Adjusting surprise medical billing requirements

(a) Amendments to the Public Health Service Act (1) Eliminating independent dispute resolution process (A) In general Section 2799A–1 of the Public Health Service Act (42 U.S.C. 300gg–111) is amended— (i) in subsection (a)— (I) in paragraph (1)(C)(iv)— (aa) in subclause (I), by inserting with respect to such services furnished before January 1, 2028, before not later than; and (bb) in subclause (II), by inserting (or, with respect to such services for which the out-of-network rate is the qualifying payment amount for such services, not later than 30 days after the bill for such services is transmitted by such provider or facility) after subsection (c)(6); and (II) in paragraph (3)(K)(ii)— (aa) in subclause (I), by striking subject to subclause (II) and inserting with respect to items and services furnished before January 1, 2028— (aa) subject to item (bb); (bb) by redesignating subclause (II) as item (bb); and (cc) by adding at the end the following new subclause: (II) with respect to items and services furnished on or after January 1, 2028, the qualifying payment amount (as defined in subparagraph (E) for such year and determined in accordance with rulemaking described in paragraph (2)(B)) for such item or service; or; (ii) in subsection (b)(1)— (I) in subparagraph (C), by inserting with respect to such services furnished before January 1, 2028, before not later than; and (II) in subparagraph (D), by inserting (or, with respect to such services for which the out-of-network rate is the qualifying payment amount for such services, not later than 30 days after the bill for such services is transmitted by such provider) after subsection (c)(6); and (iii) in subsection (c)— (I) in paragraph (1)(A), by inserting ending on or before December 31, 2027, after in a year; and (II) in paragraph (7)— (aa) in subparagraph (A), by inserting ending on or before December 31, 2027 after subsequent year; and (bb) in subparagraph (C), by inserting ending on or before December 31, 2027 after subsequent year. (B) Air ambulance services Section 2799A–2 of the Public Health Service Act (42 U.S.C. 300gg–112) is amended— (i) in subsection (a)(3)— (I) in subparagraph (A), by inserting with respect to such services furnished before January 1, 2028, before not later than; and (II) in subparagraph (B), by inserting (or, with respect to such services for which the out-of-network rate is the qualifying payment amount for such services, not later than 30 days after the bill for such services is transmitted by such provider) after subsection (b)(6); and (ii) in subsection (b)— (I) in paragraph (1)(A), by inserting ending on or before December 31, 2027, after in a year; and (II) in paragraph (7)— (aa) in subparagraph (A), by inserting ending on or before December 31, 2027 after subsequent year; and (bb) in subparagraph (C), by inserting ending on or before December 31, 2027 after subsequent year. (2) Adjusting calculation of qualifying payment amount (A) In general Section 2799A–1(a)(3)(E) of the Public Health Service Act (42 U.S.C. 300gg–111(a)(3)(E)) is amended— (i) in clause (i)— (I) in subclause (I), by striking and at the end; (II) in subclause (II)— (aa) by inserting before 2028 after or a subsequent year; and (bb) by striking the period at the end and inserting a semicolon; and (III) by adding at the end the following new subclauses: (III) for an item or service furnished during 2028, the median of the contracted rates recognized by the plan or issuer, respectively (determined only with respect to such plan or such coverage), as the total payment (including the cost-sharing amount imposed for such item or service and the amount to be paid by the plan or issuer, respectively, and the average expected amount of any incentive-based or retroactive payments or payment adjustments, including risk-sharing payments, bonuses, and penalties) under such plan or coverage, respectively, on January 31, 2019, for the same or a similar item or service that is provided by a provider in the same specialty and provided in the geographic region in which the item or service is furnished, consistent with the methodology established by the Secretary under paragraph (2), excluding any such rate in effect with a provider that did not furnish such item or service during the plan year containing January 31, 2019, increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over 2019 and such percentage increase for each of years 2020 through 2027; and (IV) for an item or service furnished during 2029 or a subsequent year, the qualifying payment amount determined under this clause for such an item or service furnished in the previous year, increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over such previous year.; (ii) in clause (ii)— (I) in the text preceding subclause (I), by inserting in a year before 2028 before in a geographic region; (II) in subclause (II), by striking the period at the end and inserting; and; (III) by redesignating subclauses (I) and (II) as items (aa) and (bb), respectively, and adjusting the margins accordingly; (IV) by striking means, with respect to and inserting the following: means— (I) with respect to; and (V) by adding at the end the following new subclause: (II) with respect to a sponsor of a group health plan or health insurance issuer offering group or individual health insurance coverage in 2028 or a subsequent year that such sponsor or issuer, respectively, did not offer during 2019— (aa) for the first year in which such group health plan, group health insurance coverage, or individual health insurance coverage, respectively, is offered, a rate (determined in accordance with a methodology established by the Secretary) for items and services that are covered by such plan or coverage and furnished during such first year; and (bb) for each subsequent year such group health plan, group health insurance coverage, or individual health insurance coverage, respectively, is offered, the qualifying payment amount determined under this clause for such items and services furnished in the previous year, increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over such previous year.; (iii) in clause (iii)— (I) in the matter preceding subclause (I), by inserting (or clause (i)(III), as applicable) after described in clause (i)(I); (II) in subclause (III)— (aa) by striking or coverage, has and inserting the following: or coverage— (aa) in the case that such first sufficient information year is a year before 2028, has; and (bb) by adding at the end the following new item: (bb) in the case that such first sufficient information year is 2028 or a subsequent year, has the meaning given the term qualifying payment amount in clause (i)(III), except that in applying such clause to such item or service, the reference to furnished during 2028 shall, for first sufficient information years subsequent to 2028, be treated as a reference to furnished during such first sufficient information year, the reference to January 31, 2019 shall be treated as a reference to the first day of such first sufficient information year, and the increase described in such clause shall not be applied; and; and (III) in subclause (IV)— (aa) by striking the period at the end and inserting; and; (bb) by striking or coverage, has and inserting the following: or coverage— (aa) in the case that such first sufficient information year is a year before 2028, has; and (cc) by adding at the end the following new item: (bb) in the case that such first sufficient information year is 2028 or a subsequent year, has the meaning given such term in clause (i)(IV), except that in applying such clause to such item or service, the reference to furnished during 2029 or a subsequent year shall, for first sufficient information years subsequent to 2028, be treated as a reference to furnished during the year after such first sufficient information year or a subsequent year.; and (iv) in clause (v)(II)— (I) in item (aa), by inserting (or clause (i)(III), as applicable) after described in clause (i)(I); and (II) in item (bb), by inserting (or clause (i)(III), as applicable) after described in clause (i)(I). (B) Updated rulemaking Section 2799A–1(a)(2)(B) of the Public Health Service Act (42 U.S.C. 300gg–111(a)(2)(B)) is amended— (i) by redesignating clauses (i) through (iv) as subclauses (I) through (IV), respectively, and adjusting the margins accordingly; (ii) by striking Not later than and inserting the following: (i) Initial rulemaking Not later than; (iii) by inserting before Such rulemaking the following new clause: (ii) Updated rules (I) In general Not later than 180 days after the date of enactment of this clause, the Secretary, in consultation with the Secretary of Labor and the Secretary of the Treasury, shall update the rules issued under clause (i) to revise the methodology the group health plan or health insurance issuer offering group or individual health insurance coverage shall use to determine the qualifying payment amount for an item or service furnished during 2028 or a subsequent year. (II) Expedited rulemaking The Secretary may promulgate an interim final rule to carry out this clause.; (iv) by striking Such rulemaking and inserting the following: (iii) Guidelines The initial rulemaking under clause (i), and the updated rules under clause (ii),; (v) by striking In carrying out clause (iii) and inserting In carrying out clause (i)(III); and (vi) by adding at the end the following new clause: (vi) Judicial review There shall be no judicial review of the methodology for determining the qualifying payment amount established under this subparagraph.. (C) Annual audits Section 2799A–1(a)(2)(A) of the Public Health Service Act (42 U.S.C. 300gg–111(a)(2)(A)) is amended— (i) in clause (ii)— (I) in subclause (I)— (aa) by striking a year (beginning with 2022) and inserting each year beginning with 2022 and ending with 2027; (bb) by striking such clause, with and inserting: such clause— (aa) with; and (cc) by adding at the end the following new item: (bb) with respect to 2028 and