[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 4023 Introduced in Senate (IS)]
<DOC>
118th CONGRESS
2d Session
S. 4023
To further protect patients and improve the accuracy of provider
directory information by eliminating ghost networks.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
March 21, 2024
Ms. Smith (for herself and Mr. Wyden) introduced the following bill;
which was read twice and referred to the Committee on Health,
Education, Labor, and Pensions
_______________________________________________________________________
A BILL
To further protect patients and improve the accuracy of provider
directory information by eliminating ghost networks.
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 ``Behavioral Health
Network and Directory Improvement Act''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Protecting patients and improving the accuracy of provider
directory information.
Sec. 3. Provider requirements to protect patients and improve the
accuracy of provider directory information.
Sec. 4. Strengthening mental health and substance use disorder parity
requirements.
Sec. 5. State and Tribal ombudsman programs relating to mental health
and substance use disorder parity.
Sec. 6. Report to Congress.
Sec. 7. Authorization of appropriations.
SEC. 2. PROTECTING PATIENTS AND IMPROVING THE ACCURACY OF PROVIDER
DIRECTORY INFORMATION.
(a) PHSA.--Section 2799A-5 of the Public Health Service Act (42
U.S.C. 300gg-115) is amended--
(1) in subsection (a)--
(A) in paragraph (1)--
(i) by striking ``For plan years beginning
on or after January 1, 2022, each'' and
inserting ``Each'';
(ii) in subparagraph (C), by striking ``;
and'' and inserting a semicolon;
(iii) in subparagraph (D), by striking the
period and inserting ``; and''; and
(iv) by adding at the end the following:
``(E) ensure that any directory, including the
database described in subparagraph (C), containing
provider directory information with respect to such
plan or such coverage complies with the requirements
developed by the appropriate agencies in accordance
with paragraph (6) in order to ensure that
participants, beneficiaries, and enrollees are able to
identify actively participating health care providers
and health care facilities.'';
(B) in paragraph (3)--
(i) in the matter preceding subparagraph
(A), by striking ``, in the case such request
is made through a telephone call''; and
(ii) in subparagraph (A), by striking
``call is received, through a written
electronic or print (as requested by such
individual) communication'' and inserting ``a
request is received, by telephone, or through a
written electronic or print communication (as
requested by such individual)'';
(C) in paragraph (4)--
(i) in subparagraph (A), by striking
``and'' at the end;
(ii) in subparagraph (B), by striking the
period and inserting ``; and''; and
(iii) by adding at the end the following:
``(C) information, in plain language, concerning
the rights of the participant, beneficiary, or enrollee
to cost-sharing protections pursuant to subsection (b)
in the event of reliance on inaccurate provider network
information supplied by a group health plan or health
insurance issuer, and contact information for, as
appropriate, the State consumer assistance program or
ombudsman or the Employee Benefits Security
Administration for more information.'';
(D) in paragraph (5), by adding at the end the
following: ``Such information shall include a
statement, in plain language, concerning the rights of
the participant, beneficiary, or enrollee to cost-
sharing protections pursuant to subsection (b) in the
event of reliance on inaccurate provider directory
information supplied by a group health plan or health
insurance issuer, and contact information for, as
appropriate, the State consumer assistance program or
ombudsman or the Employee Benefits Security
Administration for more information.'';
(E) by redesignating paragraphs (6) and (7) as
paragraphs (8) and (9), respectively;
(F) by inserting after paragraph (5) the following:
``(6) Protecting participants, beneficiaries, and enrollees
from ghost networks.--The Secretary, in collaboration with the
Secretary of Labor and the Secretary of the Treasury, shall--
``(A) not later than 4 years after the date of
enactment of the Behavioral Health Network and
Directory Improvement Act, issue final regulations
further defining the term `ghost network' (as defined
in paragraph (8)); and
``(B) not later than 4 years after the date of
enactment of the Behavioral Health Network and
Directory Improvement Act, issue final regulations,
subregulatory guidance, or program instruction on how
to assess ghost networks in health plan directories
including reasonable assumptions related to statistics
and research methods.
``(7) Database reporting and auditing to protect against
ghost networks.--
``(A) Reporting requirements.--Beginning not later
than 3 years after the date of enactment of the
Behavioral Health Network and Directory Improvement
Act, each group health plan and health insurance issuer
offering group or individual health insurance coverage
shall submit to the Secretary, at such time as the
Secretary, in coordination with the Secretary of Labor
and the Secretary of the Treasury, shall require, but
not less frequently than annually, the directory data
described in paragraph (a)(4), in a machine readable
format (as defined in section 147.210(a)(2)(xiv) of
title 45, Code of Federal Regulations (or any successor
regulations)). A health insurance issuer or a third
party administrator of a group health plan may submit
such information for all health insurance coverage or
all group health plans, collectively, that such issuer
or administrator administers. The Secretary, in
coordination with the Secretary of Labor and the
Secretary of the Treasury, shall make data submitted
under this subparagraph available on a public website.
``(B) Provider directory independent audit
requirements.--
``(i) In general.--Beginning not later than
3 years after the date of enactment of the
Behavioral Health Network and Directory
Improvement Act, each group health plan and
health insurance issuer offering group or
individual health insurance coverage shall
conduct an annual directory audit, through an
independent entity not associated with the
health plan or issuer, that considers the
factors described in clause (ii)(I)(aa) and
follows the guidelines developed under clause
(ii)(I)(bb).
``(ii) Information to be included.--
``(I) In general.--For purposes of
carrying out the audits under this
subparagraph, the Secretary shall--
``(aa) develop a list of
information required to be
included; and
``(bb) provide guidelines
for carrying out such audits,
for use by group health plans
and health insurance issuers,
on--
``(AA) the
reasonable assumptions
and research methods to
select a reasonable
sample in order to
assess provider
directory information
accuracy; and
``(BB) determining
the criteria of an
eligible auditor.
``(II) Contents.--The information
listed under subclause (I)(aa) shall
include the following:
``(aa) The proportion of
directory listings of the plan
or coverage with inaccurate
information, including
incorrect contact information,
as specified by the Secretary,
during the audit period.
``(bb) The number of in-
network items or services paid
on behalf of participants,
beneficiaries, and enrollees in
the plan or coverage to
providers or facilities who
have a network provider
contract with the health plan
or issuer and were not listed
in the directory of the health
plan or health insurance
coverage for the audit period.
``(cc) The resources of the
plan or issuer to help
participants, beneficiaries,
and enrollees locate an
accurately listed in-network
provider who is accepting new
patients.
``(dd) The proportion of
participants, beneficiaries,
and enrollees using out-of-
network providers for mental
health and substance use
disorder services, and the
proportion of participants,
beneficiaries, and enrollees
using out-of-network providers
and facilities for medical and
surgical services.
``(ee) Documentation that
the plan or issuer verifies the
accuracy of the provider
directory information every 90
days.
``(ff) Other factors as
determined by the Secretary.
``(iii) Standards for reporting.--An audit
under this subparagraph is complete if all of
the following conditions are met:
``(I) The audit report includes the
following:
``(aa) A statement by the
independent auditor that, to
the best of the auditor's
knowledge, the report is
complete and accurate, and that
reasonable assumptions related
to statistics and research
methods have been complied
with.
