G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML [DISCUSSION DRAFT] H. R. ll 116TH CONGRESS 1ST SESSION To amend the Public Health Service Act and title XI of the Social Security Act to protect health care consumers from surprise billing practices, and for other purposes. IN THE HOUSE OF REPRESENTATIVES Mr. PALLONE (for himself and Mr. WALDEN) introduced the following bill; which was referred to the Committee on lllllllllllllll A BILL To amend the Public Health Service Act and title XI of the Social Security Act to protect health care consumers from surprise billing practices, and for other purposes. 1 Be it enacted by the Senate and House of Representa- 2 tives of the United States of America in Congress assembled, 3 SECTION 1. SHORT TITLE. 4 This Act may be cited as the ‘‘No Surprises Act’’. 5 SEC. 2. PREVENTING SURPRISE MEDICAL BILLS. 6 (a) EMERGENCY SERVICES PERFORMED 7 PARTICIPATING g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 14:54 May 13, 2019 Jkt 000000 BY NON- PROVIDERS.—Section 2719A of the Pub- (720823 10) PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 2 1 lic Health Service Act (42 U.S.C. 300gg–19a) is amend2 ed— 3 (1) in subsection (b)— 4 (A) in paragraph (1)— 5 (i) in the matter preceding subpara- 6 graph (A)— 7 (I) by striking ‘‘offering group or 8 individual health insurance issuer’’ 9 and inserting ‘‘offering group or indi- 10 vidual health insurance coverage’’; 11 and 12 (II) by inserting ‘‘or, for plan 13 year 2021 or a subsequent plan year, 14 with respect to services in an inde- 15 pendent freestanding emergency de- 16 partment (as defined in paragraph 17 (2)(C))’’ after ‘‘emergency department 18 of a hospital’’; and 19 (III) striking ‘‘paragraph 20 (2)(B)’’ and inserting ‘‘paragraph 21 (2)’’; 22 (ii) in subparagraph (B), by inserting 23 ‘‘or a participating emergency facility, as 24 applicable,’’ after ‘‘participating provider’’; 25 and g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 by 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 3 1 (iii) in subparagraph (C)— 2 (I) in the matter preceding clause 3 (i), by inserting ‘‘by a nonpartici- 4 pating provider or a nonparticipating 5 emergency facility’’ after ‘‘enrollee’’; 6 (II) by striking clause (i); 7 (III) by striking ‘‘(ii)(I) such 8 services’’ and inserting ‘‘(i) such serv- 9 ices’’; 10 (IV) by striking ‘‘where the pro- 11 vider of services does not have a con- 12 tractual relationship with the plan for 13 the providing of services’’; 14 (V) by striking ‘‘emergency de- 15 partment services received from pro- 16 viders who do have such a contractual 17 relationship with the plan; and’’ and 18 inserting ‘‘emergency services received 19 from participating providers and par- 20 ticipating emergency facilities with re- 21 spect to such plan;’’; 22 (VI) by striking ‘‘(II) if such serv- 23 ices’’ and all that follows through 24 ‘‘were provided in-network’’ and in- 25 serting the following: g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 4 1 ‘‘(ii) the cost-sharing requirement (ex- 2 pressed as a copayment amount or coinsur- 3 ance rate) is not greater than the require- 4 ment that would apply if such services 5 were provided by a participating provider 6 or a participating emergency facility;’’; and 7 (VII) by adding at the end the 8 following new clauses: 9 ‘‘(iii) the group health plan or health 10 insurance issuer offering group or indi- 11 vidual health insurance coverage pays to 12 such provider or facility, respectively, the 13 amount by which the recognized amount 14 (as defined in paragraph (2)(H)) for such 15 services exceeds the cost-sharing amount 16 for such services (as determined in accord- 17 ance with clause (ii)); and 18 ‘‘(iv) there shall be counted toward 19 any deductible or out-of-pocket maximums 20 applied under the plan any cost-sharing 21 payments made by the participant, bene- 22 ficiary, or enrollee with respect to such 23 emergency services so furnished in the 24 same manner as if such cost-sharing pay- 25 ments were with respect to emergency g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 5 1 services furnished by a participating pro- 2 vider and a participating emergency facil- 3 ity.’’; and 4 (B) in paragraph (2)— 5 (i) in the matter preceding subpara- 6 graph (A), by inserting ‘‘and subsection 7 (e)’’ after ‘‘this subsection’’; 8 (ii) by redesignating subparagraphs 9 (A) through (C) as subparagraphs (B) 10 through (D), respectively; 11 (iii) by inserting before subparagraph 12 (B), as redesignated by clause (ii), the fol- 13 lowing new subparagraph: 14 ‘‘(A) EMERGENCY 15 PITAL.