4147 
tion with respect to which such a deter-
mination was so made; 
‘‘(v) the number of times the payment 
amount determined (or agreed to) under 
this subsection exceeds the qualifying pay-
ment amount, specified by items and serv-
ices; 
‘‘(vi) the amount of expenditures made 
by the Secretary during such calendar quar-
ter to carry out the IDR process; 
‘‘(vii) the total amount of fees paid 
under paragraph (8) during such calendar 
quarter; and 
‘‘(viii) the total amount of compensa-
tion paid to certified IDR entities under 
paragraph (5)(F) during such calendar 
quarter. 
‘‘(B) INFORMATION.—For purposes of sub-
paragraph (A), the information described in this 
subparagraph is, with respect to a notification 
under paragraph (1)(B) by a nonparticipating 
provider, nonparticipating emergency facility, or 
group health plan— 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04147
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4148 
‘‘(i) a description of each item and 
service included with respect to such notifi-
cation; 
‘‘(ii) the geography in which the items 
and services with respect to such notifica-
tion were provided; 
‘‘(iii) the amount of the offer submitted 
under paragraph (5)(B) by the group health 
plan and by the nonparticipating provider 
or nonparticipating emergency facility (as 
applicable) expressed as a percentage of the 
qualifying payment amount; 
‘‘(iv) whether the offer selected by the 
certified IDR entity under paragraph (5) to 
be the payment applied was the offer sub-
mitted by such plan or by such provider or 
facility (as applicable) and the amount of 
such offer so selected expressed as a percent-
age of the qualifying payment amount; 
‘‘(v) the category and practice spe-
cialty of each such provider or facility in-
volved in furnishing such items and serv-
ices; 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04148
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4149 
‘‘(vi) the identity of the group health 
plan, provider, or facility, with respect to 
the notification; 
‘‘(vii) the length of time in making 
each determination; 
‘‘(viii) the compensation paid to the 
certified IDR entity with respect to the set-
tlement or determination; and 
‘‘(ix) any other information specified 
by the Secretary. 
‘‘(C) IDR 
ENTITY
REQUIREMENTS.—For 
2022 and each subsequent year, an IDR entity, 
as a condition of certification as an IDR entity, 
shall submit to the Secretary such information 
as the Secretary determines necessary to carry 
out the provisions of this subsection. 
‘‘(D) CLARIFICATION.—The Secretary shall 
ensure the public reporting under this paragraph 
does not contain information that would disclose 
privileged or confidential information of a group 
health plan or health insurance issuer offering 
group or individual health insurance coverage or 
of a provider or facility. 
‘‘(8) ADMINISTRATIVE FEE.— 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04149
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4150 
‘‘(A) IN GENERAL.—Each party to a deter-
mination under paragraph (5) to which an enti-
ty is selected under paragraph (3) in a year 
shall pay to the Secretary, at such time and in 
such manner as specified by the Secretary, a fee 
for participating in the IDR process with respect 
to such determination in an amount described in 
subparagraph (B) for such year. 
‘‘(B) AMOUNT
OF
FEE.—The amount de-
scribed in this subparagraph for a year is an 
amount established by the Secretary in a man-
ner such that the total amount of fees paid under 
this paragraph for such year is estimated to be 
equal to the amount of expenditures estimated to 
be made by the Secretary for such year in car-
rying out the IDR process. 
‘‘(9) WAIVER AUTHORITY.—The Secretary may 
modify any deadline or other timing requirement 
specified under this subsection (other than the estab-
lishment date for the IDR process under paragraph 
(2)(A) and other than under paragraph (6)) in cases 
of extenuating circumstances, as specified by the Sec-
retary, or to ensure that all claims that occur during 
a 90-day period described in paragraph (5)(E)(ii), 
but with respect to which a notification is not per-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04150
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4151 
mitted by reason of such paragraph to be submitted 
under paragraph (1)(B) during such period, are eligi-
ble for the IDR process.’’. 
SEC. 104. HEALTH CARE PROVIDER REQUIREMENTS RE-
GARDING SURPRISE MEDICAL BILLING. 
(a) IN GENERAL.—Title XXVII of the Public Health 
Service Act (42 U.S.C. 300gg et seq.) is amended by insert-
ing after part D, as added by section 102, the following: 
‘‘PART E—HEALTH CARE PROVIDER 
REQUIREMENTS 
‘‘SEC. 2799B–1. BALANCE BILLING IN CASES OF EMERGENCY 
SERVICES. 
‘‘(a) IN GENERAL.—In the case of a participant, bene-
ficiary, or enrollee with benefits under a group health plan 
or group or individual health insurance coverage offered by 
a health insurance issuer and who is furnished during a 
plan year beginning on or after January 1, 2022, emer-
gency services (for which benefits are provided under the 
plan or coverage) with respect to an emergency medical con-
dition with respect to a visit at an emergency department 
of a hospital or an independent freestanding emergency de-
partment— 
‘‘(1) in the case that the hospital or independent 
freestanding emergency department is a nonpartici-
pating emergency facility, the emergency department 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04151
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4152 
of a hospital or independent freestanding emergency 
department shall not bill, and shall not hold liable, 
the participant, beneficiary, or enrollee for a payment 
amount for such emergency services so furnished that 
is more than the cost-sharing requirement for such 
services (as determined in accordance with clauses 
(ii) and (iii) of section 2799A–1(a)(1)(C), of section 
9816(a)(1)(C) of the Internal Revenue Code of 1986, 
and of section 716(a)(1)(C) of the Employee Retire-
ment Income Security Act of 1974, as applicable); 
and 
‘‘(2) in the case that such services are furnished 
by a nonparticipating provider, the health care pro-
vider shall not bill, and shall not hold liable, such 
participant, beneficiary, or enrollee for a payment 
amount for an emergency service furnished to such in-
dividual by such provider with respect to such emer-
gency medical condition and visit for which the indi-
vidual receives emergency services at the hospital or 
emergency department that is more than the cost- 
sharing requirement for such services furnished by the 
provider (as determined in accordance with clauses 
(ii) and (iii) of section 2799A–1(a)(1)(C), of section 
9816(a)(1)(C) of the Internal Revenue Code of 1986, 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04152
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4153 
and of section 716(a)(1)(C) of the Employee Retire-
ment Income Security Act of 1974, as applicable). 
