4193 
health plan or health insurance issuer offering 
group health insurance coverage that was party 
to such negotiations may, during the 4-day pe-
riod beginning on the day after such open nego-
tiation period, initiate the independent dispute 
resolution process under paragraph (2) with re-
spect to such item or service. The independent 
dispute resolution process shall be initiated by a 
party pursuant to the previous sentence by sub-
mission to the other party and to the Secretary 
of a notification (containing such information as 
specified by the Secretary) and for purposes of 
this subsection, the date of initiation of such 
process shall be the date of such submission or 
such other date specified by the Secretary pursu-
ant to regulations that is not later than the date 
of receipt of such notification by both the other 
party and the Secretary. 
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROC-
ESS AVAILABLE IN CASE OF FAILED OPEN NEGOTIA-
TIONS.— 
‘‘(A) ESTABLISHMENT.—Not later than 1 
year after the date of the enactment of this sub-
section, the Secretary, jointly with the Secretary 
of Health and Human Services and the Sec-
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4194 
retary of the Treasury, shall establish by regula-
tion one independent dispute resolution process 
(referred to in this subsection as the ‘IDR proc-
ess’) under which, in the case of air ambulance 
services with respect to which a provider or 
group health plan or health insurance issuer of-
fering group health insurance coverage submits a 
notification under paragraph (1)(B) (in this 
subsection referred to as a ‘qualified IDR air 
ambulance services’), a certified IDR entity 
under paragraph (4) determines, subject to sub-
paragraph (B) and in accordance with the suc-
ceeding provisions of this subsection, the amount 
of payment under the plan or coverage for such 
services furnished by such provider. 
‘‘(B) AUTHORITY
TO
CONTINUE
NEGOTIA-
TIONS.—Under the independent dispute resolu-
tion process, in the case that the parties to a de-
termination for qualified IDR air ambulance 
services agree on a payment amount for such 
services during such process but before the date 
on which the entity selected with respect to such 
determination under paragraph (4) makes such 
determination 
under 
paragraph 
(5), 
such 
amount shall be treated for purposes of section 
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4195 
716(a)(3)(K)(ii) as the amount agreed to by such 
parties for such services. In the case of an agree-
ment described in the previous sentence, the inde-
pendent dispute resolution process shall provide 
for a method to determine how to allocate be-
tween the parties to such determination the pay-
ment of the compensation of the entity selected 
with respect to such determination. 
‘‘(C) CLARIFICATION.—A nonparticipating 
provider may not, with respect to an item or 
service furnished by such provider, submit a no-
tification under paragraph (1)(B) if such pro-
vider is exempt from the requirement under sub-
section (a) of section 2799B–2 of the Public 
Health Service Act with respect to such item or 
service pursuant to subsection (b) of such section. 
‘‘(3) TREATMENT OF BATCHING OF SERVICES.— 
The provisions of section 716(c)(3) shall apply with 
respect to a notification submitted under this sub-
section with respect to air ambulance services in the 
same manner and to the same extent such provisions 
apply with respect to a notification submitted under 
section 716(c) with respect to items and services de-
scribed in such section. 
‘‘(4) IDR ENTITIES.— 
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4196 
‘‘(A) ELIGIBILITY.—An IDR entity certified 
under this subsection is an IDR entity certified 
under section 716(c)(4). 
‘‘(B) SELECTION OF CERTIFIED IDR ENTI-
TY.—The provisions of subparagraph (F) of sec-
tion 716(c)(4) shall apply with respect to select-
ing an IDR entity certified pursuant to subpara-
graph (A) with respect to the determination of 
the amount of payment under this subsection of 
air ambulance services in the same manner as 
such provisions apply with respect to selecting 
an IDR entity certified under such section with 
respect to the determination of the amount of 
payment under section 716(c) of an item or serv-
ice. An entity selected pursuant to the previous 
sentence to make a determination described in 
such sentence shall be referred to in this sub-
section as the ‘certified IDR entity’ with respect 
to such determination. 
‘‘(5) PAYMENT DETERMINATION.— 
‘‘(A) IN GENERAL.—Not later than 30 days 
after the date of selection of the certified IDR en-
tity with respect to a determination for qualified 
IDR ambulance services, the certified IDR entity 
shall— 
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4197 
‘‘(i) taking into account the consider-
ations specified in subparagraph (C), select 
one of the offers submitted under subpara-
graph (B) to be the amount of payment for 
such services determined under this sub-
section for purposes of subsection (a)(3); 
and 
‘‘(ii) notify the provider or facility and 
the group health plan or health insurance 
issuer offering group health insurance cov-
erage party to such determination of the 
offer selected under clause (i). 
‘‘(B) SUBMISSION
OF
OFFERS.—Not later 
than 10 days after the date of selection of the cer-
tified IDR entity with respect to a determination 
for qualified IDR air ambulance services, the 
provider and the group health plan or health in-
surance issuer offering group health insurance 
coverage party to such determination— 
‘‘(i) shall each submit to the certified 
IDR entity with respect to such determina-
tion— 
‘‘(I) an offer for a payment 
amount for such services furnished by 
such provider; and 
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4198 
‘‘(II) such information as re-
quested by the certified IDR entity re-
lating to such offer; and 
‘‘(ii) may each submit to the certified 
IDR entity with respect to such determina-
tion any information relating to such offer 
submitted by either party, including infor-
mation relating to any circumstance de-
scribed in subparagraph (C)(ii). 
‘‘(C) 
CONSIDERATIONS
IN
DETERMINA-
TION.— 
‘‘(i) IN
GENERAL.—In determining 
which offer is the payment to be applied 
pursuant to this paragraph, the certified 
IDR entity, with respect to the determina-
tion for a qualified IDR air ambulance 
service shall consider— 
‘‘(I) 
the 
qualifying 
payment 
amounts 
(as 
defined 
in 
section 
716(a)(3)(E)) for the applicable year 
for items and services that are com-
parable to the qualified IDR air ambu-
lance service and that are furnished in 
the same geographic region (as defined 
by the Secretary for purposes of such 
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4199 
subsection) as such qualified IDR air 
ambulance service; and 
‘‘(II) subject to clause (iii), infor-
mation on any circumstance described 
in clause (ii), such information as re-
quested in subparagraph (B)(i)(II), 
and any additional information pro-
vided in subparagraph (B)(ii). 
‘‘(ii) ADDITIONAL
CIRCUMSTANCES.— 
For purposes of clause (i)(II), the cir-
cumstances described in this clause are, 
with respect to air ambulance services in-
cluded in the notification submitted under 
paragraph (1)(B) of a nonparticipating 
provider, group health plan, or health in-
surance issuer the following: 
‘‘(I) The quality and outcomes 
measurements of the provider that fur-
nished such services. 
‘‘(II) The acuity of the individual 
receiving such services or the com-
plexity of furnishing such services to 
such individual. 
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4200 
‘‘(III) The training, experience, 
and quality of the medical personnel 
that furnished such services. 
‘‘(IV) Ambulance vehicle type, in-
cluding the clinical capability level of 
such vehicle. 
‘‘(V) Population density of the 
pick up location (such as urban, subur-
ban, rural, or frontier). 
‘‘(VI) Demonstrations of good 
faith efforts (or lack of good faith ef-
forts) made by the nonparticipating 
provider or nonparticipating facility 
or the plan or issuer to enter into net-
work agreements and, if applicable, 
contracted rates between the provider 
and the plan or issuer, as applicable, 
during the previous 4 plan years. 
‘‘(iii) PROHIBITION ON CONSIDERATION 
OF
CERTAIN
FACTORS.—In determining 
which offer is the payment amount to be 
applied with respect to qualified IDR air 
ambulance services furnished by a provider, 
the certified IDR entity with respect to such 
determination shall not consider usual and 
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4201 
customary charges, the amount that would 
have been billed by such provider with re-
spect to such services had the provisions of 
section 2799B–5 of the Public Health Serv-
ice Act not applied, or the payment or re-
imbursement rate for such services furnished 
by such provider payable by a public payor, 
including under the Medicare program 
under title XVIII of the Social Security Act, 
under the Medicaid program under title 
XIX of such Act, under the Children’s 
Health Insurance Program under title XXI 
of such Act, under the TRICARE program 
under chapter 55 of title 10, United States 
Code, or under chapter 17 of title 38, 
United States Code. 
‘‘(D) EFFECTS
OF
DETERMINATION.—The 
provisions of section 716(c)(5)(E)) shall apply 
with respect to a determination of a certified 
IDR entity under subparagraph (A), the notifi-
cation submitted with respect to such determina-
tion, the services with respect to such notifica-
tion, and the parties to such notification in the 
same manner as such provisions apply with re-
spect to a determination of a certified IDR enti-
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4202 
ty under section 716(c)(5)(E), the notification 
submitted with respect to such determination, the 
items and services with respect to such notifica-
tion, and the parties to such notification. 
‘‘(E) COSTS
OF
INDEPENDENT
DISPUTE 
RESOLUTION PROCESS.—The provisions of sec-
tion 716(c)(5)(F) shall apply to a notification 
made under this subsection, the parties to such 
notification, and a determination under sub-
paragraph (A) in the same manner and to the 
same extent such provisions apply to a notifica-
tion under section 716(c), the parties to such no-
tification and a determination made under sec-
tion 716(c)(5)(A). 
‘‘(6) TIMING OF PAYMENT.—The total plan or 
coverage payment required pursuant to subsection 
(a)(3), with respect to qualified IDR air ambulance 
services for which a determination is made under 
paragraph (5)(A) or with respect to air ambulance 
services for which a payment amount is determined 
under open negotiations under paragraph (1), shall 
be made directly to the nonparticipating provider not 
later than 30 days after the date on which such deter-
mination is made. 
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‘‘(7) PUBLICATION OF INFORMATION RELATING 
TO THE IDR PROCESS.— 
‘‘(A) IN
GENERAL.—For each calendar 
quarter in 2022 and each calendar quarter in a 
subsequent year, the Secretary shall publish on 
the public website of the Department of Labor— 
‘‘(i) the number of notifications sub-
mitted under the IDR process during such 
calendar quarter; 
‘‘(ii) the number of such notifications 
with respect to which a final determination 
was made under paragraph (5)(A); 
‘‘(iii) the information described in sub-
paragraph (B) with respect to each notifica-
tion with respect to which such a deter-
mination was so made. 
‘‘(iv) the number of times the payment 
amount determined (or agreed to) under 
this subsection exceeds the qualifying pay-
ment amount; 
‘‘(v) the amount of expenditures made 
by the Secretary during such calendar quar-
ter to carry out the IDR process; 
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4204 
‘‘(vi) the total amount of fees paid 
under paragraph (8) during such calendar 
quarter; and 
‘‘(vii) the total amount of compensa-
tion paid to certified IDR entities under 
paragraph 
(5)(E)during 
such 
calendar 
quarter. 
‘‘(B) INFORMATION WITH RESPECT TO RE-
QUESTS.—For purposes of subparagraph (A), the 
information described in this subparagraph is, 
with respect to a notification under the IDR 
process of a nonparticipating provider, group 
health plan, or health insurance issuer offering 
group health insurance coverage— 
‘‘(i) a description of each air ambu-
lance service included in such notification; 
‘‘(ii) the geography in which the serv-
ices included in such notification were pro-
vided; 
‘‘(iii) the amount of the offer submitted 
under paragraph (2) by the group health 
plan or health insurance issuer (as applica-
ble) and by the nonparticipating provider 
expressed as a percentage of the qualifying 
payment amount; 
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4205 
‘‘(iv) whether the offer selected by the 
certified IDR entity under paragraph (5) to 
be the payment applied was the offer sub-
mitted by such plan or issuer (as applica-
ble) or by such provider and the amount of 
such offer so selected expressed as a percent-
age of the qualifying payment amount; 
‘‘(v) ambulance vehicle type, including 
the clinical capability level of such vehicle; 
‘‘(vi) the identity of the group health 
plan or health insurance issuer or air am-
bulance provider with respect to such notifi-
cation; 
‘‘(vii) the length of time in making 
each determination; 
‘‘(viii) the compensation paid to the 
certified IDR entity with respect to the set-
tlement or determination; and 
‘‘(ix) any other information specified 
by the Secretary. 
‘‘(C) IDR 
ENTITY
REQUIREMENTS.—For 
2022 and each subsequent year, an IDR entity, 
as a condition of certification as an IDR entity, 
shall submit to the Secretary such information 
as the Secretary determines necessary for the 
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4206 
Secretary to carry out the provisions of this 
paragraph. 
‘‘(D) CLARIFICATION.—The Secretary shall 
ensure the public reporting under this paragraph 
does not contain information that would disclose 
privileged or confidential information of a group 
health plan or health insurance issuer offering 
group or individual health insurance coverage or 
of a provider or facility. 
‘‘(8) ADMINISTRATIVE FEE.— 
‘‘(A) IN GENERAL.—Each party to a deter-
mination under paragraph (5) to which an enti-
ty is selected under paragraph (4) in a year 
shall pay to the Secretary, at such time and in 
such manner as specified by the Secretary, a fee 
for participating in the IDR process with respect 
to such determination in an amount described in 
subparagraph (B) for such year. 
‘‘(B) AMOUNT
OF
FEE.—The amount de-
scribed in this subparagraph for a year is an 
amount established by the Secretary in a man-
ner such that the total amount of fees paid under 
this paragraph for such year is estimated to be 
equal to the amount of expenditures estimated to 
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4207 
be made by the Secretary for such year in car-
rying out the IDR process. 
‘‘(9) WAIVER AUTHORITY.—The Secretary may 
modify any deadline or other timing requirement 
specified under this subsection (other than the estab-
lishment date for the IDR process under paragraph 
(2)(A) and other than under paragraph (6)) in cases 
of extenuating circumstances, as specified by the Sec-
retary, or to ensure that all claims that occur during 
a 90-day period applied through paragraph (5)(D), 
but with respect to which a notification is not per-
mitted by reason of such paragraph to be submitted 
under paragraph (1)(B) during such period, are eligi-
ble for the IDR process. 
‘‘(c) DEFINITION.—For purposes of this section: 
‘‘(1) AIR AMBULANCE SERVICES.—The term ‘air 
ambulance service’ means medical transport by heli-
copter or airplane for patients. 
‘‘(2) QUALIFYING PAYMENT AMOUNT.—The term 
‘qualifying payment amount’ has the meaning given 
such term in section 716(a)(3). 
‘‘(3) NONPARTICIPATING
PROVIDER.—The term 
‘nonparticipating provider’ has the meaning given 
such term in section 716(a)(3).’’. 
(3) IRC AMENDMENTS.— 
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4208 
(A) IN GENERAL.—Subchapter B of chapter 
100 of the Internal Revenue Code of 1986, as 
amended by section 102(c) and further amended 
by the previous provisions of this title, is further 
amended by inserting after section 9816 the fol-
lowing: 
‘‘SEC. 9817. ENDING SURPRISE AIR AMBULANCE BILLS. 
‘‘(a) IN GENERAL.—In the case of a participant or 
beneficiary in a group health plan who receives air ambu-
lance services from a nonparticipating provider (as defined 
in section 9816(a)(3)(G)) with respect to such plan, if such 
services would be covered if provided by a participating 
provider (as defined in such section) with respect to such 
plan— 
‘‘(1) the cost-sharing requirement with respect to 
such services shall be the same requirement that would 
apply if such services were provided by such a par-
ticipating 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 partici-
pating provider; 
‘‘(2) such cost-sharing amounts shall be counted 
towards 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 
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4209 
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; and 
‘‘(3) the group health plan shall— 
‘‘(A) not later than 30 calendar days after 
the bill for such services is transmitted by such 
provider, send to the provider, an initial pay-
ment or notice of denial of payment; and 
‘‘(B) pay a total plan payment, in accord-
ance with, if applicable, subsection (b)(6), di-
rectly to such provider furnishing such services 
to such participant, beneficiary, or enrollee that 
is, with application of any initial payment 
under subparagraph (A), equal to the amount by 
which the out-of-network rate (as defined in sec-
tion 9816(a)(3)(K)) for such services and year 
involved exceeds the cost-sharing amount im-
posed under the plan for such services (as deter-
mined in accordance with paragraphs (1) and 
(2)). 
‘‘(b) DETERMINATION OF OUT-OF-NETWORK RATES TO 
BE PAID BY HEALTH PLANS; INDEPENDENT DISPUTE RES-
OLUTION PROCESS.— 
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4210 
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIA-
TION.— 
‘‘(A) IN GENERAL.—With respect to air am-
bulance services furnished in a year by a non-
participating provider, with respect to a group 
health plan, and for which a payment is re-
quired to be made by the plan pursuant to sub-
section (a)(3), the provider or plan may, during 
the 30-day period beginning on the day the pro-
vider receives a payment or a statement of de-
nial of payment from the plan regarding a claim 
for payment for such service, initiate open nego-
tiations under this paragraph between such pro-
vider and plan for purposes of determining, dur-
ing the open negotiation period, an amount 
agreed on by such provider, and such plan for 
payment (including any cost-sharing) for such 
service. For purposes of this subsection, the open 
negotiation period, with respect to air ambulance 
services, is the 30-day period beginning on the 
date of initiation of the negotiations with respect 
to such services. 
‘‘(B) ACCESSING
INDEPENDENT
DISPUTE 
RESOLUTION PROCESS IN CASE OF FAILED NEGO-
TIATIONS.—In the case of open negotiations pur-
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4211 
suant to subparagraph (A), with respect to air 
ambulance services, that do not result in a deter-
mination of an amount of payment for such 
services by the last day of the open negotiation 
period described in such subparagraph with re-
spect to such services, the provider or group 
health plan that was party to such negotiations 
may, during the 4-day period beginning on the 
day after such open negotiation period, initiate 
the independent dispute resolution process under 
paragraph (2) with respect to such services. The 
independent dispute resolution process shall be 
initiated by a party pursuant to the previous 
sentence by submission to the other party and to 
the Secretary of a notification (containing such 
information as specified by the Secretary) and 
for purposes of this subsection, the date of initi-
ation of such process shall be the date of such 
submission or such other date specified by the 
Secretary pursuant to regulations that is not 
later than the date of receipt of such notification 
by both the other party and the Secretary. 
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROC-
ESS AVAILABLE IN CASE OF FAILED OPEN NEGOTIA-
TIONS.— 
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4212 
‘‘(A) ESTABLISHMENT.—Not later than 1 
year after the date of the enactment of this sub-
section, the Secretary, jointly with the Secretary 
of Health and Human Services and the Sec-
retary of Labor, shall establish by regulation one 
independent dispute resolution process (referred 
to in this subsection as the ‘IDR process’) under 
which, in the case of air ambulance services with 
respect to which a provider or group health plan 
submits a notification under paragraph (1)(B) 
(in this subsection referred to as a ‘qualified 
IDR air ambulance services’), a certified IDR 
entity under paragraph (4) determines, subject 
to subparagraph (B) and in accordance with the 
succeeding provisions of this subsection, the 
amount of payment under the plan for such serv-
ices furnished by such provider. 
‘‘(B) AUTHORITY
TO
CONTINUE
NEGOTIA-
TIONS.—Under the independent dispute resolu-
tion process, in the case that the parties to a de-
termination for qualified IDR air ambulance 
services agree on a payment amount for such 
services during such process but before the date 
on which the entity selected with respect to such 
determination under paragraph (4) makes such 
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4213 
determination 
under 
paragraph 
(5), 
such 
amount shall be treated for purposes of section 
9816(a)(3)(K)(ii) as the amount agreed to by 
such parties for such services. In the case of an 
agreement described in the previous sentence, the 
independent dispute resolution process shall pro-
vide for a method to determine how to allocate 
between the parties to such determination the 
payment of the compensation of the entity se-
lected with respect to such determination. 
‘‘(C) CLARIFICATION.—A nonparticipating 
provider may not, with respect to an item or 
service furnished by such provider, submit a no-
tification under paragraph (1)(B) if such pro-
vider is exempt from the requirement under sub-
section (a) of section 2799B–2 of the Public 
Health Service Act with respect to such item or 
service pursuant to subsection (b) of such section. 
‘‘(3) TREATMENT OF BATCHING OF SERVICES.— 
The provisions of section 9816(c)(3) shall apply with 
respect to a notification submitted under this sub-
section with respect to air ambulance services in the 
same manner and to the same extent such provisions 
apply with respect to a notification submitted under 
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4214 
section 9816(c) with respect to items and services de-
scribed in such section. 
