Sec. 801. Protection against surprise bills
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Section 2719A of the Public Health Service Act ( 42 U.S.C. 300gg–19a ) is amended by adding at the end the following: Subject to subsection (h), in the case of an enrollee in a group health plan or group or individual health insurance coverage who receives out-of-network ancillary services at an in-network facility, including any referrals for diagnostic services, and such services would be covered under such plan or coverage if provided in-network— the cost-sharing requirement (expressed as a copayment amount, coinsurance rate, or deductible) with respect to such services shall be the same requirement that would apply if such services were provided by an in-network practitioner, and any coinsurance or deductible shall be based on in-network rates; and amounts paid toward such cost-sharing shall be counted towards the in-network deductible and in-network out-of-pocket maximum amount, as applicable, under the plan or coverage for the plan year.
Subject to subsection (h), in the case of an enrollee in a group health plan or group or individual health insurance coverage who receives out-of-network, non-emergency services that are not ancillary services, from an out-of-network provider at an in-network facility, and such services would be covered under such plan or coverage if provided in-network, the cost-sharing requirement (expressed as a copayment amount, coinsurance rate, or deductible) with respect to such services shall be the same requirement that would apply if such services were provided by an in-network practitioner, and any coinsurance or deductible shall be based on in-network rates, unless, as soon as practicable, and in no case later than 48 hours prior to providing non-emergency services that are not ancillary services— the in-network facility provides to the enrollee who is scheduled to receive such services notice that— is provided in paper or electronic form (and including electronic notification whenever practicable); states that such service will be provided out-of-network; includes the estimated amount that such practitioner or facility may charge the enrollee for such services; and provides the option to affirmatively consent to receiving such services from such practitioner or facility; such enrollee signs such notice consenting to receive such services from an out-of-network provider at an in-network facility, and acknowledging that the out-of-network services may be covered at an out-of-network cost-sharing amount, requiring higher cost-sharing obligations of the enrollee than if the service were provided by an in-network practitioner or facility; and such facility maintains documentation of the enrollee's signature or confirmation of receipt of such information under subparagraph
(B)in the enrollee's patient record for 2 years after the date of services. In the case of an enrollee in a group health plan or group or individual health insurance coverage who receives emergency services, or maternal care for a woman in labor, in the emergency department of an out-of-network facility and has not been stabilized (within the meaning of subsection (b)(2)(C)), if the patient is subsequently admitted to the out-of-network facility for care, the cost-sharing requirement (expressed as a copayment amount, coinsurance rate, or deductible) with respect to any out-of-network services provided to the enrollee prior to being stable and in a condition to receive information under (2), is the same requirement that would apply as under subsection (b)(2)(C)(ii)(II). Subject to subsection (h), in the case of an enrollee in a group health plan or group or individual health insurance coverage who receives emergency services, or maternal care for a woman in labor, in the emergency department of an out-of-network facility and has been stabilized (within the meaning of subsection (b)(2)(C)), if the patient is subsequently admitted to the out-of-network facility for care, the cost-sharing requirement (expressed as a copayment amount, coinsurance rate, or deductible) with respect to any out-of-network services is the same requirement that would apply if such services were provided by an in-network provider, unless the enrollee, once stable and in a condition to receive such information, including having sufficient mental capacity— has been provided by the facility, prior to the provision of any post-stabilization, out-of-network service at such facility, with— paper or electronic notification that the practitioner or facility is an out-of-network health care provider and the out-of-network rate of the provider, as applicable, and the option to affirmatively consent to receiving services from such practitioner or facility; and the estimated amount that such provider may charge the participant, beneficiary, or enrollee for such services involved; has been provided by the plan or coverage, prior to the provision of any post-stabilization, out-of-network service at such facility, with— paper or electronic notification (and including electronic notification whenever practicable) that the practitioner or facility is an out-of-network health care provider, and the option to affirmatively consent to receiving services from such practitioner or facility; a list of in-network practitioners or facilities in the relevant geographic area that could provide the same services, and an option for a referral to such providers; and information about whether prior authorization or other care management limitations may be required in advance of receiving in-network services at the facility; and has acknowledged, in writing, that the out-of-network services provided after the individual has been stabilized may not be covered or may be covered at an out-of-network cost-sharing amount, requiring higher cost-sharing obligations of the enrollee than if the service were provided at an in-network facility. The notice under subparagraph
