[House Report 118-258]
[From the U.S. Government Publishing Office]


118th Congress    }                                     {       Report
                          HOUSE OF REPRESENTATIVES
 1st Session      }                                     {      118-258

======================================================================

 
                  TRANSPARENCY IN BILLING ACT OF 2023

                                _______
                                

November 1, 2023.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

Ms. Foxx, from the Committee on Education and the Workforce, submitted 
                             the following

                              R E P O R T

                        [To accompany H.R. 4509]

    The Committee on Education and the Workforce, to whom was 
referred the bill (H.R. 4509) to amend the Employee Retirement 
Income Security Act of 1974 to require group health plans and 
health insurance issuers offering group health insurance 
coverage to only pay claims submitted by hospitals that have in 
place policies and procedures to ensure accurate billing 
practices, and for other purposes, having considered the same, 
reports favorably thereon with an amendment and recommends that 
the bill as amended do pass.
    The amendment is as follows:
    Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``Transparency in Billing Act of 2023''.

SEC. 2. HONEST BILLING REQUIREMENTS.

  (a) In General.--Subpart B of part 7 of subtitle B of title I of the 
Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et 
seq.) is amended by adding at the end the following new section:

``SEC. 726. HONEST BILLING REQUIREMENTS.

  ``A group health plan or health insurance issuer offering group 
health insurance coverage may not pay a claim for items and services 
furnished to an individual at an off-campus outpatient department of a 
provider (as defined in section 901(c)) submitted by a hospital (as 
defined in section 1861(e) of the Social Security Act) unless such 
claim submitted by such hospital includes the separate unique health 
identifier for the department where items and services were furnished, 
in accordance with section 901.''.
  (b) Clerical Amendment.--The table of contents of the Employee 
Retirement Income Security Act of 1974 (29 U.S.C. 1001 note) is amended 
by adding after the item relating to section 725 the following:

``Sec. 726. Honest billing requirements.''.

  (c) Effective Date.--The amendments made by this section shall take 
effect with respect to plan years beginning on or after January 1, 
2024.

SEC. 3. REGULATION OF HONEST BILLING.

  (a) In General.--Subtitle B of title I of the Employee Retirement 
Income Security Act of 1974 (29 U.S.C. 1021 et seq.) is amended by 
adding at the end the following new part:

 ``PART 9--BILLING REQUIREMENTS WITH RESPECT TO GROUP HEALTH PLANS AND 
                                COVERAGE

``SEC. 901. HONEST BILLING REQUIREMENTS.

  ``(a) In General.--A hospital may not, with respect to items and 
services furnished to an individual at an off-campus outpatient 
department of a provider, submit a claim for such items and services to 
a group health plan or health insurance issuer, and may not hold such 
individual liable for such items and services, unless--
          ``(1) such hospital obtains a separate unique health 
        identifier established for such department pursuant to section 
        1173(b) of the Social Security Act; and
          ``(2) the claim for such items and services includes such 
        separate unique health identifier for such department where 
        such items and services were furnished.
  ``(b) Process for Reporting Suspected Violations.--Not later than one 
year after the date of enactment of this section, the Secretary shall 
establish a process under which a suspected violation of this section 
may be reported to such Secretary.
  ``(c) Off-campus Outpatient Department of a Provider Defined.--For 
purposes of this paragraph, the term `off-campus outpatient department 
of a provider' means a department of a provider (as defined in section 
413.65 of title 42, Code of Federal Regulations, or any successor 
regulation) that is not located--
          ``(1) on the campus (as defined in such section) of such 
        provider; or
          ``(2) within the distance (described in such definition of 
        campus) from a remote location of a hospital facility (as 
        defined in such section).''.
  (b) Clerical Amendment.--The table of contents of the Employee 
Retirement Income Security Act of 1974 (29 U.S.C. 1001 note) is amended 
by inserting after the item relating to section 804 the following new 
item:

 ``Part 9--Billing Requirements With Respect to Group Health Plans and 
                                Coverage

``Sec. 901. Honest billing requirements.''.

SEC. 4. ENFORCEMENT.

  Section 502 of the Employee Retirement Income Security Act of 1974 
(29 U.S.C. 1132) is amended--
          (1) in subsection (a)(6), by striking ``or (9)'' and 
        inserting ``(9), or (13)''; and
          (2) in subsection (c), by adding at the end the following new 
        paragraph:
          ``(13) The Secretary may assess a civil monetary penalty 
        against a hospital for a violation under section 901 in an 
        amount--
                  ``(A) in the case of a hospital with not more than 30 
                beds (as determined under section 180.90(c)(2)(ii)(D) 
                of title 45, Code of Federal Regulations, as in effect 
                on the date of the enactment of this paragraph), not to 
                exceed $300 per day that the violation is ongoing, as 
                determined by the Secretary; and
                  ``(B) in the case of a hospital with more than 30 
                beds (as so determined), not to exceed $5,500 per each 
                such day.''.

SEC. 5. IMPLEMENTATION.

  The Secretary of Labor shall implement the amendments made by this 
Act by rulemaking.

