Requirement for explanation of benefits

(a) Advanced explanation of benefits Section 2799A–1(f) of the Public Health Service Act (42 U.S.C. 300gg–111(f)) is amended— (1) in paragraph (1)— (A) by striking subparagraph (C) and inserting the following: (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.; and (B) by adding at the end the following: (I) A notification that the recipient may be held harmless, in certain circumstances, if the information in the advanced explanation of benefits does not match the amount the recipient is billed.; and (2) by adding at the end the following: (3) Hold harmless (A) In general For plan years beginning on or after the date that is 1 year after the date on which the Secretary implements this section, a participant, beneficiary, or enrollee shall be held harmless for any amount that is substantially in excess (as defined by the Secretary in a manner consistent with the process described in section 2799B–7) of the estimate generated by the advanced explanation of benefits. (B) No patient responsibility for excess charges A group health plan or a health insurance issuer in the group or individual market shall not hold a participant, beneficiary, or enrollee responsible for excess charges described in this paragraph if such excess is the result of coverage or payment determinations that differ from projections made in the advanced explanation of benefits at the time such explanation was generated. (C) Substantial excess A participant, beneficiary, or enrollee shall not be held harmless for excess amounts if such amounts reflect the cost of medically necessary items or services furnished based on unforeseen circumstances that could not have reasonably been anticipated by the provider or facility at the time the good faith estimate was generated or by the plan or issuer at the time the advanced explanation of benefits was generated.. (b) Good faith estimates Section 2799B–6 of the Public Health Service Act (42 U.S.C. 300gg–136) is amended— (1) by striking Each health care and inserting the following: (a) In general Each health care; and (2) by adding at the end the following: (b) Hold harmless (1) In general For plan years beginning on or after the date that is 1 year after the date on which the Secretary implements section 2799A–1(f), if an individual enrolled in a group health plan or health insurance coverage (and seeks to have a claim for an item or service submitted to such plan or coverage) is responsible for any amount that is substantially in excess (as defined by the Secretary in a manner consistent the process described in section 2799B–7) of the estimate generated in the advanced explanation of benefits described in section 2799A–1(f) because the final charges for items and services were substantially in excess of the good faith estimate provided to the plan or coverage under this section, a provider shall not bill the patient for amounts substantially in excess of the advanced explanation of benefits. (2) Substantial excess An individual seeking to have a claim for an item or service covered by a group health plan or health insurance coverage shall not be held harmless for excess amounts if such amounts reflect the cost of medically necessary items or services furnished based on unforeseen circumstances that could not have reasonably been anticipated by the provider or facility at the time the good faith estimate was generated or by the plan or issuer at the time the advanced explanation of benefits was generated.. (c) 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 January 1 of the year that begins on or after the date that is 1 year after the date of enactment of the Health CARE Act of 2026, each group health plan, or a health insurance issuer offering group or individual health insurance coverage shall, within 45 days of receiving the information necessary to decide a claim for payment (as defined by the Secretary) for an item or service under the plan or coverage for which liability under the plan or coverage has been determined, 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 when an advanced explanation of benefits is provided) 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 type of site of each item or service, including office, facility, or emergency room. (vii) If applicable, a description of any discrepancies that exist between the services outlined in a patient’s advanced explanation of benefits and the explanation of benefits. (viii) The amount of any facility fee or other patient charges that were added to the final payment amount, together with a plain language explanation of the fee, if applicable. (C) If the provider or facility is a participating provider or facility with respect to the plan or coverage with respect to the furnishing of such item or service, the contracted rate under such plan or coverage for such item or service. (D) The charges submitted by the provider or facility for each item or service. (E) Information pertaining to plan type, as defined the Secretary. (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..