``(bb) A statement
explaining the assumptions,
statistics, and methods used to
select the sample and assess
provider directory information
accuracy.
``(cc) Such other
requirements as the Secretary
determines necessary.
``(II) The group health plan or
health insurer issuer makes the
independent audit available on a public
website.
``(iv) Rulemaking.--The Secretary, the
Secretary of Labor, and the Secretary of the
Treasury shall issue interim final regulations
(without prior notice and comment as generally
required under section 553 of title 5, United
States Code) concerning the national standards
for conducting audits under this subparagraph,
not later than 2 years after the date of
enactment of the Behavioral Health Network and
Directory Improvement Act.
``(C) Audits by the secretary.--
``(i) In general.--Beginning not later than
the fourth plan year after the date of
enactment of the Behavioral Health Network and
Directory Improvement Act, the Secretary shall
conduct annual audits to ensure compliance with
the auditing requirements under subparagraph
(B).
``(ii) Selection of plans and issuers.--The
Secretary, the Secretary of Labor, and the
Secretary of the Treasury (referred to in this
clause as the `Secretaries'), jointly, shall
conduct annual audits of the submissions under
subparagraph (B) of a total of not fewer than
10 group health plans or health insurance
issuers offering group or individual health
insurance coverage, as determined by the
Secretaries, that are the subjects of
complaints about ghost networks or other
complaints, or that are randomly selected by
the Secretaries.''; and
(G) in paragraph (8), as so redesignated--
(i) in the paragraph heading, by striking
``Definition'' and inserting ``Definitions'';
(ii) by striking ``For purposes of this
subsection, the term'' and inserting the
following: ``For purposes of this subsection:
``(A) Provider directory information.--The term'';
(iii) by striking ``health insurance
coverage, the name, address'' and inserting
``health insurance coverage--
``(i) the name, address where the provider
regularly sees patients'';
(iv) by striking the period and inserting
``; and''; and
(v) by adding at the end the following:
``(ii) with respect to each such provider
or facility--
``(I) whether such provider or
facility is accepting new patients;
``(II) the languages spoken and the
availability of language translators
for specified languages at each health
care facility listed in the directory;
``(III) whether the provider or
facility offers medication-assisted
treatment for opioid use disorder;
``(IV) the State license number;
``(V) the national provider
identifier;
``(VI) the age groups served by the
provider or facility, such as
pediatric, adolescent, adult, or
geriatric populations;
``(VII) whether such provider or
facility offers in-person services,
telehealth services, or both;
``(VIII) the cost-sharing tier, if
applicable; and
``(IX) health insurance plans
accepted (including the plan identifier
and type of plan).
``(B) Ghost network.--The term `ghost network'
means a group health plan or group or individual health
insurance coverage for which the provider directory
information describing the network of such plan or
coverage--
``(i) includes inaccurate contact
information with respect to a substantial share
of included listings and providers who are part
of the network;
``(ii) includes a substantial number of
providers and facilities (as specified by the
Secretary, in coordination with the Secretary
of Labor and the Secretary of the Treasury) in
a specialty who are not accepting new patients
within a time period specified by such
secretaries;
``(iii) includes a substantial number of
providers and facilities that are not part of
the network; or
``(iv) omits a substantial number of
providers and facilities that are part of the
network.''; and
(2) in subsection (b)--
(A) in paragraph (1), by striking ``and if either
of the criteria described in paragraph (2) applies with
respect to such participant, beneficiary, or enrollee
and item or service''; and
(B) by striking paragraph (2) and inserting the
following:
``(2) Reconciliation requirement.--If a nonparticipating
provider was listed as a participating provider in the posted
provider directory database, the group health plan or health
insurance issuer shall, not later than 30 days after receiving
the request for payment, notify the participant, beneficiary,
or enrollee, in plain language, that the participant,
beneficiary, or enrollee may be eligible for a refund from the
group health plan or health insurance issuer if such
participant, beneficiary, or enrollee paid the out of network
cost-sharing and did not receive a refund under section 2799B-
9(b).''.
(b) ERISA.--
(1) In general.--Section 720 of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1185i) is amended--
(A) in subsection (a)--
(i) in paragraph (1)--
(I) by striking ``For plan years
beginning on or after January 1, 2022,
each'' and inserting ``Each'';
(II) in subparagraph (C), by
striking ``; and'' and inserting a
semicolon;
(III) in subparagraph (D), by
striking the period and inserting ``;
and''; and
(IV) by adding at the end the
following:
``(E) ensure that any directory, including the
database described in subparagraph (C), containing
provider directory information with respect to such
plan or such coverage complies with the requirements
developed by the appropriate agencies in accordance
with paragraph (6) in order to ensure that
participants, beneficiaries, and enrollees are able to
identify actively participating health care providers
and health care facilities.'';
(ii) in paragraph (3)--
(I) in the matter preceding
subparagraph (A), by striking ``, in
the case such request is made through a
telephone call''; and
(II) in subparagraph (A), by
striking ``call is received, through a
written electronic or print (as
requested by such individual)
communication'' and inserting ``a
request is received, by telephone, or
through a written electronic or print
communication (as requested by such
individual)'';
(iii) in paragraph (4)--
(I) in subparagraph (A), by
striking ``and'' at the end;
(II) in subparagraph (B), by
striking the period and inserting ``;
and''; and
(III) by adding at the end the
following:
``(C) information, in plain language, concerning
the rights of the participant, beneficiary, or enrollee
to cost-sharing protections pursuant to subsection (b)
in the event of reliance on inaccurate provider network
information supplied by a group health plan or health
insurance issuer, and contact information for, as
appropriate, the State consumer assistance program or
ombudsman or the Employee Benefits Security
Administration for more information.'';
(iv) in paragraph (5), by adding at the end
the following: ``Such information shall include
a statement, in plain language, concerning the
rights of the participant, beneficiary, or
enrollee to cost-sharing protections pursuant
to subsection (b) in the event of reliance on
inaccurate provider directory information
supplied by a group health plan or health
insurance issuer, and contact information for,
as appropriate, the State consumer assistance
program or ombudsman or the Employee Benefits
Security Administration for more
information.'';
(v) by redesignating paragraphs (6) and (7)
as paragraphs (8) and (9), respectively;
(vi) by inserting after paragraph (5) the
following:
``(6) Protecting participants, beneficiaries, and enrollees
from ghost networks.--The Secretary, in collaboration with the
Secretary of Labor and the Secretary of the Treasury, shall--
``(A) not later than 4 years after the date of
enactment of the Behavioral Health Network and
Directory Improvement Act, issue final regulations
further defining the term `ghost network' (as defined
in paragraph (8)); and
``(B) not later than 4 years after the date of
enactment of the Behavioral Health Network and
Directory Improvement Act, issue final regulations,
subregulatory guidance, or program instruction on how
to assess ghost networks in health plan directories
including reasonable assumptions related to statistics
and research methods.
