II 

117TH CONGRESS 

2D SESSION S. 5093 

To further protect patients and improve the accuracy of provider directory 

information by eliminating ghost networks. 

IN THE SENATE OF THE UNITED STATES 

NOVEMBER 15, 2022 

Ms. SMITH (for herself and Mr. WYDEN) introduced the following bill; which 

was read twice and referred to the Committee on Health, Education, 

Labor, and Pensions 

A BILL 

To further protect patients and improve the accuracy of 

provider directory information by eliminating ghost networks. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Behavioral Health Net5 work and Directory Improvement Act’’. 

6 SEC. 2. PROTECTING PATIENTS AND IMPROVING THE AC7 CURACY OF PROVIDER DIRECTORY INFOR8 MATION. 

9 (a) PHSA.—Section 2799A–5 of the Public Health 

10 Service Act (42 U.S.C. 300gg–115) is amended— 


kjohnson on DSK79L0C42PROD with BILLS
2 

•S 5093 IS

1 (1) in subsection (a)— 

2 (A) in paragraph (1)— 

3 (i) by striking ‘‘For plan years begin4 ning on or after January 1, 2022, each’’ 

5 and inserting ‘‘Each’’; 

6 (ii) in subparagraph (C), by striking 

7 ‘‘; and’’ and inserting a semicolon; 

8 (iii) in subparagraph (D), by striking 

9 the period and inserting ‘‘; and’’; and 

10 (iv) by adding at the end the fol11 lowing: 

12 ‘‘(E) ensure that any directory, including 

13 the database described in subparagraph (C), 

14 containing provider directory information with 

15 respect to such plan or such coverage complies 

16 with the requirements developed by the appro17 priate agencies in accordance with paragraph 

18 (6) in order to ensure that participants, bene19 ficiaries, and enrollees are able to identify ac20 tively participating health care providers and 

21 health care facilities.’’; 

22 (B) in paragraph (2)(A), by striking ‘‘90 

23 days’’ and inserting ‘‘30 days’’; 

24 (C) in paragraph (3)— 


kjohnson on DSK79L0C42PROD with BILLS
3 

•S 5093 IS

1 (i) in the matter preceding subpara2 graph (A), by striking ‘‘, in the case such 

3 request is made through a telephone call’’; 

4 and 

5 (ii) in subparagraph (A), by striking 

6 ‘‘call is received, through a written elec7 tronic or print (as requested by such indi8 vidual) communication’’ and inserting ‘‘a 

9 request is received, by telephone, or 

10 through a written electronic or print com11 munication (as requested by such indi12 vidual)’’; 

13 (D) in paragraph (4)— 

14 (i) in subparagraph (A), by striking 

15 ‘‘and’’ at the end; 

16 (ii) in subparagraph (B), by striking 

17 the period and inserting ‘‘; and’’; and 

18 (iii) by adding at the end the fol19 lowing: 

20 ‘‘(C) information, in plain language, con21 cerning the rights of the participant, bene22 ficiary, or enrollee to cost-sharing protections 

23 pursuant to subsection (b) in the event of reli24 ance on inaccurate provider network informa25 tion supplied by a group health plan or health 


kjohnson on DSK79L0C42PROD with BILLS
4 

•S 5093 IS

1 insurance issuer, and contact information for 

2 the State consumer assistance program or om3 budsman for more information.’’; 

4 (E) in paragraph (5), by adding at the end 

5 the following: ‘‘Such information shall include a 

6 statement, in plain language, concerning the 

7 rights of the participant, beneficiary, or enrollee 

8 to cost-sharing protections pursuant to sub9 section (b) in the event of reliance on inac10 curate provider directory information supplied 

11 by a group health plan or health insurance 

12 issuer, and contact information for the State 

13 consumer assistance program or ombudsman 

14 for more information.’’; 

15 (F) by redesignating paragraphs (6) and 

16 (7) as paragraphs (8) and (9), respectively; 

17 (G) by inserting after paragraph (5) the 

18 following: 

19 ‘‘(6) PROTECTING PARTICIPANTS, BENE20 FICIARIES, AND ENROLLEES FROM GHOST NET21 WORKS.—The Secretary, in collaboration with the 

22 Secretary of Labor and the Secretary of the Treas23 ury, shall— 

24 ‘‘(A) not later than 180 days after the date 

25 of enactment of the Behavioral Health Network 


kjohnson on DSK79L0C42PROD with BILLS
5 

•S 5093 IS

1 and Directory Improvement Act, issue interim 

2 final regulations (without prior notice and com3 ment as required under section 553 of title 5, 

4 United States Code) further defining the term 

5 ‘ghost network’ (as defined in paragraph (8)); 

6 and 

7 ‘‘(B) not later than 18 months after the 

8 date of enactment of the Behavioral Health 

9 Network and Directory Improvement Act, issue 

10 interim final regulations (without prior notice 

11 and comment as required under section 553 of 

12 title 5, United States Code), subregulatory 

13 guidance, or program instruction on how to as14 sess ghost networks in health plan directories 

15 including reasonable assumptions related to sta16 tistics and research methods. 

17 ‘‘(7) DATABASE REPORTING AND AUDITING TO

18 PROTECT AGAINST GHOST NETWORKS.— 

19 ‘‘(A) REPORTING REQUIREMENTS.—Begin20 ning not later than 3 years after the date of en21 actment of the Behavioral Health Network and 

22 Directory Improvement Act, each group health 

23 plan and health insurance issuer offering group 

24 or individual health insurance coverage shall 

25 submit to the Secretary, at such time as the 


kjohnson on DSK79L0C42PROD with BILLS
6 

•S 5093 IS

1 Secretary, in coordination with the Secretary of 

2 Labor and the Secretary of the Treasury, shall 

3 require, but not less frequently than annually, 

4 the directory data described in paragraph 

5 (a)(4), in a machine readable format (as de6 fined in section 147.210(a)(2)(xiv) of title 45, 

7 Code of Federal Regulations (or any successor 

8 regulations)). The Secretary, in coordination 

9 with the Secretary of Labor and the Secretary 

10 of the Treasury, shall make data submitted 

11 under this subparagraph available on a public 

12 website. 

13 ‘‘(B) PROVIDER DIRECTORY INDEPENDENT

14 AUDIT REQUIREMENTS.— 

15 ‘‘(i) IN GENERAL.—Beginning not 

16 later than 3 years after the date of enact17 ment of the Behavioral Health Network 

18 and Directory Improvement Act, each 

19 group health plan and health insurance 

20 issuer offering group or individual health 

21 insurance coverage shall conduct an annual 

22 directory audit, through an independent 

23 entity not associated with the health plan 

24 or issuer, that considers the factors de25 scribed in clause (ii)(I)(aa) and follows the 


kjohnson on DSK79L0C42PROD with BILLS
7 

•S 5093 IS

1 guidelines developed under clause 

2 (ii)(I)(bb). 

3 ‘‘(ii) FACTORS.— 

4 ‘‘(I) IN GENERAL.—For purposes 

5 of carrying out the audits under this 

6 subparagraph, the Secretary shall— 

7 ‘‘(aa) develop a list of fac8 tors to be considered; and 

9 ‘‘(bb) provide guidelines for 

10 carrying out such audits, for use 

11 by group health plans and health 

12 insurance issuers, on— 

13 ‘‘(AA) the reasonable 

14 assumptions and research 

15 methods to select a reason16 able sample in order to as17 sess provider directory infor18 mation accuracy; and 

19 ‘‘(BB) determining the 

20 criteria of an eligible audi21 tor. 

22 ‘‘(II) CONTENTS.—The factors 

23 under subclause (I)(aa) shall include 

24 the following: 


kjohnson on DSK79L0C42PROD with BILLS
8 

•S 5093 IS

1 ‘‘(aa) A list of every health 

2 care provider and health care fa3 cility that was part of the net4 work of the applicable plan or 

5 coverage, the months during the 

6 plan year during which each such 

7 provider or facility was part of 

8 the network, and the number of 

9 participants, beneficiaries, and 

10 enrollees in the plan or coverage 

11 (including participants, bene12 ficiaries, and enrollees who are 

13 new patients of the provider) 

14 each such provider or facility 

15 treated during such period. 

16 ‘‘(bb) The proportion of di17 rectory listings of the plan or 

18 coverage with inaccurate infor19 mation, including incorrect con20 tact information, including incor21 rect contact information, as spec22 ified by the Secretary, during the 

23 audit period. 

24 ‘‘(cc) The number of in-net25 work items or services paid on 


kjohnson on DSK79L0C42PROD with BILLS
9 

•S 5093 IS

1 behalf of participants, bene2 ficiaries, and enrollees in the plan 

3 or coverage to providers or facili4 ties who have a network provider 

5 contract with the health plan or 

6 issuer and were not listed in the 

7 directory of the health plan or 

8 health insurance coverage for the 

9 audit period. 

10 ‘‘(dd) The resources of the 

11 plan or issuer to help partici12 pants, beneficiaries, and enrollees 

13 locate an accurately listed in-net14 work provider who is accepting 

15 new patients. 

16 ‘‘(ee) The proportion of par17 ticipants, beneficiaries, and en18 rollees using out-of-network pro19 viders for mental health and sub20 stance use disorder services, and 

21 the proportion of participants, 

22 beneficiaries, and enrollees using 

23 out-of-network providers and fa24 cilities for medical and surgical 

25 services. 


kjohnson on DSK79L0C42PROD with BILLS
10 

•S 5093 IS

1 ‘‘(ff) Documentation that 

2 the plan or issuer verifies the ac3 curacy of the provider directory 

4 information every 30 days. 

5 ‘‘(gg) Other factors as deter6 mined by the Secretary. 

7 ‘‘(iii) REQUIREMENTS OF THE INDE8 PENDENT AUDIT.—An audit under this 

9 subparagraph is complete if all of the fol10 lowing conditions are met: 

11 ‘‘(I) The audit report includes 

12 the following: 

13 ‘‘(aa) A statement by the 

14 independent auditor that, to the 

15 best of the auditor’s knowledge, 

16 the report is complete and accu17 rate, and that reasonable as18 sumptions related to statistics 

19 and research methods have been 

20 complied with. 

21 ‘‘(bb) A statement explain22 ing the assumptions, statistics, 

23 and methods used to select the 

24 sample and assess provider direc25 tory information accuracy. 


kjohnson on DSK79L0C42PROD with BILLS
11 

•S 5093 IS

1 ‘‘(cc) Such other informa2 tion as the Secretary determines 

3 necessary. 

4 ‘‘(II) The group health plan or 

5 health insurer issuer makes the inde6 pendent audit available on a public 

7 website. 

