,i  #aai? ,,congress  #b;d ,session  ,h4
 ,r4 #iaag  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,june #c1 #bjbf,mr4   
,langwor?y introduc$ ! foll[+ bill2 :i* 
0 ref]r$ to ! ,committee on ,en]gy &    
,comm]ce1 & 9 addition to ! ,committees 
on ,education & ,work=ce1 & ,ways &     
,means1 = a p]iod to be subsequ5tly     
det]m9$ by ! ,speak]1 9 ea* case =      
consid]ation ( su* provisions z fall )9 
! jurisdiction ( ! committee conc]n$  ,a
 ,,bill  ,to promote ! availability (   
c]ta9 heal?c>e in=mation1 & = o!r       
purposes4  #a4 ,%ort title ,?is ,act may
 be cit$ z ! ,cle> ,heal?c>e ,exp5se    
,co/ ,k ,act ( #bjbf or ! ,,*eck ,act ( 
#bjbf4  #b4 ,ov]sight ( adm9i/rative    
s]vice provid]s  7a7 ,,erisa am5dm5ts   
7#a7 ,9 g5]al ,subp>t ,b ( "p #g (      
subtitle ,b ( ! ,employee ,retirem5t    
,income ,security ,act ( #aigd 7#bi     
,u4,s4,c4 #ajba et seq47 is am5d$ by    
add+ at ! end ! foll[+3  #gbg4 ,ov]sight
 ( adm9i/rative s]vice provid]s  7a7 ,9 
g5]al ,= plan ye>s beg9n+ on or aft] !  

date t is #b ye>s aft] ! date ( enactm5t
 ( ?is section1 no agreem5t betwe5 a    
gr\p heal? plan 7z def9$ 9 section      
#gcc7;a771 ! plan sponsor ( su* plan 7z 
def9$ 9 section #c7af77;,b771 ! plan    
adm9i/rator ( su* plan 7z def9$ 9       
section #c7af77;,a771 or a bus9ess      
associate ( su* plan 7z def9$ 9 section 
#afj4ajc ( title #de1 ,code ( ,f$]al    
,regulations71 7or heal? insurance issu]
 (f]+ gr\p heal? insurance cov]age 9    
connection ) su* a plan71 & a heal?c>e  
provid]1 network or association (       
provid]s1 ?ird-p>ty adm9i/rator1 s]vice 
provid] (f]+ access to a network (      
provid]s1 ph>macy b5efit manag]s1 or any
 o!r ?ird p>ty 7ea* ref]r$ to z a heal? 
plan s]vice provid]7 is p]missible if   
su* agreem5t limits 7or delays beyond ! 
applicable report+ p]iod describ$ 9     
subsection 7b77#a77 ! disclosure (      
in=mation to gr\p heal? plans 9 su* a   
mann] t prev5ts su* plan1 issu]1 or     
entity f provid+ ! in=mation describ$ 9 
subsection 7b74  7b7 ,requir$           

disclosures  7#a7 ,cont5ts & frequ5cy ,)
 respect to plan ye>s beg9n+ on or aft] 
! date t is #b ye>s aft] ! date (       
enactm5t ( ?is section1 n less frequ5tly
 ?an qu>t]ly1 a heal? plan s]vice       
provid] %all provide to ! gr\p heal?    
plan or heal? insurance issu] ! foll[+  
in=mation at no co/ to ! gr\p heal? plan
 or heal? insurance issu]3 7,a7 ,!      
in=mation describ$ 9 section            
#gbd7;a77#a77;,b74  7,b7 ,any           
contractual & subcontractual calculation
 me?odologies1 pric+ or fee s*$ules1 or 
o!r =mulae us$ to det]m9e reimbursem5t  
am\nts to provid]s & subcontractors1    
includ+ me?odologies1 s*$ules1 fee      
/ructures1 & any appli$ adju/m5ts or    
modifi]s1 ) su* in=mation provid$ 9 a   
mann] suffici5tly detail$ to enable !   
gr\p heal? plan or heal? insurance issu]
 to accurately assess1 v]ify1 & ensure  
compliance ) ! t]ms ( any contractual & 
subcontractual agreem5t gov]n+ !        
reimbursem5t am\nts4  7,c7 ,! total     
am\nt receiv$ or expect$ to be receiv$  

by ! heal? plan s]vice provid] or its   
subcontractors 9 provid] or suppli]     
rebates1 fees1 alt]native disc\nts1 &   
all o!r remun]ation includ+ am\nts held 
9 escr[ or v>iance acc\nts t has be5    
paid or is to be paid = claims incurr$ &
 adm9i/rative s]vices includ+ data sales
 or network paym5ts4  7,d7 ,! total     
am\nt paid or expect$ to be paid by !   
heal? plan s]vice provid] or to         
subcontractors 9 rebates1 fees1         
contractual arrangem5ts1 & all o!r      
remun]ation t has be5 paid or is expect$
 to be paid = adm9i/rative & o!r        
s]vices4  7,e7 ,all paym5t data &       
reconciliation in=mation relat$ to      
alt]native comp5sation arrangem5ts      
includ+ acc\ntable c>e organizations1   
value-bas$ programs1 %>$ sav+s programs1
 inc5tive comp5sation1 bundl$ paym5ts1  
capitation arrangem5ts1 p]=mance        
paym5ts1 & any o!r reimbursem5t or      
paym5t models1 :]e ! gr\p heal? plan or 
heal? insurance issu] paid fees1 incurr$
 obligations1 or made paym5ts 9         

