,i #aaf? ,,congress #a/ ,session ,h4 ,r4 #cejb ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,june #bf1 #bjai,mr4 ,ruiz 7= himself1 ,mr4 ,buc%on1 ,mr4 ,morelle1 ,mr4 ,b]a1 ,mr4 ,w5/rup1 ,ms4 ,%alala1 ,mr4 ,taylor1 ,mr4 ,david ,p4 ,roe ( ,t5nessee1 ,mr4 ,banks1 ,mr4 ,higg9s ( ,new ,york1 ,mr4 ,grijalva1 ,mr4 ,cisn]os1 ,mr4 ,soto1 ,mr4 ,h>ris1 ,mr4 ,hudson1 ,ms4 ,s*ri]1 ,mr4 ,m>%all1 ,mr4 ,dunn1 ,mr4 ,/iv]s1 ,mr4 ,des,jarlais1 ,mr4 ,bur*ett1 ,mr4 ,riggleman1 ,mr4 ,watk9s1 ,mr4 ,joyce ( ,p5nsylvania1 ,mr4 ,smuck]1 ,ms4 ,/efanik1 ,mr4 ,?ompson ( ,p5nsylvania1 ,mr4 ,wright1 ,mr4 ,norcross1 ,mrs4 ,l[ey1 ,mr4 ,crd5as1 ,mr4 ,de,saulnier1 & ,ms4 ,kelly ( ,ill9ois7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committees on ,ways & ,means1 ,ov]sight & ,re=m1 & ,education & ,labor1 = a p]iod to be subsequ5tly det]m9$ by ! ,speak]1 9 ea* case = consid]ation ( su* provisions z fall )9 ! jurisdiction ( ! committee conc]n$ ,a ,,bill ,to am5d ! ,public ,heal? ,s]vice ,act & title ,,xi ( ! ,social ,security ,act to protect heal? c>e consum]s f surprise bill+ practices1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,protect+ ,p ,f ,surprise ,m$ical ,bills ,act4 7b7 ,table ( cont5ts ,! table ( cont5ts = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4 ,sec4 #b4 ,prev5t+ surprise m$ical bills4 ,sec4 #c4 ,transp>5cy reg>d+ 9-network & out-(-network d$uctibles4 ,sec4 #d4 ,transp>5cy = 9-network pati5ts4 ,sec4 #e4 ,report+ requirem5ts4 ,sec4 #f4 ,bill+ /atute ( limitations4 ,sec4 #g4 ,application4 ,sec4 #h4 ,/udies by ,secret>ies ( ,heal? & ,human ,s]vices & ( ,labor4 ,sec4 #i4 ,regulations4 #b4 ,prev5t+ surprise m$ical bills 7a7 ,em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is am5d$-- 7#a7 9 subsection 7b7-- 7,a7 9 p>agraph 7#a7-- 7i7 9 ! matt] prec$+ subp>agraph 7,a7-- 7,i7 by /rik+ (f]+ gr\p or individual heal? insurance issu] & ins]t+ (f]+ gr\p or individual heal? insurance cov]age2 & 7,,ii7 by /rik+ p>agraph 7#b77;,b7 & ins]t+ p>agraph 7#b72 7ii7 9 subp>agraph 7,b71 by ins]t+ or a p>ticipat+ em]g5cy facility1 z applicable1 aft] p>ticipat+ provid]2 & 7iii7 9 subp>agraph 7,c7-- 7,i7 9 ! matt] prec$+ clause 7i71 by ins]t+ by a nonp>ticipat+ provid] or a nonp>ticipat+ em]g5cy facility aft] enrollee2 7,,ii7 by /rik+ clause 7i72 7,,iii7 by /rik+ 7ii77,i7 su* s]vices & ins]t+ 7i7 su* s]vices2 7,,iv7 by /rik+ :]e ! provid] ( s]vices does n h a contractual relation%ip ) ! plan = ! provid+ ( s]vices2 7,v7 by /rik+ em]g5cy dep>tm5t s]vices receiv$ f provid]s :o d h su* a contractual relation%ip ) ! plan2 & & ins]t+ em]g5cy s]vices receiv$ f p>ticipat+ provid]s & p>ticipat+ em]g5cy facilities ) respect to su* plan22 7,,vi7 by /rik+ 7,,ii7 if su* s]vices & all t foll[s ?r\gh 7 provid$ 9-network & ins]t+ ! foll[+3 7ii7 ! co/-%>+ requirem5t 7express$ z a copaym5t am\nt1 co9surance rate1 or d$uctible7 is n great] ?an ! requirem5t t w\ld apply if su* s]vices 7 provid$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility2 2 & 7,,vii7 by add+ at ! end ! foll[+ new clauses3 7iii7 ! gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age pays to su* provid] or facility1 respectively1 subject to subsection 7f71 ! am\nt by :i* ! comm]cially reasonable rate1 z det]m9$ by ! plan or issu]1 = su* s]vices exce$s ! co/-%>+ am\nt = su* s]vices 7z det]m9$ 9 accordance ) clause 7ii7 &1 if applicable1 