,i #aaf? ,,congress #b;d ,session ,h4 ,r4 #ehjj ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,febru>y #g1 #bjbj,mr4 ,scott ( ,virg9ia 7= himself & ,ms4 ,foxx ( ,nor? ,c>ol9a7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committees on ,education & ,labor1 ,ways & ,means1 & ,ov]sight & ,re=m1 = a p]iod to be subsequ5tly det]m9$ by ! ,speak]1 9 ea* case = consid]ation ( su* provisions z fall )9 ! jurisdiction ( ! committee conc]n$ ,a ,,bill ,to end surprise m$ical bill+ & increase transp>5cy 9 heal? cov]age4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,ban ,surprise ,bill+ ,act4 #b4 ,prev5t+ surprise m$ical bills 7a7 ,public ,heal? ,s]vice ,act am5dm5ts ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is am5d$-- 7#a7 by am5d+ subsection 7b7 to read z foll[s3 7b7 ,cov]age ( ,em]g5cy ,s]vices 7#a7 ,9 g5]al ,if a gr\p heal? plan1 or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age1 provides or cov]s any b5efits ) respect to s]vices 9 an em]g5cy dep>tm5t ( a hospital or ) respect to em]g5cy s]vices 9 an indep5d5t free/&+ em]g5cy dep>tm5t 7z def9$ 9 p>agraph 7#c77;,d771 ! plan or issu] %all cov] em]g5cy s]vices 7z def9$ 9 p>agraph 7#c77;,c77-- 7,a7 )\t ! ne$ = any prior au?orization det]m9ation2 7,b7 :e!r ! heal? c>e provid] furni%+ su* s]vices is a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility1 z applicable1 ) respect to su* s]vices2 7,c7 9 a mann] s t1 if su* s]vices are provid$ to a p>ticipant1 b5efici>y1 or enrollee by a nonp>ticipat+ provid] or a nonp>ticipat+ em]g5cy facility-- 7i7 su* s]vices w be provid$ )\t impos+ any requirem5t "u ! plan or cov]age = prior au?orization ( s]vices or any limitation on cov]age t is m re/rictive ?an ! requirem5ts or limitations t apply to em]g5cy s]vices receiv$ f p>ticipat+ provid]s & p>ticipat+ em]g5cy facilities ) respect to su* plan or cov]age1 respectively2 7ii7 ! co/-%>+ requirem5t 7express$ z a copaym5t am\nt or co9surance rate7 is n great] ?an ! requirem5t t w\ld apply if su* s]vices 7 provid$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility2 7iii7 su* co/-%>+ requirem5t is calculat$ z if ! total am\nt t w\ld h be5 *>g$ = su* s]vices by su* p>ticipat+ provid] or p>ticipat+ em]g5cy facility 7 equal to ! recogniz$ am\nt 7z def9$ 9 p>agraph 7#c77;,h77 = su* s]vices1 plan or cov]age1 & ye>2 7iv7 ! gr\p heal? plan or heal? insurance issu]1 respectively1 pays to su* provid] or facility1 respectively ! am\nt by :i* ! recogniz$ am\nt = su* s]vices & ye> involv$ exce$s ! co/-%>+ am\nt = su* s]vices 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii77 & ye>2 & 7v7 any co/-%>+ paym5ts made by ! p>ticipant1 b5efici>y1 or enrollee ) respect to su* em]g5cy s]vices s furni%$ %all be c\nt$ t[>d any 9-network d$uctible or out-(-pocket maximums appli$ "u ! plan or cov]age1 respectively 7& su* 9-network d$uctible & out-(-pocket maximums %all be appli$7 9 ! same mann] z if su* co/-%>+ paym5ts 7 made ) respect to em]g5cy s]vices furni%$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility2 & 7,d7 )\t reg>d to any o!r t]m or condition ( su* cov]age 7o!r ?an exclusion or coord9ation ( b5efits1 or an affiliation or wait+ p]iod1 p]mitt$ "u section #bgjd ( ?is ,act1 includ+ z incorporat$ pursuant to section #gae ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd & section #ihae ( ! ,int]nal ,rev5ue ,code ( #aihf1 & o!r ?an applicable co/-%>+74 7#b7 ,audit process & regulations = m$ian contract$ rates 7,a7 ,audit process 7i7 ,9 g5]al ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 consultation ) appropriate ,/ate ag5cies & ! ,secret>y ( ,labor & ! ,secret>y ( ! ,treasury1 %all e/abli% ?r\gh rulemak+ a process1 9 accordance ) clause 7ii71 "u :i* gr\p heal? plans & heal? insurance issu]s (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket are audit$ by ! ,secret>y or applicable ,/ate au?ority to ensure t-- 7,i7 su* plans & cov]age are 9 compliance ) ! requirem5t ( apply+ a m$ian contract$ rate "u ?is section2 & 7,,ii7 su* m$ian contract$ rate s appli$ satisfies ! def9ition "u p>agraph 7#c77;,e7 ) respect to ! ye> involv$1 includ+ ) respect to a gr\p heal? plan or heal? insurance issu] describ$ 9 clause 7ii7 ( su* p>agraph 7#c77;,e74 7ii7 ,audit samples ,"u ! process e/abli%$ pursuant to clause 7i71 ! ,secret>y-- 7,i7 %all conduct audits describ$ 9 su* clause1 ) respect to a ye> 7beg9n+ ) #bjbb71 ( a sample ) respect to su* ye> ( claims data f n m ?an #be gr\p heal? plans & heal? insurance issu]s (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket2 & 7,,ii7 may audit any gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket if ! ,secret>y has receiv$ any compla9t ab\t su* plan or cov]age1 respectively1 t involves ! compliance ( ! plan or cov]age1 respectively1 ) ei!r ( ! requirem5ts describ$ 9 subclauses 7,i7 & 7,,ii7 ( su* clause4 7iii7 ,reports ,beg9n+ = #bjbb1 ! ,secret>y %all annually submit to ,congress a report on ! numb] ( plans & issu]s ) respect to :i* audits 7 conduct$ dur+ su* ye> pursuant to ?is subp>agraph4 7,b7 ,rulemak+ ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 consultation ) ! ,secret>y ( ,labor & ! ,secret>y ( ! ,treasury1 %all e/abli% ?r\gh rulemak+-- 7i7 ! me?odology ! gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket %all use to det]m9e ! m$ian contract$ rate1 diff]5tiat+ by l9e ( bus9ess2 7ii7 ! in=mation su* plan or issu]1 respectively1 %all %>e ) ! nonp>ticipat+ provid] or nonp>ticipat+ facility1 z applicable1 :5 mak+ su* a det]m9ation2 7iii7 ! geographic regions appli$ = purposes ( ?is subp>agraph1 tak+ into acc\nt access to items & s]vices 9 rural & und]s]v$ areas1 includ+ heal? pr(essional %ortage areas1 z def9$ 9 section #ccb2 & 7iv7 a process to receive compla9ts ( violations ( ! requirem5ts describ$ 9 subclauses 7,i7 & 7,,ii7 ( subp>agraph 7,a77i7 by gr\p heal? plans & heal? insurance issu]s (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket4 ,su* rulemak+ %all take into acc\nt paym5ts t are made by su* plan or issu]1 respectively1 t are n on a fee-=-s]vice basis4 ,su* me?odology may acc\nt = relevant paym5t adju/m5ts t take into acc\nt quality or facility type 7includ+ high] acuity sett+s & ! case-mix ( v>i\s facility types7 t are o!rwise tak5 into acc\nt = purposes ( det]m9+ paym5t am\nts ) respect to p>ticipat+ facilities4 ,9 c>ry+ out clause 7iii71 ! ,secret>y %all consult ) ! ,national ,association ( ,insurance ,commission]s to e/abli% ! geographic regions "u su* clause & %all p]iodically update su* regions1 z appropriate4 7#c7 ,def9itions ,9 ?is "p3 7,a7 ,em]g5cy dep>tm5t ( a hospital ,! t]m em]g5cy dep>tm5t ( a hospital includes a hospital outpati5t dep>tm5t t provides em]g5cy s]vices4 7,b7 ,em]g5cy m$ical condition ,! t]m em]g5cy m$ical condition means a m$ical condition manife/+ itself by acute symptoms ( suffici5t sev]ity 7includ+ sev]e pa97 su* t a prud5t layp]son1 :o possesses an av]age k ( heal? & m$ic9e1 c\ld reasonably expect ! abs5ce ( imm$iate m$ical att5tion to result 9 a condition describ$ 9 clause 7i71 7ii71 or 7iii7 ( section #ahfg7;e77#a77;,a7 ( ! ,social ,security ,act4 7,c7 ,em]g5cy s]vices 7i7 ,9 g5]al ,! t]m em]g5cy s]vices1 ) respect to an em]g5cy m$ical condition1 means-- 7,i7 a m$ical scre5+ exam9ation 7z requir$ "u section #ahfg ( ! ,social ,security ,act1 or z w\ld be requir$ "u su* section if su* section appli$ to an indep5d5t free/&+ em]g5cy dep>tm5t7 t is )9 ! capability ( ! em]g5cy dep>tm5t ( a hospital or ( an indep5d5t free/&+ em]g5cy dep>tm5t1 z applicable1 includ+ ancill>y s]vices r\t9ely available to ! em]g5cy dep>tm5t to evaluate su* em]g5cy m$ical condition2 & 7,,ii7 )9 ! capabilities ( ! /aff & facilities available at ! hospital or ! indep5d5t free/&+ em]g5cy dep>tm5t1 z applicable1 su* fur!r m$ical exam9ation & treatm5t z are requir$ "u section #ahfg ( su* ,act1 or z w\ld be requir$ "u su* section if su* section appli$ to an indep5d5t free/&+ em]g5cy dep>tm5t1 to /abilize ! pati5t4 7ii7 ,inclusion ( c]ta9 s]vices outside ( em]g5cy dep>tm5t 7,i7 ,9 g5]al ,= purposes ( ?is subsection & section #bgii;,a-#a1 9 ! case ( an individual enroll$ 9 a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket :o is furni%$ s]vices describ$ 9 clause 7i7 by a p>ticipat+ or nonp>ticipat+ provid] or a p>ticipat+ or nonp>ticipat+ em]g5cy facility to /abilize su* individual ) respect to an em]g5cy m$ical condition1 ! t]m em]g5cy s]vices %all include1 unless ea* ( ! conditions describ$ 9 subclause 7,,ii7 are met1 9 addition to ! items & s]vices describ$ 9 clause 7i71 items & s]vices = :i* b5efits are provid$ or cov]$ "u ! plan or cov]age1 respectively1 furni%$ by a nonp>ticipat+ provid] or nonp>ticipat+ facility1 reg>dless ( ! dep>tm5t ( ! hospital 9 :i* su* individual is furni%$ su* items or s]vices1 if1 aft] su* /abilization b dur+ su* visit 9 :i* su* individual is s /abiliz$1 ! provid] or facility det]m9es t su* items or s]vices are ne$$4 7,,ii7 ,conditions ,= purposes ( subclause 7,i71 ! conditions describ$ 9 ?is subclause1 ) respect to an individual :o is /abiliz$ & furni%$ additional items & s]vices describ$ 9 subclause 7,i7 aft] su* /abilization by a provid] or facility describ$ 9 subclause 7,i71 are ! foll[+3 7aa7 ,su* a provid] or facility det]m9es su* individual is able to travel us+ nonm$ical transportation or nonem]g5cy m$ical transportation4 7bb7 ,su* provid] furni%+ su* additional items & s]vices satisfies ! notice & cons5t crit]ia ( section #bgii;,a-#b7;d7 ) respect to su* items & s]vices4 7cc7 ,su* an individual is 9 a condition to receive 7z det]m9$ 9 accordance ) guidance issu$ by ! ,secret>y7 ! in=mation describ$ 9 section #bgii;,a-#b & to provide in=m$ cons5t "u su* section1 9 accordance ) applicable ,/ate law4 7,d7 ,indep5d5t free/&+ em]g5cy dep>tm5t ,! t]m indep5d5t free/&+ em]g5cy dep>tm5t means a facility t-- 7i7 is geographically sep>ate & di/9ct & lic5s$ sep>ately f a hospital "u applicable ,/ate law2 & 7ii7 provides any em]g5cy s]vices 7z def9$ 9 subp>agraph 7,c774 7,e7 ,m$ian contract$ rate 7i7 ,9 g5]al ,! t]m m$ian contract$ rate means1 subject to clauses 7ii7 & 7iii71 ) respect to a sponsor ( a gr\p heal? plan & heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket-- 7,i7 = an item or s]vice furni%$ dur+ #bjbb1 ! m$ian ( ! contract$ rates recogniz$ by ! plan or issu]1 respectively 7det]m9$ ) respect to all su* plans ( su* sponsor or all su* cov]age (f]$ by su* issu] t are (f]$ )9 ! same l9e ( bus9ess z ! plan or cov]age7 z ! total maximum paym5t 7includ+ ! co/-%>+ am\nt impos$ = su* item or s]vice & ! am\nt to be paid by ! plan or issu]1 respectively7 "u su* plans or cov]age1 respectively1 on ,janu>y #ca1 #bjai1 = ! same or a simil> item or s]vice t is provid$ by a provid] 9 ! same or simil> specialty & provid$ 9 ! geographic region 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u p>agraph 7#b77;,b71 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] #bjai1 su* p]c5tage increase ov] #bjbj1 & su* p]c5tage increase ov] #bjba2 & 7,,ii7 = an item or s]vice furni%$ dur+ #bjbc or a subsequ5t ye>1 ! m$ian contract$ rate det]m9$ "u ?is clause = su* an item or s]vice furni%$ 9 ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 7ii7 ,new plans & cov]age ,! t]m m$ian contract$ rate means1 ) respect to a sponsor ( a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket 9 a geographic region 9 :i* su* sponsor or issu]1 respectively1 did n (f] any gr\p heal? plan or heal? insurance cov]age dur+ #bjai-- 7,i7 = ! fir/ ye> 9 :i* su* gr\p heal? plan or heal? insurance cov]age1 respectively1 is (f]$ 9 su* region1 a rate 7det]m9$ 9 accordance ) a me?odology e/abli%$ by ! ,secret>y7 = items & s]vices t are cov]$ by su* plan & furni%$ dur+ su* fir/ ye>2 & 7,,ii7 = ea* subsequ5t ye> su* gr\p heal? plan or heal? insurance cov]age1 respectively1 is (f]$ 9 su* region1 ! m$ian contract$ rate det]m9$ "u ?is clause = su* items & s]vices furni%$ 9 ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 7iii7 ,insuffici5t in=mation2 newly cov]$ items & s]vices ,9 ! case ( a sponsor ( a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket t does n h suffici5t in=mation to calculate ! m$ian ( ! contract$ rates describ$ 9 clause 7i77,i7 9 #bjai 7or1 9 ! case ( a newly cov]$ item or s]vice 7z def9$ 9 clause 7iv77,,iii771 9 ! fir/ cov]age ye> 7z def9$ 9 clause 7iv77,i77 = su* item or s]vice ) respect to su* plan or cov]age7 = an item or s]vice 7includ+ ) respect to provid] type1 or am\nt1 ( claims = items or s]vices 7z det]m9$ by ! ,secret>y7 provid$ 9 a p>ticul> geographic region 7o!r ?an 9 a case ) respect to :i* clause 7ii7 applies77 ! t]m m$ian contract$ rate-- 7,i7 = an item or s]vice furni%$ dur+ #bjbb 7or1 9 ! case ( a newly cov]$ item or s]vice1 dur+ ! fir/ cov]age ye> = su* item or s]vice ) respect to su* plan or cov]age71 means su* rate = su* item or s]vice det]m9$ by ! sponsor or issu]1 respectively1 ?r\gh use ( any database t is det]m9$1 9 accordance ) rulemak+ describ$ 9 p>agraph 7#b77;,b71 to n h any conflicts ( int]e/ & to h suffici5t in=mation reflect+ all[$ am\nts paid to a heal? c>e provid] or facility = relevant s]vices furni%$ 9 ! applicable geographic region 7su* z a ,/ate all-pay] claims database72 7,,ii7 = an item or s]vice furni%$ 9 a subsequ5t ye> 7be=e ! fir/ suffici5t in=mation ye> 7z def9$ 9 clause 7iv77,,ii77 = su* item or s]vice ) respect to su* plan or cov]age71 means ! rate det]m9$ "u subclause 7,i7 or ?is subclause1 z applicable1 = su* item or s]vice = ! ye> previ\s to su* subsequ5t ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>2 7,,iii7 = an item or s]vice furni%$ 9 ! fir/ suffici5t in=mation ye> = su* item or s]vice ) respect to su* plan or cov]age1 has ! mean+ giv5 ! t]m m$ian contract$ rate 9 clause 7i77,i71 except t 9 apply+ su* clause to su* item or s]vice1 ! ref]5ce to furni%$ dur+ #bjbb %all be treat$ z a ref]5ce to furni%$ dur+ su* fir/ suffici5t in=mation ye>1 ! ref]5ce to 9 #bjai %all be treat$ z a ref]5ce to su* suffici5t in=mation ye>1 & ! increase describ$ 9 su* clause %all n be appli$2 & 7,,iv7 = an item or s]vice furni%$ 9 any ye> subsequ5t to ! fir/ suffici5t in=mation ye> = su* item or s]vice ) respect to su* plan or cov]age1 has ! mean+ giv5 su* t]m 9 clause 7i77,,ii71 except t 9 apply+ su* clause to su* item or s]vice1 ! ref]5ce to furni%$ dur+ #bjbc or a subsequ5t ye> %all be treat$ z a ref]5ce to furni%$ dur+ ! ye> aft] su* fir/ suffici5t in=mation ye> or a subsequ5t ye>4 7iv7 ,def9itions ,= purposes ( ?is subp>agraph3 7,i7 ,fir/ cov]age ye> ,! t]m fir/ cov]age ye> means1 ) respect to a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket & an item or s]vice = :i* cov]age is n (f]$ 9 #bjai "u su* plan or cov]age1 ! fir/ ye> aft] #bjai = :i* cov]age = su* item or s]vice is (f]$ "u su* plan or heal? insurance cov]age4 7,,ii7 ,fir/ suffici5t in=mation ye> ,! t]m fir/ suffici5t in=mation ye> means1 ) respect to a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket-- 7aa7 9 ! case ( an item or s]vice = :i* ! plan or cov]age does n h suffici5t in=mation to calculate ! m$ian ( ! contract$ rates describ$ 9 clause 7i77,i7 9 #bjai1 ! fir/ ye> subsequ5t to #bjbb = :i* ! sponsor or issu] has su* suffici5t in=mation to calculate ! m$ian ( su* contract$ rates 9 ! ye> previ\s to su* fir/ subsequ5t ye>2 & 7bb7 9 ! case ( a newly cov]$ item or s]vice1 ! fir/ ye> subsequ5t to ! fir/ cov]age ye> = su* item or s]vice ) respect to su* plan or cov]age = :i* ! sponsor or issu] has suffici5t in=mation to calculate ! m$ian ( ! contract$ rates describ$ 9 clause 7i77,i7 9 ! ye> previ\s to su* fir/ subsequ5t ye>4 7,,iii7 ,newly cov]$ item or s]vice ,! t]m newly cov]$ item or s]vice means1 ) respect to a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket1 an item or s]vice = :i* cov]age 0 n (f]$ 9 #bjai "u su* plan or cov]age1 b is (f]$ "u su* plan or cov]age 9 a ye> aft] #bjai4 7,f7 ,nonp>ticipat+ em]g5cy facility2 p>ticipat+ em]g5cy facility 7i7 ,nonp>ticipat+ em]g5cy facility ,! t]m nonp>ticipat+ em]g5cy facility means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 an em]g5cy dep>tm5t ( a hospital1 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t does n h a contractual relation%ip directly or indirectly ) ! plan or issu]1 respectively1 = furni%+ su* item or s]vice "u ! plan or cov]age1 respectively4 7ii7 ,p>ticipat+ em]g5cy facility ,! t]m p>ticipat+ em]g5cy facility means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 an em]g5cy dep>tm5t ( a hospital1 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t has a contractual relation%ip directly or indirectly ) ! plan or issu]1 respectively1 ) respect to ! furni%+ ( su* an item or s]vice at su* facility4 7,g7 ,nonp>ticipat+ provid]s2 p>ticipat+ provid]s 7i7 ,nonp>ticipat+ provid] ,! t]m nonp>ticipat+ provid] means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 a physician or o!r heal? c>e provid] :o is act+ )9 ! scope ( practice ( t provid]'s lic5se or c]tification "u applicable ,/ate law & :o does n h a contractual relation%ip ) ! plan or issu]1 respectively1 = furni%+ su* item or s]vice "u ! plan or cov]age1 respectively4 7ii7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 a physician or o!r heal? c>e provid] :o is act+ )9 ! scope ( practice ( t provid]'s lic5se or c]tification "u applicable ,/ate law & :o has a contractual relation%ip ) ! plan or issu]1 respectively1 = furni%+ su* item or s]vice "u ! plan or cov]age1 respectively4 7,h7 ,recogniz$ am\nt ,! t]m recogniz$ am\nt means1 ) respect to an item or s]vice furni%$ by a nonp>ticipat+ provid] or em]g5cy facility dur+ a ye> & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket-- 7i7 subject to clause 7iii71 9 ! case ( su* item or s]vice furni%$ 9 a ,/ate t has 9 effect a specifi$ ,/ate law ) respect to su* plan1 cov]age1 or issu]1 respectively1 su* a nonp>ticipat+ provid] or em]g5cy facility1 & su* an item or s]vice1 ! am\nt det]m9$ 9 accordance ) su* law2 7ii7 subject to clause 7iii71 9 ! case ( su* item or s]vice furni%$ 9 a ,/ate t does n h 9 effect a specifi$ ,/ate law1 ) respect to su* plan1 cov]age1 or issu]1 respectively1 su* a nonp>ticipat+ provid] or em]g5cy facility1 & su* an item or s]vice1 an am\nt t is ! m$ian contract$ rate 7z def9$ 9 subp>agraph 7,e77 = su* ye> & det]m9$ 9 accordance ) rulemak+ describ$ 9 p>agraph 7#b77;,b7 = su* item or s]vice2 or 7iii7 9 ! case ( su* item or s]vice furni%$ 9 a ,/ate ) an ,all-,pay] ,model ,agreem5t "u section #aaae;,a ( ! ,social ,security ,act1 ! am\nt t ! ,/ate approves "u su* sy/em = su* item or s]vice s furni%$4 7,i7 ,specifi$ ,/ate law ,! t]m specifi$ ,/ate law means1 ) respect to a ,/ate1 an item or s]vice furni%$ by a nonp>ticipat+ provid] or em]g5cy facility dur+ a ye> & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 a ,/ate law t provides = a me?od = det]m9+ ! am\nt ( paym5t t is requir$ to be cov]$ by su* a plan1 cov]age1 or issu]1 respectively 7to ! ext5t su* ,/ate law applies to su* plan1 cov]age1 or issu]1 subject to section #ead ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd7 9 ! case ( a p>ticipant1 b5efici>y1 or enrollee cov]$ "u su* plan or cov]age & receiv+ su* item or s]vice f su* a nonp>ticipat+ provid] or em]g5cy facility4 7,j7 ,/abilize ,! t]m to /abilize1 ) respect to an em]g5cy m$ical condition 7z def9$ 9 subp>agraph 7,b771 has ! mean+ give 9 section #ahfg7;e77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;dd7e77#c774 2 & 7#b7 by add+ at ! end ! foll[+ new subsections3 7e7 ,cov]age ( non-,em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities 7#a7 ,9 g5]al ,9 ! case ( items or s]vices 7o!r ?an em]g5cy s]vices to :i* subsection 7b7 applies7 = :i* any b5efits are provid$ or cov]$ by a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket furni%$ to a p>ticipant1 b5efici>y1 or enrollee ( su* plan or cov]age by a nonp>ticipat+ provid] 7z def9$ 9 subsection 7b77#c77;,g77i77 7& :o1 ) respect to su* items & s]vices1 has n satisfi$ ! notice & cons5t crit]ia ( section #bgii;,a-#b7;d77 ) respect to a visit 7z def9$ by ! ,secret>y 9 accordance ) p>agraph 7#b77;,b77 at a p>ticipat+ heal? c>e facility 7z def9$ 9 p>agraph 7#b77;,a771 ) respect to su* plan or cov]age1 respectively1 ! plan or cov]age1 respectively-- 7,a7 %all n impose on su* p>ticipant1 b5efici>y1 or enrollee a co/-%>+ am\nt 7express$ z a copaym5t am\nt or co9surance rate7 = su* items & s]vices s furni%$ t is great] ?an ! co/-%>+ am\nt t