S. 9952 Summary

• Requires health care providers to offer payment rates for applicable services at no more than 150% of Medicare reimbursement rates, with no facility fees charged for these services.

• Defines applicable services to include 66 ambulatory payment classifications (APCs) identified by Medicare Payment Advisory Commission (MedPAC), evaluation and management office visit codes (CPT 99201-99215), and preventative wellness visit codes.

• Excludes from requirements: federally qualified health centers, public hospitals, critical access hospitals, sole community hospitals, rural emergency hospitals, and safety-net hospitals with 45% or more Medicaid/uninsured payor mix.

• Requires health benefit plan contracts to include provisions limiting reimbursement to the 150% Medicare rate cap and prohibiting patient liability for amounts exceeding these rates, including copayments and coinsurance.

• Establishes penalties of up to $1,000 per improper claim or minimum $100,000 per contract violation for provider non-compliance, and up to $50,000 per day penalty for insurance carriers maintaining non-compliant contracts.