Introduced in House Passed House Introduced in Senate Passed Senate To President Became Law
02/10/2020          

Consumer Protections Against Surprise Medical Bills Act of 2020

Date Version PDF TXT
02/10/2020 Introduced in House Open

            I 

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 Caro-
lina, 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 deter-
mined 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 

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•HR 5826 IH

consumer protections, and improve health care informa-
tion transparency, and for other purposes. 

Be it enacted by the Senate and House of Representa-1

tives of the United States of America in Congress assembled, 2

SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 3

(a) SHORT TITLE.—This Act may be cited as the 4

‘‘Consumer Protections Against Surprise Medical Bills 5

Act of 2020’’. 6

(b) TABLE OF CONTENTS.—The table of contents of 7

this Act is as follows: 8

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 hon-

est advance cost estimate. 
Sec. 7. Determination through open negotiation and mediation of out-of-net-

work 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 partici-
pating 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 REQUIRE-9

MENTS ON HEALTH PLANS TO PREVENT SUR-10

PRISE MEDICAL BILLS FOR EMERGENCY 11

SERVICES. 12

(a) PHSA AMENDMENTS.— 13

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(1) IN GENERAL.—Section 2719A of the Public 1

Health Service Act (42 U.S.C. 300gg–19a) is 2

amended— 3

(A) in subsection (b)— 4

(i) in the heading, by striking ‘‘COV-5

ERAGE’’ and inserting ‘‘COST-SHARING 6

AND PAYMENT’’; 7

(ii) in paragraph (1)— 8

(I) in the matter preceding sub-9

paragraph (A)— 10

(aa) by striking ‘‘a group 11

health plan, or a health insurance 12

issuer offering group or indi-13

vidual health insurance issuer,’’ 14

and inserting ‘‘a health plan’’; 15

(bb) by inserting ‘‘and, for 16

plan year 2022 or a subsequent 17

plan year, with respect to emer-18

gency services in an independent 19

freestanding emergency depart-20

ment’’ after ‘‘emergency depart-21

ment of a hospital’’; 22

(cc) by striking ‘‘the plan or 23

issuer’’ and inserting ‘‘the plan’’; 24

and 25

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(dd) by striking ‘‘(as defined 1

in paragraph (2)(B))’’; 2

(II) in subparagraph (B), by in-3

serting ‘‘or a participating facility 4

that is an emergency department of a 5

hospital or an independent free-6

standing emergency department (in 7

this subsection referred to as a ‘par-8

ticipating emergency facility’)’’ after 9

‘‘participating provider’’; and 10

(III) in subparagraph (C)— 11

(aa) in the matter preceding 12

clause (i), by inserting ‘‘by a 13

nonparticipating provider or a 14

nonparticipating facility that is 15

an emergency department of a 16

hospital or an independent free-17

standing emergency department’’ 18

after ‘‘enrollee’’; 19

(bb) by striking clause (i); 20

(cc) by striking ‘‘(ii)(I) such 21

services’’ and inserting ‘‘(i) such 22

services’’; 23

(dd) by striking ‘‘where the 24

provider of services does not have 25

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•HR 5826 IH

a contractual relationship with 1

the plan for the providing of 2

services’’; 3

(ee) by striking ‘‘emergency 4

department services received 5

from providers who do have such 6

a contractual relationship with 7

the plan; and’’ and inserting 8

‘‘emergency services received 9

from participating providers and 10

participating emergency facilities 11

with respect to such plan;’’; 12

(ff) by striking ‘‘(II) if such 13

services’’ and all that follows 14

through ‘‘were provided in-net-15

work’’ and inserting the fol-16

lowing: 17

‘‘(ii) the cost-sharing requirement is 18

not greater than the requirement that 19

would apply if such services were furnished 20

by a participating provider or a partici-21

pating emergency facility, as applicable;’’; 22

and 23

(gg) by adding at the end 24

the following new clauses: 25

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‘‘(iii) such cost-sharing requirement is 1

calculated as if the contracted rate for 2

such services if furnished by a partici-3

pating provider or a participating emer-4

gency facility were equal to the recognized 5

amount for such services; 6

‘‘(iv) the health plan pays to such pro-7

vider or facility, respectively, the amount 8

by which the out-of-network rate for such 9

services exceeds the cost-sharing amount 10

for such services (as determined in accord-11

ance with clauses (ii) and (iii)); and 12

‘‘(v) any deductible or out-of-pocket 13

maximum that would apply if such services 14

were furnished by a participating provider 15

or a participating emergency facility shall 16

be the deductible or out-of-pocket max-17

imum that applies; and’’; and 18

(iii) by striking paragraph (2) and in-19

serting the following new paragraph: 20

‘‘(2) AUDIT PROCESS AND RULEMAKING PROC-21

ESS FOR MEDIAN CONTRACTED RATES.— 22

‘‘(A) AUDIT PROCESS.— 23

‘‘(i) IN GENERAL.—Not later than 24

July 1, 2021, the Secretary, in coordina-25

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•HR 5826 IH

tion with the Secretary of the Treasury 1

and the Secretary of Labor and in con-2

sultation with the National Association of 3

Insurance Commissioners, shall establish 4

through rulemaking a process, in accord-5

ance with clause (ii), under which health 6

plans are audited by the Secretary to en-7

sure that— 8

‘‘(I) such plans are in compliance 9

with the requirement of applying a 10

median contracted rate under this sec-11

tion; and 12

‘‘(II) that such median con-13

tracted rate so applied satisfies the 14

definition under subsection (k)(8) 15

with respect to the year involved. 16

‘‘(ii) AUDIT SAMPLES.—Under the 17

process established pursuant to clause (i), 18

the Secretary— 19

‘‘(I) shall conduct audits de-20

scribed in such clause of a sample of 21

health plans; and 22

‘‘(II) may audit any health plan 23

if the Secretary has received any com-24

plaint about such plan that involves 25

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•HR 5826 IH

the compliance of the plan with the 1

requirement described in such clause. 2

‘‘(B) RULEMAKING.—Not later than July 3

1, 2021, the Secretary, in coordination with the 4

Secretary of Labor and the Secretary of the 5

Treasury, shall establish through rulemaking— 6

‘‘(i) the methodology the sponsor or 7

issuer of a health plan shall use to deter-8

mine the median contracted rate, which 9

shall account for relevant payment adjust-10

ments that take into account facility type 11

that are otherwise taken into account for 12

purposes of determining payment amounts 13

with respect to participating facilities; and 14

‘‘(ii) the information such sponsor or 15

issuer shall share with the nonparticipating 16

provider involved when making such a de-17

termination.’’; and 18

(B) by adding at the end the following new 19

subsection: 20

‘‘(k) DEFINITIONS.—For purposes of this section: 21

‘‘(1) CONTRACTED RATE.—The term ‘con-22

tracted rate’ means, with respect to a health plan 23

and a health care provider or health care facility fur-24

nishing an item or service to a beneficiary, partici-25

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•HR 5826 IH

pant, or enrollee of such plan, the agreed upon total 1

payment amount (inclusive of any cost-sharing) to 2

such provider or facility for such item or service. 3

‘‘(2) DURING A VISIT.—The term ‘during a 4

visit’ shall, with respect to an individual who is fur-5

nished items and services at a participating facility, 6

include equipment and devices, telemedicine services, 7

imaging services, laboratory services, preoperative 8

and postoperative services, and such other items and 9

services as the Secretary may specify furnished to 10

such individual, regardless of whether or not the 11

provider furnishing such items or services is at the 12

facility. 13

‘‘(3) EMERGENCY DEPARTMENT OF A HOS-14

PITAL.—The term ‘emergency department of a hos-15

pital’ includes a hospital outpatient department that 16

provides emergency services. 17

‘‘(4) EMERGENCY MEDICAL CONDITION.—The 18

term ‘emergency medical condition’ means a medical 19

condition manifesting itself by acute symptoms of 20

sufficient severity (including severe pain) such that 21

a prudent layperson, who possesses an average 22

knowledge of health and medicine, could reasonably 23

expect the absence of immediate medical attention to 24

result in a condition described in clause (i), (ii), or 25

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•HR 5826 IH

(iii) of section 1867(e)(1)(A) of the Social Security 1

Act. 2

‘‘(5) EMERGENCY SERVICES.— 3

‘‘(A) IN GENERAL.—The term ‘emergency 4

services’, with respect to an emergency medical 5

condition, means— 6

‘‘(i) a medical screening examination 7

(as required under section 1867 of the So-8

cial Security Act, or as would be required 9

under such section if such section applied 10

to an independent freestanding emergency 11

department) that is within the capability of 12

the emergency department of a hospital or 13

of an independent freestanding emergency 14

department, as applicable, including ancil-15

lary services routinely available to the 16

emergency department to evaluate such 17

emergency medical condition; and 18

‘‘(ii) within the capabilities of the 19

staff and facilities available at the hospital 20

or the independent freestanding emergency 21

department, as applicable, such further 22

medical examination and treatment as are 23

required under section 1867 of such Act, 24

or as would be required under such section 25

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•HR 5826 IH

if such section applied to an independent 1

freestanding emergency department, to 2

stabilize the patient (regardless of the de-3

partment of the hospital in which such fur-4

ther examination or treatment is fur-5

nished). 6

‘‘(B) INCLUSION OF ADDITIONAL SERV-7

ICES.—In the case of an individual enrolled in 8

a health plan who is furnished services de-9

scribed in subparagraph (A) by a provider or 10

hospital or independent freestanding emergency 11

department to stabilize such individual with re-12

spect to an emergency medical condition, the 13

term ‘emergency services’ shall include, in addi-14

tion to those described in subparagraph (A), 15

items and services furnished as part of out-16

patient observation or an inpatient or out-17

patient stay during a visit in which such indi-18

vidual is so stabilized with respect to such 19

emergency condition if— 20

‘‘(i) such items and services would 21

otherwise be covered under such plan if 22

furnished by a participating provider or 23

participating facility; and 24

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•HR 5826 IH

‘‘(ii) such items and services are fur-1

nished— 2

‘‘(I) to maintain, improve, or re-3

solve the individual’s stabilization with 4

respect to such condition, unless any 5

circumstance described in subpara-6

graph (C) has occurred with respect 7

to such individual before such items 8

and services are furnished; or 9

‘‘(II) for any purpose not de-10

scribed in subclause (I), unless each 11

of the criteria described in subpara-12

graph (D) have been met with respect 13

to such individual and such item or 14

service. 15

‘‘(C) CIRCUMSTANCES.—For purposes of 16

subparagraph (B)(ii)(I), a circumstance de-17

scribed in this subparagraph is any of the fol-18

lowing, with respect to an individual who is a 19

beneficiary, participant, or enrollee of a health 20

plan who is furnished services described in sub-21

paragraph (A) by a hospital or independent 22

freestanding emergency department with re-23

spect to an emergency medical condition: 24

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‘‘(i) A participating provider, with re-1

