I 

116TH CONGRESS 

1ST SESSION H. R. 3502 

To amend the Public Health Service Act and title XI of the Social Security 

Act to protect health care consumers from surprise billing practices, 

and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 26, 2019 

Mr. RUIZ (for himself, Mr. BUCSHON, Mr. MORELLE, Mr. BERA, Mr. 

WENSTRUP, Ms. SHALALA, Mr. TAYLOR, Mr. DAVID P. ROE of Tennessee, Mr. BANKS, Mr. HIGGINS of New York, Mr. GRIJALVA, Mr. 

CISNEROS, Mr. SOTO, Mr. HARRIS, Mr. HUDSON, Ms. SCHRIER, Mr. 

MARSHALL, Mr. DUNN, Mr. STIVERS, Mr. DESJARLAIS, Mr. BURCHETT, 

Mr. RIGGLEMAN, Mr. WATKINS, Mr. JOYCE of Pennsylvania, Mr. 

SMUCKER, Ms. STEFANIK, Mr. THOMPSON of Pennsylvania, Mr. WRIGHT, 

Mr. NORCROSS, Mrs. LOWEY, Mr. CA ́RDENAS, Mr. DESAULNIER, and Ms. 

KELLY of Illinois) introduced the following bill; which was referred to the 

Committee on Energy and Commerce, and in addition to the Committees 

on Ways and Means, Oversight and Reform, and Education and Labor, 

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 the Public Health Service Act and title XI of 

the Social Security Act to protect health care consumers 

from 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, 


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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

2 (a) SHORT TITLE.—This Act may be cited as the 

3 ‘‘Protecting People From Surprise Medical Bills Act’’. 

4 (b) TABLE OF CONTENTS.—The table of contents for 

5 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Preventing surprise medical bills. 

Sec. 3. Transparency regarding in-network and out-of-network deductibles. 

Sec. 4. Transparency for in-network patients. 

Sec. 5. Reporting requirements. 

Sec. 6. Billing statute of limitations. 

Sec. 7. Application. 

Sec. 8. Studies by Secretaries of Health and Human Services and of Labor. 

Sec. 9. Regulations. 

6 SEC. 2. PREVENTING SURPRISE MEDICAL BILLS. 

7 (a) EMERGENCY SERVICES PERFORMED BY NON8 PARTICIPATING PROVIDERS.—Section 2719A of the Pub9 lic Health Service Act (42 U.S.C. 300gg–19a) is amend10 ed— 

11 (1) in subsection (b)— 

12 (A) in paragraph (1)— 

13 (i) in the matter preceding subpara14 graph (A)— 

15 (I) by striking ‘‘offering group or 

16 individual health insurance issuer’’ 

17 and inserting ‘‘offering group or indi18 vidual health insurance coverage’’; 

19 and 


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1 (II) by striking ‘‘paragraph 

2 (2)(B)’’ and inserting ‘‘paragraph 

3 (2)’’; 

4 (ii) in subparagraph (B), by inserting 

5 ‘‘or a participating emergency facility, as 

6 applicable,’’ after ‘‘participating provider’’; 

7 and 

8 (iii) in subparagraph (C)— 

9 (I) in the matter preceding clause 

10 (i), by inserting ‘‘by a nonpartici11 pating provider or a nonparticipating 

12 emergency facility’’ after ‘‘enrollee’’; 

13 (II) by striking clause (i); 

14 (III) by striking ‘‘(ii)(I) such 

15 services’’ and inserting ‘‘(i) such serv16 ices’’; 

17 (IV) by striking ‘‘where the pro18 vider of services does not have a con19 tractual relationship with the plan for 

20 the providing of services’’; 

21 (V) by striking ‘‘emergency de22 partment services received from pro23 viders who do have such a contractual 

24 relationship with the plan; and’’ and 

25 inserting ‘‘emergency services received 


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1 from participating providers and par2 ticipating emergency facilities with re3 spect to such plan;’’; 

4 (VI) by striking ‘‘(II) if such serv5 ices’’ and all that follows through 

6 ‘‘were provided in-network’’ and in7 serting the following: 

8 ‘‘(ii) the cost-sharing requirement (ex9 pressed as a copayment amount, coinsur10 ance rate, or deductible) is not greater 

11 than the requirement that would apply if 

12 such services were provided by a partici13 pating provider or a participating emer14 gency facility;’’; and 

15 (VII) by adding at the end the 

16 following new clauses: 

17 ‘‘(iii) the group health plan or health 

18 insurance issuer offering group or indi19 vidual health insurance coverage pays to 

