[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2328 Reported in House (RH)]
<DOC>
Union Calendar No. 587
116th CONGRESS
2d Session
H. R. 2328
[Report No. 116-332, Part I]
To reauthorize and extend funding for community health centers and the
National Health Service Corps.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
April 15, 2019
Mr. O'Halleran (for himself and Ms. Stefanik) introduced the following
bill; which was referred to the Committee on Energy and Commerce
December 9, 2019
Reported with amendments and referred to the Committee on
Transportation and Infrastructure for a period ending not later than
January 29, 2020, for consideration of such provisions of the bill as
fall within the jurisdiction of that committee pursuant to clause 1(r)
of rule X
[Strike out all after the enacting clause and insert the part printed
in italic]
January 29, 2020
Referral to the Committee on Transportation and Infrastructure extended
for a period ending not later than February 19, 2020
February 19, 2020
Referral to the Committee on Transportation and Infrastructure extended
for a period ending not later than April 23, 2020
April 23, 2020
Referral to the Committee on Transportation and Infrastructure extended
for a period ending not later than July 31, 2020
July 31, 2020
Referral to the Committee on Transportation and Infrastructure extended
for a period ending not later than September 21, 2020
September 21, 2020
Referral to the Committee on Transportation and Infrastructure extended
for a period ending not later than November 20, 2020
November 17, 2020
Referral to the Committee on Transportation and Infrastructure extended
for a period ending not later than December 31, 2020
December 31, 2020
Additional sponsors: Mr. Swalwell of California, Mr. Espaillat, Ms.
Gabbard, Ms. Omar, Ms. McCollum, Mr. Smith of Washington, Mr. Khanna,
Mr. Cohen, Mr. Grijalva, Mr. Courtney, Mrs. Hartzler, Ms. Mucarsel-
Powell, Ms. Jayapal, Ms. Kuster of New Hampshire, Mrs. Davis of
California, Mr. Rush, Mr. Lipinski, Mr. Engel, Mr. Schiff, Mr.
Cicilline, Mr. Serrano, Mr. Larsen of Washington, Mr. Krishnamoorthi,
Mr. Peters, Ms. Lee of California, Mr. Kilmer, Mr. Schrader, Mr.
Turner, Mr. King of New York, Mr. Yarmuth, Mr. Vela, Mr. Heck, Mr.
LaMalfa, Mr. Young, Mr. Delgado, Mr. Tipton, Ms. Johnson of Texas, Mr.
Hastings, Mr. Sires, Ms. Blunt Rochester, Mr. Bergman, Mrs. Watson
Coleman, Mr. Johnson of Georgia, Mr. Cole, Mr. Gomez, Ms. Kelly of
Illinois, Miss Rice of New York, Mr. Zeldin, Mr. Newhouse, Mr. Rodney
Davis of Illinois, Ms. Clarke of New York, Mr. DeFazio, Mr. Nadler, Mr.
Meeks, Mr. Stivers, Mrs. Carolyn B. Maloney of New York, Mr. Rose of
New York, Mr. Lamborn, Mr. Balderson, Mr. Fleischmann, Mr. Gallego, Ms.
Schakowsky, Mr. Welch, Mrs. Lowey, Ms. Ocasio-Cortez, Mr. Sean Patrick
Maloney of New York, Ms. Bass, Mr. Norman, Mr. Takano, Mr. Lujan, Mr.
Raskin, Ms. Judy Chu of California, Mr. Levin of Michigan, Mrs.
Dingell, Ms. Pingree, Mr. Ted Lieu of California, Ms. Torres Small of
New Mexico, Mr. DeSaulnier, Mr. Katko, Mr. Sablan, Ms. Roybal-Allard,
Mr. Bishop of Utah, Mr. Griffith, Mrs. Radewagen, Mr. Bost, Mr. Walden,
Mr. Stanton, Mr. Correa, Ms. Lofgren, Mr. Curtis, Mr. Lowenthal, Ms.
Slotkin, Ms. Finkenauer, Mr. Foster, Mr. Langevin, Mrs. Bustos, Ms.
Kaptur, Mr. Stewart, Mr. Huffman, Mr. Schneider, Mr. McAdams, Ms.
Velazquez, Ms. Jackson Lee, Mr. Soto, Mr. Cooper, Mr. Austin Scott of
Georgia, Ms. Underwood, Mr. Brindisi, Mr. Stauber, Mr. Cleaver, Mr.
Peterson, Mr. McNerney, Mr. Keating, Ms. Spanberger, Mr. Perlmutter,
Mr. Aguilar, Mr. Cox of California, Mr. Harder of California, Ms.
Kendra S. Horn of Oklahoma, Mr. Price of North Carolina, Mrs. Miller,
Mr. Van Drew, Mr. Fitzpatrick, Mr. Cisneros, Mr. Larson of Connecticut,
Mrs. Demings, and Mrs. Hayes
December 31, 2020
Committee on Transportation and Infrastructure discharged; committed to
the Committee of the Whole House on the State of the Union and ordered
to be printed
[For text of introduced bill, see copy of bill as introduced on April
15, 2019]
_______________________________________________________________________
A BILL
To reauthorize and extend funding for community health centers and the
National Health Service Corps.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Reauthorizing and
Extending America's Community Health Act'' or the ``REACH Act''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--PUBLIC HEALTH EXTENDERS
Sec. 101. Extension for community health centers, the National Health
Service Corps, and teaching health centers
that operate GME programs.
Sec. 102. Extension for special diabetes programs.
Sec. 103. Extension of Personal Responsibility Education Program.
Sec. 104. Extension of sexual risk avoidance education program.
TITLE II--MEDICARE EXTENDERS
Sec. 201. Extension of the work geographic index floor under the
Medicare program.
Sec. 202. Extension of funding outreach and assistance for low-income
programs.
Sec. 203. Extension of funding for quality measure endorsement, input,
and selection under the Medicare program.
Sec. 204. Extension of the Independence at Home Medical Practice
Demonstration Program under the Medicare
program.
Sec. 205. Extension of appropriations and transfers to the Patient-
Centered Outcomes Research Trust Fund;
extension of certain health insurance fees.
Sec. 206. Transitional coverage and retroactive Medicare part D
coverage for certain low-income
beneficiaries.
Sec. 207. Health Equity and Access for Returning Troops and
Servicemembers Act of 2019.
Sec. 208. Exclusion of complex rehabilitative manual wheelchairs from
Medicare competitive acquisition program;
Non-application of Medicare fee-schedule
adjustments for certain wheelchair
accessories and cushions.
TITLE III--MEDICAID PROVISIONS
Sec. 301. Modification of reductions in Medicaid DSH allotments.
Sec. 302. Public availability of hospital upper payment limit
demonstrations.
Sec. 303. Report by Comptroller General.
Sec. 304. Sense of Congress regarding the need to develop a more
permanent legislative solution to provide
the territories with a reliable and
consistent source of Federal funding under
the Medicaid program.
TITLE IV--NO SURPRISES ACT
Sec. 401. Short title.
Sec. 402. Preventing surprise medical bills.
Sec. 403. Government Accountability Office study on profit- and
revenue-sharing in health care.
Sec. 404. State All Payer Claims Databases.
Sec. 405. Air ambulance cost data reporting program.
Sec. 406. Report by Secretary of Labor.
Sec. 407. Billing statute of limitations.
Sec. 408. GAO report on impact of surprise billing provisions.
Sec. 409. Report by the Secretary of Health and Human Services.
TITLE V--TERRITORIES HEALTH CARE IMPROVEMENT ACT
Sec. 501. Short title.
Sec. 502. Medicaid payments for Puerto Rico and the other territories
for certain fiscal years.
Sec. 503. Application of certain requirements under Medicaid program to
certain territories.
Sec. 504. Additional program integrity requirements.
TITLE I--PUBLIC HEALTH EXTENDERS
SEC. 101. EXTENSION FOR COMMUNITY HEALTH CENTERS, THE NATIONAL HEALTH
SERVICE CORPS, AND TEACHING HEALTH CENTERS THAT OPERATE
GME PROGRAMS.
(a) Community Health Centers.--Section 10503(b)(1)(F) of the
Patient Protection and Affordable Care Act (42 U.S.C. 254b-2(b)(1)(F))
is amended by striking ``fiscal year 2019'' and inserting ``each of
fiscal years 2019 through 2023''.
(b) National Health Service Corps.--Section 10503(b)(2)(F) of the
Patient Protection and Affordable Care Act (42 U.S.C. 254b-2(b)(2)(F))
is amended by striking ``2018 and 2019'' and inserting ``2019 through
2023''.
(c) Teaching Health Centers That Operate Graduate Medical Education
Programs.--Section 340H(g)(1) of the Public Health Service Act (42
U.S.C. 256h(g)(1)) is amended by striking ``2018 and 2019'' and
inserting ``2019 through 2023''.
(d) Application.--Amounts appropriated for a program pursuant to
the amendments made by subsection (a), (b), or (c) for fiscal years
2020 through 2023 are subject to the requirements and limitations of
the most recently enacted regular or full-year continuing
appropriations Act or resolution (as of the date of obligation of
current funds) applicable to the respective program.
SEC. 102. EXTENSION FOR SPECIAL DIABETES PROGRAMS.
(a) Reauthorization of Special Diabetes Programs for Type I
Diabetes.--Section 330B(b)(2)(D) of the Public Health Service Act (42
U.S.C. 254c-2(b)(2)(D)) is amended by striking ``each of fiscal years
2018 and 2019'' and inserting ``fiscal years 2019 through 2023''.
(b) Reauthorization of Special Diabetes Programs for Indians for
Diabetes Services.--Section 330C(c)(2)(D) of the Public Health Service
Act (42 U.S.C. 254c-3(c)(2)(D)) is amended by striking ``fiscal years
2018 and 2019'' and inserting ``fiscal years 2019 through 2023''.
SEC. 103. EXTENSION OF PERSONAL RESPONSIBILITY EDUCATION PROGRAM.
Section 513 of the Social Security Act (42 U.S.C. 713) is amended--
(1) in paragraphs (1)(A) and (4)(A) of subsection (a), by
striking ``2019'' and inserting ``2023'' each place it appears;
(2) in subsection (a)(4)(B)(i), by striking ``2019'' and
inserting ``2023''; and
(3) in subsection (f), by striking ``2019'' and inserting
``2023''.
SEC. 104. EXTENSION OF SEXUAL RISK AVOIDANCE EDUCATION PROGRAM.
Section 510 of the Social Security Act (42 U.S.C. 710) is amended
by striking ``fiscal years 2018 and 2019'' each place it appears in
subsections (a)(1), (a)(2)(A), (f)(1) and (f)(2) and inserting ``fiscal
years 2019 through 2023''.
TITLE II--MEDICARE EXTENDERS
SEC. 201. EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR UNDER THE
MEDICARE PROGRAM.
Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)) is amended by striking ``2020'' and inserting ``2023''.
SEC. 202. EXTENSION OF FUNDING OUTREACH AND ASSISTANCE FOR LOW-INCOME
PROGRAMS.
(a) Additional Funding for State Health Insurance Programs.--
Subsection (a)(1)(B) of section 119 of the Medicare Improvements for
Patients and Providers Act of 2008 (42 U.S.C. 1395b-3 note), as amended
by section 3306 of the Patient Protection and Affordable Care Act
(Public Law 111-148), section 610 of the American Taxpayer Relief Act
of 2012 (Public Law 112-240), section 1110 of the Pathway for SGR
Reform Act of 2013 (Public Law 113-67), section 110 of the Protecting
Access to Medicare Act of 2014 (Public Law 113-93), section 208 of the
Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114-
10), and section 50207 of the Bipartisan Budget Act of 2018 (Public Law
115-123), is amended--
(1) in clause (vii), by striking ``and'' at the end;
(2) in clause (viii), by striking ``and'' at the end;
(3) in clause (ix), by striking the period at the end and
inserting ``; and''; and
(4) by inserting after clause (ix) the following new
clause:
``(x) for each of fiscal years 2020 through
2022, of $15,000,000.''.
(b) Additional Funding for Area Agencies on Aging.--Subsection
(b)(1)(B) of such section 119, as so amended, is amended--
(1) in clause (vii), by striking ``and'' at the end;
(2) in clause (viii), by striking ``and'' at the end;
(3) in clause (ix), by striking the period at the end and
inserting ``; and''; and
(4) by inserting after clause (ix) the following new
clause:
``(x) for each of fiscal years 2020 through
2022, of $15,000,000.''.
(c) Additional Funding for Aging and Disability Resource Centers.--
Subsection (c)(1)(B) of such section 119, as so amended, is amended--
(1) in clause (vii), by striking ``and'' at the end;
(2) in clause (viii), by striking ``and'' at the end;
(3) in clause (ix), by striking the period at the end and
inserting ``; and''; and
(4) by inserting after clause (ix) the following new
clause:
``(x) for each of fiscal years 2020 through
2022, of $5,000,000.''.
