Title: No Surprises Act
Policy area: Health

Summary:
No Surprises ActThis bill expands restrictions on charging health care plan holders out-of-network rates for certain services. First, the bill requires insurers offering plans that cover emergency services to bill plan holders no more than the median in-network rate for a particular emergency service, even if the service provider is out of network. The bill further prohibits insurers from billing plan holders more than the median in-network rate for nonemergency services provided by out-of-network providers at in-network facilities.Out-of-network providers may not bill plan holders for the difference between the in-network and out-of-network rates for emergency services. The bill further prohibits out-of-network providers from billing plan holders for the difference in rates for nonemergency services provided at an in-network facility unless the provider complies with specified notice and consent requirements. Even when complying with these requirements, an out-of-network provider may not charge plan holders for the difference in rates for such nonemergency services if the provider is based at the in-network facility and is the only provider available to deliver the particular treatment or service at the facility.The Department of Health and Human Services must provide grants to states to establish or maintain All Payer Claims Databases, which publish claims and payment information from insurers.The bill also requires insurers to publish provider directories and requires the Government Accountability Office and the Department of Labor to report on certain issues related to the commercial health care market.

[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3630 Introduced in House (IH)]

<DOC>






116th CONGRESS
  1st Session
                                H. R. 3630

To amend title XXVII of the Public Health Service Act to protect health 
care consumers from surprise billing practices, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              July 9, 2019

Mr. Pallone (for himself and Mr. Walden) introduced the following bill; 
  which was referred to the Committee on Energy and Commerce, and in 
 addition to the Committee on Education and Labor, 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 XXVII of the Public Health Service 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 ``No Surprises Act''.

SEC. 2. PREVENTING SURPRISE MEDICAL BILLS.

