[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5817 Introduced in House (IH)]

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116th CONGRESS
  2d Session
                                H. R. 5817

  To amend title XXVII of the Public Health Service Act, the Internal 
 Revenue Code of 1986, and the Employee Retirement Income Security Act 
      of 1974 to require health plans to provide to participants, 
 beneficiaries, and enrollees an advanced explanation of benefits with 
 respect to items and services scheduled to be received from providers 
  and facilities and to amend title XI of the Social Security Act to 
  require health care providers and health care facilities to provide 
good faith estimates of the expected charges for furnishing such items 
                             and services.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            February 7, 2020

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

_______________________________________________________________________

                                 A BILL


 
  To amend title XXVII of the Public Health Service Act, the Internal 
 Revenue Code of 1986, and the Employee Retirement Income Security Act 
      of 1974 to require health plans to provide to participants, 
 beneficiaries, and enrollees an advanced explanation of benefits with 
 respect to items and services scheduled to be received from providers 
  and facilities and to amend title XI of the Social Security Act to 
  require health care providers and health care facilities to provide 
good faith estimates of the expected charges for furnishing such items 
                             and services.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Fair and Honest Advance Cost 
Estimate for Patients Act of 2020''.

SEC. 2. ADVANCED EXPLANATION OF BENEFITS.

    (a) Health Plan Requirements.--
            (1) Public health service act amendment.--Subpart II of 
        part A of title XXVII of the Public Health Service Act (42 
        U.S.C. 300gg-11 et seq.) is amended by adding at the end the 
        following new section:

``SEC. 2730. ADVANCED EXPLANATION OF BENEFITS.

    ``(a) In General.--Beginning on January 1, 2022, each health plan 
shall, with respect to a notification submitted under section 
1128A(t)(1)(B) of the Social Security Act by a health care provider or 
health care facility, respectively, to the health plan for a 
participant, beneficiary, or enrollee under such health plan scheduled 
to receive an item or service from the provider or facility, not later 
than 1 business day (or, in the case such item or service was so 
scheduled at least 10 business days before such item or service is to 
be furnished (or in the case such notification was made pursuant to a 
request by such participant, beneficiary, or enrollee), 3 business 
days) after the date on which the health plan receives such 
notification, provide to the participant, beneficiary, or enrollee 
(through mail or electronic means, as requested by the participant, 
beneficiary, or enrollee) a notification including the following:
            ``(1) Whether or not the provider or facility is a 
        participating provider or a participating facility with respect 
        to the health plan with respect to the furnishing of such item 
        or service and--
                    ``(A) in the case the provider or facility is a 
                participating provider or facility with respect to the 
                health plan with respect to the furnishing of such item 
                or service, the contracted rate under such plan for 
                such item or service; and
                    ``(B) in the case the provider or facility is a 
                nonparticipating provider or facility with respect to 
                such plan, a description of how such participant, 
                beneficiary, or enrollee may obtain information on 
                providers and facilities that, with respect to such 
                health plan, are participating providers and 
                facilities.
            ``(2) The good faith estimate included in the notification 
        received from the provider or facility.
            ``(3) A good faith estimate of the amount the health plan 
        is responsible for paying for items and services included in 
        the estimate described in paragraph (2).
            ``(4) A good faith estimate of the amount of any cost-
        sharing (including with respect to the deductible and any 
        copayment or coinsurance obligation) for which the participant, 
        beneficiary, or enrollee would be responsible for such item or 
        service (as of the date of such notification).
            ``(5) A good faith estimate of the amount that the 
        participant, 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 health plan (as of the date of such notification).
            ``(6) In the case such item or service is subject to a 
        medical management technique (including concurrent review, 
        prior authorization, and step-therapy or fail-first protocols) 
        for coverage under the health plan, a disclaimer that coverage 
        for such item or service is subject to such medical management 
        technique.
            ``(7) A disclaimer that the information provided in the 
        notification is only an estimate based on the items and 
        services reasonably expected, at the time of scheduling (or 
        requesting) the item or service, to be furnished and is subject 
        to change.
            ``(8) Any other information or disclaimer the health plan 
        determines appropriate that is consistent with information and 
        disclaimers required under this section.
    ``(b) Health Plan Defined.--In this section, the term `health plan' 
means a group health plan and health insurance coverage offered by a 
heath insurance issuer in the group or individual market and includes a 
grandfathered health plan (as defined in section 1251(e) of the Patient 
Protection and Affordable Care Act).''.
            (2) Internal revenue code of 1986 amendment.--
                    (A) In general.--Subchapter B of chapter 100 of the 
                Internal Revenue Code of 1986 is amended by adding at 
                the end the following new section:

``SEC. 9816. ADVANCED EXPLANATION OF BENEFITS.

