IB 

Union Calendar No. 587 

116TH CONGRESS 

2D SESSION H. R. 2328 

[Report No. 116–332, Part I] 

To reauthorize and extend funding for community health centers and the 

National Health Service Corps. 

IN THE HOUSE OF REPRESENTATIVES 

APRIL 15, 2019 

Mr. O’HALLERAN (for himself and Ms. STEFANIK) introduced the following 

bill; which was referred to the Committee on Energy and Commerce 

DECEMBER 9, 2019 

Reported with amendments and referred to the Committee on Transportation 

and Infrastructure for a period ending not later than January 29, 2020, 

for consideration of such provisions of the bill as fall within the jurisdiction of that committee pursuant to clause 1(r) of rule X 

[Strike out all after the enacting clause and insert the part printed in italic] 

JANUARY 29, 2020 

Referral to the Committee on Transportation and Infrastructure extended for 

a period ending not later than February 19, 2020 

FEBRUARY 19, 2020 

Referral to the Committee on Transportation and Infrastructure extended for 

a period ending not later than April 23, 2020 

APRIL 23, 2020 

Referral to the Committee on Transportation and Infrastructure extended for 

a period ending not later than July 31, 2020 

JULY 31, 2020 

Referral to the Committee on Transportation and Infrastructure extended for 

a period ending not later than September 21, 2020 


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SEPTEMBER 21, 2020 

Referral to the Committee on Transportation and Infrastructure extended for 

a period ending not later than November 20, 2020 

NOVEMBER 17, 2020 

Referral to the Committee on Transportation and Infrastructure extended for 

a period ending not later than December 31, 2020 

DECEMBER 31, 2020 

Additional sponsors: Mr. SWALWELL of California, Mr. ESPAILLAT, Ms. 

GABBARD, Ms. OMAR, Ms. MCCOLLUM, Mr. SMITH of Washington, Mr. 

KHANNA, Mr. COHEN, Mr. GRIJALVA, Mr. COURTNEY, Mrs. HARTZLER, 

Ms. MUCARSEL-POWELL, Ms. JAYAPAL, Ms. KUSTER of New Hampshire, 

Mrs. DAVIS of California, Mr. RUSH, Mr. LIPINSKI, Mr. ENGEL, Mr. 

SCHIFF, Mr. CICILLINE, Mr. SERRANO, Mr. LARSEN of Washington, Mr. 

KRISHNAMOORTHI, Mr. PETERS, Ms. LEE of California, Mr. KILMER, 

Mr. SCHRADER, Mr. TURNER, Mr. KING of New York, Mr. YARMUTH, 

Mr. VELA, Mr. HECK, Mr. LAMALFA, Mr. YOUNG, Mr. DELGADO, Mr. 

TIPTON, Ms. JOHNSON of Texas, Mr. HASTINGS, Mr. SIRES, Ms. BLUNT

ROCHESTER, Mr. BERGMAN, Mrs. WATSON COLEMAN, Mr. JOHNSON of 

Georgia, Mr. COLE, Mr. GOMEZ, Ms. KELLY of Illinois, Miss RICE of 

New York, Mr. ZELDIN, Mr. NEWHOUSE, Mr. RODNEY DAVIS of Illinois, 

Ms. CLARKE of New York, Mr. DEFAZIO, Mr. NADLER, Mr. MEEKS, Mr. 

STIVERS, Mrs. CAROLYN B. MALONEY of New York, Mr. ROSE of New 

York, Mr. LAMBORN, Mr. BALDERSON, Mr. FLEISCHMANN, Mr. 

GALLEGO, Ms. SCHAKOWSKY, Mr. WELCH, Mrs. LOWEY, Ms. OCASIOCORTEZ, Mr. SEAN PATRICK MALONEY of New York, Ms. BASS, Mr. 

NORMAN, Mr. TAKANO, Mr. LUJA ́N, Mr. RASKIN, Ms. JUDY CHU of California, Mr. LEVIN of Michigan, Mrs. DINGELL, Ms. PINGREE, Mr. TED

LIEU of California, Ms. TORRES SMALL of New Mexico, Mr. 

DESAULNIER, Mr. KATKO, Mr. SABLAN, Ms. ROYBAL-ALLARD, Mr. 

BISHOP of Utah, Mr. GRIFFITH, Mrs. RADEWAGEN, Mr. BOST, Mr. WALDEN, Mr. STANTON, Mr. CORREA, Ms. LOFGREN, Mr. CURTIS, Mr. 

LOWENTHAL, Ms. SLOTKIN, Ms. FINKENAUER, Mr. FOSTER, Mr. LANGEVIN, Mrs. BUSTOS, Ms. KAPTUR, Mr. STEWART, Mr. HUFFMAN, Mr. 

SCHNEIDER, Mr. MCADAMS, Ms. VELA ́ZQUEZ, Ms. JACKSON LEE, Mr. 

SOTO, Mr. COOPER, Mr. AUSTIN SCOTT of Georgia, Ms. UNDERWOOD, 

Mr. BRINDISI, Mr. STAUBER, Mr. CLEAVER, Mr. PETERSON, Mr. 

MCNERNEY, Mr. KEATING, Ms. SPANBERGER, Mr. PERLMUTTER, Mr. 

AGUILAR, Mr. COX of California, Mr. HARDER of California, Ms. 

KENDRA S. HORN of Oklahoma, Mr. PRICE of North Carolina, Mrs. MILLER, Mr. VAN DREW, Mr. FITZPATRICK, Mr. CISNEROS, Mr. LARSON of 

Connecticut, Mrs. DEMINGS, and Mrs. HAYES


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DECEMBER 31, 2020 

Committee on Transportation and Infrastructure discharged; committed to the 

Committee of the Whole House on the State of the Union and ordered 

to be printed 

[For text of introduced bill, see copy of bill as introduced on April 15, 2019] 


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A BILL 

To reauthorize and extend funding for community health 

centers and the National Health Service Corps. 


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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; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the ‘‘Re5 authorizing and Extending America’s Community Health 

6 Act’’ or the ‘‘REACH Act’’. 

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

8 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—PUBLIC HEALTH EXTENDERS 

Sec. 101. Extension for community health centers, the National Health Service 

Corps, and teaching health centers that operate GME programs. 

Sec. 102. Extension for special diabetes programs. 

Sec. 103. Extension of Personal Responsibility Education Program. 

Sec. 104. Extension of sexual risk avoidance education program. 

TITLE II—MEDICARE EXTENDERS 

Sec. 201. Extension of the work geographic index floor under the Medicare program. 

Sec. 202. Extension of funding outreach and assistance for low-income programs. 

Sec. 203. Extension of funding for quality measure endorsement, input, and selection under the Medicare program. 

Sec. 204. Extension of the Independence at Home Medical Practice Demonstration Program under the Medicare program. 

Sec. 205. Extension of appropriations and transfers to the Patient-Centered Outcomes Research Trust Fund; extension of certain health insurance fees. 

Sec. 206. Transitional coverage and retroactive Medicare part D coverage for certain low-income beneficiaries. 

Sec. 207. Health Equity and Access for Returning Troops and Servicemembers 

Act of 2019. 

Sec. 208. Exclusion of complex rehabilitative manual wheelchairs from Medicare 

competitive acquisition program; Non-application of Medicare 

fee-schedule adjustments for certain wheelchair accessories and 

cushions. 

TITLE III—MEDICAID PROVISIONS 

Sec. 301. Modification of reductions in Medicaid DSH allotments. 

Sec. 302. Public availability of hospital upper payment limit demonstrations. 

Sec. 303. Report by Comptroller General. 

Sec. 304. Sense of Congress regarding the need to develop a more permanent legislative solution to provide the territories with a reliable and consistent source of Federal funding under the Medicaid program. 


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TITLE IV—NO SURPRISES ACT 

Sec. 401. Short title. 

Sec. 402. Preventing surprise medical bills. 

Sec. 403. Government Accountability Office study on profit- and revenue-sharing 

in health care. 

Sec. 404. State All Payer Claims Databases. 

Sec. 405. Air ambulance cost data reporting program. 

Sec. 406. Report by Secretary of Labor. 

Sec. 407. Billing statute of limitations. 

Sec. 408. GAO report on impact of surprise billing provisions. 

Sec. 409. Report by the Secretary of Health and Human Services. 

TITLE V—TERRITORIES HEALTH CARE IMPROVEMENT ACT 

Sec. 501. Short title. 

Sec. 502. Medicaid payments for Puerto Rico and the other territories for certain 

fiscal years. 

Sec. 503. Application of certain requirements under Medicaid program to certain 

territories. 

Sec. 504. Additional program integrity requirements. 

1 TITLE I—PUBLIC HEALTH 

2 EXTENDERS 

3 SEC. 101. EXTENSION FOR COMMUNITY HEALTH CENTERS, 

4 THE NATIONAL HEALTH SERVICE CORPS, AND 

5 TEACHING HEALTH CENTERS THAT OPERATE 

6 GME PROGRAMS. 

7 (a) COMMUNITY HEALTH CENTERS.—Section 

8 10503(b)(1)(F) of the Patient Protection and Affordable 

9 Care Act (42 U.S.C. 254b–2(b)(1)(F)) is amended by strik10 ing ‘‘fiscal year 2019’’ and inserting ‘‘each of fiscal years 

11 2019 through 2023’’. 

12 (b) NATIONAL HEALTH SERVICE CORPS.—Section 

13 10503(b)(2)(F) of the Patient Protection and Affordable 

14 Care Act (42 U.S.C. 254b–2(b)(2)(F)) is amended by strik15 ing ‘‘2018 and 2019’’ and inserting ‘‘2019 through 2023’’. 


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1 (c) TEACHING HEALTH CENTERS THAT OPERATE

2 GRADUATE MEDICAL EDUCATION PROGRAMS.—Section 

3 340H(g)(1) of the Public Health Service Act (42 U.S.C. 

4 256h(g)(1)) is amended by striking ‘‘2018 and 2019’’ and 

5 inserting ‘‘2019 through 2023’’. 

6 (d) APPLICATION.—Amounts appropriated for a pro7 gram pursuant to the amendments made by subsection (a), 

8 (b), or (c) for fiscal years 2020 through 2023 are subject 

9 to the requirements and limitations of the most recently en10 acted regular or full-year continuing appropriations Act or 

11 resolution (as of the date of obligation of current funds) ap12 plicable to the respective program. 

13 SEC. 102. EXTENSION FOR SPECIAL DIABETES PROGRAMS. 

14 (a) REAUTHORIZATION OF SPECIAL DIABETES PRO15 GRAMS FOR TYPE I DIABETES.—Section 330B(b)(2)(D) of 

16 the Public Health Service Act (42 U.S.C. 254c–2(b)(2)(D)) 

17 is amended by striking ‘‘each of fiscal years 2018 and 2019’’ 

18 and inserting ‘‘fiscal years 2019 through 2023’’. 

19 (b) REAUTHORIZATION OF SPECIAL DIABETES PRO20 GRAMS FOR INDIANS FOR DIABETES SERVICES.—Section 

21 330C(c)(2)(D) of the Public Health Service Act (42 U.S.C. 

22 254c–3(c)(2)(D)) is amended by striking ‘‘fiscal years 2018 

23 and 2019’’ and inserting ‘‘fiscal years 2019 through 2023’’. 


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1 SEC. 103. EXTENSION OF PERSONAL RESPONSIBILITY EDU2 CATION PROGRAM. 

3 Section 513 of the Social Security Act (42 U.S.C. 713) 

4 is amended— 

5 (1) in paragraphs (1)(A) and (4)(A) of sub6 section (a), by striking ‘‘2019’’ and inserting ‘‘2023’’ 

7 each place it appears; 

8 (2) in subsection (a)(4)(B)(i), by striking ‘‘2019’’ 

9 and inserting ‘‘2023’’; and 

10 (3) in subsection (f), by striking ‘‘2019’’ and in11 serting ‘‘2023’’. 

12 SEC. 104. EXTENSION OF SEXUAL RISK AVOIDANCE EDU13 CATION PROGRAM. 

14 Section 510 of the Social Security Act (42 U.S.C. 710) 

15 is amended by striking ‘‘fiscal years 2018 and 2019’’ each 

16 place it appears in subsections (a)(1), (a)(2)(A), (f)(1) and 

17 (f)(2) and inserting ‘‘fiscal years 2019 through 2023’’. 

18 TITLE II—MEDICARE 

19 EXTENDERS 

20 SEC. 201. EXTENSION OF THE WORK GEOGRAPHIC INDEX 

21 FLOOR UNDER THE MEDICARE PROGRAM. 

22 Section 1848(e)(1)(E) of the Social Security Act (42 

23 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘2020’’ 

24 and inserting ‘‘2023’’. 


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1 SEC. 202. EXTENSION OF FUNDING OUTREACH AND ASSIST2 ANCE FOR LOW-INCOME PROGRAMS. 

3 (a) ADDITIONAL FUNDING FOR STATE HEALTH INSUR4 ANCE PROGRAMS.—Subsection (a)(1)(B) of section 119 of 

5 the Medicare Improvements for Patients and Providers Act 

6 of 2008 (42 U.S.C. 1395b–3 note), as amended by section 

7 3306 of the Patient Protection and Affordable Care Act 

8 (Public Law 111–148), section 610 of the American Tax9 payer Relief Act of 2012 (Public Law 112–240), section 

10 1110 of the Pathway for SGR Reform Act of 2013 (Public 

11 Law 113–67), section 110 of the Protecting Access to Medi12 care Act of 2014 (Public Law 113–93), section 208 of the 

13 Medicare Access and CHIP Reauthorization Act of 2015 

14 (Public Law 114–10), and section 50207 of the Bipartisan 

15 Budget Act of 2018 (Public Law 115–123), is amended— 

16 (1) in clause (vii), by striking ‘‘and’’ at the end; 

17 (2) in clause (viii), by striking ‘‘and’’ at the end; 

18 (3) in clause (ix), by striking the period at the 

19 end and inserting ‘‘; and’’; and 

20 (4) by inserting after clause (ix) the following 

21 new clause: 

22 ‘‘(x) for each of fiscal years 2020 

23 through 2022, of $15,000,000.’’. 

24 (b) ADDITIONAL FUNDING FOR AREA AGENCIES ON

25 AGING.—Subsection (b)(1)(B) of such section 119, as so 

26 amended, is amended— 


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1 (1) in clause (vii), by striking ‘‘and’’ at the end; 

2 (2) in clause (viii), by striking ‘‘and’’ at the end; 

3 (3) in clause (ix), by striking the period at the 

4 end and inserting ‘‘; and’’; and 

5 (4) by inserting after clause (ix) the following 

6 new clause: 

7 ‘‘(x) for each of fiscal years 2020 

8 through 2022, of $15,000,000.’’. 

9 (c) ADDITIONAL FUNDING FOR AGING AND DISABILITY

10 RESOURCE CENTERS.—Subsection (c)(1)(B) of such section 

11 119, as so amended, is amended— 

12 (1) in clause (vii), by striking ‘‘and’’ at the end; 

13 (2) in clause (viii), by striking ‘‘and’’ at the end; 

14 (3) in clause (ix), by striking the period at the 

15 end and inserting ‘‘; and’’; and 

16 (4) by inserting after clause (ix) the following 

17 new clause: 

18 ‘‘(x) for each of fiscal years 2020 

19 through 2022, of $5,000,000.’’. 

20 (d) ADDITIONAL FUNDING FOR CONTRACT WITH THE

21 NATIONAL CENTER FOR BENEFITS AND OUTREACH EN22 ROLLMENT.—Subsection (d)(2) of such section 119, as so 

23 amended, is amended— 

24 (1) in clause (vii), by striking ‘‘and’’ at the end; 

25 (2) in clause (viii), by striking ‘‘and’’ at the end; 


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1 (3) in clause (ix), by striking the period at the 

2 end and inserting ‘‘; and’’; and 

3 (4) by inserting after clause (ix) the following 

4 new clause: 

5 ‘‘(x) for each of fiscal years 2020 

6 through 2022, of $15,000,000.’’. 

7 SEC. 203. EXTENSION OF FUNDING FOR QUALITY MEASURE 

8 ENDORSEMENT, INPUT, AND SELECTION 

9 UNDER THE MEDICARE PROGRAM. 

10 (a) IN GENERAL.—Section 1890(d)(2) of the Social Se11 curity Act (42 U.S.C. 1395aaa(d)(2)) is amended— 

12 (1) by striking ‘‘and $7,500,000’’ and inserting 

13 ‘‘$7,500,000’’; and 

14 (2) by striking ‘‘and 2019.’’ and inserting ‘‘and 

15 2019, and $30,000,000 for each of fiscal years 2020 

16 through 2022.’’. 

