No Surprises Act

H. R. 133—1577
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Health care provider requirements regarding surprise medical billing.
Ending surprise air ambulance bills.
Reporting requirements regarding air ambulance services.
Transparency regarding in-network and out-of-network deductibles and
out-of-pocket limitations.
Implementing protections against provider discrimination.
Reports.
Consumer protections through application of health plan external review
in cases of certain surprise medical bills.
Consumer protections through health plan requirement for fair and honest advance cost estimate.
Patient protections through transparency and patient-provider dispute
resolution.
Ensuring continuity of care.
Maintenance of price comparison tool.
State All Payer Claims Databases.
Protecting patients and improving the accuracy of provider directory information.
Advisory committee on ground ambulance and patient billing.
Implementation funding.

TITLE II—TRANSPARENCY
Sec. 201. Increasing transparency by removing gag clauses on price and quality information.
Sec. 202. Disclosure of direct and indirect compensation for brokers and consultants to employer-sponsored health plans and enrollees in plans on the
individual market.
Sec. 203. Strengthening parity in mental health and substance use disorder benefits.
Sec. 204. Reporting on pharmacy benefits and drug costs.
TITLE III—PUBLIC HEALTH PROVISIONS
Subtitle A—Extenders Provisions
Sec. 301. Extension for community health centers, the National Health Service
Corps, and teaching health centers that operate GME programs.
Sec. 302. Diabetes programs.
Subtitle B—Strengthening Public Health
Sec. 311. Improving awareness of disease prevention.
Sec. 312. Guide on evidence-based strategies for public health department obesity
prevention programs.
Sec. 313. Expanding capacity for health outcomes.
Sec. 314. Public health data system modernization.
Sec. 315. Native American suicide prevention.
Sec. 316. Reauthorization of the Young Women’s Breast Health Education and
Awareness Requires Learning Young Act of 2009.
Sec. 317. Reauthorization of school-based health centers.
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Subtitle C—FDA Amendments
Rare pediatric disease priority review voucher extension.
Conditions of use for biosimilar biological products.
Orphan drug clarification.
Modernizing the labeling of certain generic drugs.
Biological product patent transparency.

Subtitle D—Technical Corrections
Sec. 331. Technical corrections.

TITLE I—NO SURPRISES ACT
SEC. 101. SHORT TITLE.

This title may be cited as the ‘‘No Surprises Act’’.
SEC. 102. HEALTH INSURANCE REQUIREMENTS REGARDING SURPRISE
MEDICAL BILLING.

(a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.—

H. R. 133—1578
(1) 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—ADDITIONAL COVERAGE
PROVISIONS
‘‘SEC. 2799A–1. PREVENTING SURPRISE MEDICAL BILLS.

‘‘(a) 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 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—
‘‘(I) not later than 30 calendar days after the
bill for such services is transmitted by such provider or facility, sends to the provider or facility,
as applicable, an initial payment or notice of denial
of payment; and
‘‘(II) pays a total plan or coverage payment
directly to such provider or facility, respectively
(in accordance, if applicable, with the timing
requirement described in subsection (c)(6)) that
is, with application of any initial payment under
subclause (I), equal to the amount by which the
out-of-network rate (as defined in paragraph

H. R. 133—1579
(3)(K)) for such services 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-ofpocket 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 QUALIFYING PAYMENT AMOUNTS.—
‘‘(A) AUDIT PROCESS.—
‘‘(i) IN GENERAL.—Not later than October 1, 2021,
the Secretary, in consultation with 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 group or individual health
insurance coverage 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 qualifying payment amount under this section; and
‘‘(II) such qualifying payment amount 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 group
or individual health insurance coverage; and
‘‘(II) may audit any group health plan or
health insurance issuer offering group or individual health insurance coverage if the Secretary
has received any complaint or other information
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.

H. R. 133—1580
‘‘(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 group or individual
health insurance coverage shall use to determine the
qualifying payment amount, differentiating by individual market, large group market, and small group
market;
‘‘(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 group or individual
health insurance coverage.
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, taking into account the findings of the report submitted under section 109(a) of the No Surprises Act.
‘‘(3) DEFINITIONS.—In this part and part E:
‘‘(A) EMERGENCY DEPARTMENT OF A HOSPITAL.—The
term ‘emergency department of a hospital’ includes a hospital outpatient department that provides emergency services (as defined in subparagraph (C)(i)).
‘‘(B) EMERGENCY MEDICAL CONDITION.—The term
‘emergency medical condition’ means a medical condition
manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson, who
possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical
attention to result in a condition described in clause (i),
(ii), or (iii) of section 1867(e)(1)(A) of the Social Security
Act.

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‘‘(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 (regardless of the department of the
hospital in which such further examination or
treatment is furnished).
‘‘(ii) INCLUSION OF ADDITIONAL SERVICES.—
‘‘(I) IN GENERAL.—For purposes of this subsection and section 2799B–1, in the case of a
participant, beneficiary, or enrollee who is enrolled
in a group health plan or group or individual
health insurance coverage offered by a health
insurance issuer and who is furnished services
described in clause (i) with respect to an emergency
medical condition, the term ‘emergency services’
shall include, unless each of the conditions
described in subclause (II) are met, in addition
to the items and services described in clause (i),
items and services—
‘‘(aa) for which benefits are provided or
covered under the plan or coverage, respectively; and
‘‘(bb) that are furnished by a nonparticipating provider or nonparticipating emergency
facility (regardless of the department of the
hospital in which such items or services are
furnished) after the participant, beneficiary,
or enrollee is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which
the services described in clause (i) are furnished.
‘‘(II) CONDITIONS.—For purposes of subclause
(I), the conditions described in this subclause, with
respect to a participant, beneficiary, or enrollee
who is stabilized and furnished additional items
and services described in subclause (I) after such

H. R. 133—1582
stabilization by a provider or facility described in
subclause (I), are the following;
‘‘(aa) Such provider or facility determines
such individual is able to travel using nonmedical transportation or nonemergency medical
transportation.
‘‘(bb) Such provider furnishing such additional items and services satisfies the notice
and consent criteria of section 2799B–2(d) with
respect to such items and services.
‘‘(cc) Such individual is in a condition to
receive (as determined in accordance with
guidelines issued by the Secretary pursuant
to rulemaking) the information described in
section 2799B–2 and to provide informed consent under such section, in accordance with
applicable State law.
‘‘(dd) Such other conditions, as specified
by the Secretary, such as conditions relating
to coordinating care transitions to participating providers and facilities.
‘‘(D) INDEPENDENT FREESTANDING EMERGENCY DEPARTMENT.—The term ‘independent freestanding emergency
department’ means a health care facility that—
‘‘(i) is geographically separate and distinct and
licensed separately from a hospital under applicable
State law; and
‘‘(ii) provides any of the emergency services (as
defined in subparagraph (C)(i)).
‘‘(E) QUALIFYING PAYMENT AMOUNT.—
‘‘(i) IN GENERAL.—The term ‘qualifying payment
amount’ means, subject to clauses (ii) and (iii), with
respect to a sponsor of a group health plan and health
insurance issuer offering group or individual health
insurance coverage—
‘‘(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 insurance market
(specified in subclause (I), (II), (III), or (IV) of
clause (iv)) as the plan or coverage) as the total
maximum payment (including the cost-sharing
amount imposed for such item or service and the
amount to be paid by the plan or issuer, respectively) under such plans or coverage, respectively,
on January 31, 2019, for the same or a similar
item or service that is provided by a provider in
the same or similar specialty and provided in the
geographic region in which the item or service
is furnished, consistent with the methodology
established by the Secretary under paragraph
(2)(B), increased by the percentage increase in the
consumer price index for all urban consumers
(United States city average) over 2019, such

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percentage increase over 2020, and such percentage increase over 2021; and
‘‘(II) for an item or service furnished during
2023 or a subsequent year, the qualifying payment
amount determined under this clause for such an
item or service furnished in the previous year,
increased by the percentage increase in the consumer price index for all urban consumers (United
States city average) over such previous year.
‘‘(ii) NEW PLANS AND COVERAGE.—The term ‘qualifying payment amount’ means, with respect to a
sponsor of a group health plan or health insurance
issuer offering group or individual health insurance
coverage in a geographic region in which such sponsor
or issuer, respectively, did not offer any group health
plan or health insurance coverage during 2019—
‘‘(I) for the first year in which such group
health plan, group health insurance coverage, or
individual 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 or coverage and furnished during
such first year; and
‘‘(II) for each subsequent year such group
health plan, group health insurance coverage, or
individual health insurance coverage, respectively,
is offered in such region, the qualifying payment
amount determined under this clause for such
items and services furnished in the previous year,
increased by the percentage increase in the consumer price index for all urban consumers (United
States city average) over such previous year.
‘‘(iii) INSUFFICIENT INFORMATION; NEWLY COVERED
ITEMS AND SERVICES.—In the case of a sponsor of a
group health plan or health insurance issuer offering
group or individual health insurance coverage that does
not have sufficient information to calculate the median
of the contracted rates described in clause (i)(I) in
2019 (or, in the case of a newly covered item or service
(as defined in clause (v)(III)), in the first coverage
year (as defined in clause (v)(I)) for such item or service
with respect to such plan or coverage) for an item
or service (including with respect to provider type,
or amount, of claims for items or services (as determined by the Secretary) provided in a particular
geographic region (other than in a case with respect
to which clause (ii) applies)) the term ‘qualifying payment amount’—
‘‘(I) for an item or service furnished during
2022 (or, in the case of a newly covered item
or service, during the first coverage year for such
item or service with respect to such plan 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,

H. R. 133—1584
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 allpayer claims database);
‘‘(II) for an item or service furnished in a subsequent year (before the first sufficient information
year (as defined in clause (v)(II)) for such item
or service with respect to such plan or coverage),
means the rate determined under subclause (I)
or this subclause, as applicable, for such item or
service for the year previous to such subsequent
year, increased by the percentage increase in the
consumer price index for all urban consumers
(United States city average) over such previous
year;
‘‘(III) for an item or service furnished in the
first sufficient information year for such item or
service with respect to such plan or coverage, has
the meaning given the term qualifying payment
amount in clause (i)(I), except that in applying
such clause to such item or service, the reference
to ‘furnished during 2022’ shall be treated as a
reference to furnished during such first sufficient
information year, the reference to ‘in 2019’ shall
be treated as a reference to such sufficient 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) INSURANCE MARKET.—For purposes of clause
(i)(I), a health insurance market specified in this clause
is one of the following:
‘‘(I) The individual market.
‘‘(II) The large group market (other than plans
described in subclause (IV)).
‘‘(III) The small group market (other than
plans described in subclause (IV)).
‘‘(IV) In the case of a self-insured group health
plan, other self-insured group health plans.
‘‘(v) DEFINITIONS.—For purposes of this subparagraph:
‘‘(I) FIRST COVERAGE YEAR.—The term ‘first
coverage year’ means, with respect to a group
health plan or group or individual health insurance
coverage offered by a health insurance issuer and
an item or service for which coverage is not offered

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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 group or
individual health insurance coverage offered by
a health insurance issuer—
‘‘(aa) in the case of an item or service
for which the plan or coverage does not have
sufficient information to calculate the median
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 group or individual health insurance issuer offering health
insurance coverage, 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 group or individual health insurance coverage
offered by a health insurance issuer, 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 group or individual health insurance coverage
offered by a health insurance issuer, 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.

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‘‘(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 group or individual health insurance coverage offered by a health
insurance issuer, 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 group or individual
health insurance coverage offered by a health insurance issuer, 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 nonparticipating emergency facility during a year and a group health plan or
group or individual health insurance coverage offered by
a health insurance issuer—
‘‘(i) subject to clause (iii), in the case of such item
or service furnished in a State that has in effect a
specified State law with respect to such plan, coverage,
or issuer, respectively; such a nonparticipating provider
or nonparticipating emergency facility; and such an
item or service, the amount determined in accordance
with such law;
‘‘(ii) subject to clause (iii), in the case 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 nonparticipating emergency facility; and such an item or service, the amount
that is the qualifying payment amount (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 nonparticipating emergency facility during a year and a group health
plan or group or individual health insurance coverage
offered by a health insurance issuer, a State law that

H. R. 133—1587
provides for a method for determining the total amount
payable under such a plan, coverage, or issuer, respectively
(to the extent such State law applies to such plan, coverage,
or issuer, subject to section 514 of the Employee Retirement
Income Security Act of 1974) in the case of a participant,
beneficiary, or enrollee covered under such plan or coverage
and receiving such item or service from such a nonparticipating provider or nonparticipating 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)).
‘‘(K) OUT-OF-NETWORK RATE.—The term ‘out-of-network
rate’ means, with respect to an item or service furnished
in a State during a year to a participant, beneficiary,
or enrollee of a group health plan or group or individual
health insurance coverage offered by a health insurance
issuer receiving such item or service from a nonparticipating provider or nonparticipating emergency facility—
‘‘(i) subject to clause (iii), in the case of such item
or service furnished in a State that has in effect a
specified State law with respect to such plan, coverage,
or issuer, respectively; such a nonparticipating provider
or nonparticipating emergency facility; and such an
item or service, the amount determined in accordance
with such law;
‘‘(ii) subject to clause (iii), in the case such State
does not have in effect such a law with respect to
such item or service, plan, and provider or facility—
‘‘(I) subject to subclause (II), if the provider
or facility (as applicable) and such plan or coverage
agree on an amount of payment (including if such
agreed on amount is the initial payment sent by
the plan under subsection (a)(1)(C)(iv)(I),subsection
(b)(1)(C),
or
section
2799A–2(a)(3)(A),
as
applicable, or is agreed on through open negotiations under subsection (c)(1)) with respect to such
item or service, such agreed on amount; or
‘‘(II) if such provider or facility (as applicable)
and such plan or coverage enter the independent
dispute resolution process under subsection (c) and
do not so agree before the date on which a certified
IDR entity (as defined in paragraph (4) of such
subsection) makes a determination with respect
to such item or service under such subsection,
the amount of such determination; or
‘‘(iii) in the case such State has an All-Payer Model
Agreement under section 1115A of the Social Security
Act, the amount that the State approves under such
system for such item or service so furnished.
‘‘(L) COST-SHARING.—The term ‘cost-sharing’ includes
copayments, coinsurance, and deductibles.
‘‘(b) COVERAGE OF NON-EMERGENCY SERVICES PERFORMED BY
NONPARTICIPATING PROVIDERS AT CERTAIN PARTICIPATING FACILITIES.—
‘‘(1) IN GENERAL.—In the case of items or services (other
than emergency services to which subsection (a) applies) for

H. R. 133—1588
which any benefits are provided or covered by a group health
plan or health insurance issuer offering group or individual
health insurance coverage furnished to a participant, beneficiary, or enrollee of such plan or coverage by a nonparticipating provider (as defined in subsection (a)(3)(G)(i)) (and who,
with respect to such items and services, has not satisfied the
notice and consent criteria of section 2799B–2(d)) 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 requirement for such items and
services so furnished that is greater than the cost-sharing
requirement that would apply under such plan or coverage,
respectively, had such items or services been furnished
by a participating provider (as defined in subsection
(a)(3)(G)(ii));
‘‘(B) shall calculate such cost-sharing requirement as
if the total amount that would have been charged for
such items and services by such participating provider
were equal to the recognized amount (as defined in subsection (a)(3)(H)) for such items and services, plan or coverage, and year;
‘‘(C) not later than 30 calendar days after the bill
for such services is transmitted by such provider, shall
send to the provider an initial payment or notice of denial
of payment;
‘‘(D) shall pay a total plan or coverage payment
directly, in accordance, if applicable,with the timing
requirement described in subsection (c)(6), to such provider
furnishing such items and services to such participant,
beneficiary, or enrollee that is, with application of any
initial payment under subparagraph (C), equal to the
amount by which the out-of-network rate (as defined in
subsection (a)(3)(K)) for such items and services involved
exceeds the cost-sharing amount imposed under the plan
or coverage, respectively, for such items and services (as
determined in accordance with subparagraphs (A) and (B))
and year; and
‘‘(E) shall count toward any in-network deductible and
in-network out-of-pocket maximums (as applicable) applied
under the plan or coverage, respectively, any cost-sharing
payments made by the participant, beneficiary, or enrollee
(and such in-network deductible and out-of-pocket maximums shall be applied) with respect to such items and
services so furnished in the same manner as if such costsharing payments were with respect to items and services
furnished by a participating provider.
‘‘(2) DEFINITIONS.—In this section:
‘‘(A) PARTICIPATING HEALTH CARE FACILITY.—
‘‘(i) IN GENERAL.—The term ‘participating health
care facility’ means, with respect to an item or service
and a group health plan or health insurance issuer
offering group or individual health insurance coverage,
a health care facility described in clause (ii) that has
a direct or indirect contractual relationship with the

H. R. 133—1589
plan or issuer, respectively, with respect to the furnishing of such an item or service at the facility.
‘‘(ii) HEALTH CARE FACILITY DESCRIBED.—A health
care facility described in this clause, with respect to
a group health plan or group or individual health insurance coverage, is each of the following:
‘‘(I) A hospital (as defined in 1861(e) of the
Social Security Act).
‘‘(II) A hospital outpatient department.
‘‘(III) A critical access hospital (as defined in
section 1861(mm)(1) of such Act).
‘‘(IV) An ambulatory surgical center described
in section 1833(i)(1)(A) of such Act.
‘‘(V) Any other facility, specified by the Secretary, that provides items or services for which
coverage is provided under the plan or coverage,
respectively.
‘‘(B) VISIT.—The term ‘visit’ shall, with respect to items
and services furnished to an individual at a health care
facility, include equipment and devices, telemedicine services, imaging services, laboratory services, preoperative and
postoperative services, and such other items and services
as the Secretary may specify, regardless of whether or
not the provider furnishing such items or services is at
the facility.
‘‘(c) CERTAIN ACCESS FEES TO CERTAIN DATABASES.—In the
case of a sponsor of a group health plan or health insurance issuer
offering group or individual health insurance coverage that, pursuant to subsection (a)(3)(E)(iii), uses a database described in such
subsection to determine a rate to apply under such subsection
for an item or service by reason of having insufficient information
described in such subsection with respect to such item or service,
such sponsor or issuer shall cover the cost for access to such
database.’’.
(2) TRANSFER AMENDMENT.—Part D of title XXVII of the
Public Health Service Act, as added by paragraph (1), is
amended by adding at the end the following new section:
‘‘SEC. 2799A–7. OTHER PATIENT PROTECTIONS.

‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If a group health
plan, or a health insurance issuer offering group or individual
health insurance coverage, requires or provides for designation by
a participant, beneficiary, or enrollee of a participating primary
care provider, then the plan or issuer shall permit each participant,
beneficiary, and enrollee to designate any participating primary
care provider who is available to accept such individual.
‘‘(b) ACCESS TO PEDIATRIC CARE.—
‘‘(1) PEDIATRIC CARE.—In the case of a person who has
a child who is a participant, beneficiary, or enrollee under
a group health plan, or group or individual health insurance
coverage offered by a health insurance issuer, if the plan or
issuer requires or provides for the designation of a participating
primary care provider for the child, the plan or issuer shall
permit such person to designate a physician (allopathic or osteopathic) who specializes in pediatrics as the child’s primary
care provider if such provider participates in the network of
the plan or issuer.

H. R. 133—1590
‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) shall be
construed to waive any exclusions of coverage under the terms
and conditions of the plan or health insurance coverage with
respect to coverage of pediatric care.
‘‘(c) PATIENT ACCESS TO OBSTETRICAL AND GYNECOLOGICAL
CARE.—
‘‘(1) GENERAL RIGHTS.—
‘‘(A) DIRECT ACCESS.—A group health plan, or health
insurance issuer offering group or individual health 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, beneficiary,
or enrollee 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 or individual health
insurance coverage, described in this paragraph is a group
health plan or health insurance coverage that—
‘‘(A) provides coverage for obstetric or gynecologic care;
and
‘‘(B) requires the designation by a participant, beneficiary, or enrollee of a participating primary care provider.
‘‘(3) CONSTRUCTION.—Nothing in paragraph (1) shall be
construed to—
‘‘(A) waive any exclusions of coverage under the terms
and conditions of the plan or health insurance coverage
with respect to coverage of obstetrical or gynecological care;
or
‘‘(B) preclude the group health plan or health insurance
issuer involved from requiring that the obstetrical or
gynecological provider notify the primary care health care
professional or the plan or issuer of treatment decisions.’’.
(3) CONFORMING AMENDMENTS.—
(A) Section 2719A of the Public Health Service Act
(42 U.S.C. 300gg–19a) is amended by adding at the end
the following new subsection:
‘‘(e) APPLICATION.—The provisions of this section shall not apply
with respect to a group health plan, health insurance issuers,
or group or individual health insurance coverage with respect to
plan years beginning on or on January 1, 2022.’’.

H. R. 133—1591
(B) Section 2722 of the Public Health Service Act (42
U.S.C. 300gg–21) is amended—
(i) in subsection (a)(1), by inserting ‘‘and part D’’
after ‘‘subparts 1 and 2’’;
(ii) in subsection (b), by inserting ‘‘and part D’’
after ‘‘subparts 1 and 2’’;
(iii) in subsection (c)(1), by inserting ‘‘and part
D’’ after ‘‘subparts 1 and 2’’;
(iv) in subsection (c)(2), by inserting ‘‘and part
D’’ after ‘‘subparts 1 and 2’’;
(v) in subsection (c)(3), by inserting ‘‘and part D’’
after ‘‘this part’’; and
(vi) in subsection (d), in the matter preceding paragraph (1), by inserting ‘‘and part D’’ after ‘‘this part’’.
(C) Section 2723 of the Public Health Service Act (42
U.S.C. 300gg–22) is amended—
(i) in subsection (a)(1), by inserting ‘‘and part D’’
after ‘‘this part’’;
(ii) in subsection (a)(2), by inserting ‘‘or part D’’
after ‘‘this part’’;
(iii) in subsection (b)(1), by inserting ‘‘or part D’’
after ‘‘this part’’;
(iv) in subsection (b)(2)(A), by inserting ‘‘or part
D’’ after ‘‘this part’’; and
(v) in subsection (b)(2)(C)(ii), by inserting ‘‘and part
D’’ after ‘‘this part’’.
(D) Section 2724 of the Public Health Service Act (42
U.S.C. 300gg–23) is amended—
(i) in subsection (a)(1)—
(I) by striking ‘‘this part and part C insofar
as it relates to this part’’ and inserting ‘‘this part,
part D, and part C insofar as it relates to this
part or part D’’; and
(II) by inserting ‘‘or part D’’ after ‘‘requirement
of this part’’;
(ii) in subsection (a)(2), by inserting ‘‘or part D’’
after ‘‘this part’’; and
(iii) in subsection (c), by inserting ‘‘or part D’’
after ‘‘this part (other than section 2704)’’.
(b) ERISA AMENDMENTS.—
(1) IN GENERAL.—Subpart B of part 7 of title I of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1185 et seq.) is amended by adding at the end the following:
‘‘SEC. 716. PREVENTING SURPRISE MEDICAL BILLS.

‘‘(a) COVERAGE OF EMERGENCY SERVICES.—
‘‘(1) IN GENERAL.—If a group health plan, or a health 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;

H. R. 133—1592
‘‘(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 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—
‘‘(I) not later than 30 calendar days after the
bill for such services is transmitted by such provider or facility, sends to the provider or facility,
as applicable, an initial payment or notice of denial
of payment; and
‘‘(II) pays a total plan or coverage payment
directly to such provider or facility, respectively
(in accordance, if applicable, with the timing
requirement described in subsection (c)(6)) that
is, with application of any initial payment under
subclause (I), equal to the amount by which the
out-of-network rate (as defined in paragraph
(3)(K)) for such services 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).

H. R. 133—1593
‘‘(2) REGULATIONS FOR QUALIFYING PAYMENT AMOUNTS.—
Not later than July 1, 2021, the Secretary, in consultation
with the Secretary of the Treasury and the Secretary of Health
and Human Services, shall establish through rulemaking—
‘‘(A) the methodology the group health plan or health
insurance issuer offering health insurance coverage in the
group market shall use to determine the qualifying payment amount, differentiating by large group market, and
small group market;
‘‘(B) the information such plan or issuer, respectively,
shall share with the nonparticipating provider or nonparticipating facility, as applicable, when making such a
determination;
‘‘(C) the geographic regions applied for purposes of
this subparagraph, taking into account access to items
and services in rural and underserved areas, including
health professional shortage areas, as defined in section
332 of the Public Health Service Act; and
‘‘(D) a process to receive complaints of violations of
the requirements described in subclauses (I) and (II) of
subparagraph (A)(i) by group health plans and health 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 casemix of various facility types) that are otherwise taken into
account for purposes of determining payment amounts with
respect to participating facilities. In carrying out clause (iii),
the Secretary shall consult with the National Association of
Insurance Commissioners to establish the geographic regions
under such clause and shall periodically update such regions,
as appropriate, taking into account the findings of the report
submitted under section 109(a) of the No Surprises Act.
‘‘(3) DEFINITIONS.—In this subpart:
‘‘(A) EMERGENCY DEPARTMENT OF A HOSPITAL.—The
term ‘emergency department of a hospital’ includes a hospital outpatient department that provides emergency services (as defined in subparagraph (C)(i)).
‘‘(B) EMERGENCY MEDICAL CONDITION.—The term
‘emergency medical condition’ means a medical condition
manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson, who
possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical
attention to result in a condition described in clause (i),
(ii), or (iii) of section 1867(e)(1)(A) of the Social Security
Act.
‘‘(C) EMERGENCY SERVICES.—
‘‘(i) IN GENERAL.—The term ‘emergency services’,
with respect to an emergency medical condition,
means—
‘‘(I) a medical screening examination (as
required under section 1867 of the Social Security
Act, or as would be required under such section

H. R. 133—1594
if such section applied to an independent 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 (regardless of the department of the
hospital in which such further examination or
treatment is furnished).
‘‘(ii) INCLUSION OF ADDITIONAL SERVICES.—
‘‘(I) IN GENERAL.—For purposes of this subsection and section 2799B–1 of the Public Health
Service Act, in the case of a participant or beneficiary who is enrolled in a group health plan
or group health insurance coverage offered by a
health insurance issuer and who is furnished services described in clause (i) with respect to an emergency medical condition, the term ‘emergency services’ shall include, unless each of the conditions
described in subclause (II) are met, in addition
to the items and services described in clause (i),
items and services—
‘‘(aa) for which benefits are provided or
covered under the plan or coverage, respectively; and
‘‘(bb) that are furnished by a nonparticipating provider or nonparticipating emergency
facility (regardless of the department of the
hospital in which such items or services are
furnished) after the participant or beneficiary
is stabilized and as part of outpatient observation or an inpatient or outpatient stay with
respect to the visit in which the services
described in clause (i) are furnished.
‘‘(II) CONDITIONS.—For purposes of subclause
(I), the conditions described in this subclause, with
respect to a participant or beneficiary who is 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 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

H. R. 133—1595
and consent criteria of section 2799B–2(d) with
respect to such items and services.
‘‘(cc) Such individual is in a condition to
receive (as determined in accordance with
guidelines issued by the Secretary pursuant
to rulemaking) the information described in
section 2799B–2 and to provide informed consent under such section, in accordance with
applicable State law.
‘‘(dd) Such other conditions, as specified
by the Secretary, such as conditions relating
to coordinating care transitions to participating providers and facilities.
‘‘(D) INDEPENDENT FREESTANDING EMERGENCY DEPARTMENT.—The term ‘independent freestanding emergency
department’ means a health care facility that—
‘‘(i) is geographically separate and distinct and
licensed separately from a hospital under applicable
State law; and
‘‘(ii) provides any of the emergency services (as
defined in subparagraph (C)(i)).
‘‘(E) QUALIFYING PAYMENT AMOUNT.—
‘‘(i) IN GENERAL.—The term ‘qualifying payment
amount’ means, subject to clauses (ii) and (iii), with
respect to a sponsor of a group health plan and health
insurance issuer offering group health insurance coverage—
‘‘(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 insurance market
(specified in subclause (I), (II), or (III) of clause
(iv)) as the plan or coverage) as the total maximum
payment (including the cost-sharing amount
imposed for such item or service and the amount
to be paid by the plan or issuer, respectively) under
such plans or coverage, respectively, on January
31, 2019, for the same or a similar item or service
that is provided by a provider in the same or
similar specialty and provided in the geographic
region in which the item or service is furnished,
consistent with the methodology established by the
Secretary under paragraph (2), increased by the
percentage increase in the consumer price index
for all urban consumers (United States city average) over 2019, such percentage increase over
2020, and such percentage increase over 2021; and
‘‘(II) for an item or service furnished during
2023 or a subsequent year, the qualifying payment
amount determined under this clause for such an
item or service furnished in the previous year,
increased by the percentage increase in the consumer price index for all urban consumers (United
States city average) over such previous year.

H. R. 133—1596
‘‘(ii) NEW PLANS AND COVERAGE.—The term ‘qualifying payment amount’ means, with respect to a
sponsor of a group health plan or health insurance
issuer offering group health insurance coverage in a
geographic region in which such sponsor or issuer,
respectively, did not offer any group health plan or
health insurance coverage during 2019—
‘‘(I) for the first year in which such group
health plan or health insurance coverage, 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 qualifying
payment amount determined under this clause for
such items and services furnished in the previous
year, increased by the percentage increase in the
consumer price index for all urban consumers
(United States city average) over such previous
year.
‘‘(iii) INSUFFICIENT INFORMATION; NEWLY COVERED
ITEMS AND SERVICES.—In the case of a sponsor of a
group health plan or health insurance issuer offering
group health insurance coverage that does not have
sufficient information to calculate the median of the
contracted rates described in clause (i)(I) in 2019 (or,
in the case of a newly covered item or service (as
defined in clause (v)(III)), in the first coverage year
(as defined in clause (v)(I)) for such item or service
with respect to such plan or coverage) for an item
or service (including with respect to provider type,
or amount, of claims for items or services (as determined by the Secretary) provided in a particular
geographic region (other than in a case with respect
to which clause (ii) applies)) the term ‘qualifying payment amount’—
‘‘(I) for an item or service furnished during
2022 (or, in the case of a newly covered item
or service, during the first coverage year for such
item or service with respect to such plan 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), 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 allpayer claims database);
‘‘(II) for an item or service furnished in a subsequent year (before the first sufficient information
year (as defined in clause (v)(II)) for such item
or service with respect to such plan or coverage),

H. R. 133—1597
means the rate determined under subclause (I)
or this subclause, as applicable, for such item or
service for the year previous to such subsequent
year, increased by the percentage increase in the
consumer price index for all urban consumers
(United States city average) over such previous
year;
‘‘(III) for an item or service furnished in the
first sufficient information year for such item or
service with respect to such plan or coverage, has
the meaning given the term qualifying payment
amount in clause (i)(I), except that in applying
such clause to such item or service, the reference
to ‘furnished during 2022’ shall be treated as a
reference to furnished during such first sufficient
information year, the reference to ‘in 2019’ shall
be treated as a reference to such sufficient 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) INSURANCE MARKET.—For purposes of clause
(i)(I), a health insurance market specified in this clause
is one of the following:
‘‘(I) The large group market (other than plans
described in subclause (III)).
‘‘(II) The small group market (other than plans
described in subclause (III)).
‘‘(III) In the case of a self-insured group health
plan, other self-insured group health plans.
‘‘(v) DEFINITIONS.—For purposes of this subparagraph:
‘‘(I) FIRST COVERAGE YEAR.—The term ‘first
coverage year’ means, with respect to a group
health plan or group health insurance coverage
offered by a health insurance issuer and an item
or service for which coverage is not offered in
2019 under such plan or coverage, the first year
after 2019 for which coverage for such item or
service is offered under such plan or health insurance coverage.
‘‘(II) FIRST SUFFICIENT INFORMATION YEAR.—
The term ‘first sufficient information year’ means,
with respect to a group health plan or group health
insurance coverage offered by a health insurance
issuer—
‘‘(aa) in the case of an item or service
for which the plan or coverage does not have
sufficient information to calculate the median

H. R. 133—1598
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 group health insurance coverage,
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 group health insurance coverage offered by a health
insurance issuer, 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 group health insurance coverage offered by a health
insurance issuer, 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 group health
insurance coverage offered by a health insurance
issuer, 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.