    ``(a) In General.--Beginning on January 1, 2022, each health plan 
shall, with respect to a notification submitted under section 
1128A(t)(1)(B) of the Social Security Act by a health care provider or 
health care facility, respectively, to the health plan for a 
participant or beneficiary under such health plan scheduled to receive 
an item or service from the provider or facility, not later than 1 
business day (or, in the case such item or service was so scheduled at 
least 10 business days before such item or service is to be furnished 
(or in the case such notification was made pursuant to a request by 
such participant or beneficiary), 3 business days) after the date on 
which the health plan receives such notification, provide to the 
participant or beneficiary (through mail or electronic means, as 
requested by the participant or beneficiary) a notification including 
the following:
            ``(1) Whether or not the provider or facility is a 
        participating provider or a participating facility with respect 
        to the health plan with respect to the furnishing of such item 
        or service and--
                    ``(A) in the case the provider or facility is a 
                participating provider or facility with respect to the 
                health plan with respect to the furnishing of such item 
                or service, the contracted rate under such plan for 
                such item or service; and
                    ``(B) in the case the provider or facility is a 
                nonparticipating provider or facility with respect to 
                such plan, a description of how such participant or 
                beneficiary may obtain information on providers and 
                facilities that, with respect to such health plan, are 
                participating providers and facilities.
            ``(2) The good faith estimate included in the notification 
        received from the provider or facility.
            ``(3) A good faith estimate of the amount the health plan 
        is responsible for paying for items and services included in 
        the estimate described in paragraph (2).
            ``(4) A good faith estimate of the amount of any cost-
        sharing (including with respect to the deductible and any 
        copayment or coinsurance obligation) for which the participant 
        or beneficiary would be responsible for such item or service 
        (as of the date of such notification).
            ``(5) A good faith estimate of the amount that the 
        participant or beneficiary has incurred toward meeting the 
        limit of the financial responsibility (including with respect 
        to deductibles and out-of-pocket maximums) under the health 
        plan (as of the date of such notification).
            ``(6) In the case such item or service is subject to a 
        medical management technique (including concurrent review, 
        prior authorization, and step-therapy or fail-first protocols) 
        for coverage under the health plan, a disclaimer that coverage 
        for such item or service is subject to such medical management 
        technique.
            ``(7) A disclaimer that the information provided in the 
        notification is only an estimate based on the items and 
        services reasonably expected, at the time of scheduling (or 
        requesting) the item or service, to be furnished and is subject 
        to change.
            ``(8) Any other information or disclaimer the health plan 
        determines appropriate that is consistent with information and 
        disclaimers required under this section.
    ``(b) Health Plan Defined.--In this section, the term `health plan' 
means a group health plan, including any group health plan that is a 
grandfathered health plan (as defined in section 1251(e) of the Patient 
Protection and Affordable Care Act).''.
                    (B) Conforming amendment.--Section 9815(a) of the 
                Internal Revenue Code of 1986 is amended--
                            (i) in paragraph (1), by striking ``(as 
                        amended by the Patient Protection and 
                        Affordable Care Act)'' and inserting ``(other 
                        than the provisions of section 2730 of such 
                        Act)''; and
                            (ii) in paragraph (2), by inserting 
                        ``(other than the provisions of section 2730 of 
                        such Act)'' after ``a provision of such part 
                        A''.
                    (C) Clerical amendment.--The table of sections for 
                such subchapter is amended by adding at the end the 
                following new item:

``Sec. 9816. Advanced explanation of benefits.''.
            (3) Employee retirement income security act of 1974 
        amendment.--
                    (A) In general.--Subpart B of part 7 of subtitle B 
                of title I of the Employee Retirement Income Security 
                Act of 1974 (29 U.S.C. 1185 et seq.) is amended by 
                adding at the end the following new section:

``SEC. 716. ADVANCED EXPLANATION OF BENEFITS.

