4028 
health plan or group health insurance cov-
erage offered by a health insurance issuer, a 
physician or other health care provider who 
is acting within the scope of practice of that 
provider’s license or certification under ap-
plicable State law and who has a contrac-
tual relationship with the plan or issuer, re-
spectively, for furnishing such item or serv-
ice under the plan or coverage, respectively. 
‘‘(H) RECOGNIZED
AMOUNT.—The term 
‘recognized amount’ means, with respect to an 
item or service furnished by a nonparticipating 
provider or nonparticipating emergency facility 
during a year and a group health plan or group 
health insurance coverage offered by a health in-
surance issuer— 
‘‘(i) subject to clause (iii), in the case 
of such item or service furnished in a State 
that has in effect a specified State law with 
respect to such plan, coverage, or issuer, re-
spectively; such a nonparticipating provider 
or nonparticipating emergency facility; and 
such an item or service, the amount deter-
mined in accordance with such law; 
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‘‘(ii) subject to clause (iii), in the case 
of such item or service furnished in a State 
that does not have in effect a specified State 
law, with respect to such plan, coverage, or 
issuer, respectively; such a nonparticipating 
provider or nonparticipating emergency fa-
cility; and such an item or service, the 
amount that is the qualifying payment 
amount (as defined in subparagraph (E)) 
for such year and determined in accordance 
with rulemaking described in paragraph 
(2)) for such item or service; or 
‘‘(iii) in the case of such item or serv-
ice furnished in a State with 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. 
‘‘(I) SPECIFIED
STATE
LAW.—The term 
‘specified State law’ means, with respect to a 
State, an item or service furnished by a non-
participating 
provider 
or 
nonparticipating 
emergency facility during a year and a group 
health plan or group health insurance coverage 
offered by a health insurance issuer, a State law 
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that provides for a method for determining the 
total amount payable under such a plan, cov-
erage, or issuer, respectively (to the extent such 
State law applies to such plan, coverage, or 
issuer, subject to section 514) in the case of a 
participant or beneficiary covered under such 
plan or coverage and receiving such item or serv-
ice from such a nonparticipating provider or 
nonparticipating emergency facility. 
‘‘(J) STABILIZE.—The term ‘to stabilize’, 
with respect to an emergency medical condition 
(as defined in subparagraph (B)), has the mean-
ing give in section 1867(e)(3) of the Social Secu-
rity Act (42 U.S.C. 1395dd(e)(3)). 
‘‘(K) 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 group 
health plan or group health insurance coverage 
offered by a health insurance issuer receiving 
such item or service from a nonparticipating 
provider or nonparticipating emergency facil-
ity— 
‘‘(i) subject to clause (iii), in the case 
of such item or service furnished in a State 
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that has in effect a specified State law with 
respect to such plan, coverage, or issuer, re-
spectively; such a nonparticipating provider 
or nonparticipating emergency facility; and 
such an item or service, the amount deter-
mined in accordance with such law; 
‘‘(ii) subject to clause (iii), in the case 
such State does not have in effect such a 
law with respect to such item or service, 
plan, and provider or facility— 
‘‘(I) subject to subclause (II), if 
the provider or facility (as applicable) 
and such plan or coverage agree on an 
amount of payment (including if such 
agreed on amount is the initial pay-
ment sent by the plan under subsection 
(a)(1)(C)(iv)(I), subsection (b)(1)(C), 
or section 717(a)(3)(A), as applicable, 
or is agreed on through open negotia-
tions under subsection (c)(1)) with re-
spect to such item or service, such 
agreed on amount; or 
‘‘(II) if such provider or facility 
(as applicable) and such plan or cov-
erage enter the independent dispute 
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resolution process under subsection (c) 
and do not so agree before the date on 
which a certified IDR entity (as de-
fined in paragraph (4) of such sub-
section) makes a determination with 
respect to such item or service under 
such subsection, the amount of such de-
termination; or 
‘‘(iii) 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. 
‘‘(L) COST-SHARING.—The term ‘cost-shar-
ing’ includes copayments, coinsurance, and 
deductibles. 
‘‘(b) COVERAGE OF NON-EMERGENCY SERVICES PER-
FORMED BY NONPARTICIPATING PROVIDERS AT CERTAIN 
PARTICIPATING FACILITIES.— 
‘‘(1) IN GENERAL.—In the case of items or serv-
ices (other than emergency services to which sub-
section (a) applies) for which any benefits are pro-
vided or covered by a group health plan or health in-
surance issuer offering group health insurance cov-
erage furnished to a participant or beneficiary of 
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such plan or coverage by a nonparticipating provider 
(as defined in subsection (a)(3)(G)(i)) (and who, with 
respect to such items and services, has not satisfied 
the notice and consent criteria of section 2799B–2(d) 
of the Public Health Service Act) with respect to a 
visit (as defined by the Secretary in accordance with 
paragraph (2)(B)) at a participating health care fa-
cility (as defined in paragraph (2)(A)), with respect 
to such plan or coverage, respectively, the plan or cov-
erage, respectively— 
‘‘(A) shall not impose on such participant 
or beneficiary a cost-sharing requirement for 
such items and services so furnished that is 
greater than the cost-sharing requirement that 
would apply under such plan or coverage, respec-
tively, had such items or services been furnished 
by a participating provider (as defined in sub-
section (a)(3)(G)(ii)); 
‘‘(B) shall calculate such cost-sharing re-
quirement as if the total amount that would have 
been charged for such items and services by such 
participating provider were equal to the recog-
nized 
amount 
(as 
defined 
in 
subsection 
(a)(3)(H)) for such items and services, plan or 
coverage, and year; 
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‘‘(C) not later than 30 calendar days after 
the bill for such items or services is transmitted 
by such provider, shall send to the provider an 
initial payment or notice of denial of payment; 
‘‘(D) shall pay a total plan or coverage 
payment directly, in accordance, if applicable, 
with the timing requirement described in sub-
section (c)(6), to such provider furnishing such 
items and services to such participant or bene-
ficiary that is, with application of any initial 
payment under subparagraph (C), equal to the 
amount by which the out-of-network rate (as de-
fined in subsection (a)(3)(K)) for such items and 
services exceeds the cost-sharing amount imposed 
under the plan or coverage, respectively, for such 
items and services (as determined in accordance 
with subparagraphs (A) and (B)) and year; and 
‘‘(E) shall count toward any in-network de-
ductible and in-network out-of-pocket maximums 
(as applicable) applied under the plan or cov-
erage, respectively, any cost-sharing payments 
made by the participant or beneficiary (and 
such in-network deductible and out-of-pocket 
maximums shall be applied) with respect to such 
items and services so furnished in the same man-
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ner as if such cost-sharing payments were with 
respect to items and services furnished by a par-
ticipating provider. 
‘‘(2) DEFINITIONS.—In this section: 
‘‘(A) PARTICIPATING HEALTH CARE FACIL-
ITY.— 
‘‘(i) IN GENERAL.—The term ‘partici-
pating health care facility’ means, with re-
spect to an item or service and a group 
health plan or health insurance issuer offer-
ing group health insurance coverage, a 
health care facility described in clause (ii) 
that has a direct or indirect contractual re-
lationship with the plan or issuer, respec-
tively, with respect to the furnishing of such 
an item or service at the facility. 
‘‘(ii) HEALTH
CARE
FACILITY
DE-
SCRIBED.—A health care facility described 
in this clause, with respect to a group 
health plan or group health insurance cov-
erage, is each of the following: 
‘‘(I) A hospital (as defined in 
1861(e) of the Social Security Act). 
‘‘(II) A hospital outpatient de-
partment. 
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‘‘(III) A critical access hospital 
(as defined in section 1861(mm)(1) of 
such Act). 
‘‘(IV) An ambulatory surgical 
center 
described 
in 
section 
1833(i)(1)(A) of such Act. 
‘‘(V) Any other facility, specified 
by the Secretary, that provides items 
or services for which coverage is pro-
vided under the plan or coverage, re-
spectively. 
‘‘(B) VISIT.—The term ‘visit’ shall, with re-
spect to items and services furnished to an indi-
vidual at a health care facility, include equip-
ment and devices, telemedicine services, imaging 
services, laboratory services, preoperative and 
postoperative services, and such other items and 
services as the Secretary may specify, regardless 
of whether or not the provider furnishing such 
items or services is at the facility. 
‘‘(c) CERTAIN ACCESS FEES
TO CERTAIN DATA-
BASES.—In the case of a sponsor of a group health plan 
or health insurance issuer offering group health insurance 
coverage that, pursuant to subsection (a)(3)(E)(iii), uses a 
database described in such subsection to determine a rate 
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to apply under such subsection for an item or service by 
reason of having insufficient information described in such 
subsection with respect to such item or service, such sponsor 
or issuer shall cover the cost for access to such database.’’. 
(2) TRANSFER AMENDMENT.—Subpart B of part 
7 of title I of the Employee Retirement Income Secu-
rity Act of 1974 (29 U.S.C. 1185 et seq.), as amended 
by paragraph (1), is further amended by adding at 
the end the following: 
‘‘SEC. 722. OTHER PATIENT PROTECTIONS. 
‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If a 
group health plan, or a health insurance issuer offering 
group health insurance coverage, requires or provides for 
designation by a participant or beneficiary of a partici-
pating primary care provider, then the plan or issuer shall 
permit each participant and beneficiary to designate any 
participating primary care provider who is available to ac-
cept such individual. 
‘‘(b) ACCESS TO PEDIATRIC CARE.— 
‘‘(1) PEDIATRIC CARE.—In the case of a person 
who has a child who is a participant or beneficiary 
under a group health plan, or group health insurance 
coverage offered by a health insurance issuer, if the 
plan or issuer requires or provides for the designation 
of a participating primary care provider for the 
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child, the plan or issuer shall permit such person to 
designate a physician (allopathic or osteopathic) who 
specializes in pediatrics as the child’s primary care 
provider if such provider participates in the network 
of the plan or issuer. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) 
shall be construed to waive any exclusions of coverage 
under the terms and conditions of the plan or health 
insurance coverage with respect to coverage of pedi-
atric care. 
‘‘(c) PATIENT ACCESS TO OBSTETRICAL AND GYNECO-
LOGICAL CARE.— 
‘‘(1) GENERAL RIGHTS.— 
‘‘(A) DIRECT
ACCESS.—A group health 
plan, or health insurance issuer offering group 
health insurance coverage, described in para-
graph (2) may not require authorization or re-
ferral by the plan, issuer, or any person (includ-
ing a primary care provider described in para-
graph (2)(B)) in the case of a female participant 
or beneficiary who seeks coverage for obstetrical 
or gynecological care provided by a partici-
pating health care professional who specializes in 
obstetrics or gynecology. Such professional shall 
agree to otherwise adhere to such plan’s or 
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issuer’s policies and procedures, including proce-
dures regarding referrals and obtaining prior 
authorization and providing services pursuant to 
a treatment plan (if any) approved by the plan 
or issuer. 
‘‘(B) OBSTETRICAL
AND
GYNECOLOGICAL 
CARE.—A group health plan or health insurance 
issuer described in paragraph (2) shall treat the 
provision of obstetrical and gynecological care, 
and the ordering of related obstetrical and gyne-
cological items and services, pursuant to the di-
rect access described under subparagraph (A), by 
a participating health care professional who spe-
cializes in obstetrics or gynecology as the author-
ization of the primary care provider. 
‘‘(2) APPLICATION
OF
PARAGRAPH.—A group 
health plan, or health insurance issuer offering group 
health insurance coverage, described in this para-
graph is a group health plan or coverage 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. 
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‘‘(3) CONSTRUCTION.—Nothing in paragraph (1) 
shall be construed to— 
‘‘(A) waive any exclusions of coverage under 
the terms and conditions of the plan or health 
insurance coverage with respect to coverage of ob-
stetrical or gynecological care; or 
‘‘(B) preclude the group health plan or 
health insurance issuer involved from requiring 
that the obstetrical or gynecological provider no-
tify the primary care health care professional or 
the plan or issuer of treatment decisions.’’. 
(3) CLERICAL AMENDMENT.—The table of con-
tents of the Employee Retirement Income Security 
Act of 1974 is amended by inserting after the item re-
lating to section 714 the following: 
‘‘Sec. 715. Additional market reforms. 
‘‘Sec. 716. Preventing surprise medical bills. 