                                Purpose

    The hospital industry is the largest contributor to 
national health expenditures, accounting for nearly one of 
every three dollars spent on health care in the United 
States.\1\ In addition, perverse economic incentives in health 
care have fueled provider consolidation, creating upward 
pressure on health care costs.
---------------------------------------------------------------------------
    \1\https://www.cms.gov/files/document/highlights.pdf.
---------------------------------------------------------------------------
    H.R. 4509, the Transparency in Billing Act, amends the 
Employee Retirement Income Security Act of 1974 (ERISA)\2\ to 
require group health plans and health insurance issuers 
offering group health insurance coverage only to pay claims 
submitted by hospitals that have in place policies and 
procedures to ensure accurate billing practices. This 
legislation includes commonsense provisions to ensure that 
group health plans only pay for services that are appropriately 
billed for the correct site of service, and it prevents 
hospitals from obscuring the true site of service in order to 
charge higher prices via facility fees or other charges.
---------------------------------------------------------------------------
    \2\29 U.S.C. Sec. 1001 et seq.
---------------------------------------------------------------------------

                            Committee Action


                             116TH CONGRESS

Subcommittee Hearing on Examining Surprise Billing: Protecting Patients 
        from Financial Pain

    On April 2, 2019, the Subcommittee on Health, Employment, 
Labor, and Pensions (HELP) held a hearing entitled ``Examining 
Surprise Billing: Protecting Patients from Financial Pain,'' 
which discussed provider billing practices, including 
unexpected costs to consumers due, in part, to a lack of 
transparency. Witnesses further discussed the impact that 
increased transparency could have on boosting competition in 
health care. The witnesses were Ms. Ilyse Schuman, Senior Vice 
President, Health Policy, American Benefits Council, 
Washington, D.C.; Dr. Jack Hoadley, Research Professor 
Emeritus, Health Policy Institute, Georgetown University 
McCourt School of Public Policy, McLean, VA; Mr. Frederick 
Isasi, Executive Director, Families USA, Washington, D.C.; and 
Ms. Christen Linke Young, Fellow, USC-Brookings Schaeffer 
Initiative on Health Policy, Washington, D.C.

Full Committee Markup of H.R. 5800, the Ban Surprise Billing Act

    On February 11, 2020, the Committee met to mark up H.R. 
5800, the Ban Surprise Billing Act, introduced by then-Chairman 
Robert C. ``Bobby'' Scott (D-VA-3) and then-Ranking Member 
Virginia Foxx (R-NC-5). The legislation protected participants 
in employer-provided health plans from exorbitant out-of-
network costs and included provisions improving transparency 
with respect to group health plan service providers, including 
those providing brokerage and consulting services. The 
Committee favorably reported the bill by a vote of 32 yeas and 
13 nays.

                             118TH CONGRESS

Subcommittee Hearing on Reducing Health Care Costs for Working 
        Americans and Their Families

    On April 26, 2023, the HELP Subcommittee held a hearing 
entitled ``Reducing Health Care Costs for Working Americans and 
Their Families,'' which examined challenges facing employer-
sponsored health coverage, including the need for increased 
transparency in health care, addressing dishonest hospital 
billing practices, and lowering costs by expanding oversight of 
pharmacy benefit managers (PBMs). The witnesses were Mr. Joel 
White, President, Council for Affordable Health Coverage, 
Washington, D.C.; Mrs. Tracy Watts, Senior Partner, Mercer, 
Washington, D.C.; Ms. Marcie Strouse, Partner, Capitol Benefits 
Group, Des Moines, Iowa; and Ms. Sabrina Corlette, J.D., 
Research Professor and Co-Director, Center on Health Insurance 
Reforms, Georgetown University McCourt School of Public Policy, 
Washington, D.C.

Subcommittee Hearing on Competition and Transparency: The Pathway 
        Forward for a Stronger Health Care Market

    On June 21, 2023, the HELP Subcommittee held a hearing 
entitled ``Competition and Transparency: The Pathway Forward 
for a Stronger Health Care Market,'' which examined the need to 
improve competition and transparency in health care through 
honest billing practices, improving transparency rules, and 
addressing the role of PBMs in the health care market. The 
witnesses were Dr. Gloria Sachdev, President and CEO, 
Employers' Forum of Indiana, Carmel, Indiana; Ms. Sophia 
Tripoli, Senior Director of Health Policy and Director of the 
Center for Affordable Whole-Person Care, Families USA, 
Washington, D.C.; Mr. Greg Baker, CEO, AffirmedRx, Louisville, 
Kentucky; Ms. Christine Monahan, Assistant Research Professor, 
Center on Health Insurance Reforms, Georgetown University 
McCourt School of Public Policy, Washington, D.C.; and Mr. Juan 
Carlos ``JC'' Scott, President and CEO, Pharmaceutical Care 
Management Association, Washington, D.C.

Full Committee Markup of H.R. 4509, the Transparency in Billing Act

    On July 10, 2023, Chairwoman Foxx and Ranking Member Scott 
introduced H.R. 4509, the Transparency in Billing Act. On July 
12, 2023, the Committee met to mark up H.R. 4509 and adopted an 
Amendment in the Nature of a Substitute offered by Rep. Aaron 
Bean (R-FL-4), which made technical changes to H.R. 4509. The 
Committee reported the bill favorably, as amended, to the House 
of Representatives by a vote of 39 yeas and 0 nays.

