SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Protecting People From Surprise Medical Bills Act’’. 
(b) TABLE OF CONTENTS.—The table of contents for 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
Sec. 2. Preventing surprise medical bills. 
Sec. 3. Transparency regarding in-network and out-of-network deductibles. 
Sec. 4. Transparency for in-network patients. 
Sec. 5. Reporting requirements. 
Sec. 6. Billing statute of limitations. 
Sec. 7. Application. 
Sec. 8. Studies by Secretaries of Health and Human Services and of Labor. 
Sec. 9. Regulations. 
SEC. 2. PREVENTING SURPRISE MEDICAL BILLS. 
(a) EMERGENCY SERVICES PERFORMED BY NON-
PARTICIPATING PROVIDERS.—Section 2719A of the Pub-
lic Health Service Act (42 U.S.C. 300gg–19a) is amend-
ed— 
(1) in subsection (b)— 
(A) in paragraph (1)— 
(i) in the matter preceding subpara-
graph (A)— 
(I) by striking ‘‘offering group or 
individual health insurance issuer’’ 
and inserting ‘‘offering group or indi-
vidual health insurance coverage’’; 
and 
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(II) 
by 
striking 
‘‘paragraph 
(2)(B)’’ and inserting ‘‘paragraph 
(2)’’; 
(ii) in subparagraph (B), by inserting 
‘‘or a participating emergency facility, as 
applicable,’’ after ‘‘participating provider’’; 
and 
(iii) in subparagraph (C)— 
(I) in the matter preceding clause 
(i), by inserting ‘‘by a nonpartici-
pating provider or a nonparticipating 
emergency facility’’ after ‘‘enrollee’’; 
(II) by striking clause (i); 
(III) by striking ‘‘(ii)(I) such 
services’’ and inserting ‘‘(i) such serv-
ices’’; 
(IV) by striking ‘‘where the pro-
vider of services does not have a con-
tractual relationship with the plan for 
the providing of services’’; 
(V) by striking ‘‘emergency de-
partment services received from pro-
viders who do have such a contractual 
relationship with the plan; and’’ and 
inserting ‘‘emergency services received 
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from participating providers and par-
ticipating emergency facilities with re-
spect to such plan;’’; 
(VI) by striking ‘‘(II) if such serv-
ices’’ and all that follows through 
‘‘were provided in-network’’ and in-
serting the following: 
‘‘(ii) the cost-sharing requirement (ex-
pressed as a copayment amount, coinsur-
ance rate, or deductible) is not greater 
than the requirement that would apply if 
such services were provided by a partici-
pating provider or a participating emer-
gency facility;’’; and 
(VII) by adding at the end the 
following new clauses: 
‘‘(iii) the group health plan or health 
insurance issuer offering group or indi-
vidual health insurance coverage pays to 
such provider or facility, respectively, sub-
ject to subsection (f), the amount by which 
the commercially reasonable rate, as deter-
mined by the plan or issuer, for such serv-
ices exceeds the cost-sharing amount for 
such services (as determined in accordance 
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with clause (ii) and, if applicable, any 
amount to reconcile the difference between 
such rate so paid and the specified rate de-
termined under subsection (f)(1)) for such 
services; and 
‘‘(iv) there shall be counted toward 
any deductible or out-of-pocket maximums 
applied under the plan any cost-sharing 
payments made by the participant, bene-
ficiary, or enrollee with respect to such 
emergency services so furnished in the 
same manner as if such cost-sharing pay-
ments were with respect to emergency 
services furnished by a participating pro-
vider and a participating emergency facil-
ity.’’; and 
(B) in paragraph (2)— 
(i) in the matter preceding subpara-
graph (A), by inserting ‘‘and subsection 
(e)’’ after ‘‘this subsection’’; 
(ii) by redesignating subparagraph 
(C) as subparagraph (H); and 
(iii) by inserting after subparagraph 
(C) the following subparagraphs: 
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‘‘(D) NONPARTICIPATING EMERGENCY FA-
CILITY; 
PARTICIPATING
EMERGENCY
FACIL-
ITY.— 
‘‘(i) NONPARTICIPATING
EMERGENCY 
FACILITY.—The 
term 
‘nonparticipating 
emergency facility’ means, with respect to 
an item or service and a group health plan 
or health insurance coverage offered by a 
health insurance issuer, an emergency de-
partment of a hospital or an independent 
freestanding emergency department, that 
does not have a contractual relationship 
with the plan or coverage for furnishing 
such item or service. 
‘‘(ii) PARTICIPATING EMERGENCY FA-
CILITY.—The term ‘participating emer-
gency facility’ means, with respect to an 
item or service and a group health plan or 
health insurance coverage offered by a 
health insurance issuer, an emergency de-
partment of a hospital or an independent 
freestanding emergency department, that 
has a contractual relationship with the 
plan or coverage for furnishing such item 
or service. 
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amount that would apply under such plan had 
such items or services been furnished by a par-
ticipating provider; 
‘‘(B) shall pay to such provider furnishing 
such items and services to such participant, 
beneficiary, or enrollee, subject to subsection 
(f), the amount by which the commercially rea-
sonable rate, as determined by the plan or 
issuer, for such services exceeds the cost-shar-
ing amount imposed for such services (as deter-
mined in accordance with subparagraph (A)) 
and, if applicable, any amount to reconcile the 
difference between such rate so paid and the 
specified rate (determined under subsection 
(f)(1)) for such services; and 
‘‘(C) 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 items and services so furnished in the 
same manner as if such cost-sharing payments 
were with respect to items and services fur-
nished by a participating provider. 