‘‘Sec. 722. Other patient protections.’’. 
(c) IRC AMENDMENTS.— 
(1) IN GENERAL.—Subchapter B of chapter 100 
of the Internal Revenue Code of 1986 is amended by 
adding at the end the following: 
‘‘SEC. 9816. PREVENTING SURPRISE MEDICAL BILLS. 
‘‘(a) COVERAGE OF EMERGENCY SERVICES.— 
‘‘(1) IN GENERAL.—If a group health plan pro-
vides or covers any benefits with respect to services in 
an emergency department of a hospital or with re-
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spect to emergency services in an independent free-
standing emergency department (as defined in para-
graph (3)(D)), the plan shall cover emergency services 
(as defined in paragraph (3)(C))— 
‘‘(A) without the need for any prior author-
ization determination; 
‘‘(B) whether the health care provider fur-
nishing such services is a participating provider 
or a participating emergency facility, as appli-
cable, with respect to such services; 
‘‘(C) in a manner so that, if such services 
are provided to a participant or beneficiary by 
a nonparticipating provider or a nonpartici-
pating emergency facility— 
‘‘(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 
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apply if such services were provided by a 
participating provider or a participating 
emergency facility; 
‘‘(iii) such cost-sharing requirement is 
calculated as if the total amount that would 
have been charged for such services by such 
participating provider or participating 
emergency facility were equal to the recog-
nized amount (as defined in paragraph 
(3)(H)) for such services, plan, and year; 
‘‘(iv) the group health plan— 
‘‘(I) not later than 30 calendar 
days after the bill for such services is 
transmitted by such provider or facil-
ity, sends to the provider or facility, as 
applicable, an initial payment or no-
tice of denial of payment; and 
‘‘(II) pays a total plan payment 
directly to such provider or facility, re-
spectively (in accordance, if applicable, 
with the timing requirement described 
in subsection (c)(6)) that is, with ap-
plication of any initial payment under 
subclause (I), equal to the amount by 
which the out-of-network rate (as de-
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fined in paragraph (3)(K)) for such 
services 
exceeds 
the 
cost-sharing 
amount for such services (as deter-
mined in accordance with clauses (ii) 
and (iii)) and year; and 
‘‘(iv) any cost-sharing payments made 
by the participant or beneficiary with re-
spect to such emergency services so fur-
nished shall be counted toward any in-net-
work deductible or out-of-pocket maximums 
applied under the plan (and such in-net-
work deductible and out-of-pocket maxi-
mums shall be applied) in the same manner 
as if such cost-sharing payments were made 
with respect to emergency services furnished 
by a participating provider or a partici-
pating emergency facility; 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 of the Em-
ployee Retirement Income Security Act of 1974 
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and section 9815 of this Act, and other than ap-
plicable cost-sharing). 
‘‘(2) AUDIT
PROCESS
AND
REGULATIONS
FOR 
QUALIFYING PAYMENT AMOUNTS.— 
‘‘(A) AUDIT PROCESS.— 
‘‘(i) IN GENERAL.—Not later than Oc-
tober 1, 2021, the Secretary, in consultation 
with the Secretary of Health and Human 
Services and the Secretary of Labor, shall 
establish through rulemaking a process, in 
accordance with clause (ii), under which 
group health plans are audited by the Sec-
retary or applicable State authority to en-
sure that— 
‘‘(I) such plans are in compliance 
with the requirement of applying a 
qualifying payment amount under this 
section; and 
‘‘(II) such qualifying payment 
amount so applied satisfies the defini-
tion under paragraph (3)(E) with re-
spect to the year involved, including 
with respect to a group health plan de-
scribed in clause (ii) of such para-
graph (3)(E). 
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‘‘(ii) AUDIT
SAMPLES.—Under the 
process established pursuant to clause (i), 
the Secretary— 
‘‘(I) shall conduct audits described 
in such clause, with respect to a year 
(beginning with 2022), of a sample 
with respect to such year of claims 
data from not more than 25 group 
health plans; and 
‘‘(II) may audit any group health 
plan if the Secretary has received any 
complaint or other information about 
such plan or coverage, respectively, 
that involves the compliance of the 
plan with either of the requirements 
described in subclauses (I) and (II) of 
such clause. 
‘‘(iii) REPORTS.—Beginning for 2022, 
the Secretary shall annually submit to Con-
gress a report on the number of plans and 
issuers with respect to which audits were 
conducted during such year pursuant to 
this subparagraph. 
‘‘(B) RULEMAKING.—Not later than July 1, 
2021, the Secretary, in consultation with the 
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Secretary of Labor and the Secretary of Health 
and Human Services, shall establish through 
rulemaking— 
‘‘(i) the methodology the group health 
plan shall use to determine the qualifying 
payment amount, differentiating by large 
group market and small group market; 
‘‘(ii) the information such plan or 
issuer, respectively, shall share with the 
nonparticipating provider or nonpartici-
pating facility, as applicable, when making 
such a determination; 
‘‘(iii) the geographic regions applied 
for purposes of this subparagraph, taking 
into account access to items and services in 
rural and underserved areas, including 
health professional shortage areas, as de-
fined in section 332 of the Public Health 
Service Act; and 
‘‘(iv) a process to receive complaints of 
violations of the requirements described in 
subclauses (I) and (II) of subparagraph 
(A)(i) by group health plans. 
Such rulemaking shall take into account pay-
ments that are made by such plan that are not 
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on a fee-for-service basis. Such methodology may 
account for relevant payment adjustments that 
take into account quality or facility type (in-
cluding higher acuity settings and the case-mix 
of various facility types) that are otherwise taken 
into account for purposes of determining pay-
ment amounts with respect to participating fa-
cilities. In carrying out clause (iii), the Sec-
retary shall consult with the National Associa-
tion of Insurance Commissioners to establish the 
geographic regions under such clause and shall 
periodically update such regions, as appropriate, 
taking into account the findings of the report 
submitted under section 109(a) of the No Sur-
prises Act. 
‘‘(3) DEFINITIONS.—In this subchapter: 
‘‘(A) EMERGENCY DEPARTMENT OF A HOS-
PITAL.—The term ‘emergency department of a 
hospital’ includes a hospital outpatient depart-
ment that provides emergency services (as de-
fined in subparagraph (C)(i)). 
‘‘(B) EMERGENCY
MEDICAL
CONDITION.— 
The term ‘emergency medical condition’ means a 
medical condition manifesting itself by acute 
symptoms of sufficient severity (including severe 
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pain) such that a prudent layperson, who pos-
sesses an average knowledge of health and medi-
cine, could reasonably expect the absence of im-
mediate medical attention to result in a condi-
tion described in clause (i), (ii), or (iii) of sec-
tion 1867(e)(1)(A) of the Social Security Act. 
‘‘(C) EMERGENCY SERVICES.— 
‘‘(i) IN
GENERAL.—The term ‘emer-
gency services’, with respect to an emer-
gency medical condition, means— 
‘‘(I) a medical screening examina-
tion (as required under section 1867 of 
the Social Security Act, or as would be 
required under such section if such sec-
tion applied to an independent free-
standing emergency department) that 
is within the capability of the emer-
gency department of a hospital or of 
an independent freestanding emergency 
department, as applicable, including 
ancillary 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 hos-
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pital 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 re-
quired under such section if such sec-
tion applied to an independent free-
standing emergency department, to sta-
bilize the patient (regardless of the de-
partment of the hospital in which such 
further examination or treatment is 
furnished). 
‘‘(ii) INCLUSION OF ADDITIONAL SERV-
ICES.— 
‘‘(I) IN GENERAL.—For purposes 
of this subsection and section 2799B–1 
of the Public Health Service Act, in the 
case of a participant or beneficiary 
who is enrolled in a group health plan 
and who is furnished services described 
in clause (i) with respect to an emer-
gency medical condition, the term 
‘emergency services’ shall include, un-
less each of the conditions described in 
subclause (II) are met, in addition to 
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the items and services described in 
clause (i), items and services— 
‘‘(aa) for which benefits are 
provided or covered under the 
plan; and 
‘‘(bb) that are furnished by a 
nonparticipating provider or non-
participating emergency facility 
(regardless of the department of 
the hospital in which such items 
or services are furnished) after the 
participant or beneficiary is sta-
bilized and as part of outpatient 
observation or an inpatient or 
outpatient stay with respect to the 
visit in which the services de-
scribed in clause (i) are furnished. 
‘‘(II) CONDITIONS.—For purposes 
of subclause (I), the conditions de-
scribed in this subclause, with respect 
to a participant or beneficiary who is 
stabilized and furnished additional 
items and services described in sub-
clause (I) after such stabilization by a 
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provider or facility described in sub-
clause (I), are the following; 
‘‘(aa) Such provider or facil-
ity determines such individual is 
able to travel using nonmedical 
transportation or nonemergency 
medical transportation. 
‘‘(bb) Such provider fur-
nishing such additional items and 
services satisfies the notice and 
consent criteria of section 2799B– 
2(d) with respect to such items 
and services. 
‘‘(cc) Such individual is in a 
condition to receive (as deter-
mined in accordance with guide-
lines issued by the Secretary pur-
suant to rulemaking) the informa-
tion described in section 2799B–2 
and to provide informed consent 
under such section, in accordance 
with applicable State law. 
‘‘(dd) Such other conditions, 
as specified by the Secretary, such 
as conditions relating to coordi-
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nating care transitions to partici-
pating providers and facilities. 
‘‘(D) INDEPENDENT FREESTANDING EMER-
GENCY
DEPARTMENT.—The term ‘independent 
freestanding emergency department’ means a 
health care facility that— 
‘‘(i) is geographically separate and dis-
tinct and licensed separately from a hos-
pital under applicable State law; and 
‘‘(ii) provides any of the emergency 
services 
(as 
defined 
in 
subparagraph 
(C)(i)). 
‘‘(E) QUALIFYING PAYMENT AMOUNT.— 
‘‘(i) IN
GENERAL.—The term ‘quali-
fying payment amount’ means, subject to 
clauses (ii) and (iii), with respect to a 
sponsor of a group health plan— 
‘‘(I) for an item or service fur-
nished during 2022, the median of the 
contracted rates recognized by the plan 
(determined with respect to all such 
plans of such sponsor that are offered 
within the same insurance market 
(specified in subclause (I), (II), or 
(III) of clause (iv)) as the plan) as the 
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total maximum payment (including 
the cost-sharing amount imposed for 
such item or service and the amount to 
be paid by the plan) under such plans 
on January 31, 2019 for the same or 
a similar item or service that is pro-
vided by a provider in the same or 
similar specialty and provided in the 
geographic region in which the item or 
service is furnished, consistent with the 
methodology established by the Sec-
retary under paragraph (2)(B), in-
creased by the percentage increase in 
the consumer price index for all urban 
consumers (United States city average) 
over 2019, such percentage increase 
over 2020, and such percentage in-
crease over 2021; and 
‘‘(II) for an item or service fur-
nished during 2023 or a subsequent 
year, the qualifying payment amount 
determined under this clause for such 
an item or service furnished in the pre-
vious year, increased by the percentage 
increase in the consumer price index 
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for all urban consumers (United States 
city average) over such previous year. 
‘‘(ii) NEW
PLANS
AND
COVERAGE.— 
The term ‘qualifying payment amount’ 
means, with respect to a sponsor of a group 
health plan in a geographic region in which 
such sponsor, respectively, did not offer any 
group health plan or health insurance cov-
erage during 2019— 
‘‘(I) for the first year in which 
such group health plan is offered in 
such region, a rate (determined in ac-
cordance with a methodology estab-
lished by the Secretary) for items and 
services that are covered by such plan 
and furnished during such first year; 
and 
‘‘(II) for each subsequent year 
such group health plan is offered in 
such region, the qualifying payment 
amount determined under this clause 
for such items and services furnished 
in the previous year, increased by the 
percentage increase in the consumer 
price index for all urban consumers 
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(United States city average) over such 
previous year. 