    (a) Coverage of Emergency Services.--Section 2719A(b) of the Public 
Health Service Act (42 U.S.C. 300gg-19a(b)) is amended--
            (1) in paragraph (1)--
                    (A) in the matter preceding subparagraph (A)--
                            (i) by striking ``a group health plan, or a 
                        health insurance issuer offering group or 
                        individual health insurance issuer,'' and 
                        inserting ``a health plan (as defined in 
                        subsection (e)(2)(A))'';
                            (ii) by inserting ``or, for plan year 2021 
                        or a subsequent plan year, with respect to 
                        emergency services in an independent 
                        freestanding emergency department (as defined 
                        in paragraph (3)(D))'' after ``emergency 
                        department of a hospital'';
                            (iii) by striking ``the plan or issuer'' 
                        and inserting ``the plan''; and
                            (iv) by striking ``paragraph (2)(B)'' and 
                        inserting ``paragraph (3)(C)'';
                    (B) in subparagraph (B), by inserting ``or a 
                participating emergency facility, as applicable,'' 
                after ``participating provider''; and
                    (C) in subparagraph (C)--
                            (i) in the matter preceding clause (i), by 
                        inserting ``by a nonparticipating provider or a 
                        nonparticipating emergency facility'' after 
                        ``enrollee'';
                            (ii) by striking clause (i);
                            (iii) by striking ``(ii)(I) such services'' 
                        and inserting ``(i) such services'';
                            (iv) by striking ``where the provider of 
                        services does not have a contractual 
                        relationship with the plan for the providing of 
                        services'';
                            (v) by striking ``emergency department 
                        services received from providers who do have 
                        such a contractual relationship with the plan; 
                        and'' and inserting ``emergency services 
                        received from participating providers and 
                        participating emergency facilities with respect 
                        to such plan;'';
                            (vi) by striking ``(II) if such services'' 
                        and all that follows through ``were provided 
                        in-network'' and inserting the following:
                            ``(ii) the cost-sharing requirement 
                        (expressed as a copayment amount or coinsurance 
                        rate) is not greater than the requirement that 
                        would apply if such services were provided by a 
                        participating provider or a participating 
                        emergency facility;''; and
                            (vii) by adding at the end the following 
                        new clauses:
                            ``(iii) such requirement is calculated as 
                        if the total amount that would have been 
                        charged for such services by such participating 
                        provider or participating emergency facility 
                        were equal to--
                                    ``(I) in the case of such services 
                                furnished in a State described in 
                                paragraph (3)(H)(ii), the median 
                                contracted rate (as defined in 
                                paragraph (3)(E)(i)) for such services; 
                                and
                                    ``(II) in the case of such services 
                                furnished in a State described in 
                                paragraph (3)(H)(i), the lesser of--
                                            ``(aa) the amount 
                                        determined by such State for 
                                        such services in accordance 
                                        with the method described in 
                                        such paragraph; and
                                            ``(bb) the median 
                                        contracted rate (as so defined) 
                                        for such services;
                            ``(iv) the health plan pays to such 
                        provider or facility, respectively, the amount 
                        by which the recognized amount (as defined in 
                        paragraph (3)(H)) for such services exceeds the 
                        cost-sharing amount for such services (as 
                        determined in accordance with clauses (ii) and 
                        (iii)); and
                            ``(v) any cost-sharing payments made by the 
                        participant, beneficiary, or enrollee with 
                        respect to such emergency services so furnished 
                        shall be counted toward any in-network 
                        deductible or out-of-pocket maximums applied 
                        under the plan in the same manner as if such 
                        cost-sharing payments were with respect to 
                        emergency services furnished by a participating 
                        provider and a participating emergency 
                        facility; and'';
            (2) by redesignating paragraph (2) as paragraph (3);
            (3) by inserting after paragraph (1) the following new 
        paragraph:
            ``(2) Audit process for median contracted rates.--Not later 
        than July 1, 2020, the Secretary shall, in consultation with 
        appropriate State agencies, establish through rulemaking a 
        process under which sponsors and issuers of health plans are 
        audited to ensure that such sponsors and issuers are in 
        compliance with the requirement of applying a median contracted 
        rate under this section that satisfies the definition under 
        paragraph (3)(E).''; and
            (4) in paragraph (3), as redesignated by paragraph (2) of 
        this subsection--
                    (A) in the matter preceding subparagraph (A), by 
                inserting ``and subsections (e) and (f)'' after ``this 
                subsection'';
                    (B) by redesignating subparagraphs (A) through (C) 
                as subparagraphs (B) through (D), respectively;
                    (C) by inserting before subparagraph (B), as 
                redesignated by subparagraph (B) of this paragraph, the 
                following new subparagraph:
                    ``(A) Emergency department of a hospital.--The term 
                `emergency department of a hospital' includes a 
                hospital outpatient department that provides emergency 
                services.'';
                    (D) by amending subparagraph (C), as redesignated 
                by subparagraph (B) of this paragraph, to read as 
                follows:
                    ``(C) Emergency services.--
                            ``(i) In general.--The term `emergency 
                        services', with respect to an emergency medical 
                        condition means--
                                    ``(I) a medical screening 
                                examination (as required under section 
                                1867 of the Social Security Act, or as 
                                would be required under such section if 
                                such section applied to an independent 
                                freestanding emergency department) that 
                                is within the capability of the 
                                emergency department of a hospital or 
                                of an independent freestanding 
                                emergency department, as applicable, 
                                including ancillary services routinely 
                                available to the emergency department 
                                to evaluate such emergency medical 
                                condition; and
                                    ``(II) within the capabilities of 
                                the staff and facilities available at 
                                the hospital or the independent 
                                freestanding emergency department, as 
                                applicable, such further medical 
                                examination and treatment as are 
                                required under section 1867 of such 
                                Act, or as would be required under such 
                                section if such section applied to an 
                                independent freestanding emergency 
                                department, to stabilize the patient.
                            ``(ii) Inclusion of poststabilization 
                        services.--For purposes of this subsection and 
                        section 2799, in the case of an individual 
                        enrolled in a health plan who is furnished 
                        services described in clause (i) by a provider 
                        or facility to stabilize such individual with 
                        respect to an emergency medical condition, the 
                        term `emergency services' shall include such 
                        items and services in addition to those 
                        described in clause (i) that such a provider or 
                        facility determines are needed to be furnished 
                        to such individual during the visit in which 
                        such individual is so stabilized after such 
                        stabilization, unless each of the following 
                        conditions are met:
                                    ``(I) Such a provider or facility 
                                determines such individual is able to 
                                travel using nonmedical transportation 
                                or nonemergency medical transportation.
                                    ``(II) Such provider furnishing 
                                such additional items and services is 
                                in compliance with section 2799A(d) 
                                with respect to such items and 
                                services.'';
                    (E) by redesignating subparagraph (D), as 
                redesignated by subparagraph (B) of this paragraph, as 
                subparagraph (I); and
                    (F) by inserting after subparagraph (C), as 
                redesignated by subparagraph (B) of this paragraph, the 
                following new subparagraphs:
                    ``(D) Independent freestanding emergency 
                department.--The term `independent freestanding 
                emergency department' means a facility that--
                            ``(i) is geographically separate and 
                        distinct and licensed separately from a 
                        hospital under applicable State law; and
                            ``(ii) provides emergency services.
                    ``(E) Median contracted rate.--
                            ``(i) In general.--The term `median 
                        contracted rate' means, with respect to an item 
                        or service and a health plan (as defined in 
                        subsection (e)(2)(A))--
                                    ``(I) for 2021, the median of the 