                            Committee Views


                              INTRODUCTION

    Competition can drive innovation, improve quality, and 
lower prices. Unfortunately, the health care system has become 
increasingly consolidated in recent decades. Three PBM 
companies control nearly 90 percent of the market;\3\ health 
plans are becoming vertically integrated and purchasing primary 
and specialty care offices;\4\ and hospitals are consolidating 
at a rapid rate. From 1998 to 2015, 1,412 hospitals merged,\5\ 
and 90 percent of metropolitan statistical areas are considered 
consolidated for hospital services.\6\ The percentage of 
physicians' practices that are owned by or affiliated with 
hospitals has also increased.\7\
---------------------------------------------------------------------------
    \3\https://content.naic.org/cipr-topics/pharmacy-benefit-managers.
    \4\https://www.reuters.com/business/healthcare-pharmaceuticals/
which-cvs-rivals-also-own-primary-care-services-2023-02-08/.
    \5\https://www.aei.org/research-products/report/hospital-
competition-and-restrictions-on-physician-owned-hospitals/.
    \6\https://www.aei.org/research-products/report/policy-solutions-
for-hospital-consolidation/.
    \7\https://www.cbo.gov/publication/57778.
---------------------------------------------------------------------------
    Consolidation in health care has contributed to 
significantly higher prices in the commercial market compared 
to Medicare. A recent Congressional Budget Office (CBO) report 
found that commercial insurers' prices were 240 percent of 
Medicare fee-for-service prices for outpatient services and 182 
percent for inpatient services.\8\ Additionally, the prices 
that commercial insurers pay hospitals are much higher than 
hospitals' costs.\9\
---------------------------------------------------------------------------
    \8\Id.
    \9\Id.
---------------------------------------------------------------------------
    Given that hospital prices are the number one contributor 
to national health care expenditures, Congress has taken 
previous action to rein in spending on services provided at 
off-campus hospital outpatient departments (HOPDs). The 
Bipartisan Budget Act of 2015 established ``site-neutral'' 
payments under Medicare for services provided in HOPDs.\10\ 
However, the law exempted existing off- campus HOPDs and those 
under construction from complying with the requirement. As a 
result, in practice, often Medicare still pays more for 
services provided at HOPDs than it does when the same services 
are provided in a doctor's office or outside of the hospital. 
In 2022, ``Medicare [paid] 141 percent more in an HOPD than in 
a freestanding office for the first hour of chemotherapy 
infusion.''\11\
---------------------------------------------------------------------------
    \10\Pub. L. No. 114-74 (2015).
    \11\https://www.medpac.gov/document/june-2022-report-to-the-
congress-medicare-and-the-health-care-delivery-system/.
---------------------------------------------------------------------------
    Similar issues exist in the commercial market. Hospitals 
bill private health plans at higher rates than Medicare and 
often tack on hospital facility fees for provider office 
visits. In fact, prices for services provided by acquired 
physicians increase by an average of 14.1 percent after 
acquisition.\12\ Hospital consolidation and a lack of pricing 
information contribute to private plans paying double what 
Medicare would have paid for the same services.\13\ Estimated 
savings gained from applying site-neutral payments to the 
commercial market could reach nearly $60 billion annually.\14\
---------------------------------------------------------------------------
    \12\https://pubmed.ncbi.nlm.nih.gov/29727744/.
    \13\https://www.rand.org/health-care/projects/price-transparency/
hospital-pricing.html.
    \14\https://7fe67d73-acdc-4d7a-9f6a-0a2c5dd0a4bc.usrfiles.com/ugd/
7fe67d_b20c817a6e314fb0a05e331a22a2d995.pdf.
---------------------------------------------------------------------------
    During the HELP Subcommittee's June 21, 2023, hearing, Ms. 
Sachdev spoke to the need for legislation to protect plans from 
hospital facility fees applied to outpatient services, citing 
recent actions in Indiana.\15\ Ms. Monahan elaborated on this 
point, citing the challenges that plans and insurers face in 
identifying outpatient services, given the lack of transparency 
requirements on hospitals to identify services provided in the 
outpatient setting.\16\ Ms. Tripoli further provided examples 
of patients charged high hospital-facility fees, despite never 
setting foot in the hospital charging them.\17\ Members and 
witnesses called for legislation to protect employers and 
workers from unnecessary costs by requiring honest billing 
practices from hospitals for outpatient services.
---------------------------------------------------------------------------
    \15\https://edworkforce.house.gov/uploadedfiles/
sachdev_testimony.pdf.
    \16\https://edworkforce.house.gov/uploadedfiles/
monahan_testimony.pdf.
    \17\https://edworkforce.house.gov/uploadedfiles/
tripoli_testimony.pdf.
---------------------------------------------------------------------------

Support for Transparency in Billing

    Plans and consumers recognize the value of appropriate 
billing for health care services. Better Solutions for 
Healthcare applauded the Committee's focus on ensuring honest 
billing practices by hospitals to promote competition and 
transparency and to prevent markups of prices for services, all 
of which create market distortions.\18\ Similarly, Families USA 
praised the Committee's work ``to begin to remedy some of the 
most obvious health system failings by advancing legislation to 
rein in dishonest billing practices.''\19\
---------------------------------------------------------------------------
    \18\https://bettersolutionsforhealthcare.org/press-release-better-
solutions-applauds-congressional-scrutiny-on-dishonest- billing/
    \19\https://familiesusa.org/press-releases/families-usa-congress-
continues-to-make-important-strides-toward-improved- transparency/.
---------------------------------------------------------------------------

               H.R. 4509, THE TRANSPARENCY IN BILLING ACT

    H.R. 4509, the Transparency in Billing Act, amends ERISA to 
require group health plans and health insurance issuers 
offering group health insurance coverage only to pay claims 
submitted by hospitals that have in place policies and 
procedures to ensure accurate billing practices. H.R. 4509 
prevents hospitals from submitting claims without a separate 
unique health identifier for the off-campus outpatient 
department. By imposing this requirement, the legislation 
ensures that group health plans only pay for services that are 
appropriately billed for the correct site of service, and it 
prevents hospitals from obscuring the true site of service in 
order to charge higher prices via facility fees or other 
charges.

                               CONCLUSION

    H.R. 4509, the Transparency in Billing Act, reaffirms 
common sense: hospitals should only be allowed to bill at the 
correct price for the site of care where services are rendered. 
If a service is provided at an outpatient facility, it should 
be billed at the rate associated with the off-campus outpatient 
department, not as if it was provided at a hospital. The bill 
also protects plans from paying for claims for services 
rendered at an off-campus outpatient department that are 
incorrectly billed. These are important protections for plans 
and the participants and beneficiaries that they serve. 
Codifying these protections in ERISA ensures that the vast 
majority of insured Americans will benefit from these 
protections, which will result in cost savings for employers 
and workers alike.

                                Summary


                  H.R. 4509 SECTION BY SECTION SUMMARY

    The following is a section-by-section analysis of H.R. 
4509, the Transparency in Billing Act, introduced by Chairwoman 
Foxx and Ranking Member Scott and reported favorably by the 
Committee.

