H. R. 133—1587 
provides for a method for determining the total amount 
payable under such a plan, coverage, or issuer, respectively 
(to the extent such State law applies to such plan, coverage, 
or issuer, subject to section 514 of the Employee Retirement 
Income Security Act of 1974) in the case of a participant, 
beneficiary, or enrollee covered under such plan or coverage 
and receiving such item or service from such a nonpartici-
pating provider or nonparticipating emergency facility. 
‘‘(J) STABILIZE.—The term ‘to stabilize’, with respect 
to an emergency medical condition (as defined in subpara-
graph (B)), has the meaning give in section 1867(e)(3) of 
the Social Security Act (42 U.S.C. 1395dd(e)(3)). 
‘‘(K) OUT-OF-NETWORK RATE.—The term ‘out-of-network 
rate’ means, with respect to an item or service furnished 
in a State during a year to a participant, beneficiary, 
or enrollee of a group health plan or group or individual 
health insurance coverage offered by a health insurance 
issuer receiving such item or service from a nonpartici-
pating provider or nonparticipating emergency facility— 
‘‘(i) subject to clause (iii), in the case of such item 
or service furnished in a State that has in effect a 
specified State law with respect to such plan, coverage, 
or issuer, respectively; such a nonparticipating provider 
or nonparticipating emergency facility; and such an 
item or service, the amount determined in accordance 
with such law; 
‘‘(ii) subject to clause (iii), in the case such State 
does not have in effect such a law with respect to 
such item or service, plan, and provider or facility— 
‘‘(I) subject to subclause (II), if the provider 
or facility (as applicable) and such plan or coverage 
agree on an amount of payment (including if such 
agreed on amount is the initial payment sent by 
the plan under subsection (a)(1)(C)(iv)(I),subsection 
(b)(1)(C), 
or 
section 
2799A–2(a)(3)(A), 
as 
applicable, or is agreed on through open negotia-
tions under subsection (c)(1)) with respect to such 
item or service, such agreed on amount; or 
‘‘(II) if such provider or facility (as applicable) 
and such plan or coverage enter the independent 
dispute resolution process under subsection (c) and 
do not so agree before the date on which a certified 
IDR entity (as defined in paragraph (4) of such 
subsection) makes a determination with respect 
to such item or service under such subsection, 
the amount of such determination; or 
‘‘(iii) in the case such State has an All-Payer Model 
Agreement under section 1115A of the Social Security 
Act, the amount that the State approves under such 
system for such item or service so furnished. 
‘‘(L) COST-SHARING.—The term ‘cost-sharing’ includes 
copayments, coinsurance, and deductibles. 
‘‘(b) COVERAGE OF NON-EMERGENCY SERVICES PERFORMED BY 
NONPARTICIPATING PROVIDERS AT CERTAIN PARTICIPATING FACILI-
TIES.— 
‘‘(1) IN GENERAL.—In the case of items or services (other 
than emergency services to which subsection (a) applies) for
H. R. 133—1588 
which any benefits are provided or covered by a group health 
plan or health insurance issuer offering group or individual 
health insurance coverage furnished to a participant, bene-
ficiary, or enrollee of such plan or coverage by a nonpartici-
pating provider (as defined in subsection (a)(3)(G)(i)) (and who, 
with respect to such items and services, has not satisfied the 
notice and consent criteria of section 2799B–2(d)) with respect 
to a visit (as defined by the Secretary in accordance with 
paragraph (2)(B)) at a participating health care facility (as 
defined in paragraph (2)(A)), with respect to such plan or cov-
erage, respectively, the plan or coverage, respectively— 
‘‘(A) shall not impose on such participant, beneficiary, 
or enrollee a cost-sharing requirement for such items and 
services so furnished that is greater than the cost-sharing 
requirement that would apply under such plan or coverage, 
respectively, had such items or services been furnished 
by a participating provider (as defined in subsection 
(a)(3)(G)(ii)); 
‘‘(B) shall calculate such cost-sharing requirement as 
if the total amount that would have been charged for 
such items and services by such participating provider 
were equal to the recognized amount (as defined in sub-
section (a)(3)(H)) for such items and services, plan or cov-
erage, and year; 
‘‘(C) not later than 30 calendar days after the bill 
for such services is transmitted by such provider, shall 
send to the provider an initial payment or notice of denial 
of payment; 
‘‘(D) shall pay a total plan or coverage payment 
directly, in accordance, if applicable,with the timing 
requirement described in subsection (c)(6), to such provider 
furnishing such items and services to such participant, 
beneficiary, or enrollee that is, with application of any 
initial payment under subparagraph (C), equal to the 
amount by which the out-of-network rate (as defined in 
subsection (a)(3)(K)) for such items and services involved 
exceeds the cost-sharing amount imposed under the plan 
or coverage, respectively, for such items and services (as 
determined in accordance with subparagraphs (A) and (B)) 
and year; and 
‘‘(E) shall count toward any in-network deductible and 
in-network out-of-pocket maximums (as applicable) applied 
under the plan or coverage, respectively, any cost-sharing 
payments made by the participant, beneficiary, or enrollee 
(and such in-network deductible and out-of-pocket maxi-
mums shall be applied) with respect to such items and 
services so furnished in the same manner as if such cost- 
sharing payments were with respect to items and services 
furnished by a participating provider. 
‘‘(2) DEFINITIONS.—In this section: 
‘‘(A) PARTICIPATING HEALTH CARE FACILITY.— 
‘‘(i) IN GENERAL.—The term ‘participating health 
care facility’ means, with respect to an item or service 
and a group health plan or health insurance issuer 
offering group or individual health insurance coverage, 
a health care facility described in clause (ii) that has 
a direct or indirect contractual relationship with the
H. R. 133—1589 
plan or issuer, respectively, with respect to the fur-
nishing of such an item or service at the facility. 
‘‘(ii) HEALTH CARE FACILITY DESCRIBED.—A health 
care facility described in this clause, with respect to 
a group health plan or group or individual health insur-
ance coverage, is each of the following: 
‘‘(I) A hospital (as defined in 1861(e) of the 
Social Security Act). 
‘‘(II) A hospital outpatient department. 
‘‘(III) A critical access hospital (as defined in 
section 1861(mm)(1) of such Act). 
‘‘(IV) An ambulatory surgical center described 
in section 1833(i)(1)(A) of such Act. 
‘‘(V) Any other facility, specified by the Sec-
retary, that provides items or services for which 
coverage is provided under the plan or coverage, 
respectively. 
‘‘(B) VISIT.—The term ‘visit’ shall, with respect to items 
and services furnished to an individual at a health care 
facility, include equipment and devices, telemedicine serv-
ices, imaging services, laboratory services, preoperative and 
postoperative services, and such other items and services 
as the Secretary may specify, regardless of whether or 
not the provider furnishing such items or services is at 
the facility. 
‘‘(c) CERTAIN ACCESS FEES
TO CERTAIN DATABASES.—In the 
case of a sponsor of a group health plan or health insurance issuer 
offering group or individual health insurance coverage that, pursu-
ant to subsection (a)(3)(E)(iii), uses a database described in such 
subsection to determine a rate to apply under such subsection 
for an item or service by reason of having insufficient information 
described in such subsection with respect to such item or service, 
such sponsor or issuer shall cover the cost for access to such 
database.’’. 
(2) TRANSFER AMENDMENT.—Part D of title XXVII of the 
Public Health Service Act, as added by paragraph (1), is 
amended by adding at the end the following new section: 
‘‘SEC. 2799A–7. OTHER PATIENT PROTECTIONS. 
‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If a group health 
plan, or a health insurance issuer offering group or individual 
health insurance coverage, requires or provides for designation by 
a participant, beneficiary, or enrollee of a participating primary 
care provider, then the plan or issuer shall permit each participant, 
beneficiary, and enrollee to designate any participating primary 
care provider who is available to accept such individual. 
