House Energy & Commerce Committee Issues Report on Reauthorizing & Extending America's Community Health Act (Part 2 of 4)
Continued from Part 1
"(4) Database.--The database described in this paragraph is, with respect to a group health plan or health insurance issuer offering group or individual health insurance coverage, a database on the public website of such plan or issuer that contains-- "(A) a list of each health care provider and health care facility with which such plan or such issuer has a contractual relationship for furnishing items and services under such plan or such coverage; and "(B) provider directory information with respect to each such provider and facility.
"(5) Information.--The information described in this paragraph is, with respect to a print directory containing provider directory information with respect to a group health plan or individual or group health insurance coverage offered by a health insurance issuer, a notification that such information contained in such directory was accurate as of the date of publication of such directory and that an individual enrolled under such plan or such coverage should consult the database described in paragraph (4) with respect to such plan or such coverage or contact such plan or the issuer of such coverage to obtain the most current provider directory information with respect to such plan or such coverage.
"(6) Definition.--For purposes of this subsection, the term `provider directory information' includes, with respect to a group health plan and a health insurance issuer offering group or individual health insurance coverage, the name, address, specialty, and telephone number of each health care provider or health care facility with which such plan or such issuer has a contractual relationship for furnishing items and services under such plan or such coverage.
"(h) Disclosure on Patient Protections.--Each group health plan and health insurance issuer offering group or individual health insurance coverage shall make publicly available, and (if applicable) post on a public website of such plan or issuer-- "(1) information in plain language on-- "(A) the requirements and prohibitions applied under sections 2799 and 2799A (relating to prohibitions on balance billing in certain "(B) if provided for under applicable State law, any other requirements on providers and facilities regarding the amounts such providers and facilities may, with respect to an item or service, charge a participant, beneficiary, or enrollee of such plan or coverage with respect to which such a provider or facility does not have a contractual relationship for furnishing such item or service under the plan or coverage after receiving payment from the plan or coverage for such item or service and any applicable cost-sharing payment from such participant, beneficiary, or enrollee; and "(C) the requirements applied under subsections (b) and (e); and "(2) information on contacting appropriate State and Federal agencies in the case that an individual believes that such a provider or facility has violated any requirement described in paragraph (1) with respect to such individual.".
(d) Preventing Certain Cases of Balance Billing.--Title XXVII of the Public Health Service Act is amended by adding at the end the following new part:
"(a) In General.--Subject to subsection (b), in the case of a participant, beneficiary, or enrollee with benefits under a health plan (as defined in section 2799(b)) who is furnished on or after
"(b) Exception.-- "(1) In general.--Subsection (a) shall not apply to a nonparticipating provider (other than a specified provider at a participating health care facility), with respect to items or services furnished by the provider to a participant, beneficiary, or enrollee of a health plan, if the provider is in compliance with the notice and consent requirements of subsection (d).
"(2) Specified provider defined.--For purposes of paragraph (1), the term 'specified provider', with respect to a participating health care facility-- "(A) means a facility-based provider, including emergency medicine providers, anesthesiologists, pathologists, radiologists, neonatologists, assistant surgeons, hospitalists, intensivists, or other providers as determined by the Secretary; and "(B) includes, with respect to an item or service, a nonparticipating provider if there is no participating provider at such facility who can furnish such item or service.
"(c) Clarification.--In the case of a nonparticipating provider (other than a specified provider at a participating health care facility) that complies with the notice and consent requirements of subsection (d) with respect to an item or service (referred to in this subsection as a 'covered item or service'), such notice and consent requirements may not be construed as applying with respect to any item or service that is furnished as a result of unforeseen medical needs that arise at the time such covered item or service is furnished.
"(d) Compliance With Notice and Consent Requirements.-- "(1) In general.--A nonparticipating provider or nonparticipating facility is in compliance with this subsection, with respect to items or services furnished by the provider or facility to a participant, beneficiary, or enrollee of a health plan, if the provider (or, if applicable, the participating health care facility on behalf of such provider) or nonparticipating facility-- "(A) provides to the participant, beneficiary, or enrollee (or to an authorized representative of the participant, beneficiary, or enrollee) on the date on which the individual is furnished such items or services and, in the case that the participant, beneficiary, or enrollee makes an appointment to be furnished such items or services, on such date the appointment is made-- "(i) an oral explanation of the written notice described in clause (ii); and "(ii) a written notice specified by the Secretary, not later than
"(2) Information required under written notice.--For purposes of paragraph (1)(A)(ii)(I), the information described in this paragraph, with respect to a nonparticipating provider or nonparticipating facility and a participant, beneficiary, or enrollee of a health plan, is each of the following: "(A) Notification, as applicable, that the health care provider is a nonparticipating provider with respect to the health plan or the health care facility is a nonparticipating facility with respect to the health plan.