‘‘(4) IDR ENTITIES.— 
‘‘(A) ELIGIBILITY.—An IDR entity certified 
under this subsection is an IDR entity certified 
under section 9816(c)(4). 
‘‘(B) SELECTION OF CERTIFIED IDR ENTI-
TY.—The provisions of subparagraph (F) of sec-
tion 9816(c)(4) shall apply with respect to select-
ing an IDR entity certified pursuant to subpara-
graph (A) with respect to the determination of 
the amount of payment under this subsection of 
air ambulance services in the same manner as 
such provisions apply with respect to selecting 
an IDR entity certified under such section with 
respect to the determination of the amount of 
payment under section 9816(c) of an item or 
service. An entity selected pursuant to the pre-
vious sentence to make a determination described 
in such sentence shall be referred to in this sub-
section as the ‘certified IDR entity’ with respect 
to such determination. 
‘‘(5) PAYMENT DETERMINATION.— 
‘‘(A) IN GENERAL.—Not later than 30 days 
after the date of selection of the certified IDR en-
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4215 
tity with respect to a determination for qualified 
IDR ambulance services, the certified IDR entity 
shall— 
‘‘(i) taking into account the consider-
ations specified in subparagraph (C), select 
one of the offers submitted under subpara-
graph (B) to be the amount of payment for 
such services determined under this sub-
section for purposes of subsection (a)(3); 
and 
‘‘(ii) notify the provider or facility and 
the group health plan party to such deter-
mination of the offer selected under clause 
(i). 
‘‘(B) SUBMISSION
OF
OFFERS.—Not later 
than 10 days after the date of selection of the cer-
tified IDR entity with respect to a determination 
for qualified IDR air ambulance services, the 
provider and the group health plan party to such 
determination— 
‘‘(i) shall each submit to the certified 
IDR entity with respect to such determina-
tion— 
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‘‘(I) an offer for a payment 
amount for such services furnished by 
such provider; and 
‘‘(II) such information as re-
quested by the certified IDR entity re-
lating to such offer; and 
‘‘(ii) may each submit to the certified 
IDR entity with respect to such determina-
tion any information relating to such offer 
submitted by either party, including infor-
mation relating to any circumstance de-
scribed in subparagraph (C)(ii). 
‘‘(C) 
CONSIDERATIONS
IN
DETERMINA-
TION.— 
‘‘(i) IN
GENERAL.—In determining 
which offer is the payment to be applied 
pursuant to this paragraph, the certified 
IDR entity, with respect to the determina-
tion for a qualified IDR air ambulance 
service shall consider— 
‘‘(I) 
the 
qualifying 
payment 
amounts 
(as 
defined 
in 
section 
9816(a)(3)(E)) for the applicable year 
for items or services that are com-
parable to the qualified IDR air ambu-
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4217 
lance service and that are furnished in 
the same geographic region (as defined 
by the Secretary for purposes of such 
subsection) as such qualified IDR air 
ambulance service; and 
‘‘(II) subject to clause (iii), infor-
mation on any circumstance described 
in clause (ii), such information as re-
quested in subparagraph (B)(i)(II), 
and any additional information pro-
vided in subparagraph (B)(ii). 
‘‘(ii) ADDITIONAL
CIRCUMSTANCES.— 
For purposes of clause (i)(II), the cir-
cumstances described in this clause are, 
with respect to air ambulance services in-
cluded in the notification submitted under 
paragraph (1)(B) of a nonparticipating 
provider, or group health plan the fol-
lowing: 
‘‘(I) The quality and outcomes 
measurements of the provider that fur-
nished such services. 
‘‘(II) The acuity of the individual 
receiving such services or the com-
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4218 
plexity of furnishing such services to 
such individual. 
‘‘(III) The training, experience, 
and quality of the medical personnel 
that furnished such services. 
‘‘(IV) Ambulance vehicle type, in-
cluding the clinical capability level of 
such vehicle. 
‘‘(V) Population density of the 
pick up location (such as urban, subur-
ban, rural, or frontier). 
‘‘(VI) Demonstrations of good 
faith efforts (or lack of good faith ef-
forts) made by the nonparticipating 
provider or nonparticipating facility 
or the plan to enter into network agree-
ments and, if applicable, contracted 
rates between the provider and the 
plan during the previous 4 plan years. 
‘‘(iii) PROHIBITION ON CONSIDERATION 
OF
CERTAIN
FACTORS.—In determining 
which offer is the payment amount to be 
applied with respect to qualified IDR air 
ambulance services furnished by a provider, 
the certified IDR entity with respect to such 
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4219 
determination shall not consider usual and 
customary charges, the amount that would 
have been billed by such provider with re-
spect to such services had the provisions of 
section 2799B–5 of the Public Health Serv-
ice Act not applied, or the payment or re-
imbursement rate for such services furnished 
by such provider payable by a public payor, 
including under the Medicare program 
under title XVIII of the Social Security Act, 
under the Medicaid program under title 
XIX of such Act, under the Children’s 
Health Insurance Program under title XXI 
of such Act, under the TRICARE program 
under chapter 55 of title 10, United States 
Code, or under chapter 17 of title 38, 
United States Code. 
‘‘(D) EFFECTS
OF
DETERMINATION.—The 
provisions of section 9816(c)(5)(E)) shall apply 
with respect to a determination of a certified 
IDR entity under subparagraph (A), the notifi-
cation submitted with respect to such determina-
tion, the services with respect to such notifica-
tion, and the parties to such notification in the 
same manner as such provisions apply with re-
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4223 
be the payment applied was the offer sub-
mitted by such plan or issuer (as applica-
ble) or by such provider and the amount of 
such offer so selected expressed as a percent-
age of the qualifying payment amount; 
‘‘(v) ambulance vehicle type, including 
the clinical capability level of such vehicle; 
‘‘(vi) the identity of the group health 
plan or health insurance issuer or air am-
bulance provider with respect to such notifi-
cation; 
‘‘(vii) the length of time in making 
each determination; 
‘‘(viii) the compensation paid to the 
certified IDR entity with respect to the set-
tlement or determination; and 
‘‘(ix) any other information specified 
by the Secretary. 
‘‘(C) IDR 
ENTITY
REQUIREMENTS.—For 
2022 and each subsequent year, an IDR entity, 
as a condition of certification as an IDR entity, 
shall submit to the Secretary such information 
as the Secretary determines necessary for the 
Secretary to carry out the provisions of this 
paragraph. 
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4224 
‘‘(D) CLARIFICATION.—The Secretary shall 
ensure the public reporting under this paragraph 
does not contain information that would disclose 
privileged or confidential information of a group 
health plan or health insurance issuer offering 
group or individual health insurance coverage or 
of a provider or facility. 
‘‘(8) ADMINISTRATIVE FEE.— 
‘‘(A) IN GENERAL.—Each party to a deter-
mination under paragraph (5) to which an enti-
ty is selected under paragraph (4) in a year 
shall pay to the Secretary, at such time and in 
such manner as specified by the Secretary, a fee 
for participating in the IDR process with respect 
to such determination in an amount described in 
subparagraph (B) for such year. 
‘‘(B) AMOUNT
OF
FEE.—The amount de-
scribed in this subparagraph for a year is an 
amount established by the Secretary in a man-
ner such that the total amount of fees paid under 
this paragraph for such year is estimated to be 
equal to the amount of expenditures estimated to 
be made by the Secretary for such year in car-
rying out the IDR process. 
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4225 
‘‘(9) WAIVER AUTHORITY.—The Secretary may 
modify any deadline or other timing requirement 
specified under this subsection (other than the estab-
lishment date for the IDR process under paragraph 
(2)(A) and other than under paragraph (6)) in cases 
of extenuating circumstances, as specified by the Sec-
retary, or to ensure that all claims that occur during 
a 90-day period applied through paragraph (5)(D), 
but with respect to which a notification is not per-
mitted by reason of such paragraph to be submitted 
under paragraph (1)(B) during such period, are eligi-
ble for the IDR process. 
‘‘(c) DEFINITIONS.—For purposes of this section: 
‘‘(1) AIR AMBULANCE SERVICES.—The term ‘air 
ambulance service’ means medical transport by heli-
copter or airplane for patients. 
‘‘(2) QUALIFYING PAYMENT AMOUNT.—The term 
‘qualifying payment amount’ has the meaning given 
such term in section 9816(a)(3). 
‘‘(3) NONPARTICIPTING
PROVIDER.—The term 
‘nonparticipating provider’ has the meaning given 
such term in section 9816(a)(3).’’. 
(B) CLERICAL AMENDMENT.—The table of 
sections for subchapter B of chapter 100 of the 
Internal Revenue Code of 1986, as amended by 
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4226 
section 102(c)(3), is further amended by insert-
ing after the item relating to section 9816 the 
following new item: 
‘‘Sec. 9817. Ending surprise air ambulance bills.’’. 
(4) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply with respect to plan 
years beginning on or after January 1, 2022. 
(b) AIR AMBULANCE PROVIDER BALANCE BILLING.— 
Part E of title XXVII of the Public Health Service Act, 
as added and amended by section 104, is further amended 
by adding at the end the following new section: 
‘‘SEC. 2799B–5. AIR AMBULANCE SERVICES. 
‘‘In the case of a participant, beneficiary, or enrollee 
with benefits under a group health plan or group or indi-
vidual health insurance coverage offered by a health insur-
ance issuer and who is furnished in a plan year beginning 
on or after January 1, 2022, air ambulance services (for 
which benefits are available under such plan or coverage) 
from a nonparticipating provider (as defined in section 
2799A–1(a)(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 section 
2799A–2(a), section 717(a) of the Employee Retirement In-
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4227 
come Security Act of 1974, or section 9817(a) of the Inter-
nal Revenue Code of 1986, as applicable).’’. 
SEC. 106. REPORTING REQUIREMENTS REGARDING AIR AM-
BULANCE SERVICES. 
(a) REPORTING REQUIREMENTS FOR PROVIDERS OF 
AIR AMBULANCE SERVICES.— 
(1) IN GENERAL.—A provider of air ambulance 
services shall submit to the Secretary of Health and 
Human Services and the Secretary of Transpor-
tation— 
(A) not later than the date that is 90 days 
after the last day of the first calendar year be-
ginning on or after the date on which a final 
rule is promulgated pursuant to the rulemaking 
described in subsection (d), the information de-
scribed in paragraph (2) with respect to such 
plan year; and 
(B) not later than the date that is 90 days 
after the last day of the plan year immediately 
succeeding the plan year described in subpara-
graph (A), such information with respect to such 
immediately succeeding plan year. 
(2) INFORMATION DESCRIBED.—For purposes of 
paragraph (1), information described in this para-
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4228 
graph, with respect to a provider of air ambulance 
services, is each of the following: 
(A) Cost data, as determined appropriate 
by the Secretary of Health and Human Services, 
in consultation with the Secretary of Transpor-
tation, for air ambulance services furnished by 
such provider, separated to the maximum extent 
possible by air transportation costs associated 
with furnishing such air ambulance services and 
costs of medical services and supplies associated 
with furnishing such air ambulance services. 
(B) The number and location of all air am-
bulance bases operated by such provider. 
(C) The number and type of aircraft oper-
ated by such provider. 
(D) The number of air ambulance trans-
ports, disaggregated by payor mix, including— 
(i)(I) group health plans; 
(II) health insurance issuers; and 
(III) State and Federal Government 
payors; and 
(ii) uninsured individuals. 
(E) The number of claims of such provider 
that have been denied payment by a group 
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4229 
health plan or health insurance issuer and the 
reasons for any such denials. 
(F) The number of emergency and non-
emergency 
air 
ambulance 
transports, 
disaggregated by air ambulance base and type of 
aircraft. 
(G) Such other information regarding air 
ambulance services as the Secretary of Health 
and Human Services may specify. 
(b) REPORTING REQUIREMENTS FOR GROUP HEALTH 
PLANS AND HEALTH INSURANCE ISSUERS.— 
(1) PHSA.—Part D of title XXVII of the Public 
Health Service Act, as added by section 102(a)(1), is 
amended by adding after section 2799A–7, as added 
by section 102(a)(2)(A) of this Act, the following new 
section: 
‘‘SEC. 2799A–8. AIR AMBULANCE REPORT REQUIREMENTS. 
‘‘(a) IN GENERAL.—Each group health plan and 
health insurance issuer offering group or individual health 
insurance coverage shall submit to the Secretary, jointly 
with the Secretary of Labor and the Secretary of the Treas-
ury— 
‘‘(1) not later than the date that is 90 days after 
the last day of the first calendar year beginning on 
or after the date on which a final rule is promulgated 
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4230 
pursuant to the rulemaking described in section 
106(d) of the No Surprises Act, the information de-
scribed in subsection (b) with respect to such plan 
year; and 
‘‘(2) not later than the date that is 90 days after 
the last day of the calendar year immediately suc-
ceeding the plan year described in paragraph (1), 
such information with respect to such immediately 
succeeding plan year. 
‘‘(b) INFORMATION DESCRIBED.—For purposes of sub-
section (a), information described in this subsection, with 
respect to a group health plan or a health insurance issuer 
offering group or individual health insurance coverage, is 
each of the following: 
‘‘(1) Claims data for air ambulance services fur-
nished by providers of such services, disaggregated by 
each of the following factors: 
‘‘(A) Whether such services were furnished 
on an emergent or nonemergent basis. 
‘‘(B) Whether the provider of such services 
is part of a hospital-owned or sponsored pro-
gram, municipality-sponsored program, hospital 
independent partnership (hybrid) program, inde-
pendent program, or tribally operated program 
in Alaska. 
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4231 
‘‘(C) Whether the transport in which the 
services were furnished originated in a rural or 
urban area. 
‘‘(D) The type of aircraft (such as rotor 
transport or fixed wing transport) used to fur-
nish such services. 
‘‘(E) Whether the provider of such services 
has a contract with the plan or issuer, as appli-
cable, to furnish such services under the plan or 
coverage, respectively. 
‘‘(2) Such other information regarding providers 
of air ambulance services as the Secretary may speci-
fy.’’. 
(2) ERISA.— 
(A) IN GENERAL.—Subpart B of part 7 of 
title I of the Employee Retirement Income Secu-
rity Act of 1974 (29 U.S.C. 1185 et seq.) is 
amended by adding after section 722, as added 
by section 102(b)(2)(A) of this Act, the following 
new section: 
‘‘SEC. 723. AIR AMBULANCE REPORT REQUIREMENTS. 
‘‘(a) IN GENERAL.—Each group health plan and 
health insurance issuer offering group health insurance cov-
erage shall submit to the Secretary, jointly with the Sec-
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4232 
retary of Health and Human Services and the Secretary 
of the Treasury— 
‘‘(1) not later than the date that is 90 days after 
the last day of the first calendar year beginning on 
or after the date on which a final rule is promulgated 
pursuant to the rulemaking described in section 
106(d) of the No Surprises Act, the information de-
scribed in subsection (b) with respect to such plan 
year; and 
‘‘(2) not later than the date that is 90 days after 
the last day of the plan year immediately succeeding 
the calendar year described in paragraph (1), such 
information with respect to such immediately suc-
ceeding plan year. 
‘‘(b) INFORMATION DESCRIBED.—For purposes of sub-
section (a), information described in this subsection, with 
respect to a group health plan or a health insurance issuer 
offering group health insurance coverage, is each of the fol-
lowing: 
‘‘(1) Claims data for air ambulance services fur-
nished by providers of such services, disaggregated by 
each of the following factors: 
‘‘(A) Whether such services were furnished 
on an emergent or nonemergent basis. 
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4233 
‘‘(B) Whether the provider of such services 
is part of a hospital-owned or sponsored pro-
gram, municipality-sponsored program, hospital 
independent partnership (hybrid) program, inde-
pendent program, or tribally operated program 
in Alaska. 
‘‘(C) Whether the transport in which the 
services were furnished originated in a rural or 
urban area. 
‘‘(D) The type of aircraft (such as rotor 
transport or fixed wing transport) used to fur-
nish such services. 
‘‘(E) Whether the provider of such services 
has a contract with the plan or issuer, as appli-
cable, to furnish such services under the plan or 
coverage, respectively. 
‘‘(2) Such other information regarding providers 
of air ambulance services as the Secretary may speci-
fy.’’. 
(B) CLERICAL AMENDMENT.—The table of 
contents of the Employee Retirement Income Se-
curity Act of 1974 is amended by adding after 
the item relating to section 722, as added by sec-
tion 102(b) the following: 
‘‘Sec. 723. Air ambulance report requirements.’’. 
(3) IRC.— 
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4234 
(A) IN GENERAL.—Subchapter B of chapter 
100 of the Internal Revenue Code of 1986 is 
amended by adding after section 9822, as added 
by section 102(c)(2)(A) of this Act, the following 
new section: 
‘‘SEC. 9823. AIR AMBULANCE REPORT REQUIREMENTS. 
‘‘(a) IN GENERAL.—Each group health plan shall sub-
mit to the Secretary, jointly with the Secretary of Labor 
and the Secretary of Health and Human Services— 
‘‘(1) not later than the date that is 90 days after 
the last day of the first calendar year beginning on 
or after the date on which a final rule is promulgated 
pursuant to the rulemaking described in section 
106(d) of the No Surprises Act, the information de-
scribed in subsection (b) with respect to such plan 
year; and 
‘‘(2) not later than the date that is 90 days after 
the last day of the calendar year immediately suc-
ceeding the plan year described in paragraph (1), 
such information with respect to such immediately 
succeeding plan year. 
‘‘(b) INFORMATION DESCRIBED.—For purposes of sub-
section (a), information described in this subsection, with 
respect to a group health plan is each of the following: 
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4236 
(B) CLERICAL AMENDMENT.—The table of 
sections for subchapter B of chapter 100 of the 
Internal Revenue Code of 1986 is amended by 
adding after the item relating to section 9822, as 
added by section 102(c), the following new item: 
‘‘Sec. 9823. Air ambulance report requirements.’’. 
(c) PUBLICATION OF COMPREHENSIVE REPORT.— 
(1) IN GENERAL.—Not later than the date that 
is one year after the date described in subsection 
(a)(2) of section 2799A–8 of the Public Health Service 
Act, of section 723 of the Employee Retirement In-
come Security Act of 1974, and of section 9823 of the 
Internal Revenue Code of 1986, as such sections are 
added by subsection (b), the Secretary of Health and 
Human Services, in consultation with the Secretary 
of Transportation (referred to in this section as the 
‘‘Secretaries’’), shall develop, and make publicly 
available (subject to paragraph (3)), a comprehensive 
report summarizing the information submitted under 
subsection (a) and the amendments made by sub-
section (b) and including each of the following: 
(A) The percentage of providers of air am-
bulance services that are part of a hospital- 
owned or sponsored program, municipality-spon-
sored program, hospital-independent partnership 
(hybrid) program, or independent program. 
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4237 
(B) An assessment of the extent of competi-
tion among providers of air ambulance services 
on the basis of price and services offered, and 
any changes in such competition over time. 
(C) An assessment of the average charges for 
air ambulance services, amounts paid by group 
health plans and health insurance issuers offer-
ing group or individual health insurance cov-
erage to providers of air ambulance services for 
furnishing such services, and amounts paid out- 
of-pocket by consumers, and any changes in such 
amounts paid over time. 
(D) An assessment of the presence of air 
ambulance bases in, or with the capability to 
serve, rural areas, and the relative growth in air 
ambulance bases in rural and urban areas over 
time. 
(E) Any evidence of gaps in rural access to 
providers of air ambulance services. 
(F) The percentage of providers of air am-
bulance services that have contracts with group 
health plans or health insurance issuers offering 
group or individual health insurance coverage to 
furnish such services under such plans or cov-
erage, respectively. 
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4238 
(G) An assessment of whether there are in-
stances of unfair, deceptive, or predatory prac-
tices by providers of air ambulance services in 
collecting payments from patients to whom such 
services are furnished, such as referral of such 
patients to collections, lawsuits, and liens or 
wage garnishment actions. 
(H) An assessment of whether there are, 
within the air ambulance industry, instances of 
unreasonable industry concentration, excessive 
market domination, or other conditions that 
would allow at least one provider of air ambu-
lance services to unreasonably increase prices or 
exclude competition in air ambulance services in 
a given geographic region. 
