HouseH.R. 10788119th Congress
Lower Premiums, Faster Payments Act
Full Text
Official text as published. Use Ctrl+F / Cmd+F to search within the document.
[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 10788 Introduced in House (IH)]
<DOC>
119th CONGRESS
2d Session
H. R. 10788
To amend title XXVII of the Public Health Service Act, the Internal
Revenue Code of 1986, and the Employee Retirement Income Security Act
of 1974 to make certain adjustments to the surprise medical billing
requirements for private health insurance.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
October 9, 2026
Mr. Pallone introduced the following bill; which was referred to the
Committee on Energy and Commerce, and in addition to the Committees on
Education and Workforce, and Ways and Means, for a period to be
subsequently determined by the Speaker, in each case for consideration
of such provisions as fall within the jurisdiction of the committee
concerned
_______________________________________________________________________
A BILL
To amend title XXVII of the Public Health Service Act, the Internal
Revenue Code of 1986, and the Employee Retirement Income Security Act
of 1974 to make certain adjustments to the surprise medical billing
requirements for private health insurance.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Lower Premiums, Faster Payments
Act''.
SEC. 2. ADJUSTING SURPRISE MEDICAL BILLING REQUIREMENTS.
(a) Amendments to the Public Health Service Act.--
(1) Eliminating independent dispute resolution process.--
(A) In general.--Section 2799A-1 of the Public
Health Service Act (42 U.S.C. 300gg-111) is amended--
(i) in subsection (a)--
(I) in paragraph (1)(C)(iv)--
(aa) in subclause (I), by
inserting ``with respect to
such services furnished before
January 1, 2028,'' before ``not
later than''; and
(bb) in subclause (II), by
inserting ``(or, with respect
to such services for which the
out-of-network rate is the
qualifying payment amount for
such services, not later than
30 days after the bill for such
services is transmitted by such
provider or facility)'' after
``subsection (c)(6)''; and
(II) in paragraph (3)(K)(ii)--
(aa) in subclause (I), by
striking ``subject to subclause
(II)'' and inserting ``with
respect to items and services
furnished before January 1,
2028--
``(aa) subject to item
(bb)'';
(bb) by redesignating
subclause (II) as item (bb);
and
(cc) by adding at the end
the following new subclause:
``(II) with respect to items and
services furnished on or after January
1, 2028, the qualifying payment amount
(as defined in subparagraph (E) for
such year and determined in accordance
with rulemaking described in paragraph
(2)(B)) for such item or service; or'';
(ii) in subsection (b)(1)--
(I) in subparagraph (C), by
inserting ``with respect to such
services furnished before January 1,
2028,'' before ``not later than''; and
(II) in subparagraph (D), by
inserting ``(or, with respect to such
services for which the out-of-network
rate is the qualifying payment amount
for such services, not later than 30
days after the bill for such services
is transmitted by such provider)''
after ``subsection (c)(6)''; and
(iii) in subsection (c)--
(I) in paragraph (1)(A), by
inserting ``ending on or before
December 31, 2027,'' after ``in a
year''; and
(II) in paragraph (7)--
(aa) in subparagraph (A),
by inserting ``ending on or
before December 31, 2027''
after ``subsequent year''; and
(bb) in subparagraph (C),
by inserting ``ending on or
before December 31, 2027''
after ``subsequent year''.
(B) Air ambulance services.--Section 2799A-2 of the
Public Health Service Act (42 U.S.C. 300gg-112) is
amended--
(i) in subsection (a)(3)--
(I) in subparagraph (A), by
inserting ``with respect to such
services furnished before January 1,
2028,'' before ``not later than''; and
(II) in subparagraph (B), by
inserting ``(or, with respect to such
services for which the out-of-network
rate is the qualifying payment amount
for such services, not later than 30
days after the bill for such services
is transmitted by such provider)''
after ``subsection (b)(6)''; and
(ii) in subsection (b)--
(I) in paragraph (1)(A), by
inserting ``ending on or before
December 31, 2027,'' after ``in a
year''; and
(II) in paragraph (7)--
(aa) in subparagraph (A),
by inserting ``ending on or
before December 31, 2027''
after ``subsequent year''; and
(bb) in subparagraph (C),
by inserting ``ending on or
before December 31, 2027''
after ``subsequent year''.
