,i #aafth ,,congress #ast ,session ,h4 ,r4 #cfcj ,,in ,,the ,,house ,,of ,,representatives ,july #i1 #bjai,mr4 ,pallone 7for himself and ,mr4 ,walden7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committee on ,education and ,labor1 for a period to be subsequently determined by the ,speaker1 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 to protect health care consumers from surprise billing practices1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,no ,surprises ,act4 #b4 ,preventing surprise medical bills 7a7 ,coverage of emergency services ,section #bgai;,a7b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7b77 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 in the matter preceding subparagraph 7,a7-- 7i7 by striking a group health plan1 or a health insurance issuer offering group or individual health insurance issuer1 and inserting a health plan 7as defined in subsection 7e77#b77;,a772 7ii7 by inserting or1 for plan year #bjba or a subsequent plan year1 with respect to emergency services in an independent freestanding emergency department 7as defined in paragraph 7#c77;,d77 after emergency department of a hospital2 7iii7 by striking the plan or issuer and inserting the plan2 and 7iv7 by striking paragraph 7#b77;,b7 and inserting paragraph 7#c77;,c72 7,b7 in subparagraph 7,b71 by inserting or a participating emergency facility1 as applicable1 after participating provider2 and 7,c7 in subparagraph 7,c7-- 7i7 in the matter preceding clause 7i71 by inserting by a nonparticipating provider or a nonparticipating emergency facility after enrollee2 7ii7 by striking clause 7i72 7iii7 by striking 7ii77,i7 such services and inserting 7i7 such services2 7iv7 by striking where the provider of services does not have a contractual relationship with the plan for the providing of services2 7v7 by striking emergency department services received from providers who do have such a contractual relationship with the plan2 and and inserting emergency services received from participating providers and participating emergency facilities with respect to such plan22 7vi7 by striking 7,,ii7 if such services and all that follows through were provided in-network and inserting the following3 7ii7 the cost-sharing requirement 7expressed as a copayment amount or coinsurance rate7 is not greater than the requirement that would apply if such services were provided by a participating provider or a participating emergency facility2 2 and 7vii7 by adding at the end the following new clauses3 7iii7 such requirement is calculated as if the total amount that would have been charged for such services by such participating provider or participating emergency facility were equal to-- 7,i7 in the case of such services furnished in a ,state described in paragraph 7#c77;,h77ii71 the median contracted rate 7as defined in paragraph 7#c77;,e77i77 for such services2 and 7,,ii7 in the case of such services furnished in a ,state described in paragraph 7#c77;,h77i71 the lesser of-- 7aa7 the amount determined by such ,state for such services in accordance with the method described in such paragraph2 and 7bb7 the median contracted rate 7as so defined7 for such services2 7iv7 the health plan pays to such provider or facility1 respectively1 the amount by which the recognized amount 7as defined in paragraph 7#c77;,h77 for such services exceeds the cost-sharing amount for such services 7as determined in accordance with clauses 7ii7 and 7iii772 and 7v7 any cost-sharing payments made by the participant1 beneficiary1 or enrollee with respect to such emergency services so furnished shall be counted toward any in-network deductible or out-of-pocket maximums applied under the plan in the same manner as if such cost-sharing payments were with respect to emergency services furnished by a participating provider and a participating emergency facility2 and 2 7#b7 by redesignating paragraph 7#b7 as paragraph 7#c72 7#c7 by inserting after paragraph 7#a7 the following new paragraph3 7#b7 ,audit process for median contracted rates ,not later than ,july #a1 #bjbj1 the ,secretary shall1 in consultation with appropriate ,state agencies1 establish through rulemaking a process under which sponsors and issuers of health plans are audited to ensure that such sponsors and issuers are in compliance with the requirement of applying a median contracted rate under this section that satisfies the definition under paragraph 7#c77;,e74 2 and 7#d7 in paragraph 7#c71 as redesignated by paragraph 7#b7 of this subsection-- 7,a7 in the matter preceding subparagraph 7,a71 by inserting and subsections 7e7 and 7f7 after this subsection2 7,b7 by redesignating subparagraphs 7,a7 through 7,c7 as subparagraphs 7,b7 through 7,d71 respectively2 7,c7 by inserting before subparagraph 7,b71 as redesignated by subparagraph 7,b7 of this paragraph1 the following new subparagraph3 7,a7 ,emergency department of a hospital ,the term emergency department of a hospital includes a hospital outpatient department that provides emergency services4 2 7,d7 by amending subparagraph 7,c71 as redesignated by subparagraph 7,b7 of this paragraph1 to read as follows3 7,c7 ,emergency services 7i7 ,in general ,the term emergency services1 with respect to an emergency medical condition means-- 7,i7 a medical screening examination 7as required under section #ahfg of the ,social ,security ,act1 or as would be required under such section if such section applied to an independent freestanding emergency department7 that is within the capability of the emergency department of a hospital or of an independent freestanding emergency department1 as applicable1 including ancillary services routinely available to the emergency department to evaluate such emergency medical condition2 and 7,,ii7 within the capabilities of the staff and facilities available at the hospital or the independent freestanding