(I) An assessment of the frequency of pa-
tient balance billing, patient referrals to collec-
tions, lawsuits to collect balance bills, and liens 
or wage garnishment actions by providers of air 
ambulance services as part of a collections proc-
ess across hospital-owned or sponsored programs, 
municipality-sponsored programs, hospital-inde-
pendent partnership (hybrid) programs, tribally 
operated programs in Alaska, or independent 
programs, providers of air ambulance services 
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4239 
operated by public agencies (such as a State or 
county health department), and other inde-
pendent providers of air ambulance services. 
(J) An assessment of the frequency of claims 
appeals made by providers of air ambulance 
services to group health plans or health insur-
ance issuers offering group or individual health 
insurance coverage with respect to air ambulance 
services furnished to enrollees of such plans or 
coverage, respectively. 
(K) Any other cost, quality, or other data 
relating to air ambulance services or the air am-
bulance industry, as determined necessary and 
appropriate by the Secretaries. 
(2) OTHER
SOURCES
OF
INFORMATION.—The 
Secretaries may incorporate information from inde-
pendent experts or third-party sources in developing 
the comprehensive report required under paragraph 
(1). 
(3) PROTECTION
OF
PROPRIETARY
INFORMA-
TION.—The Secretaries may not make publicly avail-
able under this subsection any proprietary informa-
tion. 
(d) RULEMAKING.—Not later than the date that is one 
year after the date of the enactment of this Act, the Sec-
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4240 
retary of Health and Human Services, in consultation with 
the Secretary of Transportation, shall, through notice and 
comment rulemaking, specify the form and manner in 
which reports described in subsection (a) and in the amend-
ments made by subsection (b) shall be submitted to such 
Secretaries, taking into consideration (as applicable and to 
the extent feasible) any recommendations included in the 
report submitted by the Advisory Committee on Air Ambu-
lance and Patient Billing under section 418(e) of the FAA 
Reauthorization Act of 2018 (Public Law 115–254; 49 
U.S.C. 42301 note prec.). 
(e) CIVIL MONEY PENALTIES.— 
(1) IN GENERAL.—Subject to paragraph (2), a 
provider of air ambulance services who fails to submit 
all information required under subsection (a)(2) by 
the date described in subparagraph (A) or (B) of sub-
section (a)(1), as applicable, shall be subject to a civil 
money penalty of not more than $10,000. 
(2) EXCEPTION.—In the case of a provider of air 
ambulance services that submits only some of the in-
formation required under subsection (a)(2) by the 
date described in subparagraph (A) or (B) of sub-
section (a)(1), as applicable, the Secretary of Health 
and Human Services may waive the civil money pen-
alty imposed under paragraph (1) if such provider 
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4241 
demonstrates a good faith effort (as defined by the 
Secretary pursuant to regulation) in working with 
the Secretary to submit the remaining information 
required under subsection (a)(2). 
(3) PROCEDURE.—The provisions of section 
1128A of the Social Security Act (42 U.S.C. 1320a– 
7a), other than subsections (a) and (b) and the first 
sentence of subsection (c)(1), shall apply to civil 
money penalties under this subsection in the same 
manner as such provisions apply to a penalty or pro-
ceeding under such section. 
(f) UNFAIR AND DECEPTIVE PRACTICES AND UNFAIR 
METHODS OF COMPETITION.—The Secretary of Transpor-
tation may use any information submitted under subsection 
(a) in determining whether a provider of air ambulance 
services has violated section 41712(a) of title 49, United 
States Code. 
(g) ADVISORY COMMITTEE ON AIR AMBULANCE QUAL-
ITY AND PATIENT SAFETY.— 
(1) ESTABLISHMENT.—Not later than the date 
that is 60 days after the date of the enactment of this 
Act, the Secretary of Health and Human Services 
and the Secretary of Transportation, shall establish 
an Advisory Committee on Air Ambulance Quality 
and Patient Safety (referred to in this subsection as 
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the ‘‘Committee’’) for the purpose of reviewing options 
to establish quality, patient safety, and clinical capa-
bility standards for each clinical capability level of 
air ambulances. 
(2) MEMBERSHIP.—The Committee shall be com-
posed of the following members: 
(A) The Secretary of Health and Human 
Services, or a designee of the Secretary, who 
shall serve as the Chair of the Committee. 
(B) The Secretary of Transportation, or a 
designee of the Secretary. 
(C) One representative, to be appointed by 
the Secretary of Health and Human Services, of 
each of the following: 
(i) State health insurance regulators. 
(ii) Health care providers. 
(iii) Group health plans and health in-
surance issuers offering group or individual 
health insurance coverage. 
(iv) Patient advocacy groups. 
(v) Accrediting bodies with experience 
in quality measures. 
(D) Three representatives of the air ambu-
lance industry, to be appointed by the Secretary 
of Transportation. 
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(E) Additional three representatives not 
covered under subparagraphs (A) through (D), as 
determined necessary and appropriate by the 
Secretary of Health and Human Services and 
Secretary of Transportation. 
(3) FIRST MEETING.—Not later than the date 
that is 90 days after the date of the enactment of this 
Act, the Committee shall hold its first meeting. 
(4) DUTIES.—The Committee shall study and 
make recommendations, as appropriate, to Congress 
regarding each of the following with respect to air 
ambulance services: 
(A) Qualifications of different clinical capa-
bility levels and tiering of such levels. 
(B) Patient safety and quality standards. 
(C) Options for improving service reli-
ability during poor weather, night conditions, or 
other adverse conditions. 
(D) Differences between air ambulance vehi-
cle types, services, and technologies, and other 
flight capability standards, and the impact of 
such differences on patient safety. 
(E) Clinical triage criteria for air ambu-
lances. 
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(5) REPORT.—Not later than the date that is 
180 days after the date of the first meeting of the 
Committee, the Committee, in consultation with rel-
evant experts and stakeholders, as appropriate, shall 
develop and make publicly available a report on any 
recommendations submitted to Congress under para-
graph (4). The Committee may update such report, as 
determined appropriate by the Committee. 
(h) DEFINITIONS.—In this section, the terms ‘‘group 
health plan’’, ‘‘health insurance coverage’’, ‘‘individual 
health insurance coverage’’, ‘‘group health insurance cov-
erage’’, and ‘‘health insurance issuer’’ have the meanings 
given such terms in section 2791 of the Public Health Serv-
ice Act (42 U.S.C. 300gg–91). 
SEC. 107. TRANSPARENCY REGARDING IN-NETWORK AND 
OUT-OF-NETWORK DEDUCTIBLES AND OUT- 
OF-POCKET LIMITATIONS. 
(a) PHSA.—Section 2799A–1 of the Public Health 
Service Act, as added by section 102(a) and amended by 
section 103, is further amended by adding at the end the 
following new subsection: 
‘‘(e) TRANSPARENCY REGARDING IN-NETWORK
AND 
OUT-OF-NETWORK
DEDUCTIBLES
AND
OUT-OF-POCKET 
LIMITATIONS.—A group health plan or a health insurance 
issuer offering group or individual health insurance cov-
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erage and providing or covering any benefit with respect 
to items or services shall include, in clear writing, on any 
physical or electronic plan or insurance identification card 
issued to the participants, beneficiaries, or enrollees in the 
plan or coverage the following: 
‘‘(1) Any deductible applicable to such plan or 
coverage. 
‘‘(2) Any out-of-pocket maximum limitation ap-
plicable to such plan or coverage. 
‘‘(3) A telephone number and Internet website 
address through which such individual may seek con-
sumer assistance information, such as information re-
lated to hospitals and urgent care facilities that have 
in effect a contractual relationship with such plan or 
coverage for furnishing items and services under such 
plan or coverage’’. 
(b) ERISA.—Section 716 of the Employee Retirement 
Income Security Act of 1974, as added by section 102(b) 
and amended by section 103, is further amended by adding 
at the end the following new subsection: 
‘‘(e) TRANSPARENCY REGARDING IN-NETWORK
AND 
OUT-OF-NETWORK
DEDUCTIBLES
AND
OUT-OF-POCKET 
LIMITATIONS.—A group health plan or a health insurance 
issuer offering group health insurance coverage and pro-
viding or covering any benefit with respect to items or serv-
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4246 
ices shall include, in clear writing, on any physical or elec-
tronic plan or insurance identification card issued to the 
participants or beneficiaries in the plan or coverage the fol-
lowing: 
‘‘(1) Any deductible applicable to such plan or 
coverage. 
‘‘(2) Any out-of-pocket maximum limitation ap-
plicable to such plan or coverage. 
‘‘(3) A telephone number and Internet website 
address through which such individual may seek con-
sumer assistance information, such as information re-
lated to hospitals and urgent care facilities that have 
in effect a contractual relationship with such plan or 
coverage for furnishing items and services under such 
plan or coverage’’. 
(c) IRC.—Section 9816 of the Internal Revenue Code 
of 1986, as added by section 102(c) and amended by section 
103, is further amended by adding at the end the following 
new subsection: 
‘‘(e) TRANSPARENCY REGARDING IN-NETWORK
AND 
OUT-OF-NETWORK
DEDUCTIBLES
AND
OUT-OF-POCKET 
LIMITATIONS.—A group health plan providing or covering 
any benefit with respect to items or services shall include, 
in clear writing, on any physical or electronic plan or in-
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surance identification card issued to the participants or 
beneficiaries in the plan the following: 
‘‘(1) Any deductible applicable to such plan. 
‘‘(2) Any out-of-pocket maximum limitation ap-
plicable to such plan. 
‘‘(3) A telephone number and Internet website 
address through which such individual may seek con-
sumer assistance information, such as information re-
lated to hospitals and urgent care facilities that have 
in effect a contractual relationship with such plan for 
furnishing items and services under such plan.’’. 
(d) EFFECTIVE DATE.—The amendments made by this 
subsection shall apply with respect to plan years beginning 
on or after January 1, 2022. 
SEC. 108. IMPLEMENTING PROTECTIONS AGAINST PRO-
VIDER DISCRIMINATION. 
Not later than January 1, 2022, the Secretary of 
Health and Human Services, the Secretary of Labor, and 
the Secretary of the Treasury shall issue a proposed rule 
implementing the protections of section 2706(a) of the Pub-
lic Health Service Act (42 U.S.C. 300gg-5(a)). The Secre-
taries shall accept and consider public comments on any 
proposed rule issued pursuant to this subsection for a period 
of 60 days after the date of such issuance. Not later than 
6 months after the date of the conclusion of the comment 
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period, the Secretaries shall issue a final rule implementing 
the protections of section 2706(a) of the Public Health Serv-
ice Act (42 U.S.C. 300gg-5(a)). 
SEC. 109. REPORTS. 
(a) REPORTS
IN CONSULTATION WITH FTC AND 
AG.—Not later than January 1, 2023, and annually there-
after for each of the following 4 years, the Secretary of 
Health and Human Services, in consultation with the Fed-
eral Trade Commission and the Attorney General, shall— 
(1) conduct a study on the effects of the provi-
sions of, including amendments made by, this Act 
on— 
(A) any patterns of vertical or horizontal 
integration of health care facilities, providers, 
group health plans, or health insurance issuers 
offering group or individual health insurance 
coverage; 
(B) overall health care costs; and 
(C) access to health care items and services, 
including specialty services, in rural areas and 
health professional shortage areas, as defined in 
section 332 of the Public Health Service Act (42 
U.S.C. 254e); 
(2) for purposes of the reports under paragraph 
(3), in consultation with the Secretary of Labor and 
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4249 
the Secretary of the Treasury, make recommendations 
for 
the 
effective 
enforcement 
of 
subsections 
(a)(1)(C)(iv) and (b)(1)(C) of section 2799A–1 of the 
Public Health Service Act, subsections (a)(1)(C)(iv) 
and (b)(1)(C) of section 716 of the Employee Retire-
ment Income Security Act of 1974, and subsections 
(a)(1)(C)(iv) and (b)(1)(C) of section 9816 of the In-
ternal Revenue Code of 1986, including with respect 
to potential challenges to addressing anti-competitive 
consolidation of health care facilities, providers, group 
health plans, or health insurance issuers offering 
group or individual health insurance coverage; and 
(3) submit a report on such study and including 
such recommendations to the Committees on Energy 
and Commerce; on Education and Labor; on Ways 
and Means; and on the Judiciary of the House of 
Representatives and the Committees on Health, Edu-
cation, Labor, and Pensions; on Commerce, Science, 
and Transportation; on Finance; and on the Judici-
ary of the Senate. 
(b) GAO REPORT ON IMPACT OF SURPRISE BILLING 
PROVISIONS.—Not later than January 1, 2025, the Comp-
troller General of the United States shall submit to Congress 
a report summarizing the effects of the provisions of this 
Act, including the amendments made by such provisions, 
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on changes during the period since the date on the enact-
ment of this Act in health care provider networks of group 
health plans and group and individual health insurance 
coverage offered by a health insurance issuer, in fee sched-
ules and amounts for health care services, and to contracted 
rates under such plans or coverage. Such report shall— 
(1) to the extent practicable, sample a statis-
tically significant group of national health care pro-
viders; 
(2) examine— 
(A) provider network participation, includ-
ing nonparticipating providers furnishing items 
and services at participating facilities; 
(B) health care provider group network par-
ticipation, including specialty, size, and owner-
ship; 
(C) the impact of State surprise billing 
laws and network adequacy standards on par-
ticipation of health care providers and facilities 
in provider networks of group health plans and 
of group and individual health insurance cov-
erage offered by health insurance issuers; and 
(D) access to providers, including in rural 
and medically underserved communities and 
health professional shortage areas (as defined in 
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4251 
section 332 of the Public Health Service Act), 
and the extent of provider shortages in such com-
munities and areas; 
(3) to the extent practicable, sample a statis-
tically significant group of national health insurance 
plans and issuers and examine— 
(A) the effects of the provisions of, including 
amendments made by, this Act on premiums and 
out-of-pocket costs with respect to group health 
plans or group or individual health insurance 
coverage; 
(B) the adequacy of provider networks with 
respect to such plans or coverage; and 
(C) categories of providers of ancillary serv-
ices, as defined in section 2799B–2(b)(2) of the 
Public Health Service Act, for which such plans 
have no or a limited number of in-network pro-
viders; and 
(4) such other relevant effects of such provisions 
and amendments. 
(c) GAO REPORT ON ADEQUACY OF PROVIDER NET-
WORKS.—Not later than January 1, 2023, the Comptroller 
General of the United States shall submit to Congress, and 
make publicly available, a report on the adequacy of pro-
vider networks in group health plans and group and indi-
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vidual health insurance coverage, including legislative rec-
ommendations to improve the adequacy of such networks. 
(d) GAO REPORT ON IDR PROCESS AND POTENTIAL 
FINANCIAL RELATIONSHIPS.—Not later than December 31, 
2023, the Comptroller General of the United States shall 
conduct a study and submit to Congress a report on the 
IDR process established under this section. Such study and 
report shall include an analysis of potential financial rela-
tionships between providers and facilities that utilize the 
IDR process established by the amendments made by this 
Act and private equity investment firms. 
SEC. 110. CONSUMER PROTECTIONS THROUGH APPLICA-
TION OF HEALTH PLAN EXTERNAL REVIEW IN 
CASES 
OF 
CERTAIN 
SURPRISE 
MEDICAL 
BILLS. 
(a) IN GENERAL.—In applying the provisions of sec-
tion 2719(b) of the Public Health Service Act (42 U.S.C. 
300gg–19(b)) to group health plans and health insurance 
issuers offering group or individual health insurance cov-
erage, the Secretary of Health and Human Services, Sec-
retary of Labor, and Secretary of the Treasury, shall re-
quire, beginning not later than January 1, 2022, the exter-
nal review process described in paragraph (1) of such sec-
tion to apply with respect to any adverse determination by 
such a plan or issuer under section 2799A-1 or 2799A-2, 
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section 716 or 717 of the Employee Retirement Income Se-
curity Act of 1974, or section 9816 or 9817 of the Internal 
Revenue Code of 1986, including with respect to whether 
an item or service that is the subject to such a determina-
tion is an item or service to which such respective section 
applies. 
(b) DEFINITIONS.—The terms ‘‘group health plan’’; 
‘‘health insurance issuer’’; ‘‘group health insurance cov-
erage’’, and ‘‘individual health insurance coverage’’ have 
the meanings given such terms in section 2791 of the Public 
Health Service Act (42 U.S.C. 300gg–91), section 733 of 
the Employee Retirement Income Security Act (29 U.S.C. 
1191b), and section 9832 of the Internal Revenue Code, as 
applicable. 
SEC. 111. CONSUMER PROTECTIONS THROUGH HEALTH 
PLAN REQUIREMENT FOR FAIR AND HONEST 
ADVANCE COST ESTIMATE. 
(a) PHSA AMENDMENT.—Section 2799A–1 of the 
Public Health Service Act (42 U.S.C. 300gg–19a), as added 
by section 102 and as further amended by the previous pro-
visions of this title, is further amended by adding at the 
end the following new subsection: 
‘‘(f) ADVANCED EXPLANATION OF BENEFITS.— 
‘‘(1) IN GENERAL.—For plan years beginning on 
or after January 1, 2022, each group health plan, or 
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a health insurance issuer offering group or individual 
health insurance coverage shall, with respect to a no-
tification submitted under section 2799B–6 by a 
health care provider or health care facility to the plan 
or issuer for a participant, beneficiary, or enrollee 
under plan or coverage scheduled to receive an item 
or service from the provider or facility (or authorized 
representative of such participant, beneficiary, or en-
rollee), not later than 1 business day (or, in the case 
such item or service was so scheduled at least 10 busi-
ness days before such item or service is to be furnished 
(or in the case of a request made to such plan or cov-
erage by such participant, beneficiary, or enrollee), 3 
business days) after the date on which the plan or 
coverage receives such notification (or such request), 
provide to the participant, beneficiary, or enrollee 
(through mail or electronic means, as requested by the 
participant, beneficiary, or enrollee) a notification 
(in clear and understandable language) including the 
following: 
‘‘(A) Whether or not the provider or facility 
is a participating provider or a participating 
facility with respect to the plan or coverage with 
respect to the furnishing of such item or service 
and— 
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‘‘(i) in the case the provider or facility 
is a participating provider or facility with 
respect to the plan or coverage with respect 
to the furnishing of such item or service, the 
contracted rate under such plan or coverage 
for such item or service (based on the billing 
and diagnostic codes provided by such pro-
vider or facility); and 
‘‘(ii) in the case the provider or facil-
ity is a nonparticipating provider or facil-
ity with respect to such plan or coverage, a 
description of how such individual may ob-
tain information on providers and facilities 
that, with respect to such plan or coverage, 
are participating providers and facilities, if 
any. 
‘‘(B) The good faith estimate included in 
the notification received from the provider or fa-
cility (if applicable) based on such codes. 
‘‘(C) A good faith estimate of the amount 
the plan or coverage is responsible for paying for 
items and services included in the estimate de-
scribed in subparagraph (B). 
‘‘(D) A good faith estimate of the amount of 
any cost-sharing for which the participant, bene-
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ficiary, or enrollee would be responsible for such 
item or service (as of the date of such notifica-
tion). 
‘‘(E) A good faith estimate of the amount 
that the participant, beneficiary, or enrollee has 
incurred toward meeting the limit of the finan-
cial responsibility (including with respect to 
deductibles and out-of-pocket maximums) under 
the plan or coverage (as of the date of such noti-
fication). 
‘‘(F) In the case such item or service is sub-
ject to a medical management technique (includ-
ing concurrent review, prior authorization, and 
step-therapy or fail-first protocols) for coverage 
under the plan or coverage, a disclaimer that 
coverage for such item or service is subject to 
such medical management technique. 
‘‘(G) A disclaimer that the information pro-
vided in the notification is only an estimate 
based on the items and services reasonably ex-
pected, at the time of scheduling (or requesting) 
the item or service, to be furnished and is subject 
to change. 
‘‘(H) Any other information or disclaimer 
the plan or coverage determines appropriate that 
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is consistent with information and disclaimers 
required under this section. 
‘‘(2) AUTHORITY TO MODIFY TIMING REQUIRE-
MENTS IN THE CASE OF SPECIFIED ITEMS AND SERV-
ICES.— 
‘‘(A) IN GENERAL.—In the case of a partici-
pant, beneficiary, or enrollee scheduled to receive 
an item or service that is a specified item or 
service (as defined in subparagraph (B)), the 
Secretary may modify any timing requirements 
relating to the provision of the notification de-
scribed in paragraph (1) to such participant, 
beneficiary, or enrollee with respect to such item 
or service. Any modification made by the Sec-
retary pursuant to the previous sentence may not 
result in the provision of such notification after 
such participant, beneficiary, or enrollee has 
been furnished such item or service. 