any am\nt to reconcile ! diff]5ce betwe5 su* rate s paid & ! specifi$ rate det]m9$ "u subsection 7f77#a77 = su* s]vices2 & 7iv7 !re %all be c\nt$ t[>d any d$uctible or out-(-pocket maximums appli$ "u ! plan any co/-%>+ paym5ts made by ! p>ticipant1 b5efici>y1 or enrollee ) respect to su* em]g5cy s]vices s furni%$ 9 ! same mann] z if su* co/-%>+ paym5ts 7 ) respect to em]g5cy s]vices furni%$ by a p>ticipat+ provid] & a p>ticipat+ em]g5cy facility4 2 & 7,b7 9 p>agraph 7#b7-- 7i7 9 ! matt] prec$+ subp>agraph 7,a71 by ins]t+ & subsection 7e7 aft] ?is subsection2 7ii7 by r$esignat+ subp>agraph 7,c7 z subp>agraph 7,h72 & 7iii7 by ins]t+ aft] subp>agraph 7,c7 ! foll[+ subp>agraphs3 7,d7 ,nonp>ticipat+ em]g5cy facility2 p>ticipat+ em]g5cy facility 7i7 ,nonp>ticipat+ em]g5cy facility ,! t]m nonp>ticipat+ em]g5cy facility means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu]1 an em]g5cy dep>tm5t ( a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t1 t does n h a contractual relation%ip ) ! plan or cov]age = furni%+ su* item or s]vice4 7ii7 ,p>ticipat+ em]g5cy facility ,! t]m p>ticipat+ em]g5cy facility means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu]1 an em]g5cy dep>tm5t ( a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t1 t has a contractual relation%ip ) ! plan or cov]age = furni%+ su* item or s]vice4 7,e7 ,nonp>ticipat+ provid]s2 p>ticipat+ provid]s 7i7 ,nonp>ticipat+ provid] ,! t]m nonp>ticipat+ provid] means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu]1 a physician or o!r heal? pr(essional :o is lic5s$ by ! ,/ate involv$ to furni% su* item or s]vice & :o does n h a contractual relation%ip ) ! plan or cov]age = furni%+ su* item or s]vice4 7ii7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu]1 a physician or o!r heal? pr(essional :o is lic5s$ by ! ,/ate involv$ to furni% su* item or s]vice & :o has a contractual relation%ip ) ! plan or cov]age = furni%+ su* item or s]vice4 4 7b7 ,non-,em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7e7 ,non-,em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities 7#a7 ,9 g5]al ,9 ! case ( items or s]vices 7o!r ?an em]g5cy s]vices to :i* subsection 7b7 applies7 furni%$ to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan 7z def9$ 9 p>agraph 7#b77;,a77 by a nonp>ticipat+ provid] 7z def9$ 9 subsection 7b77#b77;,g77 dur+ a visit at a p>ticipat+ heal? c>e facility 7z def9$ 9 p>agraph 7#b77;,b77 7includ+ imag+ or laboratory s]vices s furni%$ by a nonp>ticipat+ provid] :5 ord]$ by a p>ticipat+ provid] or aft]-em]g5cy c>e furni%$ by a nonp>ticipat+ provid] 9 ! case t ! p>ticipant1 b5efici>y1 or enrollee _c travel )\t m$ical transport71 ) respect to su* plan1 ! plan-- 7,a7 %all n impose on su* p>ticipant1 b5efici>y1 or enrollee a co/-%>+ am\nt 7express$ z a copaym5t am\nt or co9surance rate7 = su* items & s]vices s furni%$ t is great] ?an ! co/-%>+ am\nt t w\ld apply "u su* plan _h su* items or s]vices be5 furni%$ by a p>ticipat+ provid]2 7,b7 %all pay to su* provid] furni%+ su* items & s]vices to su* p>ticipant1 b5efici>y1 or enrollee1 subject to subsection 7f71 ! am\nt by :i* ! comm]cially reasonable rate1 z det]m9$ by ! plan or issu]1 = su* s]vices exce$s ! co/-%>+ am\nt impos$ = su* s]vices 7z det]m9$ 9 accordance ) subp>agraph 7,a77 &1 if applicable1 any am\nt to reconcile ! diff]5ce betwe5 su* rate s paid & ! specifi$ rate 7det]m9$ "u subsection 7f77#a77 = su* s]vices2 & 7,c7 %all c\nt t[>d any d$uctible or out-(-pocket maximums appli$ "u ! plan any co/-%>+ paym5ts made by ! p>ticipant1 b5efici>y1 or enrollee ) respect to su* items & s]vices s furni%$ 9 ! same mann] z if su* co/-%>+ paym5ts 7 ) respect to items & s]vices furni%$ by a p>ticipat+ provid]4 7#b7 ,def9itions ,9 ?is subsection & subsection 7f73 7,a7 ,heal? plan ,! t]m heal? plan means a gr\p heal? plan & heal? insurance cov]age (f]$ by a hea? insurance issu] 9 ! gr\p or individual m>ket4 7,b7 ,p>ticipat+ heal? c>e facility 7i7 ,9 g5]al ,! t]m p>ticipat+ heal? c>e facility means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu]1 a heal? c>e facility describ$ 9 clause 7ii7 t has a contractual relation%ip ) ! plan or cov]age = furni%+ su* item or s]vice4 7ii7 ,heal? c>e facility describ$ ,a heal? c>e facility describ$ 9 ?is clause is ea* ( ! foll[+3 7,i7 ,a hospital 7z def9$ 9 #ahfa7;e7 ( ! ,social ,security ,act74 7,,ii7 ,a critical access hospital 7z def9$ 9 section #ahfa7mm7 ( su* ,act74 7,,iii7 ,an ambulatory surgical c5t] 7z def9$ 9 section #ahcc7;i77#a77;,a7 ( su* ,act74 7,,iv7 ,a laboratory4 7,v7 ,a radiology or imag+ c5t]4 7,,vi7 ,any o!r facility t provides s]vices t are cov]$ "u a gr\p heal? plan or heal? insurance cov]age4 7,,vii7 ,any o!r facility specifi$ by ! ,secret>y4 4 7c7 ,negotiation & arbitration process = det]m9+ prices ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 z am5d$ by subsection 7b71 is fur!r am5d$ by add+ at ! end ! foll[+ new subsection3 7f7 ,negotiation & arbitration process 7#a7 ,specifi$ am\nt ,= purposes ( subsections 7b7 & 7e7 & ?is subsection1 ! specifi$ am\nt det]m9$ "u ?is subsection1 ) respect to a heal? plan & nonp>ticipat+ provid] = an item or s]vice1 is-- 7,a7 9 ! case ! plan & provid] ent] into negotiations pursuant to p>agraph 7#b7 & su* negotiations are successful1 ! am\nt det]m9$ = su* item or s]vice pursuant to su* negotiations2 or 7,b7 9 ! case ! plans & provid] ent] into su* negotiations b su* negotiations are n successful1 ! reasonable am\nt det]m9$ = su* item or s]vice pursuant to ! indep5d5t dispute resolution process "u p>agraph 7#c74 7#b7 ,negotiations ,= purposes ( subsections 7b77#a77;,c77iii7 & 7e77#a77;,b71 9 ! case ( a paym5t ( a comm]cially reasonable rate made by a heal? plan to a nonp>ticipat+ provid] pursuant to su* respective subsection = an item or s]vice1 ! provid] & plan may1 n lat] ?an #cj days aft] ! date ( su* paym5t1 negotiate an am\nt ( paym5t 7o!r ?an ! comm]cially reasonable rate specifi$ 9 su* subsection7 to be made = su* item or s]vice4 7#c7 ,indep5d5t dispute resolution 7,a7 ,9 g5]al ,if1 by ! end ( su* #cj-;day p]iod specifi$ 9 p>agraph 7#b71 ! plan & provid] h n det]m9$ a negotiat$ am\nt = ! paym5t involv$1 ! plan or provid] may initiate an indep5d5t dispute resolution process "u ?is p>agraph to det]m9e ! am\nt ( paym5t4 7,b7 ,e/abli%m5t ( ,,idr 7i7 ,9 g5]al ,n lat] ?an ,janu>y #a1 #bjba1 ! ,secret>y1 9 consultation ) ! ,secret>y ( ,labor1 %all e/abli% a process = resolv+ paym5t disputes betwe5 heal? plans & nonp>ticipat+ provid]s = purposes ( det]m9+ am\nts ( paym5ts to be made by ! plans to ! provid]s pursuant to subsections 7b7 & 7e7 7ref]r$ to 9 ?is section z ! ,,idr process74 7ii7 ,entities ,an entity wi%+ to p>ticipate 9 ! ,,idr process "u ?is subsection %all reque/ c]tification f ! ,secret>y4 ,! ,secret>y1 9 consultation ) ! ,secret>y ( ,labor1 %all det]m9e eligibility ( applicant entities1 tak+ into consid]ation :e!r ! entity is unbias$ & unaffiliat$ ) heal? plans & provid]s & free ( conflicts ( int]e/1 9 accordance ) ! ,secret>y's rulemak+ on det]m9+ crit]ia = conflicts ( int]e/4 7iii7 ,applicable claims 7,i7 ,9 g5]al ,! ,,idr process %all be ) respect to "o or m ,curr5t ,proc$ural ,t]m9ology 7,,cpt7 codes4 7,,ii7 ,bat*+ ( claims ,claims may be bat*$ if su* claims-- 7aa7 involve id5tical plan or issu] & provid] or facility p>ties2 7bb7 involve claims ) ! same or relat$ curr5t proc$ural t]m9ology codes relevant to a p>ticul> proc$ure2 & 7cc7 involve claims t occur )9 #fj days ( ea* o!r4 7,c7 ,indep5d5t dispute resolution process 7i7 ,tim+ ,9 ! case ( an ,,idr entity t receives a reque/ "u ?is p>agraph1 ) respect to a paym5t am\nt to be paid by a heal? plan to a nonp>ticipat+ provid]-- 7,i7 ! plan & provid] may1 dur+ ! #cj-;day p]iod foll[+ ! date ( receipt ( su* reque/1 submit any in=mation or support+ docum5tation to ! ,,idr entity2 & 7,,ii7 ! ,,idr entity %all1 n lat] ?an #fj days aft] receiv+ su* reque/1 det]m9e su* am\nt4 7ii7 ,det]m9ation ( am\nt 7,i7 ,9 g5]al ,! am\nt det]m9$ by ! ,,idr entity "u clause 7i71 ) respect to a paym5t am\nt to be paid by a heal? plan to a nonp>ticipat+ provid] = an item or s]vice %all be-- 7aa7 ! initial *>ge = ! item or s]vice made by ! provid] or ! comm]cially reasonable rate paid by ! plan = ! item or s]vice "u subsections 7b77#a77;,c77iii7 or 7e77#a77;,b71 respectively1 :i*ev] is det]m9$ reasonable by ! entity bas$ on ! factors describ$ 9 subclause 7,,iii72 or 7bb7 9 ! case nei!r su* *>ge or su* rate is det]m9$ by ! entity to be reasonable1 ! f9al (f] submitt$ "u subclause 7,,ii7 t is det]m9$ m reasonable 9 accordance ) su* subclause4 7,,ii7 ,f9al (f]s ,= purposes ( subclause 7,i77bb71 ! heal? plan & ! nonp>ticipat+ provid] p>ty to ! indep5d5t dispute resolution "u ?is p>agraph %all ea* submit to ! ,,idr entity _! f9al (f] = an am\nt = ! paym5t t is subject to ! dispute n lat] ?an #cj days aft] ! ,,idr entity det]m9es "u su* subclause t nei!r ! *>ge or rate describ$ 9 subclause 7,i77aa7 7 reasonable4 ,n lat] ?an #fj days aft] su* date ( su* det]m9ation1 su* entity %all det]m9e :i* ( ! #b f9al (f]s is m reasonable bas$ on ! factors describ$ 9 subclause 7,,iii74 7,,iii7 ,factors ,= purposes ( subclauses 7,i7 & 7,,ii71 ! factors describ$ 9 ?is subclause include1 z relevant-- 7aa7 comm]cially reasonable rates = comp>able s]vices or items 9 ! same geographic area 7:i* %all take into consid]ation 9-network rates = t geographic area & n *>ges72 7bb7 ! usual & cu/om>y co/ ( ! item or s]vice involv$1 det]m9$ z ! #hj? p]c5tile ( *>ges = comp>able items & s]vices = ! specialty involv$ 9 ! geographical area 9 :i* ! item or s]vice 0 furni%$1 z det]m9$ ?r\gh ref]5ce to a m$ical claims database2 7cc7 o!r factors t may be submitt$ at ! discretion ( ei!r p>ty1 :i* may include-- 7dd7 ! level ( tra9+1 education1 exp]i5ce1 & quality & outcomes measurem5ts ( ! nonp>ticipat+ provid]2 7ee7 ! circum/ances & complexity ( ! p>ticul> dispute1 includ+ ! "t & place ( ! s]vice2 7ff7 ! provid]'s quality & outcome metrics2 7gg7 ! provid]'s usual *>ge = comp>able s]vices ) reg>d to pati5ts 9 heal? c>e plans 9 :i* ! provid] is