service is subject to such medical management tech-
nique. 
‘‘(7) A disclaimer that the information provided 
in the notification is only an estimate based on the 
items and services reasonably expected, at the time 
of scheduling (or requesting) the item or service, to 
be furnished and is subject to change. 
‘‘(8) Any other information or disclaimer the 
health plan determines appropriate that is consistent 
with information and disclaimers required under this 
section. 
‘‘(b) HEALTH PLAN DEFINED.—In this section, the 
term ‘health plan’ means a group health plan, including 
any group health plan that is a grandfathered health plan 
(as defined in section 1251(e) of the Patient Protection 
and Affordable Care Act).’’. 
(B) CONFORMING
AMENDMENT.—Section 
9815(a) of the Internal Revenue Code of 1986 
is amended— 
(i) in paragraph (1), by striking ‘‘(as 
amended by the Patient Protection and Af-
fordable Care Act)’’ and inserting ‘‘(other 
than the provisions of section 2730 of such 
Act)’’; and 
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(ii) in paragraph (2), by inserting 
‘‘(other than the provisions of section 2730 
of such Act)’’ after ‘‘a provision of such 
part A’’. 
(C) CLERICAL AMENDMENT.—The table of 
sections for such subchapter is amended by 
adding at the end the following new item: 
‘‘Sec. 9816. Advanced explanation of benefits.’’. 
(3) EMPLOYEE RETIREMENT INCOME SECURITY 
ACT OF 1974 AMENDMENT.— 
(A) IN GENERAL.—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.) is amended by adding at the end the 
following new section: 
‘‘SEC. 716. ADVANCED EXPLANATION OF BENEFITS. 
‘‘(a) IN GENERAL.—Beginning on January 1, 2022, 
each health plan shall, with respect to a notification sub-
mitted under section 1128A(t)(1)(B) of the Social Secu-
rity Act by a health care provider or health care facility, 
respectively, to the health plan for a participant or bene-
ficiary under such health plan scheduled to receive an item 
or service from the provider or facility, not later than 1 
business day (or, in the case such item or service was so 
scheduled at least 10 business days before such item or 
service is to be furnished (or in the case such notification 
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was made pursuant to a request by such participant or 
beneficiary), 3 business days) after the date on which the 
health plan receives such notification, provide to the par-
ticipant or beneficiary (through mail or electronic means, 
as requested by the participant or beneficiary) a notifica-
tion including the following: 
‘‘(1) Whether or not the provider or facility is 
a participating provider or a participating facility 
with respect to the health plan with respect to the 
furnishing of such item or service and— 
‘‘(A) in the case the provider or facility is 
a participating provider or facility with respect 
to the health plan with respect to the furnishing 
of such item or service, the contracted rate 
under such plan for such item or service; and 
‘‘(B) in the case the provider or facility is 
a nonparticipating provider or facility with re-
spect to such plan, a description of how such 
participant or beneficiary may obtain informa-
tion on providers and facilities that, with re-
spect to such health plan, are participating pro-
viders and facilities. 
‘‘(2) The good faith estimate included in the 
notification received from the provider or facility. 
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‘‘(3) A good faith estimate of the amount the 
health plan is responsible for paying for items and 
services included in the estimate described in para-
graph (2). 
‘‘(4) A good faith estimate of the amount of 
any cost-sharing (including with respect to the de-
ductible and any copayment or coinsurance obliga-
tion) for which the participant or beneficiary would 
be responsible for such item or service (as of the 
date of such notification). 
‘‘(5) A good faith estimate of the amount that 
the participant or beneficiary has incurred toward 
meeting the limit of the financial responsibility (in-
cluding with respect to deductibles and out-of-pocket 
maximums) under the health plan (as of the date of 
such notification). 
‘‘(6) In the case such item or service is subject 
to a medical management technique (including con-
current review, prior authorization, and step-therapy 
or fail-first protocols) for coverage under the health 
plan, a disclaimer that coverage for such item or 
service is subject to such medical management tech-
nique. 
‘‘(7) A disclaimer that the information provided 
in the notification is only an estimate based on the 
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items and services reasonably expected, at the time 
of scheduling (or requesting) the item or service, to 
be furnished and is subject to change. 
‘‘(8) Any other information or disclaimer the 
health plan determines appropriate that is consistent 
with information and disclaimers required under this 
section. 
‘‘(b) HEALTH PLAN DEFINED.—In this section, the 
term ‘health plan’ means a group health plan and health 
insurance coverage offered by a health insurance issuer 
in the group market and includes a grandfathered health 
plan (as defined in section 1251(e) of the Patient Protec-
tion and Affordable Care Act) that is such a plan or cov-
erage.’’. 
(B) CONFORMING
AMENDMENT.—Section 
715(a) of the Employee Retirement Income Se-
curity Act of 1974 (29 U.S.C. 1185d(a)) is 
amended— 
(i) in paragraph (1), by striking ‘‘(as 
amended by the Patient Protection and Af-
fordable Care Act)’’ and inserting ‘‘(other 
than the provisions of section 2730 of such 
Act)’’; and 
(ii) in paragraph (2), by inserting 
‘‘(other than the provisions of section 2730 
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pamtmann on DSKBC07HB2PROD with BILLS
of such Act)’’ after ‘‘a provision of such 
part A’’. 
(C) CLERICAL AMENDMENT.—The table of 
contents in section 1 of the Employee Retire-
ment Income Security Act of 1974 is amended 
by inserting after the item relating to section 
714 the following new items: 
‘‘Sec. 715. Additional market reforms. 
‘‘Sec. 716. Advanced explanation of benefits.’’. 
(b) HEALTH CARE PROVIDERS AND FACILITIES.— 
Section 1128A of the Social Security Act (42 U.S.C. 
1320a–7a) is amended by adding at the end the following 
new subsection: 
‘‘(t)(1) Each health care provider and health care fa-
cility shall, beginning January 1, 2022, in the case of an 
individual who schedules an item or service to be furnished 
to such individual by such provider or facility at least 3 
business 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 scheduled at least 10 business days before the 
date such item or service is to be so furnished (or if re-
quested by the individual), not later than 3 business days 
after the date of such scheduling or such request)— 
‘‘(A) inquire if such individual is enrolled in a 
group health plan, group or individual health insur-
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posed under the preceding sentence in the same manner 
as such provisions apply to a penalty or proceeding under 
subsection (a). 
‘‘(3) In this subsection— 
‘‘(A) the terms ‘health insurance issuer’, ‘group 
health plan’, ‘group health insurance coverage’, and 
‘individual health insurance coverage’ have the 
meaning given such terms, respectively, in section 
2791 of the Public Health Service Act; and 
‘‘(B) the term ‘Federal health care program’ 
has the meaning given such term in section 
1128B(f).’’. 
Æ 
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