w\ld apply "u su* plan or cov]age1 respectively1 _h su* items or s]vices be5 furni%$ by a p>ticipat+ provid] 7z def9$ 9 subsection 7b77#c77;,g77ii772 7,b7 %all calculate su* co/-%>+ am\nt z if ! total am\nt t w\ld h be5 *>g$ = su* items & s]vices by su* p>ticipat+ provid] 7 equal to ! recogniz$ am\nt 7z def9$ 9 subsection 7b77#c77;,h77 = su* items & s]vices1 plan or cov]age1 & ye>2 7,c7 %all pay to su* provid] furni%+ su* items & s]vices to su* p>ticipant1 b5efici>y1 or enrollee ! am\nt by :i* ! recogniz$ am\nt 7z def9$ 9 subsection 7b77#c77;,h77 = su* items & s]vices & ye> involv$ exce$s ! co/-%>+ am\nt impos$ "u ! plan or cov]age1 respectively1 = su* items & s]vices 7z det]m9$ 9 accordance ) subp>agraphs 7,a7 & 7,b772 & 7,d7 %all c\nt t[>d any 9-network d$uctible & 9-network out-(-pocket maximums 7z applicable7 appli$ "u ! plan or cov]age1 respectively1 any co/-%>+ paym5ts made by ! p>ticipant1 b5efici>y1 or enrollee 7& su* 9-network d$uctible & out-(-pocket maximums %all be appli$7 ) respect to su* items & s]vices s furni%$ 9 ! same mann] z if su* co/-%>+ paym5ts 7 ) respect to items & s]vices furni%$ by a p>ticipat+ provid]4 7#b7 ,def9itions ,9 ?is section3 7,a7 ,p>ticipat+ heal? c>e facility 7i7 ,9 g5]al ,! t]m p>ticipat+ heal? c>e facility means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket1 a heal? c>e facility describ$ 9 clause 7ii7 t has a contractual relation%ip ) ! plan or issu]1 respectively1 ) respect to ! furni%+ ( su* an item or s]vice at ! facility4 7ii7 ,heal? c>e facility describ$ ,a heal? c>e facility describ$ 9 ?is clause1 ) respect to a gr\p heal? plan or heal? insurance cov]age (f]$ 9 ! gr\p or individual m>ket1 is ea* ( ! foll[+3 7,i7 ,a hospital 7z def9$ 9 #ahfa7;e7 ( ! ,social ,security ,act74 7,,ii7 ,a hospital outpati5t dep>tm5t4 7,,iii7 ,a critical access hospital 7z def9$ 9 section #ahfa7mm7 ( su* ,act74 7,,iv7 ,an ambulatory surgical c5t] 7z def9$ 9 section #ahcc7;i77#a77;,a7 ( su* ,act74 7,v7 ,any o!r facility t provides items or s]vices = :i* cov]age is provid$ "u ! plan or cov]age1 respectively4 7,b7 ,visit ,! t]m visit %all1 ) respect to items & s]vices furni%$ to an individual at a p>ticipat+ heal? c>e facility1 include equipm5t & devices1 telem$ic9e s]vices1 imag+ s]vices1 laboratory s]vices1 & su* o!r items & s]vices z ! ,secret>y may specify1 reg>dless ( :e!r or n ! provid] furni%+ su* items or s]vices is at ! facility4 7f7 ,air ambulance s]vices 7#a7 ,9 g5]al ,9 ! case ( a p>ticipant1 b5efici>y1 or enrollee 9 a gr\p heal? plan or heal? insurance cov]age (f]$ 9 ! gr\p or individual m>ket :o receives air ambulance s]vices f a nonp>ticipat+ provid] 7z def9$ 9 subsection 7b77#c77;,g77 ) respect to su* plan or cov]age1 if su* s]vices w\ld be cov]$ if provid$ by a p>ticipat+ provid] 7z def9$ 9 su* section7 ) respect to su* plan or cov]age-- 7,a7 ! co/-%>+ requirem5t 7express$ z a copaym5t am\nt1 co9surance rate1 or d$uctible7 ) respect to su* s]vices %all be ! same requirem5t t w\ld apply if su* s]vices 7 provid$ by su* a p>ticipat+ provid]1 & any co9surance or d$uctible %all be bas$ on rates t w\ld apply = su* s]vices if !y 7 furni%$ by su* a p>ticipat+ provid]2 7,b7 su* co/-%>+ am\nts %all be c\nt$ t[>d ! 9-network d$uctible & 9-network out-(-pocket maximum am\nt "u ! plan or cov]age = ! plan ye> 7& su* 9-network d$uctible %all be appli$7 ) respect to su* items & s]vices s furni%$ 9 ! same mann] z if su* co/-%>+ paym5ts 7 ) respect to items & s]vices furni%$ by a p>ticipat+ provid]2 & 7,c7 ! plan or cov]age %all pay to su* provid] furni%+ su* s]vices to su* p>ticipant1 b5efici>y1 or enrollee ! am\nt by :i* ! recogniz$ am\nt 7z def9$ 9 & det]m9$ pursuant to subsection 7b77#c77;,h77ii77 = su* s]vices & ye> involv$ exce$s ! co/-%>+ am\nt impos$ "u ! plan or cov]age1 respectively1 = su* s]vices 7z det]m9$ 9 accordance ) subp>agraphs 7,a7 & 7,b774 7#b7 ,air ambulance s]vice def9$ ,= purposes ( ?is section1 ! t]m air ambulance s]vice means m$ical transport by helicopt] or airplane = pati5ts4 7g7 ,c]ta9 access fees to c]ta9 databases ,9 ! case ( a sponsor ( a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket t1 pursuant to subsection 7b77#c77;,e77iii71 uses a database describ$ 9 su* subsection to det]m9e a rate to apply "u su* subsection = an item or s]vice by reason ( hav+ insuffici5t in=mation describ$ 9 su* subsection ) respect to su* item or s]vice1 su* sponsor or issu] %all cov] ! co/ = access to su* database4 4 7b7 ,,erisa am5dm5ts 7#a7 ,9 g5]al ,subp>t ,b ( "p #g ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe et seq47 is am5d$ by add+ at ! end ! foll[+3 #gaf4 ,consum] protections 7a7 ,*oice ( heal? c>e pr(essional ,if a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age requires or provides = designation by a p>ticipant or b5efici>y ( a p>ticipat+ prim>y c>e provid]1 !n ! plan or issu] %all p]mit ea* p>ticipant or b5efici>y to designate any p>ticipat+ prim>y c>e provid] :o is available to accept su* individual4 7b7 ,cov]age ( ,em]g5cy ,s]vices 7#a7 ,9 g5]al ,if a gr\p heal? plan1 or a heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 provides or cov]s any b5efits ) respect to s]vices 9 an em]g5cy dep>tm5t ( a hospital or ) respect to em]g5cy s]vices 9 an indep5d5t free/&+ em]g5cy dep>tm5t 7z def9$ 9 p>agraph 7#c77;,d771 ! plan or issu] %all cov] em]g5cy s]vices 7z def9$ 9 p>agraph 7#c77;,c77-- 7,a7 )\t ! ne$ = any prior au?orization det]m9ation2 7,b7 :e!r ! heal? c>e provid] furni%+ su* s]vices is a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility1 z applicable1 ) respect to su* s]vices2 7,c7 9 a mann] s t1 if su* s]vices are provid$ to a p>ticipant or b5efici>y by a nonp>ticipat+ provid] or a nonp>ticipat+ em]g5cy facility-- 7i7 su* s]vices w be provid$ )\t impos+ any requirem5t "u ! plan = prior au?orization ( s]vices or any limitation on cov]age t is m re/rictive ?an ! requirem5ts or limitations t apply to em]g5cy s]vices receiv$ f p>ticipat+ provid]s & p>ticipat+ em]g5cy facilities ) respect to su* plan or cov]age1 respectively2 7ii7 ! co/-%>+ requirem5t 7express$ z a copaym5t am\nt or co9surance rate7 is n great] ?an ! requirem5t t w\ld apply if su* s]vices 7 provid$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility2 7iii7 su* co/-%>+ requirem5t is calculat$ z if ! total am\nt t w\ld h be5 *>g$ = su* s]vices by su* p>ticipat+ provid] or p>ticipat+ em]g5cy facility 7 equal to ! recogniz$ am\nt 7z def9$ 9 p>agraph 7#c77;,h77 = su* s]vices1 plan or cov]age1 & ye>2 7iv7 ! gr\p heal? plan or heal? insurance issu]1 respectively1 pays to su* provid] or facility1 respectively1 ! am\nt by :i* ! recogniz$ am\nt = su* s]vices & ye> involv$ exce$s ! co/-%>+ am\nt = su* s]vices 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii77 & ye>2 & 7v7 any co/-%>+ paym5ts made by ! p>ticipant or b5efici>y ) respect to su* em]g5cy s]vices s furni%$ %all be c\nt$ t[>d any 9-network d$uctible or out-(-pocket maximums appli$ "u ! plan or cov]age1 respectively 7& su* 9-network d$uctible & out-(-pocket maximums %all be appli$7 9 ! same mann] z if su* co/-%>+ paym5ts 7 made ) respect to em]g5cy s]vices furni%$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility2 & 7,d7 )\t reg>d to any o!r t]m or condition ( su* cov]age 7o!r ?an exclusion or coord9ation ( b5efits1 or an affiliation or wait+ p]iod1 p]mitt$ "u section #bgjd ( ! ,public ,heal? ,s]vice ,act1 includ+ z incorporat$ pursuant to section #gae ( ?is ,act & section #ihae ( ! ,int]nal ,rev5ue ,code ( #aihf1 & o!r ?an applicable co/-%>+74 7#b7 ,audit process & regulations = m$ian contract$ rates 7,a7 ,audit process 7i7 ,9 g5]al ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 consultation ) appropriate ,/ate ag5cies & ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ! ,treasury1 %all e/abli% ?r\gh rulemak+ a process1 9 accordance ) clause 7ii71 "u :i* gr\p heal? plans & heal? insurance issu]s (f]+ heal? insurance cov]age 9 ! gr\p m>ket are audit$ by ! ,secret>y or applicable ,/ate au?ority to ensure t-- 7,i7 su* plans & cov]age are 9 compliance ) ! requirem5t ( apply+ a m$ian contract$ rate "u ?is section2 & 7,,ii7 su* m$ian contract$ rate s appli$ satisfies ! def9ition "u p>agraph 7#c77;,e7 ) respect to ! ye> involv$1 includ+ ) respect to a gr\p heal? plan or heal? insurance issu] describ$ 9 clause 7ii7 ( su* p>agraph 7#c77;,e74 7ii7 ,audit samples ,"u ! process e/abli%$ pursuant to clause 7i71 ! ,secret>y-- 7,i7 %all conduct audits describ$ 9 su* clause1 ) respect to a ye> 7beg9n+ ) #bjbb71 ( a sample ) respect to su* ye> ( claims data f n m ?an #be gr\p heal? plans & heal? insurance issu]s (f]+ heal? insurance cov]age 9 ! gr\p m>ket2 & 7,,ii7 may audit any gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p m>ket if ! ,secret>y has receiv$ any compla9t ab\t su* plan or cov]age1 respectively1 t involves ! compliance ( ! plan or cov]age1 respectively1 ) ei!r ( ! requirem5ts describ$ 9 subclauses 7,i7 & 7,,ii7 ( su* clause4 7iii7 ,reports ,beg9n+ = #bjbb1 ! ,secret>y %all annually submit to ,congress in=mation on ! numb] ( plans & issu]s ) respect to :i* audits 7 conduct$ dur+ su* ye> pursuant to ?is subp>agraph4 7,b7 ,rulemak+ ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 consultation ) ! ,secret>y ( ! ,treasury & ! ,secret>y ( ,heal? & ,human ,s]vices1 %all e/abli% ?r\gh rulemak+-- 7i7 ! me?odology ! gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p m>ket %all use to det]m9e ! m$ian contract$ rate1 diff]5tiat+ by l9e ( bus9ess2 7ii7 ! in=mation su* plan or issu]1 respectively1 %all %>e ) ! nonp>ticipat+ provid] or nonp>ticipat+ facility1 z applicable1 :5 mak+ su* a det]m9ation2 7iii7 ! geographic regions appli$ = purposes ( ?is subp>agraph1 tak+ into acc\nt access to items & s]vices 9 rural & und]s]v$ areas1 includ+ heal? pr(essional %ortage areas1 z def9$ 9 section #ccb ( ! ,public ,heal? ,s]vice ,act2 & 7iv7 a process to receive compla9ts ( violations ( ! requirem5ts describ$ 9 subclauses 7,i7 & 7,,ii7 ( p>agraph 7#b77;,a77i7 by gr\p heal? plans & heal? insurance issu]s (f]+ heal? insurance cov]age 9 ! gr\p m>ket4 ,su* rulemak+ %all take into acc\nt paym5ts t are made by su* plan or issu]1 respectively1 t are n on a fee-=-s]vice basis4 ,su* me?odology may acc\nt = relevant paym5t adju/m5ts t take into acc\nt quality or facility type 7includ+ high] acuity sett+s & ! case-mix ( v>i\s facility types7 t are o!rwise tak5 into acc\nt = purposes ( det]m9+ paym5t am\nts ) respect to p>ticipat+ facilities4 ,9 c>ry+ out clause 7iii71 ! ,secret>y %all consult ) ! ,national ,association ( ,insurance ,commission]s to e/abli% ! geographic regions "u su* clause & %all p]iodically update su* regions1 z appropriate4 7#c7 ,def9itions ,9 ?is section3 7,a7 ,em]g5cy dep>tm5t ( a hospital ,! t]m em]g5cy dep>tm5t ( a hospital includes a hospital outpati5t dep>tm5t t provides em]g5cy s]vices4 7,b7 ,em]g5cy m$ical condition ,! t]m em]g5cy m$ical condition means a m$ical condition manife/+ itself by acute symptoms ( suffici5t sev]ity 7includ+ sev]e pa97 su* t a prud5t layp]son1 :o possesses an av]age k ( heal? & m$ic9e1 c\ld reasonably expect ! abs5ce ( imm$iate m$ical att5tion to result 9 a condition describ$ 9 clause 7i71 7ii71 or 7iii7 ( section #ahfg7;e77#a77;,a7 ( ! ,social ,security ,act4 7,c7 ,em]g5cy s]vices 7i7 ,9 g5]al ,! t]m em]g5cy s]vices1 ) respect to an em]g5cy m$ical condition1 means-- 7,i7 a m$ical scre5+ exam9ation 7z requir$ "u section #ahfg ( ! ,social ,security ,act1 or z w\ld be requir$ "u su* section if su* section appli$ to an indep5d5t free/&+ em]g5cy dep>tm5t7 t is )9 ! capability ( ! em]g5cy dep>tm5t ( a hospital or ( an indep5d5t free/&+ em]g5cy dep>tm5t1 z applicable1 includ+ ancill>y s]vices r\t9ely available to ! em]g5cy dep>tm5t to evaluate su* em]g5cy m$ical condition2 & 7,,ii7 )9 ! capabilities ( ! /aff & facilities available at ! hospital or ! indep5d5t free/&+ em]g5cy dep>tm5t1 z applicable1 su* fur!r m$ical exam9ation & treatm5t z are requir$ "u section #ahfg ( su* ,act1 or z w\ld be requir$ "u su* section if su* section appli$ to an indep5d5t free/&+ em]g5cy dep>tm5t1 to /abilize ! pati5t4 7ii7 ,inclusion ( c]ta9 s]vices outside ( em]g5cy dep>tm5t 7,i7 ,9 g5]al ,= purposes ( ?is subsection & section #bgii;,a-#a1 9 ! case ( an individual enroll$ 9 a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket :o is furni%$ s]vices describ$ 9 clause 7i7 by a p>ticipat+ or nonp>ticipat+ provid] or a p>ticipat+ or nonp>ticipat+ em]g5cy facility to /abilize su* individual ) respect to an em]g5cy m$ical condition1 ! t]m em]g5cy s]vices %all include1 unless ea* ( ! conditions describ$ 9 subclause 7,,ii7 are met1 9 addition to ! items & s]vices describ$ 9 clause 7i71 items & s]vices = :i* b5efits are provid$ or cov]$ "u ! plan or cov]age1 respectively1 furni%$ by a nonp>ticipat+ provid] or nonp>ticipat+ facility1 reg>dless ( ! dep>tm5t ( ! hospital 9 :i* su* individual is furni%$ su* items or s]vices1 if1 aft] su* /abilization b dur+ su* visit 9 :i* su* individual is s /abiliz$1 ! provid] or facility det]m9es t su* items or s]vices are ne$$4 7,,ii7 ,conditions ,= purposes ( subclause 7,i71 ! conditions describ$ 9 ?is subclause1 ) respect to an individual :o is /abiliz$ & furni%$ additional items & s]vices describ$ 9 subclause 7,i7 aft] su* /abilization by a provid] or facility describ$ 9 subclause 7,i71 are ! foll[+3 7aa7 ,su* a provid] or facility det]m9es su* individual is able to travel us+ nonm$ical transportation or nonem]g5cy m$ical transportation4 7bb7 ,su* provid] furni%+ su* additional items & s]vices satisfies ! notice & cons5t crit]ia ( section #bgii;,a-#b7;d7 ( ! ,public ,heal? ,s]vice ,act ) respect to su* items & s]vices4 7cc7 ,su* an individual is 9 a condition to receive 7z det]m9$ 9 accordance ) guidance issu$ by ! ,secret>y7 ! in=mation describ$ 9 section #bgii;,a-#b ( ! ,public ,heal? ,s]vice ,act & to provide in=m$ cons5t "u su* section1 9 accordance ) applicable ,/ate law4 7,d7 ,indep5d5t free/&+ em]g5cy dep>tm5t ,! t]m indep5d5t free/&+ em]g5cy dep>tm5t means a facility t-- 7i7 is geographically sep>ate & di/9ct & lic5s$ sep>ately f a hospital "u applicable ,/ate law2 & 7ii7 provides any em]g5cy s]vices 7z def9$ 9 subp>agraph 7,c774 7,e7 ,m$ian contract$ rate 7i7 ,9 g5]al ,! t]m m$ian contract$ rate means1 subject to clauses 7ii7 & 7iii71 ) respect to a sponsor ( a gr\p heal? plan & heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p m>ket-- 7,i7 = an item or s]vice furni%$ dur+ #bjbb1 ! m$ian ( ! contract$ rates recogniz$ by ! plan or issu]1 respectively 7det]m9$ ) respect to all su* plans ( su* sponsor or all su* cov]age (f]$ by su* issu] t are (f]$ )9 ! same l9e ( bus9ess z ! plan or cov]age7 z ! total maximum paym5t 7includ+ ! co/-%>+ am\nt impos$ = su* item or s]vice & ! am\nt to be paid by su* plan or su* issu]1 respectively7 "u su* plans or cov]age1 respectively1 on ,janu>y #ca1 #bjai1 = ! same or a simil> item or s]vice t is provid$ by a provid] 9 ! same or simil> specialty & provid$ 9 ! geographic region 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u p>agraph 7#b77;,b71 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] #bjai1 su* p]c5tage increase ov] #bjbj1 & su* p]c5tage increase ov] #bjba2 & 7,,ii7 = an item or s]vice furni%$ dur+ #bjbc or a subsequ5t ye>1 ! m$ian contract$ rate det]m9$ "u ?is clause = su* an item or s]vice furni%$ 9 ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 7ii7 ,new plans & cov]age ,! t]m m$ian contract$ rate means1 ) respect to a sponsor ( a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p m>ket 9 a geographic region 9 :i* su* sponsor or issu]1 respectively1 did n (f] any gr\p heal? plan or heal? insurance cov]age dur+ #bjai-- 7,i7 = ! fir/ ye> 9 :i* su* gr\p heal? plan or heal? insurance cov]age1 respectively1 is (f]$ 9 su* region1 a rate 7det]m9$ 9 accordance ) a me?odology e/abli%$ by ! ,secret>y7 = items & s]vices t are cov]$ by su* plan & furni%$ dur+ su* fir/ ye>2 & 7,,ii7 = ea* subsequ5t ye> su* gr\p heal? plan or heal? insurance cov]age1 respectively1 is (f]$ 9 su* region1 ! m$ian contract$ rate det]m9$ "u ?is clause = su* items & s]vices furni%$ 9 ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 7iii7 ,insuffici5t in=mation2 newly cov]$ items & s]vices ,9 ! case ( a sponsor ( a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p m>ket t does n h suffici5t in=mation to calculate ! m$ian ( ! contract$ rates describ$ 9 clause 7i77,i7 9 #bjai 7or1 9 ! case ( a newly cov]$ item or s]vice 7z def9$ 9 clause 7iv77,,iii771 9 ! fir/ cov]age ye> 7z def9$ 9 clause 7iv77,i77 = su* item or s]vice ) respect to su* plan or cov]age7 = an item or s]vice 7includ+ ) respect to provid] type1 or am\nt1 ( claims = items or s]vices 7z det]m9$ by ! ,secret>y7 provid$ 9 a p>ticul> geographic region 7o!r ?an 9 a case ) respect to :i* clause 7ii7 applies77 ! t]m m$ian contract$ rate-- 7,i7 = an item or s]vice furni%$ dur+ #bjbb 7or1 9 ! case ( a newly cov]$ item or s]vice1 dur+ ! fir/ cov]age ye> = su* item or s]vice ) respect to su* plan or cov]age71 means su* rate = su* item or s]vice det]m9$ by ! sponsor or issu]1 respectively1 ?r\gh use ( any database t is det]m9$1 9 accordance ) rulemak+ describ$ 9 p>agraph 7#b77;,b71 to n h any conflicts ( int]e/ & to h suffici5t in=mation reflect+ all[$ am\nts paid to a heal? c>e provid] or facility = relevant s]vices furni%$ 9 ! applicable geographic region 7su* z a ,/ate all-pay] claims database72 7,,ii7 = an item or s]vice furni%$ 9 a subsequ5t ye> 7be=e ! fir/ suffici5t in=mation ye> 7z def9$ 9 clause 7iv77,,ii77 = su* item or s]vice ) respect to su* plan or cov]age71 means ! rate det]m9$ "u subclause 7,i7 or ?is subclause1 z applicable1 = su* item or s]vice = ! ye> previ\s to su* subsequ5t ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>2 7,,iii7 = an item or s]vice furni%$ 9 ! fir/ suffici5t in=mation ye> = su* item or s]vice ) respect to su* plan or cov]age1 has ! mean+ giv5 ! t]m m$ian contract$ rate 9 clause 7i77,i71 except t 9 apply+ su* clause to su* item or s]vice1 ! ref]5ce to furni%$ dur+ #bjbb %all be treat$ z a ref]5ce to furni%$ dur+ su* fir/ suffici5t in=mation ye>1 ! ref]5ce to 9 #bjai %all be treat$ z a ref]5ce to su* suffici5t in=mation ye>1 & ! increase describ$ 9 su* clause %all n be appli$2 & 7,,iv7 = an item or s]vice furni%$ 9 any ye> subsequ5t to ! fir/ suffici5t in=mation ye> = su* item or s]vice ) respect to su* plan or cov]age1 has ! mean+ giv5 su* t]m 9 clause 7i77,,ii71 except t 9 apply+ su* clause to su* item or s]vice1 ! ref]5ce to furni%$ dur+ #bjbc or a subsequ5t ye> %all be treat$ z a ref]5ce to furni%$ dur+ ! ye> aft] su* fir/ suffici5t in=mation ye> or a subsequ5t ye>4 7iv7 ,def9itions ,= purposes ( ?is subp>agraph3 7,i7 ,fir/ cov]age ye> ,! t]m fir/ cov]age ye> means1 ) respect to a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p m>ket & an item or s]vice = :i* cov]age is n (f]$ 9 #bjai "u su* plan or cov]age1 ! fir/ ye> aft] #bjai = :i* cov]age = su* item or s]vice is (f]$ "u su* plan or heal? insurance cov]age4 7,,ii7 ,fir/ suffici5t in=mation ye> ,! t]m fir/ suffici5t in=mation ye> means1 ) respect to a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p m>ket-- 7aa7 9 ! case ( an item or s]vice = :i* ! plan or cov]age does n h suffici5t in=mation to calculate ! m$ian ( ! contract$ rates describ$ 9 clause 7i77,i7 9 #bjai1 ! fir/ ye> subsequ5t to #bjbb = :i* su* sponsor or issu] has su* suffici5t in=mation to calculate ! m$ian ( su* contract$ rates 9 ! ye> previ\s to su* fir/ subsequ5t ye>2 & 7bb7 9 ! case ( a newly cov]$ item or s]vice1 ! fir/ ye> subsequ5t to ! fir/ cov]age ye> = su* item or s]vice ) respect to su* plan or cov]age = :i* ! sponsor or issu] has suffici5t in=mation to calculate ! m$ian ( ! contract$ rates describ$ 9 clause 7i77,i7 9 ! ye> previ\s to su* fir/ subsequ5t ye>4 7,,iii7 ,newly cov]$ item or s]vice ,! t]m newly cov]$ item or s]vice means1 ) respect to a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p m>ket1 an item or s]vice = :i* cov]age 0 n (f]$ 9 #bjai "u su* plan or cov]age1 b is (f]$ "u su* plan or cov]age 9 a ye> aft] #bjai4 7,f7 ,nonp>ticipat+ em]g5cy facility2 p>ticipat+ em]g5cy facility 7i7 ,nonp>ticipat+ em]g5cy facility ,! t]m nonp>ticipat+ em]g5cy facility means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p m>ket1 an em]g5cy dep>tm5t ( a hospital1 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t