8 ‘‘(iv) RULEMAKING.—The Secretary, 

9 the Secretary of Labor, and the Secretary 

10 of the Treasury shall issue interim final 

11 regulations (without prior notice and com12 ment as required under section 553 of title 

13 5, United States Code) concerning the na14 tional standards for conducting audits 

15 under this subparagraph, not later than 2 

16 years after the date of enactment of the 

17 Behavioral Health Network and Directory 

18 Improvement Act. 

19 ‘‘(C) AUDITS BY THE SECRETARY.— 

20 ‘‘(i) IN GENERAL.—Beginning not 

21 later than the third plan year after the 

22 date of enactment of the Behavioral 

23 Health Network and Directory Improve24 ment Act, the Secretary shall conduct an25 nual audits to ensure compliance with the 


kjohnson on DSK79L0C42PROD with BILLS
12 

•S 5093 IS

1 provider directory requirements of this 

2 subsection. 

3 ‘‘(ii) REQUIREMENTS.—Audits con4 ducted by the Secretary under this sub5 paragraph shall— 

6 ‘‘(I) assess the accuracy of the 

7 information provided in health plan 

8 directories required under this sub9 section, including the proportion of 

10 listings with incorrect information, the 

11 last date on which the behavioral 

12 health network of the group health 

13 plan or health insurance coverage was 

14 updated, and other information deter15 mined appropriate by the Secretary; 

16 and 

17 ‘‘(II) use reasonable assumptions 

18 related to statistics and research 

19 methods to identify a representative 

20 sample of listings for analysis and 

21 such methods as the Secretary deter22 mines appropriate, which may include 

23 retrospective analysis of billing data. 

24 ‘‘(iii) SELECTION OF PLANS AND

25 ISSUERS.—The Secretary shall conduct anVerDate Sep 11 2014 21:57 Nov 16, 2022 Jkt 039200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S5093.IS S5093

kjohnson on DSK79L0C42PROD with BILLS
13 

•S 5093 IS

1 nual audits of a total of not fewer than 10 

2 group health plans or health insurance 

3 issuers offering group or individual health 

4 insurance coverage, as determined by the 

5 Secretary, that are the subjects of com6 plaints about ghost networks or other com7 plaints, or that are randomly selected by 

8 the Secretary.’’; and 

9 (H) in paragraph (8), as so redesignated— 

10 (i) in the paragraph heading, by strik11 ing ‘‘DEFINITION’’ and inserting ‘‘DEFINI12 TIONS’’; 

13 (ii) by striking ‘‘For purposes of this 

14 subsection, the term’’ and inserting the fol15 lowing: ‘‘For purposes of this subsection: 

16 ‘‘(A) PROVIDER DIRECTORY INFORMA17 TION.—The term’’; 

18 (iii) by striking ‘‘health insurance cov19 erage, the name’’ and inserting ‘‘health in20 surance coverage— 

21 ‘‘(i) the name’’; 

22 (iv) by striking the period and insert23 ing ‘‘; and’’; and 

24 (v) by adding at the end the following: 


kjohnson on DSK79L0C42PROD with BILLS
14 

•S 5093 IS

1 ‘‘(ii) with respect to each such pro2 vider or facility— 

3 ‘‘(I) whether such provider or fa4 cility is accepting new patients; 

5 ‘‘(II) the languages spoken and 

6 the availability of language translators 

7 for specified languages at each health 

8 care facility listed in the directory; 

9 ‘‘(III) whether the provider or fa10 cility offers medication-assisted treat11 ment for opioid use disorder; 

12 ‘‘(IV) the State license number; 

13 ‘‘(V) the national provider identi14 fier; 

15 ‘‘(VI) the age groups served by 

16 the provider or facility, such as pedi17 atric, adolescent, adult, or geriatric 

18 populations; 

19 ‘‘(VII) whether such provider or 

20 facility offers in-person services, tele21 health services, or both; and 

22 ‘‘(VIII) the cost-sharing tier, if 

23 applicable. 

24 ‘‘(B) GHOST NETWORK.—The term ‘ghost 

25 network’ means a group health plan or group or 


kjohnson on DSK79L0C42PROD with BILLS
15 

•S 5093 IS

1 individual health insurance coverage for which 

2 the provider directory information describing 

3 the network of such plan or coverage— 

4 ‘‘(i) does not include accurate re5 quired information for purposes of making 

6 an appointment for in-network care within 

7 a reasonable time period; 

8 ‘‘(ii) includes a meaningful number of 

9 providers and facilities (as specified by the 

10 Secretary, in coordination with the Sec11 retary of Labor and the Secretary of the 

12 Treasury) in a specialty who are not ac13 cepting new patients within a time period 

14 specified by such secretaries; 

15 ‘‘(iii) includes providers that are not 

16 part of the network; or 

17 ‘‘(iv) omits providers that are part of 

18 the network.’’; and 

19 (2) in subsection (b)— 

20 (A) in paragraph (1), by striking ‘‘and if 

21 either of the criteria described in paragraph (2) 

22 applies with respect to such participant, bene23 ficiary, or enrollee and item or service’’; and 

24 (B) by striking paragraph (2) and insert25 ing the following: 


kjohnson on DSK79L0C42PROD with BILLS
16 

•S 5093 IS

1 ‘‘(2) RECONCILIATION REQUIREMENT.—For 

2 purposes of paragraph (1), a group health plan or 

3 group or individual health insurance coverage of4 fered by a health insurance issuer, on a regular 

5 basis, shall reconcile payment requests for items or 

6 services furnished by a nonparticipating provider or 

7 a nonparticipating facility and the posted provider 

8 directory database for the day the delivered item or 

9 service was provided. If a nonparticipating provider 

10 was listed as a participating provider in the direc11 tory, the group health plan or health insurance 

12 issuer shall notify the participant, beneficiary, or en13 rollee, in plain language, that the participant, bene14 ficiary, or enrollee may be eligible for a refund from 

15 the group health plan or health insurance issuer if 

16 such participant, beneficiary, or enrollee paid the out 

17 of network cost-sharing and did not receive a refund 

18 under section 2799B–9(b).’’. 

19 (b) ERISA.— 

20 (1) IN GENERAL.—Section 720 of the Employee 

21 Retirement Income Security Act of 1974 (29 U.S.C. 

22 1185i) is amended— 

23 (A) in subsection (a)— 

24 (i) in paragraph (1)— 


kjohnson on DSK79L0C42PROD with BILLS
17 

•S 5093 IS

1 (I) by striking ‘‘For plan years 

2 beginning on or after January 1, 

3 2022, each’’ and inserting ‘‘Each’’; 

4 (II) in subparagraph (C), by 

5 striking ‘‘; and’’ and inserting a semi6 colon; 

7 (III) in subparagraph (D), by 

8 striking the period and inserting ‘‘; 

9 and’’; and 

10 (IV) by adding at the end the fol11 lowing: 

12 ‘‘(E) ensure that any directory, including 

13 the database described in subparagraph (C), 

14 containing provider directory information with 

15 respect to such plan or such coverage complies 

16 with the requirements developed by the appro17 priate agencies in accordance with paragraph 

18 (6) in order to ensure that participants, bene19 ficiaries, and enrollees are able to identify ac20 tively participating health care providers and 

21 health care facilities.’’; 

22 (ii) in paragraph (2)(A), by striking 

23 ‘‘90 days’’ and inserting ‘‘30 days’’; 

24 (iii) in paragraph (3)— 


kjohnson on DSK79L0C42PROD with BILLS
18 

•S 5093 IS

1 (I) in the matter preceding sub2 paragraph (A), by striking ‘‘, in the 

3 case such request is made through a 

4 telephone call’’; and 

5 (II) in subparagraph (A), by 

6 striking ‘‘call is received, through a 

7 written electronic or print (as re8 quested by such individual) commu9 nication’’ and inserting ‘‘a request is 

10 received, by telephone, or through a 

11 written electronic or print communica12 tion (as requested by such indi13 vidual)’’; 

14 (iv) in paragraph (4)— 

15 (I) in subparagraph (A), by strik16 ing ‘‘and’’ at the end; 

17 (II) in subparagraph (B), by 

18 striking the period and inserting ‘‘; 

19 and’’; and 

20 (III) by adding at the end the 

21 following: 

22 ‘‘(C) information, in plain language, con23 cerning the rights of the participant, bene24 ficiary, or enrollee to cost-sharing protections 

25 pursuant to subsection (b) in the event of reliVerDate Sep 11 2014 21:57 Nov 16, 2022 Jkt 039200 PO 00000 Frm 00018 Fmt 6652 Sfmt 6201 E:\BILLS\S5093.IS S5093

kjohnson on DSK79L0C42PROD with BILLS
19 

•S 5093 IS

1 ance on inaccurate provider network informa2 tion supplied by a group health plan or health 

3 insurance issuer, and contact information for 

4 the State consumer assistance program or om5 budsman for more information.’’; 

6 (v) in paragraph (5), by adding at the 

7 end the following: ‘‘Such information shall 

8 include a statement, in plain language, 

9 concerning the rights of the participant, 

10 beneficiary, or enrollee to cost-sharing pro11 tections pursuant to subsection (b) in the 

12 event of reliance on inaccurate provider di13 rectory information supplied by a group 

14 health plan or health insurance issuer, and 

15 contact information for the State consumer 

16 assistance program or ombudsman for 

17 more information.’’; 

18 (vi) by redesignating paragraphs (6) 

19 and (7) as paragraphs (8) and (9), respec20 tively; 

21 (vii) by inserting after paragraph (5) 

22 the following: 

23 ‘‘(6) PROTECTING PARTICIPANTS, BENE24 FICIARIES, AND ENROLLEES FROM GHOST NET25 WORKS.—The Secretary, in collaboration with the 


kjohnson on DSK79L0C42PROD with BILLS
20 

•S 5093 IS

1 Secretary of Labor and the Secretary of the Treas2 ury, shall— 

3 ‘‘(A) not later than 180 days after the date 

4 of enactment of the Behavioral Health Network 

5 and Directory Improvement Act, issue interim 

6 final regulations (without prior notice and com7 ment as required under section 553 of title 5, 

8 United States Code) further defining the term 

9 ‘ghost network’ (as defined in paragraph (8)); 

10 and 

11 ‘‘(B) not later than 18 months after the 

12 date of enactment of the Behavioral Health 

13 Network and Directory Improvement Act, issue 

14 interim final regulations (without prior notice 

15 and comment as required under section 553 of 

16 title 5, United States Code), subregulatory 

17 guidance, or program instruction on how to as18 sess ghost networks in health plan directories 

19 including reasonable assumptions related to sta20 tistics and research methods. 

