual, if the hospital or critical access hospital 
                does not comply with the requirements of paragraph (1) 
                with respect to the furnishing of such items or 
                services to such individual, the hospital or critical 
                access hospital (or, as applicable, the provider of 
                services or supplier furnishing such items or services 
                to such individual) 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 a hospital or critical 
                access hospital, as applicable (or by a provider of 
                services or supplier, as applicable) that is within 
                such network or that is otherwise such a participating 
                provider of services or supplier.
                    ``(B) In case of same-day emergency services.--In 
                the case of an individual with health benefits coverage 
                described in paragraph (1) who is furnished items or 
                services by a hospital or critical access hospital (or 
                provider of services or supplier furnishing services at 
                such hospital or critical access hospital) that is not 
                within the health care provider network or otherwise a 
                participating provider of services or supplier with 
                respect to such health benefits coverage of such 
                individual on the same date on which the individual 
                makes an appointment for such items or services (or 
                otherwise presents at the hospital or critical access 
                hospital for such services such as in the case of items 
                and services furnished with respect to an emergency 
                medical condition, as defined in section 1867(e)), the 
                hospital or critical access hospital (or, as 
                applicable, the provider of services or supplier 
                furnishing such items or services to such individual) 
                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 
                a hospital or critical access hospital, as applicable 
                (or by a provider of services or supplier, as 
                applicable) that is within such network or that is 
                otherwise such a participating provider of services or 
                supplier.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply with respect to agreements under section 1866(a)(1) of the Social 
Security Act (42 U.S.C. 1395cc(a)(1)) that are filed with the Secretary 
of Health and Human Services on a date that is not less than 12 months 
after the date of the enactment of this Act.