SEC. 2. PREVENTING SURPRISE MEDICAL BILLS. 
(a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.— 
Section 2719A of the Public Health Service Act (42 
U.S.C. 300gg–19a) is amended— 
(1) by amending subsection (b) to read as fol-
lows: 
‘‘(b) COVERAGE OF EMERGENCY SERVICES.— 
‘‘(1) IN GENERAL.—If a group health plan, or 
a health insurance issuer offering group or indi-
vidual health insurance coverage, provides or covers 
any benefits with respect to services in an emergency 
department of a hospital or with respect to emer-
gency services in an independent freestanding emer-
gency department (as defined in paragraph (3)(D)), 
the plan or issuer shall cover emergency services (as 
defined in paragraph (3)(C))— 
‘‘(A) without the need for any prior au-
thorization determination; 
‘‘(B) whether the health care provider fur-
nishing such services is a participating provider 
or a participating emergency facility, as appli-
cable, with respect to such services; 
‘‘(C) in a manner so that, if such services 
are provided to a participant, beneficiary, or en-
rollee by a nonparticipating provider or a non-
participating emergency facility— 
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‘‘(i) such services will be provided 
without imposing any requirement under 
the plan or coverage for prior authoriza-
tion of services or any limitation on cov-
erage that is more restrictive than the re-
quirements or limitations that apply to 
emergency services received from partici-
pating providers and participating emer-
gency facilities with respect to such plan or 
coverage, respectively; 
‘‘(ii) the cost-sharing requirement (ex-
pressed as a copayment amount or coinsur-
ance rate) is not greater than the require-
ment that would 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 partici-
pating emergency facility were equal to the 
recognized amount (as defined in para-
graph (3)(H)) for such services, plan or 
coverage, and year; 
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‘‘(iv) the group health plan or health 
insurance issuer, respectively, pays to such 
provider 
or 
facility, 
respectively 
the 
amount by which the recognized amount 
for such services and year involved exceeds 
the cost-sharing amount for such services 
(as determined in accordance with clauses 
(ii) and (iii)) and year; and 
‘‘(v) any cost-sharing payments made 
by the participant, beneficiary, or enrollee 
with respect to such emergency services so 
furnished shall be counted toward any in- 
network deductible or out-of-pocket maxi-
mums applied under the plan or coverage, 
respectively (and such in-network deduct-
ible and out-of-pocket maximums shall be 
applied) in the same manner as if such 
cost-sharing payments were made with re-
spect to emergency services furnished by a 
participating provider or a participating 
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 
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this Act, including as incorporated pursuant to 
section 715 of the Employee Retirement Income 
Security Act of 1974 and section 9815 of the 
Internal Revenue Code of 1986, and other than 
applicable cost-sharing). 
‘‘(2) AUDIT PROCESS AND REGULATIONS FOR 
MEDIAN CONTRACTED RATES.— 
‘‘(A) AUDIT PROCESS.— 
‘‘(i) IN
GENERAL.—Not later than 
July 1, 2021, the Secretary, in consulta-
tion with appropriate State agencies and 
the Secretary of Labor and the Secretary 
of the Treasury, shall establish through 
rulemaking a process, in accordance with 
clause (ii), under which group health plans 
and health insurance issuers offering 
health insurance coverage in the group or 
individual market are audited by the Sec-
retary or applicable State authority to en-
sure that— 
‘‘(I) such plans and coverage are 
in compliance with the requirement of 
applying a median contracted rate 
under this section; and 
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‘‘(II) such median contracted 
rate so applied satisfies the definition 
under paragraph (3)(E) with respect 
to the year involved, including with re-
spect to a group health plan or health 
insurance issuer described in clause 
(ii) of such paragraph (3)(E). 
‘‘(ii) AUDIT
SAMPLES.—Under the 
process established pursuant to clause (i), 
the Secretary— 
‘‘(I) shall conduct audits de-
scribed 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 health insur-
ance issuers offering health insurance 
coverage in the group or individual 
market; and 
‘‘(II) may audit any group health 
plan or health insurance issuer offer-
ing health insurance coverage in the 
group or individual market if the Sec-
retary has received any complaint 
about such plan or coverage, respec-
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tively, that involves the compliance of 
the plan or coverage, respectively, 
with either of the requirements de-
scribed in subclauses (I) and (II) of 
such clause. 
‘‘(iii) REPORTS.—Beginning for 2022, 
the Secretary shall annually submit to 
Congress 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 
Secretary of Labor and the Secretary of the 
Treasury, shall establish through rulemaking— 
‘‘(i) the methodology the group health 
plan or health insurance issuer offering 
health insurance coverage in the group or 
individual market shall use to determine 
the median contracted rate, differentiating 
by line of business; 
‘‘(ii) the information such plan or 
issuer, respectively, shall share with the 
nonparticipating provider or nonpartici-
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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; 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 and health in-
surance issuers offering health insurance 
coverage in the group or individual market. 
Such rulemaking shall take into account pay-
ments that are made by such plan or issuer, re-
spectively, that are not on a fee-for-service 
basis. Such methodology may account for rel-
evant payment adjustments that take into ac-
count quality or facility type (including higher 
acuity settings and the case-mix of various fa-
cility types) that are otherwise taken into ac-
count for purposes of determining payment 
amounts with respect to participating facilities. 
In carrying out clause (iii), the Secretary shall 
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consult with the National Association of Insur-
ance Commissioners to establish the geographic 
regions under such clause and shall periodically 
update such regions, as appropriate. 
‘‘(3) DEFINITIONS.—In this part: 
‘‘(A) EMERGENCY DEPARTMENT OF A HOS-
PITAL.—The term ‘emergency department of a 
hospital’ includes a hospital outpatient depart-
ment that provides emergency services. 
‘‘(B) EMERGENCY MEDICAL CONDITION.— 
The term ‘emergency medical condition’ means 
a medical condition manifesting itself by acute 
symptoms of sufficient severity (including se-
vere pain) such that a prudent layperson, who 
possesses an average knowledge of health and 
medicine, could reasonably expect the absence 
of immediate medical attention to result in a 
condition described in clause (i), (ii), or (iii) of 
section 1867(e)(1)(A) of the Social Security 
Act. 
‘‘(C) EMERGENCY SERVICES.— 
‘‘(i) IN GENERAL.—The term ‘emer-
gency services’, with respect to an emer-
gency medical condition, means— 
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‘‘(I) a medical screening exam-
ination (as required under section 
1867 of the Social Security Act, or as 
would be required under such section 
if such section applied to an inde-
pendent freestanding emergency de-
partment) that is within the capability 
of the emergency department of a hos-
pital or of an independent free-
standing emergency department, as 
applicable, including ancillary services 
routinely available to the emergency 
department to evaluate such emer-
gency medical condition; and 
‘‘(II) within the capabilities of 
the staff and facilities available at the 
hospital or the independent free-
standing emergency department, as 
applicable, such further medical exam-
ination and treatment as are required 
under section 1867 of such Act, or as 
would be required under such section 
if such section applied to an inde-
pendent freestanding emergency de-
partment, to stabilize the patient. 
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‘‘(ii) INCLUSION
OF
CERTAIN
SERV-
ICES
OUTSIDE
OF
EMERGENCY
DEPART-
MENT.— 
‘‘(I) IN GENERAL.—For purposes 
of this subsection and section 2799A– 
1, in the case of an individual enrolled 
in a group health plan or health in-
surance coverage offered by a health 
insurance issuer in the group or indi-
vidual market who is furnished serv-
ices described in clause (i) by a par-
ticipating or nonparticipating provider 
or a participating or nonparticipating 
emergency facility to stabilize such in-
dividual with respect to an emergency 
medical condition, the term ‘emer-
gency services’ shall include, unless 
each of the conditions described in 
subclause (II) are met, in addition to 
the items and services described in 
clause (i), items and services for 
which benefits are provided or covered 
under the plan or coverage, respec-
tively, furnished by a nonparticipating 
provider or nonparticipating facility, 
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regardless of the department of the 
hospital in which such individual is 
furnished such items or services, if, 
after such stabilization but during 
such visit in which such individual is 
so stabilized, the provider or facility 
determines that such items or services 
are needed. 
‘‘(II) 
CONDITIONS.—For 
pur-
poses of subclause (I), the conditions 
described in this subclause, with re-
spect to an individual who is stabilized 
and furnished additional items and 
services described in subclause (I) 
after such stabilization by a provider 
or facility described in subclause (I), 
are the following: 
‘‘(aa) Such a provider or fa-
cility 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 
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consent 
criteria 
of 
section 
2799A–2(d) with respect to such 
items and services. 
‘‘(cc) Such an individual is 
in a condition to receive (as de-
termined 
in 
accordance 
with 
guidance issued by the Secretary) 
the information described in sec-
tion 2799A–2 and to provide in-
formed consent under such sec-
tion, in accordance with applica-
ble State law. 
‘‘(D) 
INDEPENDENT
FREESTANDING 
EMERGENCY
DEPARTMENT.—The term ‘inde-
pendent freestanding emergency department’ 
means a facility that— 
‘‘(i) is geographically separate and 
distinct and licensed separately from a hos-
pital under applicable State law; and 
‘‘(ii) provides any emergency services 
(as defined in subparagraph (C)). 
‘‘(E) MEDIAN CONTRACTED RATE.— 
‘‘(i) IN GENERAL.—The term ‘median 
contracted rate’ means, subject to clauses 
(ii) and (iii), with respect to a sponsor of 
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a group health plan and health insurance 
issuer offering health insurance coverage in 
the group or individual market— 
‘‘(I) for an item or service fur-
nished during 2022, the median of the 
contracted rates recognized by the 
plan or issuer, respectively (deter-
mined with respect to all such plans 
of such sponsor or all such coverage 
offered by such issuer that are offered 
within the same line of business as 
the plan or coverage) as the total 
maximum payment (including the 
cost-sharing amount imposed for such 
item or service and the amount to be 
paid by the plan or issuer, respec-
tively) under such plans or coverage, 
respectively, on January 31, 2019, for 
the same or a similar item or service 
that is provided 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 
Secretary 
under 
paragraph 
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(2)(B), increased 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 increase over 2021; 
and 
‘‘(II) for an item or service fur-
nished during 2023 or a subsequent 
year, the median contracted rate de-
termined under this clause for such 
an item or service furnished in the 
previous year, increased by the per-
centage increase in the consumer price 
index for all urban consumers (United 
States city average) over such pre-
vious year. 
‘‘(ii) NEW PLANS AND COVERAGE.— 
The term ‘median contracted rate’ means, 
with respect to a sponsor of a group health 
plan or health insurance issuer offering 
health insurance coverage in the group or 
individual market in a geographic region in 
which such sponsor or issuer, respectively, 
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did not offer any group health plan or 
health insurance coverage during 2019— 
‘‘(I) for the first year in which 
such group health plan or health in-
surance coverage, respectively, is of-
fered in such region, a rate (deter-
mined in accordance with a method-
ology established 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 or health in-
surance coverage, respectively, is of-
fered in such region, the median con-
tracted rate determined under this 
clause for such items and services fur-
nished in the previous year, increased 
by the percentage increase in the con-
sumer price index for all urban con-
sumers (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 
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plan or health insurance issuer offering 
health insurance coverage in the group or 
individual market that does not have suffi-
cient 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 (iv)(III)), in the first coverage year 
(as defined in clause (iv)(I)) for such item 
or service with respect to such plan or cov-
erage) for an item or service (including 
with respect to provider type, or amount, 
of claims for items or services (as deter-
mined by the Secretary) provided in a par-
ticular geographic region (other than in a 
case with respect to which clause (ii) ap-
plies)) the term ‘median contracted rate’— 
‘‘(I) for an item or service fur-
nished during 2022 (or, in the case of 
a newly covered item or service, dur-
ing the first coverage year for such 
item or service with respect to such 
plan or coverage), means such rate for 
such item or service determined by 
the sponsor or issuer, respectively, 
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through use of any database that is 
determined, in accordance with rule-
making 
described 
in 
paragraph 
(2)(B), to not have any conflicts of in-
terest and to have sufficient informa-
tion reflecting allowed amounts paid 
to a health care provider or facility for 
relevant services furnished in the ap-
plicable geographic 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 defined in clause (iv)(II)) for such 
item or service with respect to such 
plan or coverage), means the rate de-
termined under subclause (I) or this 
subclause, as applicable, for such item 
or service for the year previous to 
such subsequent year, increased by 
the percentage increase in the con-
sumer price index for all urban con-
sumers (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 or coverage, has 
the meaning given the term median 
contracted rate in clause (i)(I), except 
that in applying such clause to such 
item or service, the reference to ‘fur-
nished during 2022’ shall be treated 
as a reference to furnished during 
such first sufficient information year, 
the reference to ‘in 2019’ shall be 
treated as a reference to such suffi-
cient 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 or coverage, has the mean-
ing given such term in clause (i)(II), 
except that in applying such clause to 
such item or service, the reference to 
‘furnished during 2023 or a subse-
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‘‘(aa) in the case of an item 
or service for which the plan or 
coverage does not have sufficient 
information to calculate the me-
dian of the contracted rates de-
scribed in clause (i)(I) in 2019, 
the first year subsequent to 2022 
for which the sponsor or issuer 
has such sufficient information to 
calculate the median of such con-
tracted 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 serv-
ice with respect to such plan or 
coverage for which the sponsor or 
issuer has sufficient information 
to calculate the median of the 
contracted rates described in 
clause (i)(I) in the year previous 
to such first subsequent year. 