21 ‘‘(7) DATABASE REPORTING AND AUDITING TO

22 PROTECT AGAINST GHOST NETWORKS.— 

23 ‘‘(A) REPORTING REQUIREMENTS.—Begin24 ning not later than 3 years after the date of en25 actment of the Behavioral Health Network and 


kjohnson on DSK79L0C42PROD with BILLS
21 

•S 5093 IS

1 Directory Improvement Act, each group health 

2 plan and health insurance issuer offering group 

3 health insurance coverage shall submit to the 

4 Secretary, at such time as the Secretary, in co5 ordination with the Secretary of Health and 

6 Human Services and the Secretary of the 

7 Treasury, shall require, but not less frequently 

8 than annually, the directory data described in 

9 paragraph (a)(4), in a machine readable format 

10 (as defined in section 147.210(a)(2)(xiv) of title 

11 45, Code of Federal Regulations (or any suc12 cessor regulations)). The Secretary, in coordina13 tion with the Secretary of Health and Human 

14 Services and the Secretary of the Treasury, 

15 shall make data submitted under this subpara16 graph available on a public website. 

17 ‘‘(B) PROVIDER DIRECTORY INDEPENDENT

18 AUDIT REQUIREMENTS.— 

19 ‘‘(i) IN GENERAL.—Beginning not 

20 later than 3 years after the date of enact21 ment of the Behavioral Health Network 

22 and Directory Improvement Act, each 

23 group health plan and health insurance 

24 issuer offering group health insurance cov25 erage shall conduct an annual directory 


kjohnson on DSK79L0C42PROD with BILLS
22 

•S 5093 IS

1 audit, through an independent entity not 

2 associated with the health plan or issuer, 

3 that considers the factors described in 

4 clause (ii)(I)(aa) and follows the guidelines 

5 developed under clause (ii)(I)(bb). 

6 ‘‘(ii) FACTORS.— 

7 ‘‘(I) IN GENERAL.—For purposes 

8 of carrying out the audits under this 

9 subparagraph, the Secretary shall— 

10 ‘‘(aa) develop a list of fac11 tors to be considered; and 

12 ‘‘(bb) provide guidelines for 

13 carrying out such audits, for use 

14 by group health plans and health 

15 insurance issuers, on— 

16 ‘‘(AA) the reasonable 

17 assumptions and research 

18 methods to select a reason19 able sample in order to as20 sess provider directory infor21 mation accuracy; and 

22 ‘‘(BB) determining the 

23 criteria of an eligible audi24 tor. 


kjohnson on DSK79L0C42PROD with BILLS
23 

•S 5093 IS

1 ‘‘(II) CONTENTS.—The factors 

2 under subclause (I)(aa) shall include 

3 the following: 

4 ‘‘(aa) A list of every health 

5 care provider and health care fa6 cility that was part of the net7 work of the applicable plan or 

8 coverage, the months during the 

9 plan year during which each such 

10 provider or facility was part of 

11 the network, and the number of 

12 participants, beneficiaries, and 

13 enrollees in the plan or coverage 

14 (including participants, bene15 ficiaries, and enrollees who are 

16 new patients of the provider) 

17 each such provider or facility 

18 treated during such period. 

19 ‘‘(bb) The proportion of di20 rectory listings of the plan or 

21 coverage with inaccurate infor22 mation, including incorrect con23 tact information, including incor24 rect contact information, as specVerDate Sep 11 2014 21:57 Nov 16, 2022 Jkt 039200 PO 00000 Frm 00023 Fmt 6652 Sfmt 6201 E:\BILLS\S5093.IS S5093

kjohnson on DSK79L0C42PROD with BILLS
24 

•S 5093 IS

1 ified by the Secretary, during the 

2 audit period. 

3 ‘‘(cc) The number of in-net4 work items or services paid on 

5 behalf of participants, bene6 ficiaries, and enrollees in the plan 

7 or coverage to providers or facili8 ties who have a network provider 

9 contract with the health plan or 

10 issuer and were not listed in the 

11 directory of the health plan or 

12 health insurance coverage for the 

13 audit period. 

14 ‘‘(dd) The resources of the 

15 plan or issuer to help partici16 pants, beneficiaries, and enrollees 

17 locate an accurately listed in-net18 work provider who is accepting 

19 new patients. 

20 ‘‘(ee) The proportion of par21 ticipants, beneficiaries, and en22 rollees using out-of-network pro23 viders for mental health and sub24 stance use disorder services, and 

25 the proportion of participants, 


kjohnson on DSK79L0C42PROD with BILLS
25 

•S 5093 IS

1 beneficiaries, and enrollees using 

2 out-of-network providers and fa3 cilities for medical and surgical 

4 services. 

5 ‘‘(ff) Documentation that 

6 the plan or issuer verifies the ac7 curacy of the provider directory 

8 information every 30 days. 

9 ‘‘(gg) Other factors as deter10 mined by the Secretary. 

11 ‘‘(iii) REQUIREMENTS OF THE INDE12 PENDENT AUDIT.—An audit under this 

13 subparagraph is complete if all of the fol14 lowing conditions are met: 

15 ‘‘(I) The audit report includes 

16 the following: 

17 ‘‘(aa) A statement by the 

18 independent auditor that, to the 

19 best of the auditor’s knowledge, 

20 the report is complete and accu21 rate, and that reasonable as22 sumptions related to statistics 

23 and research methods have been 

24 complied with. 


kjohnson on DSK79L0C42PROD with BILLS
26 

•S 5093 IS

1 ‘‘(bb) A statement explain2 ing the assumptions, statistics, 

3 and methods used to select the 

4 sample and assess provider direc5 tory information accuracy. 

6 ‘‘(cc) Such other informa7 tion as the Secretary determines 

8 necessary. 

9 ‘‘(II) The group health plan or 

10 health insurer issuer makes the inde11 pendent audit available on a public 

12 website. 

13 ‘‘(iv) RULEMAKING.—The Secretary, 

14 the Secretary of Health and Human Serv15 ices, and the Secretary of the Treasury 

16 shall issue interim final regulations (with17 out prior notice and comment as required 

18 under section 553 of title 5, United States 

19 Code) concerning the national standards 

20 for conducting audits under this subpara21 graph, not later than 2 years after the 

22 date of enactment of the Behavioral 

23 Health Network and Directory Improve24 ment Act. 

25 ‘‘(C) AUDITS BY THE SECRETARY.— 


kjohnson on DSK79L0C42PROD with BILLS
27 

•S 5093 IS

1 ‘‘(i) IN GENERAL.—Beginning not 

2 later than the third plan year after the 

3 date of enactment of the Behavioral 

4 Health Network and Directory Improve5 ment Act, the Secretary shall conduct an6 nual audits to ensure compliance with the 

7 provider directory requirements of this 

8 subsection. 

9 ‘‘(ii) REQUIREMENTS.—Audits con10 ducted by the Secretary under this sub11 paragraph shall— 

12 ‘‘(I) assess the accuracy of the 

13 information provided in health plan 

14 directories required under this sub15 section, including the proportion of 

16 listings with incorrect information, the 

17 last date on which the behavioral 

18 health network of the group health 

19 plan or health insurance coverage was 

20 updated, and other information deter21 mined appropriate by the Secretary; 

22 and 

23 ‘‘(II) use reasonable assumptions 

24 related to statistics and research 

25 methods to identify a representative 


kjohnson on DSK79L0C42PROD with BILLS
28 

•S 5093 IS

1 sample of listings for analysis and 

2 such methods as the Secretary deter3 mines appropriate, which may include 

4 retrospective analysis of billing data. 

5 ‘‘(iii) SELECTION OF PLANS AND

6 ISSUERS.—The Secretary shall conduct an7 nual audits of a total of not fewer than 10 

8 group health plans or health insurance 

9 issuers offering group health insurance 

10 coverage, as determined by the Secretary, 

11 that are the subjects of complaints about 

12 ghost networks or other complaints, or 

13 that are randomly selected by the Sec14 retary.’’; and 

15 (viii) in paragraph (8), as so redesig16 nated— 

17 (I) in the paragraph heading, by 

18 striking ‘‘DEFINITION’’ and inserting 

19 ‘‘DEFINITIONS’’; 

20 (II) by striking ‘‘For purposes of 

21 this subsection, the term’’ and insert22 ing the following: ‘‘For purposes of 

23 this subsection: 

24 ‘‘(A) PROVIDER DIRECTORY INFORMA25 TION.—The term’’; 


kjohnson on DSK79L0C42PROD with BILLS
29 

•S 5093 IS

1 (III) by striking ‘‘health insur2 ance coverage, the name’’ and insert3 ing ‘‘health insurance coverage— 

4 ‘‘(i) the name’’; 

5 (IV) by striking the period and 

6 inserting ‘‘; and’’; and 

7 (V) by adding at the end the fol8 lowing: 

9 ‘‘(ii) with respect to each such pro10 vider or facility— 

11 ‘‘(I) whether such provider or fa12 cility is accepting new patients; 

13 ‘‘(II) the languages spoken and 

14 the availability of language translators 

15 for specified languages at each health 

16 care facility listed in the directory; 

17 ‘‘(III) whether the provider or fa18 cility offers medication-assisted treat19 ment for opioid use disorder; 

20 ‘‘(IV) the State license number; 

21 ‘‘(V) the national provider identi22 fier; 

23 ‘‘(VI) the age groups served by 

24 the provider or facility, such as pediVerDate Sep 11 2014 21:57 Nov 16, 2022 Jkt 039200 PO 00000 Frm 00029 Fmt 6652 Sfmt 6201 E:\BILLS\S5093.IS S5093

kjohnson on DSK79L0C42PROD with BILLS
30 

•S 5093 IS

1 atric, adolescent, adult, or geriatric 

2 populations; 

3 ‘‘(VII) whether such provider or 

4 facility offers in-person services, tele5 health services, or both; and 

6 ‘‘(VIII) the cost-sharing tier, if 

7 applicable. 