connection ) ! gr\p heal? plan relat$ to
 su* arrangem5ts4  7#b7 ,privacy        
requirem5ts  7,a7 ,9 g5]al ,heal? plan  
s]vice provid]s %all provide ! in=mation
 or data "u p>agraph 7#a7 consi/5t ) !  
privacy1 security1 & brea* notification 
regulations at p>ts #afj & #afd ( title 
#de1 ,code ( ,f$]al ,regulations1       
promulgat$ "u subtitle ,f ( ! ,heal?    
,insurance ,portability & ,acc\ntability
 ,act ( #aiif1 subtitle ,d ( ! ,heal?   
,in=mation ,te*nology = ,cl9ical ,heal? 
,act ( #bjji1 & section #aahj ( !       
,social ,security ,act1 & %all re/rict !
 use & disclosure ( su* in=mation       
accord+ to su* privacy1 security1 &     
brea* notification regulations4 ,an     
entity t receives a disclosure f a p>ty 
9 int]e/ pursuant to subp>agraph 7,b7 or
 7,c7 %all comply ) ! privacy & security
 regulations promulgat$ "u ,,hipaa4     
7,b7 ,re/rictions ,a gr\p heal? plan    
%all comply ) section #afd4ejd7;f7 (    
title #de1 ,code ( ,f$]al ,regulations  
7or a successor regulation71 & a plan   

sponsor %all act 9 accordance ) ! t]ms (
 ! agreem5t describ$ 9 su* section4     
7,c7 ,rule ( con/ruction ,no?+ 9 ?is    
section %all be con/ru$ to modify !     
requirem5ts = ! creation1 receipt1      
ma9t5ance1 or transmission ( protect$   
heal? in=mation "u ! ,,hipaa privacy    
regulations 7#de ,c4,f4,r4 p>ts #afj &  
#afd1 subp>ts ,a & ,e74  7#c7           
,disclosure & r$isclosure  7,a7 ,9 g5]al
 ,a gr\p heal? plan receiv+ in=mation "u
 p>agraph 7#a7 may disclose su*         
in=mation only--  7i7 to ! entity f :i* 
! in=mation 0 receiv$ or to t entity's  
bus9ess associates or to ! gr\p heal?   
plan's bus9ess associates z def9$ 9     
section #afj4ajc ( title #de1 ,code (   
,f$]al ,regulations 7or successor       
regulations72 or  7ii7 z p]mitt$ by !   
,,hipaa ,privacy ,rule 7#de ,c4,f4,r4   
p>ts #afj & #afd1 subp>ts ,a & ,e74     
7,b7 ,availability ( in=mation ,to !    
ext5t ! in=mation requir$ by ?is        
subsection is made available to ! heal? 
insurance issu] (f]+ gr\p heal?         

insurance 9 connection ) a gr\p heal?   
plan1 ! heal? insurance issu] %all make 
su* in=mation available1 at ! same "t1 9
 ! same =mat1 & at no co/1 to ! gr\p    
heal? plan4  7,c7 ,failure to provide ,!
 obligation to provide in=mation        
pursuant to ?is subsection %all exi/    
not)/&+ ! pres5ce ( any =mal data-%>+   
agreem5t betwe5 ! p>ties4 ,failure to   
provide ! requir$ in=mation z specifi$  
%all con/itute a violation ( ?is ,act & 
! ,secret>y %all initiate en=cem5t      
action "u section #ejb )9 #ij days (    
becom+ aw>e ( a violation ( ?is section1
 except t no?+ 9 ?is section %all be    
con/ru$ to limit ! ,secret>y's exi/+    
au?ority "u ! ,act4  7#d7 ,data =mat    
/&>ds ,all data & in=mation provid$     
pursuant to ?is subsection %all comply )
 ! foll[+ /&>ds3 7,a7 ,all claims f a   
heal?c>e provid] %all be made to ! gr\p 
heal? plan 9 accordance ) transactions  
/&>ds adopt$ "u ,,hipaa1 z foll[s3  7i7 
,in/itutional1 pr(essional1 & d5tal     
claims & adju/m5ts to ^! claims %all be 

9 ,,asc ,x#ab,n #hcg =mat1 z transmitt$ 
by ! provid]1 or1 9 ! case ( pap]       
claims1 conv]t$ to ! ,,asc ,x#ab,n #hcg 
electronic =mat4  7ii7 ,prescription    
drug claims %all be 9 ! ,national       
,c\ncil = ,prescription ,drug ,programs 
7,,ncpdp7 =mat1 z transmitt$ by !       
provid]1 or 9 ! case ( pap] claims1     
conv]t$ to ! ,,ncpdp electronic =mat4   
7iii7 ,su* data %all be provid$ at no   
co/ to ! gr\p heal? plan4  7,b7 ,all    
claim paym5t 7or ,,eft1 electronic funds
 transf]7 & electronic remittance advice
 7,,era7 in=mation s5t by a heal? plan  
s]vice provid] %all be provid$ to ! gr\p
 heal? plan or heal? insurance issu] 9 !
 ,,asc ,x#ab,n #hce =mat 9 accordance ) 
transaction /&>ds adopt$ "u ,,hipaa1    
unmodifi$ f ! =m 9 :i* x 0 transmitt$ to
 ! heal?c>e provid]4 ,su* in=mation %all
 be provid$ at no co/ to ! gr\p heal?   
plan or heal? insurance issu]4  7,c7 ,! 
,secret>y may modify ! /&>ds set =? 9   
?is p>agraph z necess>y to align ) any  
*anges adopt$ by ! ,secret>y ( ,heal? & 