(d) Additional Funding for Contract With the National Center for
Benefits and Outreach Enrollment.--Subsection (d)(2) of such section
119, as so amended, is amended--
(1) in clause (vii), by striking ``and'' at the end;
(2) in clause (viii), by striking ``and'' at the end;
(3) in clause (ix), by striking the period at the end and
inserting ``; and''; and
(4) by inserting after clause (ix) the following new
clause:
``(x) for each of fiscal years 2020 through
2022, of $15,000,000.''.
SEC. 203. EXTENSION OF FUNDING FOR QUALITY MEASURE ENDORSEMENT, INPUT,
AND SELECTION UNDER THE MEDICARE PROGRAM.
(a) In General.--Section 1890(d)(2) of the Social Security Act (42
U.S.C. 1395aaa(d)(2)) is amended--
(1) by striking ``and $7,500,000'' and inserting
``$7,500,000''; and
(2) by striking ``and 2019.'' and inserting ``and 2019, and
$30,000,000 for each of fiscal years 2020 through 2022.''.
(b) Input for Removal of Measures.--Section 1890(b) of the Social
Security Act (42 U.S.C. 1395aaa(b)) is amended by inserting after
paragraph (3) the following:
``(4) Removal of measures.--The entity may, through the
multistakeholder groups convened under paragraph (7)(A),
provide input to the Secretary on quality and efficiency
measures described in paragraph (7)(B) that could be considered
for removal.''.
(c) Prioritization of Measure Endorsement.--Section 1890(b) of the
Social Security Act (42 U.S.C. 1395aaa(b)), as amended by subsection
(b), is further amended by adding at the end the following:
``(9) Prioritization of measure endorsement.--The entity--
``(A) during the period beginning on the date of
the enactment of this paragraph and ending on December
31, 2023, shall prioritize the endorsement of measures
relating to maternal morbidity and mortality by the
entity with a contract under subsection (a) in
connection with endorsement of measures described in
paragraph (2); and
``(B) on and after January 1, 2024, may prioritize
the endorsement of such measures by such entity.''.
SEC. 204. EXTENSION OF THE INDEPENDENCE AT HOME MEDICAL PRACTICE
DEMONSTRATION PROGRAM UNDER THE MEDICARE PROGRAM.
(a) In General.--Section 1866E(e)(1) of the Social Security Act (42
U.S.C. 1395cc-5(e)(1)) is amended by striking ``7-year'' and inserting
``10-year''.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect as if included in the enactment of Public Law 111-148.
SEC. 205. EXTENSION OF APPROPRIATIONS AND TRANSFERS TO THE PATIENT-
CENTERED OUTCOMES RESEARCH TRUST FUND; EXTENSION OF
CERTAIN HEALTH INSURANCE FEES.
(a) In General.--
(1) Internal revenue code.--Section 9511 of the Internal
Revenue Code of 1986 is amended--
(A) in subsection (b)(1)(E), by striking ``2014''
and all that follows through ``2019'' and inserting
``2014 through 2022'';
(B) in subsection (d)(2)(A), by striking ``2019''
and inserting ``2022''; and
(C) in subsection (f), by striking ``2019'' and
inserting ``2022''.
(2) Title xi.--Section 1183(a)(2) of the Social Security
Act (42 U.S.C. 1320e-2(a)(2)) is amended by striking ``2014''
and all that follows through ``2019'' and inserting ``2014
through 2022''.
(b) Extension of Certain Health Insurance Fees.--
(1) Health insurance policies.--Section 4375(e) of the
Internal Revenue Code of 1986 is amended by striking ``2019''
and inserting ``2022''.
(2) Self-insured health plans.--Section 4376(e) of the
Internal Revenue Code of 1986 is amended by striking ``2019''
and inserting ``2022''.
SEC. 206. TRANSITIONAL COVERAGE AND RETROACTIVE MEDICARE PART D
COVERAGE FOR CERTAIN LOW-INCOME BENEFICIARIES.
Section 1860D-14 of the Social Security Act (42 U.S.C. 1395w-114)
is amended--
(1) by redesignating subsection (e) as subsection (f); and
(2) by adding after subsection (d) the following new
subsection:
``(e) Limited Income Newly Eligible Transition Program.--
``(1) In general.--Beginning not later than January 1,
2021, the Secretary shall carry out a program to provide
transitional coverage for covered part D drugs for LI NET
eligible individuals in accordance with this subsection.
``(2) LI net eligible individual defined.--For purposes of
this subsection, the term `LI NET eligible individual' means a
part D eligible individual who--
``(A) meets the requirements of clauses (ii) and
(iii) of subsection (a)(3)(A); and
``(B) has not yet enrolled in a prescription drug
plan or an MA-PD plan, or, who has so enrolled, but
with respect to whom coverage under such plan has not
yet taken effect.
``(3) Transitional coverage.--For purposes of this
subsection, the term `transitional coverage' means, with
respect to an LI NET eligible individual--
``(A) immediate access to covered part D drugs at
the point of sale during the period that begins on the
first day of the month such individual is determined to
meet the requirements of clauses (ii) and (iii) of
subsection (a)(3)(A) and ends on the date that coverage
under a prescription drug plan or MA-PD plan takes
effect with respect to such individual; and
``(B) in the case of an LI NET eligible individual
who is a full-benefit dual eligible individual (as
defined in section 1935(c)(6)) or a recipient of
supplemental security income benefits under title XVI,
retroactive coverage (in the form of reimbursement of
the amounts that would have been paid under this part
had such individual been enrolled in a prescription
drug plan or MA-PD plan) of covered part D drugs
purchased by such individual during the period that
begins on the date that is the later of--
``(i) the date that such individual was
first eligible for a low-income subsidy under
this part; or
``(ii) the date that is 36 months prior to
the date such individual enrolls in a
prescription drug plan or MA-PD plan,
and ends on the date that coverage under such plan
takes effect.
``(4) Program administration.--
``(A) Single point of contact.--The Secretary
shall, to the extent feasible, administer the program
under this subsection through a contract with a single
program administrator.
``(B) Benefit design.--The Secretary shall ensure
that the transitional coverage provided to LI NET
eligible individuals under this subsection--
``(i) provides access to all covered part D
drugs under an open formulary;
``(ii) permits all pharmacies determined by
the Secretary to be in good standing to process
claims under the program;
``(iii) is consistent with such
requirements as the Secretary considers
necessary to improve patient safety and ensure
appropriate dispensing of medication; and
``(iv) meets such other requirements as the
Secretary may establish.
``(5) Relationship to other provisions of this title;
waiver authority.--
``(A) In general.--The following provisions shall
not apply with respect to the program under this
subsection:
``(i) Paragraphs (1) and (3)(B) of section
1860D-4(a) (relating to dissemination of
general information; availability of
information on changes in formulary through the
internet).
``(ii) Subparagraphs (A) and (B) of section
1860D-4(b)(3) (relating to requirements on
development and application of formularies;
formulary development).
``(iii) Paragraphs (1)(C) and (2) of
section 1860D-4(c) (relating to medication
therapy management program).
``(B) Waiver authority.--The Secretary may waive
such other requirements of titles XI and this title as
may be necessary to carry out the purposes of the
program established under this subsection.''.
SEC. 207. HEALTH EQUITY AND ACCESS FOR RETURNING TROOPS AND
SERVICEMEMBERS ACT OF 2019.
(a) Modification of Requirement for Certain Former Members of the
Armed Forces to Enroll in Medicare Part B to Be Eligible for TRICARE
for Life.--
(1) TRICARE eligibility.--
(A) In general.--Subsection (d) of section 1086 of
title 10, United States Code, is amended by adding at
the end the following new paragraph:
``(6)(A) The requirement in paragraph (2)(A) to enroll in the
supplementary medical insurance program under part B of title XVIII of
the Social Security Act (42 U.S.C. 1395j et seq.) shall not apply to a
person described in subparagraph (B) during any month in which such
person is not entitled to a benefit described in subparagraph (A) of
section 226(b)(2) of the Social Security Act (42 U.S.C. 426(b)(2)) if
such person has received the counseling and information under
subparagraph (C).
``(B) A person described in this subparagraph is a person--
``(i) who is under 65 years of age;
``(ii) who is entitled to hospital insurance benefits under
part A of title XVIII of the Social Security Act pursuant to
subparagraph (A) or (C) of section 226(b)(2) of such Act (42
U.S.C. 426(b)(2));
``(iii) whose entitlement to a benefit described in
subparagraph (A) of such section has terminated due to
performance of substantial gainful activity; and
``(iv) who is retired under chapter 61 of this title.
``(C) The Secretary of Defense shall coordinate with the Secretary
of Health and Human Services and the Commissioner of Social Security to
notify persons described in subparagraph (B) of, and provide
information and counseling regarding, the effects of not enrolling in
the supplementary medical insurance program under part B of title XVIII
of the Social Security Act (42 U.S.C. 1395j et seq.), as described in
subparagraph (A).''.
(B) Conforming amendment.--Paragraph (2)(A) of such
subsection is amended by striking ``is enrolled'' and
inserting ``except as provided by paragraph (6), is
enrolled''.
(C) Identification of persons.--Section 1110a of
such title is amended by adding at the end the
following new subsection:
``(c) Certain Individuals Not Required To Enroll in Medicare Part
B.--In carrying out subsection (a), the Secretary of Defense shall
coordinate with the Secretary of Health and Human Services and the
Commissioner of Social Security to--
``(1) identify persons described in subparagraph (B) of
section 1086(d)(6) of this title; and
``(2) provide information and counseling pursuant to
subparagraph (C) of such section.''.
(2) Non-application of medicare part b late enrollment
penalty.--Section 1839(b) of the Social Security Act (42 U.S.C.
1395r(b)) is amended, in the second sentence, by inserting ``or
months for which the individual can demonstrate that the
individual is an individual described in paragraph (6)(B) of
section 1086(d) of title 10, United States Code, who is
enrolled in the TRICARE program pursuant to such section''
after ``an individual described in section 1837(k)(3)''.
(3) Report.--Not later than October 1, 2024, the Secretary
of Defense, the Secretary of Health and Human Services, and the
Commissioner of Social Security shall jointly submit to the
Committees on Armed Services of the House of Representatives
and the Senate, the Committee on Ways and Means and the
Committee on Energy and Commerce of the House of
Representatives, and the Committee on Finance of the Senate a
report on the implementation of section 1086(d)(6) of title 10,
United States Code, as added by paragraph (1). Such report
shall include, with respect to the period covered by the
report--
(A) the number of individuals enrolled in TRICARE
for Life who are not enrolled in the supplementary
medical insurance program under part B of title XVIII
of the Social Security Act (42 U.S.C. 1395j et seq.) by
reason of such section 1086(d)(6); and
(B) the number of individuals who--
(i) are retired from the Armed Forces under
chapter 61 of title 10, United States Code;
(ii) are entitled to hospital insurance
benefits under part A of title XVIII of the
Social Security Act pursuant to receiving
benefits for 24 months as described in
subparagraph (A) or (C) of section 226(b)(2) of
such Act (42 U.S.C. 426(b)(2)); and
(iii) because of such entitlement, are no
longer enrolled in TRICARE Standard, TRICARE
Prime, TRICARE Extra, or TRICARE Select under
chapter 55 of title 10, United States Code.
(4) Deposit of savings into medicare improvement fund.--
Section 1898(b)(1) of the Social Security Act (42 U.S.C.
1395iii(b)(1)) is amended by striking ``during and after fiscal
year 2021, $0'' and inserting ``during and after fiscal year
2024, $5,000,000''.
(5) Application.--The amendments made by paragraphs (1) and
(2) shall apply with respect to a person who, on or after
October 1, 2023, is a person described in section 1086(d)(6)(B)
of title 10, United States Code, as added by paragraph (1).
(b) Coverage of Certain DNA Specimen Provenance Assay Tests Under
Medicare.--
(1) Benefit.--
(A) Coverage.--Section 1861 of the Social Security
Act (42 U.S.C. 1395x) is amended--
(i) in subsection (s)(2)--
(I) in subparagraph (GG), by
striking ``and'' at the end;
(II) in subparagraph (HH), by
striking the period and inserting ``;
and''; and
(III) by adding at the end the
following new subparagraph:
``(II) a prostate cancer DNA Specimen Provenance Assay test
(DSPA test) (as defined in subsection (kkk));''; and
(ii) by adding at the end the following new
subsection:
``(kkk) Prostate Cancer DNA Specimen Provenance Assay Test.--The
term `prostate cancer DNA Specimen Provenance Assay Test' (DSPA test)
means a test that, after a determination of cancer in one or more
prostate biopsy specimens obtained from an individual, assesses the
identity of the DNA in such specimens by comparing such DNA with the
DNA that was separately taken from such individual at the time of the
biopsy.''.