(2) Adjusting calculation of qualifying payment amount.--
(A) In general.--Section 2799A-1(a)(3)(E) of the
Public Health Service Act (42 U.S.C. 300gg-
111(a)(3)(E)) is amended--
(i) in clause (i)--
(I) in subclause (I), by striking
``and'' at the end;
(II) in subclause (II)--
(aa) by inserting ``before
2028'' after ``or a subsequent
year''; and
(bb) by striking the period
at the end and inserting a
semicolon; and
(III) by adding at the end the
following new subclauses:
``(III) for an item or service
furnished during 2028, the median of
the contracted rates recognized by the
plan or issuer, respectively
(determined only with respect to such
plan or such coverage), as the total
payment (including the cost-sharing
amount imposed for such item or service
and the amount to be paid by the plan
or issuer, respectively, and the
average expected amount of any
incentive-based or retroactive payments
or payment adjustments, including risk-
sharing payments, bonuses, and
penalties) under such plan or coverage,
respectively, on January 31, 2019, for
the same or a similar item or service
that is provided by a provider in the
same specialty and provided in the
geographic region in which the item or
service is furnished, consistent with
the methodology established by the
Secretary under paragraph (2),
excluding any such rate in effect with
a provider that did not furnish such
item or service during the plan year
containing January 31, 2019, increased
by the percentage increase in the
consumer price index for all urban
consumers (United States city average)
over 2019 and such percentage increase
for each of years 2020 through 2027;
and
``(IV) for an item or service
furnished during 2029 or a subsequent
year, the qualifying payment amount
determined under this clause for such
an item or service furnished in the
previous year, increased by the
percentage increase in the consumer
price index for all urban consumers
(United States city average) over such
previous year.'';
(ii) in clause (ii)--
(I) in the text preceding subclause
(I), by inserting ``in a year before
2028'' before ``in a geographic
region'';
(II) in subclause (II), by striking
the period at the end and inserting ``;
and'';
(III) by redesignating subclauses
(I) and (II) as items (aa) and (bb),
respectively, and adjusting the margins
accordingly;
(IV) by striking ``means, with
respect to'' and inserting the
following: ``means--
``(I) with respect to''; and
(V) by adding at the end the
following new subclause:
``(II) with respect to a sponsor of
a group health plan or health insurance
issuer offering group or individual
health insurance coverage in 2028 or a
subsequent year that such sponsor or
issuer, respectively, did not offer
during 2019--
``(aa) for the first year
in which such group health
plan, group health insurance
coverage, or individual health
insurance coverage,
respectively, is offered, a
rate (determined in accordance
with a methodology established
by the Secretary) for items and
services that are covered by
such plan or coverage and
furnished during such first
year; and
``(bb) for each subsequent
year such group health plan,
group health insurance
coverage, or individual health
insurance coverage,
respectively, is offered, the
qualifying payment amount
determined under this clause
for such items and services
furnished in the previous year,
increased by the percentage
increase in the consumer price
index for all urban consumers
(United States city average)
over such previous year.'';
(iii) in clause (iii)--
(I) in the matter preceding
subclause (I), by inserting ``(or
clause (i)(III), as applicable)'' after
``described in clause (i)(I)'';
(II) in subclause (III)--
(aa) by striking ``or
coverage, has'' and inserting
the following: ``or coverage--
``(aa) in the case that
such first sufficient
information year is a year
before 2028, has''; and
(bb) by adding at the end
the following new item:
``(bb) in the case that
such first sufficient
information year is 2028 or a
subsequent year, has the
meaning given the term
qualifying payment amount in
clause (i)(III), except that in
applying such clause to such