                                negotiated rates recognized by the 
                                sponsor or issuer of such plan 
                                (determined with respect to all such 
                                plans of such sponsor or such issuer) 
                                as the total maximum payment (including 
                                the cost-sharing amount imposed for 
                                such services (as determined in 
                                accordance with paragraph (1)(C)(ii) or 
                                subsection (e)(1)(A), as applicable) 
                                and the amount to be paid by the plan 
                                or issuer) under such plans in 2019 for 
                                the same or a similar item or service 
                                that is provided by a provider in the 
                                same or similar specialty and provided 
                                in the geographic region in which the 
                                item or service is furnished, 
                                consistent with the methodology 
                                established by the Secretary under 
                                section 2(e) of the No Surprises Act, 
                                increased by the percentage increase in 
                                the consumer price index for all urban 
                                consumers (United States city average) 
                                over 2019 and 2020; and
                                    ``(II) for 2022 and each subsequent 
                                year, the median contracted rate for 
                                the previous year, increased by the 
                                percentage increase in the consumer 
                                price index for all urban consumers 
                                (United States city average) over such 
                                previous year.
                            ``(ii) Special rule; rule of 
                        construction.--
                                    ``(I) Certain insurers.--The 
                                Secretary shall provide pursuant to 
                                rulemaking described in clause (ii) 
                                that--
                                            ``(aa) if the sponsor or 
                                        issuer of a health plan does 
                                        not have sufficient information 
                                        to calculate a median 
                                        contracted rate for an item or 
                                        service or provider type, or 
                                        amount of, claims for items or 
                                        services (as determined by the 
                                        Secretary) provided in a 
                                        particular geographic area 
                                        (other than in a case described 
                                        in item (bb)), such sponsor or 
                                        issuer shall demonstrate that 
                                        such sponsor or issuer will use 
                                        any database free of conflicts 
                                        of interest that has sufficient 
                                        information reflecting allowed 
                                        amounts paid to individual 
                                        health care providers for 
                                        relevant services provided in 
                                        the applicable geographic 
                                        region (such as All Payer 
                                        Claims Databases (as defined in 
                                        section 4(d) of the No 
                                        Surprises Act) of States), and 
                                        that such sponsor or issuer 
                                        will use any such database to 
                                        determine a median contracted 
                                        rate and cover the cost of 
                                        accessing any such database; 
                                        and
                                            ``(bb) in the case of a 
                                        sponsor or issuer offering a 
                                        health plan in a geographic 
                                        region that did not offer any 
                                        health plan in such region 
                                        during 2019, such sponsor or 
                                        issuer shall use a methodology 
                                        established by the Secretary 
                                        for determining the median 
                                        contracted rate for items and 
                                        services covered by such plan 
                                        for the first year in which 
                                        such plan is offered in such 
                                        region, and that, for each 
                                        succeeding year, the median 
                                        contracted rate for such items 
                                        and services under such plan 
                                        shall be the median contracted 
                                        rate for such items and 
                                        services under such plan for 
                                        the previous year, increased by 
                                        the percentage increase in the 
                                        consumer price index for all 
                                        urban consumers (United States 
                                        city average) over such 
                                        previous year.
                                    ``(II) Rule of construction.--
                                Nothing in this subparagraph shall 
                                prevent the sponsor or issuer of a 
                                health plan from establishing separate 
                                calculations of a median contracted 
                                rate under this subparagraph for items 
                                and services delivered in non-hospital 
                                facilities, including independent 
                                freestanding emergency departments.
                    ``(F) Nonparticipating emergency facility; 
                participating emergency facility.--
                            ``(i) Nonparticipating emergency 
                        facility.--The term `nonparticipating emergency 
                        facility' means, with respect to an item or 
                        service and a health plan, an emergency 
                        department of a hospital, or an independent 
                        freestanding emergency department, that does 
                        not have a contractual relationship with the 
                        plan (or, if applicable, issuer offering the 
                        plan) for furnishing such item or service under 
                        the plan.
                            ``(ii) Participating emergency facility.--
                        The term `participating emergency facility' 
                        means, with respect to an item or service and a 
                        health plan, an emergency department of a 
                        hospital, or an independent freestanding 
                        emergency department, that has a contractual 
                        relationship with the plan (or, if applicable, 
                        issuer offering the plan) for furnishing such 
                        item or service under the plan.
                    ``(G) Nonparticipating providers; participating 
                providers.--
                            ``(i) Nonparticipating provider.--The term 
                        `nonparticipating provider' means, with respect 
                        to an item or service and a health plan, a 
                        physician or other health care provider who is 
                        acting within the scope of practice of that 
                        provider's license or certification under 
                        applicable State law and who does not have a 
                        contractual relationship with the plan (or, if 
                        applicable, issuer offering the plan) for 
                        furnishing such item or service under the plan.
                            ``(ii) Participating provider.--The term 
                        `participating provider' means, with respect to 
                        an item or service and a health plan, a 
                        physician or other health care provider who is 
                        acting within the scope of practice of that 
                        provider's license or certification under 
                        applicable State law and who has a contractual 
                        relationship with the plan (or, if applicable, 
                        issuer offering the plan) for furnishing such 
                        item or service under the plan.
                    ``(H) Recognized amount.--The term `recognized 
                amount' means, with respect to an item or service--
                            ``(i) in the case of such item or service 
                        furnished in a State that has in effect a State 
                        law that provides for a method for determining 
                        the amount of payment that is required to be 
                        covered by a health plan regulated by such 
                        State in the case of a participant, 
                        beneficiary, or enrollee covered under such 
                        plan and receiving such item or service from a 
                        nonparticipating provider or facility, not more 
                        than the amount determined in accordance with 
                        such law plus the cost-sharing amount imposed 
                        under the plan for such item or service (as 
                        determined in accordance with paragraph 
                        (1)(C)(ii) or subsection (e)(1)(A), as 
                        applicable); or
                            ``(ii) in the case of such item or service 
                        furnished in a State that does not have in 
                        effect such a law, an amount that is at least 
                        the median contracted rate (as defined in 
                        subparagraph (E)(i) and determined in 
                        accordance with rulemaking described in 
                        subparagraph (E)(ii)) for such item or 
                        service.''.
    (b) Coverage of Non-Emergency Services Performed by 
Nonparticipating Providers at Certain Participating Facilities.--
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) Coverage of Non-Emergency Services Performed by 
Nonparticipating Providers at Certain Participating Facilities.--
            ``(1) In general.--Subject to paragraph (3), in the case of 
        items or services (other than emergency services to which 
        subsection (b) applies) furnished to a participant, 
        beneficiary, or enrollee of a health plan (as defined in 
        paragraph (2)(A)) by a nonparticipating provider (as defined in 
        subsection (b)(3)(G)(i)) during a visit (as defined by the 
        Secretary in accordance with paragraph (2)(C)) at a 
        participating health care facility (as defined in paragraph 
