Consumer Protections Against Surprise Medical Bills Act of 2020
This bill makes a series of changes related to health care costs and billing practices. Among other things, the bill
[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5826 Introduced in House (IH)]
<DOC>
116th CONGRESS
2d Session
H. R. 5826
To amend title XXVII of the Public Health Service Act, the Employee
Retirement Income Security Act of 1974, the Internal Revenue Code of
1986, and title XI of the Social Security Act to prevent certain cases
of out-of-network surprise medical bills, strengthen health care
consumer protections, and improve health care information transparency,
and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
February 10, 2020
Mr. Neal (for himself, Mr. Brady, Mr. Suozzi, Mr. LaHood, Mr. Holding,
Mr. Kelly of Pennsylvania, Mr. Estes, Mr. Thompson of California, Mr.
Beyer, Ms. Shalala, Mr. Morelle, Mr. Larson of Connecticut, Ms.
Schrier, Mr. Schneider, Mr. Danny K. Davis of Illinois, Mr. Evans, Mr.
Lewis, Mr. Higgins of New York, Mr. Nunes, Mr. Smith of Nebraska, Mr.
Ferguson, Mr. Wenstrup, Mr. Rice of South Carolina, Mrs. Walorski, Mr.
Schweikert, Mr. Reed, Mr. Arrington, Mr. Marchant, Mr. Buchanan, Mr.
Thompson of Pennsylvania, Mr. Kildee, and Mr. Smith of Missouri)
introduced the following bill; which was referred to the Committee on
Energy and Commerce, and in addition to the Committees on Ways and
Means, Education and Labor, and Transportation and Infrastructure, 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 Employee
Retirement Income Security Act of 1974, the Internal Revenue Code of
1986, and title XI of the Social Security Act to prevent certain cases
of out-of-network surprise medical bills, strengthen health care
consumer protections, and improve health care information transparency,
and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Consumer
Protections Against Surprise Medical Bills Act of 2020''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Consumer protections through requirements on health plans to
prevent surprise medical bills for
emergency services.
Sec. 3. Consumer protections through requirements on health plans to
prevent surprise medical bills for non-
emergency services performed by
nonparticipating providers at certain
participating facilities.
Sec. 4. Consumer protections through application of health plan
external review in cases of certain
surprise medical bills.
Sec. 5. Consumer protections through health plan transparency
requirements.
Sec. 6. Consumer protections through health plan requirement for fair
and honest advance cost estimate.
Sec. 7. Determination through open negotiation and mediation of out-of-
network rates to be paid by health plans.
Sec. 8. Prohibiting balance billing practices by providers for
emergency services, for services furnished
by nonparticipating provider at
participating facility, and in certain
cases of misinformation.
Sec. 9. Additional consumer protections.
Sec. 10. Reporting requirements regarding air ambulance services.
Sec. 11. GAO report on effects of legislation.
Sec. 12. Transitional rule allowing deduction for surprise billing
expenses below AGI floor.
SEC. 2. CONSUMER PROTECTIONS THROUGH REQUIREMENTS ON HEALTH PLANS TO
PREVENT SURPRISE MEDICAL BILLS FOR EMERGENCY SERVICES.
(a) PHSA Amendments.--
(1) In general.--Section 2719A of the Public Health Service
Act (42 U.S.C. 300gg-19a) is amended--
(A) in subsection (b)--
(i) in the heading, by striking
``Coverage'' and inserting ``Cost-Sharing and
Payment'';
(ii) in paragraph (1)--
(I) in the matter preceding
subparagraph (A)--
(aa) by striking ``a group
health plan, or a health
insurance issuer offering group
or individual health insurance
issuer,'' and inserting ``a
health plan'';
(bb) by inserting ``and,
for plan year 2022 or a
subsequent plan year, with
respect to emergency services
in an independent freestanding
emergency department'' after
``emergency department of a
hospital'';
(cc) by striking ``the plan
or issuer'' and inserting ``the
plan''; and
(dd) by striking ``(as
defined in paragraph (2)(B))'';
(II) in subparagraph (B), by
inserting ``or a participating facility
that is an emergency department of a
hospital or an independent freestanding
emergency department (in this
subsection referred to as a
`participating emergency facility')''
after ``participating provider''; and
(III) in subparagraph (C)--
(aa) in the matter
preceding clause (i), by
inserting ``by a
nonparticipating provider or a
nonparticipating facility that
is an emergency department of a
hospital or an independent
freestanding emergency
department'' after
``enrollee'';
(bb) by striking clause
(i);
(cc) by striking ``(ii)(I)
such services'' and inserting
``(i) such services'';
(dd) by striking ``where
the provider of services does
not have a contractual
relationship with the plan for
the providing of services'';
(ee) by striking
``emergency department services
received from providers who do
have such a contractual
relationship with the plan;
and'' and inserting ``emergency
services received from
participating providers and
participating emergency
facilities with respect to such
plan;'';
(ff) by striking ``(II) if
such services'' and all that
follows through ``were provided
in-network'' and inserting the
following:
``(ii) the cost-sharing requirement is not
greater than the requirement that would apply
if such services were furnished by a
participating provider or a participating
emergency facility, as applicable;''; and
(gg) by adding at the end
the following new clauses:
``(iii) such cost-sharing requirement is
calculated as if the contracted rate for such
services if furnished by a participating
provider or a participating emergency facility
were equal to the recognized amount for such
services;
``(iv) the health plan pays to such
provider or facility, respectively, the amount
by which the out-of-network rate for such
services exceeds the cost-sharing amount for
such services (as determined in accordance with
clauses (ii) and (iii)); and
``(v) any deductible or out-of-pocket
maximum that would apply if such services were
furnished by a participating provider or a
participating emergency facility shall be the
deductible or out-of-pocket maximum that
applies; and''; and
(iii) by striking paragraph (2) and
inserting the following new paragraph:
``(2) Audit process and rulemaking process for median
contracted rates.--
``(A) Audit process.--
``(i) In general.--Not later than July 1,
2021, the Secretary, in coordination with the
Secretary of the Treasury and the Secretary of
Labor and in consultation with the National
Association of Insurance Commissioners, shall
establish through rulemaking a process, in
accordance with clause (ii), under which health
plans are audited by the Secretary to ensure
that--
``(I) such plans are in compliance
with the requirement of applying a
median contracted rate under this
section; and
``(II) that such median contracted
rate so applied satisfies the
definition under subsection (k)(8) with
respect to the year involved.
``(ii) Audit samples.--Under the process
established pursuant to clause (i), the
Secretary--
``(I) shall conduct audits
described in such clause of a sample of
health plans; and
``(II) may audit any health plan if
the Secretary has received any
complaint about such plan that involves
the compliance of the plan with the
requirement described in such clause.
``(B) Rulemaking.--Not later than July 1, 2021, the
Secretary, in coordination with the Secretary of Labor
and the Secretary of the Treasury, shall establish
through rulemaking--
``(i) the methodology the sponsor or issuer
of a health plan shall use to determine the
median contracted rate, which shall account for
relevant payment adjustments that take into
account facility type that are otherwise taken
into account for purposes of determining
payment amounts with respect to participating
facilities; and
``(ii) the information such sponsor or
issuer shall share with the nonparticipating
provider involved when making such a
determination.''; and
(B) by adding at the end the following new
subsection:
``(k) Definitions.--For purposes of this section:
``(1) Contracted rate.--The term `contracted rate' means,
with respect to a health plan and a health care provider or
health care facility furnishing an item or service to a
beneficiary, participant, or enrollee of such plan, the agreed
upon total payment amount (inclusive of any cost-sharing) to
such provider or facility for such item or service.
``(2) During a visit.--The term `during a visit' shall,
with respect to an individual who is furnished items and
services at a participating facility, include equipment and
devices, telemedicine services, imaging services, laboratory
services, preoperative and postoperative services, and such
other items and services as the Secretary may specify furnished
to such individual, regardless of whether or not the provider
furnishing such items or services is at the facility.
``(3) Emergency department of a hospital.--The term
`emergency department of a hospital' includes a hospital
outpatient department that provides emergency services.
``(4) Emergency medical condition.--The term `emergency
medical condition' means a medical condition manifesting itself
by acute symptoms of sufficient severity (including severe
pain) such that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in a condition
described in clause (i), (ii), or (iii) of section
1867(e)(1)(A) of the Social Security Act.
``(5) Emergency services.--
``(A) In general.--The term `emergency services',
with respect to an emergency medical condition, means--
``(i) a medical screening examination (as
required under section 1867 of the Social
Security Act, or as would be required under
such section if such section applied to an
independent freestanding emergency department)
that is within the capability of the emergency
department of a hospital or of an independent
freestanding emergency department, as
applicable, including ancillary services
routinely available to the emergency department
to evaluate such emergency medical condition;
and
``(ii) within the capabilities of the staff
and facilities available at the hospital or the
independent freestanding emergency department,
as applicable, such further medical examination
and treatment as are required under section
1867 of such Act, or as would be required under
such section if such section applied to an
independent freestanding emergency department,
to stabilize the patient (regardless of the
department of the hospital in which such
further examination or treatment is furnished).
``(B) Inclusion of additional services.--In the
case of an individual enrolled in a health plan who is
furnished services described in subparagraph (A) by a
provider or hospital or independent freestanding
emergency department to stabilize such individual with
respect to an emergency medical condition, the term
`emergency services' shall include, in addition to
those described in subparagraph (A), items and services
furnished as part of outpatient observation or an
inpatient or outpatient stay during a visit in which
such individual is so stabilized with respect to such
emergency condition if--
``(i) such items and services would
otherwise be covered under such plan if
furnished by a participating provider or
participating facility; and
``(ii) such items and services are
furnished--
``(I) to maintain, improve, or
resolve the individual's stabilization
with respect to such condition, unless
any circumstance described in
subparagraph (C) has occurred with
respect to such individual before such
items and services are furnished; or
``(II) for any purpose not
described in subclause (I), unless each
of the criteria described in
subparagraph (D) have been met with
respect to such individual and such
item or service.
``(C) Circumstances.--For purposes of subparagraph
(B)(ii)(I), a circumstance described in this
subparagraph is any of the following, with respect to
an individual who is a beneficiary, participant, or
enrollee of a health plan who is furnished services
described in subparagraph (A) by a hospital or
independent freestanding emergency department with
respect to an emergency medical condition:
``(i) A participating provider, with
respect to such plan, with privileges at the
hospital or independent freestanding emergency
department assumes responsibility for the care
of the individual.
``(ii) A participating provider, with
respect to such plan, assumes responsibility
for the care of the individual through transfer
of the individual.
``(iii) The health plan and the provider
treating such individual at the hospital or
independent freestanding emergency department
for such condition reach an agreement
concerning the care for the individual.
``(iv) The individual is discharged.
``(D) Signed notice criteria.--For purposes of
subparagraph (B)(ii)(II), the criteria described in
this subparagraph, with respect to an individual and an
item or service furnished by a nonparticipating
provider or nonparticipating facility that is a
hospital or an independent freestanding emergency
department, are the following:
``(i) A written notice (as specified by the
Secretary and in a clear and understandable
manner) is provided by such provider or
facility to such individual, before such item
or service is furnished, that includes the
following information:
``(I) That such provider or
facility is a nonparticipating provider
or nonparticipating facility (as
applicable).
``(II) To the extent practicable,
the estimated amount that such
nonparticipating facility or
nonparticipating provider may charge
the individual for such item or
service.
``(III) A statement that the
individual may seek such item or
service from a provider that is a
participating provider or a hospital or
independent freestanding emergency
department that is a participating
facility and a list, if feasible, of
participating facilities or
participating providers, as applicable,
who are able to furnish such item or
service.
``(ii) Such individual is in a condition to
receive (as determined in accordance with
guidance issued by the Secretary) the
information described in clause (i) and to
confirm notice of receipt of such notice, in
accordance with applicable State law.
``(iii) The individual signs and dates such
notice confirming receipt of the notice before
such item or service is furnished.
``(6) Health plan.--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).
``(7) Independent freestanding emergency department.--The
term `independent freestanding emergency department' means a
health care facility that--
``(A) is geographically separate and distinct and
licensed separately from a hospital under applicable
State law; and
``(B) provides emergency services.
``(8) Median contracted rate.--
``(A) In general.--Subject to subparagraph (B), the
term `median contracted rate' means, with respect to a
health plan--
``(i) for an item or service furnished
during 2022, the median of the contracted rates
recognized by the sponsor or issuer of such
plan (determined with respect to all such plans
of such sponsor or such issuer that are within
the same line of business (as specified in
subparagraph (C)) as the plan involved) as the
total maximum payment under such plans in 2019
for the same or a similar item or service that
is provided by a provider or facility in the
same or similar specialty and provided in the
geographic region (established (and updated, as
appropriate) by the Secretary, in consultation
with the National Association of Insurance
Commissioners) in which the item or service is
furnished, consistent with the methodology
established by the Secretary under subsection
(b)(2)(B), increased by the percentage increase
in the consumer price index for all urban
consumers (United States city average) over
2019, 2020, and 2021;
``(ii) for an item or service furnished
during 2023 or a subsequent year through 2026,
the median contracted rate for the previous
year, increased by the percentage increase in
the consumer price index for all urban
consumers (United States city average) over
such previous year;
``(iii) for an item or service furnished
during a rebasing year (as defined in
subparagraph (D)), the median of the contracted
rates recognized by the sponsor or issuer of
such plan (determined with respect to all such
plans of such sponsor or such issuer that are
within the same line of business (as specified
in subparagraph (C)) as the plan involved) as
the total maximum payment under such plans in
such year for the same or a similar item or
service that is provided by a provider or
facility in the same or similar specialty and
provided in the geographic region (as
established pursuant to clause (i)) in which
the item or service is furnished, consistent
with the methodology established by the
Secretary under subsection (b)(2)(B); and
``(iv) for an item or service furnished
during any of the 4 years following a rebasing
year, the median contracted rate for the
previous year, increased by the percentage
increase in the consumer price index for all
urban consumers (United States city average)
over such previous year.
``(B) Use of substitute rate in case of
insufficient data.--
``(i) In general.--In the case the sponsor
or issuer of a health plan has insufficient
information (as specified by the Secretary) to
calculate the median of the contracted rates in
accordance with subparagraph (A) for a year for
an item or service furnished in a particular
geographic region (as established pursuant to
subparagraph (A)(i)) by a type of provider or
facility, the substitute rate (as defined in
clause (ii)) for such item or service shall be
deemed to be the median contracted rate for
such item or service furnished in such region
during such year by such a provider or facility
for such year under such subparagraph (A) for
such plan.
``(ii) Substitute rate.--For purposes of
clause (i), the term `substitute rate' means,
with respect to an item or service furnished by
a provider or facility in a geographic region
(established pursuant to subparagraph (A)(i))
during a year for which a health plan is
required to make payment pursuant to subsection
(b)(1), (e)(1), or (i)(1)--
``(I) if sufficient information (as
specified by the Secretary) exists to
determine the median of the contracted
rates recognized by all health plans
offered in the same line of business
(as specified in subparagraph (C)) by
any group health plan or health
insurance issuer for such an item or
service furnished in such region by
such a provider or facility during such
year using a database or other source
of information determined appropriate
by the Secretary, such median; and
``(II) if such sufficient
information does not exist, the median
of the contracted rates recognized by
all health plans offered in the same
line of business (as specified in
subparagraph (C)) by any group health
plan or health insurance issuer for
such an item or service furnished in a
similarly situated geographic region
(as determined by the Secretary) with
such sufficient information by such a
provider or facility during such year
using such a database or such other
source of information.
The Secretary shall develop a methodology for
determining a substitute rate based on a
similarly situated health plan that is not a
Federal health care program (as defined in
section 1128B(f) of the Social Security Act) in
the case a substitute rate is not calculable
under the previous sentence with respect to an
item or service.
``(C) Line of business.--A line of business
specified in this subparagraph is one of the following:
``(i) The individual market.
``(ii) The small group market.
``(iii) The large group market.
``(iv) In the case of a self-insured group
health plan, other self-insured group health
plans.
``(D) Rebasing year defined.--For purposes of
subparagraph (A), the term `rebasing year' means 2027
and every 5 years thereafter.
``(9) Nonparticipating facility; participating facility.--
``(A) Nonparticipating facility.--The term
`nonparticipating facility' means, with respect to an
item or service and a health plan, a health care
facility described in subparagraph (B)(ii) that does
not have a contractual relationship with the plan for
furnishing such item or service.
``(B) Participating facility.--
``(i) In general.--The term `participating
facility' means, with respect to an item or
service and a health plan, a health care
facility described in clause (ii) that has a
contractual relationship with the plan for
furnishing such item or service.
``(ii) Health care facility described.--A
health care facility described in this clause
is each of the following:
``(I) A hospital (as defined in
1861(e) of the Social Security Act),
including an emergency department of a
hospital.
``(II) A critical access hospital
(as defined in section 1861(mm)(1) of
such Act).
``(III) An ambulatory surgical
center (as described in section
1833(i)(1)(A) of such Act).
``(IV) A laboratory.
``(V) A radiology facility or
imaging center.
``(VI) An independent freestanding
emergency department.
``(VII) Any other facility
specified by the Secretary.
``(10) Nonparticipating providers; participating
providers.--
``(A) Nonparticipating provider.--The term
`nonparticipating provider' means, with respect to an
item or service and a health plan, a physician or other
health care provider who does not have a contractual
relationship with the plan for furnishing such item or
service under the plan.
``(B) Participating provider.--The term
`participating provider' means, with respect to an item
or service and a health plan, a physician or other
health care provider who has a contractual relationship
with the plan for furnishing such item or service under
the plan.
``(11) Out-of-network rate.--The term `out-of-network rate'
means, with respect to an item or service furnished in a State
during a year to a participant, beneficiary, or enrollee of a
health plan receiving such item or service from a
nonparticipating provider or facility--
``(A) subject to subparagraphs (C) and (D), in the
case such State has in effect a State law that provides
for a method for determining the total amount payable
under such health plan regulated by such State with
respect to such item or service furnished by such
provider or facility, such amount determined in
accordance with such law;
``(B) subject to subparagraphs (C) and (D), in the
case such State does not have in effect such a law with
respect to such item or service, plan, and provider or
facility--
``(i) subject to clause (ii), if the
provider or facility (as applicable) and such
plan agree on an amount of payment (including
if agreed on through open negotiations under
subsection (j)(1)) with respect to such item or
service, such agreed on amount; or
``(ii) if such provider or facility (as
applicable) and such plan enter the mediated
dispute process under subsection (j) and do not
so agree before the date on which a selected
independent entity (as defined in paragraph (3)
of such subsection) makes a determination with
respect to such item or service under such
subsection, the amount of such determination;
``(C) in the case such State has an All-Payer Model
Agreement under section 1115A of the Social Security
Act, the amount that the State approves under such
system for such item or service so furnished; or
``(D) in the case such health plan is a self-
insured group health plan and in the case of a State
with an agreement with such plan in effect as of the
date of the enactment of the Consumer Protections
Against Surprise Medical Bills Act of 2020, that
provides for a method for determining the total amount
payable under such health plan with respect to such
item or service furnished by such provider or facility,
such amount determined in accordance with such method.
``(12) Recognized amount.--The term `recognized amount'
means, with respect to an item or service furnished in a State
during a year to a participant, beneficiary, or enrollee of a
health plan by a nonparticipating provider or nonparticipating
facility--
``(A) subject to subparagraphs (C) and (D), in the
case such State has in effect a law described in
paragraph (11)(A) with respect to such item or service,
provider or facility, and plan, the amount determined
in accordance with such law;
``(B) subject to subparagraphs (C) and (D), in the
case such State does not have in effect such a law, an
amount that is the median contracted rate for such item
or service for such year;
``(C) subject to subparagraph (D), in the case such
State is described in paragraph (11)(C) with respect to
such item or service so furnished, the amount that the
State approves under such system for such item or
service so furnished; or
``(D) in the case such health plan is a self-
insured group health plan and in the case of a State
with an agreement with such plan in effect as of the
date of the enactment of the Consumer Protections
Against Surprise Medical Bills Act of 2020, that
provides for a method for determining the total amount
payable under such health plan with respect to such
item or service furnished by such provider or facility,
such amount determined in accordance with such method.
``(13) Stabilize.--The term `to stabilize', with respect to
an emergency medical condition, has the meaning give in section
1867(e)(3)(A) of the Social Security Act).
``(14) Cost-sharing.--The term `cost-sharing' includes
copayments, coinsurance, and deductibles.
``(l) Payment to Provider or Facility.--In the case of any payment
required to be made by a health plan pursuant to subsection (b)(1),
(e)(1), or (i)(1) to a nonparticiapting provider or nonparticipating
facility for an item or service, such payment shall be made to such
provider or facility and not to the individual receiving such item or
service.''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply with respect to plan years beginning on or after
January 1, 2022.
(b) IRC Amendments.--
(1) 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. PATIENT PROTECTIONS.
``(a) Choice of Health Care Professional.--If a health plan
requires or provides for designation by a participant or beneficiary of
a participating primary care provider, then the plan shall permit each
participant or beneficiary to designate any participating primary care
provider who is available to accept such individual.
