I 

116TH CONGRESS 

1ST SESSION H. R. 861 

To amend title XVIII of the Social Security Act to prevent surprise billing 

practices, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JANUARY 30, 2019 

Mr. DOGGETT (for himself, Mr. CARTWRIGHT, Ms. JUDY CHU of California, 

Mr. CICILLINE, Mr. COHEN, Mr. COURTNEY, Mr. DANNY K. DAVIS of 

Illinois, Ms. DELAURO, Mr. GRIJALVA, Ms. HILL of California, Ms. 

JAYAPAL, Ms. KAPTUR, Ms. KELLY of Illinois, Mr. KHANNA, Ms. 

KUSTER of New Hampshire, Ms. LEE of California, Mr. LEWIS, Ms. 

MOORE, Ms. NORTON, Ms. PINGREE, Mr. POCAN, Ms. VELA ́ZQUEZ, Ms. 

SCHAKOWSKY, Mr. LIPINSKI, Ms. DEGETTE, Mr. ESPAILLAT, Mr. 

WELCH, Ms. PORTER, and Mr. LANGEVIN) introduced the following bill; 

which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of 

such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to prevent 

surprise billing practices, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘End Surprise Billing 

5 Act of 2019’’. 


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1 SEC. 2. PREVENTING SURPRISE BILLING PRACTICES. 

2 (a) CONDITION OF PARTICIPATION IN MEDICARE.— 

3 Section 1866 of the Social Security Act (42 U.S.C. 

4 1395cc) is amended— 

5 (1) in subsection (a)(1)— 

6 (A) in subparagraph (X), by striking 

7 ‘‘and’’ at the end; 

8 (B) in subparagraph (Y), by striking at 

9 the end the period and inserting ‘‘, and’’; and 

10 (C) by inserting after such subparagraph 

11 (Y) the following new subparagraph: 

12 ‘‘(Z) in the case of a hospital or critical ac13 cess hospital, to adopt and enforce a policy to 

14 ensure compliance with the requirements of 

15 paragraphs (1) and (4) of subsection (l) and to 

16 meet the requirements of such paragraphs (re17 lating to the prevention of surprise billing prac18 tices).’’; and 

19 (2) by adding at the end the following new sub20 section: 

21 ‘‘(l) REQUIREMENT FOR PURPOSES OF PREVENTING

22 SURPRISE BILLING.— 

23 ‘‘(1) IN GENERAL.—For purposes of subsection 

24 (a)(1)(Z), the requirements described in this para25 graph are, with respect to a hospital or critical ac26 cess hospital, in the case of an individual with health 


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1 benefits coverage, including benefits under a group 

2 health plan or health insurance coverage offered in 

3 the group or individual market (as such terms are 

4 defined in section 2791 of the Public Health Service 

5 Act) or under this title, title XIX, title XXI, or an6 other government-sponsored health plan or program, 

7 who seeks to be furnished items or services or is to 

8 be furnished items or services by the hospital or crit9 ical access hospital (including by a provider of serv10 ices or supplier that furnishes items or services at 

11 the hospital or critical access hospital), that the hos12 pital or critical access hospital— 

13 ‘‘(A)(i) provides to the individual (or to a 

14 representative of the individual), on the date on 

15 which the individual makes an appointment to 

16 be furnished such items or services, if applica17 ble, and on the date on which the individual is 

18 furnished such items and services, a written no19 tice specified by the Secretary through rule20 making that— 

21 ‘‘(I) contains the information required 

22 under paragraph (2); and 

23 ‘‘(II) is signed and dated by the indi24 vidual; and 


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1 ‘‘(ii) retains a copy of each such notice for 

2 a period specified through rulemaking by the 

3 Secretary; and 

4 ‘‘(B) in the case that such hospital or crit5 ical access hospital (or provider of services or 

6 supplier furnishing services at such hospital or 

7 critical access hospital) is not within the health 

8 care provider network or otherwise a partici9 pating provider of services or supplier with re10 spect to such health benefits coverage of such 

11 individual, obtains from the individual the con12 sent described in paragraph (3). 

13 ‘‘(2) INFORMATION INCLUDED IN NOTICE.— 

14 The notice described in paragraph (1)(A) shall in15 clude, with respect to an individual with health bene16 fits coverage described in paragraph (1) who seeks 

17 to be furnished items or services or is to be fur18 nished items or services by a hospital or critical ac19 cess hospital (including by a provider of services or 

20 supplier that furnishes items or services at the hos21 pital or critical access hospital), a notification of 

22 each of the following: 

23 ‘‘(A) Whether the hospital or critical ac24 cess hospital is not within the health care pro25 vider network or otherwise a participating proVerDate Sep 11 2014 02:42 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H861.IH H861

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1 vider of services or supplier with respect to such 

2 health benefits coverage of such individual. 

3 ‘‘(B) If the hospital or critical access hos4 pital is not within such network or otherwise 

5 such a participating provider or supplier, the 

6 estimated amount that the hospital or critical 

7 access hospital will charge the individual for 

8 such items and services in excess of any cost 

9 sharing obligations that the individual would 

10 otherwise have under such health benefits cov11 erage for such items and services if the hospital 

12 or critical access hospital were within such net13 work or otherwise participating in such cov14 erage. 

15 ‘‘(C) Whether any of the providers of serv16 ices or suppliers furnishing items or services at 

17 the hospital or critical access hospital who will 

18 furnish the items or services to the individual 

19 are not within the health care provider network 

20 or otherwise a participating provider of services 

21 or supplier with respect to such health benefits 

22 coverage of such individual. 