H. R. 133—1599
‘‘(ii) PARTICIPATING PROVIDER.—The term ‘participating provider’ means, with respect to an item or
service and a group health plan or group health insurance coverage offered by a health insurance issuer,
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 nonparticipating emergency facility during a year and a group health plan or
group health insurance coverage offered by a health insurance issuer—
‘‘(i) subject to clause (iii), in the case of such item
or service furnished in a State that has in effect a
specified State law with respect to such plan, coverage,
or issuer, respectively; such a nonparticipating provider
or nonparticipating emergency facility; and such an
item or service, the amount determined in accordance
with such law;
‘‘(ii) subject to clause (iii), in the case 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 nonparticipating emergency facility; and such an item or service, the amount
that is the qualifying payment amount (as defined
in subparagraph (E)) for such year and determined
in accordance with rulemaking described in paragraph
(2)) 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 nonparticipating emergency facility during a year and a group health
plan or group health insurance coverage offered by a health
insurance issuer, a State law that provides for a method
for determining the total amount payable under such a
plan, coverage, or issuer, respectively (to the extent such
State law applies to such plan, coverage, or issuer, subject
to section 514) 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
nonparticipating 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)).
‘‘(K) OUT-OF-NETWORK RATE.—The term ‘out-of-network
rate’ means, with respect to an item or service furnished

H. R. 133—1600
in a State during a year to a participant or beneficiary
of a group health plan or group health insurance coverage
offered by a health insurance issuer receiving such item
or service from a nonparticipating provider or nonparticipating emergency facility—
‘‘(i) subject to clause (iii), in the case of such item
or service furnished in a State that has in effect a
specified State law with respect to such plan, coverage,
or issuer, respectively; such a nonparticipating provider
or nonparticipating emergency facility; and such an
item or service, the amount determined in accordance
with such law;
‘‘(ii) subject to clause (iii), in the case such State
does not have in effect such a law with respect to
such item or service, plan, and provider or facility—
‘‘(I) subject to subclause (II), if the provider
or facility (as applicable) and such plan or coverage
agree on an amount of payment (including if such
agreed on amount is the initial payment sent by
the plan under subsection (a)(1)(C)(iv)(I), subsection (b)(1)(C), or section 717(a)(3)(A), as
applicable, or is agreed on through open negotiations under subsection (c)(1)) with respect to such
item or service, such agreed on amount; or
‘‘(II) if such provider or facility (as applicable)
and such plan or coverage enter the independent
dispute resolution process under subsection (c) and
do not so agree before the date on which a certified
IDR entity (as defined in paragraph (4) of such
subsection) makes a determination with respect
to such item or service under such subsection,
the amount of such determination; or
‘‘(iii) in the case such State has an All-Payer Model
Agreement under section 1115A of the Social Security
Act, the amount that the State approves under such
system for such item or service so furnished.
‘‘(L) COST-SHARING.—The term ‘cost-sharing’ includes
copayments, coinsurance, and deductibles.
‘‘(b) COVERAGE OF NON-EMERGENCY SERVICES PERFORMED BY
NONPARTICIPATING PROVIDERS AT CERTAIN PARTICIPATING FACILITIES.—
‘‘(1) IN GENERAL.—In the case of items or services (other
than emergency services to which subsection (a) applies) for
which any benefits are provided or covered by a group health
plan or health insurance issuer offering group health insurance
coverage furnished to a participant or beneficiary of such plan
or coverage by a nonparticipating provider (as defined in subsection (a)(3)(G)(i)) (and who, with respect to such items and
services, has not satisfied the notice and consent criteria of
section 2799B–2(d) of the Public Health Service Act) with
respect to a visit (as defined by the Secretary in accordance
with paragraph (2)(B)) at a participating health care facility
(as defined in paragraph (2)(A)), with respect to such plan
or coverage, respectively, the plan or coverage, respectively—
‘‘(A) shall not impose on such participant or beneficiary
a cost-sharing requirement for such items and services

H. R. 133—1601
so furnished that is greater than the cost-sharing requirement that would apply under such plan or coverage, respectively, had such items or services been furnished by a
participating provider (as defined in subsection
(a)(3)(G)(ii));
‘‘(B) shall calculate such cost-sharing requirement as
if the total amount that would have been charged for
such items and services by such participating provider
were equal to the recognized amount (as defined in subsection (a)(3)(H)) for such items and services, plan or coverage, and year;
‘‘(C) not later than 30 calendar days after the bill
for such items or services is transmitted by such provider,
shall send to the provider an initial payment or notice
of denial of payment;
‘‘(D) shall pay a total plan or coverage payment
directly, in accordance, if applicable, with the timing
requirement described in subsection (c)(6), to such provider
furnishing such items and services to such participant or
beneficiary that is, with application of any initial payment
under subparagraph (C), equal to the amount by which
the out-of-network rate (as defined in subsection (a)(3)(K))
for such items and services exceeds the cost-sharing amount
imposed under the plan or coverage, respectively, for such
items and services (as determined in accordance with subparagraphs (A) and (B)) and year; and
‘‘(E) shall count toward any in-network deductible and
in-network out-of-pocket maximums (as applicable) applied
under the plan or coverage, respectively, any cost-sharing
payments made by the participant 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 group health insurance coverage, a health care
facility described in clause (ii) that has a direct or
indirect contractual relationship with the plan or
issuer, respectively, with respect to the furnishing of
such an item or service at the facility.
‘‘(ii) HEALTH CARE FACILITY DESCRIBED.—A health
care facility described in this clause, with respect to
a group health plan or group health insurance coverage, is each of the following:
‘‘(I) A hospital (as defined in 1861(e) of the
Social Security Act).
‘‘(II) A hospital outpatient department.
‘‘(III) A critical access hospital (as defined in
section 1861(mm)(1) of such Act).
‘‘(IV) An ambulatory surgical center described
in section 1833(i)(1)(A) of such Act.

H. R. 133—1602
‘‘(V) Any other facility, specified by the Secretary, that provides items or services for which
coverage is provided under the plan or coverage,
respectively.
‘‘(B) VISIT.—The term ‘visit’ shall, with respect to items
and services furnished to an individual at a health care
facility, include equipment and devices, telemedicine services, imaging services, laboratory services, preoperative and
postoperative services, and such other items and services
as the Secretary may specify, regardless of whether or
not the provider furnishing such items or services is at
the facility.
‘‘(c) CERTAIN ACCESS FEES TO CERTAIN DATABASES.—In the
case of a sponsor of a group health plan or health insurance issuer
offering group health insurance coverage that, pursuant to subsection (a)(3)(E)(iii), uses a database described in such subsection
to determine a rate to apply under such subsection for an item
or service by reason of having insufficient information described
in such subsection with respect to such item or service, such sponsor
or issuer shall cover the cost for access to such database.’’.
(2) TRANSFER AMENDMENT.—Subpart B of part 7 of title
I of the Employee Retirement Income Security Act of 1974
(29 U.S.C. 1185 et seq.), as amended by paragraph (1), is
further amended by adding at the end the following:
‘‘SEC. 722. OTHER PATIENT PROTECTIONS.

‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If a group health
plan, or a health insurance issuer offering group health insurance
coverage, requires or provides for designation by a participant or
beneficiary of a participating primary care provider, then the plan
or issuer shall permit each participant and beneficiary to designate
any participating primary care provider who is available to accept
such individual.
‘‘(b) ACCESS TO PEDIATRIC CARE.—
‘‘(1) PEDIATRIC CARE.—In the case of a person who has
a child who is a participant or beneficiary under a group
health plan, or group health insurance coverage offered by
a health insurance issuer, if the plan or issuer requires or
provides for the designation of a participating primary care
provider for the child, the plan or issuer shall permit such
person to designate a physician (allopathic or osteopathic) who
specializes in pediatrics as the child’s primary care provider
if such provider participates in the network of the plan or
issuer.
‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) shall be
construed to waive any exclusions of coverage under the terms
and conditions of the plan or health insurance coverage with
respect to coverage of pediatric care.
‘‘(c) PATIENT ACCESS TO OBSTETRICAL AND GYNECOLOGICAL
CARE.—
‘‘(1) GENERAL RIGHTS.—
‘‘(A) DIRECT ACCESS.—A group health plan, or health
insurance issuer offering group health insurance coverage,
described in paragraph (2) may not require authorization
or referral by the plan, issuer, or any person (including
a primary care provider described in paragraph (2)(B))
in the case of a female participant or beneficiary who

H. R. 133—1603
seeks coverage for obstetrical or gynecological care provided
by a participating health care professional who specializes
in obstetrics or gynecology. Such professional shall agree
to otherwise adhere to such plan’s or issuer’s policies and
procedures, including procedures regarding referrals and
obtaining prior authorization and providing services 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.’’.
(3) CLERICAL AMENDMENT.—The table of contents of the
Employee Retirement Income Security Act of 1974 is amended
by inserting after the item relating to section 714 the following:
‘‘Sec. 715. Additional market reforms.
‘‘Sec. 716. Preventing surprise medical bills.
‘‘Sec. 722. Other patient protections.’’.
(c) IRC AMENDMENTS.—
(1) IN GENERAL.—Subchapter

B of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at the
end the following:

‘‘SEC. 9816. PREVENTING SURPRISE MEDICAL BILLS.

‘‘(a) COVERAGE OF EMERGENCY SERVICES.—
‘‘(1) IN GENERAL.—If a group health plan provides or covers
any benefits with respect to services in an emergency 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;

H. R. 133—1604
‘‘(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 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—
‘‘(I) not later than 30 calendar days after the
bill for such services is transmitted by such provider or facility, sends to the provider or facility,
as applicable, an initial payment or notice of denial
of payment; and
‘‘(II) pays a total plan payment directly to
such provider or facility, respectively (in accordance, if applicable, with the timing requirement
described in subsection (c)(6)) that is, with application of any initial payment under subclause (I),
equal to the amount by which the out-of-network
rate (as defined in paragraph (3)(K)) for such services exceeds the cost-sharing amount for such services (as determined in accordance with clauses (ii)
and (iii)) and year; and
‘‘(iv) any cost-sharing payments made by the
participant or beneficiary with respect to such 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 the Public Health Service Act, including
as incorporated pursuant to section 715 of the Employee
Retirement Income Security Act of 1974 and section 9815
of this Act, and other than applicable cost-sharing).

H. R. 133—1605
‘‘(2) AUDIT PROCESS AND REGULATIONS FOR QUALIFYING PAYMENT AMOUNTS.—
‘‘(A) AUDIT PROCESS.—
‘‘(i) IN GENERAL.—Not later than October 1, 2021,
the Secretary, in consultation with 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 qualifying payment
amount under this section; and
‘‘(II) such qualifying payment amount 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 or other
information 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 qualifying payment amount, differentiating by large group market and small group
market;
‘‘(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 subparagraph (A)(i) by group health plans.

H. R. 133—1606
Such rulemaking shall take into account payments that
are made by such plan that are not on a fee-for-service
basis. Such methodology may account for relevant payment
adjustments that take into account quality or facility type
(including higher acuity settings and the case-mix of various facility types) that are otherwise taken into account
for purposes of determining payment amounts with respect
to participating facilities. In carrying out clause (iii), the
Secretary shall consult with the National Association of
Insurance Commissioners to establish the geographic
regions under such clause and shall periodically update
such regions, as appropriate, taking into account the
findings of the report submitted under section 109(a) of
the No Surprises Act.
‘‘(3) DEFINITIONS.—In this subchapter:
‘‘(A) EMERGENCY DEPARTMENT OF A HOSPITAL.—The
term ‘emergency department of a hospital’ includes a hospital outpatient department that provides emergency services (as defined in subparagraph (C)(i)).
‘‘(B) EMERGENCY MEDICAL CONDITION.—The term
‘emergency medical condition’ means a medical condition
manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson, who
possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical
attention to result in a condition described in clause (i),
(ii), or (iii) of section 1867(e)(1)(A) of the Social Security
Act.
‘‘(C) EMERGENCY SERVICES.—
‘‘(i) IN GENERAL.—The term ‘emergency services’,
with respect to an emergency medical condition,
means—
‘‘(I) a medical screening examination (as
required under section 1867 of the Social Security
Act, or as would be required under such section
if such section applied to an independent 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 (regardless of the department of the
hospital in which such further examination or
treatment is furnished).
‘‘(ii) INCLUSION OF ADDITIONAL SERVICES.—
‘‘(I) IN GENERAL.—For purposes of this subsection and section 2799B–1 of the Public Health

H. R. 133—1607
Service Act, in the case of a participant or beneficiary who is enrolled in a group health plan
and who is furnished services described in clause
(i) with respect to an emergency medical condition,
the term ‘emergency services’ shall include, unless
each of the conditions described in subclause (II)
are met, in addition to the items and services
described in clause (i), items and services—
‘‘(aa) for which benefits are provided or
covered under the plan; and
‘‘(bb) that are furnished by a nonparticipating provider or nonparticipating emergency
facility (regardless of the department of the
hospital in which such items or services are
furnished) after the participant or beneficiary
is stabilized and as part of outpatient observation or an inpatient or outpatient stay with
respect to the visit in which the services
described in clause (i) are furnished.
‘‘(II) CONDITIONS.—For purposes of subclause
(I), the conditions described in this subclause, with
respect to a participant or beneficiary who is 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 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 2799B–2(d) with
respect to such items and services.
‘‘(cc) Such individual is in a condition to
receive (as determined in accordance with
guidelines issued by the Secretary pursuant
to rulemaking) the information described in
section 2799B–2 and to provide informed consent under such section, in accordance with
applicable State law.
‘‘(dd) Such other conditions, as specified
by the Secretary, such as conditions relating
to coordinating care transitions to participating providers and facilities.
‘‘(D) INDEPENDENT FREESTANDING EMERGENCY DEPARTMENT.—The term ‘independent freestanding emergency
department’ means a health care facility that—
‘‘(i) is geographically separate and distinct and
licensed separately from a hospital under applicable
State law; and
‘‘(ii) provides any of the emergency services (as
defined in subparagraph (C)(i)).
‘‘(E) QUALIFYING PAYMENT AMOUNT.—
‘‘(i) IN GENERAL.—The term ‘qualifying payment
amount’ means, subject to clauses (ii) and (iii), with
respect to a sponsor of a group health plan—

H. R. 133—1608
‘‘(I) for an item or service furnished during
2022, the median of the contracted rates recognized by the plan (determined with respect to all
such plans of such sponsor that are offered within
the same insurance market (specified in subclause
(I), (II), or (III) of clause (iv)) as the plan) as
the total maximum payment (including the costsharing 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 qualifying payment
amount determined under this clause for such an
item or service furnished in the previous year,
increased by the percentage increase in the consumer price index for all urban consumers (United
States city average) over such previous year.
‘‘(ii) NEW PLANS AND COVERAGE.—The term ‘qualifying payment amount’ means, with respect to a
sponsor of a group health plan in a geographic region
in which such sponsor, respectively, did not offer any
group health plan or health insurance coverage during
2019—
‘‘(I) for the first year in which such group
health plan is offered in such region, a rate (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 qualifying
payment amount determined under this clause for
such items and services furnished in the previous
year, increased by the percentage increase in the
consumer price index for all urban consumers
(United States city average) over such previous
year.
‘‘(iii) INSUFFICIENT INFORMATION; NEWLY COVERED
ITEMS AND SERVICES.—In the case of a sponsor of a
group health plan that does not have sufficient
information to calculate the median of the contracted
rates described in clause (i)(I) in 2019 (or, in the case
of a newly covered item or service (as defined in clause
(v)(III)), in the first coverage year (as defined in clause
(v)(I)) for such item or service with respect to such
plan) for an item or service (including with respect
to provider type, or amount, of claims for items or

H. R. 133—1609
services (as determined by the Secretary) provided in
a particular geographic region (other than in a case
with respect to which clause (ii) applies)) the term
‘qualifying payment amount’—
‘‘(I) for an item or service furnished during
2022 (or, in the case of a newly covered item
or service, during the first coverage year for such
item or service with respect to such plan), means
such rate for such item or service determined by
the sponsor through use of any database that is
determined, in accordance with rulemaking
described in paragraph (2)(B), to not have any
conflicts of interest and to have sufficient 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 (v)(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 qualifying payment amount in
clause (i)(I), except that in applying such clause
to such item or service, the reference to ‘furnished
during 2022’ shall be treated as a reference to
furnished during such first sufficient information
year, the reference to ‘on January 31, 2019’ shall
be treated as a reference to in such sufficient
information year, and the increase described in
such clause shall not be applied; and
‘‘(IV) for an item or service furnished in any
year subsequent to the first sufficient information
year for such item or service with respect to such
plan, has the meaning given such term in clause
(i)(II), except that in applying such clause to such
item or service, the reference to ‘furnished during
2023 or a subsequent year’ shall be treated as
a reference to furnished during the year after such
first sufficient information year or a subsequent
year.
‘‘(iv) INSURANCE MARKET.—For purposes of clause
(i)(I), a health insurance market specified in this clause
is one of the following:
‘‘(I) The large group market (other than plans
described in subclause (III)).
‘‘(II) The small group market (other than plans
described in subclause (III)).

H. R. 133—1610
‘‘(III) In the case of a self-insured group health
plan, other self-insured group health plans.
‘‘(v) DEFINITIONS.—For purposes of this 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.—

H. R. 133—1611
‘‘(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 nonparticipating 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 nonparticipating emergency facility; and such an item or service, the amount
determined in accordance with such law;
‘‘(ii) subject to clause (iii), in the case 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 nonparticipating emergency facility; and such an item or
service, the amount that is the qualifying payment
amount (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 nonparticipating emergency facility during a year and a group health
plan, a State law that provides for a method for determining the total amount payable under such a plan (to
the extent such State law applies to such plan, subject
to section 514) in the case of a participant or beneficiary
covered under such plan and receiving such item or service
from such a nonparticipating provider or nonparticipating
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)).

H. R. 133—1612
‘‘(K) OUT-OF-NETWORK RATE.—The term ‘out-of-network
rate’ means, with respect to an item or service furnished
in a State during a year to a participant or beneficiary
of a group health plan receiving such item or service from
a nonparticipating provider or nonparticipating emergency
facility—
‘‘(i) subject to clause (iii), in the case of such item
or service furnished in a State that has in effect a
specified State law with respect to such plan; such
a nonparticipating provider or nonparticipating emergency facility; and such an item or service, the amount
determined in accordance with such law;
‘‘(ii) subject to clause (iii), in the case such State
does not have in effect such a law with respect to
such item or service, plan, and provider or facility—
‘‘(I) subject to subclause (II), if the provider
or facility (as applicable) and such plan or coverage
agree on an amount of payment (including if such
agreed on amount is the initial payment sent by
the plan under subsection (a)(1)(C)(iv)(I), subsection (b)(1)(C), or section 9817(a)(3)(A), as
applicable, or is agreed on through open negotiations under subsection (c)(1)) with respect to such
item or service, such agreed on amount; or
‘‘(II) if such provider or facility (as applicable)
and such plan or coverage enter the independent
dispute resolution process under subsection (c) and
do not so agree before the date on which a certified
IDR entity (as defined in paragraph (4) of such
subsection) makes a determination with respect
to such item or service under such subsection,
the amount of such determination; or
‘‘(iii) in the case such State has an All-Payer Model
Agreement under section 1115A of the Social Security
Act, the amount that the State approves under such
system for such item or service so furnished.
‘‘(L) COST-SHARING.—The term ‘cost-sharing’ includes
copayments, coinsurance, and deductibles.
‘‘(b) COVERAGE OF NON-EMERGENCY SERVICES PERFORMED BY
NONPARTICIPATING PROVIDERS AT CERTAIN PARTICIPATING FACILITIES.—
‘‘(1) IN GENERAL.—In the case of items or services (other
than emergency services to which subsection (a) applies) for
which any benefits are provided or covered by a group health
plan furnished to a participant or beneficiary of such plan
by a nonparticipating provider (as defined in subsection
(a)(3)(G)(i)) (and who, with respect to such items and services,
has not satisfied the notice and consent criteria of section
2799B–2(d) of the Public Health Service Act) with respect to
a visit (as defined by the Secretary in accordance with 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 requirement for such items and services
so furnished that is greater than the cost-sharing requirement that would apply under such plan had such items

H. R. 133—1613
or services been furnished by a participating provider (as
defined in subsection (a)(3)(G)(ii));
‘‘(B) shall calculate such cost-sharing requirement as
if the total amount that would have been charged for
such items and services by such participating provider
were equal to the recognized amount (as defined in subsection (a)(3)(H)) for such items and services, plan, and
year;
‘‘(C) not later than 30 calendar days after the bill
for such items or services is transmitted by such provider,
shall send to the provider an initial payment or notice
of denial of payment;
‘‘(D) shall pay a total plan payment directly, in accordance, if applicable, with the timing requirement described
in subsection (c)(6), to such provider furnishing such items
and services to such participant or beneficiary that is,
with application of any initial payment under subparagraph
(C), equal to the amount by which the out-of-network rate
(as defined in subsection (a)(3)(K)) for such items and services exceeds the cost-sharing amount imposed under the
plan for such items and services (as determined in accordance with subparagraphs (A) and (B)) and year; and
‘‘(E) shall count toward any in-network deductible and
in-network out-of-pocket maximums (as applicable) applied
under the plan, any cost-sharing payments made by the
participant or beneficiary (and such in-network deductible
and out-of-pocket maximums shall be applied) with respect
to such items and services so furnished in the same manner
as if such cost-sharing payments were with respect to items
and services furnished by a participating provider.
‘‘(2) DEFINITIONS.—In this section:
‘‘(A) PARTICIPATING HEALTH CARE FACILITY.—
‘‘(i) IN GENERAL.—The term ‘participating health
care facility’ means, with respect to an item or service
and a group health plan, a health care facility described
in clause (ii) that has a direct or indirect contractual
relationship with the plan, with respect to the 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)(1) of such Act).
‘‘(IV) An ambulatory surgical center described
in section 1833(i)(1)(A) of such Act.
‘‘(V) Any other facility, specified by the Secretary, that provides items or services for which
coverage is provided under the plan or coverage,
respectively.
‘‘(B) VISIT.—The term ‘visit’ shall, with respect to items
and services furnished to an individual at a health care

H. R. 133—1614
facility, include equipment and devices, telemedicine services, imaging services, laboratory services, preoperative and
postoperative services, and such other items and services
as the Secretary may specify, regardless of whether or
not the provider furnishing such items or services is at
the facility.
‘‘(c) CERTAIN ACCESS FEES TO CERTAIN DATABASES.—In the
case of a sponsor of a group health plan that, pursuant to subsection
(a)(3)(E)(iii), uses a database described in such subsection to 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) TRANSFER AMENDMENT.—Subchapter B of chapter 100
of the Internal Revenue Code of 1986, as amended by paragraph
(1), is further amended by adding at the end the following:
‘‘SEC. 9822. OTHER PATIENT PROTECTIONS.

‘‘(a) CHOICE OF HEALTH CARE PROFESSIONAL.—If a group health
plan requires or provides for designation by a participant or beneficiary of a participating primary care provider, then the plan
shall permit each participant and beneficiary to designate any
participating primary care provider who is available to accept such
individual.
‘‘(b) ACCESS TO PEDIATRIC CARE.—
‘‘(1) PEDIATRIC CARE.—In the case of a person who has
a child who is a participant or beneficiary under a group
health plan if the plan requires or provides for the designation
of a participating primary care provider for the child, the plan
shall permit such person to designate a physician (allopathic
or osteopathic) who specializes in pediatrics as the child’s primary care provider if such provider participates in the network
of the plan.
‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) shall be
construed to waive any exclusions of coverage under the terms
and conditions of the plan with respect to coverage of pediatric
care.
‘‘(c) PATIENT ACCESS TO OBSTETRICAL AND GYNECOLOGICAL
CARE.—
‘‘(1) GENERAL RIGHTS.—
‘‘(A) DIRECT ACCESS.—A group health plan described
in paragraph (2) may not require authorization or referral
by the plan, issuer, or any person (including a primary
care provider described in paragraph (2)(B)) in the case
of a female participant or beneficiary who seeks coverage
for obstetrical or gynecological care provided by a 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

H. R. 133—1615
(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 or issuer of treatment decisions.’’.
(3) 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. Preventing surprise medical bills.
‘‘Sec. 9822. Other patient protections.’’.
(4) CONFORMING AMENDMENTS.—
(A) IN GENERAL.—Section 223(c)

of the Internal Revenue Code of 1986 is amended—
(i) in paragraph (1), by adding at the end the
following:
‘‘(D) SPECIAL RULE FOR INDIVIDUALS RECEIVING BENEFITS SUBJECT TO SURPRISE BILLING STATUTES.—An individual shall not fail to be treated as an eligible individual
for any period merely because the individual receives benefits for medical care subject to and in accordance with
section 9816 or 9817, section 2799A–1 or 2799A–2 of the
Public Health Service Act, or section 716 or 717 of the
Employee Retirement Income Security Act of 1974, or any
State law providing similar protections to such individual.’’;
and
(ii) in paragraph (2), by adding at the end the
following:
‘‘(F) SPECIAL RULE FOR SURPRISE BILLING.—A plan shall
not fail to be treated as a high deductible health plan
by reason of providing benefits for medical care in accordance with section 9816 or 9817, section 2799A–1 or 2799A–
2 of the Public Health Service Act, or section 716 or 717
of the Employee Retirement Income Security Act of 1974,
or any State law providing similar protections to individuals, prior to the satisfaction of the deductible under paragraph (2)(A)(i).’’.
(B) EFFECTIVE DATE.—The amendments made by
subparagraph (A) shall apply for plan years beginning on
or after January 1, 2022.
(d) ADDITIONAL APPLICATION PROVISIONS.—

H. R. 133—1616
(1) APPLICATION TO FEHB.—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 sections
2799A–1, 2799A–2, and 2799A–7 of the Public Health Service Act,
sections 716, 717, and 722 of the Employee Retirement Income
Security Act of 1974, and sections 9816, 9817, and 9822 of the
Internal Revenue Code of 1986 (as applicable) in the same manner
as such provisions apply to a group health plan or health insurance
issuer offering group or individual health insurance coverage, as
described in such sections. The provisions of sections 2799B–1,
2799B–2, 2799B–3, and 2799B–5 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 an 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 group or individual health insurance coverage offered by a health
insurance issuer, as described in such sections.’’.
(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.—Sections
2799A–1, 2799A–2, and 2799A–7 of the Public Health Service
Act shall apply to grandfathered health plans for plan years
beginning on or after January 1, 2022.’’.
(3) 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 (or, in the case of the
amendment made by subsection (d)(1), with respect to contracts
entered into or renewed for contract years) beginning on or after
January 1, 2022.
SEC. 103. DETERMINATION OF OUT-OF-NETWORK RATES TO BE PAID
BY HEALTH PLANS; INDEPENDENT DISPUTE RESOLUTION PROCESS.

(a) PHSA.—Section 2799A–1, as added by section 102, is
amended—
(1) by redesignating subsection (c) as subsection (d); and
(2) by inserting after subsection (b) the following new subsection:
‘‘(c) DETERMINATION OF OUT-OF-NETWORK RATES TO BE PAID
BY HEALTH PLANS; INDEPENDENT DISPUTE RESOLUTION PROCESS.—
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIATION.—
‘‘(A) IN GENERAL.—With respect to an item or service
furnished in a year by a nonparticipating provider or a

H. R. 133—1617
nonparticipating facility, with respect to a group health
plan or health insurance issuer offering group or individual
health insurance coverage, in a State described in subsection (a)(3)(K)(ii) with respect to such plan or coverage
and provider or facility, and for which a payment is
required to be made by the plan or coverage pursuant
to subsection (a)(1) or (b)(1), the provider or facility (as
applicable) or plan or coverage may, during the 30-day
period beginning on the day the provider or facility receives
an initial payment or a notice of denial of payment from
the plan or coverage regarding a claim for payment for
such item or service, initiate open negotiations under this
paragraph between such provider or facility and plan or
coverage for purposes of determining, during the open negotiation period, an amount agreed on by such provider or
facility, respectively, and such plan or coverage for payment
(including any cost-sharing) for such item or service. For
purposes of this subsection, the open negotiation period,
with respect to an item or service, is the 30-day period
beginning on the date of initiation of the negotiations with
respect to such item or service.
‘‘(B) ACCESSING INDEPENDENT DISPUTE RESOLUTION
PROCESS IN CASE OF FAILED NEGOTIATIONS.—In the case
of open negotiations pursuant to subparagraph (A), with
respect to an item or service, that do not result in a
determination of an amount of payment for such item
or service by the last day of the open negotiation period
described in such subparagraph with respect to such item
or service, the provider or facility (as applicable) or group
health plan or health insurance issuer offering group or
individual health insurance coverage that was party to
such negotiations may, during the 4-day period beginning
on the day after such open negotiation period, initiate
the independent dispute resolution process under paragraph (2) with respect to such item or service. The independent dispute resolution process shall be initiated by
a party pursuant to the previous sentence by submission
to the other party and to the Secretary of a notification
(containing such information as specified by the Secretary)
and for purposes of this subsection, the date of initiation
of such process shall be the date of such submission or
such other date specified by the Secretary pursuant to
regulations that is not later than the date of receipt of
such notification by both the other party and the Secretary.
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROCESS AVAILABLE
IN CASE OF FAILED OPEN NEGOTIATIONS.—
‘‘(A) ESTABLISHMENT.—Not later than 1 year after the
date of the enactment of this subsection, the Secretary,
jointly with the Secretary of Labor and the Secretary of
the Treasury, shall establish by regulation one independent
dispute resolution process (referred to in this subsection
as the ‘IDR process’) under which, in the case of an item
or service with respect to which a provider or facility (as
applicable) or group health plan or health insurance issuer
offering group or individual health insurance coverage submits a notification under paragraph (1)(B) (in this subsection referred to as a ‘qualified IDR item or service’),

H. R. 133—1618
a certified IDR entity under paragraph (4) determines,
subject to subparagraph (B) and in accordance with the
succeeding provisions of this subsection, the amount of
payment under the plan or coverage for such item or service
furnished by such provider or facility.
‘‘(B) AUTHORITY TO CONTINUE NEGOTIATIONS.—Under
the independent dispute resolution process, in the case
that the parties to a determination for a qualified IDR
item or service agree on a payment amount for such item
or service during such process but before the date on which
the entity selected with respect to such determination
under paragraph (4) makes such determination under paragraph (5), such amount shall be treated for purposes of
subsection (a)(3)(K)(ii) as the amount agreed to by such
parties for such item or service. In the case of an agreement
described in the previous sentence, the independent dispute
resolution process shall provide for a method to determine
how to allocate between the parties to such determination
the payment of the compensation of the entity selected
with respect to such determination.
‘‘(C) CLARIFICATION.—A nonparticipating provider may
not, with respect to an item or service furnished by such
provider, submit a notification under paragraph (1)(B) if
such provider is exempt from the requirement under subsection (a) of section 2799B–2 with respect to such item
or service pursuant to subsection (b) of such section.
‘‘(3) TREATMENT OF BATCHING OF ITEMS AND SERVICES.—
‘‘(A) IN GENERAL.—Under the IDR process, the Secretary shall specify criteria under which multiple qualified
IDR dispute items and services are permitted to be considered jointly as part of a single determination by an entity
for purposes of encouraging the efficiency (including minimizing costs) of the IDR process. Such items and services
may be so considered only if—
‘‘(i) such items and services to be included in such
determination are furnished by the same provider or
facility;
‘‘(ii) payment for such items and services is
required to be made by the same group health plan
or health insurance issuer;
‘‘(iii) such items and services are related to the
treatment of a similar condition; and
‘‘(iv) such items and services were furnished during
the 30 day period following the date on which the
first item or service included with respect to such
determination was furnished or an alternative period
as determined by the Secretary, for use in limited
situations, such as by the consent of the parties or
in the case of low-volume items and services, to encourage procedural efficiency and minimize health plan
and provider administrative costs.
‘‘(B) TREATMENT OF BUNDLED PAYMENTS.—In carrying
out subparagraph (A), the Secretary shall provide that,
in the case of items and services which are included by
a provider or facility as part of a bundled payment, such
items and services included in such bundled payment may
be part of a single determination under this subsection.

H. R. 133—1619
‘‘(4) CERTIFICATION AND SELECTION OF IDR ENTITIES.—
‘‘(A) IN GENERAL.—The Secretary, in consultation with
the Secretary of Labor and Secretary of the Treasury, shall
establish a process to certify (including to recertify) entities
under this paragraph. Such process shall ensure that an
entity so certified—
‘‘(i) has (directly or through contracts or other
arrangements) sufficient medical, legal, and other
expertise and sufficient staffing to make determinations described in paragraph (5) on a timely basis;
‘‘(ii) is not—
‘‘(I) a group health plan or health insurance
issuer offering group or individual health insurance coverage, provider, or facility;
‘‘(II) an affiliate or a subsidiary of such a group
health plan or health insurance issuer, provider,
or facility; or
‘‘(III) an affiliate or subsidiary of a professional
or trade association of such group health plans
or health insurance issuers or of providers or facilities;
‘‘(iii) carries out the responsibilities of such an
entity in accordance with this subsection;
‘‘(iv) meets appropriate indicators of fiscal integrity;
‘‘(v) maintains the confidentiality (in accordance
with regulations promulgated by the Secretary) of
individually identifiable health information obtained
in the course of conducting such determinations;
‘‘(vi) does not under the IDR process carry out
any determination with respect to which the entity
would not pursuant to subclause (I), (II), or (III) of
subparagraph (F)(i) be eligible for selection; and
‘‘(vii) meets such other requirements as determined
appropriate by the Secretary.
‘‘(B) PERIOD OF CERTIFICATION.—Subject to subparagraph (C), each certification (including a recertification)
of an entity under the process described in subparagraph
(A) shall be for a 5-year period.
‘‘(C) REVOCATION.—A certification of an entity under
this paragraph may be revoked under the process described
in subparagraph (A) if the entity has a pattern or practice
of noncompliance with any of the requirements described
in such subparagraph.
‘‘(D) PETITION FOR DENIAL OR WITHDRAWAL.—The
process described in subparagraph (A) shall ensure that
an individual, provider, facility, or group health plan or
health insurance issuer offering group or individual health
insurance coverage may petition for a denial of a certification or a revocation of a certification with respect to
an entity under this paragraph for failure of meeting a
requirement of this subsection.
‘‘(E) SUFFICIENT NUMBER OF ENTITIES.—The process
described in subparagraph (A) shall ensure that a sufficient
number of entities are certified under this paragraph to
ensure the timely and efficient provision of determinations
described in paragraph (5).

