II 

116TH CONGRESS 

1ST SESSION S. 1531 

To amend the Public Health Service Act to provide protections for health 

insurance consumers from surprise billing. 

IN THE SENATE OF THE UNITED STATES 

MAY 16, 2019 

Mr. CASSIDY (for himself, Mr. BENNET, Mr. YOUNG, Ms. HASSAN, Ms. MURKOWSKI, Mr. CARPER, Mr. SULLIVAN, Mr. BROWN, Mr. CRAMER, Mr. 

CARDIN, Mr. KENNEDY, and Mr. CASEY) introduced the following bill; 

which was read twice and referred to the Committee on Health, Education, Labor, and Pensions 

A BILL 

To amend the Public Health Service Act to provide protections for health insurance consumers from surprise billing. 

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 ‘‘Stopping The Out5 rageous Practice of Surprise Medical Bills Act of 2019’’ 

6 or the ‘‘STOP Surprise Medical Bills Act of 2019’’. 

7 SEC. 2. FINDINGS. 

8 Congress makes the following findings: 


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1 (1) Consumers frequently struggle to determine 

2 when and how much they will pay for a medical 

3 service or procedure. A majority of consumers say 

4 health care providers rarely, if ever, discuss costs of 

5 recommended treatments and whether these treat6 ments are covered by health insurance. Almost 70 

7 percent of patients who receive bills from out-of-net8 work providers did not realize the provider was out9 of-network at the time of treatment. Patients using 

10 in-network facilities still receive claims from out-of11 network providers at high rates, over 15 percent of 

12 inpatient admissions and 5 percent of outpatient 

13 service days. Even when patients try to schedule an 

14 in-network procedure at an in-network hospital and 

15 try to ensure that all providers who administer 

16 treatment will be in-network, they may be sent a 

17 balance bill by an out-of-network provider after re18 ceiving care. If providers accepted the same health 

19 plans as the facilities at which they practice and ad20 minister care, out-of-network surprise medical bills 

21 would not be a complication for consumers sched22 uling elective procedures. 

23 (2) Surprise medical bills affect a sizeable por24 tion of the insured population. Approximately 30 

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1 surance have received a surprise medical bill within 

2 the past year. Almost 20 percent of inpatient admis3 sions by enrollees in large employer plans include at 

4 least 1 claim from an out-of-network provider, while 

5 8 percent of outpatient service days include an out6 of-network claim. 

7 (3) Surprise medical bills are an issue of par8 ticular concern to consumers. A majority of Ameri9 cans feel that softening the impact of surprise med10 ical bills should be a priority for the current Con11 gress. Eighty-six percent of Americans think it is 

12 important to protect individuals from surprise med13 ical bills. 

14 (4) Surprise medical bills for emergency care 

15 are frequently unavoidable due to the emergent and 

16 serious nature of the patient’s condition at the time 

17 of treatment. One in 5 cases of inpatient hospital 

18 admissions that originate within the emergency de19 partment result in a surprise medical bill. For inpa20 tient admissions, those that include an emergency 

21 room claim are much more likely to include a claim 

22 from an out-of-network provider than admissions 

23 without an emergency room claim. This is true 

24 whether or not enrollees use in-network facilities. 

25 Most cases of surprise medical billing occur when 


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1 privately insured individuals involuntarily see out-of2 network providers during medical emergencies. 

3 (5) The financial implications of surprise med4 ical bills can be devastating for American consumers 

5 and can prevent them from seeking timely follow-up 

6 care or from accessing necessary services. Approxi7 mately 20 percent of insured Americans struggle to 

8 pay their medical bills. Almost a third of consumers 

9 who report they are struggling to pay a medical bill 

10 also report this bill was due to charges from an out11 of-network provider that were not covered or were 

12 only partially covered by their insurer. Consumers 

13 with outstanding medical bills report delaying or 

14 skipping needed health care at rates 2 to 3 times 

15 higher than consumers without outstanding bills. 

16 Over 60 percent of consumers with outstanding 

17 medical bills report difficulties paying other bills (in18 cluding necessities such as food, heat, or housing 

19 costs) as a result of their medical bills. 


