Bills Sec. 3 — Consumer protections through requireme…

Section 2719A of the Public Health Service Act ( 42 U.S.C. 300gg–19a ), as amended by section 2(a), is further amended by inserting before subsection

(k)the following new subsection: Subject to paragraph (2), in the case of items or services (other than emergency services to which subsection

(b)applies or items and services to which subsection

(i)applies) furnished to a participant, beneficiary, or enrollee of a health plan by a nonparticipating provider during a visit (as defined by the Secretary in accordance with subsection (k)(2)) at a participating facility, if such items and services would otherwise be covered under such plan if furnished by a participating provider, the plan— shall not impose on such participant, beneficiary, 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 provider; 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 services; shall pay to such provider furnishing such items and services to such participant, beneficiary, 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 (as determined in accordance with subparagraphs

(A)and (B)); and shall apply the deductible or out-of-pocket maximum, if any, that would apply if such services were furnished by a participating provider. Paragraph

(1)shall not apply to a health plan in the case of items or services furnished to a participant, beneficiary, or enrollee of a health plan by a nonparticipating provider during a visit (as so defined by the Secretary in accordance with subsection (k)(2)) at a participating facility if the requirement described in paragraph

(1)of section 1150C(b) of the Social Security Act does not apply with respect to such provider and such items and services due to the application of paragraph

(2)of such section. . The amendment made by paragraph

(1)shall apply with respect to plan years beginning on or after January 1, 2022. Section 9816 of the Internal Revenue Code of 1986, as added by section 2(b), is amended by inserting before subsection

(k)the following new subsection: Subject to paragraph (2), in the case of items or services (other than emergency services to which subsection

(b)applies or items and services to which subsection

(i)applies) furnished to a participant or beneficiary of a health plan by a nonparticipating provider during a visit (as defined by the Secretary in accordance with subsection (k)(2)) at a participating facility, if such items and services would otherwise be covered under such plan if furnished by a participating provider, the plan— 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 provider; 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 services; 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 (as determined in accordance with subparagraphs

(A)and (B)); and shall apply the deductible or out-of-pocket maximum, if any, that would apply if such services were furnished by a participating provider. Paragraph

(1)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 (as so defined by the Secretary in accordance with subsection (k)(2)) at a participating facility if the requirement described in paragraph

(1)of section 1150C(b) of the Social Security Act does not apply with respect to such provider and such items and services due to the application of paragraph

(2)of such section. . The amendments made by paragraph

(1)shall apply with respect to plan years beginning on or after January 1, 2022. Section 716 of the Employee Retirement Income Security Act of 1974, as added by section 2(c), is amended by inserting before subsection

(k)the following new subsection: Subject to paragraph (2), in the case of items or services (other than emergency services to which subsection

(b)applies or items and services to which subsection

(i)applies) furnished to a participant or beneficiary of a health plan by a nonparticipating provider during a visit (as defined by the Secretary in accordance with subsection (k)(2)) at a participating facility, if such items and services would otherwise be covered under such plan if furnished by a participating provider, the plan— 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 provider; 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 services; 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 (as determined in accordance with subparagraphs

(A)and (B)); and shall apply the deductible or out-of-pocket maximum, if any, that would apply if such services were furnished by a participating provider. Paragraph

(1)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 (as so defined by the Secretary in accordance with subsection (k)(2)) at a participating facility if the requirement described in paragraph

(1)of section 1150C(b) of the Social Security Act does not apply with respect to such provider and such items and services due to the application of paragraph

(2)of such section. . The amendments made by paragraph

(1)shall apply with respect to plan years beginning on or after January 1, 2022.

Sec. 3. Consumer protections through requirements on health plans to prevent surprise medical bills for non-emergency services performed by nonparticipating providers at certain participating facilities