does n h a contractual relation%ip directly or indirectly ) ! plan or issu]1 respectively1 = furni%+ su* item or s]vice "u ! plan or cov]age1 respectively4 7ii7 ,p>ticipat+ em]g5cy facility ,! t]m p>ticipat+ em]g5cy facility means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p m>ket1 an em]g5cy dep>tm5t ( a hospital1 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t has a contractual relation%ip directly or indirectly ) ! plan or issu]1 respectively1 ) respect to ! furni%+ ( su* an item or s]vice at su* facility4 7,g7 ,nonp>ticipat+ provid]s2 p>ticipat+ provid]s 7i7 ,nonp>ticipat+ provid] ,! t]m nonp>ticipat+ provid] means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p m>ket1 a physician or o!r heal? c>e provid] :o is act+ )9 ! scope ( practice ( t provid]'s lic5se or c]tification "u applicable ,/ate law & :o does n h a contractual relation%ip ) ! plan or issu]1 respectively1 = furni%+ su* item or s]vice "u ! plan or cov]age1 respectively4 7ii7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p m>ket1 a physician or o!r heal? c>e provid] :o is act+ )9 ! scope ( practice ( t provid]'s lic5se or c]tification "u applicable ,/ate law & :o has a contractual relation%ip ) ! plan or issu]1 respectively1 = furni%+ su* item or s]vice "u ! plan or cov]age1 respectively4 7,h7 ,recogniz$ am\nt ,! t]m recogniz$ am\nt means1 ) respect to an item or s]vice furni%$ by a nonp>ticipat+ provid] or em]g5cy facility dur+ a ye> & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p m>ket-- 7i7 subject to clause 7iii71 9 ! case ( su* item or s]vice furni%$ 9 a ,/ate t has 9 effect a specifi$ ,/ate law ) respect to su* plan1 cov]age1 or issu]1 respectively1 su* a nonp>ticipat+ provid] or em]g5cy facility1 & su* an item or s]vice1 ! am\nt det]m9$ 9 accordance ) su* law2 7ii7 subject to clause 7iii71 9 ! case ( su* item or s]vice furni%$ 9 a ,/ate t does n h 9 effect a specifi$ ,/ate law1 ) respect to su* plan1 cov]age1 or issu]1 respectively1 su* a nonp>ticipat+ provid] or em]g5cy facility1 & su* an item or s]vice1 an am\nt t is ! m$ian contract$ rate 7z def9$ 9 subp>agraph 7,e77 = su* ye> & det]m9$ 9 accordance ) rulemak+ describ$ 9 p>agraph 7#b77;,b7 = su* item or s]vice2 or 7iii7 9 ! case ( su* item or s]vice furni%$ 9 a ,/ate ) an ,all-,pay] ,model ,agreem5t "u section #aaae;,a ( ! ,social ,security ,act1 ! am\nt t ! ,/ate approves "u su* sy/em = su* item or s]vice s furni%$4 7,i7 ,specifi$ ,/ate law ,! t]m specifi$ ,/ate law means1 ) respect to a ,/ate1 an item or s]vice furni%$ by a nonp>ticipat+ provid] or em]g5cy facility dur+ a ye> & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p m>ket1 a ,/ate law t provides = a me?od = det]m9+ ! am\nt ( paym5t t is requir$ to be cov]$ by su* a plan1 cov]age1 or issu]1 respectively 7to ! ext5t su* ,/ate law applies to su* plan1 cov]age1 or issu]1 subject to section #ead7 9 ! case ( a p>ticipant or b5efici>y cov]$ "u su* plan or cov]age & receiv+ su* item or s]vice f su* a nonp>ticipat+ provid] or em]g5cy facility4 7,j7 ,/abilize ,! t]m to /abilize1 ) respect to an em]g5cy m$ical condition 7z def9$ 9 subp>agraph 7,b771 has ! mean+ give 9 section #ahfg7;e77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;dd7e77#c774 7c7 ,access to p$iatric c>e 7#a7 ,p$iatric c>e ,9 ! case ( a p]son :o has a *ild :o is a p>ticipant or b5efici>y "u a gr\p heal? plan1 or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p m>ket1 if ! plan or issu] requires or provides = ! designation ( a p>ticipat+ prim>y c>e provid] = ! *ild1 ! plan or issu] %all p]mit su* p]son to designate a physician 7allopa?ic or o/eopa?ic7 :o specializes 9 p$iatrics z ! *ild's prim>y c>e provid] if su* provid] p>ticipates 9 ! network ( ! plan or issu]4 7#b7 ,con/ruction ,no?+ 9 p>agraph 7#a7 %all be con/ru$ to waive any exclusions ( cov]age "u ! t]ms & conditions ( ! plan or heal? insurance cov]age ) respect to cov]age ( p$iatric c>e4 7d7 ,pati5t access to ob/etrical & gynecological c>e 7#a7 ,g5]al rights 7,a7 ,direct access ,a gr\p heal? plan1 or heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 describ$ 9 p>agraph 7#b7 may n require au?orization or ref]ral by ! plan1 issu]1 or any p]son 7includ+ a prim>y c>e provid] describ$ 9 p>agraph 7#b77;,b77 9 ! case ( a female p>ticipant or b5efici>y :o seeks cov]age = ob/etrical or gynecological c>e provid$ by a p>ticipat+ heal? c>e pr(essional :o specializes 9 ob/etrics or gynecology4 ,su* pr(essional %all agree to o!rwise adh]e to su* plan's or issu]'s policies & proc$ures1 includ+ proc$ures reg>d+ ref]rals & obta9+ prior au?orization & provid+ s]vices pursuant to a treatm5t plan 7if any7 approv$ by ! plan or issu]4 7,b7 ,ob/etrical & gynecological c>e ,a gr\p heal? plan or heal? insurance issu] describ$ 9 p>agraph 7#b7 %all treat ! provision ( ob/etrical & gynecological c>e1 & ! ord]+ ( relat$ ob/etrical & gynecological items & s]vices1 pursuant to ! direct access describ$ "u subp>agraph 7,a71 by a p>ticipat+ heal? c>e pr(essional :o specializes 9 ob/etrics or gynecology z ! au?orization ( ! prim>y c>e provid]4 7#b7 ,application ( p>agraph ,a gr\p heal? plan1 or heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 describ$ 9 ?is p>agraph is a gr\p heal? plan or cov]age t-- 7,a7 provides cov]age = ob/etric or gynecologic c>e2 & 7,b7 requires ! designation by a p>ticipant or b5efici>y ( a p>ticipat+ prim>y c>e provid]4 7#c7 ,con/ruction ,no?+ 9 p>agraph 7#a7 %all be con/ru$ to-- 7,a7 waive any exclusions ( cov]age "u ! t]ms & conditions ( ! plan or heal? insurance cov]age ) respect to cov]age ( ob/etrical or gynecological c>e2 or 7,b7 preclude ! gr\p heal? plan or heal? insurance issu] involv$ f requir+ t ! ob/etrical or gynecological provid] notify ! prim>y c>e heal? c>e pr(essional or ! plan or issu] ( treatm5t decisions4 7e7 ,cov]age ( non-,em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities 7#a7 ,9 g5]al ,9 ! case ( items or s]vices 7o!r ?an em]g5cy s]vices to :i* subsection 7b7 applies7 = :i* any b5efits are provid$ or cov]$ by a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p m>ket furni%$ to a p>ticipant or b5efici>y ( su* plan or cov]age by a nonp>ticipat+ provid] 7z def9$ 9 subsection 7b77#c77;,g77i77 7& :o1 ) respect to su* items & s]vices1 has n satisfi$ ! notice & cons5t crit]ia ( section #bgii;,a-#b7;d7 ( ! ,public ,heal? ,s]vice ,act7 ) respect to a visit 7z def9$ by ! ,secret>y 9 accordance ) p>agraph 7#b77;,b77 at a p>ticipat+ heal? c>e facility 7z def9$ 9 p>agraph 7#b77;,a771 ) respect to su* plan or cov]age1 respectively1 ! plan or cov]age1 respectively-- 7,a7 %all n impose on su* p>ticipant or b5efici>y a co/-%>+ am\nt 7express$ z a copaym5t am\nt or co9surance rate7 = su* items & s]vices s furni%$ t is great] ?an ! co/-%>+ am\nt t w\ld apply "u su* plan or cov]age1 respectively1 _h su* items or s]vices be5 furni%$ by a p>ticipat+ provid] 7z def9$ 9 subsection 7b77#c77;,g77ii772 7,b7 %all calculate su* co/-%>+ am\nt z if ! total am\nt t w\ld h be5 *>g$ = su* items & s]vices by su* p>ticipat+ provid] 7 equal to ! recogniz$ am\nt 7z def9$ 9 subsection 7b77#c77;,h77 = su* items & s]vices1 plan or cov]age1 & ye>2 7,c7 %all pay to su* provid] furni%+ su* items & s]vices to su* p>ticipant or b5efici>y ! am\nt by :i* ! recogniz$ am\nt 7z def9$ 9 subsection 7b77#c77;,h77 = su* items & s]vices & ye> involv$ exce$s ! co/-%>+ am\nt impos$ "u ! plan or cov]age1 respectively1 = su* items & s]vices 7z det]m9$ 9 accordance ) subp>agraphs 7,a7 & 7,b772 & 7,d7 %all c\nt t[>d any 9-network d$uctible & 9-network out-(-pocket maximums 7z applicable7 appli$ "u ! plan or cov]age1 respectively1 any co/-%>+ paym5ts made by ! p>ticipant or b5efici>y 7& su* 9-network d$uctible & out-(-pocket maximums %all be appli$7 ) respect to su* items & s]vices s furni%$ 9 ! same mann] z if su* co/-%>+ paym5ts 7 ) respect to items & s]vices furni%$ by a p>ticipat+ provid]4 7#b7 ,def9itions ,9 ?is section3 7,a7 ,p>ticipat+ heal? c>e facility 7i7 ,9 g5]al ,! t]m p>ticipat+ heal? c>e facility means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p m>ket1 a heal? c>e facility describ$ 9 clause 7ii7 t has a contractual relation%ip ) ! plan or issu]1 respectively1 ) respect to ! furni%+ ( su* an item or s]vice at ! facility4 7ii7 ,heal? c>e facility describ$ ,a heal? c>e facility describ$ 9 ?is clause1 ) respect to a gr\p heal? plan or heal? insurance cov]age (f]$ 9 ! gr\p m>ket1 is ea* ( ! foll[+3 7,i7 ,a hospital 7z def9$ 9 #ahfa7;e7 ( ! ,social ,security ,act74 7,,ii7 ,a hospital outpati5t dep>tm5t4 7,,iii7 ,a critical access hospital 7z def9$ 9 section #ahfa7mm7 ( su* ,act74 7,,iv7 ,an ambulatory surgical c5t] 7z def9$ 9 section #ahcc7;i77#a77;,a7 ( su* ,act74 7,v7 ,any o!r facility t provides items or s]vices = :i* cov]age is provid$ "u ! plan or cov]age1 respectively4 7,b7 ,visit ,! t]m visit %all1 ) respect to items & s]vices furni%$ to an individual at a p>ticipat+ heal? c>e facility1 include equipm5t & devices1 telem$ic9e s]vices1 imag+ s]vices1 laboratory s]vices1 & su* o!r items & s]vices z ! ,secret>y may specify1 reg>dless ( :e!r or n ! provid] furni%+ su* items or s]vices is at ! facility4 7f7 ,air ambulance s]vices 7#a7 ,9 g5]al ,9 ! case ( a p>ticipant or b5efici>y 9 a gr\p heal? plan or heal? insurance cov]age (f]$ 9 ! gr\p m>ket :o receives air ambulance s]vices f a nonp>ticipat+ provid] 7z def9$ 9 subsection 7b77#c77;,g77 ) respect to su* plan or cov]age1 if su* s]vices w\ld be cov]$ if provid$ by a p>ticipat+ provid] 7z def9$ 9 su* subsection7 ) respect to su* plan or cov]age-- 7,a7 ! co/-%>+ requirem5t 7express$ z a copaym5t am\nt1 co9surance rate1 or d$uctible7 ) respect to su* s]vices %all be ! same requirem5t t w\ld apply if su* s]vices 7 provid$ by su* a p>ticipat+ provid]1 & any co9surance or d$uctible %all be bas$ on rates t w\ld apply = su* s]vices if !y 7 furni%$ by su* a p>ticipat+ provid]2 7,b7 su* co/-%>+ am\nts %all be c\nt$ t[>d ! 9-network d$uctible & 9-network out-(-pocket maximum am\nt "u ! plan or cov]age = ! plan ye> 7& su* 9-network d$uctible %all be appli$7 ) respect to su* items & s]vices s furni%$ 9 ! same mann] z if su* co/-%>+ paym5ts 7 ) respect to items & s]vices furni%$ by a p>ticipat+ provid]2 & 7,c7 ! plan or cov]age %all pay to su* provid] furni%+ su* s]vices to su* p>ticipant or b5efici>y ! am\nt by :i* ! recogniz$ am\nt 7z def9$ 9 & det]m9$ pursuant to subsection 7b77#c77;,h77ii77 = su* s]vices & ye> involv$ exce$s ! co/-%>+ am\nt impos$ "u ! plan or cov]age1 respectively1 = su* s]vices 7z det]m9$ 9 accordance ) subp>agraphs 7,a7 & 7,b774 7#b7 ,air ambulance s]vice def9$ ,= purposes ( ?is section1 ! t]m air ambulance s]vice means m$ical transport by helicopt] or airplane = pati5ts4 7g7 ,c]ta9 access fees to c]ta9 databases ,9 ! case ( a sponsor ( a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p m>ket t1 pursuant to subsection 7b77#c77;,e77iii71 uses a database describ$ 9 su* subsection to det]m9e a rate to apply "u su* subsection = an item or s]vice by reason ( hav+ insuffici5t in=mation describ$ 9 su* subsection ) respect to su* item or s]vice1 su* sponsor or issu] %all cov] ! co/ = access to su* database4 4 7#b7 ,cl]ical am5dm5t ,! table ( cont5ts ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by ins]t+ aft] ! item relat+ to section #gad ! foll[+3 ,sec4 #gae4 ,additional m>ket re=ms4 ,sec4 #gaf4 ,consum] protections4 4 7c7 ,,irc am5dm5ts 7#a7 ,9 g5]al ,sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+3 #ihaf4 ,consum] protections 7a7 ,*oice ( heal? c>e pr(essional ,if a gr\p heal? plan requires or provides = designation by a p>ticipant or b5efici>y ( a p>ticipat+ prim>y c>e provid]1 !n ! plan %all p]mit ea* p>ticipant or b5efici>y to designate any p>ticipat+ prim>y c>e provid] :o is available to accept su* individual4 7b7 ,cov]age ( ,em]g5cy ,s]vices 7#a7 ,9 g5]al ,if a gr\p heal? plan provides or cov]s any b5efits ) respect to s]vices 9 an em]g5cy dep>tm5t ( a hospital or ) respect to em]g5cy s]vices 9 an indep5d5t free/&+ em]g5cy dep>tm5t 7z def9$ 9 p>agraph 7#c77;,d771 ! plan %all cov] em]g5cy s]vices 7z def9$ 9 p>agraph 7#c77;,c77-- 7,a7 )\t ! ne$ = any prior au?orization det]m9ation2 7,b7 :e!r ! heal? c>e provid] furni%+ su* s]vices is a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility1 z applicable1 ) respect to su* s]vices2 7,c7 9 a mann] s t1 if su* s]vices are provid$ to a p>ticipant or b5efici>y by a nonp>ticipat+ provid] or a nonp>ticipat+ em]g5cy facility-- 7i7 su* s]vices w be provid$ )\t impos+ any requirem5t "u ! plan = prior au?orization ( s]vices or any limitation on cov]age t is m re/rictive ?an ! requirem5ts or limitations t apply to em]g5cy s]vices receiv$ f p>ticipat+ provid]s & p>ticipat+ em]g5cy facilities ) respect to su* plan2 7ii7 ! co/-%>+ requirem5t 7express$ z a copaym5t am\nt or co9surance rate7 is n great] ?an ! requirem5t t w\ld apply if su* s]vices 7 provid$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility2 7iii7 su* co/-%>+ requirem5t is calculat$ z if ! total am\nt t w\ld h be5 *>g$ = su* s]vices by su* p>ticipat+ provid] or p>ticipat+ em]g5cy facility 7 equal to ! recogniz$ am\nt 7z def9$ 9 p>agraph 7#c77;,h77 = su* s]vices1 plan1 & ye>2 7iv7 ! gr\p heal? plan pays to su* provid] or facility1 respectively1 ! am\nt by :i* ! recogniz$ am\nt = su* s]vices & ye> involv$ exce$s ! co/-%>+ am\nt = su* s]vices 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii77 & ye>2 & 7v7 any co/-%>+ paym5ts made by ! p>ticipant or b5efici>y ) respect to su* em]g5cy s]vices s furni%$ %all be c\nt$ t[>d any 9-network d$uctible or out-(-pocket maximums appli$ "u ! plan 7& su* 9-network d$uctible & out-(-pocket maximums %all be appli$7 9 ! same mann] z if su* co/-%>+ paym5ts 7 made ) respect to em]g5cy s]vices furni%$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility2 & 7,d7 )\t reg>d to any o!r t]m or condition ( su* cov]age 7o!r ?an exclusion or coord9ation ( b5efits1 or an affiliation or wait+ p]iod1 p]mitt$ "u section #bgjd ( ?is ,act1 includ+ z incorporat$ pursuant to section #gae ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd & section #ihae ( ?is ,act1 & o!r ?an applicable co/-%>+74 7#b7 ,audit process & regulations = m$ian contract$ rates 7,a7 ,audit process 7i7 ,9 g5]al ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 consultation ) appropriate ,/ate ag5cies & ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ,labor1 %all e/abli% ?r\gh rulemak+ a process1 9 accordance ) clause 7ii71 "u :i* gr\p heal? plans are audit$ by ! ,secret>y or applicable ,/ate au?ority to ensure t-- 7,i7 su* plans are 9 compliance ) ! requirem5t ( apply+ a m$ian contract$ rate "u ?is section2 & 7,,ii7 su* m$ian contract$ rate s appli$ satisfies ! def9ition "u p>agraph 7#c77;,e7 ) respect to ! ye> involv$1 includ+ ) respect to a gr\p heal? plan describ$ 9 clause 7ii7 ( su* p>agraph 7#c77;,e74 7ii7 ,audit samples ,"u ! process e/abli%$ pursuant to clause 7i71 ! ,secret>y-- 7,i7 %all conduct audits describ$ 9 su* clause1 ) respect to a ye> 7beg9n+ ) #bjbb71 ( a sample ) respect to su* ye> ( claims data f n m ?an #be gr\p heal? plans2 & 7,,ii7 may audit any gr\p heal? plan if ! ,secret>y has receiv$ any compla9t ab\t su* plan or cov]age1 respectively1 t involves ! compliance ( ! plan ) ei!r ( ! requirem5ts describ$ 9 subclauses 7,i7 & 7,,ii7 ( su* clause4 7iii7 ,reports ,beg9n+ = #bjbb1 ! ,secret>y %all annually submit to ,congress a report on ! numb] ( plans & issu]s ) respect to :i* audits 7 conduct$ dur+ su* ye> pursuant to ?is subp>agraph4 7,b7 ,rulemak+ ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 consultation ) ! ,secret>y ( ,labor & ! ,secret>y ( ,heal? & ,human ,s]vices1 %all e/abli% ?r\gh rulemak+-- 7i7 ! me?odology ! gr\p heal? plan %all use to det]m9e ! m$ian contract$ rate1 diff]5tiat+ by l9e ( bus9ess2 7ii7 ! in=mation su* plan or issu]1 respectively1 %all %>e ) ! nonp>ticipat+ provid] or nonp>ticipat+ facility1 z applicable1 :5 mak+ su* a det]m9ation2 7iii7 ! geographic regions appli$ = purposes ( ?is subp>agraph1 tak+ into acc\nt access to items & s]vices 9 rural & und]s]v$ areas1 includ+ heal? pr(essional %ortage areas1 z def9$ 9 section #ccb ( ! ,public ,heal? ,s]vice ,act2 & 7iv7 a process to receive compla9ts ( violations ( ! requirem5ts describ$ 9 subclauses 7,i7 & 7,,ii7 ( p>agraph 7#b77;,a77i7 by gr\p heal? plans4 ,su* rulemak+ %all take into acc\nt paym5ts t are made by su* plan t are n on a fee-=-s]vice basis4 ,su* me?odology may acc\nt = relevant paym5t adju/m5ts t take into acc\nt quality or facility type 7includ+ high] acuity sett+s & ! case-mix ( v>i\s facility types7 t are o!rwise tak5 into acc\nt = purposes ( det]m9+ paym5t am\nts ) respect to p>ticipat+ facilities4 ,9 c>ry+ out clause 7iii71 ! ,secret>y %all consult ) ! ,national ,association ( ,insurance ,commission]s to e/abli% ! geographic regions "u su* clause & %all p]iodically update su* regions1 z appropriate4 7#c7 ,def9itions ,9 ?is section3 7,a7 ,em]g5cy dep>tm5t ( a hospital ,! t]m em]g5cy dep>tm5t ( a hospital includes a hospital outpati5t dep>tm5t t provides em]g5cy s]vices4 7,b7 ,em]g5cy m$ical condition ,! t]m em]g5cy m$ical condition means a m$ical condition manife/+ itself by acute symptoms ( suffici5t sev]ity 7includ+ sev]e pa97 su* t a prud5t layp]son1 :o possesses an av]age k ( heal? & m$ic9e1 c\ld reasonably expect ! abs5ce ( imm$iate m$ical att5tion to result 9 a condition describ$ 9 clause 7i71 7ii71 or 7iii7 ( section #ahfg7;e77#a77;,a7 ( ! ,social ,security ,act4 7,c7 ,em]g5cy s]vices 7i7 ,9 g5]al ,! t]m em]g5cy s]vices1 ) respect to an em]g5cy m$ical condition1 means-- 7,i7 a m$ical scre5+ exam9ation 7z requir$ "u section #ahfg ( ! ,social ,security ,act1 or z w\ld be requir$ "u su* section if su* section appli$ to an indep5d5t free/&+ em]g5cy dep>tm5t7 t is )9 ! capability ( ! em]g5cy dep>tm5t ( a hospital or ( an indep5d5t free/&+ em]g5cy dep>tm5t1 z applicable1 includ+ ancill>y s]vices r\t9ely available to ! em]g5cy dep>tm5t to evaluate su* em]g5cy m$ical condition2 & 7,,ii7 )9 ! capabilities ( ! /aff & facilities available at ! hospital or ! indep5d5t free/&+ em]g5cy dep>tm5t1 z applicable1 su* fur!r m$ical exam9ation & treatm5t z are requir$ "u section #ahfg ( su* ,act1 or z w\ld be requir$ "u su* section if su* section appli$ to an indep5d5t free/&+ em]g5cy dep>tm5t1 to /abilize ! pati5t4 7ii7 ,inclusion ( c]ta9 s]vices outside ( em]g5cy dep>tm5t 7,i7 ,9 g5]al ,= purposes ( ?is subsection & section #bgii;,a-#a1 9 ! case ( an individual enroll$ 9 a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket :o is furni%$ s]vices describ$ 9 clause 7i7 by a p>ticipat+ or nonp>ticipat+ provid] or a p>ticipat+ or nonp>ticipat+ em]g5cy facility to /abilize su* individual ) respect to an em]g5cy m$ical condition1 ! t]m em]g5cy s]vices %all include1 unless ea* ( ! conditions describ$ 9 subclause 7,,ii7 are met1 9 addition to ! items & s]vices describ$ 9 clause 7i71 items & s]vices = :i* b5efits are provid$ or cov]$ "u ! plan or cov]age1 respectively1 furni%$ by a nonp>ticipat+ provid] or nonp>ticipat+ facility1 reg>dless ( ! dep>tm5t ( ! hospital 9 :i* su* individual is furni%$ su* items or s]vices1 if1 aft] su* /abilization b dur+ su* visit 9 :i* su* individual is s /abiliz$1 ! provid] or facility det]m9es t su* items or s]vices are ne$$4 7,,ii7 ,conditions ,= purposes ( subclause 7,i71 ! conditions describ$ 9 ?is subclause1 ) respect to an individual :o is /abiliz$ & furni%$ additional items & s]vices describ$ 9 subclause 7,i7 aft] su* /abilization by a provid] or facility describ$ 9 subclause 7,i71 are ! foll[+3 7aa7 ,su* a provid] or facility det]m9es su* individual is able to travel us+ nonm$ical transportation or nonem]g5cy m$ical transportation4 7bb7 ,su* provid] furni%+ su* additional items & s]vices satisfies ! notice & cons5t crit]ia ( section #bgii;,a-#b7;d7 ( ! ,public ,heal? ,s]vice ,act ) respect to su* items & s]vices4 7cc7 ,su* an individual is 9 a condition to receive 7z det]m9$ 9 accordance ) guidance issu$ by ! ,secret>y7 ! in=mation describ$ 9 section #bgii;,a-#b ( ! ,public ,heal? ,s]vice ,act & to provide in=m$ cons5t "u su* section1 9 accordance ) applicable ,/ate law4 7,d7 ,indep5d5t free/&+ em]g5cy dep>tm5t ,! t]m indep5d5t free/&+ em]g5cy dep>tm5t means a facility t-- 7i7 is geographically sep>ate & di/9ct & lic5s$ sep>ately f a hospital "u applicable ,/ate law2 & 7ii7 