H. R. 133—1620
‘‘(F) SELECTION OF CERTIFIED IDR ENTITY.—The Secretary shall, with respect to the determination of the
amount of payment under this subsection of an item or
service, provide for a method—
‘‘(i) that allows for the group health plan or health
insurance issuer offering group or individual health
insurance coverage and the nonparticipating provider
or the nonparticipating emergency facility (as
applicable) involved in a notification under paragraph
(1)(B) to jointly select, not later than the last day
of the 3-business day period following the date of the
initiation of the process with respect to such item
or service, for purposes of making such determination,
an entity certified under this paragraph that—
‘‘(I) is not a party to such determination or
an employee or agent of such a party;
‘‘(II) does not have a material familial, financial, or professional relationship with such a party;
and
‘‘(III) does not otherwise have a conflict of
interest with such a party (as determined by the
Secretary); and
‘‘(ii) that requires, in the case such parties do
not make such selection by such last day, the Secretary
to, not later than 6 business days after such date
of initiation—
‘‘(I) select such an entity that satisfies subclauses (I) through (III) of clause (i)); and
‘‘(II) provide notification of such selection to
the provider or facility (as applicable) and the plan
or issuer (as applicable) party to such determination.
An entity selected pursuant to the previous sentence to make a
determination described in such sentence shall be referred to in
this subsection as the ‘certified IDR entity’ with respect to such
determination.
‘‘(5) PAYMENT DETERMINATION.—
‘‘(A) IN GENERAL.—Not later than 30 days after the
date of selection of the certified IDR entity with respect
to a determination for a qualified IDR item or service,
the certified IDR entity shall—
‘‘(i) taking into account the considerations specified
in subparagraph (C), select one of the offers submitted
under subparagraph (B) to be the amount of payment
for such item or service determined under this subsection for purposes of subsection (a)(1) or (b)(1), as
applicable; and
‘‘(ii) notify the provider or facility and the group
health plan or health insurance issuer offering group
or individual health insurance coverage party to such
determination of the offer selected under clause (i).
‘‘(B) SUBMISSION OF OFFERS.—Not later than 10 days
after the date of selection of the certified IDR entity with
respect to a determination for a qualified IDR item or
service, the provider or facility and the group health plan
or health insurance issuer offering group or individual
health insurance coverage party to such determination—

H. R. 133—1621
‘‘(i) shall each submit to the certified IDR entity
with respect to such determination—
‘‘(I) an offer for a payment amount for such
item or service furnished by such provider or
facility; and
‘‘(II) such information as requested by the certified IDR entity relating to such offer; and
‘‘(ii) may each submit to the certified IDR entity
with respect to such determination any information
relating to such offer submitted by either party,
including information relating to any circumstance
described in subparagraph (C)(ii).
‘‘(C) CONSIDERATIONS IN DETERMINATION.—
‘‘(i) IN GENERAL.—In determining which offer is
the payment to be applied pursuant to this paragraph,
the certified IDR entity, with respect to the determination for a qualified IDR item or service shall consider—
‘‘(I) the qualifying payment amounts (as
defined in subsection (a)(3)(E)) for the applicable
year for items or services that are comparable
to the qualified IDR item or service and that are
furnished in the same geographic region (as
defined by the Secretary for purposes of such subsection) as such qualified IDR item or service;
and
‘‘(II) subject to subparagraph (D), information
on any circumstance described in clause (ii), such
information as requested in subparagraph
(B)(i)(II), and any additional information provided
in subparagraph (B)(ii).
‘‘(ii) ADDITIONAL CIRCUMSTANCES.—For purposes of
clause (i)(II), the circumstances described in this clause
are, with respect to a qualified IDR item or service
of a nonparticipating provider, nonparticipating emergency facility, group health plan, or health insurance
issuer of group or individual health insurance coverage
the following:
‘‘(I) The level of training, experience, and
quality and outcomes measurements of the provider or facility that furnished such item or service
(such as those endorsed by the consensus-based
entity authorized in section 1890 of the Social
Security Act).
‘‘(II) The market share held by the nonparticipating provider or facility or that of the plan or
issuer in the geographic region in which the item
or service was provided.
‘‘(III) The acuity of the individual receiving
such item or service or the complexity of furnishing
such item or service to such individual.
‘‘(IV) The teaching status, case mix, and scope
of services of the nonparticipating facility that furnished such item or service.
‘‘(V) Demonstrations of good faith efforts (or
lack of good faith efforts) made by the nonparticipating provider or nonparticipating facility or the
plan or issuer to enter into network agreements

H. R. 133—1622
and, if applicable, contracted rates between the
provider or facility, as applicable, and the plan
or issuer, as applicable, during the previous 4 plan
years.
‘‘(D) PROHIBITION ON CONSIDERATION OF CERTAIN FACTORS.—In determining which offer is the payment to be
applied with respect to qualified IDR items and services
furnished by a provider or facility, the certified IDR entity
with respect to a determination shall not consider usual
and customary charges, the amount that would have been
billed by such provider or facility with respect to such
items and services had the provisions of section 2799B–
1 or 2799B–2 (as applicable) not applied, or the payment
or reimbursement rate for such items and services furnished by such provider or facility payable by a public
payor, including under the Medicare program under title
XVIII of the Social Security Act, under the Medicaid program under title XIX of such Act, under the Children’s
Health Insurance Program under title XXI of such Act,
under the TRICARE program under chapter 55 of title
10, United States Code, or under chapter 17 of title 38,
United States Code.
‘‘(E) EFFECTS OF DETERMINATION.—
‘‘(i) IN GENERAL.—A determination of a certified
IDR entity under subparagraph (A)—
‘‘(I) shall be binding upon the parties involved,
in the absence of a fraudulent claim or evidence
of misrepresentation of facts presented to the IDR
entity involved regarding such claim; and
‘‘(II) shall not be subject to judicial review,
except in a case described in any of paragraphs
(1) through (4) of section 10(a) of title 9, United
States Code.
‘‘(ii) SUSPENSION OF CERTAIN SUBSEQUENT IDR
REQUESTS.—In the case of a determination of a certified
IDR entity under subparagraph (A), with respect to
an initial notification submitted under paragraph (1)(B)
with respect to qualified IDR items and services and
the two parties involved with such notification, the
party that submitted such notification may not submit
during the 90-day period following such determination
a subsequent notification under such paragraph
involving the same other party to such notification
with respect to such an item or service that was the
subject of such initial notification.
‘‘(iii) SUBSEQUENT SUBMISSION OF REQUESTS PERMITTED.—In the case of a notification that pursuant
to clause (ii) is not permitted to be submitted under
paragraph (1)(B) during a 90-day period specified in
such clause, if the end of the open negotiation period
specified in paragraph (1)(A), that but for this clause
would otherwise apply with respect to such notification,
occurs during such 90-day period, such paragraph
(1)(B) shall be applied as if the reference in such paragraph to the 4-day period beginning on the day after
such open negotiation period were instead a reference

H. R. 133—1623
to the 30-day period beginning on the day after the
last day of such 90-day period.
‘‘(iv) REPORTS.—The Secretary, jointly with the
Secretary of Labor and the Secretary of the Treasury,
shall examine the impact of the application of clause
(ii) and whether the application of such clause delays
payment determinations or impacts early, alternative
resolution of claims (such as through open negotiations), and shall submit to Congress, not later than
2 years after the date of implementation of such clause
an interim report (and not later than 4 years after
such date of implementation, a final report) on whether
any group health plans or health insurance issuers
offering group or individual health insurance coverage
or types of such plans or coverage have a pattern
or practice of routine denial, low payment, or downcoding of claims, or otherwise abuse the 90-day period
described in such clause, including recommendations
on ways to discourage such a pattern or practice.
‘‘(F) COSTS OF INDEPENDENT DISPUTE RESOLUTION
PROCESS.—In the case of a notification under paragraph
(1)(B) submitted by a nonparticipating provider, nonparticipating emergency facility, group health plan, or health
insurance issuer offering group or individual health insurance coverage and submitted to a certified IDR entity—
‘‘(i) if such entity makes a determination with
respect to such notification under subparagraph (A),
the party whose offer is not chosen under such subparagraph shall be responsible for paying all fees charged
by such entity; and
‘‘(ii) if the parties reach a settlement with respect
to such notification prior to such a determination, each
party shall pay half of all fees charged by such entity,
unless the parties otherwise agree.
‘‘(6) TIMING OF PAYMENT.—The total plan or coverage payment required pursuant to subsection (a)(1) or (b)(1), with
respect to a qualified IDR item or service for which a determination is made under paragraph (5)(A) or with respect to an
item or service for which a payment amount is determined
under open negotiations under paragraph (1), shall be made
directly to the nonparticipating provider or facility not later
than 30 days after the date on which such determination is
made.
‘‘(7) PUBLICATION OF INFORMATION RELATING TO THE IDR
PROCESS.—
‘‘(A) PUBLICATION OF INFORMATION.—For each calendar
quarter in 2022 and each calendar quarter in a subsequent
year, the Secretary shall make available on the public
website of the Department of Health and Human Services—
‘‘(i) the number of notifications submitted under
paragraph (1)(B) during such calendar quarter;
‘‘(ii) the size of the provider practices and the
size of the facilities submitting notifications under
paragraph (1)(B) during such calendar quarter;
‘‘(iii) the number of such notifications with respect
to which a determination was made under paragraph
(5)(A);

H. R. 133—1624
‘‘(iv) the information described in subparagraph
(B) with respect to each notification with respect to
which such a determination was so made;
‘‘(v) the number of times the payment amount
determined (or agreed to) under this subsection exceeds
the qualifying payment amount, specified by items and
services;
‘‘(vi) the amount of expenditures made by the Secretary during such calendar quarter to carry out the
IDR process;
‘‘(vii) the total amount of fees paid under paragraph (8) during such calendar quarter; and
‘‘(viii) the total amount of compensation paid to
certified IDR entities under paragraph (5)(F) during
such calendar quarter.
‘‘(B) INFORMATION.—For purposes of subparagraph (A),
the information described in this subparagraph is, with
respect to a notification under paragraph (1)(B) by a nonparticipating provider, nonparticipating emergency facility,
group health plan, or health insurance issuer offering group
or individual health insurance coverage—
‘‘(i) a description of each item and service included
with respect to such notification;
‘‘(ii) the geography in which the items and services
with respect to such notification were provided;
‘‘(iii) the amount of the offer submitted under paragraph (5)(B) 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 qualifying
payment amount;
‘‘(iv) whether the offer selected by the certified
IDR entity under paragraph (5) to be the 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 qualifying payment
amount;
‘‘(v) the category and practice specialty of each
such provider or facility involved in furnishing such
items and services;
‘‘(vi) the identity of the health plan or health insurance issuer, provider, or facility, with respect to the
notification;
‘‘(vii) the length of time in making each determination;
‘‘(viii) the compensation paid to the certified IDR
entity with respect to the settlement or determination;
and
‘‘(ix) any other information specified by the Secretary.
‘‘(C) IDR ENTITY REQUIREMENTS.—For 2022 and each
subsequent year, an IDR entity, as a condition of certification as an IDR entity, shall submit to the Secretary
such information as the Secretary determines necessary
to carry out the provisions of this subsection.

H. R. 133—1625
‘‘(D) CLARIFICATION.—The Secretary shall ensure the
public reporting under this paragraph does not contain
information that would disclose privileged or confidential
information of a group health plan or health insurance
issuer offering group or individual health insurance coverage or of a provider or facility.
‘‘(8) ADMINISTRATIVE FEE.—
‘‘(A) IN GENERAL.—Each party to a determination under
paragraph (5) to which an entity is selected under paragraph (3) in a year shall pay to the Secretary, at such
time and in such manner as specified by the Secretary,
a fee for participating in the IDR process with respect
to such determination in an amount described in subparagraph (B) for such year.
‘‘(B) AMOUNT OF FEE.—The amount described in this
subparagraph for a year is an amount established by the
Secretary in a manner such that the total amount of fees
paid under this paragraph for such year is estimated to
be equal to the amount of expenditures estimated to be
made by the Secretary for such year in carrying out the
IDR process.
‘‘(9) WAIVER AUTHORITY.—The Secretary may modify any
deadline or other timing requirement specified under this subsection (other than the establishment date for the IDR process
under paragraph (2)(A) and other than under paragraph (6))
in cases of extenuating circumstances, as specified by the Secretary, or to ensure that all claims that occur during a 90day period described in paragraph (5)(E)(ii), but with respect
to which a notification is not permitted by reason of such
paragraph to be submitted under paragraph (1)(B) during such
period, are eligible for the IDR process.’’.
(b) ERISA.—Section 716 of the Employee Retirement Income
Security Act of 1974, as added by section 102, is amended—
(1) by redesignating subsection (c) as subsection (d); and
(2) by inserting after subsection (b) the following new subsection:
‘‘(c) DETERMINATION OF OUT-OF-NETWORK RATES TO BE PAID
BY HEALTH PLANS; INDEPENDENT DISPUTE RESOLUTION PROCESS.—
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIATION.—
‘‘(A) IN GENERAL.—With respect to an item or service
furnished in a year by a nonparticipating provider or a
nonparticipating facility, with respect to a group health
plan or health insurance issuer offering group health insurance coverage, in a State described in subsection
(a)(3)(K)(ii) with respect to such plan or coverage and provider or facility, and for which a payment is required
to be made by the plan or coverage pursuant to subsection
(a)(1) or (b)(1), the provider or facility (as applicable) or
plan or coverage may, during the 30-day period beginning
on the day the provider or facility receives an initial payment or a notice of denial of payment from the plan or
coverage regarding a claim for payment for such item or
service, initiate open negotiations under this paragraph
between such provider or facility and plan or coverage
for purposes of determining, during the open negotiation
period, an amount agreed on by such provider or facility,
respectively, and such plan or coverage for payment

H. R. 133—1626
(including any cost-sharing) for such item or service. For
purposes of this subsection, the open negotiation period,
with respect to an item or service, is the 30-day period
beginning on the date of initiation of the negotiations with
respect to such item or service.
‘‘(B) ACCESSING INDEPENDENT DISPUTE RESOLUTION
PROCESS IN CASE OF FAILED NEGOTIATIONS.—In the case
of open negotiations pursuant to subparagraph (A), with
respect to an item or service, that do not result in a
determination of an amount of payment for such item
or service by the last day of the open negotiation period
described in such subparagraph with respect to such item
or service, the provider or facility (as applicable) or group
health plan or health insurance issuer offering group health
insurance coverage that was party to such negotiations
may, during the 4-day period beginning on the day after
such open negotiation period, initiate the independent dispute resolution process under paragraph (2) with respect
to such item or service. The independent dispute resolution
process shall be initiated by a party pursuant to the previous sentence by submission to the other party and to
the Secretary of a notification (containing such information
as specified by the Secretary) and for purposes of this
subsection, the date of initiation of such process shall be
the date of such submission or such other date specified
by the Secretary pursuant to regulations that is not later
than the date of receipt of such notification by both the
other party and the Secretary.
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROCESS AVAILABLE
IN CASE OF FAILED OPEN NEGOTIATIONS.—
‘‘(A) ESTABLISHMENT.—Not later than 1 year after the
date of the enactment of this subsection, the Secretary,
jointly with the Secretary of Health and Human Services
and the Secretary of the Treasury, shall establish by regulation one independent dispute resolution process (referred
to in this subsection as the ‘IDR process’) under which,
in the case of an item or service with respect to which
a provider or facility (as applicable) or group health plan
or health insurance issuer offering group health insurance
coverage submits a notification under paragraph (1)(B) (in
this subsection referred to as a ‘qualified IDR item or
service’), a certified IDR entity under paragraph (4) determines, subject to subparagraph (B) and in accordance with
the succeeding provisions of this subsection, the amount
of payment under the plan or coverage for such item or
service furnished by such provider or facility.
‘‘(B) AUTHORITY TO CONTINUE NEGOTIATIONS.—Under
the independent dispute resolution process, in the case
that the parties to a determination for a qualified IDR
item or service agree on a payment amount for such item
or service during such process but before the date on which
the entity selected with respect to such determination
under paragraph (4) makes such determination under paragraph (5), such amount shall be treated for purposes of
subsection (a)(3)(K)(ii) as the amount agreed to by such
parties for such item or service. In the case of an agreement
described in the previous sentence, the independent dispute

H. R. 133—1627
resolution process shall provide for a method to determine
how to allocate between the parties to such determination
the payment of the compensation of the entity selected
with respect to such determination.
‘‘(C) CLARIFICATION.—A nonparticipating provider may
not, with respect to an item or service furnished by such
provider, submit a notification under paragraph (1)(B) if
such provider is exempt from the requirement under subsection (a) of section 2799B–2 of the Public Health Service
Act with respect to such item or service pursuant to subsection (b) of such section.
‘‘(3) TREATMENT OF BATCHING OF ITEMS AND SERVICES.—
‘‘(A) IN GENERAL.—Under the IDR process, the Secretary shall specify criteria under which multiple qualified
IDR dispute items and services are permitted to be considered jointly as part of a single determination by an entity
for purposes of encouraging the efficiency (including minimizing costs) of the IDR process. Such items and services
may be so considered only if—
‘‘(i) such items and services to be included in such
determination are furnished by the same provider or
facility;
‘‘(ii) payment for such items and services is
required to be made by the same group health plan
or health insurance issuer;
‘‘(iii) such items and services are related to the
treatment of a similar condition; and
‘‘(iv) such items and services were furnished during
the 30 day period following the date on which the
first item or service included with respect to such
determination was furnished or an alternative period
as determined by the Secretary, for use in limited
situations, such as by the consent of the parties or
in the case of low-volume items and services, to encourage procedural efficiency and minimize health plan
and provider administrative costs.
‘‘(B) TREATMENT OF BUNDLED PAYMENTS.—In carrying
out subparagraph (A), the Secretary shall provide that,
in the case of items and services which are included by
a provider or facility as part of a bundled payment, such
items and services included in such bundled payment may
be part of a single determination under this subsection.
‘‘(4) CERTIFICATION AND SELECTION OF IDR ENTITIES.—
‘‘(A) IN GENERAL.—The Secretary, jointly with the Secretary of Health and Human Services and Secretary of
the Treasury, shall establish a process to certify (including
to recertify) entities under this paragraph. Such process
shall ensure that an entity so certified—
‘‘(i) has (directly or through contracts or other
arrangements) sufficient medical, legal, and other
expertise and sufficient staffing to make determinations described in paragraph (5) on a timely basis;
‘‘(ii) is not—
‘‘(I) a group health plan or health insurance
issuer offering group health insurance coverage,
provider, or facility;

H. R. 133—1628
‘‘(II) an affiliate or a subsidiary of such a group
health plan or health insurance issuer, provider,
or facility; or
‘‘(III) an affiliate or subsidiary of a professional
or trade association of such group health plans
or health insurance issuers or of providers or facilities;
‘‘(iii) carries out the responsibilities of such an
entity in accordance with this subsection;
‘‘(iv) meets appropriate indicators of fiscal integrity;
‘‘(v) maintains the confidentiality (in accordance
with regulations promulgated by the Secretary) of
individually identifiable health information obtained
in the course of conducting such determinations;
‘‘(vi) does not under the IDR process carry out
any determination with respect to which the entity
would not pursuant to subclause (I), (II), or (III) of
subparagraph (F)(i) be eligible for selection; and
‘‘(vii) meets such other requirements as determined
appropriate by the Secretary.
‘‘(B) PERIOD OF CERTIFICATION.—Subject to subparagraph (C), each certification (including a recertification)
of an entity under the process described in subparagraph
(A) shall be for a 5-year period.
‘‘(C) REVOCATION.—A certification of an entity under
this paragraph may be revoked under the process described
in subparagraph (A) if the entity has a pattern or practice
of noncompliance with any of the requirements described
in such subparagraph.
‘‘(D) PETITION FOR DENIAL OR WITHDRAWAL.—The
process described in subparagraph (A) shall ensure that
an individual, provider, facility, or group health plan or
health insurance issuer offering group health insurance
coverage may petition for a denial of a certification or
a revocation of a certification with respect to an entity
under this paragraph for failure of meeting a requirement
of this subsection.
‘‘(E) SUFFICIENT NUMBER OF ENTITIES.—The process
described in subparagraph (A) shall ensure that a sufficient
number of entities are certified under this paragraph to
ensure the timely and efficient provision of determinations
described in paragraph (5).
‘‘(F) SELECTION OF CERTIFIED IDR ENTITY.—The Secretary shall, with respect to the determination of the
amount of payment under this subsection of an item or
service, provide for a method—
‘‘(i) that allows for the group health plan or health
insurance issuer offering group health insurance coverage and the nonparticipating provider or the nonparticipating emergency facility (as applicable)
involved in a notification under paragraph (1)(B) to
jointly select, not later than the last day of the 3business day period following the date of the initiation
of the process with respect to such item or service,
for purposes of making such determination, an entity
certified under this paragraph that—

H. R. 133—1629
‘‘(I) is not a party to such determination or
an employee or agent of such a party;
‘‘(II) does not have a material familial, financial, or professional relationship with such a party;
and
‘‘(III) does not otherwise have a conflict of
interest with such a party (as determined by the
Secretary); and
‘‘(ii) that requires, in the case such parties do
not make such selection by such last day, the Secretary
to, not later than 6 business days after such date
of initiation—
‘‘(I) select such an entity that satisfies subclauses (I) through (III) of clause (i)); and
‘‘(II) provide notification of such selection to
the provider or facility (as applicable) and the plan
or issuer (as applicable) party to such determination.
An entity selected pursuant to the previous sentence to make a
determination described in such sentence shall be referred to in
this subsection as the ‘certified IDR entity’ with respect to such
determination.
‘‘(5) PAYMENT DETERMINATION.—
‘‘(A) IN GENERAL.—Not later than 30 days after the
date of selection of the certified IDR entity with respect
to a determination for a qualified IDR item or service,
the certified IDR entity shall—
‘‘(i) taking into account the considerations specified
in subparagraph (C), select one of the offers submitted
under subparagraph (B) to be the amount of payment
for such item or service determined under this subsection for purposes of subsection (a)(1) or (b)(1), as
applicable; and
‘‘(ii) notify the provider or facility and the group
health plan or health insurance issuer offering group
health insurance coverage party to such determination
of the offer selected under clause (i).
‘‘(B) SUBMISSION OF OFFERS.—Not later than 10 days
after the date of selection of the certified IDR entity with
respect to a determination for a qualified IDR item or
service, the provider or facility and the group health plan
or health insurance issuer offering group health insurance
coverage party to such determination—
‘‘(i) shall each submit to the certified IDR entity
with respect to such determination—
‘‘(I) an offer for a payment amount for such
item or service furnished by such provider or
facility; and
‘‘(II) such information as requested by the certified IDR entity relating to such offer; and
‘‘(ii) may each submit to the certified IDR entity
with respect to such determination any information
relating to such offer submitted by either party,
including information relating to any circumstance
described in subparagraph (C)(ii).
‘‘(C) CONSIDERATIONS IN DETERMINATION.—

H. R. 133—1630
‘‘(i) IN GENERAL.—In determining which offer is
the payment to be applied pursuant to this paragraph,
the certified IDR entity, with respect to the determination for a qualified IDR item or service shall consider—
‘‘(I) the qualifying payment amounts (as
defined in subsection (a)(3)(E)) for the applicable
year for items or services that are comparable
to the qualified IDR item or service and that are
furnished in the same geographic region (as
defined by the Secretary for purposes of such subsection) as such qualified IDR item or service;
and
‘‘(II) subject to subparagraph (D), information
on any circumstance described in clause (ii), such
information as requested in subparagraph
(B)(i)(II), and any additional information provided
in subparagraph (B)(ii).
‘‘(ii) ADDITIONAL CIRCUMSTANCES.—For purposes of
clause (i)(II), the circumstances described in this clause
are, with respect to a qualified IDR item or service
of a nonparticipating provider, nonparticipating emergency facility, group health plan, or health insurance
issuer of group health insurance coverage the following:
‘‘(I) The level of training, experience, and
quality and outcomes measurements of the provider or facility that furnished such item or service
(such as those endorsed by the consensus-based
entity authorized in section 1890 of the Social
Security Act).
‘‘(II) The market share held by the nonparticipating provider or facility or that of the plan or
issuer in the geographic region in which the item
or service was provided.
‘‘(III) The acuity of the individual receiving
such item or service or the complexity of furnishing
such item or service to such individual.
‘‘(IV) The teaching status, case mix, and scope
of services of the nonparticipating facility that furnished such item or service.
‘‘(V) Demonstrations of good faith efforts (or
lack of good faith efforts) made by the nonparticipating provider or nonparticipating facility or the
plan or issuer to enter into network agreements
and, if applicable, contracted rates between the
provider or facility, as applicable, and the plan
or issuer, as applicable, during the previous 4 plan
years.
‘‘(D) PROHIBITION ON CONSIDERATION OF CERTAIN FACTORS.—In determining which offer is the payment to be
applied with respect to qualified IDR items and services
furnished by a provider or facility, the certified IDR entity
with respect to a determination shall not consider usual
and customary charges, the amount that would have been
billed by such provider or facility with respect to such
items and services had the provisions of section 2799B–
1 of the Public Health Service Act or 2799B–2 of such
Act (as applicable) not applied, or the payment or

H. R. 133—1631
reimbursement rate for such items and services furnished
by such provider or facility payable by a public payor,
including under the Medicare program under title XVIII
of the Social Security Act, under the Medicaid program
under title XIX of such Act, under the Children’s Health
Insurance Program under title XXI of such Act, under
the TRICARE program under chapter 55 of title 10, United
States Code, or under chapter 17 of title 38, United States
Code.
‘‘(E) EFFECTS OF DETERMINATION.—
‘‘(i) IN GENERAL.—A determination of a certified
IDR entity under subparagraph (A)—
‘‘(I) shall be binding upon the parties involved,
in the absence of a fraudulent claim or evidence
of misrepresentation of facts presented to the IDR
entity involved regarding such claim; and
‘‘(II) shall not be subject to judicial review,
except in a case described in any of paragraphs
(1) through (4) of section 10(a) of title 9, United
States Code.
‘‘(ii) SUSPENSION OF CERTAIN SUBSEQUENT IDR
REQUESTS.—In the case of a determination of a certified
IDR entity under subparagraph (A), with respect to
an initial notification submitted under paragraph (1)(B)
with respect to qualified IDR items and services and
the two parties involved with such notification, the
party that submitted such notification may not submit
during the 90-day period following such determination
a subsequent notification under such paragraph
involving the same other party to such notification
with respect to such an item or service that was the
subject of such initial notification.
‘‘(iii) SUBSEQUENT SUBMISSION OF REQUESTS PERMITTED.—In the case of a notification that pursuant
to clause (ii) is not permitted to be submitted under
paragraph (1)(B) during a 90-day period specified in
such clause, if the end of the open negotiation period
specified in paragraph (1)(A), that but for this clause
would otherwise apply with respect to such notification,
occurs during such 90-day period, such paragraph
(1)(B) shall be applied as if the reference in such paragraph to the 4-day period beginning on the day after
such open negotiation period were instead a reference
to the 30-day period beginning on the day after the
last day of such 90-day period.
‘‘(iv) REPORTS.—The Secretary, jointly with the
Secretary of Health and Human Services and the Secretary of the Treasury, shall examine the impact of
the application of clause (ii) and whether the application of such clause delays payment determinations or
impacts early, alternative resolution of claims (such
as through open negotiations), and shall submit to
Congress, not later than 2 years after the date of
implementation of such clause an interim report (and
not later than 4 years after such date of implementation, a final report) on whether any group health plans
or health insurance issuers offering group or individual

H. R. 133—1632
health insurance coverage or types of such plans or
coverage have a pattern or practice of routine denial,
low payment, or down-coding of claims, or otherwise
abuse the 90-day period described in such clause,
including recommendations on ways to discourage such
a pattern or practice.
‘‘(F) COSTS OF INDEPENDENT DISPUTE RESOLUTION
PROCESS.—In the case of a notification under paragraph
(1)(B) submitted by a nonparticipating provider, nonparticipating emergency facility, group health plan, or health
insurance issuer offering group health insurance coverage
and submitted to a certified IDR entity—
‘‘(i) if such entity makes a determination with
respect to such notification under subparagraph (A),
the party whose offer is not chosen under such subparagraph shall be responsible for paying all fees charged
by such entity; and
‘‘(ii) if the parties reach a settlement with respect
to such notification prior to such a determination, each
party shall pay half of all fees charged by such entity,
unless the parties otherwise agree.
‘‘(6) TIMING OF PAYMENT.—The total plan or coverage payment required pursuant to subsection (a)(1) or (b)(1), with
respect to a qualified IDR item or service for which a determination is made under paragraph (5)(A) or with respect to an
item or service for which a payment amount is determined
under open negotiations under paragraph (1), shall be made
directly to the nonparticipating provider or facility not later
than 30 days after the date on which such determination is
made.
‘‘(7) PUBLICATION OF INFORMATION RELATING TO THE IDR
PROCESS.—
‘‘(A) PUBLICATION OF INFORMATION.—For each calendar
quarter in 2022 and each calendar quarter in a subsequent
year, the Secretary shall make available on the public
website of the Department of Labor—
‘‘(i) the number of notifications submitted under
paragraph (1)(B) during such calendar quarter;
‘‘(ii) the size of the provider practices and the
size of the facilities submitting notifications under
paragraph (1)(B) during such calendar quarter;
‘‘(iii) the number of such notifications with respect
to which a determination was made under paragraph
(5)(A);
‘‘(iv) the information described in subparagraph
(B) with respect to each notification with respect to
which such a determination was so made;
‘‘(v) the number of times the payment amount
determined (or agreed to) under this subsection exceeds
the qualifying payment amount, specified by items and
services;
‘‘(vi) the amount of expenditures made by the Secretary during such calendar quarter to carry out the
IDR process;
‘‘(vii) the total amount of fees paid under paragraph (8) during such calendar quarter; and

H. R. 133—1633
‘‘(viii) the total amount of compensation paid to
certified IDR entities under paragraph (5)(F) during
such calendar quarter.
‘‘(B) INFORMATION.—For purposes of subparagraph (A),
the information described in this subparagraph is, with
respect to a notification under paragraph (1)(B) by a nonparticipating provider, nonparticipating emergency facility,
group health plan, or health insurance issuer offering group
health insurance coverage—
‘‘(i) a description of each item and service included
with respect to such notification;
‘‘(ii) the geography in which the items and services
with respect to such notification were provided;
‘‘(iii) the amount of the offer submitted under paragraph (5)(B) 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 qualifying
payment amount;
‘‘(iv) whether the offer selected by the certified
IDR entity under paragraph (5) to be the 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 qualifying payment
amount;
‘‘(v) the category and practice specialty of each
such provider or facility involved in furnishing such
items and services;
‘‘(vi) the identity of the health plan or health insurance issuer, provider, or facility, with respect to the
notification;
‘‘(vii) the length of time in making each determination;
‘‘(viii) the compensation paid to the certified IDR
entity with respect to the settlement or determination;
and
‘‘(ix) any other information specified by the Secretary.
‘‘(C) IDR ENTITY REQUIREMENTS.—For 2022 and each
subsequent year, an IDR entity, as a condition of certification as an IDR entity, shall submit to the Secretary
such information as the Secretary determines necessary
to carry out the provisions of this subsection.
‘‘(D) CLARIFICATION.—The Secretary shall ensure the
public reporting under this paragraph does not contain
information that would disclose privileged or confidential
information of a group health plan or health insurance
issuer offering group or individual health insurance coverage or of a provider or facility.
‘‘(8) ADMINISTRATIVE FEE.—
‘‘(A) IN GENERAL.—Each party to a determination under
paragraph (5) to which an entity is selected under paragraph (3) in a year shall pay to the Secretary, at such
time and in such manner as specified by the Secretary,
a fee for participating in the IDR process with respect

H. R. 133—1634
to such determination in an amount described in subparagraph (B) for such year.
‘‘(B) AMOUNT OF FEE.—The amount described in this
subparagraph for a year is an amount established by the
Secretary in a manner such that the total amount of fees
paid under this paragraph for such year is estimated to
be equal to the amount of expenditures estimated to be
made by the Secretary for such year in carrying out the
IDR process.
‘‘(9) WAIVER AUTHORITY.—The Secretary may modify any
deadline or other timing requirement specified under this subsection (other than the establishment date for the IDR process
under paragraph (2)(A) and other than under paragraph (6))
in cases of extenuating circumstances, as specified by the Secretary, or to ensure that all claims that occur during a 90day period described in paragraph (5)(E)(ii), but with respect
to which a notification is not permitted by reason of such
paragraph to be submitted under paragraph (1)(B) during such
period, are eligible for the IDR process.’’.
(c) IRC.—Section 9816 of the Internal Revenue Code of 1986,
as added by section 102, is amended—
(1) by redesignating subsection (c) as subsection (d); and
(2) by inserting after subsection (b) the following new subsection:
‘‘(c) DETERMINATION OF OUT-OF-NETWORK RATES TO BE PAID
BY HEALTH PLANS; INDEPENDENT DISPUTE RESOLUTION PROCESS.—
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIATION.—
‘‘(A) IN GENERAL.—With respect to an item or service
furnished in a year by a nonparticipating provider or a
nonparticipating facility, with respect to a group health
plan, in a State described in subsection (a)(3)(K)(ii) with
respect to such plan and provider or facility, and for which
a payment is required to be made by the plan pursuant
to subsection (a)(1) or (b)(1), the provider or facility (as
applicable) or plan may, during the 30-day period beginning
on the day the provider or facility receives an initial payment or a notice of denial of payment from the plan
regarding a claim for payment for such item or service,
initiate open negotiations under this paragraph between
such provider or facility and plan for purposes of determining, during the open negotiation period, an amount
agreed on by such provider or facility, respectively, and
such plan for payment (including any cost-sharing) for such
item or service. For purposes of this subsection, the open
negotiation period, with respect to an item or service, is
the 30-day period beginning on the date of initiation of
the negotiations with respect to such item or service.
‘‘(B) ACCESSING INDEPENDENT DISPUTE RESOLUTION
PROCESS IN CASE OF FAILED NEGOTIATIONS.—In the case
of open negotiations pursuant to subparagraph (A), with
respect to an item or service, that do not result in a
determination of an amount of payment for such item
or service by the last day of the open negotiation period
described in such subparagraph with respect to such item
or service, the provider or facility (as applicable) or group
health plan that was party to such negotiations may, during
the 4-day period beginning on the day after such open

