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 sur-
prise billing with respect to air ambulance services. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Air Ambulance Afford-
ability Act of 2019’’. 
SEC. 2. PROHIBITING SURPRISE BILLING WITH RESPECT 
TO AIR AMBULANCE SERVICES. 
(a) AIR AMBULANCE SERVICES.— 
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(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 nonpartici-
pating 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 coinsur-
ance 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 pro-
vider for such services were equal to the 
amount determined in accordance with sub-
section (f) for such services (or, in the case of 
such services furnished in a State described in 
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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 ac-
cordance 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 partici-
pant, beneficiary, or enrollee with respect to 
such services so furnished in the same manner 
as if such cost-sharing payments were with re-
spect 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 
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‘‘(B) are furnished by a provider that is in 
compliance with the requirement of section 
1128A(t)(3) of the Social Security Act with re-
spect 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 in-
surance 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 re-
spect to air ambulance services and a group 
health plan or health insurance coverage offered 
by a health insurance issuer, a provider or sup-
plier 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 serv-
ices. 
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‘‘(D) 
PARTICIPATING
PROVIDER.—The 
term ‘participating provider’ means, with re-
spect to air ambulance services and a group 
health plan or health insurance coverage offered 
by a health insurance issuer, a provider or sup-
plier 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 fur-
nished in a State that has in effect a State 
law that provides for a method for deter-
mining the amount of payment that is re-
quired to be covered by a health plan or 
health insurance issuer offering group or 
individual health insurance coverage regu-
lated by such State in the case of a partici-
pant, 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- 
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sharing amount imposed for such services 
(as determined in accordance with para-
graph (1)); or 
‘‘(ii) in the case of such services fur-
nished in a State that does not have in ef-
fect such a law, an amount determined in 
accordance with the independent dispute 
resolution process established under sub-
section (f). 
‘‘(f) INDEPENDENT DISPUTE RESOLUTION PROC-
ESS.— 
‘‘(1) ESTABLISHMENT.— 
‘‘(A) IN GENERAL.—Not later than 1 year 
after the date of the enactment of this sub-
section, the Secretary, in consultation with the 
Secretary of Labor, shall establish by regulation 
an independent dispute resolution process (re-
ferred to in this subsection as the ‘IDR proc-
ess’) under which entities certified under para-
graph (2) (in this subsection referred to as ‘cer-
tified IDR entities’) resolve specified claims of 
nonparticipating providers or health plans, tak-
ing into account the factors described in sub-
paragraph (C). Such process shall prohibit such 
an entity from participating in the resolution of 
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such a claim if such entity has a conflict of in-
terest 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 pursu-
ant 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 con-
sideration in-network rates for that geo-
graphic area and not charges); and 
‘‘(ii) other factors that may be sub-
mitted at the discretion of either party, 
which may include— 
‘‘(I) the level of training, edu-
cation, experience, and quality and 
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outcomes measurements of the pro-
vider; 
‘‘(II) the circumstances and com-
plexity of the particular dispute, in-
cluding the time and place of the serv-
ice; 
‘‘(III) the market share held by 
the provider or that of the plan; 
‘‘(IV) demonstration of good 
faith efforts (or lack of good faith ef-
forts) made by the provider or the 
plan to contract for negotiated rates, 
if applicable; and 
‘‘(V) other relevant economic as-
pects of provider reimbursement for 
the same specialty within the same ge-
ographic area. 
‘‘(2) CERTIFICATION OF ENTITIES.— 
‘‘(A) PROCESS
OF
CERTIFICATION.—As 
part of the regulation described in paragraph 
(1), the Secretary, in consultation with the Sec-
retary of Labor, shall establish a certification 
process under which eligible entities may be cer-
tified to carry out the IDR process. 
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‘‘(B) ELIGIBILITY.—For purposes of sub-
paragraph (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 reso-
lution of a specified claim under the IDR process, 
the health plan and the nonparticipating provider in-
volved shall agree on a certified IDR entity to re-
solve 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 pro-
vider or health plan under this subsection shall, 
not later than 30 days after receiving such re-
quest, determine the amount the health plan is 
required to pay such provider or facility for 
services described in paragraph (1), in accord-
ance with subparagraph (C), in the case that a 
settlement described in subparagraph (B) is not 
reached. 
‘‘(B) SETTLEMENT.— 
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‘‘(i) IN GENERAL.—If such entity de-
termines 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 set-
tlement 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 deci-
sion of a certified IDR entity under clause 
(ii)— 
‘‘(I) shall be binding; and 
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‘‘(II) shall not be subject to judi-
cial 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
DIS-
PUTE
RESOLUTION
PROCESS.—The party 
whose calculation is not chosen under sub-
paragraph (B)(ii) shall be responsible for 
paying all fees charged by the certified 
IDR entity. If the parties reach a settle-
ment prior to completion of the IDR proc-
ess, the costs of such process shall be di-
vided 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 re-
spect to which the specified claim is made 
the amount determined under this sub-
section. 
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‘‘(v) PUBLIC AVAILABILITY.—The cer-
tified 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 in-
surance coverage offered in the group or individual market 
who is furnished on or after January 1, 2021, air ambu-
lance 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 ad-
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dition 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 nonpartici-
pating 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 of-
fered by a health insurance issuer, if— 
‘‘(A) such services are not furnished with re-
spect 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 re-
quirement of paragraph (3). 
‘‘(3)(A) For purposes of paragraph (2) and section 
2719A(e)(2) of the Public Health Service Act, a non-
participating provider is in compliance with this para-
graph, 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 
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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 docu-
mentation 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 re-
quired under subparagraph (B); and 
‘‘(BB) is signed and dated by the par-
ticipant, beneficiary, or enrollee; and 
‘‘(II) retains, for a period specified through 
rulemaking by the Secretary, a copy of the docu-
mentation 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 infor-
mation described in this subparagraph, with respect to a 
nonparticipating provider and a participant, beneficiary, 
or enrollee of a health plan or health insurance coverage 
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offered by a health insurance issuer, is a notification of 
each of the following: 
‘‘(i) That the health care provider is a non-
participating 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 con-
sent described in this subparagraph, with respect to a par-
ticipant, 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 fur-
nished such services by such provider; 
‘‘(ii) acknowledges that the participant, bene-
ficiary, or enrollee has been— 
‘‘(I) provided with a written estimate and 
an oral explanation of the charge that the par-
ticipant, beneficiary, or enrollee will be assessed 
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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 en-
rollee will not accrue toward meeting any limi-
tation that the group health plan or health in-
surance 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 de-
fined in section 2719A(e)(3) of the Public 
Health Service Act) with respect to such serv-
ices 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 pro-
ceeding under subsection (a). 
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‘‘(5) In this subsection, the terms ‘group health plan’, 
‘health insurance issuer’, and ‘health insurance coverage’ 
have the meanings given such terms, respectively, in sec-
tion 2791 of the Public Health Service Act’’. 
Æ 
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