‘‘(2) DEFINITIONS.—In this subsection and 
subsection (f): 
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‘‘(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) PARTICIPATING HEALTH CARE FACIL-
ITY.— 
‘‘(i) IN GENERAL.—The term ‘partici-
pating health care facility’ means, with re-
spect to an item or service and a group 
health plan or health insurance coverage 
offered by a health insurance issuer, a 
health care facility described in clause (ii) 
that has a contractual relationship with 
the plan or coverage for furnishing such 
item or service. 
‘‘(ii) HEALTH
CARE
FACILITY
DE-
SCRIBED.—A health care facility described 
in this clause is each of the following: 
‘‘(I) A hospital (as defined in 
1861(e) of the Social Security Act). 
‘‘(II) A critical access hospital 
(as defined in section 1861(mm) of 
such Act). 
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‘‘(III) An ambulatory surgical 
center 
(as 
defined 
in 
section 
1833(i)(1)(A) of such Act). 
‘‘(IV) A laboratory. 
‘‘(V) A radiology or imaging cen-
ter. 
‘‘(VI) Any other facility that pro-
vides services that are covered under 
a group health plan or health insur-
ance coverage. 
‘‘(VII) Any other facility speci-
fied by the Secretary.’’. 
(c) NEGOTIATION AND ARBITRATION PROCESS FOR 
DETERMINING PRICES.—Section 2719A of the Public 
Health Service Act (42 U.S.C. 300gg–19a), as amended 
by subsection (b), is further amended by adding at the 
end the following new subsection: 
‘‘(f) NEGOTIATION AND ARBITRATION PROCESS.— 
‘‘(1) SPECIFIED
AMOUNT.—For purposes of 
subsections (b) and (e) and this subsection, the spec-
ified amount determined under this subsection, with 
respect to a health plan and nonparticipating pro-
vider for an item or service, is— 
‘‘(A) in the case the plan and provider 
enter into negotiations pursuant to paragraph 
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(2) and such negotiations are successful, the 
amount determined for such item or service 
pursuant to such negotiations; or 
‘‘(B) in the case the plans and provider 
enter into such negotiations but such negotia-
tions are not successful, the reasonable amount 
determined for such item or service pursuant to 
the independent dispute resolution process 
under paragraph (3). 
‘‘(2) NEGOTIATIONS.—For purposes of sub-
sections (b)(1)(C)(iii) and (e)(1)(B), in the case of 
a payment of a commercially reasonable rate made 
by a health plan to a nonparticipating provider pur-
suant to such respective subsection for an item or 
service, the provider and plan may, not later than 30 
days after the date of such payment, negotiate an 
amount of payment (other than the commercially 
reasonable rate specified in such subsection) to be 
made for such item or service. 
‘‘(3) INDEPENDENT DISPUTE RESOLUTION.— 
‘‘(A) IN GENERAL.—If, by the end of such 
30-day period specified in paragraph (2), the 
plan and provider have not determined a nego-
tiated amount for the payment involved, the 
plan or provider may initiate an independent 
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dispute resolution process under this paragraph 
to determine the amount of payment. 
‘‘(B) ESTABLISHMENT OF IDR.— 
‘‘(i) IN
GENERAL.—Not later than 
January 1, 2021, the Secretary, in con-
sultation with the Secretary of Labor, shall 
establish a process for resolving payment 
disputes between health plans and non-
participating providers for purposes of de-
termining amounts of payments to be 
made by the plans to the providers pursu-
ant to subsections (b) and (e) (referred to 
in this section as the ‘IDR process’). 
‘‘(ii) ENTITIES.—An entity wishing to 
participate in the IDR process under this 
subsection shall request certification from 
the Secretary. The Secretary, in consulta-
tion with the Secretary of Labor, shall de-
termine eligibility of applicant entities, tak-
ing into consideration whether the entity is 
unbiased and unaffiliated with health plans 
and providers and free of conflicts of inter-
est, in accordance with the Secretary’s 
rulemaking on determining criteria for con-
flicts of interest. 
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‘‘(iii) APPLICABLE CLAIMS.— 
‘‘(I) IN
GENERAL.—The IDR 
process shall be with respect to one or 
more Current Procedural Terminology 
(‘CPT’) codes. 
‘‘(II) BATCHING
OF
CLAIMS.— 
Claims may be batched if such 
claims— 
‘‘(aa) involve identical plan 
or issuer and provider or facility 
parties; 
‘‘(bb) involve claims with the 
same or related current proce-
dural terminology codes relevant 
to a particular procedure; and 
‘‘(cc) involve claims that 
occur within 60 days of each 
other. 
‘‘(C) INDEPENDENT DISPUTE RESOLUTION 
PROCESS.— 
‘‘(i) TIMING.—In the case of an IDR 
entity that receives a request under this 
paragraph, with respect to a payment 
amount to be paid by a health plan to a 
nonparticipating provider— 
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