H. R. 133—1635
negotiation period, initiate the independent dispute resolution process under paragraph (2) with respect to such item
or service. The independent dispute resolution process shall
be initiated by a party pursuant to the previous sentence
by submission to the other party and to the Secretary
of a notification (containing such information as specified
by the Secretary) and for purposes of this subsection, the
date of initiation of such process shall be the date of such
submission or such other date specified by the Secretary
pursuant to regulations that is not later than the date
of receipt of such notification by both the other party and
the Secretary.
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROCESS AVAILABLE
IN CASE OF FAILED OPEN NEGOTIATIONS.—
‘‘(A) ESTABLISHMENT.—Not later than 1 year after the
date of the enactment of this subsection, the Secretary,
jointly with the Secretary of Health and Human Services
and the Secretary of Labor, shall establish by regulation
one independent dispute resolution process (referred to in
this subsection as the ‘IDR process’) under which, in the
case of an item or service with respect to which a provider
or facility (as applicable) or group health plan submits
a notification under paragraph (1)(B) (in this subsection
referred to as a ‘qualified IDR item or service’), a certified
IDR entity under paragraph (4) determines, subject to
subparagraph (B) and in accordance with the succeeding
provisions of this subsection, the amount of payment under
the plan for such item or service furnished by such provider
or facility.
‘‘(B) AUTHORITY TO CONTINUE NEGOTIATIONS.—Under
the independent dispute resolution process, in the case
that the parties to a determination for a qualified IDR
item or service agree on a payment amount for such item
or service during such process but before the date on which
the entity selected with respect to such determination
under paragraph (4) makes such determination under paragraph (5), such amount shall be treated for purposes of
subsection (a)(3)(K)(ii) as the amount agreed to by such
parties for such item or service. In the case of an agreement
described in the previous sentence, the independent dispute
resolution process shall provide for a method to determine
how to allocate between the parties to such determination
the payment of the compensation of the entity selected
with respect to such determination.
‘‘(C) CLARIFICATION.—A nonparticipating provider may
not, with respect to an item or service furnished by such
provider, submit a notification under paragraph (1)(B) if
such provider is exempt from the requirement under subsection (a) of section 2799B–2 of the Public Health Service
Act with respect to such item or service pursuant to subsection (b) of such section.
‘‘(3) TREATMENT OF BATCHING OF ITEMS AND SERVICES.—
‘‘(A) IN GENERAL.—Under the IDR process, the Secretary shall specify criteria under which multiple qualified
IDR dispute items and services are permitted to be considered jointly as part of a single determination by an entity

H. R. 133—1636
for purposes of encouraging the efficiency (including minimizing costs) of the IDR process. Such items and services
may be so considered only if—
‘‘(i) such items and services to be included in such
determination are furnished by the same provider or
facility;
‘‘(ii) payment for such items and services is
required to be made by the same group health plan
or health insurance issuer;
‘‘(iii) such items and services are related to the
treatment of a similar condition; and
‘‘(iv) such items and services were furnished during
the 30 day period following the date on which the
first item or service included with respect to such
determination was furnished or an alternative period
as determined by the Secretary, for use in limited
situations, such as by the consent of the parties or
in the case of low-volume items and services, to encourage procedural efficiency and minimize health plan
and provider administrative costs.
‘‘(B) TREATMENT OF BUNDLED PAYMENTS.—In carrying
out subparagraph (A), the Secretary shall provide that,
in the case of items and services which are included by
a provider or facility as part of a bundled payment, such
items and services included in such bundled payment may
be part of a single determination under this subsection.
‘‘(4) CERTIFICATION AND SELECTION OF IDR ENTITIES.—
‘‘(A) IN GENERAL.—The Secretary, jointly with the Secretary of Health and Human Services and the Secretary
of Labor, shall establish a process to certify (including
to recertify) entities under this paragraph. Such process
shall ensure that an entity so certified—
‘‘(i) has (directly or through contracts or other
arrangements) sufficient medical, legal, and other
expertise and sufficient staffing to make determinations described in paragraph (5) on a timely basis;
‘‘(ii) is not—
‘‘(I) a group health plan, provider, or facility;
‘‘(II) an affiliate or a subsidiary of such a group
health plan, provider, or facility; or
‘‘(III) an affiliate or subsidiary of a professional
or trade association of such group health plans
or of providers or facilities;
‘‘(iii) carries out the responsibilities of such an
entity in accordance with this subsection;
‘‘(iv) meets appropriate indicators of fiscal integrity;
‘‘(v) maintains the confidentiality (in accordance
with regulations promulgated by the Secretary) of
individually identifiable health information obtained
in the course of conducting such determinations;
‘‘(vi) does not under the IDR process carry out
any determination with respect to which the entity
would not pursuant to subclause (I), (II), or (III) of
subparagraph (F)(i) be eligible for selection; and
‘‘(vii) meets such other requirements as determined
appropriate by the Secretary.

H. R. 133—1637
‘‘(B) PERIOD OF CERTIFICATION.—Subject to subparagraph (C), each certification (including a recertification)
of an entity under the process described in subparagraph
(A) shall be for a 5-year period.
‘‘(C) REVOCATION.—A certification of an entity under
this paragraph may be revoked under the process described
in subparagraph (A) if the entity has a pattern or practice
of noncompliance with any of the requirements described
in such subparagraph.
‘‘(D) PETITION FOR DENIAL OR WITHDRAWAL.—The
process described in subparagraph (A) shall ensure that
an individual, provider, facility, or group health plan may
petition for a denial of a certification or a revocation of
a certification with respect to an entity under this paragraph for failure of meeting a requirement of this subsection.
‘‘(E) SUFFICIENT NUMBER OF ENTITIES.—The process
described in subparagraph (A) shall ensure that a sufficient
number of entities are certified under this paragraph to
ensure the timely and efficient provision of determinations
described in paragraph (5).
‘‘(F) SELECTION OF CERTIFIED IDR ENTITY.—The Secretary shall, with respect to the determination of the
amount of payment under this subsection of an item or
service, provide for a method—
‘‘(i) that allows for the group health plan and the
nonparticipating provider or the nonparticipating
emergency facility (as applicable) involved in a notification under paragraph (1)(B) to jointly select, not later
than the last day of the 3-business day period following
the date of the initiation of the process with respect
to such item or service, for purposes of making such
determination, an entity certified under this paragraph
that—
‘‘(I) is not a party to such determination or
an employee or agent of such a party;
‘‘(II) does not have a material familial, financial, or professional relationship with such a party;
and
‘‘(III) does not otherwise have a conflict of
interest with such a party (as determined by the
Secretary); and
‘‘(ii) that requires, in the case such parties do
not make such selection by such last day, the Secretary
to, not later than 6 business days after such date
of initiation—
‘‘(I) select such an entity that satisfies subclauses (I) through (III) of clause (i)); and
‘‘(II) provide notification of such selection to
the provider or facility (as applicable) and the plan
or issuer (as applicable) party to such determination.
An entity selected pursuant to the previous sentence to make a
determination described in such sentence shall be referred to in
this subsection as the ‘certified IDR entity’ with respect to such
determination.
‘‘(5) PAYMENT DETERMINATION.—

H. R. 133—1638
‘‘(A) IN GENERAL.—Not later than 30 days after the
date of selection of the certified IDR entity with respect
to a determination for a qualified IDR item or service,
the certified IDR entity shall—
‘‘(i) taking into account the considerations specified
in subparagraph (C), select one of the offers submitted
under subparagraph (B) to be the amount of payment
for such item or service determined under this subsection for purposes of subsection (a)(1) or (b)(1), as
applicable; and
‘‘(ii) notify the provider or facility and the group
health plan party to such determination of the offer
selected under clause (i).
‘‘(B) SUBMISSION OF OFFERS.—Not later than 10 days
after the date of selection of the certifed IDR entity with
respect to a determination for a qualified IDR item or
service, the provider or facility and the group health plan
party to such determination—
‘‘(i) shall each submit to the certified IDR entity
with respect to such determination—
‘‘(I) an offer for a payment amount for such
item or service furnished by such provider or
facility; and
‘‘(II) such information as requested by the certified IDR entity relating to such offer; and
‘‘(ii) may each submit to the certified IDR entity
with respect to such determination any information
relating to such offer submitted by either party,
including information relating to any circumstance
described in subparagraph (C)(ii).
‘‘(C) CONSIDERATIONS IN DETERMINATION.—
‘‘(i) IN GENERAL.—In determining which offer is
the payment to be applied pursuant to this paragraph,
the certified IDR entity, with respect to the determination for a qualified IDR item or service shall consider—
‘‘(I) the qualifying payment amounts (as
defined in subsection (a)(3)(E)) for the applicable
year for items or services that are comparable
to the qualified IDR item or service and that are
furnished in the same geographic region (as
defined by the Secretary for purposes of such subsection) as such qualified IDR item or service;
and
‘‘(II) subject to subparagraph (D), information
on any circumstance described in clause (ii), such
information as requested in subparagraph
(B)(i)(II), and any additional information provided
in subparagraph (B)(ii).
‘‘(ii) ADDITIONAL CIRCUMSTANCES.—For purposes of
clause (i)(II), the circumstances described in this clause
are, with respect to a qualified IDR item or service
of a nonparticipating provider, nonparticipating emergency facility, or group health plan, the following:
‘‘(I) The level of training, experience, and
quality and outcomes measurements of the provider or facility that furnished such item or service
(such as those endorsed by the consensus-based

H. R. 133—1639
entity authorized in section 1890 of the Social
Security Act).
‘‘(II) The market share held by the nonparticipating provider or facility or that of the plan or
issuer in the geographic region in which the item
or service was provided.
‘‘(III) The acuity of the individual receiving
such item or service or the complexity of furnishing
such item or service to such individual.
‘‘(IV) The teaching status, case mix, and scope
of services of the nonparticipating facility that furnished such item or service.
‘‘(V) Demonstrations of good faith efforts (or
lack of good faith efforts) made by the nonparticipating provider or nonparticipating facility or the
plan or issuer to enter into network agreements
and, if applicable, contracted rates between the
provider or facility, as applicable, and the plan
or issuer, as applicable, during the previous 4 plan
years.
‘‘(D) PROHIBITION ON CONSIDERATION OF CERTAIN FACTORS.—In determining which offer is the payment to be
applied with respect to qualified IDR items and services
furnished by a provider or facility, the certified IDR entity
with respect to a determination shall not consider usual
and customary charges, the amount that would have been
billed by such provider or facility with respect to such
items and services had the provisions of section 2799B–
1 of the Public Health Service Act or 2799B–2 of such
Act (as applicable) not applied, or the payment or
reimbursement rate for such items and services furnished
by such provider or facility payable by a public payor,
including under the Medicare program under title XVIII
of the Social Security Act, under the Medicaid program
under title XIX of such Act, under the Children’s Health
Insurance Program under title XXI of such Act, under
the TRICARE program under chapter 55 of title 10, United
States Code, or under chapter 17 of title 38, United States
Code.
‘‘(E) EFFECTS OF DETERMINATION.—
‘‘(i) IN GENERAL.—A determination of a certified
IDR entity under subparagraph (A)—
‘‘(I) shall be binding upon the parties involved,
in the absence of a fraudulent claim or evidence
of misrepresentation of facts presented to the IDR
entity involved regarding such claim; and
‘‘(II) shall not be subject to judicial review,
except in a case described in any of paragraphs
(1) through (4) of section 10(a) of title 9, United
States Code.
‘‘(ii) SUSPENSION OF CERTAIN SUBSEQUENT IDR
REQUESTS.—In the case of a determination of a certified
IDR entity under subparagraph (A), with respect to
an initial notification submitted under paragraph (1)(B)
with respect to qualified IDR items and services and
the two parties involved with such notification, the
party that submitted such notification may not submit

H. R. 133—1640
during the 90-day period following such determination
a subsequent notification under such paragraph
involving the same other party to such notification
with respect to such an item or service that was the
subject of such initial notification.
‘‘(iii) SUBSEQUENT SUBMISSION OF REQUESTS PERMITTED.—In the case of a notification that pursuant
to clause (ii) is not permitted to be submitted under
paragraph (1)(B) during a 90-day period specified in
such clause, if the end of the open negotiation period
specified in paragraph (1)(A), that but for this clause
would otherwise apply with respect to such notification,
occurs during such 90-day period, such paragraph
(1)(B) shall be applied as if the reference in such paragraph to the 4-day period beginning on the day after
such open negotiation period were instead a reference
to the 30-day period beginning on the day after the
last day of such 90-day period.
‘‘(iv) REPORTS.—The Secretary, jointly with the
Secretary of Labor and the Secretary of the Health
and Human Services, shall examine the impact of the
application of clause (ii) and whether the application
of such clause delays payment determinations or
impacts early, alternative resolution of claims (such
as through open negotiations), and shall submit to
Congress, not later than 2 years after the date of
implementation of such clause an interim report (and
not later than 4 years after such date of implementation, a final report) on whether any group health plans
or health insurance issuers offering group or individual
health insurance coverage or types of such plans or
coverage have a pattern or practice of routine denial,
low payment, or down-coding of claims, or otherwise
abuse the 90-day period described in such clause,
including recommendations on ways to discourage such
a pattern or practice.
‘‘(F) COSTS OF INDEPENDENT DISPUTE RESOLUTION
PROCESS.—In the case of a notification under paragraph
(1)(B) submitted by a nonparticipating provider, nonparticipating emergency facility, or group health plan and submitted to a certified IDR entity—
‘‘(i) if such entity makes a determination with
respect to such notification under subparagraph (A),
the party whose offer is not chosen under such subparagraph shall be responsible for paying all fees charged
by such entity; and
‘‘(ii) if the parties reach a settlement with respect
to such notification prior to such a determination, each
party shall pay half of all fees charged by such entity,
unless the parties otherwise agree.
‘‘(6) TIMING OF PAYMENT.—The total plan payment required
pursuant to subsection (a)(1) or (b)(1), with respect to a qualified
IDR item or service for which a determination is made under
paragraph (5)(A) or with respect to an item or service for

H. R. 133—1641
which a payment amount is determined under open negotiations under paragraph (1), shall be made directly to the nonparticipating provider or facility not later than 30 days after
the date on which such determination is made.
‘‘(7) PUBLICATION OF INFORMATION RELATING TO THE IDR
PROCESS.—
‘‘(A) PUBLICATION OF INFORMATION.—For each calendar
quarter in 2022 and each calendar quarter in a subsequent
year, the Secretary shall make available on the public
website of the Department of the Treasury—
‘‘(i) the number of notifications submitted under
paragraph (1)(B) during such calendar quarter;
‘‘(ii) the size of the provider practices and the
size of the facilities submitting notifications under
paragraph (1)(B) during such calendar quarter;
‘‘(iii) the number of such notifications with respect
to which a determination was made under paragraph
(5)(A);
‘‘(iv) the information described in subparagraph
(B) with respect to each notification with respect to
which such a determination was so made;
‘‘(v) the number of times the payment amount
determined (or agreed to) under this subsection exceeds
the qualifying payment amount, specified by items and
services;
‘‘(vi) the amount of expenditures made by the Secretary during such calendar quarter to carry out the
IDR process;
‘‘(vii) the total amount of fees paid under paragraph (8) during such calendar quarter; and
‘‘(viii) the total amount of compensation paid to
certified IDR entities under paragraph (5)(F) during
such calendar quarter.
‘‘(B) INFORMATION.—For purposes of subparagraph (A),
the information described in this subparagraph is, with
respect to a notification under paragraph (1)(B) by a nonparticipating provider, nonparticipating emergency facility,
or group health plan—
‘‘(i) a description of each item and service included
with respect to such notification;
‘‘(ii) the geography in which the items and services
with respect to such notification were provided;
‘‘(iii) the amount of the offer submitted under paragraph (5)(B) by the group health plan and by the
nonparticipating provider or nonparticipating emergency facility (as applicable) expressed as a percentage
of the qualifying payment amount;
‘‘(iv) whether the offer selected by the certified
IDR entity under paragraph (5) to be the payment
applied was the offer submitted by such plan or by
such provider or facility (as applicable) and the amount
of such offer so selected expressed as a percentage
of the qualifying payment amount;
‘‘(v) the category and practice specialty of each
such provider or facility involved in furnishing such
items and services;

H. R. 133—1642
‘‘(vi) the identity of the group health plan, provider,
or facility, with respect to the notification;
‘‘(vii) the length of time in making each determination;
‘‘(viii) the compensation paid to the certified IDR
entity with respect to the settlement or determination;
and
‘‘(ix) any other information specified by the Secretary.
‘‘(C) IDR ENTITY REQUIREMENTS.—For 2022 and each
subsequent year, an IDR entity, as a condition of certification as an IDR entity, shall submit to the Secretary
such information as the Secretary determines necessary
to carry out the provisions of this subsection.
‘‘(D) CLARIFICATION.—The Secretary shall ensure the
public reporting under this paragraph does not contain
information that would disclose privileged or confidential
information of a group health plan or health insurance
issuer offering group or individual health insurance coverage or of a provider or facility.
‘‘(8) ADMINISTRATIVE FEE.—
‘‘(A) IN GENERAL.—Each party to a determination under
paragraph (5) to which an entity is selected under paragraph (3) in a year shall pay to the Secretary, at such
time and in such manner as specified by the Secretary,
a fee for participating in the IDR process with respect
to such determination in an amount described in subparagraph (B) for such year.
‘‘(B) AMOUNT OF FEE.—The amount described in this
subparagraph for a year is an amount established by the
Secretary in a manner such that the total amount of fees
paid under this paragraph for such year is estimated to
be equal to the amount of expenditures estimated to be
made by the Secretary for such year in carrying out the
IDR process.
‘‘(9) WAIVER AUTHORITY.—The Secretary may modify any
deadline or other timing requirement specified under this subsection (other than the establishment date for the IDR process
under paragraph (2)(A) and other than under paragraph (6))
in cases of extenuating circumstances, as specified by the Secretary, or to ensure that all claims that occur during a 90day period described in paragraph (5)(E)(ii), but with respect
to which a notification is not permitted by reason of such
paragraph to be submitted under paragraph (1)(B) during such
period, are eligible for the IDR process.’’.
SEC. 104. HEALTH CARE PROVIDER REQUIREMENTS REGARDING SURPRISE MEDICAL BILLING.

(a) IN GENERAL.—Title XXVII of the Public Health Service
Act (42 U.S.C. 300gg et seq.) is amended by inserting after part
D, as added by section 102, the following:

H. R. 133—1643

‘‘PART E—HEALTH CARE PROVIDER
REQUIREMENTS
‘‘SEC. 2799B–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 group or
individual health insurance coverage offered by a health insurance
issuer and who is furnished during a plan year beginning on or
after January 1, 2022, emergency services (for which benefits are
provided under the 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 bill, and
shall not hold liable, the participant, beneficiary, or enrollee
for a payment amount for such emergency services so furnished
that is more than the cost-sharing requirement for such services
(as determined in accordance with clauses (ii) and (iii) of section
2799A–1(a)(1)(C), of section 9816(a)(1)(C) of the Internal Revenue Code of 1986, and of section 716(a)(1)(C) of the Employee
Retirement Income Security Act of 1974, as applicable); and
‘‘(2) in the case that such services are furnished by a
nonparticipating provider, the health care provider shall not
bill, and shall not hold liable, such participant, beneficiary,
or enrollee 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 requirement for such services furnished by the provider (as determined
in accordance with clauses (ii) and (iii) of section 2799A–
1(a)(1)(C), of section 9816(a)(1)(C) of the Internal Revenue Code
of 1986, and of section 716(a)(1)(C) of the Employee Retirement
Income Security Act of 1974, as applicable).
‘‘(b) DEFINITION.—In this section, the term ‘visit’ shall have
such meaning as applied to such term for purposes of section
2799A–1(b).
‘‘SEC. 2799B–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 group or individual health insurance coverage offered
by a health insurance issuer and who is furnished during a plan
year beginning on or after January 1, 2022, items or services
(other than emergency services to which section 2799B–1 applies)
for which benefits are provided under the 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 requirement

H. R. 133—1644
for such item or service (as determined in accordance with subparagraphs (A) and (B) of section 2799A–1(b)(1) of section 9816(b)(1)
of the Internal Revenue Code of 1986, and of section 716(b)(1)
of the Employee Retirement Income Security Act of 1974, 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 group or individual health insurance coverage
offered by a health insurance issuer, 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 periodically) 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 group or individual health
insurance coverage offered by a health insurance issuer, if
the provider (or, if applicable, the participating health care
facility on behalf of such provider) or nonparticipating facility—
‘‘(A) in the case that the participant, beneficiary, or
enrollee makes an appointment to be furnished such items
or services at least 72 hours prior to the date on which

H. R. 133—1645
the individual is to be furnished such items or services,
provides to the participant, beneficiary, or enrollee (or to
an authorized representative of the participant, beneficiary,
or enrollee) not later than 72 hours prior to the date
on which the individual is furnished such items or services
(or, in the case that the participant, beneficiary, or enrollee
makes such an appointment within 72 hours of when such
items or services are to be furnished, provides to the participant, beneficiary, or enrollee (or to an authorized representative of the participant, beneficiary, or enrollee) on such
date the appointment is made), a written notice in paper
or electronic form, as selected by the participant, beneficiary, or enrollee, (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; and
‘‘(iii) is available in the 15 most common languages
in the geographic region of the applicable facility;
‘‘(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; and
‘‘(C) provides a signed copy of such consent to the
participant, beneficiary, or enrollee through mail or email
(as selected by the participant, beneficiary, or enrollee).
‘‘(2) INFORMATION REQUIRED UNDER WRITTEN NOTICE.—For
purposes of paragraph (1)(A)(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 group or individual health
insurance coverage offered by a health insurance issuer, 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.

H. R. 133—1646
‘‘(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 group or individual health insurance
coverage offered by a health insurance issuer who is to be
furnished items or services by a nonparticipating provider or
nonparticipating facility, is a document specified by the Secretary, in consultation with the Secretary of Labor, through
guidance that shall be signed by the participant, beneficiary,
or enrollee before such items or services are furnished and
that —
‘‘(A) acknowledges (in clear and understandable language) that the participant, beneficiary, or enrollee has
been—
‘‘(i) provided with the written notice under paragraph (1)(A);
‘‘(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 innetwork deductible applied under the plan or coverage;
and
‘‘(iii) provided the opportunity to receive the written notice under paragraph (1)(A) in the form selected
by the participant, beneficiary or enrollee; and
‘‘(B) documents the date on which the participant, beneficiary, or enrollee received the written notice under paragraph (1)(A) and the date on which the individual signed
such consent to be furnished such items 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 group or individual health
insurance coverage offered by a health insurance issuer, 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 group
or individual health insurance coverage offered by a health insurance issuer (or an authorized representative of such participant,

H. R. 133—1647
beneficiary, or enrollee) a written notice in accordance with subsection (d)(1)(B), with respect to furnishing an item or service
to such participant, beneficiary, or enrollee, shall retain such notice
for at least a 7-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 (a)(3) of section 2799A–1.
‘‘(2) The term ‘participating health care facility’ has the
meaning given such term in subsection (b)(2) of section 2799A–
1.
‘‘(3) The term ‘nonparticipating facility’ means—
‘‘(A) with respect to emergency services (as defined
in section 2799A–1(a)(3)(C)(i)) and a group health plan
or group or individual health insurance coverage offered
by a health insurance issuer, 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
2799A–1(a)(3)(C)(ii) and a group health plan or group or
individual health insurance coverage offered by a health
insurance issuer, 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 2799A–1(a)(3)(C)) that are not
described in clause(ii) of such section and a group health
plan or group or individual health insurance coverage
offered by a health insurance issuer, an emergency department of a hospital, or an independent freestanding emergency department, that has a direct or indirect 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 2799A–1(a)(3)(C), of section 9816(a)(3) of the
Internal Revenue Code of 1986, and of section 716(a)(3)
of the Employee Retirement Income Security Act of 1974,
as applicable are included as emergency services (as defined
in clause (i) of such section and a group health plan or
group or individual health insurance coverage offered by
a health insurance issuer, 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.

H. R. 133—1648
‘‘SEC. 2799B–3. PROVIDER REQUIREMENTS WITH RESPECT TO DISCLOSURE ON PATIENT PROTECTIONS AGAINST BALANCE
BILLING.

‘‘Beginning not later than January 1, 2022, 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 group or individual
health insurance coverage offered by a health insurance issuer
a one-page notice (either postal or electronic mail, as specified
by the participant, beneficiary, or enrollee) in clear and understandable language containing information on—
‘‘(1) the requirements and prohibitions of such provider
or facility under sections 2799B–1 and 2799B–2 (relating to
prohibitions on balance billing in certain circumstances);
‘‘(2) any other applicable State law 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 group
or individual health insurance coverage offered by a health
insurance issuer 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.
‘‘SEC. 2799B–4. 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 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 to which paragraph
(1) applies 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 APPLICABLE SECRETARY.—A State may
notify the Secretary of Labor, Secretary of Health and Human
Services, or the Secretary of the Treasury, as applicable, of
instances of violations of sections 2799B–1, 2799B–2, or 2799B–
5 with respect to participants, beneficiaries, or enrollees under
a group health plan or group or individual health insurance
coverage, as applicable offered by a health insurance issuer
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 by
the Secretary to be in violation of a requirement to which

H. R. 133—1649
subsection (a)(1) applies, 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, establish a process to receive consumer complaints
of violations of such provisions and provide a response to such
complaints within 60 days of receipt of such complaints.
‘‘(4) EXCEPTION.—The Secretary shall waive the penalties
described under paragraph (1) with respect to a facility or
provider (including a provider of air ambulance services) who
does not knowingly violate, and should not have reasonably
known it violated, section 2799B–1 or 2799B–2 (or, in the
case of a provider of air ambulance services, section 2799B–
5) 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 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 ENFORCEMENT.—
(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. COORDINATION OF ENFORCEMENT REGARDING VIOLATIONS OF CERTAIN HEALTH CARE PROVIDER REQUIREMENTS; COMPLAINT PROCESS.

‘‘(a) INVESTIGATING VIOLATIONS.—Upon receiving a notice from
a State or the Secretary of Health and Human Services of violations
of sections 2799B–1, 2799B–2, or 2799B–5 of the Public Health
Service Act, the Secretary of Labor shall identify patterns of such
violations with respect to participants or beneficiaries under a group
health plan or group health insurance coverage offered by a health
insurance issuer and conduct an investigation pursuant to section
504 where appropriate, as determined by the Secretary. The Secretary shall coordinate with States and the Secretary of Health
and Human Services, in accordance with section 506 and with

H. R. 133—1650
section 104 of Health Insurance Portability and Accountability Act
of 1996, where appropriate, as determined by the Secretary, 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 group health
insurance coverage offered by a health insurance issuer.
‘‘(b) COMPLAINT PROCESS.— Not later than January 1, 2022,
the Secretary shall ensure a process under which the Secretary—
‘‘(1) may receive complaints from participants and beneficiaries of group health plans or group health insurance coverage offered by a health insurance issuer 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. Coordination of enforcement regarding violations of certain health care
provider requirements; complaint process.’’.
SEC. 105. ENDING SURPRISE AIR AMBULANCE BILLS.

(a) GROUP HEALTH PLANS AND INDIVIDUAL AND GROUP HEALTH
INSURANCE COVERAGE.—
(1) PHSA AMENDMENTS.—Part D of title XXVII of the Public
Health Service Act, as added and amended by section 102
and further amended by the previous provisions of this title,
is further amended by inserting after section 2799A–1 the
following:
‘‘SEC. 2799A–2. ENDING SURPRISE AIR AMBULANCE BILLS.

‘‘(a) IN GENERAL.—In the case of a participant, beneficiary,
or enrollee who is in a group health plan or group or individual
health insurance coverage offered by a health insurance issuer
and who receives air ambulance services from a nonparticipating
provider (as defined in section 2799A–1(a)(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—
‘‘(1) the cost-sharing requirement with respect to such services shall be the same requirement that would apply if such
services were provided by such a 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;
‘‘(2) such cost-sharing amounts shall be counted towards
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
‘‘(3) the group health plan or health insurance issuer,
respectively, shall—
‘‘(A) not later than 30 calendar days after the bill
for such services is transmitted by such provider, send

H. R. 133—1651

BY

to the provider, an initial payment or notice of denial
of payment; and
‘‘(B) pay a total plan or coverage payment, in accordance with, if applicable, subsection (b)(6), directly to such
provider furnishing such services to such participant, beneficiary, or enrollee that is, with application of any initial
payment under subparagraph (A), equal to the amount
by which the out-of-network rate (as defined in section
2799A–1(a)(3)(K)) 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 paragraphs (1) and (2)).
‘‘(b) DETERMINATION OF OUT-OF-NETWORK RATES TO BE PAID
HEALTH PLANS; INDEPENDENT DISPUTE RESOLUTION PROCESS.—
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIATION.—
‘‘(A) IN GENERAL.—With respect to air ambulance services furnished in a year by a nonparticipating provider,
with respect to a group health plan or health insurance
issuer offering group or individual health insurance coverage, and for which a payment is required to be made
by the plan or coverage pursuant to subsection (a)(3), the
provider or plan or coverage may, during the 30-day period
beginning on the day the provider receives an initial payment or a notice of denial of payment from the plan or
coverage regarding a claim for payment for such service,
initiate open negotiations under this paragraph between
such provider and plan or coverage for purposes of determining, during the open negotiation period, an amount
agreed on by such provider, and such plan or coverage
for payment (including any cost-sharing) for such service.
For purposes of this subsection, the open negotiation period,
with respect to air ambulance services, is the 30-day period
beginning on the date of initiation of the negotiations with
respect to such services.
‘‘(B) ACCESSING INDEPENDENT DISPUTE RESOLUTION
PROCESS IN CASE OF FAILED NEGOTIATIONS.—In the case
of open negotiations pursuant to subparagraph (A), with
respect to air ambulance services, that do not result in
a determination of an amount of payment for such services
by the last day of the open negotiation period described
in such subparagraph with respect to such services, the
provider or group health plan or health insurance issuer
offering group or individual health insurance coverage that
was party to such negotiations may, during the 4-day period
beginning on the day after such open negotiation period,
initiate the independent dispute resolution process under
paragraph (2) with respect to such item or service. The
independent dispute resolution process shall be initiated
by a party pursuant to the previous sentence by submission
to the other party and to the Secretary of a notification
(containing such information as specified by the Secretary)
and for purposes of this subsection, the date of initiation
of such process shall be the date of such submission or
such other date specified by the Secretary pursuant to
regulations that is not later than the date of receipt of
such notification by both the other party and the Secretary.