``(7) Database reporting and auditing to protect against
ghost networks.--
``(A) Reporting requirements.--Beginning not later
than 3 years after the date of enactment of the
Behavioral Health Network and Directory Improvement
Act, each group health plan and health insurance issuer
offering group health insurance coverage shall submit
to the Secretary, at such time as the Secretary, in
coordination with the Secretary of Health and Human
Services and the Secretary of the Treasury, shall
require, but not less frequently than annually, the
directory data described in paragraph (a)(4), in a
machine readable format (as defined in section
147.210(a)(2)(xiv) of title 45, Code of Federal
Regulations (or any successor regulations)). A health
insurance issuer or a third party administrator of a
group health plan may submit such information for all
health insurance coverage or all group health plans,
collectively, that such issuer or administrator
administers. The Secretary, in coordination with the
Secretary of Health and Human Services and the
Secretary of the Treasury, shall make data submitted
under this subparagraph available on a public website.
``(B) Provider directory independent audit
requirements.--
``(i) In general.--Beginning not later than
3 years after the date of enactment of the
Behavioral Health Network and Directory
Improvement Act, each group health plan and
health insurance issuer offering group health
insurance coverage shall conduct an annual
directory audit, through an independent entity
not associated with the health plan or issuer,
that considers the factors described in clause
(ii)(I)(aa) and follows the guidelines
developed under clause (ii)(I)(bb).
``(ii) Information to be included.--
``(I) In general.--For purposes of
carrying out the audits under this
subparagraph, the Secretary shall--
``(aa) develop a list of
information required to be
included; and
``(bb) provide guidelines
for carrying out such audits,
for use by group health plans
and health insurance issuers,
on--
``(AA) the
reasonable assumptions
and research methods to
select a reasonable
sample in order to
assess provider
directory information
accuracy; and
``(BB) determining
the criteria of an
eligible auditor.
``(II) Contents.--The information
listed under subclause (I)(aa) shall
include the following:
``(aa) The proportion of
directory listings of the plan
or coverage with inaccurate
information, including
incorrect contact information,
as specified by the Secretary,
during the audit period.
``(bb) The number of in-
network items or services paid
on behalf of participants,
beneficiaries, and enrollees in
the plan or coverage to
providers or facilities who
have a network provider
contract with the health plan
or issuer and were not listed
in the directory of the health
plan or health insurance
coverage for the audit period.
``(cc) The resources of the
plan or issuer to help
participants, beneficiaries,
and enrollees locate an
accurately listed in-network
provider who is accepting new
patients.
``(dd) The proportion of
participants, beneficiaries,
and enrollees using out-of-
network providers for mental
health and substance use
disorder services, and the
proportion of participants,
beneficiaries, and enrollees
using out-of-network providers
and facilities for medical and
surgical services.
``(ee) Documentation that
the plan or issuer verifies the
accuracy of the provider
directory information every 90
days.
``(ff) Other factors as
determined by the Secretary.
``(iii) Standards for reporting.--An audit
under this subparagraph is complete if all of
the following conditions are met:
``(I) The audit report includes the
following:
``(aa) A statement by the
independent auditor that, to
the best of the auditor's
knowledge, the report is
complete and accurate, and that
reasonable assumptions related
to statistics and research
methods have been complied
with.
``(bb) A statement
explaining the assumptions,
statistics, and methods used to
select the sample and assess
provider directory information
accuracy.
``(cc) Such other
requirements as the Secretary
determines necessary.
``(II) The group health plan or
health insurer issuer makes the
independent audit available on a public
website.
``(iv) Rulemaking.--The Secretary, the
Secretary of Health and Human Services, and the
Secretary of the Treasury shall issue interim
final regulations (without prior notice and
comment as generally required under section 553
of title 5, United States Code) concerning the
national standards for conducting audits under
this subparagraph, not later than 2 years after
the date of enactment of the Behavioral Health
Network and Directory Improvement Act.
``(C) Audits by the secretary.--
``(i) In general.--Beginning not later than
the fourth plan year after the date of
enactment of the Behavioral Health Network and
Directory Improvement Act, the Secretary shall
conduct annual audits to ensure compliance with
the auditing requirements under subparagraph
(B).
``(ii) Selection of plans and issuers.--The
Secretary, the Secretary of Health and Human
Services, and the Secretary of the Treasury
(referred to in this clause as the
`Secretaries'), jointly, shall conduct annual
audits of the submissions under subparagraph
(B) of a total of not fewer than 10 group
health plans or health insurance issuers
offering group health insurance coverage, as
determined by the Secretaries, that are the
subjects of complaints about ghost networks or
other complaints, or that are randomly selected
by the Secretaries.''; and
(vii) in paragraph (8), as so
redesignated--
(I) in the paragraph heading, by
striking ``Definition'' and inserting
``Definitions'';
(II) by striking ``For purposes of
this subsection, the term'' and
inserting the following: ``For purposes
of this subsection:
``(A) Provider directory information.--The term'';
(III) by striking ``health
insurance coverage, the name, address''
and inserting ``health insurance
coverage--
``(i) the name, address where the provider
regularly sees patients'';
(IV) by striking the period and
inserting ``; and''; and
(V) by adding at the end the
following:
``(ii) with respect to each such provider
or facility--
``(I) whether such provider or
facility is accepting new patients;
``(II) the languages spoken and the
availability of language translators
for specified languages at each health
care facility listed in the directory;
``(III) whether the provider or
facility offers medication-assisted
treatment for opioid use disorder;
``(IV) the State license number;
``(V) the national provider
identifier;
``(VI) the age groups served by the
provider or facility, such as
pediatric, adolescent, adult, or
geriatric populations;
``(VII) whether such provider or
facility offers in-person services,
telehealth services, or both;
``(VIII) the cost-sharing tier, if
applicable; and
``(IX) health insurance plans
accepted (including the plan identifier
and type of plan).
``(B) Ghost network.--The term `ghost network'
means a group health plan or group health insurance
coverage for which the provider directory information
describing the network of such plan or coverage--
``(i) includes inaccurate contact
information with respect to a substantial share
of included listings and providers who are part
of the network;
``(ii) includes a substantial number of
providers and facilities (as specified by the
Secretary, in coordination with the Secretary
of Health and Human Services and the Secretary
of the Treasury) in a specialty who are not
accepting new patients within a time period
specified by such secretaries;
``(iii) includes a substantial number of
providers and facilities that are not part of
the network; or
``(iv) omits a substantial number of
providers and facilities that are part of the
network.''; and
(B) in subsection (b)--
(i) in paragraph (1), by striking ``and if
either of the criteria described in paragraph
(2) applies with respect to such participant,
beneficiary, or enrollee and item or service'';
and
(ii) by striking paragraph (2) and
inserting the following:
``(2) Reconciliation requirement.--If a nonparticipating
provider was listed as a participating provider in the posted
provider directory database, the group health plan or health
insurance issuer shall, not later than 30 days after receiving
the request for payment, notify the participant, beneficiary,
or enrollee, in plain language, that the participant,
beneficiary, or enrollee may be eligible for a refund from the
group health plan or health insurance issuer if such
participant, beneficiary, or enrollee paid the out of network
cost-sharing and did not receive a refund under section 2799B-
9(b) of the Public Health Service Act (42 U.S.C. 300gg-139).''.