17 (b) INPUT FOR REMOVAL OF MEASURES.—Section 

18 1890(b) of the Social Security Act (42 U.S.C. 1395aaa(b)) 

19 is amended by inserting after paragraph (3) the following: 

20 ‘‘(4) REMOVAL OF MEASURES.—The entity may, 

21 through the multistakeholder groups convened under 

22 paragraph (7)(A), provide input to the Secretary on 

23 quality and efficiency measures described in para24 graph (7)(B) that could be considered for removal.’’. 


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1 (c) PRIORITIZATION OF MEASURE ENDORSEMENT.— 

2 Section 1890(b) of the Social Security Act (42 U.S.C. 

3 1395aaa(b)), as amended by subsection (b), is further 

4 amended by adding at the end the following: 

5 ‘‘(9) PRIORITIZATION OF MEASURE ENDORSE6 MENT.—The entity— 

7 ‘‘(A) during the period beginning on the 

8 date of the enactment of this paragraph and end9 ing on December 31, 2023, shall prioritize the 

10 endorsement of measures relating to maternal 

11 morbidity and mortality by the entity with a 

12 contract under subsection (a) in connection with 

13 endorsement of measures described in paragraph 

14 (2); and 

15 ‘‘(B) on and after January 1, 2024, may 

16 prioritize the endorsement of such measures by 

17 such entity.’’. 

18 SEC. 204. EXTENSION OF THE INDEPENDENCE AT HOME 

19 MEDICAL PRACTICE DEMONSTRATION PRO20 GRAM UNDER THE MEDICARE PROGRAM. 

21 (a) IN GENERAL.—Section 1866E(e)(1) of the Social 

22 Security Act (42 U.S.C. 1395cc–5(e)(1)) is amended by 

23 striking ‘‘7-year’’ and inserting ‘‘10-year’’. 


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1 (b) EFFECTIVE DATE.—The amendment made by sub2 section (a) shall take effect as if included in the enactment 

3 of Public Law 111–148. 

4 SEC. 205. EXTENSION OF APPROPRIATIONS AND TRANS5 FERS TO THE PATIENT-CENTERED OUTCOMES 

6 RESEARCH TRUST FUND; EXTENSION OF CER7 TAIN HEALTH INSURANCE FEES. 

8 (a) IN GENERAL.— 

9 (1) INTERNAL REVENUE CODE.—Section 9511 of 

10 the Internal Revenue Code of 1986 is amended— 

11 (A) in subsection (b)(1)(E), by striking 

12 ‘‘2014’’ and all that follows through ‘‘2019’’ and 

13 inserting ‘‘2014 through 2022’’; 

14 (B) in subsection (d)(2)(A), by striking 

15 ‘‘2019’’ and inserting ‘‘2022’’; and 

16 (C) in subsection (f), by striking ‘‘2019’’ 

17 and inserting ‘‘2022’’. 

18 (2) TITLE XI.—Section 1183(a)(2) of the Social 

19 Security Act (42 U.S.C. 1320e–2(a)(2)) is amended 

20 by striking ‘‘2014’’ and all that follows through 

21 ‘‘2019’’ and inserting ‘‘2014 through 2022’’. 

22 (b) EXTENSION OF CERTAIN HEALTH INSURANCE

23 FEES.— 


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1 (1) HEALTH INSURANCE POLICIES.—Section 

2 4375(e) of the Internal Revenue Code of 1986 is 

3 amended by striking ‘‘2019’’ and inserting ‘‘2022’’. 

4 (2) SELF-INSURED HEALTH PLANS.—Section 

5 4376(e) of the Internal Revenue Code of 1986 is 

6 amended by striking ‘‘2019’’ and inserting ‘‘2022’’. 

7 SEC. 206. TRANSITIONAL COVERAGE AND RETROACTIVE 

8 MEDICARE PART D COVERAGE FOR CERTAIN 

9 LOW-INCOME BENEFICIARIES. 

10 Section 1860D–14 of the Social Security Act (42 

11 U.S.C. 1395w–114) is amended— 

12 (1) by redesignating subsection (e) as subsection 

13 (f); and 

14 (2) by adding after subsection (d) the following 

15 new subsection: 

16 ‘‘(e) LIMITED INCOME NEWLY ELIGIBLE TRANSITION

17 PROGRAM.— 

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

19 January 1, 2021, the Secretary shall carry out a pro20 gram to provide transitional coverage for covered part 

21 D drugs for LI NET eligible individuals in accord22 ance with this subsection. 

23 ‘‘(2) LI NET ELIGIBLE INDIVIDUAL DEFINED.— 

24 For purposes of this subsection, the term ‘LI NET eliVerDate Sep 11 2014 21:36 Dec 31, 2020 Jkt 019200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6203 E:\BILLS\H2328.RH H2328

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1 gible individual’ means a part D eligible individual 

2 who— 

3 ‘‘(A) meets the requirements of clauses (ii) 

4 and (iii) of subsection (a)(3)(A); and 

5 ‘‘(B) has not yet enrolled in a prescription 

6 drug plan or an MA–PD plan, or, who has so 

7 enrolled, but with respect to whom coverage 

8 under such plan has not yet taken effect. 

9 ‘‘(3) TRANSITIONAL COVERAGE.—For purposes of 

10 this subsection, the term ‘transitional coverage’ 

11 means, with respect to an LI NET eligible indi12 vidual— 

13 ‘‘(A) immediate access to covered part D 

14 drugs at the point of sale during the period that 

15 begins on the first day of the month such indi16 vidual is determined to meet the requirements of 

17 clauses (ii) and (iii) of subsection (a)(3)(A) and 

18 ends on the date that coverage under a prescrip19 tion drug plan or MA–PD plan takes effect with 

20 respect to such individual; and 

21 ‘‘(B) in the case of an LI NET eligible indi22 vidual who is a full-benefit dual eligible indi23 vidual (as defined in section 1935(c)(6)) or a re24 cipient of supplemental security income benefits 

25 under title XVI, retroactive coverage (in the form 


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1 of reimbursement of the amounts that would 

2 have been paid under this part had such indi3 vidual been enrolled in a prescription drug plan 

4 or MA–PD plan) of covered part D drugs pur5 chased by such individual during the period that 

6 begins on the date that is the later of— 

7 ‘‘(i) the date that such individual was 

8 first eligible for a low-income subsidy under 

9 this part; or 

10 ‘‘(ii) the date that is 36 months prior 

11 to the date such individual enrolls in a pre12 scription drug plan or MA–PD plan, 

13 and ends on the date that coverage under such 

14 plan takes effect. 

15 ‘‘(4) PROGRAM ADMINISTRATION.— 

16 ‘‘(A) SINGLE POINT OF CONTACT.—The Sec17 retary shall, to the extent feasible, administer the 

18 program under this subsection through a con19 tract with a single program administrator. 

20 ‘‘(B) BENEFIT DESIGN.—The Secretary 

21 shall ensure that the transitional coverage pro22 vided to LI NET eligible individuals under this 

23 subsection— 

24 ‘‘(i) provides access to all covered part 

25 D drugs under an open formulary; 


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1 ‘‘(ii) permits all pharmacies deter2 mined by the Secretary to be in good stand3 ing to process claims under the program; 

4 ‘‘(iii) is consistent with such require5 ments as the Secretary considers necessary 

6 to improve patient safety and ensure appro7 priate dispensing of medication; and 

8 ‘‘(iv) meets such other requirements as 

9 the Secretary may establish. 

10 ‘‘(5) RELATIONSHIP TO OTHER PROVISIONS OF

11 THIS TITLE; WAIVER AUTHORITY.— 

12 ‘‘(A) IN GENERAL.—The following provi13 sions shall not apply with respect to the program 

14 under this subsection: 

15 ‘‘(i) Paragraphs (1) and (3)(B) of sec16 tion 1860D–4(a) (relating to dissemination 

17 of general information; availability of infor18 mation on changes in formulary through 

19 the internet). 

20 ‘‘(ii) Subparagraphs (A) and (B) of 

21 section 1860D–4(b)(3) (relating to require22 ments on development and application of 

23 formularies; formulary development). 


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1 ‘‘(iii) Paragraphs (1)(C) and (2) of 

2 section 1860D–4(c) (relating to medication 

3 therapy management program). 

4 ‘‘(B) WAIVER AUTHORITY.—The Secretary 

5 may waive such other requirements of titles XI 

6 and this title as may be necessary to carry out 

7 the purposes of the program established under 

8 this subsection.’’. 

9 SEC. 207. HEALTH EQUITY AND ACCESS FOR RETURNING 

10 TROOPS AND SERVICEMEMBERS ACT OF 2019. 

11 (a) MODIFICATION OF REQUIREMENT FOR CERTAIN

12 FORMER MEMBERS OF THE ARMED FORCES TO ENROLL

13 IN MEDICARE PART B TO BE ELIGIBLE FOR TRICARE 

14 FOR LIFE.— 

15 (1) TRICARE ELIGIBILITY.— 

16 (A) IN GENERAL.—Subsection (d) of section 

17 1086 of title 10, United States Code, is amended 

18 by adding at the end the following new para19 graph: 

20 ‘‘(6)(A) The requirement in paragraph (2)(A) to enroll 

21 in the supplementary medical insurance program under 

22 part B of title XVIII of the Social Security Act (42 U.S.C. 

23 1395j et seq.) shall not apply to a person described in sub24 paragraph (B) during any month in which such person is 

25 not entitled to a benefit described in subparagraph (A) of 


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1 section 226(b)(2) of the Social Security Act (42 U.S.C. 

2 426(b)(2)) if such person has received the counseling and 

3 information under subparagraph (C). 

4 ‘‘(B) A person described in this subparagraph is a per5 son— 

6 ‘‘(i) who is under 65 years of age; 

7 ‘‘(ii) who is entitled to hospital insurance bene8 fits under part A of title XVIII of the Social Security 

9 Act pursuant to subparagraph (A) or (C) of section 

10 226(b)(2) of such Act (42 U.S.C. 426(b)(2)); 

11 ‘‘(iii) whose entitlement to a benefit described in 

12 subparagraph (A) of such section has terminated due 

13 to performance of substantial gainful activity; and 

14 ‘‘(iv) who is retired under chapter 61 of this 

15 title. 

16 ‘‘(C) The Secretary of Defense shall coordinate with 

17 the Secretary of Health and Human Services and the Com18 missioner of Social Security to notify persons described in 

19 subparagraph (B) of, and provide information and coun20 seling regarding, the effects of not enrolling in the supple21 mentary medical insurance program under part B of title 

22 XVIII of the Social Security Act (42 U.S.C. 1395j et seq.), 

23 as described in subparagraph (A).’’. 

24 (B) CONFORMING AMENDMENT.—Paragraph 

25 (2)(A) of such subsection is amended by striking 


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1 ‘‘is enrolled’’ and inserting ‘‘except as provided 

2 by paragraph (6), is enrolled’’. 

3 (C) IDENTIFICATION OF PERSONS.—Section 

4 1110a of such title is amended by adding at the 

5 end the following new subsection: 

6 ‘‘(c) CERTAIN INDIVIDUALS NOT REQUIRED TO EN7 ROLL IN MEDICARE PART B.—In carrying out subsection 

8 (a), the Secretary of Defense shall coordinate with the Sec9 retary of Health and Human Services and the Commis10 sioner of Social Security to— 

11 ‘‘(1) identify persons described in subparagraph 

12 (B) of section 1086(d)(6) of this title; and 

13 ‘‘(2) provide information and counseling pursu14 ant to subparagraph (C) of such section.’’. 

15 (2) NON-APPLICATION OF MEDICARE PART B

16 LATE ENROLLMENT PENALTY.—Section 1839(b) of the 

17 Social Security Act (42 U.S.C. 1395r(b)) is amended, 

18 in the second sentence, by inserting ‘‘or months for 

19 which the individual can demonstrate that the indi20 vidual is an individual described in paragraph 

21 (6)(B) of section 1086(d) of title 10, United States 

22 Code, who is enrolled in the TRICARE program pur23 suant to such section’’ after ‘‘an individual described 

24 in section 1837(k)(3)’’. 


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1 (3) REPORT.—Not later than October 1, 2024, 

2 the Secretary of Defense, the Secretary of Health and 

3 Human Services, and the Commissioner of Social Se4 curity shall jointly submit to the Committees on 

5 Armed Services of the House of Representatives and 

6 the Senate, the Committee on Ways and Means and 

7 the Committee on Energy and Commerce of the House 

8 of Representatives, and the Committee on Finance of 

9 the Senate a report on the implementation of section 

10 1086(d)(6) of title 10, United States Code, as added 

11 by paragraph (1). Such report shall include, with re12 spect to the period covered by the report— 

13 (A) the number of individuals enrolled in 

14 TRICARE for Life who are not enrolled in the 

15 supplementary medical insurance program 

16 under part B of title XVIII of the Social Secu17 rity Act (42 U.S.C. 1395j et seq.) by reason of 

18 such section 1086(d)(6); and 

19 (B) the number of individuals who— 

20 (i) are retired from the Armed Forces 

21 under chapter 61 of title 10, United States 

22 Code; 

23 (ii) are entitled to hospital insurance 

24 benefits under part A of title XVIII of the 

25 Social Security Act pursuant to receiving 


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1 benefits for 24 months as described in sub2 paragraph (A) or (C) of section 226(b)(2) of 

3 such Act (42 U.S.C. 426(b)(2)); and 

4 (iii) because of such entitlement, are no 

5 longer enrolled in TRICARE Standard, 

6 TRICARE Prime, TRICARE Extra, or 

7 TRICARE Select under chapter 55 of title 

8 10, United States Code. 

9 (4) DEPOSIT OF SAVINGS INTO MEDICARE IM10 PROVEMENT FUND.—Section 1898(b)(1) of the Social 

11 Security Act (42 U.S.C. 1395iii(b)(1)) is amended by 

12 striking ‘‘during and after fiscal year 2021, $0’’ and 

13 inserting ‘‘during and after fiscal year 2024, 

14 $5,000,000’’. 

15 (5) APPLICATION.—The amendments made by 

16 paragraphs (1) and (2) shall apply with respect to a 

17 person who, on or after October 1, 2023, is a person 

18 described in section 1086(d)(6)(B) of title 10, United 

19 States Code, as added by paragraph (1). 

20 (b) COVERAGE OF CERTAIN DNA SPECIMEN PROVE21 NANCE ASSAY TESTS UNDER MEDICARE.— 

22 (1) BENEFIT.— 

23 (A) COVERAGE.—Section 1861 of the Social 

24 Security Act (42 U.S.C. 1395x) is amended— 

25 (i) in subsection (s)(2)— 


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1 (I) in subparagraph (GG), by 

2 striking ‘‘and’’ at the end; 

3 (II) in subparagraph (HH), by 

4 striking the period and inserting ‘‘; 

5 and’’; and 

6 (III) by adding at the end the fol7 lowing new subparagraph: 

8 ‘‘(II) a prostate cancer DNA Specimen Prove9 nance Assay test (DSPA test) (as defined in sub10 section (kkk));’’; and 

11 (ii) by adding at the end the following 

12 new subsection: 

13 ‘‘(kkk) PROSTATE CANCER DNA SPECIMEN PROVE14 NANCE ASSAY TEST.—The term ‘prostate cancer DNA Spec15 imen Provenance Assay Test’ (DSPA test) means a test 

16 that, after a determination of cancer in one or more pros17 tate biopsy specimens obtained from an individual, assesses 

18 the identity of the DNA in such specimens by comparing 

19 such DNA with the DNA that was separately taken from 

20 such individual at the time of the biopsy.’’. 

21 (B) EXCLUSION FROM COVERAGE.—Section 

22 1862(a)(1) of the Social Security Act (42 U.S.C. 

23 1395y(a)(1)) is amended— 

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

25 ‘‘and’’ at the end; 


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

2 the semicolon at the end and inserting ‘‘, 

3 and’’; and 

4 (iii) by adding at the end the following 

5 new subparagraph: 

6 ‘‘(Q) in the case of a prostate cancer DNA Speci7 men Provenance Assay test (DSPA test) (as defined 

8 in section 1861(kkk)), unless such test is furnished on 

9 or after January 1, 2021, and before January 1, 

10 2026, and such test is ordered by the physician who 

11 furnished the prostate cancer biopsy that obtained the 

12 specimen tested;’’. 