—The 16 hospital’ includes a hospital outpatient depart- 17 ment that provides emergency services.’’. 18 term ‘emergency department of a (iv) in subparagraph (C), as redesig- 19 nated by clause (ii)— 20 (I) in clause (i)— 21 (aa) by inserting ‘‘, or as 22 would be required under such 23 section if such section applied to 24 an 25 emergency g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 DEPARTMENT OF A HOS- 14:54 May 13, 2019 Jkt 000000 independent freestanding department’’ after (720823 10) PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 6 1 ‘‘section 1867 of the Social Secu- 2 rity Act’’; and 3 (bb) by inserting ‘‘or of the 4 independent freestanding emer- 5 gency department, as applicable’’ 6 after ‘‘of a hospital’’; and 7 (II) in clause (ii)— 8 (aa) by inserting ‘‘or the 9 independent freestanding emer- 10 gency department, as applicable’’ 11 after ‘‘at the hospital’’; and 12 (bb) by inserting ‘‘, or as 13 would be required under such 14 section if such section applied to 15 an 16 emergency 17 ‘‘section 1867 of such Act’’; 18 (v) by redesignating subparagraph 19 (D), as redesignated by clause (ii), as sub- 20 paragraph (I); and freestanding department,’’ after 21 (vi) by inserting after subparagraph 22 (C), as redesignated by clause (ii), the fol- 23 lowing subparagraphs: 24 ‘‘(D) 25 14:54 May 13, 2019 INDEPENDENT FREESTANDING EMERGENCY DEPARTMENT.—The g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 independent Jkt 000000 term ‘inde- (720823 10) PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 7 1 pendent freestanding emergency department’ 2 means a facility that provides emergency or un- 3 scheduled outpatient services to patients whose 4 conditions require immediate care in a setting 5 that is geographically separate and distinct 6 from a hospital and independently licensed. 7 ‘‘(E) MEDIAN 8 ‘‘(i) IN GENERAL.—The term ‘median 9 contracted rate’ means, with respect to an 10 item or service and a group health plan or 11 health insurance coverage offered by a 12 health insurance issuer, the median of the 13 negotiated rates recognized by the plan or 14 issuer as the total maximum payment (in- 15 cluding the cost-sharing amount imposed 16 for such services (as determined in accord- 17 ance with paragraph (1)(C)(ii) or sub- 18 section (e)(1)(A), as applicable) and the 19 amount to be paid by the plan or issuer) 20 for the same or a similar item or service 21 that is provided by a provider in the same 22 or similar specialty and provided in the ge- 23 ographic region in which the item or serv- 24 ice is furnished. g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 CONTRACTED RATE.— 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 8 1 ‘‘(ii) RULEMAKING.—Not later than 2 July 1, 2020, the Secretary shall through 3 rulemaking determine the methodology the 4 plan or issuer shall use to determine the 5 median contracted rate, the information 6 the plan or issuer shall share with the non- 7 participating provider involved when mak- 8 ing such a determination, and the geo- 9 graphic regions applied for purposes of this 10 subparagraph. 11 ‘‘(F) NONPARTICIPATING 12 CILITY; 13 ITY.— 14 EMERGENCY ‘‘(i) NONPARTICIPATING FACIL- EMERGENCY 15 FACILITY.—The 16 emergency facility’ means, with respect to 17 an item or service and a group health plan 18 or health insurance coverage offered by a 19 health insurance issuer, an emergency de- 20 partment of a hospital or an independent 21 freestanding emergency department, that 22 does not have a contractual relationship 23 with the plan or coverage for furnishing 24 such item or service. g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 PARTICIPATING EMERGENCY FA- 14:54 May 13, 2019 Jkt 000000 term ‘nonparticipating (720823 10) PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 9 1 ‘‘(ii) PARTICIPATING 2 CILITY.