‘‘(B) SPECIFIED
ITEM
OR
SERVICE
DE-
FINED.—For purposes of subparagraph (A), the 
term ‘specified item or service’ means an item or 
service that has low utilization or significant 
variation in costs (such as when furnished as 
part of a complex treatment), as specified by the 
Secretary.’’. 
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(b) IRC AMENDMENTS.—Section 9816 of the Internal 
Revenue Code of 1986, as added by section 102 and further 
amended by the previous provisions of this title, is further 
amended by inserting after subsection (e) the following new 
subsection: 
‘‘(f) ADVANCED EXPLANATION OF BENEFITS.— 
‘‘(1) IN GENERAL.—For plan years beginning on 
or after January 1, 2022, each group health plan 
shall, with respect to a notification submitted under 
section 2799B–6 of the Public Health Service Act by 
a health care provider or health care facility to the 
plan for a participant or beneficiary under plan 
scheduled to receive an item or service from the pro-
vider or facility (or authorized representative of such 
participant or beneficiary), not later than 1 business 
day (or, in the case such item or service was so sched-
uled at least 10 business days before such item or 
service is to be furnished (or in the case of a request 
made to such plan or coverage by such participant or 
beneficiary), 3 business days) after the date on which 
the plan receives such notification (or such request), 
provide to the participant or beneficiary (through 
mail or electronic means, as requested by the partici-
pant or beneficiary) a notification (in clear and un-
derstandable language) including the following: 
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‘‘(A) Whether or not the provider or facility 
is a participating provider or a participating 
facility with respect to the plan with respect to 
the furnishing of such item or service and— 
‘‘(i) in the case the provider or facility 
is a participating provider or facility with 
respect to the plan or coverage with respect 
to the furnishing of such item or service, the 
contracted rate under such plan for such 
item or service (based on the billing and di-
agnostic codes provided by such provider or 
facility); and 
‘‘(ii) in the case the provider or facil-
ity is a nonparticipating provider or facil-
ity with respect to such plan, a description 
of how such individual may obtain infor-
mation on providers and facilities that, 
with respect to such plan, are participating 
providers and facilities, if any. 
‘‘(B) The good faith estimate included in 
the notification received from the provider or fa-
cility (if applicable) based on such codes. 
‘‘(C) A good faith estimate of the amount 
the plan is responsible for paying for items and 
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4260 
services included in the estimate described in 
subparagraph (B). 
‘‘(D) A good faith estimate of the amount of 
any cost-sharing for which the participant or 
beneficiary would be responsible for such item or 
service (as of the date of such notification). 
‘‘(E) A good faith estimate of the amount 
that the participant or beneficiary has incurred 
toward meeting the limit of the financial respon-
sibility (including with respect to deductibles 
and out-of-pocket maximums) under the plan (as 
of the date of such notification). 
‘‘(F) In the case such item or service is sub-
ject to a medical management technique (includ-
ing concurrent review, prior authorization, and 
step-therapy or fail-first protocols) for coverage 
under the plan, a disclaimer that coverage for 
such item or service is subject to such medical 
management technique. 
‘‘(G) A disclaimer that the information pro-
vided in the notification is only an estimate 
based on the items and services reasonably ex-
pected, at the time of scheduling (or requesting) 
the item or service, to be furnished and is subject 
to change. 
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‘‘(H) Any other information or disclaimer 
the plan determines appropriate that is con-
sistent with information and disclaimers re-
quired under this section. 
‘‘(2) AUTHORITY TO MODIFY TIMING REQUIRE-
MENTS IN THE CASE OF SPECIFIED ITEMS AND SERV-
ICES.— 
‘‘(A) IN GENERAL.—In the case of a partici-
pant or beneficiary scheduled to receive an item 
or service that is a specified item or service (as 
defined in subparagraph (B)), the Secretary may 
modify any timing requirements relating to the 
provision of the notification described in para-
graph (1) to such participant or beneficiary with 
respect to such item or service. Any modification 
made by the Secretary pursuant to the previous 
sentence may not result in the provision of such 
notification after such participant or beneficiary 
has been furnished such item or service. 
‘‘(B) SPECIFIED
ITEM
OR
SERVICE
DE-
FINED.—For purposes of subparagraph (A), the 
term ‘specified item or service’ means an item or 
service that has low utilization or significant 
variation in costs (such as when furnished as 
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4262 
part of a complex treatment), as specified by the 
Secretary.’’. 
(c) ERISA AMENDMENTS.—Section 716 of the Em-
ployee Retirement Income Security Act of 1974, as added 
by section 102 and further amended by the previous amend-
ments of this title, is further amended by adding at the end 
the following new subsection: 
‘‘(f) ADVANCED EXPLANATION OF BENEFITS.— 
‘‘(1) IN GENERAL.—For plan years beginning on 
or after January 1, 2022, each group health plan, or 
a health insurance issuer offering group health insur-
ance coverage shall, with respect to a notification sub-
mitted under section 2799B–6 of the Public Health 
Service Act by a health care provider or health care 
facility to the plan or issuer for a participant or ben-
eficiary under plan or coverage scheduled to receive 
an item or service from the provider or facility (or 
authorized representative of such participant or bene-
ficiary), not later than 1 business day (or, in the case 
such item or service was so scheduled at least 10 busi-
ness days before such item or service is to be furnished 
(or in the case of a request made to such plan or cov-
erage by such participant or beneficiary), 3 business 
days) after the date on which the plan or coverage re-
ceives such notification (or such request), provide to 
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the participant or beneficiary (through mail or elec-
tronic means, as requested by the participant or bene-
ficiary) a notification (in clear and understandable 
language) including the following: 
‘‘(A) Whether or not the provider or facility 
is a participating provider or a participating 
facility with respect to the plan or coverage with 
respect to the furnishing of such item or service 
and— 
‘‘(i) in the case the provider or facility 
is a participating provider or facility with 
respect to the plan or coverage with respect 
to the furnishing of such item or service, the 
contracted rate under such plan for such 
item or service (based on the billing and di-
agnostic codes provided by such provider or 
facility); and 
‘‘(ii) in the case the provider or facil-
ity is a nonparticipating provider or facil-
ity with respect to such plan or coverage, a 
description of how such individual may ob-
tain information on providers and facilities 
that, with respect to such plan or coverage, 
are participating providers and facilities, if 
any. 
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‘‘(B) The good faith estimate included in 
the notification received from the provider or fa-
cility (if applicable) based on such codes. 
‘‘(C) A good faith estimate of the amount 
the health plan is responsible for paying for 
items and services included in the estimate de-
scribed in subparagraph (B). 
‘‘(D) A good faith estimate of the amount of 
any cost-sharing for which the participant or 
beneficiary would be responsible for such item or 
service (as of the date of such notification). 
‘‘(E) A good faith estimate of the amount 
that the participant or beneficiary has incurred 
toward meeting the limit of the financial respon-
sibility (including with respect to deductibles 
and out-of-pocket maximums) under the plan or 
coverage (as of the date of such notification). 
‘‘(F) In the case such item or service is sub-
ject to a medical management technique (includ-
ing concurrent review, prior authorization, and 
step-therapy or fail-first protocols) for coverage 
under the plan or coverage, a disclaimer that 
coverage for such item or service is subject to 
such medical management technique. 
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‘‘(G) A disclaimer that the information pro-
vided in the notification is only an estimate 
based on the items and services reasonably ex-
pected, at the time of scheduling (or requesting) 
the item or service, to be furnished and is subject 
to change. 
‘‘(H) Any other information or disclaimer 
the plan or coverage determines appropriate that 
is consistent with information and disclaimers 
required under this section. 
‘‘(2) AUTHORITY TO MODIFY TIMING REQUIRE-
MENTS IN THE CASE OF SPECIFIED ITEMS AND SERV-
ICES.— 
‘‘(A) IN GENERAL.—In the case of a partici-
pant or beneficiary scheduled to receive an item 
or service that is a specified item or service (as 
defined in subparagraph (B)), the Secretary may 
modify any timing requirements relating to the 
provision of the notification described in para-
graph (1) to such participant or beneficiary with 
respect to such item or service. Any modification 
made by the Secretary pursuant to the previous 
sentence may not result in the provision of such 
notification after such participant or beneficiary 
has been furnished such item or service. 
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‘‘(B) SPECIFIED
ITEM
OR
SERVICE
DE-
FINED.—For purposes of subparagraph (A), the 
term ‘specified item or service’ means an item or 
service that has low utilization or significant 
variation in costs (such as when furnished as 
part of a complex treatment), as specified by the 
Secretary.’’. 
SEC. 
112. 
PATIENT 
PROTECTIONS 
THROUGH 
TRANS-
PARENCY AND PATIENT-PROVIDER DISPUTE 
RESOLUTION. 
Part E of title XXVII of the Public Health Service Act 
(42 U.S.C. 300gg et seq.), as added by section 104 and fur-
ther amended by the previous provisions of this title, is fur-
ther amended by adding at the end the following new sec-
tions: 
‘‘SEC. 2799B–6. PROVISION OF INFORMATION UPON RE-
QUEST 
AND 
FOR 
SCHEDULED 
APPOINT-
MENTS. 
‘‘Each health care provider and health care facility 
shall, beginning January 1, 2022, in the case of an indi-
vidual who schedules an item or service to be furnished to 
such individual by such provider or facility at least 3 busi-
ness days before the date such item or service is to be so 
furnished, not later than 1 business day after the date of 
such scheduling (or, in the case of such an item or service 
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scheduled at least 10 business days before the date such item 
or service is to be so furnished (or if requested by the indi-
vidual), not later than 3 business days after the date of 
such scheduling or such request)— 
‘‘(1) inquire if such individual is enrolled in a 
group health plan, group or individual health insur-
ance coverage offered by a health insurance issuer, or 
a Federal health care program (and if is so enrolled 
in such plan or coverage, seeking to have a claim for 
such item or service submitted to such plan or cov-
erage); and 
‘‘(2) provide a notification (in clear and under-
standable language) of the good faith estimate of the 
expected charges for furnishing such item or service 
(including any item or service that is reasonably ex-
pected to be provided in conjunction with such sched-
uled item or service and such an item or service rea-
sonably expected to be so provided by another health 
care provider or health care facility), with the ex-
pected billing and diagnostic codes for any such item 
or service, to— 
‘‘(A) in the case the individual is enrolled 
in such a plan or such coverage (and is seeking 
to have a claim for such item or service sub-
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mitted to such plan or coverage), such plan or 
issuer of such coverage; and 
‘‘(B) in the case the individual is not de-
scribed in subparagraph (A) and not enrolled in 
a Federal health care program, the individual. 
‘‘SEC. 2799B–7. PATIENT-PROVIDER DISPUTE RESOLUTION. 
‘‘(a) IN GENERAL.—Not later than January 1, 2022, 
the Secretary shall establish a process (in this subsection 
referred to as the ‘patient-provider dispute resolution proc-
ess’) under which an uninsured individual, with respect to 
an item or service, who received, pursuant to section 
2799B–6, from a health care provider or health care facility 
a good-faith estimate of the expected charges for furnishing 
such item or service to such individual and who after being 
furnished such item or service by such provider or facility 
is billed by such provider or facility for such item or service 
for charges that are substantially in excess of such estimate, 
may seek a determination from a selected dispute resolution 
entity for the charges to be paid by such individual (in lieu 
of such amount so billed) to such provider or facility for 
such item or service. For purposes of this subsection, the 
term ‘uninsured individual’ means, with respect to an item 
or service, an individual who does not have benefits for such 
item or service under a group health plan, group or indi-
vidual health insurance coverage offered by a health insur-
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4269 
ance issuer, Federal health care program (as defined in sec-
tion 1128B(f) of the Social Security Act), or a health bene-
fits plan under chapter 89 of title 5, United States Code 
(or an individual who has benefits for such item or service 
under a group health plan or individual or group health 
insurance coverage offered by a health insurance issuer, but 
who does not seek to have a claim for such item or service 
submitted to such plan or coverage). 
‘‘(b) SELECTION OF ENTITIES.—Under the patient- 
provider dispute resolution process, the Secretary shall, 
with respect to a determination sought by an individual 
under subsection (a), with respect to charges to be paid by 
such individual to a health care provider or health care fa-
cility described in such paragraph for an item or service 
furnished to such individual by such provider or facility, 
provide for— 
‘‘(1) a method to select to make such determina-
tion an entity certified under subsection (d) that— 
‘‘(A) is not a party to such determination 
or an employee or agent of such party; 
‘‘(B) does not have a material familial, fi-
nancial, or professional relationship with such a 
party; and 
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4270 
‘‘(C) does not otherwise have a conflict of 
interest with such a party (as determined by the 
Secretary); and 
‘‘(2) the provision of a notification of such selec-
tion to the individual and the provider or facility (as 
applicable) party to such determination. 
An entity selected pursuant to the previous sentence to make 
a determination described in such sentence shall be referred 
to in this subsection as the ‘selected dispute resolution enti-
ty’ with respect to such determination. 
‘‘(c) ADMINISTRATIVE FEE.—The Secretary shall es-
tablish a fee to participate in the patient-provider dispute 
resolution process in such a manner as to not create a bar-
rier to an uninsured individual’s access to such process. 
‘‘(d) CERTIFICATION.—The Secretary shall establish or 
recognize a process to certify entities under this subpara-
graph. Such process shall ensure that an entity so certified 
satisfies at least the criteria specified in section 2799A– 
1(c).’’. 
SEC. 113. ENSURING CONTINUITY OF CARE. 
(a) PUBLIC HEALTH SERVICE ACT.—Title XXVII of 
the Public Health Service Act (42 U.S.C. 300gg et seq.) is 
amended, in the part D, as added and amended by section 
102(a) and further amended by the previous provisions of 
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this title, by inserting after section 2799A–2 the following 
new section: 
‘‘SEC. 2799A-3. CONTINUITY OF CARE. 
‘‘(a) ENSURING CONTINUITY OF CARE WITH RESPECT 
TO TERMINATIONS OF CERTAIN CONTRACTUAL RELATION-
SHIPS RESULTING IN CHANGES IN PROVIDER NETWORK 
STATUS.— 
‘‘(1) IN GENERAL.—In the case of an individual 
with benefits under a group health plan or group or 
individual health insurance coverage offered by a 
health insurance issuer and with respect to a health 
care provider or facility that has a contractual rela-
tionship with such plan or such issuer (as applicable) 
for furnishing items and services under such plan or 
such coverage, if, while such individual is a con-
tinuing care patient (as defined in subsection (b)) 
with respect to such provider or facility— 
‘‘(A) such contractual relationship is termi-
nated (as defined in subsection (b)); 
‘‘(B) benefits provided under such plan or 
such health insurance coverage with respect to 
such provider or facility are terminated because 
of a change in the terms of the participation of 
such provider or facility in such plan or cov-
erage; or 
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‘‘(C) a contract between such group health 
plan and a health insurance issuer offering 
health insurance coverage in connection with 
such plan is terminated, resulting in a loss of 
benefits provided under such plan with respect to 
such provider or facility; 
the plan or issuer, respectively, shall meet the require-
ments of paragraph (2) with respect to such indi-
vidual. 
‘‘(2) REQUIREMENTS.—The requirements of this 
paragraph are that the plan or issuer— 
‘‘(A) notify each individual enrolled under 
such plan or coverage who is a continuing care 
patient with respect to a provider or facility at 
the time of a termination described in paragraph 
(1) affecting such provider or facility on a time-
ly basis of such termination and such individ-
ual’s right to elect continued transitional care 
from such provider or facility under this section; 
‘‘(B) provide such individual with an op-
portunity to notify the plan or issuer of the indi-
vidual’s need for transitional care; and 
‘‘(C) permit the patient to elect to continue 
to have benefits provided under such plan or 
such coverage, under the same terms and condi-
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tions as would have applied and with respect to 
such items and services as would have been cov-
ered under such plan or coverage had such termi-
nation not occurred, with respect to the course of 
treatment furnished by such provider or facility 
relating to such individual’s status as a con-
tinuing care patient during the period beginning 
on the date on which the notice under subpara-
graph (A) is provided and ending on the earlier 
of— 
‘‘(i) the 90-day period beginning on 
such date; or 
‘‘(ii) the date on which such individual 
is no longer a continuing care patient with 
respect to such provider or facility. 
‘‘(b) DEFINITIONS.—In this section: 
‘‘(1) CONTINUING
CARE
PATIENT.—The term 
‘continuing care patient’ means an individual who, 
with respect to a provider or facility— 
‘‘(A) is undergoing a course of treatment for 
a serious and complex condition from the pro-
vider or facility; 
‘‘(B) is undergoing a course of institutional 
or inpatient care from the provider or facility; 
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‘‘(C) is scheduled to undergo nonelective 
surgery from the provider, including receipt of 
postoperative care from such provider or facility 
with respect to such a surgery; 
‘‘(D) is pregnant and undergoing a course 
of treatment for the pregnancy from the provider 
or facility; or 
‘‘(E) is or was determined to be terminally 
ill (as determined under section 1861(dd)(3)(A) 
of the Social Security Act) and is receiving 
treatment for such illness from such provider or 
facility. 
‘‘(2) SERIOUS AND COMPLEX CONDITION.—The 
term ‘serious and complex condition’ means, with re-
spect to a participant, beneficiary, or enrollee under 
a group health plan or group or individual health in-
surance coverage— 
‘‘(A) in the case of an acute illness, a condi-
tion that is serious enough to require specialized 
medical treatment to avoid the reasonable possi-
bility of death or permanent harm; or 
‘‘(B) in the case of a chronic illness or con-
dition, a condition that is— 
‘‘(i) is life-threatening, degenerative, 
potentially disabling, or congenital; and 
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‘‘(ii) requires specialized medical care 
over a prolonged period of time. 
‘‘(3) TERMINATED.—The term ‘terminated’ in-
cludes, with respect to a contract, the expiration or 
nonrenewal of the contract, but does not include a ter-
mination of the contract for failure to meet applicable 
quality standards or for fraud.’’. 
(b) INTERNAL REVENUE CODE.— 
(1) IN GENERAL.—Subchapter B of chapter 100 
of the Internal Revenue Code of 1986, as amended by 
sections 102(c) and 105(a)(3), is further amended by 
inserting after section 9817 the following new section: 
‘‘SEC. 9818. CONTINUITY OF CARE. 
‘‘(a) ENSURING CONTINUITY OF CARE WITH RESPECT 
TO TERMINATIONS OF CERTAIN CONTRACTUAL RELATION-
SHIPS RESULTING IN CHANGES IN PROVIDER NETWORK 
STATUS.— 
‘‘(1) IN GENERAL.—In the case of an individual 
with benefits under a group health plan and with re-
spect to a health care provider or facility that has a 
contractual relationship with such plan for furnishing 
items and services under such plan, if, while such in-
dividual is a continuing care patient (as defined in 
subsection (b)) with respect to such provider or facil-
ity— 
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‘‘(A) such contractual relationship is termi-
nated (as defined in paragraph (b)); 
‘‘(B) benefits provided under such plan with 
respect to such provider or facility are termi-
nated because of a change in the terms of the 
participation of such provider or facility in such 
plan; or 
‘‘(C) a contract between such group health 
plan and a health insurance issuer offering 
health insurance coverage in connection with 
such plan is terminated, resulting in a loss of 
benefits provided under such plan with respect to 
such provider or facility; 
the plan shall meet the requirements of paragraph (2) 
with respect to such individual. 
‘‘(2) REQUIREMENTS.—The requirements of this 
paragraph are that the plan— 
‘‘(A) notify each individual enrolled under 
such plan who is a continuing care patient with 
respect to a provider or facility at the time of a 
termination described in paragraph (1) affecting 
such provider on a timely basis of such termi-
nation and such individual’s right to elect con-
tinued transitional care from such provider or 
facility under this section; 
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4277 
‘‘(B) provide such individual with an op-
portunity to notify the plan of the individual’s 
need for transitional care; and 
‘‘(C) permit the patient to elect to continue 
to have benefits provided under such plan, under 
the same terms and conditions as would have ap-
plied and with respect to such items and services 
as would have been covered under such plan had 
such termination not occurred, with respect to 
the course of treatment furnished by such pro-
vider or facility relating to such individual’s sta-
tus as a continuing care patient during the pe-
riod beginning on the date on which the notice 
under subparagraph (A) is provided and ending 
on the earlier of— 
‘‘(i) the 90-day period beginning on 
such date; or 
‘‘(ii) the date on which such individual 
is no longer a continuing care patient with 
respect to such provider or facility. 
