,i #aafth ,,congress #b;d ,session ,h4 ,r4 #ehbf ,,in ,,the ,,house ,,of ,,representatives ,february #aj1 #bjbj,mr4 ,neal 7for himself1 ,mr4 ,brady1 ,mr4 ,suozzi1 ,mr4 ,la,hood1 ,mr4 ,holding1 ,mr4 ,kelly of ,pennsylvania1 ,mr4 ,estes1 ,mr4 ,thompson of ,california1 ,mr4 ,beyer1 ,ms4 ,shalala1 ,mr4 ,morelle1 ,mr4 ,larson of ,connecticut1 ,ms4 ,schrier1 ,mr4 ,schneider1 ,mr4 ,danny ,k4 ,davis of ,illinois1 ,mr4 ,evans1 ,mr4 ,lewis1 ,mr4 ,higgins of ,new ,york1 ,mr4 ,nunes1 ,mr4 ,smith of ,nebraska1 ,mr4 ,ferguson1 ,mr4 ,wenstrup1 ,mr4 ,rice of ,south ,carolina1 ,mrs4 ,walorski1 ,mr4 ,schweikert1 ,mr4 ,reed1 ,mr4 ,arrington1 ,mr4 ,marchant1 ,mr4 ,buchanan1 ,mr4 ,thompson of ,pennsylvania1 ,mr4 ,kildee1 and ,mr4 ,smith of ,missouri7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,ways and ,means1 ,education and ,labor1 and ,transportation and ,infrastructure1 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 ,employee ,retirement ,income ,security ,act of #aigd1 the ,internal ,revenue ,code of #aihf1 and title ,,xi of the ,social ,security ,act to prevent certain cases of out-of-network surprise medical bills1 strengthen health care consumer protections1 and improve health care information transparency1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,consumer ,protections ,against ,surprise ,medical ,bills ,act of #bjbj4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,sec4 #b4 ,consumer protections through requirements on health plans to prevent surprise medical bills for emergency services4 ,sec4 #c4 ,consumer protections through requirements on health plans to prevent surprise medical bills for non-emergency services performed by nonparticipating providers at certain participating facilities4 ,sec4 #d4 ,consumer protections through application of health plan external review in cases of certain surprise medical bills4 ,sec4 #e4 ,consumer protections through health plan transparency requirements4 ,sec4 #f4 ,consumer protections through health plan requirement for fair and honest advance cost estimate4 ,sec4 #g4 ,determination through open negotiation and mediation of out-of-network rates to be paid by health plans4 ,sec4 #h4 ,prohibiting balance billing practices by providers for emergency services1 for services furnished by nonparticipating provider at participating facility1 and in certain cases of misinformation4 ,sec4 #i4 ,additional consumer protections4 ,sec4 #aj4 ,reporting requirements regarding air ambulance services4 ,sec4 #aa4 ,,gao report on effects of legislation4 ,sec4 #ab4 ,transitional rule allowing deduction for surprise billing expenses below ,,agi floor4 #b4 ,consumer protections through requirements on health plans to prevent surprise medical bills for emergency services 7a7 ,,phsa amendments 7#a7 ,in general ,section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is amended-- 7,a7 in subsection 7b7-- 7i7 in the heading1 by striking ,coverage and inserting ,cost-,sharing and payment2 7ii7 in paragraph 7#a7-- 7,i7 in the matter preceding subparagraph 7,a7-- 7aa7 by striking a group health plan1 or a health insurance issuer offering group or individual health insurance issuer1 and inserting a health plan2 7bb7 by inserting and1 for plan year #bjbb or a subsequent plan year1 with respect to emergency services in an independent freestanding emergency department after emergency department of a hospital2 7cc7 by striking the plan or issuer and inserting the plan2 and 7dd7 by striking 7as defined in paragraph 7#b77;,b772 7,,ii7 in subparagraph 7,b71 by inserting or a participating facility that is an emergency department of a hospital or an independent freestanding emergency department 7in this subsection referred to as a participating emergency facility7 after participating provider2 and 7,,iii7 in subparagraph 7,c7-- 7aa7 in the matter preceding clause 7i71 by inserting by a nonparticipating provider or a nonparticipating facility that is an emergency department of a hospital or an independent freestanding emergency department after enrollee2 7bb7 by striking clause 7i72 7cc7 by striking 7ii77,i7 such services and inserting 7i7 such services2 7dd7 by striking where the provider of services does not have a contractual relationship with the plan for the providing of services2 7ee7 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 7ff7 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 is not greater than the requirement that would apply if such services were furnished by a participating provider or a participating emergency facility1 as applicable2 2 and 7gg7 by adding at the end the following new clauses3 7iii7 such cost-sharing requirement is calculated as if the contracted rate for such services if furnished by a participating provider or a participating emergency facility were equal to the recognized amount for such services2 7iv7 the health plan pays to such provider or facility1 respectively1 the amount by which the out-of-network rate for such services exceeds the cost-sharing amount for such services 7as determined in accordance with clauses 7ii7 and 7iii772 and 7v7 any deductible or out-of-pocket maximum that would apply if such services were furnished by a participating provider or a participating emergency facility shall be the deductible or out-of-pocket maximum that applies2 and 2 and 7iii7 by striking paragraph 7#b7 and inserting the following new paragraph3 7#b7 ,audit process and rulemaking process for median contracted rates 7,a7 ,audit process 7i7 ,in general ,not later than ,july #a1 #bjba1 the ,secretary1 in coordination with the ,secretary of the ,treasury and the ,secretary of ,labor and in consultation with the ,national ,association of ,insurance ,commissioners1 shall establish through rulemaking a process1 in accordance with clause 7ii71 under which health plans are audited by the ,secretary to ensure that-- 7,i7 such plans are in compliance with the requirement of applying a median contracted rate under this section2 and 7,,ii7 that such median contracted rate so applied satisfies the definition under subsection 7k77#h7 with respect to the year involved4 7ii7 ,audit samples ,under the process established pursuant to clause 7i71 the ,secretary-- 7,i7 shall conduct audits described in such clause of a sample of health plans2 and 7,,ii7 may audit any health plan if the ,secretary has received any complaint about such plan that involves the compliance of the plan with the requirement described in such clause4 7,b7 ,rulemaking ,not later than ,july #a1 #bjba1 the ,secretary1 in coordination with the ,secretary of ,labor and the ,secretary of the ,treasury1 shall establish through rulemaking-- 7i7 the methodology the sponsor or issuer of a health plan shall use to determine the median contracted rate1 which shall account for relevant payment adjustments that take into account facility type that are otherwise taken into account for purposes of determining payment amounts with respect to participating facilities2 and 7ii7 the information such sponsor or issuer shall share with the nonparticipating provider involved when making such a determination4 2 and 7,b7 by adding at the end the following new subsection3 7k7 ,definitions ,for purposes of this section3 7#a7 ,contracted rate ,the term contracted rate means1 with respect to a health plan and a health care provider or health care facility furnishing an item or service to a beneficiary1 participant1 or enrollee of such plan1 the agreed upon total payment amount 7inclusive of any cost-sharing7 to such provider or facility for such item or service4 7#b7 ,during a visit ,the term during a visit shall1 with respect to an individual who is furnished items and services at a participating facility1 include equipment and devices1 telemedicine services1 imaging services1 laboratory services1 preoperative and postoperative services1 and such other items and services as the ,secretary may specify furnished to such individual1 regardless of whether or not the provider furnishing such items or services is at the facility4 7#c7 ,emergency department of a hospital ,the term emergency department of a hospital includes a hospital outpatient department that provides emergency services4 7#d7 ,emergency medical condition ,the term emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity 7including severe pain7 such that a prudent layperson1 who possesses an average knowledge of health and medicine1 could reasonably expect the absence of immediate medical attention to result in a condition described in clause 7i71 7ii71 or 7iii7 of section #ahfg7;e77#a77;,a7 of the ,social ,security ,act4 7#e7 ,emergency services 7,a7 ,in general ,the term emergency services1 with respect to an emergency medical condition1 means-- 7i7 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 7ii7 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 patient 7regardless of the department of the hospital in which such further examination or treatment is furnished74 7,b7 ,inclusion of additional services ,in the case of an individual enrolled in a health plan who is furnished services described in subparagraph 7,a7 by a provider or hospital or independent freestanding emergency department to stabilize such individual with respect to an emergency medical condition1 the term emergency services shall include1 in addition to those described in subparagraph 7,a71 items and services furnished as part of outpatient observation or an inpatient or outpatient stay during a visit in which such individual is so stabilized with respect to such emergency condition if-- 7i7 such items and services would otherwise be covered under such plan if furnished by a participating provider or participating facility2 and 7ii7 such items and services are furnished-- 7,i7 to maintain1 improve1 or resolve the individual's stabilization with respect to such condition1 unless any circumstance described in subparagraph 7,c7 has occurred with respect to such individual before such items and services are furnished2 or 7,,ii7 for any purpose not described in subclause 7,i71 unless each of the criteria described in subparagraph 7,d7 have been met with respect to such individual and such item or service4 7,c7 ,circumstances ,for purposes of subparagraph 7,b77ii77,i71 a circumstance described in this subparagraph is any of the following1 with respect to an individual who is a beneficiary1 participant1 or enrollee of a health plan who is furnished services described in subparagraph 7,a7 by a hospital or independent freestanding emergency department with respect to an emergency medical condition3 7i7 ,a participating provider1 with respect to such plan1 with privileges at the hospital or independent freestanding emergency department assumes responsibility for the care of the individual4 7ii7 ,a participating provider1 with respect to such plan1 assumes responsibility for the care of the individual through transfer of the individual4 7iii7 ,the health plan and the provider treating such individual at the hospital or independent freestanding emergency department for such condition reach an agreement concerning the care for the individual4 7iv7 ,the individual is discharged4 7,d7 ,signed notice criteria ,for purposes of subparagraph 7,b77ii77,,ii71 the criteria described in this subparagraph1 with respect to an individual and an item or service furnished by a nonparticipating provider or nonparticipating facility that is a hospital or an independent freestanding emergency department1 are the following3 7i7 ,a written notice 7as specified by the ,secretary and in a clear and understandable manner7 is provided by such provider or facility to such individual1 before such item or service is furnished1 that includes the following information3 7,i7 ,that such provider or facility is a nonparticipating provider or nonparticipating facility 7as applicable74 7,,ii7 ,to the extent practicable1 the estimated amount that such nonparticipating facility or nonparticipating provider may charge the individual for such item or service4 7,,iii7 ,a statement that the individual may seek such item or service from a provider that is a participating provider or a hospital or independent freestanding emergency department that is a participating facility and a list1 if feasible1 of participating facilities or participating providers1 as applicable1 who are able to furnish such item or service4 7ii7 ,such individual is in a condition to receive 7as determined in accordance with guidance issued by the ,secretary7 the information described in clause 7i7 and to confirm notice of receipt of such notice1 in accordance with applicable ,state law4 7iii7 ,the individual signs and dates such notice confirming receipt of the notice before such item or service is furnished4 7#f7 ,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#g7 ,independent freestanding emergency department ,the term independent freestanding emergency department means a health care facility that-- 7,a7 is geographically separate and distinct and licensed separately from a hospital under applicable ,state law2 and 7,b7 provides emergency services4 7#h7 ,median contracted rate 7,a7 ,in general ,subject to subparagraph 7,b71 the term median contracted rate means1 with respect to a health plan-- 7i7 for an item or service furnished during #bjbb1 the median of the contracted rates recognized by the sponsor or issuer of such plan 7determined with respect to all such plans of such sponsor or such issuer that are within the same line of business 7as specified in subparagraph 7,c77 as the plan involved7 as the total maximum payment under such plans in #bjai for the same or a similar item or service that is provided by a provider or facility in the same or similar specialty and provided in the geographic region 7established 7and updated1 as appropriate7 by the ,secretary1 in consultation with the ,national ,association of ,insurance ,commissioners7 in which the item or service is furnished1 consistent with the methodology established by the ,secretary under subsection 7b77#b77;,b71 increased by the percentage increase in the consumer price index for all urban consumers 7,united ,states city average7 over #bjai1 #bjbj1 and #bjba2 7ii7 for an item or service furnished during #bjbc or a subsequent year through #bjbf1 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 year2 7iii7 for an item or service furnished during a rebasing year 7as defined in subparagraph 7,d771 the median of the contracted rates recognized by the sponsor or issuer of such plan 7determined with respect to all such plans of such sponsor or such issuer that are within the same line of business 7as specified in subparagraph 7,c77 as the plan involved7 as the total maximum payment under such plans in such year for the same or a similar item or service that is provided by a provider or facility in the same or similar specialty and provided in the geographic region 7as established pursuant to clause 7i77 in which the item or service is furnished1 consistent with the methodology established by the ,secretary under subsection 7b77#b77;,b72 and 7iv7 for an item or service furnished during any of the #d years following a rebasing 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 7,b7 ,use of substitute rate in case of insufficient data 7i7 ,in general ,in the case the sponsor or issuer of a health plan has insufficient information 7as specified by the ,secretary7 to calculate the median of the contracted rates in accordance with subparagraph 7,a7 for a year for an item or service furnished in a particular geographic region 7as established pursuant to subparagraph 7,a77i77 by a type of provider or facility1 the substitute rate 7as defined in clause 7ii77 for such item or service shall be deemed to be the median contracted rate for such item or service furnished in such region during such year by such a provider or facility for such year under such subparagraph 7,a7 for such plan4 7ii7 ,substitute rate ,for purposes of clause 7i71 the term substitute rate means1 with respect to an item or service furnished by a provider or facility in a geographic region 7established pursuant to subparagraph 7,a77i77 during a year for which a health plan is required to make payment pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a7-- 7,i7 if sufficient information 7as specified by the ,secretary7 exists to determine the median of the contracted rates recognized by all health plans offered in the same line of business 7as specified in subparagraph 7,c77 by any group health plan or health insurance issuer for such an item or service furnished in such region by such a provider or facility during such year using a database or other source of information determined appropriate by the ,secretary1 such median2 and 7,,ii7 if such sufficient information does not exist1 the median of the contracted rates recognized by all health plans offered in the same line of business 7as specified in subparagraph 7,c77 by any group health plan or health insurance issuer for such an item or service furnished in a similarly situated geographic region 7as determined by the ,secretary7 with such sufficient information by such a provider or facility during such year using such a database or such other source of information4 ,the ,secretary shall develop a methodology for determining a substitute rate based on a similarly situated health plan that is not a ,federal health care program 7as defined in section #aabh;,b7f7 of the ,social ,security ,act7 in the case a substitute rate is not calculable under the previous sentence with respect to an item or service4 7,c7 ,line of business ,a line of business specified in this subparagraph is one of the following3 7i7 ,the individual market4 7ii7 ,the small group market4 7iii7 ,the large group market4 7iv7 ,in the case of a self-insured group health plan1 other self-insured group health plans4 7,d7 ,rebasing year defined ,for purposes of subparagraph 7,a71 the term rebasing year means #bjbg and every #e years thereafter4 7#i7 ,nonparticipating facility2 participating facility 7,a7 ,nonparticipating facility ,the term nonparticipating facility means1 with respect to an item or service and a health plan1 a health care facility described in subparagraph 7,b77ii7 that does not have a contractual relationship with the plan for furnishing such item or service4 7,b7 ,participating facility 7i7 ,in general ,the term participating 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 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 ,act71 including an emergency department of a hospital4 7,,ii7 ,a critical access hospital 7as defined in section #ahfa7mm77#a7 of such ,act74 7,,iii7 ,an ambulatory surgical center 7as described in section #ahcc7;i77#a77;,a7 of such ,act74 7,,iv7 ,a laboratory4 7,v7 ,a radiology facility or imaging center4 7,,vi7 ,an independent freestanding emergency department4 7,,vii7 ,any other facility specified by the ,secretary4 7#aj7 ,nonparticipating providers2 participating providers 7,a7 ,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 does not have a contractual relationship with the plan for furnishing such item or service under the plan4 7,b7 ,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 has a contractual relationship with the plan for furnishing such item or service under the plan4 7#aa7 ,out-of-network rate ,the term out-of-network rate means1 with respect to an item or service furnished in a ,state during a year to a participant1 beneficiary1 or enrollee of a health plan receiving such item or service from a nonparticipating provider or facility-- 7,a7 subject to subparagraphs 7,c7 and 7,d71 in the case such ,state has in effect a ,state law that provides for a method for determining the total amount payable under such health plan regulated by such ,state with respect to such item or service furnished by such provider or facility1 such amount determined in accordance with such law2 7,b7 subject to subparagraphs 7,c7 and 7,d71 in the case such ,state does not have in effect such a law with respect to such item or service1 plan1 and provider or facility-- 7i7 subject to clause 7ii71 if the provider or facility 7as applicable7 and such plan agree on an amount of payment 7including if agreed on through open negotiations under subsection 7j77#a77 with respect to such item or service1 such agreed on amount2 or 7ii7 if such provider or facility 7as applicable7 and such plan enter the mediated dispute process under subsection 7j7 and do not so agree before the date on which a selected independent entity 7as defined in paragraph 7#c7 of such subsection7 makes a determination with respect to such item or service under such subsection1 the amount of such determination2 7,c7 in the case such ,state has an ,all-,payer ,model ,agreement under section #aaae;,a of the ,social ,security ,act1 the amount that the ,state approves under such system for such item or service so furnished2 or 7,d7 in the case such health plan is a self-insured group health plan and in the case of a ,state with an agreement with such plan in effect as of the date of the enactment of the ,consumer ,protections ,against ,surprise ,medical ,bills ,act of #bjbj1 that provides for a method for determining the total amount payable under such health plan with respect to such item or service furnished by such provider or facility1 such amount determined in accordance with such method4 7#ab7 ,recognized amount ,the term recognized amount means1 with respect to an item or service furnished in a ,state during a year to a participant1 beneficiary1 or enrollee of a health plan by a nonparticipating provider or nonparticipating facility-- 7,a7 subject to subparagraphs 7,c7 and 7,d71 in the case such ,state has in effect a law described in paragraph 7#aa77;,a7 with respect to such item or service1 provider or facility1 and plan1 the amount determined in accordance with such law2 7,b7 subject to subparagraphs 7,c7 and 7,d71 in the case such ,state does not have in effect such a law1 an amount that is the median contracted rate for such item or service for such year2 7,c7 subject to subparagraph 7,d71 in the case such ,state is described in paragraph 7#aa77;,c7 with respect to such item or service so furnished1 the amount that the ,state approves under such system for such item or service so furnished2 or 7,d7 in the case such health plan is a self-insured group health plan and in the case of a ,state with an agreement with such plan in effect as of the date of the enactment of the ,consumer ,protections ,against ,surprise ,medical ,bills ,act of #bjbj1 that provides for a method for determining the total amount payable under such health plan with respect to such item or service furnished by such provider or facility1 such amount determined in accordance with such method4 7#ac7 ,stabilize ,the term to stabilize1 with respect to an emergency medical condition1 has the meaning give in section #ahfg7;e77#c77;,a7 of the ,social ,security ,act74 7#ad7 ,cost-sharing ,the term cost-sharing includes copayments1 coinsurance1 and deductibles4 7l7 ,payment to provider or facility ,in the case of any payment required to be made by a health plan pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a7 to a nonparticiapting provider or nonparticipating facility for an item or service1 such payment shall be made to such provider or facility and not to the individual receiving such item or service4 4 7#b7 ,effective date ,the amendments made by paragraph 7#a7 shall apply with respect to plan years beginning on or after ,january #a1 #bjbb4 7b7 ,,irc amendments 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 ,patient protections 7a7 ,choice of health care professional ,if a health plan requires or provides for designation by a participant or beneficiary of a participating primary care provider1 then the plan shall permit each participant or beneficiary to designate any participating primary care provider who is available to accept such individual4 7b7 ,cost-,sharing and payment of emergency services 7#a7 ,in general ,if a health plan provides or covers any benefits with respect to services in an emergency department of a hospital and1 for plan year #bjbb or a subsequent plan year1 with respect to emergency services in an independent freestanding emergency department1 the plan shall cover emergency services-- 7,a7 without the need for any prior authorization determination2 7,b7 whether the health care provider furnishing such services is a participating provider or a participating facility that is an emergency department of a hospital or an independent freestanding emergency department 7in this subsection referred to as a participating emergency facility7 with respect to such services2 7,c7 in a manner so that1 if such services are provided to a participant or beneficiary by a nonparticipating provider or a nonparticipating facility that is an emergency department of a hospital or an independent freestanding emergency department-- 7i7 such services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from participating providers and participating emergency facilities with respect to such plan2 7ii7 the cost-sharing requirement is not greater than the requirement that would apply if such services were furnished by a participating provider or a participating emergency facility1 as applicable2 7iii7 such cost-sharing requirement is calculated as if the contracted rate for such services if furnished by a participating provider or a participating emergency facility were equal to the recognized amount for such services2 7iv7 the health plan pays to such provider or facility1 respectively1 the amount by which the out-of-network rate for such services exceeds the cost-sharing amount for such services 7as determined in accordance with clauses 7ii7 and 7iii772 and 7v7 any deductible or out-of-pocket maximum that would apply if such services were furnished by a participating provider or a participating emergency facility shall be the deductible or out-of-pocket maximum that applies2 and 7,d7 without regard to any other term or condition of such coverage 7other than exclusion or coordination of benefits1 or an affiliation or waiting