—The 3 gency facility’ means, with respect to an 4 item or service and a group health plan or 5 health insurance coverage offered by a 6 health insurance issuer, an emergency de- 7 partment of a hospital or an independent 8 freestanding emergency department, that 9 has a contractual relationship with the 10 plan or coverage for furnishing such item 11 or service. 12 ‘‘(G) NONPARTICIPATING 13 term ‘participating emer- PROVIDERS; PAR- TICIPATING PROVIDERS.— 14 ‘‘(i) NONPARTICIPATING PROVIDER.— 15 The 16 means, with respect to an item or service 17 and a group health plan or health insur- 18 ance coverage offered by a health insur- 19 ance issuer, a physician or other health 20 professional who is licensed by the State 21 involved to furnish such item or service 22 and who does not have a contractual rela- 23 tionship with the plan or coverage for fur- 24 nishing such item or service. g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 EMERGENCY FA- 14:54 May 13, 2019 Jkt 000000 term ‘nonparticipating provider’ (720823 10) PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 10 1 ‘‘(ii) PARTICIPATING 2 term ‘participating provider’ means, with 3 respect to an item or service and a group 4 health plan or health insurance coverage 5 offered by a health insurance issuer, a phy- 6 sician or other health professional who is 7 licensed by the State involved to furnish 8 such item or service and who has a con- 9 tractual relationship with the plan or cov- 10 erage for furnishing such item or service. 11 ‘‘(H) RECOGNIZED AMOUNT.—The term 12 ‘recognized amount’ means, with respect to an 13 item or service— 14 ‘‘(i) in the case of such item or service 15 furnished in a State that has in effect a 16 State law that provides for a method for 17 determining the amount of payment that is 18 required to be covered by a health plan or 19 health insurance issuer offering group or 20 individual health insurance coverage regu- 21 lated by such State in the case of a partici- 22 pant, beneficiary, or enrollee covered under 23 such plan or coverage and receiving such 24 item or service from a nonparticipating 25 provider, not more than the amount deter- g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 PROVIDER.—The 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 11 1 mined in accordance with such law plus 2 the cost-sharing amount imposed for such 3 item or service (as determined in accord- 4 ance with paragraph (1)(C)(ii) or sub- 5 section (e)(1)(A), as applicable); or 6 ‘‘(ii) in the case of such item or serv- 7 ice furnished in a State that does not have 8 in effect such a law, an amount that is at 9 least the median contracted rate (as de- 10 fined in subparagraph (E)(i) and deter- 11 mined in accordance with the regulations 12 promulgated pursuant to subparagraph 13 (E)(ii)) for such item or service.’’. 14 (b) NON-EMERGENCY SERVICES PERFORMED 15 NONPARTICIPATING PROVIDERS 16 PATING 17 AT CERTAIN PARTICI- GENERAL.—Section 2719A of the Public FACILITIES.— (1) IN 18 Health Service Act (42 U.S.C. 300gg–19a) is 19 amended by adding at the end the following new 20 subsection: 21 ‘‘(e) NON-EMERGENCY SERVICES PERFORMED 22 NONPARTICIPATING PROVIDERS 23 PATING 24 25 14:54 May 13, 2019 AT BY CERTAIN PARTICI- FACILITIES.— ‘‘(1) IN GENERAL.—In the case of items or services (other than emergency services to which g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 BY Jkt 000000 (720823 10) PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 12 1 subsection (b) applies) furnished to a participant, 2 beneficiary, or enrollee of a health plan (as defined 3 in paragraph (2)(A)) by a nonparticipating provider 4 (as defined in subsection (b)(2)(G)) during a visit at 5 a participating health care facility (as defined in 6 paragraph (2)(B)), with respect to such plan, the 7 plan— 8 ‘‘(A) shall not impose on such participant, 9 beneficiary, or enrollee a cost-sharing amount 10 (expressed as a copayment amount or coinsur- 11 ance rate) for such items and services so fur- 12 nished that is greater than the cost-sharing 13 amount that would apply under such plan had 14 such items or services been furnished by a par- 15 ticipating provider; 16 ‘‘(B) shall pay to such provider furnishing 17 such items and services to such participant, 18 beneficiary, or enrollee the amount by which the 19 recognized amount (as defined in subsection 20 (b)(2)(H)) for such services exceeds the cost- 21 sharing amount imposed for such services (as 22 determined in accordance with subparagraph 23 (A)); and 24 ‘‘(C) shall count toward any deductible or 25 out-of-pocket maximums applied under the plan g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 13 1 any cost-sharing payments made by the partici- 2 pant, beneficiary, or enrollee with respect to 3 such items and services so furnished in the 4 same manner as if such cost-sharing payments 5 were with respect to items and services fur- 6 nished by a participating provider. 