``(b) Cost-Sharing and Payment of Emergency Services.--
``(1) In general.--If a health plan provides or covers any
benefits with respect to services in an emergency department of
a hospital and, for plan year 2022 or a subsequent plan year,
with respect to emergency services in an independent
freestanding emergency department, the plan shall cover
emergency services--
``(A) without the need for any prior authorization
determination;
``(B) whether the health care provider furnishing
such services is a participating provider or a
participating facility that is an emergency department
of a hospital or an independent freestanding emergency
department (in this subsection referred to as a
`participating emergency facility') with respect to
such services;
``(C) in a manner so that, if such services are
provided to a participant or beneficiary by a
nonparticipating provider or a nonparticipating
facility that is an emergency department of a hospital
or an independent freestanding emergency department--
``(i) such services will be provided
without imposing any requirement under the plan
for prior authorization of services or any
limitation on coverage that is more restrictive
than the requirements or limitations that apply
to emergency services received from
participating providers and participating
emergency facilities with respect to such plan;
``(ii) the cost-sharing requirement is not
greater than the requirement that would apply
if such services were furnished by a
participating provider or a participating
emergency facility, as applicable;
``(iii) such cost-sharing requirement is
calculated as if the contracted rate for such
services if furnished by a participating
provider or a participating emergency facility
were equal to the recognized amount for such
services;
``(iv) the health plan pays to such
provider or facility, respectively, the amount
by which the out-of-network rate for such
services exceeds the cost-sharing amount for
such services (as determined in accordance with
clauses (ii) and (iii)); and
``(v) any deductible or out-of-pocket
maximum that would apply if such services were
furnished by a participating provider or a
participating emergency facility shall be the
deductible or out-of-pocket maximum that
applies; and
``(D) without regard to any other term or condition
of such coverage (other than exclusion or coordination
of benefits, or an affiliation or waiting period,
permitted under section 2704 of the Public Health
Service Act, including as incorporated pursuant to
section 715 of the Employee Retirement Income Security
Act of 1974 and section 9815, and other than applicable
cost-sharing).
``(2) Audit process and rulemaking process for median
contracted rates.--
``(A) Audit process.--
``(i) In general.--Not later than July 1,
2021, the Secretary, in coordination with the
Secretary of Health and Human Services and the
Secretary of Labor and in consultation with the
National Association of Insurance
Commissioners, shall establish through
rulemaking a process, in accordance with clause
(ii), under which health plans are audited by
the Secretary to ensure that--
``(I) such plans are in compliance
with the requirement of applying a
median contracted rate under this
section; and
``(II) that such median contracted
rate so applied satisfies the
definition under subsection (k)(8) with
respect to the year involved.
``(ii) Audit samples.--Under the process
established pursuant to clause (i), the
Secretary--
``(I) shall conduct audits
described in such clause of a sample of
health plans; and
``(II) may audit any health plan if
the Secretary has received any
complaint about such plan that involves
the compliance of the plan with the
requirement described in such clause.
``(B) Rulemaking.--Not later than July 1, 2021, the
Secretary, in coordination with the Secretary of Labor
and the Secretary of Health and Human Services, shall
establish through rulemaking--
``(i) the methodology the sponsor of a
health plan shall use to determine the median
contracted rate, which shall account for
relevant payment adjustments that take into
account facility type that are otherwise taken
into account for purposes of determining
payment amounts with respect to participating
facilities; and
``(ii) the information such sponsor shall
share with the nonparticipating provider
involved when making such a determination.
``(c) Access to Pediatric Care.--
``(1) Pediatric care.--In the case of a person who has a
child who is a participant or beneficiary under a health plan,
if the plan requires or provides for the designation of a
participating primary care provider for the child, the plan
shall permit such person to designate a physician (allopathic
or osteopathic) who specializes in pediatrics as the child's
primary care provider if such provider participates in the
network of the plan.
``(2) Construction.--Nothing in paragraph (1) shall be
construed to waive any exclusions of coverage under the terms
and conditions of the plan with respect to coverage of
pediatric care.
``(d) Patient Access to Obstetrical and Gynecological Care.--
``(1) General rights.--
``(A) Direct access.--A health plan described in
paragraph (2) may not require authorization or referral
by the plan or any person (including a primary care
provider described in paragraph (2)(B)) in the case of
a female participant or beneficiary who seeks coverage
for obstetrical or gynecological care provided by a
participating health care professional who specializes
in obstetrics or gynecology. Such professional shall
agree to otherwise adhere to such plan's policies and
procedures, including procedures regarding referrals
and obtaining prior authorization and providing
services pursuant to a treatment plan (if any) approved
by the plan.
``(B) Obstetrical and gynecological care.--A health
plan described in paragraph (2) shall treat the
provision of obstetrical and gynecological care, and
the ordering of related obstetrical and gynecological
items and services, pursuant to the direct access
described under subparagraph (A), by a participating
health care professional who specializes in obstetrics
or gynecology as the authorization of the primary care
provider.
``(2) Application of paragraph.--A health plan described in
this paragraph is a health plan that--
``(A) provides coverage for obstetric or
gynecologic care; and
``(B) requires the designation by a participant or
beneficiary of a participating primary care provider.
``(3) Construction.--Nothing in paragraph (1) shall be
construed to--
``(A) waive any exclusions of coverage under the
terms and conditions of the plan with respect to
coverage of obstetrical or gynecological care; or
``(B) preclude the health plan involved from
requiring that the obstetrical or gynecological
provider notify the primary care health care
professional or the plan of treatment decisions.
``(k) Definitions.--For purposes of this section:
``(1) Contracted rate.--The term `contracted rate' means,
with respect to a health plan and a health care provider or
health care facility furnishing an item or service to a
beneficiary or participant of such plan, the agreed upon total
payment amount (inclusive of any cost-sharing) to such provider
or facility for such item or service.
``(2) During a visit.--The term `during a visit' shall,
with respect to an individual who is furnished items and
services at a participating facility, include equipment and
devices, telemedicine services, imaging services, laboratory
services, preoperative and postoperative services, and such
other items and services as the Secretary may specify furnished
to such individual, regardless of whether or not the provider
furnishing such items or services is at the facility.
``(3) Emergency department of a hospital.--The term
`emergency department of a hospital' includes a hospital
outpatient department that provides emergency services.
``(4) Emergency medical condition.--The term `emergency
medical condition' means a medical condition manifesting itself
by acute symptoms of sufficient severity (including severe
pain) such that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in a condition
described in clause (i), (ii), or (iii) of section
1867(e)(1)(A) of the Social Security Act.
``(5) Emergency services.--
``(A) In general.--The term `emergency services',
with respect to an emergency medical condition, means--
``(i) a medical screening examination (as
required under section 1867 of the Social
Security Act, or as would be required under
such section if such section applied to an
independent freestanding emergency department)
that is within the capability of the emergency
department of a hospital or of an independent
freestanding emergency department, as
applicable, including ancillary services
routinely available to the emergency department
to evaluate such emergency medical condition;
and
``(ii) within the capabilities of the staff
and facilities available at the hospital or the
independent freestanding emergency department,
as applicable, such further medical examination
and treatment as are required under section
1867 of such Act, or as would be required under
such section if such section applied to an
independent freestanding emergency department,
to stabilize the patient (regardless of the
department of the hospital in which such
further examination or treatment is furnished).
``(B) Inclusion of additional services.--In the
case of an individual enrolled in a health plan who is
furnished services described in subparagraph (A) by a
provider or hospital or independent freestanding
emergency department to stabilize such individual with
respect to an emergency medical condition, the term
`emergency services' shall include, in addition to
those described in subparagraph (A), items and services
furnished as part of outpatient observation or an
inpatient or outpatient stay during a visit in which
such individual is so stabilized with respect to such
emergency condition if--
``(i) such items and services would
otherwise be covered under such plan if
furnished by a participating provider or
participating facility; and
``(ii) such items and services are
furnished--
``(I) to maintain, improve, or
resolve the individual's stabilization
with respect to such condition, unless
any circumstance described in
subparagraph (C) has occurred with
respect to such individual before such
items and services are furnished; or
``(II) for any purpose not
described in subclause (I), unless each
of the criteria described in
subparagraph (D) have been met with
respect to such individual and such
item or service.
``(C) Circumstances.--For purposes of subparagraph
(B)(ii)(I), a circumstance described in this
subparagraph is any of the following, with respect to
an individual who is a beneficiary, participant, or
enrollee of a health plan who is furnished services
described in subparagraph (A) by a hospital or
independent freestanding emergency department with
respect to an emergency medical condition:
``(i) A participating provider, with
respect to such plan, with privileges at the
hospital or independent freestanding emergency
department assumes responsibility for the care
of the individual.
``(ii) A participating provider, with
respect to such plan, assumes responsibility
for the care of the individual through transfer
of the individual.
``(iii) The health plan and the provider
treating such individual at the hospital or
independent freestanding emergency department
for such condition reach an agreement
concerning the care for the individual.
``(iv) The individual is discharged.
``(D) Signed notice criteria.--For purposes of
subparagraph (B)(ii)(II), the criteria described in
this subparagraph, with respect to an individual and an
item or service furnished by a nonparticipating
provider or nonparticipating facility that is a
hospital or an independent freestanding emergency
department, are the following:
``(i) A written notice (as specified by the
Secretary and in a clear and understandable
manner) is provided by such provider or
facility to such individual, before such item
or service is furnished, that includes the
following information:
``(I) That such provider or
facility is a nonparticipating provider
or nonparticipating facility (as
applicable).
``(II) To the extent practicable,
the estimated amount that such
nonparticipating facility or
nonparticipating provider may charge
the individual for such item or
service.
``(III) A statement that the
individual may seek such item or
service from a provider that is a
participating provider or a hospital or
independent freestanding emergency
department that is a participating
facility and a list, if feasible, of
participating facilities or
participating providers, as applicable,
who are able to furnish such item or
service.
``(ii) Such individual is in a condition to
receive (as determined in accordance with
guidance issued by the Secretary) the
information described in clause (i) and to
confirm notice of receipt of such notice, in
accordance with applicable State law.
``(iii) The individual signs and dates such
notice confirming receipt of the notice before
such item or service is furnished.
``(6) Health plan.--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).
``(7) Independent freestanding emergency department.--The
term `independent freestanding emergency department' means a
health care facility that--
``(A) is geographically separate and distinct and
licensed separately from a hospital under applicable
State law; and
``(B) provides emergency services.
``(8) Median contracted rate.--
``(A) In general.--Subject to subparagraph (B), the
term `median contracted rate' means, with respect to a
health plan--
``(i) for an item or service furnished
during 2022, the median of the contracted rates
recognized by the sponsor of such plan
(determined with respect to all such plans of
such sponsor that are within the same line of
business (as specified in subparagraph (C)) as
the plan involved) as the total maximum payment
under such plans in 2019 for the same or a
similar item or service that is provided by a
provider or facility in the same or similar
specialty and provided in the geographic region
(established (and updated, as appropriate) by
the Secretary, in consultation with the
National Association of Insurance
Commissioners) in which the item or service is
furnished, consistent with the methodology
established by the Secretary under subsection
(b)(2)(B), increased by the percentage increase
in the consumer price index for all urban
consumers (United States city average) over
2019, 2020, and 2021;
``(ii) for an item or service furnished
during 2023 or a subsequent year through 2026,
the median contracted rate for the previous
year, increased by the percentage increase in
the consumer price index for all urban
consumers (United States city average) over
such previous year;
``(iii) for an item or service furnished
during a rebasing year (as defined in
subparagraph (D)), the median of the contracted
rates recognized by the sponsor of such plan
(determined with respect to all such plans of
such sponsor that are within the same line of
business (as specified in subparagraph (C)) as
the plan involved) as the total maximum payment
under such plans in such year for the same or a
similar item or service that is provided by a
provider or facility in the same or similar
specialty and provided in the geographic region
(as established pursuant to clause (i)) in
which the item or service is furnished,
consistent with the methodology established by
the Secretary under subsection (b)(2)(B); and
``(iv) for an item or service furnished
during any of the 4 years following a rebasing
year, the median contracted rate for the
previous year, increased by the percentage
increase in the consumer price index for all
urban consumers (United States city average)
over such previous year.
``(B) Use of substitute rate in case of
insufficient data.--
``(i) In general.--In the case the sponsor
of a health plan has insufficient information
(as specified by the Secretary) to calculate
the median of the contracted rates in
accordance with subparagraph (A) for a year for
an item or service furnished in a particular
geographic region (as established pursuant to
subparagraph (A)(i)) by a type of provider or
facility, the substitute rate (as defined in
clause (ii)) for such item or service shall be
deemed to be the median contracted rate for
such item or service furnished in such region
during such year by such a provider or facility
for such year under such subparagraph (A) for
such plan.
``(ii) Substitute rate.--For purposes of
clause (i), the term `substitute rate' means,
with respect to an item or service furnished by
a provider or facility in a geographic region
(established pursuant to subparagraph (A)(i))
during a year for which a health plan is
required to make payment pursuant to subsection
(b)(1), (e)(1), or (i)(1)--
``(I) if sufficient information (as
specified by the Secretary) exists to
determine the median of the contracted
rates recognized by all health plans
offered in the same line of business
(as specified in subparagraph (C)) by
any group health plan for such an item
or service furnished in such region by
such a provider or facility during such
year using a database or other source
of information determined appropriate
by the Secretary, such median; and
``(II) if such sufficient
information does not exist, the median
of the contracted rates recognized by
all health plans offered in the same
line of business (as specified in
subparagraph (C)) by any group health
plan for such an item or service
furnished in a similarly situated
geographic region (as determined by the
Secretary) with such sufficient
information by such a provider or
facility during such year using such a
database or such other source of
information.
The Secretary shall develop a methodology for
determining a substitute rate based on a
similarly situated health plan that is not a
Federal health care program (as defined in
section 1128B(f) of the Social Security Act) in
the case a substitute rate is not calculable
under the previous sentence with respect to an
item or service.
``(C) Line of business.--A line of business
specified in this subparagraph is one of the following:
``(i) The small group market.
``(ii) The large group market.
``(iii) In the case of a self-insured group
health plan, other self-insured group health
plans.
``(D) Rebasing year defined.--For purposes of
subparagraph (A), the term `rebasing year' means 2027
and every 5 years thereafter.
``(9) Nonparticipating facility; participating facility.--
``(A) Nonparticipating facility.--The term
`nonparticipating facility' means, with respect to an
item or service and a health plan, a health care
facility described in subparagraph (B)(ii) that does
not have a contractual relationship with the plan for
furnishing such item or service.
``(B) Participating facility.--
``(i) In general.--The term `participating
facility' means, with respect to an item or
service and a health plan, a health care
facility described in clause (ii) that has a
contractual relationship with the plan for
furnishing such item or service.
``(ii) Health care facility described.--A
health care facility described in this clause
is each of the following:
``(I) A hospital (as defined in
1861(e) of the Social Security Act),
including an emergency department of a
hospital.
``(II) A critical access hospital
(as defined in section 1861(mm)(1) of
such Act).
``(III) An ambulatory surgical
center (as described in section
1833(i)(1)(A) of such Act).
``(IV) A laboratory.
``(V) A radiology facility or
imaging center.
``(VI) An independent freestanding
emergency department.
``(VII) Any other facility
specified by the Secretary.
``(10) Nonparticipating providers; participating
providers.--
``(A) Nonparticipating provider.--The term
`nonparticipating provider' means, with respect to an
item or service and a health plan, a physician or other
health care provider who does not have a contractual
relationship with the plan for furnishing such item or
service under the plan.
``(B) Participating provider.--The term
`participating provider' means, with respect to an item
or service and a health plan, a physician or other
health care provider who has a contractual relationship
with the plan for furnishing such item or service under
the plan.
``(11) Out-of-network rate.--The term `out-of-network rate'
means, with respect to an item or service furnished in a State
during a year to a participant or beneficiary of a health plan
receiving such item or service from a nonparticipating provider
or facility--
``(A) subject to subparagraphs (C) and (D), in the
case such State has in effect a State law that provides
for a method for determining the total amount payable
under such health plan regulated by such State with
respect to such item or service furnished by such
provider or facility, such amount determined in
accordance with such law;
``(B) subject to subparagraphs (C) and (D), in the
case such State does not have in effect such a law with
respect to such item or service, plan, and provider or
facility--
``(i) subject to clause (ii), if the
provider or facility (as applicable) and such
plan agree on an amount of payment (including
if agreed on through open negotiations under
subsection (j)(1)) with respect to such item or
service, such agreed on amount; or
``(ii) if such provider or facility (as
applicable) and such plan enter the mediated
dispute process under subsection (j) and do not
so agree before the date on which a selected
independent entity (as defined in paragraph (3)
of such subsection) makes a determination with
respect to such item or service under such
subsection, the amount of such determination;
``(C) in the case such State has an All-Payer Model
Agreement under section 1115A of the Social Security
Act, the amount that the State approves under such
system for such item or service so furnished; or
``(D) in the case such health plan is a self-
insured group health plan and in the case of a State
with an agreement with such plan in effect as of the
date of the enactment of the Consumer Protections
Against Surprise Medical Bills Act of 2020, that
provides for a method for determining the total amount
payable under such health plan with respect to such
item or service furnished by such provider or facility,
such amount determined in accordance with such method.
``(12) Recognized amount.--The term `recognized amount'
means, with respect to an item or service furnished in a State
during a year to a participant or beneficiary of a health plan
by a nonparticipating provider or nonparticipating facility--
``(A) subject to subparagraphs (C) and (D), in the
case such State has in effect a law described in
paragraph (11)(A) with respect to such item or service,
provider or facility, and plan, the amount determined
in accordance with such law;
``(B) subject to subparagraphs (C) and (D), in the
case such State does not have in effect such a law, an
amount that is the median contracted rate for such item
or service for such year;
``(C) in the case such State is described in
paragraph (11)(C) with respect to such item or service
so furnished, the amount that the State approves under
such system for such item or service so furnished; or
``(D) in the case such health plan is a self-
insured group health plan and in the case of a State
with an agreement with such plan in effect as of the
date of the enactment of the Consumer Protections
Against Surprise Medical Bills Act of 2020, that
provides for a method for determining the total amount
payable under such health plan with respect to such
item or service furnished by such provider or facility,
such amount determined in accordance with such method.
``(13) Stabilize.--The term `to stabilize', with respect to
an emergency medical condition, has the meaning give in section
1867(e)(3)(A) of the Social Security Act.
``(14) Cost-sharing.--The term `cost-sharing' includes
copayments, coinsurance, and deductibles.
``(l) Payment to Provider or Facility.--In the case of any payment
required to be made by a health plan pursuant to subsection (b)(1),
(e)(1), or (i)(1) to a nonparticiapting provider or nonparticipating
facility for an item or service, such payment shall be made to such
provider or facility and not to the individual receiving such item or
service.''.
(2) Conforming amendments.--
(A) Application provisions.--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, with respect to a plan year beginning on
or after January 1, 2022, the provisions of
section 2719A of such Act)''; and
(ii) in paragraph (2), by inserting
``(other than, with respect to a plan year
beginning on or after January 1, 2022, the
provisions of section 2719A of such Act)''
after the first occurrence of ``such part A''.
(B) Application to retiree-only plans.--Section
9831(a) of the Internal Revenue Code of 1986 is amended
by inserting ``(other than, with respect to a group
health plan described in paragraph (2), the
requirements of section 9816)'' before ``shall not
apply''.
(3) Clerical amendment.--The table of sections for such
subchapter is amended by adding at the end the following new
items:
``Sec. 9815. Additional market reforms.
``Sec. 9816. Patient protections.''.
(4) Effective date.--The amendments made by this subsection
shall apply with respect to plan years beginning on or after
January 1, 2022.
(c) Employee Retirement Income Security Act of 1974 Amendments.--
(1) 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. PATIENT PROTECTIONS.
``(a) Choice of Health Care Professional.--If a health plan
requires or provides for designation by a participant or beneficiary of
a participating primary care provider, then the plan shall permit each
participant or beneficiary to designate any participating primary care
provider who is available to accept such individual.
``(b) Cost-Sharing and Payment of Emergency Services.--
``(1) In general.--If a health plan provides or covers any
benefits with respect to services in an emergency department of
a hospital and, for plan year 2022 or a subsequent plan year,
with respect to emergency services in an independent
freestanding emergency department, the plan shall cover
emergency services--
``(A) without the need for any prior authorization
determination;
``(B) whether the health care provider furnishing
such services is a participating provider or a
participating facility that is an emergency department
of a hospital or an independent freestanding emergency
department (in this subsection referred to as a
`participating emergency facility') with respect to
such services;
``(C) in a manner so that, if such services are
provided to a participant or beneficiary by a
nonparticipating provider or a nonparticipating
facility that is an emergency department of a hospital
or an independent freestanding emergency department--
``(i) such services will be provided
without imposing any requirement under the plan
for prior authorization of services or any
limitation on coverage that is more restrictive
than the requirements or limitations that apply
to emergency services received from
participating providers and participating
emergency facilities with respect to such plan;
``(ii) the cost-sharing requirement is not
greater than the requirement that would apply
if such services were furnished by a
participating provider or a participating
emergency facility, as applicable;
``(iii) such cost-sharing requirement is
calculated as if the contracted rate for such
services if furnished by a participating
provider or a participating emergency facility
were equal to the recognized amount for such
services;
``(iv) the health plan pays to such
provider or facility, respectively, the amount
by which the out-of-network rate for such
services exceeds the cost-sharing amount for
such services (as determined in accordance with
clauses (ii) and (iii)); and
``(v) any deductible or out-of-pocket
maximum that would apply if such services were
furnished by a participating provider or a
participating emergency facility shall be the
deductible or out-of-pocket maximum that
applies; and
``(D) without regard to any other term or condition
of such coverage (other than exclusion or coordination
of benefits, or an affiliation or waiting period,
permitted under section 2704 of the Public Health
Service Act, including as incorporated pursuant to
section 715 and section 9815 of the Internal Revenue
Code of 1986, and other than applicable cost-sharing).
