,i #aaf? ,,congress #b;d ,session ,h4 ,r4 #ehbf ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,febru>y #aj1 #bjbj,mr4 ,neal 7= himself1 ,mr4 ,brady1 ,mr4 ,suozzi1 ,mr4 ,la,hood1 ,mr4 ,hold+1 ,mr4 ,kelly ( ,p5nsylvania1 ,mr4 ,e/es1 ,mr4 ,?ompson ( ,cali=nia1 ,mr4 ,bey]1 ,ms4 ,%alala1 ,mr4 ,morelle1 ,mr4 ,l>son ( ,connecticut1 ,ms4 ,s*ri]1 ,mr4 ,s*neid]1 ,mr4 ,danny ,k4 ,davis ( ,ill9ois1 ,mr4 ,evans1 ,mr4 ,lewis1 ,mr4 ,higg9s ( ,new ,york1 ,mr4 ,nunes1 ,mr4 ,smi? ( ,nebraska1 ,mr4 ,f]guson1 ,mr4 ,w5/rup1 ,mr4 ,rice ( ,s\? ,c>ol9a1 ,mrs4 ,walorski1 ,mr4 ,s*weik]t1 ,mr4 ,re$1 ,mr4 ,arr+ton1 ,mr4 ,m>*ant1 ,mr4 ,bu*anan1 ,mr4 ,?ompson ( ,p5nsylvania1 ,mr4 ,kildee1 & ,mr4 ,smi? ( ,miss\ri7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committees on ,ways & ,means1 ,education & ,labor1 & ,transportation & ,infra/ructure1 = 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 am5d title ,,xxvii ( ! ,public ,heal? ,s]vice ,act1 ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 ! ,int]nal ,rev5ue ,code ( #aihf1 & title ,,xi ( ! ,social ,security ,act to prev5t c]ta9 cases ( out-(-network surprise m$ical bills1 /r5g!n heal? c>e consum] protections1 & improve heal? c>e in=mation transp>5cy1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,consum] ,protections ,aga9/ ,surprise ,m$ical ,bills ,act ( #bjbj4 7b7 ,table ( cont5ts ,! table ( cont5ts ( ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4 ,sec4 #b4 ,consum] protections ?r\gh requirem5ts on heal? plans to prev5t surprise m$ical bills = em]g5cy s]vices4 ,sec4 #c4 ,consum] protections ?r\gh requirem5ts on heal? plans to prev5t surprise m$ical bills = non-em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities4 ,sec4 #d4 ,consum] protections ?r\gh application ( heal? plan ext]nal review 9 cases ( c]ta9 surprise m$ical bills4 ,sec4 #e4 ,consum] protections ?r\gh heal? plan transp>5cy requirem5ts4 ,sec4 #f4 ,consum] protections ?r\gh heal? plan requirem5t = fair & hone/ advance co/ e/imate4 ,sec4 #g4 ,det]m9ation ?r\gh op5 negotiation & m$iation ( out-(-network rates to be paid by heal? plans4 ,sec4 #h4 ,prohibit+ balance bill+ practices by provid]s = em]g5cy s]vices1 = s]vices furni%$ by nonp>ticipat+ provid] at p>ticipat+ facility1 & 9 c]ta9 cases ( mis9=mation4 ,sec4 #i4 ,additional consum] protections4 ,sec4 #aj4 ,report+ requirem5ts reg>d+ air ambulance s]vices4 ,sec4 #aa4 ,,gao report on effects ( legislation4 ,sec4 #ab4 ,transitional rule all[+ d$uction = surprise bill+ exp5ses bel[ ,,agi floor4 #b4 ,consum] protections ?r\gh requirem5ts on heal? plans to prev5t surprise m$ical bills = em]g5cy s]vices 7a7 ,,phsa am5dm5ts 7#a7 ,9 g5]al ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a7 is am5d$-- 7,a7 9 subsection 7b7-- 7i7 9 ! head+1 by /rik+ ,cov]age & ins]t+ ,co/-,%>+ & paym5t2 7ii7 9 p>agraph 7#a7-- 7,i7 9 ! matt] prec$+ subp>agraph 7,a7-- 7aa7 by /rik+ a gr\p heal? plan1 or a heal? insurance issu] (f]+ gr\p or individual heal? insurance issu]1 & ins]t+ a heal? plan2 7bb7 by ins]t+ &1 = plan ye> #bjbb or a subsequ5t plan ye>1 ) respect to em]g5cy s]vices 9 an indep5d5t free/&+ em]g5cy dep>tm5t aft] em]g5cy dep>tm5t ( a hospital2 7cc7 by /rik+ ! plan or issu] & ins]t+ ! plan2 & 7dd7 by /rik+ 7z def9$ 9 p>agraph 7#b77;,b772 7,,ii7 9 subp>agraph 7,b71 by ins]t+ or a p>ticipat+ facility t is an em]g5cy dep>tm5t ( a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t 79 ?is subsection ref]r$ to z a p>ticipat+ em]g5cy facility7 aft] p>ticipat+ provid]2 & 7,,iii7 9 subp>agraph 7,c7-- 7aa7 9 ! matt] prec$+ clause 7i71 by ins]t+ by a nonp>ticipat+ provid] or a nonp>ticipat+ facility t is an em]g5cy dep>tm5t ( a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t aft] enrollee2 7bb7 by /rik+ clause 7i72 7cc7 by /rik+ 7ii77,i7 su* s]vices & ins]t+ 7i7 su* s]vices2 7dd7 by /rik+ :]e ! provid] ( s]vices does n h a contractual relation%ip ) ! plan = ! provid+ ( s]vices2 7ee7 by /rik+ em]g5cy dep>tm5t s]vices receiv$ f provid]s :o d h su* a contractual relation%ip ) ! plan2 & & ins]t+ em]g5cy s]vices receiv$ f p>ticipat+ provid]s & p>ticipat+ em]g5cy facilities ) respect to su* plan22 7ff7 by /rik+ 7,,ii7 if su* s]vices & all t foll[s ?r\gh 7 provid$ 9-network & ins]t+ ! foll[+3 7ii7 ! co/-%>+ requirem5t is n great] ?an ! requirem5t t w\ld apply if su* s]vices 7 furni%$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility1 z applicable2 2 & 7gg7 by add+ at ! end ! foll[+ new clauses3 7iii7 su* co/-%>+ requirem5t is calculat$ z if ! contract$ rate = su* s]vices if furni%$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility 7 equal to ! recogniz$ am\nt = su* s]vices2 7iv7 ! heal? plan pays to su* provid] or facility1 respectively1 ! am\nt by :i* ! out-(-network rate = su* s]vices exce$s ! co/-%>+ am\nt = su* s]vices 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii772 & 7v7 any d$uctible or out-(-pocket maximum t w\ld apply if su* s]vices 7 furni%$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility %all be ! d$uctible or out-(-pocket maximum t applies2 & 2 & 7iii7 by /rik+ p>agraph 7#b7 & ins]t+ ! foll[+ new p>agraph3 7#b7 ,audit process & rulemak+ process = m$ian contract$ rates 7,a7 ,audit process 7i7 ,9 g5]al ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 coord9ation ) ! ,secret>y ( ! ,treasury & ! ,secret>y ( ,labor & 9 consultation ) ! ,national ,association ( ,insurance ,commission]s1 %all e/abli% ?r\gh rulemak+ a process1 9 accordance ) clause 7ii71 "u :i* heal? plans are audit$ by ! ,secret>y to ensure t-- 7,i7 su* plans are 9 compliance ) ! requirem5t ( apply+ a m$ian contract$ rate "u ?is section2 & 7,,ii7 t su* m$ian contract$ rate s appli$ satisfies ! def9ition "u subsection 7k77#h7 ) respect to ! ye> involv$4 7ii7 ,audit samples ,"u ! process e/abli%$ pursuant to clause 7i71 ! ,secret>y-- 7,i7 %all conduct audits describ$ 9 su* clause ( a sample ( heal? plans2 & 7,,ii7 may audit any heal? plan if ! ,secret>y has receiv$ any compla9t ab\t su* plan t involves ! compliance ( ! plan ) ! requirem5t describ$ 9 su* clause4 7,b7 ,rulemak+ ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 coord9ation ) ! ,secret>y ( ,labor & ! ,secret>y ( ! ,treasury1 %all e/abli% ?r\gh rulemak+-- 7i7 ! me?odology ! sponsor or issu] ( a heal? plan %all use to det]m9e ! m$ian contract$ rate1 :i* %all acc\nt = relevant paym5t adju/m5ts t take into acc\nt facility type t are o!rwise tak5 into acc\nt = purposes ( det]m9+ paym5t am\nts ) respect to p>ticipat+ facilities2 & 7ii7 ! in=mation su* sponsor or issu] %all %>e ) ! nonp>ticipat+ provid] involv$ :5 mak+ su* a det]m9ation4 2 & 7,b7 by add+ at ! end ! foll[+ new subsection3 7k7 ,def9itions ,= purposes ( ?is section3 7#a7 ,contract$ rate ,! t]m contract$ rate means1 ) respect to a heal? plan & a heal? c>e provid] or heal? c>e facility furni%+ an item or s]vice to a b5efici>y1 p>ticipant1 or enrollee ( su* plan1 ! agre$ ^u total paym5t am\nt 7inclusive ( any co/-%>+7 to su* provid] or facility = su* item or s]vice4 7#b7 ,dur+ a visit ,! t]m dur+ a visit %all1 ) respect to an individual :o is furni%$ items & s]vices at a p>ticipat+ facility1 include equipm5t & devices1 telem$ic9e s]vices1 imag+ s]vices1 laboratory s]vices1 preop]ative & po/op]ative s]vices1 & su* o!r items & s]vices z ! ,secret>y may specify furni%$ to su* individual1 reg>dless ( :e!r or n ! provid] furni%+ su* items or s]vices is at ! facility4 7#c7 ,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#d7 ,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#e7 ,em]g5cy s]vices 7,a7 ,9 g5]al ,! t]m em]g5cy s]vices1 ) respect to an em]g5cy m$ical condition1 means-- 7i7 a m$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$ical condition2 & 7ii7 )9 ! capabilities ( ! /aff & facilities available at ! hospital or ! indep5d5t free/&+ em]g5cy dep>tm5t1 z applicable1 su* fur!r m$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 ! pati5t 7reg>dless ( ! dep>tm5t ( ! hospital 9 :i* su* fur!r exam9ation or treatm5t is furni%$74 7,b7 ,inclusion ( additional s]vices ,9 ! case ( an individual enroll$ 9 a heal? plan :o is furni%$ s]vices describ$ 9 subp>agraph 7,a7 by a provid] or hospital or indep5d5t free/&+ em]g5cy dep>tm5t to /abilize su* individual ) respect to an em]g5cy m$ical condition1 ! t]m em]g5cy s]vices %all include1 9 addition to ^? describ$ 9 subp>agraph 7,a71 items & s]vices furni%$ z "p ( outpati5t obs]vation or an inpati5t or outpati5t /ay dur+ a visit 9 :i* su* individual is s /abiliz$ ) respect to su* em]g5cy condition if-- 7i7 su* items & s]vices w\ld o!rwise be cov]$ "u su* plan if furni%$ by a p>ticipat+ provid] or p>ticipat+ facility2 & 7ii7 su* items & s]vices are furni%$-- 7,i7 to ma9ta91 improve1 or resolve ! individual's /abilization ) respect to su* condition1 unless any circum/ance describ$ 9 subp>agraph 7,c7 has occurr$ ) respect to su* individual be=e su* items & s]vices are furni%$2 or 7,,ii7 = any purpose n describ$ 9 subclause 7,i71 unless ea* ( ! crit]ia describ$ 9 subp>agraph 7,d7 h be5 met ) respect to su* individual & su* item or s]vice4 7,c7 ,circum/ances ,= purposes ( subp>agraph 7,b77ii77,i71 a circum/ance describ$ 9 ?is subp>agraph is any ( ! foll[+1 ) respect to an individual :o is a b5efici>y1 p>ticipant1 or enrollee ( a heal? plan :o is furni%$ s]vices describ$ 9 subp>agraph 7,a7 by a hospital or indep5d5t free/&+ em]g5cy dep>tm5t ) respect to an em]g5cy m$ical condition3 7i7 ,a p>ticipat+ provid]1 ) respect to su* plan1 ) privileges at ! hospital or