‘‘(b) DEFINITION.—In this section, the term ‘visit’ 
shall have such meaning as applied to such term for pur-
poses of section 2799A–1(b). 
‘‘SEC. 2799B–2. BALANCE BILLING IN CASES OF NON-EMER-
GENCY 
SERVICES 
PERFORMED 
BY 
NON-
PARTICIPATING 
PROVIDERS 
AT 
CERTAIN 
PARTICIPATING FACILITIES. 
‘‘(a) IN GENERAL.—Subject to subsection (b), in the 
case of a participant, beneficiary, or enrollee with benefits 
under a group health plan or group or individual health 
insurance coverage offered by a health insurance issuer and 
who is furnished during a plan year beginning on or after 
January 1, 2022, items or services (other than emergency 
services to which section 2799B–1 applies) for which bene-
fits are provided under the plan or coverage at a partici-
pating health care facility by a nonparticipating provider, 
such provider shall not bill, and shall not hold liable, such 
participant, beneficiary, or enrollee for a payment amount 
for such an item or service furnished by such provider with 
respect to a visit at such facility that is more than the cost- 
sharing requirement for such item or service (as determined 
in accordance with subparagraphs (A) and (B) of section 
2799A–1(b)(1) of section 9816(b)(1) of the Internal Revenue 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04153
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4154 
Code of 1986, and of section 716(b)(1) of the Employee Re-
tirement Income Security Act of 1974, as applicable). 
‘‘(b) EXCEPTION.— 
‘‘(1) IN
GENERAL.—Subsection (a) shall not 
apply with respect to items or services (other than an-
cillary services described in paragraph (2)) furnished 
by a nonparticipating provider to a participant, ben-
eficiary, or enrollee of a group health plan or group 
or individual health insurance coverage offered by a 
health insurance issuer, if the provider satisfies the 
notice and consent criteria of subsection (d). 
‘‘(2) ANCILLARY
SERVICES
DESCRIBED.—For 
purposes of paragraph (1), ancillary services de-
scribed in this paragraph are, with respect to a par-
ticipating health care facility— 
‘‘(A) subject to paragraph (3), items and 
services related to emergency medicine, anesthesi-
ology, pathology, radiology, and neonatology, 
whether or not provided by a physician or non- 
physician practitioner, and items and services 
provided by assistant surgeons, hospitalists, and 
intensivists; 
‘‘(B) subject to paragraph (3), diagnostic 
services (including radiology and laboratory 
services); 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04154
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4155 
‘‘(C) items and services provided by such 
other specialty practitioners, as the Secretary 
specifies through rulemaking; and 
‘‘(D) items and services provided by a non-
participating provider if there is no partici-
pating provider who can furnish such item or 
service at such facility. 
‘‘(3) EXCEPTION.—The Secretary may, through 
rulemaking, establish a list (and update such list pe-
riodically) of advanced diagnostic laboratory tests, 
which shall not be included as an ancillary service 
described in paragraph (2) and with respect to which 
subsection (a) would apply. 
‘‘(c) CLARIFICATION.—In the case of a nonpartici-
pating provider that satisfies the notice and consent criteria 
of subsection (d) with respect to an item or service (referred 
to in this subsection as a ‘covered item or service’), such 
notice and consent criteria may not be construed as apply-
ing with respect to any item or service that is furnished 
as a result of unforeseen, urgent medical needs that arise 
at the time such covered item or service is furnished. For 
purposes of the previous sentence, a covered item or service 
shall not include an ancillary service described in sub-
section (b)(2). 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04155
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4156 
‘‘(d) NOTICE AND CONSENT TO BE TREATED BY A 
NONPARTICIPATING PROVIDER OR NONPARTICIPATING FA-
CILITY.— 
‘‘(1) IN GENERAL.—A nonparticipating provider 
or nonparticipating facility satisfies the notice and 
consent criteria of this subsection, with respect to 
items or services furnished by the provider or facility 
to a participant, beneficiary, or enrollee of a group 
health plan or group or individual health insurance 
coverage offered by a health insurance issuer, if the 
provider (or, if applicable, the participating health 
care facility on behalf of such provider) or non-
participating facility— 
‘‘(A) in the case that the participant, bene-
ficiary, or enrollee makes an appointment to be 
furnished such items or services at least 72 hours 
prior to the date on which the individual is to 
be furnished such items or services, provides to 
the participant, beneficiary, or enrollee (or to an 
authorized representative of the participant, ben-
eficiary, or enrollee) not later than 72 hours 
prior to the date on which the individual is fur-
nished such items or services (or, in the case that 
the participant, beneficiary, or enrollee makes 
such an appointment within 72 hours of when 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04156
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4157 
such items or services are to be furnished, pro-
vides to the participant, beneficiary, or enrollee 
(or to an authorized representative of the partici-
pant, beneficiary, or enrollee) on such date the 
appointment is made), a written notice in paper 
or electronic form, as selected by the participant, 
beneficiary, or enrollee, (and including electronic 
notification, as practicable) specified by the Sec-
retary, not later than July 1, 2021, through 
guidance (which shall be updated as determined 
necessary by the Secretary) that— 
‘‘(i) contains the information required 
under paragraph (2); 
‘‘(ii) clearly states that consent to re-
ceive such items and services from such non-
participating provider or nonparticipating 
facility is optional and that the partici-
pant, beneficiary, or enrollee may instead 
seek care from a participating provider or 
at a participating facility, with respect to 
such plan or coverage, as applicable, in 
which case the cost-sharing responsibility of 
the participant, beneficiary, or enrollee 
would not exceed such responsibility that 
would apply with respect to such an item or 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04157
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4158 
service that is furnished by a participating 
provider or participating facility, as appli-
cable with respect to such plan; and 
‘‘(iii) is available in the 15 most com-
mon languages in the geographic region of 
the applicable facility; 
‘‘(B) obtains from the participant, bene-
ficiary, or enrollee (or from such an authorized 
representative) the consent described in para-
graph (3) to be treated by a nonparticipating 
provider or nonparticipating facility; and 
‘‘(C) provides a signed copy of such consent 
to the participant, beneficiary, or enrollee 
through mail or email (as selected by the partici-
pant, beneficiary, or enrollee). 
