H. R. 133—1571 
(8) AUTHORIZATION OF APPROPRIATIONS.—There is author-
ized to be appropriated to carry out this subsection $25,000,000, 
to remain available until expended. 
(b) FISH AND WILDLIFE SERVICE ASIAN CARP ERADICATION PRO-
GRAM.— 
(1) ESTABLISHMENT.—The Secretary of the Interior, acting 
through the Director of the United States Fish and Wildlife 
Service, shall establish a program to provide financial assist-
ance to States to implement measures, including for manage-
ment, research, and public education activities, necessary to 
eradicate the Asian carp. 
(2) ELIGIBILITY.—A State is eligible to receive financial 
assistance under this subsection if such State has demonstrated 
to the Secretary of the Interior sufficient need to implement 
measures to eradicate the Asian carp. 
(3) PRIORITY.—In providing financial assistance under the 
program, the Secretary of the Interior shall give priority to 
States in the Cumberland River Watershed or the Tennessee 
River Watershed in which Asian carp populations are 
expanding or have been documented. 
(4) COST SHARING.— 
(A) FEDERAL SHARE.—The Federal share of the costs 
of activities carried out under the program may not exceed 
80 percent of the total costs of such activities. 
(B) IN-KIND CONTRIBUTIONS.—The non-Federal share 
of the costs of activities carried out under the program 
may be provided in the form of in-kind contributions of 
materials or services. 
(5) LIMITATION ON ADMINISTRATIVE EXPENSES.—Not more 
than 5 percent of financial assistance provided by the Secretary 
of the Interior under this subsection may be used for adminis-
trative expenses. 
(6) AUTHORIZATION OF APPROPRIATIONS.—There is author-
ized to be appropriated to the Secretary of the Interior to 
carry out this subsection $4,000,000 for each of fiscal years 
2021 through 2025. 
SEC. 510. INVASIVE SPECIES IN NONCONTIGUOUS STATES AND TERRI-
TORIES PILOT PROGRAM. 
(a) ESTABLISHMENT.—The Secretary of the Interior, acting 
through the Director of the United States Fish and Wildlife Service, 
shall establish a pilot program to carry out measures necessary 
to prevent, control, or eradicate invasive species in culturally signifi-
cant forested watersheds in noncontiguous States and territories 
of the United States in which the Corps of Engineers is carrying 
out flood risk management projects. 
(b) IMPLEMENTATION.—The Secretary of the Interior, acting 
through the Director of the United States Fish and Wildlife Service, 
is encouraged to carry out the measures described in subsection 
(a) in consultation with— 
(1) States, any territory or possession of the United States, 
and units of local government, including federally recognized 
Indian Tribes (as defined in section 4 of the Indian Self-Deter-
mination and Education Assistance Act (25 U.S.C. 5304)); and 
(2) nonprofit organizations with knowledge of, and experi-
ence in, forested watershed management, including nonprofit
H. R. 133—1572 
organizations with a primary purpose of serving and partnering 
with indigenous communities. 
(c) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 
to be appropriated to carry out the pilot program under subsection 
(a) $25,000,000 for the period of fiscal years 2022 through 2024. 
SEC. 511. SOIL MOISTURE AND SNOWPACK MONITORING. 
(a) INSTALLATION OF NETWORK.— 
(1) IN GENERAL.—In accordance with the activities required 
under section 4003(a) of the Water Resources Reform and 
Development Act of 2014 (128 Stat. 1310; 130 Stat. 1676), 
and to support the goals of the Weather Research and Fore-
casting Innovation Act of 2017 (Public Law 115–25) and the 
National Integrated Drought Information System Reauthoriza-
tion Act of 2018 (Public Law 115–423), the Secretary, in 
coordination with the Administrator of the National Oceanic 
and Atmospheric Administration (referred to in this section 
as the ‘‘Administrator’’), the Chief of the Natural Resources 
Conservation Service, the Director of the United States 
Geological Survey, and the Commissioner of Reclamation, shall 
continue installation of a network of soil moisture and plains 
snowpack monitoring stations, and modification of existing sta-
tions, in the Upper Missouri River Basin. 