(2) Civil monetary penalties for violations.--
(A) Civil monetary penalties relating to provider
directory requirements.--Section 502(c)(10) of the
Employee Retirement Income Security Act of 1974 (29
U.S.C. 1132(c)(10)(A)) is amended--
(i) in the heading, by striking ``use of
genetic information'' and inserting ``use of
genetic information and provider directory
requirements''; and
(ii) in subparagraph (A)--
(I) by inserting ``plan
administrator of a group health plan
(including a third party
administrator),'' after ``plan sponsor
of a group health plan,'';
(II) by inserting ``,
administrator,'' after ``such
sponsor''; and
(III) by striking ``for any
failure'' and all that follows through
``in connection with the plan.'' and
inserting ``for any failure by such
plan sponsor, plan administrator, or
health insurance issuer, in connection
with the plan--
``(i) to meet the requirements of
subsection (a)(1)(F), (b)(3), (c), or (d) of
section 702 or section 701 or 702(b)(1) with
respect to genetic information; or
``(ii) to meet the requirements of section
720 with respect to provider directory
information.''.
(B) Exception to the general prohibition on
enforcement.--Section 502 of such Act (29 U.S.C. 1132)
is amended--
(i) in subsection (a)(6), by striking ``or
(9)'' and inserting ``(9), or (10)''; and
(ii) in subsection (b)(3)--
(I) by striking ``subsections
(c)(9) and (a)(6)'' and inserting
``subsections (c)(9), (c)(10), and
(a)(6)'';
(II) by striking ``under subsection
(c)(9))'' and inserting ``under
subsections (c)(9) and (c)(10)), and
except with respect to enforcement by
the Secretary of section 720''; and
(III) by striking ``706(a)(1)'' and
inserting ``733(a)(1)''.
(c) IRC.--Section 9820 of the Internal Revenue Code of 1986 is
amended--
(1) in subsection (a)--
(A) in paragraph (1)--
(i) by striking ``For plan years beginning
on or after January 1, 2022, each'' and
inserting ``Each'';
(ii) in subparagraph (C), by striking ``;
and'' and inserting a semicolon;
(iii) in subparagraph (D), by striking the
period and inserting ``; and''; and
(iv) by adding at the end the following:
``(E) ensure that any directory, including the
database described in subparagraph (C), containing
provider directory information with respect to such
plan complies with the requirements developed by the
appropriate agencies in accordance with paragraph (6)
in order to ensure that participants, beneficiaries,
and enrollees are able to identify actively
participating health care providers and health care
facilities.'';
(B) in paragraph (3)--
(i) in the matter preceding subparagraph
(A), by striking ``, in the case such request
is made through a telephone call''; and
(ii) in subparagraph (A), by striking
``call is received, through a written
electronic or print (as requested by such
individual) communication'' and inserting ``a
request is received, by telephone, or through a
written electronic or print communication (as
requested by such individual)'';
(C) in paragraph (4)--
(i) in subparagraph (A), by striking
``and'' at the end;
(ii) in subparagraph (B), by striking the
period and inserting ``; and''; and
(iii) by adding at the end the following:
``(C) information, in plain language, concerning
the rights of the participant, beneficiary, or enrollee
to cost-sharing protections pursuant to subsection (b)
in the event of reliance on inaccurate provider network
information supplied by a group health plan, and
contact information for, as appropriate, the State
consumer assistance program or ombudsman or the
Employee Benefits Security Administration for more
information.'';
(D) in paragraph (5), by adding at the end the
following: ``Such information shall include a
statement, in plain language, concerning the rights of
the participant, beneficiary, or enrollee to cost-
sharing protections pursuant to subsection (b) in the
event of reliance on inaccurate provider directory
information supplied by a group health plan, and
contact information for, as appropriate, the State
consumer assistance program or ombudsman or the
Employee Benefits Security Administration for more
information.'';
(E) by redesignating paragraphs (6) and (7) as
paragraphs (8) and (9), respectively;
(F) by inserting after paragraph (5) the following:
``(6) Protecting participants, beneficiaries, and enrollees
from ghost networks.--The Secretary, in collaboration with the
Secretary of Labor and the Secretary of Health and Human
Services, shall--
``(A) not later than 4 years after the date of
enactment of the Behavioral Health Network and
Directory Improvement Act, issue final regulations
further defining the term `ghost network' (as defined
in paragraph (8)); and
``(B) not later than 4 years after the date of
enactment of the Behavioral Health Network and
Directory Improvement Act, issue final regulations,
subregulatory guidance, or program instruction on how
to assess ghost networks in health plan directories
including reasonable assumptions related to statistics
and research methods.
``(7) Database reporting and auditing to protect against
ghost networks.--
``(A) Reporting requirements.--Beginning not later
than 3 years after the date of enactment of the
Behavioral Health Network and Directory Improvement
Act, each group health plan shall submit to the
Secretary, at such time as the Secretary, in
coordination with the Secretary of Labor and the
Secretary of Health and Human Services, shall require,
but not less frequently than annually, the directory
data described in paragraph (a)(4), in a machine
readable format (as defined in section
147.210(a)(2)(xiv) of title 45, Code of Federal
Regulations (or any successor regulations)). A third
party administrator of a group health plan may submit
such information for all group health plans,
collectively, that such administrator administers. The
Secretary, in coordination with the Secretary of Labor
and the Secretary of Health and Human Services, shall
make data submitted under this subparagraph available
on a public website.
``(B) Provider directory independent audit
requirements.--
``(i) In general.--Beginning not later than
3 years after the date of enactment of the
Behavioral Health Network and Directory
Improvement Act, each group health plan shall
conduct an annual directory audit, through an
independent entity not associated with the
health plan, that considers the factors
described in clause (ii)(I)(aa) and follows the
guidelines developed under clause (ii)(I)(bb).
``(ii) Information to be included.--
``(I) In general.--For purposes of
carrying out the audits under this
subparagraph, the Secretary shall--
``(aa) develop a list of
information required to be
included; and
``(bb) provide guidelines
for carrying out such audits,
for use by group health plans,
on--
``(AA) the
reasonable assumptions
and research methods to
select a reasonable
sample in order to
assess provider
directory information
accuracy; and
``(BB) determining
the criteria of an
eligible auditor.
``(II) Contents.--The information
listed under subclause (I)(aa) shall
include the following:
``(aa) The proportion of
directory listings of the plan
with inaccurate information,
including incorrect contact
information, as specified by
the Secretary, during the audit
period.
``(bb) The number of in-
network items or services paid
on behalf of participants,
beneficiaries, and enrollees in
the plan to providers or
facilities who have a network
provider contract with the
health plan and were not listed
in the directory of the health
plan for the audit period.
``(cc) The resources of the
plan to help participants,
beneficiaries, and enrollees
locate an accurately listed in-
network provider who is
accepting new patients.
``(dd) The proportion of
participants, beneficiaries,
and enrollees using out-of-
network providers for mental
health and substance use
disorder services, and the
proportion of participants,
beneficiaries, and enrollees
using out-of-network providers
and facilities for medical and
surgical services.
``(ee) Documentation that
the plan verifies the accuracy
of the provider directory
information every 90 days.
``(ff) Other factors as
determined by the Secretary.
