[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5826 Introduced in House (IH)]

<DOC>






116th CONGRESS
  2d Session
                                H. R. 5826

  To amend title XXVII of the Public Health Service Act, the Employee 
 Retirement Income Security Act of 1974, the Internal Revenue Code of 
1986, and title XI of the Social Security Act to prevent certain cases 
   of out-of-network surprise medical bills, strengthen health care 
consumer protections, and improve health care information transparency, 
                        and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           February 10, 2020

Mr. Neal (for himself, Mr. Brady, Mr. Suozzi, Mr. LaHood, Mr. Holding, 
 Mr. Kelly of Pennsylvania, Mr. Estes, Mr. Thompson of California, Mr. 
    Beyer, Ms. Shalala, Mr. Morelle, Mr. Larson of Connecticut, Ms. 
Schrier, Mr. Schneider, Mr. Danny K. Davis of Illinois, Mr. Evans, Mr. 
 Lewis, Mr. Higgins of New York, Mr. Nunes, Mr. Smith of Nebraska, Mr. 
Ferguson, Mr. Wenstrup, Mr. Rice of South Carolina, Mrs. Walorski, Mr. 
 Schweikert, Mr. Reed, Mr. Arrington, Mr. Marchant, Mr. Buchanan, Mr. 
   Thompson of Pennsylvania, Mr. Kildee, and Mr. Smith of Missouri) 
 introduced the following bill; which was referred to the Committee on 
  Energy and Commerce, and in addition to the Committees on Ways and 
Means, Education and Labor, and Transportation and Infrastructure, 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 Employee 
 Retirement Income Security Act of 1974, the Internal Revenue Code of 
1986, and title XI of the Social Security Act to prevent certain cases 
   of out-of-network surprise medical bills, strengthen health care 
consumer protections, and improve health care information transparency, 
                        and for other purposes.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Consumer 
Protections Against Surprise Medical Bills Act of 2020''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Consumer protections through requirements on health plans to 
                            prevent surprise medical bills for 
                            emergency services.
Sec. 3. Consumer protections through requirements on health plans to 
                            prevent surprise medical bills for non-
                            emergency services performed by 
                            nonparticipating providers at certain 
                            participating facilities.
Sec. 4. Consumer protections through application of health plan 
                            external review in cases of certain 
                            surprise medical bills.
Sec. 5. Consumer protections through health plan transparency 
                            requirements.
Sec. 6. Consumer protections through health plan requirement for fair 
                            and honest advance cost estimate.
Sec. 7. Determination through open negotiation and mediation of out-of-
                            network rates to be paid by health plans.
Sec. 8. Prohibiting balance billing practices by providers for 
                            emergency services, for services furnished 
                            by nonparticipating provider at 
                            participating facility, and in certain 
                            cases of misinformation.
Sec. 9. Additional consumer protections.
Sec. 10. Reporting requirements regarding air ambulance services.
Sec. 11. GAO report on effects of legislation.
Sec. 12. Transitional rule allowing deduction for surprise billing 
                            expenses below AGI floor.

SEC. 2. CONSUMER PROTECTIONS THROUGH REQUIREMENTS ON HEALTH PLANS TO 
              PREVENT SURPRISE MEDICAL BILLS FOR EMERGENCY SERVICES.

    (a) PHSA Amendments.--
            (1) In general.--Section 2719A of the Public Health Service 
        Act (42 U.S.C. 300gg-19a) is amended--
                    (A) in subsection (b)--
                            (i) in the heading, by striking 
                        ``Coverage'' and inserting ``Cost-Sharing and 
                        Payment'';
                            (ii) in paragraph (1)--
                                    (I) in the matter preceding 
                                subparagraph (A)--
                                            (aa) by striking ``a group 
                                        health plan, or a health 
                                        insurance issuer offering group 
                                        or individual health insurance 
                                        issuer,'' and inserting ``a 
                                        health plan'';
                                            (bb) by inserting ``and, 
                                        for plan year 2022 or a 
                                        subsequent plan year, with 
                                        respect to emergency services 
                                        in an independent freestanding 
                                        emergency department'' after 
                                        ``emergency department of a 
                                        hospital'';
                                            (cc) by striking ``the plan 
                                        or issuer'' and inserting ``the 
                                        plan''; and
                                            (dd) by striking ``(as 
                                        defined in paragraph (2)(B))'';
                                    (II) in subparagraph (B), by 
                                inserting ``or a participating facility 
                                that is an emergency department of a 
                                hospital or an independent freestanding 
                                emergency department (in this 
                                subsection referred to as a 
                                `participating emergency facility')'' 
                                after ``participating provider''; and
                                    (III) in subparagraph (C)--
                                            (aa) in the matter 
                                        preceding clause (i), by 
                                        inserting ``by a 
                                        nonparticipating provider or a 
                                        nonparticipating facility that 
                                        is an emergency department of a 
                                        hospital or an independent 
                                        freestanding emergency 
                                        department'' after 
                                        ``enrollee'';
                                            (bb) by striking clause 
                                        (i);
                                            (cc) by striking ``(ii)(I) 
                                        such services'' and inserting 
                                        ``(i) such services'';
                                            (dd) by striking ``where 
                                        the provider of services does 
                                        not have a contractual 
                                        relationship with the plan for 
                                        the providing of services'';
                                            (ee) by striking 
                                        ``emergency department services 
                                        received from providers who do 
                                        have such a contractual 
                                        relationship with the plan; 
                                        and'' and inserting ``emergency 
                                        services received from 
                                        participating providers and 
                                        participating emergency 
                                        facilities with respect to such 
                                        plan;'';
                                            (ff) by striking ``(II) if 
                                        such services'' and all that 
                                        follows through ``were provided 
                                        in-network'' and inserting the 
                                        following:
                            ``(ii) the cost-sharing requirement is not 
                        greater than the requirement that would apply 
                        if such services were furnished by a 
                        participating provider or a participating 
                        emergency facility, as applicable;''; and
                                            (gg) by adding at the end 
                                        the following new clauses:
                            ``(iii) such cost-sharing requirement is 
                        calculated as if the contracted rate for such 
                        services if furnished by a participating 
                        provider or a participating emergency facility 
                        were equal to the recognized amount for such 
                        services;
                            ``(iv) the health plan pays to such 
                        provider or facility, respectively, the amount 
                        by which the out-of-network rate for such 
                        services exceeds the cost-sharing amount for 
                        such services (as determined in accordance with 
                        clauses (ii) and (iii)); and
                            ``(v) any deductible or out-of-pocket 
                        maximum that would apply if such services were 
                        furnished by a participating provider or a 
                        participating emergency facility shall be the 
                        deductible or out-of-pocket maximum that 
                        applies; and''; and
                            (iii) by striking paragraph (2) and 
                        inserting the following new paragraph:
            ``(2) Audit process and rulemaking process for median 
        contracted rates.--
                    ``(A) Audit process.--
                            ``(i) In general.--Not later than July 1, 
                        2021, the Secretary, in coordination with the 
                        Secretary of the Treasury and the Secretary of 
                        Labor and in consultation with the National 
                        Association of Insurance Commissioners, shall 
                        establish through rulemaking a process, in 
                        accordance with clause (ii), under which health 
                        plans are audited by the Secretary to ensure 
                        that--
                                    ``(I) such plans are in compliance 
                                with the requirement of applying a 
                                median contracted rate under this 
                                section; and
                                    ``(II) that such median contracted 
                                rate so applied satisfies the 
                                definition under subsection (k)(8) with 
                                respect to the year involved.
                            ``(ii) Audit samples.--Under the process 
                        established pursuant to clause (i), the 
                        Secretary--
                                    ``(I) shall conduct audits 
                                described in such clause of a sample of 
                                health plans; and
                                    ``(II) may audit any health plan if 
                                the Secretary has received any 
                                complaint about such plan that involves 
                                the compliance of the plan with the 
                                requirement described in such clause.
                    ``(B) Rulemaking.--Not later than July 1, 2021, the 
                Secretary, in coordination with the Secretary of Labor 
                and the Secretary of the Treasury, shall establish 
                through rulemaking--
                            ``(i) the methodology the sponsor or issuer 
                        of a health plan shall use to determine the 
                        median contracted rate, which shall account for 
                        relevant payment adjustments that take into 
                        account facility type that are otherwise taken 
                        into account for purposes of determining 
                        payment amounts with respect to participating 
                        facilities; and
                            ``(ii) the information such sponsor or 
                        issuer shall share with the nonparticipating 
                        provider involved when making such a 
                        determination.''; and
                    (B) by adding at the end the following new 
                subsection:
    ``(k) Definitions.--For purposes of this section:
            ``(1) Contracted rate.--The term `contracted rate' means, 
        with respect to a health plan and a health care provider or 
        health care facility furnishing an item or service to a 
        beneficiary, participant, or enrollee of such plan, the agreed 
        upon total payment amount (inclusive of any cost-sharing) to 
        such provider or facility for such item or service.
            ``(2) During a visit.--The term `during a visit' shall, 
        with respect to an individual who is furnished items and 
        services at a participating 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 furnished 
        to such individual, regardless of whether or not the provider 
        furnishing such items or services is at the facility.
            ``(3) Emergency department of a hospital.--The term 
        `emergency department of a hospital' includes a hospital 
        outpatient department that provides emergency services.
            ``(4) 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.
            ``(5) Emergency services.--
                    ``(A) 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).
                    ``(B) Inclusion of additional services.--In the 
                case of an individual enrolled in a health plan who is 
                furnished services described in subparagraph (A) by a 
                provider or hospital or independent freestanding 
                emergency department to stabilize such individual with 
                respect to an emergency medical condition, the term 
                `emergency services' shall include, in addition to 
                those described in subparagraph (A), items and services 
                furnished as part of outpatient observation or an 
                inpatient or outpatient stay during a visit in which 
                such individual is so stabilized with respect to such 
                emergency condition if--
                            ``(i) such items and services would 
                        otherwise be covered under such plan if 
                        furnished by a participating provider or 
                        participating facility; and
                            ``(ii) such items and services are 
                        furnished--
                                    ``(I) to maintain, improve, or 
                                resolve the individual's stabilization 
                                with respect to such condition, unless 
                                any circumstance described in 
                                subparagraph (C) has occurred with 
                                respect to such individual before such 
                                items and services are furnished; or
                                    ``(II) for any purpose not 
                                described in subclause (I), unless each 
                                of the criteria described in 
                                subparagraph (D) have been met with 
                                respect to such individual and such 
                                item or service.
                    ``(C) Circumstances.--For purposes of subparagraph 
                (B)(ii)(I), a circumstance described in this 
                subparagraph is any of the following, with respect to 
                an individual who is a beneficiary, participant, or 
                enrollee of a health plan who is furnished services 
                described in subparagraph (A) by a hospital or 
                independent freestanding emergency department with 
                respect to an emergency medical condition:
                            ``(i) A participating provider, with 
                        respect to such plan, with privileges at the 
                        hospital or independent freestanding emergency 
                        department assumes responsibility for the care 
                        of the individual.
                            ``(ii) A participating provider, with 
                        respect to such plan, assumes responsibility 
                        for the care of the individual through transfer 
                        of the individual.
                            ``(iii) The health plan and the provider 
                        treating such individual at the hospital or 
                        independent freestanding emergency department 
                        for such condition reach an agreement 
                        concerning the care for the individual.
                            ``(iv) The individual is discharged.
                    ``(D) Signed notice criteria.--For purposes of 
                subparagraph (B)(ii)(II), the criteria described in 
                this subparagraph, with respect to an individual and an 
                item or service furnished by a nonparticipating 
                provider or nonparticipating facility that is a 
                hospital or an independent freestanding emergency 
                department, are the following:
                            ``(i) A written notice (as specified by the 
                        Secretary and in a clear and understandable 
                        manner) is provided by such provider or 
                        facility to such individual, before such item 
                        or service is furnished, that includes the 
                        following information:
                                    ``(I) That such provider or 
                                facility is a nonparticipating provider 
                                or nonparticipating facility (as 
                                applicable).
                                    ``(II) To the extent practicable, 
                                the estimated amount that such 
                                nonparticipating facility or 
                                nonparticipating provider may charge 
                                the individual for such item or 
                                service.
                                    ``(III) A statement that the 
                                individual may seek such item or 
                                service from a provider that is a 
                                participating provider or a hospital or 
                                independent freestanding emergency 
                                department that is a participating 
                                facility and a list, if feasible, of 
                                participating facilities or 
                                participating providers, as applicable, 
                                who are able to furnish such item or 
                                service.
                            ``(ii) Such individual is in a condition to 
                        receive (as determined in accordance with 
                        guidance issued by the Secretary) the 
                        information described in clause (i) and to 
                        confirm notice of receipt of such notice, in 
                        accordance with applicable State law.
                            ``(iii) The individual signs and dates such 
                        notice confirming receipt of the notice before 
                        such item or service is furnished.
            ``(6) Health plan.--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).
            ``(7) Independent freestanding emergency department.--The 
        term `independent freestanding emergency department' means a 
        health care facility that--
                    ``(A) is geographically separate and distinct and 
                licensed separately from a hospital under applicable 
                State law; and
                    ``(B) provides emergency services.
            ``(8) Median contracted rate.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                term `median contracted rate' means, with respect to a 
                health plan--
                            ``(i) for an item or service furnished 
                        during 2022, the median of the contracted rates 
                        recognized by the sponsor or issuer of such 
                        plan (determined with respect to all such plans 
                        of such sponsor or such issuer that are within 
                        the same line of business (as specified in 
                        subparagraph (C)) as the plan involved) as the 
                        total maximum payment under such plans in 2019 
                        for the same or a similar item or service that 
                        is provided by a provider or facility in the 
                        same or similar specialty and provided in the 
                        geographic region (established (and updated, as 
                        appropriate) by the Secretary, in consultation 
                        with the National Association of Insurance 
                        Commissioners) in which the item or service is 
                        furnished, consistent with the methodology 
                        established by the Secretary under subsection 
                        (b)(2)(B), increased by the percentage increase 
                        in the consumer price index for all urban 
                        consumers (United States city average) over 
                        2019, 2020, and 2021;
                            ``(ii) for an item or service furnished 
                        during 2023 or a subsequent year through 2026, 
                        the median contracted rate for the previous 
                        year, increased by the percentage increase in 
                        the consumer price index for all urban 
                        consumers (United States city average) over 
                        such previous year;
                            ``(iii) for an item or service furnished 
                        during a rebasing year (as defined in 
                        subparagraph (D)), the median of the contracted 
                        rates recognized by the sponsor or issuer of 
                        such plan (determined with respect to all such 
                        plans of such sponsor or such issuer that are 
                        within the same line of business (as specified 
                        in subparagraph (C)) as the plan involved) as 
                        the total maximum payment under such plans in 
                        such year for the same or a similar item or 
                        service that is provided by a provider or 
                        facility in the same or similar specialty and 
                        provided in the geographic region (as 
                        established pursuant to clause (i)) in which 
                        the item or service is furnished, consistent 
                        with the methodology established by the 
                        Secretary under subsection (b)(2)(B); and
                            ``(iv) for an item or service furnished 
                        during any of the 4 years following a rebasing 
                        year, the median contracted rate for the 
                        previous year, increased by the percentage 
                        increase in the consumer price index for all 
                        urban consumers (United States city average) 
                        over such previous year.
                    ``(B) Use of substitute rate in case of 
                insufficient data.--
                            ``(i) In general.--In the case the sponsor 
                        or issuer of a health plan has insufficient 
                        information (as specified by the Secretary) to 
                        calculate the median of the contracted rates in 
                        accordance with subparagraph (A) for a year for 
                        an item or service furnished in a particular 
                        geographic region (as established pursuant to 
                        subparagraph (A)(i)) by a type of provider or 
                        facility, the substitute rate (as defined in 
                        clause (ii)) for such item or service shall be 
                        deemed to be the median contracted rate for 
                        such item or service furnished in such region 
                        during such year by such a provider or facility 
                        for such year under such subparagraph (A) for 
                        such plan.
                            ``(ii) Substitute rate.--For purposes of 
                        clause (i), the term `substitute rate' means, 
                        with respect to an item or service furnished by 
                        a provider or facility in a geographic region 
                        (established pursuant to subparagraph (A)(i)) 
                        during a year for which a health plan is 
                        required to make payment pursuant to subsection 
                        (b)(1), (e)(1), or (i)(1)--
                                    ``(I) if sufficient information (as 
                                specified by the Secretary) exists to 
                                determine the median of the contracted 
                                rates recognized by all health plans 
                                offered in the same line of business 
                                (as specified in subparagraph (C)) by 
                                any group health plan or health 
                                insurance issuer for such an item or 
                                service furnished in such region by 
                                such a provider or facility during such 
                                year using a database or other source 
                                of information determined appropriate 
                                by the Secretary, such median; and
                                    ``(II) if such sufficient 
                                information does not exist, the median 
                                of the contracted rates recognized by 
                                all health plans offered in the same 
                                line of business (as specified in 
                                subparagraph (C)) by any group health 
                                plan or health insurance issuer for 
                                such an item or service furnished in a 
                                similarly situated geographic region 
                                (as determined by the Secretary) with 
                                such sufficient information by such a 
                                provider or facility during such year 
                                using such a database or such other 
                                source of information.
                        The Secretary shall develop a methodology for 
                        determining a substitute rate based on a 
                        similarly situated health plan that is not a 
                        Federal health care program (as defined in 
                        section 1128B(f) of the Social Security Act) in 
                        the case a substitute rate is not calculable 
                        under the previous sentence with respect to an 
                        item or service.
                    ``(C) Line of business.--A line of business 
                specified in this subparagraph is one of the following:
                            ``(i) The individual market.
                            ``(ii) The small group market.
                            ``(iii) The large group market.
                            ``(iv) In the case of a self-insured group 
                        health plan, other self-insured group health 
                        plans.
                    ``(D) Rebasing year defined.--For purposes of 
                subparagraph (A), the term `rebasing year' means 2027 
                and every 5 years thereafter.
            ``(9) Nonparticipating facility; participating facility.--
                    ``(A) Nonparticipating facility.--The term 
                `nonparticipating facility' means, with respect to an 
                item or service and a health plan, a health care 
                facility described in subparagraph (B)(ii) that does 
                not have a contractual relationship with the plan for 
                furnishing such item or service.
                    ``(B) Participating facility.--
                            ``(i) In general.--The term `participating 
                        facility' means, with respect to an item or 
                        service and a health plan, a health care 
                        facility described in clause (ii) that has a 
                        contractual relationship with the plan for 
                        furnishing such item or service.
                            ``(ii) Health care facility described.--A 
                        health care facility described in this clause 
                        is each of the following:
                                    ``(I) A hospital (as defined in 
                                1861(e) of the Social Security Act), 
                                including an emergency department of a 
                                hospital.
                                    ``(II) A critical access hospital 
                                (as defined in section 1861(mm)(1) of 
                                such Act).
                                    ``(III) An ambulatory surgical 
                                center (as described in section 
                                1833(i)(1)(A) of such Act).
                                    ``(IV) A laboratory.
                                    ``(V) A radiology facility or 
                                imaging center.
                                    ``(VI) An independent freestanding 
                                emergency department.
                                    ``(VII) Any other facility 
                                specified by the Secretary.
            ``(10) Nonparticipating providers; participating 
        providers.--
                    ``(A) Nonparticipating provider.--The term 
                `nonparticipating provider' means, with respect to an 
                item or service and a health plan, a physician or other 
                health care provider who does not have a contractual 
                relationship with the plan for furnishing such item or 
                service under the plan.
                    ``(B) Participating provider.--The term 
                `participating provider' means, with respect to an item 
                or service and a health plan, a physician or other 
                health care provider who has a contractual relationship 
                with the plan for furnishing such item or service under 
                the plan.
            ``(11) 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 
        health plan receiving such item or service from a 
        nonparticipating provider or facility--
                    ``(A) subject to subparagraphs (C) and (D), in the 
                case such State has in effect a State law that provides 
                for a method for determining the total amount payable 
                under such health plan regulated by such State with 
                respect to such item or service furnished by such 
                provider or facility, such amount determined in 
                accordance with such law;
                    ``(B) subject to subparagraphs (C) and (D), 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 clause (ii), if the 
                        provider or facility (as applicable) and such 
                        plan agree on an amount of payment (including 
                        if agreed on through open negotiations under 
                        subsection (j)(1)) with respect to such item or 
                        service, such agreed on amount; or
                            ``(ii) if such provider or facility (as 
                        applicable) and such plan enter the mediated 
                        dispute process under subsection (j) and do not 
                        so agree before the date on which a selected 
                        independent entity (as defined in paragraph (3) 
                        of such subsection) makes a determination with 
                        respect to such item or service under such 
                        subsection, the amount of such determination;
                    ``(C) 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; or
                    ``(D) in the case such health plan is a self-
                insured group health plan and in the case of a State 
                with an agreement with such plan in effect as of the 
                date of the enactment of the Consumer Protections 
                Against Surprise Medical Bills Act of 2020, that 
                provides for a method for determining the total amount 
                payable under such health plan with respect to such 
                item or service furnished by such provider or facility, 
                such amount determined in accordance with such method.
            ``(12) Recognized amount.--The term `recognized amount' 
        means, with respect to an item or service furnished in a State 
        during a year to a participant, beneficiary, or enrollee of a 
        health plan by a nonparticipating provider or nonparticipating 
        facility--
                    ``(A) subject to subparagraphs (C) and (D), in the 
                case such State has in effect a law described in 
                paragraph (11)(A) with respect to such item or service, 
                provider or facility, and plan, the amount determined 
                in accordance with such law;
                    ``(B) subject to subparagraphs (C) and (D), in the 
                case such State does not have in effect such a law, an 
                amount that is the median contracted rate for such item 
                or service for such year;
                    ``(C) subject to subparagraph (D), in the case such 
                State is described in paragraph (11)(C) with respect to 
                such item or service so furnished, the amount that the 
                State approves under such system for such item or 
                service so furnished; or
                    ``(D) in the case such health plan is a self-
                insured group health plan and in the case of a State 
                with an agreement with such plan in effect as of the 
                date of the enactment of the Consumer Protections 
                Against Surprise Medical Bills Act of 2020, that 
                provides for a method for determining the total amount 
                payable under such health plan with respect to such 
                item or service furnished by such provider or facility, 
                such amount determined in accordance with such method.
            ``(13) Stabilize.--The term `to stabilize', with respect to 
        an emergency medical condition, has the meaning give in section 
        1867(e)(3)(A) of the Social Security Act).
            ``(14) Cost-sharing.--The term `cost-sharing' includes 
        copayments, coinsurance, and deductibles.
    ``(l) Payment to Provider or Facility.--In the case of any payment 
required to be made by a health plan pursuant to subsection (b)(1), 
(e)(1), or (i)(1) to a nonparticiapting provider or nonparticipating 
facility for an item or service, such payment shall be made to such 
provider or facility and not to the individual receiving such item or 
service.''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply with respect to plan years beginning on or after 
        January 1, 2022.
    (b) 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 new section:

``SEC. 9816. PATIENT PROTECTIONS.

    ``(a) Choice of Health Care Professional.--If a health plan 
requires or provides for designation by a participant or beneficiary of 
a participating primary care provider, then the plan shall permit each 
participant or beneficiary to designate any participating primary care 
provider who is available to accept such individual.
    ``(b) Cost-Sharing and Payment of Emergency Services.--
            ``(1) In general.--If a health plan provides or covers any 
        benefits with respect to services in an emergency department of 
        a hospital and, for plan year 2022 or a subsequent plan year, 
        with respect to emergency services in an independent 
        freestanding emergency department, the plan shall cover 
        emergency services--
                    ``(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 facility that is an emergency department 
                of a hospital or an independent freestanding emergency 
                department (in this subsection referred to as a 
                `participating emergency facility') 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 
                facility that is an emergency department of a hospital 
                or an independent freestanding emergency department--
                            ``(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 furnished by a 
                        participating provider or a participating 
                        emergency facility, as applicable;
                            ``(iii) such cost-sharing requirement is 
                        calculated as if the contracted rate for such 
                        services if furnished by a participating 
                        provider or a participating emergency facility 
                        were equal to the recognized amount for such 
                        services;
                            ``(iv) the health plan pays to such 
                        provider or facility, respectively, the amount 
                        by which the out-of-network rate for such 
                        services exceeds the cost-sharing amount for 
                        such services (as determined in accordance with 
                        clauses (ii) and (iii)); and
                            ``(v) any deductible or out-of-pocket 
                        maximum that would apply if such services were 
                        furnished by a participating provider or a 
                        participating emergency facility shall be the 
                        deductible or out-of-pocket maximum that 
                        applies; 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, and other than applicable 
                cost-sharing).
            ``(2) Audit process and rulemaking process for median 
        contracted rates.--
                    ``(A) Audit process.--
                            ``(i) In general.--Not later than July 1, 
                        2021, the Secretary, in coordination with the 
                        Secretary of Health and Human Services and the 
                        Secretary of Labor and in consultation with the 
                        National Association of Insurance 
                        Commissioners, shall establish through 
                        rulemaking a process, in accordance with clause 
                        (ii), under which health plans are audited by 
                        the Secretary to ensure that--
                                    ``(I) such plans are in compliance 
                                with the requirement of applying a 
                                median contracted rate under this 
                                section; and
                                    ``(II) that such median contracted 
                                rate so applied satisfies the 
                                definition under subsection (k)(8) with 
                                respect to the year involved.
                            ``(ii) Audit samples.--Under the process 
                        established pursuant to clause (i), the 
                        Secretary--
                                    ``(I) shall conduct audits 
                                described in such clause of a sample of 
                                health plans; and
                                    ``(II) may audit any health plan if 
                                the Secretary has received any 
                                complaint about such plan that involves 
                                the compliance of the plan with the 
                                requirement described in such clause.
                    ``(B) Rulemaking.--Not later than July 1, 2021, the 
                Secretary, in coordination with the Secretary of Labor 
                and the Secretary of Health and Human Services, shall 
                establish through rulemaking--
                            ``(i) the methodology the sponsor of a 
                        health plan shall use to determine the median 
                        contracted rate, which shall account for 
                        relevant payment adjustments that take into 
                        account facility type that are otherwise taken 
                        into account for purposes of determining 
                        payment amounts with respect to participating 
                        facilities; and
                            ``(ii) the information such sponsor shall 
                        share with the nonparticipating provider 
                        involved when making such a determination.
    ``(c) Access to Pediatric Care.--
            ``(1) Pediatric care.--In the case of a person who has a 
        child who is a participant or beneficiary under a 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.
    ``(d) Patient Access to Obstetrical and Gynecological Care.--
            ``(1) General rights.--
                    ``(A) Direct access.--A health plan described in 
                paragraph (2) may not require authorization or referral 
                by the plan or any person (including a primary care 
                provider described in paragraph (2)(B)) in the case of 
                a female participant or beneficiary who seeks coverage 
                for obstetrical or gynecological care provided by a 
                participating health care professional who specializes 
                in obstetrics or gynecology. Such professional shall 
                agree to otherwise adhere to such plan's policies and 
                procedures, including procedures regarding referrals 
                and obtaining prior authorization and providing 
                services pursuant to a treatment plan (if any) approved 
                by the plan.
                    ``(B) Obstetrical and gynecological care.--A health 
                plan described in paragraph (2) shall treat the 
                provision of obstetrical and gynecological care, and 
                the ordering of related obstetrical and gynecological 
                items and services, pursuant to the direct access 
                described under subparagraph (A), by a participating 
                health care professional who specializes in obstetrics 
                or gynecology as the authorization of the primary care 
                provider.
            ``(2) Application of paragraph.--A health plan described in 
        this paragraph is a 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 health plan involved from 
                requiring that the obstetrical or gynecological 
                provider notify the primary care health care 
                professional or the plan of treatment decisions.
    ``(k) Definitions.--For purposes of this section:
            ``(1) Contracted rate.--The term `contracted rate' means, 
        with respect to a health plan and a health care provider or 
        health care facility furnishing an item or service to a 
        beneficiary or participant of such plan, the agreed upon total 
        payment amount (inclusive of any cost-sharing) to such provider 
        or facility for such item or service.
            ``(2) During a visit.--The term `during a visit' shall, 
        with respect to an individual who is furnished items and 
        services at a participating 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 furnished 
        to such individual, regardless of whether or not the provider 
        furnishing such items or services is at the facility.
            ``(3) Emergency department of a hospital.--The term 
        `emergency department of a hospital' includes a hospital 
        outpatient department that provides emergency services.
            ``(4) 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.
            ``(5) Emergency services.--
                    ``(A) 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).
                    ``(B) Inclusion of additional services.--In the 
                case of an individual enrolled in a health plan who is 
                furnished services described in subparagraph (A) by a 
                provider or hospital or independent freestanding 
                emergency department to stabilize such individual with 
                respect to an emergency medical condition, the term 
                `emergency services' shall include, in addition to 
                those described in subparagraph (A), items and services 
                furnished as part of outpatient observation or an 
                inpatient or outpatient stay during a visit in which 
                such individual is so stabilized with respect to such 
                emergency condition if--
                            ``(i) such items and services would 
                        otherwise be covered under such plan if 
                        furnished by a participating provider or 
                        participating facility; and
                            ``(ii) such items and services are 
                        furnished--
                                    ``(I) to maintain, improve, or 
                                resolve the individual's stabilization 
                                with respect to such condition, unless 
                                any circumstance described in 
                                subparagraph (C) has occurred with 
                                respect to such individual before such 
                                items and services are furnished; or
                                    ``(II) for any purpose not 
                                described in subclause (I), unless each 
                                of the criteria described in 
                                subparagraph (D) have been met with 
                                respect to such individual and such 
                                item or service.
                    ``(C) Circumstances.--For purposes of subparagraph 
                (B)(ii)(I), a circumstance described in this 
                subparagraph is any of the following, with respect to 
                an individual who is a beneficiary, participant, or 
                enrollee of a health plan who is furnished services 
                described in subparagraph (A) by a hospital or 
                independent freestanding emergency department with 
                respect to an emergency medical condition:
                            ``(i) A participating provider, with 
                        respect to such plan, with privileges at the 
                        hospital or independent freestanding emergency 
                        department assumes responsibility for the care 
                        of the individual.
                            ``(ii) A participating provider, with 
                        respect to such plan, assumes responsibility 
                        for the care of the individual through transfer 
                        of the individual.
                            ``(iii) The health plan and the provider 
                        treating such individual at the hospital or 
                        independent freestanding emergency department 
                        for such condition reach an agreement 
                        concerning the care for the individual.
                            ``(iv) The individual is discharged.
                    ``(D) Signed notice criteria.--For purposes of 
                subparagraph (B)(ii)(II), the criteria described in 
                this subparagraph, with respect to an individual and an 
                item or service furnished by a nonparticipating 
                provider or nonparticipating facility that is a 
                hospital or an independent freestanding emergency 
                department, are the following:
                            ``(i) A written notice (as specified by the 
                        Secretary and in a clear and understandable 
                        manner) is provided by such provider or 
                        facility to such individual, before such item 
                        or service is furnished, that includes the 
                        following information:
                                    ``(I) That such provider or 
                                facility is a nonparticipating provider 
                                or nonparticipating facility (as 
                                applicable).
                                    ``(II) To the extent practicable, 
                                the estimated amount that such 
                                nonparticipating facility or 
                                nonparticipating provider may charge 
                                the individual for such item or 
                                service.
                                    ``(III) A statement that the 
                                individual may seek such item or 
                                service from a provider that is a 
                                participating provider or a hospital or 
                                independent freestanding emergency 
                                department that is a participating 
                                facility and a list, if feasible, of 
                                participating facilities or 
                                participating providers, as applicable, 
                                who are able to furnish such item or 
                                service.
                            ``(ii) Such individual is in a condition to 
                        receive (as determined in accordance with 
                        guidance issued by the Secretary) the 
                        information described in clause (i) and to 
                        confirm notice of receipt of such notice, in 
                        accordance with applicable State law.
                            ``(iii) The individual signs and dates such 
                        notice confirming receipt of the notice before 
                        such item or service is furnished.
            ``(6) Health plan.--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).
            ``(7) Independent freestanding emergency department.--The 
        term `independent freestanding emergency department' means a 
        health care facility that--
                    ``(A) is geographically separate and distinct and 
                licensed separately from a hospital under applicable 
                State law; and
                    ``(B) provides emergency services.
            ``(8) Median contracted rate.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                term `median contracted rate' means, with respect to a 
                health plan--
                            ``(i) for an item or service furnished 
                        during 2022, the median of the contracted rates 
                        recognized by the sponsor of such plan 
                        (determined with respect to all such plans of 
                        such sponsor that are within the same line of 
                        business (as specified in subparagraph (C)) as 
                        the plan involved) as the total maximum payment 
                        under such plans in 2019 for the same or a 
                        similar item or service that is provided by a 
                        provider or facility in the same or similar 
                        specialty and provided in the geographic region 
                        (established (and updated, as appropriate) by 
                        the Secretary, in consultation with the 
                        National Association of Insurance 
                        Commissioners) in which the item or service is 
                        furnished, consistent with the methodology 
                        established by the Secretary under subsection 
                        (b)(2)(B), increased by the percentage increase 
                        in the consumer price index for all urban 
                        consumers (United States city average) over 
                        2019, 2020, and 2021;
                            ``(ii) for an item or service furnished 
                        during 2023 or a subsequent year through 2026, 
                        the median contracted rate for the previous 
                        year, increased by the percentage increase in 
                        the consumer price index for all urban 
                        consumers (United States city average) over 
                        such previous year;
                            ``(iii) for an item or service furnished 
                        during a rebasing year (as defined in 
                        subparagraph (D)), the median of the contracted 
                        rates recognized by the sponsor of such plan 
                        (determined with respect to all such plans of 
                        such sponsor that are within the same line of 
                        business (as specified in subparagraph (C)) as 
                        the plan involved) as the total maximum payment 
                        under such plans in such year for the same or a 
                        similar item or service that is provided by a 
                        provider or facility in the same or similar 
                        specialty and provided in the geographic region 
                        (as established pursuant to clause (i)) in 
                        which the item or service is furnished, 
                        consistent with the methodology established by 
                        the Secretary under subsection (b)(2)(B); and
                            ``(iv) for an item or service furnished 
                        during any of the 4 years following a rebasing 
                        year, the median contracted rate for the 
                        previous year, increased by the percentage 
                        increase in the consumer price index for all 
                        urban consumers (United States city average) 
                        over such previous year.
                    ``(B) Use of substitute rate in case of 
                insufficient data.--
                            ``(i) In general.--In the case the sponsor 
                        of a health plan has insufficient information 
                        (as specified by the Secretary) to calculate 
                        the median of the contracted rates in 
                        accordance with subparagraph (A) for a year for 
                        an item or service furnished in a particular 
                        geographic region (as established pursuant to 
                        subparagraph (A)(i)) by a type of provider or 
                        facility, the substitute rate (as defined in 
                        clause (ii)) for such item or service shall be 
                        deemed to be the median contracted rate for 
                        such item or service furnished in such region 
                        during such year by such a provider or facility 
                        for such year under such subparagraph (A) for 
                        such plan.
                            ``(ii) Substitute rate.--For purposes of 
                        clause (i), the term `substitute rate' means, 
                        with respect to an item or service furnished by 
                        a provider or facility in a geographic region 
                        (established pursuant to subparagraph (A)(i)) 
                        during a year for which a health plan is 
                        required to make payment pursuant to subsection 
                        (b)(1), (e)(1), or (i)(1)--
                                    ``(I) if sufficient information (as 
                                specified by the Secretary) exists to 
                                determine the median of the contracted 
                                rates recognized by all health plans 
                                offered in the same line of business 
                                (as specified in subparagraph (C)) by 
                                any group health plan for such an item 
                                or service furnished in such region by 
                                such a provider or facility during such 
                                year using a database or other source 
                                of information determined appropriate 
                                by the Secretary, such median; and
                                    ``(II) if such sufficient 
                                information does not exist, the median 
                                of the contracted rates recognized by 
                                all health plans offered in the same 
                                line of business (as specified in 
                                subparagraph (C)) by any group health 
                                plan for such an item or service 
                                furnished in a similarly situated 
                                geographic region (as determined by the 
                                Secretary) with such sufficient 
                                information by such a provider or 
                                facility during such year using such a 
                                database or such other source of 
                                information.
                        The Secretary shall develop a methodology for 
                        determining a substitute rate based on a 
                        similarly situated health plan that is not a 
                        Federal health care program (as defined in 
                        section 1128B(f) of the Social Security Act) in 
                        the case a substitute rate is not calculable 
                        under the previous sentence with respect to an 
                        item or service.
                    ``(C) Line of business.--A line of business 
                specified in this subparagraph is one of the following:
                            ``(i) The small group market.
                            ``(ii) The large group market.
                            ``(iii) In the case of a self-insured group 
                        health plan, other self-insured group health 
                        plans.
                    ``(D) Rebasing year defined.--For purposes of 
                subparagraph (A), the term `rebasing year' means 2027 
                and every 5 years thereafter.
            ``(9) Nonparticipating facility; participating facility.--
                    ``(A) Nonparticipating facility.--The term 
                `nonparticipating facility' means, with respect to an 
                item or service and a health plan, a health care 
                facility described in subparagraph (B)(ii) that does 
                not have a contractual relationship with the plan for 
                furnishing such item or service.
                    ``(B) Participating facility.--
                            ``(i) In general.--The term `participating 
                        facility' means, with respect to an item or 
                        service and a health plan, a health care 
                        facility described in clause (ii) that has a 
                        contractual relationship with the plan for 
                        furnishing such item or service.
                            ``(ii) Health care facility described.--A 
                        health care facility described in this clause 
                        is each of the following:
                                    ``(I) A hospital (as defined in 
                                1861(e) of the Social Security Act), 
                                including an emergency department of a 
                                hospital.
                                    ``(II) A critical access hospital 
                                (as defined in section 1861(mm)(1) of 
                                such Act).
                                    ``(III) An ambulatory surgical 
                                center (as described in section 
                                1833(i)(1)(A) of such Act).
                                    ``(IV) A laboratory.
                                    ``(V) A radiology facility or 
                                imaging center.
                                    ``(VI) An independent freestanding 
                                emergency department.
                                    ``(VII) Any other facility 
                                specified by the Secretary.
            ``(10) Nonparticipating providers; participating 
        providers.--
                    ``(A) Nonparticipating provider.--The term 
                `nonparticipating provider' means, with respect to an 
                item or service and a health plan, a physician or other 
                health care provider who does not have a contractual 
                relationship with the plan for furnishing such item or 
                service under the plan.
                    ``(B) Participating provider.--The term 
                `participating provider' means, with respect to an item 
                or service and a health plan, a physician or other 
                health care provider who has a contractual relationship 
                with the plan for furnishing such item or service under 
                the plan.
            ``(11) 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 health plan 
        receiving such item or service from a nonparticipating provider 
        or facility--
                    ``(A) subject to subparagraphs (C) and (D), in the 
                case such State has in effect a State law that provides 
                for a method for determining the total amount payable 
                under such health plan regulated by such State with 
                respect to such item or service furnished by such 
                provider or facility, such amount determined in 
                accordance with such law;
                    ``(B) subject to subparagraphs (C) and (D), 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 clause (ii), if the 
                        provider or facility (as applicable) and such 
                        plan agree on an amount of payment (including 
                        if agreed on through open negotiations under 
                        subsection (j)(1)) with respect to such item or 
                        service, such agreed on amount; or
                            ``(ii) if such provider or facility (as 
                        applicable) and such plan enter the mediated 
                        dispute process under subsection (j) and do not 
                        so agree before the date on which a selected 
                        independent entity (as defined in paragraph (3) 
                        of such subsection) makes a determination with 
                        respect to such item or service under such 
                        subsection, the amount of such determination;
                    ``(C) 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; or
                    ``(D) in the case such health plan is a self-
                insured group health plan and in the case of a State 
                with an agreement with such plan in effect as of the 
                date of the enactment of the Consumer Protections 
                Against Surprise Medical Bills Act of 2020, that 
                provides for a method for determining the total amount 
                payable under such health plan with respect to such 
                item or service furnished by such provider or facility, 
                such amount determined in accordance with such method.
            ``(12) Recognized amount.--The term `recognized amount' 
        means, with respect to an item or service furnished in a State 
        during a year to a participant or beneficiary of a health plan 
        by a nonparticipating provider or nonparticipating facility--
                    ``(A) subject to subparagraphs (C) and (D), in the 
                case such State has in effect a law described in 
                paragraph (11)(A) with respect to such item or service, 
                provider or facility, and plan, the amount determined 
                in accordance with such law;
                    ``(B) subject to subparagraphs (C) and (D), in the 
                case such State does not have in effect such a law, an 
                amount that is the median contracted rate for such item 
                or service for such year;
                    ``(C) in the case such State is described in 
                paragraph (11)(C) with respect to such item or service 
                so furnished, the amount that the State approves under 
                such system for such item or service so furnished; or
                    ``(D) in the case such health plan is a self-
                insured group health plan and in the case of a State 
                with an agreement with such plan in effect as of the 
                date of the enactment of the Consumer Protections 
                Against Surprise Medical Bills Act of 2020, that 
                provides for a method for determining the total amount 
                payable under such health plan with respect to such 
                item or service furnished by such provider or facility, 
                such amount determined in accordance with such method.
            ``(13) Stabilize.--The term `to stabilize', with respect to 
        an emergency medical condition, has the meaning give in section 
        1867(e)(3)(A) of the Social Security Act.
            ``(14) Cost-sharing.--The term `cost-sharing' includes 
        copayments, coinsurance, and deductibles.
    ``(l) Payment to Provider or Facility.--In the case of any payment 
required to be made by a health plan pursuant to subsection (b)(1), 
(e)(1), or (i)(1) to a nonparticiapting provider or nonparticipating 
facility for an item or service, such payment shall be made to such 
provider or facility and not to the individual receiving such item or 
service.''.
            (2) Conforming amendments.--
                    (A) Application provisions.--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, with respect to a plan year beginning on 
                        or after January 1, 2022, the provisions of 
                        section 2719A of such Act)''; and
                            (ii) in paragraph (2), by inserting 
                        ``(other than, with respect to a plan year 
                        beginning on or after January 1, 2022, the 
                        provisions of section 2719A of such Act)'' 
                        after the first occurrence of ``such part A''.
                    (B) Application to retiree-only plans.--Section 
                9831(a) of the Internal Revenue Code of 1986 is amended 
                by inserting ``(other than, with respect to a group 
                health plan described in paragraph (2), the 
                requirements of section 9816)'' before ``shall not 
                apply''.
            (3) Clerical amendment.--The table of sections for such 
        subchapter is amended by adding at the end the following new 
        items:

``Sec. 9815. Additional market reforms.
``Sec. 9816. Patient protections.''.
            (4) Effective date.--The amendments made by this subsection 
        shall apply with respect to plan years beginning on or after 
        January 1, 2022.
    (c) Employee Retirement Income Security Act of 1974 Amendments.--
            (1) In general.--Subpart B of part 7 of subtitle B of title 
        I of the Employee Retirement Income Security Act of 1974 (29 
        U.S.C. 1185 et seq.) is amended by adding at the end the 
        following new section:

``SEC. 716. PATIENT PROTECTIONS.

    ``(a) Choice of Health Care Professional.--If a health plan 
requires or provides for designation by a participant or beneficiary of 
a participating primary care provider, then the plan shall permit each 
participant or beneficiary to designate any participating primary care 
provider who is available to accept such individual.
    ``(b) Cost-Sharing and Payment of Emergency Services.--
            ``(1) In general.--If a health plan provides or covers any 
        benefits with respect to services in an emergency department of 
        a hospital and, for plan year 2022 or a subsequent plan year, 
        with respect to emergency services in an independent 
        freestanding emergency department, the plan shall cover 
        emergency services--
                    ``(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 facility that is an emergency department 
                of a hospital or an independent freestanding emergency 
                department (in this subsection referred to as a 
                `participating emergency facility') 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 
                facility that is an emergency department of a hospital 
                or an independent freestanding emergency department--
                            ``(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 furnished by a 
                        participating provider or a participating 
                        emergency facility, as applicable;
                            ``(iii) such cost-sharing requirement is 
                        calculated as if the contracted rate for such 
                        services if furnished by a participating 
                        provider or a participating emergency facility 
                        were equal to the recognized amount for such 
                        services;
                            ``(iv) the health plan pays to such 
                        provider or facility, respectively, the amount 
                        by which the out-of-network rate for such 
                        services exceeds the cost-sharing amount for 
                        such services (as determined in accordance with 
                        clauses (ii) and (iii)); and
                            ``(v) any deductible or out-of-pocket 
                        maximum that would apply if such services were 
                        furnished by a participating provider or a 
                        participating emergency facility shall be the 
                        deductible or out-of-pocket maximum that 
                        applies; 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 and section 9815 of the Internal Revenue 
                Code of 1986, and other than applicable cost-sharing).
            ``(2) Audit process and rulemaking process for median 
        contracted rates.--
                    ``(A) Audit process.--
                            ``(i) In general.--Not later than July 1, 
                        2021, the Secretary, in coordination with the 
                        Secretary of Health and Human Services and the 
                        Secretary of the Treasury and in consultation 
                        with the National Association of Insurance 
                        Commissioners, shall establish through 
                        rulemaking a process, in accordance with clause 
                        (ii), under which health plans are audited by 
                        the Secretary to ensure that--
                                    ``(I) such plans are in compliance 
                                with the requirement of applying a 
                                median contracted rate under this 
                                section; and
                                    ``(II) that such median contracted 
                                rate so applied satisfies the 
                                definition under subsection (k)(8) with 
                                respect to the year involved.
                            ``(ii) Audit samples.--Under the process 
                        established pursuant to clause (i), the 
                        Secretary--
                                    ``(I) shall conduct audits 
                                described in such clause of a sample of 
                                health plans; and
                                    ``(II) may audit any health plan if 
                                the Secretary has received any 
                                complaint about such plan that involves 
                                the compliance of the plan with the 
                                requirement described in such clause.
                    ``(B) Rulemaking.--Not later than July 1, 2021, the 
                Secretary, in coordination with the Secretary of the 
                Treasury and the Secretary of Health and Human 
                Services, shall establish through rulemaking--
                            ``(i) the methodology the sponsor or issuer 
                        of a health plan shall use to determine the 
                        median contracted rate, which shall account for 
                        relevant payment adjustments that take into 
                        account facility type that are otherwise taken 
                        into account for purposes of determining 
                        payment amounts with respect to participating 
                        facilities; and
                            ``(ii) the information such sponsor or 
                        issuer shall share with the nonparticipating 
                        provider involved when making such a 
                        determination.
    ``(c) Access to Pediatric Care.--
            ``(1) Pediatric care.--In the case of a person who has a 
        child who is a participant or beneficiary under a 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.
    ``(d) Patient Access to Obstetrical and Gynecological Care.--
            ``(1) General rights.--
                    ``(A) Direct access.--A health plan described in 
                paragraph (2) may not require authorization or referral 
                by the plan or any person (including a primary care 
                provider described in paragraph (2)(B)) in the case of 
                a female participant or beneficiary who seeks coverage 
                for obstetrical or gynecological care provided by a 
                participating health care professional who specializes 
                in obstetrics or gynecology. Such professional shall 
                agree to otherwise adhere to such plan's policies and 
                procedures, including procedures regarding referrals 
                and obtaining prior authorization and providing 
                services pursuant to a treatment plan (if any) approved 
                by the plan.
                    ``(B) Obstetrical and gynecological care.--A health 
                plan described in paragraph (2) shall treat the 
                provision of obstetrical and gynecological care, and 
                the ordering of related obstetrical and gynecological 
                items and services, pursuant to the direct access 
                described under subparagraph (A), by a participating 
                health care professional who specializes in obstetrics 
                or gynecology as the authorization of the primary care 
                provider.
            ``(2) Application of paragraph.--A health plan described in 
        this paragraph is a 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 health plan involved from 
                requiring that the obstetrical or gynecological 
                provider notify the primary care health care 
                professional or the plan of treatment decisions.
    ``(k) Definitions.--For purposes of this section:
            ``(1) Contracted rate.--The term `contracted rate' means, 
        with respect to a health plan and a health care provider or 
        health care facility furnishing an item or service to a 
        beneficiary or participant of such plan, the agreed upon total 
        payment amount (inclusive of any cost-sharing) to such provider 
        or facility for such item or service.
            ``(2) During a visit.--The term `during a visit' shall, 
        with respect to an individual who is furnished items and 
        services at a participating 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 furnished 
        to such individual, regardless of whether or not the provider 
        furnishing such items or services is at the facility.
            ``(3) Emergency department of a hospital.--The term 
        `emergency department of a hospital' includes a hospital 
        outpatient department that provides emergency services.
            ``(4) 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.
            ``(5) Emergency services.--
                    ``(A) 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).
                    ``(B) Inclusion of additional services.--In the 
                case of an individual enrolled in a health plan who is 
                furnished services described in subparagraph (A) by a 
                provider or hospital or independent freestanding 
                emergency department to stabilize such individual with 
                respect to an emergency medical condition, the term 
                `emergency services' shall include, in addition to 
                those described in subparagraph (A), items and services 
                furnished as part of outpatient observation or an 
                inpatient or outpatient stay during a visit in which 
                such individual is so stabilized with respect to such 
                emergency condition if--
                            ``(i) such items and services would 
                        otherwise be covered under such plan if 
                        furnished by a participating provider or 
                        participating facility; and
                            ``(ii) such items and services are 
                        furnished--
                                    ``(I) to maintain, improve, or 
                                resolve the individual's stabilization 
                                with respect to such condition, unless 
                                any circumstance described in 
                                subparagraph (C) has occurred with 
                                respect to such individual before such 
                                items and services are furnished; or
                                    ``(II) for any purpose not 
                                described in subclause (I), unless each 
                                of the criteria described in 
                                subparagraph (D) have been met with 
                                respect to such individual and such 
                                item or service.
                    ``(C) Circumstances.--For purposes of subparagraph 
                (B)(ii)(I), a circumstance described in this 
                subparagraph is any of the following, with respect to 
                an individual who is a beneficiary, participant, or 
                enrollee of a health plan who is furnished services 
                described in subparagraph (A) by a hospital or 
                independent freestanding emergency department with 
                respect to an emergency medical condition:
                            ``(i) A participating provider, with 
                        respect to such plan, with privileges at the 
                        hospital or independent freestanding emergency 
                        department assumes responsibility for the care 
                        of the individual.
                            ``(ii) A participating provider, with 
                        respect to such plan, assumes responsibility 
                        for the care of the individual through transfer 
                        of the individual.
                            ``(iii) The health plan and the provider 
                        treating such individual at the hospital or 
                        independent freestanding emergency department 
                        for such condition reach an agreement 
                        concerning the care for the individual.
                            ``(iv) The individual is discharged.
                    ``(D) Signed notice criteria.--For purposes of 
                subparagraph (B)(ii)(II), the criteria described in 
                this subparagraph, with respect to an individual and an 
                item or service furnished by a nonparticipating 
                provider or nonparticipating facility that is a 
                hospital or an independent freestanding emergency 
                department, are the following:
                            ``(i) A written notice (as specified by the 
                        Secretary and in a clear and understandable 
                        manner) is provided by such provider or 
                        facility to such individual, before such item 
                        or service is furnished, that includes the 
                        following information:
                                    ``(I) That such provider or 
                                facility is a nonparticipating provider 
                                or nonparticipating facility (as 
                                applicable).
                                    ``(II) To the extent practicable, 
                                the estimated amount that such 
                                nonparticipating facility or 
                                nonparticipating provider may charge 
                                the individual for such item or 
                                service.
                                    ``(III) A statement that the 
                                individual may seek such item or 
                                service from a provider that is a 
                                participating provider or a hospital or 
                                independent freestanding emergency 
                                department that is a participating 
                                facility and a list, if feasible, of 
                                participating facilities or 
                                participating providers, as applicable, 
                                who are able to furnish such item or 
                                service.
                            ``(ii) Such individual is in a condition to 
                        receive (as determined in accordance with 
                        guidance issued by the Secretary) the 
                        information described in clause (i) and to 
                        confirm notice of receipt of such notice, in 
                        accordance with applicable State law.
                            ``(iii) The individual signs and dates such 
                        notice confirming receipt of the notice before 
                        such item or service is furnished.
            ``(6) Health plan.--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.
            ``(7) Independent freestanding emergency department.--The 
        term `independent freestanding emergency department' means a 
        health care facility that--
                    ``(A) is geographically separate and distinct and 
                licensed separately from a hospital under applicable 
                State law; and
                    ``(B) provides emergency services.
            ``(8) Median contracted rate.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                term `median contracted rate' means, with respect to a 
                health plan--
                            ``(i) for an item or service furnished 
                        during 2022, the median of the contracted rates 
                        recognized by the sponsor or issuer of such 
                        plan (determined with respect to all such plans 
                        of such sponsor or such issuer that are within 
                        the same line of business (as specified in 
                        subparagraph (C)) as the plan involved) as the 
                        total maximum payment under such plans in 2019 
                        for the same or a similar item or service that 
                        is provided by a provider or facility in the 
                        same or similar specialty and provided in the 
                        geographic region (established (and updated, as 
                        appropriate) by the Secretary, in consultation 
                        with the National Association of Insurance 
                        Commissioners) in which the item or service is 
                        furnished, consistent with the methodology 
                        established by the Secretary under subsection 
                        (b)(2)(B), increased by the percentage increase 
                        in the consumer price index for all urban 
                        consumers (United States city average) over 
                        2019, 2020, and 2021;
                            ``(ii) for an item or service furnished 
                        during 2023 or a subsequent year through 2026, 
                        the median contracted rate for the previous 
                        year, increased by the percentage increase in 
                        the consumer price index for all urban 
                        consumers (United States city average) over 
                        such previous year;
                            ``(iii) for an item or service furnished 
                        during a rebasing year (as defined in 
                        subparagraph (D)), the median of the contracted 
                        rates recognized by the sponsor or issuer of 
                        such plan (determined with respect to all such 
                        plans of such sponsor or issuer that are within 
                        the same line of business (as specified in 
                        subparagraph (C)) as the plan involved) as the 
                        total maximum payment under such plans in such 
                        year for the same or a similar item or service 
                        that is provided by a provider or facility in 
                        the same or similar specialty and provided in 
                        the geographic region (as established pursuant 
                        to clause (i)) in which the item or service is 
                        furnished, consistent with the methodology 
                        established by the Secretary under subsection 
                        (b)(2)(B); and
                            ``(iv) for an item or service furnished 
                        during any of the 4 years following a rebasing 
                        year, the median contracted rate for the 
                        previous year, increased by the percentage 
                        increase in the consumer price index for all 
                        urban consumers (United States city average) 
                        over such previous year.
                    ``(B) Use of substitute rate in case of 
                insufficient data.--
                            ``(i) In general.--In the case the sponsor 
                        or issuer of a health plan has insufficient 
                        information (as specified by the Secretary) to 
                        calculate the median of the contracted rates in 
                        accordance with subparagraph (A) for a year for 
                        an item or service furnished in a particular 
                        geographic region (as established pursuant to 
                        subparagraph (A)(i)) by a type of provider or 
                        facility, the substitute rate (as defined in 
                        clause (ii)) for such item or service shall be 
                        deemed to be the median contracted rate for 
                        such item or service furnished in such region 
                        during such year by such a provider or facility 
                        for such year under such subparagraph (A) for 
                        such plan.
                            ``(ii) Substitute rate.--For purposes of 
                        clause (i), the term `substitute rate' means, 
                        with respect to an item or service furnished by 
                        a provider or facility in a geographic region 
                        (established pursuant to subparagraph (A)(i)) 
                        during a year for which a health plan is 
                        required to make payment pursuant to subsection 
                        (b)(1), (e)(1), or (i)(1)--
                                    ``(I) if sufficient information (as 
                                specified by the Secretary) exists to 
                                determine the median of the contracted 
                                rates recognized by all health plans 
                                offered in the same line of business 
                                (as specified in subparagraph (C)) by 
                                any group health plan for such an item 
                                or service furnished in such region by 
                                such a provider or facility during such 
                                year using a database or other source 
                                of information determined appropriate 
                                by the Secretary, such median; and
                                    ``(II) if such sufficient 
                                information does not exist, the median 
                                of the contracted rates recognized by 
                                all health plans offered in the same 
                                line of business (as specified in 
                                subparagraph (C)) by any group health 
                                plan for such an item or service 
                                furnished in a similarly situated 
                                geographic region (as determined by the 
                                Secretary) with such sufficient 
                                information by such a provider or 
                                facility during such year using such a 
                                database or such other source of 
                                information.
                        The Secretary shall develop a methodology for 
                        determining a substitute rate based on a 
                        similarly situated health plan that is not a 
                        Federal health care program (as defined in 
                        section 1128B(f) of the Social Security Act) in 
                        the case a substitute rate is not calculable 
                        under the previous sentence with respect to an 
                        item or service.
                    ``(C) Line of business.--A line of business 
                specified in this subparagraph is one of the following:
                            ``(i) The small group market.
                            ``(ii) The large group market.
                            ``(iii) In the case of a self-insured group 
                        health plan, other self-insured group health 
                        plans.
                    ``(D) Rebasing year defined.--For purposes of 
                subparagraph (A), the term `rebasing year' means 2027 
                and every 5 years thereafter.
            ``(9) Nonparticipating facility; participating facility.--
                    ``(A) Nonparticipating facility.--The term 
                `nonparticipating facility' means, with respect to an 
                item or service and a health plan, a health care 
                facility described in subparagraph (B)(ii) that does 
                not have a contractual relationship with the plan for 
                furnishing such item or service.
                    ``(B) Participating facility.--
                            ``(i) In general.--The term `participating 
                        facility' means, with respect to an item or 
                        service and a health plan, a health care 
                        facility described in clause (ii) that has a 
                        contractual relationship with the plan for 
                        furnishing such item or service.
                            ``(ii) Health care facility described.--A 
                        health care facility described in this clause 
                        is each of the following:
                                    ``(I) A hospital (as defined in 
                                1861(e) of the Social Security Act), 
                                including an emergency department of a 
                                hospital.
                                    ``(II) A critical access hospital 
                                (as defined in section 1861(mm)(1) of 
                                such Act).
                                    ``(III) An ambulatory surgical 
                                center (as described in section 
                                1833(i)(1)(A) of such Act).
                                    ``(IV) A laboratory.
                                    ``(V) A radiology facility or 
                                imaging center.
                                    ``(VI) An independent freestanding 
                                emergency department.
                                    ``(VII) Any other facility 
                                specified by the Secretary.
            ``(10) Nonparticipating providers; participating 
        providers.--
                    ``(A) Nonparticipating provider.--The term 
                `nonparticipating provider' means, with respect to an 
                item or service and a health plan, a physician or other 
                health care provider who does not have a contractual 
                relationship with the plan for furnishing such item or 
                service under the plan.
                    ``(B) Participating provider.--The term 
                `participating provider' means, with respect to an item 
                or service and a health plan, a physician or other 
                health care provider who has a contractual relationship 
                with the plan for furnishing such item or service under 
                the plan.
            ``(11) 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 health plan 
        receiving such item or service from a nonparticipating provider 
        or facility--
                    ``(A) subject to subparagraphs (C) and (D), in the 
                case such State has in effect a State law that provides 
                for a method for determining the total amount payable 
                under such health plan regulated by such State with 
                respect to such item or service furnished by such 
                provider or facility, such amount determined in 
                accordance with such law;
                    ``(B) subject to subparagraphs (C) and (D), 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 clause (ii), if the 
                        provider or facility (as applicable) and such 
                        plan agree on an amount of payment (including 
                        if agreed on through open negotiations under 
                        subsection (j)(1)) with respect to such item or 
                        service, such agreed on amount; or
                            ``(ii) if such provider or facility (as 
                        applicable) and such plan enter the mediated 
                        dispute process under subsection (j) and do not 
                        so agree before the date on which a selected 
                        independent entity (as defined in paragraph (3) 
                        of such subsection) makes a determination with 
                        respect to such item or service under such 
                        subsection, the amount of such determination;
                    ``(C) 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; or
                    ``(D) in the case such health plan is a self-
                insured group health plan and in the case of a State 
                with an agreement with such plan in effect as of the 
                date of the enactment of the Consumer Protections 
                Against Surprise Medical Bills Act of 2020, that 
                provides for a method for determining the total amount 
                payable under such health plan with respect to such 
                item or service furnished by such provider or facility, 
                such amount determined in accordance with such method.
            ``(12) Recognized amount.--The term `recognized amount' 
        means, with respect to an item or service furnished in a State 
        during a year to a participant or beneficiary of a health plan 
        by a nonparticipating provider or nonparticipating facility--
                    ``(A) subject to subparagraphs (C) and (D), in the 
                case such State has in effect a law described in 
                paragraph (11)(A) with respect to such item or service, 
                provider or facility, and plan, the amount determined 
                in accordance with such law;
                    ``(B) subject to subparagraphs (C) and (D), in the 
                case such State does not have in effect such a law, an 
                amount that is the median contracted rate for such item 
                or service for such year;
                    ``(C) in the case such State is described in 
                paragraph (11)(C) with respect to such item or service 
                so furnished, the amount that the State approves under 
                such system for such item or service so furnished; or
                    ``(D) in the case such health plan is a self-
                insured group health plan and in the case of a State 
                with an agreement with such plan in effect as of the 
                date of the enactment of the Consumer Protections 
                Against Surprise Medical Bills Act of 2020, that 
                provides for a method for determining the total amount 
                payable under such health plan with respect to such 
                item or service furnished by such provider or facility, 
                such amount determined in accordance with such method.
            ``(13) Stabilize.--The term `to stabilize', with respect to 
        an emergency medical condition, has the meaning give in section 
        1867(e)(3)(A) of the Social Security Act).
            ``(14) Cost-sharing.--The term `cost-sharing' includes 
        copayments, coinsurance, and deductibles.
    ``(l) Payment to Provider or Facility.--In the case of any payment 
required to be made by a health plan pursuant to subsection (b)(1), 
(e)(1), or (i)(1) to a nonparticiapting provider or nonparticipating 
facility for an item or service, such payment shall be made to such 
provider or facility and not to the individual receiving such item or 
service.''.
            (2) Conforming amendment.--
                    (A) Application provisions.--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, with respect to a plan year beginning on 
                        or after January 1, 2022, the provisions of 
                        section 2719A of such Act)''; and
                            (ii) in paragraph (2), by inserting 
                        ``(other than, with respect to a plan year 
                        beginning on or after January 1, 2022, the 
                        provisions of section 2719A of such Act)'' 
                        after the first occurrence of ``such part A''.
                    (B) Application to retiree-only plans.--Section 
                732(a) of the Employee Retirement Income Security Act 
                of 1974 (29 U.S.C. 1191a(a)) is amended by striking 
                ``section 711'' and inserting ``sections 711 and 716''.
            (3) 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. Patient protections.''.
            (4) Effective date.--The amendments made by this subsection 
        shall apply with respect to plan years beginning on or after 
        January 1, 2022.