13 (2) PAYMENT AMOUNT AND RELATED REQUIRE14 MENTS.—Section 1834 of the Social Security Act (42 

15 U.S.C. 1395m) is amended by adding at the end the 

16 following new subsection: 

17 ‘‘(x) PROSTATE CANCER DNA SPECIMEN PROVENANCE

18 ASSAY TESTS.— 

19 ‘‘(1) PAYMENT FOR COVERED TESTS.— 

20 ‘‘(A) IN GENERAL.—Subject to subpara21 graph (B), the payment amount for a prostate 

22 cancer DNA Specimen Provenance Assay test 

23 (DSPA test) (as defined in section 1861(kkk)) 

24 shall be $200. Such payment shall be payment 


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1 for all of the specimens obtained from the biopsy 

2 furnished to an individual that are tested. 

3 ‘‘(B) LIMITATION.—Payment for a DSPA 

4 test under subparagraph (A) may only be made 

5 on an assignment-related basis. 

6 ‘‘(C) PROHIBITION ON SEPARATE PAY7 MENT.—No separate payment shall be made for 

8 obtaining DNA that was separately taken from 

9 an individual at the time of a biopsy described 

10 in subparagraph (A). 

11 ‘‘(2) HCPCS CODE AND MODIFIER ASSIGN12 MENT.— 

13 ‘‘(A) IN GENERAL.—The Secretary shall as14 sign one or more HCPCS codes to a prostate 

15 cancer DNA Specimen Provenance Assay test 

16 and may use a modifier to facilitate making 

17 payment under this section for such test. 

18 ‘‘(B) IDENTIFICATION OF DNA MATCH ON

19 CLAIM.—The Secretary shall require an indica20 tion on a claim for a prostate cancer DNA Spec21 imen Provenance Assay test of whether the DNA 

22 of the prostate biopsy specimens match the DNA 

23 of the individual diagnosed with prostate cancer. 

24 Such indication may be made through use of a 


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1 HCPCS code, a modifier, or other means, as de2 termined appropriate by the Secretary. 

3 ‘‘(3) DNA MATCH REVIEW.— 

4 ‘‘(A) IN GENERAL.—The Secretary shall re5 view at least three years of claims under part B 

6 for prostate cancer DNA Specimen Provenance 

7 Assay tests to identify whether the DNA of the 

8 prostate biopsy specimens match the DNA of the 

9 individuals diagnosed with prostate cancer. 

10 ‘‘(B) POSTING ON INTERNET WEBSITE.—Not 

11 later than July 1, 2023, the Secretary shall post 

12 on the internet website of the Centers for Medi13 care & Medicaid Services the findings of the re14 view conducted under subparagraph (A).’’. 

15 (3) COST-SHARING.—Section 1833(a)(1) of the 

16 Social Security Act (42 U.S.C. 1395l(a)(1)) is 

17 amended— 

18 (A) by striking ‘‘and (CC)’’ and inserting 

19 ‘‘(CC)’’; and 

20 (B) by inserting before the semicolon at the 

21 end the following: ‘‘, and (DD) with respect to 

22 a prostate cancer DNA Specimen Provenance 

23 Assay test (DSPA test) (as defined in section 

24 1861(kkk)), the amount paid shall be an amount 

25 equal to 80 percent of the lesser of the actual 


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1 charge for the test or the amount specified under 

2 section 1834(x)’’. 

3 SEC. 208. EXCLUSION OF COMPLEX REHABILITATIVE MAN4 UAL WHEELCHAIRS FROM MEDICARE COM5 PETITIVE ACQUISITION PROGRAM; NON-AP6 PLICATION OF MEDICARE FEE-SCHEDULE AD7 JUSTMENTS FOR CERTAIN WHEELCHAIR AC8 CESSORIES AND CUSHIONS. 

9 (a) EXCLUSION OF COMPLEX REHABILITATIVE MAN10 UAL WHEELCHAIRS FROM COMPETITIVE ACQUISITION PRO11 GRAM.—Section 1847(a)(2)(A) of the Social Security Act 

12 (42 U.S.C. 1395w–3(a)(2)(A)) is amended— 

13 (1) by inserting ‘‘, complex rehabilitative man14 ual wheelchairs (as determined by the Secretary), and 

15 certain manual wheelchairs (identified, as of October 

16 1, 2018, by HCPCS codes E1235, E1236, E1237, 

17 E1238, and K0008 or any successor to such codes)’’ 

18 after ‘‘group 3 or higher’’; and 

19 (2) by striking ‘‘such wheelchairs’’ and inserting 

20 ‘‘such complex rehabilitative power wheelchairs, com21 plex rehabilitative manual wheelchairs, and certain 

22 manual wheelchairs’’. 

23 (b) NON-APPLICATION OF MEDICARE FEE SCHEDULE

24 ADJUSTMENTS FOR WHEELCHAIR ACCESSORIES AND SEAT

25 AND BACK CUSHIONS WHEN FURNISHED IN CONNECTION


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1 WITH COMPLEX REHABILITATIVE MANUAL WHEEL2 CHAIRS.— 

3 (1) IN GENERAL.—Notwithstanding any other 

4 provision of law, the Secretary of Health and Human 

5 Services shall not, during the period beginning on 

6 January 1, 2020, and ending on December 31, 2020, 

7 use information on the payment determined under the 

8 competitive acquisition programs under section 1847 

9 of the Social Security Act (42 U.S.C. 1395w–3) to ad10 just the payment amount that would otherwise be rec11 ognized under section 1834(a)(1)(B)(ii) of such Act 

12 (42 U.S.C. 1395m(a)(1)(B)(ii)) for wheelchair acces13 sories (including seating systems) and seat and back 

14 cushions when furnished in connection with complex 

15 rehabilitative manual wheelchairs (as determined by 

16 the Secretary), and certain manual wheelchairs (iden17 tified, as of October 1, 2018, by HCPCS codes E1235, 

18 E1236, E1237, E1238, and K0008 or any successor 

19 to such codes). 

20 (2) IMPLEMENTATION.—Notwithstanding any 

21 other provision of law, the Secretary may implement 

22 this subsection by program instruction or otherwise. 


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1 TITLE III—MEDICAID 

2 PROVISIONS 

3 SEC. 301. MODIFICATION OF REDUCTIONS IN MEDICAID 

4 DSH ALLOTMENTS. 

5 Section 1923(f)(7)(A) of the Social Security Act (42 

6 U.S.C. 1396r–4(f)(7)(A)) is amended— 

7 (1) in clause (i), in the matter preceding sub8 clause (I), by striking ‘‘2020’’ and inserting ‘‘2022’’; 

9 and 

10 (2) in clause (ii)— 

11 (A) in subclause (I), by striking ‘‘2020’’ 

12 and inserting ‘‘2022’’; and 

13 (B) in subclause (II), by striking ‘‘for each 

14 of fiscal years 2021 through 2025’’ and inserting 

15 ‘‘for each of fiscal years 2023 through 2025’’. 

16 SEC. 302. PUBLIC AVAILABILITY OF HOSPITAL UPPER PAY17 MENT LIMIT DEMONSTRATIONS. 

18 Section 1903 of the Social Security Act (42 U.S.C. 

19 1396b) is amended by adding at the end the following new 

20 subsection: 

21 ‘‘(bb) PUBLIC AVAILABILITY OF HOSPITAL UPPER

22 PAYMENT LIMIT DEMONSTRATIONS.—The Secretary shall 

23 make publicly available upper payment limit demonstra24 tions for hospital services that a State submits with respect 

25 to a fiscal year of the State (beginning with State fiscal 


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1 year 2022) to the Administrator of the Centers for Medicare 

2 & Medicaid Services.’’. 

3 SEC. 303. REPORT BY COMPTROLLER GENERAL. 

4 Not later than the date that is 21 months after the 

5 date of the enactment of this Act, the Comptroller General 

6 of the United States shall identify and report to Congress 

7 policy considerations for legislative action with respect to 

8 establishing an equitable formula for determining dis9 proportionate share hospital allotments for States under 

10 section 1923 of the Social Security Act (42 U.S.C. 1396r– 

11 4) that takes into account the following factors: 

12 (1) The level of uncompensated care costs of hos13 pitals in a State. 

14 (2) Expenditures of a State with respect to hos15 pitals, including payment adjustments made under 

16 such section 1923 to disproportionate share hospitals 

17 (as defined under the State plan under title XIX of 

18 such Act (42 U.S.C. 1396 et seq.) pursuant to sub19 section (a)(1)(A) of such section 1923), upper pay20 ment limit supplemental payments, and other related 

21 payments that hospitals may receive from the State. 

22 (3) State policy decisions that may affect the 

23 level of uncompensated care costs of hospitals in a 

24 State. 


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1 SEC. 304. SENSE OF CONGRESS REGARDING THE NEED TO 

2 DEVELOP A MORE PERMANENT LEGISLATIVE 

3 SOLUTION TO PROVIDE THE TERRITORIES 

4 WITH A RELIABLE AND CONSISTENT SOURCE 

5 OF FEDERAL FUNDING UNDER THE MEDICAID 

6 PROGRAM. 

7 It is the sense of Congress that— 

8 (1) the territories of American Samoa, the Com9 monwealth of the Northern Mariana Islands, Guam, 

10 Puerto Rico, and the United States Virgin Islands are 

11 currently subject to Federal funding caps for their 

12 Medicaid programs; 

13 (2) as a result of these Federal funding caps, 

14 which have not been adjusted over time, the territories 

15 continue to struggle in managing their Medicaid pro16 grams, including planning for their respective finan17 cial obligations and managing health care services for 

18 low-income adults, children, pregnant women, elderly 

19 adults, and persons with disabilities; 

20 (3) to address this disparate funding treatment 

21 and to provide the territories with some measure of 

22 relief, Congress has had to enact legislation six times 

23 in the last 15 years, including multiple temporary in24 creases in the Federal funding caps, higher Federal 

25 medical assistance percentage rates, and billions of 

26 dollars in supplemental block grants; 


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1 (4) the supplemental funding provided to the ter2 ritories under title V with respect to their Medicaid 

3 programs continues Congress’ commitment to ensur4 ing the sustainability of these critically important 

5 programs and the people these programs serve; and 

6 (5) a more permanent legislative solution must 

7 be developed in order to provide the territories with 

8 a reliable and consistent source of Federal funding 

9 under their Medicaid programs so that the territories 

10 can continue to meet the health care needs of vulner11 able populations. 

12 TITLE IV—NO SURPRISES ACT 

13 SEC. 401. SHORT TITLE. 

14 This title may be cited as the ‘‘No Surprises Act’’. 

15 SEC. 402. PREVENTING SURPRISE MEDICAL BILLS. 

16 (a) COVERAGE OF EMERGENCY SERVICES.—Section 

17 2719A(b) of the Public Health Service Act (42 U.S.C. 

18 300gg–19a(b)) is amended— 

19 (1) in paragraph (1)— 

20 (A) in the matter preceding subparagraph 

21 (A)— 

22 (i) by striking ‘‘a group health plan, or 

23 a health insurance issuer offering group or 

24 individual health insurance issuer,’’ and inVerDate Sep 11 2014 21:36 Dec 31, 2020 Jkt 019200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6203 E:\BILLS\H2328.RH H2328

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1 serting ‘‘a health plan (as defined in sub2 section (e)(2)(A))’’; 

3 (ii) by inserting ‘‘or, for plan year 

4 2021 or a subsequent plan year, with re5 spect to emergency services in an inde6 pendent freestanding emergency department 

7 (as defined in paragraph (3)(D))’’ after 

8 ‘‘emergency department of a hospital’’; 

9 (iii) by striking ‘‘the plan or issuer’’ 

10 and inserting ‘‘the plan’’; and 

11 (iv) by striking ‘‘paragraph (2)(B)’’ 

12 and inserting ‘‘paragraph (3)(C)’’; 

13 (B) in subparagraph (B), by inserting ‘‘or 

14 a participating emergency facility, as applica15 ble,’’ after ‘‘participating provider’’; and 

16 (C) in subparagraph (C)— 

17 (i) in the matter preceding clause (i), 

18 by inserting ‘‘by a nonparticipating pro19 vider or a nonparticipating emergency fa20 cility’’ after ‘‘enrollee’’; 

21 (ii) by striking clause (i); 

22 (iii) by striking ‘‘(ii)(I) such services’’ 

23 and inserting ‘‘(i) such services’’; 

24 (iv) by striking ‘‘where the provider of 

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1 tionship with the plan for the providing of 

2 services’’; 

3 (v) by striking ‘‘emergency department 

4 services received from providers who do have 

5 such a contractual relationship with the 

6 plan; and’’ and inserting ‘‘emergency serv7 ices received from participating providers 

8 and participating emergency facilities with 

9 respect to such plan;’’; 

10 (vi) by striking ‘‘(II) if such services’’ 

11 and all that follows through ‘‘were provided 

12 in-network;’’ and inserting the following: 

13 ‘‘(ii) the cost-sharing requirement (ex14 pressed as a copayment amount or coinsur15 ance rate) is not greater than the require16 ment that would apply if such services were 

17 provided by a participating provider or a 

18 participating emergency facility;’’; and 

19 (vii) by adding at the end the following 

20 new clauses: 

21 ‘‘(iii) such requirement is calculated as 

22 if the total amount that would have been 

23 charged for such services by such partici24 pating provider or participating emergency 

25 facility were equal to— 


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1 ‘‘(I) in the case of such services 

2 furnished in a State described in para3 graph (3)(H)(ii), the median con4 tracted rate (as defined in paragraph 

5 (3)(E)(i)) for such services; and 

6 ‘‘(II) in the case of such services 

7 furnished in a State described in para8 graph (3)(H)(i), the lesser of— 

9 ‘‘(aa) the amount determined 

10 by such State for such services in 

11 accordance with the method de12 scribed in such paragraph; and 

13 ‘‘(bb) the median contracted 

14 rate (as so defined) for such serv15 ices; 

16 ‘‘(iv) the health plan pays to such pro17 vider or facility, respectively, the amount by 

18 which the recognized amount (as defined in 

19 paragraph (3)(H)) for such services exceeds 

20 the cost-sharing amount for such services 

21 (as determined in accordance with clauses 

22 (ii) and (iii)); and 

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

24 by the participant, beneficiary, or enrollee 

25 with respect to such emergency services so 


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1 furnished shall be counted toward any in2 network deductible or out-of-pocket maxi3 mums applied under the plan (and such in4 network deductible shall be applied) in the 

5 same manner as if such cost-sharing pay6 ments were with respect to emergency serv7 ices furnished by a participating provider 

8 and a participating emergency facility; 

9 and’’; 

10 (2) by redesignating paragraph (2) as para11 graph (3); 

12 (3) by inserting after paragraph (1) the fol13 lowing new paragraph: 

14 ‘‘(2) AUDIT PROCESS FOR MEDIAN CONTRACTED

15 RATES.— 

16 ‘‘(A) IN GENERAL.—Not later than July 1, 

17 2020, the Secretary, in consultation with appro18 priate State agencies, shall establish through 

19 rulemaking a process, in accordance with sub20 paragraph (B), under which health plans are au21 dited by such Secretaries to ensure that— 

22 ‘‘(i) such plans are in compliance with 

23 the requirement of applying a median con24 tracted rate under this section; and 


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1 ‘‘(ii) that such median contracted rate 

2 so applied satisfies the definition under 

3 paragraph (3)(E) with respect to the year 

4 involved, including with respect to a health 

5 plan described in clause (ii) of such para6 graph. 

7 ‘‘(B) AUDIT SAMPLES.—Under the process 

8 established pursuant to subparagraph (A), the 

9 Secretary— 

10 ‘‘(i) shall conduct audits described in 

11 such subparagraph, with respect to a year 

12 (beginning with 2021), of a sample with re13 spect to such year of claims data from not 

14 more than 25 health plans; and 

15 ‘‘(ii) may audit any health plan if the 

16 Secretary has received any complaint about 

17 such plan that involves the compliance of 

18 the plan with either of the requirements de19 scribed in clauses (i) and (ii) of such sub20 paragraph.’’; and 

21 (4) in paragraph (3), as redesignated by para22 graph (2) of this subsection— 

23 (A) in the matter preceding subparagraph 

24 (A), by inserting ‘‘and subsection (e)’’ after ‘‘this 

25 subsection’’; 


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1 (B) by redesignating subparagraphs (A) 

2 through (C) as subparagraphs (B) through (D), 

3 respectively; 

4 (C) by inserting before subparagraph (B), 

5 as redesignated by subparagraph (B) of this 

6 paragraph, the following new subparagraph: 

7 ‘‘(A) EMERGENCY DEPARTMENT OF A HOS8 PITAL.—The term ‘emergency department of a 

9 hospital’ includes a hospital outpatient depart10 ment that provides emergency services.’’; 

11 (D) by amending subparagraph (C), as re12 designated by subparagraph (B) of this para13 graph, to read as follows: 

14 ‘‘(C) EMERGENCY SERVICES.— 

15 ‘‘(i) IN GENERAL.—The term ‘emer16 gency services’, with respect to an emer17 gency medical condition, means— 

18 ‘‘(I) a medical screening examina19 tion (as required under section 1867 of 

20 the Social Security Act, or as would be 

21 required under such section if such sec22 tion applied to an independent free23 standing emergency department) that 

24 is within the capability of the emer25 gency department of a hospital or of 


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1 an independent freestanding emergency 

2 department, as applicable, including 

3 ancillary services routinely available to 

4 the emergency department to evaluate 

5 such emergency medical condition; and 

6 ‘‘(II) within the capabilities of the 

7 staff and facilities available at the hos8 pital or the independent freestanding 

9 emergency department, as applicable, 

10 such further medical examination and 

11 treatment as are required under section 

12 1867 of such Act, or as would be re13 quired under such section if such sec14 tion applied to an independent free15 standing emergency department, to sta16 bilize the patient. 