``(iii) Standards for reporting.--An audit
under this subparagraph is complete if all of
the following conditions are met:
``(I) The audit report includes the
following:
``(aa) A statement by the
independent auditor that, to
the best of the auditor's
knowledge, the report is
complete and accurate, and that
reasonable assumptions related
to statistics and research
methods have been complied
with.
``(bb) A statement
explaining the assumptions,
statistics, and methods used to
select the sample and assess
provider directory information
accuracy.
``(cc) Such other
requirements as the Secretary
determines necessary.
``(II) The group health plan makes
the independent audit available on a
public website.
``(iv) Rulemaking.--The Secretary, the
Secretary of Labor, and the Secretary of Health
and Human Services shall issue interim final
regulations (without prior notice and comment
as generally required under section 553 of
title 5, United States Code) concerning the
national standards for conducting audits under
this subparagraph, not later than 2 years after
the date of enactment of the Behavioral Health
Network and Directory Improvement Act.
``(C) Audits by the secretary.--
``(i) In general.--Beginning not later than
the fourth plan year after the date of
enactment of the Behavioral Health Network and
Directory Improvement Act, the Secretary shall
conduct annual audits to ensure compliance with
the auditing requirements under subparagraph
(B).
``(ii) Selection of plans.--The Secretary,
the Secretary of Labor, and the Secretary of
Health and Human Services (referred to in this
clause as the `Secretaries'), jointly, shall
conduct annual audits of the submissions under
subparagraph (B) of a total of not fewer than
10 group health plans, as determined by the
Secretaries, that are the subjects of
complaints about ghost networks or other
complaints, or that are randomly selected by
the Secretaries.''; and
(G) in paragraph (8), as so redesignated--
(i) in the paragraph heading, by striking
``Definition'' and inserting ``Definitions'';
(ii) by striking ``For purposes of this
subsection, the term'' and inserting the
following: ``For purposes of this subsection:
``(A) Provider directory information.--The term'';
(iii) by striking ``group health plan, the
name, address'' and inserting ``group health
plan--
``(i) the name, address where the provider
regularly sees patients'';
(iv) by striking the period and inserting
``; and''; and
(v) by adding at the end the following:
``(ii) with respect to each such provider
or facility--
``(I) whether such provider or
facility is accepting new patients;
``(II) the languages spoken and the
availability of language translators
for specified languages at each health
care facility listed in the directory;
``(III) whether the provider or
facility offers medication-assisted
treatment for opioid use disorder;
``(IV) the State license number;
``(V) the national provider
identifier;
``(VI) the age groups served by the
provider or facility, such as
pediatric, adolescent, adult, or
geriatric populations;
``(VII) whether such provider or
facility offers in-person services,
telehealth services, or both;
``(VIII) the cost-sharing tier, if
applicable; and
``(IX) health insurance plans
accepted (including the plan identifier
and type of plan).
``(B) Ghost network.--The term `ghost network'
means a group health plan for which the provider
directory information describing the network of such
plan--
``(i) includes inaccurate contact
information with respect to a substantial share
of included listings and providers who are part
of the network;
``(ii) includes a substantial number of
providers and facilities (as specified by the
Secretary, in coordination with the Secretary
of Labor and the Secretary of Health and Human
Services) in a specialty who are not accepting
new patients within a time period specified by
such secretaries;
``(iii) includes a substantial number of
providers and facilities that are not part of
the network; or
``(iv) omits a substantial number of
providers and facilities that are part of the
network.''; and
(2) in subsection (b)--
(A) in paragraph (1), by striking ``and if either
of the criteria described in paragraph (2) applies with
respect to such participant, beneficiary, or enrollee
and item or service''; and
(B) by striking paragraph (2) and inserting the
following:
``(2) Reconciliation requirement.--If a nonparticipating
provider was listed as a participating provider in the posted
provider directory database, the group health plan shall, not
later than 30 days after receiving the request for payment,
notify the participant, beneficiary, or enrollee, in plain
language, that the participant, beneficiary, or enrollee may be
eligible for a refund from the group health plan if such
participant, beneficiary, or enrollee paid the out of network
cost-sharing and did not receive a refund under section 2799B-
9(b) of the Public Health Service Act (42 U.S.C. 300gg-139).''.
(d) Effective Date.--The amendments made by subsections (a), (b),
and (c) shall apply with respect to group health plans, or any health
insurance issuer offering health insurance coverage in connection with
such plan, for plan years beginning after the date that is 1 year after
the date of enactment of this Act.
SEC. 3. PROVIDER REQUIREMENTS TO PROTECT PATIENTS AND IMPROVE THE
ACCURACY OF PROVIDER DIRECTORY INFORMATION.
Section 2799B-9 of the Public Health Service Act (42 U.S.C. 300gg-
139) is amended--
(1) in subsection (a)--
(A) in paragraph (3), by striking ``; and'' and
inserting a semicolon;
(B) by redesignating paragraph (4) as paragraph
(6); and
(C) by inserting after paragraph (3) the following:
``(4) subject to paragraph (5), when a provider or facility
that is not accepting new patients determines that it has the
ability to accept new patients, within 5 business days of such
determination;
``(5) when a solo practitioner or small provider, as
determined by the Secretary, determines that it has the ability
to accept new patients, within 10 business days of such
determination; and''; and
(2) by amending subsection (d) to read as follows:
``(d) Definition.--For purposes of this section, the term `provider
directory information' includes--
``(1) the name, address, specialty, telephone number, and
digital contact information of each individual health care
provider contracted to participate in any of the networks of
the group health plan or health insurance coverage involved;
``(2) the name, address, specialty, telephone number, and
digital contact information of each medical group, clinic, or
facility contracted to participate in any of the networks of
the group health plan or health insurance coverage involved;
and
``(3) with respect to each such provider, medical group,
clinic, or facility--
``(A) whether such provider, medical group, clinic,
or facility is accepting new patients;
``(B) the languages spoken and the availability of
language translators for specified languages at each
provider, medical group, clinic, or facility listed in
the directory;
``(C) whether the provider, medical group, clinic,
or facility offers medication-assisted treatment for
opioid use disorder;
``(D) the State license number;
``(E) the national provider identifier;
``(F) the age groups served by such provider,
group, clinic, or facility, such as pediatric,
adolescent, adult, or geriatric populations;
``(G) whether such provider, group, clinic, or
facility offers in-person services, telehealth
services, or both; and
``(H) the cost-sharing tier, if applicable.''.
SEC. 4. STRENGTHENING MENTAL HEALTH AND SUBSTANCE USE DISORDER PARITY
REQUIREMENTS.