‘‘(b) ACCESS TO PEDIATRIC CARE.— 
‘‘(1) PEDIATRIC CARE.—In the case of a person who has 
a child who is a participant, beneficiary, or enrollee under 
a group health plan, or group or individual health insurance 
coverage offered by a health insurance issuer, if the plan or 
issuer requires or provides for the designation of a participating 
primary care provider for the child, the plan or issuer shall 
permit such person to designate a physician (allopathic or osteo-
pathic) who specializes in pediatrics as the child’s primary 
care provider if such provider participates in the network of 
the plan or issuer.
H. R. 133—1590 
‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) shall be 
construed to waive any exclusions of coverage under the terms 
and conditions of the plan or health insurance coverage with 
respect to coverage of pediatric care. 
‘‘(c) PATIENT ACCESS
TO OBSTETRICAL
AND GYNECOLOGICAL 
CARE.— 
‘‘(1) GENERAL RIGHTS.— 
‘‘(A) DIRECT ACCESS.—A group health plan, or health 
insurance issuer offering group or individual health insur-
ance coverage, described in paragraph (2) may not require 
authorization or referral by the plan, issuer, or any person 
(including a primary care provider described in paragraph 
(2)(B)) in the case of a female participant, beneficiary, 
or enrollee who seeks coverage for obstetrical or gyneco-
logical care provided by a participating health care profes-
sional who specializes in obstetrics or gynecology. Such 
professional shall agree to otherwise adhere to such plan’s 
or issuer’s policies and procedures, including procedures 
regarding referrals and obtaining prior authorization and 
providing services pursuant to a treatment plan (if any) 
approved by the plan or issuer. 
‘‘(B) OBSTETRICAL AND GYNECOLOGICAL CARE.—A group 
health plan or health insurance issuer described in para-
graph (2) shall treat the provision of obstetrical and gyneco-
logical care, and the ordering of related obstetrical and 
gynecological items and services, pursuant to the direct 
access described under subparagraph (A), by a participating 
health care professional who specializes in obstetrics or 
gynecology as the authorization of the primary care pro-
vider. 
‘‘(2) APPLICATION
OF
PARAGRAPH.—A group health plan, 
or health insurance issuer offering group or individual health 
insurance coverage, described in this paragraph is a group 
health plan or health insurance coverage that— 
‘‘(A) provides coverage for obstetric or gynecologic care; 
and 
‘‘(B) requires the designation by a participant, bene-
ficiary, or enrollee of a participating primary care provider. 
‘‘(3) CONSTRUCTION.—Nothing in paragraph (1) shall be 
construed to— 
‘‘(A) waive any exclusions of coverage under the terms 
and conditions of the plan or health insurance coverage 
with respect to coverage of obstetrical or gynecological care; 
or 
‘‘(B) preclude the group health plan or health insurance 
issuer involved from requiring that the obstetrical or 
gynecological provider notify the primary care health care 
professional or the plan or issuer of treatment decisions.’’. 
(3) CONFORMING AMENDMENTS.— 
(A) Section 2719A of the Public Health Service Act 
(42 U.S.C. 300gg–19a) is amended by adding at the end 
the following new subsection: 
‘‘(e) APPLICATION.—The provisions of this section shall not apply 
with respect to a group health plan, health insurance issuers, 
or group or individual health insurance coverage with respect to 
plan years beginning on or on January 1, 2022.’’.
H. R. 133—1591 
(B) Section 2722 of the Public Health Service Act (42 
U.S.C. 300gg–21) is amended— 
(i) in subsection (a)(1), by inserting ‘‘and part D’’ 
after ‘‘subparts 1 and 2’’; 
(ii) in subsection (b), by inserting ‘‘and part D’’ 
after ‘‘subparts 1 and 2’’; 
(iii) in subsection (c)(1), by inserting ‘‘and part 
D’’ after ‘‘subparts 1 and 2’’; 
(iv) in subsection (c)(2), by inserting ‘‘and part 
D’’ after ‘‘subparts 1 and 2’’; 
(v) in subsection (c)(3), by inserting ‘‘and part D’’ 
after ‘‘this part’’; and 
(vi) in subsection (d), in the matter preceding para-
graph (1), by inserting ‘‘and part D’’ after ‘‘this part’’. 
(C) Section 2723 of the Public Health Service Act (42 
U.S.C. 300gg–22) is amended— 
(i) in subsection (a)(1), by inserting ‘‘and part D’’ 
after ‘‘this part’’; 
(ii) in subsection (a)(2), by inserting ‘‘or part D’’ 
after ‘‘this part’’; 
(iii) in subsection (b)(1), by inserting ‘‘or part D’’ 
after ‘‘this part’’; 
(iv) in subsection (b)(2)(A), by inserting ‘‘or part 
D’’ after ‘‘this part’’; and 
(v) in subsection (b)(2)(C)(ii), by inserting ‘‘and part 
D’’ after ‘‘this part’’. 
(D) Section 2724 of the Public Health Service Act (42 
U.S.C. 300gg–23) is amended— 
(i) in subsection (a)(1)— 
(I) by striking ‘‘this part and part C insofar 
as it relates to this part’’ and inserting ‘‘this part, 
part D, and part C insofar as it relates to this 
part or part D’’; and 
(II) by inserting ‘‘or part D’’ after ‘‘requirement 
of this part’’; 
(ii) in subsection (a)(2), by inserting ‘‘or part D’’ 
after ‘‘this part’’; and 
(iii) in subsection (c), by inserting ‘‘or part D’’ 
after ‘‘this part (other than section 2704)’’. 
(b) ERISA AMENDMENTS.— 
(1) IN GENERAL.—Subpart B of part 7 of title I of the 
Employee Retirement Income Security Act of 1974 (29 U.S.C. 
1185 et seq.) is amended by adding at the end the following: 
‘‘SEC. 716. PREVENTING SURPRISE MEDICAL BILLS. 
‘‘(a) COVERAGE OF EMERGENCY SERVICES.— 
‘‘(1) IN GENERAL.—If a group health plan, or a health insur-
ance issuer offering group health insurance coverage, provides 
or covers any benefits with respect to services in an emergency 
department of a hospital or with respect to emergency services 
in an independent freestanding emergency department (as 
defined in paragraph (3)(D)), the plan or issuer shall cover 
emergency services (as defined in paragraph (3)(C))— 
‘‘(A) without the need for any prior authorization deter-
mination;
H. R. 133—1593 
‘‘(2) REGULATIONS FOR QUALIFYING PAYMENT AMOUNTS.— 
Not later than July 1, 2021, the Secretary, in consultation 
with the Secretary of the Treasury and the Secretary of Health 
and Human Services, shall establish through rulemaking— 
‘‘(A) the methodology the group health plan or health 
insurance issuer offering health insurance coverage in the 
group market shall use to determine the qualifying pay-
ment amount, differentiating by large group market, and 
small group market; 
‘‘(B) the information such plan or issuer, respectively, 
shall share with the nonparticipating provider or non-
participating facility, as applicable, when making such a 
determination; 
‘‘(C) the geographic regions applied for purposes of 
this subparagraph, taking into account access to items 
and services in rural and underserved areas, including 
health professional shortage areas, as defined in section 
332 of the Public Health Service Act; and 
‘‘(D) a process to receive complaints of violations of 
the requirements described in subclauses (I) and (II) of 
subparagraph (A)(i) by group health plans and health insur-
ance issuers offering health insurance coverage in the group 
market. 
