,i  #aaf? ,,congress  #a/ ,session  ,h4 
,r4 #cfcj  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,july #i1 #bjai,mr4   
,pallone 7= himself & ,mr4 ,wald57      
introduc$ ! foll[+ bill2 :i* 0 ref]r$ to
 ! ,committee on ,en]gy & ,comm]ce1 & 9 
addition to ! ,committee on ,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 title ,,xxvii ( !     
,public ,heal? ,s]vice ,act to protect  
heal? c>e consum]s f surprise bill+     
practices1 & = o!r purposes4  #a4 ,%ort 
title ,?is ,act may be cit$ z ! ,no     
,surprises ,act4  #b4 ,prev5t+ surprise 
m$ical bills  7a7 ,cov]age ( em]g5cy    
s]vices ,section #bgai;,a7b7 ( ! ,public
 ,heal? ,s]vice ,act 7#db ,u4,s4,c4     
#cjj;gg-#ai;a7b77 is am5d$--  7#a7 9    
p>agraph 7#a7-- 7,a7 9 ! matt] prec$+   
subp>agraph 7,a7--  7i7 by /rik+ a gr\p 
heal? plan1 or a heal? insurance issu]  
(f]+ gr\p or individual heal? insurance 

issu]1 & ins]t+ a heal? plan 7z def9$ 9 
subsection 7e77#b77;,a772  7ii7 by      
ins]t+ or1 = plan ye> #bjba or a        
subsequ5t plan ye>1 ) respect to em]g5cy
 s]vices 9 an indep5d5t free/&+ em]g5cy 
dep>tm5t 7z def9$ 9 p>agraph 7#c77;,d77 
aft] em]g5cy dep>tm5t ( a hospital2     
7iii7 by /rik+ ! plan or issu] & ins]t+ 
! plan2 &  7iv7 by /rik+ p>agraph       
7#b77;,b7 & ins]t+ p>agraph 7#c77;,c72  
7,b7 9 subp>agraph 7,b71 by ins]t+ or a 
p>ticipat+ em]g5cy facility1 z          
applicable1 aft] p>ticipat+ provid]2 &  
7,c7 9 subp>agraph 7,c7--  7i7 9 ! matt]
 prec$+ clause 7i71 by ins]t+ by a      
nonp>ticipat+ provid] or a nonp>ticipat+
 em]g5cy facility aft] enrollee2  7ii7  
by /rik+ clause 7i72  7iii7 by /rik+    
7ii77,i7 su* s]vices & ins]t+ 7i7 su*   
s]vices2  7iv7 by /rik+ :]e ! provid] ( 
s]vices does n h a contractual          
relation%ip ) ! plan = ! provid+ (      
s]vices2  7v7 by /rik+ em]g5cy dep>tm5t 
s]vices receiv$ 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     
7vi7 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\nt 
or co9surance rate7 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 &  7vii7
 by add+ at ! end ! foll[+ new clauses3 
7iii7 su* requirem5t is calculat$ z if !
 total am\nt t w\ld h be5 *>g$ = su*    
s]vices by su* p>ticipat+ provid] or    
p>ticipat+ em]g5cy facility 7 equal to--
  7,i7 9 ! case ( su* s]vices furni%$ 9 
a ,/ate describ$ 9 p>agraph             
7#c77;,h77ii71 ! m$ian contract$ rate 7z
 def9$ 9 p>agraph 7#c77;,e77i77 = su*   
s]vices2 &  7,,ii7 9 ! case ( su*       
s]vices furni%$ 9 a ,/ate describ$ 9    
p>agraph 7#c77;,h77i71 ! less] (-- 7aa7 
! am\nt det]m9$ by su* ,/ate = su*      
s]vices 9 accordance ) ! me?od describ$ 

9 su* p>agraph2 &  7bb7 ! m$ian         
contract$ rate 7z s def9$7 = su*        
s]vices2  7iv7 ! heal? plan pays to su* 
provid] or facility1 respectively1 !    
am\nt by :i* ! recogniz$ am\nt 7z def9$ 
9 p>agraph 7#c77;,h77 = su* s]vices     
exce$s ! co/-%>+ am\nt = su* s]vices 7z 
det]m9$ 9 accordance ) clauses 7ii7 &   
7iii772 &  7v7 any co/-%>+ paym5ts made 
by ! p>ticipant1 b5efici>y1 or enrollee 
) respect to su* em]g5cy s]vices s      
furni%$ %all be c\nt$ t[>d any 9-network
 d$uctible or out-(-pocket maximums     
appli$ "u ! plan 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 facility2 &  2   
7#b7 by r$esignat+ p>agraph 7#b7 z      
p>agraph 7#c72  7#c7 by ins]t+ aft]     
p>agraph 7#a7 ! foll[+ new p>agraph3    
7#b7 ,audit process = m$ian contract$   
rates ,n lat] ?an ,july #a1 #bjbj1 !    
,secret>y %all1 9 consultation )        
appropriate ,/ate ag5cies1 e/abli% ?r\gh
 rulemak+ a process "u :i* sponsors &   

issu]s ( heal? plans are audit$ to      
ensure t su* sponsors & issu]s are 9    
compliance ) ! requirem5t ( apply+ a    
m$ian contract$ rate "u ?is section t   
satisfies ! def9ition "u p>agraph       
7#c77;,e74  2 &  7#d7 9 p>agraph 7#c71 z
 r$esignat$ by p>agraph 7#b7 ( ?is      
subsection-- 7,a7 9 ! matt] prec$+      
subp>agraph 7,a71 by ins]t+ &           
subsections 7e7 & 7f7 aft] ?is          
subsection2  7,b7 by r$esignat+         
subp>agraphs 7,a7 ?r\gh 7,c7 z          
subp>agraphs 7,b7 ?r\gh 7,d71           
respectively2  7,c7 by ins]t+ be=e      
subp>agraph 7,b71 z r$esignat$ by       
subp>agraph 7,b7 ( ?is p>agraph1 !      
foll[+ new subp>agraph3  7,a7 ,em]g5cy  
dep>tm5t ( a hospital ,! t]m em]g5cy    
dep>tm5t ( a hospital includes a        
hospital outpati5t dep>tm5t t provides  
em]g5cy s]vices4  2  7,d7 by am5d+      
subp>agraph 7,c71 z r$esignat$ by       
subp>agraph 7,b7 ( ?is p>agraph1 to read
 z foll[s3  7,c7 ,em]g5cy s]vices  7i7  
,9 g5]al ,! t]m em]g5cy s]vices1 )      

respect to an em]g5cy m$ical condition  
means-- 7,i7 a m$ical scre5+ exam9ation 
7z requir$ "u section #ahfg ( ! ,social 
,security ,act1 or z w\ld be requir$ "u 
su* section if su* section appli$ to an 
indep5d5t free/&+ em]g5cy dep>tm5t7 t is
 )9 ! capability ( ! em]g5cy dep>tm5t ( 
a hospital or ( an indep5d5t free/&+    
em]g5cy dep>tm5t1 z applicable1 includ+ 
ancill>y s]vices r\t9ely available to ! 
em]g5cy dep>tm5t to evaluate su* em]g5cy
 m$ical condition2 &  7,,ii7 )9 !       
capabilities ( ! /aff & facilities      
available at ! hospital or ! indep5d5t  
free/&+ em]g5cy dep>tm5t1 z applicable1 
su* fur!r m$ical exam9ation & treatm5t z
 are requir$ "u section #ahfg ( su*     
,act1 or z w\ld be requir$ "u su*       
section if su* section appli$ to an     
indep5d5t free/&+ em]g5cy dep>tm5t1 to  
/abilize ! pati5t4  7ii7 ,inclusion (   
po//abilization s]vices ,= purposes (   
?is subsection & section #bgii1 9 ! case
 ( an individual enroll$ 9 a heal? plan 
:o is furni%$ s]vices describ$ 9 clause 