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1 SEC. 3. PROHIBITION ON SURPRISE BALANCE BILLING AND 

2 INDEPENDENT DISPUTE RESOLUTION WITH 

3 RESPECT TO OUT-OF-NETWORK HEALTH 

4 CARE SERVICES. 

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

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

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

8 ‘‘SEC. 2729A. GENERAL PROHIBITION ON SURPRISE BAL9 ANCE BILLING. 

10 ‘‘(a) SURPRISE MEDICAL BILL.—In this title, the 

11 term ‘surprise medical bill’ means a balance bill, as de12 scribed in subsection (b), that an enrollee receives for serv13 ices provided to the enrollee where such services were— 

14 ‘‘(1) emergency services provided by an out-of15 network health care professional or at an out-of-net16 work facility; 

17 ‘‘(2) health care services that were provided— 

18 ‘‘(A) at an in-network facility (including 

19 the use of equipment, devices, telemedicine serv20 ices, or other treatments or services); and 

21 ‘‘(B) by an out-of-network health care pro22 fessional; or 

23 ‘‘(3) additional health care services required in 

24 the case of an enrollee who initially enters a hospital 

25 through the emergency room for emergency services, 

26 and then receives nonemergency services from an 


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1 out-of-network health care professional or at an out2 of-network hospital or facility after the enrollee has 

3 been stabilized (as defined in section 

4 2719A(b)(2)(C)), as determined by the treating phy5 sician. 

6 Paragraph (3) shall not apply in the case of an enrollee 

7 who is stabilized and able to travel in nonmedical trans8 port, and the enrollee (or designee of the enrollee where 

9 the enrollee is not able to comprehend the information to 

10 be provided or make related decisions) has been provided 

11 with clear, written notification that the professional or fa12 cility is an out-of-network health care professional or facil13 ity, has been given a cost estimate for services provided 

14 by the out-of-network professional or facility, and has as15 sumed, in writing, full responsibility for out-of-pocket 

16 costs associated with such out-of-network care. 

17 ‘‘(b) BALANCE BILL.—In subsection (a), the term 

18 ‘balance bill’ refers to a claim for payment for services 

19 provided to an enrollee that is in an amount equal to the 

20 difference between the actual amount charged with respect 

21 to services or care described in subsection (a) and the ex22 pected in-network cost-sharing required by the enrollee 

23 under the plan or coverage involved. 

24 ‘‘(c) PROHIBITION ON BALANCE BILLING.— 

25 ‘‘(1) PROHIBITION.— 


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1 ‘‘(A) IN GENERAL.—A group health plan, 

2 a health insurance issuer in connection with 

3 group or individual health insurance coverage, 

4 or a health care provider shall not engage in 

5 balance billing practices prohibited under this 

6 section. 

7 ‘‘(B) APPLICATION OF PROVISIONS.—Sub8 paragraph (A) shall apply— 

9 ‘‘(i) to all services provided at hos10 pitals, emergency rooms, State-accredited 

11 free-standing emergency departments, hos12 pital outpatient departments, and ambula13 tory surgery centers; and 

14 ‘‘(ii) with respect to subsection (a)(2), 

15 to the health care provider’s offices and re16 lated services (including laboratory and im17 aging services ordered by an in-network 

18 provider and provided by an out-of-network 

19 provider or laboratory). 

20 ‘‘(2) ENROLLEE LIABILITY.—With respect to 

21 the services and care described in subsection (a), an 

22 enrollee shall only be liable for the in-network cost23 sharing amount provided for in their plan or cov24 erage. For purposes of this section, such payments 

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1 ductible under the plan or coverage as well as to2 ward the enrollee’s out-of-pocket maximum limita3 tion. 

4 ‘‘(3) PENALTY.—Violations of this section shall 

5 subject the violator to a civil monetary penalty as 

6 provided for in this title. Such provisions shall not 

7 apply to a health care provider, group health plan, 

8 or health insurance issuer that unknowingly balance 

9 bills an enrollee and reimburses such enrollee within 

10 30 calendar days of such billing. 