7 ‘‘(2) DEFINITIONS.—In this subsection: 8 ‘‘(A) HEALTH term ‘health 9 plan’ means a group health plan and health in- 10 surance coverage offered by a heath insurance 11 issuer in the group or individual market. 12 ‘‘(B) PARTICIPATING 13 HEALTH CARE FACIL- ITY.— 14 ‘‘(i) IN GENERAL.—The term ‘partici- 15 pating health care facility’ means, with re- 16 spect to an item or service and a group 17 health plan or health insurance coverage 18 offered by a health insurance issuer, a 19 health care facility described in clause (ii) 20 that has a contractual relationship with 21 the plan or coverage for furnishing such 22 item or service. 23 ‘‘(ii) HEALTH CARE FACILITY 24 SCRIBED.—A 25 in this clause is each of the following: g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 PLAN.—The 14:54 May 13, 2019 Jkt 000000 DE- health care facility described (720823 10) PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 14 1 ‘‘(I) A hospital (as defined in 2 1861(e) of the Social Security Act). 3 ‘‘(II) A critical access hospital 4 (as defined in section 1861(mm) of 5 such Act). 6 ‘‘(III) An ambulatory surgical 7 center 8 1833(i)(1)(A) of such Act). 9 (as defined in section ‘‘(IV) A laboratory. 10 ‘‘(V) A radiology or imaging cen- 11 ter.’’. 12 (2) EFFECTIVE DATE.—The amendments made 13 by this subsection shall apply with respect to plan 14 years beginning on or after January 1, 2021. 15 (c) PREVENTING CERTAIN CASES OF BALANCE BILL- 16 ING.—Section 1128A of the Social Security Act (42 17 U.S.C. 1320a–7a) is amended by adding at the end the 18 following new subsections: 19 ‘‘(t)(1) In the case of an individual with benefits 20 under a health plan or health insurance coverage offered 21 in the group or individual market who is furnished on or 22 after January 1, 2021, emergency services with respect 23 to an emergency medical condition during a visit at an 24 emergency department of a hospital or an independent g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 15 1 freestanding emergency department (as defined in section 2 2719A(b)(2) of the Public Health Service Act)— 3 ‘‘(A) if the emergency department of a hospital 4 or independent freestanding emergency department 5 holds the individual liable for a payment amount for 6 such emergency services so furnished that is more 7 than the cost-sharing amount for such services (as 8 determined 9 2719A(b)(1)(C)(ii) of the Public Health Service 10 accordance with section Act); or 11 ‘‘(B) if any health care provider holds such in- 12 dividual liable for a payment amount for an emer- 13 gency service furnished to such individual by such 14 provider with respect to such emergency medical 15 condition and visit for which the individual receives 16 emergency services at the hospital or emergency de- 17 partment that is more than the cost-sharing amount 18 for such services furnished by the provider (as deter- 19 mined in accordance with section 2719A(b)(1)(C)(ii) 20 of the Public Health Service Act); 21 the hospital, emergency department, independent 22 freestanding emergency department, or health care 23 provider, respectively, shall be subject, in addition to 24 any other penalties that may be prescribed by law, g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 in 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 16 1 to a civil money penalty of not more than $øll¿ 2 for each specified claim. 3 ‘‘(2) The provisions of subsections (c), (d), (e), (g), 4 (h), (k), and (l) shall apply to a civil money penalty or 5 assessment under paragraph (1) or subsection (u) in the 6 same manner as such provisions apply to a penalty, assess7 ment, or proceeding under subsection (a). 