item or service, the reference
to `furnished during 2028'
shall, for first sufficient
information years subsequent to
2028, be treated as a reference
to furnished during such first
sufficient information year,
the reference to `January 31,
2019' shall be treated as a
reference to the first day of
such first sufficient
information year, and the
increase described in such
clause shall not be applied;
and''; and
(III) in subclause (IV)--
(aa) by striking the period
at the end and inserting ``;
and'';
(bb) by striking ``or
coverage, has'' and inserting
the following: ``or coverage--
``(aa) in the case that
such first sufficient
information year is a year
before 2028, has''; and
(cc) by adding at the end
the following new item:
``(bb) in the case that
such first sufficient
information year is 2028 or a
subsequent year, has the
meaning given such term in
clause (i)(IV), except that in
applying such clause to such
item or service, the reference
to `furnished during 2029 or a
subsequent year' shall, for
first sufficient information
years subsequent to 2028, be
treated as a reference to
furnished during the year after
such first sufficient
information year or a
subsequent year.''; and
(iv) in clause (v)(II)--
(I) in item (aa), by inserting
``(or clause (i)(III), as applicable)''
after ``described in clause (i)(I)'';
and
(II) in item (bb), by inserting
``(or clause (i)(III), as applicable)''
after ``described in clause (i)(I)''.
(B) Updated rulemaking.--Section 2799A-1(a)(2)(B)
of the Public Health Service Act (42 U.S.C. 300gg-
111(a)(2)(B)) is amended--
(i) by redesignating clauses (i) through
(iv) as subclauses (I) through (IV),
respectively, and adjusting the margins
accordingly;
(ii) by striking ``Not later than'' and
inserting the following:
``(i) Initial rulemaking.--Not later
than'';
(iii) by inserting before ``Such
rulemaking'' the following new clause:
``(ii) Updated rules.--
``(I) In general.--Not later than
180 days after the date of enactment of
this clause, the Secretary, in
consultation with the Secretary of
Labor and the Secretary of the
Treasury, shall update the rules issued
under clause (i) to revise the
methodology the group health plan or
health insurance issuer offering group
or individual health insurance coverage
shall use to determine the qualifying
payment amount for an item or service
furnished during 2028 or a subsequent
year.
``(II) Expedited rulemaking.--The
Secretary may promulgate an interim
final rule to carry out this clause.'';
(iv) by striking ``Such rulemaking'' and
inserting the following:
``(iii) Guidelines.--The initial rulemaking
under clause (i), and the updated rules under
clause (ii),'';
(v) by striking ``In carrying out clause
(iii)'' and inserting ``In carrying out clause
(i)(III)''; and
(vi) by adding at the end the following new
clause:
``(vi) Judicial review.--There shall be no
judicial review of the methodology for
determining the qualifying payment amount
established under this subparagraph.''.
(C) Annual audits.--Section 2799A-1(a)(2)(A) of the
Public Health Service Act (42 U.S.C. 300gg-
111(a)(2)(A)) is amended--
(i) in clause (ii)--
(I) in subclause (I)--
(aa) by striking ``a year
(beginning with 2022)'' and
inserting ``each year beginning
with 2022 and ending with
2027'';
(bb) by striking ``such
clause, with'' and inserting:
``such clause--
``(aa) with''; and
(cc) by adding at the end
the following new item:
``(bb) with respect to 2028
and each subsequent year, of a
sample with respect to such
year of claims data from not
less than 25 group health plans
and health insurance issuers
offering group or individual
health insurance coverage;
and''; and
(II) in subclause (II), by striking
``may'' and inserting ``shall''; and
(ii) in clause (iii)--
(I) by inserting ``(and, beginning
for 2028, shall make publicly
available)'' after ``submit to
Congress'';
(II) by striking the period at the
end and inserting ``; and'';
(III) by striking ``on the number''
and inserting: ``on--
``(I) the number''; and
(IV) by adding at the end the
following new subclause:
``(II) the findings of each such
audit.''.