        (2)(B)), with respect to such plan, the plan--
                    ``(A) shall not impose on such participant, 
                beneficiary, or enrollee a cost-sharing amount 
                (expressed as a copayment amount or coinsurance rate) 
                for such items and services so furnished that is 
                greater than the cost-sharing amount that would apply 
                under such plan had such items or services been 
                furnished by a participating provider (as defined in 
                subsection (b)(3)(G)(ii));
                    ``(B) shall calculate such cost-sharing amount as 
                if the amount that would have been charged for such 
                items and services by such participating provider were 
                equal to--
                            ``(i) in the case of such items and 
                        services furnished in a State described in 
                        subsection (b)(3)(H)(ii), the median contracted 
                        rate (as defined in subsection (b)(3)(E)(i)) 
                        for such items and services; and
                            ``(ii) in the case of such items and 
                        services furnished in a State described in 
                        subsection (b)(3)(H)(i), the lesser of--
                                    ``(I) the amount determined by such 
                                State for such items and services in 
                                accordance with the method described in 
                                such subsection; and
                                    ``(II) the median contracted rate 
                                (as so defined) for such items and 
                                services;
                    ``(C) shall pay to such provider furnishing such 
                items and services to such participant, beneficiary, or 
                enrollee the amount by which the recognized amount (as 
                defined in subsection (b)(3)(H)) for such items and 
                services exceeds the cost-sharing amount imposed under 
                the plan for such items and services (as determined in 
                accordance with subparagraphs (A) and (B)); and
                    ``(D) shall count toward any in-network deductible 
                or out-of-pocket maximums applied under the plan any 
                cost-sharing payments made by the participant, 
                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 furnished by a participating provider.
            ``(2) Definitions.--In this subsection and subsection (b):
                    ``(A) Health plan.--The term `health plan' means a 
                group health plan and health insurance coverage offered 
                by a heath insurance issuer in the group or individual 
                market and includes a grandfathered health plan (as 
                defined in section 1251(e) of the Patient Protection 
                and Affordable Care Act).
                    ``(B) Participating health care facility.--
                            ``(i) In general.--The term `participating 
                        health care facility' means, with respect to an 
                        item or service and a health plan, a health 
                        care facility described in clause (ii) that has 
                        a contractual relationship with the plan (or, 
                        if applicable, issuer offering the plan) for 
                        furnishing such item or service.
                            ``(ii) Health care facility described.--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).
                                    ``(III) An ambulatory surgical 
                                center (as defined in section 
                                1833(i)(1)(A) of such Act).
                                    ``(IV) A laboratory.
                                    ``(V) A radiology facility or 
                                imaging center.
                    ``(C) During a visit.--The term `during a visit' 
                shall, with respect to items and services furnished to 
                an individual at a participating health care facility, 
                include equipment and devices, telemedicine services, 
                imaging services, laboratory services, and such other 
                items and services as the Secretary may specify, 
                regardless of whether or not the provider furnishing 
                such items or services is at the facility.
            ``(3) Exception.--Paragraph (1) shall not apply to a health 
        plan in the case of items or services (other than emergency 
        services to which subsection (b) applies) furnished to a 
        participant, beneficiary, or enrollee of a health plan (as 
        defined in paragraph (2)(A)) by a nonparticipating provider (as 
        defined in subsection (b)(3)(G)(i)) during a visit (as defined 
        by the Secretary in accordance with paragraph (2)(C)) at a 
        participating health care facility (as defined in paragraph 
        (2)(B)) if such provider is in compliance with section 2799A(d) 
        with respect to such items and services.''.
    (c) Provider Directory Requirements; Disclosure on Patient 
Protections.--Section 2719A of the Public Health Service Act, as 
amended by subsection (b), is further amended by adding at the end the 
following new subsections:
    ``(f) Provider Directory Information Requirements.--
            ``(1) In general.--Not later than 1 year after the date of 
        the enactment of this subsection, each group health plan and 
        health insurance issuer offering group or individual health 
        insurance coverage shall--
                    ``(A) establish the verification process described 
                in paragraph (2);
                    ``(B) establish the response protocol described in 
                paragraph (3);
                    ``(C) establish the database described in paragraph 
                (4); and
                    ``(D) include in any print directory containing 
                provider directory information with respect to such 
                plan or such coverage the information described in 
                paragraph (5).
            ``(2) Verification process.--The verification process 
        described in this paragraph is, with respect to a group health 
        plan or a health insurance issuer offering group or individual 
        health insurance coverage, a process under which--
                    ``(A) not less frequently than once every 90 days, 
                such plan or such issuer (as applicable) verifies and 
                updates the provider directory information included on 
                the database described in paragraph (4) of such plan or 
                issuer of each health care provider and health care 
                facility included in such database; and
                    ``(B) such plan or such issuer removes any such 
                provider or facility with respect to which such plan or 
                such issuer has been unable to verify such information 
                during any 6-month period.
            ``(3) Response protocol.--The response protocol described 
        in this paragraph is, in the case of an individual enrolled 
        under a group health plan or group or individual health 
        insurance coverage offered by a health insurance issuer who 
        requests information on whether a health care provider or 
        health care facility has a contractual relationship to furnish 
        items and services under such plan or such coverage, a protocol 
        under which such plan or such issuer (as applicable), in the 
        case such request is made through a telephone call--
                    ``(A) responds to such individual as soon as 
                practicable and in no case later than 1 business day 
                after such call is received through a written 
                electronic communication; and
                    ``(B) retains such communication in such 
                individual's file for at least 2 years following such 
                response.
            ``(4) Database.--The database described in this paragraph 
        is, with respect to a group health plan or health insurance 
        issuer offering group or individual health insurance coverage, 
        a database on the public website of such plan or issuer that 
        contains--
                    ``(A) a list of each health care provider and 
                health care facility with which such plan or such 
                issuer has a contractual relationship for furnishing 
                items and services under such plan or such coverage; 
                and
                    ``(B) provider directory information with respect 
                to each such provider and facility.
            ``(5) Information.--The information described in this 
        paragraph is, with respect to a print directory containing 
        provider directory information with respect to a group health 
        plan or individual or group health insurance coverage offered 
        by a health insurance issuer, a notification that such 
        information contained in such directory was accurate as of the 
        date of publication of such directory and that an individual 
        enrolled under such plan or such coverage should consult the 
        database described in paragraph (4) with respect to such plan 
        or such coverage or contact such plan or the issuer of such 
        coverage to obtain the most current provider directory 
        information with respect to such plan or such coverage.
            ``(6) Definition.--For purposes of this subsection, the 
        term `provider directory information' includes, with respect to 
        a group health plan and a health insurance issuer offering 
        group or individual health insurance coverage, the name, 
        address, specialty, and telephone number of each health care 
        provider or health care facility with which such plan or such 
        issuer has a contractual relationship for furnishing items and 
        services under such plan or such coverage.
    ``(g) Disclosure on Patient Protections.--Each group health plan 
and health insurance issuer offering group or individual health 
insurance coverage shall make publicly available, and (if applicable) 
post on a public website of such plan or issuer--
            ``(1) information in plain language on--
                    ``(A) the requirements and prohibitions applied 
                under sections 2799 and 2799A (relating to prohibitions 
                on balance billing in certain circumstances);
                    ``(B) if provided for under applicable State law, 
                any other requirements on providers and facilities 
                regarding the amounts such providers and facilities 
                may, with respect to an item or service, charge a 
                participant, beneficiary, or enrollee of such plan or 
                coverage with respect to which such a provider or 
                facility does not have a contractual relationship for 
                furnishing such item or service under the plan or 
                coverage after receiving payment from the plan or 
                coverage for such item or service and any applicable 
                cost-sharing payment from such participant, 
                beneficiary, or enrollee; and
                    ``(C) the requirements applied under subsections 
                (b) and (e); and
            ``(2) information on contacting appropriate State and 
        Federal agencies in the case that an individual believes that 
        such a provider or facility has violated any requirement 
        described in paragraph (1) with respect to such individual.''.
    (d) Preventing Certain Cases of Balance Billing.--Title XXVII of 
the Public Health Service Act is amended by adding at the end the 
following new part:

         ``PART D--PREVENTING CERTAIN CASES OF BALANCE BILLING

``SEC. 2799. BALANCE BILLING IN CASES OF EMERGENCY SERVICES.

    ``(a) In General.--In the case of a participant, beneficiary, or 
enrollee with benefits under a health plan who is furnished on or after 
January 1, 2021, emergency services with respect to an emergency 
medical condition during a visit at an emergency department of a 
hospital or an independent freestanding emergency department--
            ``(1) the emergency department of a hospital or independent 
        freestanding emergency department shall not hold the 
        participant, beneficiary, or enrollee liable for a payment 
        amount for such emergency services so furnished that is more 
        than the cost-sharing amount for such services (as determined 
        in accordance with section 2719A(b)(1)(C)(ii)); and
            ``(2) a health care provider shall not hold such 
        participant, beneficiary, or enrollee liable for a payment 
        amount for an emergency service furnished to such individual by 
        such provider with respect to such emergency medical condition 
        and visit for which the individual receives emergency services 
        at the hospital or emergency department that is more than the 
        cost-sharing amount for such services furnished by the provider 
        (as determined in accordance with section 2719A(b)(1)(C)(ii)).
    ``(b) Definitions.--In this section:
            ``(1) The terms `emergency department of a hospital', 
        `emergency medical condition', `emergency services', and 
        `independent freestanding emergency department' have the 
        meanings given such terms, respectively, in section 
        2719A(b)(3).
            ``(2) The term `health plan' has the meaning given such 
        term in section 2719A(e).
            ``(3) The term `during a visit' shall have such meaning as 
        applied to such term for purposes of section 2719A(e).

``SEC. 2799A. BALANCE BILLING IN CASES OF NON-EMERGENCY SERVICES 
              PERFORMED BY NONPARTICIPATING PROVIDERS AT CERTAIN 
              PARTICIPATING FACILITIES.