(a) PHSA.--
(1) Network adequacy requirements.--Section 2726(a) of the
Public Health Service Act (42 U.S.C. 300gg-26(a)) is amended by
adding at the end the following:
``(9) Network adequacy requirements.--
``(A) In general.--The Secretary, the Secretary of
Labor, and the Secretary of the Treasury shall issue
regulations establishing national quantitative
standards for mental health and substance use disorder
network adequacy. Such standards shall consider--
``(i) the ratio of in-network mental health
providers who submitted claims under the plan
or coverage in the previous plan year,
separated by professional type of mental health
provider, to participants, beneficiaries, and
enrollees in a group health plan or health
insurance coverage;
``(ii) the ratio of in-network substance
use disorder providers who submitted claims
under the plan or coverage in the previous plan
year, separated by professional type of
substance use disorder provider, to
participants, beneficiaries, and enrollees in a
group health plan or health insurance coverage;
``(iii) separately, for mental health
services and substance use disorder services--
``(I) geographic accessibility of
providers;
``(II) geographic variation and
population dispersion;
``(III) waiting times for
appointments with participating
providers;
``(IV) hours of operation for
participating providers;
``(V) the ability of the network to
meet the needs of participants,
beneficiaries, and enrollees, including
low-income individuals, individuals who
are members of a racial or ethnic
minority, individuals who live in a
health professional shortage area,
children and adults with serious,
chronic, and complex health conditions,
individuals with physical or mental
disabilities or substance use
disorders, pediatric populations, and
individuals with limited English
proficiency;
``(VI) the availability of in-
person services, telehealth services,
and hybrid services to serve the needs
of participants, beneficiaries, and
enrollees; and
``(VII) the percentage of in-
network providers who have submitted a
claim for payment during a previous 6-
month period, as determined by the
Secretary, the Secretary of Labor, and
the Secretary of the Treasury; and
``(iv) other standards as determined by the
Secretary, the Secretary of Labor, and the
Secretary of the Treasury.
``(B) Timing.--
``(i) Issuance.--The Secretary, the
Secretary of Labor, and the Secretary of the
Treasury shall--
``(I) issue proposed regulations
required under subparagraph (A) not
later than 2 years after the date of
enactment of the Behavioral Health
Network and Directory Improvement Act;
and
``(II) issue final regulations
under subparagraph (A) not later than 1
year thereafter.
``(ii) Effective date.--The regulations
promulgated under this paragraph shall take
effect in the first plan year that begins after
the date on which such final regulations are
issued.
``(C) Audits.--The Secretary, the Secretary of
Labor, and the Secretary of the Treasury (referred to
in this subparagraph as the `Secretaries'), jointly,
shall conduct annual, targeted audits of not fewer than
10 group health plans and health insurance issuers
offering group or individual health insurance coverage
that the Secretaries select based upon the number of
complaints about mental health and substance use
disorder network adequacy to ensure compliance with the
requirements of this paragraph. Such audits shall begin
not earlier than one year after the final regulations
implementing this paragraph begin to apply to group
health plans and health insurance issuers.''.
(2) Definitions.--Paragraphs (4) and (5) of section 2726(e)
of the Public Health Service Act (42 U.S.C. 300gg-26(e)) are
amended to read as follows:
``(4) Mental health benefits.--The term `mental health
benefits' means benefits with respect to services related to a
mental health condition, defined consistently with generally
recognized independent standards of current medical practice,
such as the Diagnostic and Statistical Manual of Mental
Disorders of the American Psychiatric Association.
``(5) Substance use disorder benefits.--The term `substance
use disorder benefits' means benefits with respect to services
related to a substance use disorder, defined consistently with
generally recognized independent standards of current medical
practice, such as the Diagnostic and Statistical Manual of
Mental Disorders of the American Psychiatric Association.''.
(3) Standards for parity in reimbursement rates.--Section
2726(a) of the Public Health Service Act (42 U.S.C. 300gg-
26(a)), as amended by paragraph (1), is further amended by
adding at the end the following:
``(10) Standards for parity in reimbursement rates.--
``(A) In general.--Not later than 2 years after the
date of enactment of the Behavioral Health Network and
Directory Improvement Act, the Secretary, the Secretary
of Labor, and the Secretary of the Treasury shall issue
regulations on a standard for parity in reimbursement
rates for mental health or substance use disorder
benefits and medical and surgical benefits, based on a
comparative analysis conducted by such Secretaries
using data submitted by group health plans and health
insurance issuers, provider associations, and other
experts related to the cost of care delivery for mental
health and substance use disorder benefits.
``(B) Requests for data.--Group health plans and
health insurance issuers shall comply with any request
for data issued by the Secretary, the Secretary of
Labor, and the Secretary of the Treasury for purposes
of developing the standards under subparagraph (A), in
a manner that avoids unnecessary duplication.
``(C) Effective date.--The regulations promulgated
under subparagraph (A) shall apply to group health
plans and health insurance issuers offering group or
individual health insurance coverage beginning in the
first plan year that begins after issuance of the final
regulations.''.
(b) ERISA.--
(1) Network adequacy requirements.--Section 712(a) of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1185a(a)) is amended by adding at the end the following:
``(9) Network adequacy requirements.--
``(A) In general.--The Secretary, the Secretary of
Health and Human Services, and the Secretary of the
Treasury shall issue regulations establishing national
quantitative standards for mental health and substance
use disorder network adequacy. Such standards shall
consider--
``(i) the ratio of in-network mental health
providers who submitted claims under the plan
or coverage in the previous plan year,
separated by professional type of mental health
provider, to participants, beneficiaries, and
enrollees in a group health plan or health
insurance coverage;
``(ii) the ratio of in-network substance
use disorder providers who submitted claims
under the plan or coverage in the previous plan
year, separated by professional type of
substance use disorder provider, to
participants, beneficiaries, and enrollees in a
group health plan or health insurance coverage;
``(iii) separately, for mental health
services and substance use disorder services--
``(I) geographic accessibility of
providers;
``(II) geographic variation and
population dispersion;
``(III) waiting times for
appointments with participating
providers;
``(IV) hours of operation for
participating providers;
``(V) the ability of the network to
meet the needs of participants,
beneficiaries, and enrollees, including
low-income individuals, individuals who
are members of a racial or ethnic
minority, individuals who live in a
health professional shortage area,
children and adults with serious,
chronic, and complex health conditions,
individuals with physical or mental
disabilities or substance use
disorders, pediatric populations, and
individuals with limited English
proficiency;
``(VI) the availability of in-
person services, telehealth services,
and hybrid services to serve the needs
of participants, beneficiaries, and
enrollees; and
``(VII) the percentage of in-
network providers who have submitted a
claim for payment during a previous 6-
month period, as determined by the
Secretary, the Secretary of Health and
Human Services, and the Secretary of
the Treasury; and
``(iv) other standards as determined by the
Secretary, the Secretary of Health and Human
Services, and the Secretary of the Treasury.
``(B) Timing.--
``(i) Issuance.--The Secretary, the
Secretary of Health and Human Services, and the
Secretary of the Treasury shall--
``(I) issue proposed regulations
required under subparagraph (A) not
later than 2 years after the date of
enactment of the Behavioral Health
Network and Directory Improvement Act;
and
``(II) issue final regulations
under subparagraph (A) not later than 1
year thereafter.
``(ii) Effective date.--The regulations
promulgated under this paragraph shall take
effect in the first plan year that begins after
the date on which such final regulations are
issued.
``(C) Audits.--The Secretary, the Secretary of
Health and Human Services, and the Secretary of the
Treasury (referred to in this subparagraph as the
`Secretaries'), jointly, shall conduct annual, targeted
audits of not fewer than 10 group health plans and
health insurance issuers offering group health
insurance coverage that the Secretaries select based
upon the number of complaints about mental health and
substance use disorder network adequacy to ensure
compliance with the requirements of this paragraph.