``(2) Audit process and rulemaking process for median
contracted rates.--
``(A) Audit process.--
``(i) In general.--Not later than July 1,
2021, the Secretary, in coordination with the
Secretary of Health and Human Services and the
Secretary of the Treasury and in consultation
with the National Association of Insurance
Commissioners, shall establish through
rulemaking a process, in accordance with clause
(ii), under which health plans are audited by
the Secretary to ensure that--
``(I) such plans are in compliance
with the requirement of applying a
median contracted rate under this
section; and
``(II) that such median contracted
rate so applied satisfies the
definition under subsection (k)(8) with
respect to the year involved.
``(ii) Audit samples.--Under the process
established pursuant to clause (i), the
Secretary--
``(I) shall conduct audits
described in such clause of a sample of
health plans; and
``(II) may audit any health plan if
the Secretary has received any
complaint about such plan that involves
the compliance of the plan with the
requirement described in such clause.
``(B) Rulemaking.--Not later than July 1, 2021, the
Secretary, in coordination with the Secretary of the
Treasury and the Secretary of Health and Human
Services, shall establish through rulemaking--
``(i) the methodology the sponsor or issuer
of a health plan shall use to determine the
median contracted rate, which shall account for
relevant payment adjustments that take into
account facility type that are otherwise taken
into account for purposes of determining
payment amounts with respect to participating
facilities; and
``(ii) the information such sponsor or
issuer shall share with the nonparticipating
provider involved when making such a
determination.
``(c) Access to Pediatric Care.--
``(1) Pediatric care.--In the case of a person who has a
child who is a participant or beneficiary under a health plan,
if the plan requires or provides for the designation of a
participating primary care provider for the child, the plan
shall permit such person to designate a physician (allopathic
or osteopathic) who specializes in pediatrics as the child's
primary care provider if such provider participates in the
network of the plan.
``(2) Construction.--Nothing in paragraph (1) shall be
construed to waive any exclusions of coverage under the terms
and conditions of the plan with respect to coverage of
pediatric care.
``(d) Patient Access to Obstetrical and Gynecological Care.--
``(1) General rights.--
``(A) Direct access.--A health plan described in
paragraph (2) may not require authorization or referral
by the plan or any person (including a primary care
provider described in paragraph (2)(B)) in the case of
a female participant or beneficiary who seeks coverage
for obstetrical or gynecological care provided by a
participating health care professional who specializes
in obstetrics or gynecology. Such professional shall
agree to otherwise adhere to such plan's policies and
procedures, including procedures regarding referrals
and obtaining prior authorization and providing
services pursuant to a treatment plan (if any) approved
by the plan.
``(B) Obstetrical and gynecological care.--A health
plan described in paragraph (2) shall treat the
provision of obstetrical and gynecological care, and
the ordering of related obstetrical and gynecological
items and services, pursuant to the direct access
described under subparagraph (A), by a participating
health care professional who specializes in obstetrics
or gynecology as the authorization of the primary care
provider.
``(2) Application of paragraph.--A health plan described in
this paragraph is a health plan that--
``(A) provides coverage for obstetric or
gynecologic care; and
``(B) requires the designation by a participant or
beneficiary of a participating primary care provider.
``(3) Construction.--Nothing in paragraph (1) shall be
construed to--
``(A) waive any exclusions of coverage under the
terms and conditions of the plan with respect to
coverage of obstetrical or gynecological care; or
``(B) preclude the health plan involved from
requiring that the obstetrical or gynecological
provider notify the primary care health care
professional or the plan of treatment decisions.
``(k) Definitions.--For purposes of this section:
``(1) Contracted rate.--The term `contracted rate' means,
with respect to a health plan and a health care provider or
health care facility furnishing an item or service to a
beneficiary or participant of such plan, the agreed upon total
payment amount (inclusive of any cost-sharing) to such provider
or facility for such item or service.
``(2) During a visit.--The term `during a visit' shall,
with respect to an individual who is furnished items and
services at a participating facility, include equipment and
devices, telemedicine services, imaging services, laboratory
services, preoperative and postoperative services, and such
other items and services as the Secretary may specify furnished
to such individual, regardless of whether or not the provider
furnishing such items or services is at the facility.
``(3) Emergency department of a hospital.--The term
`emergency department of a hospital' includes a hospital
outpatient department that provides emergency services.
``(4) Emergency medical condition.--The term `emergency
medical condition' means a medical condition manifesting itself
by acute symptoms of sufficient severity (including severe
pain) such that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in a condition
described in clause (i), (ii), or (iii) of section
1867(e)(1)(A) of the Social Security Act.
``(5) Emergency services.--
``(A) In general.--The term `emergency services',
with respect to an emergency medical condition, means--
``(i) a medical screening examination (as
required under section 1867 of the Social
Security Act, or as would be required under
such section if such section applied to an
independent freestanding emergency department)
that is within the capability of the emergency
department of a hospital or of an independent
freestanding emergency department, as
applicable, including ancillary services
routinely available to the emergency department
to evaluate such emergency medical condition;
and
``(ii) within the capabilities of the staff
and facilities available at the hospital or the
independent freestanding emergency department,
as applicable, such further medical examination
and treatment as are required under section
1867 of such Act, or as would be required under
such section if such section applied to an
independent freestanding emergency department,
to stabilize the patient (regardless of the
department of the hospital in which such
further examination or treatment is furnished).
``(B) Inclusion of additional services.--In the
case of an individual enrolled in a health plan who is
furnished services described in subparagraph (A) by a
provider or hospital or independent freestanding
emergency department to stabilize such individual with
respect to an emergency medical condition, the term
`emergency services' shall include, in addition to
those described in subparagraph (A), items and services
furnished as part of outpatient observation or an
inpatient or outpatient stay during a visit in which
such individual is so stabilized with respect to such
emergency condition if--
``(i) such items and services would
otherwise be covered under such plan if
furnished by a participating provider or
participating facility; and
``(ii) such items and services are
furnished--
``(I) to maintain, improve, or
resolve the individual's stabilization
with respect to such condition, unless
any circumstance described in
subparagraph (C) has occurred with
respect to such individual before such
items and services are furnished; or
``(II) for any purpose not
described in subclause (I), unless each
of the criteria described in
subparagraph (D) have been met with
respect to such individual and such
item or service.
``(C) Circumstances.--For purposes of subparagraph
(B)(ii)(I), a circumstance described in this
subparagraph is any of the following, with respect to
an individual who is a beneficiary, participant, or
enrollee of a health plan who is furnished services
described in subparagraph (A) by a hospital or
independent freestanding emergency department with
respect to an emergency medical condition:
``(i) A participating provider, with
respect to such plan, with privileges at the
hospital or independent freestanding emergency
department assumes responsibility for the care
of the individual.
``(ii) A participating provider, with
respect to such plan, assumes responsibility
for the care of the individual through transfer
of the individual.
``(iii) The health plan and the provider
treating such individual at the hospital or
independent freestanding emergency department
for such condition reach an agreement
concerning the care for the individual.
``(iv) The individual is discharged.
``(D) Signed notice criteria.--For purposes of
subparagraph (B)(ii)(II), the criteria described in
this subparagraph, with respect to an individual and an
item or service furnished by a nonparticipating
provider or nonparticipating facility that is a
hospital or an independent freestanding emergency
department, are the following:
``(i) A written notice (as specified by the
Secretary and in a clear and understandable
manner) is provided by such provider or
facility to such individual, before such item
or service is furnished, that includes the
following information:
``(I) That such provider or
facility is a nonparticipating provider
or nonparticipating facility (as
applicable).
``(II) To the extent practicable,
the estimated amount that such
nonparticipating facility or
nonparticipating provider may charge
the individual for such item or
service.
``(III) A statement that the
individual may seek such item or
service from a provider that is a
participating provider or a hospital or
independent freestanding emergency
department that is a participating
facility and a list, if feasible, of
participating facilities or
participating providers, as applicable,
who are able to furnish such item or
service.
``(ii) Such individual is in a condition to
receive (as determined in accordance with
guidance issued by the Secretary) the
information described in clause (i) and to
confirm notice of receipt of such notice, in
accordance with applicable State law.
``(iii) The individual signs and dates such
notice confirming receipt of the notice before
such item or service is furnished.
``(6) Health plan.--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.
``(7) Independent freestanding emergency department.--The
term `independent freestanding emergency department' means a
health care facility that--
``(A) is geographically separate and distinct and
licensed separately from a hospital under applicable
State law; and
``(B) provides emergency services.
``(8) Median contracted rate.--
``(A) In general.--Subject to subparagraph (B), the
term `median contracted rate' means, with respect to a
health plan--
``(i) for an item or service furnished
during 2022, the median of the contracted rates
recognized by the sponsor or issuer of such
plan (determined with respect to all such plans
of such sponsor or such issuer that are within
the same line of business (as specified in
subparagraph (C)) as the plan involved) as the
total maximum payment under such plans in 2019
for the same or a similar item or service that
is provided by a provider or facility in the
same or similar specialty and provided in the
geographic region (established (and updated, as
appropriate) by the Secretary, in consultation
with the National Association of Insurance
Commissioners) in which the item or service is
furnished, consistent with the methodology
established by the Secretary under subsection
(b)(2)(B), increased by the percentage increase
in the consumer price index for all urban
consumers (United States city average) over
2019, 2020, and 2021;
``(ii) for an item or service furnished
during 2023 or a subsequent year through 2026,
the median contracted rate for the previous
year, increased by the percentage increase in
the consumer price index for all urban
consumers (United States city average) over
such previous year;
``(iii) for an item or service furnished
during a rebasing year (as defined in
subparagraph (D)), the median of the contracted
rates recognized by the sponsor or issuer of
such plan (determined with respect to all such
plans of such sponsor or issuer that are within
the same line of business (as specified in
subparagraph (C)) as the plan involved) as the
total maximum payment under such plans in such
year for the same or a similar item or service
that is provided by a provider or facility in
the same or similar specialty and provided in
the geographic region (as established pursuant
to clause (i)) in which the item or service is
furnished, consistent with the methodology
established by the Secretary under subsection
(b)(2)(B); and
``(iv) for an item or service furnished
during any of the 4 years following a rebasing
year, the median contracted rate for the
previous year, increased by the percentage
increase in the consumer price index for all
urban consumers (United States city average)
over such previous year.
``(B) Use of substitute rate in case of
insufficient data.--
``(i) In general.--In the case the sponsor
or issuer of a health plan has insufficient
information (as specified by the Secretary) to
calculate the median of the contracted rates in
accordance with subparagraph (A) for a year for
an item or service furnished in a particular
geographic region (as established pursuant to
subparagraph (A)(i)) by a type of provider or
facility, the substitute rate (as defined in
clause (ii)) for such item or service shall be
deemed to be the median contracted rate for
such item or service furnished in such region
during such year by such a provider or facility
for such year under such subparagraph (A) for
such plan.
``(ii) Substitute rate.--For purposes of
clause (i), the term `substitute rate' means,
with respect to an item or service furnished by
a provider or facility in a geographic region
(established pursuant to subparagraph (A)(i))
during a year for which a health plan is
required to make payment pursuant to subsection
(b)(1), (e)(1), or (i)(1)--
``(I) if sufficient information (as
specified by the Secretary) exists to
determine the median of the contracted
rates recognized by all health plans
offered in the same line of business
(as specified in subparagraph (C)) by
any group health plan for such an item
or service furnished in such region by
such a provider or facility during such
year using a database or other source
of information determined appropriate
by the Secretary, such median; and
``(II) if such sufficient
information does not exist, the median
of the contracted rates recognized by
all health plans offered in the same
line of business (as specified in
subparagraph (C)) by any group health
plan for such an item or service
furnished in a similarly situated
geographic region (as determined by the
Secretary) with such sufficient
information by such a provider or
facility during such year using such a
database or such other source of
information.
The Secretary shall develop a methodology for
determining a substitute rate based on a
similarly situated health plan that is not a
Federal health care program (as defined in
section 1128B(f) of the Social Security Act) in
the case a substitute rate is not calculable
under the previous sentence with respect to an
item or service.
``(C) Line of business.--A line of business
specified in this subparagraph is one of the following:
``(i) The small group market.
``(ii) The large group market.
``(iii) In the case of a self-insured group
health plan, other self-insured group health
plans.
``(D) Rebasing year defined.--For purposes of
subparagraph (A), the term `rebasing year' means 2027
and every 5 years thereafter.
``(9) Nonparticipating facility; participating facility.--
``(A) Nonparticipating facility.--The term
`nonparticipating facility' means, with respect to an
item or service and a health plan, a health care
facility described in subparagraph (B)(ii) that does
not have a contractual relationship with the plan for
furnishing such item or service.
``(B) Participating facility.--
``(i) In general.--The term `participating
facility' means, with respect to an item or
service and a health plan, a health care
facility described in clause (ii) that has a
contractual relationship with the plan for
furnishing such item or service.
``(ii) Health care facility described.--A
health care facility described in this clause
is each of the following:
``(I) A hospital (as defined in
1861(e) of the Social Security Act),
including an emergency department of a
hospital.
``(II) A critical access hospital
(as defined in section 1861(mm)(1) of
such Act).
``(III) An ambulatory surgical
center (as described in section
1833(i)(1)(A) of such Act).
``(IV) A laboratory.
``(V) A radiology facility or
imaging center.
``(VI) An independent freestanding
emergency department.
``(VII) Any other facility
specified by the Secretary.
``(10) Nonparticipating providers; participating
providers.--
``(A) Nonparticipating provider.--The term
`nonparticipating provider' means, with respect to an
item or service and a health plan, a physician or other
health care provider who does not have a contractual
relationship with the plan for furnishing such item or
service under the plan.
``(B) Participating provider.--The term
`participating provider' means, with respect to an item
or service and a health plan, a physician or other
health care provider who has a contractual relationship
with the plan for furnishing such item or service under
the plan.
``(11) Out-of-network rate.--The term `out-of-network rate'
means, with respect to an item or service furnished in a State
during a year to a participant or beneficiary of a health plan
receiving such item or service from a nonparticipating provider
or facility--
``(A) subject to subparagraphs (C) and (D), in the
case such State has in effect a State law that provides
for a method for determining the total amount payable
under such health plan regulated by such State with
respect to such item or service furnished by such
provider or facility, such amount determined in
accordance with such law;
``(B) subject to subparagraphs (C) and (D), in the
case such State does not have in effect such a law with
respect to such item or service, plan, and provider or
facility--
``(i) subject to clause (ii), if the
provider or facility (as applicable) and such
plan agree on an amount of payment (including
if agreed on through open negotiations under
subsection (j)(1)) with respect to such item or
service, such agreed on amount; or
``(ii) if such provider or facility (as
applicable) and such plan enter the mediated
dispute process under subsection (j) and do not
so agree before the date on which a selected
independent entity (as defined in paragraph (3)
of such subsection) makes a determination with
respect to such item or service under such
subsection, the amount of such determination;
``(C) in the case such State has an All-Payer Model
Agreement under section 1115A of the Social Security
Act, the amount that the State approves under such
system for such item or service so furnished; or
``(D) in the case such health plan is a self-
insured group health plan and in the case of a State
with an agreement with such plan in effect as of the
date of the enactment of the Consumer Protections
Against Surprise Medical Bills Act of 2020, that
provides for a method for determining the total amount
payable under such health plan with respect to such
item or service furnished by such provider or facility,
such amount determined in accordance with such method.
``(12) Recognized amount.--The term `recognized amount'
means, with respect to an item or service furnished in a State
during a year to a participant or beneficiary of a health plan
by a nonparticipating provider or nonparticipating facility--
``(A) subject to subparagraphs (C) and (D), in the
case such State has in effect a law described in
paragraph (11)(A) with respect to such item or service,
provider or facility, and plan, the amount determined
in accordance with such law;
``(B) subject to subparagraphs (C) and (D), in the
case such State does not have in effect such a law, an
amount that is the median contracted rate for such item
or service for such year;
``(C) in the case such State is described in
paragraph (11)(C) with respect to such item or service
so furnished, the amount that the State approves under
such system for such item or service so furnished; or
``(D) in the case such health plan is a self-
insured group health plan and in the case of a State
with an agreement with such plan in effect as of the
date of the enactment of the Consumer Protections
Against Surprise Medical Bills Act of 2020, that
provides for a method for determining the total amount
payable under such health plan with respect to such
item or service furnished by such provider or facility,
such amount determined in accordance with such method.
``(13) Stabilize.--The term `to stabilize', with respect to
an emergency medical condition, has the meaning give in section
1867(e)(3)(A) of the Social Security Act).
``(14) Cost-sharing.--The term `cost-sharing' includes
copayments, coinsurance, and deductibles.
``(l) Payment to Provider or Facility.--In the case of any payment
required to be made by a health plan pursuant to subsection (b)(1),
(e)(1), or (i)(1) to a nonparticiapting provider or nonparticipating
facility for an item or service, such payment shall be made to such
provider or facility and not to the individual receiving such item or
service.''.
(2) Conforming amendment.--
(A) Application provisions.--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, with respect to a plan year beginning on
or after January 1, 2022, the provisions of
section 2719A of such Act)''; and
(ii) in paragraph (2), by inserting
``(other than, with respect to a plan year
beginning on or after January 1, 2022, the
provisions of section 2719A of such Act)''
after the first occurrence of ``such part A''.
(B) Application to retiree-only plans.--Section
732(a) of the Employee Retirement Income Security Act
of 1974 (29 U.S.C. 1191a(a)) is amended by striking
``section 711'' and inserting ``sections 711 and 716''.
(3) 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. Patient protections.''.
(4) Effective date.--The amendments made by this subsection
shall apply with respect to plan years beginning on or after
January 1, 2022.
SEC. 3. CONSUMER PROTECTIONS THROUGH REQUIREMENTS ON HEALTH PLANS TO
PREVENT SURPRISE MEDICAL BILLS FOR NON-EMERGENCY SERVICES
PERFORMED BY NONPARTICIPATING PROVIDERS AT CERTAIN
PARTICIPATING FACILITIES.
(a) PHSA Amendments.--
(1) In general.--Section 2719A of the Public Health Service
Act (42 U.S.C. 300gg-19a), as amended by section 2(a), is
further amended by inserting before subsection (k) the
following new subsection:
``(e) Cost-Sharing and Payment of Non-Emergency Services Performed
by Nonparticipating Providers at Certain Participating Facilities.--
``(1) In general.--Subject to paragraph (2), in the case of
items or services (other than emergency services to which
subsection (b) applies or items and services to which
subsection (i) applies) furnished to a participant,
beneficiary, or enrollee of a health plan by a nonparticipating
provider during a visit (as defined by the Secretary in
accordance with subsection (k)(2)) at a participating facility,
if such items and services would otherwise be covered under
such plan if furnished by a participating provider, the plan--
``(A) shall not impose on such participant,
beneficiary, or enrollee a cost-sharing amount for such
items and services so furnished that is greater than
the cost-sharing amount that would apply under such
plan had such items or services been furnished by a
participating provider;
``(B) shall calculate such cost-sharing amount as
if the contracted rate for such services if furnished
by a participating provider were equal to the
recognized amount for such items and services;
``(C) shall pay to such provider furnishing such
items and services to such participant, beneficiary, or
enrollee the amount by which the out-of-network rate
for such items and services exceeds the cost-sharing
amount imposed under the plan for such items and
services (as determined in accordance with
subparagraphs (A) and (B)); and
``(D) shall apply the deductible or out-of-pocket
maximum, if any, that would apply if such services were
furnished by a participating provider.
``(2) Exception.--Paragraph (1) shall not apply to a health
plan in the case of items or services furnished to a
participant, beneficiary, or enrollee of a health plan by a
nonparticipating provider during a visit (as so defined by the
Secretary in accordance with subsection (k)(2)) at a
participating facility if the requirement described in
paragraph (1) of section 1150C(b) of the Social Security Act
does not apply with respect to such provider and such items and
services due to the application of paragraph (2) of such
section.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply with respect to plan years beginning on or after
January 1, 2022.
(b) IRC Amendments.--
(1) In general.--Section 9816 of the Internal Revenue Code
of 1986, as added by section 2(b), is amended by inserting
before subsection (k) the following new subsection:
``(e) Cost-Sharing and Payment of Non-Emergency Services Performed
by Nonparticipating Providers at Certain Participating Facilities.--
``(1) In general.--Subject to paragraph (2), in the case of
items or services (other than emergency services to which
subsection (b) applies or items and services to which
subsection (i) applies) furnished to a participant or
beneficiary of a health plan by a nonparticipating provider
during a visit (as defined by the Secretary in accordance with
subsection (k)(2)) at a participating facility, if such items
and services would otherwise be covered under such plan if
furnished by a participating provider, the plan--
``(A) shall not impose on such participant or
beneficiary a cost-sharing amount for such items and
services so furnished that is greater than the cost-
sharing amount that would apply under such plan had
such items or services been furnished by a
participating provider;
``(B) shall calculate such cost-sharing amount as
if the contracted rate for such services if furnished
by a participating provider were equal to the
recognized amount for such items and services;
``(C) shall pay to such provider furnishing such
items and services to such participant or beneficiary
the amount by which the out-of-network rate for such
items and services exceeds the cost-sharing amount
imposed under the plan for such items and services (as
determined in accordance with subparagraphs (A) and
(B)); and
``(D) shall apply the deductible or out-of-pocket
maximum, if any, that would apply if such services were
furnished by a participating provider.
``(2) Exception.--Paragraph (1) shall not apply to a health
plan in the case of items or services furnished to a
participant or beneficiary of a health plan by a
nonparticipating provider during a visit (as so defined by the
Secretary in accordance with subsection (k)(2)) at a
participating facility if the requirement described in
paragraph (1) of section 1150C(b) of the Social Security Act
does not apply with respect to such provider and such items and
services due to the application of paragraph (2) of such
section.''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply with respect to plan years beginning on or after
January 1, 2022.