(b) Amendments to the Internal Revenue Code of 1986.--
(1) Eliminating independent dispute resolution process.--
(A) In general.--Section 9816 of the Internal
Revenue Code of 1986 is amended--
(i) in subsection (a)--
(I) in paragraph (1)(C)(iv)--
(aa) in subclause (I), by
inserting ``with respect to
such services furnished before
January 1, 2028,'' before ``not
later than''; and
(bb) in subclause (II), by
inserting ``(or, with respect
to such services for which the
out-of-network rate is the
qualifying payment amount for
such services, not later than
30 days after the bill for such
services is transmitted by such
provider or facility)'' after
``subsection (c)(6)''; and
(II) in paragraph (3)(K)(ii)--
(aa) in subclause (I), by
striking ``subject to subclause
(II)'' and inserting ``with
respect to items and services
furnished before January 1,
2028--
``(aa) subject to item
(bb)'';
(bb) by redesignating
subclause (II) as item (bb);
and
(cc) by adding at the end
the following new subclause:
``(II) with respect to items and
services furnished on or after January
1, 2028, the qualifying payment amount
(as defined in subparagraph (E) for
such year and determined in accordance
with rulemaking described in paragraph
(2)(B)) for such item or service; or'';
(ii) in subsection (b)(1)--
(I) in subparagraph (C), by
inserting ``with respect to such
services furnished before January 1,
2028,'' before ``not later than''; and
(II) in subparagraph (D), by
inserting ``(or, with respect to such
services for which the out-of-network
rate is the qualifying payment amount
for such services, not later than 30
days after the bill for such services
is transmitted by such provider)''
after ``subsection (c)(6)''; and
(iii) in subsection (c)--
(I) in paragraph (1)(A), by
inserting ``ending on or before
December 31, 2027,'' after ``in a
year''; and
(II) in paragraph (7)--
(aa) in subparagraph (A),
by inserting ``ending on or
before December 31, 2027''
after ``subsequent year''; and
(bb) in subparagraph (C),
by inserting ``ending on or
before December 31, 2027''
after ``subsequent year''.
(B) Air ambulance services.--Section 9817 of the
Internal Revenue Code of 1986 is amended--
(i) in subsection (a)(3)--
(I) in subparagraph (A), by
inserting ``with respect to such
services furnished before January 1,
2028,'' before ``not later than''; and
(II) in subparagraph (B), by
inserting ``(or, with respect to such
services for which the out-of-network
rate is the qualifying payment amount
for such services, not later than 30
days after the bill for such services
is transmitted by such provider)''
after ``subsection (b)(6)''; and
(ii) in subsection (b)--
(I) in paragraph (1)(A), by
inserting ``ending on or before
December 31, 2027,'' after ``in a
year''; and
(II) in paragraph (7)--
(aa) in subparagraph (A),
by inserting ``ending on or
before December 31, 2027''
after ``subsequent year''; and
(bb) in subparagraph (C),
by inserting ``ending on or
before December 31, 2027''
after ``subsequent year''.
