provider (as determined in accordance with clauses 
(ii) and (iii) of section 2719A(b)(1)(C)). 
‘‘(b) DEFINITIONS.—In this section: 
‘‘(1) The terms ‘emergency department of a hos-
pital’, ‘emergency medical condition’, ‘emergency 
services’, and ‘independent freestanding emergency de-
partment’ have the meanings given such terms, re-
spectively, in section 2719A(b)(3). 
‘‘(2) The term ‘health plan’ has the meaning 
given such term in section 2719A(e). 
‘‘(3) The term ‘during a visit’ shall have such 
meaning as applied to such term for purposes of sec-
tion 2719A(e). 
‘‘SEC. 2799A. BALANCE BILLING IN CASES OF NON-EMER-
GENCY 
SERVICES 
PERFORMED 
BY 
NON-
PARTICIPATING 
PROVIDERS 
AT 
CERTAIN 
PARTICIPATING FACILITIES. 
‘‘(a) IN GENERAL.—Subject to subsection (b), in the 
case of a participant, beneficiary, or enrollee with benefits 
under a health plan (as defined in section 2799(b)) who 
is furnished on or after January 1, 2021, items or services 
(other than emergency services to which section 2799 ap-
plies) at a participating health care facility by a non-
participating provider, such provider shall not hold such 
participant, beneficiary, or enrollee liable for a payment 
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amount for such an item or service furnished by such pro-
vider during a visit at such facility that is more than the 
cost-sharing amount for such item or service (as determined 
in accordance with subparagraphs (A) and (B) of section 
2719A(e)(1)). 
‘‘(b) EXCEPTION.— 
‘‘(1) IN
GENERAL.—Subsection (a) shall not 
apply to a nonparticipating provider (other than a 
specified provider at a participating health care facil-
ity), with respect to items or services furnished by the 
provider to a participant, beneficiary, or enrollee of 
a health plan, if the provider is in compliance with 
the notice and consent requirements of subsection (d). 
‘‘(2) SPECIFIED PROVIDER DEFINED.—For pur-
poses of paragraph (1), the term ‘specified provider’, 
with respect to a participating health care facility— 
‘‘(A) means a facility-based provider, in-
cluding emergency medicine providers, anesthe-
siologists, 
pathologists, 
radiologists, 
neonatologists, assistant surgeons, hospitalists, 
intensivists, or other providers as determined by 
the Secretary; and 
‘‘(B) includes, with respect to an item or 
service, a nonparticipating provider if there is 
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no participating provider at such facility who 
can furnish such item or service. 
‘‘(c) CLARIFICATION.—In the case of a nonpartici-
pating provider (other than a specified provider at a par-
ticipating health care facility) that complies with the notice 
and consent requirements of subsection (d) with respect to 
an item or service (referred to in this subsection as a ‘cov-
ered item or service’), such notice and consent requirements 
may not be construed as applying with respect to any item 
or service that is furnished as a result of unforeseen medical 
needs that arise at the time such covered item or service 
is furnished. 
‘‘(d) COMPLIANCE WITH NOTICE AND CONSENT RE-
QUIREMENTS.— 
‘‘(1) IN GENERAL.—A nonparticipating provider 
or nonparticipating facility is in compliance with 
this subsection, with respect to items or services fur-
nished by the provider or facility to a participant, 
beneficiary, or enrollee of a health plan, if the pro-
vider (or, if applicable, the participating health care 
facility on behalf of such provider) or nonpartici-
pating facility— 
‘‘(A) provides to the participant, bene-
ficiary, or enrollee (or to an authorized rep-
resentative of the participant, beneficiary, or en-
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rollee) on the date on which the individual is 
furnished such items or services and, in the case 
that the participant, beneficiary, or enrollee 
makes an appointment to be furnished such 
items or services, on such date the appointment 
is made— 
‘‘(i) an oral explanation of the written 
notice described in clause (ii); and 
‘‘(ii) a written notice specified by the 
Secretary, not later than July 1, 2020, 
through guidance (which shall be updated 
as determined necessary by the Secretary) 
that— 
‘‘(I) contains the information re-
quired under paragraph (2); and 
‘‘(II) is signed and dated by the 
participant, beneficiary, or enrollee (or 
by an authorized representative of the 
participant, beneficiary, or enrollee) 
and, with respect to items or services to 
be furnished by such a provider that 
are not poststabilization services de-
scribed in section 2719A(b)(3)(C)(ii), 
is so signed and dated not less than 72 
hours prior to the participant, bene-
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ficiary, or enrollee being furnished 
such items or services by such provider; 
and 
‘‘(B) obtains from the participant, bene-
ficiary, or enrollee (or from such an authorized 
representative) the consent described in para-
graph (3). 
‘‘(2) INFORMATION REQUIRED UNDER WRITTEN 
NOTICE.—For purposes of paragraph (1)(A)(ii)(I), the 
information described in this paragraph, with respect 
to a nonparticipating provider or nonparticipating 
facility and a participant, beneficiary, or enrollee of 
a health plan, is each of the following: 
‘‘(A) Notification, as applicable, that the 
health care provider is a nonparticipating pro-
vider with respect to the health plan or the 
health care facility is a nonparticipating facility 
with respect to the health plan. 
‘‘(B) Notification of the estimated amount 
that such provider or facility may charge the 
participant, beneficiary, or enrollee for such 
items and services involved. 
‘‘(C) In the case of a nonparticipating facil-
ity, a list of any participating providers at the 
facility who are able to furnish such items and 
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services involved and notification that the par-
ticipant, beneficiary, or enrollee may be referred, 
at their option, to such a participating provider. 