(2) REQUIREMENTS.—In carrying out installation and modi-
fication activities under paragraph (1), the Secretary— 
(A) may continue to enter into agreements, including 
cooperative agreements, with State mesonet programs for 
purposes of installing new stations or modifying existing 
stations; 
(B) shall transfer ownership and all responsibilities 
for operation and maintenance of new stations to the 
respective State mesonet program for the State in which 
the monitoring station is located on completion of installa-
tion of the station; and 
(C) shall establish, in consultation with the Adminis-
trator, requirements and standards for the installation of 
new stations and modification of existing stations to ensure 
seamless data integration into— 
(i) the National Mesonet Program; 
(ii) the National Coordinated Soil Moisture Net-
work; and 
(iii) other relevant networks. 
(3) AUTHORIZATION OF APPROPRIATIONS.—There is author-
ized to be appropriated to carry out this subsection, in addition 
to any other funds authorized to be appropriated for the 
installation of a network of soil moisture and plains snowpack 
monitoring stations or the modification of existing stations in 
the Upper Missouri River Basin, $7,000,000 for each of fiscal 
years 2021 through 2025. 
(b) SOIL MOISTURE AND SNOWPACK MONITORING PILOT PRO-
GRAM.— 
(1) IN GENERAL.—Not later than 180 days after the date 
of the enactment of this Act, the Administrator shall establish 
within the National Mesonet Program a pilot program for the 
acquisition and use of data generated by the network described 
in subsection (a).
H. R. 133—1573 
(2) REQUIREMENTS.—In establishing the pilot program 
under paragraph (1), the Administrator shall— 
(A) enter into agreements with State mesonet programs 
in the Upper Missouri River Basin to acquire data gen-
erated by the network described in subsection (a) that— 
(i) are similar to the agreements in effect as of 
the date of the enactment of this Act with States 
under the National Mesonet Program; and 
(ii) allow for sharing of data with other Federal 
agencies and with institutions engaged in federally 
supported research, including the United States 
Drought Monitor, as appropriate and feasible; 
(B) in coordination with the Secretary, the Chief of 
the Natural Resources Conservation Service, the Director 
of the United States Geological Survey, and the Commis-
sioner of Reclamation, gather data from the operation of 
the network to inform ongoing efforts of the National Oce-
anic and Atmospheric Administration in support of— 
(i) the National Integrated Drought Information 
System, including the National Coordinated Soil Mois-
ture Network; 
(ii) the United States Drought Monitor; 
(iii) the National Water Model and other relevant 
national modeling efforts; 
(iv) validation, verification, and calibration of sat-
ellite-based, in situ, and other remote sensing activities 
and output products; 
(v) flood risk and water resources monitoring ini-
tiatives by the Secretary and the Commissioner; and 
(vi) any other programs or initiatives the Adminis-
trator considers appropriate; 
(C) at the request of State mesonet programs, or as 
the Administrator considers appropriate, provide technical 
assistance to such programs under the pilot program under 
paragraph (1) to ensure proper data requirements; and 
(D) ensure an appropriate mechanism for quality con-
trol and quality assurance is employed for the data acquired 
under the pilot program, such as the Meteorological Assimi-
lation Data Ingest System. 
(3) STUDY REQUIRED.— 
(A) IN GENERAL.—Not later than 1 year after the date 
of the enactment of this Act, the Administrator shall ini-
tiate a study of the pilot program required by paragraph 
(1) to evaluate the data generated by the network described 
in subsection (a) and the applications of that data to pro-
grams and initiatives described in paragraph (2)(B). 
(B) ELEMENTS.—The study required by subparagraph 
(A) shall include an assessment of— 
(i) the contribution of the soil moisture, snowpack, 
and other relevant data generated by the network 
described in subsection (a) to weather, subseasonal 
and seasonal, and climate forecasting products on the 
local, regional, and national levels; 
(ii) the enhancements made to the National 
Integrated Drought Information System, the National 
Water Model, and the United States Drought Monitor, 
and other relevant national modeling efforts, using
H. R. 133—1574 
data and derived data products generated by the net-
work; 
(iii) the contribution of data generated by the net-
work to remote sensing products and approaches; 
(iv) the viability of the ownership and operational 
structure of the network; and 
(v) any other matters the Administrator considers 
appropriate, in coordination with the Secretary, the 
Chief of the Natural Resources Conservation Service, 
the Director of the United States Geological Survey, 
and the Commissioner of Reclamation. 
