,i #aafth ,,congress #b;d ,session ,h4 ,r4 #ehag ,,in ,,the ,,house ,,of ,,representatives ,february #g1 #bjbj,mr4 ,nunes 7for himself and ,mr4 ,pascrell7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,ways and ,means1 and ,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 ,act1 the ,internal ,revenue ,code of #aihf1 and the ,employee ,retirement ,income ,security ,act of #aigd to require health plans to provide to participants1 beneficiaries1 and enrollees an advanced explanation of benefits with respect to items and services scheduled to be received from providers and facilities and to amend title ,,xi of the ,social ,security ,act to require health care providers and health care facilities to provide good faith estimates of the expected charges for furnishing such items and services4 #a4 ,short title ,this ,act may be cited as the ,fair and ,honest ,advance ,cost ,estimate for ,patients ,act of #bjbj4 #b4 ,advanced explanation of benefits 7a7 ,health plan requirements 7#a7 ,public ,health ,service ,act amendment ,subpart ,,ii of part ,a of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aa et seq47 is amended by adding at the end the following new section3 #bgcj4 ,advanced explanation of benefits 7a7 ,in general ,beginning on ,january #a1 #bjbb1 each health plan shall1 with respect to a notification submitted under section #aabh;,a7t77#a77;,b7 of the ,social ,security ,act by a health care provider or health care facility1 respectively1 to the health plan for a participant1 beneficiary1 or enrollee under such health plan scheduled to receive an item or service from the provider or facility1 not later than #a business day 7or1 in the case such item or service was so scheduled at least #aj business days before such item or service is to be furnished 7or in the case such notification was made pursuant to a request by such participant1 beneficiary1 or enrollee71 #c business days7 after the date on which the health plan receives such notification1 provide to the participant1 beneficiary1 or enrollee 7through mail or electronic means1 as requested by the participant1 beneficiary1 or enrollee7 a notification including the following3 7#a7 ,whether or not the provider or facility is a participating provider or a participating facility with respect to the health plan with respect to the furnishing of such item or service and-- 7,a7 in the case the provider or facility is a participating provider or facility with respect to the health plan with respect to the furnishing of such item or service1 the contracted rate under such plan for such item or service2 and 7,b7 in the case the provider or facility is a nonparticipating provider or facility with respect to such plan1 a description of how such participant1 beneficiary1 or enrollee may obtain information on providers and facilities that1 with respect to such health plan1 are participating providers and facilities4 7#b7 ,the good faith estimate included in the notification received from the provider or facility4 7#c7 ,a good faith estimate of the amount the health plan is responsible for paying for items and services included in the estimate described in paragraph 7#b74 7#d7 ,a good faith estimate of the amount of any cost-sharing 7including with respect to the deductible and any copayment or coinsurance obligation7 for which the participant1 beneficiary1 or enrollee would be responsible for such item or service 7as of the date of such notification74 7#e7 ,a good faith estimate of the amount that the participant1 beneficiary1 or enrollee has incurred toward meeting the limit of the financial responsibility 7including with respect to deductibles and out-of-pocket maximums7 under the health plan 7as of the date of such notification74 7#f7 ,in the case such item or service is subject to a medical management technique 7including concurrent review1 prior authorization1 and step-therapy or fail-first protocols7 for coverage under the health plan1 a disclaimer that coverage for such item or service is subject to such medical management technique4 7#g7 ,a disclaimer that the information provided in the notification is only an estimate based on the items and services reasonably expected1 at the time of scheduling 7or requesting7 the item or service1 to be furnished and is subject to change4 7#h7 ,any other information or disclaimer the health plan determines appropriate that is consistent with information and disclaimers required under this section4 7b7 ,health plan defined ,in this section1 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 4 7#b7 ,internal ,revenue ,code of #aihf amendment 7,a7 ,in general ,subchapter ,b of chapter #ajj of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new section3 #ihaf4 ,advanced explanation of benefits 7a7 ,in general ,beginning on ,january #a1 #bjbb1 each health plan shall1 with respect to a notification submitted under section #aabh;,a7t77#a77;,b7 of the ,social ,security ,act by a health care provider or health care facility1 respectively1 to the health plan for a participant or beneficiary under such health plan scheduled to receive an item or service from the provider or facility1 not later than #a business day 7or1 in the case such item or service was so scheduled at least #aj business days before such item or