Title: Ban Surprise Billing Act
Policy area: Health

Summary:
Ban Surprise Billing Act  This bill places certain limits on the cost-sharing amount for health insurance plan holders for certain services received from out-of-network providers that are based on the median in-network rate for similar services.  The bill also establishes requirements related to the practice of billing plan holders for the difference between the out-of-network rate and the in-network rate for certain services; the bill provides for an independent dispute resolution process for services with a median contracted rate of $750 or greater, among other provisions.

[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5800 Introduced in House (IH)]

<DOC>






116th CONGRESS
  2d Session
                                H. R. 5800

  To end surprise medical billing and increase transparency in health 
                               coverage.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            February 7, 2020

  Mr. Scott of Virginia (for himself and Ms. Foxx of North Carolina) 
 introduced the following bill; which was referred to the Committee on 
Energy and Commerce, and in addition to the Committees on Education and 
  Labor, Ways and Means, and Oversight and Reform, for a period to be 
subsequently determined by the Speaker, in each case for consideration 
  of such provisions as fall within the jurisdiction of the committee 
                               concerned

_______________________________________________________________________

                                 A BILL


 
  To end surprise medical billing and increase transparency in health 
                               coverage.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Ban Surprise Billing Act''.

SEC. 2. PREVENTING SURPRISE MEDICAL BILLS.

    (a) Public Health Service Act Amendments.--Section 2719A of the 
Public Health Service Act (42 U.S.C. 300gg-19a) is amended--
            (1) by amending subsection (b) to read as follows:
    ``(b) Coverage of Emergency Services.--
            ``(1) In general.--If a group health plan, or a health 
        insurance issuer offering group or individual 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 
                determination;
                    ``(B) whether the health care provider furnishing 
                such services is a participating provider or a 
                participating emergency facility, as applicable, with 
                respect to such services;
                    ``(C) in a manner so that, if such services are 
                provided to a participant, beneficiary, or enrollee by 
                a nonparticipating provider or a nonparticipating 
                emergency facility--
                            ``(i) such services will be provided 
                        without imposing any requirement under the plan 
                        or coverage for prior authorization of services 
                        or any limitation on coverage that is more 
                        restrictive than the requirements or 
                        limitations that apply to emergency services 
                        received from participating providers and 
                        participating emergency facilities with respect 
                        to such plan or coverage, respectively;
                            ``(ii) the cost-sharing requirement 
                        (expressed as a copayment amount or coinsurance 
                        rate) is not greater than the requirement that 
                        would apply if such services were provided by a 
                        participating provider or a participating 
                        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 recognized 
                        amount (as defined in paragraph (3)(H)) for 
                        such services, plan or coverage, and year;
                            ``(iv) the group health plan or health 
                        insurance issuer, respectively, pays to such 
                        provider or facility, respectively the amount 
                        by which the recognized amount for such 
                        services and year involved exceeds the cost-
                        sharing amount for such services (as determined 
                        in accordance with clauses (ii) and (iii)) and 
                        year; and
                            ``(v) any cost-sharing payments made by the 
                        participant, beneficiary, or enrollee with 
                        respect to such emergency services so furnished 
                        shall be counted toward any in-network 
                        deductible or out-of-pocket maximums applied 
                        under the plan or coverage, respectively (and 
                        such in-network deductible and out-of-pocket 
                        maximums shall be applied) in the same manner 
                        as if such cost-sharing payments were made with 
                        respect to emergency services furnished by a 
                        participating provider or a participating 
                        emergency facility; and
                    ``(D) without regard to any other term or condition 
                of such coverage (other than exclusion or coordination 
                of benefits, or an affiliation or waiting period, 
                permitted under section 2704 of this Act, including as 
                incorporated pursuant to section 715 of the Employee 
                Retirement Income Security Act of 1974 and section 9815 
                of the Internal Revenue Code of 1986, and other than 
                applicable cost-sharing).
            ``(2) Audit process and regulations for median contracted 
        rates.--
                    ``(A) Audit process.--
                            ``(i) In general.--Not later than July 1, 
                        2021, the Secretary, in consultation with 
                        appropriate State agencies and the Secretary of 
                        Labor and the Secretary of the Treasury, shall 
                        establish through rulemaking a process, in 
                        accordance with clause (ii), under which group 
                        health plans and health insurance issuers 
                        offering health insurance coverage in the group 
                        or individual market are audited by the 
                        Secretary or applicable State authority to 
                        ensure that--
                                    ``(I) such plans and coverage are 
                                in compliance with the requirement of 
                                applying a median contracted rate under 
                                this section; and
                                    ``(II) such median contracted rate 
                                so applied satisfies the definition 
                                under paragraph (3)(E) with respect to 
                                the year involved, including with 
                                respect to a group health plan or 
                                health insurance issuer described in 
                                clause (ii) of such paragraph (3)(E).
                            ``(ii) Audit samples.--Under the process 
                        established pursuant to clause (i), the 
                        Secretary--
                                    ``(I) shall conduct audits 
                                described in such clause, with respect 
                                to a year (beginning with 2022), of a 
                                sample with respect to such year of 
                                claims data from not more than 25 group 
                                health plans and health insurance 
                                issuers offering health insurance 
                                coverage in the group or individual 
                                market; and
                                    ``(II) may audit any group health 
                                plan or health insurance issuer 
                                offering health insurance coverage in 
                                the group or individual market if the 
                                Secretary has received any complaint 
                                about such plan or coverage, 
                                respectively, that involves the 
                                compliance of the plan or coverage, 
                                respectively, with either of the 
                                requirements described in subclauses 
                                (I) and (II) of such clause.
                            ``(iii) Reports.--Beginning for 2022, the 
                        Secretary shall annually submit to Congress a 
                        report on the number of plans and issuers with 
                        respect to which audits were conducted during 
                        such year pursuant to this subparagraph.
                    ``(B) Rulemaking.--Not later than July 1, 2021, the 
                Secretary, in consultation with the Secretary of Labor 
                and the Secretary of the Treasury, shall establish 
                through rulemaking--
                            ``(i) the methodology the group health plan 
                        or health insurance issuer offering health 
                        insurance coverage in the group or individual 
                        market shall use to determine the median 
                        contracted rate, differentiating by line of 
                        business;
                            ``(ii) the information such plan or issuer, 
                        respectively, shall share with the 
                        nonparticipating provider or nonparticipating 
                        facility, as applicable, when making such a 
                        determination;
                            ``(iii) the geographic regions applied for 
                        purposes of this subparagraph, taking into 
                        account access to items and services in rural 
                        and underserved areas, including health 
                        professional shortage areas, as defined in 
                        section 332; and
                            ``(iv) a process to receive complaints of 
                        violations of the requirements described in 
                        subclauses (I) and (II) of subparagraph (A)(i) 
                        by group health plans and health insurance 
                        issuers offering health insurance coverage in 
                        the group or individual 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 relevant payment adjustments that take into 
                account quality or facility type (including higher 
                acuity settings and the case-mix of various facility 
                types) that are otherwise taken into account for 
                purposes of 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.
            ``(3) Definitions.--In this part:
                    ``(A) Emergency department of a hospital.--The term 
                `emergency department of a hospital' includes a 
                hospital outpatient department that provides emergency 
                services.
                    ``(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 
                                freestanding emergency department) that 
                                is within the capability of the 
                                emergency department of a hospital or 
                                of an independent freestanding 
                                emergency department, as applicable, 
                                including ancillary services routinely 
                                available to the emergency department 
                                to evaluate such emergency medical 
                                condition; and
                                    ``(II) within the capabilities of 
                                the staff and facilities available at 
                                the hospital or the independent 
                                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.
                            ``(ii) Inclusion of certain services 
                        outside of emergency department.--
                                    ``(I) In general.--For purposes of 
                                this subsection and section 2799A-1, in 
                                the case of an individual enrolled in a 
                                group health plan or health insurance 
                                coverage offered by a health insurance 
                                issuer in the group or individual 
                                market who is furnished services 
                                described in clause (i) by a 
                                participating or nonparticipating 
                                provider or a participating or 
                                nonparticipating emergency facility to 
                                stabilize such individual 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 for which benefits are 
                                provided or covered under the plan or 
                                coverage, respectively, furnished by a 
                                nonparticipating provider or 
                                nonparticipating facility, regardless 
                                of the department of the hospital in 
                                which such individual is furnished such 
                                items or services, if, after such 
                                stabilization but during such visit in 
                                which such individual is so stabilized, 
                                the provider or facility determines 
                                that such items or services are needed.
                                    ``(II) Conditions.--For purposes of 
                                subclause (I), the conditions described 
                                in this subclause, with respect to an 
                                individual who is stabilized 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 a provider or 
                                        facility determines such 
                                        individual is able to travel 
                                        using nonmedical transportation 
                                        or nonemergency medical 
                                        transportation.
                                            ``(bb) Such provider 
                                        furnishing such additional 
                                        items and services satisfies 
                                        the notice and consent criteria 
                                        of section 2799A-2(d) with 
                                        respect to such items and 
                                        services.
                                            ``(cc) Such an individual 
                                        is in a condition to receive 
                                        (as determined in accordance 
                                        with guidance issued by the 
                                        Secretary) the information 
                                        described in section 2799A-2 
                                        and to provide informed consent 
                                        under such section, in 
                                        accordance with applicable 
                                        State law.
                    ``(D) Independent freestanding emergency 
                department.--The term `independent freestanding 
                emergency department' means a facility that--
                            ``(i) is geographically separate and 
                        distinct and licensed separately from a 
                        hospital under applicable State law; and
                            ``(ii) provides any emergency services (as 
                        defined in subparagraph (C)).
                    ``(E) Median contracted rate.--
                            ``(i) In general.--The term `median 
                        contracted rate' means, subject to clauses (ii) 
                        and (iii), with respect to a sponsor of a group 
                        health plan and health insurance issuer 
                        offering health insurance coverage in the group 
                        or individual market--
                                    ``(I) for an item or service 
                                furnished during 2022, the median of 
                                the contracted rates recognized by the 
                                plan or issuer, respectively 
                                (determined with respect to all such 
                                plans of such sponsor or all such 
                                coverage offered by such issuer that 
                                are offered within the same line of 
                                business 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)(B), increased by the 
                                percentage increase in the consumer 
                                price index for all urban consumers 
                                (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 median contracted rate 
                                determined under this clause for such 
                                an item or service 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.
                            ``(ii) New plans and coverage.--The term 
                        `median contracted rate' means, with respect to 
                        a sponsor of a group health plan or health 
                        insurance issuer offering health insurance 
                        coverage in the group or individual market 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, respectively, is 
                                offered in such region, a rate 
                                (determined in accordance with a 
                                methodology established by the 
                                Secretary) for items and services that 
                                are covered by such plan and furnished 
                                during such first year; and
                                    ``(II) for each subsequent year 
                                such group health plan or health 
                                insurance coverage, respectively, is 
                                offered in such region, the median 
                                contracted rate 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 health insurance 
                        coverage in the group or individual market 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 (iv)(III)), in the first 
                        coverage year (as defined in clause (iv)(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 
                        determined by the Secretary) provided in a 
                        particular geographic region (other than in a 
                        case with respect to which clause (ii) 
                        applies)) the term `median contracted rate'--
                                    ``(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 coverage), 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 paragraph 
                                (2)(B), to not have any conflicts of 
                                interest and to have sufficient 
                                information reflecting allowed amounts 
                                paid to a health care provider or 
                                facility for relevant services 
                                furnished in the applicable geographic 
                                region (such as a State all-payer 
                                claims database);
                                    ``(II) for an item or service 
                                furnished in a subsequent year (before 
                                the first sufficient information year 
                                (as defined in clause (iv)(II)) for 
                                such item or service with respect to 
                                such plan or coverage), means the rate 
                                determined under subclause (I) or this 
                                subclause, as applicable, for such item 
                                or service for the year previous to 
                                such subsequent year, increased by the 
                                percentage increase in the consumer 
                                price index for all urban consumers 
                                (United States city average) over such 
                                previous year;
                                    ``(III) for an item or service 
                                furnished in the first sufficient 
                                information year for such item or 
                                service with respect to such plan or 
                                coverage, has the meaning given the 
                                term median contracted rate 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 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 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 
                                subsequent year.
                            ``(iv) Definitions.--For purposes of this 
                        subparagraph:
                                    ``(I) First coverage year.--The 
                                term `first coverage year' means, with 
                                respect to a group health plan or 
                                health insurance coverage offered by a 
                                health insurance issuer in the group or 
                                individual market 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 
                                insurance coverage.
                                    ``(II) First sufficient information 
                                year.--The term `first sufficient 
                                information year' means, with respect 
                                to a group health plan or health 
                                insurance coverage offered by a health 
                                insurance issuer in the group or 
                                individual market--
                                            ``(aa) in the case of an 
                                        item or service for which the 
                                        plan or coverage does not have 
                                        sufficient information to 
                                        calculate the median of the 
                                        contracted rates described in 
                                        clause (i)(I) in 2019, the 
                                        first year subsequent to 2022 
                                        for which the sponsor or issuer 
                                        has such sufficient information 
                                        to calculate the median of such 
                                        contracted rates in the year 
                                        previous to such first 
                                        subsequent year; and
                                            ``(bb) in the case of a 
                                        newly covered item or service, 
                                        the first year subsequent to 
                                        the first coverage year for 
                                        such item or service with 
                                        respect to such plan or 
                                        coverage for which the sponsor 
                                        or issuer has sufficient 
                                        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 or health insurance 
                                issuer offering health insurance 
                                coverage in the group or individual 
                                market, 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; 
                participating emergency facility.--
                            ``(i) Nonparticipating emergency 
                        facility.--The term `nonparticipating emergency 
                        facility' means, with respect to an item or 
                        service and a group health plan or health 
                        insurance coverage offered by a health 
                        insurance issuer in the group or individual 
                        market, an emergency department of a hospital, 
                        or an independent freestanding emergency 
                        department, that does not have a contractual 
                        relationship directly or indirectly with the 
                        plan or issuer, respectively, for furnishing 
                        such item or service under the plan or 
                        coverage, respectively.
                            ``(ii) Participating emergency facility.--
                        The term `participating emergency facility' 
                        means, with respect to an item or service and a 
                        group health plan or health insurance coverage 
                        offered by a health insurance issuer in the 
                        group or individual market, an emergency 
                        department of a hospital, or an independent 
                        freestanding emergency department, that has a 
                        contractual relationship directly or indirectly 
                        with the plan or issuer, respectively, with 
                        respect to the furnishing of such an item or 
                        service at such facility.
                    ``(G) Nonparticipating providers; participating 
                providers.--
                            ``(i) Nonparticipating provider.--The term 
                        `nonparticipating provider' means, with respect 
                        to an item or service and a group health plan 
                        or health insurance coverage offered by a 
                        health insurance issuer in the group or 
                        individual market, a physician or other health 
                        care provider who is acting within the scope of 
                        practice of that provider's license or 
                        certification under applicable State law and 
                        who does not have a contractual relationship 
                        with the plan or issuer, respectively, for 
                        furnishing such item or service under the plan 
                        or coverage, respectively.
                            ``(ii) Participating provider.--The term 
                        `participating provider' means, with respect to 
                        an item or service and a group health plan or 
                        health insurance coverage offered by a health 
                        insurance issuer in the group or individual 
                        market, a physician or other health care 
                        provider who is acting within the scope of 
                        practice of that provider's license or 
                        certification under applicable State law and 
                        who has a contractual relationship with the 
                        plan or issuer, respectively, for furnishing 
                        such item or service under the plan or 
                        coverage, respectively.
                    ``(H) Recognized amount.--The term `recognized 
                amount' means, with respect to an item or service 
                furnished by a nonparticipating provider or emergency 
                facility during a year and a group health plan or 
                health insurance coverage offered by a health insurance 
                issuer in the group or individual market--
                            ``(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 emergency facility, and such an item or 
                        service, the amount determined in accordance 
                        with such law;
                            ``(ii) subject to clause (iii), in the case 
                        of such item or service furnished in a State 
                        that does not have in effect a specified State 
                        law, with respect to such plan, coverage, or 
                        issuer, respectively, such a nonparticipating 
                        provider or emergency facility, and such an 
                        item or service, an amount that is the median 
                        contracted rate (as defined in subparagraph 
                        (E)) for such year and determined in accordance 
                        with rulemaking described in paragraph (2)(B) 
                        for such item or service; or
                            ``(iii) in the case of such item or service 
                        furnished in a State with an All-Payer Model 
                        Agreement under section 1115A of the Social 
                        Security Act, the amount that the State 
                        approves under such system for such item or 
                        service so furnished.
                    ``(I) Specified state law.--The term `specified 
                State law' means, with respect to a State, an item or 
                service furnished by a nonparticipating provider or 
                emergency facility during a year and a group health 
                plan or health insurance coverage offered by a health 
                insurance issuer in the group or individual market, a 
                State law that provides for a method for determining 
                the amount of payment that is required to be covered by 
                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 nonparticipating provider or 
                emergency facility.
                    ``(J) Stabilize.--The term `to stabilize', with 
                respect to an emergency medical condition (as defined 
                in subparagraph (B)), has the meaning give in section 
                1867(e)(3) of the Social Security Act (42 U.S.C. 
                1395dd(e)(3)).''; and
            (2) by adding at the end the following new subsections:
    ``(e) Coverage of Non-Emergency Services Performed by 
Nonparticipating Providers at Certain Participating Facilities.--
            ``(1) In general.--In the case of items or services (other 
        than emergency services to which subsection (b) applies) for 
        which any benefits are provided or covered by a group health 
        plan or health insurance issuer offering health insurance 
        coverage in the group or individual market furnished to a 
        participant, beneficiary, or enrollee of such plan or coverage 
        by a nonparticipating provider (as defined in subsection 
        (b)(3)(G)(i)) (and who, with respect to such items and 
        services, has not satisfied the notice and consent criteria of 
        section 2799A-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 coverage, respectively, 
        the plan or coverage, respectively--
                    ``(A) shall not impose on such participant, 
                beneficiary, or enrollee a cost-sharing amount 
                (expressed as a copayment amount or coinsurance rate) 
                for such items and services so furnished that is 
                greater than the cost-sharing amount that would apply 
                under such plan or coverage, respectively, had such 
                items or services been furnished by a participating 
                provider (as defined in subsection (b)(3)(G)(ii));
                    ``(B) shall calculate such cost-sharing amount 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 
                subsection (b)(3)(H)) for such items and services, plan 
                or coverage, and year;
                    ``(C) shall pay to such provider furnishing such 
                items and services to such participant, beneficiary, or 
                enrollee the amount by which the recognized amount (as 
                defined in subsection (b)(3)(H)) for such items and 
                services and year 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
                    ``(D) 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 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 or 
                        health insurance issuer offering health 
                        insurance coverage in the group or individual 
                        market, a health care facility described in 
                        clause (ii) that has a 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 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) of such 
                                Act).
                                    ``(IV) An ambulatory surgical 
                                center (as defined in section 
                                1833(i)(1)(A) of such Act).
                                    ``(V) Any other facility 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 
                participating health care facility, include equipment 
                and devices, telemedicine services, imaging services, 
                laboratory 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.
    ``(f) Air Ambulance Services.--
            ``(1) In general.--In the case of a participant, 
        beneficiary, or enrollee in a group health plan or health 
        insurance coverage offered in the group or individual market 
        who receives air ambulance services from a nonparticipating 
        provider (as defined in subsection (b)(3)(G)) with respect to 
        such plan or coverage, if such services would be covered if 
        provided by a participating provider (as defined in such 
        section) with respect to such plan or coverage--
                    ``(A) the cost-sharing requirement (expressed as a 
                copayment amount, coinsurance rate, or deductible) with 
                respect to such services shall be the same requirement 
                that would apply if such services were provided by such 
                a participating provider, and any coinsurance or 
                deductible shall be based on rates that would apply for 
                such services if they were furnished by such a 
                participating provider;
                    ``(B) such cost-sharing amounts shall be counted 
                toward the in-network deductible and in-network out-of-
                pocket maximum amount under the plan or coverage for 
                the plan year (and such in-network deductible 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; and
                    ``(C) the plan or coverage shall pay to such 
                provider furnishing such services to such participant, 
                beneficiary, or enrollee the amount by which the 
                recognized amount (as defined in and determined 
                pursuant to subsection (b)(3)(H)(ii)) for such services 
                and year involved exceeds the cost-sharing amount 
                imposed under the plan or coverage, respectively, for 
                such services (as determined in accordance with 
                subparagraphs (A) and (B)).
            ``(2) Air ambulance service defined.--For purposes of this 
        section, the term `air ambulance service' means medical 
        transport by helicopter or airplane for patients.
    ``(g) Certain Access Fees to Certain Databases.--In the case of a 
sponsor of a group health plan or health insurance issuer offering 
health insurance coverage in the group or individual market that, 
pursuant to subsection (b)(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.''.
    (b) ERISA Amendments.--
            (1) 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:

``SEC. 716. CONSUMER PROTECTIONS.

    ``(a) Choice of Health Care Professional.--If a group health plan 
or 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 or beneficiary to designate any participating 
primary care provider who is available to accept such individual.
    ``(b) Coverage of Emergency Services.--
            ``(1) In general.--If a group health plan, or a health 
        insurance 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 
                determination;
                    ``(B) whether the health care provider furnishing 
                such services is a participating provider or a 
                participating emergency 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 provider 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 
                        or coverage, respectively;
                            ``(ii) the cost-sharing requirement 
                        (expressed as a copayment amount or coinsurance 
                        rate) is not greater than the requirement that 
                        would apply if such services were provided by a 
                        participating provider or a participating 
                        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 recognized 
                        amount (as defined in paragraph (3)(H)) for 
                        such services, plan or coverage, and year;
                            ``(iv) the group health plan or health 
                        insurance issuer, respectively, pays to such 
                        provider or facility, respectively, the amount 
                        by which the recognized amount for such 
                        services and year involved exceeds the cost-
                        sharing amount for such services (as determined 
                        in accordance with clauses (ii) and (iii)) and 
                        year; and
                            ``(v) any cost-sharing payments made by the 
                        participant or beneficiary with respect to such 
                        emergency services so furnished shall be 
                        counted toward any in-network deductible or 
                        out-of-pocket maximums applied under the plan 
                        or coverage, respectively (and such in-network 
                        deductible and out-of-pocket maximums shall be 
                        applied) in the same manner as if such cost-
                        sharing payments were made with respect to 
                        emergency services furnished by a participating 
                        provider or a participating emergency facility; 
                        and
                    ``(D) without regard to any other term or condition 
                of such coverage (other than exclusion or coordination 
                of benefits, or an affiliation or waiting period, 
                permitted under section 2704 of the Public Health 
                Service Act, including as incorporated pursuant to 
                section 715 of this Act and section 9815 of the 
                Internal Revenue Code of 1986, and other than 
                applicable cost-sharing).
            ``(2) Audit process and regulations for median contracted 
        rates.--
                    ``(A) Audit process.--
                            ``(i) In general.--Not later than July 1, 
                        2021, the Secretary, in consultation with 
                        appropriate State agencies and the Secretary of 
                        Health and Human Services and the Secretary of 
                        the Treasury, shall establish through 
                        rulemaking a process, in accordance with clause 
                        (ii), under which group health plans and health 
                        insurance issuers offering health insurance 
                        coverage in the group market are audited by the 
                        Secretary or applicable State authority to 
                        ensure that--
                                    ``(I) such plans and coverage are 
                                in compliance with the requirement of 
                                applying a median contracted rate under 
                                this section; and
                                    ``(II) such median contracted rate 
                                so applied satisfies the definition 
                                under paragraph (3)(E) with respect to 
                                the year involved, including with 
                                respect to a group health plan or 
                                health insurance issuer described in 
                                clause (ii) of such paragraph (3)(E).
                            ``(ii) Audit samples.--Under the process 
                        established pursuant to clause (i), the 
                        Secretary--
                                    ``(I) shall conduct audits 
                                described in such clause, with respect 
                                to a year (beginning with 2022), of a 
                                sample with respect to such year of 
                                claims data from not more than 25 group 
                                health plans and health insurance 
                                issuers offering health insurance 
                                coverage in the group market; and
                                    ``(II) may audit any group health 
                                plan or health insurance issuer 
                                offering health insurance coverage in 
                                the group market if the Secretary has 
                                received any complaint about such plan 
                                or coverage, respectively, that 
                                involves the compliance of the plan or 
                                coverage, respectively, with either of 
                                the requirements described in 
                                subclauses (I) and (II) of such clause.
                            ``(iii) Reports.--Beginning for 2022, the 
                        Secretary shall annually submit to Congress 
                        information on the number of plans and issuers 
                        with respect to which audits were conducted 
                        during such year pursuant to this subparagraph.
                    ``(B) Rulemaking.--Not later than July 1, 2021, the 
                Secretary, in consultation with the Secretary of the 
                Treasury and the Secretary of Health and Human 
                Services, shall establish through rulemaking--
                            ``(i) the methodology the group health plan 
                        or health insurance issuer offering health 
                        insurance coverage in the group market shall 
                        use to determine the median contracted rate, 
                        differentiating by line of business;
                            ``(ii) the information such plan or issuer, 
                        respectively, shall share with the 
                        nonparticipating provider or nonparticipating 
                        facility, as applicable, when making such a 
                        determination;
                            ``(iii) the geographic regions applied for 
                        purposes of this subparagraph, taking into 
                        account access to items and services in rural 
                        and underserved areas, including health 
                        professional shortage areas, as defined in 
                        section 332 of the Public Health Service Act; 
                        and
                            ``(iv) a process to receive complaints of 
                        violations of the requirements described in 
                        subclauses (I) and (II) of paragraph (2)(A)(i) 
                        by group health plans and health insurance 
                        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 relevant payment adjustments that take into 
                account quality or facility type (including higher 
                acuity settings and the case-mix of various facility 
                types) that are otherwise taken into account for 
                purposes of 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.
            ``(3) Definitions.--In this section:
                    ``(A) Emergency department of a hospital.--The term 
                `emergency department of a hospital' includes a 
                hospital outpatient department that provides emergency 
                services.
                    ``(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 
                                freestanding emergency department) that 
                                is within the capability of the 
                                emergency department of a hospital or 
                                of an independent freestanding 
                                emergency department, as applicable, 
                                including ancillary services routinely 
                                available to the emergency department 
                                to evaluate such emergency medical 
                                condition; and
                                    ``(II) within the capabilities of 
                                the staff and facilities available at 
                                the hospital or the independent 
                                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.
                            ``(ii) Inclusion of certain services 
                        outside of emergency department.--
                                    ``(I) In general.--For purposes of 
                                this subsection and section 2799A-1, in 
                                the case of an individual enrolled in a 
                                group health plan or health insurance 
                                coverage offered by a health insurance 
                                issuer in the group or individual 
                                market who is furnished services 
                                described in clause (i) by a 
                                participating or nonparticipating 
                                provider or a participating or 
                                nonparticipating emergency facility to 
                                stabilize such individual 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 for which benefits are 
                                provided or covered under the plan or 
                                coverage, respectively, furnished by a 
                                nonparticipating provider or 
                                nonparticipating facility, regardless 
                                of the department of the hospital in 
                                which such individual is furnished such 
                                items or services, if, after such 
                                stabilization but during such visit in 
                                which such individual is so stabilized, 
                                the provider or facility determines 
                                that such items or services are needed.
                                    ``(II) Conditions.--For purposes of 
                                subclause (I), the conditions described 
                                in this subclause, with respect to an 
                                individual who is stabilized 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 a provider or 
                                        facility determines such 
                                        individual is able to travel 
                                        using nonmedical transportation 
                                        or nonemergency medical 
                                        transportation.
                                            ``(bb) Such provider 
                                        furnishing such additional 
                                        items and services satisfies 
                                        the notice and consent criteria 
                                        of section 2799A-2(d) of the 
                                        Public Health Service Act with 
                                        respect to such items and 
                                        services.
                                            ``(cc) Such an individual 
                                        is in a condition to receive 
                                        (as determined in accordance 
                                        with guidance issued by the 
                                        Secretary) the information 
                                        described in section 2799A-2 of 
                                        the Public Health Service Act 
                                        and to provide informed consent 
                                        under such section, in 
                                        accordance with applicable 
                                        State law.
                    ``(D) Independent freestanding emergency 
                department.--The term `independent freestanding 
                emergency department' means a facility that--
                            ``(i) is geographically separate and 
                        distinct and licensed separately from a 
                        hospital under applicable State law; and
                            ``(ii) provides any emergency services (as 
                        defined in subparagraph (C)).
                    ``(E) Median contracted rate.--
                            ``(i) In general.--The term `median 
                        contracted rate' means, subject to clauses (ii) 
                        and (iii), with respect to a sponsor of a group 
                        health plan and health insurance issuer 
                        offering health insurance coverage in the group 
                        market--
                                    ``(I) for an item or service 
                                furnished during 2022, the median of 
                                the contracted rates recognized by the 
                                plan or issuer, respectively 
                                (determined with respect to all such 
                                plans of such sponsor or all such 
                                coverage offered by such issuer that 
                                are offered within the same line of 
                                business 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 such plan or such 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)(B), increased by the 
                                percentage increase in the consumer 
                                price index for all urban consumers 
                                (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 median contracted rate 
                                determined under this clause for such 
                                an item or service 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.
                            ``(ii) New plans and coverage.--The term 
                        `median contracted rate' means, with respect to 
                        a sponsor of a group health plan or health 
                        insurance issuer offering health insurance 
                        coverage in the group market 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, respectively, is 
                                offered in such region, a rate 
                                (determined in accordance with a 
                                methodology established by the 
                                Secretary) for items and services that 
                                are covered by such plan and furnished 
                                during such first year; and
                                    ``(II) for each subsequent year 
                                such group health plan or health 
                                insurance coverage, respectively, is 
                                offered in such region, the median 
                                contracted rate 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 health insurance 
                        coverage in the group market 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 
                        (iv)(III)), in the first coverage year (as 
                        defined in clause (iv)(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 determined by the 
                        Secretary) provided in a particular geographic 
                        region (other than in a case with respect to 
                        which clause (ii) applies)) the term `median 
                        contracted rate'--
                                    ``(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 coverage), 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 paragraph 
                                (2)(B), to not have any conflicts of 
                                interest and to have sufficient 
                                information reflecting allowed amounts 
                                paid to a health care provider or 
                                facility for relevant services 
                                furnished in the applicable geographic 
                                region (such as a State all-payer 
                                claims database);
                                    ``(II) for an item or service 
                                furnished in a subsequent year (before 
                                the first sufficient information year 
                                (as defined in clause (iv)(II)) for 
                                such item or service with respect to 
                                such plan or coverage), means the rate 
                                determined under subclause (I) or this 
                                subclause, as applicable, for such item 
                                or service for the year previous to 
                                such subsequent year, increased by the 
                                percentage increase in the consumer 
                                price index for all urban consumers 
                                (United States city average) over such 
                                previous year;
                                    ``(III) for an item or service 
                                furnished in the first sufficient 
                                information year for such item or 
                                service with respect to such plan or 
                                coverage, has the meaning given the 
                                term median contracted rate 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 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 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 
                                subsequent year.
                            ``(iv) Definitions.--For purposes of this 
                        subparagraph:
                                    ``(I) First coverage year.--The 
                                term `first coverage year' means, with 
                                respect to a group health plan or 
                                health insurance coverage offered by a 
                                health insurance issuer in the group 
                                market 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 insurance coverage.
                                    ``(II) First sufficient information 
                                year.--The term `first sufficient 
                                information year' means, with respect 
                                to a group health plan or health 
                                insurance coverage offered by a health 
                                insurance issuer in the group market--
                                            ``(aa) in the case of an 
                                        item or service for which the 
                                        plan or coverage does not have 
                                        sufficient information to 
                                        calculate the median of the 
                                        contracted rates described in 
                                        clause (i)(I) in 2019, the 
                                        first year subsequent to 2022 
                                        for which such sponsor or 
                                        issuer has such sufficient 
                                        information to calculate the 
                                        median of such contracted rates 
                                        in the year previous to such 
                                        first subsequent year; and
                                            ``(bb) in the case of a 
                                        newly covered item or service, 
                                        the first year subsequent to 
                                        the first coverage year for 
                                        such item or service with 
                                        respect to such plan or 
                                        coverage for which the sponsor 
                                        or issuer has sufficient 
                                        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 or health insurance 
                                issuer offering health insurance 
                                coverage in the group market, 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; 
                participating emergency facility.--
                            ``(i) Nonparticipating emergency 
                        facility.--The term `nonparticipating emergency 
                        facility' means, with respect to an item or 
                        service and a group health plan or health 
                        insurance coverage offered by a health 
                        insurance issuer in the group market, an 
                        emergency department of a hospital, or an 
                        independent freestanding emergency department, 
                        that does not have a contractual relationship 
                        directly or indirectly with the plan or issuer, 
                        respectively, for furnishing such item or 
                        service under the plan or coverage, 
                        respectively.
                            ``(ii) Participating emergency facility.--
                        The term `participating emergency facility' 
                        means, with respect to an item or service and a 
                        group health plan or health insurance coverage 
                        offered by a health insurance issuer in the 
                        group market, an emergency department of a 
                        hospital, or an independent freestanding 
                        emergency department, that has a contractual 
                        relationship directly or indirectly with the 
                        plan or issuer, respectively, with respect to 
                        the furnishing of such an item or service at 
                        such facility.
                    ``(G) Nonparticipating providers; participating 
                providers.--
                            ``(i) Nonparticipating provider.--The term 
                        `nonparticipating provider' means, with respect 
                        to an item or service and a group health plan 
                        or health insurance coverage offered by a 
                        health insurance issuer in the group market, a 
                        physician or other health care provider who is 
                        acting within the scope of practice of that 
                        provider's license or certification under 
                        applicable State law and who does not have a 
                        contractual relationship with the plan or 
                        issuer, respectively, for furnishing such item 
                        or service under the plan or coverage, 
                        respectively.
                            ``(ii) Participating provider.--The term 
                        `participating provider' means, with respect to 
                        an item or service and a group health plan or 
                        health insurance coverage offered by a health 
                        insurance issuer in the group market, a 
                        physician or other health care provider who is 
                        acting within the scope of practice of that 
                        provider's license or certification under 
                        applicable State law and who has a contractual 
                        relationship with the plan or issuer, 
                        respectively, for furnishing such item or 
                        service under the plan or coverage, 
                        respectively.
                    ``(H) Recognized amount.--The term `recognized 
                amount' means, with respect to an item or service 
                furnished by a nonparticipating provider or emergency 
                facility during a year and a group health plan or 
                health insurance coverage offered by a health insurance 
                issuer in the group market--
                            ``(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 emergency facility, and such an item or 
                        service, the amount determined in accordance 
                        with such law;
                            ``(ii) subject to clause (iii), in the case 
                        of such item or service furnished in a State 
                        that does not have in effect a specified State 
                        law, with respect to such plan, coverage, or 
                        issuer, respectively, such a nonparticipating 
                        provider or emergency facility, and such an 
                        item or service, an amount that is the median 
                        contracted rate (as defined in subparagraph 
                        (E)) for such year and determined in accordance 
                        with rulemaking described in paragraph (2)(B) 
                        for such item or service; or
                            ``(iii) in the case of such item or service 
                        furnished in a State with an All-Payer Model 
                        Agreement under section 1115A of the Social 
                        Security Act, the amount that the State 
                        approves under such system for such item or 
                        service so furnished.
                    ``(I) Specified state law.--The term `specified 
                State law' means, with respect to a State, an item or 
                service furnished by a nonparticipating provider or 
                emergency facility during a year and a group health 
                plan or health insurance coverage offered by a health 
                insurance issuer in the group market, a State law that 
                provides for a method for determining the amount of 
                payment that is required to be covered by such a plan, 
                coverage, or issuer, respectively (to the extent such 
                State law applies to such plan, coverage, or issuer, 
                subject to section 514) in the case of a participant or 
                beneficiary covered under such plan or coverage and 
                receiving such item or service from such a 
                nonparticipating provider or emergency facility.
                    ``(J) Stabilize.--The term `to stabilize', with 
                respect to an emergency medical condition (as defined 
                in subparagraph (B)), has the meaning give in section 
                1867(e)(3) of the Social Security Act (42 U.S.C. 
                1395dd(e)(3)).
    ``(c) 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 health insurance coverage offered by a health 
        insurance issuer in the group market, 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.
    ``(d) 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 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 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 
                paragraph (2) shall treat the provision of obstetrical 
                and gynecological 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 
                provider.
            ``(2) Application of paragraph.--A group health plan, or 
        health insurance issuer offering group health insurance 
        coverage, 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 
                beneficiary 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.
    ``(e) Coverage of Non-Emergency Services Performed by 
Nonparticipating Providers at Certain Participating Facilities.--
            ``(1) In general.--In the case of items or services (other 
        than emergency services to which subsection (b) applies) for 
        which any benefits are provided or covered by a group health 
        plan or health insurance issuer offering health insurance 
        coverage in the group market furnished to a participant or 
        beneficiary of such plan or coverage by a nonparticipating 
        provider (as defined in subsection (b)(3)(G)(i)) (and who, with 
        respect to such items and services, has not satisfied the 
        notice and consent criteria of section 2799A-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 amount (expressed as a 
                copayment amount or coinsurance rate) for such items 
                and services so furnished that is greater than the 
                cost-sharing amount that would apply under such plan or 
                coverage, respectively, had such items or services been 
                furnished by a participating provider (as defined in 
                subsection (b)(3)(G)(ii));
                    ``(B) shall calculate such cost-sharing amount 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 
                subsection (b)(3)(H)) for such items and services, plan 
                or coverage, and year;
                    ``(C) shall pay to such provider furnishing such 
                items and services to such participant or beneficiary 
                the amount by which the recognized amount (as defined 
                in subsection (b)(3)(H)) for such items and services 
                and year 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
                    ``(D) 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 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 health 
                        insurance coverage in the group market, a 
                        health care facility described in clause (ii) 
                        that has a 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 health 
                        insurance coverage offered in the group 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) of such 
                                Act).
                                    ``(IV) An ambulatory surgical 
                                center (as defined in section 
                                1833(i)(1)(A) of such Act).
                                    ``(V) Any other facility 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 
                participating health care facility, include equipment 
                and devices, telemedicine services, imaging services, 
                laboratory 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.
    ``(f) Air Ambulance Services.--
            ``(1) In general.--In the case of a participant or 
        beneficiary in a group health plan or health insurance coverage 
        offered in the group market who receives air ambulance services 
        from a nonparticipating provider (as defined in subsection 
        (b)(3)(G)) with respect to such plan or coverage, if such 
        services would be covered if provided by a participating 
        provider (as defined in such subsection) with respect to such 
        plan or coverage--
                    ``(A) the cost-sharing requirement (expressed as a 
                copayment amount, coinsurance rate, or deductible) with 
                respect to such services shall be the same requirement 
                that would apply if such services were provided by such 
                a participating provider, and any coinsurance or 
                deductible shall be based on rates that would apply for 
                such services if they were furnished by such a 
                participating provider;
                    ``(B) such cost-sharing amounts shall be counted 
                toward the in-network deductible and in-network out-of-
                pocket maximum amount under the plan or coverage for 
                the plan year (and such in-network deductible 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; and
                    ``(C) the plan or coverage shall pay to such 
                provider furnishing such services to such participant 
                or beneficiary the amount by which the recognized 
                amount (as defined in and determined pursuant to 
                subsection (b)(3)(H)(ii)) for such services and year 
                involved exceeds the cost-sharing amount imposed under 
                the plan or coverage, respectively, for such services 
                (as determined in accordance with subparagraphs (A) and 
                (B)).
            ``(2) Air ambulance service defined.--For purposes of this 
        section, the term `air ambulance service' means medical 
        transport by helicopter or airplane for patients.
    ``(g) Certain Access Fees to Certain Databases.--In the case of a 
sponsor of a group health plan or health insurance issuer offering 
health insurance coverage in the group market that, pursuant to 
subsection (b)(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) 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. Consumer 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. CONSUMER PROTECTIONS.