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‘‘(III) NEWLY COVERED ITEM OR 
SERVICE.—The term ‘newly covered 
item or service’ means, with respect to 
a group health plan or health insur-
ance issuer offering health insurance 
coverage in the group or individual 
market, 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
FACIL-
ITY.— 
‘‘(i) NONPARTICIPATING
EMERGENCY 
FACILITY.—The 
term 
‘nonparticipating 
emergency facility’ means, with respect to 
an item or service and a group health plan 
or health insurance coverage offered by a 
health insurance issuer in the group or in-
dividual market, an emergency department 
of a hospital, or an independent free-
standing emergency department, that does 
not have a contractual relationship directly 
or indirectly with the plan or issuer, re-
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spectively, for furnishing such item or serv-
ice under the plan or coverage, respec-
tively. 
‘‘(ii) PARTICIPATING EMERGENCY FA-
CILITY.—The term ‘participating emer-
gency facility’ means, with respect to an 
item or service and a group health plan or 
health insurance coverage offered by a 
health insurance issuer in the group or in-
dividual market, an emergency department 
of a hospital, or an independent free-
standing emergency department, that has 
a contractual relationship directly or indi-
rectly with the plan or issuer, respectively, 
with respect 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 or health insur-
ance coverage offered by a health insur-
ance issuer in the group or individual mar-
ket, a physician or other health care pro-
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vider who is acting within the scope of 
practice of that provider’s license or certifi-
cation under applicable 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 or coverage, respectively. 
‘‘(ii) PARTICIPATING PROVIDER.—The 
term ‘participating provider’ means, with 
respect to an item or service and a group 
health plan or health insurance coverage 
offered by a health insurance issuer in the 
group or individual market, 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 has a contractual 
relationship with the plan or issuer, respec-
tively, for furnishing such item or service 
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 emergency facility during a year 
and a group health plan or health insurance 
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coverage offered by a health insurance issuer in 
the group or individual market— 
‘‘(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, respectively, such a nonpartici-
pating provider or 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 
of such item or service furnished in a State 
that does not have in effect a specified 
State law, with respect to such plan, cov-
erage, or issuer, respectively, such a non-
participating provider or emergency facil-
ity, and such an item or service, an 
amount that is the median contracted rate 
(as defined in subparagraph (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 
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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 emergency facility dur-
ing a year and a group health plan or health in-
surance coverage offered by a health insurance 
issuer in the group or individual market, a 
State law that provides for a method for deter-
mining the amount of payment that is required 
to be covered by such a plan, coverage, or 
issuer, respectively (to the extent such State 
law applies to such plan, coverage, or issuer, 
subject to section 514 of the Employee Retire-
ment Income Security Act of 1974) in the case 
of a participant, beneficiary, or enrollee covered 
under such plan or coverage and receiving such 
item or service from such a nonparticipating 
provider or emergency facility. 
‘‘(J) STABILIZE.—The term ‘to stabilize’, 
with respect to an emergency medical condition 
(as defined in subparagraph (B)), has the 
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meaning give in section 1867(e)(3) of the Social 
Security Act (42 U.S.C. 1395dd(e)(3)).’’; and 
(2) by adding at the end the following new sub-
sections: 
‘‘(e) COVERAGE
OF
NON-EMERGENCY
SERVICES 
PERFORMED BY NONPARTICIPATING PROVIDERS AT CER-
TAIN PARTICIPATING FACILITIES.— 
‘‘(1) IN
GENERAL.—In the case of items or 
services (other than emergency services to which 
subsection (b) applies) for which any benefits are 
provided or covered by a group health plan or health 
insurance issuer offering health insurance coverage 
in the group or individual market furnished to a 
participant, beneficiary, or enrollee of such plan or 
coverage by a nonparticipating provider (as defined 
in subsection (b)(3)(G)(i)) (and who, with respect to 
such items and services, has not satisfied the notice 
and consent criteria of section 2799A–2(d)) with re-
spect to a visit (as defined by the Secretary in ac-
cordance with paragraph (2)(B)) at a participating 
health care facility (as defined in paragraph (2)(A)), 
with respect to such plan or coverage, respectively, 
the plan or coverage, respectively— 
‘‘(A) shall not impose on such participant, 
beneficiary, or enrollee a cost-sharing amount 
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(expressed as a copayment amount or coinsur-
ance rate) for such items and services so fur-
nished that is greater than the cost-sharing 
amount that would apply under such plan or 
coverage, respectively, had such items or serv-
ices been furnished by a participating provider 
(as defined in subsection (b)(3)(G)(ii)); 
‘‘(B) shall calculate such cost-sharing 
amount as if the total amount that would have 
been charged for such items and services by 
such participating provider were equal to the 
recognized amount (as defined in subsection 
(b)(3)(H)) for such items and services, plan or 
coverage, and year; 
‘‘(C) shall pay to such provider furnishing 
such items and services to such participant, 
beneficiary, or enrollee the amount by which the 
recognized amount (as defined in subsection 
(b)(3)(H)) for such items and services and year 
involved exceeds the cost-sharing amount im-
posed under the plan or coverage, respectively, 
for such items and services (as determined in 
accordance with subparagraphs (A) and (B)); 
and 
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‘‘(D) shall count toward any in-network 
deductible and in-network out-of-pocket maxi-
mums (as applicable) applied under the plan or 
coverage, respectively, any cost-sharing pay-
ments made by the participant, beneficiary, or 
enrollee (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 or health insurance issuer of-
fering health insurance coverage in the 
group or individual market, a health care 
facility described in clause (ii) that has a 
contractual relationship with the plan or 
issuer, respectively, with respect to the fur-
nishing of such an item or service at the 
facility. 
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‘‘(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 
offered 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) of 
such Act). 
‘‘(IV) An ambulatory surgical 
center 
(as 
defined 
in 
section 
1833(i)(1)(A) of such Act). 
‘‘(V) Any other facility that pro-
vides items or services for which cov-
erage is provided under the plan or 
coverage, respectively. 
‘‘(B) VISIT.—The term ‘visit’ shall, with 
respect to items and services furnished to an in-
dividual at a participating health care facility, 
include equipment and devices, telemedicine 
services, imaging services, laboratory services, 
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and such other items and services as the Sec-
retary may specify, regardless of whether or not 
the provider furnishing such items or services is 
at the facility. 
‘‘(f) AIR AMBULANCE SERVICES.— 
‘‘(1) IN GENERAL.—In the case of a partici-
pant, beneficiary, or enrollee in a group health plan 
or health insurance coverage offered in the group or 
individual market who receives air ambulance serv-
ices from a nonparticipating provider (as defined in 
subsection (b)(3)(G)) with respect to such plan or 
coverage, if such services would be covered if pro-
vided by a participating provider (as defined in such 
section) with respect to such plan or coverage— 
‘‘(A) the cost-sharing requirement (ex-
pressed as a copayment amount, coinsurance 
rate, or deductible) with respect to such services 
shall be the same requirement that would apply 
if such services were provided by such a partici-
pating provider, and any coinsurance or deduct-
ible shall be based on rates that would apply for 
such services if they were furnished by such a 
participating provider; 
‘‘(B) such cost-sharing amounts shall be 
counted toward the in-network deductible and 
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in-network out-of-pocket maximum amount 
under the plan or coverage for the plan year 
(and such in-network deductible shall be ap-
plied) with respect to such items and services so 
furnished in the same manner as if such cost- 
sharing payments were with respect to items 
and services furnished by a participating pro-
vider; and 
‘‘(C) the plan or coverage shall pay to such 
provider furnishing such services to such partic-
ipant, beneficiary, or enrollee the amount by 
which the recognized amount (as defined in and 
determined 
pursuant 
to 
subsection 
(b)(3)(H)(ii)) for such services and year in-
volved exceeds the cost-sharing amount imposed 
under the plan or coverage, respectively, for 
such services (as determined in accordance with 
subparagraphs (A) and (B)). 
‘‘(2) AIR AMBULANCE SERVICE DEFINED.—For 
purposes of this section, the term ‘air ambulance 
service’ means medical transport by helicopter or 
airplane for patients. 
‘‘(g) CERTAIN ACCESS FEES TO CERTAIN DATA-
BASES.—In the case of a sponsor of a group health plan 
or health insurance issuer offering health insurance cov-
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erage in the group or individual market that, pursuant to 
subsection (b)(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 insuf-
ficient information described in such subsection with re-
spect to such item or service, such sponsor or issuer shall 
cover the cost for access to such database.’’. 
(b) ERISA AMENDMENTS.— 
(1) IN GENERAL.—Subpart B of part 7 of sub-
title B of title I of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1185 et seq.) is 
amended by adding at the end the following: 
‘‘SEC. 716. CONSUMER PROTECTIONS. 
‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If 
a group health plan or 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 or beneficiary to designate any 
participating primary care provider who is available to ac-
cept such individual. 
‘‘(b) COVERAGE OF EMERGENCY SERVICES.— 
‘‘(1) IN GENERAL.—If a group health plan, or 
a health insurance issuer offering group health in-
surance coverage, provides or covers any benefits 
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with respect to services in an emergency department 
of a hospital or with respect to emergency services 
in an independent freestanding emergency depart-
ment (as defined in paragraph (3)(D)), the plan or 
issuer shall cover emergency services (as defined in 
paragraph (3)(C))— 
‘‘(A) without the need for any prior au-
thorization determination; 
‘‘(B) whether the health care provider fur-
nishing such services is a participating provider 
or a participating 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-
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spect to such plan or coverage, respec-
tively; 
‘‘(ii) the cost-sharing requirement (ex-
pressed as a copayment amount or coinsur-
ance rate) is not greater than the require-
ment that would 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 partici-
pating emergency facility were equal to the 
recognized amount (as defined in para-
graph (3)(H)) for such services, plan or 
coverage, and year; 
‘‘(iv) the group health plan or health 
insurance issuer, respectively, pays to such 
provider 
or 
facility, 
respectively, 
the 
amount by which the recognized amount 
for such services and year involved exceeds 
the cost-sharing amount for such services 
(as determined in accordance with clauses 
(ii) and (iii)) and year; and 
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‘‘(v) 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 maxi-
mums applied under the plan or coverage, 
respectively (and such in-network deduct-
ible and out-of-pocket maximums shall be 
applied) in the same manner as if such 
cost-sharing payments were made with re-
spect to emergency services furnished by a 
participating provider or a participating 
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 this Act 
and section 9815 of the Internal Revenue Code 
of 1986, and other than applicable cost-shar-
ing). 
‘‘(2) AUDIT PROCESS AND REGULATIONS FOR 
MEDIAN CONTRACTED RATES.— 
‘‘(A) AUDIT PROCESS.— 
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‘‘(i) IN
GENERAL.—Not later than 
July 1, 2021, the Secretary, in consulta-
tion with appropriate State agencies and 
the Secretary of Health and Human Serv-
ices and the Secretary of the Treasury, 
shall establish through rulemaking a proc-
ess, in accordance with clause (ii), under 
which group health plans and health insur-
ance issuers offering health insurance cov-
erage in the group market are audited by 
the Secretary or applicable State authority 
to ensure that— 
‘‘(I) such plans and coverage are 
in compliance with the requirement of 
applying a median contracted rate 
under this section; and 
‘‘(II) such median contracted 
rate so applied satisfies the definition 
under paragraph (3)(E) with respect 
to the year involved, including with re-
spect to a group health plan or health 
insurance issuer described in clause 
(ii) of such paragraph (3)(E). 
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‘‘(ii) AUDIT
SAMPLES.—Under the 
process established pursuant to clause (i), 
the Secretary— 
‘‘(I) shall conduct audits de-
scribed 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 health insur-
ance issuers offering health insurance 
coverage in the group market; and 
‘‘(II) may audit any group health 
plan or health insurance issuer offer-
ing health insurance coverage in the 
group market if the Secretary has re-
ceived any complaint about such plan 
or coverage, respectively, that involves 
the compliance of the plan or cov-
erage, respectively, 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 
Congress information on the number of 
plans and issuers with respect to which au-
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dits were conducted during such year pur-
suant to this subparagraph. 
‘‘(B) RULEMAKING.—Not later than July 
1, 2021, the Secretary, in consultation with the 
Secretary of the Treasury and the Secretary of 
Health and Human Services, shall establish 
through rulemaking— 
‘‘(i) the methodology the group health 
plan or health insurance issuer offering 
health insurance coverage in the group 
market shall use to determine the median 
contracted rate, differentiating by line of 
business; 
‘‘(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 
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‘‘(iv) a process to receive complaints 
of violations of the requirements described 
in subclauses (I) and (II) of paragraph 
(2)(A)(i) by group health plans and health 
insurance issuers offering health insurance 
coverage in the group market. 
Such rulemaking shall take into account pay-
ments that are made by such plan or issuer, re-
spectively, that are not on a fee-for-service 
basis. Such methodology may account for rel-
evant payment adjustments that take into ac-
count quality or facility type (including higher 
acuity settings and the case-mix of various fa-
cility types) that are otherwise taken into ac-
count for purposes of determining payment 
amounts with respect to participating facilities. 
In carrying out clause (iii), the Secretary shall 
consult with the National Association of Insur-
ance Commissioners to establish the geographic 
regions under such clause and shall periodically 
update such regions, as appropriate. 
‘‘(3) DEFINITIONS.—In this section: 
‘‘(A) EMERGENCY DEPARTMENT OF A HOS-
PITAL.—The term ‘emergency department of a 
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hospital’ includes a hospital outpatient depart-
ment that provides emergency services. 