‘‘(3) CONSENT
DESCRIBED.—For purposes of 
paragraph (1)(B), the consent described in this para-
graph, with respect to a participant, beneficiary, or 
enrollee of a health plan who is to be furnished items 
or services by a nonparticipating provider or non-
participating facility, is a document specified by the 
Secretary through rulemaking that— 
‘‘(A) is signed by the participant, bene-
ficiary, or enrollee (or by an authorized rep-
resentative of the participant, beneficiary, or en-
rollee) and, with respect to items or services to 
be furnished by such a provider or facility that 
are not poststabilization services described in 
section 2719A(b)(3)(C)(ii), is so signed not less 
than 72 hours prior to the participant, bene-
ficiary, or enrollee being furnished such items or 
services by such provider or facility; 
‘‘(B) acknowledges that the participant, 
beneficiary, or enrollee has been— 
‘‘(i) provided with a written estimate 
and an oral explanation of the charge that 
the participant, beneficiary, or enrollee will 
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be assessed for the items or services antici-
pated to be furnished to the participant, 
beneficiary, or enrollee by such provider or 
facility; and 
‘‘(ii) informed that the payment of 
such charge by the participant, beneficiary, 
or enrollee may not accrue toward meeting 
any limitation that the health plan places 
on cost-sharing; and 
‘‘(C) documents the consent of the partici-
pant, beneficiary, or enrollee to— 
‘‘(i) be furnished with such items or 
services by such provider or facility; and 
‘‘(ii) in the case that the individual is 
so furnished such items or services, be 
charged an amount that may be greater 
than the amount that would otherwise be 
charged the individual if furnished by a 
participating provider or participating fa-
cility with respect to such items or services 
and plan. 
‘‘(e) RETENTION OF CERTAIN DOCUMENTS.—A non-
participating provider (or, in the case of a nonpartici-
pating provider at a participating health care facility, such 
facility) or nonparticipating facility that obtains from a 
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participant, beneficiary, or enrollee of a health plan (or an 
authorized representative of such participant, beneficiary, 
or enrollee) a written notice in accordance with subsection 
(c)(1)(ii), with respect to furnishing an item or service to 
such participant, beneficiary, or enrollee, shall retain such 
notice for at least a 2-year period after the date on which 
such item or service is so furnished. 
‘‘(f) DEFINITIONS.—In this section: 
‘‘(1) The terms ‘nonparticipating provider’ and 
‘participating provider’ have the meanings given such 
terms, respectively, in subsection (b)(3) of section 
2719A. 
‘‘(2) The terms ‘participating health care facil-
ity’ and ‘health plan’ have the meanings given such 
terms, respectively, in subsection (e)(2) of section 
2719A. 
‘‘(3) 
The 
term 
‘nonparticipating 
facility’ 
means— 
‘‘(A) with respect to emergency services (as 
defined in section 2719A(b)(3)(C)(i)) and a 
health plan, an emergency department of a hos-
pital, or an independent freestanding emergency 
department, that does not have a contractual re-
lationship with the plan (or, if applicable, issuer 
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offering the plan) for furnishing such services 
under the plan; and 
‘‘(B) with respect to poststabilization serv-
ices described in section 2719A(b)(3)(C)(ii) and 
a health plan, an emergency department of a 
hospital (or other department of such hospital), 
or an independent freestanding emergency de-
partment, that does not have a contractual rela-
tionship with the plan (or, if applicable, issuer 
offering the plan) for furnishing such services 
under the plan. 
‘‘(4) The term ‘participating facility’ means— 
‘‘(A) with respect to emergency services (as 
defined in section 2719A(b)(3)(C)(i)) and a 
health plan, an emergency department of a hos-
pital, or an independent freestanding emergency 
department, that has a contractual relationship 
with the plan (or, if applicable, issuer offering 
the plan) for furnishing such services under the 
plan; and 
‘‘(B) with respect to poststabilization serv-
ices described in section 2719A(b)(3)(C)(ii) and 
a health plan, an emergency department of a 
hospital (or other department of such hospital), 
or an independent freestanding emergency de-
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partment, that has a contractual relationship 
with the plan (or, if applicable, issuer offering 
the plan) for furnishing such services under the 
plan. 
‘‘SEC. 2799B. PROVIDER REQUIREMENTS WITH RESPECT TO 
PROVIDER DIRECTORY INFORMATION. 
‘‘Not later than 1 year after the date of the enactment 
of this section, each health care provider and health care 
facility shall establish a process under which such provider 
or facility transmits, to each health insurance issuer offer-
ing group or individual health insurance coverage and 
group health plan with which such provider or facility has 
in effect a contractual relationship for furnishing items and 
services under such coverage or such plan, provider direc-
tory information (as defined in section 2719A(g)(6)) with 
respect to such provider or facility, as applicable. Such pro-
vider or facility shall so transmit such information to such 
issuer offering such coverage or such group health plan— 
‘‘(1) when the provider or facility enters into 
such a relationship with respect to such coverage of-
fered by such issuer or with respect to such plan; 
‘‘(2) when the provider or facility terminates 
such relationship with respect to such coverage offered 
by such issuer or with respect to such plan; 
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‘‘(3) when there are any other material changes 
to such provider directory information of the provider 
or facility with respect to such coverage offered by 
such issuer or with respect to such plan; 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. 
‘‘SEC. 2799C. PROVIDER REQUIREMENT WITH RESPECT TO 
PUBLIC PROVISION OF INFORMATION. 