Such rulemaking shall take into account payments that are 
made by such plan or issuer, respectively, that are not on 
a fee-for-service basis. Such methodology may account for rel-
evant payment adjustments that take into account quality or 
facility type (including higher acuity settings and the case- 
mix of various facility types) that are otherwise taken into 
account for purposes of determining payment amounts with 
respect to participating facilities. In carrying out clause (iii), 
the Secretary shall consult with the National Association of 
Insurance Commissioners to establish the geographic regions 
under such clause and shall periodically update such regions, 
as appropriate, taking into account the findings of the report 
submitted under section 109(a) of the No Surprises Act. 
‘‘(3) DEFINITIONS.—In this subpart: 
‘‘(A) EMERGENCY
DEPARTMENT
OF
A
HOSPITAL.—The 
term ‘emergency department of a hospital’ includes a hos-
pital outpatient department that provides emergency serv-
ices (as defined in subparagraph (C)(i)). 
‘‘(B) EMERGENCY
MEDICAL
CONDITION.—The term 
‘emergency medical condition’ means a medical condition 
manifesting itself by acute symptoms of sufficient severity 
(including severe pain) such that a prudent layperson, who 
possesses an average knowledge of health and medicine, 
could reasonably expect the absence of immediate medical 
attention to result in a condition described in clause (i), 
(ii), or (iii) of section 1867(e)(1)(A) of the Social Security 
Act. 
‘‘(C) EMERGENCY SERVICES.— 
‘‘(i) IN GENERAL.—The term ‘emergency services’, 
with respect to an emergency medical condition, 
means— 
‘‘(I) a medical screening examination (as 
required under section 1867 of the Social Security 
Act, or as would be required under such section
H. R. 133—1594 
if such section applied to an independent free-
standing emergency department) that is within 
the capability of the emergency department of a 
hospital or of an independent freestanding emer-
gency 
department, 
as 
applicable, 
including 
ancillary services routinely available to the emer-
gency department to evaluate such emergency 
medical condition; and 
‘‘(II) within the capabilities of the staff and 
facilities available at the hospital or the inde-
pendent freestanding emergency department, as 
applicable, such further medical examination and 
treatment as are required under section 1867 of 
such Act, or as would be required under such 
section if such section applied to an independent 
freestanding emergency department, to stabilize 
the patient (regardless of the department of the 
hospital in which such further examination or 
treatment is furnished). 
‘‘(ii) INCLUSION OF ADDITIONAL SERVICES.— 
‘‘(I) IN GENERAL.—For purposes of this sub-
section and section 2799B–1 of the Public Health 
Service Act, in the case of a participant or bene-
ficiary who is enrolled in a group health plan 
or group health insurance coverage offered by a 
health insurance issuer and who is furnished serv-
ices described in clause (i) with respect to an emer-
gency medical condition, the term ‘emergency serv-
ices’ shall include, unless each of the conditions 
described in subclause (II) are met, in addition 
to the items and services described in clause (i), 
items and services— 
‘‘(aa) for which benefits are provided or 
covered under the plan or coverage, respec-
tively; and 
‘‘(bb) that are furnished by a nonpartici-
pating provider or nonparticipating emergency 
facility (regardless of the department of the 
hospital in which such items or services are 
furnished) after the participant or beneficiary 
is stabilized and as part of outpatient observa-
tion or an inpatient or outpatient stay with 
respect to the visit in which the services 
described in clause (i) are furnished. 
‘‘(II) CONDITIONS.—For purposes of subclause 
(I), the conditions described in this subclause, with 
respect to a participant or beneficiary who is sta-
bilized and furnished additional items and services 
described in subclause (I) after such stabilization 
by a provider or facility described in subclause 
(I), are the following; 
‘‘(aa) Such provider or facility determines 
such individual is able to travel using nonmed-
ical transportation or nonemergency medical 
transportation. 
‘‘(bb) Such provider furnishing such addi-
tional items and services satisfies the notice
H. R. 133—1595 
and consent criteria of section 2799B–2(d) with 
respect to such items and services. 
‘‘(cc) Such individual is in a condition to 
receive (as determined in accordance with 
guidelines issued by the Secretary pursuant 
to rulemaking) the information described in 
section 2799B–2 and to provide informed con-
sent under such section, in accordance with 
applicable State law. 
‘‘(dd) Such other conditions, as specified 
by the Secretary, such as conditions relating 
to coordinating care transitions to partici-
pating providers and facilities. 
‘‘(D) INDEPENDENT FREESTANDING EMERGENCY DEPART-
MENT.—The term ‘independent freestanding emergency 
department’ means a health care facility that— 
‘‘(i) is geographically separate and distinct and 
licensed separately from a hospital under applicable 
State law; and 
‘‘(ii) provides any of the emergency services (as 
defined in subparagraph (C)(i)). 
‘‘(E) QUALIFYING PAYMENT AMOUNT.— 
‘‘(i) IN GENERAL.—The term ‘qualifying payment 
amount’ means, subject to clauses (ii) and (iii), with 
respect to a sponsor of a group health plan and health 
insurance issuer offering group health insurance cov-
erage— 
‘‘(I) for an item or service furnished during 
2022, the median of the contracted rates recog-
nized by the plan or issuer, respectively (deter-
mined with respect to all such plans of such 
sponsor or all such coverage offered by such issuer 
that are offered within the same insurance market 
(specified in subclause (I), (II), or (III) of clause 
(iv)) as the plan or coverage) as the total maximum 
payment 
(including 
the 
cost-sharing 
amount 
imposed for such item or service and the amount 
to be paid by the plan or issuer, respectively) under 
such plans or coverage, respectively, on January 
31, 2019, for the same or a similar item or service 
that is provided by a provider in the same or 
similar specialty and provided in the geographic 
region in which the item or service is furnished, 
consistent with the methodology established by the 
Secretary under paragraph (2), increased by the 
percentage increase in the consumer price index 
for all urban consumers (United States city aver-
age) over 2019, such percentage increase over 
2020, and such percentage increase over 2021; and 
‘‘(II) for an item or service furnished during 
2023 or a subsequent year, the qualifying payment 
amount determined under this clause for such an 
item or service furnished in the previous year, 
increased by the percentage increase in the con-
sumer price index for all urban consumers (United 
States city average) over such previous year.
H. R. 133—1596 
‘‘(ii) NEW PLANS AND COVERAGE.—The term ‘quali-
fying payment amount’ means, with respect to a 
sponsor of a group health plan or health insurance 
issuer offering group health insurance coverage in a 
geographic region in which such sponsor or issuer, 
respectively, did not offer any group health plan or 
health insurance coverage during 2019— 
‘‘(I) for the first year in which such group 
health plan or health insurance coverage, respec-
tively, is offered in such region, a rate (determined 
in accordance with a methodology established by 
the Secretary) for items and services that are cov-
ered by such plan and furnished during such first 
year; and 
‘‘(II) for each subsequent year such group 
health plan or health insurance coverage, respec-
tively, is offered in such region, the qualifying 
payment amount determined under this clause for 
such items and services furnished in the previous 
year, increased by the percentage increase in the 
consumer price index for all urban consumers 
(United States city average) over such previous 
year. 