each subsequent year, of a sample with respect to such year of claims data from not less than 25 group health plans and health insurance issuers offering group or individual health insurance coverage; and; and (II) in subclause (II), by striking may and inserting shall; and (ii) in clause (iii)— (I) by inserting (and, beginning for 2028, shall make publicly available) after submit to Congress; (II) by striking the period at the end and inserting; and; (III) by striking on the number and inserting: on— (I) the number; and (IV) by adding at the end the following new subclause: (II) the findings of each such audit.. (b) Amendments to the Internal Revenue Code of 1986 (1) Eliminating independent dispute resolution process (A) In general Section 9816 of the Internal Revenue Code of 1986 is amended— (i) in subsection (a)— (I) in paragraph (1)(C)(iv)— (aa) in subclause (I), by inserting with respect to such services furnished before January 1, 2028, before not later than; and (bb) in subclause (II), by inserting (or, with respect to such services for which the out-of-network rate is the qualifying payment amount for such services, not later than 30 days after the bill for such services is transmitted by such provider or facility) after subsection (c)(6); and (II) in paragraph (3)(K)(ii)— (aa) in subclause (I), by striking subject to subclause (II) and inserting with respect to items and services furnished before January 1, 2028— (aa) subject to item (bb); (bb) by redesignating subclause (II) as item (bb); and (cc) by adding at the end the following new subclause: (II) with respect to items and services furnished on or after January 1, 2028, the qualifying payment amount (as defined in subparagraph (E) for such year and determined in accordance with rulemaking described in paragraph (2)(B)) for such item or service; or; (ii) in subsection (b)(1)— (I) in subparagraph (C), by inserting with respect to such services furnished before January 1, 2028, before not later than; and (II) in subparagraph (D), by inserting (or, with respect to such services for which the out-of-network rate is the qualifying payment amount for such services, not later than 30 days after the bill for such services is transmitted by such provider) after subsection (c)(6); and (iii) in subsection (c)— (I) in paragraph (1)(A), by inserting ending on or before December 31, 2027, after in a year; and (II) in paragraph (7)— (aa) in subparagraph (A), by inserting ending on or before December 31, 2027 after subsequent year; and (bb) in subparagraph (C), by inserting ending on or before December 31, 2027 after subsequent year. (B) Air ambulance services Section 9817 of the Internal Revenue Code of 1986 is amended— (i) in subsection (a)(3)— (I) in subparagraph (A), by inserting with respect to such services furnished before January 1, 2028, before not later than; and (II) in subparagraph (B), by inserting (or, with respect to such services for which the out-of-network rate is the qualifying payment amount for such services, not later than 30 days after the bill for such services is transmitted by such provider) after subsection (b)(6); and (ii) in subsection (b)— (I) in paragraph (1)(A), by inserting ending on or before December 31, 2027, after in a year; and (II) in paragraph (7)— (aa) in subparagraph (A), by inserting ending on or before December 31, 2027 after subsequent year; and (bb) in subparagraph (C), by inserting ending on or before December 31, 2027 after subsequent year. (2) Adjusting calculation of qualifying payment amount (A) In general Section 9816(a)(3)(E) of the Internal Revenue Code of 1986 is amended— (i) in clause (i)— (I) in subclause (I), by striking and at the end; (II) in subclause (II)— (aa) by inserting before 2028 after or a subsequent year; and (bb) by striking the period at the end and inserting a semicolon; and (III) by adding at the end the following new subclauses: (III) for an item or service furnished during 2028, the median of the contracted rates recognized by the plan (determined only with respect to such plan), as the total payment (including the cost-sharing amount imposed for such item or service and the amount to be paid by the plan, and the average expected amount of any incentive-based or retroactive payments or payment adjustments, including risk-sharing payments, bonuses, and penalties) under such plan on January 31, 2019, for the same or a similar item or service that is provided by a provider in the same specialty and provided in the geographic region in which the item or service is furnished, consistent with the methodology established by the Secretary under paragraph (2), excluding any such rate in effect with a provider that did not furnish such item or service during the plan year containing January 31, 2019, increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over 2019 and such percentage increase for each of years 2020 through 2027; and (IV) for an item or service furnished during 2029 or a subsequent year, the qualifying payment amount determined under this clause for