emergency department1 as applicable1 such further medical examination and treatment as are required under section #ahfg of such ,act1 or as would be required under such section if such section applied to an independent freestanding emergency department1 to stabilize the patient4 7ii7 ,inclusion of poststabilization services ,for purposes of this subsection and section #bgii1 in the case of an individual enrolled in a health plan who is furnished services described in clause 7i7 by a provider or facility to stabilize such individual with respect to an emergency medical condition1 the term emergency services shall include such items and services in addition to those described in clause 7i7 that such a provider or facility determines are needed to be furnished to such individual during the visit in which such individual is so stabilized after such stabilization1 unless each of the following conditions are met3 7,i7 ,such a provider or facility determines such individual is able to travel using nonmedical transportation or nonemergency medical transportation4 7,,ii7 ,such provider furnishing such additional items and services is in compliance with section #bgii;,a7d7 with respect to such items and services4 2 7,e7 by redesignating subparagraph 7,d71 as redesignated by subparagraph 7,b7 of this paragraph1 as subparagraph 7,i72 and 7,f7 by inserting after subparagraph 7,c71 as redesignated by subparagraph 7,b7 of this paragraph1 the following new subparagraphs3 7,d7 ,independent freestanding emergency department ,the term independent freestanding emergency department means a facility that-- 7i7 is geographically separate and distinct and licensed separately from a hospital under applicable ,state law2 and 7ii7 provides emergency services4 7,e7 ,median contracted rate 7i7 ,in general ,the term median contracted rate means1 with respect to an item or service and a health plan 7as defined in subsection 7e77#b77;,a77-- 7,i7 for #bjba1 the median of the negotiated rates recognized by the sponsor or issuer of such plan 7determined with respect to all such plans of such sponsor or such issuer7 as the total maximum payment 7including the cost-sharing amount imposed for such services 7as determined in accordance with paragraph 7#a77;,c77ii7 or subsection 7e77#a77;,a71 as applicable7 and the amount to be paid by the plan or issuer7 under such plans in #bjai for the same or a similar item or service that is provided by a provider in the same or similar specialty and provided in the geographic region in which the item or service is furnished1 consistent with the methodology established by the ,secretary under section #b7;e7 of the ,no ,surprises ,act1 increased by the percentage increase in the consumer price index for all urban consumers 7,united ,states city average7 over #bjai and #bjbj2 and 7,,ii7 for #bjbb and each subsequent year1 the median contracted rate for the previous year1 increased by the percentage increase in the consumer price index for all urban consumers 7,united ,states city average7 over such previous year4 7ii7 ,special rule2 rule of construction 7,i7 ,certain insurers ,the ,secretary shall provide pursuant to rulemaking described in clause 7ii7 that-- 7aa7 if the sponsor or issuer of a health plan does not have sufficient information to calculate a median contracted rate for an item or service or provider type1 or amount of1 claims for items or services 7as determined by the ,secretary7 provided in a particular geographic area 7other than in a case described in item 7bb771 such sponsor or issuer shall demonstrate that such sponsor or issuer will use any database free of conflicts of interest that has sufficient information reflecting allowed amounts paid to individual health care providers for relevant services provided in the applicable geographic region 7such as ,all ,payer ,claims ,databases 7as defined in section #d7;d7 of the ,no ,surprises ,act7 of ,states71 and that such sponsor or issuer will use any such database to determine a median contracted rate and cover the cost of accessing any such database2 and 7bb7 in the case of a sponsor or issuer offering a health plan in a geographic region that did not offer any health plan in such region during #bjai1 such sponsor or issuer shall use a methodology established by the ,secretary for determining the median contracted rate for items and services covered by such plan for the first year in which such plan is offered in such region1 and that1 for each succeeding year1 the median contracted rate for such items and services under such plan shall be the median contracted rate for such items and services under such plan for the previous year1 increased by the percentage increase in the consumer price index for all urban consumers 7,united ,states city average7 over such previous year4 7,,ii7 ,rule of construction ,nothing in this subparagraph shall prevent the sponsor or issuer of a health plan from establishing separate calculations of a median contracted rate under this subparagraph for items and services delivered in non-hospital facilities1 including independent freestanding emergency departments4 7,f7 ,nonparticipating emergency facility2 participating emergency facility 7i7 ,nonparticipating emergency facility ,the term nonparticipating emergency facility means1 with respect to an item or service and a health plan1 an emergency department of a hospital1 or an independent freestanding emergency department1 that does not have a contractual relationship with the plan 7or1 if applicable1 issuer offering the plan7 for furnishing such item or service under the plan4 7ii7 ,participating emergency facility ,the term participating emergency facility means1 with respect to an item or service and a health plan1 an emergency department of a hospital1 or an independent freestanding emergency department1 that has a contractual relationship