period1 permitted under section #bgjd of the ,public ,health ,service ,act1 including as incorporated pursuant to section #gae of the ,employee ,retirement ,income ,security ,act of #aigd and section #ihae1 and other than applicable cost-sharing74 7#b7 ,audit process and rulemaking process for median contracted rates 7,a7 ,audit process 7i7 ,in general ,not later than ,july #a1 #bjba1 the ,secretary1 in coordination with the ,secretary of ,health and ,human ,services and the ,secretary of ,labor and in consultation with the ,national ,association of ,insurance ,commissioners1 shall establish through rulemaking a process1 in accordance with clause 7ii71 under which health plans are audited by the ,secretary to ensure that-- 7,i7 such plans are in compliance with the requirement of applying a median contracted rate under this section2 and 7,,ii7 that such median contracted rate so applied satisfies the definition under subsection 7k77#h7 with respect to the year involved4 7ii7 ,audit samples ,under the process established pursuant to clause 7i71 the ,secretary-- 7,i7 shall conduct audits described in such clause of a sample of health plans2 and 7,,ii7 may audit any health plan if the ,secretary has received any complaint about such plan that involves the compliance of the plan with the requirement described in such clause4 7,b7 ,rulemaking ,not later than ,july #a1 #bjba1 the ,secretary1 in coordination with the ,secretary of ,labor and the ,secretary of ,health and ,human ,services1 shall establish through rulemaking-- 7i7 the methodology the sponsor of a health plan shall use to determine the median contracted rate1 which shall account for relevant payment adjustments that take into account facility type that are otherwise taken into account for purposes of determining payment amounts with respect to participating facilities2 and 7ii7 the information such sponsor shall share with the nonparticipating provider involved when making such a determination4 7c7 ,access to pediatric care 7#a7 ,pediatric care ,in the case of a person who has a child who is a participant or beneficiary under a health plan1 if the plan requires or provides for the designation of a participating primary care provider for the child1 the plan shall permit such person to designate a physician 7allopathic or osteopathic7 who specializes in pediatrics as the child's primary care provider if such provider participates in the network of the plan4 7#b7 ,construction ,nothing in paragraph 7#a7 shall be construed to waive any exclusions of coverage under the terms and conditions of the plan with respect to coverage of pediatric care4 7d7 ,patient access to obstetrical and gynecological care 7#a7 ,general rights 7,a7 ,direct access ,a health plan described in paragraph 7#b7 may not require authorization or referral by the plan or any person 7including a primary care provider described in paragraph 7#b77;,b77 in the case of a female participant or beneficiary who seeks coverage for obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology4 ,such professional shall agree to otherwise adhere to such plan's policies and procedures1 including procedures regarding referrals and obtaining prior authorization and providing services pursuant to a treatment plan 7if any7 approved by the plan4 7,b7 ,obstetrical and gynecological care ,a health plan described in paragraph 7#b7 shall treat the provision of obstetrical and gynecological care1 and the ordering of related obstetrical and gynecological items and services1 pursuant to the direct access described under subparagraph 7,a71 by a participating health care professional who specializes in obstetrics or gynecology as the authorization of the primary care provider4 7#b7 ,application of paragraph ,a health plan described in this paragraph is a health plan that-- 7,a7 provides coverage for obstetric or gynecologic care2 and 7,b7 requires the designation by a participant or beneficiary of a participating primary care provider4 7#c7 ,construction ,nothing in paragraph 7#a7 shall be construed to-- 7,a7 waive any exclusions of coverage under the terms and conditions of the plan with respect to coverage of obstetrical or gynecological care2 or 7,b7 preclude the health plan involved from requiring that the obstetrical or gynecological provider notify the primary care health care professional or the plan of treatment decisions4 7k7 ,definitions ,for purposes of this section3 7#a7 ,contracted rate ,the term contracted rate means1 with respect to a health plan and a health care provider or health care facility furnishing an item or service to a beneficiary or participant of such plan1 the agreed upon total payment amount 7inclusive of any cost-sharing7 to such provider or facility for such item or service4 7#b7 ,during a visit ,the term during a visit shall1 with respect to an individual who is furnished items and services at a participating facility1 include equipment and devices1 telemedicine services1 imaging services1 laboratory services1 preoperative and postoperative services1 and such other items and services as the ,secretary may specify furnished to such individual1 regardless of whether or not the provider furnishing such items or services is at the facility4 7#c7 ,emergency department of a hospital ,the term emergency department of a hospital includes a hospital outpatient department that provides emergency services4 7#d7 ,emergency medical condition ,the term emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity 7including severe pain7 such that a prudent layperson1 who possesses an average knowledge of health and medicine1 could reasonably expect the absence of immediate medical attention to result in a condition described in clause 7i71 7ii71 or 7iii7 of section #ahfg7;e77#a77;,a7 of the ,social ,security ,act4 7#e7 ,emergency services 7,a7 ,in general ,the term emergency services1 with respect to an emergency medical condition1 means-- 7i7 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 7ii7 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 patient 7regardless of the department of the hospital in which such further examination or treatment is furnished74 7,b7 ,inclusion of additional services ,in the case of an individual enrolled in a health plan who is furnished services described in subparagraph 7,a7 by a provider or hospital or independent freestanding emergency department to stabilize such individual with respect to an emergency medical condition1 the term emergency services shall include1 in addition to those described in subparagraph 7,a71 items and services furnished as part of outpatient observation or an inpatient or outpatient stay during a visit in which such individual is so stabilized with respect to such emergency condition if-- 7i7 such items and services would otherwise be covered under such plan if furnished by a participating provider or participating facility2 and 7ii7 such items and services are furnished-- 7,i7 to maintain1 improve1 or resolve the individual's stabilization with respect to such condition1 unless any circumstance described in subparagraph 7,c7 has occurred with respect to such individual before such items and services are furnished2 or 7,,ii7 for any purpose not described in subclause 7,i71 unless each of the criteria described in subparagraph 7,d7 have been met with respect to such individual and such item or service4 7,c7 ,circumstances ,for purposes of subparagraph 7,b77ii77,i71 a circumstance described in this subparagraph is any of the following1 with respect to an individual who is a beneficiary1 participant1 or enrollee of a health plan who is furnished services described in subparagraph 7,a7 by a hospital or independent freestanding emergency department with respect to an emergency medical condition3 7i7 ,a participating provider1 with respect to such plan1 with privileges at the hospital or independent freestanding emergency department assumes responsibility for the care of the individual4 7ii7 ,a participating provider1 with respect to such plan1 assumes responsibility for the care of the individual through transfer of the individual4 7iii7 ,the health plan and the provider treating such individual at the hospital or independent freestanding emergency department for such condition reach an agreement concerning the care for the individual4 7iv7 ,the individual is discharged4 7,d7 ,signed notice criteria ,for purposes of subparagraph 7,b77ii77,,ii71 the criteria described in this subparagraph1 with respect to an individual and an item or service furnished by a nonparticipating provider or nonparticipating facility that is a hospital or an independent freestanding emergency department1 are the following3 7i7 ,a written notice 7as specified by the ,secretary and in a clear and understandable manner7 is provided by such provider or facility to such individual1 before such item or service is furnished1 that includes the following information3 7,i7 ,that such provider or facility is a nonparticipating provider or nonparticipating facility 7as applicable74 7,,ii7 ,to the extent practicable1 the estimated amount that such nonparticipating facility or nonparticipating provider may charge the individual for such item or service4 7,,iii7 ,a statement that the individual may seek such item or service from a provider that is a participating provider or a hospital or independent freestanding emergency department that is a participating facility and a list1 if feasible1 of participating facilities or participating providers1 as applicable1 who are able to furnish such item or service4 7ii7 ,such individual is in a condition to receive 7as determined in accordance with guidance issued by the ,secretary7 the information described in clause 7i7 and to confirm notice of receipt of such notice1 in accordance with applicable ,state law4 7iii7 ,the individual signs and dates such notice confirming receipt of the notice before such item or service is furnished4 7#f7 ,health plan ,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 7#g7 ,independent freestanding emergency department ,the term independent freestanding emergency department means a health care facility that-- 7,a7 is geographically separate and distinct and licensed separately from a hospital under applicable ,state law2 and 7,b7 provides emergency services4 7#h7 ,median contracted rate 7,a7 ,in general ,subject to subparagraph 7,b71 the term median contracted rate means1 with respect to a health plan-- 7i7 for an item or service furnished during #bjbb1 the median of the contracted rates recognized by the sponsor of such plan 7determined with respect to all such plans of such sponsor that are within the same line of business 7as specified in subparagraph 7,c77 as the plan involved7 as the total maximum payment under such plans in #bjai for the same or a similar item or service that is provided by a provider or facility in the same or similar specialty and provided in the geographic region 7established 7and updated1 as appropriate7 by the ,secretary1 in consultation with the ,national ,association of ,insurance ,commissioners7 in which the item or service is furnished1 consistent with the methodology established by the ,secretary under subsection 7b77#b77;,b71 increased by the percentage increase in the consumer price index for all urban consumers 7,united ,states city average7 over #bjai1 #bjbj1 and #bjba2 7ii7 for an item or service furnished during #bjbc or a subsequent year through #bjbf1 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 year2 7iii7 for an item or service furnished during a rebasing year 7as defined in subparagraph 7,d771 the median of the contracted rates recognized by the sponsor of such plan 7determined with respect to all such plans of such sponsor that are within the same line of business 7as specified in subparagraph 7,c77 as the plan involved7 as the total maximum payment under such plans in such year for the same or a similar item or service that is provided by a provider or facility in the same or similar specialty and provided in the geographic region 7as established pursuant to clause 7i77 in which the item or service is furnished1 consistent with the methodology established by the ,secretary under subsection 7b77#b77;,b72 and 7iv7 for an item or service furnished during any of the #d years following a rebasing 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 7,b7 ,use of substitute rate in case of insufficient data 7i7 ,in general ,in the case the sponsor of a health plan has insufficient information 7as specified by the ,secretary7 to calculate the median of the contracted rates in accordance with subparagraph 7,a7 for a year for an item or service furnished in a particular geographic region 7as established pursuant to subparagraph 7,a77i77 by a type of provider or facility1 the substitute rate 7as defined in clause 7ii77 for such item or service shall be deemed to be the median contracted rate for such item or service furnished in such region during such year by such a provider or facility for such year under such subparagraph 7,a7 for such plan4 7ii7 ,substitute rate ,for purposes of clause 7i71 the term substitute rate means1 with respect to an item or service furnished by a provider or facility in a geographic region 7established pursuant to subparagraph 7,a77i77 during a year for which a health plan is required to make payment pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a7-- 7,i7 if sufficient information 7as specified by the ,secretary7 exists to determine the median of the contracted rates recognized by all health plans offered in the same line of business 7as specified in subparagraph 7,c77 by any group health plan for such an item or service furnished in such region by such a provider or facility during such year using a database or other source of information determined appropriate by the ,secretary1 such median2 and 7,,ii7 if such sufficient information does not exist1 the median of the contracted rates recognized by all health plans offered in the same line of business 7as specified in subparagraph 7,c77 by any group health plan for such an item or service furnished in a similarly situated geographic region 7as determined by the ,secretary7 with such sufficient information by such a provider or facility during such year using such a database or such other source of information4 ,the ,secretary shall develop a methodology for determining a substitute rate based on a similarly situated health plan that is not a ,federal health care program 7as defined in section #aabh;,b7f7 of the ,social ,security ,act7 in the case a substitute rate is not calculable under the previous sentence with respect to an item or service4 7,c7 ,line of business ,a line of business specified in this subparagraph is one of the following3 7i7 ,the small group market4 7ii7 ,the large group market4 7iii7 ,in the case of a self-insured group health plan1 other self-insured group health plans4 7,d7 ,rebasing year defined ,for purposes of subparagraph 7,a71 the term rebasing year means #bjbg and every #e years thereafter4 7#i7 ,nonparticipating facility2 participating facility 7,a7 ,nonparticipating facility ,the term nonparticipating facility means1 with respect to an item or service and a health plan1 a health care facility described in subparagraph 7,b77ii7 that does not have a contractual relationship with the plan for furnishing such item or service4 7,b7 ,participating facility 7i7 ,in general ,the term participating 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 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 ,act71 including an emergency department of a hospital4 7,,ii7 ,a critical access hospital 7as defined in section #ahfa7mm77#a7 of such ,act74 7,,iii7 ,an ambulatory surgical center 7as described in section #ahcc7;i77#a77;,a7 of such ,act74 7,,iv7 ,a laboratory4 7,v7 ,a radiology facility or imaging center4 7,,vi7 ,an independent freestanding emergency department4 7,,vii7 ,any other facility specified by the ,secretary4 7#aj7 ,nonparticipating providers2 participating providers 7,a7 ,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 does not have a contractual relationship with the plan for furnishing such item or service under the plan4 7,b7 ,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 has a contractual relationship with the plan for furnishing such item or service under the plan4 7#aa7 ,out-of-network rate ,the term out-of-network rate means1 with respect to an item or service furnished in a ,state during a year to a participant or beneficiary of a health plan receiving such item or service from a nonparticipating provider or facility-- 7,a7 subject to subparagraphs 7,c7 and 7,d71 in the case such ,state has in effect a ,state law that provides for a method for determining the total amount payable under such health plan regulated by such ,state with respect to such item or service furnished by such provider or facility1 such amount determined in accordance with such law2 7,b7 subject to subparagraphs 7,c7 and 7,d71 in the case such ,state does not have in effect such a law with respect to such item or service1 plan1 and provider or facility-- 7i7 subject to clause 7ii71 if the provider or facility 7as applicable7 and such plan agree on an amount of payment 7including if agreed on through open negotiations under subsection 7j77#a77 with respect to such item or service1 such agreed on amount2 or 7ii7 if such provider or facility 7as applicable7 and such plan enter the mediated dispute process under subsection 7j7 and do not so agree before the date on which a selected independent entity 7as defined in paragraph 7#c7 of such subsection7 makes a determination with respect to such item or service under such subsection1 the amount of such determination2 7,c7 in the case such ,state has an ,all-,payer ,model ,agreement under section #aaae;,a of the ,social ,security ,act1 the amount that the ,state approves under such system for such item or service so furnished2 or 7,d7 in the case such health plan is a self-insured group health plan and in the case of a ,state with an agreement with such plan in effect as of the date of the enactment of the ,consumer ,protections ,against ,surprise ,medical ,bills ,act of #bjbj1 that provides for a method for determining the total amount payable under such health plan with respect to such item or service furnished by such provider or facility1 such amount determined in accordance with such method4 7#ab7 ,recognized amount ,the term recognized amount means1 with respect to an item or service furnished in a ,state during a year to a participant or beneficiary of a health plan by a nonparticipating provider or nonparticipating facility-- 7,a7 subject to subparagraphs 7,c7 and 7,d71 in the case such ,state has in effect a law described in paragraph 7#aa77;,a7 with respect to such item or service1 provider or facility1 and plan1 the amount determined in accordance with such law2 7,b7 subject to subparagraphs 7,c7 and 7,d71 in the case such ,state does not have in effect such a law1 an amount that is the median contracted rate for such item or service for such year2 7,c7 in the case such ,state is described in paragraph 7#aa77;,c7 with respect to such item or service so furnished1 the amount that the ,state approves under such system for such item or service so furnished2 or 7,d7 in the case such health plan is a self-insured group health plan and in the case of a ,state with an agreement with such plan in effect as of the date of the enactment of the ,consumer ,protections ,against ,surprise ,medical ,bills ,act of #bjbj1 that provides for a method for determining the total amount payable under such health plan with respect to such item or service furnished by such provider or facility1 such amount determined in accordance with such method4 7#ac7 ,stabilize ,the term to stabilize1 with respect to an emergency medical condition1 has the meaning give in section #ahfg7;e77#c77;,a7 of the ,social ,security ,act4 7#ad7 ,cost-sharing ,the term cost-sharing includes copayments1 coinsurance1 and deductibles4 7l7 ,payment to provider or facility ,in the case of any payment required to be made by a health plan pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a7 to a nonparticiapting provider or nonparticipating facility for an item or service1 such payment shall be made to such provider or facility and not to the individual receiving such item or service4 4 7#b7 ,conforming amendments 7,a7 ,application provisions ,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 than1 with respect to a plan year beginning on or after ,january #a1 #bjbb1 the provisions of section #bgai;,a of such ,act72 and 7ii7 in paragraph 7#b71 by inserting 7other than1 with respect to a plan year beginning on or after ,january #a1 #bjbb1 the provisions of section #bgai;,a of such ,act7 after the first occurrence of such part ,a4 7,b7 ,application to retiree-only plans ,section #ihca7;a7 of the ,internal ,revenue ,code of #aihf is amended by inserting 7other than1 with respect to a group health plan described in paragraph 7#b71 the requirements of section #ihaf7 before shall not apply4 7#c7 ,clerical amendment ,the table of sections for such subchapter is amended by adding at the end the following new items3 ,sec4 #ihae4 ,additional market reforms4 ,sec4 #ihaf4 ,patient protections4 4 7#d7 ,effective date ,the amendments made by this subsection shall apply with respect to plan years beginning on or after ,january #a1 #bjbb4 7c7 ,employee ,retirement ,income ,security ,act of #aigd amendments 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 ,patient protections 7a7 ,choice of health care professional ,if a health plan requires or provides for designation by a participant or beneficiary of a participating primary care provider1 then the plan shall permit each participant or beneficiary to designate any participating primary care provider who is available to accept such individual4 7b7 ,cost-,sharing and payment of emergency services 7#a7 ,in general ,if a health plan provides or covers any benefits with respect to services in an emergency department of a hospital and1 for plan year #bjbb or a subsequent plan year1 with respect to emergency services in an independent freestanding emergency department1 the plan shall cover emergency services-- 7,a7 without the need for any prior authorization determination2 7,b7 whether the health care provider furnishing such services is a participating provider or a participating facility that is an emergency department of a hospital or an independent freestanding emergency department 7in this subsection referred to as a participating emergency facility7 with respect to such services2 7,c7 in a manner so that1 if such services are provided to a participant or beneficiary by a nonparticipating provider or a nonparticipating facility that is an emergency department of a hospital or an independent freestanding emergency department-- 7i7 such services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from participating providers and participating emergency facilities with respect to such plan2 7ii7 the cost-sharing requirement is not greater than the requirement that would apply if such services were furnished by a participating provider or a participating emergency facility1 as applicable2 7iii7 such cost-sharing requirement is calculated as if the contracted rate for such services if furnished by a participating provider or a participating emergency facility were equal to the recognized amount for such services2 7iv7 the health plan pays to such provider or facility1 respectively1 the amount by which the out-of-network rate for such services exceeds the cost-sharing amount for such services 7as determined in accordance with clauses 7ii7 and 7iii772 and 7v7 any deductible or out-of-pocket maximum that would apply if such services were furnished by a participating provider or a participating emergency facility shall be the deductible or out-of-pocket maximum that applies2 and 7,d7 without regard to any other term or condition of such coverage 7other than exclusion or coordination of benefits1 or an affiliation or waiting period1 permitted under section #bgjd of the ,public ,health ,service ,act1 including as incorporated pursuant to section #gae and section #ihae of the ,internal ,revenue ,code of #aihf1 and other than applicable cost-sharing74 7#b7 ,audit process and rulemaking process for median contracted rates 7,a7 ,audit process 7i7 ,in general ,not later than ,july #a1 #bjba1 the ,secretary1 in coordination with the ,secretary of ,health and ,human ,services and the ,secretary of the ,treasury and in consultation with the ,national ,association of ,insurance ,commissioners1 shall establish through rulemaking a process1 in accordance with clause 7ii71 under which health plans are audited by the ,secretary to ensure that-- 7,i7 such plans are in compliance with the requirement of applying a median contracted rate under this section2 and 7,,ii7 that such median contracted rate so applied satisfies the definition under subsection 7k77#h7 with respect to the year involved4 7ii7 ,audit samples ,under the process established pursuant to clause 7i71 the ,secretary-- 7,i7 shall conduct audits described in such clause of a sample of health plans2 and 7,,ii7 may audit any health plan if the ,secretary has received any complaint about such plan that involves the compliance of the plan with the requirement described in such clause4 7,b7 ,rulemaking ,not later than ,july #a1 #bjba1 the ,secretary1 in coordination with the ,secretary of the ,treasury and the ,secretary of ,health and ,human ,services1 shall establish through rulemaking-- 7i7 the methodology the sponsor or issuer of a health plan shall use to determine the median contracted rate1 which shall account for relevant payment adjustments that take into account facility type that are otherwise taken into account for purposes of determining payment amounts with respect to participating facilities2 and 7ii7 the information such sponsor or issuer shall share with the nonparticipating provider involved when making such a determination4 7c7 ,access to