HR4710-119

1. Short title This Act may be cited as the No Surprises Act Enforcement Act.

3. Additional penalties for late payment or non-payment after IDR entity payment determination Section 2799A–1(c)(6) of the Public Health Service Act (42 U.S.C. 300gg–111(c)(6)) is amended— in the paragraph heading, by inserting ; penalty for late payment or non-payment after payment; by striking The total plan and inserting the following: The total plan in subparagraph (A), as so inserted, by adding at the end the following new sentence: In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan or coverage the difference between such determination and such sum not later than 30 days after the date on which such determination is made.; and by adding at the end the following new subparagraphs: In the case of a plan or coverage, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or coverage or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary. In the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between— the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(1)(C)(iv)(I) or (b)(1)(C), as applicable; and the out-of-network rate (as defined in subsection (a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service). Any amount owed under clause (i) shall be subject to interest in a manner specified by the Secretary. Section 2799A–2(b)(6) of the Public Health Service Act (42 U.S.C. 300gg–112(b)(6)) is amended— in the paragraph heading, by inserting ; penalty for late payment or non-payment after payment; by striking The total plan and inserting the following: The total plan in subparagraph (A), as so inserted, by adding at the end the following new sentence: In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan or coverage the difference between such determination and such sum not later than 30 days after the date on which such determination is made.; and by adding at the end the following new subparagraphs: In the case of a plan or coverage, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or coverage or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary. In the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between— the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(3)(A); and the out-of-network rate (as defined in section 2799–1(a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service). Any amount owed under clause (i) shall be subject to interest in a manner specified by the Secretary. Section 716(c)(6) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185e(c)(6)) is amended— in the paragraph heading, by inserting ; penalty for late payment or non-payment after payment; by striking The total plan and inserting the following: The total plan in subparagraph (A), as so inserted, by adding at the end the following new sentence: In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan or coverage the difference between such determination and such sum not later than 30 days after the date on which such determination is made.; and by adding at the end the following new subparagraphs: In the case of a plan or coverage, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or coverage or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary. In the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between— the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(1)(C)(iv)(I) or (b)(1)(C), as applicable; and the out-of-network rate (as defined in subsection (a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service). Any amount owed under clause (i) shall be subject to interest in a manner specified by the Secretary. Section 717(b)(6) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185f(b)(6)) is amended— in the paragraph heading, by inserting ; penalty for late payment or non-payment after payment; by striking The total plan and inserting the following: The total plan in subparagraph (A), as so inserted, by adding at the end the following new sentence: In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan or coverage the difference between such determination and such sum not later than 30 days after the date on which such determination is made.; and by adding at the end the following new subparagraphs: In the case of a plan or coverage, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or coverage or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary. In the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between— the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(3)(A); and the out-of-network rate (as defined in section 716(a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service). Any amount owed under clause (i) shall be subject to interest in a manner specified by the Secretary. Section 9816(c)(6) of the Internal Revenue Code of 1986 is amended— in the paragraph heading, by inserting ; penalty for late payment or non-payment after payment; by striking The total plan and inserting the following: The total plan in subparagraph (A), as so inserted, by adding at the end the following new sentence: In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan the difference between such determination and such sum not later than 30 days after the date on which such determination is made.; and by adding at the end the following new subparagraphs: In the case of a plan, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary. In the case of a plan, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan (as applicable) an amount that is three times the difference between— the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(1)(C)(iv)(I) or (b)(1)(C), as applicable; and the out-of-network rate (as defined in subsection (a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service). Any amount owed under clause (i) shall be subject to interest in a manner specified by the Secretary. Section 9817(b)(6) of the Internal Revenue Code of 1986 is amended— in the paragraph heading, by inserting ; penalty for late payment or non-payment after payment; by striking The total plan and inserting the following: The total plan in subparagraph (A), as so inserted, by adding at the end the following new sentence: In the case such determination is an amount less than the sum of the initial payment for such item or service and any cost sharing required to be paid by the individual receiving such item or service, the nonparticipating provider or facility furnishing such item or service shall pay to such plan the difference between such determination and such sum not later than 30 days after the date on which such determination is made.; and by adding at the end the following new subparagraphs: In the case of a plan, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary. In the case of a plan, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan (as applicable) an amount that is three times the difference