‘‘(B) EMERGENCY MEDICAL CONDITION.— 
The term ‘emergency medical condition’ means 
a medical condition manifesting itself by acute 
symptoms of sufficient severity (including se-
vere pain) such that a prudent layperson, who 
possesses an average knowledge of health and 
medicine, could reasonably expect the absence 
of immediate medical attention to result in a 
condition described in clause (i), (ii), or (iii) of 
section 1867(e)(1)(A) of the Social Security 
Act. 
‘‘(C) EMERGENCY SERVICES.— 
‘‘(i) IN GENERAL.—The term ‘emer-
gency services’, with respect to an emer-
gency medical condition, means— 
‘‘(I) a medical screening exam-
ination (as required under section 
1867 of the Social Security Act, or as 
would be required under such section 
if such section applied to an inde-
pendent freestanding emergency de-
partment) that is within the capability 
of the emergency department of a hos-
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pital or of an independent free-
standing emergency department, as 
applicable, including ancillary services 
routinely available to the emergency 
department to evaluate such emer-
gency medical condition; and 
‘‘(II) within the capabilities of 
the staff and facilities available at the 
hospital or the independent free-
standing emergency department, as 
applicable, such further medical exam-
ination and treatment as are required 
under section 1867 of such Act, or as 
would be required under such section 
if such section applied to an inde-
pendent freestanding emergency de-
partment, to stabilize the patient. 
‘‘(ii) INCLUSION
OF
CERTAIN
SERV-
ICES
OUTSIDE
OF
EMERGENCY
DEPART-
MENT.— 
‘‘(I) IN GENERAL.—For purposes 
of this subsection and section 2799A– 
1, in the case of an individual enrolled 
in a group health plan or health in-
surance coverage offered by a health 
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insurance issuer in the group or indi-
vidual market who is furnished serv-
ices described in clause (i) by a par-
ticipating or nonparticipating provider 
or a participating or nonparticipating 
emergency facility to stabilize such in-
dividual with respect to an emergency 
medical condition, the term ‘emer-
gency services’ shall include, unless 
each of the conditions described in 
subclause (II) are met, in addition to 
the items and services described in 
clause (i), items and services for 
which benefits are provided or covered 
under the plan or coverage, respec-
tively, furnished by a nonparticipating 
provider or nonparticipating facility, 
regardless of the department of the 
hospital in which such individual is 
furnished such items or services, if, 
after such stabilization but during 
such visit in which such individual is 
so stabilized, the provider or facility 
determines that such items or services 
are needed. 
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‘‘(II) 
CONDITIONS.—For 
pur-
poses of subclause (I), the conditions 
described in this subclause, with re-
spect to an individual who is stabilized 
and furnished additional items and 
services described in subclause (I) 
after such stabilization by a provider 
or facility described in subclause (I), 
are the following: 
‘‘(aa) Such a provider or fa-
cility 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 
2799A–2(d) of the Public Health 
Service Act with respect to such 
items and services. 
‘‘(cc) Such an individual is 
in a condition to receive (as de-
termined 
in 
accordance 
with 
guidance issued by the Secretary) 
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the information described in sec-
tion 2799A–2 of the Public 
Health Service Act and to pro-
vide informed consent under such 
section, in accordance with appli-
cable State law. 
‘‘(D) 
INDEPENDENT
FREESTANDING 
EMERGENCY
DEPARTMENT.—The term ‘inde-
pendent freestanding emergency department’ 
means a facility that— 
‘‘(i) is geographically separate and 
distinct and licensed separately from a hos-
pital under applicable State law; and 
‘‘(ii) provides any emergency services 
(as defined in subparagraph (C)). 
‘‘(E) MEDIAN CONTRACTED RATE.— 
‘‘(i) IN GENERAL.—The term ‘median 
contracted rate’ means, subject to clauses 
(ii) and (iii), with respect to a sponsor of 
a group health plan and health insurance 
issuer offering health insurance coverage in 
the group market— 
‘‘(I) for an item or service fur-
nished during 2022, the median of the 
contracted rates recognized by the 
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plan or issuer, respectively (deter-
mined with respect to all such plans 
of such sponsor or all such coverage 
offered by such issuer that are offered 
within the same line of business as 
the plan or coverage) as the total 
maximum payment (including the 
cost-sharing amount imposed for such 
item or service and the amount to be 
paid by such plan or such issuer, re-
spectively) under such plans or cov-
erage, respectively, on January 31, 
2019, for the same or a similar item 
or service that is provided by a pro-
vider in the same or similar specialty 
and provided in the geographic region 
in which the item or service is fur-
nished, consistent with the method-
ology established by the Secretary 
under paragraph (2)(B), increased by 
the percentage increase in the con-
sumer price index for all urban con-
sumers (United States city average) 
over 2019, such percentage increase 
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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 median contracted rate de-
termined under this clause for such 
an item or service furnished in the 
previous year, increased by the per-
centage increase in the consumer price 
index for all urban consumers (United 
States city average) over such pre-
vious year. 
‘‘(ii) NEW PLANS AND COVERAGE.— 
The term ‘median contracted rate’ means, 
with respect to a sponsor of a group health 
plan or health insurance issuer offering 
health insurance coverage in the group 
market in a geographic region in which 
such sponsor or issuer, respectively, did 
not offer any group health plan or health 
insurance coverage during 2019— 
‘‘(I) for the first year in which 
such group health plan or health in-
surance coverage, respectively, is of-
fered in such region, a rate (deter-
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mined in accordance with a method-
ology established 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 or health in-
surance coverage, respectively, is of-
fered in such region, the median con-
tracted rate determined under this 
clause for such items and services fur-
nished in the previous year, increased 
by the percentage increase in the con-
sumer price index for all urban con-
sumers (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 or health insurance issuer offering 
health insurance coverage in the group 
market that does not have sufficient infor-
mation to calculate the median of the con-
tracted rates described in clause (i)(I) in 
2019 (or, in the case of a newly covered 
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item or service (as defined in clause 
(iv)(III)), in the first coverage year (as de-
fined in clause (iv)(I)) for such item or 
service with respect to such plan or cov-
erage) for an item or service (including 
with respect to provider type, or amount, 
of claims for items or services (as deter-
mined by the Secretary) provided in a par-
ticular geographic region (other than in a 
case with respect to which clause (ii) ap-
plies)) the term ‘median contracted rate’— 
‘‘(I) for an item or service fur-
nished during 2022 (or, in the case of 
a newly covered item or service, dur-
ing the first coverage year for such 
item or service with respect to such 
plan or coverage), means such rate for 
such item or service determined by 
the sponsor or issuer, respectively, 
through use of any database that is 
determined, in accordance with rule-
making 
described 
in 
paragraph 
(2)(B), to not have any conflicts of in-
terest and to have sufficient informa-
tion reflecting allowed amounts paid 
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to a health care provider or facility for 
relevant services furnished in the ap-
plicable geographic 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 defined in clause (iv)(II)) for such 
item or service with respect to such 
plan or coverage), means the rate de-
termined under subclause (I) or this 
subclause, as applicable, for such item 
or service for the year previous to 
such subsequent year, increased by 
the percentage increase in the con-
sumer price index for all urban con-
sumers (United States city average) 
over such previous year; 
‘‘(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 or coverage, has 
the meaning given the term median 
contracted rate in clause (i)(I), except 
that in applying such clause to such 
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item or service, the reference to ‘fur-
nished during 2022’ shall be treated 
as a reference to furnished during 
such first sufficient information year, 
the reference to ‘in 2019’ shall be 
treated as a reference to such suffi-
cient 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 or coverage, has the mean-
ing given such term in clause (i)(II), 
except that in applying such clause to 
such item or service, the reference to 
‘furnished during 2023 or a subse-
quent year’ shall be treated as a ref-
erence to furnished during the year 
after such first sufficient information 
year or a subsequent year. 
‘‘(iv) DEFINITIONS.—For purposes of 
this subparagraph: 
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‘‘(I) FIRST
COVERAGE
YEAR.— 
The term ‘first coverage year’ means, 
with respect to a group health plan or 
health insurance coverage offered by a 
health insurance issuer in the group 
market and an item or service for 
which coverage is not offered in 2019 
under such plan or coverage, the first 
year after 2019 for which coverage for 
such item or service is offered under 
such plan or health insurance cov-
erage. 
‘‘(II) FIRST SUFFICIENT INFOR-
MATION YEAR.—The term ‘first suffi-
cient information year’ means, with 
respect to a group health plan or 
health insurance coverage offered by a 
health insurance issuer in the group 
market— 
‘‘(aa) in the case of an item 
or service for which the plan or 
coverage does not have sufficient 
information to calculate the me-
dian of the contracted rates de-
scribed in clause (i)(I) in 2019, 
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the first year subsequent to 2022 
for which such sponsor or issuer 
has such sufficient information to 
calculate the median of such con-
tracted 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 serv-
ice with respect to such plan or 
coverage for which the sponsor or 
issuer has sufficient information 
to calculate the median of the 
contracted rates described 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 or health insur-
ance issuer offering health insurance 
coverage in the group market, an item 
or service for which coverage was not 
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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
FACIL-
ITY.— 
‘‘(i) NONPARTICIPATING
EMERGENCY 
FACILITY.—The 
term 
‘nonparticipating 
emergency facility’ means, with respect to 
an item or service and a group health plan 
or health insurance coverage offered by a 
health insurance issuer in the group mar-
ket, an emergency department of a hos-
pital, or an independent freestanding emer-
gency department, that does not have a 
contractual relationship directly or indi-
rectly with the plan or issuer, respectively, 
for furnishing such item or service under 
the plan or coverage, respectively. 
‘‘(ii) PARTICIPATING EMERGENCY FA-
CILITY.—The term ‘participating emer-
gency facility’ means, with respect to an 
item or service and a group health plan or 
health insurance coverage offered by a 
health insurance issuer in the group mar-
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ket, an emergency department of a hos-
pital, or an independent freestanding emer-
gency department, that has a contractual 
relationship directly or indirectly with the 
plan or issuer, respectively, with respect 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 or health insur-
ance coverage offered by a health insur-
ance issuer in the group market, a physi-
cian 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 does not have 
a contractual relationship with the plan or 
issuer, respectively, for furnishing such 
item or service under the plan or coverage, 
respectively. 
‘‘(ii) PARTICIPATING PROVIDER.—The 
term ‘participating provider’ means, with 
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respect to an item or service and a group 
health plan or health insurance coverage 
offered by a health insurance issuer in the 
group market, a physician or other health 
care provider who is acting within the 
scope of practice of that provider’s license 
or certification under applicable State law 
and who has a contractual relationship 
with the plan or issuer, respectively, for 
furnishing such item or service 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 emergency facility during a year 
and a group health plan or health insurance 
coverage offered by a health insurance issuer in 
the group market— 
‘‘(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, respectively, such a nonpartici-
pating provider or emergency facility, and 
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such an item or service, the amount deter-
mined 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, cov-
erage, or issuer, respectively, such a non-
participating provider or emergency facil-
ity, and such an item or service, an 
amount that is the median contracted rate 
(as defined in subparagraph (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 emergency facility dur-
ing a year and a group health plan or health in-
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surance coverage offered by a health insurance 
issuer in the group market, a State law that 
provides for a method for determining the 
amount of payment that is required to be cov-
ered by such a plan, coverage, or issuer, respec-
tively (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 receiv-
ing such item or service from such a nonpartici-
pating provider or emergency facility. 
‘‘(J) STABILIZE.—The term ‘to stabilize’, 
with respect to an emergency medical condition 
(as defined in subparagraph (B)), has the 
meaning give in section 1867(e)(3) of the Social 
Security Act (42 U.S.C. 1395dd(e)(3)). 
‘‘(c) 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 health insurance cov-
erage offered by a health insurance issuer in the 
group market, if the plan or issuer requires or pro-
vides for the designation of a participating primary 
care provider for the child, the plan or issuer shall 
permit such person to designate a physician 
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(allopathic or osteopathic) who specializes in pediat-
rics as the child’s primary care provider if such pro-
vider participates in the network of the plan or 
issuer. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph 
(1) shall be construed to waive any exclusions of cov-
erage under the terms and conditions of the plan or 
health insurance coverage with respect to coverage 
of pediatric care. 
‘‘(d) PATIENT ACCESS TO OBSTETRICAL AND GYNE-
COLOGICAL 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 partici-
pant or beneficiary who seeks coverage for ob-
stetrical or gynecological care provided by a 
participating health care professional who spe-
cializes in obstetrics or gynecology. Such profes-
sional shall agree to otherwise adhere to such 
plan’s or issuer’s policies and procedures, in-
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cluding procedures regarding referrals and ob-
taining prior authorization and providing serv-
ices pursuant to a treatment plan (if any) ap-
proved by the plan or issuer. 
‘‘(B) OBSTETRICAL AND GYNECOLOGICAL 
CARE.—A group health plan or health insur-
ance issuer described in paragraph (2) shall 
treat the provision of obstetrical and gyneco-
logical care, and the ordering of related obstet-
rical and gynecological items and services, pur-
suant to the direct access described under sub-
paragraph (A), by a participating health care 
professional who specializes in obstetrics or 
gynecology as the authorization of the primary 
care provider. 
‘‘(2) APPLICATION OF PARAGRAPH.—A group 
health plan, or health insurance issuer offering 
group health insurance coverage, described in this 
paragraph 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 cov-
erage of obstetrical or gynecological care; or 
‘‘(B) preclude the group health plan or 
health insurance issuer involved from requiring 
that the obstetrical or gynecological provider 
notify the primary care health care professional 
or the plan or issuer of treatment decisions. 