‘‘(iii) 
INSUFFICIENT
INFORMATION; 
NEWLY COVERED ITEMS AND SERVICES.—In 
the case of a sponsor of a group health plan 
that does not have sufficient information to 
calculate the median of the contracted rates 
described in clause (i)(I) in 2019 (or, in the 
case of a newly covered item or service (as 
defined in clause (v)(III)), in the first cov-
erage year (as defined in clause (v)(I)) for 
such item or service with respect to such 
plan) for an item or service (including with 
respect to provider type, or amount, of 
claims for items or services (as determined 
by the Secretary) provided in a particular 
geographic region (other than in a case with 
respect to which clause (ii) applies)) the 
term ‘qualifying payment amount’— 
‘‘(I) for an item or service fur-
nished during 2022 (or, in the case of 
a newly covered item or service, during 
the first coverage year for such item or 
service with respect to such plan), 
means such rate for such item or serv-
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ice determined by the sponsor through 
use of any database that is determined, 
in accordance with rulemaking de-
scribed in paragraph (2)(B), to not 
have any conflicts of interest and to 
have sufficient information reflecting 
allowed amounts paid to a health care 
provider or facility for relevant serv-
ices furnished in the applicable geo-
graphic region (such as a State all- 
payer claims database); 
‘‘(II) for an item or service fur-
nished in a subsequent year (before the 
first sufficient information year (as de-
fined in clause (v)(II)) for such item or 
service with respect to such plan), 
means the rate determined under sub-
clause (I) or this subclause, as applica-
ble, for such item or service for the 
year previous to such subsequent year, 
increased by the percentage increase in 
the consumer price index for all urban 
consumers (United States city average) 
over such previous year; 
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‘‘(III) for an item or service fur-
nished in the first sufficient informa-
tion year for such item or service with 
respect to such plan, has the meaning 
given the term qualifying payment 
amount in clause (i)(I), except that in 
applying such clause to such item or 
service, the reference to ‘furnished dur-
ing 2022’ shall be treated as a ref-
erence to furnished during such first 
sufficient information year, the ref-
erence to ‘on January 31, 2019’ shall 
be treated as a reference to in such suf-
ficient information year, and the in-
crease described in such clause shall 
not be applied; and 
‘‘(IV) for an item or service fur-
nished in any year subsequent to the 
first sufficient information year for 
such item or service with respect to 
such plan, has the meaning given such 
term in clause (i)(II), except that in 
applying such clause to such item or 
service, the reference to ‘furnished dur-
ing 2023 or a subsequent year’ shall be 
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4058 
treated as a reference to furnished dur-
ing the year after such first sufficient 
information year or a subsequent year. 
‘‘(iv) INSURANCE MARKET.—For pur-
poses of clause (i)(I), a health insurance 
market specified in this clause is one of the 
following: 
‘‘(I) The large group market 
(other than plans described in sub-
clause (III)). 
‘‘(II) The small group market 
(other than plans described in sub-
clause (III)). 
‘‘(III) In the case of a self-insured 
group health plan, other self-insured 
group health plans. 
‘‘(v) DEFINITIONS.—For purposes of 
this subparagraph: 
‘‘(I) FIRST COVERAGE YEAR.—The 
term ‘first coverage year’ means, with 
respect to a group health plan and an 
item or service for which coverage is 
not offered in 2019 under such plan or 
coverage, the first year after 2019 for 
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which coverage for such item or service 
is offered under such plan. 
‘‘(II) FIRST
SUFFICIENT
INFOR-
MATION YEAR.—The term ‘first suffi-
cient information year’ means, with 
respect to a group health plan— 
‘‘(aa) in the case of an item 
or service for which the plan does 
not have sufficient information to 
calculate the median of the con-
tracted rates described in clause 
(i)(I) in 2019, the first year sub-
sequent to 2022 for which such 
sponsor has such sufficient infor-
mation to calculate the median of 
such contracted rates in the year 
previous to such first subsequent 
year; and 
‘‘(bb) in the case of a newly 
covered item or service, the first 
year subsequent to the first cov-
erage year for such item or service 
with respect to such plan for 
which the sponsor has sufficient 
information to calculate the me-
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dian of the contracted rates de-
scribed in clause (i)(I) in the year 
previous to such first subsequent 
year. 
‘‘(III) NEWLY COVERED ITEM OR 
SERVICE.—The term ‘newly covered 
item or service’ means, with respect to 
a group health plan, an item or service 
for which coverage was not offered in 
2019 under such plan or coverage, but 
is offered under such plan or coverage 
in a year after 2019. 
‘‘(F) NONPARTICIPATING
EMERGENCY
FA-
CILITY; PARTICIPATING EMERGENCY FACILITY.— 
‘‘(i) NONPARTICIPATING
EMERGENCY 
FACILITY.—The 
term 
‘nonparticipating 
emergency facility’ means, with respect to 
an item or service and a group health plan, 
an emergency department of a hospital, or 
an independent freestanding emergency de-
partment, that does not have a contractual 
relationship directly or indirectly with the 
plan for furnishing such item or service 
under the plan. 
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4061 
‘‘(ii) PARTICIPATING EMERGENCY FA-
CILITY.—The term ‘participating emergency 
facility’ means, with respect to an item or 
service and a group health plan, an emer-
gency department of a hospital, or an inde-
pendent freestanding emergency depart-
ment, that has a contractual relationship 
directly or indirectly with the plan, with re-
spect to the furnishing of such an item or 
service at such facility. 
‘‘(G) NONPARTICIPATING PROVIDERS; PAR-
TICIPATING PROVIDERS.— 
‘‘(i) NONPARTICIPATING
PROVIDER.— 
The 
term 
‘nonparticipating 
provider’ 
means, with respect to an item or service 
and a group health plan, a physician or 
other health care provider who is acting 
within the scope of practice of that pro-
vider’s license or certification under appli-
cable State law and who does not have a 
contractual relationship with the plan or 
issuer, respectively, for furnishing such item 
or service under the plan. 
‘‘(ii) PARTICIPATING
PROVIDER.—The 
term ‘participating provider’ means, with 
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respect to an item or service and a group 
health plan, a physician or other health 
care provider who is acting within the scope 
of practice of that provider’s license or cer-
tification under applicable State law and 
who has a contractual relationship with the 
plan for furnishing such item or service 
under the plan. 
‘‘(H) RECOGNIZED
AMOUNT.—The term 
‘recognized amount’ means, with respect to an 
item or service furnished by a nonparticipating 
provider or nonparticipating emergency facility 
during a year and a group health plan— 
‘‘(i) subject to clause (iii), in the case 
of such item or service furnished in a State 
that has in effect a specified State law with 
respect to such plan; such a nonpartici-
pating provider or nonparticipating emer-
gency facility; and such an item or service, 
the amount determined in accordance with 
such law; 
‘‘(ii) subject to clause (iii), in the case 
of such item or service furnished in a State 
that does not have in effect a specified State 
law, with respect to such plan; such a non-
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participating provider or nonparticipating 
emergency facility; and such an item or 
service, the amount that is the qualifying 
payment amount (as defined in subpara-
graph (E)) for such year and determined in 
accordance with rulemaking described in 
paragraph (2)(B)) for such item or service; 
or 
‘‘(iii) in the case of such item or serv-
ice furnished in a State with 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. 
‘‘(I) SPECIFIED
STATE
LAW.—The term 
‘specified State law’ means, with respect to a 
State, an item or service furnished by a non-
participating 
provider 
or 
nonparticipating 
emergency facility during a year and a group 
health plan, a State law that provides for a 
method for determining the total amount payable 
under such a plan (to the extent such State law 
applies to such plan, subject to section 514) in 
the case of a participant or beneficiary covered 
under such plan and receiving such item or serv-
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ice from such a nonparticipating provider or 
nonparticipating emergency facility. 
‘‘(J) STABILIZE.—The term ‘to stabilize’, 
with respect to an emergency medical condition 
(as defined in subparagraph (B)), has the mean-
ing give in section 1867(e)(3) of the Social Secu-
rity Act (42 U.S.C. 1395dd(e)(3)). 
‘‘(K) 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 group 
health plan receiving such item or service from 
a nonparticipating provider or nonparticipating 
emergency facility— 
‘‘(i) subject to clause (iii), in the case 
of such item or service furnished in a State 
that has in effect a specified State law with 
respect to such plan; such a nonpartici-
pating provider or nonparticipating emer-
gency facility; and such an item or service, 
the amount determined in accordance with 
such law; 
‘‘(ii) subject to clause (iii), in the case 
such State does not have in effect such a 
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law with respect to such item or service, 
plan, and provider or facility— 
‘‘(I) subject to subclause (II), if 
the provider or facility (as applicable) 
and such plan or coverage agree on an 
amount of payment (including if such 
agreed on amount is the initial pay-
ment sent by the plan under subsection 
(a)(1)(C)(iv)(I), subsection (b)(1)(C), 
or section 9817(a)(3)(A), as applicable, 
or is agreed on through open negotia-
tions under subsection (c)(1)) with re-
spect to such item or service, such 
agreed on amount; or 
‘‘(II) if such provider or facility 
(as applicable) and such plan or cov-
erage enter the independent dispute 
resolution process under subsection (c) 
and do not so agree before the date on 
which a certified IDR entity (as de-
fined in paragraph (4) of such sub-
section) makes a determination with 
respect to such item or service under 
such subsection, the amount of such de-
termination; or 
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‘‘(iii) 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. 
‘‘(L) COST-SHARING.—The term ‘cost-shar-
ing’ includes copayments, coinsurance, and 
deductibles. 
‘‘(b) COVERAGE OF NON-EMERGENCY SERVICES PER-
FORMED BY NONPARTICIPATING PROVIDERS AT CERTAIN 
PARTICIPATING FACILITIES.— 
‘‘(1) IN GENERAL.—In the case of items or serv-
ices (other than emergency services to which sub-
section (a) applies) for which any benefits are pro-
vided or covered by a group health plan furnished to 
a participant or beneficiary of such plan by a non-
participating provider (as defined in subsection 
(a)(3)(G)(i)) (and who, with respect to such items 
and services, has not satisfied the notice and consent 
criteria of section 2799B–2(d) of the Public Health 
Service Act) with respect to a visit (as defined by the 
Secretary in accordance with paragraph (2)(B)) at a 
participating health care facility (as defined in para-
graph (2)(A)), with respect to such plan, the plan— 
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‘‘(A) shall not impose on such participant 
or beneficiary a cost-sharing requirement for 
such items and services so furnished that is 
greater than the cost-sharing requirement that 
would apply under such plan had such items or 
services been furnished by a participating pro-
vider (as defined in subsection (a)(3)(G)(ii)); 
‘‘(B) shall calculate such cost-sharing re-
quirement as if the total amount that would have 
been charged for such items and services by such 
participating provider were equal to the recog-
nized 
amount 
(as 
defined 
in 
subsection 
(a)(3)(H)) for such items and services, plan, and 
year; 
‘‘(C) not later than 30 calendar days after 
the bill for such items or services is transmitted 
by such provider, shall send to the provider an 
initial payment or notice of denial of payment; 
‘‘(D) shall pay a total plan payment di-
rectly, in accordance, if applicable, with the tim-
ing requirement described in subsection (c)(6), to 
such provider furnishing such items and services 
to such participant or beneficiary that is, with 
application of any initial payment under sub-
paragraph (C), equal to the amount by which the 
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out-of-network rate (as defined in subsection 
(a)(3)(K)) 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 
year; and 
‘‘(E) shall count toward any in-network de-
ductible and in-network out-of-pocket maximums 
(as applicable) applied under the plan, any cost- 
sharing payments made by the participant or 
beneficiary (and such in-network deductible and 
out-of-pocket maximums shall be applied) with 
respect to such items and services so furnished in 
the same manner as if such cost-sharing pay-
ments were with respect to items and services 
furnished by a participating provider. 
‘‘(2) DEFINITIONS.—In this section: 
‘‘(A) PARTICIPATING HEALTH CARE FACIL-
ITY.— 
‘‘(i) IN GENERAL.—The term ‘partici-
pating health care facility’ means, with re-
spect to an item or service and a group 
health plan, a health care facility described 
in clause (ii) that has a direct or indirect 
contractual relationship with the plan, with 
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4069 
respect to the furnishing of such an item or 
service at the facility. 
‘‘(ii) HEALTH
CARE
FACILITY
DE-
SCRIBED.—A health care facility described 
in this clause, with respect to a group 
health plan or health insurance coverage of-
fered in the group or individual market, is 
each of the following: 
‘‘(I) A hospital (as defined in 
1861(e) of the Social Security Act). 
‘‘(II) A hospital outpatient de-
partment. 
‘‘(III) A critical access hospital 
(as defined in section 1861(mm)(1) of 
such Act). 