‘‘(2) INFORMATION REQUIRED UNDER WRITTEN 
NOTICE.—For purposes of paragraph (1)(A)(i), the 
information described in this paragraph, with respect 
to a nonparticipating provider or nonparticipating 
facility and a participant, beneficiary, or enrollee of 
a group health plan or group or individual health in-
surance coverage offered by a health insurance issuer, 
is each of the following: 
‘‘(A) Notification, as applicable, that the 
health care provider is a nonparticipating pro-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04158
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4159 
vider with respect to the health plan or the 
health care facility is a nonparticipating facility 
with respect to the health plan. 
‘‘(B) Notification of the good faith estimated 
amount that such provider or facility may 
charge the participant, beneficiary, or enrollee 
for such items and services involved, including a 
notification that the provision of such estimate 
or consent to be treated under paragraph (3) 
does not constitute a contract with respect to the 
charges estimated for such items and services. 
‘‘(C) In the case of a participating facility 
and a nonparticipating provider, a list of any 
participating providers at the facility who are 
able to furnish such items and services involved 
and notification that the participant, bene-
ficiary, or enrollee may be referred, at their op-
tion, to such a participating provider. 
‘‘(D) Information about whether prior au-
thorization or other care management limita-
tions may be required in advance of receiving 
such items or services at the facility. 
‘‘(3) CONSENT DESCRIBED TO BE TREATED BY A 
NONPARTICIPATING PROVIDER OR NONPARTICIPATING 
FACILITY.—For purposes of paragraph (1)(B), the 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04159
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4160 
consent described in this paragraph, with respect to 
a participant, beneficiary, or enrollee of a group 
health plan or group or individual health insurance 
coverage offered by a health insurance issuer who is 
to be furnished items or services by a nonpartici-
pating provider or nonparticipating facility, is a doc-
ument specified by the Secretary, in consultation with 
the Secretary of Labor, through guidance that shall be 
signed by the participant, beneficiary, or enrollee be-
fore such items or services are furnished and that — 
‘‘(A) acknowledges (in clear and under-
standable language) that the participant, bene-
ficiary, or enrollee has been— 
‘‘(i) provided with the written notice 
under paragraph (1)(A); 
‘‘(ii) informed that the payment of 
such charge by the participant, beneficiary, 
or enrollee may not accrue toward meeting 
any limitation that the plan or coverage 
places on cost-sharing, including an expla-
nation that such payment may not apply to 
an in-network deductible applied under the 
plan or coverage; and 
‘‘(iii) provided the opportunity to re-
ceive the written notice under paragraph 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04160
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4161 
(1)(A) in the form selected by the partici-
pant, beneficiary or enrollee; and 
‘‘(B) documents the date on which the par-
ticipant, beneficiary, or enrollee received the 
written notice under paragraph (1)(A) and the 
date on which the individual signed such consent 
to be furnished such items or services by such 
provider or facility. 
‘‘(4) RULE OF CONSTRUCTION.—The consent de-
scribed in paragraph (3), with respect to a partici-
pant, beneficiary, or enrollee of a group health plan 
or group or individual health insurance coverage of-
fered by a health insurance issuer, shall constitute 
only consent to the receipt of the information pro-
vided pursuant to this subsection and shall not con-
stitute a contractual agreement of the participant, 
beneficiary, or enrollee to any estimated charge or 
amount included in such information. 
‘‘(e) RETENTION OF CERTAIN DOCUMENTS.—A non-
participating facility (with respect to such facility or any 
nonparticipating provider at such facility) or a partici-
pating facility (with respect to nonparticipating providers 
at such facility) that obtains from a participant, bene-
ficiary, or enrollee of a group health plan or group or indi-
vidual health insurance coverage offered by a health insur-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04161
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4162 
ance issuer (or an authorized representative of such partici-
pant, beneficiary, or enrollee) a written notice in accord-
ance with subsection (d)(1)(B), with respect to furnishing 
an item or service to such participant, beneficiary, or en-
rollee, shall retain such notice for at least a 7-year period 
after the date on which such item or service is so furnished. 
‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) The terms ‘nonparticipating provider’ and 
‘participating provider’ have the meanings given such 
terms, respectively, in subsection (a)(3) of section 
2799A–1. 
‘‘(2) The term ‘participating health care facility’ 
has the meaning given such term in subsection (b)(2) 
of section 2799A–1. 
‘‘(3) 
The 
term 
‘nonparticipating 
facility’ 
means— 
‘‘(A) with respect to emergency services (as 
defined in section 2799A–1(a)(3)(C)(i)) and a 
group health plan or group or individual health 
insurance coverage offered by a health insurance 
issuer, an emergency department of a hospital, 
or an independent freestanding emergency de-
partment, that does not have a contractual rela-
tionship with the plan or issuer, respectively, 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04162
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4163 
with respect to the furnishing of such services 
under the plan or coverage, respectively; and 
‘‘(B) with respect to services described in 
section 2799A–1(a)(3)(C)(ii) and a group health 
plan or group or individual health insurance 
coverage offered by a health insurance issuer, a 
hospital or an independent freestanding emer-
gency department, that does not have a contrac-
tual relationship with the plan or issuer, respec-
tively, with respect to the furnishing of such 
services under the plan or coverage, respectively. 
‘‘(4) The term ‘participating facility’ means— 
‘‘(A) with respect to emergency services (as 
defined 
in 
clause 
(i) 
of 
section 
2799A– 
1(a)(3)(C)) that are not described in clause(ii) of 
such section and a group health plan or group 
or individual health insurance coverage offered 
by a health insurance issuer, an emergency de-
partment of a hospital, or an independent free-
standing emergency department, that has a di-
rect or indirect contractual relationship with the 
plan or issuer, respectively, with respect to the 
furnishing of such services under the plan or cov-
erage, respectively; and 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04163
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4164 
‘‘(B) with respect to services that pursuant 
to clause (ii) of section 2799A–1(a)(3)(C), of sec-
tion 9816(a)(3) of the Internal Revenue Code of 
1986, and of section 716(a)(3) of the Employee 
Retirement Income Security Act of 1974, as ap-
plicable are included as emergency services (as 
defined in clause (i) of such section and a group 
health plan or group or individual health insur-
ance coverage offered by a health insurance 
issuer, a hospital or an independent freestanding 
emergency department, that has a contractual re-
lationship with the plan or coverage, respec-
tively, with respect to the furnishing of such 
services under the plan or coverage, respectively. 