‘‘(b) DEFINITIONS.—In this section: 
‘‘(1) CONTINUING
CARE
PATIENT.—The term 
‘continuing care patient’ means an individual who, 
with respect to a provider or facility— 
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4278 
‘‘(A) is undergoing a course of treatment for 
a serious and complex condition from the pro-
vider or facility; 
‘‘(B) is undergoing a course of institutional 
or inpatient care from the provider or facility; 
‘‘(C) is scheduled to undergo nonelective 
surgery from the provider or facility, including 
receipt of postoperative care from such provider 
or facility with respect to such a surgery; 
‘‘(D) is pregnant and undergoing a course 
of treatment for the pregnancy from the provider 
or facility; or 
‘‘(E) is or was determined to be terminally 
ill (as determined under section 1861(dd)(3)(A) 
of the Social Security Act) and is receiving 
treatment for such illness from such provider or 
facility. 
‘‘(2) SERIOUS AND COMPLEX CONDITION.—The 
term ‘serious and complex condition’ means, with re-
spect to a participant or beneficiary under a group 
health plan— 
‘‘(A) in the case of an acute illness, a condi-
tion that is serious enough to require specialized 
medical treatment to avoid the reasonable possi-
bility of death or permanent harm; or 
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4279 
‘‘(B) in the case of a chronic illness or con-
dition, a condition that— 
‘‘(i) is life-threatening, degenerative, 
potentially disabling, or congenital; and 
‘‘(ii) requires specialized medical care 
over a prolonged period of time. 
‘‘(3) TERMINATED.—The term ‘terminated’ in-
cludes, with respect to a contract, the expiration or 
nonrenewal of the contract, but does not include a ter-
mination of the contract for failure to meet applicable 
quality standards or for fraud.’’. 
(2) CLERICAL AMENDMENT.—The table of sec-
tions for such subchapter, as amended by the previous 
sections, is further amended by inserting after the 
item relating to section 9817 the following new item: 
‘‘Sec. 9818. Continuity of care.’’. 
(c) EMPLOYEE
RETIREMENT
INCOME
SECURITY 
ACT.— 
(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.), as 
amended by section 102(c) and further amended by 
the previous provisions of this title, is further amend-
ed by inserting after section 717 the following new 
section: 
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4280 
‘‘SEC. 718. CONTINUITY OF CARE. 
‘‘(a) ENSURING CONTINUITY OF CARE WITH RESPECT 
TO TERMINATIONS OF CERTAIN CONTRACTUAL RELATION-
SHIPS RESULTING IN CHANGES IN PROVIDER NETWORK 
STATUS.— 
‘‘(1) IN GENERAL.—In the case of an individual 
with benefits under a group health plan or group 
health insurance coverage offered by a health insur-
ance issuer and with respect to a health care provider 
or facility that has a contractual relationship with 
such plan or such issuer (as applicable) for furnishing 
items and services under such plan or such coverage, 
if, while such individual is a continuing care patient 
(as defined in subsection (b)) with respect to such 
provider or facility— 
‘‘(A) such contractual relationship is termi-
nated (as defined in paragraph (b)); 
‘‘(B) benefits provided under such plan or 
such health insurance coverage with respect to 
such provider or facility are terminated because 
of a change in the terms of the participation of 
the provider or facility in such plan or coverage; 
or 
‘‘(C) a contract between such group health 
plan and a health insurance issuer offering 
health insurance coverage in connection with 
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such plan is terminated, resulting in a loss of 
benefits provided under such plan with respect to 
such provider or facility; 
the plan or issuer, respectively, shall meet the require-
ments of paragraph (2) with respect to such indi-
vidual. 
‘‘(2) REQUIREMENTS.—The requirements of this 
paragraph are that the plan or issuer— 
‘‘(A) notify each individual enrolled under 
such plan or coverage who is a continuing care 
patient with respect to a provider or facility at 
the time of a termination described in paragraph 
(1) affecting such provider or facility on a time-
ly basis of such termination and such individ-
ual’s right to elect continued transitional care 
from such provider or facility under this section; 
‘‘(B) provide such individual with an op-
portunity to notify the plan or issuer of the indi-
vidual’s need for transitional care; and 
‘‘(C) permit the patient to elect to continue 
to have benefits provided under such plan or 
such coverage, under the same terms and condi-
tions as would have applied and with respect to 
such items and services as would have been cov-
ered under such plan or coverage had such termi-
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nation not occurred, with respect to the course of 
treatment furnished by such provider or facility 
relating to such individual’s status as a con-
tinuing care patient during the period beginning 
on the date on which the notice under subpara-
graph (A) is provided and ending on the earlier 
of— 
‘‘(i) the 90-day period beginning on 
such date; or 
‘‘(ii) the date on which such individual 
is no longer a continuing care patient with 
respect to such provider or facility. 
‘‘(b) DEFINITIONS.—In this section: 
‘‘(1) CONTINUING
CARE
PATIENT.—The term 
‘continuing care patient’ means an individual who, 
with respect to a provider or facility— 
‘‘(A) is undergoing a course of treatment for 
a serious and complex condition from the pro-
vider or facility; 
‘‘(B) is undergoing a course of institutional 
or inpatient care from the provider or facility; 
‘‘(C) is scheduled to undergo nonelective 
surgery from the provide or facility, including 
receipt of postoperative care from such provider 
or facility with respect to such a surgery; 
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4283 
‘‘(D) is pregnant and undergoing a course 
of treatment for the pregnancy from the provider 
or facility; or 
‘‘(E) is or was determined to be terminally 
ill (as determined under section 1861(dd)(3)(A) 
of the Social Security Act) and is receiving 
treatment for such illness from such provider or 
facility. 
‘‘(2) SERIOUS AND COMPLEX CONDITION.—The 
term ‘serious and complex condition’ means, with re-
spect to a participant or beneficiary under a group 
health plan or group health insurance coverage— 
‘‘(A) in the case of an acute illness, a condi-
tion that is serious enough to require specialized 
medical treatment to avoid the reasonable possi-
bility of death or permanent harm; or 
‘‘(B) in the case of a chronic illness or con-
dition, a condition that— 
‘‘(i) is life-threatening, degenerative, 
potentially disabling, or congenital; and 
‘‘(ii) requires specialized medical care 
over a prolonged period of time. 
‘‘(3) TERMINATED.—The term ‘terminated’ in-
cludes, with respect to a contract, the expiration or 
nonrenewal of the contract, but does not include a ter-
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mination of the contract for failure to meet applicable 
quality standards or for fraud.’’. 
(2) CLERICAL AMENDMENT.—The table of con-
tents in section 1 of the Employee Retirement Income 
Security Act of 1974 is amended by inserting after 
the item relating to section 716 the following new 
item: 
‘‘Sec. 718. Continuity of care.’’. 
(d) PROVIDER REQUIREMENT.—Part E of title XXVII 
of the Public Health Service Act (42 U.S.C. 300gg et seq.), 
as added by section 104 and further amended by the pre-
vious provisions of this title, is further amended by adding 
at the end the following new section: 
‘‘SEC. 2799B–8. CONTINUITY OF CARE. 
‘‘A health care provider or health care facility shall, 
in the case of an individual furnished items and services 
by such provider or facility for which coverage is provided 
under a group health plan or group or individual health 
insurance coverage pursuant to section 2799A–3, section 
9818 of the Internal Revenue Code of 1986, or section 718 
of the Employee Retirement Income Security Act of 1974— 
‘‘(1) accept payment from such plan or such 
issuer (as applicable) (and cost-sharing from such in-
dividual, if applicable, in accordance with subsection 
(a)(2)(C) of such section 2799A–3, 9818, or 718) for 
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such items and services as payment in full for such 
items and services; and 
‘‘(2) continue to adhere to all policies, proce-
dures, and quality standards imposed by such plan or 
issuer with respect to such individual and such items 
and services in the same manner as if such termi-
nation had not occurred.’’. 
(e) EFFECTIVE DATE.—The amendments made by sub-
sections (a), (b), and (c) shall apply with respect to plan 
years beginning on or after January 1, 2022. 
SEC. 114. MAINTENANCE OF PRICE COMPARISON TOOL. 
(a) PUBLIC HEALTH SERVICE ACT.—Title XXVII of 
the Public Health Service Act (42 U.S.C. 300gg et seq.) is 
amended, in part D, as added and amended by section 102 
and further amended by the previous provisions of this title, 
by inserting after section 2799A–3 the following new sec-
tion: 
‘‘SEC. 2799A–4. MAINTENANCE OF PRICE COMPARISON 
TOOL. 
‘‘A group health plan or a health insurance issuer of-
fering group or individual health insurance coverage shall 
offer price comparison guidance by telephone and make 
available on the Internet website of the plan or issuer a 
price comparison tool that (to the extent practicable) allows 
an individual enrolled under such plan or coverage, with 
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respect to such plan year, such geographic region, and par-
ticipating providers with respect to such plan or coverage, 
to compare the amount of cost-sharing that the individual 
would be responsible for paying under such plan or coverage 
with respect to the furnishing of a specific item or service 
by any such provider.’’. 
(b) INTERNAL REVENUE CODE.— 
(1) IN GENERAL.—Subchapter B of chapter 100 
of the Internal Revenue Code of 1986, as amended by 
sections 102, 105, and 113, is further amended by in-
serting after section 9818 the following new section: 
‘‘SEC. 9819. MAINTENANCE OF PRICE COMPARISON TOOL. 
‘‘A group health plan shall offer price comparison 
guidance by telephone and make available on the Internet 
website of the plan or issuer a price comparison tool that 
(to the extent practicable) allows an individual enrolled 
under such plan, with respect to such plan year, such geo-
graphic region, and participating providers with respect to 
such plan or coverage, to compare the amount of cost-shar-
ing that the individual would be responsible for paying 
under such plan with respect to the furnishing of a specific 
item or service by any such provider.’’. 
(2) CLERICAL AMENDMENT.—The table of sec-
tions for such subchapter, as amended by the previous 
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sections, is further amended by inserting after the 
item relating to section 9818 the following new item: 
‘‘Sec. 9819. Maintenance of price comparison tool.’’. 
(c) EMPLOYEE
RETIREMENT
INCOME
SECURITY 
ACT.— 
(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.), as 
amended by sections 102, 105, and 113, is further 
amended by inserting after section 718 the following 
new section: 
‘‘SEC. 719. MAINTENANCE OF PRICE COMPARISON TOOL. 
‘‘A group health plan or a health insurance issuer of-
fering group health insurance coverage shall offer price com-
parison guidance by telephone and make available on the 
Internet website of the plan or issuer a price comparison 
tool that (to the extent practicable) allows an individual 
enrolled under such plan or coverage, with respect to such 
plan year, such geographic region, and participating pro-
viders with respect to such plan or coverage, to compare 
the amount of cost-sharing that the individual would be re-
sponsible for paying under such plan or coverage with re-
spect to the furnishing of a specific item or service by any 
such provider.’’. 
(2) CLERICAL AMENDMENT.—The table of con-
tents in section 1 of the Employee Retirement Income 
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Security Act of 1974, as amended by the previous 
provisions of this title, is further amended by insert-
ing after the item relating to section 716 the following 
new item: 
‘‘Sec. 719. Maintenance of price comparison tool.’’. 
(d) EFFECTIVE DATE.—The amendments made by this 
section shall apply with respect to plan years beginning on 
or after January 1, 2022. 
SEC. 115. STATE ALL PAYER CLAIMS DATABASES. 
(a) GRANTS TO STATES.—Part B of title III of the 
Public Health Service Act (42 U.S.C. 243 et seq.) is amend-
ed by adding at the end the following: 
‘‘SEC. 320B. STATE ALL PAYER CLAIMS DATABASES. 
‘‘(a) IN GENERAL.—The Secretary shall make one-time 
grants to eligible States for the purposes described in sub-
section (b). 
‘‘(b) USES.—A State may use a grant received under 
subsection (a) for one of the following purposes: 
‘‘(1) To establish a State All Payer Claims 
Database. 
‘‘(2) To improve an existing State All Payer 
Claims Databases. 
‘‘(c) ELIGIBILITY.—To be eligible to receive a grant 
under subsection (a), a State shall submit to the Secretary 
an application at such time, in such manner, and con-
taining such information as the Secretary specifies, includ-
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ing, with respect to a State All Payer Claims Database, 
at least specifics on how the State will ensure uniform data 
collection and the privacy and security of such data. 
‘‘(d) GRANT PERIOD AND AMOUNT.—Grants awarded 
under this section shall be for a period of 3-years, and in 
an amount of $2,500,000, of which $1,000,000 shall be made 
available to the State for each of the first 2 years of the 
grant period, and $500,000 shall be made available to the 
State for the third year of the grant period. 
‘‘(e) AUTHORIZED USERS.— 
‘‘(1) APPLICATION.—An entity desiring author-
ization for access to a State All Payer Claims Data-
base that has received a grant under this section shall 
submit to the State All Payer Claims Database an 
application for such access, which shall include— 
‘‘(A) in the case of an entity requesting ac-
cess for research purposes— 
‘‘(i) a description of the uses and meth-
odologies for evaluating health system per-
formance using such data; and 
‘‘(ii) documentation of approval of the 
research by an institutional review board, if 
applicable for a particular plan of research; 
or 
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4290 
‘‘(B) in the case of an entity such as an em-
ployer, health insurance issuer, third-party ad-
ministrator, or health care provider, requesting 
access for the purpose of quality improvement or 
cost-containment, a description of the intended 
uses for such data. 
‘‘(2) REQUIREMENTS.— 
‘‘(A) ACCESS FOR RESEARCH PURPOSES.— 
Upon approval of an application for research 
purposes under paragraph (1)(A), the authorized 
user shall enter into a data use and confiden-
tiality agreement with the State All Payer 
Claims Database that has received a grant under 
this subsection, which shall include a prohibition 
on attempts to reidentify and disclose individ-
ually identifiable health information and propri-
etary financial information. 
‘‘(B) CUSTOMIZED
REPORTS.—Employers 
and employer organizations may request cus-
tomized reports from a State All Payer Claims 
Database that has received a grant under this 
section, at cost, subject to the requirements of 
this section with respect to privacy, security, and 
proprietary financial information. 
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4291 
‘‘(C) NON-CUSTOMIZED REPORTS.—A State 
All Payer Claims Database that has received a 
grant under this section shall make available to 
all authorized users aggregate data sets available 
through the State All Payer Claims Database, 
free of charge. 
‘‘(3) WAIVERS.—The Secretary may waive the 
requirements of this subsection of a State All Payer 
Claims Database to provide access of entities to such 
database if such State All Payer Claims Database is 
substantially in compliance with this subsection. 
‘‘(f) EXPANDED ACCESS.— 
‘‘(1) MULTI-STATE
APPLICATIONS.—The Sec-
retary may prioritize applications submitted by a 
State whose application demonstrates that the State 
will work with other State All Payer Claims Data-
bases to establish a single application for access to 
data by authorized users across multiple States. 
‘‘(2) EXPANSION OF DATA SETS.—The Secretary 
may prioritize applications submitted by a State 
whose application demonstrates that the State will 
implement the reporting format for self-insured group 
health plans described in section 735 of the Employee 
Retirement Income Security Act of 1974. 
‘‘(g) DEFINITIONS.—In this section— 
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‘‘(1) the term ‘individually identifiable health 
information’ has the meaning given such term in sec-
tion 1171(6) of the Social Security Act; 
‘‘(2) the term ‘proprietary financial information’ 
means data that would disclose the terms of a specific 
contract between an individual health care provider 
or facility and a specific group health plan, managed 
care entity (as defined in section 1932(a)(1)(B) of the 
Social Security Act) or other managed care organiza-
tion, or health insurance issuer offering group or in-
dividual health insurance coverage; and 
‘‘(3) the term ‘State All Payer Claims Database’ 
means, with respect to a State, a database that may 
include medical claims, pharmacy claims, dental 
claims, and eligibility and provider files, which are 
collected from private and public payers. 
‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—To carry 
out this section, there is authorized to be appropriated 
$50,000,000 for each of fiscal years 2022 and 2023, and 
$25,000,000 for fiscal year 2024, to remain available until 
expended.’’. 
(b) STANDARDIZED REPORTING FORMAT.— 
Subpart C of part 7 of subtitle B of title I of the 
Employee Retirement Income Security Act of 1974 
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(29 U.S.C. 1191 et seq.) is amended by adding at the 
end the following: 
‘‘SEC. 735. STANDARDIZED REPORTING FORMAT. 
‘‘(a) IN GENERAL.—Not later than 1 year after the 
date of enactment of this section, the Secretary shall estab-
lish (and periodically update) a standardized reporting for-
mat for the voluntary reporting, by group health plans to 
State All Payer Claims Databases, of medical claims, phar-
macy claims, dental claims, and eligibility and provider 
files that are collected from private and public payers, and 
shall provide guidance to States on the process by which 
States may collect such data from such plans in the stand-
ardized reporting format. 
‘‘(b) CONSULTATION.— 
‘‘(1) ADVISORY COMMITTEE.—Not later than 90 
days after the date of enactment of this section, the 
Secretary shall convene an Advisory Committee (re-
ferred to in this section as the ‘Committee’), con-
sisting of 15 members to advise the Secretary regard-
ing the format and guidance described in paragraph 
(1). 
‘‘(2) MEMBERSHIP.— 
‘‘(A) APPOINTMENT.—In accordance with 
subparagraph (B), not later than 90 days after 
the date of enactment this section, the Secretary, 
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in coordination with the Secretary of Health and 
Human Services, shall appoint under subpara-
graph (B)(iii), and the Comptroller General of 
the United States shall appoint under subpara-
graph (B)(iv), members who have distinguished 
themselves in the fields of health services re-
search, health economics, health informatics, 
data privacy and security, or the governance of 
State All Payer Claims Databases, or who rep-
resent organizations likely to submit data to or 
use the database, including patients, employers, 
or employee organizations that sponsor group 
health plans, health care providers, health insur-
ance issuers, or third-party administrators of 
group health plans. Such members shall serve 3- 
year terms on a staggered basis. Vacancies on the 
Committee shall be filled by appointment con-
sistent with this paragraph not later than 3 
months after the vacancy arises. 
‘‘(B) COMPOSITION.—The Committee shall 
be comprised of— 
‘‘(i) the Assistant Secretary of Em-
ployee Benefits and Security Administra-
tion of the Department of Labor, or a des-
ignee of such Assistant Secretary; 
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‘‘(ii) the Assistant Secretary for Plan-
ning and Evaluation of the Department of 
Health and Human Services, or a designee 
of such Assistant Secretary; 
‘‘(iii) members appointed by the Sec-
retary, in coordination with the Secretary 
of Health and Human Services, includ-
ing— 
‘‘(I) 1 member to serve as the 
chair of the Committee; 
‘‘(II) 1 representative of the Cen-
ters for Medicare & Medicaid Services; 
‘‘(III) 1 representative of the 
Agency for Healthcare Research and 
Quality; 
‘‘(IV) 1 representative of the Of-
fice for Civil Rights of the Department 
of Health and Human Services with 
expertise in data privacy and security; 
‘‘(V) 1 representative of the Na-
tional Center for Health Statistics; 
‘‘(VI) 1 representative of the Of-
fice of the National Coordinator for 
Health Information Technology; and 
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‘‘(VII) 1 representative of a State 
All-Payer Claims Database; 
‘‘(iv) members appointed by the Comp-
troller General of the United States, includ-
ing— 
‘‘(I) 1 representative of an em-
ployer that sponsors a group health 
plan; 
‘‘(II) 1 representative of an em-
ployee organization that sponsors a 
group health plan; 
‘‘(III) 1 academic researcher with 
expertise in health economics or health 
services research; 
‘‘(IV) 1 consumer advocate; and 
‘‘(V) 2 additional members. 
‘‘(3) REPORT.—Not later than 180 days after the 
date of enactment of this section, the Committee shall 
report to the Secretary, the Committee on Health, 
Education, Labor, and Pensions of the Senate, and 
the Committee on Energy and Commerce and the 
Committee on Education and Labor of the House of 
Representatives. Such report shall include rec-
ommendations on the establishment of the format and 
guidance described in subsection (a). 