spect to such plan, with privileges at the 2

hospital or independent freestanding emer-3

gency department assumes responsibility 4

for the care of the individual. 5

‘‘(ii) A participating provider, with re-6

spect to such plan, assumes responsibility 7

for the care of the individual through 8

transfer of the individual. 9

‘‘(iii) The health plan and the pro-10

vider treating such individual at the hos-11

pital or independent freestanding emer-12

gency department for such condition reach 13

an agreement concerning the care for the 14

individual. 15

‘‘(iv) The individual is discharged. 16

‘‘(D) SIGNED NOTICE CRITERIA.—For pur-17

poses of subparagraph (B)(ii)(II), the criteria 18

described in this subparagraph, with respect to 19

an individual and an item or service furnished 20

by a nonparticipating provider or nonpartici-21

pating facility that is a hospital or an inde-22

pendent freestanding emergency department, 23

are the following: 24

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•HR 5826 IH

‘‘(i) A written notice (as specified by 1

the Secretary and in a clear and under-2

standable manner) is provided by such pro-3

vider or facility to such individual, before 4

such item or service is furnished, that in-5

cludes the following information: 6

‘‘(I) That such provider or facil-7

ity is a nonparticipating provider or 8

nonparticipating facility (as applica-9

ble). 10

‘‘(II) To the extent practicable, 11

the estimated amount that such non-12

participating facility or nonpartici-13

pating provider may charge the indi-14

vidual for such item or service. 15

‘‘(III) A statement that the indi-16

vidual may seek such item or service 17

from a provider that is a participating 18

provider or a hospital or independent 19

freestanding emergency department 20

that is a participating facility and a 21

list, if feasible, of participating facili-22

ties or participating providers, as ap-23

plicable, who are able to furnish such 24

item or service. 25

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•HR 5826 IH

‘‘(ii) Such individual is in a condition 1

to receive (as determined in accordance 2

with guidance issued by the Secretary) the 3

information described in clause (i) and to 4

confirm notice of receipt of such notice, in 5

accordance with applicable State law. 6

‘‘(iii) The individual signs and dates 7

such notice confirming receipt of the notice 8

before such item or service is furnished. 9

‘‘(6) HEALTH PLAN.—The term ‘health plan’ 10

means a group health plan and health insurance cov-11

erage offered by a heath insurance issuer in the 12

group or individual market and includes a grand-13

fathered health plan (as defined in section 1251(e) 14

of the Patient Protection and Affordable Care Act). 15

‘‘(7) INDEPENDENT FREESTANDING EMER-16

GENCY DEPARTMENT.—The term ‘independent free-17

standing emergency department’ means a health 18

care facility that— 19

‘‘(A) is geographically separate and dis-20

tinct and licensed separately from a hospital 21

under applicable State law; and 22

‘‘(B) provides emergency services. 23

‘‘(8) MEDIAN CONTRACTED RATE.— 24

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•HR 5826 IH

‘‘(A) IN GENERAL.—Subject to subpara-1

graph (B), the term ‘median contracted rate’ 2

means, with respect to a health plan— 3

‘‘(i) for an item or service furnished 4

during 2022, the median of the contracted 5

rates recognized by the sponsor or issuer 6

of such plan (determined with respect to 7

all such plans of such sponsor or such 8

issuer that are within the same line of 9

business (as specified in subparagraph (C)) 10

as the plan involved) as the total maximum 11

payment under such plans in 2019 for the 12

same or a similar item or service that is 13

provided by a provider or facility in the 14

same or similar specialty and provided in 15

the geographic region (established (and up-16

dated, as appropriate) by the Secretary, in 17

consultation with the National Association 18

of Insurance Commissioners) in which the 19

item or service is furnished, consistent with 20

the methodology established by the Sec-21

retary under subsection (b)(2)(B), in-22

creased by the percentage increase in the 23

consumer price index for all urban con-24

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•HR 5826 IH

sumers (United States city average) over 1

2019, 2020, and 2021; 2

‘‘(ii) for an item or service furnished 3

during 2023 or a subsequent year through 4

2026, the median contracted rate for the 5

previous year, increased by the percentage 6

increase in the consumer price index for all 7

urban consumers (United States city aver-8

age) over such previous year; 9

‘‘(iii) for an item or service furnished 10

during a rebasing year (as defined in sub-11

paragraph (D)), the median of the con-12

tracted rates recognized by the sponsor or 13

issuer of such plan (determined with re-14

spect to all such plans of such sponsor or 15

such issuer that are within the same line 16

of business (as specified in subparagraph 17

(C)) as the plan involved) as the total max-18

imum payment under such plans in such 19

year for the same or a similar item or serv-20

ice that is provided by a provider or facility 21

in the same or similar specialty and pro-22

vided in the geographic region (as estab-23

lished pursuant to clause (i)) in which the 24

item or service is furnished, consistent with 25

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•HR 5826 IH

the methodology established by the Sec-1

retary under subsection (b)(2)(B); and 2

‘‘(iv) for an item or service furnished 3

during any of the 4 years following a re-4

basing year, the median contracted rate for 5

the previous year, increased by the per-6

centage increase in the consumer price 7

index for all urban consumers (United 8

States city average) over such previous 9

year. 10

‘‘(B) USE OF SUBSTITUTE RATE IN CASE 11

OF INSUFFICIENT DATA.— 12

‘‘(i) IN GENERAL.—In the case the 13

sponsor or issuer of a health plan has in-14

sufficient information (as specified by the 15

Secretary) to calculate the median of the 16

contracted rates in accordance with sub-17

paragraph (A) for a year for an item or 18

service furnished in a particular geographic 19

region (as established pursuant to subpara-20

graph (A)(i)) by a type of provider or facil-21

ity, the substitute rate (as defined in 22

clause (ii)) for such item or service shall be 23

deemed to be the median contracted rate 24

for such item or service furnished in such 25

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•HR 5826 IH

region during such year by such a provider 1

or facility for such year under such sub-2

paragraph (A) for such plan. 3

‘‘(ii) SUBSTITUTE RATE.—For pur-4

poses of clause (i), the term ‘substitute 5

rate’ means, with respect to an item or 6

service furnished by a provider or facility 7

in a geographic region (established pursu-8

ant to subparagraph (A)(i)) during a year 9

for which a health plan is required to make 10

payment pursuant to subsection (b)(1), 11

(e)(1), or (i)(1)— 12

‘‘(I) if sufficient information (as 13

specified by the Secretary) exists to 14

determine the median of the con-15

tracted rates recognized by all health 16

plans offered in the same line of busi-17

ness (as specified in subparagraph 18

(C)) by any group health plan or 19

health insurance issuer for such an 20

item or service furnished in such re-21

gion by such a provider or facility 22

during such year using a database or 23

other source of information deter-24

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•HR 5826 IH

mined appropriate by the Secretary, 1

such median; and 2

‘‘(II) if such sufficient informa-3

tion does not exist, the median of the 4

contracted rates recognized by all 5

health plans offered in the same line 6

of business (as specified in subpara-7

graph (C)) by any group health plan 8

or health insurance issuer for such an 9

item or service furnished in a simi-10

larly situated geographic region (as 11

determined by the Secretary) with 12

such sufficient information by such a 13

provider or facility during such year 14

using such a database or such other 15

source of information. 16

The Secretary shall develop a methodology 17

for determining a substitute rate based on 18

a similarly situated health plan that is not 19

a Federal health care program (as defined 20

in section 1128B(f) of the Social Security 21

Act) in the case a substitute rate is not 22

calculable under the previous sentence with 23

respect to an item or service. 24

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21 

•HR 5826 IH

‘‘(C) LINE OF BUSINESS.—A line of busi-1

ness specified in this subparagraph is one of the 2

following: 3

‘‘(i) The individual market. 4

‘‘(ii) The small group market. 5

‘‘(iii) The large group market. 6

‘‘(iv) In the case of a self-insured 7

group health plan, other self-insured group 8

health plans. 9

‘‘(D) REBASING YEAR DEFINED.—For pur-10

poses of subparagraph (A), the term ‘rebasing 11

year’ means 2027 and every 5 years thereafter. 12

‘‘(9) NONPARTICIPATING FACILITY; PARTICI-13

PATING FACILITY.— 14

‘‘(A) NONPARTICIPATING FACILITY.—The 15

term ‘nonparticipating facility’ means, with re-16

spect to an item or service and a health plan, 17

a health care facility described in subparagraph 18

(B)(ii) that does not have a contractual rela-19

tionship with the plan for furnishing such item 20

or service. 21

‘‘(B) PARTICIPATING FACILITY.— 22

‘‘(i) IN GENERAL.—The term ‘partici-23

pating facility’ means, with respect to an 24

item or service and a health plan, a health 25

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22 

•HR 5826 IH

care facility described in clause (ii) that 1

has a contractual relationship with the 2

plan for furnishing such item or service. 3

‘‘(ii) HEALTH CARE FACILITY DE-4

SCRIBED.—A health care facility described 5

in this clause is each of the following: 6

‘‘(I) A hospital (as defined in 7

1861(e) of the Social Security Act), 8

including an emergency department of 9

a hospital. 10

‘‘(II) A critical access hospital 11

(as defined in section 1861(mm)(1) of 12

such Act). 13

‘‘(III) An ambulatory surgical 14

center (as described in section 15

1833(i)(1)(A) of such Act). 16

‘‘(IV) A laboratory. 17

‘‘(V) A radiology facility or imag-18

ing center. 19

‘‘(VI) An independent free-20

standing emergency department. 21

‘‘(VII) Any other facility speci-22

fied by the Secretary. 23

‘‘(10) NONPARTICIPATING PROVIDERS; PARTICI-24

PATING PROVIDERS.— 25

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23 

•HR 5826 IH

‘‘(A) NONPARTICIPATING PROVIDER.—The 1

term ‘nonparticipating provider’ means, with re-2

spect to an item or service and a health plan, 3

a physician or other health care provider who 4

does not have a contractual relationship with 5

the plan for furnishing such item or service 6

under the plan. 7

‘‘(B) PARTICIPATING PROVIDER.—The 8

term ‘participating provider’ means, with re-9

spect to an item or service and a health plan, 10

a physician or other health care provider who 11

has a contractual relationship with the plan for 12

furnishing such item or service under the plan. 13

‘‘(11) OUT-OF-NETWORK RATE.—The term 14

‘out-of-network rate’ means, with respect to an item 15

or service furnished in a State during a year to a 16

participant, beneficiary, or enrollee of a health plan 17

receiving such item or service from a nonpartici-18

pating provider or facility— 19

‘‘(A) subject to subparagraphs (C) and 20

(D), in the case such State has in effect a State 21

law that provides for a method for determining 22

the total amount payable under such health 23

plan regulated by such State with respect to 24

such item or service furnished by such provider 25

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24 

•HR 5826 IH

or facility, such amount determined in accord-1

ance with such law; 2

‘‘(B) subject to subparagraphs (C) and 3

(D), in the case such State does not have in ef-4

fect such a law with respect to such item or 5

service, plan, and provider or facility— 6

‘‘(i) subject to clause (ii), if the pro-7

vider or facility (as applicable) and such 8

plan agree on an amount of payment (in-9

cluding if agreed on through open negotia-10

tions under subsection (j)(1)) with respect 11

to such item or service, such agreed on 12

amount; or 13

‘‘(ii) if such provider or facility (as 14

applicable) and such plan enter the medi-15

ated dispute process under subsection (j) 16

and do not so agree before the date on 17

which a selected independent entity (as de-18

fined in paragraph (3) of such subsection) 19

makes a determination with respect to 20

such item or service under such subsection, 21

the amount of such determination; 22

‘‘(C) in the case such State has an All- 23

Payer Model Agreement under section 1115A of 24

the Social Security Act, the amount that the 25

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25 

•HR 5826 IH

State approves under such system for such item 1

or service so furnished; or 2

‘‘(D) in the case such health plan is a self- 3

insured group health plan and in the case of a 4

State with an agreement with such plan in ef-5

fect as of the date of the enactment of the Con-6

sumer Protections Against Surprise Medical 7

Bills Act of 2020, that provides for a method 8

for determining the total amount payable under 9

such health plan with respect to such item or 10

service furnished by such provider or facility, 11

such amount determined in accordance with 12

such method. 13

‘‘(12) RECOGNIZED AMOUNT.—The term ‘recog-14

nized amount’ means, with respect to an item or 15

service furnished in a State during a year to a par-16

ticipant, beneficiary, or enrollee of a health plan by 17

a nonparticipating provider or nonparticipating facil-18

ity— 19

‘‘(A) subject to subparagraphs (C) and 20

(D), in the case such State has in effect a law 21

described in paragraph (11)(A) with respect to 22

such item or service, provider or facility, and 23

plan, the amount determined in accordance with 24

such law; 25

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26 

•HR 5826 IH

‘‘(B) subject to subparagraphs (C) and 1

(D), in the case such State does not have in ef-2

fect such a law, an amount that is the median 3

contracted rate for such item or service for such 4

year; 5

‘‘(C) subject to subparagraph (D), in the 6

case such State is described in paragraph 7

(11)(C) with respect to such item or service so 8

furnished, the amount that the State approves 9

under such system for such item or service so 10

furnished; or 11

‘‘(D) in the case such health plan is a self- 12

insured group health plan and in the case of a 13

State with an agreement with such plan in ef-14

fect as of the date of the enactment of the Con-15

sumer Protections Against Surprise Medical 16

Bills Act of 2020, that provides for a method 17

for determining the total amount payable under 18

such health plan with respect to such item or 19

service furnished by such provider or facility, 20

such amount determined in accordance with 21

such method. 22

‘‘(13) STABILIZE.—The term ‘to stabilize’, with 23

respect to an emergency medical condition, has the 24

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27 

•HR 5826 IH

meaning give in section 1867(e)(3)(A) of the Social 1

Security Act). 2

‘‘(14) COST-SHARING.—The term ‘cost-sharing’ 3

includes copayments, coinsurance, and deductibles. 4

‘‘(l) PAYMENT TO PROVIDER OR FACILITY.—In the 5

case of any payment required to be made by a health plan 6

pursuant to subsection (b)(1), (e)(1), or (i)(1) to a 7

nonparticiapting provider or nonparticipating facility for 8

an item or service, such payment shall be made to such 9

provider or facility and not to the individual receiving such 10

item or service.’’. 11

(2) EFFECTIVE DATE.—The amendments made 12

by paragraph (1) shall apply with respect to plan 13

years beginning on or after January 1, 2022. 14

(b) IRC AMENDMENTS.— 15

(1) IN GENERAL.—Subchapter B of chapter 16

100 of the Internal Revenue Code of 1986 is amend-17

ed by adding at the end the following new section: 18

‘‘SEC. 9816. PATIENT PROTECTIONS. 19

‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If 20

a health plan requires or provides for designation by a par-21

ticipant or beneficiary of a participating primary care pro-22

vider, then the plan shall permit each participant or bene-23

ficiary to designate any participating primary care pro-24

vider who is available to accept such individual. 25

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28 

•HR 5826 IH

‘‘(b) COST-SHARING AND PAYMENT OF EMERGENCY 1

SERVICES.— 2

‘‘(1) IN GENERAL.—If a health plan provides or 3

covers any benefits with respect to services in an 4

emergency department of a hospital and, for plan 5

year 2022 or a subsequent plan year, with respect 6

to emergency services in an independent free-7

standing emergency department, the plan shall cover 8

emergency services— 9

‘‘(A) without the need for any prior au-10

thorization determination; 11

‘‘(B) whether the health care provider fur-12

nishing such services is a participating provider 13

or a participating facility that is an emergency 14

department of a hospital or an independent 15

freestanding emergency department (in this 16

subsection referred to as a ‘participating emer-17

gency facility’) with respect to such services; 18

‘‘(C) in a manner so that, if such services 19

are provided to a participant or beneficiary by 20

a nonparticipating provider or a nonpartici-21

pating facility that is an emergency department 22

of a hospital or an independent freestanding 23

emergency department— 24

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29 

•HR 5826 IH

‘‘(i) such services will be provided 1

without imposing any requirement under 2

the plan for prior authorization of services 3

or any limitation on coverage that is more 4

restrictive than the requirements or limita-5

tions that apply to emergency services re-6

ceived from participating providers and 7

participating emergency facilities with re-8

spect to such plan; 9

‘‘(ii) the cost-sharing requirement is 10

not greater than the requirement that 11

would apply if such services were furnished 12

by a participating provider or a partici-13

pating emergency facility, as applicable; 14

‘‘(iii) such cost-sharing requirement is 15

calculated as if the contracted rate for 16

such services if furnished by a partici-17

pating provider or a participating emer-18

gency facility were equal to the recognized 19

amount for such services; 20

‘‘(iv) the health plan pays to such pro-21

vider or facility, respectively, the amount 22

by which the out-of-network rate for such 23

services exceeds the cost-sharing amount 24

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30 

•HR 5826 IH

for such services (as determined in accord-1

ance with clauses (ii) and (iii)); and 2

‘‘(v) any deductible or out-of-pocket 3

maximum that would apply if such services 4

were furnished by a participating provider 5

or a participating emergency facility shall 6

be the deductible or out-of-pocket max-7

imum that applies; and 8

‘‘(D) without regard to any other term or 9

condition of such coverage (other than exclusion 10

or coordination of benefits, or an affiliation or 11

waiting period, permitted under section 2704 of 12

the Public Health Service Act, including as in-13

corporated pursuant to section 715 of the Em-14

ployee Retirement Income Security Act of 1974 15

and section 9815, and other than applicable 16

cost-sharing). 17

‘‘(2) AUDIT PROCESS AND RULEMAKING PROC-18

ESS FOR MEDIAN CONTRACTED RATES.— 19

‘‘(A) AUDIT PROCESS.— 20

‘‘(i) IN GENERAL.—Not later than 21

July 1, 2021, the Secretary, in coordina-22

tion with the Secretary of Health and 23

Human Services and the Secretary of 24

Labor and in consultation with the Na-25

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31 

•HR 5826 IH

tional Association of Insurance Commis-1

sioners, shall establish through rulemaking 2

a process, in accordance with clause (ii), 3

under which health plans are audited by 4

the Secretary to ensure that— 5

‘‘(I) such plans are in compliance 6

with the requirement of applying a 7

median contracted rate under this sec-8

tion; and 9

‘‘(II) that such median con-10

tracted rate so applied satisfies the 11

definition under subsection (k)(8) 12

with respect to the year involved. 13

‘‘(ii) AUDIT SAMPLES.—Under the 14

process established pursuant to clause (i), 15

the Secretary— 16

‘‘(I) shall conduct audits de-17

scribed in such clause of a sample of 18

health plans; and 19

‘‘(II) may audit any health plan 20

if the Secretary has received any com-21

plaint about such plan that involves 22

the compliance of the plan with the 23

requirement described in such clause. 24

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32 

•HR 5826 IH

‘‘(B) RULEMAKING.—Not later than July 1

1, 2021, the Secretary, in coordination with the 2

Secretary of Labor and the Secretary of Health 3

and Human Services, shall establish through 4

rulemaking— 5

‘‘(i) the methodology the sponsor of a 6

health plan shall use to determine the me-7

dian contracted rate, which shall account 8

for relevant payment adjustments that 9

take into account facility type that are oth-10

erwise taken into account for purposes of 11

determining payment amounts with respect 12

to participating facilities; and 13

‘‘(ii) the information such sponsor 14

shall share with the nonparticipating pro-15

vider involved when making such a deter-16

mination. 17

‘‘(c) ACCESS TO PEDIATRIC CARE.— 18

‘‘(1) PEDIATRIC CARE.—In the case of a person 19

who has a child who is a participant or beneficiary 20

under a health plan, if the plan requires or provides 21

for the designation of a participating primary care 22

provider for the child, the plan shall permit such 23

person to designate a physician (allopathic or osteo-24

pathic) who specializes in pediatrics as the child’s 25

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33 

•HR 5826 IH

primary care provider if such provider participates 1

in the network of the plan. 2

‘‘(2) CONSTRUCTION.—Nothing in paragraph 3

(1) shall be construed to waive any exclusions of cov-4

erage under the terms and conditions of the plan 5

with respect to coverage of pediatric care. 6

‘‘(d) PATIENT ACCESS TO OBSTETRICAL AND GYNE-7

COLOGICAL CARE.— 8

‘‘(1) GENERAL RIGHTS.— 9

‘‘(A) DIRECT ACCESS.—A health plan de-10

scribed in paragraph (2) may not require au-11

thorization or referral by the plan or any per-12

son (including a primary care provider de-13

scribed in paragraph (2)(B)) in the case of a fe-14

male participant or beneficiary who seeks cov-15

erage for obstetrical or gynecological care pro-16

vided by a participating health care professional 17

who specializes in obstetrics or gynecology. 18

Such professional shall agree to otherwise ad-19

here to such plan’s policies and procedures, in-20

cluding procedures regarding referrals and ob-21

taining prior authorization and providing serv-22

ices pursuant to a treatment plan (if any) ap-23

proved by the plan. 24

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34 

•HR 5826 IH

‘‘(B) OBSTETRICAL AND GYNECOLOGICAL 1

CARE.—A health plan described in paragraph 2

(2) shall treat the provision of obstetrical and 3

gynecological care, and the ordering of related 4

obstetrical and gynecological items and services, 5

pursuant to the direct access described under 6

subparagraph (A), by a participating health 7

care professional who specializes in obstetrics or 8

gynecology as the authorization of the primary 9

care provider. 10

‘‘(2) APPLICATION OF PARAGRAPH.—A health 11

plan described in this paragraph is a health plan 12

that— 13

‘‘(A) provides coverage for obstetric or 14

gynecologic care; and 15

‘‘(B) requires the designation by a partici-16

pant or beneficiary of a participating primary 17

care provider. 18

‘‘(3) CONSTRUCTION.—Nothing in paragraph 19

(1) shall be construed to— 20

‘‘(A) waive any exclusions of coverage 21

under the terms and conditions of the plan with 22

respect to coverage of obstetrical or gyneco-23

logical care; or 24

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35 

•HR 5826 IH

‘‘(B) preclude the health plan involved 1

from requiring that the obstetrical or gyneco-2

logical provider notify the primary care health 3

care professional or the plan of treatment deci-4

sions. 5

‘‘(k) DEFINITIONS.—For purposes of this section: 6

‘‘(1) CONTRACTED RATE.—The term ‘con-7

tracted rate’ means, with respect to a health plan 8

and a health care provider or health care facility fur-9

nishing an item or service to a beneficiary or partici-10

pant of such plan, the agreed upon total payment 11

amount (inclusive of any cost-sharing) to such pro-12

vider or facility for such item or service. 13

‘‘(2) DURING A VISIT.—The term ‘during a 14

visit’ shall, with respect to an individual who is fur-15

nished items and services at a participating facility, 16

include equipment and devices, telemedicine services, 17

imaging services, laboratory services, preoperative 18

and postoperative services, and such other items and 19

services as the Secretary may specify furnished to 20

such individual, regardless of whether or not the 21

provider furnishing such items or services is at the 22

facility. 23

‘‘(3) EMERGENCY DEPARTMENT OF A HOS-24

PITAL.—The term ‘emergency department of a hos-25

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36 

•HR 5826 IH

pital’ includes a hospital outpatient department that 1

provides emergency services. 2

‘‘(4) EMERGENCY MEDICAL CONDITION.—The 3

term ‘emergency medical condition’ means a medical 4

condition manifesting itself by acute symptoms of 5

sufficient severity (including severe pain) such that 6

a prudent layperson, who possesses an average 7

knowledge of health and medicine, could reasonably 8

expect the absence of immediate medical attention to 9

result in a condition described in clause (i), (ii), or 10

(iii) of section 1867(e)(1)(A) of the Social Security 11

Act. 12

‘‘(5) EMERGENCY SERVICES.— 13

‘‘(A) IN GENERAL.—The term ‘emergency 14

services’, with respect to an emergency medical 15

condition, means— 16

‘‘(i) a medical screening examination 17

(as required under section 1867 of the So-18

cial Security Act, or as would be required 19

under such section if such section applied 20

to an independent freestanding emergency 21

department) that is within the capability of 22

the emergency department of a hospital or 23

of an independent freestanding emergency 24

department, as applicable, including ancil-25

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37 

•HR 5826 IH

lary services routinely available to the 1

emergency department to evaluate such 2

emergency medical condition; and 3

‘‘(ii) within the capabilities of the 4

staff and facilities available at the hospital 5

or the independent freestanding emergency 6

department, as applicable, such further 7

medical examination and treatment as are 8

required under section 1867 of such Act, 9

or as would be required under such section 10

if such section applied to an independent 11

freestanding emergency department, to 12

stabilize the patient (regardless of the de-13

partment of the hospital in which such fur-14

ther examination or treatment is fur-15

nished). 16

‘‘(B) INCLUSION OF ADDITIONAL SERV-17

ICES.—In the case of an individual enrolled in 18

a health plan who is furnished services de-19

scribed in subparagraph (A) by a provider or 20

hospital or independent freestanding emergency 21

department to stabilize such individual with re-22

spect to an emergency medical condition, the 23

term ‘emergency services’ shall include, in addi-24

tion to those described in subparagraph (A), 25

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38 

•HR 5826 IH

items and services furnished as part of out-1

patient observation or an inpatient or out-2

patient stay during a visit in which such indi-3

vidual is so stabilized with respect to such 4

emergency condition if— 5

‘‘(i) such items and services would 6

otherwise be covered under such plan if 7

furnished by a participating provider or 8

participating facility; and 9

‘‘(ii) such items and services are fur-10

nished— 11

‘‘(I) to maintain, improve, or re-12

solve the individual’s stabilization with 13

respect to such condition, unless any 14

circumstance described in subpara-15

graph (C) has occurred with respect 16

to such individual before such items 17

and services are furnished; or 18

‘‘(II) for any purpose not de-19

scribed in subclause (I), unless each 20

of the criteria described in subpara-21

graph (D) have been met with respect 22

to such individual and such item or 23

service. 24

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‘‘(C) CIRCUMSTANCES.—For purposes of 1

subparagraph (B)(ii)(I), a circumstance de-2

scribed in this subparagraph is any of the fol-3

lowing, with respect to an individual who is a 4

beneficiary, participant, or enrollee of a health 5

plan who is furnished services described in sub-6

paragraph (A) by a hospital or independent 7

freestanding emergency department with re-8

spect to an emergency medical condition: 9

‘‘(i) A participating provider, with re-10

spect to such plan, with privileges at the 11

hospital or independent freestanding emer-12

gency department assumes responsibility 13

for the care of the individual. 14

‘‘(ii) A participating provider, with re-15

spect to such plan, assumes responsibility 16

for the care of the individual through 17

transfer of the individual. 18

‘‘(iii) The health plan and the pro-19

vider treating such individual at the hos-20

pital or independent freestanding emer-21

gency department for such condition reach 22

an agreement concerning the care for the 23

individual. 24

‘‘(iv) The individual is discharged. 25

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•HR 5826 IH

‘‘(D) SIGNED NOTICE CRITERIA.—For pur-1

poses of subparagraph (B)(ii)(II), the criteria 2

described in this subparagraph, with respect to 3

an individual and an item or service furnished 4

by a nonparticipating provider or nonpartici-5

pating facility that is a hospital or an inde-6

pendent freestanding emergency department, 7

are the following: 8

‘‘(i) A written notice (as specified by 9

the Secretary and in a clear and under-10

standable manner) is provided by such pro-11

vider or facility to such individual, before 12

such item or service is furnished, that in-13

cludes the following information: 14

‘‘(I) That such provider or facil-15

ity is a nonparticipating provider or 16

nonparticipating facility (as applica-17

ble). 18

‘‘(II) To the extent practicable, 19

the estimated amount that such non-20

participating facility or nonpartici-21

pating provider may charge the indi-22

vidual for such item or service. 23

‘‘(III) A statement that the indi-24

vidual may seek such item or service 25

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41 

•HR 5826 IH

from a provider that is a participating 1

provider or a hospital or independent 2

freestanding emergency department 3

that is a participating facility and a 4

list, if feasible, of participating facili-5

ties or participating providers, as ap-6

plicable, who are able to furnish such 7

item or service. 8

‘‘(ii) Such individual is in a condition 9

to receive (as determined in accordance 10

with guidance issued by the Secretary) the 11

information described in clause (i) and to 12

confirm notice of receipt of such notice, in 13

accordance with applicable State law. 14

‘‘(iii) The individual signs and dates 15

such notice confirming receipt of the notice 16

before such item or service is furnished. 17

‘‘(6) HEALTH PLAN.—The term ‘health plan’ 18

means a group health plan, including any group 19

health plan that is a grandfathered health plan (as 20

defined in section 1251(e) of the Patient Protection 21

and Affordable Care Act). 22

‘‘(7) INDEPENDENT FREESTANDING EMER-23

GENCY DEPARTMENT.—The term ‘independent free-24

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42 

•HR 5826 IH

standing emergency department’ means a health 1

care facility that— 2

‘‘(A) is geographically separate and dis-3

tinct and licensed separately from a hospital 4

under applicable State law; and 5

‘‘(B) provides emergency services. 6

‘‘(8) MEDIAN CONTRACTED RATE.— 7

‘‘(A) IN GENERAL.—Subject to subpara-8

graph (B), the term ‘median contracted rate’ 9

means, with respect to a health plan— 10

‘‘(i) for an item or service furnished 11

during 2022, the median of the contracted 12

rates recognized by the sponsor of such 13

plan (determined with respect to all such 14

plans of such sponsor that are within the 15

same line of business (as specified in sub-16

paragraph (C)) as the plan involved) as the 17

total maximum payment under such plans 18

in 2019 for the same or a similar item or 19

service that is provided by a provider or fa-20

cility in the same or similar specialty and 21

provided in the geographic region (estab-22

lished (and updated, as appropriate) by the 23

Secretary, in consultation with the Na-24

tional Association of Insurance Commis-25

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43 

•HR 5826 IH

sioners) in which the item or service is fur-1

nished, consistent with the methodology es-2

tablished by the Secretary under sub-3

section (b)(2)(B), increased by the percent-4

age increase in the consumer price index 5

for all urban consumers (United States 6

city average) over 2019, 2020, and 2021; 7

‘‘(ii) for an item or service furnished 8

during 2023 or a subsequent year through 9

2026, the median contracted rate for the 10

previous year, increased by the percentage 11

increase in the consumer price index for all 12

urban consumers (United States city aver-13

age) over such previous year; 14

‘‘(iii) for an item or service furnished 15

during a rebasing year (as defined in sub-16

paragraph (D)), the median of the con-17

tracted rates recognized by the sponsor of 18

such plan (determined with respect to all 19

such plans of such sponsor that are within 20

the same line of business (as specified in 21

subparagraph (C)) as the plan involved) as 22

the total maximum payment under such 23

plans in such year for the same or a simi-24

lar item or service that is provided by a 25

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44 

•HR 5826 IH

provider or facility in the same or similar 1

specialty and provided in the geographic 2

region (as established pursuant to clause 3

(i)) in which the item or service is fur-4

nished, consistent with the methodology es-5

tablished by the Secretary under sub-6

section (b)(2)(B); and 7

‘‘(iv) for an item or service furnished 8

during any of the 4 years following a re-9

basing year, the median contracted rate for 10

the previous year, increased by the per-11

centage increase in the consumer price 12

index for all urban consumers (United 13

States city average) over such previous 14

year. 15

‘‘(B) USE OF SUBSTITUTE RATE IN CASE 16

OF INSUFFICIENT DATA.— 17

‘‘(i) IN GENERAL.—In the case the 18

sponsor of a health plan has insufficient 19

information (as specified by the Secretary) 20

to calculate the median of the contracted 21

rates in accordance with subparagraph (A) 22

for a year for an item or service furnished 23

in a particular geographic region (as estab-24

lished pursuant to subparagraph (A)(i)) by 25

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45 

•HR 5826 IH

a type of provider or facility, the substitute 1

rate (as defined in clause (ii)) for such 2

item or service shall be deemed to be the 3

median contracted rate for such item or 4

service furnished in such region during 5

such year by such a provider or facility for 6

such year under such subparagraph (A) for 7

such plan. 8

‘‘(ii) SUBSTITUTE RATE.—For pur-9

poses of clause (i), the term ‘substitute 10

rate’ means, with respect to an item or 11

service furnished by a provider or facility 12

in a geographic region (established pursu-13

ant to subparagraph (A)(i)) during a year 14

for which a health plan is required to make 15

payment pursuant to subsection (b)(1), 16

(e)(1), or (i)(1)— 17

‘‘(I) if sufficient information (as 18

specified by the Secretary) exists to 19

determine the median of the con-20

tracted rates recognized by all health 21

plans offered in the same line of busi-22

ness (as specified in subparagraph 23

(C)) by any group health plan for 24

such an item or service furnished in 25

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46 

•HR 5826 IH

such region by such a provider or fa-1

cility during such year using a data-2

base or other source of information 3

determined appropriate by the Sec-4

retary, such median; and 5

‘‘(II) if such sufficient informa-6

tion does not exist, the median of the 7

contracted rates recognized by all 8

health plans offered in the same line 9

of business (as specified in subpara-10

graph (C)) by any group health plan 11

for such an item or service furnished 12

in a similarly situated geographic re-13

gion (as determined by the Secretary) 14

with such sufficient information by 15

such a provider or facility during such 16

year using such a database or such 17

other source of information. 18

The Secretary shall develop a methodology 19

for determining a substitute rate based on 20

a similarly situated health plan that is not 21

a Federal health care program (as defined 22

in section 1128B(f) of the Social Security 23

Act) in the case a substitute rate is not 24

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47 

•HR 5826 IH

calculable under the previous sentence with 1

respect to an item or service. 2

‘‘(C) LINE OF BUSINESS.—A line of busi-3

ness specified in this subparagraph is one of the 4

following: 5

‘‘(i) The small group market. 6

‘‘(ii) The large group market. 7

‘‘(iii) In the case of a self-insured 8

group health plan, other self-insured group 9

health plans. 10

‘‘(D) REBASING YEAR DEFINED.—For pur-11

poses of subparagraph (A), the term ‘rebasing 12

year’ means 2027 and every 5 years thereafter. 13

‘‘(9) NONPARTICIPATING FACILITY; PARTICI-14

PATING FACILITY.— 15

‘‘(A) NONPARTICIPATING FACILITY.—The 16

term ‘nonparticipating facility’ means, with re-17

spect to an item or service and a health plan, 18

a health care facility described in subparagraph 19

(B)(ii) that does not have a contractual rela-20

tionship with the plan for furnishing such item 21

or service. 22

‘‘(B) PARTICIPATING FACILITY.— 23

‘‘(i) IN GENERAL.—The term ‘partici-24

pating facility’ means, with respect to an 25

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48 

•HR 5826 IH

item or service and a health plan, a health 1

care facility described in clause (ii) that 2

has a contractual relationship with the 3

plan for furnishing such item or service. 4

‘‘(ii) HEALTH CARE FACILITY DE-5

SCRIBED.—A health care facility described 6

in this clause is each of the following: 7

‘‘(I) A hospital (as defined in 8

1861(e) of the Social Security Act), 9

including an emergency department of 10

a hospital. 11

‘‘(II) A critical access hospital 12

(as defined in section 1861(mm)(1) of 13

such Act). 14

‘‘(III) An ambulatory surgical 15

center (as described in section 16

1833(i)(1)(A) of such Act). 17

‘‘(IV) A laboratory. 18

‘‘(V) A radiology facility or imag-19

ing center. 20

‘‘(VI) An independent free-21

standing emergency department. 22

‘‘(VII) Any other facility speci-23

fied by the Secretary. 24

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49 

•HR 5826 IH

‘‘(10) NONPARTICIPATING PROVIDERS; PARTICI-1

PATING PROVIDERS.— 2

‘‘(A) NONPARTICIPATING PROVIDER.—The 3

term ‘nonparticipating provider’ means, with re-4

spect to an item or service and a health plan, 5

a physician or other health care provider who 6

does not have a contractual relationship with 7

the plan for furnishing such item or service 8

under the plan. 9

‘‘(B) PARTICIPATING PROVIDER.—The 10

term ‘participating provider’ means, with re-11

spect to an item or service and a health plan, 12

a physician or other health care provider who 13

has a contractual relationship with the plan for 14

furnishing such item or service under the plan. 15

‘‘(11) OUT-OF-NETWORK RATE.—The term 16

‘out-of-network rate’ means, with respect to an item 17

or service furnished in a State during a year to a 18

participant or beneficiary of a health plan receiving 19

such item or service from a nonparticipating pro-20

vider or facility— 21

‘‘(A) subject to subparagraphs (C) and 22

(D), in the case such State has in effect a State 23

law that provides for a method for determining 24

the total amount payable under such health 25

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50 

•HR 5826 IH

plan regulated by such State with respect to 1

such item or service furnished by such provider 2

or facility, such amount determined in accord-3

ance with such law; 4

‘‘(B) subject to subparagraphs (C) and 5

(D), in the case such State does not have in ef-6

fect such a law with respect to such item or 7

service, plan, and provider or facility— 8

‘‘(i) subject to clause (ii), if the pro-9

vider or facility (as applicable) and such 10

plan agree on an amount of payment (in-11

cluding if agreed on through open negotia-12

tions under subsection (j)(1)) with respect 13

to such item or service, such agreed on 14

amount; or 15

‘‘(ii) if such provider or facility (as 16

applicable) and such plan enter the medi-17

ated dispute process under subsection (j) 18

and do not so agree before the date on 19

which a selected independent entity (as de-20

fined in paragraph (3) of such subsection) 21

makes a determination with respect to 22

such item or service under such subsection, 23

the amount of such determination; 24

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51 

•HR 5826 IH

‘‘(C) in the case such State has an All- 1

Payer Model Agreement under section 1115A of 2

the Social Security Act, the amount that the 3

State approves under such system for such item 4

or service so furnished; or 5

‘‘(D) in the case such health plan is a self- 6

insured group health plan and in the case of a 7

State with an agreement with such plan in ef-8

fect as of the date of the enactment of the Con-9

sumer Protections Against Surprise Medical 10

Bills Act of 2020, that provides for a method 11

for determining the total amount payable under 12

such health plan with respect to such item or 13

service furnished by such provider or facility, 14

such amount determined in accordance with 15

such method. 16

‘‘(12) RECOGNIZED AMOUNT.—The term ‘recog-17

nized amount’ means, with respect to an item or 18

service furnished in a State during a year to a par-19

ticipant or beneficiary of a health plan by a non-20

participating provider or nonparticipating facility— 21

‘‘(A) subject to subparagraphs (C) and 22

(D), in the case such State has in effect a law 23

described in paragraph (11)(A) with respect to 24

such item or service, provider or facility, and 25

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52 

•HR 5826 IH

plan, the amount determined in accordance with 1

such law; 2

‘‘(B) subject to subparagraphs (C) and 3

(D), in the case such State does not have in ef-4

fect such a law, an amount that is the median 5

contracted rate for such item or service for such 6

year; 7

‘‘(C) in the case such State is described in 8

paragraph (11)(C) with respect to such item or 9

service so furnished, the amount that the State 10

approves under such system for such item or 11

service so furnished; or 12

‘‘(D) in the case such health plan is a self- 13

insured group health plan and in the case of a 14

State with an agreement with such plan in ef-15

fect as of the date of the enactment of the Con-16

sumer Protections Against Surprise Medical 17

Bills Act of 2020, that provides for a method 18

for determining the total amount payable under 19

such health plan with respect to such item or 20

service furnished by such provider or facility, 21

such amount determined in accordance with 22

such method. 23

‘‘(13) STABILIZE.—The term ‘to stabilize’, with 24

respect to an emergency medical condition, has the 25

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•HR 5826 IH

meaning give in section 1867(e)(3)(A) of the Social 1

Security Act. 2

‘‘(14) COST-SHARING.—The term ‘cost-sharing’ 3

includes copayments, coinsurance, and deductibles. 4

‘‘(l) PAYMENT TO PROVIDER OR FACILITY.—In the 5

case of any payment required to be made by a health plan 6

pursuant to subsection (b)(1), (e)(1), or (i)(1) to a 7

nonparticiapting provider or nonparticipating facility for 8

an item or service, such payment shall be made to such 9

provider or facility and not to the individual receiving such 10

item or service.’’. 11

(2) CONFORMING AMENDMENTS.— 12

(A) APPLICATION PROVISIONS.—Section 13

9815(a) of the Internal Revenue Code of 1986 14

is amended— 15

(i) in paragraph (1), by striking ‘‘(as 16

amended by the Patient Protection and Af-17

fordable Care Act)’’ and inserting ‘‘(other 18

than, with respect to a plan year beginning 19

on or after January 1, 2022, the provisions 20

of section 2719A of such Act)’’; and 21

(ii) in paragraph (2), by inserting 22

‘‘(other than, with respect to a plan year 23

beginning on or after January 1, 2022, the 24

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54 

•HR 5826 IH

provisions of section 2719A of such Act)’’ 1

after the first occurrence of ‘‘such part A’’. 2

(B) APPLICATION TO RETIREE-ONLY 3

PLANS.—Section 9831(a) of the Internal Rev-4

enue Code of 1986 is amended by inserting 5

‘‘(other than, with respect to a group health 6

plan described in paragraph (2), the require-7

ments of section 9816)’’ before ‘‘shall not 8

apply’’. 9

(3) CLERICAL AMENDMENT.—The table of sec-10

tions for such subchapter is amended by adding at 11

the end the following new items: 12

‘‘Sec. 9815. Additional market reforms. 
‘‘Sec. 9816. Patient protections.’’. 

(4) EFFECTIVE DATE.—The amendments made 13

by this subsection shall apply with respect to plan 14

years beginning on or after January 1, 2022. 15

(c) EMPLOYEE RETIREMENT INCOME SECURITY ACT 16

OF 1974 AMENDMENTS.— 17

(1) IN GENERAL.—Subpart B of part 7 of sub-18

title B of title I of the Employee Retirement Income 19

Security Act of 1974 (29 U.S.C. 1185 et seq.) is 20

amended by adding at the end the following new sec-21

tion: 22

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•HR 5826 IH

‘‘SEC. 716. PATIENT PROTECTIONS. 1

‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If 2

a health plan requires or provides for designation by a par-3

ticipant or beneficiary of a participating primary care pro-4

vider, then the plan shall permit each participant or bene-5

ficiary to designate any participating primary care pro-6

vider who is available to accept such individual. 7

‘‘(b) COST-SHARING AND PAYMENT OF EMERGENCY 8

SERVICES.— 9

‘‘(1) IN GENERAL.—If a health plan provides or 10

covers any benefits with respect to services in an 11

emergency department of a hospital and, for plan 12

year 2022 or a subsequent plan year, with respect 13

to emergency services in an independent free-14

standing emergency department, the plan shall cover 15

emergency services— 16

‘‘(A) without the need for any prior au-17

thorization determination; 18

‘‘(B) whether the health care provider fur-19

nishing such services is a participating provider 20

or a participating facility that is an emergency 21

department of a hospital or an independent 22

freestanding emergency department (in this 23

subsection referred to as a ‘participating emer-24

gency facility’) with respect to such services; 25

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•HR 5826 IH

‘‘(C) in a manner so that, if such services 1

are provided to a participant or beneficiary by 2

a nonparticipating provider or a nonpartici-3

pating facility that is an emergency department 4

of a hospital or an independent freestanding 5

emergency department— 6

‘‘(i) such services will be provided 7

without imposing any requirement under 8

the plan for prior authorization of services 9

or any limitation on coverage that is more 10

restrictive than the requirements or limita-11

tions that apply to emergency services re-12

ceived from participating providers and 13

participating emergency facilities with re-14

spect to such plan; 15

‘‘(ii) the cost-sharing requirement is 16

not greater than the requirement that 17

would apply if such services were furnished 18

by a participating provider or a partici-19

pating emergency facility, as applicable; 20

‘‘(iii) such cost-sharing requirement is 21

calculated as if the contracted rate for 22

such services if furnished by a partici-23

pating provider or a participating emer-24

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57 

•HR 5826 IH

gency facility were equal to the recognized 1

amount for such services; 2

‘‘(iv) the health plan pays to such pro-3

vider or facility, respectively, the amount 4

by which the out-of-network rate for such 5

services exceeds the cost-sharing amount 6

for such services (as determined in accord-7

ance with clauses (ii) and (iii)); and 8

‘‘(v) any deductible or out-of-pocket 9

maximum that would apply if such services 10

were furnished by a participating provider 11

or a participating emergency facility shall 12

be the deductible or out-of-pocket max-13

imum that applies; and 14

‘‘(D) without regard to any other term or 15

condition of such coverage (other than exclusion 16

or coordination of benefits, or an affiliation or 17

waiting period, permitted under section 2704 of 18

the Public Health Service Act, including as in-19

corporated pursuant to section 715 and section 20

9815 of the Internal Revenue Code of 1986, 21

and other than applicable cost-sharing). 22

‘‘(2) AUDIT PROCESS AND RULEMAKING PROC-23

ESS FOR MEDIAN CONTRACTED RATES.— 24

‘‘(A) AUDIT PROCESS.— 25

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‘‘(i) IN GENERAL.—Not later than 1