20 such provider or facility, respectively, sub21 ject to subsection (f), the amount by which 

22 the commercially reasonable rate, as deter23 mined by the plan or issuer, for such serv24 ices exceeds the cost-sharing amount for 

25 such services (as determined in accordance 


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1 with clause (ii) and, if applicable, any 

2 amount to reconcile the difference between 

3 such rate so paid and the specified rate de4 termined under subsection (f)(1)) for such 

5 services; and 

6 ‘‘(iv) there shall be counted toward 

7 any deductible or out-of-pocket maximums 

8 applied under the plan any cost-sharing 

9 payments made by the participant, bene10 ficiary, or enrollee with respect to such 

11 emergency services so furnished in the 

12 same manner as if such cost-sharing pay13 ments were with respect to emergency 

14 services furnished by a participating pro15 vider and a participating emergency facil16 ity.’’; and 

17 (B) in paragraph (2)— 

18 (i) in the matter preceding subpara19 graph (A), by inserting ‘‘and subsection 

20 (e)’’ after ‘‘this subsection’’; 

21 (ii) by redesignating subparagraph 

22 (C) as subparagraph (H); and 

23 (iii) by inserting after subparagraph 

24 (C) the following subparagraphs: 


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1 ‘‘(D) NONPARTICIPATING EMERGENCY FA2 CILITY; PARTICIPATING EMERGENCY FACIL3 ITY.— 

4 ‘‘(i) NONPARTICIPATING EMERGENCY

5 FACILITY.—The term ‘nonparticipating 

6 emergency facility’ means, with respect to 

7 an item or service and a group health plan 

8 or health insurance coverage offered by a 

9 health insurance issuer, an emergency de10 partment of a hospital or an independent 

11 freestanding emergency department, that 

12 does not have a contractual relationship 

13 with the plan or coverage for furnishing 

14 such item or service. 

15 ‘‘(ii) PARTICIPATING EMERGENCY FA16 CILITY.—The term ‘participating emer17 gency facility’ means, with respect to an 

18 item or service and a group health plan or 

19 health insurance coverage offered by a 

20 health insurance issuer, an emergency de21 partment of a hospital or an independent 

22 freestanding emergency department, that 

23 has a contractual relationship with the 

24 plan or coverage for furnishing such item 

25 or service. 


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1 ‘‘(E) NONPARTICIPATING PROVIDERS; PAR2 TICIPATING PROVIDERS.— 

3 ‘‘(i) NONPARTICIPATING PROVIDER.— 

4 The term ‘nonparticipating provider’ 

5 means, with respect to an item or service 

6 and a group health plan or health insur7 ance coverage offered by a health insur8 ance issuer, a physician or other health 

9 professional who is licensed by the State 

10 involved to furnish such item or service 

11 and who does not have a contractual rela12 tionship with the plan or coverage for fur13 nishing such item or service. 

14 ‘‘(ii) PARTICIPATING PROVIDER.—The 

15 term ‘participating provider’ means, with 

16 respect to an item or service and a group 

17 health plan or health insurance coverage 

18 offered by a health insurance issuer, a phy19 sician or other health professional who is 

20 licensed by the State involved to furnish 

21 such item or service and who has a con22 tractual relationship with the plan or cov23 erage for furnishing such item or service.’’. 

24 (b) NON-EMERGENCY SERVICES PERFORMED BY

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1 PATING FACILITIES.—Section 2719A of the Public Health 

2 Service Act (42 U.S.C. 300gg–19a) is amended by adding 

3 at the end the following new subsection: 

4 ‘‘(e) NON-EMERGENCY SERVICES PERFORMED BY

5 NONPARTICIPATING PROVIDERS AT CERTAIN PARTICI6 PATING FACILITIES.— 

7 ‘‘(1) IN GENERAL.—In the case of items or 

8 services (other than emergency services to which 

9 subsection (b) applies) furnished to a participant, 

10 beneficiary, or enrollee of a health plan (as defined 

11 in paragraph (2)(A)) by a nonparticipating provider 

12 (as defined in subsection (b)(2)(G)) during a visit at 

13 a participating health care facility (as defined in 

14 paragraph (2)(B)) (including imaging or laboratory 

15 services so furnished by a nonparticipating provider 

16 when ordered by a participating provider or after17 emergency care furnished by a nonparticipating pro18 vider in the case that the participant, beneficiary, or 