17 ‘‘(ii) INCLUSION OF

18 POSTSTABILIZATION SERVICES.—For pur19 poses of this subsection and section 2799, in 

20 the case of an individual enrolled in a 

21 health plan who is furnished services de22 scribed in clause (i) by a provider or facil23 ity to stabilize such individual with respect 

24 to an emergency medical condition, the 

25 term ‘emergency services’ shall include such 


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1 items and services in addition to those de2 scribed in clause (i) that such a provider or 

3 facility determines are needed to be fur4 nished (after such stabilization but during 

5 such visit in which such individual is so 

6 stabilized) to such individual, unless each of 

7 the following conditions are met: 

8 ‘‘(I) Such a provider or facility 

9 determines such individual is able to 

10 travel using nonmedical transportation 

11 or nonemergency medical transpor12 tation. 

13 ‘‘(II) Such provider furnishing 

14 such additional items and services is 

15 in compliance with section 2799A(d) 

16 with respect to such items and serv17 ices.’’; 

18 (E) by redesignating subparagraph (D), as 

19 redesignated by subparagraph (B) of this para20 graph, as subparagraph (I); and 

21 (F) by inserting after subparagraph (C), as 

22 redesignated by subparagraph (B) of this para23 graph, the following new subparagraphs: 

24 ‘‘(D) INDEPENDENT FREESTANDING EMER25 GENCY DEPARTMENT.—The term ‘independent 


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1 freestanding emergency department’ means a fa2 cility that— 

3 ‘‘(i) is geographically separate and dis4 tinct and licensed separately from a hos5 pital under applicable State law; and 

6 ‘‘(ii) provides emergency services. 

7 ‘‘(E) MEDIAN CONTRACTED RATE.— 

8 ‘‘(i) IN GENERAL.—The term ‘median 

9 contracted rate’ means, with respect to an 

10 item or service and a health plan (as de11 fined in subsection (e)(2)(A))— 

12 ‘‘(I) for 2021, the median of the 

13 negotiated rates recognized by the 

14 sponsor or issuer of such plan (deter15 mined with respect to all such plans of 

16 such sponsor or such issuer that are 

17 within the same line of business) as the 

18 total maximum payment (including 

19 the cost-sharing amount imposed for 

20 such services (as determined in accord21 ance with clauses (ii) and (iii) of 

22 paragraph (1)(C) or subparagraphs 

23 (A) and (B) of subsection (e)(1), as ap24 plicable) and the amount to be paid by 

25 the plan or issuer) under such plans in 


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1 2019 for the same or a similar item or 

2 service that is provided by a provider 

3 in the same or similar specialty and 

4 provided in the geographic region in 

5 which the item or service is furnished, 

6 consistent with the methodology estab7 lished by the Secretary under section 

8 402(e) of the No Surprises Act, in9 creased by the percentage increase in 

10 the consumer price index for all urban 

11 consumers (United States city average) 

12 over 2019 and 2020; and 

13 ‘‘(II) for 2022 and each subse14 quent year, the median contracted rate 

15 determined under this clause for the 

16 previous year, increased by the per17 centage increase in the consumer price 

18 index for all urban consumers (United 

19 States city average) over such previous 

20 year. 

21 ‘‘(ii) SPECIAL RULE.—The Secretary 

22 shall provide pursuant to rulemaking de23 scribed in section 402(e) of the No Surprises 

24 Act that— 


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1 ‘‘(I) if the sponsor or issuer of a 

2 health plan does not have sufficient in3 formation to calculate a median con4 tracted rate for an item or service or 

5 provider type, or amount of, claims for 

6 items or services (as determined by the 

7 Secretary) provided in a particular ge8 ographic area (other than in a case de9 scribed in item (bb)), such sponsor or 

10 issuer shall demonstrate that such 

11 sponsor or issuer will use any database 

12 free of conflicts of interest that has suf13 ficient information reflecting allowed 

14 amounts paid to a health care provider 

15 for relevant services provided in the 

16 applicable geographic region (such as 

17 State All Payer Claims Databases (as 

18 defined in section 404(d) of such Act)), 

19 and that such sponsor or issuer will 

20 use any such database to determine a 

21 median contracted rate and cover the 

22 cost of accessing any such database; 

23 and 

24 ‘‘(II) in the case of a sponsor or 

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1 graphic region that did not offer any 

2 health plan in such region during 

3 2019, such sponsor or issuer shall use 

4 a methodology established by the Sec5 retary for determining the median con6 tracted rate for items and services cov7 ered by such plan for the first year in 

8 which such plan is offered in such re9 gion, and that, for each succeeding 

10 year, the median contracted rate for 

11 such items and services under such 

12 plan shall be the median contracted 

13 rate for such items and services under 

14 such plan for the previous year, in15 creased by the percentage increase in 

16 the consumer price index for all urban 

17 consumers (United States city average) 

18 over such previous year. 

19 ‘‘(F) NONPARTICIPATING EMERGENCY FA20 CILITY; PARTICIPATING EMERGENCY FACILITY.— 

21 ‘‘(i) NONPARTICIPATING EMERGENCY

22 FACILITY.—The term ‘nonparticipating 

23 emergency facility’ means, with respect to 

24 an item or service and a health plan, an 

25 emergency department of a hospital, or an 


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1 independent freestanding emergency depart2 ment, that does not have a contractual rela3 tionship with the plan (or, if applicable, 

4 issuer offering the plan) for furnishing such 

5 item or service under the plan. 

6 ‘‘(ii) PARTICIPATING EMERGENCY FA7 CILITY.—The term ‘participating emergency 

8 facility’ means, with respect to an item or 

9 service and a health plan, an emergency de10 partment of a hospital, or an independent 

11 freestanding emergency department, that 

12 has a contractual relationship with the plan 

13 (or, if applicable, issuer offering the plan) 

14 for furnishing such item or service under 

15 the plan. 

16 ‘‘(G) NONPARTICIPATING PROVIDERS; PAR17 TICIPATING PROVIDERS.— 

18 ‘‘(i) NONPARTICIPATING PROVIDER.— 

19 The term ‘nonparticipating provider’ 

20 means, with respect to an item or service 

21 and a health plan, a physician or other 

22 health care provider who is acting within 

23 the scope of practice of that provider’s li24 cense or certification under applicable State 

25 law and who does not have a contractual reVerDate Sep 11 2014 21:36 Dec 31, 2020 Jkt 019200 PO 00000 Frm 00045 Fmt 6652 Sfmt 6203 E:\BILLS\H2328.RH H2328

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1 lationship with the plan (or, if applicable, 

2 issuer offering the plan) for furnishing such 

3 item or service under the plan. 

4 ‘‘(ii) PARTICIPATING PROVIDER.—The 

5 term ‘participating provider’ means, with 

6 respect to an item or service and a health 

7 plan, a physician or other health care pro8 vider who is acting within the scope of 

9 practice of that provider’s license or certifi10 cation under applicable State law and who 

11 has a contractual relationship with the plan 

12 (or, if applicable, issuer offering the plan) 

13 for furnishing such item or service under 

14 the plan. 

15 ‘‘(H) RECOGNIZED AMOUNT.—The term 

16 ‘recognized amount’ means, with respect to an 

17 item or service— 

18 ‘‘(i) in the case of such item or service 

19 furnished in a State that has in effect a 

20 State law that provides for a method for de21 termining the amount of payment that is 

22 required to be covered by a health plan reg23 ulated by such State in the case of a partic24 ipant, beneficiary, or enrollee covered under 

25 such plan and receiving such item or service 


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1 from a nonparticipating provider or facil2 ity, not more than the amount determined 

3 in accordance with such law plus the cost4 sharing amount imposed under the plan for 

5 such item or service (as determined in ac6 cordance with clauses (ii) and (iii) of para7 graph (1)(C) or subparagraphs (A) and (B) 

8 of subsection (e)(1), as applicable); or 

9 ‘‘(ii) in the case of such item or service 

10 furnished in a State that does not have in 

11 effect such a law, an amount that is at least 

12 the median contracted rate (as defined in 

13 subparagraph (E)(i) and determined in ac14 cordance with rulemaking described in sec15 tion 402(e) of the No Surprises Act) for 

16 such item or service.’’. 

17 (b) COVERAGE OF NON-EMERGENCY SERVICES PER18 FORMED BY NONPARTICIPATING PROVIDERS AT CERTAIN

19 PARTICIPATING FACILITIES; INDEPENDENT DISPUTE RESO20 LUTION PROCESS.—Section 2719A of the Public Health 

21 Service Act (42 U.S.C. 300gg–19a) is amended by adding 

22 at the end the following new subsections: 

23 ‘‘(e) COVERAGE OF NON-EMERGENCY SERVICES PER24 FORMED BY NONPARTICIPATING PROVIDERS AT CERTAIN

25 PARTICIPATING FACILITIES.— 


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1 ‘‘(1) IN GENERAL.—Subject to paragraph (3), in 

2 the case of items or services (other than emergency 

3 services to which subsection (b) applies) furnished to 

4 a participant, beneficiary, or enrollee of a health plan 

5 (as defined in paragraph (2)(A)) by a nonpartici6 pating provider (as defined in subsection (b)(3)(G)(i)) 

7 during a visit (as defined by the Secretary in accord8 ance with paragraph (2)(C)) at a participating 

9 health care facility (as defined in paragraph (2)(B)), 

10 with respect to such plan, the plan— 

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

12 beneficiary, or enrollee a cost-sharing amount 

13 (expressed as a copayment amount or coinsur14 ance rate) for such items and services so fur15 nished that is greater than the cost-sharing 

16 amount that would apply under such plan had 

17 such items or services been furnished by a par18 ticipating provider (as defined in subsection 

19 (b)(3)(G)(ii)); 

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

21 amount as if the amount that would have been 

22 charged for such items and services by such par23 ticipating provider were equal to— 

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1 section (b)(3)(H)(ii), the median contracted 

2 rate (as defined in subsection (b)(3)(E)(i)) 

3 for such items and services; and 

4 ‘‘(ii) in the case of such items and 

5 services furnished in a State described in 

6 subsection (b)(3)(H)(i), the lesser of— 

7 ‘‘(I) the amount determined by 

8 such State for such items and services 

9 in accordance with the method de10 scribed in such subsection; and 

11 ‘‘(II) the median contracted rate 

12 (as so defined) for such items and serv13 ices; 

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

15 such items and services to such participant, ben16 eficiary, or enrollee the amount by which the rec17 ognized amount (as defined in subsection 

18 (b)(3)(H)) for such items and services exceeds the 

19 cost-sharing amount imposed under the plan for 

20 such items and services (as determined in ac21 cordance with subparagraphs (A) and (B)); and 

22 ‘‘(D) shall count toward any in-network de23 ductible or out-of-pocket maximums applied 

24 under the plan any cost-sharing payments made 

25 by the participant, beneficiary, or enrollee (and 


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1 such in-network deductible shall be applied) with 

2 respect to such items and services so furnished in 

3 the same manner as if such cost-sharing pay4 ments were with respect to items and services 

5 furnished by a participating provider. 

6 ‘‘(2) DEFINITIONS.—In this subsection and sub7 section (b): 

8 ‘‘(A) HEALTH PLAN.—The term ‘health 

9 plan’ means a group health plan and health in10 surance coverage offered by a heath insurance 

11 issuer in the group or individual market and in12 cludes a grandfathered health plan (as defined in 

13 section 1251(e) of the Patient Protection and Af14 fordable Care Act). 

15 ‘‘(B) PARTICIPATING HEALTH CARE FACIL16 ITY.— 

17 ‘‘(i) IN GENERAL.—The term ‘partici18 pating health care facility’ means, with re19 spect to an item or service and a health 

20 plan, a health care facility described in 

21 clause (ii) that has a contractual relation22 ship with the plan (or, if applicable, issuer 

23 offering the plan) for furnishing such item 

24 or service. 


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1 ‘‘(ii) HEALTH CARE FACILITY DE2 SCRIBED.—A health care facility described 

3 in this clause is each of the following: 

4 ‘‘(I) A hospital (as defined in 

5 1861(e) of the Social Security Act). 

6 ‘‘(II) A critical access hospital (as 

7 defined in section 1861(mm) of such 

8 Act). 

9 ‘‘(III) An ambulatory surgical 

10 center (as defined in section 

11 1833(i)(1)(A) of such Act). 

12 ‘‘(IV) A laboratory. 

13 ‘‘(V) A radiology facility or imag14 ing center. 

15 ‘‘(C) DURING A VISIT.—The term ‘during a 

16 visit’ shall, with respect to items and services 

17 furnished to an individual at a participating 

18 health care facility, include equipment and de19 vices, telemedicine services, imaging services, lab20 oratory services, and such other items and serv21 ices as the Secretary may specify, regardless of 

22 whether or not the provider furnishing such 

23 items or services is at the facility. 

24 ‘‘(3) EXCEPTION.—Paragraph (1) shall not 

25 apply to a health plan in the case of items or services 


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1 (other than emergency services to which subsection (b) 

2 applies) furnished to a participant, beneficiary, or 

3 enrollee of a health plan (as defined in paragraph 

4 (2)(A)) by a nonparticipating provider (as defined in 

5 subsection (b)(3)(G)(i)) during a visit (as defined by 

6 the Secretary in accordance with paragraph (2)(C)) 

7 at a participating health care facility (as defined in 

8 paragraph (2)(B)) if such provider is in compliance 

9 with section 2799A(d) with respect to such items and 

10 services. 

11 ‘‘(f) INDEPENDENT DISPUTE RESOLUTION PROC12 ESS.— 

13 ‘‘(1) ESTABLISHMENT.— 

14 ‘‘(A) IN GENERAL.—Not later than 1 year 

15 after the date of the enactment of this subsection, 

16 the Secretary, in consultation with the Secretary 

17 of Labor, shall establish by regulation an inde18 pendent dispute resolution process (referred to in 

19 this subsection as the ‘IDR process’) under 

20 which— 

21 ‘‘(i) a nonparticipating provider (as 

22 defined in subparagraph (G) of subsection 

23 (b)(3)), nonparticipating emergency facility 

24 (as defined in subparagraph (F) of such 

25 subsection), or health plan (as defined in 


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1 subsection (e)(2)(A)) may submit a request 

2 for resolution by an entity certified under 

3 paragraph (2) (in this subsection referred to 

4 as a ‘certified IDR entity’) of a specified 

5 claim; and 

6 ‘‘(ii) in the case a settlement described 

7 in subparagraph (B) of paragraph (4) is 

8 not reached with respect to such claim, such 

9 entity so resolves such claim in accordance 

10 with such paragraph. 

11 ‘‘(B) DEFINITIONS.—In this subsection: 

12 ‘‘(i) SPECIFIED CLAIM.— 

13 ‘‘(I) IN GENERAL.—Subject to 

14 subclause (II), the term ‘specified 

15 claim’ means a claim by a nonpartici16 pating provider, a nonparticipating 

17 emergency facility, or a health plan 

18 with respect to qualifying items and 

19 services (as defined in clause (ii)) fur20 nished by such provider or facility in 

21 a State described in subparagraph 

22 (H)(ii) of subsection (b)(3) for which a 

23 health plan is required to make pay24 ment pursuant to subsection (b)(1) or 

25 subsection (e)(1)— 


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1 ‘‘(aa) that such payment 

2 should be increased or decreased; 

3 and 

4 ‘‘(bb) that is made not later 

5 than— 

6 ‘‘(AA) in the case of 

7 such a claim filed by such a 

8 provider or facility, the date 

9 on which the appeal with re10 spect to such items and serv11 ices described in clause 

12 (ii)(I)(aa)(AA) has been re13 solved (or the date that is 30 

14 days after such appeal is 

15 filed, whichever is earlier); or 

16 ‘‘(BB) in the case of 

17 such a claim filed by such 

18 plan, the date on which the 

19 period described in clause 

20 (ii)(I)(bb)(BB) with respect 

21 to such items and services 

22 elapses. 

