Title: Protecting Patients from Surprise Medical Bills Act
Policy area: Health

Summary:
Protecting Patients from Surprise Medical Bills Act  This bill prohibits balance billing the holder of a self-insured group health plan (plans in which an employer pays claims to providers for health benefits offered to employees) for emergency and specified nonemergency services. Balance billing is the practice of charging a plan holder for the difference between a provider's rate for a service and the in-network rate.  First, the bill requires self-insured group health plans that cover emergency services to comply with the requirements for other types of group health plans. This includes the requirement to bill a plan holder no more than the in-network cost-sharing amount for covered emergency services, even if the provider is out-of-network. Second, the bill prohibits emergency services providers from billing a self-insured group plan holder for any remaining balance for covered services not paid to the provider by the employer.  Further, unless a plan holder has the option to select an in-network provider, an out-of-network provider of covered, nonemergency services is prohibited from billing plan holders for the difference in rates for such services when provided at an in-network facility.  Employers must pay out-of-network providers for services subject to the requirements of this bill (1) the amount the provider claims, (2) the usual and customary amount for such services in that community, or (3) an amount agreed to within 60 days of when the claim is submitted. Otherwise the parties may enter voluntary binding arbitration.

[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4223 Introduced in House (IH)]

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116th CONGRESS
  1st Session
                                H. R. 4223

To amend the Employee Retirement Income Security Act of 1974 to protect 
                 patients from surprise medical bills.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            August 30, 2019

  Mr. Spano introduced the following bill; which was referred to the 
                    Committee on Education and Labor

_______________________________________________________________________

                                 A BILL


 
To amend the Employee Retirement Income Security Act of 1974 to protect 
                 patients from surprise medical bills.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Protecting Patients from Surprise 
Medical Bills Act''.

SEC. 2. PROHIBITION ON SURPRISE MEDICAL BILLING.

    Subpart B of part 7 of title I of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at 
the end the following:

``SEC. 716. PROHIBITION ON SURPRISE MEDICAL BILLING.

