I 
116TH CONGRESS 
1ST SESSION H. R. 4223 
To amend the Employee Retirement Income Security Act of 1974 to protect 
patients from surprise medical bills. 
IN THE HOUSE OF REPRESENTATIVES 
AUGUST 30, 2019 
Mr. SPANO introduced the following bill; which was referred to the Committee 
on Education and Labor 
A BILL 
To amend the Employee Retirement Income Security Act 
of 1974 to protect patients from surprise medical bills. 
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 ‘‘Protecting Patients 
from Surprise Medical Bills Act’’. 
SEC. 2. PROHIBITION ON SURPRISE MEDICAL BILLING. 
Subpart B of part 7 of title I of the Employee Retire-
ment Income Security Act of 1974 (29 U.S.C. 1185 et 
seq.) is amended by adding at the end the following: 
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‘‘SEC. 716. PROHIBITION ON SURPRISE MEDICAL BILLING. 
‘‘(a) DEFINITIONS.—In this section: 
‘‘(1) BALANCE BILL.—The term ‘balance bill’ 
means the collection or attempted collection from a 
participant or beneficiary of any amount in excess of 
the applicable copayments, coinsurance, or deduct-
ible for services covered under the participant or 
beneficiary’s group health plan. 
‘‘(2) EMERGENCY
MEDICAL
CONDITION.—The 
term ‘emergency medical condition’ means the condi-
tion described in section 2719A(b)(2)(A) of the Pub-
lic Health Service Act. 
‘‘(3) EMERGENCY SERVICES.—The term ‘emer-
gency services’ means the services described in sec-
tion 2719A(b)(2)(B) of the Public Health Service 
Act. 
‘‘(4) EMERGENCY
SERVICES
PROVIDER.—The 
term ‘emergency services provider’ means a facility 
or facility-based provider that bills a participant or 
beneficiary for emergency services. 
‘‘(5) FACILITY.—The term ‘facility’ means an 
entity providing health care services, as licensed or 
authorized by a State. 
‘‘(6) FACILITY-BASED
PROVIDER.—The term 
‘facility-based provider’ means a physician, health 
care professional, or entity that has entered into an 
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agreement with a facility to provide health care serv-
ices to patients of that facility. 
‘‘(b) EMERGENCY SERVICES.— 
‘‘(1) PROHIBITION ON BALANCE BILLING.—A 
self-insured group health plan shall be solely liable 
for making payments to an emergency services pro-
vider for emergency services covered under the plan 
that are provided to a participant or beneficiary, and 
such participant or beneficiary shall not be liable to 
the emergency services provider for any amount for 
such services other than the applicable copayment, 
coinsurance, or deductible amount required under 
the plan for covered emergency services. Emergency 
service providers shall not balance bill a participant 
or beneficiary under a self-insured group health plan 
for any covered emergency services provided to such 
participant or beneficiary. 
‘‘(2) COST
SHARING
LIMITATION
AND
PRIOR 
AUTHORIZATION.—If a self-insured group health 
plan provides coverage for any benefits with respect 
to emergency services, such coverage shall be in ac-
cordance with the provisions of section 2719A(b) of 
the Public Health Service Act and— 
‘‘(A) if such services are provided by an 
out-of-network provider, the cost-sharing re-
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quirements (including any deductible amount 
and the out-of-pocket limit) applicable to such 
services shall be the same as the cost-sharing 
requirement that would apply if such services 
were provided by an in-network provider; 
‘‘(B) prior authorization shall not be re-
quired for pre-hospital transport or treatment; 
and 
‘‘(C) payment by the plan shall be made 
directly to the emergency services provider. 
‘‘(c) COVERED NON-EMERGENCY SERVICES.—Facil-
ity-based providers shall not balance bill a patient for cov-
ered non-emergency services if the services are provided 
at an in-network facility and the participant or beneficiary 
did not have the ability or opportunity to select to receive 
such services from an in-network provider. 