19 enrollee cannot travel without medical transport), 

20 with respect to such plan, the plan— 

21 ‘‘(A) shall not impose on such participant, 

22 beneficiary, or enrollee a cost-sharing amount 

23 (expressed as a copayment amount or coinsur24 ance rate) for such items and services so fur25 nished that is greater than the cost-sharing 


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1 amount that would apply under such plan had 

2 such items or services been furnished by a par3 ticipating provider; 

4 ‘‘(B) shall pay to such provider furnishing 

5 such items and services to such participant, 

6 beneficiary, or enrollee, subject to subsection 

7 (f), the amount by which the commercially rea8 sonable rate, as determined by the plan or 

9 issuer, for such services exceeds the cost-shar10 ing amount imposed for such services (as deter11 mined in accordance with subparagraph (A)) 

12 and, if applicable, any amount to reconcile the 

13 difference between such rate so paid and the 

14 specified rate (determined under subsection 

15 (f)(1)) for such services; and 

16 ‘‘(C) shall count toward any deductible or 

17 out-of-pocket maximums applied under the plan 

18 any cost-sharing payments made by the partici19 pant, beneficiary, or enrollee with respect to 

20 such items and services so furnished in the 

21 same manner as if such cost-sharing payments 

22 were with respect to items and services fur23 nished by a participating provider. 

24 ‘‘(2) DEFINITIONS.—In this subsection and 

25 subsection (f): 


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1 ‘‘(A) HEALTH PLAN.—The term ‘health 

2 plan’ means a group health plan and health in3 surance coverage offered by a heath insurance 

4 issuer in the group or individual market. 

5 ‘‘(B) PARTICIPATING HEALTH CARE FACIL6 ITY.— 

7 ‘‘(i) IN GENERAL.—The term ‘partici8 pating health care facility’ means, with re9 spect to an item or service and a group 

10 health plan or health insurance coverage 

11 offered by a health insurance issuer, a 

12 health care facility described in clause (ii) 

13 that has a contractual relationship with 

14 the plan or coverage for furnishing such 

15 item or service. 

16 ‘‘(ii) HEALTH CARE FACILITY DE17 SCRIBED.—A health care facility described 

18 in this clause is each of the following: 

19 ‘‘(I) A hospital (as defined in 

20 1861(e) of the Social Security Act). 

21 ‘‘(II) A critical access hospital 

22 (as defined in section 1861(mm) of 

23 such Act). 


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1 ‘‘(III) An ambulatory surgical 

2 center (as defined in section 

3 1833(i)(1)(A) of such Act). 

4 ‘‘(IV) A laboratory. 

5 ‘‘(V) A radiology or imaging cen6 ter. 

7 ‘‘(VI) Any other facility that pro8 vides services that are covered under 

9 a group health plan or health insur10 ance coverage. 

11 ‘‘(VII) Any other facility speci12 fied by the Secretary.’’. 

13 (c) NEGOTIATION AND ARBITRATION PROCESS FOR

14 DETERMINING PRICES.—Section 2719A of the Public 

15 Health Service Act (42 U.S.C. 300gg–19a), as amended 

16 by subsection (b), is further amended by adding at the 

17 end the following new subsection: 

18 ‘‘(f) NEGOTIATION AND ARBITRATION PROCESS.— 

19 ‘‘(1) SPECIFIED AMOUNT.—For purposes of 

20 subsections (b) and (e) and this subsection, the spec21 ified amount determined under this subsection, with 

22 respect to a health plan and nonparticipating pro23 vider for an item or service, is— 

24 ‘‘(A) in the case the plan and provider 

25 enter into negotiations pursuant to paragraph 


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1 (2) and such negotiations are successful, the 

2 amount determined for such item or service 

3 pursuant to such negotiations; or 

4 ‘‘(B) in the case the plans and provider 

5 enter into such negotiations but such negotia6 tions are not successful, the reasonable amount 

7 determined for such item or service pursuant to 

8 the independent dispute resolution process 

9 under paragraph (3). 

10 ‘‘(2) NEGOTIATIONS.—For purposes of sub11 sections (b)(1)(C)(iii) and (e)(1)(B), in the case of 

12 a payment of a commercially reasonable rate made 

13 by a health plan to a nonparticipating provider pur14 suant to such respective subsection for an item or 

15 service, the provider and plan may, not later than 30 

16 days after the date of such payment, negotiate an 

17 amount of payment (other than the commercially 

18 reasonable rate specified in such subsection) to be 

19 made for such item or service. 