(2) Adjusting calculation of qualifying payment amount.--
(A) In general.--Section 9816(a)(3)(E) of the
Internal Revenue Code of 1986 is amended--
(i) in clause (i)--
(I) in subclause (I), by striking
``and'' at the end;
(II) in subclause (II)--
(aa) by inserting ``before
2028'' after ``or a subsequent
year''; and
(bb) by striking the period
at the end and inserting a
semicolon; and
(III) by adding at the end the
following new subclauses:
``(III) for an item or service
furnished during 2028, the median of
the contracted rates recognized by the
plan (determined only with respect to
such plan), as the total payment
(including the cost-sharing amount
imposed for such item or service and
the amount to be paid by the plan, and
the average expected amount of any
incentive-based or retroactive payments
or payment adjustments, including risk-
sharing payments, bonuses, and
penalties) under such plan on January
31, 2019, for the same or a similar
item or service that is provided by a
provider in the same specialty and
provided in the geographic region in
which the item or service is furnished,
consistent with the methodology
established by the Secretary under
paragraph (2), excluding any such rate
in effect with a provider that did not
furnish such item or service during the
plan year containing January 31, 2019,
increased by the percentage increase in
the consumer price index for all urban
consumers (United States city average)
over 2019 and such percentage increase
for each of years 2020 through 2027;
and
``(IV) for an item or service
furnished during 2029 or a subsequent
year, the qualifying payment amount
determined under this clause for such
an item or service furnished in the
previous year, increased by the
percentage increase in the consumer
price index for all urban consumers
(United States city average) over such
previous year.'';
(ii) in clause (ii)--
(I) in the text preceding subclause
(I), by inserting ``in a year before
2028'' before ``in a geographic
region'';
(II) in subclause (II), by striking
the period at the end and inserting ``;
and'';
(III) by redesignating subclauses
(I) and (II) as items (aa) and (bb),
respectively, and adjusting the margins
accordingly;
(IV) by striking ``means, with
respect to'' and inserting the
following: ``means--
``(I) with respect to''; and
(V) by adding at the end the
following new subclause:
``(II) with respect to a sponsor of
a group health plan offered in 2028 or
a subsequent year that such sponsor did
not offer during 2019--
``(aa) for the first year
in which such group health plan
is offered, a rate (determined
in accordance with a
methodology established by the
Secretary) for items and
services that are covered by
such plan and furnished during
such first year; and
``(bb) for each subsequent
year such group health plan is
offered, the qualifying payment
amount determined under this
clause for such items and
services furnished in the
previous year, increased by the
percentage increase in the
consumer price index for all
urban consumers (United States
city average) over such
previous year.'';
(iii) in clause (iii)--
(I) in the matter preceding
subclause (I), by inserting ``(or
clause (i)(III), as applicable)'' after
``described in clause (i)(I)'';
(II) in subclause (III)--
(aa) by striking ``such
plan, has'' and inserting the
following: ``such plan--
``(aa) in the case that
such first sufficient
information year is a year
before 2028, has''; and
(bb) by adding at the end
the following new item:
``(bb) in the case that
such first sufficient
information year is 2028 or a
subsequent year, has the
meaning given the term
qualifying payment amount in
clause (i)(III), except that in
applying such clause to such
item or service, the reference
to `furnished during 2028'
shall, for first sufficient
information years subsequent to
2028, be treated as a reference
to furnished during such first
sufficient information year,
the reference to `January 31,
2019' shall be treated as a
reference to the first day of
such first sufficient
information year, and the
increase described in such
clause shall not be applied;
and''; and
(III) in subclause (IV)--
(aa) by striking the period
at the end and inserting ``;
and'';
(bb) by striking ``such
plan, has'' and inserting the
following: ``such plan--
``(aa) in the case that
such first sufficient
information year is a year
before 2028, has''; and
(cc) by adding at the end
the following new item:
``(bb) in the case that
such first sufficient
information year is 2028 or a
subsequent year, has the
meaning given such term in
clause (i)(IV), except that in
applying such clause to such
item or service, the reference
to `furnished during 2029 or a
subsequent year' shall, for
first sufficient information
years subsequent to 2028, be
treated as a reference to
furnished during the year after
such first sufficient
information year or a
subsequent year.''; and
(iv) in clause (v)(II)--
(I) in item (aa), by inserting
``(or clause (i)(III), as applicable)''
after ``described in clause (i)(I)'';
and
(II) in item (bb), by inserting
``(or clause (i)(III), as applicable)''
after ``described in clause (i)(I)''.