with the plan 7or1 if applicable1 issuer offering the plan7 for furnishing such item or service under the plan4 7,g7 ,nonparticipating providers2 participating providers 7i7 ,nonparticipating provider ,the term nonparticipating provider means1 with respect to an item or service and a health plan1 a physician or other health care provider who is acting within the scope of practice of that provider's license or certification under applicable ,state law and who does not have a contractual relationship with the plan 7or1 if applicable1 issuer offering the plan7 for furnishing such item or service under the plan4 7ii7 ,participating provider ,the term participating provider means1 with respect to an item or service and a health plan1 a physician or other health care provider who is acting within the scope of practice of that provider's license or certification under applicable ,state law and who has a contractual relationship with the plan 7or1 if applicable1 issuer offering the plan7 for furnishing such item or service under the plan4 7,h7 ,recognized amount ,the term recognized amount means1 with respect to an item or service-- 7i7 in the case of such item or service furnished in a ,state that has in effect a ,state law that provides for a method for determining the amount of payment that is required to be covered by a health plan regulated by such ,state in the case of a participant1 beneficiary1 or enrollee covered under such plan and receiving such item or service from a nonparticipating provider or facility1 not more than the amount determined in accordance with such law plus the cost-sharing amount imposed under the plan for such item or service 7as determined in accordance with paragraph 7#a77;,c77ii7 or subsection 7e77#a77;,a71 as applicable72 or 7ii7 in the case of such item or service furnished in a ,state that does not have in effect such a law1 an amount that is at least the median contracted rate 7as defined in subparagraph 7,e77i7 and determined in accordance with rulemaking described in subparagraph 7,e77ii77 for such item or service4 4 7b7 ,coverage of non-,emergency services performed by nonparticipating providers at certain participating facilities ,section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is amended by adding at the end the following new subsection3 7e7 ,coverage of non-,emergency services performed by nonparticipating providers at certain participating facilities 7#a7 ,in general ,subject to paragraph 7#c71 in the case of items or services 7other than emergency services to which subsection 7b7 applies7 furnished to a participant1 beneficiary1 or enrollee of a health plan 7as defined in paragraph 7#b77;,a77 by a nonparticipating provider 7as defined in subsection 7b77#c77;,g77i77 during a visit 7as defined by the ,secretary in accordance with paragraph 7#b77;,c77 at a participating health care facility 7as defined in paragraph 7#b77;,b771 with respect to such plan1 the plan-- 7,a7 shall not impose on such participant1 beneficiary1 or enrollee a cost-sharing amount 7expressed as a copayment amount or coinsurance rate7 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 7as defined in subsection 7b77#c77;,g77ii772 7,b7 shall calculate such cost-sharing amount as if the amount that would have been charged for such items and services by such participating provider were equal to-- 7i7 in the case of such items and services furnished in a ,state described in subsection 7b77#c77;,h77ii71 the median contracted rate 7as defined in subsection 7b77#c77;,e77i77 for such items and services2 and 7ii7 in the case of such items and services furnished in a ,state described in subsection 7b77#c77;,h77i71 the lesser of-- 7,i7 the amount determined by such ,state for such items and services in accordance with the method described in such subsection2 and 7,,ii7 the median contracted rate 7as so defined7 for such items and services2 7,c7 shall pay to such provider furnishing such items and services to such participant1 beneficiary1 or enrollee the amount by which the recognized amount 7as defined in subsection 7b77#c77;,h77 for such items and services exceeds the cost-sharing amount imposed under the plan for such items and services 7as determined in accordance with subparagraphs 7,a7 and 7,b772 and 7,d7 shall count toward any in-network deductible or out-of-pocket maximums applied under the plan any cost-sharing payments made by the participant1 beneficiary1 or enrollee with respect to such items and services so furnished in the same manner as if such cost-sharing payments were with respect to items and services furnished by a participating provider4 7#b7 ,definitions ,in this subsection and subsection 7b73 7,a7 ,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 7as defined in section #abea7;e7 of the ,patient ,protection and ,affordable ,care ,act74 7,b7 ,participating health care facility 7i7 ,in general ,the term participating health care facility means1 with respect to an item or service and a health plan1 a health care facility described in clause 7ii7 that has a contractual relationship with the plan 7or1 if applicable1 issuer offering the plan7 for furnishing such item or service4 7ii7 ,health care facility described ,a health care facility described in this clause is each of the following3 7,i7 ,a hospital 7as defined in #ahfa7;e7 of the ,social ,security ,act74 7,,ii7 ,a critical access hospital 7as defined in section #ahfa7mm7 of such ,act74 7,,iii7 ,an ambulatory surgical center 7as defined in section #ahcc7;i77#a77;,a7 of such ,act74 7,,iv7 ,a laboratory4 7,v7 ,a radiology facility or imaging center4 7,c7 ,during a visit ,the term during a visit shall1 with respect to items and services furnished to an individual at a participating health care facility1 include equipment and devices1 telemedicine services1 imaging services1 laboratory services1 and such other