20 ‘‘(3) INDEPENDENT DISPUTE RESOLUTION.— 

21 ‘‘(A) IN GENERAL.—If, by the end of such 

22 30-day period specified in paragraph (2), the 

23 plan and provider have not determined a nego24 tiated amount for the payment involved, the 

25 plan or provider may initiate an independent 


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1 dispute resolution process under this paragraph 

2 to determine the amount of payment. 

3 ‘‘(B) ESTABLISHMENT OF IDR.— 

4 ‘‘(i) IN GENERAL.—Not later than 

5 January 1, 2021, the Secretary, in con6 sultation with the Secretary of Labor, shall 

7 establish a process for resolving payment 

8 disputes between health plans and non9 participating providers for purposes of de10 termining amounts of payments to be 

11 made by the plans to the providers pursu12 ant to subsections (b) and (e) (referred to 

13 in this section as the ‘IDR process’). 

14 ‘‘(ii) ENTITIES.—An entity wishing to 

15 participate in the IDR process under this 

16 subsection shall request certification from 

17 the Secretary. The Secretary, in consulta18 tion with the Secretary of Labor, shall de19 termine eligibility of applicant entities, tak20 ing into consideration whether the entity is 

21 unbiased and unaffiliated with health plans 

22 and providers and free of conflicts of inter23 est, in accordance with the Secretary’s 

24 rulemaking on determining criteria for con25 flicts of interest. 


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1 ‘‘(iii) APPLICABLE CLAIMS.— 

2 ‘‘(I) IN GENERAL.—The IDR 

3 process shall be with respect to one or 

4 more Current Procedural Terminology 

5 (‘CPT’) codes. 

6 ‘‘(II) BATCHING OF CLAIMS.— 

7 Claims may be batched if such 

8 claims— 

9 ‘‘(aa) involve identical plan 

10 or issuer and provider or facility 

11 parties; 

12 ‘‘(bb) involve claims with the 

13 same or related current proce14 dural terminology codes relevant 

15 to a particular procedure; and 

16 ‘‘(cc) involve claims that 

17 occur within 60 days of each 

18 other. 

19 ‘‘(C) INDEPENDENT DISPUTE RESOLUTION

20 PROCESS.— 

21 ‘‘(i) TIMING.—In the case of an IDR 

22 entity that receives a request under this 

23 paragraph, with respect to a payment 

24 amount to be paid by a health plan to a 

25 nonparticipating provider— 


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1 ‘‘(I) the plan and provider may, 

2 during the 30-day period following the 

3 date of receipt of such request, submit 

4 any information or supporting docu5 mentation to the IDR entity; and 

6 ‘‘(II) the IDR entity shall, not 

7 later than 60 days after receiving 

8 such request, determine such amount. 

9 ‘‘(ii) DETERMINATION OF AMOUNT.— 

10 ‘‘(I) IN GENERAL.—The amount 

11 determined by the IDR entity under 

12 clause (i), with respect to a payment 

13 amount to be paid by a health plan to 

14 a nonparticipating provider for an 

15 item or service shall be— 

16 ‘‘(aa) the initial charge for 

17 the item or service made by the 

18 provider or the commercially rea19 sonable rate paid by the plan for 

20 the item or service under sub21 sections (b)(1)(C)(iii) or 

22 (e)(1)(B), respectively, whichever 

23 is determined reasonable by the 

24 entity based on the factors de25 scribed in subclause (III); or 


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1 ‘‘(bb) in the case neither 

2 such charge or such rate is deter3 mined by the entity to be reason4 able, the final offer submitted 

5 under subclause (II) that is de6 termined more reasonable in ac7 cordance with such subclause. 

8 ‘‘(II) FINAL OFFERS.—For pur9 poses of subclause (I)(bb), the health 

10 plan and the nonparticipating pro11 vider party to the independent dispute 

12 resolution under this paragraph shall 

13 each submit to the IDR entity their 

14 final offer for an amount for the pay15 ment that is subject to the dispute not 

16 later than 30 days after the IDR enti17 ty determines under such subclause 

18 that neither the charge or rate de19 scribed in subclause (I)(aa) were rea20 sonable. Not later than 60 days after 

21 such date of such determination, such 

22 entity shall determine which of the 2 

23 final offers is more reasonable based 

24 on the factors described in subclause 

25 (III). 