(B) Updated rulemaking.--Section 9816(a)(2)(B) of
the Internal Revenue Code of 1986 is amended--
(i) by redesignating clauses (i) through
(iv) as subclauses (I) through (IV),
respectively, and adjusting the margins
accordingly;
(ii) by striking ``Not later than'' and
inserting the following:
``(i) Initial rulemaking.--Not later
than'';
(iii) by inserting before ``Such
rulemaking'' the following new clause:
``(ii) Updated rules.--
``(I) In general.--Not later than
180 days after the date of enactment of
this clause, the Secretary, in
consultation with the Secretary of
Labor and the Secretary of Health and
Human Services, shall update the rules
issued under clause (i) to revise the
methodology the group health plan shall
use to determine the qualifying payment
amount for an item or service furnished
during 2028 or a subsequent year.
``(II) Expedited rulemaking.--The
Secretary may promulgate an interim
final rule to carry out this clause.'';
(iv) by striking ``Such rulemaking'' and
inserting the following:
``(iii) Guidelines.--The initial rulemaking
under clause (i), and the updated rules under
clause (ii),'';
(v) by striking ``In carrying out clause
(iii)'' and inserting ``In carrying out clause
(i)(III)''; and
(vi) by adding at the end the following new
clause:
``(vi) Judicial review.--There shall be no
judicial review of the methodology for
determining the qualifying payment amount
established under this subparagraph.''.
(C) Annual audits.--Section 9816(a)(2)(A) of the
Internal Revenue Code of 1986 is amended--
(i) in clause (ii)--
(I) in subclause (I)--
(aa) by striking ``a year
(beginning with 2022)'' and
inserting ``each year beginning
with 2022 and ending with
2027'';
(bb) by striking ``such
clause, with'' and inserting:
``such clause--
``(aa) with''; and
(cc) by adding at the end
the following new item:
``(bb) with respect to 2028
and each subsequent year, of a
sample with respect to such
year of claims data from not
less than 25 group health
plans; and''; and
(II) in subclause (II), by striking
``may'' and inserting ``shall''; and
(ii) in clause (iii)--
(I) by inserting ``(and, beginning
for 2028, shall make publicly
available)'' after ``submit to
Congress'';
(II) by striking the period at the
end and inserting ``; and'';
(III) by striking ``on the number''
and inserting: ``on--
``(I) the number''; and
(IV) by adding at the end the
following new subclause:
``(II) the findings of each such
audit.''.
(c) Amendments to the Employee Retirement Income Security Act of
1974.--
(1) Eliminating independent dispute resolution process.--
(A) In general.--Section 716 of the Employee
Retirement Income Security Act of 1974 (29 U.S.C.
1185e) is amended--
(i) in subsection (a)--
(I) in paragraph (1)(C)(iv)--
(aa) in subclause (I), by
inserting ``with respect to
such services furnished before
January 1, 2028,'' before ``not
later than''; and
(bb) in subclause (II), by
inserting ``(or, with respect
to such services for which the
out-of-network rate is the
qualifying payment amount for
such services, not later than
30 days after the bill for such
services is transmitted by such
provider or facility)'' after
``subsection (c)(6)''; and
(II) in paragraph (3)(K)(ii)--
(aa) in subclause (I), by
striking ``subject to subclause
(II)'' and inserting ``with
respect to items and services
furnished before January 1,
2028--
``(aa) subject to item
(bb)'';
(bb) by redesignating
subclause (II) as item (bb);
and
(cc) by adding at the end
the following new subclause:
``(II) with respect to items and
services furnished on or after January
1, 2028, the qualifying payment amount
(as defined in subparagraph (E) for
such year and determined in accordance
with rulemaking described in paragraph
(2)(B)) for such item or service; or'';
(ii) in subsection (b)(1)--
(I) in subparagraph (C), by
inserting ``with respect to such
services furnished before January 1,
2028,'' before ``not later than''; and
(II) in subparagraph (D), by
inserting ``(or, with respect to such
services for which the out-of-network
rate is the qualifying payment amount
for such services, not later than 30
days after the bill for such services
is transmitted by such provider)''
after ``subsection (c)(6)''; and
(iii) in subsection (c)--
(I) in paragraph (1)(A), by
inserting ``ending on or before
December 31, 2027,'' after ``in a
year''; and
(II) in paragraph (7)--
(aa) in subparagraph (A),
by inserting ``ending on or
before December 31, 2027''
after ``subsequent year''; and
(bb) in subparagraph (C),
by inserting ``ending on or
before December 31, 2027''
after ``subsequent year''.