SEC. 3. CONSUMER PROTECTIONS THROUGH REQUIREMENTS ON HEALTH PLANS TO 
              PREVENT SURPRISE MEDICAL BILLS FOR NON-EMERGENCY SERVICES 
              PERFORMED BY NONPARTICIPATING PROVIDERS AT CERTAIN 
              PARTICIPATING FACILITIES.

    (a) PHSA Amendments.--
            (1) In general.--Section 2719A of the Public Health Service 
        Act (42 U.S.C. 300gg-19a), as amended by section 2(a), is 
        further amended by inserting before subsection (k) the 
        following new subsection:
    ``(e) Cost-Sharing and Payment of Non-Emergency Services Performed 
by Nonparticipating Providers at Certain Participating Facilities.--
            ``(1) In general.--Subject to paragraph (2), in the case of 
        items or services (other than emergency services to which 
        subsection (b) applies or items and services to which 
        subsection (i) applies) furnished to a participant, 
        beneficiary, or enrollee of a health plan by a nonparticipating 
        provider during a visit (as defined by the Secretary in 
        accordance with subsection (k)(2)) at a participating facility, 
        if such items and services would otherwise be covered under 
        such plan if furnished by a participating provider, the plan--
                    ``(A) shall not impose on such participant, 
                beneficiary, or enrollee a cost-sharing amount for such 
                items and services so furnished that is greater than 
                the cost-sharing amount that would apply under such 
                plan had such items or services been furnished by a 
                participating provider;
                    ``(B) shall calculate such cost-sharing amount as 
                if the contracted rate for such services if furnished 
                by a participating provider were equal to the 
                recognized amount for such items and services;
                    ``(C) shall pay to such provider furnishing such 
                items and services to such participant, beneficiary, or 
                enrollee the amount by which the out-of-network rate 
                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
                    ``(D) shall apply the deductible or out-of-pocket 
                maximum, if any, that would apply if such services were 
                furnished by a participating provider.
            ``(2) Exception.--Paragraph (1) shall not apply to a health 
        plan in the case of items or services furnished to a 
        participant, beneficiary, or enrollee of a health plan by a 
        nonparticipating provider during a visit (as so defined by the 
        Secretary in accordance with subsection (k)(2)) at a 
        participating facility if the requirement described in 
        paragraph (1) of section 1150C(b) of the Social Security Act 
        does not apply with respect to such provider and such items and 
        services due to the application of paragraph (2) of such 
        section.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply with respect to plan years beginning on or after 
        January 1, 2022.
    (b) IRC Amendments.--
            (1) In general.--Section 9816 of the Internal Revenue Code 
        of 1986, as added by section 2(b), is amended by inserting 
        before subsection (k) the following new subsection:
    ``(e) Cost-Sharing and Payment of Non-Emergency Services Performed 
by Nonparticipating Providers at Certain Participating Facilities.--
            ``(1) In general.--Subject to paragraph (2), in the case of 
        items or services (other than emergency services to which 
        subsection (b) applies or items and services to which 
        subsection (i) applies) furnished to a participant or 
        beneficiary of a health plan by a nonparticipating provider 
        during a visit (as defined by the Secretary in accordance with 
        subsection (k)(2)) at a participating facility, if such items 
        and services would otherwise be covered under such plan if 
        furnished by a participating provider, the plan--
                    ``(A) shall not impose on such participant or 
                beneficiary a cost-sharing amount for such items and 
                services so furnished that is greater than the cost-
                sharing amount that would apply under such plan had 
                such items or services been furnished by a 
                participating provider;
                    ``(B) shall calculate such cost-sharing amount as 
                if the contracted rate for such services if furnished 
                by a participating provider were equal to the 
                recognized amount for such items and services;
                    ``(C) shall pay to such provider furnishing such 
                items and services to such participant or beneficiary 
                the amount by which the out-of-network rate 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
                    ``(D) shall apply the deductible or out-of-pocket 
                maximum, if any, that would apply if such services were 
                furnished by a participating provider.
            ``(2) Exception.--Paragraph (1) shall not apply to a health 
        plan in the case of items or services furnished to a 
        participant or beneficiary of a health plan by a 
        nonparticipating provider during a visit (as so defined by the 
        Secretary in accordance with subsection (k)(2)) at a 
        participating facility if the requirement described in 
        paragraph (1) of section 1150C(b) of the Social Security Act 
        does not apply with respect to such provider and such items and 
        services due to the application of paragraph (2) of such 
        section.''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply with respect to plan years beginning on or after 
        January 1, 2022.
    (c) ERISA Amendments.--
            (1) In general.--Section 716 of the Employee Retirement 
        Income Security Act of 1974, as added by section 2(c), is 
        amended by inserting before subsection (k) the following new 
        subsection:
    ``(e) Cost-Sharing and Payment of Non-Emergency Services Performed 
by Nonparticipating Providers at Certain Participating Facilities.--
            ``(1) In general.--Subject to paragraph (2), in the case of 
        items or services (other than emergency services to which 
        subsection (b) applies or items and services to which 
        subsection (i) applies) furnished to a participant or 
        beneficiary of a health plan by a nonparticipating provider 
        during a visit (as defined by the Secretary in accordance with 
        subsection (k)(2)) at a participating facility, if such items 
        and services would otherwise be covered under such plan if 
        furnished by a participating provider, the plan--
                    ``(A) shall not impose on such participant or 
                beneficiary a cost-sharing amount for such items and 
                services so furnished that is greater than the cost-
                sharing amount that would apply under such plan had 
                such items or services been furnished by a 
                participating provider;
                    ``(B) shall calculate such cost-sharing amount as 
                if the contracted rate for such services if furnished 
                by a participating provider were equal to the 
                recognized amount for such items and services;
                    ``(C) shall pay to such provider furnishing such 
                items and services to such participant or beneficiary 
                the amount by which the out-of-network rate 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
                    ``(D) shall apply the deductible or out-of-pocket 
                maximum, if any, that would apply if such services were 
                furnished by a participating provider.
            ``(2) Exception.--Paragraph (1) shall not apply to a health 
        plan in the case of items or services furnished to a 
        participant or beneficiary of a health plan by a 
        nonparticipating provider during a visit (as so defined by the 
        Secretary in accordance with subsection (k)(2)) at a 
        participating facility if the requirement described in 
        paragraph (1) of section 1150C(b) of the Social Security Act 
        does not apply with respect to such provider and such items and 
        services due to the application of paragraph (2) of such 
        section.''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply with respect to plan years beginning on or after 
        January 1, 2022.

SEC. 4. CONSUMER PROTECTIONS THROUGH APPLICATION OF HEALTH PLAN 
              EXTERNAL REVIEW IN CASES OF CERTAIN SURPRISE MEDICAL 
              BILLS.

    Section 2719(b)(1) of the Public Health Service Act (42 U.S.C. 
300gg-19(b)(1)) is amended--
            (1) by striking ``at a minimum, includes'' and inserting 
        ``at a minimum--
                    ``(A) includes'';
            (2) by striking at the end ``or'' and inserting ``and''; 
        and
            (3) by adding at the end the following new subparagraph:
                    ``(B) beginning not later than January 1, 2022, 
                applies such external review process with respect to 
                any adverse determination by such plan or issuer under 
                subsection (b) of section 2719A, subsection (e) of such 
                section, or subsection (i) of such section, 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 subsection (b), (e), or (i) applies; 
                or''.

SEC. 5. CONSUMER PROTECTIONS THROUGH HEALTH PLAN TRANSPARENCY 
              REQUIREMENTS.

