Sec. 6. Consumer protections through health plan requirement for fair and honest advance cost estimate
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Section 2719A of the Public Health Service Act ( 42 U.S.C. 300gg–19a ), as amended by sections 2(a), 3(a), and 5(a), is further amended by inserting before subsection
(k)the following new subsections: Beginning on January 1, 2022, each health plan shall, with respect to a notification submitted under section 1150D(b)(2)(A) of the Social Security Act by a health care provider or health care facility, respectively, to the health plan for a participant, beneficiary, or enrollee under such health plan scheduled to receive an item or service from the provider or facility, not later than 1 business day (or, in the case such item or service was so scheduled at least 10 business days before such item or service is to be furnished (or in the case such notification was made pursuant to a request by such participant, beneficiary, or enrollee), 3 business days) after the date on which the health plan receives such notification, provide to the participant, beneficiary, or enrollee (through mail or electronic means, as requested by the participant, beneficiary, or enrollee) a notification (in clear and understandable language) including the following: 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— 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 service, the contracted rate under such plan for such item or service; and in the case the provider or facility is a nonparticipating provider or facility with respect to such plan, a description of how such individual may obtain information on providers and facilities that, with respect to such health plan, are participating providers and facilities. The good faith estimate included in the notification received from the provider or facility. 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 (2). A good faith estimate of the amount of any cost-sharing (including with respect to the deductible and any copayment or coinsurance obligation) for which the participant, beneficiary, or enrollee would be responsible for such item or service (as of the date of such notification). A good faith estimate of the amount that the participant, beneficiary, or enrollee has incurred toward meeting the limit of the financial responsibility (including with respect to deductibles and out-of-pocket maximums) under the health plan (as of the date of such notification). In the case such item or service is subject to a medical management technique (including concurrent review, prior authorization, and step-therapy or fail-first protocols) for coverage under the health plan, a disclaimer that coverage for such item or service is subject to such medical management technique. A disclaimer that the information provided in the notification is only an estimate based on the items and services reasonably expected, at the time of scheduling (or requesting) the item or service, to be furnished and is subject to change. 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 facilities, or of participating providers, as applicable, who are able to furnish such items and services involved. Any other information or disclaimer the health plan determines appropriate that is consistent with information and disclaimers required under this section. For plan years beginning on or after January 1, 2022, in the case of an item or service furnished to a participant, beneficiary, or enrollee of a health plan by a nonparticipating provider or a nonparticipating facility, 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
(2)applies with respect to such participant, beneficiary, or enrollee and item or service, the plan— 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 provider; 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— the most recent (as of the date such item or service was furnished) contracted rate in effect between such provider or facility and such plan for such item or service furnished under such plan, if any; or if no contracted rate described in clause
(i)exists, the recognized amount for such item or service; shall pay to such nonparticipating provider or facility furnishing such item or service to such participant, beneficiary, or enrollee the amount by which— if a contracted rate described in subparagraph (B)(i) exists, the most recent (as of the date such item or services was furnished) such rate; or if no contracted rate described in such subparagraph exists, 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 or a participating facility. For purposes of paragraph (1), the criteria described in this paragraph, with respect to an item or service furnished to a participant, beneficiary, or enrollee of a health plan by a nonparticipating provider or a nonparticipating facility, are the following: The participant, beneficiary, or enrollee received a notification under subsection
(h)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 facility, with respect to the plan for furnishing such item or service. A notification was not provided, in accordance with subsection (h), to the participant, beneficiary, or enrollee, and the participant, beneficiary, or enrollee requested through the response protocol of the plan under subsection (f)(3) 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 facility. . Section 9816 of the Internal Revenue Code of 1986, as added by section 2(b) and amended by sections 3(b) and 5(b), is further amended by inserting before subsection
(k)the following new subsections: Beginning on January 1, 2022, each health plan shall, with respect to a notification submitted under section 1150D(b)(2)(A) of the Social Security Act by a health care provider or health care facility, respectively, to the health plan for a participant or beneficiary under such health plan scheduled to receive an item or service from the provider or facility, not later than 1 business day (or, in the case such item or service was so scheduled at least 10 business days before such item or service is to be furnished (or in the case such notification was made pursuant to a request by such participant or beneficiary), 3 business days) after the date on which the health plan receives such notification, provide to the participant or beneficiary (through mail or electronic means, as requested by the participant or beneficiary) a notification (in clear and understable language) including the following: 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— 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 service, the contracted rate under such plan for such item or service; and in the case the provider or facility is a nonparticipating provider or facility with respect to such plan, a description of how such individual may obtain information on providers and facilities that, with respect to such health plan, are participating providers and facilities. The good faith estimate included in the notification received from the provider or facility. 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 (2). A good faith estimate of the amount of any cost-sharing (including with respect to the deductible and any copayment or coinsurance obligation) for which the participant or beneficiary would be responsible for such item or service (as of the date of such notification). A good faith estimate of the amount that the participant or beneficiary has incurred toward meeting the limit of the financial responsibility (including with respect to deductibles and out-of-pocket maximums) under the health plan (as of the date of such notification). In the case such item or service is subject to a medical management technique (including concurrent review, prior authorization, and step-therapy or fail-first protocols) for coverage under the health plan, a disclaimer that coverage for such item or service is subject to such medical management technique. A disclaimer that the information provided in the notification is only an estimate based on the items and services reasonably expected, at the time of scheduling (or requesting) the item or service, to be furnished and is subject to change. 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 facilities, or of participating providers, as applicable, who are able to furnish such items and services involved. Any other information or disclaimer the health plan determines appropriate that is consistent with information and disclaimers required under this section. For plan years beginning on or after January 1, 2022, 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 facility, 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