11 ‘‘SEC. 2729B. OUT-OF-NETWORK BILLING. 

12 ‘‘(a) PROHIBITION.— 

13 ‘‘(1) IN GENERAL.—An enrollee may not be 

14 billed in excess of the in-network cost-sharing 

15 amount for services or care provided under section 

16 2729A (a surprise medical bill situation). 

17 ‘‘(2) AUTOMATIC PAYMENT.— 

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

19 or health insurance issuer in connection with 

20 group or individual health insurance coverage, 

21 shall pay the median in-network rate under the 

22 plan or coverage, less the applicable enrollee in23 network cost-sharing, directly to the health care 

24 provider as provided for in this section. 


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1 ‘‘(B) REQUEST FOR ALTERNATIVE RATE.— 

2 Upon payment under subparagraph (A), the 

3 plan or issuer shall provide to the health care 

4 provider information about how the provider 

5 may initiate independent dispute resolution 

6 under such subsection with respect to such pay7 ment. The plan, issuer, or provider may nego8 tiate an alternative amount or initiate inde9 pendent dispute resolution under subsection (b) 

10 during the 30-day period beginning on the date 

11 on which the automatic payment is made under 

12 this subsection. 

13 ‘‘(b) ESTABLISHMENT OF IDR PROCESS; CERTIFI14 CATION OF ENTITIES.— 

15 ‘‘(1) ESTABLISHMENT.—Not later than 1 year 

16 after the date of enactment of this section, the Sec17 retary, in consultation with the Secretary of Labor, 

18 shall establish a process for resolving payment dis19 putes between group health plans, or health insur20 ance issuers offering health insurance coverage in 

21 the group market, and out-of-network health care 

22 providers in surprise medical bill situations in ac23 cordance with this section (referred to in this section 

24 as the ‘IDR process’). 


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1 ‘‘(2) CERTIFICATION OF ENTITIES.—An entity 

2 wishing to participate in the IDR process under this 

3 subsection shall request certification from the Sec4 retary. The Secretary, in consultation with the Sec5 retary of Labor, shall determine eligibility of appli6 cant entities, taking into consideration whether the 

7 entity is unbiased and unaffiliated with health plans 

8 and providers and free of conflicts of interest, in ac9 cordance with the Secretary’s rulemaking on deter10 mining criteria for conflicts of interest. 

11 ‘‘(3) IDR ENTITY.—Under the process estab12 lished under paragraph (1), the parties in the inde13 pendent dispute resolution process shall jointly agree 

14 upon an independent dispute resolution entity. In 

15 the event that parties cannot agree, one will be se16 lected at random jointly by the Department of 

17 Health and Human Services and the Department of 

18 Labor. 

19 ‘‘(c) APPLICABLE CLAIMS.— 

20 ‘‘(1) IN GENERAL.—The IDR process shall be 

21 with respect to one or more Current Procedural Ter22 minology (‘CPT’) codes. 

23 ‘‘(2) BATCHING OF CLAIMS.—Health care facili24 ties and providers and group health plans or health 

25 insurance issuers may batch claims if such claims— 


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1 ‘‘(A) involve identical plan or issuer and 

2 provider or facility parties; 

3 ‘‘(B) involve claims with the same or re4 lated current procedural terminology codes rel5 evant to a particular procedure; and 

6 ‘‘(C) involve claims that occur within 30 

7 days of each other. 

8 ‘‘(d) INDEPENDENT DISPUTE RESOLUTION PROC9 ESS.— 

10 ‘‘(1) TIMING.—An independent dispute resolu11 tion entity that receives a request under this section 

12 shall, not later than 30 days after receiving such re13 quest, determine the amount the group health plan, 

14 or health insurance issuer offering health insurance 

15 coverage in the group market, is required to pay the 

16 out-of-network health care provider. Such amount 

17 shall be— 

18 ‘‘(A) the amount determined by the parties 

19 through a settlement under paragraph (2); or 

20 ‘‘(B) the amount determined reasonable by 

21 the entity in accordance with paragraph (3). 

