Introduced in House Passed House Introduced in Senate Passed Senate To President Became Law
02/07/2020          

Ban Surprise Billing Act

Date Version PDF TXT
02/07/2020 Introduced in House Open

            I 

116TH CONGRESS 
2D SESSION H. R. 5800 

To end surprise medical billing and increase transparency in health coverage. 

IN THE HOUSE OF REPRESENTATIVES 

FEBRUARY 7, 2020 
Mr. SCOTT of Virginia (for himself and Ms. FOXX of North Carolina) intro-

duced the following bill; which was referred to the Committee on Energy 
and Commerce, and in addition to the Committees on Education and 
Labor, Ways and Means, and Oversight and Reform, 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 con-
cerned 

A BILL 
To end surprise medical billing and increase transparency 

in health coverage. 

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. 3

This Act may be cited as the ‘‘Ban Surprise Billing 4

Act’’. 5

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SEC. 2. PREVENTING SURPRISE MEDICAL BILLS. 1

(a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.— 2

Section 2719A of the Public Health Service Act (42 3

U.S.C. 300gg–19a) is amended— 4

(1) by amending subsection (b) to read as fol-5

lows: 6

‘‘(b) COVERAGE OF EMERGENCY SERVICES.— 7

‘‘(1) IN GENERAL.—If a group health plan, or 8

a health insurance issuer offering group or indi-9

vidual health insurance coverage, provides or covers 10

any benefits with respect to services in an emergency 11

department of a hospital or with respect to emer-12

gency services in an independent freestanding emer-13

gency department (as defined in paragraph (3)(D)), 14

the plan or issuer shall cover emergency services (as 15

defined in paragraph (3)(C))— 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 emergency facility, as appli-21

cable, with respect to such services; 22

‘‘(C) in a manner so that, if such services 23

are provided to a participant, beneficiary, or en-24

rollee by a nonparticipating provider or a non-25

participating emergency facility— 26

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‘‘(i) such services will be provided 1

without imposing any requirement under 2

the plan or coverage for prior authoriza-3

tion of services or any limitation on cov-4

erage that is more restrictive than the re-5

quirements or limitations that apply to 6

emergency services received from partici-7

pating providers and participating emer-8

gency facilities with respect to such plan or 9

coverage, respectively; 10

‘‘(ii) the cost-sharing requirement (ex-11

pressed as a copayment amount or coinsur-12

ance rate) is not greater than the require-13

ment that would apply if such services 14

were provided by a participating provider 15

or a participating emergency facility; 16

‘‘(iii) such cost-sharing requirement is 17

calculated as if the total amount that 18

would have been charged for such services 19

by such participating provider or partici-20

pating emergency facility were equal to the 21

recognized amount (as defined in para-22

graph (3)(H)) for such services, plan or 23

coverage, and year; 24

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‘‘(iv) the group health plan or health 1

insurance issuer, respectively, pays to such 2

provider or facility, respectively the 3

amount by which the recognized amount 4

for such services and year involved exceeds 5

the cost-sharing amount for such services 6

(as determined in accordance with clauses 7

(ii) and (iii)) and year; and 8

‘‘(v) any cost-sharing payments made 9

by the participant, beneficiary, or enrollee 10

with respect to such emergency services so 11

furnished shall be counted toward any in- 12

network deductible or out-of-pocket maxi-13

mums applied under the plan or coverage, 14

respectively (and such in-network deduct-15

ible and out-of-pocket maximums shall be 16

applied) in the same manner as if such 17

cost-sharing payments were made with re-18

spect to emergency services furnished by a 19

participating provider or a participating 20

emergency facility; and 21

‘‘(D) without regard to any other term or 22

condition of such coverage (other than exclusion 23

or coordination of benefits, or an affiliation or 24

waiting period, permitted under section 2704 of 25

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this Act, including as incorporated pursuant to 1

section 715 of the Employee Retirement Income 2

Security Act of 1974 and section 9815 of the 3

Internal Revenue Code of 1986, and other than 4

applicable cost-sharing). 5

‘‘(2) AUDIT PROCESS AND REGULATIONS FOR 6

MEDIAN CONTRACTED RATES.— 7

‘‘(A) AUDIT PROCESS.— 8

‘‘(i) IN GENERAL.—Not later than 9

July 1, 2021, the Secretary, in consulta-10

tion with appropriate State agencies and 11

the Secretary of Labor and the Secretary 12

of the Treasury, shall establish through 13

rulemaking a process, in accordance with 14

clause (ii), under which group health plans 15

and health insurance issuers offering 16

health insurance coverage in the group or 17

individual market are audited by the Sec-18

retary or applicable State authority to en-19

sure that— 20

‘‘(I) such plans and coverage are 21

in compliance with the requirement of 22

applying a median contracted rate 23

under this section; and 24

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‘‘(II) such median contracted 1

rate so applied satisfies the definition 2

under paragraph (3)(E) with respect 3

to the year involved, including with re-4

spect to a group health plan or health 5

insurance issuer described in clause 6

(ii) of such paragraph (3)(E). 7

‘‘(ii) AUDIT SAMPLES.—Under the 8

process established pursuant to clause (i), 9

the Secretary— 10

‘‘(I) shall conduct audits de-11

scribed in such clause, with respect to 12

a year (beginning with 2022), of a 13

sample with respect to such year of 14

claims data from not more than 25 15

group health plans and health insur-16

ance issuers offering health insurance 17

coverage in the group or individual 18

market; and 19

‘‘(II) may audit any group health 20

plan or health insurance issuer offer-21

ing health insurance coverage in the 22

group or individual market if the Sec-23

retary has received any complaint 24

about such plan or coverage, respec-25

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tively, that involves the compliance of 1

the plan or coverage, respectively, 2

with either of the requirements de-3

scribed in subclauses (I) and (II) of 4

such clause. 5

‘‘(iii) REPORTS.—Beginning for 2022, 6

the Secretary shall annually submit to 7

Congress a report on the number of plans 8

and issuers with respect to which audits 9

were conducted during such year pursuant 10

to this subparagraph. 11

‘‘(B) RULEMAKING.—Not later than July 12

1, 2021, the Secretary, in consultation with the 13

Secretary of Labor and the Secretary of the 14

Treasury, shall establish through rulemaking— 15

‘‘(i) the methodology the group health 16

plan or health insurance issuer offering 17

health insurance coverage in the group or 18

individual market shall use to determine 19

the median contracted rate, differentiating 20

by line of business; 21

‘‘(ii) the information such plan or 22

issuer, respectively, shall share with the 23

nonparticipating provider or nonpartici-24

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pating facility, as applicable, when making 1

such a determination; 2

‘‘(iii) the geographic regions applied 3

for purposes of this subparagraph, taking 4

into account access to items and services in 5

rural and underserved areas, including 6

health professional shortage areas, as de-7

fined in section 332; and 8

‘‘(iv) a process to receive complaints 9

of violations of the requirements described 10

in subclauses (I) and (II) of subparagraph 11

(A)(i) by group health plans and health in-12

surance issuers offering health insurance 13

coverage in the group or individual market. 14

Such rulemaking shall take into account pay-15

ments that are made by such plan or issuer, re-16

spectively, that are not on a fee-for-service 17

basis. Such methodology may account for rel-18

evant payment adjustments that take into ac-19

count quality or facility type (including higher 20

acuity settings and the case-mix of various fa-21

cility types) that are otherwise taken into ac-22

count for purposes of determining payment 23

amounts with respect to participating facilities. 24

In carrying out clause (iii), the Secretary shall 25

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consult with the National Association of Insur-1

ance Commissioners to establish the geographic 2

regions under such clause and shall periodically 3

update such regions, as appropriate. 4

‘‘(3) DEFINITIONS.—In this part: 5

‘‘(A) EMERGENCY DEPARTMENT OF A HOS-6

PITAL.—The term ‘emergency department of a 7

hospital’ includes a hospital outpatient depart-8

ment that provides emergency services. 9

‘‘(B) EMERGENCY MEDICAL CONDITION.— 10

The term ‘emergency medical condition’ means 11

a medical condition manifesting itself by acute 12

symptoms of sufficient severity (including se-13

vere pain) such that a prudent layperson, who 14

possesses an average knowledge of health and 15

medicine, could reasonably expect the absence 16

of immediate medical attention to result in a 17

condition described in clause (i), (ii), or (iii) of 18

section 1867(e)(1)(A) of the Social Security 19

Act. 20

‘‘(C) EMERGENCY SERVICES.— 21

‘‘(i) IN GENERAL.—The term ‘emer-22

gency services’, with respect to an emer-23

gency medical condition, means— 24

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‘‘(I) a medical screening exam-1

ination (as required under section 2

1867 of the Social Security Act, or as 3

would be required under such section 4

if such section applied to an inde-5

pendent freestanding emergency de-6

partment) that is within the capability 7

of the emergency department of a hos-8

pital or of an independent free-9

standing emergency department, as 10

applicable, including ancillary services 11

routinely available to the emergency 12

department to evaluate such emer-13

gency medical condition; and 14

‘‘(II) within the capabilities of 15

the staff and facilities available at the 16

hospital or the independent free-17

standing emergency department, as 18

applicable, such further medical exam-19

ination and treatment as are required 20

under section 1867 of such Act, or as 21

would be required under such section 22

if such section applied to an inde-23

pendent freestanding emergency de-24

partment, to stabilize the patient. 25

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‘‘(ii) INCLUSION OF CERTAIN SERV-1

ICES OUTSIDE OF EMERGENCY DEPART-2

MENT.— 3

‘‘(I) IN GENERAL.—For purposes 4

of this subsection and section 2799A– 5

1, in the case of an individual enrolled 6

in a group health plan or health in-7

surance coverage offered by a health 8

insurance issuer in the group or indi-9

vidual market who is furnished serv-10

ices described in clause (i) by a par-11

ticipating or nonparticipating provider 12

or a participating or nonparticipating 13

emergency facility to stabilize such in-14

dividual with respect to an emergency 15

medical condition, the term ‘emer-16

gency services’ shall include, unless 17

each of the conditions described in 18

subclause (II) are met, in addition to 19

the items and services described in 20

clause (i), items and services for 21

which benefits are provided or covered 22

under the plan or coverage, respec-23

tively, furnished by a nonparticipating 24

provider or nonparticipating facility, 25

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regardless of the department of the 1

hospital in which such individual is 2

furnished such items or services, if, 3

after such stabilization but during 4

such visit in which such individual is 5

so stabilized, the provider or facility 6

determines that such items or services 7

are needed. 8

‘‘(II) CONDITIONS.—For pur-9

poses of subclause (I), the conditions 10

described in this subclause, with re-11

spect to an individual who is stabilized 12

and furnished additional items and 13

services described in subclause (I) 14

after such stabilization by a provider 15

or facility described in subclause (I), 16

are the following: 17

‘‘(aa) Such a provider or fa-18

cility determines such individual 19

is able to travel using nonmedical 20

transportation or nonemergency 21

medical transportation. 22

‘‘(bb) Such provider fur-23

nishing such additional items and 24

services satisfies the notice and 25

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consent criteria of section 1

2799A–2(d) with respect to such 2

items and services. 3

‘‘(cc) Such an individual is 4

in a condition to receive (as de-5

termined in accordance with 6

guidance issued by the Secretary) 7

the information described in sec-8

tion 2799A–2 and to provide in-9

formed consent under such sec-10

tion, in accordance with applica-11

ble State law. 12

‘‘(D) INDEPENDENT FREESTANDING 13

EMERGENCY DEPARTMENT.—The term ‘inde-14

pendent freestanding emergency department’ 15

means a facility that— 16

‘‘(i) is geographically separate and 17

distinct and licensed separately from a hos-18

pital under applicable State law; and 19

‘‘(ii) provides any emergency services 20

(as defined in subparagraph (C)). 21

‘‘(E) MEDIAN CONTRACTED RATE.— 22

‘‘(i) IN GENERAL.—The term ‘median 23

contracted rate’ means, subject to clauses 24

(ii) and (iii), with respect to a sponsor of 25

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a group health plan and health insurance 1

issuer offering health insurance coverage in 2

the group or individual market— 3

‘‘(I) for an item or service fur-4

nished during 2022, the median of the 5

contracted rates recognized by the 6

plan or issuer, respectively (deter-7

mined with respect to all such plans 8

of such sponsor or all such coverage 9

offered by such issuer that are offered 10

within the same line of business as 11

the plan or coverage) as the total 12

maximum payment (including the 13

cost-sharing amount imposed for such 14

item or service and the amount to be 15

paid by the plan or issuer, respec-16

tively) under such plans or coverage, 17

respectively, on January 31, 2019, for 18

the same or a similar item or service 19

that is provided by a provider in the 20

same or similar specialty and provided 21

in the geographic region in which the 22

item or service is furnished, consistent 23

with the methodology established by 24

the Secretary under paragraph 25

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(2)(B), increased by the percentage 1

increase in the consumer price index 2

for all urban consumers (United 3

States city average) over 2019, such 4

percentage increase over 2020, and 5

such percentage increase over 2021; 6

and 7

‘‘(II) for an item or service fur-8

nished during 2023 or a subsequent 9

year, the median contracted rate de-10

termined under this clause for such 11

an item or service furnished in the 12

previous year, increased by the per-13

centage increase in the consumer price 14

index for all urban consumers (United 15

States city average) over such pre-16

vious year. 17

‘‘(ii) NEW PLANS AND COVERAGE.— 18

The term ‘median contracted rate’ means, 19

with respect to a sponsor of a group health 20

plan or health insurance issuer offering 21

health insurance coverage in the group or 22

individual market in a geographic region in 23

which such sponsor or issuer, respectively, 24

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did not offer any group health plan or 1

health insurance coverage during 2019— 2

‘‘(I) for the first year in which 3

such group health plan or health in-4

surance coverage, respectively, is of-5

fered in such region, a rate (deter-6

mined in accordance with a method-7

ology established by the Secretary) for 8

items and services that are covered by 9

such plan and furnished during such 10

first year; and 11

‘‘(II) for each subsequent year 12

such group health plan or health in-13

surance coverage, respectively, is of-14

fered in such region, the median con-15

tracted rate determined under this 16

clause for such items and services fur-17

nished in the previous year, increased 18

by the percentage increase in the con-19

sumer price index for all urban con-20

sumers (United States city average) 21

over such previous year. 22

‘‘(iii) INSUFFICIENT INFORMATION; 23

NEWLY COVERED ITEMS AND SERVICES.— 24

In the case of a sponsor of a group health 25

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plan or health insurance issuer offering 1

health insurance coverage in the group or 2

individual market that does not have suffi-3

cient information to calculate the median 4

of the contracted rates described in clause 5

(i)(I) in 2019 (or, in the case of a newly 6

covered item or service (as defined in 7

clause (iv)(III)), in the first coverage year 8

(as defined in clause (iv)(I)) for such item 9

or service with respect to such plan or cov-10

erage) for an item or service (including 11

with respect to provider type, or amount, 12

of claims for items or services (as deter-13

mined by the Secretary) provided in a par-14

ticular geographic region (other than in a 15

case with respect to which clause (ii) ap-16

plies)) the term ‘median contracted rate’— 17

‘‘(I) for an item or service fur-18

nished during 2022 (or, in the case of 19

a newly covered item or service, dur-20

ing the first coverage year for such 21

item or service with respect to such 22

plan or coverage), means such rate for 23

such item or service determined by 24

the sponsor or issuer, respectively, 25

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through use of any database that is 1

determined, in accordance with rule-2

making described in paragraph 3

(2)(B), to not have any conflicts of in-4

terest and to have sufficient informa-5

tion reflecting allowed amounts paid 6

to a health care provider or facility for 7

relevant services furnished in the ap-8

plicable geographic region (such as a 9

State all-payer claims database); 10

‘‘(II) for an item or service fur-11

nished in a subsequent year (before 12

the first sufficient information year 13

(as defined in clause (iv)(II)) for such 14

item or service with respect to such 15

plan or coverage), means the rate de-16

termined under subclause (I) or this 17

subclause, as applicable, for such item 18

or service for the year previous to 19

such subsequent year, increased by 20

the percentage increase in the con-21

sumer price index for all urban con-22

sumers (United States city average) 23

over such previous year; 24

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‘‘(III) for an item or service fur-1

nished in the first sufficient informa-2

tion year for such item or service with 3

respect to such plan or coverage, has 4

the meaning given the term median 5

contracted rate in clause (i)(I), except 6

that in applying such clause to such 7

item or service, the reference to ‘fur-8

nished during 2022’ shall be treated 9

as a reference to furnished during 10

such first sufficient information year, 11

the reference to ‘in 2019’ shall be 12

treated as a reference to such suffi-13

cient information year, and the in-14

crease described in such clause shall 15

not be applied; and 16

‘‘(IV) for an item or service fur-17

nished in any year subsequent to the 18

first sufficient information year for 19

such item or service with respect to 20

such plan or coverage, has the mean-21

ing given such term in clause (i)(II), 22

except that in applying such clause to 23

such item or service, the reference to 24

‘furnished during 2023 or a subse-25

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quent year’ shall be treated as a ref-1