indep5d5t free/&+ em]g5cy dep>tm5t assumes responsibility = ! c>e ( ! individual4 7ii7 ,a p>ticipat+ provid]1 ) respect to su* plan1 assumes responsibility = ! c>e ( ! individual ?r\gh transf] ( ! individual4 7iii7 ,! heal? plan & ! provid] treat+ su* individual at ! hospital or indep5d5t free/&+ em]g5cy dep>tm5t = su* condition rea* an agreem5t conc]n+ ! c>e = ! individual4 7iv7 ,! individual is dis*>g$4 7,d7 ,sign$ notice crit]ia ,= purposes ( subp>agraph 7,b77ii77,,ii71 ! crit]ia describ$ 9 ?is subp>agraph1 ) respect to an individual & an item or s]vice furni%$ by a nonp>ticipat+ provid] or nonp>ticipat+ facility t is a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t1 are ! foll[+3 7i7 ,a writt5 notice 7z specifi$ by ! ,secret>y & 9 a cle> & und]/&able mann]7 is provid$ by su* provid] or facility to su* individual1 be=e su* item or s]vice is furni%$1 t includes ! foll[+ in=mation3 7,i7 ,t su* provid] or facility is a nonp>ticipat+ provid] or nonp>ticipat+ facility 7z applicable74 7,,ii7 ,to ! ext5t practicable1 ! e/imat$ am\nt t su* nonp>ticipat+ facility or nonp>ticipat+ provid] may *>ge ! individual = su* item or s]vice4 7,,iii7 ,a /atem5t t ! individual may seek su* item or s]vice f a provid] t is a p>ticipat+ provid] or a hospital or indep5d5t free/&+ em]g5cy dep>tm5t t is a p>ticipat+ facility & a li/1 if feasible1 ( p>ticipat+ facilities or p>ticipat+ provid]s1 z applicable1 :o are able to furni% su* item or s]vice4 7ii7 ,su* individual is 9 a condition to receive 7z det]m9$ 9 accordance ) guidance issu$ by ! ,secret>y7 ! in=mation describ$ 9 clause 7i7 & to confirm notice ( receipt ( su* notice1 9 accordance ) applicable ,/ate law4 7iii7 ,! individual signs & dates su* notice confirm+ receipt ( ! notice be=e su* item or s]vice is furni%$4 7#f7 ,heal? plan ,! t]m heal? plan means a gr\p heal? plan & heal? insurance cov]age (f]$ by a hea? insurance issu] 9 ! gr\p or individual m>ket & includes a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act74 7#g7 ,indep5d5t free/&+ em]g5cy dep>tm5t ,! t]m indep5d5t free/&+ em]g5cy dep>tm5t means a heal? c>e facility t-- 7,a7 is geographically sep>ate & di/9ct & lic5s$ sep>ately f a hospital "u applicable ,/ate law2 & 7,b7 provides em]g5cy s]vices4 7#h7 ,m$ian contract$ rate 7,a7 ,9 g5]al ,subject to subp>agraph 7,b71 ! t]m m$ian contract$ rate means1 ) respect to a heal? plan-- 7i7 = an item or s]vice furni%$ dur+ #bjbb1 ! m$ian ( ! contract$ rates recogniz$ by ! sponsor or issu] ( su* plan 7det]m9$ ) respect to all su* plans ( su* sponsor or su* issu] t are )9 ! same l9e ( bus9ess 7z specifi$ 9 subp>agraph 7,c77 z ! plan involv$7 z ! total maximum paym5t "u su* plans 9 #bjai = ! same or a simil> item or s]vice t is provid$ by a provid] or facility 9 ! same or simil> specialty & provid$ 9 ! geographic region 7e/abli%$ 7& updat$1 z appropriate7 by ! ,secret>y1 9 consultation ) ! ,national ,association ( ,insurance ,commission]s7 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u subsection 7b77#b77;,b71 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] #bjai1 #bjbj1 & #bjba2 7ii7 = an item or s]vice furni%$ dur+ #bjbc or a subsequ5t ye> ?r\gh #bjbf1 ! m$ian contract$ rate = ! 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>2 7iii7 = an item or s]vice furni%$ dur+ a rebas+ ye> 7z def9$ 9 subp>agraph 7,d771 ! m$ian ( ! contract$ rates recogniz$ by ! sponsor or issu] ( su* plan 7det]m9$ ) respect to all su* plans ( su* sponsor or su* issu] t are )9 ! same l9e ( bus9ess 7z specifi$ 9 subp>agraph 7,c77 z ! plan involv$7 z ! total maximum paym5t "u su* plans 9 su* ye> = ! same or a simil> item or s]vice t is provid$ by a provid] or facility 9 ! same or simil> specialty & provid$ 9 ! geographic region 7z e/abli%$ pursuant to clause 7i77 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u subsection 7b77#b77;,b72 & 7iv7 = an item or s]vice furni%$ dur+ any ( ! #d ye>s foll[+ a rebas+ ye>1 ! m$ian contract$ rate = ! 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,b7 ,use ( sub/itute rate 9 case ( insuffici5t data 7i7 ,9 g5]al ,9 ! case ! sponsor or issu] ( a heal? plan has insuffici5t in=mation 7z specifi$ by ! ,secret>y7 to calculate ! m$ian ( ! contract$ rates 9 accordance ) subp>agraph 7,a7 = a ye> = an item or s]vice furni%$ 9 a p>ticul> geographic region 7z e/abli%$ pursuant to subp>agraph 7,a77i77 by a type ( provid] or facility1 ! sub/itute rate 7z def9$ 9 clause 7ii77 = su* item or s]vice %all be deem$ to be ! m$ian contract$ rate = su* item or s]vice furni%$ 9 su* region dur+ su* ye> by su* a provid] or facility = su* ye> "u su* subp>agraph 7,a7 = su* plan4 7ii7 ,sub/itute rate ,= purposes ( clause 7i71 ! t]m sub/itute rate means1 ) respect to an item or s]vice furni%$ by a