‘‘(e) COVERAGE
OF
NON-EMERGENCY
SERVICES 
PERFORMED BY NONPARTICIPATING PROVIDERS AT CER-
TAIN PARTICIPATING FACILITIES.— 
‘‘(1) IN
GENERAL.—In the case of items or 
services (other than emergency services to which 
subsection (b) applies) for which any benefits are 
provided or covered by a group health plan or health 
insurance issuer offering health insurance coverage 
in the group market furnished to a participant or 
beneficiary of such plan or coverage by a nonpartici-
pating 
provider 
(as 
defined 
in 
subsection 
(b)(3)(G)(i)) (and who, with respect to such items 
and services, has not satisfied the notice and consent 
criteria of section 2799A–2(d) of the Public Health 
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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 
paragraph (2)(A)), with respect to such plan or cov-
erage, respectively, the plan or coverage, respec-
tively— 
‘‘(A) shall not impose on such participant 
or beneficiary a cost-sharing amount (expressed 
as a copayment amount or coinsurance rate) for 
such items and services so furnished that is 
greater than the cost-sharing amount that 
would apply under such plan or coverage, re-
spectively, had such items or services been fur-
nished by a participating provider (as defined in 
subsection (b)(3)(G)(ii)); 
‘‘(B) shall calculate such cost-sharing 
amount as if the total amount that would have 
been charged for such items and services by 
such participating provider were equal to the 
recognized amount (as defined in subsection 
(b)(3)(H)) for such items and services, plan or 
coverage, and year; 
‘‘(C) shall pay to such provider furnishing 
such items and services to such participant or 
beneficiary the amount by which the recognized 
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amount (as defined in subsection (b)(3)(H)) for 
such items and services and year involved ex-
ceeds 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 
‘‘(D) shall count toward any in-network 
deductible and in-network out-of-pocket maxi-
mums (as applicable) applied under the plan or 
coverage, respectively, any cost-sharing pay-
ments 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 payments 
were with respect to items and services fur-
nished 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 or health insurance issuer of-
fering health insurance coverage in the 
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group market, a health care facility de-
scribed in clause (ii) that has a contractual 
relationship 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 health insurance coverage 
offered in the group 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) of 
such Act). 
‘‘(IV) An ambulatory surgical 
center 
(as 
defined 
in 
section 
1833(i)(1)(A) of such Act). 
‘‘(V) Any other facility that pro-
vides items or services for which cov-
erage is provided under the plan or 
coverage, respectively. 
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‘‘(B) VISIT.—The term ‘visit’ shall, with 
respect to items and services furnished to an in-
dividual at a participating health care facility, 
include equipment and devices, telemedicine 
services, imaging services, laboratory services, 
and such other items and services as the Sec-
retary may specify, regardless of whether or not 
the provider furnishing such items or services is 
at the facility. 
‘‘(f) AIR AMBULANCE SERVICES.— 
‘‘(1) IN GENERAL.—In the case of a participant 
or beneficiary in a group health plan or health insur-
ance coverage offered in the group market who re-
ceives air ambulance services from a nonpartici-
pating provider (as defined in subsection (b)(3)(G)) 
with respect to such plan or coverage, if such serv-
ices would be covered if provided by a participating 
provider (as defined in such subsection) with respect 
to such plan or coverage— 
‘‘(A) the cost-sharing requirement (ex-
pressed as a copayment amount, coinsurance 
rate, or deductible) with respect to such services 
shall be the same requirement that would apply 
if such services were provided by such a partici-
pating provider, and any coinsurance or deduct-
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ible shall be based on rates that would apply for 
such services if they were furnished by such a 
participating provider; 
‘‘(B) such cost-sharing amounts shall be 
counted toward the in-network deductible and 
in-network out-of-pocket maximum amount 
under the plan or coverage for the plan year 
(and such in-network deductible shall be ap-
plied) with respect to such items and services so 
furnished in the same manner as if such cost- 
sharing payments were with respect to items 
and services furnished by a participating pro-
vider; and 
‘‘(C) the plan or coverage shall pay to such 
provider furnishing such services to such partic-
ipant or beneficiary the amount by which the 
recognized amount (as defined in and deter-
mined pursuant to subsection (b)(3)(H)(ii)) for 
such services and year involved exceeds the 
cost-sharing amount imposed under the plan or 
coverage, respectively, for such services (as de-
termined in accordance with subparagraphs (A) 
and (B)). 
‘‘(2) AIR AMBULANCE SERVICE DEFINED.—For 
purposes of this section, the term ‘air ambulance 
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service’ means medical transport by helicopter or 
airplane for patients. 
‘‘(g) CERTAIN ACCESS FEES TO CERTAIN DATA-
BASES.—In the case of a sponsor of a group health plan 
or health insurance issuer offering health insurance cov-
erage in the group market that, pursuant to subsection 
(b)(3)(E)(iii), uses a database described in such sub-
section to determine a rate to apply under such subsection 
for an item or service by reason of having insufficient in-
formation 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) CLERICAL AMENDMENT.—The table of con-
tents of the Employee Retirement Income Security 
Act of 1974 is amended by inserting after the item 
relating to section 714 the following: 
‘‘Sec. 715. Additional market reforms. 
‘‘Sec. 716. Consumer protections.’’. 
(c) IRC AMENDMENTS.— 
(1) IN
GENERAL.—Subchapter B of chapter 
100 of the Internal Revenue Code of 1986 is amend-
ed by adding at the end the following: 
‘‘SEC. 9816. CONSUMER 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 
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care provider, then the plan shall permit each participant 
or beneficiary to designate any participating primary care 
provider who is available to accept such individual. 
‘‘(b) 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-
spect to emergency services in an independent free-
standing emergency department (as defined in para-
graph (3)(D)), the plan shall cover emergency serv-
ices (as defined in paragraph (3)(C))— 
‘‘(A) without the need for any prior au-
thorization determination; 
‘‘(B) whether the health care provider fur-
nishing such services is a participating provider 
or a participating 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 
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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 (ex-
pressed as a copayment amount or coinsur-
ance rate) is not greater than the require-
ment that would 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 partici-
pating emergency facility were equal to the 
recognized amount (as defined in para-
graph (3)(H)) for such services, plan, and 
year; 
‘‘(iv) the group health plan pays to 
such provider or facility, respectively, the 
amount by which the recognized amount 
for such services and year involved exceeds 
the cost-sharing amount for such services 
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(as determined in accordance with clauses 
(ii) and (iii)) and year; and 
‘‘(v) 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 maxi-
mums applied under the plan (and such in- 
network deductible and out-of-pocket maxi-
mums shall be applied) in the same man-
ner as if such cost-sharing payments were 
made with respect to emergency services 
furnished by a participating provider or a 
participating 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 
this Act, including as incorporated pursuant to 
section 715 of the Employee Retirement Income 
Security Act of 1974 and section 9815 of this 
Act, and other than applicable cost-sharing). 
‘‘(2) AUDIT PROCESS AND REGULATIONS FOR 
MEDIAN CONTRACTED RATES.— 
‘‘(A) AUDIT PROCESS.— 
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‘‘(i) IN
GENERAL.—Not later than 
July 1, 2021, the Secretary, in consulta-
tion with appropriate State agencies and 
the Secretary of Health and Human Serv-
ices and the Secretary of Labor, shall es-
tablish 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 
median contracted rate under this sec-
tion; and 
‘‘(II) such median contracted 
rate so applied satisfies the definition 
under paragraph (3)(E) with respect 
to the year involved, including with re-
spect to a group health plan described 
in clause (ii) of such paragraph 
(3)(E). 
‘‘(ii) AUDIT
SAMPLES.—Under the 
process established pursuant to clause (i), 
the Secretary— 
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‘‘(I) shall conduct audits de-
scribed 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 about such plan or cov-
erage, respectively, that involves the 
compliance of the plan with either of 
the requirements described in sub-
clauses (I) and (II) of such clause. 
‘‘(iii) REPORTS.—Beginning for 2022, 
the Secretary shall annually submit to 
Congress 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 
Secretary of Labor and the Secretary of Health 
and Human Services, shall establish through 
rulemaking— 
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‘‘(i) the methodology the group health 
plan shall use to determine the median 
contracted rate, differentiating by line of 
business; 
‘‘(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 paragraph 
(2)(A)(i) by group health plans. 
Such rulemaking shall take into account pay-
ments that are made by such plan that are not 
on a fee-for-service basis. Such methodology 
may account for relevant payment adjustments 
that take into account quality or facility type 
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(including higher acuity settings and the case- 
mix of various facility types) that are otherwise 
taken into account for purposes of determining 
payment amounts with respect to participating 
facilities. 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 appro-
priate. 
‘‘(3) DEFINITIONS.—In this section: 
‘‘(A) EMERGENCY DEPARTMENT OF A HOS-
PITAL.—The term ‘emergency department of a 
hospital’ includes a hospital outpatient depart-
ment that provides emergency services. 
‘‘(B) EMERGENCY MEDICAL CONDITION.— 
The term ‘emergency medical condition’ means 
a medical condition manifesting itself by acute 
symptoms of sufficient severity (including se-
vere pain) such that a prudent layperson, who 
possesses an average knowledge of health and 
medicine, could reasonably expect the absence 
of immediate medical attention to result in a 
condition described in clause (i), (ii), or (iii) of 
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section 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 exam-
ination (as required under section 
1867 of the Social Security Act, or as 
would be required under such section 
if such section applied to an inde-
pendent freestanding emergency de-
partment) that is within the capability 
of the emergency department of a hos-
pital or of an independent free-
standing emergency department, as 
applicable, including ancillary services 
routinely available to the emergency 
department to evaluate such emer-
gency medical condition; and 
‘‘(II) within the capabilities of 
the staff and facilities available at the 
hospital or the independent free-
standing emergency department, as 
applicable, such further medical exam-
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ination and treatment as are required 
under section 1867 of such Act, or as 
would be required under such section 
if such section applied to an inde-
pendent freestanding emergency de-
partment, to stabilize the patient. 
‘‘(ii) INCLUSION
OF
CERTAIN
SERV-
ICES
OUTSIDE
OF
EMERGENCY
DEPART-
MENT.— 
‘‘(I) IN GENERAL.—For purposes 
of this subsection and section 2799A– 
1, in the case of an individual enrolled 
in a group health plan or health in-
surance coverage offered by a health 
insurance issuer in the group or indi-
vidual market who is furnished serv-
ices described in clause (i) by a par-
ticipating or nonparticipating provider 
or a participating or nonparticipating 
emergency facility to stabilize such in-
dividual with respect to an emergency 
medical condition, the term ‘emer-
gency services’ shall include, unless 
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 for 
which benefits are provided or covered 
under the plan or coverage, respec-
tively, furnished by a nonparticipating 
provider or nonparticipating facility, 
regardless of the department of the 
hospital in which such individual is 
furnished such items or services, if, 
after such stabilization but during 
such visit in which such individual is 
so stabilized, the provider or facility 
determines that such items or services 
are needed. 
‘‘(II) 
CONDITIONS.—For 
pur-
poses of subclause (I), the conditions 
described in this subclause, with re-
spect to an individual who is stabilized 
and furnished additional items and 
services described in subclause (I) 
after such stabilization by a provider 
or facility described in subclause (I), 
are the following: 
‘‘(aa) Such a provider or fa-
cility determines such individual 
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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 
2799A–2(d) of the Public Health 
Service Act with respect to such 
items and services. 
‘‘(cc) Such an individual is 
in a condition to receive (as de-
termined 
in 
accordance 
with 
guidance issued by the Secretary) 
the information described in sec-
tion 2799A–2 of the Public 
Health Service Act and to pro-
vide informed consent under such 
section, in accordance with appli-
cable State law. 
‘‘(D) 
INDEPENDENT
FREESTANDING 
EMERGENCY
DEPARTMENT.—The term ‘inde-
pendent freestanding emergency department’ 
means a facility that— 
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‘‘(i) is geographically separate and 
distinct and licensed separately from a hos-
pital under applicable State law; and 
‘‘(ii) provides any emergency services 
(as defined in subparagraph (C)). 
‘‘(E) MEDIAN CONTRACTED RATE.— 
‘‘(i) IN GENERAL.—The term ‘median 
contracted rate’ 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 line of busi-
ness as the 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 provided by a pro-
vider in the same or similar specialty 
and provided in the geographic region 
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in which the item or service is fur-
nished, consistent with the method-
ology established by the Secretary 
under paragraph (2)(B), increased by 
the percentage increase in the con-
sumer price index for all urban con-
sumers (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 median contracted rate de-
termined under this clause for such 
an item or service furnished in the 
previous year, increased by the per-
centage increase in the consumer price 
index for all urban consumers (United 
States city average) over such pre-
vious year. 
