I 

116TH CONGRESS 

1ST SESSION H. R. 3784 

To amend title XXVII of the Public Health Service Act and title XI of 

the Social Security Act to prohibit surprise billing with respect to air 

ambulance services. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 16, 2019 

Mr. NEGUSE introduced the following bill; which was referred to the 

Committee on Energy and Commerce 

A BILL 

To amend title XXVII of the Public Health Service Act 

and title XI of the Social Security Act to prohibit surprise billing with respect to air ambulance services. 

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 ‘‘Air Ambulance Afford5 ability Act of 2019’’. 

6 SEC. 2. PROHIBITING SURPRISE BILLING WITH RESPECT 

7 TO AIR AMBULANCE SERVICES. 

8 (a) AIR AMBULANCE SERVICES.— 


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1 (1) IN GENERAL.—Section 2719A of the Public 

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

3 amended by adding at the end the following new 

4 subsections: 

5 ‘‘(e) AIR AMBULANCE SERVICES.— 

6 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

7 in the case of air ambulance services furnished to a 

8 participant, beneficiary, or enrollee of a health plan 

9 (as defined in paragraph (3)(A)) by a nonpartici10 pating provider (as defined in paragraph (3)(C)), the 

11 plan— 

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

13 beneficiary, or enrollee a cost-sharing amount 

14 (expressed as a copayment amount or coinsur15 ance rate) for such services so furnished that is 

16 greater than the cost-sharing amount that 

17 would apply under such plan had such services 

18 been furnished by a participating provider; 

19 ‘‘(B) shall calculate such cost-sharing 

20 amount as if the negotiated rate that would 

21 have been charged by such participating pro22 vider for such services were equal to the 

23 amount determined in accordance with sub24 section (f) for such services (or, in the case of 

25 such services furnished in a State described in 


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1 paragraph (3)(E)(i), the amount determined by 

2 such State for such services in accordance with 

3 the method described in such paragraph); 

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

5 such services to such participant, beneficiary, or 

6 enrollee the amount by which the recognized 

7 amount (as defined in paragraph (3)(E)) for 

8 such services exceeds the cost-sharing amount 

9 imposed for such services (as determined in ac10 cordance with subparagraphs (A) and (B)); and 

11 ‘‘(D) shall count toward any deductible or 

12 out-of-pocket maximums applied under the plan 

13 any cost-sharing payments made by the partici14 pant, beneficiary, or enrollee with respect to 

15 such services so furnished in the same manner 

16 as if such cost-sharing payments were with re17 spect to services furnished by a participating 

18 provider. 

19 ‘‘(2) EXCEPTION FOR CERTAIN SERVICES.—The 

20 provisions of paragraph (1) shall not apply in the 

21 case of air ambulance services that— 

22 ‘‘(A) are not furnished with respect to an 

23 individual with an emergency medical condition 

24 (as defined in subsection (b)(2)(A)); and 


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1 ‘‘(B) are furnished by a provider that is in 

2 compliance with the requirement of section 

3 1128A(t)(3) of the Social Security Act with re4 spect to such services. 

5 ‘‘(3) DEFINITIONS.—In this subsection and 

6 subsection (f): 

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

8 plan’ means a group health plan and health in9 surance coverage offered by a heath insurance 

10 issuer in the group or individual market. 

11 ‘‘(B) PROVIDER.—The term ‘provider’ 

12 means a provider of services or a supplier (as 

13 such terms are defined in section 1861 of the 

14 Social Security Act). 

15 ‘‘(C) NONPARTICIPATING PROVIDER.—The 

16 term ‘nonparticipating provider’ means, with re17 spect to air ambulance services and a group 

18 health plan or health insurance coverage offered 

19 by a health insurance issuer, a provider or sup20 plier of such services that is licensed by the 

21 State involved to furnish such services and that 

22 does not have a contractual relationship with 

23 the plan or coverage for furnishing such serv24 ices. 


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1 ‘‘(D) PARTICIPATING PROVIDER.—The 

2 term ‘participating provider’ means, with re3 spect to air ambulance services and a group 

4 health plan or health insurance coverage offered 

5 by a health insurance issuer, a provider or sup6 plier of such services that is licensed by the 

7 State involved to furnish such services and that 

8 has a contractual relationship with the plan or 

9 coverage for services. 

