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[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3784 Introduced in House (IH)]

<DOC>

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.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Air Ambulance Affordability Act of 
2019''.

SEC. 2. PROHIBITING SURPRISE BILLING WITH RESPECT TO AIR AMBULANCE 
              SERVICES.

    (a) Air Ambulance Services.--
            (1) In general.--Section 2719A of the Public Health Service 
        Act (42 U.S.C. 300gg-19a) is amended by adding at the end the 
        following new subsections:
    ``(e) Air Ambulance Services.--
            ``(1) In general.--Subject to paragraph (2), in the case of 
        air ambulance services furnished to a participant, beneficiary, 
        or enrollee of a health plan (as defined in paragraph (3)(A)) 
        by a nonparticipating provider (as defined in paragraph 
        (3)(C)), the plan--
                    ``(A) shall not impose on such participant, 
                beneficiary, or enrollee a cost-sharing amount 
                (expressed as a copayment amount or coinsurance rate) 
                for such services so furnished that is greater than the 
                cost-sharing amount that would apply under such plan 
                had such services been furnished by a participating 
                provider;
                    ``(B) shall calculate such cost-sharing amount as 
                if the negotiated rate that would have been charged by 
                such participating provider for such services were 
                equal to the amount determined in accordance with 
                subsection (f) for such services (or, in the case of 
                such services furnished in a State described in 
                paragraph (3)(E)(i), the amount determined by such 
                State for such services in accordance with the method 
                described in such paragraph);
                    ``(C) shall pay to such provider furnishing such 
                services to such participant, beneficiary, or enrollee 
                the amount by which the recognized amount (as defined 
                in paragraph (3)(E)) for such services exceeds the 
                cost-sharing amount imposed for such services (as 
                determined in accordance with subparagraphs (A) and 
                (B)); and
                    ``(D) shall count toward any deductible or out-of-
                pocket maximums applied under the plan any cost-sharing 
                payments made by the participant, beneficiary, or 
                enrollee with respect to such services so furnished in 
                the same manner as if such cost-sharing payments were 
                with respect to services furnished by a participating 
                provider.
            ``(2) Exception for certain services.--The provisions of 
        paragraph (1) shall not apply in the case of air ambulance 
        services that--
                    ``(A) are not furnished with respect to an 
                individual with an emergency medical condition (as 
                defined in subsection (b)(2)(A)); and
                    ``(B) are furnished by a provider that is in 
                compliance with the requirement of section 1128A(t)(3) 
                of the Social Security Act with respect to such 
                services.
            ``(3) Definitions.--In this subsection and subsection (f):
                    ``(A) Health plan.--The term `health plan' means a 
                group health plan and health insurance coverage offered 
                by a heath insurance issuer in the group or individual 
                market.
                    ``(B) Provider.--The term `provider' means a 
                provider of services or a supplier (as such terms are 
                defined in section 1861 of the Social Security Act).
                    ``(C) Nonparticipating provider.--The term 
                `nonparticipating provider' means, with respect to air 
                ambulance services and a group health plan or health 
                insurance coverage offered by a health insurance 
                issuer, a provider or supplier of such services that is 
                licensed by the State involved to furnish such services 
                and that does not have a contractual relationship with 
                the plan or coverage for furnishing such services.
                    ``(D) Participating provider.--The term 
                `participating provider' means, with respect to air 
                ambulance services and a group health plan or health 
                insurance coverage offered by a health insurance 
                issuer, a provider or supplier of such services that is 
                licensed by the State involved to furnish such services 
                and that has a contractual relationship with the plan 
                or coverage for services.
                    ``(E) Recognized amount.--The term `recognized 
                amount' means, with respect to air ambulance services--
                            ``(i) in the case of such services 
                        furnished in a State that has in effect a State 
                        law that provides for a method for determining 
                        the amount of payment that is required to be 
                        covered by a health plan or health insurance 
                        issuer offering group or individual health 
                        insurance coverage regulated by such State in 
                        the case of a participant, beneficiary, or 
                        enrollee covered under such plan or coverage 
                        and receiving such services from a 
                        nonparticipating provider, not more than the 
                        amount determined in accordance with such law 
                        plus the cost-sharing amount imposed for such 
                        services (as determined in accordance with 
                        paragraph (1)); or
                            ``(ii) in the case of such services 
                        furnished in a State that does not have in 
                        effect such a law, an amount determined in 
                        accordance with the independent dispute 
                        resolution process established under subsection 
                        (f).
    ``(f) Independent Dispute Resolution Process.--
            ``(1) Establishment.--
                    ``(A) In general.--Not later than 1 year after the 
                date of the enactment of this subsection, the 
                Secretary, in consultation with the Secretary of Labor, 
                shall establish by regulation an independent dispute 
                resolution process (referred to in this subsection as 
                the `IDR process') under which entities certified under 
                paragraph (2) (in this subsection referred to as 
                `certified IDR entities') resolve specified claims of 
                nonparticipating providers or health plans, taking into 
                account the factors described in subparagraph (C). Such 
                process shall prohibit such an entity from 
                participating in the resolution of such a claim if such 
                entity has a conflict of interest with respect to such 
                provider, facility, or the health plan involved.