such an item or service furnished in the previous year, increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over such previous year.; (ii) in clause (ii)— (I) in the text preceding subclause (I), by inserting in a year before 2028 before in a geographic region; (II) in subclause (II), by striking the period at the end and inserting; and; (III) by redesignating subclauses (I) and (II) as items (aa) and (bb), respectively, and adjusting the margins accordingly; (IV) by striking means, with respect to and inserting the following: means— (I) with respect to; and (V) by adding at the end the following new subclause: (II) with respect to a sponsor of a group health plan offered in 2028 or a subsequent year that such sponsor did not offer during 2019— (aa) for the first year in which such group health plan is offered, a rate (determined in accordance with a methodology established by the Secretary) for items and services that are covered by such plan and furnished during such first year; and (bb) for each subsequent year such group health plan is offered, the qualifying payment amount determined under this clause for such items and services furnished in the previous year, increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over such previous year.; (iii) in clause (iii)— (I) in the matter preceding subclause (I), by inserting (or clause (i)(III), as applicable) after described in clause (i)(I); (II) in subclause (III)— (aa) by striking such plan, has and inserting the following: such plan— (aa) in the case that such first sufficient information year is a year before 2028, has; and (bb) by adding at the end the following new item: (bb) in the case that such first sufficient information year is 2028 or a subsequent year, has the meaning given the term qualifying payment amount in clause (i)(III), except that in applying such clause to such item or service, the reference to furnished during 2028 shall, for first sufficient information years subsequent to 2028, be treated as a reference to furnished during such first sufficient information year, the reference to January 31, 2019 shall be treated as a reference to the first day of such first sufficient information year, and the increase described in such clause shall not be applied; and; and (III) in subclause (IV)— (aa) by striking the period at the end and inserting; and; (bb) by striking such plan, has and inserting the following: such plan— (aa) in the case that such first sufficient information year is a year before 2028, has; and (cc) by adding at the end the following new item: (bb) in the case that such first sufficient information year is 2028 or a subsequent year, has the meaning given such term in clause (i)(IV), except that in applying such clause to such item or service, the reference to furnished during 2029 or a subsequent year shall, for first sufficient information years subsequent to 2028, be treated as a reference to furnished during the year after such first sufficient information year or a subsequent year.; and (iv) in clause (v)(II)— (I) in item (aa), by inserting (or clause (i)(III), as applicable) after described in clause (i)(I); and (II) in item (bb), by inserting (or clause (i)(III), as applicable) after described in clause (i)(I). (B) Updated rulemaking Section 9816(a)(2)(B) of the Internal Revenue Code of 1986 is amended— (i) by redesignating clauses (i) through (iv) as subclauses (I) through (IV), respectively, and adjusting the margins accordingly; (ii) by striking Not later than and inserting the following: (i) Initial rulemaking Not later than; (iii) by inserting before Such rulemaking the following new clause: (ii) Updated rules (I) In general Not later than 180 days after the date of enactment of this clause, the Secretary, in consultation with the Secretary of Labor and the Secretary of Health and Human Services, shall update the rules issued under clause (i) to revise the methodology the group health plan shall use to determine the qualifying payment amount for an item or service furnished during 2028 or a subsequent year. (II) Expedited rulemaking The Secretary may promulgate an interim final rule to carry out this clause.; (iv) by striking Such rulemaking and inserting the following: (iii) Guidelines The initial rulemaking under clause (i), and the updated rules under clause (ii),; (v) by striking In carrying out clause (iii) and inserting In carrying out clause (i)(III); and (vi) by adding at the end the following new clause: (vi) Judicial review There shall be no judicial review of the methodology for determining the qualifying payment amount established under this subparagraph.. (C) Annual audits Section 9816(a)(2)(A) of the Internal Revenue Code of 1986 is amended— (i) in clause (ii)— (I) in subclause (I)— (aa) by striking a year (beginning with 2022) and inserting each year beginning with 2022 and ending with 2027; (bb) by striking such clause, with and inserting: such clause— (aa) with; and (cc) by adding at the end the following new item: (bb) with respect to 2028 and each subsequent