Title: Fair Billing Act of 2017
Policy area: Health

Summary:
Fair Billing Act of 2017
This bill restricts Medicare providers from employing certain surprise-billing practices and provides for a review process with respect to such practices.

[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3877 Introduced in House (IH)]

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115th CONGRESS
  1st Session
                                H. R. 3877

To amend title XVIII of the Social Security Act to protect health care 
   consumers from surprise billing practices, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 28, 2017

Ms. Michelle Lujan Grisham of New Mexico introduced the following bill; 
  which was referred to the Committee on Energy and Commerce, and in 
    addition to the Committee on Ways and Means, for a period to be 
subsequently determined by the Speaker, in each case for consideration 
  of such provisions as fall within the jurisdiction of the committee 
                               concerned

_______________________________________________________________________

                                 A BILL


 
To amend title XVIII of the Social Security Act to protect health care 
   consumers from surprise billing practices, and for other purposes.

    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 ``Fair Billing Act of 2017''.

SEC. 2. PROTECTING HEALTH CARE CONSUMERS FROM SURPRISE BILLING 
              PRACTICES.

    (a) Providers.--Section 1866 of the Social Security Act (42 U.S.C. 
1395cc) is amended--
            (1) in subsection (a)(1)--
                    (A) in subparagraph (X), by striking ``and'' at the 
                end;
                    (B) in subparagraph (Y), by striking the period at 
                the end and inserting ``, and''; and
                    (C) by inserting after subparagraph (Y) the 
                following new subparagraph:
            ``(Z) in the case of a hospital or critical access 
        hospital, to meet the requirements of paragraphs (1), (2), and 
        (3) of subsection (l).''; and
            (2) by adding at the end the following new subsection:
    ``(l) No Surprise Billing at In-Network Facilities; Emergency 
Services; External Review of Certain Payments.--
            ``(1) No surprise billing at in-network facilities.--
                    ``(A) In general.--Subject to subparagraph (B), in 
                the case of an individual with benefits under a health 
                care plan who is furnished items or services at a 
                relevant facility (including items or services 
                furnished by a provider of services or supplier at such 
                facility) that is within the health care provider 
                network or otherwise a participating provider of 
                services or supplier with respect to the health care 
                plan of such individual, the relevant facility (or the 
                provider of services or supplier) may not hold the 
                individual liable for more than the amount that the 
                individual would have been required to pay in cost 
                sharing if such items or services had been furnished by 
                a relevant facility (or, as applicable, by a provider 
                of services or supplier) that is within the health care 
                provider network or otherwise a participating provider 
                of services or supplier with respect to the health care 
                plan of such individual.
                    ``(B) Exception for notification and written 
                consent.--Subparagraph (A) shall not apply in the case 
                of a relevant facility (or provider of services or 
                supplier at such facility) that, not later than 72 
                hours before furnishing items or services to an 
                individual (or, in the case where such items or 
                services are scheduled to be furnished less than 72 
                hours from the time of scheduling, 24 hours before 
                furnishing such items or services), notifies such 
                individual of an estimate of the individual's 
                anticipated total out-of-pocket cost of care for such 
                items and services and obtains written consent from 
                such individual.
            ``(2) Emergency services.--In the case of an individual 
        with benefits under a health care plan who is furnished items 
        or services with respect to an emergency medical condition at a 
        hospital or critical access hospital (including items or 
        services furnished by a provider of services or a supplier at 
        the hospital or critical access hospital), the hospital or 
        critical access hospital (or the provider of services or 
        supplier) may not charge the individual more than the amount 
        that the individual would have been required to pay in cost 
        sharing if such items or services had been furnished by a 
        hospital or critical access hospital (or by a provider of 
        services or supplier) within such network or otherwise a 
        participating provider of services.
            ``(3) Review process.--A relevant facility shall 
        participate in any review process requested, and comply with 
        any determination made, under section 3 of the Fair Billing Act 
        of 2017.
            ``(4) Definitions.--In this subsection:
                    ``(A) Emergency medical condition.--The term 
                `emergency medical condition' has the meaning given 
                such term in section 1867(e).
                    ``(B) Health care plan.--The term `health care 
                plan' means--
                            ``(i) a group health plan;
                            ``(ii) group health insurance coverage;
                            ``(iii) individual health insurance 
                        coverage; or
                            ``(iv) a Federal health care program (as 
                        defined in section 1128B(f)).
                    ``(C) Public health service act terms.--The terms 
                `group health plan', `group health insurance coverage', 
                and `individual health insurance coverage' have the 
                meanings given those terms, respectively, under section 
                2791 of the Public Health Service Act (42 U.S.C. 300gg-
                91).
                    ``(D) Relevant facility.--The term `relevant 
                facility' means a hospital or critical access 
                hospital.''.
    (b) Insurers.--Section 2719A of the Public Health Service Act (42 
U.S.C. 300gg-19a) is amended by adding at the end the following new 
subsection:
    ``(e) Payment Review Process.--A group health plan or a health 
insurance issuer offering group or individual health insurance shall 
participate in any review process requested, and comply with any 
determination made, under section 3 of the Fair Billing Act of 2017.''.
    (c) Effective Date.--The amendments made by this section shall 
apply with respect to items or services furnished on or after the date 
that is one year after the date of the enactment of this Act.