erence to furnished during the year 2

after such first sufficient information 3

year or a subsequent year. 4

‘‘(iv) DEFINITIONS.—For purposes of 5

this subparagraph: 6

‘‘(I) FIRST COVERAGE YEAR.— 7

The term ‘first coverage year’ means, 8

with respect to a group health plan or 9

health insurance coverage offered by a 10

health insurance issuer in the group 11

or individual market and an item or 12

service for which coverage is not of-13

fered in 2019 under such plan or cov-14

erage, the first year after 2019 for 15

which coverage for such item or serv-16

ice is offered under such plan or 17

health insurance coverage. 18

‘‘(II) FIRST SUFFICIENT INFOR-19

MATION YEAR.—The term ‘first suffi-20

cient information year’ means, with 21

respect to a group health plan or 22

health insurance coverage offered by a 23

health insurance issuer in the group 24

or individual market— 25

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21 

•HR 5800 IH

‘‘(aa) in the case of an item 1

or service for which the plan or 2

coverage does not have sufficient 3

information to calculate the me-4

dian of the contracted rates de-5

scribed in clause (i)(I) in 2019, 6

the first year subsequent to 2022 7

for which the sponsor or issuer 8

has such sufficient information to 9

calculate the median of such con-10

tracted rates in the year previous 11

to such first subsequent year; 12

and 13

‘‘(bb) in the case of a newly 14

covered item or service, the first 15

year subsequent to the first cov-16

erage year for such item or serv-17

ice with respect to such plan or 18

coverage for which the sponsor or 19

issuer has sufficient information 20

to calculate the median of the 21

contracted rates described in 22

clause (i)(I) in the year previous 23

to such first subsequent year. 24

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22 

•HR 5800 IH

‘‘(III) NEWLY COVERED ITEM OR 1

SERVICE.—The term ‘newly covered 2

item or service’ means, with respect to 3

a group health plan or health insur-4

ance issuer offering health insurance 5

coverage in the group or individual 6

market, an item or service for which 7

coverage was not offered in 2019 8

under such plan or coverage, but is 9

offered under such plan or coverage in 10

a year after 2019. 11

‘‘(F) NONPARTICIPATING EMERGENCY FA-12

CILITY; PARTICIPATING EMERGENCY FACIL-13

ITY.— 14

‘‘(i) NONPARTICIPATING EMERGENCY 15

FACILITY.—The term ‘nonparticipating 16

emergency facility’ means, with respect to 17

an item or service and a group health plan 18

or health insurance coverage offered by a 19

health insurance issuer in the group or in-20

dividual market, an emergency department 21

of a hospital, or an independent free-22

standing emergency department, that does 23

not have a contractual relationship directly 24

or indirectly with the plan or issuer, re-25

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23 

•HR 5800 IH

spectively, for furnishing such item or serv-1

ice under the plan or coverage, respec-2

tively. 3

‘‘(ii) PARTICIPATING EMERGENCY FA-4

CILITY.—The term ‘participating emer-5

gency facility’ means, with respect to an 6

item or service and a group health plan or 7

health insurance coverage offered by a 8

health insurance issuer in the group or in-9

dividual market, an emergency department 10

of a hospital, or an independent free-11

standing emergency department, that has 12

a contractual relationship directly or indi-13

rectly with the plan or issuer, respectively, 14

with respect to the furnishing of such an 15

item or service at such facility. 16

‘‘(G) NONPARTICIPATING PROVIDERS; PAR-17

TICIPATING PROVIDERS.— 18

‘‘(i) NONPARTICIPATING PROVIDER.— 19

The term ‘nonparticipating provider’ 20

means, with respect to an item or service 21

and a group health plan or health insur-22

ance coverage offered by a health insur-23

ance issuer in the group or individual mar-24

ket, a physician or other health care pro-25

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24 

•HR 5800 IH

vider who is acting within the scope of 1

practice of that provider’s license or certifi-2

cation under applicable State law and who 3

does not have a contractual relationship 4

with the plan or issuer, respectively, for 5

furnishing such item or service under the 6

plan or coverage, respectively. 7

‘‘(ii) PARTICIPATING PROVIDER.—The 8

term ‘participating provider’ means, with 9

respect to an item or service and a group 10

health plan or health insurance coverage 11

offered by a health insurance issuer in the 12

group or individual market, a physician or 13

other health care provider who is acting 14

within the scope of practice of that pro-15

vider’s license or certification under appli-16

cable State law and who has a contractual 17

relationship with the plan or issuer, respec-18

tively, for furnishing such item or service 19

under the plan or coverage, respectively. 20

‘‘(H) RECOGNIZED AMOUNT.—The term 21

‘recognized amount’ means, with respect to an 22

item or service furnished by a nonparticipating 23

provider or emergency facility during a year 24

and a group health plan or health insurance 25

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25 

•HR 5800 IH

coverage offered by a health insurance issuer in 1

the group or individual market— 2

‘‘(i) subject to clause (iii), in the case 3

of such item or service furnished in a State 4

that has in effect a specified State law 5

with respect to such plan, coverage, or 6

issuer, respectively, such a nonpartici-7

pating provider or emergency facility, and 8

such an item or service, the amount deter-9

mined in accordance with such law; 10

‘‘(ii) subject to clause (iii), in the case 11

of such item or service furnished in a State 12

that does not have in effect a specified 13

State law, with respect to such plan, cov-14

erage, or issuer, respectively, such a non-15

participating provider or emergency facil-16

ity, and such an item or service, an 17

amount that is the median contracted rate 18

(as defined in subparagraph (E)) for such 19

year and determined in accordance with 20

rulemaking described in paragraph (2)(B) 21

for such item or service; or 22

‘‘(iii) in the case of such item or serv-23

ice furnished in a State with an All-Payer 24

Model Agreement under section 1115A of 25

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26 

•HR 5800 IH

the Social Security Act, the amount that 1

the State approves under such system for 2

such item or service so furnished. 3

‘‘(I) SPECIFIED STATE LAW.—The term 4

‘specified State law’ means, with respect to a 5

State, an item or service furnished by a non-6

participating provider or emergency facility dur-7

ing a year and a group health plan or health in-8

surance coverage offered by a health insurance 9

issuer in the group or individual market, a 10

State law that provides for a method for deter-11

mining the amount of payment that is required 12

to be covered by such a plan, coverage, or 13

issuer, respectively (to the extent such State 14

law applies to such plan, coverage, or issuer, 15

subject to section 514 of the Employee Retire-16

ment Income Security Act of 1974) in the case 17

of a participant, beneficiary, or enrollee covered 18

under such plan or coverage and receiving such 19

item or service from such a nonparticipating 20

provider or emergency facility. 21

‘‘(J) STABILIZE.—The term ‘to stabilize’, 22

with respect to an emergency medical condition 23

(as defined in subparagraph (B)), has the 24

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27 

•HR 5800 IH

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

Security Act (42 U.S.C. 1395dd(e)(3)).’’; and 2

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

sections: 4

‘‘(e) COVERAGE OF NON-EMERGENCY SERVICES 5

PERFORMED BY NONPARTICIPATING PROVIDERS AT CER-6

TAIN PARTICIPATING FACILITIES.— 7

‘‘(1) IN GENERAL.—In the case of items or 8

services (other than emergency services to which 9

subsection (b) applies) for which any benefits are 10

provided or covered by a group health plan or health 11

insurance issuer offering health insurance coverage 12

in the group or individual market furnished to a 13

participant, beneficiary, or enrollee of such plan or 14

coverage by a nonparticipating provider (as defined 15

in subsection (b)(3)(G)(i)) (and who, with respect to 16

such items and services, has not satisfied the notice 17

and consent criteria of section 2799A–2(d)) with re-18

spect to a visit (as defined by the Secretary in ac-19

cordance with paragraph (2)(B)) at a participating 20

health care facility (as defined in paragraph (2)(A)), 21

with respect to such plan or coverage, respectively, 22

the plan or coverage, respectively— 23

‘‘(A) shall not impose on such participant, 24

beneficiary, or enrollee a cost-sharing amount 25

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28 

•HR 5800 IH

(expressed as a copayment amount or coinsur-1

ance rate) for such items and services so fur-2

nished that is greater than the cost-sharing 3

amount that would apply under such plan or 4

coverage, respectively, had such items or serv-5

ices been furnished by a participating provider 6

(as defined in subsection (b)(3)(G)(ii)); 7

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

amount as if the total amount that would have 9

been charged for such items and services by 10

such participating provider were equal to the 11

recognized amount (as defined in subsection 12

(b)(3)(H)) for such items and services, plan or 13

coverage, and year; 14

‘‘(C) shall pay to such provider furnishing 15

such items and services to such participant, 16

beneficiary, or enrollee the amount by which the 17

recognized amount (as defined in subsection 18

(b)(3)(H)) for such items and services and year 19

involved exceeds the cost-sharing amount im-20

posed under the plan or coverage, respectively, 21

for such items and services (as determined in 22

accordance with subparagraphs (A) and (B)); 23

and 24

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29 

•HR 5800 IH

‘‘(D) shall count toward any in-network 1

deductible and in-network out-of-pocket maxi-2

mums (as applicable) applied under the plan or 3

coverage, respectively, any cost-sharing pay-4

ments made by the participant, beneficiary, or 5

enrollee (and such in-network deductible and 6

out-of-pocket maximums shall be applied) with 7

respect to such items and services so furnished 8

in the same manner as if such cost-sharing pay-9

ments were with respect to items and services 10

furnished by a participating provider. 11

‘‘(2) DEFINITIONS.—In this section: 12

‘‘(A) PARTICIPATING HEALTH CARE FACIL-13

ITY.— 14

‘‘(i) IN GENERAL.—The term ‘partici-15

pating health care facility’ means, with re-16

spect to an item or service and a group 17

health plan or health insurance issuer of-18

fering health insurance coverage in the 19

group or individual market, a health care 20

facility described in clause (ii) that has a 21

contractual relationship with the plan or 22

issuer, respectively, with respect to the fur-23

nishing of such an item or service at the 24

facility. 25

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30 

•HR 5800 IH

‘‘(ii) HEALTH CARE FACILITY DE-1

SCRIBED.—A health care facility described 2

in this clause, with respect to a group 3

health plan or health insurance coverage 4

offered in the group or individual market, 5

is each of the following: 6

‘‘(I) A hospital (as defined in 7

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

‘‘(II) A hospital outpatient de-9

partment. 10

‘‘(III) A critical access hospital 11

(as defined in section 1861(mm) of 12

such Act). 13

‘‘(IV) An ambulatory surgical 14

center (as defined in section 15

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

‘‘(V) Any other facility that pro-17

vides items or services for which cov-18

erage is provided under the plan or 19

coverage, respectively. 20

‘‘(B) VISIT.—The term ‘visit’ shall, with 21

respect to items and services furnished to an in-22

dividual at a participating health care facility, 23

include equipment and devices, telemedicine 24

services, imaging services, laboratory services, 25

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31 

•HR 5800 IH

and such other items and services as the Sec-1

retary may specify, regardless of whether or not 2

the provider furnishing such items or services is 3

at the facility. 4

‘‘(f) AIR AMBULANCE SERVICES.— 5

‘‘(1) IN GENERAL.—In the case of a partici-6

pant, beneficiary, or enrollee in a group health plan 7

or health insurance coverage offered in the group or 8

individual market who receives air ambulance serv-9

ices from a nonparticipating provider (as defined in 10

subsection (b)(3)(G)) with respect to such plan or 11

coverage, if such services would be covered if pro-12

vided by a participating provider (as defined in such 13

section) with respect to such plan or coverage— 14

‘‘(A) the cost-sharing requirement (ex-15

pressed as a copayment amount, coinsurance 16

rate, or deductible) with respect to such services 17

shall be the same requirement that would apply 18

if such services were provided by such a partici-19

pating provider, and any coinsurance or deduct-20

ible shall be based on rates that would apply for 21

such services if they were furnished by such a 22

participating provider; 23

‘‘(B) such cost-sharing amounts shall be 24

counted toward the in-network deductible and 25

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32 

•HR 5800 IH

in-network out-of-pocket maximum amount 1

under the plan or coverage for the plan year 2

(and such in-network deductible shall be ap-3

plied) with respect to such items and services so 4

furnished in the same manner as if such cost- 5

sharing payments were with respect to items 6

and services furnished by a participating pro-7

vider; and 8

‘‘(C) the plan or coverage shall pay to such 9

provider furnishing such services to such partic-10

ipant, beneficiary, or enrollee the amount by 11

which the recognized amount (as defined in and 12

determined pursuant to subsection 13

(b)(3)(H)(ii)) for such services and year in-14

volved exceeds the cost-sharing amount imposed 15

under the plan or coverage, respectively, for 16

such services (as determined in accordance with 17

subparagraphs (A) and (B)). 18

‘‘(2) AIR AMBULANCE SERVICE DEFINED.—For 19

purposes of this section, the term ‘air ambulance 20

service’ means medical transport by helicopter or 21

airplane for patients. 22

‘‘(g) CERTAIN ACCESS FEES TO CERTAIN DATA-23

BASES.—In the case of a sponsor of a group health plan 24

or health insurance issuer offering health insurance cov-25

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33 

•HR 5800 IH

erage in the group or individual market that, pursuant to 1

subsection (b)(3)(E)(iii), uses a database described in 2

such subsection to determine a rate to apply under such 3

subsection for an item or service by reason of having insuf-4

ficient information described in such subsection with re-5

spect to such item or service, such sponsor or issuer shall 6

cover the cost for access to such database.’’. 7

(b) ERISA AMENDMENTS.— 8

(1) IN GENERAL.—Subpart B of part 7 of sub-9

title B of title I of the Employee Retirement Income 10

Security Act of 1974 (29 U.S.C. 1185 et seq.) is 11

amended by adding at the end the following: 12

‘‘SEC. 716. CONSUMER PROTECTIONS. 13

‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If 14

a group health plan or health insurance issuer offering 15

group health insurance coverage requires or provides for 16

designation by a participant or beneficiary of a partici-17

pating primary care provider, then the plan or issuer shall 18

permit each participant or beneficiary to designate any 19

participating primary care provider who is available to ac-20

cept such individual. 21

‘‘(b) COVERAGE OF EMERGENCY SERVICES.— 22

‘‘(1) IN GENERAL.—If a group health plan, or 23

a health insurance issuer offering group health in-24

surance coverage, provides or covers any benefits 25

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34 

•HR 5800 IH

with respect to services in an emergency department 1

of a hospital or with respect to emergency services 2

in an independent freestanding emergency depart-3

ment (as defined in paragraph (3)(D)), the plan or 4

issuer shall cover emergency services (as defined in 5

paragraph (3)(C))— 6

‘‘(A) without the need for any prior au-7

thorization determination; 8

‘‘(B) whether the health care provider fur-9

nishing such services is a participating provider 10

or a participating emergency facility, as appli-11

cable, with respect to such services; 12

‘‘(C) in a manner so that, if such services 13

are provided to a participant or beneficiary by 14

a nonparticipating provider or a nonpartici-15

pating emergency facility— 16

‘‘(i) such services will be provided 17

without imposing any requirement under 18

the plan for prior authorization of services 19

or any limitation on coverage that is more 20

restrictive than the requirements or limita-21

tions that apply to emergency services re-22

ceived from participating providers and 23

participating emergency facilities with re-24

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35 

•HR 5800 IH

spect to such plan or coverage, respec-1

tively; 2

‘‘(ii) the cost-sharing requirement (ex-3

pressed as a copayment amount or coinsur-4

ance rate) is not greater than the require-5

ment that would apply if such services 6

were provided by a participating provider 7

or a participating emergency facility; 8

‘‘(iii) such cost-sharing requirement is 9

calculated as if the total amount that 10

would have been charged for such services 11

by such participating provider or partici-12

pating emergency facility were equal to the 13

recognized amount (as defined in para-14

graph (3)(H)) for such services, plan or 15

coverage, and year; 16

‘‘(iv) the group health plan or health 17

insurance issuer, respectively, pays to such 18

provider or facility, respectively, the 19

amount by which the recognized amount 20

for such services and year involved exceeds 21

the cost-sharing amount for such services 22

(as determined in accordance with clauses 23

(ii) and (iii)) and year; and 24

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36 

•HR 5800 IH

‘‘(v) any cost-sharing payments made 1

by the participant or beneficiary with re-2

spect to such emergency services so fur-3

nished shall be counted toward any in-net-4

work deductible or out-of-pocket maxi-5

mums applied under the plan or coverage, 6

respectively (and such in-network deduct-7

ible and out-of-pocket maximums shall be 8

applied) in the same manner as if such 9

cost-sharing payments were made with re-10

spect to emergency services furnished by a 11

participating provider or a participating 12

emergency facility; and 13

‘‘(D) without regard to any other term or 14

condition of such coverage (other than exclusion 15

or coordination of benefits, or an affiliation or 16

waiting period, permitted under section 2704 of 17

the Public Health Service Act, including as in-18

corporated pursuant to section 715 of this Act 19

and section 9815 of the Internal Revenue Code 20

of 1986, and other than applicable cost-shar-21

ing). 22

‘‘(2) AUDIT PROCESS AND REGULATIONS FOR 23

MEDIAN CONTRACTED RATES.— 24

‘‘(A) AUDIT PROCESS.— 25

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37 

•HR 5800 IH

‘‘(i) IN GENERAL.—Not later than 1

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

tion with appropriate State agencies and 3

the Secretary of Health and Human Serv-4

ices and the Secretary of the Treasury, 5

shall establish through rulemaking a proc-6

ess, in accordance with clause (ii), under 7

which group health plans and health insur-8

ance issuers offering health insurance cov-9

erage in the group market are audited by 10

the Secretary or applicable State authority 11

to ensure that— 12

‘‘(I) such plans and coverage are 13

in compliance with the requirement of 14

applying a median contracted rate 15

under this section; and 16

‘‘(II) such median contracted 17

rate so applied satisfies the definition 18

under paragraph (3)(E) with respect 19

to the year involved, including with re-20

spect to a group health plan or health 21

insurance issuer described in clause 22

(ii) of such paragraph (3)(E). 23

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38 

•HR 5800 IH

‘‘(ii) AUDIT SAMPLES.—Under the 1

process established pursuant to clause (i), 2

the Secretary— 3

‘‘(I) shall conduct audits de-4

scribed in such clause, with respect to 5

a year (beginning with 2022), of a 6

sample with respect to such year of 7

claims data from not more than 25 8

group health plans and health insur-9

ance issuers offering health insurance 10

coverage in the group market; and 11

‘‘(II) may audit any group health 12

plan or health insurance issuer offer-13

ing health insurance coverage in the 14

group market if the Secretary has re-15

ceived any complaint about such plan 16

or coverage, respectively, that involves 17

the compliance of the plan or cov-18

erage, respectively, with either of the 19

requirements described in subclauses 20

(I) and (II) of such clause. 21

‘‘(iii) REPORTS.—Beginning for 2022, 22

the Secretary shall annually submit to 23

Congress information on the number of 24

plans and issuers with respect to which au-25

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39 

•HR 5800 IH

dits were conducted during such year pur-1

suant to this subparagraph. 2

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

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

Secretary of the Treasury and the Secretary of 5

Health and Human Services, shall establish 6

through rulemaking— 7

‘‘(i) the methodology the group health 8

plan or health insurance issuer offering 9

health insurance coverage in the group 10

market shall use to determine the median 11

contracted rate, differentiating by line of 12

business; 13

‘‘(ii) the information such plan or 14

issuer, respectively, shall share with the 15

nonparticipating provider or nonpartici-16

pating facility, as applicable, when making 17

such a determination; 18

‘‘(iii) the geographic regions applied 19

for purposes of this subparagraph, taking 20

into account access to items and services in 21

rural and underserved areas, including 22

health professional shortage areas, as de-23

fined in section 332 of the Public Health 24

Service Act; and 25

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•HR 5800 IH

‘‘(iv) a process to receive complaints 1

of violations of the requirements described 2

in subclauses (I) and (II) of paragraph 3

(2)(A)(i) by group health plans and health 4

insurance issuers offering health insurance 5

coverage in the group market. 6

Such rulemaking shall take into account pay-7

ments that are made by such plan or issuer, re-8

spectively, that are not on a fee-for-service 9

basis. Such methodology may account for rel-10

evant payment adjustments that take into ac-11

count quality or facility type (including higher 12

acuity settings and the case-mix of various fa-13

cility types) that are otherwise taken into ac-14

count for purposes of determining payment 15

amounts with respect to participating facilities. 16

In carrying out clause (iii), the Secretary shall 17

consult with the National Association of Insur-18

ance Commissioners to establish the geographic 19

regions under such clause and shall periodically 20

update such regions, as appropriate. 21

‘‘(3) DEFINITIONS.—In this section: 22

‘‘(A) EMERGENCY DEPARTMENT OF A HOS-23

PITAL.—The term ‘emergency department of a 24

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41 

•HR 5800 IH

hospital’ includes a hospital outpatient depart-1

ment that provides emergency services. 2

‘‘(B) EMERGENCY MEDICAL CONDITION.— 3

The term ‘emergency medical condition’ means 4

a medical condition manifesting itself by acute 5

symptoms of sufficient severity (including se-6

vere pain) such that a prudent layperson, who 7

possesses an average knowledge of health and 8

medicine, could reasonably expect the absence 9

of immediate medical attention to result in a 10

condition described in clause (i), (ii), or (iii) of 11

section 1867(e)(1)(A) of the Social Security 12

Act. 13

‘‘(C) EMERGENCY SERVICES.— 14

‘‘(i) IN GENERAL.—The term ‘emer-15

gency services’, with respect to an emer-16

gency medical condition, means— 17

‘‘(I) a medical screening exam-18

ination (as required under section 19

1867 of the Social Security Act, or as 20

would be required under such section 21

if such section applied to an inde-22

pendent freestanding emergency de-23

partment) that is within the capability 24

of the emergency department of a hos-25

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42 

•HR 5800 IH

pital or of an independent free-1

standing emergency department, as 2

applicable, including ancillary services 3

routinely available to the emergency 4

department to evaluate such emer-5

gency medical condition; and 6

‘‘(II) within the capabilities of 7

the staff and facilities available at the 8

hospital or the independent free-9

standing emergency department, as 10

applicable, such further medical exam-11

ination and treatment as are required 12

under section 1867 of such Act, or as 13

would be required under such section 14

if such section applied to an inde-15

pendent freestanding emergency de-16

partment, to stabilize the patient. 17

‘‘(ii) INCLUSION OF CERTAIN SERV-18

ICES OUTSIDE OF EMERGENCY DEPART-19

MENT.— 20

‘‘(I) IN GENERAL.—For purposes 21

of this subsection and section 2799A– 22

1, in the case of an individual enrolled 23

in a group health plan or health in-24

surance coverage offered by a health 25

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43 

•HR 5800 IH

insurance issuer in the group or indi-1

vidual market who is furnished serv-2

ices described in clause (i) by a par-3

ticipating or nonparticipating provider 4

or a participating or nonparticipating 5

emergency facility to stabilize such in-6

dividual with respect to an emergency 7

medical condition, the term ‘emer-8

gency services’ shall include, unless 9

each of the conditions described in 10

subclause (II) are met, in addition to 11

the items and services described in 12

clause (i), items and services for 13

which benefits are provided or covered 14

under the plan or coverage, respec-15

tively, furnished by a nonparticipating 16

provider or nonparticipating facility, 17

regardless of the department of the 18

hospital in which such individual is 19

furnished such items or services, if, 20

after such stabilization but during 21

such visit in which such individual is 22

so stabilized, the provider or facility 23

determines that such items or services 24

are needed. 25

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•HR 5800 IH

‘‘(II) CONDITIONS.—For pur-1

poses of subclause (I), the conditions 2

described in this subclause, with re-3

spect to an individual who is stabilized 4

and furnished additional items and 5

services described in subclause (I) 6

after such stabilization by a provider 7

or facility described in subclause (I), 8

are the following: 9

‘‘(aa) Such a provider or fa-10

cility determines such individual 11

is able to travel using nonmedical 12

transportation or nonemergency 13

medical transportation. 14

‘‘(bb) Such provider fur-15

nishing such additional items and 16

services satisfies the notice and 17

consent criteria of section 18

2799A–2(d) of the Public Health 19

Service Act with respect to such 20

items and services. 21

‘‘(cc) Such an individual is 22

in a condition to receive (as de-23

termined in accordance with 24

guidance issued by the Secretary) 25

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45 

•HR 5800 IH

the information described in sec-1

tion 2799A–2 of the Public 2

Health Service Act and to pro-3

vide informed consent under such 4

section, in accordance with appli-5

cable State law. 6

‘‘(D) INDEPENDENT FREESTANDING 7

EMERGENCY DEPARTMENT.—The term ‘inde-8

pendent freestanding emergency department’ 9

means a facility that— 10

‘‘(i) is geographically separate and 11

distinct and licensed separately from a hos-12

pital under applicable State law; and 13

‘‘(ii) provides any emergency services 14

(as defined in subparagraph (C)). 15

‘‘(E) MEDIAN CONTRACTED RATE.— 16

‘‘(i) IN GENERAL.—The term ‘median 17

contracted rate’ means, subject to clauses 18

(ii) and (iii), with respect to a sponsor of 19

a group health plan and health insurance 20

issuer offering health insurance coverage in 21

the group market— 22

‘‘(I) for an item or service fur-23

nished during 2022, the median of the 24

contracted rates recognized by the 25

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46 

•HR 5800 IH

plan or issuer, respectively (deter-1

mined with respect to all such plans 2

of such sponsor or all such coverage 3

offered by such issuer that are offered 4

within the same line of business as 5

the plan or coverage) as the total 6

maximum payment (including the 7

cost-sharing amount imposed for such 8

item or service and the amount to be 9

paid by such plan or such issuer, re-10

spectively) under such plans or cov-11

erage, respectively, on January 31, 12

2019, for the same or a similar item 13

or service that is provided by a pro-14

vider in the same or similar specialty 15

and provided in the geographic region 16

in which the item or service is fur-17

nished, consistent with the method-18

ology established by the Secretary 19

under paragraph (2)(B), increased by 20

the percentage increase in the con-21

sumer price index for all urban con-22

sumers (United States city average) 23

over 2019, such percentage increase 24

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47 

•HR 5800 IH

over 2020, and such percentage in-1

crease over 2021; and 2

‘‘(II) for an item or service fur-3

nished during 2023 or a subsequent 4

year, the median contracted rate de-5

termined under this clause for such 6

an item or service furnished in the 7

previous year, increased by the per-8

centage increase in the consumer price 9

index for all urban consumers (United 10

States city average) over such pre-11

vious year. 12

‘‘(ii) NEW PLANS AND COVERAGE.— 13

The term ‘median contracted rate’ means, 14

with respect to a sponsor of a group health 15

plan or health insurance issuer offering 16

health insurance coverage in the group 17

market in a geographic region in which 18

such sponsor or issuer, respectively, did 19

not offer any group health plan or health 20

insurance coverage during 2019— 21

‘‘(I) for the first year in which 22

such group health plan or health in-23

surance coverage, respectively, is of-24

fered in such region, a rate (deter-25

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48 

•HR 5800 IH

mined in accordance with a method-1

ology established by the Secretary) for 2

items and services that are covered by 3

such plan and furnished during such 4

first year; and 5

‘‘(II) for each subsequent year 6

such group health plan or health in-7

surance coverage, respectively, is of-8

fered in such region, the median con-9

tracted rate determined under this 10

clause for such items and services fur-11

nished in the previous year, increased 12

by the percentage increase in the con-13

sumer price index for all urban con-14

sumers (United States city average) 15

over such previous year. 16

‘‘(iii) INSUFFICIENT INFORMATION; 17

NEWLY COVERED ITEMS AND SERVICES.— 18

In the case of a sponsor of a group health 19

plan or health insurance issuer offering 20

health insurance coverage in the group 21

market that does not have sufficient infor-22

mation to calculate the median of the con-23

tracted rates described in clause (i)(I) in 24

2019 (or, in the case of a newly covered 25

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49 

•HR 5800 IH

item or service (as defined in clause 1

(iv)(III)), in the first coverage year (as de-2

fined in clause (iv)(I)) for such item or 3

service with respect to such plan or cov-4

erage) for an item or service (including 5

with respect to provider type, or amount, 6

of claims for items or services (as deter-7

mined by the Secretary) provided in a par-8

ticular geographic region (other than in a 9

case with respect to which clause (ii) ap-10

plies)) the term ‘median contracted rate’— 11

‘‘(I) for an item or service fur-12

nished during 2022 (or, in the case of 13

a newly covered item or service, dur-14

ing the first coverage year for such 15

item or service with respect to such 16

plan or coverage), means such rate for 17

such item or service determined by 18

the sponsor or issuer, respectively, 19

through use of any database that is 20

determined, in accordance with rule-21

making described in paragraph 22

(2)(B), to not have any conflicts of in-23

terest and to have sufficient informa-24

tion reflecting allowed amounts paid 25

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50 

•HR 5800 IH

to a health care provider or facility for 1

relevant services furnished in the ap-2

plicable geographic region (such as a 3

State all-payer claims database); 4

‘‘(II) for an item or service fur-5

nished in a subsequent year (before 6

the first sufficient information year 7

(as defined in clause (iv)(II)) for such 8

item or service with respect to such 9

plan or coverage), means the rate de-10

termined under subclause (I) or this 11

subclause, as applicable, for such item 12

or service for the year previous to 13

such subsequent year, increased by 14

the percentage increase in the con-15

sumer price index for all urban con-16

sumers (United States city average) 17

over such previous year; 18

‘‘(III) for an item or service fur-19

nished in the first sufficient informa-20

