calculable under the previous sentence with 
respect to an item or service. 
‘‘(C) LINE OF BUSINESS.—A line of busi-
ness specified in this subparagraph is one of the 
following: 
‘‘(i) The small group market. 
‘‘(ii) The large group market. 
‘‘(iii) In the case of a self-insured 
group health plan, other self-insured group 
health plans. 
‘‘(D) REBASING YEAR DEFINED.—For pur-
poses of subparagraph (A), the term ‘rebasing 
year’ means 2027 and every 5 years thereafter. 
‘‘(9) NONPARTICIPATING
FACILITY; PARTICI-
PATING FACILITY.— 
‘‘(A) NONPARTICIPATING
FACILITY.—The 
term ‘nonparticipating facility’ means, with re-
spect to an item or service and a health plan, 
a health care facility described in subparagraph 
(B)(ii) that does not have a contractual rela-
tionship with the plan for furnishing such item 
or service. 
‘‘(B) PARTICIPATING FACILITY.— 
‘‘(i) IN GENERAL.—The term ‘partici-
pating facility’ means, with respect to an 
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item or service and a health plan, a health 
care facility described in clause (ii) that 
has a contractual relationship with the 
plan for furnishing such item or service. 
‘‘(ii) HEALTH
CARE
FACILITY
DE-
SCRIBED.—A health care facility described 
in this clause is each of the following: 
‘‘(I) A hospital (as defined in 
1861(e) of the Social Security Act), 
including an emergency department of 
a hospital. 
‘‘(II) A critical access hospital 
(as defined in section 1861(mm)(1) of 
such Act). 
‘‘(III) An ambulatory surgical 
center 
(as 
described 
in 
section 
1833(i)(1)(A) of such Act). 
‘‘(IV) A laboratory. 
‘‘(V) A radiology facility or imag-
ing center. 
‘‘(VI) 
An 
independent 
free-
standing emergency department. 
‘‘(VII) Any other facility speci-
fied by the Secretary. 
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‘‘(10) NONPARTICIPATING PROVIDERS; PARTICI-
PATING PROVIDERS.— 
‘‘(A) NONPARTICIPATING PROVIDER.—The 
term ‘nonparticipating provider’ means, with re-
spect to an item or service and a health plan, 
a physician or other health care provider who 
does not have a contractual relationship with 
the plan for furnishing such item or service 
under the plan. 
‘‘(B) 
PARTICIPATING
PROVIDER.—The 
term ‘participating provider’ means, with re-
spect to an item or service and a health plan, 
a physician or other health care provider who 
has a contractual relationship with the plan for 
furnishing such item or service under the plan. 
‘‘(11) OUT-OF-NETWORK
RATE.—The term 
‘out-of-network rate’ means, with respect to an item 
or service furnished in a State during a year to a 
participant or beneficiary of a health plan receiving 
such item or service from a nonparticipating pro-
vider or facility— 
‘‘(A) subject to subparagraphs (C) and 
(D), in the case such State has in effect a State 
law that provides for a method for determining 
the total amount payable under such health 
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plan regulated by such State with respect to 
such item or service furnished by such provider 
or facility, such amount determined in accord-
ance with such law; 
‘‘(B) subject to subparagraphs (C) and 
(D), in the case such State does not have in ef-
fect such a law with respect to such item or 
service, plan, and provider or facility— 
‘‘(i) subject to clause (ii), if the pro-
vider or facility (as applicable) and such 
plan agree on an amount of payment (in-
cluding if agreed on through open negotia-
tions under subsection (j)(1)) with respect 
to such item or service, such agreed on 
amount; or 
‘‘(ii) if such provider or facility (as 
applicable) and such plan enter the medi-
ated dispute process under subsection (j) 
and do not so agree before the date on 
which a selected independent entity (as de-
fined in paragraph (3) of such subsection) 
makes a determination with respect to 
such item or service under such subsection, 
the amount of such determination; 
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‘‘(C) in the case such State has an All- 
Payer Model Agreement under section 1115A of 
the Social Security Act, the amount that the 
State approves under such system for such item 
or service so furnished; or 
‘‘(D) in the case such health plan is a self- 
insured group health plan and in the case of a 
State with an agreement with such plan in ef-
fect as of the date of the enactment of the Con-
sumer Protections Against Surprise Medical 
Bills Act of 2020, that provides for a method 
for determining the total amount payable under 
such health plan with respect to such item or 
service furnished by such provider or facility, 
such amount determined in accordance with 
such method. 
‘‘(12) RECOGNIZED AMOUNT.—The term ‘recog-
nized amount’ means, with respect to an item or 
service furnished in a State during a year to a par-
ticipant or beneficiary of a health plan by a non-
participating provider or nonparticipating facility— 
‘‘(A) subject to subparagraphs (C) and 
(D), in the case such State has in effect a law 
described in paragraph (11)(A) with respect to 
such item or service, provider or facility, and 
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plan, the amount determined in accordance with 
such law; 
‘‘(B) subject to subparagraphs (C) and 
(D), in the case such State does not have in ef-
fect such a law, an amount that is the median 
contracted rate for such item or service for such 
year; 
‘‘(C) in the case such State is described in 
paragraph (11)(C) with respect to such item or 
service so furnished, the amount that the State 
approves under such system for such item or 
service so furnished; or 
‘‘(D) in the case such health plan is a self- 
insured group health plan and in the case of a 
State with an agreement with such plan in ef-
fect as of the date of the enactment of the Con-
sumer Protections Against Surprise Medical 
Bills Act of 2020, that provides for a method 
for determining the total amount payable under 
such health plan with respect to such item or 
service furnished by such provider or facility, 
such amount determined in accordance with 
such method. 
‘‘(13) STABILIZE.—The term ‘to stabilize’, with 
respect to an emergency medical condition, has the 
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meaning give in section 1867(e)(3)(A) of the Social 
Security Act. 
‘‘(14) COST-SHARING.—The term ‘cost-sharing’ 
includes copayments, coinsurance, and deductibles. 
‘‘(l) PAYMENT TO PROVIDER OR FACILITY.—In the 
case of any payment required to be made by a health plan 
pursuant to subsection (b)(1), (e)(1), or (i)(1) to a 
nonparticiapting provider or nonparticipating facility for 
an item or service, such payment shall be made to such 
provider or facility and not to the individual receiving such 
item or service.’’. 
(2) CONFORMING AMENDMENTS.— 
(A) APPLICATION
PROVISIONS.—Section 
9815(a) of the Internal Revenue Code of 1986 
is amended— 
(i) in paragraph (1), by striking ‘‘(as 
amended by the Patient Protection and Af-
fordable Care Act)’’ and inserting ‘‘(other 
than, with respect to a plan year beginning 
on or after January 1, 2022, the provisions 
of section 2719A of such Act)’’; and 
(ii) in paragraph (2), by inserting 
‘‘(other than, with respect to a plan year 
beginning on or after January 1, 2022, the 
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provisions of section 2719A of such Act)’’ 
after the first occurrence of ‘‘such part A’’. 
(B) 
APPLICATION
TO
RETIREE-ONLY 
PLANS.—Section 9831(a) of the Internal Rev-
enue Code of 1986 is amended by inserting 
‘‘(other than, with respect to a group health 
plan described in paragraph (2), the require-
ments of section 9816)’’ before ‘‘shall not 
apply’’. 
(3) CLERICAL AMENDMENT.—The table of sec-
tions for such subchapter is amended by adding at 
the end the following new items: 
‘‘Sec. 9815. Additional market reforms. 
‘‘Sec. 9816. Patient protections.’’. 
(4) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply with respect to plan 
years beginning on or after January 1, 2022. 
(c) EMPLOYEE RETIREMENT INCOME SECURITY ACT 
OF 1974 AMENDMENTS.— 
(1) IN GENERAL.—Subpart B of part 7 of sub-
title B of title I of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1185 et seq.) is 
amended by adding at the end the following new sec-
tion: 
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‘‘SEC. 716. PATIENT PROTECTIONS. 
‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If 
a health plan requires or provides for designation by a par-
ticipant or beneficiary of a participating primary care pro-
vider, then the plan shall permit each participant or bene-
ficiary to designate any participating primary care pro-
vider who is available to accept such individual. 
‘‘(b) COST-SHARING AND PAYMENT OF EMERGENCY 
SERVICES.— 
‘‘(1) IN GENERAL.—If a health plan provides or 
covers any benefits with respect to services in an 
emergency department of a hospital and, for plan 
year 2022 or a subsequent plan year, with respect 
to emergency services in an independent free-
standing emergency department, the plan shall cover 
emergency services— 
‘‘(A) without the need for any prior au-
thorization determination; 
‘‘(B) whether the health care provider fur-
nishing such services is a participating provider 
or a participating facility that is an emergency 
department of a hospital or an independent 
freestanding emergency department (in this 
subsection referred to as a ‘participating emer-
gency facility’) with respect to such services; 
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‘‘(C) in a manner so that, if such services 
are provided to a participant or beneficiary by 
a nonparticipating provider or a nonpartici-
pating facility that is an emergency department 
of a hospital or an independent freestanding 
emergency department— 
‘‘(i) such services will be provided 
without imposing any requirement under 
the plan for prior authorization of services 
or any limitation on coverage that is more 
restrictive than the requirements or limita-
tions that apply to emergency services re-
ceived from participating providers and 
participating emergency facilities with re-
spect to such plan; 
‘‘(ii) the cost-sharing requirement is 
not greater than the requirement that 
would apply if such services were furnished 
by a participating provider or a partici-
pating emergency facility, as applicable; 
‘‘(iii) such cost-sharing requirement is 
calculated as if the contracted rate for 
such services if furnished by a partici-
pating provider or a participating emer-
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gency facility were equal to the recognized 
amount for such services; 
‘‘(iv) the health plan pays to such pro-
vider or facility, respectively, the amount 
by which the out-of-network rate for such 
services exceeds the cost-sharing amount 
for such services (as determined in accord-
ance with clauses (ii) and (iii)); and 
‘‘(v) any deductible or out-of-pocket 
maximum that would apply if such services 
were furnished by a participating provider 
or a participating emergency facility shall 
be the deductible or out-of-pocket max-
imum that applies; and 
‘‘(D) without regard to any other term or 
condition of such coverage (other than exclusion 
or coordination of benefits, or an affiliation or 
waiting period, permitted under section 2704 of 
the Public Health Service Act, including as in-
corporated pursuant to section 715 and section 
9815 of the Internal Revenue Code of 1986, 
and other than applicable cost-sharing). 
‘‘(2) AUDIT PROCESS AND RULEMAKING PROC-
ESS FOR MEDIAN CONTRACTED RATES.— 
‘‘(A) AUDIT PROCESS.— 
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‘‘(i) IN
GENERAL.—Not later than 
July 1, 2021, the Secretary, in coordina-
tion with the Secretary of Health and 
Human Services and the Secretary of the 
Treasury and in consultation with the Na-
tional Association of Insurance Commis-
sioners, shall establish through rulemaking 
a process, in accordance with clause (ii), 
under which health plans are audited by 
the Secretary to ensure that— 
‘‘(I) such plans are in compliance 
with the requirement of applying a 
median contracted rate under this sec-
tion; and 
‘‘(II) that such median con-
tracted rate so applied satisfies the 
definition under subsection (k)(8) 
with respect to the year involved. 
‘‘(ii) AUDIT
SAMPLES.—Under the 
process established pursuant to clause (i), 
the Secretary— 
‘‘(I) shall conduct audits de-
scribed in such clause of a sample of 
health plans; and 
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‘‘(II) may audit any health plan 
if the Secretary has received any com-
plaint about such plan that involves 
the compliance of the plan with the 
requirement described in such clause. 
‘‘(B) RULEMAKING.—Not later than July 
1, 2021, the Secretary, in coordination with the 
Secretary of the Treasury and the Secretary of 
Health and Human Services, shall establish 
through rulemaking— 
‘‘(i) the methodology the sponsor or 
issuer of a health plan shall use to deter-
mine the median contracted rate, which 
shall account for relevant payment adjust-
ments that take into account facility type 
that are otherwise taken into account for 
purposes of determining payment amounts 
with respect to participating facilities; and 
‘‘(ii) the information such sponsor or 
issuer shall share with the nonparticipating 
provider involved when making such a de-
termination. 
‘‘(c) ACCESS TO PEDIATRIC CARE.— 
‘‘(1) PEDIATRIC CARE.—In the case of a person 
who has a child who is a participant or beneficiary 
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under a health plan, if the plan requires or provides 
for the designation of a participating primary care 
provider for the child, the plan shall permit such 
person to designate a physician (allopathic or osteo-
pathic) who specializes in pediatrics as the child’s 
primary care provider if such provider participates 
in the network of the plan. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph 
(1) shall be construed to waive any exclusions of cov-
erage under the terms and conditions of the plan 
with respect to coverage of pediatric care. 
‘‘(d) PATIENT ACCESS TO OBSTETRICAL AND GYNE-
COLOGICAL CARE.— 
‘‘(1) GENERAL RIGHTS.— 
‘‘(A) DIRECT ACCESS.—A health plan de-
scribed in paragraph (2) may not require au-
thorization or referral by the plan or any per-
son (including a primary care provider de-
scribed in paragraph (2)(B)) in the case of a fe-
male participant or beneficiary who seeks cov-
erage for obstetrical or gynecological care pro-
vided by a participating health care professional 
who specializes in obstetrics or gynecology. 
Such professional shall agree to otherwise ad-
here to such plan’s policies and procedures, in-
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cluding procedures regarding referrals and ob-
taining prior authorization and providing serv-
ices pursuant to a treatment plan (if any) ap-
proved by the plan. 
‘‘(B) OBSTETRICAL AND GYNECOLOGICAL 
CARE.—A health plan described in paragraph 
(2) shall treat the provision of obstetrical and 
gynecological care, and the ordering of related 
obstetrical and gynecological items and services, 
pursuant to the direct access described under 
subparagraph (A), by a participating health 
care professional who specializes in obstetrics or 
gynecology as the authorization of the primary 
care provider. 
‘‘(2) APPLICATION OF PARAGRAPH.—A health 
plan described in this paragraph is a health plan 
that— 
‘‘(A) provides coverage for obstetric or 
gynecologic care; and 
‘‘(B) requires the designation by a partici-
pant or beneficiary of a participating primary 
care provider. 
‘‘(3) CONSTRUCTION.—Nothing in paragraph 
(1) shall be construed to— 
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‘‘(A) waive any exclusions of coverage 
under the terms and conditions of the plan with 
respect to coverage of obstetrical or gyneco-
logical care; or 
‘‘(B) preclude the health plan involved 
from requiring that the obstetrical or gyneco-
logical provider notify the primary care health 
care professional or the plan of treatment deci-
sions. 
‘‘(k) DEFINITIONS.—For purposes of this section: 
‘‘(1) CONTRACTED
RATE.—The term ‘con-
tracted rate’ means, with respect to a health plan 
and a health care provider or health care facility fur-
nishing an item or service to a beneficiary or partici-
pant of such plan, the agreed upon total payment 
amount (inclusive of any cost-sharing) to such pro-
vider or facility for such item or service. 
‘‘(2) DURING
A
VISIT.—The term ‘during a 
visit’ shall, with respect to an individual who is fur-
nished items and services at a participating facility, 
include equipment and devices, telemedicine services, 
imaging services, laboratory services, preoperative 
and postoperative services, and such other items and 
services as the Secretary may specify furnished to 
such individual, regardless of whether or not the 
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provider furnishing such items or services is at the 
facility. 