items and services as the ,secretary may specify1 regardless of whether or not the provider furnishing such items or services is at the facility4 7#c7 ,exception ,paragraph 7#a7 shall not apply to a health plan in the case of items or services 7other than emergency services to which subsection 7b7 applies7 furnished to a participant1 beneficiary1 or enrollee of a health plan 7as defined in paragraph 7#b77;,a77 by a nonparticipating provider 7as defined in subsection 7b77#c77;,g77i77 during a visit 7as defined by the ,secretary in accordance with paragraph 7#b77;,c77 at a participating health care facility 7as defined in paragraph 7#b77;,b77 if such provider is in compliance with section #bgii;,a7d7 with respect to such items and services4 4 7c7 ,provider directory requirements2 disclosure on patient protections ,section #bgai;,a of the ,public ,health ,service ,act1 as amended by subsection 7b71 is further amended by adding at the end the following new subsections3 7f7 ,provider directory information requirements 7#a7 ,in general ,not later than #a year after the date of the enactment of this subsection1 each group health plan and health insurance issuer offering group or individual health insurance coverage shall-- 7,a7 establish the verification process described in paragraph 7#b72 7,b7 establish the response protocol described in paragraph 7#c72 7,c7 establish the database described in paragraph 7#d72 and 7,d7 include in any print directory containing provider directory information with respect to such plan or such coverage the information described in paragraph 7#e74 7#b7 ,verification process ,the verification process described in this paragraph is1 with respect to a group health plan or a health insurance issuer offering group or individual health insurance coverage1 a process under which-- 7,a7 not less frequently than once every #ij days1 such plan or such issuer 7as applicable7 verifies and updates the provider directory information included on the database described in paragraph 7#d7 of such plan or issuer of each health care provider and health care facility included in such database2 and 7,b7 such plan or such issuer removes any such provider or facility with respect to which such plan or such issuer has been unable to verify such information during any #f-month period4 7#c7 ,response protocol ,the response protocol described in this paragraph is1 in the case of an individual enrolled under a group health plan or group or individual health insurance coverage offered by a health insurance issuer who requests information on whether a health care provider or health care facility has a contractual relationship to furnish items and services under such plan or such coverage1 a protocol under which such plan or such issuer 7as applicable71 in the case such request is made through a telephone call-- 7,a7 responds to such individual as soon as practicable and in no case later than #a business day after such call is received through a written electronic communication2 and 7,b7 retains such communication in such individual's file for at least #b years following such response4 7#d7 ,database ,the database described in this paragraph is1 with respect to a group health plan or health insurance issuer offering group or individual health insurance coverage1 a database on the public website of such plan or issuer that contains-- 7,a7 a list of each health care provider and health care facility with which such plan or such issuer has a contractual relationship for furnishing items and services under such plan or such coverage2 and 7,b7 provider directory information with respect to each such provider and facility4 7#e7 ,information ,the information described in this paragraph is1 with respect to a print directory containing provider directory information with respect to a group health plan or individual or group health insurance coverage offered by a health insurance issuer1 a notification that such information contained in such directory was accurate as of the date of publication of such directory and that an individual enrolled under such plan or such coverage should consult the database described in paragraph 7#d7 with respect to such plan or such coverage or contact such plan or the issuer of such coverage to obtain the most current provider directory information with respect to such plan or such coverage4 7#f7 ,definition ,for purposes of this subsection1 the term provider directory information includes1 with respect to a group health plan and a health insurance issuer offering group or individual health insurance coverage1 the name1 address1 specialty1 and telephone number of each health care provider or health care facility with which such plan or such issuer has a contractual relationship for furnishing items and services under such plan or such coverage4 7g7 ,disclosure on patient protections ,each group health plan and health insurance issuer offering group or individual health insurance coverage shall make publicly available1 and 7if applicable7 post on a public website of such plan or issuer-- 7#a7 information in plain language on-- 7,a7 the requirements and prohibitions applied under sections #bgii and #bgii;,a 7relating to prohibitions on balance billing in certain circumstances72 7,b7 if provided for under applicable ,state law1 any other requirements on providers and facilities regarding the amounts such providers and facilities may1 with respect to an item or service1 charge a participant1 beneficiary1 or enrollee of such plan or coverage with respect to which such a provider or facility does not have a contractual relationship for furnishing such item or service under the plan or coverage after receiving payment from the plan or coverage for such item or service and any applicable cost-sharing payment from such participant1 beneficiary1 or enrollee2 and 7,c7 the requirements