tion year for such item or service with 21

respect to such plan or coverage, has 22

the meaning given the term median 23

contracted rate in clause (i)(I), except 24

that in applying such clause to such 25

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51 

•HR 5800 IH

item or service, the reference to ‘fur-1

nished during 2022’ shall be treated 2

as a reference to furnished during 3

such first sufficient information year, 4

the reference to ‘in 2019’ shall be 5

treated as a reference to such suffi-6

cient information year, and the in-7

crease described in such clause shall 8

not be applied; and 9

‘‘(IV) for an item or service fur-10

nished in any year subsequent to the 11

first sufficient information year for 12

such item or service with respect to 13

such plan or coverage, has the mean-14

ing given such term in clause (i)(II), 15

except that in applying such clause to 16

such item or service, the reference to 17

‘furnished during 2023 or a subse-18

quent year’ shall be treated as a ref-19

erence to furnished during the year 20

after such first sufficient information 21

year or a subsequent year. 22

‘‘(iv) DEFINITIONS.—For purposes of 23

this subparagraph: 24

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•HR 5800 IH

‘‘(I) FIRST COVERAGE YEAR.— 1

The term ‘first coverage year’ means, 2

with respect to a group health plan or 3

health insurance coverage offered by a 4

health insurance issuer in the group 5

market and an item or service for 6

which coverage is not offered in 2019 7

under such plan or coverage, the first 8

year after 2019 for which coverage for 9

such item or service is offered under 10

such plan or health insurance cov-11

erage. 12

‘‘(II) FIRST SUFFICIENT INFOR-13

MATION YEAR.—The term ‘first suffi-14

cient information year’ means, with 15

respect to a group health plan or 16

health insurance coverage offered by a 17

health insurance issuer in the group 18

market— 19

‘‘(aa) in the case of an item 20

or service for which the plan or 21

coverage does not have sufficient 22

information to calculate the me-23

dian of the contracted rates de-24

scribed in clause (i)(I) in 2019, 25

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53 

•HR 5800 IH

the first year subsequent to 2022 1

for which such sponsor or issuer 2

has such sufficient information to 3

calculate the median of such con-4

tracted rates in the year previous 5

to such first subsequent year; 6

and 7

‘‘(bb) in the case of a newly 8

covered item or service, the first 9

year subsequent to the first cov-10

erage year for such item or serv-11

ice with respect to such plan or 12

coverage for which the sponsor or 13

issuer has sufficient information 14

to calculate the median of the 15

contracted rates described in 16

clause (i)(I) in the year previous 17

to such first subsequent year. 18

‘‘(III) NEWLY COVERED ITEM OR 19

SERVICE.—The term ‘newly covered 20

item or service’ means, with respect to 21

a group health plan or health insur-22

ance issuer offering health insurance 23

coverage in the group market, an item 24

or service for which coverage was not 25

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54 

•HR 5800 IH

offered in 2019 under such plan or 1

coverage, but is offered under such 2

plan or coverage in a year after 2019. 3

‘‘(F) NONPARTICIPATING EMERGENCY FA-4

CILITY; PARTICIPATING EMERGENCY FACIL-5

ITY.— 6

‘‘(i) NONPARTICIPATING EMERGENCY 7

FACILITY.—The term ‘nonparticipating 8

emergency facility’ means, with respect to 9

an item or service and a group health plan 10

or health insurance coverage offered by a 11

health insurance issuer in the group mar-12

ket, an emergency department of a hos-13

pital, or an independent freestanding emer-14

gency department, that does not have a 15

contractual relationship directly or indi-16

rectly with the plan or issuer, respectively, 17

for furnishing such item or service under 18

the plan or coverage, respectively. 19

‘‘(ii) PARTICIPATING EMERGENCY FA-20

CILITY.—The term ‘participating emer-21

gency facility’ means, with respect to an 22

item or service and a group health plan or 23

health insurance coverage offered by a 24

health insurance issuer in the group mar-25

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55 

•HR 5800 IH

ket, an emergency department of a hos-1

pital, or an independent freestanding emer-2

gency department, that has a contractual 3

relationship directly or indirectly with the 4

plan or issuer, respectively, with respect to 5

the furnishing of such an item or service at 6

such facility. 7

‘‘(G) NONPARTICIPATING PROVIDERS; PAR-8

TICIPATING PROVIDERS.— 9

‘‘(i) NONPARTICIPATING PROVIDER.— 10

The term ‘nonparticipating provider’ 11

means, with respect to an item or service 12

and a group health plan or health insur-13

ance coverage offered by a health insur-14

ance issuer in the group market, a physi-15

cian or other health care provider who is 16

acting within the scope of practice of that 17

provider’s license or certification under ap-18

plicable State law and who does not have 19

a contractual relationship with the plan or 20

issuer, respectively, for furnishing such 21

item or service under the plan or coverage, 22

respectively. 23

‘‘(ii) PARTICIPATING PROVIDER.—The 24

term ‘participating provider’ means, with 25

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56 

•HR 5800 IH

respect to an item or service and a group 1

health plan or health insurance coverage 2

offered by a health insurance issuer in the 3

group market, a physician or other health 4

care provider who is acting within the 5

scope of practice of that provider’s license 6

or certification under applicable State law 7

and who has a contractual relationship 8

with the plan or issuer, respectively, for 9

furnishing such item or service under the 10

plan or coverage, respectively. 11

‘‘(H) RECOGNIZED AMOUNT.—The term 12

‘recognized amount’ means, with respect to an 13

item or service furnished by a nonparticipating 14

provider or emergency facility during a year 15

and a group health plan or health insurance 16

coverage offered by a health insurance issuer in 17

the group market— 18

‘‘(i) subject to clause (iii), in the case 19

of such item or service furnished in a State 20

that has in effect a specified State law 21

with respect to such plan, coverage, or 22

issuer, respectively, such a nonpartici-23

pating provider or emergency facility, and 24

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57 

•HR 5800 IH

such an item or service, the amount deter-1

mined in accordance with such law; 2

‘‘(ii) subject to clause (iii), in the case 3

of such item or service furnished in a State 4

that does not have in effect a specified 5

State law, with respect to such plan, cov-6

erage, or issuer, respectively, such a non-7

participating provider or emergency facil-8

ity, and such an item or service, an 9

amount that is the median contracted rate 10

(as defined in subparagraph (E)) for such 11

year and determined in accordance with 12

rulemaking described in paragraph (2)(B) 13

for such item or service; or 14

‘‘(iii) in the case of such item or serv-15

ice furnished in a State with an All-Payer 16

Model Agreement under section 1115A of 17

the Social Security Act, the amount that 18

the State approves under such system for 19

such item or service so furnished. 20

‘‘(I) SPECIFIED STATE LAW.—The term 21

‘specified State law’ means, with respect to a 22

State, an item or service furnished by a non-23

participating provider or emergency facility dur-24

ing a year and a group health plan or health in-25

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58 

•HR 5800 IH

surance coverage offered by a health insurance 1

issuer in the group market, a State law that 2

provides for a method for determining the 3

amount of payment that is required to be cov-4

ered by such a plan, coverage, or issuer, respec-5

tively (to the extent such State law applies to 6

such plan, coverage, or issuer, subject to section 7

514) in the case of a participant or beneficiary 8

covered under such plan or coverage and receiv-9

ing such item or service from such a nonpartici-10

pating provider or emergency facility. 11

‘‘(J) STABILIZE.—The term ‘to stabilize’, 12

with respect to an emergency medical condition 13

(as defined in subparagraph (B)), has the 14

meaning give in section 1867(e)(3) of the Social 15

Security Act (42 U.S.C. 1395dd(e)(3)). 16

‘‘(c) ACCESS TO PEDIATRIC CARE.— 17

‘‘(1) PEDIATRIC CARE.—In the case of a person 18

who has a child who is a participant or beneficiary 19

under a group health plan, or health insurance cov-20

erage offered by a health insurance issuer in the 21

group market, if the plan or issuer requires or pro-22

vides for the designation of a participating primary 23

care provider for the child, the plan or issuer shall 24

permit such person to designate a physician 25

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59 

•HR 5800 IH

(allopathic or osteopathic) who specializes in pediat-1

rics as the child’s primary care provider if such pro-2

vider participates in the network of the plan or 3

issuer. 4

‘‘(2) CONSTRUCTION.—Nothing in paragraph 5

(1) shall be construed to waive any exclusions of cov-6

erage under the terms and conditions of the plan or 7

health insurance coverage with respect to coverage 8

of pediatric care. 9

‘‘(d) PATIENT ACCESS TO OBSTETRICAL AND GYNE-10

COLOGICAL CARE.— 11

‘‘(1) GENERAL RIGHTS.— 12

‘‘(A) DIRECT ACCESS.—A group health 13

plan, or health insurance issuer offering group 14

health insurance coverage, described in para-15

graph (2) may not require authorization or re-16

ferral by the plan, issuer, or any person (includ-17

ing a primary care provider described in para-18

graph (2)(B)) in the case of a female partici-19

pant or beneficiary who seeks coverage for ob-20

stetrical or gynecological care provided by a 21

participating health care professional who spe-22

cializes in obstetrics or gynecology. Such profes-23

sional shall agree to otherwise adhere to such 24

plan’s or issuer’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 or issuer. 4

‘‘(B) OBSTETRICAL AND GYNECOLOGICAL 5

CARE.—A group health plan or health insur-6

ance issuer described in paragraph (2) shall 7

treat the provision of obstetrical and gyneco-8

logical care, and the ordering of related obstet-9

rical and gynecological items and services, pur-10

suant to the direct access described under sub-11

paragraph (A), by a participating health care 12

professional who specializes in obstetrics or 13

gynecology as the authorization of the primary 14

care provider. 15

‘‘(2) APPLICATION OF PARAGRAPH.—A group 16

health plan, or health insurance issuer offering 17

group health insurance coverage, described in this 18

paragraph is a group health plan or coverage that— 19

‘‘(A) provides coverage for obstetric or 20

gynecologic care; and 21

‘‘(B) requires the designation by a partici-22

pant or beneficiary of a participating primary 23

care provider. 24

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‘‘(3) CONSTRUCTION.—Nothing in paragraph 1

(1) shall be construed to— 2

‘‘(A) waive any exclusions of coverage 3

under the terms and conditions of the plan or 4

health insurance coverage with respect to cov-5

erage of obstetrical or gynecological care; or 6

‘‘(B) preclude the group health plan or 7

health insurance issuer involved from requiring 8

that the obstetrical or gynecological provider 9

notify the primary care health care professional 10

or the plan or issuer of treatment decisions. 11

‘‘(e) COVERAGE OF NON-EMERGENCY SERVICES 12

PERFORMED BY NONPARTICIPATING PROVIDERS AT CER-13

TAIN PARTICIPATING FACILITIES.— 14

‘‘(1) IN GENERAL.—In the case of items or 15

services (other than emergency services to which 16

subsection (b) applies) for which any benefits are 17

provided or covered by a group health plan or health 18

insurance issuer offering health insurance coverage 19

in the group market furnished to a participant or 20

beneficiary of such plan or coverage by a nonpartici-21

pating provider (as defined in subsection 22

(b)(3)(G)(i)) (and who, with respect to such items 23

and services, has not satisfied the notice and consent 24

criteria of section 2799A–2(d) of the Public Health 25

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Service Act) with respect to a visit (as defined by 1

the Secretary in accordance with paragraph (2)(B)) 2

at a participating health care facility (as defined in 3

paragraph (2)(A)), with respect to such plan or cov-4

erage, respectively, the plan or coverage, respec-5

tively— 6

‘‘(A) shall not impose on such participant 7

or beneficiary a cost-sharing amount (expressed 8

as a copayment amount or coinsurance rate) for 9

such items and services so furnished that is 10

greater than the cost-sharing amount that 11

would apply under such plan or coverage, re-12

spectively, had such items or services been fur-13

nished by a participating provider (as defined in 14

subsection (b)(3)(G)(ii)); 15

‘‘(B) shall calculate such cost-sharing 16

amount as if the total amount that would have 17

been charged for such items and services by 18

such participating provider were equal to the 19

recognized amount (as defined in subsection 20

(b)(3)(H)) for such items and services, plan or 21

coverage, and year; 22

‘‘(C) shall pay to such provider furnishing 23

such items and services to such participant or 24

beneficiary the amount by which the recognized 25

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amount (as defined in subsection (b)(3)(H)) for 1

such items and services and year involved ex-2

ceeds the cost-sharing amount imposed under 3

the plan or coverage, respectively, for such 4

items and services (as determined in accordance 5

with subparagraphs (A) and (B)); and 6

‘‘(D) shall count toward any in-network 7

deductible and in-network out-of-pocket maxi-8

mums (as applicable) applied under the plan or 9

coverage, respectively, any cost-sharing pay-10

ments made by the participant or beneficiary 11

(and such in-network deductible and out-of- 12

pocket maximums shall be applied) with respect 13

to such items and services so furnished in the 14

same manner as if such cost-sharing payments 15

were with respect to items and services fur-16

nished by a participating provider. 17

‘‘(2) DEFINITIONS.—In this section: 18

‘‘(A) PARTICIPATING HEALTH CARE FACIL-19

ITY.— 20

‘‘(i) IN GENERAL.—The term ‘partici-21

pating health care facility’ means, with re-22

spect to an item or service and a group 23

health plan or health insurance issuer of-24

fering health insurance coverage in the 25

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group market, a health care facility de-1

scribed in clause (ii) that has a contractual 2

relationship with the plan or issuer, respec-3

tively, with respect to the furnishing of 4

such an item or service at the facility. 5

‘‘(ii) HEALTH CARE FACILITY DE-6

SCRIBED.—A health care facility described 7

in this clause, with respect to a group 8

health plan or health insurance coverage 9

offered in the group market, is each of the 10

following: 11

‘‘(I) A hospital (as defined in 12

1861(e) of the Social Security Act). 13

‘‘(II) A hospital outpatient de-14

partment. 15

‘‘(III) A critical access hospital 16

(as defined in section 1861(mm) of 17

such Act). 18

‘‘(IV) An ambulatory surgical 19

center (as defined in section 20

1833(i)(1)(A) of such Act). 21

‘‘(V) Any other facility that pro-22

vides items or services for which cov-23

erage is provided under the plan or 24

coverage, respectively. 25

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‘‘(B) VISIT.—The term ‘visit’ shall, with 1

respect to items and services furnished to an in-2

dividual at a participating health care facility, 3

include equipment and devices, telemedicine 4

services, imaging services, laboratory services, 5

and such other items and services as the Sec-6

retary may specify, regardless of whether or not 7

the provider furnishing such items or services is 8

at the facility. 9

‘‘(f) AIR AMBULANCE SERVICES.— 10

‘‘(1) IN GENERAL.—In the case of a participant 11

or beneficiary in a group health plan or health insur-12

ance coverage offered in the group market who re-13

ceives air ambulance services from a nonpartici-14

pating provider (as defined in subsection (b)(3)(G)) 15

with respect to such plan or coverage, if such serv-16

ices would be covered if provided by a participating 17

provider (as defined in such subsection) with respect 18

to such plan or coverage— 19

‘‘(A) the cost-sharing requirement (ex-20

pressed as a copayment amount, coinsurance 21

rate, or deductible) with respect to such services 22

shall be the same requirement that would apply 23

if such services were provided by such a partici-24

pating provider, and any coinsurance or deduct-25

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66 

•HR 5800 IH

ible shall be based on rates that would apply for 1

such services if they were furnished by such a 2

participating provider; 3

‘‘(B) such cost-sharing amounts shall be 4

counted toward the in-network deductible and 5

in-network out-of-pocket maximum amount 6

under the plan or coverage for the plan year 7

(and such in-network deductible shall be ap-8

plied) with respect to such items and services so 9

furnished in the same manner as if such cost- 10

sharing payments were with respect to items 11

and services furnished by a participating pro-12

vider; and 13

‘‘(C) the plan or coverage shall pay to such 14

provider furnishing such services to such partic-15

ipant or beneficiary the amount by which the 16

recognized amount (as defined in and deter-17

mined pursuant to subsection (b)(3)(H)(ii)) for 18

such services and year involved exceeds the 19

cost-sharing amount imposed under the plan or 20

coverage, respectively, for such services (as de-21

termined in accordance with subparagraphs (A) 22

and (B)). 23

‘‘(2) AIR AMBULANCE SERVICE DEFINED.—For 24

purposes of this section, the term ‘air ambulance 25

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service’ means medical transport by helicopter or 1

airplane for patients. 2

‘‘(g) CERTAIN ACCESS FEES TO CERTAIN DATA-3

BASES.—In the case of a sponsor of a group health plan 4

or health insurance issuer offering health insurance cov-5

erage in the group market that, pursuant to subsection 6

(b)(3)(E)(iii), uses a database described in such sub-7

section to determine a rate to apply under such subsection 8

for an item or service by reason of having insufficient in-9

formation described in such subsection with respect to 10

such item or service, such sponsor or issuer shall cover 11

the cost for access to such database.’’. 12

(2) CLERICAL AMENDMENT.—The table of con-13

tents of the Employee Retirement Income Security 14

Act of 1974 is amended by inserting after the item 15

relating to section 714 the following: 16

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

(c) IRC AMENDMENTS.— 17

(1) IN GENERAL.—Subchapter B of chapter 18

100 of the Internal Revenue Code of 1986 is amend-19

ed by adding at the end the following: 20

‘‘SEC. 9816. CONSUMER PROTECTIONS. 21

‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If 22

a group health plan requires or provides for designation 23

by a participant or beneficiary of a participating primary 24

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68 

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care provider, then the plan shall permit each participant 1

or beneficiary to designate any participating primary care 2

provider who is available to accept such individual. 3

‘‘(b) COVERAGE OF EMERGENCY SERVICES.— 4

‘‘(1) IN GENERAL.—If a group health plan pro-5

vides or covers any benefits with respect to services 6

in an emergency department of a hospital or with re-7

spect to emergency services in an independent free-8

standing emergency department (as defined in para-9

graph (3)(D)), the plan shall cover emergency serv-10

ices (as defined in paragraph (3)(C))— 11

‘‘(A) without the need for any prior au-12

thorization determination; 13

‘‘(B) whether the health care provider fur-14

nishing such services is a participating provider 15

or a participating emergency facility, as appli-16

cable, with respect to such services; 17

‘‘(C) in a manner so that, if such services 18

are provided to a participant or beneficiary by 19

a nonparticipating provider or a nonpartici-20

pating emergency facility— 21

‘‘(i) such services will be provided 22

without imposing any requirement under 23

the plan for prior authorization of services 24

or any limitation on coverage that is more 25

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69 

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restrictive than the requirements or limita-1

tions that apply to emergency services re-2

ceived from participating providers and 3

participating emergency facilities with re-4

spect to such plan; 5

‘‘(ii) the cost-sharing requirement (ex-6

pressed as a copayment amount or coinsur-7

ance rate) is not greater than the require-8

ment that would apply if such services 9

were provided by a participating provider 10

or a participating emergency facility; 11

‘‘(iii) such cost-sharing requirement is 12

calculated as if the total amount that 13

would have been charged for such services 14

by such participating provider or partici-15

pating emergency facility were equal to the 16

recognized amount (as defined in para-17

graph (3)(H)) for such services, plan, and 18

year; 19

‘‘(iv) the group health plan pays to 20

such provider or facility, respectively, the 21

amount by which the recognized amount 22

for such services and year involved exceeds 23

the cost-sharing amount for such services 24

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(as determined in accordance with clauses 1

(ii) and (iii)) and year; and 2

‘‘(v) any cost-sharing payments made 3

by the participant or beneficiary with re-4

spect to such emergency services so fur-5

nished shall be counted toward any in-net-6

work deductible or out-of-pocket maxi-7

mums applied under the plan (and such in- 8

network deductible and out-of-pocket maxi-9

mums shall be applied) in the same man-10

ner as if such cost-sharing payments were 11

made with respect to emergency services 12

furnished by a participating provider or a 13

participating emergency facility; 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

this Act, including as incorporated pursuant to 19

section 715 of the Employee Retirement Income 20

Security Act of 1974 and section 9815 of this 21

Act, and other than applicable cost-sharing). 22

‘‘(2) AUDIT PROCESS AND REGULATIONS FOR 23

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 consulta-2

tion with appropriate State agencies and 3

the Secretary of Health and Human Serv-4

ices and the Secretary of Labor, shall es-5

tablish through rulemaking a process, in 6

accordance with clause (ii), under which 7

group health plans are audited by the Sec-8

retary or applicable State authority to en-9

sure 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) such median contracted 15

rate so applied satisfies the definition 16

under paragraph (3)(E) with respect 17

to the year involved, including with re-18

spect to a group health plan described 19

in clause (ii) of such paragraph 20

(3)(E). 21

‘‘(ii) AUDIT SAMPLES.—Under the 22

process established pursuant to clause (i), 23

the Secretary— 24

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‘‘(I) shall conduct audits de-1

scribed in such clause, with respect to 2

a year (beginning with 2022), of a 3

sample with respect to such year of 4

claims data from not more than 25 5

group health plans; and 6

‘‘(II) may audit any group health 7

plan if the Secretary has received any 8

complaint about such plan or cov-9

erage, respectively, that involves the 10

compliance of the plan with either of 11

the requirements described in sub-12

clauses (I) and (II) of such clause. 13

‘‘(iii) REPORTS.—Beginning for 2022, 14

the Secretary shall annually submit to 15

Congress a report on the number of plans 16

and issuers with respect to which audits 17

were conducted during such year pursuant 18

to this subparagraph. 19

‘‘(B) RULEMAKING.—Not later than July 20

1, 2021, the Secretary, in consultation with the 21

Secretary of Labor and the Secretary of Health 22

and Human Services, shall establish through 23

rulemaking— 24

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‘‘(i) the methodology the group health 1

plan shall use to determine the median 2

contracted rate, differentiating by line of 3

business; 4

‘‘(ii) the information such plan or 5

issuer, respectively, shall share with the 6

nonparticipating provider or nonpartici-7

pating facility, as applicable, when making 8

such a determination; 9

‘‘(iii) the geographic regions applied 10

for purposes of this subparagraph, taking 11

into account access to items and services in 12

rural and underserved areas, including 13

health professional shortage areas, as de-14

fined in section 332 of the Public Health 15

Service Act; and 16

‘‘(iv) a process to receive complaints 17

of violations of the requirements described 18

in subclauses (I) and (II) of paragraph 19

(2)(A)(i) by group health plans. 20

Such rulemaking shall take into account pay-21

ments that are made by such plan that are not 22

on a fee-for-service basis. Such methodology 23

may account for relevant payment adjustments 24

that take into account quality or facility type 25

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74 

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(including higher acuity settings and the case- 1

mix of various facility types) that are otherwise 2

taken into account for purposes of determining 3

payment amounts with respect to participating 4

facilities. In carrying out clause (iii), the Sec-5

retary shall consult with the National Associa-6

tion of Insurance Commissioners to establish 7

the geographic regions under such clause and 8

shall periodically update such regions, as appro-9

priate. 10

‘‘(3) DEFINITIONS.—In this section: 11

‘‘(A) EMERGENCY DEPARTMENT OF A HOS-12

PITAL.—The term ‘emergency department of a 13

hospital’ includes a hospital outpatient depart-14

ment that provides emergency services. 15

‘‘(B) EMERGENCY MEDICAL CONDITION.— 16

The term ‘emergency medical condition’ means 17

a medical condition manifesting itself by acute 18

symptoms of sufficient severity (including se-19

vere pain) such that a prudent layperson, who 20

possesses an average knowledge of health and 21

medicine, could reasonably expect the absence 22

of immediate medical attention to result in a 23

condition described in clause (i), (ii), or (iii) of 24

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75 

•HR 5800 IH

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

Act. 2

‘‘(C) EMERGENCY SERVICES.— 3

‘‘(i) IN GENERAL.—The term ‘emer-4

gency services’, with respect to an emer-5

gency medical condition, means— 6

‘‘(I) a medical screening exam-7

ination (as required under section 8

1867 of the Social Security Act, or as 9

would be required under such section 10

if such section applied to an inde-11

pendent freestanding emergency de-12

partment) that is within the capability 13

of the emergency department of a hos-14

pital or of an independent free-15

standing emergency department, as 16

applicable, including ancillary services 17

routinely available to the emergency 18

department to evaluate such emer-19

gency medical condition; and 20

‘‘(II) within the capabilities of 21

the staff and facilities available at the 22

hospital or the independent free-23

standing emergency department, as 24

applicable, such further medical exam-25

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ination and treatment as are required 1

under section 1867 of such Act, or as 2

would be required under such section 3

if such section applied to an inde-4

pendent freestanding emergency de-5

partment, to stabilize the patient. 6

‘‘(ii) INCLUSION OF CERTAIN SERV-7

ICES OUTSIDE OF EMERGENCY DEPART-8

MENT.— 9

‘‘(I) IN GENERAL.—For purposes 10

of this subsection and section 2799A– 11

1, in the case of an individual enrolled 12

in a group health plan or health in-13

surance coverage offered by a health 14

insurance issuer in the group or indi-15

vidual market who is furnished serv-16

ices described in clause (i) by a par-17

ticipating or nonparticipating provider 18

or a participating or nonparticipating 19

emergency facility to stabilize such in-20

dividual with respect to an emergency 21

medical condition, the term ‘emer-22

gency services’ shall include, unless 23

each of the conditions described in 24

subclause (II) are met, in addition to 25

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the items and services described in 1

clause (i), items and services for 2

which benefits are provided or covered 3

under the plan or coverage, respec-4

tively, furnished by a nonparticipating 5

provider or nonparticipating facility, 6

regardless of the department of the 7

hospital in which such individual is 8

furnished such items or services, if, 9

after such stabilization but during 10

such visit in which such individual is 11

so stabilized, the provider or facility 12

determines that such items or services 13

are needed. 14

‘‘(II) CONDITIONS.—For pur-15

poses of subclause (I), the conditions 16

described in this subclause, with re-17

spect to an individual who is stabilized 18

and furnished additional items and 19

services described in subclause (I) 20

after such stabilization by a provider 21

or facility described in subclause (I), 22

are the following: 23

‘‘(aa) Such a provider or fa-24

cility determines such individual 25

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78 

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is able to travel using nonmedical 1

transportation or nonemergency 2

medical transportation. 3

‘‘(bb) Such provider fur-4

nishing such additional items and 5

services satisfies the notice and 6

consent criteria of section 7

2799A–2(d) of the Public Health 8

Service Act with respect to such 9

items and services. 10

‘‘(cc) Such an individual is 11

in a condition to receive (as de-12

termined in accordance with 13

guidance issued by the Secretary) 14

the information described in sec-15

tion 2799A–2 of the Public 16

Health Service Act and to pro-17

vide informed consent under such 18

section, in accordance with appli-19

cable State law. 20

‘‘(D) INDEPENDENT FREESTANDING 21

EMERGENCY DEPARTMENT.—The term ‘inde-22

pendent freestanding emergency department’ 23

means a facility that— 24

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‘‘(i) is geographically separate and 1

distinct and licensed separately from a hos-2

pital under applicable State law; and 3

‘‘(ii) provides any emergency services 4

(as defined in subparagraph (C)). 5

‘‘(E) MEDIAN CONTRACTED RATE.— 6

‘‘(i) IN GENERAL.—The term ‘median 7

contracted rate’ means, subject to clauses 8

(ii) and (iii), with respect to a sponsor of 9

a group health plan— 10

‘‘(I) for an item or service fur-11

nished during 2022, the median of the 12

contracted rates recognized by the 13

plan (determined with respect to all 14

such plans of such sponsor that are 15

offered within the same line of busi-16

ness as the total maximum payment 17

(including the cost-sharing amount 18

imposed for such item or service and 19

the amount to be paid by the plan)) 20

under such plans on January 31, 21

2019, for the same or a similar item 22

or service that is provided by a pro-23

vider in the same or similar specialty 24

and provided in the geographic region 25

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in which the item or service is fur-1

nished, consistent with the method-2

ology established by the Secretary 3

under paragraph (2)(B), increased by 4

the percentage increase in the con-5

sumer price index for all urban con-6

sumers (United States city average) 7

over 2019, such percentage increase 8

over 2020, and such percentage in-9

crease over 2021; and 10

‘‘(II) for an item or service fur-11

nished during 2023 or a subsequent 12

year, the median contracted rate de-13

termined under this clause for such 14

an item or service furnished in the 15

previous year, increased by the per-16

centage increase in the consumer price 17

index for all urban consumers (United 18

States city average) over such pre-19

vious year. 20

‘‘(ii) NEW PLANS AND COVERAGE.— 21

The term ‘median contracted rate’ means, 22

with respect to a sponsor of a group health 23

plan in a geographic region in which such 24

sponsor, respectively, did not offer any 25

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group health plan or health insurance cov-1

erage during 2019— 2

‘‘(I) for the first year in which 3

such group health plan is offered in 4

such region, a rate (determined in ac-5

cordance with a methodology estab-6

lished by the Secretary) for items and 7

services that are covered by such plan 8

and furnished during such first year; 9

and 10

‘‘(II) for each subsequent year 11

such group health plan is offered in 12

such region, the median contracted 13

rate determined under this clause for 14

such items and services furnished in 15

the previous year, increased by the 16

percentage increase in the consumer 17

price index for all urban consumers 18

(United States city average) over such 19

previous year. 20

‘‘(iii) INSUFFICIENT INFORMATION; 21

NEWLY COVERED ITEMS AND SERVICES.— 22

In the case of a sponsor of a group health 23

plan that does not have sufficient informa-24

tion to calculate the median of the con-25

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tracted rates described in clause (i)(I) in 1