22 ‘‘(2) SETTLEMENT.— 

23 ‘‘(A) IN GENERAL.—If the independent 

24 dispute resolution entity determines, based on 

25 the amounts indicated in the request under this 


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1 section, that a settlement between the group 

2 health plan, or health insurance issuer offering 

3 health insurance coverage in the group market, 

4 and the out-of-network health care provider is 

5 likely, the independent dispute resolution entity 

6 may direct the parties to attempt, for a period 

7 not to exceed 10 days, a good faith negotiation 

8 for a settlement. 

9 ‘‘(B) TIMING.—The period for a settlement 

10 described in subparagraph (A) shall accrue to11 wards the 30-day period required under para12 graph (1). 

13 ‘‘(3) DETERMINATION OF AMOUNT.— 

14 ‘‘(A) FINAL OFFERS.—In the absence of a 

15 settlement under paragraph (2), the group 

16 health plan, or health insurance issuer offering 

17 health insurance coverage in the group market, 

18 and the out-of-network health care provider 

19 shall each submit to the independent dispute 

20 resolution entity their final offer. Such entity 

21 shall determine which of the 2 amounts is more 

22 reasonable based on the factors described in 

23 subparagraph (D). 

24 ‘‘(B) FINAL DECISIONS.—The amount that 

25 is determined to be the more reasonable amount 


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1 under subparagraph (A) shall be the final deci2 sion of the independent dispute resolution entity 

3 as to the amount the group health plan, or 

4 health insurance issuer offering health insur5 ance coverage in the group market, is required 

6 to pay the out-of-network health care provider. 

7 ‘‘(C) SERVICE UNITS.—A final determina8 tion under subparagraph (B) may include the 

9 resolution of disputes for multiple items or serv10 ices, if such determination is in regard to items 

11 or services that are eligible for independent dis12 pute resolution under subsection (c)(2). 

13 ‘‘(D) FACTORS.—In determining which 

14 final offer to select as the more reasonable 

15 amount under subparagraph (A), the inde16 pendent dispute resolution entity shall consider 

17 relevant factors including— 

18 ‘‘(i) commercially reasonable rates for 

19 comparable services or items in the same 

20 geographic area (which shall take into con21 sideration in-network rates for that geo22 graphic area and not charges); and 

23 ‘‘(ii) other factors that may be sub24 mitted at the discretion of either party, 

25 which may include— 


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1 ‘‘(I) the level of training, edu2 cation, experience, and quality and 

3 outcomes measurements of the out-of4 network health care provider; 

5 ‘‘(II) the circumstances and com6 plexity of the particular dispute, in7 cluding the time and place of the serv8 ice; 

9 ‘‘(III) the market share held by 

10 the out-of-network health care pro11 vider or that of the plan or issuer; 

12 ‘‘(IV) demonstration of good 

13 faith efforts (or lack of good faith ef14 forts) made by the out-of-network 

15 provider or the plan to contract and 

16 prior negotiated rates, if applicable; 

17 and 

18 ‘‘(V) other relevant economic as19 pects of provider reimbursement for 

20 the same specialty within the same ge21 ographic area. 

22 ‘‘(E) EFFECT OF DETERMINATION.—A 

23 final determination of an independent dispute 

24 resolution entity under subparagraph (B)— 

25 ‘‘(i) shall be binding; and 


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1 ‘‘(ii) shall not be subject to judicial re2 view, except in cases comparable to those 

3 described in section 10(a) of title 9, United 

4 States Code, as determined by the Sec5 retary in consultation with the Secretary of 

6 Labor, and cases in which information sub7 mitted by one party was determined to be 

8 fraudulent. 

9 ‘‘(4) PRIVACY LAWS.—An independent dispute 

10 resolution entity shall, in conducting an independent 

11 dispute resolution process under this subsection, 

12 comply with all applicable Federal and State privacy 

13 laws. 

14 ‘‘(5) PUBLIC AVAILABILITY.—The reasonable 

15 amount determined by an independent dispute reso16 lution entity under this subsection with respect to 

17 any claim shall not be confidential, except that infor18 mation submitted to the independent dispute entity 

19 shall be kept confidential. Independent dispute enti20 ties may consider past decisions awarded by inde21 pendent dispute entities during the independent dis22 pute resolution process. 