8 ‘‘(3) In this subsection and subsection (u): 9 ‘‘(A) The terms ‘emergency medical condition’ 10 and ‘emergency services’ have the meanings given 11 such terms, respectively, in section 2719A(b)(2) of 12 the Public Health Service Act. 13 ‘‘(B) The terms ‘group health plan’, ‘health in- 14 surance issuer’, and ‘health insurance coverage’ have 15 the meanings given such terms, respectively, in sec- 16 tion 2791 of the Public Health Service Act. 17 ‘‘(u)(1) Subject to paragraph (2), in the case of an 18 individual with benefits under a health plan or health in19 surance coverage offered in the group or individual market 20 who is furnished on or after January 1, 2021, items or 21 services (other than emergency services to which sub22 section (t) applies) at a participating health care facility 23 by a nonparticipating provider, if such provider holds such 24 individual liable for a payment amount for such an item 25 or service furnished by such provider during a visit at such g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 17 1 facility that is more than the cost-sharing amount for such 2 item or service (as determined in accordance with section 3 2719A(e)(1)(A) of the Public Health Service Act), such 4 provider shall be subject, in addition to any other penalties 5 that may be prescribed by law, to a civil money penalty 6 of not more than $øll¿ for each specified claim. 7 ‘‘(2) Paragraph (1) shall not apply to a nonpartici- 8 pating provider (other than a facility-based provider), with 9 respect to items or services furnished by the provider at 10 a participating health care facility to a participant, bene11 ficiary, or enrollee of a health plan or health insurance 12 coverage offered by a health insurance issuer, if the pro13 vider is in compliance with the requirement of paragraph 14 (3). For purposes of the previous sentence, the term ‘facil15 ity-based provider’ means emergency medicine providers, 16 anesthesiologists, 17 neonatologists, pathologists, assistant surgeons, radiologists, hospitalists, 18 intensivists, or other providers as determined by the Sec19 retary. 20 ‘‘(3) (A) For purposes of paragraph (2) a nonpartici- 21 pating provider is in compliance with this paragraph, with 22 respect to items or services furnished by the provider at 23 a participating health care facility to a participant, bene24 ficiary, or enrollee of a health plan or health insurance g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00017 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 18 1 coverage offered by a health insurance issuer, if the pro2 vider— 3 ‘‘(i)(I) provides to the participant, beneficiary, 4 or enrollee (or to a representative of the participant, 5 beneficiary, or enrollee), on the date on which the 6 participant, beneficiary, or enrollee makes an ap- 7 pointment to be furnished such items or services, if 8 applicable, and on the date on which the individual 9 is furnished such items and services— 10 ‘‘(aa) an oral explanation of the writ- 11 ten notice described in item (bb) and such 12 documentation of the provision of such ex- 13 planation, as the Secretary determines ap- 14 propriate; and 15 ‘‘(bb) a written notice specified, not 16 later than July 1, 2020, by the Secretary 17 through rulemaking that— 18 ‘‘(AA) contains the information 19 required under subparagraph (B); and 20 ‘‘(BB) is signed and dated by the 21 participant, beneficiary, or enrollee; 22 and 23 ‘‘(II) retain, for a period specified through rule- 24 making by the Secretary, a copy of the documenta- g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 19 1 tion described in subclause (I)(aa) and the written 2 notice described in subclause (I)(bb); and 3 ‘‘(ii) obtains from the participant, beneficiary, 4 or enrollee (or representative) the consent described 5 in subparagraph (C). 6 ‘‘(B) For purposes of subparagraph (A)(i), the infor- 7 mation described in this subparagraph, with respect to a 8 nonparticipating provider and a participant, beneficiary, 9 or enrollee of a health plan or health insurance coverage 10 offered by a health insurance issuer, is a notification of 11 each of the following: 12 ‘‘(i) That the health care provider is a non- 13 participating provider with respect to the group 14 health plan or health insurance coverage. 