(4) REPORT REQUIRED.—Not later than 4 years after the 
date of the enactment of this Act, the Administrator shall 
submit to the appropriate congressional committees a report— 
(A) setting forth the findings of the study required 
by paragraph (3); and 
(B) making recommendations based on those findings 
to improve weather, subseasonal, seasonal, and climate 
monitoring nationally. 
(5) GOVERNMENT ACCOUNTABILITY OFFICE AUDIT.— 
(A) IN GENERAL.—Not later than 60 days after the 
report required by paragraph (4) is submitted, the Comp-
troller General of the United States shall initiate an audit 
to evaluate that report and determine whether— 
(i) the Administrator, in conducting the pilot pro-
gram under paragraph (1), has utilized the relevant 
data generated by the network described in subsection 
(a) in the manner most beneficial to the programs 
and initiatives described in paragraph (2)(B); 
(ii) the acquisition agreements entered into under 
paragraph (2)(A) with State mesonet programs fully 
comply with the requirements of that paragraph; and 
(iii) the heads of other agencies, including the Sec-
retary, the Chief of the Natural Resources Conserva-
tion Service, the Director of the United States 
Geological Survey, and the Commissioner of Reclama-
tion, are utilizing the data generated by the network 
to better inform and improve the missions of those 
agencies. 
(B) REPORT REQUIRED.—Not later than 270 days after 
initiating the audit required by subparagraph (A), the 
Comptroller General shall submit to the appropriate 
congressional committees a report setting forth the findings 
of the audit. 
(6) APPROPRIATE CONGRESSIONAL COMMITTEES DEFINED.— 
In this subsection, the term ‘‘appropriate congressional commit-
tees’’ means— 
(A) the Committee on Commerce, Science, and 
Transportation, the Committee on Environment and Public 
Works, and the Committee on Energy and Natural 
Resources of the Senate; and 
(B) the Committee on Transportation and Infrastruc-
ture, the Committee on Science, Space, and Technology, 
and the Committee on Natural Resources of the House 
of Representatives.
H. R. 133—1575 
SEC. 512. GREAT LAKES ST. LAWRENCE SEAWAY DEVELOPMENT COR-
PORATION. 
(a) RENAMING
THE SAINT LAWRENCE SEAWAY DEVELOPMENT 
CORPORATION.—The Act of May 13, 1954 (33 U.S.C. 981 et seq.) 
is amended— 
(1) in section 1 (33 U.S.C. 981), by striking ‘‘Saint Lawrence 
Seaway Development Corporation’’ and inserting ‘‘Great Lakes 
St. Lawrence Seaway Development Corporation’’; and 
(2) in section 2(b) (33 U.S.C. 982(b)), by striking ‘‘Saint 
Lawrence Seaway Development Corporation’’ and inserting 
‘‘Great Lakes St. Lawrence Seaway Development Corporation’’. 
(b) REFERENCES.—Any reference to the Saint Lawrence Seaway 
Development Corporation in any law, regulation, document, record, 
Executive order, or other paper of the United States shall be deemed 
to be a reference to the Great Lakes St. Lawrence Seaway Develop-
ment Corporation. 
(c) TECHNICAL AND CONFORMING AMENDMENTS.— 
(1) TITLE 5.—Section 5315 of title 5, United States Code, 
is amended by striking ‘‘Saint Lawrence Seaway Development 
Corporation’’ and inserting ‘‘Great Lakes St. Lawrence Seaway 
Development Corporation’’. 
(2) TITLE
18.—Section 2282B of title 18, United States 
Code, is amended by striking ‘‘Saint Lawrence Seaway Develop-
ment Corporation’’ and inserting ‘‘Great Lakes St. Lawrence 
Seaway Development Corporation’’. 
(3) INTERNAL
REVENUE
CODE.—Section 9505(a)(2) of the 
Internal Revenue Code of 1986 (26 U.S.C. 9505(a)(2)) is 
amended by striking ‘‘Saint Lawrence Seaway Development 
Corporation’’ and inserting ‘‘Great Lakes St. Lawrence Seaway 
Development Corporation’’. 
(4) TITLE 31.—Section 9101(3)(K) of title 31, United States 
Code, is amended by striking ‘‘Saint Lawrence Seaway Develop-
ment Corporation’’ and inserting ‘‘Great Lakes St. Lawrence 
Seaway Development Corporation’’. 
