Sec. 3. Prohibition on surprise balance billing and independent dispute resolution with respect to out-of-network health care services
1,690 words·~8 min read·
/bill/116/s/1531/is/section-3·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Subpart II of part A of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg et seq.) is amended by adding at the end the following: In this title, the term surprise medical bill means a balance bill, as described in subsection (b), that an enrollee receives for services provided to the enrollee where such services were— emergency services provided by an out-of-network health care professional or at an out-of-network facility; health care services that were provided— at an in-network facility (including the use of equipment, devices, telemedicine services, or other treatments or services); and by an out-of-network health care professional; or additional health care services required in the case of an enrollee who initially enters a hospital through the emergency room for emergency services, and then receives nonemergency services from an out-of-network health care professional or at an out-of-network hospital or facility after the enrollee has been stabilized (as defined in section 2719A(b)(2)(C)), as determined by the treating physician.
Paragraph
(3)shall not apply in the case of an enrollee who is stabilized and able to travel in nonmedical transport, and the enrollee (or designee of the enrollee where the enrollee is not able to comprehend the information to be provided or make related decisions) has been provided with clear, written notification that the professional or facility is an out-of-network health care professional or facility, has been given a cost estimate for services provided by the out-of-network professional or facility, and has assumed, in writing, full responsibility for out-of-pocket costs associated with such out-of-network care. In subsection (a), the term balance bill refers to a claim for payment for services provided to an enrollee that is in an amount equal to the difference between the actual amount charged with respect to services or care described in subsection
(a)and the expected in-network cost-sharing required by the enrollee under the plan or coverage involved. A group health plan, a health insurance issuer in connection with group or individual health insurance coverage, or a health care provider shall not engage in balance billing practices prohibited under this section. Subparagraph
(A)shall apply— to all services provided at hospitals, emergency rooms, State-accredited free-standing emergency departments, hospital outpatient departments, and ambulatory surgery centers; and with respect to subsection (a)(2), to the health care provider’s offices and related services (including laboratory and imaging services ordered by an in-network provider and provided by an out-of-network provider or laboratory). With respect to the services and care described in subsection (a), an enrollee shall only be liable for the in-network cost-sharing amount provided for in their plan or coverage. For purposes of this section, such payments by the enrollee shall count toward the in-network deductible under the plan or coverage as well as toward the enrollee’s out-of-pocket maximum limitation. Violations of this section shall subject the violator to a civil monetary penalty as provided for in this title. Such provisions shall not apply to a health care provider, group health plan, or health insurance issuer that unknowingly balance bills an enrollee and reimburses such enrollee within 30 calendar days of such billing. An enrollee may not be billed in excess of the in-network cost-sharing amount for services or care provided under section 2729A (a surprise medical bill situation). A group health plan, or health insurance issuer in connection with group or individual health insurance coverage, shall pay the median in-network rate under the plan or coverage, less the applicable enrollee in-network cost-sharing, directly to the health care provider as provided for in this section. Upon payment under subparagraph (A), the plan or issuer shall provide to the health care provider information about how the provider may initiate independent dispute resolution under such subsection with respect to such payment. The plan, issuer, or provider may negotiate an alternative amount or initiate independent dispute resolution under subsection
(b)during the 30-day period beginning on the date on which the automatic payment is made under this subsection. Not later than 1 year after the date of enactment of this section, the Secretary, in consultation with the Secretary of Labor, shall establish a process for resolving payment disputes between group health plans, or health insurance issuers offering health insurance coverage in the group market, and out-of-network health care providers in surprise medical bill situations in accordance with this section (referred to in this section as the IDR process ). An entity wishing to participate in the IDR process under this subsection shall request certification from the Secretary. The Secretary, in consultation with the Secretary of Labor, shall determine eligibility of applicant entities, taking into consideration whether the entity is unbiased and unaffiliated with health plans and providers and free of conflicts of interest, in accordance with the Secretary’s rulemaking on determining criteria for conflicts of interest. Under the process established under paragraph (1), the parties in the independent dispute resolution process shall jointly agree upon an independent dispute resolution entity. In the event that parties cannot agree, one will be selected at random jointly by the Department of Health and Human Services and the Department of Labor. The IDR process shall be with respect