applied under subsections 7b7 and 7e72 and 7#b7 information on contacting appropriate ,state and ,federal agencies in the case that an individual believes that such a provider or facility has violated any requirement described in paragraph 7#a7 with respect to such individual4 4 7d7 ,preventing certain cases of balance billing ,title ,,xxvii of the ,public ,health ,service ,act is amended by adding at the end the following new part3 ,d ,preventing ,certain ,cases of ,balance ,billing #bgii4 ,balance billing in cases of emergency services 7a7 ,in general ,in the case of a participant1 beneficiary1 or enrollee with benefits under a health plan who is furnished on or after ,january #a1 #bjba1 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-- 7#a7 the emergency department of a hospital or independent freestanding emergency department shall not hold the participant1 beneficiary1 or enrollee liable for a payment amount for such emergency services so furnished that is more than the cost-sharing amount for such services 7as determined in accordance with section #bgai;,a7b77#a77;,c77ii772 and 7#b7 a health care provider shall not hold such participant1 beneficiary1 or enrollee liable for a payment amount for an emergency service furnished to such individual by such provider with respect to such emergency medical condition and visit for which the individual receives emergency services at the hospital or emergency department that is more than the cost-sharing amount for such services furnished by the provider 7as determined in accordance with section #bgai;,a7b77#a77;,c77ii774 7b7 ,definitions ,in this section3 7#a7 ,the terms emergency department of a hospital1 emergency medical condition1 emergency services1 and independent freestanding emergency department have the meanings given such terms1 respectively1 in section #bgai;,a7b77#c74 7#b7 ,the term health plan has the meaning given such term in section #bgai;,a7e74 7#c7 ,the term during a visit shall have such meaning as applied to such term for purposes of section #bgai;,a7e74 #bgii;,a4 ,balance billing in cases of non-emergency services performed by nonparticipating providers at certain participating facilities 7a7 ,in general ,subject to subsection 7b71 in the case of a participant1 beneficiary1 or enrollee with benefits under a health plan 7as defined in section #bgii7;b77 who is furnished on or after ,january #a1 #bjba1 items or services 7other than emergency services to which section #bgii applies7 at a participating health care facility by a nonparticipating provider1 such provider shall not hold such participant1 beneficiary1 or enrollee liable 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 7as determined in accordance with subparagraphs 7,a7 and 7,b7 of section #bgai;,a7e77#a774 7b7 ,exception 7#a7 ,in general ,subsection 7a7 shall not apply to a nonparticipating provider 7other than a specified provider at a participating health care facility71 with respect to items or services furnished by the provider to a participant1 beneficiary1 or enrollee of a health plan1 if the provider is in compliance with the notice and consent requirements of subsection 7d74 7#b7 ,specified provider defined ,for purposes of paragraph 7#a71 the term specified provider1 with respect to a participating health care facility-- 7,a7 means a facility-based provider1 including emergency medicine providers1 anesthesiologists1 pathologists1 radiologists1 neonatologists1 assistant surgeons1 hospitalists1 intensivists1 or other providers as determined by the ,secretary2 and 7,b7 includes1 with respect to an item or service1 a nonparticipating provider if there is no participating provider at such facility who can furnish such item or service4 7c7 ,clarification ,in the case of a nonparticipating provider 7other than a specified provider at a participating health care facility7 that complies with the notice and consent requirements of subsection 7d7 with respect to an item or service 7referred to in this subsection as a covered item or service71 such notice and consent requirements may not be construed as applying with respect to any item or service that is furnished as a result of unforeseen medical needs that arise at the time such covered item or service is furnished4 7d7 ,compliance with notice and consent requirements 7#a7 ,in general ,a nonparticipating provider or nonparticipating facility is in compliance with this subsection1 with respect to items or services furnished by the provider or facility to a participant1 beneficiary1 or enrollee of a health plan1 if the provider 7or1 if applicable1 the participating health care facility on behalf of such provider7 or nonparticipating facility-- 7,a7 provides to the participant1 beneficiary1 or enrollee 7or to an authorized representative of the participant1 beneficiary1 or enrollee71 on the date on which the participant1 beneficiary1 or enrollee makes an appointment to be furnished such items or services1 if applicable1 and on the date on which the individual is furnished such items or services-- 7i7 an oral explanation of the written notice described in clause 7ii72 and 7ii7 a written notice specified1 not later than ,july #a1 #bjbj1 by the ,secretary through guidance 7which shall be updated as determined necessary by the ,secretary7 that-- 7,i7 contains the information required under paragraph 7#b72 and 7,,ii7 is signed and dated by the participant1 beneficiary1 or enrollee 7or by an authorized representative of the participant1 beneficiary1 or enrollee7 and1 with respect to items or services to be furnished by such a provider that are not poststabilization services described in section #bgai;,a7b77#c77;,c77ii71 is so signed and dated not less than #gb hours prior to the participant1 beneficiary1 or enrollee being furnished such items or services by such provider2 and 7,b7 obtains from the participant1 