(c) ERISA Amendments.--
(1) In general.--Section 716 of the Employee Retirement
Income Security Act of 1974, as added by section 2(c), is
amended by inserting before subsection (k) the following new
subsection:
``(e) Cost-Sharing and Payment of Non-Emergency Services Performed
by Nonparticipating Providers at Certain Participating Facilities.--
``(1) In general.--Subject to paragraph (2), in the case of
items or services (other than emergency services to which
subsection (b) applies or items and services to which
subsection (i) applies) furnished to a participant or
beneficiary of a health plan by a nonparticipating provider
during a visit (as defined by the Secretary in accordance with
subsection (k)(2)) at a participating facility, if such items
and services would otherwise be covered under such plan if
furnished by a participating provider, the plan--
``(A) shall not impose on such participant or
beneficiary a cost-sharing amount for such items and
services so furnished that is greater than the cost-
sharing amount that would apply under such plan had
such items or services been furnished by a
participating provider;
``(B) shall calculate such cost-sharing amount as
if the contracted rate for such services if furnished
by a participating provider were equal to the
recognized amount for such items and services;
``(C) shall pay to such provider furnishing such
items and services to such participant or beneficiary
the amount by which the out-of-network rate for such
items and services exceeds the cost-sharing amount
imposed under the plan for such items and services (as
determined in accordance with subparagraphs (A) and
(B)); and
``(D) shall apply the deductible or out-of-pocket
maximum, if any, that would apply if such services were
furnished by a participating provider.
``(2) Exception.--Paragraph (1) shall not apply to a health
plan in the case of items or services furnished to a
participant or beneficiary of a health plan by a
nonparticipating provider during a visit (as so defined by the
Secretary in accordance with subsection (k)(2)) at a
participating facility if the requirement described in
paragraph (1) of section 1150C(b) of the Social Security Act
does not apply with respect to such provider and such items and
services due to the application of paragraph (2) of such
section.''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply with respect to plan years beginning on or after
January 1, 2022.
SEC. 4. CONSUMER PROTECTIONS THROUGH APPLICATION OF HEALTH PLAN
EXTERNAL REVIEW IN CASES OF CERTAIN SURPRISE MEDICAL
BILLS.
Section 2719(b)(1) of the Public Health Service Act (42 U.S.C.
300gg-19(b)(1)) is amended--
(1) by striking ``at a minimum, includes'' and inserting
``at a minimum--
``(A) includes'';
(2) by striking at the end ``or'' and inserting ``and'';
and
(3) by adding at the end the following new subparagraph:
``(B) beginning not later than January 1, 2022,
applies such external review process with respect to
any adverse determination by such plan or issuer under
subsection (b) of section 2719A, subsection (e) of such
section, or subsection (i) of such section, including
with respect to whether an item or service that is the
subject to such a determination is an item or service
to which such subsection (b), (e), or (i) applies;
or''.
SEC. 5. CONSUMER PROTECTIONS THROUGH HEALTH PLAN TRANSPARENCY
REQUIREMENTS.
(a) PHSA Amendments.--Section 2719A of the Public Health Service
Act (42 U.S.C. 300gg-19a), as amended by sections 2(a) and 3(a), is
further amended by inserting before subsection (k) the following new
subsections:
``(f) Provider Directory Requirements.--
``(1) In general.--Beginning not later than January 1,
2022, each health plan shall--
``(A) establish the verification process described
in paragraph (2);
``(B) establish the response protocol described in
paragraph (3);
``(C) establish the database described in paragraph
(4); and
``(D) include in any directory (other than the
database described in subparagraph (C)) containing
provider directory information with respect to such
plan the information described in paragraph (5).
``(2) Verification process.--The verification process
described in this paragraph is, with respect to a health plan,
a process--
``(A) under which such plan verifies and updates
the provider directory information included on the
database described in paragraph (4) of such plan of--
``(i) not less frequently than once every
90 days, a random sample of at least 10 percent
of health care providers and health care
facilities included in such database; and
``(ii) any such provider or such facility
included in such database that has not
submitted any claim to such plan during a 12-
month period;
``(B) that establishes a procedure for the removal
from such database of such a provider or facility with
respect to which such plan has been unable to verify
such information during a period specified by the plan;
and
``(C) that provides for the update of such database
within 2 business days of such plan receiving from such
a provider or facility information pursuant to section
1150D of the Social Security Act.
``(3) Response protocol.--The response protocol described
in this paragraph is, in the case of an individual enrolled in
a health plan who requests information through a telephone call
or email on whether a health care provider or health care
facility has a contractual relationship to furnish items and
services under such plan, a protocol under which such plan--
``(A) responds to such individual as soon as
practicable, and in no case later than 1 business day
after such call or email is received, through a written
electronic or paper (as requested by such individual)
communication; and
``(B) retains such communication in such
individual's file for at least 2 years following such
response.
``(4) Database.--The database described in this paragraph
is, with respect to a health plan, a database on the public
website of such plan or issuer that contains--
``(A) a list of each health care provider and
health care facility with which such plan has a
contractual relationship for furnishing items and
services under such plan; and
``(B) provider directory information with respect
to each such provider and facility.
``(5) Information.--The information described in this
paragraph is, with respect to a directory containing provider
directory information with respect to a health plan, a
notification that such information contained in such directory
was accurate as of the date of publication of such directory
and that an individual enrolled under such plan should consult
the database described in paragraph (4) with respect to such
plan or contact such plan to obtain the most current provider
directory information with respect to such plan.
``(6) Definition.--For purposes of this section, the term
`provider directory information' includes, with respect to a
health plan, the name, address, specialty, and telephone number
of each health care provider or health care facility with which
such plan has a contractual relationship for furnishing items
and services under such plan.
``(g) Disclosure on Patient Protections Against Balance Billing.--
Beginning not later than January 1, 2022, each health plan shall make
publicly available, post on a website of such plan available to
individuals enrolled under such plan, and include on each explanation
of benefits for an item or service with respect to which the
requirements under subsection (b), (e), or (i) applies--
``(1) information in plain language on--
``(A) the requirements and prohibitions applied
under section 1150C of the Social Security Act
(relating to prohibitions on balance billing in certain
circumstances);
``(B) if provided for under applicable State law,
any other requirements on providers and facilities
regarding the amounts such providers and facilities
may, with respect to an item or service, charge a
participant, beneficiary, or enrollee of such plan with
respect to which such a provider is a nonparticipating
provider or facility is a nonparticipating facility,
with respect to such plan, for furnishing such item or
service after receiving payment from the plan for such
item or service and any applicable cost-sharing payment
from such participant, beneficiary, or enrollee; and
``(C) the requirements applied under subsections
(b), (e), and (i); and
``(2) information in plain language on contacting
appropriate State and Federal agencies in the case that an
individual believes that such a health plan, provider, or
facility has violated any requirement described in paragraph
(1) with respect to such individual.''.
(b) IRC Amendments.--Section 9816 of the Internal Revenue Code of
1986, as added by section 2(b) and amended by section 3(b), is further
amended by inserting before subsection (k) the following new
subsections:
``(f) Provider Directory Requirements.--
``(1) In general.--Beginning not later than January 1,
2022, each health plan shall--
``(A) establish the verification process described
in paragraph (2);
``(B) establish the response protocol described in
paragraph (3);
``(C) establish the database described in paragraph
(4); and
``(D) include in any directory (other than the
database described in subparagraph (C)) containing
provider directory information with respect to such
plan the information described in paragraph (5).
``(2) Verification process.--The verification process
described in this paragraph is, with respect to a health plan,
a process--
``(A) under which such plan verifies and updates
the provider directory information included on the
database described in paragraph (4) of such plan of--
``(i) not less frequently than once every
90 days, a random sample of at least 10 percent
of health care providers and health care
facilities included in such database; and
``(ii) any such provider or such facility
included in such database that has not
submitted any claim to such plan during a 12-
month period;
``(B) that establishes a procedure for the removal
from such database of such a provider or facility with
respect to which such plan has been unable to verify
such information during a period specified by the plan;
and
``(C) that provides for the update of such database
within 2 business days of such plan receiving from such
a provider or facility information pursuant to section
1150D of the Social Security Act.
``(3) Response protocol.--The response protocol described
in this paragraph is, in the case of an individual enrolled in
a health plan who requests information through a telephone call
or email on whether a health care provider or health care
facility has a contractual relationship to furnish items and
services under such plan, a protocol under which such plan--
``(A) responds to such individual as soon as
practicable, and in no case later than 1 business day
after such call or email is received, through a written
electronic or paper (as requested by such individual)
communication; and
``(B) retains such communication in such
individual's file for at least 2 years following such
response.
``(4) Database.--The database described in this paragraph
is, with respect to a health plan, a database on the public
website of such plan or issuer that contains--
``(A) a list of each health care provider and
health care facility with which such plan has a
contractual relationship for furnishing items and
services under such plan; and
``(B) provider directory information with respect
to each such provider and facility.
``(5) Information.--The information described in this
paragraph is, with respect to a directory containing provider
directory information with respect to a health plan, a
notification that such information contained in such directory
was accurate as of the date of publication of such directory
and that an individual enrolled under such plan should consult
the database described in paragraph (4) with respect to such
plan or contact such plan to obtain the most current provider
directory information with respect to such plan.
``(6) Definition.--For purposes of this section, the term
`provider directory information' includes, with respect to a
health plan, the name, address, specialty, and telephone number
of each health care provider or health care facility with which
such plan has a contractual relationship for furnishing items
and services under such plan.
``(g) Disclosure on Patient Protections Against Balance Billing.--
Beginning not later than January 1, 2022, each health plan shall make
publicly available, post on a website of such plan available to
individuals enrolled under such plan, and include on each explanation
of benefits for an item or service with respect to which the
requirements under subsection (b), (e), or (i) applies--
``(1) information in plain language on--
``(A) the requirements and prohibitions applied
under section 1150C of the Social Security Act
(relating to prohibitions on balance billing in certain
circumstances);
``(B) if provided for under applicable State law,
any other requirements on providers and facilities
regarding the amounts such providers and facilities
may, with respect to an item or service, charge a
participant or beneficiary of such plan with respect to
which such a provider is a nonparticipating provider or
facility is a nonparticipating facility, with respect
to such plan, for furnishing such item or service after
receiving payment from the plan for such item or
service and any applicable cost-sharing payment from
such participant or beneficiary; and
``(C) the requirements applied under subsections
(b), (e), and (i); and
``(2) information in plain language on contacting
appropriate State and Federal agencies in the case that an
individual believes that such a health plan, provider, or
facility has violated any requirement described in paragraph
(1) with respect to such individual.''.
(c) ERISA Amendments.--Section 716 of the Employee Retirement
Income Security Act of 1974, as added by section 2(c) and amended by
section 3(c), is further amended by inserting before subsection (k) the
following new subsections:
``(f) Provider Directory Requirements.--
``(1) In general.--Beginning not later than January 1,
2022, each health plan shall--
``(A) establish the verification process described
in paragraph (2);
``(B) establish the response protocol described in
paragraph (3);
``(C) establish the database described in paragraph
(4); and
``(D) include in any directory (other than the
database described in subparagraph (C)) containing
provider directory information with respect to such
plan the information described in paragraph (5).
``(2) Verification process.--The verification process
described in this paragraph is, with respect to a health plan,
a process--
``(A) under which such plan verifies and updates
the provider directory information included on the
database described in paragraph (4) of such plan of--
``(i) not less frequently than once every
90 days, a random sample of at least 10 percent
of health care providers and health care
facilities included in such database; and
``(ii) any such provider or such facility
included in such database that has not
submitted any claim to such plan during a 12-
month period;
``(B) that establishes a procedure for the removal
from such database of such a provider or facility with
respect to which such plan has been unable to verify
such information during a period specified by the plan;
and
``(C) that provides for the update of such database
within 2 business days of such plan receiving from such
a provider or facility information pursuant to section
1150D of the Social Security Act.
``(3) Response protocol.--The response protocol described
in this paragraph is, in the case of an individual enrolled in
a health plan who requests information through a telephone call
or email on whether a health care provider or health care
facility has a contractual relationship to furnish items and
services under such plan, a protocol under which such plan--
``(A) responds to such individual as soon as
practicable, and in no case later than 1 business day
after such call or email is received, through a written
electronic or paper (as requested by such individual)
communication; and
``(B) retains such communication in such
individual's file for at least 2 years following such
response.
``(4) Database.--The database described in this paragraph
is, with respect to a health plan, a database on the public
website of such plan or issuer that contains--
``(A) a list of each health care provider and
health care facility with which such plan has a
contractual relationship for furnishing items and
services under such plan; and
``(B) provider directory information with respect
to each such provider and facility.
``(5) Information.--The information described in this
paragraph is, with respect to a directory containing provider
directory information with respect to a health plan, a
notification that such information contained in such directory
was accurate as of the date of publication of such directory
and that an individual enrolled under such plan should consult
the database described in paragraph (4) with respect to such
plan or contact such plan to obtain the most current provider
directory information with respect to such plan.
``(6) Definition.--For purposes of this section, the term
`provider directory information' includes, with respect to a
health plan, the name, address, specialty, and telephone number
of each health care provider or health care facility with which
such plan has a contractual relationship for furnishing items
and services under such plan.
``(g) Disclosure on Patient Protections Against Balance Billing.--
Beginning not later than January 1, 2022, each health plan shall make
publicly available, post on a website of such plan available to
individuals enrolled under such plan, and include on each explanation
of benefits for an item or service with respect to which the
requirements under subsection (b), (e), or (i) applies--
``(1) information in plain language on--
``(A) the requirements and prohibitions applied
under section 1150C of the Social Security Act
(relating to prohibitions on balance billing in certain
circumstances);
``(B) if provided for under applicable State law,
any other requirements on providers and facilities
regarding the amounts such providers and facilities
may, with respect to an item or service, charge a
participant or beneficiary of such plan with respect to
which such a provider is a nonparticipating provider or
facility is a nonparticipating facility, with respect
to such plan, for furnishing such item or service after
receiving payment from the plan for such item or
service and any applicable cost-sharing payment from
such participant or beneficiary; and
``(C) the requirements applied under subsections
(b), (e), and (i); and
``(2) information in plain language on contacting
appropriate State and Federal agencies in the case that an
individual believes that such a health plan, provider, or
facility has violated any requirement described in paragraph
(1) with respect to such individual.''.
SEC. 6. CONSUMER PROTECTIONS THROUGH HEALTH PLAN REQUIREMENT FOR FAIR
AND HONEST ADVANCE COST ESTIMATE.
(a) PHSA Amendment.--Section 2719A of the Public Health Service Act
(42 U.S.C. 300gg-19a), as amended by sections 2(a), 3(a), and 5(a), is
further amended by inserting before subsection (k) the following new
subsections:
``(h) Advanced Explanation of Benefits.--Beginning on January 1,
2022, each health plan shall, with respect to a notification submitted
under section 1150D(b)(2)(A) 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 (in clear and understandable
language) 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 individual 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) A statement that the individual may seek such an item
or service from a provider that is a participating provider or
a facility that is a participating facility and a list of
participating facilities, or of participating providers, as
applicable, who are able to furnish such items and services
involved.
``(9) Any other information or disclaimer the health plan
determines appropriate that is consistent with information and
disclaimers required under this section.
``(i) Cost-Sharing and Payment for Services Provided Based on
Reliance on Incorrect Provider Network Information.--
``(1) In general.--For plan years beginning on or after
January 1, 2022, in the case of an item or service furnished to
a participant, beneficiary, or enrollee of a health plan by a
nonparticipating provider or a nonparticipating facility, if
such item or service would otherwise be covered under such plan
if furnished by a participating provider or participating
facility and if either of the criteria described in paragraph
(2) applies with respect to such participant, beneficiary, or
enrollee and item or service, the plan--
``(A) shall not impose on such enrollee a cost-
sharing amount for such item or service so furnished
that is greater than the cost-sharing amount that would
apply under such plan had such item or service been
furnished by a participating provider;
``(B) shall calculate such cost-sharing amount as
if the contracted rate for such item or service
furnished by such a participating provider or facility
were equal to--
``(i) the most recent (as of the date such
item or service was furnished) contracted rate
in effect between such provider or facility and
such plan for such item or service furnished
under such plan, if any; or
``(ii) if no contracted rate described in
clause (i) exists, the recognized amount for
such item or service;
``(C) shall pay to such nonparticipating provider
or facility furnishing such item or service to such
participant, beneficiary, or enrollee the amount by
which--
``(i) if a contracted rate described in
subparagraph (B)(i) exists, the most recent (as
of the date such item or services was
furnished) such rate; or
``(ii) if no contracted rate described in
such subparagraph exists, the out-of-network
rate;
for such items and services exceeds the cost-sharing
amount imposed under the plan for such items and
services (as determined in accordance with
subparagraphs (A) and (B)); and
``(D) shall apply the deductible or out-of-pocket
maximum, if any, that would apply if such services were
furnished by a participating provider or a
participating facility.
``(2) Criteria described.--For purposes of paragraph (1),
the criteria described in this paragraph, with respect to an
item or service furnished to a participant, beneficiary, or
enrollee of a health plan by a nonparticipating provider or a
nonparticipating facility, are the following:
``(A) The participant, beneficiary, or enrollee
received a notification under subsection (h) with
respect to such item and service to be furnished and
such notification provided information that the
provider was a participating provider or facility was a
participating facility, with respect to the plan for
furnishing such item or service.
``(B) A notification was not provided, in
accordance with subsection (h), to the participant,
beneficiary, or enrollee, and the participant,
beneficiary, or enrollee requested through the response
protocol of the plan under subsection (f)(3)
information on whether the provider was a participating
provider or facility was a participating facility with
respect to the plan for furnishing such item or service
and was informed through such protocol that the
provider was such a participating provider or facility
was such a participating facility.''.
(b) IRC Amendments.--Section 9816 of the Internal Revenue Code of
1986, as added by section 2(b) and amended by sections 3(b) and 5(b),
is further amended by inserting before subsection (k) the following new
subsections:
``(h) Advanced Explanation of Benefits.--Beginning on January 1,
2022, each health plan shall, with respect to a notification submitted
under section 1150D(b)(2)(A) 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 (in clear
and understable language) 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 individual 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) A statement that the individual may seek such an item
or service from a provider that is a participating provider or
a facility that is a participating facility and a list of
participating facilities, or of participating providers, as
applicable, who are able to furnish such items and services
involved.
``(9) Any other information or disclaimer the health plan
determines appropriate that is consistent with information and
disclaimers required under this section.
``(i) Cost-Sharing and Payment for Services Provided Based on
Reliance on Incorrect Provider Network Information.--
``(1) In general.--For plan years beginning on or after
January 1, 2022, in the case of an item or service furnished to
a participant or beneficiary of a health plan by a
nonparticipating provider or a nonparticipating facility, if
such item or service would otherwise be covered under such plan
if furnished by a participating provider or participating
facility and if either of the criteria described in paragraph
(2) applies with respect to such participant or beneficiary and
item or service, the plan--
``(A) shall not impose on such enrollee a cost-
sharing amount for such item or service so furnished
that is greater than the cost-sharing amount that would
apply under such plan had such item or service been
furnished by a participating provider;
``(B) shall calculate such cost-sharing amount as
if the contracted rate for such item or service
furnished by such a participating provider or facility
were equal to--
``(i) the most recent (as of the date such
item or service was furnished) contracted rate
in effect between such provider or facility and
such plan for such item or service furnished
under such plan, if any; or
``(ii) if no contracted rate described in
clause (i) exists, the recognized amount for
such item or service;
``(C) shall pay to such nonparticipating provider
or facility furnishing such item or service to such
participant or beneficiary the amount by which--
``(i) if a contracted rate described in
subparagraph (B)(i) exists, the most recent (as
of the date such item or services was
furnished) such rate; or
``(ii) if no contracted rate described in
such subparagraph exists, the out-of-network
rate;
for such items and services exceeds the cost-sharing
amount imposed under the plan for such items and
services (as determined in accordance with
subparagraphs (A) and (B)); and
``(D) shall apply the deductible or out-of-pocket
maximum, if any, that would apply if such services were
furnished by a participating provider or a
participating facility.
``(2) Criteria described.--For purposes of paragraph (1),
the criteria described in this paragraph, with respect to an
item or service furnished to a participant or beneficiary of a
health plan by a nonparticipating provider or a
nonparticipating facility, are the following:
``(A) The participant or beneficiary received a
notification under subsection (h) with respect to such
item and service to be furnished and such notification
provided information that the provider was a
participating provider or facility was a participating
facility, with respect to the plan for furnishing such
item or service.
``(B) A notification was not provided, in
accordance with subsection (h), to the participant or
beneficiary and the participant or beneficiary
requested through the response protocol of the plan
under subsection (f)(3) information on whether the
provider was a participating provider or facility was a
participating facility with respect to the plan for
furnishing such item or service and was informed
through such protocol that the provider was such a
participating provider or facility was such a
participating facility.''.
(c) ERISA Amendments.--Section 716 of the Employee Retirement
Income Security Act of 1974, as added by section 2(c) and amended by
sections 3(c) and 5(c), is further amended by inserting before
subsection (k) the following new subsections:
``(h) Advanced Explanation of Benefits.--Beginning on January 1,
2022, each health plan shall, with respect to a notification submitted
under section 1150D(b)(2)(A) 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 (in clear
and understandable language) 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 individual 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) A statement that the individual may seek such an item
or service from a provider that is a participating provider or
a facility that is a participating facility and a list of
participating facilities, or of participating providers, as
applicable, who are able to furnish such items and services
involved.
``(9) Any other information or disclaimer the health plan
determines appropriate that is consistent with information and
disclaimers required under this section.