15 ‘‘(ii) The estimated amount that such provider 16 will charge the participant, beneficiary, or enrollee 17 for such items and services involved. 18 ‘‘(C) For purposes of subparagraph (A)(ii), the con- 19 sent described in this subparagraph, with respect to a par20 ticipant, beneficiary, or enrollee of a group health plan or 21 health insurance coverage offered by a health insurance 22 issuer, who is to be furnished items or services by a non23 participating provider, is a document specified by the Sec24 retary through rulemaking that— g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00019 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 20 1 ‘‘(i) is signed by the participant, beneficiary, or 2 enrollee (or by a representative of the participant, 3 beneficiary, or enrollee) not less than 24 hours prior 4 to the participant, beneficiary, or enrollee being fur- 5 nished such items or services by such provider; 6 7 ‘‘(ii) acknowledges that the participant, beneficiary, or enrollee has been— 8 ‘‘(I) provided with a written estimate and 9 an oral explanation of the charge that the par- 10 ticipant, beneficiary, or enrollee will be assessed 11 for the items or services anticipated to be fur- 12 nished to the participant, beneficiary, or en- 13 rollee by such nonparticipating provider; and 14 ‘‘(II) informed that the payment of such 15 charge by the participant, beneficiary, or en- 16 rollee will not accrue toward meeting any limi- 17 tation that the group health plan or health in- 18 surance coverage places on cost-sharing; and 19 ‘‘(iii) documents the consent of the participant, 20 beneficiary, or enrollee to— 21 ‘‘(I) be furnished with such items or serv- 22 ices by such nonparticipating provider; and 23 ‘‘(II) in the case that the individual is so 24 furnished such items or services, be charged an 25 amount that may be greater than the amount g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00020 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 21 1 that would otherwise be changed the individual 2 if furnished by a participating provider with re- 3 spect to such items or services and plan or cov- 4 erage. 5 ‘‘(4) For purposes of this subsection, the terms ‘non- 6 participating provider’ and ‘participating health care facil7 ity’ have such meanings given such terms under sub8 sections (b)(2) and (e)(2), respectively, of section 2719A 9 of the Public Health Service Act.’’. 10 (d) STATE ALL PAYER CLAIMS DATABASES.— 11 (1) IN Secretary of Health and 12 Human Services shall make one-time grants to eligi- 13 ble States for the purposes described in paragraph 14 (2). 15 (2) USES.—A State may use a grant received 16 under paragraph (1) for one of the following pur- 17 poses: 18 (A) To establish an All Payer Claims 19 Database for the State. 20 (B) To maintain an existing All Payer 21 Claims Databases for the State. 22 (3) ELIGIBILITY.—To be eligible to receive a 23 grant under paragraph (1) a State shall submit to 24 the Secretary an application at such time, in such 25 manner, and containing such information as the Sec- g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 GENERAL.—The 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00021 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X G:\P\16\H\ACA\ECD\SURPRISEBILL_02.XML 22 1 retary specifies. Such information shall include, with 2 respect to an All Payer Claims Database for the 3 State, at least specifics on how the State will ensure 4 uniform data collection through the database and 5 the security of such data submitted to and main- 6 tained in the database. 7 (4) ALL pur- 8 poses of this subsection, the term ‘‘All Payer Claims 9 Database’’ means, with respect to a State, a State 10 database that may include medical claims, pharmacy 11 claims, dental claims, and eligibility and provider 12 files, which are collected from private and public 13 payers. 14 (5) AUTHORIZATION OF APPROPRIATIONS.—To 15 carry out this subsection, there are appropriated 16 $50,000,000, to remain available until expended. g:\VHLC\051319\051319.238.xml May 13, 2019 (2:54 p.m.) VerDate 0ct 09 2002 PAYER CLAIMS DATABASE.—For 14:54 May 13, 2019 Jkt 000000 (720823 10) PO 00000 Frm 00022 Fmt 6652 Sfmt 6201 C:\USERS\JRSHAP~1\APPDATA\ROAMING\SOFTQUAD\XMETAL\7.0\GEN\C\SURPRI~1.X