‘‘(IV) An ambulatory surgical 
center 
described 
in 
section 
1833(i)(1)(A) of such Act. 
‘‘(V) Any other facility, specified 
by the Secretary, that provides items 
or services for which coverage is pro-
vided under the plan or coverage, re-
spectively. 
‘‘(B) VISIT.—The term ‘visit’ shall, with re-
spect to items and services furnished to an indi-
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vidual at a health care facility, include equip-
ment and devices, telemedicine services, imaging 
services, laboratory services, preoperative and 
postoperative services, and such other items and 
services as the Secretary may specify, regardless 
of whether or not the provider furnishing such 
items or services is at the facility. 
‘‘(c) CERTAIN ACCESS FEES
TO CERTAIN DATA-
BASES.—In the case of a sponsor of a group health plan 
that, pursuant to subsection (a)(3)(E)(iii), uses a database 
described in such subsection to determine a rate to apply 
under such subsection for an item or service by reason of 
having insufficient information described in such subsection 
with respect to such item or service, such sponsor shall cover 
the cost for access to such database.’’. 
(2) TRANSFER AMENDMENT.—Subchapter B of 
chapter 100 of the Internal Revenue Code of 1986, as 
amended by paragraph (1), is further amended by 
adding at the end the following: 
‘‘SEC. 9822. OTHER PATIENT PROTECTIONS. 
‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If a 
group health plan requires or provides for designation by 
a participant or beneficiary of a participating primary 
care provider, then the plan shall permit each participant 
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and beneficiary to designate any participating primary 
care provider who is available to accept such individual. 
‘‘(b) ACCESS TO PEDIATRIC CARE.— 
‘‘(1) PEDIATRIC CARE.—In the case of a person 
who has a child who is a participant or beneficiary 
under a group health plan if the plan requires or pro-
vides 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 coverage 
under the terms and conditions of the plan with re-
spect to coverage of pediatric care. 
‘‘(c) PATIENT ACCESS TO OBSTETRICAL AND GYNECO-
LOGICAL CARE.— 
‘‘(1) GENERAL RIGHTS.— 
‘‘(A) DIRECT ACCESS.—A group health plan 
described in paragraph (2) may not require au-
thorization or referral by the plan, issuer, or any 
person (including a primary care provider de-
scribed in paragraph (2)(B)) in the case of a fe-
male participant or beneficiary who seeks cov-
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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 adhere to 
such plan’s policies and procedures, including 
procedures regarding referrals and obtaining 
prior authorization and providing services pur-
suant to a treatment plan (if any) approved by 
the plan. 
‘‘(B) OBSTETRICAL
AND
GYNECOLOGICAL 
CARE.—A group health plan described in para-
graph (2) shall treat the provision of obstetrical 
and gynecological care, and the ordering of re-
lated obstetrical and gynecological items and 
services, pursuant to the direct access described 
under subparagraph (A), by a participating 
health care professional who specializes in obstet-
rics or gynecology as the authorization of the 
primary care provider. 
‘‘(2) APPLICATION
OF
PARAGRAPH.—A group 
health plan described in this paragraph is a group 
health plan that— 
‘‘(A) provides coverage for obstetric or 
gynecologic care; and 
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‘‘(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— 
‘‘(A) waive any exclusions of coverage under 
the terms and conditions of the plan with respect 
to coverage of obstetrical or gynecological care; or 
‘‘(B) preclude the group health plan in-
volved from requiring that the obstetrical or gyn-
ecological provider notify the primary care 
health care professional or the plan or issuer of 
treatment decisions.’’. 
(3) CLERICAL AMENDMENT.—The table of sec-
tions for subchapter B of chapter 100 of the Internal 
Revenue Code of 1986 is amended by adding at the 
end the following new item: 
‘‘Sec. 9815. Additional market reforms. 
‘‘Sec. 9816. Preventing surprise medical bills. 
‘‘Sec. 9822. Other patient protections.’’. 
(4) CONFORMING AMENDMENTS.— 
(A) IN GENERAL.—Section 223(c) of the In-
ternal Revenue Code of 1986 is amended— 
(i) in paragraph (1), by adding at the 
end the following: 
‘‘(D) SPECIAL RULE FOR INDIVIDUALS RE-
CEIVING BENEFITS SUBJECT TO SURPRISE BILL-
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ING STATUTES.—An individual shall not fail to 
be treated as an eligible individual for any pe-
riod merely because the individual receives bene-
fits for medical care subject to and in accordance 
with section 9816 or 9817, section 2799A–1 or 
2799A–2 of the Public Health Service Act, or 
section 716 or 717 of the Employee Retirement 
Income Security Act of 1974, or any State law 
providing similar protections to such indi-
vidual.’’; and 
(ii) in paragraph (2), by adding at the 
end the following: 
‘‘(F) SPECIAL RULE FOR SURPRISE BILL-
ING.—A plan shall not fail to be treated as a 
high deductible health plan by reason of pro-
viding benefits for medical care in accordance 
with section 9816 or 9817, section 2799A–1 or 
2799A–2 of the Public Health Service Act, or 
section 716 or 717 of the Employee Retirement 
Income Security Act of 1974, or any State law 
providing similar protections to individuals, 
prior to the satisfaction of the deductible under 
paragraph (2)(A)(i).’’. 
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(B) EFFECTIVE
DATE.—The amendments 
made by subparagraph (A) shall apply for plan 
years beginning on or after January 1, 2022. 
(d) ADDITIONAL APPLICATION PROVISIONS.— 
(1) APPLICATION
TO
FEHB.—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 provi-
sions of sections 2799A–1, 2799A–2, and 2799A–7 of the 
Public Health Service Act, sections 716, 717, and 722 of 
the Employee Retirement Income Security Act of 1974, and 
sections 9816, 9817, and 9822 of the Internal Revenue Code 
of 1986 (as applicable) in the same manner as such provi-
sions apply to a group health plan or health insurance 
issuer offering group or individual health insurance cov-
erage, as described in such sections. The provisions of sec-
tions 2799B–1, 2799B–2, 2799B–3, and 2799B–5 of the 
Public Health Service Act shall apply to a health care pro-
vider and facility and an air ambulance provider described 
in such respective sections with respect to an enrollee in 
a health benefits plan under this chapter in the same man-
ner as such provisions apply to such a provider and facility 
with respect to an enrollee in a group health plan or group 
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4076 
or individual health insurance coverage offered by a health 
insurance issuer, as described in such sections.’’. 
(2) APPLICATION TO GRANDFATHERED PLANS.— 
Section 1251(a) of the Patient Protection and Afford-
able Care Act (42 U.S.C. 18011(a)) is amended by 
adding at the end the following: 
‘‘(5) 
APPLICATION
OF
ADDITIONAL
PROVI-
SIONS.—Sections 2799A–1, 2799A–2, and 2799A–7 of 
the Public Health Service Act shall apply to grand-
fathered health plans for plan years beginning on or 
after January 1, 2022.’’. 
(3) RULE OF CONSTRUCTION.—Nothing in this 
title, including the amendments made by this title 
may be construed as modifying, reducing, or elimi-
nating— 
(A) the protections under section 222 of the 
Indian Health Care Improvement Act (25 U.S.C. 
1621u) and under subpart I of part 136 of title 
42, Code of Federal Regulations (or any suc-
cessor regulation), against payment liability for 
a patient who receives contract health services 
that are authorized by the Indian Health Serv-
ice; or 
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(B) 
the 
requirements 
under 
section 
1866(a)(1)(U) of the Social Security Act (42 
U.S.C. 1395cc(a)(1)(U)). 
(e) EFFECTIVE DATE.—The amendments made by this 
section shall apply with respect to plan years (or, in the 
case of the amendment made by subsection (d)(1), with re-
spect to contracts entered into or renewed for contract 
years) beginning on or after January 1, 2022. 
SEC. 103. DETERMINATION OF OUT-OF-NETWORK RATES TO 
BE PAID BY HEALTH PLANS; INDEPENDENT 
DISPUTE RESOLUTION PROCESS. 
(a) PHSA.—Section 2799A–1, as added by section 
102, is amended— 
(1) by redesignating subsection (c) as subsection 
(d); and 
(2) by inserting after subsection (b) the following 
new subsection: 
‘‘(c) DETERMINATION OF OUT-OF-NETWORK RATES TO 
BE PAID BY HEALTH PLANS; INDEPENDENT DISPUTE RES-
OLUTION PROCESS.— 
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIA-
TION.— 
‘‘(A) IN GENERAL.—With respect to an item 
or service furnished in a year by a nonpartici-
pating provider or a nonparticipating facility, 
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with respect to a group health plan or health in-
surance issuer offering group or individual 
health insurance coverage, in a State described 
in subsection (a)(3)(K)(ii) with respect to such 
plan or coverage and provider or facility, and 
for which a payment is required to be made by 
the plan or coverage pursuant to subsection 
(a)(1) or (b)(1), the provider or facility (as ap-
plicable) or plan or coverage may, during the 
30-day period beginning on the day the provider 
or facility receives an initial payment or a no-
tice of denial of payment from the plan or cov-
erage regarding a claim for payment for such 
item or service, initiate open negotiations under 
this paragraph between such provider or facility 
and plan or coverage for purposes of deter-
mining, during the open negotiation period, an 
amount agreed on by such provider or facility, 
respectively, and such plan or coverage for pay-
ment (including any cost-sharing) for such item 
or service. For purposes of this subsection, the 
open negotiation period, with respect to an item 
or service, is the 30-day period beginning on the 
date of initiation of the negotiations with respect 
to such item or service. 
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‘‘(B) ACCESSING
INDEPENDENT
DISPUTE 
RESOLUTION PROCESS IN CASE OF FAILED NEGO-
TIATIONS.—In the case of open negotiations pur-
suant to subparagraph (A), with respect to an 
item or service, that do not result in a deter-
mination of an amount of payment for such item 
or service by the last day of the open negotiation 
period described in such subparagraph with re-
spect to such item or service, the provider or fa-
cility (as applicable) or group health plan or 
health insurance issuer offering group or indi-
vidual health insurance coverage that was party 
to such negotiations may, during the 4-day pe-
riod beginning on the day after such open nego-
tiation period, initiate the independent dispute 
resolution process under paragraph (2) with re-
spect to such item or service. The independent 
dispute resolution process shall be initiated by a 
party pursuant to the previous sentence by sub-
mission to the other party and to the Secretary 
of a notification (containing such information as 
specified by the Secretary) and for purposes of 
this subsection, the date of initiation of such 
process shall be the date of such submission or 
such other date specified by the Secretary pursu-
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ant to regulations that is not later than the date 
of receipt of such notification by both the other 
party and the Secretary. 
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROC-
ESS AVAILABLE IN CASE OF FAILED OPEN NEGOTIA-
TIONS.— 
‘‘(A) ESTABLISHMENT.—Not later than 1 
year after the date of the enactment of this sub-
section, the Secretary, jointly with the Secretary 
of Labor and the Secretary of the Treasury, shall 
establish by regulation one independent dispute 
resolution process (referred to in this subsection 
as the ‘IDR process’) under which, in the case of 
an item or service with respect to which a pro-
vider or facility (as applicable) or group health 
plan or health insurance issuer offering group or 
individual health insurance coverage submits a 
notification under paragraph (1)(B) (in this 
subsection referred to as a ‘qualified IDR item or 
service’), a certified IDR entity under paragraph 
(4) determines, subject to subparagraph (B) and 
in accordance with the succeeding provisions of 
this subsection, the amount of payment under the 
plan or coverage for such item or service fur-
nished by such provider or facility. 
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4081 
‘‘(B) AUTHORITY
TO
CONTINUE
NEGOTIA-
TIONS.—Under the independent dispute resolu-
tion process, in the case that the parties to a de-
termination for a qualified IDR item or service 
agree on a payment amount for such item or 
service during such process but before the date on 
which the entity selected with respect to such de-
termination under paragraph (4) makes such de-
termination under paragraph (5), such amount 
shall be treated for purposes of subsection 
(a)(3)(K)(ii) as the amount agreed to by such 
parties for such item or service. In the case of an 
agreement described in the previous sentence, the 
independent dispute resolution process shall pro-
vide for a method to determine how to allocate 
between the parties to such determination the 
payment of the compensation of the entity se-
lected with respect to such determination. 