    ``(a) Choice of Health Care Professional.--If a group health plan 
requires or provides for designation by a participant or beneficiary of 
a participating primary care provider, then the plan shall permit each 
participant or beneficiary to designate any participating primary care 
provider who is available to accept such individual.
    ``(b) Coverage of Emergency Services.--
            ``(1) In general.--If a group health plan 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 shall cover emergency services 
        (as defined in paragraph (3)(C))--
                    ``(A) without the need for any prior authorization 
                determination;
                    ``(B) whether the health care provider furnishing 
                such services is a participating provider or a 
                participating emergency 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 provider 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 
                        (expressed as a copayment amount or coinsurance 
                        rate) is not greater than the requirement that 
                        would apply if such services were provided by a 
                        participating provider or a participating 
                        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 recognized 
                        amount (as defined in paragraph (3)(H)) for 
                        such services, plan, and year;
                            ``(iv) the group health plan pays to such 
                        provider or facility, respectively, the amount 
                        by which the recognized amount for such 
                        services and year involved exceeds the cost-
                        sharing amount for such services (as determined 
                        in accordance with clauses (ii) and (iii)) and 
                        year; and
                            ``(v) any cost-sharing payments made by the 
                        participant or beneficiary with respect to such 
                        emergency services so furnished shall be 
                        counted toward any in-network deductible or 
                        out-of-pocket maximums applied under the plan 
                        (and such in-network deductible and out-of-
                        pocket maximums shall be applied) in the same 
                        manner as if such cost-sharing payments were 
                        made with respect to emergency services 
                        furnished by a participating provider or a 
                        participating emergency facility; and
                    ``(D) without regard to any other term or condition 
                of such coverage (other than exclusion or coordination 
                of benefits, or an affiliation or waiting period, 
                permitted under section 2704 of this Act, including as 
                incorporated pursuant to section 715 of the Employee 
                Retirement Income Security Act of 1974 and section 9815 
                of this Act, and other than applicable cost-sharing).
            ``(2) Audit process and regulations for median contracted 
        rates.--
                    ``(A) Audit process.--
                            ``(i) In general.--Not later than July 1, 
                        2021, the Secretary, in consultation with 
                        appropriate State agencies and the Secretary of 
                        Health and Human Services and the Secretary of 
                        Labor, shall establish through rulemaking a 
                        process, in accordance with clause (ii), under 
                        which group health plans are audited by the 
                        Secretary or applicable State authority to 
                        ensure that--
                                    ``(I) such plans are in compliance 
                                with the requirement of applying a 
                                median contracted rate under this 
                                section; and
                                    ``(II) such median contracted rate 
                                so applied satisfies the definition 
                                under paragraph (3)(E) with respect to 
                                the year involved, including with 
                                respect to a group health plan 
                                described in clause (ii) of such 
                                paragraph (3)(E).
                            ``(ii) Audit samples.--Under the process 
                        established pursuant to clause (i), the 
                        Secretary--
                                    ``(I) shall conduct audits 
                                described in such clause, with respect 
                                to a year (beginning with 2022), of a 
                                sample with respect to such year of 
                                claims data from not more than 25 group 
                                health plans; and
                                    ``(II) may audit any group health 
                                plan if the Secretary has received any 
                                complaint about such plan or coverage, 
                                respectively, that involves the 
                                compliance of the plan with either of 
                                the requirements described in 
                                subclauses (I) and (II) of such clause.
                            ``(iii) Reports.--Beginning for 2022, the 
                        Secretary shall annually submit to Congress a 
                        report on the number of plans and issuers with 
                        respect to which audits were conducted during 
                        such year pursuant to this subparagraph.
                    ``(B) Rulemaking.--Not later than July 1, 2021, the 
                Secretary, in consultation with the Secretary of Labor 
                and the Secretary of Health and Human Services, shall 
                establish through rulemaking--
                            ``(i) the methodology the group health plan 
                        shall use to determine the median contracted 
                        rate, differentiating by line of business;
                            ``(ii) the information such plan or issuer, 
                        respectively, shall share with the 
                        nonparticipating provider or nonparticipating 
                        facility, as applicable, when making such a 
                        determination;
                            ``(iii) the geographic regions applied for 
                        purposes of this subparagraph, taking into 
                        account access to items and services in rural 
                        and underserved areas, including health 
                        professional shortage areas, as defined in 
                        section 332 of the Public Health Service Act; 
                        and
                            ``(iv) a process to receive complaints of 
                        violations of the requirements described in 
                        subclauses (I) and (II) of paragraph (2)(A)(i) 
                        by group health plans.
                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 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.
            ``(3) Definitions.--In this section:
                    ``(A) Emergency department of a hospital.--The term 
                `emergency department of a hospital' includes a 
                hospital outpatient department that provides emergency 
                services.
                    ``(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 
                                freestanding emergency department) that 
                                is within the capability of the 
                                emergency department of a hospital or 
                                of an independent freestanding 
                                emergency department, as applicable, 
                                including ancillary services routinely 
                                available to the emergency department 
                                to evaluate such emergency medical 
                                condition; and
                                    ``(II) within the capabilities of 
                                the staff and facilities available at 
                                the hospital or the independent 
                                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.
                            ``(ii) Inclusion of certain services 
                        outside of emergency department.--
                                    ``(I) In general.--For purposes of 
                                this subsection and section 2799A-1, in 
                                the case of an individual enrolled in a 
                                group health plan or health insurance 
                                coverage offered by a health insurance 
                                issuer in the group or individual 
                                market who is furnished services 
                                described in clause (i) by a 
                                participating or nonparticipating 
                                provider or a participating or 
                                nonparticipating emergency facility to 
                                stabilize such individual 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 for which benefits are 
                                provided or covered under the plan or 
                                coverage, respectively, furnished by a 
                                nonparticipating provider or 
                                nonparticipating facility, regardless 
                                of the department of the hospital in 
                                which such individual is furnished such 
                                items or services, if, after such 
                                stabilization but during such visit in 
                                which such individual is so stabilized, 
                                the provider or facility determines 
                                that such items or services are needed.
                                    ``(II) Conditions.--For purposes of 
                                subclause (I), the conditions described 
                                in this subclause, with respect to an 
                                individual who is stabilized 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 a provider or 
                                        facility determines such 
                                        individual is able to travel 
                                        using nonmedical transportation 
                                        or nonemergency medical 
                                        transportation.
                                            ``(bb) Such provider 
                                        furnishing such additional 
                                        items and services satisfies 
                                        the notice and consent criteria 
                                        of section 2799A-2(d) of the 
                                        Public Health Service Act with 
                                        respect to such items and 
                                        services.
                                            ``(cc) Such an individual 
                                        is in a condition to receive 
                                        (as determined in accordance 
                                        with guidance issued by the 
                                        Secretary) the information 
                                        described in section 2799A-2 of 
                                        the Public Health Service Act 
                                        and to provide informed consent 
                                        under such section, in 
                                        accordance with applicable 
                                        State law.
                    ``(D) Independent freestanding emergency 
                department.--The term `independent freestanding 
                emergency department' means a facility that--
                            ``(i) is geographically separate and 
                        distinct and licensed separately from a 
                        hospital under applicable State law; and
                            ``(ii) provides any emergency services (as 
                        defined in subparagraph (C)).
                    ``(E) Median contracted rate.--
                            ``(i) In general.--The term `median 
                        contracted rate' means, subject to clauses (ii) 
                        and (iii), with respect to a sponsor of a group 
                        health plan--
                                    ``(I) for an item or service 
                                furnished during 2022, the median of 
                                the contracted rates recognized by the 
                                plan (determined with respect to all 
                                such plans of such sponsor that are 
                                offered within the same line of 
                                business 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 
                                provided in the geographic region in 
                                which the item or service is furnished, 
                                consistent with the methodology 
                                established by the Secretary under 
                                paragraph (2)(B), increased by the 
                                percentage increase in the consumer 
                                price index for all urban consumers 
                                (United States city average) over 2019, 
                                such 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 median contracted rate 
                                determined under this clause for such 
                                an item or service 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.
                            ``(ii) New plans and coverage.--The term 
                        `median contracted rate' 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 (determined in 
                                accordance with a methodology 
                                established 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 median contracted rate 
                                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 (iv)(III)), in the first coverage year 
                        (as defined in clause (iv)(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 
                        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 `median 
                        contracted rate'--
                                    ``(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 
                                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 subsequent year (before 
                                the first sufficient information year 
                                (as defined in clause (iv)(II)) for 
                                such item or service with respect to 
                                such plan), 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, has 
                                the meaning given the term median 
                                contracted rate 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) Definitions.--For purposes of this 
                        subparagraph:
                                    ``(I) First coverage year.--The 
                                term `first coverage year' means, with 
                                respect to a group health plan 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.
                                    ``(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 contracted 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 
                                        subsequent year; and
                                            ``(bb) in the case of a 
                                        newly covered item or service, 
                                        the first year subsequent to 
                                        the first coverage year for 
                                        such item or service with 
                                        respect to such plan 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; 
                participating 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 independent 
                        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 independent 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 
                providers.--
                            ``(i) Nonparticipating provider.--The term 
                        `nonparticipating provider' means, with respect 
                        to an item or service and a group health plan, 
                        a physician or other health care provider who 
                        is acting within the scope of practice of that 
                        provider's license or certification under 
                        applicable State law and who does not have a 
                        contractual relationship with the plan or 
                        issuer, respectively, for furnishing such item 
                        or service under the plan.
                            ``(ii) Participating provider.--The term 
                        `participating provider' means, with respect to 
                        an item or service and a group health plan, a 
                        physician or other health care provider who is 
                        acting within the scope of practice of that 
                        provider's license or certification under 
                        applicable State law and who has a contractual 
                        relationship with the plan for furnishing such 
                        item or service under the plan.
                    ``(H) Recognized amount.--The term `recognized 
                amount' means, with respect to an item or service 
                furnished by a nonparticipating provider or emergency 
                facility during a year and a group health plan--
                            ``(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 emergency facility; and such an 
                        item or service, the amount determined in 
                        accordance with such law;
                            ``(ii) subject to clause (iii), in the case 
                        of such item or service furnished in a State 
                        that does not have in effect a specified State 
                        law, with respect to such plan; such a 
                        nonparticipating provider or emergency 
                        facility; and such an item or service, an 
                        amount that is the median contracted rate (as 
                        defined in subparagraph (E)) for such year and 
                        determined in accordance with rulemaking 
                        described in paragraph (2)(B) for such item or 
                        service; or
                            ``(iii) in the case of such item or service 
                        furnished in a State with an All-Payer Model 
                        Agreement under section 1115A of the Social 
                        Security Act, the amount that the State 
                        approves under such system for such item or 
                        service so furnished.
                    ``(I) Specified state law.--The term `specified 
                State law' means, with respect to a State, an item or 
                service furnished by a nonparticipating provider or 
                emergency facility during a year and a group health 
                plan, a State law that provides for a method for 
                determining the amount of payment that is required to 
                be covered by such a plan (to the extent such State law 
                applies to such plan, subject to section 514 of the 
                Employee Retirement Income Security Act of 1974) in the 
                case of a participant or beneficiary covered under such 
                plan and receiving such item or service from such a 
                nonparticipating provider or emergency facility.
                    ``(J) Stabilize.--The term `to stabilize', with 
                respect to an emergency medical condition (as defined 
                in subparagraph (B)), has the meaning give in section 
                1867(e)(3) of the Social Security Act (42 U.S.C. 
                1395dd(e)(3)).
    ``(c) 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 
        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 with respect to coverage of 
        pediatric care.
    ``(d) 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 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 participating 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 treatment plan (if 
                any) approved by the plan.
                    ``(B) Obstetrical and gynecological care.--A group 
                health plan described in paragraph (2) shall treat the 
                provision of obstetrical and gynecological 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 
                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 
                beneficiary 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 of treatment decisions.
    ``(e) Coverage of Non-Emergency Services Performed by 
Nonparticipating Providers at Certain Participating Facilities.--
            ``(1) In general.--In the case of items or services (other 
        than emergency services to which subsection (b) 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 
        (b)(3)(G)(i)) (and who, with respect to such items and 
        services, has not satisfied the notice and consent criteria of 
        section 2799A-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, 
        the plan--
                    ``(A) shall not impose on such participant or 
                beneficiary a cost-sharing amount (expressed as a 
                copayment amount or coinsurance rate) for such items 
                and services so furnished that is greater than the 
                cost-sharing amount that would apply under such plan 
                had such items or services been furnished by a 
                participating provider (as defined in subsection 
                (b)(3)(G)(ii));
                    ``(B) shall calculate such cost-sharing amount 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 
                subsection (b)(3)(H)) for such items and services, 
                plan, and year;
                    ``(C) shall pay to such provider furnishing such 
                items and services to such participant or beneficiary 
                the amount by which the recognized amount (as defined 
                in subsection (b)(3)(H)) for such items and services 
                and year involved exceeds the cost-sharing amount 
                imposed under the plan for such items and services (as 
                determined in accordance with subparagraphs (A) and 
                (B)); and
                    ``(D) 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 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 contractual relationship with the 
                        plan, 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, 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) of such 
                                Act).
                                    ``(IV) An ambulatory surgical 
                                center (as defined in section 
                                1833(i)(1)(A) of such Act).
                                    ``(V) Any other facility 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 
                participating health care facility, include equipment 
                and devices, telemedicine services, imaging services, 
                laboratory 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.
    ``(f) Air Ambulance Services.--
            ``(1) In general.--In the case of a participant or 
        beneficiary in a group health plan who receives air ambulance 
        services from a nonparticipating provider (as defined in 
        subsection (b)(3)(G)) with respect to such plan or coverage, if 
        such services would be covered if provided by a participating 
        provider (as defined in such subsection) with respect to such 
        plan--
                    ``(A) the cost-sharing requirement (expressed as a 
                copayment amount, coinsurance rate, or deductible) with 
                respect to such services shall be the same requirement 
                that would apply if such services were provided by such 
                a participating provider, and any coinsurance or 
                deductible shall be based on rates that would apply for 
                such services if they were furnished by such a 
                participating provider;
                    ``(B) such cost-sharing amounts shall be counted 
                toward the in-network deductible and in-network out-of-
                pocket maximum amount under the plan for the plan year 
                (and such in-network deductible shall 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; and
                    ``(C) the plan or coverage shall pay to such 
                provider furnishing such services to such participant 
                or beneficiary the amount by which the recognized 
                amount (as defined in and determined pursuant to 
                subsection (b)(3)(H)(ii)) for such services and year 
                involved exceeds the cost-sharing amount imposed under 
                the plan for such services (as determined in accordance 
                with subparagraphs (A) and (B)).
            ``(2) Air ambulance service defined.--For purposes of this 
        section, the term `air ambulance service' means medical 
        transport by helicopter or airplane for patients.
    ``(g) Certain Access Fees to Certain Databases.--In the case of a 
sponsor of a group health plan that, pursuant to subsection 
(b)(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 shall 
cover the cost for access to such database.''.
            (2) Clerical amendment.--The table of sections for 
        subchapter 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. Consumer protections.''.
    (d) Additional Application Provisions.--
            (1) Application to fehb.--
                    (A) In general.--Section 8902 of title 5, United 
                States Code, is amended by adding at the end the 
                following new subsection:
    ``(p) Each contract under this chapter shall require the carrier to 
comply with requirements described in the provisions of section 2719A 
of the Public Health Service Act and sections 2730 and 2731 of such 
Act, sections 716, 717, and 718 of the Employee Retirement Income 
Security Act of 1974, sections 9816, 9817, and 9818 of the Internal 
Revenue Code of 1986 (as applicable), and section 2(d) of the Ban 
Surprise Billing Act in the same manner as such provisions apply to a 
group health plan or health insurance issuer offering health insurance 
coverage, as described in such sections. The provisions of sections 
2799A-1, 2799A-2, 2799A-3, and 2799A-4 of the Public Health Service Act 
shall apply to a health care provider and facility and an air ambulance 
provider described in such respective sections with respect to a 
participant, beneficiary, or enrollee in a health benefits plan under 
this chapter in the same manner as such provisions apply to such a 
provider and facility with respect to an enrollee in a group health 
plan or health insurance coverage offered by a health insurance issuer 
in the group or individual market, as described in such sections.''.
                    (B) Effective date.--The amendment made by this 
                paragraph shall apply with respect to contracts entered 
                into or renewed for contract years beginning on or 
                after January 1, 2022.
            (2) Application to grandfathered plans.--Section 1251(a) of 
        the Patient Protection and Affordable Care Act (42 U.S.C. 
        18011(a)) is amended by adding at the end the following:
            ``(5) Application of additional provisions.--Subsections 
        (b), (e), (f), (g), and (h) of section 2719A of the Public 
        Health Service Act shall apply to grandfathered health plans 
        for plan years beginning on or after January 1, 2022.''.
            (3) Coordination.--The Secretary of the Treasury, the 
        Secretary of Health and Human Services, and the Secretary of 
        Labor shall ensure, through the execution of an interagency 
        memorandum of understanding among such Secretaries, that--
                    (A) regulations, rulings, and interpretations 
                issued by such Secretaries relating to the same matter 
                over which two or more such Secretaries have 
                responsibility under this title (and the amendments 
                made by this title) are administered so as to have the 
                same effect at all times; and
                    (B) coordination of policies relating to enforcing 
                the same requirements through such Secretaries in order 
                to have a coordinated enforcement strategy that avoids 
                duplication of enforcement efforts and assigns 
                priorities in enforcement.
            (4) Rule of construction.--Nothing in this title, including 
        the amendments made by this title may be construed as 
        modifying, reducing, or eliminating--
                    (A) the protections under section 222 of the Indian 
                Health Care Improvement Act (25 U.S.C. 1621u) and under 
                subpart I of part 136 of title 42, Code of Federal 
                Regulations (or any successor regulation), against 
                payment liability for a patient who receives contract 
                health services that are authorized by the Indian 
                Health Service; or
                    (B) the requirements under section 1866(a)(1)(U) of 
                the Social Security Act (42 U.S.C. 1395cc(a)(1)(U)).
    (e) Effective Date.--The amendments made by this section shall 
apply with respect to plan years beginning on or after January 1, 2022.