pediatric care 7#a7 ,pediatric care ,in the case of a person who has a child who is a participant or beneficiary under a health plan1 if the plan requires or provides for the designation of a participating primary care provider for the child1 the plan shall permit such person to designate a physician 7allopathic or osteopathic7 who specializes in pediatrics as the child's primary care provider if such provider participates in the network of the plan4 7#b7 ,construction ,nothing in paragraph 7#a7 shall be construed to waive any exclusions of coverage under the terms and conditions of the plan with respect to coverage of pediatric care4 7d7 ,patient access to obstetrical and gynecological care 7#a7 ,general rights 7,a7 ,direct access ,a health plan described in paragraph 7#b7 may not require authorization or referral by the plan or any person 7including a primary care provider described in paragraph 7#b77;,b77 in the case of a female participant or beneficiary who seeks coverage for obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology4 ,such professional shall agree to otherwise adhere to such plan's policies and procedures1 including procedures regarding referrals and obtaining prior authorization and providing services pursuant to a treatment plan 7if any7 approved by the plan4 7,b7 ,obstetrical and gynecological care ,a health plan described in paragraph 7#b7 shall treat the provision of obstetrical and gynecological care1 and the ordering of related obstetrical and gynecological items and services1 pursuant to the direct access described under subparagraph 7,a71 by a participating health care professional who specializes in obstetrics or gynecology as the authorization of the primary care provider4 7#b7 ,application of paragraph ,a health plan described in this paragraph is a health plan that-- 7,a7 provides coverage for obstetric or gynecologic care2 and 7,b7 requires the designation by a participant or beneficiary of a participating primary care provider4 7#c7 ,construction ,nothing in paragraph 7#a7 shall be construed to-- 7,a7 waive any exclusions of coverage under the terms and conditions of the plan with respect to coverage of obstetrical or gynecological care2 or 7,b7 preclude the health plan involved from requiring that the obstetrical or gynecological provider notify the primary care health care professional or the plan of treatment decisions4 7k7 ,definitions ,for purposes of this section3 7#a7 ,contracted rate ,the term contracted rate means1 with respect to a health plan and a health care provider or health care facility furnishing an item or service to a beneficiary or participant of such plan1 the agreed upon total payment amount 7inclusive of any cost-sharing7 to such provider or facility for such item or service4 7#b7 ,during a visit ,the term during a visit shall1 with respect to an individual who is furnished items and services at a participating facility1 include equipment and devices1 telemedicine services1 imaging services1 laboratory services1 preoperative and postoperative services1 and such other items and services as the ,secretary may specify furnished to such individual1 regardless of whether or not the provider furnishing such items or services is at the facility4 7#c7 ,emergency department of a hospital ,the term emergency department of a hospital includes a hospital outpatient department that provides emergency services4 7#d7 ,emergency medical condition ,the term emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity 7including severe pain7 such that a prudent layperson1 who possesses an average knowledge of health and medicine1 could reasonably expect the absence of immediate medical attention to result in a condition described in clause 7i71 7ii71 or 7iii7 of section #ahfg7;e77#a77;,a7 of the ,social ,security ,act4 7#e7 ,emergency services 7,a7 ,in general ,the term emergency services1 with respect to an emergency medical condition1 means-- 7i7 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 7ii7 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 patient 7regardless of the department of the hospital in which such further examination or treatment is furnished74 7,b7 ,inclusion of additional services ,in the case of an individual enrolled in a health plan who is furnished services described in subparagraph 7,a7 by a provider or hospital or independent freestanding emergency department to stabilize such individual with respect to an emergency medical condition1 the term emergency services shall include1 in addition to those described in subparagraph 7,a71 items and services furnished as part of outpatient observation or an inpatient or outpatient stay during a visit in which such individual is so stabilized with respect to such emergency condition if-- 7i7 such items and services would otherwise be covered under such plan if furnished by a participating provider or participating facility2 and 7ii7 such items and services are furnished-- 7,i7 to maintain1 improve1 or resolve the individual's stabilization with respect to such condition1 unless any circumstance described in subparagraph 7,c7 has occurred with respect to such individual before such items and services are furnished2 or 7,,ii7 for any purpose not described in subclause 7,i71 unless each of the criteria described in subparagraph 7,d7 have been met with respect to such individual and such item or service4 7,c7 ,circumstances ,for purposes of subparagraph 7,b77ii77,i71 a circumstance described in this subparagraph is any of the following1 with respect to an individual who is a beneficiary1 participant1 or enrollee of a health plan who is furnished services described in subparagraph 7,a7 by a hospital or independent freestanding emergency department with respect to an emergency medical condition3 7i7 ,a participating provider1 with respect to such plan1 with privileges at the hospital or independent freestanding emergency department assumes responsibility for the care of the individual4 7ii7 ,a participating provider1 with respect to such plan1 assumes responsibility for the care of the individual through transfer of the individual4 7iii7 ,the health plan and the provider treating such individual at the hospital or independent freestanding emergency department for such condition reach an agreement concerning the care for the individual4 7iv7 ,the individual is discharged4 7,d7 ,signed notice criteria ,for purposes of subparagraph 7,b77ii77,,ii71 the criteria described in this subparagraph1 with respect to an individual and an item or service furnished by a nonparticipating provider or nonparticipating facility that is a hospital or an independent freestanding emergency department1 are the following3 7i7 ,a written notice 7as specified by the ,secretary and in a clear and understandable manner7 is provided by such provider or facility to such individual1 before such item or service is furnished1 that includes the following information3 7,i7 ,that such provider or facility is a nonparticipating provider or nonparticipating facility 7as applicable74 7,,ii7 ,to the extent practicable1 the estimated amount that such nonparticipating facility or nonparticipating provider may charge the individual for such item or service4 7,,iii7 ,a statement that the individual may seek such item or service from a provider that is a participating provider or a hospital or independent freestanding emergency department that is a participating facility and a list1 if feasible1 of participating facilities or participating providers1 as applicable1 who are able to furnish such item or service4 7ii7 ,such individual is in a condition to receive 7as determined in accordance with guidance issued by the ,secretary7 the information described in clause 7i7 and to confirm notice of receipt of such notice1 in accordance with applicable ,state law4 7iii7 ,the individual signs and dates such notice confirming receipt of the notice before such item or service is furnished4 7#f7 ,health plan ,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 7#g7 ,independent freestanding emergency department ,the term independent freestanding emergency department means a health care facility that-- 7,a7 is geographically separate and distinct and licensed separately from a hospital under applicable ,state law2 and 7,b7 provides emergency services4 7#h7 ,median contracted rate 7,a7 ,in general ,subject to subparagraph 7,b71 the term median contracted rate means1 with respect to a health plan-- 7i7 for an item or service furnished during #bjbb1 the median of the contracted rates recognized by the sponsor or issuer of such plan 7determined with respect to all such plans of such sponsor or such issuer that are within the same line of business 7as specified in subparagraph 7,c77 as the plan involved7 as the total maximum payment under such plans in #bjai for the same or a similar item or service that is provided by a provider or facility in the same or similar specialty and provided in the geographic region 7established 7and updated1 as appropriate7 by the ,secretary1 in consultation with the ,national ,association of ,insurance ,commissioners7 in which the item or service is furnished1 consistent with the methodology established by the ,secretary under subsection 7b77#b77;,b71 increased by the percentage increase in the consumer price index for all urban consumers 7,united ,states city average7 over #bjai1 #bjbj1 and #bjba2 7ii7 for an item or service furnished during #bjbc or a subsequent year through #bjbf1 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 year2 7iii7 for an item or service furnished during a rebasing year 7as defined in subparagraph 7,d771 the median of the contracted rates recognized by the sponsor or issuer of such plan 7determined with respect to all such plans of such sponsor or issuer that are within the same line of business 7as specified in subparagraph 7,c77 as the plan involved7 as the total maximum payment under such plans in such year for the same or a similar item or service that is provided by a provider or facility in the same or similar specialty and provided in the geographic region 7as established pursuant to clause 7i77 in which the item or service is furnished1 consistent with the methodology established by the ,secretary under subsection 7b77#b77;,b72 and 7iv7 for an item or service furnished during any of the #d years following a rebasing 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 7,b7 ,use of substitute rate in case of insufficient data 7i7 ,in general ,in the case the sponsor or issuer of a health plan has insufficient information 7as specified by the ,secretary7 to calculate the median of the contracted rates in accordance with subparagraph 7,a7 for a year for an item or service furnished in a particular geographic region 7as established pursuant to subparagraph 7,a77i77 by a type of provider or facility1 the substitute rate 7as defined in clause 7ii77 for such item or service shall be deemed to be the median contracted rate for such item or service furnished in such region during such year by such a provider or facility for such year under such subparagraph 7,a7 for such plan4 7ii7 ,substitute rate ,for purposes of clause 7i71 the term substitute rate means1 with respect to an item or service furnished by a provider or facility in a geographic region 7established pursuant to subparagraph 7,a77i77 during a year for which a health plan is required to make payment pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a7-- 7,i7 if sufficient information 7as specified by the ,secretary7 exists to determine the median of the contracted rates recognized by all health plans offered in the same line of business 7as specified in subparagraph 7,c77 by any group health plan for such an item or service furnished in such region by such a provider or facility during such year using a database or other source of information determined appropriate by the ,secretary1 such median2 and 7,,ii7 if such sufficient information does not exist1 the median of the contracted rates recognized by all health plans offered in the same line of business 7as specified in subparagraph 7,c77 by any group health plan for such an item or service furnished in a similarly situated geographic region 7as determined by the ,secretary7 with such sufficient information by such a provider or facility during such year using such a database or such other source of information4 ,the ,secretary shall develop a methodology for determining a substitute rate based on a similarly situated health plan that is not a ,federal health care program 7as defined in section #aabh;,b7f7 of the ,social ,security ,act7 in the case a substitute rate is not calculable under the previous sentence with respect to an item or service4 7,c7 ,line of business ,a line of business specified in this subparagraph is one of the following3 7i7 ,the small group market4 7ii7 ,the large group market4 7iii7 ,in the case of a self-insured group health plan1 other self-insured group health plans4 7,d7 ,rebasing year defined ,for purposes of subparagraph 7,a71 the term rebasing year means #bjbg and every #e years thereafter4 7#i7 ,nonparticipating facility2 participating facility 7,a7 ,nonparticipating facility ,the term nonparticipating facility means1 with respect to an item or service and a health plan1 a health care facility described in subparagraph 7,b77ii7 that does not have a contractual relationship with the plan for furnishing such item or service4 7,b7 ,participating facility 7i7 ,in general ,the term participating 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 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 ,act71 including an emergency department of a hospital4 7,,ii7 ,a critical access hospital 7as defined in section #ahfa7mm77#a7 of such ,act74 7,,iii7 ,an ambulatory surgical center 7as described in section #ahcc7;i77#a77;,a7 of such ,act74 7,,iv7 ,a laboratory4 7,v7 ,a radiology facility or imaging center4 7,,vi7 ,an independent freestanding emergency department4 7,,vii7 ,any other facility specified by the ,secretary4 7#aj7 ,nonparticipating providers2 participating providers 7,a7 ,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 does not have a contractual relationship with the plan for furnishing such item or service under the plan4 7,b7 ,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 has a contractual relationship with the plan for furnishing such item or service under the plan4 7#aa7 ,out-of-network rate ,the term out-of-network rate means1 with respect to an item or service furnished in a ,state during a year to a participant or beneficiary of a health plan receiving such item or service from a nonparticipating provider or facility-- 7,a7 subject to subparagraphs 7,c7 and 7,d71 in the case such ,state has in effect a ,state law that provides for a method for determining the total amount payable under such health plan regulated by such ,state with respect to such item or service furnished by such provider or facility1 such amount determined in accordance with such law2 7,b7 subject to subparagraphs 7,c7 and 7,d71 in the case such ,state does not have in effect such a law with respect to such item or service1 plan1 and provider or facility-- 7i7 subject to clause 7ii71 if the provider or facility 7as applicable7 and such plan agree on an amount of payment 7including if agreed on through open negotiations under subsection 7j77#a77 with respect to such item or service1 such agreed on amount2 or 7ii7 if such provider or facility 7as applicable7 and such plan enter the mediated dispute process under subsection 7j7 and do not so agree before the date on which a selected independent entity 7as defined in paragraph 7#c7 of such subsection7 makes a determination with respect to such item or service under such subsection1 the amount of such determination2 7,c7 in the case such ,state has an ,all-,payer ,model ,agreement under section #aaae;,a of the ,social ,security ,act1 the amount that the ,state approves under such system for such item or service so furnished2 or 7,d7 in the case such health plan is a self-insured group health plan and in the case of a ,state with an agreement with such plan in effect as of the date of the enactment of the ,consumer ,protections ,against ,surprise ,medical ,bills ,act of #bjbj1 that provides for a method for determining the total amount payable under such health plan with respect to such item or service furnished by such provider or facility1 such amount determined in accordance with such method4 7#ab7 ,recognized amount ,the term recognized amount means1 with respect to an item or service furnished in a ,state during a year to a participant or beneficiary of a health plan by a nonparticipating provider or nonparticipating facility-- 7,a7 subject to subparagraphs 7,c7 and 7,d71 in the case such ,state has in effect a law described in paragraph 7#aa77;,a7 with respect to such item or service1 provider or facility1 and plan1 the amount determined in accordance with such law2 7,b7 subject to subparagraphs 7,c7 and 7,d71 in the case such ,state does not have in effect such a law1 an amount that is the median contracted rate for such item or service for such year2 7,c7 in the case such ,state is described in paragraph 7#aa77;,c7 with respect to such item or service so furnished1 the amount that the ,state approves under such system for such item or service so furnished2 or 7,d7 in the case such health plan is a self-insured group health plan and in the case of a ,state with an agreement with such plan in effect as of the date of the enactment of the ,consumer ,protections ,against ,surprise ,medical ,bills ,act of #bjbj1 that provides for a method for determining the total amount payable under such health plan with respect to such item or service furnished by such provider or facility1 such amount determined in accordance with such method4 7#ac7 ,stabilize ,the term to stabilize1 with respect to an emergency medical condition1 has the meaning give in section #ahfg7;e77#c77;,a7 of the ,social ,security ,act74 7#ad7 ,cost-sharing ,the term cost-sharing includes copayments1 coinsurance1 and deductibles4 7l7 ,payment to provider or facility ,in the case of any payment required to be made by a health plan pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a7 to a nonparticiapting provider or nonparticipating facility for an item or service1 such payment shall be made to such provider or facility and not to the individual receiving such item or service4 4 7#b7 ,conforming amendment 7,a7 ,application provisions ,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 than1 with respect to a plan year beginning on or after ,january #a1 #bjbb1 the provisions of section #bgai;,a of such ,act72 and 7ii7 in paragraph 7#b71 by inserting 7other than1 with respect to a plan year beginning on or after ,january #a1 #bjbb1 the provisions of section #bgai;,a of such ,act7 after the first occurrence of such part ,a4 7,b7 ,application to retiree-only plans ,section #gcb7;a7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aaia;a7a77 is amended by striking section #gaa and inserting sections #gaa and #gaf4 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 ,patient protections4 4 7#d7 ,effective date ,the amendments made by this subsection shall apply with respect to plan years beginning on or after ,january #a1 #bjbb4 #c4 ,consumer protections through requirements on health plans to prevent surprise medical bills for non-emergency services performed by nonparticipating providers at certain participating facilities 7a7 ,,phsa amendments 7#a7 ,in general ,section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 as amended by section #b7;a71 is further amended by inserting before subsection 7k7 the following new subsection3 7e7 ,cost-,sharing and payment of non-,emergency services performed by nonparticipating providers at certain participating facilities 7#a7 ,in general ,subject to paragraph 7#b71 in the case of items or services 7other than emergency services to which subsection 7b7 applies or items and services to which subsection 7i7 applies7 furnished to a participant1 beneficiary1 or enrollee of a health plan by a nonparticipating provider during a visit 7as defined by the ,secretary in accordance with subsection 7k77#b77 at a participating facility1 if such items and services would otherwise be covered under such plan if furnished by a participating provider1 the plan-- 7,a7 shall not impose on such participant1 beneficiary1 or enrollee a cost-sharing amount 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 provider2 7,b7 shall calculate such cost-sharing amount as if the contracted rate for such services if furnished by a participating provider were equal to the recognized amount 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 out-of-network rate 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 apply the deductible or out-of-pocket maximum1 if any1 that would apply if such services were furnished by a participating provider4 7#b7 ,exception ,paragraph 7#a7 shall not apply to a health plan in the case of items or services furnished to a participant1 beneficiary1 or enrollee of a health plan by a nonparticipating provider during a visit 7as so defined by the ,secretary in accordance with subsection 7k77#b77 at a participating facility if the requirement described in paragraph 7#a7 of section #aaej;,c7b7 of the ,social ,security ,act does not apply with respect to such provider and such items and services due to the application of paragraph 7#b7 of such section4 4 7#b7 ,effective date ,the amendment made by paragraph 7#a7 shall apply with respect to plan years beginning on or after ,january #a1 #bjbb4 7b7 ,,irc amendments 7#a7 ,in general ,section #ihaf of the ,internal ,revenue ,code of #aihf1 as added by section #b7;b71 is amended by inserting before subsection 7k7 the following new subsection3 7e7 ,cost-,sharing and payment of non-,emergency services performed by nonparticipating providers at certain participating facilities 7#a7 ,in general ,subject to paragraph 7#b71 in the case of items or services 7other than emergency services to which subsection 7b7 applies or items and services to which subsection 7i7 applies7 furnished to a participant or beneficiary of a health plan by a nonparticipating provider during a visit 7as defined by the ,secretary in accordance with subsection 7k77#b77 at a participating facility1 if such items and services would otherwise be covered under such plan if furnished by a participating provider1 the plan-- 7,a7 shall not impose on such participant or beneficiary a cost-sharing amount 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 provider2 7,b7 shall calculate such cost-sharing amount as if the contracted rate for such services if furnished by a participating provider were equal to the recognized amount for such items and services2 7,c7 shall pay to such provider furnishing such items and services to such participant or beneficiary the amount by which the out-of-network rate 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 apply the deductible or out-of-pocket maximum1 if any1 that would apply if such services were furnished by a participating provider4 7#b7 ,exception ,paragraph 7#a7 shall not apply to a health plan in the case of items or services furnished to a participant or beneficiary of a health plan by a nonparticipating provider during a visit 7as so defined by the ,secretary in accordance with subsection 7k77#b77 at a participating facility if the requirement described in paragraph 7#a7 of section #aaej;,c7b7 of the ,social ,security ,act does not apply with respect to such provider and such items and services due to the application of paragraph 7#b7 of such section4 4 7#b7 ,effective date ,the amendments made by paragraph 7#a7 shall apply with respect to plan years beginning on or after ,january #a1 #bjbb4 7c7 ,,erisa amendments 7#a7 ,in general ,section #gaf of the ,employee ,retirement ,income ,security ,act of #aigd1 as added by section #b7;c71 is amended by inserting before subsection 7k7 the following new subsection3 7e7 ,cost-,sharing and payment of non-,emergency services performed by nonparticipating providers at certain participating facilities 7#a7 ,in general ,subject to paragraph 7#b71 in the case of items or services 7other than emergency services to which subsection 7b7 applies or items and services to which subsection 7i7 applies7 furnished to a participant or beneficiary of a health plan by a nonparticipating provider during a visit 7as defined by the ,secretary in accordance with subsection 7k77#b77 at a participating facility1 if such items and services would otherwise be covered under such plan if furnished by a participating provider1 the plan-- 7,a7 shall not impose on such participant or beneficiary a cost-sharing amount 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 provider2 7,b7 shall calculate such cost-sharing amount as if the contracted rate for such services if furnished by a participating provider were equal to the recognized amount for such items and services2 7,c7 shall pay to such provider furnishing such items and services to such participant or beneficiary the amount by which the out-of-network rate 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 apply the deductible or out-of-pocket maximum1 if any1 that would apply if such services were furnished by a participating provider4 7#b7 ,exception ,paragraph 7#a7 shall not apply to a health plan in the case of items or services furnished to a participant or beneficiary of a health plan by a nonparticipating provider during a visit 7as so defined by the ,secretary in accordance with subsection 7k77#b77 at a participating facility if the requirement described in paragraph 7#a7 of section #aaej;,c7b7 of the ,social ,security ,act does not apply with respect to such provider and such items and services due to the application of paragraph 7#b7 of such section4 4 7#b7 ,effective date ,the amendments made by paragraph 7#a7 shall apply with respect to plan years beginning on or after ,january #a1 #bjbb4 #d4 ,consumer protections through application of health plan