‘‘(iii) INSUFFICIENT INFORMATION; NEWLY COVERED 
ITEMS AND SERVICES.—In the case of a sponsor of a 
group health plan or health insurance issuer offering 
group health insurance coverage that does not have 
sufficient information to calculate the median of the 
contracted rates described in clause (i)(I) in 2019 (or, 
in the case of a newly covered item or service (as 
defined in clause (v)(III)), in the first coverage year 
(as defined in clause (v)(I)) for such item or service 
with respect to such plan or coverage) for an item 
or service (including with respect to provider type, 
or amount, of claims for items or services (as deter-
mined by the Secretary) provided in a particular 
geographic region (other than in a case with respect 
to which clause (ii) applies)) the term ‘qualifying pay-
ment amount’— 
‘‘(I) for an item or service furnished during 
2022 (or, in the case of a newly covered item 
or service, during the first coverage year for such 
item or service with respect to such plan or cov-
erage), means such rate for such item or service 
determined by the sponsor or issuer, respectively, 
through use of any database that is determined, 
in accordance with rulemaking described in para-
graph (2), to not have any conflicts of interest 
and to have sufficient information reflecting 
allowed amounts paid to a health care provider 
or facility for relevant services furnished in the 
applicable geographic region (such as a State all- 
payer claims database); 
‘‘(II) for an item or service furnished in a sub-
sequent year (before the first sufficient information 
year (as defined in clause (v)(II)) for such item 
or service with respect to such plan or coverage),
H. R. 133—1597 
means the rate determined under subclause (I) 
or this subclause, as applicable, for such item or 
service for the year previous to such subsequent 
year, increased by the percentage increase in the 
consumer price index for all urban consumers 
(United States city average) over such previous 
year; 
‘‘(III) for an item or service furnished in the 
first sufficient information year for such item or 
service with respect to such plan or coverage, has 
the meaning given the term qualifying payment 
amount in clause (i)(I), except that in applying 
such clause to such item or service, the reference 
to ‘furnished during 2022’ shall be treated as a 
reference to furnished during such first sufficient 
information year, the reference to ‘in 2019’ shall 
be treated as a reference to such sufficient informa-
tion year, and the increase described in such clause 
shall not be applied; and 
‘‘(IV) for an item or service furnished in any 
year subsequent to the first sufficient information 
year for such item or service with respect to such 
plan or coverage, has the meaning given such term 
in clause (i)(II), except that in applying such clause 
to such item or service, the reference to ‘furnished 
during 2023 or a subsequent year’ shall be treated 
as a reference to furnished during the year after 
such first sufficient information year or a subse-
quent year. 
‘‘(iv) INSURANCE MARKET.—For purposes of clause 
(i)(I), a health insurance market specified in this clause 
is one of the following: 
‘‘(I) The large group market (other than plans 
described in subclause (III)). 
‘‘(II) The small group market (other than plans 
described in subclause (III)). 
‘‘(III) In the case of a self-insured group health 
plan, other self-insured group health plans. 
‘‘(v) DEFINITIONS.—For purposes of this subpara-
graph: 
‘‘(I) FIRST
COVERAGE
YEAR.—The term ‘first 
coverage year’ means, with respect to a group 
health plan or group health insurance coverage 
offered by a health insurance issuer and an item 
or service for which coverage is not offered in 
2019 under such plan or coverage, the first year 
after 2019 for which coverage for such item or 
service is offered under such plan or health insur-
ance coverage. 
‘‘(II) FIRST SUFFICIENT INFORMATION YEAR.— 
The term ‘first sufficient information year’ means, 
with respect to a group health plan or group health 
insurance coverage offered by a health insurance 
issuer— 
‘‘(aa) in the case of an item or service 
for which the plan or coverage does not have 
sufficient information to calculate the median
H. R. 133—1600 
in a State during a year to a participant or beneficiary 
of a group health plan or group health insurance coverage 
offered by a health insurance issuer receiving such item 
or service from a nonparticipating provider or nonpartici-
pating emergency facility— 
‘‘(i) subject to clause (iii), in the case of such item 
or service furnished in a State that has in effect a 
specified State law with respect to such plan, coverage, 
or issuer, respectively; such a nonparticipating provider 
or nonparticipating emergency facility; and such an 
item or service, the amount determined in accordance 
with such law; 
‘‘(ii) subject to clause (iii), in the case such State 
does not have in effect such a law with respect to 
such item or service, plan, and provider or facility— 
‘‘(I) subject to subclause (II), if the provider 
or facility (as applicable) and such plan or coverage 
agree on an amount of payment (including if such 
agreed on amount is the initial payment sent by 
the plan under subsection (a)(1)(C)(iv)(I), sub-
section 
(b)(1)(C), 
or 
section 
717(a)(3)(A), 
as 
applicable, or is agreed on through open negotia-
tions under subsection (c)(1)) with respect to such 
item or service, such agreed on amount; or 
‘‘(II) if such provider or facility (as applicable) 
and such plan or coverage enter the independent 
dispute resolution process under subsection (c) and 
do not so agree before the date on which a certified 
IDR entity (as defined in paragraph (4) of such 
subsection) makes a determination with respect 
to such item or service under such subsection, 
the amount of such determination; or 
‘‘(iii) in the case such State has an All-Payer Model 
Agreement under section 1115A of the Social Security 
Act, the amount that the State approves under such 
system for such item or service so furnished. 
‘‘(L) COST-SHARING.—The term ‘cost-sharing’ includes 
copayments, coinsurance, and deductibles. 
‘‘(b) COVERAGE OF NON-EMERGENCY SERVICES PERFORMED BY 
NONPARTICIPATING PROVIDERS AT CERTAIN PARTICIPATING FACILI-
TIES.— 
‘‘(1) IN GENERAL.—In the case of items or services (other 
than emergency services to which subsection (a) applies) for 
which any benefits are provided or covered by a group health 
plan or health insurance issuer offering group health insurance 
coverage furnished to a participant or beneficiary of such plan 
or coverage by a nonparticipating provider (as defined in sub-
section (a)(3)(G)(i)) (and who, with respect to such items and 
services, has not satisfied the notice and consent criteria of 
section 2799B–2(d) of the Public Health Service Act) with 
respect to a visit (as defined by the Secretary in accordance 
with paragraph (2)(B)) at a participating health care facility 
(as defined in paragraph (2)(A)), with respect to such plan 
or coverage, respectively, the plan or coverage, respectively— 
‘‘(A) shall not impose on such participant or beneficiary 
a cost-sharing requirement for such items and services
H. R. 133—1601 
so furnished that is greater than the cost-sharing require-
ment that would apply under such plan or coverage, respec-
tively, had such items or services been furnished by a 
participating 
provider 
(as 
defined 
in 
subsection 
(a)(3)(G)(ii)); 
‘‘(B) shall calculate such cost-sharing requirement as 
if the total amount that would have been charged for 
such items and services by such participating provider 
were equal to the recognized amount (as defined in sub-
section (a)(3)(H)) for such items and services, plan or cov-
erage, and year; 
‘‘(C) not later than 30 calendar days after the bill 
for such items or services is transmitted by such provider, 
shall send to the provider an initial payment or notice 
of denial of payment; 
‘‘(D) shall pay a total plan or coverage payment 
directly, in accordance, if applicable, with the timing 
requirement described in subsection (c)(6), to such provider 
furnishing such items and services to such participant or 
beneficiary that is, with application of any initial payment 
under subparagraph (C), equal to the amount by which 
the out-of-network rate (as defined in subsection (a)(3)(K)) 
for such items and services exceeds the cost-sharing amount 
imposed under the plan or coverage, respectively, for such 
items and services (as determined in accordance with sub-
paragraphs (A) and (B)) and year; and 
‘‘(E) shall count toward any in-network deductible and 
in-network out-of-pocket maximums (as applicable) applied 
under the plan or coverage, respectively, any cost-sharing 
payments made by the participant or beneficiary (and such 
in-network deductible and out-of-pocket maximums shall 
be applied) with respect to such items and services so 
furnished in the same manner as if such cost-sharing pay-
ments were with respect to items and services furnished 
by a participating provider. 
‘‘(2) DEFINITIONS.—In this section: 
‘‘(A) PARTICIPATING HEALTH CARE FACILITY.— 
‘‘(i) IN GENERAL.—The term ‘participating health 
care facility’ means, with respect to an item or service 
and a group health plan or health insurance issuer 
offering group health insurance coverage, a health care 
facility described in clause (ii) that has a direct or 
indirect contractual relationship with the plan or 
issuer, respectively, with respect to the furnishing of 
such an item or service at the facility. 