SEC. 3. PREVENTING CERTAIN CASES OF BALANCE BILLING.

    (a) In General.--Title XXVII of the Public Health Service Act (42 
U.S.C. 300gg et seq.) is amended by adding at the end the following new 
part:

              ``PART D--HEALTH CARE PROVIDER REQUIREMENTS

``SEC. 2799A-1. BALANCE BILLING IN CASES OF EMERGENCY SERVICES.

    ``(a) In General.--In the case of a participant, beneficiary, or 
enrollee with benefits under a group health plan or health insurance 
coverage offered by a health insurance issuer in the group or 
individual market who is furnished during a plan year beginning on or 
after January 1, 2022, emergency services for which any benefit is 
provided under such plan or coverage with respect to an emergency 
medical condition with respect to a visit at an emergency department of 
a hospital or an independent freestanding emergency department--
            ``(1) in the case that the hospital or independent 
        freestanding emergency department is a nonparticipating 
        emergency facility, the emergency department of a hospital or 
        independent freestanding emergency department shall not hold 
        the participant, beneficiary, or enrollee liable for a payment 
        amount for such emergency services so furnished that is more 
        than the cost-sharing amount for such services (as determined 
        in accordance with clauses (ii) and (iii) of section 
        2719A(b)(1)(C), section 716(b)(1)(C) of the Employee Retirement 
        Income Security Act of 1974, and section 9816(b)(1)(C) of the 
        Internal Revenue Code of 1986, as applicable); and
            ``(2) in the case that such services are furnished by a 
        nonparticipating provider, the health care provider shall not 
        hold such participant, beneficiary, or enrollee liable for a 
        payment amount for an emergency service furnished to such 
        individual by such provider with respect to such emergency 
        medical condition and visit for which the individual receives 
        emergency services at the hospital or emergency department that 
        is more than the cost-sharing amount for such services 
        furnished by the provider (as determined in accordance with 
        clauses (ii) and (iii) of section 2719A(b)(1)(C), section 
        716(b)(1)(C) of the Employee Retirement Income Security Act of 
        1974, and section 9816(b)(1)(C) of the Internal Revenue Code of 
        1986, as applicable).
    ``(b) Definition.--In this section, the term `visit' shall have 
such meaning as applied to such term for purposes of section 2719A(e).

``SEC. 2799A-2. BALANCE BILLING IN CASES OF NON-EMERGENCY SERVICES 
              PERFORMED BY NONPARTICIPATING 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 group 
health plan or health insurance coverage offered by a health insurance 
issuer in the group or individual market who is furnished during a plan 
year beginning on or after January 1, 2022, items or services (other 
than emergency services to which section 2799A-1 applies) for which any 
benefit is provided under such plan or coverage at a participating 
health care facility by a nonparticipating provider, such provider 
shall not bill, and shall not hold liable, such participant, 
beneficiary, or enrollee for a payment amount for such an item or 
service furnished by such provider with respect to 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), section 716(e)(1) of the Employee Retirement 
Income Security Act of 1974, and section 9816(e)(1) of the Internal 
Revenue Code of 1986, as applicable).
    ``(b) Exception.--
            ``(1) In general.--Subsection (a) shall not apply with 
        respect to items or services (other than ancillary services 
        described in paragraph (2)) furnished by a nonparticipating 
        provider to a participant, beneficiary, or enrollee of a group 
        health plan or health insurance coverage offered by a health 
        insurance issuer in the group or individual market, if the 
        provider satisfies the notice and consent criteria of 
        subsection (d).
            ``(2) Ancillary services described.--For purposes of 
        paragraph (1), ancillary services described in this paragraph 
        are, with respect to a participating health care facility--
                    ``(A) subject to paragraph (3), items and services 
                related to emergency medicine, anesthesiology, 
                pathology, radiology, and neonatology, whether or not 
                provided by a physician or non-physician practitioner, 
                and items and services provided by assistant surgeons, 
                hospitalists, and intensivists;
                    ``(B) subject to paragraph (3), diagnostic services 
                (including radiology and laboratory services);
                    ``(C) items and services provided by such other 
                specialty practitioners, as the Secretary specifies 
                through rulemaking; and
                    ``(D) items and services provided by a 
                nonparticipating provider if there is no participating 
                provider who can furnish such item or service at such 
                facility.
            ``(3) Exception.--The Secretary may, through rulemaking, 
        establish a list (and update such list) of advanced diagnostic 
        laboratory tests, which shall not be included as an ancillary 
        service described in paragraph (2) and with respect to which 
        subsection (a) would apply.
    ``(c) Clarification.--In the case of a nonparticipating provider 
that satisfies the notice and consent criteria of subsection (d) with 
respect to an item or service (referred to in this subsection as a 
`covered item or service'), such notice and consent criteria may not be 
construed as applying with respect to any item or service that is 
furnished as a result of unforeseen, urgent medical needs that arise at 
the time such covered item or service is furnished. For purposes of the 
previous sentence, a covered item or service shall not include an 
ancillary service described in subsection (b)(2).
    ``(d) Notice and Consent To Be Treated by a Nonparticipating 
Provider or Nonparticipating Facility.--
            ``(1) In general.--A nonparticipating provider or 
        nonparticipating facility satisfies the notice and consent 
        criteria of this subsection, with respect to items or services 
        furnished by the provider or facility to a participant, 
        beneficiary, or enrollee of a group health plan or health 
        insurance coverage offered by a health insurance issuer in the 
        group or individual market, if the provider (or, if applicable, 
        the participating health care facility on behalf of such 
        provider) or nonparticipating facility--
                    ``(A) provides to the participant, beneficiary, or 
                enrollee (or to an authorized representative of the 
                participant, beneficiary, or enrollee) 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 in paper or 
                        electronic form (and including electronic 
                        notification, as practicable) specified by the 
                        Secretary, not later than July 1, 2021, through 
                        guidance (which shall be updated as determined 
                        necessary by the Secretary) that--
                                    ``(I) contains the information 
                                required under paragraph (2);
                                    ``(II) clearly states that consent 
                                to receive such items and services from 
                                such nonparticipating provider or 
                                nonparticipating facility is optional 
                                and that the participant, beneficiary, 
                                or enrollee may instead seek care from 
                                a participating provider or at a 
                                participating facility, with respect to 
                                such plan or coverage, as applicable, 
                                in which case the cost-sharing 
                                responsibility of the participant, 
                                beneficiary, or enrollee would not 
                                exceed such responsibility that would 
                                apply with respect to such an item or 
                                service that is furnished by a 
                                participating provider or participating 
                                facility, as applicable with respect to 
                                such plan;
                                    ``(III) is available in the fifteen 
                                most common languages in the geographic 
                                region of the applicable facility and, 
                                in the case the primary language of the 
                                beneficiary, participant, or enrollee, 
                                respectively, is not one of such 15 
                                languages, makes a good faith effort to 
                                also provide such notice orally in such 
                                primary language of the beneficiary, 
                                participant, or enrollee; and
                                    ``(IV) 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 described in section 
                                2719A(b)(3)(C)(ii), is so signed and 
                                dated not less than 72 hours prior to 
                                the participant, beneficiary, or 
                                enrollee being furnished such items or 
                                services by such provider; and
                    ``(B) obtains from the participant, beneficiary, or 
                enrollee (or from such an authorized representative) 
                the consent described in paragraph (3) to be treated by 
                a nonparticipating provider or nonparticipating 
                facility.
            ``(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 group health plan or health insurance coverage 
        offered by a health insurance issuer in the group or individual 
        market, is each of the following:
                    ``(A) Notification, as applicable, that the health 
                care provider is a nonparticipating provider 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 good faith estimated 
                amount that such provider or facility may charge the 
                participant, beneficiary, or enrollee for such items 
                and services involved, including a notification that 
                the provision of such estimate or consent to be treated 
                under paragraph (3) does not constitute a contract with 
                respect to the charges estimated for such items and 
                services.
                    ``(C) In the case of a participating facility and a 
                nonparticipating provider, a list of any participating 
                providers at the facility who are able to furnish such 
                items and services involved and notification that the 
                participant, beneficiary, or enrollee may be referred, 
                at their option, to such a participating provider.
                    ``(D) Information about whether prior authorization 
                or other care management limitations may be required in 
                advance of receiving such items or services at the 
                facility.
            ``(3) Consent described to be treated by a nonparticipating 
        provider or nonparticipating facility.--For purposes of 
        paragraph (1)(B), the consent described in this paragraph, with 
        respect to a participant, beneficiary, or enrollee of a group 
        health plan or health insurance coverage offered by a health 
        insurance issuer in the group or individual market who is to be 
        furnished items or services by a nonparticipating provider or 
        nonparticipating facility, is a document specified by the 
        Secretary through rulemaking, in consultation with the 
        Secretary of Labor, that--
                    ``(A) acknowledges that the participant, 
                beneficiary, or enrollee has been--
                            ``(i) provided with a written good faith 
                        estimate and an oral explanation of the charge 
                        that may be applied for the items or services 
                        anticipated to be furnished 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 plan or coverage places on 
                        cost-sharing, including an explanation that 
                        such payment may not apply to an in-network 
                        deductible applied under the plan or coverage; 
                        and
                    ``(B) documents the consent of the participant, 
                beneficiary, or enrollee to be furnished such item or 
                services by such provider or facility.
            ``(4) Rule of construction.--The consent described in 
        paragraph (3), with respect to a participant, beneficiary, or 
        enrollee of a group health plan or health insurance coverage 
        offered by a health insurance issuer in the group or individual 
        market, shall constitute only consent to the receipt of the 
        information provided pursuant to this subsection and shall not 
        constitute a contractual agreement of the participant, 
        beneficiary, or enrollee to any estimated charge or amount 
        included in such information.
    ``(e) Retention of Certain Documents.--A nonparticipating facility 
(with respect to such facility or any nonparticipating provider at such 
facility) or a participating facility (with respect to nonparticipating 
providers at such facility) that obtains from a participant, 
beneficiary, or enrollee of a group health plan or health insurance 
coverage offered by a health insurance issuer in the group or 
individual market (or an authorized representative of such participant, 
beneficiary, or enrollee) a written notice in accordance with 
subsection (d)(1)(A)(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 term `participating health care facility' has the 
        meaning given such term 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 group 
                health plan or health insurance coverage offered by a 
                health insurance issuer in the group or individual 
                market, an emergency department of a hospital, or an 
                independent freestanding emergency department, that 
                does not have a contractual relationship with the plan 
                or issuer, respectively, with respect to the furnishing 
                of such services under the plan or coverage, 
                respectively; and
                    ``(B) with respect to services described in section 
                2719A(b)(3)(C)(ii) and a group health plan or health 
                insurance coverage offered by a health insurance issuer 
                in the group or individual market, a hospital or an 
                independent freestanding emergency department, that 
                does not have a contractual relationship with the plan 
                or issuer, respectively, with respect to the furnishing 
                of such services under the plan or coverage, 
                respectively.
            ``(4) The term `participating facility' means--
                    ``(A) with respect to emergency services (as 
                defined in clause (i) of section 2719A(b)(3)(C)) that 
                are not described in clause (ii) of such section and a 
                group health plan or health insurance coverage offered 
                by a health insurance issuer in the group or individual 
                market, an emergency department of a hospital, or an 
                independent freestanding emergency department, that has 
                a contractual relationship with the plan or issuer, 
                respectively, with respect to the furnishing of such 
                services under the plan or coverage, respectively; and
                    ``(B) with respect to services that pursuant to 
                clause (ii) of section 2719A(b)(3)(C) are included as 
                emergency services (as defined in clause (i) of such 
                section) and a group health plan or health insurance 
                coverage offered by a health insurance issuer in the 
                group or individual market, a hospital or an 
                independent freestanding emergency department, that has 
                a contractual relationship with the plan or coverage, 
                respectively, with respect to the furnishing of such 
                services under the plan or coverage, respectively.

``SEC. 2799A-3. PROVIDER REQUIREMENT WITH RESPECT TO PUBLIC PROVISION 
              OF INFORMATION.

    ``(a) In General.--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 and provide to individuals 
who are participants, beneficiaries, or enrollees of a group health 
plan or health insurance coverage offered by a health insurance issuer 
in the group or individual market a one-page notice in plain language 
containing information on--
            ``(1) the requirements and prohibitions of such provider or 
        facility under sections 2799A-1, 2799A-2, and 2799A-4 (relating 
        to prohibitions on balance billing in certain circumstances);
            ``(2) 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 
        group health plan or health insurance coverage offered by a 
        health insurance issuer in the group or individual market with 
        respect to which such provider or facility does not have a 
        contractual relationship for furnishing such item or service 
        under the plan or coverage, respectively, after receiving 
        payment from the plan or coverage, respectively, for such item 
        or service and any applicable cost-sharing payment from such 
        participant, beneficiary, or enrollee; and
            ``(3) information on contacting appropriate State and 
        Federal agencies in the case that an individual believes that 
        such provider or facility has violated any requirement 
        described in paragraph (1) or (2) with respect to such 
        individual.
    ``(b) Guidance.--Not later than 6 months after the date of the 
enactment of this section, the Secretary, in consultation with the 
Secretary of Labor, shall issue guidance on the requirements for the 
notice under this section.