,human ,s]vices pursuant to ! au?ority  
provid$ "u section #aagc ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#acbj;d-#b74  7c7 ,prohibit$ contractual
 provisions ,any provision 9 an agreem5t
 betwe5 a gr\p heal? plan1 ! plan       
sponsor1 ! plan adm9i/rator1 or a       
bus9ess associate ( su* plan or a heal? 
insurance issu] & a heal? plan s]vice   
provid] t unduly delays or limits a gr\p
 heal? plan's or heal? insurance issu]'s
 access to in=mation describ$ 9 ?is     
section or t re/ricts ! =mat or tim+ ( !
 provision ( su* in=mation 9 a mann] t  
is inconsi/5t ) ! requirem5ts ( ?is     
section %all be prohibit$ &1 if a gr\p  
heal? plan or heal? insurance issu]     
ent]s into su* agreem5t1 %all be deem$  
void z aga9/ public policy4  7d7        
,p5alties = non-,compliance ,any failure
 by a heal? plan s]vice provid] to      
comply ) ! requirem5ts ( ?is section    
%all result 9 ! imposition ( a civil    
p5alty ( #ajj1jjj = ea* day ! violation 
cont9ues1 9 addition to any o!r p5alties

 prescrib$ by law4  7e7 ,regulations ,! 
,secret>y %all implem5t ?is section     
?r\gh notice & comm5t rulemak+ 9        
accordance ) section #eec ( title #e1   
,unit$ ,/ates ,code4  4  7#b7 ,p5alty   
7,a7 ,9 g5]al ,section #ejb7;a7 ( !     
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4 #aacb7;a77  
is am5d$ by add+ at ! end ! foll[+ new  
p>agraph3  7#ad7 ,! ,secret>y may assess
 a civil p5alty aga9/ any p]son (       
#ajj1jjj p] day = ea* violation by any  
p]son ( section #gbf4  4  7,b7 ,te*nical
 am5dm5t ,p>agraph 7#f7 ( section       
#ejb7;a7 ( ! ,employee ,retirem5t       
,income ,security ,act ( #aigd 7#bi     
,u4,s4,c4 #aacb7;a77 is am5d$ by /rik+  
or 7#i7 & ins]t+ x ) ! phrase 7#i71     
7#ac71 or 7#ad74  7b7 ,,phsa am5dm5ts   
7#a7 ,9 g5]al ,"p ,d ( title ,,xxvii ( !
 ,public ,heal? ,s]vice ,act 7#db       
,u4,s4,c4 #cjj;gg-#aaa et seq47 is am5d$
 by add+ at ! end ! foll[+3             
#bgii;,a-#ab4 ,ov]sight ( adm9i/rative  
s]vice provid]s  7a7  ,9 g5]al  ,= plan 

ye>s beg9n+ on or aft] ! date t is #a   
ye> aft] ! date ( enactm5t ( ?is        
section1 no agreem5t betwe5 a gr\p heal?
 plan t is a self-fund$1 non-,f$]al     
gov]nm5tal plan1 z def9$ 9 section      
#bgia7;d77#h77;,c7 7#db ,u4,s4,c4       
#cjj;gg-#ia7;d77#h77;,c771 & a heal?c>e 
provid]1 network or association (       
provid]s1 ?ird-p>ty adm9i/rator1 s]vice 
provid] (f]+ access to a network (      
provid]s1 ph>macy b5efit manag]s1 or any
 o!r ?ird p>ty 7ea* ref]r$ to 9 ?is     
section z a heal? plan s]vice provid]7  
is p]missible if su* agreem5t limits 7or
 delays beyond ! applicable report+     
p]iod describ$ 9 subsection 7b77#a77 !  
disclosure ( in=mation to gr\p heal?    
plans 9 su* a mann] t prev5ts su* plan1 
issu]1 or entity f provid+ ! in=mation  
describ$ 9 subsection 7b74  7b7 ,requir$
 disclosures  7#a7 ,cont5ts & frequ5cy  
,) respect to plan ye>s beg9n+ on or    
aft] ! date t is #a ye> aft] ! date (   
enactm5t ( ?is section1 n less frequ5tly
 ?an qu>t]ly1 a heal? plan s]vice       

provid] %all provide to ! gr\p heal?    
plan t is a self-fund$1 non-,f$]al      
gov]nm5tal plan ! foll[+ in=mation at no
 co/ to ! plan3 7,a7 ,! in=mation       
describ$ 9 section                      
#bgii;,a-#i7;a77#a77;,b7 7#db ,u4,s4,c4 
#cjj;gg-#aai7;a77#a77;,b774  7,b7 ,any  
contractual & subcontractual calculation
 me?odologies1 pric+ or fee s*$ules1 or 
o!r =mulae us$ to det]m9e reimbursem5t  
am\nts to provid]s & subcontractors1    
includ+ me?odologies1 s*$ules1 fee      
/ructures1 & any appli$ adju/m5ts or    
modifi]s1 ) su* in=mation provid$ 9 a   
mann] suffici5tly detail$ to enable !   
gr\p heal? plan to accurately assess1   
v]ify1 & ensure compliance ) ! t]ms (   
any contractual & subcontractual        
agreem5t gov]n+ ! reimbursem5t am\nts4  
7,c7 ,! total am\nt receiv$ or expect$  
to be receiv$ by ! heal? plan s]vice    
provid] or its subcontractors 9 provid] 
or suppli] rebates1 fees1 alt]native    
disc\nts1 & all o!r remun]ation includ+ 
am\nts held 9 escr[ or v>iance acc\nts t