(B) Exclusion from coverage.--Section 1862(a)(1) of
the Social Security Act (42 U.S.C. 1395y(a)(1)) is
amended--
(i) in subparagraph (O), by striking
``and'' at the end;
(ii) in subparagraph (P), by striking the
semicolon at the end and inserting ``, and'';
and
(iii) by adding at the end the following
new subparagraph:
``(Q) in the case of a prostate cancer DNA Specimen
Provenance Assay test (DSPA test) (as defined in section
1861(kkk)), unless such test is furnished on or after January
1, 2021, and before January 1, 2026, and such test is ordered
by the physician who furnished the prostate cancer biopsy that
obtained the specimen tested;''.
(2) Payment amount and related requirements.--Section 1834
of the Social Security Act (42 U.S.C. 1395m) is amended by
adding at the end the following new subsection:
``(x) Prostate Cancer DNA Specimen Provenance Assay Tests.--
``(1) Payment for covered tests.--
``(A) In general.--Subject to subparagraph (B), the
payment amount for a prostate cancer DNA Specimen
Provenance Assay test (DSPA test) (as defined in
section 1861(kkk)) shall be $200. Such payment shall be
payment for all of the specimens obtained from the
biopsy furnished to an individual that are tested.
``(B) Limitation.--Payment for a DSPA test under
subparagraph (A) may only be made on an assignment-
related basis.
``(C) Prohibition on separate payment.--No separate
payment shall be made for obtaining DNA that was
separately taken from an individual at the time of a
biopsy described in subparagraph (A).
``(2) HCPCS code and modifier assignment.--
``(A) In general.--The Secretary shall assign one
or more HCPCS codes to a prostate cancer DNA Specimen
Provenance Assay test and may use a modifier to
facilitate making payment under this section for such
test.
``(B) Identification of dna match on claim.--The
Secretary shall require an indication on a claim for a
prostate cancer DNA Specimen Provenance Assay test of
whether the DNA of the prostate biopsy specimens match
the DNA of the individual diagnosed with prostate
cancer. Such indication may be made through use of a
HCPCS code, a modifier, or other means, as determined
appropriate by the Secretary.
``(3) DNA match review.--
``(A) In general.--The Secretary shall review at
least three years of claims under part B for prostate
cancer DNA Specimen Provenance Assay tests to identify
whether the DNA of the prostate biopsy specimens match
the DNA of the individuals diagnosed with prostate
cancer.
``(B) Posting on internet website.--Not later than
July 1, 2023, the Secretary shall post on the internet
website of the Centers for Medicare & Medicaid Services
the findings of the review conducted under subparagraph
(A).''.
(3) Cost-sharing.--Section 1833(a)(1) of the Social
Security Act (42 U.S.C. 1395l(a)(1)) is amended--
(A) by striking ``and (CC)'' and inserting
``(CC)''; and
(B) by inserting before the semicolon at the end
the following: ``, and (DD) with respect to a prostate
cancer DNA Specimen Provenance Assay test (DSPA test)
(as defined in section 1861(kkk)), the amount paid
shall be an amount equal to 80 percent of the lesser of
the actual charge for the test or the amount specified
under section 1834(x)''.
SEC. 208. EXCLUSION OF COMPLEX REHABILITATIVE MANUAL WHEELCHAIRS FROM
MEDICARE COMPETITIVE ACQUISITION PROGRAM; NON-APPLICATION
OF MEDICARE FEE-SCHEDULE ADJUSTMENTS FOR CERTAIN
WHEELCHAIR ACCESSORIES AND CUSHIONS.
(a) Exclusion of Complex Rehabilitative Manual Wheelchairs From
Competitive Acquisition Program.--Section 1847(a)(2)(A) of the Social
Security Act (42 U.S.C. 1395w-3(a)(2)(A)) is amended--
(1) by inserting ``, complex rehabilitative manual
wheelchairs (as determined by the Secretary), and certain
manual wheelchairs (identified, as of October 1, 2018, by HCPCS
codes E1235, E1236, E1237, E1238, and K0008 or any successor to
such codes)'' after ``group 3 or higher''; and
(2) by striking ``such wheelchairs'' and inserting ``such
complex rehabilitative power wheelchairs, complex
rehabilitative manual wheelchairs, and certain manual
wheelchairs''.
(b) Non-Application of Medicare Fee Schedule Adjustments for
Wheelchair Accessories and Seat and Back Cushions When Furnished in
Connection With Complex Rehabilitative Manual Wheelchairs.--
(1) In general.--Notwithstanding any other provision of
law, the Secretary of Health and Human Services shall not,
during the period beginning on January 1, 2020, and ending on
December 31, 2020, use information on the payment determined
under the competitive acquisition programs under section 1847
of the Social Security Act (42 U.S.C. 1395w-3) to adjust the
payment amount that would otherwise be recognized under section
1834(a)(1)(B)(ii) of such Act (42 U.S.C. 1395m(a)(1)(B)(ii))
for wheelchair accessories (including seating systems) and seat
and back cushions when furnished in connection with complex
rehabilitative manual wheelchairs (as determined by the
Secretary), and certain manual wheelchairs (identified, as of
October 1, 2018, by HCPCS codes E1235, E1236, E1237, E1238, and
K0008 or any successor to such codes).
(2) Implementation.--Notwithstanding any other provision of
law, the Secretary may implement this subsection by program
instruction or otherwise.
TITLE III--MEDICAID PROVISIONS
SEC. 301. MODIFICATION OF REDUCTIONS IN MEDICAID DSH ALLOTMENTS.
Section 1923(f)(7)(A) of the Social Security Act (42 U.S.C. 1396r-
4(f)(7)(A)) is amended--
(1) in clause (i), in the matter preceding subclause (I),
by striking ``2020'' and inserting ``2022''; and
(2) in clause (ii)--
(A) in subclause (I), by striking ``2020'' and
inserting ``2022''; and
(B) in subclause (II), by striking ``for each of
fiscal years 2021 through 2025'' and inserting ``for
each of fiscal years 2023 through 2025''.
SEC. 302. PUBLIC AVAILABILITY OF HOSPITAL UPPER PAYMENT LIMIT
DEMONSTRATIONS.
Section 1903 of the Social Security Act (42 U.S.C. 1396b) is
amended by adding at the end the following new subsection:
``(bb) Public Availability of Hospital Upper Payment Limit
Demonstrations.--The Secretary shall make publicly available upper
payment limit demonstrations for hospital services that a State submits
with respect to a fiscal year of the State (beginning with State fiscal
year 2022) to the Administrator of the Centers for Medicare & Medicaid
Services.''.
SEC. 303. REPORT BY COMPTROLLER GENERAL.
Not later than the date that is 21 months after the date of the
enactment of this Act, the Comptroller General of the United States
shall identify and report to Congress policy considerations for
legislative action with respect to establishing an equitable formula
for determining disproportionate share hospital allotments for States
under section 1923 of the Social Security Act (42 U.S.C. 1396r-4) that
takes into account the following factors:
(1) The level of uncompensated care costs of hospitals in a
State.
(2) Expenditures of a State with respect to hospitals,
including payment adjustments made under such section 1923 to
disproportionate share hospitals (as defined under the State
plan under title XIX of such Act (42 U.S.C. 1396 et seq.)
pursuant to subsection (a)(1)(A) of such section 1923), upper
payment limit supplemental payments, and other related payments
that hospitals may receive from the State.
(3) State policy decisions that may affect the level of
uncompensated care costs of hospitals in a State.
SEC. 304. SENSE OF CONGRESS REGARDING THE NEED TO DEVELOP A MORE
PERMANENT LEGISLATIVE SOLUTION TO PROVIDE THE TERRITORIES
WITH A RELIABLE AND CONSISTENT SOURCE OF FEDERAL FUNDING
UNDER THE MEDICAID PROGRAM.
It is the sense of Congress that--
(1) the territories of American Samoa, the Commonwealth of
the Northern Mariana Islands, Guam, Puerto Rico, and the United
States Virgin Islands are currently subject to Federal funding
caps for their Medicaid programs;
(2) as a result of these Federal funding caps, which have
not been adjusted over time, the territories continue to
struggle in managing their Medicaid programs, including
planning for their respective financial obligations and
managing health care services for low-income adults, children,
pregnant women, elderly adults, and persons with disabilities;
(3) to address this disparate funding treatment and to
provide the territories with some measure of relief, Congress
has had to enact legislation six times in the last 15 years,
including multiple temporary increases in the Federal funding
caps, higher Federal medical assistance percentage rates, and
billions of dollars in supplemental block grants;
(4) the supplemental funding provided to the territories
under title V with respect to their Medicaid programs continues
Congress' commitment to ensuring the sustainability of these
critically important programs and the people these programs
serve; and
(5) a more permanent legislative solution must be developed
in order to provide the territories with a reliable and
consistent source of Federal funding under their Medicaid
programs so that the territories can continue to meet the
health care needs of vulnerable populations.
TITLE IV--NO SURPRISES ACT
SEC. 401. SHORT TITLE.
This title may be cited as the ``No Surprises Act''.
SEC. 402. PREVENTING SURPRISE MEDICAL BILLS.
(a) Coverage of Emergency Services.--Section 2719A(b) of the Public
Health Service Act (42 U.S.C. 300gg-19a(b)) is amended--
(1) in paragraph (1)--
(A) in the matter preceding subparagraph (A)--
(i) by striking ``a group health plan, or a
health insurance issuer offering group or
individual health insurance issuer,'' and
inserting ``a health plan (as defined in
subsection (e)(2)(A))'';
(ii) by inserting ``or, for plan year 2021
or a subsequent plan year, with respect to
emergency services in an independent
freestanding emergency department (as defined
in paragraph (3)(D))'' after ``emergency
department of a hospital'';
(iii) by striking ``the plan or issuer''
and inserting ``the plan''; and
(iv) by striking ``paragraph (2)(B)'' and
inserting ``paragraph (3)(C)'';
(B) in subparagraph (B), by inserting ``or a
participating emergency facility, as applicable,''
after ``participating provider''; and
(C) in subparagraph (C)--
(i) in the matter preceding clause (i), by
inserting ``by a nonparticipating provider or a
nonparticipating emergency facility'' after
``enrollee'';
(ii) by striking clause (i);
(iii) by striking ``(ii)(I) such services''
and inserting ``(i) such services'';
(iv) by striking ``where the provider of
services does not have a contractual
relationship with the plan for the providing of
services'';
(v) by striking ``emergency department
services received from providers who do have
such a contractual relationship with the plan;
and'' and inserting ``emergency services
received from participating providers and
participating emergency facilities with respect
to such plan;'';
(vi) by striking ``(II) if such services''
and all that follows through ``were provided
in-network;'' and inserting the following:
``(ii) the cost-sharing requirement
(expressed as a copayment amount or coinsurance
rate) is not greater than the requirement that
would apply if such services were provided by a
participating provider or a participating
emergency facility;''; and
(vii) by adding at the end the following
new clauses:
``(iii) such requirement is calculated as
if the total amount that would have been
charged for such services by such participating
provider or participating emergency facility
were equal to--
``(I) in the case of such services
furnished in a State described in
paragraph (3)(H)(ii), the median
contracted rate (as defined in
paragraph (3)(E)(i)) for such services;
and
``(II) in the case of such services
furnished in a State described in
paragraph (3)(H)(i), the lesser of--
``(aa) the amount
determined by such State for
such services in accordance
with the method described in
such paragraph; and
``(bb) the median
contracted rate (as so defined)
for such services;
``(iv) the health plan pays to such
provider or facility, respectively, the amount
by which the recognized amount (as defined in
paragraph (3)(H)) for such services exceeds the
cost-sharing amount for such services (as
determined in accordance with clauses (ii) and
(iii)); and
``(v) any cost-sharing payments made by the
participant, beneficiary, or enrollee with
respect to such emergency services so furnished
shall be counted toward any in-network
deductible or out-of-pocket maximums applied
under the plan (and such in-network deductible
shall be applied) in the same manner as if such
cost-sharing payments were with respect to
emergency services furnished by a participating
provider and a participating emergency
facility; and'';
(2) by redesignating paragraph (2) as paragraph (3);
(3) by inserting after paragraph (1) the following new
paragraph:
``(2) Audit process for median contracted rates.--
``(A) In general.--Not later than July 1, 2020, the
Secretary, in consultation with appropriate State
agencies, shall establish through rulemaking a process,
in accordance with subparagraph (B), under which health
plans are audited by such Secretaries to ensure that--
``(i) such plans are in compliance with the
requirement of applying a median contracted
rate under this section; and
``(ii) that such median contracted rate so
applied satisfies the definition under
paragraph (3)(E) with respect to the year
involved, including with respect to a health
plan described in clause (ii) of such
paragraph.