    ``(a) Definitions.--In this section:
            ``(1) Balance bill.--The term `balance bill' means the 
        collection or attempted collection from a participant or 
        beneficiary of any amount in excess of the applicable 
        copayments, coinsurance, or deductible for services covered 
        under the participant or beneficiary's group health plan.
            ``(2) Emergency medical condition.--The term `emergency 
        medical condition' means the condition described in section 
        2719A(b)(2)(A) of the Public Health Service Act.
            ``(3) Emergency services.--The term `emergency services' 
        means the services described in section 2719A(b)(2)(B) of the 
        Public Health Service Act.
            ``(4) Emergency services provider.--The term `emergency 
        services provider' means a facility or facility-based provider 
        that bills a participant or beneficiary for emergency services.
            ``(5) Facility.--The term `facility' means an entity 
        providing health care services, as licensed or authorized by a 
        State.
            ``(6) Facility-based provider.--The term `facility-based 
        provider' means a physician, health care professional, or 
        entity that has entered into an agreement with a facility to 
        provide health care services to patients of that facility.
    ``(b) Emergency Services.--
            ``(1) Prohibition on balance billing.--A self-insured group 
        health plan shall be solely liable for making payments to an 
        emergency services provider for emergency services covered 
        under the plan that are provided to a participant or 
        beneficiary, and such participant or beneficiary shall not be 
        liable to the emergency services provider for any amount for 
        such services other than the applicable copayment, coinsurance, 
        or deductible amount required under the plan for covered 
        emergency services. Emergency service providers shall not 
        balance bill a participant or beneficiary under a self-insured 
        group health plan for any covered emergency services provided 
        to such participant or beneficiary.
            ``(2) Cost sharing limitation and prior authorization.--If 
        a self-insured group health plan provides coverage for any 
        benefits with respect to emergency services, such coverage 
        shall be in accordance with the provisions of section 2719A(b) 
        of the Public Health Service Act and--
                    ``(A) if such services are provided by an out-of-
                network provider, the cost-sharing requirements 
                (including any deductible amount and the out-of-pocket 
                limit) applicable to such services shall be the same as 
                the cost-sharing requirement that would apply if such 
                services were provided by an in-network provider;
                    ``(B) prior authorization shall not be required for 
                pre-hospital transport or treatment; and
                    ``(C) payment by the plan shall be made directly to 
                the emergency services provider.
    ``(c) Covered Non-Emergency Services.--Facility-based providers 
shall not balance bill a patient for covered non-emergency services if 
the services are provided at an in-network facility and the participant 
or beneficiary did not have the ability or opportunity to select to 
receive such services from an in-network provider.
    ``(d) Reimbursements for Out-of-Network Payments.--A self-insured 
group health plan shall reimburse a health care provider for out-of-
network emergency and non-emergency services described in subsections 
(b) and (c) based on one of the following payment methodologies:
            ``(1) The amount of the claim made by the provider for such 
        services.
            ``(2) The usual and customary amount charged by the 
        provider for similar services in the community where the 
        services were provided.
            ``(3) The amount mutually agreed to by the plan and the 
        provider during the 60-day period after the date on which the 
        claim is submitted.
    ``(e) Voluntary Binding Arbitration.--
            ``(1) In general.--If a self-insured group health plan and 
        health care provider are unable to resolve a dispute with 
        respect to billing for services described in subsection (b) or 
        (c), such provider may voluntarily initiate binding arbitration 
        with such plan under this subsection. The Secretary shall 
        establish by rule methods of aggregation for claim disputes 
        submitted to voluntary binding arbitration under this 
        subsection.
            ``(2) Arbitration organizations.--
                    ``(A) In general.--The Secretary shall enter into 
                contracts with outside organizations to conduct timely, 
                voluntary binding arbitration proceedings under this 
                subsection. To be eligible for such a contract, an 
                organization shall have at least 5 years of experience 
                serving as a neutral party in complex dispute 
                resolution proceedings.
                    ``(B) Limitation.--An organization shall not be 
                eligible to enter into a contract under subparagraph 
                (A) if the organization has been employed by, consulted 
                for, or otherwise had a business relationship (other 
                than the receipt of arbitration fees) with a health 
                plan, health insurance issuer, facility, or health care 
                professional during the 3-year period immediately 
                preceding the effective date of the contract with the 
                Secretary or during the term of such contract.
                    ``(C) Arbitrator.--An arbitrator may not be 
                assigned by an organization to resolve a dispute under 
                this paragraph if the arbitrator has been employed by, 
                consulted for, or otherwise had a business relationship 
                (other than the receipt of arbitration fees) with a 
                health plan, health insurance issuer, facility, or 
                health care professional during the 3-year period 
                immediately preceding the request for arbitration.
            ``(3) Eligibility.--To be eligible for voluntary binding 
        arbitration under this subsection the claim involved shall--
                    ``(A) in the case of a claim relating to facility 
                health care services, be not less than $3,000; and
                    ``(B) in the case of a claim relating to 
                professional services, be not less than $500.
        Such amounts shall be adjusted by the Secretary each year by 
        the percentage increase in the consumer price index.
            ``(4) Procedures.--The following procedures shall apply 
        during a voluntary arbitration proceeding under this 
        subsection:
                    ``(A) The plan or provider involved may make an 
                offer to settle the disputed claim. The party to whom 
                such an offer is directed shall respond to such offer 
                within 15 days after receipt of the offer.
                    ``(B) If the party receiving an offer to settle 
                under paragraph (A) does not accept such offer, and the 
                arbitrator issues a final order with respect to the 
                disputed claim that is more than 90 percent or less 
                than 110 percent of the offer amount, the party 
                receiving the offer is deemed a non-prevailing party 
                for purpose of paragraph (5).
                    ``(C) A final order under this paragraph is subject 
                to judicial review under this Act.
                    ``(D) All parties to a dispute that is subject to 
                arbitration under this subsection may agree to settle 
                claim at any time, for any amount, regardless of 
                whether an offer to settle was made or rejected.
            ``(5) Review costs.--
                    ``(A) In general.--The entity that does not prevail 
                under an arbitrator's final order under voluntary 
                binding arbitration under this subsection shall pay the 
                review costs.
                    ``(B) Apportionment of costs.--In the case that 
                both parties to voluntary binding arbitration under 
                this subsection prevail in part, the review costs shall 
                be apportioned among the parties in proportion to the 
                final judgment. The apportionment shall be based on the 
                disputed claim amount.
                    ``(C) Failure to pay.--If a party to voluntary 
                binding arbitration under this subsection fails to pay 
                any amount of the ordered review costs within 35 days 
                after the arbitrator's final order, the party shall be 
                subject to a penalty of $500 for each day that such 
                amount is not paid.
    ``(f) Network Transparency.--A self-insured group health plan 
shall--
            ``(1) not later than 1 year after the date of enactment of 
        this section, publish on their internet website a list of 
        network providers, and update such list on a monthly basis; and
            ``(2) not later than 1 year after the date of enactment of 
        this section, and annually thereafter, provide an annual 
        notification to participants and beneficiaries concerning the 
        potential for balance billing when using out-of-network 
        providers.''.
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