10 ‘‘(E) RECOGNIZED AMOUNT.—The term 

11 ‘recognized amount’ means, with respect to air 

12 ambulance services— 

13 ‘‘(i) in the case of such services fur14 nished in a State that has in effect a State 

15 law that provides for a method for deter16 mining the amount of payment that is re17 quired to be covered by a health plan or 

18 health insurance issuer offering group or 

19 individual health insurance coverage regu20 lated by such State in the case of a partici21 pant, beneficiary, or enrollee covered under 

22 such plan or coverage and receiving such 

23 services from a nonparticipating provider, 

24 not more than the amount determined in 

25 accordance with such law plus the costVerDate Sep 11 2014 22:47 Jul 25, 2019 Jkt 034408 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H3784.IH H3784

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1 sharing amount imposed for such services 

2 (as determined in accordance with para3 graph (1)); or 

4 ‘‘(ii) in the case of such services fur5 nished in a State that does not have in ef6 fect such a law, an amount determined in 

7 accordance with the independent dispute 

8 resolution process established under sub9 section (f). 

10 ‘‘(f) INDEPENDENT DISPUTE RESOLUTION PROC11 ESS.— 

12 ‘‘(1) ESTABLISHMENT.— 

13 ‘‘(A) IN GENERAL.—Not later than 1 year 

14 after the date of the enactment of this sub15 section, the Secretary, in consultation with the 

16 Secretary of Labor, shall establish by regulation 

17 an independent dispute resolution process (re18 ferred to in this subsection as the ‘IDR proc19 ess’) under which entities certified under para20 graph (2) (in this subsection referred to as ‘cer21 tified IDR entities’) resolve specified claims of 

22 nonparticipating providers or health plans, tak23 ing into account the factors described in sub24 paragraph (C). Such process shall prohibit such 

25 an entity from participating in the resolution of 


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1 such a claim if such entity has a conflict of in2 terest with respect to such provider, facility, or 

3 the health plan involved. 

4 ‘‘(B) SPECIFIED CLAIM.—For purposes of 

5 subparagraph (A), the term ‘specified claim’ 

6 means a claim by a nonparticipating provider or 

7 health plan that, with respect to air ambulance 

8 services furnished by such provider for which a 

9 health plan is required to make payment pursu10 ant to subsection (e)(1), is made under the IDR 

11 process not later than 30 days after the services 

12 are furnished. 

13 ‘‘(C) FACTORS.—The factors described in 

14 this subparagraph include— 

15 ‘‘(i) commercially reasonable rates for 

16 comparable services furnished in the same 

17 geographic area (which shall take into con18 sideration in-network rates for that geo19 graphic area and not charges); and 

20 ‘‘(ii) other factors that may be sub21 mitted at the discretion of either party, 

22 which may include— 

23 ‘‘(I) the level of training, edu24 cation, experience, and quality and 


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1 outcomes measurements of the pro2 vider; 

3 ‘‘(II) the circumstances and com4 plexity of the particular dispute, in5 cluding the time and place of the serv6 ice; 

7 ‘‘(III) the market share held by 

8 the provider or that of the plan; 

9 ‘‘(IV) demonstration of good 

10 faith efforts (or lack of good faith ef11 forts) made by the provider or the 

12 plan to contract for negotiated rates, 

13 if applicable; and 

14 ‘‘(V) other relevant economic as15 pects of provider reimbursement for 

16 the same specialty within the same ge17 ographic area. 

18 ‘‘(2) CERTIFICATION OF ENTITIES.— 

19 ‘‘(A) PROCESS OF CERTIFICATION.—As 

20 part of the regulation described in paragraph 

21 (1), the Secretary, in consultation with the Sec22 retary of Labor, shall establish a certification 

23 process under which eligible entities may be cer24 tified to carry out the IDR process. 


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1 ‘‘(B) ELIGIBILITY.—For purposes of sub2 paragraph (A), an eligible entity is an entity 

3 that is a nongovernmental entity (such as the 

4 American Arbitration Association). 

5 ‘‘(3) SELECTION OF CERTIFIED IDR ENTITY

6 FOR A SPECIFIED CLAIM.—With respect to the reso7 lution of a specified claim under the IDR process, 

8 the health plan and the nonparticipating provider in9 volved shall agree on a certified IDR entity to re10 solve such claim. In the case that such plan and 

11 such provider cannot so agree, such an entity shall 

12 be selected by the Secretary at random. 