7i7 by a provid] or facility to /abilize
 su* individual ) respect to an em]g5cy 
m$ical condition1 ! t]m em]g5cy s]vices 
%all include su* items & s]vices 9      
addition to ^? describ$ 9 clause 7i7 t  
su* a provid] or facility det]m9es are  
ne$$ to be furni%$ to su* individual    
dur+ ! visit 9 :i* su* individual is s  
/abiliz$ aft] su* /abilization1 unless  
ea* ( ! foll[+ conditions are met3  7,i7
 ,su* a provid] or facility det]m9es su*
 individual is able to travel us+       
nonm$ical transportation or nonem]g5cy  
m$ical transportation4  7,,ii7 ,su*     
provid] furni%+ su* additional items &  
s]vices is 9 compliance ) section       
#bgii;,a7d7 ) respect to su* items &    
s]vices4  2  7,e7 by r$esignat+         
subp>agraph 7,d71 z r$esignat$ by       
subp>agraph 7,b7 ( ?is p>agraph1 z      
subp>agraph 7,i72 &  7,f7 by ins]t+ aft]
 subp>agraph 7,c71 z r$esignat$ by      
subp>agraph 7,b7 ( ?is p>agraph1 !      
foll[+ new subp>agraphs3  7,d7          
,indep5d5t free/&+ em]g5cy dep>tm5t ,!  

t]m indep5d5t free/&+ em]g5cy dep>tm5t  
means a facility t-- 7i7 is             
geographically sep>ate & di/9ct & lic5s$
 sep>ately f a hospital "u applicable   
,/ate law2 &  7ii7 provides em]g5cy     
s]vices4  7,e7 ,m$ian contract$ rate    
7i7 ,9 g5]al ,! t]m m$ian contract$ rate
 means1 ) respect to an item or s]vice &
 a heal? plan 7z def9$ 9 subsection     
7e77#b77;,a77--  7,i7 = #bjba1 ! m$ian (
 ! negotiat$ rates recogniz$ by !       
sponsor or issu] ( su* plan 7det]m9$ )  
respect to all su* plans ( su* sponsor  
or su* issu]7 z ! total maximum paym5t  
7includ+ ! co/-%>+ am\nt impos$ = su*   
s]vices 7z det]m9$ 9 accordance )       
p>agraph 7#a77;,c77ii7 or subsection    
7e77#a77;,a71 z applicable7 & ! am\nt to
 be paid by ! plan or issu]7 "u su*     
plans 9 #bjai = ! same or a simil> item 
or s]vice t is provid$ by a provid] 9 ! 
same or simil> specialty & provid$ 9 !  
geographic region 9 :i* ! item or s]vice
 is furni%$1 consi/5t ) ! me?odology    
e/abli%$ by ! ,secret>y "u section      

#b7;e7 ( ! ,no ,surprises ,act1 increas$
 by ! p]c5tage increase 9 ! consum]     
price index = all urban consum]s 7,unit$
 ,/ates city av]age7 ov] #bjai & #bjbj2 
&  7,,ii7 = #bjbb & ea* subsequ5t ye>1 !
 m$ian contract$ rate = ! previ\s ye>1  
increas$ by ! p]c5tage increase 9 !     
consum] price index = all urban consum]s
 7,unit$ ,/ates city av]age7 ov] su*    
previ\s ye>4  7ii7 ,special rule2 rule (
 con/ruction  7,i7 ,c]ta9 insur]s ,!    
,secret>y %all provide pursuant to      
rulemak+ describ$ 9 clause 7ii7 t-- 7aa7
 if ! sponsor or issu] ( a heal? plan   
does n h suffici5t in=mation to         
calculate a m$ian contract$ rate = an   
item or s]vice or provid] type1 or am\nt
 (1 claims = items or s]vices 7z det]m9$
 by ! ,secret>y7 provid$ 9 a p>ticul>   
geographic area 7o!r ?an 9 a case       
describ$ 9 item 7bb771 su* sponsor or   
issu] %all demon/rate t su* sponsor or  
issu] w use any database free (         
conflicts ( int]e/ t has suffici5t      
in=mation reflect+ all[$ am\nts paid to 

individual heal? c>e provid]s = relevant
 s]vices provid$ 9 ! applicable         
geographic region 7su* z ,all ,pay]     
,claims ,databases 7z def9$ 9 section   
#d7;d7 ( ! ,no ,surprises ,act7 (       
,/ates71 & t su* sponsor or issu] w use 
any su* database to det]m9e a m$ian     
contract$ rate & cov] ! co/ ( access+   
any su* database2 &  7bb7 9 ! case ( a  
sponsor or issu] (f]+ a heal? plan 9 a  
geographic region t did n (f] any heal? 
plan 9 su* region dur+ #bjai1 su*       
sponsor or issu] %all use a me?odology  
e/abli%$ by ! ,secret>y = det]m9+ !     
m$ian contract$ rate = items & s]vices  
cov]$ by su* plan = ! fir/ ye> 9 :i* su*
 plan is (f]$ 9 su* region1 & t1 = ea*  
succe$+ ye>1 ! m$ian contract$ rate =   
su* items & s]vices "u su* plan %all be 
! m$ian contract$ rate = su* items &    
s]vices "u su* plan = ! previ\s ye>1    
increas$ by ! p]c5tage increase 9 !     
consum] price index = all urban consum]s
 7,unit$ ,/ates city av]age7 ov] su*    
previ\s ye>4  7,,ii7 ,rule ( con/ruction