‘‘(C) CLARIFICATION.—A nonparticipating 
provider may not, with respect to an item or 
service furnished by such provider, submit a no-
tification under paragraph (1)(B) if such pro-
vider is exempt from the requirement under sub-
section (a) of section 2799B–2 with respect to 
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4082 
such item or service pursuant to subsection (b) of 
such section. 
‘‘(3) TREATMENT OF BATCHING OF ITEMS AND 
SERVICES.— 
‘‘(A) IN GENERAL.—Under the IDR process, 
the Secretary shall specify criteria under which 
multiple qualified IDR dispute items and serv-
ices are permitted to be considered jointly as 
part of a single determination by an entity for 
purposes of encouraging the efficiency (including 
minimizing costs) of the IDR process. Such 
items and services may be so considered only 
if— 
‘‘(i) such items and services to be in-
cluded in such determination are furnished 
by the same provider or facility; 
‘‘(ii) payment for such items and serv-
ices is required to be made by the same 
group health plan or health insurance 
issuer; 
‘‘(iii) such items and services are re-
lated to the treatment of a similar condi-
tion; and 
‘‘(iv) such items and services were fur-
nished during the 30 day period following 
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4083 
the date on which the first item or service 
included with respect to such determination 
was furnished or an alternative period as 
determined by the Secretary, for use in lim-
ited situations, such as by the consent of the 
parties or in the case of low-volume items 
and services, to encourage procedural effi-
ciency and minimize health plan and pro-
vider administrative costs. 
‘‘(B) 
TREATMENT
OF
BUNDLED
PAY-
MENTS.—In carrying out subparagraph (A), the 
Secretary shall provide that, in the case of items 
and services which are included by a provider or 
facility as part of a bundled payment, such 
items and services included in such bundled pay-
ment may be part of a single determination 
under this subsection. 
‘‘(4) CERTIFICATION AND SELECTION OF IDR EN-
TITIES.— 
‘‘(A) IN GENERAL.—The Secretary, in con-
sultation with the Secretary of Labor and Sec-
retary of the Treasury, shall establish a process 
to certify (including to recertify) entities under 
this paragraph. Such process shall ensure that 
an entity so certified— 
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‘‘(i) has (directly or through contracts 
or other arrangements) sufficient medical, 
legal, and other expertise and sufficient 
staffing to make determinations described in 
paragraph (5) on a timely basis; 
‘‘(ii) is not— 
‘‘(I) a group health plan or health 
insurance issuer offering group or in-
dividual health insurance coverage, 
provider, or facility; 
‘‘(II) an affiliate or a subsidiary 
of such a group health plan or health 
insurance issuer, provider, or facility; 
or 
‘‘(III) an affiliate or subsidiary of 
a professional or trade association of 
such group health plans or health in-
surance issuers or of providers or fa-
cilities; 
‘‘(iii) carries out the responsibilities of 
such an entity in accordance with this sub-
section; 
‘‘(iv) meets appropriate indicators of 
fiscal integrity; 
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4085 
‘‘(v) maintains the confidentiality (in 
accordance with regulations promulgated by 
the Secretary) of individually identifiable 
health information obtained in the course of 
conducting such determinations; 
‘‘(vi) does not under the IDR process 
carry out any determination with respect to 
which the entity would not pursuant to sub-
clause (I), (II), or (III) of subparagraph 
(F)(i) be eligible for selection; and 
‘‘(vii) meets such other requirements as 
determined appropriate by the Secretary. 
‘‘(B) PERIOD OF CERTIFICATION.—Subject 
to subparagraph (C), each certification (includ-
ing a recertification) of an entity under the 
process described in subparagraph (A) shall be 
for a 5-year period. 
‘‘(C) REVOCATION.—A certification of an 
entity under this paragraph may be revoked 
under the process described in subparagraph (A) 
if the entity has a pattern or practice of non-
compliance with any of the requirements de-
scribed in such subparagraph. 
‘‘(D) PETITION
FOR
DENIAL
OR
WITH-
DRAWAL.—The process described in subpara-
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graph (A) shall ensure that an individual, pro-
vider, facility, or group health plan or health in-
surance issuer offering group or individual 
health insurance coverage may petition for a de-
nial of a certification or a revocation of a certifi-
cation with respect to an entity under this para-
graph for failure of meeting a requirement of 
this subsection. 
‘‘(E) SUFFICIENT NUMBER OF ENTITIES.— 
The process described in subparagraph (A) shall 
ensure that a sufficient number of entities are 
certified under this paragraph to ensure the 
timely and efficient provision of determinations 
described in paragraph (5). 
‘‘(F) SELECTION OF CERTIFIED IDR ENTI-
TY.—The Secretary shall, with respect to the de-
termination of the amount of payment under 
this subsection of an item or service, provide for 
a method— 
‘‘(i) that allows for the group health 
plan or health insurance issuer offering 
group or individual health insurance cov-
erage and the nonparticipating provider or 
the nonparticipating emergency facility (as 
applicable) involved in a notification under 
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4087 
paragraph (1)(B) to jointly select, not later 
than the last day of the 3-business day pe-
riod following the date of the initiation of 
the process with respect to such item or 
service, for purposes of making such deter-
mination, an entity certified under this 
paragraph that— 
‘‘(I) is not a party to such deter-
mination or an employee or agent of 
such a party; 
‘‘(II) does not have a material fa-
milial, financial, or professional rela-
tionship with such a party; and 
‘‘(III) does not otherwise have a 
conflict of interest with such a party 
(as determined by the Secretary); and 
‘‘(ii) that requires, in the case such 
parties do not make such selection by such 
last day, the Secretary to, not later than 6 
business days after such date of initiation— 
‘‘(I) select such an entity that sat-
isfies subclauses (I) through (III) of 
clause (i)); and 
‘‘(II) provide notification of such 
selection to the provider or facility (as 
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applicable) and the plan or issuer (as 
applicable) party to such determina-
tion. 
An entity selected pursuant to the previous sentence to make 
a determination described in such sentence shall be referred 
to in this subsection as the ‘certified IDR entity’ with re-
spect to such determination. 
‘‘(5) PAYMENT DETERMINATION.— 
‘‘(A) IN GENERAL.—Not later than 30 days 
after the date of selection of the certified IDR en-
tity with respect to a determination for a quali-
fied IDR item or service, the certified IDR entity 
shall— 
‘‘(i) taking into account the consider-
ations specified in subparagraph (C), select 
one of the offers submitted under subpara-
graph (B) to be the amount of payment for 
such item or service determined under this 
subsection for purposes of subsection (a)(1) 
or (b)(1), as applicable; and 
‘‘(ii) notify the provider or facility and 
the group health plan or health insurance 
issuer offering group or individual health 
insurance coverage party to such determina-
tion of the offer selected under clause (i). 
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4089 
‘‘(B) SUBMISSION
OF
OFFERS.—Not later 
than 10 days after the date of selection of the cer-
tified IDR entity with respect to a determination 
for a qualified IDR item or service, the provider 
or facility and the group health plan or health 
insurance issuer offering group or individual 
health insurance coverage party to such deter-
mination— 
‘‘(i) shall each submit to the certified 
IDR entity with respect to such determina-
tion— 
‘‘(I) an offer for a payment 
amount for such item or service fur-
nished by such provider or facility; 
and 
‘‘(II) such information as re-
quested by the certified IDR entity re-
lating to such offer; and 
‘‘(ii) may each submit to the certified 
IDR entity with respect to such determina-
tion any information relating to such offer 
submitted by either party, including infor-
mation relating to any circumstance de-
scribed in subparagraph (C)(ii). 
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4090 
‘‘(C) 
CONSIDERATIONS
IN
DETERMINA-
TION.— 
‘‘(i) IN
GENERAL.—In determining 
which offer is the payment to be applied 
pursuant to this paragraph, the certified 
IDR entity, with respect to the determina-
tion for a qualified IDR item or service 
shall consider— 
‘‘(I) 
the 
qualifying 
payment 
amounts (as defined in subsection 
(a)(3)(E)) for the applicable year for 
items or services that are comparable 
to the qualified IDR item or service 
and that are furnished in the same ge-
ographic region (as defined by the Sec-
retary for purposes of such subsection) 
as such qualified IDR item or service; 
and 
‘‘(II) subject to subparagraph (D), 
information on any circumstance de-
scribed in clause (ii), such information 
as 
requested 
in 
subparagraph 
(B)(i)(II), and any additional infor-
mation 
provided 
in 
subparagraph 
(B)(ii). 
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‘‘(ii) ADDITIONAL
CIRCUMSTANCES.— 
For purposes of clause (i)(II), the cir-
cumstances described in this clause are, 
with respect to a qualified IDR item or 
service of a nonparticipating provider, non-
participating emergency facility, group 
health plan, or health insurance issuer of 
group or individual health insurance cov-
erage the following: 
‘‘(I) The level of training, experi-
ence, and quality and outcomes meas-
urements of the provider or facility 
that furnished such item or service 
(such as those endorsed by the con-
sensus-based entity authorized in sec-
tion 1890 of the Social Security Act). 
‘‘(II) The market share held by 
the nonparticipating provider or facil-
ity or that of the plan or issuer in the 
geographic region in which the item or 
service was provided. 
‘‘(III) The acuity of the indi-
vidual receiving such item or service or 
the complexity of furnishing such item 
or service to such individual. 
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‘‘(IV) The teaching status, case 
mix, and scope of services of the non-
participating facility that furnished 
such item or service. 
‘‘(V) Demonstrations of good faith 
efforts (or lack of good faith efforts) 
made by the nonparticipating provider 
or nonparticipating facility or the 
plan or issuer to enter into network 
agreements and, if applicable, con-
tracted rates between the provider or 
facility, as applicable, and the plan or 
issuer, as applicable, during the pre-
vious 4 plan years. 
‘‘(D) PROHIBITION ON CONSIDERATION OF 
CERTAIN FACTORS.—In determining which offer 
is the payment to be applied with respect to 
qualified IDR items and services furnished by a 
provider or facility, the certified IDR entity with 
respect to a determination shall not consider 
usual and customary charges, the amount that 
would have been billed by such provider or facil-
ity with respect to such items and services had 
the provisions of section 2799B–1 or 2799B–2 
(as applicable) not applied, or the payment or 
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reimbursement rate for such items and services 
furnished by such provider or facility payable by 
a public payor, including under the Medicare 
program under title XVIII of the Social Security 
Act, under the Medicaid program under title 
XIX of such Act, under the Children’s Health In-
surance Program under title XXI of such Act, 
under the TRICARE program under chapter 55 
of title 10, United States Code, or under chapter 
17 of title 38, United States Code. 
‘‘(E) EFFECTS OF DETERMINATION.— 
‘‘(i) IN GENERAL.—A determination of 
a certified IDR entity under subparagraph 
(A)— 
‘‘(I) shall be binding upon the 
parties involved, in the absence of a 
fraudulent claim or evidence of mis-
representation of facts presented to the 
IDR entity involved regarding such 
claim; and 
‘‘(II) shall not be subject to judi-
cial review, except in a case described 
in any of paragraphs (1) through (4) 
of section 10(a) of title 9, United 
States Code. 
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4094 
‘‘(ii) SUSPENSION OF CERTAIN SUBSE-
QUENT IDR REQUESTS.—In the case of a de-
termination of a certified IDR entity under 
subparagraph (A), with respect to an initial 
notification submitted under paragraph 
(1)(B) with respect to qualified IDR items 
and services and the two parties involved 
with such notification, the party that sub-
mitted such notification may not submit 
during the 90-day period following such de-
termination a subsequent notification under 
such paragraph involving the same other 
party to such notification with respect to 
such an item or service that was the subject 
of such initial notification. 
‘‘(iii) SUBSEQUENT
SUBMISSION
OF 
REQUESTS PERMITTED.—In the case of a 
notification that pursuant to clause (ii) is 
not permitted to be submitted under para-
graph (1)(B) during a 90-day period speci-
fied in such clause, if the end of the open 
negotiation period specified in paragraph 
(1)(A), that but for this clause would other-
wise apply with respect to such notification, 
occurs during such 90-day period, such 
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paragraph (1)(B) shall be applied as if the 
reference in such paragraph to the 4-day 
period beginning on the day after such open 
negotiation period were instead a reference 
to the 30-day period beginning on the day 
after the last day of such 90-day period. 