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1 ‘‘(III) FACTORS.—For purposes 

2 of subclauses (I) and (II), the factors 

3 described in this subclause include, as 

4 relevant— 

5 ‘‘(aa) commercially reason6 able rates for comparable services 

7 or items in the same geographic 

8 area (which shall take into con9 sideration in-network rates for 

10 that geographic area and not 

11 charges); 

12 ‘‘(bb) the usual and cus13 tomary cost of the item or service 

14 involved, determined as the 80th 

15 percentile of charges for com16 parable items and services for the 

17 specialty involved in the geo18 graphical area in which the item 

19 or service was furnished, as de20 termined through reference to a 

21 medical claims database; 

22 ‘‘(cc) other factors that may 

23 be submitted at the discretion of 

24 either party, which may in25 clude— 


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1 ‘‘(dd) the level of training, 

2 education, experience, and quality 

3 and outcomes measurements of 

4 the nonparticipating provider; 

5 ‘‘(ee) the circumstances and 

6 complexity of the particular dis7 pute, including the time and 

8 place of the service; 

9 ‘‘(ff) the provider’s quality 

10 and outcome metrics; 

11 ‘‘(gg) the provider’s usual 

12 charge for comparable services 

13 with regard to patients in health 

14 care plans in which the provider 

15 is not participating; 

16 ‘‘(hh) the individual patient 

17 characteristics; and 

18 ‘‘(ii) other relevant economic 

19 and clinical factors. 

20 ‘‘(IV) FINAL DECISIONS.—The 

21 amount that is determined to be the 

22 more reasonable amount under item 

23 (aa) or (bb) of subclause (I), as appli24 cable, shall be the final decision of the 

25 IDR entity as to the amount the 


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1 health plan is required to pay the pro2 vider. 

3 ‘‘(V) EFFECT OF DETERMINA4 TION.—A final determination of an 

5 IDR entity under subclause (IV)— 

6 ‘‘(aa) shall be binding; and 

7 ‘‘(bb) shall not be subject to 

8 judicial review, except in cases 

9 comparable to those described in 

10 section 10(a) of title 9, United 

11 States Code, as determined by 

12 the Secretary in consultation 

13 with the Secretary of Labor, and 

14 cases in which information sub15 mitted by one party was deter16 mined to be fraudulent. 

17 ‘‘(iii) PRIVACY LAWS.—An IDR entity 

18 shall, in conducting an independent dispute 

19 resolution process under this paragraph, 

20 comply with all applicable Federal and 

21 State privacy laws. 

22 ‘‘(iv) PUBLIC AVAILABILITY.—The 

23 reasonable amount determined by an IDR 

24 entity under this paragraph with respect to 

25 any claim shall not be confidential, except 


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1 that information submitted to the IDR en2 tity shall be kept confidential. IDR entities 

3 may consider past decisions awarded by 

4 independent dispute entities during the 

5 independent dispute resolution process. 

6 ‘‘(v) COSTS OF INDEPENDENT DIS7 PUTE RESOLUTION PROCESS.—The non8 prevailing party shall be responsible for 

9 paying all fees charged by the IDR entity. 

10 If the parties reach a settlement prior to 

11 completion of the IDR process, the costs of 

12 the independent dispute resolution process 

13 shall be divided equally between the par14 ties. 

15 ‘‘(vi) PAYMENT.—Any difference be16 tween— 

17 ‘‘(I) the amount determined to be 

18 paid by one party of the dispute reso19 lution to another pursuant to this 

20 paragraph; and 

21 ‘‘(II) the amounts already paid 

22 under subsection (b) or (e) before en23 tering into the process under this 

24 paragraph, 


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1 shall be paid not later than 15 days after 

2 the date on which the entity makes a de3 termination with respect to such amount. 

4 ‘‘(D) PUBLICATION.—The Secretary shall 

5 publish aggregated results of the independent 

6 dispute resolution by geographic region in order 

7 to give more guidance to providers and health 

8 plans.’’. 

9 (d) PREVENTING CERTAIN CASES OF BALANCE

10 BILLING.—Section 1128A of the Social Security Act (42 

11 U.S.C. 1320a–7a) is amended by adding at the end the 

12 following new subsections: 

13 ‘‘(t)(1) Subject to paragraph (3), in the case of an 

14 individual with benefits under a health plan or health in15 surance coverage offered in the group or individual market 

16 who is furnished on or after January 1, 2021, emergency 

17 services with respect to an emergency medical condition 

18 during a visit at an emergency department of a hospital— 

19 ‘‘(A) if the emergency department of a hospital 

20 holds the individual liable for a payment amount for 

21 such emergency services so furnished that is more 

22 than the cost-sharing amount for such services (as 

23 determined in accordance with section 

24 2719A(b)(1)(C)(ii) of the Public Health Service 

25 Act); or 


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1 ‘‘(B) if any health care provider holds such in2 dividual liable for a payment amount for an emer3 gency service furnished to such individual by such 