13 ‘‘(4) PAYMENT DETERMINATION.— 

14 ‘‘(A) TIMING.—A certified IDR entity that 

15 receives a request from a nonparticipating pro16 vider or health plan under this subsection shall, 

17 not later than 30 days after receiving such re18 quest, determine the amount the health plan is 

19 required to pay such provider or facility for 

20 services described in paragraph (1), in accord21 ance with subparagraph (C), in the case that a 

22 settlement described in subparagraph (B) is not 

23 reached. 

24 ‘‘(B) SETTLEMENT.— 


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1 ‘‘(i) IN GENERAL.—If such entity de2 termines that a settlement between the 

3 health plan and the provider is likely, the 

4 entity may direct the parties to attempt, 

5 for a period not to exceed 10 days, a good 

6 faith negotiation for a settlement. 

7 ‘‘(ii) TIMING.—The period for a set8 tlement described in clause (i) shall accrue 

9 towards the 30-day period required under 

10 subparagraph (A). 

11 ‘‘(C) DETERMINATION OF AMOUNT.— 

12 ‘‘(i) DECISIONS.—The health plan and 

13 the nonparticipating provider shall each 

14 submit to the certified IDR entity a final 

15 offer of payment with respect to services 

16 which are the subject of the specified 

17 claim. Such entity shall select the offer 

18 that such entity determines is the most 

19 reasonable based on the factors described 

20 in paragraph (1)(C). 

21 ‘‘(ii) EFFECT OF DECISION.—A deci22 sion of a certified IDR entity under clause 

23 (ii)— 

24 ‘‘(I) shall be binding; and 


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1 ‘‘(II) shall not be subject to judi2 cial review, except in a case described 

3 in any of paragraphs (1) through (4) 

4 of section 10(a) of title 9, United 

5 States Code, as determined by the 

6 Secretary in consultation with the 

7 Secretary of Labor. 

8 ‘‘(iii) COSTS OF INDEPENDENT DIS9 PUTE RESOLUTION PROCESS.—The party 

10 whose calculation is not chosen under sub11 paragraph (B)(ii) shall be responsible for 

12 paying all fees charged by the certified 

13 IDR entity. If the parties reach a settle14 ment prior to completion of the IDR proc15 ess, the costs of such process shall be di16 vided equally between the parties, unless 

17 the parties otherwise agree. 

18 ‘‘(iv) PAYMENT.—Not later than 30 

19 days after a decision described in clause (i) 

20 is made, the health plan shall pay to the 

21 provider or supplier of the services with re22 spect to which the specified claim is made 

23 the amount determined under this sub24 section. 


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1 ‘‘(v) PUBLIC AVAILABILITY.—The cer2 tified IDR entity shall make each final 

3 offer selected under clause (i) available to 

4 the public. Any information submitted to 

5 the entity by the health plan, provider, or 

6 facility, other than such final offer, may 

7 not be disclosed by the entity.’’. 

8 (2) EFFECTIVE DATE.—The amendments made 

9 by this subsection shall apply with respect to plan 

10 years beginning on or after January 1, 2021. 

11 (b) PREVENTING CERTAIN CASES OF BALANCE

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

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

14 following new subsections: 

15 ‘‘(t)(1) Subject to paragraph (2), in the case of an 

16 individual with benefits under a health plan or health in17 surance coverage offered in the group or individual market 

18 who is furnished on or after January 1, 2021, air ambu19 lance services by a nonparticipating provider (as defined 

20 in section 2719A(e)(3) of the Public Health Service Act), 

21 if such provider holds the individual liable for a payment 

22 amount for such services so furnished that is more than 

23 the cost-sharing amount for such services (as determined 

24 in accordance with section 2719A(e)(1) of the Public 

25 Health Service Act), such provider shall be subject, in adVerDate Sep 11 2014 22:47 Jul 25, 2019 Jkt 034408 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H3784.IH H3784

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1 dition to any other penalties that may be prescribed by 

2 law, to a civil money penalty of not more than an amount 

3 determined appropriate by the Secretary for each specified 

4 claim. 

5 ‘‘(2) Paragraph (1) shall not apply to a nonpartici6 pating provider, with respect to air ambulance services 

7 furnished by the provider to a participant, beneficiary, or 

8 enrollee of a health plan or health insurance coverage of9 fered by a health insurance issuer, if— 

10 ‘‘(A) such services are not furnished with re11 spect to an individual with an emergency medical 

12 condition (as defined in section 2719A(e)(3) of the 

13 Public Health Service Act); and 

14 ‘‘(B) the provider is in compliance with the re15 quirement of paragraph (3). 