provid] or facility 9 a geographic region 7e/abli%$ pursuant to subp>agraph 7,a77i77 dur+ a ye> = :i* a heal? plan is requir$ to make paym5t pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a7-- 7,i7 if suffici5t in=mation 7z specifi$ by ! ,secret>y7 exi/s to det]m9e ! m$ian ( ! contract$ rates recogniz$ by all heal? plans (f]$ 9 ! same l9e ( bus9ess 7z specifi$ 9 subp>agraph 7,c77 by any gr\p heal? plan or heal? insurance issu] = su* an item or s]vice furni%$ 9 su* region by su* a provid] or facility dur+ su* ye> us+ a database or o!r s\rce ( in=mation det]m9$ appropriate by ! ,secret>y1 su* m$ian2 & 7,,ii7 if su* suffici5t in=mation does n exi/1 ! m$ian ( ! contract$ rates recogniz$ by all heal? plans (f]$ 9 ! same l9e ( bus9ess 7z specifi$ 9 subp>agraph 7,c77 by any gr\p heal? plan or heal? insurance issu] = su* an item or s]vice furni%$ 9 a simil>ly situat$ geographic region 7z det]m9$ by ! ,secret>y7 ) su* suffici5t in=mation by su* a provid] or facility dur+ su* ye> us+ su* a database or su* o!r s\rce ( in=mation4 ,! ,secret>y %all develop a me?odology = det]m9+ a sub/itute rate bas$ on a simil>ly situat$ heal? plan t is n a ,f$]al heal? c>e program 7z def9$ 9 section #aabh;,b7f7 ( ! ,social ,security ,act7 9 ! case a sub/itute rate is n calculable "u ! previ\s s5t5ce ) respect to an item or s]vice4 7,c7 ,l9e ( bus9ess ,a l9e ( bus9ess specifi$ 9 ?is subp>agraph is "o ( ! foll[+3 7i7 ,! individual m>ket4 7ii7 ,! small gr\p m>ket4 7iii7 ,! l>ge gr\p m>ket4 7iv7 ,9 ! case ( a self-insur$ gr\p heal? plan1 o!r self-insur$ gr\p heal? plans4 7,d7 ,rebas+ ye> def9$ ,= purposes ( subp>agraph 7,a71 ! t]m rebas+ ye> means #bjbg & e #e ye>s !reaft]4 7#i7 ,nonp>ticipat+ facility2 p>ticipat+ facility 7,a7 ,nonp>ticipat+ facility ,! t]m nonp>ticipat+ facility means1 ) respect to an item or s]vice & a heal? plan1 a heal? c>e facility describ$ 9 subp>agraph 7,b77ii7 t does n h a contractual relation%ip ) ! plan = furni%+ su* item or s]vice4 7,b7 ,p>ticipat+ facility 7i7 ,9 g5]al ,! t]m p>ticipat+ facility means1 ) respect to an item or s]vice & a heal? plan1 a heal? c>e facility describ$ 9 clause 7ii7 t has a contractual relation%ip ) ! plan = furni%+ su* item or s]vice4 7ii7 ,heal? c>e facility describ$ ,a heal? c>e facility describ$ 9 ?is clause is ea* ( ! foll[+3 7,i7 ,a hospital 7z def9$ 9 #ahfa7;e7 ( ! ,social ,security ,act71 includ+ an em]g5cy dep>tm5t ( a hospital4 7,,ii7 ,a critical access hospital 7z def9$ 9 section #ahfa7mm77#a7 ( su* ,act74 7,,iii7 ,an ambulatory surgical c5t] 7z describ$ 9 section #ahcc7;i77#a77;,a7 ( su* ,act74 7,,iv7 ,a laboratory4 7,v7 ,a radiology facility or imag+ c5t]4 7,,vi7 ,an indep5d5t free/&+ em]g5cy dep>tm5t4 7,,vii7 ,any o!r facility specifi$ by ! ,secret>y4 7#aj7 ,nonp>ticipat+ provid]s2 p>ticipat+ provid]s 7,a7 ,nonp>ticipat+ provid] ,! t]m nonp>ticipat+ provid] means1 ) respect to an item or s]vice & a heal? plan1 a physician or o!r heal? c>e provid] :o does n h a contractual relation%ip ) ! plan = furni%+ su* item or s]vice "u ! plan4 7,b7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] means1 ) respect to an item or s]vice & a heal? plan1 a physician or o!r heal? c>e provid] :o has a contractual relation%ip ) ! plan = furni%+ su* item or s]vice "u ! plan4 7#aa7 ,out-(-network rate ,! t]m out-(-network rate means1 ) respect to an item or s]vice furni%$ 9 a ,/ate dur+ a ye> to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan receiv+ su* item or s]vice f a nonp>ticipat+ provid] or facility-- 7,a7 subject to subp>agraphs 7,c7 & 7,d71 9 ! case su* ,/ate has 9 effect a ,/ate law t provides = a me?od = det]m9+ ! total am\nt payable "u su* heal? plan regulat$ by su* ,/ate ) respect to su* item or s]vice furni%$ by su* provid] or facility1 su* am\nt det]m9$ 9 accordance ) su* law2 7,b7 subject to subp>agraphs 7,c7 & 7,d71 9 ! case su* ,/ate does n h 9 effect su* a law ) respect to su* item or s]vice1 plan1 & provid] or facility-- 7i7 subject to clause 7ii71 if ! provid] or facility 7z applicable7 & su* plan agree on an am\nt ( paym5t 7includ+ if agre$ on ?r\gh op5 negotiations "u subsection 7j77#a77 ) respect to su* item or s]vice1 su* agre$ on am\nt2 or 7ii7 if su* provid] or facility 7z applicable7 & su* plan ent] ! m$iat$ dispute process "u subsection 7j7 & d n s agree be=e ! date on :i* a select$ indep5d5t entity 7z def9$ 9 p>agraph 7#c7 ( su* subsection7 makes a det]m9ation ) respect to su* item or s]vice "u su* subsection1 ! am\nt ( su* det]m9ation2 7,c7 9 ! case su* ,/ate has 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%$2 or 7,d7 9 ! case su* heal? plan is a self-insur$ gr\p heal? plan & 9 ! case ( a ,/ate ) an agreem5t ) su* plan 9 effect z ( ! date ( ! enactm5t ( ! ,consum] ,protections ,aga9/ ,surprise ,m$ical ,bills ,act ( #bjbj1 t provides = a me?od = det]m9+ ! total am\nt payable "u su* heal? plan ) respect to su* item or s]vice furni%$ by su* provid] or facility1 su* am\nt det]m9$ 9 accordance ) su* me?od4 7#ab7 ,recogniz$ am\nt ,! t]m recogniz$ am\nt means1 ) respect to an item or s]vice furni%$ 9 a ,/ate dur+ a ye> to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan by a nonp>ticipat+ provid] or nonp>ticipat+ facility-- 7,a7 subject to subp>agraphs 7,c7 & 7,d71 9 ! case su* ,/ate has 9 effect a law describ$ 9 p>agraph 7#aa77;,a7 ) respect to su* item or s]vice1 provid] or facility1 & plan1 ! am\nt det]m9$ 9 accordance ) su* law2 7,b7 subject to subp>agraphs 7,c7 & 7,d71 9 ! case su* ,/ate does n h 9 effect su* a law1 an am\nt t is ! m$ian contract$ rate = su* item or s]vice = su* ye>2 7,c7 subject to subp>agraph 7,d71 9 ! case su* ,/ate is describ$ 9 p>agraph 7#aa77;,c7 ) respect to su* item or s]vice s furni%$1 ! am\nt t ! ,/ate approves "u su* sy/em = su* item or s]vice s furni%$2 or 7,d7 9 ! case su* heal? plan is a self-insur$ gr\p heal? plan & 9 ! case ( a ,/ate ) an agreem5t ) su* plan 9 effect z ( ! date ( ! enactm5t ( ! ,consum] ,protections ,aga9/ ,surprise ,m$ical ,bills ,act ( #bjbj1 t provides = a me?od = det]m9+ ! total am\nt payable "u su* heal? plan ) respect to su* item or s]vice furni%$ by su* provid] or facility1 su* am\nt det]m9$ 9 accordance ) su* me?od4 7#ac7 ,/abilize ,! t]m to /abilize1 ) respect to an em]g5cy m$ical condition1 has ! mean+ give 9 section #ahfg7;e77#c77;,a7 ( ! ,social ,security ,act74 7#ad7 ,co/-%>+ ,! t]m co/-%>+ includes copaym5ts1 co9surance1 & d$uctibles4 7l7 ,paym5t to provid] or facility ,9 ! case ( any paym5t requir$ to be made by a heal? plan pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a7 to a nonp>ticiapt+ provid] or nonp>ticipat+ facility = an item or s]vice1 su* paym5t %all be made to su* provid] or facility & n to ! individual receiv+ su* item or s]vice4 4 7#b7 ,effective date ,! am5dm5ts made by p>agraph 7#a7 %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb4 7b7 ,,irc am5dm5ts 7#a7 ,9 g5]al ,sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new section3 #ihaf4 ,pati5t protections 7a7 ,*oice ( heal? c>e pr(essional ,if a 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 ,co/-,%>+ & paym5t ( em]g5cy s]vices 7#a7 ,9 g5]al ,if a heal? plan provides or cov]s any b5efits ) respect to s]vices 9 an em]g5cy dep>tm5t ( a hospital &1 = plan ye> #bjbb or a subsequ5t plan ye>1 ) respect to em]g5cy s]vices 9 an indep5d5t free/&+ em]g5cy dep>tm5t1 ! plan %all cov] em]g5cy s]vices-- 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+ facility t is an em]g5cy dep>tm5t ( a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t 79 ?is subsection ref]r$ to z a p>ticipat+ em]g5cy facility7 ) 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+ facility t is an em]g5cy dep>tm5t ( a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t-- 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 is n great] ?an ! requirem5t t w\ld apply if su* s]vices 7 furni%$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility1 z applicable2 7iii7 su* co/-%>+ requirem5t is calculat$ z if ! contract$ rate = su* s]vices if furni%$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility 7 equal to ! recogniz$ am\nt = su* s]vices2 7iv7 ! heal? plan pays to su* provid] or facility1 respectively1 ! am\nt by :i* ! out-(-network rate = su* s]vices exce$s ! co/-%>+ am\nt = su* s]vices 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii772 & 7v7 any d$uctible or out-(-pocket maximum t w\ld apply if su* s]vices 7 furni%$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility %all be ! d$uctible or out-(-pocket maximum t applies2 & 7,d7 )\t reg>d to any o!r t]m or condition ( su* cov]age 7o!r ?an exclusion or coord9ation ( b5efits1 or an affiliation or wait+ p]iod1 p]mitt$ "u section #bgjd ( ! ,public ,heal? ,s]vice ,act1 includ+ z incorporat$ pursuant to section #gae ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd & section #ihae1 & o!r ?an applicable co/-%>+74 7#b7 ,audit process & rulemak+ process = m$ian contract$ rates 7,a7 ,audit process 7i7 ,9 g5]al ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 coord9ation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ,labor & 9 consultation ) ! ,national ,association ( ,insurance ,commission]s1 %all e/abli% ?r\gh rulemak+ a process1 9 accordance ) clause 7ii71 "u :i* heal? plans are audit$ by ! ,secret>y to ensure t-- 7,i7 su* plans are 9 compliance ) ! requirem5t ( apply+ a m$ian contract$ rate "u ?is section2 & 7,,ii7 t su* m$ian contract$ rate s appli$ satisfies ! def9ition "u subsection 7k77#h7 ) respect to ! ye> involv$4 