                    ``(B) Specified claim.--For purposes of 
                subparagraph (A), the term `specified claim' means a 
                claim by a nonparticipating provider or health plan 
                that, with respect to air ambulance services furnished 
                by such provider for which a health plan is required to 
                make payment pursuant to subsection (e)(1), is made 
                under the IDR process not later than 30 days after the 
                services are furnished.
                    ``(C) Factors.--The factors described in this 
                subparagraph include--
                            ``(i) commercially reasonable rates for 
                        comparable services furnished in the same 
                        geographic area (which shall take into 
                        consideration in-network rates for that 
                        geographic area and not charges); and
                            ``(ii) other factors that may be submitted 
                        at the discretion of either party, which may 
                        include--
                                    ``(I) the level of training, 
                                education, experience, and quality and 
                                outcomes measurements of the provider;
                                    ``(II) the circumstances and 
                                complexity of the particular dispute, 
                                including the time and place of the 
                                service;
                                    ``(III) the market share held by 
                                the provider or that of the plan;
                                    ``(IV) demonstration of good faith 
                                efforts (or lack of good faith efforts) 
                                made by the provider or the plan to 
                                contract for negotiated rates, if 
                                applicable; and
                                    ``(V) other relevant economic 
                                aspects of provider reimbursement for 
                                the same specialty within the same 
                                geographic area.
            ``(2) Certification of entities.--
                    ``(A) Process of certification.--As part of the 
                regulation described in paragraph (1), the Secretary, 
                in consultation with the Secretary of Labor, shall 
                establish a certification process under which eligible 
                entities may be certified to carry out the IDR process.
                    ``(B) Eligibility.--For purposes of subparagraph 
                (A), an eligible entity is an entity that is a 
                nongovernmental entity (such as the American 
                Arbitration Association).
            ``(3) Selection of certified idr entity for a specified 
        claim.--With respect to the resolution of a specified claim 
        under the IDR process, the health plan and the nonparticipating 
        provider involved shall agree on a certified IDR entity to 
        resolve such claim. In the case that such plan and such 
        provider cannot so agree, such an entity shall be selected by 
        the Secretary at random.
            ``(4) Payment determination.--
                    ``(A) Timing.--A certified IDR entity that receives 
                a request from a nonparticipating provider or health 
                plan under this subsection shall, not later than 30 
                days after receiving such request, determine the amount 
                the health plan is required to pay such provider or 
                facility for services described in paragraph (1), in 
                accordance with subparagraph (C), in the case that a 
                settlement described in subparagraph (B) is not 
                reached.
                    ``(B) Settlement.--
                            ``(i) In general.--If such entity 
                        determines that a settlement between the health 
                        plan and the provider is likely, the entity may 
                        direct the parties to attempt, for a period not 
                        to exceed 10 days, a good faith negotiation for 
                        a settlement.
                            ``(ii) Timing.--The period for a settlement 
                        described in clause (i) shall accrue towards 
                        the 30-day period required under subparagraph 
                        (A).
                    ``(C) Determination of amount.--
                            ``(i) Decisions.--The health plan and the 
                        nonparticipating provider shall each submit to 
                        the certified IDR entity a final offer of 
                        payment with respect to services which are the 
                        subject of the specified claim. Such entity 
                        shall select the offer that such entity 
                        determines is the most reasonable based on the 
                        factors described in paragraph (1)(C).
                            ``(ii) Effect of decision.--A decision of a 
                        certified IDR entity under clause (ii)--
                                    ``(I) shall be binding; and
                                    ``(II) shall not be subject to 
                                judicial review, except in a case 
                                described in any of paragraphs (1) 
                                through (4) of section 10(a) of title 
                                9, United States Code, as determined by 
                                the Secretary in consultation with the 
                                Secretary of Labor.
                            ``(iii) Costs of independent dispute 
                        resolution process.--The party whose 
                        calculation is not chosen under subparagraph 
                        (B)(ii) shall be responsible for paying all 
                        fees charged by the certified IDR entity. If 
                        the parties reach a settlement prior to 
                        completion of the IDR process, the costs of 
                        such process shall be divided equally between 
                        the parties, unless the parties otherwise 
                        agree.
                            ``(iv) Payment.--Not later than 30 days 
                        after a decision described in clause (i) is 
                        made, the health plan shall pay to the provider 
                        or supplier of the services with respect to 
                        which the specified claim is made the amount 
                        determined under this subsection.
                            ``(v) Public availability.--The certified 
                        IDR entity shall make each final offer selected 
                        under clause (i) available to the public. Any 
                        information submitted to the entity by the 
                        health plan, provider, or facility, other than 
                        such final offer, may not be disclosed by the 
                        entity.''.
            (2) Effective date.--The amendments made by this subsection 
        shall apply with respect to plan years beginning on or after 
        January 1, 2021.