23 ‘‘(II) LIMITATION ON PACKAGING

24 OF ITEMS AND SERVICES IN A SPECI25 FIED CLAIM.—The term ‘specified 


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1 claim’ shall not include, in the case 

2 such claim is made by such provider, 

3 facility, or plan with respect to mul4 tiple items and services, any claim 

5 with respect to items and services fur6 nished by such provider or facility if— 

7 ‘‘(aa) such items and services 

8 were not furnished by the same 

9 provider or facility; 

10 ‘‘(bb) payment for such items 

11 and services made pursuant to 

12 subsection (b)(1) or subsection 

13 (e)(1) was made by multiple 

14 health plans; 

15 ‘‘(cc) such items and services 

16 are not related to the treatment of 

17 the same condition; or 

18 ‘‘(dd) such items and services 

19 were not furnished within 30 days 

20 of the date of the earliest item or 

21 service furnished that is included 

22 in such claim. 

23 ‘‘(ii) QUALIFYING ITEMS AND SERV24 ICES.— 


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1 ‘‘(I) IN GENERAL.—Subject to 

2 subclause (II), the term ‘qualifying 

3 items and services’ means— 

4 ‘‘(aa) with respect to a speci5 fied claim made by a nonpartici6 pating provider or nonpartici7 pating emergency facility, items 

8 and services furnished by such 

9 provider or facility for which a 

10 health plan is required to make 

11 payment pursuant to subsection 

12 (b)(1) or subsection (e)(1), but 

13 only if— 

14 ‘‘(AA) such items and 

15 services are included in an 

16 appeal filed under such 

17 plan’s internal appeals proc18 ess not later than 30 days 

19 after such payment is re20 ceived; and 

21 ‘‘(BB) such appeal 

22 under such plan’s internal 

23 appeals process has been re24 solved, or a 30-day period 


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1 has elapsed since such appeal 

2 was so filed; and 

3 ‘‘(bb) with respect to a speci4 fied claim made by a health plan, 

5 items and services furnished by 

6 such a provider or facility for 

7 which such health plan is required 

8 to make payment pursuant to 

9 subsection (b)(1) or subsection 

10 (e)(1), but only if— 

11 ‘‘(AA) such plan sub12 mits a notice to such pro13 vider or facility not later 

14 than 30 days after such pro15 vider or facility receives such 

16 payment that such plan dis17 putes the amount of such 

18 payment with respect to such 

19 items and services; and 

20 ‘‘(BB) a 30-day period 

21 has elapsed since the submis22 sion of such notice. 

23 ‘‘(II) LIMITATION.—The term 

24 ‘qualifying items and services’ shall 

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1 nished in a geographic area during a 

2 year by such provider or facility for 

3 which a health plan is required to 

4 make payment pursuant to subsection 

5 (b)(1) or subsection (e)(1) if the me6 dian contracted rate (as defined in 

7 subsection (b)(3)(E)) under such plan 

8 for such year with respect to such item 

9 or service furnished by such a provider 

10 or such a facility in such area does not 

11 exceed— 

12 ‘‘(aa) with respect to an item 

13 or service furnished during 2021, 

14 $1,250; and 

15 ‘‘(bb) with respect to an item 

16 or service furnished during a sub17 sequent year, the amount specified 

18 under this subclause for the pre19 vious year, increased by the per20 centage increase in the consumer 

21 price index for all urban con22 sumers (United States city aver23 age) over such previous year. 

24 ‘‘(2) CERTIFICATION OF ENTITIES.— 


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1 ‘‘(A) PROCESS OF CERTIFICATION.—The 

2 process described in paragraph (1) shall include 

3 a certification process under which eligible enti4 ties may be certified to carry out the IDR proc5 ess. 

6 ‘‘(B) ELIGIBILITY.— 

7 ‘‘(i) IN GENERAL.—For purposes of 

8 subparagraph (A), an eligible entity is an 

9 entity that is a nongovernmental entity that 

10 agrees to comply with the fee limitations de11 scribed in clause (ii). 

12 ‘‘(ii) FEE LIMITATION.—For purposes 

13 of clause (i), the fee limitations described in 

14 this clause are limitations established by the 

15 Secretary on the amount a certified IDR 

16 entity may charge a nonparticipating pro17 vider, nonparticipating emergency facility, 

18 or health plan for services furnished by such 

19 entity with respect to the resolution of a 

20 specified claim of such provider, facility, or 

21 plan under the process described in para22 graph (1). 

23 ‘‘(3) SELECTION OF CERTIFIED IDR ENTITY FOR

24 A SPECIFIED CLAIM.—With respect to the resolution of 

25 a specified claim under the IDR process, the health 


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1 plan and the nonparticipating provider or the non2 participating emergency facility (as applicable) in3 volved shall agree on a certified IDR entity to resolve 

4 such claim. In the case that such plan and such pro5 vider or facility (as applicable) cannot so agree, such 

6 an entity shall be selected by the Secretary at ran7 dom. 

8 ‘‘(4) PAYMENT DETERMINATION.— 

9 ‘‘(A) TIMING.—A certified IDR entity se10 lected under paragraph (3) by a health plan and 

11 a nonparticipating provider or a nonpartici12 pating emergency facility (as applicable) with 

13 respect to a specified claim shall, subject to sub14 paragraph (B), not later than 30 days after 

15 being so selected, determine the total reimburse16 ment that should have been made for items and 

17 services included in such claim in accordance 

18 with subparagraph (C). 

19 ‘‘(B) SETTLEMENT.— 

20 ‘‘(i) IN GENERAL.—If such entity de21 termines that a settlement between the 

22 health plan and the provider or facility is 

23 likely with respect to a specified claim, the 

24 entity may direct the parties to attempt, for 


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1 a period not to exceed 10 days, a good faith 

2 negotiation for a settlement of such claim. 

3 ‘‘(ii) TIMING.—The period for a settle4 ment described in clause (i) shall accrue to5 wards the 30-day period described in sub6 paragraph (A). 

7 ‘‘(C) DETERMINATION OF AMOUNT.— 

8 ‘‘(i) IN GENERAL.—The health plan 

9 and the nonparticipating provider or non10 participating emergency facility (as appli11 cable) shall, with respect to a specified 

12 claim, each submit to the certified IDR en13 tity a final offer of payment or reimburse14 ment (as applicable) with respect to items 

15 and services which are the subject of the 

16 specified claim. Such entity shall determine 

17 which such offer is the most reasonable in 

18 accordance with clause (ii). 

19 ‘‘(ii) CONSIDERATIONS IN DETERMINA20 TION.— 

21 ‘‘(I) IN GENERAL.—In deter22 mining which final offer is the most 

23 reasonable under clause (i), the cer24 tified IDR entity shall consider— 


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1 ‘‘(aa) the median contracted 

2 rates (as defined in subsection 

3 (b)(3)(E)) for items or services 

4 that are comparable to the items 

5 and services included in the speci6 fied claim and that are furnished 

7 in the same geographic area (as 

8 defined by the Secretary for pur9 poses of such subsection) as such 

10 items and services (not including 

11 any facility fees with respect to 

12 such rates); and 

13 ‘‘(bb) the circumstances de14 scribed in subclause (II), if any 

15 information with respect to such 

16 circumstances is submitted by ei17 ther party. 

18 ‘‘(II) ADDITIONAL CIR19 CUMSTANCES.—For purposes of sub20 clause (I)(bb), the circumstances de21 scribed in this subclause are, with re22 spect to items and services included in 

23 the specified claim of a nonpartici24 pating provider, nonparticipating 


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1 emergency facility, or health plan, the 

2 following: 

3 ‘‘(aa) The level of training, 

4 education, experience, and quality 

5 and outcomes measurements of the 

6 provider or facility that furnished 

7 such items and services. 

8 ‘‘(bb) Any other extenuating 

9 circumstances with respect to the 

10 furnishing of such items and serv11 ices that relate to the acuity of the 

12 individual receiving such items 

13 and services or the complexity of 

14 furnishing such items and services 

15 to such individual. 

16 ‘‘(III) PROHIBITION ON CONSID17 ERATION OF BILLED CHARGES.—In de18 termining which final offer is the most 

19 reasonable under clause (i) with re20 spect to items and services furnished by 

21 a provider or facility and included in 

22 a specified claim, the certified IDR en23 tity may not consider the amount that 

24 would have been billed by such pro25 vider or facility with respect to such 


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1 items and services had the provisions 

2 of section 2799 or 2799A (as applica3 ble) not applied. 

4 ‘‘(iii) EFFECT OF DETERMINATION.—A 

5 determination of a certified IDR entity 

6 under clause (i)— 

7 ‘‘(I) shall be binding; and 

8 ‘‘(II) shall not be subject to judi9 cial review, except in a case described 

10 in any of paragraphs (1) through (4) 

11 of section 10(a) of title 9, United 

12 States Code. 

13 ‘‘(iv) COSTS OF INDEPENDENT DIS14 PUTE RESOLUTION PROCESS.—In the case 

15 of a specified claim made by a nonpartici16 pating provider, nonparticipating emer17 gency facility, or health plan and submitted 

18 to a certified IDR entity— 

19 ‘‘(I) if such entity makes a deter20 mination with respect to such claim 

21 under clause (i), the party whose offer 

22 is not chosen under such clause shall be 

23 responsible for paying all fees charged 

24 by such entity; and 


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1 ‘‘(II) if the parties reach a settle2 ment with respect to such claim prior 

3 to such a determination, such fees shall 

4 be divided equally between the parties, 

5 unless the parties otherwise agree. 

6 ‘‘(v) PAYMENT.—Not later than 30 

7 days after a determination described in 

8 clause (i) is made with respect to a specified 

9 claim of a nonparticipating provider, non10 participating emergency facility, or health 

11 plan— 

12 ‘‘(I) in the case that such deter13 mination finds that the amount paid 

14 with respect to such specified claim by 

15 the health plan should have been great16 er than the amount so paid, such plan 

17 shall pay directly to the provider or fa18 cility (as applicable) the difference be19 tween the amount so paid and the 

20 amount so determined; and 

21 ‘‘(II) in the case that such deter22 mination finds that the amount paid 

23 with respect to such specified claim by 

24 the health plan should have been less 

25 than the amount so paid, the provider 


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1 or facility (as applicable) shall pay di2 rectly to the plan the difference between 

3 the amount so paid and the amount so 

4 determined. 

5 ‘‘(5) PUBLICATION OF INFORMATION RELATING

6 TO DISPUTES.— 

7 ‘‘(A) IN GENERAL.—For 2021 and each sub8 sequent year, the Secretary and the Secretary of 

9 Labor shall publish on the public website of the 

10 Department of Health and Human Services and 

11 the Department of Labor, respectively— 

12 ‘‘(i) the number of specified claims 

13 filed during such year; 

14 ‘‘(ii) the number of such claims with 

15 respect to which a final determination was 

16 made under paragraph (4)(C)(i); and 

17 ‘‘(iii) the information described in sub18 paragraph (B) with respect to each specified 

19 claim with respect to which such a decision 

20 was so made. 

21 ‘‘(B) INFORMATION WITH RESPECT TO

22 SPECIFIED CLAIMS.—For purposes of subpara23 graph (A), the information described in this sub24 paragraph is, with respect to a specified claim 


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1 of a nonparticiapting provider, nonparticipating 

2 emergency facility, or health plan— 

3 ‘‘(i) a description of each item and 

4 service included in such claim; 

5 ‘‘(ii) the amount of the offer submitted 

6 under paragraph (4)(C)(i) by the health 

7 plan and by the nonparticipating provider 

8 or nonparticipating emergency facility (as 

9 applicable); 

10 ‘‘(iii) whether the offer selected by the 

11 certified IDR entity under such paragraph 

12 was the offer submitted by such plan or by 

13 such provider or facility (as applicable) and 

14 the amount of such offer so selected; and 

15 ‘‘(iv) the category and practice spe16 cialty of each such provider or facility in17 volved in furnishing such items and serv18 ices. 

19 ‘‘(C) CONFIDENTIALITY OF PARTIES.—None 

20 of the information published under this para21 graph may specify the identity of a health plan, 

22 provider, facility, or individual with respect to 

23 a specified claim.’’. 

24 (c) PROVIDER DIRECTORY REQUIREMENTS; DISCLO25 SURE ON PATIENT PROTECTIONS.—Section 2719A of the 


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1 Public Health Service Act, as amended by subsection (b), 

2 is further amended by adding at the end the following new 

3 subsections: 

4 ‘‘(g) PROVIDER DIRECTORY INFORMATION REQUIRE5 MENTS.— 

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

7 the date of the enactment of this subsection, each 

8 group health plan and health insurance issuer offer9 ing group or individual health insurance coverage 

10 shall— 

11 ‘‘(A) establish the verification process de12 scribed in paragraph (2); 

13 ‘‘(B) establish the response protocol de14 scribed in paragraph (3); 

15 ‘‘(C) establish the database described in 

16 paragraph (4); and 

17 ‘‘(D) include in any print directory con18 taining provider directory information with re19 spect to such plan or such coverage the informa20 tion described in paragraph (5). 

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

22 process described in this paragraph is, with respect to 

23 a group health plan or a health insurance issuer of24 fering group or individual health insurance coverage, 

25 a process— 


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1 ‘‘(A) under which not less frequently than 

2 once every 90 days, such plan or such issuer (as 

3 applicable) verifies and updates the provider di4 rectory information included on the database de5 scribed in paragraph (4) of such plan or issuer 

6 of each health care provider and health care fa7 cility included in such database; and 

8 ‘‘(B) that establishes a procedure for the re9 moval of such a provider or facility with respect 

10 to which such plan or issuer has been unable to 

11 verify such information during a period speci12 fied by the plan or issuer. 

13 ‘‘(3) RESPONSE PROTOCOL.—The response pro14 tocol described in this paragraph is, in the case of an 

15 individual enrolled under a group health plan or 

16 group or individual health insurance coverage offered 

17 by a health insurance issuer who requests information 

18 on whether a health care provider or health care facil19 ity has a contractual relationship to furnish items 

20 and services under such plan or such coverage, a pro21 tocol under which such plan or such issuer (as appli22 cable), in the case such request is made through a tele23 phone call— 

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

25 practicable and in no case later than 1 business 


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1 day after such call is received through a written 

2 electronic communication; and 

3 ‘‘(B) retains such communication in such 

4 individual’s file for at least 2 years following 

5 such response. 

6 ‘‘(4) DATABASE.—The database described in this 

7 paragraph is, with respect to a group health plan or 

8 health insurance issuer offering group or individual 

9 health insurance coverage, a database on the public 

10 website of such plan or issuer that contains— 

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

12 health care facility with which such plan or such 

13 issuer has a contractual relationship for fur14 nishing items and services under such plan or 

15 such coverage; and 

16 ‘‘(B) provider directory information with 

17 respect to each such provider and facility. 

18 ‘‘(5) INFORMATION.—The information described 

19 in this paragraph is, with respect to a print directory 

20 containing provider directory information with re21 spect to a group health plan or individual or group 

22 health insurance coverage offered by a health insur23 ance issuer, a notification that such information con24 tained in such directory was accurate as of the date 

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1 vidual enrolled under such plan or such coverage 

2 should consult the database described in paragraph 

3 (4) with respect to such plan or such coverage or con4 tact such plan or the issuer of such coverage to obtain 

5 the most current provider directory information with 

6 respect to such plan or such coverage. 

7 ‘‘(6) DEFINITION.—For purposes of this sub8 section, the term ‘provider directory information’ in9 cludes, with respect to a group health plan and a 

10 health insurance issuer offering group or individual 

11 health insurance coverage, the name, address, spe12 cialty, and telephone number of each health care pro13 vider or health care facility with which such plan or 

14 such issuer has a contractual relationship for fur15 nishing items and services under such plan or such 

16 coverage. 