2019 (or, in the case of a newly covered 2

item or service (as defined in clause 3

(iv)(III)), in the first coverage year (as de-4

fined in clause (iv)(I)) for such item or 5

service with respect to such plan) for an 6

item or service (including with respect to 7

provider type, or amount, of claims for 8

items or services (as determined by the 9

Secretary) provided in a particular geo-10

graphic region (other than in a case with 11

respect to which clause (ii) applies)) the 12

term ‘median contracted rate’— 13

‘‘(I) for an item or service fur-14

nished during 2022 (or, in the case of 15

a newly covered item or service, dur-16

ing the first coverage year for such 17

item or service with respect to such 18

plan), means such rate for such item 19

or service determined by the sponsor 20

through use of any database that is 21

determined, in accordance with rule-22

making described in paragraph 23

(2)(B), to not have any conflicts of in-24

terest and to have sufficient informa-25

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tion reflecting allowed amounts paid 1

to a health care provider or facility for 2

relevant services furnished in the ap-3

plicable geographic region (such as a 4

State all-payer claims database); 5

‘‘(II) for an item or service fur-6

nished in a subsequent year (before 7

the first sufficient information year 8

(as defined in clause (iv)(II)) for such 9

item or service with respect to such 10

plan), means the rate determined 11

under subclause (I) or this subclause, 12

as applicable, for such item or service 13

for the year previous to such subse-14

quent year, increased by the percent-15

age increase in the consumer price 16

index for all urban consumers (United 17

States city average) over such pre-18

vious year; 19

‘‘(III) for an item or service fur-20

nished in the first sufficient informa-21

tion year for such item or service with 22

respect to such plan, has the meaning 23

given the term median contracted rate 24

in clause (i)(I), except that in apply-25

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ing such clause to such item or serv-1

ice, the reference to ‘furnished during 2

2022’ shall be treated as a reference 3

to furnished during such first suffi-4

cient information year, the reference 5

to ‘on January 31, 2019,’ shall be 6

treated as a reference to in such suffi-7

cient information year, and the in-8

crease described in such clause shall 9

not be applied; and 10

‘‘(IV) for an item or service fur-11

nished in any year subsequent to the 12

first sufficient information year for 13

such item or service with respect to 14

such plan, has the meaning given such 15

term in clause (i)(II), except that in 16

applying such clause to such item or 17

service, the reference to ‘furnished 18

during 2023 or a subsequent year’ 19

shall be treated as a reference to fur-20

nished during the year after such first 21

sufficient information year or a subse-22

quent year. 23

‘‘(iv) DEFINITIONS.—For purposes of 24

this subparagraph: 25

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‘‘(I) FIRST COVERAGE YEAR.— 1

The term ‘first coverage year’ means, 2

with respect to a group health plan 3

and an item or service for which cov-4

erage is not offered in 2019 under 5

such plan or coverage, the first year 6

after 2019 for which coverage for 7

such item or service is offered under 8

such plan. 9

‘‘(II) FIRST SUFFICIENT INFOR-10

MATION YEAR.—The term ‘first suffi-11

cient information year’ means, with 12

respect to a group health plan— 13

‘‘(aa) in the case of an item 14

or service for which the plan does 15

not have sufficient information to 16

calculate the median of the con-17

tracted rates described in clause 18

(i)(I) in 2019, the first year sub-19

sequent to 2022 for which such 20

sponsor has such sufficient infor-21

mation to calculate the median of 22

such contracted rates in the year 23

previous to such first subsequent 24

year; and 25

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‘‘(bb) in the case of a newly 1

covered item or service, the first 2

year subsequent to the first cov-3

erage year for such item or serv-4

ice with respect to such plan for 5

which the sponsor has sufficient 6

information to calculate the me-7

dian of the contracted rates de-8

scribed in clause (i)(I) in the 9

year previous to such first subse-10

quent year. 11

‘‘(III) NEWLY COVERED ITEM OR 12

SERVICE.—The term ‘newly covered 13

item or service’ means, with respect to 14

a group health plan, an item or serv-15

ice for which coverage was not offered 16

in 2019 under such plan or coverage, 17

but is offered under such plan or cov-18

erage in a year after 2019. 19

‘‘(F) NONPARTICIPATING EMERGENCY FA-20

CILITY; PARTICIPATING EMERGENCY FACIL-21

ITY.— 22

‘‘(i) NONPARTICIPATING EMERGENCY 23

FACILITY.—The term ‘nonparticipating 24

emergency facility’ means, with respect to 25

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an item or service and a group health plan, 1

an emergency department of a hospital, or 2

an independent freestanding emergency de-3

partment, that does not have a contractual 4

relationship directly or indirectly with the 5

plan for furnishing such item or service 6

under the plan. 7

‘‘(ii) PARTICIPATING EMERGENCY FA-8

CILITY.—The term ‘participating emer-9

gency facility’ means, with respect to an 10

item or service and a group health plan, an 11

emergency department of a hospital, or an 12

independent freestanding emergency de-13

partment, that has a contractual relation-14

ship directly or indirectly with the plan, 15

with respect to the furnishing of such an 16

item or service at such facility. 17

‘‘(G) NONPARTICIPATING PROVIDERS; PAR-18

TICIPATING PROVIDERS.— 19

‘‘(i) NONPARTICIPATING PROVIDER.— 20

The term ‘nonparticipating provider’ 21

means, with respect to an item or service 22

and a group health plan, a physician or 23

other health care provider who is acting 24

within the scope of practice of that pro-25

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vider’s license or certification under appli-1

cable State law and who does not have a 2

contractual relationship with the plan or 3

issuer, respectively, for furnishing such 4

item or service under the plan. 5

‘‘(ii) PARTICIPATING PROVIDER.—The 6

term ‘participating provider’ means, with 7

respect to an item or service and a group 8

health plan, a physician or other health 9

care provider who is acting within the 10

scope of practice of that provider’s license 11

or certification under applicable State law 12

and who has a contractual relationship 13

with the plan for furnishing such item or 14

service under the plan. 15

‘‘(H) RECOGNIZED AMOUNT.—The term 16

‘recognized amount’ means, with respect to an 17

item or service furnished by a nonparticipating 18

provider or emergency facility during a year 19

and a group health plan— 20

‘‘(i) subject to clause (iii), in the case 21

of such item or service furnished in a State 22

that has in effect a specified State law 23

with respect to such plan; such a non-24

participating provider or emergency facil-25

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ity; and such an item or service, the 1

amount determined in accordance with 2

such law; 3

‘‘(ii) subject to clause (iii), in the case 4

of such item or service furnished in a State 5

that does not have in effect a specified 6

State law, with respect to such plan; such 7

a nonparticipating provider or emergency 8

facility; and such an item or service, an 9

amount that is the median contracted rate 10

(as defined in subparagraph (E)) for such 11

year and determined in accordance with 12

rulemaking described in paragraph (2)(B) 13

for such item or service; or 14

‘‘(iii) in the case of such item or serv-15

ice furnished in a State with an All-Payer 16

Model Agreement under section 1115A of 17

the Social Security Act, the amount that 18

the State approves under such system for 19

such item or service so furnished. 20

‘‘(I) SPECIFIED STATE LAW.—The term 21

‘specified State law’ means, with respect to a 22

State, an item or service furnished by a non-23

participating provider or emergency facility dur-24

ing a year and a group health plan, a State law 25

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that provides for a method for determining the 1

amount of payment that is required to be cov-2

ered by such a plan (to the extent such State 3

law applies to such plan, subject to section 514 4

of the Employee Retirement Income Security 5

Act of 1974) in the case of a participant or 6

beneficiary covered under such plan and receiv-7

ing such item or service from such a nonpartici-8

pating provider or emergency facility. 9

‘‘(J) STABILIZE.—The term ‘to stabilize’, 10

with respect to an emergency medical condition 11

(as defined in subparagraph (B)), has the 12

meaning give in section 1867(e)(3) of the Social 13

Security Act (42 U.S.C. 1395dd(e)(3)). 14

‘‘(c) ACCESS TO PEDIATRIC CARE.— 15

‘‘(1) PEDIATRIC CARE.—In the case of a person 16

who has a child who is a participant or beneficiary 17

under a group health plan, if the plan requires or 18

provides for the designation of a participating pri-19

mary care provider for the child, the plan shall per-20

mit such person to designate a physician (allopathic 21

or osteopathic) who specializes in pediatrics as the 22

child’s primary care provider if such provider par-23

ticipates in the network of the plan or issuer. 24

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‘‘(2) CONSTRUCTION.—Nothing in paragraph 1

(1) shall be construed to waive any exclusions of cov-2

erage under the terms and conditions of the plan 3

with respect to coverage of pediatric care. 4

‘‘(d) PATIENT ACCESS TO OBSTETRICAL AND GYNE-5

COLOGICAL CARE.— 6

‘‘(1) GENERAL RIGHTS.— 7

‘‘(A) DIRECT ACCESS.—A group health 8

plan described in paragraph (2) may not re-9

quire authorization or referral by the plan or 10

any person (including a primary care provider 11

described in paragraph (2)(B)) in the case of a 12

female participant or beneficiary who seeks cov-13

erage for obstetrical or gynecological care pro-14

vided by a participating health care professional 15

who specializes in obstetrics or gynecology. 16

Such professional shall agree to otherwise ad-17

here to such plan’s policies and procedures, in-18

cluding procedures regarding referrals and ob-19

taining prior authorization and providing serv-20

ices pursuant to a treatment plan (if any) ap-21

proved by the plan. 22

‘‘(B) OBSTETRICAL AND GYNECOLOGICAL 23

CARE.—A group health plan described in para-24

graph (2) shall treat the provision of obstetrical 25

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and gynecological care, and the ordering of re-1

lated obstetrical and gynecological items and 2

services, pursuant to the direct access described 3

under subparagraph (A), by a participating 4

health care professional who specializes in ob-5

stetrics or gynecology as the authorization of 6

the primary care provider. 7

‘‘(2) APPLICATION OF PARAGRAPH.—A group 8

health plan described in this paragraph is a group 9

health plan that— 10

‘‘(A) provides coverage for obstetric or 11

gynecologic care; and 12

‘‘(B) requires the designation by a partici-13

pant or beneficiary of a participating primary 14

care provider. 15

‘‘(3) CONSTRUCTION.—Nothing in paragraph 16

(1) shall be construed to— 17

‘‘(A) waive any exclusions of coverage 18

under the terms and conditions of the plan with 19

respect to coverage of obstetrical or gyneco-20

logical care; or 21

‘‘(B) preclude the group health plan in-22

volved from requiring that the obstetrical or 23

gynecological provider notify the primary care 24

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health care professional or the plan of treat-1

ment decisions. 2

‘‘(e) COVERAGE OF NON-EMERGENCY SERVICES 3

PERFORMED BY NONPARTICIPATING PROVIDERS AT CER-4

TAIN PARTICIPATING FACILITIES.— 5

‘‘(1) IN GENERAL.—In the case of items or 6

services (other than emergency services to which 7

subsection (b) applies) for which any benefits are 8

provided or covered by a group health plan furnished 9

to a participant or beneficiary of such plan by a 10

nonparticipating provider (as defined in subsection 11

(b)(3)(G)(i)) (and who, with respect to such items 12

and services, has not satisfied the notice and consent 13

criteria of section 2799A–2(d) of the Public Health 14

Service Act) with respect to a visit (as defined by 15

the Secretary in accordance with paragraph (2)(B)) 16

at a participating health care facility (as defined in 17

paragraph (2)(A)), with respect to such plan, the 18

plan— 19

‘‘(A) shall not impose on such participant 20

or beneficiary a cost-sharing amount (expressed 21

as a copayment amount or coinsurance rate) for 22

such items and services so furnished that is 23

greater than the cost-sharing amount that 24

would apply under such plan had such items or 25

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services been furnished by a participating pro-1

vider (as defined in subsection (b)(3)(G)(ii)); 2

‘‘(B) shall calculate such cost-sharing 3

amount as if the total amount that would have 4

been charged for such items and services by 5

such participating provider were equal to the 6

recognized amount (as defined in subsection 7

(b)(3)(H)) for such items and services, plan, 8

and year; 9

‘‘(C) shall pay to such provider furnishing 10

such items and services to such participant or 11

beneficiary the amount by which the recognized 12

amount (as defined in subsection (b)(3)(H)) for 13

such items and services and year involved ex-14

ceeds the cost-sharing amount imposed under 15

the plan for such items and services (as deter-16

mined in accordance with subparagraphs (A) 17

and (B)); and 18

‘‘(D) shall count toward any in-network 19

deductible and in-network out-of-pocket maxi-20

mums (as applicable) applied under the plan, 21

any cost-sharing payments made by the partici-22

pant or beneficiary (and such in-network de-23

ductible shall be applied) with respect to such 24

items and services so furnished in the same 25

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95 

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manner as if such cost-sharing payments were 1

with respect to items and services furnished by 2

a participating provider. 3

‘‘(2) DEFINITIONS.—In this section: 4

‘‘(A) PARTICIPATING HEALTH CARE FACIL-5

ITY.— 6

‘‘(i) IN GENERAL.—The term ‘partici-7

pating health care facility’ means, with re-8

spect to an item or service and a group 9

health plan, a health care facility described 10

in clause (ii) that has a contractual rela-11

tionship with the plan, with respect to the 12

furnishing of such an item or service at the 13

facility. 14

‘‘(ii) HEALTH CARE FACILITY DE-15

SCRIBED.—A health care facility described 16

in this clause, with respect to a group 17

health plan, is each of the following: 18

‘‘(I) A hospital (as defined in 19

1861(e) of the Social Security Act). 20

‘‘(II) A hospital outpatient de-21

partment. 22

‘‘(III) A critical access hospital 23

(as defined in section 1861(mm) of 24

such Act). 25

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96 

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‘‘(IV) An ambulatory surgical 1

center (as defined in section 2

1833(i)(1)(A) of such Act). 3

‘‘(V) Any other facility that pro-4

vides items or services for which cov-5

erage is provided under the plan or 6

coverage, respectively. 7

‘‘(B) VISIT.—The term ‘visit’ shall, with 8

respect to items and services furnished to an in-9

dividual at a participating health care facility, 10

include equipment and devices, telemedicine 11

services, imaging services, laboratory services, 12

and such other items and services as the Sec-13

retary may specify, regardless of whether or not 14

the provider furnishing such items or services is 15

at the facility. 16

‘‘(f) AIR AMBULANCE SERVICES.— 17

‘‘(1) IN GENERAL.—In the case of a participant 18

or beneficiary in a group health plan who receives 19

air ambulance services from a nonparticipating pro-20

vider (as defined in subsection (b)(3)(G)) with re-21

spect to such plan or coverage, if such services 22

would be covered if provided by a participating pro-23

vider (as defined in such subsection) with respect to 24

such plan— 25

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‘‘(A) the cost-sharing requirement (ex-1

pressed as a copayment amount, coinsurance 2

rate, or deductible) with respect to such services 3

shall be the same requirement that would apply 4

if such services were provided by such a partici-5

pating provider, and any coinsurance or deduct-6

ible shall be based on rates that would apply for 7

such services if they were furnished by such a 8

participating provider; 9

‘‘(B) such cost-sharing amounts shall be 10

counted toward the in-network deductible and 11

in-network out-of-pocket maximum amount 12

under the plan for the plan year (and such in- 13

network deductible shall be applied) with re-14

spect to such items and services so furnished in 15

the same manner as if such cost-sharing pay-16

ments were with respect to items and services 17

furnished by a participating provider; and 18

‘‘(C) the plan or coverage shall pay to such 19

provider furnishing such services to such partic-20

ipant or beneficiary the amount by which the 21

recognized amount (as defined in and deter-22

mined pursuant to subsection (b)(3)(H)(ii)) for 23

such services and year involved exceeds the 24

cost-sharing amount imposed under the plan for 25

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98 

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such services (as determined in accordance with 1

subparagraphs (A) and (B)). 2

‘‘(2) AIR AMBULANCE SERVICE DEFINED.—For 3

purposes of this section, the term ‘air ambulance 4

service’ means medical transport by helicopter or 5

airplane for patients. 6

‘‘(g) CERTAIN ACCESS FEES TO CERTAIN DATA-7

BASES.—In the case of a sponsor of a group health plan 8

that, pursuant to subsection (b)(3)(E)(iii), uses a data-9

base described in such subsection to determine a rate to 10

apply under such subsection for an item or service by rea-11

son of having insufficient information described in such 12

subsection with respect to such item or service, such spon-13

sor shall cover the cost for access to such database.’’. 14

(2) CLERICAL AMENDMENT.—The table of sec-15

tions for subchapter B of chapter 100 of the Inter-16

nal Revenue Code of 1986 is amended by adding at 17

the end the following new item: 18

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

(d) ADDITIONAL APPLICATION PROVISIONS.— 19

(1) APPLICATION TO FEHB.— 20

(A) IN GENERAL.—Section 8902 of title 5, 21

United States Code, is amended by adding at 22

the end the following new subsection: 23

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‘‘(p) Each contract under this chapter shall require 1

the carrier to comply with requirements described in the 2

provisions of section 2719A of the Public Health Service 3

Act and sections 2730 and 2731 of such Act, sections 716, 4

717, and 718 of the Employee Retirement Income Secu-5

rity Act of 1974, sections 9816, 9817, and 9818 of the 6

Internal Revenue Code of 1986 (as applicable), and sec-7

tion 2(d) of the Ban Surprise Billing Act in the same man-8

ner as such provisions apply to a group health plan or 9

health insurance issuer offering health insurance coverage, 10

as described in such sections. The provisions of sections 11

2799A–1, 2799A–2, 2799A–3, and 2799A–4 of the Public 12

Health Service Act shall apply to a health care provider 13

and facility and an air ambulance provider described in 14

such respective sections with respect to a participant, ben-15

eficiary, or enrollee in a health benefits plan under this 16

chapter in the same manner as such provisions apply to 17

such a provider and facility with respect to an enrollee 18

in a group health plan or health insurance coverage of-19

fered by a health insurance issuer in the group or indi-20

vidual market, as described in such sections.’’. 21

(B) EFFECTIVE DATE.—The amendment 22

made by this paragraph shall apply with respect 23

to contracts entered into or renewed for con-24

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•HR 5800 IH

tract years beginning on or after January 1, 1

2022. 2

(2) APPLICATION TO GRANDFATHERED 3

PLANS.—Section 1251(a) of the Patient Protection 4

and Affordable Care Act (42 U.S.C. 18011(a)) is 5

amended by adding at the end the following: 6

‘‘(5) APPLICATION OF ADDITIONAL PROVI-7

SIONS.—Subsections (b), (e), (f), (g), and (h) of sec-8

tion 2719A of the Public Health Service Act shall 9

apply to grandfathered health plans for plan years 10

beginning on or after January 1, 2022.’’. 11

(3) COORDINATION.—The Secretary of the 12

Treasury, the Secretary of Health and Human Serv-13

ices, and the Secretary of Labor shall ensure, 14

through the execution of an interagency memo-15

randum of understanding among such Secretaries, 16

that— 17

(A) regulations, rulings, and interpreta-18

tions issued by such Secretaries relating to the 19

same matter over which two or more such Sec-20

retaries have responsibility under this title (and 21

the amendments made by this title) are admin-22

istered so as to have the same effect at all 23

times; and 24

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101 

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(B) coordination of policies relating to en-1

forcing the same requirements through such 2

Secretaries in order to have a coordinated en-3

forcement strategy that avoids duplication of 4

enforcement efforts and assigns priorities in en-5

forcement. 6

(4) RULE OF CONSTRUCTION.—Nothing in this 7

title, including the amendments made by this title 8

may be construed as modifying, reducing, or elimi-9

nating— 10

(A) the protections under section 222 of 11

the Indian Health Care Improvement Act (25 12

U.S.C. 1621u) and under subpart I of part 136 13

of title 42, Code of Federal Regulations (or any 14

successor regulation), against payment liability 15

for a patient who receives contract health serv-16

ices that are authorized by the Indian Health 17

Service; or 18

(B) the requirements under section 19

1866(a)(1)(U) of the Social Security Act (42 20

U.S.C. 1395cc(a)(1)(U)). 21

(e) EFFECTIVE DATE.—The amendments made by 22

this section shall apply with respect to plan years begin-23

ning on or after January 1, 2022. 24

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102 

•HR 5800 IH

SEC. 3. PREVENTING CERTAIN CASES OF BALANCE BILL-1

ING. 2

(a) IN GENERAL.—Title XXVII of the Public Health 3

Service Act (42 U.S.C. 300gg et seq.) is amended by add-4

ing at the end the following new part: 5

‘‘PART D—HEALTH CARE PROVIDER 6

REQUIREMENTS 7

‘‘SEC. 2799A–1. BALANCE BILLING IN CASES OF EMERGENCY 8

SERVICES. 9

‘‘(a) IN GENERAL.—In the case of a participant, ben-10

eficiary, or enrollee with benefits under a group health 11

plan or health insurance coverage offered by a health in-12

surance issuer in the group or individual market who is 13

furnished during a plan year beginning on or after Janu-14

ary 1, 2022, emergency services for which any benefit is 15

provided under such plan or coverage with respect to an 16

emergency medical condition with respect to a visit at an 17

emergency department of a hospital or an independent 18

freestanding emergency department— 19

‘‘(1) in the case that the hospital or inde-20

pendent freestanding emergency department is a 21

nonparticipating emergency facility, the emergency 22

department of a hospital or independent free-23

standing emergency department shall not hold the 24

participant, beneficiary, or enrollee liable for a pay-25

ment amount for such emergency services so fur-26

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103 

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nished that is more than the cost-sharing amount 1

for such services (as determined in accordance with 2

clauses (ii) and (iii) of section 2719A(b)(1)(C), sec-3

tion 716(b)(1)(C) of the Employee Retirement In-4

come Security Act of 1974, and section 5

9816(b)(1)(C) of the Internal Revenue Code of 6

1986, as applicable); and 7

‘‘(2) in the case that such services are furnished 8

by a nonparticipating provider, the health care pro-9

vider shall not hold such participant, beneficiary, or 10

enrollee liable for a payment amount for an emer-11

gency service furnished to such individual by such 12

provider with respect to such emergency medical 13

condition and visit for which the individual receives 14

emergency services at the hospital or emergency de-15

partment that is more than the cost-sharing amount 16

for such services furnished by the provider (as deter-17

mined in accordance with clauses (ii) and (iii) of sec-18

tion 2719A(b)(1)(C), section 716(b)(1)(C) of the 19

Employee Retirement Income Security Act of 1974, 20

and section 9816(b)(1)(C) of the Internal Revenue 21

Code of 1986, as applicable). 22

‘‘(b) DEFINITION.—In this section, the term ‘visit’ 23

shall have such meaning as applied to such term for pur-24

poses of section 2719A(e). 25

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‘‘SEC. 2799A–2. BALANCE BILLING IN CASES OF NON-EMER-1