‘‘Each health care provider and health care facility 
shall make publicly available, and (if applicable) post on 
a public website of such provider or facility— 
‘‘(1) information in plain language on— 
‘‘(A) the requirements and prohibitions of 
such provider or facility under sections 2799 and 
2799A (relating to prohibitions on balance bill-
ing in certain circumstances); and 
‘‘(B) if provided for under applicable State 
law, any other requirements on such provider or 
facility regarding the amounts such provider or 
facility may, with respect to an item or service, 
charge a participant, beneficiary, or enrollee of 
a health plan (as defined in section 2719A(e)(2)) 
with respect to which such provider or facility 
does not have a contractual relationship for fur-
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nishing such item or service under the plan after 
receiving payment from the plan for such item 
or service and any applicable cost-sharing pay-
ment from such participant, beneficiary, or en-
rollee; and 
‘‘(2) information on contacting appropriate 
State and Federal agencies in the case that an indi-
vidual believes that such provider or facility has vio-
lated any requirement described in paragraph (1) 
with respect to such individual. 
‘‘SEC. 2799D. ENFORCEMENT. 
‘‘(a) STATE ENFORCEMENT.— 
‘‘(1) STATE AUTHORITY.—Each State may re-
quire a provider or health care facility subject to the 
requirements of sections 2719A(f), 2799, 2799A, 
2799B, or 2799C to satisfy such requirements appli-
cable to the provider or facility. 
‘‘(2) FAILURE TO IMPLEMENT REQUIREMENTS.— 
In the case of a determination by the Secretary that 
a State has failed to substantially enforce the require-
ments specified in paragraph (1) with respect to ap-
plicable providers and facilities in the State, the Sec-
retary shall enforce such requirements under sub-
section (b) insofar as they relate to violations of such 
requirements occurring in such State. 
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‘‘(b) SECRETARIAL ENFORCEMENT AUTHORITY.— 
‘‘(1) IN GENERAL.—If a provider or facility is 
found to be in violation specified in subsection (a)(1) 
by the Secretary, the Secretary may apply a civil 
monetary penalty with respect to such provider or fa-
cility in an amount not to exceed $10,000 per viola-
tion. The provisions of subsections (c), (d), (e), (g), 
(h), (k), and (l) of section 1128A of the Social Secu-
rity Act shall apply to a civil monetary penalty or 
assessment under this subsection in the same manner 
as such provisions apply to a penalty, assessment, or 
proceeding under subsection (a) of such section. 
‘‘(2) LIMITATION.—The provisions of paragraph 
(1) shall apply to enforcement of a provision (or pro-
visions) specified in subsection (a)(1) only as pro-
vided under subsection (a)(2). 
‘‘(3) COMPLAINT PROCESS.—The Secretary shall, 
through rulemaking, establish a process to receive con-
sumer complaints of violations of such provisions and 
resolve such complaints within 60 days of receipt of 
such complaints. 
‘‘(4) EXCEPTION.—The Secretary shall waive the 
penalties described under paragraph (1) with respect 
to a facility or provider who does not knowingly vio-
late, and should not have reasonably known it vio-
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lated, section 2799 or 2799A with respect to a partici-
pant, beneficiary, or enrollee, if such facility or prac-
titioner, within 30 days of the violation, withdraws 
the bill that was in violation of such provision and 
reimburses the health plan or enrollee, as applicable, 
in an amount equal to the difference between the 
amount billed and the amount allowed to be billed 
under the provision, plus interest, at an interest rate 
determined by the Secretary. 
‘‘(5) HARDSHIP
EXEMPTION.—The Secretary 
may establish a hardship exemption to the penalties 
under this subsection. 
‘‘(c) CONTINUED APPLICABILITY OF STATE LAW.—The 
sections specified in subsection (a)(1) shall not be construed 
to supersede any provision of State law which establishes, 
implements, or continues in effect any requirement or pro-
hibition except to the extent that such requirement or prohi-
bition prevents the application of a requirement or prohibi-
tion of such a section.’’. 
(e) RULEMAKING FOR MEDIAN CONTRACTED RATES.— 
Not later than July 1, 2020, the Secretary of Health and 
Human Services, jointly with the Secretary of Labor, shall 
establish through rulemaking— 
(1) the methodology the sponsor or issuer of a 
health plan (as defined in subsection (e) of section 
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2719A of the Public Health Service Act (42 U.S.C. 
300gg–19a), as added by subsection (b) of this sec-
tion) shall use to determine the median contracted 
rate (as defined in section 2719A(b) of such Act, as 
amended by subsection (a) of this section), differen-
tiating by business line; 
(2) the information such sponsor or issuer shall 
share with the nonparticipating provider (as defined 
in such section) involved when making such a deter-
mination; and 
(3) the geographic regions applied for purposes 
of subparagraph (E) of section 2719A(b)(3), as 
amended by subsection (a) of this section, taking into 
account the needs of rural and underserved areas, in-
cluding health professional shortage areas. 
Such rulemaking shall take into account payments that are 
made by such sponsor or issuer that are not on a fee-for- 
service basis. Such methodology may account for relevant 
payment adjustments that take into account facility type 
(including higher acuity settings and the case-mix of var-
ious facility types) that are otherwise taken into account 
for purposes of determining payment amounts with respect 
to participating facilities. 
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(f) EFFECTIVE DATE.—The amendments made by sub-
sections (a) and (b) shall apply with respect to plan years 
beginning on or after January 1, 2021. 
SEC. 403. GOVERNMENT ACCOUNTABILITY OFFICE STUDY 
ON 
PROFIT- 
AND 
REVENUE-SHARING 
IN 
HEALTH CARE. 