8 ‘‘(B) GHOST NETWORK.—The term ‘ghost 

9 network’ means a group health plan or group 

10 health insurance coverage for which the pro11 vider directory information describing the net12 work of such plan or coverage— 

13 ‘‘(i) does not include accurate re14 quired information for purposes of making 

15 an appointment for in-network care within 

16 a reasonable time period; 

17 ‘‘(ii) includes a meaningful number of 

18 providers and facilities (as specified by the 

19 Secretary, in coordination with the Sec20 retary of Health and Human Services and 

21 the Secretary of the Treasury) in a spe22 cialty who are not accepting new patients 

23 within a time period specified by such sec24 retaries; 


kjohnson on DSK79L0C42PROD with BILLS
31 

•S 5093 IS

1 ‘‘(iii) includes providers that are not 

2 part of the network; or 

3 ‘‘(iv) omits providers that are part of 

4 the network.’’; and 

5 (B) in subsection (b)— 

6 (i) in paragraph (1), by striking ‘‘and 

7 if either of the criteria described in para8 graph (2) applies with respect to such par9 ticipant, beneficiary, or enrollee and item 

10 or service’’; and 

11 (ii) by striking paragraph (2) and in12 serting the following: 

13 ‘‘(2) RECONCILIATION REQUIREMENT.—For 

14 purposes of paragraph (1), a group health plan or 

15 group health insurance coverage offered by a health 

16 insurance issuer, on a regular basis, shall reconcile 

17 payment requests for items or services furnished by 

18 a nonparticipating provider or a nonparticipating fa19 cility and the posted provider directory database for 

20 the day the delivered item or service was provided. 

21 If a nonparticipating provider was listed as a partici22 pating provider in the directory, the group health 

23 plan or health insurance issuer shall notify the par24 ticipant, beneficiary, or enrollee, in plain language, 

25 that the participant, beneficiary, or enrollee may be 


kjohnson on DSK79L0C42PROD with BILLS
32 

•S 5093 IS

1 eligible for a refund from the group health plan or 

2 health insurance issuer if such participant, bene3 ficiary, or enrollee paid the out of network cost-shar4 ing and did not receive a refund under section 

5 2799B–9(b) of the Public Health Service Act (42 

6 U.S.C. 300gg–139).’’. 

7 (2) CIVIL MONETARY PENALTIES FOR VIOLA8 TIONS.— 

9 (A) CIVIL MONETARY PENALTIES RELAT10 ING TO PROVIDER DIRECTORY REQUIRE11 MENTS.—Section 502(c)(10) of the Employee 

12 Retirement Income Security Act of 1974 (29 

13 U.S.C. 1132(c)(10)(A)) is amended— 

14 (i) in the heading, by striking ‘‘USE

15 OF GENETIC INFORMATION’’ and inserting 

16 ‘‘USE OF GENETIC INFORMATION AND PRO17 VIDER DIRECTORY REQUIREMENTS’’; and 

18 (ii) in subparagraph (A)— 

19 (I) by striking ‘‘any plan sponsor 

20 of a group health plan’’ and inserting 

21 ‘‘any plan sponsor or plan adminis22 trator of a group health plan’’; and 

23 (II) by striking ‘‘for any failure’’ 

24 and all that follows through ‘‘in con25 nection with the plan.’’ and inserting 


kjohnson on DSK79L0C42PROD with BILLS
33 

•S 5093 IS

1 ‘‘for any failure by such plan sponsor, 

2 plan administrator, or health insur3 ance issuer, in connection with the 

4 plan— 

5 ‘‘(i) to meet the requirements of sub6 section (a)(1)(F), (b)(3), (c), or (d) of sec7 tion 702 or section 701 or 702(b)(1) with 

8 respect to genetic information; or 

9 ‘‘(ii) to meet the requirements of sec10 tion 720 with respect to provider directory 

11 information.’’. 

12 (B) EXCEPTION TO THE GENERAL PROHI13 BITION ON ENFORCEMENT.—Section 502 of 

14 such Act (29 U.S.C. 1132) is amended— 

15 (i) in subsection (a)(6), by striking 

16 ‘‘or (9)’’ and inserting ‘‘(9), or (10)’’; and 

17 (ii) in subsection (b)(3)— 

18 (I) by striking ‘‘subsections 

19 (c)(9) and (a)(6)’’ and inserting ‘‘sub20 sections (c)(9), (c)(10), and (a)(6)’’; 

21 (II) by striking ‘‘under sub22 section (c)(9))’’ and inserting ‘‘under 

23 subsections (c)(9) and (c)(10)), and 

24 except with respect to enforcement by 

25 the Secretary of section 720’’; and 


kjohnson on DSK79L0C42PROD with BILLS
34 

•S 5093 IS

1 (III) by striking ‘‘706(a)(1)’’ and 

2 inserting ‘‘733(a)(1)’’. 

3 (C) EFFECTIVE DATE.—The amendments 

4 made by subparagraph (A) shall apply with re5 spect to group health plans, or any health in6 surance issuer offering health insurance cov7 erage in connection with such plan, for plan 

8 years beginning after the date that is 1 year 

9 after the date of enactment of this Act. 

10 (c) IRC.—Section 9820 of the Internal Revenue Code 

11 of 1986 is amended— 

12 (1) in subsection (a)— 

13 (A) in paragraph (1)— 

14 (i) by striking ‘‘For plan years begin15 ning on or after January 1, 2022, each’’ 

16 and inserting ‘‘Each’’; 

17 (ii) in subparagraph (C), by striking 

18 ‘‘; and’’ and inserting a semicolon; 

19 (iii) in subparagraph (D), by striking 

20 the period and inserting ‘‘; and’’; and 

21 (iv) by adding at the end the fol22 lowing: 

23 ‘‘(E) ensure that any directory, including 

24 the database described in subparagraph (C), 

25 containing provider directory information with 


kjohnson on DSK79L0C42PROD with BILLS
35 

•S 5093 IS

1 respect to such plan complies with the require2 ments developed by the appropriate agencies in 

3 accordance with paragraph (6) in order to en4 sure that participants, beneficiaries, and enroll5 ees are able to identify actively participating 

6 health care providers and health care facili7 ties.’’; 

8 (B) in paragraph (2)(A), by striking ‘‘90 

9 days’’ and inserting ‘‘30 days’’; 

10 (C) in paragraph (3)— 

11 (i) in the matter preceding subpara12 graph (A), by striking ‘‘, in the case such 

13 request is made through a telephone call’’; 

14 and 

15 (ii) in subparagraph (A), by striking 

16 ‘‘call is received, through a written elec17 tronic or print (as requested by such indi18 vidual) communication’’ and inserting ‘‘a 

19 request is received, by telephone, or 

20 through a written electronic or print com21 munication (as requested by such indi22 vidual)’’; 

23 (D) in paragraph (4)— 

24 (i) in subparagraph (A), by striking 

25 ‘‘and’’ at the end; 


kjohnson on DSK79L0C42PROD with BILLS
36 

•S 5093 IS

1 (ii) in subparagraph (B), by striking 

2 the period and inserting ‘‘; and’’; and 

3 (iii) by adding at the end the fol4 lowing: 

5 ‘‘(C) information, in plain language, con6 cerning the rights of the participant, bene7 ficiary, or enrollee to cost-sharing protections 

8 pursuant to subsection (b) in the event of reli9 ance on inaccurate provider network informa10 tion supplied by a group health plan, and con11 tact information for the State consumer assist12 ance program or ombudsman for more informa13 tion.’’; 

14 (E) in paragraph (5), by adding at the end 

15 the following: ‘‘Such information shall include a 

16 statement, in plain language, concerning the 

17 rights of the participant, beneficiary, or enrollee 

18 to cost-sharing protections pursuant to sub19 section (b) in the event of reliance on inac20 curate provider directory information supplied 

21 by a group health plan, and contact information 

22 for the State consumer assistance program or 

23 ombudsman for more information.’’; 

24 (F) by redesignating paragraphs (6) and 

25 (7) as paragraphs (8) and (9), respectively; 


kjohnson on DSK79L0C42PROD with BILLS
37 

•S 5093 IS

1 (G) by inserting after paragraph (5) the 

2 following: 

3 ‘‘(6) PROTECTING PARTICIPANTS, BENE4 FICIARIES, AND ENROLLEES FROM GHOST NET5 WORKS.—The Secretary, in collaboration with the 

6 Secretary of Labor and the Secretary of Health and 

7 Human Services, shall— 

8 ‘‘(A) not later than 180 days after the date 

9 of enactment of the Behavioral Health Network 

10 and Directory Improvement Act, issue interim 

11 final regulations (without prior notice and com12 ment as required under section 553 of title 5, 

13 United States Code) further defining the term 

14 ‘ghost network’ (as defined in paragraph (8)); 

15 and 

16 ‘‘(B) not later than 18 months after the 

17 date of enactment of the Behavioral Health 

18 Network and Directory Improvement Act, issue 

19 interim final regulations (without prior notice 

20 and comment as required under section 553 of 

21 title 5, United States Code), subregulatory 

22 guidance, or program instruction on how to as23 sess ghost networks in health plan directories 

24 including reasonable assumptions related to sta25 tistics and research methods. 


kjohnson on DSK79L0C42PROD with BILLS
38 

•S 5093 IS

1 ‘‘(7) DATABASE REPORTING AND AUDITING TO

2 PROTECT AGAINST GHOST NETWORKS.— 

3 ‘‘(A) REPORTING REQUIREMENTS.—Begin4 ning not later than 3 years after the date of en5 actment of the Behavioral Health Network and 

6 Directory Improvement Act, each group health 

7 plan shall submit to the Secretary, at such time 

8 as the Secretary, in coordination with the Sec9 retary of Labor and the Secretary of Health 

10 and Human Services, shall require, but not less 

11 frequently than annually, the directory data de12 scribed in paragraph (a)(4), in a machine read13 able format (as defined in section 

14 147.210(a)(2)(xiv) of title 45, Code of Federal 

15 Regulations (or any successor regulations)). 

16 The Secretary, in coordination with the Sec17 retary of Labor and the Secretary of Health 

18 and Human Services, shall make data sub19 mitted under this subparagraph available on a 

20 public website. 

21 ‘‘(B) PROVIDER DIRECTORY INDEPENDENT

22 AUDIT REQUIREMENTS.— 

23 ‘‘(i) IN GENERAL.—Beginning not 

24 later than 3 years after the date of enact25 ment of the Behavioral Health Network 


kjohnson on DSK79L0C42PROD with BILLS
39 

•S 5093 IS

1 and Directory Improvement Act, each 

2 group health plan shall conduct an annual 

3 directory audit, through an independent 

4 entity not associated with the health plan, 

5 that considers the factors described in 

6 clause (ii)(I)(aa) and follows the guidelines 

7 developed under clause (ii)(I)(bb). 