n p>ticipat+2 7hh7 ! individual pati5t *>act]i/ics2 & 7ii7 o!r relevant economic & cl9ical factors4 7,,iv7 ,f9al decisions ,! am\nt t is det]m9$ to be ! m reasonable am\nt "u item 7aa7 or 7bb7 ( subclause 7,i71 z applicable1 %all be ! f9al decision ( ! ,,idr entity z to ! am\nt ! heal? plan is requir$ to pay ! provid]4 7,v7 ,effect ( det]m9ation ,a f9al det]m9ation ( an ,,idr entity "u subclause 7,,iv7-- 7aa7 %all be b9d+2 & 7bb7 %all n be subject to judicial review1 except 9 cases comp>able to ^? describ$ 9 section #aj7;a7 ( title #i1 ,unit$ ,/ates ,code1 z det]m9$ by ! ,secret>y 9 consultation ) ! ,secret>y ( ,labor1 & cases 9 :i* in=mation submitt$ by "o p>ty 0 det]m9$ to be fraudul5t4 7iii7 ,privacy laws ,an ,,idr entity %all1 9 conduct+ an indep5d5t dispute resolution process "u ?is p>agraph1 comply ) all applicable ,f$]al & ,/ate privacy laws4 7iv7 ,public availability ,! reasonable am\nt det]m9$ by an ,,idr entity "u ?is p>agraph ) respect to any claim %all n be confid5tial1 except t in=mation submitt$ to ! ,,idr entity %all be kept confid5tial4 ,,idr entities may consid] pa/ decisions aw>d$ by indep5d5t dispute entities dur+ ! indep5d5t dispute resolution process4 7v7 ,co/s ( indep5d5t dispute resolution process ,! nonprevail+ p>ty %all be responsible = pay+ all fees *>g$ by ! ,,idr entity4 ,if ! p>ties rea* a settlem5t prior to completion ( ! ,,idr process1 ! co/s ( ! indep5d5t dispute resolution process %all be divid$ equally betwe5 ! p>ties4 7vi7 ,paym5t ,any diff]5ce betwe5-- 7,i7 ! am\nt det]m9$ to be paid by "o p>ty ( ! dispute resolution to ano!r pursuant to ?is p>agraph2 & 7,,ii7 ! am\nts already paid "u subsection 7b7 or 7e7 be=e ent]+ into ! process "u ?is p>agraph1 %all be paid n lat] ?an #ae days aft] ! date on :i* ! entity makes a det]m9ation ) respect to su* am\nt4 7,d7 ,publication ,! ,secret>y %all publi% aggregat$ results ( ! indep5d5t dispute resolution by geographic region 9 ord] to give m guidance to provid]s & heal? plans4 4 7d7 ,prev5t+ c]ta9 cases ( balance bill+ ,section #aabh;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;a7 is am5d$ by add+ at ! end ! foll[+ new subsections3 7t7 7#a7 ,subject to p>agraph 7#c71 9 ! case ( an individual ) b5efits "u a heal? plan or heal? insurance cov]age (f]$ 9 ! gr\p or individual m>ket :o is furni%$ on or aft] ,janu>y #a1 #bjba1 em]g5cy s]vices ) respect to an em]g5cy m$ical condition dur+ a visit at an em]g5cy dep>tm5t ( a hospital-- 7,a7 if ! em]g5cy dep>tm5t ( a hospital holds ! individual liable = a paym5t am\nt = su* em]g5cy s]vices s furni%$ t is m ?an ! co/-%>+ am\nt = su* s]vices 7z det]m9$ 9 accordance ) section #bgai;,a7b77#a77;,c77ii7 ( ! ,public ,heal? ,s]vice ,act72 or 7,b7 if any heal? c>e provid] holds su* individual liable = a paym5t am\nt = an em]g5cy s]vice furni%$ to su* individual by su* provid] ) respect to su* em]g5cy m$ical condition & visit = :i* ! individual receives em]g5cy s]vices at ! hospital or em]g5cy dep>tm5t t is m ?an ! co/-%>+ am\nt = su* s]vices furni%$ by ! provid] 7z det]m9$ 9 accordance ) section #bgai;,a7b77#a77;,c77ii7 ( ! ,public ,heal? ,s]vice ,act71 ! hospital1 em]g5cy dep>tm5t or heal? c>e provid]1 respectively1 %all be subject1 9 addition to any o!r p5alties t may be prescrib$ by law1 to a civil money p5alty ( n m ?an an am\nt det]m9$ appropriate by ! ,secret>y = ea* specifi$ claim4 7#b7 ,! provisions ( subsections 7c71 7d71 7e71 7g71 7h71 7k71 & 7l7 %all apply to a civil money p5alty or assessm5t "u p>agraph 7#a7 or subsection 7u7 9 ! same mann] z su* provisions apply to a p5alty1 assessm5t1 or proce$+ "u subsection 7a74 7#c7 ,p>agraph 7#a7 %all n apply to an em]g5cy dep>tm5t ( a hospital or a provid]1 ) respect to items or s]vices furni%$ to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu]1 if ! em]g5cy dep>tm5t ( ! hospital or ! provid]1 respectively1 reimburses su* p>ticipant1 b5efici>y1 or enrollee any am\nt = su* an item or s]vice t is m ?an ! co/-%>+ am\nt = su* item or s]vice 7z det]m9$ 9 accordance ) section #bgai;,a7e77#a77;,a77 n lat] ?an #cj days aft] ! date ! em]g5cy dep>tm5t ( ! hospital or provid]1 respectively1 knew or %\ld h kn[n su* excess paym5t 0 9 violation ( ?is subsection4 7#d7 ,9 ?is subsection & subsection 7u73 7,a7 ,! t]ms em]g5cy m$ical condition & em]g5cy s]vices h ! mean+s giv5 su* t]ms1 respectively1 9 section #bgai;,a7b77#b7 ( ! ,public ,heal? ,s]vice ,act4 7,b7 ,! t]ms gr\p heal? plan1 heal? insurance issu]1 & heal? insurance cov]age h ! mean+s giv5 su* t]ms1 respectively1 9 section #bgia ( ! ,public ,heal? ,s]vice ,act4 7u7 7#a7 ,subject to p>agraph 7#b71 9 ! case ( an individual ) b5efits "u a heal? plan or heal? insurance cov]age (f]$ 9 ! gr\p or individual m>ket :o is furni%$ on or aft] ,janu>y #a1 #bjba1 items or s]vices 7o!r ?an em]g5cy s]vices to :i* subsection 7t7 applies7 dur+ an episode ( c>e 7z def9$ by ! ,secret>y7 at a p>ticipat+ heal? c>e facility by a nonp>ticipat+ provid] 7includ+ imag+ or laboratory s]vices s furni%$ by a nonp>ticipat+ provid] :5 ord]$ by a p>ticipat+ provid] or aft]-em]g5cy c>e furni%$ by a nonp>ticipat+ provid] 9 ! case t ! p>ticipant1 b5efici>y1 or enrollee _c travel )\t m$ical transport71 if su* nonp>ticipat+ provid] holds su* individual liable = a paym5t am\nt = su* an item or s]vice furni%$ by su* provid] t is m ?an ! co/-%>+ am\nt = su* item or s]vice 7z det]m9$ 9 accordance ) section #bgai;,a7e77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act71 su* provid] %all be subject1 9 addition to any o!r p5alties t may be prescrib$ by law1 to a civil money p5alty ( n m ?an an am\nt det]m9$ appropriate by ! ,secret>y = ea* specifi$ claim4 7#b7 ,p>agraph 7#a7 %all n apply to a nonp>ticipat+ provid]1 ) respect to items or s]vices furni%$ by ! provid] to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu]1 if ! provid] reimburses su* p>ticipant1 b5efici>y1 or enrollee any am\nt = su* an item or s]vice t is m ?an ! co/-%>+ am\nt = su* item or s]vice 7z det]m9$ 9 accordance ) section #bgai;,a7e77#a77;,a77 n lat] ?an #cj days aft] ! date ! provid] knew or %\ld h kn[n su* excess paym5t 0 9 violation ( ?is subsection4 7#c7 ,= purposes ( ?is subsection1 ! t]ms nonp>ticipat+ provid] & p>ticipat+ heal? c>e facility h su* mean+s giv5 su* t]ms "u subsections 7b77#b7 & 7e77#b71 respectively1 ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act4 4 7e7 ,effective date ,! am5dm5ts made by ?is section %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjba4 #c4 ,transp>5cy reg>d+ 9-network & out-(-network d$uctibles 7a7 ,9 g5]al ,subp>t ,,ii ( "p ,a ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 is am5d$ by add+ at ! end ! foll[+3 #bgbi;,a4 ,transp>5cy reg>d+ 9-network & out-(-network d$uctibles 7a7 ,9 g5]al ,a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age & provid+ or cov]+ any b5efit ) respect to items or s]vices %all include1 9 cle> writ+1 on any plan or insurance id5tification c>d issu$ to enrollees 9 ! plan or cov]age ! am\nt ( ! 