‘‘(iv) REPORTS.—The Secretary, joint-
ly with the Secretary of Labor and the Sec-
retary of the Treasury, shall examine the 
impact of the application of clause (ii) and 
whether the application of such clause 
delays payment determinations or impacts 
early, alternative resolution of claims (such 
as through open negotiations), and shall 
submit to Congress, not later than 2 years 
after the date of implementation of such 
clause an interim report (and not later 
than 4 years after such date of implementa-
tion, a final report) on whether any group 
health plans or health insurance issuers of-
fering group or individual health insurance 
coverage or types of such plans or coverage 
have a pattern or practice of routine denial, 
low payment, or down-coding of claims, or 
otherwise abuse the 90-day period described 
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4096 
in such clause, including recommendations 
on ways to discourage such a pattern or 
practice. 
‘‘(F) COSTS
OF
INDEPENDENT
DISPUTE 
RESOLUTION PROCESS.—In the case of a notifi-
cation under paragraph (1)(B) submitted by a 
nonparticipating 
provider, 
nonparticipating 
emergency facility, group health plan, or health 
insurance issuer offering group or individual 
health insurance coverage and submitted to a 
certified IDR entity— 
‘‘(i) if such entity makes a determina-
tion with respect to such notification under 
subparagraph (A), the party whose offer is 
not chosen under such subparagraph shall 
be responsible for paying all fees charged by 
such entity; and 
‘‘(ii) if the parties reach a settlement 
with respect to such notification prior to 
such a determination, each party shall pay 
half of all fees charged by such entity, unless 
the parties otherwise agree. 
‘‘(6) TIMING OF PAYMENT.—The total plan or 
coverage payment required pursuant to subsection 
(a)(1) or (b)(1), with respect to a qualified IDR item 
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or service for which a determination is made under 
paragraph (5)(A) or with respect to an item or serv-
ice for which a payment amount is determined under 
open negotiations under paragraph (1), shall be made 
directly to the nonparticipating provider or facility 
not later than 30 days after the date on which such 
determination is made. 
‘‘(7) PUBLICATION OF INFORMATION RELATING 
TO THE IDR PROCESS.— 
‘‘(A) PUBLICATION OF INFORMATION.—For 
each calendar quarter in 2022 and each calendar 
quarter in a subsequent year, the Secretary shall 
make available on the public website of the De-
partment of Health and Human Services— 
‘‘(i) the number of notifications sub-
mitted under paragraph (1)(B) during such 
calendar quarter; 
‘‘(ii) the size of the provider practices 
and the size of the facilities submitting noti-
fications under paragraph (1)(B) during 
such calendar quarter; 
‘‘(iii) the number of such notifications 
with respect to which a determination was 
made under paragraph (5)(A); 
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‘‘(iv) the information described in sub-
paragraph (B) with respect to each notifica-
tion with respect to which such a deter-
mination was so made; 
‘‘(v) the number of times the payment 
amount determined (or agreed to) under 
this subsection exceeds the qualifying pay-
ment amount, specified by items and serv-
ices; 
‘‘(vi) the amount of expenditures made 
by the Secretary during such calendar quar-
ter to carry out the IDR process; 
‘‘(vii) the total amount of fees paid 
under paragraph (8) during such calendar 
quarter; and 
‘‘(viii) the total amount of compensa-
tion paid to certified IDR entities under 
paragraph (5)(F) during such calendar 
quarter. 
‘‘(B) INFORMATION.—For purposes of sub-
paragraph (A), the information described in this 
subparagraph is, with respect to a notification 
under paragraph (1)(B) by a nonparticipating 
provider, nonparticipating emergency facility, 
group health plan, or health insurance issuer of-
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fering group or individual health insurance cov-
erage— 
‘‘(i) a description of each item and 
service included with respect to such notifi-
cation; 
‘‘(ii) the geography in which the items 
and services with respect to such notifica-
tion were provided; 
‘‘(iii) the amount of the offer submitted 
under paragraph (5)(B) by the group health 
plan or health insurance issuer (as applica-
ble) and by the nonparticipating provider 
or nonparticipating emergency facility (as 
applicable) expressed as a percentage of the 
qualifying payment amount; 
‘‘(iv) whether the offer selected by the 
certified IDR entity under paragraph (5) to 
be the payment applied was the offer sub-
mitted by such plan or issuer (as applica-
ble) or by such provider or facility (as ap-
plicable) and the amount of such offer so se-
lected expressed as a percentage of the quali-
fying payment amount; 
‘‘(v) the category and practice spe-
cialty of each such provider or facility in-
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4100 
volved in furnishing such items and serv-
ices; 
‘‘(vi) the identity of the health plan or 
health insurance issuer, provider, or facil-
ity, with respect to the notification; 
‘‘(vii) the length of time in making 
each determination; 
‘‘(viii) the compensation paid to the 
certified IDR entity with respect to the set-
tlement or determination; and 
‘‘(ix) any other information specified 
by the Secretary. 
‘‘(C) IDR 
ENTITY
REQUIREMENTS.—For 
2022 and each subsequent year, an IDR entity, 
as a condition of certification as an IDR entity, 
shall submit to the Secretary such information 
as the Secretary determines necessary to carry 
out the provisions of this subsection. 
‘‘(D) CLARIFICATION.—The Secretary shall 
ensure the public reporting under this paragraph 
does not contain information that would disclose 
privileged or confidential information of a group 
health plan or health insurance issuer offering 
group or individual health insurance coverage or 
of a provider or facility. 
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4101 
‘‘(8) ADMINISTRATIVE FEE.— 
‘‘(A) IN GENERAL.—Each party to a deter-
mination under paragraph (5) to which an enti-
ty is selected under paragraph (3) in a year 
shall pay to the Secretary, at such time and in 
such manner as specified by the Secretary, a fee 
for participating in the IDR process with respect 
to such determination in an amount described in 
subparagraph (B) for such year. 
‘‘(B) AMOUNT
OF
FEE.—The amount de-
scribed in this subparagraph for a year is an 
amount established by the Secretary in a man-
ner such that the total amount of fees paid under 
this paragraph for such year is estimated to be 
equal to the amount of expenditures estimated to 
be made by the Secretary for such year in car-
rying out the IDR process. 
‘‘(9) WAIVER AUTHORITY.—The Secretary may 
modify any deadline or other timing requirement 
specified under this subsection (other than the estab-
lishment date for the IDR process under paragraph 
(2)(A) and other than under paragraph (6)) in cases 
of extenuating circumstances, as specified by the Sec-
retary, or to ensure that all claims that occur during 
a 90-day period described in paragraph (5)(E)(ii), 
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but with respect to which a notification is not per-
mitted by reason of such paragraph to be submitted 
under paragraph (1)(B) during such period, are eligi-
ble for the IDR process.’’. 
(b) ERISA.—Section 716 of the Employee Retirement 
Income Security Act of 1974, as added by section 102, is 
amended— 
(1) by redesignating subsection (c) as subsection 
(d); and 
(2) by inserting after subsection (b) the following 
new subsection: 
‘‘(c) DETERMINATION OF OUT-OF-NETWORK RATES TO 
BE PAID BY HEALTH PLANS; INDEPENDENT DISPUTE RES-
OLUTION PROCESS.— 
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIA-
TION.— 
‘‘(A) IN GENERAL.—With respect to an item 
or service furnished in a year by a nonpartici-
pating provider or a nonparticipating facility, 
with respect to a group health plan or health in-
surance issuer offering group health insurance 
coverage, in a State described in subsection 
(a)(3)(K)(ii) with respect to such plan or cov-
erage and provider or facility, and for which a 
payment is required to be made by the plan or 
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coverage pursuant to subsection (a)(1) or (b)(1), 
the provider or facility (as applicable) or plan or 
coverage may, during the 30-day period begin-
ning on the day the provider or facility receives 
an initial payment or a notice of denial of pay-
ment from the plan or coverage regarding a 
claim for payment for such item or service, ini-
tiate open negotiations under this paragraph be-
tween such provider or facility and plan or cov-
erage for purposes of determining, during the 
open negotiation period, an amount agreed on 
by such provider or facility, respectively, and 
such plan or coverage for payment (including 
any cost-sharing) for such item or service. For 
purposes of this subsection, the open negotiation 
period, with respect to an item or service, is the 
30-day period beginning on the date of initiation 
of the negotiations with respect to such item or 
service. 
‘‘(B) ACCESSING
INDEPENDENT
DISPUTE 
RESOLUTION PROCESS IN CASE OF FAILED NEGO-
TIATIONS.—In the case of open negotiations pur-
suant to subparagraph (A), with respect to an 
item or service, that do not result in a deter-
mination of an amount of payment for such item 
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or service by the last day of the open negotiation 
period described in such subparagraph with re-
spect to such item or service, the provider or fa-
cility (as applicable) or group health plan or 
health insurance issuer offering group health in-
surance coverage that was party to such negotia-
tions may, during the 4-day period beginning on 
the day after such open negotiation period, ini-
tiate the independent dispute resolution process 
under paragraph (2) with respect to such item or 
service. The independent dispute resolution proc-
ess shall be initiated by a party pursuant to the 
previous sentence by submission to the other 
party and to the Secretary of a notification 
(containing such information as specified by the 
Secretary) and for purposes of this subsection, 
the date of initiation of such process shall be the 
date of such submission or such other date speci-
fied by the Secretary pursuant to regulations 
that is not later than the date of receipt of such 
notification by both the other party and the Sec-
retary. 
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROC-
ESS AVAILABLE IN CASE OF FAILED OPEN NEGOTIA-
TIONS.— 
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‘‘(A) ESTABLISHMENT.—Not later than 1 
year after the date of the enactment of this sub-
section, the Secretary, jointly with the Secretary 
of Health and Human Services and the Sec-
retary of the Treasury, shall establish by regula-
tion one independent dispute resolution process 
(referred to in this subsection as the ‘IDR proc-
ess’) under which, in the case of an item or serv-
ice with respect to which a provider or facility 
(as applicable) or group health plan or health 
insurance issuer offering group health insurance 
coverage submits a notification under paragraph 
(1)(B) (in this subsection referred to as a ‘quali-
fied IDR item or service’), a certified IDR entity 
under paragraph (4) determines, subject to sub-
paragraph (B) and in accordance with the suc-
ceeding provisions of this subsection, the amount 
of payment under the plan or coverage for such 
item or service furnished by such provider or fa-
cility. 
‘‘(B) AUTHORITY
TO
CONTINUE
NEGOTIA-
TIONS.—Under the independent dispute resolu-
tion process, in the case that the parties to a de-
termination for a qualified IDR item or service 
agree on a payment amount for such item or 
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service during such process but before the date on 
which the entity selected with respect to such de-
termination under paragraph (4) makes such de-
termination under paragraph (5), such amount 
shall be treated for purposes of subsection 
(a)(3)(K)(ii) as the amount agreed to by such 
parties for such item or service. In the case of an 
agreement described in the previous sentence, the 
independent dispute resolution process shall pro-
vide for a method to determine how to allocate 
between the parties to such determination the 
payment of the compensation of the entity se-
lected with respect to such determination. 
‘‘(C) CLARIFICATION.—A nonparticipating 
provider may not, with respect to an item or 
service furnished by such provider, submit a no-
tification under paragraph (1)(B) if such pro-
vider is exempt from the requirement under sub-
section (a) of section 2799B–2 of the Public 
Health Service Act with respect to such item or 
service pursuant to subsection (b) of such section. 
‘‘(3) TREATMENT OF BATCHING OF ITEMS AND 
SERVICES.— 
‘‘(A) IN GENERAL.—Under the IDR process, 
the Secretary shall specify criteria under which 
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4107 
multiple qualified IDR dispute items and serv-
ices are permitted to be considered jointly as 
part of a single determination by an entity for 
purposes of encouraging the efficiency (including 
minimizing costs) of the IDR process. Such 
items and services may be so considered only 
if— 
‘‘(i) such items and services to be in-
cluded in such determination are furnished 
by the same provider or facility; 
‘‘(ii) payment for such items and serv-
ices is required to be made by the same 
group health plan or health insurance 
issuer; 
‘‘(iii) such items and services are re-
lated to the treatment of a similar condi-
tion; and 
‘‘(iv) such items and services were fur-
nished during the 30 day period following 
the date on which the first item or service 
included with respect to such determination 
was furnished or an alternative period as 
determined by the Secretary, for use in lim-
ited situations, such as by the consent of the 
parties or in the case of low-volume items 
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4108 
and services, to encourage procedural effi-
ciency and minimize health plan and pro-
vider administrative costs. 