‘‘(ii) NEW PLANS AND COVERAGE.— 
The term ‘median contracted rate’ means, 
with respect to a sponsor of a group health 
plan in a geographic region in which such 
sponsor, respectively, did not offer any 
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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 median contracted 
rate 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 
(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 informa-
tion to calculate the median of the con-
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tracted rates described in clause (i)(I) in 
2019 (or, in the case of a newly covered 
item or service (as defined in clause 
(iv)(III)), in the first coverage year (as de-
fined in clause (iv)(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 geo-
graphic region (other than in a case with 
respect to which clause (ii) applies)) the 
term ‘median contracted rate’— 
‘‘(I) for an item or service fur-
nished during 2022 (or, in the case of 
a newly covered item or service, dur-
ing the first coverage year for such 
item or service with respect to such 
plan), means such rate for such item 
or service determined by the sponsor 
through use of any database that is 
determined, in accordance with rule-
making 
described 
in 
paragraph 
(2)(B), to not have any conflicts of in-
terest and to have sufficient informa-
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tion reflecting allowed amounts paid 
to a health care provider or facility for 
relevant services furnished in the ap-
plicable geographic 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 defined in clause (iv)(II)) for such 
item or service with respect to such 
plan), means the rate determined 
under subclause (I) or this subclause, 
as applicable, for such item or service 
for the year previous to such subse-
quent year, increased by the percent-
age increase in the consumer price 
index for all urban consumers (United 
States city average) over such pre-
vious year; 
‘‘(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 median contracted rate 
in clause (i)(I), except that in apply-
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ing such clause to such item or serv-
ice, the reference to ‘furnished during 
2022’ shall be treated as a reference 
to furnished during such first suffi-
cient information year, the reference 
to ‘on January 31, 2019,’ shall be 
treated as a reference to in such suffi-
cient 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 
during 2023 or a subsequent year’ 
shall be treated as a reference to fur-
nished during the year after such first 
sufficient information year or a subse-
quent year. 
‘‘(iv) DEFINITIONS.—For purposes of 
this subparagraph: 
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‘‘(I) FIRST
COVERAGE
YEAR.— 
The term ‘first coverage year’ means, 
with respect to a group health plan 
and an item or service for which cov-
erage is not offered in 2019 under 
such plan or coverage, the first year 
after 2019 for 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 
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‘‘(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 serv-
ice with respect to such plan for 
which the sponsor has sufficient 
information to calculate the me-
dian of the contracted rates de-
scribed in clause (i)(I) in the 
year previous to such first subse-
quent 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 serv-
ice for which coverage was not offered 
in 2019 under such plan or coverage, 
but is offered under such plan or cov-
erage in a year after 2019. 
‘‘(F) NONPARTICIPATING EMERGENCY FA-
CILITY; 
PARTICIPATING
EMERGENCY
FACIL-
ITY.— 
‘‘(i) NONPARTICIPATING
EMERGENCY 
FACILITY.—The 
term 
‘nonparticipating 
emergency facility’ means, with respect to 
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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. 
‘‘(ii) PARTICIPATING EMERGENCY FA-
CILITY.—The term ‘participating emer-
gency 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 has a contractual relation-
ship directly or indirectly with the plan, 
with respect 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-
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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 
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 certification 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 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 non-
participating provider or emergency facil-
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ity; 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 nonparticipating provider or emergency 
facility; and such an item or service, an 
amount that is the median contracted rate 
(as defined in subparagraph (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 emergency facility dur-
ing a year and a group health plan, a State law 
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that provides for a method for determining the 
amount of payment that is required to be cov-
ered by such a plan (to the extent such State 
law applies to such plan, subject to section 514 
of the Employee Retirement Income Security 
Act of 1974) in the case of a participant or 
beneficiary covered under such plan and receiv-
ing such item or service from such a nonpartici-
pating provider or emergency facility. 
‘‘(J) STABILIZE.—The term ‘to stabilize’, 
with respect to an emergency medical condition 
(as defined in subparagraph (B)), has the 
meaning give in section 1867(e)(3) of the Social 
Security Act (42 U.S.C. 1395dd(e)(3)). 
‘‘(c) 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 
provides for the designation of a participating pri-
mary care provider for the child, the plan shall per-
mit such person to designate a physician (allopathic 
or osteopathic) who specializes in pediatrics as the 
child’s primary care provider if such provider par-
ticipates in the network of the plan or issuer. 
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‘‘(2) CONSTRUCTION.—Nothing in paragraph 
(1) shall be construed to waive any exclusions of cov-
erage under the terms and conditions of the plan 
with respect to coverage of pediatric care. 
‘‘(d) PATIENT ACCESS TO OBSTETRICAL AND GYNE-
COLOGICAL CARE.— 
‘‘(1) GENERAL RIGHTS.— 
‘‘(A) DIRECT
ACCESS.—A group health 
plan described in paragraph (2) may not re-
quire authorization or referral by the plan or 
any person (including a primary care provider 
described in paragraph (2)(B)) in the case of a 
female participant or beneficiary who seeks cov-
erage for obstetrical or gynecological care pro-
vided by a participating health care professional 
who specializes in obstetrics or gynecology. 
Such professional shall agree to otherwise ad-
here to such plan’s policies and procedures, in-
cluding procedures regarding referrals and ob-
taining prior authorization and providing serv-
ices pursuant to a treatment plan (if any) ap-
proved by the plan. 
‘‘(B) OBSTETRICAL AND GYNECOLOGICAL 
CARE.—A group health plan described in para-
graph (2) shall treat the provision of obstetrical 
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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 ob-
stetrics 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 
‘‘(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 gyneco-
logical care; or 
‘‘(B) preclude the group health plan in-
volved from requiring that the obstetrical or 
gynecological provider notify the primary care 
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health care professional or the plan of treat-
ment decisions. 
‘‘(e) COVERAGE
OF
NON-EMERGENCY
SERVICES 
PERFORMED BY NONPARTICIPATING PROVIDERS AT CER-
TAIN PARTICIPATING FACILITIES.— 
‘‘(1) IN
GENERAL.—In the case of items or 
services (other than emergency services to which 
subsection (b) applies) for which any benefits are 
provided or covered by a group health plan furnished 
to a participant or beneficiary of such plan by a 
nonparticipating provider (as defined in subsection 
(b)(3)(G)(i)) (and who, with respect to such items 
and services, has not satisfied the notice and consent 
criteria of section 2799A–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 
paragraph (2)(A)), with respect to such plan, the 
plan— 
‘‘(A) shall not impose on such participant 
or beneficiary a cost-sharing amount (expressed 
as a copayment amount or coinsurance rate) for 
such items and services so furnished that is 
greater than the cost-sharing amount that 
would apply under such plan had such items or 
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services been furnished by a participating pro-
vider (as defined in subsection (b)(3)(G)(ii)); 
‘‘(B) shall calculate such cost-sharing 
amount as if the total amount that would have 
been charged for such items and services by 
such participating provider were equal to the 
recognized amount (as defined in subsection 
(b)(3)(H)) for such items and services, plan, 
and year; 
‘‘(C) shall pay to such provider furnishing 
such items and services to such participant or 
beneficiary the amount by which the recognized 
amount (as defined in subsection (b)(3)(H)) for 
such items and services and year involved ex-
ceeds the cost-sharing amount imposed under 
the plan for such items and services (as deter-
mined in accordance with subparagraphs (A) 
and (B)); and 
‘‘(D) shall count toward any in-network 
deductible and in-network out-of-pocket maxi-
mums (as applicable) applied under the plan, 
any cost-sharing payments made by the partici-
pant or beneficiary (and such in-network de-
ductible shall be applied) with respect to such 
items and services so furnished in the same 
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manner as if such cost-sharing payments 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 contractual rela-
tionship with the plan, 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, 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) of 
such Act). 
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‘‘(IV) An ambulatory surgical 
center 
(as 
defined 
in 
section 
1833(i)(1)(A) of such Act). 
‘‘(V) Any other facility that pro-
vides items or services for which cov-
erage is provided under the plan or 
coverage, respectively. 
‘‘(B) VISIT.—The term ‘visit’ shall, with 
respect to items and services furnished to an in-
dividual at a participating health care facility, 
include equipment and devices, telemedicine 
services, imaging services, laboratory services, 
and such other items and services as the Sec-
retary may specify, regardless of whether or not 
the provider furnishing such items or services is 
at the facility. 
‘‘(f) AIR AMBULANCE SERVICES.— 
‘‘(1) IN GENERAL.—In the case of a participant 
or beneficiary in a group health plan who receives 
air ambulance services from a nonparticipating pro-
vider (as defined in subsection (b)(3)(G)) with re-
spect to such plan or coverage, if such services 
would be covered if provided by a participating pro-
vider (as defined in such subsection) with respect to 
such plan— 
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‘‘(A) the cost-sharing requirement (ex-
pressed as a copayment amount, coinsurance 
rate, or deductible) with respect to such services 
shall be the same requirement that would apply 
if such services were provided by such a partici-
pating provider, and any coinsurance or deduct-
ible shall be based on rates that would apply for 
such services if they were furnished by such a 
participating provider; 
‘‘(B) such cost-sharing amounts shall be 
counted toward the in-network deductible and 
in-network out-of-pocket maximum amount 
under the plan for the plan year (and such in- 
network deductible shall be applied) with re-
spect 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; and 
‘‘(C) the plan or coverage shall pay to such 
provider furnishing such services to such partic-
ipant or beneficiary the amount by which the 
recognized amount (as defined in and deter-
mined pursuant to subsection (b)(3)(H)(ii)) for 
such services and year involved exceeds the 
cost-sharing amount imposed under the plan for 
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such services (as determined in accordance with 
subparagraphs (A) and (B)). 
‘‘(2) AIR AMBULANCE SERVICE DEFINED.—For 
purposes of this section, the term ‘air ambulance 
service’ means medical transport by helicopter or 
airplane for patients. 
‘‘(g) CERTAIN ACCESS FEES TO CERTAIN DATA-
BASES.—In the case of a sponsor of a group health plan 
that, pursuant to subsection (b)(3)(E)(iii), uses a data-
base described in such subsection to determine a rate to 
apply under such subsection for an item or service by rea-
son of having insufficient information described in such 
subsection with respect to such item or service, such spon-
sor shall cover the cost for access to such database.’’. 
(2) CLERICAL AMENDMENT.—The table of sec-
tions for subchapter B of chapter 100 of the Inter-
nal Revenue Code of 1986 is amended by adding at 
the end the following new item: 
‘‘Sec. 9815. Additional market reforms. 
‘‘Sec. 9816. Consumer protections.’’. 
(d) ADDITIONAL APPLICATION PROVISIONS.— 
(1) APPLICATION TO FEHB.— 
(A) IN GENERAL.—Section 8902 of title 5, 
United States Code, is amended by adding at 
the end the following new subsection: 
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‘‘(p) Each contract under this chapter shall require 
the carrier to comply with requirements described in the 
provisions of section 2719A of the Public Health Service 
Act and sections 2730 and 2731 of such Act, sections 716, 
717, and 718 of the Employee Retirement Income Secu-
rity Act of 1974, sections 9816, 9817, and 9818 of the 
Internal Revenue Code of 1986 (as applicable), and sec-
tion 2(d) of the Ban Surprise Billing Act in the same man-
ner as such provisions apply to a group health plan or 
health insurance issuer offering health insurance coverage, 
as described in such sections. The provisions of sections 
2799A–1, 2799A–2, 2799A–3, and 2799A–4 of the Public 
Health Service Act shall apply to a health care provider 
and facility and an air ambulance provider described in 
such respective sections with respect to a participant, ben-
eficiary, or enrollee in a health benefits plan under this 
chapter in the same manner as such provisions apply to 
such a provider and facility with respect to an enrollee 
in a group health plan or health insurance coverage of-
fered by a health insurance issuer in the group or indi-
vidual market, as described in such sections.’’. 
(B) EFFECTIVE
DATE.—The amendment 
made by this paragraph shall apply with respect 
to contracts entered into or renewed for con-
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100 
tract years beginning on or after January 1, 
2022. 
(2) 
APPLICATION
TO
GRANDFATHERED 
PLANS.—Section 1251(a) of the Patient Protection 
and Affordable Care Act (42 U.S.C. 18011(a)) is 
amended by adding at the end the following: 
‘‘(5) APPLICATION
OF
ADDITIONAL
PROVI-
SIONS.—Subsections (b), (e), (f), (g), and (h) of sec-
tion 2719A of the Public Health Service Act shall 
apply to grandfathered health plans for plan years 
beginning on or after January 1, 2022.’’. 
(3) COORDINATION.—The Secretary of the 
Treasury, the Secretary of Health and Human Serv-
ices, and the Secretary of Labor shall ensure, 
through the execution of an interagency memo-
randum of understanding among such Secretaries, 
that— 
(A) regulations, rulings, and interpreta-
tions issued by such Secretaries relating to the 
same matter over which two or more such Sec-
retaries have responsibility under this title (and 
the amendments made by this title) are admin-
istered so as to have the same effect at all 
times; and 
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101 
(B) coordination of policies relating to en-
forcing the same requirements through such 
Secretaries in order to have a coordinated en-
forcement strategy that avoids duplication of 
enforcement efforts and assigns priorities in en-
forcement. 
(4) 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 
successor regulation), against payment liability 
for a patient who receives contract health serv-
ices that are authorized by the Indian Health 
Service; or 
(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 begin-
ning on or after January 1, 2022. 
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102 
SEC. 3. PREVENTING CERTAIN CASES OF BALANCE BILL-
ING. 
(a) IN GENERAL.—Title XXVII of the Public Health 
Service Act (42 U.S.C. 300gg et seq.) is amended by add-
ing at the end the following new part: 
‘‘PART D—HEALTH CARE PROVIDER 
REQUIREMENTS 
‘‘SEC. 2799A–1. BALANCE BILLING IN CASES OF EMERGENCY 
SERVICES. 