23 ‘‘(D) If any of such providers of services or 

24 suppliers are not within such network or other25 wise such a participating provider or supplier, 


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1 the estimated amount that such providers of 

2 services or suppliers will charge the individual 

3 for such items and services in excess of any cost 

4 sharing obligations that the individual would 

5 otherwise have for such items and services if 

6 the providers of services or suppliers were with7 in the such network or otherwise participating 

8 in such coverage. 

9 ‘‘(3) CONSENT DESCRIBED.—For purposes of 

10 paragraph (1)(B), the consent described in this 

11 paragraph, with respect to an individual with health 

12 benefits coverage described in paragraph (1) who is 

13 to be furnished items or services by a hospital or 

14 critical access hospital (or provider of services or 

15 supplier furnishing services at such hospital or crit16 ical access hospital) that is not within the health 

17 care provider network or otherwise a participating 

18 provider of services or supplier with respect to such 

19 health benefits coverage of such individual, is a doc20 ument specified by the Secretary through rule21 making that is signed by the individual (or by a rep22 resentative of the individual) not less than 24 hours 

23 prior to the individual being furnished such items or 

24 services by such hospital, critical access hospital, 


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1 provider of services, or supplier, respectively, and 

2 that— 

3 ‘‘(A) acknowledges that the individual has 

4 been— 

5 ‘‘(i) provided with a written estimate 

6 of the charge that the individual will be as7 sessed for the items or services anticipated 

8 to be furnished to the individual by the 

9 hospital, critical access hospital, provider 

10 of services, or supplier that is not within 

11 such network or otherwise such a partici12 pating provider of services or supplier; and 

13 ‘‘(ii) informed that the payment of 

14 such charge by the individual will not ac15 crue toward any limitation that the health 

16 benefits coverage places upon the annual 

17 out-of-pocket expenses to be paid by the 

18 individual or upon the in-network deduct19 ible to be paid by the individual; and 

20 ‘‘(B) documents the consent of the indi21 vidual to— 

22 ‘‘(i) be furnished with such items or 

23 services by such hospital, critical access 

24 hospital, provider of services, or supplier, 

25 as applicable; and 


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1 ‘‘(ii) in the case that the individual is 

2 so furnished such items or services, be 

3 charged an amount approximate to the es4 timated charge described in subparagraph 

5 (A)(i) with respect to such items or serv6 ices. 

7 ‘‘(4) LIMITATIONS ON PAYMENT BY INDI8 VIDUAL.—For purposes of subsection (a)(1)(Z), the 

9 requirements under this paragraph are the following: 

10 ‘‘(A) IN CASE OF NONCOMPLIANCE BY

11 HOSPITALS AND CRITICAL ACCESS HOS12 PITALS.—In the case of an individual with 

13 health benefits coverage described in paragraph 

14 (1) who is furnished items or services by a hos15 pital or critical access hospital (or provider of 

16 services or supplier furnishing services at such 

17 hospital or critical access hospital) that is not 

18 within the health care provider network or oth19 erwise a participating provider of services or 

20 supplier with respect to such health benefits 

21 coverage of such individual, if the hospital or 

22 critical access hospital does not comply with the 

23 requirements of paragraph (1) with respect to 

24 the furnishing of such items or services to such 

25 individual, the hospital or critical access hosVerDate Sep 11 2014 02:42 Feb 09, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H861.IH H861

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1 pital (or, as applicable, the provider of services 

2 or supplier furnishing such items or services to 

3 such individual) may not charge the individual 

4 more than the amount that the individual would 

5 have been required to pay in cost sharing if 

6 such items or services had been furnished by a 

7 hospital or critical access hospital, as applicable 

8 (or by a provider of services or supplier, as ap9 plicable) that is within such network or that is 

10 otherwise such a participating provider of serv11 ices or supplier. 

12 ‘‘(B) IN CASE OF SAME-DAY EMERGENCY

13 SERVICES.—In the case of an individual with 

14 health benefits coverage described in paragraph 

15 (1) who is furnished items or services by a hos16 pital or critical access hospital (or provider of 

17 services or supplier furnishing services at such 

18 hospital or critical access hospital) that is not 

19 within the health care provider network or oth20 erwise a participating provider of services or 

21 supplier with respect to such health benefits 

22 coverage of such individual on the same date on 

23 which the individual makes an appointment for 

24 such items or services (or otherwise presents at 

25 the hospital or critical access hospital for such 


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1 services such as in the case of items and serv2 ices furnished with respect to an emergency 

3 medical condition, as defined in section 

4 1867(e)), the hospital or critical access hospital 

5 (or, as applicable, the provider of services or 

6 supplier furnishing such items or services to 

7 such individual) may not charge the individual 

8 more than the amount that the individual would 

9 have been required to pay in cost sharing if 

10 such items or services had been furnished by a 

11 hospital or critical access hospital, as applicable 

12 (or by a provider of services or supplier, as ap13 plicable) that is within such network or that is 

14 otherwise such a participating provider of serv15 ices or supplier.’’. 

16 (b) EFFECTIVE DATE.—The amendments made by 

17 subsection (a) shall apply with respect to agreements 

18 under section 1866(a)(1) of the Social Security Act (42 

19 U.S.C. 1395cc(a)(1)) that are filed with the Secretary of 

20 Health and Human Services on a date that is not less 

21 than 12 months after the date of the enactment of this 

22 Act. 

Æ 


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