4 provider with respect to such emergency medical 

5 condition and visit for which the individual receives 

6 emergency services at the hospital or emergency de7 partment that is more than the cost-sharing amount 

8 for such services furnished by the provider (as deter9 mined in accordance with section 2719A(b)(1)(C)(ii) 

10 of the Public Health Service Act), 

11 the hospital, emergency department or health care pro12 vider, respectively, shall be subject, in addition to any 

13 other penalties that may be prescribed by law, to a civil 

14 money penalty of not more than an amount determined 

15 appropriate by the Secretary for each specified claim. 

16 ‘‘(2) The provisions of subsections (c), (d), (e), (g), 

17 (h), (k), and (l) shall apply to a civil money penalty or 

18 assessment under paragraph (1) or subsection (u) in the 

19 same manner as such provisions apply to a penalty, assess20 ment, or proceeding under subsection (a). 

21 ‘‘(3) Paragraph (1) shall not apply to an emergency 

22 department of a hospital or a provider, with respect to 

23 items or services furnished to a participant, beneficiary, 

24 or enrollee of a health plan or health insurance coverage 

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1 partment of the hospital or the provider, respectively, re2 imburses such participant, beneficiary, or enrollee any 

3 amount for such an item or service that is more than the 

4 cost-sharing amount for such item or service (as deter5 mined in accordance with section 2719A(e)(1)(A)) not 

6 later than 30 days after the date the emergency depart7 ment of the hospital or provider, respectively, knew or 

8 should have known such excess payment was in violation 

9 of this subsection. 

10 ‘‘(4) In this subsection and subsection (u): 

11 ‘‘(A) The terms ‘emergency medical condition’ 

12 and ‘emergency services’ have the meanings given 

13 such terms, respectively, in section 2719A(b)(2) of 

14 the Public Health Service Act. 

15 ‘‘(B) The terms ‘group health plan’, ‘health in16 surance issuer’, and ‘health insurance coverage’ have 

17 the meanings given such terms, respectively, in sec18 tion 2791 of the Public Health Service Act. 

19 ‘‘(u)(1) Subject to paragraph (2), in the case of an 

20 individual with benefits under a health plan or health in21 surance coverage offered in the group or individual market 

22 who is furnished on or after January 1, 2021, items or 

23 services (other than emergency services to which sub24 section (t) applies) during an episode of care (as defined 

25 by the Secretary) at a participating health care facility 


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1 by a nonparticipating provider (including imaging or lab2 oratory services so furnished by a nonparticipating pro3 vider when ordered by a participating provider or after4 emergency care furnished by a nonparticipating provider 

5 in the case that the participant, beneficiary, or enrollee 

6 cannot travel without medical transport), if such non7 participating provider holds such individual liable for a 

8 payment amount for such an item or service furnished by 

9 such provider that is more than the cost-sharing amount 

10 for such item or service (as determined in accordance with 

11 section 2719A(e)(1)(A) of the Public Health Service Act), 

12 such provider shall be subject, in addition to any other 

13 penalties that may be prescribed by law, to a civil money 

14 penalty of not more than an amount determined appro15 priate by the Secretary for each specified claim. 

16 ‘‘(2) Paragraph (1) shall not apply to a nonpartici17 pating provider, with respect to items or services furnished 

18 by the provider to a participant, beneficiary, or enrollee 

19 of a health plan or health insurance coverage offered by 

20 a health insurance issuer, if the provider reimburses such 

21 participant, beneficiary, or enrollee any amount for such 

22 an item or service that is more than the cost-sharing 

23 amount for such item or service (as determined in accord24 ance with section 2719A(e)(1)(A)) not later than 30 days 


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1 after the date the provider knew or should have known 

2 such excess payment was in violation of this subsection. 

3 ‘‘(3) For purposes of this subsection, the terms ‘non4 participating provider’ and ‘participating health care facil5 ity’ have such meanings given such terms under sub6 sections (b)(2) and (e)(2), respectively, of section 2719A 

7 of the Public Health Service Act.’’. 

8 (e) EFFECTIVE DATE.—The amendments made by 

9 this section shall apply with respect to plan years begin10 ning on or after January 1, 2021. 