‘‘(a) IN GENERAL.—In the case of a participant, ben-
eficiary, or enrollee with benefits under a group health 
plan or health insurance coverage offered by a health in-
surance issuer in the group or individual market who is 
furnished during a plan year beginning on or after Janu-
ary 1, 2022, emergency services for which any benefit is 
provided under such plan or coverage with respect to an 
emergency medical condition with respect to a visit at an 
emergency department of a hospital or an independent 
freestanding emergency department— 
‘‘(1) in the case that the hospital or inde-
pendent freestanding emergency department is a 
nonparticipating emergency facility, the emergency 
department of a hospital or independent free-
standing emergency department shall not hold the 
participant, beneficiary, or enrollee liable for a pay-
ment amount for such emergency services so fur-
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103 
nished that is more than the cost-sharing amount 
for such services (as determined in accordance with 
clauses (ii) and (iii) of section 2719A(b)(1)(C), sec-
tion 716(b)(1)(C) of the Employee Retirement In-
come 
Security 
Act 
of 
1974, 
and 
section 
9816(b)(1)(C) of the Internal Revenue Code of 
1986, as applicable); and 
‘‘(2) in the case that such services are furnished 
by a nonparticipating provider, the health care pro-
vider shall not hold such participant, beneficiary, or 
enrollee liable for a payment amount for an emer-
gency service furnished to such individual by such 
provider with respect to such emergency medical 
condition and visit for which the individual receives 
emergency services at the hospital or emergency de-
partment that is more than the cost-sharing amount 
for such services furnished by the provider (as deter-
mined in accordance with clauses (ii) and (iii) of sec-
tion 2719A(b)(1)(C), section 716(b)(1)(C) of the 
Employee Retirement Income Security Act of 1974, 
and section 9816(b)(1)(C) of the Internal Revenue 
Code of 1986, as applicable). 
‘‘(b) DEFINITION.—In this section, the term ‘visit’ 
shall have such meaning as applied to such term for pur-
poses of section 2719A(e). 
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104 
‘‘SEC. 2799A–2. BALANCE BILLING IN CASES OF NON-EMER-
GENCY 
SERVICES 
PERFORMED 
BY 
NON-
PARTICIPATING 
PROVIDERS 
AT 
CERTAIN 
PARTICIPATING FACILITIES. 
‘‘(a) IN GENERAL.—Subject to subsection (b), in the 
case of a participant, beneficiary, or enrollee with benefits 
under a group health plan or health insurance coverage 
offered by a health insurance issuer in the group or indi-
vidual market who is furnished during a plan year begin-
ning on or after January 1, 2022, items or services (other 
than emergency services to which section 2799A–1 ap-
plies) for which any benefit is provided under such plan 
or coverage at a participating health care facility by a non-
participating provider, such provider shall not bill, and 
shall not hold liable, such participant, beneficiary, or en-
rollee for a payment amount for such an item or service 
furnished by such provider with respect to a visit at such 
facility that is more than the cost-sharing amount for such 
item or service (as determined in accordance with subpara-
graphs (A) and (B) of section 2719A(e)(1), section 
716(e)(1) of the Employee Retirement Income Security 
Act of 1974, and section 9816(e)(1) of the Internal Rev-
enue Code of 1986, as applicable). 
‘‘(b) EXCEPTION.— 
‘‘(1) IN
GENERAL.—Subsection (a) shall not 
apply with respect to items or services (other than 
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105 
ancillary services described in paragraph (2)) fur-
nished by a nonparticipating provider to a partici-
pant, beneficiary, or enrollee of a group health plan 
or health insurance coverage offered by a health in-
surance issuer in the group or individual market, if 
the provider satisfies the notice and consent criteria 
of subsection (d). 
‘‘(2) ANCILLARY
SERVICES
DESCRIBED.—For 
purposes of paragraph (1), ancillary services de-
scribed in this paragraph are, with respect to a par-
ticipating health care facility— 
‘‘(A) subject to paragraph (3), items and 
services related to emergency medicine, anesthe-
siology, pathology, radiology, and neonatology, 
whether or not provided by a physician or non- 
physician practitioner, and items and services 
provided by assistant surgeons, hospitalists, and 
intensivists; 
‘‘(B) subject to paragraph (3), diagnostic 
services (including radiology and laboratory 
services); 
‘‘(C) items and services provided by such 
other specialty practitioners, as the Secretary 
specifies through rulemaking; and 
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106 
‘‘(D) items and services provided by a non-
participating provider if there is no partici-
pating provider who can furnish such item or 
service at such facility. 
‘‘(3) EXCEPTION.—The Secretary may, through 
rulemaking, establish a list (and update such list) of 
advanced diagnostic laboratory tests, which shall not 
be included as an ancillary service described in para-
graph (2) and with respect to which subsection (a) 
would apply. 
‘‘(c) CLARIFICATION.—In the case of a nonpartici-
pating provider that satisfies the notice and consent cri-
teria of subsection (d) with respect to an item or service 
(referred to in this subsection as a ‘covered item or serv-
ice’), such notice and consent criteria may not be con-
strued as applying with respect to any item or service that 
is furnished as a result of unforeseen, urgent medical 
needs that arise at the time such covered item or service 
is furnished. For purposes of the previous sentence, a cov-
ered item or service shall not include an ancillary service 
described in subsection (b)(2). 
‘‘(d) NOTICE AND CONSENT TO BE TREATED BY A 
NONPARTICIPATING PROVIDER
OR NONPARTICIPATING 
FACILITY.— 
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107 
‘‘(1) IN GENERAL.—A nonparticipating provider 
or nonparticipating facility satisfies the notice and 
consent criteria of this subsection, with respect to 
items or services furnished by the provider or facility 
to a participant, beneficiary, or enrollee of a group 
health plan or health insurance coverage offered by 
a health insurance issuer in the group or individual 
market, if the provider (or, if applicable, the partici-
pating health care facility on behalf of such pro-
vider) or nonparticipating facility— 
‘‘(A) provides to the participant, bene-
ficiary, or enrollee (or to an authorized rep-
resentative of the participant, beneficiary, or 
enrollee) on the date on which the individual is 
furnished such items or services and, in the 
case that the participant, beneficiary, or en-
rollee makes an appointment to be furnished 
such items or services, on such date the ap-
pointment is made— 
‘‘(i) an oral explanation of the written 
notice described in clause (ii); and 
‘‘(ii) a written notice in paper or elec-
tronic form (and including electronic notifi-
cation, as practicable) specified by the Sec-
retary, not later than July 1, 2021, 
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108 
through guidance (which shall be updated 
as determined necessary by the Secretary) 
that— 
‘‘(I) contains the information re-
quired under paragraph (2); 
‘‘(II) clearly states that consent 
to receive such items and services 
from such nonparticipating provider 
or nonparticipating facility is optional 
and that the participant, beneficiary, 
or enrollee may instead seek care from 
a participating provider or at a par-
ticipating facility, with respect to such 
plan or coverage, as applicable, in 
which case the cost-sharing responsi-
bility of the participant, beneficiary, 
or enrollee would not exceed such re-
sponsibility that would apply with re-
spect to such an item or service that 
is furnished by a participating pro-
vider or participating facility, as ap-
plicable with respect to such plan; 
‘‘(III) is available in the fifteen 
most common languages in the geo-
graphic region of the applicable facil-
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109 
ity and, in the case the primary lan-
guage of the beneficiary, participant, 
or enrollee, respectively, is not one of 
such 15 languages, makes a good 
faith effort to also provide such notice 
orally in such primary language of the 
beneficiary, participant, or enrollee; 
and 
‘‘(IV) is signed and dated by the 
participant, beneficiary, or enrollee (or 
by an authorized representative of the 
participant, beneficiary, or enrollee) 
and, with respect to items or services 
to be furnished by such a provider 
that are not poststabilization services 
described 
in 
section 
2719A(b)(3)(C)(ii), is so signed and 
dated not less than 72 hours prior to 
the participant, beneficiary, or en-
rollee being furnished such items or 
services by such provider; and 
‘‘(B) obtains from the participant, bene-
ficiary, or enrollee (or from such an authorized 
representative) the consent described in para-
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110 
graph (3) to be treated by a nonparticipating 
provider or nonparticipating facility. 
‘‘(2) INFORMATION REQUIRED UNDER WRITTEN 
NOTICE.—For purposes of paragraph (1)(A)(ii)(I), 
the information described in this paragraph, with re-
spect to a nonparticipating provider or nonpartici-
pating facility and a participant, beneficiary, or en-
rollee of a group health plan or health insurance cov-
erage offered by a health insurance issuer in the 
group or individual market, is each of the following: 
‘‘(A) Notification, as applicable, that the 
health care provider is a nonparticipating pro-
vider with respect to the health plan or the 
health care facility is a nonparticipating facility 
with respect to the health plan. 
‘‘(B) Notification of the good faith esti-
mated amount that such provider or facility 
may charge the participant, beneficiary, or en-
rollee for such items and services involved, in-
cluding a notification that the provision of such 
estimate or consent to be treated under para-
graph (3) does not constitute a contract with 
respect to the charges estimated for such items 
and services. 
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111 
‘‘(C) In the case of a participating facility 
and a nonparticipating provider, a list of any 
participating providers at the facility who are 
able to furnish such items and services involved 
and notification that the participant, bene-
ficiary, or enrollee may be referred, at their op-
tion, to such a participating provider. 
‘‘(D) Information about whether prior au-
thorization or other care management limita-
tions may be required in advance of receiving 
such items or services at the facility. 
‘‘(3) CONSENT DESCRIBED TO BE TREATED BY 
A
NONPARTICIPATING
PROVIDER
OR
NONPARTICI-
PATING
FACILITY.—For purposes of paragraph 
(1)(B), the consent described in this paragraph, with 
respect to a participant, beneficiary, or enrollee of a 
group health plan or health insurance coverage of-
fered by a health insurance issuer in the group or 
individual market who is to be furnished items or 
services by a nonparticipating provider or nonpartici-
pating facility, is a document specified by the Sec-
retary through rulemaking, in consultation with the 
Secretary of Labor, that— 
‘‘(A) acknowledges that the participant, 
beneficiary, or enrollee has been— 
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112 
‘‘(i) provided with a written good faith 
estimate and an oral explanation of the 
charge that may be applied for the items 
or services anticipated to be furnished by 
such provider or facility; and 
‘‘(ii) informed that the payment of 
such charge by the participant, beneficiary, 
or enrollee may not accrue toward meeting 
any limitation that the plan or coverage 
places on cost-sharing, including an expla-
nation that such payment may not apply to 
an in-network deductible applied under the 
plan or coverage; and 
‘‘(B) documents the consent of the partici-
pant, beneficiary, or enrollee to be furnished 
such item or services by such provider or facil-
ity. 
‘‘(4) RULE
OF
CONSTRUCTION.—The consent 
described in paragraph (3), with respect to a partici-
pant, beneficiary, or enrollee of a group health plan 
or health insurance coverage offered by a health in-
surance issuer in the group or individual market, 
shall constitute only consent to the receipt of the in-
formation provided pursuant to this subsection and 
shall not constitute a contractual agreement of the 
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113 
participant, beneficiary, or enrollee to any estimated 
charge or amount included in such information. 
‘‘(e) RETENTION OF CERTAIN DOCUMENTS.—A non-
participating facility (with respect to such facility or any 
nonparticipating provider at such facility) or a partici-
pating facility (with respect to nonparticipating providers 
at such facility) that obtains from a participant, bene-
ficiary, or enrollee of a group health plan or health insur-
ance coverage offered by a health insurance issuer in the 
group or individual market (or an authorized representa-
tive of such participant, beneficiary, or enrollee) a written 
notice in accordance with subsection (d)(1)(A)(ii), with re-
spect to furnishing an item or service to such participant, 
beneficiary, or enrollee, shall retain such notice for at least 
a 2-year period after the date on which such item or serv-
ice is so furnished. 
‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) The terms ‘nonparticipating provider’ and 
‘participating provider’ have the meanings given 
such terms, respectively, in subsection (b)(3) of sec-
tion 2719A. 
‘‘(2) The term ‘participating health care facil-
ity’ has the meaning given such term in subsection 
(e)(2) of section 2719A. 
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114 
‘‘(3) 
The 
term 
‘nonparticipating 
facility’ 
means— 
‘‘(A) with respect to emergency services (as 
defined in section 2719A(b)(3)(C)(i)) and a 
group health plan or health insurance coverage 
offered by a health insurance issuer in the 
group or individual market, an emergency de-
partment of a hospital, or an independent free-
standing emergency department, that does not 
have a contractual relationship with the plan or 
issuer, respectively, with respect to the fur-
nishing of such services under the plan or cov-
erage, respectively; and 
‘‘(B) with respect to services described in 
section 2719A(b)(3)(C)(ii) and a group health 
plan or health insurance coverage offered by a 
health insurance issuer in the group or indi-
vidual market, a hospital or an independent 
freestanding emergency department, that does 
not have a contractual relationship with the 
plan or issuer, respectively, with respect to the 
furnishing of such services under the plan or 
coverage, respectively. 
‘‘(4) The term ‘participating facility’ means— 
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‘‘(A) with respect to emergency services (as 
defined in clause (i) of section 2719A(b)(3)(C)) 
that are not described in clause (ii) of such sec-
tion and a group health plan or health insur-
ance coverage offered by a health insurance 
issuer in the group or individual market, an 
emergency department of a hospital, or an inde-
pendent freestanding emergency department, 
that has a contractual relationship with the 
plan or issuer, respectively, with respect to the 
furnishing of such services under the plan or 
coverage, respectively; and 
‘‘(B) with respect to services that pursuant 
to clause (ii) of section 2719A(b)(3)(C) are in-
cluded as emergency services (as defined in 
clause (i) of such section) and a group health 
plan or health insurance coverage offered by a 
health insurance issuer in the group or indi-
vidual market, a hospital or an independent 
freestanding emergency department, that has a 
contractual relationship with the plan or cov-
erage, respectively, with respect to the fur-
nishing of such services under the plan or cov-
erage, respectively. 