H. R. 133—1652
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROCESS AVAILABLE
IN CASE OF FAILED OPEN NEGOTIATIONS.—
‘‘(A) ESTABLISHMENT.—Not later than 1 year after the
date of the enactment of this subsection, the Secretary,
jointly with the Secretary of Labor and the Secretary of
the Treasury, shall establish by regulation one independent
dispute resolution process (referred to in this subsection
as the ‘IDR process’) under which, in the case of air ambulance services with respect to which a provider or group
health plan or health insurance issuer offering group or
individual health insurance coverage submits a notification
under paragraph (1)(B) (in this subsection referred to as
a ‘qualified IDR air ambulance services’), a certified IDR
entity under paragraph (4) determines, subject to subparagraph (B) and in accordance with the succeeding provisions
of this subsection, the amount of payment under the plan
or coverage for such services furnished by such provider.
‘‘(B) AUTHORITY TO CONTINUE NEGOTIATIONS.—Under
the independent dispute resolution process, in the case
that the parties to a determination for qualified IDR air
ambulance services agree on a payment amount for such
services during such process but before the date on which
the entity selected with respect to such determination
under paragraph (4) makes such determination under paragraph (5), such amount shall be treated for purposes of
section 2799A–1(a)(3)(K)(ii) as the amount agreed to by
such parties for such services. In the case of an agreement
described in the previous sentence, the independent dispute
resolution process shall provide for a method to determine
how to allocate between the parties to such determination
the payment of the compensation of the entity selected
with respect to such determination.
‘‘(C) CLARIFICATION.—A nonparticipating provider may
not, with respect to an item or service furnished by such
provider, submit a notification under paragraph (1)(B) if
such provider is exempt from the requirement under subsection (a) of section 2799B–2 with respect to such item
or service pursuant to subsection (b) of such section.
‘‘(3) TREATMENT OF BATCHING OF SERVICES.—The provisions
of section 2799A–1(c)(3) shall apply with respect to a notification submitted under this subsection with respect to air ambulance services in the same manner and to the same extent
such provisions apply with respect to a notification submitted
under section 2799A–1(c) with respect to items and services
described in such section.
‘‘(4) IDR ENTITIES.—
‘‘(A) ELIGIBILITY.—An IDR entity certified under this
subsection is an IDR entity certified under section 2799A–
1(c)(4).
‘‘(B) SELECTION OF CERTIFIED IDR ENTITY.—The provisions of subparagraph (F) of section 2799A–1(c)(4) shall
apply with respect to selecting an IDR entity certified
pursuant to subparagraph (A) with respect to the determination of the amount of payment under this subsection
of air ambulance services in the same manner as such
provisions apply with respect to selecting an IDR entity

H. R. 133—1653
certified under such section with respect to the determination of the amount of payment under section 2799A–1(c)
of an item or service. An entity selected pursuant to the
previous sentence to make a determination described in
such sentence shall be referred to in this subsection as
the ‘certified IDR entity’ with respect to such determination.
‘‘(5) PAYMENT DETERMINATION.—
‘‘(A) IN GENERAL.—Not later than 30 days after the
date of selection of the certified IDR entity with respect
to a determination for qualified IDR ambulance services,
the certified IDR entity shall—
‘‘(i) taking into account the considerations specified
in subparagraph (C), select one of the offers submitted
under subparagraph (B) to be the amount of payment
for such services determined under this subsection for
purposes of subsection (a)(3); and
‘‘(ii) notify the provider or facility and the group
health plan or health insurance issuer offering group
or individual health insurance coverage party to such
determination of the offer selected under clause (i).
‘‘(B) SUBMISSION OF OFFERS.—Not later than 10 days
after the date of selection of the certified IDR entity with
respect to a determination for qualified IDR air ambulance
services, the provider and the group health plan or health
insurance issuer offering group or individual health insurance coverage party to such determination—
‘‘(i) shall each submit to the certified IDR entity
with respect to such determination—
‘‘(I) an offer for a payment amount for such
services furnished by such provider; and
‘‘(II) such information as requested by the certified IDR entity relating to such offer; and
‘‘(ii) may each submit to the certified IDR entity
with respect to such determination any information
relating to such offer submitted by either party,
including information relating to any circumstance
described in subparagraph (C)(ii).
‘‘(C) CONSIDERATIONS IN DETERMINATION.—
‘‘(i) IN GENERAL.—In determining which offer is
the payment to be applied pursuant to this paragraph,
the certified IDR entity, with respect to the determination for a qualified IDR air ambulance service shall
consider—
‘‘(I) the qualifying payment amounts (as
defined in section 2799A–1(a)(3)(E)) for the
applicable year for items or services that are comparable to the qualified IDR air ambulance service
and that are furnished in the same geographic
region (as defined by the Secretary for purposes
of such subsection) as such qualified IDR air ambulance service; and
‘‘(II) subject to clause (iii), information on any
circumstance described in clause (ii), such information as requested in subparagraph (B)(i)(II), and
any additional information provided in subparagraph (B)(ii).

H. R. 133—1654
‘‘(ii) ADDITIONAL CIRCUMSTANCES.—For purposes of
clause (i)(II), the circumstances described in this clause
are, with respect to air ambulance services included
in the notification submitted under paragraph (1)(B)
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) The acuity of the individual receiving
such services or the complexity of furnishing such
services to such individual.
‘‘(III) The training, experience, and quality of
the medical personnel that furnished such services.
‘‘(IV) Ambulance vehicle type, including the
clinical capability level of such vehicle.
‘‘(V) Population density of the pick up location
(such as urban, suburban, rural, or frontier).
‘‘(VI) Demonstrations of good faith efforts (or
lack of good faith efforts) made by the nonparticipating provider or nonparticipating facility or the
plan or issuer to enter into network agreements
and, if applicable, contracted rates between the
provider and the plan or issuer, as applicable,
during the previous 4 plan years.
‘‘(iii) PROHIBITION ON CONSIDERATION OF CERTAIN
FACTORS.—In determining which offer is the payment
amount to be applied with respect to qualified IDR
air ambulance services furnished by a provider, the
certified IDR entity with respect to such determination
shall not consider usual and customary charges, the
amount that would have been billed by such provider
with respect to such services had the provisions of
section 2799B–5 not applied, or the payment or
reimbursement rate for such services furnished by such
provider payable by a public payor, including under
the Medicare program under title XVIII of the Social
Security Act, under the Medicaid program under title
XIX of such Act, under the Children’s Health Insurance
Program under title XXI of such Act, under the
TRICARE program under chapter 55 of title 10, United
States Code, or under chapter 17 of title 38, United
States Code.
‘‘(D) EFFECTS OF DETERMINATION.—The provisions of
section 2799A–1(c)(5)(E)) shall apply with respect to a
determination of a certified IDR entity under subparagraph
(A), the notification submitted with respect to such determination, the services with respect to such notification,
and the parties to such notification in the same manner
as such provisions apply with respect to a determination
of a certified IDR entity under section 2799A–1(c)(5)(E),
the notification submitted with respect to such determination, the items and services with respect to such notification, and the parties to such notification.
‘‘(E) COSTS OF INDEPENDENT DISPUTE RESOLUTION
PROCESS.—The provisions of section 2799A–1(c)(5)(F) shall
apply to a notification made under this subsection, the
parties to such notification, and a determination under

H. R. 133—1655
subparagraph (A) in the same manner and to the same
extent such provisions apply to a notification under section
2799A–1(c), the parties to such notification and a determination made under section 2799A–1(c)(5)(A).
‘‘(6) TIMING OF PAYMENT.—The total plan or coverage payment required pursuant to subsection (a)(3), with respect to
qualified IDR air ambulance services for which a determination
is made under paragraph (5)(A) or with respect to an air
ambulance service for which a payment amount is determined
under open negotiations under paragraph (1), shall be made
directly to the nonparticipating provider not later than 30 days
after the date on which such determination is made.
‘‘(7) PUBLICATION OF INFORMATION RELATING TO THE IDR
PROCESS.—
‘‘(A) IN GENERAL.—For each calendar quarter in 2022
and each calendar quarter in a subsequent year, the Secretary shall publish on the public website of the Department of Health and Human Services—
‘‘(i) the number of notifications submitted under
the IDR process during such calendar quarter;
‘‘(ii) the number of such notifications with respect
to which a final determination was made under paragraph (5)(A);
‘‘(iii) the information described in subparagraph
(B) with respect to each notification with respect to
which such a determination was so made.
‘‘(iv) the number of times the payment amount
determined (or agreed to) under this subsection exceeds
the qualifying payment amount;
‘‘(v) the amount of expenditures made by the Secretary during such calendar quarter to carry out the
IDR process;
‘‘(vi) the total amount of fees paid under paragraph
(8) during such calendar quarter; and
‘‘(vii) the total amount of compensation paid to
certified IDR entities under paragraph (5)(E)during
such calendar quarter.
‘‘(B) INFORMATION WITH RESPECT TO REQUESTS.—For
purposes of subparagraph (A), the information described
in this subparagraph is, with respect to a notification under
the IDR process of a nonparticipating provider, group
health plan, or health insurance issuer offering group or
individual health insurance coverage—
‘‘(i) a description of each air ambulance service
included in such notification;
‘‘(ii) the geography in which the services included
in such notification were provided;
‘‘(iii) the amount of the offer submitted under paragraph (2) by the group health plan or health insurance
issuer (as applicable) and by the nonparticipating provider expressed as a percentage of the qualifying payment amount;
‘‘(iv) whether the offer selected by the certified
IDR entity under paragraph (5) to be the payment
applied was the offer submitted by such plan or issuer
(as applicable) or by such provider and the amount

H. R. 133—1656
of such offer so selected expressed as a percentage
of the qualifying payment amount;
‘‘(v) ambulance vehicle type, including the clinical
capability level of such vehicle;
‘‘(vi) the identity of the group health plan or health
insurance issuer or air ambulance provider with
respect to such notification;
‘‘(vii) the length of time in making each determination;
‘‘(viii) the compensation paid to the certified IDR
entity with respect to the settlement or determination;
and
‘‘(ix) any other information specified by the Secretary.
‘‘(C) IDR ENTITY REQUIREMENTS.—For 2022 and each
subsequent year, an IDR entity, as a condition of certification as an IDR entity, shall submit to the Secretary
such information as the Secretary determines necessary
for the Secretary to carry out the provisions of this paragraph.
‘‘(D) CLARIFICATION.—The Secretary shall ensure the
public reporting under this paragraph does not contain
information that would disclose privileged or confidential
information of a group health plan or health insurance
issuer offering group or individual health insurance coverage or of a provider or facility.
‘‘(8) ADMINISTRATIVE FEE.—
‘‘(A) IN GENERAL.—Each party to a determination under
paragraph (5) to which an entity is selected under paragraph (4) in a year shall pay to the Secretary, at such
time and in such manner as specified by the Secretary,
a fee for participating in the IDR process with respect
to such determination in an amount described in subparagraph (B) for such year.
‘‘(B) AMOUNT OF FEE.—The amount described in this
subparagraph for a year is an amount established by the
Secretary in a manner such that the total amount of fees
paid under this paragraph for such year is estimated to
be equal to the amount of expenditures estimated to be
made by the Secretary for such year in carrying out the
IDR process.
‘‘(9) WAIVER AUTHORITY.—The Secretary may modify any
deadline or other timing requirement specified under this subsection (other than the establishment date for the IDR process
under paragraph (2)(A) and other than under paragraph (6))
in cases of extenuating circumstances, as specified by the Secretary, or to ensure that all claims that occur during a 90day period applied through paragraph (5)(D), but with respect
to which a notification is not permitted by reason of such
paragraph to be submitted under paragraph (1)(B) during such
period, are eligible for the IDR process.
‘‘(c) DEFINITIONS.—For purposes of this section:
‘‘(1) AIR AMBULANCE SERVICE.—The term ‘air ambulance
service’ means medical transport by helicopter or airplane for
patients.

H. R. 133—1657
‘‘(2) QUALIFYING PAYMENT AMOUNT.—The term ‘qualifying
payment amount’ has the meaning given such term in section
2799A–1(a)(3).
‘‘(3) NONPARTICIPATING PROVIDER.—The term ‘nonparticipating provider’ has the meaning given such term in section
2799A–1(a)(3).’’.
(2) ERISA AMENDMENT.—
(A) IN GENERAL.—Subpart B of part 7 of title I of
the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185 et seq.), as amended by section 102(b) and
further amended by the previous provisions of this title,
is further amended by inserting after section 716 the following:
‘‘SEC. 717. ENDING SURPRISE AIR AMBULANCE BILLS.

‘‘(a) IN GENERAL.—In the case of a participant or beneficiary
who is in a group health plan or group health insurance coverage
offered by a health insurance issuer and who receives air ambulance
services from a nonparticipating provider (as defined in section
716(a)(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—
‘‘(1) the cost-sharing requirement with respect to such services shall be the same requirement that would apply if such
services were provided by such a 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;
‘‘(2) such cost-sharing amounts shall be counted towards
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
‘‘(3) the group health plan or health insurance issuer,
respectively, shall—
‘‘(A) not later than 30 calendar days after the bill
for such services is transmitted by such provider, send
to the provider, an initial payment or notice of denial
of payment; and
‘‘(B) pay a total plan or coverage payment, in accordance with, if applicable, subsection (b)(6), directly to such
provider furnishing such services to such participant, beneficiary, or enrollee that is, with application of any initial
payment under subparagraph (A), equal to the amount
by which the out-of-network rate (as defined in section
716(a)(3)(K)) 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 paragraphs (1) and (2)).
‘‘(b) DETERMINATION OF OUT-OF-NETWORK RATES TO BE PAID
BY HEALTH PLANS; INDEPENDENT DISPUTE RESOLUTION PROCESS.—
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIATION.—
‘‘(A) IN GENERAL.—With respect to air ambulance services furnished in a year by a nonparticipating provider,
with respect to a group health plan or health insurance

H. R. 133—1658
issuer offering group health insurance coverage, and for
which a payment is required to be made by the plan
or coverage pursuant to subsection (a)(3), the provider or
plan or coverage may, during the 30-day period beginning
on the day the provider receives a payment or a statement
of denial of payment from the plan or coverage regarding
a claim for payment for such service, initiate open negotiations under this paragraph between such provider and
plan or coverage for purposes of determining, during the
open negotiation period, an amount agreed on by such
provider, and such plan or coverage for payment (including
any cost-sharing) for such service. For purposes of this
subsection, the open negotiation period, with respect to
air ambulance services, is the 30-day period beginning
on the date of initiation of the negotiations with respect
to such services.
‘‘(B) ACCESSING INDEPENDENT DISPUTE RESOLUTION
PROCESS IN CASE OF FAILED NEGOTIATIONS.—In the case
of open negotiations pursuant to subparagraph (A), with
respect to air ambulance services, that do not result in
a determination of an amount of payment for such services
by the last day of the open negotiation period described
in such subparagraph with respect to such services, the
provider or group health plan or health insurance issuer
offering group health insurance coverage that was party
to such negotiations may, during the 4-day period beginning
on the day after such open negotiation period, initiate
the independent dispute resolution process under paragraph (2) with respect to such item or service. The independent dispute resolution process shall be initiated by
a party pursuant to the previous sentence by submission
to the other party and to the Secretary of a notification
(containing such information as specified by the Secretary)
and for purposes of this subsection, the date of initiation
of such process shall be the date of such submission or
such other date specified by the Secretary pursuant to
regulations that is not later than the date of receipt of
such notification by both the other party and the Secretary.
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROCESS AVAILABLE
IN CASE OF FAILED OPEN NEGOTIATIONS.—
‘‘(A) ESTABLISHMENT.—Not later than 1 year after the
date of the enactment of this subsection, the Secretary,
jointly with the Secretary of Health and Human Services
and the Secretary of the Treasury, shall establish by regulation one independent dispute resolution process (referred
to in this subsection as the ‘IDR process’) under which,
in the case of air ambulance services with respect to which
a provider or group health plan or health insurance issuer
offering group health insurance coverage submits a notification under paragraph (1)(B) (in this subsection referred
to as a ‘qualified IDR air ambulance services’), a certified
IDR entity under paragraph (4) determines, subject to
subparagraph (B) and in accordance with the succeeding
provisions of this subsection, the amount of payment under
the plan or coverage for such services furnished by such
provider.

H. R. 133—1659
‘‘(B) AUTHORITY TO CONTINUE NEGOTIATIONS.—Under
the independent dispute resolution process, in the case
that the parties to a determination for qualified IDR air
ambulance services agree on a payment amount for such
services during such process but before the date on which
the entity selected with respect to such determination
under paragraph (4) makes such determination under paragraph (5), such amount shall be treated for purposes of
section 716(a)(3)(K)(ii) as the amount agreed to by such
parties for such services. In the case of an agreement
described in the previous sentence, the independent dispute
resolution process shall provide for a method to determine
how to allocate between the parties to such determination
the payment of the compensation of the entity selected
with respect to such determination.
‘‘(C) CLARIFICATION.—A nonparticipating provider may
not, with respect to an item or service furnished by such
provider, submit a notification under paragraph (1)(B) if
such provider is exempt from the requirement under subsection (a) of section 2799B–2 of the Public Health Service
Act with respect to such item or service pursuant to subsection (b) of such section.
‘‘(3) TREATMENT OF BATCHING OF SERVICES.—The provisions
of section 716(c)(3) shall apply with respect to a notification
submitted under this subsection with respect to air ambulance
services in the same manner and to the same extent such
provisions apply with respect to a notification submitted under
section 716(c) with respect to items and services described
in such section.
‘‘(4) IDR ENTITIES.—
‘‘(A) ELIGIBILITY.—An IDR entity certified under this
subsection is an IDR entity certified under section 716(c)(4).
‘‘(B) SELECTION OF CERTIFIED IDR ENTITY.—The provisions of subparagraph (F) of section 716(c)(4) shall apply
with respect to selecting an IDR entity certified pursuant
to subparagraph (A) with respect to the determination of
the amount of payment under this subsection of air ambulance services in the same manner as such provisions apply
with respect to selecting an IDR entity certified under
such section with respect to the determination of the
amount of payment under section 716(c) of an item or
service. An entity selected pursuant to the previous sentence to make a determination described in such sentence
shall be referred to in this subsection as the ‘certified
IDR entity’ with respect to such determination.
‘‘(5) PAYMENT DETERMINATION.—
‘‘(A) IN GENERAL.—Not later than 30 days after the
date of selection of the certified IDR entity with respect
to a determination for qualified IDR ambulance services,
the certified IDR entity shall—
‘‘(i) taking into account the considerations specified
in subparagraph (C), select one of the offers submitted
under subparagraph (B) to be the amount of payment
for such services determined under this subsection for
purposes of subsection (a)(3); and
‘‘(ii) notify the provider or facility and the group
health plan or health insurance issuer offering group

H. R. 133—1660
health insurance coverage party to such determination
of the offer selected under clause (i).
‘‘(B) SUBMISSION OF OFFERS.—Not later than 10 days
after the date of selection of the certified IDR entity with
respect to a determination for qualified IDR air ambulance
services, the provider and the group health plan or health
insurance issuer offering group health insurance coverage
party to such determination—
‘‘(i) shall each submit to the certified IDR entity
with respect to such determination—
‘‘(I) an offer for a payment amount for such
services furnished by such provider; and
‘‘(II) such information as requested by the certified IDR entity relating to such offer; and
‘‘(ii) may each submit to the certified IDR entity
with respect to such determination any information
relating to such offer submitted by either party,
including information relating to any circumstance
described in subparagraph (C)(ii).
‘‘(C) CONSIDERATIONS IN DETERMINATION.—
‘‘(i) IN GENERAL.—In determining which offer is
the payment to be applied pursuant to this paragraph,
the certified IDR entity, with respect to the determination for a qualified IDR air ambulance service shall
consider—
‘‘(I) the qualifying payment amounts (as
defined in section 716(a)(3)(E)) for the applicable
year for items and services that are comparable
to the qualified IDR air ambulance service and
that are furnished in the same geographic region
(as defined by the Secretary for purposes of such
subsection) as such qualified IDR air ambulance
service; and
‘‘(II) subject to clause (iii), information on any
circumstance described in clause (ii), such information as requested in subparagraph (B)(i)(II), and
any additional information provided in subparagraph (B)(ii).
‘‘(ii) ADDITIONAL CIRCUMSTANCES.—For purposes of
clause (i)(II), the circumstances described in this clause
are, with respect to air ambulance services included
in the notification submitted under paragraph (1)(B)
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) The acuity of the individual receiving
such services or the complexity of furnishing such
services to such individual.
‘‘(III) The training, experience, and quality of
the medical personnel that furnished such services.
‘‘(IV) Ambulance vehicle type, including the
clinical capability level of such vehicle.
‘‘(V) Population density of the pick up location
(such as urban, suburban, rural, or frontier).

H. R. 133—1661
‘‘(VI) Demonstrations of good faith efforts (or
lack of good faith efforts) made by the nonparticipating provider or nonparticipating facility or the
plan or issuer to enter into network agreements
and, if applicable, contracted rates between the
provider and the plan or issuer, as applicable,
during the previous 4 plan years.
‘‘(iii) PROHIBITION ON CONSIDERATION OF CERTAIN
FACTORS.—In determining which offer is the payment
amount to be applied with respect to qualified IDR
air ambulance services furnished by a provider, the
certified IDR entity with respect to such determination
shall not consider usual and customary charges, the
amount that would have been billed by such provider
with respect to such services had the provisions of
section 2799B–5 of the Public Health Service Act not
applied, or the payment or reimbursement rate for
such services furnished by such provider payable by
a public payor, including under the Medicare program
under title XVIII of the Social Security Act, under
the Medicaid program under title XIX of such Act,
under the Children’s Health Insurance Program under
title XXI of such Act, under the TRICARE program
under chapter 55 of title 10, United States Code, or
under chapter 17 of title 38, United States Code.
‘‘(D) EFFECTS OF DETERMINATION.—The provisions of
section 716(c)(5)(E)) shall apply with respect to a determination of a certified IDR entity under subparagraph
(A), the notification submitted with respect to such determination, the services with respect to such notification,
and the parties to such notification in the same manner
as such provisions apply with respect to a determination
of a certified IDR entity under section 716(c)(5)(E), the
notification submitted with respect to such determination,
the items and services with respect to such notification,
and the parties to such notification.
‘‘(E) COSTS OF INDEPENDENT DISPUTE RESOLUTION
PROCESS.—The provisions of section 716(c)(5)(F) shall apply
to a notification made under this subsection, the parties
to such notification, and a determination under subparagraph (A) in the same manner and to the same extent
such provisions apply to a notification under section 716(c),
the parties to such notification and a determination made
under section 716(c)(5)(A).
‘‘(6) TIMING OF PAYMENT.—The total plan or coverage payment required pursuant to subsection (a)(3), with respect to
qualified IDR air ambulance services for which a determination
is made under paragraph (5)(A) or with respect to air ambulance services for which a payment amount is determined under
open negotiations under paragraph (1), shall be made directly
to the nonparticipating provider not later than 30 days after
the date on which such determination is made.
‘‘(7) PUBLICATION OF INFORMATION RELATING TO THE IDR
PROCESS.—

H. R. 133—1662
‘‘(A) IN GENERAL.—For each calendar quarter in 2022
and each calendar quarter in a subsequent year, the Secretary shall publish on the public website of the Department of Labor—
‘‘(i) the number of notifications submitted under
the IDR process during such calendar quarter;
‘‘(ii) the number of such notifications with respect
to which a final determination was made under paragraph (5)(A);
‘‘(iii) the information described in subparagraph
(B) with respect to each notification with respect to
which such a determination was so made.
‘‘(iv) the number of times the payment amount
determined (or agreed to) under this subsection exceeds
the qualifying payment amount;
‘‘(v) the amount of expenditures made by the Secretary during such calendar quarter to carry out the
IDR process;
‘‘(vi) the total amount of fees paid under paragraph
(8) during such calendar quarter; and
‘‘(vii) the total amount of compensation paid to
certified IDR entities under paragraph (5)(E)during
such calendar quarter.
‘‘(B) INFORMATION WITH RESPECT TO REQUESTS.—For
purposes of subparagraph (A), the information described
in this subparagraph is, with respect to a notification under
the IDR process of a nonparticipating provider, group
health plan, or health insurance issuer offering group
health insurance coverage—
‘‘(i) a description of each air ambulance service
included in such notification;
‘‘(ii) the geography in which the services included
in such notification were provided;
‘‘(iii) the amount of the offer submitted under paragraph (2) by the group health plan or health insurance
issuer (as applicable) and by the nonparticipating provider expressed as a percentage of the qualifying payment amount;
‘‘(iv) whether the offer selected by the certified
IDR entity under paragraph (5) to be the payment
applied was the offer submitted by such plan or issuer
(as applicable) or by such provider and the amount
of such offer so selected expressed as a percentage
of the qualifying payment amount;
‘‘(v) ambulance vehicle type, including the clinical
capability level of such vehicle;
‘‘(vi) the identity of the group health plan or health
insurance issuer or air ambulance provider with
respect to such notification;
‘‘(vii) the length of time in making each determination;
‘‘(viii) the compensation paid to the certified IDR
entity with respect to the settlement or determination;
and
‘‘(ix) any other information specified by the Secretary.

H. R. 133—1663
‘‘(C) IDR ENTITY REQUIREMENTS.—For 2022 and each
subsequent year, an IDR entity, as a condition of certification as an IDR entity, shall submit to the Secretary
such information as the Secretary determines necessary
for the Secretary to carry out the provisions of this paragraph.
‘‘(D) CLARIFICATION.—The Secretary shall ensure the
public reporting under this paragraph does not contain
information that would disclose privileged or confidential
information of a group health plan or health insurance
issuer offering group or individual health insurance coverage or of a provider or facility.
‘‘(8) ADMINISTRATIVE FEE.—
‘‘(A) IN GENERAL.—Each party to a determination under
paragraph (5) to which an entity is selected under paragraph (4) in a year shall pay to the Secretary, at such
time and in such manner as specified by the Secretary,
a fee for participating in the IDR process with respect
to such determination in an amount described in subparagraph (B) for such year.
‘‘(B) AMOUNT OF FEE.—The amount described in this
subparagraph for a year is an amount established by the
Secretary in a manner such that the total amount of fees
paid under this paragraph for such year is estimated to
be equal to the amount of expenditures estimated to be
made by the Secretary for such year in carrying out the
IDR process.
‘‘(9) WAIVER AUTHORITY.—The Secretary may modify any
deadline or other timing requirement specified under this subsection (other than the establishment date for the IDR process
under paragraph (2)(A) and other than under paragraph (6))
in cases of extenuating circumstances, as specified by the Secretary, or to ensure that all claims that occur during a 90day period applied through paragraph (5)(D), but with respect
to which a notification is not permitted by reason of such
paragraph to be submitted under paragraph (1)(B) during such
period, are eligible for the IDR process.
‘‘(c) DEFINITION.—For purposes of this section:
‘‘(1) AIR AMBULANCE SERVICES.—The term ‘air ambulance
service’ means medical transport by helicopter or airplane for
patients.
‘‘(2) QUALIFYING PAYMENT AMOUNT.—The term ‘qualifying
payment amount’ has the meaning given such term in section
716(a)(3).
‘‘(3) NONPARTICIPATING PROVIDER.—The term ‘nonparticipating provider’ has the meaning given such term in section
716(a)(3).’’.
(3) IRC AMENDMENTS.—
(A) IN GENERAL.—Subchapter B of chapter 100 of the
Internal Revenue Code of 1986, as amended by section
102(c) and further amended by the previous provisions
of this title, is further amended by inserting after section
9816 the following:
‘‘SEC. 9817. ENDING SURPRISE AIR AMBULANCE BILLS.

‘‘(a) IN GENERAL.—In the case of a participant or beneficiary
in a group health plan who receives air ambulance services from

H. R. 133—1664
a nonparticipating provider (as defined in section 9816(a)(3)(G))
with respect to such plan, if such services would be covered if
provided by a participating provider (as defined in such section)
with respect to such plan—
‘‘(1) the cost-sharing requirement with respect to such services shall be the same requirement that would apply if such
services were provided by such a 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;
‘‘(2) such cost-sharing amounts shall be counted towards
the in-network deductible and in-network out-of-pocket maximum amount under the plan for the plan year (and such
in-network deductible shall 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
‘‘(3) the group health plan shall—
‘‘(A) not later than 30 calendar days after the bill
for such services is transmitted by such provider, send
to the provider, an initial payment or notice of denial
of payment; and
‘‘(B) pay a total plan payment, in accordance with,
if applicable, subsection (b)(6), directly to such provider
furnishing such services to such participant, beneficiary,
or enrollee that is, with application of any initial payment
under subparagraph (A), equal to the amount by which
the out-of-network rate (as defined in section 9816(a)(3)(K))
for such services and year involved exceeds the cost-sharing
amount imposed under the plan for such services (as determined in accordance with paragraphs (1) and (2)).
‘‘(b) DETERMINATION OF OUT-OF-NETWORK RATES TO BE PAID
BY HEALTH PLANS; INDEPENDENT DISPUTE RESOLUTION PROCESS.—
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIATION.—
‘‘(A) IN GENERAL.—With respect to air ambulance services furnished in a year by a nonparticipating provider,
with respect to a group health plan, and for which a payment is required to be made by the plan pursuant to
subsection (a)(3), the provider or plan may, during the
30-day period beginning on the day the provider receives
a payment or a statement of denial of payment from the
plan regarding a claim for payment for such service, initiate
open negotiations under this paragraph between such provider and plan for purposes of determining, during the
open negotiation period, an amount agreed on by such
provider, and such plan for payment (including any costsharing) for such service. For purposes of this subsection,
the open negotiation period, with respect to air ambulance
services, is the 30-day period beginning on the date of
initiation of the negotiations with respect to such services.
‘‘(B) ACCESSING INDEPENDENT DISPUTE RESOLUTION
PROCESS IN CASE OF FAILED NEGOTIATIONS.—In the case
of open negotiations pursuant to subparagraph (A), with
respect to air ambulance services, that do not result in
a determination of an amount of payment for such services
by the last day of the open negotiation period described
in such subparagraph with respect to such services, the

H. R. 133—1665
provider or group health plan that was party to such negotiations may, during the 4-day period beginning on the
day after such open negotiation period, initiate the independent dispute resolution process under paragraph (2)
with respect to such services. The independent dispute
resolution process shall be initiated by a party pursuant
to the previous sentence by submission to the other party
and to the Secretary of a notification (containing such
information as specified by the Secretary) and for purposes
of this subsection, the date of initiation of such process
shall be the date of such submission or such other date
specified by the Secretary pursuant to regulations that
is not later than the date of receipt of such notification
by both the other party and the Secretary.
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROCESS AVAILABLE
IN CASE OF FAILED OPEN NEGOTIATIONS.—
‘‘(A) ESTABLISHMENT.—Not later than 1 year after the
date of the enactment of this subsection, the Secretary,
jointly with the Secretary of Health and Human Services
and the Secretary of Labor, shall establish by regulation
one independent dispute resolution process (referred to in
this subsection as the ‘IDR process’) under which, in the
case of air ambulance services with respect to which a
provider or group health plan submits a notification under
paragraph (1)(B) (in this subsection referred to as a ‘qualified IDR air ambulance services’), a certified IDR entity
under paragraph (4) determines, subject to subparagraph
(B) and in accordance with the succeeding provisions of
this subsection, the amount of payment under the plan
for such services furnished by such provider.
‘‘(B) AUTHORITY TO CONTINUE NEGOTIATIONS.—Under
the independent dispute resolution process, in the case
that the parties to a determination for qualified IDR air
ambulance services agree on a payment amount for such
services during such process but before the date on which
the entity selected with respect to such determination
under paragraph (4) makes such determination under paragraph (5), such amount shall be treated for purposes of
section 9816(a)(3)(K)(ii) as the amount agreed to by such
parties for such services. In the case of an agreement
described in the previous sentence, the independent dispute
resolution process shall provide for a method to determine
how to allocate between the parties to such determination
the payment of the compensation of the entity selected
with respect to such determination.
‘‘(C) CLARIFICATION.—A nonparticipating provider may
not, with respect to an item or service furnished by such
provider, submit a notification under paragraph (1)(B) if
such provider is exempt from the requirement under subsection (a) of section 2799B–2 of the Public Health Service
Act with respect to such item or service pursuant to subsection (b) of such section.
‘‘(3) TREATMENT OF BATCHING OF SERVICES.—The provisions
of section 9816(c)(3) shall apply with respect to a notification
submitted under this subsection with respect to air ambulance
services in the same manner and to the same extent such
provisions apply with respect to a notification submitted under

H. R. 133—1666
section 9816(c) with respect to items and services described
in such section.
‘‘(4) IDR ENTITIES.—
‘‘(A) ELIGIBILITY.—An IDR entity certified under this
subsection is an IDR entity certified under section
9816(c)(4).
‘‘(B) SELECTION OF CERTIFIED IDR ENTITY.—The provisions of subparagraph (F) of section 9816(c)(4) shall apply
with respect to selecting an IDR entity certified pursuant
to subparagraph (A) with respect to the determination of
the amount of payment under this subsection of air ambulance services in the same manner as such provisions apply
with respect to selecting an IDR entity certified under
such section with respect to the determination of the
amount of payment under section 9816(c) of an item or
service. An entity selected pursuant to the previous sentence to make a determination described in such sentence
shall be referred to in this subsection as the ‘certified
IDR entity’ with respect to such determination.
‘‘(5) PAYMENT DETERMINATION.—
‘‘(A) IN GENERAL.—Not later than 30 days after the
date of selection of the certified IDR entity with respect
to a determination for qualified IDR ambulance services,
the certified IDR entity shall—
‘‘(i) taking into account the considerations specified
in subparagraph (C), select one of the offers submitted
under subparagraph (B) to be the amount of payment
for such services determined under this subsection for
purposes of subsection (a)(3); and
‘‘(ii) notify the provider or facility and the group
health plan party to such determination of the offer
selected under clause (i).
‘‘(B) SUBMISSION OF OFFERS.—Not later than 10 days
after the date of selection of the certified IDR entity with
respect to a determination for qualified IDR air ambulance
services, the provider and the group health plan party
to such determination—
‘‘(i) shall each submit to the certified IDR entity
with respect to such determination—
‘‘(I) an offer for a payment amount for such
services furnished by such provider; and
‘‘(II) such information as requested by the certified IDR entity relating to such offer; and
‘‘(ii) may each submit to the certified IDR entity
with respect to such determination any information
relating to such offer submitted by either party,
including information relating to any circumstance
described in subparagraph (C)(ii).
‘‘(C) CONSIDERATIONS IN DETERMINATION.—
‘‘(i) IN GENERAL.—In determining which offer is
the payment to be applied pursuant to this paragraph,
the certified IDR entity, with respect to the determination for a qualified IDR air ambulance service shall
consider—
‘‘(I) the qualifying payment amounts (as
defined in section 9816(a)(3)(E)) for the applicable
year for items or services that are comparable