beneficiary1 or enrollee 7or from such an authorized representative7 the consent described in paragraph 7#c74 7#b7 ,information required under written notice ,for purposes of paragraph 7#a77;,a77ii77,i71 the information described in this paragraph1 with respect to a nonparticipating provider or nonparticipating facility and a participant1 beneficiary1 or enrollee of a health plan1 is each of the following3 7,a7 ,notification1 as applicable1 that the health care provider is a nonparticipating provider with respect to the health plan or the health care facility is a nonparticipating facility with respect to the health plan4 7,b7 ,notification of the estimated amount that such provider or facility may charge the participant1 beneficiary1 or enrollee for such items and services involved4 7,c7 ,in the case of a nonparticipating facility1 a list of any participating providers at the facility who are able to furnish such items and services involved and notification that the participant1 beneficiary1 or enrollee may be referred1 at their option1 to such a participating provider4 7#c7 ,consent described ,for purposes of paragraph 7#a77;,b71 the consent described in this paragraph1 with respect to a participant1 beneficiary1 or enrollee of a health plan who is to be furnished items or services by a nonparticipating provider or nonparticipating facility1 is a document specified by the ,secretary through rulemaking that-- 7,a7 is signed by the participant1 beneficiary1 or enrollee 7or by an authorized representative of the participant1 beneficiary1 or enrollee7 and1 with respect to items or services to be furnished by such a provider or facility that are not poststabilization services described in section #bgai;,a7b77#c77;,c77ii71 is so signed not less than #gb hours prior to the participant1 beneficiary1 or enrollee being furnished such items or services by such provider or facility2 7,b7 acknowledges that the participant1 beneficiary1 or enrollee has been-- 7i7 provided with a written estimate and an oral explanation of the charge that the participant1 beneficiary1 or enrollee will be assessed for the items or services anticipated to be furnished to the participant1 beneficiary1 or enrollee by such provider or facility2 and 7ii7 informed that the payment of such charge by the participant1 beneficiary1 or enrollee may not accrue toward meeting any limitation that the health plan places on cost-sharing2 and 7,c7 documents the consent of the participant1 beneficiary1 or enrollee to-- 7i7 be furnished with such items or services by such provider or facility2 and 7ii7 in the case that the individual is so furnished such items or services1 be charged an amount that may be greater than the amount that would otherwise be charged the individual if furnished by a participating provider or participating facility with respect to such items or services and plan4 7e7 ,retention of certain documents ,a nonparticipating provider 7or1 in the case of a nonparticipating provider at a participating health care facility1 such facility7 or nonparticipating facility that obtains from a participant1 beneficiary1 or enrollee of a health plan 7or an authorized representative of such participant1 beneficiary1 or enrollee7 a written notice in accordance with subsection 7c77#a77;ii71 with respect to furnishing an item or service to such participant1 beneficiary1 or enrollee1 shall retain such notice for at least a #b-year period after the date on which such item or service is so furnished4 7f7 ,definitions ,in this section3 7#a7 ,the terms nonparticipating provider and participating provider have the meanings given such terms1 respectively1 in subsection 7b77#c7 of section #bgai;,a4 7#b7 ,the terms participating health care facility and health plan have the meanings given such terms1 respectively1 in subsection 7e77#b7 of section #bgai;,a4 7#c7 ,the term nonparticipating facility means-- 7,a7 with respect to emergency services 7as defined in section #bgai;,a7b77#c77;,c77i77 and a health plan1 an emergency department of a hospital1 or an independent freestanding emergency department1 that does not have a contractual relationship with the plan 7or1 if applicable1 issuer offering the plan7 for furnishing such services under the plan2 and 7,b7 with respect to poststabilization services described in section #bgai;,a7b77#c77;,c77ii7 and a health plan1 an emergency department of a hospital 7or other department of such hospital71 or an independent freestanding emergency department1 that does not have a contractual relationship with the plan 7or1 if applicable1 issuer offering the plan7 for furnishing such services under the plan4 7#d7 ,the term participating facility means-- 7,a7 with respect to emergency services 7as defined in section #bgai;,a7b77#c77;,c77i77 and a health plan1 an emergency department of a hospital1 or an independent freestanding emergency department1 that has a contractual relationship with the plan 7or1 if applicable1 issuer offering the plan7 for furnishing such services under the plan2 and 7,b7 with respect to poststabilization services described in section #bgai;,a7b77#c77;,c77ii7 and a health plan1 an emergency department of a hospital 7or other department of such hospital71 or an independent freestanding emergency department1 that has a contractual relationship with the plan 7or1 if applicable1 issuer offering the plan7 for furnishing such services under the plan4 #bgii;,b4 ,provider requirements with respect to provider directory information ,not later than #a year after the date of the enactment of this section1 each health care provider and health care facility shall establish a process under which such provider or facility transmits1 to each health insurance issuer offering group or individual health insurance coverage and group health plan with which such provider or facility has in effect a contractual