July 1, 2021, the Secretary, in coordina-2

tion with the Secretary of Health and 3

Human Services and the Secretary of the 4

Treasury and in consultation with the Na-5

tional Association of Insurance Commis-6

sioners, shall establish through rulemaking 7

a process, in accordance with clause (ii), 8

under which health plans are audited by 9

the Secretary to ensure that— 10

‘‘(I) such plans are in compliance 11

with the requirement of applying a 12

median contracted rate under this sec-13

tion; and 14

‘‘(II) that such median con-15

tracted rate so applied satisfies the 16

definition under subsection (k)(8) 17

with respect to the year involved. 18

‘‘(ii) AUDIT SAMPLES.—Under the 19

process established pursuant to clause (i), 20

the Secretary— 21

‘‘(I) shall conduct audits de-22

scribed in such clause of a sample of 23

health plans; and 24

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‘‘(II) may audit any health plan 1

if the Secretary has received any com-2

plaint about such plan that involves 3

the compliance of the plan with the 4

requirement described in such clause. 5

‘‘(B) RULEMAKING.—Not later than July 6

1, 2021, the Secretary, in coordination with the 7

Secretary of the Treasury and the Secretary of 8

Health and Human Services, shall establish 9

through rulemaking— 10

‘‘(i) the methodology the sponsor or 11

issuer of a health plan shall use to deter-12

mine the median contracted rate, which 13

shall account for relevant payment adjust-14

ments that take into account facility type 15

that are otherwise taken into account for 16

purposes of determining payment amounts 17

with respect to participating facilities; and 18

‘‘(ii) the information such sponsor or 19

issuer shall share with the nonparticipating 20

provider involved when making such a de-21

termination. 22

‘‘(c) ACCESS TO PEDIATRIC CARE.— 23

‘‘(1) PEDIATRIC CARE.—In the case of a person 24

who has a child who is a participant or beneficiary 25

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under a health plan, if the plan requires or provides 1

for the designation of a participating primary care 2

provider for the child, the plan shall permit such 3

person to designate a physician (allopathic or osteo-4

pathic) who specializes in pediatrics as the child’s 5

primary care provider if such provider participates 6

in the network of the plan. 7

‘‘(2) CONSTRUCTION.—Nothing in paragraph 8

(1) shall be construed to waive any exclusions of cov-9

erage under the terms and conditions of the plan 10

with respect to coverage of pediatric care. 11

‘‘(d) PATIENT ACCESS TO OBSTETRICAL AND GYNE-12

COLOGICAL CARE.— 13

‘‘(1) GENERAL RIGHTS.— 14

‘‘(A) DIRECT ACCESS.—A health plan de-15

scribed in paragraph (2) may not require au-16

thorization or referral by the plan or any per-17

son (including a primary care provider de-18

scribed in paragraph (2)(B)) in the case of a fe-19

male participant or beneficiary who seeks cov-20

erage for obstetrical or gynecological care pro-21

vided by a participating health care professional 22

who specializes in obstetrics or gynecology. 23

Such professional shall agree to otherwise ad-24

here to such plan’s policies and procedures, in-25

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cluding procedures regarding referrals and ob-1

taining prior authorization and providing serv-2

ices pursuant to a treatment plan (if any) ap-3

proved by the plan. 4

‘‘(B) OBSTETRICAL AND GYNECOLOGICAL 5

CARE.—A health plan described in paragraph 6

(2) shall treat the provision of obstetrical and 7

gynecological care, and the ordering of related 8

obstetrical and gynecological items and services, 9

pursuant to the direct access described under 10

subparagraph (A), by a participating health 11

care professional who specializes in obstetrics or 12

gynecology as the authorization of the primary 13

care provider. 14

‘‘(2) APPLICATION OF PARAGRAPH.—A health 15

plan described in this paragraph is a health plan 16

that— 17

‘‘(A) provides coverage for obstetric or 18

gynecologic care; and 19

‘‘(B) requires the designation by a partici-20

pant or beneficiary of a participating primary 21

care provider. 22

‘‘(3) CONSTRUCTION.—Nothing in paragraph 23

(1) shall be construed to— 24

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‘‘(A) waive any exclusions of coverage 1

under the terms and conditions of the plan with 2

respect to coverage of obstetrical or gyneco-3

logical care; or 4

‘‘(B) preclude the health plan involved 5

from requiring that the obstetrical or gyneco-6

logical provider notify the primary care health 7

care professional or the plan of treatment deci-8

sions. 9

‘‘(k) DEFINITIONS.—For purposes of this section: 10

‘‘(1) CONTRACTED RATE.—The term ‘con-11

tracted rate’ means, with respect to a health plan 12

and a health care provider or health care facility fur-13

nishing an item or service to a beneficiary or partici-14

pant of such plan, the agreed upon total payment 15

amount (inclusive of any cost-sharing) to such pro-16

vider or facility for such item or service. 17

‘‘(2) DURING A VISIT.—The term ‘during a 18

visit’ shall, with respect to an individual who is fur-19

nished items and services at a participating facility, 20

include equipment and devices, telemedicine services, 21

imaging services, laboratory services, preoperative 22

and postoperative services, and such other items and 23

services as the Secretary may specify furnished to 24

such individual, regardless of whether or not the 25

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provider furnishing such items or services is at the 1

facility. 2

‘‘(3) EMERGENCY DEPARTMENT OF A HOS-3

PITAL.—The term ‘emergency department of a hos-4

pital’ includes a hospital outpatient department that 5

provides emergency services. 6

‘‘(4) EMERGENCY MEDICAL CONDITION.—The 7

term ‘emergency medical condition’ means a medical 8

condition manifesting itself by acute symptoms of 9

sufficient severity (including severe pain) such that 10

a prudent layperson, who possesses an average 11

knowledge of health and medicine, could reasonably 12

expect the absence of immediate medical attention to 13

result in a condition described in clause (i), (ii), or 14

(iii) of section 1867(e)(1)(A) of the Social Security 15

Act. 16

‘‘(5) EMERGENCY SERVICES.— 17

‘‘(A) IN GENERAL.—The term ‘emergency 18

services’, with respect to an emergency medical 19

condition, means— 20

‘‘(i) a medical screening examination 21

(as required under section 1867 of the So-22

cial Security Act, or as would be required 23

under such section if such section applied 24

to an independent freestanding emergency 25

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department) that is within the capability of 1

the emergency department of a hospital or 2

of an independent freestanding emergency 3

department, as applicable, including ancil-4

lary services routinely available to the 5

emergency department to evaluate such 6

emergency medical condition; and 7

‘‘(ii) within the capabilities of the 8

staff and facilities available at the hospital 9

or the independent freestanding emergency 10

department, as applicable, such further 11

medical examination and treatment as are 12

required under section 1867 of such Act, 13

or as would be required under such section 14

if such section applied to an independent 15

freestanding emergency department, to 16

stabilize the patient (regardless of the de-17

partment of the hospital in which such fur-18

ther examination or treatment is fur-19

nished). 20

‘‘(B) INCLUSION OF ADDITIONAL SERV-21

ICES.—In the case of an individual enrolled in 22

a health plan who is furnished services de-23

scribed in subparagraph (A) by a provider or 24

hospital or independent freestanding emergency 25

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department to stabilize such individual with re-1

spect to an emergency medical condition, the 2

term ‘emergency services’ shall include, in addi-3

tion to those described in subparagraph (A), 4

items and services furnished as part of out-5

patient observation or an inpatient or out-6

patient stay during a visit in which such indi-7

vidual is so stabilized with respect to such 8

emergency condition if— 9

‘‘(i) such items and services would 10

otherwise be covered under such plan if 11

furnished by a participating provider or 12

participating facility; and 13

‘‘(ii) such items and services are fur-14

nished— 15

‘‘(I) to maintain, improve, or re-16

solve the individual’s stabilization with 17

respect to such condition, unless any 18

circumstance described in subpara-19

graph (C) has occurred with respect 20

to such individual before such items 21

and services are furnished; or 22

‘‘(II) for any purpose not de-23

scribed in subclause (I), unless each 24

of the criteria described in subpara-25

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66 

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graph (D) have been met with respect 1

to such individual and such item or 2

service. 3

‘‘(C) CIRCUMSTANCES.—For purposes of 4

subparagraph (B)(ii)(I), a circumstance de-5

scribed in this subparagraph is any of the fol-6

lowing, with respect to an individual who is a 7

beneficiary, participant, or enrollee of a health 8

plan who is furnished services described in sub-9

paragraph (A) by a hospital or independent 10

freestanding emergency department with re-11

spect to an emergency medical condition: 12

‘‘(i) A participating provider, with re-13

spect to such plan, with privileges at the 14

hospital or independent freestanding emer-15

gency department assumes responsibility 16

for the care of the individual. 17

‘‘(ii) A participating provider, with re-18

spect to such plan, assumes responsibility 19

for the care of the individual through 20

transfer of the individual. 21

‘‘(iii) The health plan and the pro-22

vider treating such individual at the hos-23

pital or independent freestanding emer-24

gency department for such condition reach 25

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67 

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an agreement concerning the care for the 1

individual. 2

‘‘(iv) The individual is discharged. 3

‘‘(D) SIGNED NOTICE CRITERIA.—For pur-4

poses of subparagraph (B)(ii)(II), the criteria 5

described in this subparagraph, with respect to 6

an individual and an item or service furnished 7

by a nonparticipating provider or nonpartici-8

pating facility that is a hospital or an inde-9

pendent freestanding emergency department, 10

are the following: 11

‘‘(i) A written notice (as specified by 12

the Secretary and in a clear and under-13

standable manner) is provided by such pro-14

vider or facility to such individual, before 15

such item or service is furnished, that in-16

cludes the following information: 17

‘‘(I) That such provider or facil-18

ity is a nonparticipating provider or 19

nonparticipating facility (as applica-20

ble). 21

‘‘(II) To the extent practicable, 22

the estimated amount that such non-23

participating facility or nonpartici-24

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68 

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pating provider may charge the indi-1

vidual for such item or service. 2

‘‘(III) A statement that the indi-3

vidual may seek such item or service 4

from a provider that is a participating 5

provider or a hospital or independent 6

freestanding emergency department 7

that is a participating facility and a 8

list, if feasible, of participating facili-9

ties or participating providers, as ap-10

plicable, who are able to furnish such 11

item or service. 12

‘‘(ii) Such individual is in a condition 13

to receive (as determined in accordance 14

with guidance issued by the Secretary) the 15

information described in clause (i) and to 16

confirm notice of receipt of such notice, in 17

accordance with applicable State law. 18

‘‘(iii) The individual signs and dates 19

such notice confirming receipt of the notice 20

before such item or service is furnished. 21

‘‘(6) HEALTH PLAN.—The term ‘health plan’ 22

means a group health plan and health insurance cov-23

erage offered by a health insurance issuer in the 24

group market and includes a grandfathered health 25

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69 

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plan (as defined in section 1251(e) of the Patient 1

Protection and Affordable Care Act) that is such a 2

plan or coverage. 3

‘‘(7) INDEPENDENT FREESTANDING EMER-4

GENCY DEPARTMENT.—The term ‘independent free-5

standing emergency department’ means a health 6

care facility that— 7

‘‘(A) is geographically separate and dis-8

tinct and licensed separately from a hospital 9

under applicable State law; and 10

‘‘(B) provides emergency services. 11

‘‘(8) MEDIAN CONTRACTED RATE.— 12

‘‘(A) IN GENERAL.—Subject to subpara-13

graph (B), the term ‘median contracted rate’ 14

means, with respect to a health plan— 15

‘‘(i) for an item or service furnished 16

during 2022, the median of the contracted 17

rates recognized by the sponsor or issuer 18

of such plan (determined with respect to 19

all such plans of such sponsor or such 20

issuer that are within the same line of 21

business (as specified in subparagraph (C)) 22

as the plan involved) as the total maximum 23

payment under such plans in 2019 for the 24

same or a similar item or service that is 25

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provided by a provider or facility in the 1

same or similar specialty and provided in 2

the geographic region (established (and up-3

dated, as appropriate) by the Secretary, in 4

consultation with the National Association 5

of Insurance Commissioners) in which the 6

item or service is furnished, consistent with 7

the methodology established by the Sec-8

retary under subsection (b)(2)(B), in-9

creased by the percentage increase in the 10

consumer price index for all urban con-11

sumers (United States city average) over 12

2019, 2020, and 2021; 13

‘‘(ii) for an item or service furnished 14

during 2023 or a subsequent year through 15

2026, the median contracted rate for the 16

previous year, increased by the percentage 17

increase in the consumer price index for all 18

urban consumers (United States city aver-19

age) over such previous year; 20

‘‘(iii) for an item or service furnished 21

during a rebasing year (as defined in sub-22

paragraph (D)), the median of the con-23

tracted rates recognized by the sponsor or 24

issuer of such plan (determined with re-25

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spect to all such plans of such sponsor or 1

issuer that are within the same line of 2

business (as specified in subparagraph (C)) 3

as the plan involved) as the total maximum 4

payment under such plans in such year for 5

the same or a similar item or service that 6

is provided by a provider or facility in the 7

same or similar specialty and provided in 8

the geographic region (as established pur-9

suant to clause (i)) in which the item or 10

service is furnished, consistent with the 11

methodology established by the Secretary 12

under subsection (b)(2)(B); and 13

‘‘(iv) for an item or service furnished 14

during any of the 4 years following a re-15

basing year, the median contracted rate for 16

the previous year, increased by the per-17

centage increase in the consumer price 18

index for all urban consumers (United 19

States city average) over such previous 20

year. 21

‘‘(B) USE OF SUBSTITUTE RATE IN CASE 22

OF INSUFFICIENT DATA.— 23

‘‘(i) IN GENERAL.—In the case the 24

sponsor or issuer of a health plan has in-25

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sufficient information (as specified by the 1

Secretary) to calculate the median of the 2

contracted rates in accordance with sub-3

paragraph (A) for a year for an item or 4

service furnished in a particular geographic 5

region (as established pursuant to subpara-6

graph (A)(i)) by a type of provider or facil-7

ity, the substitute rate (as defined in 8

clause (ii)) for such item or service shall be 9

deemed to be the median contracted rate 10

for such item or service furnished in such 11

region during such year by such a provider 12

or facility for such year under such sub-13

paragraph (A) for such plan. 14

‘‘(ii) SUBSTITUTE RATE.—For pur-15

poses of clause (i), the term ‘substitute 16

rate’ means, with respect to an item or 17

service furnished by a provider or facility 18

in a geographic region (established pursu-19

ant to subparagraph (A)(i)) during a year 20

for which a health plan is required to make 21

payment pursuant to subsection (b)(1), 22

(e)(1), or (i)(1)— 23

‘‘(I) if sufficient information (as 24

specified by the Secretary) exists to 25

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73 

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determine the median of the con-1

tracted rates recognized by all health 2

plans offered in the same line of busi-3

ness (as specified in subparagraph 4

(C)) by any group health plan for 5

such an item or service furnished in 6

such region by such a provider or fa-7

cility during such year using a data-8

base or other source of information 9

determined appropriate by the Sec-10

retary, such median; and 11

‘‘(II) if such sufficient informa-12

tion does not exist, the median of the 13

contracted rates recognized by all 14

health plans offered in the same line 15

of business (as specified in subpara-16

graph (C)) by any group health plan 17

for such an item or service furnished 18

in a similarly situated geographic re-19

gion (as determined by the Secretary) 20

with such sufficient information by 21

such a provider or facility during such 22

year using such a database or such 23

other source of information. 24

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The Secretary shall develop a methodology 1

for determining a substitute rate based on 2

a similarly situated health plan that is not 3

a Federal health care program (as defined 4

in section 1128B(f) of the Social Security 5

Act) in the case a substitute rate is not 6

calculable under the previous sentence with 7

respect to an item or service. 8

‘‘(C) LINE OF BUSINESS.—A line of busi-9

ness specified in this subparagraph is one of the 10

following: 11

‘‘(i) The small group market. 12

‘‘(ii) The large group market. 13

‘‘(iii) In the case of a self-insured 14

group health plan, other self-insured group 15

health plans. 16

‘‘(D) REBASING YEAR DEFINED.—For pur-17

poses of subparagraph (A), the term ‘rebasing 18

year’ means 2027 and every 5 years thereafter. 19

‘‘(9) NONPARTICIPATING FACILITY; PARTICI-20

PATING FACILITY.— 21

‘‘(A) NONPARTICIPATING FACILITY.—The 22

term ‘nonparticipating facility’ means, with re-23

spect to an item or service and a health plan, 24

a health care facility described in subparagraph 25

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75 

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(B)(ii) that does not have a contractual rela-1

tionship with the plan for furnishing such item 2

or service. 3

‘‘(B) PARTICIPATING FACILITY.— 4

‘‘(i) IN GENERAL.—The term ‘partici-5

pating facility’ means, with respect to an 6

item or service and a health plan, a health 7

care facility described in clause (ii) that 8

has a contractual relationship with the 9

plan for furnishing such item or service. 10

‘‘(ii) HEALTH CARE FACILITY DE-11

SCRIBED.—A health care facility described 12

in this clause is each of the following: 13

‘‘(I) A hospital (as defined in 14

1861(e) of the Social Security Act), 15

including an emergency department of 16

a hospital. 17

‘‘(II) A critical access hospital 18

(as defined in section 1861(mm)(1) of 19

such Act). 20

‘‘(III) An ambulatory surgical 21

center (as described in section 22

1833(i)(1)(A) of such Act). 23

‘‘(IV) A laboratory. 24

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76 

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‘‘(V) A radiology facility or imag-1

ing center. 2

‘‘(VI) An independent free-3

standing emergency department. 4

‘‘(VII) Any other facility speci-5

fied by the Secretary. 6

‘‘(10) NONPARTICIPATING PROVIDERS; PARTICI-7

PATING PROVIDERS.— 8

‘‘(A) NONPARTICIPATING PROVIDER.—The 9

term ‘nonparticipating provider’ means, with re-10

spect to an item or service and a health plan, 11

a physician or other health care provider who 12

does not have a contractual relationship with 13

the plan for furnishing such item or service 14

under the plan. 15

‘‘(B) PARTICIPATING PROVIDER.—The 16

term ‘participating provider’ means, with re-17

spect to an item or service and a health plan, 18

a physician or other health care provider who 19

has a contractual relationship with the plan for 20

furnishing such item or service under the plan. 21

‘‘(11) OUT-OF-NETWORK RATE.—The term 22

‘out-of-network rate’ means, with respect to an item 23

or service furnished in a State during a year to a 24

participant or beneficiary of a health plan receiving 25

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such item or service from a nonparticipating pro-1

vider or facility— 2

‘‘(A) subject to subparagraphs (C) and 3

(D), in the case such State has in effect a State 4

law that provides for a method for determining 5

the total amount payable under such health 6

plan regulated by such State with respect to 7

such item or service furnished by such provider 8

or facility, such amount determined in accord-9

ance with such law; 10

‘‘(B) subject to subparagraphs (C) and 11

(D), in the case such State does not have in ef-12

fect such a law with respect to such item or 13

service, plan, and provider or facility— 14

‘‘(i) subject to clause (ii), if the pro-15

vider or facility (as applicable) and such 16

plan agree on an amount of payment (in-17

cluding if agreed on through open negotia-18

tions under subsection (j)(1)) with respect 19

to such item or service, such agreed on 20

amount; or 21

‘‘(ii) if such provider or facility (as 22

applicable) and such plan enter the medi-23

ated dispute process under subsection (j) 24

and do not so agree before the date on 25

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which a selected independent entity (as de-1

fined in paragraph (3) of such subsection) 2

makes a determination with respect to 3

such item or service under such subsection, 4

the amount of such determination; 5

‘‘(C) in the case such State has an All- 6

Payer Model Agreement under section 1115A of 7

the Social Security Act, the amount that the 8

State approves under such system for such item 9

or service so furnished; or 10

‘‘(D) in the case such health plan is a self- 11

insured group health plan and in the case of a 12

State with an agreement with such plan in ef-13

fect as of the date of the enactment of the Con-14

sumer Protections Against Surprise Medical 15

Bills Act of 2020, that provides for a method 16

for determining the total amount payable under 17

such health plan with respect to such item or 18

service furnished by such provider or facility, 19

such amount determined in accordance with 20

such method. 21

‘‘(12) RECOGNIZED AMOUNT.—The term ‘recog-22

nized amount’ means, with respect to an item or 23

service furnished in a State during a year to a par-24

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ticipant or beneficiary of a health plan by a non-1

participating provider or nonparticipating facility— 2

‘‘(A) subject to subparagraphs (C) and 3

(D), in the case such State has in effect a law 4

described in paragraph (11)(A) with respect to 5

such item or service, provider or facility, and 6

plan, the amount determined in accordance with 7

such law; 8

‘‘(B) subject to subparagraphs (C) and 9

(D), in the case such State does not have in ef-10

fect such a law, an amount that is the median 11

contracted rate for such item or service for such 12

year; 13

‘‘(C) in the case such State is described in 14

paragraph (11)(C) with respect to such item or 15

service so furnished, the amount that the State 16

approves under such system for such item or 17

service so furnished; or 18

‘‘(D) in the case such health plan is a self- 19

insured group health plan and in the case of a 20

State with an agreement with such plan in ef-21

fect as of the date of the enactment of the Con-22

sumer Protections Against Surprise Medical 23

Bills Act of 2020, that provides for a method 24

for determining the total amount payable under 25

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such health plan with respect to such item or 1

service furnished by such provider or facility, 2

such amount determined in accordance with 3

such method. 4

‘‘(13) STABILIZE.—The term ‘to stabilize’, with 5

respect to an emergency medical condition, has the 6

meaning give in section 1867(e)(3)(A) of the Social 7

Security Act). 8

‘‘(14) COST-SHARING.—The term ‘cost-sharing’ 9

includes copayments, coinsurance, and deductibles. 10

‘‘(l) PAYMENT TO PROVIDER OR FACILITY.—In the 11

case of any payment required to be made by a health plan 12

pursuant to subsection (b)(1), (e)(1), or (i)(1) to a 13

nonparticiapting provider or nonparticipating facility for 14

an item or service, such payment shall be made to such 15

provider or facility and not to the individual receiving such 16

item or service.’’. 17

(2) CONFORMING AMENDMENT.— 18

(A) APPLICATION PROVISIONS.—Section 19

715(a) of the Employee Retirement Income Se-20

curity Act of 1974 (29 U.S.C. 1185d(a)) is 21

amended— 22

(i) in paragraph (1), by striking ‘‘(as 23

amended by the Patient Protection and Af-24

fordable Care Act)’’ and inserting ‘‘(other 25

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than, with respect to a plan year beginning 1

on or after January 1, 2022, the provisions 2

of section 2719A of such Act)’’; and 3

(ii) in paragraph (2), by inserting 4

‘‘(other than, with respect to a plan year 5

beginning on or after January 1, 2022, the 6

provisions of section 2719A of such Act)’’ 7

after the first occurrence of ‘‘such part A’’. 8

(B) APPLICATION TO RETIREE-ONLY 9

PLANS.—Section 732(a) of the Employee Re-10

tirement Income Security Act of 1974 (29 11

U.S.C. 1191a(a)) is amended by striking ‘‘sec-12

tion 711’’ and inserting ‘‘sections 711 and 13

716’’. 14

(3) CLERICAL AMENDMENT.—The table of con-15

tents in section 1 of the Employee Retirement In-16

come Security Act of 1974 is amended by inserting 17

after the item relating to section 714 the following 18

new items: 19

‘‘Sec. 715. Additional market reforms. 
‘‘Sec. 716. Patient protections.’’. 

(4) EFFECTIVE DATE.—The amendments made 20

by this subsection shall apply with respect to plan 21

years beginning on or after January 1, 2022. 22

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SEC. 3. CONSUMER PROTECTIONS THROUGH REQUIRE-1

MENTS ON HEALTH PLANS TO PREVENT SUR-2

PRISE MEDICAL BILLS FOR NON-EMERGENCY 3

SERVICES PERFORMED BY NONPARTICI-4

PATING PROVIDERS AT CERTAIN PARTICI-5

PATING FACILITIES. 6

(a) PHSA AMENDMENTS.— 7

(1) IN GENERAL.—Section 2719A of the Public 8

Health Service Act (42 U.S.C. 300gg–19a), as 9

amended by section 2(a), is further amended by in-10

serting before subsection (k) the following new sub-11

section: 12

‘‘(e) COST-SHARING AND PAYMENT OF NON-EMER-13

GENCY SERVICES PERFORMED BY NONPARTICIPATING 14

PROVIDERS AT CERTAIN PARTICIPATING FACILITIES.— 15

‘‘(1) IN GENERAL.—Subject to paragraph (2), 16

in the case of items or services (other than emer-17

gency services to which subsection (b) applies or 18

items and services to which subsection (i) applies) 19

furnished to a participant, beneficiary, or enrollee of 20

a health plan by a nonparticipating provider during 21

a visit (as defined by the Secretary in accordance 22

with subsection (k)(2)) at a participating facility, if 23

such items and services would otherwise be covered 24

under such plan if furnished by a participating pro-25

vider, the plan— 26

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‘‘(A) shall not impose on such participant, 1

beneficiary, or enrollee a cost-sharing amount 2

for such items and services so furnished that is 3

greater than the cost-sharing amount that 4

would apply under such plan had such items or 5

services been furnished by a participating pro-6

vider; 7

‘‘(B) shall calculate such cost-sharing 8

amount as if the contracted rate for such serv-9

ices if furnished by a participating provider 10

were equal to the recognized amount for such 11

items and services; 12

‘‘(C) shall pay to such provider furnishing 13

such items and services to such participant, 14

beneficiary, or enrollee the amount by which the 15

out-of-network rate for such items and services 16

exceeds the cost-sharing amount imposed under 17

the plan for such items and services (as deter-18

mined in accordance with subparagraphs (A) 19

and (B)); and 20

‘‘(D) shall apply the deductible or out-of- 21

pocket maximum, if any, that would apply if 22

such services were furnished by a participating 23

provider. 24

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‘‘(2) EXCEPTION.—Paragraph (1) shall not 1

apply to a health plan in the case of items or serv-2

ices furnished to a participant, beneficiary, or en-3

rollee of a health plan by a nonparticipating provider 4

during a visit (as so defined by the Secretary in ac-5

cordance with subsection (k)(2)) at a participating 6

facility if the requirement described in paragraph (1) 7

of section 1150C(b) of the Social Security Act does 8

not apply with respect to such provider and such 9

items and services due to the application of para-10

graph (2) of such section.’’. 11

(2) EFFECTIVE DATE.—The amendment made 12

by paragraph (1) shall apply with respect to plan 13

years beginning on or after January 1, 2022. 14

(b) IRC AMENDMENTS.— 15

(1) IN GENERAL.—Section 9816 of the Internal 16

Revenue Code of 1986, as added by section 2(b), is 17

amended by inserting before subsection (k) the fol-18

lowing new subsection: 19

‘‘(e) COST-SHARING AND PAYMENT OF NON-EMER-20

GENCY SERVICES PERFORMED BY NONPARTICIPATING 21

PROVIDERS AT CERTAIN PARTICIPATING FACILITIES.— 22

‘‘(1) IN GENERAL.—Subject to paragraph (2), 23

in the case of items or services (other than emer-24

gency services to which subsection (b) applies or 25

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items and services to which subsection (i) applies) 1

furnished to a participant or beneficiary of a health 2

plan by a nonparticipating provider during a visit 3

(as defined by the Secretary in accordance with sub-4

section (k)(2)) at a participating facility, if such 5

items and services would otherwise be covered under 6

such plan if furnished by a participating provider, 7

the plan— 8

‘‘(A) shall not impose on such participant 9

or beneficiary a cost-sharing amount for such 10

items and services so furnished that is greater 11

than the cost-sharing amount that would apply 12

under such plan had such items or services been 13

furnished by a participating provider; 14

‘‘(B) shall calculate such cost-sharing 15

amount as if the contracted rate for such serv-16

ices if furnished by a participating provider 17

were equal to the recognized amount for such 18

items and services; 19

‘‘(C) shall pay to such provider furnishing 20

such items and services to such participant or 21

beneficiary the amount by which the out-of-net-22

work rate for such items and services exceeds 23

the cost-sharing amount imposed under the 24

plan for such items and services (as determined 25

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86 

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in accordance with subparagraphs (A) and (B)); 1

and 2

‘‘(D) shall apply the deductible or out-of- 3

pocket maximum, if any, that would apply if 4

such services were furnished by a participating 5

provider. 6

‘‘(2) EXCEPTION.—Paragraph (1) shall not 7

apply to a health plan in the case of items or serv-8

ices furnished to a participant or beneficiary of a 9

health plan by a nonparticipating provider during a 10

visit (as so defined by the Secretary in accordance 11

with subsection (k)(2)) at a participating facility if 12

the requirement described in paragraph (1) of sec-13

tion 1150C(b) of the Social Security Act does not 14

apply with respect to such provider and such items 15

and services due to the application of paragraph (2) 16

of such section.’’. 17

(2) EFFECTIVE DATE.—The amendments made 18

by paragraph (1) shall apply with respect to plan 19

years beginning on or after January 1, 2022. 20

(c) ERISA AMENDMENTS.— 21

(1) IN GENERAL.—Section 716 of the Employee 22

Retirement Income Security Act of 1974, as added 23

by section 2(c), is amended by inserting before sub-24

section (k) the following new subsection: 25

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‘‘(e) COST-SHARING AND PAYMENT OF NON-EMER-1

GENCY SERVICES PERFORMED BY NONPARTICIPATING 2

PROVIDERS AT CERTAIN PARTICIPATING FACILITIES.— 3

‘‘(1) IN GENERAL.—Subject to paragraph (2), 4

in the case of items or services (other than emer-5

gency services to which subsection (b) applies or 6

items and services to which subsection (i) applies) 7

furnished to a participant or beneficiary of a health 8

plan by a nonparticipating provider during a visit 9

(as defined by the Secretary in accordance with sub-10

section (k)(2)) at a participating facility, if such 11

items and services would otherwise be covered under 12

such plan if furnished by a participating provider, 13

the plan— 14

‘‘(A) shall not impose on such participant 15

or beneficiary a cost-sharing amount for such 16

items and services so furnished that is greater 17

than the cost-sharing amount that would apply 18

under such plan had such items or services been 19

furnished by a participating provider; 20

‘‘(B) shall calculate such cost-sharing 21

amount as if the contracted rate for such serv-22

ices if furnished by a participating provider 23

were equal to the recognized amount for such 24

items and services; 25

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‘‘(C) shall pay to such provider furnishing 1

such items and services to such participant or 2

beneficiary the amount by which the out-of-net-3

work rate for such items and services exceeds 4

the cost-sharing amount imposed under the 5

plan for such items and services (as determined 6

in accordance with subparagraphs (A) and (B)); 7

and 8

‘‘(D) shall apply the deductible or out-of- 9

pocket maximum, if any, that would apply if 10

such services were furnished by a participating 11

provider. 12

‘‘(2) EXCEPTION.—Paragraph (1) shall not 13

apply to a health plan in the case of items or serv-14

ices furnished to a participant or beneficiary of a 15

health plan by a nonparticipating provider during a 16

visit (as so defined by the Secretary in accordance 17

with subsection (k)(2)) at a participating facility if 18

the requirement described in paragraph (1) of sec-19

tion 1150C(b) of the Social Security Act does not 20

apply with respect to such provider and such items 21

and services due to the application of paragraph (2) 22

of such section.’’. 23

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(2) EFFECTIVE DATE.—The amendments made 1

by paragraph (1) shall apply with respect to plan 2

years beginning on or after January 1, 2022. 3

SEC. 4. CONSUMER PROTECTIONS THROUGH APPLICATION 4

OF HEALTH PLAN EXTERNAL REVIEW IN 5

CASES OF CERTAIN SURPRISE MEDICAL 6

BILLS. 7

Section 2719(b)(1) of the Public Health Service Act 8

(42 U.S.C. 300gg–19(b)(1)) is amended— 9

(1) by striking ‘‘at a minimum, includes’’ and 10

inserting ‘‘at a minimum— 11

‘‘(A) includes’’; 12

(2) by striking at the end ‘‘or’’ and inserting 13

‘‘and’’; and 14

(3) by adding at the end the following new sub-15

paragraph: 16

‘‘(B) beginning not later than January 1, 17

2022, applies such external review process with 18

respect to any adverse determination by such 19

plan or issuer under subsection (b) of section 20

2719A, subsection (e) of such section, or sub-21

section (i) of such section, including with re-22

spect to whether an item or service that is the 23

subject to such a determination is an item or 24

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service to which such subsection (b), (e), or (i) 1

applies; or’’. 2

SEC. 5. CONSUMER PROTECTIONS THROUGH HEALTH PLAN 3

TRANSPARENCY REQUIREMENTS. 4

(a) PHSA AMENDMENTS.—Section 2719A of the 5

Public Health Service Act (42 U.S.C. 300gg–19a), as 6

amended by sections 2(a) and 3(a), is further amended 7

by inserting before subsection (k) the following new sub-8

sections: 9

‘‘(f) PROVIDER DIRECTORY REQUIREMENTS.— 10

‘‘(1) IN GENERAL.—Beginning not later than 11

January 1, 2022, each health plan shall— 12

‘‘(A) establish the verification process de-13

scribed in paragraph (2); 14

‘‘(B) establish the response protocol de-15

scribed in paragraph (3); 16

‘‘(C) establish the database described in 17

paragraph (4); and 18

‘‘(D) include in any directory (other than 19

the database described in subparagraph (C)) 20

containing provider directory information with 21

respect to such plan the information described 22

in paragraph (5). 23

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‘‘(2) VERIFICATION PROCESS.—The verification 1

process described in this paragraph is, with respect 2

to a health plan, a process— 3

‘‘(A) under which such plan verifies and 4

updates the provider directory information in-5

cluded on the database described in paragraph 6

(4) of such plan of— 7

‘‘(i) not less frequently than once 8

every 90 days, a random sample of at least 9

10 percent of health care providers and 10

health care facilities included in such data-11

base; and 12

‘‘(ii) any such provider or such facility 13

included in such database that has not 14

submitted any claim to such plan during a 15

12-month period; 16

‘‘(B) that establishes a procedure for the 17

removal from such database of such a provider 18

or facility with respect to which such plan has 19

been unable to verify such information during a 20

period specified by the plan; and 21

‘‘(C) that provides for the update of such 22

database within 2 business days of such plan 23

receiving from such a provider or facility infor-24

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mation pursuant to section 1150D of the Social 1