H. R. 133—1667
to the qualified IDR air ambulance service and
that are furnished in the same geographic region
(as defined by the Secretary for purposes of such
subsection) as such qualified IDR air ambulance
service; and
‘‘(II) subject to clause (iii), information on any
circumstance described in clause (ii), such information as requested in subparagraph (B)(i)(II), and
any additional information provided in subparagraph (B)(ii).
‘‘(ii) ADDITIONAL CIRCUMSTANCES.—For purposes of
clause (i)(II), the circumstances described in this clause
are, with respect to air ambulance services included
in the notification submitted under paragraph (1)(B)
of a nonparticipating provider, or group health plan
the following:
‘‘(I) The quality and outcomes measurements
of the provider that furnished such services.
‘‘(II) The acuity of the individual receiving
such services or the complexity of furnishing such
services to such individual.
‘‘(III) The training, experience, and quality of
the medical personnel that furnished such services.
‘‘(IV) Ambulance vehicle type, including the
clinical capability level of such vehicle.
‘‘(V) Population density of the pick up location
(such as urban, suburban, rural, or frontier).
‘‘(VI) Demonstrations of good faith efforts (or
lack of good faith efforts) made by the nonparticipating provider or nonparticipating facility or the
plan to enter into network agreements and, if
applicable, contracted rates between the provider
and the plan during the previous 4 plan years.
‘‘(iii) PROHIBITION ON CONSIDERATION OF CERTAIN
FACTORS.—In determining which offer is the payment
amount to be applied with respect to qualified IDR
air ambulance services furnished by a provider, the
certified IDR entity with respect to such determination
shall not consider usual and customary charges, the
amount that would have been billed by such provider
with respect to such services had the provisions of
section 2799B–5 of the Public Health Service Act not
applied, or the payment or reimbursement rate for
such services furnished by such provider payable by
a public payor, including under the Medicare program
under title XVIII of the Social Security Act, under
the Medicaid program under title XIX of such Act,
under the Children’s Health Insurance Program under
title XXI of such Act, under the TRICARE program
under chapter 55 of title 10, United States Code, or
under chapter 17 of title 38, United States Code.
‘‘(D) EFFECTS OF DETERMINATION.—The provisions of
section 9816(c)(5)(E)) shall apply with respect to a determination of a certified IDR entity under subparagraph
(A), the notification submitted with respect to such determination, the services with respect to such notification,
and the parties to such notification in the same manner

H. R. 133—1668
as such provisions apply with respect to a determination
of a certified IDR entity under section 9816(c)(5)(E), the
notification submitted with respect to such determination,
the items and services with respect to such notification,
and the parties to such notification.
‘‘(E) COSTS OF INDEPENDENT DISPUTE RESOLUTION
PROCESS.—The provisions of section 9816(c)(5)(F) shall
apply to a notification made under this subsection, the
parties to such notification, and a determination under
subparagraph (A) in the same manner and to the same
extent such provisions apply to a notification under section
9816(c), the parties to such notification and a determination
made under section 9816(c)(5)(A).
‘‘(6) TIMING OF PAYMENT.—The total plan payment required
pursuant to subsection (a)(3), with respect to qualified IDR
air ambulance services for which a determination is made under
paragraph (5)(A) or with respect to air ambulance services
for which a payment amount is determined under open negotiations under paragraph (1), shall be made directly to the nonparticipating provider not later than 30 days after the date
on which such determination is made.
‘‘(7) PUBLICATION OF INFORMATION RELATING TO THE IDR
PROCESS.—
‘‘(A) IN GENERAL.—For each calendar quarter in 2022
and each calendar quarter in a subsequent year, the Secretary shall publish on the public website of the Department of the Treasury—
‘‘(i) the number of notifications submitted under
the IDR process during such calendar quarter;
‘‘(ii) the number of such notifications with respect
to which a final determination was made under paragraph (5)(A);
‘‘(iii) the information described in subparagraph
(B) with respect to each notification with respect to
which such a determination was so made.
‘‘(iv) the number of times the payment amount
determined (or agreed to) under this subsection exceeds
the qualifying payment amount;
‘‘(v) the amount of expenditures made by the Secretary during such calendar quarter to carry out the
IDR process;
‘‘(vi) the total amount of fees paid under paragraph
(8) during such calendar quarter; and
‘‘(vii) the total amount of compensation paid to
certified IDR entities under paragraph (5)(E)during
such calendar quarter.
‘‘(B) INFORMATION WITH RESPECT TO REQUESTS.—For
purposes of subparagraph (A), the information described
in this subparagraph is, with respect to a notification under
the IDR process of a nonparticipating provider, or group
health plan—
‘‘(i) a description of each air ambulance service
included in such notification;
‘‘(ii) the geography in which the services included
in such notification were provided;

H. R. 133—1669
‘‘(iii) the amount of the offer submitted under paragraph (2) by the group health plan and by the nonparticipating provider expressed as a percentage of
the qualifying payment amount;
‘‘(iv) whether the offer selected by the certified
IDR entity under paragraph (5) to be the payment
applied was the offer submitted by such plan or issuer
(as applicable) or by such provider and the amount
of such offer so selected expressed as a percentage
of the qualifying payment amount;
‘‘(v) ambulance vehicle type, including the clinical
capability level of such vehicle;
‘‘(vi) the identity of the group health plan or health
insurance issuer or air ambulance provider with
respect to such notification;
‘‘(vii) the length of time in making each determination;
‘‘(viii) the compensation paid to the certified IDR
entity with respect to the settlement or determination;
and
‘‘(ix) any other information specified by the Secretary.
‘‘(C) IDR ENTITY REQUIREMENTS.—For 2022 and each
subsequent year, an IDR entity, as a condition of certification as an IDR entity, shall submit to the Secretary
such information as the Secretary determines necessary
for the Secretary to carry out the provisions of this paragraph.
‘‘(D) CLARIFICATION.—The Secretary shall ensure the
public reporting under this paragraph does not contain
information that would disclose privileged or confidential
information of a group health plan or health insurance
issuer offering group or individual health insurance coverage or of a provider or facility.
‘‘(8) ADMINISTRATIVE FEE.—
‘‘(A) IN GENERAL.—Each party to a determination under
paragraph (5) to which an entity is selected under paragraph (4) in a year shall pay to the Secretary, at such
time and in such manner as specified by the Secretary,
a fee for participating in the IDR process with respect
to such determination in an amount described in subparagraph (B) for such year.
‘‘(B) AMOUNT OF FEE.—The amount described in this
subparagraph for a year is an amount established by the
Secretary in a manner such that the total amount of fees
paid under this paragraph for such year is estimated to
be equal to the amount of expenditures estimated to be
made by the Secretary for such year in carrying out the
IDR process.
‘‘(9) WAIVER AUTHORITY.—The Secretary may modify any
deadline or other timing requirement specified under this subsection (other than the establishment date for the IDR process
under paragraph (2)(A) and other than under paragraph (6))
in cases of extenuating circumstances, as specified by the Secretary, or to ensure that all claims that occur during a 90day period applied through paragraph (5)(D), but with respect
to which a notification is not permitted by reason of such

H. R. 133—1670
paragraph to be submitted under paragraph (1)(B) during such
period, are eligible for the IDR process.
‘‘(c) DEFINITIONS.—For purposes of this section:
‘‘(1) AIR AMBULANCE SERVICES.—The term ‘air ambulance
service’ means medical transport by helicopter or airplane for
patients.
‘‘(2) QUALIFYING PAYMENT AMOUNT.—The term ‘qualifying
payment amount’ has the meaning given such term in section
9816(a)(3).
‘‘(3) NONPARTICIPTING PROVIDER.—The term ‘nonparticipating provider’ has the meaning given such term in section
9816(a)(3).’’.
(B) CLERICAL AMENDMENT.—The table of sections for
subchapter B of chapter 100 of the Internal Revenue Code
of 1986, as amended by section 102(c)(3), is further
amended by inserting after the item relating to section
9816 the following new item:
‘‘Sec. 9817. Ending surprise air ambulance bills.’’.
(4) EFFECTIVE DATE.—The amendments

made by this subsection shall apply with respect to plan years beginning on
or after January 1, 2022.
(b) AIR AMBULANCE PROVIDER BALANCE BILLING.—Part E of
title XXVII of the Public Health Service Act, as added and amended
by section 104, is further amended by adding at the end the following new section:
‘‘SEC. 2799B–5. AIR AMBULANCE SERVICES.

‘‘In the case of a participant, beneficiary, or enrollee with benefits under a group health plan or group or individual health insurance coverage offered by a health insurance issuer and who is
furnished in a plan year beginning on or after January 1, 2022,
air ambulance services (for which benefits are available under such
plan or coverage) from a nonparticipating provider (as defined in
section 2799A–1(a)(3)(G)) with respect to such plan or coverage,
such provider shall not bill, and shall not hold liable, such participant, beneficiary, or enrollee for a payment amount for such service
furnished by such provider that is more than the cost-sharing
amount for such service (as determined in accordance with paragraphs (1) and (2) of section 2799A–2(a), section 717(a) of the
Employee Retirement Income Security Act of 1974, or section
9817(a) of the Internal Revenue Code of 1986, as applicable).’’.
SEC. 106. REPORTING REQUIREMENTS REGARDING AIR AMBULANCE
SERVICES.

(a) REPORTING REQUIREMENTS FOR PROVIDERS OF AIR AMBUSERVICES.—
(1) IN GENERAL.—A provider of air ambulance services shall
submit to the Secretary of Health and Human Services and
the Secretary of Transportation—
(A) not later than the date that is 90 days after the
last day of the first calendar year beginning on or after
the date on which a final rule is promulgated pursuant
to the rulemaking described in subsection (d), the information described in paragraph (2) with respect to such plan
year; and

LANCE

H. R. 133—1671
(B) not later than the date that is 90 days after the
last day of the plan year immediately succeeding the plan
year described in subparagraph (A), such information with
respect to such immediately succeeding plan year.
(2) INFORMATION DESCRIBED.—For purposes of paragraph
(1), information described in this paragraph, with respect to
a provider of air ambulance services, is each of the following:
(A) Cost data, as determined appropriate by the Secretary of Health and Human Services, in consultation with
the Secretary of Transportation, for air ambulance services
furnished by such provider, separated to the maximum
extent possible by air transportation costs associated with
furnishing such air ambulance services and costs of medical
services and supplies associated with furnishing such air
ambulance services.
(B) The number and location of all air ambulance bases
operated by such provider.
(C) The number and type of aircraft operated by such
provider.
(D) The number of air ambulance transports,
disaggregated by payor mix, including—
(i)(I) group health plans;
(II) health insurance issuers; and
(III) State and Federal Government payors; and
(ii) uninsured individuals.
(E) The number of claims of such provider that have
been denied payment by a group health plan or health
insurance issuer and the reasons for any such denials.
(F) The number of emergency and nonemergency air
ambulance transports, disaggregated by air ambulance base
and type of aircraft.
(G) Such other information regarding air ambulance
services as the Secretary of Health and Human Services
may specify.
(b) REPORTING REQUIREMENTS FOR GROUP HEALTH PLANS AND
HEALTH INSURANCE ISSUERS.—
(1) PHSA.—Part D of title XXVII of the Public Health
Service Act, as added by section 102(a)(1), is amended by adding
after section 2799A–7, as added by section 102(a)(2)(A) of this
Act, the following new section:
‘‘SEC. 2799A–8. AIR AMBULANCE REPORT REQUIREMENTS.

‘‘(a) IN GENERAL.—Each group health plan and health insurance
issuer offering group or individual health insurance coverage shall
submit to the Secretary, jointly with the Secretary of Labor and
the Secretary of the Treasury—
‘‘(1) not later than the date that is 90 days after the
last day of the first calendar year beginning on or after the
date on which a final rule is promulgated pursuant to the
rulemaking described in section 106(d) of the No Surprises
Act, the information described in subsection (b) with respect
to such plan year; and
‘‘(2) not later than the date that is 90 days after the
last day of the calendar year immediately succeeding the plan
year described in paragraph (1), such information with respect
to such immediately succeeding plan year.

H. R. 133—1672
‘‘(b) INFORMATION DESCRIBED.—For purposes of subsection (a),
information described in this subsection, with respect to a group
health plan or a health insurance issuer offering group or individual
health insurance coverage, is each of the following:
‘‘(1) Claims data for air ambulance services furnished by
providers of such services, disaggregated by each of the following factors:
‘‘(A) Whether such services were furnished on an emergent or nonemergent basis.
‘‘(B) Whether the provider of such services is part
of a hospital-owned or sponsored program, municipalitysponsored program, hospital independent partnership
(hybrid) program, independent program, or tribally operated program in Alaska.
‘‘(C) Whether the transport in which the services were
furnished originated in a rural or urban area.
‘‘(D) The type of aircraft (such as rotor transport or
fixed wing transport) used to furnish such services.
‘‘(E) Whether the provider of such services has a contract with the plan or issuer, as applicable, to furnish
such services under the plan or coverage, respectively.
‘‘(2) Such other information regarding providers of air
ambulance services as the Secretary may specify.’’.
(2) ERISA.—
(A) IN GENERAL.—Subpart B of part 7 of title I of
the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185 et seq.) is amended by adding after section
722, as added by section 102(b)(2)(A) of this Act, the following new section:
‘‘SEC. 723. AIR AMBULANCE REPORT REQUIREMENTS.

‘‘(a) IN GENERAL.—Each group health plan and health insurance
issuer offering group health insurance coverage shall submit to
the Secretary, jointly with the Secretary of Health and Human
Services and the Secretary of the Treasury—
‘‘(1) not later than the date that is 90 days after the
last day of the first calendar year beginning on or after the
date on which a final rule is promulgated pursuant to the
rulemaking described in section 106(d) of the No Surprises
Act, the information described in subsection (b) with respect
to such plan year; and
‘‘(2) not later than the date that is 90 days after the
last day of the plan year immediately succeeding the calendar
year described in paragraph (1), such information with respect
to such immediately succeeding plan year.
‘‘(b) INFORMATION DESCRIBED.—For purposes of subsection (a),
information described in this subsection, with respect to a group
health plan or a health insurance issuer offering group health
insurance coverage, is each of the following:
‘‘(1) Claims data for air ambulance services furnished by
providers of such services, disaggregated by each of the following factors:
‘‘(A) Whether such services were furnished on an emergent or nonemergent basis.
‘‘(B) Whether the provider of such services is part
of a hospital-owned or sponsored program, municipalitysponsored program, hospital independent partnership

H. R. 133—1673
(hybrid) program, independent program, or tribally operated program in Alaska.
‘‘(C) Whether the transport in which the services were
furnished originated in a rural or urban area.
‘‘(D) The type of aircraft (such as rotor transport or
fixed wing transport) used to furnish such services.
‘‘(E) Whether the provider of such services has a contract with the plan or issuer, as applicable, to furnish
such services under the plan or coverage, respectively.
‘‘(2) Such other information regarding providers of air
ambulance services as the Secretary may specify.’’.
(B) CLERICAL AMENDMENT.—The table of contents of
the Employee Retirement Income Security Act of 1974 is
amended by adding after the item relating to section 722,
as added by section 102(b) the following:
‘‘Sec. 723. Air ambulance report requirements.’’.

(3) IRC.—
(A) IN GENERAL.—Subchapter B of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding after
section 9822, as added by section 102(c)(2)(A) of this Act,
the following new section:
‘‘SEC. 9823. AIR AMBULANCE REPORT REQUIREMENTS.

‘‘(a) IN GENERAL.—Each group health plan shall submit to
the Secretary, jointly with the Secretary of Labor and the Secretary
of Health and Human Services—
‘‘(1) not later than the date that is 90 days after the
last day of the first calendar year beginning on or after the
date on which a final rule is promulgated pursuant to the
rulemaking described in section 106(d) of the No Surprises
Act, the information described in subsection (b) with respect
to such plan year; and
‘‘(2) not later than the date that is 90 days after the
last day of the calendar year immediately succeeding the plan
year described in paragraph (1), such information with respect
to such immediately succeeding plan year.
‘‘(b) INFORMATION DESCRIBED.—For purposes of subsection (a),
information described in this subsection, with respect to a group
health plan is each of the following:
‘‘(1) Claims data for air ambulance services furnished by
providers of such services, disaggregated by each of the following factors:
‘‘(A) Whether such services were furnished on an emergent or nonemergent basis.
‘‘(B) Whether the provider of such services is part
of a hospital-owned or sponsored program, municipalitysponsored program, hospital independent partnership
(hybrid) program, independent program, or tribally operated program in Alaska.
‘‘(C) Whether the transport in which the services were
furnished originated in a rural or urban area.
‘‘(D) The type of aircraft (such as rotor transport or
fixed wing transport) used to furnish such services.
‘‘(E) Whether the provider of such services has a contract with the plan or issuer, as applicable, to furnish
such services under the plan or coverage, respectively.

H. R. 133—1674
‘‘(2) Such other information regarding providers of air
ambulance services as the Secretary may specify.’’.
(B) CLERICAL AMENDMENT.—The table of sections for
subchapter B of chapter 100 of the Internal Revenue Code
of 1986 is amended by adding after the item relating to
section 9822, as added by section 102(c), the following
new item:
‘‘Sec. 9823. Air ambulance report requirements.’’.
(c) PUBLICATION OF COMPREHENSIVE REPORT.—
(1) IN GENERAL.—Not later than the date

that is one year
after the date described in subsection (a)(2) of section 2799A–
8 of the Public Health Service Act, of section 723 of the
Employee Retirement Income Security Act of 1974, and of section 9823 of the Internal Revenue Code of 1986, as such sections
are added by subsection (b), the Secretary of Health and Human
Services, in consultation with the Secretary of Transportation
(referred to in this section as the ‘‘Secretaries’’), shall develop,
and make publicly available (subject to paragraph (3)), a comprehensive report summarizing the information submitted
under subsection (a) and the amendments made by subsection
(b) and including each of the following:
(A) The percentage of providers of air ambulance services that are part of a hospital-owned or sponsored program,
municipality-sponsored program, hospital-independent
partnership (hybrid) program, or independent program.
(B) An assessment of the extent of competition among
providers of air ambulance services on the basis of price
and services offered, and any changes in such competition
over time.
(C) An assessment of the average charges for air ambulance services, amounts paid by group health plans and
health insurance issuers offering group or individual health
insurance coverage to providers of air ambulance services
for furnishing such services, and amounts paid out-ofpocket by consumers, and any changes in such amounts
paid over time.
(D) An assessment of the presence of air ambulance
bases in, or with the capability to serve, rural areas, and
the relative growth in air ambulance bases in rural and
urban areas over time.
(E) Any evidence of gaps in rural access to providers
of air ambulance services.
(F) The percentage of providers of air ambulance services that have contracts with group health plans or health
insurance issuers offering group or individual health insurance coverage to furnish such services under such plans
or coverage, respectively.
(G) An assessment of whether there are instances of
unfair, deceptive, or predatory practices by providers of
air ambulance services in collecting payments from patients
to whom such services are furnished, such as referral of
such patients to collections, lawsuits, and liens or wage
garnishment actions.
(H) An assessment of whether there are, within the
air ambulance industry, instances of unreasonable industry

H. R. 133—1675
concentration, excessive market domination, or other conditions that would allow at least one provider of air ambulance services to unreasonably increase prices or exclude
competition in air ambulance services in a given geographic
region.
(I) An assessment of the frequency of patient balance
billing, patient referrals to collections, lawsuits to collect
balance bills, and liens or wage garnishment actions by
providers of air ambulance services as part of a collections
process across hospital-owned or sponsored programs,
municipality-sponsored programs, hospital-independent
partnership (hybrid) programs, tribally operated programs
in Alaska, or independent programs, providers of air ambulance services operated by public agencies (such as a State
or county health department), and other independent providers of air ambulance services.
(J) An assessment of the frequency of claims appeals
made by providers of air ambulance services to group
health plans or health insurance issuers offering group
or individual health insurance coverage with respect to
air ambulance services furnished to enrollees of such plans
or coverage, respectively.
(K) Any other cost, quality, or other data relating to
air ambulance services or the air ambulance industry, as
determined necessary and appropriate by the Secretaries.
(2) OTHER SOURCES OF INFORMATION.—The Secretaries may
incorporate information from independent experts or thirdparty sources in developing the comprehensive report required
under paragraph (1).
(3) PROTECTION OF PROPRIETARY INFORMATION.—The Secretaries may not make publicly available under this subsection
any proprietary information.
(d) RULEMAKING.—Not later than the date that is one year
after the date of the enactment of this Act, the Secretary of Health
and Human Services, in consultation with the Secretary of
Transportation, shall, through notice and comment rulemaking,
specify the form and manner in which reports described in subsection (a) and in the amendments made by subsection (b) shall
be submitted to such Secretaries, taking into consideration (as
applicable and to the extent feasible) any recommendations included
in the report submitted by the Advisory Committee on Air Ambulance and Patient Billing under section 418(e) of the FAA Reauthorization Act of 2018 (Public Law 115–254; 49 U.S.C. 42301 note
prec.).
(e) CIVIL MONEY PENALTIES.—
(1) IN GENERAL.—Subject to paragraph (2), a provider of
air ambulance services who fails to submit all information
required under subsection (a)(2) by the date described in
subparagraph (A) or (B) of subsection (a)(1), as applicable,
shall be subject to a civil money penalty of not more than
$10,000.
(2) EXCEPTION.—In the case of a provider of air ambulance
services that submits only some of the information required
under subsection (a)(2) by the date described in subparagraph
(A) or (B) of subsection (a)(1), as applicable, the Secretary
of Health and Human Services may waive the civil money

H. R. 133—1676
penalty imposed under paragraph (1) if such provider demonstrates a good faith effort (as defined by the Secretary pursuant to regulation) in working with the Secretary to submit
the remaining information required under subsection (a)(2).
(3) PROCEDURE.—The provisions of section 1128A of the
Social Security Act (42 U.S.C. 1320a–7a), other than subsections (a) and (b) and the first sentence of subsection (c)(1),
shall apply to civil money penalties under this subsection in
the same manner as such provisions apply to a penalty or
proceeding under such section.
(f) UNFAIR AND DECEPTIVE PRACTICES AND UNFAIR METHODS
OF COMPETITION.—The Secretary of Transportation may use any
information submitted under subsection (a) in determining whether
a provider of air ambulance services has violated section 41712(a)
of title 49, United States Code.
(g) ADVISORY COMMITTEE ON AIR AMBULANCE QUALITY AND
PATIENT SAFETY.—
(1) ESTABLISHMENT.—Not later than the date that is 60
days after the date of the enactment of this Act, the Secretary
of Health and Human Services and the Secretary of Transportation, shall establish an Advisory Committee on Air Ambulance Quality and Patient Safety (referred to in this subsection
as the ‘‘Committee’’) for the purpose of reviewing options to
establish quality, patient safety, and clinical capability standards for each clinical capability level of air ambulances.
(2) MEMBERSHIP.—The Committee shall be composed of
the following members:
(A) The Secretary of Health and Human Services, or
a designee of the Secretary, who shall serve as the Chair
of the Committee.
(B) The Secretary of Transportation, or a designee
of the Secretary.
(C) One representative, to be appointed by the Secretary of Health and Human Services, of each of the following:
(i) State health insurance regulators.
(ii) Health care providers.
(iii) Group health plans and health insurance
issuers offering group or individual health insurance
coverage.
(iv) Patient advocacy groups.
(v) Accrediting bodies with experience in quality
measures.
(D) Three representatives of the air ambulance
industry, to be appointed by the Secretary of Transportation.
(E) Additional three representatives not covered under
subparagraphs (A) through (D), as determined necessary
and appropriate by the Secretary of Health and Human
Services and Secretary of Transportation.
(3) FIRST MEETING.—Not later than the date that is 90
days after the date of the enactment of this Act, the Committee
shall hold its first meeting.
(4) DUTIES.—The Committee shall study and make recommendations, as appropriate, to Congress regarding each of
the following with respect to air ambulance services:

H. R. 133—1677
(A) Qualifications of different clinical capability levels
and tiering of such levels.
(B) Patient safety and quality standards.
(C) Options for improving service reliability during
poor weather, night conditions, or other adverse conditions.
(D) Differences between air ambulance vehicle types,
services, and technologies, and other flight capability standards, and the impact of such differences on patient safety.
(E) Clinical triage criteria for air ambulances.
(5) REPORT.—Not later than the date that is 180 days
after the date of the first meeting of the Committee, the Committee, in consultation with relevant experts and stakeholders,
as appropriate, shall develop and make publicly available a
report on any recommendations submitted to Congress under
paragraph (4). The Committee may update such report, as
determined appropriate by the Committee.
(h) DEFINITIONS.—In this section, the terms ‘‘group health
plan’’, ‘‘health insurance coverage’’, ‘‘individual health insurance
coverage’’, ‘‘group health insurance coverage’’, and ‘‘health insurance
issuer’’ have the meanings given such terms in section 2791 of
the Public Health Service Act (42 U.S.C. 300gg–91).
SEC. 107. TRANSPARENCY REGARDING IN-NETWORK AND OUT-OF-NETWORK DEDUCTIBLES AND OUT-OF-POCKET LIMITATIONS.

(a) PHSA.—Section 2799A–1 of the Public Health Service Act,
as added by section 102(a) and amended by section 103, is further
amended by adding at the end the following new subsection:
‘‘(e) TRANSPARENCY REGARDING IN-NETWORK AND OUT-OF-NETWORK DEDUCTIBLES AND OUT-OF-POCKET LIMITATIONS.—A group
health plan or a health insurance issuer offering group or individual
health insurance coverage and providing or covering any benefit
with respect to items or services shall include, in clear writing,
on any physical or electronic plan or insurance identification card
issued to the participants, beneficiaries, or enrollees in the plan
or coverage the following:
‘‘(1) Any deductible applicable to such plan or coverage.
‘‘(2) Any out-of-pocket maximum limitation applicable to
such plan or coverage.
‘‘(3) A telephone number and Internet website address
through which such individual may seek consumer assistance
information, such as information related to hospitals and urgent
care facilities that have in effect a contractual relationship
with such plan or coverage for furnishing items and services
under such plan or coverage’’.
(b) ERISA.—Section 716 of the Employee Retirement Income
Security Act of 1974, as added by section 102(b) and amended
by section 103, is further amended by adding at the end the following new subsection:
‘‘(e) TRANSPARENCY REGARDING IN-NETWORK AND OUT-OF-NETWORK DEDUCTIBLES AND OUT-OF-POCKET LIMITATIONS.—A group
health plan or a health insurance issuer offering group health
insurance coverage and providing or covering any benefit with
respect to items or services shall include, in clear writing, on
any physical or electronic plan or insurance identification card
issued to the participants or beneficiaries in the plan or coverage
the following:
‘‘(1) Any deductible applicable to such plan or coverage.

H. R. 133—1678
‘‘(2) Any out-of-pocket maximum limitation applicable to
such plan or coverage.
‘‘(3) A telephone number and Internet website address
through which such individual may seek consumer assistance
information, such as information related to hospitals and urgent
care facilities that have in effect a contractual relationship
with such plan or coverage for furnishing items and services
under such plan or coverage’’.
(c) IRC.—Section 9816 of the Internal Revenue Code of 1986,
as added by section 102(c) and amended by section 103, is further
amended by adding at the end the following new subsection:
‘‘(e) TRANSPARENCY REGARDING IN-NETWORK AND OUT-OF-NETWORK DEDUCTIBLES AND OUT-OF-POCKET LIMITATIONS.—A group
health plan providing or covering any benefit with respect to items
or services shall include, in clear writing, on any physical or electronic plan or insurance identification card issued to the participants or beneficiaries in the plan the following:
‘‘(1) Any deductible applicable to such plan.
‘‘(2) Any out-of-pocket maximum limitation applicable to
such plan.
‘‘(3) A telephone number and Internet website address
through which such individual may seek consumer assistance
information, such as information related to hospitals and urgent
care facilities that have in effect a contractual relationship
with such plan for furnishing items and services under such
plan.’’.
(d) EFFECTIVE DATE.—The amendments made by this subsection shall apply with respect to plan years beginning on or
after January 1, 2022.
SEC.

108.

IMPLEMENTING PROTECTIONS
DISCRIMINATION.

AGAINST

PROVIDER

Not later than January 1, 2022, the Secretary of Health and
Human Services, the Secretary of Labor, and the Secretary of
the Treasury shall issue a proposed rule implementing the protections of section 2706(a) of the Public Health Service Act (42 U.S.C.
300gg-5(a)). The Secretaries shall accept and consider public comments on any proposed rule issued pursuant to this subsection
for a period of 60 days after the date of such issuance. Not later
than 6 months after the date of the conclusion of the comment
period, the Secretaries shall issue a final rule implementing the
protections of section 2706(a) of the Public Health Service Act
(42 U.S.C. 300gg-5(a)).
SEC. 109. REPORTS.

(a) REPORTS IN CONSULTATION WITH FTC AND AG.—Not later
than January 1, 2023, and annually thereafter for each of the
following 4 years, the Secretary of Health and Human Services,
in consultation with the Federal Trade Commission and the
Attorney General, shall—
(1) conduct a study on the effects of the provisions of,
including amendments made by, this Act on—
(A) any patterns of vertical or horizontal integration
of health care facilities, providers, group health plans, or
health insurance issuers offering group or individual health
insurance coverage;
(B) overall health care costs; and

H. R. 133—1679
(C) access to health care items and services, including
specialty services, in rural areas and health professional
shortage areas, as defined in section 332 of the Public
Health Service Act (42 U.S.C. 254e);
(2) for purposes of the reports under paragraph (3), in
consultation with the Secretary of Labor and the Secretary
of the Treasury, make recommendations for the effective
enforcement of subsections (a)(1)(C)(iv) and (b)(1)(C) of section
2799A–1 of the Public Health Service Act, subsections
(a)(1)(C)(iv) and (b)(1)(C) of section 716 of the Employee Retirement Income Security Act of 1974, and subsections (a)(1)(C)(iv)
and (b)(1)(C) of section 9816 of the Internal Revenue Code
of 1986, including with respect to potential challenges to
addressing anti-competitive consolidation of health care facilities, providers, group health plans, or health insurance issuers
offering group or individual health insurance coverage; and
(3) submit a report on such study and including such
recommendations to the Committees on Energy and Commerce;
on Education and Labor; on Ways and Means; and on the
Judiciary of the House of Representatives and the Committees
on Health, Education, Labor, and Pensions; on Commerce,
Science, and Transportation; on Finance; and on the Judiciary
of the Senate.
(b) GAO REPORT ON IMPACT OF SURPRISE BILLING PROVISIONS.—Not later than January 1, 2025, the Comptroller General
of the United States shall submit to Congress a report summarizing
the effects of the provisions of this Act, including the amendments
made by such provisions, on changes during the period since the
date on the enactment of this Act in health care provider networks
of group health plans and group and individual health insurance
coverage offered by a health insurance issuer, in fee schedules
and amounts for health care services, and to contracted rates under
such plans or coverage. Such report shall—
(1) to the extent practicable, sample a statistically significant group of national health care providers;
(2) examine—
(A) provider network participation, including nonparticipating providers furnishing items and services at
participating facilities;
(B) health care provider group network participation,
including specialty, size, and ownership;
(C) the impact of State surprise billing laws and network adequacy standards on participation of health care
providers and facilities in provider networks of group health
plans and of group and individual health insurance coverage offered by health insurance issuers; and
(D) access to providers, including in rural and medically underserved communities and health professional
shortage areas (as defined in section 332 of the Public
Health Service Act), and the extent of provider shortages
in such communities and areas;
(3) to the extent practicable, sample a statistically significant group of national health insurance plans and issuers and
examine—
(A) the effects of the provisions of, including amendments made by, this Act on premiums and out-of-pocket

H. R. 133—1680
costs with respect to group health plans or group or individual health insurance coverage;
(B) the adequacy of provider networks with respect
to such plans or coverage; and
(C) categories of providers of ancillary services, as
defined in section 2799B–2(b)(2) of the Public Health
Service Act, for which such plans have no or a limited
number of in-network providers; and
(4) such other relevant effects of such provisions and
amendments.
(c) GAO REPORT ON ADEQUACY OF PROVIDER NETWORKS.—Not
later than January 1, 2023, the Comptroller General of the United
States shall submit to Congress, and make publicly available, a
report on the adequacy of provider networks in group health plans
and group and individual health insurance coverage, including legislative recommendations to improve the adequacy of such networks.
(d) GAO REPORT ON IDR PROCESS AND POTENTIAL FINANCIAL
RELATIONSHIPS.—Not later than December 31, 2023, the Comptroller General of the United States shall conduct a study and
submit to Congress a report on the IDR process established under
this section. Such study and report shall include an analysis of
potential financial relationships between providers and facilities
that utilize the IDR process established by the amendments made
by this Act and private equity investment firms.
SEC. 110. CONSUMER PROTECTIONS THROUGH APPLICATION OF
HEALTH PLAN EXTERNAL REVIEW IN CASES OF CERTAIN
SURPRISE MEDICAL BILLS.

(a) IN GENERAL.—In applying the provisions of section 2719(b)
of the Public Health Service Act (42 U.S.C. 300gg–19(b)) to group
health plans and health insurance issuers offering group or individual health insurance coverage, the Secretary of Health and
Human Services, Secretary of Labor, and Secretary of the Treasury,
shall require, beginning not later than January 1, 2022, the external
review process described in paragraph (1) of such section to apply
with respect to any adverse determination by such a plan or issuer
under section 2799A-1 or 2799A-2, section 716 or 717 of the
Employee Retirement Income Security Act of 1974, or section 9816
or 9817 of the Internal Revenue Code of 1986, including with
respect to whether an item or service that is the subject to such
a determination is an item or service to which such respective
section applies.
(b) DEFINITIONS.—The terms ‘‘group health plan’’; ‘‘health insurance issuer’’; ‘‘group health insurance coverage’’, and ‘‘individual
health insurance coverage’’ have the meanings given such terms
in section 2791 of the Public Health Service Act (42 U.S.C. 300gg–
91), section 733 of the Employee Retirement Income Security Act
(29 U.S.C. 1191b), and section 9832 of the Internal Revenue Code,
as applicable.
SEC.