GENCY SERVICES PERFORMED BY NON-2

PARTICIPATING PROVIDERS AT CERTAIN 3

PARTICIPATING FACILITIES. 4

‘‘(a) IN GENERAL.—Subject to subsection (b), in the 5

case of a participant, beneficiary, or enrollee with benefits 6

under a group health plan or health insurance coverage 7

offered by a health insurance issuer in the group or indi-8

vidual market who is furnished during a plan year begin-9

ning on or after January 1, 2022, items or services (other 10

than emergency services to which section 2799A–1 ap-11

plies) for which any benefit is provided under such plan 12

or coverage at a participating health care facility by a non-13

participating provider, such provider shall not bill, and 14

shall not hold liable, such participant, beneficiary, or en-15

rollee for a payment amount for such an item or service 16

furnished by such provider with respect to a visit at such 17

facility that is more than the cost-sharing amount for such 18

item or service (as determined in accordance with subpara-19

graphs (A) and (B) of section 2719A(e)(1), section 20

716(e)(1) of the Employee Retirement Income Security 21

Act of 1974, and section 9816(e)(1) of the Internal Rev-22

enue Code of 1986, as applicable). 23

‘‘(b) EXCEPTION.— 24

‘‘(1) IN GENERAL.—Subsection (a) shall not 25

apply with respect to items or services (other than 26

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105 

•HR 5800 IH

ancillary services described in paragraph (2)) fur-1

nished by a nonparticipating provider to a partici-2

pant, beneficiary, or enrollee of a group health plan 3

or health insurance coverage offered by a health in-4

surance issuer in the group or individual market, if 5

the provider satisfies the notice and consent criteria 6

of subsection (d). 7

‘‘(2) ANCILLARY SERVICES DESCRIBED.—For 8

purposes of paragraph (1), ancillary services de-9

scribed in this paragraph are, with respect to a par-10

ticipating health care facility— 11

‘‘(A) subject to paragraph (3), items and 12

services related to emergency medicine, anesthe-13

siology, pathology, radiology, and neonatology, 14

whether or not provided by a physician or non- 15

physician practitioner, and items and services 16

provided by assistant surgeons, hospitalists, and 17

intensivists; 18

‘‘(B) subject to paragraph (3), diagnostic 19

services (including radiology and laboratory 20

services); 21

‘‘(C) items and services provided by such 22

other specialty practitioners, as the Secretary 23

specifies through rulemaking; and 24

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106 

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‘‘(D) items and services provided by a non-1

participating provider if there is no partici-2

pating provider who can furnish such item or 3

service at such facility. 4

‘‘(3) EXCEPTION.—The Secretary may, through 5

rulemaking, establish a list (and update such list) of 6

advanced diagnostic laboratory tests, which shall not 7

be included as an ancillary service described in para-8

graph (2) and with respect to which subsection (a) 9

would apply. 10

‘‘(c) CLARIFICATION.—In the case of a nonpartici-11

pating provider that satisfies the notice and consent cri-12

teria of subsection (d) with respect to an item or service 13

(referred to in this subsection as a ‘covered item or serv-14

ice’), such notice and consent criteria may not be con-15

strued as applying with respect to any item or service that 16

is furnished as a result of unforeseen, urgent medical 17

needs that arise at the time such covered item or service 18

is furnished. For purposes of the previous sentence, a cov-19

ered item or service shall not include an ancillary service 20

described in subsection (b)(2). 21

‘‘(d) NOTICE AND CONSENT TO BE TREATED BY A 22

NONPARTICIPATING PROVIDER OR NONPARTICIPATING 23

FACILITY.— 24

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107 

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‘‘(1) IN GENERAL.—A nonparticipating provider 1

or nonparticipating facility satisfies the notice and 2

consent criteria of this subsection, with respect to 3

items or services furnished by the provider or facility 4

to a participant, beneficiary, or enrollee of a group 5

health plan or health insurance coverage offered by 6

a health insurance issuer in the group or individual 7

market, if the provider (or, if applicable, the partici-8

pating health care facility on behalf of such pro-9

vider) or nonparticipating facility— 10

‘‘(A) provides to the participant, bene-11

ficiary, or enrollee (or to an authorized rep-12

resentative of the participant, beneficiary, or 13

enrollee) on the date on which the individual is 14

furnished such items or services and, in the 15

case that the participant, beneficiary, or en-16

rollee makes an appointment to be furnished 17

such items or services, on such date the ap-18

pointment is made— 19

‘‘(i) an oral explanation of the written 20

notice described in clause (ii); and 21

‘‘(ii) a written notice in paper or elec-22

tronic form (and including electronic notifi-23

cation, as practicable) specified by the Sec-24

retary, not later than July 1, 2021, 25

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108 

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through guidance (which shall be updated 1

as determined necessary by the Secretary) 2

that— 3

‘‘(I) contains the information re-4

quired under paragraph (2); 5

‘‘(II) clearly states that consent 6

to receive such items and services 7

from such nonparticipating provider 8

or nonparticipating facility is optional 9

and that the participant, beneficiary, 10

or enrollee may instead seek care from 11

a participating provider or at a par-12

ticipating facility, with respect to such 13

plan or coverage, as applicable, in 14

which case the cost-sharing responsi-15

bility of the participant, beneficiary, 16

or enrollee would not exceed such re-17

sponsibility that would apply with re-18

spect to such an item or service that 19

is furnished by a participating pro-20

vider or participating facility, as ap-21

plicable with respect to such plan; 22

‘‘(III) is available in the fifteen 23

most common languages in the geo-24

graphic region of the applicable facil-25

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109 

•HR 5800 IH

ity and, in the case the primary lan-1

guage of the beneficiary, participant, 2

or enrollee, respectively, is not one of 3

such 15 languages, makes a good 4

faith effort to also provide such notice 5

orally in such primary language of the 6

beneficiary, participant, or enrollee; 7

and 8

‘‘(IV) is signed and dated by the 9

participant, beneficiary, or enrollee (or 10

by an authorized representative of the 11

participant, beneficiary, or enrollee) 12

and, with respect to items or services 13

to be furnished by such a provider 14

that are not poststabilization services 15

described in section 16

2719A(b)(3)(C)(ii), is so signed and 17

dated not less than 72 hours prior to 18

the participant, beneficiary, or en-19

rollee being furnished such items or 20

services by such provider; and 21

‘‘(B) obtains from the participant, bene-22

ficiary, or enrollee (or from such an authorized 23

representative) the consent described in para-24

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110 

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graph (3) to be treated by a nonparticipating 1

provider or nonparticipating facility. 2

‘‘(2) INFORMATION REQUIRED UNDER WRITTEN 3

NOTICE.—For purposes of paragraph (1)(A)(ii)(I), 4

the information described in this paragraph, with re-5

spect to a nonparticipating provider or nonpartici-6

pating facility and a participant, beneficiary, or en-7

rollee of a group health plan or health insurance cov-8

erage offered by a health insurance issuer in the 9

group or individual market, is each of the following: 10

‘‘(A) Notification, as applicable, that the 11

health care provider is a nonparticipating pro-12

vider with respect to the health plan or the 13

health care facility is a nonparticipating facility 14

with respect to the health plan. 15

‘‘(B) Notification of the good faith esti-16

mated amount that such provider or facility 17

may charge the participant, beneficiary, or en-18

rollee for such items and services involved, in-19

cluding a notification that the provision of such 20

estimate or consent to be treated under para-21

graph (3) does not constitute a contract with 22

respect to the charges estimated for such items 23

and services. 24

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111 

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‘‘(C) In the case of a participating facility 1

and a nonparticipating provider, a list of any 2

participating providers at the facility who are 3

able to furnish such items and services involved 4

and notification that the participant, bene-5

ficiary, or enrollee may be referred, at their op-6

tion, to such a participating provider. 7

‘‘(D) Information about whether prior au-8

thorization or other care management limita-9

tions may be required in advance of receiving 10

such items or services at the facility. 11

‘‘(3) CONSENT DESCRIBED TO BE TREATED BY 12

A NONPARTICIPATING PROVIDER OR NONPARTICI-13

PATING FACILITY.—For purposes of paragraph 14

(1)(B), the consent described in this paragraph, with 15

respect to a participant, beneficiary, or enrollee of a 16

group health plan or health insurance coverage of-17

fered by a health insurance issuer in the group or 18

individual market who is to be furnished items or 19

services by a nonparticipating provider or nonpartici-20

pating facility, is a document specified by the Sec-21

retary through rulemaking, in consultation with the 22

Secretary of Labor, that— 23

‘‘(A) acknowledges that the participant, 24

beneficiary, or enrollee has been— 25

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112 

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‘‘(i) provided with a written good faith 1

estimate and an oral explanation of the 2

charge that may be applied for the items 3

or services anticipated to be furnished by 4

such provider or facility; and 5

‘‘(ii) informed that the payment of 6

such charge by the participant, beneficiary, 7

or enrollee may not accrue toward meeting 8

any limitation that the plan or coverage 9

places on cost-sharing, including an expla-10

nation that such payment may not apply to 11

an in-network deductible applied under the 12

plan or coverage; and 13

‘‘(B) documents the consent of the partici-14

pant, beneficiary, or enrollee to be furnished 15

such item or services by such provider or facil-16

ity. 17

‘‘(4) RULE OF CONSTRUCTION.—The consent 18

described in paragraph (3), with respect to a partici-19

pant, beneficiary, or enrollee of a group health plan 20

or health insurance coverage offered by a health in-21

surance issuer in the group or individual market, 22

shall constitute only consent to the receipt of the in-23

formation provided pursuant to this subsection and 24

shall not constitute a contractual agreement of the 25

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113 

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participant, beneficiary, or enrollee to any estimated 1

charge or amount included in such information. 2

‘‘(e) RETENTION OF CERTAIN DOCUMENTS.—A non-3

participating facility (with respect to such facility or any 4

nonparticipating provider at such facility) or a partici-5

pating facility (with respect to nonparticipating providers 6

at such facility) that obtains from a participant, bene-7

ficiary, or enrollee of a group health plan or health insur-8

ance coverage offered by a health insurance issuer in the 9

group or individual market (or an authorized representa-10

tive of such participant, beneficiary, or enrollee) a written 11

notice in accordance with subsection (d)(1)(A)(ii), with re-12

spect to furnishing an item or service to such participant, 13

beneficiary, or enrollee, shall retain such notice for at least 14

a 2-year period after the date on which such item or serv-15

ice is so furnished. 16

‘‘(f) DEFINITIONS.—In this section: 17

‘‘(1) The terms ‘nonparticipating provider’ and 18

‘participating provider’ have the meanings given 19

such terms, respectively, in subsection (b)(3) of sec-20

tion 2719A. 21

‘‘(2) The term ‘participating health care facil-22

ity’ has the meaning given such term in subsection 23

(e)(2) of section 2719A. 24

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114 

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‘‘(3) The term ‘nonparticipating facility’ 1

means— 2

‘‘(A) with respect to emergency services (as 3

defined in section 2719A(b)(3)(C)(i)) and a 4

group health plan or health insurance coverage 5

offered by a health insurance issuer in the 6

group or individual market, an emergency de-7

partment of a hospital, or an independent free-8

standing emergency department, that does not 9

have a contractual relationship with the plan or 10

issuer, respectively, with respect to the fur-11

nishing of such services under the plan or cov-12

erage, respectively; and 13

‘‘(B) with respect to services described in 14

section 2719A(b)(3)(C)(ii) and a group health 15

plan or health insurance coverage offered by a 16

health insurance issuer in the group or indi-17

vidual market, a hospital or an independent 18

freestanding emergency department, that does 19

not have a contractual relationship with the 20

plan or issuer, respectively, with respect to the 21

furnishing of such services under the plan or 22

coverage, respectively. 23

‘‘(4) The term ‘participating facility’ means— 24

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115 

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‘‘(A) with respect to emergency services (as 1

defined in clause (i) of section 2719A(b)(3)(C)) 2

that are not described in clause (ii) of such sec-3

tion and a group health plan or health insur-4

ance coverage offered by a health insurance 5

issuer in the group or individual market, an 6

emergency department of a hospital, or an inde-7

pendent freestanding emergency department, 8

that has a contractual relationship with the 9

plan or issuer, respectively, with respect to the 10

furnishing of such services under the plan or 11

coverage, respectively; and 12

‘‘(B) with respect to services that pursuant 13

to clause (ii) of section 2719A(b)(3)(C) are in-14

cluded as emergency services (as defined in 15

clause (i) of such section) and a group health 16

plan or health insurance coverage offered by a 17

health insurance issuer in the group or indi-18

vidual market, a hospital or an independent 19

freestanding emergency department, that has a 20

contractual relationship with the plan or cov-21

erage, respectively, with respect to the fur-22

nishing of such services under the plan or cov-23

erage, respectively. 24

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‘‘SEC. 2799A–3. PROVIDER REQUIREMENT WITH RESPECT 1

TO PUBLIC PROVISION OF INFORMATION. 2

‘‘(a) IN GENERAL.—Each health care provider and 3

health care facility shall make publicly available, and (if 4

applicable) post on a public website of such provider or 5

facility and provide to individuals who are participants, 6

beneficiaries, or enrollees of a group health plan or health 7

insurance coverage offered by a health insurance issuer 8

in the group or individual market a one-page notice in 9

plain language containing information on— 10

‘‘(1) the requirements and prohibitions of such 11

provider or facility under sections 2799A–1, 2799A– 12

2, and 2799A–4 (relating to prohibitions on balance 13

billing in certain circumstances); 14

‘‘(2) if provided for under applicable State law, 15

any other requirements on such provider or facility 16

regarding the amounts such provider or facility may, 17

with respect to an item or service, charge a partici-18

pant, beneficiary, or enrollee of a group health plan 19

or health insurance coverage offered by a health in-20

surance issuer in the group or individual market 21

with respect to which such provider or facility does 22

not have a contractual relationship for furnishing 23

such item or service under the plan or coverage, re-24

spectively, after receiving payment from the plan or 25

coverage, respectively, for such item or service and 26

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any applicable cost-sharing payment from such par-1

ticipant, beneficiary, or enrollee; and 2

‘‘(3) information on contacting appropriate 3

State and Federal agencies in the case that an indi-4

vidual believes that such provider or facility has vio-5

lated any requirement described in paragraph (1) or 6

(2) with respect to such individual. 7

‘‘(b) GUIDANCE.—Not later than 6 months after the 8

date of the enactment of this section, the Secretary, in 9

consultation with the Secretary of Labor, shall issue guid-10

ance on the requirements for the notice under this section. 11

‘‘SEC. 2799A–4. AIR AMBULANCE SERVICES. 12

‘‘In the case of a participant, beneficiary, or enrollee 13

with benefits under a group health plan or health insur-14

ance coverage offered by a health insurance issuer in the 15

group or individual market who is furnished on or after 16

January 1, 2022, air ambulance services from a non-17

participating provider (as defined in section 18

2719A(b)(3)(G)) with respect to such plan or coverage, 19

such provider shall not bill, and shall not hold liable, such 20

participant, beneficiary, or enrollee for a payment amount 21

for such service furnished by such provider that is more 22

than the cost-sharing amount for such service (as deter-23

mined in accordance with paragraphs (1) and (2) of sec-24

tion 2719A(f), section 716(f) of the Employee Retirement 25

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Income Security Act of 1974, or section 9816(f) of the 1

Internal Revenue Code of 1986, as applicable). 2

‘‘SEC. 2799A–5. ENFORCEMENT. 3

‘‘(a) STATE ENFORCEMENT.— 4

‘‘(1) STATE AUTHORITY.—Each State may re-5

quire a provider or health care facility (including a 6

provider of air ambulance services) subject to the re-7

quirements of this part (except section 2799A–5) to 8

satisfy such requirements applicable to the provider 9

or facility. 10

‘‘(2) FAILURE TO IMPLEMENT REQUIRE-11

MENTS.—In the case of a determination by the Sec-12

retary that a State has failed to substantially en-13

force the requirements specified in paragraph (1) 14

with respect to applicable providers and facilities in 15

the State, the Secretary shall enforce such require-16

ments under subsection (b) insofar as they relate to 17

violations of such requirements occurring in such 18

State. 19

‘‘(3) NOTIFICATION OF SECRETARY OF 20

LABOR.—A State may notify the Secretary of Labor 21

of instances of violations of sections 2799A–1, 22

2799A–2, or 2799A–4 with respect to participants 23

or beneficiaries under a group health plan or health 24

insurance coverage offered by a health insurance 25

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119 

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issuer in the group market and any enforcement ac-1

tions taken against providers or facilities as a result 2

of such violations, including the disposition of any 3

such enforcement actions. 4

‘‘(b) SECRETARIAL ENFORCEMENT AUTHORITY.— 5

‘‘(1) IN GENERAL.—If a provider or facility is 6

found to be in violation of a requirement specified in 7

subsection (a)(1) by the Secretary, the Secretary 8

may apply a civil monetary penalty with respect to 9

such provider or facility (including, as applicable, a 10

provider of air ambulance services) in an amount not 11

to exceed $10,000 per violation. The provisions of 12

subsections (c) (with the exception of the first sen-13

tence of paragraph (1) of such subsection), (d), (e), 14

(g), (h), (k), and (l) of section 1128A of the Social 15

Security Act shall apply to a civil monetary penalty 16

or assessment under this subsection in the same 17

manner as such provisions apply to a penalty, as-18

sessment, or proceeding under subsection (a) of such 19

section. 20

‘‘(2) LIMITATION.—The provisions of para-21

graph (1) shall apply to enforcement of a provision 22

(or provisions) specified in subsection (a)(1) only as 23

provided under subsection (a)(2). 24

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‘‘(3) COMPLAINT PROCESS.—The Secretary 1

shall, through rulemaking conducted in consultation 2

with the Secretary of Labor, establish a process to 3

receive consumer complaints of violations of such 4

provisions and resolve such complaints within 60 5

days of receipt of such complaints. Such process 6

shall provide that the Secretary of Labor be in-7

formed of complaints by participants or beneficiaries 8

under a group health plan or health insurance cov-9

erage offered by a health insurance issuer in the 10

group market and any enforcement actions against 11

providers resulting from such complaints, including 12

the disposition of any such enforcement actions. 13

‘‘(4) EXCEPTION.—The Secretary may waive 14

the penalties described under paragraph (1) with re-15

spect to a facility or provider (including a provider 16

of air ambulance services) who does not knowingly 17

violate, and should not have reasonably known it vio-18

lated, sections 2799A–1, 2799A–2, or 2799A–4 with 19

respect to a participant, beneficiary, or enrollee, if 20

such facility or provider, within 30 days of the viola-21

tion, withdraws the bill that was in violation of such 22

provision and reimburses the health plan or partici-23

pant, beneficiary, or enrollee, as applicable, in an 24

amount equal to the difference between the amount 25

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121 

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billed and the amount allowed to be billed under the 1

provision, plus interest, at an interest rate deter-2

mined by the Secretary. 3

‘‘(5) HARDSHIP EXEMPTION.—The Secretary 4

may establish a hardship exemption to the penalties 5

under this subsection. 6

‘‘(c) CONTINUED APPLICABILITY OF STATE LAW.— 7

The sections specified in subsection (a)(1) shall not be 8

construed to supersede any provision of State law which 9

establishes, implements, or continues in effect any require-10

ment or prohibition except to the extent that such require-11

ment or prohibition prevents the application of a require-12

ment or prohibition of such a section.’’. 13

(b) SECRETARY OF LABOR INVESTIGATIVE AUTHOR-14

ITY.— 15

(1) IN GENERAL.—Part 5 of subtitle B of title 16

I of the Employee Retirement Income Security Act 17

of 1974 (29 U.S.C. 1131 et seq.) is amended by 18

adding at the end the following new section: 19

‘‘SEC. 522. INVESTIGATIVE AUTHORITY REGARDING VIOLA-20

TIONS OF CERTAIN HEALTH CARE PROVIDER 21

REQUIREMENTS; COMPLAINT PROCESS. 22

‘‘(a) INVESTIGATIVE AUTHORITY.—Upon receiving a 23

notice from a State or the Secretary of Health and Human 24

Services of violations of sections 2799A–1, 2799A–2, or 25

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2799A–4 of the Public Health Service Act, the Secretary 1

of Labor shall have the power to conduct an investigation 2

to identify patterns of such violations with respect to par-3

ticipants or beneficiaries under a group health plan or 4

health insurance coverage offered in connection with a 5

group health plan by a health insurance issuer in the 6

group market. The Secretary may assist States, the Sec-7

retary of Health and Human Services, plans, or issuers 8

to ensure that appropriate measures have been taken to 9

correct such violations retrospectively and prospectively 10

with respect to participants or beneficiaries under a group 11

health plan or health insurance coverage offered in connec-12

tion with a group health plan by a health insurance issuer 13

in the group market. 14

‘‘(b) COMPLAINT PROCESS.—Not later than January 15

1, 2022, the Secretary shall establish a process under 16

which the Secretary— 17

‘‘(1) may receive complaints from participants 18

and beneficiaries of group health plans or health in-19

surance coverage offered in connection with such 20

plans relating to alleged violations of the sections 21

specified in subsection (a); and 22

‘‘(2) transmits such complaints to States or the 23

Secretary of Health and Human Services (as deter-24

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123 

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mined appropriate by the Secretary) for potential 1

enforcement actions.’’. 2

(2) TECHNICAL AMENDMENT.—The table of 3

contents in section 1 of the Employee Retirement 4

Income Security Act of 1974 (29 U.S.C. 1001 et 5

seq.) is amended by inserting after the item relating 6

to section 521 the following new item: 7

‘‘Sec. 522. Investigative authority regarding violations of certain health care 
provider requirements; complaint process.’’. 