‘‘(ii) HEALTH CARE FACILITY DESCRIBED.—A health 
care facility described in this clause, with respect to 
a group health plan or group health insurance cov-
erage, is each of the following: 
‘‘(I) A hospital (as defined in 1861(e) of the 
Social Security Act). 
‘‘(II) A hospital outpatient department. 
‘‘(III) A critical access hospital (as defined in 
section 1861(mm)(1) of such Act). 
‘‘(IV) An ambulatory surgical center described 
in section 1833(i)(1)(A) of such Act.
H. R. 133—1602 
‘‘(V) Any other facility, specified by the Sec-
retary, that provides items or services for which 
coverage is provided under the plan or coverage, 
respectively. 
‘‘(B) VISIT.—The term ‘visit’ shall, with respect to items 
and services furnished to an individual at a health care 
facility, include equipment and devices, telemedicine serv-
ices, imaging services, laboratory services, preoperative and 
postoperative services, and such other items and services 
as the Secretary may specify, regardless of whether or 
not the provider furnishing such items or services is at 
the facility. 
‘‘(c) CERTAIN ACCESS FEES
TO CERTAIN DATABASES.—In the 
case of a sponsor of a group health plan or health insurance issuer 
offering group health insurance coverage that, pursuant to sub-
section (a)(3)(E)(iii), uses a database described in such subsection 
to determine a rate to apply under such subsection for an item 
or service by reason of having insufficient information described 
in such subsection with respect to such item or service, such sponsor 
or issuer shall cover the cost for access to such database.’’. 
(2) TRANSFER AMENDMENT.—Subpart B of part 7 of title 
I of the Employee Retirement Income Security Act of 1974 
(29 U.S.C. 1185 et seq.), as amended by paragraph (1), is 
further amended by adding at the end the following: 
‘‘SEC. 722. OTHER PATIENT PROTECTIONS. 
‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If a group health 
plan, or a health insurance issuer offering group health insurance 
coverage, requires or provides for designation by a participant or 
beneficiary of a participating primary care provider, then the plan 
or issuer shall permit each participant and beneficiary to designate 
any participating primary care provider who is available to accept 
such individual. 
‘‘(b) ACCESS TO PEDIATRIC CARE.— 
‘‘(1) PEDIATRIC CARE.—In the case of a person who has 
a child who is a participant or beneficiary under a group 
health plan, or group health insurance coverage offered by 
a health insurance issuer, if the plan or issuer requires or 
provides for the designation of a participating primary care 
provider for the child, the plan or issuer shall permit such 
person to designate a physician (allopathic or osteopathic) who 
specializes in pediatrics as the child’s primary care provider 
if such provider participates in the network of the plan or 
issuer. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) shall be 
construed to waive any exclusions of coverage under the terms 
and conditions of the plan or health insurance coverage with 
respect to coverage of pediatric care. 
‘‘(c) PATIENT ACCESS
TO OBSTETRICAL
AND GYNECOLOGICAL 
CARE.— 
‘‘(1) GENERAL RIGHTS.— 
‘‘(A) DIRECT ACCESS.—A group health plan, or health 
insurance issuer offering group health insurance coverage, 
described in paragraph (2) may not require authorization 
or referral by the plan, issuer, or any person (including 
a primary care provider described in paragraph (2)(B)) 
in the case of a female participant or beneficiary who
H. R. 133—1603 
seeks coverage for obstetrical or gynecological care provided 
by a participating health care professional who specializes 
in obstetrics or gynecology. Such professional shall agree 
to otherwise adhere to such plan’s or issuer’s policies and 
procedures, including procedures regarding referrals and 
obtaining prior authorization and providing services pursu-
ant to a treatment plan (if any) approved by the plan 
or issuer. 
‘‘(B) OBSTETRICAL AND GYNECOLOGICAL CARE.—A group 
health plan or health insurance issuer described in para-
graph (2) shall treat the provision of obstetrical and gyneco-
logical care, and the ordering of related obstetrical and 
gynecological items and services, pursuant to the direct 
access described under subparagraph (A), by a participating 
health care professional who specializes in obstetrics or 
gynecology as the authorization of the primary care pro-
vider. 
‘‘(2) APPLICATION
OF
PARAGRAPH.—A group health plan, 
or health insurance issuer offering group health insurance cov-
erage, described in this paragraph is a group health plan or 
coverage that— 
‘‘(A) provides coverage for obstetric or gynecologic care; 
and 
‘‘(B) requires the designation by a participant or bene-
ficiary of a participating primary care provider. 
‘‘(3) CONSTRUCTION.—Nothing in paragraph (1) shall be 
construed to— 
‘‘(A) waive any exclusions of coverage under the terms 
and conditions of the plan or health insurance coverage 
with respect to coverage of obstetrical or gynecological care; 
or 
‘‘(B) preclude the group health plan or health insurance 
issuer involved from requiring that the obstetrical or 
gynecological provider notify the primary care health care 
professional or the plan or issuer of treatment decisions.’’. 
(3) CLERICAL AMENDMENT.—The table of contents of the 
Employee Retirement Income Security Act of 1974 is amended 
by inserting after the item relating to section 714 the following: 
‘‘Sec. 715. Additional market reforms. 
‘‘Sec. 716. Preventing surprise medical bills. 
‘‘Sec. 722. Other patient protections.’’. 
(c) IRC AMENDMENTS.— 
(1) IN
GENERAL.—Subchapter B of chapter 100 of the 
Internal Revenue Code of 1986 is amended by adding at the 
end the following: 
‘‘SEC. 9816. PREVENTING SURPRISE MEDICAL BILLS. 
‘‘(a) COVERAGE OF EMERGENCY SERVICES.— 
‘‘(1) IN GENERAL.—If a group health plan provides or covers 
any benefits with respect to services in an emergency depart-
ment of a hospital or with respect to emergency services in 
an independent freestanding emergency department (as defined 
in paragraph (3)(D)), the plan shall cover emergency services 
(as defined in paragraph (3)(C))— 
‘‘(A) without the need for any prior authorization deter-
mination;
H. R. 133—1604 
‘‘(B) whether the health care provider furnishing such 
services is a participating provider or a participating emer-
gency facility, as applicable, with respect to such services; 
‘‘(C) in a manner so that, if such services are provided 
to a participant or beneficiary by a nonparticipating pro-
vider or a nonparticipating emergency facility— 
‘‘(i) such services will be provided without imposing 
any requirement under the plan for prior authorization 
of services or any limitation on coverage that is more 
restrictive than the requirements or limitations that 
apply to emergency services received from participating 
providers and participating emergency facilities with 
respect to such plan; 
‘‘(ii) the cost-sharing requirement is not greater 
than the requirement that would apply if such services 
were provided by a participating provider or a partici-
pating emergency facility; 
‘‘(iii) such cost-sharing requirement is calculated 
as if the total amount that would have been charged 
for such services by such participating provider or 
participating emergency facility were equal to the rec-
ognized amount (as defined in paragraph (3)(H)) for 
such services, plan, and year; 
‘‘(iv) the group health plan— 
‘‘(I) not later than 30 calendar days after the 
bill for such services is transmitted by such pro-
vider or facility, sends to the provider or facility, 
as applicable, an initial payment or notice of denial 
of payment; and 
‘‘(II) pays a total plan payment directly to 
such provider or facility, respectively (in accord-
ance, if applicable, with the timing requirement 
described in subsection (c)(6)) that is, with applica-
tion of any initial payment under subclause (I), 
equal to the amount by which the out-of-network 
rate (as defined in paragraph (3)(K)) for such serv-
ices exceeds the cost-sharing amount for such serv-
ices (as determined in accordance with clauses (ii) 
and (iii)) and year; and 
‘‘(iv) any cost-sharing payments made by the 
participant or beneficiary with respect to such emer-
gency services so furnished shall be counted toward 
any in-network deductible or out-of-pocket maximums 
applied under the plan (and such in-network deductible 
and out-of-pocket maximums shall be applied) in the 
same manner as if such cost-sharing payments were 
made with respect to emergency services furnished 
by a participating provider or a participating emer-
gency facility; and 
‘‘(D) without regard to any other term or condition 
of such coverage (other than exclusion or coordination of 
benefits, or an affiliation or waiting period, permitted under 
section 2704 of the Public Health Service Act, including 
as incorporated pursuant to section 715 of the Employee 
Retirement Income Security Act of 1974 and section 9815 
of this Act, and other than applicable cost-sharing).