 ,no?+ 9 ?is subp>agraph %all prev5t !  
sponsor or issu] ( a heal? plan f       
e/abli%+ sep>ate calculations ( a m$ian 
contract$ rate "u ?is subp>agraph =     
items & s]vices deliv]$ 9 non-hospital  
facilities1 includ+ indep5d5t free/&+   
em]g5cy dep>tm5ts4  7,f7 ,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 heal? plan1 an em]g5cy       
dep>tm5t ( a hospital1 or an indep5d5t  
free/&+ em]g5cy dep>tm5t1 t does n h a  
contractual relation%ip ) ! plan 7or1 if
 applicable1 issu] (f]+ ! plan7 =       
furni%+ su* item or s]vice "u ! plan4   
7ii7 ,p>ticipat+ em]g5cy facility ,! t]m
 p>ticipat+ em]g5cy facility means1 )   
respect to an item or s]vice & a heal?  
plan1 an em]g5cy dep>tm5t ( a hospital1 
or an indep5d5t free/&+ em]g5cy         
dep>tm5t1 t has a contractual           
relation%ip ) ! plan 7or1 if applicable1
 issu] (f]+ ! plan7 = furni%+ su* item  

or s]vice "u ! plan4  7,g7              
,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 heal?  
plan1 a physician or o!r heal? c>e      
provid] :o is act+ )9 ! scope ( practice
 ( t provid]'s lic5se or c]tification "u
 applicable ,/ate law & :o does n h a   
contractual relation%ip ) ! plan 7or1 if
 applicable1 issu] (f]+ ! plan7 =       
furni%+ su* item or s]vice "u ! plan4   
7ii7 ,p>ticipat+ provid] ,! t]m         
p>ticipat+ provid] means1 ) respect to  
an item or s]vice & a heal? plan1 a     
physician or o!r heal? c>e provid] :o is
 act+ )9 ! scope ( practice ( t         
provid]'s lic5se or c]tification "u     
applicable ,/ate law & :o has a         
contractual relation%ip ) ! plan 7or1 if
 applicable1 issu] (f]+ ! plan7 =       
furni%+ su* item or s]vice "u ! plan4   
7,h7 ,recogniz$ am\nt ,! t]m recogniz$  
am\nt means1 ) respect to an item or    
s]vice-- 7i7 9 ! case ( su* item or     

s]vice furni%$ 9 a ,/ate t has 9 effect 
a ,/ate law t provides = a me?od =      
det]m9+ ! am\nt ( paym5t t is requir$ to
 be cov]$ by a heal? plan regulat$ by   
su* ,/ate 9 ! case ( a p>ticipant1      
b5efici>y1 or enrollee cov]$ "u su* plan
 & receiv+ su* item or s]vice f a       
nonp>ticipat+ provid] or facility1 n m  
?an ! am\nt det]m9$ 9 accordance ) su*  
law plus ! co/-%>+ am\nt impos$ "u !    
plan = su* item or s]vice 7z det]m9$ 9  
accordance ) p>agraph 7#a77;,c77ii7 or  
subsection 7e77#a77;,a71 z applicable72 
or  7ii7 9 ! case ( su* item or s]vice  
furni%$ 9 a ,/ate t does n h 9 effect   
su* a law1 an am\nt t is at lea/ ! m$ian
 contract$ rate 7z def9$ 9 subp>agraph  
7,e77i7 & det]m9$ 9 accordance )        
rulemak+ describ$ 9 subp>agraph         
7,e77ii77 = su* item or s]vice4  4  7b7 
,cov]age ( 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 ,cov]age ( non-,em]g5cy s]vices     
p]=m$ by nonp>ticipat+ provid]s at c]ta9
 p>ticipat+ facilities  7#a7 ,9 g5]al   
,subject to p>agraph 7#c71 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#c77;,g77i77 dur+ a visit 7z def9$  
by ! ,secret>y 9 accordance ) p>agraph  
7#b77;,c77 at a p>ticipat+ heal? c>e    
facility 7z def9$ 9 p>agraph 7#b77;,b771
 ) 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] 7z def9$ 9 subsection           
7b77#c77;,g77ii772  7,b7 %all calculate 

su* co/-%>+ am\nt z if ! am\nt t w\ld h 
be5 *>g$ = su* items & s]vices by su*   
p>ticipat+ provid] 7 equal to--  7i7 9 !
 case ( su* items & s]vices furni%$ 9 a 
,/ate describ$ 9 subsection             
7b77#c77;,h77ii71 ! m$ian contract$ rate
 7z def9$ 9 subsection 7b77#c77;,e77i77 
= su* items & s]vices2 &  7ii7 9 ! case 
( su* items & s]vices furni%$ 9 a ,/ate 
describ$ 9 subsection 7b77#c77;,h77i71 !
 less] (--  7,i7 ! am\nt det]m9$ by su* 
,/ate = su* items & s]vices 9 accordance
 ) ! me?od describ$ 9 su* subsection2 & 
7,,ii7 ! m$ian contract$ rate 7z s      
def9$7 = su* items & s]vices2  7,c7 %all
 pay to su* provid] furni%+ su* items & 
s]vices to su* p>ticipant1 b5efici>y1 or
 enrollee ! am\nt by :i* ! recogniz$    
am\nt 7z def9$ 9 subsection             
7b77#c77;,h77 = su* items & s]vices     
exce$s ! co/-%>+ am\nt impos$ "u ! plan 
= su* items & s]vices 7z det]m9$ 9      
accordance ) subp>agraphs 7,a7 & 7,b772 
&  7,d7 %all c\nt t[>d any 9-network    
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 7b73 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>ket & includes a        
gr&fa!r$ heal? plan 7z def9$ 9 section  
#abea7;e7 ( ! ,pati5t ,protection &     
,af=dable ,c>e ,act74  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 heal?  
plan1 a heal? c>e facility describ$ 9   
clause 7ii7 t has a contractual         
relation%ip ) ! plan 7or1 if applicable1
 issu] (f]+ ! plan7 = 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
 facility or imag+ c5t]4  7,c7 ,dur+ a  
visit ,! t]m dur+ a visit %all1 )       
respect to items & s]vices furni%$ to an
 individual at a p>ticipat+ heal? c>e   
facility1 include equipm5t & devices1   
telem$ic9e s]vices1 imag+ s]vices1      
laboratory s]vices1 & su* o!r items &   
s]vices z ! ,secret>y may specify1      
reg>dless ( :e!r or n ! provid] furni%+ 
su* items or s]vices is at ! facility4  
7#c7 ,exception ,p>agraph 7#a7 %all n   
apply to a heal? plan 9 ! case ( items  
or s]vices 7o!r ?an em]g5cy s]vices to  
:i* subsection 7b7 applies7 furni%$ 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#c77;,g77i77    

dur+ a visit 7z def9$ by ! ,secret>y 9  
accordance ) p>agraph 7#b77;,c77 at a   
p>ticipat+ heal? c>e facility 7z def9$ 9
 p>agraph 7#b77;,b77 if su* provid] is 9
 compliance ) section #bgii;,a7d7 )     
respect to su* items & s]vices4  4  7c7 
,provid] directory requirem5ts2         
disclosure on pati5t protections        
,section #bgai;,a ( ! ,public ,heal?    
,s]vice ,act1 z am5d$ by subsection 7b71
 is fur!r am5d$ by add+ at ! end !      
foll[+ new subsections3  7f7 ,provid]   
directory in=mation requirem5ts  7#a7 ,9
 g5]al ,n lat] ?an #a ye> aft] ! date ( 
! enactm5t ( ?is subsection1 ea* gr\p   
heal? plan & heal? insurance issu] (f]+ 
gr\p or individual heal? insurance      
cov]age %all--  7,a7 e/abli% !          
v]ification process describ$ 9 p>agraph 
7#b72  7,b7 e/abli% ! response protocol 
describ$ 9 p>agraph 7#c72  7,c7 e/abli% 
! database describ$ 9 p>agraph 7#d72 &  
7,d7 include 9 any pr9t directory       
conta9+ provid] directory in=mation )   
respect to su* plan or su* cov]age !    