23 ‘‘(6) COSTS OF INDEPENDENT DISPUTE RESO24 LUTION PROCESS.—The nonprevailing party shall be 

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1 pendent dispute resolution entity. If the parties 

2 reach a settlement prior to completion of the inde3 pendent dispute resolution process, the costs of the 

4 independent dispute resolution process shall be di5 vided equally between the parties. 

6 ‘‘(7) PAYMENT.—Group health plans and 

7 health insurance issuers with respect to group health 

8 coverage shall pay directly to the health care pro9 vider amounts determined by the independent dis10 pute resolution entity within 30 days of the date on 

11 which the entity makes a determination with respect 

12 to such amount. A plan or issuer that fails to com13 ply with this paragraph shall be subject to the pen14 alties described in section 2729A(c)(3).’’. 

15 (b) EMERGENCY SERVICES.—Section 

16 2719A(b)(1)(C)(ii)(II) of the Public Health Service Act 

17 (42 U.S.C. 300gg–19a(b)(1)(C)(ii)(II)) is amended by in18 serting ‘‘, deductible amount,’’ after ‘‘copayment amount’’. 

19 SEC. 4. NOTIFICATION OF NEW INSURANCE PRODUCTS TO 

20 IN-NETWORK PROVIDERS. 

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

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

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

24 following: 


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1 ‘‘SEC. 2729C. NOTIFICATION OF NEW INSURANCE PROD2 UCTS TO IN-NETWORK PROVIDERS. 

3 ‘‘If a health care provider has a contract to provide 

4 in-network services to enrollees in a group health plan or 

5 health insurance coverage offered by a health insurance 

6 issuer, the plan or issuer shall notify the in-network pro7 vider within 7 days of offering any new insurance product 

8 for which the in-network provider would be eligible to en9 roll as an in-network provider.’’. 

10 SEC. 5. TRANSPARENCY REGARDING IN-NETWORK AND 

11 OUT-OF-NETWORK DEDUCTIBLES. 

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 section 4, is further amended by adding at the end the 

15 following: 

16 ‘‘SEC. 2729D. 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 SEC. 6. ENSURING ENROLLEE ACCESS TO COST-SHARING 

5 INFORMATION. 

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

7 XXVII of the Public Health Service Act (42 U.S.C. 

8 300gg–11 et seq.), as amended by section 5, is further 

9 amended by adding at the end the following: 

10 ‘‘SEC. 2729E. PROVISION OF COST-SHARING INFORMATION. 

11 ‘‘(a) COST-SHARING DISCLOSURE FOR MEDICAL

12 SERVICES.— 

13 ‘‘(1) PROVIDER DISCLOSURES.—A group health 

14 plan or a health insurance issuer offering group or 

15 individual health insurance coverage shall not con16 tract with a health care provider with respect to the 

17 plan or coverage unless the provider agrees to pro18 vide an enrollee in the plan or coverage, at the time 

19 of scheduling an elective health care service, or not 

20 later than 48 hours of the enrollee requesting such 

21 information, the expected enrollee cost-sharing for 

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1 cific service, such as expected cost-sharing of labora2 tory services). 

3 ‘‘(2) INSURER DISCLOSURES.—A group health 

4 plan or a health insurance issuer offering group or 

5 individual health insurance coverage shall provide an 

6 enrollee in the plan or coverage with a good faith es7 timate of the enrollee’s cost-sharing (including 

8 deductibles, copayments, and coinsurance) for which 

9 the enrollee would be responsible for paying with re10 spect to a specific elective health care service (in11 cluding any service that is reasonably expected to be 

12 provided in conjunction with such specific service 

13 such as expected cost-sharing of laboratory services), 

14 not later than 48 hours after receiving a request for 

15 such information by an enrollee. 