H. R. 133—1606 
Such rulemaking shall take into account payments that 
are made by such plan that are not on a fee-for-service 
basis. Such methodology may account for relevant payment 
adjustments that take into account quality or facility type 
(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. In carrying out clause (iii), the 
Secretary shall consult with the National Association of 
Insurance Commissioners to establish the geographic 
regions under such clause and shall periodically update 
such regions, as appropriate, taking into account the 
findings of the report submitted under section 109(a) of 
the No Surprises Act. 
‘‘(3) DEFINITIONS.—In this subchapter: 
‘‘(A) EMERGENCY
DEPARTMENT
OF
A
HOSPITAL.—The 
term ‘emergency department of a hospital’ includes a hos-
pital outpatient department that provides emergency serv-
ices (as defined in subparagraph (C)(i)). 
‘‘(B) EMERGENCY
MEDICAL
CONDITION.—The term 
‘emergency medical condition’ means a medical condition 
manifesting itself by acute symptoms of sufficient severity 
(including severe pain) such that a prudent layperson, who 
possesses an average knowledge of health and medicine, 
could reasonably expect the absence of immediate medical 
attention to result in a condition described in clause (i), 
(ii), or (iii) of section 1867(e)(1)(A) of the Social Security 
Act. 
‘‘(C) EMERGENCY SERVICES.— 
‘‘(i) IN GENERAL.—The term ‘emergency services’, 
with respect to an emergency medical condition, 
means— 
‘‘(I) a medical screening examination (as 
required under section 1867 of the Social Security 
Act, or as would be required under such section 
if such section applied to an independent free-
standing emergency department) that is within 
the capability of the emergency department of a 
hospital or of an independent freestanding emer-
gency 
department, 
as 
applicable, 
including 
ancillary services routinely available to the emer-
gency department to evaluate such emergency 
medical condition; and 
‘‘(II) within the capabilities of the staff and 
facilities available at the hospital or the inde-
pendent freestanding emergency department, as 
applicable, such further medical examination and 
treatment as are required under section 1867 of 
such Act, or as would be required under such 
section if such section applied to an independent 
freestanding emergency department, to stabilize 
the patient (regardless of the department of the 
hospital in which such further examination or 
treatment is furnished). 
‘‘(ii) INCLUSION OF ADDITIONAL SERVICES.— 
‘‘(I) IN GENERAL.—For purposes of this sub-
section and section 2799B–1 of the Public Health
H. R. 133—1607 
Service Act, in the case of a participant or bene-
ficiary who is enrolled in a group health plan 
and who is furnished services described in clause 
(i) with respect to an emergency medical condition, 
the term ‘emergency services’ shall include, unless 
each of the conditions described in subclause (II) 
are met, in addition to the items and services 
described in clause (i), items and services— 
‘‘(aa) for which benefits are provided or 
covered under the plan; and 
‘‘(bb) that are furnished by a nonpartici-
pating provider or nonparticipating emergency 
facility (regardless of the department of the 
hospital in which such items or services are 
furnished) after the participant or beneficiary 
is stabilized and as part of outpatient observa-
tion or an inpatient or outpatient stay with 
respect to the visit in which the services 
described in clause (i) are furnished. 
‘‘(II) CONDITIONS.—For purposes of subclause 
(I), the conditions described in this subclause, with 
respect to a participant or beneficiary who is sta-
bilized and furnished additional items and services 
described in subclause (I) after such stabilization 
by a provider or facility described in subclause 
(I), are the following; 
‘‘(aa) Such provider or facility determines 
such individual is able to travel using nonmed-
ical transportation or nonemergency medical 
transportation. 
‘‘(bb) Such provider furnishing such addi-
tional items and services satisfies the notice 
and consent criteria of section 2799B–2(d) with 
respect to such items and services. 
‘‘(cc) Such individual is in a condition to 
receive (as determined in accordance with 
guidelines issued by the Secretary pursuant 
to rulemaking) the information described in 
section 2799B–2 and to provide informed con-
sent under such section, in accordance with 
applicable State law. 
‘‘(dd) Such other conditions, as specified 
by the Secretary, such as conditions relating 
to coordinating care transitions to partici-
pating providers and facilities. 
‘‘(D) INDEPENDENT FREESTANDING EMERGENCY DEPART-
MENT.—The term ‘independent freestanding emergency 
department’ means a health care facility that— 
‘‘(i) is geographically separate and distinct and 
licensed separately from a hospital under applicable 
State law; and 
‘‘(ii) provides any of the emergency services (as 
defined in subparagraph (C)(i)). 
‘‘(E) QUALIFYING PAYMENT AMOUNT.— 
‘‘(i) IN GENERAL.—The term ‘qualifying payment 
amount’ means, subject to clauses (ii) and (iii), with 
respect to a sponsor of a group health plan—
H. R. 133—1608 
‘‘(I) for an item or service furnished during 
2022, the median of the contracted rates recog-
nized by the plan (determined with respect to all 
such plans of such sponsor that are offered within 
the same insurance market (specified in subclause 
(I), (II), or (III) of clause (iv)) as the plan) as 
the total maximum payment (including the cost- 
sharing amount imposed for such item or service 
and the amount to be paid by the plan) under 
such plans on January 31, 2019 for the same or 
a similar item or service that is provided by a 
provider in the same or similar specialty and pro-
vided in the geographic region in which the item 
or service is furnished, consistent with the method-
ology established by the Secretary under para-
graph (2)(B), increased by the percentage increase 
in the consumer price index for all urban con-
sumers (United States city average) over 2019, 
such percentage increase over 2020, and such 
percentage increase over 2021; and 
‘‘(II) for an item or service furnished during 
2023 or a subsequent year, the qualifying payment 
amount determined under this clause for such an 
item or service furnished in the previous year, 
increased by the percentage increase in the con-
sumer price index for all urban consumers (United 
States city average) over such previous year. 
‘‘(ii) NEW PLANS AND COVERAGE.—The term ‘quali-
fying payment amount’ means, with respect to a 
sponsor of a group health plan in a geographic region 
in which such sponsor, respectively, did not offer any 
group health plan or health insurance coverage during 
2019— 
‘‘(I) for the first year in which such group 
health plan is offered in such region, a rate (deter-
mined in accordance with a methodology estab-
lished by the Secretary) for items and services 
that are covered by such plan and furnished during 
such first year; and 
‘‘(II) for each subsequent year such group 
health plan is offered in such region, the qualifying 
payment amount determined under this clause for 
such items and services furnished in the previous 
year, increased by the percentage increase in the 
consumer price index for all urban consumers 
(United States city average) over such previous 
year. 
