Senate Bill Uses Federal Benchmark to Resolve Surprise Medical Bills

June 21, 2019

The Senate Health, Education, Labor, and Pensions (HELP) Committee released a bipartisan bill containing nearly three dozen provisions to reduce out-of-pocket health care costs and increase health care price transparency, including using a federal benchmark to resolve surprise medical bills.

The benchmark would be based on the median in-network rate of a procedure in a geographic area.  This is the same approach included in the House Energy and Commerce Committee's bipartisan discussion draft released last month.

The HELP Committee bill would also:

  • Prohibit contract clauses that restrict employer access to their claims data and sharing the data with business associates (third parties) to reduce health care costs;

  • Require self-insured employers to submit their claims data to a national all-payer claims database, but enable employers to request access to the data for cost-containment and quality improvement purposes;

  • Require employers to verify and update information on the provider networks every 90 days;

  • Ban anti-competitive terms in facility and insurance contracts that limit access to higher quality/lower cost care;

  • Prohibit PBMs from engaging in spread pricing, or charging a plan sponsor or patient more for a drug than the PBM paid to acquire the drug; and

  • Require PBMs to pass on 100% of any rebates or discounts to the plan sponsor.

Looking ahead:  Chairman Alexander (R-TN) plans to mark up the bill next week.  Meanwhile, a group of bipartisan senators led by Sen. Bill Cassidy (R-LA) have introduced a bill that would use arbitration to resolve surprise bills, an approach preferred by the provider community.