provides any em]g5cy s]vices 7z def9$ 9 subp>agraph 7,c774 7,e7 ,m$ian contract$ rate 7i7 ,9 g5]al ,! t]m m$ian contract$ rate means1 subject to clauses 7ii7 & 7iii71 ) respect to a sponsor ( a gr\p heal? plan-- 7,i7 = an item or s]vice furni%$ dur+ #bjbb1 ! m$ian ( ! contract$ rates recogniz$ by ! plan 7det]m9$ ) respect to all su* plans ( su* sponsor t are (f]$ )9 ! same l9e ( bus9ess z ! total maximum paym5t 7includ+ ! co/-%>+ am\nt impos$ = su* item or s]vice & ! am\nt to be paid by ! plan77 "u su* plans on ,janu>y #ca1 #bjai1 = ! same or a simil> item or s]vice t is provid$ by a provid] 9 ! same or simil> specialty & provid$ 9 ! geographic region 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u p>agraph 7#b77;,b71 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] #bjai1 su* p]c5tage increase ov] #bjbj1 & su* p]c5tage increase ov] #bjba2 & 7,,ii7 = an item or s]vice furni%$ dur+ #bjbc or a subsequ5t ye>1 ! m$ian contract$ rate det]m9$ "u ?is clause = su* an item or s]vice furni%$ 9 ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 7ii7 ,new plans & cov]age ,! t]m m$ian contract$ rate means1 ) respect to a sponsor ( a gr\p heal? plan 9 a geographic region 9 :i* su* sponsor1 respectively1 did n (f] any gr\p heal? plan or heal? insurance cov]age dur+ #bjai-- 7,i7 = ! fir/ ye> 9 :i* su* gr\p heal? plan is (f]$ 9 su* region1 a rate 7det]m9$ 9 accordance ) a me?odology e/abli%$ by ! ,secret>y7 = items & s]vices t are cov]$ by su* plan & furni%$ dur+ su* fir/ ye>2 & 7,,ii7 = ea* subsequ5t ye> su* gr\p heal? plan is (f]$ 9 su* region1 ! m$ian contract$ rate det]m9$ "u ?is clause = su* items & s]vices furni%$ 9 ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 7iii7 ,insuffici5t in=mation2 newly cov]$ items & s]vices ,9 ! case ( a sponsor ( a gr\p heal? plan t does n h suffici5t in=mation to calculate ! m$ian ( ! contract$ rates describ$ 9 clause 7i77,i7 9 #bjai 7or1 9 ! case ( a newly cov]$ item or s]vice 7z def9$ 9 clause 7iv77,,iii771 9 ! fir/ cov]age ye> 7z def9$ 9 clause 7iv77,i77 = su* item or s]vice ) respect to su* plan7 = an item or s]vice 7includ+ ) respect to provid] type1 or am\nt1 ( claims = items or s]vices 7z det]m9$ by ! ,secret>y7 provid$ 9 a p>ticul> geographic region 7o!r ?an 9 a case ) respect to :i* clause 7ii7 applies77 ! t]m m$ian contract$ rate-- 7,i7 = an item or s]vice furni%$ dur+ #bjbb 7or1 9 ! case ( a newly cov]$ item or s]vice1 dur+ ! fir/ cov]age ye> = su* item or s]vice ) respect to su* plan71 means su* rate = su* item or s]vice det]m9$ by ! sponsor ?r\gh use ( any database t is det]m9$1 9 accordance ) rulemak+ describ$ 9 p>agraph 7#b77;,b71 to n h any conflicts ( int]e/ & to h suffici5t in=mation reflect+ all[$ am\nts paid to a heal? c>e provid] or facility = relevant s]vices furni%$ 9 ! applicable geographic region 7su* z a ,/ate all-pay] claims database72 7,,ii7 = an item or s]vice furni%$ 9 a subsequ5t ye> 7be=e ! fir/ suffici5t in=mation ye> 7z def9$ 9 clause 7iv77,,ii77 = su* item or s]vice ) respect to su* plan71 means ! rate det]m9$ "u subclause 7,i7 or ?is subclause1 z applicable1 = su* item or s]vice = ! ye> previ\s to su* subsequ5t ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>2 7,,iii7 = an item or s]vice furni%$ 9 ! fir/ suffici5t in=mation ye> = su* item or s]vice ) respect to su* plan1 has ! mean+ giv5 ! t]m m$ian contract$ rate 9 clause 7i77,i71 except t 9 apply+ su* clause to su* item or s]vice1 ! ref]5ce to furni%$ dur+ #bjbb %all be treat$ z a ref]5ce to furni%$ dur+ su* fir/ suffici5t in=mation ye>1 ! ref]5ce to on ,janu>y #ca1 #bjai1 %all be treat$ z a ref]5ce to 9 su* suffici5t in=mation ye>1 & ! increase describ$ 9 su* clause %all n be appli$2 & 7,,iv7 = an item or s]vice furni%$ 9 any ye> subsequ5t to ! fir/ suffici5t in=mation ye> = su* item or s]vice ) respect to su* plan1 has ! mean+ giv5 su* t]m 9 clause 7i77,,ii71 except t 9 apply+ su* clause to su* item or s]vice1 ! ref]5ce to furni%$ dur+ #bjbc or a subsequ5t ye> %all be treat$ z a ref]5ce to furni%$ dur+ ! ye> aft] su* fir/ suffici5t in=mation ye> or a subsequ5t ye>4 7iv7 ,def9itions ,= purposes ( ?is subp>agraph3 7,i7 ,fir/ cov]age ye> ,! t]m fir/ cov]age ye> means1 ) respect to a gr\p heal? plan & an item or s]vice = :i* cov]age is n (f]$ 9 #bjai "u su* plan or cov]age1 ! fir/ ye> aft] #bjai = :i* cov]age = su* item or s]vice is (f]$ "u su* plan4 7,,ii7 ,fir/ suffici5t in=mation ye> ,! t]m fir/ suffici5t in=mation ye> means1 ) respect to a gr\p heal? plan-- 7aa7 9 ! case ( an item or s]vice = :i* ! plan does n h suffici5t in=mation to calculate ! m$ian ( ! contract$ rates describ$ 9 clause 7i77,i7 9 #bjai1 ! fir/ ye> subsequ5t to #bjbb = :i* su* sponsor has su* suffici5t in=mation to calculate ! m$ian ( su* contract$ rates 9 ! ye> previ\s to su* fir/ subsequ5t ye>2 & 7bb7 9 ! case ( a newly cov]$ item or s]vice1 ! fir/ ye> subsequ5t to ! fir/ cov]age ye> = su* item or s]vice ) respect to su* plan = :i* ! sponsor has suffici5t in=mation to calculate ! m$ian ( ! contract$ rates describ$ 9 clause 7i77,i7 9 ! ye> previ\s to su* fir/ subsequ5t ye>4 7,,iii7 ,newly cov]$ item or s]vice ,! t]m newly cov]$ item or s]vice means1 ) respect to a gr\p heal? plan1 an item or s]vice = :i* cov]age 0 n (f]$ 9 #bjai "u su* plan or cov]age1 b is (f]$ "u su* plan or cov]age 9 a ye> aft] #bjai4 7,f7 ,nonp>ticipat+ em]g5cy facility2 p>ticipat+ em]g5cy facility 7i7 ,nonp>ticipat+ em]g5cy facility ,! t]m nonp>ticipat+ em]g5cy facility means1 ) respect to an item or s]vice & a gr\p heal? plan1 an em]g5cy dep>tm5t ( a hospital1 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t does n h a contractual relation%ip directly or indirectly ) ! plan = furni%+ su* item or s]vice "u ! plan4 7ii7 ,p>ticipat+ em]g5cy facility ,! t]m p>ticipat+ em]g5cy facility means1 ) respect to an item or s]vice & a gr\p heal? plan1 an em]g5cy dep>tm5t ( a hospital1 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t has a contractual relation%ip directly or indirectly ) ! plan1 ) respect to ! furni%+ ( su* an item or s]vice at su* facility4 7,g7 ,nonp>ticipat+ provid]s2 p>ticipat+ provid]s 7i7 ,nonp>ticipat+ provid] ,! t]m nonp>ticipat+ provid] means1 ) respect to an item or s]vice & a gr\p heal? plan1 a physician or o!r heal? c>e provid] :o is act+ )9 ! scope ( practice ( t provid]'s lic5se or c]tification "u applicable ,/ate law & :o does n h a contractual relation%ip ) ! plan or issu]1 respectively1 = furni%+ su* item or s]vice "u ! plan4 7ii7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] means1 ) respect to an item or s]vice & a gr\p heal? plan1 a physician or o!r heal? c>e provid] :o is act+ )9 ! scope ( practice ( t provid]'s lic5se or c]tification "u applicable ,/ate law & :o has a contractual relation%ip ) ! plan = furni%+ su* item or s]vice "u ! plan4 7,h7 ,recogniz$ am\nt ,! t]m recogniz$ am\nt means1 ) respect to an item or s]vice furni%$ by a nonp>ticipat+ provid] or em]g5cy facility dur+ a ye> & a gr\p heal? plan-- 7i7 subject to clause 7iii71 9 ! case ( su* item or s]vice furni%$ 9 a ,/ate t has 9 effect a specifi$ ,/ate law ) respect to su* plan2 su* a nonp>ticipat+ provid] or em]g5cy facility2 & su* an item or s]vice1 ! am\nt det]m9$ 9 accordance ) su* law2 7ii7 subject to clause 7iii71 9 ! case ( su* item or s]vice furni%$ 9 a ,/ate t does n h 9 effect a specifi$ ,/ate law1 ) respect to su* plan2 su* a nonp>ticipat+ provid] or em]g5cy facility2 & su* an item or s]vice1 an am\nt t is ! m$ian contract$ rate 7z def9$ 9 subp>agraph 7,e77 = su* ye> & det]m9$ 9 accordance ) rulemak+ describ$ 9 p>agraph 7#b77;,b7 = su* item or s]vice2 or 7iii7 9 ! case ( su* item or s]vice furni%$ 9 a ,/ate ) an ,all-,pay] ,model ,agreem5t "u section #aaae;,a ( ! ,social ,security ,act1 ! am\nt t ! ,/ate approves "u su* sy/em = su* item or s]vice s furni%$4 7,i7 ,specifi$ ,/ate law ,! t]m specifi$ ,/ate law means1 ) respect to a ,/ate1 an item or s]vice furni%$ by a nonp>ticipat+ provid] or em]g5cy facility dur+ a ye> & a gr\p heal? plan1 a ,/ate law t provides = a me?od = det]m9+ ! am\nt ( paym5t t is requir$ to be cov]$ by su* a plan 7to ! ext5t su* ,/ate law applies to su* plan1 subject to section #ead ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd7 9 ! case ( a p>ticipant or b5efici>y cov]$ "u su* plan & receiv+ su* item or s]vice f su* a nonp>ticipat+ provid] or em]g5cy facility4 7,j7 ,/abilize ,! t]m to /abilize1 ) respect to an em]g5cy m$ical condition 7z def9$ 9 subp>agraph 7,b771 has ! mean+ give 9 section #ahfg7;e77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;dd7e77#c774 7c7 ,access to p$iatric c>e 7#a7 ,p$iatric c>e ,9 ! case ( a p]son :o has a *ild :o is a p>ticipant or b5efici>y "u a gr\p heal? plan1 if ! plan requires or provides = ! designation ( a p>ticipat+ prim>y c>e provid] = ! *ild1 ! plan %all p]mit su* p]son to designate a physician 7allopa?ic or o/eopa?ic7 :o specializes 9 p$iatrics z ! *ild's prim>y c>e provid] if su* provid] p>ticipates 9 ! network ( ! plan or issu]4 7#b7 ,con/ruction ,no?+ 9 p>agraph 7#a7 %all be con/ru$ to waive any exclusions ( cov]age "u ! t]ms & conditions ( ! plan ) respect to cov]age ( p$iatric c>e4 7d7 ,pati5t access to ob/etrical & gynecological c>e 7#a7 ,g5]al rights 7,a7 ,direct access ,a gr\p heal? plan describ$ 9 p>agraph 7#b7 may n require au?orization or ref]ral by ! plan or any p]son 7includ+ a prim>y c>e provid] describ$ 9 p>agraph 7#b77;,b77 9 ! case ( a female p>ticipant or b5efici>y :o seeks cov]age = ob/etrical or gynecological c>e provid$ by a p>ticipat+ heal? c>e pr(essional :o specializes 9 ob/etrics or gynecology4 ,su* pr(essional %all agree to o!rwise adh]e to su* plan's policies & proc$ures1 includ+ proc$ures reg>d+ ref]rals & obta9+ prior au?orization & provid+ s]vices pursuant to a treatm5t plan 7if any7 approv$ by ! plan4 7,b7 ,ob/etrical & gynecological c>e ,a gr\p heal? plan describ$ 9 p>agraph 7#b7 %all treat ! provision ( ob/etrical & gynecological c>e1 & ! ord]+ ( relat$ ob/etrical & gynecological items & s]vices1 pursuant to ! direct access describ$ "u subp>agraph 7,a71 by a p>ticipat+ heal? c>e pr(essional :o specializes 9 ob/etrics or gynecology z ! au?orization ( ! prim>y c>e provid]4 7#b7 ,application ( p>agraph ,a gr\p heal? plan describ$ 9 ?is p>agraph is a gr\p heal? plan t-- 7,a7 provides cov]age = ob/etric or gynecologic c>e2 & 7,b7 requires ! designation by a p>ticipant or b5efici>y ( a p>ticipat+ prim>y c>e provid]4 7#c7 ,con/ruction ,no?+ 9 p>agraph 7#a7 %all be con/ru$ to-- 7,a7 waive any exclusions ( cov]age "u ! t]ms & conditions ( ! plan ) respect to cov]age ( ob/etrical or gynecological c>e2 or 7,b7 preclude ! gr\p heal? plan involv$ f requir+ t ! ob/etrical or gynecological provid] notify ! prim>y c>e heal? c>e pr(essional or ! plan ( treatm5t decisions4 7e7 ,cov]age ( non-,em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities 7#a7 ,9 g5]al ,9 ! case ( items or s]vices 7o!r ?an em]g5cy s]vices to :i* subsection 7b7 applies7 = :i* any b5efits are provid$ or cov]$ by a gr\p heal? plan furni%$ to a p>ticipant or b5efici>y ( su* plan by a nonp>ticipat+ provid] 7z def9$ 9 subsection 7b77#c77;,g77i77 7& :o1 ) respect to su* items & s]vices1 has n satisfi$ ! notice & cons5t crit]ia ( section #bgii;,a-#b7;d7 ( ! ,public ,heal? ,s]vice ,act7 ) respect to a visit 7z def9$ by ! ,secret>y 9 accordance ) p>agraph 7#b77;,b77 at a p>ticipat+ heal? c>e facility 7z def9$ 9 p>agraph 7#b77;,a771 ) respect to su* plan1 ! plan-- 7,a7 %all n impose on su* p>ticipant or b5efici>y a co/-%>+ am\nt 7express$ z a copaym5t am\nt or co9surance rate7 = su* items & s]vices s furni%$ t is great] ?an ! co/-%>+ am\nt t w\ld apply "u su* plan _h su* items or s]vices be5 furni%$ by a p>ticipat+ provid] 7z def9$ 9 subsection 7b77#c77;,g77ii772 7,b7 %all calculate su* co/-%>+ am\nt z if ! total am\nt t w\ld h be5 *>g$ = su* items & s]vices by su* p>ticipat+ provid] 7 equal to ! recogniz$ am\nt 7z def9$ 9 subsection 7b77#c77;,h77 = su* items & s]vices1 plan1 & ye>2 7,c7 %all pay to su* provid] furni%+ su* items & s]vices to su* p>ticipant or b5efici>y ! am\nt by :i* ! recogniz$ am\nt 7z def9$ 9 subsection 7b77#c77;,h77 = su* items & s]vices & ye> involv$ exce$s ! co/-%>+ am\nt impos$ "u ! plan = su* items & s]vices 7z det]m9$ 9 accordance ) subp>agraphs 7,a7 & 7,b772 & 7,d7 %all c\nt t[>d any 9-network d$uctible & 9-network out-(-pocket maximums 7z applicable7 appli$ "u ! plan1 any co/-%>+ paym5ts made by ! p>ticipant or b5efici>y 7& su* 9-network d$uctible %all be appli$7 ) respect to su* items & s]vices s furni%$ 9 ! same mann] z if su* co/-%>+ paym5ts 7 ) respect to items & s]vices furni%$ by a p>ticipat+ provid]4 7#b7 ,def9itions ,9 ?is section3 7,a7 ,p>ticipat+ heal? c>e facility 7i7 ,9 g5]al ,! t]m p>ticipat+ heal? c>e facility means1 ) respect to an item or s]vice & a gr\p heal? plan1 a heal? c>e facility describ$ 9 clause 7ii7 t has a contractual relation%ip ) ! plan1 ) respect to ! furni%+ ( su* an item or s]vice at ! facility4 7ii7 ,heal? c>e facility describ$ ,a heal? c>e facility describ$ 9 ?is clause1 ) respect to a gr\p heal? plan1 is ea* ( ! foll[+3 7,i7 ,a hospital 7z def9$ 9 #ahfa7;e7 ( ! ,social ,security ,act74 7,,ii7 ,a hospital outpati5t dep>tm5t4 7,,iii7 ,a critical access hospital 7z def9$ 9 section #ahfa7mm7 ( su* ,act74 7,,iv7 ,an ambulatory surgical c5t] 7z def9$ 9 section #ahcc7;i77#a77;,a7 ( su* ,act74 7,v7 ,any o!r facility t provides items or s]vices = :i* cov]age is provid$ "u ! plan or cov]age1 respectively4 7,b7 ,visit ,! t]m visit %all1 ) respect to items & s]vices furni%$ to an individual at a p>ticipat+ heal? c>e facility1 include equipm5t & devices1 telem$ic9e s]vices1 imag+ s]vices1 laboratory s]vices1 & su* o!r items & s]vices z ! ,secret>y may specify1 reg>dless ( :e!r or n ! provid] furni%+ su* items or s]vices is at ! facility4 7f7 ,air ambulance s]vices 7#a7 ,9 g5]al ,9 ! case ( a p>ticipant or b5efici>y 9 a gr\p heal? plan :o receives air ambulance s]vices f a nonp>ticipat+ provid] 7z def9$ 9 subsection 7b77#c77;,g77 ) respect to su* plan or cov]age1 if su* s]vices w\ld be cov]$ if provid$ by a p>ticipat+ provid] 7z def9$ 9 su* subsection7 ) respect to su* plan-- 7,a7 ! co/-%>+ requirem5t 7express$ z a copaym5t am\nt1 co9surance rate1 or d$uctible7 ) respect to su* s]vices %all be ! same requirem5t t w\ld apply if su* s]vices 7 provid$ by su* a p>ticipat+ provid]1 & any co9surance or d$uctible %all be bas$ on rates t w\ld apply = su* s]vices if !y 7 furni%$ by su* a p>ticipat+ provid]2 7,b7 su* co/-%>+ am\nts %all be c\nt$ t[>d ! 9-network d$uctible & 9-network out-(-pocket maximum am\nt "u ! plan = ! plan ye> 7& su* 9-network d$uctible %all be appli$7 ) respect to su* items & s]vices s furni%$ 9 ! same mann] z if su* co/-%>+ paym5ts 7 ) respect to items & s]vices furni%$ by a p>ticipat+ provid]2 & 7,c7 ! plan or cov]age %all pay to su* provid] furni%+ su* s]vices to su* p>ticipant or b5efici>y ! am\nt by :i* ! recogniz$ am\nt 7z def9$ 9 & det]m9$ pursuant to subsection 7b77#c77;,h77ii77 = su* s]vices & ye> involv$ exce$s ! co/-%>+ am\nt impos$ "u ! plan = su* s]vices 7z det]m9$ 9 accordance ) subp>agraphs 7,a7 & 7,b774 7#b7 ,air ambulance s]vice def9$ ,= purposes ( ?is section1 ! t]m air ambulance s]vice means m$ical transport by helicopt] or airplane = pati5ts4 7g7 ,c]ta9 access fees to c]ta9 databases ,9 ! case ( a sponsor ( a gr\p heal? plan t1 pursuant to subsection 7b77#c77;,e77iii71 uses a database describ$ 9 su* subsection to det]m9e a rate to apply "u su* subsection = an item or s]vice by reason ( hav+ insuffici5t in=mation describ$ 9 su* subsection ) respect to su* item or s]vice1 su* sponsor %all cov] ! co/ = access to su* database4 4 7#b7 ,cl]ical am5dm5t ,! table ( sections = sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new item3 ,sec4 #ihae4 ,additional m>ket re=ms4 ,sec4 #ihaf4 ,consum] protections4 4 7d7 ,additional application provisions 7#a7 ,application to ,,fehb 7,a7 ,9 g5]al ,section #hijb ( title #e1 ,unit$ ,/ates ,code1 is am5d$ by add+ at ! end ! foll[+ new subsection3 7p7 ,ea* contract "u ?is *apt] %all require ! c>ri] to comply ) requirem5ts describ$ 9 ! provisions ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act & sections #bgcj & #bgca ( su* ,act1 sections #gaf1 #gag1 & #gah ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 sections #ihaf1 #ihag1 & #ihah ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable71 & section #b7;d7 ( ! ,ban ,surprise ,bill+ ,act 9 ! same mann] z su* provisions apply to a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age1 z describ$ 9 su* sections4 ,! provisions ( sections #bgii;,a-#a1 #bgii;,a-#b1 #bgii;,a-#c1 & #bgii;,a-#d ( ! ,public ,heal? ,s]vice ,act %all apply to a heal? c>e provid] & facility & an air ambulance provid] describ$ 9 su* respective sections ) respect to a p>ticipant1 b5efici>y1 or enrollee 9 a heal? b5efits plan "u ?is *apt] 9 ! same mann] z su* provisions apply to su* a provid] & facility ) respect to an enrollee 9 a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 z describ$ 9 su* sections4 4 7,b7 ,effective date ,! am5dm5t made by ?is p>agraph %all apply ) respect to contracts ent]$ into or r5ew$ = contract ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb4 7#b7 ,application to ,gr&fa!r$ ,plans ,section #abea7;a7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjaa7;a77 is am5d$ by add+ at ! end ! foll[+3 7#e7 ,application ( additional provisions ,subsections 7b71 7e71 7f71 7g71 & 7h7 ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act %all apply to gr&fa!r$ heal? plans = plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb4 4 7#c7 ,coord9ation ,! ,secret>y ( ! ,treasury1 ! ,secret>y ( ,heal? & ,human ,s]vices1 & ! ,secret>y ( ,labor %all ensure1 ?r\gh ! execution ( an int]ag5cy memor&um ( und]/&+ among su* ,secret>ies1 t-- 7,a7 regulations1 rul+s1 & int]pretations issu$ by su* ,secret>ies relat+ to ! same matt] ov] :i* two or m su* ,secret>ies h responsibility "u ?is title 7& ! am5dm5ts made by ?is title7 are adm9i/]$ s z to h ! same effect at all times2 & 7,b7 coord9ation ( policies relat+ to en=c+ ! same requirem5ts ?r\gh su* ,secret>ies 9 ord] to h a coord9at$ en=cem5t /rategy t avoids duplication ( en=cem5t ef=ts & assigns priorities 9 en=cem5t4 7#d7 ,rule ( con/ruction ,no?