Fair and Honest Advance Cost Estimate for Patients Act of 2020
This bill requires health care providers and private health insurance plans to provide certain estimates for the costs of services that are scheduled three or more business days in advance. Specifically, providers must inquire whether an individual scheduling such service is enrolled in a health plan, including a government health care program, and intends to seek benefits for the service under the plan. Within a specified time period prior to administering such service, the provider must submit to the individual’s plan, or to the individual if the individual is not enrolled in a plan, an estimate of expected charges for the service. Providers are subject to a maximum fine of $10,000 for each failure to provide such an estimate.
Within a specified time period after receiving an estimate from a provider for a service, private health insurance plans must provide the plan holder with specified benefits information that includes but is not limited to
[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5817 Introduced in House (IH)]
<DOC>
116th CONGRESS
2d Session
H. R. 5817
To amend title XXVII of the Public Health Service Act, the Internal
Revenue Code of 1986, and the Employee Retirement Income Security Act
of 1974 to require health plans to provide to participants,
beneficiaries, and enrollees an advanced explanation of benefits with
respect to items and services scheduled to be received from providers
and facilities and to amend title XI of the Social Security Act to
require health care providers and health care facilities to provide
good faith estimates of the expected charges for furnishing such items
and services.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
February 7, 2020
Mr. Nunes (for himself and Mr. Pascrell) introduced the following bill;
which was referred to the Committee on Energy and Commerce, and in
addition to the Committees on Ways and Means, and Education and Labor,
for a period to be subsequently determined by the Speaker, in each case
for consideration of such provisions as fall within the jurisdiction of
the committee concerned
_______________________________________________________________________
A BILL
To amend title XXVII of the Public Health Service Act, the Internal
Revenue Code of 1986, and the Employee Retirement Income Security Act
of 1974 to require health plans to provide to participants,
beneficiaries, and enrollees an advanced explanation of benefits with
respect to items and services scheduled to be received from providers
and facilities and to amend title XI of the Social Security Act to
require health care providers and health care facilities to provide
good faith estimates of the expected charges for furnishing such items
and services.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Fair and Honest Advance Cost
Estimate for Patients Act of 2020''.
SEC. 2. ADVANCED EXPLANATION OF BENEFITS.
(a) Health Plan Requirements.--
(1) Public health service act amendment.--Subpart II of
part A of title XXVII of the Public Health Service Act (42
U.S.C. 300gg-11 et seq.) is amended by adding at the end the
following new section:
``SEC. 2730. ADVANCED EXPLANATION OF BENEFITS.
``(a) In General.--Beginning on January 1, 2022, each health plan
shall, with respect to a notification submitted under section
1128A(t)(1)(B) of the Social Security Act by a health care provider or
health care facility, respectively, to the health plan for a
participant, beneficiary, or enrollee under such health plan scheduled
to receive an item or service from the provider or facility, not later
than 1 business day (or, in the case such item or service was so
scheduled at least 10 business days before such item or service is to
be furnished (or in the case such notification was made pursuant to a
request by such participant, beneficiary, or enrollee), 3 business
days) after the date on which the health plan receives such
notification, provide to the participant, beneficiary, or enrollee
(through mail or electronic means, as requested by the participant,
beneficiary, or enrollee) a notification including the following:
``(1) Whether or not the provider or facility is a
participating provider or a participating facility with respect
to the health plan with respect to the furnishing of such item
or service and--
``(A) in the case the provider or facility is a
participating provider or facility with respect to the
health plan with respect to the furnishing of such item
or service, the contracted rate under such plan for
such item or service; and
``(B) in the case the provider or facility is a
nonparticipating provider or facility with respect to
such plan, a description of how such participant,
beneficiary, or enrollee may obtain information on
providers and facilities that, with respect to such
health plan, are participating providers and
facilities.
``(2) The good faith estimate included in the notification
received from the provider or facility.
``(3) A good faith estimate of the amount the health plan
is responsible for paying for items and services included in
the estimate described in paragraph (2).
``(4) A good faith estimate of the amount of any cost-
sharing (including with respect to the deductible and any
copayment or coinsurance obligation) for which the participant,
beneficiary, or enrollee would be responsible for such item or
service (as of the date of such notification).
``(5) A good faith estimate of the amount that the
participant, beneficiary, or enrollee has incurred toward
meeting the limit of the financial responsibility (including
with respect to deductibles and out-of-pocket maximums) under
the health plan (as of the date of such notification).
``(6) In the case such item or service is subject to a
medical management technique (including concurrent review,
prior authorization, and step-therapy or fail-first protocols)
for coverage under the health plan, a disclaimer that coverage
for such item or service is subject to such medical management
technique.
``(7) A disclaimer that the information provided in the
notification is only an estimate based on the items and
services reasonably expected, at the time of scheduling (or
requesting) the item or service, to be furnished and is subject
to change.