8 ‘‘(ii) FACTORS.— 

9 ‘‘(I) IN GENERAL.—For purposes 

10 of carrying out the audits under this 

11 subparagraph, the Secretary shall— 

12 ‘‘(aa) develop a list of fac13 tors to be considered; and 

14 ‘‘(bb) provide guidelines for 

15 carrying out such audits, for use 

16 by group health plans, on— 

17 ‘‘(AA) the reasonable 

18 assumptions and research 

19 methods to select a reason20 able sample in order to as21 sess provider directory infor22 mation accuracy; and 

23 ‘‘(BB) determining the 

24 criteria of an eligible audi25 tor. 


kjohnson on DSK79L0C42PROD with BILLS
40 

•S 5093 IS

1 ‘‘(II) CONTENTS.—The factors 

2 under subclause (I)(aa) shall include 

3 the following: 

4 ‘‘(aa) A list of every health 

5 care provider and health care fa6 cility that was part of the net7 work of the applicable plan, the 

8 months during the plan year dur9 ing which each such provider or 

10 facility was part of the network, 

11 and the number of participants, 

12 beneficiaries, and enrollees in the 

13 plan (including participants, 

14 beneficiaries, and enrollees who 

15 are new patients of the provider) 

16 each such provider or facility 

17 treated during such period. 

18 ‘‘(bb) The proportion of di19 rectory listings of the plan with 

20 inaccurate information, including 

21 incorrect contact information, in22 cluding incorrect contact infor23 mation, as specified by the Sec24 retary, during the audit period. 


kjohnson on DSK79L0C42PROD with BILLS
41 

•S 5093 IS

1 ‘‘(cc) The number of in-net2 work items or services paid on 

3 behalf of participants, bene4 ficiaries, and enrollees in the plan 

5 to providers or facilities who have 

6 a network provider contract with 

7 the health plan and were not list8 ed in the directory of the health 

9 plan for the audit period. 

10 ‘‘(dd) The resources of the 

11 plan to help participants, bene12 ficiaries, and enrollees locate an 

13 accurately listed in-network pro14 vider who is accepting new pa15 tients. 

16 ‘‘(ee) The proportion of par17 ticipants, beneficiaries, and en18 rollees using out-of-network pro19 viders for mental health and sub20 stance use disorder services, and 

21 the proportion of participants, 

22 beneficiaries, and enrollees using 

23 out-of-network providers and fa24 cilities for medical and surgical 

25 services. 


kjohnson on DSK79L0C42PROD with BILLS
42 

•S 5093 IS

1 ‘‘(ff) Documentation that 

2 the plan verifies the accuracy of 

3 the provider directory informa4 tion every 30 days. 

5 ‘‘(gg) Other factors as deter6 mined by the Secretary. 

7 ‘‘(iii) REQUIREMENTS OF THE INDE8 PENDENT AUDIT.—An audit under this 

9 subparagraph is complete if all of the fol10 lowing conditions are met: 

11 ‘‘(I) The audit report includes 

12 the following: 

13 ‘‘(aa) A statement by the 

14 independent auditor that, to the 

15 best of the auditor’s knowledge, 

16 the report is complete and accu17 rate, and that reasonable as18 sumptions related to statistics 

19 and research methods have been 

20 complied with. 

21 ‘‘(bb) A statement explain22 ing the assumptions, statistics, 

23 and methods used to select the 

24 sample and assess provider direc25 tory information accuracy. 


kjohnson on DSK79L0C42PROD with BILLS
43 

•S 5093 IS

1 ‘‘(cc) Such other informa2 tion as the Secretary determines 

3 necessary. 

4 ‘‘(II) The group health plan 

5 makes the independent audit available 

6 on a public website. 

7 ‘‘(iv) RULEMAKING.—The Secretary, 

8 the Secretary of Labor, and the Secretary 

9 of Health and Human Services shall issue 

10 interim final regulations (without prior no11 tice and comment as required under sec12 tion 553 of title 5, United States Code) 

13 concerning the national standards for con14 ducting audits under this subparagraph, 

15 not later than 2 years after the date of en16 actment of the Behavioral Health Network 

17 and Directory Improvement Act. 

18 ‘‘(C) AUDITS BY THE SECRETARY.— 

19 ‘‘(i) IN GENERAL.—Beginning not 

20 later than the third plan year after the 

21 date of enactment of the Behavioral 

22 Health Network and Directory Improve23 ment Act, the Secretary shall conduct an24 nual audits to ensure compliance with the 


kjohnson on DSK79L0C42PROD with BILLS
44 

•S 5093 IS

1 provider directory requirements of this 

2 subsection. 

3 ‘‘(ii) REQUIREMENTS.—Audits con4 ducted by the Secretary under this sub5 paragraph shall— 

6 ‘‘(I) assess the accuracy of the 

7 information provided in health plan 

8 directories required under this sub9 section, including the proportion of 

10 listings with incorrect information, the 

11 last date on which the behavioral 

12 health network of the group health 

13 plan was updated, and other informa14 tion determined appropriate by the 

15 Secretary; and 

16 ‘‘(II) use reasonable assumptions 

17 related to statistics and research 

18 methods to identify a representative 

19 sample of listings for analysis and 

20 such methods as the Secretary deter21 mines appropriate, which may include 

22 retrospective analysis of billing data. 

23 ‘‘(iii) SELECTION OF PLANS.—The 

24 Secretary shall conduct annual audits of a 

25 total of not fewer than 10 group health 


kjohnson on DSK79L0C42PROD with BILLS
45 

•S 5093 IS

1 plans, as determined by the Secretary, that 

2 are the subjects of complaints about ghost 

3 networks or other complaints, or that are 

4 randomly selected by the Secretary.’’; and 

5 (H) in paragraph (8), as so redesignated— 

6 (i) in the paragraph heading, by strik7 ing ‘‘DEFINITION’’ and inserting ‘‘DEFINI8 TIONS’’; 

9 (ii) by striking ‘‘For purposes of this 

10 subsection, the term’’ and inserting the fol11 lowing: ‘‘For purposes of this subsection: 

12 ‘‘(A) PROVIDER DIRECTORY INFORMA13 TION.—The term’’; 

14 (iii) by striking ‘‘group health plan, 

15 the name’’ and inserting ‘‘group health 

16 plan— 

17 ‘‘(i) the name’’; 

18 (iv) by striking the period and insert19 ing ‘‘; and’’; and 

20 (v) by adding at the end the following: 

21 ‘‘(ii) with respect to each such pro22 vider or facility— 

23 ‘‘(I) whether such provider or fa24 cility is accepting new patients; 


kjohnson on DSK79L0C42PROD with BILLS
46 

•S 5093 IS

1 ‘‘(II) the languages spoken and 

2 the availability of language translators 

3 for specified languages at each health 

4 care facility listed in the directory; 

5 ‘‘(III) whether the provider or fa6 cility offers medication-assisted treat7 ment for opioid use disorder; 

8 ‘‘(IV) the State license number; 

9 ‘‘(V) the national provider identi10 fier; 

11 ‘‘(VI) the age groups served by 

12 the provider or facility, such as pedi13 atric, adolescent, adult, or geriatric 

14 populations; 

15 ‘‘(VII) whether such provider or 

16 facility offers in-person services, tele17 health services, or both; and 

18 ‘‘(VIII) the cost-sharing tier, if 

19 applicable. 

20 ‘‘(B) GHOST NETWORK.—The term ‘ghost 

21 network’ means a group health plan for which 

22 the provider directory information describing 

23 the network of such plan— 

24 ‘‘(i) does not include accurate re25 quired information for purposes of making 


kjohnson on DSK79L0C42PROD with BILLS
47 

•S 5093 IS

1 an appointment for in-network care within 

2 a reasonable time period; 

3 ‘‘(ii) includes a meaningful number of 

4 providers and facilities (as specified by the 

5 Secretary, in coordination with the Sec6 retary of Labor and the Secretary of 

7 Health and Human Services) in a specialty 

8 who are not accepting new patients within 

9 a time period specified by such secretaries; 

10 ‘‘(iii) includes providers that are not 

11 part of the network; or 

12 ‘‘(iv) omits providers that are part of 

13 the network.’’; and 

14 (2) in subsection (b)— 

15 (A) in paragraph (1), by striking ‘‘and if 

16 either of the criteria described in paragraph (2) 

17 applies with respect to such participant, bene18 ficiary, or enrollee and item or service’’; and 

19 (B) by striking paragraph (2) and insert20 ing the following: 

21 ‘‘(2) RECONCILIATION REQUIREMENT.—For 

22 purposes of paragraph (1), a group health plan, on 

23 a regular basis, shall reconcile payment requests for 

24 items or services furnished by a nonparticipating 

25 provider or a nonparticipating facility and the posted 


kjohnson on DSK79L0C42PROD with BILLS
48 

•S 5093 IS

1 provider directory database for the day the delivered 

2 item or service was provided. If a nonparticipating 

3 provider was listed as a participating provider in the 

4 directory, the group health plan shall notify the par5 ticipant, beneficiary, or enrollee, in plain language, 

6 that the participant, beneficiary, or enrollee may be 

7 eligible for a refund from the group health plan if 

8 such participant, beneficiary, or enrollee paid the out 

9 of network cost-sharing and did not receive a refund 

10 under section 2799B–9(b) of the Public Health 

11 Service Act (42 U.S.C. 300gg–139).’’. 

12 SEC. 3. PROVIDER REQUIREMENTS TO PROTECT PATIENTS 

13 AND IMPROVE THE ACCURACY OF PROVIDER 

14 DIRECTORY INFORMATION. 

15 Section 2799B–9 of the Public Health Service Act 

16 (42 U.S.C. 300gg–139) is amended— 

17 (1) in subsection (a)— 

18 (A) in paragraph (3), by striking ‘‘; and’’ 

19 and inserting a semicolon; 

20 (B) by redesignating paragraph (4) as 

21 paragraph (6); and 

22 (C) by inserting after paragraph (3) the 

23 following: 

24 ‘‘(4) subject to paragraph (5), when a provider 

25 or facility that is not accepting new patients deterVerDate Sep 11 2014 21:57 Nov 16, 2022 Jkt 039200 PO 00000 Frm 00048 Fmt 6652 Sfmt 6201 E:\BILLS\S5093.IS S5093

kjohnson on DSK79L0C42PROD with BILLS
49 

•S 5093 IS

1 mines that it has the ability to accept new patients, 

2 within 5 business days of such determination; 

3 ‘‘(5) when a solo practitioner or small provider, 

4 as determined by the Secretary, determines that it 

5 has the ability to accept new patients, within 10 

6 business days of such determination; and’’; and 

7 (2) by amending subsection (d) to read as fol8 lows: 

9 ‘‘(d) DEFINITION.—For purposes of this section, the 

10 term ‘provider directory information’ includes— 

11 ‘‘(1) the name, address, specialty, telephone 

12 number, and digital contact information of each in13 dividual health care provider contracted to partici14 pate in any of the networks of the group health plan 

15 or health insurance coverage involved; 

16 ‘‘(2) the name, address, specialty, telephone 

17 number, and digital contact information of each 

18 medical group, clinic, or facility contracted to par19 ticipate in any of the networks of the group health 

20 plan or health insurance coverage involved; and 

21 ‘‘(3) with respect to each such provider, medical 

22 group, clinic, or facility— 

23 ‘‘(A) whether such provider, medical group, 

24 clinic, or facility is accepting new patients; 


kjohnson on DSK79L0C42PROD with BILLS
50 

•S 5093 IS

1 ‘‘(B) the languages spoken and the avail2 ability of language translators for specified lan3 guages at each provider, medical group, clinic, 

4 or facility listed in the directory; 

5 ‘‘(C) whether the provider, medical group, 

6 clinic, or facility offers medication-assisted 

7 treatment for opioid use disorder; 

8 ‘‘(D) the State license number; 

9 ‘‘(E) the national provider identifier; 

10 ‘‘(F) the age groups served by such pro11 vider, group, clinic, or facility, such as pedi12 atric, adolescent, adult, or geriatric populations; 

13 ‘‘(G) whether such provider, group, clinic, 

14 or facility offers in-person services, telehealth 

15 services, or both; and 

16 ‘‘(H) the cost-sharing tier, if applicable.’’. 