Such audits shall begin not earlier than one year after
the final regulations implementing this paragraph begin
to apply to group health plans and health insurance
issuers.''.
(2) Definitions.--Paragraphs (4) and (5) of section 712(e)
of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185a(e)) are amended to read as follows:
``(4) Mental health benefits.--The term `mental health
benefits' means benefits with respect to services related to a
mental health condition, defined consistently with generally
recognized independent standards of current medical practice,
such as the Diagnostic and Statistical Manual of Mental
Disorders of the American Psychiatric Association.
``(5) Substance use disorder benefits.--The term `substance
use disorder benefits' means benefits with respect to services
related to a substance use disorder, defined consistently with
generally recognized independent standards of current medical
practice, such as the Diagnostic and Statistical Manual of
Mental Disorders of the American Psychiatric Association.''.
(3) Standards for parity in reimbursement rates.--Section
712(a) of the Employee Retirement Income Security Act of 1974
(29 U.S.C. 1185a(a)), as amended by paragraph (1), is further
amended by adding at the end the following:
``(10) Standards for parity in reimbursement rates.--
``(A) In general.--Not later than 2 years after the
date of enactment of the Behavioral Health Network and
Directory Improvement Act, the Secretary, the Secretary
of Health and Human Services, and the Secretary of the
Treasury shall issue regulations on a standard for
parity in reimbursement rates for mental health or
substance use disorder benefits and medical and
surgical benefits, based on a comparative analysis
conducted by such Secretaries using data submitted by
group health plans and health insurance issuers,
provider associations, and other experts related to the
cost of care delivery for mental health and substance
use disorder benefits.
``(B) Requests for data.--Group health plans and
health insurance issuers shall comply with any request
for data issued by the Secretary, the Secretary of
Health and Human Services, and the Secretary of the
Treasury for purposes of developing the standards under
subparagraph (A), in a manner that avoids unnecessary
duplication.
``(C) Effective date.--The regulations promulgated
under subparagraph (A) shall apply to group health
plans and health insurance issuers offering group
health insurance coverage beginning in the first plan
year that begins after issuance of the final
regulations.''.
(c) IRC.--
(1) Network adequacy requirements.--Section 9812(a) of the
Internal Revenue Code of 1986 is amended by adding at the end
the following:
``(9) Network adequacy requirements.--
``(A) In general.--The Secretary, the Secretary of
Health and Human Services, and the Secretary of Labor
shall issue regulations establishing national
quantitative standards for mental health and substance
use disorder network adequacy. Such standards shall
consider--
``(i) the ratio of in-network mental health
providers who submitted claims under the plan
in the previous plan year, separated by
professional type of mental health provider, to
participants, beneficiaries, and enrollees in a
group health plan;
``(ii) the ratio of in-network substance
use disorder providers who submitted claims
under the plan in the previous plan year,
separated by professional type of substance use
disorder provider, to participants,
beneficiaries, and enrollees in a group health
plan;
``(iii) separately, for mental health
services and substance use disorder services--
``(I) geographic accessibility of
providers;
``(II) geographic variation and
population dispersion;
``(III) waiting times for
appointments with participating
providers;
``(IV) hours of operation for
participating providers;
``(V) the ability of the network to
meet the needs of participants,
beneficiaries, and enrollees, including
low-income individuals, individuals who
are members of a racial or ethnic
minority, individuals who live in a
health professional shortage area,
children and adults with serious,
chronic, and complex health conditions,
individuals with physical or mental
disabilities or substance use
disorders, pediatric populations, and
individuals with limited English
proficiency;
``(VI) the availability of in-
person services, telehealth services,
and hybrid services to serve the needs
of participants, beneficiaries, and
enrollees; and
``(VII) the percentage of in-
network providers who have submitted a
claim for payment during a previous 6-
month period, as determined by the
Secretary, the Secretary of Health and
Human Services, and the Secretary of
Labor; and
``(iv) other standards as determined by the
Secretary, the Secretary of Health and Human
Services, and the Secretary of Labor.
``(B) Timing.--
``(i) Issuance.--The Secretary, the
Secretary of Health and Human Services, and the
Secretary of Labor shall--
``(I) issue proposed regulations
required under subparagraph (A) not
later than 2 years after the date of
enactment of the Behavioral Health
Network and Directory Improvement Act;
and
``(II) issue final regulations
under subparagraph (A) not later than 1
year thereafter.
``(ii) Effective date.--The regulations
promulgated under this paragraph shall take
effect in the first plan year that begins after
the date on which such final regulations are
issued.
``(C) Audits.--The Secretary, the Secretary of
Health and Human Services, and the Secretary of Labor
(referred to in this subparagraph as the
`Secretaries'), jointly, shall conduct annual, targeted
audits of not fewer than 10 group health plans that the
Secretaries select based upon the number of complaints
about mental health and substance use disorder network
adequacy to ensure compliance with the requirements of
this paragraph. Such audits shall begin not earlier
than one year after the final regulations implementing
this paragraph begin to apply to group health plans.''.
(2) Definitions.--Paragraphs (4) and (5) of section 9812(e)
of the Internal Revenue Code of 1986 are amended to read as
follows:
``(4) Mental health benefits.--The term `mental health
benefits' means benefits with respect to services related to a
mental health condition, defined consistently with generally
recognized independent standards of current medical practice,
such as the Diagnostic and Statistical Manual of Mental
Disorders of the American Psychiatric Association.
``(5) Substance use disorder benefits.--The term `substance
use disorder benefits' means benefits with respect to services
related to a substance use disorder, defined consistently with
generally recognized independent standards of current medical
practice, such as the Diagnostic and Statistical Manual of
Mental Disorders of the American Psychiatric Association.''.
(3) Standards for parity in reimbursement rates.--Section
9812(a) of the Internal Revenue Code of 1986, as amended by
paragraph (1), is further amended by adding at the end the
following:
``(10) Standards for parity in reimbursement rates.--
``(A) In general.--Not later than 2 years after the
date of enactment of the Behavioral Health Network and
Directory Improvement Act, the Secretary, the Secretary
of Health and Human Services, and the Secretary of
Labor shall issue regulations on a standard for parity
in reimbursement rates for mental health or substance
use disorder benefits and medical and surgical
benefits, based on a comparative analysis conducted by
such Secretaries using data submitted by group health
plans, provider associations, and other experts related
to the cost of care delivery for mental health and
substance use disorder benefits.
``(B) Requests for data.--Group health plans shall
comply with any request for data issued by the
Secretary, the Secretary of Health and Human Services,
and the Secretary of Labor for purposes of developing
the standards under subparagraph (A), in a manner that
avoids unnecessary duplication.
``(C) Effective date.--The regulations promulgated
under subparagraph (A) shall apply to group health
plans beginning in the first plan year that begins
after issuance of the final regulations.''.
SEC. 5. STATE AND TRIBAL OMBUDSMAN PROGRAMS RELATING TO MENTAL HEALTH
AND SUBSTANCE USE DISORDER PARITY.
Part C of title XXVII of the Public Health Service Act (42 U.S.C.