    (a) PHSA Amendments.--Section 2719A of the Public Health Service 
Act (42 U.S.C. 300gg-19a), as amended by sections 2(a) and 3(a), is 
further amended by inserting before subsection (k) the following new 
subsections:
    ``(f) Provider Directory Requirements.--
            ``(1) In general.--Beginning not later than January 1, 
        2022, each 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 health plan, 
        a process--
                    ``(A) under which such plan verifies and updates 
                the provider directory information included on the 
                database described in paragraph (4) of such plan of--
                            ``(i) not less frequently than once every 
                        90 days, a random sample of at least 10 percent 
                        of health care providers and health care 
                        facilities included in such database; and
                            ``(ii) any such provider or such facility 
                        included in such database that has not 
                        submitted any claim to such plan during a 12-
                        month period;
                    ``(B) that establishes a procedure for the removal 
                from such database of such a provider or facility with 
                respect to which such plan has been unable to verify 
                such information during a period specified by the plan; 
                and
                    ``(C) that provides for the update of such database 
                within 2 business days of such plan receiving from such 
                a provider or facility information pursuant to section 
                1150D of the Social Security Act.
            ``(3) Response protocol.--The response protocol described 
        in this paragraph is, in the case of an individual enrolled in 
        a health plan who requests information through a telephone call 
        or email 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--
                    ``(A) responds to such individual as soon as 
                practicable, and in no case later than 1 business day 
                after such call or email is received, through a written 
                electronic or paper (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 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 has a 
                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 directory containing provider 
        directory information with respect to a 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 section, the term 
        `provider directory information' includes, with respect to a 
        health plan, the name, address, specialty, and telephone number 
        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.
    ``(g) Disclosure on Patient Protections Against Balance Billing.--
Beginning not later than January 1, 2022, each health plan shall make 
publicly available, post on a website of such plan available to 
individuals enrolled under such plan, and include on each explanation 
of benefits for an item or service with respect to which the 
requirements under subsection (b), (e), or (i) applies--
            ``(1) information in plain language on--
                    ``(A) the requirements and prohibitions applied 
                under section 1150C of the Social Security Act 
                (relating to prohibitions on balance billing in certain 
                circumstances);
                    ``(B) if provided for under applicable State law, 
                any other requirements on providers and facilities 
                regarding the amounts such providers and facilities 
                may, with respect to an item or service, charge a 
                participant, beneficiary, or enrollee of such plan with 
                respect to which such a provider is a nonparticipating 
                provider or facility is a nonparticipating facility, 
                with respect to such plan, for furnishing such item or 
                service after receiving payment from the plan for such 
                item or service and any applicable cost-sharing payment 
                from such participant, beneficiary, or enrollee; and
                    ``(C) the requirements applied under subsections 
                (b), (e), and (i); and
            ``(2) information in plain language on contacting 
        appropriate State and Federal agencies in the case that an 
        individual believes that such a health plan, provider, or 
        facility has violated any requirement described in paragraph 
        (1) with respect to such individual.''.
    (b) IRC Amendments.--Section 9816 of the Internal Revenue Code of 
1986, as added by section 2(b) and amended by section 3(b), is further 
amended by inserting before subsection (k) the following new 
subsections:
    ``(f) Provider Directory Requirements.--
            ``(1) In general.--Beginning not later than January 1, 
        2022, each 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 health plan, 
        a process--
                    ``(A) under which such plan verifies and updates 
                the provider directory information included on the 
                database described in paragraph (4) of such plan of--
                            ``(i) not less frequently than once every 
                        90 days, a random sample of at least 10 percent 
                        of health care providers and health care 
                        facilities included in such database; and
                            ``(ii) any such provider or such facility 
                        included in such database that has not 
                        submitted any claim to such plan during a 12-
                        month period;
                    ``(B) that establishes a procedure for the removal 
                from such database of such a provider or facility with 
                respect to which such plan has been unable to verify 
                such information during a period specified by the plan; 
                and
                    ``(C) that provides for the update of such database 
                within 2 business days of such plan receiving from such 
                a provider or facility information pursuant to section 
                1150D of the Social Security Act.
            ``(3) Response protocol.--The response protocol described 
        in this paragraph is, in the case of an individual enrolled in 
        a health plan who requests information through a telephone call 
        or email 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--
                    ``(A) responds to such individual as soon as 
                practicable, and in no case later than 1 business day 
                after such call or email is received, through a written 
                electronic or paper (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 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 has a 
                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 directory containing provider 
        directory information with respect to a 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 section, the term 
        `provider directory information' includes, with respect to a 
        health plan, the name, address, specialty, and telephone number 
        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.
    ``(g) Disclosure on Patient Protections Against Balance Billing.--
Beginning not later than January 1, 2022, each health plan shall make 
publicly available, post on a website of such plan available to 
individuals enrolled under such plan, and include on each explanation 
of benefits for an item or service with respect to which the 
requirements under subsection (b), (e), or (i) applies--
            ``(1) information in plain language on--
                    ``(A) the requirements and prohibitions applied 
                under section 1150C of the Social Security 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 is a nonparticipating provider or 
                facility is a nonparticipating facility, with respect 
                to such plan, for furnishing such item or service after 
                receiving payment from the plan for such item or 
                service and any applicable cost-sharing payment from 
                such participant or beneficiary; and
                    ``(C) the requirements applied under subsections 
                (b), (e), and (i); and
            ``(2) information in plain language on contacting 
        appropriate State and Federal agencies in the case that an 
        individual believes that such a health plan, provider, or 
        facility has violated any requirement described in paragraph 
        (1) with respect to such individual.''.
    (c) ERISA Amendments.--Section 716 of the Employee Retirement 
Income Security Act of 1974, as added by section 2(c) and amended by 
section 3(c), is further amended by inserting before subsection (k) the 
following new subsections:
    ``(f) Provider Directory Requirements.--
            ``(1) In general.--Beginning not later than January 1, 
        2022, each 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 health plan, 
        a process--
                    ``(A) under which such plan verifies and updates 
                the provider directory information included on the 
                database described in paragraph (4) of such plan of--
                            ``(i) not less frequently than once every 
                        90 days, a random sample of at least 10 percent 
                        of health care providers and health care 
                        facilities included in such database; and
                            ``(ii) any such provider or such facility 
                        included in such database that has not 
                        submitted any claim to such plan during a 12-
                        month period;
                    ``(B) that establishes a procedure for the removal 
                from such database of such a provider or facility with 
                respect to which such plan has been unable to verify 
                such information during a period specified by the plan; 
                and
                    ``(C) that provides for the update of such database 
                within 2 business days of such plan receiving from such 
                a provider or facility information pursuant to section 
                1150D of the Social Security Act.
            ``(3) Response protocol.--The response protocol described 
        in this paragraph is, in the case of an individual enrolled in 
        a health plan who requests information through a telephone call 
        or email 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--
                    ``(A) responds to such individual as soon as 
                practicable, and in no case later than 1 business day 
                after such call or email is received, through a written 
                electronic or paper (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 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 has a 
                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 directory containing provider 
        directory information with respect to a 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 section, the term 
        `provider directory information' includes, with respect to a 
        health plan, the name, address, specialty, and telephone number 
        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.
    ``(g) Disclosure on Patient Protections Against Balance Billing.--
Beginning not later than January 1, 2022, each health plan shall make 
publicly available, post on a website of such plan available to 
individuals enrolled under such plan, and include on each explanation 
of benefits for an item or service with respect to which the 
requirements under subsection (b), (e), or (i) applies--
            ``(1) information in plain language on--
                    ``(A) the requirements and prohibitions applied 
                under section 1150C of the Social Security 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 is a nonparticipating provider or 
                facility is a nonparticipating facility, with respect 
                to such plan, for furnishing such item or service after 
                receiving payment from the plan for such item or 
                service and any applicable cost-sharing payment from 
                such participant or beneficiary; and
                    ``(C) the requirements applied under subsections 
                (b), (e), and (i); and
            ``(2) information in plain language on contacting 
        appropriate State and Federal agencies in the case that an 
        individual believes that such a health plan, provider, or 
        facility has violated any requirement described in paragraph 
        (1) with respect to such individual.''.

SEC. 6. CONSUMER PROTECTIONS THROUGH HEALTH PLAN REQUIREMENT FOR FAIR 
              AND HONEST ADVANCE COST ESTIMATE.

    (a) PHSA Amendment.--Section 2719A of the Public Health Service Act 
(42 U.S.C. 300gg-19a), as amended by sections 2(a), 3(a), and 5(a), is 
further amended by inserting before subsection (k) the following new 
subsections:
    ``(h) Advanced Explanation of Benefits.--Beginning on January 1, 
2022, each health plan shall, with respect to a notification submitted 
under section 1150D(b)(2)(A) 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 (in clear and understandable 
language) 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 individual 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) A statement that the individual may seek such an item 
        or service from a provider that is a participating provider or 
        a facility that is a participating facility and a list of 
        participating facilities, or of participating providers, as 
        applicable, who are able to furnish such items and services 
        involved.
            ``(9) Any other information or disclaimer the health plan 
        determines appropriate that is consistent with information and 
        disclaimers required under this section.
    ``(i) Cost-Sharing and Payment 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 health plan by a 
        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, beneficiary, or 
        enrollee and item or service, the plan--
                    ``(A) shall not impose on such 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 had such item or service been 
                furnished by a participating provider;
                    ``(B) shall calculate such cost-sharing amount as 
                if the contracted rate for such item or service 
                furnished by such a participating provider or facility 
                were equal to--
                            ``(i) the most recent (as of the date such 
                        item or service was furnished) contracted rate 
                        in effect between such provider or facility and 
                        such plan for such item or service furnished 
                        under such plan, if any; or
                            ``(ii) if no contracted rate described in 
                        clause (i) exists, the recognized amount for 
                        such item or service;
                    ``(C) shall pay to such nonparticipating provider 
                or facility furnishing such item or service to such 
                participant, beneficiary, or enrollee the amount by 
                which--
                            ``(i) if a contracted rate described in 
                        subparagraph (B)(i) exists, the most recent (as 
                        of the date such item or services was 
                        furnished) such rate; or
                            ``(ii) if no contracted rate described in 
                        such subparagraph exists, the out-of-network 
                        rate;
                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
                    ``(D) 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 health plan by a nonparticipating provider or a 
        nonparticipating facility, are the following:
                    ``(A) The participant, beneficiary, or enrollee 
                received a notification under subsection (h) with 
                respect to such item and service to be furnished and 
                such notification provided information 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) A notification was not provided, in 
                accordance with subsection (h), to the participant, 
                beneficiary, or enrollee, and the participant, 
                beneficiary, or enrollee requested through the response 
                protocol of the plan under subsection (f)(3) 
                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.''.
    (b) IRC Amendments.--Section 9816 of the Internal Revenue Code of 
1986, as added by section 2(b) and amended by sections 3(b) and 5(b), 
is further amended by inserting before subsection (k) the following new 
subsections:
    ``(h) Advanced Explanation of Benefits.--Beginning on January 1, 
2022, each health plan shall, with respect to a notification submitted 
under section 1150D(b)(2)(A) 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 (in clear 
and understable language) 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 individual 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) A statement that the individual may seek such an item 
        or service from a provider that is a participating provider or 
        a facility that is a participating facility and a list of 
        participating facilities, or of participating providers, as 
        applicable, who are able to furnish such items and services 
        involved.
            ``(9) Any other information or disclaimer the health plan 
        determines appropriate that is consistent with information and 
        disclaimers required under this section.
    ``(i) Cost-Sharing and Payment 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 health plan by a 
        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 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 had such item or service been 
                furnished by a participating provider;
                    ``(B) shall calculate such cost-sharing amount as 
                if the contracted rate for such item or service 
                furnished by such a participating provider or facility 
                were equal to--
                            ``(i) the most recent (as of the date such 
                        item or service was furnished) contracted rate 
                        in effect between such provider or facility and 
                        such plan for such item or service furnished 
                        under such plan, if any; or
                            ``(ii) if no contracted rate described in 
                        clause (i) exists, the recognized amount for 
                        such item or service;
                    ``(C) shall pay to such nonparticipating provider 
                or facility furnishing such item or service to such 
                participant or beneficiary the amount by which--
                            ``(i) if a contracted rate described in 
                        subparagraph (B)(i) exists, the most recent (as 
                        of the date such item or services was 
                        furnished) such rate; or
                            ``(ii) if no contracted rate described in 
                        such subparagraph exists, the out-of-network 
                        rate;
                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
                    ``(D) 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 
        health plan by a nonparticipating provider or a 
        nonparticipating facility, are the following:
                    ``(A) The participant or beneficiary received a 
                notification under subsection (h) with respect to such 
                item and service to be furnished and such notification 
                provided information 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) A notification was not provided, in 
                accordance with subsection (h), to the participant or 
                beneficiary and the participant or beneficiary 
                requested through the response protocol of the plan 
                under subsection (f)(3) 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) ERISA Amendments.--Section 716 of the Employee Retirement 
Income Security Act of 1974, as added by section 2(c) and amended by 
sections 3(c) and 5(c), is further amended by inserting before 
subsection (k) the following new subsections:
    ``(h) Advanced Explanation of Benefits.--Beginning on January 1, 
2022, each health plan shall, with respect to a notification submitted 
under section 1150D(b)(2)(A) 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 (in clear 
and understandable language) 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 individual 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) A statement that the individual may seek such an item 
        or service from a provider that is a participating provider or 
        a facility that is a participating facility and a list of 
        participating facilities, or of participating providers, as 
        applicable, who are able to furnish such items and services 
        involved.
            ``(9) Any other information or disclaimer the health plan 
        determines appropriate that is consistent with information and 
        disclaimers required under this section.
    ``(i) Cost-Sharing and Payment 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 health plan by a 
        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 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 had such item or service been 
                furnished by a participating provider;
                    ``(B) shall calculate such cost-sharing amount as 
                if the contracted rate for such item or service 
                furnished by such a participating provider or facility 
                were equal to--
                            ``(i) the most recent (as of the date such 
                        item or service was furnished) contracted rate 
                        in effect between such provider or facility and 
                        such plan for such item or service furnished 
                        under such plan, if any; or
                            ``(ii) if no contracted rate described in 
                        clause (i) exists, the recognized amount for 
                        such item or service;
                    ``(C) shall pay to such nonparticipating provider 
                or facility furnishing such item or service to such 
                participant or beneficiary the amount by which--
                            ``(i) if a contracted rate described in 
                        subparagraph (B)(i) exists, the most recent (as 
                        of the date such item or services was 
                        furnished) such rate; or
                            ``(ii) if no contracted rate described in 
                        such subparagraph exists, the out-of-network 
                        rate;
                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
                    ``(D) 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 
        health plan by a nonparticipating provider or a 
        nonparticipating facility, are the following:
                    ``(A) The participant or beneficiary received a 
                notification under subsection (h) with respect to such 
                item and service to be furnished and such notification 
                provided information 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) A notification was not provided, in 
                accordance with subsection (h), to the participant or 
                beneficiary and the participant or beneficiary 
                requested through the response protocol of the plan 
                under subsection (f)(3) 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.''.

SEC. 7. DETERMINATION THROUGH OPEN NEGOTIATION AND MEDIATION OF OUT-OF-
              NETWORK RATES TO BE PAID BY HEALTH PLANS.