11 SEC. 3. TRANSPARENCY REGARDING IN-NETWORK AND 

12 OUT-OF-NETWORK DEDUCTIBLES. 

13 (a) IN GENERAL.—Subpart II of part A of title 

14 XXVII of the Public Health Service Act (42 U.S.C. 300gg 

15 et seq.) is amended by adding at the end the following: 

16 ‘‘SEC. 2729A. TRANSPARENCY REGARDING IN-NETWORK 

17 AND OUT-OF-NETWORK DEDUCTIBLES. 

18 ‘‘(a) IN GENERAL.—A group health plan or a health 

19 insurance issuer offering group or individual health insur20 ance coverage and providing or covering any benefit with 

21 respect to items or services shall include, in clear writing, 

22 on any plan or insurance identification card issued to en23 rollees in the plan or coverage the amount of the in-net24 work and out-of-network deductibles and the out-of-pocket 

25 maximum limitation that apply to such plan or coverage. 


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1 ‘‘(b) GUIDANCE.—The Secretary, in consultation 

2 with the Secretary of Labor, shall issue guidance to imple3 ment subsection (a).’’. 

4 (b) EFFECTIVE DATE.—The amendment made by 

5 subsection (a) shall apply with respect to plan years begin6 ning on or after the date that is one year after the date 

7 of the enactment of this Act. 

8 SEC. 4. TRANSPARENCY FOR IN-NETWORK PATIENTS. 

9 Subpart II of part A of title XXVII of the Public 

10 Health Service Act (42 U.S.C. 300gg et seq.), as amended 

11 by section 3, is further amended by adding at the end the 

12 following: 

13 ‘‘SEC. 2729B. TRANSPARENCY FOR IN-NETWORK PATIENTS. 

14 ‘‘(a) STANDARDS.—Not later than January 1, 2021, 

15 the Secretary shall, through rulemaking, establish trans16 parency standards to provide better information to individ17 uals who are enrolled in group health plans or health in18 surance coverage offered in the individual or group market 

19 (as such terms are defined in section 2791 of the Public 

20 Health Service Act (42 U.S.C. 300gg–91)) about which 

21 health care providers are participating in the network of 

22 the plan or coverage in which such an individual is en23 rolled. Such standards shall at a minimum provide for the 

24 following: 


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1 ‘‘(1) Such plans and coverage offer provider di2 rectories online and in print. 

3 ‘‘(2) Annual audits of such provider directories, 

4 as specified by the Secretary. 

5 ‘‘(3) Monthly updates of such online directories. 

6 ‘‘(b) GUIDANCE.—Beginning January 1, 2022, a 

7 group health plan or a health insurance issuer offering 

8 group or individual health insurance coverage shall be in 

9 compliance with the standards established pursuant to 

10 subsection (a).’’. 

11 SEC. 5. REPORTING REQUIREMENTS. 

12 Subpart II of part A of title XXVII of the Public 

13 Health Service Act (42 U.S.C. 300gg et seq.), as amended 

14 by sections 3 and 4, is further amended by adding at the 

15 end the following: 

16 ‘‘SEC. 2729C. TRANSPARENCY REQUIREMENTS. 

17 ‘‘(a) IN GENERAL.—Each group health plan and 

18 health insurance issuer offering group or individual health 

19 insurance coverage shall annually report (beginning for 

20 plan year 2021) to the Secretary and the Secretary of 

21 Labor, with respect to the applicable plan or coverage for 

22 the applicable plan year— 

23 ‘‘(1) the total claims that were submitted by in24 network health care providers with respect to enroll25 ees under the plan or coverage, and the number of 


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1 such claims that were paid and the number of such 

2 claims that were denied; 

3 ‘‘(2) the total claims that were submitted by 

4 out-of-network health care providers with respect to 

5 enrollees under the plan or coverage, and the num6 ber of such claims that were paid and the number 

7 of such claims that were denied; 

8 ‘‘(3) with respect to each out-of-network claim, 

9 the out-of-pocket costs to the enrollee for the serv10 ices; 

11 ‘‘(4) the number of out-of-network claims re12 ported under paragraph (2) that are for emergency 

13 services; and 

14 ‘‘(5) the number of out-of-network claims re15 ported under paragraph (2) that relate to care at in16 network hospitals or facilities provided by out-of-net17 work providers. 

18 ‘‘(b) CLARIFICATION.—The information required to 

19 be submitted under this section shall be in addition to the 

20 information required to be submitted under section 

21 2715A.’’. 