Security Act. 2

‘‘(3) RESPONSE PROTOCOL.—The response pro-3

tocol described in this paragraph is, in the case of 4

an individual enrolled in a health plan who requests 5

information through a telephone call or email on 6

whether a health care provider or health care facility 7

has a contractual relationship to furnish items and 8

services under such plan, a protocol under which 9

such plan— 10

‘‘(A) responds to such individual as soon 11

as practicable, and in no case later than 1 busi-12

ness day after such call or email is received, 13

through a written electronic or paper (as re-14

quested by such individual) communication; and 15

‘‘(B) retains such communication in such 16

individual’s file for at least 2 years following 17

such response. 18

‘‘(4) DATABASE.—The database described in 19

this paragraph is, with respect to a health plan, a 20

database on the public website of such plan or issuer 21

that contains— 22

‘‘(A) a list of each health care provider and 23

health care facility with which such plan has a 24

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contractual relationship for furnishing items 1

and services under such plan; and 2

‘‘(B) provider directory information with 3

respect to each such provider and facility. 4

‘‘(5) INFORMATION.—The information de-5

scribed in this paragraph is, with respect to a direc-6

tory containing provider directory information with 7

respect to a health plan, a notification that such in-8

formation contained in such directory was accurate 9

as of the date of publication of such directory and 10

that an individual enrolled under such plan should 11

consult the database described in paragraph (4) with 12

respect to such plan or contact such plan to obtain 13

the most current provider directory information with 14

respect to such plan. 15

‘‘(6) DEFINITION.—For purposes of this sec-16

tion, the term ‘provider directory information’ in-17

cludes, with respect to a health plan, the name, ad-18

dress, specialty, and telephone number of each 19

health care provider or health care facility with 20

which such plan has a contractual relationship for 21

furnishing items and services under such plan. 22

‘‘(g) DISCLOSURE ON PATIENT PROTECTIONS 23

AGAINST BALANCE BILLING.—Beginning not later than 24

January 1, 2022, each health plan shall make publicly 25

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available, post on a website of such plan available to indi-1

viduals enrolled under such plan, and include on each ex-2

planation of benefits for an item or service with respect 3

to which the requirements under subsection (b), (e), or 4

(i) applies— 5

‘‘(1) information in plain language on— 6

‘‘(A) the requirements and prohibitions ap-7

plied under section 1150C of the Social Secu-8

rity Act (relating to prohibitions on balance bill-9

ing in certain circumstances); 10

‘‘(B) if provided for under applicable State 11

law, any other requirements on providers and 12

facilities regarding the amounts such providers 13

and facilities may, with respect to an item or 14

service, charge a participant, beneficiary, or en-15

rollee of such plan with respect to which such 16

a provider is a nonparticipating provider or fa-17

cility is a nonparticipating facility, with respect 18

to such plan, for furnishing such item or service 19

after receiving payment from the plan for such 20

item or service and any applicable cost-sharing 21

payment from such participant, beneficiary, or 22

enrollee; and 23

‘‘(C) the requirements applied under sub-24

sections (b), (e), and (i); and 25

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‘‘(2) information in plain language on con-1

tacting appropriate State and Federal agencies in 2

the case that an individual believes that such a 3

health plan, provider, or facility has violated any re-4

quirement described in paragraph (1) with respect to 5

such individual.’’. 6

(b) IRC AMENDMENTS.—Section 9816 of the Inter-7

nal Revenue Code of 1986, as added by section 2(b) and 8

amended by section 3(b), is further amended by inserting 9

before subsection (k) the following new subsections: 10

‘‘(f) PROVIDER DIRECTORY REQUIREMENTS.— 11

‘‘(1) IN GENERAL.—Beginning not later than 12

January 1, 2022, each health plan shall— 13

‘‘(A) establish the verification process de-14

scribed in paragraph (2); 15

‘‘(B) establish the response protocol de-16

scribed in paragraph (3); 17

‘‘(C) establish the database described in 18

paragraph (4); and 19

‘‘(D) include in any directory (other than 20

the database described in subparagraph (C)) 21

containing provider directory information with 22

respect to such plan the information described 23

in paragraph (5). 24

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‘‘(2) VERIFICATION PROCESS.—The verification 1

process described in this paragraph is, with respect 2

to a health plan, a process— 3

‘‘(A) under which such plan verifies and 4

updates the provider directory information in-5

cluded on the database described in paragraph 6

(4) of such plan of— 7

‘‘(i) not less frequently than once 8

every 90 days, a random sample of at least 9

10 percent of health care providers and 10

health care facilities included in such data-11

base; and 12

‘‘(ii) any such provider or such facility 13

included in such database that has not 14

submitted any claim to such plan during a 15

12-month period; 16

‘‘(B) that establishes a procedure for the 17

removal from such database of such a provider 18

or facility with respect to which such plan has 19

been unable to verify such information during a 20

period specified by the plan; and 21

‘‘(C) that provides for the update of such 22

database within 2 business days of such plan 23

receiving from such a provider or facility infor-24

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•HR 5826 IH

mation pursuant to section 1150D of the Social 1

Security Act. 2

‘‘(3) RESPONSE PROTOCOL.—The response pro-3

tocol described in this paragraph is, in the case of 4

an individual enrolled in a health plan who requests 5

information through a telephone call or email on 6

whether a health care provider or health care facility 7

has a contractual relationship to furnish items and 8

services under such plan, a protocol under which 9

such plan— 10

‘‘(A) responds to such individual as soon 11

as practicable, and in no case later than 1 busi-12

ness day after such call or email is received, 13

through a written electronic or paper (as re-14

quested by such individual) communication; and 15

‘‘(B) retains such communication in such 16

individual’s file for at least 2 years following 17

such response. 18

‘‘(4) DATABASE.—The database described in 19

this paragraph is, with respect to a health plan, a 20

database on the public website of such plan or issuer 21

that contains— 22

‘‘(A) a list of each health care provider and 23

health care facility with which such plan has a 24

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98 

•HR 5826 IH

contractual relationship for furnishing items 1

and services under such plan; and 2

‘‘(B) provider directory information with 3

respect to each such provider and facility. 4

‘‘(5) INFORMATION.—The information de-5

scribed in this paragraph is, with respect to a direc-6

tory containing provider directory information with 7

respect to a health plan, a notification that such in-8

formation contained in such directory was accurate 9

as of the date of publication of such directory and 10

that an individual enrolled under such plan should 11

consult the database described in paragraph (4) with 12

respect to such plan or contact such plan to obtain 13

the most current provider directory information with 14

respect to such plan. 15

‘‘(6) DEFINITION.—For purposes of this sec-16

tion, the term ‘provider directory information’ in-17

cludes, with respect to a health plan, the name, ad-18

dress, specialty, and telephone number of each 19

health care provider or health care facility with 20

which such plan has a contractual relationship for 21

furnishing items and services under such plan. 22

‘‘(g) DISCLOSURE ON PATIENT PROTECTIONS 23

AGAINST BALANCE BILLING.—Beginning not later than 24

January 1, 2022, each health plan shall make publicly 25

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99 

•HR 5826 IH

available, post on a website of such plan available to indi-1

viduals enrolled under such plan, and include on each ex-2

planation of benefits for an item or service with respect 3

to which the requirements under subsection (b), (e), or 4

(i) applies— 5

‘‘(1) information in plain language on— 6

‘‘(A) the requirements and prohibitions ap-7

plied under section 1150C of the Social Secu-8

rity Act (relating to prohibitions on balance bill-9

ing in certain circumstances); 10

‘‘(B) if provided for under applicable State 11

law, any other requirements on providers and 12

facilities regarding the amounts such providers 13

and facilities may, with respect to an item or 14

service, charge a participant or beneficiary of 15

such plan with respect to which such a provider 16

is a nonparticipating provider or facility is a 17

nonparticipating facility, with respect to such 18

plan, for furnishing such item or service after 19

receiving payment from the plan for such item 20

or service and any applicable cost-sharing pay-21

ment from such participant or beneficiary; and 22

‘‘(C) the requirements applied under sub-23

sections (b), (e), and (i); and 24

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100 

•HR 5826 IH

‘‘(2) information in plain language on con-1

tacting appropriate State and Federal agencies in 2

the case that an individual believes that such a 3

health plan, provider, or facility has violated any re-4

quirement described in paragraph (1) with respect to 5

such individual.’’. 6

(c) ERISA AMENDMENTS.—Section 716 of the Em-7

ployee Retirement Income Security Act of 1974, as added 8

by section 2(c) and amended by section 3(c), is further 9

amended by inserting before subsection (k) the following 10

new subsections: 11

‘‘(f) PROVIDER DIRECTORY REQUIREMENTS.— 12

‘‘(1) IN GENERAL.—Beginning not later than 13

January 1, 2022, each health plan shall— 14

‘‘(A) establish the verification process de-15

scribed in paragraph (2); 16

‘‘(B) establish the response protocol de-17

scribed in paragraph (3); 18

‘‘(C) establish the database described in 19

paragraph (4); and 20

‘‘(D) include in any directory (other than 21

the database described in subparagraph (C)) 22

containing provider directory information with 23

respect to such plan the information described 24

in paragraph (5). 25

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101 

•HR 5826 IH

‘‘(2) VERIFICATION PROCESS.—The verification 1

process described in this paragraph is, with respect 2

to a health plan, a process— 3

‘‘(A) under which such plan verifies and 4

updates the provider directory information in-5

cluded on the database described in paragraph 6

(4) of such plan of— 7

‘‘(i) not less frequently than once 8

every 90 days, a random sample of at least 9

10 percent of health care providers and 10

health care facilities included in such data-11

base; and 12

‘‘(ii) any such provider or such facility 13

included in such database that has not 14

submitted any claim to such plan during a 15

12-month period; 16

‘‘(B) that establishes a procedure for the 17

removal from such database of such a provider 18

or facility with respect to which such plan has 19

been unable to verify such information during a 20

period specified by the plan; and 21

‘‘(C) that provides for the update of such 22

database within 2 business days of such plan 23

receiving from such a provider or facility infor-24

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•HR 5826 IH

mation pursuant to section 1150D of the Social 1

Security Act. 2

‘‘(3) RESPONSE PROTOCOL.—The response pro-3

tocol described in this paragraph is, in the case of 4

an individual enrolled in a health plan who requests 5

information through a telephone call or email on 6

whether a health care provider or health care facility 7

has a contractual relationship to furnish items and 8

services under such plan, a protocol under which 9

such plan— 10

‘‘(A) responds to such individual as soon 11

as practicable, and in no case later than 1 busi-12

ness day after such call or email is received, 13

through a written electronic or paper (as re-14

quested by such individual) communication; and 15

‘‘(B) retains such communication in such 16

individual’s file for at least 2 years following 17

such response. 18

‘‘(4) DATABASE.—The database described in 19

this paragraph is, with respect to a health plan, a 20

database on the public website of such plan or issuer 21

that contains— 22

‘‘(A) a list of each health care provider and 23

health care facility with which such plan has a 24

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103 

•HR 5826 IH

contractual relationship for furnishing items 1

and services under such plan; and 2

‘‘(B) provider directory information with 3

respect to each such provider and facility. 4

‘‘(5) INFORMATION.—The information de-5

scribed in this paragraph is, with respect to a direc-6

tory containing provider directory information with 7

respect to a health plan, a notification that such in-8

formation contained in such directory was accurate 9

as of the date of publication of such directory and 10

that an individual enrolled under such plan should 11

consult the database described in paragraph (4) with 12

respect to such plan or contact such plan to obtain 13

the most current provider directory information with 14

respect to such plan. 15

‘‘(6) DEFINITION.—For purposes of this sec-16

tion, the term ‘provider directory information’ in-17

cludes, with respect to a health plan, the name, ad-18

dress, specialty, and telephone number of each 19

health care provider or health care facility with 20

which such plan has a contractual relationship for 21

furnishing items and services under such plan. 22

‘‘(g) DISCLOSURE ON PATIENT PROTECTIONS 23

AGAINST BALANCE BILLING.—Beginning not later than 24

January 1, 2022, each health plan shall make publicly 25

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104 

•HR 5826 IH

available, post on a website of such plan available to indi-1

viduals enrolled under such plan, and include on each ex-2

planation of benefits for an item or service with respect 3

to which the requirements under subsection (b), (e), or 4

(i) applies— 5

‘‘(1) information in plain language on— 6

‘‘(A) the requirements and prohibitions ap-7

plied under section 1150C of the Social Secu-8

rity Act (relating to prohibitions on balance bill-9

ing in certain circumstances); 10

‘‘(B) if provided for under applicable State 11

law, any other requirements on providers and 12

facilities regarding the amounts such providers 13

and facilities may, with respect to an item or 14

service, charge a participant or beneficiary of 15

such plan with respect to which such a provider 16

is a nonparticipating provider or facility is a 17

nonparticipating facility, with respect to such 18

plan, for furnishing such item or service after 19

receiving payment from the plan for such item 20

or service and any applicable cost-sharing pay-21

ment from such participant or beneficiary; and 22

‘‘(C) the requirements applied under sub-23

sections (b), (e), and (i); and 24

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‘‘(2) information in plain language on con-1

tacting appropriate State and Federal agencies in 2

the case that an individual believes that such a 3

health plan, provider, or facility has violated any re-4

quirement described in paragraph (1) with respect to 5

such individual.’’. 6

SEC. 6. CONSUMER PROTECTIONS THROUGH HEALTH PLAN 7

REQUIREMENT FOR FAIR AND HONEST AD-8

VANCE COST ESTIMATE. 9

(a) PHSA AMENDMENT.—Section 2719A of the Pub-10

lic Health Service Act (42 U.S.C. 300gg–19a), as amend-11

ed by sections 2(a), 3(a), and 5(a), is further amended 12

by inserting before subsection (k) the following new sub-13

sections: 14

‘‘(h) ADVANCED EXPLANATION OF BENEFITS.—Be-15

ginning on January 1, 2022, each health plan shall, with 16

respect to a notification submitted under section 17

1150D(b)(2)(A) of the Social Security Act by a health 18

care provider or health care facility, respectively, to the 19

health plan for a participant, beneficiary, or enrollee under 20

such health plan scheduled to receive an item or service 21

from the provider or facility, not later than 1 business day 22

(or, in the case such item or service was so scheduled at 23

least 10 business days before such item or service is to 24

be furnished (or in the case such notification was made 25

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106 

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pursuant to a request by such participant, beneficiary, or 1

enrollee), 3 business days) after the date on which the 2

health plan receives such notification, provide to the par-3

ticipant, beneficiary, or enrollee (through mail or elec-4

tronic means, as requested by the participant, beneficiary, 5

or enrollee) a notification (in clear and understandable 6

language) including the following: 7

‘‘(1) Whether or not the provider or facility is 8

a participating provider or a participating facility 9

with respect to the health plan with respect to the 10

furnishing of such item or service and— 11

‘‘(A) in the case the provider or facility is 12

a participating provider or facility with respect 13

to the health plan with respect to the furnishing 14

of such item or service, the contracted rate 15

under such plan for such item or service; and 16

‘‘(B) in the case the provider or facility is 17

a nonparticipating provider or facility with re-18

spect to such plan, a description of how such 19

individual may obtain information on providers 20

and facilities that, with respect to such health 21

plan, are participating providers and facilities. 22

‘‘(2) The good faith estimate included in the 23

notification received from the provider or facility. 24

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107 

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‘‘(3) A good faith estimate of the amount the 1

health plan is responsible for paying for items and 2

services included in the estimate described in para-3

graph (2). 4

‘‘(4) A good faith estimate of the amount of 5

any cost-sharing (including with respect to the de-6

ductible and any copayment or coinsurance obliga-7

tion) for which the participant, beneficiary, or en-8

rollee would be responsible for such item or service 9

(as of the date of such notification). 10

‘‘(5) A good faith estimate of the amount that 11

the participant, beneficiary, or enrollee has incurred 12

toward meeting the limit of the financial responsi-13

bility (including with respect to deductibles and out- 14

of-pocket maximums) under the health plan (as of 15

the date of such notification). 16

‘‘(6) In the case such item or service is subject 17

to a medical management technique (including con-18

current review, prior authorization, and step-therapy 19

or fail-first protocols) for coverage under the health 20

plan, a disclaimer that coverage for such item or 21

service is subject to such medical management tech-22

nique. 23

‘‘(7) A disclaimer that the information provided 24

in the notification is only an estimate based on the 25

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items and services reasonably expected, at the time 1

of scheduling (or requesting) the item or service, to 2

be furnished and is subject to change. 3

‘‘(8) A statement that the individual may seek 4

such an item or service from a provider that is a 5

participating provider or a facility that is a partici-6

pating facility and a list of participating facilities, or 7

of participating providers, as applicable, who are 8

able to furnish such items and services involved. 9

‘‘(9) Any other information or disclaimer the 10

health plan determines appropriate that is consistent 11

with information and disclaimers required under this 12

section. 13

‘‘(i) COST-SHARING AND PAYMENT FOR SERVICES 14

PROVIDED BASED ON RELIANCE ON INCORRECT PRO-15

VIDER NETWORK INFORMATION.— 16

‘‘(1) IN GENERAL.—For plan years beginning 17

on or after January 1, 2022, in the case of an item 18

or service furnished to a participant, beneficiary, or 19

enrollee of a health plan by a nonparticipating pro-20

vider or a nonparticipating facility, if such item or 21

service would otherwise be covered under such plan 22

if furnished by a participating provider or partici-23

pating facility and if either of the criteria described 24

in paragraph (2) applies with respect to such partici-25

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109 

•HR 5826 IH

pant, beneficiary, or enrollee and item or service, the 1

plan— 2

‘‘(A) shall not impose on such enrollee a 3

cost-sharing amount for such item or service so 4

furnished that is greater than the cost-sharing 5

amount that would apply under such plan had 6

such item or service been furnished by a partici-7

pating provider; 8

‘‘(B) shall calculate such cost-sharing 9

amount as if the contracted rate for such item 10

or service furnished by such a participating pro-11

vider or facility were equal to— 12

‘‘(i) the most recent (as of the date 13

such item or service was furnished) con-14

tracted rate in effect between such pro-15

vider or facility and such plan for such 16

item or service furnished under such plan, 17

if any; or 18

‘‘(ii) if no contracted rate described in 19

clause (i) exists, the recognized amount for 20

such item or service; 21

‘‘(C) shall pay to such nonparticipating 22

provider or facility furnishing such item or serv-23

ice to such participant, beneficiary, or enrollee 24

the amount by which— 25

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110 

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‘‘(i) if a contracted rate described in 1

subparagraph (B)(i) exists, the most re-2

cent (as of the date such item or services 3

was furnished) such rate; or 4

‘‘(ii) if no contracted rate described in 5

such subparagraph exists, the out-of-net-6

work rate; 7

for such items and services exceeds the cost- 8

sharing amount imposed under the plan for 9

such items and services (as determined in ac-10

cordance with subparagraphs (A) and (B)); and 11

‘‘(D) shall apply the deductible or out-of- 12

pocket maximum, if any, that would apply if 13

such services were furnished by a participating 14

provider or a participating facility. 15

‘‘(2) CRITERIA DESCRIBED.—For purposes of 16

paragraph (1), the criteria described in this para-17

graph, with respect to an item or service furnished 18

to a participant, beneficiary, or enrollee of a health 19

plan by a nonparticipating provider or a nonpartici-20

pating facility, are the following: 21

‘‘(A) The participant, beneficiary, or en-22

rollee received a notification under subsection 23

(h) with respect to such item and service to be 24

furnished and such notification provided infor-25

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mation that the provider was a participating 1

provider or facility was a participating facility, 2

with respect to the plan for furnishing such 3

item or service. 4

‘‘(B) A notification was not provided, in 5

accordance with subsection (h), to the partici-6

pant, beneficiary, or enrollee, and the partici-7

pant, beneficiary, or enrollee requested through 8

the response protocol of the plan under sub-9

section (f)(3) information on whether the pro-10

vider was a participating provider or facility 11

was a participating facility with respect to the 12

plan for furnishing such item or service and 13

was informed through such protocol that the 14

provider was such a participating provider or 15

facility was such a participating facility.’’. 16

(b) IRC AMENDMENTS.—Section 9816 of the Inter-17

nal Revenue Code of 1986, as added by section 2(b) and 18

amended by sections 3(b) and 5(b), is further amended 19

by inserting before subsection (k) the following new sub-20

sections: 21

‘‘(h) ADVANCED EXPLANATION OF BENEFITS.—Be-22

ginning on January 1, 2022, each health plan shall, with 23

respect to a notification submitted under section 24

1150D(b)(2)(A) of the Social Security Act by a health 25

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112 

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care provider or health care facility, respectively, to the 1

health plan for a participant or beneficiary under such 2

health plan scheduled to receive an item or service from 3

the provider or facility, not later than 1 business day (or, 4

in the case such item or service was so scheduled at least 5

10 business days before such item or service is to be fur-6

nished (or in the case such notification was made pursuant 7

to a request by such participant or beneficiary), 3 business 8

days) after the date on which the health plan receives such 9

notification, provide to the participant or beneficiary 10

(through mail or electronic means, as requested by the 11

participant or beneficiary) a notification (in clear and 12

understable language) including the following: 13

‘‘(1) Whether or not the provider or facility is 14

a participating provider or a participating facility 15

with respect to the health plan with respect to the 16

furnishing of such item or service and— 17

‘‘(A) in the case the provider or facility is 18

a participating provider or facility with respect 19

to the health plan with respect to the furnishing 20

of such item or service, the contracted rate 21

under such plan for such item or service; and 22

‘‘(B) in the case the provider or facility is 23

a nonparticipating provider or facility with re-24

spect to such plan, a description of how such 25

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113 

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individual may obtain information on providers 1

and facilities that, with respect to such health 2

plan, are participating providers and facilities. 3

‘‘(2) The good faith estimate included in the 4

notification received from the provider or facility. 5

‘‘(3) A good faith estimate of the amount the 6

health plan is responsible for paying for items and 7

services included in the estimate described in para-8

graph (2). 9

‘‘(4) A good faith estimate of the amount of 10

any cost-sharing (including with respect to the de-11

ductible and any copayment or coinsurance obliga-12

tion) for which the participant or beneficiary would 13

be responsible for such item or service (as of the 14

date of such notification). 15

‘‘(5) A good faith estimate of the amount that 16

the participant or beneficiary has incurred toward 17

meeting the limit of the financial responsibility (in-18

cluding with respect to deductibles and out-of-pocket 19

maximums) under the health plan (as of the date of 20

such notification). 21

‘‘(6) In the case such item or service is subject 22

to a medical management technique (including con-23

current review, prior authorization, and step-therapy 24

or fail-first protocols) for coverage under the health 25

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114 

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plan, a disclaimer that coverage for such item or 1

service is subject to such medical management tech-2

nique. 3

‘‘(7) A disclaimer that the information provided 4

in the notification is only an estimate based on the 5

items and services reasonably expected, at the time 6

of scheduling (or requesting) the item or service, to 7

be furnished and is subject to change. 8

‘‘(8) A statement that the individual may seek 9

such an item or service from a provider that is a 10

participating provider or a facility that is a partici-11

pating facility and a list of participating facilities, or 12

of participating providers, as applicable, who are 13

able to furnish such items and services involved. 14

‘‘(9) Any other information or disclaimer the 15

health plan determines appropriate that is consistent 16

with information and disclaimers required under this 17

section. 18

‘‘(i) COST-SHARING AND PAYMENT FOR SERVICES 19

PROVIDED BASED ON RELIANCE ON INCORRECT PRO-20

VIDER NETWORK INFORMATION.— 21

‘‘(1) IN GENERAL.—For plan years beginning 22

on or after January 1, 2022, in the case of an item 23

or service furnished to a participant or beneficiary of 24

a health plan by a nonparticipating provider or a 25

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nonparticipating facility, if such item or service 1

would otherwise be covered under such plan if fur-2

nished by a participating provider or participating 3

facility and if either of the criteria described in para-4

graph (2) applies with respect to such participant or 5

beneficiary and item or service, the plan— 6

‘‘(A) shall not impose on such enrollee a 7

cost-sharing amount for such item or service so 8

furnished that is greater than the cost-sharing 9

amount that would apply under such plan had 10

such item or service been furnished by a partici-11

pating provider; 12

‘‘(B) shall calculate such cost-sharing 13

amount as if the contracted rate for such item 14

or service furnished by such a participating pro-15

vider or facility were equal to— 16

‘‘(i) the most recent (as of the date 17

such item or service was furnished) con-18

tracted rate in effect between such pro-19

vider or facility and such plan for such 20

item or service furnished under such plan, 21

if any; or 22

‘‘(ii) if no contracted rate described in 23

clause (i) exists, the recognized amount for 24

such item or service; 25

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‘‘(C) shall pay to such nonparticipating 1

provider or facility furnishing such item or serv-2

ice to such participant or beneficiary the 3

amount by which— 4

‘‘(i) if a contracted rate described in 5

subparagraph (B)(i) exists, the most re-6

cent (as of the date such item or services 7

was furnished) such rate; or 8

‘‘(ii) if no contracted rate described in 9

such subparagraph exists, the out-of-net-10

work rate; 11

for such items and services exceeds the cost- 12

sharing amount imposed under the plan for 13

such items and services (as determined in ac-14

cordance with subparagraphs (A) and (B)); and 15

‘‘(D) shall apply the deductible or out-of- 16

pocket maximum, if any, that would apply if 17

such services were furnished by a participating 18

provider or a participating facility. 19

‘‘(2) CRITERIA DESCRIBED.—For purposes of 20

paragraph (1), the criteria described in this para-21

graph, with respect to an item or service furnished 22

to a participant or beneficiary of a health plan by 23

a nonparticipating provider or a nonparticipating fa-24

cility, are the following: 25

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‘‘(A) The participant or beneficiary re-1

ceived a notification under subsection (h) with 2

respect to such item and service to be furnished 3

and such notification provided information that 4

the provider was a participating provider or fa-5

cility was a participating facility, with respect 6

to the plan for furnishing such item or service. 7

‘‘(B) A notification was not provided, in 8

accordance with subsection (h), to the partici-9

pant or beneficiary and the participant or bene-10

ficiary requested through the response protocol 11

of the plan under subsection (f)(3) information 12

on whether the provider was a participating 13

provider or facility was a participating facility 14

with respect to the plan for furnishing such 15

item or service and was informed through such 16

protocol that the provider was such a partici-17

pating provider or facility was such a partici-18

pating facility.’’. 19

(c) ERISA AMENDMENTS.—Section 716 of the Em-20

ployee Retirement Income Security Act of 1974, as added 21

by section 2(c) and amended by sections 3(c) and 5(c), 22

is further amended by inserting before subsection (k) the 23

following new subsections: 24

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‘‘(h) ADVANCED EXPLANATION OF BENEFITS.—Be-1

ginning on January 1, 2022, each health plan shall, with 2

respect to a notification submitted under section 3

1150D(b)(2)(A) of the Social Security Act by a health 4

care provider or health care facility, respectively, to the 5

health plan for a participant or beneficiary under such 6

health plan scheduled to receive an item or service from 7

the provider or facility, not later than 1 business day (or, 8

in the case such item or service was so scheduled at least 9

10 business days before such item or service is to be fur-10

nished (or in the case such notification was made pursuant 11

to a request by such participant or beneficiary), 3 business 12

days) after the date on which the health plan receives such 13

notification, provide to the participant or beneficiary 14

(through mail or electronic means, as requested by the 15

participant or beneficiary) a notification (in clear and un-16

derstandable language) including the following: 17

‘‘(1) Whether or not the provider or facility is 18

a participating provider or a participating facility 19

with respect to the health plan with respect to the 20

furnishing of such item or service and— 21

‘‘(A) in the case the provider or facility is 22

a participating provider or facility with respect 23

to the health plan with respect to the furnishing 24

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•HR 5826 IH

of such item or service, the contracted rate 1

under such plan for such item or service; and 2

‘‘(B) in the case the provider or facility is 3

a nonparticipating provider or facility with re-4

spect to such plan, a description of how such 5

individual may obtain information on providers 6

and facilities that, with respect to such health 7

plan, are participating providers and facilities. 8

‘‘(2) The good faith estimate included in the 9

notification received from the provider or facility. 10

‘‘(3) A good faith estimate of the amount the 11

health plan is responsible for paying for items and 12

services included in the estimate described in para-13

graph (2). 14

‘‘(4) A good faith estimate of the amount of 15

any cost-sharing (including with respect to the de-16

ductible and any copayment or coinsurance obliga-17

tion) for which the participant or beneficiary would 18

be responsible for such item or service (as of the 19

date of such notification). 20

‘‘(5) A good faith estimate of the amount that 21

the participant or beneficiary has incurred toward 22

meeting the limit of the financial responsibility (in-23

cluding with respect to deductibles and out-of-pocket 24

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maximums) under the health plan (as of the date of 1

such notification). 2

‘‘(6) In the case such item or service is subject 3

to a medical management technique (including con-4

current review, prior authorization, and step-therapy 5

or fail-first protocols) for coverage under the health 6

plan, a disclaimer that coverage for such item or 7

service is subject to such medical management tech-8

nique. 9

‘‘(7) A disclaimer that the information provided 10

in the notification is only an estimate based on the 11

items and services reasonably expected, at the time 12

of scheduling (or requesting) the item or service, to 13

be furnished and is subject to change. 14

‘‘(8) A statement that the individual may seek 15

such an item or service from a provider that is a 16

participating provider or a facility that is a partici-17

pating facility and a list of participating facilities, or 18

of participating providers, as applicable, who are 19

able to furnish such items and services involved. 20

‘‘(9) Any other information or disclaimer the 21

health plan determines appropriate that is consistent 22

with information and disclaimers required under this 23

section. 24

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‘‘(i) COST-SHARING AND PAYMENT FOR SERVICES 1