in=mation describ$ 9 p>agraph 7#e74     
7#b7 ,v]ification process ,! v]ification
 process describ$ 9 ?is p>agraph is1 )  
respect to a gr\p heal? plan or a heal? 
insurance issu] (f]+ gr\p or individual 
heal? insurance cov]age1 a process "u   
:i*--  7,a7 n less frequ5tly ?an once e 
#ij days1 su* plan or su* issu] 7z      
applicable7 v]ifies & updates ! provid] 
directory in=mation includ$ on !        
database describ$ 9 p>agraph 7#d7 ( su* 
plan or issu] ( ea* heal? c>e provid] & 
heal? c>e facility includ$ 9 su*        
database2 &  7,b7 su* plan or su* issu] 
removes any su* provid] or facility )   
respect to :i* su* plan or su* issu] has
 be5 unable to v]ify su* in=mation dur+ 
any #f-mon? p]iod4  7#c7 ,response      
protocol ,! response protocol describ$ 9
 ?is p>agraph is1 9 ! case ( an         
individual enroll$ "u a gr\p heal? plan 
or gr\p or individual heal? insurance   
cov]age (f]$ by a heal? insurance issu] 
:o reque/s in=mation on :e!r a heal? c>e
 provid] or heal? c>e facility has a    

contractual relation%ip to furni% items 
& s]vices "u su* plan or su* cov]age1 a 
protocol "u :i* su* plan or su* issu] 7z
 applicable71 9 ! case su* reque/ is    
made ?r\gh a telephone call--  7,a7     
responds to su* individual z soon z     
practicable & 9 no case lat] ?an #a     
bus9ess day aft] su* call is receiv$    
?r\gh a writt5 electronic communication2
 &  7,b7 reta9s su* communication 9 su* 
individual's file = at lea/ #b ye>s     
foll[+ su* response4  7#d7 ,database ,! 
database describ$ 9 ?is p>agraph is1 )  
respect to a gr\p heal? plan or heal?   
insurance issu] (f]+ gr\p or individual 
heal? insurance cov]age1 a database on !
 public website ( su* plan or issu] t   
conta9s--  7,a7 a li/ ( ea* heal? c>e   
provid] & heal? c>e facility ) :i* su*  
plan or su* issu] has a contractual     
relation%ip = furni%+ items & s]vices "u
 su* plan or su* cov]age2 &  7,b7       
provid] directory in=mation ) respect to
 ea* su* provid] & facility4  7#e7      
,in=mation ,! in=mation describ$ 9 ?is  

p>agraph is1 ) respect to a pr9t        
directory conta9+ provid] directory     
in=mation ) respect to a gr\p heal? plan
 or individual or gr\p heal? insurance  
cov]age (f]$ by a heal? insurance issu]1
 a notification t su* in=mation conta9$ 
9 su* directory 0 accurate z ( ! date ( 
publication ( su* directory & t an      
individual enroll$ "u su* plan or su*   
cov]age %\ld consult ! database describ$
 9 p>agraph 7#d7 ) respect to su* plan  
or su* cov]age or contact su* plan or ! 
issu] ( su* cov]age to obta9 ! mo/      
curr5t provid] directory in=mation )    
respect to su* plan or su* cov]age4     
7#f7 ,def9ition ,= purposes ( ?is       
subsection1 ! t]m provid] directory     
in=mation includes1 ) respect to a gr\p 
heal? plan & a heal? insurance issu]    
(f]+ gr\p or individual heal? insurance 
cov]age1 ! "n1 address1 specialty1 &    
telephone numb] ( ea* heal? c>e provid] 
or heal? c>e facility ) :i* su* plan or 
su* issu] has a contractual relation%ip 
= furni%+ items & s]vices "u su* plan or

 su* cov]age4  7g7 ,disclosure on pati5t
 protections ,ea* gr\p heal? plan &     
heal? insurance issu] (f]+ gr\p or      
individual heal? insurance cov]age %all 
make publicly available1 & 7if          
applicable7 po/ on a public website (   
su* plan or issu]--  7#a7 in=mation 9   
pla9 language on-- 7,a7 ! requirem5ts & 
prohibitions appli$ "u sections #bgii & 
#bgii;,a 7relat+ to prohibitions on     
balance bill+ 9 c]ta9 circum/ances72    
7,b7 if provid$ = "u applicable ,/ate   
law1 any o!r requirem5ts on provid]s &  
facilities reg>d+ ! am\nts su* provid]s 
& facilities may1 ) respect to an item  
or s]vice1 *>ge a p>ticipant1 b5efici>y1
 or enrollee ( su* plan or cov]age )    
respect to :i* su* a provid] or facility
 does n h a contractual relation%ip =   
furni%+ su* item or s]vice "u ! plan or 
cov]age aft] receiv+ paym5t f ! plan or 
cov]age = su* item or s]vice & any      
applicable co/-%>+ paym5t f su*         
p>ticipant1 b5efici>y1 or enrollee2 &   
7,c7 ! requirem5ts appli$ "u subsections

 7b7 & 7e72 &  7#b7 in=mation on        
contact+ appropriate ,/ate & ,f$]al     
ag5cies 9 ! case t an individual        
believes t su* a provid] or facility has
 violat$ any requirem5t describ$ 9      
p>agraph 7#a7 ) respect to su*          
individual4  4  7d7 ,prev5t+ c]ta9 cases
 ( balance bill+ ,title ,,xxvii ( !     
,public ,heal? ,s]vice ,act is am5d$ by 
add+ at ! end ! foll[+ new "p3  ,d      
,prev5t+ ,c]ta9 ,cases ( ,balance ,bill+
  #bgii4 ,balance bill+ 9 cases (       
em]g5cy s]vices  7a7 ,9 g5]al ,9 ! case 
( a p>ticipant1 b5efici>y1 or enrollee )
 b5efits "u a heal? plan :o is furni%$  
on or aft] ,janu>y #a1 #bjba1 em]g5cy   
s]vices ) respect to an em]g5cy m$ical  
condition dur+ a visit at an em]g5cy    
dep>tm5t ( a hospital or an indep5d5t   
free/&+ em]g5cy dep>tm5t--  7#a7 !      
em]g5cy dep>tm5t ( a hospital or        
indep5d5t free/&+ em]g5cy dep>tm5t %all 
n hold ! p>ticipant1 b5efici>y1 or      
enrollee liable = a paym5t am\nt = su*  
em]g5cy s]vices s furni%$ t is m ?an !  

