Bills Sec. 5 — Consumer protections through health pl…

Section 2719A of the Public Health Service Act ( 42 U.S.C. 300gg–19a ), as amended by sections 2(a) and 3(a), is further amended by inserting before subsection

(k)the following new subsections: Beginning not later than January 1, 2022, each health plan shall— establish the verification process described in paragraph (2); establish the response protocol described in paragraph (3); establish the database described in paragraph (4); and include in any directory (other than the database described in subparagraph (C)) containing provider directory information with respect to such plan the information described in paragraph (5). The verification process described in this paragraph is, with respect to a health plan, a process— under which such plan verifies and updates the provider directory information included on the database described in paragraph

(4)of such plan of— not less frequently than once every 90 days, a random sample of at least 10 percent of health care providers and health care facilities included in such database; and any such provider or such facility included in such database that has not submitted any claim to such plan during a 12-month period; 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 plan; and that provides for the update of such database within 2 business days of such plan receiving from such a provider or facility information pursuant to section 1150D of the Social Security Act. The response protocol described in this paragraph is, 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 plan, a protocol under which such plan— responds to such individual as soon as practicable, and in no case later than 1 business day after such call or email is received, through a written electronic or paper (as requested by such individual) communication; and retains such communication in such individual’s file for at least 2 years following such response. The database described in this paragraph is, with respect to a health plan, a database on the public website of such plan or issuer that contains— 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 plan; and provider directory information with respect to each such provider and facility. The information described in this paragraph is, with respect to a directory containing provider directory information with respect to a health plan, 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

(4)with respect to such plan or contact such plan to obtain the most current provider directory information with respect to such plan. For purposes of this section, the term provider directory information includes, with respect to a health plan, the name, address, specialty, 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 plan. Beginning not later than January 1, 2022, each health plan shall make publicly available, post on a website of such plan available to individuals enrolled under such plan, and include on each explanation of benefits for an item or service with respect to which the requirements under subsection (b), (e), or

(i)applies— information in plain language on— the requirements and prohibitions applied under section 1150C of the Social Security Act (relating to prohibitions on balance billing in certain circumstances); 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 with respect to which such a provider is a nonparticipating provider or facility is a nonparticipating facility, with respect to such plan, 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, beneficiary, or enrollee; and the requirements applied under subsections (b), (e), and (i); and information in plain language on contacting appropriate State and Federal agencies in the case that an individual believes that such a health plan, provider, or facility has violated any requirement described in paragraph

(1)with respect to such individual. . Section 9816 of the Internal Revenue Code of 1986, as added by section 2(b) and amended by section 3(b), is further amended by inserting before subsection

(k)the following new subsections: Beginning not later than January 1, 2022, each health plan shall— establish the verification process described in paragraph (2); establish the response protocol described in paragraph (3); establish the database described in paragraph (4); and include in any directory (other than the database described in subparagraph (C)) containing provider directory information with respect to such plan the information described in paragraph (5). The verification process described in this paragraph is, with respect to a health plan, a process— under which such plan verifies and updates the provider directory information included on the database described in paragraph

(4)of such plan of— not less frequently than once every 90 days, a random sample of at least 10 percent of health care providers and health care facilities included in such database; and any such provider or such facility included in such database that has not submitted any claim to such plan during a 12-month period; 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 plan; and that provides for the update of such database within 2 business days of such plan receiving from such a provider or facility information pursuant to section 1150D of the Social Security Act. The response protocol described in this paragraph is, 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 plan, a protocol under which such plan— responds to such individual as soon as practicable, and in no case later than 1 business day after such call or email is received, through a written electronic or paper (as requested by such individual) communication; and retains such communication in such individual’s file for at least 2 years following such response. The database described in this paragraph is, with respect to a health plan, a database on the public website of such plan or issuer that contains— 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 plan; and provider directory information with respect to each such provider and facility. The information described in this paragraph is, with respect to a directory containing provider directory information with respect to a health plan, 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

(4)with respect to such plan or contact such plan to obtain the most current provider directory information with respect to such plan. For purposes of this section, the term provider directory information includes, with respect to a health plan, the name, address, specialty, 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 plan. Beginning not later than January 1, 2022, each health plan shall make publicly available, post on a website of such plan available to individuals enrolled under such plan, and include on each explanation of benefits for an item or service with respect to which the requirements under subsection (b), (e), or

(i)applies— information in plain language on— the requirements and prohibitions applied under section 1150C of the Social Security Act (relating to prohibitions on balance billing in certain circumstances); 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 or beneficiary of such plan with respect to which such a provider is a nonparticipating provider or facility is a nonparticipating facility, with respect to such plan, 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 beneficiary; and the requirements applied under subsections (b), (e), and (i); and information in plain language on contacting appropriate State and Federal agencies in the case that an individual believes that such a health plan, provider, or facility has violated any requirement described in paragraph

(1)with respect to such individual. . Section 716 of the Employee Retirement Income Security Act of 1974, as added by section 2(c) and amended by section 3(c), is further amended by inserting before subsection

(k)the following new subsections: Beginning not later than January 1, 2022, each health plan shall— establish the verification process described in paragraph (2); establish the response protocol described in paragraph (3); establish the database described in paragraph (4); and include in any directory (other than the database described in subparagraph (C)) containing provider directory information with respect to such plan the information described in paragraph (5). The verification process described in this paragraph is, with respect to a health plan, a process— under which such plan verifies and updates the provider directory information included on the database described in paragraph

(4)of such plan of— not less frequently than once every 90 days, a random sample of at least 10 percent of health care providers and health care facilities included in such database; and any such provider or such facility included in such database that has not submitted any claim to such plan during a 12-month period; 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 plan; and that provides for the update of such database within 2 business days of such plan receiving from such a provider or facility information pursuant to section 1150D of the Social Security Act. The response protocol described in this paragraph is, 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 plan, a protocol under which such plan— responds to such individual as soon as practicable, and in no case later than 1 business day after such call or email is received, through a written electronic or paper (as requested by such individual) communication; and retains such communication in such individual’s file for at least 2 years following such response. The database described in this paragraph is, with respect to a health plan, a database on the public website of such plan or issuer that contains— 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 plan; and provider directory information with respect to each such provider and facility. The information described in this paragraph is, with respect to a directory containing provider directory information with respect to a health plan, 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

(4)with respect to such plan or contact such plan to obtain the most current provider directory information with respect to such plan. For purposes of this section, the term provider directory information includes, with respect to a health plan, the name, address, specialty, 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 plan. Beginning not later than January 1, 2022, each health plan shall make publicly available, post on a website of such plan available to individuals enrolled under such plan, and include on each explanation of benefits for an item or service with respect to which the requirements under subsection (b), (e), or

(i)applies— information in plain language on— the requirements and prohibitions applied under section 1150C of the Social Security Act (relating to prohibitions on balance billing in certain circumstances); 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 or beneficiary of such plan with respect to which such a provider is a nonparticipating provider or facility is a nonparticipating facility, with respect to such plan, 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 beneficiary; and the requirements applied under subsections (b), (e), and (i); and information in plain language on contacting appropriate State and Federal agencies in the case that an individual believes that such a health plan, provider, or facility has violated any requirement described in paragraph

(1)with respect to such individual. .

Sec. 5. Consumer protections through health plan transparency requirements