(5) WATER
RESOURCES
DEVELOPMENT
ACT
OF
1986.—The 
Water Resources Development Act of 1986 (33 U.S.C. 2211 
et seq.) is amended— 
(A) in section 206 (33 U.S.C. 2234), by striking ‘‘Saint 
Lawrence Seaway Development Corporation’’ and inserting 
‘‘Great Lakes St. Lawrence Seaway Development Corpora-
tion’’; 
(B) in section 210(a)(1) (33 U.S.C. 2238(a)(1)), by 
striking ‘‘Saint Lawrence Seaway Development Corpora-
tion’’ and inserting ‘‘Great Lakes St. Lawrence Seaway 
Development Corporation’’; 
(C) in section 214(2)(B) (33 U.S.C. 2241(2)(B)), by 
striking ‘‘Saint Lawrence Seaway Development Corpora-
tion’’ and inserting ‘‘Great Lakes St. Lawrence Seaway 
Development Corporation’’; and 
(D) in section 1132(b) (33 U.S.C. 2309(b)), by striking 
‘‘Saint Lawrence Seaway Development Corporation’’ and 
inserting ‘‘Great Lakes St. Lawrence Seaway Development 
Corporation’’ each place it appears. 
(6) TITLE 46.—Title 46, United States Code, is amended— 
(A) in section 2109, by striking ‘‘Saint Lawrence Sea-
way Development Corporation’’ and inserting ‘‘Great Lakes 
St. Lawrence Seaway Development Corporation’’;
H. R. 133—1577 
Sec. 104. Health care provider requirements regarding surprise medical billing. 
Sec. 105. Ending surprise air ambulance bills. 
Sec. 106. Reporting requirements regarding air ambulance services. 
Sec. 107. Transparency regarding in-network and out-of-network deductibles and 
out-of-pocket limitations. 
Sec. 108. Implementing protections against provider discrimination. 
Sec. 109. Reports. 
Sec. 110. Consumer protections through application of health plan external review 
in cases of certain surprise medical bills. 
Sec. 111. Consumer protections through health plan requirement for fair and hon-
est advance cost estimate. 
Sec. 112. Patient protections through transparency and patient-provider dispute 
resolution. 
Sec. 113. Ensuring continuity of care. 
Sec. 114. Maintenance of price comparison tool. 
Sec. 115. State All Payer Claims Databases. 
Sec. 116. Protecting patients and improving the accuracy of provider directory in-
formation. 
Sec. 117. Advisory committee on ground ambulance and patient billing. 
Sec. 118. Implementation funding. 
TITLE II—TRANSPARENCY 
Sec. 201. Increasing transparency by removing gag clauses on price and quality in-
formation. 
Sec. 202. Disclosure of direct and indirect compensation for brokers and consult-
ants to employer-sponsored health plans and enrollees in plans on the 
individual market. 
Sec. 203. Strengthening parity in mental health and substance use disorder bene-
fits. 
Sec. 204. Reporting on pharmacy benefits and drug costs. 
TITLE III—PUBLIC HEALTH PROVISIONS 
Subtitle A—Extenders Provisions 
Sec. 301. Extension for community health centers, the National Health Service 
Corps, and teaching health centers that operate GME programs. 
Sec. 302. Diabetes programs. 
Subtitle B—Strengthening Public Health 
Sec. 311. Improving awareness of disease prevention. 
Sec. 312. Guide on evidence-based strategies for public health department obesity 
prevention programs. 
Sec. 313. Expanding capacity for health outcomes. 
Sec. 314. Public health data system modernization. 
Sec. 315. Native American suicide prevention. 
Sec. 316. Reauthorization of the Young Women’s Breast Health Education and 
Awareness Requires Learning Young Act of 2009. 
Sec. 317. Reauthorization of school-based health centers. 
Subtitle C—FDA Amendments 
Sec. 321. Rare pediatric disease priority review voucher extension. 
Sec. 322. Conditions of use for biosimilar biological products. 
Sec. 323. Orphan drug clarification. 
Sec. 324. Modernizing the labeling of certain generic drugs. 
Sec. 325. Biological product patent transparency. 
Subtitle D—Technical Corrections 
Sec. 331. Technical corrections. 
TITLE I—NO SURPRISES ACT 
SEC. 101. SHORT TITLE. 
This title may be cited as the ‘‘No Surprises Act’’. 
SEC. 102. HEALTH INSURANCE REQUIREMENTS REGARDING SURPRISE 
MEDICAL BILLING. 