+ 9 ?is title1 includ+ ! am5dm5ts made by ?is title may be con/ru$ z modify+1 r$uc+1 or elim9at+-- 7,a7 ! protections "u section #bbb ( ! ,indian ,heal? ,c>e ,improvem5t ,act 7#be ,u4,s4,c4 #afbau7 & "u subp>t ,i ( "p #acf ( title #db1 ,code ( ,f$]al ,regulations 7or any successor regulation71 aga9/ paym5t liability = a pati5t :o receives contract heal? s]vices t are au?oriz$ by ! ,indian ,heal? ,s]vice2 or 7,b7 ! requirem5ts "u section #ahff7;a77#a77,u7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7a77#a77,u774 7e7 ,effective date ,! am5dm5ts made by ?is section %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb4 #c4 ,prev5t+ c]ta9 cases ( balance bill+ 7a7 ,9 g5]al ,title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 is am5d$ by add+ at ! end ! foll[+ new "p3 ,d ,heal? ,c>e ,provid] ,requirem5ts #bgii;,a-#a4 ,balance bill+ 9 cases ( em]g5cy s]vices 7a7 ,9 g5]al ,9 ! case ( a p>ticipant1 b5efici>y1 or enrollee ) b5efits "u a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket :o is furni%$ dur+ a plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbb1 em]g5cy s]vices = :i* any b5efit is provid$ "u su* plan or cov]age ) respect to an em]g5cy m$ical condition ) respect to a visit at an em]g5cy dep>tm5t ( a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t-- 7#a7 9 ! case t ! hospital or indep5d5t free/&+ em]g5cy dep>tm5t is a nonp>ticipat+ em]g5cy facility1 ! em]g5cy dep>tm5t ( a hospital or indep5d5t free/&+ em]g5cy dep>tm5t %all n hold ! p>ticipant1 b5efici>y1 or enrollee liable = a paym5t am\nt = su* em]g5cy s]vices s furni%$ t is m ?an ! co/-%>+ am\nt = su* s]vices 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii7 ( section #bgai;,a7b77#a77;,c71 section #gaf7;b77#a77;,c7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 & section #ihaf7;b77#a77;,c7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z applicable72 & 7#b7 9 ! case t su* s]vices are furni%$ by a nonp>ticipat+ provid]1 ! heal? c>e provid] %all n hold su* p>ticipant1 b5efici>y1 or enrollee liable = a paym5t am\nt = an em]g5cy s]vice furni%$ to su* individual by su* provid] ) respect to su* em]g5cy m$ical condition & visit = :i* ! individual receives em]g5cy s]vices at ! hospital or em]g5cy dep>tm5t t is m ?an ! co/-%>+ am\nt = su* s]vices furni%$ by ! provid] 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii7 ( section #bgai;,a7b77#a77;,c71 section #gaf7;b77#a77;,c7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 & section #ihaf7;b77#a77;,c7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z applicable74 7b7 ,def9ition ,9 ?is section1 ! t]m visit %all h su* mean+ z appli$ to su* t]m = purposes ( section #bgai;,a7e74 #bgii;,a-#b4 ,balance bill+ 9 cases ( non-em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities 7a7 ,9 g5]al ,subject to subsection 7b71 9 ! case ( a p>ticipant1 b5efici>y1 or enrollee ) b5efits "u a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket :o is furni%$ dur+ a plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbb1 items or s]vices 7o!r ?an em]g5cy s]vices to :i* section #bgii;,a-#a applies7 = :i* any b5efit is provid$ "u su* plan or cov]age at a p>ticipat+ heal? c>e facility by a nonp>ticipat+ provid]1 su* provid] %all n bill1 & %all n hold liable1 su* p>ticipant1 b5efici>y1 or enrollee = a paym5t am\nt = su* an item or s]vice furni%$ by su* provid] ) respect to a visit at su* facility t is m ?an ! co/-%>+ am\nt = su* item or s]vice 7z det]m9$ 9 accordance ) subp>agraphs 7,a7 & 7,b7 ( section #bgai;,a7e77#a71 section #gaf7;e77#a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 & section #ihaf7;e77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z applicable74 7b7 ,exception 7#a7 ,9 g5]al ,subsection 7a7 %all n apply ) respect to items or s]vices 7o!r ?an ancill>y s]vices describ$ 9 p>agraph 7#b77 furni%$ by a nonp>ticipat+ provid] to a p>ticipant1 b5efici>y1 or enrollee ( a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 if ! provid] satisfies ! notice & cons5t crit]ia ( subsection 7d74 7#b7 ,ancill>y s]vices describ$ ,= purposes ( p>agraph 7#a71 ancill>y s]vices describ$ 9 ?is p>agraph are1 ) respect to a p>ticipat+ heal? c>e facility-- 7,a7 subject to p>agraph 7#c71 items & s]vices relat$ to em]g5cy m$ic9e1 ane/hesiology1 pa?ology1 radiology1 & neonatology1 :e!r or n provid$ by a physician or non-physician practition]1 & items & s]vices provid$ by assi/ant surgeons1 hospitali/s1 & int5sivi/s2 7,b7 subject to p>agraph 7#c71 diagno/ic s]vices 7includ+ radiology & laboratory s]vices72 7,c7 items & s]vices provid$ by su* o!r specialty practition]s1 z ! ,secret>y specifies ?r\gh rulemak+2 & 7,d7 items & s]vices provid$ by a nonp>ticipat+ provid] if !re is no p>ticipat+ provid] :o c furni% su* item or s]vice at su* facility4 7#c7 ,exception ,! ,secret>y may1 ?r\gh rulemak+1 e/abli% a li/ 7& update su* li/7 ( advanc$ diagno/ic laboratory te/s1 :i* %all n be includ$ z an ancill>y s]vice describ$ 9 p>agraph 7#b7 & ) respect to :i* subsection 7a7 w\ld apply4 7c7 ,cl>ification ,9 ! case ( a nonp>ticipat+ provid] t satisfies ! notice & cons5t crit]ia ( subsection 7d7 ) respect to an item or s]vice 7ref]r$ to 9 ?is subsection z a cov]$ item or s]vice71 su* notice & cons5t crit]ia may n be con/ru$ z apply+ ) respect to any item or s]vice t is furni%$ z a result ( un=ese51 urg5t m$ical ne$s t arise at ! "t su* cov]$ item or s]vice is furni%$4 ,= purposes ( ! previ\s s5t5ce1 a cov]$ item or s]vice %all n include an ancill>y s]vice describ$ 9 subsection 7b77#b74 7d7 ,notice & cons5t ,to be treat$ by a nonp>ticipat+ provid] or nonp>ticipat+ facility 7#a7 ,9 g5]al ,a nonp>ticipat+ provid] or nonp>ticipat+ facility satisfies ! notice & cons5t crit]ia ( ?is subsection1 ) respect to items or s]vices furni%$ by ! provid] or facility to a p>ticipant1 b5efici>y1 or enrollee ( a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 if ! provid] 7or1 if applicable1 ! p>ticipat+ heal? c>e facility on behalf ( su* provid]7 or nonp>ticipat+ facility-- 7,a7 provides to ! p>ticipant1 b5efici>y1 or enrollee 7or to an au?oriz$ repres5tative ( ! p>ticipant1 b5efici>y1 or enrollee7 on ! date on :i* ! individual is furni%$ su* items or s]vices &1 9 ! case t ! p>ticipant1 b5efici>y1 or enrollee makes an appo9tm5t to be furni%$ su* items or s]vices1 on su* date ! appo9tm5t is made-- 7i7 an oral explanation ( ! writt5 notice describ$ 9 clause 7ii72 & 7ii7 a writt5 notice 9 pap] or electronic =m 7& includ+ electronic notification1 z practicable7 specifi$ by ! ,secret>y1 n lat] ?an ,july #a1 #bjba1 ?r\gh guidance 7:i* %all be updat$ z det]m9$ necess>y by ! ,secret>y7 t-- 7,i7 conta9s ! in=mation requir$ "u p>agraph 7#b72 7,,ii7 cle>ly /ates t cons5t to receive su* items & s]vices f su* nonp>ticipat+ provid] or nonp>ticipat+ facility is optional & t ! p>ticipant1 b5efici>y1 or enrollee may in/ead seek c>e f a p>ticipat+ provid] or at a p>ticipat+ facility1 ) respect to su* plan or cov]age1 z applicable1 9 :i* case ! co/-%>+ responsibility ( ! p>ticipant1 b5efici>y1 or enrollee w\ld n exce$ su* responsibility t w\ld apply ) respect to su* an item or s]vice t is furni%$ by a p>ticipat+ provid] or p>ticipat+ facility1 z applicable ) respect to su* plan2 7,,iii7 is available 9 ! fifte5 mo/ common languages 9 ! geographic region ( ! applicable facility &1 9 ! case ! prim>y language ( ! b5efici>y1 p>ticipant1 or enrollee1 respectively1 is n "o ( su* #ae languages1 makes a good fai? ef=t to also provide su* notice orally 9 su* prim>y language ( ! b5efici>y1 p>ticipant1 or enrollee2 & 7,,iv7 is sign$ & dat$ by ! p>ticipant1 b5efici>y1 or enrollee 7or by an au?oriz$ repres5tative ( ! p>ticipant1 b5efici>y1 or enrollee7 &1 ) respect to items or s]vices to be furni%$ by su* a provid] t are n po//abilization s]vices describ$ 9 section #bgai;,a7b77#c77;,c77ii71 is s sign$ & dat$ n less ?an #gb h\rs prior to ! p>ticipant1 b5efici>y1 or enrollee be+ furni%$ su* items or s]vices by su* provid]2 & 7,b7 obta9s f ! p>ticipant1 b5efici>y1 or enrollee 7or f su* an au?oriz$ repres5tative7 ! cons5t describ$ 9 p>agraph 7#c7 to be treat$ by a nonp>ticipat+ provid] or nonp>ticipat+ facility4 7#b7 ,in=mation requir$ "u writt5 notice ,= purposes ( p>agraph 7#a77;,a77ii77,i71 ! in=mation describ$ 9 ?is p>agraph1 ) respect to a nonp>ticipat+ provid] or nonp>ticipat+ facility & a p>ticipant1 b5efici>y1 or enrollee ( a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 is ea* ( ! foll[+3 7,a7 ,notification1 z applicable1 t ! heal? c>e provid] is a nonp>ticipat+ provid] ) respect to ! heal? plan or ! heal? c>e facility is a nonp>ticipat+ facility ) respect to ! heal? plan4 7,b7 ,notification ( ! good fai? e/imat$ am\nt t su* provid] or facility may *>ge ! p>ticipant1 b5efici>y1 or enrollee = su* items & s]vices involv$1 includ+ a notification t ! provision ( su* e/imate or cons5t to be treat$ "u p>agraph 7#c7 does n con/itute a contract ) respect to ! *>ges e/imat$ = su* items & s]vices4 7,c7 ,9 ! case ( a p>ticipat+ facility & a nonp>ticipat+ provid]1 a li/ ( any p>ticipat+ provid]s at ! facility :o are able to furni% su* items & s]vices involv$ & notification t ! p>ticipant1 b5efici>y1 or enrollee may be ref]r$1 at _! option1 to su* a p>ticipat+ provid]4 7,d7 ,in=mation ab\t :e!r prior au?orization or o!r c>e managem5t limitations may be requir$ 9 advance ( receiv+ su* items or s]vices at ! facility4 7#c7 ,cons5t describ$ to be treat$ by a nonp>ticipat+ provid] or nonp>ticipat+ facility ,= purposes ( p>agraph 7#a77;,b71 ! cons5t describ$ 9 ?is p>agraph1 ) respect to a p>ticipant1 b5efici>y1 or enrollee ( a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket :o is to be furni%$ items or s]vices by a nonp>ticipat+ provid] or nonp>ticipat+ facility1 is a docum5t specifi$ by ! ,secret>y ?r\gh rulemak+1 9 consultation ) ! ,secret>y ( ,labor1 t-- 7,a7 ackn[l$ges t ! p>ticipant1 b5efici>y1 or enrollee has be5-- 7i7 provid$ ) a writt5 good fai? e/imate & an oral explanation ( ! *>ge t may be appli$ = ! items or s]vices anticipat$ to be furni%$ by su* provid] or facility2 & 7ii7 in=m$ t ! paym5t ( su* *>ge by ! p>ticipant1 b5efici>y1 or enrollee may n accrue t[>d meet+ any limitation t ! plan or cov]age places on co/-%>+1 includ+ an explanation t su* paym5t may n apply to an 9-network d$uctible appli$ "u ! plan or cov]age2 & 7,b7 docum5ts ! cons5t ( ! p>ticipant1 b5efici>y1 or enrollee to be furni%$ su* item or s]vices by su* provid] or facility4 7#d7 ,rule ( con/ruction ,! cons5t describ$ 9 p>agraph 7#c71 ) respect to a p>ticipant1 b5efici>y1 or enrollee ( a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 %all con/itute only cons5t to ! receipt ( ! in=mation provid$ pursuant to ?is subsection & %all n con/itute a contractual agreem5t ( ! p>ticipant1 b5efici>y1 or enrollee to any e/imat$ *>ge or am\nt includ$ 9 su* in=mation4 7e7 ,ret5tion ( c]ta9 docum5ts ,a nonp>ticipat+ facility 7) respect to su* facility or any nonp>ticipat+ provid] at su* facility7 or a p>ticipat+ facility 7) respect to nonp>ticipat+ provid]s at su* facility7 t obta9s f a p>ticipant1 b5efici>y1 or enrollee ( a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket 7or an au?oriz$ repres5tative ( su* p>ticipant1 b5efici>y1 or enrollee7 a writt5 notice 9 accordance ) subsection 7d77#a77;,a77ii71 ) respect to furni%+ an item or s]vice to su* p>ticipant1 b5efici>y1 or enrollee1 %all reta9 su* notice = at lea/ a #b-ye> p]iod aft] ! date on :i* su* item or s]vice is s furni%$4 7f7 ,def9itions ,9 ?is section3 7#a7 ,! t]ms nonp>ticipat+ provid] & p>ticipat+ provid] h ! mean+s giv5 su* t]ms1 respectively1 9 subsection 7b77#c7 ( section #bgai;,a4 7#b7 ,! t]m p>ticipat+ heal? c>e facility has ! mean+ giv5 su* t]m 9 subsection 7e77#b7 ( section #bgai;,a4 7#c7 ,! t]m nonp>ticipat+ facility means-- 7,a7 ) respect to em]g5cy s]vices 7z def9$ 9 section #bgai;,a7b77#c77;,c77i77 & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 an em]g5cy dep>tm5t ( a hospital1 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t does n h a contractual relation%ip ) ! plan or issu]1 respectively1 ) respect to ! furni%+ ( su* s]vices "u ! plan or cov]age1 respectively2 & 7,b7 ) respect to s]vices describ$ 9 section #bgai;,a7b77#c77;,c77ii7 & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t1 t does n h a contractual relation%ip ) ! plan or issu]1 respectively1 ) respect to ! furni%+ ( su* s]vices "u ! plan or cov]age1 respectively4 7#d7 ,! t]m p>ticipat+ facility means-- 7,a7 ) respect to em]g5cy s]vices 7z def9$ 9 clause 7i7 ( section #bgai;,a7b77#c77;,c77 t are n describ$ 9 clause 7ii7 ( su* section & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 an em]g5cy dep>tm5t ( a hospital1 or an indep5d5t free/&+ em]g5cy dep>tm5t1 t has a contractual relation%ip ) ! plan or issu]1 respectively1 ) respect to ! furni%+ ( su* s]vices "u ! plan or cov]age1 respectively2 & 7,b7 ) respect to s]vices t pursuant to clause 7ii7 ( section #bgai;,a7b77#c77;,c7 are includ$ z em]g5cy s]vices 7z def9$ 9 clause 7i7 ( su* section7 & a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t1 t has a contractual relation%ip ) ! plan or cov]age1 respectively1 ) respect to ! furni%+ ( su* s]vices "u ! plan or cov]age1 respectively4 #bgii;,a-#c4 ,provid] requirem5t ) respect to public provision ( in=mation 7a7 ,9 g5]al ,ea* heal? c>e provid] & heal? c>e facility %all make publicly available1 & 7if applicable7 po/ on a public website ( su* provid] or facility & provide to individuals :o are p>ticipants1 b5efici>ies1 or enrollees ( a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket a "o-page notice 9 pla9 language conta9+ in=mation on-- 7#a7 ! requirem5ts & prohibitions ( su* provid] or facility "u sections #bgii;,a-#a1 #bgii;,a-#b1 & #bgii;,a-#d 7relat+ to prohibitions on balance bill+ 9 c]ta9 circum/ances72 7#b7 if provid$ = "u applicable ,/ate law1 any o!r requirem5ts on su* provid] or facility reg>d+ ! am\nts su* provid] or facility may1 ) respect to an item or s]vice1 *>ge a p>ticipant1 b5efici>y1 or enrollee ( a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket ) respect to :i* su* provid] or facility does n h a contractual relation%ip = furni%+ su* item or s]vice "u ! plan or cov]age1 respectively1 aft] receiv+ paym5t f ! plan or cov]age1 respectively1 = su* item or s]vice & any applicable co/-%>+ paym5t f su* p>ticipant1 b5efici>y1 or enrollee2 & 7#c7 in=mation on contact+ appropriate ,/ate & ,f$]al ag5cies 9 ! case t an individual believes t su* provid] or facility has violat$ any requirem5t describ$ 9 p>agraph 7#a7 or 7#b7 ) respect to su* individual4 7b7 ,guidance ,n lat] ?an #f mon?s aft] ! date ( ! enactm5t ( ?is section1 ! ,secret>y1 9 consultation ) ! ,secret>y ( ,labor1 %all issue guidance on ! requirem5ts = ! notice "u ?is section4 #bgii;,a-#d4 ,air ambulance s]vices ,9 ! case ( a p>ticipant1 b5efici>y1 or enrollee ) b5efits "u a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket :o is furni%$ on or aft] ,janu>y #a1 #bjbb1 air ambulance s]vices f a nonp>ticipat+ provid] 7z def9$ 9 section #bgai;,a7b77#c77;,g77 ) respect to su* plan or cov]age1 su* provid] %all n bill1 & %all n hold liable1 su* p>ticipant1 b5efici>y1 or enrollee = a paym5t am\nt = su* s]vice furni%$ by su* provid] t is m ?an ! co/-%>+ am\nt = su* s]vice 7z det]m9$ 9 accordance ) p>agraphs 7#a7 & 7#b7 ( section #bgai;,a7f71 section #gaf7;f7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihaf7;f7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z applicable74 #bgii;,a-#e4 ,en=cem5t 7a7 ,/ate en=cem5t 7#a7 ,/ate au?ority ,ea* ,/ate may require a provid] or heal? c>e facility 7includ+ a provid] ( air ambulance s]vices7 subject to ! requirem5ts ( ?is "p 7except section #bgii;,a-#e7 to satisfy su* requirem5ts applicable to ! provid] or facility4 7#b7 ,failure to implem5t requirem5ts ,9 ! case ( a det]m9ation by ! ,secret>y t a ,/ate has fail$ to sub/antially en=ce ! requirem5ts specifi$ 9 p>agraph 7#a7 ) respect to applicable provid]s & facilities 9 ! ,/ate1 ! ,secret>y %all en=ce su* requirem5ts "u subsection 7b7 ins(> z !y relate to violations ( su* requirem5ts occurr+ 9 su* ,/ate4 7#c7 ,notification ( ,secret>y ( ,labor ,a ,/ate may notify ! ,secret>y ( ,labor ( in/ances ( violations ( sections #bgii;,a-#a1 #bgii;,a-#b1 or #bgii;,a-#d ) respect to p>ticipants or b5efici>ies "u a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p m>ket & any en=cem5t actions tak5 aga9/ provid]s or facilities z a result ( su* violations1 includ+ ! disposition ( any su* en=cem5t actions4 7b7 ,secret>ial en=cem5t au?ority 7#a7 ,9 g5]al ,if a provid] or facility is f\nd to be 9 violation ( a requirem5t specifi$ 9 subsection 7a77#a7 by ! ,secret>y1 ! ,secret>y may apply a civil monet>y p5alty ) respect to su* provid] or facility 7includ+1 z applicable1 a provid] ( air ambulance s]vices7 9 an am\nt n to exce$ #aj1jjj p] violation4 ,! provisions ( subsections 7c7 7) ! exception ( ! fir/ s5t5ce ( p>agraph 7#a7 ( su* subsection71 7d71 7e71 7g71 7h71 7k71 & 7l7 ( section #aabh;,a ( ! ,social ,security ,act %all apply to a civil monet>y p5alty or assessm5t "u ?is subsection 9 ! same mann] z su* provisions apply to a p5alty1 assessm5t1 or proce$+ "u subsection 7a7 ( su* section4 7#b7 ,limitation ,! provisions ( p>agraph 7#a7 %all apply to en=cem5t ( a provision 7or provisions7 specifi$ 9 subsection 7a77#a7 only z provid$ "u subsection 7a77#b74 7#c7 ,compla9t process ,! ,secret>y %all1 ?r\gh rulemak+ conduct$ 9 consultation ) ! ,secret>y ( ,labor1 e/abli% a process to receive consum] compla9ts ( violations ( su* provisions & resolve su* compla9ts )9 #fj days ( receipt ( su* compla9ts4 ,su* process %all provide t ! ,secret>y ( ,labor be in=m$ ( compla9ts by p>ticipants or b5efici>ies "u a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p m>ket & any en=cem5t actions aga9/ provid]s result+ f su* compla9ts1 includ+ ! disposition ( any su* en=cem5t actions4 7#d7 ,exception ,! ,secret>y may waive ! p5alties describ$ "u p>agraph 7#a7 ) respect to a facility or provid] 7includ+ a provid] ( air ambulance s]vices7 :o does n kn[+ly violate1 & %\ld n h reasonably kn[n x violat$1 sections #bgii;,a-#a1 #bgii;,a-#b1 or #bgii;,a-#d ) respect to a p>ticipant1 b5efici>y1 or enrollee1 if su* facility or provid]1 )9 #cj days ( ! violation1 )draws ! bill t 0 9 violation ( su* provision & reimburses ! heal? plan or p>ticipant1 b5efici>y1 or enrollee1 z applicable1 9 an am\nt equal to ! diff]5ce betwe5 ! am\nt bill$ & ! am\nt all[$ to be bill$ "u ! provision1 plus int]e/1 at an int]e/ rate det]m9$ by ! ,secret>y4 7#e7 ,h>d%ip exemption ,! ,secret>y may e/abli% a h>d%ip exemption to ! p5alties "u ?is subsection4 7c7 ,cont9u$ ,applicability ( ,/ate ,law ,! sections specifi$ 9 subsection 7a77#a7 %all n be con/ru$ to sup]s$e any provision ( ,/ate law :i* e/abli%es1 implem5ts1 or cont9ues 9 effect any requirem5t or prohibition except to ! ext5t t su* requirem5t or prohibition prev5ts ! application ( a requirem5t or prohibition ( su* a section4 4 7b7 ,secret>y ( ,labor inve/igative au?ority 7#a7 ,9 g5]al ,"p #e ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aaca et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #ebb4 ,inve/igative au?ority reg>d+ violations ( c]ta9 heal? c>e provid] requirem5ts2 compla9t process 7a7 ,inve/igative au?ority ,^u receiv+ a notice f a ,/ate or ! ,secret>y ( ,heal? & ,human ,s]vices ( violations ( sections #bgii;,a-#a1 #bgii;,a-#b1 or #bgii;,a-#d ( ! ,public ,heal? ,s]vice ,act1 ! ,secret>y ( ,labor %all h ! p[] to conduct an inve/igation to id5tify patt]ns ( su* violations ) respect to p>ticipants or b5efici>ies "u a gr\p heal? plan or heal? insurance cov]age (f]$ 9 connection ) a gr\p heal? plan by a heal? insurance issu] 9 ! gr\p m>ket4 ,! ,secret>y may assi/ ,/ates1 ! ,secret>y ( ,heal? & ,human ,s]vices1 plans1 or issu]s to ensure t appropriate measures h be5 tak5 to correct su* violations retrospectively & prospectively ) respect to p>ticipants or b5efici>ies "u a gr\p heal? plan or heal? insurance cov]age (f]$ 9 connection ) a gr\p heal? plan by a heal? insurance issu] 9 ! gr\p m>ket4 7b7 ,compla9t process ,n lat] ?an ,janu>y #a1 #bjbb1 ! ,secret>y %all e/abli% a process "u :i* ! ,secret>y-- 7#a7 may receive compla9ts f p>ticipants & b5efici>ies ( gr\p heal? plans or heal? insurance cov]age (f]$ 9 connection ) su* plans relat+ to alleg$ violations ( ! sections specifi$ 9 subsection 7a72 & 7#b7 transmits su* compla9ts to ,/ates or ! ,secret>y ( ,heal? & ,human ,s]vices 7z det]m9$ appropriate by ! ,secret>y7 = pot5tial en=cem5t actions4 4 7#b7 ,te*nical am5dm5t ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajja et seq47 is am5d$ by ins]t+ aft] ! item relat+ to section #eba ! foll[+ new item3 ,sec4 #ebb4 ,inve/igative au?ority reg>d+ violations ( c]ta9 heal? c>e provid] requirem5ts2 compla9t process4 4 7c7 ,disclosure ( c]ta9 protections aga9/ balance bill+ ,section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 z add$ by section #b1 is fur!r am5d$ by add+ at ! end ! foll[+ new subsection3 7h7 ,disclosure ( c]ta9 protections aga9/ balance bill+ ,ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all make publicly available1 & 7if applicable7 po/ on a public website ( su* plan or issu]-- 7#a7 in=mation 9 pla9 language on-- 7,a7 ! requirem5ts & prohibitions appli$ "u sections #bgii;,a-#a1 #bgii;,a-#b & #bgii;,a-#d ( ! ,public ,heal? ,s]vice ,act 7relat+ to prohibitions on balance bill+ 9 c]ta9 circum/ances72 7,b7 if provid$ = "u applicable ,/ate law1 any o!r requirem5ts on provid]s & facilities reg>d+ ! am\nts su* provid]s & facilities may1 ) respect to an item or s]vice1 *>ge a p>ticipant1 b5efici>y1 or enrollee ( su* plan or cov]age ) respect to :i* su* a provid] or facility does n h a contractual relation%ip = furni%+ su* item or s]vice "u ! plan or cov]age aft] receiv+ paym5t f ! plan or cov]age = su* item or s]vice & any applicable co/-%>+ paym5t f su* p>ticipant1 b5efici>y1 or enrollee2 & 7,c7 ! requirem5ts appli$ "u subsections 7b71 7e71 & 7f72 & 7#b7 in=mation on contact+ appropriate ,/ate & ,f$]al ag5cies 9 ! case t an individual believes t su* a provid] or facility has violat$ any requirem5t describ$ 9 p>agraph 7#a7 ) respect to su* individual4 4 #d4 ,indep5d5t dispute resolution process 7a7 ,e/abli%m5t 7#a7 ,9 g5]al ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is section1 ! ,secret>y ( ,heal? & ,human ,s]vices1 ! ,secret>y ( ,labor1 & ! ,secret>y ( ! ,treasury 