(A)shall be in a format determined by the Secretary to give a reasonable layperson clear comprehension of the terms of the agreement, including all possible financial responsibilities, including the requirements that the notice— does not exceed one page in length; is readily identifiable for its purpose and as a contract of consent; clearly states that consent to potential out-of-network charges is optional and that the enrollee has the choice to transfer to an in-network facility; includes an estimate of the amount that such provider will charge the participant, beneficiary, or enrollee for such services involved; and be available in the 15 most common languages in the facility’s geographic area, with the facility making a good faith effort to provide oral notice in the enrollee’s primary language if it is not one of such 15 languages. A facility shall maintain documentation of notice given to an enrollee pursuant to this subsection and the enrollee's confirmation of receipt of such information in the enrollee's patient record for 2 years after the date of services. Not later than 6 months after the date of enactment of this subsection, the Secretary shall issue regulations to carry out this subsection, which shall include clarification on how to determine whether an individual is stabilized and the timing of the notice required under this paragraph. A facility or practitioner furnishing— emergency services, as defined in subsection (b)(2), regardless of the State in which the patient resides; out-of-network services at an in-network facility described in subsection (e)(1); out-of-network services at an in-network facility described in subsection (e)(2), where the notice and consent for receiving such services out-of-network did not meet the requirement of such subsection; services furnished by an out-of-network provider after an enrollee has been admitted to the hospital for emergency services but prior to stabilization, as described in subsection (f)(1); or out-of-network services furnished after the enrollee has been stabilized (within the meaning of subsection (b)(2)(C)), where the notice and option for receiving care at an alternate facility required under subsection (f)(2) have not been provided to the enrollee and the enrollee did not give consent under subsection (f)(3), may not bill an enrollee in a group health plan or group or individual health insurance coverage for amounts beyond the cost-sharing amount that would apply under subsection (b)(1)(C)(ii)(II), (e)(1), (e)(2), or (f), as applicable. A facility furnishing services described in paragraph
(1)shall provide enrollees in a group health plan or group or individual health insurance coverage with a one-page notice, in 16-point font, upon intake at the emergency room or being admitted at the facility of the prohibition on balance billing under paragraph
(1)and who to contact for recourse if they are sent a balance bill in violation of such paragraph. The facility shall be responsible for obtaining the signature from the enrollee on such notice. The Secretary shall issue regulations within 6 months of the date of enactment of this subsection on the requirements for the notice under this paragraph. Nothing in this section shall prevent a State from establishing or continuing in effect, with respect to health insurance issuers, facilities, or practitioners, an alternate method under State law for determining the appropriate compensation for services described in subsection (b), (e), or (f). In the case of group health plans or group or individual health insurance coverage offered in a State that has not established an alternate method described in paragraph (1), such as arbitration or a benchmark, or for services described in subsection (b), (e), or
(f)that are not covered by such State’s alternate method described in paragraph (1), the provisions of this section shall apply. Subsections (b), (e), and
(f)shall apply to a self-insured group health plan that is not subject to State insurance regulation. In this section: The term in-network , with respect to a group health plan or health insurance coverage means a provider that has a contractual relationship with the plan. The term enrollee , with respect to health insurance coverage or a group health plan, includes a participant, dependent, or beneficiary. The term ancillary services means non-emergency care that is— provided by anesthesiologists, pathologists, emergency medicine providers, intensivists, radiologists, neonatologists, hospitalists, and assistant surgeons, whether the care is provided by a physician or non-physician practitioner; a diagnostic service (including radiology and lab services); or provided by such other specialty practitioner not typically selected by the patients receiving the care, which the Secretary may add periodically to such definition through rulemaking. . Part C of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg–91 et seq.) is amended by adding at the end the following: Subject to subsection (b), a facility or practitioner that violates a requirement under section 2719A(g)(1) or fails to provide notice or obtain consent as required under subsection (e)(2) or (f)(2) shall be subject to a civil monetary penalty of not more than $10,000 for each act constituting such violation. The provisions of section 1128A of the Social Security Act, 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. The Secretary shall waive the penalties described under subsection
(a)with respect to a facility or, practitioner who does not knowingly violate, and should not have reasonably known it violated, section 2719A(g)(1) with respect to an enrollee, if such facility or practitioner, within 30 days of the violation, withdraws the bill that was in violation of section 2719A(g)(1), and, as applicable, reimburses the group health plan, health insurance issuer, or enrollee, in an amount equal to the difference between the amount billed and the amount allowed to be billed under section 2719A(g)(1), plus interest, at an interest rate determined by the Secretary. The Secretary may establish a hardship exemption to the penalties under this section. The Secretary shall waive penalties under this section with respect to a facility or practitioner that has already been subject to enforcement action under State law for a violation described in subsection (a). . Section 1251(a) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18011(a) ) is amended by adding at the end the following: Subsections
(b)through
(h)of section 2719A of the Public Health Service Act ( 42 U.S.C. 300gg–19a ) shall apply to grandfathered health plans for plan years beginning with the second plan year that begins after the date of enactment of this paragraph. . Section 8904 of title 5, United States Code, is amended by adding at the end the following: Any health benefits plan offered under this chapter shall be treated as a group health plan or group or individual health insurance coverage for purposes of subsections
(e)through
(g)of section 2719A of the Public Health Service Act ( 42 U.S.C. 300gg–19a ) (except for paragraph
(3)of such subsection (g)). .
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- 42 USC 300gg–19a
- 42 USC 300gg–91
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