``(B) Audit samples.--Under the process established
pursuant to subparagraph (A), the Secretary--
``(i) shall conduct audits described in
such subparagraph, with respect to a year
(beginning with 2021), of a sample with respect
to such year of claims data from not more than
25 health plans; and
``(ii) may audit any health plan if the
Secretary has received any complaint about such
plan that involves the compliance of the plan
with either of the requirements described in
clauses (i) and (ii) of such subparagraph.'';
and
(4) in paragraph (3), as redesignated by paragraph (2) of
this subsection--
(A) in the matter preceding subparagraph (A), by
inserting ``and subsection (e)'' after ``this
subsection'';
(B) by redesignating subparagraphs (A) through (C)
as subparagraphs (B) through (D), respectively;
(C) by inserting before subparagraph (B), as
redesignated by subparagraph (B) of this paragraph, the
following new subparagraph:
``(A) Emergency department of a hospital.--The term
`emergency department of a hospital' includes a
hospital outpatient department that provides emergency
services.'';
(D) by amending subparagraph (C), as redesignated
by subparagraph (B) of this paragraph, to read as
follows:
``(C) Emergency services.--
``(i) In general.--The term `emergency
services', with respect to an emergency medical
condition, means--
``(I) a medical screening
examination (as required under section
1867 of the Social Security Act, or as
would be required under such section if
such section applied to an independent
freestanding emergency department) that
is within the capability of the
emergency department of a hospital or
of an independent freestanding
emergency department, as applicable,
including ancillary services routinely
available to the emergency department
to evaluate such emergency medical
condition; and
``(II) within the capabilities of
the staff and facilities available at
the hospital or the independent
freestanding emergency department, as
applicable, such further medical
examination and treatment as are
required under section 1867 of such
Act, or as would be required under such
section if such section applied to an
independent freestanding emergency
department, to stabilize the patient.
``(ii) Inclusion of poststabilization
services.--For purposes of this subsection and
section 2799, in the case of an individual
enrolled in a health plan who is furnished
services described in clause (i) by a provider
or facility to stabilize such individual with
respect to an emergency medical condition, the
term `emergency services' shall include such
items and services in addition to those
described in clause (i) that such a provider or
facility determines are needed to be furnished
(after such stabilization but during such visit
in which such individual is so stabilized) to
such individual, unless each of the following
conditions are met:
``(I) Such a provider or facility
determines such individual is able to
travel using nonmedical transportation
or nonemergency medical transportation.
``(II) Such provider furnishing
such additional items and services is
in compliance with section 2799A(d)
with respect to such items and
services.'';
(E) by redesignating subparagraph (D), as
redesignated by subparagraph (B) of this paragraph, as
subparagraph (I); and
(F) by inserting after subparagraph (C), as
redesignated by subparagraph (B) of this paragraph, the
following new subparagraphs:
``(D) Independent freestanding emergency
department.--The term `independent freestanding
emergency department' means a facility that--
``(i) is geographically separate and
distinct and licensed separately from a
hospital under applicable State law; and
``(ii) provides emergency services.
``(E) Median contracted rate.--
``(i) In general.--The term `median
contracted rate' means, with respect to an item
or service and a health plan (as defined in
subsection (e)(2)(A))--
``(I) for 2021, the median of the
negotiated rates recognized by the
sponsor or issuer of such plan
(determined with respect to all such
plans of such sponsor or such issuer
that are within the same line of
business) as the total maximum payment
(including the cost-sharing amount
imposed for such services (as
determined in accordance with clauses
(ii) and (iii) of paragraph (1)(C) or
subparagraphs (A) and (B) of subsection
(e)(1), as applicable) and the amount
to be paid by the plan or issuer) under
such plans in 2019 for the same or a
similar item or service that is
provided by a provider in the same or
similar specialty and provided in the
geographic region in which the item or
service is furnished, consistent with
the methodology established by the
Secretary under section 402(e) of the
No Surprises Act, increased by the
percentage increase in the consumer
price index for all urban consumers
(United States city average) over 2019
and 2020; and
``(II) for 2022 and each subsequent
year, the median contracted rate
determined under this clause for 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) Special rule.--The Secretary shall
provide pursuant to rulemaking described in
section 402(e) of the No Surprises Act that--
``(I) if the sponsor or issuer of a
health plan does not have sufficient
information to calculate a median
contracted rate for an item or service
or provider type, or amount of, claims
for items or services (as determined by
the Secretary) provided in a particular
geographic area (other than in a case
described in item (bb)), such sponsor
or issuer shall demonstrate that such
sponsor or issuer will use any database
free of conflicts of interest that has
sufficient information reflecting
allowed amounts paid to a health care
provider for relevant services provided
in the applicable geographic region
(such as State All Payer Claims
Databases (as defined in section 404(d)
of such Act)), and that such sponsor or
issuer will use any such database to
determine a median contracted rate and
cover the cost of accessing any such
database; and
``(II) in the case of a sponsor or
issuer offering a health plan in a
geographic region that did not offer
any health plan in such region during
2019, such sponsor or issuer shall use
a methodology established by the
Secretary for determining the median
contracted rate for items and services
covered by such plan for the first year
in which such plan is offered in such
region, and that, for each succeeding
year, the median contracted rate for
such items and services under such plan
shall be the median contracted rate for
such items and services under such plan
for 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.
``(F) Nonparticipating emergency facility;
participating emergency facility.--
``(i) Nonparticipating emergency
facility.--The term `nonparticipating emergency
facility' means, with respect to an item or
service and a health plan, an emergency
department of a hospital, or an independent
freestanding emergency department, that does
not have a contractual relationship with the
plan (or, if applicable, issuer offering the
plan) for furnishing such item or service under
the plan.
``(ii) Participating emergency facility.--
The term `participating emergency facility'
means, with respect to an item or service and a
health plan, an emergency department of a
hospital, or an independent freestanding
emergency department, that has a contractual
relationship with the plan (or, if applicable,
issuer offering the plan) for furnishing such
item or service under the plan.
``(G) Nonparticipating providers; participating
providers.--
``(i) Nonparticipating provider.--The term
`nonparticipating provider' means, with respect
to an item or service and a health plan, a
physician or other health care provider who is
acting within the scope of practice of that
provider's license or certification under
applicable State law and who does not have a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for
furnishing such item or service under the plan.
``(ii) Participating provider.--The term
`participating provider' means, with respect to
an item or service and a health plan, a
physician or other health care provider who is
acting within the scope of practice of that
provider's license or certification under
applicable State law and who has a contractual
relationship with the plan (or, if applicable,
issuer offering the plan) for furnishing such
item or service under the plan.
``(H) Recognized amount.--The term `recognized
amount' means, with respect to an item or service--
``(i) in the case of such item or service
furnished in a State that has in effect a State
law that provides for a method for determining
the amount of payment that is required to be
covered by a health plan regulated by such
State in the case of a participant,
beneficiary, or enrollee covered under such
plan and receiving such item or service from a
nonparticipating provider or facility, not more
than the amount determined in accordance with
such law plus the cost-sharing amount imposed
under the plan for such item or service (as
determined in accordance with clauses (ii) and
(iii) of paragraph (1)(C) or subparagraphs (A)
and (B) of subsection (e)(1), as applicable);
or
``(ii) in the case of such item or service
furnished in a State that does not have in
effect such a law, an amount that is at least
the median contracted rate (as defined in
subparagraph (E)(i) and determined in
accordance with rulemaking described in section
402(e) of the No Surprises Act) for such item
or service.''.
(b) Coverage of Non-emergency Services Performed by
Nonparticipating Providers at Certain Participating Facilities;
Independent Dispute Resolution Process.--Section 2719A of the Public
Health Service Act (42 U.S.C. 300gg-19a) is amended by adding at the
end the following new subsections:
``(e) Coverage of Non-emergency Services Performed by
Nonparticipating Providers at Certain Participating Facilities.--
``(1) In general.--Subject to paragraph (3), in the case of
items or services (other than emergency services to which
subsection (b) applies) furnished to a participant,
beneficiary, or enrollee of a health plan (as defined in
paragraph (2)(A)) by a nonparticipating provider (as defined in
subsection (b)(3)(G)(i)) during a visit (as defined by the
Secretary in accordance with paragraph (2)(C)) at a
participating health care facility (as defined in paragraph
(2)(B)), with respect to such plan, the plan--
``(A) shall not impose on such participant,
beneficiary, or enrollee a cost-sharing amount
(expressed as a copayment amount or coinsurance rate)
for such items and services so furnished that is
greater than the cost-sharing amount that would apply
under such plan had such items or services been
furnished by a participating provider (as defined in
subsection (b)(3)(G)(ii));
``(B) shall calculate such cost-sharing amount as
if the amount that would have been charged for such
items and services by such participating provider were
equal to--
``(i) in the case of such items and
services furnished in a State described in
subsection (b)(3)(H)(ii), the median contracted
rate (as defined in subsection (b)(3)(E)(i))
for such items and services; and
``(ii) in the case of such items and
services furnished in a State described in
subsection (b)(3)(H)(i), the lesser of--
``(I) the amount determined by such
State for such items and services in
accordance with the method described in
such subsection; and
``(II) the median contracted rate
(as so defined) for such items and
services;
``(C) shall pay to such provider furnishing such
items and services to such participant, beneficiary, or
enrollee the amount by which the recognized amount (as
defined in subsection (b)(3)(H)) for such items and
services exceeds the cost-sharing amount imposed under
the plan for such items and services (as determined in
accordance with subparagraphs (A) and (B)); and
``(D) shall count toward any in-network deductible
or out-of-pocket maximums applied under the plan any
cost-sharing payments made by the participant,
beneficiary, or enrollee (and such in-network
deductible shall be applied) with respect to such items
and services so furnished in the same manner as if such
cost-sharing payments were with respect to items and
services furnished by a participating provider.
``(2) Definitions.--In this subsection and subsection (b):
``(A) Health plan.--The term `health plan' means a
group health plan and health insurance coverage offered
by a heath 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).
``(B) Participating health care facility.--
``(i) In general.--The term `participating
health care facility' means, with respect to an
item or service and a health plan, a health
care facility described in clause (ii) that has
a contractual relationship with the plan (or,
if applicable, issuer offering the plan) for
furnishing such item or service.
``(ii) Health care facility described.--A
health care facility described in this clause
is each of the following:
``(I) A hospital (as defined in
1861(e) of the Social Security Act).
``(II) A critical access hospital
(as defined in section 1861(mm) of such
Act).
``(III) An ambulatory surgical
center (as defined in section
1833(i)(1)(A) of such Act).
``(IV) A laboratory.
``(V) A radiology facility or
imaging center.
``(C) During a visit.--The term `during a visit'
shall, with respect to items and services furnished to
an individual at a participating health care facility,
include equipment and devices, telemedicine services,
imaging services, laboratory services, and such other
items and services as the Secretary may specify,
regardless of whether or not the provider furnishing
such items or services is at the facility.
``(3) Exception.--Paragraph (1) shall not apply to a health
plan in the case of items or services (other than emergency
services to which subsection (b) applies) furnished to a
participant, beneficiary, or enrollee of a health plan (as
defined in paragraph (2)(A)) by a nonparticipating provider (as
defined in subsection (b)(3)(G)(i)) during a visit (as defined
by the Secretary in accordance with paragraph (2)(C)) at a
participating health care facility (as defined in paragraph
(2)(B)) if such provider is in compliance with section 2799A(d)
with respect to such items and services.
``(f) Independent Dispute Resolution Process.--
``(1) Establishment.--
``(A) In general.--Not later than 1 year after the
date of the enactment of this subsection, the
Secretary, in consultation with the Secretary of Labor,
shall establish by regulation an independent dispute
resolution process (referred to in this subsection as
the `IDR process') under which--
``(i) a nonparticipating provider (as
defined in subparagraph (G) of subsection
(b)(3)), nonparticipating emergency facility
(as defined in subparagraph (F) of such
subsection), or health plan (as defined in
subsection (e)(2)(A)) may submit a request for
resolution by an entity certified under
paragraph (2) (in this subsection referred to
as a `certified IDR entity') of a specified
claim; and
``(ii) in the case a settlement described
in subparagraph (B) of paragraph (4) is not
reached with respect to such claim, such entity
so resolves such claim in accordance with such
paragraph.
``(B) Definitions.--In this subsection:
``(i) Specified claim.--
``(I) In general.--Subject to
subclause (II), the term `specified
claim' means a claim by a
nonparticipating provider, a
nonparticipating emergency facility, or
a health plan with respect to
qualifying items and services (as
defined in clause (ii)) furnished by
such provider or facility in a State
described in subparagraph (H)(ii) of
subsection (b)(3) for which a health
plan is required to make payment
pursuant to subsection (b)(1) or
subsection (e)(1)--
``(aa) that such payment
should be increased or
decreased; and
``(bb) that is made not
later than--
``(AA) in the case
of such a claim filed
by such a provider or
facility, the date on
which the appeal with
respect to such items
and services described
in clause
(ii)(I)(aa)(AA) has
been resolved (or the
date that is 30 days
after such appeal is
filed, whichever is
earlier); or
``(BB) in the case
of such a claim filed
by such plan, the date
on which the period
described in clause
(ii)(I)(bb)(BB) with
respect to such items
and services elapses.