(a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.—
H. R. 133—1578 
(1) IN GENERAL.—Title XXVII of the Public Health Service 
Act (42 U.S.C. 300gg et seq.) is amended by adding at the 
end the following new part: 
‘‘PART D—ADDITIONAL COVERAGE 
PROVISIONS 
‘‘SEC. 2799A–1. PREVENTING SURPRISE MEDICAL BILLS. 
‘‘(a) COVERAGE OF EMERGENCY SERVICES.— 
‘‘(1) IN GENERAL.—If a group health plan, or a health insur-
ance issuer offering group or individual health insurance cov-
erage, provides or covers any benefits with respect to services 
in an emergency department of a hospital or with respect 
to emergency 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 para-
graph (3)(C))— 
‘‘(A) without the need for any prior authorization deter-
mination; 
‘‘(B) whether the health care provider furnishing such 
services is a participating provider or a participating emer-
gency facility, as applicable, with respect to such services; 
‘‘(C) in a manner so that, if such services are provided 
to a participant, beneficiary, or enrollee by a nonpartici-
pating provider or a nonparticipating emergency facility— 
‘‘(i) such services will be provided without imposing 
any requirement under the plan or coverage for prior 
authorization of services or any limitation on coverage 
that is more restrictive than the requirements or 
limitations that apply to emergency services received 
from participating providers and participating emer-
gency facilities with respect to such plan or coverage, 
respectively; 
‘‘(ii) the cost-sharing requirement is not greater 
than the requirement that would apply if such services 
were provided by a participating provider or a partici-
pating emergency facility; 
‘‘(iii) such cost-sharing requirement is calculated 
as if the total amount that would have been charged 
for such services by such participating provider or 
participating emergency facility were equal to the rec-
ognized amount (as defined in paragraph (3)(H)) for 
such services, plan or coverage, and year; 
‘‘(iv) the group health plan or health insurance 
issuer, respectively— 
‘‘(I) not later than 30 calendar days after the 
bill for such services is transmitted by such pro-
vider or facility, sends to the provider or facility, 
as applicable, an initial payment or notice of denial 
of payment; and 
‘‘(II) pays a total plan or coverage payment 
directly to such provider or facility, respectively 
(in accordance, if applicable, with the timing 
requirement described in subsection (c)(6)) that 
is, with application of any initial payment under 
subclause (I), equal to the amount by which the 
out-of-network rate (as defined in paragraph
H. R. 133—1579 
(3)(K)) for such services exceeds the cost-sharing 
amount for such services (as determined in accord-
ance 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 
maximums applied under the plan or coverage, respec-
tively (and such in-network deductible and out-of- 
pocket maximums shall be applied) in the same 
manner as if such cost-sharing payments were made 
with respect to emergency services furnished by a 
participating provider or a 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 the Internal Revenue 
Code of 1986, and other than applicable cost-sharing). 
‘‘(2) AUDIT PROCESS AND REGULATIONS FOR QUALIFYING PAY-
MENT AMOUNTS.— 
‘‘(A) AUDIT PROCESS.— 
‘‘(i) IN GENERAL.—Not later than October 1, 2021, 
the Secretary, in consultation with the Secretary of 
Labor and the Secretary of the Treasury, shall estab-
lish through rulemaking a process, in accordance with 
clause (ii), under which group health plans and health 
insurance issuers offering group or individual health 
insurance coverage 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 qualifying pay-
ment amount under this section; and 
‘‘(II) such qualifying payment amount so 
applied satisfies the definition under paragraph 
(3)(E) with respect to the year involved, including 
with respect to a group health plan or health insur-
ance issuer described in clause (ii) of such para-
graph (3)(E). 
‘‘(ii) AUDIT
SAMPLES.—Under the process estab-
lished pursuant to clause (i), the Secretary— 
‘‘(I) shall conduct audits described in such 
clause, with respect to a year (beginning with 
2022), of a sample with respect to such year of 
claims data from not more than 25 group health 
plans and health insurance issuers offering group 
or individual health insurance coverage; and 
‘‘(II) may audit any group health plan or 
health insurance issuer offering group or indi-
vidual health insurance coverage if the Secretary 
has received any complaint or other information 
about such plan or coverage, respectively, that 
involves the compliance of the plan or coverage, 
respectively, with either of the requirements 
described in subclauses (I) and (II) of such clause.