external review in cases of certain surprise medical bills ,section #bgai7;b77#a7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai7;b77#a77 is amended-- 7#a7 by striking at a minimum1 includes and inserting at a minimum-- 7,a7 includes 2 7#b7 by striking at the end or and inserting and2 and 7#c7 by adding at the end the following new subparagraph3 7,b7 beginning not later than ,january #a1 #bjbb1 applies such external review process with respect to any adverse determination by such plan or issuer under subsection 7b7 of section #bgai;,a1 subsection 7e7 of such section1 or subsection 7i7 of such section1 including with respect to whether an item or service that is the subject to such a determination is an item or service to which such subsection 7b71 7e71 or 7i7 applies2 or 4 #e4 ,consumer protections through health plan transparency requirements 7a7 ,,phsa amendments ,section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 as amended by sections #b7;a7 and #c7;a71 is further amended by inserting before subsection 7k7 the following new subsections3 7f7 ,provider directory requirements 7#a7 ,in general ,beginning not later than ,january #a1 #bjbb1 each health plan 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 directory 7other than the database described in subparagraph 7,c77 containing provider directory information with respect to such plan the information described in paragraph 7#e74 7#b7 ,verification process ,the verification process described in this paragraph is1 with respect to a health plan1 a process-- 7,a7 under which such plan verifies and updates the provider directory information included on the database described in paragraph 7#d7 of such plan of-- 7i7 not less frequently than once every #ij days1 a random sample of at least #aj percent of health care providers and health care facilities included in such database2 and 7ii7 any such provider or such facility included in such database that has not submitted any claim to such plan during a #ab-month period2 7,b7 that establishes a procedure for the removal from such database of such a provider or facility with respect to which such plan has been unable to verify such information during a period specified by the plan2 and 7,c7 that provides for the update of such database within #b business days of such plan receiving from such a provider or facility information pursuant to section #aaej;,d of the ,social ,security ,act4 7#c7 ,response protocol ,the response protocol described in this paragraph is1 in the case of an individual enrolled in a health plan who requests information through a telephone call or email on whether a health care provider or health care facility has a contractual relationship to furnish items and services under such plan1 a protocol under which such plan-- 7,a7 responds to such individual as soon as practicable1 and in no case later than #a business day after such call or email is received1 through a written electronic or paper 7as requested by such individual7 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 health plan1 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 has a contractual relationship for furnishing items and services under such plan2 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 directory containing provider directory information with respect to a health plan1 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 should consult the database described in paragraph 7#d7 with respect to such plan or contact such plan to obtain the most current provider directory information with respect to such plan4 7#f7 ,definition ,for purposes of this section1 the term provider directory information includes1 with respect to a health plan1 the name1 address1 specialty1 and telephone number of each health care provider or health care facility with which such plan has a contractual relationship for furnishing items and services under such plan4 7g7 ,disclosure on patient protections against balance billing ,beginning not later than ,january #a1 #bjbb1 each health plan shall make publicly available1 post on a website of such plan available to individuals enrolled under such plan1 and include on each explanation of benefits for an item or service with respect to which the requirements under subsection 7b71 7e71 or 7i7 applies-- 7#a7 information in plain language on-- 7,a7 the requirements and prohibitions applied under section #aaej;,c of the ,social ,security ,act 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 with respect to which such a provider is a nonparticipating provider or facility is a nonparticipating facility1 with respect to such plan1 for furnishing such item or service 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,c7 the requirements applied under subsections 7b71 7e71 and 7i72 and 7#b7 information in plain language on contacting appropriate ,state and ,federal agencies in the case that an individual believes that such a health plan1 provider1 or facility has violated any requirement described in paragraph 7#a7 with respect to such individual4 4 7b7 ,,irc amendments ,section #ihaf of the ,internal ,revenue ,code of #aihf1 as added by section #b7;b7 and amended by section #c7;b71 is further amended by inserting before subsection 7k7 the following new subsections3 7f7 ,provider directory requirements 7#a7 ,in general ,beginning not later than ,january #a1 #bjbb1 each health plan 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 directory 7other than the database described in subparagraph 7,c77 containing provider directory information with respect to such plan the information described in paragraph 7#e74 7#b7 ,verification process ,the verification process described in this paragraph is1 with respect to a health plan1 a process-- 7,a7 under which such plan verifies and updates the provider directory information included on the database described in paragraph 7#d7 of such plan of-- 7i7 not less frequently than once every #ij days1 a random sample of at least #aj percent of health care providers and health care facilities included in such database2 and 7ii7 any such provider or such facility included in such database that has not submitted any claim to such plan during a #ab-month period2 7,b7 that establishes a procedure for the removal from such database of such a provider or facility with respect to which such plan has been unable to verify such information during a period specified by the plan2 and 7,c7 that provides for the update of such database within #b business days of such plan receiving from such a provider or facility information pursuant to section #aaej;,d of the ,social ,security ,act4 7#c7 ,response protocol ,the response protocol described in this paragraph is1 in the case of an individual enrolled in a health plan who requests information through a telephone call or email on whether a health care provider or health care facility has a contractual relationship to furnish items and services under such plan1 a protocol under which such plan-- 7,a7 responds to such individual as soon as practicable1 and in no case later than #a business day after such call or email is received1 through a written electronic or paper 7as requested by such individual7 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 health plan1 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 has a contractual relationship for furnishing items and services under such plan2 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 directory containing provider directory information with respect to a health plan1 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 should consult the database described in paragraph 7#d7 with respect to such plan or contact such plan to obtain the most current provider directory information with respect to such plan4 7#f7 ,definition ,for purposes of this section1 the term provider directory information includes1 with respect to a health plan1 the name1 address1 specialty1 and telephone number of each health care provider or health care facility with which such plan has a contractual relationship for furnishing items and services under such plan4 7g7 ,disclosure on patient protections against balance billing ,beginning not later than ,january #a1 #bjbb1 each health plan shall make publicly available1 post on a website of such plan available to individuals enrolled under such plan1 and include on each explanation of benefits for an item or service with respect to which the requirements under subsection 7b71 7e71 or 7i7 applies-- 7#a7 information in plain language on-- 7,a7 the requirements and prohibitions applied under section #aaej;,c of the ,social ,security ,act 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 participant or beneficiary of such plan with respect to which such a provider is a nonparticipating provider or facility is a nonparticipating facility1 with respect to such plan1 for furnishing such item or service after receiving payment from the plan for such item or service and any applicable cost-sharing payment from such participant or beneficiary2 and 7,c7 the requirements applied under subsections 7b71 7e71 and 7i72 and 7#b7 information in plain language on contacting appropriate ,state and ,federal agencies in the case that an individual believes that such a health plan1 provider1 or facility has violated any requirement described in paragraph 7#a7 with respect to such individual4 4 7c7 ,,erisa amendments ,section #gaf of the ,employee ,retirement ,income ,security ,act of #aigd1 as added by section #b7;c7 and amended by section #c7;c71 is further amended by inserting before subsection 7k7 the following new subsections3 7f7 ,provider directory requirements 7#a7 ,in general ,beginning not later than ,january #a1 #bjbb1 each health plan 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 directory 7other than the database described in subparagraph 7,c77 containing provider directory information with respect to such plan the information described in paragraph 7#e74 7#b7 ,verification process ,the verification process described in this paragraph is1 with respect to a health plan1 a process-- 7,a7 under which such plan verifies and updates the provider directory information included on the database described in paragraph 7#d7 of such plan of-- 7i7 not less frequently than once every #ij days1 a random sample of at least #aj percent of health care providers and health care facilities included in such database2 and 7ii7 any such provider or such facility included in such database that has not submitted any claim to such plan during a #ab-month period2 7,b7 that establishes a procedure for the removal from such database of such a provider or facility with respect to which such plan has been unable to verify such information during a period specified by the plan2 and 7,c7 that provides for the update of such database within #b business days of such plan receiving from such a provider or facility information pursuant to section #aaej;,d of the ,social ,security ,act4 7#c7 ,response protocol ,the response protocol described in this paragraph is1 in the case of an individual enrolled in a health plan who requests information through a telephone call or email on whether a health care provider or health care facility has a contractual relationship to furnish items and services under such plan1 a protocol under which such plan-- 7,a7 responds to such individual as soon as practicable1 and in no case later than #a business day after such call or email is received1 through a written electronic or paper 7as requested by such individual7 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 health plan1 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 has a contractual relationship for furnishing items and services under such plan2 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 directory containing provider directory information with respect to a health plan1 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 should consult the database described in paragraph 7#d7 with respect to such plan or contact such plan to obtain the most current provider directory information with respect to such plan4 7#f7 ,definition ,for purposes of this section1 the term provider directory information includes1 with respect to a health plan1 the name1 address1 specialty1 and telephone number of each health care provider or health care facility with which such plan has a contractual relationship for furnishing items and services under such plan4 7g7 ,disclosure on patient protections against balance billing ,beginning not later than ,january #a1 #bjbb1 each health plan shall make publicly available1 post on a website of such plan available to individuals enrolled under such plan1 and include on each explanation of benefits for an item or service with respect to which the requirements under subsection 7b71 7e71 or 7i7 applies-- 7#a7 information in plain language on-- 7,a7 the requirements and prohibitions applied under section #aaej;,c of the ,social ,security ,act 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 participant or beneficiary of such plan with respect to which such a provider is a nonparticipating provider or facility is a nonparticipating facility1 with respect to such plan1 for furnishing such item or service after receiving payment from the plan for such item or service and any applicable cost-sharing payment from such participant or beneficiary2 and 7,c7 the requirements applied under subsections 7b71 7e71 and 7i72 and 7#b7 information in plain language on contacting appropriate ,state and ,federal agencies in the case that an individual believes that such a health plan1 provider1 or facility has violated any requirement described in paragraph 7#a7 with respect to such individual4 4 #f4 ,consumer protections through health plan requirement for fair and honest advance cost estimate 7a7 ,,phsa amendment ,section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 as amended by sections #b7;a71 #c7;a71 and #e7;a71 is further amended by inserting before subsection 7k7 the following new subsections3 7h7 ,advanced explanation of benefits ,beginning on ,january #a1 #bjbb1 each health plan shall1 with respect to a notification submitted under section #aaej;,d7b77#b77;,a7 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 7in clear and understandable language7 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 individual 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 ,a statement that the individual may seek such an item or service from a provider that is a participating provider or a facility that is a participating facility and a list of participating facilities1 or of participating providers1 as applicable1 who are able to furnish such items and services involved4 7#i7 ,any other information or disclaimer the health plan determines appropriate that is consistent with information and disclaimers required under this section4 7i7 ,cost-,sharing and payment for services provided based on reliance on incorrect provider network information 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbb1 in the case of an item or service furnished to a participant1 beneficiary1 or enrollee of a health plan by a nonparticipating provider or a nonparticipating facility1 if such item or service would otherwise be covered under such plan if furnished by a participating provider or participating facility and if either of the criteria described in paragraph 7#b7 applies with respect to such participant1 beneficiary1 or enrollee and item or service1 the plan-- 7,a7 shall not impose on such enrollee a cost-sharing amount for such item or service so furnished that is greater than the cost-sharing amount that would apply under such plan had such item or service been furnished by a participating provider2 7,b7 shall calculate such cost-sharing amount as if the contracted rate for such item or service furnished by such a participating provider or facility were equal to-- 7i7 the most recent 7as of the date such item or service was furnished7 contracted rate in effect between such provider or facility and such plan for such item or service furnished under such plan1 if any2 or 7ii7 if no contracted rate described in clause 7i7 exists1 the recognized amount for such item or service2 7,c7 shall pay to such nonparticipating provider or facility furnishing such item or service to such participant1 beneficiary1 or enrollee the amount by which-- 7i7 if a contracted rate described in subparagraph 7,b77i7 exists1 the most recent 7as of the date such item or services was furnished7 such rate2 or 7ii7 if no contracted rate described in such subparagraph exists1 the out-of-network rate2 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 apply the deductible or out-of-pocket maximum1 if any1 that would apply if such services were furnished by a participating provider or a participating facility4 7#b7 ,criteria described ,for purposes of paragraph 7#a71 the criteria described in this paragraph1 with respect to an item or service furnished to a participant1 beneficiary1 or enrollee of a health plan by a nonparticipating provider or a nonparticipating facility1 are the following3 7,a7 ,the participant1 beneficiary1 or enrollee received a notification under subsection 7h7 with respect to such item and service to be furnished and such notification provided information that the provider was a participating provider or facility was a participating facility1 with respect to the plan for furnishing such item or service4 7,b7 ,a notification was not provided1 in accordance with subsection 7h71 to the participant1 beneficiary1 or enrollee1 and the participant1 beneficiary1 or enrollee requested through the response protocol of the plan under subsection 7f77#c7 information on whether the provider was a participating provider or facility was a participating facility with respect to the plan for furnishing such item or service and was informed through such protocol that the provider was such a participating provider or facility was such a participating facility4 4 7b7 ,,irc amendments ,section #ihaf of the ,internal ,revenue ,code of #aihf1 as added by section #b7;b7 and amended by sections #c7;b7 and #e7;b71 is further amended by inserting before subsection 7k7 the following new subsections3 7h7 ,advanced explanation of benefits ,beginning on ,january #a1 #bjbb1 each health plan shall1 with respect to a notification submitted under section #aaej;,d7b77#b77;,a7 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 7in clear and understable language7 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 individual 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 ,a statement that the individual may seek such an item or service from a provider that is a participating provider or a facility that is a participating facility and a list of participating facilities1 or of participating providers1 as applicable1 who are able to furnish such items and services involved4 7#i7 ,any other information or disclaimer the health plan determines appropriate that is consistent with information and disclaimers required under this section4 7i7 ,cost-,sharing and payment for services provided based on reliance on incorrect provider network information 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbb1 in the case of an item or service furnished to a participant or beneficiary of a health plan by a nonparticipating provider or a nonparticipating facility1 if such item or service would otherwise be covered under such plan if furnished by a participating provider or participating facility and if either of the criteria described in paragraph 7#b7 applies with respect to such participant or beneficiary and item or service1 the plan-- 7,a7 shall not impose on such enrollee a cost-sharing amount for such item or service so furnished that is greater than the cost-sharing amount that would apply under such plan had such item or service been furnished by a participating provider2 7,b7 shall calculate such cost-sharing amount as if the contracted rate for such item or service furnished by such a participating provider or facility were equal to-- 7i7 the most recent 7as of the date such item or service was furnished7 contracted rate in effect between such provider or facility and such plan for such item or service furnished under such plan1 if any2 or 7ii7 if no contracted rate described in clause 7i7 exists1 the recognized amount for such item or service2 7,c7 shall pay to such nonparticipating provider or facility furnishing such item or service to such participant or beneficiary the amount by which-- 7i7 if a contracted rate described in subparagraph 7,b77i7 exists1 the most recent 7as of the date such item or services was furnished7 such rate2 or 7ii7 if no contracted rate described in such subparagraph exists1 the out-of-network rate2 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 apply the deductible or out-of-pocket maximum1 if any1 that would apply if such services were furnished by a participating provider or a participating facility4 7#b7 ,criteria described ,for purposes of paragraph 7#a71 the criteria described in this paragraph1 with respect to an item or service furnished to a participant or beneficiary of a health plan by a nonparticipating provider or a nonparticipating facility1 are the following3 7,a7 ,the participant or beneficiary received a notification under subsection 7h7 with respect to such item and service to be furnished and such notification provided information that the provider was a participating provider or facility was a participating facility1 with respect to the plan for furnishing such item or service4 7,b7 ,a notification was not provided1 in accordance with subsection 7h71 to the participant or beneficiary and the participant or beneficiary requested through the response protocol of the plan under subsection 7f77#c7 information on whether the provider was a participating provider or facility was a participating facility with respect to the plan for furnishing such item or service and was informed through such protocol that the provider was such a participating provider or facility was such a participating facility4 4 7c7 ,,erisa amendments ,section #gaf of the ,employee ,retirement ,income ,security ,act of #aigd1 as added by section #b7;c7 and amended by sections #c7;c7 and #e7;c71 is further amended by inserting before subsection 7k7 the following new subsections3 7h7 ,advanced explanation of benefits ,beginning on ,january #a1 #bjbb1 each health plan shall1 with respect to a notification submitted under section #aaej;,d7b77#b77;,a7 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 7in clear and understandable language7 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 individual 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 ,a statement that the individual may seek such an item or service from a provider that is a participating provider or a facility that is a participating facility and a list of participating facilities1 or of participating providers1 as applicable1 who are able to furnish such items and services involved4 7#i7 ,any other information or disclaimer the health plan determines appropriate that is consistent with information and disclaimers required under this section4 7i7 ,cost-,sharing and payment for services provided based on reliance on incorrect provider network information 7#a7 ,in general ,for plan years beginning on or after ,january #a1 #bjbb1 in the case of an item or service furnished to a participant or beneficiary of a health plan by a nonparticipating provider or a nonparticipating facility1 if such item or service would otherwise be covered under such plan if furnished by a participating provider or participating facility and if either of the criteria described in paragraph 7#b7 applies with respect to such participant or beneficiary and item or service1 the plan-- 7,a7 shall not impose on such enrollee a cost-sharing amount for such item or service so furnished that is greater than the cost-sharing amount that would apply under such plan had such item or service been furnished by a participating provider2 7,b7 shall calculate such cost-sharing amount as if the contracted rate for such item or service furnished by such a participating provider or facility were equal to-- 7i7 the most recent 7as of the date such item or service was furnished7 contracted rate in effect between such provider or facility and such plan for such item or service furnished under such plan1 if any2 or 7ii7 if no contracted rate described in clause 7i7 exists1 the recognized amount for such item or service2 7,c7 shall pay to such nonparticipating provider or facility furnishing such item or service to such participant or beneficiary the amount by which-- 7i7 if a contracted rate described in subparagraph 7,b77i7 exists1 the most recent 7as of the date such item or services was furnished7 such rate2 or 7ii7 if no contracted rate described in such subparagraph exists1 the out-of-network rate2 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 apply the deductible or out-of-pocket maximum1 if any1 that would apply if such services were furnished by a participating provider or a participating facility4 7#b7 ,criteria described ,for purposes of paragraph 7#a71 the criteria described in this paragraph1 with respect to an item or service furnished to a participant or beneficiary of a health plan by a nonparticipating provider or a nonparticipating facility1 are the following3 7,a7 ,the participant or beneficiary received a notification under subsection 7h7 with respect to such item and service to be furnished and such notification provided information that the provider was a participating provider or facility was a participating facility1 with respect to the plan for furnishing such item or service4 7,b7 ,a notification was not provided1 in accordance with subsection 7h71 to the participant or beneficiary and the participant or beneficiary requested through the response protocol of the plan under subsection 7f77#c7 information on whether the provider was a participating provider or facility was a participating facility with respect