co/-%>+ am\nt = su* s]vices 7z det]m9$ 9
 accordance ) section                   
#bgai;,a7b77#a77;,c77ii772 &  7#b7 a    
heal? c>e provid] %all n hold su*       
p>ticipant1 b5efici>y1 or enrollee      
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;,c77ii774  7b7 
,def9itions ,9 ?is section3 7#a7 ,! t]ms
 em]g5cy dep>tm5t ( a hospital1 em]g5cy 
m$ical condition1 em]g5cy s]vices1 &    
indep5d5t free/&+ em]g5cy dep>tm5t h !  
mean+s giv5 su* t]ms1 respectively1 9   
section #bgai;,a7b77#c74  7#b7 ,! t]m   
heal? plan has ! mean+ giv5 su* t]m 9   
section #bgai;,a7e74  7#c7 ,! t]m dur+ a
 visit %all h su* mean+ z appli$ to su* 
t]m = purposes ( section #bgai;,a7e74   
#bgii;,a4 ,balance bill+ 9 cases (      

non-em]g5cy s]vices p]=m$ by            
nonp>ticipat+ provid]s at c]ta9         
p>ticipat+ facilities  7a7 ,9 g5]al     
,subject to subsection 7b71 9 ! case ( a
 p>ticipant1 b5efici>y1 or enrollee )   
b5efits "u a heal? plan 7z def9$ 9      
section #bgii7;b77 :o is furni%$ on or  
aft] ,janu>y #a1 #bjba1 items or s]vices
 7o!r ?an em]g5cy s]vices to :i* section
 #bgii applies7 at a p>ticipat+ heal?   
c>e facility by a nonp>ticipat+ provid]1
 su* provid] %all n hold su* p>ticipant1
 b5efici>y1 or enrollee liable = a      
paym5t am\nt = su* an item or s]vice    
furni%$ by su* provid] dur+ a visit at  
su* facility t is m ?an ! co/-%>+ am\nt 
= su* item or s]vice 7z det]m9$ 9       
accordance ) subp>agraphs 7,a7 & 7,b7 ( 
section #bgai;,a7e77#a774  7b7          
,exception  7#a7 ,9 g5]al ,subsection   
7a7 %all n apply to a nonp>ticipat+     
provid] 7o!r ?an a specifi$ provid] at a
 p>ticipat+ heal? c>e facility71 )      
respect to items or s]vices furni%$ by !
 provid] to a p>ticipant1 b5efici>y1 or 

enrollee ( a heal? plan1 if ! provid] is
 9 compliance ) ! notice & cons5t       
requirem5ts ( subsection 7d74  7#b7     
,specifi$ provid] def9$ ,= purposes (   
p>agraph 7#a71 ! t]m specifi$ provid]1 )
 respect to a p>ticipat+ heal? c>e      
facility-- 7,a7 means a facility-bas$   
provid]1 includ+ em]g5cy m$ic9e         
provid]s1 ane/hesiologi/s1 pa?ologi/s1  
radiologi/s1 neonatologi/s1 assi/ant    
surgeons1 hospitali/s1 int5sivi/s1 or   
o!r provid]s z det]m9$ by ! ,secret>y2 &
  7,b7 includes1 ) respect to an item or
 s]vice1 a nonp>ticipat+ provid] if !re 
is no p>ticipat+ provid] at su* facility
 :o c furni% su* item or s]vice4  7c7   
,cl>ification ,9 ! case ( a             
nonp>ticipat+ provid] 7o!r ?an a        
specifi$ provid] at a p>ticipat+ heal?  
c>e facility7 t complies ) ! notice &   
cons5t requirem5ts ( subsection 7d7 )   
respect to an item or s]vice 7ref]r$ to 
9 ?is subsection z a cov]$ item or      
s]vice71 su* notice & cons5t requirem5ts
 may n be con/ru$ z apply+ ) respect to 

any item or s]vice t is furni%$ z a     
result ( un=ese5 m$ical ne$s t arise at 
! "t su* cov]$ item or s]vice is        
furni%$4  7d7 ,compliance ) notice &    
cons5t requirem5ts  7#a7 ,9 g5]al ,a    
nonp>ticipat+ provid] or nonp>ticipat+  
facility is 9 compliance ) ?is          
subsection1 ) respect to items or       
s]vices furni%$ by ! provid] or facility
 to a p>ticipant1 b5efici>y1 or enrollee
 ( a heal? plan1 if ! provid] 7or1 if   
applicable1 ! p>ticipat+ heal? c>e      
facility on behalf ( su* provid]7 or    
nonp>ticipat+ facility--  7,a7 provides 
to ! p>ticipant1 b5efici>y1 or enrollee 
7or to an au?oriz$ repres5tative ( !    
p>ticipant1 b5efici>y1 or enrollee71 on 
! date on :i* ! p>ticipant1 b5efici>y1  
or enrollee makes an appo9tm5t to be    
furni%$ su* items or s]vices1 if        
applicable1 & on ! date on :i* !        
individual is furni%$ su* items or      
s]vices--  7i7 an oral explanation ( !  
writt5 notice describ$ 9 clause 7ii72 & 
7ii7 a writt5 notice specifi$1 n lat]   

?an ,july #a1 #bjbj1 by ! ,secret>y     
?r\gh guidance 7:i* %all be updat$ z    
det]m9$ necess>y by ! ,secret>y7 t--    
7,i7 conta9s ! in=mation requir$ "u     
p>agraph 7#b72 &  7,,ii7 is sign$ & dat$
 by ! p>ticipant1 b5efici>y1 or enrollee
 7or by an au?oriz$ repres5tative ( !   
p>ticipant1 b5efici>y1 or enrollee7 &1 )
 respect to items or s]vices to be      
furni%$ by su* a provid] t are n        
po//abilization s]vices describ$ 9      
section #bgai;,a7b77#c77;,c77ii71 is s  
sign$ & dat$ n less ?an #gb h\rs prior  
to ! p>ticipant1 b5efici>y1 or enrollee 
be+ furni%$ su* items or s]vices by su* 
provid]2 &  7,b7 obta9s f ! p>ticipant1 
b5efici>y1 or enrollee 7or f su* an     
au?oriz$ repres5tative7 ! cons5t        
describ$ 9 p>agraph 7#c74  7#b7         
,in=mation requir$ "u writt5 notice ,=  
purposes ( p>agraph 7#a77;,a77ii77,i71 !
 in=mation describ$ 9 ?is p>agraph1 )   
respect to a nonp>ticipat+ provid] or   
nonp>ticipat+ facility & a p>ticipant1  
b5efici>y1 or enrollee ( a heal? plan1  

is ea* ( ! foll[+3  7,a7 ,notification1 
z applicable1 t ! heal? c>e provid] is a
 nonp>ticipat+ provid] ) respect to !   
heal? plan or ! heal? c>e facility is a 
nonp>ticipat+ facility ) respect to !   
heal? plan4  7,b7 ,notification ( !     
e/imat$ am\nt t su* provid] or facility 
may *>ge ! p>ticipant1 b5efici>y1 or    
enrollee = su* items & s]vices involv$4 
7,c7 ,9 ! case ( a nonp>ticipat+        
facility1 a li/ ( any p>ticipat+        
provid]s at ! facility :o are able to   
furni% su* items & s]vices involv$ &    
notification t ! p>ticipant1 b5efici>y1 
or enrollee may be ref]r$1 at _! option1
 to su* a p>ticipat+ provid]4  7#c7     
,cons5t describ$ ,= purposes ( p>agraph 
7#a77;,b71 ! cons5t describ$ 9 ?is      
p>agraph1 ) respect to a p>ticipant1    
b5efici>y1 or enrollee ( a heal? plan :o
 is to be furni%$ items or s]vices by a 
nonp>ticipat+ provid] or nonp>ticipat+  
facility1 is a docum5t specifi$ by !    
,secret>y ?r\gh rulemak+ t--  7,a7 is   
sign$ by ! p>ticipant1 b5efici>y1 or    