7ii7 ,audit samples ,"u ! process e/abli%$ pursuant to clause 7i71 ! ,secret>y-- 7,i7 %all conduct audits describ$ 9 su* clause ( a sample ( heal? plans2 & 7,,ii7 may audit any heal? plan if ! ,secret>y has receiv$ any compla9t ab\t su* plan t involves ! compliance ( ! plan ) ! requirem5t describ$ 9 su* clause4 7,b7 ,rulemak+ ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 coord9ation ) ! ,secret>y ( ,labor & ! ,secret>y ( ,heal? & ,human ,s]vices1 %all e/abli% ?r\gh rulemak+-- 7i7 ! me?odology ! sponsor ( a heal? plan %all use to det]m9e ! m$ian contract$ rate1 :i* %all acc\nt = relevant paym5t adju/m5ts t take into acc\nt facility type t are o!rwise tak5 into acc\nt = purposes ( det]m9+ paym5t am\nts ) respect to p>ticipat+ facilities2 & 7ii7 ! in=mation su* sponsor %all %>e ) ! nonp>ticipat+ provid] involv$ :5 mak+ su* a det]m9ation4 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 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$iatrics z ! *ild's prim>y c>e provid] if su* provid] p>ticipates 9 ! network ( ! plan4 7#b7 ,con/ruction ,no?+ 9 p>agraph 7#a7 %all be con/ru$ to waive any exclusions ( cov]age "u ! t]ms & conditions ( ! plan ) respect to cov]age ( p$iatric c>e4 7d7 ,pati5t access to ob/etrical & gynecological c>e 7#a7 ,g5]al rights 7,a7 ,direct access ,a heal? plan describ$ 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 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 heal? plan describ$ 9 ?is p>agraph is a 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 ! 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 7k7 ,def9itions ,= purposes ( ?is section3 7#a7 ,contract$ rate ,! t]m contract$ rate means1 ) respect to a heal? plan & a heal? c>e provid] or heal? c>e facility furni%+ an item or s]vice to a b5efici>y or p>ticipant ( su* plan1 ! agre$ ^u total paym5t am\nt 7inclusive ( any co/-%>+7 to su* provid] or facility = su* item or s]vice4 7#b7 ,dur+ a visit ,! t]m dur+ a visit %all1 ) respect to an individual :o is furni%$ items & s]vices at a p>ticipat+ facility1 include equipm5t & devices1 telem$ic9e s]vices1 imag+ s]vices1 laboratory s]vices1 preop]ative & po/op]ative s]vices1 & su* o!r items & s]vices z ! ,secret>y may specify furni%$ to su* individual1 reg>dless ( :e!r or n ! provid] furni%+ su* items or s]vices is at ! facility4 7#c7 ,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#d7 ,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#e7 ,em]g5cy s]vices 7,a7 ,9 g5]al ,! t]m em]g5cy s]vices1 ) respect to an em]g5cy m$ical condition1 means-- 7i7 a m$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$ical condition2 & 7ii7 )9 ! capabilities ( ! /aff & facilities available at ! hospital or ! indep5d5t free/&+ em]g5cy dep>tm5t1 z applicable1 su* fur!r m$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 ! pati5t 7reg>dless ( ! dep>tm5t ( ! hospital 9 :i* su* fur!r exam9ation or treatm5t is furni%$74 7,b7 ,inclusion ( additional s]vices ,9 ! case ( an individual enroll$ 9 a heal? plan :o is furni%$ s]vices describ$ 9 subp>agraph 7,a7 by a provid] or hospital or indep5d5t free/&+ em]g5cy dep>tm5t to /abilize su* individual ) respect to an em]g5cy m$ical condition1 ! t]m em]g5cy s]vices %all include1 9 addition to ^? describ$ 9 subp>agraph 7,a71 items & s]vices furni%$ z "p ( outpati5t obs]vation or an inpati5t or outpati5t /ay dur+ a visit 9 :i* su* individual is s /abiliz$ ) respect to su* em]g5cy condition if-- 7i7 su* items & s]vices w\ld o!rwise be cov]$ "u su* plan if furni%$ by a p>ticipat+ provid] or p>ticipat+ facility2 & 7ii7 su* items & s]vices are furni%$-- 7,i7 to ma9ta91 improve1 or resolve ! individual's /abilization ) respect to su* condition1 unless any circum/ance describ$ 9 subp>agraph 7,c7 has occurr$ ) respect to su* individual be=e su* items & s]vices are furni%$2 or 7,,ii7 = any purpose n describ$ 9 subclause 7,i71 unless ea* ( ! crit]ia describ$ 9 subp>agraph 7,d7 h be5 met ) respect to su* individual & su* item or s]vice4 7,c7 ,circum/ances ,= purposes ( subp>agraph 7,b77ii77,i71 a circum/ance describ$ 9 ?is subp>agraph is any ( ! foll[+1 ) respect to an individual :o is a b5efici>y1 p>ticipant1 or enrollee ( a heal? plan :o is furni%$ s]vices describ$ 9 subp>agraph 7,a7 by a hospital or indep5d5t free/&+ em]g5cy dep>tm5t ) respect to an em]g5cy m$ical condition3 7i7 ,a p>ticipat+ provid]1 ) respect to su* plan1 ) privileges at ! hospital or indep5d5t free/&+ em]g5cy dep>tm5t assumes responsibility = ! c>e ( ! individual4 7ii7 ,a p>ticipat+ provid]1 ) respect to su* plan1 assumes responsibility = ! c>e ( ! individual ?r\gh transf] ( ! individual4 7iii7 ,! heal? plan & ! provid] treat+ su* individual at ! hospital or indep5d5t free/&+ em]g5cy dep>tm5t = su* condition