(B) Air ambulance services.--Section 717 of the
Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185f) is amended--
(i) in subsection (a)(3)--
(I) in subparagraph (A), by
inserting ``with respect to such
services furnished before January 1,
2028,'' before ``not later than''; and
(II) in subparagraph (B), by
inserting ``(or, with respect to such
services for which the out-of-network
rate is the qualifying payment amount
for such services, not later than 30
days after the bill for such services
is transmitted by such provider)''
after ``subsection (b)(6)''; and
(ii) in subsection (b)--
(I) in paragraph (1)(A), by
inserting ``ending on or before
December 31, 2027,'' after ``in a
year''; and
(II) in paragraph (7)--
(aa) in subparagraph (A),
by inserting ``ending on or
before December 31, 2027''
after ``subsequent year''; and
(bb) in subparagraph (C),
by inserting ``ending on or
before December 31, 2027''
after ``subsequent year''.
(2) Adjusting calculation of qualifying payment amount.--
(A) In general.--Section 716(a)(3)(E) of the
Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185e(a)(3)(E)) is amended--
(i) in clause (i)--
(I) in subclause (I), by striking
``and'' at the end;
(II) in subclause (II)--
(aa) by inserting ``before
2028'' after ``or a subsequent
year''; and
(bb) by striking the period
at the end and inserting a
semicolon; and
(III) by adding at the end the
following new subclauses:
``(III) for an item or service
furnished during 2028, the median of
the contracted rates recognized by the
plan or issuer, respectively
(determined only with respect to such
plan or such coverage), as the total
payment (including the cost-sharing
amount imposed for such item or service
and the amount to be paid by the plan
or issuer, respectively, and the
average expected amount of any
incentive-based or retroactive payments
or payment adjustments, including risk-
sharing payments, bonuses, and
penalties) under such plan or coverage,
respectively, on January 31, 2019, for
the same or a similar item or service
that is provided by a provider in the
same specialty and provided in the
geographic region in which the item or
service is furnished, consistent with
the methodology established by the
Secretary under paragraph (2),
excluding any such rate in effect with
a provider that did not furnish such
item or service during the plan year
containing January 31, 2019, increased
by the percentage increase in the
consumer price index for all urban
consumers (United States city average)
over 2019 and such percentage increase
for each of years 2020 through 2027;
and
``(IV) for an item or service
furnished during 2029 or a subsequent
year, the qualifying payment amount
determined under this clause for such
an item or service furnished in the
previous year, increased by the
percentage increase in the consumer
price index for all urban consumers
(United States city average) over such
previous year.'';
(ii) in clause (ii)--
(I) in the text preceding subclause
(I), by inserting ``in a year before
2028'' before ``in a geographic
region'';
(II) in subclause (II), by striking
the period at the end and inserting ``;
and'';
(III) by redesignating subclauses
(I) and (II) as items (aa) and (bb),
respectively, and adjusting the margins
accordingly;
(IV) by striking ``means, with
respect to'' and inserting the
following: ``means--
``(I) with respect to''; and
(V) by adding at the end the
following new subclause:
``(II) with respect to a sponsor of
a group health plan or health insurance
issuer offering group health insurance
coverage in 2028 or a subsequent year
that such sponsor or issuer,
respectively, did not offer during
2019--
``(aa) for the first year
in which such group health plan
or group health insurance
coverage, respectively, is
offered, a rate (determined in
accordance with a methodology
established by the Secretary)
for items and services that are
covered by such plan or
coverage and furnished during
such first year; and
``(bb) for each subsequent