    (b) Preventing Certain Cases of Balance Billing.--Section 1128A of 
the Social Security Act (42 U.S.C. 1320a-7a) is amended by adding at 
the end the following new subsections:
    ``(t)(1) Subject to paragraph (2), in the case of an individual 
with benefits under a health plan or health insurance coverage offered 
in the group or individual market who is furnished on or after January 
1, 2021, air ambulance services by a nonparticipating provider (as 
defined in section 2719A(e)(3) of the Public Health Service Act), if 
such provider holds the individual liable for a payment amount for such 
services so furnished that is more than the cost-sharing amount for 
such services (as determined in accordance with section 2719A(e)(1) of 
the Public Health Service Act), such provider shall be subject, in 
addition to any other penalties that may be prescribed by law, to a 
civil money penalty of not more than an amount determined appropriate 
by the Secretary for each specified claim.
    ``(2) Paragraph (1) shall not apply to a nonparticipating provider, 
with respect to air ambulance services furnished by the provider to a 
participant, beneficiary, or enrollee of a health plan or health 
insurance coverage offered by a health insurance issuer, if--
            ``(A) such services are not furnished with respect to an 
        individual with an emergency medical condition (as defined in 
        section 2719A(e)(3) of the Public Health Service Act); and
            ``(B) the provider is in compliance with the requirement of 
        paragraph (3).
    ``(3)(A) For purposes of paragraph (2) and section 2719A(e)(2) of 
the Public Health Service Act, a nonparticipating provider is in 
compliance with this paragraph, with respect to air ambulance services 
furnished by the provider to a participant, beneficiary, or enrollee of 
a health plan or health insurance coverage offered by a health 
insurance issuer, if the provider--
            ``(i)(I) provides to the participant, beneficiary, or 
        enrollee (or to a representative of the participant, 
        beneficiary, or enrollee), on the date on which the 
        participant, beneficiary, or enrollee schedules such services, 
        if applicable, and on the date on which the individual is 
        furnished such services--
                    ``(aa) an oral explanation of the written notice 
                described in item (bb) and such documentation of the 
                provision of such explanation, as the Secretary 
                determines appropriate; and
                    ``(bb) a written notice specified, not later than 
                July 1, 2020, by the Secretary through rulemaking 
                that--
                            ``(AA) contains the information required 
                        under subparagraph (B); and
                            ``(BB) is signed and dated by the 
                        participant, beneficiary, or enrollee; and
            ``(II) retains, for a period specified through rulemaking 
        by the Secretary, a copy of the documentation described in 
        subclause (I)(aa) and the written notice described in subclause 
        (I)(bb); and
            ``(ii) obtains from the participant, beneficiary, or 
        enrollee (or representative) the consent described in 
        subparagraph (C).
    ``(B) For purposes of subparagraph (A)(i), the information 
described in this subparagraph, with respect to a nonparticipating 
provider and a participant, beneficiary, or enrollee of a health plan 
or health insurance coverage offered by a health insurance issuer, is a 
notification of each of the following:
            ``(i) That the health care provider is a nonparticipating 
        provider with respect to the group health plan or health 
        insurance coverage.
            ``(ii) The estimated amount that such provider will charge 
        the participant, beneficiary, or enrollee for such services 
        involved.
    ``(C) For purposes of subparagraph (A)(ii), the consent described 
in this subparagraph, with respect to a participant, beneficiary, or 
enrollee of a group health plan or health insurance coverage offered by 
a health insurance issuer, who is to be furnished air ambulance 
services by a nonparticipating provider, is a document specified by the 
Secretary through rulemaking that--
            ``(i) is signed by the participant, beneficiary, or 
        enrollee (or by a representative of the participant, 
        beneficiary, or enrollee) not less than 24 hours prior to the 
        participant, beneficiary, or enrollee being furnished such 
        services by such provider;
            ``(ii) acknowledges that the participant, beneficiary, or 
        enrollee has been--
                    ``(I) provided with a written estimate and an oral 
                explanation of the charge that the participant, 
                beneficiary, or enrollee will be assessed for the 
                services anticipated to be furnished to the 
                participant, beneficiary, or enrollee by such 
                nonparticipating provider; and
                    ``(II) informed that the payment of such charge by 
                the participant, beneficiary, or enrollee will not 
                accrue toward meeting any limitation that the group 
                health plan or health insurance coverage places on 
                cost-sharing; and
            ``(iii) documents the consent of the participant, 
        beneficiary, or enrollee to--
                    ``(I) be furnished with such services by such 
                nonparticipating provider; and
                    ``(II) in the case that the individual is so 
                furnished such services, be charged an amount that may 
                be greater than the amount that would otherwise be 
                changed the individual if furnished by a participating 
                provider (as defined in section 2719A(e)(3) of the 
                Public Health Service Act) with respect to such 
                services and plan or coverage.
    ``(4) The provisions of subsections (c), (d), (e), (g), (h), (k), 
and (l) shall apply to a civil money penalty or assessment under 
paragraph (1) in the same manner as such provisions apply to a penalty, 
assessment, or proceeding under subsection (a).
    ``(5) In this subsection, the terms `group health plan', `health 
insurance issuer', and `health insurance coverage' have the meanings 
given such terms, respectively, in section 2791 of the Public Health 
Service Act''.
                                 <all>
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