between— the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(3)(A); and the out-of-network rate (as defined in section 9816(a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service). Any amount owed under clause (i) shall be subject to interest in a manner specified by the Secretary. (A)Timing of paymentThe total plan; (B)NotificationIn the case of a plan or coverage, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or coverage or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary. (C)Penalty for late payment or non-payment (i)In generalIn the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between— (I)the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(1)(C)(iv)(I) or (b)(1)(C), as applicable; and (II)the out-of-network rate (as defined in subsection (a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service). (ii)InterestAny amount owed under clause (i) shall be subject to interest in a manner specified by the Secretary.. (A)Timing of paymentThe total plan; (B)NotificationIn the case of a plan or coverage, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or coverage or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary. (C)Penalty for late payment or non-payment (i)In generalIn the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between— (I)the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(3)(A); and (II)the out-of-network rate (as defined in section 2799–1(a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service). (ii)InterestAny amount owed under clause (i) shall be subject to interest in a manner specified by the Secretary.. (A)Timing of paymentThe total plan; (B)NotificationIn the case of a plan or coverage, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or coverage or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary. (C)Penalty for late payment or non-payment (i)In generalIn the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between— (I)the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(1)(C)(iv)(I) or (b)(1)(C), as applicable; and (II)the out-of-network rate (as defined in subsection (a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service). (ii)InterestAny amount owed under clause (i) shall be subject to interest in a manner specified by the Secretary.. (A)Timing of paymentThe total plan; (B)NotificationIn the case of a plan or coverage, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or coverage or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary. (C)Penalty for late payment or non-payment (i)In generalIn the case of a plan or coverage, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or coverage or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan or coverage (as applicable) an amount that is three times the difference between— (I)the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(3)(A); and (II)the out-of-network rate (as defined in section 716(a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service). (ii)InterestAny amount owed under clause (i) shall be subject to interest in a manner specified by the Secretary.. (A)Timing of paymentThe total plan; (B)NotificationIn the case of a plan, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary. (C)Penalty for late payment or non-payment (i)In generalIn the case of a plan, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan (as applicable) an amount that is three times the difference between— (I)the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(1)(C)(iv)(I) or (b)(1)(C), as applicable; and (II)the out-of-network rate (as defined in subsection (a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service). (ii)InterestAny amount owed under clause (i) shall be subject to interest in a manner specified by the Secretary.. (A)Timing of paymentThe total plan; (B)NotificationIn the case of a plan, or a nonparticipating provider or facility, required to make a payment pursuant to a determination described in subparagraph (A), such plan or nonparticipating provider or facility shall submit to the Secretary a notification of such payment as of the date such payment is made in a manner specified by the Secretary. (C)Penalty for late payment or non-payment (i)In generalIn the case of a plan, or a nonparticipating provider or facility, that has not made the required payment described in subparagraph (A) with respect to an item or service in the time period described in such subparagraph, in addition to making such payment, such plan or nonparticipating provider or facility shall also pay to the nonparticipating provider or facility or plan (as applicable) an amount that is three times the difference between— (I)the initial payment (or, in the case of a notice of denial of payment, $0) described in subsection (a)(3)(A); and (II)the out-of-network rate (as defined in section 9816(a)(3)(K)) for such item or service (less any cost sharing required to be paid by the individual receiving such item or service). (ii)InterestAny amount owed under clause (i) shall be subject to interest in a manner specified by the Secretary..

4. Transparency reporting requirements Section 2799A–1(a)(2)(A)(iii) of the Public Health Service Act (42 U.S.C. 300gg–111(a)(2)(A)(iii)) is amended to read as follows: Beginning for 2022 and ending on December 31 of the calendar year in which the Enhanced Enforcement of Health Coverage Act is enacted, the Secretary shall annually submit to Congress a report on the number of plans and issuers with respect to which audits were conducted during such year pursuant to this subparagraph. With respect to the first calendar year following the date of the enactment of the Enhanced Enforcement of Health Coverage Act, not later than February 1 of such year, and every 6 months thereafter, the Secretary, in coordination with the Secretary of Labor and the Secretary of the Treasury, shall submit to the Committee on Ways and Means, the Committee on Energy and Commerce, and the Committee on Education and Workforce of the House of Representatives, and the Committee on Finance and the Committee on Health, Education, Labor and Pensions of the Senate, a report on any audits conducted pursuant to this subparagraph during the applicable reporting period, and any enforcement actions taken during such period in accordance with the provisions of this part, including— the total number of audits conducted under this subparagraph; the number of audits conducted pursuant to clause (ii)(I); the number of complaints submitted by providers and by participants, beneficiaries, and enrollees with respect to a violation of this part; any enforcement actions taken as a result of a complaint submitted by a provider or by a participant, a beneficiary, or an enrollee, with respect to the provisions of this part; the total number of, and the aggregate dollar amount of, any civil monetary penalties issued in accordance with this part; a summary of