rea* an agreem5t conc]n+ ! c>e = ! individual4 7iv7 ,! individual is dis*>g$4 7,d7 ,sign$ notice crit]ia ,= purposes ( subp>agraph 7,b77ii77,,ii71 ! crit]ia describ$ 9 ?is subp>agraph1 ) respect to an individual & an item or s]vice furni%$ by a nonp>ticipat+ provid] or nonp>ticipat+ facility t is a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t1 are ! foll[+3 7i7 ,a writt5 notice 7z specifi$ by ! ,secret>y & 9 a cle> & und]/&able mann]7 is provid$ by su* provid] or facility to su* individual1 be=e su* item or s]vice is furni%$1 t includes ! foll[+ in=mation3 7,i7 ,t su* provid] or facility is a nonp>ticipat+ provid] or nonp>ticipat+ facility 7z applicable74 7,,ii7 ,to ! ext5t practicable1 ! e/imat$ am\nt t su* nonp>ticipat+ facility or nonp>ticipat+ provid] may *>ge ! individual = su* item or s]vice4 7,,iii7 ,a /atem5t t ! individual may seek su* item or s]vice f a provid] t is a p>ticipat+ provid] or a hospital or indep5d5t free/&+ em]g5cy dep>tm5t t is a p>ticipat+ facility & a li/1 if feasible1 ( p>ticipat+ facilities or p>ticipat+ provid]s1 z applicable1 :o are able to furni% su* item or s]vice4 7ii7 ,su* individual is 9 a condition to receive 7z det]m9$ 9 accordance ) guidance issu$ by ! ,secret>y7 ! in=mation describ$ 9 clause 7i7 & to confirm notice ( receipt ( su* notice1 9 accordance ) applicable ,/ate law4 7iii7 ,! individual signs & dates su* notice confirm+ receipt ( ! notice be=e su* item or s]vice is furni%$4 7#f7 ,heal? plan ,! t]m heal? plan means a gr\p heal? plan1 includ+ any gr\p heal? plan t is a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act74 7#g7 ,indep5d5t free/&+ em]g5cy dep>tm5t ,! t]m indep5d5t free/&+ em]g5cy dep>tm5t means a heal? c>e facility t-- 7,a7 is geographically sep>ate & di/9ct & lic5s$ sep>ately f a hospital "u applicable ,/ate law2 & 7,b7 provides em]g5cy s]vices4 7#h7 ,m$ian contract$ rate 7,a7 ,9 g5]al ,subject to subp>agraph 7,b71 ! t]m m$ian contract$ rate means1 ) respect to a heal? plan-- 7i7 = an item or s]vice furni%$ dur+ #bjbb1 ! m$ian ( ! contract$ rates recogniz$ by ! sponsor ( su* plan 7det]m9$ ) respect to all su* plans ( su* sponsor t are )9 ! same l9e ( bus9ess 7z specifi$ 9 subp>agraph 7,c77 z ! plan involv$7 z ! total maximum paym5t "u su* plans 9 #bjai = ! same or a simil> item or s]vice t is provid$ by a provid] or facility 9 ! same or simil> specialty & provid$ 9 ! geographic region 7e/abli%$ 7& updat$1 z appropriate7 by ! ,secret>y1 9 consultation ) ! ,national ,association ( ,insurance ,commission]s7 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u subsection 7b77#b77;,b71 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] #bjai1 #bjbj1 & #bjba2 7ii7 = an item or s]vice furni%$ dur+ #bjbc or a subsequ5t ye> ?r\gh #bjbf1 ! m$ian contract$ rate = ! 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>2 7iii7 = an item or s]vice furni%$ dur+ a rebas+ ye> 7z def9$ 9 subp>agraph 7,d771 ! m$ian ( ! contract$ rates recogniz$ by ! sponsor ( su* plan 7det]m9$ ) respect to all su* plans ( su* sponsor t are )9 ! same l9e ( bus9ess 7z specifi$ 9 subp>agraph 7,c77 z ! plan involv$7 z ! total maximum paym5t "u su* plans 9 su* ye> = ! same or a simil> item or s]vice t is provid$ by a provid] or facility 9 ! same or simil> specialty & provid$ 9 ! geographic region 7z e/abli%$ pursuant to clause 7i77 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u subsection 7b77#b77;,b72 & 7iv7 = an item or s]vice furni%$ dur+ any ( ! #d ye>s foll[+ a rebas+ ye>1 ! m$ian contract$ rate = ! 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,b7 ,use ( sub/itute rate 9 case ( insuffici5t data 7i7 ,9 g5]al ,9 ! case ! sponsor ( a heal? plan has insuffici5t in=mation 7z specifi$ by ! ,secret>y7 to calculate ! m$ian ( ! contract$ rates 9 accordance ) subp>agraph 7,a7 = a ye> = an item or s]vice furni%$ 9 a p>ticul> geographic region 7z e/abli%$ pursuant to subp>agraph 7,a77i77 by a type ( provid] or facility1 ! sub/itute rate 7z def9$ 9 clause 7ii77 = su* item or s]vice %all be deem$ to be ! m$ian contract$ rate = su* item or s]vice furni%$ 9 su* region dur+ su* ye> by su* a provid] or facility = su* ye> "u su* subp>agraph 7,a7 = su* plan4 7ii7 ,sub/itute rate ,= purposes ( clause 7i71 ! t]m sub/itute rate means1 ) respect to an item or s]vice furni%$ by a provid] or facility 9 a geographic region 7e/abli%$ pursuant to subp>agraph 7,a77i77 dur+ a ye> = :i* a heal? plan is requir$ to make paym5t pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a7-- 7,i7 if suffici5t in=mation 7z specifi$ by ! ,secret>y7 exi/s to det]m9e ! m$ian ( ! contract$ rates recogniz$ by all heal? plans (f]$ 9 ! same l9e ( bus9ess 7z specifi$ 9 subp>agraph 7,c77 by any gr\p heal? plan = su* an item or s]vice furni%$ 9 