111.

CONSUMER PROTECTIONS THROUGH HEALTH PLAN
REQUIREMENT FOR FAIR AND HONEST ADVANCE COST
ESTIMATE.

(a) PHSA AMENDMENT.—Section 2799A–1 of the Public Health
Service Act (42 U.S.C. 300gg–19a), as added by section 102 and
as further amended by the previous provisions of this title, is
further amended by adding at the end the following new subsection:
‘‘(f) ADVANCED EXPLANATION OF BENEFITS.—

H. R. 133—1681
‘‘(1) IN GENERAL.—For plan years beginning on or after
January 1, 2022, each group health plan, or a health insurance
issuer offering group or individual health insurance coverage
shall, with respect to a notification submitted under section
2799B–6 by a health care provider or health care facility to
the plan or issuer for a participant, beneficiary, or enrollee
under plan or coverage scheduled to receive an item or service
from the provider or facility (or authorized representative of
such participant, beneficiary, or enrollee), not later than 1
business day (or, in the case such item or service was so
scheduled at least 10 business days before such item or service
is to be furnished (or in the case of a request made to such
plan or coverage by such participant, beneficiary, or enrollee),
3 business days) after the date on which the plan or coverage
receives such notification (or such request), provide to the
participant, beneficiary, or enrollee (through mail or electronic
means, as requested by the participant, beneficiary, or enrollee)
a notification (in clear and understandable language) including
the following:
‘‘(A) Whether or not the provider or facility is a participating provider or a participating facility with respect to
the plan or coverage with respect to the furnishing of
such item or service and—
‘‘(i) in the case the provider or facility is a participating provider or facility with respect to the plan
or coverage with respect to the furnishing of such
item or service, the contracted rate under such plan
or coverage for such item or service (based on the
billing and diagnostic codes provided by such provider
or facility); and
‘‘(ii) in the case the provider or facility is a nonparticipating provider or facility with respect to such
plan or coverage, a description of how such individual
may obtain information on providers and facilities that,
with respect to such plan or coverage, are participating
providers and facilities, if any.
‘‘(B) The good faith estimate included in the notification
received from the provider or facility (if applicable) based
on such codes.
‘‘(C) A good faith estimate of the amount the plan
or coverage is responsible for paying for items and services
included in the estimate described in subparagraph (B).
‘‘(D) A good faith estimate of the amount of any costsharing for which the participant, beneficiary, or enrollee
would be responsible for such item or service (as of the
date of such notification).
‘‘(E) A good faith estimate of the amount that the
participant, beneficiary, or enrollee has incurred toward
meeting the limit of the financial responsibility (including
with respect to deductibles and out-of-pocket maximums)
under the plan or coverage (as of the date of such notification).
‘‘(F) In the case such item or service is subject to
a medical management technique (including concurrent
review, prior authorization, and step-therapy or fail-first

H. R. 133—1682
protocols) for coverage under the plan or coverage, a disclaimer that coverage for such item or service is subject
to such medical management technique.
‘‘(G) A disclaimer that the information provided in
the notification is only an estimate based on the items
and services reasonably expected, at the time of scheduling
(or requesting) the item or service, to be furnished and
is subject to change.
‘‘(H) Any other information or disclaimer the plan or
coverage determines appropriate that is consistent with
information and disclaimers required under this section.
‘‘(2) AUTHORITY TO MODIFY TIMING REQUIREMENTS IN THE
CASE OF SPECIFIED ITEMS AND SERVICES.—
‘‘(A) IN GENERAL.—In the case of a participant, beneficiary, or enrollee scheduled to receive an item or service
that is a specified item or service (as defined in subparagraph (B)), the Secretary may modify any timing requirements relating to the provision of the notification described
in paragraph (1) to such participant, beneficiary, or enrollee
with respect to such item or service. Any modification
made by the Secretary pursuant to the previous sentence
may not result in the provision of such notification after
such participant, beneficiary, or enrollee has been furnished
such item or service.
‘‘(B) SPECIFIED ITEM OR SERVICE DEFINED.—For purposes of subparagraph (A), the term ‘specified item or
service’ means an item or service that has low utilization
or significant variation in costs (such as when furnished
as part of a complex treatment), as specified by the Secretary.’’.
(b) IRC AMENDMENTS.—Section 9816 of the Internal Revenue
Code of 1986, as added by section 102 and further amended by
the previous provisions of this title, is further amended by inserting
after subsection (e) the following new subsection:
‘‘(f) ADVANCED EXPLANATION OF BENEFITS.—
‘‘(1) IN GENERAL.—For plan years beginning on or after
January 1, 2022, each group health plan shall, with respect
to a notification submitted under section 2799B–6 of the Public
Health Service Act by a health care provider or health care
facility to the plan for a participant or beneficiary under plan
scheduled to receive an item or service from the provider or
facility (or authorized representative of such participant or
beneficiary), not later than 1 business day (or, in the case
such item or service was so scheduled at least 10 business
days before such item or service is to be furnished (or in
the case of a request made to such plan or coverage by such
participant or beneficiary), 3 business days) after the date
on which the plan receives such notification (or such request),
provide to the participant or beneficiary (through mail or electronic means, as requested by the participant or beneficiary)
a notification (in clear and understandable language) including
the following:
‘‘(A) Whether or not the provider or facility is a participating provider or a participating facility with respect to
the plan with respect to the furnishing of such item or
service and—

H. R. 133—1683
‘‘(i) in the case the provider or facility is a participating provider or facility with respect to the plan
or coverage with respect to the furnishing of such
item or service, the contracted rate under such plan
for such item or service (based on the billing and
diagnostic codes provided by such provider or facility);
and
‘‘(ii) in the case the provider or facility is a nonparticipating provider or facility with respect to such
plan, a description of how such individual may obtain
information on providers and facilities that, with
respect to such plan, are participating providers and
facilities, if any.
‘‘(B) The good faith estimate included in the notification
received from the provider or facility (if applicable) based
on such codes.
‘‘(C) A good faith estimate of the amount the plan
is responsible for paying for items and services included
in the estimate described in subparagraph (B).
‘‘(D) A good faith estimate of the amount of any costsharing for which the participant or beneficiary would be
responsible for such item or service (as of the date of
such notification).
‘‘(E) A good faith estimate of the amount that the
participant or beneficiary has incurred toward meeting the
limit of the financial responsibility (including with respect
to deductibles and out-of-pocket maximums) under the plan
(as of the date of such notification).
‘‘(F) In the case such item or service is subject to
a medical management technique (including concurrent
review, prior authorization, and step-therapy or fail-first
protocols) for coverage under the plan, a disclaimer that
coverage for such item or service is subject to such medical
management technique.
‘‘(G) A disclaimer that the information provided in
the notification is only an estimate based on the items
and services reasonably expected, at the time of scheduling
(or requesting) the item or service, to be furnished and
is subject to change.
‘‘(H) Any other information or disclaimer the plan
determines appropriate that is consistent with information
and disclaimers required under this section.
‘‘(2) AUTHORITY TO MODIFY TIMING REQUIREMENTS IN THE
CASE OF SPECIFIED ITEMS AND SERVICES.—
‘‘(A) IN GENERAL.—In the case of a participant or beneficiary scheduled to receive an item or service that is a
specified item or service (as defined in subparagraph (B)),
the Secretary may modify any timing requirements relating
to the provision of the notification described in paragraph
(1) to such participant or beneficiary with respect to such
item or service. Any modification made by the Secretary
pursuant to the previous sentence may not result in the
provision of such notification after such participant or beneficiary has been furnished such item or service.
‘‘(B) SPECIFIED ITEM OR SERVICE DEFINED.—For purposes of subparagraph (A), the term ‘specified item or
service’ means an item or service that has low utilization

H. R. 133—1684
or significant variation in costs (such as when furnished
as part of a complex treatment), as specified by the Secretary.’’.
(c) ERISA AMENDMENTS.—Section 716 of the Employee Retirement Income Security Act of 1974, as added by section 102 and
further amended by the previous amendments of this title, is further
amended by adding at the end the following new subsection:
‘‘(f) ADVANCED EXPLANATION OF BENEFITS.—
‘‘(1) IN GENERAL.—For plan years beginning on or after
January 1, 2022, each group health plan, or a health insurance
issuer offering group health insurance coverage shall, with
respect to a notification submitted under section 2799B–6 of
the Public Health Service Act by a health care provider or
health care facility to the plan or issuer for a participant
or beneficiary under plan or coverage scheduled to receive
an item or service from the provider or facility (or authorized
representative of such participant or beneficiary), not later
than 1 business day (or, in the case such item or service
was so scheduled at least 10 business days before such item
or service is to be furnished (or in the case of a request made
to such plan or coverage by such participant or beneficiary),
3 business days) after the date on which the plan or coverage
receives such notification (or such request), provide to the
participant or beneficiary (through mail or electronic means,
as requested by the participant or beneficiary) a notification
(in clear and understandable language) including the following:
‘‘(A) Whether or not the provider or facility is a participating provider or a participating facility with respect to
the plan or coverage with respect to the furnishing of
such item or service and—
‘‘(i) in the case the provider or facility is a participating provider or facility with respect to the plan
or coverage with respect to the furnishing of such
item or service, the contracted rate under such plan
for such item or service (based on the billing and
diagnostic codes provided by such provider or facility);
and
‘‘(ii) in the case the provider or facility is a nonparticipating provider or facility with respect to such
plan or coverage, a description of how such individual
may obtain information on providers and facilities that,
with respect to such plan or coverage, are participating
providers and facilities, if any.
‘‘(B) The good faith estimate included in the notification
received from the provider or facility (if applicable) based
on such codes.
‘‘(C) A good faith estimate of the amount the health
plan is responsible for paying for items and services
included in the estimate described in subparagraph (B).
‘‘(D) A good faith estimate of the amount of any costsharing for which the participant or beneficiary would be
responsible for such item or service (as of the date of
such notification).
‘‘(E) A good faith estimate of the amount that the
participant or beneficiary has incurred toward meeting the
limit of the financial responsibility (including with respect

H. R. 133—1685
to deductibles and out-of-pocket maximums) under the plan
or coverage (as of the date of such notification).
‘‘(F) In the case such item or service is subject to
a medical management technique (including concurrent
review, prior authorization, and step-therapy or fail-first
protocols) for coverage under the plan or coverage, a disclaimer that coverage for such item or service is subject
to such medical management technique.
‘‘(G) A disclaimer that the information provided in
the notification is only an estimate based on the items
and services reasonably expected, at the time of scheduling
(or requesting) the item or service, to be furnished and
is subject to change.
‘‘(H) Any other information or disclaimer the plan or
coverage determines appropriate that is consistent with
information and disclaimers required under this section.
‘‘(2) AUTHORITY TO MODIFY TIMING REQUIREMENTS IN THE
CASE OF SPECIFIED ITEMS AND SERVICES.—
‘‘(A) IN GENERAL.—In the case of a participant or beneficiary scheduled to receive an item or service that is a
specified item or service (as defined in subparagraph (B)),
the Secretary may modify any timing requirements relating
to the provision of the notification described in paragraph
(1) to such participant or beneficiary with respect to such
item or service. Any modification made by the Secretary
pursuant to the previous sentence may not result in the
provision of such notification after such participant or beneficiary has been furnished such item or service.
‘‘(B) SPECIFIED ITEM OR SERVICE DEFINED.—For purposes of subparagraph (A), the term ‘specified item or
service’ means an item or service that has low utilization
or significant variation in costs (such as when furnished
as part of a complex treatment), as specified by the Secretary.’’.
SEC. 112. PATIENT PROTECTIONS THROUGH TRANSPARENCY AND
PATIENT-PROVIDER DISPUTE RESOLUTION.

Part E of title XXVII of the Public Health Service Act (42
U.S.C. 300gg et seq.), as added by section 104 and further amended
by the previous provisions of this title, is further amended by
adding at the end the following new sections:
‘‘SEC. 2799B–6. PROVISION OF INFORMATION UPON REQUEST AND FOR
SCHEDULED APPOINTMENTS.

‘‘Each health care provider and health care facility shall, beginning January 1, 2022, in the case of an individual who schedules
an item or service to be furnished to such individual by such
provider or facility at least 3 business days before the date such
item or service is to be so furnished, not later than 1 business
day after the date of such scheduling (or, in the case of such
an item or service scheduled at least 10 business days before
the date such item or service is to be so furnished (or if requested
by the individual), not later than 3 business days after the date
of such scheduling or such request)—
‘‘(1) inquire if such individual is enrolled in a group health
plan, group or individual health insurance coverage offered
by a health insurance issuer, or a Federal health care program
(and if is so enrolled in such plan or coverage, seeking to

H. R. 133—1686
have a claim for such item or service submitted to such plan
or coverage); and
‘‘(2) provide a notification (in clear and understandable
language) of the good faith estimate of the expected charges
for furnishing such item or service (including any item or
service that is reasonably expected to be provided in conjunction
with such scheduled item or service and such an item or service
reasonably expected to be so provided by another health care
provider or health care facility), with the expected billing and
diagnostic codes for any such item or service, to—
‘‘(A) in the case the individual is enrolled in such
a plan or such coverage (and is seeking to have a claim
for such item or service submitted to such plan or coverage),
such plan or issuer of such coverage; and
‘‘(B) in the case the individual is not described in
subparagraph (A) and not enrolled in a Federal health
care program, the individual.
‘‘SEC. 2799B–7. PATIENT-PROVIDER DISPUTE RESOLUTION.

‘‘(a) IN GENERAL.—Not later than January 1, 2022, the Secretary shall establish a process (in this subsection referred to as
the ‘patient-provider dispute resolution process’) under which an
uninsured individual, with respect to an item or service, who
received, pursuant to section 2799B–6, from a health care provider
or health care facility a good-faith estimate of the expected charges
for furnishing such item or service to such individual and who
after being furnished such item or service by such provider or
facility is billed by such provider or facility for such item or service
for charges that are substantially in excess of such estimate, may
seek a determination from a selected dispute resolution entity for
the charges to be paid by such individual (in lieu of such amount
so billed) to such provider or facility for such item or service.
For purposes of this subsection, the term ‘uninsured individual’
means, with respect to an item or service, an individual who does
not have benefits for such item or service under a group health
plan, group or individual health insurance coverage offered by a
health insurance issuer, Federal health care program (as defined
in section 1128B(f) of the Social Security Act), or a health benefits
plan under chapter 89 of title 5, United States Code (or an individual who has benefits for such item or service under a group
health plan or individual or group health insurance coverage offered
by a health insurance issuer, but who does not seek to have a
claim for such item or service submitted to such plan or coverage).
‘‘(b) SELECTION OF ENTITIES.—Under the patient-provider dispute resolution process, the Secretary shall, with respect to a determination sought by an individual under subsection (a), with respect
to charges to be paid by such individual to a health care provider
or health care facility described in such paragraph for an item
or service furnished to such individual by such provider or facility,
provide for—
‘‘(1) a method to select to make such determination an
entity certified under subsection (d) that—
‘‘(A) is not a party to such determination or an
employee or agent of such party;
‘‘(B) does not have a material familial, financial, or
professional relationship with such a party; and

H. R. 133—1687
‘‘(C) does not otherwise have a conflict of interest with
such a party (as determined by the Secretary); and
‘‘(2) the provision of a notification of such selection to
the individual and the provider or facility (as applicable) party
to such determination.
An entity selected pursuant to the previous sentence to make a
determination described in such sentence shall be referred to in
this subsection as the ‘selected dispute resolution entity’ with
respect to such determination.
‘‘(c) ADMINISTRATIVE FEE.—The Secretary shall establish a fee
to participate in the patient-provider dispute resolution process
in such a manner as to not create a barrier to an uninsured
individual’s access to such process.
‘‘(d) CERTIFICATION.—The Secretary shall establish or recognize
a process to certify entities under this subparagraph. Such process
shall ensure that an entity so certified satisfies at least the criteria
specified in section 2799A–1(c).’’.
SEC. 113. ENSURING CONTINUITY OF CARE.

(a) PUBLIC HEALTH SERVICE ACT.—Title XXVII of the Public
Health Service Act (42 U.S.C. 300gg et seq.) is amended, in the
part D, as added and amended by section 102(a) and further
amended by the previous provisions of this title, by inserting after
section 2799A–2 the following new section:
‘‘SEC. 2799A-3. CONTINUITY OF CARE.

‘‘(a) ENSURING CONTINUITY OF CARE WITH RESPECT TO TERMINATIONS OF CERTAIN CONTRACTUAL RELATIONSHIPS RESULTING IN
CHANGES IN PROVIDER NETWORK STATUS.—
‘‘(1) IN GENERAL.—In the case of an individual with benefits
under a group health plan or group or individual health insurance coverage offered by a health insurance issuer and with
respect to a health care provider or facility that has a contractual relationship with such plan or such issuer (as applicable)
for furnishing items and services under such plan or such
coverage, if, while such individual is a continuing care patient
(as defined in subsection (b)) with respect to such provider
or facility—
‘‘(A) such contractual relationship is terminated (as
defined in subsection (b));
‘‘(B) benefits provided under such plan or such health
insurance coverage with respect to such provider or facility
are terminated because of a change in the terms of the
participation of such provider or facility in such plan or
coverage; or
‘‘(C) a contract between such group health plan and
a health insurance issuer offering health insurance coverage in connection with such plan is terminated, resulting
in a loss of benefits provided under such plan with respect
to such provider or facility;
the plan or issuer, respectively, shall meet the requirements
of paragraph (2) with respect to such individual.
‘‘(2) REQUIREMENTS.—The requirements of this paragraph
are that the plan or issuer—
‘‘(A) notify each individual enrolled under such plan
or coverage who is a continuing care patient with respect
to a provider or facility at the time of a termination
described in paragraph (1) affecting such provider or facility

H. R. 133—1688
on a timely basis of such termination and such individual’s
right to elect continued transitional care from such provider
or facility under this section;
‘‘(B) provide such individual with an opportunity to
notify the plan or issuer of the individual’s need for transitional care; and
‘‘(C) permit the patient to elect to continue to have
benefits provided under such plan or such coverage, under
the same terms and conditions as would have applied and
with respect to such items and services as would have
been covered under such plan or coverage had such termination not occurred, with respect to the course of treatment
furnished by such provider or facility relating to such
individual’s status as a continuing care patient during the
period beginning on the date on which the notice under
subparagraph (A) is provided and ending on the earlier
of—
‘‘(i) the 90-day period beginning on such date; or
‘‘(ii) the date on which such individual is no longer
a continuing care patient with respect to such provider
or facility.
‘‘(b) DEFINITIONS.—In this section:
‘‘(1) CONTINUING CARE PATIENT.—The term ‘continuing care
patient’ means an individual who, with respect to a provider
or facility—
‘‘(A) is undergoing a course of treatment for a serious
and complex condition from the provider or facility;
‘‘(B) is undergoing a course of institutional or inpatient
care from the provider or facility;
‘‘(C) is scheduled to undergo nonelective surgery from
the provider, including receipt of postoperative care from
such provider or facility with respect to such a surgery;
‘‘(D) is pregnant and undergoing a course of treatment
for the pregnancy from the provider or facility; or
‘‘(E) is or was determined to be terminally ill (as determined under section 1861(dd)(3)(A) of the Social Security
Act) and is receiving treatment for such illness from such
provider or facility.
‘‘(2) SERIOUS AND COMPLEX CONDITION.—The term ‘serious
and complex condition’ means, with respect to a participant,
beneficiary, or enrollee under a group health plan or group
or individual health insurance coverage—
‘‘(A) in the case of an acute illness, a condition that
is serious enough to require specialized medical treatment
to avoid the reasonable possibility of death or permanent
harm; or
‘‘(B) in the case of a chronic illness or condition, a
condition that is—
‘‘(i) is life-threatening, degenerative, potentially
disabling, or congenital; and
‘‘(ii) requires specialized medical care over a prolonged period of time.
‘‘(3) TERMINATED.—The term ‘terminated’ includes, with
respect to a contract, the expiration or nonrenewal of the contract, but does not include a termination of the contract for
failure to meet applicable quality standards or for fraud.’’.
(b) INTERNAL REVENUE CODE.—

H. R. 133—1689
(1) IN GENERAL.—Subchapter B of chapter 100 of the
Internal Revenue Code of 1986, as amended by sections 102(c)
and 105(a)(3), is further amended by inserting after section
9817 the following new section:
‘‘SEC. 9818. CONTINUITY OF CARE.

‘‘(a) ENSURING CONTINUITY OF CARE WITH RESPECT TO TERMINATIONS OF CERTAIN CONTRACTUAL RELATIONSHIPS RESULTING IN
CHANGES IN PROVIDER NETWORK STATUS.—
‘‘(1) IN GENERAL.—In the case of an individual with benefits
under a group health plan and with respect to a health care
provider or facility that has a contractual relationship with
such plan for furnishing items and services under such plan,
if, while such individual is a continuing care patient (as defined
in subsection (b)) with respect to such provider or facility—
‘‘(A) such contractual relationship is terminated (as
defined in paragraph (b));
‘‘(B) benefits provided under such plan with respect
to such provider or facility are terminated because of a
change in the terms of the participation of such provider
or facility in such plan; or
‘‘(C) a contract between such group health plan and
a health insurance issuer offering health insurance coverage in connection with such plan is terminated, resulting
in a loss of benefits provided under such plan with respect
to such provider or facility;
the plan shall meet the requirements of paragraph (2) with
respect to such individual.
‘‘(2) REQUIREMENTS.—The requirements of this paragraph
are that the plan—
‘‘(A) notify each individual enrolled under such plan
who is a continuing care patient with respect to a provider
or facility at the time of a termination described in paragraph (1) affecting such provider on a timely basis of such
termination and such individual’s right to elect continued
transitional care from such provider or facility under this
section;
‘‘(B) provide such individual with an opportunity to
notify the plan of the individual’s need for transitional
care; and
‘‘(C) permit the patient to elect to continue to have
benefits provided under such plan, under the same terms
and conditions as would have applied and with respect
to such items and services as would have been covered
under such plan had such termination not occurred, with
respect to the course of treatment furnished by such provider or facility relating to such individual’s status as a
continuing care patient during the period beginning on
the date on which the notice under subparagraph (A) is
provided and ending on the earlier of—
‘‘(i) the 90-day period beginning on such date; or
‘‘(ii) the date on which such individual is no longer
a continuing care patient with respect to such provider
or facility.
‘‘(b) DEFINITIONS.—In this section:

H. R. 133—1690
‘‘(1) CONTINUING CARE PATIENT.—The term ‘continuing care
patient’ means an individual who, with respect to a provider
or facility—
‘‘(A) is undergoing a course of treatment for a serious
and complex condition from the provider or facility;
‘‘(B) is undergoing a course of institutional or inpatient
care from the provider or facility;
‘‘(C) is scheduled to undergo nonelective surgery from
the provider or facility, including receipt of postoperative
care from such provider or facility with respect to such
a surgery;
‘‘(D) is pregnant and undergoing a course of treatment
for the pregnancy from the provider or facility; or
‘‘(E) is or was determined to be terminally ill (as determined under section 1861(dd)(3)(A) of the Social Security
Act) and is receiving treatment for such illness from such
provider or facility.
‘‘(2) SERIOUS AND COMPLEX CONDITION.—The term ‘serious
and complex condition’ means, with respect to a participant
or beneficiary under a group health plan—
‘‘(A) in the case of an acute illness, a condition that
is serious enough to require specialized medical treatment
to avoid the reasonable possibility of death or permanent
harm; or
‘‘(B) in the case of a chronic illness or condition, a
condition that—
‘‘(i) is life-threatening, degenerative, potentially
disabling, or congenital; and
‘‘(ii) requires specialized medical care over a prolonged period of time.
‘‘(3) TERMINATED.—The term ‘terminated’ includes, with
respect to a contract, the expiration or nonrenewal of the contract, but does not include a termination of the contract for
failure to meet applicable quality standards or for fraud.’’.
(2) CLERICAL AMENDMENT.—The table of sections for such
subchapter, as amended by the previous sections, is further
amended by inserting after the item relating to section 9817
the following new item:
‘‘Sec. 9818. Continuity of care.’’.
(c) EMPLOYEE RETIREMENT INCOME
(1) IN GENERAL.—Subpart B

SECURITY ACT.—
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 102(c)
and further amended by the previous provisions of this title,
is further amended by inserting after section 717 the following
new section:

‘‘SEC. 718. CONTINUITY OF CARE.

‘‘(a) ENSURING CONTINUITY OF CARE WITH RESPECT TO TERMINATIONS OF CERTAIN CONTRACTUAL RELATIONSHIPS RESULTING IN
CHANGES IN PROVIDER NETWORK STATUS.—
‘‘(1) IN GENERAL.—In the case of an individual with benefits
under a group health plan or group health insurance coverage
offered by a health insurance issuer and with respect to a
health care provider or facility that has a contractual relationship with such plan or such issuer (as applicable) for furnishing

H. R. 133—1691
items and services under such plan or such coverage, if, while
such individual is a continuing care patient (as defined in
subsection (b)) with respect to such provider or facility—
‘‘(A) such contractual relationship is terminated (as
defined in paragraph (b));
‘‘(B) benefits provided under such plan or such health
insurance coverage with respect to such provider or facility
are terminated because of a change in the terms of the
participation of the provider or facility in such plan or
coverage; or
‘‘(C) a contract between such group health plan and
a health insurance issuer offering health insurance coverage in connection with such plan is terminated, resulting
in a loss of benefits provided under such plan with respect
to such provider or facility;
the plan or issuer, respectively, shall meet the requirements
of paragraph (2) with respect to such individual.
‘‘(2) REQUIREMENTS.—The requirements of this paragraph
are that the plan or issuer—
‘‘(A) notify each individual enrolled under such plan
or coverage who is a continuing care patient with respect
to a provider or facility at the time of a termination
described in paragraph (1) affecting such provider or facility
on a timely basis of such termination and such individual’s
right to elect continued transitional care from such provider
or facility under this section;
‘‘(B) provide such individual with an opportunity to
notify the plan or issuer of the individual’s need for transitional care; and
‘‘(C) permit the patient to elect to continue to have
benefits provided under such plan or such coverage, under
the same terms and conditions as would have applied and
with respect to such items and services as would have
been covered under such plan or coverage had such termination not occurred, with respect to the course of treatment
furnished by such provider or facility relating to such
individual’s status as a continuing care patient during the
period beginning on the date on which the notice under
subparagraph (A) is provided and ending on the earlier
of—
‘‘(i) the 90-day period beginning on such date; or
‘‘(ii) the date on which such individual is no longer
a continuing care patient with respect to such provider
or facility.
‘‘(b) DEFINITIONS.—In this section:
‘‘(1) CONTINUING CARE PATIENT.—The term ‘continuing care
patient’ means an individual who, with respect to a provider
or facility—
‘‘(A) is undergoing a course of treatment for a serious
and complex condition from the provider or facility;
‘‘(B) is undergoing a course of institutional or inpatient
care from the provider or facility;
‘‘(C) is scheduled to undergo nonelective surgery from
the provide or facility, including receipt of postoperative
care from such provider or facility with respect to such
a surgery;

H. R. 133—1692
‘‘(D) is pregnant and undergoing a course of treatment
for the pregnancy from the provider or facility; or
‘‘(E) is or was determined to be terminally ill (as determined under section 1861(dd)(3)(A) of the Social Security
Act) and is receiving treatment for such illness from such
provider or facility.
‘‘(2) SERIOUS AND COMPLEX CONDITION.—The term ‘serious
and complex condition’ means, with respect to a participant
or beneficiary under a group health plan or group health insurance coverage—
‘‘(A) in the case of an acute illness, a condition that
is serious enough to require specialized medical treatment
to avoid the reasonable possibility of death or permanent
harm; or
‘‘(B) in the case of a chronic illness or condition, a
condition that—
‘‘(i) is life-threatening, degenerative, potentially
disabling, or congenital; and
‘‘(ii) requires specialized medical care over a prolonged period of time.
‘‘(3) TERMINATED.—The term ‘terminated’ includes, with
respect to a contract, the expiration or nonrenewal of the contract, but does not include a termination of the contract for
failure to meet applicable quality standards or for fraud.’’.
(2) CLERICAL AMENDMENT.—The table of contents in section
1 of the Employee Retirement Income Security Act of 1974
is amended by inserting after the item relating to section 716
the following new item:
‘‘Sec. 718. Continuity of care.’’.
(d) PROVIDER REQUIREMENT.—Part

E of title XXVII of the
Public Health Service Act (42 U.S.C. 300gg et seq.), as added
by section 104 and further amended by the previous provisions
of this title, is further amended by adding at the end the following
new section:

‘‘SEC. 2799B–8. CONTINUITY OF CARE.

‘‘A health care provider or health care facility shall, in the
case of an individual furnished items and services by such provider
or facility for which coverage is provided under a group health
plan or group or individual health insurance coverage pursuant
to section 2799A–3, section 9818 of the Internal Revenue Code
of 1986, or section 718 of the Employee Retirement Income Security
Act of 1974—
‘‘(1) accept payment from such plan or such issuer (as
applicable) (and cost-sharing from such individual, if applicable,
in accordance with subsection (a)(2)(C) of such section 2799A–
3, 9818, or 718) for such items and services as payment in
full for such items and services; and
‘‘(2) continue to adhere to all policies, procedures, and
quality standards imposed by such plan or issuer with respect
to such individual and such items and services in the same
manner as if such termination had not occurred.’’.
(e) EFFECTIVE DATE.—The amendments made by subsections
(a), (b), and (c) shall apply with respect to plan years beginning
on or after January 1, 2022.

H. R. 133—1693
SEC. 114. MAINTENANCE OF PRICE COMPARISON TOOL.

(a) PUBLIC HEALTH SERVICE ACT.—Title XXVII of the Public
Health Service Act (42 U.S.C. 300gg et seq.) is amended, in part
D, as added and amended by section 102 and further amended
by the previous provisions of this title, by inserting after section
2799A–3 the following new section:
‘‘SEC. 2799A–4. MAINTENANCE OF PRICE COMPARISON TOOL.

‘‘A group health plan or a health insurance issuer offering
group or individual health insurance coverage shall offer price
comparison guidance by telephone and make available on the Internet website of the plan or issuer a price comparison tool that
(to the extent practicable) allows an individual enrolled under such
plan or coverage, with respect to such plan year, such geographic
region, and participating providers with respect to such plan or
coverage, to compare the amount of cost-sharing that the individual
would be responsible for paying under such plan or coverage with
respect to the furnishing of a specific item or service by any such
provider.’’.
(b) INTERNAL REVENUE CODE.—
(1) IN GENERAL.—Subchapter B of chapter 100 of the
Internal Revenue Code of 1986, as amended by sections 102,
105, and 113, is further amended by inserting after section
9818 the following new section:
‘‘SEC. 9819. MAINTENANCE OF PRICE COMPARISON TOOL.

‘‘A group health plan shall offer price comparison guidance
by telephone and make available on the Internet website of the
plan or issuer a price comparison tool that (to the extent practicable)
allows an individual enrolled under such plan, with respect to
such plan year, such geographic region, and participating providers
with respect to such plan or coverage, to compare the amount
of cost-sharing that the individual would be responsible for paying
under such plan with respect to the furnishing of a specific item
or service by any such provider.’’.
(2) CLERICAL AMENDMENT.—The table of sections for such
subchapter, as amended by the previous sections, is further
amended by inserting after the item relating to section 9818
the following new item:
‘‘Sec. 9819. Maintenance of price comparison tool.’’.
(c) EMPLOYEE RETIREMENT INCOME SECURITY ACT.—
(1) IN GENERAL.—Subpart B of part 7 of subtitle

B of
title I of the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1185 et seq.), as amended by sections 102,
105, and 113, is further amended by inserting after section
718 the following new section:

‘‘SEC. 719. MAINTENANCE OF PRICE COMPARISON TOOL.

‘‘A group health plan or a health insurance issuer offering
group health insurance coverage shall offer price comparison guidance by telephone and make available on the Internet website
of the plan or issuer a price comparison tool that (to the extent
practicable) allows an individual enrolled under such plan or coverage, with respect to such plan year, such geographic region,
and participating providers with respect to such plan or coverage,
to compare the amount of cost-sharing that the individual would

H. R. 133—1694
be responsible for paying under such plan or coverage with respect
to the furnishing of a specific item or service by any such provider.’’.
(2) CLERICAL AMENDMENT.—The table of contents in section
1 of the Employee Retirement Income Security Act of 1974,
as amended by the previous provisions of this title, is further
amended by inserting after the item relating to section 716
the following new item:
‘‘Sec. 719. Maintenance of price comparison tool.’’.
(d) EFFECTIVE DATE.—The amendments

made by this section
shall apply with respect to plan years beginning on or after January
1, 2022.
SEC. 115. STATE ALL PAYER CLAIMS DATABASES.

(a) GRANTS TO STATES.—Part B of title III of the Public Health
Service Act (42 U.S.C. 243 et seq.) is amended by adding at the
end the following:
‘‘SEC. 320B. STATE ALL PAYER CLAIMS DATABASES.