(a) STUDY.—The Comptroller General of the United 
States shall conduct a study to— 
(1) describe what is known about profit- and 
revenue-sharing relationships in the commercial 
health care markets, including those relationships 
that— 
(A) involve one or more— 
(i) physician groups that practice 
within a hospital included in the profit- or 
revenue-sharing relationship, or refer pa-
tients to such hospital; 
(ii) laboratory, radiology, or pharmacy 
services that are delivered to privately in-
sured patients of such hospital; 
(iii) surgical services; 
(iv) hospitals or group purchasing or-
ganizations; or 
(v) rehabilitation or physical therapy 
facilities or services; and 
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(B) include revenue- or profit-sharing 
whether through a joint venture, management or 
professional services agreement, or other form of 
gain-sharing contract; 
(2) describe Federal oversight of such relation-
ships, including authorities of the Department of 
Health and Human Services and the Federal Trade 
Commission to review such relationships and their 
potential to increase costs for patients, and identify 
limitations in such oversight; and 
(3) as appropriate, make recommendations to 
improve Federal oversight of such relationships. 
(b) REPORT.—Not later than 2 years after the date 
of the enactment of this Act, the Comptroller General of the 
United States shall prepare and submit a report on the 
study conducted under subsection (a) to the Committee on 
Health, Education, Labor, and Pensions of the Senate and 
the Committee on Education and Labor and Committee on 
Energy and Commerce of the House of Representatives. 
SEC. 404. STATE ALL PAYER CLAIMS DATABASES. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services shall make one-time grants to eligible 
States for the purposes described in subsection (b). 
(b) USES.—A State may use a grant received under 
subsection (a) for one of the following purposes: 
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(1) To establish an All Payer Claims Database 
for the State. 
(2) To maintain an existing All Payer Claims 
Databases for the State. 
(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. Such 
information shall include, with respect to an All Payer 
Claims Database for the State, at least specifics on how the 
State will ensure uniform data collection through the data-
base and the security of such data submitted to and main-
tained in the database. 
(d) ALL PAYER CLAIMS DATABASE.—For purposes of 
this section, the term ‘‘All Payer Claims Database’’ means, 
with respect to a State, a State database that may include 
medical claims, pharmacy claims, dental claims, and eligi-
bility and provider files, which are collected from private 
and public payers. 
(e) AUTHORIZATION OF APPROPRIATIONS.—To carry 
out this section, there are authorized to be appropriated 
$50,000,000, to remain available until expended. 
SEC. 405. AIR AMBULANCE COST DATA REPORTING PRO-
GRAM. 
(a) COST DATA REPORTING PROGRAM.— 
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(1) IN GENERAL.—Not later than 6 months after 
the date of the promulgation of the rule under sub-
section (c), and annually thereafter, a provider of 
emergency air medical services shall submit to the 
Secretary of Health and Human Services the infor-
mation specified in subsection (b) with respect to the 
preceding 180-day period (in the case of the initial 
period) and the preceding 1-year period (in each sub-
sequent period). 
(2) PUBLICATION.—Not later than 180 days 
after the date the Secretary of Health and Human 
Services receives from a provider described in para-
graph (1) the information specified in subsection (b), 
the Secretary shall make publicly available such in-
formation. 
(b) SPECIFIED INFORMATION.—Information described 
in subsection (a) is— 
(1) information, with respect to a claim for an 
item or service— 
(A) identified as paid by health insurance 
coverage offered in the group or individual mar-
ket or a group health plan (including a self-in-
sured plan); 
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(B) identified as paid for non-emergent 
transport requiring prior authorization and 
emergent transport; 
(C) identified as paid for hospital-affiliated 
providers and independent providers; 
(D) identified as paid for rural transport 
and urban transport; 
(E) identified as provided using rotor 
transport and fixed wing transport; and 
(F) identified as furnished by a provider of 
emergency air medical services that has a con-
tractual relationship with the plan or coverage of 
an individual for which such item or service is 
provided and such a provider that does not have 
a contractual relationship with the plan or cov-
erage or such an individual; and 
(2) cost data for an air ambulance service fur-
nished by such a provider of emergency air medical 
services that the Secretary of Health and Human 
Services, in consultation with suppliers and providers 
of such services, determines appropriate, separated by 
the cost of air travel and the cost of emergency med-
ical services and supplies. 
(c) RULEMAKING.—Not later than 1 year after the date 
of the enactment of this Act, the Secretary of Health and 
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Human Services shall determine the form and manner for 
submitting the information described in subsection (b) 
through notice and comment rulemaking. 
(d) CIVIL MONETARY PENALTIES.— 
(1) IN GENERAL.—A provider of emergency air 
medical services who violates the requirements of sub-
section (a)(1) shall be subject to a civil monetary pen-
alty of not more than $10,000 for each act consti-
tuting such violation. 
(2) 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) of such subsection, shall 
apply to civil monetary penalties under this sub-
section in the same manner as such provisions apply 
to a penalty or proceeding under such section. 
(e) REPORTING.— 
(1) SECRETARY OF HEALTH AND HUMAN SERV-
ICES.—Not later than July 1, 2023, the Secretary of 
Health and Human Services shall submit to Congress 
a report summarizing the information and data spec-
ified in subsection (b). 
(2) COMPTROLLER
GENERAL.—Not later than 
July 1, 2023, the Comptroller General of the United 
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States shall submit to Congress a report that in-
cludes— 
(A) an analysis of the cost variation of pro-
viders of emergency air ambulance services by 
geography and status; and 
(B) any other recommendations the Comp-
troller General determines appropriate, which 
may include a recommendation of an adequate 
amount of reimbursement for such services that 
reflects operational costs of such providers in 
order to preserve access to emergency air ambu-
lance services. 
(f) LIMITATION.—The information publicly disclosed 
under subsection (a) and the reports under subsection (f) 
may not contain any proprietary information. 