79 ?is section ref]r$ to z ! ,secret>ies7 %all jo9tly e/abli% by regulation an indep5d5t dispute resolution process 79 ?is section ref]r$ to z ! ,,idr process7 "u :i*1 ) respect to a paym5t made by a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket pursuant to subsection 7b77#a71 7e77#a71 or 7f77#a7 ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act1 section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable7 us+ ! recogniz$ am\nt 7z def9$ 9 & det]m9$ pursuant to section #bgai;,a7b77#c77;,h77ii7 ( ! ,public ,heal? ,s]vice ,act or subsection 7b77#c77;,h77ii7 ( section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd or section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf1 z applicable7 to a nonp>ticipat+ provid] 7z def9$ 9 subp>agraph 7,g7 ( section #bgai;,a7b77#c7 ( ! ,public ,heal? ,s]vice ,act or subp>agraph 7,g7 ( subsection 7b77#c7 ( section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd or section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf1 z applicable7 or a nonp>ticipat+ em]g5cy facility 7z def9$ 9 subp>agraph 7,f7 ( su* section #bgai;,a7b77#c7 or su* subsection 7b77#c7 ( su* section #gaf or su* section #ihaf1 z applicable7 ) respect to an item or s]vice 7or1 9 ! case ( paym5t made "u section #bgai;,a7f77#a7 ( ! ,public ,heal? ,s]vice ,act or subsection 7f77#a7 ( section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd or section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf1 z applicable1 ) respect to air ambulance s]vices7 furni%$ by su* provid] or facility-- 7,a7 subject to subp>agraph 7,b71 ! nonp>ticipat+ provid]1 nonp>ticipat+ em]g5cy facility1 or gr\p heal? plan or heal? insurance issu]1 respectively1 may1 n lat] ?an ! date specifi$ 9 p>agraph 7#b71 submit a reque/ t su* paym5t %\ld be increas$ or decreas$2 & 7,b7 9 ! case a settlem5t describ$ 9 subsection 7d77#b7 is n rea*$ ) respect to su* reque/1 an entity c]tifi$ & select$ "u subsection 7c7 %all det]m9e 9 accordance ) su* p>agraph an alt]native paym5t to be appli$1 ) respect to su* reque/4 7#b7 ,date specifi$ ,= purposes ( p>agraph 7#a77;,a71 ! date specifi$ 9 ?is p>agraph is-- 7,a7 9 ! case ( a reque/ describ$ 9 su* p>agraph 7#a77;,a7 be+ submitt$ by a nonp>ticipat+ provid] or nonp>ticipat+ em]g5cy facility1 ) respect to items & s]vices 7or air ambulance s]vices7 describ$ 9 p>agraph 7#a71 ! date t is #cj days aft] ! applicable date describ$ 9 subsection 7b77#b77;,a77ii72 or 7,b7 9 ! case ( su* a reque/ fil$ by a gr\p heal? plan or heal? insurance issu]1 ! date t is #cj days aft] ! date ( ! submission ( ! notice describ$ 9 subsection 7b77#a77;,b77ii74 7#c7 ,cl>ification ,a nonp>ticipat+ provid] may n1 ) respect to an item or s]vice 7or air ambulance s]vice7 furni%$ by su* provid]1 submit a reque/ "u ! ,,idr process if su* provid] is exempt f ! requirem5t "u subsection 7a7 ( section #bgii;,a-#b ( ! ,public ,heal? ,s]vice ,act ) respect to su* item or s]vice pursuant to subsection 7e7 ( su* section4 7b7 ,requirem5ts = reque/s ,to be eligible = submission "u ,,idr process 7#a7 ,tim+ requirem5ts ,a reque/ may n be submitt$ "u ! ,,idr process1 ) respect to items & s]vices 7or air ambulance s]vices7 furni%$ by a nonp>ticipat+ provid] or nonp>ticipat+ em]g5cy facility = :i* a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket made a paym5t pursuant to subsection 7b77#a71 7e77#a71 or 7f77#a7 ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act or subsection 7b77#a71 7e77#a71 or 7f77#a7 ( section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd or section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable7 unless-- 7,a7 9 ! case su* reque/ is be+ submitt$ by ! nonp>ticipat+ provid] or nonp>ticipat+ em]g5cy facility-- 7i7 ! provid] or facility1 respectively1 fil$1 n lat] ?an #cj days aft] ! date su* paym5t is receiv$ by ! provid] or facility1 respectively1 an appeal "u ! appeals process ( ! gr\p heal? plan or heal? insurance issu]1 ! subject ( :i* includes ! paym5t = su* items & s]vices 7or air ambulance s]vices72 & 7ii7 su* reque/ is n submitt$ be=e ! soon] ( ! date on :i* su* appeal has be5 resolv$ or ! date t is #cj days aft] ! date on :i* su* appeal is s fil$2 or 7,b7 9 ! case su* reque/ is be+ submitt$ by ! gr\p heal? plan or heal? insurance issu]-- 7i7 ! gr\p heal? plan or heal? insurance issu]1 respectively1 n lat] ?an #cj days aft] su* provid] or facility1 respectively1 receives su* paym5t1 submits to su* provid] or facility1 respectively1 a notice t su* plan or issu]1 respectively1 disputes ! am\nt ( su* paym5t ) respect to su* items & s]vices 7or air ambulance s]vices72 & 7ii7 su* reque/ is n submitt$ be=e ! date t is #cj days aft] ! date ( ! submission ( su* notice4 7#b7 ,m9imum m$ian contract$ rate ,a reque/ may n be submitt$ "u ! ,,idr process1 ) respect to items & s]vices 7or air ambulance s]vices7 furni%$ 9 a geographic area by a nonp>ticipat+ provid] or nonp>ticipat+ em]g5cy facility = :i* a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket made a paym5t pursuant to subsection 7b77#a71 7e77#a71 or 7f77#a7 ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act or subsection 7b77#a71 7e77#a71 or 7f77#a7 ( section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd or section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable7 unless-- 7,a7 9 ! case su* item or s]vice is furni%$ dur+ #bjbb1 ! m$ian contract$ rate 7z def9$ 9 subsection 7b77#c77;,e7 ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act or subsection 7b77#c77;,e7 ( section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd or section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable77 = su* ye> "u su* plan or su* cov]age ) respect to ea* su* item or s]vice furni%$ by su* a provid] or su* a facility 9 su* area is at lea/ #gej 7or1 9 ! case ( air ambulance s]vices1 is at lea/ #be1jjj72 or 7,b7 9 ! case su* item or s]vice 7or air ambulance s]vices7 is furni%$ dur+ a subsequ5t ye>1 ! m$ian contract$ rate 7z s def9$7 = su* ye> "u su* plan or su* cov]age ) respect to ea* su* item or s]vice furni%$ by su* a provid] or su* a facility 9 su* area is at lea/ ! am\nt appli$ "u ?is p>agraph = ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 7#c7 ,limitation on bat*+ ( items & s]vices 9 a reque/ ,a reque/ may n be submitt$ "u ! ,,idr process by a nonp>ticipat+ provid]1 nonp>ticipat+ em]g5cy facility1 or a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket1 ) respect to multiple items & s]vices 7or multiple air ambulance s]vices71 unless-- 7,a7 all su* items & s]vices 7or air ambulance s]vices7 includ$ 9 su* reque/ are furni%$ by ! same provid] or facility2 7,b7 paym5t = all su* items & s]vices 7or air ambulance s]vices7 made pursuant to subsection 7b77#a71 7e77#a71 or 7f77#a7 ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act or subsection 7b77#a71 7e77#a71 or 7f77#a7 ( section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd or section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable7 0 made by a s+le gr\p heal? plan or heal? insurance cov]age2 7,c7 all su* items & s]vices 7or air ambulance s]vices7 are relat$ to ! treatm5t ( ! same condition2 & 7,d7 all su* items & s]vices 7 furni%$ dur+ ! #cj-;day p]iod foll[+ ! date on :i* ! fir/ item or s]vice 7or air ambulance s]vice7 includ$ 9 su* reque/ 0 furni%$4 7c7 ,,idr entities 7#a7 ,process ( c]tification ,! process describ$ 9 subsection 7a7 %all include a c]tification process "u :i* eligible entities may be c]tifi$ to c>ry out ! ,,idr process4 7#b7 ,c]tification 7,a7 ,9 g5]al ,an entity wi%+ to p>ticipate 9 ! ,,idr process "u ?is section %all reque/ c]tification f ! ,secret>ies4 ,! ,secret>ies %all det]m9e :e!r or n to c]tify applicant entities1 tak+ into consid]ation :e!r ! entity is unbias$ & unaffiliat$ ) heal? insurance issu]s1 gr\p heal? plans1 heal? c>e facilities1 & heal? c>e provid]s & free ( conflicts ( int]e/1 9 accordance ) ! ,secret>ies' rulemak+ on det]m9+ crit]ia = conflicts ( int]e/4 7,b7 ,eligible entities ,= purposes ( ?is section1 an eligible entity is an entity t is a nongov]nm5tal entity & t agrees to comply ) ! fee limitations describ$ 9 subp>agraph 7,c74 7,c7 ,fee limitations ,= purposes ( subp>agraph 7,b71 ! fee limitations describ$ 9 ?is subp>agraph are limitations e/abli%$ by ! ,secret>ies = ! am\nt a c]tifi$ ,,idr entity may *>ge a nonp>ticipat+ provid]1 nonp>ticipat+ em]g5cy facility1 gr\p heal? plan1 or heal? insurance issu] (f]+ hea? insurance cov]age 9 ! gr\p or individual m>ket = s]vices furni%$ by su* entity ) respect to ! resolution ( a specifi$ reque/ ( su* provid]1 facility1 plan1 or issu] "u ! process describ$ 9 subsection 7a74 7#c7 ,selection ( c]tifi$ ,,idr entity ,! gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket & ! nonp>ticipat+ provid] or ! nonp>ticipat+ em]g5cy facility 7z applicable7 involv$ 9 a reque/ submitt$ "u ! ,,idr process %all agree on a c]tifi$ ,,idr entity to resolve su* reque/4 ,9 ! case t su* plan or issu] 7z applicable7 & su* provid] or facility 7z applicable7 _c s agree1 su* an entity %all be select$ by ! ,secret>ies at r&om1 9 accordance ) a mann] & timel9e specifi$ by ! ,secret>ies4 7d7 ,paym5t det]m9ation 7#a7 ,tim+ ,a c]tifi$ ,,idr entity select$ "u subsection 7c77#c7 ) respect to a reque/ "u ! ,,idr process %all1 subject to p>agraph 7#b71 n lat] ?an #cj days aft] be+ s select$1 det]m9e ! alt]native paym5t t %\ld be made = items & s]vices 7or air ambulance s]vices7 includ$ 9 su* reque/ 9 accordance ) p>agraph 7#c74 7#b7 ,settlem5t 7,a7 ,9 g5]al ,if su* entity det]m9es t a settlem5t betwe5 ! gr\p heal? plan or issu]1 z applicable1 & ! provid] or facility1 z applicable1 is likely ) respect to a reque/ "u ! ,,idr process1 ! entity may direct ! p>ties to attempt1 = a p]iod n to exce$ #aj days1 a good fai? negotiation = a settlem5t ( su* reque/4 7,b7 ,tim+ ,! p]iod = a settlem5t describ$ 9 subp>agraph 7,a7 %all accrue t[>d ! #cj-;day p]iod describ$ 9 p>agraph 7#a74 7#c7 ,det]m9ation ( alt]native paym5t 7,a7 ,9 g5]al ,! gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket 7z applicable7 & ! nonp>ticipat+ provid] or nonp>ticipat+ em]g5cy facility 7z applicable7 involv$ %all1 ) respect to a reque/ "u ! ,,idr process1 ea* submit to ! c]tifi$ ,,idr entity select$ "u subsection 7c77#c7 = su* reque/ a f9al (f] to be consid]$ = ! alt]native paym5t to be appli$ ) respect to items & s]vices 7or air ambulance s]vices7 :i* are ! subject ( ! reque/4 ,su* entity %all det]m9e1 9 accordance ) subp>agraph 7,b71 :i* su* (f] is ! mo/ reasonable & w be appli$ z ! alt]native paym5t4 7,b7 ,consid]ations 9 det]m9ation 7i7 ,9 g5]al ,9 det]m9+ :i* f9al (f] is ! alt]native paym5t to be appli$1 ! c]tifi$ ,,idr entity select$ "u subsection 7c77#c7 = su* reque/ %all consid]-- 7,i7 ! m$ian contract$ rates 7z def9$ 9 subsection 7b77#c77;,e7 ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act or subsection 7b77#c77;,e7 ( section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd or section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable77 = ! applicable ye> = items or s]vices 7or air ambulance s]vices7 t are comp>able to ! items & s]vices 7or air ambulance s]vices7 includ$ 9 ! reque/ & t are furni%$ 9 ! same geographic area 7z def9$ by ! ,secret>ies = purposes ( su* subsection7 z su* items & s]vices 7or air ambulance s]vices7 7n includ+ any facility fees ) respect to su* rates72 & 7,,ii7 9 ! case ( items & s]vices 7o!r ?an air ambulances s]vices71 ea* circum/ance describ$ 9 clause 7ii7 ) respect to :i* in=mation is submitt$ by ei!r p>ty or1 9 ! case ( air ambulance s]vices1 ea* circum/ance describ$ 9 clause 7iii7 ) respect to :i* in=mation is submitt$ by ei!r p>ty4 7ii7 ,additional circum/ances = c]ta9 items & s]vices ,= purposes ( clause 7i77,,ii71 ! circum/ances describ$ 9 ?is clause are1 ) respect to items & s]vices 7o!r ?an air ambulance s]vices7 includ$ 9 ! reque/ "u ! ,,idr process ( a nonp>ticipat+ provid]1 nonp>ticipat+ em]g5cy facility1 gr\p heal? plan1 or heal? insurance issu] ! foll[+3 7,i7 ,! level ( tra9+1 education1 exp]i5ce1 & quality & outcomes measurem5ts ( ! provid] or facility t furni%$ su* items & s]vices 7su* z ^? endors$ by ! cons5sus-bas$ entity au?oriz$ "u section #ahij ( ! ,social ,security ,act74 7,,ii7 ,! m>ket %>e held by ! provid] or facility1 or ! plan or issu]1 9 ! geographic area 9 :i* ! item or s]vice 0 provid$4 7,,iii7 ,any o!r ext5uat+ circum/ances ) respect to ! furni%+ ( su* items & s]vices t relate to ! acuity ( ! individual receiv+ su* items & s]vices or ! complexity ( furni%+ su* items & s]vices to su* individual4 7iii7 ,additional circum/ances = air ambulance s]vices ,= purposes ( clause 7i77,,ii71 ! circum/ances describ$ 9 ?is clause are1 ) respect to air ambulance s]vices includ$ 9 ! reque/ "u ! ,,idr process ( a nonp>ticipat+ provid]1 gr\p heal? plan1 or heal? insurance issu] ! foll[+3 7,i7 ,! quality & outcomes measurem5ts ( ! provid] t furni%$ su* s]vices4 7,,ii7 ,any o!r ext5uat+ circum/ances ) respect to ! furni%+ ( su* s]vices t relate to ! acuity ( ! individual receiv+ su* s]vices or ! complexity ( furni%+ su* s]vices to su* individual4 7,,iii7 ,! tra9+1 education1 exp]i5ce1 & quality ( ! m$ical p]sonnel t furni%$ su* s]vices4 7,,iv7 ,ambulance vehicle type1 includ+ ! cl9ical capability level ( su* vehicle4 7,v7 ,population d5sity ( ! pick up location 7su* z urban1 suburban1 rural1 or fronti]74 7iv7 ,prohibition on consid]ation ( bill$ *>ges ,9 det]m9+ :i* f9al (f] is ! alt]native paym5t am\nt to be appli$ ) respect to items & s]vices 7or air ambulance s]vices7 furni%$ by a provid] or facility & includ$ 9 ! reque/ "u ! ,,idr process1 ! c]tifi$ ,,idr entity select$ "u subsection 7c77#c7 ) respect to su* reque/ %all n consid] ! am\nt t w\ld h be5 bill$ by su* provid] or facility ) respect to su* items & s]vices _h ! provisions ( section #bgii;,a-#a1 #bgii;,a-#b1 or #bgii;,a-#d ( ! ,public ,heal? ,s]vice ,act 7z applicable7 n appli$4 7,c7 ,effects ( det]m9ation 7i7 ,9 g5]al ,a det]m9ation ( a c]tifi$ ,,idr entity "u subp>agraph 7,a7 %all be b9d+4 7ii7 ,limitation on c]ta9 subsequ5t ,,idr claims ,9 ! case ( a det]m9ation ( a c]tifi$ ,,idr entity "u subp>agraph 7,a71 ) respect to a reque/ submitt$ "u subsection 7a77#a77;,a7 & ! two p>ties involv$ ) su* reque/1 ! p>ty t submitt$ su* initial reque/ may n submit dur+ ! #ij-;day p]iod foll[+ su* det]m9ation a subsequ5t reque/ "u su* subsection involv+ ! same o!r p>ty to su* reque/ ) respect to su* an item or s]vice 7or air ambulance s]vice7 t 0 ! subject ( su* initial reque/4 7,d7 ,co/s ( indep5d5t dispute resolution process ,9 ! case ( a reque/ made by a nonp>ticipat+ provid]1 nonp>ticipat+ em]g5cy facility1 gr\p heal? plan1 or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket & submitt$ to a c]tifi$ ,,idr entity-- 7i7 if su* entity makes a det]m9ation ) respect to su* reque/ "u subp>agraph 7,a71 ! p>ty ^: (f] is n *os5 "u su* clause %all be responsible = pay+ all fees *>g$ by su* entity2 & 7ii7 if ! p>ties rea* a settlem5t ) respect to su* reque/ prior to su* a det]m9ation1 ea* p>ty %all pay half ( all fees *>g$ by su* entity1 unless ! p>ties o!rwise agree4 7,e7 ,paym5t ,n lat] ?an #cj days aft] ! date on :i* a det]m9ation describ$ 9 subp>agraph 7,b7 is made ) respect to a reque/ "u ! ,,idr process ( a nonp>ticipat+ provid]1 nonp>ticipat+ em]g5cy facility1 gr\p heal? plan1 or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket-- 7i7 9 ! case t ! alt]native paym5t det]m9$ to be appli$ is great] ?an ! am\nt paid ) respect to su* reque/1 su* plan or issu] 7z applicable7 %all pay directly to ! provid] or facility 7z applicable7 ! diff]5ce betwe5 su* alt]native paym5t & ! am\nt s paid2 & 7ii7 9 ! case t ! alt]native paym5t det]m9$ to be appli$ is less ?an ! am\nt paid ) respect to su* reque/1 su* provid] or facility 7z applicable7 %all pay directly to ! plan or issu] 7z applicable7 ! diff]5ce betwe5 ! am\nt s paid & su* alt]native paym5t4 7e7 ,publication ( in=mation relat+ to disputes 7#a7 ,publication ( in=mation ,= #bjbb & ea* subsequ5t ye>1 ! ,secret>ies %all make available on ! public website ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 & ! ,dep>tm5t ( ! ,treasury-- 7,a7 ! numb] ( reque/s submitt$ "u ! ,,idr process dur+ su* ye>2 7,b7 ! practice size ( ! provid]s & facilities submitt+ reque/s "u ! ,,idr process dur+ su* ye>2 7,c7 ! numb] ( su* reque/s ) respect to :i* a f9al det]m9ation 0 made "u subsection 7d77#c77;,a72 & 7,d7 ! in=mation describ$ 9 p>agraph 7#b7 ) respect to ea* reque/ ) respect to :i* su* a det]m9ation 0 s made4 7#b7 ,in=mation ) respect to reque/s ,= purposes ( p>agraph 7#a71 ! in=mation describ$ 9 ?is p>agraph is1 ) respect to a reque/ "u ! ,,idr process ( a nonp>ticipat+ provid]1 nonp>ticipat+ em]g5cy facility1 gr\p heal? plan1 or heal? insurance issu] (f]+ heal? insurance cov]age 9 ! gr\p or individual m>ket-- 7,a7 a description ( ea* item & s]vice 7or air ambulance s]vice7 includ$ 9 su* reque/2 7,b7 ! geography 9 :i* ! items & s]vices 7or air ambulance s]vices7 includ$ 9 su* reque/ 7 provid$2 7,c7 ! am\nt ( ! (f] submitt$ "u subsection 7d77#c77;,a7 by ! gr\p heal? plan or heal? insurance issu] 7z applicable7 & by ! nonp>ticipat+ provid] or nonp>ticipat+ em]g5cy facility 7z applicable7 express$ z a p]c5tage ( ! m$ian contract$ rate2 7,d7 :e!r ! (f] select$ by ! c]tifi$ ,,idr entity "u su* subsection to be ! alt]native paym5t appli$ 0 ! (f] submitt$ by su* plan or issu] 7z applicable7 or by su* provid] or facility 7z applicable7 & ! am\nt ( su* (f] s select$ express$ z a p]c5tage ( ! m$ian contract$ rate2 7,e7 ! category & practice specialty ( ea* su* provid] or facility involv$ 9 furni%+ su* items & s]vices 7or1 9 ! case ( air ambulance s]vices1 ! ambulance vehicle type1 includ+ ! cl9ical capability level ( su* vehicle72 & 7,f7 ! id5tity ( ! gr\p heal? plan or heal? insurance issu]1 provid]1 or facility1 ) respect to ! reque/4 7#c7 ,,idr entity requirem5ts ,= #bjbb & ea* subsequ5t ye>1 an ,,idr entity1 z a condition ( c]tification z an ,,idr entity1 %all submit to ! ,secret>ies su* in=mation z ! ,secret>ies det]m9es necess>y = ! ,secret>ies to c>ry out ! provisions ( ?is subsection4 7f7 ,en=cem5t 7#a7 ,9 g5]al ,any heal? c>e provid]1 heal? c>e facility1 gr\p heal? plan1 or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age t violates a provision ( ?is section %all be subject to a civil monet>y p5alty 9 an am\nt n to exce$ #aj1jjj = ea* su* violation4 7#b7 ,application ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 7o!r ?an subsections 7a7 & 7b7 & ! fir/ s5t5ce ( subsection 7c77#a77 %all apply ) respect to a civil monet>y p5alty impos$ "u ?is subsection 9 ! same mann] z su* provisions apply ) respect to a p5alty or proce$+ "u subsection 7a7 ( su* section1 except t any ref]5ce to ! ,secret>y 9 su* provisions %all be treat$ z a ref]5ce to ! ,secret>ies4 7g7 ,def9itions ,9 ?is subsection1 t]ms gr\p heal? plan1 gr\p m>ket1 heal? insurance issu]1 heal? insurance cov]age1 individual heal? insurance cov]age1 gr\p heal? insurance cov]age1 & individual m>ket h ! mean+s giv5 su* t]ms1 respectively1 9 section #bgia ( ! ,public ,heal? ,s]vice ,act4 #e4 ,advisory committee on gr\nd ambulance & pati5t bill+ 7a7 ,9 g5]al ,n lat] ?an #fj days aft] ! date ( enactm5t ( ?is ,act1 ! ,secret>y ( ,labor1 ,secret>y ( ,heal? & ,human ,s]vices1 & ! ,secret>y ( ! ,treasury 7! ,secret>ies7 %all jo9tly e/abli% an advisory committee = ! purpose ( review+ options to improve ! disclosure ( *>ges & fees = gr\nd ambulance s]vices1 bett] in=m consum]s ( insurance options = su* s]vices1 & protect consum]s f balance bill+4 7b7 ,composition ( ! advisory committee ,! advisory committee %all be compos$ ( ! foll[+ memb]s3 7#a7 ,! ,secret>y ( ,labor1 or ! ,secret>y's designee4 7#b7 ,! ,secret>y ( ,heal? & ,human ,s]vices1 or ! ,secret>y's designee4 7#c7 ,! ,secret>y ( ! ,treasury1 or ! ,secret>y's designee4 7#d7 ,"o repres5tative1 to be appo9t$ jo9tly by ! ,secret>ies1 = ea* ( ! foll[+3 7,a7 ,ea* relevant ,f$]al ag5cy1 z det]m9$ by ! ,secret>ies4 7,b7 ,/ate insurance regulators4 7,c7 ,heal? insurance provid]s or trade organization4 7,d7 ,pati5t advocacy gr\ps4 7,e7 ,consum] advocacy gr\ps4 7,f7 ,/ate & local gov]nm5ts4 7,g7 ,physician specializ+ 9 em]g5cy1 trauma1 c>diac1 or /roke4 7#e7 ,?ree repres5tatives1 to be appo9t$ jo9tly by ! ,secret>ies1 to repres5t ! v>i\s segm5ts ( ! gr\nd ambulance indu/ry4 