relationship for furnishing items and services under such coverage or such plan1 provider directory information 7as defined in section #bgai;,a7f77#f77 with respect to such provider or facility1 as applicable4 ,such provider or facility shall so transmit such information to such issuer offering such coverage or such group health plan-- 7#a7 when the provider or facility enters into such a relationship with respect to such coverage offered by such issuer or with respect to such plan2 7#b7 when the provider or facility terminates such relationship with respect to such coverage offered by such issuer or with respect to such plan2 7#c7 when there are any other material changes to such provider directory information of the provider or facility with respect to such coverage offered by such issuer or with respect to such plan2 and 7#d7 at any other time determined appropriate by the provider1 facility1 or the ,secretary4 #bgii;,c4 ,provider requirement with respect to public provision of information ,each health care provider and health care facility shall make publicly available1 and 7if applicable7 post on a public website of such provider or facility-- 7#a7 information in plain language on-- 7,a7 the requirements and prohibitions of such provider or facility under sections #bgii and #bgii;,a 7relating to prohibitions on balance billing in certain circumstances72 and 7,b7 if provided for under applicable ,state law1 any other requirements on such provider or facility regarding the amounts such provider or facility may1 with respect to an item or service1 charge a participant1 beneficiary1 or enrollee of a health plan 7as defined in section #bgai;,a7e77#b77 with respect to which such provider or facility does not have a contractual relationship for furnishing such item or service under the plan after receiving payment from the plan for such item or service and any applicable cost-sharing payment from such participant1 beneficiary1 or enrollee2 and 7#b7 information on contacting appropriate ,state and ,federal agencies in the case that an individual believes that such provider or facility has violated any requirement described in paragraph 7#a7 with respect to such individual4 #bgii;,d4 ,enforcement 7a7 ,state enforcement 7#a7 ,state authority ,each ,state may require a provider or health care facility subject to the requirements of sections #bgii1 #bgii;,a1 #bgii;,b1 or #bgii;,c to satisfy such requirements applicable to the provider or facility4 7#b7 ,failure to implement requirements ,in the case of a ,state that fails to substantially enforce the requirements set forth in this part with respect to applicable providers and facilities in the ,state1 the ,secretary shall enforce the requirements of this part under subsection 7b7 insofar as they relate to actions prohibited under this part occurring in such ,state4 7b7 ,secretarial enforcement authority 7#a7 ,in general ,if a provider or facility is found to be in violation of this part by the ,secretary1 the ,secretary may apply a civil monetary penalty with respect to such provider or facility in an amount not to exceed #aj1jjj per violation4 ,the provisions of subsections 7c71 7d71 7e71 7g71 7h71 7k71 and 7l7 of section #aabh;,a of the ,social ,security ,act shall apply to a civil monetary penalty or assessment under this subsection in the same manner as such provisions apply to a penalty1 assessment1 or proceeding under subsection 7a7 of such section4 7#b7 ,limitation ,the provisions of paragraph 7#a7 shall apply to enforcement of a provision 7or provisions7 of this part only as provided under subsection 7a77#b74 7#c7 ,complaint process ,the ,secretary shall1 through rulemaking1 establish a process to receive consumer complaints of violations of this part and resolve such complaints within #fj days of receipt of such complaints4 7#d7 ,exception ,the ,secretary shall waive the penalties described under paragraph 7#a7 with respect to a facility or provider who does not knowingly violate1 and should not have reasonably known it violated1 a provision of this part with respect to a participant1 beneficiary1 or enrollee1 if such facility or practitioner1 within #cj days of the violation1 withdraws the bill that was in violation of such provision1 and reimburses the health plan or enrollee1 as applicable1 in an amount equal to the difference between the amount billed and the amount allowed to be billed under the provision1 plus interest1 at an interest rate determined by the ,secretary4 7#e7 ,hardship exemption ,the ,secretary may establish a hardship exemption to the penalties under this subsection4 7c7 ,continued ,applicability of ,state ,law ,this part shall not be construed to supersede any provision of ,state law which establishes1 implements1 or continues in effect any requirement or prohibition except to the extent that such requirement or prohibition prevents the application of a requirement or prohibition of this part4 4 7e7 ,rulemaking for median contracted rates ,not later than ,july #a1 #bjbj1 the ,secretary of ,health and ,human ,services1 jointly with the ,secretary of ,labor1 shall establish through rulemaking the methodology the sponsor or issuer of a health plan 7as defined in subsection 7e7 of section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 as added by subsection 7b7 of this section7 shall use to determine the median contracted rate 7as defined in section #bgai;,a7b7 of such ,act1 as amended by subsection 7a7 of this section71 the information such sponsor or issuer shall share with the nonparticipating provider 7as defined in such section7 involved when making such a determination1 and the geographic regions applied for purposes of this subparagraph 7,e7 of section #bgai;,a7b77#c71 as amended by subsection 7a7 of this section4 7f7 ,effective date ,the amendments made by subsections 7a7 and 7b7 shall apply with respect