‘‘SEC. 2799B–3. PROVIDER REQUIREMENTS WITH RESPECT 
TO DISCLOSURE ON PATIENT PROTECTIONS 
AGAINST BALANCE BILLING. 
‘‘Beginning not later than January 1, 2022, each 
health care provider and health care facility shall make 
publicly available, and (if applicable) post on a public 
website of such provider or facility and provide to individ-
uals who are participants, beneficiaries, or enrollees of a 
group health plan or group or individual health insurance 
coverage offered by a health insurance issuer a one-page no-
tice (either postal or electronic mail, as specified by the par-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04164
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4165 
ticipant, beneficiary, or enrollee) in clear and understand-
able language containing information on— 
‘‘(1) the requirements and prohibitions of such 
provider or facility under sections 2799B–1 and 
2799B–2 (relating to prohibitions on balance billing 
in certain circumstances); 
‘‘(2) any other applicable State law requirements 
on such provider or facility regarding the amounts 
such provider or facility may, with respect to an item 
or service, charge a participant, beneficiary, or en-
rollee of a group health plan or group or individual 
health insurance coverage offered by a health insur-
ance issuer with respect to which such provider or fa-
cility does not have a contractual relationship for fur-
nishing such item or service under the plan or cov-
erage, respectively, after receiving payment from the 
plan or coverage, respectively, for such item or service 
and any applicable cost-sharing payment from such 
participant, beneficiary, or enrollee; and 
‘‘(3) information on contacting appropriate 
State and Federal agencies in the case that an indi-
vidual believes that such provider or facility has vio-
lated any requirement described in paragraph (1) or 
(2) with respect to such individual. 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04165
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4166 
‘‘SEC. 2799B–4. ENFORCEMENT. 
‘‘(a) STATE ENFORCEMENT.— 
‘‘(1) STATE AUTHORITY.—Each State may re-
quire a provider or health care facility (including a 
provider of air ambulance services) subject to the re-
quirements of this part to satisfy such requirements 
applicable to the provider or facility. 
‘‘(2) FAILURE TO IMPLEMENT REQUIREMENTS.— 
In the case of a determination by the Secretary that 
a State has failed to substantially enforce the require-
ments to which paragraph (1) applies with respect to 
applicable providers and facilities in the State, the 
Secretary shall enforce such requirements under sub-
section (b) insofar as they relate to violations of such 
requirements occurring in such State. 
‘‘(3) 
NOTIFICATION
OF
APPLICABLE
SEC-
RETARY.—A State may notify the Secretary of Labor, 
Secretary of Health and Human Services, or the Sec-
retary of the Treasury, as applicable, of instances of 
violations of sections 2799B–1, 2799B–2, or 2799B– 
5 with respect to participants, beneficiaries, or enroll-
ees under a group health plan or group or individual 
health insurance coverage, as applicable offered by a 
health insurance issuer and any enforcement actions 
taken against providers or facilities as a result of 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04166
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4167 
such violations, including the disposition of any such 
enforcement actions. 
‘‘(b) SECRETARIAL ENFORCEMENT AUTHORITY.— 
‘‘(1) IN GENERAL.—If a provider or facility is 
found by the Secretary to be in violation of a require-
ment to which subsection (a)(1) applies, the Secretary 
may apply a civil monetary penalty with respect to 
such provider or facility (including, as applicable, a 
provider of air ambulance services) in an amount not 
to exceed $10,000 per violation. The provisions of sub-
sections (c) (with the exception of the first sentence of 
paragraph (1) of such subsection), (d), (e), (g), (h), 
(k), and (l) of section 1128A of the Social Security 
Act shall apply to a civil monetary penalty or assess-
ment under this subsection in the same manner as 
such provisions apply to a penalty, assessment, or 
proceeding under subsection (a) of such section. 
‘‘(2) LIMITATION.—The provisions of paragraph 
(1) shall apply to enforcement of a provision (or pro-
visions) specified in subsection (a)(1) only as pro-
vided under subsection (a)(2). 
‘‘(3) COMPLAINT PROCESS.—The Secretary shall, 
through rulemaking, establish a process to receive con-
sumer complaints of violations of such provisions and 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04167
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4168 
provide a response to such complaints within 60 days 
of receipt of such complaints. 
‘‘(4) EXCEPTION.—The Secretary shall waive the 
penalties described under paragraph (1) with respect 
to a facility or provider (including a provider of air 
ambulance services) who does not knowingly violate, 
and should not have reasonably known it violated, 
section 2799B–1 or 2799B–2 (or, in the case of a pro-
vider of air ambulance services, section 2799B–5) 
with respect to a participant, beneficiary, or enrollee, 
if such facility or provider, within 30 days of the vio-
lation, withdraws the bill that was in violation of 
such provision and reimburses the health plan or en-
rollee, as applicable, in an amount equal to the dif-
ference between the amount billed and the amount al-
lowed to be billed under the provision, plus interest, 
at an interest rate determined by the Secretary. 
‘‘(5) HARDSHIP
EXEMPTION.—The Secretary 
may establish a hardship exemption to the penalties 
under this subsection. 
‘‘(c) CONTINUED APPLICABILITY OF STATE LAW.—The 
sections specified in subsection (a)(1) shall not be construed 
to supersede any provision of State law which establishes, 
implements, or continues in effect any requirement or pro-
hibition except to the extent that such requirement or prohi-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04168
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4169 
bition prevents the application of a requirement or prohibi-
tion of such a section.’’. 
(b) SECRETARY OF LABOR ENFORCEMENT.— 
(1) IN GENERAL.—Part 5 of subtitle B of title I 
of the Employee Retirement Income Security Act of 
1974 (29 U.S.C. 1131 et seq.) is amended by adding 
at the end the following new section: 
‘‘SEC. 522. COORDINATION OF ENFORCEMENT REGARDING 
VIOLATIONS OF CERTAIN HEALTH CARE PRO-
VIDER REQUIREMENTS; COMPLAINT PROC-
ESS. 