17 SEC. 4. STRENGTHENING MENTAL HEALTH AND SUB18 STANCE USE DISORDER PARITY REQUIRE19 MENTS. 

20 (a) PHSA.— 

21 (1) NETWORK ADEQUACY REQUIREMENTS.— 

22 Section 2726(a) of the Public Health Service Act 

23 (42 U.S.C. 300gg–26(a)) is amended by adding at 

24 the end the following: 

25 ‘‘(9) NETWORK ADEQUACY REQUIREMENTS.— 


kjohnson on DSK79L0C42PROD with BILLS
51 

•S 5093 IS

1 ‘‘(A) IN GENERAL.—The Secretary, the 

2 Secretary of Labor, and the Secretary of the 

3 Treasury shall issue regulations establishing na4 tional quantitative standards for mental health 

5 and substance use disorder network adequacy. 

6 Such standards shall consider— 

7 ‘‘(i) the ratio of in-network mental 

8 health providers, separated by professional 

9 type of mental health provider, to partici10 pants, beneficiaries, and enrollees in a 

11 group health plan or health insurance cov12 erage; 

13 ‘‘(ii) the ratio of in-network substance 

14 use disorder providers, separated by pro15 fessional type of substance use disorder 

16 provider, to participants, beneficiaries, and 

17 enrollees in a group health plan or health 

18 insurance coverage; 

19 ‘‘(iii) separately, for each of mental 

20 health services and substance use disorder 

21 services— 

22 ‘‘(I) geographic accessibility of 

23 providers; 

24 ‘‘(II) geographic variation and 

25 population dispersion; 


kjohnson on DSK79L0C42PROD with BILLS
52 

•S 5093 IS

1 ‘‘(III) waiting times for appoint2 ments with participating providers; 

3 ‘‘(IV) hours of operation for par4 ticipating providers; 

5 ‘‘(V) the ability of the network to 

6 meet the needs of participants, bene7 ficiaries, and enrollees, including low8 income individuals, individuals who 

9 are members of a racial or ethnic mi10 nority, individuals who live in a health 

11 professional shortage area, children 

12 and adults with serious, chronic, and 

13 complex health conditions, individuals 

14 with physical or mental disabilities or 

15 substance use disorders, pediatric 

16 populations, and individuals with lim17 ited English proficiency; 

18 ‘‘(VI) the availability of in-person 

19 services, telehealth services, and hy20 brid services to serve the needs of par21 ticipants, beneficiaries, and enrollees; 

22 and 

23 ‘‘(VII) the percentage of in-net24 work providers who have submitted a 


kjohnson on DSK79L0C42PROD with BILLS
53 

•S 5093 IS

1 claim for payment during the previous 

2 6 months; and 

3 ‘‘(iv) other standards as determined 

4 by the Secretary, the Secretary of Labor, 

5 and the Secretary of the Treasury. 

6 ‘‘(B) TIMING.— 

7 ‘‘(i) ISSUANCE.—The Secretary, the 

8 Secretary of Labor, and the Secretary of 

9 the Treasury shall— 

10 ‘‘(I) issue proposed regulations 

11 required under subparagraph (A) not 

12 later than 2 years after the date of 

13 enactment of the Behavioral Health 

14 Network and Directory Improvement 

15 Act; and 

16 ‘‘(II) issue final regulations 

17 under subparagraph (A) not later 

18 than 1 year thereafter. 

19 ‘‘(ii) EFFECTIVE DATE.—The regula20 tions promulgated under this paragraph 

21 shall take effect in the first plan year that 

22 begins after the date on which such final 

23 regulations are issued. 

24 ‘‘(C) AUDITS.—The Secretary, the Sec25 retary of Labor, and the Secretary of the 


kjohnson on DSK79L0C42PROD with BILLS
54 

•S 5093 IS

1 Treasury shall conduct annual, targeted audits 

2 of not fewer than 10 group health plans and 

3 health insurance issuers offering group or indi4 vidual health insurance coverage that the Secre5 taries determine to be the subject of the great6 est number of complaints about mental health 

7 and substance use disorder network adequacy 

8 to ensure compliance with the requirements of 

9 this paragraph. Such audits shall begin not ear10 lier than one year after the final regulations im11 plementing this paragraph begin to apply to 

12 group health plans and health insurance 

13 issuers.’’. 

14 (2) DEFINITIONS.—Paragraphs (4) and (5) of 

15 section 2726(e) of the Public Health Service Act (42 

16 U.S.C. 300gg–26(e)) are amended to read as fol17 lows: 

18 ‘‘(4) MENTAL HEALTH BENEFITS.—The term 

19 ‘mental health benefits’ means benefits with respect 

20 to services related to a mental health condition, de21 fined consistently with generally recognized inde22 pendent standards of current medical practice, such 

23 as the Diagnostic and Statistical Manual of Mental 

24 Disorders of the American Psychiatric Association. 


kjohnson on DSK79L0C42PROD with BILLS
55 

•S 5093 IS

1 ‘‘(5) SUBSTANCE USE DISORDER BENEFITS.— 

2 The term ‘substance use disorder benefits’ means 

3 benefits with respect to services related to a sub4 stance use disorder, defined consistently with gen5 erally recognized independent standards of current 

6 medical practice, such as the Diagnostic and Statis7 tical Manual of Mental Disorders of the American 

8 Psychiatric Association.’’. 

9 (3) STANDARDS FOR PARITY IN REIMBURSE10 MENT RATES.—Section 2726(a) of the Public Health 

11 Service Act (42 U.S.C. 300gg–26(a)), as amended 

12 by paragraph (1), is further amended by adding at 

13 the end the following: 

14 ‘‘(10) STANDARDS FOR PARITY IN REIMBURSE15 MENT RATES.— 

16 ‘‘(A) IN GENERAL.—Not later than 2 years 

17 after the date of enactment of the Behavioral 

18 Health Network and Directory Improvement 

19 Act, the Secretary, the Secretary of Labor, and 

20 the Secretary of the Treasury shall issue regu21 lations on a standard for parity in reimburse22 ment rates for mental health or substance use 

23 disorder benefits and medical and surgical bene24 fits, based on a comparative analysis conducted 

25 by such Secretaries using data submitted by 


kjohnson on DSK79L0C42PROD with BILLS
56 

•S 5093 IS

1 group health plans and health insurance 

2 issuers, provider associations, and other experts 

3 related to the cost of care delivery for mental 

4 health and substance use disorder benefits. 

5 ‘‘(B) REQUESTS FOR DATA.—Group health 

6 plans and health insurance issuers shall comply 

7 with any request for data issued by the Sec8 retary, the Secretary of Labor, and the Sec9 retary of the Treasury for purposes of devel10 oping the standards under subparagraph (A). 

11 ‘‘(C) EFFECTIVE DATE.—The regulations 

12 promulgated under subparagraph (A) shall 

13 apply to group health plans and health insur14 ance issuers offering group or individual health 

15 insurance coverage beginning in the first plan 

16 year that begins after issuance of the final reg17 ulations.’’. 

18 (b) ERISA.— 

19 (1) NETWORK ADEQUACY REQUIREMENTS.— 

20 Section 712(a) of the Employee Retirement Income 

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

22 amended by adding at the end the following: 

23 ‘‘(9) NETWORK ADEQUACY REQUIREMENTS.— 

24 ‘‘(A) IN GENERAL.—The Secretary, the 

25 Secretary of Health and Human Services, and 


kjohnson on DSK79L0C42PROD with BILLS
57 

•S 5093 IS

1 the Secretary of the Treasury shall issue regu2 lations establishing national quantitative stand3 ards for mental health and substance use dis4 order network adequacy. Such standards shall 

5 consider— 

6 ‘‘(i) the ratio of in-network mental 

7 health providers, separated by professional 

8 type of mental health provider, to partici9 pants, beneficiaries, and enrollees in a 

10 group health plan or health insurance cov11 erage; 

12 ‘‘(ii) the ratio of in-network substance 

13 use disorder providers, separated by pro14 fessional type of substance use disorder 

15 provider, to participants, beneficiaries, and 

16 enrollees in a group health plan or health 

17 insurance coverage; 

18 ‘‘(iii) separately, for each of mental 

19 health services and substance use disorder 

20 services— 

21 ‘‘(I) geographic accessibility of 

22 providers; 

23 ‘‘(II) geographic variation and 

24 population dispersion; 


kjohnson on DSK79L0C42PROD with BILLS
58 

•S 5093 IS

1 ‘‘(III) waiting times for appoint2 ments with participating providers; 

3 ‘‘(IV) hours of operation for par4 ticipating providers; 

5 ‘‘(V) the ability of the network to 

6 meet the needs of participants, bene7 ficiaries, and enrollees, including low8 income individuals, individuals who 

9 are members of a racial or ethnic mi10 nority, individuals who live in a health 

11 professional shortage area, children 

12 and adults with serious, chronic, and 

13 complex health conditions, individuals 

14 with physical or mental disabilities or 

15 substance use disorders, pediatric 

16 populations, and individuals with lim17 ited English proficiency; 

18 ‘‘(VI) the availability of in-person 

19 services, telehealth services, and hy20 brid services to serve the needs of par21 ticipants, beneficiaries, and enrollees; 

22 and 

23 ‘‘(VII) the percentage of in-net24 work providers who have submitted a 


kjohnson on DSK79L0C42PROD with BILLS
59 

•S 5093 IS

1 claim for payment during the previous 

2 6 months; and 

3 ‘‘(iv) other standards as determined 

4 by the Secretary, the Secretary of Health 

5 and Human Services, and the Secretary of 

6 the Treasury. 