SEC. 3. REVIEW PROCESS FOR SURPRISE BILLING PRACTICES.

    (a) State Election.--Each State may elect, at such time and in such 
manner as the Secretary of Health and Human Services (the 
``Secretary'') shall prescribe, to establish a review process described 
in subsection (c) to be available at the request of a health care plan 
or provider of services or supplier.
    (b) Failure To Establish an External Review Process or Implement 
Standards.--In the case of a State that does not elect under subsection 
(a) to establish a review process described in subsection (c), the 
Secretary shall make available within the State such a review process 
to be available at the request of a health care plan or provider of 
services or supplier.
    (c) Review Process.--In the case of payment from a health care plan 
to a provider of services or supplier for items or services furnished 
by such provider or supplier to an individual with benefits under such 
plan in a case in which section 1866(l)(1)(A) or subsection (l)(2) of 
such section applies and such plan or such provider or supplier 
requests a review of such payment, a review process described in this 
subsection is a process by which an independent health care expert 
determines the amount of the payment to be made by such plan to such 
provider or supplier using the methodology described in subsection (d) 
and notifies the individual furnished such items or services of such 
determination within 30 days of making such determination.
    (d) Methodology.--In the case of payment from a health care plan to 
a provider of services or supplier for items or services furnished by 
such provider or supplier to an individual with benefits under such 
plan, the methodology described in this subsection consists of an 
independent health care expert determining an amount to be paid by the 
plan to the provider or supplier by selecting one of the following 
amounts:
            (1) The lesser of--
                    (A) an amount proposed by the provider of services 
                or supplier that furnished such items or services; and
                    (B) an amount that is equal to the 80th percentile 
                of the amount paid for such items and services, as 
                reported by a national all-payer claims database or, if 
                available, a State or regional all-payer claims 
                database, as determined by the independent health care 
                expert.
            (2) The greater of--
                    (A) an amount proposed by the health plan providing 
                health benefits coverage to such individual with 
                respect to such items and services; and
                    (B) 1.25 multiplied by the Medicare fee schedule 
                for such items and services (or, if such items and 
                services are not covered under Medicare, an amount 
                determined by the Secretary).
    (e) Reconsideration.--An individual furnished items or services by 
a provider of services or supplier for which payment is determined in 
accordance with the review process described in subsection (c) may, 
within 30 days of receiving notification of such determination, file a 
written request for a reconsideration of such determination with the 
independent health care expert making such determination. Such expert 
shall, within 30 days of receiving such request, determine whether such 
determination should be revised and notify such individual of any 
change to such determination.
    (f) Cost-Sharing Clarification.--Any cost sharing (including any 
copayment or coinsurance) that an individual may be responsible for 
after a determination is made under subsection (c) shall count towards 
such individual's annual deductible with respect to the health care 
plan of such individual.
    (g) Definitions.--In this section:
            (1) Health care plan.--The term ``health care plan'' has 
        the meaning given such term in section 1866(l)(4) of the Social 
        Security Act (42 U.S.C. 1395cc(l)(4)).
            (2) Independent health care expert defined.--The term 
        ``independent health care expert'' means an individual who is, 
        with respect to a payment for items and services--
                    (A) an expert in health care billing;
                    (B) free of conflicts of interest with respect to 
                such payment; and
                    (C) appointed by a State or the Secretary to make 
                determinations under the external review process 
                described in subsection (c).
            (3) Provider of services.--The term ``provider of 
        services'' has the meaning given such term in section 1861 of 
        the Social Security Act (42 U.S.C. 1395x).
            (4) State.--The term ``State'' has the meaning given such 
        term in section 210 of the Social Security Act (42 U.S.C. 410).
            (5) Supplier.--The term ``supplier'' has the meaning given 
        such term in section 1861 of the Social Security Act (42 U.S.C. 
        1395x).
    (h) Grants to States.--
            (1) In general.--The Secretary of Health and Human Services 
        shall provide grants, not later than 90 days after the date of 
        the enactment of this Act, to eligible States to establish and 
        implement a review process described in subsection (a).
            (2) Eligible state.--For purposes of this subsection, the 
        term ``eligible State'' means a State that has elected under 
        subsection (a) to establish a review process and that has 
        submitted an application to the Secretary at such time, in such 
        manner, and containing such information as the Secretary may 
        require.
            (3) Authorization of appropriations.--There is authorized 
        to be appropriated to the Secretary of Health and Human 
        Services $4,000,000,000 to award grants under this subsection.
    (i) Effective Date.--This section shall apply with respect to items 
or services furnished on or after the date that is one year after the 
date of the enactment of this Act.
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