‘‘(a) INVESTIGATING VIOLATIONS.—Upon receiving a 
notice from a State or the Secretary of Health and Human 
Services of violations of sections 2799B–1, 2799B–2, or 
2799B–5 of the Public Health Service Act, the Secretary 
of Labor shall identify patterns of such violations with re-
spect to participants or beneficiaries under a group health 
plan or group health insurance coverage offered by a health 
insurance issuer and conduct an investigation pursuant to 
section 504 where appropriate, as determined by the Sec-
retary. The Secretary shall coordinate with States and the 
Secretary of Health and Human Services, in accordance 
with section 506 and with section 104 of Health Insurance 
Portability and Accountability Act of 1996, where appro-
priate, as determined by the Secretary, to ensure that ap-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04169
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4170 
propriate measures have been taken to correct such viola-
tions retrospectively and prospectively with respect to par-
ticipants or beneficiaries under a group health plan or 
group health insurance coverage offered by a health insur-
ance issuer. 
‘‘(b) COMPLAINT PROCESS.— Not later than January 
1, 2022, the Secretary shall ensure a process under which 
the Secretary— 
‘‘(1) may receive complaints from participants 
and beneficiaries of group health plans or group 
health insurance coverage offered by a health insur-
ance issuer relating to alleged violations of the sec-
tions specified in subsection (a); and 
‘‘(2) transmits such complaints to States or the 
Secretary of Health and Human Services (as deter-
mined appropriate by the Secretary) for potential en-
forcement actions.’’. 
(2) TECHNICAL AMENDMENT.—The table of con-
tents in section 1 of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1001 et seq.) is 
amended by inserting after the item relating to sec-
tion 521 the following new item: 
‘‘Sec. 522. Coordination of enforcement regarding violations of certain health care 
provider requirements; complaint process.’’. 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04170
Fmt 6652
Sfmt 6213
Z:\116\ENGROSS\H133.EAH
h133
4171 
SEC. 105. ENDING SURPRISE AIR AMBULANCE BILLS. 
(a) GROUP HEALTH PLANS
AND INDIVIDUAL
AND 
GROUP HEALTH INSURANCE COVERAGE.— 
(1) PHSA AMENDMENTS.—Part D of title XXVII 
of the Public Health Service Act, as added and 
amended by section 102 and further amended by the 
previous provisions of this title, is further amended 
by inserting after section 2799A–1 the following: 
‘‘SEC. 2799A–2. ENDING SURPRISE AIR AMBULANCE BILLS. 
‘‘(a) IN GENERAL.—In the case of a participant, bene-
ficiary, or enrollee who is in a group health plan or group 
or individual health insurance coverage offered by a health 
insurance issuer and who receives air ambulance services 
from a nonparticipating provider (as defined in section 
2799A–1(a)(3)(G)) with respect to such plan or coverage, 
if such services would be covered if provided by a partici-
pating provider (as defined in such section) with respect 
to such plan or coverage— 
‘‘(1) the cost-sharing requirement with respect to 
such services shall be the same requirement that would 
apply if such services were provided by such a par-
ticipating provider, and any coinsurance or deduct-
ible shall be based on rates that would apply for such 
services if they were furnished by such a partici-
pating provider; 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04171
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4172 
‘‘(2) such cost-sharing amounts shall be counted 
towards the in-network deductible and in-network 
out-of-pocket maximum amount under the plan or 
coverage for the plan year (and such in-network de-
ductible shall be applied) with respect to such items 
and services so furnished in the same manner as if 
such cost-sharing payments were with respect to items 
and services furnished by a participating provider; 
and 
‘‘(3) the group health plan or health insurance 
issuer, respectively, shall— 
‘‘(A) not later than 30 calendar days after 
the bill for such services is transmitted by such 
provider, send to the provider, an initial pay-
ment or notice of denial of payment; and 
‘‘(B) pay a total plan or coverage payment, 
in accordance with, if applicable, subsection 
(b)(6), directly to such provider furnishing such 
services to such participant, beneficiary, or en-
rollee that is, with application of any initial 
payment under subparagraph (A), equal to the 
amount by which the out-of-network rate (as de-
fined in section 2799A–1(a)(3)(K)) for such serv-
ices and year involved exceeds the cost-sharing 
amount imposed under the plan or coverage, re-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04172
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4173 
spectively, for such services (as determined in ac-
cordance with paragraphs (1) and (2)). 
‘‘(b) DETERMINATION OF OUT-OF-NETWORK RATES TO 
BE PAID BY HEALTH PLANS; INDEPENDENT DISPUTE RES-
OLUTION PROCESS.— 
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIA-
TION.— 
‘‘(A) IN GENERAL.—With respect to air am-
bulance services furnished in a year by a non-
participating provider, with respect to a group 
health plan or health insurance issuer offering 
group or individual health insurance coverage, 
and for which a payment is required to be made 
by the plan or coverage pursuant to subsection 
(a)(3), the provider or plan or coverage may, 
during the 30-day period beginning on the day 
the provider receives an initial payment or a no-
tice of denial of payment from the plan or cov-
erage regarding a claim for payment for such 
service, initiate open negotiations under this 
paragraph between such provider and plan or 
coverage for purposes of determining, during the 
open negotiation period, an amount agreed on 
by such provider, and such plan or coverage for 
payment (including any cost-sharing) for such 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04173
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4174 
service. For purposes of this subsection, the open 
negotiation period, with respect to air ambulance 
services, is the 30-day period beginning on the 
date of initiation of the negotiations with respect 
to such services. 
‘‘(B) ACCESSING
INDEPENDENT
DISPUTE 
RESOLUTION PROCESS IN CASE OF FAILED NEGO-
TIATIONS.—In the case of open negotiations pur-
suant to subparagraph (A), with respect to air 
ambulance services, that do not result in a deter-
mination of an amount of payment for such 
services by the last day of the open negotiation 
period described in such subparagraph with re-
spect to such services, the provider or group 
health plan or health insurance issuer offering 
group or individual health insurance coverage 
that was party to such negotiations may, during 
the 4-day period beginning on the day after such 
open negotiation period, initiate the independent 
dispute resolution process under paragraph (2) 
with respect to such item or service. The inde-
pendent dispute resolution process shall be initi-
ated by a party pursuant to the previous sen-
tence by submission to the other party and to the 
Secretary of a notification (containing such in-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04174
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4175 
formation as specified by the Secretary) and for 
purposes of this subsection, the date of initiation 
of such process shall be the date of such submis-
sion or such other date specified by the Secretary 
pursuant to regulations that is not later than the 
date of receipt of such notification by both the 
other party and the Secretary. 
