H.R. 5817 - Fair and Honest Advance Cost Estimate for Patients Act of 2020

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the "Fair and Honest Advance Cost Estimate for Patients Act of 2020".

SEC. 2. ADVANCED EXPLANATION OF BENEFITS.

(a) HEALTH PLAN REQUIREMENTS. —

(1) PUBLIC HEALTH SERVICE ACT AMENDMENT. — Subpart II of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–11 et seq.) is amended by adding at the end the following new section:

"SEC. 2730. ADVANCED EXPLANATION OF BENEFITS.

"(a) IN GENERAL. — Beginning on January 1, 2022, each health plan shall, with respect to a notification submitted under section 1128A(t)(1)(B) 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 including the following:

"(1) 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 —

"(A) 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

"(B) in the case the provider or facility is a nonparticipating provider or facility with respect to such plan, a description of how such participant, beneficiary, or enrollee may obtain information on providers and facilities that, with respect to such health plan, are participating providers and facilities.

"(2) The good faith estimate included in the notification received from the provider or facility.

"(3) 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).

"(4) 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).

"(5) 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).

"(6) 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.

"(7) 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.

"(8) Any other information or disclaimer the health plan determines appropriate that is consistent with information and disclaimers required under this section.

"(b) HEALTH PLAN DEFINED. — In this section, the term 'health plan' means a group health plan and health insurance coverage offered by a health insurance issuer in the group or individual market and includes a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act).".

(2) INTERNAL REVENUE CODE OF 1986 AMENDMENT. —

(A) IN GENERAL. — Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:

"SEC. 9816. ADVANCED EXPLANATION OF BENEFITS.

"(a) IN GENERAL. — Beginning on January 1, 2022, each health plan shall, with respect to a notification submitted under section 1128A(t)(1)(B) 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 including the following:

"(1) 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 —

"(A) 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

B) in the case the provider or facility is a nonparticipating provider or facility with respect to such plan, a description of how such participant or beneficiary may obtain information on providers and facilities that, with respect to such health plan, are participating providers and facilities.

"(2) The good faith estimate included in the notification received from the provider or facility.

"(3) 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).

"(4) 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).

"(5) 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).

"(6) 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.

"(7) 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.

"(8) Any other information or disclaimer the health plan determines appropriate that is consistent with information and disclaimers required under this section.

"(b) HEALTH PLAN DEFINED. — In this section, the term 'health plan' means a group health plan, including any group health plan that is a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act).".

(B) CONFORMING AMENDMENT. — Section 9815(a) of the Internal Revenue Code of 1986 is amended —

(i) in paragraph (1), by striking "(as amended by the Patient Protection and Affordable Care Act)" and inserting "(other than the provisions of section 2730 of such Act)"; and

(ii) in paragraph (2), by inserting "(other than the provisions of section 2730 of such Act)" after "a provision of such part A".

(C) CLERICAL AMENDMENT. — The table of sections for such subchapter is amended by adding at the end the following new item:

"Sec. 9816. Advanced explanation of benefits.".

(3) EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 AMENDMENT. —

(A) IN GENERAL. — Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the following new section:

"SEC. 716. ADVANCED EXPLANATION OF BENEFITS.

"(a) IN GENERAL. — Beginning on January 1, 2022, each health plan shall, with respect to a notification submitted under section 1128A(t)(1)(B) 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 including the following:

"(1) 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 —

"(A) 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

"(B) in the case the provider or facility is a nonparticipating provider or facility with respect to such plan, a description of how such participant or beneficiary may obtain information on providers and facilities that, with respect to such health plan, are participating providers and facilities.

"(2) The good faith estimate included in the notification received from the provider or facility.

"(3) 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).

"(4) 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).

"(5) 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).

"(6) 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.

"(7) 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.

"(8) Any other information or disclaimer the health plan determines appropriate that is consistent with information and disclaimers required under this section.

"(b) HEALTH PLAN DEFINED. — In this section, the term 'health plan' means a group health plan and health insurance coverage offered by a health insurance issuer in the group market and includes a grandfathered health plan (as defined in section 1251(e) of the Patient Protection and Affordable Care Act) that is such a plan or coverage.".

(B) CONFORMING AMENDMENT. — Section 715(a) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185d(a)) is amended —

(i) in paragraph (1), by striking "(as amended by the Patient Protection and Affordable Care Act)" and inserting "(other than the provisions of section 2730 of such Act)"; and

(ii) in paragraph (2), by inserting "(other than the provisions of section 2730 of such Act)" after "a provision of such part A".

(C) CLERICAL AMENDMENT. — The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 is amended by inserting after the item relating to section 714 the following new items:

"Sec. 715. Additional market reforms.

"Sec. 716. Advanced explanation of benefits.".

(b) HEALTH CARE PROVIDERS AND FACILITIES. — Section 1128A of the Social Security Act (42 U.S.C. 1320a–7a) is amended by adding at the end the following new subsection:

"(t)(1) Each health care provider and health care facility shall, beginning January 1, 2022, in the case of an individual who schedules an item or service to be furnished to such individual by such provider or facility at least 3 business days before the date such item or service is to be so furnished, not later than 1 business day after the date of such scheduling (or, in the case of such an item or service scheduled at least 10 business days before the date such item or service is to be so furnished (or if requested by the individual), not later than 3 business days after the date of such scheduling or such request) —

"(A) inquire if such individual is enrolled in a group health plan, group or individual health insurance coverage offered by a health insurance issuer, or a Federal health care program (and if is so enrolled in such plan or coverage, seeking to have a claim for such item or service submitted to such plan or coverage); and

"(B) provide a notification of the good faith estimate of the expected charges for furnishing such item or service (including any item or service that is reasonably expected to be provided in conjunction with such scheduled item or service) to —

"(i) in the case the individual is enrolled in such a plan or such coverage (and is seeking to have a claim for such item or service submitted to such plan or coverage), such plan or issuer of such coverage; and

"(ii) in the case the individual is not described in clause (i) and not enrolled in a Federal health care program, the individual.

"(2) Each health care provider or health care facility that fails to provide the estimate as required under paragraph (1) shall be subject to a civil monetary penalty in an amount not to exceed $10,000 for each such failure. The provisions of this section (other than subsection (a), subsection (b), the first sentence of subsection (c)(1), and subsection (o)) shall apply to a civil monetary penalty imposed under the preceding sentence in the same manner as such provisions apply to a penalty or proceeding under subsection (a).

"(3) In this subsection —

"(A) the terms 'health insurance issuer', 'group health plan', 'group health insurance coverage', and 'individual health insurance coverage' have the meaning given such terms, respectively, in section 2791 of the Public Health Service Act; and

"(B) the term 'Federal health care program' has the meaning given such term in section 1128B(f).".