enrollee 7or by an au?oriz$             
repres5tative ( ! p>ticipant1 b5efici>y1
 or enrollee7 &1 ) respect to items or  
s]vices to be furni%$ by su* a provid]  
or facility t are n po//abilization     
s]vices describ$ 9 section              
#bgai;,a7b77#c77;,c77ii71 is s sign$ n  
less ?an #gb h\rs prior to ! p>ticipant1
 b5efici>y1 or enrollee be+ furni%$ su* 
items or s]vices by su* provid] or      
facility2  7,b7 ackn[l$ges t !          
p>ticipant1 b5efici>y1 or enrollee has  
be5-- 7i7 provid$ ) a writt5 e/imate &  
an oral explanation ( ! *>ge t !        
p>ticipant1 b5efici>y1 or enrollee w be 
assess$ = ! items or s]vices anticipat$ 
to be furni%$ to ! p>ticipant1          
b5efici>y1 or enrollee by su* provid] or
 facility2 &  7ii7 in=m$ t ! paym5t (   
su* *>ge by ! p>ticipant1 b5efici>y1 or 
enrollee may n accrue t[>d meet+ any    
limitation t ! heal? plan places on     
co/-%>+2 &  7,c7 docum5ts ! cons5t ( !  
p>ticipant1 b5efici>y1 or enrollee to-- 
7i7 be furni%$ ) su* items or s]vices by

 su* provid] or facility2 &  7ii7 9 !   
case t ! individual is s furni%$ su*    
items or s]vices1 be *>g$ an am\nt t may
 be great] ?an ! am\nt t w\ld o!rwise be
 *>g$ ! individual if furni%$ by a      
p>ticipat+ provid] or p>ticipat+        
facility ) respect to su* items or      
s]vices & plan4  7e7 ,ret5tion ( c]ta9  
docum5ts ,a nonp>ticipat+ provid] 7or1 9
 ! case ( a nonp>ticipat+ provid] at a  
p>ticipat+ heal? c>e facility1 su*      
facility7 or nonp>ticipat+ facility t   
obta9s f a p>ticipant1 b5efici>y1 or    
enrollee ( a heal? plan 7or an au?oriz$ 
repres5tative ( su* p>ticipant1         
b5efici>y1 or enrollee7 a writt5 notice 
9 accordance ) subsection 7c77#a77;ii71 
) respect to furni%+ an item or s]vice  
to su* p>ticipant1 b5efici>y1 or        
enrollee1 %all reta9 su* notice = at    
lea/ a #b-ye> p]iod aft] ! date on :i*  
su* item or s]vice is s furni%$4  7f7   
,def9itions ,9 ?is section3 7#a7 ,! t]ms
 nonp>ticipat+ provid] & p>ticipat+     
provid] h ! mean+s giv5 su* t]ms1       

respectively1 9 subsection 7b77#c7 (    
section #bgai;,a4  7#b7 ,! t]ms         
p>ticipat+ heal? c>e facility & heal?   
plan h ! mean+s giv5 su* t]ms1          
respectively1 9 subsection 7e77#b7 (    
section #bgai;,a4  7#c7 ,! t]m          
nonp>ticipat+ facility means--  7,a7 )  
respect to em]g5cy s]vices 7z def9$ 9   
section #bgai;,a7b77#c77;,c77i77 & a    
heal? plan1 an em]g5cy dep>tm5t ( a     
hospital1 or an indep5d5t free/&+       
em]g5cy dep>tm5t1 t does n h a          
contractual relation%ip ) ! plan 7or1 if
 applicable1 issu] (f]+ ! plan7 =       
furni%+ su* s]vices "u ! plan2 &  7,b7 )
 respect to po//abilization s]vices     
describ$ 9 section                      
#bgai;,a7b77#c77;,c77ii7 & a heal? plan1
 an em]g5cy dep>tm5t ( a hospital 7or   
o!r dep>tm5t ( su* hospital71 or an     
indep5d5t free/&+ em]g5cy dep>tm5t1 t   
does n h a contractual relation%ip ) !  
plan 7or1 if applicable1 issu] (f]+ !   
plan7 = furni%+ su* s]vices "u ! plan4  
7#d7 ,! t]m p>ticipat+ facility means-- 

7,a7 ) respect to em]g5cy s]vices 7z    
def9$ 9 section #bgai;,a7b77#c77;,c77i77
 & a heal? plan1 an em]g5cy dep>tm5t ( a
 hospital1 or an indep5d5t free/&+      
em]g5cy dep>tm5t1 t has a contractual   
relation%ip ) ! plan 7or1 if applicable1
 issu] (f]+ ! plan7 = furni%+ su*       
s]vices "u ! plan2 &  7,b7 ) respect to 
po//abilization s]vices describ$ 9      
section #bgai;,a7b77#c77;,c77ii7 & a    
heal? plan1 an em]g5cy dep>tm5t ( a     
hospital 7or o!r dep>tm5t ( su*         
hospital71 or an indep5d5t free/&+      
em]g5cy dep>tm5t1 t has a contractual   
relation%ip ) ! plan 7or1 if applicable1
 issu] (f]+ ! plan7 = furni%+ su*       
s]vices "u ! plan4  #bgii;,b4 ,provid]  
requirem5ts ) respect to provid]        
directory in=mation ,n lat] ?an #a ye>  
aft] ! date ( ! enactm5t ( ?is section1 
ea* heal? c>e provid] & heal? c>e       
facility %all e/abli% a process "u :i*  
su* provid] or facility transmits1 to   
ea* heal? insurance issu] (f]+ gr\p or  
individual heal? insurance cov]age &    

gr\p heal? plan ) :i* su* provid] or    
facility has 9 effect a contractual     
relation%ip = furni%+ items & s]vices "u
 su* cov]age or su* plan1 provid]       
directory in=mation 7z def9$ 9 section  
#bgai;,a7f77#f77 ) respect to su*       
provid] or facility1 z applicable4 ,su* 
provid] or facility %all s transmit su* 
in=mation to su* issu] (f]+ su* cov]age 
or su* gr\p heal? plan--  7#a7 :5 !     
provid] or facility ent]s into su* a    
relation%ip ) respect to su* cov]age    
(f]$ by su* issu] or ) respect to su*   
plan2  7#b7 :5 ! provid] or facility    
t]m9ates su* relation%ip ) respect to   
su* cov]age (f]$ by su* issu] or )      
respect to su* plan2  7#c7 :5 !re are   
any o!r mat]ial *anges to su* provid]   
directory in=mation ( ! provid] or      
facility ) respect to su* cov]age (f]$  
by su* issu] or ) respect to su* plan2 &
  7#d7 at any o!r "t det]m9$ appropriate
 by ! provid]1 facility1 or ! ,secret>y4
  #bgii;,c4 ,provid] requirem5t )       
respect to public provision ( in=mation 