"(B) Notification of the estimated amount that such provider or facility may charge the participant, beneficiary, or enrollee for such items and services involved.
"(C) In the case of a nonparticipating facility, a list of any participating providers at the facility who are able to furnish such items and services involved and notification that the participant, beneficiary, or enrollee may be referred, at their option, to such a participating provider.
"(3) Consent described.--For purposes of paragraph (1)(B), the consent described in this paragraph, with respect to a participant, beneficiary, or enrollee of a health plan who is to be furnished items or services by a nonparticipating provider or nonparticipating facility, is a document specified by the Secretary through rulemaking that-- "(A) is signed by the participant, beneficiary, or enrollee (or by an authorized representative of the participant, beneficiary, or enrollee) and, with respect to items or services to be furnished by such a provider or facility that are not poststabilization services described in section 2719A(b)(3)(C)(ii), is so signed not less than 72 hours prior to the participant, beneficiary, or enrollee being furnished such items or services by such provider or facility; "(B) acknowledges that the participant, beneficiary, or enrollee has been-- "(i) provided with a written estimate and an oral explanation of the charge that the participant, beneficiary, or enrollee will be assessed for the items or services anticipated to be furnished to the participant, beneficiary, or enrollee by such provider or facility; and "(ii) informed that the payment of such charge by the participant, beneficiary, or enrollee may not accrue toward meeting any limitation that the health plan places on cost- sharing; and "(C) documents the consent of the participant, beneficiary, or enrollee to-- "(i) be furnished with such items or services by such provider or facility; and "(ii) in the case that the individual is so furnished such items or services, be charged an amount that may be greater than the amount that would otherwise be charged the individual if furnished by a participating provider or participating facility with respect to such items or services and plan.
"(e) Retention of Certain Documents.--A nonparticipating provider (or, in the case of a nonparticipating provider at a participating health care facility, such facility) or nonparticipating facility that obtains from a participant, beneficiary, or enrollee of a health plan (or an authorized representative of such participant, beneficiary, or enrollee) a written notice in accordance with subsection (c)(1)(ii), with respect to furnishing an item or service to such participant, beneficiary, or enrollee, shall retain such notice for at least a 2- year period after the date on which such item or service is so furnished.
"(f) Definitions.--In this section: "(1) The terms 'nonparticipating provider' and 'participating provider' have the meanings given such terms, respectively, in subsection (b)(3) of section 2719A.
"(2) The terms 'participating health care facility' and 'health plan' have the meanings given such terms, respectively, in subsection (e)(2) of section 2719A.
"(3) The term 'nonparticipating facility' means-- "(A) with respect to emergency services (as defined in section 2719A(b)(3)(C)(i)) and a health plan, an emergency department of a hospital, or an independent freestanding emergency department, that does not have a contractual relationship with the plan (or, if applicable, issuer offering the plan) for furnishing such services under the plan; and "(B) with respect to poststabilization services described in section 2719A(b)(3)(C)(ii) and a health plan, an emergency department of a hospital (or other department of such hospital), or an independent freestanding emergency department, that does not have a contractual relationship with the plan (or, if applicable, issuer offering the plan) for furnishing such services under the plan.
"(4) The term 'participating facility' means-- "(A) with respect to emergency services (as defined in section 2719A(b)(3)(C)(i)) and a health plan, an emergency department of a hospital, or an independent freestanding emergency department, that has a contractual relationship with the plan (or, if applicable, issuer offering the plan) for furnishing such services under the plan; and "(B) with respect to poststabilization services described in section 2719A(b)(3)(C)(ii) and a health plan, an emergency department of a hospital (or other department of such hospital), or an independent freestanding emergency department, that has a contractual relationship with the plan (or, if applicable, issuer offering the plan) for furnishing such services under the plan.