PROVIDED BASED ON RELIANCE ON INCORRECT PRO-2

VIDER NETWORK INFORMATION.— 3

‘‘(1) IN GENERAL.—For plan years beginning 4

on or after January 1, 2022, in the case of an item 5

or service furnished to a participant or beneficiary of 6

a health plan by a nonparticipating provider or a 7

nonparticipating facility, if such item or service 8

would otherwise be covered under such plan if fur-9

nished by a participating provider or participating 10

facility and if either of the criteria described in para-11

graph (2) applies with respect to such participant or 12

beneficiary and item or service, the plan— 13

‘‘(A) shall not impose on such enrollee a 14

cost-sharing amount for such item or service so 15

furnished that is greater than the cost-sharing 16

amount that would apply under such plan had 17

such item or service been furnished by a partici-18

pating provider; 19

‘‘(B) shall calculate such cost-sharing 20

amount as if the contracted rate for such item 21

or service furnished by such a participating pro-22

vider or facility were equal to— 23

‘‘(i) the most recent (as of the date 24

such item or service was furnished) con-25

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tracted rate in effect between such pro-1

vider or facility and such plan for such 2

item or service furnished under such plan, 3

if any; or 4

‘‘(ii) if no contracted rate described in 5

clause (i) exists, the recognized amount for 6

such item or service; 7

‘‘(C) shall pay to such nonparticipating 8

provider or facility furnishing such item or serv-9

ice to such participant or beneficiary the 10

amount by which— 11

‘‘(i) if a contracted rate described in 12

subparagraph (B)(i) exists, the most re-13

cent (as of the date such item or services 14

was furnished) such rate; or 15

‘‘(ii) if no contracted rate described in 16

such subparagraph exists, the out-of-net-17

work rate; 18

for such items and services exceeds the cost- 19

sharing amount imposed under the plan for 20

such items and services (as determined in ac-21

cordance with subparagraphs (A) and (B)); and 22

‘‘(D) shall apply the deductible or out-of- 23

pocket maximum, if any, that would apply if 24

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such services were furnished by a participating 1

provider or a participating facility. 2

‘‘(2) CRITERIA DESCRIBED.—For purposes of 3

paragraph (1), the criteria described in this para-4

graph, with respect to an item or service furnished 5

to a participant or beneficiary of a health plan by 6

a nonparticipating provider or a nonparticipating fa-7

cility, are the following: 8

‘‘(A) The participant or beneficiary re-9

ceived a notification under subsection (h) with 10

respect to such item and service to be furnished 11

and such notification provided information that 12

the provider was a participating provider or fa-13

cility was a participating facility, with respect 14

to the plan for furnishing such item or service. 15

‘‘(B) A notification was not provided, in 16

accordance with subsection (h), to the partici-17

pant or beneficiary and the participant or bene-18

ficiary requested through the response protocol 19

of the plan under subsection (f)(3) information 20

on whether the provider was a participating 21

provider or facility was a participating facility 22

with respect to the plan for furnishing such 23

item or service and was informed through such 24

protocol that the provider was such a partici-25

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124 

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pating provider or facility was such a partici-1

pating facility.’’. 2

SEC. 7. DETERMINATION THROUGH OPEN NEGOTIATION 3

AND MEDIATION OF OUT-OF-NETWORK RATES 4

TO BE PAID BY HEALTH PLANS. 5

(a) PHSA AMENDMENT.—Section 2719A of the Pub-6

lic Health Service Act (42 U.S.C. 300gg–19a), as amend-7

ed by sections 2(a), 3(a), 5(a), and 6(a), is further amend-8

ed by inserting before subsection (k) the following new 9

subsection: 10

‘‘(j) DETERMINATION OF OUT-OF-NETWORK RATES 11

TO BE PAID BY HEALTH PLANS.— 12

‘‘(1) DETERMINATION THROUGH OPEN NEGO-13

TIATION.— 14

‘‘(A) IN GENERAL.—With respect to an 15

item or service furnished in a year by a non-16

participating provider or a nonparticipating fa-17

cility, with respect to a health plan, in a State 18

described in subparagraph (B) of subsection 19

(k)(11) with respect to such plan and provider 20

or facility, and for which a payment is required 21

to be made by the health plan pursuant to sub-22

section (b)(1), (e)(1), or (i)(1), the provider or 23

facility (as applicable) or plan may, during the 24

30-day period beginning on the day the provider 25

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125 

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or facility receives a response from the plan re-1

garding a claim for payment for such item or 2

service, initiate open negotiations under this 3

paragraph between such provider or facility and 4

plan for purposes of determining, during the 5

open negotiation period, an amount agreed on 6

by such provider or facility, respectively, and 7

such plan for payment (including any cost-shar-8

ing) for such item or service. For purposes of 9

this subsection, the open negotiation period, 10

with respect to an item or service, is the 30-day 11

period beginning on the date of initiation of the 12

negotiations with respect to such item or serv-13

ice. 14

‘‘(B) EXCHANGE OF INFORMATION.—In 15

carrying out negotiations initiated under sub-16

paragraph (A), with respect to an item or serv-17

ice described in such subparagraph furnished in 18

a year, not later than the fifth business day of 19

the open negotiation period described in such 20

subparagraph with respect to such item or serv-21

ice— 22

‘‘(i) the health plan that is party to 23

such negotiations shall notify the provider 24

or facility that is party to such negotia-25

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126 

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tions of the median contracted rate for 1

such item or service and year; and 2

‘‘(ii) such provider or facility shall no-3

tify such health plan of— 4

‘‘(I) the median of the total 5

amount of reimbursement (including 6

any cost-sharing) paid, for the most 7

recent year for which information is 8

available, to such provider or facility 9

for furnishing such item or service to 10

a participant, beneficiary, or enrollee 11

of a health plan that, at the time such 12

item or service was furnished, had a 13

contract in effect with such provider 14

or facility with respect to the fur-15

nishing of such item or service; 16

‘‘(II) in the case that information 17

described in subclause (I) is not avail-18

able, such information as specified by 19

the Secretary; and 20

‘‘(III) any additional information 21

specified by the Secretary. 22

‘‘(C) ACCESSING MEDIATED DISPUTE 23

PROCESS IN CASE OF FAILED NEGOTIATIONS.— 24

In the case of open negotiations pursuant to 25

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127 

•HR 5826 IH

subparagraph (A), with respect to an item or 1

service, that do not result in a determination of 2

an amount of payment for such item or service 3

by the last day of the open negotiation period 4

described in such subparagraph with respect to 5

such item or service, the provider or facility (as 6

applicable) or health plan that was party to 7

such negotiations may, during the 2-day period 8

beginning on the day after such open negotia-9

tion period, initiate the mediated dispute proc-10

ess under paragraph (2) with respect to such 11

item or service. The mediated dispute process 12

shall be initiated by a party pursuant to the 13

previous sentence by submission to the other 14

party and to the Secretary of a notification 15

(containing such information as specified by the 16

Secretary) and for purposes of this subsection, 17

the date of initiation of such process shall be 18

the date of such submission or such other date 19

specified by the Secretary pursuant to regula-20

tions that is not later than the date of receipt 21

of such notification by both the other party and 22

the Secretary. 23

‘‘(2) MEDIATED DISPUTE PROCESS AVAILABLE 24

IN CASE OF FAILED OPEN NEGOTIATIONS.— 25

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128 

•HR 5826 IH

‘‘(A) ESTABLISHMENT.—Not later than 1

July 1, 2021, the Secretary, in coordination 2

with the Secretary of the Treasury and the Sec-3

retary of Labor, shall establish a process (in 4

this subsection referred to as the ‘mediated dis-5

pute process’) under which, in the case of an 6

item or service with respect to which a provider 7

or facility (as applicable) or health plan submits 8

a notification under paragraph (1)(C) (in this 9

subsection referred to as a ‘qualified mediated 10

dispute item or service’), an entity selected 11

under paragraph (3) determines, subject to sub-12

paragraph (B) and in accordance with the suc-13

ceeding provisions of this subsection, the 14

amount of payment under the health plan for 15

such item or service furnished by such provider 16

or facility. 17

‘‘(B) AUTHORITY TO CONTINUE NEGOTIA-18

TIONS.—Under the mediated dispute process, in 19

the case that the parties to a determination for 20

a qualified mediated dispute item or service 21

agree on a payment amount for such item or 22

service during such process but before the date 23

on which the entity selected with respect to 24

such determination under paragraph (3) makes 25

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129 

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such determination, such amount shall be treat-1

ed for purposes of subsection (k)(11)(B) as the 2

amount agreed to by such parties for such item 3

or service. In the case of an agreement de-4

scribed in the previous sentence, the mediated 5

dispute process shall provide for a method to 6

determine how to allocate between the parties 7

to such determination the payment of the com-8

pensation of the entity selected with respect to 9

such determination. 10

‘‘(3) SELECTION UNDER MEDIATED DISPUTE 11

PROCESS.—Under the mediated dispute process, the 12

Secretary shall, with respect to the determination of 13

the amount of payment under this subsection of a 14

qualified mediated dispute item or service, provide 15

for a method— 16

‘‘(A) that allows the parties to such deter-17

mination to jointly select, not later than the last 18

day of the 3-day period following the date of 19

the initiation of the process with respect to such 20

item or service, for purposes of making such de-21

termination, an entity certified under paragraph 22

(7) that— 23

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‘‘(i) is not a party to such determina-1

tion or an employee or agent of such a 2

party; 3

‘‘(ii) does not have a material familial, 4

financial, or professional relationship with 5

such a party; and 6

‘‘(iii) does not otherwise have a con-7

flict of interest with such a party (as de-8

termined by the Secretary); and 9

‘‘(B) that requires, in the case such parties 10

do not make such selection by such last day, 11

the Secretary to, not later than 6 days after 12

such date of initiation— 13

‘‘(i) select such an entity that satisfies 14

clauses (i) through (iii) of subparagraph 15

(A); and 16

‘‘(ii) provide notification of such selec-17

tion to the provider or facility (as applica-18

ble) and the health plan party to such de-19

termination. 20

An entity selected pursuant to the previous sentence 21

to make a determination described in such sentence 22

shall be referred to in this subsection as the ‘selected 23

independent entity’ with respect to such determina-24

tion. 25

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‘‘(4) TREATMENT OF CONSIDERATION OF MUL-1

TIPLE ITEMS AND SERVICES.— 2

‘‘(A) IN GENERAL.—Under the mediated 3

dispute process, the Secretary shall specify cri-4

teria under which multiple qualified mediated 5

dispute items and services are permitted to be 6

considered jointly as part of a single determina-7

tion by an entity for purposes of encouraging 8

the efficiency (including minimizing costs) of 9

the mediated dispute process. Such items and 10

services may be so considered only if— 11

‘‘(i) such items and services to be in-12

cluded in such determination are furnished 13

by the same provider or facility; 14

‘‘(ii) payment for such items and serv-15

ices is required to be made by the same 16

health plan; and 17

‘‘(iii) such items and services are re-18

lated to the treatment of a similar condi-19

tion. 20

‘‘(B) TREATMENT OF BUNDLED PAY-21

MENTS.—In carrying out subparagraph (A), the 22

Secretary shall provide that, in the case of 23

items and services which are included by a pro-24

vider or facility as part of a bundled payment, 25

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132 

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such items and services included in such bun-1