,ea* heal? c>e provid] & heal? c>e      
facility %all make publicly available1 &
 7if applicable7 po/ on a public website
 ( su* provid] or facility--  7#a7      
in=mation 9 pla9 language on-- 7,a7 !   
requirem5ts & prohibitions ( su* provid]
 or facility "u sections #bgii &        
#bgii;,a 7relat+ to prohibitions on     
balance bill+ 9 c]ta9 circum/ances72 &  
7,b7 if provid$ = "u applicable ,/ate   
law1 any o!r requirem5ts on su* provid] 
or facility reg>d+ ! am\nts su* provid] 
or facility may1 ) respect to an item or
 s]vice1 *>ge a p>ticipant1 b5efici>y1  
or enrollee ( a heal? plan 7z def9$ 9   
section #bgai;,a7e77#b77 ) respect to   
:i* su* provid] or facility does n h a  
contractual relation%ip = furni%+ su*   
item or s]vice "u ! plan aft] receiv+   
paym5t f ! plan = su* item or s]vice &  
any applicable co/-%>+ paym5t f su*     
p>ticipant1 b5efici>y1 or enrollee2 &   
7#b7 in=mation on contact+ appropriate  
,/ate & ,f$]al ag5cies 9 ! case t an    
individual believes t su* provid] or    

facility has violat$ any requirem5t     
describ$ 9 p>agraph 7#a7 ) respect to   
su* individual4  #bgii;,d4 ,en=cem5t    
7a7 ,/ate en=cem5t  7#a7 ,/ate au?ority 
,ea* ,/ate may require a provid] or     
heal? c>e facility subject to !         
requirem5ts ( sections #bgii1 #bgii;,a1 
#bgii;,b1 or #bgii;,c to satisfy su*    
requirem5ts applicable to ! provid] or  
facility4  7#b7 ,failure to implem5t    
requirem5ts ,9 ! case ( a ,/ate t fails 
to sub/antially en=ce ! requirem5ts set 
=? 9 ?is "p ) respect to applicable     
provid]s & facilities 9 ! ,/ate1 !      
,secret>y %all en=ce ! requirem5ts ( ?is
 "p "u subsection 7b7 ins(> z !y relate 
to actions prohibit$ "u ?is "p occurr+ 9
 su* ,/ate4  7b7 ,secret>ial en=cem5t   
au?ority  7#a7 ,9 g5]al ,if a provid] or
 facility is f\nd to be 9 violation (   
?is "p by ! ,secret>y1 ! ,secret>y may  
apply a civil monet>y p5alty ) respect  
to su* provid] or facility 9 an am\nt n 
to exce$ #aj1jjj p] violation4 ,!       
provisions ( subsections 7c71 7d71 7e71 

7g71 7h71 7k71 & 7l7 ( section #aabh;,a 
( ! ,social ,security ,act %all apply to
 a civil monet>y p5alty or assessm5t "u 
?is subsection 9 ! same mann] z su*     
provisions apply to a p5alty1 assessm5t1
 or proce$+ "u subsection 7a7 ( su*     
section4  7#b7 ,limitation ,! provisions
 ( p>agraph 7#a7 %all apply to en=cem5t 
( a provision 7or provisions7 ( ?is "p  
only z provid$ "u subsection 7a77#b74   
7#c7 ,compla9t process ,! ,secret>y     
%all1 ?r\gh rulemak+1 e/abli% a process 
to receive consum] compla9ts (          
violations ( ?is "p & resolve su*       
compla9ts )9 #fj days ( receipt ( su*   
compla9ts4  7#d7 ,exception ,! ,secret>y
 %all waive ! p5alties describ$ "u      
p>agraph 7#a7 ) respect to a facility or
 provid] :o does n kn[+ly violate1 &    
%\ld n h reasonably kn[n x violat$1 a   
provision ( ?is "p ) respect to a       
p>ticipant1 b5efici>y1 or enrollee1 if  
su* facility or practition]1 )9 #cj days
 ( ! violation1 )draws ! bill t 0 9     
violation ( su* provision1 & reimburses 

! heal? plan or enrollee1 z applicable1 
9 an am\nt equal to ! diff]5ce betwe5 ! 
am\nt bill$ & ! am\nt all[$ to be bill$ 
"u ! provision1 plus int]e/1 at an      
int]e/ rate det]m9$ by ! ,secret>y4     
7#e7 ,h>d%ip exemption ,! ,secret>y may 
e/abli% a h>d%ip exemption to ! p5alties
 "u ?is subsection4  7c7 ,cont9u$       
,applicability ( ,/ate ,law ,?is "p %all
 n be con/ru$ to sup]s$e any provision (
 ,/ate law :i* e/abli%es1 implem5ts1 or 
cont9ues 9 effect any requirem5t or     
prohibition except to ! ext5t t su*     
requirem5t or prohibition prev5ts !     
application ( a requirem5t or           
prohibition ( ?is "p4  4  7e7 ,rulemak+ 
= m$ian contract$ rates ,n lat] ?an     
,july #a1 #bjbj1 ! ,secret>y ( ,heal? & 
,human ,s]vices1 jo9tly ) ! ,secret>y ( 
,labor1 %all e/abli% ?r\gh rulemak+ !   
me?odology ! sponsor or issu] ( a heal? 
plan 7z def9$ 9 subsection 7e7 ( section
 #bgai;,a ( ! ,public ,heal? ,s]vice    
,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 z   
add$ by subsection 7b7 ( ?is section7   

%all use to det]m9e ! m$ian contract$   
rate 7z def9$ 9 section #bgai;,a7b7 (   
su* ,act1 z am5d$ by subsection 7a7 (   
?is section71 ! in=mation su* sponsor or
 issu] %all %>e ) ! nonp>ticipat+       
provid] 7z def9$ 9 su* section7 involv$ 
:5 mak+ su* a det]m9ation1 & !          
geographic regions appli$ = purposes (  
?is subp>agraph 7,e7 ( section          
#bgai;,a7b77#c71 z am5d$ by subsection  
7a7 ( ?is section4  7f7 ,effective date 
,! am5dm5ts made by subsections 7a7 &   
7b7 %all apply ) respect to plan ye>s   
beg9n+ on or aft] ,janu>y #a1 #bjba4    
#c4 ,gov]nm5t ,acc\ntability ,(fice /udy
 on pr(it- & rev5ue-%>+ 9 heal? c>e  7a7
 ,/udy ,n lat] ?an #a ye> aft] ! date ( 
enactm5t ( ?is ,act1 ! ,comptroll]      
,g5]al ( ! ,unit$ ,/ates %all conduct a 
/udy to--  7#a7 describe :at is kn[n    
ab\t pr(it- & rev5ue-%>+ relation%ips 9 
! comm]cial heal? c>e m>kets1 includ+ ^?
 relation%ips t--  7,a7 involve "o or   
m-- 7i7 physician gr\ps t practice )9 a 
hospital includ$ 9 ! pr(it- or          