16 ‘‘(b) ELECTRONICALLY AVAILABLE PRICE INFORMA17 TION.—A group health plan or a health insurance issuer 

18 offering group or individual health insurance coverage 

19 shall provide to enrollees the out-of-pocket costs and bene20 fits information at all sites of care and for all providers 

21 included in the plan network. Such information shall be 

22 made available to enrollees through an internet website or 

23 an application. Information about the availability of such 

24 price information through such means shall be provided 


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1 to each enrollee upon enrollment, or renewal, in the health 

2 plan or health insurance coverage.’’. 

3 (b) EFFECTIVE DATES.— 

4 (1) COST-SHARING DISCLOSURES.—Subsection 

5 (a)(1) of section 2729E of the Public Health Service 

6 Act, as added by subsection (a), shall apply with re7 spect to plan years beginning on or after January 1, 

8 2020. 

9 (2) AVAILABILITY OF INFORMATION.—Sub10 section (b) of section 2729E of the Public Health 

11 Service Act, as added by subsection (a), shall apply 

12 with respect to plan years beginning on or after Jan13 uary 1, 2021. 

14 SEC. 7. MEDICAL LOSS RATIO. 

15 Section 2718(a)(1) of the Public Health Service Act 

16 (42 U.S.C. 300gg–18(a)(1)) is amended by inserting be17 fore the period the following: ‘‘(including, in the case of 

18 group health plans, the amount of independent dispute 

19 process expenses incurred by the plan)’’. 

20 SEC. 8. TRANSPARENCY REQUIREMENTS ON HOSPITALS. 

21 Section 2718 of the Public Health Service Act (42 

22 U.S.C. 300gg–18) is amended by adding at the end the 

23 following: 

24 ‘‘(f) TRANSPARENCY REQUIREMENTS ON HOS25 PITALS.— 


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1 ‘‘(1) REQUIREMENTS FOR HOSPITALS AND PHY2 SICIAN GROUPS.—Each hospital operating within the 

3 United States shall for each year disclose on its 

4 internet website and in printed materials, any finan5 cial relationship or profit-sharing agreement the hos6 pital maintains with a physician group. 

7 ‘‘(2) REQUIRED INFORMATION.— 

8 ‘‘(A) IN GENERAL.—Each hospital oper9 ating within the United States shall include an10 cillary services provided by individuals such as 

11 phlebotomists, laboratory technicians, and echo12 cardiogram technicians within each hospital bill 

13 that is provided to patients. 

14 ‘‘(B) STUDY.—Not later than 1 year after 

15 the date of enactment of this Act, the Secretary 

16 shall conduct a study on the feasibility of hos17 pitals and hospital-based provider groups pro18 viding to patients a single, unified bill for all 

19 services provided within an episode of care.’’. 

20 SEC. 9. TRANSPARENCY REQUIREMENTS ON INSURANCE. 

21 (a) GROUP HEALTH PLAN REPORTING.—Part C of 

22 title XXVII of the Public Health Service Act (42 U.S.C. 

23 300gg–91 et seq.) is amended by adding at the end the 

24 following: 


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1 ‘‘SEC. 2795. TRANSPARENCY REQUIREMENTS FOR GROUP 

2 HEALTH PLANS. 

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

4 health insurance issuer offering group or individual health 

5 insurance coverage shall annually report to the Secretary 

6 of Health and Human Services and the Secretary of 

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

8 the applicable plan year— 

9 ‘‘(1) the total claims that were submitted by in10 network health care providers with respect to enroll11 ees under the plan or coverage, and the number of 

12 such claims that were paid and the number of such 

13 claims that were denied; 

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

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

16 enrollees under the plan or coverage, and the num17 ber of such claims that were paid and the number 

18 of such claims that were denied; 

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

20 the out-of-pocket costs, including applicable cost21 sharing amounts, to the enrollee for the services, 

22 and the difference between the billed charge and the 

23 amount the plan pays, adjusted by any balance bill24 ing limitation through State and Federal regulatory 

25 and statutory requirements that might apply; 


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1 ‘‘(4) the number of out-of-network claims re2 ported under paragraph (2) that are for emergency 

3 services; and 

4 ‘‘(5) the number of out-of-network claims re5 ported under paragraph (2) that relate to care at in6 network hospitals or facilities provided by out-of-net7 work providers. 