300gg-91 et seq.) is amended--
(1) by redesignating section 2794 (42 U.S.C. 300gg-95)
(regarding uniform fraud and abuse referral format), as added
by section 6603 of the Patient Protection and Affordable Care
Act (Public Law 111-148), as section 2795; and
(2) by adding at the end the following:
``SEC. 2796. STATE AND TRIBAL OMBUDSMAN PROGRAMS RELATING TO MENTAL
HEALTH AND SUBSTANCE USE DISORDER PARITY.
``(a) In General.--The Secretary shall make grants to eligible
entities, designated by a State, Indian Tribe, or Tribal organization,
as described in subsection (b), for the purpose of--
``(1) establishing or supporting State and Tribal mental
health and substance use disorder parity ombudsman programs
to--
``(A) educate consumers about the mental health and
substance use disorder coverage in individual plans,
group health plans, self-insured plans, and State
Medicaid managed care plans;
``(B) assist consumers in understanding their
rights as health benefits plan members, including
appeal processes and how to use such benefits, and how
to access appropriate medical information;
``(C) assist consumers in exercising their rights
under the provisions of part D, including resolving
problems related to a group health plan or health
insurance issuer erroneously charging a consumer out-
of-network rates for services listed in-network on the
group health plan or health insurance issuer's provider
directory;
``(D) identify, investigate, and help resolve
complaints related to mental health and substance use
disorder coverage (including potential violations of
the mental health and substance use disorder parity
laws) on behalf of consumers;
``(E) maintain a toll-free hotline and website for
consumers;
``(F) collect, track, and quantify problems and
inquiries encountered by consumers; and
``(G) other activities as defined by the Secretary;
and
``(2) provide support and training for such State and
Tribal mental health parity ombudsman programs (such as through
the establishment of a mental health parity ombudsman program
resource center).
``(b) Eligibility.--To be eligible to receive a grant under this
section, a State, Indian Tribe, or Tribal organization shall designate
an ombudsman or consumer assistance program or other independent entity
that--
``(1) has specialized knowledge of mental health conditions
and substance use disorders and experience resolving inquiries
and complaints; and
``(2) directly, or in coordination with departments of
insurance, and consumer assistance organizations, receives and
responds to inquiries and complaints concerning access to
mental health and substance use disorder services.
``(c) Criteria.--A State, Indian Tribe, or Tribal organization that
receives a grant under this section shall comply with criteria
established by the Secretary for carrying out activities under such
grant.
``(d) Data Collection.--As a condition of receiving a grant, an
eligible entity shall agree to--
``(1) collect and report data to the Secretary, State
legislature, and relevant State agencies, including the
departments of insurance and the State attorney general, on the
numbers and types of problems and inquiries encountered by
individuals with respect to access to behavioral health
services; and
``(2) report to the Secretary on how identified problems
were addressed, including through promising practices related
to responding to mental health and substance use disorder
coverage issues, including appeals and education.
``(e) Report to Congress.--Not later than 4 years after the date of
the enactment of the Behavioral Health Network and Directory
Improvement Act, the Secretary shall submit to Congress a report on the
data collected under subsection.
``(f) Definitions.--In this section, the terms `Indian Tribe' and
`Tribal organization' have the meanings given such terms in section 4
of the Indian Self-Determination and Education Assistance Act.
``(g) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated $20,000,000 for fiscal year
2025 and $10,000,000 for fiscal year 2026 and each fiscal year
thereafter.''.
SEC. 6. REPORT TO CONGRESS.
(a) In General.--Not later than 6 years after the date of enactment
of this Act and every 2 years for the next 10 years, the Secretary of
Health and Human Services, the Secretary of Labor, and the Secretary of
the Treasury (collectively referred to in this section as the
``Secretaries'') shall jointly submit to Congress and make publicly
available a report to assess the prevalence of ghost networks and the
adequacy of mental health and substance use disorder networks, in
accordance with section 2726(a)(9) of the Public Health Service Act,
section 712(a)(9) of the Employee Retirement Income Security Act of
1974, and section 9812(a)(9) of the Internal Revenue Code of 1986, as
amended by section 4. Such report shall include the following:
(1) Aggregate information about group health plans and
health insurance issuers determined by the Secretaries to be
out of compliance with the provider directory requirements
under section 2799A-5 of the Public Health Service Act, section
720 of the Employee Retirement Income Security Act of 1974, and
section 9820 of the Internal Revenue Code of 1986, as amended
by section 2.
(2) Aggregate information about group health plans and
health insurance issuers determined by the Secretaries to be
out of compliance with the requirements for parity in mental
health and substance use disorder benefits under section 2726
of the Public Health Service Act (42 U.S.C. 300gg-26), section
712 of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185a), and section 9812 of the Internal Revenue Code of
1986, as amended by section 4.
(3) A summary of findings through audits, in the aggregate,
under section 2799A-5(a)(7)(C) of the Public Health Service
Act, section 720(a)(7)(C) of the Employee Retirement Income
Security Act of 1974, and section 9820(a)(7)(C) of the Internal
Revenue Code of 1986, as amended by section 2, including--
(A) the accuracy of provider directory information,
sectioned out by accuracy of the provider's name,
address, specialty, telephone number, digital contact
information, whether the providers are accepting new
patients, in-network status, linguistic- and cultural-
competency, and availability of medications for opioid
use disorder;
(B) the number of plans and individuals enrolled in
a group health plan or group or individual health
insurance coverage that offers a mental health and
substance use disorder network that meets the network
adequacy standards under, as applicable, section 2799A-
5 of the Public Health Service Act, section 720 of the
Employee Retirement Income Security Act of 1974, or
section 9820 of the Internal Revenue Code of 1986, as
amended by section 2; and
(C) the number of individuals enrolled in a group
health plan or group or individual health insurance
coverage with a ghost network.
(4) A comparative analysis of in-network and out-of-network
reimbursement rates for mental health and substance use
disorder services compared to medical and surgical services by
group health plans and health insurance issuers.
(b) Definition.--In this section, the term ``ghost network'' has
the meaning given such term in section 2799A-5(a)(8) of the Public
Health Service Act, section 720(a)(8) of the Employee Retirement Income
Security Act of 1974, and section 9820(a)(8) of the Internal Revenue
Code of 1986, as amended by section 2.
SEC. 7. AUTHORIZATION OF APPROPRIATIONS.
(a) Administrative Functions.--To carry out sections 4, 5, and 6,
including the amendments made by such sections, there are authorized to
be appropriated to the Secretary of Health and Human Services, the
Secretary of Labor, and the Secretary of the Treasury such sums as may
be necessary.
(b) Protecting Patients and Improving the Accuracy of Provider
Directory Information.--To carry out section 2, including the
amendments made by such section, in addition to amounts otherwise made
available for such purposes, there are authorized to be appropriated--
(1) to the Secretary of Health and Human Services, for
purposes of carrying out the amendments made by subsection (a)
of such section--
(A) $15,200,000 for each of fiscal years 2025 and
2026;
(B) $17,000,000 for fiscal year 2027; and
(C) $10,000,000 for fiscal year 2028 and each
fiscal year thereafter; and
(2) to the Secretary of Labor, for purposes of carrying out
the amendments made by subsection (b) of such section,
$22,000,000 for fiscal year 2025 and each fiscal year
thereafter.
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