year, of a sample with respect to such year of claims data from not less than 25 group health plans; and; and (II) in subclause (II), by striking may and inserting shall; and (ii) in clause (iii)— (I) by inserting (and, beginning for 2028, shall make publicly available) after submit to Congress; (II) by striking the period at the end and inserting; and; (III) by striking on the number and inserting: on— (I) the number; and (IV) by adding at the end the following new subclause: (II) the findings of each such audit.. (c) Amendments to the Employee Retirement Income Security Act of 1974 (1) Eliminating independent dispute resolution process (A) In general Section 716 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185e) is amended— (i) in subsection (a)— (I) in paragraph (1)(C)(iv)— (aa) in subclause (I), by inserting with respect to such services furnished before January 1, 2028, before not later than; and (bb) in subclause (II), by inserting (or, with respect to such services for which the out-of-network rate is the qualifying payment amount for such services, not later than 30 days after the bill for such services is transmitted by such provider or facility) after subsection (c)(6); and (II) in paragraph (3)(K)(ii)— (aa) in subclause (I), by striking subject to subclause (II) and inserting with respect to items and services furnished before January 1, 2028— (aa) subject to item (bb); (bb) by redesignating subclause (II) as item (bb); and (cc) by adding at the end the following new subclause: (II) with respect to items and services furnished on or after January 1, 2028, the qualifying payment amount (as defined in subparagraph (E) for such year and determined in accordance with rulemaking described in paragraph (2)(B)) for such item or service; or; (ii) in subsection (b)(1)— (I) in subparagraph (C), by inserting with respect to such services furnished before January 1, 2028, before not later than; and (II) in subparagraph (D), by inserting (or, with respect to such services for which the out-of-network rate is the qualifying payment amount for such services, not later than 30 days after the bill for such services is transmitted by such provider) after subsection (c)(6); and (iii) in subsection (c)— (I) in paragraph (1)(A), by inserting ending on or before December 31, 2027, after in a year; and (II) in paragraph (7)— (aa) in subparagraph (A), by inserting ending on or before December 31, 2027 after subsequent year; and (bb) in subparagraph (C), by inserting ending on or before December 31, 2027 after subsequent year. (B) Air ambulance services Section 717 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185f) is amended— (i) in subsection (a)(3)— (I) in subparagraph (A), by inserting with respect to such services furnished before January 1, 2028, before not later than; and (II) in subparagraph (B), by inserting (or, with respect to such services for which the out-of-network rate is the qualifying payment amount for such services, not later than 30 days after the bill for such services is transmitted by such provider) after subsection (b)(6); and (ii) in subsection (b)— (I) in paragraph (1)(A), by inserting ending on or before December 31, 2027, after in a year; and (II) in paragraph (7)— (aa) in subparagraph (A), by inserting ending on or before December 31, 2027 after subsequent year; and (bb) in subparagraph (C), by inserting ending on or before December 31, 2027 after subsequent year. (2) Adjusting calculation of qualifying payment amount (A) In general Section 716(a)(3)(E) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185e(a)(3)(E)) is amended— (i) in clause (i)— (I) in subclause (I), by striking and at the end; (II) in subclause (II)— (aa) by inserting before 2028 after or a subsequent year; and (bb) by striking the period at the end and inserting a semicolon; and (III) by adding at the end the following new subclauses: (III) for an item or service furnished during 2028, the median of the contracted rates recognized by the plan or issuer, respectively (determined only with respect to such plan or such coverage), as the total payment (including the cost-sharing amount imposed for such item or service and the amount to be paid by the plan or issuer, respectively, and the average expected amount of any incentive-based or retroactive payments or payment adjustments, including risk-sharing payments, bonuses, and penalties) under such plan or coverage, respectively, on January 31, 2019, for the same or a similar item or service that is provided by a provider in the same specialty and provided in the geographic region in which the item or service is furnished, consistent with the methodology established by the Secretary under paragraph (2), excluding any such rate in effect with a provider that did not furnish such item or service during the plan year containing January 31, 2019, increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over 2019 and such percentage increase for each of years 2020 through 2027; and (IV) for an item or service furnished during 2029 