Fair and Honest Advance Cost Estimate for Patients Act of 2020

I 116TH CONGRESS 2D SESSION H. R. 5817 To amend title XXVII of the Public Health Service Act, the Internal Revenue Code of 1986, and the Employee Retirement Income Security Act of 1974 to require health plans to provide to participants, beneficiaries, and enrollees an advanced explanation of benefits with respect to items and services scheduled to be received from providers and facilities and to amend title XI of the Social Security Act to require health care providers and health care facilities to provide good faith estimates of the expected charges for furnishing such items and services. IN THE HOUSE OF REPRESENTATIVES FEBRUARY 7, 2020 Mr. NUNES (for himself and Mr. PASCRELL) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Labor, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdic- tion of the committee concerned A BILL To amend title XXVII of the Public Health Service Act, the Internal Revenue Code of 1986, and the Employee Retirement Income Security Act of 1974 to require health plans to provide to participants, beneficiaries, and enrollees an advanced explanation of benefits with re- spect to items and services scheduled to be received from providers and facilities and to amend title XI of the Social Security Act to require health care providers and health care facilities to provide good faith estimates of VerDate Sep 11 2014 01:25 Feb 13, 2020 Jkt 099200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6652 E:\BILLS\H5817.IH H5817 pamtmann on DSKBC07HB2PROD with BILLS 2 •HR 5817 IH the expected charges for furnishing such items and serv- ices. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Fair and Honest Ad- 4 vance Cost Estimate for Patients Act of 2020’’. 5 SEC. 2. ADVANCED EXPLANATION OF BENEFITS. 6 (a) HEALTH PLAN REQUIREMENTS.— 7 (1) PUBLIC HEALTH SERVICE ACT AMEND- 8 MENT.—Subpart II of part A of title XXVII of the 9 Public Health Service Act (42 U.S.C. 300gg–11 et 10 seq.) is amended by adding at the end the following 11 new section: 12 ‘‘SEC. 2730. ADVANCED EXPLANATION OF BENEFITS. 13 ‘‘(a) IN GENERAL.—Beginning on January 1, 2022, 14 each health plan shall, with respect to a notification sub- 15 mitted under section 1128A(t)(1)(B) of the Social Secu- 16 rity Act by a health care provider or health care facility, 17 respectively, to the health plan for a participant, bene- 18 ficiary, or enrollee under such health plan scheduled to 19 receive an item or service from the provider or facility, 20 not later than 1 business day (or, in the case such item 21 or service was so scheduled at least 10 business days be- 22 fore such item or service is to be furnished (or in the case 23 such notification was made pursuant to a request by such 24 VerDate Sep 11 2014 01:25 Feb 13, 2020 Jkt 099200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H5817.IH H5817 pamtmann on DSKBC07HB2PROD with BILLS 3 •HR 5817 IH participant, beneficiary, or enrollee), 3 business days) 1 after the date on which the health plan receives such noti- 2 fication, provide to the participant, beneficiary, or enrollee 3 (through mail or electronic means, as requested by the 4 participant, beneficiary, or enrollee) a notification includ- 5 ing the following: 6 ‘‘(1) Whether or not the provider or facility is 7 a participating provider or a participating facility 8 with respect to the health plan with respect to the 9 furnishing of such item or service and— 10 ‘‘(A) in the case the provider or facility is 11 a participating provider or facility with respect 12 to the health plan with respect to the furnishing 13 of such item or service, the contracted rate 14 under such plan for such item or service; and 15 ‘‘(B) in the case the provider or facility is 16 a nonparticipating provider or facility with re- 17 spect to such plan, a description of how such 18 participant, beneficiary, or enrollee may obtain 19 information on providers and facilities that, 20 with respect to such health plan, are partici- 21 pating providers and facilities. 22 ‘‘(2) The good faith estimate included in the 23 notification received from the provider or facility. 24 VerDate Sep 11 2014 01:25 Feb 13, 2020 Jkt 099200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H5817.IH H5817 pamtmann on DSKBC07HB2PROD with BILLS 4 •HR 5817 IH ‘‘(3) A good faith estimate of the amount the 1 health plan is responsible for paying for items and 2 services included in the estimate described in para- 3 graph (2). 4 ‘‘(4) A good faith estimate of the amount of 5 any cost-sharing (including with respect to the de- 6 ductible and any copayment or coinsurance obliga- 7 tion) for which the participant, beneficiary, or en- 8 rollee would be responsible for such item or service 9 (as of the date of such notification). 