Section 1. Short title

    Section 1 provides that the short title is ``Transparency 
in Billing Act.''

Section 2. Honest billing requirements

    Section 2 amends the Employee Retirement Income Security 
Act of 1974 (ERISA) to prevent group health plans and health 
insurance issuers from paying a claim submitted by a hospital 
unless the hospital is in compliance with Section 3. The 
effective date of Section 2 is January 1, 2024.

Section 3. Regulation of honest billing

    Section 3 amends ERISA to disallow hospitals from 
submitting a claim for items or services furnished at an off-
campus outpatient department to a group health plan or health 
insurance issuer unless (1) the hospital obtains a separate 
unique health identifier for the off-campus outpatient 
department, and (2) the claim for these items or services 
furnished at an off-campus outpatient department includes a 
separate unique health identifier.

Section 4. Enforcement

    Section 4 authorizes the U.S. Secretary of Labor to assess 
civil monetary penalties against hospitals for violations: $300 
per day for ongoing violations for hospitals with not more than 
30 beds and $5,500 per day for ongoing violations for hospitals 
with more than 30 beds.

                       Explanation of Amendments

    The amendments, including the amendment in the nature of a 
substitute, are explained in the body of this report.

            Application of the Law to the Legislative Branch

    Section 102(b)3 of Public Law 104-1 requires a description 
of the application of this bill to the legislative branch. H.R. 
4509 takes important steps to increase accountability that will 
benefit health care consumers--including access for any 
eligible employees of the Legislative Branch--by protecting 
employer-sponsored health plans from paying for incorrectly 
billed outpatient health claims.

         Statement of General Performance Goals and Objections

    The goal of H.R. 4509 is to protect employer-sponsored 
health plans from overpaying for services that are incorrectly 
billed by hospital outpatient facilities.

            Required Committee Hearing and Related Hearings

    In compliance with clause 3(c)(6) of rule XIII of the Rules 
of House of Representatives, the following hearings held during 
the 118th Congress were used to develop or consider H.R. 4509: 
on April 26, 2023, the HELP Subcommittee held a hearing 
entitled ``Reducing Health Care Costs for Working Americans and 
Their Families''; on June 13, 2023, the Committee held a 
hearing entitled ``Examining the Policies and Priorities of the 
U.S. Department of Health and Human Services''; and on June 21, 
2023, the HELP Subcommittee held a hearing entitled 
``Competition and Transparency: The Pathway Forward for a 
Stronger Health Care Market.''

                       Unfunded Mandate Statement

    Pursuant to Section 423 of the Congressional Budget and 
Impoundment Control Act of 1974, Pub. L. No. 93-344 (as amended 
by Section 101(a)(2) of the Unfunded Mandates Reform Act of 
1995, Pub. L. No. 104-4), the Committee adopts as its own the 
cost estimate prepared by the Congressional Budget Office (CBO) 
pursuant to section 402 of the Congressional Budget and 
Impoundment Control Act of 1974.

                           Earmark Statement

    H.R. 4509 does not contain any congressional earmarks, 
limited tax benefits, or limited tariff benefits as defined in 
clause 9 of rule XXI of the Rules of the House of 
Representatives.

                            Roll Call Votes

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee Report to include, for 
each record vote on a motion to report the measure or matter 
and on any amendments offered to the measure or matter, the 
total number of votes for and against and the names of the 
Members voting for and against.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                    Duplication of Federal Programs

    No provision of H.R. 4509 establishes or reauthorizes a 
program of the Federal Government known to be duplicative of 
another Federal program, a program that was included in any 
report from the Government Accountability Office to Congress 
pursuant to section 21 of Public Law 111-139, or a program 
related to a program identified in the most recent Catalog of 
Federal Domestic Assistance.

  Statement of Oversight Findings and Recommendations of the Committee

    In compliance with clause 3(c)(1) of rule XIII and clause 
2(b)(1) of rule X of the Rules of the House of Representatives, 
the Committee's oversight findings and recommendations are 
reflected in the body of this report.

               New Budget Authority and CBO Cost Estimate

    With respect to the requirements of clause 3(c)(2) of rule 
XIII of the Rules of the House of Representatives and section 
308(a) of the Congressional Budget Act of 1974 and with respect 
to requirements of clause 3(c)(3) of rule XIII of the Rules of 
the House of Representatives and section 402 of the 
Congressional Budget Act of 1974, the Committee requested a 
cost estimate from the Congressional Budget Office. The 
Committee adopts the following estimate for H.R. 4509 provided 
by the Congressional Budget Office to Majority staff via email 
on August 16, 2023: ``For H.R. 4509 (Transparency in Billing 
Act of 2023, with time stamp July 11, 2023 at 9:50am), 
consistent with the preliminary estimate we shared on 7/6/2023, 
we estimate over the 2024-2033 period, there would be a 
decrease in direct spending by $403 million and increase in 
revenues by $1,919 million, for a total decrease in the deficit 
of about $2,321 million (components do not sum to total due to 
rounding). Of that reduction in the deficit, $81 million is a 
reduction in Medicare outlays.''

                        Committee Cost Estimate

    Clause 3(d)(1) of rule XIII of the Rules of the House of 
Representatives requires an estimate and a comparison of the 
costs that would be incurred in carrying out H.R. 4509. 
However, clause 3(d)(2)(B) of that rule provides that this 
requirement does not apply when, as with the present report, 
the committee adopts as its own the cost estimate of the bill 
prepared by the Congressional Budget Office under section 402 
of the Congressional Budget Act.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italics, and existing law in which no 
change is proposed is shown in roman):

            EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974


                   short title and table of contents

  Section 1. This Act may be cited as the ``Employee Retirement 
Income Security Act of 1974''.