``(i) Cost-Sharing and Payment for Services Provided Based on
Reliance on Incorrect Provider Network Information.--
``(1) In general.--For plan years beginning on or after
January 1, 2022, in the case of an item or service furnished to
a participant or beneficiary of a health plan by a
nonparticipating provider or a nonparticipating facility, if
such item or service would otherwise be covered under such plan
if furnished by a participating provider or participating
facility and if either of the criteria described in paragraph
(2) applies with respect to such participant or beneficiary and
item or service, the plan--
``(A) shall not impose on such enrollee a cost-
sharing amount for such item or service so furnished
that is greater than the cost-sharing amount that would
apply under such plan had such item or service been
furnished by a participating provider;
``(B) shall calculate such cost-sharing amount as
if the contracted rate for such item or service
furnished by such a participating provider or facility
were equal to--
``(i) the most recent (as of the date such
item or service was furnished) contracted rate
in effect between such provider or facility and
such plan for such item or service furnished
under such plan, if any; or
``(ii) if no contracted rate described in
clause (i) exists, the recognized amount for
such item or service;
``(C) shall pay to such nonparticipating provider
or facility furnishing such item or service to such
participant or beneficiary the amount by which--
``(i) if a contracted rate described in
subparagraph (B)(i) exists, the most recent (as
of the date such item or services was
furnished) such rate; or
``(ii) if no contracted rate described in
such subparagraph exists, the out-of-network
rate;
for such items and services exceeds the cost-sharing
amount imposed under the plan for such items and
services (as determined in accordance with
subparagraphs (A) and (B)); and
``(D) shall apply the deductible or out-of-pocket
maximum, if any, that would apply if such services were
furnished by a participating provider or a
participating facility.
``(2) Criteria described.--For purposes of paragraph (1),
the criteria described in this paragraph, with respect to an
item or service furnished to a participant or beneficiary of a
health plan by a nonparticipating provider or a
nonparticipating facility, are the following:
``(A) The participant or beneficiary received a
notification under subsection (h) with respect to such
item and service to be furnished and such notification
provided information that the provider was a
participating provider or facility was a participating
facility, with respect to the plan for furnishing such
item or service.
``(B) A notification was not provided, in
accordance with subsection (h), to the participant or
beneficiary and the participant or beneficiary
requested through the response protocol of the plan
under subsection (f)(3) information on whether the
provider was a participating provider or facility was a
participating facility with respect to the plan for
furnishing such item or service and was informed
through such protocol that the provider was such a
participating provider or facility was such a
participating facility.''.
SEC. 7. DETERMINATION THROUGH OPEN NEGOTIATION AND MEDIATION OF OUT-OF-
NETWORK RATES TO BE PAID BY HEALTH PLANS.
(a) PHSA Amendment.--Section 2719A of the Public Health Service Act
(42 U.S.C. 300gg-19a), as amended by sections 2(a), 3(a), 5(a), and
6(a), is further amended by inserting before subsection (k) the
following new subsection:
``(j) Determination of Out-of-Network Rates To Be Paid by Health
Plans.--
``(1) Determination through open negotiation.--
``(A) In general.--With respect to an item or
service furnished in a year by a nonparticipating
provider or a nonparticipating facility, with respect
to a health plan, in a State described in subparagraph
(B) of subsection (k)(11) with respect to such plan and
provider or facility, and for which a payment is
required to be made by the health plan pursuant to
subsection (b)(1), (e)(1), or (i)(1), the provider or
facility (as applicable) or plan may, during the 30-day
period beginning on the day the provider or facility
receives a response from the plan regarding a claim for
payment for such item or service, initiate open
negotiations under this paragraph between such provider
or facility and plan for purposes of determining,
during the open negotiation period, an amount agreed on
by such provider or facility, respectively, and such
plan for payment (including any cost-sharing) for such
item or service. For purposes of this subsection, the
open negotiation period, with respect to an item or
service, is the 30-day period beginning on the date of
initiation of the negotiations with respect to such
item or service.
``(B) Exchange of information.--In carrying out
negotiations initiated under subparagraph (A), with
respect to an item or service described in such
subparagraph furnished in a year, not later than the
fifth business day of the open negotiation period
described in such subparagraph with respect to such
item or service--
``(i) the health plan that is party to such
negotiations shall notify the provider or
facility that is party to such negotiations of
the median contracted rate for such item or
service and year; and
``(ii) such provider or facility shall
notify such health plan of--
``(I) the median of the total
amount of reimbursement (including any
cost-sharing) paid, for the most recent
year for which information is
available, to such provider or facility
for furnishing such item or service to
a participant, beneficiary, or enrollee
of a health plan that, at the time such
item or service was furnished, had a
contract in effect with such provider
or facility with respect to the
furnishing of such item or service;
``(II) in the case that information
described in subclause (I) is not
available, such information as
specified by the Secretary; and
``(III) any additional information
specified by the Secretary.
``(C) Accessing mediated dispute process in case of
failed negotiations.--In the case of open negotiations
pursuant to subparagraph (A), with respect to an item
or service, that do not result in a determination of an
amount of payment for such item or service by the last
day of the open negotiation period described in such
subparagraph with respect to such item or service, the
provider or facility (as applicable) or health plan
that was party to such negotiations may, during the 2-
day period beginning on the day after such open
negotiation period, initiate the mediated dispute
process under paragraph (2) with respect to such item
or service. The mediated dispute process shall be
initiated by a party pursuant to the previous sentence
by submission to the other party and to the Secretary
of a notification (containing such information as
specified by the Secretary) and for purposes of this
subsection, the date of initiation of such process
shall be the date of such submission or such other date
specified by the Secretary pursuant to regulations that
is not later than the date of receipt of such
notification by both the other party and the Secretary.
``(2) Mediated dispute process available in case of failed
open negotiations.--
``(A) Establishment.--Not later than July 1, 2021,
the Secretary, in coordination with the Secretary of
the Treasury and the Secretary of Labor, shall
establish a process (in this subsection referred to as
the `mediated dispute process') under which, in the
case of an item or service with respect to which a
provider or facility (as applicable) or health plan
submits a notification under paragraph (1)(C) (in this
subsection referred to as a `qualified mediated dispute
item or service'), an entity selected under paragraph
(3) determines, subject to subparagraph (B) and in
accordance with the succeeding provisions of this
subsection, the amount of payment under the health plan
for such item or service furnished by such provider or
facility.
``(B) Authority to continue negotiations.--Under
the mediated dispute process, in the case that the
parties to a determination for a qualified mediated
dispute item or service agree on a payment amount for
such item or service during such process but before the
date on which the entity selected with respect to such
determination under paragraph (3) makes such
determination, such amount shall be treated for
purposes of subsection (k)(11)(B) as the amount agreed
to by such parties for such item or service. In the
case of an agreement described in the previous
sentence, the mediated dispute process shall provide
for a method to determine how to allocate between the
parties to such determination the payment of the
compensation of the entity selected with respect to
such determination.
``(3) Selection under mediated dispute process.--Under the
mediated dispute process, the Secretary shall, with respect to
the determination of the amount of payment under this
subsection of a qualified mediated dispute item or service,
provide for a method--
``(A) that allows the parties to such determination
to jointly select, not later than the last day of the
3-day period following the date of the initiation of
the process with respect to such item or service, for
purposes of making such determination, an entity
certified under paragraph (7) that--
``(i) is not a party to such determination
or an employee or agent of such a party;
``(ii) does not have a material familial,
financial, or professional relationship with
such a party; and
``(iii) does not otherwise have a conflict
of interest with such a party (as determined by
the Secretary); and
``(B) that requires, in the case such parties do
not make such selection by such last day, the Secretary
to, not later than 6 days after such date of
initiation--
``(i) select such an entity that satisfies
clauses (i) through (iii) of subparagraph (A);
and
``(ii) provide notification of such
selection to the provider or facility (as
applicable) and the health plan party to such
determination.
An entity selected pursuant to the previous sentence to make a
determination described in such sentence shall be referred to
in this subsection as the `selected independent entity' with
respect to such determination.
``(4) Treatment of consideration of multiple items and
services.--
``(A) In general.--Under the mediated dispute
process, the Secretary shall specify criteria under
which multiple qualified mediated dispute items and
services are permitted to be considered jointly as part
of a single determination by an entity for purposes of
encouraging the efficiency (including minimizing costs)
of the mediated dispute process. Such items and
services may be so considered only if--
``(i) such items and services to be
included in such determination are furnished by
the same provider or facility;
``(ii) payment for such items and services
is required to be made by the same health plan;
and
``(iii) such items and services are related
to the treatment of a similar condition.
``(B) Treatment of bundled payments.--In carrying
out subparagraph (A), the Secretary shall provide that,
in the case of items and services which are included by
a provider or facility as part of a bundled payment,
such items and services included in such bundled
payment may be part of a single determination under
this subsection.
``(C) Waiver of deadlines.--For purposes of
permitting joint consideration of qualified mediated
dispute items and services as part of a single
determination under the criteria specified pursuant to
subparagraph (A), the Secretary may waive any deadline
specified in this subsection.
``(5) Determination of payment amount.--
``(A) In general.--Not later than 30 days after the
date of initiation of the mediated dispute resolution,
with respect to a qualified mediated dispute item or
service, the selected independent entity with respect
to a determination under this subsection for such item
or service shall--
``(i) taking into account only the
considerations specified in subparagraph
(C)(i), select one of the offers submitted
under subparagraph (B) to be the amount of
payment for such item or service determined
under this subsection for purposes of
subsection (b)(1), (e)(1), or (i)(1), as
applicable; and
``(ii) notify the provider or facility and
the health plan party to such determination of
the offer selected under clause (i).
``(B) Submission of offers.--Not later than 10 days
after the date of initiation of the mediated dispute
resolution with respect to a determination for a
qualified mediated dispute item or service, the
provider or facility and the health plan party to such
determination shall each submit to the selected
independent entity--
``(i) an offer for a payment amount under
for such item or service furnished by such
provider or facility;
``(ii) information relating to such offer;
and
``(iii) such other information as requested
by the selected independent entity.
``(C) Considerations.--
``(i) In general.--For purposes of
subparagraph (A), the considerations specified
in this subparagraph, with respect to a
determination for a qualified mediated dispute
item or service, are the following:
``(I) The median contracted rate
for such item or service.
``(II) Subject to clause (ii),
information that is submitted pursuant
to subparagraph (B).
``(ii) Treatment of certain
considerations.--In making a determination with
respect to a qualified mediated dispute item or
service pursuant to subparagraph (A)(i), a
selected independent entity may not take into
account usual and customary charges for the
item or service nor charges billed by the
provider or facility for the item or service.
``(6) Selected independent entity compensation.--
``(A) In general.--Not later than 5 days after
receiving a notification described in paragraph
(5)(A)(ii) from a selected independent entity with
respect to the determination of a payment amount for a
qualified mediated dispute item or service, the party
to such determination whose offer submitted under
paragraph (5)(B) was not selected by the entity shall
pay to such entity a fee in compensation for the
services of such entity in accordance with the
guidelines on such compensation established by the
Secretary under subparagraph (B).
``(B) Guidelines on compensation.--For purposes of
subparagraph (A), the Secretary shall establish
guidelines with respect to the compensation of a
selected independent entity for the services of such
entity with respect to determinations under the
mediated dispute process. Such guidelines shall provide
that such compensation reimburses the entity for at
least the costs of such entity in performing the duties
of the entity under the mediated dispute process.
``(7) Certification of entities.--
``(A) In general.--The Secretary shall establish or
recognize a process to certify (including
recertification of) entities under this paragraph. Such
process shall ensure that an entity so certified--
``(i) has (directly or through contracts or
other arrangements) sufficient medical, legal,
and other expertise and sufficient staffing to
make determinations described in paragraph (2)
on a timely basis;
``(ii) is not--
``(I) a health plan, provider, or
facility;
``(II) an affiliate or a subsidiary
of a health plan, provider, or
facility; or
``(III) an affiliate or subsidiary
of a professional or trade association
of health plans or of providers or
facilities;
``(iii) carries out the responsibilities of
such an entity in accordance with this
subsection;
``(iv) meets appropriate indicators of
fiscal integrity;
``(v) maintains the confidentiality (in
accordance with regulations promulgated by the
Secretary) of individually identifiable health
information obtained in the course of
conducting such determinations;
``(vi) does not under the mediated dispute
process carry out any determination with
respect to which the entity would not pursuant
to clause (i), (ii), or (iii) of paragraph
(3)(A) be eligible for selection; and
``(vii) meets such other requirements as
determined appropriate by the Secretary.
``(B) Period of certification.--Subject to
subparagraph (C), each certification (including a
recertification) of an entity under the process
described in subparagraph (A) shall be for a 5-year
period.
``(C) Revocation.--A certification of an entity
under this paragraph may be revoked under the process
described in subparagraph (A) if the entity has a
pattern or practice of noncompliance with any of the
requirements described in such subparagraph.
``(D) Petition for denial or withdrawal.--The
process described in subparagraph (A) shall ensure that
an individual, provider, facility, or health plan may
petition for a denial of a certification or a
revocation of a certification with respect to an entity
under this paragraph for failure of meeting a
requirement of this subsection.
``(E) Sufficient number of entities.--The process
described in subparagraph (A) shall ensure that a
sufficient number of entities are certified under this
paragraph to ensure the timely and efficient provision
of determinations described in paragraph (2).
``(F) Provision of information.--
``(i) In general.--An entity certified
under this paragraph shall provide to the
Secretary, in such manner as the Secretary may
require and on a quarterly basis (as specified
by the Secretary), such information as the
Secretary determines appropriate to assure
compliance with the requirements described in
subparagraph (A) and to monitor and assess the
determinations made by such entity and to
ensure the absence of bias in making such
determinations. Such information shall include
information described in clause (ii) but shall
not include individually identifiable health
information.
``(ii) Information to be included.--The
information described in this clause with
respect to an entity is the following:
``(I) The number of payment
determinations described in paragraph
(2) made by such entity, disaggregated
by--
``(aa) the line of business
(as specified in subsection
(k)(8)(C)) of the health plans
party to such determinations;
and
``(bb) the type of
providers and facilities party
to such determinations.
``(II) A description of each item
or service included in each such
determination.
``(III) The amount of each offer
submitted to the entity for each such
determination.
``(IV) The amount of each such
determination.
``(V) The length of time in making
each such determination.
``(VI) The compensation paid to
such entity with respect to each such
determination.
``(VII) Any other information
specified by the Secretary.
``(8) Administrative fee.--
``(A) In general.--Each party to a determination to
which an entity is selected under paragraph (3) in a
year shall pay to the Secretary, at such time and in
such manner as specified by the Secretary, a fee for
participating in the mediated dispute process with
respect to such determination in an amount described in
subparagraph (B) for such year.
``(B) Amount of fee.--The amount described in this
subparagraph for a year is an amount established by the
Secretary in a manner such that the total amount of
fees paid under this paragraph for such year is
estimated to be equal to the amount of expenditures
estimated to be made by the Secretary for such year in
carrying out the mediated dispute process.
``(9) Secretarial report; publication of information.--
``(A) Secretarial report.--Beginning not later than
July 1, 2023, the Secretary shall, in coordination with
the Secretary of the Treasury and the Secretary of
Labor, periodically study and submit to Congress a
report on--
``(i) the extent to which the payment
amount determined under this subsection for an
item or service furnished in a year (or
otherwise agreed to by a health plan and
provider or facility for purposes of
determining payment by the plan to the provider
or facility pursuant to subsection (b)(1),
(e)(1), or (i)(1)) differs from the median
contracted rate for such item or service and
year, including the number of times such
determined (or agreed to) amount exceeds such
median contracted rate; and
``(ii) the effect of such difference on the
cost-sharing for such item or service for a
participant, beneficiary, or enrollee of a
health plan.
``(B) Publication of information.--Beginning with
July 1, 2023, and for each calendar quarter thereafter,
the Secretary shall, in coordination with the Secretary
of the Treasury and the Secretary of Labor, make
publicly available a summary of the following:
``(i) The information described in
subclauses (I) through (V) of clause (ii) of
paragraph (7)(F) that was submitted to the
Secretary under clause (i) of such paragraph
during such quarter.
``(ii) The amount of expenditures made by
the Secretary during such year to carry out the
mediated dispute process.
``(iii) The total amount of fees paid under
paragraph (8) during such quarter.
``(iv) The total amount of compensation
paid to selected independent entities under
paragraph (6) during such quarter.''.
(b) IRC Amendments.--Section 9816 of the Internal Revenue Code of
1986, as added by section 2(b) and amended by sections 3(b), 5(b), and
6(b), is further amended by inserting before subsection (k) the
following new subsection:
``(j) Determination of Out-of-Network Rates To Be Paid by Health
Plans.--
``(1) Determination through open negotiation.--
``(A) In general.--With respect to an item or
service furnished in a year by a nonparticipating
provider or a nonparticipating facility, with respect
to a health plan, in a State described in subparagraph
(B) of subsection (k)(11) with respect to such plan and
provider or facility, and for which a payment is
required to be made by the health plan pursuant to
subsection (b)(1), (e)(1), or (i)(1), the provider or
facility (as applicable) or plan may, during the 30-day
period beginning on the day the provider or facility
receives a response from the plan regarding a claim for
payment for such item or service, initiate open
negotiations under this paragraph between such provider
or facility and plan for purposes of determining,
during the open negotiation period, an amount agreed on
by such provider or facility, respectively, and such
plan for payment (including any cost-sharing) for such
item or service. For purposes of this subsection, the
open negotiation period, with respect to an item or
service, is the 30-day period beginning on the date of
initiation of the negotiations with respect to such
item or service.
``(B) Exchange of information.--In carrying out
negotiations initiated under subparagraph (A), with
respect to an item or service described in such
subparagraph furnished in a year, not later than the
fifth business day of the open negotiation period
described in such subparagraph with respect to such
item or service--
``(i) the health plan that is party to such
negotiations shall notify the provider or
facility that is party to such negotiations of
the median contracted rate for such item or
service and year; and
``(ii) such provider or facility shall
notify such health plan of--
``(I) the median of the total
amount of reimbursement (including any
cost-sharing) paid, for the most recent
year for which information is
available, to such provider or facility
for furnishing such item or service to
a participant or beneficiary of a
health plan that, at the time such item
or service was furnished, had a
contract in effect with such provider
or facility with respect to the
furnishing of such item or service;
``(II) in the case that information
described in subclause (I) is not
available, such information as
specified by the Secretary; and
``(III) any additional information
specified by the Secretary.
``(C) Accessing mediated dispute process in case of
failed negotiations.--In the case of open negotiations
pursuant to subparagraph (A), with respect to an item
or service, that do not result in a determination of an
amount of payment for such item or service by the last
day of the open negotiation period described in such
subparagraph with respect to such item or service, the
provider or facility (as applicable) or health plan
that was party to such negotiations may, during the 2-
day period beginning on the day after such open
negotiation period, initiate the mediated dispute
process under paragraph (2) with respect to such item
or service. The mediated dispute process shall be
initiated by a party pursuant to the previous sentence
by submission to the other party and to the Secretary
of a notification (containing such information as
specified by the Secretary) and for purposes of this
subsection, the date of initiation of such process
shall be the date of such submission or such other date
specified by the Secretary pursuant to regulations that
is not later than the date of receipt of such
notification by both the other party and the Secretary.
``(2) Mediated dispute process available in case of failed
open negotiations.--
``(A) Establishment.--Not later than July 1, 2021,
the Secretary, in coordination with the Secretary of
Health and Human Services and the Secretary of Labor,
shall establish a process (in this subsection referred
to as the `mediated dispute process') under which, in
the case of an item or service with respect to which a
provider or facility (as applicable) or health plan
submits a notification under paragraph (1)(C) (in this
subsection referred to as a `qualified mediated dispute
item or service'), an entity selected under paragraph
(3) determines, subject to subparagraph (B) and in
accordance with the succeeding provisions of this
subsection, the amount of payment under the health plan
for such item or service furnished by such provider or
facility.
``(B) Authority to continue negotiations.--Under
the mediated dispute process, in the case that the
parties to a determination for a qualified mediated
dispute item or service agree on a payment amount for
such item or service during such process but before the
date on which the entity selected with respect to such
determination under paragraph (3) makes such
determination, such amount shall be treated for
purposes of subsection (k)(11)(B) as the amount agreed
to by such parties for such item or service. In the
case of an agreement described in the previous
sentence, the mediated dispute process shall provide
for a method to determine how to allocate between the
parties to such determination the payment of the
compensation of the entity selected with respect to
such determination.
``(3) Selection under mediated dispute process.--Under the
mediated dispute process, the Secretary shall, with respect to
the determination of the amount of payment under this
subsection of a qualified mediated dispute item or service,
provide for a method--
``(A) that allows the parties to such determination
to jointly select, not later than the last day of the
3-day period following the date of the initiation of
the process with respect to such item or service, for
purposes of making such determination, an entity
certified under paragraph (7) that--
``(i) is not a party to such determination
or an employee or agent of such a party;
``(ii) does not have a material familial,
financial, or professional relationship with
such a party; and
``(iii) does not otherwise have a conflict
of interest with such a party (as determined by
the Secretary); and
``(B) that requires, in the case such parties do
not make such selection by such last day, the Secretary
to, not later than 6 days after such date of
initiation--
``(i) select such an entity that satisfies
clauses (i) through (iii) of subparagraph (A);
and
``(ii) provide notification of such
selection to the provider or facility (as
applicable) and the health plan party to such
determination.
An entity selected pursuant to the previous sentence to make a
determination described in such sentence shall be referred to
in this subsection as the `selected independent entity' with
respect to such determination.