9-network & out-(-network d$uctibles & ! out-(-pocket maximum limitation t apply to su* plan or cov]age4 7b7 ,guidance ,! ,secret>y1 9 consultation ) ! ,secret>y ( ,labor1 %all issue guidance to implem5t subsection 7a74 4 7b7 ,effective date ,! am5dm5t made by subsection 7a7 %all apply ) respect to plan ye>s beg9n+ on or aft] ! date t is "o ye> aft] ! date ( ! enactm5t ( ?is ,act4 #d4 ,transp>5cy = 9-network pati5ts ,subp>t ,,ii ( "p ,a ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq471 z am5d$ by section #c1 is fur!r am5d$ by add+ at ! end ! foll[+3 #bgbi;,b4 ,transp>5cy = 9-network pati5ts 7a7 ,/&>ds ,n lat] ?an ,janu>y #a1 #bjba1 ! ,secret>y %all1 ?r\gh rulemak+1 e/abli% transp>5cy /&>ds to provide bett] in=mation to individuals :o are enroll$ 9 gr\p heal? plans or heal? insurance cov]age (f]$ 9 ! individual or gr\p m>ket 7z su* t]ms are def9$ 9 section #bgia ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ia77 ab\t :i* heal? c>e provid]s are p>ticipat+ 9 ! network ( ! plan or cov]age 9 :i* su* an individual is enroll$4 ,su* /&>ds %all at a m9imum provide = ! foll[+3 7#a7 ,su* plans & cov]age (f] provid] directories onl9e & 9 pr9t4 7#b7 ,annual audits ( su* provid] directories1 z specifi$ by ! ,secret>y4 7#c7 ,mon?ly updates ( su* onl9e directories4 7b7 ,guidance ,beg9n+ ,janu>y #a1 #bjbb1 a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all be 9 compliance ) ! /&>ds e/abli%$ pursuant to subsection 7a74 4 #e4 ,report+ requirem5ts ,subp>t ,,ii ( "p ,a ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq471 z am5d$ by sections #c & #d1 is fur!r am5d$ by add+ at ! end ! foll[+3 #bgbi;,c4 ,transp>5cy requirem5ts 7a7 ,9 g5]al ,ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all annually report 7beg9n+ = plan ye> #bjba7 to ! ,secret>y & ! ,secret>y ( ,labor1 ) respect to ! applicable plan or cov]age = ! applicable plan ye>-- 7#a7 ! total claims t 7 submitt$ by 9-network heal? c>e provid]s ) respect to enrollees "u ! plan or cov]age1 & ! numb] ( su* claims t 7 paid & ! numb] ( su* claims t 7 d5i$2 7#b7 ! total claims t 7 submitt$ by out-(-network heal? c>e provid]s ) respect to enrollees "u ! plan or cov]age1 & ! numb] ( su* claims t 7 paid & ! numb] ( su* claims t 7 d5i$2 7#c7 ) respect to ea* out-(-network claim1 ! out-(-pocket co/s to ! enrollee = ! s]vices2 7#d7 ! numb] ( out-(-network claims report$ "u p>agraph 7#b7 t are = em]g5cy s]vices2 & 7#e7 ! numb] ( out-(-network claims report$ "u p>agraph 7#b7 t relate to c>e at 9-network hospitals or facilities provid$ by out-(-network provid]s4 7b7 ,cl>ification ,! in=mation requir$ to be submitt$ "u ?is section %all be 9 addition to ! in=mation requir$ to be submitt$ "u section #bgae;,a4 4 #f4 ,bill+ /atute ( limitations ,not)/&+ any o!r provision ( law1 a heal? c>e provid] may n seek reimbursem5t f an individual = a s]vice furni%$ by su* provid] to su* individual m ?an a ye> aft] su* date ( s]vice4 ,any provid] t bills an individual 9 violation ( ! previ\s s5t5ce %all be subject to a civil monet>y p5alty 9 su* am\nt z specifi$ by ! ,secret>y ( ,heal? & ,human ,s]vices4 #g4 ,application 7a7 ,non-,application 9 cases ( ,/ates ) c]ta9 balance bill+ laws ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7g7 ,9 any case 9 :i* a ,/ate has 9 effect a law or regulation t prohibits balance bill+ or o!rwise provides an alt]nate me?od = resolv+ a dispute betwe5 a heal? plan & provid] = det]m9+ comp5sation = s]vices describ$ 9 subsections 7b71 7e71 or 7f71 ! provisions ( su* law & n ! provisions ( ?is ,act %all apply to heal? plans 7except self-insur$ gr\p heal? plans t are n subject to ,/ate insurance regulation71 heal? c>e provid]s1 & individuals 9 su* ,/ate s long z su* law does n require an individual to pay m 9 co/-%>+ ?an ! am\nt t w\ld o!rwise be requir$ ( su* individual "u ?is section4 4 7b7 ,application to ,,fehb 7#a7 ,9 g5]al ,section #hijb ( title #e1 ,unit$ ,/ates ,code1 is am5d$ by add+ at ! end ! foll[+ new subsection3 7p7 ,ea* contract "u ?is *apt] %all require ! c>ri] to comply ) requirem5ts describ$ 9 ! provisions ( subsections 7b71 7e71 & 7f7 ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act & sections #bgbi;,a & #bgbi;,b ( su* ,act 9 ! same mann] z ^? provisions apply to a gr\ps heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age1 z describ$ 9 su* sections4 4 7#b7 ,effective date ,! am5dm5t made by ?is subsection %all apply ) respect to contracts ent]$ into or r5ew$ = contract ye>s beg9n+ at lea/ "o ye> aft] ! date ( enactm5t ( ?is ,act4 #h4 ,/udies by ,secret>ies ( ,heal? & ,human ,s]vices & ( ,labor 7a7 ,impact /udy ,n lat] ?an #c ye>s aft] ! date ( enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) ! ,secret>y ( ,labor1 %all conduct a /udy ( ! effects ( ?is ,act 7includ+ ! am5dm5ts made by ?is ,act71 & submit to ,congress 7& make public7 a report on ! f9d+s ( su* /udy1 :i* %all include in=mation & analysis on-- 7#a7 ! f9ancial impact on pati5t responsibility = heal? c>e sp5d+ & ov]all heal? c>e sp5d+2 7#b7 ! incid5ce & preval5ce ( ! deliv]y ( unanticipat$ out-(-network heal? c>e s]vices1 9 ! cases ( em]g5cy s]vices & 9 ! cases ( c>e at 9-network hospitals or facilities provid$ by out-(-network provid]s2 7#c7 ! adequacy ( provid] networks (f]$ by heal? plans & heal? insurance issu]s 7z su* t]ms are def9$ 9 section #bgia ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ia772 7#d7 a comp>ison ( ! diff]5t claims databases us$ & ! impact ( us+ su* databases on reimbursem5t rates2 7#e7 ! numb] ( bills t are settl$ ?r\gh negotiations pursuant to subsection 7f77#b7 ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 z add$ by section #b1 & ! numb] ( bills t g to ! indep5d5t dispute resolution process "u subsection 7f77#c7 ( su* section1 z s add$2 7#f7 ! adm9i/rative co/ ( su* indep5d5t dispute resolution process2 & 7#g7 ! e/imat$ impact ( su* indep5d5t dispute resolution process on heal? insurance premiums & d$uctibles4 7b7 ,bill+ feasibility /udy ,n lat] ?an #c ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all conduct1 & submit to ,congress 7& make public71 a feasibility /udy on ! provision ( a s+le bill = all s]vices provid$ = a s+le episode ( c>e1 z def9$ by ! ,secret>y4 #i4 ,regulations ,n lat] ?an "o ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y ( ,labor & ! ,secret>y ( ,heal? & ,human ,s]vices %all promulgate regulations p]ta9+ to c>ry out ! provisions 7includ+ am5dm5ts made by7 ?is ,act4