(c) DISCLOSURE OF CERTAIN PROTECTIONS 8

AGAINST BALANCE BILLING.—Section 716 of the Em-9

ployee Retirement Income Security Act of 1974, as added 10

by section 2, is further amended by adding at the end the 11

following new subsection: 12

‘‘(h) DISCLOSURE OF CERTAIN PROTECTIONS 13

AGAINST BALANCE BILLING.—Each group health plan 14

and health insurance issuer offering group health insur-15

ance coverage shall make publicly available, and (if appli-16

cable) post on a public website of such plan or issuer— 17

‘‘(1) information in plain language on— 18

‘‘(A) the requirements and prohibitions ap-19

plied under sections 2799A–1, 2799A–2 and 20

2799A–4 of the Public Health Service Act (re-21

lating to prohibitions on balance billing in cer-22

tain circumstances); 23

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124 

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‘‘(B) if provided for under applicable State 1

law, any other requirements on providers and 2

facilities regarding the amounts such providers 3

and facilities may, with respect to an item or 4

service, charge a participant, beneficiary, or en-5

rollee of such plan or coverage with respect to 6

which such a provider or facility does not have 7

a contractual relationship for furnishing such 8

item or service under the plan or coverage after 9

receiving payment from the plan or coverage for 10

such item or service and any applicable cost- 11

sharing payment from such participant, bene-12

ficiary, or enrollee; and 13

‘‘(C) the requirements applied under sub-14

sections (b), (e), and (f); and 15

‘‘(2) information on contacting appropriate 16

State and Federal agencies in the case that an indi-17

vidual believes that such a provider or facility has 18

violated any requirement described in paragraph (1) 19

with respect to such individual.’’. 20

SEC. 4. INDEPENDENT DISPUTE RESOLUTION PROCESS. 21

(a) ESTABLISHMENT.— 22

(1) IN GENERAL.—Not later than 1 year after 23

the date of the enactment of this section, the Sec-24

retary of Health and Human Services, the Secretary 25

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125 

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of Labor, and the Secretary of the Treasury (in this 1

section referred to as the ‘‘Secretaries’’) shall jointly 2

establish by regulation an independent dispute reso-3

lution process (in this section referred to as the 4

‘‘IDR process’’) under which, with respect to a pay-5

ment made by a group health plan or health insur-6

ance issuer offering health insurance coverage in the 7

group or individual market pursuant to subsection 8

(b)(1), (e)(1), or (f)(1) of section 2719A of the Pub-9

lic Health Service Act, section 716 of the Employee 10

Retirement Income Security Act of 1974, or section 11

9816 of the Internal Revenue Code of 1986 (as ap-12

plicable) using the recognized amount (as defined in 13

and determined pursuant to section 14

2719A(b)(3)(H)(ii) of the Public Health Service Act 15

or subsection (b)(3)(H)(ii) of section 716 of the Em-16

ployee Retirement Income Security Act of 1974 or 17

section 9816 of the Internal Revenue Code of 1986, 18

as applicable) to a nonparticipating provider (as de-19

fined in subparagraph (G) of section 2719A(b)(3) of 20

the Public Health Service Act or subparagraph (G) 21

of subsection (b)(3) of section 716 of the Employee 22

Retirement Income Security Act of 1974 or section 23

9816 of the Internal Revenue Code of 1986, as ap-24

plicable) or a nonparticipating emergency facility (as 25

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126 

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defined in subparagraph (F) of such section 1

2719A(b)(3) or such subsection (b)(3) of such sec-2

tion 716 or such section 9816, as applicable) with 3

respect to an item or service (or, in the case of pay-4

ment made under section 2719A(f)(1) of the Public 5

Health Service Act or subsection (f)(1) of section 6

716 of the Employee Retirement Income Security 7

Act of 1974 or section 9816 of the Internal Revenue 8

Code of 1986, as applicable, with respect to air am-9

bulance services) furnished by such provider or facil-10

ity— 11

(A) subject to subparagraph (B), the non-12

participating provider, nonparticipating emer-13

gency facility, or group health plan or health in-14

surance issuer, respectively, may, not later than 15

the date specified in paragraph (2), submit a 16

request that such payment should be increased 17

or decreased; and 18

(B) in the case a settlement described in 19

subsection (d)(2) is not reached with respect to 20

such request, an entity certified and selected 21

under subsection (c) shall determine in accord-22

ance with such paragraph an alternative pay-23

ment to be applied, with respect to such re-24

quest. 25

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127 

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(2) DATE SPECIFIED.—For purposes of para-1

graph (1)(A), the date specified in this paragraph 2

is— 3

(A) in the case of a request described in 4

such paragraph (1)(A) being submitted by a 5

nonparticipating provider or nonparticipating 6

emergency facility, with respect to items and 7

services (or air ambulance services) described in 8

paragraph (1), the date that is 30 days after 9

the applicable date described in subsection 10

(b)(2)(A)(ii); or 11

(B) in the case of such a request filed by 12

a group health plan or health insurance issuer, 13

the date that is 30 days after the date of the 14

submission of the notice described in subsection 15

(b)(1)(B)(ii). 16

(3) CLARIFICATION.—A nonparticipating pro-17

vider may not, with respect to an item or service (or 18

air ambulance service) furnished by such provider, 19

submit a request under the IDR process if such pro-20

vider is exempt from the requirement under sub-21

section (a) of section 2799A–2 of the Public Health 22

Service Act with respect to such item or service pur-23

suant to subsection (e) of such section. 24

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128 

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(b) REQUIREMENTS FOR REQUESTS TO BE ELIGI-1

BLE FOR SUBMISSION UNDER IDR PROCESS.— 2

(1) TIMING REQUIREMENTS.—A request may 3

not be submitted under the IDR process, with re-4

spect to items and services (or air ambulance serv-5

ices) furnished by a nonparticipating provider or 6

nonparticipating emergency facility for which a 7

group health plan or health insurance issuer offering 8

health insurance coverage in the group or individual 9

market made a payment pursuant to subsection 10

(b)(1), (e)(1), or (f)(1) of section 2719A of the Pub-11

lic Health Service Act or subsection (b)(1), (e)(1), or 12

(f)(1) of section 716 of the Employee Retirement In-13

come Security Act of 1974 or section 9816 of the 14

Internal Revenue Code of 1986 (as applicable) un-15

less— 16

(A) in the case such request is being sub-17

mitted by the nonparticipating provider or non-18

participating emergency facility— 19

(i) the provider or facility, respec-20

tively, filed, not later than 30 days after 21

the date such payment is received by the 22

provider or facility, respectively, an appeal 23

under the appeals process of the group 24

health plan or health insurance issuer, the 25

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129 

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subject of which includes the payment for 1

such items and services (or air ambulance 2

services); and 3

(ii) such request is not submitted be-4

fore the sooner of the date on which such 5

appeal has been resolved or the date that 6

is 30 days after the date on which such ap-7

peal is so filed; or 8

(B) in the case such request is being sub-9

mitted by the group health plan or health insur-10

ance issuer— 11

(i) the group health plan or health in-12

surance issuer, respectively, not later than 13

30 days after such provider or facility, re-14

spectively, receives such payment, submits 15

to such provider or facility, respectively, a 16

notice that such plan or issuer, respec-17

tively, disputes the amount of such pay-18

ment with respect to such items and serv-19

ices (or air ambulance services); and 20

(ii) such request is not submitted be-21

fore the date that is 30 days after the date 22

of the submission of such notice. 23

(2) MINIMUM MEDIAN CONTRACTED RATE.—A 24

request may not be submitted under the IDR proc-25

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ess, with respect to items and services (or air ambu-1

lance services) furnished in a geographic area by a 2

nonparticipating provider or nonparticipating emer-3

gency facility for which a group health plan or 4

health insurance issuer offering health insurance 5

coverage in the group or individual market made a 6

payment pursuant to subsection (b)(1), (e)(1), or 7

(f)(1) of section 2719A of the Public Health Service 8

Act or subsection (b)(1), (e)(1), or (f)(1) of section 9

716 of the Employee Retirement Income Security 10

Act of 1974 or section 9816 of the Internal Revenue 11

Code of 1986 (as applicable) unless— 12

(A) in the case such item or service is fur-13

nished during 2022, the median contracted rate 14

(as defined in subsection (b)(3)(E) of section 15

2719A of the Public Health Service Act or sub-16

section (b)(3)(E) of section 716 of the Em-17

ployee Retirement Income Security Act of 1974 18

or section 9816 of the Internal Revenue Code 19

of 1986 (as applicable)) for such year under 20

such plan or such coverage with respect to each 21

such item or service furnished by such a pro-22

vider or such a facility in such area is at least 23

$750 (or, in the case of air ambulance services, 24

is at least $25,000); or 25

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131 

•HR 5800 IH

(B) in the case such item or service (or air 1

ambulance services) is furnished during a sub-2

sequent year, the median contracted rate (as so 3

defined) for such year under such plan or such 4

coverage with respect to each such item or serv-5

ice furnished by such a provider or such a facil-6

ity in such area is at least the amount applied 7

under this paragraph for the previous year, in-8

creased by the percentage increase in the con-9

sumer price index for all urban consumers 10

(United States city average) over such previous 11

year. 12

(3) LIMITATION ON BATCHING OF ITEMS AND 13

SERVICES IN A REQUEST.—A request may not be 14

submitted under the IDR process by a nonpartici-15

pating provider, nonparticipating emergency facility, 16

or a group health plan or health insurance issuer of-17

fering health insurance coverage in the group or in-18

dividual market, with respect to multiple items and 19

services (or multiple air ambulance services), un-20

less— 21

(A) all such items and services (or air am-22

bulance services) included in such request are 23

furnished by the same provider or facility; 24

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132 

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(B) payment for all such items and serv-1

ices (or air ambulance services) made pursuant 2

to subsection (b)(1), (e)(1), or (f)(1) of section 3

2719A of the Public Health Service Act or sub-4

section (b)(1), (e)(1), or (f)(1) of section 716 of 5

the Employee Retirement Income Security Act 6

of 1974 or section 9816 of the Internal Rev-7

enue Code of 1986 (as applicable) was made by 8

a single group health plan or health insurance 9

coverage; 10

(C) all such items and services (or air am-11

bulance services) are related to the treatment of 12

the same condition; and 13

(D) all such items and services were fur-14

nished during the 30-day period following the 15

date on which the first item or service (or air 16

ambulance service) included in such request was 17

furnished. 18

(c) IDR ENTITIES.— 19

(1) PROCESS OF CERTIFICATION.—The process 20

described in subsection (a) shall include a certifi-21

cation process under which eligible entities may be 22

certified to carry out the IDR process. 23

(2) CERTIFICATION.— 24

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(A) IN GENERAL.—An entity wishing to 1

participate in the IDR process under this sec-2

tion shall request certification from the Secre-3

taries. The Secretaries shall determine whether 4

or not to certify applicant entities, taking into 5

consideration whether the entity is unbiased 6

and unaffiliated with health insurance issuers, 7

group health plans, health care facilities, and 8

health care providers and free of conflicts of in-9

terest, in accordance with the Secretaries’ rule-10

making on determining criteria for conflicts of 11

interest. 12

(B) ELIGIBLE ENTITIES.—For purposes of 13

this section, an eligible entity is an entity that 14

is a nongovernmental entity and that agrees to 15

comply with the fee limitations described in 16

subparagraph (C). 17

(C) FEE LIMITATIONS.—For purposes of 18

subparagraph (B), the fee limitations described 19

in this subparagraph are limitations established 20

by the Secretaries for the amount a certified 21

IDR entity may charge a nonparticipating pro-22

vider, nonparticipating emergency facility, 23

group health plan, or health insurance issuer 24

offering heath insurance coverage in the group 25

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134 

•HR 5800 IH

or individual market for services furnished by 1

such entity with respect to the resolution of a 2

specified request of such provider, facility, plan, 3

or issuer under the process described in sub-4

section (a). 5

(3) SELECTION OF CERTIFIED IDR ENTITY.— 6

The group health plan or health insurance issuer of-7

fering health insurance coverage in the group or in-8

dividual market and the nonparticipating provider or 9

the nonparticipating emergency facility (as applica-10

ble) involved in a request submitted under the IDR 11

process shall agree on a certified IDR entity to re-12

solve such request. In the case that such plan or 13

issuer (as applicable) and such provider or facility 14

(as applicable) cannot so agree, such an entity shall 15

be selected by the Secretaries at random, in accord-16

ance with a manner and timeline specified by the 17

Secretaries. 18

(d) PAYMENT DETERMINATION.— 19

(1) TIMING.—A certified IDR entity selected 20

under subsection (c)(3) with respect to a request 21

under the IDR process shall, subject to paragraph 22

(2), not later than 30 days after being so selected, 23

determine the alternative payment that should be 24

made for items and services (or air ambulance serv-25

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135 

•HR 5800 IH

ices) included in such request in accordance with 1

paragraph (3). 2

(2) SETTLEMENT.— 3

(A) IN GENERAL.—If such entity deter-4

mines that a settlement between the group 5

health plan or issuer, as applicable, and the 6

provider or facility, as applicable, is likely with 7

respect to a request under the IDR process, the 8

entity may direct the parties to attempt, for a 9

period not to exceed 10 days, a good faith nego-10

tiation for a settlement of such request. 11

(B) TIMING.—The period for a settlement 12

described in subparagraph (A) shall accrue to-13

ward the 30-day period described in paragraph 14

(1). 15

(3) DETERMINATION OF ALTERNATIVE PAY-16

MENT.— 17

(A) IN GENERAL.—The group health plan 18

or health insurance issuer offering health insur-19

ance coverage in the group or individual market 20

(as applicable) and the nonparticipating pro-21

vider or nonparticipating emergency facility (as 22

applicable) involved shall, with respect to a re-23

quest under the IDR process, each submit to 24

the certified IDR entity selected under sub-25

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136 

•HR 5800 IH

section (c)(3) for such request a final offer to 1

be considered for the alternative payment to be 2

applied with respect to items and services (or 3

air ambulance services) which are the subject of 4

the request. Such entity shall determine, in ac-5

cordance with subparagraph (B), which such 6

offer is the most reasonable and will be applied 7

as the alternative payment. 8

(B) CONSIDERATIONS IN DETERMINA-9

TION.— 10

(i) IN GENERAL.—In determining 11

which final offer is the alternative payment 12

to be applied, the certified IDR entity se-13

lected under subsection (c)(3) for such re-14

quest shall consider— 15

(I) the median contracted rates 16

(as defined in subsection (b)(3)(E) of 17

section 2719A of the Public Health 18

Service Act or subsection (b)(3)(E) of 19

section 716 of the Employee Retire-20

ment Income Security Act of 1974 or 21

section 9816 of the Internal Revenue 22

Code of 1986 (as applicable)) for the 23

applicable year for items or services 24

(or air ambulance services) that are 25

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137 

•HR 5800 IH

comparable to the items and services 1

(or air ambulance services) included 2

in the request and that are furnished 3

in the same geographic area (as de-4

fined by the Secretaries for purposes 5

of such subsection) as such items and 6

services (or air ambulance services) 7

(not including any facility fees with 8

respect to such rates); and 9

(II) in the case of items and 10

services (other than air ambulances 11

services), each circumstance described 12

in clause (ii) with respect to which in-13

formation is submitted by either party 14

or, in the case of air ambulance serv-15

ices, each circumstance described in 16

clause (iii) with respect to which in-17

formation is submitted by either 18

party. 19

(ii) ADDITIONAL CIRCUMSTANCES FOR 20

CERTAIN ITEMS AND SERVICES.—For pur-21

poses of clause (i)(II), the circumstances 22

described in this clause are, with respect to 23

items and services (other than air ambu-24

lance services) included in the request 25

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138 

•HR 5800 IH

under the IDR process of a nonpartici-1

pating provider, nonparticipating emer-2

gency facility, group health plan, or health 3

insurance issuer the following: 4

(I) The level of training, edu-5

cation, experience, and quality and 6

outcomes measurements of the pro-7

vider or facility that furnished such 8

items and services (such as those en-9

dorsed by the consensus-based entity 10

authorized under section 1890 of the 11

Social Security Act). 12

(II) The market share held by 13

the provider or facility, or the plan or 14

issuer, in the geographic area in 15

which the item or service was pro-16

vided. 17

(III) Any other extenuating cir-18

cumstances with respect to the fur-19

nishing of such items and services 20

that relate to the acuity of the indi-21

vidual receiving such items and serv-22

ices or the complexity of furnishing 23

such items and services to such indi-24

vidual. 25

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139 

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(iii) ADDITIONAL CIRCUMSTANCES 1

FOR AIR AMBULANCE SERVICES.—For pur-2

poses of clause (i)(II), the circumstances 3

described in this clause are, with respect to 4

air ambulance services included in the re-5

quest under the IDR process of a non-6

participating provider, group health plan, 7

or health insurance issuer the following: 8

(I) The quality and outcomes 9

measurements of the provider that 10

furnished such services. 11

(II) Any other extenuating cir-12

cumstances with respect to the fur-13

nishing of such services that relate to 14

the acuity of the individual receiving 15

such services or the complexity of fur-16

nishing such services to such indi-17

vidual. 18

(III) The training, education, ex-19

perience, and quality of the medical 20

personnel that furnished such serv-21

ices. 22

(IV) Ambulance vehicle type, in-23

cluding the clinical capability level of 24

such vehicle. 25

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140 

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(V) Population density of the 1

pick up location (such as urban, sub-2

urban, rural, or frontier). 3

(iv) PROHIBITION ON CONSIDERATION 4

OF BILLED CHARGES.—In determining 5

which final offer is the alternative payment 6

amount to be applied with respect to items 7

and services (or air ambulance services) 8

furnished by a provider or facility and in-9

cluded in the request under the IDR proc-10

ess, the certified IDR entity selected under 11

subsection (c)(3) with respect to such re-12

quest shall not consider the amount that 13

would have been billed by such provider or 14

facility with respect to such items and 15

services had the provisions of section 16

2799A–1, 2799A–2, or 2799A–4 of the 17

Public Health Service Act (as applicable) 18

not applied. 19

(C) EFFECTS OF DETERMINATION.— 20

(i) IN GENERAL.—A determination of 21

a certified IDR entity under subparagraph 22

(A) shall be binding. 23

(ii) LIMITATION ON CERTAIN SUBSE-24

QUENT IDR CLAIMS.—In the case of a de-25

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141 

•HR 5800 IH

termination of a certified IDR entity under 1

subparagraph (A), with respect to a re-2

quest submitted under subsection (a)(1)(A) 3

and the two parties involved with such re-4

quest, the party that submitted such initial 5

request may not submit during the 90-day 6

period following such determination a sub-7

sequent request under such subsection in-8

volving the same other party to such re-9

quest with respect to such an item or serv-10

ice (or air ambulance service) that was the 11

subject of such initial request. 12

(D) COSTS OF INDEPENDENT DISPUTE 13

RESOLUTION PROCESS.—In the case of a re-14

quest made by a nonparticipating provider, non-15

participating emergency facility, group health 16

plan, or health insurance issuer offering health 17

insurance coverage in the group or individual 18

market and submitted to a certified IDR enti-19

ty— 20

(i) if such entity makes a determina-21

tion with respect to such request under 22

subparagraph (A), the party whose offer is 23

not chosen under such clause shall be re-24

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142 

•HR 5800 IH

sponsible for paying all fees charged by 1

such entity; and 2

(ii) if the parties reach a settlement 3

with respect to such request prior to such 4

a determination, each party shall pay half 5

of all fees charged by such entity, unless 6

the parties otherwise agree. 7

(E) PAYMENT.—Not later than 30 days 8

after the date on which a determination de-9

scribed in subparagraph (B) is made with re-10

spect to a request under the IDR process of a 11

nonparticipating provider, nonparticipating 12

emergency facility, group health plan, or health 13

insurance issuer offering health insurance cov-14

erage in the group or individual market— 15

(i) in the case that the alternative 16

payment determined to be applied is great-17

er than the amount paid with respect to 18

such request, such plan or issuer (as appli-19

cable) shall pay directly to the provider or 20

facility (as applicable) the difference be-21

tween such alternative payment and the 22

amount so paid; and 23

(ii) in the case that the alternative 24

payment determined to be applied is less 25

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143 

•HR 5800 IH

than the amount paid with respect to such 1

request, such provider or facility (as appli-2

cable) shall pay directly to the plan or 3

issuer (as applicable) the difference be-4

tween the amount so paid and such alter-5

native payment. 6

(e) PUBLICATION OF INFORMATION RELATING TO 7

DISPUTES.— 8

(1) PUBLICATION OF INFORMATION.—For 2022 9

and each subsequent year, the Secretaries shall 10

make available on the public website of the Depart-11

ment of Health and Human Services, the Depart-12

ment of Labor, and the Department of the Treas-13

ury— 14

(A) the number of requests submitted 15

under the IDR process during such year; 16

(B) the practice size of the providers and 17

facilities submitting requests under the IDR 18

process during such year; 19

(C) the number of such requests with re-20

spect to which a final determination was made 21

under subsection (d)(3)(A); and 22

(D) the information described in para-23

graph (2) with respect to each request with re-24

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144 

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spect to which such a determination was so 1

made. 2

(2) INFORMATION WITH RESPECT TO RE-3

QUESTS.—For purposes of paragraph (1), the infor-4

mation described in this paragraph is, with respect 5

to a request under the IDR process of a nonpartici-6

pating provider, nonparticipating emergency facility, 7

group health plan, or health insurance issuer offer-8

ing health insurance coverage in the group or indi-9

vidual market— 10

(A) a description of each item and service 11

(or air ambulance service) included in such re-12

quest; 13

(B) the geography in which the items and 14

services (or air ambulance services) included in 15

such request were provided; 16

(C) the amount of the offer submitted 17

under subsection (d)(3)(A) by the group health 18

plan or health insurance issuer (as applicable) 19

and by the nonparticipating provider or non-20

participating emergency facility (as applicable) 21

expressed as a percentage of the median con-22

tracted rate; 23

(D) whether the offer selected by the cer-24

tified IDR entity under such subsection to be 25

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145 

•HR 5800 IH

the alternative payment applied was the offer 1

submitted by such plan or issuer (as applicable) 2

or by such provider or facility (as applicable) 3

and the amount of such offer so selected ex-4

pressed as a percentage of the median con-5

tracted rate; 6

(E) the category and practice specialty of 7

each such provider or facility involved in fur-8

nishing such items and services (or, in the case 9

of air ambulance services, the ambulance vehicle 10

type, including the clinical capability level of 11

such vehicle); and 12

(F) the identity of the group health plan or 13

health insurance issuer, provider, or facility, 14

with respect to the request. 15

(3) IDR ENTITY REQUIREMENTS.—For 2022 16

and each subsequent year, an IDR entity, as a con-17

dition of certification as an IDR entity, shall submit 18

to the Secretaries such information as the Secre-19

taries determines necessary for the Secretaries to 20

carry out the provisions of this subsection. 21

(f) ENFORCEMENT.— 22

(1) IN GENERAL.—Any health care provider, 23

health care facility, group health plan, or health in-24

surance issuer offering group or individual health in-25

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146 

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surance coverage that violates a provision of this 1

section shall be subject to a civil monetary penalty 2

in an amount not to exceed $10,000 for each such 3

violation. 4

(2) APPLICATION.—The provisions of section 5

1128A of the Social Security Act (other than sub-6

sections (a) and (b) and the first sentence of sub-7

section (c)(1)) shall apply with respect to a civil 8

monetary penalty imposed under this subsection in 9

the same manner as such provisions apply with re-10

spect to a penalty or proceeding under subsection 11

(a) of such section, except that any reference to ‘‘the 12

Secretary’’ in such provisions shall be treated as a 13

reference to ‘‘the Secretaries’’. 14

(g) DEFINITIONS.—In this subsection, terms ‘‘group 15

health plan’’, ‘‘group market’’, ‘‘health insurance issuer’’, 16

‘‘health insurance coverage’’, ‘‘individual health insurance 17

coverage’’, ‘‘group health insurance coverage’’, and ‘‘indi-18

vidual market’’ have the meanings given such terms, re-19

spectively, in section 2791 of the Public Health Service 20

Act. 21

SEC. 5. ADVISORY COMMITTEE ON GROUND AMBULANCE 22

AND PATIENT BILLING. 23

(a) IN GENERAL.—Not later than 60 days after the 24

date of enactment of this Act, the Secretary of Labor, Sec-25

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147 

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retary of Health and Human Services, and the Secretary 1

of the Treasury (the Secretaries) shall jointly establish an 2

advisory committee for the purpose of reviewing options 3

to improve the disclosure of charges and fees for ground 4

ambulance services, better inform consumers of insurance 5

options for such services, and protect consumers from bal-6

ance billing. 7

(b) COMPOSITION OF THE ADVISORY COMMITTEE.— 8

The advisory committee shall be composed of the following 9

members: 10

(1) The Secretary of Labor, or the Secretary’s 11

designee. 12

(2) The Secretary of Health and Human Serv-13

ices, or the Secretary’s designee. 14

(3) The Secretary of the Treasury, or the Sec-15

retary’s designee. 16

(4) One representative, to be appointed jointly 17

by the Secretaries, for each of the following: 18

(A) Each relevant Federal agency, as de-19

termined by the Secretaries. 20

(B) State insurance regulators. 21

(C) Health insurance providers or trade or-22

ganization. 23

(D) Patient advocacy groups. 24

(E) Consumer advocacy groups. 25

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148 

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(F) State and local governments. 1