to the plan for furnishing such item or service and was informed through such protocol that the provider was such a participating provider or facility was such a participating facility4 4 #g4 ,determination through open negotiation and mediation of out-of-network rates to be paid by health plans 7a7 ,,phsa amendment ,section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 as amended by sections #b7;a71 #c7;a71 #e7;a71 and #f7;a71 is further amended by inserting before subsection 7k7 the following new subsection3 7j7 ,determination of out-of-,network rates ,to be paid by health plans 7#a7 ,determination through open negotiation 7,a7 ,in general ,with respect to an item or service furnished in a year by a nonparticipating provider or a nonparticipating facility1 with respect to a health plan1 in a ,state described in subparagraph 7,b7 of subsection 7k77#aa7 with respect to such plan and provider or facility1 and for which a payment is required to be made by the health plan pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a71 the provider or facility 7as applicable7 or plan may1 during the #cj-;day period beginning on the day the provider or facility receives a response from the plan regarding a claim for payment for such item or service1 initiate open negotiations under this paragraph between such provider or facility and plan for purposes of determining1 during the open negotiation period1 an amount agreed on by such provider or facility1 respectively1 and such plan for payment 7including any cost-sharing7 for such item or service4 ,for purposes of this subsection1 the open negotiation period1 with respect to an item or service1 is the #cj-;day period beginning on the date of initiation of the negotiations with respect to such item or service4 7,b7 ,exchange of information ,in carrying out negotiations initiated under subparagraph 7,a71 with respect to an item or service described in such subparagraph furnished in a year1 not later than the fifth business day of the open negotiation period described in such subparagraph with respect to such item or service-- 7i7 the health plan that is party to such negotiations shall notify the provider or facility that is party to such negotiations of the median contracted rate for such item or service and year2 and 7ii7 such provider or facility shall notify such health plan of-- 7,i7 the median of the total amount of reimbursement 7including any cost-sharing7 paid1 for the most recent year for which information is available1 to such provider or facility for furnishing such item or service to a participant1 beneficiary1 or enrollee of a health plan that1 at the time such item or service was furnished1 had a contract in effect with such provider or facility with respect to the furnishing of such item or service2 7,,ii7 in the case that information described in subclause 7,i7 is not available1 such information as specified by the ,secretary2 and 7,,iii7 any additional information specified by the ,secretary4 7,c7 ,accessing mediated dispute process in case of failed negotiations ,in the case of open negotiations pursuant to subparagraph 7,a71 with respect to an item or service1 that do not result in a determination of an amount of payment for such item or service by the last day of the open negotiation period described in such subparagraph with respect to such item or service1 the provider or facility 7as applicable7 or health plan that was party to such negotiations may1 during the #b-;day period beginning on the day after such open negotiation period1 initiate the mediated dispute process under paragraph 7#b7 with respect to such item or service4 ,the mediated dispute process shall be initiated by a party pursuant to the previous sentence by submission to the other party and to the ,secretary of a notification 7containing such information as specified by the ,secretary7 and for purposes of this subsection1 the date of initiation of such process shall be the date of such submission or such other date specified by the ,secretary pursuant to regulations that is not later than the date of receipt of such notification by both the other party and the ,secretary4 7#b7 ,mediated dispute process available in case of failed open negotiations 7,a7 ,establishment ,not later than ,july #a1 #bjba1 the ,secretary1 in coordination with the ,secretary of the ,treasury and the ,secretary of ,labor1 shall establish a process 7in this subsection referred to as the mediated dispute process7 under which1 in the case of an item or service with respect to which a provider or facility 7as applicable7 or health plan submits a notification under paragraph 7#a77;,c7 7in this subsection referred to as a qualified mediated dispute item or service71 an entity selected under paragraph 7#c7 determines1 subject to subparagraph 7,b7 and in accordance with the succeeding provisions of this subsection1 the amount of payment under the health plan for such item or service furnished by such provider or facility4 7,b7 ,authority to continue negotiations ,under the mediated dispute process1 in the case that the parties to a determination for a qualified mediated dispute item or service agree on a payment amount for such item or service during such process but before the date on which the entity selected with respect to such determination under paragraph 7#c7 makes such determination1 such amount shall be treated for purposes of subsection 7k77#aa77;,b7 as the amount agreed to by such parties for such item or service4 ,in the case of an agreement described in the previous sentence1 the mediated dispute process shall provide for a method to determine how to allocate between the parties to such determination the payment of the compensation of the entity selected with respect to such determination4 7#c7 ,selection under mediated dispute process ,under the mediated dispute process1 the ,secretary shall1 with respect to the determination of the amount of payment under this subsection of a qualified mediated dispute item or service1 provide for a method-- 7,a7 that allows the parties to such determination to jointly select1 not later than the last day of the #c-;day period following the date of the initiation of the process with respect to such item or service1 for purposes of making such determination1 an entity certified under paragraph 7#g7 that-- 7i7 is not a party to such determination or an employee or agent of such a party2 7ii7 does not have a material familial1 financial1 or professional relationship with such a party2 and 7iii7 does not otherwise have a conflict of interest with such a party 7as determined by the ,secretary72 and 7,b7 that requires1 in the case such parties do not make such selection by such last day1 the ,secretary to1 not later than #f days after such date of initiation-- 7i7 select such an entity that satisfies clauses 7i7 through 7iii7 of subparagraph 7,a72 and 7ii7 provide notification of such selection to the provider or facility 7as applicable7 and the health plan party to such determination4 ,an entity selected pursuant to the previous sentence to make a determination described in such sentence shall be referred to in this subsection as the selected independent entity with respect to such determination4 7#d7 ,treatment of consideration of multiple items and services 7,a7 ,in general ,under the mediated dispute process1 the ,secretary shall specify criteria under which multiple qualified mediated dispute items and services are permitted to be considered jointly as part of a single determination by an entity for purposes of encouraging the efficiency 7including minimizing costs7 of the mediated dispute process4 ,such items and services may be so considered only if-- 7i7 such items and services to be included in such determination are furnished by the same provider or facility2 7ii7 payment for such items and services is required to be made by the same health plan2 and 7iii7 such items and services are related to the treatment of a similar condition4 7,b7 ,treatment of bundled payments ,in carrying out subparagraph 7,a71 the ,secretary shall provide that1 in the case of items and services which are included by a provider or facility as part of a bundled payment1 such items and services included in such bundled payment may be part of a single determination under this subsection4 7,c7 ,waiver of deadlines ,for purposes of permitting joint consideration of qualified mediated dispute items and services as part of a single determination under the criteria specified pursuant to subparagraph 7,a71 the ,secretary may waive any deadline specified in this subsection4 7#e7 ,determination of payment amount 7,a7 ,in general ,not later than #cj days after the date of initiation of the mediated dispute resolution1 with respect to a qualified mediated dispute item or service1 the selected independent entity with respect to a determination under this subsection for such item or service shall-- 7i7 taking into account only the considerations specified in subparagraph 7,c77i71 select one of the offers submitted under subparagraph 7,b7 to be the amount of payment for such item or service determined under this subsection for purposes of subsection 7b77#a71 7e77#a71 or 7i77#a71 as applicable2 and 7ii7 notify the provider or facility and the health plan party to such determination of the offer selected under clause 7i74 7,b7 ,submission of offers ,not later than #aj days after the date of initiation of the mediated dispute resolution with respect to a determination for a qualified mediated dispute item or service1 the provider or facility and the health plan party to such determination shall each submit to the selected independent entity-- 7i7 an offer for a payment amount under for such item or service furnished by such provider or facility2 7ii7 information relating to such offer2 and 7iii7 such other information as requested by the selected independent entity4 7,c7 ,considerations 7i7 ,in general ,for purposes of subparagraph 7,a71 the considerations specified in this subparagraph1 with respect to a determination for a qualified mediated dispute item or service1 are the following3 7,i7 ,the median contracted rate for such item or service4 7,,ii7 ,subject to clause 7ii71 information that is submitted pursuant to subparagraph 7,b74 7ii7 ,treatment of certain considerations ,in making a determination with respect to a qualified mediated dispute item or service pursuant to subparagraph 7,a77i71 a selected independent entity may not take into account usual and customary charges for the item or service nor charges billed by the provider or facility for the item or service4 7#f7 ,selected independent entity compensation 7,a7 ,in general ,not later than #e days after receiving a notification described in paragraph 7#e77;,a77ii7 from a selected independent entity with respect to the determination of a payment amount for a qualified mediated dispute item or service1 the party to such determination whose offer submitted under paragraph 7#e77;,b7 was not selected by the entity shall pay to such entity a fee in compensation for the services of such entity in accordance with the guidelines on such compensation established by the ,secretary under subparagraph 7,b74 7,b7 ,guidelines on compensation ,for purposes of subparagraph 7,a71 the ,secretary shall establish guidelines with respect to the compensation of a selected independent entity for the services of such entity with respect to determinations under the mediated dispute process4 ,such guidelines shall provide that such compensation reimburses the entity for at least the costs of such entity in performing the duties of the entity under the mediated dispute process4 7#g7 ,certification of entities 7,a7 ,in general ,the ,secretary shall establish or recognize a process to certify 7including recertification of7 entities under this paragraph4 ,such process shall ensure that an entity so certified-- 7i7 has 7directly or through contracts or other arrangements7 sufficient medical1 legal1 and other expertise and sufficient staffing to make determinations described in paragraph 7#b7 on a timely basis2 7ii7 is not-- 7,i7 a health plan1 provider1 or facility2 7,,ii7 an affiliate or a subsidiary of a health plan1 provider1 or facility2 or 7,,iii7 an affiliate or subsidiary of a professional or trade association of health plans or of providers or facilities2 7iii7 carries out the responsibilities of such an entity in accordance with this subsection2 7iv7 meets appropriate indicators of fiscal integrity2 7v7 maintains the confidentiality 7in accordance with regulations promulgated by the ,secretary7 of individually identifiable health information obtained in the course of conducting such determinations2 7vi7 does not under the mediated dispute process carry out any determination with respect to which the entity would not pursuant to clause 7i71 7ii71 or 7iii7 of paragraph 7#c77;,a7 be eligible for selection2 and 7vii7 meets such other requirements as determined appropriate by the ,secretary4 7,b7 ,period of certification ,subject to subparagraph 7,c71 each certification 7including a recertification7 of an entity under the process described in subparagraph 7,a7 shall be for a #e-year period4 7,c7 ,revocation ,a certification of an entity under this paragraph may be revoked under the process described in subparagraph 7,a7 if the entity has a pattern or practice of noncompliance with any of the requirements described in such subparagraph4 7,d7 ,petition for denial or withdrawal ,the process described in subparagraph 7,a7 shall ensure that an individual1 provider1 facility1 or health plan may petition for a denial of a certification or a revocation of a certification with respect to an entity under this paragraph for failure of meeting a requirement of this subsection4 7,e7 ,sufficient number of entities ,the process described in subparagraph 7,a7 shall ensure that a sufficient number of entities are certified under this paragraph to ensure the timely and efficient provision of determinations described in paragraph 7#b74 7,f7 ,provision of information 7i7 ,in general ,an entity certified under this paragraph shall provide to the ,secretary1 in such manner as the ,secretary may require and on a quarterly basis 7as specified by the ,secretary71 such information as the ,secretary determines appropriate to assure compliance with the requirements described in subparagraph 7,a7 and to monitor and assess the determinations made by such entity and to ensure the absence of bias in making such determinations4 ,such information shall include information described in clause 7ii7 but shall not include individually identifiable health information4 7ii7 ,information to be included ,the information described in this clause with respect to an entity is the following3 7,i7 ,the number of payment determinations described in paragraph 7#b7 made by such entity1 disaggregated by-- 7aa7 the line of business 7as specified in subsection 7k77#h77;,c77 of the health plans party to such determinations2 and 7bb7 the type of providers and facilities party to such determinations4 7,,ii7 ,a description of each item or service included in each such determination4 7,,iii7 ,the amount of each offer submitted to the entity for each such determination4 7,,iv7 ,the amount of each such determination4 7,v7 ,the length of time in making each such determination4 7,,vi7 ,the compensation paid to such entity with respect to each such determination4 7,,vii7 ,any other information specified by the ,secretary4 7#h7 ,administrative fee 7,a7 ,in general ,each party to a determination to which an entity is selected under paragraph 7#c7 in a year shall pay to the ,secretary1 at such time and in such manner as specified by the ,secretary1 a fee for participating in the mediated dispute process with respect to such determination in an amount described in subparagraph 7,b7 for such year4 7,b7 ,amount of fee ,the amount described in this subparagraph for a year is an amount established by the ,secretary in a manner such that the total amount of fees paid under this paragraph for such year is estimated to be equal to the amount of expenditures estimated to be made by the ,secretary for such year in carrying out the mediated dispute process4 7#i7 ,secretarial report2 publication of information 7,a7 ,secretarial report ,beginning not later than ,july #a1 #bjbc1 the ,secretary shall1 in coordination with the ,secretary of the ,treasury and the ,secretary of ,labor1 periodically study and submit to ,congress a report on-- 7i7 the extent to which the payment amount determined under this subsection for an item or service furnished in a year 7or otherwise agreed to by a health plan and provider or facility for purposes of determining payment by the plan to the provider or facility pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a77 differs from the median contracted rate for such item or service and year1 including the number of times such determined 7or agreed to7 amount exceeds such median contracted rate2 and 7ii7 the effect of such difference on the cost-sharing for such item or service for a participant1 beneficiary1 or enrollee of a health plan4 7,b7 ,publication of information ,beginning with ,july #a1 #bjbc1 and for each calendar quarter thereafter1 the ,secretary shall1 in coordination with the ,secretary of the ,treasury and the ,secretary of ,labor1 make publicly available a summary of the following3 7i7 ,the information described in subclauses 7,i7 through 7,v7 of clause 7ii7 of paragraph 7#g77;,f7 that was submitted to the ,secretary under clause 7i7 of such paragraph during such quarter4 7ii7 ,the amount of expenditures made by the ,secretary during such year to carry out the mediated dispute process4 7iii7 ,the total amount of fees paid under paragraph 7#h7 during such quarter4 7iv7 ,the total amount of compensation paid to selected independent entities under paragraph 7#f7 during such quarter4 4 7b7 ,,irc amendments ,section #ihaf of the ,internal ,revenue ,code of #aihf1 as added by section #b7;b7 and amended by sections #c7;b71 #e7;b71 and #f7;b71 is further amended by inserting before subsection 7k7 the following new subsection3 7j7 ,determination of out-of-,network rates ,to be paid by health plans 7#a7 ,determination through open negotiation 7,a7 ,in general ,with respect to an item or service furnished in a year by a nonparticipating provider or a nonparticipating facility1 with respect to a health plan1 in a ,state described in subparagraph 7,b7 of subsection 7k77#aa7 with respect to such plan and provider or facility1 and for which a payment is required to be made by the health plan pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a71 the provider or facility 7as applicable7 or plan may1 during the #cj-;day period beginning on the day the provider or facility receives a response from the plan regarding a claim for payment for such item or service1 initiate open negotiations under this paragraph between such provider or facility and plan for purposes of determining1 during the open negotiation period1 an amount agreed on by such provider or facility1 respectively1 and such plan for payment 7including any cost-sharing7 for such item or service4 ,for purposes of this subsection1 the open negotiation period1 with respect to an item or service1 is the #cj-;day period beginning on the date of initiation of the negotiations with respect to such item or service4 7,b7 ,exchange of information ,in carrying out negotiations initiated under subparagraph 7,a71 with respect to an item or service described in such subparagraph furnished in a year1 not later than the fifth business day of the open negotiation period described in such subparagraph with respect to such item or service-- 7i7 the health plan that is party to such negotiations shall notify the provider or facility that is party to such negotiations of the median contracted rate for such item or service and year2 and 7ii7 such provider or facility shall notify such health plan of-- 7,i7 the median of the total amount of reimbursement 7including any cost-sharing7 paid1 for the most recent year for which information is available1 to such provider or facility for furnishing such item or service to a participant or beneficiary of a health plan that1 at the time such item or service was furnished1 had a contract in effect with such provider or facility with respect to the furnishing of such item or service2 7,,ii7 in the case that information described in subclause 7,i7 is not available1 such information as specified by the ,secretary2 and 7,,iii7 any additional information specified by the ,secretary4 7,c7 ,accessing mediated dispute process in case of failed negotiations ,in the case of open negotiations pursuant to subparagraph 7,a71 with respect to an item or service1 that do not result in a determination of an amount of payment for such item or service by the last day of the open negotiation period described in such subparagraph with respect to such item or service1 the provider or facility 7as applicable7 or health plan that was party to such negotiations may1 during the #b-;day period beginning on the day after such open negotiation period1 initiate the mediated dispute process under paragraph 7#b7 with respect to such item or service4 ,the mediated dispute process shall be initiated by a party pursuant to the previous sentence by submission to the other party and to the ,secretary of a notification 7containing such information as specified by the ,secretary7 and for purposes of this subsection1 the date of initiation of such process shall be the date of such submission or such other date specified by the ,secretary pursuant to regulations that is not later than the date of receipt of such notification by both the other party and the ,secretary4 7#b7 ,mediated dispute process available in case of failed open negotiations 7,a7 ,establishment ,not later than ,july #a1 #bjba1 the ,secretary1 in coordination with the ,secretary of ,health and ,human ,services and the ,secretary of ,labor1 shall establish a process 7in this subsection referred to as the mediated dispute process7 under which1 in the case of an item or service with respect to which a provider or facility 7as applicable7 or health plan submits a notification under paragraph 7#a77;,c7 7in this subsection referred to as a qualified mediated dispute item or service71 an entity selected under paragraph 7#c7 determines1 subject to subparagraph 7,b7 and in accordance with the succeeding provisions of this subsection1 the amount of payment under the health plan for such item or service furnished by such provider or facility4 7,b7 ,authority to continue negotiations ,under the mediated dispute process1 in the case that the parties to a determination for a qualified mediated dispute item or service agree on a payment amount for such item or service during such process but before the date on which the entity selected with respect to such determination under paragraph 7#c7 makes such determination1 such amount shall be treated for purposes of subsection 7k77#aa77;,b7 as the amount agreed to by such parties for such item or service4 ,in the case of an agreement described in the previous sentence1 the mediated dispute process shall provide for a method to determine how to allocate between the parties to such determination the payment of the compensation of the entity selected with respect to such determination4 7#c7 ,selection under mediated dispute process ,under the mediated dispute process1 the ,secretary shall1 with respect to the determination of the amount of payment under this subsection of a qualified mediated dispute item or service1 provide for a method-- 7,a7 that allows the parties to such determination to jointly select1 not later than the last day of the #c-;day period following the date of the initiation of the process with respect to such item or service1 for purposes of making such determination1 an entity certified under paragraph 7#g7 that-- 7i7 is not a party to such determination or an employee or agent of such a party2 7ii7 does not have a material familial1 financial1 or professional relationship with such a party2 and 7iii7 does not otherwise have a conflict of interest with such a party 7as determined by the ,secretary72 and 7,b7 that requires1 in the case such parties do not make such selection by such last day1 the ,secretary to1 not later than #f days after such date of initiation-- 7i7 select such an entity that satisfies clauses 7i7 through 7iii7 of subparagraph 7,a72 and 7ii7 provide notification of such selection to the provider or facility 7as applicable7 and the health plan party to such determination4 ,an entity selected pursuant to the previous sentence to make a determination described in such sentence shall be referred to in this subsection as the selected independent entity with respect to such determination4 7#d7 ,treatment of consideration of multiple items and services 7,a7 ,in general ,under the mediated dispute process1 the ,secretary shall specify criteria under which multiple qualified mediated dispute items and services are permitted to be considered jointly as part of a single determination by an entity for purposes of encouraging the efficiency 7including minimizing costs7 of the mediated dispute process4 ,such items and services may be so considered only if-- 7i7 such items and services to be included in such determination are furnished by the same provider or facility2 7ii7 payment for such items and services is required to be made by the same health plan2 and 7iii7 such items and services are related to the treatment of a similar condition4 7,b7 ,treatment of bundled payments ,in carrying out subparagraph 7,a71 the ,secretary shall provide that1 in the case of items and services which are included by a provider or facility as part of a bundled payment1 such items and services included in such bundled payment may be part of a single determination under this subsection4 7,c7 ,waiver of deadlines ,for purposes of permitting joint consideration of qualified mediated dispute items and services as part of a single determination under the criteria specified