                            TABLE OF CONTENTS

Sec. 1. Short title and table of contents.
     * * * * * * *

                 Part 7--Group Health Plan Requirements

     * * * * * * *

                      Subpart B--Other Requirements

     * * * * * * *
Sec. 726. Honest billing requirements.
     * * * * * * *

  Part 9--Billing Requirements with Respect to Group Health Plans and 
                                Coverage.

Sec. 901. Honest billing requirements.
     * * * * * * *

TITLE I--PROTECTION OF EMPLOYEE BENEFIT RIGHTS

           *       *       *       *       *       *       *



Subtitle B--Regulatory Provisions

           *       *       *       *       *       *       *



Part 5--Administration and Enforcement

           *       *       *       *       *       *       *



                           civil enforcement

  Sec. 502. (a) A civil action may be brought--
          (1) by a participant or beneficiary--
                  (A) for the relief provided for in subsection 
                (c) of this section, or
                  (B) to recover benefits due to him under the 
                terms of his plan, to enforce his rights under 
                the terms of the plan, or to clarify his rights 
                to future benefits under the terms of the plan;
          (2) by the Secretary, or by a participant, 
        beneficiary or fiduciary for appropriate relief under 
        section 409;
          (3) by a participant, beneficiary, or fiduciary (A) 
        to enjoin any act or practice which violates any 
        provision of this title or the terms of the plan, or 
        (B) to obtain other appropriate equitable relief (i) to 
        redress such violations or (ii) to enforce any 
        provisions of this title or the terms of the plan;
          (4) by the Secretary, or by a participant, or 
        beneficiary for appropriate relief in the case of a 
        violation of section 105(c) or 113(a);
          (5) except as otherwise provided in subsection (b), 
        by the Secretary (A) to enjoin any act or practice 
        which violates any provision of this title, or (B) to 
        obtain other appropriate equitable relief (i) to 
        redress such violation or (ii) to enforce any provision 
        of this title;
          (6)by the Secretary to collect any civil penalty 
        under paragraph (2), (4), (5), (6), (7), (8), [or (9)] 
        (9), or (13)  of subsection (c) or under subsection (i) 
        or (l);
          (7) by a State to enforce compliance with a qualified 
        medical child support order (as defined in section 
        609(a)(2)(A));
          (8) by the Secretary, or by an employer or other 
        person referred to in section 101(f)(1), (A) to enjoin 
        any act or practice which violates subsection (f) of 
        section 101, or (B) to obtain appropriate equitable 
        relief (i) to redress such violation or (ii) to enforce 
        such subsection;
          (9) in the event that the purchase of an insurance 
        contract or insurance annuity in connection with 
        termination of an individual's status as a participant 
        covered under a pension plan with respect to all or any 
        portion of the participant's pension benefit under such 
        plan constitutes a violation of part 4 of this title or 
        the terms of the plan, by the Secretary, by any 
        individual who was a participant or beneficiary at the 
        time of the alleged violation, or by a fiduciary, to 
        obtain appropriate relief, including the posting of 
        security if necessary, to assure receipt by the 
        participant or beneficiary of the amounts provided or 
        to be provided by such insurance contract or annuity, 
        plus reasonable prejudgment interest on such amounts;
          (10) in the case of a multiemployer plan that has 
        been certified by the actuary to be in endangered or 
        critical status under section 305, if the plan 
        sponsor--
                  (A) has not adopted a funding improvement or 
                rehabilitation plan under that section by the 
                deadline established in such section, or
                  (B) fails to update or comply with the terms 
                of the funding improvement or rehabilitation 
                plan in accordance with the requirements of 
                such section,
        by an employer that has an obligation to contribute 
        with respect to the multiemployer plan or an employee 
        organization that represents active participants in the 
        multiemployer plan, for an order compelling the plan 
        sponsor to adopt a funding improvement or 
        rehabilitation plan or to update or comply with the 
        terms of the funding improvement or rehabilitation plan 
        in accordance with the requirements of such section and 
        the funding improvement or rehabilitation plan; or
          (11) in the case of a multiemployer plan, by an 
        employee representative, or any employer that has an 
        obligation to contribute to the plan, (A) to enjoin any 
        act or practice which violates subsection (k) of 
        section 101 (or, in the case of an employer, subsection 
        (l) of such section), or (B) to obtain appropriate 
        equitable relief (i) to redress such violation or (ii) 
        to enforce such subsection.
  (b)(1) In the case of a plan which is qualified under section 
401(a), 403(a), or 405(a) of the Internal Revenue Code of 1986 
(or with respect to which an application to so qualify has been 
filed and has not been finally determined) the Secretary may 
exercise his authority under subsection (a)(5) with respect to 
a violation of, or the enforcement of, parts 2 and 3 of this 
subtitle (relating to participation, vesting, and funding), 
only if--
          (A) requested by the Secretary of the Treasury, or
          (B) one or more participants, beneficiaries, or 
        fiduciaries, of such plan request in writing (in such 
        manner as the Secretary shall prescribe by regulation) 
        that he exercise such authority on their behalf. In the 
        case of such a request under this paragraph he may 
        exercise such authority only if he determines that such 
        violation affects, or such enforcement is necessary to 
        protect, claims of participants or beneficiaries to 
        benefits under the plan.
  (2) The Secretary shall not initiate an action to enforce 
section 515.
  (3) Except as provided in subsections (c)(9) and (a)(6) (with 
respect to collecting civil penalties under subsection (c)(9)), 
the Secretary is not authorized to enforce under this part any 
requirement of part 7 against a health insurance issuer 
offering health insurance coverage in connection with a group 
health plan (as defined in section 706(a)(1)). Nothing in this 
paragraph shall affect the authority of the Secretary to issue 
regulations to carry out such part.
  (c)(1) Any administrator (A) who fails to meet the 
requirements of paragraph (1) or (4) of section 606, section 
101(e)(1), section 101(f),, section 105(a), or section 113(a) 
with respect to a participant or beneficiary, or (B) who fails 
or refuses to comply with a request for any information which 
such administrator is required by this title to furnish to a 
participant or beneficiary (unless such failure or refusal 
results from matters reasonably beyond the control of the 
administrator) by mailing the material requested to the last 
known address of the requesting participant or beneficiary 
within 30 days after such request may in the court's discretion 
be personally liable to such participant or beneficiary in the 
amount of up to $100 a day from the date of such failure or 
refusal, and the court may in its discretion order such other 
relief as it deems proper. For purposes of this paragraph, each 
violation described in subparagraph (A) with respect to any 
single participant, and each violation described in 
subparagraph (B) with respect to any single participant or 
beneficiary, shall be treated as a separate violation.
  (2) The Secretary may assess a civil penalty against any plan 
administrator of up to $1,000 a day from the date of such plan 
administrator's failure or refusal to file the annual report 
required to be filed with the Secretary under section 
101(b)(1). For purposes of this paragraph, an annual report 
that has been rejected under section 104(a)(4) for failure to 
provide material information shall not be treated as having 
been filed with the Secretary.
  (3) Any employer maintaining a plan who fails to meet the 
notice requirement of section 101(d) with respect to any 
participant or beneficiary or who fails to meet the 
requirements of section 101(e)(2) with respect to any person or 
who fails to meet the requirements of section 302(d)(12)(E) 
with respect to any person may in the court's discretion be 
liable to such participant or beneficiary or to such person in 
the amount of up to $100 a day from the date of such failure, 
and the court may in its discretion order such other relief as 