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‘‘SEC. 2799A–3. PROVIDER REQUIREMENT WITH RESPECT 
TO PUBLIC PROVISION OF INFORMATION. 
‘‘(a) IN GENERAL.—Each health care provider and 
health care facility shall make publicly available, and (if 
applicable) post on a public website of such provider or 
facility and provide to individuals who are participants, 
beneficiaries, or enrollees of a group health plan or health 
insurance coverage offered by a health insurance issuer 
in the group or individual market a one-page notice in 
plain language containing information on— 
‘‘(1) the requirements and prohibitions of such 
provider or facility under sections 2799A–1, 2799A– 
2, and 2799A–4 (relating to prohibitions on balance 
billing in certain circumstances); 
‘‘(2) if provided for under applicable State law, 
any other requirements on such provider or facility 
regarding the amounts such provider or facility may, 
with respect to an item or service, charge a partici-
pant, beneficiary, or enrollee of a group health plan 
or health insurance coverage offered by a health in-
surance issuer in the group or individual market 
with respect to which such provider or facility does 
not have a contractual relationship for furnishing 
such item or service under the plan or coverage, re-
spectively, after receiving payment from the plan or 
coverage, respectively, for such item or service and 
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any applicable cost-sharing payment from such par-
ticipant, beneficiary, or enrollee; and 
‘‘(3) information on contacting appropriate 
State and Federal agencies in the case that an indi-
vidual believes that such provider or facility has vio-
lated any requirement described in paragraph (1) or 
(2) with respect to such individual. 
‘‘(b) GUIDANCE.—Not later than 6 months after the 
date of the enactment of this section, the Secretary, in 
consultation with the Secretary of Labor, shall issue guid-
ance on the requirements for the notice under this section. 
‘‘SEC. 2799A–4. AIR AMBULANCE SERVICES. 
‘‘In the case of a participant, beneficiary, or enrollee 
with benefits under a group health plan or health insur-
ance coverage offered by a health insurance issuer in the 
group or individual market who is furnished on or after 
January 1, 2022, air ambulance services from a non-
participating 
provider 
(as 
defined 
in 
section 
2719A(b)(3)(G)) with respect to such plan or coverage, 
such provider shall not bill, and shall not hold liable, such 
participant, beneficiary, or enrollee for a payment amount 
for such service furnished by such provider that is more 
than the cost-sharing amount for such service (as deter-
mined in accordance with paragraphs (1) and (2) of sec-
tion 2719A(f), section 716(f) of the Employee Retirement 
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Income Security Act of 1974, or section 9816(f) of the 
Internal Revenue Code of 1986, as applicable). 
‘‘SEC. 2799A–5. ENFORCEMENT. 
‘‘(a) STATE ENFORCEMENT.— 
‘‘(1) STATE AUTHORITY.—Each State may re-
quire a provider or health care facility (including a 
provider of air ambulance services) subject to the re-
quirements of this part (except section 2799A–5) to 
satisfy such requirements applicable to the provider 
or facility. 
‘‘(2) 
FAILURE
TO
IMPLEMENT
REQUIRE-
MENTS.—In the case of a determination by the Sec-
retary that a State has failed to substantially en-
force the requirements specified in paragraph (1) 
with respect to applicable providers and facilities in 
the State, the Secretary shall enforce such require-
ments under subsection (b) insofar as they relate to 
violations of such requirements occurring in such 
State. 
‘‘(3) 
NOTIFICATION
OF
SECRETARY
OF 
LABOR.—A State may notify the Secretary of Labor 
of instances of violations of sections 2799A–1, 
2799A–2, or 2799A–4 with respect to participants 
or beneficiaries under a group health plan or health 
insurance coverage offered by a health insurance 
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issuer in the group market and any enforcement ac-
tions taken against providers or facilities as a result 
of such violations, including the disposition of any 
such enforcement actions. 
‘‘(b) SECRETARIAL ENFORCEMENT AUTHORITY.— 
‘‘(1) IN GENERAL.—If a provider or facility is 
found to be in violation of a requirement specified in 
subsection (a)(1) by the Secretary, the Secretary 
may apply a civil monetary penalty with respect to 
such provider or facility (including, as applicable, a 
provider of air ambulance services) in an amount not 
to exceed $10,000 per violation. The provisions of 
subsections (c) (with the exception of the first sen-
tence of paragraph (1) of such subsection), (d), (e), 
(g), (h), (k), and (l) of section 1128A of the Social 
Security Act shall apply to a civil monetary penalty 
or assessment under this subsection in the same 
manner as such provisions apply to a penalty, as-
sessment, or proceeding under subsection (a) of such 
section. 
‘‘(2) LIMITATION.—The provisions of para-
graph (1) shall apply to enforcement of a provision 
(or provisions) specified in subsection (a)(1) only as 
provided under subsection (a)(2). 
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‘‘(3) COMPLAINT
PROCESS.—The Secretary 
shall, through rulemaking conducted in consultation 
with the Secretary of Labor, establish a process to 
receive consumer complaints of violations of such 
provisions and resolve such complaints within 60 
days of receipt of such complaints. Such process 
shall provide that the Secretary of Labor be in-
formed of complaints by participants or beneficiaries 
under a group health plan or health insurance cov-
erage offered by a health insurance issuer in the 
group market and any enforcement actions against 
providers resulting from such complaints, including 
the disposition of any such enforcement actions. 
‘‘(4) EXCEPTION.—The Secretary may waive 
the penalties described under paragraph (1) with re-
spect to a facility or provider (including a provider 
of air ambulance services) who does not knowingly 
violate, and should not have reasonably known it vio-
lated, sections 2799A–1, 2799A–2, or 2799A–4 with 
respect to a participant, beneficiary, or enrollee, if 
such facility or provider, within 30 days of the viola-
tion, withdraws the bill that was in violation of such 
provision and reimburses the health plan or partici-
pant, beneficiary, or enrollee, as applicable, in an 
amount equal to the difference between the amount 
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billed and the amount allowed to be billed under the 
provision, plus interest, at an interest rate deter-
mined by the Secretary. 
‘‘(5) HARDSHIP
EXEMPTION.—The Secretary 
may establish a hardship exemption to the penalties 
under this subsection. 
‘‘(c) CONTINUED APPLICABILITY OF STATE LAW.— 
The sections specified in subsection (a)(1) shall not be 
construed to supersede any provision of State law which 
establishes, implements, or continues in effect any require-
ment or prohibition except to the extent that such require-
ment or prohibition prevents the application of a require-
ment or prohibition of such a section.’’. 
(b) SECRETARY OF LABOR INVESTIGATIVE AUTHOR-
ITY.— 
(1) IN GENERAL.—Part 5 of subtitle B of title 
I of the Employee Retirement Income Security Act 
of 1974 (29 U.S.C. 1131 et seq.) is amended by 
adding at the end the following new section: 
‘‘SEC. 522. INVESTIGATIVE AUTHORITY REGARDING VIOLA-
TIONS OF CERTAIN HEALTH CARE PROVIDER 
REQUIREMENTS; COMPLAINT PROCESS. 
‘‘(a) INVESTIGATIVE AUTHORITY.—Upon receiving a 
notice from a State or the Secretary of Health and Human 
Services of violations of sections 2799A–1, 2799A–2, or 
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2799A–4 of the Public Health Service Act, the Secretary 
of Labor shall have the power to conduct an investigation 
to identify patterns of such violations with respect to par-
ticipants or beneficiaries under a group health plan or 
health insurance coverage offered in connection with a 
group health plan by a health insurance issuer in the 
group market. The Secretary may assist States, the Sec-
retary of Health and Human Services, plans, or issuers 
to ensure that appropriate measures have been taken to 
correct such violations retrospectively and prospectively 
with respect to participants or beneficiaries under a group 
health plan or health insurance coverage offered in connec-
tion with a group health plan by a health insurance issuer 
in the group market. 
‘‘(b) COMPLAINT PROCESS.—Not later than January 
1, 2022, the Secretary shall establish a process under 
which the Secretary— 
‘‘(1) may receive complaints from participants 
and beneficiaries of group health plans or health in-
surance coverage offered in connection with such 
plans relating to alleged violations of the sections 
specified in subsection (a); and 
‘‘(2) transmits such complaints to States or the 
Secretary of Health and Human Services (as deter-
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123 
mined appropriate by the Secretary) for potential 
enforcement actions.’’. 
(2) TECHNICAL
AMENDMENT.—The table of 
contents in section 1 of the Employee Retirement 
Income Security Act of 1974 (29 U.S.C. 1001 et 
seq.) is amended by inserting after the item relating 
to section 521 the following new item: 
‘‘Sec. 522. Investigative authority regarding violations of certain health care 
provider requirements; complaint process.’’. 
(c) 
DISCLOSURE
OF
CERTAIN
PROTECTIONS 
AGAINST BALANCE BILLING.—Section 716 of the Em-
ployee Retirement Income Security Act of 1974, as added 
by section 2, is further amended by adding at the end the 
following new subsection: 
‘‘(h) 
DISCLOSURE
OF
CERTAIN
PROTECTIONS 
AGAINST BALANCE BILLING.—Each group health plan 
and health insurance issuer offering group health insur-
ance coverage shall make publicly available, and (if appli-
cable) post on a public website of such plan or issuer— 
‘‘(1) information in plain language on— 
‘‘(A) the requirements and prohibitions ap-
plied under sections 2799A–1, 2799A–2 and 
2799A–4 of the Public Health Service Act (re-
lating to prohibitions on balance billing in cer-
tain circumstances); 
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124 
‘‘(B) if provided for under applicable State 
law, any other requirements on providers and 
facilities regarding the amounts such providers 
and facilities may, with respect to an item or 
service, charge a participant, beneficiary, or en-
rollee of such plan or coverage with respect to 
which such a provider or facility does not have 
a contractual relationship for furnishing such 
item or service under the plan or coverage after 
receiving payment from the plan or coverage for 
such item or service and any applicable cost- 
sharing payment from such participant, bene-
ficiary, or enrollee; and 
‘‘(C) the requirements applied under sub-
sections (b), (e), and (f); and 
‘‘(2) information on contacting appropriate 
State and Federal agencies in the case that an indi-
vidual believes that such a provider or facility has 
violated any requirement described in paragraph (1) 
with respect to such individual.’’. 
SEC. 4. INDEPENDENT DISPUTE RESOLUTION PROCESS. 
(a) ESTABLISHMENT.— 
(1) IN GENERAL.—Not later than 1 year after 
the date of the enactment of this section, the Sec-
retary of Health and Human Services, the Secretary 
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125 
of Labor, and the Secretary of the Treasury (in this 
section referred to as the ‘‘Secretaries’’) shall jointly 
establish by regulation an independent dispute reso-
lution process (in this section referred to as the 
‘‘IDR process’’) under which, with respect to a pay-
ment made by a group health plan or health insur-
ance issuer offering health insurance coverage in the 
group or individual market pursuant to subsection 
(b)(1), (e)(1), or (f)(1) of section 2719A of the Pub-
lic Health Service Act, section 716 of the Employee 
Retirement Income Security Act of 1974, or section 
9816 of the Internal Revenue Code of 1986 (as ap-
plicable) using the recognized amount (as defined in 
and 
determined 
pursuant 
to 
section 
2719A(b)(3)(H)(ii) of the Public Health Service Act 
or subsection (b)(3)(H)(ii) of section 716 of the Em-
ployee Retirement Income Security Act of 1974 or 
section 9816 of the Internal Revenue Code of 1986, 
as applicable) to a nonparticipating provider (as de-
fined in subparagraph (G) of section 2719A(b)(3) of 
the Public Health Service Act or subparagraph (G) 
of subsection (b)(3) of section 716 of the Employee 
Retirement Income Security Act of 1974 or section 
9816 of the Internal Revenue Code of 1986, as ap-
plicable) or a nonparticipating emergency facility (as 
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126 
defined in subparagraph (F) of such section 
2719A(b)(3) or such subsection (b)(3) of such sec-
tion 716 or such section 9816, as applicable) with 
respect to an item or service (or, in the case of pay-
ment made under section 2719A(f)(1) of the Public 
Health Service Act or subsection (f)(1) of section 
716 of the Employee Retirement Income Security 
Act of 1974 or section 9816 of the Internal Revenue 
Code of 1986, as applicable, with respect to air am-
bulance services) furnished by such provider or facil-
ity— 
(A) subject to subparagraph (B), the non-
participating provider, nonparticipating emer-
gency facility, or group health plan or health in-
surance issuer, respectively, may, not later than 
the date specified in paragraph (2), submit a 
request that such payment should be increased 
or decreased; and 
(B) in the case a settlement described in 
subsection (d)(2) is not reached with respect to 
such request, an entity certified and selected 
under subsection (c) shall determine in accord-
ance with such paragraph an alternative pay-
ment to be applied, with respect to such re-
quest. 
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127 
(2) DATE SPECIFIED.—For purposes of para-
graph (1)(A), the date specified in this paragraph 
is— 
(A) in the case of a request described in 
such paragraph (1)(A) being submitted by a 
nonparticipating provider or nonparticipating 
emergency facility, with respect to items and 
services (or air ambulance services) described in 
paragraph (1), the date that is 30 days after 
the applicable date described in subsection 
(b)(2)(A)(ii); or 
(B) in the case of such a request filed by 
a group health plan or health insurance issuer, 
the date that is 30 days after the date of the 
submission of the notice described in subsection 
(b)(1)(B)(ii). 
(3) CLARIFICATION.—A nonparticipating pro-
vider may not, with respect to an item or service (or 
air ambulance service) furnished by such provider, 
submit a request under the IDR process if such pro-
vider is exempt from the requirement under sub-
section (a) of section 2799A–2 of the Public Health 
Service Act with respect to such item or service pur-
suant to subsection (e) of such section. 