22 SEC. 6. BILLING STATUTE OF LIMITATIONS. 

23 Notwithstanding any other provision of law, a health 

24 care provider may not seek reimbursement from an indi25 vidual for a service furnished by such provider to such inVerDate Sep 11 2014 20:56 Jul 09, 2019 Jkt 089200 PO 00000 Frm 00028 Fmt 6652 Sfmt 6201 E:\BILLS\H3502.IH H3502

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1 dividual more than a year after such date of service. Any 

2 provider that bills an individual in violation of the previous 

3 sentence shall be subject to a civil monetary penalty in 

4 such amount as specified by the Secretary of Health and 

5 Human Services. 

6 SEC. 7. APPLICATION. 

7 (a) NON-APPLICATION IN CASES OF STATES WITH

8 CERTAIN BALANCE BILLING LAWS.—Section 2719A of 

9 the Public Health Service Act (42 U.S.C. 300gg–19a) is 

10 amended by adding at the end the following new sub11 section: 

12 ‘‘(g) In any case in which a State has in effect a law 

13 or regulation that prohibits balance billing or otherwise 

14 provides an alternate method for resolving a dispute be15 tween a health plan and provider for determining com16 pensation for services described in subsections (b), (e), or 

17 (f), the provisions of such law and not the provisions of 

18 this Act shall apply to health plans (except self-insured 

19 group health plans that are not subject to State insurance 

20 regulation), health care providers, and individuals in such 

21 State so long as such law does not require an individual 

22 to pay more in cost-sharing than the amount that would 

23 otherwise be required of such individual under this sec24 tion.’’. 

25 (b) APPLICATION TO FEHB.— 


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1 (1) IN GENERAL.—Section 8902 of title 5, 

2 United States Code, is amended by adding at the 

3 end the following new subsection: 

4 ‘‘(p) Each contract under this chapter shall require 

5 the carrier to comply with requirements described in the 

6 provisions of subsections (b), (e), and (f) of section 2719A 

7 of the Public Health Service Act and sections 2729A and 

8 2729B of such Act in the same manner as those provisions 

9 apply to a groups health plan or health insurance issuer 

10 offering health insurance coverage, as described in such 

11 sections.’’. 

12 (2) EFFECTIVE DATE.—The amendment made 

13 by this subsection shall apply with respect to con14 tracts entered into or renewed for contract years be15 ginning at least one year after the date of enactment 

16 of this Act. 

17 SEC. 8. STUDIES BY SECRETARIES OF HEALTH AND HUMAN 

18 SERVICES AND OF LABOR. 

19 (a) IMPACT STUDY.—Not later than 3 years after the 

20 date of enactment of this Act, the Secretary of Health and 

21 Human Services, in consultation with the Secretary of 

22 Labor, shall conduct a study of the effects of this Act (in23 cluding the amendments made by this Act), and submit 

24 to Congress (and make public) a report on the findings 


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1 of such study, which shall include information and anal2 ysis on— 

3 (1) the financial impact on patient responsi4 bility for health care spending and overall health 

5 care spending; 

6 (2) the incidence and prevalence of the delivery 

7 of unanticipated out-of-network health care services, 

8 in the cases of emergency services and in the cases 

9 of care at in-network hospitals or facilities provided 

10 by out-of-network providers; 

11 (3) the adequacy of provider networks offered 

12 by health plans and health insurance issuers (as 

13 such terms are defined in section 2791 of the Public 

14 Health Service Act (42 U.S.C. 300gg–91)); 

15 (4) a comparison of the different claims data16 bases used and the impact of using such databases 

17 on reimbursement rates; 

18 (5) the number of bills that are settled through 

19 negotiations pursuant to subsection (f)(2) of section 

20 2719A of the Public Health Service Act (42 U.S.C. 

21 300gg–19a), as added by section 2, and the number 

22 of bills that go to the independent dispute resolution 

23 process under subsection (f)(3) of such section, as so 

24 added; 


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1 (6) the administrative cost of such independent 

2 dispute resolution process; and 

3 (7) the estimated impact of such independent 

4 dispute resolution process on health insurance pre5 miums and deductibles. 

6 (b) BILLING FEASIBILITY STUDY.—Not later than 3 

7 years after the date of the enactment of this Act, the Sec8 retary of Health and Human Services shall conduct, and 

9 submit to Congress (and make public), a feasibility study 

10 on the provision of a single bill for all services provided 

11 for a single episode of care, as defined by the Secretary. 

12 SEC. 9. REGULATIONS. 

13 Not later than one year after the date of the enact14 ment of this Act, the Secretary of Labor and the Secretary 

15 of Health and Human Services shall promulgate regula16 tions pertaining to carry out the provisions (including 

17 amendments made by) this Act. 

Æ 


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