pursuant to subparagraph 7,a71 the ,secretary may waive any deadline specified in this subsection4 7#e7 ,determination of payment amount 7,a7 ,in general ,not later than #cj days after the date of initiation of the mediated dispute resolution1 with respect to a qualified mediated dispute item or service1 the selected independent entity with respect to a determination under this subsection for such item or service shall-- 7i7 taking into account only the considerations specified in subparagraph 7,c77i71 select one of the offers submitted under subparagraph 7,b7 to be the amount of payment for such item or service determined under this subsection for purposes of subsection 7b77#a71 7e77#a71 or 7i77#a71 as applicable2 and 7ii7 notify the provider or facility and the health plan party to such determination of the offer selected under clause 7i74 7,b7 ,submission of offers ,not later than #aj days after the date of initiation of the mediated dispute resolution with respect to a determination for a qualified mediated dispute item or service1 the provider or facility and the health plan party to such determination shall each submit to the selected independent entity-- 7i7 an offer for a payment amount under for such item or service furnished by such provider or facility2 7ii7 information relating to such offer2 and 7iii7 such other information as requested by the selected independent entity4 7,c7 ,considerations 7i7 ,in general ,for purposes of subparagraph 7,a71 the considerations specified in this subparagraph1 with respect to a determination for a qualified mediated dispute item or service1 are the following3 7,i7 ,the median contracted rate for such item or service4 7,,ii7 ,subject to clause 7ii71 information that is submitted pursuant to subparagraph 7,b74 7ii7 ,treatment of certain considerations ,in making a determination with respect to a qualified mediated dispute item or service pursuant to subparagraph 7,a77i71 a selected independent entity may not take into account usual and customary charges for the item or service nor charges billed by the provider or facility for the item or service4 7#f7 ,selected independent entity compensation 7,a7 ,in general ,not later than #e days after receiving a notification described in paragraph 7#e77;,a77ii7 from a selected independent entity with respect to the determination of a payment amount for a qualified mediated dispute item or service1 the party to such determination whose offer submitted under paragraph 7#e77;,b7 was not selected by the entity shall pay to such entity a fee in compensation for the services of such entity in accordance with the guidelines on such compensation established by the ,secretary under subparagraph 7,b74 7,b7 ,guidelines on compensation ,for purposes of subparagraph 7,a71 the ,secretary shall establish guidelines with respect to the compensation of a selected independent entity for the services of such entity with respect to determinations under the mediated dispute process4 ,such guidelines shall provide that such compensation reimburses the entity for at least the costs of such entity in performing the duties of the entity under the mediated dispute process4 7#g7 ,certification of entities 7,a7 ,in general ,the ,secretary shall establish or recognize a process to certify 7including recertification of7 entities under this paragraph4 ,such process shall ensure that an entity so certified-- 7i7 has 7directly or through contracts or other arrangements7 sufficient medical1 legal1 and other expertise and sufficient staffing to make determinations described in paragraph 7#b7 on a timely basis2 7ii7 is not-- 7,i7 a health plan1 provider1 or facility2 7,,ii7 an affiliate or a subsidiary of a health plan1 provider1 or facility2 or 7,,iii7 an affiliate or subsidiary of a professional or trade association of health plans or of providers or facilities2 7iii7 carries out the responsibilities of such an entity in accordance with this subsection2 7iv7 meets appropriate indicators of fiscal integrity2 7v7 maintains the confidentiality 7in accordance with regulations promulgated by the ,secretary7 of individually identifiable health information obtained in the course of conducting such determinations2 7vi7 does not under the mediated dispute process carry out any determination with respect to which the entity would not pursuant to clause 7i71 7ii71 or 7iii7 of paragraph 7#c77;,a7 be eligible for selection2 and 7vii7 meets such other requirements as determined appropriate by the ,secretary4 7,b7 ,period of certification ,subject to subparagraph 7,c71 each certification 7including a recertification7 of an entity under the process described in subparagraph 7,a7 shall be for a #e-year period4 7,c7 ,revocation ,a certification of an entity under this paragraph may be revoked under the process described in subparagraph 7,a7 if the entity has a pattern or practice of noncompliance with any of the requirements described in such subparagraph4 7,d7 ,petition for denial or withdrawal ,the process described in subparagraph 7,a7 shall ensure that an individual1 provider1 facility1 or health plan may petition for a denial of a certification or a revocation of a certification with respect to an entity under this paragraph for failure of meeting a requirement of this subsection4 7,e7 ,sufficient number of entities ,the process described in subparagraph 7,a7 shall ensure that a sufficient number of entities are certified under this paragraph to ensure the timely and efficient provision of determinations described in paragraph 7#b74 7,f7 ,provision of information 7i7 ,in general ,an entity certified under this paragraph shall provide to the ,secretary1 in such manner as the ,secretary may require and on a quarterly basis 7as specified by the ,secretary71 such information as the ,secretary determines appropriate to assure compliance with the requirements described in subparagraph 7,a7 and to monitor and assess the determinations made by such entity and to ensure the absence of bias in making such determinations4 ,such information shall include information described in clause 7ii7 but shall not include individually identifiable health information4 7ii7 ,information to be included ,the information described in this clause with respect to an entity is the following3 7,i7 ,the number of payment determinations described in paragraph 7#b7 made by such entity1 disaggregated by-- 7aa7 the line of business 7as specified in subsection 7k77#h77;,c77 of the health plans party to such determinations2 and 7bb7 the type of providers and facilities party to such determinations4 7,,ii7 ,a description of each item or service included in each such determination4 7,,iii7 ,the amount of each offer submitted to the entity for each such determination4 7,,iv7 ,the amount of each such determination4 7,v7 ,the length of time in making each such determination4 7,,vi7 ,the compensation paid to such entity with respect to each such determination4 7,,vii7 ,any other information specified by the ,secretary4 7#h7 ,administrative fee 7,a7 ,in general ,each party to a determination to which an entity is selected under paragraph 7#c7 in a year shall pay to the ,secretary1 at such time and in such manner as specified by the ,secretary1 a fee for participating in the mediated dispute process with respect to such determination in an amount described in subparagraph 7,b7 for such year4 7,b7 ,amount of fee ,the amount described in this subparagraph for a year is an amount established by the ,secretary in a manner such that the total amount of fees paid under this paragraph for such year is estimated to be equal to the amount of expenditures estimated to be made by the ,secretary for such year in carrying out the mediated dispute process4 7#i7 ,secretarial report2 publication of information 7,a7 ,secretarial report ,beginning not later than ,july #a1 #bjbc1 the ,secretary shall1 in coordination with the ,secretary of ,health and ,human ,services and the ,secretary of ,labor1 periodically study and submit to ,congress a report on-- 7i7 the extent to which the payment amount determined under this subsection for an item or service furnished in a year 7or otherwise agreed to by a health plan and provider or facility for purposes of determining payment by the plan to the provider or facility pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a77 differs from the median contracted rate for such item or service and year1 including the number of times such determined 7or agreed to7 amount exceeds such median contracted rate2 and 7ii7 the effect of such difference on the cost-sharing for such item or service for a participant or beneficiary of a health plan4 7,b7 ,publication of information ,beginning with ,july #a1 #bjbc1 and for each calendar quarter thereafter1 the ,secretary shall1 in coordination with the ,secretary of ,health and ,human ,services and the ,secretary of ,labor1 make publicly available a summary of the following3 7i7 ,the information described in subclauses 7,i7 through 7,v7 of clause 7ii7 of paragraph 7#g77;,f7 that was submitted to the ,secretary under clause 7i7 of such paragraph during such quarter4 7ii7 ,the amount of expenditures made by the ,secretary during such year to carry out the mediated dispute process4 7iii7 ,the total amount of fees paid under paragraph 7#h7 during such quarter4 7iv7 ,the total amount of compensation paid to selected independent entities under paragraph 7#f7 during such quarter4 4 7c7 ,,erisa amendments ,section #gaf of the ,employee ,retirement ,income ,security ,act of #aigd1 as added by section #b7;c7 and amended by sections #c7;c71 #e7;c71 and #f7;c71 is further amended by inserting before subsection 7k7 the following new subsection3 7j7 ,determination of out-of-,network rates ,to be paid by health plans 7#a7 ,determination through open negotiation 7,a7 ,in general ,with respect to an item or service furnished in a year by a nonparticipating provider or a nonparticipating facility1 with respect to a health plan1 in a ,state described in subparagraph 7,b7 of subsection 7k77#aa7 with respect to such plan and provider or facility1 and for which a payment is required to be made by the health plan pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a71 the provider or facility 7as applicable7 or plan may1 during the #cj-;day period beginning on the day the provider or facility receives a response from the plan regarding a claim for payment for such item or service1 initiate open negotiations under this paragraph between such provider or facility and plan for purposes of determining1 during the open negotiation period1 an amount agreed on by such provider or facility1 respectively1 and such plan for payment 7including any cost-sharing7 for such item or service4 ,for purposes of this subsection1 the open negotiation period1 with respect to an item or service1 is the #cj-;day period beginning on the date of initiation of the negotiations with respect to such item or service4 7,b7 ,exchange of information ,in carrying out negotiations initiated under subparagraph 7,a71 with respect to an item or service described in such subparagraph furnished in a year1 not later than the fifth business day of the open negotiation period described in such subparagraph with respect to such item or service-- 7i7 the health plan that is party to such negotiations shall notify the provider or facility that is party to such negotiations of the median contracted rate for such item or service and year2 and 7ii7 such provider or facility shall notify such health plan of-- 7,i7 the median of the total amount of reimbursement 7including any cost-sharing7 paid1 for the most recent year for which information is available1 to such provider or facility for furnishing such item or service to a participant or beneficiary of a health plan that1 at the time such item or service was furnished1 had a contract in effect with such provider or facility with respect to the furnishing of such item or service2 7,,ii7 in the case that information described in subclause 7,i7 is not available1 such information as specified by the ,secretary2 and 7,,iii7 any additional information specified by the ,secretary4 7,c7 ,accessing mediated dispute process in case of failed negotiations ,in the case of open negotiations pursuant to subparagraph 7,a71 with respect to an item or service1 that do not result in a determination of an amount of payment for such item or service by the last day of the open negotiation period described in such subparagraph with respect to such item or service1 the provider or facility 7as applicable7 or health plan that was party to such negotiations may1 during the #b-;day period beginning on the day after such open negotiation period1 initiate the mediated dispute process under paragraph 7#b7 with respect to such item or service4 ,the mediated dispute process shall be initiated by a party pursuant to the previous sentence by submission to the other party and to the ,secretary of a notification 7containing such information as specified by the ,secretary7 and for purposes of this subsection1 the date of initiation of such process shall be the date of such submission or such other date specified by the ,secretary pursuant to regulations that is not later than the date of receipt of such notification by both the other party and the ,secretary4 7#b7 ,mediated dispute process available in case of failed open negotiations 7,a7 ,establishment ,not later than ,july #a1 #bjba1 the ,secretary1 in coordination with the ,secretary of ,health and ,human ,services and the ,secretary of the ,treasury1 shall establish a process 7in this subsection referred to as the mediated dispute process7 under which1 in the case of an item or service with respect to which a provider or facility 7as applicable7 or health plan submits a notification under paragraph 7#a77;,c7 7in this subsection referred to as a qualified mediated dispute item or service71 an entity selected under paragraph 7#c7 determines1 subject to subparagraph 7,b7 and in accordance with the succeeding provisions of this subsection1 the amount of payment under the health plan for such item or service furnished by such provider or facility4 7,b7 ,authority to continue negotiations ,under the mediated dispute process1 in the case that the parties to a determination for a qualified mediated dispute item or service agree on a payment amount for such item or service during such process but before the date on which the entity selected with respect to such determination under paragraph 7#c7 makes such determination1 such amount shall be treated for purposes of subsection 7k77#aa77;,b7 as the amount agreed to by such parties for such item or service4 ,in the case of an agreement described in the previous sentence1 the mediated dispute process shall provide for a method to determine how to allocate between the parties to such determination the payment of the compensation of the entity selected with respect to such determination4 7#c7 ,selection under mediated dispute process ,under the mediated dispute process1 the ,secretary shall1 with respect to the determination of the amount of payment under this subsection of a qualified mediated dispute item or service1 provide for a method-- 7,a7 that allows the parties to such determination to jointly select1 not later than the last day of the #c-;day period following the date of the initiation of the process with respect to such item or service1 for purposes of making such determination1 an entity certified under paragraph 7#g7 that-- 7i7 is not a party to such determination or an employee or agent of such a party2 7ii7 does not have a material familial1 financial1 or professional relationship with such a party2 and 7iii7 does not otherwise have a conflict of interest with such a party 7as determined by the ,secretary72 and 7,b7 that requires1 in the case such parties do not make such selection by such last day1 the ,secretary to1 not later than #f days after such date of initiation-- 7i7 select such an entity that satisfies clauses 7i7 through 7iii7 of subparagraph 7,a72 and 7ii7 provide notification of such selection to the provider or facility 7as applicable7 and the health plan party to such determination4 ,an entity selected pursuant to the previous sentence to make a determination described in such sentence shall be referred to in this subsection as the selected independent entity with respect to such determination4 7#d7 ,treatment of consideration of multiple items and services 7,a7 ,in general ,under the mediated dispute process1 the ,secretary shall specify criteria under which multiple qualified mediated dispute items and services are permitted to be considered jointly as part of a single determination by an entity for purposes of encouraging the efficiency 7including minimizing costs7 of the mediated dispute process4 ,such items and services may be so considered only if-- 7i7 such items and services to be included in such determination are furnished by the same provider or facility2 7ii7 payment for such items and services is required to be made by the same health plan2 and 7iii7 such items and services are related to the treatment of a similar condition4 7,b7 ,treatment of bundled payments ,in carrying out subparagraph 7,a71 the ,secretary shall provide that1 in the case of items and services which are included by a provider or facility as part of a bundled payment1 such items and services included in such bundled payment may be part of a single determination under this subsection4 7,c7 ,waiver of deadlines ,for purposes of permitting joint consideration of qualified mediated dispute items and services as part of a single determination under the criteria specified pursuant to subparagraph 7,a71 the ,secretary may waive any deadline specified in this subsection4 7#e7 ,determination of payment amount 7,a7 ,in general ,not later than #cj days after the date of initiation of the mediated dispute resolution1 with respect to a qualified mediated dispute item or service1 the selected independent entity with respect to a determination under this subsection for such item or service shall-- 7i7 taking into account only the considerations specified in subparagraph 7,c77i71 select one of the offers submitted under subparagraph 7,b7 to be the amount of payment for such item or service determined under this subsection for purposes of subsection 7b77#a71 7e77#a71 or 7i77#a71 as applicable2 and 7ii7 notify the provider or facility and the health plan party to such determination of the offer selected under clause 7i74 7,b7 ,submission of offers ,not later than #aj days after the date of initiation of the mediated dispute resolution with respect to a determination for a qualified mediated dispute item or service1 the provider or facility and the health plan party to such determination shall each submit to the selected independent entity-- 7i7 an offer for a payment amount under for such item or service furnished by such provider or facility2 7ii7 information relating to such offer2 and 7iii7 such other information as requested by the selected independent entity4 7,c7 ,considerations 7i7 ,in general ,for purposes of subparagraph 7,a71 the considerations specified in this subparagraph1 with respect to a determination for a qualified mediated dispute item or service1 are the following3 7,i7 ,the median contracted rate for such item or service4 7,,ii7 ,subject to clause 7ii71 information that is submitted pursuant to subparagraph 7,b74 7ii7 ,treatment of certain considerations ,in making a determination with respect to a qualified mediated dispute item or service pursuant to subparagraph 7,a77i71 a selected independent entity may not take into account usual and customary charges for the item or service nor charges billed by the provider or facility for the item or service4 7#f7 ,selected independent entity compensation 7,a7 ,in general ,not later than #e days after receiving a notification described in paragraph 7#e77;,a77ii7 from a selected independent entity with respect to the determination of a payment amount for a qualified mediated dispute item or service1 the party to such determination whose offer submitted under paragraph 7#e77;,b7 was not selected by the entity shall pay to such entity a fee in compensation for the services of such entity in accordance with the guidelines on such compensation established by the ,secretary under subparagraph 7,b74 7,b7 ,guidelines on compensation ,for purposes of subparagraph 7,a71 the ,secretary shall establish guidelines with respect to the compensation of a selected independent entity for the services of such entity with respect to determinations under the mediated dispute process4 ,such guidelines shall provide that such compensation reimburses the entity for at least the costs of such entity in performing the duties of the entity under the mediated dispute process4 7#g7 ,certification of entities 7,a7 ,in general ,the ,secretary shall establish or recognize a process to certify 7including recertification of7 entities under this paragraph4 ,such process shall ensure that an entity so certified-- 7i7 has 7directly or through contracts or other arrangements7 sufficient medical1 legal1 and other expertise and sufficient staffing to make determinations described in paragraph 7#b7 on a timely basis2 7ii7 is not-- 7,i7 a health plan1 provider1 or facility2 7,,ii7 an affiliate or a subsidiary of a health plan1 provider1 or facility2 or 7,,iii7 an affiliate or subsidiary of a professional or trade association of health plans or of providers or facilities2 7iii7 carries out the responsibilities of such an entity in accordance with this subsection2 7iv7 meets appropriate indicators of fiscal integrity2 7v7 maintains the confidentiality 7in accordance with regulations promulgated by the ,secretary7 of individually identifiable health information obtained in the course of conducting such determinations2 7vi7 does not under the mediated dispute process carry out any determination with respect to which the entity would not pursuant to clause 7i71 7ii71 or 7iii7 of paragraph 7#c77;,a7 be eligible for selection2 and 7vii7 meets such other requirements as determined appropriate by the ,secretary4 7,b7 ,period of certification ,subject to subparagraph 7,c71 each certification 7including a recertification7 of an entity under the process described in subparagraph 7,a7 shall be for a #e-year period4 7,c7 ,revocation ,a certification of an entity under this paragraph may be revoked under the process described in subparagraph 7,a7 if the entity has a pattern or practice of noncompliance with any of the requirements described in such subparagraph4 7,d7 ,petition for denial or withdrawal ,the process described in subparagraph 7,a7 shall ensure that an individual1 provider1 facility1 or health plan may petition for a denial of a certification or a revocation of a certification with respect to an entity under this paragraph for failure of meeting a requirement of this subsection4 7,e7 ,sufficient number of entities ,the process described in subparagraph 7,a7 shall ensure that a sufficient number of entities are certified under this paragraph to ensure the timely and efficient provision of determinations described in paragraph 7#b74 7,f7 ,provision of information 7i7 ,in general ,an entity certified under this paragraph shall provide to the ,secretary1 in such manner as the ,secretary may require and on a quarterly basis 7as specified by the ,secretary71 such information as the ,secretary determines appropriate to assure compliance with the requirements described in subparagraph 7,a7 and to monitor and assess the determinations made by such entity and to ensure the absence of bias in making such determinations4 ,such information shall include information described in clause 7ii7 but shall not include individually identifiable health information4 7ii7 ,information to be included ,the information described in this clause with respect to an entity is the following3 7,i7 ,the number of payment determinations described in paragraph 7#b7 made by such entity1 disaggregated by-- 7aa7 the line of business 7as specified in subsection 7k77#h77;,c77 of the health plans party to such determinations2 and 7bb7 the type of providers and facilities party to such determinations4 7,,ii7 ,a description of each item or service included in each such determination4 7,,iii7 ,the amount of each offer submitted to the entity for each such determination4 7,,iv7 ,the amount of each such determination4 7,v7 ,the length of time in making each such determination4 7,,vi7 ,the compensation paid to such entity with respect to each such determination4 7,,vii7 ,any other information specified by the ,secretary4 7#h7 ,administrative fee 7,a7 ,in general ,each party to a determination to which an entity is selected under paragraph 7#c7 in a year shall pay to the ,secretary1 at such time and in such manner as specified by the ,secretary1 a fee for participating in the mediated dispute process with respect to such determination in an amount described in subparagraph 7,b7 for such year4 7,b7 ,amount of fee ,the amount described in this subparagraph for a year is an amount established by the ,secretary in a manner such that the total amount of fees paid under this paragraph for such year is estimated to be equal to the amount of expenditures estimated to be made by the ,secretary for such year in carrying out the mediated dispute process4 7#i7 ,secretarial report2 publication of information 7,a7 ,secretarial report ,beginning not later than ,july #a1 #bjbc1 the ,secretary shall1 in coordination with the ,secretary of ,health and ,human ,services and the ,secretary of the ,treasury1 periodically study and submit to ,congress a report on-- 7i7 the extent to which the payment amount determined under this subsection for an item or service furnished in a year 7or otherwise agreed to by a health plan and provider or facility for purposes of determining payment by the plan to the provider or facility pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a77 differs from the median contracted rate for such item or service and year1 including the number of times such