‘‘(3) EMERGENCY
DEPARTMENT
OF
A
HOS-
PITAL.—The term ‘emergency department of a hos-
pital’ includes a hospital outpatient department that 
provides emergency services. 
‘‘(4) EMERGENCY
MEDICAL
CONDITION.—The 
term ‘emergency medical condition’ means a medical 
condition manifesting itself by acute symptoms of 
sufficient severity (including severe pain) such that 
a prudent layperson, who possesses an average 
knowledge of health and medicine, could reasonably 
expect the absence of immediate medical attention to 
result in a condition described in clause (i), (ii), or 
(iii) of section 1867(e)(1)(A) of the Social Security 
Act. 
‘‘(5) EMERGENCY SERVICES.— 
‘‘(A) IN GENERAL.—The term ‘emergency 
services’, with respect to an emergency medical 
condition, means— 
‘‘(i) a medical screening examination 
(as required under section 1867 of the So-
cial Security Act, or as would be required 
under such section if such section applied 
to an independent freestanding emergency 
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department) that is within the capability of 
the emergency department of a hospital or 
of an independent freestanding emergency 
department, as applicable, including ancil-
lary services routinely available to the 
emergency department to evaluate such 
emergency medical condition; and 
‘‘(ii) within the capabilities of the 
staff and facilities available at the hospital 
or the independent freestanding emergency 
department, as applicable, such further 
medical examination and treatment as are 
required under section 1867 of such Act, 
or as would be required under such section 
if such section applied to an independent 
freestanding emergency department, to 
stabilize the patient (regardless of the de-
partment of the hospital in which such fur-
ther examination or treatment is fur-
nished). 
‘‘(B) INCLUSION
OF
ADDITIONAL
SERV-
ICES.—In the case of an individual enrolled in 
a health plan who is furnished services de-
scribed in subparagraph (A) by a provider or 
hospital or independent freestanding emergency 
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department to stabilize such individual with re-
spect to an emergency medical condition, the 
term ‘emergency services’ shall include, in addi-
tion to those described in subparagraph (A), 
items and services furnished as part of out-
patient observation or an inpatient or out-
patient stay during a visit in which such indi-
vidual is so stabilized with respect to such 
emergency condition if— 
‘‘(i) such items and services would 
otherwise be covered under such plan if 
furnished by a participating provider or 
participating facility; and 
‘‘(ii) such items and services are fur-
nished— 
‘‘(I) to maintain, improve, or re-
solve the individual’s stabilization with 
respect to such condition, unless any 
circumstance described in subpara-
graph (C) has occurred with respect 
to such individual before such items 
and services are furnished; or 
‘‘(II) for any purpose not de-
scribed in subclause (I), unless each 
of the criteria described in subpara-
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graph (D) have been met with respect 
to such individual and such item or 
service. 
‘‘(C) CIRCUMSTANCES.—For purposes of 
subparagraph (B)(ii)(I), a circumstance de-
scribed in this subparagraph is any of the fol-
lowing, with respect to an individual who is a 
beneficiary, participant, or enrollee of a health 
plan who is furnished services described in sub-
paragraph (A) by a hospital or independent 
freestanding emergency department with re-
spect to an emergency medical condition: 
‘‘(i) A participating provider, with re-
spect to such plan, with privileges at the 
hospital or independent freestanding emer-
gency department assumes responsibility 
for the care of the individual. 
‘‘(ii) A participating provider, with re-
spect to such plan, assumes responsibility 
for the care of the individual through 
transfer of the individual. 
‘‘(iii) The health plan and the pro-
vider treating such individual at the hos-
pital or independent freestanding emer-
gency department for such condition reach 
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an agreement concerning the care for the 
individual. 
‘‘(iv) The individual is discharged. 
‘‘(D) SIGNED NOTICE CRITERIA.—For pur-
poses of subparagraph (B)(ii)(II), the criteria 
described in this subparagraph, with respect to 
an individual and an item or service furnished 
by a nonparticipating provider or nonpartici-
pating facility that is a hospital or an inde-
pendent freestanding emergency department, 
are the following: 
‘‘(i) A written notice (as specified by 
the Secretary and in a clear and under-
standable manner) is provided by such pro-
vider or facility to such individual, before 
such item or service is furnished, that in-
cludes the following information: 
‘‘(I) That such provider or facil-
ity is a nonparticipating provider or 
nonparticipating facility (as applica-
ble). 
‘‘(II) To the extent practicable, 
the estimated amount that such non-
participating facility or nonpartici-
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pating provider may charge the indi-
vidual for such item or service. 
‘‘(III) A statement that the indi-
vidual may seek such item or service 
from a provider that is a participating 
provider or a hospital or independent 
freestanding emergency department 
that is a participating facility and a 
list, if feasible, of participating facili-
ties or participating providers, as ap-
plicable, who are able to furnish such 
item or service. 
‘‘(ii) Such individual is in a condition 
to receive (as determined in accordance 
with guidance issued by the Secretary) the 
information described in clause (i) and to 
confirm notice of receipt of such notice, in 
accordance with applicable State law. 
‘‘(iii) The individual signs and dates 
such notice confirming receipt of the notice 
before such item or service is furnished. 
‘‘(6) HEALTH PLAN.—The term ‘health plan’ 
means a group health plan and health insurance cov-
erage offered by a health insurance issuer in the 
group market and includes a grandfathered health 
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plan (as defined in section 1251(e) of the Patient 
Protection and Affordable Care Act) that is such a 
plan or coverage. 
‘‘(7) INDEPENDENT
FREESTANDING
EMER-
GENCY DEPARTMENT.—The term ‘independent free-
standing emergency department’ means a health 
care facility that— 
‘‘(A) is geographically separate and dis-
tinct and licensed separately from a hospital 
under applicable State law; and 
‘‘(B) provides emergency services. 
‘‘(8) MEDIAN CONTRACTED RATE.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the term ‘median contracted rate’ 
means, with respect to a health plan— 
‘‘(i) for an item or service furnished 
during 2022, the median of the contracted 
rates recognized by the sponsor or issuer 
of such plan (determined with respect to 
all such plans of such sponsor or such 
issuer that are within the same line of 
business (as specified in subparagraph (C)) 
as the plan involved) as the total maximum 
payment under such plans in 2019 for the 
same or a similar item or service that is 
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provided by a provider or facility in the 
same or similar specialty and provided in 
the geographic region (established (and up-
dated, as appropriate) by the Secretary, in 
consultation with the National Association 
of Insurance Commissioners) in which the 
item or service is furnished, consistent with 
the methodology established by the Sec-
retary under subsection (b)(2)(B), in-
creased by the percentage increase in the 
consumer price index for all urban con-
sumers (United States city average) over 
2019, 2020, and 2021; 
‘‘(ii) for an item or service furnished 
during 2023 or a subsequent year through 
2026, the median contracted rate for the 
previous year, increased by the percentage 
increase in the consumer price index for all 
urban consumers (United States city aver-
age) over such previous year; 
‘‘(iii) for an item or service furnished 
during a rebasing year (as defined in sub-
paragraph (D)), the median of the con-
tracted rates recognized by the sponsor or 
issuer of such plan (determined with re-
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spect to all such plans of such sponsor or 
issuer that are within the same line of 
business (as specified in subparagraph (C)) 
as the plan involved) as the total maximum 
payment under such plans in such year for 
the same or a similar item or service that 
is provided by a provider or facility in the 
same or similar specialty and provided in 
the geographic region (as established pur-
suant to clause (i)) in which the item or 
service is furnished, consistent with the 
methodology established by the Secretary 
under subsection (b)(2)(B); and 
‘‘(iv) for an item or service furnished 
during any of the 4 years following a re-
basing year, the median contracted rate for 
the previous year, increased by the per-
centage increase in the consumer price 
index for all urban consumers (United 
States city average) over such previous 
year. 