or a subsequent year, the qualifying payment amount determined under this clause for such an item or service furnished in the previous year, increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over such previous year.; (ii) in clause (ii)— (I) in the text preceding subclause (I), by inserting in a year before 2028 before in a geographic region; (II) in subclause (II), by striking the period at the end and inserting; and; (III) by redesignating subclauses (I) and (II) as items (aa) and (bb), respectively, and adjusting the margins accordingly; (IV) by striking means, with respect to and inserting the following: means— (I) with respect to; and (V) by adding at the end the following new subclause: (II) with respect to a sponsor of a group health plan or health insurance issuer offering group health insurance coverage in 2028 or a subsequent year that such sponsor or issuer, respectively, did not offer during 2019— (aa) for the first year in which such group health plan or group health insurance coverage, respectively, is offered, a rate (determined in accordance with a methodology established by the Secretary) for items and services that are covered by such plan or coverage and furnished during such first year; and (bb) for each subsequent year such group health plan or group health insurance coverage, respectively, is offered, the qualifying payment amount determined under this clause for such items and services furnished in the previous year, increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over such previous year.; (iii) in clause (iii)— (I) in the matter preceding subclause (I), by inserting (or clause (i)(III), as applicable) after described in clause (i)(I); (II) in subclause (III)— (aa) by striking or coverage, has and inserting the following: or coverage— (aa) in the case that such first sufficient information year is a year before 2028, has; and (bb) by adding at the end the following new item: (bb) in the case that such first sufficient information year is 2028 or a subsequent year, has the meaning given the term qualifying payment amount in clause (i)(III), except that in applying such clause to such item or service, the reference to furnished during 2028 shall, for first sufficient information years subsequent to 2028, be treated as a reference to furnished during such first sufficient information year, the reference to January 31, 2019 shall be treated as a reference to the first day of such first sufficient information year, and the increase described in such clause shall not be applied; and; and (III) in subclause (IV)— (aa) by striking the period at the end and inserting; and; (bb) by striking or coverage, has and inserting the following: or coverage— (aa) in the case that such first sufficient information year is a year before 2028, has; and (cc) by adding at the end the following new item: (bb) in the case that such first sufficient information year is 2028 or a subsequent year, has the meaning given such term in clause (i)(IV), except that in applying such clause to such item or service, the reference to furnished during 2029 or a subsequent year shall, for first sufficient information years subsequent to 2028, be treated as a reference to furnished during the year after such first sufficient information year or a subsequent year.; and (iv) in clause (v)(II)— (I) in item (aa), by inserting (or clause (i)(III), as applicable) after described in clause (i)(I); and (II) in item (bb), by inserting (or clause (i)(III), as applicable) after described in clause (i)(I). (B) Updated rulemaking Section 716(a)(2) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185e(a)(2)) is amended— (i) by redesignating subparagraphs (A) through (D) as clauses (i) through (iv), respectively, and adjusting the margins accordingly; (ii) by striking Not later than and inserting the following: (A) Initial rulemaking Not later than; (iii) by inserting before Such rulemaking the following new clause: (B) Updated rules (i) In general Not later than 180 days after the date of enactment of this clause, the Secretary, in consultation with the Secretary of the Treasury and the Secretary of Health and Human Services, shall update the rules issued under subparagraph (A) to revise the methodology the group health plan or health insurance issuer offering group health insurance coverage shall use to determine the qualifying payment amount for an item or service furnished during 2028 or a subsequent year. (ii) Expedited rulemaking The Secretary may promulgate an interim final rule to carry out this subparagraph.; (iv) by striking Such rulemaking and inserting the following: (C) Guidelines The initial rulemaking under subparagraph (A), and the updated rules under subparagraph (B),; (v) by striking In carrying out clause (iii) and inserting In carrying out subparagraph (A)(iii); and (vi) by adding at the end the following new subparagraph: (D) Judicial review There shall be no judicial review of the methodology for determining the qualifying payment amount established under this paragraph..