    (a) PHSA Amendment.--Section 2719A of the Public Health Service Act 
(42 U.S.C. 300gg-19a), as amended by sections 2(a), 3(a), 5(a), and 
6(a), is further amended by inserting before subsection (k) the 
following new subsection:
    ``(j) Determination of Out-of-Network Rates To Be Paid by Health 
Plans.--
            ``(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 health plan, in a State described in subparagraph 
                (B) of subsection (k)(11) with respect to such plan and 
                provider or facility, and for which a payment is 
                required to be made by the health plan pursuant to 
                subsection (b)(1), (e)(1), or (i)(1), the provider or 
                facility (as applicable) or plan may, during the 30-day 
                period beginning on the day the provider or facility 
                receives a response 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) Exchange of information.--In carrying out 
                negotiations initiated under subparagraph (A), with 
                respect to an item or service described in such 
                subparagraph furnished in a year, not later than the 
                fifth business day of the open negotiation period 
                described in such subparagraph with respect to such 
                item or service--
                            ``(i) the health plan that is party to such 
                        negotiations shall notify the provider or 
                        facility that is party to such negotiations of 
                        the median contracted rate for such item or 
                        service and year; and
                            ``(ii) such provider or facility shall 
                        notify such health plan of--
                                    ``(I) the median of the total 
                                amount of reimbursement (including any 
                                cost-sharing) paid, for the most recent 
                                year for which information is 
                                available, to such provider or facility 
                                for furnishing such item or service to 
                                a participant, beneficiary, or enrollee 
                                of a health plan that, at the time such 
                                item or service was furnished, had a 
                                contract in effect with such provider 
                                or facility with respect to the 
                                furnishing of such item or service;
                                    ``(II) in the case that information 
                                described in subclause (I) is not 
                                available, such information as 
                                specified by the Secretary; and
                                    ``(III) any additional information 
                                specified by the Secretary.
                    ``(C) Accessing mediated dispute 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 health plan 
                that was party to such negotiations may, during the 2-
                day period beginning on the day after such open 
                negotiation period, initiate the mediated dispute 
                process under paragraph (2) with respect to such item 
                or service. The mediated dispute 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) Mediated dispute process available in case of failed 
        open negotiations.--
                    ``(A) Establishment.--Not later than July 1, 2021, 
                the Secretary, in coordination with the Secretary of 
                the Treasury and the Secretary of Labor, shall 
                establish a process (in this subsection referred to as 
                the `mediated dispute process') under which, in the 
                case of an item or service with respect to which a 
                provider or facility (as applicable) or health plan 
                submits a notification under paragraph (1)(C) (in this 
                subsection referred to as a `qualified mediated dispute 
                item or service'), an entity selected under paragraph 
                (3) determines, subject to subparagraph (B) and in 
                accordance with the succeeding provisions of this 
                subsection, the amount of payment under the health plan 
                for such item or service furnished by such provider or 
                facility.
                    ``(B) Authority to continue negotiations.--Under 
                the mediated dispute process, in the case that the 
                parties to a determination for a qualified mediated 
                dispute 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 (3) makes such 
                determination, such amount shall be treated for 
                purposes of subsection (k)(11)(B) 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 mediated dispute 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.
            ``(3) Selection under mediated dispute process.--Under the 
        mediated dispute process, the Secretary shall, with respect to 
        the determination of the amount of payment under this 
        subsection of a qualified mediated dispute item or service, 
        provide for a method--
                    ``(A) that allows the parties to such determination 
                to jointly select, not later than the last day of the 
                3-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 paragraph (7) 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
                    ``(B) that requires, in the case such parties do 
                not make such selection by such last day, the Secretary 
                to, not later than 6 days after such date of 
                initiation--
                            ``(i) select such an entity that satisfies 
                        clauses (i) through (iii) of subparagraph (A); 
                        and
                            ``(ii) provide notification of such 
                        selection to the provider or facility (as 
                        applicable) and the health plan 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 independent entity' with 
        respect to such determination.
            ``(4) Treatment of consideration of multiple items and 
        services.--
                    ``(A) In general.--Under the mediated dispute 
                process, the Secretary shall specify criteria under 
                which multiple qualified mediated 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 mediated dispute 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 health plan; 
                        and
                            ``(iii) such items and services are related 
                        to the treatment of a similar condition.
                    ``(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.
                    ``(C) Waiver of deadlines.--For purposes of 
                permitting joint consideration of qualified mediated 
                dispute items and services as part of a single 
                determination under the criteria specified pursuant to 
                subparagraph (A), the Secretary may waive any deadline 
                specified in this subsection.
            ``(5) Determination of payment amount.--
                    ``(A) In general.--Not later than 30 days after the 
                date of initiation of the mediated dispute resolution, 
                with respect to a qualified mediated dispute item or 
                service, the selected independent entity with respect 
                to a determination under this subsection for such item 
                or service shall--
                            ``(i) taking into account only the 
                        considerations specified in subparagraph 
                        (C)(i), 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 (b)(1), (e)(1), or (i)(1), as 
                        applicable; and
                            ``(ii) notify the provider or facility and 
                        the 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 initiation of the mediated dispute 
                resolution with respect to a determination for a 
                qualified mediated dispute item or service, the 
                provider or facility and the health plan party to such 
                determination shall each submit to the selected 
                independent entity--
                            ``(i) an offer for a payment amount under 
                        for such item or service furnished by such 
                        provider or facility;
                            ``(ii) information relating to such offer; 
                        and
                            ``(iii) such other information as requested 
                        by the selected independent entity.
                    ``(C) Considerations.--
                            ``(i) In general.--For purposes of 
                        subparagraph (A), the considerations specified 
                        in this subparagraph, with respect to a 
                        determination for a qualified mediated dispute 
                        item or service, are the following:
                                    ``(I) The median contracted rate 
                                for such item or service.
                                    ``(II) Subject to clause (ii), 
                                information that is submitted pursuant 
                                to subparagraph (B).
                            ``(ii) Treatment of certain 
                        considerations.--In making a determination with 
                        respect to a qualified mediated dispute item or 
                        service pursuant to subparagraph (A)(i), a 
                        selected independent entity may not take into 
                        account usual and customary charges for the 
                        item or service nor charges billed by the 
                        provider or facility for the item or service.
            ``(6) Selected independent entity compensation.--
                    ``(A) In general.--Not later than 5 days after 
                receiving a notification described in paragraph 
                (5)(A)(ii) from a selected independent entity with 
                respect to the determination of a payment amount for a 
                qualified mediated dispute item or service, the party 
                to such determination whose offer submitted under 
                paragraph (5)(B) was not selected by the entity shall 
                pay to such entity a fee in compensation for the 
                services of such entity in accordance with the 
                guidelines on such compensation established by the 
                Secretary under subparagraph (B).
                    ``(B) Guidelines on compensation.--For purposes of 
                subparagraph (A), the Secretary shall establish 
                guidelines with respect to the compensation of a 
                selected independent entity for the services of such 
                entity with respect to determinations under the 
                mediated dispute process. Such guidelines shall provide 
                that such compensation reimburses the entity for at 
                least the costs of such entity in performing the duties 
                of the entity under the mediated dispute process.
            ``(7) Certification of entities.--
                    ``(A) In general.--The Secretary shall establish or 
                recognize a process to certify (including 
                recertification of) 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 (2) 
                        on a timely basis;
                            ``(ii) is not--
                                    ``(I) a health plan, provider, or 
                                facility;
                                    ``(II) an affiliate or a subsidiary 
                                of a health plan, provider, or 
                                facility; or
                                    ``(III) an affiliate or subsidiary 
                                of a professional or trade association 
                                of 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 mediated dispute 
                        process carry out any determination with 
                        respect to which the entity would not pursuant 
                        to clause (i), (ii), or (iii) of paragraph 
                        (3)(A) 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 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 (2).
                    ``(F) Provision of information.--
                            ``(i) In general.--An entity certified 
                        under this paragraph shall provide to the 
                        Secretary, in such manner as the Secretary may 
                        require and on a quarterly basis (as specified 
                        by the Secretary), such information as the 
                        Secretary determines appropriate to assure 
                        compliance with the requirements described in 
                        subparagraph (A) and to monitor and assess the 
                        determinations made by such entity and to 
                        ensure the absence of bias in making such 
                        determinations. Such information shall include 
                        information described in clause (ii) but shall 
                        not include individually identifiable health 
                        information.
                            ``(ii) Information to be included.--The 
                        information described in this clause with 
                        respect to an entity is the following:
                                    ``(I) The number of payment 
                                determinations described in paragraph 
                                (2) made by such entity, disaggregated 
                                by--
                                            ``(aa) the line of business 
                                        (as specified in subsection 
                                        (k)(8)(C)) of the health plans 
                                        party to such determinations; 
                                        and
                                            ``(bb) the type of 
                                        providers and facilities party 
                                        to such determinations.
                                    ``(II) A description of each item 
                                or service included in each such 
                                determination.
                                    ``(III) The amount of each offer 
                                submitted to the entity for each such 
                                determination.
                                    ``(IV) The amount of each such 
                                determination.
                                    ``(V) The length of time in making 
                                each such determination.
                                    ``(VI) The compensation paid to 
                                such entity with respect to each such 
                                determination.
                                    ``(VII) Any other information 
                                specified by the Secretary.
            ``(8) Administrative fee.--
                    ``(A) In general.--Each party to a determination 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 mediated dispute 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 mediated dispute process.
            ``(9) Secretarial report; publication of information.--
                    ``(A) Secretarial report.--Beginning not later than 
                July 1, 2023, the Secretary shall, in coordination with 
                the Secretary of the Treasury and the Secretary of 
                Labor, periodically study and submit to Congress a 
                report on--
                            ``(i) the extent to which the payment 
                        amount determined under this subsection for an 
                        item or service furnished in a year (or 
                        otherwise agreed to by a health plan and 
                        provider or facility for purposes of 
                        determining payment by the plan to the provider 
                        or facility pursuant to subsection (b)(1), 
                        (e)(1), or (i)(1)) differs from the median 
                        contracted rate for such item or service and 
                        year, including the number of times such 
                        determined (or agreed to) amount exceeds such 
                        median contracted rate; and
                            ``(ii) the effect of such difference on the 
                        cost-sharing for such item or service for a 
                        participant, beneficiary, or enrollee of a 
                        health plan.
                    ``(B) Publication of information.--Beginning with 
                July 1, 2023, and for each calendar quarter thereafter, 
                the Secretary shall, in coordination with the Secretary 
                of the Treasury and the Secretary of Labor, make 
                publicly available a summary of the following:
                            ``(i) The information described in 
                        subclauses (I) through (V) of clause (ii) of 
                        paragraph (7)(F) that was submitted to the 
                        Secretary under clause (i) of such paragraph 
                        during such quarter.
                            ``(ii) The amount of expenditures made by 
                        the Secretary during such year to carry out the 
                        mediated dispute process.
                            ``(iii) The total amount of fees paid under 
                        paragraph (8) during such quarter.
                            ``(iv) The total amount of compensation 
                        paid to selected independent entities under 
                        paragraph (6) during such quarter.''.
    (b) IRC Amendments.--Section 9816 of the Internal Revenue Code of 
1986, as added by section 2(b) and amended by sections 3(b), 5(b), and 
6(b), is further amended by inserting before subsection (k) the 
following new subsection:
    ``(j) Determination of Out-of-Network Rates To Be Paid by Health 
Plans.--
            ``(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 health plan, in a State described in subparagraph 
                (B) of subsection (k)(11) with respect to such plan and 
                provider or facility, and for which a payment is 
                required to be made by the health plan pursuant to 
                subsection (b)(1), (e)(1), or (i)(1), the provider or 
                facility (as applicable) or plan may, during the 30-day 
                period beginning on the day the provider or facility 
                receives a response 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) Exchange of information.--In carrying out 
                negotiations initiated under subparagraph (A), with 
                respect to an item or service described in such 
                subparagraph furnished in a year, not later than the 
                fifth business day of the open negotiation period 
                described in such subparagraph with respect to such 
                item or service--
                            ``(i) the health plan that is party to such 
                        negotiations shall notify the provider or 
                        facility that is party to such negotiations of 
                        the median contracted rate for such item or 
                        service and year; and
                            ``(ii) such provider or facility shall 
                        notify such health plan of--
                                    ``(I) the median of the total 
                                amount of reimbursement (including any 
                                cost-sharing) paid, for the most recent 
                                year for which information is 
                                available, to such provider or facility 
                                for furnishing such item or service to 
                                a participant or beneficiary of a 
                                health plan that, at the time such item 
                                or service was furnished, had a 
                                contract in effect with such provider 
                                or facility with respect to the 
                                furnishing of such item or service;
                                    ``(II) in the case that information 
                                described in subclause (I) is not 
                                available, such information as 
                                specified by the Secretary; and
                                    ``(III) any additional information 
                                specified by the Secretary.
                    ``(C) Accessing mediated dispute 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 health plan 
                that was party to such negotiations may, during the 2-
                day period beginning on the day after such open 
                negotiation period, initiate the mediated dispute 
                process under paragraph (2) with respect to such item 
                or service. The mediated dispute 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) Mediated dispute process available in case of failed 
        open negotiations.--
                    ``(A) Establishment.--Not later than July 1, 2021, 
                the Secretary, in coordination with the Secretary of 
                Health and Human Services and the Secretary of Labor, 
                shall establish a process (in this subsection referred 
                to as the `mediated dispute process') under which, in 
                the case of an item or service with respect to which a 
                provider or facility (as applicable) or health plan 
                submits a notification under paragraph (1)(C) (in this 
                subsection referred to as a `qualified mediated dispute 
                item or service'), an entity selected under paragraph 
                (3) determines, subject to subparagraph (B) and in 
                accordance with the succeeding provisions of this 
                subsection, the amount of payment under the health plan 
                for such item or service furnished by such provider or 
                facility.
                    ``(B) Authority to continue negotiations.--Under 
                the mediated dispute process, in the case that the 
                parties to a determination for a qualified mediated 
                dispute 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 (3) makes such 
                determination, such amount shall be treated for 
                purposes of subsection (k)(11)(B) 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 mediated dispute 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.
            ``(3) Selection under mediated dispute process.--Under the 
        mediated dispute process, the Secretary shall, with respect to 
        the determination of the amount of payment under this 
        subsection of a qualified mediated dispute item or service, 
        provide for a method--
                    ``(A) that allows the parties to such determination 
                to jointly select, not later than the last day of the 
                3-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 paragraph (7) 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
                    ``(B) that requires, in the case such parties do 
                not make such selection by such last day, the Secretary 
                to, not later than 6 days after such date of 
                initiation--
                            ``(i) select such an entity that satisfies 
                        clauses (i) through (iii) of subparagraph (A); 
                        and
                            ``(ii) provide notification of such 
                        selection to the provider or facility (as 
                        applicable) and the health plan 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 independent entity' with 
        respect to such determination.
            ``(4) Treatment of consideration of multiple items and 
        services.--
                    ``(A) In general.--Under the mediated dispute 
                process, the Secretary shall specify criteria under 
                which multiple qualified mediated 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 mediated dispute 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 health plan; 
                        and
                            ``(iii) such items and services are related 
                        to the treatment of a similar condition.
                    ``(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.
                    ``(C) Waiver of deadlines.--For purposes of 
                permitting joint consideration of qualified mediated 
                dispute items and services as part of a single 
                determination under the criteria specified pursuant to 
                subparagraph (A), the Secretary may waive any deadline 
                specified in this subsection.
            ``(5) Determination of payment amount.--
                    ``(A) In general.--Not later than 30 days after the 
                date of initiation of the mediated dispute resolution, 
                with respect to a qualified mediated dispute item or 
                service, the selected independent entity with respect 
                to a determination under this subsection for such item 
                or service shall--
                            ``(i) taking into account only the 
                        considerations specified in subparagraph 
                        (C)(i), 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 (b)(1), (e)(1), or (i)(1), as 
                        applicable; and
                            ``(ii) notify the provider or facility and 
                        the 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 initiation of the mediated dispute 
                resolution with respect to a determination for a 
                qualified mediated dispute item or service, the 
                provider or facility and the health plan party to such 
                determination shall each submit to the selected 
                independent entity--
                            ``(i) an offer for a payment amount under 
                        for such item or service furnished by such 
                        provider or facility;
                            ``(ii) information relating to such offer; 
                        and
                            ``(iii) such other information as requested 
                        by the selected independent entity.
                    ``(C) Considerations.--
                            ``(i) In general.--For purposes of 
                        subparagraph (A), the considerations specified 
                        in this subparagraph, with respect to a 
                        determination for a qualified mediated dispute 
                        item or service, are the following:
                                    ``(I) The median contracted rate 
                                for such item or service.
                                    ``(II) Subject to clause (ii), 
                                information that is submitted pursuant 
                                to subparagraph (B).
                            ``(ii) Treatment of certain 
                        considerations.--In making a determination with 
                        respect to a qualified mediated dispute item or 
                        service pursuant to subparagraph (A)(i), a 
                        selected independent entity may not take into 
                        account usual and customary charges for the 
                        item or service nor charges billed by the 
                        provider or facility for the item or service.
            ``(6) Selected independent entity compensation.--
                    ``(A) In general.--Not later than 5 days after 
                receiving a notification described in paragraph 
                (5)(A)(ii) from a selected independent entity with 
                respect to the determination of a payment amount for a 
                qualified mediated dispute item or service, the party 
                to such determination whose offer submitted under 
                paragraph (5)(B) was not selected by the entity shall 
                pay to such entity a fee in compensation for the 
                services of such entity in accordance with the 
                guidelines on such compensation established by the 
                Secretary under subparagraph (B).
                    ``(B) Guidelines on compensation.--For purposes of 
                subparagraph (A), the Secretary shall establish 
                guidelines with respect to the compensation of a 
                selected independent entity for the services of such 
                entity with respect to determinations under the 
                mediated dispute process. Such guidelines shall provide 
                that such compensation reimburses the entity for at 
                least the costs of such entity in performing the duties 
                of the entity under the mediated dispute process.
            ``(7) Certification of entities.--
                    ``(A) In general.--The Secretary shall establish or 
                recognize a process to certify (including 
                recertification of) 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 (2) 
                        on a timely basis;
                            ``(ii) is not--
                                    ``(I) a health plan, provider, or 
                                facility;
                                    ``(II) an affiliate or a subsidiary 
                                of a health plan, provider, or 
                                facility; or
                                    ``(III) an affiliate or subsidiary 
                                of a professional or trade association 
                                of 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 mediated dispute 
                        process carry out any determination with 
                        respect to which the entity would not pursuant 
                        to clause (i), (ii), or (iii) of paragraph 
                        (3)(A) 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 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 (2).
                    ``(F) Provision of information.--
                            ``(i) In general.--An entity certified 
                        under this paragraph shall provide to the 
                        Secretary, in such manner as the Secretary may 
                        require and on a quarterly basis (as specified 
                        by the Secretary), such information as the 
                        Secretary determines appropriate to assure 
                        compliance with the requirements described in 
                        subparagraph (A) and to monitor and assess the 
                        determinations made by such entity and to 
                        ensure the absence of bias in making such 
                        determinations. Such information shall include 
                        information described in clause (ii) but shall 
                        not include individually identifiable health 
                        information.
                            ``(ii) Information to be included.--The 
                        information described in this clause with 
                        respect to an entity is the following:
                                    ``(I) The number of payment 
                                determinations described in paragraph 
                                (2) made by such entity, disaggregated 
                                by--
                                            ``(aa) the line of business 
                                        (as specified in subsection 
                                        (k)(8)(C)) of the health plans 
                                        party to such determinations; 
                                        and
                                            ``(bb) the type of 
                                        providers and facilities party 
                                        to such determinations.
                                    ``(II) A description of each item 
                                or service included in each such 
                                determination.
                                    ``(III) The amount of each offer 
                                submitted to the entity for each such 
                                determination.
                                    ``(IV) The amount of each such 
                                determination.
                                    ``(V) The length of time in making 
                                each such determination.
                                    ``(VI) The compensation paid to 
                                such entity with respect to each such 
                                determination.
                                    ``(VII) Any other information 
                                specified by the Secretary.
            ``(8) Administrative fee.--
                    ``(A) In general.--Each party to a determination 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 mediated dispute 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 mediated dispute process.
            ``(9) Secretarial report; publication of information.--
                    ``(A) Secretarial report.--Beginning not later than 
                July 1, 2023, the Secretary shall, in coordination with 
                the Secretary of Health and Human Services and the 
                Secretary of Labor, periodically study and submit to 
                Congress a report on--
                            ``(i) the extent to which the payment 
                        amount determined under this subsection for an 
                        item or service furnished in a year (or 
                        otherwise agreed to by a health plan and 
                        provider or facility for purposes of 
                        determining payment by the plan to the provider 
                        or facility pursuant to subsection (b)(1), 
                        (e)(1), or (i)(1)) differs from the median 
                        contracted rate for such item or service and 
                        year, including the number of times such 
                        determined (or agreed to) amount exceeds such 
                        median contracted rate; and
                            ``(ii) the effect of such difference on the 
                        cost-sharing for such item or service for a 
                        participant or beneficiary of a health plan.
                    ``(B) Publication of information.--Beginning with 
                July 1, 2023, and for each calendar quarter thereafter, 
                the Secretary shall, in coordination with the Secretary 
                of Health and Human Services and the Secretary of 
                Labor, make publicly available a summary of the 
                following:
                            ``(i) The information described in 
                        subclauses (I) through (V) of clause (ii) of 
                        paragraph (7)(F) that was submitted to the 
                        Secretary under clause (i) of such paragraph 
                        during such quarter.
                            ``(ii) The amount of expenditures made by 
                        the Secretary during such year to carry out the 
                        mediated dispute process.
                            ``(iii) The total amount of fees paid under 
                        paragraph (8) during such quarter.
                            ``(iv) The total amount of compensation 
                        paid to selected independent entities under 
                        paragraph (6) during such quarter.''.
    (c) ERISA Amendments.--Section 716 of the Employee Retirement 
Income Security Act of 1974, as added by section 2(c) and amended by 
sections 3(c), 5(c), and 6(c), is further amended by inserting before 
subsection (k) the following new subsection:
    ``(j) Determination of Out-of-Network Rates To Be Paid by Health 
Plans.--
            ``(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 health plan, in a State described in subparagraph 
                (B) of subsection (k)(11) with respect to such plan and 
                provider or facility, and for which a payment is 
                required to be made by the health plan pursuant to 
                subsection (b)(1), (e)(1), or (i)(1), the provider or 
                facility (as applicable) or plan may, during the 30-day 
                period beginning on the day the provider or facility 
                receives a response 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) Exchange of information.--In carrying out 
                negotiations initiated under subparagraph (A), with 
                respect to an item or service described in such 
                subparagraph furnished in a year, not later than the 
                fifth business day of the open negotiation period 
                described in such subparagraph with respect to such 
                item or service--
                            ``(i) the health plan that is party to such 
                        negotiations shall notify the provider or 
                        facility that is party to such negotiations of 
                        the median contracted rate for such item or 
                        service and year; and
                            ``(ii) such provider or facility shall 
                        notify such health plan of--
                                    ``(I) the median of the total 
                                amount of reimbursement (including any 
                                cost-sharing) paid, for the most recent 
                                year for which information is 
                                available, to such provider or facility 
                                for furnishing such item or service to 
                                a participant or beneficiary of a 
                                health plan that, at the time such item 
                                or service was furnished, had a 
                                contract in effect with such provider 
                                or facility with respect to the 
                                furnishing of such item or service;
                                    ``(II) in the case that information 
                                described in subclause (I) is not 
                                available, such information as 
                                specified by the Secretary; and
                                    ``(III) any additional information 
                                specified by the Secretary.
                    ``(C) Accessing mediated dispute 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 health plan 
                that was party to such negotiations may, during the 2-
                day period beginning on the day after such open 
                negotiation period, initiate the mediated dispute 
                process under paragraph (2) with respect to such item 
                or service. The mediated dispute 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) Mediated dispute process available in case of failed 
        open negotiations.--
                    ``(A) Establishment.--Not later than July 1, 2021, 
                the Secretary, in coordination with the Secretary of 
                Health and Human Services and the Secretary of the 
                Treasury, shall establish a process (in this subsection 
                referred to as the `mediated dispute process') under 
                which, in the case of an item or service with respect 
                to which a provider or facility (as applicable) or 
                health plan submits a notification under paragraph 
                (1)(C) (in this subsection referred to as a `qualified 
                mediated dispute item or service'), an entity selected 
                under paragraph (3) determines, subject to subparagraph 
                (B) and in accordance with the succeeding provisions of 
                this subsection, the amount of payment under the health 
                plan for such item or service furnished by such 
                provider or facility.
                    ``(B) Authority to continue negotiations.--Under 
                the mediated dispute process, in the case that the 
                parties to a determination for a qualified mediated 
                dispute 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 (3) makes such 
                determination, such amount shall be treated for 
                purposes of subsection (k)(11)(B) 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 mediated dispute 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.
            ``(3) Selection under mediated dispute process.--Under the 
        mediated dispute process, the Secretary shall, with respect to 
        the determination of the amount of payment under this 
        subsection of a qualified mediated dispute item or service, 
        provide for a method--
                    ``(A) that allows the parties to such determination 
                to jointly select, not later than the last day of the 
                3-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 paragraph (7) 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
                    ``(B) that requires, in the case such parties do 
                not make such selection by such last day, the Secretary 
                to, not later than 6 days after such date of 
                initiation--
                            ``(i) select such an entity that satisfies 
                        clauses (i) through (iii) of subparagraph (A); 
                        and
                            ``(ii) provide notification of such 
                        selection to the provider or facility (as 
                        applicable) and the health plan 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 independent entity' with 
        respect to such determination.
            ``(4) Treatment of consideration of multiple items and 
        services.--
                    ``(A) In general.--Under the mediated dispute 
                process, the Secretary shall specify criteria under 
                which multiple qualified mediated 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 mediated dispute 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 health plan; 
                        and
                            ``(iii) such items and services are related 
                        to the treatment of a similar condition.
                    ``(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.
                    ``(C) Waiver of deadlines.--For purposes of 
                permitting joint consideration of qualified mediated 
                dispute items and services as part of a single 
                determination under the criteria specified pursuant to 
                subparagraph (A), the Secretary may waive any deadline 
                specified in this subsection.
            ``(5) Determination of payment amount.--
                    ``(A) In general.--Not later than 30 days after the 
                date of initiation of the mediated dispute resolution, 
                with respect to a qualified mediated dispute item or 
                service, the selected independent entity with respect 
                to a determination under this subsection for such item 
                or service shall--
                            ``(i) taking into account only the 
                        considerations specified in subparagraph 
                        (C)(i), 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 (b)(1), (e)(1), or (i)(1), as 
                        applicable; and
                            ``(ii) notify the provider or facility and 
                        the 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 initiation of the mediated dispute 
                resolution with respect to a determination for a 
                qualified mediated dispute item or service, the 
                provider or facility and the health plan party to such 
                determination shall each submit to the selected 
                independent entity--
                            ``(i) an offer for a payment amount under 
                        for such item or service furnished by such 
                        provider or facility;
                            ``(ii) information relating to such offer; 
                        and
                            ``(iii) such other information as requested 
                        by the selected independent entity.
                    ``(C) Considerations.--
                            ``(i) In general.--For purposes of 
                        subparagraph (A), the considerations specified 
                        in this subparagraph, with respect to a 
                        determination for a qualified mediated dispute 
                        item or service, are the following:
                                    ``(I) The median contracted rate 
                                for such item or service.
                                    ``(II) Subject to clause (ii), 
                                information that is submitted pursuant 
                                to subparagraph (B).
                            ``(ii) Treatment of certain 
                        considerations.--In making a determination with 
                        respect to a qualified mediated dispute item or 
                        service pursuant to subparagraph (A)(i), a 
                        selected independent entity may not take into 
                        account usual and customary charges for the 
                        item or service nor charges billed by the 
                        provider or facility for the item or service.
            ``(6) Selected independent entity compensation.--
                    ``(A) In general.--Not later than 5 days after 
                receiving a notification described in paragraph 
                (5)(A)(ii) from a selected independent entity with 
                respect to the determination of a payment amount for a 
                qualified mediated dispute item or service, the party 
                to such determination whose offer submitted under 
                paragraph (5)(B) was not selected by the entity shall 
                pay to such entity a fee in compensation for the 
                services of such entity in accordance with the 
                guidelines on such compensation established by the 
                Secretary under subparagraph (B).
                    ``(B) Guidelines on compensation.--For purposes of 
                subparagraph (A), the Secretary shall establish 
                guidelines with respect to the compensation of a 
                selected independent entity for the services of such 
                entity with respect to determinations under the 
                mediated dispute process. Such guidelines shall provide 
                that such compensation reimburses the entity for at 
                least the costs of such entity in performing the duties 
                of the entity under the mediated dispute process.
            ``(7) Certification of entities.--
                    ``(A) In general.--The Secretary shall establish or 
                recognize a process to certify (including 
                recertification of) 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 (2) 
                        on a timely basis;
                            ``(ii) is not--
                                    ``(I) a health plan, provider, or 
                                facility;
                                    ``(II) an affiliate or a subsidiary 
                                of a health plan, provider, or 
                                facility; or
                                    ``(III) an affiliate or subsidiary 
                                of a professional or trade association 
                                of 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 mediated dispute 
                        process carry out any determination with 
                        respect to which the entity would not pursuant 
                        to clause (i), (ii), or (iii) of paragraph 
                        (3)(A) 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 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 (2).
                    ``(F) Provision of information.--
                            ``(i) In general.--An entity certified 
                        under this paragraph shall provide to the 
                        Secretary, in such manner as the Secretary may 
                        require and on a quarterly basis (as specified 
                        by the Secretary), such information as the 
                        Secretary determines appropriate to assure 
                        compliance with the requirements described in 
                        subparagraph (A) and to monitor and assess the 
                        determinations made by such entity and to 
                        ensure the absence of bias in making such 
                        determinations. Such information shall include 
                        information described in clause (ii) but shall 
                        not include individually identifiable health 
                        information.
                            ``(ii) Information to be included.--The 
                        information described in this clause with 
                        respect to an entity is the following:
                                    ``(I) The number of payment 
                                determinations described in paragraph 
                                (2) made by such entity, disaggregated 
                                by--
                                            ``(aa) the line of business 
                                        (as specified in subsection 
                                        (k)(8)(C)) of the health plans 
                                        party to such determinations; 
                                        and
                                            ``(bb) the type of 
                                        providers and facilities party 
                                        to such determinations.
                                    ``(II) A description of each item 
                                or service included in each such 
                                determination.
                                    ``(III) The amount of each offer 
                                submitted to the entity for each such 
                                determination.
                                    ``(IV) The amount of each such 
                                determination.
                                    ``(V) The length of time in making 
                                each such determination.
                                    ``(VI) The compensation paid to 
                                such entity with respect to each such 
                                determination.
                                    ``(VII) Any other information 
                                specified by the Secretary.
            ``(8) Administrative fee.--
                    ``(A) In general.--Each party to a determination 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 mediated dispute 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 mediated dispute process.
            ``(9) Secretarial report; publication of information.--
                    ``(A) Secretarial report.--Beginning not later than 
                July 1, 2023, the Secretary shall, in coordination with 
                the Secretary of Health and Human Services and the 
                Secretary of the Treasury, periodically study and 
                submit to Congress a report on--
                            ``(i) the extent to which the payment 
                        amount determined under this subsection for an 
                        item or service furnished in a year (or 
                        otherwise agreed to by a health plan and 
                        provider or facility for purposes of 
                        determining payment by the plan to the provider 
                        or facility pursuant to subsection (b)(1), 
                        (e)(1), or (i)(1)) differs from the median 
                        contracted rate for such item or service and 
                        year, including the number of times such 
                        determined (or agreed to) amount exceeds such 
                        median contracted rate; and
                            ``(ii) the effect of such difference on the 
                        cost-sharing for such item or service for a 
                        participant or beneficiary of a health plan.
                    ``(B) Publication of information.--Beginning with 
                July 1, 2023, and for each calendar quarter thereafter, 
                the Secretary shall, in coordination with the Secretary 
                of Health and Human Services and the Secretary of 
                Labor, make publicly available a summary of the 
                following:
                            ``(i) The information described in 
                        subclauses (I) through (V) of clause (ii) of 
                        paragraph (7)(F) that was submitted to the 
                        Secretary under clause (i) of such paragraph 
                        during such quarter.
                            ``(ii) The amount of expenditures made by 
                        the Secretary during such year to carry out the 
                        mediated dispute process.
                            ``(iii) The total amount of fees paid under 
                        paragraph (8) during such quarter.
                            ``(iv) The total amount of compensation 
                        paid to selected independent entities under 
                        paragraph (6) during such quarter.''.
    (d) Rule of Construction.--Nothing in this Act, or the amendment 
made by this Act, shall be construed as removing any obligation of a 
health plan (as defined in subsection (k)(6) of section 2719A of the 
Public Health Service Act (42 U.S.C. 300gg-19A), as amended by this 
Act) to provide payment to a health care provider or health care 
facility for items and services furnished by such provider or facility 
to an individual enrolled in such plan.