``(II) Limitation on packaging of
items and services in a specified
claim.--The term `specified claim'
shall not include, in the case such
claim is made by such provider,
facility, or plan with respect to
multiple items and services, any claim
with respect to items and services
furnished by such provider or facility
if--
``(aa) such items and
services were not furnished by
the same provider or facility;
``(bb) payment for such
items and services made
pursuant to subsection (b)(1)
or subsection (e)(1) was made
by multiple health plans;
``(cc) such items and
services are not related to the
treatment of the same
condition; or
``(dd) such items and
services were not furnished
within 30 days of the date of
the earliest item or service
furnished that is included in
such claim.
``(ii) Qualifying items and services.--
``(I) In general.--Subject to
subclause (II), the term `qualifying
items and services' means--
``(aa) with respect to a
specified claim made by a
nonparticipating provider or
nonparticipating emergency
facility, items and services
furnished by such provider or
facility for which a health
plan is required to make
payment pursuant to subsection
(b)(1) or subsection (e)(1),
but only if--
``(AA) such items
and services are
included in an appeal
filed under such plan's
internal appeals
process not later than
30 days after such
payment is received;
and
``(BB) such appeal
under such plan's
internal appeals
process has been
resolved, or a 30-day
period has elapsed
since such appeal was
so filed; and
``(bb) with respect to a
specified claim made by a
health plan, items and services
furnished by such a provider or
facility for which such health
plan is required to make
payment pursuant to subsection
(b)(1) or subsection (e)(1),
but only if--
``(AA) such plan
submits a notice to
such provider or
facility not later than
30 days after such
provider or facility
receives such payment
that such plan disputes
the amount of such
payment with respect to
such items and
services; and
``(BB) a 30-day
period has elapsed
since the submission of
such notice.
``(II) Limitation.--The term
`qualifying items and services' shall
not include an item or service
furnished in a geographic area during a
year by such provider or facility for
which a health plan is required to make
payment pursuant to subsection (b)(1)
or subsection (e)(1) if the median
contracted rate (as defined in
subsection (b)(3)(E)) under such plan
for such year with respect to such item
or service furnished by such a provider
or such a facility in such area does
not exceed--
``(aa) with respect to an
item or service furnished
during 2021, $1,250; and
``(bb) with respect to an
item or service furnished
during a subsequent year, the
amount specified under this
subclause for 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.
``(2) Certification of entities.--
``(A) Process of certification.--The process
described in paragraph (1) shall include a
certification process under which eligible entities may
be certified to carry out the IDR process.
``(B) Eligibility.--
``(i) In general.--For purposes of
subparagraph (A), an eligible entity is an
entity that is a nongovernmental entity that
agrees to comply with the fee limitations
described in clause (ii).
``(ii) Fee limitation.--For purposes of
clause (i), the fee limitations described in
this clause are limitations established by the
Secretary on the amount a certified IDR entity
may charge a nonparticipating provider,
nonparticipating emergency facility, or health
plan for services furnished by such entity with
respect to the resolution of a specified claim
of such provider, facility, or plan under the
process described in paragraph (1).
``(3) Selection of certified idr entity for a specified
claim.--With respect to the resolution of a specified claim
under the IDR process, the health plan and the nonparticipating
provider or the nonparticipating emergency facility (as
applicable) involved shall agree on a certified IDR entity to
resolve such claim. In the case that such plan and such
provider or facility (as applicable) cannot so agree, such an
entity shall be selected by the Secretary at random.
``(4) Payment determination.--
``(A) Timing.--A certified IDR entity selected
under paragraph (3) by a health plan and a
nonparticipating provider or a nonparticipating
emergency facility (as applicable) with respect to a
specified claim shall, subject to subparagraph (B), not
later than 30 days after being so selected, determine
the total reimbursement that should have been made for
items and services included in such claim in accordance
with subparagraph (C).
``(B) Settlement.--
``(i) In general.--If such entity
determines that a settlement between the health
plan and the provider or facility is likely
with respect to a specified claim, the entity
may direct the parties to attempt, for a period
not to exceed 10 days, a good faith negotiation
for a settlement of such claim.
``(ii) Timing.--The period for a settlement
described in clause (i) shall accrue towards
the 30-day period described in subparagraph
(A).
``(C) Determination of amount.--
``(i) In general.--The health plan and the
nonparticipating provider or nonparticipating
emergency facility (as applicable) shall, with
respect to a specified claim, each submit to
the certified IDR entity a final offer of
payment or reimbursement (as applicable) with
respect to items and services which are the
subject of the specified claim. Such entity
shall determine which such offer is the most
reasonable in accordance with clause (ii).
``(ii) Considerations in determination.--
``(I) In general.--In determining
which final offer is the most
reasonable under clause (i), the
certified IDR entity shall consider--
``(aa) the median
contracted rates (as defined in
subsection (b)(3)(E)) for items
or services that are comparable
to the items and services
included in the specified claim
and that are furnished in the
same geographic area (as
defined by the Secretary for
purposes of such subsection) as
such items and services (not
including any facility fees
with respect to such rates);
and
``(bb) the circumstances
described in subclause (II), if
any information with respect to
such circumstances is submitted
by either party.
``(II) Additional circumstances.--
For purposes of subclause (I)(bb), the
circumstances described in this
subclause are, with respect to items
and services included in the specified
claim of a nonparticipating provider,
nonparticipating emergency facility, or
health plan, the following:
``(aa) The level of
training, education,
experience, and quality and
outcomes measurements of the
provider or facility that
furnished such items and
services.
``(bb) Any other
extenuating circumstances with
respect to the furnishing of
such items and services that
relate to the acuity of the
individual receiving such items
and services or the complexity
of furnishing such items and
services to such individual.
``(III) Prohibition on
consideration of billed charges.--In
determining which final offer is the
most reasonable under clause (i) with
respect to items and services furnished
by a provider or facility and included
in a specified claim, the certified IDR
entity may not consider the amount that
would have been billed by such provider
or facility with respect to such items
and services had the provisions of
section 2799 or 2799A (as applicable)
not applied.
``(iii) Effect of determination.--A
determination of a certified IDR entity under
clause (i)--
``(I) shall be binding; and
``(II) shall not be subject to
judicial review, except in a case
described in any of paragraphs (1)
through (4) of section 10(a) of title
9, United States Code.
``(iv) Costs of independent dispute
resolution process.--In the case of a specified
claim made by a nonparticipating provider,
nonparticipating emergency facility, or health
plan and submitted to a certified IDR entity--
``(I) if such entity makes a
determination with respect to such
claim under clause (i), the party whose
offer is not chosen under such clause
shall be responsible for paying all
fees charged by such entity; and
``(II) if the parties reach a
settlement with respect to such claim
prior to such a determination, such
fees shall be divided equally between
the parties, unless the parties
otherwise agree.
``(v) Payment.--Not later than 30 days
after a determination described in clause (i)
is made with respect to a specified claim of a
nonparticipating provider, nonparticipating
emergency facility, or health plan--
``(I) in the case that such
determination finds that the amount
paid with respect to such specified
claim by the health plan should have
been greater than the amount so paid,
such plan shall pay directly to the
provider or facility (as applicable)
the difference between the amount so
paid and the amount so determined; and
``(II) in the case that such
determination finds that the amount
paid with respect to such specified
claim by the health plan should have
been less than the amount so paid, the
provider or facility (as applicable)
shall pay directly to the plan the
difference between the amount so paid
and the amount so determined.
``(5) Publication of information relating to disputes.--
``(A) In general.--For 2021 and each subsequent
year, the Secretary and the Secretary of Labor shall
publish on the public website of the Department of
Health and Human Services and the Department of Labor,
respectively--
``(i) the number of specified claims filed
during such year;
``(ii) the number of such claims with
respect to which a final determination was made
under paragraph (4)(C)(i); and
``(iii) the information described in
subparagraph (B) with respect to each specified
claim with respect to which such a decision was
so made.
``(B) Information with respect to specified
claims.--For purposes of subparagraph (A), the
information described in this subparagraph is, with
respect to a specified claim of a nonparticiapting
provider, nonparticipating emergency facility, or
health plan--
``(i) a description of each item and
service included in such claim;
``(ii) the amount of the offer submitted
under paragraph (4)(C)(i) by the health plan
and by the nonparticipating provider or
nonparticipating emergency facility (as
applicable);
``(iii) whether the offer selected by the
certified IDR entity under such paragraph was
the offer submitted by such plan or by such
provider or facility (as applicable) and the
amount of such offer so selected; and
``(iv) the category and practice specialty
of each such provider or facility involved in
furnishing such items and services.
``(C) Confidentiality of parties.--None of the
information published under this paragraph may specify
the identity of a health plan, provider, facility, or
individual with respect to a specified claim.''.
(c) Provider Directory Requirements; Disclosure on Patient
Protections.--Section 2719A of the Public Health Service Act, as
amended by subsection (b), is further amended by adding at the end the
following new subsections:
``(g) Provider Directory Information Requirements.--
``(1) In general.--Not later than 1 year after the date of
the enactment of this subsection, each group health plan and
health insurance issuer offering group or individual health
insurance coverage shall--
``(A) establish the verification process described
in paragraph (2);
``(B) establish the response protocol described in
paragraph (3);
``(C) establish the database described in paragraph
(4); and
``(D) include in any print directory containing
provider directory information with respect to such
plan or such coverage the information described in
paragraph (5).
``(2) Verification process.--The verification process
described in this paragraph is, with respect to a group health
plan or a health insurance issuer offering group or individual
health insurance coverage, a process--
``(A) under which not less frequently than once
every 90 days, such plan or such issuer (as applicable)
verifies and updates the provider directory information
included on the database described in paragraph (4) of
such plan or issuer of each health care provider and
health care facility included in such database; and
``(B) that establishes a procedure for the removal
of such a provider or facility with respect to which
such plan or issuer has been unable to verify such
information during a period specified by the plan or
issuer.
``(3) Response protocol.--The response protocol described
in this paragraph is, in the case of an individual enrolled
under a group health plan or group or individual health
insurance coverage offered by a health insurance issuer who
requests information on whether a health care provider or
health care facility has a contractual relationship to furnish
items and services under such plan or such coverage, a protocol
under which such plan or such issuer (as applicable), in the
case such request is made through a telephone call--
``(A) responds to such individual as soon as
practicable and in no case later than 1 business day
after such call is received through a written
electronic communication; and
``(B) retains such communication in such
individual's file for at least 2 years following such
response.
``(4) Database.--The database described in this paragraph
is, with respect to a group health plan or health insurance
issuer offering group or individual health insurance coverage,
a database on the public website of such plan or issuer that
contains--
``(A) a list of each health care provider and
health care facility with which such plan or such
issuer has a contractual relationship for furnishing
items and services under such plan or such coverage;
and
``(B) provider directory information with respect
to each such provider and facility.
``(5) Information.--The information described in this
paragraph is, with respect to a print directory containing
provider directory information with respect to a group health
plan or individual or group health insurance coverage offered
by a health insurance issuer, a notification that such
information contained in such directory was accurate as of the
date of publication of such directory and that an individual
enrolled under such plan or such coverage should consult the
database described in paragraph (4) with respect to such plan
or such coverage or contact such plan or the issuer of such
coverage to obtain the most current provider directory
information with respect to such plan or such coverage.
``(6) Definition.--For purposes of this subsection, the
term `provider directory information' includes, with respect to
a group health plan and a health insurance issuer offering
group or individual health insurance coverage, the name,
address, specialty, and telephone number of each health care
provider or health care facility with which such plan or such
issuer has a contractual relationship for furnishing items and
services under such plan or such coverage.
``(h) Disclosure on Patient Protections.--Each group health plan
and health insurance issuer offering group or individual health
insurance coverage shall make publicly available, and (if applicable)
post on a public website of such plan or issuer--
``(1) information in plain language on--
``(A) the requirements and prohibitions applied
under sections 2799 and 2799A (relating to prohibitions
on balance billing in certain circumstances);
``(B) if provided for under applicable State law,
any other requirements on providers and facilities
regarding the amounts such providers and facilities
may, with respect to an item or service, charge a
participant, beneficiary, or enrollee of such plan or
coverage with respect to which such a provider or
facility does not have a contractual relationship for
furnishing such item or service under the plan or
coverage after receiving payment from the plan or
coverage for such item or service and any applicable
cost-sharing payment from such participant,
beneficiary, or enrollee; and
``(C) the requirements applied under subsections
(b) and (e); and
``(2) information on contacting appropriate State and
Federal agencies in the case that an individual believes that
such a provider or facility has violated any requirement
described in paragraph (1) with respect to such individual.''.
(d) Preventing Certain Cases of Balance Billing.--Title XXVII of
the Public Health Service Act is amended by adding at the end the
following new part:
``PART D--PREVENTING CERTAIN CASES OF BALANCE BILLING
``SEC. 2799. BALANCE BILLING IN CASES OF EMERGENCY SERVICES.