``SEC. 2799A-4. AIR AMBULANCE SERVICES.

    ``In the case of a participant, beneficiary, or enrollee with 
benefits under a group health plan or health insurance coverage offered 
by a health insurance issuer in the group or individual market who is 
furnished on or after January 1, 2022, air ambulance services from a 
nonparticipating provider (as defined in section 2719A(b)(3)(G)) with 
respect to such plan or coverage, such provider shall not bill, and 
shall not hold liable, such participant, beneficiary, or enrollee for a 
payment amount for such service furnished by such provider that is more 
than the cost-sharing amount for such service (as determined in 
accordance with paragraphs (1) and (2) of section 2719A(f), section 
716(f) of the Employee Retirement Income Security Act of 1974, or 
section 9816(f) of the Internal Revenue Code of 1986, as applicable).

``SEC. 2799A-5. ENFORCEMENT.

    ``(a) State Enforcement.--
            ``(1) State authority.--Each State may require a provider 
        or health care facility (including a provider of air ambulance 
        services) subject to the requirements of this part (except 
        section 2799A-5) to satisfy such requirements applicable 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 requirements specified in paragraph 
        (1) with respect to applicable providers and facilities in the 
        State, the Secretary shall enforce such requirements under 
        subsection (b) insofar as they relate to violations of such 
        requirements occurring in such State.
            ``(3) Notification of secretary of labor.--A State may 
        notify the Secretary of Labor of instances of violations of 
        sections 2799A-1, 2799A-2, or 2799A-4 with respect to 
        participants or beneficiaries under a group health plan or 
        health insurance coverage offered by a health insurance issuer 
        in the group market and any enforcement actions taken against 
        providers or facilities as a result of such violations, 
        including the disposition of any such enforcement actions.
    ``(b) Secretarial Enforcement Authority.--
            ``(1) In general.--If a provider or facility is found to be 
        in violation of a requirement specified in subsection (a)(1) by 
        the Secretary, the Secretary may apply a civil monetary penalty 
        with respect to such provider or facility (including, as 
        applicable, a provider of air ambulance services) in an amount 
        not to exceed $10,000 per violation. The provisions of 
        subsections (c) (with the exception of the first sentence of 
        paragraph (1) of such subsection), (d), (e), (g), (h), (k), and 
        (l) of section 1128A of the Social Security 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 provisions) specified 
        in subsection (a)(1) only as provided under subsection (a)(2).
            ``(3) Complaint process.--The Secretary shall, through 
        rulemaking conducted in consultation with the Secretary of 
        Labor, establish a process to receive consumer complaints of 
        violations of such provisions and resolve such complaints 
        within 60 days of receipt of such complaints. Such process 
        shall provide that the Secretary of Labor be informed of 
        complaints by participants or beneficiaries under a group 
        health plan or health insurance coverage offered by a health 
        insurance issuer in the group market and any enforcement 
        actions against providers resulting from such complaints, 
        including the disposition of any such enforcement actions.
            ``(4) Exception.--The Secretary may waive the penalties 
        described under paragraph (1) with respect to a facility or 
        provider (including a provider of air ambulance services) who 
        does not knowingly violate, and should not have reasonably 
        known it violated, sections 2799A-1, 2799A-2, or 2799A-4 with 
        respect to a participant, beneficiary, or enrollee, if such 
        facility or provider, within 30 days of the violation, 
        withdraws the bill that was in violation of such provision and 
        reimburses the health plan or participant, beneficiary, 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 prohibition except to the extent that such requirement 
or prohibition prevents the application of a requirement or prohibition 
of such a section.''.
    (b) Secretary of Labor Investigative Authority.--
            (1) In general.--Part 5 of subtitle B of title I of the 
        Employee Retirement Income Security Act of 1974 (29 U.S.C. 1131 
        et seq.) is amended by adding at the end the following new 
        section:

``SEC. 522. INVESTIGATIVE AUTHORITY REGARDING VIOLATIONS OF CERTAIN 
              HEALTH CARE PROVIDER REQUIREMENTS; COMPLAINT PROCESS.

    ``(a) Investigative Authority.--Upon receiving a notice from a 
State or the Secretary of Health and Human Services of violations of 
sections 2799A-1, 2799A-2, or 2799A-4 of the Public Health Service Act, 
the Secretary of Labor shall have the power to conduct an investigation 
to identify patterns of such violations with respect to participants or 
beneficiaries under a group health plan or health insurance coverage 
offered in connection with a group health plan by a health insurance 
issuer in the group market. The Secretary may assist States, the 
Secretary of Health and Human Services, plans, or issuers to ensure 
that appropriate measures have been taken to correct such violations 
retrospectively and prospectively with respect to participants or 
beneficiaries under a group health plan or health insurance coverage 
offered in connection with a group health plan by a health insurance 
issuer in the group market.
    ``(b) Complaint Process.--Not later than January 1, 2022, the 
Secretary shall establish a process under which the Secretary--
            ``(1) may receive complaints from participants and 
        beneficiaries of group health plans or health insurance 
        coverage offered in connection with such plans relating to 
        alleged violations of the sections specified in subsection (a); 
        and
            ``(2) transmits such complaints to States or the Secretary 
        of Health and Human Services (as determined appropriate by the 
        Secretary) for potential enforcement actions.''.
            (2) Technical amendment.--The table of contents in section 
        1 of the Employee Retirement Income Security Act of 1974 (29 
        U.S.C. 1001 et seq.) is amended by inserting after the item 
        relating to section 521 the following new item:

``Sec. 522. Investigative authority regarding violations of certain 
                            health care provider requirements; 
                            complaint process.''.
    (c) Disclosure of Certain Protections Against Balance Billing.--
Section 716 of the Employee Retirement Income Security Act of 1974, as 
added by section 2, is further amended by adding at the end the 
following new subsection:
    ``(h) Disclosure of Certain Protections Against Balance Billing.--
Each group health plan and health insurance issuer offering group 
health insurance coverage shall make publicly available, and (if 
applicable) post on a public website of such plan or issuer--
            ``(1) information in plain language on--
                    ``(A) the requirements and prohibitions applied 
                under sections 2799A-1, 2799A-2 and 2799A-4 of the 
                Public Health Service Act (relating to prohibitions on 
                balance billing in certain circumstances);
                    ``(B) if provided for under applicable State law, 
                any other requirements on providers and facilities 
                regarding the amounts such providers and facilities 
                may, with respect to an item or service, charge a 
                participant, beneficiary, or enrollee of such plan or 
                coverage with respect to which such a provider or 
                facility does not have a contractual relationship for 
                furnishing such item or service under the plan or 
                coverage after receiving payment from the plan or 
                coverage for such item or service and any applicable 
                cost-sharing payment from such participant, 
                beneficiary, or enrollee; and
                    ``(C) the requirements applied under subsections 
                (b), (e), and (f); and
            ``(2) information on contacting appropriate State and 
        Federal agencies in the case that an individual believes that 
        such a provider or facility has violated any requirement 
        described in paragraph (1) with respect to such individual.''.

SEC. 4. INDEPENDENT DISPUTE RESOLUTION PROCESS.

    (a) Establishment.--
            (1) In general.--Not later than 1 year after the date of 
        the enactment of this section, the Secretary of Health and 
        Human Services, the Secretary of Labor, and the Secretary of 
        the Treasury (in this section referred to as the 
        ``Secretaries'') shall jointly establish by regulation an 
        independent dispute resolution process (in this section 
        referred to as the ``IDR process'') under which, with respect 
        to a payment made by a group health plan or health insurance 
        issuer offering health insurance coverage in the group or 
        individual market pursuant to subsection (b)(1), (e)(1), or 
        (f)(1) of section 2719A of the Public Health Service Act, 
        section 716 of the Employee Retirement Income Security Act of 
        1974, or section 9816 of the Internal Revenue Code of 1986 (as 
        applicable) using the recognized amount (as defined in and 
        determined pursuant to section 2719A(b)(3)(H)(ii) of the Public 
        Health Service Act or subsection (b)(3)(H)(ii) of section 716 
        of the Employee Retirement Income Security Act of 1974 or 
        section 9816 of the Internal Revenue Code of 1986, as 
        applicable) to a nonparticipating provider (as defined in 
        subparagraph (G) of section 2719A(b)(3) of the Public Health 
        Service Act or subparagraph (G) of subsection (b)(3) of section 
        716 of the Employee Retirement Income Security Act of 1974 or 
        section 9816 of the Internal Revenue Code of 1986, as 
        applicable) or a nonparticipating emergency facility (as 
        defined in subparagraph (F) of such section 2719A(b)(3) or such 
        subsection (b)(3) of such section 716 or such section 9816, as 
        applicable) with respect to an item or service (or, in the case 
        of payment made under section 2719A(f)(1) of the Public Health 
        Service Act or subsection (f)(1) of section 716 of the Employee 
        Retirement Income Security Act of 1974 or section 9816 of the 
        Internal Revenue Code of 1986, as applicable, with respect to 
        air ambulance services) furnished by such provider or 
        facility--
                    (A) subject to subparagraph (B), the 
                nonparticipating provider, nonparticipating emergency 
                facility, or group health plan or health insurance 
                issuer, respectively, may, not later than the date 
                specified in paragraph (2), submit a request that such 
                payment should be increased or decreased; and
                    (B) in the case a settlement described in 
                subsection (d)(2) is not reached with respect to such 
                request, an entity certified and selected under 
                subsection (c) shall determine in accordance with such 
                paragraph an alternative payment to be applied, with 
                respect to such request.
            (2) Date specified.--For purposes of paragraph (1)(A), the 
        date specified in this paragraph is--
                    (A) in the case of a request described in such 
                paragraph (1)(A) being submitted by a nonparticipating 
                provider or nonparticipating emergency facility, with 
                respect to items and services (or air ambulance 
                services) described in paragraph (1), the date that is 
                30 days after the applicable date described in 
                subsection (b)(2)(A)(ii); or
                    (B) in the case of such a request filed by a group 
                health plan or health insurance issuer, the date that 
                is 30 days after the date of the submission of the 
                notice described in subsection (b)(1)(B)(ii).
            (3) Clarification.--A nonparticipating provider may not, 
        with respect to an item or service (or air ambulance service) 
        furnished by such provider, submit a request under the IDR 
        process if such provider is exempt from the requirement under 
        subsection (a) of section 2799A-2 of the Public Health Service 
        Act with respect to such item or service pursuant to subsection 
        (e) of such section.
    (b) Requirements for Requests To Be Eligible for Submission Under 
IDR Process.--
            (1) Timing requirements.--A request may not be submitted 
        under the IDR process, with respect to items and services (or 
        air ambulance services) furnished by a nonparticipating 
        provider or nonparticipating emergency facility for which a 
        group health plan or health insurance issuer offering health 
        insurance coverage in the group or individual market made a 
        payment pursuant to subsection (b)(1), (e)(1), or (f)(1) of 
        section 2719A of the Public Health Service Act or subsection 
        (b)(1), (e)(1), or (f)(1) of section 716 of the Employee 
        Retirement Income Security Act of 1974 or section 9816 of the 
        Internal Revenue Code of 1986 (as applicable) unless--
                    (A) in the case such request is being submitted by 
                the nonparticipating provider or nonparticipating 
                emergency facility--
                            (i) the provider or facility, respectively, 
                        filed, not later than 30 days after the date 
                        such payment is received by the provider or 
                        facility, respectively, an appeal under the 
                        appeals process of the group health plan or 
                        health insurance issuer, the subject of which 
                        includes the payment for such items and 
                        services (or air ambulance services); and
                            (ii) such request is not submitted before 
                        the sooner of the date on which such appeal has 
                        been resolved or the date that is 30 days after 
                        the date on which such appeal is so filed; or
                    (B) in the case such request is being submitted by 
                the group health plan or health insurance issuer--
                            (i) the group health plan or health 
                        insurance issuer, respectively, not later than 
                        30 days after such provider or facility, 
                        respectively, receives such payment, submits to 
                        such provider or facility, respectively, a 
                        notice that such plan or issuer, respectively, 
                        disputes the amount of such payment with 
                        respect to such items and services (or air 
                        ambulance services); and
                            (ii) such request is not submitted before 
                        the date that is 30 days after the date of the 
                        submission of such notice.
            (2) Minimum median contracted rate.--A request may not be 
        submitted under the IDR process, with respect to items and 
        services (or air ambulance services) furnished in a geographic 
        area by a nonparticipating provider or nonparticipating 
        emergency facility for which a group health plan or health 
        insurance issuer offering health insurance coverage in the 
        group or individual market made a payment pursuant to 
        subsection (b)(1), (e)(1), or (f)(1) of section 2719A of the 
        Public Health Service Act or subsection (b)(1), (e)(1), or 
        (f)(1) of section 716 of the Employee Retirement Income 
        Security Act of 1974 or section 9816 of the Internal Revenue 
        Code of 1986 (as applicable) unless--
                    (A) in the case such item or service is furnished 
                during 2022, the median contracted rate (as defined in 
                subsection (b)(3)(E) of section 2719A of the Public 
                Health Service Act or subsection (b)(3)(E) of section 
                716 of the Employee Retirement Income Security Act of 
                1974 or section 9816 of the Internal Revenue Code of 
                1986 (as applicable)) for such year under such plan or 
                such coverage with respect to each such item or service 
                furnished by such a provider or such a facility in such 
                area is at least $750 (or, in the case of air ambulance 
                services, is at least $25,000); or
                    (B) in the case such item or service (or air 
                ambulance services) is furnished during a subsequent 
                year, the median contracted rate (as so defined) for 
                such year under such plan or such coverage with respect 
                to each such item or service furnished by such a 
                provider or such a facility in such area is at least 
                the amount applied under this paragraph for 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.
            (3) Limitation on batching of items and services in a 
        request.--A request may not be submitted under the IDR process 
        by a nonparticipating provider, nonparticipating emergency 
        facility, or a group health plan or health insurance issuer 
        offering health insurance coverage in the group or individual 
        market, with respect to multiple items and services (or 
        multiple air ambulance services), unless--
                    (A) all such items and services (or air ambulance 
                services) included in such request are furnished by the 
                same provider or facility;
                    (B) payment for all such items and services (or air 
                ambulance services) made pursuant to subsection (b)(1), 
                (e)(1), or (f)(1) of section 2719A of the Public Health 
                Service Act or subsection (b)(1), (e)(1), or (f)(1) of 
                section 716 of the Employee Retirement Income Security 
                Act of 1974 or section 9816 of the Internal Revenue 
                Code of 1986 (as applicable) was made by a single group 
                health plan or health insurance coverage;
                    (C) all such items and services (or air ambulance 
                services) are related to the treatment of the same 
                condition; and
                    (D) all such items and services were furnished 
                during the 30-day period following the date on which 
                the first item or service (or air ambulance service) 
                included in such request was furnished.
    (c) IDR Entities.--
            (1) Process of certification.--The process described in 
        subsection (a) shall include a certification process under 
        which eligible entities may be certified to carry out the IDR 
        process.
            (2) Certification.--
                    (A) In general.--An entity wishing to participate 
                in the IDR process under this section shall request 
                certification from the Secretaries. The Secretaries 
                shall determine whether or not to certify applicant 
                entities, taking into consideration whether the entity 
                is unbiased and unaffiliated with health insurance 
                issuers, group health plans, health care facilities, 
                and health care providers and free of conflicts of 
                interest, in accordance with the Secretaries' 
                rulemaking on determining criteria for conflicts of 
                interest.
                    (B) Eligible entities.--For purposes of this 
                section, an eligible entity is an entity that is a 
                nongovernmental entity and that agrees to comply with 
                the fee limitations described in subparagraph (C).
                    (C) Fee limitations.--For purposes of subparagraph 
                (B), the fee limitations described in this subparagraph 
                are limitations established by the Secretaries for the 
                amount a certified IDR entity may charge a 
                nonparticipating provider, nonparticipating emergency 
                facility, group health plan, or health insurance issuer 
                offering heath insurance coverage in the group or 
                individual market for services furnished by such entity 
                with respect to the resolution of a specified request 
                of such provider, facility, plan, or issuer under the 
                process described in subsection (a).
            (3) Selection of certified idr entity.--The group health 
        plan or health insurance issuer offering health insurance 
        coverage in the group or individual market and the 
        nonparticipating provider or the nonparticipating emergency 
        facility (as applicable) involved in a request submitted under 
        the IDR process shall agree on a certified IDR entity to 
        resolve such request. In the case that such plan or issuer (as 
        applicable) and such provider or facility (as applicable) 
        cannot so agree, such an entity shall be selected by the 
        Secretaries at random, in accordance with a manner and timeline 
        specified by the Secretaries.
    (d) Payment Determination.--
            (1) Timing.--A certified IDR entity selected under 
        subsection (c)(3) with respect to a request under the IDR 
        process shall, subject to paragraph (2), not later than 30 days 
        after being so selected, determine the alternative payment that 
        should be made for items and services (or air ambulance 
        services) included in such request in accordance with paragraph 
        (3).
            (2) Settlement.--
                    (A) In general.--If such entity determines that a 
                settlement between the group health plan or issuer, as 
                applicable, and the provider or facility, as 
                applicable, is likely with respect to a request under 
                the IDR process, the entity may direct the parties to 
                attempt, for a period not to exceed 10 days, a good 
                faith negotiation for a settlement of such request.
                    (B) Timing.--The period for a settlement described 
                in subparagraph (A) shall accrue toward the 30-day 
                period described in paragraph (1).
            (3) Determination of alternative payment.--
                    (A) In general.--The group health plan or health 
                insurance issuer offering health insurance coverage in 
                the group or individual market (as applicable) and the 
                nonparticipating provider or nonparticipating emergency 
                facility (as applicable) involved shall, with respect 
                to a request under the IDR process, each submit to the 
                certified IDR entity selected under subsection (c)(3) 
                for such request a final offer to be considered for the 
                alternative payment to be applied with respect to items 
                and services (or air ambulance services) which are the 
                subject of the request. Such entity shall determine, in 
                accordance with subparagraph (B), which such offer is 
                the most reasonable and will be applied as the 
                alternative payment.
                    (B) Considerations in determination.--
                            (i) In general.--In determining which final 
                        offer is the alternative payment to be applied, 
                        the certified IDR entity selected under 
                        subsection (c)(3) for such request shall 
                        consider--
                                    (I) the median contracted rates (as 
                                defined in subsection (b)(3)(E) of 
                                section 2719A of the Public Health 
                                Service Act or subsection (b)(3)(E) of 
                                section 716 of the Employee Retirement 
                                Income Security Act of 1974 or section 
                                9816 of the Internal Revenue Code of 
                                1986 (as applicable)) for the 
                                applicable year for items or services 
                                (or air ambulance services) that are 
                                comparable to the items and services 
                                (or air ambulance services) included in 
                                the request and that are furnished in 
                                the same geographic area (as defined by 
                                the Secretaries for purposes of such 
                                subsection) as such items and services 
                                (or air ambulance services) (not 
                                including any facility fees with 
                                respect to such rates); and
                                    (II) in the case of items and 
                                services (other than air ambulances 
                                services), each circumstance described 
                                in clause (ii) with respect to which 
                                information is submitted by either 
                                party or, in the case of air ambulance 
                                services, each circumstance described 
                                in clause (iii) with respect to which 
                                information is submitted by either 
                                party.
                            (ii) Additional circumstances for certain 
                        items and services.--For purposes of clause 
                        (i)(II), the circumstances described in this 
                        clause are, with respect to items and services 
                        (other than air ambulance services) included in 
                        the request under the IDR process of a 
                        nonparticipating provider, nonparticipating 
                        emergency facility, group health plan, or 
                        health insurance issuer the following:
                                    (I) The level of training, 
                                education, experience, and quality and 
                                outcomes measurements of the provider 
                                or facility that furnished such items 
                                and services (such as those endorsed by 
                                the consensus-based entity authorized 
                                under section 1890 of the Social 
                                Security Act).
                                    (II) The market share held by the 
                                provider or facility, or the plan or 
                                issuer, in the geographic area in which 
                                the item or service was provided.
                                    (III) Any other extenuating 
                                circumstances with respect to the 
                                furnishing of such items and services 
                                that relate to the acuity of the 
                                individual receiving such items and 
                                services or the complexity of 
                                furnishing such items and services to 
                                such individual.
                            (iii) Additional circumstances for air 
                        ambulance services.--For purposes of clause 
                        (i)(II), the circumstances described in this 
                        clause are, with respect to air ambulance 
                        services included in the request under the IDR 
                        process of a nonparticipating provider, group 
                        health plan, or health insurance issuer the 
                        following:
                                    (I) The quality and outcomes 
                                measurements of the provider that 
                                furnished such services.
                                    (II) Any other extenuating 
                                circumstances with respect to the 
                                furnishing of such services that relate 
                                to the acuity of the individual 
                                receiving such services or the 
                                complexity of furnishing such services 
                                to such individual.
                                    (III) The training, education, 
                                experience, and quality of the medical 
                                personnel that furnished such services.
                                    (IV) Ambulance vehicle type, 
                                including the clinical capability level 
                                of such vehicle.
                                    (V) Population density of the pick 
                                up location (such as urban, suburban, 
                                rural, or frontier).
                            (iv) Prohibition on consideration of billed 
                        charges.--In determining which final offer is 
                        the alternative payment amount to be applied 
                        with respect to items and services (or air 
                        ambulance services) furnished by a provider or 
                        facility and included in the request under the 
                        IDR process, the certified IDR entity selected 
                        under subsection (c)(3) with respect to such 
                        request shall not consider the amount that 
                        would have been billed by such provider or 
                        facility with respect to such items and 
                        services had the provisions of section 2799A-1, 
                        2799A-2, or 2799A-4 of the Public Health 
                        Service Act (as applicable) not applied.
                    (C) Effects of determination.--
                            (i) In general.--A determination of a 
                        certified IDR entity under subparagraph (A) 
                        shall be binding.
                            (ii) Limitation on certain subsequent idr 
                        claims.--In the case of a determination of a 
                        certified IDR entity under subparagraph (A), 
                        with respect to a request submitted under 
                        subsection (a)(1)(A) and the two parties 
                        involved with such request, the party that 
                        submitted such initial request may not submit 
                        during the 90-day period following such 
                        determination a subsequent request under such 
                        subsection involving the same other party to 
                        such request with respect to such an item or 
                        service (or air ambulance service) that was the 
                        subject of such initial request.
                    (D) Costs of independent dispute resolution 
                process.--In the case of a request made by a 
                nonparticipating provider, nonparticipating emergency 
                facility, group health plan, or health insurance issuer 
                offering health insurance coverage in the group or 
                individual market and submitted to a certified IDR 
                entity--
                            (i) if such entity makes a determination 
                        with respect to such request under subparagraph 
                        (A), the party whose offer is not chosen under 
                        such clause shall be responsible for paying all 
                        fees charged by such entity; and
                            (ii) if the parties reach a settlement with 
                        respect to such request prior to such a 
                        determination, each party shall pay half of all 
                        fees charged by such entity, unless the parties 
                        otherwise agree.
                    (E) Payment.--Not later than 30 days after the date 
                on which a determination described in subparagraph (B) 
                is made with respect to a request under the IDR process 
                of a nonparticipating provider, nonparticipating 
                emergency facility, group health plan, or health 
                insurance issuer offering health insurance coverage in 
                the group or individual market--
                            (i) in the case that the alternative 
                        payment determined to be applied is greater 
                        than the amount paid with respect to such 
                        request, such plan or issuer (as applicable) 
                        shall pay directly to the provider or facility 
                        (as applicable) the difference between such 
                        alternative payment and the amount so paid; and
                            (ii) in the case that the alternative 
                        payment determined to be applied is less than 
                        the amount paid with respect to such request, 
                        such provider or facility (as applicable) shall 
                        pay directly to the plan or issuer (as 
                        applicable) the difference between the amount 
                        so paid and such alternative payment.
    (e) Publication of Information Relating to Disputes.--
            (1) Publication of information.--For 2022 and each 
        subsequent year, the Secretaries shall make available on the 
        public website of the Department of Health and Human Services, 
        the Department of Labor, and the Department of the Treasury--
                    (A) the number of requests submitted under the IDR 
                process during such year;
                    (B) the practice size of the providers and 
                facilities submitting requests under the IDR process 
                during such year;
                    (C) the number of such requests with respect to 
                which a final determination was made under subsection 
                (d)(3)(A); and
                    (D) the information described in paragraph (2) with 
                respect to each request with respect to which such a 
                determination was so made.
            (2) Information with respect to requests.--For purposes of 
        paragraph (1), the information described in this paragraph is, 
        with respect to a request under the IDR process of a 
        nonparticipating provider, nonparticipating emergency facility, 
        group health plan, or health insurance issuer offering health 
        insurance coverage in the group or individual market--
                    (A) a description of each item and service (or air 
                ambulance service) included in such request;
                    (B) the geography in which the items and services 
                (or air ambulance services) included in such request 
                were provided;
                    (C) the amount of the offer submitted under 
                subsection (d)(3)(A) by the group health plan or health 
                insurance issuer (as applicable) and by the 
                nonparticipating provider or nonparticipating emergency 
                facility (as applicable) expressed as a percentage of 
                the median contracted rate;
                    (D) whether the offer selected by the certified IDR 
                entity under such subsection to be the alternative 
                payment applied was the offer submitted by such plan or 
                issuer (as applicable) or by such provider or facility 
                (as applicable) and the amount of such offer so 
                selected expressed as a percentage of the median 
                contracted rate;
                    (E) the category and practice specialty of each 
                such provider or facility involved in furnishing such 
                items and services (or, in the case of air ambulance 
                services, the ambulance vehicle type, including the 
                clinical capability level of such vehicle); and
                    (F) the identity of the group health plan or health 
                insurance issuer, provider, or facility, with respect 
                to the request.
            (3) IDR entity requirements.--For 2022 and each subsequent 
        year, an IDR entity, as a condition of certification as an IDR 
        entity, shall submit to the Secretaries such information as the 
        Secretaries determines necessary for the Secretaries to carry 
        out the provisions of this subsection.
    (f) Enforcement.--
            (1) In general.--Any health care provider, health care 
        facility, group health plan, or health insurance issuer 
        offering group or individual health insurance coverage that 
        violates a provision of this section shall be subject to a 
        civil monetary penalty in an amount not to exceed $10,000 for 
        each such violation.
            (2) Application.--The provisions of section 1128A of the 
        Social Security Act (other than subsections (a) and (b) and the 
        first sentence of subsection (c)(1)) shall apply with respect 
        to a civil monetary penalty imposed under this subsection in 
        the same manner as such provisions apply with respect to a 
        penalty or proceeding under subsection (a) of such section, 
        except that any reference to ``the Secretary'' in such 
        provisions shall be treated as a reference to ``the 
        Secretaries''.
    (g) Definitions.--In this subsection, terms ``group health plan'', 
``group market'', ``health insurance issuer'', ``health insurance 
coverage'', ``individual health insurance coverage'', ``group health 
insurance coverage'', and ``individual market'' have the meanings given 
such terms, respectively, in section 2791 of the Public Health Service 
Act.

SEC. 5. ADVISORY COMMITTEE ON GROUND AMBULANCE AND PATIENT BILLING.

    (a) In General.--Not later than 60 days after the date of enactment 
of this Act, the Secretary of Labor, Secretary of Health and Human 
Services, and the Secretary of the Treasury (the Secretaries) shall 
jointly establish an advisory committee for the purpose of reviewing 
options to improve the disclosure of charges and fees for ground 
ambulance services, better inform consumers of insurance options for 
such services, and protect consumers from balance billing.
    (b) Composition of the Advisory Committee.--The advisory committee 
shall be composed of the following members:
            (1) The Secretary of Labor, or the Secretary's designee.
            (2) The Secretary of Health and Human Services, or the 
        Secretary's designee.
            (3) The Secretary of the Treasury, or the Secretary's 
        designee.
            (4) One representative, to be appointed jointly by the 
        Secretaries, for each of the following:
                    (A) Each relevant Federal agency, as determined by 
                the Secretaries.
                    (B) State insurance regulators.
                    (C) Health insurance providers or trade 
                organization.
                    (D) Patient advocacy groups.
                    (E) Consumer advocacy groups.
                    (F) State and local governments.
                    (G) Physician specializing in emergency, trauma, 
                cardiac, or stroke.
            (5) Three representatives, to be appointed jointly by the 
        Secretaries, to represent the various segments of the ground 
        ambulance industry.
            (6) Up to an additional three representatives otherwise not 
        described in paragraphs (1) through (5), as determined 
        necessary and appropriate by the Secretaries.
    (c) Consultation.--The advisory committee shall, as appropriate, 
consult with relevant experts and stakeholders, including those not 
otherwise included under subsection (b), while conducting the review 
described in subsection (a).
    (d) Recommendations.--The advisory committee shall make 
recommendations with respect to disclosure of charges and fees for 
ground ambulance services and insurance coverage, consumer protection 
and enforcement authorities of the Departments of Labor, Health and 
Human Services, and the Treasury and State authorities, and the 
prevention of balance billing to consumers. The recommendations shall 
address, at a minimum--
            (1) options, best practices, and identified standards to 
        prevent instances of balance billing;
            (2) steps that can be taken by State legislatures, State 
        insurance regulators, State attorneys general, and other State 
        officials as appropriate, consistent with current legal 
        authorities regarding consumer protection; and
            (3) legislative options for Congress to prevent balance 
        billing.
    (e) Report.--Not later than 180 days after the date of the first 
meeting of the advisory committee, the advisory committee shall submit 
to the Secretaries, and the Committees on Education and Labor, Energy 
and Commerce, and Ways and Means of the House of Representatives and 
the Committees on Finance and Health, Education, Labor, and Pensions a 
report containing the recommendations made under subsection (d).
    (f) Rulemaking.--Upon receipt of the report under subsection (e), 
the Secretaries shall consider the recommendations of the advisory 
committee and issue regulations or other guidance as deemed necessary 
to provide consumer protections for patients of ground ambulance 
providers.

SEC. 6. IMPROVING PROVIDER DIRECTORIES.

    (a) PHSA.--Part A of title XXVII of the Public Health Service Act 
(42 U.S.C. 300gg et seq.) is amended by adding at the end the following 
new section:

``SEC. 2730. PROTECTING PATIENTS AND IMPROVING THE ACCURACY OF PROVIDER 
              DIRECTORY INFORMATION.

    ``(a) Network Status of Providers.--
            ``(1) In general.--Beginning on the date that is one year 
        after the date of enactment of this section, a group health 
        plan or a health insurance issuer offering group or individual 
        health insurance coverage shall--
                    ``(A) establish business processes to ensure that 
                all enrollees in such plan or coverage receive proof of 
                a health care provider's network status, based on what 
                a plan or issuer knows or should know--
                            ``(i) upon a telephone inquiry by an 
                        enrollee--
                                    ``(I) through a written electronic 
                                communication from the plan or issuer 
                                to the enrollee, as soon as practicable 
                                and not later than 1 business day after 
                                such inquiry is made by such 
                                participant, beneficiary, or enrollee 
                                for such information;
                                    ``(II) through an oral 
                                communication from the plan or issuer 
                                to the enrollee, as soon as practicable 
                                and not later than 1 business day after 
                                such inquiry is made by such enrollee 
                                for such information, which 
                                communication shall be documented by 
                                such plan or issuer, and such 
                                documentation shall be kept in the 
                                enrollee's file for a minimum of 2 
                                years; and
                            ``(ii) in real-time through an online 
                        health care provider directory search tool 
                        maintained by the plan or issuer; and
                    ``(B) include in any print directory--
                            ``(i) a disclosure that the information 
                        included in the directory is accurate as of the 
                        date of the last data update and that enrollees 
                        or prospective enrollees should consult the 
                        group health plan's or issuer's electronic 
                        provider directory on its website or call a 
                        specified customer service telephone number to 
                        obtain the most current provider directory 
                        information; and
                            ``(ii) a list of the categories of 
                        providers of ancillary services for which the 
                        plan or coverage has no in-network providers.
            ``(2) Group health plan and health insurance issuer 
        business processes.--Beginning on the date that is one year 
        after the date of the enactment of this section, a group health 
        plan or a health insurance issuer offering group or individual 
        health insurance coverage shall establish business processes 
        to--
                    ``(A) verify and update, at least once every 90 
                days, the provider directory information for all 
                providers included in the online health care provider 
                directory search tool described in paragraph 
                (1)(A)(ii); and
                    ``(B) remove any provider from such online 
                directory search tool if such provider has not verified 
                the directory information within the previous 6 months 
                or the plan or issuer has been unable to verify the 
                provider's network participation.
    ``(b) Cost-Sharing Limitations.--A group health plan or a health 
insurance issuer offering group or individual health insurance coverage 
shall not apply, and shall ensure that no provider applies, cost-
sharing to an enrollee for treatment or services provided by a health 
care provider in excess of the normal cost-sharing applied for such 
treatment or services provided in-network (including any balance bill 
issued by the health care provider involved), if such enrollee, or 
health care provider referring such enrollee, demonstrates (based on 
the electronic, written information described in subsection 
(a)(1)(A)(i)(I), the oral confirmation described in subsection 
(a)(1)(A)(i)(II) received by the enrollee not more than 30 days before 
the date the treatment or services were received, or a copy of the 
online provider directory described in subsection (a)(1)(A)(ii) on a 
date not more than 30 days before the date the treatment or services 
were received), that the enrollee relied on the information described 
in subsection (a)(1) for which such enrollee provides such 
documentation, that indicated that the provider is an in-network 
provider, if the provider was out-of-network at the time the treatment 
or service involved was received.
    ``(c) Definition.--For purposes of this section, the term `provider 
directory information' includes the names, addresses, specialty, and 
telephone numbers of individual health care providers, and the names, 
addresses, and telephone numbers of each medical group, clinic, or 
facility contracted to participate in any of the networks of the group 
health plan or health insurance coverage involved.
    ``(d) Rule of Construction.--Nothing in this section shall be 
construed to preempt any provision of State law relating to health care 
provider directories.''.
    (b) ERISA.--Subpart B of part 7 of subtitle B of title I of the 
Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et 
seq.), as amended by section 2, is further amended by adding at the end 
the following:

``SEC. 717. PROTECTING PATIENTS AND IMPROVING THE ACCURACY OF PROVIDER 
              DIRECTORY INFORMATION.

    ``(a) Network Status of Providers.--
            ``(1) In general.--Beginning on the date that is one year 
        after the date of enactment of this section, a group health 
        plan (or health insurance coverage offered in connection with 
        such a plan) shall--
                    ``(A) establish business processes to ensure that 
                all participants and beneficiaries in such plan or 
                coverage receive proof of a health care provider's 
                network status, based on what a plan or issuer of such 
                coverage knows or should know--
                            ``(i) upon a telephone inquiry by a 
                        participant or beneficiary--
                                    ``(I) through a written electronic 
                                communication from the plan or issuer 
                                to the participant or beneficiary, as 
                                soon as practicable and not later than 
                                1 business day after such inquiry is 
                                made by such participant or beneficiary 
                                for such information;
                                    ``(II) through an oral 
                                communication from the plan or issuer 
                                to the participant or beneficiary, as 
                                soon as practicable and not later than 
                                1 business day after such inquiry is 
                                made by such participant or beneficiary 
                                for such information, which 
                                communication shall be documented by 
                                such plan or issuer, and such 
                                documentation shall be kept in the 
                                participant's or beneficiary's file for 
                                a minimum of 2 years; and
                            ``(ii) in real-time through an online 
                        health care provider directory search tool 
                        maintained by the plan or issuer; and
                    ``(B) include in any print directory--
                            ``(i) a disclosure that the information 
                        included in the directory is accurate as of the 
                        date of the last data update and that 
                        participants or beneficiaries or prospective 
                        participants or beneficiaries should consult 
                        the group health plan's or issuer's electronic 
                        provider directory on its website or call a 
                        specified customer service telephone number to 
                        obtain the most current provider directory 
                        information; and
                            ``(ii) a list of the categories of 
                        providers of ancillary services for which the 
                        plan or coverage has no in-network providers.
            ``(2) Group health plan and health insurance issuer 
        business processes.--Beginning on the date that is one year 
        after the date of enactment of this section, a group health 
        plan (or health insurance coverage offered in connection with 
        such a plan) shall establish business processes to--
                    ``(A) verify and update, at least once every 90 
                days, the provider directory information for all 
                providers included in the online health care provider 
                directory search tool described in paragraph 
                (1)(A)(ii); and
                    ``(B) remove any provider from such online 
                directory search tool if such provider has not verified 
                the directory information within the previous 6 months 
                or the plan or issuer has been unable to verify the 
                provider's network participation.
    ``(b) Cost-Sharing Limitations.--A group health plan (or health 
insurance coverage offered in connection with such a plan) shall not 
apply, and shall ensure that no provider applies, cost-sharing to a 
participant or beneficiary for treatment or services provided by a 
health care provider in excess of the normal cost-sharing applied for 
such treatment or services provided in-network (including any balance 
bill issued by the health care provider involved), if such participant 
or beneficiary, or health care provider referring such participant or 
beneficiary, demonstrates (based on the electronic, written information 
described in subsection (a)(1)(A)(i)(I), the oral confirmation 
described in subsection (a)(1)(A)(i)(II) received by the participant or 
beneficiary not more than 30 days before the date the treatment or 
services were received, or a copy of the online provider directory 
described in subsection (a)(1)(A)(ii) on a date not more than 30 days 
before the date the treatment or services were received), that the 
participant or beneficiary relied on the information described in 
subsection (a)(1) for which such participant or beneficiary provides 
such documentation, that indicated that the provider is an in-network 
provider, if the provider was out-of-network at the time the treatment 
or service involved was received.
    ``(c) Definition.--For purposes of this section, the term `provider 
directory information' includes the names, addresses, specialty, and 
telephone numbers of individual health care providers, and the names, 
addresses, and telephone numbers of each medical group, clinic, or 
facility contracted to participate in any of the networks of the group 
health plan or health insurance coverage involved.''.
    (c) IRC.--Subchapter B of chapter 100 of the Internal Revenue Code 
of 1986, as amended by section 2, is further amended by adding at the 
end the following:

``SEC. 9817. PROTECTING PATIENTS AND IMPROVING THE ACCURACY OF PROVIDER 
              DIRECTORY INFORMATION.

    ``(a) Network Status of Providers.--
            ``(1) In general.--Beginning on the date that is one year 
        after the date of enactment of this section, a group health 
        plan shall--
                    ``(A) establish business processes to ensure that 
                all participants or beneficiaries in such plan receive 
                proof of a health care provider's network status, based 
                on what a plan or issuer knows or should know--
                            ``(i) upon a telephone inquiry by a 
                        participant or beneficiary--
                                    ``(I) through a written electronic 
                                communication from the plan to the 
                                participant or beneficiary, as soon as 
                                practicable and not later than 1 
                                business day after such inquiry is made 
                                by such participant or beneficiary for 
                                such information;
                                    ``(II) through an oral 
                                communication from the plan to the 
                                participant or beneficiary, as soon as 
                                practicable and not later than 1 
                                business day after such inquiry is made 
                                by such participant or beneficiary for 
                                such information, which communication 
                                shall be documented by such plan, and 
                                such documentation shall be kept in the 
                                participant's or beneficiary's file for 
                                a minimum of 2 years; and
                            ``(ii) in real-time through an online 
                        health care provider directory search tool 
                        maintained by the plan; and
                    ``(B) include in any print directory--
                            ``(i) a disclosure that the information 
                        included in the directory is accurate as of the 
                        date of the last data update and that 
                        participants or beneficiaries or prospective 
                        participants or beneficiaries should consult 
                        the group health plan's electronic provider 
                        directory on its website or call a specified 
                        customer service telephone number to obtain the 
                        most current provider directory information; 
                        and
                            ``(ii) a list of the categories of 
                        providers of ancillary services for which the 
                        plan or coverage has no in-network providers.
            ``(2) Group health plan business processes.--Beginning on 
        the date that is one year after the date of enactment of this 
        section, a group health plan shall establish business processes 
        to--
                    ``(A) verify and update, at least once every 90 
                days, the provider directory information for all 
                providers included in the online health care provider 
                directory search tool described in paragraph 
                (1)(A)(ii); and
                    ``(B) remove any provider from such online 
                directory search tool if such provider has not verified 
                the directory information within the previous 6 months 
                or the plan or issuer has been unable to verify the 
                provider's network participation.
    ``(b) Cost-Sharing Limitations.--A group health plan shall not 
apply, and shall ensure that no provider applies, cost-sharing to a 
participant or beneficiary for treatment or services provided by a 
health care provider in excess of the normal cost-sharing applied for 
such treatment or services provided in-network (including any balance 
bill issued by the health care provider involved), if such participant 
or beneficiary, or health care provider referring such participant or 
beneficiary, demonstrates (based on the electronic, written information 
described in subsection (a)(1)(A)(i)(I), the oral confirmation 
described in subsection (a)(1)(A)(i)(II) received by the participant or 
beneficiary not more than 30 days before the date the treatment or 
services were received, or a copy of the online provider directory 
described in subsection (a)(1)(A)(ii) on a date not more than 30 days 
before the date the treatment or services were received), that the 
participant or beneficiary relied on the information described in 
subsection (a)(1) for which such participant or beneficiary provides 
such documentation, that indicated that the provider is an in-network 
provider, if the provider was out-of-network at the time the treatment 
or service involved was received.
    ``(c) Definition.--For purposes of this section, the term `provider 
directory information' includes the names, addresses, specialty, and 
telephone numbers of individual health care providers, and the names, 
addresses, and telephone numbers of each medical group, clinic, or 
facility contracted to participate in any of the networks of the group 
health plan involved.
    ``(d) Rule of Construction.--Nothing in this section shall be 
construed to preempt any provision of State law relating to health care 
provider directories.''.
    (d) Clerical Amendments.--
            (1) ERISA.--The table of contents in section 1 of the 
        Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 
        et seq.), as amended by section 2, is further amended by 
        inserting after the item relating to section 716 the following 
        new item:

``Sec. 717. Protecting patients and improving the accuracy of provider 
                            directory information.''.
            (2) IRC.--The table of sections for subchapter B of chapter 
        100 of the Internal Revenue Code of 1986, as amended by section 
        2, is further amended by adding at the end the following new 
        item:

``Sec. 9817. Protecting patients and improving the accuracy of provider 
                            directory information.''.
    (e) Provider Requirements.--Part D of title XXVII of the Public 
Health Service Act (42 U.S.C. 300gg et seq.), as added by section 3, is 
amended--
            (1) by redesignating section 2799A-5 as section 2799A-7; 
        and
            (2) by inserting after section 2799A-4 the following new 
        section:

``SEC. 2799A-5. PROVIDER REQUIREMENTS TO PROTECT PATIENTS AND IMPROVE 
              THE ACCURACY OF PROVIDER DIRECTORY INFORMATION.

    ``(a) Provider Business Processes.--A health care provider shall 
have in place business processes to ensure the timely provision of 
provider directory information to a group health plan or a health 
insurance issuer offering group or individual health insurance coverage 
to support compliance by such plans or issuers with section 2730(a)(1), 
section 717(a)(1) of the Employee Retirement Income Security Act of 
1974, or section 9817(a)(1) of the Internal Revenue Code of 1986 (as 
applicable). Such providers shall submit provider directory information 
to a plan or issuers, at a minimum--
            ``(1) when the provider begins a network agreement with a 
        plan or with an issuer with respect to certain coverage;
            ``(2) when the provider terminates a network agreement with 
        a plan or with an issuer with respect to certain coverage;
            ``(3) when there are material changes to the content of 
        provider directory information described in section 2730(a)(1), 
        section 717(a)(1) of the Employee Retirement Income Security 
        Act of 1974, or section 9817(a)(1) of the Internal Revenue Code 
        of 1986 (as applicable); and
            ``(4) every 90 days throughout the duration of the network 
        agreement with a plan or issuer.
    ``(b) Enforcement.--
            ``(1) Civil penalties.--
                    ``(A) In general.--Subject to paragraph (2), a 
                health care provider that violates a requirement under 
                subsection (a) or takes actions that prevent a group 
                health plan or health insurance issuer from complying 
                with subsection (a)(1) or (b) of sections 2730, 717 of 
                the Employee Retirement Income Security Act of 1974, or 
                9817 of the Internal Revenue Code of 1986 (as 
                applicable) shall be subject to a civil monetary 
                penalty of not more than $10,000 for each act 
                constituting such violation.
                    ``(B) Safe harbor.--The Secretary may waive the 
                penalty described under paragraph (1) with respect to a 
                health care provider that unknowingly violates section 
                2730(b)(1), section 717(b)(1) of the Employee 
                Retirement Income Security Act of 1974, or section 
                9817(b)(1) of the Internal Revenue Code of 1986 (as 
                applicable) with respect to an enrollee if such 
                provider rescinds the bill involved and, if applicable, 
                reimburses the enrollee within 30 days of the date on 
                which the provider billed the enrollee in violation of 
                such subsection.
                    ``(C) Procedure.--The provisions of section 1128A 
                of the Social Security Act, other than subsections (a) 
                and (b) and the first sentence of subsection (c)(1) of 
                such section, shall apply to civil money penalties 
                under this subsection in the same manner as such 
                provisions apply to a penalty or proceeding under 
                section 1128A of the Social Security Act.
            ``(2) Refunds to enrollees.--If a health care provider 
        submits a bill to an enrollee based on cost-sharing for 
        treatment or services provided by the health care provider that 
        is in excess of the normal cost-sharing applied for such 
        treatment or services provided in-network, as prohibited under 
        section 2730(b), section 717(b) of the Employee Retirement 
        Income Security Act of 1974, or section 9817(b) of the Internal 
        Revenue Code of 1986 (as applicable) and the enrollee pays such 
        bill, the provider shall reimburse the enrollee for the full 
        amount paid by the enrollee in excess of the in-network cost-
        sharing amount for the treatment or services involved, plus 
        interest, at an interest rate determined by the Secretary.
    ``(c) Limitation.--Nothing in this section shall prohibit a 
provider from requiring in the terms of a contract, or contract 
termination, with a group health plan or health insurance issuer--
            ``(1) that the plan or issuer remove, at the time of 
        termination of such contract, the provider from a directory of 
        the plan or issuer described in section 2730(a)(1), section 
        717(a)(1) of the Employee Retirement Income Security Act of 
        1974, or section 9817(a)(1) of the Internal Revenue Code of 
        1986 (as applicable); or
            ``(2) that the plan or issuer bear financial 
        responsibility, including under section 2730(b), section 717(b) 
        of the Employee Retirement Income Security Act of 1974, or 
        section 9817(b) of the Internal Revenue Code of 1986 (as 
        applicable) for providing inaccurate network status information 
        to an enrollee.
    ``(d) Definition.--For purposes of this section, the term `provider 
directory information' includes the names, addresses, specialty, and 
telephone numbers of individual health care providers, and the names, 
addresses, and telephone numbers of each medical group, clinic, or 
facility contracted to participate in any of the networks of the group 
health plan or health insurance coverage involved.
    ``(e) Rule of Construction.--Nothing in this section shall be 
construed to preempt any provision of State law relating to health care 
provider directories.''.

SEC. 7. INCREASING TRANSPARENCY IN HEALTH COVERAGE.

    (a) Disclosure of Direct and Indirect Compensation for Brokers and 
Consultants to Employer-Sponsored Health Plans and Enrollees in Plans 
on the Individual Market.--
            (1) Group health plans.--Section 408(b)(2) of the Employee 
        Retirement Income Security Act of 1974 (29 U.S.C. 1108(b)(2)) 
        is amended--
                    (A) by striking ``(2) Contracting or making'' and 
                inserting ``(2)(A) Contracting or making''; and
                    (B) by adding at the end the following:
            ``(B)(i) No contract or arrangement for services between a 
        covered plan and a covered service provider, and no extension 
        or renewal of such a contract or arrangement, is reasonable 
        within the meaning of this paragraph unless the requirements of 
        this subparagraph are met.
            ``(ii)(I) For purposes of this subparagraph:
                    ``(aa) The term `covered plan' means a group health 
                plan as defined section 733(a).
                    ``(bb) The term `covered service provider' means a 
                service provider that enters into a contract or 
                arrangement with the covered plan and reasonably 
                expects $1,000 (or such amount as the Secretary may 
                establish in regulations to account for inflation since 
                the date of the enactment of the Ban Surprise Billing 
                Act, as appropriate) or more in compensation, direct or 
                indirect, to be received in connection with providing 
                one or more of the following services, pursuant to the 
                contract or arrangement, regardless of whether such 
                services will be performed, or such compensation 
                received, by the covered service provider, an 
                affiliate, or a subcontractor:
                            ``(AA) Brokerage services, for which the 
                        covered service provider, an affiliate, or a 
                        subcontractor reasonably expects to receive 
                        indirect compensation or direct compensation 
                        described in item (dd), provided to a covered 
                        plan with respect to selection of insurance 
                        products (including vision and dental), 
                        recordkeeping services, medical management 
                        vendor, benefits administration (including 
                        vision and dental), stop-loss insurance, 
                        pharmacy benefit management services, wellness 
                        services, transparency tools and vendors, group 
                        purchasing organization preferred vendor 
                        panels, disease management vendors and 
                        products, compliance services, employee 
                        assistance programs, or third party 
                        administration services.
                            ``(BB) Consulting, for which the covered 
                        service provider, an affiliate, or a 
                        subcontractor reasonably expects to receive 
                        indirect compensation or direct compensation 
                        described in item (dd), related to the 
                        development or implementation of plan design, 
                        insurance or insurance product selection 
                        (including vision and dental), recordkeeping, 
                        medical management, benefits administration 
                        selection (including vision and dental), stop-
                        loss insurance, pharmacy benefit management 
                        services, wellness design and management 
                        services, transparency tools, group purchasing 
                        organization agreements and services, 
                        participation in and services from preferred 
                        vendor panels, disease management, compliance 
                        services, employee assistance programs, or 
                        third party administration services.
                    ``(cc) The term `affiliate', with respect to a 
                covered service provider, means an entity that directly 
                or indirectly (through one or more intermediaries) 
                controls, is controlled by, or is under common control 
                with, such provider, or is an officer, director, or 
                employee of, or partner in, such provider.
                    ``(dd)(AA) The term `compensation' means anything 
                of monetary value, but does not include non-monetary 
                compensation valued at $250 (or such amount as the 
                Secretary may establish in regulations to account for 
                inflation since the date of enactment of the Ban 
                Surprise Billing Act, as appropriate) or less, in the 
                aggregate, during the term of the contract or 
                arrangement.
                    ``(BB) The term `direct compensation' means 
                compensation received directly from a covered plan.
                    ``(CC) The term `indirect compensation' means 
                compensation received from any source other than the 
                covered plan, the plan sponsor, the covered service 
                provider, or an affiliate. Compensation received from a 
                subcontractor is indirect compensation, unless it is 
                received in connection with services performed under a 
                contract or arrangement with a subcontractor.
                    ``(ee) The term `responsible plan fiduciary' means 
                a fiduciary with authority to cause the covered plan to 
                enter into, or extend or renew, the contract or 
                arrangement.
                    ``(ff) The term `subcontractor' means any person or 
                entity (or an affiliate of such person or entity) that 
                is not an affiliate of the covered service provider and 
                that, pursuant to a contract or arrangement with the 
                covered service provider or an affiliate, reasonably 
                expects to receive $1,000 (or such amount as the 
                Secretary may establish in regulations to account for 
                inflation since the date of enactment of the Ban 
                Surprise Billing Act, as appropriate) or more in 
                compensation for performing one or more services 
                described in item (bb) under a contract or arrangement 
                with the covered plan.
            ``(II) For purposes of this subparagraph, a description of 
        compensation or cost may be expressed as a monetary amount, 
        formula, or a per capita charge for each enrollee or, if the 
        compensation or cost cannot reasonably be expressed in such 
        terms, by any other reasonable method, including a disclosure 
        that additional compensation may be earned but may not be 
        calculated at the time of contract if such a disclosure 
        includes a description of the circumstances under which the 
        additional compensation may be earned and a reasonable and good 
        faith estimate if the covered service provider cannot otherwise 
        readily describe compensation or cost and explains the 
        methodology and assumptions used to prepare such estimate. Any 
        such description shall contain sufficient information to permit 
        evaluation of the reasonableness of the compensation or cost.
            ``(III) No person or entity is a `covered service provider' 
        within the meaning of subclause (I)(bb) solely on the basis of 
        providing services as an affiliate or a subcontractor that is 
        performing one or more of the services described in subitem 
        (AA) or (BB) of such subclause under the contract or 
        arrangement with the covered plan.
            ``(iii) A covered service provider shall disclose to a 
        responsible plan fiduciary, in writing, the following:
                    ``(I) A description of the services to be provided 
                to the covered plan pursuant to the contract or 
                arrangement.
                    ``(II) If applicable, a statement that the covered 
                service provider, an affiliate, or a subcontractor will 
                provide, or reasonably expects to provide, services 
                pursuant to the contract or arrangement directly to the 
                covered plan as a fiduciary (within the meaning of 
                section 3(21)).
                    ``(III) A description of all direct compensation, 
                either in the aggregate or by service, that the covered 
                service provider, an affiliate, or a subcontractor 
                reasonably expects to receive in connection with the 
                services described in subclause (I).
                    ``(IV)(aa) A description of all indirect 
                compensation that the covered service provider, an 
                affiliate, or a subcontractor reasonably expects to 
                receive in connection with the services described in 
                subclause (I)--
                            ``(AA) including compensation from a vendor 
                        to a brokerage firm based on a structure of 
                        incentives not solely related to the contract 
                        with the covered plan; and
                            ``(BB) not including compensation received 
                        by an employee from an employer on account of 
                        work performed by the employee.
                    ``(bb) A description of the arrangement between the 
                payer and the covered service provider, an affiliate, 
                or a subcontractor, as applicable, pursuant to which 
                such indirect compensation is paid.
                    ``(cc) Identification of the services for which the 
                indirect compensation will be received, if applicable.
                    ``(dd) Identification of the payer of the indirect 
                compensation.
                    ``(V) A description of any compensation that will 
                be paid among the covered service provider, an 
                affiliate, or a subcontractor, in connection with the 
                services described in subclause (I) if such 
                compensation is set on a transaction basis (such as 
                commissions, finder's fees, or other similar incentive 
                compensation based on business placed or retained), 
                including identification of the services for which such 
                compensation will be paid and identification of the 
                payers and recipients of such compensation (including 
                the status of a payer or recipient as an affiliate or a 
                subcontractor), regardless of whether such compensation 
                also is disclosed pursuant to subclause (III) or (IV).
                    ``(VI) A description of any compensation that the 
                covered service provider, an affiliate, or a 
                subcontractor reasonably expects to receive in 
                connection with termination of the contract or 
                arrangement, and how any prepaid amounts will be 
                calculated and refunded upon such termination.
            ``(iv) A covered service provider shall disclose to a 
        responsible plan fiduciary, in writing a description of the 
        manner in which the compensation described in clause (iii), as 
        applicable, will be received.
            ``(v)(I) A covered service provider shall disclose the 
        information required under clauses (iii) and (iv) to the 
        responsible plan fiduciary not later than the date that is 
        reasonably in advance of the date on which the contract or 
        arrangement is entered into, and extended or renewed.
            ``(II) A covered service provider shall disclose any change 
        to the information required under clause (iii) and (iv) as soon 
        as practicable, but not later than 60 days from the date on 
        which the covered service provider is informed of such change, 
        unless such disclosure is precluded due to extraordinary 
        circumstances beyond the covered service provider's control, in 
        which case the information shall be disclosed as soon as 
        practicable.
            ``(vi)(I) Upon the written request of the responsible plan 
        fiduciary or covered plan administrator, a covered service 
        provider shall furnish any other information relating to the 
        compensation received in connection with the contract or 
        arrangement that is required for the covered plan to comply 
        with the reporting and disclosure requirements under this Act.
            ``(II) The covered service provider shall disclose the 
        information required under clause (iii)(I) reasonably in 
        advance of the date upon which such responsible plan fiduciary 
        or covered plan administrator states that it is required to 
        comply with the applicable reporting or disclosure requirement, 
        unless such disclosure is precluded due to extraordinary 
        circumstances beyond the covered service provider's control, in 
        which case the information shall be disclosed as soon as 
        practicable.
            ``(vii) No contract or arrangement will fail to be 
        reasonable under this subparagraph solely because the covered 
        service provider, acting in good faith and with reasonable 
        diligence, makes an error or omission in disclosing the 
        information required pursuant to clause (iii) (or a change to 
        such information disclosed pursuant to clause (v)(II)) or 
        clause (vi), provided that the covered service provider 
        discloses the correct information to the responsible plan 
        fiduciary as soon as practicable, but not later than 30 days 
        from the date on which the covered service provider knows of 
        such error or omission.
            ``(viii)(I) Pursuant to subsection (a), subparagraphs (C) 
        and (D) of section 406(a)(1) shall not apply to a responsible 
        plan fiduciary, notwithstanding any failure by a covered 
        service provider to disclose information required under clause 
        (iii), if the following conditions are met:
                    ``(aa) The responsible plan fiduciary did not know 
                that the covered service provider failed or would fail 
                to make required disclosures and reasonably believed 
                that the covered service provider disclosed the 
                information required to be disclosed.
                    ``(bb) The responsible plan fiduciary, upon 
                discovering that the covered service provider failed to 
                disclose the required information, requests in writing 
                that the covered service provider furnish such 
                information.
                    ``(cc) If the covered service provider fails to 
                comply with a written request described in subclause 
                (II) within 90 days of the request, the responsible 
                plan fiduciary notifies the Secretary of the covered 
                service provider's failure, in accordance with 
                subclauses (II) and (III).
            ``(II) A notice described in subclause (I)(cc) shall 
        contain--
                    ``(aa) the name of the covered plan;
                    ``(bb) the plan number used for the annual report 
                on the covered plan;
                    ``(cc) the plan sponsor's name, address, and 
                employer identification number;
                    ``(dd) the name, address, and telephone number of 
                the responsible plan fiduciary;
                    ``(ee) the name, address, phone number, and, if 
                known, employer identification number of the covered 
                service provider;
                    ``(ff) a description of the services provided to 
                the covered plan;
                    ``(gg) a description of the information that the 
                covered service provider failed to disclose;
                    ``(hh) the date on which such information was 
                requested in writing from the covered service provider; 
                and
                    ``(ii) a statement as to whether the covered 
                service provider continues to provide services to the 
                plan.
            ``(III) A notice described in subclause (I)(cc) shall be 
        filed with the Department not later than 30 days following the 
        earlier of--
                    ``(aa) The covered service provider's refusal to 
                furnish the information requested by the written 
                request described in subclause (I)(bb); or
                    ``(bb) 90 days after the written request referred 
                to in subclause (I)(cc) is made.
            ``(IV) If the covered service provider fails to comply with 
        the written request under subclause (I)(bb) within 90 days of 
        such request, the responsible plan fiduciary shall determine 
        whether to terminate or continue the contract or arrangement 
        under section 404. If the requested information relates to 
        future services and is not disclosed promptly after the end of 
        the 90-day period, the responsible plan fiduciary shall 
        terminate the contract or arrangement as expeditiously as 
        possible, consistent with such duty of prudence.
            ``(ix) Nothing in this subparagraph shall be construed to 
        supersede any provision of State law that governs disclosures 
        by parties that provide the services described in this section, 
        except to the extent that such law prevents the application of 
        a requirement of this section.''.
            (2) Applicability of existing regulations.--Nothing in the 
        amendments made by paragraph (1) shall be construed to affect 
        the applicability of section 2550.408b-2 of title 29, Code of 
        Federal Regulations (or any successor regulations), with 
        respect to any applicable entity other than a covered plan or a 
        covered service provider (as defined in section 
        408(b)(2)(B)(ii) of the Employee Retirement Income Security Act 
        of 1974, as amended by paragraph (1)).
            (3) Individual market coverage.--Subpart 1 of part B of 
        title XXVII of the Public Health Service Act (42 U.S.C. 300gg-
        41 et seq.) is amended by adding at the end the following:

``SEC. 2746. DISCLOSURE TO ENROLLEES OF INDIVIDUAL MARKET COVERAGE.

    ``(a) In General.--A health insurance issuer offering individual 
health insurance coverage shall make disclosures to enrollees in such 
coverage, as described in subsection (b), and reports to the Secretary, 
as described in subsection (c), regarding direct or indirect 
compensation provided to an agent or broker associated with enrolling 
individuals in such coverage.
    ``(b) Disclosure.--A health insurance issuer described in 
subsection (a) shall disclose to an enrollee the amount of direct or 
indirect compensation provided to an agent or broker for services 
provided by such agent or broker associated with plan selection and 
enrollment. Such disclosure shall be--
            ``(1) made prior to the individual finalizing plan 
        selection; and
            ``(2) included on any documentation confirming the 
        individual's enrollment.
    ``(c) Reporting.--A health insurance issuer described in subsection 
(a) shall annually report to the Secretary, prior to the beginning of 
open enrollment, any direct or indirect compensation provided to an 
agent or broker associated with enrolling individuals in such coverage.
    ``(d) Rulemaking.--Not later than 1 year after the date of 
enactment of the Ban Surprise Billing Act, the Secretary shall 
finalize, through notice-and-comment rulemaking, the form and manner in 
which issuers described in subsection (a) are required to make the 
disclosures described in subsection (b) and the reports described in 
subsection (c). Such rulemaking may also include adjustments to notice 
requirements to reflect the different processes for plan renewals, in 
order to provide enrollees with full, timely information.''.
            (4) Transition rule.--No contract executed prior to the 
        effective date described in paragraph (5) by a group health 
        plan subject to the requirements of section 408(b)(2)(B) of the 
        Employee Retirement Income Security Act of 1974 (as amended by 
        paragraph (1)) or by a health insurance issuer subject to the 
        requirements of section 2746 of the Public Health Service Act 
        (as added by paragraph (3)) shall be subject to the 
        requirements of such section 408(b)(2)(B) or such section 2746, 
        as applicable.
            (5) Effective date.--The amendments made by paragraphs (1) 
        and (3) shall apply beginning one year after the date of 
        enactment of this Act.
    (b) Standardized Reporting Format.--Section 716 of the Employee 
Retirement Income Security Act of 1974, as added by section 2 and 
amended by section 3(c), is further amended by adding at the end the 
following new subsection:
    ``(i) Standardized Reporting Format.--
            ``(1) In general.--Not later than 1 year after the date of 
        enactment of this subsection, the Secretary shall establish a 
        standardized reporting format for the reporting, by group 
        health plans (or health insurance coverage offered in 
        connection with such a plan) to State All Payer Claims 
        Databases, of medical claims, pharmacy claims, dental claims, 
        and eligibility and provider files that are collected from 
        private and public payers, and shall provide guidance to States 
        on the process by which States may collect such data from such 
        plans or coverage in the standardized reporting format.
            ``(2) Definition.--In this subsection, the term `State All 
        Payer Claims Database' means, with respect to a State, a 
        database that may include medical claims, pharmacy claims, 
        dental claims, and eligibility and provider files, which are 
        collected from private and public payers.''.

SEC. 8. ACCESS TO COST-SHARING INFORMATION.

    (a) Insurer and Plan Requirements.--
            (1) PHSA.--Part A of title XXVII of the Public Health 
        Service Act (42 U.S.C. 300gg-11 et seq.), as amended by section 
        6(a), is further amended by inserting after section 2730 the 
        following:

``SEC. 2731. PROVISION OF COST-SHARING INFORMATION.

    ``A group health plan or a health insurance issuer offering group 
or individual health insurance coverage shall provide a participant, 
beneficiary, or enrollee in the plan or coverage with a good faith 
estimate of the enrollee's cost-sharing (including deductibles, 
copayments, and coinsurance) for which the participant, beneficiary, or 
enrollee may be responsible for paying with respect to a specific 
health care service (including any service that is reasonably expected 
to be provided in conjunction with such specific service), as soon as 
practicable and not later than 2 business days after a request for such 
information by a participant, beneficiary, or enrollee.''.
            (2) ERISA.--Subpart B of part 7 of subtitle B of title I of 
        the Employee Retirement Income Security Act of 1974 (29 U.S.C. 
        1185 et seq.), as amended by section 6(b), is further amended 
        by adding at the end the following:

``SEC. 718. PROVISION OF COST-SHARING INFORMATION.

    ``A group health plan (or health insurance coverage offered in 
connection with such a plan) shall provide a participant or beneficiary 
in the plan or coverage with a good faith estimate of the participant's 
or beneficiary's cost-sharing (including deductibles, copayments, and 
coinsurance) for which the participant or beneficiary may be 
responsible for paying with respect to a specific health care service 
(including any service that is reasonably expected to be provided in 
conjunction with such specific service), as soon as practicable and not 
later than 2 business days after a request for such information by a 
participant or beneficiary.''.
            (3) IRC.--Subchapter B of chapter 100 of the Internal 
        Revenue Code of 1986, as amended by section 6(c), is further 
        amended by adding at the end the following:

``SEC. 9818. PROVISION OF COST-SHARING INFORMATION.

    ``A group health plan shall provide a participant or beneficiary in 
the plan with a good faith estimate of the participant's or 
beneficiary's cost-sharing (including deductibles, copayments, and 
coinsurance) for which the participant or beneficiary may be 
responsible for paying with respect to a specific health care service 
(including any service that is reasonably expected to be provided in 
conjunction with such specific service), as soon as practicable and not 
later than 2 business days after a request for such information by a 
participant or beneficiary.''.
            (4) Clerical amendments.--
                    (A) ERISA.--The table of contents in section 1 of 
                the Employee Retirement Income Security Act of 1974 (29 
                U.S.C. 1001 et seq.), as amended by section 8(b)(4), is 
                further amended by inserting after the item relating to 
                section 717 the following new item:

``Sec. 718. Provision of cost-sharing information.''.
                    (B) IRC.--The table of sections for subchapter B of 
                chapter 100 of the Internal Revenue Code of 1986, as 
                amended by section 8(b)(4), is further amended by 
                adding at the end the following new item:

``Sec. 9818. Provision of cost-sharing information.''.
    (b) Provider Requirements.--Part D of title XXVII of the Public 
Health Service Act, as added by section 3 and amended by section 6, is 
further amended by inserting before section 2799A-7 the following new 
section:

``SEC. 2799A-6. PROVISION OF COST-SHARING INFORMATION.

    ``A provider that is in-network with respect to a group health plan 
or a health insurance issuer offering group or individual health 
insurance coverage shall, upon request by a participant, beneficiary, 
or enrollee, provide to a participant, beneficiary, or enrollee in the 
plan or coverage the following information, together with accurate and 
complete information about the participant's, beneficiary's, or 
enrollee's coverage under the applicable plan or coverage:
            ``(1) As soon as practicable and not later than 2 business 
        days after the participant, beneficiary, or enrollee requests 
        such information, a good faith estimate of the expected 
        participant, beneficiary, or enrollee cost-sharing for the 
        provision of a particular health care service (including any 
        service that is reasonably expected to be provided in 
        conjunction with such specific service).
            ``(2) As soon as practicable and not later than 2 business 
        days after a participant, beneficiary, or enrollee requests 
        such information, the contact information for any ancillary 
        providers for a scheduled health care service.''.
    (c) Effective Date.--The amendments made by subsections (a) and (b) 
shall apply with respect to plan years beginning on or after the date 
that is 18 months after the date of enactment of this Act.

SEC. 9. TRANSPARENCY REGARDING IN-NETWORK AND OUT-OF-NETWORK 
              DEDUCTIBLES AND OUT-OF-POCKET LIMITATIONS.

    (a) PHSA.--Section 2719A of the Public Health Service Act, as 
amended by section 2, is further amended by adding at the end the 
following new subsection:
    ``(g) Transparency Regarding In-Network and Out-of-Network 
Deductibles and Out-of-Pocket Limitations.--
            ``(1) In general.--A group health plan or a health 
        insurance issuer offering group or individual health insurance 
        coverage and providing or covering any benefit with respect to 
        items or services shall include, in clear writing, on any plan 
        or insurance identification card issued to enrollees in the 
        plan or coverage the amount of the in-network and out-of-
        network deductibles and the in-network and out-of-network out-
        of-pocket maximum limitation that apply to such plan or 
        coverage.
            ``(2) Guidance.--The Secretary, in consultation with the 
        Secretary of Labor and Secretary of the Treasury, shall issue 
        guidance to implement paragraph (1).''.
    (b) ERISA.--Section 716 of the Employee Retirement Income Security 
Act of 1974, as added by section 2 and as amended by sections 3(c) and 
7(b), is further amended by adding at the end the following new 
subsection:
    ``(j) Transparency Regarding In-Network and Out-of-Network 
Deductibles and Out-of-Pocket Limitations.--
            ``(1) In general.--A group health plan or a health 
        insurance issuer offering group health insurance coverage and 
        providing or covering any benefit with respect to items or 
        services shall include, in clear writing, on any plan or 
        insurance identification card issued to participants or 
        beneficiaries in the plan or coverage the amount of the in-
        network and out-of-network deductibles and the in-network and 
        out-of-network out-of-pocket maximum limitation that apply to 
        such plan or coverage.
            ``(2) Guidance.--The Secretary, in consultation with the 
        Secretary of Health and Human Services and Secretary of the 
        Treasury, shall issue guidance to implement paragraph (1).''.
    (c) IRC.--Section 9816 of the Internal Revenue Code of 1986, as 
added by section 2, is further amended by adding at the end the 
following new subsection:
    ``(h) Transparency Regarding In-Network and Out-of-Network 
Deductibles and Out-of-Pocket Limitations.--
            ``(1) In general.--A group health plan providing or 
        covering any benefit with respect to items or services shall 
        include, in clear writing, on any plan or insurance 
        identification card issued to participants or beneficiaries in 
        the plan the amount of the in-network and out-of-network 
        deductibles and the in-network and out-of-network out-of-pocket 
        maximum limitation that apply to such plan.
            ``(2) Guidance.--The Secretary, in consultation with the 
        Secretary of Health and Human Services and Secretary of Labor, 
        shall issue guidance to implement paragraph (1).''.
    (d) Effective Date.--The amendments made by this subsection shall 
apply with respect to plan years beginning on or after January 1, 2022.
                                 <all>