"Not later than 1 year after the date of the enactment of this section, each health care provider and health care facility shall establish a process under which such provider or facility transmits, to each health insurance issuer offering group or individual health insurance coverage and group health plan with which such provider or facility has in effect a contractual relationship for furnishing items and services under such coverage or such plan, provider directory information (as defined in section 2719A(g)(6)) with respect to such provider or facility, as applicable. Such provider or facility shall so transmit such information to such issuer offering such coverage or such group health plan-- "(1) when the provider or facility enters into such a relationship with respect to such coverage offered by such issuer or with respect to such plan; "(2) when the provider or facility terminates such relationship with respect to such coverage offered by such issuer or with respect to such plan; "(3) when there are any other material changes to such provider directory information of the provider or facility with respect to such coverage offered by such issuer or with respect to such plan; and "(4) at any other time (including upon the request of such issuer or plan) determined appropriate by the provider, facility, or the Secretary.
"Each health care provider and health care facility shall make publicly available, and (if applicable) post on a public website of such provider or facility-- "(1) information in plain language on-- "(A) the requirements and prohibitions of such provider or facility under sections 2799 and 2799A (relating to prohibitions on balance billing in certain circumstances); and "(B) if provided for under applicable State law, any other requirements on such provider or facility regarding the amounts such provider or facility may, with respect to an item or service, charge a participant, beneficiary, or enrollee of a health plan (as defined in section 2719A(e)(2)) with respect to which such provider or facility does not have a contractual relationship for furnishing such item or service under the plan after receiving payment from the plan for such item or service and any applicable cost- sharing payment from such participant, beneficiary, or enrollee; and "(2) information on contacting appropriate State and Federal agencies in the case that an individual believes that such provider or facility has violated any requirement described in paragraph (1) with respect to such individual.
"(a) State Enforcement.-- "(1) State authority.--Each State may require a provider or health care facility subject to the requirements of sections 2719A(f), 2799, 2799A, 2799B, or 2799C to satisfy such requirements applicable to the provider or facility.
"(2) Failure to implement requirements.--In the case of a determination by the Secretary that a State has failed to substantially enforce the requirements specified in paragraph (1) with respect to applicable providers and facilities in the State, the Secretary shall enforce such requirements under subsection (b) insofar as they relate to violations of such requirements occurring in such State.
"(b)
"(2) Limitation.--The provisions of paragraph (1) shall apply to enforcement of a provision (or provisions) specified in subsection (a)(1) only as provided under subsection (a)(2).
"(3) Complaint process.--The Secretary shall, through rulemaking, establish a process to receive consumer complaints of violations of such provisions and resolve such complaints within 60 days of receipt of such complaints.
"(4) Exception.--The Secretary shall waive the penalties described under paragraph (1) with respect to a facility or provider who does not knowingly violate, and should not have reasonably known it violated, section 2799 or 2799A with respect to a participant, beneficiary, or enrollee, if such facility or practitioner, within 30 days of the violation, withdraws the bill that was in violation of such provision and reimburses the health plan or enrollee, as applicable, in an amount equal to the difference between the amount billed and the amount allowed to be billed under the provision, plus interest, at an interest rate determined by the Secretary.
"(5) Hardship exemption.--The Secretary may establish a hardship exemption to the penalties under this subsection.
"(c) Continued Applicability of State Law.--The sections specified in subsection (a)(1) shall not be construed to supersede any provision of State law which establishes, implements, or continues in effect any requirement or prohibition except to the extent that such requirement or prohibition prevents the application of a requirement or prohibition of such a section.".
(e) Rulemaking for Median Contracted Rates.--Not later than
Such rulemaking shall take into account payments that are made by such sponsor or issuer that are not on a fee-for-service basis. Such methodology may account for relevant payment adjustments that take into account facility type (including higher acuity settings and the case- mix of various facility types) that are otherwise taken into account for purposes of determining payment amounts with respect to participating facilities.
(f) Effective Date.--The amendments made by subsections (a) and (b) shall apply with respect to plan years beginning on or after
(a) Study.--The Comptroller General of
(b) Report.--Not later than 2 years after the date of the enactment of this Act, the Comptroller General of
(a) In General.--The Secretary of
(b) Uses.--A State may use a grant received under subsection (a) for one of the following purposes: (1) To establish an All Payer Claims Database for the State.
