Sec. 304. Protecting patients and improving the accuracy of provider directory information

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Subpart II of part A of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg–11 et seq.), as amended by sections 301 and 302, is further amended by adding at the end the following: Beginning on the date that is one year after the date of enactment of this section, a group health plan or a health insurance issuer offering group or individual health insurance coverage shall— establish business processes to ensure that all enrollees in such plan or coverage receive proof of a health care provider’s network status— through a written electronic communication from the plan or issuer to the enrollee, as soon as practicable and not later than 1 business day after a telephone inquiry is made by such enrollee for such information; and in real-time through an online health care provider directory search tool maintained by the plan or issuer; and include in any print directory a disclosure that the information included in the directory is accurate as of the date of the last data update and that enrollees or prospective enrollees should consult the group health plan or issuer’s electronic provider directory on its website or call a specified customer service telephone number to obtain the most current provider directory information.

Beginning on the date that is one year after the date of enactment of the Lower Health Care Costs Act , a group health plan or a health insurance issuer offering group or individual health insurance coverage shall establish business processes to— verify and update, at least once every 90 days, the provider directory information for all providers included in the online health care provider directory search tool described in paragraph (1)(A)(ii); and remove any provider from such online directory search tool if such provider has not verified the directory information within the previous 6 months or the plan or issuer has been unable to verify the provider's network participation.

A group health plan or a health insurance issuer offering group or individual health insurance coverage shall not apply, and shall ensure that no provider applies cost-sharing to an enrollee for treatment or services provided by a health care provider in excess of the normal cost-sharing applied for in-network care (including any balance bill issued by the health care provider involved), if such enrollee, or health care provider referring such enrollee, demonstrates (based on the electronic information described in subsection (a)(1)(A)(i) or a copy of the online provider directory described in subsection (a)(1)(A)(ii) on the date the enrollee attempted to obtain the provider’s network status) that the enrollee relied on the information described in subsection (a)(1), if the provider’s network status or directory information on such directory was incorrect at the time the treatment or services involved was provided.

If a health care provider submits a bill to an enrollee in violation of paragraph (1), and the enrollee pays such bill, the provider shall reimburse the enrollee for the full amount paid by the enrollee in excess of the in-network cost-sharing amount for the treatment or services involved, plus interest, at an interest rate determined by the Secretary. A health care provider shall have in place business processes to ensure the timely provision of provider directory information to a group health plan or a health insurance issuer offering group or individual health insurance coverage to support compliance by such plans or issuers with subsection (a)(1).

Such providers shall submit provider directory information to a plan or issuers, at a minimum— when the provider begins a network agreement with a plan or with an issuer with respect to certain coverage; when the provider terminates a network agreement with a plan or with an issuer with respect to certain coverage; when there are material changes to the content of provider directory information described in subsection (a)(1); and every 90 days throughout the duration of the network agreement with a plan or issuer.

Subject to paragraph (2), a health care provider that violates a requirement under subsection

(c)or takes actions that prevent a group health plan or health insurance issuer from complying with subsection (a)(1) or

(b)shall be subject to a civil monetary penalty of not more than $10,000 for each act constituting such violation. The Secretary may waive the penalty described under paragraph

(1)with respect to a health care provider that unknowingly violates subsection (b)(1) with respect to an enrollee if such provider rescinds the bill involved and, if applicable, reimburses the enrollee within 30 days of the date on which the provider billed the enrollee in violation of such subsection. The provisions of section 1128A of the Social Security Act, other than subsections

(a)and

(b)and the first sentence of subsection (c)(1) of such section, shall apply to civil money penalties under this subsection in the same manner as such provisions apply to a penalty or proceeding under section 1128A of the Social Security Act. Nothing in this section shall prohibit a provider from requiring in the terms of a contract, or contract termination, with a group health plan or health insurance issuer— that the plan or issuer remove, at the time of termination of such contract, the provider from a directory of the plan or issuer described in subsection (a)(1); or that the plan or issuer bear financial responsibility, including under subsection (b), for providing inaccurate network status information to an enrollee. For purposes of this section, the term provider directory information includes the names, addresses, specialty, and telephone numbers of individual health care providers, and the names, addresses, and telephone numbers of each medical group, clinic, or facility contracted to participate in any of the networks of the group health plan or health insurance coverage involved. Nothing in this section shall be construed to preempt any provision of State law relating to health care provider directories or network adequacy. .

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42 USC 300gg–11

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Sec. 304

Protecting patients and improving the accuracy of provider directory information

Cite42 USC 300gg–11

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