16 ‘‘(3)(A) For purposes of paragraph (2) and section 

17 2719A(e)(2) of the Public Health Service Act, a non18 participating provider is in compliance with this para19 graph, with respect to air ambulance services furnished 

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

21 of a health plan or health insurance coverage offered by 

22 a health insurance issuer, if the provider— 

23 ‘‘(i)(I) provides to the participant, beneficiary, 

24 or enrollee (or to a representative of the participant, 

25 beneficiary, or enrollee), on the date on which the 


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1 participant, beneficiary, or enrollee schedules such 

2 services, if applicable, and on the date on which the 

3 individual is furnished such services— 

4 ‘‘(aa) an oral explanation of the written 

5 notice described in item (bb) and such docu6 mentation of the provision of such explanation, 

7 as the Secretary determines appropriate; and 

8 ‘‘(bb) a written notice specified, not later 

9 than July 1, 2020, by the Secretary through 

10 rulemaking that— 

11 ‘‘(AA) contains the information re12 quired under subparagraph (B); and 

13 ‘‘(BB) is signed and dated by the par14 ticipant, beneficiary, or enrollee; and 

15 ‘‘(II) retains, for a period specified through 

16 rulemaking by the Secretary, a copy of the docu17 mentation described in subclause (I)(aa) and the 

18 written notice described in subclause (I)(bb); and 

19 ‘‘(ii) obtains from the participant, beneficiary, 

20 or enrollee (or representative) the consent described 

21 in subparagraph (C). 

22 ‘‘(B) For purposes of subparagraph (A)(i), the infor23 mation described in this subparagraph, with respect to a 

24 nonparticipating provider and a participant, beneficiary, 

25 or enrollee of a health plan or health insurance coverage 


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1 offered by a health insurance issuer, is a notification of 

2 each of the following: 

3 ‘‘(i) That the health care provider is a non4 participating provider with respect to the group 

5 health plan or health insurance coverage. 

6 ‘‘(ii) The estimated amount that such provider 

7 will charge the participant, beneficiary, or enrollee 

8 for such services involved. 

9 ‘‘(C) For purposes of subparagraph (A)(ii), the con10 sent described in this subparagraph, with respect to a par11 ticipant, beneficiary, or enrollee of a group health plan or 

12 health insurance coverage offered by a health insurance 

13 issuer, who is to be furnished air ambulance services by 

14 a nonparticipating provider, is a document specified by the 

15 Secretary through rulemaking that— 

16 ‘‘(i) is signed by the participant, beneficiary, or 

17 enrollee (or by a representative of the participant, 

18 beneficiary, or enrollee) not less than 24 hours prior 

19 to the participant, beneficiary, or enrollee being fur20 nished such services by such provider; 

21 ‘‘(ii) acknowledges that the participant, bene22 ficiary, or enrollee has been— 

23 ‘‘(I) provided with a written estimate and 

24 an oral explanation of the charge that the par25 ticipant, beneficiary, or enrollee will be assessed 


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1 for the services anticipated to be furnished to 

2 the participant, beneficiary, or enrollee by such 

3 nonparticipating provider; and 

4 ‘‘(II) informed that the payment of such 

5 charge by the participant, beneficiary, or en6 rollee will not accrue toward meeting any limi7 tation that the group health plan or health in8 surance coverage places on cost-sharing; and 

9 ‘‘(iii) documents the consent of the participant, 

10 beneficiary, or enrollee to— 

11 ‘‘(I) be furnished with such services by 

12 such nonparticipating provider; and 

13 ‘‘(II) in the case that the individual is so 

14 furnished such services, be charged an amount 

15 that may be greater than the amount that 

16 would otherwise be changed the individual if 

17 furnished by a participating provider (as de18 fined in section 2719A(e)(3) of the Public 

19 Health Service Act) with respect to such serv20 ices and plan or coverage. 

21 ‘‘(4) The provisions of subsections (c), (d), (e), (g), 

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

23 assessment under paragraph (1) in the same manner as 

24 such provisions apply to a penalty, assessment, or pro25 ceeding under subsection (a). 


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1 ‘‘(5) In this subsection, the terms ‘group health plan’, 

2 ‘health insurance issuer’, and ‘health insurance coverage’ 

3 have the meanings given such terms, respectively, in sec4 tion 2791 of the Public Health Service Act’’. 

Æ 


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