``(a) In General.--In the case of a participant, beneficiary, or
enrollee with benefits under a health plan who is furnished on or after
January 1, 2021, emergency services with respect to an emergency
medical condition during a visit at an emergency department of a
hospital or an independent freestanding emergency department--
``(1) the emergency department of a hospital or independent
freestanding emergency department shall not hold the
participant, beneficiary, or enrollee liable for a payment
amount for such emergency services so furnished that is more
than the cost-sharing amount for such services (as determined
in accordance with clauses (ii) and (iii) of section
2719A(b)(1)(C)); and
``(2) a health care provider shall not hold such
participant, beneficiary, or enrollee liable for a payment
amount for an emergency service furnished to such individual by
such provider with respect to such emergency medical condition
and visit for which the individual receives emergency services
at the hospital or emergency department that is more than the
cost-sharing amount for such services furnished by the provider
(as determined in accordance with clauses (ii) and (iii) of
section 2719A(b)(1)(C)).
``(b) Definitions.--In this section:
``(1) The terms `emergency department of a hospital',
`emergency medical condition', `emergency services', and
`independent freestanding emergency department' have the
meanings given such terms, respectively, in section
2719A(b)(3).
``(2) The term `health plan' has the meaning given such
term in section 2719A(e).
``(3) The term `during a visit' shall have such meaning as
applied to such term for purposes of section 2719A(e).
``SEC. 2799A. BALANCE BILLING IN CASES OF NON-EMERGENCY SERVICES
PERFORMED BY NONPARTICIPATING PROVIDERS AT CERTAIN
PARTICIPATING FACILITIES.
``(a) In General.--Subject to subsection (b), in the case of a
participant, beneficiary, or enrollee with benefits under a health plan
(as defined in section 2799(b)) who is furnished on or after January 1,
2021, items or services (other than emergency services to which section
2799 applies) at a participating health care facility by a
nonparticipating provider, such provider shall not hold such
participant, beneficiary, or enrollee liable for a payment amount for
such an item or service furnished by such provider during a visit at
such facility that is more than the cost-sharing amount for such item
or service (as determined in accordance with subparagraphs (A) and (B)
of section 2719A(e)(1)).
``(b) Exception.--
``(1) In general.--Subsection (a) shall not apply to a
nonparticipating provider (other than a specified provider at a
participating health care facility), with respect to items or
services furnished by the provider to a participant,
beneficiary, or enrollee of a health plan, if the provider is
in compliance with the notice and consent requirements of
subsection (d).
``(2) Specified provider defined.--For purposes of
paragraph (1), the term `specified provider', with respect to a
participating health care facility--
``(A) means a facility-based provider, including
emergency medicine providers, anesthesiologists,
pathologists, radiologists, neonatologists, assistant
surgeons, hospitalists, intensivists, or other
providers as determined by the Secretary; and
``(B) includes, with respect to an item or service,
a nonparticipating provider if there is no
participating provider at such facility who can furnish
such item or service.
``(c) Clarification.--In the case of a nonparticipating provider
(other than a specified provider at a participating health care
facility) that complies with the notice and consent requirements of
subsection (d) with respect to an item or service (referred to in this
subsection as a `covered item or service'), such notice and consent
requirements may not be construed as applying with respect to any item
or service that is furnished as a result of unforeseen medical needs
that arise at the time such covered item or service is furnished.
``(d) Compliance With Notice and Consent Requirements.--
``(1) In general.--A nonparticipating provider or
nonparticipating facility is in compliance with this
subsection, with respect to items or services furnished by the
provider or facility to a participant, beneficiary, or enrollee
of a health plan, if the provider (or, if applicable, the
participating health care facility on behalf of such provider)
or nonparticipating facility--
``(A) provides to the participant, beneficiary, or
enrollee (or to an authorized representative of the
participant, beneficiary, or enrollee) on the date on
which the individual is furnished such items or
services and, in the case that the participant,
beneficiary, or enrollee makes an appointment to be
furnished such items or services, on such date the
appointment is made--
``(i) an oral explanation of the written
notice described in clause (ii); and
``(ii) a written notice specified by the
Secretary, not later than July 1, 2020, through
guidance (which shall be updated as determined
necessary by the Secretary) that--
``(I) contains the information
required under paragraph (2); and
``(II) is signed and dated by the
participant, beneficiary, or enrollee
(or by an authorized representative of
the participant, beneficiary, or
enrollee) and, with respect to items or
services to be furnished by such a
provider that are not poststabilization
services described in section
2719A(b)(3)(C)(ii), is so signed and
dated not less than 72 hours prior to
the participant, beneficiary, or
enrollee being furnished such items or
services by such provider; and
``(B) obtains from the participant, beneficiary, or
enrollee (or from such an authorized representative)
the consent described in paragraph (3).
``(2) Information required under written notice.--For
purposes of paragraph (1)(A)(ii)(I), the information described
in this paragraph, with respect to a nonparticipating provider
or nonparticipating facility and a participant, beneficiary, or
enrollee of a health plan, is each of the following:
``(A) Notification, as applicable, that the health
care provider is a nonparticipating provider with
respect to the health plan or the health care facility
is a nonparticipating facility with respect to the
health plan.
``(B) Notification of the estimated amount that
such provider or facility may charge the participant,
beneficiary, or enrollee for such items and services
involved.
``(C) In the case of a nonparticipating facility, a
list of any participating providers at the facility who
are able to furnish such items and services involved
and notification that the participant, beneficiary, or
enrollee may be referred, at their option, to such a
participating provider.
``(3) Consent described.--For purposes of paragraph (1)(B),
the consent described in this paragraph, with respect to a
participant, beneficiary, or enrollee of a health plan who is
to be furnished items or services by a nonparticipating
provider or nonparticipating facility, is a document specified
by the Secretary through rulemaking that--
``(A) is signed by the participant, beneficiary, or
enrollee (or by an authorized representative of the
participant, beneficiary, or enrollee) and, with
respect to items or services to be furnished by such a
provider or facility that are not poststabilization
services described in section 2719A(b)(3)(C)(ii), is so
signed not less than 72 hours prior to the participant,
beneficiary, or enrollee being furnished such items or
services by such provider or facility;
``(B) acknowledges that the participant,
beneficiary, or enrollee has been--
``(i) provided with a written estimate and
an oral explanation of the charge that the
participant, beneficiary, or enrollee will be
assessed for the items or services anticipated
to be furnished to the participant,
beneficiary, or enrollee by such provider or
facility; and
``(ii) informed that the payment of such
charge by the participant, beneficiary, or
enrollee may not accrue toward meeting any
limitation that the health plan places on cost-
sharing; and
``(C) documents the consent of the participant,
beneficiary, or enrollee to--
``(i) be furnished with such items or
services by such provider or facility; and
``(ii) in the case that the individual is
so furnished such items or services, be charged
an amount that may be greater than the amount
that would otherwise be charged the individual
if furnished by a participating provider or
participating facility with respect to such
items or services and plan.
``(e) Retention of Certain Documents.--A nonparticipating provider
(or, in the case of a nonparticipating provider at a participating
health care facility, such facility) or nonparticipating facility that
obtains from a participant, beneficiary, or enrollee of a health plan
(or an authorized representative of such participant, beneficiary, or
enrollee) a written notice in accordance with subsection (c)(1)(ii),
with respect to furnishing an item or service to such participant,
beneficiary, or enrollee, shall retain such notice for at least a 2-
year period after the date on which such item or service is so
furnished.
``(f) Definitions.--In this section:
``(1) The terms `nonparticipating provider' and
`participating provider' have the meanings given such terms,
respectively, in subsection (b)(3) of section 2719A.
``(2) The terms `participating health care facility' and
`health plan' have the meanings given such terms, respectively,
in subsection (e)(2) of section 2719A.
``(3) The term `nonparticipating facility' means--
``(A) with respect to emergency services (as
defined in section 2719A(b)(3)(C)(i)) and a health
plan, an emergency department of a hospital, or an
independent freestanding emergency department, that
does not have a contractual relationship with the plan
(or, if applicable, issuer offering the plan) for
furnishing such services under the plan; and
``(B) with respect to poststabilization services
described in section 2719A(b)(3)(C)(ii) and a health
plan, an emergency department of a hospital (or other
department of such hospital), or an independent
freestanding emergency department, that does not have a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for furnishing
such services under the plan.
``(4) The term `participating facility' means--
``(A) with respect to emergency services (as
defined in section 2719A(b)(3)(C)(i)) and a health
plan, an emergency department of a hospital, or an
independent freestanding emergency department, that has
a contractual relationship with the plan (or, if
applicable, issuer offering the plan) for furnishing
such services under the plan; and
``(B) with respect to poststabilization services
described in section 2719A(b)(3)(C)(ii) and a health
plan, an emergency department of a hospital (or other
department of such hospital), or an independent
freestanding emergency department, that has a
contractual relationship with the plan (or, if
applicable, issuer offering the plan) for furnishing
such services under the plan.
``SEC. 2799B. PROVIDER REQUIREMENTS WITH RESPECT TO PROVIDER DIRECTORY
INFORMATION.
``Not later than 1 year after the date of the enactment of this
section, each health care provider and health care facility shall
establish a process under which such provider or facility transmits, to
each health insurance issuer offering group or individual health
insurance coverage and group health plan with which such provider or
facility has in effect a contractual relationship for furnishing items
and services under such coverage or such plan, provider directory
information (as defined in section 2719A(g)(6)) with respect to such
provider or facility, as applicable. Such provider or facility shall so
transmit such information to such issuer offering such coverage or such
group health plan--
``(1) when the provider or facility enters into such a
relationship with respect to such coverage offered by such
issuer or with respect to such plan;
``(2) when the provider or facility terminates such
relationship with respect to such coverage offered by such
issuer or with respect to such plan;
``(3) when there are any other material changes to such
provider directory information of the provider or facility with
respect to such coverage offered by such issuer or with respect
to such plan; and
``(4) at any other time (including upon the request of such
issuer or plan) determined appropriate by the provider,
facility, or the Secretary.
``SEC. 2799C. PROVIDER REQUIREMENT WITH RESPECT TO PUBLIC PROVISION OF
INFORMATION.
``Each health care provider and health care facility shall make
publicly available, and (if applicable) post on a public website of
such provider or facility--
``(1) information in plain language on--
``(A) the requirements and prohibitions of such
provider or facility under sections 2799 and 2799A
(relating to prohibitions on balance billing in certain
circumstances); and
``(B) if provided for under applicable State law,
any other requirements on such provider or facility
regarding the amounts such provider or facility may,
with respect to an item or service, charge a
participant, beneficiary, or enrollee of a health plan
(as defined in section 2719A(e)(2)) with respect to
which such provider or facility does not have a
contractual relationship for furnishing such item or
service under the plan after receiving payment from the
plan for such item or service and any applicable cost-
sharing payment from such participant, beneficiary, or
enrollee; and
``(2) information on contacting appropriate State and
Federal agencies in the case that an individual believes that
such provider or facility has violated any requirement
described in paragraph (1) with respect to such individual.
``SEC. 2799D. ENFORCEMENT.
``(a) State Enforcement.--
``(1) State authority.--Each State may require a provider
or health care facility subject to the requirements of sections
2719A(f), 2799, 2799A, 2799B, or 2799C to satisfy such
requirements applicable to the provider or facility.
``(2) Failure to implement requirements.--In the case of a
determination by the Secretary that a State has failed to
substantially enforce the requirements specified in paragraph
(1) with respect to applicable providers and facilities in the
State, the Secretary shall enforce such requirements under
subsection (b) insofar as they relate to violations of such
requirements occurring in such State.
``(b) Secretarial Enforcement Authority.--
``(1) In general.--If a provider or facility is found to be
in violation specified in subsection (a)(1) by the Secretary,
the Secretary may apply a civil monetary penalty with respect
to such provider or facility in an amount not to exceed $10,000
per violation. The provisions of subsections (c), (d), (e),
(g), (h), (k), and (l) of section 1128A of the Social Security
Act shall apply to a civil monetary penalty or assessment under
this subsection in the same manner as such provisions apply to
a penalty, assessment, or proceeding under subsection (a) of
such section.
``(2) Limitation.--The provisions of paragraph (1) shall
apply to enforcement of a provision (or provisions) specified
in subsection (a)(1) only as provided under subsection (a)(2).
``(3) Complaint process.--The Secretary shall, through
rulemaking, establish a process to receive consumer complaints
of violations of such provisions and resolve such complaints
within 60 days of receipt of such complaints.