‘‘(iii) INSUFFICIENT INFORMATION; NEWLY COVERED 
ITEMS AND SERVICES.—In the case of a sponsor of a 
group health plan that does not have sufficient 
information to calculate the median of the contracted 
rates described in clause (i)(I) in 2019 (or, in the case 
of a newly covered item or service (as defined in clause 
(v)(III)), in the first coverage year (as defined in clause 
(v)(I)) for such item or service with respect to such 
plan) for an item or service (including with respect 
to provider type, or amount, of claims for items or
H. R. 133—1609 
services (as determined by the Secretary) provided in 
a particular geographic region (other than in a case 
with respect to which clause (ii) applies)) the term 
‘qualifying payment amount’— 
‘‘(I) for an item or service furnished during 
2022 (or, in the case of a newly covered item 
or service, during the first coverage year for such 
item or service with respect to such plan), means 
such rate for such item or service determined by 
the sponsor through use of any database that is 
determined, 
in 
accordance 
with 
rulemaking 
described in paragraph (2)(B), to not have any 
conflicts of interest and to have sufficient informa-
tion reflecting allowed amounts paid to a health 
care provider or facility for relevant services fur-
nished in the applicable geographic region (such 
as a State all-payer claims database); 
‘‘(II) for an item or service furnished in a sub-
sequent year (before the first sufficient information 
year (as defined in clause (v)(II)) for such item 
or service with respect to such plan), means the 
rate determined under subclause (I) or this sub-
clause, as applicable, for such item or service for 
the year previous to such subsequent year, 
increased by the percentage increase in the con-
sumer price index for all urban consumers (United 
States city average) over such previous year; 
‘‘(III) for an item or service furnished in the 
first sufficient information year for such item or 
service with respect to such plan, has the meaning 
given the term qualifying payment amount in 
clause (i)(I), except that in applying such clause 
to such item or service, the reference to ‘furnished 
during 2022’ shall be treated as a reference to 
furnished during such first sufficient information 
year, the reference to ‘on January 31, 2019’ shall 
be treated as a reference to in such sufficient 
information year, and the increase described in 
such clause shall not be applied; and 
‘‘(IV) for an item or service furnished in any 
year subsequent to the first sufficient information 
year for such item or service with respect to such 
plan, has the meaning given such term in clause 
(i)(II), except that in applying such clause to such 
item or service, the reference to ‘furnished during 
2023 or a subsequent year’ shall be treated as 
a reference to furnished during the year after such 
first sufficient information year or a subsequent 
year. 
‘‘(iv) INSURANCE MARKET.—For purposes of clause 
(i)(I), a health insurance market specified in this clause 
is one of the following: 
‘‘(I) The large group market (other than plans 
described in subclause (III)). 
‘‘(II) The small group market (other than plans 
described in subclause (III)).
H. R. 133—1610 
‘‘(III) In the case of a self-insured group health 
plan, other self-insured group health plans. 
‘‘(v) DEFINITIONS.—For purposes of this subpara-
graph: 
‘‘(I) FIRST
COVERAGE
YEAR.—The term ‘first 
coverage year’ means, with respect to a group 
health plan and an item or service for which cov-
erage is not offered in 2019 under such plan or 
coverage, the first year after 2019 for which cov-
erage for such item or service is offered under 
such plan. 
‘‘(II) FIRST SUFFICIENT INFORMATION YEAR.— 
The term ‘first sufficient information year’ means, 
with respect to a group health plan— 
‘‘(aa) in the case of an item or service 
for which the plan does not have sufficient 
information to calculate the median of the con-
tracted rates described in clause (i)(I) in 2019, 
the first year subsequent to 2022 for which 
such sponsor has such sufficient information 
to calculate the median of such contracted 
rates in the year previous to such first subse-
quent year; and 
‘‘(bb) in the case of a newly covered item 
or service, the first year subsequent to the 
first coverage year for such item or service 
with respect to such plan for which the sponsor 
has sufficient information to calculate the 
median of the contracted rates described in 
clause (i)(I) in the year previous to such first 
subsequent year. 
‘‘(III) NEWLY COVERED ITEM OR SERVICE.—The 
term ‘newly covered item or service’ means, with 
respect to a group health plan, an item or service 
for which coverage was not offered in 2019 under 
such plan or coverage, but is offered under such 
plan or coverage in a year after 2019. 
‘‘(F) NONPARTICIPATING EMERGENCY FACILITY; PARTICI-
PATING EMERGENCY FACILITY.— 
‘‘(i) NONPARTICIPATING EMERGENCY FACILITY.—The 
term ‘nonparticipating emergency facility’ means, with 
respect to an item or service and a group health plan, 
an emergency department of a hospital, or an inde-
pendent freestanding emergency department, that does 
not have a contractual relationship directly or 
indirectly with the plan for furnishing such item or 
service under the plan. 
‘‘(ii) PARTICIPATING
EMERGENCY
FACILITY.—The 
term ‘participating emergency facility’ means, with 
respect to an item or service and a group health plan, 
an emergency department of a hospital, or an inde-
pendent freestanding emergency department, that has 
a contractual relationship directly or indirectly with 
the plan, with respect to the furnishing of such an 
item or service at such facility. 
‘‘(G) NONPARTICIPATING PROVIDERS; PARTICIPATING PRO-
VIDERS.—
H. R. 133—1612 
‘‘(K) OUT-OF-NETWORK RATE.—The term ‘out-of-network 
rate’ means, with respect to an item or service furnished 
in a State during a year to a participant or beneficiary 
of a group health plan receiving such item or service from 
a nonparticipating provider or nonparticipating emergency 
facility— 
‘‘(i) subject to clause (iii), in the case of such item 
or service furnished in a State that has in effect a 
specified State law with respect to such plan; such 
a nonparticipating provider or nonparticipating emer-
gency facility; and such an item or service, the amount 
determined in accordance with such law; 
‘‘(ii) subject to clause (iii), in the case such State 
does not have in effect such a law with respect to 
such item or service, plan, and provider or facility— 
‘‘(I) subject to subclause (II), if the provider 
or facility (as applicable) and such plan or coverage 
agree on an amount of payment (including if such 
agreed on amount is the initial payment sent by 
the plan under subsection (a)(1)(C)(iv)(I), sub-
section (b)(1)(C), or section 9817(a)(3)(A), as 
applicable, or is agreed on through open negotia-
tions under subsection (c)(1)) with respect to such 
item or service, such agreed on amount; or 
‘‘(II) if such provider or facility (as applicable) 
and such plan or coverage enter the independent 
dispute resolution process under subsection (c) and 
do not so agree before the date on which a certified 
IDR entity (as defined in paragraph (4) of such 
subsection) makes a determination with respect 
to such item or service under such subsection, 
the amount of such determination; or 
‘‘(iii) in the case such State has an All-Payer Model 
Agreement under section 1115A of the Social Security 
Act, the amount that the State approves under such 
system for such item or service so furnished. 
‘‘(L) COST-SHARING.—The term ‘cost-sharing’ includes 
copayments, coinsurance, and deductibles. 
‘‘(b) COVERAGE OF NON-EMERGENCY SERVICES PERFORMED BY 
NONPARTICIPATING PROVIDERS AT CERTAIN PARTICIPATING FACILI-
TIES.— 
‘‘(1) IN GENERAL.—In the case of items or services (other 
than emergency services to which subsection (a) applies) for 
which any benefits are provided or covered by a group health 
plan furnished to a participant or beneficiary of such plan 
by a nonparticipating provider (as defined in subsection 
(a)(3)(G)(i)) (and who, with respect to such items and services, 
has not satisfied the notice and consent criteria of section 
2799B–2(d) of the Public Health Service Act) with respect to 
a visit (as defined by the Secretary in accordance with para-
graph (2)(B)) at a participating health care facility (as defined 
in paragraph (2)(A)), with respect to such plan, the plan— 
‘‘(A) shall not impose on such participant or beneficiary 
a cost-sharing requirement for such items and services 
so furnished that is greater than the cost-sharing require-
ment that would apply under such plan had such items
H. R. 133—1613 
or services been furnished by a participating provider (as 
defined in subsection (a)(3)(G)(ii)); 
‘‘(B) shall calculate such cost-sharing requirement as 
if the total amount that would have been charged for 
such items and services by such participating provider 
were equal to the recognized amount (as defined in sub-
section (a)(3)(H)) for such items and services, plan, and 
year; 
‘‘(C) not later than 30 calendar days after the bill 
for such items or services is transmitted by such provider, 
shall send to the provider an initial payment or notice 
of denial of payment; 
‘‘(D) shall pay a total plan payment directly, in accord-
ance, if applicable, with the timing requirement described 
in subsection (c)(6), to such provider furnishing such items 
and services to such participant or beneficiary that is, 
with application of any initial payment under subparagraph 
(C), equal to the amount by which the out-of-network rate 
(as defined in subsection (a)(3)(K)) for such items and serv-
ices exceeds the cost-sharing amount imposed under the 
plan for such items and services (as determined in accord-
ance with subparagraphs (A) and (B)) and year; and 
‘‘(E) shall count toward any in-network deductible and 
in-network out-of-pocket maximums (as applicable) applied 
under the plan, any cost-sharing payments made by the 
participant or beneficiary (and such in-network deductible 
and out-of-pocket maximums shall be applied) with respect 
to such items and services so furnished in the same manner 
as if such cost-sharing payments were with respect to items 
and services furnished by a participating provider. 