7#f7 ,up to an additional ?ree repres5tatives o!rwise n describ$ 9 p>agraphs 7#a7 ?r\gh 7#e71 z det]m9$ necess>y & appropriate by ! ,secret>ies4 7c7 ,consultation ,! advisory committee %all1 z appropriate1 consult ) relevant exp]ts & /akehold]s1 includ+ ^? n o!rwise includ$ "u subsection 7b71 :ile conduct+ ! review describ$ 9 subsection 7a74 7d7 ,recomm5dations ,! advisory committee %all make recomm5dations ) respect to disclosure ( *>ges & fees = gr\nd ambulance s]vices & insurance cov]age1 consum] protection & en=cem5t au?orities ( ! ,dep>tm5ts ( ,labor1 ,heal? & ,human ,s]vices1 & ! ,treasury & ,/ate au?orities1 & ! prev5tion ( balance bill+ to consum]s4 ,! recomm5dations %all address1 at a m9imum-- 7#a7 options1 be/ practices1 & id5tifi$ /&>ds to prev5t in/ances ( balance bill+2 7#b7 /eps t c be tak5 by ,/ate legislatures1 ,/ate insurance regulators1 ,/ate attorneys g5]al1 & o!r ,/ate (ficials z appropriate1 consi/5t ) curr5t legal au?orities reg>d+ consum] protection2 & 7#c7 legislative options = ,congress to prev5t balance bill+4 7e7 ,report ,n lat] ?an #ahj days aft] ! date ( ! fir/ meet+ ( ! advisory committee1 ! advisory committee %all submit to ! ,secret>ies1 & ! ,committees on ,education & ,labor1 ,en]gy & ,comm]ce1 & ,ways & ,means ( ! ,h\se ( ,repres5tatives & ! ,committees on ,f9ance & ,heal?1 ,education1 ,labor1 & ,p5sions a report conta9+ ! recomm5dations made "u subsection 7d74 7f7 ,rulemak+ ,^u receipt ( ! report "u subsection 7e71 ! ,secret>ies %all consid] ! recomm5dations ( ! advisory committee & issue regulations or o!r guidance z deem$ necess>y to provide consum] protections = pati5ts ( gr\nd ambulance provid]s4 #f4 ,improv+ provid] directories 7a7 ,,phsa ,"p ,a ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #bgcj4 ,protect+ pati5ts & improv+ ! accuracy ( provid] directory in=mation 7a7 ,network /atus ( provid]s 7#a7 ,9 g5]al ,beg9n+ on ! date t is "o ye> aft] ! date ( enactm5t ( ?is section1 a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all-- 7,a7 e/abli% bus9ess processes to ensure t all enrollees 9 su* plan or cov]age receive pro( ( a heal? c>e provid]'s network /atus1 bas$ on :at a plan or issu] kn[s or %\ld "k-- 7i7 ^u a telephone inquiry by an enrollee-- 7,i7 ?r\gh a writt5 electronic communication f ! plan or issu] to ! enrollee1 z soon z practicable & n lat] ?an #a bus9ess day aft] su* inquiry is made by su* p>ticipant1 b5efici>y1 or enrollee = su* in=mation2 7,,ii7 ?r\gh an oral communication f ! plan or issu] to ! enrollee1 z soon z practicable & n lat] ?an #a bus9ess day aft] su* inquiry is made by su* enrollee = su* in=mation1 :i* communication %all be docum5t$ by su* plan or issu]1 & su* docum5tation %all be kept 9 ! enrollee's file = a m9imum ( #b ye>s2 & 7ii7 9 real-"t ?r\gh an onl9e heal? c>e provid] directory se>* tool ma9ta9$ by ! plan or issu]2 & 7,b7 include 9 any pr9t directory-- 7i7 a disclosure t ! in=mation includ$ 9 ! directory is accurate z ( ! date ( ! la/ data update & t enrollees or prospective enrollees %\ld consult ! gr\p heal? plan's or issu]'s electronic provid] directory on its website or call a specifi$ cu/om] s]vice telephone numb] to obta9 ! mo/ curr5t provid] directory in=mation2 & 7ii7 a li/ ( ! categories ( provid]s ( ancill>y s]vices = :i* ! plan or cov]age has no 9-network provid]s4 7#b7 ,gr\p heal? plan & heal? insurance issu] bus9ess processes ,beg9n+ on ! date t is "o ye> aft] ! date ( ! enactm5t ( ?is section1 a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all e/abli% bus9ess processes to-- 7,a7 v]ify & update1 at lea/ once e #ij days1 ! provid] directory in=mation = all provid]s includ$ 9 ! onl9e heal? c>e provid] directory se>* tool describ$ 9 p>agraph 7#a77;,a77ii72 & 7,b7 remove any provid] f su* onl9e directory se>* tool if su* provid] has n v]ifi$ ! directory in=mation )9 ! previ\s #f mon?s or ! plan or issu] has be5 unable to v]ify ! provid]'s network p>ticipation4 7b7 ,co/-,%>+ limitations ,a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all n apply1 & %all ensure t no provid] applies1 co/-%>+ to an enrollee = treatm5t or s]vices provid$ by a heal? c>e provid] 9 excess ( ! normal co/-%>+ appli$ = su* treatm5t or s]vices provid$ 9-network 7includ+ any balance bill issu$ by ! heal? c>e provid] involv$71 if su* enrollee1 or heal? c>e provid] ref]r+ su* enrollee1 demon/rates 7bas$ on ! electronic1 writt5 in=mation describ$ 9 subsection 7a77#a77;,a77i77,i71 ! oral confirmation describ$ 9 subsection 7a77#a77;,a77i77,,ii7 receiv$ by ! enrollee n m ?an #cj days be=e ! date ! treatm5t or s]vices 7 receiv$1 or a copy ( ! onl9e provid] directory describ$ 9 subsection 7a77#a77;,a77ii7 on a date n m ?an #cj days be=e ! date ! treatm5t or s]vices 7 receiv$71 t ! enrollee reli$ on ! in=mation describ$ 9 subsection 7a77#a7 = :i* su* enrollee provides su* docum5tation1 t indicat$ t ! provid] is an 9-network provid]1 if ! provid] 0 out-(-network at ! "t ! treatm5t or s]vice involv$ 0 receiv$4 7c7 ,def9ition ,= purposes ( ?is section1 ! t]m provid] directory in=mation includes ! names1 addresses1 specialty1 & telephone numb]s ( individual heal? c>e provid]s1 & ! names1 addresses1 & telephone numb]s ( ea* m$ical gr\p1 cl9ic1 or facility contract$ to p>ticipate 9 any ( ! networks ( ! gr\p heal? plan or heal? insurance cov]age involv$4 7d7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to preempt any provision ( ,/ate law relat+ to heal? c>e provid] directories4 4 7b7 ,,erisa ,subp>t ,b ( "p #g ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe et seq471 z am5d$ by section #b1 is fur!r am5d$ by add+ at ! end ! foll[+3 #gag4 ,protect+ pati5ts & improv+ ! accuracy ( provid] directory in=mation 7a7 ,network /atus ( provid]s 7#a7 ,9 g5]al ,beg9n+ on ! date t is "o ye> aft] ! date ( enactm5t ( ?is section1 a gr\p heal? plan 7or heal? insurance cov]age (f]$ 9 connection ) su* a plan7 %all-- 7,a7 e/abli% bus9ess processes to ensure t all p>ticipants & b5efici>ies 9 su* plan or cov]age receive pro( ( a heal? c>e provid]'s network /atus1 bas$ on :at a plan or issu] ( su* cov]age kn[s or %\ld "k-- 7i7 ^u a telephone inquiry by a p>ticipant or b5efici>y-- 7,i7 ?r\gh a writt5 electronic communication f ! plan or issu] to ! p>ticipant or b5efici>y1 z soon z practicable & n lat] ?an #a bus9ess day aft] su* inquiry is made by su* p>ticipant or b5efici>y = su* in=mation2 7,,ii7 ?r\gh an oral communication f ! plan or issu] to ! p>ticipant or b5efici>y1 z soon z practicable & n lat] ?an #a bus9ess day aft] su* inquiry is made by su* p>ticipant or b5efici>y = su* in=mation1 :i* communication %all be docum5t$ by su* plan or issu]1 & su* docum5tation %all be kept 9 ! p>ticipant's or b5efici>y's file = a m9imum ( #b ye>s2 & 7ii7 9 real-"t ?r\gh an onl9e heal? c>e provid] directory se>* tool ma9ta9$ by ! plan or issu]2 & 7,b7 include 9 any pr9t directory-- 7i7 a disclosure t ! in=mation includ$ 9 ! directory is accurate z ( ! date ( ! la/ data update & t p>ticipants or b5efici>ies or prospective p>ticipants or b5efici>ies %\ld consult ! gr\p heal? plan's or issu]'s electronic provid] directory on its website or call a specifi$ cu/om] s]vice telephone numb] to obta9 ! mo/ curr5t provid] directory in=mation2 & 7ii7 a li/ ( ! categories ( provid]s ( ancill>y s]vices = :i* ! plan or cov]age has no 9-network provid]s4 7#b7 ,gr\p heal? plan & heal? insurance issu] bus9ess processes ,beg9n+ on ! date t is "o ye> aft] ! date ( enactm5t ( ?is section1 a gr\p heal? plan 7or heal? insurance cov]age (f]$ 9 connection ) su* a plan7 %all e/abli% bus9ess processes to-- 7,a7 v]ify & update1 at lea/ once e #ij days1 ! provid] directory in=mation = all provid]s includ$ 9 ! onl9e heal? c>e provid] directory se>* tool describ$ 9 p>agraph 7#a77;,a77ii72 & 7,b7 remove any provid] f su* onl9e directory se>* tool if su* provid] has n v]ifi$ ! directory in=mation )9 ! previ\s #f mon?s or ! plan or issu] has be5 unable to v]ify ! provid]'s network p>ticipation4 7b7 ,co/-,%>+ limitations ,a gr\p heal? plan 7or heal? insurance cov]age (f]$ 9 connection ) su* a plan7 %all n apply1 & %all ensure t no provid] applies1 co/-%>+ to a p>ticipant or b5efici>y = treatm5t or s]vices provid$ by a heal? c>e provid] 9 excess ( ! normal co/-%>+ appli$ = su* treatm5t or s]vices provid$ 9-network 7includ+ any balance bill issu$ by ! heal? c>e provid] involv$71 if su* p>ticipant or b5efici>y1 or heal? c>e provid] ref]r+ su* p>ticipant or b5efici>y1 demon/rates 7bas$ on ! electronic1 writt5 in=mation describ$ 9 subsection 7a77#a77;,a77i77,i71 ! oral confirmation describ$ 9 subsection 7a77#a77;,a77i77,,ii7 receiv$ by ! p>ticipant or b5efici>y n m ?an #cj days be=e ! date ! treatm5t or s]vices 7 receiv$1 or a copy ( ! onl9e provid] directory describ$ 9 subsection 7a77#a77;,a77ii7 on a date n m ?an #cj days be=e ! date ! treatm5t or s]vices 7 receiv$71 t ! p>ticipant or b5efici>y reli$ on ! in=mation describ$ 9 subsection 7a77#a7 = :i* su* p>ticipant or b5efici>y provides su* docum5tation1 t indicat$ t ! provid] is an 9-network provid]1 if ! provid] 0 out-(-network at ! "t ! treatm5t or s]vice involv$ 0 receiv$4 7c7 ,def9ition ,= purposes ( ?is section1 ! t]m provid] directory in=mation includes ! names1 addresses1 specialty1 & telephone numb]s ( individual heal? c>e provid]s1 & ! names1 addresses1 & telephone numb]s ( ea* m$ical gr\p1 cl9ic1 or facility contract$ to p>ticipate 9 any ( ! networks ( ! gr\p heal? plan or heal? insurance cov]age involv$4 4 7c7 ,,irc ,sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by section #b1 is fur!r am5d$ by add+ at ! end ! foll[+3 #ihag4 ,protect+ pati5ts & improv+ ! accuracy ( provid] directory in=mation 7a7 ,network /atus ( provid]s 7#a7 ,9 g5]al ,beg9n+ on ! date t is "o ye> aft] ! date ( enactm5t ( ?is section1 a gr\p heal? plan %all-- 7,a7 e/abli% bus9ess processes to ensure t all p>ticipants or b5efici>ies 9 su* plan receive pro( ( a heal? c>e provid]'s network /atus1 bas$ on :at a plan or issu] kn[s or %\ld "k-- 7i7 ^u a telephone inquiry by a p>ticipant or b5efici>y-- 7,i7 ?r\gh a writt5 electronic communication f ! plan to ! p>ticipant or b5efici>y1 z soon z practicable & n lat] ?an #a bus9ess day aft] su* inquiry is made by su* p>ticipant or b5efici>y = su* in=mation2 7,,ii7 ?r\gh an oral communication f ! plan to ! p>ticipant or b5efici>y1 z soon z practicable & n lat] ?an #a bus9ess day aft] su* inquiry is made by su* p>ticipant or b5efici>y = su* in=mation1 :i* communication %all be docum5t$ by su* plan1 & su* docum5tation %all be kept 9 ! p>ticipant's or b5efici>y's file = a m9imum ( #b ye>s2 & 7ii7 9 real-"t ?r\gh an onl9e heal? c>e provid] directory se>* tool ma9ta9$ by ! plan2 & 7,b7 include 9 any pr9t directory-- 7i7 a disclosure t ! in=mation includ$ 9 ! directory is accurate z ( ! date ( ! la/ data update & t p>ticipants or b5efici>ies or prospective p>ticipants or b5efici>ies %\ld consult ! gr\p heal? plan's electronic provid] directory on its website or call a specifi$ cu/om] s]vice telephone numb] to obta9 ! mo/ curr5t provid] directory in=mation2 & 7ii7 a li/ ( ! categories ( provid]s ( ancill>y s]vices = :i* ! plan or cov]age has no 9-network provid]s4 7#b7 ,gr\p heal? plan bus9ess processes ,beg9n+ on ! date t is "o ye> aft] ! date ( enactm5t ( ?is section1 a gr\p heal? plan %all e/abli% bus9ess processes to-- 7,a7 v]ify & update1 at lea/ once e #ij days1 ! provid] directory in=mation = all provid]s includ$ 9 ! onl9e heal? c>e provid] directory se>* tool describ$ 9 p>agraph 7#a77;,a77ii72 & 7,b7 remove any provid] f su* onl9e directory se>* tool if su* provid] has n v]ifi$ ! directory in=mation )9 ! previ\s #f mon?s or ! plan or issu] has be5 unable to v]ify ! provid]'s network p>ticipation4 7b7 ,co/-,%>+ limitations ,a gr\p heal? plan %all n apply1 & %all ensure t no provid] applies1 co/-%>+ to a p>ticipant or b5efici>y = treatm5t or s]vices provid$ by a heal? c>e provid] 9 excess ( ! normal co/-%>+ appli$ = su* treatm5t or s]vices provid$ 9-network 7includ+ any balance bill issu$ by ! heal? c>e provid] involv$71 if su* p>ticipant or b5efici>y1 or heal? c>e provid] ref]r+ su* p>ticipant or b5efici>y1 demon/rates 7bas$ on ! electronic1 writt5 in=mation describ$ 9 subsection 7a77#a77;,a77i77,i71 ! oral confirmation describ$ 9 subsection 7a77#a77;,a77i77,,ii7 receiv$ by ! p>ticipant or b5efici>y n m ?an #cj days be=e ! date ! treatm5t or s]vices 7 receiv$1 or a copy ( ! onl9e provid] directory describ$ 9 subsection 7a77#a77;,a77ii7 on a date n m ?an #cj days be=e ! date ! treatm5t or s]vices 7 receiv$71 t ! p>ticipant or b5efici>y reli$ on ! in=mation describ$ 9 subsection 7a77#a7 = :i* su* p>ticipant or b5efici>y provides su* docum5tation1 t indicat$ t ! provid] is an 9-network provid]1 if ! provid] 0 out-(-network at ! "t ! treatm5t or s]vice involv$ 0 receiv$4 7c7 ,def9ition ,= purposes ( ?is section1 ! t]m provid] directory in=mation includes ! names1 addresses1 specialty1 & telephone numb]s ( individual heal? c>e provid]s1 & ! names1 addresses1 & telephone numb]s ( ea* m$ical gr\p1 cl9ic1 or facility contract$ to p>ticipate 9 any ( ! networks ( ! gr\p heal? plan involv$4 7d7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to preempt any provision ( ,/ate law relat+ to heal? c>e provid] directories4 4 7d7 ,cl]ical am5dm5ts 7#a7 ,,erisa ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajja et seq471 z am5d$ by section #b1 is fur!r am5d$ by ins]t+ aft] ! item relat+ to section #gaf ! foll[+ new item3 ,sec4 #gag4 ,protect+ pati5ts & improv+ ! accuracy ( provid] directory in=mation4 4 7#b7 ,,irc ,! table ( sections = sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by section #b1 is fur!r am5d$ by add+ at ! end ! foll[+ new item3 ,sec4 #ihag4 ,protect+ pati5ts & improv+ ! accuracy ( provid] directory in=mation4 4 7e7 ,provid] requirem5ts ,"p ,d ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq471 z add$ by section #c1 is am5d$-- 7#a7 by r$esignat+ section #bgii;,a-#e z section #bgii;,a-#g2 & 7#b7 by ins]t+ aft] section #bgii;,a-#d ! foll[+ new section3 #bgii;,a-#e4 ,provid] requirem5ts to protect pati5ts & improve ! accuracy ( provid] directory in=mation 7a7 ,provid] bus9ess processes ,a heal? c>e provid] %all h 9 place bus9ess processes to ensure ! timely provision ( provid] directory in=mation to a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age to support compliance by su* plans or issu]s ) section #bgcj7;a77#a71 section #gag7;a77#a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihag7;a77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable74 ,su* provid]s %all submit provid] directory in=mation to a plan or issu]s1 at a m9imum-- 7#a7 :5 ! provid] beg9s a network agreem5t ) a plan or ) an issu] ) respect to c]ta9 cov]age2 7#b7 :5 ! provid] t]m9ates a network agreem5t ) a plan or ) an issu] ) respect to c]ta9 cov]age2 7#c7 :5 !re are mat]ial *anges to ! cont5t ( provid] directory in=mation describ$ 9 section #bgcj7;a77#a71 section #gag7;a77#a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihag7;a77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable72 & 7#d7 e #ij days ?r\gh\t ! duration ( ! network agreem5t ) a plan or issu]4 7b7 ,en=cem5t 7#a7 ,civil p5alties 7,a7 ,9 g5]al ,subject to p>agraph 7#b71 a heal? c>e provid] t violates a requirem5t "u subsection 7a7 or takes actions t prev5t a gr\p heal? plan or heal? insurance issu] f comply+ ) subsection 7a77#a7 or 7b7 ( sections #bgcj1 #gag ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or #ihag ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable7 %all be subject to a civil monet>y p5alty ( n m ?an #aj1jjj = ea* act con/itut+ su* violation4 7,b7 ,safe h>bor ,! ,secret>y may waive ! p5alty describ$ "u p>agraph 7#a7 ) respect to a heal? c>e provid] t unkn[+ly violates section #bgcj7;b77#a71 section #gag7;b77#a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihag7;b77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable7 ) respect to an enrollee if su* provid] resc9ds ! bill involv$ &1 if applicable1 reimburses ! enrollee )9 #cj days ( ! date on :i* ! provid] bill$ ! enrollee 9 violation ( su* subsection4 7,c7 ,proc$ure ,! provisions ( section #aabh;,a ( ! ,social ,security ,act1 o!r ?an subsections 7a7 & 7b7 & ! fir/ s5t5ce ( subsection 7c77#a7 ( su* section1 %all apply to civil money p5alties "u ?is subsection 9 ! same mann] z su* provisions apply to a p5alty or proce$+ "u section #aabh;,a ( ! ,social ,security ,act4 7#b7 ,refunds to enrollees ,if a heal? c>e provid] submits a bill to an enrollee bas$ on co/-%>+ = treatm5t or s]vices provid$ by ! heal? c>e provid] t is 9 excess ( ! normal co/-%>+ appli$ = su* treatm5t or s]vices provid$ 9-network1 z prohibit$ "u section #bgcj7;b71 section #gag7;b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihag7;b7 ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable7 & ! enrollee pays su* bill1 ! provid] %all reimburse ! enrollee = ! full am\nt paid by ! enrollee 9 excess ( ! 9-network co/-%>+ am\nt = ! treatm5t or s]vices involv$1 plus int]e/1 at an int]e/ rate det]m9$ by ! ,secret>y4 7c7 ,limitation ,no?+ 9 ?is section %all prohibit a provid] f requir+ 9 ! t]ms ( a contract1 or contract t]m9ation1 ) a gr\p heal? plan or heal? insurance issu]-- 7#a7 t ! plan or issu] remove1 at ! "t ( t]m9ation ( su* contract1 ! provid] f a directory ( ! plan or issu] describ$ 9 section #bgcj7;a77#a71 section #gag7;a77#a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihag7;a77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable72 or 7#b7 t ! plan or issu] be> f9ancial responsibility1 includ+ "u section #bgcj7;b71 section #gag7;b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihag7;b7 ( ! ,int]nal ,rev5ue ,code ( #aihf 7z applicable7 = provid+ inaccurate network /atus in=mation to an enrollee4 7d7 ,def9ition ,= purposes ( ?is section1 ! t]m provid] directory in=mation includes ! names1 addresses1 specialty1 & telephone numb]s ( individual heal? c>e provid]s1 & ! names1 addresses1 & telephone numb]s ( ea* m$ical gr\p1 cl9ic1 or facility contract$ to p>ticipate 9 any ( ! networks ( ! gr\p heal? plan or heal? insurance cov]age involv$4 7e7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to preempt any provision ( ,/ate law relat+ to heal? c>e provid] directories4 4 #g4 ,increas+ transp>5cy 9 heal? cov]age 7a7 ,disclosure ( direct & indirect comp5sation = brok]s & consultants to employ]-,sponsor$ heal? plans & enrollees 9 plans on ! individual m>ket 7#a7 ,gr\p heal? plans ,section #djh7;b77#b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aajh7;b77#b77 is am5d$-- 7,a7 by /rik+ 7#b7 ,contract+ or mak+ & ins]t+ 7#b77;,a7 ,contract+ or mak+2 & 7,b7 by add+ at ! end ! foll[+3 7,b7 7i7 ,no contract or arrangem5t = s]vices betwe5 a cov]$ plan & a cov]$ s]vice provid]1 & no ext5sion or r5ewal ( su* a contract or arrangem5t1 is reasonable )9 ! mean+ ( ?is p>agraph unless ! requirem5ts ( ?is subp>agraph are met4 7ii7 7,i7 ,= purposes ( ?is subp>agraph3 7aa7 ,! t]m cov]$ plan means a gr\p heal? plan z def9$ section #gcc7;a74 7bb7 ,! t]m cov]$ s]vice provid] means a s]vice provid] t ent]s into a contract or arrangem5t ) ! cov]$ plan & reasonably expects #a1jjj 7or su* am\nt z ! ,secret>y may e/abli% 9 regulations to acc\nt = inflation s9ce ! date ( ! enactm5t ( ! ,ban ,surprise ,bill+ ,act1 z appropriate7 or m 9 comp5sation1 direct or indirect1 to be receiv$ 9 connection ) provid+ "o or m ( ! foll[+ s]vices1 pursuant to ! contract or arrangem5t1 reg>dless ( :e!r su* s]vices w be p]=m$1 or su* comp5sation receiv$1 by ! cov]$ s]vice provid]1 an affiliate1 or a subcontractor3 7,,aa7 ,brok]age s]vices1 = :i* ! cov]$ s]vice provid]1 an affiliate1 or a subcontractor reasonably expects to receive indirect comp5sation or direct comp5sation describ$ 9 item 7dd71 provid$ to a cov]$ plan ) respect to selection ( insurance products 7includ+ vision & d5tal71 recordkeep+ s]vices1 m$ical managem5t v5dor1 b5efits adm9i/ration 7includ+ vision & d5tal71 /op-loss insurance1 ph>macy b5efit managem5t s]vices1 wellness s]vices1 transp>5cy tools & v5dors1 gr\p pur*as+ organization pref]r$ v5dor panels1 disease managem5t v5dors & products1 compliance s]vices1 employee assi/ance programs1 or ?ird p>ty adm9i/ration s]vices4 7,,bb7 ,consult+1 = :i* ! cov]$ s]vice provid]1 an affiliate1 or a subcontractor reasonably expects to receive indirect comp5sation or direct comp5sation describ$ 9 item 7dd71 relat$ to ! developm5t or implem5tation ( plan design1 insurance or insurance product selection 7includ+ vision & d5tal71 recordkeep+1 m$ical managem5t1 b5efits adm9i/ration selection 7includ+ vision & d5tal71 /op-loss insurance1 ph>macy b5efit managem5t s]vices1 wellness design & managem5t s]vices1 transp>5cy tools1 gr\p pur*as+ organization agreem5ts & s]vices1 p>ticipation 9 & s]vices f pref]r$ v5dor panels1 disease managem5t1 compliance s]vices1 employee assi/ance programs1 or ?ird p>ty adm9i/ration s]vices4 7cc7 ,! t]m affiliate1 ) respect to a cov]$ s]vice provid]1 means an entity t directly or indirectly 7?r\gh "o or m int]m$i>ies7 controls1 is controll$ by1 or is "u common control )1 su* provid]1 or is an (fic]1 director1 or employee (1 or p>tn] 91 su* provid]4 7dd7 7,,aa7 ,! t]m comp5sation means any?