``(4) Treatment of consideration of multiple items and
services.--
``(A) In general.--Under the mediated dispute
process, the Secretary shall specify criteria under
which multiple qualified mediated dispute items and
services are permitted to be considered jointly as part
of a single determination by an entity for purposes of
encouraging the efficiency (including minimizing costs)
of the mediated dispute process. Such items and
services may be so considered only if--
``(i) such items and services to be
included in such determination are furnished by
the same provider or facility;
``(ii) payment for such items and services
is required to be made by the same health plan;
and
``(iii) such items and services are related
to the treatment of a similar condition.
``(B) Treatment of bundled payments.--In carrying
out subparagraph (A), the Secretary shall provide that,
in the case of items and services which are included by
a provider or facility as part of a bundled payment,
such items and services included in such bundled
payment may be part of a single determination under
this subsection.
``(C) Waiver of deadlines.--For purposes of
permitting joint consideration of qualified mediated
dispute items and services as part of a single
determination under the criteria specified pursuant to
subparagraph (A), the Secretary may waive any deadline
specified in this subsection.
``(5) Determination of payment amount.--
``(A) In general.--Not later than 30 days after the
date of initiation of the mediated dispute resolution,
with respect to a qualified mediated dispute item or
service, the selected independent entity with respect
to a determination under this subsection for such item
or service shall--
``(i) taking into account only the
considerations specified in subparagraph
(C)(i), select one of the offers submitted
under subparagraph (B) to be the amount of
payment for such item or service determined
under this subsection for purposes of
subsection (b)(1), (e)(1), or (i)(1), as
applicable; and
``(ii) notify the provider or facility and
the health plan party to such determination of
the offer selected under clause (i).
``(B) Submission of offers.--Not later than 10 days
after the date of initiation of the mediated dispute
resolution with respect to a determination for a
qualified mediated dispute item or service, the
provider or facility and the health plan party to such
determination shall each submit to the selected
independent entity--
``(i) an offer for a payment amount under
for such item or service furnished by such
provider or facility;
``(ii) information relating to such offer;
and
``(iii) such other information as requested
by the selected independent entity.
``(C) Considerations.--
``(i) In general.--For purposes of
subparagraph (A), the considerations specified
in this subparagraph, with respect to a
determination for a qualified mediated dispute
item or service, are the following:
``(I) The median contracted rate
for such item or service.
``(II) Subject to clause (ii),
information that is submitted pursuant
to subparagraph (B).
``(ii) Treatment of certain
considerations.--In making a determination with
respect to a qualified mediated dispute item or
service pursuant to subparagraph (A)(i), a
selected independent entity may not take into
account usual and customary charges for the
item or service nor charges billed by the
provider or facility for the item or service.
``(6) Selected independent entity compensation.--
``(A) In general.--Not later than 5 days after
receiving a notification described in paragraph
(5)(A)(ii) from a selected independent entity with
respect to the determination of a payment amount for a
qualified mediated dispute item or service, the party
to such determination whose offer submitted under
paragraph (5)(B) was not selected by the entity shall
pay to such entity a fee in compensation for the
services of such entity in accordance with the
guidelines on such compensation established by the
Secretary under subparagraph (B).
``(B) Guidelines on compensation.--For purposes of
subparagraph (A), the Secretary shall establish
guidelines with respect to the compensation of a
selected independent entity for the services of such
entity with respect to determinations under the
mediated dispute process. Such guidelines shall provide
that such compensation reimburses the entity for at
least the costs of such entity in performing the duties
of the entity under the mediated dispute process.
``(7) Certification of entities.--
``(A) In general.--The Secretary shall establish or
recognize a process to certify (including
recertification of) entities under this paragraph. Such
process shall ensure that an entity so certified--
``(i) has (directly or through contracts or
other arrangements) sufficient medical, legal,
and other expertise and sufficient staffing to
make determinations described in paragraph (2)
on a timely basis;
``(ii) is not--
``(I) a health plan, provider, or
facility;
``(II) an affiliate or a subsidiary
of a health plan, provider, or
facility; or
``(III) an affiliate or subsidiary
of a professional or trade association
of health plans or of providers or
facilities;
``(iii) carries out the responsibilities of
such an entity in accordance with this
subsection;
``(iv) meets appropriate indicators of
fiscal integrity;
``(v) maintains the confidentiality (in
accordance with regulations promulgated by the
Secretary) of individually identifiable health
information obtained in the course of
conducting such determinations;
``(vi) does not under the mediated dispute
process carry out any determination with
respect to which the entity would not pursuant
to clause (i), (ii), or (iii) of paragraph
(3)(A) be eligible for selection; and
``(vii) meets such other requirements as
determined appropriate by the Secretary.
``(B) Period of certification.--Subject to
subparagraph (C), each certification (including a
recertification) of an entity under the process
described in subparagraph (A) shall be for a 5-year
period.
``(C) Revocation.--A certification of an entity
under this paragraph may be revoked under the process
described in subparagraph (A) if the entity has a
pattern or practice of noncompliance with any of the
requirements described in such subparagraph.
``(D) Petition for denial or withdrawal.--The
process described in subparagraph (A) shall ensure that
an individual, provider, facility, or health plan may
petition for a denial of a certification or a
revocation of a certification with respect to an entity
under this paragraph for failure of meeting a
requirement of this subsection.
``(E) Sufficient number of entities.--The process
described in subparagraph (A) shall ensure that a
sufficient number of entities are certified under this
paragraph to ensure the timely and efficient provision
of determinations described in paragraph (2).
``(F) Provision of information.--
``(i) In general.--An entity certified
under this paragraph shall provide to the
Secretary, in such manner as the Secretary may
require and on a quarterly basis (as specified
by the Secretary), such information as the
Secretary determines appropriate to assure
compliance with the requirements described in
subparagraph (A) and to monitor and assess the
determinations made by such entity and to
ensure the absence of bias in making such
determinations. Such information shall include
information described in clause (ii) but shall
not include individually identifiable health
information.
``(ii) Information to be included.--The
information described in this clause with
respect to an entity is the following:
``(I) The number of payment
determinations described in paragraph
(2) made by such entity, disaggregated
by--
``(aa) the line of business
(as specified in subsection
(k)(8)(C)) of the health plans
party to such determinations;
and
``(bb) the type of
providers and facilities party
to such determinations.
``(II) A description of each item
or service included in each such
determination.
``(III) The amount of each offer
submitted to the entity for each such
determination.
``(IV) The amount of each such
determination.
``(V) The length of time in making
each such determination.
``(VI) The compensation paid to
such entity with respect to each such
determination.
``(VII) Any other information
specified by the Secretary.
``(8) Administrative fee.--
``(A) In general.--Each party to a determination to
which an entity is selected under paragraph (3) in a
year shall pay to the Secretary, at such time and in
such manner as specified by the Secretary, a fee for
participating in the mediated dispute process with
respect to such determination in an amount described in
subparagraph (B) for such year.
``(B) Amount of fee.--The amount described in this
subparagraph for a year is an amount established by the
Secretary in a manner such that the total amount of
fees paid under this paragraph for such year is
estimated to be equal to the amount of expenditures
estimated to be made by the Secretary for such year in
carrying out the mediated dispute process.
``(9) Secretarial report; publication of information.--
``(A) Secretarial report.--Beginning not later than
July 1, 2023, the Secretary shall, in coordination with
the Secretary of Health and Human Services and the
Secretary of Labor, periodically study and submit to
Congress a report on--
``(i) the extent to which the payment
amount determined under this subsection for an
item or service furnished in a year (or
otherwise agreed to by a health plan and
provider or facility for purposes of
determining payment by the plan to the provider
or facility pursuant to subsection (b)(1),
(e)(1), or (i)(1)) differs from the median
contracted rate for such item or service and
year, including the number of times such
determined (or agreed to) amount exceeds such
median contracted rate; and
``(ii) the effect of such difference on the
cost-sharing for such item or service for a
participant or beneficiary of a health plan.
``(B) Publication of information.--Beginning with
July 1, 2023, and for each calendar quarter thereafter,
the Secretary shall, in coordination with the Secretary
of Health and Human Services and the Secretary of
Labor, make publicly available a summary of the
following:
``(i) The information described in
subclauses (I) through (V) of clause (ii) of
paragraph (7)(F) that was submitted to the
Secretary under clause (i) of such paragraph
during such quarter.
``(ii) The amount of expenditures made by
the Secretary during such year to carry out the
mediated dispute process.
``(iii) The total amount of fees paid under
paragraph (8) during such quarter.
``(iv) The total amount of compensation
paid to selected independent entities under
paragraph (6) during such quarter.''.
(c) ERISA Amendments.--Section 716 of the Employee Retirement
Income Security Act of 1974, as added by section 2(c) and amended by
sections 3(c), 5(c), and 6(c), is further amended by inserting before
subsection (k) the following new subsection:
``(j) Determination of Out-of-Network Rates To Be Paid by Health
Plans.--
``(1) Determination through open negotiation.--
``(A) In general.--With respect to an item or
service furnished in a year by a nonparticipating
provider or a nonparticipating facility, with respect
to a health plan, in a State described in subparagraph
(B) of subsection (k)(11) with respect to such plan and
provider or facility, and for which a payment is
required to be made by the health plan pursuant to
subsection (b)(1), (e)(1), or (i)(1), the provider or
facility (as applicable) or plan may, during the 30-day
period beginning on the day the provider or facility
receives a response from the plan regarding a claim for
payment for such item or service, initiate open
negotiations under this paragraph between such provider
or facility and plan for purposes of determining,
during the open negotiation period, an amount agreed on
by such provider or facility, respectively, and such
plan for payment (including any cost-sharing) for such
item or service. For purposes of this subsection, the
open negotiation period, with respect to an item or
service, is the 30-day period beginning on the date of
initiation of the negotiations with respect to such
item or service.
``(B) Exchange of information.--In carrying out
negotiations initiated under subparagraph (A), with
respect to an item or service described in such
subparagraph furnished in a year, not later than the
fifth business day of the open negotiation period
described in such subparagraph with respect to such
item or service--
``(i) the health plan that is party to such
negotiations shall notify the provider or
facility that is party to such negotiations of
the median contracted rate for such item or
service and year; and
``(ii) such provider or facility shall
notify such health plan of--
``(I) the median of the total
amount of reimbursement (including any
cost-sharing) paid, for the most recent
year for which information is
available, to such provider or facility
for furnishing such item or service to
a participant or beneficiary of a
health plan that, at the time such item
or service was furnished, had a
contract in effect with such provider
or facility with respect to the
furnishing of such item or service;
``(II) in the case that information
described in subclause (I) is not
available, such information as
specified by the Secretary; and
``(III) any additional information
specified by the Secretary.
``(C) Accessing mediated dispute process in case of
failed negotiations.--In the case of open negotiations
pursuant to subparagraph (A), with respect to an item
or service, that do not result in a determination of an
amount of payment for such item or service by the last
day of the open negotiation period described in such
subparagraph with respect to such item or service, the
provider or facility (as applicable) or health plan
that was party to such negotiations may, during the 2-
day period beginning on the day after such open
negotiation period, initiate the mediated dispute
process under paragraph (2) with respect to such item
or service. The mediated dispute process shall be
initiated by a party pursuant to the previous sentence
by submission to the other party and to the Secretary
of a notification (containing such information as
specified by the Secretary) and for purposes of this
subsection, the date of initiation of such process
shall be the date of such submission or such other date
specified by the Secretary pursuant to regulations that
is not later than the date of receipt of such
notification by both the other party and the Secretary.
``(2) Mediated dispute process available in case of failed
open negotiations.--
``(A) Establishment.--Not later than July 1, 2021,
the Secretary, in coordination with the Secretary of
Health and Human Services and the Secretary of the
Treasury, shall establish a process (in this subsection
referred to as the `mediated dispute process') under
which, in the case of an item or service with respect
to which a provider or facility (as applicable) or
health plan submits a notification under paragraph
(1)(C) (in this subsection referred to as a `qualified
mediated dispute item or service'), an entity selected
under paragraph (3) determines, subject to subparagraph
(B) and in accordance with the succeeding provisions of
this subsection, the amount of payment under the health
plan for such item or service furnished by such
provider or facility.
``(B) Authority to continue negotiations.--Under
the mediated dispute process, in the case that the
parties to a determination for a qualified mediated
dispute item or service agree on a payment amount for
such item or service during such process but before the
date on which the entity selected with respect to such
determination under paragraph (3) makes such
determination, such amount shall be treated for
purposes of subsection (k)(11)(B) as the amount agreed
to by such parties for such item or service. In the
case of an agreement described in the previous
sentence, the mediated dispute process shall provide
for a method to determine how to allocate between the
parties to such determination the payment of the
compensation of the entity selected with respect to
such determination.
``(3) Selection under mediated dispute process.--Under the
mediated dispute process, the Secretary shall, with respect to
the determination of the amount of payment under this
subsection of a qualified mediated dispute item or service,
provide for a method--
``(A) that allows the parties to such determination
to jointly select, not later than the last day of the
3-day period following the date of the initiation of
the process with respect to such item or service, for
purposes of making such determination, an entity
certified under paragraph (7) that--
``(i) is not a party to such determination
or an employee or agent of such a party;
``(ii) does not have a material familial,
financial, or professional relationship with
such a party; and
``(iii) does not otherwise have a conflict
of interest with such a party (as determined by
the Secretary); and
``(B) that requires, in the case such parties do
not make such selection by such last day, the Secretary
to, not later than 6 days after such date of
initiation--
``(i) select such an entity that satisfies
clauses (i) through (iii) of subparagraph (A);
and
``(ii) provide notification of such
selection to the provider or facility (as
applicable) and the health plan party to such
determination.
An entity selected pursuant to the previous sentence to make a
determination described in such sentence shall be referred to
in this subsection as the `selected independent entity' with
respect to such determination.
``(4) Treatment of consideration of multiple items and
services.--
``(A) In general.--Under the mediated dispute
process, the Secretary shall specify criteria under
which multiple qualified mediated dispute items and
services are permitted to be considered jointly as part
of a single determination by an entity for purposes of
encouraging the efficiency (including minimizing costs)
of the mediated dispute process. Such items and
services may be so considered only if--
``(i) such items and services to be
included in such determination are furnished by
the same provider or facility;
``(ii) payment for such items and services
is required to be made by the same health plan;
and
``(iii) such items and services are related
to the treatment of a similar condition.
``(B) Treatment of bundled payments.--In carrying
out subparagraph (A), the Secretary shall provide that,
in the case of items and services which are included by
a provider or facility as part of a bundled payment,
such items and services included in such bundled
payment may be part of a single determination under
this subsection.
``(C) Waiver of deadlines.--For purposes of
permitting joint consideration of qualified mediated
dispute items and services as part of a single
determination under the criteria specified pursuant to
subparagraph (A), the Secretary may waive any deadline
specified in this subsection.
``(5) Determination of payment amount.--
``(A) In general.--Not later than 30 days after the
date of initiation of the mediated dispute resolution,
with respect to a qualified mediated dispute item or
service, the selected independent entity with respect
to a determination under this subsection for such item
or service shall--
``(i) taking into account only the
considerations specified in subparagraph
(C)(i), select one of the offers submitted
under subparagraph (B) to be the amount of
payment for such item or service determined
under this subsection for purposes of
subsection (b)(1), (e)(1), or (i)(1), as
applicable; and
``(ii) notify the provider or facility and
the health plan party to such determination of
the offer selected under clause (i).
``(B) Submission of offers.--Not later than 10 days
after the date of initiation of the mediated dispute
resolution with respect to a determination for a
qualified mediated dispute item or service, the
provider or facility and the health plan party to such
determination shall each submit to the selected
independent entity--
``(i) an offer for a payment amount under
for such item or service furnished by such
provider or facility;
``(ii) information relating to such offer;
and
``(iii) such other information as requested
by the selected independent entity.
``(C) Considerations.--
``(i) In general.--For purposes of
subparagraph (A), the considerations specified
in this subparagraph, with respect to a
determination for a qualified mediated dispute
item or service, are the following:
``(I) The median contracted rate
for such item or service.
``(II) Subject to clause (ii),
information that is submitted pursuant
to subparagraph (B).
``(ii) Treatment of certain
considerations.--In making a determination with
respect to a qualified mediated dispute item or
service pursuant to subparagraph (A)(i), a
selected independent entity may not take into
account usual and customary charges for the
item or service nor charges billed by the
provider or facility for the item or service.
``(6) Selected independent entity compensation.--
``(A) In general.--Not later than 5 days after
receiving a notification described in paragraph
(5)(A)(ii) from a selected independent entity with
respect to the determination of a payment amount for a
qualified mediated dispute item or service, the party
to such determination whose offer submitted under
paragraph (5)(B) was not selected by the entity shall
pay to such entity a fee in compensation for the
services of such entity in accordance with the
guidelines on such compensation established by the
Secretary under subparagraph (B).
``(B) Guidelines on compensation.--For purposes of
subparagraph (A), the Secretary shall establish
guidelines with respect to the compensation of a
selected independent entity for the services of such
entity with respect to determinations under the
mediated dispute process. Such guidelines shall provide
that such compensation reimburses the entity for at
least the costs of such entity in performing the duties
of the entity under the mediated dispute process.
``(7) Certification of entities.--
``(A) In general.--The Secretary shall establish or
recognize a process to certify (including
recertification of) entities under this paragraph. Such
process shall ensure that an entity so certified--
``(i) has (directly or through contracts or
other arrangements) sufficient medical, legal,
and other expertise and sufficient staffing to
make determinations described in paragraph (2)
on a timely basis;
``(ii) is not--
``(I) a health plan, provider, or
facility;
``(II) an affiliate or a subsidiary
of a health plan, provider, or
facility; or
``(III) an affiliate or subsidiary
of a professional or trade association
of health plans or of providers or
facilities;
``(iii) carries out the responsibilities of
such an entity in accordance with this
subsection;
``(iv) meets appropriate indicators of
fiscal integrity;
``(v) maintains the confidentiality (in
accordance with regulations promulgated by the
Secretary) of individually identifiable health
information obtained in the course of
conducting such determinations;
``(vi) does not under the mediated dispute
process carry out any determination with
respect to which the entity would not pursuant
to clause (i), (ii), or (iii) of paragraph
(3)(A) be eligible for selection; and
``(vii) meets such other requirements as
determined appropriate by the Secretary.
``(B) Period of certification.--Subject to
subparagraph (C), each certification (including a
recertification) of an entity under the process
described in subparagraph (A) shall be for a 5-year
period.
``(C) Revocation.--A certification of an entity
under this paragraph may be revoked under the process
described in subparagraph (A) if the entity has a
pattern or practice of noncompliance with any of the
requirements described in such subparagraph.
``(D) Petition for denial or withdrawal.--The
process described in subparagraph (A) shall ensure that
an individual, provider, facility, or health plan may
petition for a denial of a certification or a
revocation of a certification with respect to an entity
under this paragraph for failure of meeting a
requirement of this subsection.
``(E) Sufficient number of entities.--The process
described in subparagraph (A) shall ensure that a
sufficient number of entities are certified under this
paragraph to ensure the timely and efficient provision
of determinations described in paragraph (2).
``(F) Provision of information.--
``(i) In general.--An entity certified
under this paragraph shall provide to the
Secretary, in such manner as the Secretary may
require and on a quarterly basis (as specified
by the Secretary), such information as the
Secretary determines appropriate to assure
compliance with the requirements described in
subparagraph (A) and to monitor and assess the
determinations made by such entity and to
ensure the absence of bias in making such
determinations. Such information shall include
information described in clause (ii) but shall
not include individually identifiable health
information.
``(ii) Information to be included.--The
information described in this clause with
respect to an entity is the following:
``(I) The number of payment
determinations described in paragraph
(2) made by such entity, disaggregated
by--
``(aa) the line of business
(as specified in subsection
(k)(8)(C)) of the health plans
party to such determinations;
and
``(bb) the type of
providers and facilities party
to such determinations.
``(II) A description of each item
or service included in each such
determination.
``(III) The amount of each offer
submitted to the entity for each such
determination.
``(IV) The amount of each such
determination.
``(V) The length of time in making
each such determination.
``(VI) The compensation paid to
such entity with respect to each such
determination.
``(VII) Any other information
specified by the Secretary.
``(8) Administrative fee.--
``(A) In general.--Each party to a determination to
which an entity is selected under paragraph (3) in a
year shall pay to the Secretary, at such time and in
such manner as specified by the Secretary, a fee for
participating in the mediated dispute process with
respect to such determination in an amount described in
subparagraph (B) for such year.
``(B) Amount of fee.--The amount described in this
subparagraph for a year is an amount established by the
Secretary in a manner such that the total amount of
fees paid under this paragraph for such year is
estimated to be equal to the amount of expenditures
estimated to be made by the Secretary for such year in
carrying out the mediated dispute process.
``(9) Secretarial report; publication of information.--
``(A) Secretarial report.--Beginning not later than
July 1, 2023, the Secretary shall, in coordination with
the Secretary of Health and Human Services and the
Secretary of the Treasury, periodically study and
submit to Congress a report on--
``(i) the extent to which the payment
amount determined under this subsection for an
item or service furnished in a year (or
otherwise agreed to by a health plan and
provider or facility for purposes of
determining payment by the plan to the provider
or facility pursuant to subsection (b)(1),
(e)(1), or (i)(1)) differs from the median
contracted rate for such item or service and
year, including the number of times such
determined (or agreed to) amount exceeds such
median contracted rate; and
``(ii) the effect of such difference on the
cost-sharing for such item or service for a
participant or beneficiary of a health plan.
``(B) Publication of information.--Beginning with
July 1, 2023, and for each calendar quarter thereafter,
the Secretary shall, in coordination with the Secretary
of Health and Human Services and the Secretary of
Labor, make publicly available a summary of the
following:
``(i) The information described in
subclauses (I) through (V) of clause (ii) of
paragraph (7)(F) that was submitted to the
Secretary under clause (i) of such paragraph
during such quarter.
``(ii) The amount of expenditures made by
the Secretary during such year to carry out the
mediated dispute process.
``(iii) The total amount of fees paid under
paragraph (8) during such quarter.
``(iv) The total amount of compensation
paid to selected independent entities under
paragraph (6) during such quarter.''.
(d) Rule of Construction.--Nothing in this Act, or the amendment
made by this Act, shall be construed as removing any obligation of a
health plan (as defined in subsection (k)(6) of section 2719A of the
Public Health Service Act (42 U.S.C. 300gg-19A), as amended by this
Act) to provide payment to a health care provider or health care
facility for items and services furnished by such provider or facility
to an individual enrolled in such plan.
SEC. 8. PROHIBITING BALANCE BILLING PRACTICES BY PROVIDERS FOR
EMERGENCY SERVICES, FOR SERVICES FURNISHED BY
NONPARTICIPATING PROVIDER AT PARTICIPATING FACILITY, AND
IN CERTAIN CASES OF MISINFORMATION.
(a) No Balance Billing.--Part A of title XI of the Social Security
Act (42 U.S.C. 1301 et seq.) is amended by adding at the end the
following new section:
``SEC. 1150C. PROHIBITION ON CERTAIN BALANCE BILLING PRACTICES.
``(a) Emergency Services.--In the case of an individual with
benefits under a group health plan or health insurance coverage offered
in the group or individual market who is furnished in a plan year that
begins on or after January 1, 2022, emergency services with respect to
an emergency medical condition during a visit at an emergency
department of a hospital or an independent freestanding emergency
department--
``(1) if the hospital or independent freestanding emergency
department does not have a contractual relationship with such
plan or coverage for furnishing such services, the hospital or
independent freestanding emergency department shall not bill,
and shall not hold liable, the individual for a payment amount
for such emergency services so furnished that is more than the
cost-sharing amount for such services (as determined in
accordance with section 2719A(b) of the Public Health Service
Act, section 716(b) of the Employee Retirement Income Security
Act of 1974, or section 9816(b) of the Internal Revenue Code of
1986, as applicable); and
``(2) a health care provider without a contractual
relationship with such plan or coverage for furnishing such
services shall not bill, and shall not hold liable, such
individual for a payment amount for such services furnished to
such individual by such provider with respect to such emergency
medical condition and visit for which the individual receives
emergency services at the emergency department of the hospital
or independent freestanding emergency department that is more
than the cost-sharing amount for such services furnished by the
provider (as determined in accordance with section 2719A(b) of
the Public Health Service Act, section 716(b) of the Employee
Retirement Income Security Act of 1974, or section 9816(b) of
the Internal Revenue Code of 1986, as applicable).
``(b) Services Furnished by Nonparticipating Provider at
Participating Facility.--
``(1) In general.--Subject to paragraph (2), in the case of
an individual with benefits under a health plan who is
furnished items or services (other than emergency services to
which subsection (a) applies or items and services to which
subsection (c) applies) in a plan year that, with respect to
such plan or such coverage (as applicable), begins on or after
January 1, 2022, at a participating facility by a
nonparticipating provider, such provider shall not bill, and
shall not hold liable, such individual for a payment amount for
such an item or service furnished by such provider during a
visit at such facility that is more than the cost-sharing
amount for such item or service (as determined in accordance
with section 2719A(e) of the Public Health Service Act, section
716(e) of the Employee Retirement Income Security Act of 1974,
or section 9816(e) of the Internal Revenue Code of 1986, as
applicable).
``(2) Exception in case notice provided.--Paragraph (1)
shall not apply with respect to items and services (other than
items and services described in paragraph (3)) furnished to an
individual enrolled in a group health plan or in health
insurance coverage offered in the group or individual market by
a health care provider that does not have a contractual
relationship with such plan or coverage for furnishing such
items and services if the following criteria are met:
``(A) A written notice (as specified by the
Secretary and in clear and understandable language) is
provided by the provider to such individual, not later
than 48 hours before such items and services are to be
so furnished, that includes the following information:
``(i) A statement verifying that the
provider does not have such a relationship with
such plan or coverage.
``(ii) The estimated amount that such
provider may charge the individual for such
items and services.
``(iii) A statement that the individual may
seek such items or services from a health care
provider that does have such a contractual
relationship and a list, if feasible, of
providers with such a relationship who are able
to furnish such items and services involved.
``(B) On the date such item or service is to be
furnished, before such item or service is so furnished,
the individual signs and dates such notice confirming
receipt of the notice and consent of the individual to
be so furnished such items and services.
``(C) A copy of such signed and dated notice is
provided by the provider to the plan or coverage.
``(3) Items and services described.--The items and services
described in this paragraph are items and services furnished by
a specified provider (as defined in subsection (f)(3)).
``(c) Reliance on Incorrect Provider Information.--In the case of
an individual who is furnished items or services by a health care
provider or health care facility for which a group health plan or
health insurance issuer is required to make payment under section
2719A(i) of the Public Health Service Act, section 716(i) of the
Employee Retirement Income Security Act of 1974, or section 9816(i) of
the Internal Revenue Code of 1986, such provider or facility shall not
bill, and shall not hold liable, such individual for a payment amount
for such an item or service that is more than the cost-sharing amount
for such item or service (as determined in accordance with section
2719A(i) of the Public Health Service Act, section 716(i) of the
Employee Retirement Income Security Act of 1974, or section 9816(i) of
the Internal Revenue Code of 1986, as applicable).
``(d) Compliance With Requirements Under Open Negotiation and
Mediated Dispute Resolution Processes.--A health care provider or
health care facility shall comply with any requirement imposed on such
provider or facility, respectively, under section 2719A(j) of the
Public Health Service Act, 9816(j) of the Internal Revenue Code of
1986, or 716(j) of the Employee Retirement Income Security Act of 1974.
``(e) Penalty.--
``(1) In general.--Any health care provider or health care
facility that violates a provision of this section shall be
subject to a civil monetary penalty in an amount not to exceed
$10,000 for each such violation.
``(2) Application of provisions.--The provisions of section
1128A (other than subsection (a), subsection (b), the first
sentence of subsection (c)(1), and subsection (o)) shall apply
with respect to a civil monetary penalty imposed under this
subsection in the same manner as such provisions apply with
respect to a penalty or proceeding under subsection (a) of such
section.
``(f) Definitions.--For purposes of this section and sections 1150D
and 1150E:
``(1) The terms `during a visit',`emergency department of a
hospital', `emergency medical condition', `emergency services',
`independent freestanding emergency department',
`nonparticipating provider', `nonparticipating facility',
`participating facility', `participating provider' have the
meanings given such terms, respectively, in section 2719A(k) of
the Public Health Service Act.
``(2) The terms `group health plan', `group market',
`health insurance issuer', `health insurance coverage', and
`individual market' have the meanings given such terms,
respectively, in section 2791 of the Public Health Service Act.
``(3) The term `specified provider', with respect to an
individual with benefits under a group health plan or health
insurance coverage and a hospital with a contractual
relationship with such plan or coverage for furnishing items
and services--
``(A) means an ancillary health care provider,
including emergency medicine providers or suppliers,
anesthesiologists, pathologists, radiologists,
neonatologists, assistant surgeons, hospitalists,
intensivists, or other providers determined by the
Secretary (including providers who furnish similar
items and services as the providers specified in this
paragraph); and
``(B) includes, with respect to an item or service,
any health care provider furnishing such item or
service at such hospital if there is no health care
provider at such hospital who can furnish such item or
service who has such a relationship with such plan or
coverage for furnishing such item or service.''.
(b) Provider Directory; Patient-Provider Dispute Resolution
Process.--Part A of title XI of the Social Security Act (42 U.S.C. 1301
et seq.), as amended by subsection (a), is further amended by adding at
the end the following new sections:
``SEC. 1150D. PATIENT PROTECTIONS AGAINST SURPRISE BILLING THROUGH
TRANSPARENCY.
``(a) Submission of Information to Health Plans of Certain Provider
Information.--Beginning not later than 1 year after the date of the
enactment of this section, each health care provider and health care
facility shall establish a process under which such provider or
facility transmits, to each health insurance issuer offering group or
individual health insurance coverage and group health plan with which
such provider or supplier has in effect a contractual relationship for
furnishing items and services under such coverage or such plan,
provider directory information (as defined in section 2719A(f)(6) of
the Public Health Service Act, section 716(f)(6) of the Employee
Retirement Income Security Act of 1974, or section 9816(f)(6) of the
Internal Revenue Code of 1986, as applicable) with respect to such
provider or facility, as applicable. Such provider or facility shall so
transmit such information to such issuer offering such coverage or such
group health plan--
``(1) when there are any material changes (including a
change in address, telephone number, or other contact
information) to such provider directory information of the
provider or facility with respect to such coverage offered by
such issuer or with respect to such plan; and
``(2) at any other time (including upon the request of such
issuer or plan) determined appropriate by the provider,
facility, or the Secretary.
``(b) Provision of Information Upon Request and for Scheduled
Appointments.--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)--
``(1) 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
``(2) provide a notification (in clear and understandable
language) 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--
``(A) 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
``(B) in the case the individual is not described
in subparagraph (A) and not enrolled in a Federal
health care program, the individual.
``(c) Continuity of Care.--A health care provider or health care
facility shall, in the case of an individual furnished items and
services by such provider or facility for which coverage is provided
under a group health plan or group or individual health insurance
coverage pursuant to section 2730 of such Act, section 9817 of the
Internal Revenue Code of 1986, or section 717 of the Employee
Retirement Income Security Act of 1974--
``(1) accept payment from such plan or such issuer (as
applicable) (and cost-sharing from such individual, if
applicable, in accordance with subsection (a)(2)(C) of such
section 2730, 9817, or 717) for such items and services as
payment in full for such items and services; and
``(2) continue to adhere to all policies, procedures, and
quality standards imposed by such plan or issuer with respect
to such individual and such items and services in the same
manner as if such termination had not occurred.
``(d) Limitation.--Beginning on January 1, 2022, a health care
provider or health care facility may not initiate a process to seek
reimbursement of payment for items and services furnished to an
individual enrolled in a group health plan or health insurance coverage
offered in the group or individual market more than 1 year after the
date on which such items and services were so furnished.
``(e) Penalty.--
``(1) General penalty.--
``(A) In general.--Except as provided in paragraph
(2), any health care provider or health care facility
that violates a provision of this section shall be
subject to a civil monetary penalty in an amount not to
exceed $10,000 for each such violation.
``(B) Application of provisions.--The provisions of
section 1128A (other than subsection (a), subsection
(b), the first sentence of subsection (c)(1), and
subsection (o)) shall apply with respect to a civil
monetary penalty imposed under this paragraph in the
same manner as such provisions apply with respect to a
penalty or proceeding under subsection (a) of such
section.
``(2) Provider directory information penalty.--
``(A) In general.--Each health care provider or
health care facility that fails to transmit information
as required under subsection (a) shall be subject to a
civil monetary penalty of $1,000 for each day such
provider or facility (as applicable) fails to so
transmit such information.
``(B) Application of provisions.--The provisions of
section 1128A (other than subsection (a), subsection
(b), the first sentence of subsection (c)(1),
subsection (d), and subsection (o)) shall apply with
respect to a civil monetary penalty imposed under this
paragraph in the same manner as such provisions apply
with respect to a penalty or proceeding under
subsection (a) of such section.
``SEC. 1150E. PATIENT-PROVIDER DISPUTE RESOLUTION.
``(a) In General.--Not later than July 1, 2021, the Secretary shall
establish a process (in this subsection referred to as the `patient-
provider dispute resolution process') under which an uninsured
individual, with respect to an item or service, who received, pursuant
to section 1150D(b), from a health care provider or health care
facility a good-faith estimate of the expected charges for furnishing
such item or service to such individual and who after being furnished
such item or service by such provider or facility is billed by such
provider or facility for such item or service for charges that are
substantially in excess of such estimate, may seek a determination from
a selected dispute resolution entity for the charges to be paid by such
individual (in lieu of such amount so billed) to such provider or
facility for such item or service. For purposes of this subsection, the
term `uninsured individual' means, with respect to an item or service,
an individual who does not have benefits for such item or service under
a group health plan, health insurance coverage offered in the group or
individual market by a health insurance issuer, Federal health care
program (as defined in section 1128B(f)), or a health benefits plan
under chapter 89 of title 5, United States Code (or an individual who
has benefits for such item or service under a group health plan or
health insurance coverage offered in the group or individual market by
a health insurance issuer, but who does not seek to have a claim for
such item or service submitted to such plan or coverage).
``(b) Selection of Entities.--Under the patient-provider dispute
resolution process, the Secretary shall, with respect to a
determination sought by an individual under subsection (a), with
respect to charges to be paid by such individual to a health care
provider or health care facility described in such paragraph for an
item or service furnished to such individual by such provider or
facility, provide for--
``(1) a method to select to make such determination an
entity certified under subsection (d) that--
``(A) is not a party to such determination or an
employee or agent of such party;
``(B) does not have a material familial, financial,
or professional relationship with such a party; and
``(C) does not otherwise have a conflict of
interest with such a party (as determined by the
Secretary); and
``(2) the provision of a notification of such selection to
the individual and the provider or facility (as applicable)
party to such determination.
An entity selected pursuant to the previous sentence to make a
determination described in such sentence shall be referred to in this
subsection as the `selected dispute resolution entity' with respect to
such determination.
``(c) Administrative Fee.--The Secretary shall establish a fee to
participate in the patient-provider dispute resolution process in such
a manner as to not create a barrier to an uninsured individual's access
to such process.
``(d) Certification.--The Secretary shall establish or recognize a
process to certify entities under this subparagraph. Such process shall
ensure that an entity so certified satisfies at least the criteria
specified in section 2719A(j)(7) of the Public Health Service Act.''.
SEC. 9. ADDITIONAL CONSUMER PROTECTIONS.
(a) Public Health Service Act.--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 sections:
``SEC. 2730. CONTINUITY OF CARE.
``(a) Ensuring Continuity of Care With Respect to Terminations of
Certain Contractual Relationships Resulting in Changes in Provider
Network Status.--
``(1) In general.--In the case of an individual with
benefits under a group health plan or group or individual
health insurance coverage offered by a health insurance issuer
and with respect to a health care provider or facility that has
a contractual relationship with such plan or such issuer (as
applicable) for furnishing items and services under such plan
or such coverage, if, while such individual is a continuing
care patient (as defined in subsection (b)) with respect to
such provider or facility--
``(A) such contractual relationship is terminated
(as defined in subsection (b));
``(B) benefits provided under such plan or such
health insurance coverage with respect to such provider
or facility are terminated because of a change in the
terms of the participation of such provider or facility
in such plan or coverage; or
``(C) a contract between such group health plan and
a health insurance issuer offering health insurance
coverage in connection with such plan is terminated,
resulting in a loss of benefits provided under such
plan with respect to such provider or facility;
the plan or issuer, respectively, shall meet the requirements
of paragraph (2) with respect to such individual.
``(2) Requirements.--The requirements of this paragraph are
that the plan or issuer--
``(A) notify each individual enrolled under such
plan or coverage who is a continuing care patient with
respect to a provider or facility at the time of a
termination described in paragraph (1) affecting such
provider or facility on a timely basis of such
termination and such individual's right to elect
continued transitional care from such provider or
facility under this section;
``(B) provide such individual with an opportunity
to notify the plan or issuer of the individual's need
for transitional care; and
``(C) permit the patient to elect to continue to
have benefits provided under such plan or such
coverage, under the same terms and conditions as would
have applied and with respect to such items and
services as would have been covered under such plan or
coverage had such termination not occurred, with
respect to the course of treatment furnished by such
provider or facility relating to such individual's
status as a continuing care patient during the period
beginning on the date on which the notice under
subparagraph (A) is provided and ending on the earlier
of--
``(i) the 90-day period beginning on such
date; or
``(ii) the date on which such individual is
no longer a continuing care patient with
respect to such provider or facility.
``(b) Definitions.--In this section:
``(1) Continuing care patient.--The term `continuing care
patient' means an individual who, with respect to a provider or
facility--
``(A) is undergoing a course of treatment for a
serious and complex condition from the provider or
facility;
``(B) is undergoing a course of institutional or
inpatient care from the provider or facility;
``(C) is scheduled to undergo nonelective surgery
from the provider, including receipt of postoperative
care from such provider or facility with respect to
such a surgery;
``(D) is pregnant and undergoing a course of
treatment for the pregnancy from the provider or
facility; or
``(E) is or was determined to be terminally ill (as
determined under section 1861(dd)(3)(A) of the Social
Security Act) and is receiving treatment for such
illness from such provider or facility.
``(2) Serious and complex condition.--The term `serious and
complex condition' means, with respect to a participant,
beneficiary, or enrollee under a group health plan or health
insurance coverage--
``(A) in the case of an acute illness, a condition
that is serious enough to require specialized medical
treatment to avoid the reasonable possibility of death
or permanent harm; or
``(B) in the case of a chronic illness or
condition, a condition that is--
``(i) is life-threatening, degenerative,
potentially disabling, or congenital; and
``(ii) requires specialized medical care
over a prolonged period of time.
``(3) Terminated.--The term `terminated' includes, with
respect to a contract, the expiration or nonrenewal of the
contract, but does not include a termination of the contract
for failure to meet applicable quality standards or for fraud.
``SEC. 2731. INFORMATION REQUIRED TO BE INCLUDED ON HEALTH INSURANCE
MEMBERSHIP CARDS.
``In the case of a group health plan or health insurance issuer
offering group or individual health insurance coverage that provides a
physical or electronic card indicating membership in such plan or
coverage to an individual enrolled under such plan or coverage, such
group health plan or issuer shall include on such card each of the
following:
``(1) The nearest hospital to the primary residence of such
individual that has in effect a contractual relationship with
such plan or coverage for furnishing items and services under
such plan or coverage.
``(2) A telephone number or Internet website address
through which such individual may seek consumer assistance
information, such as information related to hospitals and
urgent care facilities that have in effect a contractual
relationship with such plan or coverage for furnishing items
and services under such plan or coverage.
``(3) Any deductible applicable to such individual.
``(4) Any out-of-pocket maximum applicable to such
individual.
``(5) Any cost-sharing obligation applicable to such
individual for a visit at an emergency department, or urgent
care facility, that has in effect a contractual relationship
with such plan or coverage for furnishing items and services
under such plan or coverage.
``SEC. 2732. MAINTENANCE OF PRICE COMPARISON TOOL.
``In connection with the offering of a group health plan or group
or individual health insurance coverage in a geographic region for a
plan year, a plan sponsor or health insurance issuer, respectively,
shall employ an individual to offer price comparison guidance, or make
available on an Internet website a price comparison tool, that (to the
extent practicable) allows an individual enrolled under such plan or
coverage, with respect to such plan year and such geographic region, to
compare the amount (determined by historic claims data of participating
providers with respect to such plan or coverage) of cost-sharing
(including deductibles, copayments, and coinsurance) that the
individual would be responsible for paying under such plan or coverage
with respect to the furnishing of a specific item or service by any
such provider.''.
(b) Internal Revenue Code.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986, as amended by the previous
sections, is further amended by adding at the end the following
new sections:
``SEC. 9817. CONTINUITY OF CARE.
``(a) Ensuring Continuity of Care With Respect to Terminations of
Certain Contractual Relationships Resulting in Changes in Provider
Network Status.--
``(1) In general.--In the case of an individual with
benefits under a group health plan and with respect to a health
care provider or facility that has a contractual relationship
with such plan for furnishing items and services under such
plan, if, while such individual is a continuing care patient
(as defined in subsection (b)) with respect to such provider or
facility--
``(A) such contractual relationship is terminated
(as defined in paragraph (b));
``(B) benefits provided under such plan with
respect to such provider or facility are terminated
because of a change in the terms of the participation
of such provider or facility in such plan; or
``(C) a contract between such group health plan and
a health insurance issuer offering health insurance
coverage in connection with such plan is terminated,
resulting in a loss of benefits provided under such
plan with respect to such provider or facility;
the plan shall meet the requirements of paragraph (2) with
respect to such individual.
``(2) Requirements.--The requirements of this paragraph are
that the plan--
``(A) notify each individual enrolled under such
plan who is a continuing care patient with respect to a
provider or facility at the time of a termination
described in paragraph (1) affecting such provider on a
timely basis of such termination and such individual's
right to elect continued transitional care from such
provider or facility under this section;
``(B) provide such individual with an opportunity
to notify the plan of the individual's need for
transitional care; and
``(C) permit the patient to elect to continue to
have benefits provided under such plan, under the same
terms and conditions as would have applied and with
respect to such items and services as would have been
covered under such plan had such termination not
occurred, with respect to the course of treatment
furnished by such provider or facility relating to such
individual's status as a continuing care patient during
the period beginning on the date on which the notice
under subparagraph (A) is provided and ending on the
earlier of--
``(i) the 90-day period beginning on such
date; or
``(ii) the date on which such individual is
no longer a continuing care patient with
respect to such provider or facility.
``(b) Definitions.--In this section:
``(1) Continuing care patient.--The term `continuing care
patient' means an individual who, with respect to a provider or
facility--
``(A) is undergoing a course of treatment for a
serious and complex condition from the provider or
facility;
``(B) is undergoing a course of institutional or
inpatient care from the provider or facility;
``(C) is scheduled to undergo nonelective surgery
from the provider or facility, including receipt of
postoperative care from such provider or facility with
respect to such a surgery;
``(D) is pregnant and undergoing a course of
treatment for the pregnancy from the provider or
facility; or
``(E) is or was determined to be terminally ill (as
determined under section 1861(dd)(3)(A) of the Social
Security Act) and is receiving treatment for such
illness from such provider or facility.
``(2) Serious and complex condition.--The term `serious and
complex condition' means, with respect to a participant,
beneficiary, or enrollee under a group health plan--
``(A) in the case of an acute illness, a condition
that is serious enough to require specialized medical
treatment to avoid the reasonable possibility of death
or permanent harm; or
``(B) in the case of a chronic illness or
condition, a condition that--
``(i) is life-threatening, degenerative,
potentially disabling, or congenital; and
``(ii) requires specialized medical care
over a prolonged period of time.
``(3) Terminated.--The term `terminated' includes, with
respect to a contract, the expiration or nonrenewal of the
contract, but does not include a termination of the contract
for failure to meet applicable quality standards or for fraud.
``SEC. 9818. INFORMATION REQUIRED TO BE INCLUDED ON HEALTH INSURANCE
MEMBERSHIP CARDS.
``In the case of a group health plan that provides a physical or
electronic card indicating membership in such plan to an individual
enrolled under such plan, such group health plan shall include on such
card each of the following:
``(1) The nearest hospital to the primary residence of such
individual that has in effect a contractual relationship with
such plan for furnishing items and services under such plan.
``(2) A telephone number or Internet website address
through which such individual may seek consumer assistance
information, such as information related to hospitals and
urgent care facilities that have in effect a contractual
relationship with such plan for furnishing items and services
under such plan.
``(3) Any deductible applicable to such individual.
``(4) Any out-of-pocket maximum applicable to such
individual.
``(5) Any cost-sharing obligation applicable to such
individual for a visit at an emergency department, or urgent
care facility, that has in effect a contractual relationship
with such plan for furnishing items and services under such
plan.
``SEC. 9819. MAINTENANCE OF PRICE COMPARISON TOOL.
``In connection with the offering of a group health plan in a
geographic region for a plan year, a plan sponsor shall employ an
individual to offer price comparison guidance, or make available on an
Internet website a price comparison tool, that (to the extent
practicable) allows an individual enrolled under such plan, with
respect to such plan year and such geographic region, to compare the
amount (determined by historic claims data of participating providers
with respect to such plan) of cost-sharing (including deductibles,
copayments, and coinsurance) that the individual would be responsible
for paying under such plan with respect to the furnishing of a specific
item or service by any such provider.''.
(2) Conforming amendment.--Section 9815(a) of the Internal
Revenue Code of 1986, as amended by section 2(b), is further
amended--
(A) in paragraph (1), by striking ``section 2719A''
and inserting ``section 2719A, 2730, 2731, or 2732'';
and
(B) in paragraph (2), by striking ``section 2719A''
and inserting ``section 2719A, 2730, 2731, or 2732''.
(3) Clerical amendment.--The table of sections for such
subchapter, as amended by section 2(b), is further amended by
adding at the end the following new items:
``Sec. 9817. Continuity of care.
``Sec. 9818. Information required to be included on health insurance
membership cards.
``Sec. 9819. Maintenance of price comparison tool.''.
(c) Employee Retirement Income Security Act.--
(1) 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.), as amended by section 2(c), is further
amended by adding at the end the following new sections:
``SEC. 717. CONTINUITY OF CARE.
``(a) Ensuring Continuity of Care With Respect to Terminations of
Certain Contractual Relationships Resulting in Changes in Provider
Network Status.--
``(1) In general.--In the case of an individual with
benefits under a group health plan or health insurance coverage
offered by a health insurance issuer in connection with a group
health plan and with respect to a health care provider or
facility that has a contractual relationship with such plan or
such issuer (as applicable) for furnishing items and services
under such plan or such coverage, if, while such individual is
a continuing care patient (as defined in subsection (b)) with
respect to such provider or facility--
``(A) such contractual relationship is terminated
(as defined in paragraph (b));
``(B) benefits provided under such plan or such
health insurance coverage with respect to such provider
or facility are terminated because of a change in the
terms of the participation of the provider or facility
in such plan or coverage; or
``(C) a contract between such group health plan and
a health insurance issuer offering health insurance
coverage in connection with such plan is terminated,
resulting in a loss of benefits provided under such
plan with respect to such provider or facility;
the plan or issuer, respectively, shall meet the requirements
of paragraph (2) with respect to such individual.
``(2) Requirements.--The requirements of this paragraph are
that the plan or issuer--
``(A) notify each individual enrolled under such
plan or coverage who is a continuing care patient with
respect to a provider or facility at the time of a
termination described in paragraph (1) affecting such
provider or facility on a timely basis of such
termination and such individual's right to elect
continued transitional care from such provider or
facility under this section;
``(B) provide such individual with an opportunity
to notify the plan or issuer of the individual's need
for transitional care; and
``(C) permit the patient to elect to continue to
have benefits provided under such plan or such
coverage, under the same terms and conditions as would
have applied and with respect to such items and
services as would have been covered under such plan or
coverage had such termination not occurred, with
respect to the course of treatment furnished by such
provider or facility relating to such individual's
status as a continuing care patient during the period
beginning on the date on which the notice under
subparagraph (A) is provided and ending on the earlier
of--
``(i) the 90-day period beginning on such
date; or
``(ii) the date on which such individual is
no longer a continuing care patient with
respect to such provider or facility.
``(b) Definitions.--In this section:
``(1) Continuing care patient.--The term `continuing care
patient' means an individual who, with respect to a provider or
facility--
``(A) is undergoing a course of treatment for a
serious and complex condition from the provider or
facility;
``(B) is undergoing a course of institutional or
inpatient care from the provider or facility;
``(C) is scheduled to undergo nonelective surgery
from the provide or facility, including receipt of
postoperative care from such provider or facility with
respect to such a surgery;
``(D) is pregnant and undergoing a course of
treatment for the pregnancy from the provider or
facility; or
``(E) is or was determined to be terminally ill (as
determined under section 1861(dd)(3)(A) of the Social
Security Act) and is receiving treatment for such
illness from such provider or facility.
``(2) Serious and complex condition.--The term `serious and
complex condition' means, with respect to a participant,
beneficiary, or enrollee under a group health plan or health
insurance coverage--
``(A) in the case of an acute illness, a condition
that is serious enough to require specialized medical
treatment to avoid the reasonable possibility of death
or permanent harm; or
``(B) in the case of a chronic illness or
condition, a condition that--
``(i) is life-threatening, degenerative,
potentially disabling, or congenital; and
``(ii) requires specialized medical care
over a prolonged period of time.
``(3) Terminated.--The term `terminated' includes, with
respect to a contract, the expiration or nonrenewal of the
contract, but does not include a termination of the contract
for failure to meet applicable quality standards or for fraud.
``SEC. 718. INFORMATION REQUIRED TO BE INCLUDED ON HEALTH INSURANCE
MEMBERSHIP CARDS.
``In the case of a group health plan or health insurance issuer
offering group health insurance coverage that provides a physical or
electronic card indicating membership in such plan or coverage to an
individual enrolled under such plan or coverage, such group health plan
or issuer shall include on such card each of the following:
``(1) The nearest hospital to the primary residence of such
individual that has in effect a contractual relationship with
such plan or coverage for furnishing items and services under
such plan or coverage.
``(2) A telephone number or Internet website address
through which such individual may seek consumer assistance
information, such as information related to hospitals and
urgent care facilities that have in effect a contractual
relationship with such plan or coverage for furnishing items
and services under such plan or coverage.
``(3) Any deductible applicable to such individual.
``(4) Any out-of-pocket maximum applicable to such
individual.
``(5) Any cost-sharing obligation applicable to such
individual for a visit at an emergency department, or urgent
care facility, that has in effect a contractual relationship
with such plan or coverage for furnishing items and services
under such plan or coverage.
``SEC. 719. MAINTENANCE OF PRICE COMPARISON TOOL.
``In connection with the offering of a group health plan or group
health insurance coverage in a geographic region for a plan year, a
plan sponsor or health insurance issuer, respectively, shall employ an
individual to offer price comparison guidance, or make available on an
Internet website a price comparison tool, that (to the extent
practicable) allows an individual enrolled under such plan or coverage,
with respect to such plan year and such geographic region, to compare
the amount (determined by historic claims data of participating
providers with respect to such plan or coverage) of cost-sharing
(including deductibles, copayments, and coinsurance) that the
individual would be responsible for paying under such plan or coverage
with respect to the furnishing of a specific item or service by any
such provider.''.
(2) Conforming amendment.--Section 715(a) of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1185d(a)), as
amended by section 2(c), is further amended--
(A) in paragraph (1), by striking ``section 2719A''
and inserting ``section 2719A, 2730, 2731, or 2732'';
and
(B) in paragraph (2), by striking ``section 2719A''
and inserting ``section 2719A, 2730, 2731, or 2732''.
(3) 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 716 the
following new items:
``Sec. 717. Continuity of care.
``Sec. 718. Information required to be included on health insurance
membership cards.
``Sec. 719. Maintenance of price comparison tool.''.
(d) Effective Date.--The amendments made by this section shall
apply with respect to plan years beginning on or after January 1, 2022.
SEC. 10. REPORTING REQUIREMENTS REGARDING AIR AMBULANCE SERVICES.
(a) Reporting Requirements for Providers of Air Ambulance
Services.--
(1) In general.--A provider of air ambulance services shall
submit to the Secretary of Health and Human Services and the
Secretary of Transportation--
(A) not later than the date that is 90 days after
the last day of the first plan year beginning on or
after the date on which a final rule is promulgated
pursuant to the rulemaking described in subsection (d),
the information described in paragraph (2) with respect
to such plan year; and
(B) not later than the date that is 90 days after
the last day of the plan year immediately succeeding
the plan year described in subparagraph (A), such
information with respect to such immediately succeeding
plan year.
(2) Information described.--For purposes of paragraph (1),
information described in this paragraph, with respect to a
provider of air ambulance services, is each of the following:
(A) Cost data, as determined appropriate by the
Secretary of Health and Human Services, in consultation
with the Secretary of Transportation, for air ambulance
services furnished by such provider, separated to the
maximum extent possible by air transportation costs
associated with furnishing such air ambulance services
and costs of medical services and supplies associated
with furnishing such air ambulance services.
(B) The number and location of all air ambulance
bases operated by such provider.
(C) The number and type of aircraft operated by
such provider.
(D) The number of air ambulance transports,
disaggregated by payor mix, including group health
plans, health insurance issuers, and Government payors.
(E) The number of claims of such provider that have
been denied payment by a group health plan or health
insurance issuer and the reasons for any such denials.
(F) The number of emergency and nonemergency air
ambulance transports, disaggregated by air ambulance
base and type of aircraft.
(b) Reporting Requirements for Group Health Plans and Health
Insurance Issuers.--
(1) In general.--Each group health plan and health
insurance issuer offering health insurance coverage in the
individual or group market shall submit to the Secretary of
Health and Human Services--
(A) not later than the date that is 90 days after
the last day of the first plan year beginning on or
after the date on which a final rule is promulgated
pursuant to the rulemaking described in subsection (d),
the information described in paragraph (2) with respect
to such plan year; and
(B) not later than the date that is 90 days after
the last day of the plan year immediately succeeding
the plan year described in subparagraph (A), such
information with respect to such immediately succeeding
plan year.
(2) Information described.--For purposes of paragraph (1),
information described in this paragraph, with respect to a
group health plan or a health insurance issuer offering health
insurance coverage in the individual or group market, is each
of the following:
(A) Claims data for air ambulance services
furnished by providers of such services, disaggregated
by each of the following factors:
(i) Whether such services were furnished on
an emergent or nonemergent basis.
(ii) Whether the provider of such services
is part of a hospital-owned or sponsored
program, municipality-sponsored program,
hospital independent partnership (hybrid)
program, or independent program.
(iii) Whether such services were furnished
in a rural or urban area.
(iv) The type of aircraft (such as rotor
transport or fixed wing transport) used to
furnish such services.
(v) Whether the provider of such services
has a contract with the plan or issuer, as
applicable, to furnish such services under the
plan or coverage, respectively.
(B) Such other information regarding providers of
air ambulance services as the Secretary of Health and
Human Services may specify.
(c) Publication of Comprehensive Report.--
(1) In general.--Not later than the date that is one year
after the date described in subsection (b)(1)(B), the Secretary
of Health and Human Services, in consultation with the
Secretary of Transportation (referred to in this section as the
``Secretaries''), shall develop, and make publicly available
(subject to paragraph (3)), a comprehensive report summarizing
the information submitted under subsections (a) and (b) and
including each of the following:
(A) The percentage of providers of air ambulance
services that are part of a hospital-owned or sponsored
program, municipality-sponsored program, hospital-
independent partnership (hybrid) program, or
independent program.
(B) An assessment of the extent of competition
among providers of air ambulance services on the basis
of price and services offered, and any changes in such
competition over time.
(C) An assessment of the average charges for air
ambulance services, amounts paid by group health plans
and health insurance issuers offering health insurance
coverage in the individual or group market to providers
of air ambulance services for furnishing such services,
and amounts paid out-of-pocket by consumers, and any
changes in such amounts paid over time.
(D) An assessment of the presence of air ambulance
bases in, or with the capability to serve, rural areas,
and the relative growth in air ambulance bases in rural
and urban areas over time.
(E) Any evidence of gaps in rural access to
providers of air ambulance services.
(F) The percentage of providers of air ambulance
services that have contracts with group health plans or
health insurance issuers offering health insurance
coverage in the individual or group market to furnish
such services under such plans or coverage,
respectively.
(G) An assessment of whether there are instances of
unfair, deceptive, or predatory practices by providers
of air ambulance services in collecting payments from
patients to whom such services are furnished, such as
referral of such patients to collections, lawsuits, and
liens or wage garnishment actions.
(H) An assessment of whether there are instances of
group health plans or health insurance issuers not
providing substantial reasons for refusing to enter
into contract negotiations with providers of air
ambulance services.
(I) An assessment of whether there are, within the
air ambulance industry, instances of unreasonable
industry concentration, excessive market domination, or
other conditions that would allow at least one provider
of air ambulance services to unreasonably increase
prices or exclude competition in air ambulance services
in a given geographic region.
(J) An assessment of the frequency of patient
balance billing, patient referrals to collections,
lawsuits to collect balance bills, and liens or wage
garnishment actions by providers of air ambulance
services as part of a collections process across
hospital-owned or sponsored programs, municipality-
sponsored programs, hospital-independent partnership
(hybrid) programs, or independent programs, providers
of air ambulance services operated by public agencies
(such as a State or county health department), and
other independent providers of air ambulance services.
(K) An assessment of the frequency of claims
appeals made by providers of air ambulance services to
group health plans or health insurance issuers offering
health insurance coverage in the individual or group
market with respect to air ambulance services furnished
to enrollees of such plans or coverage, respectively.
(L) Any other cost, quality, or other data relating
to air ambulance services or the air ambulance
industry, as determined necessary and appropriate by
the Secretaries.
(2) Other sources of information.--The Secretaries may
incorporate information from independent experts or third-party
sources in developing the comprehensive report required under
paragraph (1).
(3) Protection of proprietary information.--The Secretaries
may not make publicly available under this subsection any
proprietary information.
(d) Rulemaking.--Not later than the date that is one year after the
date of the enactment of this Act, the Secretary of Health and Human
Services, in consultation with the Secretary of Transportation, shall,
through notice and comment rulemaking, specify the form and manner in
which reports described in subsections (a) and (b) shall be submitted
to such Secretaries, taking into consideration (as applicable and to
the extent feasible) any recommendations included in the report
submitted by the Advisory Committee on Air Ambulance and Patient
Billing under section 418(e) of the FAA Reauthorization Act of 2018
(Public Law 115-254; 49 U.S.C. 42301 note prec.).
(e) Civil Money Penalties.--
(1) In general.--Subject to paragraph (2), a provider of
air ambulance services who fails to submit all information
required under subsection (a)(2) by the date described in
subparagraph (A) or (B) of subsection (a)(1), as applicable,
shall be subject to a civil money penalty of not more than
$10,000.
(2) Exception.--In the case of a provider of air ambulance
services that submits only some of the information required
under subsection (a)(2) by the date described in subparagraph
(A) or (B) of subsection (a)(1), as applicable, the Secretary
of Health and Human Services may waive the civil money penalty
imposed under paragraph (1) if such provider demonstrates a
good faith effort in working with the Secretary to submit the
remaining information required under subsection (a)(2).
(3) Procedure.--The provisions of section 1128A of the
Social Security Act (42 U.S.C. 1320a-7a), other than
subsections (a) and (b) and the first sentence of subsection
(c)(1), shall apply to civil money penalties under this
subsection in the same manner as such provisions apply to a
penalty or proceeding under such section.
(f) Unfair and Deceptive Practices and Unfair Methods of
Competition.--The Secretary of Transportation may use any information
submitted under subsection (a) in determining whether a provider of air
ambulance services has violated section 41712(a) of title 49, United
States Code.
(g) Understanding Air Ambulance Quality and Patient Safety.--Not
later than 1 year after the date of the enactment of this Act, the
Comptroller General of the United States shall conduct a study and
submit to Congress a report on options to establish quality, patient
safety, service reliability, and clinical capability standards for each
clinical capability level of air ambulances. Such report shall include
analysis and recommendations, as appropriate, to Congress regarding
each of the following with respect to air ambulance services:
(1) Qualifications of different clinical capability levels
and tiering of such levels.
(2) Patient safety and quality standards.
(3) Options for improving service reliability during poor
weather, night conditions, or other adverse conditions.
(4) Differences between air ambulance vehicle types,
services, and technologies, and other flight capability
standards, and the impact of such differences on patient
safety.
(5) Clinical triage criteria for air ambulances.
(h) Definitions.--In this section, the terms ``group health plan'',
``health insurance coverage'', and ``health insurance issuer'' have the
meanings given such terms in section 2791 of the Public Health Service
Act (42 U.S.C. 300gg-91).
SEC. 11. GAO REPORT ON EFFECTS OF LEGISLATION.
Not later than 2 years after the date of the enactment of this Act,
the Comptroller General of the United States shall submit to Congress a
report summarizing the effects of the provisions of this Act, including
the amendments made by such provisions, on changes during such period
in health care provider networks of group health plans and health
insurance coverage offered by a health insurance issuer in the group or
individual market, in fee schedules and amounts for health care
services, and to contracted rates under such plans or coverage. Such
report shall--
(1) to the extent practicable, sample a statistically
significant group of national health care providers; and
(2) examine--
(A) provider network participation, including
nonparticipating providers furnishing items and
services at participating facilities;
(B) health care provider group network
participation, including specialty, size, and
ownership; and
(C) the impact of State surprise billing laws and
network adequacy standards on participation of health
care providers and facilities in provider networks of
group health plans and of health insurance coverage
offered by health insurance issuers in the group or
individual market.
SEC. 12. TRANSITIONAL RULE ALLOWING DEDUCTION FOR SURPRISE BILLING
EXPENSES BELOW AGI FLOOR.
(a) In General.--Section 213 of the Internal Revenue Code of 1986
is amended by adding at the end the following new subsection:
``(g) Transitional Rule Allowing Deduction for Surprise Billing
Expenses Below AGI Floor.--
``(1) In general.--In addition to the deduction allowed by
subsection (a) for any taxable year, there shall be allowed as
a deduction an amount equal to the lesser of--
``(A) the excess of--
``(i) the surprise billing expenses which
would be allowed as a deduction for such
taxable year under subsection (a) if such
subsection were applied without regard to the
limitation based on the taxpayer's adjusted
gross income, over
``(ii) $600, or
``(B) the applicable percentage of the taxpayer's
adjusted gross income.
``(2) Surprise billing expenses.--For purposes of this
subsection, the term `surprise billing expenses' means expenses
paid for medical care of an individual who is a participant,
beneficiary, or enrollee in a group health plan or in group or
individual health insurance coverage offered by a health
insurance issuer (as such terms are defined in section 2791 of
the Public Health Service Act), if--
``(A) benefits are provided for such medical care
under such plan or coverage, and
``(B) such medical care--
``(i) is furnished by a provider without a
contractual relationship with such plan or
coverage with respect to the furnishing of such
medical care during a visit at a facility with
a contractual relationship with such plan or
coverage, or
``(ii) is furnished in an emergency
department of a hospital or an independent
freestanding emergency department.
``(3) Applicable percentage.--For purposes of this section,
the term `applicable percentage' means, with respect to any
taxpayer for any taxable year, the percentage in effect under
subsection (a) with respect to such taxpayer for such taxable
year.
``(4) Limitations.--Surprise billing expenses shall be
taken into account under paragraph (1) only if such expenses
are paid during the period beginning on January 1, 2020, and
ending on the date which is 1 year after the day before the
date specified in section 2(a)(5) of the Consumer Protections
Against Surprise Medical Bills Act of 2020.''.
(b) Conforming Amendments.--Sections 105(f), 162(l)(3), and
7702B(e)(2) of such Code are each amended by striking ``213(a)'' and
inserting ``213''.
(c) Effective Date.--The amendments made by this section shall
apply to taxable years ending after December 31, 2019.
<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, Education and Labor, and Transportation and Infrastructure, 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, Education and Labor, and Transportation and Infrastructure, 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, Education and Labor, and Transportation and Infrastructure, 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, Education and Labor, and Transportation and Infrastructure, 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.
Referred to the Subcommittee on Aviation.
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Committee Consideration and Mark-up Session Held.
Ordered to be Reported in the Nature of a Substitute (Amended) by Voice Vote.