17 ‘‘(h) DISCLOSURE ON PATIENT PROTECTIONS.—Each 

18 group health plan and health insurance issuer offering 

19 group or individual health insurance coverage shall make 

20 publicly available, and (if applicable) post on a public 

21 website of such plan or issuer— 

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

23 ‘‘(A) the requirements and prohibitions ap24 plied under sections 2799 and 2799A (relating to 


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1 prohibitions on balance billing in certain cir2 cumstances); 

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

4 law, any other requirements on providers and fa5 cilities regarding the amounts such providers 

6 and facilities may, with respect to an item or 

7 service, charge a participant, beneficiary, or en8 rollee of such plan or coverage with respect to 

9 which such a provider or facility does not have 

10 a contractual relationship for furnishing such 

11 item or service under the plan or coverage after 

12 receiving payment from the plan or coverage for 

13 such item or service and any applicable cost14 sharing payment from such participant, bene15 ficiary, or enrollee; and 

16 ‘‘(C) the requirements applied under sub17 sections (b) and (e); and 

18 ‘‘(2) information on contacting appropriate 

19 State and Federal agencies in the case that an indi20 vidual believes that such a provider or facility has 

21 violated any requirement described in paragraph (1) 

22 with respect to such individual.’’. 

23 (d) PREVENTING CERTAIN CASES OF BALANCE BILL24 ING.—Title XXVII of the Public Health Service Act is 

25 amended by adding at the end the following new part: 


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1 ‘‘PART D—PREVENTING CERTAIN CASES OF 

2 BALANCE BILLING 

3 ‘‘SEC. 2799. BALANCE BILLING IN CASES OF EMERGENCY 

4 SERVICES. 

5 ‘‘(a) IN GENERAL.—In the case of a participant, bene6 ficiary, or enrollee with benefits under a health plan who 

7 is furnished on or after January 1, 2021, emergency serv8 ices with respect to an emergency medical condition during 

9 a visit at an emergency department of a hospital or an 

10 independent freestanding emergency department— 

11 ‘‘(1) the emergency department of a hospital or 

12 independent freestanding emergency department shall 

13 not hold the participant, beneficiary, or enrollee liable 

14 for a payment amount for such emergency services so 

15 furnished that is more than the cost-sharing amount 

16 for such services (as determined in accordance with 

17 clauses (ii) and (iii) of section 2719A(b)(1)(C)); and 

18 ‘‘(2) a health care provider shall not hold such 

19 participant, beneficiary, or enrollee liable for a pay20 ment amount for an emergency service furnished to 

21 such individual by such provider with respect to such 

22 emergency medical condition and visit for which the 

23 individual receives emergency services at the hospital 

24 or emergency department that is more than the cost25 sharing amount for such services furnished by the 


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1 provider (as determined in accordance with clauses 

2 (ii) and (iii) of section 2719A(b)(1)(C)). 

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

4 ‘‘(1) The terms ‘emergency department of a hos5 pital’, ‘emergency medical condition’, ‘emergency 

6 services’, and ‘independent freestanding emergency de7 partment’ have the meanings given such terms, re8 spectively, in section 2719A(b)(3). 

9 ‘‘(2) The term ‘health plan’ has the meaning 

10 given such term in section 2719A(e). 

11 ‘‘(3) The term ‘during a visit’ shall have such 

12 meaning as applied to such term for purposes of sec13 tion 2719A(e). 

14 ‘‘SEC. 2799A. BALANCE BILLING IN CASES OF NON-EMER15 GENCY SERVICES PERFORMED BY NON16 PARTICIPATING PROVIDERS AT CERTAIN 

17 PARTICIPATING FACILITIES. 

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

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

20 under a health plan (as defined in section 2799(b)) who 

21 is furnished on or after January 1, 2021, items or services 

22 (other than emergency services to which section 2799 ap23 plies) at a participating health care facility by a non24 participating provider, such provider shall not hold such 

25 participant, beneficiary, or enrollee liable for a payment 


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1 amount for such an item or service furnished by such pro2 vider during a visit at such facility that is more than the 

3 cost-sharing amount for such item or service (as determined 

4 in accordance with subparagraphs (A) and (B) of section 

5 2719A(e)(1)). 

6 ‘‘(b) EXCEPTION.— 

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

8 apply to a nonparticipating provider (other than a 

9 specified provider at a participating health care facil10 ity), with respect to items or services furnished by the 

11 provider to a participant, beneficiary, or enrollee of 

12 a health plan, if the provider is in compliance with 

13 the notice and consent requirements of subsection (d). 

14 ‘‘(2) SPECIFIED PROVIDER DEFINED.—For pur15 poses of paragraph (1), the term ‘specified provider’, 

16 with respect to a participating health care facility— 

17 ‘‘(A) means a facility-based provider, in18 cluding emergency medicine providers, anesthe19 siologists, pathologists, radiologists, 

20 neonatologists, assistant surgeons, hospitalists, 

21 intensivists, or other providers as determined by 

22 the Secretary; and 

23 ‘‘(B) includes, with respect to an item or 

24 service, a nonparticipating provider if there is 


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1 no participating provider at such facility who 

2 can furnish such item or service. 

3 ‘‘(c) CLARIFICATION.—In the case of a nonpartici4 pating provider (other than a specified provider at a par5 ticipating health care facility) that complies with the notice 

6 and consent requirements of subsection (d) with respect to 

7 an item or service (referred to in this subsection as a ‘cov8 ered item or service’), such notice and consent requirements 

9 may not be construed as applying with respect to any item 

10 or service that is furnished as a result of unforeseen medical 

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

12 is furnished. 

13 ‘‘(d) COMPLIANCE WITH NOTICE AND CONSENT RE14 QUIREMENTS.— 

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

16 or nonparticipating facility is in compliance with 

17 this subsection, with respect to items or services fur18 nished by the provider or facility to a participant, 

19 beneficiary, or enrollee of a health plan, if the pro20 vider (or, if applicable, the participating health care 

21 facility on behalf of such provider) or nonpartici22 pating facility— 

23 ‘‘(A) provides to the participant, bene24 ficiary, or enrollee (or to an authorized rep25 resentative of the participant, beneficiary, or enVerDate Sep 11 2014 21:36 Dec 31, 2020 Jkt 019200 PO 00000 Frm 00076 Fmt 6652 Sfmt 6203 E:\BILLS\H2328.RH H2328

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1 rollee) on the date on which the individual is 

2 furnished such items or services and, in the case 

3 that the participant, beneficiary, or enrollee 

4 makes an appointment to be furnished such 

5 items or services, on such date the appointment 

6 is made— 

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

8 notice described in clause (ii); and 

9 ‘‘(ii) a written notice specified by the 

10 Secretary, not later than July 1, 2020, 

11 through guidance (which shall be updated 

12 as determined necessary by the Secretary) 

13 that— 

14 ‘‘(I) contains the information re15 quired under paragraph (2); and 

16 ‘‘(II) is signed and dated by the 

17 participant, beneficiary, or enrollee (or 

18 by an authorized representative of the 

19 participant, beneficiary, or enrollee) 

20 and, with respect to items or services to 

21 be furnished by such a provider that 

22 are not poststabilization services de23 scribed in section 2719A(b)(3)(C)(ii), 

24 is so signed and dated not less than 72 

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1 ficiary, or enrollee being furnished 

2 such items or services by such provider; 

3 and 

4 ‘‘(B) obtains from the participant, bene5 ficiary, or enrollee (or from such an authorized 

6 representative) the consent described in para7 graph (3). 

8 ‘‘(2) INFORMATION REQUIRED UNDER WRITTEN

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

10 information described in this paragraph, with respect 

11 to a nonparticipating provider or nonparticipating 

12 facility and a participant, beneficiary, or enrollee of 

13 a health plan, is each of the following: 

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

15 health care provider is a nonparticipating pro16 vider with respect to the health plan or the 

17 health care facility is a nonparticipating facility 

18 with respect to the health plan. 

19 ‘‘(B) Notification of the estimated amount 

20 that such provider or facility may charge the 

21 participant, beneficiary, or enrollee for such 

22 items and services involved. 

23 ‘‘(C) In the case of a nonparticipating facil24 ity, a list of any participating providers at the 

25 facility who are able to furnish such items and 


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1 services involved and notification that the par2 ticipant, beneficiary, or enrollee may be referred, 

3 at their option, to such a participating provider. 

4 ‘‘(3) CONSENT DESCRIBED.—For purposes of 

5 paragraph (1)(B), the consent described in this para6 graph, with respect to a participant, beneficiary, or 

7 enrollee of a health plan who is to be furnished items 

8 or services by a nonparticipating provider or non9 participating facility, is a document specified by the 

10 Secretary through rulemaking that— 

11 ‘‘(A) is signed by the participant, bene12 ficiary, or enrollee (or by an authorized rep13 resentative of the participant, beneficiary, or en14 rollee) and, with respect to items or services to 

15 be furnished by such a provider or facility that 

16 are not poststabilization services described in 

17 section 2719A(b)(3)(C)(ii), is so signed not less 

18 than 72 hours prior to the participant, bene19 ficiary, or enrollee being furnished such items or 

20 services by such provider or facility; 

21 ‘‘(B) acknowledges that the participant, 

22 beneficiary, or enrollee has been— 

23 ‘‘(i) provided with a written estimate 

24 and an oral explanation of the charge that 

25 the participant, beneficiary, or enrollee will 


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1 be assessed for the items or services antici2 pated to be furnished to the participant, 

3 beneficiary, or enrollee by such provider or 

4 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 health plan places 

9 on cost-sharing; and 

10 ‘‘(C) documents the consent of the partici11 pant, beneficiary, or enrollee to— 

12 ‘‘(i) be furnished with such items or 

13 services by such provider or facility; and 

14 ‘‘(ii) in the case that the individual is 

15 so furnished such items or services, be 

16 charged an amount that may be greater 

17 than the amount that would otherwise be 

18 charged the individual if furnished by a 

19 participating provider or participating fa20 cility with respect to such items or services 

21 and plan. 

22 ‘‘(e) RETENTION OF CERTAIN DOCUMENTS.—A non23 participating provider (or, in the case of a nonpartici24 pating provider at a participating health care facility, such 

25 facility) or nonparticipating facility that obtains from a 


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1 participant, beneficiary, or enrollee of a health plan (or an 

2 authorized representative of such participant, beneficiary, 

3 or enrollee) a written notice in accordance with subsection 

4 (c)(1)(ii), with respect to furnishing an item or service to 

5 such participant, beneficiary, or enrollee, shall retain such 

6 notice for at least a 2-year period after the date on which 

7 such item or service is so furnished. 

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

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

10 ‘participating provider’ have the meanings given such 

11 terms, respectively, in subsection (b)(3) of section 

12 2719A. 

13 ‘‘(2) The terms ‘participating health care facil14 ity’ and ‘health plan’ have the meanings given such 

15 terms, respectively, in subsection (e)(2) of section 

16 2719A. 

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

18 means— 

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

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

21 health plan, an emergency department of a hos22 pital, or an independent freestanding emergency 

23 department, that does not have a contractual re24 lationship with the plan (or, if applicable, issuer 


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1 offering the plan) for furnishing such services 

2 under the plan; and 

3 ‘‘(B) with respect to poststabilization serv4 ices described in section 2719A(b)(3)(C)(ii) and 

5 a health plan, an emergency department of a 

6 hospital (or other department of such hospital), 

7 or an independent freestanding emergency de8 partment, that does not have a contractual rela9 tionship with the plan (or, if applicable, issuer 

10 offering the plan) for furnishing such services 

11 under the plan. 

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

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

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

15 health plan, an emergency department of a hos16 pital, or an independent freestanding emergency 

17 department, that has a contractual relationship 

18 with the plan (or, if applicable, issuer offering 

19 the plan) for furnishing such services under the 

20 plan; and 

21 ‘‘(B) with respect to poststabilization serv22 ices described in section 2719A(b)(3)(C)(ii) and 

23 a health plan, an emergency department of a 

24 hospital (or other department of such hospital), 

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1 partment, that has a contractual relationship 

2 with the plan (or, if applicable, issuer offering 

3 the plan) for furnishing such services under the 

4 plan. 

5 ‘‘SEC. 2799B. PROVIDER REQUIREMENTS WITH RESPECT TO 

6 PROVIDER DIRECTORY INFORMATION. 

7 ‘‘Not later than 1 year after the date of the enactment 

8 of this section, each health care provider and health care 

9 facility shall establish a process under which such provider 

10 or facility transmits, to each health insurance issuer offer11 ing group or individual health insurance coverage and 

12 group health plan with which such provider or facility has 

13 in effect a contractual relationship for furnishing items and 

14 services under such coverage or such plan, provider direc15 tory information (as defined in section 2719A(g)(6)) with 

16 respect to such provider or facility, as applicable. Such pro17 vider or facility shall so transmit such information to such 

18 issuer offering such coverage or such group health plan— 

19 ‘‘(1) when the provider or facility enters into 

20 such a relationship with respect to such coverage of21 fered by such issuer or with respect to such plan; 

22 ‘‘(2) when the provider or facility terminates 

23 such relationship with respect to such coverage offered 

24 by such issuer or with respect to such plan; 


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1 ‘‘(3) when there are any other material changes 

2 to such provider directory information of the provider 

3 or facility with respect to such coverage offered by 

4 such issuer or with respect to such plan; and 

5 ‘‘(4) at any other time (including upon the re6 quest of such issuer or plan) determined appropriate 

7 by the provider, facility, or the Secretary. 

8 ‘‘SEC. 2799C. PROVIDER REQUIREMENT WITH RESPECT TO 

9 PUBLIC PROVISION OF INFORMATION. 

10 ‘‘Each health care provider and health care facility 

11 shall make publicly available, and (if applicable) post on 

12 a public website of such provider or facility— 

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

14 ‘‘(A) the requirements and prohibitions of 

15 such provider or facility under sections 2799 and 

16 2799A (relating to prohibitions on balance bill17 ing in certain circumstances); and 

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

19 law, any other requirements on such provider or 

20 facility regarding the amounts such provider or 

21 facility may, with respect to an item or service, 

22 charge a participant, beneficiary, or enrollee of 

23 a health plan (as defined in section 2719A(e)(2)) 

24 with respect to which such provider or facility 

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1 nishing such item or service under the plan after 

2 receiving payment from the plan for such item 

3 or service and any applicable cost-sharing pay4 ment from such participant, beneficiary, or en5 rollee; and 

6 ‘‘(2) information on contacting appropriate 

7 State and Federal agencies in the case that an indi8 vidual believes that such provider or facility has vio9 lated any requirement described in paragraph (1) 

10 with respect to such individual. 

11 ‘‘SEC. 2799D. ENFORCEMENT. 

12 ‘‘(a) STATE ENFORCEMENT.— 

13 ‘‘(1) STATE AUTHORITY.—Each State may re14 quire a provider or health care facility subject to the 

15 requirements of sections 2719A(f), 2799, 2799A, 

16 2799B, or 2799C to satisfy such requirements appli17 cable to the provider or facility. 

18 ‘‘(2) FAILURE TO IMPLEMENT REQUIREMENTS.— 

19 In the case of a determination by the Secretary that 

20 a State has failed to substantially enforce the require21 ments specified in paragraph (1) with respect to ap22 plicable providers and facilities in the State, the Sec23 retary shall enforce such requirements under sub24 section (b) insofar as they relate to violations of such 

25 requirements occurring in such State. 


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1 ‘‘(b) SECRETARIAL ENFORCEMENT AUTHORITY.— 

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

3 found to be in violation specified in subsection (a)(1) 

4 by the Secretary, the Secretary may apply a civil 

5 monetary penalty with respect to such provider or fa6 cility in an amount not to exceed $10,000 per viola7 tion. The provisions of subsections (c), (d), (e), (g), 

8 (h), (k), and (l) of section 1128A of the Social Secu9 rity Act shall apply to a civil monetary penalty or 

10 assessment under this subsection in the same manner 

11 as such provisions apply to a penalty, assessment, or 

12 proceeding under subsection (a) of such section. 

13 ‘‘(2) LIMITATION.—The provisions of paragraph 

14 (1) shall apply to enforcement of a provision (or pro15 visions) specified in subsection (a)(1) only as pro16 vided under subsection (a)(2). 

17 ‘‘(3) COMPLAINT PROCESS.—The Secretary shall, 

18 through rulemaking, establish a process to receive con19 sumer complaints of violations of such provisions and 

20 resolve such complaints within 60 days of receipt of 

21 such complaints. 

22 ‘‘(4) EXCEPTION.—The Secretary shall waive the 

23 penalties described under paragraph (1) with respect 

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1 lated, section 2799 or 2799A with respect to a partici2 pant, beneficiary, or enrollee, if such facility or prac3 titioner, within 30 days of the violation, withdraws 

4 the bill that was in violation of such provision and 

5 reimburses the health plan or enrollee, as applicable, 

6 in an amount equal to the difference between the 

7 amount billed and the amount allowed to be billed 

8 under the provision, plus interest, at an interest rate 

9 determined by the Secretary. 