any non-monetary corrective action taken against a group health plan or health insurance issuer offering group or individual health insurance coverage for a violation of this part; and a description of the 3 most commonly reported violations of this part. For purposes of this subclause, the term applicable reporting period means the 6 month period prior to each report submitted under item (aa). Section 9816(a)(2)(A)(iii) of the Internal Revenue Code of 1986 is amended to read as follows: Beginning for 2022 and ending on December 31 of the calendar year in which the Enhanced Enforcement of Health Coverage Act is enacted, the Secretary shall annually submit to Congress a report on the number of plans with respect to which audits were conducted during such year pursuant to this subparagraph. With respect to the first calendar year following the date of the enactment of the Enhanced Enforcement of Health Coverage Act, not later than February 1 of such year, and every 6 months thereafter, the Secretary, in coordination with the Secretary of Labor and the Secretary of Health and Human Services, shall submit to the Committee on Ways and Means, the Committee on Energy and Commerce, and the Committee on Education and Workforce of the House of Representatives, and the Committee on Finance and the Committee on Health, Education, Labor and Pensions of the Senate, a report on audits performed pursuant to this subparagraph during the applicable reporting period, and any enforcement actions taken during such period in accordance with the provisions of an applicable section, including— the total number of audits conducted under this subparagraph; the number of audits conducted pursuant to clause (ii)(I); the number of complaints submitted by providers and by participants and beneficiaries with respect to a violation of an applicable section; any enforcement actions taken pursuant to a violation of an applicable section; the total number of, and the aggregate dollar amount of, any civil monetary penalties issued in accordance with an applicable section; a summary of any non-monetary corrective action taken against a group health plan for a violation of an applicable section; and a description of the 3 most commonly reported violations of an applicable section. In this subclause: The term applicable reporting period means the 6 month period prior to each report submitted under item (aa). The term applicable section means this section and each of sections 9817 through 9825. (iii)Reporting (I)Initial reportingBeginning for 2022 and ending on December 31 of the calendar year in which the Enhanced Enforcement of Health Coverage Act is enacted, the Secretary shall annually submit to Congress a report on the number of plans and issuers with respect to which audits were conducted during such year pursuant to this subparagraph. (II)Subsequent reporting (aa) In general With respect to the first calendar year following the date of the enactment of the Enhanced Enforcement of Health Coverage Act, not later than February 1 of such year, and every 6 months thereafter, the Secretary, in coordination with the Secretary of Labor and the Secretary of the Treasury, shall submit to the Committee on Ways and Means, the Committee on Energy and Commerce, and the Committee on Education and Workforce of the House of Representatives, and the Committee on Finance and the Committee on Health, Education, Labor and Pensions of the Senate, a report on any audits conducted pursuant to this subparagraph during the applicable reporting period, and any enforcement actions taken during such period in accordance with the provisions of this part, including— (AA) the total number of audits conducted under this subparagraph; (BB) the number of audits conducted pursuant to clause (ii)(I); (CC) the number of complaints submitted by providers and by participants, beneficiaries, and enrollees with respect to a violation of this part; (DD) any enforcement actions taken as a result of a complaint submitted by a provider or by a participant, a beneficiary, or an enrollee, with respect to the provisions of this part; (EE) the total number of, and the aggregate dollar amount of, any civil monetary penalties issued in accordance with this part; (FF) a summary of any non-monetary corrective action taken against a group health plan or health insurance issuer offering group or individual health insurance coverage for a violation of this part; and (GG) a description of the 3 most commonly reported violations of this part. (bb)Applicable reporting periodFor purposes of this subclause, the term applicable reporting period means the 6 month period prior to each report submitted under item (aa).. (iii)Reporting (I)Initial reportingBeginning for 2022 and ending on December 31 of the calendar year in which the Enhanced Enforcement of Health Coverage Act is enacted, the Secretary shall annually submit to Congress a report on the number of plans with respect to which audits were conducted during such year pursuant to this subparagraph. (II)Subsequent reporting (aa) In general With respect to the first calendar year following the date of the enactment of the Enhanced Enforcement of Health Coverage Act, not later than February 1 of such year, and every 6 months thereafter, the Secretary, in coordination with the Secretary of Labor and the Secretary of Health and Human Services, shall submit to the Committee on Ways and Means, the Committee on Energy and Commerce, and the Committee on Education and Workforce of the House of Representatives, and the Committee on Finance and the Committee on Health, Education, Labor and Pensions of the Senate, a report on audits performed pursuant to this subparagraph during the applicable reporting period, and any enforcement actions taken during such period in accordance with the provisions of an applicable section, including— (AA) the total number of audits conducted under this subparagraph; (BB) the number of audits conducted pursuant to clause (ii)(I); (CC) the number of complaints submitted by providers and by participants and beneficiaries with respect to a violation of an applicable section; (DD) any enforcement actions taken pursuant to a violation of an applicable section; (EE) the total number of, and the aggregate dollar amount of, any civil monetary penalties issued in accordance with an applicable section; (FF) a summary of any non-monetary corrective action taken against a group health plan for a violation of an applicable section; and (GG) a description of the 3 most commonly reported violations of an applicable section. (bb)DefinitionsIn this subclause: (AA)Applicable reporting periodThe term applicable reporting period means the 6 month period prior to each report submitted under item (aa). (BB)Applicable sectionThe term applicable section means this section and each of sections 9817 through 9825..