determined 7or agreed to7 amount exceeds such median contracted rate2 and 7ii7 the effect of such difference on the cost-sharing for such item or service for a participant or beneficiary of a health plan4 7,b7 ,publication of information ,beginning with ,july #a1 #bjbc1 and for each calendar quarter thereafter1 the ,secretary shall1 in coordination with the ,secretary of ,health and ,human ,services and the ,secretary of ,labor1 make publicly available a summary of the following3 7i7 ,the information described in subclauses 7,i7 through 7,v7 of clause 7ii7 of paragraph 7#g77;,f7 that was submitted to the ,secretary under clause 7i7 of such paragraph during such quarter4 7ii7 ,the amount of expenditures made by the ,secretary during such year to carry out the mediated dispute process4 7iii7 ,the total amount of fees paid under paragraph 7#h7 during such quarter4 7iv7 ,the total amount of compensation paid to selected independent entities under paragraph 7#f7 during such quarter4 4 7d7 ,rule of construction ,nothing in this ,act1 or the amendment made by this ,act1 shall be construed as removing any obligation of a health plan 7as defined in subsection 7k77#f7 of section #bgai;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;,a71 as amended by this ,act7 to provide payment to a health care provider or health care facility for items and services furnished by such provider or facility to an individual enrolled in such plan4 #h4 ,prohibiting balance billing practices by providers for emergency services1 for services furnished by nonparticipating provider at participating facility1 and in certain cases of misinformation 7a7 ,no balance billing ,part ,a of title ,,xi of the ,social ,security ,act 7#db ,u4,s4,c4 #acja et seq47 is amended by adding at the end the following new section3 #aaej;,c4 ,prohibition on certain balance billing practices 7a7 ,emergency services ,in the case of an individual with benefits under a group health plan or health insurance coverage offered in the group or individual market who is furnished in a plan year that begins on or after ,january #a1 #bjbb1 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 if the hospital or independent freestanding emergency department does not have a contractual relationship with such plan or coverage for furnishing such services1 the hospital or independent freestanding emergency department shall not bill1 and shall not hold liable1 the individual 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;,a7b7 of the ,public ,health ,service ,act1 section #gaf7;b7 of the ,employee ,retirement ,income ,security ,act of #aigd1 or section #ihaf7;b7 of the ,internal ,revenue ,code of #aihf1 as applicable72 and 7#b7 a health care provider without a contractual relationship with such plan or coverage for furnishing such services shall not bill1 and shall not hold liable1 such individual for a payment amount for such services 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 emergency department of the hospital or independent freestanding emergency department that is more than the cost-sharing amount for such services furnished by the provider 7as determined in accordance with section #bgai;,a7b7 of the ,public ,health ,service ,act1 section #gaf7;b7 of the ,employee ,retirement ,income ,security ,act of #aigd1 or section #ihaf7;b7 of the ,internal ,revenue ,code of #aihf1 as applicable74 7b7 ,services furnished by nonparticipating provider at participating facility 7#a7 ,in general ,subject to paragraph 7#b71 in the case of an individual with benefits under a health plan who is furnished items or services 7other than emergency services to which subsection 7a7 applies or items and services to which subsection 7c7 applies7 in a plan year that1 with respect to such plan or such coverage 7as applicable71 begins on or after ,january #a1 #bjbb1 at a participating facility by a nonparticipating provider1 such provider shall not bill1 and shall not hold liable1 such individual 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 section #bgai;,a7e7 of the ,public ,health ,service ,act1 section #gaf7;e7 of the ,employee ,retirement ,income ,security ,act of #aigd1 or section #ihaf7;e7 of the ,internal ,revenue ,code of #aihf1 as applicable74 7#b7 ,exception in case notice provided ,paragraph 7#a7 shall not apply with respect to items and services 7other than items and services described in paragraph 7#c77 furnished to an individual enrolled in a group health plan or in health insurance coverage offered in the group or individual market by a health care provider that does not have a contractual relationship with such plan or coverage for furnishing such items and services if the following criteria are met3 7,a7 ,a written notice 7as specified by the ,secretary and in clear and understandable language7 is provided by the provider to such individual1 not later than #dh hours before such items and services are to be so furnished1 that includes the following information3 7i7 ,a statement verifying that the provider does not have such a relationship with such plan or coverage4 7ii7 ,the estimated amount that such provider may charge the individual for such items and services4 7iii7 ,a statement that the individual may seek such items or services from a health care provider that does have such a contractual relationship and a list1 if feasible1 of providers with such a relationship who are able to furnish such items and services involved4 7,b7 ,on the date such item or service is to be furnished1 before such item or service is so furnished1 the individual signs and dates such notice confirming receipt of the notice and consent of the individual to be so furnished such items and services4 7,c7 ,a copy of such signed and dated notice is provided by the provider to the plan or coverage4 7#c7 ,items and services described ,the items and services described in this paragraph are items and services furnished by a specified provider 7as defined in subsection 7f77#c774 7c7 ,reliance on incorrect provider information ,in the case of an individual who is furnished items or services by a health care provider or health care facility for which a group health plan or health insurance issuer is required to make payment under section #bgai;,a7i7 of the ,public ,health ,service ,act1 section #gaf7;i7 of the ,employee ,retirement ,income ,security ,act of #aigd1 or section #ihaf7;i7 of the ,internal ,revenue ,code of #aihf1 such provider or facility shall not bill1 and shall not hold liable1 such individual for a payment amount for such an item or service that is more than the cost-sharing amount for such item or service 7as determined in accordance with section #bgai;,a7i7 of the ,public ,health ,service ,act1 section #gaf7;i7 of the ,employee ,retirement ,income ,security ,act of #aigd1 or section #ihaf7;i7 of the ,internal ,revenue ,code of #aihf1 as applicable74 7d7 ,compliance with requirements under open negotiation and mediated dispute resolution processes ,a health care provider or health care facility shall comply with any requirement imposed on such provider or facility1 respectively1 under section #bgai;,a7j7 of the ,public ,health ,service ,act1 #ihaf7;j7 of the ,internal ,revenue ,code of #aihf1 or #gaf7;j7 of the ,employee ,retirement ,income ,security ,act of #aigd4 7e7 ,penalty 7#a7 ,in general ,any health care provider or health care facility that violates a provision of this section shall be subject to a civil monetary penalty in an amount not to exceed #aj1jjj for each such violation4 7#b7 ,application of provisions ,the provisions of section #aabh;,a 7other than subsection 7a71 subsection 7b71 the first sentence of subsection 7c77#a71 and subsection 7o77 shall apply with respect to a civil monetary penalty imposed under this subsection in the same manner as such provisions apply with respect to a penalty or proceeding under subsection 7a7 of such section4 7f7 ,definitions ,for purposes of this section and sections #aaej;,d and #aaej;,e3 7#a7 ,the terms during a visit1emergency department of a hospital1 emergency medical condition1 emergency services1 independent freestanding emergency department1 nonparticipating provider1 nonparticipating facility1 participating facility1 participating provider have the meanings given such terms1 respectively1 in section #bgai;,a7k7 of the ,public ,health ,service ,act4 7#b7 ,the terms group health plan1 group market1 health insurance issuer1 health insurance coverage1 and individual market have the meanings given such terms1 respectively1 in section #bgia of the ,public ,health ,service ,act4 7#c7 ,the term specified provider1 with respect to an individual with benefits under a group health plan or health insurance coverage and a hospital with a contractual relationship with such plan or coverage for furnishing items and services-- 7,a7 means an ancillary health care provider1 including emergency medicine providers or suppliers1 anesthesiologists1 pathologists1 radiologists1 neonatologists1 assistant surgeons1 hospitalists1 intensivists1 or other providers determined by the ,secretary 7including providers who furnish similar items and services as the providers specified in this paragraph72 and 7,b7 includes1 with respect to an item or service1 any health care provider furnishing such item or service at such hospital if there is no health care provider at such hospital who can furnish such item or service who has such a relationship with such plan or coverage for furnishing such item or service4 4 7b7 ,provider directory2 patient-,provider dispute resolution process ,part ,a of title ,,xi of the ,social ,security ,act 7#db ,u4,s4,c4 #acja et seq471 as amended by subsection 7a71 is further amended by adding at the end the following new sections3 #aaej;,d4 ,patient protections against surprise billing through transparency 7a7 ,submission of information to health plans of certain provider information ,beginning 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 supplier 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#f7 of the ,public ,health ,service ,act1 section #gaf7;f77#f7 of the ,employee ,retirement ,income ,security ,act of #aigd1 or section #ihaf7;f77#f7 of the ,internal ,revenue ,code of #aihf1 as applicable7 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 there are any material changes 7including a change in address1 telephone number1 or other contact information7 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#b7 at any other time 7including upon the request of such issuer or plan7 determined appropriate by the provider1 facility1 or the ,secretary4 7b7 ,provision of information upon request and for scheduled appointments ,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 7in clear and understandable language7 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-- 7,a7 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 7,b7 in the case the individual is not described in subparagraph 7,a7 and not enrolled in a ,federal health care program1 the individual4 7c7 ,continuity of care ,a health care provider or health care facility shall1 in the case of an individual furnished items and services by such provider or facility for which coverage is provided under a group health plan or group or individual health insurance coverage pursuant to section #bgcj of such ,act1 section #ihag of the ,internal ,revenue ,code of #aihf1 or section #gag of the ,employee ,retirement ,income ,security ,act of #aigd-- 7#a7 accept payment from such plan or such issuer 7as applicable7 7and cost-sharing from such individual1 if applicable1 in accordance with subsection 7a77#b77;,c7 of such section #bgcj1 #ihag1 or #gag7 for such items and services as payment in full for such items and services2 and 7#b7 continue to adhere to all policies1 procedures1 and quality standards imposed by such plan or issuer with respect to such individual and such items and services in the same manner as if such termination had not occurred4 7d7 ,limitation ,beginning on ,january #a1 #bjbb1 a health care provider or health care facility may not initiate a process to seek reimbursement of payment for items and services furnished to an individual enrolled in a group health plan or health insurance coverage offered in the group or individual market more than #a year after the date on which such items and services were so furnished4 7e7 ,penalty 7#a7 ,general penalty 7,a7 ,in general ,except as provided in paragraph 7#b71 any health care provider or health care facility that violates a provision of this section shall be subject to a civil monetary penalty in an amount not to exceed #aj1jjj for each such violation4 7,b7 ,application of provisions ,the provisions of section #aabh;,a 7other than subsection 7a71 subsection 7b71 the first sentence of subsection 7c77#a71 and subsection 7o77 shall apply with respect to a civil monetary penalty imposed under this paragraph in the same manner as such provisions apply with respect to a penalty or proceeding under subsection 7a7 of such section4 7#b7 ,provider directory information penalty 7,a7 ,in general ,each health care provider or health care facility that fails to transmit information as required under subsection 7a7 shall be subject to a civil monetary penalty of #a1jjj for each day such provider or facility 7as applicable7 fails to so transmit such information4 7,b7 ,application of provisions ,the provisions of section #aabh;,a 7other than subsection 7a71 subsection 7b71 the first sentence of subsection 7c77#a71 subsection 7d71 and subsection 7o77 shall apply with respect to a civil monetary penalty imposed under this paragraph in the same manner as such provisions apply with respect to a penalty or proceeding under subsection 7a7 of such section4 #aaej;,e4 ,patient-provider dispute resolution 7a7 ,in general ,not later than ,july #a1 #bjba1 the ,secretary shall establish a process 7in this subsection referred to as the patient-provider dispute resolution process7 under which an uninsured individual1 with respect to an item or service1 who received1 pursuant to section #aaej;,d7b71 from a health care provider or health care facility a good-faith estimate of the expected charges for furnishing such item or service to such individual and who after being furnished such item or service by such provider or facility is billed by such provider or facility for such item or service for charges that are substantially in excess of such estimate1 may seek a determination from a selected dispute resolution entity for the charges to be paid by such individual 7in lieu of such amount so billed7 to such provider or facility for such item or service4 ,for purposes of this subsection1 the term uninsured individual means1 with respect to an item or service1 an individual who does not have benefits for such item or service under a group health plan1 health insurance coverage offered in the group or individual market by a health insurance issuer1 ,federal health care program 7as defined in section #aabh;,b7f771 or a health benefits plan under chapter #hi of title #e1 ,united ,states ,code 7or an individual who has benefits for such item or service under a group health plan or health insurance coverage offered in the group or individual market by a health insurance issuer1 but who does not seek to have a claim for such item or service submitted to such plan or coverage74 7b7 ,selection of entities ,under the patient-provider dispute resolution process1 the ,secretary shall1 with respect to a determination sought by an individual under subsection 7a71 with respect to charges to be paid by such individual to a health care provider or health care facility described in such paragraph for an item or service furnished to such individual by such provider or facility1 provide for-- 7#a7 a method to select to make such determination an entity certified under subsection 7d7 that-- 7,a7 is not a party to such determination or an employee or agent of such party2 7,b7 does not have a material familial1 financial1 or professional relationship with such a party2 and 7,c7 does not otherwise have a conflict of interest with such a party 7as determined by the ,secretary72 and 7#b7 the provision of a notification of such selection to the individual and the provider or facility 7as applicable7 party to such determination4 ,an entity selected pursuant to the previous sentence to make a determination described in such sentence shall be referred to in this subsection as the selected dispute resolution entity with respect to such determination4 7c7 ,administrative fee ,the ,secretary shall establish a fee to participate in the patient-provider dispute resolution process in such a manner as to not create a barrier to an uninsured individual's access to such process4 7d7 ,certification ,the ,secretary shall establish or recognize a process to certify entities under this subparagraph4 ,such process shall ensure that an entity so certified satisfies at least the criteria specified in section #bgai;,a7j77#g7 of the ,public ,health ,service ,act4 4 #i4 ,additional consumer protections 7a7 ,public ,health ,service ,act ,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 sections3 #bgcj4 ,continuity of care 7a7 ,ensuring continuity of care with respect to terminations of certain contractual relationships resulting in changes in provider network status 7#a7 ,in general ,in the case of an individual with benefits under a group health plan or group or individual health insurance coverage offered by a health insurance issuer and with respect to a health care provider or facility that has a contractual relationship with such plan or such issuer 7as applicable7 for furnishing items and services under such plan or such coverage1 if1 while such individual is a continuing care patient 7as defined in subsection 7b77 with respect to such provider or facility-- 7,a7 such contractual relationship is terminated 7as defined in subsection 7b772 7,b7 benefits provided under such plan or such health insurance coverage with respect to such provider or facility are terminated because of a change in the terms of the participation of such provider or facility in such plan or coverage2 or 7,c7 a contract between such group health plan and a health insurance issuer offering health insurance coverage in connection with such plan is terminated1 resulting in a loss of benefits provided under such plan with respect to such provider or facility2 the plan or issuer1 respectively1 shall meet the requirements of paragraph 7#b7 with respect to such individual4 7#b7 ,requirements ,the requirements of this paragraph are that the plan or issuer-- 7,a7 notify each individual enrolled under such plan or coverage who is a continuing care patient with respect to a provider or facility at the time of a termination described in paragraph 7#a7 affecting such provider or facility on a timely basis of such termination and such individual's right to elect continued transitional care from such provider or facility under this section2 7,b7 provide such individual with an opportunity to notify the plan or issuer of the individual's need for transitional care2 and 7,c7 permit the patient to elect to continue to have benefits provided under such plan or such coverage1 under the same terms and conditions as would have applied and with respect to such items and services as would have been covered under such plan or coverage had such termination not occurred1 with respect to the course of treatment furnished by such provider or facility relating to such individual's status as a continuing care patient during the period beginning on the date on which the notice under subparagraph 7,a7 is provided and ending on the earlier of-- 7i7 the #ij-;day period beginning on such date2 or 7ii7 the date on which such individual is no longer a continuing care patient with respect to such provider or facility4 7b7 ,definitions ,in this section3 7#a7 ,continuing care patient ,the term continuing care patient means an individual who1 with respect to a provider or facility-- 7,a7 is undergoing a course of treatment for a serious and complex condition from the provider or facility2 7,b7 is undergoing a course of institutional or inpatient care from the provider or facility2 7,c7 is scheduled to undergo nonelective surgery from the provider1 including receipt of postoperative care from such provider or facility with respect to such a surgery2 7,d7 is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility2 or 7,e7 is or was determined to be terminally ill 7as determined under section #ahfa7;dd77#c77;,a7 of the ,social ,security ,act7 and is receiving treatment for such illness from such provider or facility4 7#b7 ,serious and complex condition ,the term serious and complex condition means1 with respect to a participant1 beneficiary1 or enrollee under a group health plan or health insurance coverage-- 7,a7 in the case of an acute illness1 a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm2 or 7,b7 in the case of a chronic illness or condition1 a condition that is-- 7i7 is life-threatening1 degenerative1 potentially disabling1 or congenital2 and 7ii7 requires specialized medical care over a prolonged period of time4 7#c7 ,terminated ,the term terminated includes1 with respect to a contract1 the expiration or nonrenewal of the contract1 but does not include a termination of the contract for failure to meet applicable quality standards or for fraud4 #bgca4 ,information required to be included on health insurance membership cards ,in the case of a group health plan or health insurance issuer offering group or individual health insurance coverage that provides a physical or electronic card indicating membership in such plan or coverage to an individual enrolled under such plan or coverage1 such group health plan or issuer shall include on such card each of the following3 7#a7 ,the nearest hospital to the primary residence of such individual that has in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage4 7#b7 ,a telephone number or ,internet website address through which such individual may seek consumer assistance information1 such as information related to hospitals and urgent care facilities that have in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage4 7#c7 ,any deductible applicable to such individual4 7#d7 ,any out-of-pocket maximum applicable to such individual4 7#e7 ,any cost-sharing obligation applicable to such individual for a visit at an emergency department1 or urgent care facility1 that has in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage4 #bgcb4 ,maintenance of price comparison tool ,in connection with the offering of a group health plan or group or individual health insurance coverage in a geographic region for a plan year1 a plan sponsor or health insurance issuer1 respectively1 shall employ an individual to offer price comparison guidance1 or make available on an ,internet website a price comparison tool1 that 7to the extent practicable7 allows an individual enrolled under such plan or coverage1 with respect to such plan year and such geographic region1 to compare the amount 7determined by historic claims data of participating providers with respect to such plan or coverage7 of cost-sharing 7including deductibles1 copayments1 and coinsurance7 that the individual would be responsible for paying under such plan or coverage with respect to the furnishing of a specific item or service by any such provider4 4 7b7 ,internal ,revenue ,code 7#a7 ,in general ,subchapter ,b of chapter #ajj of the ,internal ,revenue ,code of #aihf1 as amended by the previous sections1 is further amended by adding at the end the following new sections3 #ihag4 ,continuity of care 7a7 ,ensuring continuity of care with respect to terminations of certain contractual relationships resulting in changes in provider network status 7#a7 ,in general ,in the case of an individual with benefits under a group health plan and with respect to a health care provider or facility that has a contractual relationship with such plan for furnishing items and services under such plan1 if1 while such individual is a continuing care patient 7as defined in subsection 7b77 with respect to such provider or facility-- 7,a7 such contractual relationship is terminated 7as defined in paragraph 7b772 7,b7 benefits provided under such plan with respect to such provider or facility are terminated because of a change in the terms of the participation of such provider or facility in such plan2 or 7,c7 a contract between such group health plan and a health insurance issuer offering health insurance coverage in connection with such plan is terminated1 resulting in a loss of benefits provided under such plan with respect to such provider or facility2 the plan shall meet the requirements of paragraph 7#b7 with respect to such individual4 7#b7 ,requirements ,the requirements of this paragraph are that the plan-- 7,a7 notify each individual enrolled under such plan who is a continuing care patient with respect to a provider or facility at the time of a termination described in paragraph 7#a7 affecting such provider on a timely basis of such termination and such individual's right to elect continued transitional care from such provider or facility under this section2 7,b7 provide such individual with an opportunity to notify the plan of the individual's need for transitional care2 and 7,c7 permit the patient to elect to continue to have benefits provided under such plan1 under the same terms and conditions as would have applied and with respect to such items and services as would have been covered under such plan had such termination not occurred1 with respect to the course of treatment furnished by such provider or facility relating to such individual's status as a continuing care patient during the period beginning on the date on which the notice under subparagraph 7,a7 is provided and ending on the earlier of-- 7i7 the #ij-;day period beginning on such date2 or 7ii7 the date on which such individual is no longer a continuing care patient with respect to such provider or facility4 7b7 ,definitions ,in this section3 7#a7 ,continuing care patient ,the term