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‘‘(c) STATE ALL PAYER CLAIMS DATABASE.—In this 
section, the term ‘State All Payer Claims Database’ means, 
with respect to a State, a database that may include med-
ical claims, pharmacy claims, dental claims, and eligibility 
and provider files, which are collected from private and 
public payers. 
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—To carry 
out this section, there are authorized to be appropriated 
$5,000,000 for fiscal year 2021, to remain available until 
expended or, if sooner, until the date described in subsection 
(e). 
‘‘(e) SUNSET.—Beginning on the date on which the re-
port is submitted under subsection (b)(3), subsection (b) 
shall have no force or effect.’’. 
SEC. 116. PROTECTING PATIENTS AND IMPROVING THE AC-
CURACY OF PROVIDER DIRECTORY INFORMA-
TION. 
(a) PHSA.—Part D of title XXVII of the Public 
Health Service Act (42 U.S.C. 300gg et seq.), as added and 
amended by section 102 and further amended by the pre-
vious provisions of this title, is further amended by insert-
ing after section 2799A–4 the following: 
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‘‘SEC. 2799A–5. PROTECTING PATIENTS AND IMPROVING 
THE ACCURACY OF PROVIDER DIRECTORY IN-
FORMATION. 
‘‘(a) PROVIDER DIRECTORY INFORMATION REQUIRE-
MENTS.— 
‘‘(1) IN GENERAL.—For plan years beginning on 
or after January 1, 2022, each group health plan and 
health insurance issuer offering group or individual 
health insurance coverage shall— 
‘‘(A) establish the verification process de-
scribed in paragraph (2); 
‘‘(B) establish the response protocol de-
scribed in paragraph (3); 
‘‘(C) establish the database described in 
paragraph (4); and 
‘‘(D) include in any directory (other than 
the database described in subparagraph (C)) con-
taining provider directory information with re-
spect to such plan or such coverage the informa-
tion described in paragraph (5). 
‘‘(2) VERIFICATION PROCESS.—The verification 
process described in this paragraph is, with respect to 
a group health plan or a health insurance issuer of-
fering group or individual health insurance coverage, 
a process— 
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4299 
‘‘(A) under which, not less frequently than 
once every 90 days, such plan or such issuer (as 
applicable) verifies and updates the provider di-
rectory information included on the database de-
scribed in paragraph (4) of such plan or issuer 
of each health care provider and health care fa-
cility included in such database; 
‘‘(B) that establishes a procedure for the re-
moval of such a provider or facility with respect 
to which such plan or issuer has been unable to 
verify such information during a period speci-
fied by the plan or issuer; and 
‘‘(C) that provides for the update of such 
database within 2 business days of such plan or 
issuer receiving from such a provider or facility 
information pursuant to section 2799B–9. 
‘‘(3) RESPONSE PROTOCOL.—The response pro-
tocol described in this paragraph is, in the case of an 
individual enrolled under a group health plan or 
group or individual health insurance coverage offered 
by a health insurance issuer who requests information 
through a telephone call or electronic, web-based, or 
Internet-based means on whether a health care pro-
vider or health care facility has a contractual rela-
tionship to furnish items and services under such 
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4300 
plan or such coverage, a protocol under which such 
plan or such issuer (as applicable), in the case such 
request is made through a telephone call— 
‘‘(A) responds to such individual as soon as 
practicable and in no case later than 1 business 
day after such call is received, through a written 
electronic or print (as requested by such indi-
vidual) communication; and 
‘‘(B) retains such communication in such 
individual’s file for at least 2 years following 
such response. 
‘‘(4) DATABASE.—The database described in this 
paragraph is, with respect to a group health plan or 
health insurance issuer offering group or individual 
health insurance coverage, a database on the public 
website of such plan or issuer that contains— 
‘‘(A) a list of each health care provider and 
health care facility with which such plan or such 
issuer has a direct or indirect contractual rela-
tionship for furnishing items and services under 
such plan or such coverage; and 
‘‘(B) provider directory information with 
respect to each such provider and facility. 
‘‘(5) INFORMATION.—The information described 
in this paragraph is, with respect to a print directory 
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4301 
containing provider directory information with re-
spect to a group health plan or individual or group 
health insurance coverage offered by a health insur-
ance issuer, a notification that such information con-
tained in such directory was accurate as of the date 
of publication of such directory and that an indi-
vidual enrolled under such plan or such coverage 
should consult the database described in paragraph 
(4) with respect to such plan or such coverage or con-
tact such plan or the issuer of such coverage to obtain 
the most current provider directory information with 
respect to such plan or such coverage. 
‘‘(6) DEFINITION.—For purposes of this sub-
section, the term ‘provider directory information’ in-
cludes, with respect to a group health plan and a 
health insurance issuer offering group or individual 
health insurance coverage, the name, address, spe-
cialty, telephone number, and digital contact infor-
mation of each health care provider or health care fa-
cility with which such plan or such issuer has a con-
tractual relationship for furnishing items and services 
under such plan or such coverage. 
‘‘(7) RULE OF CONSTRUCTION.—Nothing in this 
section shall be construed to preempt any provision of 
State law relating to health care provider directories. 
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‘‘(b) COST-SHARING FOR SERVICES PROVIDED BASED 
ON RELIANCE ON INCORRECT PROVIDER NETWORK INFOR-
MATION.— 
‘‘(1) IN GENERAL.—For plan years beginning on 
or after January 1, 2022, in the case of an item or 
service furnished to a participant, beneficiary, or en-
rollee of a group health plan or group or individual 
health insurance coverage offered by a health insur-
ance issuer by a nonparticipating provider or a non-
participating facility, if such item or service would 
otherwise be covered under such plan or coverage if 
furnished by a participating provider or partici-
pating facility and if either of the criteria described 
in paragraph (2) applies with respect to such partici-
pant, beneficiary, or enrollee and item or service, the 
plan or coverage— 
‘‘(A) shall not impose on such participant, 
beneficiary, or enrollee a cost-sharing amount for 
such item or service so furnished that is greater 
than the cost-sharing amount that would apply 
under such plan or coverage had such item or 
service been furnished by a participating pro-
vider; and 
‘‘(B) shall apply the deductible or out-of- 
pocket maximum, if any, that would apply if 
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4303 
such services were furnished by a participating 
provider or a participating facility. 
‘‘(2) CRITERIA
DESCRIBED.—For purposes of 
paragraph (1), the criteria described in this para-
graph, with respect to an item or service furnished to 
a participant, beneficiary, or enrollee of a group 
health plan or group or individual health insurance 
coverage offered by a health insurance issuer by a 
nonparticipating provider or a nonparticipating fa-
cility, are the following: 
‘‘(A) The participant, beneficiary, or en-
rollee received through a database, provider di-
rectory, or response protocol described in sub-
section (a) information with respect to such item 
and service to be furnished and such information 
provided that the provider was a participating 
provider or facility was a participating facility, 
with respect to the plan for furnishing such item 
or service. 
‘‘(B) The information was not provided, in 
accordance with subsection (a), to the partici-
pant, beneficiary, or enrollee and the partici-
pant, beneficiary, or enrollee requested through 
the response protocol described in subsection 
(a)(3) of the plan or coverage information on 
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4304 
whether the provider was a participating pro-
vider or facility was a participating facility 
with respect to the plan for furnishing such item 
or service and was informed through such pro-
tocol that the provider was such a participating 
provider or facility was such a participating fa-
cility. 
‘‘(c) DISCLOSURE ON PATIENT PROTECTIONS AGAINST 
BALANCE BILLING.—For plan years beginning on or after 
January 1, 2022, each group health plan and health insur-
ance issuer offering group or individual health insurance 
coverage shall make publicly available, post on a public 
website of such plan or issuer, and include on each expla-
nation of benefits for an item or service with respect to 
which the requirements under section 2799A–1 applies— 
‘‘(1) information in plain language on— 
‘‘(A) the requirements and prohibitions ap-
plied under sections 2799B–1 and 2799B–2 (re-
lating to prohibitions on balance billing in cer-
tain circumstances); 
‘‘(B) if provided for under applicable State 
law, any other requirements on providers and fa-
cilities regarding the amounts such providers 
and facilities may, with respect to an item or 
service, charge a participant, beneficiary, or en-
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4305 
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 section 
2799A-1; 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.’’. 
(b) ERISA.—Subpart B of part 7 of subtitle B of title 
I of the Employee Retirement Income Security Act of 1974 
(29 U.S.C. 1185 et seq.), as amended by sections 102, 105, 
113, and 114, is further amended by inserting after section 
719 the following: 
‘‘SEC. 720. PROTECTING PATIENTS AND IMPROVING THE AC-
CURACY OF PROVIDER DIRECTORY INFORMA-
TION. 
‘‘(a) PROVIDER DIRECTORY INFORMATION REQUIRE-
MENTS.— 
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‘‘(1) IN GENERAL.—For plan years beginning on 
or after January 1, 2022, each group health plan and 
health insurance issuer offering group health insur-
ance coverage shall— 
‘‘(A) establish the verification process de-
scribed in paragraph (2); 
‘‘(B) establish the response protocol de-
scribed in paragraph (3); 
‘‘(C) establish the database described in 
paragraph (4); and 
‘‘(D) include in any directory (other than 
the database described in subparagraph (C)) con-
taining provider directory information with re-
spect to such plan or such coverage the informa-
tion described in paragraph (5). 
‘‘(2) VERIFICATION PROCESS.—The verification 
process described in this paragraph is, with respect to 
a group health plan or a health insurance issuer of-
fering group health insurance coverage, a process— 
‘‘(A) under which, not less frequently than 
once every 90 days, such plan or such issuer (as 
applicable) verifies and updates the provider di-
rectory information included on the database de-
scribed in paragraph (4) of such plan or issuer 
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of each health care provider and health care fa-
cility included in such database; 
‘‘(B) that establishes a procedure for the re-
moval of such a provider or facility with respect 
to which such plan or issuer has been unable to 
verify such information during a period speci-
fied by the plan or issuer; and 
‘‘(C) that provides for the update of such 
database within 2 business days of such plan or 
issuer receiving from such a provider or facility 
information pursuant to section 2799B–9 of the 
Public Health Service Act. 
‘‘(3) RESPONSE PROTOCOL.—The response pro-
tocol described in this paragraph is, in the case of an 
individual enrolled under a group health plan or 
group health insurance coverage offered by a health 
insurance issuer who requests information through a 
telephone call or electronic, web-based, or Internet- 
based means on whether a health care provider or 
health care facility has a contractual relationship to 
furnish items and services under such plan or such 
coverage, a protocol under which such plan or such 
issuer (as applicable), in the case such request is 
made through a telephone call— 
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‘‘(A) responds to such individual as soon as 
practicable and in no case later than 1 business 
day after such call is received, through a written 
electronic or print (as requested by such indi-
vidual) communication; and 
‘‘(B) retains such communication in such 
individual’s file for at least 2 years following 
such response. 
‘‘(4) DATABASE.—The database described in this 
paragraph is, with respect to a group health plan or 
health insurance issuer offering group health insur-
ance coverage, a database on the public website of 
such plan or issuer that contains— 
‘‘(A) a list of each health care provider and 
health care facility with which such plan or such 
issuer has a direct or indirect contractual rela-
tionship for furnishing items and services under 
such plan or such coverage; and 
‘‘(B) provider directory information with 
respect to each such provider and facility. 
‘‘(5) INFORMATION.—The information described 
in this paragraph is, with respect to a print directory 
containing provider directory information with re-
spect to a group health plan or group health insur-
ance coverage offered by a health insurance issuer, a 
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notification that such information contained in such 
directory was accurate as of the date of publication 
of such directory and that an individual enrolled 
under such plan or such coverage should consult the 
database described in paragraph (4) with respect to 
such plan or such coverage or contact such plan or the 
issuer of such coverage to obtain the most current pro-
vider directory information with respect to such plan 
or such coverage. 
‘‘(6) DEFINITION.—For purposes of this sub-
section, the term ‘provider directory information’ in-
cludes, with respect to a group health plan and a 
health insurance issuer offering group health insur-
ance coverage, the name, address, specialty, telephone 
number, and digital contact information of each 
health care provider or health care facility with which 
such plan or such issuer has a contractual relation-
ship for furnishing items and services under such 
plan or such coverage. 
‘‘(7) RULE OF CONSTRUCTION.—Nothing in this 
section shall be construed to preempt any provision of 
State law relating to health care provider directories, 
to the extent such State law applies to such plan, cov-
erage, or issuer, subject to section 514. 
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‘‘(b) COST-SHARING FOR SERVICES PROVIDED BASED 
ON RELIANCE ON INCORRECT PROVIDER NETWORK INFOR-
MATION.— 
‘‘(1) IN GENERAL.—For plan years beginning on 
or after January 1, 2022, in the case of an item or 
service furnished to a participant or beneficiary of a 
group health plan or group health insurance coverage 
offered by a health insurance issuer by a nonpartici-
pating provider or a nonparticipating facility, if 
such item or service would otherwise be covered under 
such plan or coverage if furnished by a participating 
provider or participating facility and if either of the 
criteria described in paragraph (2) applies with re-
spect to such participant or beneficiary and item or 
service, the plan or coverage— 
‘‘(A) shall not impose on such participant 
or beneficiary a cost-sharing amount for such 
item or service so furnished that is greater than 
the cost-sharing amount that would apply under 
such plan or coverage had such item or service 
been furnished by a participating provider; and 
‘‘(B) shall apply the deductible or out-of- 
pocket maximum, if any, that would apply if 
such services were furnished by a participating 
provider or a participating facility. 
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‘‘(2) CRITERIA
DESCRIBED.—For purposes of 
paragraph (1), the criteria described in this para-
graph, with respect to an item or service furnished to 
a participant or beneficiary of a group health plan 
or group health insurance coverage offered by a health 
insurance issuer by a nonparticipating provider or a 
nonparticipating facility, are the following: 
‘‘(A) The participant or beneficiary received 
through a database, provider directory, or re-
sponse protocol described in subsection (a) infor-
mation with respect to such item and service to 
be furnished and such information provided that 
the provider was a participating provider or fa-
cility was a participating facility, with respect 
to the plan for furnishing such item or service. 
‘‘(B) The information was not provided, in 
accordance with subsection (a), to the partici-
pant or beneficiary and the participant or bene-
ficiary requested through the response protocol 
described in subsection (a)(3) of the plan or cov-
erage information on whether the provider was a 
participating provider or facility was a partici-
pating facility with respect to the plan for fur-
nishing such item or service and was informed 
through such protocol that the provider was such 
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a participating provider or facility was such a 
participating facility. 
‘‘(c) DISCLOSURE ON PATIENT PROTECTIONS AGAINST 
BALANCE BILLING.—For plan years beginning on or after 
January 1, 2022, each group health plan and health insur-
ance issuer offering group health insurance coverage shall 
make publicly available, post on a public website of such 
plan or issuer, and include on each explanation of benefits 
for an item or service with respect to which the require-
ments under section 716 applies— 
‘‘(1) information in plain language on— 
‘‘(A) the requirements and prohibitions ap-
plied under sections 2799B–1 and 2799B–2 of 
the Public Health Service Act (relating to prohi-
bitions on balance billing in certain cir-
cumstances); 
‘‘(B) if provided for under applicable State 
law, any other requirements on providers and fa-
cilities regarding the amounts such providers 
and facilities may, with respect to an item or 
service, charge a participant or beneficiary 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 pay-
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ment from the plan or coverage for such item or 
service and any applicable cost sharing payment 
from such participant or beneficiary; and 
‘‘(C) the requirements applied under section 
716; 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.’’. 
(c) IRC.—Subchapter B of chapter 100 of the Internal 
Revenue Code of 1986, as amended by sections 102, 105, 
113, and 114, is further amended by inserting after section 
9819 the following: 
‘‘SEC. 9820. PROTECTING PATIENTS AND IMPROVING THE 
ACCURACY OF PROVIDER DIRECTORY INFOR-
MATION. 
‘‘(a) PROVIDER DIRECTORY INFORMATION REQUIRE-
MENTS.— 
‘‘(1) IN GENERAL.—For plan years beginning on 
or after January 1, 2022, each group health plan 
shall— 
‘‘(A) establish the verification process de-
scribed in paragraph (2); 
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‘‘(B) establish the response protocol de-
scribed in paragraph (3); 
‘‘(C) establish the database described in 
paragraph (4); and 
‘‘(D) include in any directory (other than 
the database described in subparagraph (C)) con-
taining provider directory information with re-
spect to such plan the information described in 
paragraph (5). 
‘‘(2) VERIFICATION PROCESS.—The verification 
process described in this paragraph is, with respect to 
a group health plan, a process— 
‘‘(A) under which, not less frequently than 
once every 90 days, such plan verifies and up-
dates the provider directory information in-
cluded on the database described in paragraph 
(4) of such plan or issuer of each health care 
provider and health care facility included in 
such database; 
‘‘(B) that establishes a procedure for the re-
moval of such a provider or facility with respect 
to which such plan or issuer has been unable to 
verify such information during a period speci-
fied by the plan or issuer; and 
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‘‘(C) that provides for the update of such 
database within 2 business days of such plan or 
issuer receiving from such a provider or facility 
information pursuant to section 2799B–9 of the 
Public Health Service Act. 
‘‘(3) RESPONSE PROTOCOL.—The response pro-
tocol described in this paragraph is, in the case of an 
individual enrolled under a group health plan who 
requests information through a telephone call or elec-
tronic, web-based, or Internet-based means on whether 
a health care provider or health care facility has a 
contractual relationship to furnish items and services 
under such plan, a protocol under which such plan or 
such issuer (as applicable), in the case such request 
is made through a telephone call— 
‘‘(A) responds to such individual as soon as 
practicable and in no case later than 1 business 
day after such call is received, through a written 
electronic or print (as requested by such indi-
vidual) communication; and 
‘‘(B) retains such communication in such 
individual’s file for at least 2 years following 
such response. 
‘‘(4) DATABASE.—The database described in this 
paragraph is, with respect to a group health plan, a 
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database on the public website of such plan or issuer 
that contains— 
‘‘(A) a list of each health care provider and 
health care facility with which such plan or such 
issuer has a direct or indirect contractual rela-
tionship for furnishing items and services under 
such plan; and 
‘‘(B) provider directory information with 
respect to each such provider and facility. 
‘‘(5) INFORMATION.—The information described 
in this paragraph is, with respect to a print directory 
containing provider directory information with re-
spect to a group health plan, a notification that such 
information contained in such directory was accurate 
as of the date of publication of such directory and 
that an individual enrolled under such plan should 
consult the database described in paragraph (4) with 
respect to such plan or contact such plan to obtain 
the most current provider directory information with 
respect to such plan. 
‘‘(6) DEFINITION.—For purposes of this sub-
section, the term ‘provider directory information’ in-
cludes, with respect to a group health plan, the name, 
address, specialty, telephone number, and digital con-
tact information of each health care provider or 
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health care facility with which such plan has a con-
tractual relationship for furnishing items and services 
under such plan. 
‘‘(7) RULE OF CONSTRUCTION.—Nothing in this 
section shall be construed to preempt any provision of 
State law relating to health care provider directories. 
‘‘(b) COST-SHARING FOR SERVICES PROVIDED BASED 
ON RELIANCE ON INCORRECT PROVIDER NETWORK INFOR-
MATION.— 
‘‘(1) IN GENERAL.—For plan years beginning on 
or after January 1, 2022, in the case of an item or 
service furnished to a participant or beneficiary of a 
group health plan by a nonparticipating provider or 
a nonparticipating facility, if such item or service 
would otherwise be covered under such plan if fur-
nished by a participating provider or participating 
facility and if either of the criteria described in para-
graph (2) applies with respect to such participant or 
beneficiary and item or service, the plan— 
‘‘(A) shall not impose on such participant 
or beneficiary a cost-sharing amount for such 
item or service so furnished that is greater than 
the cost-sharing amount that would apply under 
such plan had such item or service been fur-
nished by a participating provider; and 
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‘‘(B) shall apply the deductible or out-of- 
pocket maximum, if any, that would apply if 
such services were furnished by a participating 
provider or a participating facility. 