rev5ue-%>+ relation%ip1 or ref] pati5ts 
to su* hospital2  7ii7 laboratory1      
radiology1 or ph>macy s]vices t are     
deliv]$ to privately insur$ pati5ts (   
su* hospital2  7iii7 surgical s]vices2  
7iv7 hospitals or gr\p pur*as+          
organizations2 or  7v7 rehabilitation or
 physical !rapy facilities or s]vices2 &
  7,b7 include rev5ue- or pr(it-%>+ :e!r
 ?r\gh a jo9t v5ture1 managem5t or      
pr(essional s]vices agreem5t1 or o!r =m 
( ga9-%>+ contract2  7#b7 describe      
,f$]al ov]sight ( su* relation%ips1     
includ+ au?orities ( ! ,dep>tm5t (      
,heal? & ,human ,s]vices & ! ,f$]al     
,trade ,commission to review su*        
relation%ips & _! pot5tial to increase  
co/s = pati5ts1 & id5tify limitations 9 
su* ov]sight2 &  7#c7 z appropriate1    
make recomm5dations to improve ,f$]al   
ov]sight ( su* relation%ips4  7b7       
,report ,n lat] ?an #a ye> aft] ! date (
 enactm5t ( ?is ,act1 ! ,comptroll]     
,g5]al ( ! ,unit$ ,/ates %all prep>e &  
submit a report on ! /udy conduct$ "u   

subsection 7a7 to ! ,committee on       
,heal?1 ,education1 ,labor1 & ,p5sions (
 ! ,s5ate & ! ,committee on ,education &
 ,labor & ,committee on ,en]gy &        
,comm]ce ( ! ,h\se ( ,repres5tatives4   
#d4 ,/ate ,all ,pay] ,claims ,databases 
7a7 ,9 g5]al ,! ,secret>y ( ,heal? &    
,human ,s]vices %all make "o-"t grants  
to eligible ,/ates = ! purposes describ$
 9 subsection 7b74  7b7 ,uses ,a ,/ate  
may use a grant receiv$ "u subsection   
7a7 = "o ( ! foll[+ purposes3 7#a7 ,to  
e/abli% an ,all ,pay] ,claims ,database 
= ! ,/ate4  7#b7 ,to ma9ta9 an exi/+    
,all ,pay] ,claims ,databases = ! ,/ate4
  7c7 ,eligibility ,to be eligible to   
receive a grant "u subsection 7a71 a    
,/ate %all submit to ! ,secret>y an     
application at su* "t1 9 su* mann]1 &   
conta9+ su* in=mation z ! ,secret>y     
specifies4 ,su* in=mation %all include1 
) respect to an ,all ,pay] ,claims      
,database = ! ,/ate1 at lea/ specifics  
on h[ ! ,/ate w ensure uni=m data       
collection ?r\gh ! database & ! security

 ( su* data submitt$ to & ma9ta9$ 9 !   
database4  7d7 ,all ,pay] ,claims       
,database ,= purposes ( ?is section1 !  
t]m ,all ,pay] ,claims ,database means1 
) respect to a ,/ate1 a ,/ate database t
 may include m$ical claims1 ph>macy     
claims1 d5tal claims1 & eligibility &   
provid] files1 :i* are collect$ f       
private & public pay]s4  7e7            
,au?orization ( appropriations ,to c>ry 
out ?is section1 !re are au?oriz$ to be 
appropriat$ #ej1jjj1jjj1 to rema9       
available until exp5d$4  #e4 ,simplify+ 
em]g5cy air ambulance bill+  7a7 ,9     
g5]al ,provid]s ( em]g5cy air m$ical    
s]vices %all submit to a gr\p heal? plan
 or heal? insurance issu] (f]+ gr\p or  
individual heal? insurance cov]age1     
toge!r ) an electronic claims           
transaction ) respect to an enrollee 9  
su* plan or cov]age1 a description (    
*>ges = su* s]vices t are sep>at$ by--  
7#a7 ! co/ ( air travel2 &  7#b7 ! co/ (
 em]g5cy m$ical s]vices & supplies4  7b7
 ,rulemak+ ,n lat] ?an #a ye> aft] !    

date ( ! enactm5t ( ?is ,act1 !         
,secret>y ( ,heal? & ,human ,s]vices    
%all det]m9e ! =m & mann] = submitt+ !  
description ( *>ges 9 subsection 7a7    
?r\gh notice & comm5t rulemak+4  7c7    
,civil monet>y p5alties  7#a7 ,9 g5]al  
,a provid] ( em]g5cy air m$ical s]vices 
:o violates ! requirem5t ( subsection   
7a7 %all be subject to a civil monet>y  
p5alty ( n m ?an #aj1jjj = ea* act      
con/itut+ su* violation4  7#b7 ,proc$ure
 ,! provisions ( section #aabh;,a ( !   
,social ,security ,act 7#db ,u4,s4,c4   
#acbj;a-#g;a71 o!r ?an subsections 7a7 &
 7b7 & ! fir/ s5t5ce ( subsection       
7c77#a7 ( su* section1 %all apply to    
civil money p5alties "u ?is subsection 9
 ! same mann] z su* provisions apply to 
a p5alty or proce$+ "u section #aabh;,a 
( ! ,social ,security ,act4  7d7        
,def9itions ,9 ?is section1 ! t]ms gr\p 
heal? plan1 heal? insurance cov]age1 &  
heal? insurance issu] h ! mean+s giv5   
su* t]ms 9 section #bgia ( ! ,public    
,heal? ,s]vice ,act 7#db ,u4,s4,c4      

#cjj;gg-#ia74  7e7 ,effective date ,!   
requirem5t "u subsection 7a7 %all take  
effect #f mon?s aft] ! rules describ$ 9 
subsection 7b7 are f9aliz$4  #f4 ,report
 by ,secret>y ( ,labor ,n lat] ?an "o   
ye> aft] ! date ( ! enactm5t ( ?is ,act1
 & annually !reaft] = ea* ( ! foll[+ #e 
ye>s1 ! ,secret>y ( ,labor %all--  7#a7 
conduct a /udy (-- 7,a7 ! effects ( !   
provisions (1 includ+ am5dm5ts made by1 
?is ,act on premiums & out-(-pocket co/s
 9 gr\p heal? plans1 includ+            
out-(-pocket co/s t are p]mitt$ by      
reason ( compliance ) section           
#bgii;,a7d7 ( ! ,public ,heal? ,s]vice  
,act1 z add$ by section #b7;d72  7,b7 ! 
adequacy ( provid] networks 9 gr\p heal?
 plans2 &  7,c7 su* o!r effects ( su*   
provisions1 & am5dm5ts1 z ! ,secret>y   
deems relevant2 &  7#b7 submit a report 
on su* /udy to ! ,committee on ,heal?1  
,education1 ,labor1 & ,p5sions ( !      
,s5ate & ! ,committee on ,education &   
,labor & ! ,committee on ,en]gy &       
,comm]ce ( ! ,h\se ( ,repres5tatives4