10 ‘‘(5) A good faith estimate of the amount that 11 the participant, beneficiary, or enrollee has incurred 12 toward meeting the limit of the financial responsi- 13 bility (including with respect to deductibles and out- 14 of-pocket maximums) under the health plan (as of 15 the date of such notification). 16 ‘‘(6) In the case such item or service is subject 17 to a medical management technique (including con- 18 current review, prior authorization, and step-therapy 19 or fail-first protocols) for coverage under the health 20 plan, a disclaimer that coverage for such item or 21 service is subject to such medical management tech- 22 nique. 23 ‘‘(7) A disclaimer that the information provided 24 in the notification is only an estimate based on the 25 VerDate Sep 11 2014 01:25 Feb 13, 2020 Jkt 099200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H5817.IH H5817 pamtmann on DSKBC07HB2PROD with BILLS 5 •HR 5817 IH items and services reasonably expected, at the time 1 of scheduling (or requesting) the item or service, to 2 be furnished and is subject to change. 3 ‘‘(8) Any other information or disclaimer the 4 health plan determines appropriate that is consistent 5 with information and disclaimers required under this 6 section. 7 ‘‘(b) HEALTH PLAN DEFINED.—In this section, the 8 term ‘health plan’ means a group health plan and health 9 insurance coverage offered by a heath insurance issuer in 10 the group or individual market and includes a grand- 11 fathered health plan (as defined in section 1251(e) of the 12 Patient Protection and Affordable Care Act).’’. 13 (2) INTERNAL REVENUE CODE OF 1986 AMEND- 14 MENT.— 15 (A) IN GENERAL.—Subchapter B of chap- 16 ter 100 of the Internal Revenue Code of 1986 17 is amended by adding at the end the following 18 new section: 19 ‘‘SEC. 9816. ADVANCED EXPLANATION OF BENEFITS. 20 ‘‘(a) IN GENERAL.—Beginning on January 1, 2022, 21 each health plan shall, with respect to a notification sub- 22 mitted under section 1128A(t)(1)(B) of the Social Secu- 23 rity Act by a health care provider or health care facility, 24 respectively, to the health plan for a participant or bene- 25 VerDate Sep 11 2014 01:25 Feb 13, 2020 Jkt 099200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H5817.IH H5817 pamtmann on DSKBC07HB2PROD with BILLS 6 •HR 5817 IH ficiary under such health plan scheduled to receive an item 1 or service from the provider or facility, not later than 1 2 business day (or, in the case such item or service was so 3 scheduled at least 10 business days before such item or 4 service is to be furnished (or in the case such notification 5 was made pursuant to a request by such participant or 6 beneficiary), 3 business days) after the date on which the 7 health plan receives such notification, provide to the par- 8 ticipant or beneficiary (through mail or electronic means, 9 as requested by the participant or beneficiary) a notifica- 10 tion including the following: 11 ‘‘(1) Whether or not the provider or facility is 12 a participating provider or a participating facility 13 with respect to the health plan with respect to the 14 furnishing of such item or service and— 15 ‘‘(A) in the case the provider or facility is 16 a participating provider or facility with respect 17 to the health plan with respect to the furnishing 18 of such item or service, the contracted rate 19 under such plan for such item or service; and 20 ‘‘(B) in the case the provider or facility is 21 a nonparticipating provider or facility with re- 22 spect to such plan, a description of how such 23 participant or beneficiary may obtain informa- 24 tion on providers and facilities that, with re- 25 VerDate Sep 11 2014 01:25 Feb 13, 2020 Jkt 099200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H5817.IH H5817 pamtmann on DSKBC07HB2PROD with BILLS 7 •HR 5817 IH spect to such health plan, are participating pro- 1 viders and facilities. 2 ‘‘(2) The good faith estimate included in the 3 notification received from the provider or facility. 4 ‘‘(3) A good faith estimate of the amount the 5 health plan is responsible for paying for items and 6 services included in the estimate described in para- 7 graph (2). 8 ‘‘(4) A good faith estimate of the amount of 9 any cost-sharing (including with respect to the de- 10 ductible and any copayment or coinsurance obliga- 11 tion) for which the participant or beneficiary would 12 be responsible for such item or service (as of the 13 date of such notification). 14 ‘‘(5) A good faith estimate of the amount that 15 the participant or beneficiary has incurred toward 16 meeting the limit of the financial responsibility (in- 17 cluding with respect to deductibles and out-of-pocket 18 maximums) under the health plan (as of the date of 19 such notification). 