‘‘(B) USE OF SUBSTITUTE RATE IN CASE 
OF INSUFFICIENT DATA.— 
‘‘(i) IN
GENERAL.—In the case the 
sponsor or issuer of a health plan has in-
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sufficient information (as specified by the 
Secretary) to calculate the median of the 
contracted rates in accordance with sub-
paragraph (A) for a year for an item or 
service furnished in a particular geographic 
region (as established pursuant to subpara-
graph (A)(i)) by a type of provider or facil-
ity, the substitute rate (as defined in 
clause (ii)) for such item or service shall be 
deemed to be the median contracted rate 
for such item or service furnished in such 
region during such year by such a provider 
or facility for such year under such sub-
paragraph (A) for such plan. 
‘‘(ii) SUBSTITUTE
RATE.—For pur-
poses of clause (i), the term ‘substitute 
rate’ means, with respect to an item or 
service furnished by a provider or facility 
in a geographic region (established pursu-
ant to subparagraph (A)(i)) during a year 
for which a health plan is required to make 
payment pursuant to subsection (b)(1), 
(e)(1), or (i)(1)— 
‘‘(I) if sufficient information (as 
specified by the Secretary) exists to 
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determine the median of the con-
tracted rates recognized by all health 
plans offered in the same line of busi-
ness (as specified in subparagraph 
(C)) by any group health plan for 
such an item or service furnished in 
such region by such a provider or fa-
cility during such year using a data-
base or other source of information 
determined appropriate by the Sec-
retary, such median; and 
‘‘(II) if such sufficient informa-
tion does not exist, the median of the 
contracted rates recognized by all 
health plans offered in the same line 
of business (as specified in subpara-
graph (C)) by any group health plan 
for such an item or service furnished 
in a similarly situated geographic re-
gion (as determined by the Secretary) 
with such sufficient information by 
such a provider or facility during such 
year using such a database or such 
other source of information. 
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The Secretary shall develop a methodology 
for determining a substitute rate based on 
a similarly situated health plan that is not 
a Federal health care program (as defined 
in section 1128B(f) of the Social Security 
Act) in the case a substitute rate is not 
calculable under the previous sentence with 
respect to an item or service. 
‘‘(C) LINE OF BUSINESS.—A line of busi-
ness specified in this subparagraph is one of the 
following: 
‘‘(i) The small group market. 
‘‘(ii) The large group market. 
‘‘(iii) In the case of a self-insured 
group health plan, other self-insured group 
health plans. 
‘‘(D) REBASING YEAR DEFINED.—For pur-
poses of subparagraph (A), the term ‘rebasing 
year’ means 2027 and every 5 years thereafter. 
‘‘(9) NONPARTICIPATING
FACILITY; PARTICI-
PATING FACILITY.— 
‘‘(A) NONPARTICIPATING
FACILITY.—The 
term ‘nonparticipating facility’ means, with re-
spect to an item or service and a health plan, 
a health care facility described in subparagraph 
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(B)(ii) that does not have a contractual rela-
tionship with the plan for furnishing such item 
or service. 
‘‘(B) PARTICIPATING FACILITY.— 
‘‘(i) IN GENERAL.—The term ‘partici-
pating facility’ means, with respect to an 
item or service and a health plan, a health 
care facility described in clause (ii) that 
has a contractual relationship with the 
plan for furnishing such item or service. 
‘‘(ii) HEALTH
CARE
FACILITY
DE-
SCRIBED.—A health care facility described 
in this clause is each of the following: 
‘‘(I) A hospital (as defined in 
1861(e) of the Social Security Act), 
including an emergency department of 
a hospital. 
‘‘(II) A critical access hospital 
(as defined in section 1861(mm)(1) of 
such Act). 
‘‘(III) An ambulatory surgical 
center 
(as 
described 
in 
section 
1833(i)(1)(A) of such Act). 
‘‘(IV) A laboratory. 
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‘‘(V) A radiology facility or imag-
ing center. 
‘‘(VI) 
An 
independent 
free-
standing emergency department. 
‘‘(VII) Any other facility speci-
fied by the Secretary. 
‘‘(10) NONPARTICIPATING PROVIDERS; PARTICI-
PATING PROVIDERS.— 
‘‘(A) NONPARTICIPATING PROVIDER.—The 
term ‘nonparticipating provider’ means, with re-
spect to an item or service and a health plan, 
a physician or other health care provider who 
does not have a contractual relationship with 
the plan for furnishing such item or service 
under the plan. 
‘‘(B) 
PARTICIPATING
PROVIDER.—The 
term ‘participating provider’ means, with re-
spect to an item or service and a health plan, 
a physician or other health care provider who 
has a contractual relationship with the plan for 
furnishing such item or service under the plan. 
‘‘(11) OUT-OF-NETWORK
RATE.—The term 
‘out-of-network rate’ means, with respect to an item 
or service furnished in a State during a year to a 
participant or beneficiary of a health plan receiving 
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such item or service from a nonparticipating pro-
vider or facility— 
‘‘(A) subject to subparagraphs (C) and 
(D), in the case such State has in effect a State 
law that provides for a method for determining 
the total amount payable under such health 
plan regulated by such State with respect to 
such item or service furnished by such provider 
or facility, such amount determined in accord-
ance with such law; 
‘‘(B) subject to subparagraphs (C) and 
(D), in the case such State does not have in ef-
fect such a law with respect to such item or 
service, plan, and provider or facility— 
‘‘(i) subject to clause (ii), if the pro-
vider or facility (as applicable) and such 
plan agree on an amount of payment (in-
cluding if agreed on through open negotia-
tions under subsection (j)(1)) with respect 
to such item or service, such agreed on 
amount; or 
‘‘(ii) if such provider or facility (as 
applicable) and such plan enter the medi-
ated dispute process under subsection (j) 
and do not so agree before the date on 
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which a selected independent entity (as de-
fined in paragraph (3) of such subsection) 
makes a determination with respect to 
such item or service under such subsection, 
the amount of such determination; 
‘‘(C) in the case such State has an All- 
Payer Model Agreement under section 1115A of 
the Social Security Act, the amount that the 
State approves under such system for such item 
or service so furnished; or 
‘‘(D) in the case such health plan is a self- 
insured group health plan and in the case of a 
State with an agreement with such plan in ef-
fect as of the date of the enactment of the Con-
sumer Protections Against Surprise Medical 
Bills Act of 2020, that provides for a method 
for determining the total amount payable under 
such health plan with respect to such item or 
service furnished by such provider or facility, 
such amount determined in accordance with 
such method. 
‘‘(12) RECOGNIZED AMOUNT.—The term ‘recog-
nized amount’ means, with respect to an item or 
service furnished in a State during a year to a par-
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ticipant or beneficiary of a health plan by a non-
participating provider or nonparticipating facility— 
‘‘(A) subject to subparagraphs (C) and 
(D), in the case such State has in effect a law 
described in paragraph (11)(A) with respect to 
such item or service, provider or facility, and 
plan, the amount determined in accordance with 
such law; 
‘‘(B) subject to subparagraphs (C) and 
(D), in the case such State does not have in ef-
fect such a law, an amount that is the median 
contracted rate for such item or service for such 
year; 
‘‘(C) in the case such State is described in 
paragraph (11)(C) with respect to such item or 
service so furnished, the amount that the State 
approves under such system for such item or 
service so furnished; or 
‘‘(D) in the case such health plan is a self- 
insured group health plan and in the case of a 
State with an agreement with such plan in ef-
fect as of the date of the enactment of the Con-
sumer Protections Against Surprise Medical 
Bills Act of 2020, that provides for a method 
for determining the total amount payable under 
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such health plan with respect to such item or 
service furnished by such provider or facility, 
such amount determined in accordance with 
such method. 
‘‘(13) STABILIZE.—The term ‘to stabilize’, with 
respect to an emergency medical condition, has the 
meaning give in section 1867(e)(3)(A) of the Social 
Security Act). 
‘‘(14) COST-SHARING.—The term ‘cost-sharing’ 
includes copayments, coinsurance, and deductibles. 
‘‘(l) PAYMENT TO PROVIDER OR FACILITY.—In the 
case of any payment required to be made by a health plan 
pursuant to subsection (b)(1), (e)(1), or (i)(1) to a 
nonparticiapting provider or nonparticipating facility for 
an item or service, such payment shall be made to such 
provider or facility and not to the individual receiving such 
item or service.’’. 
(2) CONFORMING AMENDMENT.— 
(A) APPLICATION
PROVISIONS.—Section 
715(a) of the Employee Retirement Income Se-
curity Act of 1974 (29 U.S.C. 1185d(a)) is 
amended— 
(i) in paragraph (1), by striking ‘‘(as 
amended by the Patient Protection and Af-
fordable Care Act)’’ and inserting ‘‘(other 
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than, with respect to a plan year beginning 
on or after January 1, 2022, the provisions 
of section 2719A of such Act)’’; and 
(ii) in paragraph (2), by inserting 
‘‘(other than, with respect to a plan year 
beginning on or after January 1, 2022, the 
provisions of section 2719A of such Act)’’ 
after the first occurrence of ‘‘such part A’’. 
(B) 
APPLICATION
TO
RETIREE-ONLY 
PLANS.—Section 732(a) of the Employee Re-
tirement Income Security Act of 1974 (29 
U.S.C. 1191a(a)) is amended by striking ‘‘sec-
tion 711’’ and inserting ‘‘sections 711 and 
716’’. 
(3) CLERICAL AMENDMENT.—The table of con-
tents in section 1 of the Employee Retirement In-
come Security Act of 1974 is amended by inserting 
after the item relating to section 714 the following 
new items: 
‘‘Sec. 715. Additional market reforms. 
‘‘Sec. 716. Patient protections.’’. 
(4) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply with respect to plan 
years beginning on or after January 1, 2022. 
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SEC. 3. CONSUMER PROTECTIONS THROUGH REQUIRE-
MENTS ON HEALTH PLANS TO PREVENT SUR-
PRISE MEDICAL BILLS FOR NON-EMERGENCY 
SERVICES 
PERFORMED 
BY 
NONPARTICI-
PATING PROVIDERS AT CERTAIN PARTICI-
PATING FACILITIES. 
(a) PHSA AMENDMENTS.— 
(1) IN GENERAL.—Section 2719A of the Public 
Health Service Act (42 U.S.C. 300gg–19a), as 
amended by section 2(a), is further amended by in-
serting before subsection (k) the following new sub-
section: 
‘‘(e) COST-SHARING AND PAYMENT OF NON-EMER-
GENCY SERVICES PERFORMED
BY NONPARTICIPATING 
PROVIDERS AT CERTAIN PARTICIPATING FACILITIES.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
in the case of items or services (other than emer-
gency services to which subsection (b) applies or 
items and services to which subsection (i) applies) 
furnished to a participant, beneficiary, or enrollee of 
a health plan by a nonparticipating provider during 
a visit (as defined by the Secretary in accordance 
with subsection (k)(2)) at a participating facility, if 
such items and services would otherwise be covered 
under such plan if furnished by a participating pro-
vider, the plan— 
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‘‘(A) shall not impose on such participant, 
beneficiary, or enrollee a cost-sharing amount 
for such items and services so furnished that is 
greater than the cost-sharing amount that 
would apply under such plan had such items or 
services been furnished by a participating pro-
vider; 
‘‘(B) shall calculate such cost-sharing 
amount as if the contracted rate for such serv-
ices if furnished by a participating provider 
were equal to the recognized amount for such 
items and services; 
‘‘(C) shall pay to such provider furnishing 
such items and services to such participant, 
beneficiary, or enrollee the amount by which the 
out-of-network rate for such items and services 
exceeds the cost-sharing amount imposed under 
the plan for such items and services (as deter-
mined in accordance with subparagraphs (A) 
and (B)); and 
‘‘(D) shall apply the deductible or out-of- 
pocket maximum, if any, that would apply if 
such services were furnished by a participating 
provider. 
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‘‘(2) EXCEPTION.—Paragraph (1) shall not 
apply to a health plan in the case of items or serv-
ices furnished to a participant, beneficiary, or en-
rollee of a health plan by a nonparticipating provider 
during a visit (as so defined by the Secretary in ac-
cordance with subsection (k)(2)) at a participating 
facility if the requirement described in paragraph (1) 
of section 1150C(b) of the Social Security Act does 
not apply with respect to such provider and such 
items and services due to the application of para-
graph (2) of such section.’’. 
(2) EFFECTIVE DATE.—The amendment made 
by paragraph (1) shall apply with respect to plan 
years beginning on or after January 1, 2022. 
(b) IRC AMENDMENTS.— 
(1) IN GENERAL.—Section 9816 of the Internal 
Revenue Code of 1986, as added by section 2(b), is 
amended by inserting before subsection (k) the fol-
lowing new subsection: 
‘‘(e) COST-SHARING AND PAYMENT OF NON-EMER-
GENCY SERVICES PERFORMED
BY NONPARTICIPATING 
PROVIDERS AT CERTAIN PARTICIPATING FACILITIES.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
in the case of items or services (other than emer-
gency services to which subsection (b) applies or 
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items and services to which subsection (i) applies) 
furnished to a participant or beneficiary of a health 
plan by a nonparticipating provider during a visit 
(as defined by the Secretary in accordance with sub-
section (k)(2)) at a participating facility, if such 
items and services would otherwise be covered under 
such plan if furnished by a participating provider, 
the plan— 
‘‘(A) shall not impose on such participant 
or beneficiary a cost-sharing amount for such 
items and services so furnished that is greater 
than the cost-sharing amount that would apply 
under such plan had such items or services been 
furnished by a participating provider; 
‘‘(B) shall calculate such cost-sharing 
amount as if the contracted rate for such serv-
ices if furnished by a participating provider 
were equal to the recognized amount for such 
items and services; 
‘‘(C) shall pay to such provider furnishing 
such items and services to such participant or 
beneficiary the amount by which the out-of-net-
work rate for such items and services exceeds 
the cost-sharing amount imposed under the 
plan for such items and services (as determined 
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in accordance with subparagraphs (A) and (B)); 
and 
‘‘(D) shall apply the deductible or out-of- 
pocket maximum, if any, that would apply if 
such services were furnished by a participating 
provider. 
‘‘(2) EXCEPTION.—Paragraph (1) shall not 
apply to a health plan in the case of items or serv-
ices furnished to a participant or beneficiary of a 
health plan by a nonparticipating provider during a 
visit (as so defined by the Secretary in accordance 
with subsection (k)(2)) at a participating facility if 
the requirement described in paragraph (1) of sec-
tion 1150C(b) of the Social Security Act does not 
apply with respect to such provider and such items 
and services due to the application of paragraph (2) 
of such section.’’. 
(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall apply with respect to plan 
years beginning on or after January 1, 2022. 
(c) ERISA AMENDMENTS.— 
(1) IN GENERAL.—Section 716 of the Employee 
Retirement Income Security Act of 1974, as added 
by section 2(c), is amended by inserting before sub-
section (k) the following new subsection: 
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‘‘(e) COST-SHARING AND PAYMENT OF NON-EMER-
GENCY SERVICES PERFORMED
BY NONPARTICIPATING 
PROVIDERS AT CERTAIN PARTICIPATING FACILITIES.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
in the case of items or services (other than emer-
gency services to which subsection (b) applies or 
items and services to which subsection (i) applies) 
furnished to a participant or beneficiary of a health 
plan by a nonparticipating provider during a visit 
(as defined by the Secretary in accordance with sub-
section (k)(2)) at a participating facility, if such 
items and services would otherwise be covered under 
such plan if furnished by a participating provider, 
the plan— 
‘‘(A) shall not impose on such participant 
or beneficiary a cost-sharing amount for such 
items and services so furnished that is greater 
than the cost-sharing amount that would apply 
under such plan had such items or services been 
furnished by a participating provider; 
‘‘(B) shall calculate such cost-sharing 
amount as if the contracted rate for such serv-
ices if furnished by a participating provider 
were equal to the recognized amount for such 
items and services; 
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‘‘(C) shall pay to such provider furnishing 
such items and services to such participant or 
beneficiary the amount by which the out-of-net-
work rate for such items and services exceeds 
the cost-sharing amount imposed under the 
plan for such items and services (as determined 
in accordance with subparagraphs (A) and (B)); 
and 
‘‘(D) shall apply the deductible or out-of- 
pocket maximum, if any, that would apply if 
such services were furnished by a participating 
provider. 
‘‘(2) EXCEPTION.—Paragraph (1) shall not 
apply to a health plan in the case of items or serv-
ices furnished to a participant or beneficiary of a 
health plan by a nonparticipating provider during a 
visit (as so defined by the Secretary in accordance 
with subsection (k)(2)) at a participating facility if 
the requirement described in paragraph (1) of sec-
tion 1150C(b) of the Social Security Act does not 
apply with respect to such provider and such items 
and services due to the application of paragraph (2) 
of such section.’’. 
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(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall apply with respect to plan 
years beginning on or after January 1, 2022. 
SEC. 4. CONSUMER PROTECTIONS THROUGH APPLICATION 
OF HEALTH PLAN EXTERNAL REVIEW IN 
CASES 
OF 
CERTAIN 
SURPRISE 
MEDICAL 
BILLS. 
Section 2719(b)(1) of the Public Health Service Act 
(42 U.S.C. 300gg–19(b)(1)) is amended— 
(1) by striking ‘‘at a minimum, includes’’ and 
inserting ‘‘at a minimum— 
‘‘(A) includes’’; 
(2) by striking at the end ‘‘or’’ and inserting 
‘‘and’’; and 
(3) by adding at the end the following new sub-
paragraph: 
‘‘(B) beginning not later than January 1, 
2022, applies such external review process with 
respect to any adverse determination by such 
plan or issuer under subsection (b) of section 
2719A, subsection (e) of such section, or sub-
section (i) of such section, including with re-
spect to whether an item or service that is the 
subject to such a determination is an item or 
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service to which such subsection (b), (e), or (i) 
applies; or’’. 
SEC. 5. CONSUMER PROTECTIONS THROUGH HEALTH PLAN 
TRANSPARENCY REQUIREMENTS. 
(a) PHSA AMENDMENTS.—Section 2719A of the 
Public Health Service Act (42 U.S.C. 300gg–19a), as 
amended by sections 2(a) and 3(a), is further amended 
by inserting before subsection (k) the following new sub-
sections: 
‘‘(f) PROVIDER DIRECTORY REQUIREMENTS.— 
‘‘(1) IN GENERAL.—Beginning not later than 
January 1, 2022, each health plan shall— 
‘‘(A) establish the verification process de-
scribed in paragraph (2); 
‘‘(B) establish the response protocol de-
scribed in paragraph (3); 
‘‘(C) establish the database described in 
paragraph (4); and 
‘‘(D) include in any directory (other than 
the database described in subparagraph (C)) 
containing provider directory information with 
respect to such plan the information described 
in paragraph (5). 
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‘‘(2) VERIFICATION PROCESS.—The verification 
process described in this paragraph is, with respect 
to a health plan, a process— 
‘‘(A) under which such plan verifies and 
updates the provider directory information in-
cluded on the database described in paragraph 
(4) of such plan of— 
‘‘(i) not less frequently than once 
every 90 days, a random sample of at least 
10 percent of health care providers and 
health care facilities included in such data-
base; and 
‘‘(ii) any such provider or such facility 
included in such database that has not 
submitted any claim to such plan during a 
12-month period; 
‘‘(B) that establishes a procedure for the 
removal from such database of such a provider 
or facility with respect to which such plan has 
been unable to verify such information during a 
period specified by the plan; and 
‘‘(C) that provides for the update of such 
database within 2 business days of such plan 
receiving from such a provider or facility infor-
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02:30 Feb 11, 2020
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mation pursuant to section 1150D of the Social 
Security Act. 
‘‘(3) RESPONSE PROTOCOL.—The response pro-
tocol described in this paragraph is, in the case of 
an individual enrolled in a health plan who requests 
information through a telephone call or email on 
whether a health care provider or health care facility 
has a contractual relationship to furnish items and 
services under such plan, a protocol under which 
such plan— 
‘‘(A) responds to such individual as soon 
as practicable, and in no case later than 1 busi-
ness day after such call or email is received, 
through a written electronic or paper (as re-
quested by such individual) communication; and 
‘‘(B) retains such communication in such 
individual’s file for at least 2 years following 
such response. 
‘‘(4) DATABASE.—The database described in 
this paragraph is, with respect to a health plan, a 
database on the public website of such plan or issuer 
that contains— 
‘‘(A) a list of each health care provider and 
health care facility with which such plan has a 
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contractual relationship for furnishing items 
and services under such plan; and 
‘‘(B) provider directory information with 
respect to each such provider and facility. 
‘‘(5) 
INFORMATION.—The 
information 
de-
scribed in this paragraph is, with respect to a direc-
tory containing provider directory information with 
respect to a health plan, a notification that such in-
formation contained in such directory was accurate 
as of the date of publication of such directory and 
that an individual enrolled under such plan should 
consult the database described in paragraph (4) with 
respect to such plan or contact such plan to obtain 
the most current provider directory information with 
respect to such plan. 
‘‘(6) DEFINITION.—For purposes of this sec-
tion, the term ‘provider directory information’ in-
cludes, with respect to a health plan, the name, ad-
dress, specialty, and telephone number of each 
health care provider or health care facility with 
which such plan has a contractual relationship for 
furnishing items and services under such plan. 
‘‘(g) 
DISCLOSURE
ON
PATIENT
PROTECTIONS 
AGAINST BALANCE BILLING.—Beginning not later than 
January 1, 2022, each health plan shall make publicly 
VerDate Sep 11 2014 
02:30 Feb 11, 2020
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available, post on a website of such plan available to indi-
viduals enrolled under such plan, and include on each ex-
planation of benefits for an item or service with respect 
to which the requirements under subsection (b), (e), or 
(i) applies— 
‘‘(1) information in plain language on— 
‘‘(A) the requirements and prohibitions ap-
plied under section 1150C of the Social Secu-
rity Act (relating to prohibitions on balance bill-
ing in certain circumstances); 
‘‘(B) if provided for under applicable State 
law, any other requirements on providers and 
facilities regarding the amounts such providers 
and facilities may, with respect to an item or 
service, charge a participant, beneficiary, or en-
rollee of such plan with respect to which such 
a provider is a nonparticipating provider or fa-
cility is a nonparticipating facility, with respect 
to such plan, for furnishing such item or service 
after receiving payment from the plan for such 
item or service and any applicable cost-sharing 
payment from such participant, beneficiary, or 
enrollee; and 
‘‘(C) the requirements applied under sub-
sections (b), (e), and (i); and 
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‘‘(2) information in plain language on con-
tacting appropriate State and Federal agencies in 
the case that an individual believes that such a 
health plan, provider, or facility has violated any re-
quirement described in paragraph (1) with respect to 
such individual.’’. 
(b) IRC AMENDMENTS.—Section 9816 of the Inter-
nal Revenue Code of 1986, as added by section 2(b) and 
amended by section 3(b), is further amended by inserting 
before subsection (k) the following new subsections: 
‘‘(f) PROVIDER DIRECTORY REQUIREMENTS.— 
‘‘(1) IN GENERAL.—Beginning not later than 
January 1, 2022, each health plan shall— 
‘‘(A) establish the verification process de-
scribed in paragraph (2); 
‘‘(B) establish the response protocol de-
scribed in paragraph (3); 
‘‘(C) establish the database described in 
paragraph (4); and 
‘‘(D) include in any directory (other than 
the database described in subparagraph (C)) 
containing provider directory information with 
respect to such plan the information described 
in paragraph (5). 
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‘‘(2) VERIFICATION PROCESS.—The verification 
process described in this paragraph is, with respect 
to a health plan, a process— 
‘‘(A) under which such plan verifies and 
updates the provider directory information in-
cluded on the database described in paragraph 
(4) of such plan of— 
‘‘(i) not less frequently than once 
every 90 days, a random sample of at least 
10 percent of health care providers and 
health care facilities included in such data-
base; and 
‘‘(ii) any such provider or such facility 
included in such database that has not 
submitted any claim to such plan during a 
12-month period; 
‘‘(B) that establishes a procedure for the 
removal from such database of such a provider 
or facility with respect to which such plan has 
been unable to verify such information during a 
period specified by the plan; and 
‘‘(C) that provides for the update of such 
database within 2 business days of such plan 
receiving from such a provider or facility infor-
VerDate Sep 11 2014 
02:30 Feb 11, 2020
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kjohnson on DSK79L0C42PROD with BILLS
mation pursuant to section 1150D of the Social 
Security Act. 
‘‘(3) RESPONSE PROTOCOL.—The response pro-
tocol described in this paragraph is, in the case of 
an individual enrolled in a health plan who requests 
information through a telephone call or email on 
whether a health care provider or health care facility 
has a contractual relationship to furnish items and 
services under such plan, a protocol under which 
such plan— 
‘‘(A) responds to such individual as soon 
as practicable, and in no case later than 1 busi-
ness day after such call or email is received, 
through a written electronic or paper (as re-
quested by such individual) communication; and 
‘‘(B) retains such communication in such 
individual’s file for at least 2 years following 
such response. 
‘‘(4) DATABASE.—The database described in 
this paragraph is, with respect to a health plan, a 
database on the public website of such plan or issuer 
that contains— 
‘‘(A) a list of each health care provider and 
health care facility with which such plan has a 
VerDate Sep 11 2014 
02:30 Feb 11, 2020
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contractual relationship for furnishing items 
and services under such plan; and 
‘‘(B) provider directory information with 
respect to each such provider and facility. 
‘‘(5) 
INFORMATION.—The 
information 
de-
scribed in this paragraph is, with respect to a direc-
tory containing provider directory information with 
respect to a health plan, a notification that such in-
formation contained in such directory was accurate 
as of the date of publication of such directory and 
that an individual enrolled under such plan should 
consult the database described in paragraph (4) with 
respect to such plan or contact such plan to obtain 
the most current provider directory information with 
respect to such plan. 
‘‘(6) DEFINITION.—For purposes of this sec-
tion, the term ‘provider directory information’ in-
cludes, with respect to a health plan, the name, ad-
dress, specialty, and telephone number of each 
health care provider or health care facility with 
which such plan has a contractual relationship for 
furnishing items and services under such plan. 
‘‘(g) 
DISCLOSURE
ON
PATIENT
PROTECTIONS 
AGAINST BALANCE BILLING.—Beginning not later than 
January 1, 2022, each health plan shall make publicly 
VerDate Sep 11 2014 
02:30 Feb 11, 2020
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available, post on a website of such plan available to indi-
viduals enrolled under such plan, and include on each ex-
planation of benefits for an item or service with respect 
to which the requirements under subsection (b), (e), or 
(i) applies— 
‘‘(1) information in plain language on— 
‘‘(A) the requirements and prohibitions ap-
plied under section 1150C of the Social Secu-
rity Act (relating to prohibitions on balance bill-
ing in certain circumstances); 
‘‘(B) if provided for under applicable State 
law, any other requirements on providers and 
facilities regarding the amounts such providers 
and facilities may, with respect to an item or 
service, charge a participant or beneficiary of 
such plan with respect to which such a provider 
is a nonparticipating provider or facility is a 
nonparticipating facility, with respect to such 
plan, for furnishing such item or service after 
receiving payment from the plan for such item 
or service and any applicable cost-sharing pay-
ment from such participant or beneficiary; and 
‘‘(C) the requirements applied under sub-
sections (b), (e), and (i); and 
VerDate Sep 11 2014 
02:30 Feb 11, 2020
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100 
‘‘(2) information in plain language on con-
tacting appropriate State and Federal agencies in 
the case that an individual believes that such a 
health plan, provider, or facility has violated any re-
quirement described in paragraph (1) with respect to 
such individual.’’. 
(c) ERISA AMENDMENTS.—Section 716 of the Em-
ployee Retirement Income Security Act of 1974, as added 
by section 2(c) and amended by section 3(c), is further 
amended by inserting before subsection (k) the following 
new subsections: 
‘‘(f) PROVIDER DIRECTORY REQUIREMENTS.— 
‘‘(1) IN GENERAL.—Beginning not later than 
January 1, 2022, each health plan shall— 
‘‘(A) establish the verification process de-
scribed in paragraph (2); 
‘‘(B) establish the response protocol de-
scribed in paragraph (3); 
‘‘(C) establish the database described in 
paragraph (4); and 
‘‘(D) include in any directory (other than 
the database described in subparagraph (C)) 
containing provider directory information with 
respect to such plan the information described 
in paragraph (5). 
VerDate Sep 11 2014 
02:30 Feb 11, 2020
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101 
‘‘(2) VERIFICATION PROCESS.—The verification 
process described in this paragraph is, with respect 
to a health plan, a process— 
‘‘(A) under which such plan verifies and 
updates the provider directory information in-
cluded on the database described in paragraph 
(4) of such plan of— 
‘‘(i) not less frequently than once 
every 90 days, a random sample of at least 
10 percent of health care providers and 
health care facilities included in such data-
base; and 
‘‘(ii) any such provider or such facility 
included in such database that has not 
submitted any claim to such plan during a 
12-month period; 
‘‘(B) that establishes a procedure for the 
removal from such database of such a provider 
or facility with respect to which such plan has 
been unable to verify such information during a 
period specified by the plan; and 
‘‘(C) that provides for the update of such 
database within 2 business days of such plan 
receiving from such a provider or facility infor-
VerDate Sep 11 2014 
02:30 Feb 11, 2020
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102 
mation pursuant to section 1150D of the Social 
Security Act. 
‘‘(3) RESPONSE PROTOCOL.—The response pro-
tocol described in this paragraph is, in the case of 
an individual enrolled in a health plan who requests 
information through a telephone call or email on 
whether a health care provider or health care facility 
has a contractual relationship to furnish items and 
services under such plan, a protocol under which 
such plan— 
‘‘(A) responds to such individual as soon 
as practicable, and in no case later than 1 busi-
ness day after such call or email is received, 
through a written electronic or paper (as re-
quested by such individual) communication; and 
‘‘(B) retains such communication in such 
individual’s file for at least 2 years following 
such response. 
‘‘(4) DATABASE.—The database described in 
this paragraph is, with respect to a health plan, a 
database on the public website of such plan or issuer 
that contains— 
‘‘(A) a list of each health care provider and 
health care facility with which such plan has a 
VerDate Sep 11 2014 
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103 
contractual relationship for furnishing items 
and services under such plan; and 
‘‘(B) provider directory information with 
respect to each such provider and facility. 
‘‘(5) 
INFORMATION.—The 
information 
de-
scribed in this paragraph is, with respect to a direc-
tory containing provider directory information with 
respect to a health plan, a notification that such in-
formation contained in such directory was accurate 
as of the date of publication of such directory and 
that an individual enrolled under such plan should 
consult the database described in paragraph (4) with 
respect to such plan or contact such plan to obtain 
the most current provider directory information with 
respect to such plan. 
‘‘(6) DEFINITION.—For purposes of this sec-
tion, the term ‘provider directory information’ in-
cludes, with respect to a health plan, the name, ad-
dress, specialty, and telephone number of each 
health care provider or health care facility with 
which such plan has a contractual relationship for 
furnishing items and services under such plan. 
‘‘(g) 
DISCLOSURE
ON
PATIENT
PROTECTIONS 
AGAINST BALANCE BILLING.—Beginning not later than 
January 1, 2022, each health plan shall make publicly 
VerDate Sep 11 2014 
02:30 Feb 11, 2020
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104 
available, post on a website of such plan available to indi-
viduals enrolled under such plan, and include on each ex-
planation of benefits for an item or service with respect 
to which the requirements under subsection (b), (e), or 
(i) applies— 
‘‘(1) information in plain language on— 
‘‘(A) the requirements and prohibitions ap-
plied under section 1150C of the Social Secu-
rity Act (relating to prohibitions on balance bill-
ing in certain circumstances); 
‘‘(B) if provided for under applicable State 
law, any other requirements on providers and 
facilities regarding the amounts such providers 
and facilities may, with respect to an item or 
service, charge a participant or beneficiary of 
such plan with respect to which such a provider 
is a nonparticipating provider or facility is a 
nonparticipating facility, with respect to such 
plan, for furnishing such item or service after 
receiving payment from the plan for such item 
or service and any applicable cost-sharing pay-
ment from such participant or beneficiary; and 
‘‘(C) the requirements applied under sub-
sections (b), (e), and (i); and 
VerDate Sep 11 2014 
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105 
‘‘(2) information in plain language on con-
tacting appropriate State and Federal agencies in 
the case that an individual believes that such a 
health plan, provider, or facility has violated any re-
quirement described in paragraph (1) with respect to 
such individual.’’. 
SEC. 6. CONSUMER PROTECTIONS THROUGH HEALTH PLAN 
REQUIREMENT FOR FAIR AND HONEST AD-
VANCE COST ESTIMATE. 
(a) PHSA AMENDMENT.—Section 2719A of the Pub-
lic Health Service Act (42 U.S.C. 300gg–19a), as amend-
ed by sections 2(a), 3(a), and 5(a), is further amended 
by inserting before subsection (k) the following new sub-
sections: 
‘‘(h) ADVANCED EXPLANATION OF BENEFITS.—Be-
ginning on January 1, 2022, each health plan shall, with 
respect to a notification submitted under section 
1150D(b)(2)(A) of the Social Security Act by a health 
care provider or health care facility, respectively, to the 
health plan for a participant, beneficiary, or enrollee under 
such health plan scheduled to receive an item or service 
from the provider or facility, 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 such notification was made 
VerDate Sep 11 2014 
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106 
pursuant to a request by such participant, beneficiary, or 
enrollee), 3 business days) after the date on which the 
health plan receives such notification, provide to the par-
ticipant, beneficiary, or enrollee (through mail or elec-
tronic means, as requested by the participant, beneficiary, 
or enrollee) a notification (in clear and understandable 
language) including the following: 
‘‘(1) Whether or not the provider or facility is 
a participating provider or a participating facility 
with respect to the health plan with respect to the 
furnishing of such item or service and— 
‘‘(A) in the case the provider or facility is 
a participating provider or facility with respect 
to the health plan with respect to the furnishing 
of such item or service, the contracted rate 
under such plan for such item or service; and 
‘‘(B) in the case the provider or facility is 
a nonparticipating provider or facility with re-
spect to such plan, a description of how such 
individual may obtain information on providers 
and facilities that, with respect to such health 
plan, are participating providers and facilities. 
‘‘(2) The good faith estimate included in the 
notification received from the provider or facility. 
VerDate Sep 11 2014 
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107 
‘‘(3) A good faith estimate of the amount the 
health plan is responsible for paying for items and 
services included in the estimate described in para-
graph (2). 
‘‘(4) A good faith estimate of the amount of 
any cost-sharing (including with respect to the de-
ductible and any copayment or coinsurance obliga-
tion) for which the participant, beneficiary, or en-
rollee would be responsible for such item or service 
(as of the date of such notification). 
‘‘(5) A good faith estimate of the amount that 
the participant, beneficiary, or enrollee has incurred 
toward meeting the limit of the financial responsi-
bility (including with respect to deductibles and out- 
of-pocket maximums) under the health plan (as of 
the date of such notification). 
‘‘(6) In the case such item or service is subject 
to a medical management technique (including con-
current review, prior authorization, and step-therapy 
or fail-first protocols) for coverage under the health 
plan, a disclaimer that coverage for such item or 
service is subject to such medical management tech-
nique. 
‘‘(7) A disclaimer that the information provided 
in the notification is only an estimate based on the 
VerDate Sep 11 2014 
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108 
items and services reasonably expected, at the time 
of scheduling (or requesting) the item or service, to 
be furnished and is subject to change. 
‘‘(8) A statement that the individual may seek 
such an item or service from a provider that is a 
participating provider or a facility that is a partici-
pating facility and a list of participating facilities, or 
of participating providers, as applicable, who are 
able to furnish such items and services involved. 
‘‘(9) Any other information or disclaimer the 
health plan determines appropriate that is consistent 
with information and disclaimers required under this 
section. 
‘‘(i) COST-SHARING AND PAYMENT FOR SERVICES 
PROVIDED BASED ON RELIANCE ON INCORRECT PRO-
VIDER NETWORK INFORMATION.— 
‘‘(1) IN GENERAL.—For plan years beginning 
on or after January 1, 2022, in the case of an item 
or service furnished to a participant, beneficiary, or 
enrollee of a health plan by a nonparticipating pro-
vider or a nonparticipating facility, if such item or 
service would otherwise be covered under such plan 
if furnished by a participating provider or partici-
pating facility and if either of the criteria described 
in paragraph (2) applies with respect to such partici-
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109 
pant, beneficiary, or enrollee and item or service, the 
plan— 
‘‘(A) shall not impose on such enrollee a 
cost-sharing amount for such item or service so 
furnished that is greater than the cost-sharing 
amount that would apply under such plan had 
such item or service been furnished by a partici-
pating provider; 
‘‘(B) shall calculate such cost-sharing 
amount as if the contracted rate for such item 
or service furnished by such a participating pro-
vider or facility were equal to— 
‘‘(i) the most recent (as of the date 
such item or service was furnished) con-
tracted rate in effect between such pro-
vider or facility and such plan for such 
item or service furnished under such plan, 
if any; or 
‘‘(ii) if no contracted rate described in 
clause (i) exists, the recognized amount for 
such item or service; 
‘‘(C) shall pay to such nonparticipating 
provider or facility furnishing such item or serv-
ice to such participant, beneficiary, or enrollee 
the amount by which— 
VerDate Sep 11 2014 
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110 
‘‘(i) if a contracted rate described in 
subparagraph (B)(i) exists, the most re-
cent (as of the date such item or services 
was furnished) such rate; or 
‘‘(ii) if no contracted rate described in 
such subparagraph exists, the out-of-net-
work rate; 
for such items and services exceeds the cost- 
sharing amount imposed under the plan for 
such items and services (as determined in ac-
cordance with subparagraphs (A) and (B)); and 
‘‘(D) shall apply the deductible or out-of- 
pocket maximum, if any, that would apply if 
such services were furnished by a participating 
provider or a participating facility. 
‘‘(2) CRITERIA DESCRIBED.—For purposes of 
paragraph (1), the criteria described in this para-
graph, with respect to an item or service furnished 
to a participant, beneficiary, or enrollee of a health 
plan by a nonparticipating provider or a nonpartici-
pating facility, are the following: 
‘‘(A) The participant, beneficiary, or en-
rollee received a notification under subsection 
(h) with respect to such item and service to be 
furnished and such notification provided infor-
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