``(8) Any other information or disclaimer the health plan
determines appropriate that is consistent with information and
disclaimers required under this section.
``(b) Health Plan Defined.--In this section, the term `health plan'
means a group health plan and health insurance coverage offered by a
heath insurance issuer in the group or individual market and includes a
grandfathered health plan (as defined in section 1251(e) of the Patient
Protection and Affordable Care Act).''.
(2) Internal revenue code of 1986 amendment.--
(A) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at
the end the following new section:
``SEC. 9816. ADVANCED EXPLANATION OF BENEFITS.
``(a) In General.--Beginning on January 1, 2022, each health plan
shall, with respect to a notification submitted under section
1128A(t)(1)(B) of the Social Security Act by a health care provider or
health care facility, respectively, to the health plan for a
participant or beneficiary under such health plan scheduled to receive
an item or service from the provider or facility, not later than 1
business day (or, in the case such item or service was so scheduled at
least 10 business days before such item or service is to be furnished
(or in the case such notification was made pursuant to a request by
such participant or beneficiary), 3 business days) after the date on
which the health plan receives such notification, provide to the
participant or beneficiary (through mail or electronic means, as
requested by the participant or beneficiary) a notification including
the following:
``(1) Whether or not the provider or facility is a
participating provider or a participating facility with respect
to the health plan with respect to the furnishing of such item
or service and--
``(A) in the case the provider or facility is a
participating provider or facility with respect to the
health plan with respect to the furnishing of such item
or service, the contracted rate under such plan for
such item or service; and
``(B) in the case the provider or facility is a
nonparticipating provider or facility with respect to
such plan, a description of how such participant or
beneficiary may obtain information on providers and
facilities that, with respect to such health plan, are
participating providers and facilities.
``(2) The good faith estimate included in the notification
received from the provider or facility.
``(3) A good faith estimate of the amount the health plan
is responsible for paying for items and services included in
the estimate described in paragraph (2).
``(4) A good faith estimate of the amount of any cost-
sharing (including with respect to the deductible and any
copayment or coinsurance obligation) for which the participant
or beneficiary would be responsible for such item or service
(as of the date of such notification).
``(5) A good faith estimate of the amount that the
participant or beneficiary has incurred toward meeting the
limit of the financial responsibility (including with respect
to deductibles and out-of-pocket maximums) under the health
plan (as of the date of such notification).
``(6) In the case such item or service is subject to a
medical management technique (including concurrent review,
prior authorization, and step-therapy or fail-first protocols)
for coverage under the health plan, a disclaimer that coverage
for such item or service is subject to such medical management
technique.
``(7) A disclaimer that the information provided in the
notification is only an estimate based on the items and
services reasonably expected, at the time of scheduling (or
requesting) the item or service, to be furnished and is subject
to change.
``(8) Any other information or disclaimer the health plan
determines appropriate that is consistent with information and
disclaimers required under this section.
``(b) Health Plan Defined.--In this section, the term `health plan'
means a group health plan, including any group health plan that is a
grandfathered health plan (as defined in section 1251(e) of the Patient
Protection and Affordable Care Act).''.
(B) Conforming amendment.--Section 9815(a) of the
Internal Revenue Code of 1986 is amended--
(i) in paragraph (1), by striking ``(as
amended by the Patient Protection and
Affordable Care Act)'' and inserting ``(other
than the provisions of section 2730 of such
Act)''; and
(ii) in paragraph (2), by inserting
``(other than the provisions of section 2730 of
such Act)'' after ``a provision of such part
A''.
(C) Clerical amendment.--The table of sections for
such subchapter is amended by adding at the end the
following new item:
``Sec. 9816. Advanced explanation of benefits.''.
(3) Employee retirement income security act of 1974
amendment.--
(A) In general.--Subpart B of part 7 of subtitle B
of title I of the Employee Retirement Income Security
Act of 1974 (29 U.S.C. 1185 et seq.) is amended by
adding at the end the following new section:
``SEC. 716. ADVANCED EXPLANATION OF BENEFITS.
``(a) In General.--Beginning on January 1, 2022, each health plan
shall, with respect to a notification submitted under section
1128A(t)(1)(B) of the Social Security Act by a health care provider or
health care facility, respectively, to the health plan for a
participant or beneficiary under such health plan scheduled to receive
an item or service from the provider or facility, not later than 1
business day (or, in the case such item or service was so scheduled at
least 10 business days before such item or service is to be furnished
(or in the case such notification was made pursuant to a request by
such participant or beneficiary), 3 business days) after the date on
which the health plan receives such notification, provide to the
participant or beneficiary (through mail or electronic means, as
requested by the participant or beneficiary) a notification including
the following:
``(1) Whether or not the provider or facility is a
participating provider or a participating facility with respect
to the health plan with respect to the furnishing of such item
or service and--
``(A) in the case the provider or facility is a
participating provider or facility with respect to the
health plan with respect to the furnishing of such item
or service, the contracted rate under such plan for
such item or service; and
``(B) in the case the provider or facility is a
nonparticipating provider or facility with respect to
such plan, a description of how such participant or
beneficiary may obtain information on providers and
facilities that, with respect to such health plan, are
participating providers and facilities.