H. R. 133—1580 
‘‘(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 rule-
making— 
‘‘(i) the methodology the group health plan or 
health insurance issuer offering group or individual 
health insurance coverage shall use to determine the 
qualifying payment amount, differentiating by indi-
vidual market, large group market, and small group 
market; 
‘‘(ii) the information such plan or issuer, respec-
tively, shall share with the nonparticipating provider 
or nonparticipating 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 defined 
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 insurance issuers offering group or individual 
health insurance coverage. 
Such rulemaking shall take into account payments that 
are made by such plan or issuer, respectively, 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 (including higher acuity 
settings and the case-mix of various facility types) that 
are otherwise taken into account for purposes of deter-
mining payment amounts with respect to participating 
facilities. In carrying out clause (iii), the Secretary shall 
consult with the National Association of Insurance Commis-
sioners to establish the geographic regions under such 
clause and shall periodically update such regions, as appro-
priate, taking into account the findings of the report sub-
mitted under section 109(a) of the No Surprises Act. 
‘‘(3) DEFINITIONS.—In this part and part E: 
‘‘(A) EMERGENCY
DEPARTMENT
OF
A
HOSPITAL.—The 
term ‘emergency department of a hospital’ includes a hos-
pital outpatient department that provides emergency serv-
ices (as defined in subparagraph (C)(i)). 
‘‘(B) EMERGENCY
MEDICAL
CONDITION.—The term 
‘emergency medical condition’ means a medical condition 
manifesting itself by acute symptoms of sufficient severity 
(including severe 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.
H. R. 133—1581 
‘‘(C) EMERGENCY SERVICES.— 
‘‘(i) IN GENERAL.—The term ‘emergency services’, 
with respect to an emergency medical condition, 
means— 
‘‘(I) a medical screening examination (as 
required under section 1867 of the Social Security 
Act, or as would be required under such section 
if such section applied to an independent free-
standing emergency department) that is within 
the capability of the emergency department of a 
hospital or of an independent freestanding emer-
gency 
department, 
as 
applicable, 
including 
ancillary services routinely available to the emer-
gency department to evaluate such emergency 
medical condition; and 
‘‘(II) within the capabilities of the staff and 
facilities available at the hospital or the inde-
pendent freestanding emergency department, as 
applicable, such further medical examination and 
treatment as are required under section 1867 of 
such Act, or as would be required under such 
section if such section applied to an independent 
freestanding emergency department, to stabilize 
the patient (regardless of the department of the 
hospital in which such further examination or 
treatment is furnished). 
‘‘(ii) INCLUSION OF ADDITIONAL SERVICES.— 
‘‘(I) IN GENERAL.—For purposes of this sub-
section and section 2799B–1, in the case of a 
participant, beneficiary, or enrollee who is enrolled 
in a group health plan or group or individual 
health insurance coverage offered by a health 
insurance issuer and who is furnished services 
described in clause (i) with respect to an emergency 
medical condition, the term ‘emergency 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— 
‘‘(aa) for which benefits are provided or 
covered under the plan or coverage, respec-
tively; and 
‘‘(bb) that are furnished by a nonpartici-
pating provider or nonparticipating emergency 
facility (regardless of the department of the 
hospital in which such items or services are 
furnished) after the participant, beneficiary, 
or enrollee is stabilized and as part of out-
patient observation or an inpatient or out-
patient stay with respect to the visit in which 
the services described in clause (i) are fur-
nished. 
‘‘(II) CONDITIONS.—For purposes of subclause 
(I), the conditions described in this subclause, with 
respect to a participant, beneficiary, or enrollee 
who is stabilized and furnished additional items 
and services described in subclause (I) after such
H. R. 133—1582 
stabilization by a provider or facility described in 
subclause (I), are the following; 
‘‘(aa) Such provider or facility determines 
such individual is able to travel using nonmed-
ical transportation or nonemergency medical 
transportation. 
‘‘(bb) Such provider furnishing such addi-
tional items and services satisfies the notice 
and consent criteria of section 2799B–2(d) with 
respect to such items and services. 
‘‘(cc) Such individual is in a condition to 
receive (as determined in accordance with 
guidelines issued by the Secretary pursuant 
to rulemaking) the information described in 
section 2799B–2 and to provide informed con-
sent under such section, in accordance with 
applicable State law. 