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROC-
ESS AVAILABLE IN CASE OF FAILED OPEN NEGOTIA-
TIONS.— 
‘‘(A) ESTABLISHMENT.—Not later than 1 
year after the date of the enactment of this sub-
section, the Secretary, jointly with the Secretary 
of Labor and the Secretary of the Treasury, shall 
establish by regulation one independent dispute 
resolution process (referred to in this subsection 
as the ‘IDR process’) under which, in the case of 
air ambulance services with respect to which a 
provider or group health plan or health insur-
ance issuer offering group or individual health 
insurance coverage submits a notification under 
paragraph (1)(B) (in this subsection referred to 
as a ‘qualified IDR air ambulance services’), a 
certified IDR entity under paragraph (4) deter-
mines, subject to subparagraph (B) and in ac-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04175
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4176 
cordance with the succeeding provisions of this 
subsection, the amount of payment under the 
plan or coverage for such services furnished by 
such provider. 
‘‘(B) AUTHORITY
TO
CONTINUE
NEGOTIA-
TIONS.—Under the independent dispute resolu-
tion process, in the case that the parties to a de-
termination for qualified IDR air ambulance 
services agree on a payment amount for such 
services during such process but before the date 
on which the entity selected with respect to such 
determination under paragraph (4) makes such 
determination 
under 
paragraph 
(5), 
such 
amount shall be treated for purposes of section 
2799A–1(a)(3)(K)(ii) as the amount agreed to by 
such parties for such services. In the case of an 
agreement described in the previous sentence, the 
independent dispute resolution process shall pro-
vide for a method to determine how to allocate 
between the parties to such determination the 
payment of the compensation of the entity se-
lected with respect to such determination. 
‘‘(C) CLARIFICATION.—A nonparticipating 
provider may not, with respect to an item or 
service furnished by such provider, submit a no-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04176
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4177 
tification under paragraph (1)(B) if such pro-
vider is exempt from the requirement under sub-
section (a) of section 2799B–2 with respect to 
such item or service pursuant to subsection (b) of 
such section. 
‘‘(3) TREATMENT OF BATCHING OF SERVICES.— 
The provisions of section 2799A–1(c)(3) shall apply 
with respect to a notification submitted under this 
subsection with respect to air ambulance services in 
the same manner and to the same extent such provi-
sions apply with respect to a notification submitted 
under section 2799A–1(c) with respect to items and 
services described in such section. 
‘‘(4) IDR ENTITIES.— 
‘‘(A) ELIGIBILITY.—An IDR entity certified 
under this subsection is an IDR entity certified 
under section 2799A–1(c)(4). 
‘‘(B) SELECTION OF CERTIFIED IDR ENTI-
TY.—The provisions of subparagraph (F) of sec-
tion 2799A–1(c)(4) shall apply with respect to 
selecting an IDR entity certified pursuant to 
subparagraph (A) with respect to the determina-
tion of the amount of payment under this sub-
section of air ambulance services in the same 
manner as such provisions apply with respect to 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04177
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4178 
selecting an IDR entity certified under such sec-
tion with respect to the determination of the 
amount of payment under section 2799A–1(c) of 
an item or service. An entity selected pursuant 
to the previous sentence to make a determination 
described in such sentence shall be referred to in 
this subsection as the ‘certified IDR entity’ with 
respect to such determination. 
‘‘(5) PAYMENT DETERMINATION.— 
‘‘(A) IN GENERAL.—Not later than 30 days 
after the date of selection of the certified IDR en-
tity with respect to a determination for qualified 
IDR ambulance services, the certified IDR entity 
shall— 
‘‘(i) taking into account the consider-
ations specified in subparagraph (C), select 
one of the offers submitted under subpara-
graph (B) to be the amount of payment for 
such services determined under this sub-
section for purposes of subsection (a)(3); 
and 
‘‘(ii) notify the provider or facility and 
the group health plan or health insurance 
issuer offering group or individual health 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04178
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4179 
insurance coverage party to such determina-
tion of the offer selected under clause (i). 
‘‘(B) SUBMISSION
OF
OFFERS.—Not later 
than 10 days after the date of selection of the cer-
tified IDR entity with respect to a determination 
for qualified IDR air ambulance services, the 
provider and the group health plan or health in-
surance issuer offering group or individual 
health insurance coverage party to such deter-
mination— 
‘‘(i) shall each submit to the certified 
IDR entity with respect to such determina-
tion— 
‘‘(I) an offer for a payment 
amount for such services furnished by 
such provider; and 
‘‘(II) such information as re-
quested by the certified IDR entity re-
lating to such offer; and 
‘‘(ii) may each submit to the certified 
IDR entity with respect to such determina-
tion any information relating to such offer 
submitted by either party, including infor-
mation relating to any circumstance de-
scribed in subparagraph (C)(ii). 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04179
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4180 
‘‘(C) 
CONSIDERATIONS
IN
DETERMINA-
TION.— 
‘‘(i) IN
GENERAL.—In determining 
which offer is the payment to be applied 
pursuant to this paragraph, the certified 
IDR entity, with respect to the determina-
tion for a qualified IDR air ambulance 
service shall consider— 
‘‘(I) 
the 
qualifying 
payment 
amounts (as defined in section 2799A– 
1(a)(3)(E)) for the applicable year for 
items or services that are comparable 
to the qualified IDR air ambulance 
service and that are furnished in the 
same geographic region (as defined by 
the Secretary for purposes of such sub-
section) as such qualified IDR air am-
bulance service; and 
‘‘(II) subject to clause (iii), infor-
mation on any circumstance described 
in clause (ii), such information as re-
quested in subparagraph (B)(i)(II), 
and any additional information pro-
vided in subparagraph (B)(ii). 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04180
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4181 
‘‘(ii) ADDITIONAL
CIRCUMSTANCES.— 
For purposes of clause (i)(II), the cir-
cumstances described in this clause are, 
with respect to air ambulance services in-
cluded in the notification submitted under 
paragraph (1)(B) of a nonparticipating 
provider, group health plan, or health in-
surance issuer the following: 
‘‘(I) The quality and outcomes 
measurements of the provider that fur-
nished such services. 
‘‘(II) The acuity of the individual 
receiving such services or the com-
plexity of furnishing such services to 
such individual. 
‘‘(III) The training, experience, 
and quality of the medical personnel 
that furnished such services. 
‘‘(IV) Ambulance vehicle type, in-
cluding the clinical capability level of 
such vehicle. 
‘‘(V) Population density of the 
pick up location (such as urban, subur-
ban, rural, or frontier). 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04181
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4182 
‘‘(VI) Demonstrations of good 
faith efforts (or lack of good faith ef-
forts) made by the nonparticipating 
provider or nonparticipating facility 
or the plan or issuer to enter into net-
work agreements and, if applicable, 
contracted rates between the provider 
and the plan or issuer, as applicable, 
during the previous 4 plan years. 
‘‘(iii) PROHIBITION ON CONSIDERATION 
OF
CERTAIN
FACTORS.—In determining 
which offer is the payment amount to be 
applied with respect to qualified IDR air 
ambulance services furnished by a provider, 
the certified IDR entity with respect to such 
determination shall not consider usual and 
customary charges, the amount that would 
have been billed by such provider with re-
spect to such services had the provisions of 
section 2799B–5 not applied, or the pay-
ment or reimbursement rate for such serv-
ices furnished by such provider payable by 
a public payor, including under the Medi-
care program under title XVIII of the So-
cial Security Act, under the Medicaid pro-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04182
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4183 
gram under title XIX of such Act, under the 
Children’s Health Insurance Program under 
title XXI of such Act, under the TRICARE 
program under chapter 55 of title 10, 
United States Code, or under chapter 17 of 
title 38, United States Code. 
‘‘(D) EFFECTS
OF
DETERMINATION.—The 
provisions of section 2799A–1(c)(5)(E)) shall 
apply with respect to a determination of a cer-
tified IDR entity under subparagraph (A), the 
notification submitted with respect to such deter-
mination, the services with respect to such notifi-
cation, and the parties to such notification in 
the same manner as such provisions apply with 
respect to a determination of a certified IDR en-
tity under section 2799A–1(c)(5)(E), the notifi-
cation submitted with respect to such determina-
tion, the items and services with respect to such 
notification, and the parties to such notification. 
‘‘(E) COSTS
OF
INDEPENDENT
DISPUTE 
RESOLUTION PROCESS.—The provisions of sec-
tion 2799A–1(c)(5)(F) shall apply to a notifica-
tion made under this subsection, the parties to 
such notification, and a determination under 
subparagraph (A) in the same manner and to 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04183
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4184 
the same extent such provisions apply to a noti-
fication under section 2799A–1(c), the parties to 
such notification and a determination made 
under section 2799A–1(c)(5)(A). 
‘‘(6) TIMING OF PAYMENT.—The total plan or 
coverage payment required pursuant to subsection 
(a)(3), with respect to qualified IDR air ambulance 
services for which a determination is made under 
paragraph (5)(A) or with respect to an air ambulance 
service for which a payment amount is determined 
under open negotiations under paragraph (1), shall 
be made directly to the nonparticipating provider not 
later than 30 days after the date on which such deter-
mination is made. 
‘‘(7) PUBLICATION OF INFORMATION RELATING 
TO THE IDR PROCESS.— 
‘‘(A) IN
GENERAL.—For each calendar 
quarter in 2022 and each calendar quarter in a 
subsequent year, the Secretary shall publish on 
the public website of the Department of Health 
and Human Services— 
‘‘(i) the number of notifications sub-
mitted under the IDR process during such 
calendar quarter; 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04184
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4185 
‘‘(ii) the number of such notifications 
with respect to which a final determination 
was made under paragraph (5)(A); 
‘‘(iii) the information described in sub-
paragraph (B) with respect to each notifica-
tion with respect to which such a deter-
mination was so made. 
‘‘(iv) the number of times the payment 
amount determined (or agreed to) under 
this subsection exceeds the qualifying pay-
ment amount; 
‘‘(v) the amount of expenditures made 
by the Secretary during such calendar quar-
ter to carry out the IDR process; 
‘‘(vi) the total amount of fees paid 
under paragraph (8) during such calendar 
quarter; and 
‘‘(vii) the total amount of compensa-
tion paid to certified IDR entities under 
paragraph 
(5)(E)during 
such 
calendar 
quarter. 
‘‘(B) INFORMATION WITH RESPECT TO RE-
QUESTS.—For purposes of subparagraph (A), the 
information described in this subparagraph is, 
with respect to a notification under the IDR 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04185
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4186 
process of a nonparticipating provider, group 
health plan, or health insurance issuer offering 
group or individual health insurance coverage— 
‘‘(i) a description of each air ambu-
lance service included in such notification; 
‘‘(ii) the geography in which the serv-
ices included in such notification were pro-
vided; 
‘‘(iii) the amount of the offer submitted 
under paragraph (2) by the group health 
plan or health insurance issuer (as applica-
ble) and by the nonparticipating provider 
expressed as a percentage of the qualifying 
payment amount; 
‘‘(iv) whether the offer selected by the 
certified IDR entity under paragraph (5) to 
be the payment applied was the offer sub-
mitted by such plan or issuer (as applica-
ble) or by such provider and the amount of 
such offer so selected expressed as a percent-
age of the qualifying payment amount; 
‘‘(v) ambulance vehicle type, including 
the clinical capability level of such vehicle; 
‘‘(vi) the identity of the group health 
plan or health insurance issuer or air am-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04186
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4187 
bulance provider with respect to such notifi-
cation; 
‘‘(vii) the length of time in making 
each determination; 
‘‘(viii) the compensation paid to the 
certified IDR entity with respect to the set-
tlement or determination; and 
‘‘(ix) any other information specified 
by the Secretary. 
‘‘(C) IDR 
ENTITY
REQUIREMENTS.—For 
2022 and each subsequent year, an IDR entity, 
as a condition of certification as an IDR entity, 
shall submit to the Secretary such information 
as the Secretary determines necessary for the 
Secretary to carry out the provisions of this 
paragraph. 
‘‘(D) CLARIFICATION.—The Secretary shall 
ensure the public reporting under this paragraph 
does not contain information that would disclose 
privileged or confidential information of a group 
health plan or health insurance issuer offering 
group or individual health insurance coverage or 
of a provider or facility. 
‘‘(8) ADMINISTRATIVE FEE.— 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04187
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4188 
‘‘(A) IN GENERAL.—Each party to a deter-
mination under paragraph (5) to which an enti-
ty is selected under paragraph (4) in a year 
shall pay to the Secretary, at such time and in 
such manner as specified by the Secretary, a fee 
for participating in the IDR process with respect 
to such determination in an amount described in 
subparagraph (B) for such year. 
‘‘(B) AMOUNT
OF
FEE.—The amount de-
scribed in this subparagraph for a year is an 
amount established by the Secretary in a man-
ner such that the total amount of fees paid under 
this paragraph for such year is estimated to be 
equal to the amount of expenditures estimated to 
be made by the Secretary for such year in car-
rying out the IDR process. 
‘‘(9) WAIVER AUTHORITY.—The Secretary may 
modify any deadline or other timing requirement 
specified under this subsection (other than the estab-
lishment date for the IDR process under paragraph 
(2)(A) and other than under paragraph (6)) in cases 
of extenuating circumstances, as specified by the Sec-
retary, or to ensure that all claims that occur during 
a 90-day period applied through paragraph (5)(D), 
but with respect to which a notification is not per-
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04188
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4189 
mitted by reason of such paragraph to be submitted 
under paragraph (1)(B) during such period, are eligi-
ble for the IDR process. 
‘‘(c) DEFINITIONS.—For purposes of this section: 
‘‘(1) AIR AMBULANCE SERVICE.—The term ‘air 
ambulance service’ means medical transport by heli-
copter or airplane for patients. 
‘‘(2) QUALIFYING PAYMENT AMOUNT.—The term 
‘qualifying payment amount’ has the meaning given 
such term in section 2799A–1(a)(3). 
‘‘(3) NONPARTICIPATING
PROVIDER.—The term 
‘nonparticipating provider’ has the meaning given 
such term in section 2799A–1(a)(3).’’. 
(2) ERISA AMENDMENT.— 
(A) IN GENERAL.—Subpart B of part 7 of 
title I of the Employee Retirement Income Secu-
rity Act of 1974 (29 U.S.C. 1185 et seq.), as 
amended by section 102(b) and further amended 
by the previous provisions of this title, is further 
amended by inserting after section 716 the fol-
lowing: 
‘‘SEC. 717. ENDING SURPRISE AIR AMBULANCE BILLS. 
‘‘(a) IN GENERAL.—In the case of a participant or 
beneficiary who is in a group health plan or group health 
insurance coverage offered by a health insurance issuer and 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04189
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4190 
who receives air ambulance services from a nonpartici-
pating provider (as defined in section 716(a)(3)(G)) with 
respect to such plan or coverage, if such services would be 
covered if provided by a participating provider (as defined 
in such section) with respect to such plan or coverage— 
‘‘(1) the cost-sharing requirement with respect to 
such services shall be the same requirement that would 
apply if such services were provided by such a par-
ticipating provider, and any coinsurance or deduct-
ible shall be based on rates that would apply for such 
services if they were furnished by such a partici-
pating provider; 
‘‘(2) such cost-sharing amounts shall be counted 
towards the in-network deductible and in-network 
out-of-pocket maximum amount under the plan or 
coverage for the plan year (and such in-network de-
ductible shall be applied) with respect to such items 
and services so furnished in the same manner as if 
such cost-sharing payments were with respect to items 
and services furnished by a participating provider; 
and 
‘‘(3) the group health plan or health insurance 
issuer, respectively, shall— 
‘‘(A) not later than 30 calendar days after 
the bill for such services is transmitted by such 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04190
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4191 
provider, send to the provider, an initial pay-
ment or notice of denial of payment; and 
‘‘(B) pay a total plan or coverage payment, 
in accordance with, if applicable, subsection 
(b)(6), directly to such provider furnishing such 
services to such participant, beneficiary, or en-
rollee that is, with application of any initial 
payment under subparagraph (A), equal to the 
amount by which the out-of-network rate (as de-
fined in section 716(a)(3)(K)) for such services 
and year involved exceeds the cost-sharing 
amount imposed under the plan or coverage, re-
spectively, for such services (as determined in ac-
cordance with paragraphs (1) and (2)). 
‘‘(b) DETERMINATION OF OUT-OF-NETWORK RATES TO 
BE PAID BY HEALTH PLANS; INDEPENDENT DISPUTE RES-
OLUTION PROCESS.— 
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIA-
TION.— 
‘‘(A) IN GENERAL.—With respect to air am-
bulance services furnished in a year by a non-
participating provider, with respect to a group 
health plan or health insurance issuer offering 
group health insurance coverage, and for which 
a payment is required to be made by the plan 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04191
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133
4192 
or coverage pursuant to subsection (a)(3), the 
provider or plan or coverage may, during the 30- 
day period beginning on the day the provider re-
ceives a payment or a statement of denial of 
payment from the plan or coverage regarding a 
claim for payment for such service, initiate open 
negotiations under this paragraph between such 
provider and plan or coverage for purposes of de-
termining, during the open negotiation period, 
an amount agreed on by such provider, and such 
plan or coverage for payment (including any 
cost-sharing) for such service. For purposes of 
this subsection, the open negotiation period, with 
respect to air ambulance services, is the 30-day 
period beginning on the date of initiation of the 
negotiations with respect to such services. 
‘‘(B) ACCESSING
INDEPENDENT
DISPUTE 
RESOLUTION PROCESS IN CASE OF FAILED NEGO-
TIATIONS.—In the case of open negotiations pur-
suant to subparagraph (A), with respect to air 
ambulance services, that do not result in a deter-
mination of an amount of payment for such 
services by the last day of the open negotiation 
period described in such subparagraph with re-
spect to such services, the provider or group 
VerDate Sep 11 2014 
22:37 Dec 23, 2020
Jkt 000000
PO 00000
Frm 04192
Fmt 6652
Sfmt 6203
Z:\116\ENGROSS\H133.EAH
h133