``(4) Exception.--The Secretary shall waive the penalties
described under paragraph (1) with respect to a facility or
provider who does not knowingly violate, and should not have
reasonably known it violated, section 2799 or 2799A with
respect to a participant, beneficiary, or enrollee, if such
facility or practitioner, within 30 days of the violation,
withdraws the bill that was in violation of such provision and
reimburses the health plan or enrollee, as applicable, in an
amount equal to the difference between the amount billed and
the amount allowed to be billed under the provision, plus
interest, at an interest rate determined by the Secretary.
``(5) Hardship exemption.--The Secretary may establish a
hardship exemption to the penalties under this subsection.
``(c) Continued Applicability of State Law.--The sections specified
in subsection (a)(1) shall not be construed to supersede any provision
of State law which establishes, implements, or continues in effect any
requirement or prohibition except to the extent that such requirement
or prohibition prevents the application of a requirement or prohibition
of such a section.''.
(e) Rulemaking for Median Contracted Rates.--Not later than July 1,
2020, the Secretary of Health and Human Services, jointly with the
Secretary of Labor, shall establish through rulemaking--
(1) the methodology the sponsor or issuer of a health plan
(as defined in subsection (e) of section 2719A of the Public
Health Service Act (42 U.S.C. 300gg-19a), as added by
subsection (b) of this section) shall use to determine the
median contracted rate (as defined in section 2719A(b) of such
Act, as amended by subsection (a) of this section),
differentiating by business line;
(2) the information such sponsor or issuer shall share with
the nonparticipating provider (as defined in such section)
involved when making such a determination; and
(3) the geographic regions applied for purposes of
subparagraph (E) of section 2719A(b)(3), as amended by
subsection (a) of this section, taking into account the needs
of rural and underserved areas, including health professional
shortage areas.
Such rulemaking shall take into account payments that are made by such
sponsor or issuer that are not on a fee-for-service basis. Such
methodology may account for relevant payment adjustments that take into
account facility type (including higher acuity settings and the case-
mix of various facility types) that are otherwise taken into account
for purposes of determining payment amounts with respect to
participating facilities.
(f) Effective Date.--The amendments made by subsections (a) and (b)
shall apply with respect to plan years beginning on or after January 1,
2021.
SEC. 403. GOVERNMENT ACCOUNTABILITY OFFICE STUDY ON PROFIT- AND
REVENUE-SHARING IN HEALTH CARE.
(a) Study.--The Comptroller General of the United States shall
conduct a study to--
(1) describe what is known about profit- and revenue-
sharing relationships in the commercial health care markets,
including those relationships that--
(A) involve one or more--
(i) physician groups that practice within a
hospital included in the profit- or revenue-
sharing relationship, or refer patients to such
hospital;
(ii) laboratory, radiology, or pharmacy
services that are delivered to privately
insured patients of such hospital;
(iii) surgical services;
(iv) hospitals or group purchasing
organizations; or
(v) rehabilitation or physical therapy
facilities or services; and
(B) include revenue- or profit-sharing whether
through a joint venture, management or professional
services agreement, or other form of gain-sharing
contract;
(2) describe Federal oversight of such relationships,
including authorities of the Department of Health and Human
Services and the Federal Trade Commission to review such
relationships and their potential to increase costs for
patients, and identify limitations in such oversight; and
(3) as appropriate, make recommendations to improve Federal
oversight of such relationships.
(b) Report.--Not later than 2 years after the date of the enactment
of this Act, the Comptroller General of the United States shall prepare
and submit a report on the study conducted under subsection (a) to the
Committee on Health, Education, Labor, and Pensions of the Senate and
the Committee on Education and Labor and Committee on Energy and
Commerce of the House of Representatives.
SEC. 404. STATE ALL PAYER CLAIMS DATABASES.
(a) In General.--The Secretary of Health and Human Services shall
make one-time grants to eligible States for the purposes described in
subsection (b).
(b) Uses.--A State may use a grant received under subsection (a)
for one of the following purposes:
(1) To establish an All Payer Claims Database for the
State.
(2) To maintain an existing All Payer Claims Databases for
the State.
(c) Eligibility.--To be eligible to receive a grant under
subsection (a), a State shall submit to the Secretary an application at
such time, in such manner, and containing such information as the
Secretary specifies. Such information shall include, with respect to an
All Payer Claims Database for the State, at least specifics on how the
State will ensure uniform data collection through the database and the
security of such data submitted to and maintained in the database.
(d) All Payer Claims Database.--For purposes of this section, the
term ``All Payer Claims Database'' means, with respect to a State, a
State database that may include medical claims, pharmacy claims, dental
claims, and eligibility and provider files, which are collected from
private and public payers.
(e) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated $50,000,000, to remain
available until expended.
SEC. 405. AIR AMBULANCE COST DATA REPORTING PROGRAM.
(a) Cost Data Reporting Program.--
(1) In general.--Not later than 6 months after the date of
the promulgation of the rule under subsection (c), and annually
thereafter, a provider of emergency air medical services shall
submit to the Secretary of Health and Human Services the
information specified in subsection (b) with respect to the
preceding 180-day period (in the case of the initial period)
and the preceding 1-year period (in each subsequent period).
(2) Publication.--Not later than 180 days after the date
the Secretary of Health and Human Services receives from a
provider described in paragraph (1) the information specified
in subsection (b), the Secretary shall make publicly available
such information.
(b) Specified Information.--Information described in subsection (a)
is--
(1) information, with respect to a claim for an item or
service--
(A) identified as paid by health insurance coverage
offered in the group or individual market or a group
health plan (including a self-insured plan);
(B) identified as paid for non-emergent transport
requiring prior authorization and emergent transport;
(C) identified as paid for hospital-affiliated
providers and independent providers;
(D) identified as paid for rural transport and
urban transport;
(E) identified as provided using rotor transport
and fixed wing transport; and
(F) identified as furnished by a provider of
emergency air medical services that has a contractual
relationship with the plan or coverage of an individual
for which such item or service is provided and such a
provider that does not have a contractual relationship
with the plan or coverage or such an individual; and
(2) cost data for an air ambulance service furnished by
such a provider of emergency air medical services that the
Secretary of Health and Human Services, in consultation with
suppliers and providers of such services, determines
appropriate, separated by the cost of air travel and the cost
of emergency medical services and supplies.
(c) Rulemaking.--Not later than 1 year after the date of the
enactment of this Act, the Secretary of Health and Human Services shall
determine the form and manner for submitting the information described
in subsection (b) through notice and comment rulemaking.
(d) Civil Monetary Penalties.--
(1) In general.--A provider of emergency air medical
services who violates the requirements of subsection (a)(1)
shall be subject to a civil monetary penalty of not more than
$10,000 for each act constituting such violation.
(2) Procedure.--The provisions of section 1128A of the
Social Security Act (42 U.S.C. 1320a-7a), other than
subsections (a) and (b) and the first sentence of subsection
(c)(1) of such subsection, shall apply to civil monetary
penalties under this subsection in the same manner as such
provisions apply to a penalty or proceeding under such section.
(e) Reporting.--
(1) Secretary of health and human services.--Not later than
July 1, 2023, the Secretary of Health and Human Services shall
submit to Congress a report summarizing the information and
data specified in subsection (b).
(2) Comptroller general.--Not later than July 1, 2023, the
Comptroller General of the United States shall submit to
Congress a report that includes--
(A) an analysis of the cost variation of providers
of emergency air ambulance services by geography and
status; and
(B) any other recommendations the Comptroller
General determines appropriate, which may include a
recommendation of an adequate amount of reimbursement
for such services that reflects operational costs of
such providers in order to preserve access to emergency
air ambulance services.
(f) Limitation.--The information publicly disclosed under
subsection (a) and the reports under subsection (f) may not contain any
proprietary information.
SEC. 406. REPORT BY SECRETARY OF LABOR.
Not later than one year after the date of the enactment of this
Act, and annually thereafter for each of the following 5 years, the
Secretary of Labor shall--
(1) conduct a study of--
(A) the effects of the provisions of, including
amendments made by, this Act on premiums and out-of-
pocket costs in group health plans, including out-of-
pocket costs that are permitted by reason of compliance
with section 2799A(d) of the Public Health Service Act,
as added by section 2(d);
(B) the adequacy of provider networks in group
health plans; and
(C) such other effects of such provisions, and
amendments, as the Secretary deems relevant; and
(2) submit a report on such study to the Committee on
Health, Education, Labor, and Pensions of the Senate and the
Committee on Education and Labor and the Committee on Energy
and Commerce of the House of Representatives.
SEC. 407. BILLING STATUTE OF LIMITATIONS.
Notwithstanding any other provision of law, a health care provider
or health care facility (or health insurance issuer offering health
insurance coverage or group health plan) may not initiate a process to
seek reimbursement from an individual for a service furnished by such
provider or facility to such individual more than a year after such
date of service. Any provider, facility, issuer, or plan that bills an
individual in violation of the previous sentence shall be subject to a
civil monetary penalty in such amount as specified by the Secretary of
Health and Human Services.
SEC. 408. GAO REPORT ON IMPACT OF SURPRISE BILLING PROVISIONS.
Not later than 3 years after the date of the enactment of this Act,
the Comptroller General of the United States shall submit to Congress a
report containing the following:
(1) What is known about the impacts of the provisions of
this Act, including the amendments made by this Act, on the
incidence and prevalence of the furnishing of items and
services to individuals enrolled under a group health plan or
health insurance coverage by health care providers and health
care facilities that do not have a contractual relationship
with such plan or such coverage (as applicable) for furnishing
such items and services to such an individual.
(2) What is known about such impacts on provider shortages
and accessibility to such providers, focusing on rural and
medically underserved communities.
(3) The number of grants that have been awarded under
section 404 (relating to State All Payer Claims Databases) and
for what purposes States have used funds made available under
such grants.
(4) An analysis of how data made available through State
All Payer Claims Databases receiving funding under such grants
has been used.
SEC. 409. REPORT BY THE SECRETARY OF HEALTH AND HUMAN SERVICES.
Not later than one year after the date of the enactment of this
Act, and annually thereafter for each of the following 5 years, the
Secretary of Health and Human Services shall--
(1) conduct a study of--
(A) the effects of the provisions of, including
amendments made by, this Act on premiums and out-of-
pocket costs with respect to individual health
insurance coverage and small group health plans;
(B) the adequacy of provider networks with respect
to individual health insurance coverage and small group
health plans, taking into consideration maximum travel
time and distance; and
(C) such other effects of such provisions, and
amendments, as the Secretary deems relevant; and
(2) submit a report on such study to the Committee on
Health, Education, Labor, and Pensions of the Senate and the
Committee on Education and Labor and the Committee on Energy
and Commerce of the House of Representatives.
TITLE V--TERRITORIES HEALTH CARE IMPROVEMENT ACT
SEC. 501. SHORT TITLE.
This title may be cited as the ``Territories Health Care
Improvement Act''.
SEC. 502. MEDICAID PAYMENTS FOR PUERTO RICO AND THE OTHER TERRITORIES
FOR CERTAIN FISCAL YEARS.
(a) Treatment of Cap.--Section 1108(g) of the Social Security Act
(42 U.S.C. 1308(g)) is amended--
(1) in paragraph (2)--
(A) in the matter preceding subparagraph (A), by
striking ``subject to and section 1323(a)(2) of the
Patient Protection and Affordable Care Act paragraphs
(3) and (5)'' and inserting ``subject to section
1323(a)(2) of the Patient Protection and Affordable
Care Act and paragraphs (3) and (5)'';
(B) in subparagraph (A)--
(i) by striking ``Puerto Rico shall not
exceed the sum of'' and inserting ``Puerto Rico
shall not exceed--
``(i) except as provided in clause (ii),
the sum of'';
(ii) by striking ``$100,000;'' and
inserting ``$100,000; and''; and
(iii) by adding at the end the following
new clause:
``(ii) for each of fiscal years 2020
through 2023, the amount specified in paragraph
(6) for each such fiscal year;'';
(C) in subparagraph (B)--
(i) by striking ``the Virgin Islands shall
not exceed the sum of'' and inserting ``the
Virgin Islands shall not exceed--
``(i) except as provided in clause (ii),
the sum of'';
(ii) by striking ``$10,000;'' and inserting
``$10,000; and''; and
(iii) by adding at the end the following
new clause:
``(ii) for each of fiscal years 2020
through 2025, $126,000,000;'';
(D) in subparagraph (C)--
(i) by striking ``Guam shall not exceed the
sum of'' and inserting ``Guam shall not
exceed--
``(i) except as provided in clause (ii),
the sum of'';
(ii) by striking ``$10,000;'' and inserting
``$10,000; and''; and
(iii) by adding at the end the following
new clause:
``(ii) for each of fiscal years 2020
through 2025, $127,000,000;'';
(E) in subparagraph (D)--
(i) by striking ``the Northern Mariana
Islands shall not exceed the sum of'' and
inserting ``the Northern Mariana Islands shall
not exceed--
``(i) except as provided in clause (ii),
the sum of''; and
(ii) by adding at the end the following new
clause:
``(ii) for each of fiscal years 2020
through 2025, $60,000,000; and''; and
(F) in subparagraph (E)--
(i) by striking ``American Samoa shall not
exceed the sum of'' and inserting ``American
Samoa shall not exceed--
``(i) except as provided in clause (ii),
the sum of'';
(ii) by striking ``$10,000.'' and inserting
``$10,000; and''; and
(iii) by adding at the end the following
new clause:
``(ii) for each of fiscal years 2020
through 2025, $84,000,000.''; and
(2) by adding at the end the following new paragraph:
``(6) Application to puerto rico for fiscal years 2020
through 2023.--For purposes of paragraph (2)(A)(ii), the amount
specified in this paragraph is--
``(A) for fiscal year 2020, $2,823,188,000;
``(B) for fiscal year 2021, $2,919,072,000;
``(C) for fiscal year 2022, $3,012,610,000; and
``(D) for fiscal year 2023, $3,114,331,000.''.