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128 
(b) REQUIREMENTS FOR REQUESTS TO BE ELIGI-
BLE FOR SUBMISSION UNDER IDR PROCESS.— 
(1) TIMING
REQUIREMENTS.—A request may 
not be submitted under the IDR process, with re-
spect to items and services (or air ambulance serv-
ices) furnished by a nonparticipating provider or 
nonparticipating emergency facility for which a 
group health plan or health insurance issuer offering 
health insurance coverage in the group or individual 
market made a payment pursuant to subsection 
(b)(1), (e)(1), or (f)(1) of section 2719A of the Pub-
lic Health Service Act or subsection (b)(1), (e)(1), or 
(f)(1) of section 716 of the Employee Retirement In-
come Security Act of 1974 or section 9816 of the 
Internal Revenue Code of 1986 (as applicable) un-
less— 
(A) in the case such request is being sub-
mitted by the nonparticipating provider or non-
participating emergency facility— 
(i) the provider or facility, respec-
tively, filed, not later than 30 days after 
the date such payment is received by the 
provider or facility, respectively, an appeal 
under the appeals process of the group 
health plan or health insurance issuer, the 
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129 
subject of which includes the payment for 
such items and services (or air ambulance 
services); and 
(ii) such request is not submitted be-
fore the sooner of the date on which such 
appeal has been resolved or the date that 
is 30 days after the date on which such ap-
peal is so filed; or 
(B) in the case such request is being sub-
mitted by the group health plan or health insur-
ance issuer— 
(i) the group health plan or health in-
surance issuer, respectively, not later than 
30 days after such provider or facility, re-
spectively, receives such payment, submits 
to such provider or facility, respectively, a 
notice that such plan or issuer, respec-
tively, disputes the amount of such pay-
ment with respect to such items and serv-
ices (or air ambulance services); and 
(ii) such request is not submitted be-
fore the date that is 30 days after the date 
of the submission of such notice. 
(2) MINIMUM MEDIAN CONTRACTED RATE.—A 
request may not be submitted under the IDR proc-
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130 
ess, with respect to items and services (or air ambu-
lance services) furnished in a geographic area by a 
nonparticipating provider or nonparticipating emer-
gency facility for which a group health plan or 
health insurance issuer offering health insurance 
coverage in the group or individual market made a 
payment pursuant to subsection (b)(1), (e)(1), or 
(f)(1) of section 2719A of the Public Health Service 
Act or subsection (b)(1), (e)(1), or (f)(1) of section 
716 of the Employee Retirement Income Security 
Act of 1974 or section 9816 of the Internal Revenue 
Code of 1986 (as applicable) unless— 
(A) in the case such item or service is fur-
nished during 2022, the median contracted rate 
(as defined in subsection (b)(3)(E) of section 
2719A of the Public Health Service Act or sub-
section (b)(3)(E) of section 716 of the Em-
ployee Retirement Income Security Act of 1974 
or section 9816 of the Internal Revenue Code 
of 1986 (as applicable)) for such year under 
such plan or such coverage with respect to each 
such item or service furnished by such a pro-
vider or such a facility in such area is at least 
$750 (or, in the case of air ambulance services, 
is at least $25,000); or 
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131 
(B) in the case such item or service (or air 
ambulance services) is furnished during a sub-
sequent year, the median contracted rate (as so 
defined) for such year under such plan or such 
coverage with respect to each such item or serv-
ice furnished by such a provider or such a facil-
ity in such area is at least the amount applied 
under this paragraph for the previous year, in-
creased by the percentage increase in the con-
sumer price index for all urban consumers 
(United States city average) over such previous 
year. 
(3) LIMITATION ON BATCHING OF ITEMS AND 
SERVICES IN A REQUEST.—A request may not be 
submitted under the IDR process by a nonpartici-
pating provider, nonparticipating emergency facility, 
or a group health plan or health insurance issuer of-
fering health insurance coverage in the group or in-
dividual market, with respect to multiple items and 
services (or multiple air ambulance services), un-
less— 
(A) all such items and services (or air am-
bulance services) included in such request are 
furnished by the same provider or facility; 
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132 
(B) payment for all such items and serv-
ices (or air ambulance services) made pursuant 
to subsection (b)(1), (e)(1), or (f)(1) of section 
2719A of the Public Health Service Act or sub-
section (b)(1), (e)(1), or (f)(1) of section 716 of 
the Employee Retirement Income Security Act 
of 1974 or section 9816 of the Internal Rev-
enue Code of 1986 (as applicable) was made by 
a single group health plan or health insurance 
coverage; 
(C) all such items and services (or air am-
bulance services) are related to the treatment of 
the same condition; and 
(D) all such items and services were fur-
nished during the 30-day period following the 
date on which the first item or service (or air 
ambulance service) included in such request was 
furnished. 
(c) IDR ENTITIES.— 
(1) PROCESS OF CERTIFICATION.—The process 
described in subsection (a) shall include a certifi-
cation process under which eligible entities may be 
certified to carry out the IDR process. 
(2) CERTIFICATION.— 
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133 
(A) IN GENERAL.—An entity wishing to 
participate in the IDR process under this sec-
tion shall request certification from the Secre-
taries. The Secretaries shall determine whether 
or not to certify applicant entities, taking into 
consideration whether the entity is unbiased 
and unaffiliated with health insurance issuers, 
group health plans, health care facilities, and 
health care providers and free of conflicts of in-
terest, in accordance with the Secretaries’ rule-
making on determining criteria for conflicts of 
interest. 
(B) ELIGIBLE ENTITIES.—For purposes of 
this section, an eligible entity is an entity that 
is a nongovernmental entity and that agrees to 
comply with the fee limitations described in 
subparagraph (C). 
(C) FEE LIMITATIONS.—For purposes of 
subparagraph (B), the fee limitations described 
in this subparagraph are limitations established 
by the Secretaries for the amount a certified 
IDR entity may charge a nonparticipating pro-
vider, 
nonparticipating 
emergency 
facility, 
group health plan, or health insurance issuer 
offering heath insurance coverage in the group 
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134 
or individual market for services furnished by 
such entity with respect to the resolution of a 
specified request of such provider, facility, plan, 
or issuer under the process described in sub-
section (a). 
(3) SELECTION OF CERTIFIED IDR ENTITY.— 
The group health plan or health insurance issuer of-
fering health insurance coverage in the group or in-
dividual market and the nonparticipating provider or 
the nonparticipating emergency facility (as applica-
ble) involved in a request submitted under the IDR 
process shall agree on a certified IDR entity to re-
solve such request. In the case that such plan or 
issuer (as applicable) and such provider or facility 
(as applicable) cannot so agree, such an entity shall 
be selected by the Secretaries at random, in accord-
ance with a manner and timeline specified by the 
Secretaries. 
(d) PAYMENT DETERMINATION.— 
(1) TIMING.—A certified IDR entity selected 
under subsection (c)(3) with respect to a request 
under the IDR process shall, subject to paragraph 
(2), not later than 30 days after being so selected, 
determine the alternative payment that should be 
made for items and services (or air ambulance serv-
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135 
ices) included in such request in accordance with 
paragraph (3). 
(2) SETTLEMENT.— 
(A) IN
GENERAL.—If such entity deter-
mines that a settlement between the group 
health plan or issuer, as applicable, and the 
provider or facility, as applicable, is likely with 
respect to a request under the IDR process, the 
entity may direct the parties to attempt, for a 
period not to exceed 10 days, a good faith nego-
tiation for a settlement of such request. 
(B) TIMING.—The period for a settlement 
described in subparagraph (A) shall accrue to-
ward the 30-day period described in paragraph 
(1). 
(3) DETERMINATION
OF
ALTERNATIVE
PAY-
MENT.— 
(A) IN GENERAL.—The group health plan 
or health insurance issuer offering health insur-
ance coverage in the group or individual market 
(as applicable) and the nonparticipating pro-
vider or nonparticipating emergency facility (as 
applicable) involved shall, with respect to a re-
quest under the IDR process, each submit to 
the certified IDR entity selected under sub-
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pamtmann on DSKBC07HB2PROD with BILLS
136 
section (c)(3) for such request a final offer to 
be considered for the alternative payment to be 
applied with respect to items and services (or 
air ambulance services) which are the subject of 
the request. Such entity shall determine, in ac-
cordance with subparagraph (B), which such 
offer is the most reasonable and will be applied 
as the alternative payment. 
(B) 
CONSIDERATIONS
IN
DETERMINA-
TION.— 
(i) IN
GENERAL.—In determining 
which final offer is the alternative payment 
to be applied, the certified IDR entity se-
lected under subsection (c)(3) for such re-
quest shall consider— 
(I) the median contracted rates 
(as defined in subsection (b)(3)(E) of 
section 2719A of the Public Health 
Service Act or subsection (b)(3)(E) of 
section 716 of the Employee Retire-
ment Income Security Act of 1974 or 
section 9816 of the Internal Revenue 
Code of 1986 (as applicable)) for the 
applicable year for items or services 
(or air ambulance services) that are 
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pamtmann on DSKBC07HB2PROD with BILLS
137 
comparable to the items and services 
(or air ambulance services) included 
in the request and that are furnished 
in the same geographic area (as de-
fined by the Secretaries for purposes 
of such subsection) as such items and 
services (or air ambulance services) 
(not including any facility fees with 
respect to such rates); and 
(II) in the case of items and 
services (other than air ambulances 
services), each circumstance described 
in clause (ii) with respect to which in-
formation is submitted by either party 
or, in the case of air ambulance serv-
ices, each circumstance described in 
clause (iii) with respect to which in-
formation is submitted by either 
party. 
(ii) ADDITIONAL CIRCUMSTANCES FOR 
CERTAIN ITEMS AND SERVICES.—For pur-
poses of clause (i)(II), the circumstances 
described in this clause are, with respect to 
items and services (other than air ambu-
lance services) included in the request 
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pamtmann on DSKBC07HB2PROD with BILLS
138 
under the IDR process of a nonpartici-
pating provider, nonparticipating emer-
gency facility, group health plan, or health 
insurance issuer the following: 
(I) The level of training, edu-
cation, experience, and quality and 
outcomes measurements of the pro-
vider or facility that furnished such 
items and services (such as those en-
dorsed by the consensus-based entity 
authorized under section 1890 of the 
Social Security Act). 
(II) The market share held by 
the provider or facility, or the plan or 
issuer, in the geographic area in 
which the item or service was pro-
vided. 
(III) Any other extenuating cir-
cumstances with respect to the fur-
nishing of such items and services 
that relate to the acuity of the indi-
vidual receiving such items and serv-
ices or the complexity of furnishing 
such items and services to such indi-
vidual. 
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pamtmann on DSKBC07HB2PROD with BILLS
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(iii) 
ADDITIONAL
CIRCUMSTANCES 
FOR AIR AMBULANCE SERVICES.—For pur-
poses of clause (i)(II), the circumstances 
described in this clause are, with respect to 
air ambulance services included in the re-
quest under the IDR process of a non-
participating provider, group health plan, 
or health insurance issuer the following: 
(I) The quality and outcomes 
measurements of the provider that 
furnished such services. 
(II) Any other extenuating cir-
cumstances with respect to the fur-
nishing of such services that relate to 
the acuity of the individual receiving 
such services or the complexity of fur-
nishing such services to such indi-
vidual. 
(III) The training, education, ex-
perience, and quality of the medical 
personnel that furnished such serv-
ices. 
(IV) Ambulance vehicle type, in-
cluding the clinical capability level of 
such vehicle. 
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pamtmann on DSKBC07HB2PROD with BILLS
140 
(V) Population density of the 
pick up location (such as urban, sub-
urban, rural, or frontier). 
(iv) PROHIBITION ON CONSIDERATION 
OF
BILLED
CHARGES.—In determining 
which final offer is the alternative payment 
amount to be applied with respect to items 
and services (or air ambulance services) 
furnished by a provider or facility and in-
cluded in the request under the IDR proc-
ess, the certified IDR entity selected under 
subsection (c)(3) with respect to such re-
quest shall not consider the amount that 
would have been billed by such provider or 
facility with respect to such items and 
services had the provisions of section 
2799A–1, 2799A–2, or 2799A–4 of the 
Public Health Service Act (as applicable) 
not applied. 
(C) EFFECTS OF DETERMINATION.— 
(i) IN GENERAL.—A determination of 
a certified IDR entity under subparagraph 
(A) shall be binding. 
(ii) LIMITATION ON CERTAIN SUBSE-
QUENT IDR CLAIMS.—In the case of a de-
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pamtmann on DSKBC07HB2PROD with BILLS
141 
termination of a certified IDR entity under 
subparagraph (A), with respect to a re-
quest submitted under subsection (a)(1)(A) 
and the two parties involved with such re-
quest, the party that submitted such initial 
request may not submit during the 90-day 
period following such determination a sub-
sequent request under such subsection in-
volving the same other party to such re-
quest with respect to such an item or serv-
ice (or air ambulance service) that was the 
subject of such initial request. 
(D) COSTS
OF
INDEPENDENT
DISPUTE 
RESOLUTION PROCESS.—In the case of a re-
quest made by a nonparticipating provider, non-
participating emergency facility, group health 
plan, or health insurance issuer offering health 
insurance coverage in the group or individual 
market and submitted to a certified IDR enti-
ty— 
(i) if such entity makes a determina-
tion with respect to such request under 
subparagraph (A), the party whose offer is 
not chosen under such clause shall be re-
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