‘‘(d) REIMBURSEMENTS
FOR
OUT-OF-NETWORK 
PAYMENTS.—A self-insured group health plan shall reim-
burse a health care provider for out-of-network emergency 
and non-emergency services described in subsections (b) 
and (c) based on one of the following payment methodolo-
gies: 
‘‘(1) The amount of the claim made by the pro-
vider for such services. 
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‘‘(2) The usual and customary amount charged 
by the provider for similar services in the community 
where the services were provided. 
‘‘(3) The amount mutually agreed to by the 
plan and the provider during the 60-day period after 
the date on which the claim is submitted. 
‘‘(e) VOLUNTARY BINDING ARBITRATION.— 
‘‘(1) IN
GENERAL.—If a self-insured group 
health plan and health care provider are unable to 
resolve a dispute with respect to billing for services 
described in subsection (b) or (c), such provider may 
voluntarily initiate binding arbitration with such 
plan under this subsection. The Secretary shall es-
tablish by rule methods of aggregation for claim dis-
putes submitted to voluntary binding arbitration 
under this subsection. 
‘‘(2) ARBITRATION ORGANIZATIONS.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
enter into contracts with outside organizations 
to conduct timely, voluntary binding arbitration 
proceedings under this subsection. To be eligi-
ble for such a contract, an organization shall 
have at least 5 years of experience serving as a 
neutral party in complex dispute resolution pro-
ceedings. 
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‘‘(A) in the case of a claim relating to fa-
cility health care services, be not less than 
$3,000; and 
‘‘(B) in the case of a claim relating to pro-
fessional services, be not less than $500. 
Such amounts shall be adjusted by the Secretary 
each year by the percentage increase in the con-
sumer price index. 
‘‘(4) PROCEDURES.—The following procedures 
shall apply during a voluntary arbitration proceeding 
under this subsection: 
‘‘(A) The plan or provider involved may 
make an offer to settle the disputed claim. The 
party to whom such an offer is directed shall 
respond to such offer within 15 days after re-
ceipt of the offer. 
‘‘(B) If the party receiving an offer to set-
tle under paragraph (A) does not accept such 
offer, and the arbitrator issues a final order 
with respect to the disputed claim that is more 
than 90 percent or less than 110 percent of the 
offer amount, the party receiving the offer is 
deemed a non-prevailing party for purpose of 
paragraph (5). 
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‘‘(C) A final order under this paragraph is 
subject to judicial review under this Act. 
‘‘(D) All parties to a dispute that is sub-
ject to arbitration under this subsection may 
agree to settle claim at any time, for any 
amount, regardless of whether an offer to settle 
was made or rejected. 
‘‘(5) REVIEW COSTS.— 
‘‘(A) IN GENERAL.—The entity that does 
not prevail under an arbitrator’s final order 
under voluntary binding arbitration under this 
subsection shall pay the review costs. 
‘‘(B) APPORTIONMENT OF COSTS.—In the 
case that both parties to voluntary binding arbi-
tration under this subsection prevail in part, 
the review costs shall be apportioned among the 
parties in proportion to the final judgment. The 
apportionment shall be based on the disputed 
claim amount. 
‘‘(C) FAILURE TO PAY.—If a party to vol-
untary binding arbitration under this subsection 
fails to pay any amount of the ordered review 
costs within 35 days after the arbitrator’s final 
order, the party shall be subject to a penalty of 
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$500 for each day that such amount is not 
paid. 
‘‘(f) NETWORK
TRANSPARENCY.—A self-insured 
group health plan shall— 
‘‘(1) not later than 1 year after the date of en-
actment of this section, publish on their internet 
website a list of network providers, and update such 
list on a monthly basis; and 
‘‘(2) not later than 1 year after the date of en-
actment of this section, and annually thereafter, pro-
vide an annual notification to participants and bene-
ficiaries concerning the potential for balance billing 
when using out-of-network providers.’’. 
Æ 
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