Requirement for explanation of benefits

(a) PHSA Amendments (1) Emergency services Section 2799A–1(f)(1)(C) of the Public Health Service Act (42 U.S.C. 300gg–111(f)(1)(C)) is amended to read as follows: (C) A good faith estimate of the amount the plan or coverage is responsible for paying for items and services included in the estimate described in subparagraph (B), including a plain language description of each item or service and all applicable billing codes for each item or service, including modifiers, using standard and commonly recognized billing code sets that are clearly identified.. (2) Explanation of benefits Section 2799A–1 of the Public Health Service Act (42 U.S.C. 300gg–111) is amended by adding at the end the following: (g) Explanation of benefits (1) In general For plan years beginning on or after January 1, 2026, each group health plan, or a health insurance issuer offering group or individual health insurance coverage shall, within 45 days of receiving any request for payment for an item or service under the plan, 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 and utilizing substantially the same format as the advanced explanation of benefits required by subsection (f) to enable comparison) including the following: (A) Whether or not the provider or facility is a participating provider or a participating facility with respect to the plan or coverage with respect to the furnishing of such item or service. (B) An itemized explanation of benefits that includes the following: (i) A plain language description of each item or service. (ii) All applicable billing codes for each item or service, including modifiers, using standard and commonly recognized billing code sets that are clearly identified. (iii) The amount the plan or coverage is responsible for paying for each item or service. (iv) The amount of any cost-sharing for which the participant, beneficiary, or enrollee is responsible for each item or service (as of the date of such notification). (v) 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 plan or coverage (as of the date of such notification). (vi) The site of each item or service. (2) Format If applicable, the notification described in paragraph (1) may be provided in conjunction with, or as part of, a notice of a claim determination or other communication required by section 2719(a) (42 U.S.C. 300gg–19(a)), or regulations thereunder. (h) Regulations The Secretary shall implement this section through notice and comment rulemaking in accordance with section 553 of title 5, United States Code.. (b) IRC amendments (1) Emergency services Section 9816(f)(1)(C) of the Internal Revenue Code of 1986 is amended to read as follows: (C) A good faith estimate of the amount the plan is responsible for paying for items and services included in the estimate described in subparagraph (B), including a plain language description of each item or service and all applicable billing codes for each item or service, including modifiers, using standard and commonly recognized billing code sets that are clearly identified.. (2) Explanation of benefits Section 9816 of the Internal Revenue Code of 1986 is amended by adding at the end the following: (g) Explanation of benefits (1) In general For plan years beginning on or after January 1, 2026, each group health plan shall, within 45 days of receiving any request for payment for an item or service under the plan, 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 and utilizing substantially the same format as the advanced explanation of benefits required by subsection (f) to enable comparison) including the following: (A) Whether or not the provider or facility is a participating provider or a participating facility with respect to the plan with respect to the furnishing of such item or service. (B) An itemized explanation of benefits that includes the following: (i) A plain language description of each item or service. (ii) All applicable billing codes for each item or service, including modifiers, using standard and commonly recognized billing code sets that are clearly identified. (iii) The amount the plan is responsible for paying for each item or service. (iv) The amount of any cost-sharing for which the participant or beneficiary is responsible for each item or service (as of the date of such notification). (v) 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 plan (as of the date of such notification). (vi) The site of each item or service. (2) Format If applicable, the notification described in paragraph (1) may be provided in conjunction with, or as part of, a notice of a claim determination or other communication required by section 503 of the Employee Retirement Income Security Act of 1974 or regulations thereunder. (h) Regulations The Secretary shall implement this section through notice and comment rulemaking in accordance with section 553 of title 5, United States Code.. (c) ERISA amendments (1) Emergency services Section 716(f)(1)(C) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185e(f)(1)(C)) is amended to read as follows: (C) A good faith estimate of the amount the health plan is responsible for paying for items and services included in the estimate described in subparagraph (B), including a plain language description of each item or service and all applicable billing codes for each item or service, including modifiers, using standard and commonly recognized billing code sets that are clearly identified.. (2) Explanation of benefits Section 716 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185e) is amended by adding at the end the following: (g) Explanation of benefits (1) In general For plan years beginning on or after January 1, 2026, each group health plan or health insurance issuer offering group health insurance coverage shall, within 45 days of receiving any request for payment for an item or service under the plan, 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 and utilizing substantially the same format as the advanced explanation of benefits required by subsection (f) to enable comparison) including the following: (A) Whether or not the provider or facility is a participating provider or a participating facility with respect to the plan or coverage with respect to the furnishing of such item or service. (B) An itemized explanation of benefits that includes the following: (i) A plain language description of each item or service. (ii) All applicable billing codes for each item or service, including modifiers, using standard and commonly recognized billing code sets that are clearly identified. (iii) The amount the plan or coverage is responsible for paying for each item or service. (iv) The amount of any cost-sharing for which the participant or beneficiary is responsible for each item or service (as of the date of such notification). (v) 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 plan or coverage (as of the date of such notification). (vi) The site of each item or service. (2) Format If applicable, the notification described in paragraph (1) may be provided in conjunction with, or as part of, a notice of a claim determination or other communication required by section 503 or regulations thereunder. (h) Regulations The Secretary shall implement this section through notice and comment rulemaking in accordance with section 553 of title 5, United States Code..