to plan years beginning on or after ,january #a1 #bjba4 #c4 ,government ,accountability ,office study on profit- and revenue-sharing in health care 7a7 ,study ,not later than #a year after the date of enactment of this ,act1 the ,comptroller ,general of the ,united ,states shall conduct a study to-- 7#a7 describe what is known about profit- and revenue-sharing relationships in the commercial health care markets1 including those relationships that-- 7,a7 involve one or more-- 7i7 physician groups that practice within a hospital included in the profit- or revenue-sharing relationship1 or refer patients to such hospital2 7ii7 laboratory1 radiology1 or pharmacy services that are delivered to privately insured patients of such hospital2 7iii7 surgical services2 7iv7 hospitals or group purchasing organizations2 or 7v7 rehabilitation or physical therapy facilities or services2 and 7,b7 include revenue- or profit-sharing whether through a joint venture1 management or professional services agreement1 or other form of gain-sharing contract2 7#b7 describe ,federal oversight of such relationships1 including authorities of the ,department of ,health and ,human ,services and the ,federal ,trade ,commission to review such relationships and their potential to increase costs for patients1 and identify limitations in such oversight2 and 7#c7 as appropriate1 make recommendations to improve ,federal oversight of such relationships4 7b7 ,report ,not later than #a year after the date of enactment of this ,act1 the ,comptroller ,general of the ,united ,states shall prepare and submit a report on the study conducted under subsection 7a7 to the ,committee on ,health1 ,education1 ,labor1 and ,pensions of the ,senate and the ,committee on ,education and ,labor and ,committee on ,energy and ,commerce of the ,house of ,representatives4 #d4 ,state ,all ,payer ,claims ,databases 7a7 ,in general ,the ,secretary of ,health and ,human ,services shall make one-time grants to eligible ,states for the purposes described in subsection 7b74 7b7 ,uses ,a ,state may use a grant received under subsection 7a7 for one of the following purposes3 7#a7 ,to establish an ,all ,payer ,claims ,database for the ,state4 7#b7 ,to maintain an existing ,all ,payer ,claims ,databases for the ,state4 7c7 ,eligibility ,to be eligible to receive a grant under subsection 7a71 a ,state shall submit to the ,secretary an application at such time1 in such manner1 and containing such information as the ,secretary specifies4 ,such information shall include1 with respect to an ,all ,payer ,claims ,database for the ,state1 at least specifics on how the ,state will ensure uniform data collection through the database and the security of such data submitted to and maintained in the database4 7d7 ,all ,payer ,claims ,database ,for purposes of this section1 the term ,all ,payer ,claims ,database means1 with respect to a ,state1 a ,state database that may include medical claims1 pharmacy claims1 dental claims1 and eligibility and provider files1 which are collected from private and public payers4 7e7 ,authorization of appropriations ,to carry out this section1 there are authorized to be appropriated #ej1jjj1jjj1 to remain available until expended4 #e4 ,simplifying emergency air ambulance billing 7a7 ,in general ,providers of emergency air medical services shall submit to a group health plan or health insurance issuer offering group or individual health insurance coverage1 together with an electronic claims transaction with respect to an enrollee in such plan or coverage1 a description of charges for such services that are separated by-- 7#a7 the cost of air travel2 and 7#b7 the cost of emergency medical services and supplies4 7b7 ,rulemaking ,not later than #a year after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall determine the form and manner for submitting the description of charges in subsection 7a7 through notice and comment rulemaking4 7c7 ,civil monetary penalties 7#a7 ,in general ,a provider of emergency air medical services who violates the requirement of subsection 7a7 shall be subject to a civil monetary penalty of not more than #aj1jjj for each act constituting such violation4 7#b7 ,procedure ,the provisions of section #aabh;,a of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;a71 other than subsections 7a7 and 7b7 and the first sentence of subsection 7c77#a7 of such section1 shall apply to civil money penalties under this subsection in the same manner as such provisions apply to a penalty or proceeding under section #aabh;,a of the ,social ,security ,act4 7d7 ,definitions ,in this section1 the terms group health plan1 health insurance coverage1 and health insurance issuer have the meanings given such terms in section #bgia of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ia74 7e7 ,effective date ,the requirement under subsection 7a7 shall take effect #f months after the rules described in subsection 7b7 are finalized4 #f4 ,report by ,secretary of ,labor ,not later than one year after the date of the enactment of this ,act1 and annually thereafter for each of the following #e years1 the ,secretary of ,labor shall-- 7#a7 conduct a study of-- 7,a7 the effects of the provisions of1 including amendments made by1 this ,act on premiums and out-of-pocket costs in group health plans1 including out-of-pocket costs that are permitted by reason of compliance with section #bgii;,a7d7 of the ,public ,health ,service ,act1 as added by section #b7;d72 7,b7 the adequacy of provider networks in group health plans2 and 7,c7 such other effects of such provisions1 and amendments1 as the ,secretary deems relevant2 and 7#b7 submit a report on such study to the ,committee on ,health1 ,education1 ,labor1 and ,pensions of the ,senate and the ,committee on ,education and ,labor and the ,committee on ,energy and ,commerce of the ,house of ,representatives4