7 ‘‘(B) TIMING.— 

8 ‘‘(i) ISSUANCE.—The Secretary, the 

9 Secretary of Health and Human Services, 

10 and the Secretary of the Treasury shall— 

11 ‘‘(I) issue proposed regulations 

12 required under subparagraph (A) not 

13 later than 2 years after the date of 

14 enactment of the Behavioral Health 

15 Network and Directory Improvement 

16 Act; and 

17 ‘‘(II) issue final regulations 

18 under subparagraph (A) not later 

19 than 1 year thereafter. 

20 ‘‘(ii) EFFECTIVE DATE.—The regula21 tions promulgated under this paragraph 

22 shall take effect in the first plan year that 

23 begins after the date on which such final 

24 regulations are issued. 


kjohnson on DSK79L0C42PROD with BILLS
60 

•S 5093 IS

1 ‘‘(C) AUDITS.—The Secretary, the Sec2 retary of Health and Human Services, and the 

3 Secretary of the Treasury shall conduct annual, 

4 targeted audits of not fewer than 10 group 

5 health plans and health insurance issuers offer6 ing group health insurance coverage that the 

7 Secretaries determine to be the subject of the 

8 greatest number of complaints about mental 

9 health and substance use disorder network ade10 quacy to ensure compliance with the require11 ments of this paragraph. Such audits shall 

12 begin not earlier than one year after the final 

13 regulations implementing this paragraph begin 

14 to apply to group health plans and health insur15 ance issuers.’’. 

16 (2) DEFINITIONS.—Paragraphs (4) and (5) of 

17 section 712(e) of the Employee Retirement Income 

18 Security Act of 1974 (29 U.S.C. 1185a(e)) are 

19 amended to read as follows: 

20 ‘‘(4) MENTAL HEALTH BENEFITS.—The term 

21 ‘mental health benefits’ means benefits with respect 

22 to services related to a mental health condition, de23 fined consistently with generally recognized inde24 pendent standards of current medical practice, such 


kjohnson on DSK79L0C42PROD with BILLS
61 

•S 5093 IS

1 as the Diagnostic and Statistical Manual of Mental 

2 Disorders of the American Psychiatric Association. 

3 ‘‘(5) SUBSTANCE USE DISORDER BENEFITS.— 

4 The term ‘substance use disorder benefits’ means 

5 benefits with respect to services related to a sub6 stance use disorder, defined consistently with gen7 erally recognized independent standards of current 

8 medical practice, such as the Diagnostic and Statis9 tical Manual of Mental Disorders of the American 

10 Psychiatric Association.’’. 

11 (3) STANDARDS FOR PARITY IN REIMBURSE12 MENT RATES.—Section 712(a) of the Employee Re13 tirement Income Security Act of 1974 (29 U.S.C. 

14 1185a(a)), as amended by paragraph (1), is further 

15 amended by adding at the end the following: 

16 ‘‘(10) STANDARDS FOR PARITY IN REIMBURSE17 MENT RATES.— 

18 ‘‘(A) IN GENERAL.—Not later than 2 years 

19 after the date of enactment of the Behavioral 

20 Health Network and Directory Improvement 

21 Act, the Secretary, the Secretary of Health and 

22 Human Services, and the Secretary of the 

23 Treasury shall issue regulations on a standard 

24 for parity in reimbursement rates for mental 

25 health or substance use disorder benefits and 


kjohnson on DSK79L0C42PROD with BILLS
62 

•S 5093 IS

1 medical and surgical benefits, based on a com2 parative analysis conducted by such Secretaries 

3 using data submitted by group health plans and 

4 health insurance issuers, provider associations, 

5 and other experts related to the cost of care de6 livery for mental health and substance use dis7 order benefits. 

8 ‘‘(B) REQUESTS FOR DATA.—Group health 

9 plans and health insurance issuers shall comply 

10 with any request for data issued by the Sec11 retary, the Secretary of Health and Human 

12 Services, and the Secretary of the Treasury for 

13 purposes of developing the standards under 

14 subparagraph (A). 

15 ‘‘(C) EFFECTIVE DATE.—The regulations 

16 promulgated under subparagraph (A) shall 

17 apply to group health plans and health insur18 ance issuers offering group health insurance 

19 coverage beginning in the first plan year that 

20 begins after issuance of the final regulations.’’. 

21 (c) IRC.— 

22 (1) NETWORK ADEQUACY REQUIREMENTS.— 

23 Section 9812(a) of the Internal Revenue Code of 

24 1986 is amended by adding at the end the following: 

25 ‘‘(9) NETWORK ADEQUACY REQUIREMENTS.— 


kjohnson on DSK79L0C42PROD with BILLS
63 

•S 5093 IS

1 ‘‘(A) IN GENERAL.—The Secretary, the 

2 Secretary of Health and Human Services, and 

3 the Secretary of Labor shall issue regulations 

4 establishing national quantitative standards for 

5 mental health and substance use disorder net6 work adequacy. Such standards shall consider— 

7 ‘‘(i) the ratio of in-network mental 

8 health providers, separated by professional 

9 type of mental health provider, to partici10 pants, beneficiaries, and enrollees in a 

11 group health plan; 

12 ‘‘(ii) the ratio of in-network substance 

13 use disorder providers, separated by pro14 fessional type of substance use disorder 

15 provider, to participants, beneficiaries, and 

16 enrollees in a group health plan; 

17 ‘‘(iii) separately, for each of mental 

18 health services and substance use disorder 

19 services— 

20 ‘‘(I) geographic accessibility of 

21 providers; 

22 ‘‘(II) geographic variation and 

23 population dispersion; 

24 ‘‘(III) waiting times for appoint25 ments with participating providers; 


kjohnson on DSK79L0C42PROD with BILLS
64 

•S 5093 IS

1 ‘‘(IV) hours of operation for par2 ticipating providers; 

3 ‘‘(V) the ability of the network to 

4 meet the needs of participants, bene5 ficiaries, and enrollees, including low6 income individuals, individuals who 

7 are members of a racial or ethnic mi8 nority, individuals who live in a health 

9 professional shortage area, children 

10 and adults with serious, chronic, and 

11 complex health conditions, individuals 

12 with physical or mental disabilities or 

13 substance use disorders, pediatric 

14 populations, and individuals with lim15 ited English proficiency; 

16 ‘‘(VI) the availability of in-person 

17 services, telehealth services, and hy18 brid services to serve the needs of par19 ticipants, beneficiaries, and enrollees; 

20 and 

21 ‘‘(VII) the percentage of in-net22 work providers who have submitted a 

23 claim for payment during the previous 

24 6 months; and 


kjohnson on DSK79L0C42PROD with BILLS
65 

•S 5093 IS

1 ‘‘(iv) other standards as determined 

2 by the Secretary, the Secretary of Health 

3 and Human Services, and the Secretary of 

4 Labor. 

5 ‘‘(B) TIMING.— 

6 ‘‘(i) ISSUANCE.—The Secretary, the 

7 Secretary of Health and Human Services, 

8 and the Secretary of Labor shall— 

9 ‘‘(I) issue proposed regulations 

10 required under subparagraph (A) not 

11 later than 2 years after the date of 

12 enactment of the Behavioral Health 

13 Network and Directory Improvement 

14 Act; and 

15 ‘‘(II) issue final regulations 

16 under subparagraph (A) not later 

17 than 1 year thereafter. 

18 ‘‘(ii) EFFECTIVE DATE.—The regula19 tions promulgated under this paragraph 

20 shall take effect in the first plan year that 

21 begins after the date on which such final 

22 regulations are issued. 

23 ‘‘(C) AUDITS.—The Secretary, the Sec24 retary of Health and Human Services, and the 

25 Secretary of Labor shall conduct annual, tarVerDate Sep 11 2014 21:57 Nov 16, 2022 Jkt 039200 PO 00000 Frm 00065 Fmt 6652 Sfmt 6201 E:\BILLS\S5093.IS S5093

kjohnson on DSK79L0C42PROD with BILLS
66 

•S 5093 IS

1 geted audits of not fewer than 10 group health 

2 plans that the Secretaries determine to be the 

3 subject of the greatest number of complaints 

4 about mental health and substance use disorder 

5 network adequacy to ensure compliance with 

6 the requirements of this paragraph. Such audits 

7 shall begin not earlier than one year after the 

8 final regulations implementing this paragraph 

9 begin to apply to group health plans.’’. 

10 (2) DEFINITIONS.—Paragraphs (4) and (5) of 

11 section 9812(e) of the Internal Revenue Code of 

12 1986 are amended to read as follows: 

13 ‘‘(4) MENTAL HEALTH BENEFITS.—The term 

14 ‘mental health benefits’ means benefits with respect 

15 to services related to a mental health condition, de16 fined consistently with generally recognized inde17 pendent standards of current medical practice, such 

18 as the Diagnostic and Statistical Manual of Mental 

19 Disorders of the American Psychiatric Association. 

20 ‘‘(5) SUBSTANCE USE DISORDER BENEFITS.— 

21 The term ‘substance use disorder benefits’ means 

22 benefits with respect to services related to a sub23 stance use disorder, defined consistently with gen24 erally recognized independent standards of current 

25 medical practice, such as the Diagnostic and StatisVerDate Sep 11 2014 21:57 Nov 16, 2022 Jkt 039200 PO 00000 Frm 00066 Fmt 6652 Sfmt 6201 E:\BILLS\S5093.IS S5093

kjohnson on DSK79L0C42PROD with BILLS
67 

•S 5093 IS

1 tical Manual of Mental Disorders of the American 

2 Psychiatric Association.’’. 

3 (3) STANDARDS FOR PARITY IN REIMBURSE4 MENT RATES.—Section 9812(a) of the Internal Rev5 enue Code of 1986, as amended by paragraph (1), 

6 is further amended by adding at the end the fol7 lowing: 

8 ‘‘(10) STANDARDS FOR PARITY IN REIMBURSE9 MENT RATES.— 

10 ‘‘(A) IN GENERAL.—Not later than 2 years 

11 after the date of enactment of the Behavioral 

12 Health Network and Directory Improvement 

13 Act, the Secretary, the Secretary of Health and 

14 Human Services, and the Secretary of Labor 

15 shall issue regulations on a standard for parity 

16 in reimbursement rates for mental health or 

17 substance use disorder benefits and medical and 

18 surgical benefits, based on a comparative anal19 ysis conducted by such Secretaries using data 

20 submitted by group health plans, provider asso21 ciations, and other experts related to the cost of 

22 care delivery for mental health and substance 

23 use disorder benefits. 