‘‘(B) 
TREATMENT
OF
BUNDLED
PAY-
MENTS.—In carrying out subparagraph (A), the 
Secretary shall provide that, in the case of items 
and services which are included by a provider or 
facility as part of a bundled payment, such 
items and services included in such bundled pay-
ment may be part of a single determination 
under this subsection. 
‘‘(4) CERTIFICATION AND SELECTION OF IDR EN-
TITIES.— 
‘‘(A) IN GENERAL.—The Secretary, jointly 
with the Secretary of Health and Human Serv-
ices and Secretary of the Treasury, shall estab-
lish a process to certify (including to recertify) 
entities under this paragraph. Such process shall 
ensure that an entity so certified— 
‘‘(i) has (directly or through contracts 
or other arrangements) sufficient medical, 
legal, and other expertise and sufficient 
staffing to make determinations described in 
paragraph (5) on a timely basis; 
‘‘(ii) is not— 
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4109 
‘‘(I) a group health plan or health 
insurance issuer offering group health 
insurance coverage, provider, or facil-
ity; 
‘‘(II) an affiliate or a subsidiary 
of such a group health plan or health 
insurance issuer, provider, or facility; 
or 
‘‘(III) an affiliate or subsidiary of 
a professional or trade association of 
such group health plans or health in-
surance issuers or of providers or fa-
cilities; 
‘‘(iii) carries out the responsibilities of 
such an entity in accordance with this sub-
section; 
‘‘(iv) meets appropriate indicators of 
fiscal integrity; 
‘‘(v) maintains the confidentiality (in 
accordance with regulations promulgated by 
the Secretary) of individually identifiable 
health information obtained in the course of 
conducting such determinations; 
‘‘(vi) does not under the IDR process 
carry out any determination with respect to 
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4110 
which the entity would not pursuant to sub-
clause (I), (II), or (III) of subparagraph 
(F)(i) be eligible for selection; and 
‘‘(vii) meets such other requirements as 
determined appropriate by the Secretary. 
‘‘(B) PERIOD OF CERTIFICATION.—Subject 
to subparagraph (C), each certification (includ-
ing a recertification) of an entity under the 
process described in subparagraph (A) shall be 
for a 5-year period. 
‘‘(C) REVOCATION.—A certification of an 
entity under this paragraph may be revoked 
under the process described in subparagraph (A) 
if the entity has a pattern or practice of non-
compliance with any of the requirements de-
scribed in such subparagraph. 
‘‘(D) PETITION
FOR
DENIAL
OR
WITH-
DRAWAL.—The process described in subpara-
graph (A) shall ensure that an individual, pro-
vider, facility, or group health plan or health in-
surance issuer offering group health insurance 
coverage may petition for a denial of a certifi-
cation or a revocation of a certification with re-
spect to an entity under this paragraph for fail-
ure of meeting a requirement of this subsection. 
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4111 
‘‘(E) SUFFICIENT NUMBER OF ENTITIES.— 
The process described in subparagraph (A) shall 
ensure that a sufficient number of entities are 
certified under this paragraph to ensure the 
timely and efficient provision of determinations 
described in paragraph (5). 
‘‘(F) SELECTION OF CERTIFIED IDR ENTI-
TY.—The Secretary shall, with respect to the de-
termination of the amount of payment under 
this subsection of an item or service, provide for 
a method— 
‘‘(i) that allows for the group health 
plan or health insurance issuer offering 
group health insurance coverage and the 
nonparticipating provider or the non-
participating emergency facility (as appli-
cable) involved in a notification under 
paragraph (1)(B) to jointly select, not later 
than the last day of the 3-business day pe-
riod following the date of the initiation of 
the process with respect to such item or 
service, for purposes of making such deter-
mination, an entity certified under this 
paragraph that— 
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4112 
‘‘(I) is not a party to such deter-
mination or an employee or agent of 
such a party; 
‘‘(II) does not have a material fa-
milial, financial, or professional rela-
tionship with such a party; and 
‘‘(III) does not otherwise have a 
conflict of interest with such a party 
(as determined by the Secretary); and 
‘‘(ii) that requires, in the case such 
parties do not make such selection by such 
last day, the Secretary to, not later than 6 
business days after such date of initiation— 
‘‘(I) select such an entity that sat-
isfies subclauses (I) through (III) of 
clause (i)); and 
‘‘(II) provide notification of such 
selection to the provider or facility (as 
applicable) and the plan or issuer (as 
applicable) party to such determina-
tion. 
An entity selected pursuant to the previous sentence to make 
a determination described in such sentence shall be referred 
to in this subsection as the ‘certified IDR entity’ with re-
spect to such determination. 
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4113 
‘‘(5) PAYMENT DETERMINATION.— 
‘‘(A) IN GENERAL.—Not later than 30 days 
after the date of selection of the certified IDR en-
tity with respect to a determination for a quali-
fied IDR item or service, the certified IDR entity 
shall— 
‘‘(i) taking into account the consider-
ations specified in subparagraph (C), select 
one of the offers submitted under subpara-
graph (B) to be the amount of payment for 
such item or service determined under this 
subsection for purposes of subsection (a)(1) 
or (b)(1), as applicable; and 
‘‘(ii) notify the provider or facility and 
the group health plan or health insurance 
issuer offering group health insurance cov-
erage party to such determination of the 
offer selected under clause (i). 
‘‘(B) SUBMISSION
OF
OFFERS.—Not later 
than 10 days after the date of selection of the cer-
tified IDR entity with respect to a determination 
for a qualified IDR item or service, the provider 
or facility and the group health plan or health 
insurance issuer offering group health insurance 
coverage party to such determination— 
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4114 
‘‘(i) shall each submit to the certified 
IDR entity with respect to such determina-
tion— 
‘‘(I) an offer for a payment 
amount for such item or service fur-
nished by such provider or facility; 
and 
‘‘(II) such information as re-
quested by the certified IDR entity re-
lating to such offer; and 
‘‘(ii) may each submit to the certified 
IDR entity with respect to such determina-
tion any information relating to such offer 
submitted by either party, including infor-
mation relating to any circumstance de-
scribed in subparagraph (C)(ii). 
‘‘(C) 
CONSIDERATIONS
IN
DETERMINA-
TION.— 
‘‘(i) IN
GENERAL.—In determining 
which offer is the payment to be applied 
pursuant to this paragraph, the certified 
IDR entity, with respect to the determina-
tion for a qualified IDR item or service 
shall consider— 
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4115 
‘‘(I) 
the 
qualifying 
payment 
amounts (as defined in subsection 
(a)(3)(E)) for the applicable year for 
items or services that are comparable 
to the qualified IDR item or service 
and that are furnished in the same ge-
ographic region (as defined by the Sec-
retary for purposes of such subsection) 
as such qualified IDR item or service; 
and 
‘‘(II) subject to subparagraph (D), 
information on any circumstance de-
scribed in clause (ii), such information 
as 
requested 
in 
subparagraph 
(B)(i)(II), and any additional infor-
mation 
provided 
in 
subparagraph 
(B)(ii). 
‘‘(ii) ADDITIONAL
CIRCUMSTANCES.— 
For purposes of clause (i)(II), the cir-
cumstances described in this clause are, 
with respect to a qualified IDR item or 
service of a nonparticipating provider, non-
participating emergency facility, group 
health plan, or health insurance issuer of 
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4116 
group health insurance coverage the fol-
lowing: 
‘‘(I) The level of training, experi-
ence, and quality and outcomes meas-
urements of the provider or facility 
that furnished such item or service 
(such as those endorsed by the con-
sensus-based entity authorized in sec-
tion 1890 of the Social Security Act). 
‘‘(II) The market share held by 
the nonparticipating provider or facil-
ity or that of the plan or issuer in the 
geographic region in which the item or 
service was provided. 
‘‘(III) The acuity of the indi-
vidual receiving such item or service or 
the complexity of furnishing such item 
or service to such individual. 
‘‘(IV) The teaching status, case 
mix, and scope of services of the non-
participating facility that furnished 
such item or service. 
‘‘(V) Demonstrations of good faith 
efforts (or lack of good faith efforts) 
made by the nonparticipating provider 
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4117 
or nonparticipating facility or the 
plan or issuer to enter into network 
agreements and, if applicable, con-
tracted rates between the provider or 
facility, as applicable, and the plan or 
issuer, as applicable, during the pre-
vious 4 plan years. 
‘‘(D) PROHIBITION ON CONSIDERATION OF 
CERTAIN FACTORS.—In determining which offer 
is the payment to be applied with respect to 
qualified IDR items and services furnished by a 
provider or facility, the certified IDR entity with 
respect to a determination shall not consider 
usual and customary charges, the amount that 
would have been billed by such provider or facil-
ity with respect to such items and services had 
the provisions of section 2799B–1 of the Public 
Health Service Act or 2799B–2 of such Act (as 
applicable) not applied, or the payment or reim-
bursement rate for such items and services fur-
nished by such provider or facility payable by a 
public payor, including under the Medicare pro-
gram under title XVIII of the Social Security 
Act, under the Medicaid program under title 
XIX of such Act, under the Children’s Health In-
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4118 
surance Program under title XXI of such Act, 
under the TRICARE program under chapter 55 
of title 10, United States Code, or under chapter 
17 of title 38, United States Code. 
‘‘(E) EFFECTS OF DETERMINATION.— 
‘‘(i) IN GENERAL.—A determination of 
a certified IDR entity under subparagraph 
(A)— 
‘‘(I) shall be binding upon the 
parties involved, in the absence of a 
fraudulent claim or evidence of mis-
representation of facts presented to the 
IDR entity involved regarding such 
claim; and 
‘‘(II) shall not be subject to judi-
cial review, except in a case described 
in any of paragraphs (1) through (4) 
of section 10(a) of title 9, United 
States Code. 
‘‘(ii) SUSPENSION OF CERTAIN SUBSE-
QUENT IDR REQUESTS.—In the case of a de-
termination of a certified IDR entity under 
subparagraph (A), with respect to an initial 
notification submitted under paragraph 
(1)(B) with respect to qualified IDR items 
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4119 
and services and the two parties involved 
with such notification, the party that sub-
mitted such notification may not submit 
during the 90-day period following such de-
termination a subsequent notification under 
such paragraph involving the same other 
party to such notification with respect to 
such an item or service that was the subject 
of such initial notification. 
‘‘(iii) SUBSEQUENT
SUBMISSION
OF 
REQUESTS PERMITTED.—In the case of a 
notification that pursuant to clause (ii) is 
not permitted to be submitted under para-
graph (1)(B) during a 90-day period speci-
fied in such clause, if the end of the open 
negotiation period specified in paragraph 
(1)(A), that but for this clause would other-
wise apply with respect to such notification, 
occurs during such 90-day period, such 
paragraph (1)(B) shall be applied as if the 
reference in such paragraph to the 4-day 
period beginning on the day after such open 
negotiation period were instead a reference 
to the 30-day period beginning on the day 
after the last day of such 90-day period. 
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‘‘(iv) REPORTS.—The Secretary, joint-
ly with the Secretary of Health and Human 
Services and the Secretary of the Treasury, 
shall examine the impact of the application 
of clause (ii) and whether the application of 
such clause delays payment determinations 
or impacts early, alternative resolution of 
claims (such as through open negotiations), 
and shall submit to Congress, not later than 
2 years after the date of implementation of 
such clause an interim report (and not later 
than 4 years after such date of implementa-
tion, a final report) on whether any group 
health plans or health insurance issuers of-
fering group or individual health insurance 
coverage or types of such plans or coverage 
have a pattern or practice of routine denial, 
low payment, or down-coding of claims, or 
otherwise abuse the 90-day period described 
in such clause, including recommendations 
on ways to discourage such a pattern or 
practice. 
‘‘(F) COSTS
OF
INDEPENDENT
DISPUTE 
RESOLUTION PROCESS.—In the case of a notifi-
cation under paragraph (1)(B) submitted by a 
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nonparticipating 
provider, 
nonparticipating 
emergency facility, group health plan, or health 
insurance issuer offering group health insurance 
coverage and submitted to a certified IDR enti-
ty— 
‘‘(i) if such entity makes a determina-
tion with respect to such notification under 
subparagraph (A), the party whose offer is 
not chosen under such subparagraph shall 
be responsible for paying all fees charged by 
such entity; and 
‘‘(ii) if the parties reach a settlement 
with respect to such notification prior to 
such a determination, each party shall pay 
half of all fees charged by such entity, unless 
the parties otherwise agree. 