it deems proper.
  (4) The Secretary may assess a civil penalty of not more than 
$1,000 a day for each violation by any person of subsection 
(j), (k), or (l) of section 101 or section 514(e)(3).
  (5) The Secretary may assess a civil penalty against any 
person of up to $1,000 a day from the date of the person's 
failure or refusal to file the information required to be filed 
by such person with the Secretary under regulations prescribed 
pursuant to section 101(g).
  (6) If, within 30 days of a request by the Secretary to a 
plan administrator for documents under section 104(a)(6), the 
plan administrator fails to furnish the material requested to 
the Secretary, the Secretary may assess a civil penalty against 
the plan administrator of up to $100 a day from the date of 
such failure (but in no event in excess of $1,000 per request). 
No penalty shall be imposed under this paragraph for any 
failure resulting from matters reasonably beyond the control of 
the plan administrator.
  (7) The Secretary may assess a civil penalty against a plan 
administrator of up to $100 a day from the date of the plan 
administrator's failure or refusal to provide notice to 
participants and beneficiaries in accordance with subsection 
(i) or (m) of section 101. For purposes of this paragraph, each 
violation with respect to any single participant or beneficiary 
shall be treated as a separate violation.
          (8) The Secretary may assess against any plan sponsor 
        of a multiemployer plan a civil penalty of not more 
        than $1,100 per day--
                  (A) for each violation by such sponsor of the 
                requirement under section 305 to adopt by the 
                deadline established in that section a funding 
                improvement plan or rehabilitation plan with 
                respect to a multiemployer plan which is in 
                endangered or critical status, or
                  (B) in the case of a plan in endangered 
                status which is not in seriously endangered 
                status, for failure by the plan to meet the 
                applicable benchmarks under section 305 by the 
                end of the funding improvement period with 
                respect to the plan.
  (9)(A) The Secretary may assess a civil penalty against any 
employer of up to $100 a day from the date of the employer's 
failure to meet the notice requirement of section 
701(f)(3)(B)(i)(I). For purposes of this subparagraph, each 
violation with respect to any single employee shall be treated 
as a separate violation.
  (B) The Secretary may assess a civil penalty against any plan 
administrator of up to $100 a day from the date of the plan 
administrator's failure to timely provide to any State the 
information required to be disclosed under section 
701(f)(3)(B)(ii). For purposes of this subparagraph, each 
violation with respect to any single participant or beneficiary 
shall be treated as a separate violation.
          (10) Secretarial enforcement authority relating to 
        use of genetic information.--
                  (A) General rule.--The Secretary may impose a 
                penalty against any plan sponsor of a group 
                health plan, or any health insurance issuer 
                offering health insurance coverage in 
                connection with the plan, for any failure by 
                such sponsor or issuer to meet the requirements 
                of subsection (a)(1)(F), (b)(3), (c), or (d) of 
                section 702 or section 701 or 702(b)(1) with 
                respect to genetic information, in connection 
                with the plan.
                  (B) Amount.--
                          (i) In general.--The amount of the 
                        penalty imposed by subparagraph (A) 
                        shall be $100 for each day in the 
                        noncompliance period with respect to 
                        each participant or beneficiary to whom 
                        such failure relates.
                          (ii) Noncompliance period.--For 
                        purposes of this paragraph, the term 
                        ``noncompliance period'' means, with 
                        respect to any failure, the period--
                                  (I) beginning on the date 
                                such failure first occurs; and
                                  (II) ending on the date the 
                                failure is corrected.
                  (C) Minimum penalties where failure 
                discovered.--Notwithstanding clauses (i) and 
                (ii) of subparagraph (D):
                          (i) In general.--In the case of 1 or 
                        more failures with respect to a 
                        participant or beneficiary--
                                  (I) which are not corrected 
                                before the date on which the 
                                plan receives a notice from the 
                                Secretary of such violation; 
                                and
                                  (II) which occurred or 
                                continued during the period 
                                involved;
                        the amount of penalty imposed by 
                        subparagraph (A) by reason of such 
                        failures with respect to such 
                        participant or beneficiary shall not be 
                        less than $2,500.
                          (ii) Higher minimum penalty where 
                        violations are more than de minimis.--
                        To the extent violations for which any 
                        person is liable under this paragraph 
                        for any year are more than de minimis, 
                        clause (i) shall be applied by 
                        substituting ``$15,000'' for ``$2,500'' 
                        with respect to such person.
                  (D) Limitations.--
                          (i) Penalty not to apply where 
                        failure not discovered exercising 
                        reasonable diligence.--No penalty shall 
                        be imposed by subparagraph (A) on any 
                        failure during any period for which it 
                        is established to the satisfaction of 
                        the Secretary that the person otherwise 
                        liable for such penalty did not know, 
                        and exercising reasonable diligence 
                        would not have known, that such failure 
                        existed.
                          (ii) Penalty not to apply to failures 
                        corrected within certain periods.--No 
                        penalty shall be imposed by 
                        subparagraph (A) on any failure if--
                                  (I) such failure was due to 
                                reasonable cause and not to 
                                willful neglect; and
                                  (II) such failure is 
                                corrected during the 30-day 
                                period beginning on the first 
                                date the person otherwise 
                                liable for such penalty knew, 
                                or exercising reasonable 
                                diligence would have known, 
                                that such failure existed.
                          (iii) Overall limitation for 
                        unintentional failures.--In the case of 
                        failures which are due to reasonable 
                        cause and not to willful neglect, the 
                        penalty imposed by subparagraph (A) for 
                        failures shall not exceed the amount 
                        equal to the lesser of--
                                  (I) 10 percent of the 
                                aggregate amount paid or 
                                incurred by the plan sponsor 
                                (or predecessor plan sponsor) 
                                during the preceding taxable 
                                year for group health plans; or
                                  (II) $500,000.
                  (E) Waiver by secretary.--In the case of a 
                failure which is due to reasonable cause and 
                not to willful neglect, the Secretary may waive 
                part or all of the penalty imposed by 
                subparagraph (A) to the extent that the payment 
                of such penalty would be excessive relative to 
                the failure involved.
                  (F) Definitions.--Terms used in this 
                paragraph which are defined in section 733 
                shall have the meanings provided such terms in 
                such section.
  (11) The Secretary and the Secretary of Health and Human 