year such group health plan or
group health insurance
coverage, respectively, is
offered, the qualifying payment
amount determined under this
clause for such items and
services furnished in the
previous year, increased by the
percentage increase in the
consumer price index for all
urban consumers (United States
city average) over such
previous year.'';
(iii) in clause (iii)--
(I) in the matter preceding
subclause (I), by inserting ``(or
clause (i)(III), as applicable)'' after
``described in clause (i)(I)'';
(II) in subclause (III)--
(aa) by striking ``or
coverage, has'' and inserting
the following: ``or coverage--
``(aa) in the case that
such first sufficient
information year is a year
before 2028, has''; and
(bb) by adding at the end
the following new item:
``(bb) in the case that
such first sufficient
information year is 2028 or a
subsequent year, has the
meaning given the term
qualifying payment amount in
clause (i)(III), except that in
applying such clause to such
item or service, the reference
to `furnished during 2028'
shall, for first sufficient
information years subsequent to
2028, be treated as a reference
to furnished during such first
sufficient information year,
the reference to `January 31,
2019' shall be treated as a
reference to the first day of
such first sufficient
information year, and the
increase described in such
clause shall not be applied;
and''; and
(III) in subclause (IV)--
(aa) by striking the period
at the end and inserting ``;
and'';
(bb) by striking ``or
coverage, has'' and inserting
the following: ``or coverage--
``(aa) in the case that
such first sufficient
information year is a year
before 2028, has''; and
(cc) by adding at the end
the following new item:
``(bb) in the case that
such first sufficient
information year is 2028 or a
subsequent year, has the
meaning given such term in
clause (i)(IV), except that in
applying such clause to such
item or service, the reference
to `furnished during 2029 or a
subsequent year' shall, for
first sufficient information
years subsequent to 2028, be
treated as a reference to
furnished during the year after
such first sufficient
information year or a
subsequent year.''; and
(iv) in clause (v)(II)--
(I) in item (aa), by inserting
``(or clause (i)(III), as applicable)''
after ``described in clause (i)(I)'';
and
(II) in item (bb), by inserting
``(or clause (i)(III), as applicable)''
after ``described in clause (i)(I)''.
(B) Updated rulemaking.--Section 716(a)(2) of the
Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185e(a)(2)) is amended--
(i) by redesignating subparagraphs (A)
through (D) as clauses (i) through (iv),
respectively, and adjusting the margins
accordingly;
(ii) by striking ``Not later than'' and
inserting the following:
``(A) Initial rulemaking.--Not later than'';
(iii) by inserting before ``Such
rulemaking'' the following new clause:
``(B) Updated rules.--
``(i) In general.--Not later than 180 days
after the date of enactment of this clause, the
Secretary, in consultation with the Secretary
of the Treasury and the Secretary of Health and
Human Services, shall update the rules issued
under subparagraph (A) to revise the
methodology the group health plan or health
insurance issuer offering group health
insurance coverage shall use to determine the
qualifying payment amount for an item or
service furnished during 2028 or a subsequent
year.
``(ii) Expedited rulemaking.--The Secretary
may promulgate an interim final rule to carry
out this subparagraph.'';
(iv) by striking ``Such rulemaking'' and
inserting the following:
``(C) Guidelines.--The initial rulemaking under
subparagraph (A), and the updated rules under
subparagraph (B),'';
(v) by striking ``In carrying out clause
(iii)'' and inserting ``In carrying out
subparagraph (A)(iii)''; and
(vi) by adding at the end the following new
subparagraph:
``(D) Judicial review.--There shall be no judicial
review of the methodology for determining the
qualifying payment amount established under this
paragraph.''.
<all>