‘‘(6) TIMING OF PAYMENT.—The total plan or 
coverage payment required pursuant to subsection 
(a)(1) or (b)(1), with respect to a qualified IDR item 
or service for which a determination is made under 
paragraph (5)(A) or with respect to an item or serv-
ice for which a payment amount is determined under 
open negotiations under paragraph (1), shall be made 
directly to the nonparticipating provider or facility 
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not later than 30 days after the date on which such 
determination is made. 
‘‘(7) PUBLICATION OF INFORMATION RELATING 
TO THE IDR PROCESS.— 
‘‘(A) PUBLICATION OF INFORMATION.—For 
each calendar quarter in 2022 and each calendar 
quarter in a subsequent year, the Secretary shall 
make available on the public website of the De-
partment of Labor— 
‘‘(i) the number of notifications sub-
mitted under paragraph (1)(B) during such 
calendar quarter; 
‘‘(ii) the size of the provider practices 
and the size of the facilities submitting noti-
fications under paragraph (1)(B) during 
such calendar quarter; 
‘‘(iii) the number of such notifications 
with respect to which a determination was 
made under paragraph (5)(A); 
‘‘(iv) the information described in sub-
paragraph (B) with respect to each notifica-
tion with respect to which such a deter-
mination was so made; 
‘‘(v) the number of times the payment 
amount determined (or agreed to) under 
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this subsection exceeds the qualifying pay-
ment amount, specified by items and serv-
ices; 
‘‘(vi) the amount of expenditures made 
by the Secretary during such calendar quar-
ter to carry out the IDR process; 
‘‘(vii) the total amount of fees paid 
under paragraph (8) during such calendar 
quarter; and 
‘‘(viii) the total amount of compensa-
tion paid to certified IDR entities under 
paragraph (5)(F) during such calendar 
quarter. 
‘‘(B) INFORMATION.—For purposes of sub-
paragraph (A), the information described in this 
subparagraph is, with respect to a notification 
under paragraph (1)(B) by a nonparticipating 
provider, nonparticipating emergency facility, 
group health plan, or health insurance issuer of-
fering group health insurance coverage— 
‘‘(i) a description of each item and 
service included with respect to such notifi-
cation; 
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‘‘(ii) the geography in which the items 
and services with respect to such notifica-
tion were provided; 
‘‘(iii) the amount of the offer submitted 
under paragraph (5)(B) by the group health 
plan or health insurance issuer (as applica-
ble) and by the nonparticipating provider 
or nonparticipating emergency facility (as 
applicable) expressed as a percentage of the 
qualifying payment amount; 
‘‘(iv) whether the offer selected by the 
certified IDR entity under paragraph (5) to 
be the payment applied was the offer sub-
mitted by such plan or issuer (as applica-
ble) or by such provider or facility (as ap-
plicable) and the amount of such offer so se-
lected expressed as a percentage of the quali-
fying payment amount; 
‘‘(v) the category and practice spe-
cialty of each such provider or facility in-
volved in furnishing such items and serv-
ices; 
‘‘(vi) the identity of the health plan or 
health insurance issuer, provider, or facil-
ity, with respect to the notification; 
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‘‘(vii) the length of time in making 
each determination; 
‘‘(viii) the compensation paid to the 
certified IDR entity with respect to the set-
tlement or determination; and 
‘‘(ix) any other information specified 
by the Secretary. 
‘‘(C) IDR 
ENTITY
REQUIREMENTS.—For 
2022 and each subsequent year, an IDR entity, 
as a condition of certification as an IDR entity, 
shall submit to the Secretary such information 
as the Secretary determines necessary to carry 
out the provisions of this subsection. 
‘‘(D) CLARIFICATION.—The Secretary shall 
ensure the public reporting under this paragraph 
does not contain information that would disclose 
privileged or confidential information of a group 
health plan or health insurance issuer offering 
group or individual health insurance coverage or 
of a provider or facility. 
‘‘(8) ADMINISTRATIVE FEE.— 
‘‘(A) IN GENERAL.—Each party to a deter-
mination under paragraph (5) to which an enti-
ty is selected under paragraph (3) in a year 
shall pay to the Secretary, at such time and in 
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4126 
such manner as specified by the Secretary, a fee 
for participating in the IDR process with respect 
to such determination in an amount described in 
subparagraph (B) for such year. 
‘‘(B) AMOUNT
OF
FEE.—The amount de-
scribed in this subparagraph for a year is an 
amount established by the Secretary in a man-
ner such that the total amount of fees paid under 
this paragraph for such year is estimated to be 
equal to the amount of expenditures estimated to 
be made by the Secretary for such year in car-
rying out the IDR process. 
‘‘(9) WAIVER AUTHORITY.—The Secretary may 
modify any deadline or other timing requirement 
specified under this subsection (other than the estab-
lishment date for the IDR process under paragraph 
(2)(A) and other than under paragraph (6)) in cases 
of extenuating circumstances, as specified by the Sec-
retary, or to ensure that all claims that occur during 
a 90-day period described in paragraph (5)(E)(ii), 
but with respect to which a notification is not per-
mitted by reason of such paragraph to be submitted 
under paragraph (1)(B) during such period, are eligi-
ble for the IDR process.’’. 
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(c) IRC.—Section 9816 of the Internal Revenue Code 
of 1986, as added by section 102, is amended— 
(1) by redesignating subsection (c) as subsection 
(d); and 
(2) by inserting after subsection (b) the following 
new subsection: 
‘‘(c) DETERMINATION OF OUT-OF-NETWORK RATES TO 
BE PAID BY HEALTH PLANS; INDEPENDENT DISPUTE RES-
OLUTION PROCESS.— 
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIA-
TION.— 
‘‘(A) IN GENERAL.—With respect to an item 
or service furnished in a year by a nonpartici-
pating provider or a nonparticipating facility, 
with respect to a group health plan, in a State 
described in subsection (a)(3)(K)(ii) with respect 
to such plan and provider or facility, and for 
which a payment is required to be made by the 
plan pursuant to subsection (a)(1) or (b)(1), the 
provider or facility (as applicable) or plan may, 
during the 30-day period beginning on the day 
the provider or facility receives an initial pay-
ment or a notice of denial of payment from the 
plan regarding a claim for payment for such 
item or service, initiate open negotiations under 
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this paragraph between such provider or facility 
and plan for purposes of determining, during the 
open negotiation period, an amount agreed on 
by such provider or facility, respectively, and 
such plan for payment (including any cost-shar-
ing) for such item or service. For purposes of this 
subsection, the open negotiation period, with re-
spect to an item or service, is the 30-day period 
beginning on the date of initiation of the nego-
tiations with respect to such item or service. 
‘‘(B) ACCESSING
INDEPENDENT
DISPUTE 
RESOLUTION PROCESS IN CASE OF FAILED NEGO-
TIATIONS.—In the case of open negotiations pur-
suant to subparagraph (A), with respect to an 
item or service, that do not result in a deter-
mination of an amount of payment for such item 
or service by the last day of the open negotiation 
period described in such subparagraph with re-
spect to such item or service, the provider or fa-
cility (as applicable) or group health plan that 
was party to such negotiations may, during the 
4-day period beginning on the day after such 
open negotiation period, initiate the independent 
dispute resolution process under paragraph (2) 
with respect to such item or service. The inde-
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pendent dispute resolution process shall be initi-
ated by a party pursuant to the previous sen-
tence by submission to the other party and to the 
Secretary of a notification (containing such in-
formation as specified by the Secretary) and for 
purposes of this subsection, the date of initiation 
of such process shall be the date of such submis-
sion or such other date specified by the Secretary 
pursuant to regulations that is not later than the 
date of receipt of such notification by both the 
other party and the Secretary. 
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROC-
ESS AVAILABLE IN CASE OF FAILED OPEN NEGOTIA-
TIONS.— 
‘‘(A) ESTABLISHMENT.—Not later than 1 
year after the date of the enactment of this sub-
section, the Secretary, jointly with the Secretary 
of Health and Human Services and the Sec-
retary of Labor, shall establish by regulation one 
independent dispute resolution process (referred 
to in this subsection as the ‘IDR process’) under 
which, in the case of an item or service with re-
spect to which a provider or facility (as applica-
ble) or group health plan submits a notification 
under paragraph (1)(B) (in this subsection re-
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ferred to as a ‘qualified IDR item or service’), a 
certified IDR entity under paragraph (4) deter-
mines, subject to subparagraph (B) and in ac-
cordance with the succeeding provisions of this 
subsection, the amount of payment under the 
plan for such item or service furnished by such 
provider or facility. 
‘‘(B) AUTHORITY
TO
CONTINUE
NEGOTIA-
TIONS.—Under the independent dispute resolu-
tion process, in the case that the parties to a de-
termination for a qualified IDR item or service 
agree on a payment amount for such item or 
service during such process but before the date on 
which the entity selected with respect to such de-
termination under paragraph (4) makes such de-
termination under paragraph (5), such amount 
shall be treated for purposes of subsection 
(a)(3)(K)(ii) as the amount agreed to by such 
parties for such item or service. In the case of an 
agreement described in the previous sentence, the 
independent dispute resolution process shall pro-
vide for a method to determine how to allocate 
between the parties to such determination the 
payment of the compensation of the entity se-
lected with respect to such determination. 
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‘‘(C) CLARIFICATION.—A nonparticipating 
provider may not, with respect to an item or 
service furnished by such provider, submit a no-
tification under paragraph (1)(B) if such pro-
vider is exempt from the requirement under sub-
section (a) of section 2799B–2 of the Public 
Health Service Act with respect to such item or 
service pursuant to subsection (b) of such section. 
‘‘(3) TREATMENT OF BATCHING OF ITEMS AND 
SERVICES.— 
‘‘(A) IN GENERAL.—Under the IDR process, 
the Secretary shall specify criteria under which 
multiple qualified IDR dispute items and serv-
ices are permitted to be considered jointly as 
part of a single determination by an entity for 
purposes of encouraging the efficiency (including 
minimizing costs) of the IDR process. Such 
items and services may be so considered only 
if— 
‘‘(i) such items and services to be in-
cluded in such determination are furnished 
by the same provider or facility; 
‘‘(ii) payment for such items and serv-
ices is required to be made by the same 
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group health plan or health insurance 
issuer; 
‘‘(iii) such items and services are re-
lated to the treatment of a similar condi-
tion; and 
‘‘(iv) such items and services were fur-
nished during the 30 day period following 
the date on which the first item or service 
included with respect to such determination 
was furnished or an alternative period as 
determined by the Secretary, for use in lim-
ited situations, such as by the consent of the 
parties or in the case of low-volume items 
and services, to encourage procedural effi-
ciency and minimize health plan and pro-
vider administrative costs. 
‘‘(B) 
TREATMENT
OF
BUNDLED
PAY-
MENTS.—In carrying out subparagraph (A), the 
Secretary shall provide that, in the case of items 
and services which are included by a provider or 
facility as part of a bundled payment, such 
items and services included in such bundled pay-
ment may be part of a single determination 
under this subsection. 
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5267 
(A) in the paragraph heading, by striking 
‘‘REQUIREMENT’’ and inserting ‘‘AND
COST- 
SHARING REQUIREMENTS’’; 
(B) in subparagraph (A), in the matter pre-
ceding clause (i), by striking ‘‘The Secretary 
shall recover from the District as reimbursable 
expenses’’ and inserting ‘‘Subject to subpara-
graph (C), the District shall be liable under this 
subsection for an amount equal to’’; 
(C) in subparagraph (B), in the matter pre-
ceding clause (i), by striking ‘‘Secretary shall re-
cover reimbursable expenses’’ and inserting ‘‘Dis-
trict shall pay the Project costs for which the 
District is liable’’; and 
(D) by striking subparagraph (C) and in-
serting the following: 
‘‘(C) CREDIT.—In determining the exact 
amount for which the District is liable under 
this paragraph, the Secretary shall— 
‘‘(i) review and approve all final costs 
associated with the completion of the 
Project; and 
‘‘(ii) credit the district for all amounts 
paid by the District for engineering work 
and improvements directly associated with 
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