SEC. 406. REPORT BY SECRETARY OF LABOR. 
Not later than one year after the date of the enactment 
of this Act, and annually thereafter for each of the following 
5 years, the Secretary of Labor shall— 
(1) conduct a study of— 
(A) the effects of the provisions of, including 
amendments made by, this Act on premiums and 
out-of-pocket costs in group health plans, includ-
ing out-of-pocket costs that are permitted by rea-
son of compliance with section 2799A(d) of the 
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Public Health Service Act, as added by section 
2(d); 
(B) the adequacy of provider networks in 
group health plans; and 
(C) such other effects of such provisions, and 
amendments, as the Secretary deems relevant; 
and 
(2) submit a report on such study to the Com-
mittee on Health, Education, Labor, and Pensions of 
the Senate and the Committee on Education and 
Labor and the Committee on Energy and Commerce 
of the House of Representatives. 
SEC. 407. BILLING STATUTE OF LIMITATIONS. 
Notwithstanding any other provision of law, a health 
care provider or health care facility (or health insurance 
issuer offering health insurance coverage or group health 
plan) may not initiate a process to seek reimbursement 
from an individual for a service furnished by such provider 
or facility to such individual more than a year after such 
date of service. Any provider, facility, issuer, or plan that 
bills an individual in violation of the previous sentence 
shall be subject to a civil monetary penalty in such amount 
as specified by the Secretary of Health and Human Serv-
ices. 
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SEC. 408. GAO REPORT ON IMPACT OF SURPRISE BILLING 
PROVISIONS. 
Not later than 3 years after the date of the enactment 
of this Act, the Comptroller General of the United States 
shall submit to Congress a report containing the following: 
(1) What is known about the impacts of the pro-
visions of this Act, including the amendments made 
by this Act, on the incidence and prevalence of the 
furnishing of items and services to individuals en-
rolled under a group health plan or health insurance 
coverage by health care providers and health care fa-
cilities that do not have a contractual relationship 
with such plan or such coverage (as applicable) for 
furnishing such items and services to such an indi-
vidual. 
(2) What is known about such impacts on pro-
vider shortages and accessibility to such providers, fo-
cusing on rural and medically underserved commu-
nities. 
(3) The number of grants that have been award-
ed under section 404 (relating to State All Payer 
Claims Databases) and for what purposes States have 
used funds made available under such grants. 
(4) An analysis of how data made available 
through State All Payer Claims Databases receiving 
funding under such grants has been used. 
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SEC. 409. REPORT BY THE SECRETARY OF HEALTH AND 
HUMAN SERVICES. 
Not later than one year after the date of the enactment 
of this Act, and annually thereafter for each of the following 
5 years, the Secretary of Health and Human Services 
shall— 
(1) conduct a study of— 
(A) the effects of the provisions of, including 
amendments made by, this Act on premiums and 
out-of-pocket costs with respect to individual 
health insurance coverage and small group 
health plans; 
(B) the adequacy of provider networks with 
respect to individual health insurance coverage 
and small group health plans, taking into con-
sideration maximum travel time and distance; 
and 
(C) such other effects of such provisions, and 
amendments, as the Secretary deems relevant; 
and 
(2) submit a report on such study to the Com-
mittee on Health, Education, Labor, and Pensions of 
the Senate and the Committee on Education and 
Labor and the Committee on Energy and Commerce 
of the House of Representatives. 
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TITLE V—TERRITORIES HEALTH 
CARE IMPROVEMENT ACT 
SEC. 501. SHORT TITLE. 
This title may be cited as the ‘‘Territories Health Care 
Improvement Act’’. 
SEC. 502. MEDICAID PAYMENTS FOR PUERTO RICO AND THE 
OTHER TERRITORIES FOR CERTAIN FISCAL 
YEARS. 
(a) TREATMENT OF CAP.—Section 1108(g) of the So-
cial Security Act (42 U.S.C. 1308(g)) is amended— 
(1) in paragraph (2)— 
(A) in the matter preceding subparagraph 
(A), 
by 
striking 
‘‘subject 
to 
and 
section 
1323(a)(2) of the Patient Protection and Afford-
able Care Act paragraphs (3) and (5)’’ and in-
serting ‘‘subject to section 1323(a)(2) of the Pa-
tient Protection and Affordable Care Act and 
paragraphs (3) and (5)’’; 
(B) in subparagraph (A)— 
(i) by striking ‘‘Puerto Rico shall not 
exceed the sum of’’ and inserting ‘‘Puerto 
Rico shall not exceed— 
‘‘(i) except as provided in clause (ii), 
the sum of’’; 
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100 
(ii) by striking ‘‘$100,000;’’ and in-
serting ‘‘$100,000; and’’; and 
(iii) by adding at the end the following 
new clause: 
‘‘(ii) for each of fiscal years 2020 
through 2023, the amount specified in para-
graph (6) for each such fiscal year;’’; 
(C) in subparagraph (B)— 
(i) by striking ‘‘the Virgin Islands 
shall not exceed the sum of’’ and inserting 
‘‘the Virgin Islands shall not exceed— 
‘‘(i) except as provided in clause (ii), 
the sum of’’; 
(ii) by striking ‘‘$10,000;’’ and insert-
ing ‘‘$10,000; and’’; and 
(iii) by adding at the end the following 
new clause: 
‘‘(ii) for each of fiscal years 2020 
through 2025, $126,000,000;’’; 
(D) in subparagraph (C)— 
(i) by striking ‘‘Guam shall not exceed 
the sum of’’ and inserting ‘‘Guam shall not 
exceed— 
‘‘(i) except as provided in clause (ii), 
the sum of’’; 
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101 
(ii) by striking ‘‘$10,000;’’ and insert-
ing ‘‘$10,000; and’’; and 
(iii) by adding at the end the following 
new clause: 
‘‘(ii) for each of fiscal years 2020 
through 2025, $127,000,000;’’; 
(E) in subparagraph (D)— 
(i) by striking ‘‘the Northern Mariana 
Islands shall not exceed the sum of’’ and in-
serting ‘‘the Northern Mariana Islands shall 
not exceed— 
‘‘(i) except as provided in clause (ii), 
the sum of’’; and 
(ii) by adding at the end the following 
new clause: 
‘‘(ii) for each of fiscal years 2020 
through 2025, $60,000,000; and’’; and 
(F) in subparagraph (E)— 
(i) by striking ‘‘American Samoa shall 
not exceed the sum of’’ and inserting 
‘‘American Samoa shall not exceed— 
‘‘(i) except as provided in clause (ii), 
the sum of’’; 
(ii) by striking ‘‘$10,000.’’ and insert-
ing ‘‘$10,000; and’’; and 
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102 
(iii) by adding at the end the following 
new clause: 
‘‘(ii) for each of fiscal years 2020 
through 2025, $84,000,000.’’; and 
(2) by adding at the end the following new para-
graph: 
‘‘(6) APPLICATION TO PUERTO RICO FOR FISCAL 
YEARS 2020 THROUGH 2023.—For purposes of para-
graph (2)(A)(ii), the amount specified in this para-
graph is— 
‘‘(A) for fiscal year 2020, $2,823,188,000; 
‘‘(B) for fiscal year 2021, $2,919,072,000; 
‘‘(C) for fiscal year 2022, $3,012,610,000; 
and 
‘‘(D) for fiscal year 2023, $3,114,331,000.’’. 
(b) TREATMENT OF FUNDING UNDER ENHANCED AL-
LOTMENT PROGRAM.—Section 1935(e) of the Social Secu-
rity Act (42 U.S.C. 1396u–5(e)) is amended— 
(1) in paragraph (1)(B), by striking ‘‘if the 
State’’ and inserting ‘‘subject to paragraph (4), if the 
State’’; 
(2) by redesignating paragraph (4) as para-
graph (5); and 
(3) by inserting after paragraph (3) the fol-
lowing new paragraph: 
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103 
‘‘(4) TREATMENT OF FUNDING FOR CERTAIN FIS-
CAL YEARS.— 
‘‘(A) 
PUERTO
RICO.—Notwithstanding 
paragraph (1)(B), in the case that Puerto Rico 
establishes and submits to the Secretary a plan 
described in paragraph (2) with respect to any 
of fiscal years 2020 through 2023, the amount 
specified in paragraph (3) for Puerto Rico for 
such a year shall be taken into account in apply-
ing subparagraph (A)(ii) of section 1108(g)(2) 
for such year. 
‘‘(B) 
OTHER
TERRITORIES.—Notwith-
standing paragraph (1)(B), in the case that the 
Virgin Islands, Guam, the Northern Mariana Is-
lands, or American Samoa establishes and sub-
mits to the Secretary a plan described in para-
graph (2) with respect to any of fiscal years 
2020 through 2025, the amount specified in 
paragraph (3) for the Virgin Islands, Guam, the 
Northern Mariana Islands, or American Samoa, 
as the case may be, shall be taken into account 
in 
applying, 
as 
applicable, 
subparagraph 
(B)(ii), (C)(ii), (D)(ii), or (E)(ii) of section 
1108(g)(2) for such year.’’. 
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104 
(c) INCREASED FMAP.—Section 1905 of the Social Se-
curity Act (42 U.S.C. 1396d(b)) is amended— 
(1) in subsection (b), by striking ‘‘and (aa)’’ and 
inserting ‘‘(aa), and (ff)’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(ff) TEMPORARY INCREASE IN FMAP FOR TERRI-
TORIES FOR CERTAIN FISCAL YEARS.— 
‘‘(1) PUERTO RICO.—Notwithstanding subsection 
(b) and subject to subsection (z)(2), the Federal med-
ical assistance percentage for Puerto Rico shall be 
equal to— 
‘‘(A) 83 percent for fiscal years 2020 and 
2021; and 
‘‘(B) 76 percent for fiscal years 2022 and 
2023. 
‘‘(2) VIRGIN
ISLANDS.—Notwithstanding sub-
section (b) and subject to subsection (z)(2), the Fed-
eral medical assistance percentage for the Virgin Is-
lands shall be equal to— 
‘‘(A) 100 percent for fiscal year 2020; 
‘‘(B) 83 percent for fiscal years 2021 
through 2024; and 
‘‘(C) 76 percent for fiscal year 2025. 
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105 
‘‘(3) 
OTHER
TERRITORIES.—Notwithstanding 
subsection (b) and subject to subsection (z)(2), the 
Federal medical assistance percentage for Guam, the 
Northern Mariana Islands, and American Samoa 
shall be equal to— 
‘‘(A) 100 percent for fiscal years 2020 and 
2021; 
‘‘(B) 83 percent for fiscal years 2022 
through 2024; and 
‘‘(C) 76 percent for fiscal year 2025.’’. 
(d) ANNUAL REPORT.—Section 1108(g) of the Social 
Security Act (42 U.S.C. 1308(g)), as amended by subsection 
(a), is further amended by adding at the end the following 
new paragraph: 
‘‘(7) ANNUAL REPORT.— 
‘‘(A) IN GENERAL.—Not later than the date 
that is 180 days after the end of each fiscal year 
(beginning with fiscal year 2020 and ending 
with fiscal year 2025), in the case that a speci-
fied territory receives a Medicaid cap increase, 
or an increase in the Federal medical assistance 
percentage for such territory under section 
1905(ff), for such fiscal year, such territory shall 
submit to the Chair and Ranking Member of the 
Committee on Energy and Commerce of the 
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106 
House of Representatives and the Chair and 
Ranking Member of the Committee on Finance of 
the Senate a report that describes how such terri-
tory has used such Medicaid cap increase, or 
such increase in the Federal medical assistance 
percentage, as applicable, to increase access to 
health care under the State Medicaid plan of 
such territory under title XIX (or a waiver of 
such plan). Such report may include— 
‘‘(i) the extent to which such territory 
has, with respect to such plan (or waiver)— 
‘‘(I) increased payments to health 
care providers; 
‘‘(II) increased covered benefits; 
‘‘(III) expanded health care pro-
vider networks; or 
‘‘(IV) improved in any other 
manner the carrying out of such plan 
(or waiver); and 
‘‘(ii) any other information as deter-
mined necessary by such territory. 
‘‘(B) DEFINITIONS.—In this paragraph: 
‘‘(i) MEDICAID
CAP
INCREASE.—The 
term ‘Medicaid cap increase’ means, with 
respect to a specified territory and fiscal 
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107 
year, any increase in the amounts otherwise 
determined under this subsection for such 
territory for such fiscal year by reason of 
the amendments made by section 502(a) of 
the Territories Health Care Improvement 
Act. 
‘‘(ii) 
SPECIFIED
TERRITORY.—The 
term ‘specified territory’ means Puerto 
Rico, the Virgin Islands, Guam, the North-
ern 
Mariana 
Islands, 
and 
American 
Samoa.’’. 
SEC. 
503. 
APPLICATION 
OF 
CERTAIN 
REQUIREMENTS 
UNDER MEDICAID PROGRAM TO CERTAIN 
TERRITORIES. 
(a) APPLICATION OF PAYMENT ERROR RATE MEAS-
UREMENT REQUIREMENTS
TO PUERTO RICO.—Section 
1903(u)(4) of the Social Security Act (42 U.S.C. 
1396b(u)(4)) is amended— 
(1) by striking ‘‘to Puerto Rico, Guam’’ and in-
serting ‘‘to Guam’’; and 
(2) by striking ‘‘or American Samoa.’’ and in-
serting ‘‘or American Samoa, or, for fiscal years be-
fore fiscal year 2023, to Puerto Rico.’’. 
(b) APPLICATION OF ASSET VERIFICATION PROGRAM 
REQUIREMENTS TO PUERTO RICO AND VIRGIN ISLANDS.— 
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108 
Section 1940(a) of the Social Security Act (42 U.S.C. 
1396w(a)) is amended— 
(1) in paragraph (3)(A), by adding at the end 
the following new clause: 
‘‘(iii) IMPLEMENTATION
IN
PUERTO 
RICO AND VIRGIN ISLANDS.—The Secretary 
shall require Puerto Rico to implement an 
asset verification program under this sub-
section by the end of fiscal year 2022 and 
the Virgin Islands to implement such a pro-
gram by the end of fiscal year 2023.’’; and 
(2) in paragraph (4)— 
(A) in the paragraph heading, by striking 
‘‘EXEMPTION
OF
TERRITORIES’’ and inserting 
‘‘EXEMPTION OF CERTAIN TERRITORIES’’; and 
(B) by striking ‘‘and the District of Colum-
bia’’ and inserting ‘‘, the District of Columbia, 
Puerto Rico, and the Virgin Islands’’. 
(c) APPLICATION OF CERTAIN DATA REPORTING AND 
PROGRAM INTEGRITY REQUIREMENTS TO NORTHERN MAR-
IANA ISLANDS, AMERICAN SAMOA, AND GUAM.— 
(1) IN GENERAL.—Section 1902 of the Social Se-
curity Act (42 U.S.C. 1396a) is amended by adding 
at the end the following new subsection: 
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109 
‘‘(qq) APPLICATION OF CERTAIN DATA REPORTING 
AND PROGRAM INTEGRITY REQUIREMENTS TO NORTHERN 
MARIANA ISLANDS, AMERICAN SAMOA, AND GUAM.—Not 
later than October 1, 2023, the Northern Mariana Islands, 
American Samoa, and Guam shall— 
‘‘(1) implement methods, satisfactory to the Sec-
retary, for the collection and reporting of reliable 
data to the Transformed Medicaid Statistical Infor-
mation System (T–MSIS) (or a successor system); 
and 
‘‘(2) demonstrate progress in establishing a State 
medicaid fraud control unit described in section 
1903(q).’’. 
(2) CONFORMING AMENDMENT.—Section 1902(j) 
of the Social Security Act (42 U.S.C. 1396a(j)) is 
amended— 
(A) by striking ‘‘or the requirement’’ and 
inserting ‘‘, the requirement’’; and 
(B) by inserting before the period at the end 
the following: ‘‘, or the requirement under sub-
section (qq)(1) (relating to data reporting)’’. 
SEC. 504. ADDITIONAL PROGRAM INTEGRITY REQUIRE-
MENTS. 
(a) AUDIT
RELATING
TO
FRAUD, WASTE, 
AND 
ABUSE.—Not sooner than the date that is one year after 
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110 
the date of the enactment of this Act, the Inspector General 
of the Department of Health and Human Services (referred 
to in this section as the ‘‘Inspector General’’) shall conduct 
an audit of Puerto Rico with respect to any part of the 
administration of Puerto Rico’s State plan under title XIX 
of the Social Security Act (42 U.S.C. 1396 et seq.) (or a 
waiver of such plan), such as contracting protocols, denials 
of care, and financial management, that the Inspector Gen-
eral determines to be at high risk for waste, fraud, or abuse. 
(b) PLAN FOR AUDITS AND INVESTIGATIONS OF CON-
TRACTING PRACTICES.—Not later than the date that is one 
year after the date of the enactment of this Act, the Inspec-
tor General shall develop and submit to Congress a plan 
for auditing and investigating contracting practices relat-
ing to Puerto Rico’s State plan under title XIX of the Social 
Security Act (42 U.S.C. 1396 et seq.) (or a waiver of such 
plan). 
(c) REPORT ON CONTRACTING OVERSIGHT AND AP-
PROVAL.—Not later than the date that is two years after 
the date of the enactment of this Act, the Comptroller Gen-
eral of the United States shall issue, and submit to the 
Chair and Ranking Member of the Committee on Energy 
and Commerce of the House of Representatives and the 
Chair and Ranking Member of the Committee on Finance 
of the Senate, a report on contracting oversight and ap-
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111 
proval with respect to Puerto Rico’s State plan under title 
XIX of the Social Security Act (42 U.S.C. 1396 et seq.) 
(or a waiver of such plan). Such report shall— 
(1) examine— 
(A) the process used by Puerto Rico to 
evaluate bids and award contracts under such 
plan (or waiver); 
(B) which contracts are not subject to com-
petitive bidding or requests for proposals under 
such plan (or waiver); and 
(C) oversight by the Centers for Medicare & 
Medicaid Services of contracts awarded under 
such plan (or waiver); and 
(2) include any recommendations for Congress, 
the Secretary of Health and Human Services, or 
Puerto Rico relating to changes that the Inspector 
General determines necessary to improve the program 
integrity of such plan (or waiver). 
(d) REEVALUATION OF WAIVERS OF MEDICAID FRAUD 
CONTROL UNIT REQUIREMENT.—Not later than the date 
that is one year after the date of the enactment of this Act, 
the Secretary of Health and Human Services shall— 
(1) reevaluate any waiver approved (and in ef-
fect as of the date of the enactment of this Act) for 
Guam, the Northern Mariana Islands, or American 
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112 
Samoa under subsection (a)(61) or subsection (j) of 
section 1902 of the Social Security Act (42 U.S.C. 
1396a) with respect to the requirement to establish a 
State medicaid fraud control unit (as described in 
section 1903(q) of such Act (42 U.S.C. 1396b(q)); and 
(2) determine whether any such waiver should 
continue to be approved with respect to Guam, the 
Northern Mariana Islands, or American Samoa, re-
spectively, after October 1, 2023. 
(e) SYSTEM FOR TRACKING FEDERAL FUNDING PRO-
VIDED TO PUERTO RICO.—Section 1902 of the Social Secu-
rity Act (42 U.S.C. 1396a), as amended by section 503(c), 
is further amended by adding at the end the following new 
subsection: 
‘‘(rr) PROGRAM
INTEGRITY
REQUIREMENTS
FOR 
PUERTO RICO.— 
‘‘(1) SYSTEM FOR TRACKING FEDERAL FUNDING 
PROVIDED TO PUERTO RICO.— 
‘‘(A) IN GENERAL.—Puerto Rico shall estab-
lish and maintain a system for tracking any 
amounts paid by the Federal Government to 
Puerto Rico with respect to the State plan of 
Puerto Rico (or a waiver of such plan). Under 
such system, Puerto Rico shall ensure that infor-
mation is available, with respect to each quarter 
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113 
in a fiscal year (beginning with the first quarter 
beginning on or after the date that is one year 
after the date of the enactment of this sub-
section), on the following: 
‘‘(i) In the case of a quarter other than 
the first quarter of such fiscal year— 
‘‘(I) the total amount expended by 
Puerto Rico during any previous quar-
ter of such fiscal year under the State 
plan of Puerto Rico (or a waiver of 
such plan); and 
‘‘(II) a description of how such 
amount was so expended. 
‘‘(ii) The total amount that Puerto 
Rico expects to expend during the quarter 
under the State plan of Puerto Rico (or a 
waiver of such plan), and a description of 
how Puerto Rico expects to expend such 
amount. 
‘‘(B) REPORT TO CMS.—For each quarter 
with respect to which Puerto Rico is required 
under subparagraph (A) to ensure that informa-
tion described in such subparagraph is available, 
Puerto Rico shall submit to the Administrator of 
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114 
the Centers for Medicare & Medicaid Services a 
report on such information for such quarter. 
‘‘(2) SUBMISSION OF DOCUMENTATION ON CON-
TRACTS UPON REQUEST.—Puerto Rico shall, upon re-
quest, submit to the Administrator of the Centers for 
Medicare & Medicaid Services all documentation re-
quested with respect to contracts awarded under the 
State plan of Puerto Rico (or a waiver of such 
plan).’’. 
Amend the title so as to read: ‘‘A bill to reauthorize 
and extend funding for critical public health programs 
that improve access to health care and strengthen the 
health care workforce, to extend provisions of the Medi-
care program, to strengthen the Medicaid program in the 
territories, to protect health care consumers from sur-
prise billing practices, and for other purposes.’’. 
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Union Calendar No. 587 
116TH CONGRESS 
2D SESSION 
H. R. 2328 
[Report No. 116–332, Part I] 
A BILL 
To reauthorize and extend funding for community 
health centers and the National Health Service 
Corps. 
DECEMBER 31, 2020 
Committee on Transportation and Infrastructure dis-
charged; committed to the Committee of the Whole 
House on the State of the Union and ordered to be 
printed 
VerDate Sep 11 2014 
21:36 Dec 31, 2020
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