 has be5 paid or is to be paid = claims 
incurr$ & adm9i/rative s]vices includ+  
data sales or network paym5ts4  7,d7 ,! 
total am\nt paid or expect$ to be paid  
by ! heal? plan s]vice provid] or to    
subcontractors 9 rebates1 fees1         
contractual arrangem5ts1 & all o!r      
remun]ation t has be5 paid or is expect$
 to be paid = adm9i/rative & o!r        
s]vices4  7,e7 ,all paym5t data &       
reconciliation in=mation relat$ to      
alt]native comp5sation arrangem5ts      
includ+ acc\ntable c>e organizations1   
value-bas$ programs1 %>$ sav+s programs1
 inc5tive comp5sation1 bundl$ paym5ts1  
capitation arrangem5ts1 p]=mance        
paym5ts1 & any o!r reimbursem5t or      
paym5t models1 :]e ! gr\p heal? plan    
paid fees1 incurr$ obligations1 or made 
paym5ts 9 connection ) ! gr\p heal? plan
 relat$ to su* arrangem5ts4  7#b7       
,privacy requirem5ts  7,a7 ,9 g5]al     
,heal? plan s]vice provid]s %all provide
 ! in=mation or data "u p>agraph 7#a7   
consi/5t ) ! privacy1 security1 & brea* 

notification regulations at p>ts #afj & 
#afd ( title #de1 ,code ( ,f$]al        
,regulations1 promulgat$ "u subtitle ,f 
( ! ,heal? ,insurance ,portability &    
,acc\ntability ,act ( #aiif1 subtitle ,d
 ( ! ,heal? ,in=mation ,te*nology =     
,cl9ical ,heal? ,act ( #bjji1 & section 
#aahj ( ! ,social ,security ,act1 & %all
 re/rict ! use & disclosure ( su*       
in=mation accord+ to su* privacy1       
security1 & brea* notification          
regulations4 ,an entity t receives a    
disclosure f a p>ty 9 int]e/ pursuant to
 subp>agraph 7,b7 or 7,c7 %all comply ) 
! privacy & security regulations        
promulgat$ "u ,,hipaa4  7,b7            
,re/rictions ,a gr\p heal? plan t is a  
self-fund$1 non-,f$]al gov]nm5tal plan  
%all comply ) section #afd4ejd7;f7 (    
title #de1 ,code ( ,f$]al ,regulations  
7or a successor regulation71 & a plan   
sponsor %all act 9 accordance ) ! t]ms (
 ! agreem5t describ$ 9 su* section4     
7,c7 ,rule ( con/ruction ,no?+ 9 ?is    
section %all be con/ru$ to modify !     

requirem5ts = ! creation1 receipt1      
ma9t5ance1 or transmission ( protect$   
heal? in=mation "u ! ,,hipaa privacy    
regulations 7#de ,c4,f4,r4 p>ts #afj &  
#afd1 subp>ts ,a & ,e74  7#c7           
,disclosure & r$isclosure  7,a7 ,9 g5]al
 ,a gr\p heal? plan t is a self-fund$1  
non-,f$]al gov]nm5tal plan receiv+      
in=mation "u p>agraph 7#a7 may disclose 
su* in=mation only--  7i7 to ! entity f 
:i* ! in=mation 0 receiv$ or to t       
entity's bus9ess associates z def9$ 9   
section #afj4ajc ( title #de1 ,code (   
,f$]al ,regulations 7or successor       
regulations72 or  7ii7 z p]mitt$ by !   
,,hipaa ,privacy ,rule 7#de ,c4,f4,r4   
p>ts #afj & #afd1 subp>ts ,a & ,e74     
7,b7 ,rule ( con/ruction ,no?+ 9 ?is    
section %all be con/ru$ to prev5t a gr\p
 heal? plan t is a self-fund$1          
non-,f$]al gov]nm5tal plan1 or a heal?  
plan s]vice provid] provid+ s]vices )   
respect to su* a plan1 f plac+          
reasonable re/rictions on ! public      
disclosure ( ! in=mation describ$ 9     

p>agraph 7#a71 except t su* plan or     
entity may n re/rict disclosure ( su*   
in=mation to ! ,dep>tm5t ( ,heal? &     
,human ,s]vices1 ! ,dep>tm5t ( ,labor1 !
 ,dep>tm5t ( ! ,treasury1 or !          
,comptroll] ,g5]al ( ! ,unit$ ,/ates4   
7,c7 ,failure to provide ,! obligation  
to provide in=mation pursuant to ?is    
subsection %all exi/ not)/&+ ! pres5ce (
 any =mal data-%>+ agreem5t betwe5 !    
p>ties4 ,failure to provide ! requir$   
in=mation z specifi$ %all con/itute a   
violation ( ?is ,act & ! ,secret>y %all 
initiate en=cem5t action "u section     
#bgbc7;b7 7#db ,u4,s4,c4                
#cjj;gg-#bb7;b77 )9 #ij days ( becom+   
aw>e ( a violation ( ?is section1 except
 t no?+ 9 ?is section %all be con/ru$ to
 limit ! ,secret>y's exi/+ au?ority "u  
?is ,act4  7#d7 ,data =mat /&>ds ,all   
data & in=mation provid$ pursuant to ?is
 subsection %all comply ) ! foll[+      
/&>ds3 7,a7 ,all claims f a heal?c>e    
provid] %all be made to ! gr\p heal?    
plan 9 accordance ) /&>ds adopt$ "u     

,,hipaa at section #afb4aaja ( title    
#de1 ,code ( ,f$]al ,regulations1 z     
foll[s3  7i7 ,in/itutional1 pr(essional1
 & d5tal claims & adju/m5ts to ^! claims
 %all be provid$ to ! gr\p heal? plan t 
is a self-fund$1 non-,f$]al gov]nm5tal  
plan 9 ! ,,asc ,x#ab,n #hcg =mat4  7ii7 
,prescription drug claims %all be 9 !   
,national ,c\ncil = ,prescription ,drug 
,programs 7,,ncpdp7 =mat4  7iii7 ,!     
files %all be unmodifi$ copies ( ! files
 s5t f ! provid]4 ,9 ! ev5t t pap]      
claims are s5t by ! provid]1 !y %all be 
conv]t$ to ! appropriate /&>d electronic
 =mat4 ,su* data %all be provid$ at no  
co/ to ! gr\p heal? plan4  7,b7 ,all    
claim paym5t 7or ,,eft1 electronic funds
 transf]7 & electronic remittance advice
 7,,era7 in=mation s5t by a heal? plan  
s]vice provid] %all be provid$ to ! gr\p
 heal? plan or heal? insurance issu] 9 !
 ,,asc ,x#ab,n #hce =mat1 9 accordance )
 /&>ds adopt$ "u ,,hipaa at section     
#afb4afjb ( title #de1 ,code ( ,f$]al   
,regulations1 unmodifi$ f ! =m 9 :i* x 0

 transmitt$ to ! heal?c>e provid]4 ,su* 
in=mation %all be provid$ at no co/ to !
 gr\p heal? plan4  7,c7 ,! ,secret>y may
 modify ! /&>ds set =? 9 ?is p>agraph z 
necess>y to align ) any *anges adopt$ by
 ! ,secret>y pursuant to ! au?ority     
provid$ "u section #aagc ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#acbj;d-#b74  7c7 ,prohibit$ contractual
 provisions ,any provision 9 an agreem5t
 t unduly delays or limits a gr\p heal? 
plan t is a self-fund$1 non-,f$]al      
gov]nm5tal plan's access to in=mation   
describ$ 9 ?is section or t re/ricts !  
=mat or tim+ ( ! provision ( su*        
in=mation 9 a mann] t is inconsi/5t ) ! 
requirem5ts ( ?is section %all be       
prohibit$ &1 if a self-fund$1 non-,f$]al
 gov]nm5tal plan ent]s into su*         
agreem5t1 %all be deem$ void z aga9/    
public policy4  7d7 ,regulations ,!     
,secret>y %all implem5t ?is section     
?r\gh notice & comm5t rulemak+ 9        
accordance ) section #eec ( title #e1   
,unit$ ,/ates ,code4  4  7#b7 ,p5alty   

,section #bgbc7;b7 ( ! ,public ,heal?   
,s]vice ,act 7#db ,u4,s4,c4             
#cjj;gg-#bb7;b77 is am5d$ by add+ at !  
end ! foll[+3  7#d7 ,en=cem5t au?ority  
relat+ to heal? plan s]vice provid]s    
,not)/&+ any provisions to ! contr>y1 ! 
,secret>y may assess a p5alty aga9/ a   
heal? plan s]vice provid]1 z def9$ 9    
section #bgii;,a-#ab7;a7 7#db ,u4,s4,c4 
#cjj;gg-#aba7;a771 ( #ajj1jjj p] day =  
ea* violation ( su* section1 pursuant to
 sub/antially simil> processes &        
proc$ures z ^? set =? 9 section         
#bgbc7;b77#b77;,d7 ?r\gh 7,g7 7#db      
,u4,s4,c4 #cjj;gg-#aba7;b77#b77;,d7     
?r\gh 7,g774  4  #c4 ,requirem5t =      
explanation ( b5efits  7a7 ,,phsa       
,am5dm5ts  7#a7 ,em]g5cy s]vices        
,section #bgii;,a-#a7;f77#a77;,c7 ( !   
,public ,heal? ,s]vice ,act 7#db        
,u4,s4,c4 #cjj;gg-#aaa7;f77#a77;,c77 is 
am5d$ to read z foll[s3  7,c7 ,a good   
fai? e/imate ( ! am\nt ! plan or cov]age
 is responsible = pay+ = items & s]vices
 includ$ 9 ! e/imate describ$ 9         

subp>agraph 7,b71 includ+ a pla9        
language description ( ea* item or      
s]vice & all applicable bill+ codes =   
ea* item or s]vice1 includ+ modifi]s1   
us+ /&>d & commonly recogniz$ bill+ code
 sets t are cle>ly id5tifi$4  4  7#b7   
,explanation ( b5efits ,section         
#bgii;,a-#a ( ! ,public ,heal? ,s]vice  
,act 7#db ,u4,s4,c4 #cjj;gg-#aaa7 is    
am5d$ by add+ at ! end ! foll[+3  7g7   
,explanation ( b5efits  7#a7 ,9 g5]al ,=
 plan ye>s beg9n+ on or aft] ,janu>y #a1
 #bjbf1 ea* gr\p heal? plan1 or a heal? 
insurance issu] (f]+ gr\p or individual 
heal? insurance cov]age %all1 )9 #de    
days ( receiv+ any reque/ = paym5t = an 
item or s]vice "u ! plan1 provide to !  
p>ticipant1 b5efici>y1 or enrollee      
7?r\gh mail or electronic means1 z      
reque/$ by ! p>ticipant1 b5efici>y1 or  
enrollee7 a notification 79 cle> &      
und]/&able language & utiliz+           
sub/antially ! same =mat z ! advanc$    
explanation ( b5efits requir$ by        
subsection 7f7 to enable comp>ison7     

includ+ ! foll[+3 7,a7 ,:e!r or n !     
provid] or facility is a p>ticipat+     
provid] or a p>ticipat+ facility )      
respect to ! plan or cov]age ) respect  
to ! furni%+ ( su* item or s]vice4  7,b7
 ,an itemiz$ explanation ( b5efits t    
includes ! foll[+3 7i7 ,a pla9 language 
description ( ea* item or s]vice4  7ii7 
,all applicable bill+ codes = ea* item  
or s]vice1 includ+ modifi]s1 us+ /&>d & 
commonly recogniz$ bill+ code sets t are
 cle>ly id5tifi$4  7iii7 ,! am\nt ! plan
 or cov]age is responsible = pay+ = ea* 
item or s]vice4  7iv7 ,! am\nt ( any    
co/-%>+ = :i* ! p>ticipant1 b5efici>y1  
or enrollee is responsible = ea* item or
 s]vice 7z ( ! date ( su* notification74
  7v7 ,! am\nt t ! p>ticipant1          
b5efici>y1 or enrollee has incurr$ t[>d 
meet+ ! limit ( ! f9ancial              
responsibility 7includ+ ) respect to    
d$uctibles & out-(-pocket maximums7 "u !
 plan or cov]age 7z ( ! date ( su*      
notification74  7vi7 ,! site ( ea* item 
or s]vice4  7#b7 ,=mat ,if applicable1 !

 notification describ$ 9 p>agraph 7#a7  
may be provid$ 9 conjunction )1 or z "p 
(1 a notice ( a claim det]m9ation or o!r
 communication requir$ by section       
#bgai7;a7 7#db ,u4,s4,c4                
#cjj;gg-#ai7;a771 or regulations        
!reund]4  7h7 ,regulations ,! ,secret>y 
%all implem5t ?is section ?r\gh notice &
 comm5t rulemak+ 9 accordance ) section 
#eec ( title #e1 ,unit$ ,/ates ,code4  4
  7b7 ,,irc am5dm5ts  7#a7 ,em]g5cy     
s]vices ,section #ihaf7;f77#a77;,c7 ( ! 
,int]nal ,rev5ue ,code ( #aihf is am5d$ 
to read z foll[s3  7,c7 ,a good fai?    
e/imate ( ! am\nt ! plan is responsible 
= pay+ = items & s]vices includ$ 9 !    
e/imate describ$ 9 subp>agraph 7,b71    
includ+ a pla9 language description (   
ea* item or s]vice & all applicable     
bill+ codes = ea* item or s]vice1       
includ+ modifi]s1 us+ /&>d & commonly   
recogniz$ bill+ code sets t are cle>ly  
id5tifi$4  4  7#b7 ,explanation (       
b5efits ,section #ihaf ( ! ,int]nal     
,rev5ue ,code ( #aihf is am5d$ by add+  

at ! end ! foll[+3  7g7 ,explanation (  
b5efits  7#a7 ,9 g5]al ,= plan ye>s     
beg9n+ on or aft] ,janu>y #a1 #bjbf1 ea*
 gr\p heal? plan %all1 )9 #de days (    
receiv+ any reque/ = paym5t = an item or
 s]vice "u ! plan1 provide to !         
p>ticipant or b5efici>y 7?r\gh mail or  
electronic means1 z reque/$ by !        
p>ticipant or b5efici>y7 a notification 
79 cle> & und]/&able language & utiliz+ 
sub/antially ! same =mat z ! advanc$    
explanation ( b5efits requir$ by        
subsection 7f7 to enable comp>ison7     
includ+ ! foll[+3 7,a7 ,:e!r or n !     
provid] or facility is a p>ticipat+     
provid] or a p>ticipat+ facility )      
respect to ! plan ) respect to ! furni%+
 ( su* item or s]vice4  7,b7 ,an itemiz$
 explanation ( b5efits t includes !     
foll[+3 7i7 ,a pla9 language description
 ( ea* item or s]vice4  7ii7 ,all       
applicable bill+ codes = ea* item or    
s]vice1 includ+ modifi]s1 us+ /&>d &    
commonly recogniz$ bill+ code sets t are
 cle>ly id5tifi$4  7iii7 ,! am\nt ! plan

 is responsible = pay+ = ea* item or    
s]vice4  7iv7 ,! am\nt ( any co/-%>+ =  
:i* ! p>ticipant or b5efici>y is        
responsible = ea* item or s]vice 7z ( ! 
date ( su* notification74  7v7 ,! am\nt 
t ! p>ticipant or b5efici>y has incurr$ 
t[>d meet+ ! limit ( ! f9ancial         
responsibility 7includ+ ) respect to    
d$uctibles & out-(-pocket maximums7 "u !
 plan 7z ( ! date ( su* notification74  
7vi7 ,! site ( ea* item or s]vice4  7#b7
 ,=mat ,if applicable1 ! notification   
describ$ 9 p>agraph 7#a7 may be provid$ 
9 conjunction )1 or z "p (1 a notice ( a
 claim det]m9ation or o!r communication 
requir$ by section #ejc ( ! ,employee   
,retirem5t ,income ,security ,act (     
#aigd or regulations !reund]4  7h7      
,regulations ,! ,secret>y %all implem5t 
?is section ?r\gh notice & comm5t       
rulemak+ 9 accordance ) section #eec (  
title #e1 ,unit$ ,/ates ,code4  4  7c7  
,,erisa am5dm5ts  7#a7 ,em]g5cy s]vices 
,section #gaf7;f77#a77;,c7 ( ! ,employee
 ,retirem5t ,income ,security ,act (    

#aigd 7#bi ,u4,s4,c4                    
#aahe;e7f77#a77;,c77 is am5d$ to read z 
foll[s3  7,c7 ,a good fai? e/imate ( !  
am\nt ! heal? plan is responsible = pay+
 = items & s]vices includ$ 9 ! e/imate  
describ$ 9 subp>agraph 7,b71 includ+ a  
pla9 language description ( ea* item or 
s]vice & all applicable bill+ codes =   
ea* item or s]vice1 includ+ modifi]s1   
us+ /&>d & commonly recogniz$ bill+ code
 sets t are cle>ly id5tifi$4  4  7#b7   
,explanation ( b5efits ,section #gaf ( !
 ,employee ,retirem5t ,income ,security 
,act ( #aigd 7#bi ,u4,s4,c4 #aahe;e7 is 
am5d$ by add+ at ! end ! foll[+3  7g7   
,explanation ( b5efits  7#a7 ,9 g5]al ,=
 plan ye>s beg9n+ on or aft] ,janu>y #a1
 #bjbf1 ea* gr\p heal? plan or heal?    
insurance issu] (f]+ gr\p heal?         
insurance cov]age %all1 )9 #de days (   
receiv+ any reque/ = paym5t = an item or
 s]vice "u ! plan1 provide to !         
p>ticipant or b5efici>y 7?r\gh mail or  
electronic means1 z reque/$ by !        
p>ticipant or b5efici>y7 a notification 

79 cle> & und]/&able language & utiliz+ 
sub/antially ! same =mat z ! advanc$    
explanation ( b5efits requir$ by        
subsection 7f7 to enable comp>ison7     
includ+ ! foll[+3 7,a7 ,:e!r or n !     
provid] or facility is a p>ticipat+     
provid] or a p>ticipat+ facility )      
respect to ! plan or cov]age ) respect  
to ! furni%+ ( su* item or s]vice4  7,b7
 ,an itemiz$ explanation ( b5efits t    
includes ! foll[+3 7i7 ,a pla9 language 
description ( ea* item or s]vice4  7ii7 
,all applicable bill+ codes = ea* item  
or s]vice1 includ+ modifi]s1 us+ /&>d & 
commonly recogniz$ bill+ code sets t are
 cle>ly id5tifi$4  7iii7 ,! am\nt ! plan
 or cov]age is responsible = pay+ = ea* 
item or s]vice4  7iv7 ,! am\nt ( any    
co/-%>+ = :i* ! p>ticipant or b5efici>y 
is responsible = ea* item or s]vice 7z (
 ! date ( su* notification74  7v7 ,!    
am\nt t ! p>ticipant or b5efici>y has   
incurr$ t[>d meet+ ! limit ( ! f9ancial 
responsibility 7includ+ ) respect to    
d$uctibles & out-(-pocket maximums7 "u !

 plan or cov]age 7z ( ! date ( su*      
notification74  7vi7 ,! site ( ea* item 
or s]vice4  7#b7 ,=mat ,if applicable1 !
 notification describ$ 9 p>agraph 7#a7  
may be provid$ 9 conjunction )1 or z "p 
(1 a notice ( a claim det]m9ation or o!r
 communication requir$ by section #ejc  
or regulations !reund]4  7h7            
,regulations ,! ,secret>y %all implem5t 
?is section ?r\gh notice & comm5t       
rulemak+ 9 accordance ) section #eec (  
title #e1 ,unit$ ,/ates ,code4  4  #d4  
,provision ( itemiz$ bills ,"p ,e (     
title ,,xxvii ( ! ,public ,heal? ,s]vice
 ,act 7#db ,u4,s4,c4 #cjj;gg-#aca et    
seq47 is am5d$ by add+ at ! end !       
foll[+3  #bgii;,b-#aj4 ,provid]         
requirem5ts = itemiz$ bills  7a7        
,requirem5ts  7#a7 ,itemiz$ bill & o!r  
in=mation requir$  7,a7  ,9 g5]al  ,a   
heal?c>e provid] or heal?c>e facility t 
reque/s paym5t f an individual aft]     
provid+ a heal?c>e item or s]vice to !  
pati5t %all include ) su* reque/ a      
writt51 itemiz$ bill ( ! co/ ( ea*      

reasonably expect$ item or s]vice !     
heal?c>e provid] or heal?c>e facility   
provid$ to ! individual1 includ+        
teleheal? visits or visits by o!r       
electronic means4 ,! heal?c>e provid] or
 heal?c>e facility %all provide !       
itemiz$ bill n lat] ?an #cj days aft] ! 
heal?c>e provid] or heal?c>e facility   
receiv$ a f9al paym5t on ! provid$      
s]vice or supply f a ?ird p>ty4  7,b7   
,requir$ in=mation  ,= ea* item or      
s]vice provid$ by ! heal?c>e provid] or 
facility or = :i* ! heal?c>e provid] or 
facility is bill+ ! individual1 !       
itemiz$ bill mu/ include--  7i7 a pla9  
language description ( ea* di/9ct       
heal?c>e item or s]vice2  7ii7 all      
applicable bill+ codes = ea* di/9ct     
heal?c>e item or s]vice1 includ+        
modifi]s1 us+ /&>d & commonly recogniz$ 
bill+ code sets t are cle>ly id5tifi$2  
7iii7 ! price & bill$ am\nt1 if diff]5t1
 ( ea* di/9ct heal?c>e item or s]vice or
 if ! provid] or facility is (f]+ b9d+1 
all-9 prices = bundl$ items & s]vices1 !

 total b9d+ price = bundl$ items &      
s]vices & bill$ am\nt2  7iv7 any paym5ts
 made to ! heal?c>e provid] or heal?c>e 
facility by or on behalf ( ! individual 
7includ+ paym5ts by any heal? plan or   
insurance7 = any heal?c>e item or s]vice
 cov]$ 9 ! itemiz$ bill2  7v7 in=mation 
ab\t ! availability ( language-assi/ance
 s]vices = individuals ) limit$ ,engli% 
pr(ici5cy 7,,lep72  7vi7 ! id5tification
 ( an (fice or individual at ! heal?c>e 
provid] or heal?c>e facility1 includ+   
phone numb] & email address1 t %all be  
able to discuss ! specific details ( !  
itemiz$ /atem5t & be au?oriz$ to make   
appropriate *anges !reto2 &  7vii7      
in=mation ab\t ! heal?c>e provid]'s or  
heal?c>e facility's *>ity c>e policies &
 in/ructions on h[ to apply = *>ity c>e4
  7#b7 ,collections actions  7,a7  ,9   
g5]al  ,a heal?c>e provid] or heal?c>e  
facility %all n take any collections    
actions aga9/ an individual--  7i7 = any
 provid$ heal?c>e item or s]vice unless 
! heal?c>e provid] or heal?c>e facility 

has compli$ ) p>agraph 7#a72 or  7ii7 ) 
respect to any items or s]vices = :i* ! 
am\nt appe>+ on an itemiz$ bill describ$
 above 9 p>agraph 7#a7 exce$s ! am\nt   
disclos$ pursuant to ,f$]al heal?c>e    
price transp>5cy regulations1 includ+ "p
 #ahj ( title #de1 ,code ( ,f$]al       
,regulations1 or provid$ 9 a good fai?  
e/imate t complies ) section #bgii;,b-#f
 ( ?is ,act & section #adi4faj ( title  
#de1 ,code ( ,f$]al ,regulations1 or    
ano!r good fai? e/imate provid$ by a    
heal?c>e entity cov]$ "u ?is section b n
 o!rwise cov]$ "u su* section           
#bgii;,b-#f unless ! provid] or facility
 docum5ts t ! additional items or       
s]vices 7 m$ically necess>y due to      
un=ese5 complications or a              
pati5t-initiat$ *ange1 & c\ld n         
reasonably h be5 anticipat$4  7,b7      
,burd5 ( pro( ,! burd5 ( pro( "u        
subp>agraph 7,a77ii7 %all re/ ) !       
provid]1 & abs5t ! docum5tation describ$
 9 su* subp>agraph1 ! good fai? e/imate 
%all be b9d+4  7b7 ,failure ,to comply  

7#a7 ,p5alties ,! ,secret>y %all impose 
p5alties on any heal?c>e provid] or     
heal?c>e facility t fails to comply ) ! 
requirem5ts ( ?is section 9 an am\nt n  
to exce$ #aj1jjj = ea* in/ance ( failure
 to comply4  7#b7  ,presumption 9 favor 
( individual  ,if a heal?c>e provid] or 
heal?c>e facility fails to comply ) !   
requirem5ts ( ?is section1 ! presumption
 %all be t *>ges 7 sub/antially 9 excess
 ( ! good fai? e/imate 7z set =? 9      
section #bgii;,b-#f7 = ! purpose ( any  
pati5t-provid] dispute1 includ+ 9       
accordance ) section #bgii;,b-#g &      
regulations promulgat$ !reund]4  7c7    
,regulations ,! ,secret>y %all implem5t 
?is section ?r\gh notice & comm5t       
rulemak+ 9 accordance ) section #eec (  
title #e1 ,unit$ ,/ates ,code4  4