``(2) The good faith estimate included in the notification
received from the provider or facility.
``(3) A good faith estimate of the amount the health plan
is responsible for paying for items and services included in
the estimate described in paragraph (2).
``(4) A good faith estimate of the amount of any cost-
sharing (including with respect to the deductible and any
copayment or coinsurance obligation) for which the participant
or beneficiary would be responsible for such item or service
(as of the date of such notification).
``(5) A good faith estimate of the amount that the
participant or beneficiary has incurred toward meeting the
limit of the financial responsibility (including with respect
to deductibles and out-of-pocket maximums) under the health
plan (as of the date of such notification).
``(6) In the case such item or service is subject to a
medical management technique (including concurrent review,
prior authorization, and step-therapy or fail-first protocols)
for coverage under the health plan, a disclaimer that coverage
for such item or service is subject to such medical management
technique.
``(7) A disclaimer that the information provided in the
notification is only an estimate based on the items and
services reasonably expected, at the time of scheduling (or
requesting) the item or service, to be furnished and is subject
to change.
``(8) Any other information or disclaimer the health plan
determines appropriate that is consistent with information and
disclaimers required under this section.
``(b) Health Plan Defined.--In this section, the term `health plan'
means a group health plan and health insurance coverage offered by a
health insurance issuer in the group market and includes a
grandfathered health plan (as defined in section 1251(e) of the Patient
Protection and Affordable Care Act) that is such a plan or coverage.''.
(B) Conforming amendment.--Section 715(a) of the
Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185d(a)) is amended--
(i) in paragraph (1), by striking ``(as
amended by the Patient Protection and
Affordable Care Act)'' and inserting ``(other
than the provisions of section 2730 of such
Act)''; and
(ii) in paragraph (2), by inserting
``(other than the provisions of section 2730 of
such Act)'' after ``a provision of such part
A''.
(C) Clerical amendment.--The table of contents in
section 1 of the Employee Retirement Income Security
Act of 1974 is amended by inserting after the item
relating to section 714 the following new items:
``Sec. 715. Additional market reforms.
``Sec. 716. Advanced explanation of benefits.''.
(b) Health Care Providers and Facilities.--Section 1128A of the
Social Security Act (42 U.S.C. 1320a-7a) is amended by adding at the
end the following new subsection:
``(t)(1) Each health care provider and health care facility shall,
beginning January 1, 2022, in the case of an individual who schedules
an item or service to be furnished to such individual by such provider
or facility at least 3 business days before the date such item or
service is to be so furnished, not later than 1 business day after the
date of such scheduling (or, in the case of such an item or service
scheduled at least 10 business days before the date such item or
service is to be so furnished (or if requested by the individual), not
later than 3 business days after the date of such scheduling or such
request)--
``(A) inquire if such individual is enrolled in a group
health plan, group or individual health insurance coverage
offered by a health insurance issuer, or a Federal health care
program (and if is so enrolled in such plan or coverage,
seeking to have a claim for such item or service submitted to
such plan or coverage); and
``(B) provide a notification of the good faith estimate of
the expected charges for furnishing such item or service
(including any item or service that is reasonably expected to
be provided in conjunction with such scheduled item or service)
to--
``(i) in the case the individual is enrolled in
such a plan or such coverage (and is seeking to have a
claim for such item or service submitted to such plan
or coverage), such plan or issuer of such coverage; and
``(ii) in the case the individual is not described
in clause (i) and not enrolled in a Federal health care
program, the individual.
``(2) Each health care provider or health care facility that fails
to provide the estimate as required under paragraph (1) shall be
subject to a civil monetary penalty in an amount not to exceed $10,000
for each such failure. The provisions of this section (other than
subsection (a), subsection (b), the first sentence of subsection
(c)(1), and subsection (o)) shall apply to a civil monetary penalty
imposed under the preceding sentence in the same manner as such
provisions apply to a penalty or proceeding under subsection (a).
``(3) In this subsection--
``(A) the terms `health insurance issuer', `group health
plan', `group health insurance coverage', and `individual
health insurance coverage' have the meaning given such terms,
respectively, in section 2791 of the Public Health Service Act;
and
``(B) the term `Federal health care program' has the
meaning given such term in section 1128B(f).''.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Labor, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Labor, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Labor, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Health.
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