‘‘(dd) Such other conditions, as specified 
by the Secretary, such as conditions relating 
to coordinating care transitions to partici-
pating providers and facilities. 
‘‘(D) INDEPENDENT FREESTANDING EMERGENCY DEPART-
MENT.—The term ‘independent freestanding emergency 
department’ means a health care facility that— 
‘‘(i) is geographically separate and distinct and 
licensed separately from a hospital under applicable 
State law; and 
‘‘(ii) provides any of the emergency services (as 
defined in subparagraph (C)(i)). 
‘‘(E) QUALIFYING PAYMENT AMOUNT.— 
‘‘(i) IN GENERAL.—The term ‘qualifying payment 
amount’ means, subject to clauses (ii) and (iii), with 
respect to a sponsor of a group health plan and health 
insurance issuer offering group or individual health 
insurance coverage— 
‘‘(I) for an item or service furnished during 
2022, the median of the contracted rates recog-
nized 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 insurance market 
(specified in subclause (I), (II), (III), or (IV) of 
clause (iv)) 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 
(2)(B), increased by the percentage increase in the 
consumer price index for all urban consumers 
(United States city average) over 2019, such
H. R. 133—1583 
percentage increase over 2020, and such percent-
age increase over 2021; and 
‘‘(II) for an item or service furnished during 
2023 or a subsequent year, the qualifying payment 
amount determined under this clause for such an 
item or service furnished in the previous year, 
increased by the percentage increase in the con-
sumer price index for all urban consumers (United 
States city average) over such previous year. 
‘‘(ii) NEW PLANS AND COVERAGE.—The term ‘quali-
fying payment amount’ means, with respect to a 
sponsor of a group health plan or health insurance 
issuer offering group or individual health insurance 
coverage 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, group health insurance coverage, or 
individual health insurance coverage, respectively, 
is offered in such region, a rate (determined in 
accordance with a methodology established by the 
Secretary) for items and services that are covered 
by such plan or coverage and furnished during 
such first year; and 
‘‘(II) for each subsequent year such group 
health plan, group health insurance coverage, or 
individual health insurance coverage, respectively, 
is offered in such region, the qualifying payment 
amount determined under this clause for such 
items and services furnished in the previous year, 
increased by the percentage increase in the con-
sumer 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 or health insurance issuer offering 
group or individual health insurance coverage that does 
not have sufficient information to calculate the median 
of the contracted rates described in clause (i)(I) in 
2019 (or, in the case of a newly covered item or service 
(as defined in clause (v)(III)), in the first coverage 
year (as defined in clause (v)(I)) for such item or service 
with respect to such plan or coverage) 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 particular 
geographic region (other than in a case with respect 
to which clause (ii) applies)) the term ‘qualifying pay-
ment amount’— 
‘‘(I) for an item or service furnished during 
2022 (or, in the case of a newly covered item 
or service, during the first coverage year for such 
item or service with respect to such plan or cov-
erage), means such rate for such item or service 
determined by the sponsor or issuer, respectively, 
through use of any database that is determined,
H. R. 133—1584 
in accordance with rulemaking described in para-
graph (2)(B), to not have any conflicts of interest 
and to have sufficient information reflecting 
allowed amounts paid to a health care provider 
or facility for relevant services furnished in the 
applicable geographic region (such as a State all- 
payer claims database); 
‘‘(II) for an item or service furnished in a sub-
sequent year (before the first sufficient information 
year (as defined in clause (v)(II)) for such item 
or service with respect to such plan or coverage), 
means the rate determined 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 
consumer price index for all urban consumers 
(United States city average) over such previous 
year; 
‘‘(III) for an item or service furnished in the 
first sufficient information year for such item or 
service with respect to such plan or coverage, has 
the meaning given the term qualifying payment 
amount in clause (i)(I), except that in applying 
such clause to such item or service, the reference 
to ‘furnished 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 sufficient informa-
tion year, and the increase described in such clause 
shall not be applied; and 
‘‘(IV) for an item or service furnished in any 
year subsequent to the first sufficient information 
year for such item or service with respect to such 
plan or coverage, 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 furnished during the year after 
such first sufficient information year or a subse-
quent year. 
‘‘(iv) INSURANCE MARKET.—For purposes of clause 
(i)(I), a health insurance market specified in this clause 
is one of the following: 
‘‘(I) The individual market. 