(G) Physician specializing in emergency, 2

trauma, cardiac, or stroke. 3

(5) Three representatives, to be appointed joint-4

ly by the Secretaries, to represent the various seg-5

ments of the ground ambulance industry. 6

(6) Up to an additional three representatives 7

otherwise not described in paragraphs (1) through 8

(5), as determined necessary and appropriate by the 9

Secretaries. 10

(c) CONSULTATION.—The advisory committee shall, 11

as appropriate, consult with relevant experts and stake-12

holders, including those not otherwise included under sub-13

section (b), while conducting the review described in sub-14

section (a). 15

(d) RECOMMENDATIONS.—The advisory committee 16

shall make recommendations with respect to disclosure of 17

charges and fees for ground ambulance services and insur-18

ance coverage, consumer protection and enforcement au-19

thorities of the Departments of Labor, Health and Human 20

Services, and the Treasury and State authorities, and the 21

prevention of balance billing to consumers. The rec-22

ommendations shall address, at a minimum— 23

(1) options, best practices, and identified stand-24

ards to prevent instances of balance billing; 25

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149 

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(2) steps that can be taken by State legisla-1

tures, State insurance regulators, State attorneys 2

general, and other State officials as appropriate, 3

consistent with current legal authorities regarding 4

consumer protection; and 5

(3) legislative options for Congress to prevent 6

balance billing. 7

(e) REPORT.—Not later than 180 days after the date 8

of the first meeting of the advisory committee, the advi-9

sory committee shall submit to the Secretaries, and the 10

Committees on Education and Labor, Energy and Com-11

merce, and Ways and Means of the House of Representa-12

tives and the Committees on Finance and Health, Edu-13

cation, Labor, and Pensions a report containing the rec-14

ommendations made under subsection (d). 15

(f) RULEMAKING.—Upon receipt of the report under 16

subsection (e), the Secretaries shall consider the rec-17

ommendations of the advisory committee and issue regula-18

tions or other guidance as deemed necessary to provide 19

consumer protections for patients of ground ambulance 20

providers. 21

SEC. 6. IMPROVING PROVIDER DIRECTORIES. 22

(a) PHSA.—Part A of title XXVII of the Public 23

Health Service Act (42 U.S.C. 300gg et seq.) is amended 24

by adding at the end the following new section: 25

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150 

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‘‘SEC. 2730. PROTECTING PATIENTS AND IMPROVING THE 1

ACCURACY OF PROVIDER DIRECTORY INFOR-2

MATION. 3

‘‘(a) NETWORK STATUS OF PROVIDERS.— 4

‘‘(1) IN GENERAL.—Beginning on the date that 5

is one year after the date of enactment of this sec-6

tion, a group health plan or a health insurance 7

issuer offering group or individual health insurance 8

coverage shall— 9

‘‘(A) establish business processes to ensure 10

that all enrollees in such plan or coverage re-11

ceive proof of a health care provider’s network 12

status, based on what a plan or issuer knows or 13

should know— 14

‘‘(i) upon a telephone inquiry by an 15

enrollee— 16

‘‘(I) through a written electronic 17

communication from the plan or 18

issuer to the enrollee, as soon as prac-19

ticable and not later than 1 business 20

day after such inquiry is made by 21

such participant, beneficiary, or en-22

rollee for such information; 23

‘‘(II) through an oral commu-24

nication from the plan or issuer to the 25

enrollee, as soon as practicable and 26

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151 

•HR 5800 IH

not later than 1 business day after 1

such inquiry is made by such enrollee 2

for such information, which commu-3

nication shall be documented by such 4

plan or issuer, and such documenta-5

tion shall be kept in the enrollee’s file 6

for a minimum of 2 years; and 7

‘‘(ii) in real-time through an online 8

health care provider directory search tool 9

maintained by the plan or issuer; and 10

‘‘(B) include in any print directory— 11

‘‘(i) a disclosure that the information 12

included in the directory is accurate as of 13

the date of the last data update and that 14

enrollees or prospective enrollees should 15

consult the group health plan’s or issuer’s 16

electronic provider directory on its website 17

or call a specified customer service tele-18

phone number to obtain the most current 19

provider directory information; and 20

‘‘(ii) a list of the categories of pro-21

viders of ancillary services for which the 22

plan or coverage has no in-network pro-23

viders. 24

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‘‘(2) GROUP HEALTH PLAN AND HEALTH IN-1

SURANCE ISSUER BUSINESS PROCESSES.—Beginning 2

on the date that is one year after the date of the en-3

actment of this section, a group health plan or a 4

health insurance issuer offering group or individual 5

health insurance coverage shall establish business 6

processes to— 7

‘‘(A) verify and update, at least once every 8

90 days, the provider directory information for 9

all providers included in the online health care 10

provider directory search tool described in para-11

graph (1)(A)(ii); and 12

‘‘(B) remove any provider from such online 13

directory search tool if such provider has not 14

verified the directory information within the 15

previous 6 months or the plan or issuer has 16

been unable to verify the provider’s network 17

participation. 18

‘‘(b) COST-SHARING LIMITATIONS.—A group health 19

plan or a health insurance issuer offering group or indi-20

vidual health insurance coverage shall not apply, and shall 21

ensure that no provider applies, cost-sharing to an enrollee 22

for treatment or services provided by a health care pro-23

vider in excess of the normal cost-sharing applied for such 24

treatment or services provided in-network (including any 25

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153 

•HR 5800 IH

balance bill issued by the health care provider involved), 1

if such enrollee, or health care provider referring such en-2

rollee, demonstrates (based on the electronic, written in-3

formation described in subsection (a)(1)(A)(i)(I), the oral 4

confirmation described in subsection (a)(1)(A)(i)(II) re-5

ceived by the enrollee not more than 30 days before the 6

date the treatment or services were received, or a copy 7

of the online provider directory described in subsection 8

(a)(1)(A)(ii) on a date not more than 30 days before the 9

date the treatment or services were received), that the en-10

rollee relied on the information described in subsection 11

(a)(1) for which such enrollee provides such documenta-12

tion, that indicated that the provider is an in-network pro-13

vider, if the provider was out-of-network at the time the 14

treatment or service involved was received. 15

‘‘(c) DEFINITION.—For purposes of this section, the 16

term ‘provider directory information’ includes the names, 17

addresses, specialty, and telephone numbers of individual 18

health care providers, and the names, addresses, and tele-19

phone numbers of each medical group, clinic, or facility 20

contracted to participate in any of the networks of the 21

group health plan or health insurance coverage involved. 22

‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec-23

tion shall be construed to preempt any provision of State 24

law relating to health care provider directories.’’. 25

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(b) ERISA.—Subpart B of part 7 of subtitle B of 1

title I of the Employee Retirement Income Security Act 2

of 1974 (29 U.S.C. 1185 et seq.), as amended by section 3

2, is further amended by adding at the end the following: 4

‘‘SEC. 717. PROTECTING PATIENTS AND IMPROVING THE 5

ACCURACY OF PROVIDER DIRECTORY INFOR-6

MATION. 7

‘‘(a) NETWORK STATUS OF PROVIDERS.— 8

‘‘(1) IN GENERAL.—Beginning on the date that 9

is one year after the date of enactment of this sec-10

tion, a group health plan (or health insurance cov-11

erage offered in connection with such a plan) shall— 12

‘‘(A) establish business processes to ensure 13

that all participants and beneficiaries in such 14

plan or coverage receive proof of a health care 15

provider’s network status, based on what a plan 16

or issuer of such coverage knows or should 17

know— 18

‘‘(i) upon a telephone inquiry by a 19

participant or beneficiary— 20

‘‘(I) through a written electronic 21

communication from the plan or 22

issuer to the participant or bene-23

ficiary, as soon as practicable and not 24

later than 1 business day after such 25

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155 

•HR 5800 IH

inquiry is made by such participant or 1

beneficiary for such information; 2

‘‘(II) through an oral commu-3

nication from the plan or issuer to the 4

participant or beneficiary, as soon as 5

practicable and not later than 1 busi-6

ness day after such inquiry is made by 7

such participant or beneficiary for 8

such information, which communica-9

tion shall be documented by such plan 10

or issuer, and such documentation 11

shall be kept in the participant’s or 12

beneficiary’s file for a minimum of 2 13

years; and 14

‘‘(ii) in real-time through an online 15

health care provider directory search tool 16

maintained by the plan or issuer; and 17

‘‘(B) include in any print directory— 18

‘‘(i) a disclosure that the information 19

included in the directory is accurate as of 20

the date of the last data update and that 21

participants or beneficiaries or prospective 22

participants or beneficiaries should consult 23

the group health plan’s or issuer’s elec-24

tronic provider directory on its website or 25

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156 

•HR 5800 IH

call a specified customer service telephone 1

number to obtain the most current pro-2

vider directory information; and 3

‘‘(ii) a list of the categories of pro-4

viders of ancillary services for which the 5

plan or coverage has no in-network pro-6

viders. 7

‘‘(2) GROUP HEALTH PLAN AND HEALTH IN-8

SURANCE ISSUER BUSINESS PROCESSES.—Beginning 9

on the date that is one year after the date of enact-10

ment of this section, a group health plan (or health 11

insurance coverage offered in connection with such a 12

plan) shall establish business processes to— 13

‘‘(A) verify and update, at least once every 14

90 days, the provider directory information for 15

all providers included in the online health care 16

provider directory search tool described in para-17

graph (1)(A)(ii); and 18

‘‘(B) remove any provider from such online 19

directory search tool if such provider has not 20

verified the directory information within the 21

previous 6 months or the plan or issuer has 22

been unable to verify the provider’s network 23

participation. 24

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‘‘(b) COST-SHARING LIMITATIONS.—A group health 1

plan (or health insurance coverage offered in connection 2

with such a plan) shall not apply, and shall ensure that 3

no provider applies, cost-sharing to a participant or bene-4

ficiary for treatment or services provided by a health care 5

provider in excess of the normal cost-sharing applied for 6

such treatment or services provided in-network (including 7

any balance bill issued by the health care provider in-8

volved), if such participant or beneficiary, or health care 9

provider referring such participant or beneficiary, dem-10

onstrates (based on the electronic, written information de-11

scribed in subsection (a)(1)(A)(i)(I), the oral confirmation 12

described in subsection (a)(1)(A)(i)(II) received by the 13

participant or beneficiary not more than 30 days before 14

the date the treatment or services were received, or a copy 15

of the online provider directory described in subsection 16

(a)(1)(A)(ii) on a date not more than 30 days before the 17

date the treatment or services were received), that the par-18

ticipant or beneficiary relied on the information described 19

in subsection (a)(1) for which such participant or bene-20

ficiary provides such documentation, that indicated that 21

the provider is an in-network provider, if the provider was 22

out-of-network at the time the treatment or service in-23

volved was received. 24

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158 

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‘‘(c) DEFINITION.—For purposes of this section, the 1

term ‘provider directory information’ includes the names, 2

addresses, specialty, and telephone numbers of individual 3

health care providers, and the names, addresses, and tele-4

phone numbers of each medical group, clinic, or facility 5

contracted to participate in any of the networks of the 6

group health plan or health insurance coverage involved.’’. 7

(c) IRC.—Subchapter B of chapter 100 of the Inter-8

nal Revenue Code of 1986, as amended by section 2, is 9

further amended by adding at the end the following: 10

‘‘SEC. 9817. PROTECTING PATIENTS AND IMPROVING THE 11

ACCURACY OF PROVIDER DIRECTORY INFOR-12

MATION. 13

‘‘(a) NETWORK STATUS OF PROVIDERS.— 14

‘‘(1) IN GENERAL.—Beginning on the date that 15

is one year after the date of enactment of this sec-16

tion, a group health plan shall— 17

‘‘(A) establish business processes to ensure 18

that all participants or beneficiaries in such 19

plan receive proof of a health care provider’s 20

network status, based on what a plan or issuer 21

knows or should know— 22

‘‘(i) upon a telephone inquiry by a 23

participant or beneficiary— 24

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159 

•HR 5800 IH

‘‘(I) through a written electronic 1

communication from the plan to the 2

participant or beneficiary, as soon as 3

practicable and not later than 1 busi-4

ness day after such inquiry is made by 5

such participant or beneficiary for 6

such information; 7

‘‘(II) through an oral commu-8

nication from the plan to the partici-9

pant or beneficiary, as soon as prac-10

ticable and not later than 1 business 11

day after such inquiry is made by 12

such participant or beneficiary for 13

such information, which communica-14

tion shall be documented by such 15

plan, and such documentation shall be 16

kept in the participant’s or bene-17

ficiary’s file for a minimum of 2 18

years; and 19

‘‘(ii) in real-time through an online 20

health care provider directory search tool 21

maintained by the plan; and 22

‘‘(B) include in any print directory— 23

‘‘(i) a disclosure that the information 24

included in the directory is accurate as of 25

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160 

•HR 5800 IH

the date of the last data update and that 1

participants or beneficiaries or prospective 2

participants or beneficiaries should consult 3

the group health plan’s electronic provider 4

directory on its website or call a specified 5

customer service telephone number to ob-6

tain the most current provider directory in-7

formation; and 8

‘‘(ii) a list of the categories of pro-9

viders of ancillary services for which the 10

plan or coverage has no in-network pro-11

viders. 12

‘‘(2) GROUP HEALTH PLAN BUSINESS PROC-13

ESSES.—Beginning on the date that is one year 14

after the date of enactment of this section, a group 15

health plan shall establish business processes to— 16

‘‘(A) verify and update, at least once every 17

90 days, the provider directory information for 18

all providers included in the online health care 19

provider directory search tool described in para-20

graph (1)(A)(ii); and 21

‘‘(B) remove any provider from such online 22

directory search tool if such provider has not 23

verified the directory information within the 24

previous 6 months or the plan or issuer has 25

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161 

•HR 5800 IH

been unable to verify the provider’s network 1

participation. 2

‘‘(b) COST-SHARING LIMITATIONS.—A group health 3

plan shall not apply, and shall ensure that no provider 4

applies, cost-sharing to a participant or beneficiary for 5

treatment or services provided by a health care provider 6

in excess of the normal cost-sharing applied for such treat-7

ment or services provided in-network (including any bal-8

ance bill issued by the health care provider involved), if 9

such participant or beneficiary, or health care provider re-10

ferring such participant or beneficiary, demonstrates 11

(based on the electronic, written information described in 12

subsection (a)(1)(A)(i)(I), the oral confirmation described 13

in subsection (a)(1)(A)(i)(II) received by the participant 14

or beneficiary not more than 30 days before the date the 15

treatment or services were received, or a copy of the online 16

provider directory described in subsection (a)(1)(A)(ii) on 17

a date not more than 30 days before the date the treat-18

ment or services were received), that the participant or 19

beneficiary relied on the information described in sub-20

section (a)(1) for which such participant or beneficiary 21

provides such documentation, that indicated that the pro-22

vider is an in-network provider, if the provider was out- 23

of-network at the time the treatment or service involved 24

was received. 25

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162 

•HR 5800 IH

‘‘(c) DEFINITION.—For purposes of this section, the 1

term ‘provider directory information’ includes the names, 2

addresses, specialty, and telephone numbers of individual 3

health care providers, and the names, addresses, and tele-4

phone numbers of each medical group, clinic, or facility 5

contracted to participate in any of the networks of the 6

group health plan involved. 7

‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec-8

tion shall be construed to preempt any provision of State 9

law relating to health care provider directories.’’. 10

(d) CLERICAL AMENDMENTS.— 11

(1) ERISA.—The table of contents in section 1 12

of the Employee Retirement Income Security Act of 13

1974 (29 U.S.C. 1001 et seq.), as amended by sec-14

tion 2, is further amended by inserting after the 15

item relating to section 716 the following new item: 16

‘‘Sec. 717. Protecting patients and improving the accuracy of provider directory 
information.’’. 

(2) IRC.—The table of sections for subchapter 17

B of chapter 100 of the Internal Revenue Code of 18

1986, as amended by section 2, is further amended 19

by adding at the end the following new item: 20

‘‘Sec. 9817. Protecting patients and improving the accuracy of provider direc-
tory information.’’. 

(e) PROVIDER REQUIREMENTS.—Part D of title 21

XXVII of the Public Health Service Act (42 U.S.C. 300gg 22

et seq.), as added by section 3, is amended— 23

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•HR 5800 IH

(1) by redesignating section 2799A–5 as section 1

2799A–7; and 2

(2) by inserting after section 2799A–4 the fol-3

lowing new section: 4

‘‘SEC. 2799A–5. PROVIDER REQUIREMENTS TO PROTECT PA-5

TIENTS AND IMPROVE THE ACCURACY OF 6

PROVIDER DIRECTORY INFORMATION. 7

‘‘(a) PROVIDER BUSINESS PROCESSES.—A health 8

care provider shall have in place business processes to en-9

sure the timely provision of provider directory information 10

to a group health plan or a health insurance issuer offer-11

ing group or individual health insurance coverage to sup-12

port compliance by such plans or issuers with section 13

2730(a)(1), section 717(a)(1) of the Employee Retirement 14

Income Security Act of 1974, or section 9817(a)(1) of the 15

Internal Revenue Code of 1986 (as applicable). Such pro-16

viders shall submit provider directory information to a 17

plan or issuers, at a minimum— 18

‘‘(1) when the provider begins a network agree-19

ment with a plan or with an issuer with respect to 20

certain coverage; 21

‘‘(2) when the provider terminates a network 22

agreement with a plan or with an issuer with respect 23

to certain coverage; 24

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164 

•HR 5800 IH

‘‘(3) when there are material changes to the 1

content of provider directory information described 2

in section 2730(a)(1), section 717(a)(1) of the Em-3

ployee Retirement Income Security Act of 1974, or 4

section 9817(a)(1) of the Internal Revenue Code of 5

1986 (as applicable); and 6

‘‘(4) every 90 days throughout the duration of 7

the network agreement with a plan or issuer. 8

‘‘(b) ENFORCEMENT.— 9

‘‘(1) CIVIL PENALTIES.— 10

‘‘(A) IN GENERAL.—Subject to paragraph 11

(2), a health care provider that violates a re-12

quirement under subsection (a) or takes actions 13

that prevent a group health plan or health in-14

surance issuer from complying with subsection 15

(a)(1) or (b) of sections 2730, 717 of the Em-16

ployee Retirement Income Security Act of 1974, 17

or 9817 of the Internal Revenue Code of 1986 18

(as applicable) shall be subject to a civil mone-19

tary penalty of not more than $10,000 for each 20

act constituting such violation. 21

‘‘(B) SAFE HARBOR.—The Secretary may 22

waive the penalty described under paragraph 23

(1) with respect to a health care provider that 24

unknowingly violates section 2730(b)(1), section 25

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717(b)(1) of the Employee Retirement Income 1

Security Act of 1974, or section 9817(b)(1) of 2

the Internal Revenue Code of 1986 (as applica-3

ble) with respect to an enrollee if such provider 4

rescinds the bill involved and, if applicable, re-5

imburses the enrollee within 30 days of the date 6

on which the provider billed the enrollee in vio-7

lation of such subsection. 8

‘‘(C) PROCEDURE.—The provisions of sec-9

tion 1128A of the Social Security Act, other 10

than subsections (a) and (b) and the first sen-11

tence of subsection (c)(1) of such section, shall 12

apply to civil money penalties under this sub-13

section in the same manner as such provisions 14

apply to a penalty or proceeding under section 15

1128A of the Social Security Act. 16

‘‘(2) REFUNDS TO ENROLLEES.—If a health 17

care provider submits a bill to an enrollee based on 18

cost-sharing for treatment or services provided by 19

the health care provider that is in excess of the nor-20

mal cost-sharing applied for such treatment or serv-21

ices provided in-network, as prohibited under section 22

2730(b), section 717(b) of the Employee Retirement 23

Income Security Act of 1974, or section 9817(b) of 24

the Internal Revenue Code of 1986 (as applicable) 25

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166 

•HR 5800 IH

and the enrollee pays such bill, the provider shall re-1

imburse the enrollee for the full amount paid by the 2

enrollee in excess of the in-network cost-sharing 3

amount for the treatment or services involved, plus 4

interest, at an interest rate determined by the Sec-5

retary. 6

‘‘(c) LIMITATION.—Nothing in this section shall pro-7

hibit a provider from requiring in the terms of a contract, 8

or contract termination, with a group health plan or health 9

insurance issuer— 10

‘‘(1) that the plan or issuer remove, at the time 11

of termination of such contract, the provider from a 12

directory of the plan or issuer described in section 13

2730(a)(1), section 717(a)(1) of the Employee Re-14

tirement Income Security Act of 1974, or section 15

9817(a)(1) of the Internal Revenue Code of 1986 16

(as applicable); or 17

‘‘(2) that the plan or issuer bear financial re-18

sponsibility, including under section 2730(b), section 19

717(b) of the Employee Retirement Income Security 20

Act of 1974, or section 9817(b) of the Internal Rev-21

enue Code of 1986 (as applicable) for providing in-22

accurate network status information to an enrollee. 23

‘‘(d) DEFINITION.—For purposes of this section, the 24

term ‘provider directory information’ includes the names, 25

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167 

•HR 5800 IH

addresses, specialty, and telephone numbers of individual 1

health care providers, and the names, addresses, and tele-2

phone numbers of each medical group, clinic, or facility 3

contracted to participate in any of the networks of the 4

group health plan or health insurance coverage involved. 5

‘‘(e) RULE OF CONSTRUCTION.—Nothing in this sec-6

tion shall be construed to preempt any provision of State 7

law relating to health care provider directories.’’. 8

SEC. 7. INCREASING TRANSPARENCY IN HEALTH COV-9

ERAGE. 10

(a) DISCLOSURE OF DIRECT AND INDIRECT COM-11

PENSATION FOR BROKERS AND CONSULTANTS TO EM-12

PLOYER-SPONSORED HEALTH PLANS AND ENROLLEES IN 13

PLANS ON THE INDIVIDUAL MARKET.— 14

(1) GROUP HEALTH PLANS.—Section 408(b)(2) 15

of the Employee Retirement Income Security Act of 16

1974 (29 U.S.C. 1108(b)(2)) is amended— 17

(A) by striking ‘‘(2) Contracting or mak-18

ing’’ and inserting ‘‘(2)(A) Contracting or mak-19

ing’’; and 20

(B) by adding at the end the following: 21

‘‘(B)(i) No contract or arrangement for services 22

between a covered plan and a covered service pro-23

vider, and no extension or renewal of such a contract 24

or arrangement, is reasonable within the meaning of 25

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168 

•HR 5800 IH

this paragraph unless the requirements of this sub-1

paragraph are met. 2

‘‘(ii)(I) For purposes of this subparagraph: 3

‘‘(aa) The term ‘covered plan’ means a 4

group health plan as defined section 733(a). 5

‘‘(bb) The term ‘covered service provider’ 6

means a service provider that enters into a con-7

tract or arrangement with the covered plan and 8

reasonably expects $1,000 (or such amount as 9

the Secretary may establish in regulations to 10

account for inflation since the date of the enact-11

ment of the Ban Surprise Billing Act, as appro-12

priate) or more in compensation, direct or indi-13

rect, to be received in connection with providing 14

one or more of the following services, pursuant 15

to the contract or arrangement, regardless of 16

whether such services will be performed, or such 17

compensation received, by the covered service 18

provider, an affiliate, or a subcontractor: 19

‘‘(AA) Brokerage services, for which 20

the covered service provider, an affiliate, or 21

a subcontractor reasonably expects to re-22

ceive indirect compensation or direct com-23

pensation described in item (dd), provided 24

to a covered plan with respect to selection 25

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169 

•HR 5800 IH

of insurance products (including vision and 1

dental), recordkeeping services, medical 2

management vendor, benefits administra-3

tion (including vision and dental), stop-loss 4

insurance, pharmacy benefit management 5

services, wellness services, transparency 6

tools and vendors, group purchasing orga-7

nization preferred vendor panels, disease 8

management vendors and products, compli-9

ance services, employee assistance pro-10

grams, or third party administration serv-11

ices. 12

‘‘(BB) Consulting, for which the cov-13

ered service provider, an affiliate, or a sub-14

contractor reasonably expects to receive in-15

direct compensation or direct compensation 16

described in item (dd), related to the devel-17

opment or implementation of plan design, 18

insurance or insurance product selection 19

(including vision and dental), record-20

keeping, medical management, benefits ad-21

ministration selection (including vision and 22

dental), stop-loss insurance, pharmacy ben-23

efit management services, wellness design 24

and management services, transparency 25

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•HR 5800 IH

tools, group purchasing organization agree-1

ments and services, participation in and 2

services from preferred vendor panels, dis-3

ease management, compliance services, em-4

ployee assistance programs, or third party 5

administration services. 6

‘‘(cc) The term ‘affiliate’, with respect to a 7

covered service provider, means an entity that 8

directly or indirectly (through one or more 9

intermediaries) controls, is controlled by, or is 10

under common control with, such provider, or is 11

an officer, director, or employee of, or partner 12

in, such provider. 13

‘‘(dd)(AA) The term ‘compensation’ means 14

anything of monetary value, but does not in-15

clude non-monetary compensation valued at 16

$250 (or such amount as the Secretary may es-17

tablish in regulations to account for inflation 18

since the date of enactment of the Ban Surprise 19

Billing Act, as appropriate) or less, in the ag-20

gregate, during the term of the contract or ar-21

rangement. 22

‘‘(BB) The term ‘direct compensation’ 23

means compensation received directly from a 24

covered plan. 25

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‘‘(CC) The term ‘indirect compensation’ 1