SEC. 8. PROHIBITING BALANCE BILLING PRACTICES BY PROVIDERS FOR 
              EMERGENCY SERVICES, FOR SERVICES FURNISHED BY 
              NONPARTICIPATING PROVIDER AT PARTICIPATING FACILITY, AND 
              IN CERTAIN CASES OF MISINFORMATION.

    (a) No Balance Billing.--Part A of title XI of the Social Security 
Act (42 U.S.C. 1301 et seq.) is amended by adding at the end the 
following new section:

``SEC. 1150C. PROHIBITION ON CERTAIN BALANCE BILLING PRACTICES.

    ``(a) Emergency Services.--In the case of an individual with 
benefits under a group health plan or health insurance coverage offered 
in the group or individual market who is furnished in a plan year that 
begins on or after January 1, 2022, emergency services with respect to 
an emergency medical condition during a visit at an emergency 
department of a hospital or an independent freestanding emergency 
department--
            ``(1) if the hospital or independent freestanding emergency 
        department does not have a contractual relationship with such 
        plan or coverage for furnishing such services, the hospital or 
        independent freestanding emergency department shall not bill, 
        and shall not hold liable, the individual for a payment amount 
        for such emergency services so furnished that is more than the 
        cost-sharing amount for such services (as determined in 
        accordance with section 2719A(b) of the Public Health Service 
        Act, section 716(b) of the Employee Retirement Income Security 
        Act of 1974, or section 9816(b) of the Internal Revenue Code of 
        1986, as applicable); and
            ``(2) a health care provider without a contractual 
        relationship with such plan or coverage for furnishing such 
        services shall not bill, and shall not hold liable, such 
        individual for a payment amount for such services 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 emergency department of the hospital 
        or independent freestanding emergency department that is more 
        than the cost-sharing amount for such services furnished by the 
        provider (as determined in accordance with section 2719A(b) of 
        the Public Health Service Act, section 716(b) of the Employee 
        Retirement Income Security Act of 1974, or section 9816(b) of 
        the Internal Revenue Code of 1986, as applicable).
    ``(b) Services Furnished by Nonparticipating Provider at 
Participating Facility.--
            ``(1) In general.--Subject to paragraph (2), in the case of 
        an individual with benefits under a health plan who is 
        furnished items or services (other than emergency services to 
        which subsection (a) applies or items and services to which 
        subsection (c) applies) in a plan year that, with respect to 
        such plan or such coverage (as applicable), begins on or after 
        January 1, 2022, at a participating facility by a 
        nonparticipating provider, such provider shall not bill, and 
        shall not hold liable, such individual for a payment amount for 
        such an item or service furnished by such provider during a 
        visit at such facility that is more than the cost-sharing 
        amount for such item or service (as determined in accordance 
        with section 2719A(e) of the Public Health Service Act, section 
        716(e) of the Employee Retirement Income Security Act of 1974, 
        or section 9816(e) of the Internal Revenue Code of 1986, as 
        applicable).
            ``(2) Exception in case notice provided.--Paragraph (1) 
        shall not apply with respect to items and services (other than 
        items and services described in paragraph (3)) furnished to an 
        individual enrolled in a group health plan or in health 
        insurance coverage offered in the group or individual market by 
        a health care provider that does not have a contractual 
        relationship with such plan or coverage for furnishing such 
        items and services if the following criteria are met:
                    ``(A) A written notice (as specified by the 
                Secretary and in clear and understandable language) is 
                provided by the provider to such individual, not later 
                than 48 hours before such items and services are to be 
                so furnished, that includes the following information:
                            ``(i) A statement verifying that the 
                        provider does not have such a relationship with 
                        such plan or coverage.
                            ``(ii) The estimated amount that such 
                        provider may charge the individual for such 
                        items and services.
                            ``(iii) A statement that the individual may 
                        seek such items or services from a health care 
                        provider that does have such a contractual 
                        relationship and a list, if feasible, of 
                        providers with such a relationship who are able 
                        to furnish such items and services involved.
                    ``(B) On the date such item or service is to be 
                furnished, before such item or service is so furnished, 
                the individual signs and dates such notice confirming 
                receipt of the notice and consent of the individual to 
                be so furnished such items and services.
                    ``(C) A copy of such signed and dated notice is 
                provided by the provider to the plan or coverage.
            ``(3) Items and services described.--The items and services 
        described in this paragraph are items and services furnished by 
        a specified provider (as defined in subsection (f)(3)).
    ``(c) Reliance on Incorrect Provider Information.--In the case of 
an individual who is furnished items or services by a health care 
provider or health care facility for which a group health plan or 
health insurance issuer is required to make payment under section 
2719A(i) of the Public Health Service Act, section 716(i) of the 
Employee Retirement Income Security Act of 1974, or section 9816(i) of 
the Internal Revenue Code of 1986, such provider or facility shall not 
bill, and shall not hold liable, such individual for a payment amount 
for such an item or service that is more than the cost-sharing amount 
for such item or service (as determined in accordance with section 
2719A(i) of the Public Health Service Act, section 716(i) of the 
Employee Retirement Income Security Act of 1974, or section 9816(i) of 
the Internal Revenue Code of 1986, as applicable).
    ``(d) Compliance With Requirements Under Open Negotiation and 
Mediated Dispute Resolution Processes.--A health care provider or 
health care facility shall comply with any requirement imposed on such 
provider or facility, respectively, under section 2719A(j) of the 
Public Health Service Act, 9816(j) of the Internal Revenue Code of 
1986, or 716(j) of the Employee Retirement Income Security Act of 1974.
    ``(e) Penalty.--
            ``(1) In general.--Any health care provider or health care 
        facility that violates a provision of this section shall be 
        subject to a civil monetary penalty in an amount not to exceed 
        $10,000 for each such violation.
            ``(2) Application of provisions.--The provisions of section 
        1128A (other than subsection (a), subsection (b), the first 
        sentence of subsection (c)(1), and subsection (o)) shall apply 
        with respect to a civil monetary penalty imposed under this 
        subsection in the same manner as such provisions apply with 
        respect to a penalty or proceeding under subsection (a) of such 
        section.
    ``(f) Definitions.--For purposes of this section and sections 1150D 
and 1150E:
            ``(1) The terms `during a visit',`emergency department of a 
        hospital', `emergency medical condition', `emergency services', 
        `independent freestanding emergency department', 
        `nonparticipating provider', `nonparticipating facility', 
        `participating facility', `participating provider' have the 
        meanings given such terms, respectively, in section 2719A(k) of 
        the Public Health Service Act.
            ``(2) The terms `group health plan', `group market', 
        `health insurance issuer', `health insurance coverage', and 
        `individual market' have the meanings given such terms, 
        respectively, in section 2791 of the Public Health Service Act.
            ``(3) The term `specified provider', with respect to an 
        individual with benefits under a group health plan or health 
        insurance coverage and a hospital with a contractual 
        relationship with such plan or coverage for furnishing items 
        and services--
                    ``(A) means an ancillary health care provider, 
                including emergency medicine providers or suppliers, 
                anesthesiologists, pathologists, radiologists, 
                neonatologists, assistant surgeons, hospitalists, 
                intensivists, or other providers determined by the 
                Secretary (including providers who furnish similar 
                items and services as the providers specified in this 
                paragraph); and
                    ``(B) includes, with respect to an item or service, 
                any health care provider furnishing such item or 
                service at such hospital if there is no health care 
                provider at such hospital who can furnish such item or 
                service who has such a relationship with such plan or 
                coverage for furnishing such item or service.''.
    (b) Provider Directory; Patient-Provider Dispute Resolution 
Process.--Part A of title XI of the Social Security Act (42 U.S.C. 1301 
et seq.), as amended by subsection (a), is further amended by adding at 
the end the following new sections:

``SEC. 1150D. PATIENT PROTECTIONS AGAINST SURPRISE BILLING THROUGH 
              TRANSPARENCY.