service is to be furnished 7or in the case such notification was made pursuant to a request by such participant or beneficiary71 #c business days7 after the date on which the health plan receives such notification1 provide to the participant or beneficiary 7through mail or electronic means1 as requested by the participant or beneficiary7 a notification including the following3 7#a7 ,whether or not the provider or facility is a participating provider or a participating facility with respect to the health plan with respect to the furnishing of such item or service and-- 7,a7 in the case the provider or facility is a participating provider or facility with respect to the health plan with respect to the furnishing of such item or service1 the contracted rate under such plan for such item or service2 and 7,b7 in the case the provider or facility is a nonparticipating provider or facility with respect to such plan1 a description of how such participant or beneficiary may obtain information on providers and facilities that1 with respect to such health plan1 are participating providers and facilities4 7#b7 ,the good faith estimate included in the notification received from the provider or facility4 7#c7 ,a good faith estimate of the amount the health plan is responsible for paying for items and services included in the estimate described in paragraph 7#b74 7#d7 ,a good faith estimate of the amount of any cost-sharing 7including with respect to the deductible and any copayment or coinsurance obligation7 for which the participant or beneficiary would be responsible for such item or service 7as of the date of such notification74 7#e7 ,a good faith estimate of the amount that the participant or beneficiary has incurred toward meeting the limit of the financial responsibility 7including with respect to deductibles and out-of-pocket maximums7 under the health plan 7as of the date of such notification74 7#f7 ,in the case such item or service is subject to a medical management technique 7including concurrent review1 prior authorization1 and step-therapy or fail-first protocols7 for coverage under the health plan1 a disclaimer that coverage for such item or service is subject to such medical management technique4 7#g7 ,a disclaimer that the information provided in the notification is only an estimate based on the items and services reasonably expected1 at the time of scheduling 7or requesting7 the item or service1 to be furnished and is subject to change4 7#h7 ,any other information or disclaimer the health plan determines appropriate that is consistent with information and disclaimers required under this section4 7b7 ,health plan defined ,in this section1 the term health plan means a group health plan1 including any group health plan that is a grandfathered health plan 7as defined in section #abea7;e7 of the ,patient ,protection and ,affordable ,care ,act74 4 7,b7 ,conforming amendment ,section #ihae7;a7 of the ,internal ,revenue ,code of #aihf is amended-- 7i7 in paragraph 7#a71 by striking 7as amended by the ,patient ,protection and ,affordable ,care ,act7 and inserting 7other than the provisions of section #bgcj of such ,act72 and 7ii7 in paragraph 7#b71 by inserting 7other than the provisions of section #bgcj of such ,act7 after a provision of such part ,a4 7,c7 ,clerical amendment ,the table of sections for such subchapter is amended by adding at the end the following new item3 ,sec4 #ihaf4 ,advanced explanation of benefits4 4 7#c7 ,employee ,retirement ,income ,security ,act of #aigd amendment 7,a7 ,in general ,subpart ,b of part #g of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe et seq47 is amended by adding at the end the following new section3 #gaf4 ,advanced explanation of benefits 7a7 ,in general ,beginning on ,january #a1 #bjbb1 each health plan shall1 with respect to a notification submitted under section #aabh;,a7t77#a77;,b7 of the ,social ,security ,act by a health care provider or health care facility1 respectively1 to the health plan for a participant or beneficiary under such health plan scheduled to receive an item or service from the provider or facility1 not later than #a business day 7or1 in the case such item or service was so scheduled at least #aj business days before such item or service is to be furnished 7or in the case such notification was made pursuant to a request by such participant or beneficiary71 #c business days7 after the date on which the health plan receives such notification1 provide to the participant or beneficiary 7through mail or electronic means1 as requested by the participant or beneficiary7 a notification including the following3 7#a7 ,whether or not the provider or facility is a participating provider or a participating facility with respect to the health plan with respect to the furnishing of such item or service and-- 7,a7 in the case the provider or facility is a participating provider or facility with respect to the health plan with respect to the furnishing of such item or service1 the contracted rate under such plan for such item or service2 and 7,b7 in the case the provider or facility is a nonparticipating provider or facility with respect to such plan1 a description of how such participant or beneficiary may obtain information on providers and facilities that1 with