24 ‘‘(B) REQUESTS FOR DATA.—Group health 

25 plans shall comply with any request for data 


kjohnson on DSK79L0C42PROD with BILLS
68 

•S 5093 IS

1 issued by the Secretary, the Secretary of Health 

2 and Human Services, and the Secretary of 

3 Labor for purposes of developing the standards 

4 under subparagraph (A). 

5 ‘‘(C) EFFECTIVE DATE.—The regulations 

6 promulgated under subparagraph (A) shall 

7 apply to group health plans beginning in the 

8 first plan year that begins after issuance of the 

9 final regulations.’’. 

10 SEC. 5. STATE AND TRIBAL OMBUDSMAN PROGRAMS RE11 LATING TO MENTAL HEALTH AND SUB12 STANCE USE DISORDER PARITY. 

13 Part C of title XXVII of the Public Health Service 

14 Act (42 U.S.C. 300gg–91 et seq.) is amended— 

15 (1) by redesignating section 2794 (42 U.S.C. 

16 300gg–95) (regarding uniform fraud and abuse re17 ferral format), as added by section 6603 of the Pa18 tient Protection and Affordable Care Act (Public 

19 Law 111–148), as section 2795; and 

20 (2) by adding at the end the following: 

21 ‘‘SEC. 2796. STATE AND TRIBAL OMBUDSMAN PROGRAMS 

22 RELATING TO MENTAL HEALTH AND SUB23 STANCE USE DISORDER PARITY. 

24 ‘‘(a) IN GENERAL.—The Secretary shall make grants 

25 to eligible entities, designated by a State, Indian Tribe, 


kjohnson on DSK79L0C42PROD with BILLS
69 

•S 5093 IS

1 or Tribal organization, as described in subsection (b), for 

2 the purpose of— 

3 ‘‘(1) establishing or supporting State and Trib4 al mental health and substance use disorder parity 

5 ombudsman programs to— 

6 ‘‘(A) educate consumers about the mental 

7 health and substance use disorder coverage in 

8 individual plans, group health plans, self-in9 sured plans, and State Medicaid managed care 

10 plans; 

11 ‘‘(B) assist consumers in understanding 

12 their rights as health benefits plan members, 

13 including appeal processes and how to use such 

14 benefits, and how to access appropriate medical 

15 information; 

16 ‘‘(C) assist consumers in exercising their 

17 rights under the provisions of part D, including 

18 resolving problems related to a group health 

19 plan or health insurance issuer erroneously 

20 charging a consumer out-of-network rates for 

21 services listed in-network on the group health 

22 plan or health insurance issuer’s provider direc23 tory; 

24 ‘‘(D) identify, investigate, and help resolve 

25 complaints related to mental health and subVerDate Sep 11 2014 21:57 Nov 16, 2022 Jkt 039200 PO 00000 Frm 00069 Fmt 6652 Sfmt 6201 E:\BILLS\S5093.IS S5093

kjohnson on DSK79L0C42PROD with BILLS
70 

•S 5093 IS

1 stance use disorder coverage (including poten2 tial violations of the mental health and sub3 stance use disorder parity laws) on behalf of 

4 consumers; 

5 ‘‘(E) maintain a toll-free hotline and 

6 website for consumers; 

7 ‘‘(F) collect, track, and quantify problems 

8 and inquiries encountered by consumers; and 

9 ‘‘(G) other activities as defined by the Sec10 retary; and 

11 ‘‘(2) provide support and training for such 

12 State and Tribal mental health parity ombudsman 

13 programs (such as through the establishment of a 

14 mental health parity ombudsman program resource 

15 center). 

16 ‘‘(b) ELIGIBILITY.—To be eligible to receive a grant 

17 under this section, a State, Indian Tribe, or Tribal organi18 zation shall designate an ombudsman or consumer assist19 ance program or other independent entity that— 

20 ‘‘(1) has specialized knowledge of mental health 

21 conditions and substance use disorders and experi22 ence resolving inquiries and complaints; and 

23 ‘‘(2) directly, or in coordination with depart24 ments of insurance, and consumer assistance organi25 zations, receives and responds to inquiries and comVerDate Sep 11 2014 21:57 Nov 16, 2022 Jkt 039200 PO 00000 Frm 00070 Fmt 6652 Sfmt 6201 E:\BILLS\S5093.IS S5093

kjohnson on DSK79L0C42PROD with BILLS
71 

•S 5093 IS

1 plaints concerning access to mental health and sub2 stance use disorder services. 

3 ‘‘(c) CRITERIA.—A State, Indian Tribe, or Tribal or4 ganization that receives a grant under this section shall 

5 comply with criteria established by the Secretary for car6 rying out activities under such grant. 

7 ‘‘(d) DATA COLLECTION.—As a condition of receiving 

8 a grant, an eligible entity shall agree to— 

9 ‘‘(1) collect and report data to the Secretary, 

10 State legislature, and relevant State agencies, in11 cluding the departments of insurance and the State 

12 attorney general, on the numbers and types of prob13 lems and inquiries encountered by individuals with 

14 respect to access to behavioral health services; and 

15 ‘‘(2) report to the Secretary on how identified 

16 problems were addressed, including through prom17 ising practices related to responding to mental 

18 health and substance use disorder coverage issues, 

19 including appeals and education. 

20 ‘‘(e) REPORT TO CONGRESS.—Not later than 4 years 

21 after the date of the enactment of the Behavioral Health 

22 Network and Directory Improvement Act, the Secretary 

23 shall submit to Congress a report on the data collected 

24 under subsection. 


kjohnson on DSK79L0C42PROD with BILLS
72 

•S 5093 IS

1 ‘‘(f) DEFINITIONS.—In this section, the terms ‘In2 dian Tribe’ and ‘Tribal organization’ have the meanings 

3 given such terms in section 4 of the Indian Self-Deter4 mination and Education Assistance Act. 

5 ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—To 

6 carry out this section, there are authorized to be appro7 priated $20,000,000 for fiscal year 2024 and $10,000,000 

8 for fiscal year 2025 and each fiscal year thereafter.’’. 

9 SEC. 6. REPORT TO CONGRESS. 

10 (a) IN GENERAL.—Not later than 6 years after the 

11 date of enactment of this Act and every 2 years for the 

12 next 10 years, the Secretary of Health and Human Serv13 ices, the Secretary of Labor, and the Secretary of the 

14 Treasury (collectively referred to in this section as the 

15 ‘‘Secretaries’’) shall jointly submit to Congress and make 

16 publicly available a report to assess the prevalence of ghost 

17 networks and the adequacy of mental health and sub18 stance use disorder networks, in accordance with section 

19 2726(a)(9) of the Public Health Service Act, section 

20 712(a)(9) of the Employee Retirement Income Security 

21 Act of 1974, and section 9812(a)(9) of the Internal Rev22 enue Code of 1986, as amended by section 4. Such report 

23 shall include the following: 

24 (1) Aggregate information about group health 

25 plans and health insurance issuers determined by 


kjohnson on DSK79L0C42PROD with BILLS
73 

•S 5093 IS

1 the Secretaries to be out of compliance with the pro2 vider directory requirements under section 2799A–5 

3 of the Public Health Service Act, section 720 of the 

4 Employee Retirement Income Security Act of 1974, 

5 and section 9820 of the Internal Revenue Code of 

6 1986, as amended by section 2. 

7 (2) Aggregate information about group health 

8 plans and health insurance issuers determined by 

9 the Secretaries to be out of compliance with the re10 quirements for parity in mental health and sub11 stance use disorder benefits under section 2726 of 

12 the Public Health Service Act (42 U.S.C. 300gg– 

13 26), section 712 of the Employee Retirement Income 

14 Security Act of 1974 (29 U.S.C. 1185a), and section 

15 9812 of the Internal Revenue Code of 1986, as 

16 amended by section 4. 

17 (3) A summary of findings through audits, in 

18 the aggregate, under section 2799A–5(a)(7)(C) of 

19 the Public Health Service Act, section 720(a)(7)(C) 

20 of the Employee Retirement Income Security Act of 

21 1974, and section 9820(a)(7)(C) of the Internal 

22 Revenue Code of 1986, as amended by section 2, in23 cluding— 

24 (A) the provider directory accuracy rating 

25 assigned by the Secretaries; 


kjohnson on DSK79L0C42PROD with BILLS
74 

•S 5093 IS

1 (B) the accuracy of provider directory in2 formation, sectioned out by accuracy of the pro3 vider’s name, address, specialty, telephone num4 ber, digital contact information, whether the 

5 providers are accepting new patients, in-net6 work status, linguistic- and cultural-com7 petency, and availability of medications for 

8 opioid use disorder; 

9 (C) the number of plans and individuals 

10 enrolled in a group health plan or group or in11 dividual health insurance coverage that offers a 

12 mental health and substance use disorder net13 work that meets the network adequacy stand14 ards under, as applicable, section 2799A–5 of 

15 the Public Health Service Act, section 720 of 

16 the Employee Retirement Income Security Act 

17 of 1974, or section 9820 of the Internal Rev18 enue Code of 1986, as amended by section 2; 

19 and 

20 (D) the number of individuals enrolled in 

21 a group health plan or group or individual 

22 health insurance coverage with a ghost network. 

23 (4) A comparative analysis of in-network and 

24 out-of-network reimbursement rates for mental 

25 health and substance use disorder services compared 


kjohnson on DSK79L0C42PROD with BILLS
75 

•S 5093 IS

1 to medical and surgical services by group health 

2 plans and health insurance issuers. 

3 (b) DEFINITION.—In this section, the term ‘‘ghost 

4 network’’ has the meaning given such term in section 

5 2799A–5(a)(8) of the Public Health Service Act, section 

6 720(a)(8) of the Employee Retirement Income Security 

7 Act of 1974, and section 9820(a)(8) of the Internal Rev8 enue Code of 1986, as amended by section 2. 

9 SEC. 7. AUTHORIZATION OF APPROPRIATIONS. 

10 To carry out this Act, including the amendments 

11 made by this Act, in addition to amounts otherwise made 

12 available for such purposes, there are authorized to be ap13 propriated $28,000,000 for each of fiscal years 2023 

14 through 2032. 

Æ 


kjohnson on DSK79L0C42PROD with BILLS