(b) Treatment of Funding Under Enhanced Allotment Program.--Section
1935(e) of the Social Security Act (42 U.S.C. 1396u-5(e)) is amended--
(1) in paragraph (1)(B), by striking ``if the State'' and
inserting ``subject to paragraph (4), if the State'';
(2) by redesignating paragraph (4) as paragraph (5); and
(3) by inserting after paragraph (3) the following new
paragraph:
``(4) Treatment of funding for certain fiscal years.--
``(A) Puerto rico.--Notwithstanding paragraph
(1)(B), in the case that Puerto Rico establishes and
submits to the Secretary a plan described in paragraph
(2) with respect to any of fiscal years 2020 through
2023, the amount specified in paragraph (3) for Puerto
Rico for such a year shall be taken into account in
applying subparagraph (A)(ii) of section 1108(g)(2) for
such year.
``(B) Other territories.--Notwithstanding paragraph
(1)(B), in the case that the Virgin Islands, Guam, the
Northern Mariana Islands, or American Samoa establishes
and submits to the Secretary a plan described in
paragraph (2) with respect to any of fiscal years 2020
through 2025, the amount specified in paragraph (3) for
the Virgin Islands, Guam, the Northern Mariana Islands,
or American Samoa, as the case may be, shall be taken
into account in applying, as applicable, subparagraph
(B)(ii), (C)(ii), (D)(ii), or (E)(ii) of section
1108(g)(2) for such year.''.
(c) Increased FMAP.--Section 1905 of the Social Security Act (42
U.S.C. 1396d(b)) is amended--
(1) in subsection (b), by striking ``and (aa)'' and
inserting ``(aa), and (ff)''; and
(2) by adding at the end the following new subsection:
``(ff) Temporary Increase in FMAP for Territories for Certain
Fiscal Years.--
``(1) Puerto rico.--Notwithstanding subsection (b) and
subject to subsection (z)(2), the Federal medical assistance
percentage for Puerto Rico shall be equal to--
``(A) 83 percent for fiscal years 2020 and 2021;
and
``(B) 76 percent for fiscal years 2022 and 2023.
``(2) Virgin islands.--Notwithstanding subsection (b) and
subject to subsection (z)(2), the Federal medical assistance
percentage for the Virgin Islands shall be equal to--
``(A) 100 percent for fiscal year 2020;
``(B) 83 percent for fiscal years 2021 through
2024; and
``(C) 76 percent for fiscal year 2025.
``(3) Other territories.--Notwithstanding subsection (b)
and subject to subsection (z)(2), the Federal medical
assistance percentage for Guam, the Northern Mariana Islands,
and American Samoa shall be equal to--
``(A) 100 percent for fiscal years 2020 and 2021;
``(B) 83 percent for fiscal years 2022 through
2024; and
``(C) 76 percent for fiscal year 2025.''.
(d) Annual Report.--Section 1108(g) of the Social Security Act (42
U.S.C. 1308(g)), as amended by subsection (a), is further amended by
adding at the end the following new paragraph:
``(7) Annual report.--
``(A) In general.--Not later than the date that is
180 days after the end of each fiscal year (beginning
with fiscal year 2020 and ending with fiscal year
2025), in the case that a specified territory receives
a Medicaid cap increase, or an increase in the Federal
medical assistance percentage for such territory under
section 1905(ff), for such fiscal year, such territory
shall submit to the Chair and Ranking Member of the
Committee on Energy and Commerce of the House of
Representatives and the Chair and Ranking Member of the
Committee on Finance of the Senate a report that
describes how such territory has used such Medicaid cap
increase, or such increase in the Federal medical
assistance percentage, as applicable, to increase
access to health care under the State Medicaid plan of
such territory under title XIX (or a waiver of such
plan). Such report may include--
``(i) the extent to which such territory
has, with respect to such plan (or waiver)--
``(I) increased payments to health
care providers;
``(II) increased covered benefits;
``(III) expanded health care
provider networks; or
``(IV) improved in any other manner
the carrying out of such plan (or
waiver); and
``(ii) any other information as determined
necessary by such territory.
``(B) Definitions.--In this paragraph:
``(i) Medicaid cap increase.--The term
`Medicaid cap increase' means, with respect to
a specified territory and fiscal year, any
increase in the amounts otherwise determined
under this subsection for such territory for
such fiscal year by reason of the amendments
made by section 502(a) of the Territories
Health Care Improvement Act.
``(ii) Specified territory.--The term
`specified territory' means Puerto Rico, the
Virgin Islands, Guam, the Northern Mariana
Islands, and American Samoa.''.
SEC. 503. APPLICATION OF CERTAIN REQUIREMENTS UNDER MEDICAID PROGRAM TO
CERTAIN TERRITORIES.
(a) Application of Payment Error Rate Measurement Requirements to
Puerto Rico.--Section 1903(u)(4) of the Social Security Act (42 U.S.C.
1396b(u)(4)) is amended--
(1) by striking ``to Puerto Rico, Guam'' and inserting ``to
Guam''; and
(2) by striking ``or American Samoa.'' and inserting ``or
American Samoa, or, for fiscal years before fiscal year 2023,
to Puerto Rico.''.
(b) Application of Asset Verification Program Requirements to
Puerto Rico and Virgin Islands.--Section 1940(a) of the Social Security
Act (42 U.S.C. 1396w(a)) is amended--
(1) in paragraph (3)(A), by adding at the end the following
new clause:
``(iii) Implementation in puerto rico and
virgin islands.--The Secretary shall require
Puerto Rico to implement an asset verification
program under this subsection by the end of
fiscal year 2022 and the Virgin Islands to
implement such a program by the end of fiscal
year 2023.''; and
(2) in paragraph (4)--
(A) in the paragraph heading, by striking
``Exemption of territories'' and inserting ``Exemption
of certain territories''; and
(B) by striking ``and the District of Columbia''
and inserting ``, the District of Columbia, Puerto
Rico, and the Virgin Islands''.
(c) Application of Certain Data Reporting and Program Integrity
Requirements to Northern Mariana Islands, American Samoa, and Guam.--
(1) In general.--Section 1902 of the Social Security Act
(42 U.S.C. 1396a) is amended by adding at the end the following
new subsection:
``(qq) Application of Certain Data Reporting and Program Integrity
Requirements to Northern Mariana Islands, American Samoa, and Guam.--
Not later than October 1, 2023, the Northern Mariana Islands, American
Samoa, and Guam shall--
``(1) implement methods, satisfactory to the Secretary, for
the collection and reporting of reliable data to the
Transformed Medicaid Statistical Information System (T-MSIS)
(or a successor system); and
``(2) demonstrate progress in establishing a State medicaid
fraud control unit described in section 1903(q).''.
(2) Conforming amendment.--Section 1902(j) of the Social
Security Act (42 U.S.C. 1396a(j)) is amended--
(A) by striking ``or the requirement'' and
inserting ``, the requirement''; and
(B) by inserting before the period at the end the
following: ``, or the requirement under subsection
(qq)(1) (relating to data reporting)''.
SEC. 504. ADDITIONAL PROGRAM INTEGRITY REQUIREMENTS.
(a) Audit Relating to Fraud, Waste, and Abuse.--Not sooner than the
date that is one year after the date of the enactment of this Act, the
Inspector General of the Department of Health and Human Services
(referred to in this section as the ``Inspector General'') shall
conduct an audit of Puerto Rico with respect to any part of the
administration of Puerto Rico's State plan under title XIX of the
Social Security Act (42 U.S.C. 1396 et seq.) (or a waiver of such
plan), such as contracting protocols, denials of care, and financial
management, that the Inspector General determines to be at high risk
for waste, fraud, or abuse.
(b) Plan for Audits and Investigations of Contracting Practices.--
Not later than the date that is one year after the date of the
enactment of this Act, the Inspector General shall develop and submit
to Congress a plan for auditing and investigating contracting practices
relating to Puerto Rico's State plan under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.) (or a waiver of such plan).
(c) Report on Contracting Oversight and Approval.--Not later than
the date that is two years after the date of the enactment of this Act,
the Comptroller General of the United States shall issue, and submit to
the Chair and Ranking Member of the Committee on Energy and Commerce of
the House of Representatives and the Chair and Ranking Member of the
Committee on Finance of the Senate, a report on contracting oversight
and approval with respect to Puerto Rico's State plan under title XIX
of the Social Security Act (42 U.S.C. 1396 et seq.) (or a waiver of
such plan). Such report shall--
(1) examine--
(A) the process used by Puerto Rico to evaluate
bids and award contracts under such plan (or waiver);
(B) which contracts are not subject to competitive
bidding or requests for proposals under such plan (or
waiver); and
(C) oversight by the Centers for Medicare &
Medicaid Services of contracts awarded under such plan
(or waiver); and
(2) include any recommendations for Congress, the Secretary
of Health and Human Services, or Puerto Rico relating to
changes that the Inspector General determines necessary to
improve the program integrity of such plan (or waiver).
(d) Reevaluation of Waivers of Medicaid Fraud Control Unit
Requirement.--Not later than the date that is one year after the date
of the enactment of this Act, the Secretary of Health and Human
Services shall--
(1) reevaluate any waiver approved (and in effect as of the
date of the enactment of this Act) for Guam, the Northern
Mariana Islands, or American Samoa under subsection (a)(61) or
subsection (j) of section 1902 of the Social Security Act (42
U.S.C. 1396a) with respect to the requirement to establish a
State medicaid fraud control unit (as described in section
1903(q) of such Act (42 U.S.C. 1396b(q)); and
(2) determine whether any such waiver should continue to be
approved with respect to Guam, the Northern Mariana Islands, or
American Samoa, respectively, after October 1, 2023.
(e) System for Tracking Federal Funding Provided to Puerto Rico.--
Section 1902 of the Social Security Act (42 U.S.C. 1396a), as amended
by section 503(c), is further amended by adding at the end the
following new subsection:
``(rr) Program Integrity Requirements for Puerto Rico.--
``(1) System for tracking federal funding provided to
puerto rico.--
``(A) In general.--Puerto Rico shall establish and
maintain a system for tracking any amounts paid by the
Federal Government to Puerto Rico with respect to the
State plan of Puerto Rico (or a waiver of such plan).
Under such system, Puerto Rico shall ensure that
information is available, with respect to each quarter
in a fiscal year (beginning with the first quarter
beginning on or after the date that is one year after
the date of the enactment of this subsection), on the
following:
``(i) In the case of a quarter other than
the first quarter of such fiscal year--
``(I) the total amount expended by
Puerto Rico during any previous quarter
of such fiscal year under the State
plan of Puerto Rico (or a waiver of
such plan); and
``(II) a description of how such
amount was so expended.
``(ii) The total amount that Puerto Rico
expects to expend during the quarter under the
State plan of Puerto Rico (or a waiver of such
plan), and a description of how Puerto Rico
expects to expend such amount.
``(B) Report to cms.--For each quarter with respect
to which Puerto Rico is required under subparagraph (A)
to ensure that information described in such
subparagraph is available, Puerto Rico shall submit to
the Administrator of the Centers for Medicare &
Medicaid Services a report on such information for such
quarter.
``(2) Submission of documentation on contracts upon
request.--Puerto Rico shall, upon request, submit to the
Administrator of the Centers for Medicare & Medicaid Services
all documentation requested with respect to contracts awarded
under the State plan of Puerto Rico (or a waiver of such
plan).''.
Amend the title so as to read: ``A bill to reauthorize and
extend funding for critical public health programs that improve
access to health care and strengthen the health care workforce,
to extend provisions of the Medicare program, to strengthen the
Medicaid program in the territories, to protect health care
consumers from surprise billing practices, and for other
purposes.''.
Union Calendar No. 587
116th CONGRESS
2d Session
H. R. 2328
[Report No. 116-332, Part I]
_______________________________________________________________________
A BILL
To reauthorize and extend funding for community health centers and the
National Health Service Corps.
_______________________________________________________________________
December 31, 2020
Committee on Transportation and Infrastructure discharged; committed to
the Committee of the Whole House on the State of the Union and ordered
to be printed