continuing care patient means an individual who1 with respect to a provider or facility-- 7,a7 is undergoing a course of treatment for a serious and complex condition from the provider or facility2 7,b7 is undergoing a course of institutional or inpatient care from the provider or facility2 7,c7 is scheduled to undergo nonelective surgery from the provider or facility1 including receipt of postoperative care from such provider or facility with respect to such a surgery2 7,d7 is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility2 or 7,e7 is or was determined to be terminally ill 7as determined under section #ahfa7;dd77#c77;,a7 of the ,social ,security ,act7 and is receiving treatment for such illness from such provider or facility4 7#b7 ,serious and complex condition ,the term serious and complex condition means1 with respect to a participant1 beneficiary1 or enrollee under a group health plan-- 7,a7 in the case of an acute illness1 a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm2 or 7,b7 in the case of a chronic illness or condition1 a condition that-- 7i7 is life-threatening1 degenerative1 potentially disabling1 or congenital2 and 7ii7 requires specialized medical care over a prolonged period of time4 7#c7 ,terminated ,the term terminated includes1 with respect to a contract1 the expiration or nonrenewal of the contract1 but does not include a termination of the contract for failure to meet applicable quality standards or for fraud4 #ihah4 ,information required to be included on health insurance membership cards ,in the case of a group health plan that provides a physical or electronic card indicating membership in such plan to an individual enrolled under such plan1 such group health plan shall include on such card each of the following3 7#a7 ,the nearest hospital to the primary residence of such individual that has in effect a contractual relationship with such plan for furnishing items and services under such plan4 7#b7 ,a telephone number or ,internet website address through which such individual may seek consumer assistance information1 such as information related to hospitals and urgent care facilities that have in effect a contractual relationship with such plan for furnishing items and services under such plan4 7#c7 ,any deductible applicable to such individual4 7#d7 ,any out-of-pocket maximum applicable to such individual4 7#e7 ,any cost-sharing obligation applicable to such individual for a visit at an emergency department1 or urgent care facility1 that has in effect a contractual relationship with such plan for furnishing items and services under such plan4 #ihai4 ,maintenance of price comparison tool ,in connection with the offering of a group health plan in a geographic region for a plan year1 a plan sponsor shall employ an individual to offer price comparison guidance1 or make available on an ,internet website a price comparison tool1 that 7to the extent practicable7 allows an individual enrolled under such plan1 with respect to such plan year and such geographic region1 to compare the amount 7determined by historic claims data of participating providers with respect to such plan7 of cost-sharing 7including deductibles1 copayments1 and coinsurance7 that the individual would be responsible for paying under such plan with respect to the furnishing of a specific item or service by any such provider4 4 7#b7 ,conforming amendment ,section #ihae7;a7 of the ,internal ,revenue ,code of #aihf1 as amended by section #b7;b71 is further amended-- 7,a7 in paragraph 7#a71 by striking section #bgai;,a and inserting section #bgai;,a1 #bgcj1 #bgca1 or #bgcb2 and 7,b7 in paragraph 7#b71 by striking section #bgai;,a and inserting section #bgai;,a1 #bgcj1 #bgca1 or #bgcb4 7#c7 ,clerical amendment ,the table of sections for such subchapter1 as amended by section #b7;b71 is further amended by adding at the end the following new items3 ,sec4 #ihag4 ,continuity of care4 ,sec4 #ihah4 ,information required to be included on health insurance membership cards4 ,sec4 #ihai4 ,maintenance of price comparison tool4 4 7c7 ,employee ,retirement ,income ,security ,act 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 seq471 as amended by section #b7;c71 is further amended by adding at the end the following new sections3 #gag4 ,continuity of care 7a7 ,ensuring continuity of care with respect to terminations of certain contractual relationships resulting in changes in provider network status 7#a7 ,in general ,in the case of an individual with benefits under a group health plan or health insurance coverage offered by a health insurance issuer in connection with a group health plan and with respect to a health care provider or facility that has a contractual relationship with such plan or such issuer 7as applicable7 for furnishing items and services under such plan or such coverage1 if1 while such individual is a continuing care patient 7as defined in subsection 7b77 with respect to such provider or facility-- 7,a7 such contractual relationship is terminated 7as defined in paragraph 7b772 7,b7 benefits provided under such plan or such health insurance coverage with respect to such provider or facility are terminated because of a change in the terms of the participation of the provider or facility in such plan or coverage2 or 7,c7 a contract between such group health plan and a health insurance issuer offering health insurance coverage in connection with such plan is terminated1 resulting in a loss of benefits provided under such plan with respect to such provider or facility2 the plan or issuer1 respectively1 shall meet the requirements of paragraph 7#b7 with respect to such individual4 7#b7 ,requirements ,the requirements of this paragraph are that the plan or issuer-- 7,a7 notify each individual enrolled under such plan or coverage who is a continuing care patient with respect to a provider or facility at the time of a termination described in paragraph 7#a7 affecting such provider or facility on a timely basis of such termination and such individual's right to elect continued transitional care from such provider or facility under this section2 7,b7 provide such individual with an opportunity to notify the plan or issuer of the individual's need for transitional care2 and 7,c7 permit the patient to elect to continue to have benefits provided under such plan or such coverage1 under the same terms and conditions as would have applied and with respect to such items and services as would have been covered under such plan or coverage had such termination not occurred1 with respect to the course of treatment furnished by such provider or facility relating to such individual's status as a continuing care patient during the period beginning on the date on which the notice under subparagraph 7,a7 is provided and ending on the earlier of-- 7i7 the #ij-;day period beginning on such date2 or 7ii7 the date on which such individual is no longer a continuing care patient with respect to such provider or facility4 7b7 ,definitions ,in this section3 7#a7 ,continuing care patient ,the term continuing care patient means an individual who1 with respect to a provider or facility-- 7,a7 is undergoing a course of treatment for a serious and complex condition from the provider or facility2 7,b7 is undergoing a course of institutional or inpatient care from the provider or facility2 7,c7 is scheduled to undergo nonelective surgery from the provide or facility1 including receipt of postoperative care from such provider or facility with respect to such a surgery2 7,d7 is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility2 or 7,e7 is or was determined to be terminally ill 7as determined under section #ahfa7;dd77#c77;,a7 of the ,social ,security ,act7 and is receiving treatment for such illness from such provider or facility4 7#b7 ,serious and complex condition ,the term serious and complex condition means1 with respect to a participant1 beneficiary1 or enrollee under a group health plan or health insurance coverage-- 7,a7 in the case of an acute illness1 a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm2 or 7,b7 in the case of a chronic illness or condition1 a condition that-- 7i7 is life-threatening1 degenerative1 potentially disabling1 or congenital2 and 7ii7 requires specialized medical care over a prolonged period of time4 7#c7 ,terminated ,the term terminated includes1 with respect to a contract1 the expiration or nonrenewal of the contract1 but does not include a termination of the contract for failure to meet applicable quality standards or for fraud4 #gah4 ,information required to be included on health insurance membership cards ,in the case of a group health plan or health insurance issuer offering group health insurance coverage that provides a physical or electronic card indicating membership in such plan or coverage to an individual enrolled under such plan or coverage1 such group health plan or issuer shall include on such card each of the following3 7#a7 ,the nearest hospital to the primary residence of such individual that has in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage4 7#b7 ,a telephone number or ,internet website address through which such individual may seek consumer assistance information1 such as information related to hospitals and urgent care facilities that have in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage4 7#c7 ,any deductible applicable to such individual4 7#d7 ,any out-of-pocket maximum applicable to such individual4 7#e7 ,any cost-sharing obligation applicable to such individual for a visit at an emergency department1 or urgent care facility1 that has in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage4 #gai4 ,maintenance of price comparison tool ,in connection with the offering of a group health plan or group health insurance coverage in a geographic region for a plan year1 a plan sponsor or health insurance issuer1 respectively1 shall employ an individual to offer price comparison guidance1 or make available on an ,internet website a price comparison tool1 that 7to the extent practicable7 allows an individual enrolled under such plan or coverage1 with respect to such plan year and such geographic region1 to compare the amount 7determined by historic claims data of participating providers with respect to such plan or coverage7 of cost-sharing 7including deductibles1 copayments1 and coinsurance7 that the individual would be responsible for paying under such plan or coverage with respect to the furnishing of a specific item or service by any such provider4 4 7#b7 ,conforming amendment ,section #gae7;a7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aahe;d7a771 as amended by section #b7;c71 is further amended-- 7,a7 in paragraph 7#a71 by striking section #bgai;,a and inserting section #bgai;,a1 #bgcj1 #bgca1 or #bgcb2 and 7,b7 in paragraph 7#b71 by striking section #bgai;,a and inserting section #bgai;,a1 #bgcj1 #bgca1 or #bgcb4 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 #gaf the following new items3 ,sec4 #gag4 ,continuity of care4 ,sec4 #gah4 ,information required to be included on health insurance membership cards4 ,sec4 #gai4 ,maintenance of price comparison tool4 4 7d7 ,effective date ,the amendments made by this section shall apply with respect to plan years beginning on or after ,january #a1 #bjbb4 #aj4 ,reporting requirements regarding air ambulance services 7a7 ,reporting requirements for providers of air ambulance services 7#a7 ,in general ,a provider of air ambulance services shall submit to the ,secretary of ,health and ,human ,services and the ,secretary of ,transportation-- 7,a7 not later than the date that is #ij days after the last day of the first plan year beginning on or after the date on which a final rule is promulgated pursuant to the rulemaking described in subsection 7d71 the information described in paragraph 7#b7 with respect to such plan year2 and 7,b7 not later than the date that is #ij days after the last day of the plan year immediately succeeding the plan year described in subparagraph 7,a71 such information with respect to such immediately succeeding plan year4 7#b7 ,information described ,for purposes of paragraph 7#a71 information described in this paragraph1 with respect to a provider of air ambulance services1 is each of the following3 7,a7 ,cost data1 as determined appropriate by the ,secretary of ,health and ,human ,services1 in consultation with the ,secretary of ,transportation1 for air ambulance services furnished by such provider1 separated to the maximum extent possible by air transportation costs associated with furnishing such air ambulance services and costs of medical services and supplies associated with furnishing such air ambulance services4 7,b7 ,the number and location of all air ambulance bases operated by such provider4 7,c7 ,the number and type of aircraft operated by such provider4 7,d7 ,the number of air ambulance transports1 disaggregated by payor mix1 including group health plans1 health insurance issuers1 and ,government payors4 7,e7 ,the number of claims of such provider that have been denied payment by a group health plan or health insurance issuer and the reasons for any such denials4 7,f7 ,the number of emergency and nonemergency air ambulance transports1 disaggregated by air ambulance base and type of aircraft4 7b7 ,reporting requirements for group health plans and health insurance issuers 7#a7 ,in general ,each group health plan and health insurance issuer offering health insurance coverage in the individual or group market shall submit to the ,secretary of ,health and ,human ,services-- 7,a7 not later than the date that is #ij days after the last day of the first plan year beginning on or after the date on which a final rule is promulgated pursuant to the rulemaking described in subsection 7d71 the information described in paragraph 7#b7 with respect to such plan year2 and 7,b7 not later than the date that is #ij days after the last day of the plan year immediately succeeding the plan year described in subparagraph 7,a71 such information with respect to such immediately succeeding plan year4 7#b7 ,information described ,for purposes of paragraph 7#a71 information described in this paragraph1 with respect to a group health plan or a health insurance issuer offering health insurance coverage in the individual or group market1 is each of the following3 7,a7 ,claims data for air ambulance services furnished by providers of such services1 disaggregated by each of the following factors3 7i7 ,whether such services were furnished on an emergent or nonemergent basis4 7ii7 ,whether the provider of such services is part of a hospital-owned or sponsored program1 municipality-sponsored program1 hospital independent partnership 7hybrid7 program1 or independent program4 7iii7 ,whether such services were furnished in a rural or urban area4 7iv7 ,the type of aircraft 7such as rotor transport or fixed wing transport7 used to furnish such services4 7v7 ,whether the provider of such services has a contract with the plan or issuer1 as applicable1 to furnish such services under the plan or coverage1 respectively4 7,b7 ,such other information regarding providers of air ambulance services as the ,secretary of ,health and ,human ,services may specify4 7c7 ,publication of comprehensive report 7#a7 ,in general ,not later than the date that is one year after the date described in subsection 7b77#a77;,b71 the ,secretary of ,health and ,human ,services1 in consultation with the ,secretary of ,transportation 7referred to in this section as the ,secretaries71 shall develop1 and make publicly available 7subject to paragraph 7#c771 a comprehensive report summarizing the information submitted under subsections 7a7 and 7b7 and including each of the following3 7,a7 ,the percentage of providers of air ambulance services that are part of a hospital-owned or sponsored program1 municipality-sponsored program1 hospital-independent partnership 7hybrid7 program1 or independent program4 7,b7 ,an assessment of the extent of competition among providers of air ambulance services on the basis of price and services offered1 and any changes in such competition over time4 7,c7 ,an assessment of the average charges for air ambulance services1 amounts paid by group health plans and health insurance issuers offering health insurance coverage in the individual or group market to providers of air ambulance services for furnishing such services1 and amounts paid out-of-pocket by consumers1 and any changes in such amounts paid over time4 7,d7 ,an assessment of the presence of air ambulance bases in1 or with the capability to serve1 rural areas1 and the relative growth in air ambulance bases in rural and urban areas over time4 7,e7 ,any evidence of gaps in rural access to providers of air ambulance services4 7,f7 ,the percentage of providers of air ambulance services that have contracts with group health plans or health insurance issuers offering health insurance coverage in the individual or group market to furnish such services under such plans or coverage1 respectively4 7,g7 ,an assessment of whether there are instances of unfair1 deceptive1 or predatory practices by providers of air ambulance services in collecting payments from patients to whom such services are furnished1 such as referral of such patients to collections1 lawsuits1 and liens or wage garnishment actions4 7,h7 ,an assessment of whether there are instances of group health plans or health insurance issuers not providing substantial reasons for refusing to enter into contract negotiations with providers of air ambulance services4 7,i7 ,an assessment of whether there are1 within the air ambulance industry1 instances of unreasonable industry concentration1 excessive market domination1 or other conditions that would allow at least one provider of air ambulance services to unreasonably increase prices or exclude competition in air ambulance services in a given geographic region4 7,j7 ,an assessment of the frequency of patient balance billing1 patient referrals to collections1 lawsuits to collect balance bills1 and liens or wage garnishment actions by providers of air ambulance services as part of a collections process across hospital-owned or sponsored programs1 municipality-sponsored programs1 hospital-independent partnership 7hybrid7 programs1 or independent programs1 providers of air ambulance services operated by public agencies 7such as a ,state or county health department71 and other independent providers of air ambulance services4 7,k7 ,an assessment of the frequency of claims appeals made by providers of air ambulance services to group health plans or health insurance issuers offering health insurance coverage in the individual or group market with respect to air ambulance services furnished to enrollees of such plans or coverage1 respectively4 7,l7 ,any other cost1 quality1 or other data relating to air ambulance services or the air ambulance industry1 as determined necessary and appropriate by the ,secretaries4 7#b7 ,other sources of information ,the ,secretaries may incorporate information from independent experts or third-party sources in developing the comprehensive report required under paragraph 7#a74 7#c7 ,protection of proprietary information ,the ,secretaries may not make publicly available under this subsection any proprietary information4 7d7 ,rulemaking ,not later than the date that is one year after the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services1 in consultation with the ,secretary of ,transportation1 shall1 through notice and comment rulemaking1 specify the form and manner in which reports described in subsections 7a7 and 7b7 shall be submitted to such ,secretaries1 taking into consideration 7as applicable and to the extent feasible7 any recommendations included in the report submitted by the ,advisory ,committee on ,air ,ambulance and ,patient ,billing under section #dah7;e7 of the ,,faa ,reauthorization ,act of #bjah 7,public ,law #aae-bed2 #di ,u4,s4,c4 #dbcja note prec474 7e7 ,civil money penalties 7#a7 ,in general ,subject to paragraph 7#b71 a provider of air ambulance services who fails to submit all information required under subsection 7a77#b7 by the date described in subparagraph 7,a7 or 7,b7 of subsection 7a77#a71 as applicable1 shall be subject to a civil money penalty of not more than #aj1jjj4 7#b7 ,exception ,in the case of a provider of air ambulance services that submits only some of the information required under subsection 7a77#b7 by the date described in subparagraph 7,a7 or 7,b7 of subsection 7a77#a71 as applicable1 the ,secretary of ,health and ,human ,services may waive the civil money penalty imposed under paragraph 7#a7 if such provider demonstrates a good faith effort in working with the ,secretary to submit the remaining information required under subsection 7a77#b74 7#c7 ,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#a71 shall apply to civil money penalties under this subsection in the same manner as such provisions apply to a penalty or proceeding under such section4 7f7 ,unfair and deceptive practices and unfair methods of competition ,the ,secretary of ,transportation may use any information submitted under subsection 7a7 in determining whether a provider of air ambulance services has violated section #dagab7;a7 of title #di1 ,united ,states ,code4 7g7 ,understanding air ambulance quality and patient safety ,not later than #a year after the date of the enactment of this ,act1 the ,comptroller ,general of the ,united ,states shall conduct a study and submit to ,congress a report on options to establish quality1 patient safety1 service reliability1 and clinical capability standards for each clinical capability level of air ambulances4 ,such report shall include analysis and recommendations1 as appropriate1 to ,congress regarding each of the following with respect to air ambulance services3 7#a7 ,qualifications of different clinical capability levels and tiering of such levels4 7#b7 ,patient safety and quality standards4 7#c7 ,options for improving service reliability during poor weather1 night conditions1 or other adverse conditions4 7#d7 ,differences between air ambulance vehicle types1 services1 and technologies1 and other flight capability standards1 and the impact of such differences on patient safety4 7#e7 ,clinical triage criteria for air ambulances4 7h7 ,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 #aa4 ,,gao report on effects of legislation ,not later than #b years after the date of the enactment of this ,act1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report summarizing the effects of the provisions of this ,act1 including the amendments made by such provisions1 on changes during such period in health care provider networks of group health plans and health insurance coverage offered by a health insurance issuer in the group or individual market1 in fee schedules and amounts for health care services1 and to contracted rates under such plans or coverage4 ,such report shall-- 7#a7 to the extent practicable1 sample a statistically significant group of national health care providers2 and 7#b7 examine-- 7,a7 provider network participation1 including nonparticipating providers furnishing items and services at participating facilities2 7,b7 health care provider group network participation1 including specialty1 size1 and ownership2 and 7,c7 the impact of ,state surprise billing laws and network adequacy standards on participation of health care providers and facilities in provider networks of group health plans and of health insurance coverage offered by health insurance issuers in the group or individual market4 #ab4 ,transitional rule allowing deduction for surprise billing expenses below ,,agi floor 7a7 ,in general ,section #bac of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subsection3 7g7 ,transitional rule allowing deduction for surprise billing expenses below ,,agi floor 7#a7 ,in general ,in addition to the deduction allowed by subsection 7a7 for any taxable year1 there shall be allowed as a deduction an amount equal to the lesser of-- 7,a7 the excess of-- 7i7 the surprise billing expenses which would be allowed as a deduction for such taxable year under subsection 7a7 if such subsection were applied without regard to the limitation based on the taxpayer's adjusted gross income1 over 7ii7 #fjj1 or 7,b7 the applicable percentage of the taxpayer's adjusted gross income4 7#b7 ,surprise billing expenses ,for purposes of this subsection1 the term surprise billing expenses means expenses paid for medical care of an individual who is a participant1 beneficiary1 or enrollee in a group health plan or in group or individual health insurance coverage offered by a health insurance issuer 7as such terms are defined in section #bgia of the ,public ,health ,service ,act71 if-- 7,a7 benefits are provided for such medical care under such plan or coverage1 and 7,b7 such medical care-- 7i7 is furnished by a provider without a contractual relationship with such plan or coverage with respect to the furnishing of such medical care during a visit at a facility with a contractual relationship with such plan or coverage1 or 7ii7 is furnished in an emergency department of a hospital or an independent freestanding emergency department4 7#c7 ,applicable percentage ,for purposes of this section1 the term applicable percentage means1 with respect to any taxpayer for any taxable year1 the percentage in effect under subsection 7a7 with respect to such taxpayer for such taxable year4 7#d7 ,limitations ,surprise billing expenses shall be taken into account under paragraph 7#a7 only if such expenses are paid during the period beginning on ,january #a1 #bjbj1 and ending on the date which is #a year after the day before the date specified in section #b7;a77#e7 of the ,consumer ,protections ,against ,surprise ,medical ,bills ,act of #bjbj4 4 7b7 ,conforming amendments ,sections #aje7;f71 #afb7l77#c71 and #ggjb;,b7e77#b7 of such ,code are each amended by striking #bac7;a7 and inserting #bac4 7c7 ,effective date ,the amendments made by this section shall apply to taxable years ending after ,december #ca1 #bjai4