20 ‘‘(6) In the case such item or service is subject 21 to a medical management technique (including con- 22 current review, prior authorization, and step-therapy 23 or fail-first protocols) for coverage under the health 24 plan, a disclaimer that coverage for such item or 25 VerDate Sep 11 2014 01:25 Feb 13, 2020 Jkt 099200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H5817.IH H5817 pamtmann on DSKBC07HB2PROD with BILLS 8 •HR 5817 IH service is subject to such medical management tech- 1 nique. 2 ‘‘(7) A disclaimer that the information provided 3 in the notification is only an estimate based on the 4 items and services reasonably expected, at the time 5 of scheduling (or requesting) the item or service, to 6 be furnished and is subject to change. 7 ‘‘(8) Any other information or disclaimer the 8 health plan determines appropriate that is consistent 9 with information and disclaimers required under this 10 section. 11 ‘‘(b) HEALTH PLAN DEFINED.—In this section, the 12 term ‘health plan’ means a group health plan, including 13 any group health plan that is a grandfathered health plan 14 (as defined in section 1251(e) of the Patient Protection 15 and Affordable Care Act).’’. 16 (B) CONFORMING AMENDMENT.—Section 17 9815(a) of the Internal Revenue Code of 1986 18 is amended— 19 (i) in paragraph (1), by striking ‘‘(as 20 amended by the Patient Protection and Af- 21 fordable Care Act)’’ and inserting ‘‘(other 22 than the provisions of section 2730 of such 23 Act)’’; and 24 VerDate Sep 11 2014 01:25 Feb 13, 2020 Jkt 099200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H5817.IH H5817 pamtmann on DSKBC07HB2PROD with BILLS 9 •HR 5817 IH (ii) in paragraph (2), by inserting 1 ‘‘(other than the provisions of section 2730 2 of such Act)’’ after ‘‘a provision of such 3 part A’’. 4 (C) CLERICAL AMENDMENT.—The table of 5 sections for such subchapter is amended by 6 adding at the end the following new item: 7 ‘‘Sec. 9816. Advanced explanation of benefits.’’. (3) EMPLOYEE RETIREMENT INCOME SECURITY 8 ACT OF 1974 AMENDMENT.— 9 (A) IN GENERAL.—Subpart B of part 7 of 10 subtitle B of title I of the Employee Retirement 11 Income Security Act of 1974 (29 U.S.C. 1185 12 et seq.) is amended by adding at the end the 13 following new section: 14 ‘‘SEC. 716. ADVANCED EXPLANATION OF BENEFITS. 15 ‘‘(a) IN GENERAL.—Beginning on January 1, 2022, 16 each health plan shall, with respect to a notification sub- 17 mitted under section 1128A(t)(1)(B) of the Social Secu- 18 rity Act by a health care provider or health care facility, 19 respectively, to the health plan for a participant or bene- 20 ficiary under such health plan scheduled to receive an item 21 or service from the provider or facility, not later than 1 22 business day (or, in the case such item or service was so 23 scheduled at least 10 business days before such item or 24 service is to be furnished (or in the case such notification 25 VerDate Sep 11 2014 01:25 Feb 13, 2020 Jkt 099200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H5817.IH H5817 pamtmann on DSKBC07HB2PROD with BILLS 10 •HR 5817 IH was made pursuant to a request by such participant or 1 beneficiary), 3 business days) after the date on which the 2 health plan receives such notification, provide to the par- 3 ticipant or beneficiary (through mail or electronic means, 4 as requested by the participant or beneficiary) a notifica- 5 tion including the following: 6 ‘‘(1) Whether or not the provider or facility is 7 a participating provider or a participating facility 8 with respect to the health plan with respect to the 9 furnishing of such item or service and— 10 ‘‘(A) in the case the provider or facility is 11 a participating provider or facility with respect 12 to the health plan with respect to the furnishing 13 of such item or service, the contracted rate 14 under such plan for such item or service; and 15 ‘‘(B) in the case the provider or facility is 16 a nonparticipating provider or facility with re- 17 spect to such plan, a description of how such 18 participant or beneficiary may obtain informa- 19 tion on providers and facilities that, with re- 20 spect to such health plan, are participating pro- 21 viders and facilities. 22 ‘‘(2) The good faith estimate included in the 23 notification received from the provider or facility. 24 VerDate Sep 11 2014 01:25 Feb 13, 2020 Jkt 099200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H5817.IH H5817 pamtmann on DSKBC07HB2PROD with BILLS 11 •HR 5817 IH ‘‘(3) A good faith estimate of the amount the 1 health plan is responsible for paying for items and 2 services included in the estimate described in para- 3 graph (2). 4 ‘‘(4) A good faith estimate of the amount of 5 any cost-sharing (including with respect to the de- 6 ductible and any copayment or coinsurance obliga- 7 tion) for which the participant or beneficiary would 8 be responsible for such item or service (as of the 9 date of such notification). 10 ‘‘(5) A good faith estimate of the amount that [Text truncated for display. 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