H. R. 133—1678 
‘‘(2) Any out-of-pocket maximum limitation applicable to 
such plan or coverage. 
‘‘(3) A telephone number and Internet website address 
through which such individual may seek consumer assistance 
information, such as information related to hospitals and urgent 
care facilities that have in effect a contractual relationship 
with such plan or coverage for furnishing items and services 
under such plan or coverage’’. 
(c) IRC.—Section 9816 of the Internal Revenue Code of 1986, 
as added by section 102(c) and amended by section 103, is further 
amended by adding at the end the following new subsection: 
‘‘(e) TRANSPARENCY REGARDING IN-NETWORK AND OUT-OF-NET-
WORK DEDUCTIBLES
AND OUT-OF-POCKET LIMITATIONS.—A group 
health plan providing or covering any benefit with respect to items 
or services shall include, in clear writing, on any physical or elec-
tronic plan or insurance identification card issued to the partici-
pants or beneficiaries in the plan the following: 
‘‘(1) Any deductible applicable to such plan. 
‘‘(2) Any out-of-pocket maximum limitation applicable to 
such plan. 
‘‘(3) A telephone number and Internet website address 
through which such individual may seek consumer assistance 
information, such as information related to hospitals and urgent 
care facilities that have in effect a contractual relationship 
with such plan for furnishing items and services under such 
plan.’’. 
(d) EFFECTIVE DATE.—The amendments made by this sub-
section shall apply with respect to plan years beginning on or 
after January 1, 2022. 
SEC. 
108. 
IMPLEMENTING 
PROTECTIONS 
AGAINST 
PROVIDER 
DISCRIMINATION. 
Not later than January 1, 2022, the Secretary of Health and 
Human Services, the Secretary of Labor, and the Secretary of 
the Treasury shall issue a proposed rule implementing the protec-
tions of section 2706(a) of the Public Health Service Act (42 U.S.C. 
300gg-5(a)). The Secretaries shall accept and consider public com-
ments on any proposed rule issued pursuant to this subsection 
for a period of 60 days after the date of such issuance. Not later 
than 6 months after the date of the conclusion of the comment 
period, the Secretaries shall issue a final rule implementing the 
protections of section 2706(a) of the Public Health Service Act 
(42 U.S.C. 300gg-5(a)). 
SEC. 109. REPORTS. 
(a) REPORTS IN CONSULTATION WITH FTC AND AG.—Not later 
than January 1, 2023, and annually thereafter for each of the 
following 4 years, the Secretary of Health and Human Services, 
in consultation with the Federal Trade Commission and the 
Attorney General, shall— 
(1) conduct a study on the effects of the provisions of, 
including amendments made by, this Act on— 
(A) any patterns of vertical or horizontal integration 
of health care facilities, providers, group health plans, or 
health insurance issuers offering group or individual health 
insurance coverage; 
(B) overall health care costs; and
H. R. 133—1679 
(C) access to health care items and services, including 
specialty services, in rural areas and health professional 
shortage areas, as defined in section 332 of the Public 
Health Service Act (42 U.S.C. 254e); 
(2) for purposes of the reports under paragraph (3), in 
consultation with the Secretary of Labor and the Secretary 
of the Treasury, make recommendations for the effective 
enforcement of subsections (a)(1)(C)(iv) and (b)(1)(C) of section 
2799A–1 of the Public Health Service Act, subsections 
(a)(1)(C)(iv) and (b)(1)(C) of section 716 of the Employee Retire-
ment Income Security Act of 1974, and subsections (a)(1)(C)(iv) 
and (b)(1)(C) of section 9816 of the Internal Revenue Code 
of 1986, including with respect to potential challenges to 
addressing anti-competitive consolidation of health care facili-
ties, providers, group health plans, or health insurance issuers 
offering group or individual health insurance coverage; and 
(3) submit a report on such study and including such 
recommendations to the Committees on Energy and Commerce; 
on Education and Labor; on Ways and Means; and on the 
Judiciary of the House of Representatives and the Committees 
on Health, Education, Labor, and Pensions; on Commerce, 
Science, and Transportation; on Finance; and on the Judiciary 
of the Senate. 
(b) GAO REPORT
ON IMPACT
OF SURPRISE BILLING PROVI-
SIONS.—Not later than January 1, 2025, the Comptroller General 
of the United States shall submit to Congress a report summarizing 
the effects of the provisions of this Act, including the amendments 
made by such provisions, on changes during the period since the 
date on the enactment of this Act in health care provider networks 
of group health plans and group and individual health insurance 
coverage offered by a health insurance issuer, in fee schedules 
and amounts for health care services, and to contracted rates under 
such plans or coverage. Such report shall— 
(1) to the extent practicable, sample a statistically signifi-
cant group of national health care providers; 
(2) examine— 
(A) provider network participation, including non-
participating providers furnishing items and services at 
participating facilities; 
(B) health care provider group network participation, 
including specialty, size, and ownership; 
(C) the impact of State surprise billing laws and net-
work adequacy standards on participation of health care 
providers and facilities in provider networks of group health 
plans and of group and individual health insurance cov-
erage offered by health insurance issuers; and 
(D) access to providers, including in rural and medi-
cally underserved communities and health professional 
shortage areas (as defined in section 332 of the Public 
Health Service Act), and the extent of provider shortages 
in such communities and areas; 
(3) to the extent practicable, sample a statistically signifi-
cant group of national health insurance plans and issuers and 
examine— 
(A) the effects of the provisions of, including amend-
ments made by, this Act on premiums and out-of-pocket
H. R. 133—1680 
costs with respect to group health plans or group or indi-
vidual health insurance coverage; 
(B) the adequacy of provider networks with respect 
to such plans or coverage; and 
(C) categories of providers of ancillary services, as 
defined in section 2799B–2(b)(2) of the Public Health 
Service Act, for which such plans have no or a limited 
number of in-network providers; and 
(4) such other relevant effects of such provisions and 
amendments. 
(c) GAO REPORT ON ADEQUACY OF PROVIDER NETWORKS.—Not 
later than January 1, 2023, the Comptroller General of the United 
States shall submit to Congress, and make publicly available, a 
report on the adequacy of provider networks in group health plans 
and group and individual health insurance coverage, including legis-
lative recommendations to improve the adequacy of such networks. 
(d) GAO REPORT ON IDR PROCESS AND POTENTIAL FINANCIAL 
RELATIONSHIPS.—Not later than December 31, 2023, the Comp-
troller General of the United States shall conduct a study and 
submit to Congress a report on the IDR process established under 
this section. Such study and report shall include an analysis of 
potential financial relationships between providers and facilities 
that utilize the IDR process established by the amendments made 
by this Act and private equity investment firms. 
SEC. 110. CONSUMER PROTECTIONS THROUGH APPLICATION OF 
HEALTH PLAN EXTERNAL REVIEW IN CASES OF CERTAIN 
SURPRISE MEDICAL BILLS. 
(a) IN GENERAL.—In applying the provisions of section 2719(b) 
of the Public Health Service Act (42 U.S.C. 300gg–19(b)) to group 
health plans and health insurance issuers offering group or indi-
vidual health insurance coverage, the Secretary of Health and 
Human Services, Secretary of Labor, and Secretary of the Treasury, 
shall require, beginning not later than January 1, 2022, the external 
review process described in paragraph (1) of such section to apply 
with respect to any adverse determination by such a plan or issuer 
under section 2799A-1 or 2799A-2, section 716 or 717 of the 
Employee Retirement Income Security Act of 1974, or section 9816 
or 9817 of the Internal Revenue Code of 1986, including with 
respect to whether an item or service that is the subject to such 
a determination is an item or service to which such respective 
section applies. 
(b) DEFINITIONS.—The terms ‘‘group health plan’’; ‘‘health insur-
ance issuer’’; ‘‘group health insurance coverage’’, and ‘‘individual 
health insurance coverage’’ have the meanings given such terms 
in section 2791 of the Public Health Service Act (42 U.S.C. 300gg– 
91), section 733 of the Employee Retirement Income Security Act 
(29 U.S.C. 1191b), and section 9832 of the Internal Revenue Code, 
as applicable. 
SEC. 
111. 
CONSUMER 
PROTECTIONS 
THROUGH 
HEALTH 
PLAN 
REQUIREMENT FOR FAIR AND HONEST ADVANCE COST 
ESTIMATE. 
(a) PHSA AMENDMENT.—Section 2799A–1 of the Public Health 
Service Act (42 U.S.C. 300gg–19a), as added by section 102 and 
as further amended by the previous provisions of this title, is 
further amended by adding at the end the following new subsection: 
‘‘(f) ADVANCED EXPLANATION OF BENEFITS.—
H. R. 133—1681 
‘‘(1) IN GENERAL.—For plan years beginning on or after 
January 1, 2022, each group health plan, or a health insurance 
issuer offering group or individual health insurance coverage 
shall, with respect to a notification submitted under section 
2799B–6 by a health care provider or health care facility to 
the plan or issuer for a participant, beneficiary, or enrollee 
under plan or coverage scheduled to receive an item or service 
from the provider or facility (or authorized representative of 
such participant, beneficiary, or enrollee), not later than 1 
business day (or, in the case such item or service was so 
scheduled at least 10 business days before such item or service 
is to be furnished (or in the case of a request made to such 
plan or coverage by such participant, beneficiary, or enrollee), 
3 business days) after the date on which the plan or coverage 
receives such notification (or such request), provide to the 
participant, beneficiary, or enrollee (through mail or electronic 
means, as requested by the participant, beneficiary, or enrollee) 
a notification (in clear and understandable language) including 
the following: 
‘‘(A) Whether or not the provider or facility is a partici-
pating provider or a participating facility with respect to 
the plan or coverage with respect to the furnishing of 
such item or service and— 
‘‘(i) in the case the provider or facility is a partici-
pating provider or facility with respect to the plan 
or coverage with respect to the furnishing of such 
item or service, the contracted rate under such plan 
or coverage for such item or service (based on the 
billing and diagnostic codes provided by such provider 
or facility); and 
‘‘(ii) in the case the provider or facility is a non-
participating provider or facility with respect to such 
plan or coverage, a description of how such individual 
may obtain information on providers and facilities that, 
with respect to such plan or coverage, are participating 
providers and facilities, if any. 
‘‘(B) The good faith estimate included in the notification 
received from the provider or facility (if applicable) based 
on such codes. 
‘‘(C) A good faith estimate of the amount the plan 
or coverage is responsible for paying for items and services 
included in the estimate described in subparagraph (B). 
‘‘(D) A good faith estimate of the amount of any cost- 
sharing for which the participant, beneficiary, or enrollee 
would be responsible for such item or service (as of the 
date of such notification). 
‘‘(E) A good faith estimate of the amount that the 
participant, beneficiary, or enrollee has incurred toward 
meeting the limit of the financial responsibility (including 
with respect to deductibles and out-of-pocket maximums) 
under the plan or coverage (as of the date of such notifica-
tion). 
‘‘(F) In the case such item or service is subject to 
a medical management technique (including concurrent 
review, prior authorization, and step-therapy or fail-first
H. R. 133—1682 
protocols) for coverage under the plan or coverage, a dis-
claimer that coverage for such item or service is subject 
to such medical management technique. 
‘‘(G) A disclaimer that the information provided in 
the notification is only an estimate based on the items 
and services reasonably expected, at the time of scheduling 
(or requesting) the item or service, to be furnished and 
is subject to change. 
‘‘(H) Any other information or disclaimer the plan or 
coverage determines appropriate that is consistent with 
information and disclaimers required under this section. 
‘‘(2) AUTHORITY TO MODIFY TIMING REQUIREMENTS IN THE 
CASE OF SPECIFIED ITEMS AND SERVICES.— 
‘‘(A) IN GENERAL.—In the case of a participant, bene-
ficiary, or enrollee scheduled to receive an item or service 
that is a specified item or service (as defined in subpara-
graph (B)), the Secretary may modify any timing require-
ments relating to the provision of the notification described 
in paragraph (1) to such participant, beneficiary, or enrollee 
with respect to such item or service. Any modification 
made by the Secretary pursuant to the previous sentence 
may not result in the provision of such notification after 
such participant, beneficiary, or enrollee has been furnished 
such item or service. 
‘‘(B) SPECIFIED ITEM OR SERVICE DEFINED.—For pur-
poses of subparagraph (A), the term ‘specified item or 
service’ means an item or service that has low utilization 
or significant variation in costs (such as when furnished 
as part of a complex treatment), as specified by the Sec-
retary.’’. 
(b) IRC AMENDMENTS.—Section 9816 of the Internal Revenue 
Code of 1986, as added by section 102 and further amended by 
the previous provisions of this title, is further amended by inserting 
after subsection (e) the following new subsection: 
‘‘(f) ADVANCED EXPLANATION OF BENEFITS.— 
‘‘(1) IN GENERAL.—For plan years beginning on or after 
January 1, 2022, each group health plan shall, with respect 
to a notification submitted under section 2799B–6 of the Public 
Health Service Act by a health care provider or health care 
facility to the plan for a participant or beneficiary under plan 
scheduled to receive an item or service from the provider or 
facility (or authorized representative of such participant or 
beneficiary), not later than 1 business day (or, in the case 
such item or service was so scheduled at least 10 business 
days before such item or service is to be furnished (or in 
the case of a request made to such plan or coverage by such 
participant or beneficiary), 3 business days) after the date 
on which the plan receives such notification (or such request), 
provide to the participant or beneficiary (through mail or elec-
tronic means, as requested by the participant or beneficiary) 
a notification (in clear and understandable language) including 
the following: 
‘‘(A) Whether or not the provider or facility is a partici-
pating provider or a participating facility with respect to 
the plan with respect to the furnishing of such item or 
service and—
H. R. 133—1683 
‘‘(i) in the case the provider or facility is a partici-
pating provider or facility with respect to the plan 
or coverage with respect to the furnishing of such 
item or service, the contracted rate under such plan 
for such item or service (based on the billing and 
diagnostic codes provided by such provider or facility); 
and 
‘‘(ii) in the case the provider or facility is a non-
participating provider or facility with respect to such 
plan, a description of how such individual may obtain 
information on providers and facilities that, with 
respect to such plan, are participating providers and 
facilities, if any. 
‘‘(B) The good faith estimate included in the notification 
received from the provider or facility (if applicable) based 
on such codes. 
‘‘(C) A good faith estimate of the amount the plan 
is responsible for paying for items and services included 
in the estimate described in subparagraph (B). 
‘‘(D) A good faith estimate of the amount of any cost- 
sharing for which the participant or beneficiary would be 
responsible for such item or service (as of the date of 
such notification). 
‘‘(E) A good faith estimate of the amount that the 
participant or beneficiary has incurred toward meeting the 
limit of the financial responsibility (including with respect 
to deductibles and out-of-pocket maximums) under the plan 
(as of the date of such notification). 
‘‘(F) In the case such item or service is subject to 
a medical management technique (including concurrent 
review, prior authorization, and step-therapy or fail-first 
protocols) for coverage under the plan, a disclaimer that 
coverage for such item or service is subject to such medical 
management technique. 
‘‘(G) A disclaimer that the information provided in 
the notification is only an estimate based on the items 
and services reasonably expected, at the time of scheduling 
(or requesting) the item or service, to be furnished and 
is subject to change. 
‘‘(H) Any other information or disclaimer the plan 
determines appropriate that is consistent with information 
and disclaimers required under this section. 
‘‘(2) AUTHORITY TO MODIFY TIMING REQUIREMENTS IN THE 
CASE OF SPECIFIED ITEMS AND SERVICES.— 
‘‘(A) IN GENERAL.—In the case of a participant or bene-
ficiary scheduled to receive an item or service that is a 
specified item or service (as defined in subparagraph (B)), 
the Secretary may modify any timing requirements relating 
to the provision of the notification described in paragraph 
(1) to such participant or beneficiary with respect to such 
item or service. Any modification made by the Secretary 
pursuant to the previous sentence may not result in the 
provision of such notification after such participant or bene-
ficiary has been furnished such item or service. 
‘‘(B) SPECIFIED ITEM OR SERVICE DEFINED.—For pur-
poses of subparagraph (A), the term ‘specified item or 
service’ means an item or service that has low utilization
H. R. 133—1684 
or significant variation in costs (such as when furnished 
as part of a complex treatment), as specified by the Sec-
retary.’’. 
(c) ERISA AMENDMENTS.—Section 716 of the Employee Retire-
ment Income Security Act of 1974, as added by section 102 and 
further amended by the previous amendments of this title, is further 
amended by adding at the end the following new subsection: 
‘‘(f) ADVANCED EXPLANATION OF BENEFITS.— 
‘‘(1) IN GENERAL.—For plan years beginning on or after 
January 1, 2022, each group health plan, or a health insurance 
issuer offering group health insurance coverage shall, with 
respect to a notification submitted under section 2799B–6 of 
the Public Health Service Act by a health care provider or 
health care facility to the plan or issuer for a participant 
or beneficiary under plan or coverage scheduled to receive 
an item or service from the provider or facility (or authorized 
representative of such participant or beneficiary), not later 
than 1 business day (or, in the case such item or service 
was so scheduled at least 10 business days before such item 
or service is to be furnished (or in the case of a request made 
to such plan or coverage by such participant or beneficiary), 
3 business days) after the date on which the plan or coverage 
receives such notification (or such request), provide to the 
participant or beneficiary (through mail or electronic means, 
as requested by the participant or beneficiary) a notification 
(in clear and understandable language) including the following: 
‘‘(A) Whether or not the provider or facility is a partici-
pating provider or a participating facility with respect to 
the plan or coverage with respect to the furnishing of 
such item or service and— 
‘‘(i) in the case the provider or facility is a partici-
pating provider or facility with respect to the plan 
or coverage with respect to the furnishing of such 
item or service, the contracted rate under such plan 
for such item or service (based on the billing and 
diagnostic codes provided by such provider or facility); 
and 
‘‘(ii) in the case the provider or facility is a non-
participating provider or facility with respect to such 
plan or coverage, a description of how such individual 
may obtain information on providers and facilities that, 
with respect to such plan or coverage, are participating 
providers and facilities, if any. 
‘‘(B) The good faith estimate included in the notification 
received from the provider or facility (if applicable) based 
on such codes. 
‘‘(C) A good faith estimate of the amount the health 
plan is responsible for paying for items and services 
included in the estimate described in subparagraph (B). 
‘‘(D) A good faith estimate of the amount of any cost- 
sharing for which the participant or beneficiary would be 
responsible for such item or service (as of the date of 
such notification). 
‘‘(E) A good faith estimate of the amount that the 
participant or beneficiary has incurred toward meeting the 
limit of the financial responsibility (including with respect
H. R. 133—1685 
to deductibles and out-of-pocket maximums) under the plan 
or coverage (as of the date of such notification). 
‘‘(F) In the case such item or service is subject to 
a medical management technique (including concurrent 
review, prior authorization, and step-therapy or fail-first 
protocols) for coverage under the plan or coverage, a dis-
claimer that coverage for such item or service is subject 
to such medical management technique. 
‘‘(G) A disclaimer that the information provided in 
the notification is only an estimate based on the items 
and services reasonably expected, at the time of scheduling 
(or requesting) the item or service, to be furnished and 
is subject to change. 
‘‘(H) Any other information or disclaimer the plan or 
coverage determines appropriate that is consistent with 
information and disclaimers required under this section. 
‘‘(2) AUTHORITY TO MODIFY TIMING REQUIREMENTS IN THE 
CASE OF SPECIFIED ITEMS AND SERVICES.— 
‘‘(A) IN GENERAL.—In the case of a participant or bene-
ficiary scheduled to receive an item or service that is a 
specified item or service (as defined in subparagraph (B)), 
the Secretary may modify any timing requirements relating 
to the provision of the notification described in paragraph 
(1) to such participant or beneficiary with respect to such 
item or service. Any modification made by the Secretary 
pursuant to the previous sentence may not result in the 
provision of such notification after such participant or bene-
ficiary has been furnished such item or service. 
‘‘(B) SPECIFIED ITEM OR SERVICE DEFINED.—For pur-
poses of subparagraph (A), the term ‘specified item or 
service’ means an item or service that has low utilization 
or significant variation in costs (such as when furnished 
as part of a complex treatment), as specified by the Sec-
retary.’’. 
SEC. 112. PATIENT PROTECTIONS THROUGH TRANSPARENCY AND 
PATIENT-PROVIDER DISPUTE RESOLUTION. 
Part E of title XXVII of the Public Health Service Act (42 
U.S.C. 300gg et seq.), as added by section 104 and further amended 
by the previous provisions of this title, is further amended by 
adding at the end the following new sections: 
‘‘SEC. 2799B–6. PROVISION OF INFORMATION UPON REQUEST AND FOR 
SCHEDULED APPOINTMENTS. 
‘‘Each health care provider and health care facility shall, begin-
ning January 1, 2022, in the case of an individual who schedules 
an item or service to be furnished to such individual by such 
provider or facility at least 3 business days before the date such 
item or service is to be so furnished, not later than 1 business 
day after the date of such scheduling (or, in the case of such 
an item or service scheduled at least 10 business days before 
the date such item or service is to be so furnished (or if requested 
by the individual), not later than 3 business days after the date 
of such scheduling or such request)— 
‘‘(1) inquire if such individual is enrolled in a group health 
plan, group or individual health insurance coverage offered 
by a health insurance issuer, or a Federal health care program 
(and if is so enrolled in such plan or coverage, seeking to
H. R. 133—1686 
have a claim for such item or service submitted to such plan 
or coverage); and 
‘‘(2) provide a notification (in clear and understandable 
language) of the good faith estimate of the expected charges 
for furnishing such item or service (including any item or 
service that is reasonably expected to be provided in conjunction 
with such scheduled item or service and such an item or service 
reasonably expected to be so provided by another health care 
provider or health care facility), with the expected billing and 
diagnostic codes for any such item or service, to— 
‘‘(A) in the case the individual is enrolled in such 
a plan or such coverage (and is seeking to have a claim 
for such item or service submitted to such plan or coverage), 
such plan or issuer of such coverage; and 
‘‘(B) in the case the individual is not described in 
subparagraph (A) and not enrolled in a Federal health 
care program, the individual. 
‘‘SEC. 2799B–7. PATIENT-PROVIDER DISPUTE RESOLUTION. 
‘‘(a) IN GENERAL.—Not later than January 1, 2022, the Sec-
retary shall establish a process (in this subsection referred to as 
the ‘patient-provider dispute resolution process’) under which an 
uninsured individual, with respect to an item or service, who 
received, pursuant to section 2799B–6, from a health care provider 
or health care facility a good-faith estimate of the expected charges 
for furnishing such item or service to such individual and who 
after being furnished such item or service by such provider or 
facility is billed by such provider or facility for such item or service 
for charges that are substantially in excess of such estimate, may 
seek a determination from a selected dispute resolution entity for 
the charges to be paid by such individual (in lieu of such amount 
so billed) to such provider or facility for such item or service. 
For purposes of this subsection, the term ‘uninsured individual’ 
means, with respect to an item or service, an individual who does 
not have benefits for such item or service under a group health 
plan, group or individual health insurance coverage offered by a 
health insurance issuer, Federal health care program (as defined 
in section 1128B(f) of the Social Security Act), or a health benefits 
plan under chapter 89 of title 5, United States Code (or an indi-
vidual who has benefits for such item or service under a group 
health plan or individual or group health insurance coverage offered 
by a health insurance issuer, but who does not seek to have a 
claim for such item or service submitted to such plan or coverage). 
‘‘(b) SELECTION OF ENTITIES.—Under the patient-provider dis-
pute resolution process, the Secretary shall, with respect to a deter-
mination sought by an individual under subsection (a), with respect 
to charges to be paid by such individual to a health care provider 
or health care facility described in such paragraph for an item 
or service furnished to such individual by such provider or facility, 
provide for— 
‘‘(1) a method to select to make such determination an 
entity certified under subsection (d) that— 
‘‘(A) is not a party to such determination or an 
employee or agent of such party; 
‘‘(B) does not have a material familial, financial, or 
professional relationship with such a party; and