means compensation received from any source 2

other than the covered plan, the plan sponsor, 3

the covered service provider, or an affiliate. 4

Compensation received from a subcontractor is 5

indirect compensation, unless it is received in 6

connection with services performed under a con-7

tract or arrangement with a subcontractor. 8

‘‘(ee) The term ‘responsible plan fiduciary’ 9

means a fiduciary with authority to cause the 10

covered plan to enter into, or extend or renew, 11

the contract or arrangement. 12

‘‘(ff) The term ‘subcontractor’ means any 13

person or entity (or an affiliate of such person 14

or entity) that is not an affiliate of the covered 15

service provider and that, pursuant to a con-16

tract or arrangement with the covered service 17

provider or an affiliate, reasonably expects to 18

receive $1,000 (or such amount as the Sec-19

retary may establish in regulations to account 20

for inflation since the date of enactment of the 21

Ban Surprise Billing Act, as appropriate) or 22

more in compensation for performing one or 23

more services described in item (bb) under a 24

contract or arrangement with the covered plan. 25

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‘‘(II) For purposes of this subparagraph, a de-1

scription of compensation or cost may be expressed 2

as a monetary amount, formula, or a per capita 3

charge for each enrollee or, if the compensation or 4

cost cannot reasonably be expressed in such terms, 5

by any other reasonable method, including a disclo-6

sure that additional compensation may be earned 7

but may not be calculated at the time of contract if 8

such a disclosure includes a description of the cir-9

cumstances under which the additional compensation 10

may be earned and a reasonable and good faith esti-11

mate if the covered service provider cannot otherwise 12

readily describe compensation or cost and explains 13

the methodology and assumptions used to prepare 14

such estimate. Any such description shall contain 15

sufficient information to permit evaluation of the 16

reasonableness of the compensation or cost. 17

‘‘(III) No person or entity is a ‘covered service 18

provider’ within the meaning of subclause (I)(bb) 19

solely on the basis of providing services as an affil-20

iate or a subcontractor that is performing one or 21

more of the services described in subitem (AA) or 22

(BB) of such subclause under the contract or ar-23

rangement with the covered plan. 24

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‘‘(iii) A covered service provider shall disclose to 1

a responsible plan fiduciary, in writing, the fol-2

lowing: 3

‘‘(I) A description of the services to be pro-4

vided to the covered plan pursuant to the con-5

tract or arrangement. 6

‘‘(II) If applicable, a statement that the 7

covered service provider, an affiliate, or a sub-8

contractor will provide, or reasonably expects to 9

provide, services pursuant to the contract or ar-10

rangement directly to the covered plan as a fi-11

duciary (within the meaning of section 3(21)). 12

‘‘(III) A description of all direct compensa-13

tion, either in the aggregate or by service, that 14

the covered service provider, an affiliate, or a 15

subcontractor reasonably expects to receive in 16

connection with the services described in sub-17

clause (I). 18

‘‘(IV)(aa) A description of all indirect com-19

pensation that the covered service provider, an 20

affiliate, or a subcontractor reasonably expects 21

to receive in connection with the services de-22

scribed in subclause (I)— 23

‘‘(AA) including compensation from a 24

vendor to a brokerage firm based on a 25

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174 

•HR 5800 IH

structure of incentives not solely related to 1

the contract with the covered plan; and 2

‘‘(BB) not including compensation re-3

ceived by an employee from an employer 4

on account of work performed by the em-5

ployee. 6

‘‘(bb) A description of the arrangement be-7

tween the payer and the covered service pro-8

vider, an affiliate, or a subcontractor, as appli-9

cable, pursuant to which such indirect com-10

pensation is paid. 11

‘‘(cc) Identification of the services for 12

which the indirect compensation will be re-13

ceived, if applicable. 14

‘‘(dd) Identification of the payer of the in-15

direct compensation. 16

‘‘(V) A description of any compensation 17

that will be paid among the covered service pro-18

vider, an affiliate, or a subcontractor, in con-19

nection with the services described in subclause 20

(I) if such compensation is set on a transaction 21

basis (such as commissions, finder’s fees, or 22

other similar incentive compensation based on 23

business placed or retained), including identi-24

fication of the services for which such com-25

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175 

•HR 5800 IH

pensation will be paid and identification of the 1

payers and recipients of such compensation (in-2

cluding the status of a payer or recipient as an 3

affiliate or a subcontractor), regardless of 4

whether such compensation also is disclosed 5

pursuant to subclause (III) or (IV). 6

‘‘(VI) A description of any compensation 7

that the covered service provider, an affiliate, or 8

a subcontractor reasonably expects to receive in 9

connection with termination of the contract or 10

arrangement, and how any prepaid amounts 11

will be calculated and refunded upon such ter-12

mination. 13

‘‘(iv) A covered service provider shall disclose to 14

a responsible plan fiduciary, in writing a description 15

of the manner in which the compensation described 16

in clause (iii), as applicable, will be received. 17

‘‘(v)(I) A covered service provider shall disclose 18

the information required under clauses (iii) and (iv) 19

to the responsible plan fiduciary not later than the 20

date that is reasonably in advance of the date on 21

which the contract or arrangement is entered into, 22

and extended or renewed. 23

‘‘(II) A covered service provider shall disclose 24

any change to the information required under clause 25

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176 

•HR 5800 IH

(iii) and (iv) as soon as practicable, but not later 1

than 60 days from the date on which the covered 2

service provider is informed of such change, unless 3

such disclosure is precluded due to extraordinary cir-4

cumstances beyond the covered service provider’s 5

control, in which case the information shall be dis-6

closed as soon as practicable. 7

‘‘(vi)(I) Upon the written request of the respon-8

sible plan fiduciary or covered plan administrator, a 9

covered service provider shall furnish any other in-10

formation relating to the compensation received in 11

connection with the contract or arrangement that is 12

required for the covered plan to comply with the re-13

porting and disclosure requirements under this Act. 14

‘‘(II) The covered service provider shall disclose 15

the information required under clause (iii)(I) reason-16

ably in advance of the date upon which such respon-17

sible plan fiduciary or covered plan administrator 18

states that it is required to comply with the applica-19

ble reporting or disclosure requirement, unless such 20

disclosure is precluded due to extraordinary cir-21

cumstances beyond the covered service provider’s 22

control, in which case the information shall be dis-23

closed as soon as practicable. 24

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177 

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‘‘(vii) No contract or arrangement will fail to be 1

reasonable under this subparagraph solely because 2

the covered service provider, acting in good faith and 3

with reasonable diligence, makes an error or omis-4

sion in disclosing the information required pursuant 5

to clause (iii) (or a change to such information dis-6

closed pursuant to clause (v)(II)) or clause (vi), pro-7

vided that the covered service provider discloses the 8

correct information to the responsible plan fiduciary 9

as soon as practicable, but not later than 30 days 10

from the date on which the covered service provider 11

knows of such error or omission. 12

‘‘(viii)(I) Pursuant to subsection (a), subpara-13

graphs (C) and (D) of section 406(a)(1) shall not 14

apply to a responsible plan fiduciary, notwith-15

standing any failure by a covered service provider to 16

disclose information required under clause (iii), if 17

the following conditions are met: 18

‘‘(aa) The responsible plan fiduciary did 19

not know that the covered service provider 20

failed or would fail to make required disclosures 21

and reasonably believed that the covered service 22

provider disclosed the information required to 23

be disclosed. 24

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178 

•HR 5800 IH

‘‘(bb) The responsible plan fiduciary, upon 1

discovering that the covered service provider 2

failed to disclose the required information, re-3

quests in writing that the covered service pro-4

vider furnish such information. 5

‘‘(cc) If the covered service provider fails 6

to comply with a written request described in 7

subclause (II) within 90 days of the request, 8

the responsible plan fiduciary notifies the Sec-9

retary of the covered service provider’s failure, 10

in accordance with subclauses (II) and (III). 11

‘‘(II) A notice described in subclause (I)(cc) 12

shall contain— 13

‘‘(aa) the name of the covered plan; 14

‘‘(bb) the plan number used for the annual 15

report on the covered plan; 16

‘‘(cc) the plan sponsor’s name, address, 17

and employer identification number; 18

‘‘(dd) the name, address, and telephone 19

number of the responsible plan fiduciary; 20

‘‘(ee) the name, address, phone number, 21

and, if known, employer identification number 22

of the covered service provider; 23

‘‘(ff) a description of the services provided 24

to the covered plan; 25

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179 

•HR 5800 IH

‘‘(gg) a description of the information that 1

the covered service provider failed to disclose; 2

‘‘(hh) the date on which such information 3

was requested in writing from the covered serv-4

ice provider; and 5

‘‘(ii) a statement as to whether the covered 6

service provider continues to provide services to 7

the plan. 8

‘‘(III) A notice described in subclause (I)(cc) 9

shall be filed with the Department not later than 30 10

days following the earlier of— 11

‘‘(aa) The covered service provider’s re-12

fusal to furnish the information requested by 13

the written request described in subclause 14

(I)(bb); or 15

‘‘(bb) 90 days after the written request re-16

ferred to in subclause (I)(cc) is made. 17

‘‘(IV) If the covered service provider fails to 18

comply with the written request under subclause 19

(I)(bb) within 90 days of such request, the respon-20

sible plan fiduciary shall determine whether to ter-21

minate or continue the contract or arrangement 22

under section 404. If the requested information re-23

lates to future services and is not disclosed promptly 24

after the end of the 90-day period, the responsible 25

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180 

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plan fiduciary shall terminate the contract or ar-1

rangement as expeditiously as possible, consistent 2

with such duty of prudence. 3

‘‘(ix) Nothing in this subparagraph shall be 4

construed to supersede any provision of State law 5

that governs disclosures by parties that provide the 6

services described in this section, except to the ex-7

tent that such law prevents the application of a re-8

quirement of this section.’’. 9

(2) APPLICABILITY OF EXISTING REGULA-10

TIONS.—Nothing in the amendments made by para-11

graph (1) shall be construed to affect the applica-12

bility of section 2550.408b–2 of title 29, Code of 13

Federal Regulations (or any successor regulations), 14

with respect to any applicable entity other than a 15

covered plan or a covered service provider (as de-16

fined in section 408(b)(2)(B)(ii) of the Employee 17

Retirement Income Security Act of 1974, as amend-18

ed by paragraph (1)). 19

(3) INDIVIDUAL MARKET COVERAGE.—Subpart 20

1 of part B of title XXVII of the Public Health 21

Service Act (42 U.S.C. 300gg–41 et seq.) is amend-22

ed by adding at the end the following: 23

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181 

•HR 5800 IH

‘‘SEC. 2746. DISCLOSURE TO ENROLLEES OF INDIVIDUAL 1

MARKET COVERAGE. 2

‘‘(a) IN GENERAL.—A health insurance issuer offer-3

ing individual health insurance coverage shall make disclo-4

sures to enrollees in such coverage, as described in sub-5

section (b), and reports to the Secretary, as described in 6

subsection (c), regarding direct or indirect compensation 7

provided to an agent or broker associated with enrolling 8

individuals in such coverage. 9

‘‘(b) DISCLOSURE.—A health insurance issuer de-10

scribed in subsection (a) shall disclose to an enrollee the 11

amount of direct or indirect compensation provided to an 12

agent or broker for services provided by such agent or 13

broker associated with plan selection and enrollment. Such 14

disclosure shall be— 15

‘‘(1) made prior to the individual finalizing plan 16

selection; and 17

‘‘(2) included on any documentation confirming 18

the individual’s enrollment. 19

‘‘(c) REPORTING.—A health insurance issuer de-20

scribed in subsection (a) shall annually report to the Sec-21

retary, prior to the beginning of open enrollment, any di-22

rect or indirect compensation provided to an agent or 23

broker associated with enrolling individuals in such cov-24

erage. 25

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‘‘(d) RULEMAKING.—Not later than 1 year after the 1

date of enactment of the Ban Surprise Billing Act, the 2

Secretary shall finalize, through notice-and-comment rule-3

making, the form and manner in which issuers described 4

in subsection (a) are required to make the disclosures de-5

scribed in subsection (b) and the reports described in sub-6

section (c). Such rulemaking may also include adjustments 7

to notice requirements to reflect the different processes 8

for plan renewals, in order to provide enrollees with full, 9

timely information.’’. 10

(4) TRANSITION RULE.—No contract executed 11

prior to the effective date described in paragraph (5) 12

by a group health plan subject to the requirements 13

of section 408(b)(2)(B) of the Employee Retirement 14

Income Security Act of 1974 (as amended by para-15

graph (1)) or by a health insurance issuer subject to 16

the requirements of section 2746 of the Public 17

Health Service Act (as added by paragraph (3)) 18

shall be subject to the requirements of such section 19

408(b)(2)(B) or such section 2746, as applicable. 20

(5) EFFECTIVE DATE.—The amendments made 21

by paragraphs (1) and (3) shall apply beginning one 22

year after the date of enactment of this Act. 23

(b) STANDARDIZED REPORTING FORMAT.—Section 24

716 of the Employee Retirement Income Security Act of 25

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183 

•HR 5800 IH

1974, as added by section 2 and amended by section 3(c), 1

is further amended by adding at the end the following new 2

subsection: 3

‘‘(i) STANDARDIZED REPORTING FORMAT.— 4

‘‘(1) IN GENERAL.—Not later than 1 year after 5

the date of enactment of this subsection, the Sec-6

retary shall establish a standardized reporting for-7

mat for the reporting, by group health plans (or 8

health insurance coverage offered in connection with 9

such a plan) to State All Payer Claims Databases, 10

of medical claims, pharmacy claims, dental claims, 11

and eligibility and provider files that are collected 12

from private and public payers, and shall provide 13

guidance to States on the process by which States 14

may collect such data from such plans or coverage 15

in the standardized reporting format. 16

‘‘(2) DEFINITION.—In this subsection, the term 17

‘State All Payer Claims Database’ means, with re-18

spect to a State, a database that may include med-19

ical claims, pharmacy claims, dental claims, and eli-20

gibility and provider files, which are collected from 21

private and public payers.’’. 22

SEC. 8. ACCESS TO COST-SHARING INFORMATION. 23

(a) INSURER AND PLAN REQUIREMENTS.— 24

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184 

•HR 5800 IH

(1) PHSA.—Part A of title XXVII of the Pub-1

lic Health Service Act (42 U.S.C. 300gg–11 et seq.), 2

as amended by section 6(a), is further amended by 3

inserting after section 2730 the following: 4

‘‘SEC. 2731. PROVISION OF COST-SHARING INFORMATION. 5

‘‘A group health plan or a health insurance issuer of-6

fering group or individual health insurance coverage shall 7

provide a participant, beneficiary, or enrollee in the plan 8

or coverage with a good faith estimate of the enrollee’s 9

cost-sharing (including deductibles, copayments, and coin-10

surance) for which the participant, beneficiary, or enrollee 11

may be responsible for paying with respect to a specific 12

health care service (including any service that is reason-13

ably expected to be provided in conjunction with such spe-14

cific service), as soon as practicable and not later than 15

2 business days after a request for such information by 16

a participant, beneficiary, or enrollee.’’. 17

(2) ERISA.—Subpart B of part 7 of subtitle B 18

of title I of the Employee Retirement Income Secu-19

rity Act of 1974 (29 U.S.C. 1185 et seq.), as 20

amended by section 6(b), is further amended by add-21

ing at the end the following: 22

‘‘SEC. 718. PROVISION OF COST-SHARING INFORMATION. 23

‘‘A group health plan (or health insurance coverage 24

offered in connection with such a plan) shall provide a par-25

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185 

•HR 5800 IH

ticipant or beneficiary in the plan or coverage with a good 1

faith estimate of the participant’s or beneficiary’s cost- 2

sharing (including deductibles, copayments, and coinsur-3

ance) for which the participant or beneficiary may be re-4

sponsible for paying with respect to a specific health care 5

service (including any service that is reasonably expected 6

to be provided in conjunction with such specific service), 7

as soon as practicable and not later than 2 business days 8

after a request for such information by a participant or 9

beneficiary.’’. 10

(3) IRC.—Subchapter B of chapter 100 of the 11

Internal Revenue Code of 1986, as amended by sec-12

tion 6(c), is further amended by adding at the end 13

the following: 14

‘‘SEC. 9818. PROVISION OF COST-SHARING INFORMATION. 15

‘‘A group health plan shall provide a participant or 16

beneficiary in the plan with a good faith estimate of the 17

participant’s or beneficiary’s cost-sharing (including 18

deductibles, copayments, and coinsurance) for which the 19

participant or beneficiary may be responsible for paying 20

with respect to a specific health care service (including any 21

service that is reasonably expected to be provided in con-22

junction with such specific service), as soon as practicable 23

and not later than 2 business days after a request for such 24

information by a participant or beneficiary.’’. 25

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186 

•HR 5800 IH

(4) CLERICAL AMENDMENTS.— 1

(A) ERISA.—The table of contents in sec-2

tion 1 of the Employee Retirement Income Se-3

curity Act of 1974 (29 U.S.C. 1001 et seq.), as 4

amended by section 8(b)(4), is further amended 5

by inserting after the item relating to section 6

717 the following new item: 7

‘‘Sec. 718. Provision of cost-sharing information.’’. 

(B) IRC.—The table of sections for sub-8

chapter B of chapter 100 of the Internal Rev-9

enue Code of 1986, as amended by section 10

8(b)(4), is further amended by adding at the 11

end the following new item: 12

‘‘Sec. 9818. Provision of cost-sharing information.’’. 

(b) PROVIDER REQUIREMENTS.—Part D of title 13

XXVII of the Public Health Service Act, as added by sec-14

tion 3 and amended by section 6, is further amended by 15

inserting before section 2799A–7 the following new sec-16

tion: 17

‘‘SEC. 2799A–6. PROVISION OF COST-SHARING INFORMA-18

TION. 19

‘‘A provider that is in-network with respect to a 20

group health plan or a health insurance issuer offering 21

group or individual health insurance coverage shall, upon 22

request by a participant, beneficiary, or enrollee, provide 23

to a participant, beneficiary, or enrollee in the plan or cov-24

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187 

•HR 5800 IH

erage the following information, together with accurate 1

and complete information about the participant’s, bene-2

ficiary’s, or enrollee’s coverage under the applicable plan 3

or coverage: 4

‘‘(1) As soon as practicable and not later than 5

2 business days after the participant, beneficiary, or 6

enrollee requests such information, a good faith esti-7

mate of the expected participant, beneficiary, or en-8

rollee cost-sharing for the provision of a particular 9

health care service (including any service that is rea-10

sonably expected to be provided in conjunction with 11

such specific service). 12

‘‘(2) As soon as practicable and not later than 13

2 business days after a participant, beneficiary, or 14

enrollee requests such information, the contact infor-15

mation for any ancillary providers for a scheduled 16

health care service.’’. 17

(c) EFFECTIVE DATE.—The amendments made by 18

subsections (a) and (b) shall apply with respect to plan 19

years beginning on or after the date that is 18 months 20

after the date of enactment of this Act. 21

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SEC. 9. TRANSPARENCY REGARDING IN-NETWORK AND 1

OUT-OF-NETWORK DEDUCTIBLES AND OUT- 2

OF-POCKET LIMITATIONS. 3

(a) PHSA.—Section 2719A of the Public Health 4

Service Act, as amended by section 2, is further amended 5

by adding at the end the following new subsection: 6

‘‘(g) TRANSPARENCY REGARDING IN-NETWORK AND 7

OUT-OF-NETWORK DEDUCTIBLES AND OUT-OF-POCKET 8

LIMITATIONS.— 9

‘‘(1) IN GENERAL.—A group health plan or a 10

health insurance issuer offering group or individual 11

health insurance coverage and providing or covering 12

any benefit with respect to items or services shall in-13

clude, in clear writing, on any plan or insurance 14

identification card issued to enrollees in the plan or 15

coverage the amount of the in-network and out-of- 16

network deductibles and the in-network and out-of- 17

network out-of-pocket maximum limitation that 18

apply to such plan or coverage. 19

‘‘(2) GUIDANCE.—The Secretary, in consulta-20

tion with the Secretary of Labor and Secretary of 21

the Treasury, shall issue guidance to implement 22

paragraph (1).’’. 23

(b) ERISA.—Section 716 of the Employee Retire-24

ment Income Security Act of 1974, as added by section 25

2 and as amended by sections 3(c) and 7(b), is further 26

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189 

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amended by adding at the end the following new sub-1

section: 2

‘‘(j) TRANSPARENCY REGARDING IN-NETWORK AND 3

OUT-OF-NETWORK DEDUCTIBLES AND OUT-OF-POCKET 4

LIMITATIONS.— 5

‘‘(1) IN GENERAL.—A group health plan or a 6

health insurance issuer offering group health insur-7

ance coverage and providing or covering any benefit 8

with respect to items or services shall include, in 9

clear writing, on any plan or insurance identification 10

card issued to participants or beneficiaries in the 11

plan or coverage the amount of the in-network and 12

out-of-network deductibles and the in-network and 13

out-of-network out-of-pocket maximum limitation 14

that apply to such plan or coverage. 15

‘‘(2) GUIDANCE.—The Secretary, in consulta-16

tion with the Secretary of Health and Human Serv-17

ices and Secretary of the Treasury, shall issue guid-18

ance to implement paragraph (1).’’. 19

(c) IRC.—Section 9816 of the Internal Revenue Code 20

of 1986, as added by section 2, is further amended by 21

adding at the end the following new subsection: 22

‘‘(h) TRANSPARENCY REGARDING IN-NETWORK AND 23

OUT-OF-NETWORK DEDUCTIBLES AND OUT-OF-POCKET 24

LIMITATIONS.— 25

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190 

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‘‘(1) IN GENERAL.—A group health plan pro-1

viding or covering any benefit with respect to items 2

or services shall include, in clear writing, on any 3

plan or insurance identification card issued to par-4

ticipants or beneficiaries in the plan the amount of 5

the in-network and out-of-network deductibles and 6

the in-network and out-of-network out-of-pocket 7

maximum limitation that apply to such plan. 8

‘‘(2) GUIDANCE.—The Secretary, in consulta-9

tion with the Secretary of Health and Human Serv-10

ices and Secretary of Labor, shall issue guidance to 11

implement paragraph (1).’’. 12

(d) EFFECTIVE DATE.—The amendments made by 13

this subsection shall apply with respect to plan years be-14

ginning on or after January 1, 2022. 15

Æ 

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		Superintendent of Documents
	2020-02-08T04:49:09-0500
	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
Robert Scott D-VA 02/07/2020 Sponsor
Virginia Foxx R-NC 02/07/2020 Cosponsor
Date Branch Action
02/11/2020 President Ordered to be Reported (Amended) by the Yeas and Nays: 32 - 13.Action By: Committee on Education and Labor
02/11/2020 President Committee Consideration and Mark-up Session Held.Action By: Committee on Education and Labor
02/07/2020 President Referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Labor, Ways and Means, and Oversight and Reform, 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
02/07/2020 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
(b)Standardized reporting formatSection 716 of the Employee Retirement Income Security Act of 1974, as added by section 2 and amended by section 3(c), is further amended by adding at the end the following new subsection: (i)Standardized reporting format (1)In generalNot later than 1 year after the date of enactment of this subsection, the Secretary shall establish a standardized reporting format for the reporting, by group health plans (or health insurance coverage offered in connec

Commerce
Foxx of North Carolina) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Labor, Ways and Means, and Oversight and Reform, 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 end surprise medical billing and increase transparency in health coverage

Consumer protection
Consumer protections (a)Choice of health care professionalIf a group health plan or health insurance issuer offering group health insurance coverage requires or provides for designation by a participant or beneficiary of a participating primary care provider, then the plan or issuer shall permit each participant or beneficiary to designate any participating primary care provider who is available to accept such individual

Costs
(D)Costs of independent dispute resolution processIn the case of a request made by a nonparticipating provider, nonparticipating emergency facility, group health plan, or health insurance issuer offering health insurance coverage in the group or individual market and submitted to a certified IDR entity— (i)if such entity makes a determination with respect to such request under subparagraph (A), the party whose offer is not chosen under such clause shall be responsible for paying all fees char


End Bill TEXT Points.
Date Bill Major Title
Committee Name
Subject Type