‘‘(a) IN GENERAL.—The Secretary shall make one-time grants
to eligible States for the purposes described in subsection (b).
‘‘(b) USES.—A State may use a grant received under subsection
(a) for one of the following purposes:
‘‘(1) To establish a State All Payer Claims Database.
‘‘(2) To improve an existing State All Payer Claims Databases.
‘‘(c) ELIGIBILITY.—To be eligible to receive a grant under subsection (a), a State shall submit to the Secretary an application
at such time, in such manner, and containing such information
as the Secretary specifies, including, with respect to a State All
Payer Claims Database, at least specifics on how the State will
ensure uniform data collection and the privacy and security of
such data.
‘‘(d) GRANT PERIOD AND AMOUNT.—Grants awarded under this
section shall be for a period of 3-years, and in an amount of
$2,500,000, of which $1,000,000 shall be made available to the
State for each of the first 2 years of the grant period, and $500,000
shall be made available to the State for the third year of the
grant period.
‘‘(e) AUTHORIZED USERS.—
‘‘(1) APPLICATION.—An entity desiring authorization for
access to a State All Payer Claims Database that has received
a grant under this section shall submit to the State All Payer
Claims Database an application for such access, which shall
include—
‘‘(A) in the case of an entity requesting access for
research purposes—
‘‘(i) a description of the uses and methodologies
for evaluating health system performance using such
data; and
‘‘(ii) documentation of approval of the research by
an institutional review board, if applicable for a particular plan of research; or
‘‘(B) in the case of an entity such as an employer,
health insurance issuer, third-party administrator, or
health care provider, requesting access for the purpose

H. R. 133—1695
of quality improvement or cost-containment, a description
of the intended uses for such data.
‘‘(2) REQUIREMENTS.—
‘‘(A) ACCESS FOR RESEARCH PURPOSES.—Upon approval
of an application for research purposes under paragraph
(1)(A), the authorized user shall enter into a data use
and confidentiality agreement with the State All Payer
Claims Database that has received a grant under this
subsection, which shall include a prohibition on attempts
to reidentify and disclose individually identifiable health
information and proprietary financial information.
‘‘(B) CUSTOMIZED REPORTS.—Employers and employer
organizations may request customized reports from a State
All Payer Claims Database that has received a grant under
this section, at cost, subject to the requirements of this
section with respect to privacy, security, and proprietary
financial information.
‘‘(C) NON-CUSTOMIZED REPORTS.—A State All Payer
Claims Database that has received a grant under this
section shall make available to all authorized users aggregate data sets available through the State All Payer Claims
Database, free of charge.
‘‘(3) WAIVERS.—The Secretary may waive the requirements
of this subsection of a State All Payer Claims Database to
provide access of entities to such database if such State All
Payer Claims Database is substantially in compliance with
this subsection.
‘‘(f) EXPANDED ACCESS.—
‘‘(1) MULTI-STATE APPLICATIONS.—The Secretary may
prioritize applications submitted by a State whose application
demonstrates that the State will work with other State All
Payer Claims Databases to establish a single application for
access to data by authorized users across multiple States.
‘‘(2) EXPANSION OF DATA SETS.—The Secretary may
prioritize applications submitted by a State whose application
demonstrates that the State will implement the reporting format for self-insured group health plans described in section
735 of the Employee Retirement Income Security Act of 1974.
‘‘(g) DEFINITIONS.—In this section—
‘‘(1) the term ‘individually identifiable health information’
has the meaning given such term in section 1171(6) of the
Social Security Act;
‘‘(2) the term ‘proprietary financial information’ means data
that would disclose the terms of a specific contract between
an individual health care provider or facility and a specific
group health plan, managed care entity (as defined in section
1932(a)(1)(B) of the Social Security Act) or other managed care
organization, or health insurance issuer offering group or individual health insurance coverage; and
‘‘(3) the term ‘State All Payer Claims Database’ means,
with respect to a State, a database that may include medical
claims, pharmacy claims, dental claims, and eligibility and
provider files, which are collected from private and public
payers.
‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—To carry out this
section, there is authorized to be appropriated $50,000,000 for each

H. R. 133—1696
of fiscal years 2022 and 2023, and $25,000,000 for fiscal year
2024, to remain available until expended.’’.
(b) STANDARDIZED REPORTING FORMAT.—
Subpart C of part 7 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1191 et
seq.) is amended by adding at the end the following:
‘‘SEC. 735. STANDARDIZED REPORTING FORMAT.

‘‘(a) IN GENERAL.—Not later than 1 year after the date of
enactment of this section, the Secretary shall establish (and periodically update) a standardized reporting format for the voluntary
reporting, by group health plans 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 in the standardized reporting format.
‘‘(b) CONSULTATION.—
‘‘(1) ADVISORY COMMITTEE.—Not later than 90 days after
the date of enactment of this section, the Secretary shall convene an Advisory Committee (referred to in this section as
the ‘Committee’), consisting of 15 members to advise the Secretary regarding the format and guidance described in paragraph (1).
‘‘(2) MEMBERSHIP.—
‘‘(A) APPOINTMENT.—In accordance with subparagraph
(B), not later than 90 days after the date of enactment
this section, the Secretary, in coordination with the Secretary of Health and Human Services, shall appoint under
subparagraph (B)(iii), and the Comptroller General of the
United States shall appoint under subparagraph (B)(iv),
members who have distinguished themselves in the fields
of health services research, health economics, health
informatics, data privacy and security, or the governance
of State All Payer Claims Databases, or who represent
organizations likely to submit data to or use the database,
including patients, employers, or employee organizations
that sponsor group health plans, health care providers,
health insurance issuers, or third-party administrators of
group health plans. Such members shall serve 3-year terms
on a staggered basis. Vacancies on the Committee shall
be filled by appointment consistent with this paragraph
not later than 3 months after the vacancy arises.
‘‘(B) COMPOSITION.—The Committee shall be comprised
of—
‘‘(i) the Assistant Secretary of Employee Benefits
and Security Administration of the Department of
Labor, or a designee of such Assistant Secretary;
‘‘(ii) the Assistant Secretary for Planning and
Evaluation of the Department of Health and Human
Services, or a designee of such Assistant Secretary;
‘‘(iii) members appointed by the Secretary, in
coordination with the Secretary of Health and Human
Services, including—
‘‘(I) 1 member to serve as the chair of the
Committee;

H. R. 133—1697
‘‘(II) 1 representative of the Centers for Medicare & Medicaid Services;
‘‘(III) 1 representative of the Agency for
Healthcare Research and Quality;
‘‘(IV) 1 representative of the Office for Civil
Rights of the Department of Health and Human
Services with expertise in data privacy and security;
‘‘(V) 1 representative of the National Center
for Health Statistics;
‘‘(VI) 1 representative of the Office of the
National Coordinator for Health Information Technology; and
‘‘(VII) 1 representative of a State All-Payer
Claims Database;
‘‘(iv) members appointed by the Comptroller General of the United States, including—
‘‘(I) 1 representative of an employer that sponsors a group health plan;
‘‘(II) 1 representative of an employee organization that sponsors a group health plan;
‘‘(III) 1 academic researcher with expertise in
health economics or health services research;
‘‘(IV) 1 consumer advocate; and
‘‘(V) 2 additional members.
‘‘(3) REPORT.—Not later than 180 days after the date of
enactment of this section, the Committee shall report to the
Secretary, the Committee on Health, Education, Labor, and
Pensions of the Senate, and the Committee on Energy and
Commerce and the Committee on Education and Labor of the
House of Representatives. Such report shall include recommendations on the establishment of the format and guidance
described in subsection (a).
‘‘(c) STATE ALL PAYER CLAIMS DATABASE.—In this section, the
term ‘State All Payer Claims Database’ means, with respect to
a State, a database that may include medical claims, pharmacy
claims, dental claims, and eligibility and provider files, which are
collected from private and public payers.
‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—To carry out this
section, there are authorized to be appropriated $5,000,000 for
fiscal year 2021, to remain available until expended or, if sooner,
until the date described in subsection (e).
‘‘(e) SUNSET.—Beginning on the date on which the report is
submitted under subsection (b)(3), subsection (b) shall have no
force or effect.’’.
SEC. 116. PROTECTING PATIENTS AND IMPROVING THE ACCURACY
OF PROVIDER DIRECTORY INFORMATION.

(a) PHSA.—Part D of title XXVII of the Public Health Service
Act (42 U.S.C. 300gg et seq.), as added and amended by section
102 and further amended by the previous provisions of this title,
is further amended by inserting after section 2799A–4 the following:
‘‘SEC.

2799A–5. PROTECTING PATIENTS AND IMPROVING THE
ACCURACY OF PROVIDER DIRECTORY INFORMATION.

‘‘(a) PROVIDER DIRECTORY INFORMATION REQUIREMENTS.—
‘‘(1) IN GENERAL.—For plan years beginning on or after
January 1, 2022, each group health plan and health insurance

H. R. 133—1698
issuer offering group or individual health insurance coverage
shall—
‘‘(A) establish the verification process described in paragraph (2);
‘‘(B) establish the response protocol described in paragraph (3);
‘‘(C) establish the database described in paragraph (4);
and
‘‘(D) include in any directory (other than the database
described in subparagraph (C)) containing provider directory information with respect to such plan or such coverage
the information described in paragraph (5).
‘‘(2) VERIFICATION PROCESS.—The verification process
described in this paragraph is, with respect to a group health
plan or a health insurance issuer offering group or individual
health insurance coverage, a process—
‘‘(A) under which, not less frequently than once every
90 days, such plan or such issuer (as applicable) verifies
and updates the provider directory information included
on the database described in paragraph (4) of such plan
or issuer of each health care provider and health care
facility included in such database;
‘‘(B) that establishes a procedure for the removal of
such a provider or facility with respect to which such
plan or issuer has been unable to verify such information
during a period specified by the plan or issuer; and
‘‘(C) that provides for the update of such database
within 2 business days of such plan or issuer receiving
from such a provider or facility information pursuant to
section 2799B–9.
‘‘(3) RESPONSE PROTOCOL.—The response protocol described
in this paragraph is, in the case of an individual enrolled
under a group health plan or group or individual health insurance coverage offered by a health insurance issuer who requests
information through a telephone call or electronic, web-based,
or Internet-based means on whether a health care provider
or health care facility has a contractual relationship to furnish
items and services under such plan or such coverage, a protocol
under which such plan or such issuer (as applicable), in the
case such request is made through a telephone call—
‘‘(A) responds to such individual as soon as practicable
and in no case later than 1 business day after such call
is received, through a written electronic or print (as
requested by such individual) communication; and
‘‘(B) retains such communication in such individual’s
file for at least 2 years following such response.
‘‘(4) DATABASE.—The database described in this paragraph
is, with respect to a group health plan or health insurance
issuer offering group or individual health insurance coverage,
a database on the public website of such plan or issuer that
contains—
‘‘(A) a list of each health care provider and health
care facility with which such plan or such issuer has a
direct or indirect contractual relationship for furnishing
items and services under such plan or such coverage; and
‘‘(B) provider directory information with respect to each
such provider and facility.

H. R. 133—1699
‘‘(5) INFORMATION.—The information described in this paragraph is, with respect to a print directory containing provider
directory information with respect to a group health plan or
individual or group health insurance coverage offered by a
health insurance issuer, a notification that such information
contained in such directory was accurate as of the date of
publication of such directory and that an individual enrolled
under such plan or such coverage should consult the database
described in paragraph (4) with respect to such plan or such
coverage or contact such plan or the issuer of such coverage
to obtain the most current provider directory information with
respect to such plan or such coverage.
‘‘(6) DEFINITION.—For purposes of this subsection, the term
‘provider directory information’ includes, with respect to a group
health plan and a health insurance issuer offering group or
individual health insurance coverage, the name, address, specialty, telephone number, and digital contact information of
each health care provider or health care facility with which
such plan or such issuer has a contractual relationship for
furnishing items and services under such plan or such coverage.
‘‘(7) RULE OF CONSTRUCTION.—Nothing in this section shall
be construed to preempt any provision of State law relating
to health care provider directories.
‘‘(b) COST-SHARING FOR SERVICES PROVIDED BASED ON RELIANCE
ON INCORRECT PROVIDER NETWORK INFORMATION.—
‘‘(1) IN GENERAL.—For plan years beginning on or after
January 1, 2022, in the case of an item or service furnished
to a participant, beneficiary, or enrollee of a group health
plan or group or individual health insurance coverage offered
by a health insurance issuer by a nonparticipating provider
or a nonparticipating facility, if such item or service would
otherwise be covered under such plan or coverage if furnished
by a participating provider or participating facility and if either
of the criteria described in paragraph (2) applies with respect
to such participant, beneficiary, or enrollee and item or service,
the plan or coverage—
‘‘(A) shall not impose on such participant, beneficiary,
or enrollee a cost-sharing amount for such item or service
so furnished that is greater than the cost-sharing amount
that would apply under such plan or coverage had such
item or service been furnished by a participating provider;
and
‘‘(B) shall apply the deductible or out-of-pocket maximum, if any, that would apply if such services were furnished by a participating provider or a participating
facility.
‘‘(2) CRITERIA DESCRIBED.—For purposes of paragraph (1),
the criteria described in this paragraph, with respect to an
item or service furnished to a participant, beneficiary, or
enrollee of a group health plan or group or individual health
insurance coverage offered by a health insurance issuer by
a nonparticipating provider or a nonparticipating facility, are
the following:
‘‘(A) The participant, beneficiary, or enrollee received
through a database, provider directory, or response protocol
described in subsection (a) information with respect to such
item and service to be furnished and such information

H. R. 133—1700
provided that the provider was a participating provider
or facility was a participating facility, with respect to the
plan for furnishing such item or service.
‘‘(B) The information was not provided, in accordance
with subsection (a), to the participant, beneficiary, or
enrollee and the participant, beneficiary, or enrollee
requested through the response protocol described in subsection (a)(3) of the plan or coverage information on
whether the provider was a participating provider or
facility was a participating facility with respect to the
plan for furnishing such item or service and was informed
through such protocol that the provider was such a participating provider or facility was such a participating facility.
‘‘(c) DISCLOSURE ON PATIENT PROTECTIONS AGAINST BALANCE
BILLING.—For plan years beginning on or after January 1, 2022,
each group health plan and health insurance issuer offering group
or individual health insurance coverage shall make publicly available, post on a public website of such plan or issuer, and include
on each explanation of benefits for an item or service with respect
to which the requirements under section 2799A–1 applies—
‘‘(1) information in plain language on—
‘‘(A) the requirements and prohibitions applied under
sections 2799B–1 and 2799B–2 (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 section 2799A1; 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.’’.
(b) ERISA.—Subpart B of part 7 of subtitle B of title I of
the Employee Retirement Income Security Act of 1974 (29 U.S.C.
1185 et seq.), as amended by sections 102, 105, 113, and 114,
is further amended by inserting after section 719 the following:
‘‘SEC. 720. PROTECTING PATIENTS AND IMPROVING THE ACCURACY
OF PROVIDER DIRECTORY INFORMATION.

‘‘(a) PROVIDER DIRECTORY INFORMATION REQUIREMENTS.—
‘‘(1) IN GENERAL.—For plan years beginning on or after
January 1, 2022, each group health plan and health insurance
issuer offering group health insurance coverage shall—
‘‘(A) establish the verification process described in paragraph (2);
‘‘(B) establish the response protocol described in paragraph (3);

H. R. 133—1701
‘‘(C) establish the database described in paragraph (4);
and
‘‘(D) include in any directory (other than the database
described in subparagraph (C)) containing provider directory information with respect to such plan or such coverage
the information described in paragraph (5).
‘‘(2) VERIFICATION PROCESS.—The verification process
described in this paragraph is, with respect to a group health
plan or a health insurance issuer offering group health insurance coverage, a process—
‘‘(A) under which, not less frequently than once every
90 days, such plan or such issuer (as applicable) verifies
and updates the provider directory information included
on the database described in paragraph (4) of such plan
or issuer of each health care provider and health care
facility included in such database;
‘‘(B) that establishes a procedure for the removal of
such a provider or facility with respect to which such
plan or issuer has been unable to verify such information
during a period specified by the plan or issuer; and
‘‘(C) that provides for the update of such database
within 2 business days of such plan or issuer receiving
from such a provider or facility information pursuant to
section 2799B–9 of the Public Health Service Act.
‘‘(3) RESPONSE PROTOCOL.—The response protocol described
in this paragraph is, in the case of an individual enrolled
under a group health plan or group health insurance coverage
offered by a health insurance issuer who requests information
through a telephone call or electronic, web-based, or Internetbased means on whether a health care provider or health
care facility has a contractual relationship to furnish items
and services under such plan or such coverage, a protocol
under which such plan or such issuer (as applicable), in the
case such request is made through a telephone call—
‘‘(A) responds to such individual as soon as practicable
and in no case later than 1 business day after such call
is received, through a written electronic or print (as
requested by such individual) communication; and
‘‘(B) retains such communication in such individual’s
file for at least 2 years following such response.
‘‘(4) DATABASE.—The database described in this paragraph
is, with respect to a group health plan or health insurance
issuer offering group health insurance coverage, a database
on the public website of such plan or issuer that contains—
‘‘(A) a list of each health care provider and health
care facility with which such plan or such issuer has a
direct or indirect contractual relationship for furnishing
items and services under such plan or such coverage; and
‘‘(B) provider directory information with respect to each
such provider and facility.
‘‘(5) INFORMATION.—The information described in this paragraph is, with respect to a print directory containing provider
directory information with respect to a group health plan or
group health insurance coverage offered by a health insurance
issuer, a notification that such information contained in such
directory was accurate as of the date of publication of such
directory and that an individual enrolled under such plan or

H. R. 133—1702
such coverage should consult the database described in paragraph (4) with respect to such plan or such coverage or contact
such plan or the issuer of such coverage to obtain the most
current provider directory information with respect to such
plan or such coverage.
‘‘(6) DEFINITION.—For purposes of this subsection, the term
‘provider directory information’ includes, with respect to a group
health plan and a health insurance issuer offering group health
insurance coverage, the name, address, specialty, telephone
number, and digital contact information of each health care
provider or health care facility with which such plan or such
issuer has a contractual relationship for furnishing items and
services under such plan or such coverage.
‘‘(7) RULE OF CONSTRUCTION.—Nothing in this section shall
be construed to preempt any provision of State law relating
to health care provider directories, to the extent such State
law applies to such plan, coverage, or issuer, subject to section
514.
‘‘(b) COST-SHARING FOR SERVICES PROVIDED BASED ON RELIANCE
ON INCORRECT PROVIDER NETWORK INFORMATION.—
‘‘(1) IN GENERAL.—For plan years beginning on or after
January 1, 2022, in the case of an item or service furnished
to a participant or beneficiary of a group health plan or group
health insurance coverage offered by a health insurance issuer
by a nonparticipating provider or a nonparticipating facility,
if such item or service would otherwise be covered under such
plan or coverage if furnished by a participating provider or
participating facility and if either of the criteria described in
paragraph (2) applies with respect to such participant or beneficiary and item or service, the plan or coverage—
‘‘(A) shall not impose on such participant or beneficiary
a cost-sharing amount for such item or service so furnished
that is greater than the cost-sharing amount that would
apply under such plan or coverage had such item or service
been furnished by a participating provider; and
‘‘(B) shall apply the deductible or out-of-pocket maximum, if any, that would apply if such services were furnished by a participating provider or a participating
facility.
‘‘(2) CRITERIA DESCRIBED.—For purposes of paragraph (1),
the criteria described in this paragraph, with respect to an
item or service furnished to a participant or beneficiary of
a group health plan or group health insurance coverage offered
by a health insurance issuer by a nonparticipating provider
or a nonparticipating facility, are the following:
‘‘(A) The participant or beneficiary received through
a database, provider directory, or response protocol
described in subsection (a) information with respect to such
item and service to be furnished and such information
provided that the provider was a participating provider
or facility was a participating facility, with respect to the
plan for furnishing such item or service.
‘‘(B) The information was not provided, in accordance
with subsection (a), to the participant or beneficiary and
the participant or beneficiary requested through the
response protocol described in subsection (a)(3) of the plan
or coverage information on whether the provider was a

H. R. 133—1703
participating provider or facility was a participating facility
with respect to the plan for furnishing such item or service
and was informed through such protocol that the provider
was such a participating provider or facility was such a
participating facility.
‘‘(c) DISCLOSURE ON PATIENT PROTECTIONS AGAINST BALANCE
BILLING.—For plan years beginning on or after January 1, 2022,
each group health plan and health insurance issuer offering group
health insurance coverage shall make publicly available, post on
a public website of such plan or issuer, and include on each explanation of benefits for an item or service with respect to which
the requirements under section 716 applies—
‘‘(1) information in plain language on—
‘‘(A) the requirements and prohibitions applied under
sections 2799B–1 and 2799B–2 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 or beneficiary
of such plan or coverage with respect to which such a
provider or facility does not have a contractual relationship
for furnishing such item or service under the plan or coverage after receiving payment from the plan or coverage
for such item or service and any applicable cost sharing
payment from such participant or beneficiary; and
‘‘(C) the requirements applied under section 716; and
‘‘(2) information on contacting appropriate State and Federal agencies in the case that an individual believes that such
a provider or facility has violated any requirement described
in paragraph (1) with respect to such individual.’’.
(c) IRC.—Subchapter B of chapter 100 of the Internal Revenue
Code of 1986, as amended by sections 102, 105, 113, and 114,
is further amended by inserting after section 9819 the following:
‘‘SEC. 9820. PROTECTING PATIENTS AND IMPROVING THE ACCURACY
OF PROVIDER DIRECTORY INFORMATION.

‘‘(a) PROVIDER DIRECTORY INFORMATION REQUIREMENTS.—
‘‘(1) IN GENERAL.—For plan years beginning on or after
January 1, 2022, each group health plan shall—
‘‘(A) establish the verification process described in paragraph (2);
‘‘(B) establish the response protocol described in paragraph (3);
‘‘(C) establish the database described in paragraph (4);
and
‘‘(D) include in any directory (other than the database
described in subparagraph (C)) containing provider directory information with respect to such plan the information
described in paragraph (5).
‘‘(2) VERIFICATION PROCESS.—The verification process
described in this paragraph is, with respect to a group health
plan, a process—
‘‘(A) under which, not less frequently than once every
90 days, such plan verifies and updates the provider directory information included on the database described in

H. R. 133—1704
paragraph (4) of such plan or issuer of each health care
provider and health care facility included in such database;
‘‘(B) that establishes a procedure for the removal of
such a provider or facility with respect to which such
plan or issuer has been unable to verify such information
during a period specified by the plan or issuer; and
‘‘(C) that provides for the update of such database
within 2 business days of such plan or issuer receiving
from such a provider or facility information pursuant to
section 2799B–9 of the Public Health Service Act.
‘‘(3) RESPONSE PROTOCOL.—The response protocol described
in this paragraph is, in the case of an individual enrolled
under a group health plan who requests information through
a telephone call or electronic, web-based, or Internet-based
means on whether a health care provider or health care facility
has a contractual relationship to furnish items and services
under such plan, a protocol under which such plan or such
issuer (as applicable), in the case such request is made through
a telephone call—
‘‘(A) responds to such individual as soon as practicable
and in no case later than 1 business day after such call
is received, through a written electronic or print (as
requested by such individual) communication; and
‘‘(B) retains such communication in such individual’s
file for at least 2 years following such response.
‘‘(4) DATABASE.—The database described in this paragraph
is, with respect to a group health plan, a database on the
public website of such plan or issuer that contains—
‘‘(A) a list of each health care provider and health
care facility with which such plan or such issuer has a
direct or indirect contractual relationship for furnishing
items and services under such plan; and
‘‘(B) provider directory information with respect to each
such provider and facility.
‘‘(5) INFORMATION.—The information described in this paragraph is, with respect to a print directory containing provider
directory information with respect to a group health plan, a
notification that such information contained in such directory
was accurate as of the date of publication of such directory
and that an individual enrolled under such plan should consult
the database described in paragraph (4) with respect to such
plan or contact such plan to obtain the most current provider
directory information with respect to such plan.
‘‘(6) DEFINITION.—For purposes of this subsection, the term
‘provider directory information’ includes, with respect to a group
health plan, the name, address, specialty, telephone number,
and digital contact information of each health care provider
or health care facility with which such plan has a contractual
relationship for furnishing items and services under such plan.
‘‘(7) RULE OF CONSTRUCTION.—Nothing in this section shall
be construed to preempt any provision of State law relating
to health care provider directories.
‘‘(b) COST-SHARING FOR SERVICES PROVIDED BASED ON RELIANCE
ON INCORRECT PROVIDER NETWORK INFORMATION.—
‘‘(1) IN GENERAL.—For plan years beginning on or after
January 1, 2022, in the case of an item or service furnished
to a participant or beneficiary of a group health plan by a

H. R. 133—1705
nonparticipating provider or a nonparticipating facility, if such
item or service would otherwise be covered under such plan
if furnished by a participating provider or participating facility
and if either of the criteria described in paragraph (2) applies
with respect to such participant or beneficiary and item or
service, the plan—
‘‘(A) shall not impose on such participant or beneficiary
a cost-sharing amount for such item or service so furnished
that is greater than the cost-sharing amount that would
apply under such plan had such item or service been furnished by a participating provider; and
‘‘(B) shall apply the deductible or out-of-pocket maximum, if any, that would apply if such services were furnished by a participating provider or a participating
facility.
‘‘(2) CRITERIA DESCRIBED.—For purposes of paragraph (1),
the criteria described in this paragraph, with respect to an
item or service furnished to a participant or beneficiary of
a group health plan by a nonparticipating provider or a nonparticipating facility, are the following:
‘‘(A) The participant or beneficiary received through
a database, provider directory, or response protocol
described in subsection (a) information with respect to such
item and service to be furnished and such information
provided that the provider was a participating provider
or facility was a participating facility, with respect to the
plan for furnishing such item or service.
‘‘(B) The information was not provided, in accordance
with subsection (a), to the participant or beneficiary and
the participant or beneficiary requested through the
response protocol described in subsection (a)(3) of the plan
information on whether the provider was a participating
provider or facility was a participating facility with respect
to the plan for furnishing such item or service and was
informed through such protocol that the provider was such
a participating provider or facility was such a participating
facility.
‘‘(c) DISCLOSURE ON PATIENT PROTECTIONS AGAINST BALANCE
BILLING.—For plan years beginning on or after January 1, 2022,
each group health plan shall make publicly available, post on a
public website of such plan or issuer, and include on each explanation of benefits for an item or service with respect to which
the requirements under section 9816 applies—
‘‘(1) information in plain language on—
‘‘(A) the requirements and prohibitions applied under
sections 2799B–1 and 2799B–2 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 or beneficiary
of such plan with respect to which such a provider or
facility does not have a contractual relationship for furnishing such item or service under the plan after receiving
payment from the plan for such item or service and any

H. R. 133—1706
applicable cost sharing payment from such participant or
beneficiary; and
‘‘(C) the requirements applied under section 9816; 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.’’.
(d) CLERICAL AMENDMENTS.—
(1) ERISA.—The table of contents in section 1 of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1001 et seq.), as amended by the previous provisions of this
title, is further amended by inserting after the item relating
to section 719 the following new item:
‘‘720. 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
the previous provisions of this title, is further amended by
inserting after the item relating to section 9819 the following
new item:
‘‘9820. Protecting patients and improving the accuracy of provider directory information.’’.
(e) PROVIDER REQUIREMENTS.—Part E of title XXVII of the

Public Health Service Act (42 U.S.C. 300gg et seq.), as added
by section 104 and as further amended by the previous provisions
of this title, is further amended by adding at the end the following:
‘‘SEC. 2799B–9. PROVIDER REQUIREMENTS TO PROTECT PATIENTS AND
IMPROVE THE ACCURACY OF PROVIDER DIRECTORY
INFORMATION.

‘‘(a) PROVIDER BUSINESS PROCESSES.—Beginning not later than
January 1, 2022, each health care provider and each health care
facility shall have in place business processes to ensure the timely
provision of provider 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 2799A–5(a)(1), section 720(a)(1) of the Employee Retirement Income Security Act of 1974, or section 9820(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 or facility begins a network agreement with a plan or with an issuer with respect to certain
coverage;
‘‘(2) when the provider or facility terminates a network
agreement with a plan or with an issuer with respect to certain
coverage;
‘‘(3) when there are material changes to the content of
provider directory information of the provider or facility
described in section 2799A–5(a)(1), section 720(a)(1) of the
Employee Retirement Income Security Act of 1974, or section
9820(a)(1) of the Internal Revenue Code of 1986, as applicable;
and

H. R. 133—1707
‘‘(4) at any other time (including upon the request of such
issuer or plan) determined appropriate by the provider, facility,
or the Secretary.
‘‘(b) 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 innetwork, as prohibited under section 2799A–5(b), section 720(b)
of the Employee Retirement Income Security Act of 1974, or section
9820(b) of the Internal Revenue Code of 1986, as applicable, and
the enrollee pays such bill, the provider shall reimburse the enrollee
for the full amount paid by the enrollee in excess of the in-network
cost-sharing amount for the treatment or services involved, plus
interest, at an interest rate 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 2799A–5(a), section 720(a)
of the Employee Retirement Income Security Act of 1974, or
section 9820(a) of the Internal Revenue Code of 1986, as
applicable; or
‘‘(2) that the plan or issuer bear financial responsibility,
including under section 2799A–5(b), section 720(b) of the
Employee Retirement Income Security Act of 1974, or section
9820(b) of the Internal Revenue Code of 1986, as applicable,
for providing inaccurate network status information to an
enrollee.
‘‘(d) DEFINITION.—For purposes of this section, the term ‘provider directory information’ includes the names, addresses, specialty, telephone numbers, and digital contact information of individual health care providers, and the names, addresses, telephone
numbers, and digital contact information of each medical group,
clinic, or facility 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. 117. ADVISORY COMMITTEE ON GROUND AMBULANCE AND
PATIENT BILLING.

(a) IN GENERAL.—Not later than 90 days after the date of
enactment of this Act, the Secretary of Labor, 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.

H. R. 133—1708
(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.
(D) Patient advocacy groups.
(E) Consumer advocacy groups.
(F) State and local governments.
(G) Physician specializing in emergency, trauma, cardiac, or stroke.
(H) State Emergency Medical Services Officials.
(I) Emergency medical technicians, paramedics, and
other emergency medical services personnel.
(5) Three representatives, to be appointed jointly by the
Secretaries, to represent the various segments of the ground
ambulance industry.
(6) Up to an additional 2 representatives 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).
SEC. 118. IMPLEMENTATION FUNDING.

(a) IN GENERAL.—For the purposes described in subsection
(b), there are appropriated, out of amounts in the Treasury not
otherwise appropriated, to the Secretary of Health and Human
Services, the Secretary of Labor, and the Secretary of the Treasury,
$500,000,000 for fiscal year 2021, to remain available until
expended through 2024.

H. R. 133—1709
(b) PERMITTED PURPOSES.—The purposes described in this subsection are limited to the following purposes, insofar as such purposes are to carry out the provisions of, including the amendments
made by, this title and title II:
(1) Preparing, drafting, and issuing proposed and final
regulations or interim regulations.
(2) Preparing, drafting, and issuing guidance and public
information.
(3) Preparing and holding public meetings.
(4) Preparing, drafting, and publishing reports.
(5) Enforcement of such provisions.
(6) Reporting, collection, and analysis of data.
(7) Establishment and initial implementation of the processes for independent dispute resolution and implementation
of patient-provider dispute resolution under such provisions.
(8) Conducting audits.
(9) Other administrative duties necessary for implementation of such provisions.
(c) TRANSPARENCY OF IMPLEMENTATION FUNDS.—Each Secretary described in subsection (a) shall annually submit to the
Committees on Energy and Commerce, on Ways and Means, on
Education and Labor, and on Appropriations of the House of Representatives and on the Committees on Health, Education, Labor,
and Pensions and on Appropriations of the Senate a report on
funds expended pursuant to funds appropriated under this section.

TITLE II—TRANSPARENCY
SEC. 201. INCREASING TRANSPARENCY BY REMOVING GAG CLAUSES
ON PRICE AND QUALITY INFORMATION.

(a) PHSA.—Part D of title XXVII of the Public Health Service
Act (42 U.S.C. 300gg et seq.), as added and amended by title
I, is further amended by adding at the end the following:
‘‘SEC. 2799A–9. INCREASING TRANSPARENCY BY REMOVING GAG
CLAUSES ON PRICE AND QUALITY INFORMATION.

‘‘(a) INCREASING PRICE AND QUALITY TRANSPARENCY FOR PLAN
SPONSORS AND GROUP AND INDIVIDUAL MARKET CONSUMERS.—
‘‘(1) GROUP HEALTH PLANS.—A group health plan or health
insurance issuer offering group health insurance coverage may
not enter into an agreement with a health care provider, network or association of providers, third-party administrator, or
other service provider offering access to a network of providers
that would directly or indirectly restrict a group health plan
or health insurance issuer offering such coverage from—
‘‘(A) providing provider-specific cost or quality of care
information or data, through a consumer engagement tool
or any other means, to referring providers, the plan
sponsor, enrollees, or individuals eligible to become
enrollees of the plan or coverage;
‘‘(B) electronically accessing de-identified claims and
encounter information or data for each enrollee in the
plan or coverage, upon request and consistent with the
privacy regulations promulgated pursuant to section 264(c)
of the Health Insurance Portability and Accountability Act
of 1996, the amendments made by the Genetic Information