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

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

10 information required to be submitted under section 

11 2715A.’’. 

12 SEC. 10. APPLICABILITY TO STATES WITH SURPRISE BILL13 ING LAWS. 

14 (a) GENERAL APPLICATION.— 

15 (1) IN GENERAL.—Nothing in this Act, or the 

16 amendments made by this Act, shall be construed to 

17 prohibit a State from enacting patient protections 

18 that are greater than those provided for in such 

19 amendments. 

20 (2) APPLICATION TO ALL PLANS.—In the case 

21 of a group health plan, individual health plan, and 

22 non-Federal governmental health plan offered in a 

23 State that has not enacted a law to determine the 

24 payment resolution between enrollees and health 

25 care facilities or professionals relating to surprise 


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1 medical bills, the procedures applicable to self-in2 sured group health plans for the resolution of sur3 prise medical bills under this Act (including the 

4 amendments made by this Act), shall apply to deter5 mine compensation with respect to a surprise med6 ical bill, until such time as the State enacts a law 

7 providing for such a resolution methodology. 

8 (b) PROVISIONS APPLICABLE TO ERISA.—Section 

9 715 of the Employee Retirement Income Security Act of 

10 1974 (29 U.S.C. 1185d) is amended by adding at the end 

11 the following: 

12 ‘‘(c) PROHIBITIONS ON BALANCE BILLING.— 

13 ‘‘(1) FULLY INSURED PLANS.—In the case of a 

14 fully insured group health plan— 

15 ‘‘(A) a State may establish procedures for 

16 determining the appropriate compensation ap17 plicable to surprise medical bills between a par18 ticipant or beneficiary and a health care facility 

19 or professional so long as the methodology used 

20 relies on the definition of ‘surprise medical bill’ 

21 and the prohibitions contained in section 2729A 

22 of the Public Health Service Act; and 

23 ‘‘(B) a State may enact laws relating to 

24 rate-setting, independent dispute resolution, an 


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1 in-network guarantee, or an alternative method2 ology that complies with paragraph (1). 

3 ‘‘(2) SELF-INSURED PLANS.—In the case of a 

4 self-insured group health plan, the resolution meth5 odology provided for under section 2729A of the 

6 Public Health Service Act, shall be used to deter7 mine compensation with respect to a surprise med8 ical bill.’’. 

9 (c) FEHBP.—In the case of a health plan under 

10 chapter 89 of title 5, United States Code, the resolution 

11 methodology provided for under this Act (including the 

12 amendments made by this Act), shall be used to determine 

13 compensation with respect to a surprise medical bill. 

14 SEC. 11. BALANCE BILLING STUDY. 

15 (a) IN GENERAL.—Not later than 3 years after the 

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

17 Human Services, in consultation with the Secretary of 

18 Labor, shall conduct a study of the effects of this Act (in19 cluding the amendments made by this Act), and submit 

20 to Congress a report on the findings of such study, which 

21 shall include information and analysis on— 

22 (1) the financial impact on patient responsi23 bility for health care spending and overall health 

24 care spending; 


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1 (2) the incidence and prevalence of the delivery 

2 of out-of-network health care services; 

3 (3) the adequacy of provider networks offered 

4 by health plans and health insurance issuers (as 

5 such terms are defined in section 2791 of the Public 

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

7 (4) the impact of connecting reimbursement to 

8 different claims databases; 

9 (5) the number of bills that go to the inde10 pendent dispute resolution process; and 

11 (6) the administrative cost of the independent 

12 dispute resolution process and estimated impact on 

13 health insurance premiums and deductibles. 

14 (b) INFORMATION REQUIREMENTS.—The informa15 tion provided in the report under subsection (a) shall be— 

16 (1) disaggregated by State and according to the 

17 fully insured and the self-insured markets; and 

18 (2) with respect to paragraphs (1) through (3) 

19 of such subsection, made available to the public elec20 tronically in a searchable database. 

Æ 


pbinns on DSK79D2C42PROD with BILLS