Services shall maintain such ongoing consultation as may be 
necessary and appropriate to coordinate enforcement under this 
subsection with enforcement under section 1144(c)(8) of the 
Social Security Act.
          (12) The Secretary may assess a civil penalty against 
        any sponsor of a CSEC plan of up to $100 a day from the 
        date of the plan sponsor's failure to comply with the 
        requirements of section 306(j)(3) to establish or 
        update a funding restoration plan.
          (13) The Secretary may assess a civil monetary 
        penalty against a hospital for a violation under 
        section 901 in an amount--
                  (A) in the case of a hospital with not more 
                than 30 beds (as determined under section 
                180.90(c)(2)(ii)(D) of title 45, Code of 
                Federal Regulations, as in effect on the date 
                of the enactment of this paragraph), not to 
                exceed $300 per day that the violation is 
                ongoing, as determined by the Secretary; and
                  (B) in the case of a hospital with more than 
                30 beds (as so determined), not to exceed 
                $5,500 per each such day.
  (d)(1) An employee benefit plan may sue or be sued under this 
title as an entity. Service of summons, subpena, or other legal 
process of a court upon a trustee or an administrator of an 
employee benefit plan in his capacity as such shall constitute 
service upon the employee benefit plan. In a case where a plan 
has not designated in the summary plan description of the plan 
an individual as agent for the service of legal process, 
service upon the Secretary shall constitute such service. The 
Secretary, not later than 15 days after receipt of service 
under the preceding sentence, shall notify the administrator or 
any trustee of the plan of receipt of such service.
  (2) Any money judgment under this title against an employee 
benefit plan shall be enforceable only against the plan as an 
entity and shall not be enforceable against any other person 
unless liability against such person is established in his 
individual capacity under this title.
  (e)(1) Except for actions under subsection (a)(1)(B) of this 
section, the district courts of the United States shall have 
exclusive jurisdiction of civil actions under this title 
brought by the Secretary or by a participant, beneficiary, 
fiduciary, or any person referred to in section 101(f)(1). 
State courts of competent jurisdiction and district courts of 
the United States shall have concurrent jurisdiction of actions 
under paragraphs (1)(B) and (7) of subsection (a) of this 
section.
  (2) Where an action under this title is brought in a district 
court of the United States, it may be brought in the district 
where the plan is administered, where the breach took place, or 
where a defendant resides or may be found, and process may be 
served in any other district where a defendant resides or may 
be found.
  (f) The district courts of the United States shall have 
jurisdiction, without respect to the amount in controversy or 
the citizenship of the parties, to grant the relief provided 
for in subsection (a) of this section in any action.
  (g)(1) In any action under this title (other than an action 
described in paragraph (2)) by a participant, beneficiary, or 
fiduciary, the court in its discretion may allow a reasonable 
attorney's fee and costs of action to either party.
  (2) In any action under this title by a fiduciary for or on 
behalf of a plan to enforce section 515 in which a judgment in 
favor of the plan is awarded, the court shall award the plan--
          (A) the unpaid contributions,
          (B) interest on the unpaid contributions,
          (C) an amount equal to the greater of--
                  (i) interest on the unpaid contributions, or
                  (ii) liquidated damages provided for under 
                the plan in an amount not in excess of 20 
                percent (or such higher percentage as may be 
                permitted under Federal or State law) of the 
                amount determined by the court under 
                subparagraph (A),
          (D) reasonable attorney's fees and costs of the 
        action, to be paid by the defendant, and
          (E) such other legal or equitable relief as the court 
        deems appropriate.
For purposes of this paragraph, interest on unpaid 
contributions shall be determined by using the rate provided 
under the plan, or, if none, the rate prescribed under section 
6621 of the Internal Revenue Code of 1986.
  (h) A copy of the complaint in any action under this title by 
a participant, beneficiary, or fiduciary (other than an action 
brought by one or more participants or beneficiaries under 
subsection (a)(1)(B) which is solely for the purpose of 
recovering benefits due such participants under the terms of 
the plan) shall be served upon the Secretary and the Secretary 
of the Treasury by certified mail. Either Secretary shall have 
the right in his discretion to intervene in any action, except 
that the Secretary of the Treasury may not intervene in any 
action under part 4 of this subtitle. If the Secretary brings 
an action under subsection (a) on behalf of a participant or 
beneficiary, he shall notify the Secretary of the Treasury.
  (i) In the case of a transaction prohibited by section 406 by 
a party in interest with respect to a plan to which this part 
applies, the Secretary may assess a civil penalty against such 
party in interest. The amount of such penalty may not exceed 5 
percent of the amount involved in each such transaction (as 
defined in section 4975(f)(4) of the Internal Revenue Code of 
1986) for each year or part thereof during which the prohibited 
transaction continues, except that, if the transaction is not 
corrected (in such manner as the Secretary shall prescribe in 
regulations which shall be consistent with section 4975(f)(5) 
of such Code) within 90 days after notice from the Secretary 
(or such longer period as the Secretary may permit), such 
penalty may be in an amount not more than 100 percent of the 
amount involved. This subsection shall not apply to a 
transaction with respect to a plan described in section 
4975(e)(1) of such Code.
  (j) In all civil actions under this title, attorneys 
appointed by the Secretary may represent the Secretary (except 
as provided in section 518(a) of title 28, United States Code), 
but all such litigation shall be subject to the direction and 
control of the Attorney General.
  (k) Suits by an administrator, fiduciary, participant, or 
beneficiary of an employee benefit plan to review a final order 
of the Secretary, to restrain the Secretary from taking any 
action contrary to the provisions of this Act, or to compel him 
to take action required under this title, may be brought in the 
district court of the United States for the district where the 
plan has its principal office, or in the United States District 
Court for the District of Columbia.
  (l)(1) In the case of--
          (A) any breach of fiduciary responsibility under (or 
        other violation of) part 4 by a fiduciary, or
          (B) any knowing participation in such a breach or 
        violation by any other person,
the Secretary shall assess a civil penalty against such 
fiduciary or other person in an amount equal to 20 percent of 
the applicable recovery amount.
  (2) For purposes of paragraph (1), the term ``applicable 
recovery amount'' means any amount which is recovered from a 
fiduciary or other person with respect to a breach or violation 
described in paragraph (1)--
          (A) pursuant to any settlement agreement with the 
        Secretary, or
          (B) ordered by a court to be paid by such fiduciary 
        or other person to a plan or its participants and 
        beneficiaries in a judicial proceeding instituted by 
        the Secretary under subsection (a)(2) or (a)(5).
  (3) The Secretary may, in the Secretary's sole discretion, 
waive or reduce the penalty under paragraph (1) if the 
Secretary determines in writing that--
          (A) the fiduciary or other person acted reasonably 
        and in good faith, or
          (B) it is reasonable to expect that the fiduciary or 
        other person will not be able to restore all losses to 
        the plan (or to provide the relief ordered pursuant to 
        subsection (a)(9)) without severe financial hardship 
        unless such waiver or reduction is granted.
  (4) The penalty imposed on a fiduciary or other person under 
this subsection with respect to any transaction shall be 
reduced by the amount of any penalty or tax imposed on such 
fiduciary or other person with respect to such transaction 
under subsection (i) of this section and section 4975 of the 
Internal Revenue Code of 1986.
  (m) In the case of a distribution to a pension plan 
participant or beneficiary in violation of section 206(e) by a 
plan fiduciary, the Secretary shall assess a penalty against 
such fiduciary in an amount equal to the value of the 
distribution. Such penalty shall not exceed $10,000 for each 
such distribution.