    ``(a) In General.--Subject to subsection (b), in the case of a 
participant, beneficiary, or enrollee with benefits under a health plan 
(as defined in section 2799(b)) who is furnished on or after January 1, 
2021, items or services (other than emergency services to which section 
2799 applies) at a participating health care facility by a 
nonparticipating provider, such provider shall not hold such 
participant, beneficiary, or enrollee liable for a payment amount for 
such an item or service furnished by such provider during a visit at 
such facility that is more than the cost-sharing amount for such item 
or service (as determined in accordance with subparagraphs (A) and (B) 
of section 2719A(e)(1)).
    ``(b) Exception.--
            ``(1) In general.--Subsection (a) shall not apply to a 
        nonparticipating provider (other than a specified provider at a 
        participating health care facility), with respect to items or 
        services furnished by the provider to a participant, 
        beneficiary, or enrollee of a health plan, if the provider is 
        in compliance with the notice and consent requirements of 
        subsection (d).
            ``(2) Specified provider defined.--For purposes of 
        paragraph (1), the term `specified provider', with respect to a 
        participating health care facility--
                    ``(A) means a facility-based provider, including 
                emergency medicine providers, anesthesiologists, 
                pathologists, radiologists, neonatologists, assistant 
                surgeons, hospitalists, intensivists, or other 
                providers as determined by the Secretary; and
                    ``(B) includes, with respect to an item or service, 
                a nonparticipating provider if there is no 
                participating provider at such facility who can furnish 
                such item or service.
    ``(c) Clarification.--In the case of a nonparticipating provider 
(other than a specified provider at a participating health care 
facility) that complies with the notice and consent requirements of 
subsection (d) with respect to an item or service (referred to in this 
subsection as a `covered item or service'), such notice and consent 
requirements may not be construed as applying with respect to any item 
or service that is furnished as a result of unforeseen medical needs 
that arise at the time such covered item or service is furnished.
    ``(d) Compliance With Notice and Consent Requirements.--
            ``(1) In general.--A nonparticipating provider or 
        nonparticipating facility is in compliance with this 
        subsection, with respect to items or services furnished by the 
        provider or facility to a participant, beneficiary, or enrollee 
        of a health plan, if the provider (or, if applicable, the 
        participating health care facility on behalf of such provider) 
        or nonparticipating facility--
                    ``(A) provides to the participant, beneficiary, or 
                enrollee (or to an authorized representative of the 
                participant, beneficiary, or enrollee), on the date on 
                which the participant, beneficiary, or enrollee makes 
                an appointment to be furnished such items or services, 
                if applicable, and on the date on which the individual 
                is furnished such items or services--
                            ``(i) an oral explanation of the written 
                        notice described in clause (ii); and
                            ``(ii) a written notice specified, not 
                        later than July 1, 2020, by the Secretary 
                        through guidance (which shall be updated as 
                        determined necessary by the Secretary) that--
                                    ``(I) contains the information 
                                required under paragraph (2); and
                                    ``(II) is signed and dated by the 
                                participant, beneficiary, or enrollee 
                                (or by an authorized representative of 
                                the participant, beneficiary, or 
                                enrollee) and, with respect to items or 
                                services to be furnished by such a 
                                provider that are not poststabilization 
                                services described in section 
                                2719A(b)(3)(C)(ii), is so signed and 
                                dated not less than 72 hours prior to 
                                the participant, beneficiary, or 
                                enrollee being furnished such items or 
                                services by such provider; and
                    ``(B) obtains from the participant, beneficiary, or 
                enrollee (or from such an authorized representative) 
                the consent described in paragraph (3).
            ``(2) Information required under written notice.--For 
        purposes of paragraph (1)(A)(ii)(I), the information described 
        in this paragraph, with respect to a nonparticipating provider 
        or nonparticipating facility and a participant, beneficiary, or 
        enrollee of a health plan, is each of the following:
                    ``(A) Notification, as applicable, that the health 
                care provider is a nonparticipating provider with 
                respect to the health plan or the health care facility 
                is a nonparticipating facility with respect to the 
                health plan.
                    ``(B) Notification of the estimated amount that 
                such provider or facility may charge the participant, 
                beneficiary, or enrollee for such items and services 
                involved.
                    ``(C) In the case of a nonparticipating facility, a 
                list of any participating providers at the facility who 
                are able to furnish such items and services involved 
                and notification that the participant, beneficiary, or 
                enrollee may be referred, at their option, to such a 
                participating provider.
            ``(3) Consent described.--For purposes of paragraph (1)(B), 
        the consent described in this paragraph, with respect to a 
        participant, beneficiary, or enrollee of a health plan who is 
        to be furnished items or services by a nonparticipating 
        provider or nonparticipating facility, is a document specified 
        by the Secretary through rulemaking that--
                    ``(A) is signed by the participant, beneficiary, or 
                enrollee (or by an authorized representative of the 
                participant, beneficiary, or enrollee) and, with 
                respect to items or services to be furnished by such a 
                provider or facility that are not poststabilization 
                services described in section 2719A(b)(3)(C)(ii), is so 
                signed not less than 72 hours prior to the participant, 
                beneficiary, or enrollee being furnished such items or 
                services by such provider or facility;
                    ``(B) acknowledges that the participant, 
                beneficiary, or enrollee has been--
                            ``(i) provided with a written estimate and 
                        an oral explanation of the charge that the 
                        participant, beneficiary, or enrollee will be 
                        assessed for the items or services anticipated 
                        to be furnished to the participant, 
                        beneficiary, or enrollee by such provider or 
                        facility; and
                            ``(ii) informed that the payment of such 
                        charge by the participant, beneficiary, or 
                        enrollee may not accrue toward meeting any 
                        limitation that the health plan places on cost-
                        sharing; and
                    ``(C) documents the consent of the participant, 
                beneficiary, or enrollee to--
                            ``(i) be furnished with such items or 
                        services by such provider or facility; and
                            ``(ii) in the case that the individual is 
                        so furnished such items or services, be charged 
                        an amount that may be greater than the amount 
                        that would otherwise be charged the individual 
                        if furnished by a participating provider or 
                        participating facility with respect to such 
                        items or services and plan.
    ``(e) Retention of Certain Documents.--A nonparticipating provider 
(or, in the case of a nonparticipating provider at a participating 
health care facility, such facility) or nonparticipating facility that 
obtains from a participant, beneficiary, or enrollee of a health plan 
(or an authorized representative of such participant, beneficiary, or 
enrollee) a written notice in accordance with subsection (c)(1)(ii), 
with respect to furnishing an item or service to such participant, 
beneficiary, or enrollee, shall retain such notice for at least a 2-
year period after the date on which such item or service is so 
furnished.
    ``(f) Definitions.--In this section:
            ``(1) The terms `nonparticipating provider' and 
        `participating provider' have the meanings given such terms, 
        respectively, in subsection (b)(3) of section 2719A.
            ``(2) The terms `participating health care facility' and 
        `health plan' have the meanings given such terms, respectively, 
        in subsection (e)(2) of section 2719A.
            ``(3) The term `nonparticipating facility' means--
                    ``(A) with respect to emergency services (as 
                defined in section 2719A(b)(3)(C)(i)) and a health 
                plan, an emergency department of a hospital, or an 
                independent freestanding emergency department, that 
                does not have a contractual relationship with the plan 
                (or, if applicable, issuer offering the plan) for 
                furnishing such services under the plan; and
                    ``(B) with respect to poststabilization services 
                described in section 2719A(b)(3)(C)(ii) and a health 
                plan, an emergency department of a hospital (or other 
                department of such hospital), or an independent 
                freestanding emergency department, that does not have a 
                contractual relationship with the plan (or, if 
                applicable, issuer offering the plan) for furnishing 
                such services under the plan.
            ``(4) The term `participating facility' means--
                    ``(A) with respect to emergency services (as 
                defined in section 2719A(b)(3)(C)(i)) and a health 
                plan, an emergency department of a hospital, or an 
                independent freestanding emergency department, that has 
                a contractual relationship with the plan (or, if 
                applicable, issuer offering the plan) for furnishing 
                such services under the plan; and
                    ``(B) with respect to poststabilization services 
                described in section 2719A(b)(3)(C)(ii) and a health 
                plan, an emergency department of a hospital (or other 
                department of such hospital), or an independent 
                freestanding emergency department, that has a 
                contractual relationship with the plan (or, if 
                applicable, issuer offering the plan) for furnishing 
                such services under the plan.