    ``(a) In General.--Beginning on January 1, 2022, each health plan 
shall, with respect to a notification submitted under section 
1128A(t)(1)(B) of the Social Security Act by a health care provider or 
health care facility, respectively, to the health plan for a 
participant or beneficiary under such health plan scheduled to receive 
an item or service from the provider or facility, not later than 1 
business day (or, in the case such item or service was so scheduled at 
least 10 business days before such item or service is to be furnished 
(or in the case such notification was made pursuant to a request by 
such participant or beneficiary), 3 business days) after the date on 
which the health plan receives such notification, provide to the 
participant or beneficiary (through mail or electronic means, as 
requested by the participant or beneficiary) a notification including 
the following:
            ``(1) Whether or not the provider or facility is a 
        participating provider or a participating facility with respect 
        to the health plan with respect to the furnishing of such item 
        or service and--
                    ``(A) in the case the provider or facility is a 
                participating provider or facility with respect to the 
                health plan with respect to the furnishing of such item 
                or service, the contracted rate under such plan for 
                such item or service; and
                    ``(B) in the case the provider or facility is a 
                nonparticipating provider or facility with respect to 
                such plan, a description of how such participant or 
                beneficiary may obtain information on providers and 
                facilities that, with respect to such health plan, are 
                participating providers and facilities.
            ``(2) The good faith estimate included in the notification 
        received from the provider or facility.
            ``(3) A good faith estimate of the amount the health plan 
        is responsible for paying for items and services included in 
        the estimate described in paragraph (2).
            ``(4) A good faith estimate of the amount of any cost-
        sharing (including with respect to the deductible and any 
        copayment or coinsurance obligation) for which the participant 
        or beneficiary would be responsible for such item or service 
        (as of the date of such notification).
            ``(5) A good faith estimate of the amount that the 
        participant or beneficiary has incurred toward meeting the 
        limit of the financial responsibility (including with respect 
        to deductibles and out-of-pocket maximums) under the health 
        plan (as of the date of such notification).
            ``(6) In the case such item or service is subject to a 
        medical management technique (including concurrent review, 
        prior authorization, and step-therapy or fail-first protocols) 
        for coverage under the health plan, a disclaimer that coverage 
        for such item or service is subject to such medical management 
        technique.
            ``(7) A disclaimer that the information provided in the 
        notification is only an estimate based on the items and 
        services reasonably expected, at the time of scheduling (or 
        requesting) the item or service, to be furnished and is subject 
        to change.
            ``(8) Any other information or disclaimer the health plan 
        determines appropriate that is consistent with information and 
        disclaimers required under this section.
    ``(b) Health Plan Defined.--In this section, the term `health plan' 
means a group health plan and health insurance coverage offered by a 
health insurance issuer in the group market and includes a 
grandfathered health plan (as defined in section 1251(e) of the Patient 
Protection and Affordable Care Act) that is such a plan or coverage.''.
                    (B) Conforming amendment.--Section 715(a) of the 
                Employee Retirement Income Security Act of 1974 (29 
                U.S.C. 1185d(a)) is amended--
                            (i) in paragraph (1), by striking ``(as 
                        amended by the Patient Protection and 
                        Affordable Care Act)'' and inserting ``(other 
                        than the provisions of section 2730 of such 
                        Act)''; and
                            (ii) in paragraph (2), by inserting 
                        ``(other than the provisions of section 2730 of 
                        such Act)'' after ``a provision of such part 
                        A''.
                    (C) 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 714 the following new items:

``Sec. 715. Additional market reforms.
``Sec. 716. Advanced explanation of benefits.''.
    (b) Health Care Providers and Facilities.--Section 1128A of the 
Social Security Act (42 U.S.C. 1320a-7a) is amended by adding at the 
end the following new subsection:
    ``(t)(1) Each health care provider and health care 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)--
            ``(A) 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 have a claim for such item or service submitted to 
        such plan or coverage); and
            ``(B) provide a notification 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) 
        to--
                    ``(i) 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
                    ``(ii) in the case the individual is not described 
                in clause (i) and not enrolled in a Federal health care 
                program, the individual.
    ``(2) Each health care provider or health care facility that fails 
to provide the estimate as required under paragraph (1) shall be 
subject to a civil monetary penalty in an amount not to exceed $10,000 
for each such failure. The provisions of this section (other than 
subsection (a), subsection (b), the first sentence of subsection 
(c)(1), and subsection (o)) shall apply to a civil monetary penalty 
imposed under the preceding sentence in the same manner as such 
provisions apply to a penalty or proceeding under subsection (a).
    ``(3) In this subsection--
            ``(A) the terms `health insurance issuer', `group health 
        plan', `group health insurance coverage', and `individual 
        health insurance coverage' have the meaning given such terms, 
        respectively, in section 2791 of the Public Health Service Act; 
        and
            ``(B) the term `Federal health care program' has the 
        meaning given such term in section 1128B(f).''.
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