‘‘(II) The large group market (other than plans 
described in subclause (IV)). 
‘‘(III) The small group market (other than 
plans described in subclause (IV)). 
‘‘(IV) In the case of a self-insured group health 
plan, other self-insured group health plans. 
‘‘(v) DEFINITIONS.—For purposes of this subpara-
graph: 
‘‘(I) FIRST
COVERAGE
YEAR.—The term ‘first 
coverage year’ means, with respect to a group 
health plan or group or individual health insurance 
coverage offered by a health insurance issuer and 
an item or service for which coverage is not offered
H. R. 133—1585 
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 coverage. 
‘‘(II) FIRST SUFFICIENT INFORMATION YEAR.— 
The term ‘first sufficient information year’ means, 
with respect to a group health plan or group or 
individual health insurance coverage offered by 
a health insurance issuer— 
‘‘(aa) in the case of an item or service 
for which the plan or coverage does not have 
sufficient information to calculate the median 
of the contracted rates described in clause (i)(I) 
in 2019, the first year subsequent to 2022 
for which the sponsor or issuer has such suffi-
cient information to calculate the median of 
such contracted rates in the year previous to 
such first subsequent year; and 
‘‘(bb) in the case of a newly covered item 
or service, the first year subsequent to the 
first coverage year for such item or service 
with respect to such plan or coverage for which 
the sponsor or issuer has sufficient informa-
tion to calculate the median of the contracted 
rates described in clause (i)(I) in the year pre-
vious 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 group or indi-
vidual health insurance issuer offering health 
insurance coverage, 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 FACILITY; PARTICI-
PATING EMERGENCY FACILITY.— 
‘‘(i) NONPARTICIPATING EMERGENCY FACILITY.—The 
term ‘nonparticipating emergency facility’ means, with 
respect to an item or service and a group health plan 
or group or individual health insurance coverage 
offered by a health insurance issuer, 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, respectively, for furnishing such 
item or service under the plan or coverage, respectively. 
‘‘(ii) PARTICIPATING
EMERGENCY
FACILITY.—The 
term ‘participating emergency facility’ means, with 
respect to an item or service and a group health plan 
or group or individual health insurance coverage 
offered by a health insurance issuer, an emergency 
department of a hospital, or an independent free-
standing emergency 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.
H. R. 133—1586 
‘‘(G) NONPARTICIPATING PROVIDERS; PARTICIPATING PRO-
VIDERS.— 
‘‘(i) NONPARTICIPATING PROVIDER.—The term ‘non-
participating provider’ means, with respect to an item 
or service and a group health plan or group or indi-
vidual health insurance coverage offered by a health 
insurance issuer, a physician or other health care pro-
vider who is acting within the scope of practice of 
that provider’s license or certification under applicable 
State law and who does not have a contractual relation-
ship with the plan or issuer, respectively, for furnishing 
such item or service under the plan or coverage, respec-
tively. 
‘‘(ii) PARTICIPATING PROVIDER.—The term ‘partici-
pating provider’ means, with respect to an item or 
service and a group health plan or group or individual 
health insurance coverage offered by a health insur-
ance issuer, a physician or other health care provider 
who is acting within the scope of practice of that pro-
vider’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 nonparticipating emer-
gency facility during a year and a group health plan or 
group or individual health insurance coverage offered by 
a health insurance issuer— 
‘‘(i) subject to clause (iii), in the case of such item 
or service furnished in a State that has in effect a 
specified State law with respect to such plan, coverage, 
or issuer, respectively; such a nonparticipating provider 
or nonparticipating emergency facility; and such an 
item or service, the amount determined in accordance 
with such law; 
‘‘(ii) subject to clause (iii), in the case of such 
item or service furnished in a State that does not 
have in effect a specified State law, with respect to 
such plan, coverage, or issuer, respectively; such a 
nonparticipating provider or nonparticipating emer-
gency facility; and such an item or service, the amount 
that is the qualifying payment amount (as defined 
in subparagraph (E)) for such year and determined 
in accordance with rulemaking described in paragraph 
(2)(B)) for such item or service; or 
‘‘(iii) in the case of such item or service 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 nonparticipating provider or nonpartici-
pating emergency facility during a year and a group health 
plan or group or individual health insurance coverage 
offered by a health insurance issuer, a State law that