``SEC. 2799B. PROVIDER REQUIREMENTS WITH RESPECT TO PROVIDER DIRECTORY 
              INFORMATION.

    ``Not later than 1 year after the date of the enactment of this 
section, each health care provider and health care facility shall 
establish a process under which such provider or facility transmits, to 
each health insurance issuer offering group or individual health 
insurance coverage and group health plan with which such provider or 
facility has in effect a contractual relationship for furnishing items 
and services under such coverage or such plan, provider directory 
information (as defined in section 2719A(f)(6)) with respect to such 
provider or facility, as applicable. Such provider or facility shall so 
transmit such information to such issuer offering such coverage or such 
group health plan--
            ``(1) when the provider or facility enters into such a 
        relationship with respect to such coverage offered by such 
        issuer or with respect to such plan;
            ``(2) when the provider or facility terminates such 
        relationship with respect to such coverage offered by such 
        issuer or with respect to such plan;
            ``(3) when there are any other material changes to such 
        provider directory information of the provider or facility with 
        respect to such coverage offered by such issuer or with respect 
        to such plan; and
            ``(4) at any other time determined appropriate by the 
        provider, facility, or the Secretary.

``SEC. 2799C. PROVIDER REQUIREMENT WITH RESPECT TO PUBLIC PROVISION OF 
              INFORMATION.

    ``Each health care provider and health care facility shall make 
publicly available, and (if applicable) post on a public website of 
such provider or facility--
            ``(1) information in plain language on--
                    ``(A) the requirements and prohibitions of such 
                provider or facility under sections 2799 and 2799A 
                (relating to prohibitions on balance billing in certain 
                circumstances); and
                    ``(B) if provided for under applicable State law, 
                any other requirements on such provider or facility 
                regarding the amounts such provider or facility may, 
                with respect to an item or service, charge a 
                participant, beneficiary, or enrollee of a health plan 
                (as defined in section 2719A(e)(2)) with respect to 
                which such provider or facility does not have a 
                contractual relationship for furnishing such item or 
                service under the plan after receiving payment from the 
                plan for such item or service and any applicable cost-
                sharing payment from such participant, beneficiary, or 
                enrollee; and
            ``(2) information on contacting appropriate State and 
        Federal agencies in the case that an individual believes that 
        such provider or facility has violated any requirement 
        described in paragraph (1) with respect to such individual.

``SEC. 2799D. ENFORCEMENT.

    ``(a) State Enforcement.--
            ``(1) State authority.--Each State may require a provider 
        or health care facility subject to the requirements of sections 
        2799, 2799A, 2799B, or 2799C to satisfy such requirements 
        applicable to the provider or facility.
            ``(2) Failure to implement requirements.--In the case of a 
        State that fails to substantially enforce the requirements set 
        forth in this part with respect to applicable providers and 
        facilities in the State, the Secretary shall enforce the 
        requirements of this part under subsection (b) insofar as they 
        relate to actions prohibited under this part occurring in such 
        State.
    ``(b) Secretarial Enforcement Authority.--
            ``(1) In general.--If a provider or facility is found to be 
        in violation of this part by the Secretary, the Secretary may 
        apply a civil monetary penalty with respect to such provider or 
        facility in an amount not to exceed $10,000 per violation. The 
        provisions of subsections (c), (d), (e), (g), (h), (k), and (l) 
        of section 1128A of the Social Security Act shall apply to a 
        civil monetary penalty or assessment under this subsection in 
        the same manner as such provisions apply to a penalty, 
        assessment, or proceeding under subsection (a) of such section.
            ``(2) Limitation.--The provisions of paragraph (1) shall 
        apply to enforcement of a provision (or provisions) of this 
        part only as provided under subsection (a)(2).
            ``(3) Complaint process.--The Secretary shall, through 
        rulemaking, establish a process to receive consumer complaints 
        of violations of this part and resolve such complaints within 
        60 days of receipt of such complaints.
            ``(4) Exception.--The Secretary shall waive the penalties 
        described under paragraph (1) with respect to a facility or 
        provider who does not knowingly violate, and should not have 
        reasonably known it violated, a provision of this part with 
        respect to a participant, beneficiary, or enrollee, if such 
        facility or practitioner, within 30 days of the violation, 
        withdraws the bill that was in violation of such provision, and 
        reimburses the health plan or enrollee, as applicable, in an 
        amount equal to the difference between the amount billed and 
        the amount allowed to be billed under the provision, plus 
        interest, at an interest rate determined by the Secretary.
            ``(5) Hardship exemption.--The Secretary may establish a 
        hardship exemption to the penalties under this subsection.
    ``(c) Continued Applicability of State Law.--This part shall not be 
construed to supersede any provision of State law which establishes, 
implements, or continues in effect any requirement or prohibition 
except to the extent that such requirement or prohibition prevents the 
application of a requirement or prohibition of this part.''.
    (e) Rulemaking for Median Contracted Rates.--Not later than July 1, 
2020, the Secretary of Health and Human Services, jointly with the 
Secretary of Labor, shall establish through rulemaking the methodology 
the sponsor or issuer of a health plan (as defined in subsection (e) of 
section 2719A of the Public Health Service Act (42 U.S.C. 300gg-19a), 
as added by subsection (b) of this section) shall use to determine the 
median contracted rate (as defined in section 2719A(b) of such Act, as 
amended by subsection (a) of this section), the information such 
sponsor or issuer shall share with the nonparticipating provider (as 
defined in such section) involved when making such a determination, and 
the geographic regions applied for purposes of this subparagraph (E) of 
section 2719A(b)(3), as amended by subsection (a) of this section.
    (f) Effective Date.--The amendments made by subsections (a) and (b) 
shall apply with respect to plan years beginning on or after January 1, 
2021.