+ ( monet>y value1 b does n include non-monet>y comp5sation valu$ at #bej 7or su* am\nt z ! ,secret>y may e/abli% 9 regulations to acc\nt = inflation s9ce ! date ( enactm5t ( ! ,ban ,surprise ,bill+ ,act1 z appropriate7 or less1 9 ! aggregate1 dur+ ! t]m ( ! contract or arrangem5t4 7,,bb7 ,! t]m direct comp5sation means comp5sation receiv$ directly f a cov]$ plan4 7,,cc7 ,! t]m indirect comp5sation means comp5sation receiv$ f any s\rce o!r ?an ! cov]$ plan1 ! plan sponsor1 ! cov]$ s]vice provid]1 or an affiliate4 ,comp5sation receiv$ f a subcontractor is indirect comp5sation1 unless x is receiv$ 9 connection ) s]vices p]=m$ "u a contract or arrangem5t ) a subcontractor4 7ee7 ,! t]m responsible plan fiduci>y means a fiduci>y ) au?ority to cause ! cov]$ plan to ent] into1 or ext5d or r5ew1 ! contract or arrangem5t4 7ff7 ,! t]m subcontractor means any p]son or entity 7or an affiliate ( su* p]son or entity7 t is n an affiliate ( ! cov]$ s]vice provid] & t1 pursuant to a contract or arrangem5t ) ! cov]$ s]vice provid] or an affiliate1 reasonably expects to receive #a1jjj 7or su* am\nt z ! ,secret>y may e/abli% 9 regulations to acc\nt = inflation s9ce ! date ( enactm5t ( ! ,ban ,surprise ,bill+ ,act1 z appropriate7 or m 9 comp5sation = p]=m+ "o or m s]vices describ$ 9 item 7bb7 "u a contract or arrangem5t ) ! cov]$ plan4 7,,ii7 ,= purposes ( ?is subp>agraph1 a description ( comp5sation or co/ may be express$ z a monet>y am\nt1 =mula1 or a p] capita *>ge = ea* enrollee or1 if ! comp5sation or co/ _c reasonably be express$ 9 su* t]ms1 by any o!r reasonable me?od1 includ+ a disclosure t additional comp5sation may be e>n$ b may n be calculat$ at ! "t ( contract if su* a disclosure includes a description ( ! circum/ances "u :i* ! additional comp5sation may be e>n$ & a reasonable & good fai? e/imate if ! cov]$ s]vice provid] _c o!rwise readily describe comp5sation or co/ & expla9s ! me?odology & assumptions us$ to prep>e su* e/imate4 ,any su* description %all conta9 suffici5t in=mation to p]mit evaluation ( ! reasonabl5ess ( ! comp5sation or co/4 7,,iii7 ,no p]son or entity is a cov]$ s]vice provid] )9 ! mean+ ( subclause 7,i77bb7 solely on ! basis ( provid+ s]vices z an affiliate or a subcontractor t is p]=m+ "o or m ( ! s]vices describ$ 9 subitem 7,,aa7 or 7,,bb7 ( su* subclause "u ! contract or arrangem5t ) ! cov]$ plan4 7iii7 ,a cov]$ s]vice provid] %all disclose to a responsible plan fiduci>y1 9 writ+1 ! foll[+3 7,i7 ,a description ( ! s]vices to be provid$ to ! cov]$ plan pursuant to ! contract or arrangem5t4 7,,ii7 ,if applicable1 a /atem5t t ! cov]$ s]vice provid]1 an affiliate1 or a subcontractor w provide1 or reasonably expects to provide1 s]vices pursuant to ! contract or arrangem5t directly to ! cov]$ plan z a fiduci>y 7)9 ! mean+ ( section #c7ba774 7,,iii7 ,a description ( all direct comp5sation1 ei!r 9 ! aggregate or by s]vice1 t ! cov]$ s]vice provid]1 an affiliate1 or a subcontractor reasonably expects to receive 9 connection ) ! s]vices describ$ 9 subclause 7,i74 7,,iv7 7aa7 ,a description ( all indirect comp5sation t ! cov]$ s]vice provid]1 an affiliate1 or a subcontractor reasonably expects to receive 9 connection ) ! s]vices describ$ 9 subclause 7,i7-- 7,,aa7 includ+ comp5sation f a v5dor to a brok]age firm bas$ on a /ructure ( inc5tives n solely relat$ to ! contract ) ! cov]$ plan2 & 7,,bb7 n includ+ comp5sation receiv$ by an employee f an employ] on acc\nt ( "w p]=m$ by ! employee4 7bb7 ,a description ( ! arrangem5t betwe5 ! pay] & ! cov]$ s]vice provid]1 an affiliate1 or a subcontractor1 z applicable1 pursuant to :i* su* indirect comp5sation is paid4 7cc7 ,id5tification ( ! s]vices = :i* ! indirect comp5sation w be receiv$1 if applicable4 7dd7 ,id5tification ( ! pay] ( ! indirect comp5sation4 7,v7 ,a description ( any comp5sation t w be paid among ! cov]$ s]vice provid]1 an affiliate1 or a subcontractor1 9 connection ) ! s]vices describ$ 9 subclause 7,i7 if su* comp5sation is set on a transaction basis 7su* z commissions1 f9d]'s fees1 or o!r simil> inc5tive comp5sation bas$ on bus9ess plac$ or reta9$71 includ+ id5tification ( ! s]vices = :i* su* comp5sation w be paid & id5tification ( ! pay]s & recipi5ts ( su* comp5sation 7includ+ ! /atus ( a pay] or recipi5t z an affiliate or a subcontractor71 reg>dless ( :e!r su* comp5sation also is disclos$ pursuant to subclause 7,,iii7 or 7,,iv74 7,,vi7 ,a description ( any comp5sation t ! cov]$ s]vice provid]1 an affiliate1 or a subcontractor reasonably expects to receive 9 connection ) t]m9ation ( ! contract or arrangem5t1 & h[ any prepaid am\nts w be calculat$ & refund$ ^u su* t]m9ation4 7iv7 ,a cov]$ s]vice provid] %all disclose to a responsible plan fiduci>y1 9 writ+ a description ( ! mann] 9 :i* ! comp5sation describ$ 9 clause 7iii71 z applicable1 w be receiv$4 7v7 7,i7 ,a cov]$ s]vice provid] %all disclose ! in=mation requir$ "u clauses 7iii7 & 7iv7 to ! responsible plan fiduci>y n lat] ?an ! date t is reasonably 9 advance ( ! date on :i* ! contract or arrangem5t is ent]$ into1 & ext5d$ or r5ew$4 7,,ii7 ,a cov]$ s]vice provid] %all disclose any *ange to ! in=mation requir$ "u clause 7iii7 & 7iv7 z soon z practicable1 b n lat] ?an #fj days f ! date on :i* ! cov]$ s]vice provid] is in=m$ ( su* *ange1 unless su* disclosure is preclud$ due to extraord9>y circum/ances beyond ! cov]$ s]vice provid]'s control1 9 :i* case ! in=mation %all be disclos$ z soon z practicable4 7vi7 7,i7 ,^u ! writt5 reque/ ( ! responsible plan fiduci>y or cov]$ plan adm9i/rator1 a cov]$ s]vice provid] %all furni% any o!r in=mation relat+ to ! comp5sation receiv$ 9 connection ) ! contract or arrangem5t t is requir$ = ! cov]$ plan to comply ) ! report+ & disclosure requirem5ts "u ?is ,act4 7,,ii7 ,! cov]$ s]vice provid] %all disclose ! in=mation requir$ "u clause 7iii77,i7 reasonably 9 advance ( ! date ^u :i* su* responsible plan fiduci>y or cov]$ plan adm9i/rator /ates t x is requir$ to comply ) ! applicable report+ or disclosure requirem5t1 unless su* disclosure is preclud$ due to extraord9>y circum/ances beyond ! cov]$ s]vice provid]'s control1 9 :i* case ! in=mation %all be disclos$ z soon z practicable4 7vii7 ,no contract or arrangem5t w fail to be reasonable "u ?is subp>agraph solely because ! cov]$ s]vice provid]1 act+ 9 good fai? & ) reasonable dilig5ce1 makes an error or omission 9 disclos+ ! in=mation requir$ pursuant to clause 7iii7 7or a *ange to su* in=mation disclos$ pursuant to clause 7v77,,ii77 or clause 7vi71 provid$ t ! cov]$ s]vice provid] discloses ! correct in=mation to ! responsible plan fiduci>y z soon z practicable1 b n lat] ?an #cj days f ! date on :i* ! cov]$ s]vice provid] kn[s ( su* error or omission4 7viii7 7,i7 ,pursuant to subsection 7a71 subp>agraphs 7,c7 & 7,d7 ( section #djf7;a77#a7 %all n apply to a responsible plan fiduci>y1 not)/&+ any failure by a cov]$ s]vice provid] to disclose in=mation requir$ "u clause 7iii71 if ! foll[+ conditions are met3 7aa7 ,! responsible plan fiduci>y did n "k t ! cov]$ s]vice provid] fail$ or w\ld fail to make requir$ disclosures & reasonably believ$ t ! cov]$ s]vice provid] disclos$ ! in=mation requir$ to be disclos$4 7bb7 ,! responsible plan fiduci>y1 ^u discov]+ t ! cov]$ s]vice provid] fail$ to disclose ! requir$ in=mation1 reque/s 9 writ+ t ! cov]$ s]vice provid] furni% su* in=mation4 7cc7 ,if ! cov]$ s]vice provid] fails to comply ) a writt5 reque/ describ$ 9 subclause 7,,ii7 )9 #ij days ( ! reque/1 ! responsible plan fiduci>y notifies ! ,secret>y ( ! cov]$ s]vice provid]'s failure1 9 accordance ) subclauses 7,,ii7 & 7,,iii74 7,,ii7 ,a notice describ$ 9 subclause 7,i77cc7 %all conta9-- 7aa7 ! "n ( ! cov]$ plan2 7bb7 ! plan numb] us$ = ! annual report on ! cov]$ plan2 7cc7 ! plan sponsor's "n1 address1 & employ] id5tification numb]2 7dd7 ! "n1 address1 & telephone numb] ( ! responsible plan fiduci>y2 7ee7 ! "n1 address1 phone numb]1 &1 if kn[n1 employ] id5tification numb] ( ! cov]$ s]vice provid]2 7ff7 a description ( ! s]vices provid$ to ! cov]$ plan2 7gg7 a description ( ! in=mation t ! cov]$ s]vice provid] fail$ to disclose2 7hh7 ! date on :i* su* in=mation 0 reque/$ 9 writ+ f ! cov]$ s]vice provid]2 & 7ii7 a /atem5t z to :e!r ! cov]$ s]vice provid] cont9ues to provide s]vices to ! plan4 7,,iii7 ,a notice describ$ 9 subclause 7,i77cc7 %all be fil$ ) ! ,dep>tm5t n lat] ?an #cj days foll[+ ! e>li] (-- 7aa7 ,! cov]$ s]vice provid]'s refusal to furni% ! in=mation reque/$ by ! writt5 reque/ describ$ 9 subclause 7,i77bb72 or 7bb7 #ij days aft] ! writt5 reque/ ref]r$ to 9 subclause 7,i77cc7 is made4 7,,iv7 ,if ! cov]$ s]vice provid] fails to comply ) ! writt5 reque/ "u subclause 7,i77bb7 )9 #ij days ( su* reque/1 ! responsible plan fiduci>y %all det]m9e :e!r to t]m9ate or cont9ue ! contract or arrangem5t "u section #djd4 ,if ! reque/$ in=mation relates to future s]vices & is n disclos$ promptly aft] ! end ( ! #ij-;day p]iod1 ! responsible plan fiduci>y %all t]m9ate ! contract or arrangem5t z exp$iti\sly z possible1 consi/5t ) su* duty ( prud5ce4 7ix7 ,no?+ 9 ?is subp>agraph %all be con/ru$ to sup]s$e any provision ( ,/ate law t gov]ns disclosures by p>ties t provide ! s]vices describ$ 9 ?is section1 except to ! ext5t t su* law prev5ts ! application ( a requirem5t ( ?is section4 4 7#b7 ,applicability ( exi/+ regulations ,no?+ 9 ! am5dm5ts made by p>agraph 7#a7 %all be con/ru$ to affect ! applicability ( section #beej4djh;b-#b ( title #bi1 ,code ( ,f$]al ,regulations 7or any successor regulations71 ) respect to any applicable entity o!r ?an a cov]$ plan or a cov]$ s]vice provid] 7z def9$ 9 section #djh7;b77#b77;,b77ii7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 z am5d$ by p>agraph 7#a774 7#c7 ,individual m>ket cov]age ,subp>t #a ( "p ,b ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#da et seq47 is am5d$ by add+ at ! end ! foll[+3 #bgdf4 ,disclosure to enrollees ( individual m>ket cov]age 7a7 ,9 g5]al ,a heal? insurance issu] (f]+ individual heal? insurance cov]age %all make disclosures to enrollees 9 su* cov]age1 z describ$ 9 subsection 7b71 & reports to ! ,secret>y1 z describ$ 9 subsection 7c71 reg>d+ direct or indirect comp5sation provid$ to an ag5t or brok] associat$ ) enroll+ individuals 9 su* cov]age4 7b7 ,disclosure ,a heal? insurance issu] describ$ 9 subsection 7a7 %all disclose to an enrollee ! am\nt ( direct or indirect comp5sation provid$ to an ag5t or brok] = s]vices provid$ by su* ag5t or brok] associat$ ) plan selection & enrollm5t4 ,su* disclosure %all be-- 7#a7 made prior to ! individual f9aliz+ plan selection2 & 7#b7 includ$ on any docum5tation confirm+ ! individual's enrollm5t4 7c7 ,report+ ,a heal? insurance issu] describ$ 9 subsection 7a7 %all annually report to ! ,secret>y1 prior to ! beg9n+ ( op5 enrollm5t1 any direct or indirect comp5sation provid$ to an ag5t or brok] associat$ ) enroll+ individuals 9 su* cov]age4 7d7 ,rulemak+ ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ! ,ban ,surprise ,bill+ ,act1 ! ,secret>y %all f9alize1 ?r\gh notice-&-comm5t rulemak+1 ! =m & mann] 9 :i* issu]s describ$ 9 subsection 7a7 are requir$ to make ! disclosures describ$ 9 subsection 7b7 & ! reports describ$ 9 subsection 7c74 ,su* rulemak+ may also include adju/m5ts to notice requirem5ts to reflect ! diff]5t processes = plan r5ewals1 9 ord] to provide enrollees ) full1 timely in=mation4 4 7#d7 ,transition rule ,no contract execut$ prior to ! effective date describ$ 9 p>agraph 7#e7 by a gr\p heal? plan subject to ! requirem5ts ( section #djh7;b77#b77;,b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7z am5d$ by p>agraph 7#a77 or by a heal? insurance issu] subject to ! requirem5ts ( section #bgdf ( ! ,public ,heal? ,s]vice ,act 7z add$ by p>agraph 7#c77 %all be subject to ! requirem5ts ( su* section #djh7;b77#b77;,b7 or su* section #bgdf1 z applicable4 7#e7 ,effective date ,! am5dm5ts made by p>agraphs 7#a7 & 7#c7 %all apply beg9n+ "o ye> aft] ! date ( enactm5t ( ?is ,act4 7b7 ,/&>diz$ report+ =mat ,section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 z add$ by section #b & am5d$ by section #c7;c71 is fur!r am5d$ by add+ at ! end ! foll[+ new subsection3 7i7 ,/&>diz$ report+ =mat 7#a7 ,9 g5]al ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is subsection1 ! ,secret>y %all e/abli% a /&>diz$ report+ =mat = ! report+1 by gr\p heal? plans 7or heal? insurance cov]age (f]$ 9 connection ) su* a plan7 to ,/ate ,all ,pay] ,claims ,databases1 ( m$ical claims1 ph>macy claims1 d5tal claims1 & eligibility & provid] files t are collect$ f private & public pay]s1 & %all provide guidance to ,/ates on ! process by :i* ,/ates may collect su* data f su* plans or cov]age 9 ! /&>diz$ report+ =mat4 7#b7 ,def9ition ,9 ?is subsection1 ! t]m ,/ate ,all ,pay] ,claims ,database means1 ) respect to a ,/ate1 a database t may include m$ical claims1 ph>macy claims1 d5tal claims1 & eligibility & provid] files1 :i* are collect$ f private & public pay]s4 4 #h4 ,access to co/-%>+ in=mation 7a7 ,insur] & plan requirem5ts 7#a7 ,,phsa ,"p ,a ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aa et seq471 z am5d$ by section #f7;a71 is fur!r am5d$ by ins]t+ aft] section #bgcj ! foll[+3 #bgca4 ,provision ( co/-%>+ in=mation ,a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all provide a p>ticipant1 b5efici>y1 or enrollee 9 ! plan or cov]age ) a good fai? e/imate ( ! enrollee's co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 = :i* ! p>ticipant1 b5efici>y1 or enrollee may be responsible = pay+ ) respect to a specific heal? c>e s]vice 7includ+ any s]vice t is reasonably expect$ to be provid$ 9 conjunction ) su* specific s]vice71 z soon z practicable & n lat] ?an #b bus9ess days aft] a reque/ = su* in=mation by a p>ticipant1 b5efici>y1 or enrollee4 4 7#b7 ,,erisa ,subp>t ,b ( "p #g ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe et seq471 z am5d$ by section #f7;b71 is fur!r am5d$ by add+ at ! end ! foll[+3 #gah4 ,provision ( co/-%>+ in=mation ,a gr\p heal? plan 7or heal? insurance cov]age (f]$ 9 connection ) su* a plan7 %all provide a p>ticipant or b5efici>y 9 ! plan or cov]age ) a good fai? e/imate ( ! p>ticipant's or b5efici>y's co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 = :i* ! p>ticipant or b5efici>y may be responsible = pay+ ) respect to a specific heal? c>e s]vice 7includ+ any s]vice t is reasonably expect$ to be provid$ 9 conjunction ) su* specific s]vice71 z soon z practicable & n lat] ?an #b bus9ess days aft] a reque/ = su* in=mation by a p>ticipant or b5efici>y4 4 7#c7 ,,irc ,sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by section #f7;c71 is fur!r am5d$ by add+ at ! end ! foll[+3 #ihah4 ,provision ( co/-%>+ in=mation ,a gr\p heal? plan %all provide a p>ticipant or b5efici>y 9 ! plan ) a good fai? e/imate ( ! p>ticipant's or b5efici>y's co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 = :i* ! p>ticipant or b5efici>y may be responsible = pay+ ) respect to a specific heal? c>e s]vice 7includ+ any s]vice t is reasonably expect$ to be provid$ 9 conjunction ) su* specific s]vice71 z soon z practicable & n lat] ?an #b bus9ess days aft] a reque/ = su* in=mation by a p>ticipant or b5efici>y4 4 7#d7 ,cl]ical am5dm5ts 7,a7 ,,erisa ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajja et seq471 z am5d$ by section #h7;b77#d71 is fur!r am5d$ by ins]t+ aft] ! item relat+ to section #gag ! foll[+ new item3 ,sec4 #gah4 ,provision ( co/-%>+ in=mation4 4 7,b7 ,,irc ,! table ( sections = sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by section #h7;b77#d71 is fur!r am5d$ by add+ at ! end ! foll[+ new item3 ,sec4 #ihah4 ,provision ( co/-%>+ in=mation4 4 7b7 ,provid] requirem5ts ,"p ,d ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act1 z add$ by section #c & am5d$ by section #f1 is fur!r am5d$ by ins]t+ be=e section #bgii;,a-#g ! foll[+ new section3 #bgii;,a-#f4 ,provision ( co/-%>+ in=mation ,a provid] t is 9-network ) respect to a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all1 ^u reque/ by a p>ticipant1 b5efici>y1 or enrollee1 provide to a p>ticipant1 b5efici>y1 or enrollee 9 ! plan or cov]age ! foll[+ in=mation1 toge!r ) accurate & complete in=mation ab\t ! p>ticipant's1 b5efici>y's1 or enrollee's cov]age "u ! applicable plan or cov]age3 7#a7 ,z soon z practicable & n lat] ?an #b bus9ess days aft] ! p>ticipant1 b5efici>y1 or enrollee reque/s su* in=mation1 a good fai? e/imate ( ! expect$ p>ticipant1 b5efici>y1 or enrollee co/-%>+ = ! provision ( a p>ticul> heal? c>e s]vice 7includ+ any s]vice t is reasonably expect$ to be provid$ 9 conjunction ) su* specific s]vice74 7#b7 ,z soon z practicable & n lat] ?an #b bus9ess days aft] a p>ticipant1 b5efici>y1 or enrollee reque/s su* in=mation1 ! contact in=mation = any ancill>y provid]s = a s*$ul$ heal? c>e s]vice4 4 7c7 ,effective date ,! am5dm5ts made by subsections 7a7 & 7b7 %all apply ) respect to plan ye>s beg9n+ on or aft] ! date t is #ah mon?s aft] ! date ( enactm5t ( ?is ,act4 #i4 ,transp>5cy reg>d+ 9-network & out-(-network d$uctibles & out-(-pocket limitations 7a7 ,,phsa ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act1 z am5d$ by section #b1 is fur!r am5d$ by add+ at ! end ! foll[+ new subsection3 7g7 ,transp>5cy reg>d+ 9-,network & out-(-,network d$uctibles & out-(-,pocket limitations 7#a7 ,9 g5]al ,a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age & provid+ or cov]+ any b5efit ) respect to items or s]vices %all include1 9 cle> writ+1 on any plan or insurance id5tification c>d issu$ to enrollees 9 ! plan or cov]age ! am\nt ( ! 9-network & out-(-network d$uctibles & ! 9-network & out-(-network out-(-pocket maximum limitation t apply to su* plan or cov]age4 7#b7 ,guidance ,! ,secret>y1 9 consultation ) ! ,secret>y ( ,labor & ,secret>y ( ! ,treasury1 %all issue guidance to implem5t p>agraph 7#a74 4 7b7 ,,erisa ,section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 z add$ by section #b & z am5d$ by sections #c7;c7 & #g7;b71 is fur!r am5d$ by add+ at ! end ! foll[+ new subsection3 7j7 ,transp>5cy reg>d+ 9-,network & out-(-,network d$uctibles & out-(-,pocket limitations 7#a7 ,9 g5]al ,a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p heal? insurance cov]age & provid+ or cov]+ any b5efit ) respect to items or s]vices %all include1 9 cle> writ+1 on any plan or insurance id5tification c>d issu$ to p>ticipants or b5efici>ies 9 ! plan or cov]age ! am\nt ( ! 9-network & out-(-network d$uctibles & ! 9-network & out-(-network out-(-pocket maximum limitation t apply to su* plan or cov]age4 7#b7 ,guidance ,! ,secret>y1 9 consultation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ,secret>y ( ! ,treasury1 %all issue guidance to implem5t p>agraph 7#a74 4 7c7 ,,irc ,section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf1 z add$ by section #b1 is fur!r am5d$ by add+ at ! end ! foll[+ new subsection3 7h7 ,transp>5cy reg>d+ 9-,network & out-(-,network d$uctibles & out-(-,pocket limitations 7#a7 ,9 g5]al ,a gr\p heal? plan provid+ or cov]+ any b5efit ) respect to items or s]vices %all include1 9 cle> writ+1 on any plan or insurance id5tification c>d issu$ to p>ticipants or b5efici>ies 9 ! plan ! am\nt ( ! 9-network & out-(-network d$uctibles & ! 9-network & out-(-network out-(-pocket maximum limitation t apply to su* plan4 7#b7 ,guidance ,! ,secret>y1 9 consultation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ,secret>y ( ,labor1 %all issue guidance to implem5t p>agraph 7#a74 4 7d7 ,effective date ,! am5dm5ts made by ?is subsection %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb4