‘‘(I) the plan and provider may, 
during the 30-day period following the 
date of receipt of such request, submit 
any information or supporting docu-
mentation to the IDR entity; and 
‘‘(II) the IDR entity shall, not 
later than 60 days after receiving 
such request, determine such amount. 
‘‘(ii) DETERMINATION OF AMOUNT.— 
‘‘(I) IN GENERAL.—The amount 
determined by the IDR entity under 
clause (i), with respect to a payment 
amount to be paid by a health plan to 
a nonparticipating provider for an 
item or service shall be— 
‘‘(aa) the initial charge for 
the item or service made by the 
provider or the commercially rea-
sonable rate paid by the plan for 
the item or service under sub-
sections 
(b)(1)(C)(iii) 
or 
(e)(1)(B), respectively, whichever 
is determined reasonable by the 
entity based on the factors de-
scribed in subclause (III); or 
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‘‘(bb) in the case neither 
such charge or such rate is deter-
mined by the entity to be reason-
able, the final offer submitted 
under subclause (II) that is de-
termined more reasonable in ac-
cordance with such subclause. 
‘‘(II) FINAL OFFERS.—For pur-
poses of subclause (I)(bb), the health 
plan and the nonparticipating pro-
vider party to the independent dispute 
resolution under this paragraph shall 
each submit to the IDR entity their 
final offer for an amount for the pay-
ment that is subject to the dispute not 
later than 30 days after the IDR enti-
ty determines under such subclause 
that neither the charge or rate de-
scribed in subclause (I)(aa) were rea-
sonable. Not later than 60 days after 
such date of such determination, such 
entity shall determine which of the 2 
final offers is more reasonable based 
on the factors described in subclause 
(III). 
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‘‘(III) FACTORS.—For purposes 
of subclauses (I) and (II), the factors 
described in this subclause include, as 
relevant— 
‘‘(aa) commercially reason-
able rates for comparable services 
or items in the same geographic 
area (which shall take into con-
sideration in-network rates for 
that geographic area and not 
charges); 
‘‘(bb) the usual and cus-
tomary cost of the item or service 
involved, determined as the 80th 
percentile of charges for com-
parable items and services for the 
specialty involved in the geo-
graphical area in which the item 
or service was furnished, as de-
termined through reference to a 
medical claims database; 
‘‘(cc) other factors that may 
be submitted at the discretion of 
either party, which may in-
clude— 
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‘‘(dd) the level of training, 
education, experience, and quality 
and outcomes measurements of 
the nonparticipating provider; 
‘‘(ee) the circumstances and 
complexity of the particular dis-
pute, including the time and 
place of the service; 
‘‘(ff) the provider’s quality 
and outcome metrics; 
‘‘(gg) the provider’s usual 
charge for comparable services 
with regard to patients in health 
care plans in which the provider 
is not participating; 
‘‘(hh) the individual patient 
characteristics; and 
‘‘(ii) other relevant economic 
and clinical factors. 
‘‘(IV) FINAL
DECISIONS.—The 
amount that is determined to be the 
more reasonable amount under item 
(aa) or (bb) of subclause (I), as appli-
cable, shall be the final decision of the 
IDR entity as to the amount the 
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health plan is required to pay the pro-
vider. 
‘‘(V) EFFECT
OF
DETERMINA-
TION.—A final determination of an 
IDR entity under subclause (IV)— 
‘‘(aa) shall be binding; and 
‘‘(bb) shall not be subject to 
judicial review, except in cases 
comparable to those described in 
section 10(a) of title 9, United 
States Code, as determined by 
the Secretary in consultation 
with the Secretary of Labor, and 
cases in which information sub-
mitted by one party was deter-
mined to be fraudulent. 
‘‘(iii) PRIVACY LAWS.—An IDR entity 
shall, in conducting an independent dispute 
resolution process under this paragraph, 
comply with all applicable Federal and 
State privacy laws. 
‘‘(iv) 
PUBLIC
AVAILABILITY.—The 
reasonable amount determined by an IDR 
entity under this paragraph with respect to 
any claim shall not be confidential, except 
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that information submitted to the IDR en-
tity shall be kept confidential. IDR entities 
may consider past decisions awarded by 
independent dispute entities during the 
independent dispute resolution process. 
‘‘(v) COSTS
OF
INDEPENDENT
DIS-
PUTE
RESOLUTION
PROCESS.—The non-
prevailing party shall be responsible for 
paying all fees charged by the IDR entity. 
If the parties reach a settlement prior to 
completion of the IDR process, the costs of 
the independent dispute resolution process 
shall be divided equally between the par-
ties. 
‘‘(vi) PAYMENT.—Any difference be-
tween— 
‘‘(I) the amount determined to be 
paid by one party of the dispute reso-
lution to another pursuant to this 
paragraph; and 
‘‘(II) the amounts already paid 
under subsection (b) or (e) before en-
tering into the process under this 
paragraph, 
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shall be paid not later than 15 days after 
the date on which the entity makes a de-
termination with respect to such amount. 
‘‘(D) PUBLICATION.—The Secretary shall 
publish aggregated results of the independent 
dispute resolution by geographic region in order 
to give more guidance to providers and health 
plans.’’. 
(d) PREVENTING CERTAIN CASES
OF BALANCE 
BILLING.—Section 1128A of the Social Security Act (42 
U.S.C. 1320a–7a) is amended by adding at the end the 
following new subsections: 
‘‘(t)(1) Subject to paragraph (3), in the case of an 
individual with benefits under a health plan or health in-
surance coverage offered in the group or individual market 
who is furnished on or after January 1, 2021, emergency 
services with respect to an emergency medical condition 
during a visit at an emergency department of a hospital— 
‘‘(A) if the emergency department of a hospital 
holds the individual liable for a payment amount for 
such emergency services so furnished that is more 
than the cost-sharing amount for such services (as 
determined 
in 
accordance 
with 
section 
2719A(b)(1)(C)(ii) of the Public Health Service 
Act); or 
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‘‘(B) if any health care provider holds such in-
dividual liable for a payment amount for an emer-
gency service furnished to such individual by such 
provider with respect to such emergency medical 
condition and visit for which the individual receives 
emergency services at the hospital or emergency de-
partment that is more than the cost-sharing amount 
for such services furnished by the provider (as deter-
mined in accordance with section 2719A(b)(1)(C)(ii) 
of the Public Health Service Act), 
the hospital, emergency department or health care pro-
vider, respectively, shall be subject, in addition to any 
other penalties that may be prescribed by law, to a civil 
money penalty of not more than an amount determined 
appropriate by the Secretary for each specified claim. 
‘‘(2) The provisions of subsections (c), (d), (e), (g), 
(h), (k), and (l) shall apply to a civil money penalty or 
assessment under paragraph (1) or subsection (u) in the 
same manner as such provisions apply to a penalty, assess-
ment, or proceeding under subsection (a). 
‘‘(3) Paragraph (1) shall not apply to an emergency 
department of a hospital or a provider, with respect to 
items or services furnished to a participant, beneficiary, 
or enrollee of a health plan or health insurance coverage 
offered by a health insurance issuer, if the emergency de-
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partment of the hospital or the provider, respectively, re-
imburses such participant, beneficiary, or enrollee any 
amount for such an item or service that is more than the 
cost-sharing amount for such item or service (as deter-
mined in accordance with section 2719A(e)(1)(A)) not 
later than 30 days after the date the emergency depart-
ment of the hospital or provider, respectively, knew or 
should have known such excess payment was in violation 
of this subsection. 
‘‘(4) In this subsection and subsection (u): 
‘‘(A) The terms ‘emergency medical condition’ 
and ‘emergency services’ have the meanings given 
such terms, respectively, in section 2719A(b)(2) of 
the Public Health Service Act. 
‘‘(B) The terms ‘group health plan’, ‘health in-
surance issuer’, and ‘health insurance coverage’ have 
the meanings given such terms, respectively, in sec-
tion 2791 of the Public Health Service Act. 
‘‘(u)(1) Subject to paragraph (2), in the case of an 
individual with benefits under a health plan or health in-
surance coverage offered in the group or individual market 
who is furnished on or after January 1, 2021, items or 
services (other than emergency services to which sub-
section (t) applies) during an episode of care (as defined 
by the Secretary) at a participating health care facility 
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by a nonparticipating provider (including imaging or lab-
oratory services so furnished by a nonparticipating pro-
vider when ordered by a participating provider or after- 
emergency care furnished by a nonparticipating provider 
in the case that the participant, beneficiary, or enrollee 
cannot travel without medical transport), if such non-
participating provider holds such individual liable for a 
payment amount for such an item or service furnished by 
such provider that is more than the cost-sharing amount 
for such item or service (as determined in accordance with 
section 2719A(e)(1)(A) of the Public Health Service Act), 
such provider shall be subject, in addition to any other 
penalties that may be prescribed by law, to a civil money 
penalty of not more than an amount determined appro-
priate by the Secretary for each specified claim. 
‘‘(2) Paragraph (1) shall not apply to a nonpartici-
pating provider, with respect to items or services furnished 
by the provider to a participant, beneficiary, or enrollee 
of a health plan or health insurance coverage offered by 
a health insurance issuer, if the provider reimburses such 
participant, beneficiary, or enrollee any amount for such 
an item or service that is more than the cost-sharing 
amount for such item or service (as determined in accord-
ance with section 2719A(e)(1)(A)) not later than 30 days 
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after the date the provider knew or should have known 
such excess payment was in violation of this subsection. 
‘‘(3) For purposes of this subsection, the terms ‘non-
participating provider’ and ‘participating health care facil-
ity’ have such meanings given such terms under sub-
sections (b)(2) and (e)(2), respectively, of section 2719A 
of the Public Health Service Act.’’. 
(e) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to plan years begin-
ning on or after January 1, 2021. 
SEC. 3. TRANSPARENCY REGARDING IN-NETWORK AND 
OUT-OF-NETWORK DEDUCTIBLES. 
(a) IN GENERAL.—Subpart II of part A of title 
XXVII of the Public Health Service Act (42 U.S.C. 300gg 
et seq.) is amended by adding at the end the following: 
‘‘SEC. 2729A. TRANSPARENCY REGARDING IN-NETWORK 
AND OUT-OF-NETWORK DEDUCTIBLES. 
‘‘(a) IN GENERAL.—A group health plan or a health 
insurance issuer offering group or individual health insur-
ance coverage and providing or covering any benefit with 
respect to items or services shall include, in clear writing, 
on any plan or insurance identification card issued to en-
rollees in the plan or coverage the amount of the in-net-
work and out-of-network deductibles and the out-of-pocket 
maximum limitation that apply to such plan or coverage. 
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‘‘(b) GUIDANCE.—The Secretary, in consultation 
with the Secretary of Labor, shall issue guidance to imple-
ment subsection (a).’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply with respect to plan years begin-
ning on or after the date that is one year after the date 
of the enactment of this Act. 
SEC. 4. TRANSPARENCY FOR IN-NETWORK PATIENTS. 
Subpart II of part A of title XXVII of the Public 
Health Service Act (42 U.S.C. 300gg et seq.), as amended 
by section 3, is further amended by adding at the end the 
following: 
‘‘SEC. 2729B. TRANSPARENCY FOR IN-NETWORK PATIENTS. 
‘‘(a) STANDARDS.—Not later than January 1, 2021, 
the Secretary shall, through rulemaking, establish trans-
parency standards to provide better information to individ-
uals who are enrolled in group health plans or health in-
surance coverage offered in the individual or group market 
(as such terms are defined in section 2791 of the Public 
Health Service Act (42 U.S.C. 300gg–91)) about which 
health care providers are participating in the network of 
the plan or coverage in which such an individual is en-
rolled. Such standards shall at a minimum provide for the 
following: 
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‘‘(1) Such plans and coverage offer provider di-
rectories online and in print. 
‘‘(2) Annual audits of such provider directories, 
as specified by the Secretary. 
‘‘(3) Monthly updates of such online directories. 
‘‘(b) GUIDANCE.—Beginning January 1, 2022, a 
group health plan or a health insurance issuer offering 
group or individual health insurance coverage shall be in 
compliance with the standards established pursuant to 
subsection (a).’’. 
SEC. 5. REPORTING REQUIREMENTS. 
Subpart II of part A of title XXVII of the Public 
Health Service Act (42 U.S.C. 300gg et seq.), as amended 
by sections 3 and 4, is further amended by adding at the 
end the following: 
‘‘SEC. 2729C. TRANSPARENCY REQUIREMENTS. 
‘‘(a) IN GENERAL.—Each group health plan and 
health insurance issuer offering group or individual health 
insurance coverage shall annually report (beginning for 
plan year 2021) to the Secretary and the Secretary of 
Labor, with respect to the applicable plan or coverage for 
the applicable plan year— 
‘‘(1) the total claims that were submitted by in- 
network health care providers with respect to enroll-
ees under the plan or coverage, and the number of 
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such claims that were paid and the number of such 
claims that were denied; 
‘‘(2) the total claims that were submitted by 
out-of-network health care providers with respect to 
enrollees under the plan or coverage, and the num-
ber of such claims that were paid and the number 
of such claims that were denied; 
‘‘(3) with respect to each out-of-network claim, 
the out-of-pocket costs to the enrollee for the serv-
ices; 
‘‘(4) the number of out-of-network claims re-
ported under paragraph (2) that are for emergency 
services; and 
‘‘(5) the number of out-of-network claims re-
ported under paragraph (2) that relate to care at in- 
network hospitals or facilities provided by out-of-net-
work providers. 
‘‘(b) CLARIFICATION.—The information required to 
be submitted under this section shall be in addition to the 
information required to be submitted under section 
2715A.’’. 
SEC. 6. BILLING STATUTE OF LIMITATIONS. 
Notwithstanding any other provision of law, a health 
care provider may not seek reimbursement from an indi-
vidual for a service furnished by such provider to such in-
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dividual more than a year after such date of service. Any 
provider that bills an individual in violation of the previous 
sentence shall be subject to a civil monetary penalty in 
such amount as specified by the Secretary of Health and 
Human Services. 
SEC. 7. APPLICATION. 
(a) NON-APPLICATION IN CASES OF STATES WITH 
CERTAIN BALANCE BILLING LAWS.—Section 2719A of 
the Public Health Service Act (42 U.S.C. 300gg–19a) is 
amended by adding at the end the following new sub-
section: 
‘‘(g) In any case in which a State has in effect a law 
or regulation that prohibits balance billing or otherwise 
provides an alternate method for resolving a dispute be-
tween a health plan and provider for determining com-
pensation for services described in subsections (b), (e), or 
(f), the provisions of such law and not the provisions of 
this Act shall apply to health plans (except self-insured 
group health plans that are not subject to State insurance 
regulation), health care providers, and individuals in such 
State so long as such law does not require an individual 
to pay more in cost-sharing than the amount that would 
otherwise be required of such individual under this sec-
tion.’’. 
(b) APPLICATION TO FEHB.— 
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(1) IN
GENERAL.—Section 8902 of title 5, 
United States Code, is amended by adding at the 
end the following new subsection: 
‘‘(p) Each contract under this chapter shall require 
the carrier to comply with requirements described in the 
provisions of subsections (b), (e), and (f) of section 2719A 
of the Public Health Service Act and sections 2729A and 
2729B of such Act in the same manner as those provisions 
apply to a groups health plan or health insurance issuer 
offering health insurance coverage, as described in such 
sections.’’. 
(2) EFFECTIVE DATE.—The amendment made 
by this subsection shall apply with respect to con-
tracts entered into or renewed for contract years be-
ginning at least one year after the date of enactment 
of this Act. 
SEC. 8. STUDIES BY SECRETARIES OF HEALTH AND HUMAN 
SERVICES AND OF LABOR. 
(a) IMPACT STUDY.—Not later than 3 years after the 
date of enactment of this Act, the Secretary of Health and 
Human Services, in consultation with the Secretary of 
Labor, shall conduct a study of the effects of this Act (in-
cluding the amendments made by this Act), and submit 
to Congress (and make public) a report on the findings 
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of such study, which shall include information and anal-
ysis on— 
(1) the financial impact on patient responsi-
bility for health care spending and overall health 
care spending; 
(2) the incidence and prevalence of the delivery 
of unanticipated out-of-network health care services, 
in the cases of emergency services and in the cases 
of care at in-network hospitals or facilities provided 
by out-of-network providers; 
(3) the adequacy of provider networks offered 
by health plans and health insurance issuers (as 
such terms are defined in section 2791 of the Public 
Health Service Act (42 U.S.C. 300gg–91)); 
(4) a comparison of the different claims data-
bases used and the impact of using such databases 
on reimbursement rates; 
(5) the number of bills that are settled through 
negotiations pursuant to subsection (f)(2) of section 
2719A of the Public Health Service Act (42 U.S.C. 
300gg–19a), as added by section 2, and the number 
of bills that go to the independent dispute resolution 
process under subsection (f)(3) of such section, as so 
added; 
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(6) the administrative cost of such independent 
dispute resolution process; and 
(7) the estimated impact of such independent 
dispute resolution process on health insurance pre-
miums and deductibles. 
(b) BILLING FEASIBILITY STUDY.—Not later than 3 
years after the date of the enactment of this Act, the Sec-
retary of Health and Human Services shall conduct, and 
submit to Congress (and make public), a feasibility study 
on the provision of a single bill for all services provided 
for a single episode of care, as defined by the Secretary. 
SEC. 9. REGULATIONS. 
Not later than one year after the date of the enact-
ment of this Act, the Secretary of Labor and the Secretary 
of Health and Human Services shall promulgate regula-
tions pertaining to carry out the provisions (including 
amendments made by) this Act. 
Æ 
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