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

11 may establish a hardship exemption to the penalties 

12 under this subsection. 

13 ‘‘(c) CONTINUED APPLICABILITY OF STATE LAW.—The 

14 sections specified in subsection (a)(1) shall not be construed 

15 to supersede any provision of State law which establishes, 

16 implements, or continues in effect any requirement or pro17 hibition except to the extent that such requirement or prohi18 bition prevents the application of a requirement or prohibi19 tion of such a section.’’. 

20 (e) RULEMAKING FOR MEDIAN CONTRACTED RATES.— 

21 Not later than July 1, 2020, the Secretary of Health and 

22 Human Services, jointly with the Secretary of Labor, shall 

23 establish through rulemaking— 

24 (1) the methodology the sponsor or issuer of a 

25 health plan (as defined in subsection (e) of section 


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1 2719A of the Public Health Service Act (42 U.S.C. 

2 300gg–19a), as added by subsection (b) of this sec3 tion) shall use to determine the median contracted 

4 rate (as defined in section 2719A(b) of such Act, as 

5 amended by subsection (a) of this section), differen6 tiating by business line; 

7 (2) the information such sponsor or issuer shall 

8 share with the nonparticipating provider (as defined 

9 in such section) involved when making such a deter10 mination; and 

11 (3) the geographic regions applied for purposes 

12 of subparagraph (E) of section 2719A(b)(3), as 

13 amended by subsection (a) of this section, taking into 

14 account the needs of rural and underserved areas, in15 cluding health professional shortage areas. 

16 Such rulemaking shall take into account payments that are 

17 made by such sponsor or issuer that are not on a fee-for18 service basis. Such methodology may account for relevant 

19 payment adjustments that take into account facility type 

20 (including higher acuity settings and the case-mix of var21 ious facility types) that are otherwise taken into account 

22 for purposes of determining payment amounts with respect 

23 to participating facilities. 


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1 (f) EFFECTIVE DATE.—The amendments made by sub2 sections (a) and (b) shall apply with respect to plan years 

3 beginning on or after January 1, 2021. 

4 SEC. 403. GOVERNMENT ACCOUNTABILITY OFFICE STUDY 

5 ON PROFIT- AND REVENUE-SHARING IN 

6 HEALTH CARE. 

7 (a) STUDY.—The Comptroller General of the United 

8 States shall conduct a study to— 

9 (1) describe what is known about profit- and 

10 revenue-sharing relationships in the commercial 

11 health care markets, including those relationships 

12 that— 

13 (A) involve one or more— 

14 (i) physician groups that practice 

15 within a hospital included in the profit- or 

16 revenue-sharing relationship, or refer pa17 tients to such hospital; 

18 (ii) laboratory, radiology, or pharmacy 

19 services that are delivered to privately in20 sured patients of such hospital; 

21 (iii) surgical services; 

22 (iv) hospitals or group purchasing or23 ganizations; or 

24 (v) rehabilitation or physical therapy 

25 facilities or services; and 


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1 (B) include revenue- or profit-sharing 

2 whether through a joint venture, management or 

3 professional services agreement, or other form of 

4 gain-sharing contract; 

5 (2) describe Federal oversight of such relation6 ships, including authorities of the Department of 

7 Health and Human Services and the Federal Trade 

8 Commission to review such relationships and their 

9 potential to increase costs for patients, and identify 

10 limitations in such oversight; and 

11 (3) as appropriate, make recommendations to 

12 improve Federal oversight of such relationships. 

13 (b) REPORT.—Not later than 2 years after the date 

14 of the enactment of this Act, the Comptroller General of the 

15 United States shall prepare and submit a report on the 

16 study conducted under subsection (a) to the Committee on 

17 Health, Education, Labor, and Pensions of the Senate and 

18 the Committee on Education and Labor and Committee on 

19 Energy and Commerce of the House of Representatives. 

20 SEC. 404. STATE ALL PAYER CLAIMS DATABASES. 

21 (a) IN GENERAL.—The Secretary of Health and 

22 Human Services shall make one-time grants to eligible 

23 States for the purposes described in subsection (b). 

24 (b) USES.—A State may use a grant received under 

25 subsection (a) for one of the following purposes: 


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1 (1) To establish an All Payer Claims Database 

2 for the State. 

3 (2) To maintain an existing All Payer Claims 

4 Databases for the State. 

5 (c) ELIGIBILITY.—To be eligible to receive a grant 

6 under subsection (a), a State shall submit to the Secretary 

7 an application at such time, in such manner, and con8 taining such information as the Secretary specifies. Such 

9 information shall include, with respect to an All Payer 

10 Claims Database for the State, at least specifics on how the 

11 State will ensure uniform data collection through the data12 base and the security of such data submitted to and main13 tained in the database. 

14 (d) ALL PAYER CLAIMS DATABASE.—For purposes of 

15 this section, the term ‘‘All Payer Claims Database’’ means, 

16 with respect to a State, a State database that may include 

17 medical claims, pharmacy claims, dental claims, and eligi18 bility and provider files, which are collected from private 

19 and public payers. 

20 (e) AUTHORIZATION OF APPROPRIATIONS.—To carry 

21 out this section, there are authorized to be appropriated 

22 $50,000,000, to remain available until expended. 

23 SEC. 405. AIR AMBULANCE COST DATA REPORTING PRO24 GRAM. 

25 (a) COST DATA REPORTING PROGRAM.— 


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1 (1) IN GENERAL.—Not later than 6 months after 

2 the date of the promulgation of the rule under sub3 section (c), and annually thereafter, a provider of 

4 emergency air medical services shall submit to the 

5 Secretary of Health and Human Services the infor6 mation specified in subsection (b) with respect to the 

7 preceding 180-day period (in the case of the initial 

8 period) and the preceding 1-year period (in each sub9 sequent period). 

10 (2) PUBLICATION.—Not later than 180 days 

11 after the date the Secretary of Health and Human 

12 Services receives from a provider described in para13 graph (1) the information specified in subsection (b), 

14 the Secretary shall make publicly available such in15 formation. 

16 (b) SPECIFIED INFORMATION.—Information described 

17 in subsection (a) is— 

18 (1) information, with respect to a claim for an 

19 item or service— 

20 (A) identified as paid by health insurance 

21 coverage offered in the group or individual mar22 ket or a group health plan (including a self-in23 sured plan); 


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1 (B) identified as paid for non-emergent 

2 transport requiring prior authorization and 

3 emergent transport; 

4 (C) identified as paid for hospital-affiliated 

5 providers and independent providers; 

6 (D) identified as paid for rural transport 

7 and urban transport; 

8 (E) identified as provided using rotor 

9 transport and fixed wing transport; and 

10 (F) identified as furnished by a provider of 

11 emergency air medical services that has a con12 tractual relationship with the plan or coverage of 

13 an individual for which such item or service is 

14 provided and such a provider that does not have 

15 a contractual relationship with the plan or cov16 erage or such an individual; and 

17 (2) cost data for an air ambulance service fur18 nished by such a provider of emergency air medical 

19 services that the Secretary of Health and Human 

20 Services, in consultation with suppliers and providers 

21 of such services, determines appropriate, separated by 

22 the cost of air travel and the cost of emergency med23 ical services and supplies. 

24 (c) RULEMAKING.—Not later than 1 year after the date 

25 of the enactment of this Act, the Secretary of Health and 


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1 Human Services shall determine the form and manner for 

2 submitting the information described in subsection (b) 

3 through notice and comment rulemaking. 

4 (d) CIVIL MONETARY PENALTIES.— 

5 (1) IN GENERAL.—A provider of emergency air 

6 medical services who violates the requirements of sub7 section (a)(1) shall be subject to a civil monetary pen8 alty of not more than $10,000 for each act consti9 tuting such violation. 

10 (2) PROCEDURE.—The provisions of section 

11 1128A of the Social Security Act (42 U.S.C. 1320a– 

12 7a), other than subsections (a) and (b) and the first 

13 sentence of subsection (c)(1) of such subsection, shall 

14 apply to civil monetary penalties under this sub15 section in the same manner as such provisions apply 

16 to a penalty or proceeding under such section. 

17 (e) REPORTING.— 

18 (1) SECRETARY OF HEALTH AND HUMAN SERV19 ICES.—Not later than July 1, 2023, the Secretary of 

20 Health and Human Services shall submit to Congress 

21 a report summarizing the information and data spec22 ified in subsection (b). 

23 (2) COMPTROLLER GENERAL.—Not later than 

24 July 1, 2023, the Comptroller General of the United 


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1 States shall submit to Congress a report that in2 cludes— 

3 (A) an analysis of the cost variation of pro4 viders of emergency air ambulance services by 

5 geography and status; and 

6 (B) any other recommendations the Comp7 troller General determines appropriate, which 

8 may include a recommendation of an adequate 

9 amount of reimbursement for such services that 

10 reflects operational costs of such providers in 

11 order to preserve access to emergency air ambu12 lance services. 

13 (f) LIMITATION.—The information publicly disclosed 

14 under subsection (a) and the reports under subsection (f) 

15 may not contain any proprietary information. 

16 SEC. 406. REPORT BY SECRETARY OF LABOR. 

17 Not later than one year after the date of the enactment 

18 of this Act, and annually thereafter for each of the following 

19 5 years, the Secretary of Labor shall— 

20 (1) conduct a study of— 

21 (A) the effects of the provisions of, including 

22 amendments made by, this Act on premiums and 

23 out-of-pocket costs in group health plans, includ24 ing out-of-pocket costs that are permitted by rea25 son of compliance with section 2799A(d) of the 


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1 Public Health Service Act, as added by section 

2 2(d); 

3 (B) the adequacy of provider networks in 

4 group health plans; and 

5 (C) such other effects of such provisions, and 

6 amendments, as the Secretary deems relevant; 

7 and 

8 (2) submit a report on such study to the Com9 mittee on Health, Education, Labor, and Pensions of 

10 the Senate and the Committee on Education and 

11 Labor and the Committee on Energy and Commerce 

12 of the House of Representatives. 

13 SEC. 407. BILLING STATUTE OF LIMITATIONS. 

14 Notwithstanding any other provision of law, a health 

15 care provider or health care facility (or health insurance 

16 issuer offering health insurance coverage or group health 

17 plan) may not initiate a process to seek reimbursement 

18 from an individual for a service furnished by such provider 

19 or facility to such individual more than a year after such 

20 date of service. Any provider, facility, issuer, or plan that 

21 bills an individual in violation of the previous sentence 

22 shall be subject to a civil monetary penalty in such amount 

23 as specified by the Secretary of Health and Human Serv24 ices. 


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1 SEC. 408. GAO REPORT ON IMPACT OF SURPRISE BILLING 

2 PROVISIONS. 

3 Not later than 3 years after the date of the enactment 

4 of this Act, the Comptroller General of the United States 

5 shall submit to Congress a report containing the following: 

6 (1) What is known about the impacts of the pro7 visions of this Act, including the amendments made 

8 by this Act, on the incidence and prevalence of the 

9 furnishing of items and services to individuals en10 rolled under a group health plan or health insurance 

11 coverage by health care providers and health care fa12 cilities that do not have a contractual relationship 

13 with such plan or such coverage (as applicable) for 

14 furnishing such items and services to such an indi15 vidual. 

16 (2) What is known about such impacts on pro17 vider shortages and accessibility to such providers, fo18 cusing on rural and medically underserved commu19 nities. 

20 (3) The number of grants that have been award21 ed under section 404 (relating to State All Payer 

22 Claims Databases) and for what purposes States have 

23 used funds made available under such grants. 

24 (4) An analysis of how data made available 

25 through State All Payer Claims Databases receiving 

26 funding under such grants has been used. 


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1 SEC. 409. REPORT BY THE SECRETARY OF HEALTH AND 

2 HUMAN SERVICES. 

3 Not later than one year after the date of the enactment 

4 of this Act, and annually thereafter for each of the following 

5 5 years, the Secretary of Health and Human Services 

6 shall— 

7 (1) conduct a study of— 

8 (A) the effects of the provisions of, including 

9 amendments made by, this Act on premiums and 

10 out-of-pocket costs with respect to individual 

11 health insurance coverage and small group 

12 health plans; 

13 (B) the adequacy of provider networks with 

14 respect to individual health insurance coverage 

15 and small group health plans, taking into con16 sideration maximum travel time and distance; 

17 and 

18 (C) such other effects of such provisions, and 

19 amendments, as the Secretary deems relevant; 

20 and 

21 (2) submit a report on such study to the Com22 mittee on Health, Education, Labor, and Pensions of 

23 the Senate and the Committee on Education and 

24 Labor and the Committee on Energy and Commerce 

25 of the House of Representatives. 


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1 TITLE V—TERRITORIES HEALTH 

2 CARE IMPROVEMENT ACT 

3 SEC. 501. SHORT TITLE. 

4 This title may be cited as the ‘‘Territories Health Care 

5 Improvement Act’’. 

6 SEC. 502. MEDICAID PAYMENTS FOR PUERTO RICO AND THE 

7 OTHER TERRITORIES FOR CERTAIN FISCAL 

8 YEARS. 

9 (a) TREATMENT OF CAP.—Section 1108(g) of the So10 cial Security Act (42 U.S.C. 1308(g)) is amended— 

11 (1) in paragraph (2)— 

12 (A) in the matter preceding subparagraph 

13 (A), by striking ‘‘subject to and section 

14 1323(a)(2) of the Patient Protection and Afford15 able Care Act paragraphs (3) and (5)’’ and in16 serting ‘‘subject to section 1323(a)(2) of the Pa17 tient Protection and Affordable Care Act and 

18 paragraphs (3) and (5)’’; 

19 (B) in subparagraph (A)— 

20 (i) by striking ‘‘Puerto Rico shall not 

21 exceed the sum of’’ and inserting ‘‘Puerto 

22 Rico shall not exceed— 

23 ‘‘(i) except as provided in clause (ii), 

24 the sum of’’; 


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1 (ii) by striking ‘‘$100,000;’’ and in2 serting ‘‘$100,000; and’’; and 

3 (iii) by adding at the end the following 

4 new clause: 

5 ‘‘(ii) for each of fiscal years 2020 

6 through 2023, the amount specified in para7 graph (6) for each such fiscal year;’’; 

8 (C) in subparagraph (B)— 

9 (i) by striking ‘‘the Virgin Islands 

10 shall not exceed the sum of’’ and inserting 

11 ‘‘the Virgin Islands shall not exceed— 

12 ‘‘(i) except as provided in clause (ii), 

13 the sum of’’; 

14 (ii) by striking ‘‘$10,000;’’ and insert15 ing ‘‘$10,000; and’’; and 

16 (iii) by adding at the end the following 

17 new clause: 

18 ‘‘(ii) for each of fiscal years 2020 

19 through 2025, $126,000,000;’’; 

20 (D) in subparagraph (C)— 

21 (i) by striking ‘‘Guam shall not exceed 

22 the sum of’’ and inserting ‘‘Guam shall not 

23 exceed— 

24 ‘‘(i) except as provided in clause (ii), 

25 the sum of’’; 


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1 (ii) by striking ‘‘$10,000;’’ and insert2 ing ‘‘$10,000; and’’; and 

3 (iii) by adding at the end the following 

4 new clause: 

5 ‘‘(ii) for each of fiscal years 2020 

6 through 2025, $127,000,000;’’; 

7 (E) in subparagraph (D)— 

8 (i) by striking ‘‘the Northern Mariana 

9 Islands shall not exceed the sum of’’ and in10 serting ‘‘the Northern Mariana Islands shall 

11 not exceed— 

12 ‘‘(i) except as provided in clause (ii), 

13 the sum of’’; and 

14 (ii) by adding at the end the following 

15 new clause: 

16 ‘‘(ii) for each of fiscal years 2020 

17 through 2025, $60,000,000; and’’; and 

18 (F) in subparagraph (E)— 

19 (i) by striking ‘‘American Samoa shall 

20 not exceed the sum of’’ and inserting 

21 ‘‘American Samoa shall not exceed— 

22 ‘‘(i) except as provided in clause (ii), 

23 the sum of’’; 

24 (ii) by striking ‘‘$10,000.’’ and insert25 ing ‘‘$10,000; and’’; and 


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1 (iii) by adding at the end the following 

2 new clause: 

3 ‘‘(ii) for each of fiscal years 2020 

4 through 2025, $84,000,000.’’; and 

5 (2) by adding at the end the following new para6 graph: 

7 ‘‘(6) APPLICATION TO PUERTO RICO FOR FISCAL

8 YEARS 2020 THROUGH 2023.—For purposes of para9 graph (2)(A)(ii), the amount specified in this para10 graph is— 

11 ‘‘(A) for fiscal year 2020, $2,823,188,000; 

12 ‘‘(B) for fiscal year 2021, $2,919,072,000; 

13 ‘‘(C) for fiscal year 2022, $3,012,610,000; 

14 and 

15 ‘‘(D) for fiscal year 2023, $3,114,331,000.’’. 