respect to such health plan1 are participating providers and facilities4 7#b7 ,the good faith estimate included in the notification received from the provider or facility4 7#c7 ,a good faith estimate of the amount the health plan is responsible for paying for items and services included in the estimate described in paragraph 7#b74 7#d7 ,a good faith estimate of the amount of any cost-sharing 7including with respect to the deductible and any copayment or coinsurance obligation7 for which the participant or beneficiary would be responsible for such item or service 7as of the date of such notification74 7#e7 ,a good faith estimate of the amount that the participant or beneficiary has incurred toward meeting the limit of the financial responsibility 7including with respect to deductibles and out-of-pocket maximums7 under the health plan 7as of the date of such notification74 7#f7 ,in the case such item or service is subject to a medical management technique 7including concurrent review1 prior authorization1 and step-therapy or fail-first protocols7 for coverage under the health plan1 a disclaimer that coverage for such item or service is subject to such medical management technique4 7#g7 ,a disclaimer that the information provided in the notification is only an estimate based on the items and services reasonably expected1 at the time of scheduling 7or requesting7 the item or service1 to be furnished and is subject to change4 7#h7 ,any other information or disclaimer the health plan determines appropriate that is consistent with information and disclaimers required under this section4 7b7 ,health plan defined ,in this section1 the term health plan means a group health plan and health insurance coverage offered by a health insurance issuer in the group market and includes a grandfathered health plan 7as defined in section #abea7;e7 of the ,patient ,protection and ,affordable ,care ,act7 that is such a plan or coverage4 4 7,b7 ,conforming amendment ,section #gae7;a7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe;d7a77 is amended-- 7i7 in paragraph 7#a71 by striking 7as amended by the ,patient ,protection and ,affordable ,care ,act7 and inserting 7other than the provisions of section #bgcj of such ,act72 and 7ii7 in paragraph 7#b71 by inserting 7other than the provisions of section #bgcj of such ,act7 after a provision of such part ,a4 7,c7 ,clerical amendment ,the table of contents in section #a of the ,employee ,retirement ,income ,security ,act of #aigd is amended by inserting after the item relating to section #gad the following new items3 ,sec4 #gae4 ,additional market reforms4 ,sec4 #gaf4 ,advanced explanation of benefits4 4 7b7 ,health care providers and facilities ,section #aabh;,a of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;a7 is amended by adding at the end the following new subsection3 7t7 7#a7 ,each health care provider and health care facility shall1 beginning ,january #a1 #bjbb1 in the case of an individual who schedules an item or service to be furnished to such individual by such provider or facility at least #c business days before the date such item or service is to be so furnished1 not later than #a business day after the date of such scheduling 7or1 in the case of such an item or service scheduled at least #aj business days before the date such item or service is to be so furnished 7or if requested by the individual71 not later than #c business days after the date of such scheduling or such request7-- 7,a7 inquire if such individual is enrolled in a group health plan1 group or individual health insurance coverage offered by a health insurance issuer1 or a ,federal health care program 7and if is so enrolled in such plan or coverage1 seeking to have a claim for such item or service submitted to such plan or coverage72 and 7,b7 provide a notification of the good faith estimate of the expected charges for furnishing such item or service 7including any item or service that is reasonably expected to be provided in conjunction with such scheduled item or service7 to-- 7i7 in the case the individual is enrolled in such a plan or such coverage 7and is seeking to have a claim for such item or service submitted to such plan or coverage71 such plan or issuer of such coverage2 and 7ii7 in the case the individual is not described in clause 7i7 and not enrolled in a ,federal health care program1 the individual4 7#b7 ,each health care provider or health care facility that fails to provide the estimate as required under paragraph 7#a7 shall be subject to a civil monetary penalty in an amount not to exceed #aj1jjj for each such failure4 ,the provisions of this section 7other than subsection 7a71 subsection 7b71 the first sentence of subsection 7c77#a71 and subsection 7o77 shall apply to a civil monetary penalty imposed under the preceding sentence in the same manner as such provisions apply to a penalty or proceeding under subsection 7a74 7#c7 ,in this subsection-- 7,a7 the terms health insurance issuer1 group health plan1 group health insurance coverage1 and individual health insurance coverage have the meaning given such terms1 respectively1 in section #bgia of the ,public ,health ,service ,act2 and 7,b7 the term ,federal health care program has the meaning given such term in section #aabh;,b7f74 4