‘‘(2) CRITERIA
DESCRIBED.—For purposes of 
paragraph (1), the criteria described in this para-
graph, with respect to an item or service furnished to 
a participant or beneficiary of a group health plan 
by a nonparticipating provider or a nonparticipating 
facility, are the following: 
‘‘(A) The participant or beneficiary received 
through a database, provider directory, or re-
sponse protocol described in subsection (a) infor-
mation with respect to such item and service to 
be furnished and such information provided that 
the provider was a participating provider or fa-
cility was a participating facility, with respect 
to the plan for furnishing such item or service. 
‘‘(B) The information was not provided, in 
accordance with subsection (a), to the partici-
pant or beneficiary and the participant or bene-
ficiary requested through the response protocol 
described in subsection (a)(3) of the plan infor-
mation on whether the provider was a partici-
pating provider or facility was a participating 
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4319 
facility with respect to the plan for furnishing 
such item or service and was informed through 
such protocol that the provider was such a par-
ticipating provider or facility was such a par-
ticipating facility. 
‘‘(c) DISCLOSURE ON PATIENT PROTECTIONS AGAINST 
BALANCE BILLING.—For plan years beginning on or after 
January 1, 2022, each group health plan shall make pub-
licly available, post on a public website of such plan or 
issuer, and include on each explanation of benefits for an 
item or service with respect to which the requirements under 
section 9816 applies— 
‘‘(1) information in plain language on— 
‘‘(A) the requirements and prohibitions ap-
plied under sections 2799B–1 and 2799B–2 of 
the Public Health Service Act(relating to prohi-
bitions on balance billing in certain cir-
cumstances); 
‘‘(B) if provided for under applicable State 
law, any other requirements on providers and fa-
cilities regarding the amounts such providers 
and facilities may, with respect to an item or 
service, charge a participant or beneficiary of 
such plan with respect to which such a provider 
or facility does not have a contractual relation-
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ship for furnishing such item or service under 
the plan after receiving payment from the plan 
for such item or service and any applicable cost 
sharing payment from such participant or bene-
ficiary; and 
‘‘(C) the requirements applied under section 
9816; 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.’’. 
(d) CLERICAL AMENDMENTS.— 
(1) ERISA.—The table of contents in section 1 
of the Employee Retirement Income Security Act of 
1974 (29 U.S.C. 1001 et seq.), as amended by the pre-
vious provisions of this title, is further amended by 
inserting after the item relating to section 719 the fol-
lowing new item: 
‘‘720. Protecting patients and improving the accuracy of provider directory infor-
mation.’’. 
(2) IRC.—The table of sections for subchapter B 
of chapter 100 of the Internal Revenue Code of 1986, 
as amended by the previous provisions of this title, is 
further amended by inserting after the item relating 
to section 9819 the following new item: 
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‘‘9820. Protecting patients and improving the accuracy of provider directory in-
formation.’’. 
(e) PROVIDER REQUIREMENTS.—Part E of title XXVII 
of the Public Health Service Act (42 U.S.C. 300gg et seq.), 
as added by section 104 and as further amended by the pre-
vious provisions of this title, is further amended by adding 
at the end the following: 
‘‘SEC. 2799B–9. PROVIDER REQUIREMENTS TO PROTECT PA-
TIENTS AND IMPROVE THE ACCURACY OF 
PROVIDER DIRECTORY INFORMATION. 
‘‘(a) PROVIDER BUSINESS PROCESSES.—Beginning 
not later than January 1, 2022, each health care provider 
and each health care facility shall have in place business 
processes to ensure the timely provision of provider direc-
tory information to a group health plan or a health insur-
ance issuer offering group or individual health insurance 
coverage to support compliance by such plans or issuers 
with section 2799A–5(a)(1), section 720(a)(1) of the Em-
ployee Retirement Income Security Act of 1974, or section 
9820(a)(1) of the Internal Revenue Code of 1986, as appli-
cable. Such providers shall submit provider directory infor-
mation to a plan or issuers, at a minimum— 
‘‘(1) when the provider or facility begins a net-
work agreement with a plan or with an issuer with 
respect to certain coverage; 
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‘‘(2) when the provider or facility terminates a 
network agreement with a plan or with an issuer 
with respect to certain coverage; 
‘‘(3) when there are material changes to the con-
tent of provider directory information of the provider 
or facility described in section 2799A–5(a)(1), section 
720(a)(1) of the Employee Retirement Income Secu-
rity Act of 1974, or section 9820(a)(1) of the Internal 
Revenue Code of 1986, as applicable; and 
‘‘(4) at any other time (including upon the re-
quest of such issuer or plan) determined appropriate 
by the provider, facility, or the Secretary. 
‘‘(b) REFUNDS TO ENROLLEES.—If a health care pro-
vider submits a bill to an enrollee based on cost-sharing 
for treatment or services provided by the health care pro-
vider that is in excess of the normal cost-sharing applied 
for such treatment or services provided in-network, as pro-
hibited under section 2799A–5(b), section 720(b) of the Em-
ployee Retirement Income Security Act of 1974, or section 
9820(b) of the Internal Revenue Code of 1986, as applicable, 
and the enrollee pays such bill, the provider shall reimburse 
the enrollee for the full amount paid by the enrollee in excess 
of the in-network cost-sharing amount for the treatment or 
services involved, plus interest, at an interest rate deter-
mined by the Secretary. 
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‘‘(c) LIMITATION.—Nothing in this section shall pro-
hibit a provider from requiring in the terms of a contract, 
or contract termination, with a group health plan or health 
insurance issuer— 
‘‘(1) that the plan or issuer remove, at the time 
of termination of such contract, the provider from a 
directory of the plan or issuer described in section 
2799A–5(a), section 720(a) of the Employee Retire-
ment Income Security Act of 1974, or section 9820(a) 
of the Internal Revenue Code of 1986, as applicable; 
or 
‘‘(2) that the plan or issuer bear financial re-
sponsibility, including under section 2799A–5(b), sec-
tion 720(b) of the Employee Retirement Income Secu-
rity Act of 1974, or section 9820(b) of the Internal 
Revenue Code of 1986, as applicable, for providing 
inaccurate network status information to an enrollee. 
‘‘(d) DEFINITION.—For purposes of this section, the 
term ‘provider directory information’ includes the names, 
addresses, specialty, telephone numbers, and digital contact 
information of individual health care providers, and the 
names, addresses, telephone numbers, and digital contact 
information of each medical group, clinic, or facility con-
tracted to participate in any of the networks of the group 
health plan or health insurance coverage involved. 
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‘‘(e) RULE OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed to preempt any provision of State 
law relating to health care provider directories.’’. 
SEC. 117. ADVISORY COMMITTEE ON GROUND AMBULANCE 
AND PATIENT BILLING. 
(a) IN GENERAL.—Not later than 90 days after the 
date of enactment of this Act, the Secretary of Labor, Sec-
retary of Health and Human Services, and the Secretary 
of the Treasury (the Secretaries) shall jointly establish an 
advisory committee for the purpose of reviewing options to 
improve the disclosure of charges and fees for ground ambu-
lance services, better inform consumers of insurance options 
for such services, and protect consumers from balance bill-
ing. 
(b) COMPOSITION OF THE ADVISORY COMMITTEE.— 
The advisory committee shall be composed of the following 
members: 
(1) The Secretary of Labor, or the Secretary’s 
designee. 
(2) The Secretary of Health and Human Serv-
ices, or the Secretary’s designee. 
(3) The Secretary of the Treasury, or the Sec-
retary’s designee. 
(4) One representative, to be appointed jointly 
by the Secretaries, for each of the following: 
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(A) Each relevant Federal agency, as deter-
mined by the Secretaries. 
(B) State insurance regulators. 
(C) Health insurance providers. 
(D) Patient advocacy groups. 
(E) Consumer advocacy groups. 
(F) State and local governments. 
(G) Physician specializing in emergency, 
trauma, cardiac, or stroke. 
(H) State Emergency Medical Services Offi-
cials. 
(I) Emergency medical technicians, para-
medics, and other emergency medical services 
personnel. 
(5) Three representatives, to be appointed jointly 
by the Secretaries, to represent the various segments 
of the ground ambulance industry. 
(6) Up to an additional 2 representatives other-
wise not described in paragraphs (1) through (5), as 
determined necessary and appropriate by the Secre-
taries. 
(c) CONSULTATION.—The advisory committee shall, as 
appropriate, consult with relevant experts and stakeholders, 
including those not otherwise included under subsection (b), 
while conducting the review described in subsection (a). 
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4326 
(d) RECOMMENDATIONS.—The advisory committee 
shall make recommendations with respect to disclosure of 
charges and fees for ground ambulance services and insur-
ance coverage, consumer protection and enforcement au-
thorities of the Departments of Labor, Health and Human 
Services, and the Treasury and State authorities, and the 
prevention of balance billing to consumers. The rec-
ommendations shall address, at a minimum— 
(1) options, best practices, and identified stand-
ards to prevent instances of balance billing; 
(2) steps that can be taken by State legislatures, 
State insurance regulators, State attorneys general, 
and other State officials as appropriate, consistent 
with current legal authorities regarding consumer 
protection; and 
(3) legislative options for Congress to prevent 
balance billing. 
(e) REPORT.—Not later than 180 days after the date 
of the first meeting of the advisory committee, the advisory 
committee shall submit to the Secretaries, and the Commit-
tees on Education and Labor, Energy and Commerce, and 
Ways and Means of the House of Representatives and the 
Committees on Finance and Health, Education, Labor, and 
Pensions a report containing the recommendations made 
under subsection (d). 
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4327 
SEC. 118. IMPLEMENTATION FUNDING. 
(a) IN GENERAL.—For the purposes described in sub-
section (b), there are appropriated, out of amounts in the 
Treasury not otherwise appropriated, to the Secretary of 
Health and Human Services, the Secretary of Labor, and 
the Secretary of the Treasury, $500,000,000 for fiscal year 
2021, to remain available until expended through 2024. 
(b) PERMITTED PURPOSES.—The purposes described 
in this subsection are limited to the following purposes, in-
sofar as such purposes are to carry out the provisions of, 
including the amendments made by, this title and title II: 
(1) Preparing, drafting, and issuing proposed 
and final regulations or interim regulations. 
(2) Preparing, drafting, and issuing guidance 
and public information. 
(3) Preparing and holding public meetings. 
(4) Preparing, drafting, and publishing reports. 
(5) Enforcement of such provisions. 
(6) Reporting, collection, and analysis of data. 
(7) Establishment and initial implementation of 
the processes for independent dispute resolution and 
implementation of patient-provider dispute resolution 
under such provisions. 
(8) Conducting audits. 
(9) Other administrative duties necessary for im-
plementation of such provisions. 
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(c) TRANSPARENCY OF IMPLEMENTATION FUNDS.— 
Each Secretary described in subsection (a) shall annually 
submit to the Committees on Energy and Commerce, on 
Ways and Means, on Education and Labor, and on Appro-
priations of the House of Representatives and on the Com-
mittees on Health, Education, Labor, and Pensions and on 
Appropriations of the Senate a report on funds expended 
pursuant to funds appropriated under this section. 
TITLE II—TRANSPARENCY 
SEC. 201. INCREASING TRANSPARENCY BY REMOVING GAG 
CLAUSES ON PRICE AND QUALITY INFORMA-
TION. 
(a) PHSA.—Part D of title XXVII of the Public 
Health Service Act (42 U.S.C. 300gg et seq.), as added and 
amended by title I, is further amended by adding at the 
end the following: 
‘‘SEC. 2799A–9. INCREASING TRANSPARENCY BY REMOVING 
GAG CLAUSES ON PRICE AND QUALITY IN-
FORMATION. 
‘‘(a) INCREASING PRICE AND QUALITY TRANSPARENCY 
FOR PLAN SPONSORS AND GROUP AND INDIVIDUAL MAR-
KET CONSUMERS.— 
‘‘(1) GROUP HEALTH PLANS.—A group health 
plan or health insurance issuer offering group health 
insurance coverage may not enter into an agreement 
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with a health care provider, network or association of 
providers, third-party administrator, or other service 
provider offering access to a network of providers that 
would directly or indirectly restrict a group health 
plan or health insurance issuer offering such coverage 
from— 
‘‘(A) providing provider-specific cost or 
quality of care information or data, through a 
consumer engagement tool or any other means, to 
referring providers, the plan sponsor, enrollees, 
or individuals eligible to become enrollees of the 
plan or coverage; 
‘‘(B) electronically accessing de-identified 
claims and encounter information or data for 
each enrollee in the plan or coverage, upon re-
quest and consistent with the privacy regulations 
promulgated pursuant to section 264(c) of the 
Health Insurance Portability and Accountability 
Act of 1996, the amendments made by the Ge-
netic Information Nondiscrimination Act of 
2008, and the Americans with Disabilities Act of 
1990, including, on a per claim basis— 
‘‘(i) financial information, such as the 
allowed amount, or any other claim-related 
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financial obligations included in the pro-
vider contract; 
‘‘(ii) provider information, including 
name and clinical designation; 
‘‘(iii) service codes; or 
‘‘(iv) any other data element included 
in claim or encounter transactions; or 
‘‘(C) sharing information or data described 
in subparagraph (A) or (B), or directing that 
such data be shared, with a business associate as 
defined in section 160.103 of title 45, Code of 
Federal Regulations (or successor regulations), 
consistent with the privacy regulations promul-
gated pursuant to section 264(c) of the Health 
Insurance Portability and Accountability Act of 
1996, the amendments made by the Genetic In-
formation Nondiscrimination Act of 2008, and 
the Americans with Disabilities Act of 1990. 
‘‘(2) INDIVIDUAL
HEALTH
INSURANCE
COV-
ERAGE.—A health insurance issuer offering indi-
vidual health insurance coverage may not enter into 
an agreement with a health care provider, network or 
association of providers, or other service provider of-
fering access to a network of providers that would di-
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rectly or indirectly restrict the health insurance issuer 
from— 
‘‘(A) providing provider-specific price or 
quality of care information, through a consumer 
engagement tool or any other means, to referring 
providers, enrollees, or individuals eligible to be-
come enrollees of the plan or coverage; or 
‘‘(B) sharing, for plan design, plan admin-
istration, and plan, financial, legal, and quality 
improvement activities, data described in sub-
paragraph (A) with a business associate as de-
fined in section 160.103 of title 45, Code of Fed-
eral Regulations (or successor regulations), con-
sistent with the privacy regulations promulgated 
pursuant to section 264(c) of the Health Insur-
ance Portability and Accountability Act of 1996, 
the amendments made by the Genetic Informa-
tion Nondiscrimination Act of 2008, and the 
Americans with Disabilities Act of 1990. 
‘‘(3) CLARIFICATION REGARDING PUBLIC DISCLO-
SURE
OF
INFORMATION.—Nothing in paragraph 
(1)(A) or (2)(A) prevents a health care provider, net-
work or association of providers, or other service pro-
vider from placing reasonable restrictions on the pub-
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lic disclosure of the information described in such 
paragraphs (1) and (2). 
‘‘(4) ATTESTATION.—A group health plan or a 
health insurance issuer offering group or individual 
health insurance coverage shall annually submit to 
the Secretary an attestation that such plan or issuer 
of such coverage is in compliance with the require-
ments of this subsection. 
‘‘(5) RULES OF CONSTRUCTION.—Nothing in this 
section shall be construed to modify or eliminate ex-
isting privacy protections and standards under State 
and Federal law. Nothing in this subsection shall be 
construed to otherwise limit access by a group health 
plan, plan sponsor, or health insurance issuer to data 
as permitted under the privacy regulations promul-
gated pursuant to section 264(c) of the Health Insur-
ance Portability and Accountability Act of 1996, the 
amendments made by the Genetic Information Non-
discrimination Act of 2008, and the Americans with 
Disabilities Act of 1990.’’. 
(b) ERISA.—Subpart B of part 7 of subtitle B of title 
I of the Employee Retirement Income Security Act of 1974 
(29 U.S.C. 1185 et seq.), as amended by title I, is further 
amended by adding at the end the following: 
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‘‘SEC. 724. INCREASING TRANSPARENCY BY REMOVING GAG 
CLAUSES ON PRICE AND QUALITY INFORMA-
TION. 
‘‘(a) INCREASING PRICE AND QUALITY TRANSPARENCY 
FOR PLAN SPONSORS AND CONSUMERS.— 
‘‘(1) IN GENERAL.—A group health plan (or an 
issuer of health insurance coverage offered in connec-
tion with such a plan) may not enter into an agree-
ment with a health care provider, network or associa-
tion of providers, third-party administrator, or other 
service provider offering access to a network of pro-
viders that would directly or indirectly restrict a 
group health plan or health insurance issuer offering 
such coverage from— 
‘‘(A) providing provider-specific cost or 
quality of care information or data, through a 
consumer engagement tool or any other means, to 
referring providers, the plan sponsor, partici-
pants or beneficiaries, or individuals eligible to 
become participants or beneficiaries of the plan 
or coverage; 
‘‘(B) electronically accessing de-identified 
claims and encounter information or data for 
each participant or beneficiary in the plan or 
coverage, upon request and consistent with the 
privacy regulations promulgated pursuant to 
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section 264(c) of the Health Insurance Port-
ability and Accountability Act of 1996, the 
amendments made by the Genetic Information 
Nondiscrimination Act of 2008, and the Ameri-
cans with Disabilities Act of 1990, including, on 
a per claim basis— 
‘‘(i) financial information, such as the 
allowed amount, or any other claim-related 
financial obligations included in the pro-
vider contract; 
‘‘(ii) provider information, including 
name and clinical designation; 
‘‘(iii) service codes; or 
‘‘(iv) any other data element included 
in claim or encounter transactions; or 
‘‘(C) sharing information or data described 
in subparagraph (A) or (B), or directing that 
such data be shared, with a business associate as 
defined in section 160.103 of title 45, Code of 
Federal Regulations (or successor regulations), 
consistent with the privacy regulations promul-
gated pursuant to section 264(c) of the Health 
Insurance Portability and Accountability Act of 
1996, the amendments made by the Genetic In-
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formation Nondiscrimination Act of 2008, and 
the Americans with Disabilities Act of 1990. 
‘‘(2) CLARIFICATION REGARDING PUBLIC DISCLO-
SURE
OF
INFORMATION.—Nothing in paragraph 
(1)(A) prevents a health care provider, network or as-
sociation of providers, or other service provider from 
placing reasonable restrictions on the public disclo-
sure of the information described in such paragraph 
(1). 
‘‘(3) ATTESTATION.—A group health plan (or 
health insurance coverage offered in connection with 
such a plan) shall annually submit to the Secretary 
an attestation that such plan or issuer of such cov-
erage is in compliance with the requirements of this 
subsection. 
‘‘(4) RULES OF CONSTRUCTION.—Nothing in this 
section shall be construed to modify or eliminate ex-
isting privacy protections and standards under State 
and Federal law. Nothing in this subsection shall be 
construed to otherwise limit access by a group health 
plan, plan sponsor, or health insurance issuer to data 
as permitted under the privacy regulations promul-
gated pursuant to section 264(c) of the Health Insur-
ance Portability and Accountability Act of 1996, the 
amendments made by the Genetic Information Non-
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4336 
discrimination Act of 2008, and the Americans with 
Disabilities Act of 1990.’’. 
(c) IRC.—Subchapter B of chapter 100 of the Internal 
Revenue Code of 1986, as amended by title I, is further 
amended by adding at the end the following: 
‘‘SEC. 9824. INCREASING TRANSPARENCY BY REMOVING 
GAG CLAUSES ON PRICE AND QUALITY IN-
FORMATION. 
‘‘(a) INCREASING PRICE AND QUALITY TRANSPARENCY 
FOR PLAN SPONSORS AND CONSUMERS.— 
‘‘(1) IN GENERAL.—A group health plan may 
not enter into an agreement with a health care pro-
vider, network or association of providers, third-party 
administrator, or other service provider offering ac-
cess to a network of providers that would directly or 
indirectly restrict a group health plan from— 
‘‘(A) providing provider-specific cost or 
quality of care information or data, through a 
consumer engagement tool or any other means, to 
referring providers, the plan sponsor, partici-
pants or beneficiaries, or individuals eligible to 
become participants or beneficiaries of the plan; 
‘‘(B) electronically accessing de-identified 
claims and encounter information or data for 
each participant or beneficiary in the plan, 
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upon request and consistent with the privacy 
regulations promulgated pursuant to section 
264(c) of the Health Insurance Portability and 
Accountability Act of 1996, the amendments 
made 
by 
the 
Genetic 
Information 
Non-
discrimination Act of 2008, and the Americans 
with Disabilities Act of 1990, including, on a 
per claim basis— 
‘‘(i) financial information, such as the 
allowed amount, or any other claim-related 
financial obligations included in the pro-
vider contract; 
‘‘(ii) provider information, including 
name and clinical designation; 
‘‘(iii) service codes; or 
‘‘(iv) any other data element included 
in claim or encounter transactions; or 
‘‘(C) sharing information or data described 
in subparagraph (A) or (B), or directing that 
such data be shared, with a business associate as 
defined in section 160.103 of title 45, Code of 
Federal Regulations (or successor regulations), 
consistent with the privacy regulations promul-
gated pursuant to section 264(c) of the Health 
Insurance Portability and Accountability Act of 
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1996, the amendments made by the Genetic In-
formation Nondiscrimination Act of 2008, and 
the Americans with Disabilities Act of 1990. 
‘‘(2) CLARIFICATION REGARDING PUBLIC DISCLO-
SURE
OF
INFORMATION.—Nothing in paragraph 
(1)(A) prevents a health care provider, network or as-
sociation of providers, or other service provider from 
placing reasonable restrictions on the public disclo-
sure of the information described in such paragraph 
(1). 
‘‘(3) ATTESTATION.—A group health plan shall 
annually submit to the Secretary an attestation that 
such plan is in compliance with the requirements of 
this subsection. 
‘‘(4) RULES OF CONSTRUCTION.—Nothing in this 
section shall be construed to modify or eliminate ex-
isting privacy protections and standards under State 
and Federal law. Nothing in this subsection shall be 
construed to otherwise limit access by a group health 
plan or plan sponsor to data as permitted under the 
privacy regulations promulgated pursuant to section 
264(c) of the Health Insurance Portability and Ac-
countability Act of 1996, the amendments made by 
the Genetic Information Nondiscrimination Act of 
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4339 
2008, and the Americans with Disabilities Act of 
1990.’’. 
(d) CLERICAL AMENDMENTS.— 
(1) ERISA.—The table of contents in section 1 
of the Employee Retirement Income Security Act of 
1974 (29 U.S.C. 1001 et seq.), as amended by title I, 
is further amended by inserting after the item relat-
ing to section 723 the following new item: 
‘‘Sec. 724. Increasing transparency by removing gag clauses on price and quality 
information.’’. 
(2) IRC.—The table of sections for subchapter B 
of chapter 100 of the Internal Revenue Code of 1986, 
as amended by title I, is further amended by adding 
at the end the following new item: 
‘‘Sec. 9824. Increasing transparency by removing gag clauses on price and qual-
ity information.’’. 
SEC. 202. DISCLOSURE OF DIRECT AND INDIRECT COM-
PENSATION FOR BROKERS AND CONSULT-
ANTS 
TO 
EMPLOYER-SPONSORED 
HEALTH 
PLANS AND ENROLLEES IN PLANS ON THE IN-
DIVIDUAL MARKET. 
(a) GROUP HEALTH PLANS.—Section 408(b)(2) of the 
Employee Retirement Income Security Act of 1974 (29 
U.S.C. 1108(b)(2)) is amended— 
(1) by striking ‘‘(2) Contracting or making’’ and 
inserting ‘‘(2)(A) Contracting or making’’; and 
(2) by adding at the end the following: 
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‘‘(B)(i) No contract or arrangement for services 
between a covered plan and a covered service pro-
vider, and no extension or renewal of such a contract 
or arrangement, is reasonable within the meaning of 
this paragraph unless the requirements of this clause 
are met. 
‘‘(ii)(I) For purposes of this subparagraph: 
‘‘(aa) The term ‘covered plan’ means a 
group health plan as defined section 733(a). 
‘‘(bb) The term ‘covered service provider’ 
means a service provider that enters into a con-
tract or arrangement with the covered plan and 
reasonably expects $1,000 (or such amount as the 
Secretary may establish in regulations to ac-
count for inflation since the date of enactment of 
the Consolidated Appropriations Act, 2021, as 
appropriate) or more in compensation, direct or 
indirect, to be received in connection with pro-
viding one or more of the following services, pur-
suant to the contract or arrangement, regardless 
of whether such services will be performed, or 
such compensation received, by the covered serv-
ice provider, an affiliate, or a subcontractor: 
‘‘(AA) Brokerage services, for which the 
covered service provider, an affiliate, or a 
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4341 
subcontractor reasonably expects to receive 
indirect compensation or direct compensa-
tion described in item (dd), provided to a 
covered plan with respect to selection of in-
surance products (including vision and den-
tal), recordkeeping services, medical man-
agement vendor, benefits administration 
(including vision and dental), stop-loss in-
surance, pharmacy benefit management 
services, wellness services, transparency 
tools and vendors, group purchasing organi-
zation preferred vendor panels, disease 
management vendors and products, compli-
ance services, employee assistance programs, 
or third party administration services. 
‘‘(BB) Consulting, for which the cov-
ered service provider, an affiliate, or a sub-
contractor reasonably expects to receive in-
direct compensation or direct compensation 
described in item (dd), related to the devel-
opment or implementation of plan design, 
insurance or insurance product selection 
(including vision and dental), record-
keeping, medical management, benefits ad-
ministration selection (including vision and 
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dental), stop-loss insurance, pharmacy ben-
efit management services, wellness design 
and management services, transparency 
tools, group purchasing organization agree-
ments and services, participation in and 
services from preferred vendor panels, dis-
ease management, compliance services, em-
ployee assistance programs, or third party 
administration services. 
‘‘(cc) The term ‘affiliate’, with respect to a 
covered service provider, means an entity that 
directly or indirectly (through one or more inter-
mediaries) controls, is controlled by, or is under 
common control with, such provider, or is an of-
ficer, director, or employee of, or partner in, 
such provider. 
‘‘(dd)(AA) The term ‘compensation’ means 
anything of monetary value, but does not include 
non-monetary compensation valued at $250 (or 
such amount as the Secretary may establish in 
regulations to account for inflation since the date 
of enactment of the Consolidated Appropriations 
Act, 2021, as appropriate) or less, in the aggre-
gate, during the term of the contract or arrange-
ment. 
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4343 
‘‘(BB) The term ‘direct compensation’ 
means compensation received directly from a 
covered plan. 
‘‘(CC) The term ‘indirect compensation’ 
means compensation received from any source 
other than the covered plan, the plan sponsor, the 
covered service provider, or an affiliate. Com-
pensation received from a subcontractor is indi-
rect compensation, unless it is received in con-
nection with services performed under a contract 
or arrangement with a subcontractor. 
‘‘(ee) The term ‘responsible plan fiduciary’ 
means a fiduciary with authority to cause the 
covered plan to enter into, or extend or renew, 
the contract or arrangement. 
‘‘(ff) The term ‘subcontractor’ means any 
person or entity (or an affiliate of such person 
or entity) that is not an affiliate of the covered 
service provider and that, pursuant to a contract 
or arrangement with the covered service provider 
or an affiliate, reasonably expects to receive 
$1,000 (or such amount as the Secretary may es-
tablish in regulations to account for inflation 
since the date of enactment of the Consolidated 
Appropriations Act, 2021, as appropriate) or 
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more in compensation for performing one or 
more services described in item (bb) under a con-
tract or arrangement with the covered plan. 
‘‘(II) For purposes of this subparagraph, a de-
scription of compensation or cost may be expressed as 
a monetary amount, formula, or a per capita charge 
for each enrollee or, if the compensation or cost can-
not reasonably be expressed in such terms, by any 
other reasonable method, including a disclosure that 
additional compensation may be earned but may not 
be calculated at the time of contract if such a disclo-
sure includes a description of the circumstances under 
which the additional compensation may be earned 
and a reasonable and good faith estimate if the cov-
ered service provider cannot otherwise readily describe 
compensation or cost and explains the methodology 
and assumptions used to prepare such estimate. Any 
such description shall contain sufficient information 
to permit evaluation of the reasonableness of the com-
pensation or cost. 
‘‘(III) No person or entity is a ‘covered service 
provider’ within the meaning of subclause (I)(bb) sole-
ly on the basis of providing services as an affiliate or 
a subcontractor that is performing one or more of the 
services described in subitem (AA) or (BB) of such 
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subclause under the contract or arrangement with the 
covered plan. 
‘‘(iii) A covered service provider shall disclose to 
a responsible plan fiduciary, in writing, the fol-
lowing: 
‘‘(I) A description of the services to be pro-
vided to the covered plan pursuant to the con-
tract or arrangement. 
‘‘(II) If applicable, a statement that the cov-
ered service provider, an affiliate, or a subcon-
tractor will provide, or reasonably expects to 
provide, services pursuant to the contract or ar-
rangement directly to the covered plan as a fidu-
ciary (within the meaning of section 3(21)). 
‘‘(III) A description of all direct compensa-
tion, either in the aggregate or by service, that 
the covered service provider, an affiliate, or a 
subcontractor reasonably expects to receive in 
connection with the services described in sub-
clause (I). 
‘‘(IV)(aa) A description of all indirect com-
pensation that the covered service provider, an 
affiliate, or a subcontractor reasonably expects to 
receive in connection with the services described 
in subclause (I)— 
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‘‘(AA) including compensation from a 
vendor to a brokerage firm based on a struc-
ture of incentives not solely related to the 
contract with the covered plan; and 
‘‘(BB) not including compensation re-
ceived by an employee from an employer on 
account of work performed by the employee. 
‘‘(bb) A description of the arrangement be-
tween the payer and the covered service provider, 
an affiliate, or a subcontractor, as applicable, 
pursuant to which such indirect compensation is 
paid. 
‘‘(cc) Identification of the services for which 
the indirect compensation will be received, if ap-
plicable. 
‘‘(dd) Identification of the payer of the indi-
rect compensation. 
‘‘(V) A description of any compensation 
that will be paid among the covered service pro-
vider, an affiliate, or a subcontractor, in connec-
tion with the services described in subclause (I) 
if such compensation is set on a transaction 
basis (such as commissions, finder’s fees, or other 
similar incentive compensation based on business 
placed or retained), including identification of 
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4347 
the services for which such compensation will be 
paid and identification of the payers and recipi-
ents of such compensation (including the status 
of a payer or recipient as an affiliate or a sub-
contractor), regardless of whether such compensa-
tion also is disclosed pursuant to subclause (III) 
or (IV). 
‘‘(VI) A description of any compensation 
that the covered service provider, an affiliate, or 
a subcontractor reasonably expects to receive in 
connection with termination of the contract or 
arrangement, and how any prepaid amounts 
will be calculated and refunded upon such termi-
nation. 
‘‘(iv) A covered service provider shall disclose to 
a responsible plan fiduciary, in writing a description 
of the manner in which the compensation described in 
clause (iii), as applicable, will be received. 
‘‘(v)(I) A covered service provider shall disclose 
the information required under clauses (iii) and (iv) 
to the responsible plan fiduciary not later than the 
date that is reasonably in advance of the date on 
which the contract or arrangement is entered into, 
and extended or renewed. 
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‘‘(II) A covered service provider shall disclose 
any change to the information required under clause 
(iii) and (iv) as soon as practicable, but not later 
than 60 days from the date on which the covered serv-
ice provider is informed of such change, unless such 
disclosure is precluded due to extraordinary cir-
cumstances beyond the covered service provider’s con-
trol, in which case the information shall be disclosed 
as soon as practicable. 
‘‘(vi)(I) Upon the written request of the respon-
sible plan fiduciary or covered plan administrator, a 
covered service provider shall furnish any other infor-
mation relating to the compensation received in con-
nection with the contract or arrangement that is re-
quired for the covered plan to comply with the report-
ing and disclosure requirements under this Act. 
‘‘(II) The covered service provider shall disclose 
the information required under clause (iii)(I) reason-
ably in advance of the date upon which such respon-
sible plan fiduciary or covered plan administrator 
states that it is required to comply with the applica-
ble reporting or disclosure requirement, unless such 
disclosure is precluded due to extraordinary cir-
cumstances beyond the covered service provider’s con-
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4349 
trol, in which case the information shall be disclosed 
as soon as practicable. 
‘‘(vii) No contract or arrangement will fail to be 
reasonable under this subparagraph solely because the 
covered service provider, acting in good faith and 
with reasonable diligence, makes an error or omission 
in disclosing the information required pursuant to 
clause (iii) (or a change to such information disclosed 
pursuant to clause (v)(II)) or clause (vi), provided 
that the covered service provider discloses the correct 
information to the responsible plan fiduciary as soon 
as practicable, but not later than 30 days from the 
date on which the covered service provider knows of 
such error or omission. 
‘‘(viii)(I) Pursuant to subsection (a), subpara-
graphs (C) and (D) of section 406(a)(1) shall not 
apply to a responsible plan fiduciary, notwith-
standing any failure by a covered service provider to 
disclose information required under clause (iii), if the 
following conditions are met: 
‘‘(aa) The responsible plan fiduciary did 
not know that the covered service provider failed 
or would fail to make required disclosures and 
reasonably believed that the covered service pro-
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4350 
vider disclosed the information required to be 
disclosed. 
‘‘(bb) The responsible plan fiduciary, upon 
discovering that the covered service provider 
failed to disclose the required information, re-
quests in writing that the covered service pro-
vider furnish such information. 
‘‘(cc) If the covered service provider fails to 
comply with a written request described in sub-
clause (II) within 90 days of the request, the re-
sponsible plan fiduciary notifies the Secretary of 
the covered service provider’s failure, in accord-
ance with subclauses (II) and (III). 
‘‘(II) A notice described in subclause (I)(cc) shall 
contain— 
‘‘(aa) the name of the covered plan; 
‘‘(bb) the plan number used for the annual 
report on the covered plan; 
‘‘(cc) the plan sponsor’s name, address, and 
employer identification number; 
‘‘(dd) the name, address, and telephone 
number of the responsible plan fiduciary; 
‘‘(ee) the name, address, phone number, 
and, if known, employer identification number of 
the covered service provider; 
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‘‘(ff) a description of the services provided 
to the covered plan; 
‘‘(gg) a description of the information that 
the covered service provider failed to disclose; 
‘‘(hh) the date on which such information 
was requested in writing from the covered service 
provider; and 
‘‘(ii) a statement as to whether the covered 
service provider continues to provide services to 
the plan. 
‘‘(III) A notice described in subclause (I)(cc) 
shall be filed with the Department not later than 30 
days following the earlier of— 
‘‘(aa) The covered service provider’s refusal 
to furnish the information requested by the writ-
ten request described in subclause (I)(bb); or 
‘‘(bb) 90 days after the written request re-
ferred to in subclause (I)(cc) is made. 
‘‘(IV) If the covered service provider fails to com-
ply with the written request under subclause (I)(bb) 
within 90 days of such request, the responsible plan 
fiduciary shall determine whether to terminate or 
continue the contract or arrangement under section 
404. If the requested information relates to future 
services and is not disclosed promptly after the end 
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of the 90-day period, the responsible plan fiduciary 
shall terminate the contract or arrangement as expe-
ditiously as possible, consistent with such duty of 
prudence. 
‘‘(ix) Nothing in this subparagraph shall be con-
strued to supersede any provision of State law that 
governs disclosures by parties that provide the services 
described in this section, except to the extent that such 
law prevents the application of a requirement of this 
section.’’. 
(b) APPLICABILITY
OF EXISTING REGULATIONS.— 
Nothing in the amendments made by subsection (a) shall 
be construed to affect the applicability of section 2550.408b– 
2 of title 29, Code of Federal Regulations (or any successor 
regulations), with respect to any applicable entity other 
than a covered plan or a covered service provider (as de-
fined in section 408(b)(2)(B)(ii) of the Employee Retire-
ment Income Security Act of 1974, as amended by sub-
section (a)). 
(c) INDIVIDUAL MARKET COVERAGE.—Subpart 1 of 
part B of title XXVII of the Public Health Service Act (42 
U.S.C. 300gg–41 et seq.) is amended by adding at the end 
the following: 
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‘‘SEC. 2746. DISCLOSURE TO ENROLLEES OF INDIVIDUAL 
MARKET COVERAGE. 
‘‘(a) IN GENERAL.—A health insurance issuer offering 
individual health insurance coverage or a health insurance 
issuer offering short-term limited duration insurance cov-
erage shall make disclosures to enrollees in such coverage, 
as described in subsection (b), and reports to the Secretary, 
as described in subsection (c), regarding direct or indirect 
compensation provided by the issuer to an agent or broker 
associated with enrolling individuals in such coverage. 
‘‘(b) DISCLOSURE.—A health insurance issuer de-
scribed in subsection (a) shall disclose to an enrollee the 
amount of direct or indirect compensation provided to an 
agent or broker for services provided by such agent or broker 
associated with plan selection and enrollment. Such disclo-
sure shall be— 
‘‘(1) made prior to the individual finalizing 
plan selection; and 
‘‘(2) included on any documentation confirming 
the individual’s enrollment. 
‘‘(c) REPORTING.—A health insurance issuer described 
in subsection (a) shall annually report to the Secretary, 
prior to the beginning of open enrollment, any direct or 
indirect compensation provided to an agent or broker asso-
ciated with enrolling individuals in such coverage. 
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‘‘(d) RULEMAKING.—Not later than 1 year after the 
date of enactment of the Consolidated Appropriations Act, 
2021, the Secretary shall finalize, through notice-and-com-
ment rulemaking, the timing, form, and manner in which 
issuers described in subsection (a) are required to make the 
disclosures described in subsection (b) and the reports de-
scribed in subsection (c). Such rulemaking may also include 
adjustments to notice requirements to reflect the different 
processes for plan renewals, in order to provide enrollees 
with full, timely information.’’. 
(d) TRANSITION RULE.—No contract executed prior to 
the effective date described in subsection (e) by a group 
health plan subject to the requirements of section 
408(b)(2)(B) of the Employee Retirement Income Security 
Act of 1974 (as amended by subsection (a)) or by a health 
insurance issuer subject to the requirements of section 2746 
of the Public Health Service Act (as added by subsection 
(c)) shall be subject to the requirements of such section 
408(b)(2)(B) or such section 2746, as applicable. 
(e) APPLICATION.—The amendments made by sub-
sections (a) and (c) shall apply beginning 1 year after the 
date of enactment of this Act. 
SEC. 203. STRENGTHENING PARITY IN MENTAL HEALTH 
AND SUBSTANCE USE DISORDER BENEFITS. 
(a) IN GENERAL.— 
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(1) PHSA.—Section 2726(a) of the Public 
Health Service Act (42 U.S.C. 300gg–26(a)) is 
amended by adding at the end the following: 
‘‘(8) COMPLIANCE REQUIREMENTS.— 
‘‘(A) NONQUANTITATIVE TREATMENT LIMI-
TATION (NQTL) REQUIREMENTS.—In the case of a 
group health plan or a health insurance issuer 
offering group or individual health insurance 
coverage that provides both medical and surgical 
benefits and mental health or substance use dis-
order benefits and that imposes nonquantitative 
treatment limitations (referred to in this section 
as ‘NQTLs’) on mental health or substance use 
disorder benefits, such plan or issuer shall per-
form and document comparative analyses of the 
design and application of NQTLs and, beginning 
45 days after the date of enactment of the Con-
solidated Appropriations Act, 2021, make avail-
able to the applicable State authority (or, as ap-
plicable, to the Secretary of Labor or the Sec-
retary of Health and Human Services), upon re-
quest, the comparative analyses and the fol-
lowing information: 
‘‘(i) The specific plan or coverage 
terms or other relevant terms regarding the 
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NQTLs and a description of all mental 
health or substance use disorder and med-
ical or surgical benefits to which each such 
term applies in each respective benefits clas-
sification. 
‘‘(ii) The factors used to determine that 
the NQTLs will apply to mental health or 
substance use disorder benefits and medical 
or surgical benefits. 
‘‘(iii) The evidentiary standards used 
for the factors identified in clause (ii), when 
applicable, provided that every factor shall 
be defined, and any other source or evidence 
relied upon to design and apply the NQTLs 
to mental health or substance use disorder 
benefits and medical or surgical benefits. 
‘‘(iv) The comparative analyses dem-
onstrating that the processes, strategies, evi-
dentiary standards, and other factors used 
to apply the NQTLs to mental health or 
substance use disorder benefits, as written 
and in operation, are comparable to, and 
are applied no more stringently than, the 
processes, strategies, evidentiary standards, 
and other factors used to apply the NQTLs 
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