(2)applies with respect to such participant or beneficiary and item or service, the plan— 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 provider; 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— the most recent (as of the date such item or service was furnished) contracted rate in effect between such provider or facility and such plan for such item or service furnished under such plan, if any; or if no contracted rate described in clause
(i)exists, the recognized amount for such item or service; shall pay to such nonparticipating provider or facility furnishing such item or service to such participant or beneficiary the amount by which— if a contracted rate described in subparagraph (B)(i) exists, the most recent (as of the date such item or services was furnished) such rate; or if no contracted rate described in such subparagraph exists, 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 or a participating facility. For purposes of paragraph (1), the criteria described in this paragraph, with respect to an item or service furnished to a participant or beneficiary of a health plan by a nonparticipating provider or a nonparticipating facility, are the following: The participant or beneficiary received a notification under subsection
(h)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 facility, with respect to the plan for furnishing such item or service. A notification was not provided, in accordance with subsection (h), to the participant or beneficiary and the participant or beneficiary requested through the response protocol of the plan under subsection (f)(3) 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 facility. . Section 716 of the Employee Retirement Income Security Act of 1974, as added by section 2(c) and amended by sections 3(c) and 5(c), is further amended by inserting before subsection
(k)the following new subsections: Beginning on January 1, 2022, each health plan shall, with respect to a notification submitted under section 1150D(b)(2)(A) of the Social Security Act by a health care provider or health care facility, respectively, to the health plan for a participant or beneficiary under such health plan scheduled to receive an item or service from the provider or facility, not later than 1 business day (or, in the case such item or service was so scheduled at least 10 business days before such item or service is to be furnished (or in the case such notification was made pursuant to a request by such participant or beneficiary), 3 business days) after the date on which the health plan receives such notification, provide to the participant or beneficiary (through mail or electronic means, as requested by the participant or beneficiary) a notification (in clear and understandable language) including the following: 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— 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 service, the contracted rate under such plan for such item or service; and in the case the provider or facility is a nonparticipating provider or facility with respect to such plan, a description of how such individual may obtain information on providers and facilities that, with respect to such health plan, are participating providers and facilities. The good faith estimate included in the notification received from the provider or facility. 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 (2). A good faith estimate of the amount of any cost-sharing (including with respect to the deductible and any copayment or coinsurance obligation) for which the participant or beneficiary would be responsible for such item or service (as of the date of such notification). A good faith estimate of the amount that the participant or beneficiary has incurred toward meeting the limit of the financial responsibility (including with respect to deductibles and out-of-pocket maximums) under the health plan (as of the date of such notification). In the case such item or service is subject to a medical management technique (including concurrent review, prior authorization, and step-therapy or fail-first protocols) for coverage under the health plan, a disclaimer that coverage for such item or service is subject to such medical management technique. A disclaimer that the information provided in the notification is only an estimate based on the items and services reasonably expected, at the time of scheduling (or requesting) the item or service, to be furnished and is subject to change. 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 facilities, or of participating providers, as applicable, who are able to furnish such items and services involved. Any other information or disclaimer the health plan determines appropriate that is consistent with information and disclaimers required under this section. For plan years beginning on or after January 1, 2022, 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 facility, 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
(2)applies with respect to such participant or beneficiary and item or service, the plan— 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 provider; 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— the most recent (as of the date such item or service was furnished) contracted rate in effect between such provider or facility and such plan for such item or service furnished under such plan, if any; or if no contracted rate described in clause
(i)exists, the recognized amount for such item or service; shall pay to such nonparticipating provider or facility furnishing such item or service to such participant or beneficiary the amount by which— if a contracted rate described in subparagraph (B)(i) exists, the most recent (as of the date such item or services was furnished) such rate; or if no contracted rate described in such subparagraph exists, 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 or a participating facility. For purposes of paragraph (1), the criteria described in this paragraph, with respect to an item or service furnished to a participant or beneficiary of a health plan by a nonparticipating provider or a nonparticipating facility, are the following: The participant or beneficiary received a notification under subsection
(h)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 facility, with respect to the plan for furnishing such item or service. A notification was not provided, in accordance with subsection (h), to the participant or beneficiary and the participant or beneficiary requested through the response protocol of the plan under subsection (f)(3) 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 facility. .
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- 42 USC 300gg–19a
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Sec. 6
Consumer protections through health plan requirement for fair and honest advance cost estimate
Cite42 USC 300gg–19a
Cites 1Cited by 0 across 0 sources