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Part 7--Group Health Plan Requirements

           *       *       *       *       *       *       *



Subpart B--Other Requirements

           *       *       *       *       *       *       *



SEC. 726. HONEST BILLING REQUIREMENTS.

  A group health plan or health insurance issuer offering group 
health insurance coverage may not pay a claim for items and 
services furnished to an individual at an off-campus outpatient 
department of a provider (as defined in section 901(c)) 
submitted by a hospital (as defined in section 1861(e) of the 
Social Security Act) unless such claim submitted by such 
hospital includes the separate unique health identifier for the 
department where items and services were furnished, in 
accordance with section 901.

           *       *       *       *       *       *       *


  PART 9--BILLING REQUIREMENTS WITH RESPECT TO GROUP HEALTH PLANS AND 
                                COVERAGE

SEC. 901. HONEST BILLING REQUIREMENTS.

  (a) In General.--A hospital may not, with respect to items 
and services furnished to an individual at an off-campus 
outpatient department of a provider, submit a claim for such 
items and services to a group health plan or health insurance 
issuer, and may not hold such individual liable for such items 
and services, unless--
          (1) such hospital obtains a separate unique health 
        identifier established for such department pursuant to 
        section 1173(b) of the Social Security Act; and
          (2) the claim for such items and services includes 
        such separate unique health identifier for such 
        department where such items and services were 
        furnished.
  (b) Process for Reporting Suspected Violations.--Not later 
than one year after the date of enactment of this section, the 
Secretary shall establish a process under which a suspected 
violation of this section may be reported to such Secretary.
  (c) Off-campus Outpatient Department of a Provider Defined.--
For purposes of this paragraph, the term ``off-campus 
outpatient department of a provider'' means a department of a 
provider (as defined in section 413.65 of title 42, Code of 
Federal Regulations, or any successor regulation) that is not 
located--
          (1) on the campus (as defined in such section) of 
        such provider; or
          (2) within the distance (described in such definition 
        of campus) from a remote location of a hospital 
        facility (as defined in such section).

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