dled payment may be part of a single deter-2

mination under this subsection. 3

‘‘(C) WAIVER OF DEADLINES.—For pur-4

poses of permitting joint consideration of quali-5

fied mediated dispute items and services as part 6

of a single determination under the criteria 7

specified pursuant to subparagraph (A), the 8

Secretary may waive any deadline specified in 9

this subsection. 10

‘‘(5) DETERMINATION OF PAYMENT AMOUNT.— 11

‘‘(A) IN GENERAL.—Not later than 30 12

days after the date of initiation of the mediated 13

dispute resolution, with respect to a qualified 14

mediated dispute item or service, the selected 15

independent entity with respect to a determina-16

tion under this subsection for such item or serv-17

ice shall— 18

‘‘(i) taking into account only the con-19

siderations specified in subparagraph 20

(C)(i), select one of the offers submitted 21

under subparagraph (B) to be the amount 22

of payment for such item or service deter-23

mined under this subsection for purposes 24

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133 

•HR 5826 IH

of subsection (b)(1), (e)(1), or (i)(1), as 1

applicable; and 2

‘‘(ii) notify the provider or facility and 3

the health plan party to such determina-4

tion of the offer selected under clause (i). 5

‘‘(B) SUBMISSION OF OFFERS.—Not later 6

than 10 days after the date of initiation of the 7

mediated dispute resolution with respect to a 8

determination for a qualified mediated dispute 9

item or service, the provider or facility and the 10

health plan party to such determination shall 11

each submit to the selected independent enti-12

ty— 13

‘‘(i) an offer for a payment amount 14

under for such item or service furnished by 15

such provider or facility; 16

‘‘(ii) information relating to such 17

offer; and 18

‘‘(iii) such other information as re-19

quested by the selected independent entity. 20

‘‘(C) CONSIDERATIONS.— 21

‘‘(i) IN GENERAL.—For purposes of 22

subparagraph (A), the considerations spec-23

ified in this subparagraph, with respect to 24

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134 

•HR 5826 IH

a determination for a qualified mediated 1

dispute item or service, are the following: 2

‘‘(I) The median contracted rate 3

for such item or service. 4

‘‘(II) Subject to clause (ii), infor-5

mation that is submitted pursuant to 6

subparagraph (B). 7

‘‘(ii) TREATMENT OF CERTAIN CON-8

SIDERATIONS.—In making a determination 9

with respect to a qualified mediated dis-10

pute item or service pursuant to subpara-11

graph (A)(i), a selected independent entity 12

may not take into account usual and cus-13

tomary charges for the item or service nor 14

charges billed by the provider or facility for 15

the item or service. 16

‘‘(6) SELECTED INDEPENDENT ENTITY COM-17

PENSATION.— 18

‘‘(A) IN GENERAL.—Not later than 5 days 19

after receiving a notification described in para-20

graph (5)(A)(ii) from a selected independent 21

entity with respect to the determination of a 22

payment amount for a qualified mediated dis-23

pute item or service, the party to such deter-24

mination whose offer submitted under para-25

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135 

•HR 5826 IH

graph (5)(B) was not selected by the entity 1

shall pay to such entity a fee in compensation 2

for the services of such entity in accordance 3

with the guidelines on such compensation estab-4

lished by the Secretary under subparagraph 5

(B). 6

‘‘(B) GUIDELINES ON COMPENSATION.— 7

For purposes of subparagraph (A), the Sec-8

retary shall establish guidelines with respect to 9

the compensation of a selected independent en-10

tity for the services of such entity with respect 11

to determinations under the mediated dispute 12

process. Such guidelines shall provide that such 13

compensation reimburses the entity for at least 14

the costs of such entity in performing the duties 15

of the entity under the mediated dispute proc-16

ess. 17

‘‘(7) CERTIFICATION OF ENTITIES.— 18

‘‘(A) IN GENERAL.—The Secretary shall 19

establish or recognize a process to certify (in-20

cluding recertification of) entities under this 21

paragraph. Such process shall ensure that an 22

entity so certified— 23

‘‘(i) has (directly or through contracts 24

or other arrangements) sufficient medical, 25

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136 

•HR 5826 IH

legal, and other expertise and sufficient 1

staffing to make determinations described 2

in paragraph (2) on a timely basis; 3

‘‘(ii) is not— 4

‘‘(I) a health plan, provider, or 5

facility; 6

‘‘(II) an affiliate or a subsidiary 7

of a health plan, provider, or facility; 8

or 9

‘‘(III) an affiliate or subsidiary of 10

a professional or trade association of 11

health plans or of providers or facili-12

ties; 13

‘‘(iii) carries out the responsibilities of 14

such an entity in accordance with this sub-15

section; 16

‘‘(iv) meets appropriate indicators of 17

fiscal integrity; 18

‘‘(v) maintains the confidentiality (in 19

accordance with regulations promulgated 20

by the Secretary) of individually identifi-21

able health information obtained in the 22

course of conducting such determinations; 23

‘‘(vi) does not under the mediated dis-24

pute process carry out any determination 25

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137 

•HR 5826 IH

with respect to which the entity would not 1

pursuant to clause (i), (ii), or (iii) of para-2

graph (3)(A) be eligible for selection; and 3

‘‘(vii) meets such other requirements 4

as determined appropriate by the Sec-5

retary. 6

‘‘(B) PERIOD OF CERTIFICATION.—Subject 7

to subparagraph (C), each certification (includ-8

ing a recertification) of an entity under the 9

process described in subparagraph (A) shall be 10

for a 5-year period. 11

‘‘(C) REVOCATION.—A certification of an 12

entity under this paragraph may be revoked 13

under the process described in subparagraph 14

(A) if the entity has a pattern or practice of 15

noncompliance with any of the requirements de-16

scribed in such subparagraph. 17

‘‘(D) PETITION FOR DENIAL OR WITH-18

DRAWAL.—The process described in subpara-19

graph (A) shall ensure that an individual, pro-20

vider, facility, or health plan may petition for a 21

denial of a certification or a revocation of a cer-22

tification with respect to an entity under this 23

paragraph for failure of meeting a requirement 24

of this subsection. 25

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138 

•HR 5826 IH

‘‘(E) SUFFICIENT NUMBER OF ENTI-1

TIES.—The process described in subparagraph 2

(A) shall ensure that a sufficient number of en-3

tities are certified under this paragraph to en-4

sure the timely and efficient provision of deter-5

minations described in paragraph (2). 6

‘‘(F) PROVISION OF INFORMATION.— 7

‘‘(i) IN GENERAL.—An entity certified 8

under this paragraph shall provide to the 9

Secretary, in such manner as the Secretary 10

may require and on a quarterly basis (as 11

specified by the Secretary), such informa-12

tion as the Secretary determines appro-13

priate to assure compliance with the re-14

quirements described in subparagraph (A) 15

and to monitor and assess the determina-16

tions made by such entity and to ensure 17

the absence of bias in making such deter-18

minations. Such information shall include 19

information described in clause (ii) but 20

shall not include individually identifiable 21

health information. 22

‘‘(ii) INFORMATION TO BE IN-23

CLUDED.—The information described in 24

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139 

•HR 5826 IH

this clause with respect to an entity is the 1

following: 2

‘‘(I) The number of payment de-3

terminations described in paragraph 4

(2) made by such entity, 5

disaggregated by— 6

‘‘(aa) the line of business 7

(as specified in subsection 8

(k)(8)(C)) of the health plans 9

party to such determinations; 10

and 11

‘‘(bb) the type of providers 12

and facilities party to such deter-13

minations. 14

‘‘(II) A description of each item 15

or service included in each such deter-16

mination. 17

‘‘(III) The amount of each offer 18

submitted to the entity for each such 19

determination. 20

‘‘(IV) The amount of each such 21

determination. 22

‘‘(V) The length of time in mak-23

ing each such determination. 24

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140 

•HR 5826 IH

‘‘(VI) The compensation paid to 1

such entity with respect to each such 2

determination. 3

‘‘(VII) Any other information 4

specified by the Secretary. 5

‘‘(8) ADMINISTRATIVE FEE.— 6

‘‘(A) IN GENERAL.—Each party to a deter-7

mination to which an entity is selected under 8

paragraph (3) in a year shall pay to the Sec-9

retary, at such time and in such manner as 10

specified by the Secretary, a fee for partici-11

pating in the mediated dispute process with re-12

spect to such determination in an amount de-13

scribed in subparagraph (B) for such year. 14

‘‘(B) AMOUNT OF FEE.—The amount de-15

scribed in this subparagraph for a year is an 16

amount established by the Secretary in a man-17

ner such that the total amount of fees paid 18

under this paragraph for such year is estimated 19

to be equal to the amount of expenditures esti-20

mated to be made by the Secretary for such 21

year in carrying out the mediated dispute proc-22

ess. 23

‘‘(9) SECRETARIAL REPORT; PUBLICATION OF 24

INFORMATION.— 25

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141 

•HR 5826 IH

‘‘(A) SECRETARIAL REPORT.—Beginning 1

not later than July 1, 2023, the Secretary shall, 2

in coordination with the Secretary of the Treas-3

ury and the Secretary of Labor, periodically 4

study and submit to Congress a report on— 5

‘‘(i) the extent to which the payment 6

amount determined under this subsection 7

for an item or service furnished in a year 8

(or otherwise agreed to by a health plan 9

and provider or facility for purposes of de-10

termining payment by the plan to the pro-11

vider or facility pursuant to subsection 12

(b)(1), (e)(1), or (i)(1)) differs from the 13

median contracted rate for such item or 14

service and year, including the number of 15

times such determined (or agreed to) 16

amount exceeds such median contracted 17

rate; and 18

‘‘(ii) the effect of such difference on 19

the cost-sharing for such item or service 20

for a participant, beneficiary, or enrollee of 21

a health plan. 22

‘‘(B) PUBLICATION OF INFORMATION.— 23

Beginning with July 1, 2023, and for each cal-24

endar quarter thereafter, the Secretary shall, in 25

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142 

•HR 5826 IH

coordination with the Secretary of the Treasury 1

and the Secretary of Labor, make publicly 2

available a summary of the following: 3

‘‘(i) The information described in sub-4

clauses (I) through (V) of clause (ii) of 5

paragraph (7)(F) that was submitted to 6

the Secretary under clause (i) of such 7

paragraph during such quarter. 8

‘‘(ii) The amount of expenditures 9

made by the Secretary during such year to 10

carry out the mediated dispute process. 11

‘‘(iii) The total amount of fees paid 12

under paragraph (8) during such quarter. 13

‘‘(iv) The total amount of compensa-14

tion paid to selected independent entities 15

under paragraph (6) during such quar-16

ter.’’. 17

(b) IRC AMENDMENTS.—Section 9816 of the Inter-18

nal Revenue Code of 1986, as added by section 2(b) and 19

amended by sections 3(b), 5(b), and 6(b), is further 20

amended by inserting before subsection (k) the following 21

new subsection: 22

‘‘(j) DETERMINATION OF OUT-OF-NETWORK RATES 23

TO BE PAID BY HEALTH PLANS.— 24

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143 

•HR 5826 IH

‘‘(1) DETERMINATION THROUGH OPEN NEGO-1

TIATION.— 2

‘‘(A) IN GENERAL.—With respect to an 3

item or service furnished in a year by a non-4

participating provider or a nonparticipating fa-5

cility, with respect to a health plan, in a State 6

described in subparagraph (B) of subsection 7

(k)(11) with respect to such plan and provider 8

or facility, and for which a payment is required 9

to be made by the health plan pursuant to sub-10

section (b)(1), (e)(1), or (i)(1), the provider or 11

facility (as applicable) or plan may, during the 12

30-day period beginning on the day the provider 13

or facility receives a response from the plan re-14

garding a claim for payment for such item or 15

service, initiate open negotiations under this 16

paragraph between such provider or facility and 17

plan for purposes of determining, during the 18

open negotiation period, an amount agreed on 19

by such provider or facility, respectively, and 20

such plan for payment (including any cost-shar-21

ing) for such item or service. For purposes of 22

this subsection, the open negotiation period, 23

with respect to an item or service, is the 30-day 24

period beginning on the date of initiation of the 25

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144 

•HR 5826 IH

negotiations with respect to such item or serv-1

ice. 2

‘‘(B) EXCHANGE OF INFORMATION.—In 3

carrying out negotiations initiated under sub-4

paragraph (A), with respect to an item or serv-5

ice described in such subparagraph furnished in 6

a year, not later than the fifth business day of 7

the open negotiation period described in such 8

subparagraph with respect to such item or serv-9

ice— 10

‘‘(i) the health plan that is party to 11

such negotiations shall notify the provider 12

or facility that is party to such negotia-13

tions of the median contracted rate for 14

such item or service and year; and 15

‘‘(ii) such provider or facility shall no-16

tify such health plan of— 17

‘‘(I) the median of the total 18

amount of reimbursement (including 19

any cost-sharing) paid, for the most 20

recent year for which information is 21

available, to such provider or facility 22

for furnishing such item or service to 23

a participant or beneficiary of a 24

health plan that, at the time such 25

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145 

•HR 5826 IH

item or service was furnished, had a 1

contract in effect with such provider 2

or facility with respect to the fur-3

nishing of such item or service; 4

‘‘(II) in the case that information 5

described in subclause (I) is not avail-6

able, such information as specified by 7

the Secretary; and 8

‘‘(III) any additional information 9

specified by the Secretary. 10

‘‘(C) ACCESSING MEDIATED DISPUTE 11

PROCESS IN CASE OF FAILED NEGOTIATIONS.— 12

In the case of open negotiations pursuant to 13

subparagraph (A), with respect to an item or 14

service, that do not result in a determination of 15

an amount of payment for such item or service 16

by the last day of the open negotiation period 17

described in such subparagraph with respect to 18

such item or service, the provider or facility (as 19

applicable) or health plan that was party to 20

such negotiations may, during the 2-day period 21

beginning on the day after such open negotia-22

tion period, initiate the mediated dispute proc-23

ess under paragraph (2) with respect to such 24

item or service. The mediated dispute process 25

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146 

•HR 5826 IH

shall be initiated by a party pursuant to the 1

previous sentence by submission to the other 2

party and to the Secretary of a notification 3

(containing such information as specified by the 4

Secretary) and for purposes of this subsection, 5

the date of initiation of such process shall be 6

the date of such submission or such other date 7

specified by the Secretary pursuant to regula-8

tions that is not later than the date of receipt 9

of such notification by both the other party and 10

the Secretary. 11

‘‘(2) MEDIATED DISPUTE PROCESS AVAILABLE 12

IN CASE OF FAILED OPEN NEGOTIATIONS.— 13

‘‘(A) ESTABLISHMENT.—Not later than 14

July 1, 2021, the Secretary, in coordination 15

with the Secretary of Health and Human Serv-16

ices and the Secretary of Labor, shall establish 17

a process (in this subsection referred to as the 18

‘mediated dispute process’) under which, in the 19

case of an item or service with respect to which 20

a provider or facility (as applicable) or health 21

plan submits a notification under paragraph 22

(1)(C) (in this subsection referred to as a 23

‘qualified mediated dispute item or service’), an 24

entity selected under paragraph (3) determines, 25

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147 

•HR 5826 IH

subject to subparagraph (B) and in accordance 1

with the succeeding provisions of this sub-2

section, the amount of payment under the 3

health plan for such item or service furnished 4

by such provider or facility. 5

‘‘(B) AUTHORITY TO CONTINUE NEGOTIA-6

TIONS.—Under the mediated dispute process, in 7

the case that the parties to a determination for 8

a qualified mediated dispute item or service 9

agree on a payment amount for such item or 10

service during such process but before the date 11

on which the entity selected with respect to 12

such determination under paragraph (3) makes 13

such determination, such amount shall be treat-14

ed for purposes of subsection (k)(11)(B) as the 15

amount agreed to by such parties for such item 16

or service. In the case of an agreement de-17

scribed in the previous sentence, the mediated 18

dispute process shall provide for a method to 19

determine how to allocate between the parties 20

to such determination the payment of the com-21

pensation of the entity selected with respect to 22

such determination. 23

‘‘(3) SELECTION UNDER MEDIATED DISPUTE 24

PROCESS.—Under the mediated dispute process, the 25

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148 

•HR 5826 IH

Secretary shall, with respect to the determination of 1

the amount of payment under this subsection of a 2

qualified mediated dispute item or service, provide 3

for a method— 4

‘‘(A) that allows the parties to such deter-5

mination to jointly select, not later than the last 6

day of the 3-day period following the date of 7

the initiation of the process with respect to such 8

item or service, for purposes of making such de-9

termination, an entity certified under paragraph 10

(7) that— 11

‘‘(i) is not a party to such determina-12

tion or an employee or agent of such a 13

party; 14

‘‘(ii) does not have a material familial, 15

financial, or professional relationship with 16

such a party; and 17

‘‘(iii) does not otherwise have a con-18

flict of interest with such a party (as de-19

termined by the Secretary); and 20

‘‘(B) that requires, in the case such parties 21

do not make such selection by such last day, 22

the Secretary to, not later than 6 days after 23

such date of initiation— 24

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149 

•HR 5826 IH

‘‘(i) select such an entity that satisfies 1

clauses (i) through (iii) of subparagraph 2

(A); and 3

‘‘(ii) provide notification of such selec-4

tion to the provider or facility (as applica-5

ble) and the health plan party to such de-6

termination. 7

An entity selected pursuant to the previous sentence 8

to make a determination described in such sentence 9

shall be referred to in this subsection as the ‘selected 10

independent entity’ with respect to such determina-11

tion. 12

‘‘(4) TREATMENT OF CONSIDERATION OF MUL-13

TIPLE ITEMS AND SERVICES.— 14

‘‘(A) IN GENERAL.—Under the mediated 15

dispute process, the Secretary shall specify cri-16

teria under which multiple qualified mediated 17

dispute items and services are permitted to be 18

considered jointly as part of a single determina-19

tion by an entity for purposes of encouraging 20

the efficiency (including minimizing costs) of 21

the mediated dispute process. Such items and 22

services may be so considered only if— 23

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150 

•HR 5826 IH

‘‘(i) such items and services to be in-1

cluded in such determination are furnished 2

by the same provider or facility; 3

‘‘(ii) payment for such items and serv-4

ices is required to be made by the same 5

health plan; and 6

‘‘(iii) such items and services are re-7

lated to the treatment of a similar condi-8

tion. 9

‘‘(B) TREATMENT OF BUNDLED PAY-10

MENTS.—In carrying out subparagraph (A), the 11

Secretary shall provide that, in the case of 12

items and services which are included by a pro-13

vider or facility as part of a bundled payment, 14

such items and services included in such bun-15

dled payment may be part of a single deter-16

mination under this subsection. 17

‘‘(C) WAIVER OF DEADLINES.—For pur-18

poses of permitting joint consideration of quali-19

fied mediated dispute items and services as part 20

of a single determination under the criteria 21

specified pursuant to subparagraph (A), the 22

Secretary may waive any deadline specified in 23

this subsection. 24

‘‘(5) DETERMINATION OF PAYMENT AMOUNT.— 25

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151 

•HR 5826 IH

‘‘(A) IN GENERAL.—Not later than 30 1

days after the date of initiation of the mediated 2

dispute resolution, with respect to a qualified 3

mediated dispute item or service, the selected 4

independent entity with respect to a determina-5

tion under this subsection for such item or serv-6

ice shall— 7

‘‘(i) taking into account only the con-8

siderations specified in subparagraph 9

(C)(i), select one of the offers submitted 10

under subparagraph (B) to be the amount 11

of payment for such item or service deter-12

mined under this subsection for purposes 13

of subsection (b)(1), (e)(1), or (i)(1), as 14

applicable; and 15

‘‘(ii) notify the provider or facility and 16

the health plan party to such determina-17

tion of the offer selected under clause (i). 18

‘‘(B) SUBMISSION OF OFFERS.—Not later 19

than 10 days after the date of initiation of the 20

mediated dispute resolution with respect to a 21

determination for a qualified mediated dispute 22

item or service, the provider or facility and the 23

health plan party to such determination shall 24

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152 

•HR 5826 IH

each submit to the selected independent enti-1

ty— 2

‘‘(i) an offer for a payment amount 3

under for such item or service furnished by 4

such provider or facility; 5

‘‘(ii) information relating to such 6

offer; and 7

‘‘(iii) such other information as re-8

quested by the selected independent entity. 9

‘‘(C) CONSIDERATIONS.— 10

‘‘(i) IN GENERAL.—For purposes of 11

subparagraph (A), the considerations spec-12

ified in this subparagraph, with respect to 13

a determination for a qualified mediated 14

dispute item or service, are the following: 15

‘‘(I) The median contracted rate 16

for such item or service. 17

‘‘(II) Subject to clause (ii), infor-18

mation that is submitted pursuant to 19

subparagraph (B). 20

‘‘(ii) TREATMENT OF CERTAIN CON-21

SIDERATIONS.—In making a determination 22

with respect to a qualified mediated dis-23

pute item or service pursuant to subpara-24

graph (A)(i), a selected independent entity 25

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may not take into account usual and cus-1

tomary charges for the item or service nor 2

charges billed by the provider or facility for 3

the item or service. 4

‘‘(6) SELECTED INDEPENDENT ENTITY COM-5

PENSATION.— 6

‘‘(A) IN GENERAL.—Not later than 5 days 7

after receiving a notification described in para-8

graph (5)(A)(ii) from a selected independent 9

entity with respect to the determination of a 10

payment amount for a qualified mediated dis-11

pute item or service, the party to such deter-12

mination whose offer submitted under para-13

graph (5)(B) was not selected by the entity 14

shall pay to such entity a fee in compensation 15

for the services of such entity in accordance 16

with the guidelines on such compensation estab-17

lished by the Secretary under subparagraph 18

(B). 19

‘‘(B) GUIDELINES ON COMPENSATION.— 20

For purposes of subparagraph (A), the Sec-21

retary shall establish guidelines with respect to 22

the compensation of a selected independent en-23

tity for the services of such entity with respect 24

to determinations under the mediated dispute 25

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process. Such guidelines shall provide that such 1

compensation reimburses the entity for at least 2

the costs of such entity in performing the duties 3

of the entity under the mediated dispute proc-4

ess. 5

‘‘(7) CERTIFICATION OF ENTITIES.— 6

‘‘(A) IN GENERAL.—The Secretary shall 7

establish or recognize a process to certify (in-8

cluding recertification of) entities under this 9

paragraph. Such process shall ensure that an 10

entity so certified— 11

‘‘(i) has (directly or through contracts 12

or other arrangements) sufficient medical, 13

legal, and other expertise and sufficient 14

staffing to make determinations described 15

in paragraph (2) on a timely basis; 16

‘‘(ii) is not— 17

‘‘(I) a health plan, provider, or 18

facility; 19

‘‘(II) an affiliate or a subsidiary 20

of a health plan, provider, or facility; 21

or 22

‘‘(III) an affiliate or subsidiary of 23

a professional or trade association of 24

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health plans or of providers or facili-1

ties; 2

‘‘(iii) carries out the responsibilities of 3

such an entity in accordance with this sub-4

section; 5

‘‘(iv) meets appropriate indicators of 6

fiscal integrity; 7

‘‘(v) maintains the confidentiality (in 8

accordance with regulations promulgated 9

by the Secretary) of individually identifi-10

able health information obtained in the 11

course of conducting such determinations; 12

‘‘(vi) does not under the mediated dis-13

pute process carry out any determination 14

with respect to which the entity would not 15

pursuant to clause (i), (ii), or (iii) of para-16

graph (3)(A) be eligible for selection; and 17

‘‘(vii) meets such other requirements 18

as determined appropriate by the Sec-19

retary. 20

‘‘(B) PERIOD OF CERTIFICATION.—Subject 21

to subparagraph (C), each certification (includ-22

ing a recertification) of an entity under the 23

process described in subparagraph (A) shall be 24

for a 5-year period. 25

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‘‘(C) REVOCATION.—A certification of an 1

entity under this paragraph may be revoked 2

under the process described in subparagraph 3

(A) if the entity has a pattern or practice of 4

noncompliance with any of the requirements de-5

scribed in such subparagraph. 6

‘‘(D) PETITION FOR DENIAL OR WITH-7

DRAWAL.—The process described in subpara-8

graph (A) shall ensure that an individual, pro-9

vider, facility, or health plan may petition for a 10

denial of a certification or a revocation of a cer-11

tification with respect to an entity under this 12

paragraph for failure of meeting a requirement 13

of this subsection. 14

‘‘(E) SUFFICIENT NUMBER OF ENTI-15

TIES.—The process described in subparagraph 16

(A) shall ensure that a sufficient number of en-17

tities are certified under this paragraph to en-18

sure the timely and efficient provision of deter-19

minations described in paragraph (2). 20

‘‘(F) PROVISION OF INFORMATION.— 21

‘‘(i) IN GENERAL.—An entity certified 22

under this paragraph shall provide to the 23

Secretary, in such manner as the Secretary 24

may require and on a quarterly basis (as 25

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specified by the Secretary), such informa-1

tion as the Secretary determines appro-2

priate to assure compliance with the re-3

quirements described in subparagraph (A) 4

and to monitor and assess the determina-5

tions made by such entity and to ensure 6

the absence of bias in making such deter-7

minations. Such information shall include 8

information described in clause (ii) but 9

shall not include individually identifiable 10

health information. 11

‘‘(ii) INFORMATION TO BE IN-12

CLUDED.—The information described in 13

this clause with respect to an entity is the 14

following: 15

‘‘(I) The number of payment de-16

terminations described in paragraph 17

(2) made by such entity, 18

disaggregated by— 19

‘‘(aa) the line of business 20

(as specified in subsection 21

(k)(8)(C)) of the health plans 22

party to such determinations; 23

and 24

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‘‘(bb) the type of providers 1

and facilities party to such deter-2

minations. 3

‘‘(II) A description of each item 4

or service included in each such deter-5

mination. 6

‘‘(III) The amount of each offer 7

submitted to the entity for each such 8

determination. 9

‘‘(IV) The amount of each such 10

determination. 11

‘‘(V) The length of time in mak-12

ing each such determination. 13

‘‘(VI) The compensation paid to 14

such entity with respect to each such 15

determination. 16

‘‘(VII) Any other information 17

specified by the Secretary. 18

‘‘(8) ADMINISTRATIVE FEE.— 19

‘‘(A) IN GENERAL.—Each party to a deter-20

mination to which an entity is selected under 21

paragraph (3) in a year shall pay to the Sec-22

retary, at such time and in such manner as 23

specified by the Secretary, a fee for partici-24

pating in the mediated dispute process with re-25

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spect to such determination in an amount de-1

scribed in subparagraph (B) for such year. 2

‘‘(B) AMOUNT OF FEE.—The amount de-3

scribed in this subparagraph for a year is an 4

amount established by the Secretary in a man-5

ner such that the total amount of fees paid 6

under this paragraph for such year is estimated 7

to be equal to the amount of expenditures esti-8

mated to be made by the Secretary for such 9

year in carrying out the mediated dispute proc-10

ess. 11

‘‘(9) SECRETARIAL REPORT; PUBLICATION OF 12

INFORMATION.— 13

‘‘(A) SECRETARIAL REPORT.—Beginning 14

not later than July 1, 2023, the Secretary shall, 15

in coordination with the Secretary of Health 16

and Human Services and the Secretary of 17

Labor, periodically study and submit to Con-18

gress a report on— 19

‘‘(i) the extent to which the payment 20

amount determined under this subsection 21

for an item or service furnished in a year 22

(or otherwise agreed to by a health plan 23

and provider or facility for purposes of de-24

termining payment by the plan to the pro-25

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vider or facility pursuant to subsection 1

(b)(1), (e)(1), or (i)(1)) differs from the 2

median contracted rate for such item or 3

service and year, including the number of 4

times such determined (or agreed to) 5

amount exceeds such median contracted 6

rate; and 7

‘‘(ii) the effect of such difference on 8

the cost-sharing for such item or service 9

for a participant or beneficiary of a health 10

plan. 11

‘‘(B) PUBLICATION OF INFORMATION.— 12

Beginning with July 1, 2023, and for each cal-13

endar quarter thereafter, the Secretary shall, in 14

coordination with the Secretary of Health and 15

Human Services and the Secretary of Labor, 16

make publicly available a summary of the fol-17

lowing: 18

‘‘(i) The information described in sub-19

clauses (I) through (V) of clause (ii) of 20

paragraph (7)(F) that was submitted to 21

the Secretary under clause (i) of such 22

paragraph during such quarter. 23

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‘‘(ii) The amount of expenditures 1

made by the Secretary during such year to 2

carry out the mediated dispute process. 3

‘‘(iii) The total amount of fees paid 4

under paragraph (8) during such quarter. 5

‘‘(iv) The total amount of compensa-6

tion paid to selected independent entities 7

under paragraph (6) during such quar-8

ter.’’. 9

(c) ERISA AMENDMENTS.—Section 716 of the Em-10

ployee Retirement Income Security Act of 1974, as added 11

by section 2(c) and amended by sections 3(c), 5(c), and 12

6(c), is further amended by inserting before subsection (k) 13

the following new subsection: 14

‘‘(j) DETERMINATION OF OUT-OF-NETWORK RATES 15

TO BE PAID BY HEALTH PLANS.— 16

‘‘(1) DETERMINATION THROUGH OPEN NEGO-17

TIATION.— 18

‘‘(A) IN GENERAL.—With respect to an 19

item or service furnished in a year by a non-20

participating provider or a nonparticipating fa-21

cility, with respect to a health plan, in a State 22

described in subparagraph (B) of subsection 23

(k)(11) with respect to such plan and provider 24

or facility, and for which a payment is required 25

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to be made by the health plan pursuant to sub-1

section (b)(1), (e)(1), or (i)(1), the provider or 2

facility (as applicable) or plan may, during the 3

30-day period beginning on the day the provider 4

or facility receives a response from the plan re-5

garding a claim for payment for such item or 6

service, initiate open negotiations under this 7

paragraph between such provider or facility and 8

plan for purposes of determining, during the 9

open negotiation period, an amount agreed on 10

by such provider or facility, respectively, and 11

such plan for payment (including any cost-shar-12

ing) for such item or service. For purposes of 13

this subsection, the open negotiation period, 14

with respect to an item or service, is the 30-day 15

period beginning on the date of initiation of the 16

negotiations with respect to such item or serv-17

ice. 18

‘‘(B) EXCHANGE OF INFORMATION.—In 19

carrying out negotiations initiated under sub-20

paragraph (A), with respect to an item or serv-21

ice described in such subparagraph furnished in 22

a year, not later than the fifth business day of 23

the open negotiation period described in such 24

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163 

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subparagraph with respect to such item or serv-1

ice— 2

‘‘(i) the health plan that is party to 3

such negotiations shall notify the provider 4

or facility that is party to such negotia-5

tions of the median contracted rate for 6

such item or service and year; and 7

‘‘(ii) such provider or facility shall no-8

tify such health plan of— 9

‘‘(I) the median of the total 10

amount of reimbursement (including 11

any cost-sharing) paid, for the most 12

recent year for which information is 13

available, to such provider or facility 14

for furnishing such item or service to 15

a participant or beneficiary of a 16

health plan that, at the time such 17

item or service was furnished, had a 18

contract in effect with such provider 19

or facility with respect to the fur-20

nishing of such item or service; 21

‘‘(II) in the case that information 22

described in subclause (I) is not avail-23

able, such information as specified by 24

the Secretary; and 25

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‘‘(III) any additional information 1

specified by the Secretary. 2

‘‘(C) ACCESSING MEDIATED DISPUTE 3

PROCESS IN CASE OF FAILED NEGOTIATIONS.— 4

In the case of open negotiations pursuant to 5

subparagraph (A), with respect to an item or 6

service, that do not result in a determination of 7

an amount of payment for such item or service 8

by the last day of the open negotiation period 9

described in such subparagraph with respect to 10

such item or service, the provider or facility (as 11

applicable) or health plan that was party to 12

such negotiations may, during the 2-day period 13

beginning on the day after such open negotia-14

tion period, initiate the mediated dispute proc-15

ess under paragraph (2) with respect to such 16

item or service. The mediated dispute process 17

shall be initiated by a party pursuant to the 18

previous sentence by submission to the other 19

party and to the Secretary of a notification 20

(containing such information as specified by the 21

Secretary) and for purposes of this subsection, 22

the date of initiation of such process shall be 23

the date of such submission or such other date 24

specified by the Secretary pursuant to regula-25

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165 

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tions that is not later than the date of receipt 1

of such notification by both the other party and 2

the Secretary. 3

‘‘(2) MEDIATED DISPUTE PROCESS AVAILABLE 4

IN CASE OF FAILED OPEN NEGOTIATIONS.— 5

‘‘(A) ESTABLISHMENT.—Not later than 6

July 1, 2021, the Secretary, in coordination 7

with the Secretary of Health and Human Serv-8

ices and the Secretary of the Treasury, shall es-9

tablish a process (in this subsection referred to 10

as the ‘mediated dispute process’) under which, 11

in the case of an item or service with respect 12

to which a provider or facility (as applicable) or 13

health plan submits a notification under para-14

graph (1)(C) (in this subsection referred to as 15

a ‘qualified mediated dispute item or service’), 16

an entity selected under paragraph (3) deter-17

mines, subject to subparagraph (B) and in ac-18

cordance with the succeeding provisions of this 19

subsection, the amount of payment under the 20

health plan for such item or service furnished 21

by such provider or facility. 22

‘‘(B) AUTHORITY TO CONTINUE NEGOTIA-23

TIONS.—Under the mediated dispute process, in 24

the case that the parties to a determination for 25

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a qualified mediated dispute item or service 1

agree on a payment amount for such item or 2

service during such process but before the date 3

on which the entity selected with respect to 4

such determination under paragraph (3) makes 5

such determination, such amount shall be treat-6

ed for purposes of subsection (k)(11)(B) as the 7

amount agreed to by such parties for such item 8

or service. In the case of an agreement de-9

scribed in the previous sentence, the mediated 10

dispute process shall provide for a method to 11

determine how to allocate between the parties 12

to such determination the payment of the com-13

pensation of the entity selected with respect to 14

such determination. 15

‘‘(3) SELECTION UNDER MEDIATED DISPUTE 16

PROCESS.—Under the mediated dispute process, the 17

Secretary shall, with respect to the determination of 18

the amount of payment under this subsection of a 19

qualified mediated dispute item or service, provide 20

for a method— 21

‘‘(A) that allows the parties to such deter-22

mination to jointly select, not later than the last 23

day of the 3-day period following the date of 24

the initiation of the process with respect to such 25

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167 

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item or service, for purposes of making such de-1

termination, an entity certified under paragraph 2

(7) that— 3

‘‘(i) is not a party to such determina-4

tion or an employee or agent of such a 5

party; 6

‘‘(ii) does not have a material familial, 7

financial, or professional relationship with 8

such a party; and 9

‘‘(iii) does not otherwise have a con-10

flict of interest with such a party (as de-11

termined by the Secretary); and 12

‘‘(B) that requires, in the case such parties 13

do not make such selection by such last day, 14

the Secretary to, not later than 6 days after 15

such date of initiation— 16

‘‘(i) select such an entity that satisfies 17

clauses (i) through (iii) of subparagraph 18

(A); and 19

‘‘(ii) provide notification of such selec-20

tion to the provider or facility (as applica-21

ble) and the health plan party to such de-22

termination. 23

An entity selected pursuant to the previous sentence 24

to make a determination described in such sentence 25

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shall be referred to in this subsection as the ‘selected 1

independent entity’ with respect to such determina-2

tion. 3

‘‘(4) TREATMENT OF CONSIDERATION OF MUL-4

TIPLE ITEMS AND SERVICES.— 5

‘‘(A) IN GENERAL.—Under the mediated 6

dispute process, the Secretary shall specify cri-7

teria under which multiple qualified mediated 8

dispute items and services are permitted to be 9

considered jointly as part of a single determina-10

tion by an entity for purposes of encouraging 11

the efficiency (including minimizing costs) of 12

the mediated dispute process. Such items and 13

services may be so considered only if— 14

‘‘(i) such items and services to be in-15

cluded in such determination are furnished 16

by the same provider or facility; 17

‘‘(ii) payment for such items and serv-18

ices is required to be made by the same 19

health plan; and 20

‘‘(iii) such items and services are re-21

lated to the treatment of a similar condi-22

tion. 23

‘‘(B) TREATMENT OF BUNDLED PAY-24

MENTS.—In carrying out subparagraph (A), the 25

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169 

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Secretary shall provide that, in the case of 1

items and services which are included by a pro-2

vider or facility as part of a bundled payment, 3

such items and services included in such bun-4

dled payment may be part of a single deter-5

mination under this subsection. 6

‘‘(C) WAIVER OF DEADLINES.—For pur-7

poses of permitting joint consideration of quali-8

fied mediated dispute items and services as part 9

of a single determination under the criteria 10

specified pursuant to subparagraph (A), the 11

Secretary may waive any deadline specified in 12

this subsection. 13

‘‘(5) DETERMINATION OF PAYMENT AMOUNT.— 14

‘‘(A) IN GENERAL.—Not later than 30 15

days after the date of initiation of the mediated 16

dispute resolution, with respect to a qualified 17

mediated dispute item or service, the selected 18

independent entity with respect to a determina-19

tion under this subsection for such item or serv-20

ice shall— 21

‘‘(i) taking into account only the con-22

siderations specified in subparagraph 23

(C)(i), select one of the offers submitted 24

under subparagraph (B) to be the amount 25

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170 

•HR 5826 IH

of payment for such item or service deter-1

mined under this subsection for purposes 2

of subsection (b)(1), (e)(1), or (i)(1), as 3

applicable; and 4

‘‘(ii) notify the provider or facility and 5

the health plan party to such determina-6

tion of the offer selected under clause (i). 7

‘‘(B) SUBMISSION OF OFFERS.—Not later 8

than 10 days after the date of initiation of the 9

mediated dispute resolution with respect to a 10

determination for a qualified mediated dispute 11

item or service, the provider or facility and the 12

health plan party to such determination shall 13

each submit to the selected independent enti-14

ty— 15

‘‘(i) an offer for a payment amount 16

under for such item or service furnished by 17

such provider or facility; 18

‘‘(ii) information relating to such 19

offer; and 20

‘‘(iii) such other information as re-21

quested by the selected independent entity. 22

‘‘(C) CONSIDERATIONS.— 23

‘‘(i) IN GENERAL.—For purposes of 24

subparagraph (A), the considerations spec-25

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ified in this subparagraph, with respect to 1

a determination for a qualified mediated 2

dispute item or service, are the following: 3

‘‘(I) The median contracted rate 4

for such item or service. 5

‘‘(II) Subject to clause (ii), infor-6

mation that is submitted pursuant to 7

subparagraph (B). 8

‘‘(ii) TREATMENT OF CERTAIN CON-9

SIDERATIONS.—In making a determination 10

with respect to a qualified mediated dis-11

pute item or service pursuant to subpara-12

graph (A)(i), a selected independent entity 13

may not take into account usual and cus-14

tomary charges for the item or service nor 15

charges billed by the provider or facility for 16

the item or service. 17

‘‘(6) SELECTED INDEPENDENT ENTITY COM-18

PENSATION.— 19

‘‘(A) IN GENERAL.—Not later than 5 days 20

after receiving a notification described in para-21

graph (5)(A)(ii) from a selected independent 22

entity with respect to the determination of a 23

payment amount for a qualified mediated dis-24

pute item or service, the party to such deter-25

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mination whose offer submitted under para-1

graph (5)(B) was not selected by the entity 2

shall pay to such entity a fee in compensation 3

for the services of such entity in accordance 4

with the guidelines on such compensation estab-5

lished by the Secretary under subparagraph 6

(B). 7

‘‘(B) GUIDELINES ON COMPENSATION.— 8

For purposes of subparagraph (A), the Sec-9

retary shall establish guidelines with respect to 10

the compensation of a selected independent en-11

tity for the services of such entity with respect 12

to determinations under the mediated dispute 13

process. Such guidelines shall provide that such 14

compensation reimburses the entity for at least 15

the costs of such entity in performing the duties 16

of the entity under the mediated dispute proc-17

ess. 18

‘‘(7) CERTIFICATION OF ENTITIES.— 19

‘‘(A) IN GENERAL.—The Secretary shall 20

establish or recognize a process to certify (in-21

cluding recertification of) entities under this 22

paragraph. Such process shall ensure that an 23

entity so certified— 24

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173 

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‘‘(i) has (directly or through contracts 1

or other arrangements) sufficient medical, 2

legal, and other expertise and sufficient 3

staffing to make determinations described 4

in paragraph (2) on a timely basis; 5

‘‘(ii) is not— 6

‘‘(I) a health plan, provider, or 7

facility; 8

‘‘(II) an affiliate or a subsidiary 9

of a health plan, provider, or facility; 10

or 11

‘‘(III) an affiliate or subsidiary of 12

a professional or trade association of 13

health plans or of providers or facili-14

ties; 15

‘‘(iii) carries out the responsibilities of 16

such an entity in accordance with this sub-17

section; 18

‘‘(iv) meets appropriate indicators of 19

fiscal integrity; 20

‘‘(v) maintains the confidentiality (in 21

accordance with regulations promulgated 22

by the Secretary) of individually identifi-23

able health information obtained in the 24

course of conducting such determinations; 25

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174 

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‘‘(vi) does not under the mediated dis-1