SEC. 3. GOVERNMENT ACCOUNTABILITY OFFICE STUDY ON PROFIT- AND REVENUE-
              SHARING IN HEALTH CARE.

    (a) Study.--Not later than 1 year after the date of enactment of 
this Act, the Comptroller General of the United States shall conduct a 
study to--
            (1) describe what is known about profit- and revenue-
        sharing relationships in the commercial health care markets, 
        including those relationships that--
                    (A) involve one or more--
                            (i) physician groups that practice within a 
                        hospital included in the profit- or revenue-
                        sharing relationship, or refer patients to such 
                        hospital;
                            (ii) laboratory, radiology, or pharmacy 
                        services that are delivered to privately 
                        insured patients of such hospital;
                            (iii) surgical services;
                            (iv) hospitals or group purchasing 
                        organizations; or
                            (v) rehabilitation or physical therapy 
                        facilities or services; and
                    (B) include revenue- or profit-sharing whether 
                through a joint venture, management or professional 
                services agreement, or other form of gain-sharing 
                contract;
            (2) describe Federal oversight of such relationships, 
        including authorities of the Department of Health and Human 
        Services and the Federal Trade Commission to review such 
        relationships and their potential to increase costs for 
        patients, and identify limitations in such oversight; and
            (3) as appropriate, make recommendations to improve Federal 
        oversight of such relationships.
    (b) Report.--Not later than 1 year after the date of enactment of 
this Act, the Comptroller General of the United States shall prepare 
and submit a report on the study conducted under subsection (a) to the 
Committee on Health, Education, Labor, and Pensions of the Senate and 
the Committee on Education and Labor and Committee on Energy and 
Commerce of the House of Representatives.

SEC. 4. STATE ALL PAYER CLAIMS DATABASES.

    (a) In General.--The Secretary of Health and Human Services shall 
make one-time grants to eligible States for the purposes described in 
subsection (b).
    (b) Uses.--A State may use a grant received under subsection (a) 
for one of the following purposes:
            (1) To establish an All Payer Claims Database for the 
        State.
            (2) To maintain an existing All Payer Claims Databases for 
        the State.
    (c) Eligibility.--To be eligible to receive a grant under 
subsection (a), a State shall submit to the Secretary an application at 
such time, in such manner, and containing such information as the 
Secretary specifies. Such information shall include, with respect to an 
All Payer Claims Database for the State, at least specifics on how the 
State will ensure uniform data collection through the database and the 
security of such data submitted to and maintained in the database.
    (d) All Payer Claims Database.--For purposes of this section, the 
term ``All Payer Claims Database'' means, with respect to a State, a 
State database that may include medical claims, pharmacy claims, dental 
claims, and eligibility and provider files, which are collected from 
private and public payers.
    (e) Authorization of Appropriations.--To carry out this section, 
there are authorized to be appropriated $50,000,000, to remain 
available until expended.

SEC. 5. SIMPLIFYING EMERGENCY AIR AMBULANCE BILLING.

    (a) In General.--Providers of emergency air medical services shall 
submit to a group health plan or health insurance issuer offering group 
or individual health insurance coverage, together with an electronic 
claims transaction with respect to an enrollee in such plan or 
coverage, a description of charges for such services that are separated 
by--
            (1) the cost of air travel; and
            (2) the cost of emergency medical services and supplies.
    (b) Rulemaking.--Not later than 1 year after the date of the 
enactment of this Act, the Secretary of Health and Human Services shall 
determine the form and manner for submitting the description of charges 
in subsection (a) through notice and comment rulemaking.
    (c) Civil Monetary Penalties.--
            (1) In general.--A provider of emergency air medical 
        services who violates the requirement of subsection (a) shall 
        be subject to a civil monetary penalty of not more than $10,000 
        for each act constituting such violation.
            (2) Procedure.--The provisions of section 1128A of the 
        Social Security Act (42 U.S.C. 1320a-7a), other than 
        subsections (a) and (b) and the first sentence of subsection 
        (c)(1) of such section, shall apply to civil money penalties 
        under this subsection in the same manner as such provisions 
        apply to a penalty or proceeding under section 1128A of the 
        Social Security Act.
    (d) Definitions.--In this section, the terms ``group health plan'', 
``health insurance coverage'', and ``health insurance issuer'' have the 
meanings given such terms in section 2791 of the Public Health Service 
Act (42 U.S.C. 300gg-91).
    (e) Effective Date.--The requirement under subsection (a) shall 
take effect 6 months after the rules described in subsection (b) are 
finalized.

SEC. 6. REPORT BY SECRETARY OF LABOR.

    Not later than one year after the date of the enactment of this 
Act, and annually thereafter for each of the following 5 years, the 
Secretary of Labor shall--
            (1) conduct a study of--
                    (A) the effects of the provisions of, including 
                amendments made by, this Act on premiums and out-of-
                pocket costs in group health plans, including out-of-
                pocket costs that are permitted by reason of compliance 
                with section 2799A(d) of the Public Health Service Act, 
                as added by section 2(d);
                    (B) the adequacy of provider networks in group 
                health plans; and
                    (C) such other effects of such provisions, and 
                amendments, as the Secretary deems relevant; and
            (2) submit a report on such study to the Committee on 
        Health, Education, Labor, and Pensions of the Senate and the 
        Committee on Education and Labor and the Committee on Energy 
        and Commerce of the House of Representatives.
                                 <all>