‘‘(2) DEFINITIONS.—In this section: 
‘‘(A) PARTICIPATING HEALTH CARE FACILITY.— 
‘‘(i) IN GENERAL.—The term ‘participating health 
care facility’ means, with respect to an item or service 
and a group health plan, a health care facility described 
in clause (ii) that has a direct or indirect contractual 
relationship with the plan, with respect to the fur-
nishing of such an item or service at the facility. 
‘‘(ii) HEALTH CARE FACILITY DESCRIBED.—A health 
care facility described in this clause, with respect to 
a group health plan or health insurance coverage 
offered in the group or individual market, is each of 
the following: 
‘‘(I) A hospital (as defined in 1861(e) of the 
Social Security Act). 
‘‘(II) A hospital outpatient department. 
‘‘(III) A critical access hospital (as defined in 
section 1861(mm)(1) of such Act). 
‘‘(IV) An ambulatory surgical center described 
in section 1833(i)(1)(A) of such Act. 
‘‘(V) Any other facility, specified by the Sec-
retary, that provides items or services for which 
coverage is provided under the plan or coverage, 
respectively. 
‘‘(B) VISIT.—The term ‘visit’ shall, with respect to items 
and services furnished to an individual at a health care
H. R. 133—1614 
facility, include equipment and devices, telemedicine serv-
ices, imaging services, laboratory services, preoperative and 
postoperative services, and such other items and services 
as the Secretary may specify, regardless of whether or 
not the provider furnishing such items or services is at 
the facility. 
‘‘(c) CERTAIN ACCESS FEES
TO CERTAIN DATABASES.—In the 
case of a sponsor of a group health plan that, pursuant to subsection 
(a)(3)(E)(iii), uses a database described in such subsection to deter-
mine a rate to apply under such subsection for an item or service 
by reason of having insufficient information described in such sub-
section with respect to such item or service, such sponsor shall 
cover the cost for access to such database.’’. 
(2) TRANSFER AMENDMENT.—Subchapter B of chapter 100 
of the Internal Revenue Code of 1986, as amended by paragraph 
(1), is further amended by adding at the end the following: 
‘‘SEC. 9822. OTHER PATIENT PROTECTIONS. 
‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If a group health 
plan requires or provides for designation by a participant or bene-
ficiary of a participating primary care provider, then the plan 
shall permit each participant and beneficiary to designate any 
participating primary care provider who is available to accept such 
individual. 
‘‘(b) ACCESS TO PEDIATRIC CARE.— 
‘‘(1) PEDIATRIC CARE.—In the case of a person who has 
a child who is a participant or beneficiary under a group 
health plan if the plan requires or provides for the designation 
of a participating primary care provider for the child, the plan 
shall permit such person to designate a physician (allopathic 
or osteopathic) who specializes in pediatrics as the child’s pri-
mary care provider if such provider participates in the network 
of the plan. 
‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) shall be 
construed to waive any exclusions of coverage under the terms 
and conditions of the plan with respect to coverage of pediatric 
care. 
‘‘(c) PATIENT ACCESS
TO OBSTETRICAL
AND GYNECOLOGICAL 
CARE.— 
‘‘(1) GENERAL RIGHTS.— 
‘‘(A) DIRECT ACCESS.—A group health plan described 
in paragraph (2) may not require authorization or referral 
by the plan, issuer, or any person (including a primary 
care provider described in paragraph (2)(B)) in the case 
of a female participant or beneficiary who seeks coverage 
for obstetrical or gynecological care provided by a partici-
pating health care professional who specializes in obstetrics 
or gynecology. Such professional shall agree to otherwise 
adhere to such plan’s policies and procedures, including 
procedures 
regarding 
referrals 
and 
obtaining 
prior 
authorization and providing services pursuant to a treat-
ment plan (if any) approved by the plan. 
‘‘(B) OBSTETRICAL AND GYNECOLOGICAL CARE.—A group 
health plan described in paragraph (2) shall treat the provi-
sion of obstetrical and gynecological care, and the ordering 
of related obstetrical and gynecological items and services, 
pursuant to the direct access described under subparagraph
H. R. 133—1615 
(A), by a participating health care professional who special-
izes in obstetrics or gynecology as the authorization of 
the primary care provider. 
‘‘(2) APPLICATION
OF
PARAGRAPH.—A group health plan 
described in this paragraph is a group health plan that— 
‘‘(A) provides coverage for obstetric or gynecologic care; 
and 
‘‘(B) requires the designation by a participant or bene-
ficiary of a participating primary care provider. 
‘‘(3) CONSTRUCTION.—Nothing in paragraph (1) shall be 
construed to— 
‘‘(A) waive any exclusions of coverage under the terms 
and conditions of the plan with respect to coverage of 
obstetrical or gynecological care; or 
‘‘(B) preclude the group health plan involved from 
requiring that the obstetrical or gynecological provider 
notify the primary care health care professional or the 
plan or issuer of treatment decisions.’’. 
(3) CLERICAL AMENDMENT.—The table of sections for sub-
chapter B of chapter 100 of the Internal Revenue Code of 
1986 is amended by adding at the end the following new item: 
‘‘Sec. 9815. Additional market reforms. 
‘‘Sec. 9816. Preventing surprise medical bills. 
‘‘Sec. 9822. Other patient protections.’’. 
(4) CONFORMING AMENDMENTS.— 
(A) IN GENERAL.—Section 223(c) of the Internal Rev-
enue Code of 1986 is amended— 
(i) in paragraph (1), by adding at the end the 
following: 
‘‘(D) SPECIAL RULE FOR INDIVIDUALS RECEIVING BENE-
FITS
SUBJECT
TO
SURPRISE
BILLING
STATUTES.—An indi-
vidual shall not fail to be treated as an eligible individual 
for any period merely because the individual receives bene-
fits for medical care subject to and in accordance with 
section 9816 or 9817, section 2799A–1 or 2799A–2 of the 
Public Health Service Act, or section 716 or 717 of the 
Employee Retirement Income Security Act of 1974, or any 
State law providing similar protections to such individual.’’; 
and 
(ii) in paragraph (2), by adding at the end the 
following: 
‘‘(F) SPECIAL RULE FOR SURPRISE BILLING.—A plan shall 
not fail to be treated as a high deductible health plan 
by reason of providing benefits for medical care in accord-
ance with section 9816 or 9817, section 2799A–1 or 2799A– 
2 of the Public Health Service Act, or section 716 or 717 
of the Employee Retirement Income Security Act of 1974, 
or any State law providing similar protections to individ-
uals, prior to the satisfaction of the deductible under para-
graph (2)(A)(i).’’. 
(B) EFFECTIVE
DATE.—The amendments made by 
subparagraph (A) shall apply for plan years beginning on 
or after January 1, 2022. 
(d) ADDITIONAL APPLICATION PROVISIONS.—