pute process carry out any determination 2

with respect to which the entity would not 3

pursuant to clause (i), (ii), or (iii) of para-4

graph (3)(A) be eligible for selection; and 5

‘‘(vii) meets such other requirements 6

as determined appropriate by the Sec-7

retary. 8

‘‘(B) PERIOD OF CERTIFICATION.—Subject 9

to subparagraph (C), each certification (includ-10

ing a recertification) of an entity under the 11

process described in subparagraph (A) shall be 12

for a 5-year period. 13

‘‘(C) REVOCATION.—A certification of an 14

entity under this paragraph may be revoked 15

under the process described in subparagraph 16

(A) if the entity has a pattern or practice of 17

noncompliance with any of the requirements de-18

scribed in such subparagraph. 19

‘‘(D) PETITION FOR DENIAL OR WITH-20

DRAWAL.—The process described in subpara-21

graph (A) shall ensure that an individual, pro-22

vider, facility, or health plan may petition for a 23

denial of a certification or a revocation of a cer-24

tification with respect to an entity under this 25

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175 

•HR 5826 IH

paragraph for failure of meeting a requirement 1

of this subsection. 2

‘‘(E) SUFFICIENT NUMBER OF ENTI-3

TIES.—The process described in subparagraph 4

(A) shall ensure that a sufficient number of en-5

tities are certified under this paragraph to en-6

sure the timely and efficient provision of deter-7

minations described in paragraph (2). 8

‘‘(F) PROVISION OF INFORMATION.— 9

‘‘(i) IN GENERAL.—An entity certified 10

under this paragraph shall provide to the 11

Secretary, in such manner as the Secretary 12

may require and on a quarterly basis (as 13

specified by the Secretary), such informa-14

tion as the Secretary determines appro-15

priate to assure compliance with the re-16

quirements described in subparagraph (A) 17

and to monitor and assess the determina-18

tions made by such entity and to ensure 19

the absence of bias in making such deter-20

minations. Such information shall include 21

information described in clause (ii) but 22

shall not include individually identifiable 23

health information. 24

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176 

•HR 5826 IH

‘‘(ii) INFORMATION TO BE IN-1

CLUDED.—The information described in 2

this clause with respect to an entity is the 3

following: 4

‘‘(I) The number of payment de-5

terminations described in paragraph 6

(2) made by such entity, 7

disaggregated by— 8

‘‘(aa) the line of business 9

(as specified in subsection 10

(k)(8)(C)) of the health plans 11

party to such determinations; 12

and 13

‘‘(bb) the type of providers 14

and facilities party to such deter-15

minations. 16

‘‘(II) A description of each item 17

or service included in each such deter-18

mination. 19

‘‘(III) The amount of each offer 20

submitted to the entity for each such 21

determination. 22

‘‘(IV) The amount of each such 23

determination. 24

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177 

•HR 5826 IH

‘‘(V) The length of time in mak-1

ing each such determination. 2

‘‘(VI) The compensation paid to 3

such entity with respect to each such 4

determination. 5

‘‘(VII) Any other information 6

specified by the Secretary. 7

‘‘(8) ADMINISTRATIVE FEE.— 8

‘‘(A) IN GENERAL.—Each party to a deter-9

mination to which an entity is selected under 10

paragraph (3) in a year shall pay to the Sec-11

retary, at such time and in such manner as 12

specified by the Secretary, a fee for partici-13

pating in the mediated dispute process with re-14

spect to such determination in an amount de-15

scribed in subparagraph (B) for such year. 16

‘‘(B) AMOUNT OF FEE.—The amount de-17

scribed in this subparagraph for a year is an 18

amount established by the Secretary in a man-19

ner such that the total amount of fees paid 20

under this paragraph for such year is estimated 21

to be equal to the amount of expenditures esti-22

mated to be made by the Secretary for such 23

year in carrying out the mediated dispute proc-24

ess. 25

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178 

•HR 5826 IH

‘‘(9) SECRETARIAL REPORT; PUBLICATION OF 1

INFORMATION.— 2

‘‘(A) SECRETARIAL REPORT.—Beginning 3

not later than July 1, 2023, the Secretary shall, 4

in coordination with the Secretary of Health 5

and Human Services and the Secretary of the 6

Treasury, periodically study and submit to Con-7

gress a report on— 8

‘‘(i) the extent to which the payment 9

amount determined under this subsection 10

for an item or service furnished in a year 11

(or otherwise agreed to by a health plan 12

and provider or facility for purposes of de-13

termining payment by the plan to the pro-14

vider or facility pursuant to subsection 15

(b)(1), (e)(1), or (i)(1)) differs from the 16

median contracted rate for such item or 17

service and year, including the number of 18

times such determined (or agreed to) 19

amount exceeds such median contracted 20

rate; and 21

‘‘(ii) the effect of such difference on 22

the cost-sharing for such item or service 23

for a participant or beneficiary of a health 24

plan. 25

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179 

•HR 5826 IH

‘‘(B) PUBLICATION OF INFORMATION.— 1

Beginning with July 1, 2023, and for each cal-2

endar quarter thereafter, the Secretary shall, in 3

coordination with the Secretary of Health and 4

Human Services and the Secretary of Labor, 5

make publicly available a summary of the fol-6

lowing: 7

‘‘(i) The information described in sub-8

clauses (I) through (V) of clause (ii) of 9

paragraph (7)(F) that was submitted to 10

the Secretary under clause (i) of such 11

paragraph during such quarter. 12

‘‘(ii) The amount of expenditures 13

made by the Secretary during such year to 14

carry out the mediated dispute process. 15

‘‘(iii) The total amount of fees paid 16

under paragraph (8) during such quarter. 17

‘‘(iv) The total amount of compensa-18

tion paid to selected independent entities 19

under paragraph (6) during such quar-20

ter.’’. 21

(d) RULE OF CONSTRUCTION.—Nothing in this Act, 22

or the amendment made by this Act, shall be construed 23

as removing any obligation of a health plan (as defined 24

in subsection (k)(6) of section 2719A of the Public Health 25

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180 

•HR 5826 IH

Service Act (42 U.S.C. 300gg–19A), as amended by this 1

Act) to provide payment to a health care provider or 2

health care facility for items and services furnished by 3

such provider or facility to an individual enrolled in such 4

plan. 5

SEC. 8. PROHIBITING BALANCE BILLING PRACTICES BY 6

PROVIDERS FOR EMERGENCY SERVICES, FOR 7

SERVICES FURNISHED BY NONPARTICI-8

PATING PROVIDER AT PARTICIPATING FACIL-9

ITY, AND IN CERTAIN CASES OF MISINFORMA-10

TION. 11

(a) NO BALANCE BILLING.—Part A of title XI of the 12

Social Security Act (42 U.S.C. 1301 et seq.) is amended 13

by adding at the end the following new section: 14

‘‘SEC. 1150C. PROHIBITION ON CERTAIN BALANCE BILLING 15

PRACTICES. 16

‘‘(a) EMERGENCY SERVICES.—In the case of an indi-17

vidual with benefits under a group health plan or health 18

insurance coverage offered in the group or individual mar-19

ket who is furnished in a plan year that begins on or after 20

January 1, 2022, emergency services with respect to an 21

emergency medical condition during a visit at an emer-22

gency department of a hospital or an independent free-23

standing emergency department— 24

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181 

•HR 5826 IH

‘‘(1) if the hospital or independent freestanding 1

emergency department does not have a contractual 2

relationship with such plan or coverage for fur-3

nishing such services, the hospital or independent 4

freestanding emergency department shall not bill, 5

and shall not hold liable, the individual for a pay-6

ment amount for such emergency services so fur-7

nished that is more than the cost-sharing amount 8

for such services (as determined in accordance with 9

section 2719A(b) of the Public Health Service Act, 10

section 716(b) of the Employee Retirement Income 11

Security Act of 1974, or section 9816(b) of the In-12

ternal Revenue Code of 1986, as applicable); and 13

‘‘(2) a health care provider without a contrac-14

tual relationship with such plan or coverage for fur-15

nishing such services shall not bill, and shall not 16

hold liable, such individual for a payment amount 17

for such services furnished to such individual by 18

such provider with respect to such emergency med-19

ical condition and visit for which the individual re-20

ceives emergency services at the emergency depart-21

ment of the hospital or independent freestanding 22

emergency department that is more than the cost- 23

sharing amount for such services furnished by the 24

provider (as determined in accordance with section 25

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182 

•HR 5826 IH

2719A(b) of the Public Health Service Act, section 1

716(b) of the Employee Retirement Income Security 2

Act of 1974, or section 9816(b) of the Internal Rev-3

enue Code of 1986, as applicable). 4

‘‘(b) SERVICES FURNISHED BY NONPARTICIPATING 5

PROVIDER AT PARTICIPATING FACILITY.— 6

‘‘(1) IN GENERAL.—Subject to paragraph (2), 7

in the case of an individual with benefits under a 8

health plan who is furnished items or services (other 9

than emergency services to which subsection (a) ap-10

plies or items and services to which subsection (c) 11

applies) in a plan year that, with respect to such 12

plan or such coverage (as applicable), begins on or 13

after January 1, 2022, at a participating facility by 14

a nonparticipating provider, such provider shall not 15

bill, and shall not hold liable, such individual for a 16

payment amount for such an item or service fur-17

nished by such provider during a visit at such facil-18

ity that is more than the cost-sharing amount for 19

such item or service (as determined in accordance 20

with section 2719A(e) of the Public Health Service 21

Act, section 716(e) of the Employee Retirement In-22

come Security Act of 1974, or section 9816(e) of the 23

Internal Revenue Code of 1986, as applicable). 24

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183 

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‘‘(2) EXCEPTION IN CASE NOTICE PROVIDED.— 1

Paragraph (1) shall not apply with respect to items 2

and services (other than items and services described 3

in paragraph (3)) furnished to an individual enrolled 4

in a group health plan or in health insurance cov-5

erage offered in the group or individual market by 6

a health care provider that does not have a contrac-7

tual relationship with such plan or coverage for fur-8

nishing such items and services if the following cri-9

teria are met: 10

‘‘(A) A written notice (as specified by the 11

Secretary and in clear and understandable lan-12

guage) is provided by the provider to such indi-13

vidual, not later than 48 hours before such 14

items and services are to be so furnished, that 15

includes the following information: 16

‘‘(i) A statement verifying that the 17

provider does not have such a relationship 18

with such plan or coverage. 19

‘‘(ii) The estimated amount that such 20

provider may charge the individual for 21

such items and services. 22

‘‘(iii) A statement that the individual 23

may seek such items or services from a 24

health care provider that does have such a 25

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184 

•HR 5826 IH

contractual relationship and a list, if fea-1

sible, of providers with such a relationship 2

who are able to furnish such items and 3

services involved. 4

‘‘(B) On the date such item or service is 5

to be furnished, before such item or service is 6

so furnished, the individual signs and dates 7

such notice confirming receipt of the notice and 8

consent of the individual to be so furnished 9

such items and services. 10

‘‘(C) A copy of such signed and dated no-11

tice is provided by the provider to the plan or 12

coverage. 13

‘‘(3) ITEMS AND SERVICES DESCRIBED.—The 14

items and services described in this paragraph are 15

items and services furnished by a specified provider 16

(as defined in subsection (f)(3)). 17

‘‘(c) RELIANCE ON INCORRECT PROVIDER INFORMA-18

TION.—In the case of an individual who is furnished items 19

or services by a health care provider or health care facility 20

for which a group health plan or health insurance issuer 21

is required to make payment under section 2719A(i) of 22

the Public Health Service Act, section 716(i) of the Em-23

ployee Retirement Income Security Act of 1974, or section 24

9816(i) of the Internal Revenue Code of 1986, such pro-25

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185 

•HR 5826 IH

vider or facility shall not bill, and shall not hold liable, 1

such individual for a payment amount for such an item 2

or service that is more than the cost-sharing amount for 3

such item or service (as determined in accordance with 4

section 2719A(i) of the Public Health Service Act, section 5

716(i) of the Employee Retirement Income Security Act 6

of 1974, or section 9816(i) of the Internal Revenue Code 7

of 1986, as applicable). 8

‘‘(d) COMPLIANCE WITH REQUIREMENTS UNDER 9

OPEN NEGOTIATION AND MEDIATED DISPUTE RESOLU-10

TION PROCESSES.—A health care provider or health care 11

facility shall comply with any requirement imposed on 12

such provider or facility, respectively, under section 13

2719A(j) of the Public Health Service Act, 9816(j) of the 14

Internal Revenue Code of 1986, or 716(j) of the Employee 15

Retirement Income Security Act of 1974. 16

‘‘(e) PENALTY.— 17

‘‘(1) IN GENERAL.—Any health care provider or 18

health care facility that violates a provision of this 19

section shall be subject to a civil monetary penalty 20

in an amount not to exceed $10,000 for each such 21

violation. 22

‘‘(2) APPLICATION OF PROVISIONS.—The provi-23

sions of section 1128A (other than subsection (a), 24

subsection (b), the first sentence of subsection 25

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186 

•HR 5826 IH

(c)(1), and subsection (o)) shall apply with respect 1

to a civil monetary penalty imposed under this sub-2

section in the same manner as such provisions apply 3

with respect to a penalty or proceeding under sub-4

section (a) of such section. 5

‘‘(f) DEFINITIONS.—For purposes of this section and 6

sections 1150D and 1150E: 7

‘‘(1) The terms ‘during a visit’,‘emergency de-8

partment of a hospital’, ‘emergency medical condi-9

tion’, ‘emergency services’, ‘independent freestanding 10

emergency department’, ‘nonparticipating provider’, 11

‘nonparticipating facility’, ‘participating facility’, 12

‘participating provider’ have the meanings given 13

such terms, respectively, in section 2719A(k) of the 14

Public Health Service Act. 15

‘‘(2) The terms ‘group health plan’, ‘group mar-16

ket’, ‘health insurance issuer’, ‘health insurance cov-17

erage’, and ‘individual market’ have the meanings 18

given such terms, respectively, in section 2791 of the 19

Public Health Service Act. 20

‘‘(3) The term ‘specified provider’, with respect 21

to an individual with benefits under a group health 22

plan or health insurance coverage and a hospital 23

with a contractual relationship with such plan or 24

coverage for furnishing items and services— 25

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187 

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‘‘(A) means an ancillary health care pro-1

vider, including emergency medicine providers 2

or suppliers, anesthesiologists, pathologists, ra-3

diologists, neonatologists, assistant surgeons, 4

hospitalists, intensivists, or other providers de-5

termined by the Secretary (including providers 6

who furnish similar items and services as the 7

providers specified in this paragraph); and 8

‘‘(B) includes, with respect to an item or 9

service, any health care provider furnishing 10

such item or service at such hospital if there is 11

no health care provider at such hospital who 12

can furnish such item or service who has such 13

a relationship with such plan or coverage for 14

furnishing such item or service.’’. 15

(b) PROVIDER DIRECTORY; PATIENT-PROVIDER DIS-16

PUTE RESOLUTION PROCESS.—Part A of title XI of the 17

Social Security Act (42 U.S.C. 1301 et seq.), as amended 18

by subsection (a), is further amended by adding at the 19

end the following new sections: 20

‘‘SEC. 1150D. PATIENT PROTECTIONS AGAINST SURPRISE 21

BILLING THROUGH TRANSPARENCY. 22

‘‘(a) SUBMISSION OF INFORMATION TO HEALTH 23

PLANS OF CERTAIN PROVIDER INFORMATION.—Begin-24

ning not later than 1 year after the date of the enactment 25

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188 

•HR 5826 IH

of this section, each health care provider and health care 1

facility shall establish a process under which such provider 2

or facility transmits, to each health insurance issuer offer-3

ing group or individual health insurance coverage and 4

group health plan with which such provider or supplier 5

has in effect a contractual relationship for furnishing 6

items and services under such coverage or such plan, pro-7

vider directory information (as defined in section 8

2719A(f)(6) of the Public Health Service Act, section 9

716(f)(6) of the Employee Retirement Income Security 10

Act of 1974, or section 9816(f)(6) of the Internal Revenue 11

Code of 1986, as applicable) with respect to such provider 12

or facility, as applicable. Such provider or facility shall so 13

transmit such information to such issuer offering such 14

coverage or such group health plan— 15

‘‘(1) when there are any material changes (in-16

cluding a change in address, telephone number, or 17

other contact information) to such provider directory 18

information of the provider or facility with respect to 19

such coverage offered by such issuer or with respect 20

to such plan; and 21

‘‘(2) at any other time (including upon the re-22

quest of such issuer or plan) determined appropriate 23

by the provider, facility, or the Secretary. 24

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189 

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‘‘(b) PROVISION OF INFORMATION UPON REQUEST 1

AND FOR SCHEDULED APPOINTMENTS.—Each health care 2

provider and health care facility shall, beginning January 3

1, 2022, in the case of an individual who schedules an 4

item or service to be furnished to such individual by such 5

provider or facility at least 3 business days before the date 6

such item or service is to be so furnished, not later than 7

1 business day after the date of such scheduling (or, in 8

the case of such an item or service scheduled at least 10 9

business days before the date such item or service is to 10

be so furnished (or if requested by the individual), not 11

later than 3 business days after the date of such sched-12

uling or such request)— 13

‘‘(1) inquire if such individual is enrolled in a 14

group health plan, group or individual health insur-15

ance coverage offered by a health insurance issuer, 16

or a Federal health care program (and if is so en-17

rolled in such plan or coverage, seeking to have a 18

claim for such item or service submitted to such 19

plan or coverage); and 20

‘‘(2) provide a notification (in clear and under-21

standable language) of the good faith estimate of the 22

expected charges for furnishing such item or service 23

(including any item or service that is reasonably ex-24

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190 

•HR 5826 IH

pected to be provided in conjunction with such 1

scheduled item or service) to— 2

‘‘(A) in the case the individual is enrolled 3

in such a plan or such coverage (and is seeking 4

to have a claim for such item or service sub-5

mitted to such plan or coverage), such plan or 6

issuer of such coverage; and 7

‘‘(B) in the case the individual is not de-8

scribed in subparagraph (A) and not enrolled in 9

a Federal health care program, the individual. 10

‘‘(c) CONTINUITY OF CARE.—A health care provider 11

or health care facility shall, in the case of an individual 12

furnished items and services by such provider or facility 13

for which coverage is provided under a group health plan 14

or group or individual health insurance coverage pursuant 15

to section 2730 of such Act, section 9817 of the Internal 16

Revenue Code of 1986, or section 717 of the Employee 17

Retirement Income Security Act of 1974— 18

‘‘(1) accept payment from such plan or such 19

issuer (as applicable) (and cost-sharing from such 20

individual, if applicable, in accordance with sub-21

section (a)(2)(C) of such section 2730, 9817, or 22

717) for such items and services as payment in full 23

for such items and services; and 24

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‘‘(2) continue to adhere to all policies, proce-1

dures, and quality standards imposed by such plan 2

or issuer with respect to such individual and such 3

items and services in the same manner as if such 4

termination had not occurred. 5

‘‘(d) LIMITATION.—Beginning on January 1, 2022, 6

a health care provider or health care facility may not ini-7

tiate a process to seek reimbursement of payment for 8

items and services furnished to an individual enrolled in 9

a group health plan or health insurance coverage offered 10

in the group or individual market more than 1 year after 11

the date on which such items and services were so fur-12

nished. 13

‘‘(e) PENALTY.— 14

‘‘(1) GENERAL PENALTY.— 15

‘‘(A) IN GENERAL.—Except as provided in 16

paragraph (2), any health care provider or 17

health care facility that violates a provision of 18

this section shall be subject to a civil monetary 19

penalty in an amount not to exceed $10,000 for 20

each such violation. 21

‘‘(B) APPLICATION OF PROVISIONS.—The 22

provisions of section 1128A (other than sub-23

section (a), subsection (b), the first sentence of 24

subsection (c)(1), and subsection (o)) shall 25

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apply with respect to a civil monetary penalty 1

imposed under this paragraph in the same man-2

ner as such provisions apply with respect to a 3

penalty or proceeding under subsection (a) of 4

such section. 5

‘‘(2) PROVIDER DIRECTORY INFORMATION PEN-6

ALTY.— 7

‘‘(A) IN GENERAL.—Each health care pro-8

vider or health care facility that fails to trans-9

mit information as required under subsection 10

(a) shall be subject to a civil monetary penalty 11

of $1,000 for each day such provider or facility 12

(as applicable) fails to so transmit such infor-13

mation. 14

‘‘(B) APPLICATION OF PROVISIONS.—The 15

provisions of section 1128A (other than sub-16

section (a), subsection (b), the first sentence of 17

subsection (c)(1), subsection (d), and subsection 18

(o)) shall apply with respect to a civil monetary 19

penalty imposed under this paragraph in the 20

same manner as such provisions apply with re-21

spect to a penalty or proceeding under sub-22

section (a) of such section. 23

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‘‘SEC. 1150E. PATIENT-PROVIDER DISPUTE RESOLUTION. 1

‘‘(a) IN GENERAL.—Not later than July 1, 2021, the 2

Secretary shall establish a process (in this subsection re-3

ferred to as the ‘patient-provider dispute resolution proc-4

ess’) under which an uninsured individual, with respect 5

to an item or service, who received, pursuant to section 6

1150D(b), from a health care provider or health care facil-7

ity a good-faith estimate of the expected charges for fur-8

nishing such item or service to such individual and who 9

after being furnished such item or service by such provider 10

or facility is billed by such provider or facility for such 11

item or service for charges that are substantially in excess 12

of such estimate, may seek a determination from a se-13

lected dispute resolution entity for the charges to be paid 14

by such individual (in lieu of such amount so billed) to 15

such provider or facility for such item or service. For pur-16

poses of this subsection, the term ‘uninsured individual’ 17

means, with respect to an item or service, an individual 18

who does not have benefits for such item or service under 19

a group health plan, health insurance coverage offered in 20

the group or individual market by a health insurance 21

issuer, Federal health care program (as defined in section 22

1128B(f)), or a health benefits plan under chapter 89 of 23

title 5, United States Code (or an individual who has bene-24

fits for such item or service under a group health plan 25

or health insurance coverage offered in the group or indi-26

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194 

•HR 5826 IH

vidual market by a health insurance issuer, but who does 1

not seek to have a claim for such item or service submitted 2

to such plan or coverage). 3

‘‘(b) SELECTION OF ENTITIES.—Under the patient- 4

provider dispute resolution process, the Secretary shall, 5

with respect to a determination sought by an individual 6

under subsection (a), with respect to charges to be paid 7

by such individual to a health care provider or health care 8

facility described in such paragraph for an item or service 9

furnished to such individual by such provider or facility, 10

provide for— 11

‘‘(1) a method to select to make such deter-12

mination an entity certified under subsection (d) 13

that— 14

‘‘(A) is not a party to such determination 15

or an employee or agent of such party; 16

‘‘(B) does not have a material familial, fi-17

nancial, or professional relationship with such a 18

party; and 19

‘‘(C) does not otherwise have a conflict of 20

interest with such a party (as determined by 21

the Secretary); and 22

‘‘(2) the provision of a notification of such se-23

lection to the individual and the provider or facility 24

(as applicable) party to such determination. 25

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195 

•HR 5826 IH

An entity selected pursuant to the previous sentence to 1

make a determination described in such sentence shall be 2

referred to in this subsection as the ‘selected dispute reso-3

lution entity’ with respect to such determination. 4

‘‘(c) ADMINISTRATIVE FEE.—The Secretary shall es-5

tablish a fee to participate in the patient-provider dispute 6

resolution process in such a manner as to not create a 7

barrier to an uninsured individual’s access to such process. 8

‘‘(d) CERTIFICATION.—The Secretary shall establish 9

or recognize a process to certify entities under this sub-10

paragraph. Such process shall ensure that an entity so cer-11

tified satisfies at least the criteria specified in section 12

2719A(j)(7) of the Public Health Service Act.’’. 13

SEC. 9. ADDITIONAL CONSUMER PROTECTIONS. 14

(a) PUBLIC HEALTH SERVICE ACT.—Subpart II of 15

part A of title XXVII of the Public Health Service Act 16

(42 U.S.C. 300gg–11 et seq.) is amended by adding at 17

the end the following new sections: 18

‘‘SEC. 2730. CONTINUITY OF CARE. 19

‘‘(a) ENSURING CONTINUITY OF CARE WITH RE-20

SPECT TO TERMINATIONS OF CERTAIN CONTRACTUAL 21

RELATIONSHIPS RESULTING IN CHANGES IN PROVIDER 22

NETWORK STATUS.— 23

‘‘(1) IN GENERAL.—In the case of an individual 24

with benefits under a group health plan or group or 25

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196 

•HR 5826 IH

individual health insurance coverage offered by a 1

health insurance issuer and with respect to a health 2

care provider or facility that has a contractual rela-3

tionship with such plan or such issuer (as applica-4

ble) for furnishing items and services under such 5

plan or such coverage, if, while such individual is a 6

continuing care patient (as defined in subsection (b)) 7

with respect to such provider or facility— 8

‘‘(A) such contractual relationship is termi-9

nated (as defined in subsection (b)); 10

‘‘(B) benefits provided under such plan or 11

such health insurance coverage with respect to 12

such provider or facility are terminated because 13

of a change in the terms of the participation of 14

such provider or facility in such plan or cov-15

erage; or 16

‘‘(C) a contract between such group health 17

plan and a health insurance issuer offering 18

health insurance coverage in connection with 19

such plan is terminated, resulting in a loss of 20

benefits provided under such plan with respect 21

to such provider or facility; 22

the plan or issuer, respectively, shall meet the re-23

quirements of paragraph (2) with respect to such in-24

dividual. 25

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197 

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‘‘(2) REQUIREMENTS.—The requirements of 1

this paragraph are that the plan or issuer— 2

‘‘(A) notify each individual enrolled under 3

such plan or coverage who is a continuing care 4

patient with respect to a provider or facility at 5

the time of a termination described in para-6

graph (1) affecting such provider or facility on 7

a timely basis of such termination and such in-8

dividual’s right to elect continued transitional 9

care from such provider or facility under this 10

section; 11

‘‘(B) provide such individual with an op-12

portunity to notify the plan or issuer of the in-13

dividual’s need for transitional care; and 14

‘‘(C) permit the patient to elect to continue 15

to have benefits provided under such plan or 16

such coverage, under the same terms and condi-17

tions as would have applied and with respect to 18

such items and services as would have been cov-19

ered under such plan or coverage had such ter-20

mination not occurred, with respect to the 21

course of treatment furnished by such provider 22

or facility relating to such individual’s status as 23

a continuing care patient during the period be-24

ginning on the date on which the notice under 25

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198 

•HR 5826 IH

subparagraph (A) is provided and ending on the 1

earlier of— 2

‘‘(i) the 90-day period beginning on 3

such date; or 4

‘‘(ii) the date on which such individual 5

is no longer a continuing care patient with 6

respect to such provider or facility. 7

‘‘(b) DEFINITIONS.—In this section: 8

‘‘(1) CONTINUING CARE PATIENT.—The term 9

‘continuing care patient’ means an individual who, 10

with respect to a provider or facility— 11

‘‘(A) is undergoing a course of treatment 12

for a serious and complex condition from the 13

provider or facility; 14

‘‘(B) is undergoing a course of institu-15

tional or inpatient care from the provider or fa-16

cility; 17

‘‘(C) is scheduled to undergo nonelective 18

surgery from the provider, including receipt of 19

postoperative care from such provider or facility 20

with respect to such a surgery; 21

‘‘(D) is pregnant and undergoing a course 22

of treatment for the pregnancy from the pro-23

vider or facility; or 24

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199 

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‘‘(E) is or was determined to be terminally 1

ill (as determined under section 1861(dd)(3)(A) 2

of the Social Security Act) and is receiving 3

treatment for such illness from such provider or 4

facility. 5

‘‘(2) SERIOUS AND COMPLEX CONDITION.—The 6

term ‘serious and complex condition’ means, with re-7

spect to a participant, beneficiary, or enrollee under 8

a group health plan or health insurance coverage— 9

‘‘(A) in the case of an acute illness, a con-10

dition that is serious enough to require special-11

ized medical treatment to avoid the reasonable 12

possibility of death or permanent harm; or 13

‘‘(B) in the case of a chronic illness or con-14

dition, a condition that is— 15

‘‘(i) is life-threatening, degenerative, 16

potentially disabling, or congenital; and 17

‘‘(ii) requires specialized medical care 18

over a prolonged period of time. 19

‘‘(3) TERMINATED.—The term ‘terminated’ in-20

cludes, with respect to a contract, the expiration or 21

nonrenewal of the contract, but does not include a 22

termination of the contract for failure to meet appli-23

cable quality standards or for fraud. 24

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200 

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‘‘SEC. 2731. INFORMATION REQUIRED TO BE INCLUDED ON 1

HEALTH INSURANCE MEMBERSHIP CARDS. 2

‘‘In the case of a group health plan or health insur-3

ance issuer offering group or individual health insurance 4

coverage that provides a physical or electronic card indi-5

cating membership in such plan or coverage to an indi-6

vidual enrolled under such plan or coverage, such group 7

health plan or issuer shall include on such card each of 8

the following: 9

‘‘(1) The nearest hospital to the primary resi-10

dence of such individual that has in effect a contrac-11

tual relationship with such plan or coverage for fur-12

nishing items and services under such plan or cov-13

erage. 14

‘‘(2) A telephone number or Internet website 15

address through which such individual may seek con-16

sumer assistance information, such as information 17

related to hospitals and urgent care facilities that 18

have in effect a contractual relationship with such 19

plan or coverage for furnishing items and services 20

under such plan or coverage. 21

‘‘(3) Any deductible applicable to such indi-22

vidual. 23

‘‘(4) Any out-of-pocket maximum applicable to 24

such individual. 25

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201 

•HR 5826 IH

‘‘(5) Any cost-sharing obligation applicable to 1

such individual for a visit at an emergency depart-2

ment, or urgent care facility, that has in effect a 3

contractual relationship with such plan or coverage 4

for furnishing items and services under such plan or 5

coverage. 6

‘‘SEC. 2732. MAINTENANCE OF PRICE COMPARISON TOOL. 7

‘‘In connection with the offering of a group health 8

plan or group or individual health insurance coverage in 9

a geographic region for a plan year, a plan sponsor or 10

health insurance issuer, respectively, shall employ an indi-11

vidual to offer price comparison guidance, or make avail-12

able on an Internet website a price comparison tool, that 13

(to the extent practicable) allows an individual enrolled 14

under such plan or coverage, with respect to such plan 15

year and such geographic region, to compare the amount 16

(determined by historic claims data of participating pro-17

viders with respect to such plan or coverage) of cost-shar-18

ing (including deductibles, copayments, and coinsurance) 19

that the individual would be responsible for paying under 20

such plan or coverage with respect to the furnishing of 21

a specific item or service by any such provider.’’. 22

(b) INTERNAL REVENUE CODE.— 23

(1) IN GENERAL.—Subchapter B of chapter 24

100 of the Internal Revenue Code of 1986, as 25

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202 

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amended by the previous sections, is further amend-1

ed by adding at the end the following new sections: 2

‘‘SEC. 9817. CONTINUITY OF CARE. 3

‘‘(a) ENSURING CONTINUITY OF CARE WITH RE-4

SPECT TO TERMINATIONS OF CERTAIN CONTRACTUAL 5

RELATIONSHIPS RESULTING IN CHANGES IN PROVIDER 6

NETWORK STATUS.— 7

‘‘(1) IN GENERAL.—In the case of an individual 8

with benefits under a group health plan and with re-9

spect to a health care provider or facility that has 10

a contractual relationship with such plan for fur-11

nishing items and services under such plan, if, while 12

such individual is a continuing care patient (as de-13

fined in subsection (b)) with respect to such provider 14

or facility— 15

‘‘(A) such contractual relationship is termi-16

nated (as defined in paragraph (b)); 17

‘‘(B) benefits provided under such plan 18

with respect to such provider or facility are ter-19

minated because of a change in the terms of the 20

participation of such provider or facility in such 21

plan; or 22

‘‘(C) a contract between such group health 23

plan and a health insurance issuer offering 24

health insurance coverage in connection with 25

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203 

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such plan is terminated, resulting in a loss of 1

benefits provided under such plan with respect 2

to such provider or facility; 3

the plan shall meet the requirements of paragraph 4

(2) with respect to such individual. 5

‘‘(2) REQUIREMENTS.—The requirements of 6

this paragraph are that the plan— 7

‘‘(A) notify each individual enrolled under 8

such plan who is a continuing care patient with 9

respect to a provider or facility at the time of 10

a termination described in paragraph (1) affect-11

ing such provider on a timely basis of such ter-12

mination and such individual’s right to elect 13

continued transitional care from such provider 14

or facility under this section; 15

‘‘(B) provide such individual with an op-16

portunity to notify the plan of the individual’s 17

need for transitional care; and 18

‘‘(C) permit the patient to elect to continue 19

to have benefits provided under such plan, 20

under the same terms and conditions as would 21

have applied and with respect to such items and 22

services as would have been covered under such 23

plan had such termination not occurred, with 24

respect to the course of treatment furnished by 25

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204 

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such provider or facility relating to such indi-1

vidual’s status as a continuing care patient dur-2

ing the period beginning on the date on which 3

the notice under subparagraph (A) is provided 4

and ending on the earlier of— 5

‘‘(i) the 90-day period beginning on 6

such date; or 7

‘‘(ii) the date on which such individual 8

is no longer a continuing care patient with 9

respect to such provider or facility. 10

‘‘(b) DEFINITIONS.—In this section: 11

‘‘(1) CONTINUING CARE PATIENT.—The term 12

‘continuing care patient’ means an individual who, 13

with respect to a provider or facility— 14

‘‘(A) is undergoing a course of treatment 15

for a serious and complex condition from the 16

provider or facility; 17

‘‘(B) is undergoing a course of institu-18

tional or inpatient care from the provider or fa-19

cility; 20

‘‘(C) is scheduled to undergo nonelective 21

surgery from the provider or facility, including 22

receipt of postoperative care from such provider 23

or facility with respect to such a surgery; 24

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205 

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‘‘(D) is pregnant and undergoing a course 1

of treatment for the pregnancy from the pro-2

vider or facility; or 3

‘‘(E) is or was determined to be terminally 4

ill (as determined under section 1861(dd)(3)(A) 5

of the Social Security Act) and is receiving 6

treatment for such illness from such provider or 7

facility. 8

‘‘(2) SERIOUS AND COMPLEX CONDITION.—The 9

term ‘serious and complex condition’ means, with re-10

spect to a participant, beneficiary, or enrollee under 11

a group health plan— 12

‘‘(A) in the case of an acute illness, a con-13

dition that is serious enough to require special-14

ized medical treatment to avoid the reasonable 15

possibility of death or permanent harm; or 16

‘‘(B) in the case of a chronic illness or con-17

dition, a condition that— 18

‘‘(i) is life-threatening, degenerative, 19

potentially disabling, or congenital; and 20

‘‘(ii) requires specialized medical care 21

over a prolonged period of time. 22

‘‘(3) TERMINATED.—The term ‘terminated’ in-23

cludes, with respect to a contract, the expiration or 24

nonrenewal of the contract, but does not include a 25

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termination of the contract for failure to meet appli-1

cable quality standards or for fraud. 2

‘‘SEC. 9818. INFORMATION REQUIRED TO BE INCLUDED ON 3

HEALTH INSURANCE MEMBERSHIP CARDS. 4

‘‘In the case of a group health plan that provides a 5

physical or electronic card indicating membership in such 6

plan to an individual enrolled under such plan, such group 7

health plan shall include on such card each of the fol-8

lowing: 9

‘‘(1) The nearest hospital to the primary resi-10

dence of such individual that has in effect a contrac-11

tual relationship with such plan for furnishing items 12

and services under such plan. 13

‘‘(2) A telephone number or Internet website 14

address through which such individual may seek con-15

sumer assistance information, such as information 16

related to hospitals and urgent care facilities that 17

have in effect a contractual relationship with such 18

plan for furnishing items and services under such 19

plan. 20

‘‘(3) Any deductible applicable to such indi-21

vidual. 22

‘‘(4) Any out-of-pocket maximum applicable to 23

such individual. 24

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207 

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‘‘(5) Any cost-sharing obligation applicable to 1

such individual for a visit at an emergency depart-2

ment, or urgent care facility, that has in effect a 3

contractual relationship with such plan for fur-4

nishing items and services under such plan. 5

‘‘SEC. 9819. MAINTENANCE OF PRICE COMPARISON TOOL. 6

‘‘In connection with the offering of a group health 7

plan in a geographic region for a plan year, a plan sponsor 8

shall employ an individual to offer price comparison guid-9

ance, or make available on an Internet website a price 10

comparison tool, that (to the extent practicable) allows an 11

individual enrolled under such plan, with respect to such 12

plan year and such geographic region, to compare the 13

amount (determined by historic claims data of partici-14

pating providers with respect to such plan) of cost-sharing 15

(including deductibles, copayments, and coinsurance) that 16

the individual would be responsible for paying under such 17

plan with respect to the furnishing of a specific item or 18

service by any such provider.’’. 19

(2) CONFORMING AMENDMENT.—Section 20

9815(a) of the Internal Revenue Code of 1986, as 21

amended by section 2(b), is further amended— 22

(A) in paragraph (1), by striking ‘‘section 23

2719A’’ and inserting ‘‘section 2719A, 2730, 24

2731, or 2732’’; and 25

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208 

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(B) in paragraph (2), by striking ‘‘section 1

2719A’’ and inserting ‘‘section 2719A, 2730, 2

2731, or 2732’’. 3

(3) CLERICAL AMENDMENT.—The table of sec-4

tions for such subchapter, as amended by section 5

2(b), is further amended by adding at the end the 6

following new items: 7

‘‘Sec. 9817. Continuity of care. 
‘‘Sec. 9818. Information required to be included on health insurance member-

ship cards. 
‘‘Sec. 9819. Maintenance of price comparison tool.’’. 

(c) EMPLOYEE RETIREMENT INCOME SECURITY 8

ACT.— 9

(1) IN GENERAL.—Subpart B of part 7 of sub-10

title B of title I of the Employee Retirement Income 11

Security Act of 1974 (29 U.S.C. 1185 et seq.), as 12

amended by section 2(c), is further amended by add-13

ing at the end the following new sections: 14

‘‘SEC. 717. CONTINUITY OF CARE. 15

‘‘(a) ENSURING CONTINUITY OF CARE WITH RE-16

SPECT TO TERMINATIONS OF CERTAIN CONTRACTUAL 17

RELATIONSHIPS RESULTING IN CHANGES IN PROVIDER 18

NETWORK STATUS.— 19

‘‘(1) IN GENERAL.—In the case of an individual 20

with benefits under a group health plan or health in-21

surance coverage offered by a health insurance 22

issuer in connection with a group health plan and 23

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•HR 5826 IH

with respect to a health care provider or facility that 1

has a contractual relationship with such plan or 2

such issuer (as applicable) for furnishing items and 3

services under such plan or such coverage, if, while 4

such individual is a continuing care patient (as de-5

fined in subsection (b)) with respect to such provider 6

or facility— 7

‘‘(A) such contractual relationship is termi-8

nated (as defined in paragraph (b)); 9

‘‘(B) benefits provided under such plan or 10

such health insurance coverage with respect to 11

such provider or facility are terminated because 12

of a change in the terms of the participation of 13

the provider or facility in such plan or coverage; 14

or 15

‘‘(C) a contract between such group health 16

plan and a health insurance issuer offering 17

health insurance coverage in connection with 18

such plan is terminated, resulting in a loss of 19

benefits provided under such plan with respect 20

to such provider or facility; 21

the plan or issuer, respectively, shall meet the re-22

quirements of paragraph (2) with respect to such in-23

dividual. 24

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‘‘(2) REQUIREMENTS.—The requirements of 1

this paragraph are that the plan or issuer— 2

‘‘(A) notify each individual enrolled under 3

such plan or coverage who is a continuing care 4

patient with respect to a provider or facility at 5

the time of a termination described in para-6

graph (1) affecting such provider or facility on 7

a timely basis of such termination and such in-8

dividual’s right to elect continued transitional 9

care from such provider or facility under this 10

section; 11

‘‘(B) provide such individual with an op-12

portunity to notify the plan or issuer of the in-13

dividual’s need for transitional care; and 14

‘‘(C) permit the patient to elect to continue 15

to have benefits provided under such plan or 16

such coverage, under the same terms and condi-17

tions as would have applied and with respect to 18

such items and services as would have been cov-19

ered under such plan or coverage had such ter-20

mination not occurred, with respect to the 21

course of treatment furnished by such provider 22

or facility relating to such individual’s status as 23

a continuing care patient during the period be-24

ginning on the date on which the notice under 25

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211 

•HR 5826 IH

subparagraph (A) is provided and ending on the 1

earlier of— 2

‘‘(i) the 90-day period beginning on 3

such date; or 4

‘‘(ii) the date on which such individual 5

is no longer a continuing care patient with 6

respect to such provider or facility. 7

‘‘(b) DEFINITIONS.—In this section: 8

‘‘(1) CONTINUING CARE PATIENT.—The term 9

‘continuing care patient’ means an individual who, 10

with respect to a provider or facility— 11

‘‘(A) is undergoing a course of treatment 12

for a serious and complex condition from the 13

provider or facility; 14

‘‘(B) is undergoing a course of institu-15

tional or inpatient care from the provider or fa-16

cility; 17

‘‘(C) is scheduled to undergo nonelective 18

surgery from the provide or facility, including 19

receipt of postoperative care from such provider 20

or facility with respect to such a surgery; 21

‘‘(D) is pregnant and undergoing a course 22

of treatment for the pregnancy from the pro-23

vider or facility; or 24

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212 

•HR 5826 IH

‘‘(E) is or was determined to be terminally 1

ill (as determined under section 1861(dd)(3)(A) 2

of the Social Security Act) and is receiving 3

treatment for such illness from such provider or 4

facility. 5

‘‘(2) SERIOUS AND COMPLEX CONDITION.—The 6

term ‘serious and complex condition’ means, with re-7

spect to a participant, beneficiary, or enrollee under 8

a group health plan or health insurance coverage— 9

‘‘(A) in the case of an acute illness, a con-10

dition that is serious enough to require special-11

ized medical treatment to avoid the reasonable 12

possibility of death or permanent harm; or 13

‘‘(B) in the case of a chronic illness or con-14

dition, a condition that— 15

‘‘(i) is life-threatening, degenerative, 16

potentially disabling, or congenital; and 17

‘‘(ii) requires specialized medical care 18

over a prolonged period of time. 19

‘‘(3) TERMINATED.—The term ‘terminated’ in-20

cludes, with respect to a contract, the expiration or 21

nonrenewal of the contract, but does not include a 22

termination of the contract for failure to meet appli-23

cable quality standards or for fraud. 24

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213 

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‘‘SEC. 718. INFORMATION REQUIRED TO BE INCLUDED ON 1

HEALTH INSURANCE MEMBERSHIP CARDS. 2

‘‘In the case of a group health plan or health insur-3

ance issuer offering group health insurance coverage that 4

provides a physical or electronic card indicating member-5

ship in such plan or coverage to an individual enrolled 6

under such plan or coverage, such group health plan or 7

issuer shall include on such card each of the following: 8

‘‘(1) The nearest hospital to the primary resi-9

dence of such individual that has in effect a contrac-10

tual relationship with such plan or coverage for fur-11

nishing items and services under such plan or cov-12

erage. 13

‘‘(2) A telephone number or Internet website 14

address through which such individual may seek con-15

sumer assistance information, such as information 16

related to hospitals and urgent care facilities that 17

have in effect a contractual relationship with such 18

plan or coverage for furnishing items and services 19

under such plan or coverage. 20

‘‘(3) Any deductible applicable to such indi-21

vidual. 22

‘‘(4) Any out-of-pocket maximum applicable to 23

such individual. 24

‘‘(5) Any cost-sharing obligation applicable to 25

such individual for a visit at an emergency depart-26

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214 

•HR 5826 IH

ment, or urgent care facility, that has in effect a 1

contractual relationship with such plan or coverage 2

for furnishing items and services under such plan or 3

coverage. 4

‘‘SEC. 719. MAINTENANCE OF PRICE COMPARISON TOOL. 5

‘‘In connection with the offering of a group health 6

plan or group health insurance coverage in a geographic 7

region for a plan year, a plan sponsor or health insurance 8

issuer, respectively, shall employ an individual to offer 9

price comparison guidance, or make available on an Inter-10

net website a price comparison tool, that (to the extent 11

practicable) allows an individual enrolled under such plan 12

or coverage, with respect to such plan year and such geo-13

graphic region, to compare the amount (determined by 14

historic claims data of participating providers with respect 15

to such plan or coverage) of cost-sharing (including 16

deductibles, copayments, and coinsurance) that the indi-17

vidual would be responsible for paying under such plan 18

or coverage with respect to the furnishing of a specific 19

item or service by any such provider.’’. 20

(2) CONFORMING AMENDMENT.—Section 21

715(a) of the Employee Retirement Income Security 22

Act of 1974 (29 U.S.C. 1185d(a)), as amended by 23

section 2(c), is further amended— 24

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215 

•HR 5826 IH

(A) in paragraph (1), by striking ‘‘section 1

2719A’’ and inserting ‘‘section 2719A, 2730, 2

2731, or 2732’’; and 3

(B) in paragraph (2), by striking ‘‘section 4

2719A’’ and inserting ‘‘section 2719A, 2730, 5

2731, or 2732’’. 6

(3) CLERICAL AMENDMENT.—The table of con-7

tents in section 1 of the Employee Retirement In-8

come Security Act of 1974 is amended by inserting 9

after the item relating to section 716 the following 10

new items: 11

‘‘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 12

this section shall apply with respect to plan years begin-13

ning on or after January 1, 2022. 14

SEC. 10. REPORTING REQUIREMENTS REGARDING AIR AM-15

BULANCE SERVICES. 16

(a) REPORTING REQUIREMENTS FOR PROVIDERS OF 17

AIR AMBULANCE SERVICES.— 18

(1) IN GENERAL.—A provider of air ambulance 19

services shall submit to the Secretary of Health and 20

Human Services and the Secretary of Transpor-21

tation— 22

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216 

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(A) not later than the date that is 90 days 1

after the last day of the first plan year begin-2

ning on or after the date on which a final rule 3

is promulgated pursuant to the rulemaking de-4

scribed in subsection (d), the information de-5

scribed in paragraph (2) with respect to such 6

plan year; and 7

(B) not later than the date that is 90 days 8

after the last day of the plan year immediately 9

succeeding the plan year described in subpara-10

graph (A), such information with respect to 11

such immediately succeeding plan year. 12

(2) INFORMATION DESCRIBED.—For purposes 13

of paragraph (1), information described in this para-14

graph, with respect to a provider of air ambulance 15

services, is each of the following: 16

(A) Cost data, as determined appropriate 17

by the Secretary of Health and Human Serv-18

ices, in consultation with the Secretary of 19

Transportation, for air ambulance services fur-20

nished by such provider, separated to the max-21

imum extent possible by air transportation costs 22

associated with furnishing such air ambulance 23

services and costs of medical services and sup-24

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217 

•HR 5826 IH

plies associated with furnishing such air ambu-1

lance services. 2

(B) The number and location of all air am-3

bulance bases operated by such provider. 4

(C) The number and type of aircraft oper-5

ated by such provider. 6

(D) The number of air ambulance trans-7

ports, disaggregated by payor mix, including 8

group health plans, health insurance issuers, 9

and Government payors. 10

(E) The number of claims of such provider 11

that have been denied payment by a group 12

health plan or health insurance issuer and the 13

reasons for any such denials. 14

(F) The number of emergency and non-15

emergency air ambulance transports, 16

disaggregated by air ambulance base and type 17

of aircraft. 18

(b) REPORTING REQUIREMENTS FOR GROUP 19

HEALTH PLANS AND HEALTH INSURANCE ISSUERS.— 20

(1) IN GENERAL.—Each group health plan and 21

health insurance issuer offering health insurance 22

coverage in the individual or group market shall sub-23

mit to the Secretary of Health and Human Serv-24

ices— 25

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218 

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(A) not later than the date that is 90 days 1

after the last day of the first plan year begin-2

ning on or after the date on which a final rule 3

is promulgated pursuant to the rulemaking de-4

scribed in subsection (d), the information de-5

scribed in paragraph (2) with respect to such 6

plan year; and 7

(B) not later than the date that is 90 days 8

after the last day of the plan year immediately 9

succeeding the plan year described in subpara-10

graph (A), such information with respect to 11

such immediately succeeding plan year. 12

(2) INFORMATION DESCRIBED.—For purposes 13

of paragraph (1), information described in this para-14

graph, with respect to a group health plan or a 15

health insurance issuer offering health insurance 16

coverage in the individual or group market, is each 17

of the following: 18

(A) Claims data for air ambulance services 19

furnished by providers of such services, 20

disaggregated by each of the following factors: 21

(i) Whether such services were fur-22

nished on an emergent or nonemergent 23

basis. 24

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219 

•HR 5826 IH

(ii) Whether the provider of such serv-1

ices is part of a hospital-owned or spon-2

sored program, municipality-sponsored pro-3

gram, hospital independent partnership 4

(hybrid) program, or independent program. 5

(iii) Whether such services were fur-6

nished in a rural or urban area. 7

(iv) The type of aircraft (such as 8

rotor transport or fixed wing transport) 9

used to furnish such services. 10

(v) Whether the provider of such serv-11

ices has a contract with the plan or issuer, 12

as applicable, to furnish such services 13

under the plan or coverage, respectively. 14

(B) Such other information regarding pro-15

viders of air ambulance services as the Sec-16

retary of Health and Human Services may 17

specify. 18

(c) PUBLICATION OF COMPREHENSIVE REPORT.— 19

(1) IN GENERAL.—Not later than the date that 20

is one year after the date described in subsection 21

(b)(1)(B), the Secretary of Health and Human Serv-22

ices, in consultation with the Secretary of Transpor-23

tation (referred to in this section as the ‘‘Secre-24

taries’’), shall develop, and make publicly available 25

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220 

•HR 5826 IH

(subject to paragraph (3)), a comprehensive report 1

summarizing the information submitted under sub-2

sections (a) and (b) and including each of the fol-3

lowing: 4

(A) The percentage of providers of air am-5

bulance services that are part of a hospital- 6

owned or sponsored program, municipality- 7

sponsored program, hospital-independent part-8

nership (hybrid) program, or independent pro-9

gram. 10

(B) An assessment of the extent of com-11

petition among providers of air ambulance serv-12

ices on the basis of price and services offered, 13

and any changes in such competition over time. 14

(C) An assessment of the average charges 15

for air ambulance services, amounts paid by 16

group health plans and health insurance issuers 17

offering health insurance coverage in the indi-18

vidual or group market to providers of air am-19

bulance services for furnishing such services, 20

and amounts paid out-of-pocket by consumers, 21

and any changes in such amounts paid over 22

time. 23

(D) An assessment of the presence of air 24

ambulance bases in, or with the capability to 25

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221 

•HR 5826 IH

serve, rural areas, and the relative growth in air 1

ambulance bases in rural and urban areas over 2

time. 3

(E) Any evidence of gaps in rural access to 4

providers of air ambulance services. 5

(F) The percentage of providers of air am-6

bulance services that have contracts with group 7

health plans or health insurance issuers offering 8

health insurance coverage in the individual or 9

group market to furnish such services under 10

such plans or coverage, respectively. 11

(G) An assessment of whether there are in-12

stances of unfair, deceptive, or predatory prac-13

tices by providers of air ambulance services in 14

collecting payments from patients to whom such 15

services are furnished, such as referral of such 16

patients to collections, lawsuits, and liens or 17

wage garnishment actions. 18

(H) An assessment of whether there are 19

instances of group health plans or health insur-20

ance issuers not providing substantial reasons 21

for refusing to enter into contract negotiations 22

with providers of air ambulance services. 23

(I) An assessment of whether there are, 24

within the air ambulance industry, instances of 25

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222 

•HR 5826 IH

unreasonable industry concentration, excessive 1

market domination, or other conditions that 2

would allow at least one provider of air ambu-3

lance services to unreasonably increase prices or 4

exclude competition in air ambulance services in 5

a given geographic region. 6

(J) An assessment of the frequency of pa-7

tient balance billing, patient referrals to collec-8

tions, lawsuits to collect balance bills, and liens 9

or wage garnishment actions by providers of air 10

ambulance services as part of a collections proc-11

ess across hospital-owned or sponsored pro-12

grams, municipality-sponsored programs, hos-13

pital-independent partnership (hybrid) pro-14

grams, or independent programs, providers of 15

air ambulance services operated by public agen-16

cies (such as a State or county health depart-17

ment), and other independent providers of air 18

ambulance services. 19

(K) An assessment of the frequency of 20

claims appeals made by providers of air ambu-21

lance services to group health plans or health 22

insurance issuers offering health insurance cov-23

erage in the individual or group market with re-24

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223 

•HR 5826 IH

spect to air ambulance services furnished to en-1

rollees of such plans or coverage, respectively. 2

(L) Any other cost, quality, or other data 3

relating to air ambulance services or the air 4

ambulance industry, as determined necessary 5

and appropriate by the Secretaries. 6

(2) OTHER SOURCES OF INFORMATION.—The 7

Secretaries may incorporate information from inde-8

pendent experts or third-party sources in developing 9

the comprehensive report required under paragraph 10

(1). 11

(3) PROTECTION OF PROPRIETARY INFORMA-12

TION.—The Secretaries may not make publicly avail-13

able under this subsection any proprietary informa-14

tion. 15

(d) RULEMAKING.—Not later than the date that is 16

one year after the date of the enactment of this Act, the 17

Secretary of Health and Human Services, in consultation 18

with the Secretary of Transportation, shall, through notice 19

and comment rulemaking, specify the form and manner 20

in which reports described in subsections (a) and (b) shall 21

be submitted to such Secretaries, taking into consideration 22

(as applicable and to the extent feasible) any recommenda-23

tions included in the report submitted by the Advisory 24

Committee on Air Ambulance and Patient Billing under 25

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224 

•HR 5826 IH

section 418(e) of the FAA Reauthorization Act of 2018 1

(Public Law 115–254; 49 U.S.C. 42301 note prec.). 2

(e) CIVIL MONEY PENALTIES.— 3

(1) IN GENERAL.—Subject to paragraph (2), a 4

provider of air ambulance services who fails to sub-5

mit all information required under subsection (a)(2) 6

by the date described in subparagraph (A) or (B) of 7

subsection (a)(1), as applicable, shall be subject to 8

a civil money penalty of not more than $10,000. 9

(2) EXCEPTION.—In the case of a provider of 10

air ambulance services that submits only some of the 11

information required under subsection (a)(2) by the 12

date described in subparagraph (A) or (B) of sub-13

section (a)(1), as applicable, the Secretary of Health 14

and Human Services may waive the civil money pen-15

alty imposed under paragraph (1) if such provider 16

demonstrates a good faith effort in working with the 17

Secretary to submit the remaining information re-18

quired under subsection (a)(2). 19

(3) PROCEDURE.—The provisions of section 20

1128A of the Social Security Act (42 U.S.C. 1320a– 21

7a), other than subsections (a) and (b) and the first 22

sentence of subsection (c)(1), shall apply to civil 23

money penalties under this subsection in the same 24

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225 

•HR 5826 IH

manner as such provisions apply to a penalty or pro-1

ceeding under such section. 2

(f) UNFAIR AND DECEPTIVE PRACTICES AND UN-3

FAIR METHODS OF COMPETITION.—The Secretary of 4

Transportation may use any information submitted under 5

subsection (a) in determining whether a provider of air 6

ambulance services has violated section 41712(a) of title 7

49, United States Code. 8

(g) UNDERSTANDING AIR AMBULANCE QUALITY AND 9

PATIENT SAFETY.—Not later than 1 year after the date 10

of the enactment of this Act, the Comptroller General of 11

the United States shall conduct a study and submit to 12

Congress a report on options to establish quality, patient 13

safety, service reliability, and clinical capability standards 14

for each clinical capability level of air ambulances. Such 15

report shall include analysis and recommendations, as ap-16

propriate, to Congress regarding each of the following with 17

respect to air ambulance services: 18

(1) Qualifications of different clinical capability 19

levels and tiering of such levels. 20

(2) Patient safety and quality standards. 21

(3) Options for improving service reliability 22

during poor weather, night conditions, or other ad-23

verse conditions. 24

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226 

•HR 5826 IH

(4) Differences between air ambulance vehicle 1

types, services, and technologies, and other flight ca-2

pability standards, and the impact of such dif-3

ferences on patient safety. 4

(5) Clinical triage criteria for air ambulances. 5

(h) DEFINITIONS.—In this section, the terms ‘‘group 6

health plan’’, ‘‘health insurance coverage’’, and ‘‘health in-7

surance issuer’’ have the meanings given such terms in 8

section 2791 of the Public Health Service Act (42 U.S.C. 9

300gg–91). 10

SEC. 11. GAO REPORT ON EFFECTS OF LEGISLATION. 11

Not later than 2 years after the date of the enact-12

ment of this Act, the Comptroller General of the United 13

States shall submit to Congress a report summarizing the 14

effects of the provisions of this Act, including the amend-15

ments made by such provisions, on changes during such 16

period in health care provider networks of group health 17

plans and health insurance coverage offered by a health 18

insurance issuer in the group or individual market, in fee 19

schedules and amounts for health care services, and to 20

contracted rates under such plans or coverage. Such re-21

port shall— 22

(1) to the extent practicable, sample a statis-23

tically significant group of national health care pro-24

viders; and 25

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227 

•HR 5826 IH

(2) examine— 1

(A) provider network participation, includ-2

ing nonparticipating providers furnishing items 3

and services at participating facilities; 4

(B) health care provider group network 5

participation, including specialty, size, and own-6

ership; and 7

(C) the impact of State surprise billing 8

laws and network adequacy standards on par-9

ticipation of health care providers and facilities 10

in provider networks of group health plans and 11

of health insurance coverage offered by health 12

insurance issuers in the group or individual 13

market. 14

SEC. 12. TRANSITIONAL RULE ALLOWING DEDUCTION FOR 15

SURPRISE BILLING EXPENSES BELOW AGI 16

FLOOR. 17

(a) IN GENERAL.—Section 213 of the Internal Rev-18

enue Code of 1986 is amended by adding at the end the 19

following new subsection: 20

‘‘(g) TRANSITIONAL RULE ALLOWING DEDUCTION 21

FOR SURPRISE BILLING EXPENSES BELOW AGI 22

FLOOR.— 23

‘‘(1) IN GENERAL.—In addition to the deduc-24

tion allowed by subsection (a) for any taxable year, 25

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228 

•HR 5826 IH

there shall be allowed as a deduction an amount 1

equal to the lesser of— 2

‘‘(A) the excess of— 3

‘‘(i) the surprise billing expenses 4

which would be allowed as a deduction for 5

such taxable year under subsection (a) if 6

such subsection were applied without re-7

gard to the limitation based on the tax-8

payer’s adjusted gross income, over 9

‘‘(ii) $600, or 10

‘‘(B) the applicable percentage of the tax-11

payer’s adjusted gross income. 12

‘‘(2) SURPRISE BILLING EXPENSES.—For pur-13

poses of this subsection, the term ‘surprise billing 14

expenses’ means expenses paid for medical care of 15

an individual who is a participant, beneficiary, or en-16

rollee in a group health plan or in group or indi-17

vidual health insurance coverage offered by a health 18

insurance issuer (as such terms are defined in sec-19

tion 2791 of the Public Health Service Act), if— 20

‘‘(A) benefits are provided for such medical 21

care under such plan or coverage, and 22

‘‘(B) such medical care— 23

‘‘(i) is furnished by a provider without 24

a contractual relationship with such plan 25

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229 

•HR 5826 IH

or coverage with respect to the furnishing 1

of such medical care during a visit at a fa-2

cility with a contractual relationship with 3

such plan or coverage, or 4

‘‘(ii) is furnished in an emergency de-5

partment of a hospital or an independent 6

freestanding emergency department. 7

‘‘(3) APPLICABLE PERCENTAGE.—For purposes 8

of this section, the term ‘applicable percentage’ 9

means, with respect to any taxpayer for any taxable 10

year, the percentage in effect under subsection (a) 11

with respect to such taxpayer for such taxable year. 12

‘‘(4) LIMITATIONS.—Surprise billing expenses 13

shall be taken into account under paragraph (1) only 14

if such expenses are paid during the period begin-15

ning on January 1, 2020, and ending on the date 16

which is 1 year after the day before the date speci-17

fied in section 2(a)(5) of the Consumer Protections 18

Against Surprise Medical Bills Act of 2020.’’. 19

(b) CONFORMING AMENDMENTS.—Sections 105(f), 20

162(l)(3), and 7702B(e)(2) of such Code are each amend-21

ed by striking ‘‘213(a)’’ and inserting ‘‘213’’. 22

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230 

•HR 5826 IH

(c) EFFECTIVE DATE.—The amendments made by 1

this section shall apply to taxable years ending after De-2

cember 31, 2019. 3

Æ 

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		Superintendent of Documents
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	US GPO, Washington, DC 20401
	Superintendent of Documents
	GPO attests that this document has not been altered since it was disseminated by GPO
        

Picture Name From Date Type
Richard Neal D-MA 02/10/2020 Sponsor
Brad Wenstrup R-OH 02/10/2020 Cosponsor
Jackie Walorski R-IN 02/10/2020 Cosponsor
Glenn Thompson R-PA 02/10/2020 Cosponsor
Mike Thompson D-CA 02/10/2020 Cosponsor
Thomas Suozzi D-NY 02/10/2020 Cosponsor
Adrian Smith R-NE 02/10/2020 Cosponsor
Jason Smith R-MO 02/10/2020 Cosponsor
Donna Shalala D-FL 02/10/2020 Cosponsor
Terri Sewell D-AL 02/14/2020 Cosponsor
David Schweikert R-AZ 02/10/2020 Cosponsor
Kim Schrier D-WA 02/10/2020 Cosponsor
1 to 12 of 41 Desc 12
Date Branch Action
02/12/2020 President Ordered to be Reported in the Nature of a Substitute (Amended) by Voice Vote.Action By: Committee on Ways and Means
02/12/2020 President Committee Consideration and Mark-up Session Held.Action By: Committee on Ways and Means
02/11/2020 President Referred to the Subcommittee on Aviation.Action By: Committee on Transportation and Infrastructure
02/10/2020 President 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.Action By: House of Representatives
02/10/2020 President Introduced in HouseAction By: House of Representatives
Summary
Congress - Bill Number Major Title
Branch Vote Date Yes No Not Voting
Wiki







Bill TEXT Points.
This Bill has been listed with the following Subjects from Texts:
Claims


Law


California
Thompson of California, Mr

Commerce
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 concernedA BILLTo amend title XXVII of the Public Health Service Act, the Employee Retirement Income Security Act


End Bill TEXT Points.
Date Bill Major Title
Committee Name
Subject Type