to one or more Current Procedural Terminology ( CPT ) codes. Health care facilities and providers and group health plans or health insurance issuers may batch claims if such claims— involve identical plan or issuer and provider or facility parties; involve claims with the same or related current procedural terminology codes relevant to a particular procedure; and involve claims that occur within 30 days of each other. An independent dispute resolution entity that receives a request under this section shall, not later than 30 days after receiving such request, determine the amount the group health plan, or health insurance issuer offering health insurance coverage in the group market, is required to pay the out-of-network health care provider. Such amount shall be— the amount determined by the parties through a settlement under paragraph (2); or the amount determined reasonable by the entity in accordance with paragraph (3). If the independent dispute resolution entity determines, based on the amounts indicated in the request under this section, that a settlement between the group health plan, or health insurance issuer offering health insurance coverage in the group market, and the out-of-network health care provider is likely, the independent dispute resolution entity may direct the parties to attempt, for a period not to exceed 10 days, a good faith negotiation for a settlement. The period for a settlement described in subparagraph
(A)shall accrue towards the 30-day period required under paragraph (1). In the absence of a settlement under paragraph (2), the group health plan, or health insurance issuer offering health insurance coverage in the group market, and the out-of-network health care provider shall each submit to the independent dispute resolution entity their final offer. Such entity shall determine which of the 2 amounts is more reasonable based on the factors described in subparagraph (D). The amount that is determined to be the more reasonable amount under subparagraph
(A)shall be the final decision of the independent dispute resolution entity as to the amount the group health plan, or health insurance issuer offering health insurance coverage in the group market, is required to pay the out-of-network health care provider. A final determination under subparagraph
(B)may include the resolution of disputes for multiple items or services, if such determination is in regard to items or services that are eligible for independent dispute resolution under subsection (c)(2). In determining which final offer to select as the more reasonable amount under subparagraph (A), the independent dispute resolution entity shall consider relevant factors including— commercially reasonable rates for comparable services or items in the same geographic area (which shall take into consideration in-network rates for that geographic area and not charges); and other factors that may be submitted at the discretion of either party, which may include— the level of training, education, experience, and quality and outcomes measurements of the out-of-network health care provider; the circumstances and complexity of the particular dispute, including the time and place of the service; the market share held by the out-of-network health care provider or that of the plan or issuer; demonstration of good faith efforts (or lack of good faith efforts) made by the out-of-network provider or the plan to contract and prior negotiated rates, if applicable; and other relevant economic aspects of provider reimbursement for the same specialty within the same geographic area. A final determination of an independent dispute resolution entity under subparagraph (B)— shall be binding; and shall not be subject to judicial review, except in cases comparable to those described in section 10(a) of title 9, United States Code, as determined by the Secretary in consultation with the Secretary of Labor, and cases in which information submitted by one party was determined to be fraudulent. An independent dispute resolution entity shall, in conducting an independent dispute resolution process under this subsection, comply with all applicable Federal and State privacy laws. The reasonable amount determined by an independent dispute resolution entity under this subsection with respect to any claim shall not be confidential, except that information submitted to the independent dispute entity shall be kept confidential. Independent dispute entities may consider past decisions awarded by independent dispute entities during the independent dispute resolution process. The nonprevailing party shall be responsible for paying all fees charged by the independent dispute resolution entity. If the parties reach a settlement prior to completion of the independent dispute resolution process, the costs of the independent dispute resolution process shall be divided equally between the parties. Group health plans and health insurance issuers with respect to group health coverage shall pay directly to the health care provider amounts determined by the independent dispute resolution entity within 30 days of the date on which the entity makes a determination with respect to such amount. A plan or issuer that fails to comply with this paragraph shall be subject to the penalties described in section 2729A(c)(3). . Section 2719A(b)(1)(C)(ii)(II) of the Public Health Service Act (42 U.S.C. 300gg–19a(b)(1)(C)(ii)(II)) is amended by inserting , deductible amount, after copayment amount .
Connectionstraces to 1
Traces to 1 document
1 reference not yet in our index
- 42 USC 300gg–19a(b)(1)(C)(ii)(II)
Citation graph
cites case law
Sec. 3
Prohibition on surprise balance billing and independent dispute resolution with respect to out-of-network health care services
Cite42 USC 300gg–19a(b)(1)(C)(ii)(II)
Cites 2Cited by 0 across 0 sources