    ``(a) Submission of Information to Health Plans of Certain Provider 
Information.--Beginning not later than 1 year after the date of the 
enactment of this section, each health care provider and health care 
facility shall establish a process under which such provider or 
facility transmits, to each health insurance issuer offering group or 
individual health insurance coverage and group health plan with which 
such provider or supplier has in effect a contractual relationship for 
furnishing items and services under such coverage or such plan, 
provider directory information (as defined in section 2719A(f)(6) of 
the Public Health Service Act, section 716(f)(6) of the Employee 
Retirement Income Security Act of 1974, or section 9816(f)(6) of the 
Internal Revenue Code of 1986, as applicable) with respect to such 
provider or facility, as applicable. Such provider or facility shall so 
transmit such information to such issuer offering such coverage or such 
group health plan--
            ``(1) when there are any material changes (including a 
        change in address, telephone number, or other contact 
        information) to such provider directory information of the 
        provider or facility with respect to such coverage offered by 
        such issuer or with respect to such plan; and
            ``(2) at any other time (including upon the request of such 
        issuer or plan) determined appropriate by the provider, 
        facility, or the Secretary.
    ``(b) 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 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) 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.
    ``(c) 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 2730 of such Act, section 9817 of the 
Internal Revenue Code of 1986, or section 717 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 2730, 9817, or 717) 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.
    ``(d) Limitation.--Beginning on January 1, 2022, a health care 
provider or health care facility may not initiate a process to seek 
reimbursement of payment for items and services furnished to an 
individual enrolled in a group health plan or health insurance coverage 
offered in the group or individual market more than 1 year after the 
date on which such items and services were so furnished.
    ``(e) Penalty.--
            ``(1) General penalty.--
                    ``(A) In general.--Except as provided in paragraph 
                (2), any health care provider or health care facility 
                that violates a provision of this section shall be 
                subject to a civil monetary penalty in an amount not to 
                exceed $10,000 for each such violation.
                    ``(B) Application of provisions.--The provisions of 
                section 1128A (other than subsection (a), subsection 
                (b), the first sentence of subsection (c)(1), and 
                subsection (o)) shall apply with respect to a civil 
                monetary penalty imposed under this paragraph in the 
                same manner as such provisions apply with respect to a 
                penalty or proceeding under subsection (a) of such 
                section.
            ``(2) Provider directory information penalty.--
                    ``(A) In general.--Each health care provider or 
                health care facility that fails to transmit information 
                as required under subsection (a) shall be subject to a 
                civil monetary penalty of $1,000 for each day such 
                provider or facility (as applicable) fails to so 
                transmit such information.
                    ``(B) Application of provisions.--The provisions of 
                section 1128A (other than subsection (a), subsection 
                (b), the first sentence of subsection (c)(1), 
                subsection (d), and subsection (o)) shall apply with 
                respect to a civil monetary penalty imposed under this 
                paragraph in the same manner as such provisions apply 
                with respect to a penalty or proceeding under 
                subsection (a) of such section.

``SEC. 1150E. PATIENT-PROVIDER DISPUTE RESOLUTION.

    ``(a) In General.--Not later than July 1, 2021, 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 1150D(b), 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, health insurance coverage offered in the group or 
individual market by a health insurance issuer, Federal health care 
program (as defined in section 1128B(f)), 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 
health insurance coverage offered in the group or individual market 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
                    ``(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 2719A(j)(7) of the Public Health Service Act.''.

SEC. 9. ADDITIONAL CONSUMER PROTECTIONS.

    (a) Public Health Service Act.--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 sections:

``SEC. 2730. 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 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 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.

``SEC. 2731. INFORMATION REQUIRED TO BE INCLUDED ON HEALTH INSURANCE 
              MEMBERSHIP CARDS.

    ``In the case of a group health plan or health insurance issuer 
offering group or individual health insurance coverage that provides a 
physical or electronic card indicating membership in such plan or 
coverage to an individual enrolled under such plan or coverage, such 
group health plan or issuer shall include on such card each of the 
following:
            ``(1) The nearest hospital to the primary residence of such 
        individual that has in effect a contractual relationship with 
        such plan or coverage for furnishing items and services under 
        such plan or coverage.
            ``(2) A telephone number or 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.
            ``(3) Any deductible applicable to such individual.
            ``(4) Any out-of-pocket maximum applicable to such 
        individual.
            ``(5) Any cost-sharing obligation applicable to such 
        individual for a visit at an emergency department, or urgent 
        care facility, that has in effect a contractual relationship 
        with such plan or coverage for furnishing items and services 
        under such plan or coverage.

``SEC. 2732. MAINTENANCE OF PRICE COMPARISON TOOL.

    ``In connection with the offering of a group health plan or group 
or individual health insurance coverage in a geographic region for a 
plan year, a plan sponsor or health insurance issuer, respectively, 
shall employ an individual to offer price comparison guidance, or make 
available on an Internet website a price comparison tool, that (to the 
extent practicable) allows an individual enrolled under such plan or 
coverage, with respect to such plan year and such geographic region, to 
compare the amount (determined by historic claims data of participating 
providers with respect to such plan or coverage) of cost-sharing 
(including deductibles, copayments, and coinsurance) 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 the previous 
        sections, is further amended by adding at the end the following 
        new sections:

``SEC. 9817. 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:
            ``(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, 
        beneficiary, or enrollee 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.

``SEC. 9818. INFORMATION REQUIRED TO BE INCLUDED ON HEALTH INSURANCE 
              MEMBERSHIP CARDS.

    ``In the case of a group health plan that provides a physical or 
electronic card indicating membership in such plan to an individual 
enrolled under such plan, such group health plan shall include on such 
card each of the following:
            ``(1) The nearest hospital to the primary residence of such 
        individual that has in effect a contractual relationship with 
        such plan for furnishing items and services under such plan.
            ``(2) A telephone number or 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.
            ``(3) Any deductible applicable to such individual.
            ``(4) Any out-of-pocket maximum applicable to such 
        individual.
            ``(5) Any cost-sharing obligation applicable to such 
        individual for a visit at an emergency department, or urgent 
        care facility, that has in effect a contractual relationship 
        with such plan for furnishing items and services under such 
        plan.

``SEC. 9819. MAINTENANCE OF PRICE COMPARISON TOOL.

    ``In connection with the offering of a group health plan in a 
geographic region for a plan year, a plan sponsor shall employ an 
individual to offer price comparison guidance, or make available on an 
Internet website a price comparison tool, that (to the extent 
practicable) allows an individual enrolled under such plan, with 
respect to such plan year and such geographic region, to compare the 
amount (determined by historic claims data of participating providers 
with respect to such plan) of cost-sharing (including deductibles, 
copayments, and coinsurance) 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) Conforming amendment.--Section 9815(a) of the Internal 
        Revenue Code of 1986, as amended by section 2(b), is further 
        amended--
                    (A) in paragraph (1), by striking ``section 2719A'' 
                and inserting ``section 2719A, 2730, 2731, or 2732''; 
                and
                    (B) in paragraph (2), by striking ``section 2719A'' 
                and inserting ``section 2719A, 2730, 2731, or 2732''.
            (3) Clerical amendment.--The table of sections for such 
        subchapter, as amended by section 2(b), is further amended by 
        adding at the end the following new items:

``Sec. 9817. Continuity of care.
``Sec. 9818. Information required to be included on health insurance 
                            membership cards.
``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 section 2(c), is further 
        amended by adding at the end the following new sections:

``SEC. 717. 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 health insurance coverage 
        offered by a health insurance issuer in connection with a group 
        health plan 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 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;
                    ``(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 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.

``SEC. 718. INFORMATION REQUIRED TO BE INCLUDED ON HEALTH INSURANCE 
              MEMBERSHIP CARDS.

    ``In the case of a group health plan or health insurance issuer 
offering group health insurance coverage that provides a physical or 
electronic card indicating membership in such plan or coverage to an 
individual enrolled under such plan or coverage, such group health plan 
or issuer shall include on such card each of the following:
            ``(1) The nearest hospital to the primary residence of such 
        individual that has in effect a contractual relationship with 
        such plan or coverage for furnishing items and services under 
        such plan or coverage.
            ``(2) A telephone number or 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.
            ``(3) Any deductible applicable to such individual.
            ``(4) Any out-of-pocket maximum applicable to such 
        individual.
            ``(5) Any cost-sharing obligation applicable to such 
        individual for a visit at an emergency department, or urgent 
        care facility, that has in effect a contractual relationship 
        with such plan or coverage for furnishing items and services 
        under such plan or coverage.

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

    ``In connection with the offering of a group health plan or group 
health insurance coverage in a geographic region for a plan year, a 
plan sponsor or health insurance issuer, respectively, shall employ an 
individual to offer price comparison guidance, or make available on an 
Internet website a price comparison tool, that (to the extent 
practicable) allows an individual enrolled under such plan or coverage, 
with respect to such plan year and such geographic region, to compare 
the amount (determined by historic claims data of participating 
providers with respect to such plan or coverage) of cost-sharing 
(including deductibles, copayments, and coinsurance) 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.''.
            (2) Conforming amendment.--Section 715(a) of the Employee 
        Retirement Income Security Act of 1974 (29 U.S.C. 1185d(a)), as 
        amended by section 2(c), is further amended--
                    (A) in paragraph (1), by striking ``section 2719A'' 
                and inserting ``section 2719A, 2730, 2731, or 2732''; 
                and
                    (B) in paragraph (2), by striking ``section 2719A'' 
                and inserting ``section 2719A, 2730, 2731, or 2732''.
            (3) 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 items:

``Sec. 717. Continuity of care.
``Sec. 718. Information required to be included on health insurance 
                            membership cards.
``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. 10. REPORTING REQUIREMENTS REGARDING AIR AMBULANCE SERVICES.

    (a) Reporting Requirements for Providers of Air Ambulance 
Services.--
            (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 plan 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
                    (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 group health 
                plans, health insurance issuers, and Government payors.
                    (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.
    (b) Reporting Requirements for Group Health Plans and Health 
Insurance Issuers.--
            (1) In general.--Each group health plan and health 
        insurance issuer offering health insurance coverage in the 
        individual or group market shall submit to the Secretary of 
        Health and Human Services--
                    (A) not later than the date that is 90 days after 
                the last day of the first plan 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
                    (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 
        group health plan or a health insurance issuer offering health 
        insurance coverage in the individual or group market, is each 
        of the following:
                    (A) Claims data for air ambulance services 
                furnished by providers of such services, disaggregated 
                by each of the following factors:
                            (i) Whether such services were furnished on 
                        an emergent or nonemergent basis.
                            (ii) Whether the provider of such services 
                        is part of a hospital-owned or sponsored 
                        program, municipality-sponsored program, 
                        hospital independent partnership (hybrid) 
                        program, or independent program.
                            (iii) Whether such services were furnished 
                        in a rural or urban area.
                            (iv) The type of aircraft (such as rotor 
                        transport or fixed wing transport) used to 
                        furnish such services.
                            (v) 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.
                    (B) Such other information regarding providers of 
                air ambulance services as the Secretary of Health and 
                Human Services may specify.
    (c) Publication of Comprehensive Report.--
            (1) In general.--Not later than the date that is one year 
        after the date described in subsection (b)(1)(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 subsections (a) and (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 health insurance 
                coverage in the individual or group market to providers 
                of air ambulance services for furnishing such services, 
                and amounts paid out-of-pocket 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 health insurance 
                coverage in the individual or group market 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 instances of 
                group health plans or health insurance issuers not 
                providing substantial reasons for refusing to enter 
                into contract negotiations with providers of air 
                ambulance services.
                    (I) An assessment of whether there are, within the 
                air ambulance industry, instances of unreasonable 
                industry 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.
                    (J) 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, 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.
                    (K) An assessment of the frequency of claims 
                appeals made by providers of air ambulance services to 
                group health plans or health insurance issuers offering 
                health insurance coverage in the individual or group 
                market with respect to air ambulance services furnished 
                to enrollees of such plans or coverage, respectively.
                    (L) 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 third-party 
        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 subsections (a) and (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 penalty 
        imposed under paragraph (1) if such provider demonstrates a 
        good faith effort 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) Understanding Air Ambulance Quality and Patient Safety.--Not 
later than 1 year after the date of the enactment of this Act, the 
Comptroller General of the United States shall conduct a study and 
submit to Congress a report on options to establish quality, patient 
safety, service reliability, and clinical capability standards for each 
clinical capability level of air ambulances. Such report shall include 
analysis and recommendations, as appropriate, to Congress regarding 
each of the following with respect to air ambulance services:
            (1) Qualifications of different clinical capability levels 
        and tiering of such levels.
            (2) Patient safety and quality standards.
            (3) Options for improving service reliability during poor 
        weather, night conditions, or other adverse conditions.
            (4) Differences between air ambulance vehicle types, 
        services, and technologies, and other flight capability 
        standards, and the impact of such differences on patient 
        safety.
            (5) Clinical triage criteria for air ambulances.
    (h) Definitions.--In this section, the terms ``group health plan'', 
``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. 11. GAO REPORT ON EFFECTS OF LEGISLATION.

    Not later than 2 years after the date of the enactment of this Act, 
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 such period 
in health care provider networks of group health plans and health 
insurance coverage offered by a health insurance issuer in the group or 
individual market, 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; and
            (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; and
                    (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 health insurance coverage 
                offered by health insurance issuers in the group or 
                individual market.

SEC. 12. TRANSITIONAL RULE ALLOWING DEDUCTION FOR SURPRISE BILLING 
              EXPENSES BELOW AGI FLOOR.

    (a) In General.--Section 213 of the Internal Revenue Code of 1986 
is amended by adding at the end the following new subsection:
    ``(g) Transitional Rule Allowing Deduction for Surprise Billing 
Expenses Below AGI Floor.--
            ``(1) In general.--In addition to the deduction allowed by 
        subsection (a) for any taxable year, there shall be allowed as 
        a deduction an amount equal to the lesser of--
                    ``(A) the excess of--
                            ``(i) the surprise billing expenses which 
                        would be allowed as a deduction for such 
                        taxable year under subsection (a) if such 
                        subsection were applied without regard to the 
                        limitation based on the taxpayer's adjusted 
                        gross income, over
                            ``(ii) $600, or
                    ``(B) the applicable percentage of the taxpayer's 
                adjusted gross income.
            ``(2) Surprise billing expenses.--For purposes of this 
        subsection, the term `surprise billing expenses' means expenses 
        paid for medical care of an individual who is a participant, 
        beneficiary, or enrollee in a group health plan or in group or 
        individual health insurance coverage offered by a health 
        insurance issuer (as such terms are defined in section 2791 of 
        the Public Health Service Act), if--
                    ``(A) benefits are provided for such medical care 
                under such plan or coverage, and
                    ``(B) such medical care--
                            ``(i) is furnished by a provider without a 
                        contractual relationship with such plan or 
                        coverage with respect to the furnishing of such 
                        medical care during a visit at a facility with 
                        a contractual relationship with such plan or 
                        coverage, or
                            ``(ii) is furnished in an emergency 
                        department of a hospital or an independent 
                        freestanding emergency department.
            ``(3) Applicable percentage.--For purposes of this section, 
        the term `applicable percentage' means, with respect to any 
        taxpayer for any taxable year, the percentage in effect under 
        subsection (a) with respect to such taxpayer for such taxable 
        year.
            ``(4) Limitations.--Surprise billing expenses shall be 
        taken into account under paragraph (1) only if such expenses 
        are paid during the period beginning on January 1, 2020, and 
        ending on the date which is 1 year after the day before the 
        date specified in section 2(a)(5) of the Consumer Protections 
        Against Surprise Medical Bills Act of 2020.''.
    (b) Conforming Amendments.--Sections 105(f), 162(l)(3), and 
7702B(e)(2) of such Code are each amended by striking ``213(a)'' and 
inserting ``213''.
    (c) Effective Date.--The amendments made by this section shall 
apply to taxable years ending after December 31, 2019.
                                 <all>