(2) To maintain an existing All Payer Claims Databases for the State.
(c) Eligibility.--To be eligible to receive a grant under subsection (a), a State shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary specifies. Such information shall include, with respect to an All Payer Claims Database for the State, at least specifics on how the State will ensure uniform data collection through the database and the security of such data submitted to and maintained in the database.
(d) All Payer Claims Database.--For purposes of this section, the term "All Payer Claims Database" means, with respect to a State, a State database that may include medical claims, pharmacy claims, dental claims, and eligibility and provider files, which are collected from private and public payers.
(e) Authorization of Appropriations.--To carry out this section, there are authorized to be appropriated
(a) Cost Data Reporting Program.-- (1) In general.--Not later than 6 months after the date of the promulgation of the rule under subsection (c), and annually thereafter, a provider of emergency air medical services shall submit to the Secretary of
(2) Publication.--Not later than 180 days after the date the Secretary of
(b) Specified Information.--Information described in subsection (a) is-- (1) information, with respect to a claim for an item or service-- (A) identified as paid by health insurance coverage offered in the group or individual market or a group health plan (including a self-insured plan); (B) identified as paid for non-emergent transport requiring prior authorization and emergent transport; (C) identified as paid for hospital-affiliated providers and independent providers; (D) identified as paid for rural transport and urban transport; (E) identified as provided using rotor transport and fixed wing transport; and (F) identified as furnished by a provider of emergency air medical services that has a contractual relationship with the plan or coverage of an individual for which such item or service is provided and such a provider that does not have a contractual relationship with the plan or coverage or such an individual; and (2) cost data for an air ambulance service furnished by such a provider of emergency air medical services that the Secretary of
(c) Rulemaking.--Not later than 1 year after the date of the enactment of this Act, the Secretary of
(d) Civil Monetary Penalties.-- (1) In general.--A provider of emergency air medical services who violates the requirements of subsection (a)(1) shall be subject to a civil monetary penalty of not more than
(2) Procedure.--The provisions of section 1128A of the Social Security Act (42 U.S.C. 1320a-7a), other than subsections (a) and (b) and the first sentence of subsection (c)(1) of such subsection, shall apply to civil monetary penalties under this subsection in the same manner as such provisions apply to a penalty or proceeding under such section.
(e) Reporting.-- (1) Secretary of health and human services.--Not later than
(2) Comptroller general.--Not later than
(f) Limitation.--The information publicly disclosed under subsection (a) and the reports under subsection (f) may not contain any proprietary information.
Not later than one year after the date of the enactment of this Act, and annually thereafter for each of the following 5 years, the Secretary of Labor shall-- (1) conduct a study of-- (A) the effects of the provisions of, including amendments made by, this Act on premiums and out-of- pocket costs in group health plans, including out-of- pocket costs that are permitted by reason of compliance with section 2799A(d) of the Public Health Service Act, as added by section 2(d); (B) the adequacy of provider networks in group health plans; and (C) such other effects of such provisions, and amendments, as the Secretary deems relevant; and (2) submit a report on such study to the
Notwithstanding any other provision of law, a health care provider or health care facility (or health insurance issuer offering health insurance coverage or group health plan) may not initiate a process to seek reimbursement from an individual for a service furnished by such provider or facility to such individual more than a year after such date of service. Any provider, facility, issuer, or plan that bills an individual in violation of the previous sentence shall be subject to a civil monetary penalty in such amount as specified by the Secretary of
Not later than 3 years after the date of the enactment of this Act, the Comptroller General of
(2) What is known about such impacts on provider shortages and accessibility to such providers, focusing on rural and medically underserved communities.
(3) The number of grants that have been awarded under section 404 (relating to State All Payer Claims Databases) and for what purposes States have used funds made available under such grants.
(4) An analysis of how data made available through State All Payer Claims Databases receiving funding under such grants has been used.
Not later than one year after the date of the enactment of this Act, and annually thereafter for each of the following 5 years, the Secretary of
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House Energy & Commerce Committee Issues Report on Reauthorizing & Extending America's Community Health Act (Part 1 of 4)
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