16 (b) TREATMENT OF FUNDING UNDER ENHANCED AL17 LOTMENT PROGRAM.—Section 1935(e) of the Social Secu18 rity Act (42 U.S.C. 1396u–5(e)) is amended— 

19 (1) in paragraph (1)(B), by striking ‘‘if the 

20 State’’ and inserting ‘‘subject to paragraph (4), if the 

21 State’’; 

22 (2) by redesignating paragraph (4) as para23 graph (5); and 

24 (3) by inserting after paragraph (3) the fol25 lowing new paragraph: 


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1 ‘‘(4) TREATMENT OF FUNDING FOR CERTAIN FIS2 CAL YEARS.— 

3 ‘‘(A) PUERTO RICO.—Notwithstanding 

4 paragraph (1)(B), in the case that Puerto Rico 

5 establishes and submits to the Secretary a plan 

6 described in paragraph (2) with respect to any 

7 of fiscal years 2020 through 2023, the amount 

8 specified in paragraph (3) for Puerto Rico for 

9 such a year shall be taken into account in apply10 ing subparagraph (A)(ii) of section 1108(g)(2) 

11 for such year. 

12 ‘‘(B) OTHER TERRITORIES.—Notwith13 standing paragraph (1)(B), in the case that the 

14 Virgin Islands, Guam, the Northern Mariana Is15 lands, or American Samoa establishes and sub16 mits to the Secretary a plan described in para17 graph (2) with respect to any of fiscal years 

18 2020 through 2025, the amount specified in 

19 paragraph (3) for the Virgin Islands, Guam, the 

20 Northern Mariana Islands, or American Samoa, 

21 as the case may be, shall be taken into account 

22 in applying, as applicable, subparagraph 

23 (B)(ii), (C)(ii), (D)(ii), or (E)(ii) of section 

24 1108(g)(2) for such year.’’. 


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1 (c) INCREASED FMAP.—Section 1905 of the Social Se2 curity Act (42 U.S.C. 1396d(b)) is amended— 

3 (1) in subsection (b), by striking ‘‘and (aa)’’ and 

4 inserting ‘‘(aa), and (ff)’’; and 

5 (2) by adding at the end the following new sub6 section: 

7 ‘‘(ff) TEMPORARY INCREASE IN FMAP FOR TERRI8 TORIES FOR CERTAIN FISCAL YEARS.— 

9 ‘‘(1) PUERTO RICO.—Notwithstanding subsection 

10 (b) and subject to subsection (z)(2), the Federal med11 ical assistance percentage for Puerto Rico shall be 

12 equal to— 

13 ‘‘(A) 83 percent for fiscal years 2020 and 

14 2021; and 

15 ‘‘(B) 76 percent for fiscal years 2022 and 

16 2023. 

17 ‘‘(2) VIRGIN ISLANDS.—Notwithstanding sub18 section (b) and subject to subsection (z)(2), the Fed19 eral medical assistance percentage for the Virgin Is20 lands shall be equal to— 

21 ‘‘(A) 100 percent for fiscal year 2020; 

22 ‘‘(B) 83 percent for fiscal years 2021 

23 through 2024; and 

24 ‘‘(C) 76 percent for fiscal year 2025. 


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1 ‘‘(3) OTHER TERRITORIES.—Notwithstanding 

2 subsection (b) and subject to subsection (z)(2), the 

3 Federal medical assistance percentage for Guam, the 

4 Northern Mariana Islands, and American Samoa 

5 shall be equal to— 

6 ‘‘(A) 100 percent for fiscal years 2020 and 

7 2021; 

8 ‘‘(B) 83 percent for fiscal years 2022 

9 through 2024; and 

10 ‘‘(C) 76 percent for fiscal year 2025.’’. 

11 (d) ANNUAL REPORT.—Section 1108(g) of the Social 

12 Security Act (42 U.S.C. 1308(g)), as amended by subsection 

13 (a), is further amended by adding at the end the following 

14 new paragraph: 

15 ‘‘(7) ANNUAL REPORT.— 

16 ‘‘(A) IN GENERAL.—Not later than the date 

17 that is 180 days after the end of each fiscal year 

18 (beginning with fiscal year 2020 and ending 

19 with fiscal year 2025), in the case that a speci20 fied territory receives a Medicaid cap increase, 

21 or an increase in the Federal medical assistance 

22 percentage for such territory under section 

23 1905(ff), for such fiscal year, such territory shall 

24 submit to the Chair and Ranking Member of the 

25 Committee on Energy and Commerce of the 


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1 House of Representatives and the Chair and 

2 Ranking Member of the Committee on Finance of 

3 the Senate a report that describes how such terri4 tory has used such Medicaid cap increase, or 

5 such increase in the Federal medical assistance 

6 percentage, as applicable, to increase access to 

7 health care under the State Medicaid plan of 

8 such territory under title XIX (or a waiver of 

9 such plan). Such report may include— 

10 ‘‘(i) the extent to which such territory 

11 has, with respect to such plan (or waiver)— 

12 ‘‘(I) increased payments to health 

13 care providers; 

14 ‘‘(II) increased covered benefits; 

15 ‘‘(III) expanded health care pro16 vider networks; or 

17 ‘‘(IV) improved in any other 

18 manner the carrying out of such plan 

19 (or waiver); and 

20 ‘‘(ii) any other information as deter21 mined necessary by such territory. 

22 ‘‘(B) DEFINITIONS.—In this paragraph: 

23 ‘‘(i) MEDICAID CAP INCREASE.—The 

24 term ‘Medicaid cap increase’ means, with 

25 respect to a specified territory and fiscal 


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1 year, any increase in the amounts otherwise 

2 determined under this subsection for such 

3 territory for such fiscal year by reason of 

4 the amendments made by section 502(a) of 

5 the Territories Health Care Improvement 

6 Act. 

7 ‘‘(ii) SPECIFIED TERRITORY.—The 

8 term ‘specified territory’ means Puerto 

9 Rico, the Virgin Islands, Guam, the North10 ern Mariana Islands, and American 

11 Samoa.’’. 

12 SEC. 503. APPLICATION OF CERTAIN REQUIREMENTS 

13 UNDER MEDICAID PROGRAM TO CERTAIN 

14 TERRITORIES. 

15 (a) APPLICATION OF PAYMENT ERROR RATE MEAS16 UREMENT REQUIREMENTS TO PUERTO RICO.—Section 

17 1903(u)(4) of the Social Security Act (42 U.S.C. 

18 1396b(u)(4)) is amended— 

19 (1) by striking ‘‘to Puerto Rico, Guam’’ and in20 serting ‘‘to Guam’’; and 

21 (2) by striking ‘‘or American Samoa.’’ and in22 serting ‘‘or American Samoa, or, for fiscal years be23 fore fiscal year 2023, to Puerto Rico.’’. 

24 (b) APPLICATION OF ASSET VERIFICATION PROGRAM

25 REQUIREMENTS TO PUERTO RICO AND VIRGIN ISLANDS.— 


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1 Section 1940(a) of the Social Security Act (42 U.S.C. 

2 1396w(a)) is amended— 

3 (1) in paragraph (3)(A), by adding at the end 

4 the following new clause: 

5 ‘‘(iii) IMPLEMENTATION IN PUERTO

6 RICO AND VIRGIN ISLANDS.—The Secretary 

7 shall require Puerto Rico to implement an 

8 asset verification program under this sub9 section by the end of fiscal year 2022 and 

10 the Virgin Islands to implement such a pro11 gram by the end of fiscal year 2023.’’; and 

12 (2) in paragraph (4)— 

13 (A) in the paragraph heading, by striking 

14 ‘‘EXEMPTION OF TERRITORIES’’ and inserting 

15 ‘‘EXEMPTION OF CERTAIN TERRITORIES’’; and 

16 (B) by striking ‘‘and the District of Colum17 bia’’ and inserting ‘‘, the District of Columbia, 

18 Puerto Rico, and the Virgin Islands’’. 

19 (c) APPLICATION OF CERTAIN DATA REPORTING AND

20 PROGRAM INTEGRITY REQUIREMENTS TO NORTHERN MAR21 IANA ISLANDS, AMERICAN SAMOA, AND GUAM.— 

22 (1) IN GENERAL.—Section 1902 of the Social Se23 curity Act (42 U.S.C. 1396a) is amended by adding 

24 at the end the following new subsection: 


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1 ‘‘(qq) APPLICATION OF CERTAIN DATA REPORTING

2 AND PROGRAM INTEGRITY REQUIREMENTS TO NORTHERN

3 MARIANA ISLANDS, AMERICAN SAMOA, AND GUAM.—Not 

4 later than October 1, 2023, the Northern Mariana Islands, 

5 American Samoa, and Guam shall— 

6 ‘‘(1) implement methods, satisfactory to the Sec7 retary, for the collection and reporting of reliable 

8 data to the Transformed Medicaid Statistical Infor9 mation System (T–MSIS) (or a successor system); 

10 and 

11 ‘‘(2) demonstrate progress in establishing a State 

12 medicaid fraud control unit described in section 

13 1903(q).’’. 

14 (2) CONFORMING AMENDMENT.—Section 1902(j) 

15 of the Social Security Act (42 U.S.C. 1396a(j)) is 

16 amended— 

17 (A) by striking ‘‘or the requirement’’ and 

18 inserting ‘‘, the requirement’’; and 

19 (B) by inserting before the period at the end 

20 the following: ‘‘, or the requirement under sub21 section (qq)(1) (relating to data reporting)’’. 

22 SEC. 504. ADDITIONAL PROGRAM INTEGRITY REQUIRE23 MENTS. 

24 (a) AUDIT RELATING TO FRAUD, WASTE, AND

25 ABUSE.—Not sooner than the date that is one year after 


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1 the date of the enactment of this Act, the Inspector General 

2 of the Department of Health and Human Services (referred 

3 to in this section as the ‘‘Inspector General’’) shall conduct 

4 an audit of Puerto Rico with respect to any part of the 

5 administration of Puerto Rico’s State plan under title XIX 

6 of the Social Security Act (42 U.S.C. 1396 et seq.) (or a 

7 waiver of such plan), such as contracting protocols, denials 

8 of care, and financial management, that the Inspector Gen9 eral determines to be at high risk for waste, fraud, or abuse. 

10 (b) PLAN FOR AUDITS AND INVESTIGATIONS OF CON11 TRACTING PRACTICES.—Not later than the date that is one 

12 year after the date of the enactment of this Act, the Inspec13 tor General shall develop and submit to Congress a plan 

14 for auditing and investigating contracting practices relat15 ing to Puerto Rico’s State plan under title XIX of the Social 

16 Security Act (42 U.S.C. 1396 et seq.) (or a waiver of such 

17 plan). 

18 (c) REPORT ON CONTRACTING OVERSIGHT AND AP19 PROVAL.—Not later than the date that is two years after 

20 the date of the enactment of this Act, the Comptroller Gen21 eral of the United States shall issue, and submit to the 

22 Chair and Ranking Member of the Committee on Energy 

23 and Commerce of the House of Representatives and the 

24 Chair and Ranking Member of the Committee on Finance 

25 of the Senate, a report on contracting oversight and apVerDate Sep 11 2014 21:36 Dec 31, 2020 Jkt 019200 PO 00000 Frm 00110 Fmt 6652 Sfmt 6203 E:\BILLS\H2328.RH H2328

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1 proval with respect to Puerto Rico’s State plan under title 

2 XIX of the Social Security Act (42 U.S.C. 1396 et seq.) 

3 (or a waiver of such plan). Such report shall— 

4 (1) examine— 

5 (A) the process used by Puerto Rico to 

6 evaluate bids and award contracts under such 

7 plan (or waiver); 

8 (B) which contracts are not subject to com9 petitive bidding or requests for proposals under 

10 such plan (or waiver); and 

11 (C) oversight by the Centers for Medicare & 

12 Medicaid Services of contracts awarded under 

13 such plan (or waiver); and 

14 (2) include any recommendations for Congress, 

15 the Secretary of Health and Human Services, or 

16 Puerto Rico relating to changes that the Inspector 

17 General determines necessary to improve the program 

18 integrity of such plan (or waiver). 

19 (d) REEVALUATION OF WAIVERS OF MEDICAID FRAUD

20 CONTROL UNIT REQUIREMENT.—Not later than the date 

21 that is one year after the date of the enactment of this Act, 

22 the Secretary of Health and Human Services shall— 

23 (1) reevaluate any waiver approved (and in ef24 fect as of the date of the enactment of this Act) for 

25 Guam, the Northern Mariana Islands, or American 


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1 Samoa under subsection (a)(61) or subsection (j) of 

2 section 1902 of the Social Security Act (42 U.S.C. 

3 1396a) with respect to the requirement to establish a 

4 State medicaid fraud control unit (as described in 

5 section 1903(q) of such Act (42 U.S.C. 1396b(q)); and 

6 (2) determine whether any such waiver should 

7 continue to be approved with respect to Guam, the 

8 Northern Mariana Islands, or American Samoa, re9 spectively, after October 1, 2023. 

10 (e) SYSTEM FOR TRACKING FEDERAL FUNDING PRO11 VIDED TO PUERTO RICO.—Section 1902 of the Social Secu12 rity Act (42 U.S.C. 1396a), as amended by section 503(c), 

13 is further amended by adding at the end the following new 

14 subsection: 

15 ‘‘(rr) PROGRAM INTEGRITY REQUIREMENTS FOR

16 PUERTO RICO.— 

17 ‘‘(1) SYSTEM FOR TRACKING FEDERAL FUNDING

18 PROVIDED TO PUERTO RICO.— 

19 ‘‘(A) IN GENERAL.—Puerto Rico shall estab20 lish and maintain a system for tracking any 

21 amounts paid by the Federal Government to 

22 Puerto Rico with respect to the State plan of 

23 Puerto Rico (or a waiver of such plan). Under 

24 such system, Puerto Rico shall ensure that infor25 mation is available, with respect to each quarter 


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1 in a fiscal year (beginning with the first quarter 

2 beginning on or after the date that is one year 

3 after the date of the enactment of this sub4 section), on the following: 

5 ‘‘(i) In the case of a quarter other than 

6 the first quarter of such fiscal year— 

7 ‘‘(I) the total amount expended by 

8 Puerto Rico during any previous quar9 ter of such fiscal year under the State 

10 plan of Puerto Rico (or a waiver of 

11 such plan); and 

12 ‘‘(II) a description of how such 

13 amount was so expended. 

14 ‘‘(ii) The total amount that Puerto 

15 Rico expects to expend during the quarter 

16 under the State plan of Puerto Rico (or a 

17 waiver of such plan), and a description of 

18 how Puerto Rico expects to expend such 

19 amount. 

20 ‘‘(B) REPORT TO CMS.—For each quarter 

21 with respect to which Puerto Rico is required 

22 under subparagraph (A) to ensure that informa23 tion described in such subparagraph is available, 

24 Puerto Rico shall submit to the Administrator of 


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1 the Centers for Medicare & Medicaid Services a 

2 report on such information for such quarter. 

3 ‘‘(2) SUBMISSION OF DOCUMENTATION ON CON4 TRACTS UPON REQUEST.—Puerto Rico shall, upon re5 quest, submit to the Administrator of the Centers for 

6 Medicare & Medicaid Services all documentation re7 quested with respect to contracts awarded under the 

8 State plan of Puerto Rico (or a waiver of such 

9 plan).’’. 

Amend the title so as to read: ‘‘A bill to reauthorize 

and extend funding for critical public health programs 

that improve access to health care and strengthen the 

health care workforce, to extend provisions of the Medicare program, to strengthen the Medicaid program in the 

territories, to protect health care consumers from surprise billing practices, and for other purposes.’’. 


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Union Calendar No. 587 

116TH CONGRESS 

2D SESSION H. R. 2328 

[Report No. 116–332, Part I] 

A BILL 

To reauthorize and extend funding for community 

Corps. health centers and the National Health Service 

DECEMBER 31, 2020 

Committee on Transportation and Infrastructure disprinted House on the State of the Union and ordered to be charged; committed to the Committee of the Whole 


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