su* region by su* a provid] or facility dur+ su* ye> us+ a database or o!r s\rce ( in=mation det]m9$ appropriate by ! ,secret>y1 su* m$ian2 & 7,,ii7 if su* suffici5t in=mation does n exi/1 ! m$ian ( ! contract$ rates recogniz$ by all heal? plans (f]$ 9 ! same l9e ( bus9ess 7z specifi$ 9 subp>agraph 7,c77 by any gr\p heal? plan = su* an item or s]vice furni%$ 9 a simil>ly situat$ geographic region 7z det]m9$ by ! ,secret>y7 ) su* suffici5t in=mation by su* a provid] or facility dur+ su* ye> us+ su* a database or su* o!r s\rce ( in=mation4 ,! ,secret>y %all develop a me?odology = det]m9+ a sub/itute rate bas$ on a simil>ly situat$ heal? plan t is n a ,f$]al heal? c>e program 7z def9$ 9 section #aabh;,b7f7 ( ! ,social ,security ,act7 9 ! case a sub/itute rate is n calculable "u ! previ\s s5t5ce ) respect to an item or s]vice4 7,c7 ,l9e ( bus9ess ,a l9e ( bus9ess specifi$ 9 ?is subp>agraph is "o ( ! foll[+3 7i7 ,! small gr\p m>ket4 7ii7 ,! l>ge gr\p m>ket4 7iii7 ,9 ! case ( a self-insur$ gr\p heal? plan1 o!r self-insur$ gr\p heal? plans4 7,d7 ,rebas+ ye> def9$ ,= purposes ( subp>agraph 7,a71 ! t]m rebas+ ye> means #bjbg & e #e ye>s !reaft]4 7#i7 ,nonp>ticipat+ facility2 p>ticipat+ facility 7,a7 ,nonp>ticipat+ facility ,! t]m nonp>ticipat+ facility means1 ) respect to an item or s]vice & a heal? plan1 a heal? c>e facility describ$ 9 subp>agraph 7,b77ii7 t does n h a contractual relation%ip ) ! plan = furni%+ su* item or s]vice4 7,b7 ,p>ticipat+ facility 7i7 ,9 g5]al ,! t]m p>ticipat+ facility means1 ) respect to an item or s]vice & a heal? plan1 a heal? c>e facility describ$ 9 clause 7ii7 t has a contractual relation%ip ) ! plan = furni%+ su* item or s]vice4 7ii7 ,heal? c>e facility describ$ ,a heal? c>e facility describ$ 9 ?is clause is ea* ( ! foll[+3 7,i7 ,a hospital 7z def9$ 9 #ahfa7;e7 ( ! ,social ,security ,act71 includ+ an em]g5cy dep>tm5t ( a hospital4 7,,ii7 ,a critical access hospital 7z def9$ 9 section #ahfa7mm77#a7 ( su* ,act74 7,,iii7 ,an ambulatory surgical c5t] 7z describ$ 9 section #ahcc7;i77#a77;,a7 ( su* ,act74 7,,iv7 ,a laboratory4 7,v7 ,a radiology facility or imag+ c5t]4 7,,vi7 ,an indep5d5t free/&+ em]g5cy dep>tm5t4 7,,vii7 ,any o!r facility specifi$ by ! ,secret>y4 7#aj7 ,nonp>ticipat+ provid]s2 p>ticipat+ provid]s 7,a7 ,nonp>ticipat+ provid] ,! t]m nonp>ticipat+ provid] means1 ) respect to an item or s]vice & a heal? plan1 a physician or o!r heal? c>e provid] :o does n h a contractual relation%ip ) ! plan = furni%+ su* item or s]vice "u ! plan4 7,b7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] means1 ) respect to an item or s]vice & a heal? plan1 a physician or o!r heal? c>e provid] :o has a contractual relation%ip ) ! plan = furni%+ su* item or s]vice "u ! plan4 7#aa7 ,out-(-network rate ,! t]m out-(-network rate means1 ) respect to an item or s]vice furni%$ 9 a ,/ate dur+ a ye> to a p>ticipant or b5efici>y ( a heal? plan receiv+ su* item or s]vice f a nonp>ticipat+ provid] or facility-- 7,a7 subject to subp>agraphs 7,c7 & 7,d71 9 ! case su* ,/ate has 9 effect a ,/ate law t provides = a me?od = det]m9+ ! total am\nt payable "u su* heal? plan regulat$ by su* ,/ate ) respect to su* item or s]vice furni%$ by su* provid] or facility1 su* am\nt det]m9$ 9 accordance ) su* law2 7,b7 subject to subp>agraphs 7,c7 & 7,d71 9 ! case su* ,/ate does n h 9 effect su* a law ) respect to su* item or s]vice1 plan1 & provid] or facility-- 7i7 subject to clause 7ii71 if ! provid] or facility 7z applicable7 & su* plan agree on an am\nt ( paym5t 7includ+ if agre$ on ?r\gh op5 negotiations "u subsection 7j77#a77 ) respect to su* item or s]vice1 su* agre$ on am\nt2 or 7ii7 if su* provid] or facility 7z applicable7 & su* plan ent] ! m$iat$ dispute process "u subsection 7j7 & d n s agree be=e ! date on :i* a select$ indep5d5t entity 7z def9$ 9 p>agraph 7#c7 ( su* subsection7 makes a det]m9ation ) respect to su* item or s]vice "u su* subsection1 ! am\nt ( su* det]m9ation2 7,c7 9 ! case su* ,/ate has 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%$2 or 7,d7 9 ! case su* heal? plan is a self-insur$ gr\p heal? plan & 9 ! case ( a ,/ate ) an agreem5t ) su* plan 9 effect z ( ! date ( ! enactm5t ( ! ,consum] ,protections ,aga9/ ,surprise ,m$ical ,bills ,act ( #bjbj1 t provides = a me?od = det]m9+ ! total am\nt payable "u su* heal? plan ) respect to su* item or s]vice furni%$ by su* provid] or facility1 su* am\nt det]m9$ 9 accordance ) su* me?od4 7#ab7 ,recogniz$ am\nt ,! t]m recogniz$ am\nt means1 ) respect to an item or s]vice furni%$ 9 a ,/ate dur+ a ye> to a p>ticipant or b5efici>y ( a heal? plan by a nonp>ticipat+ provid] or nonp>ticipat+ facility-- 7,a7 subject to subp>agraphs 7,c7 & 7,d71 9 ! case su* ,/ate has 9 effect a law describ$ 9 p>agraph 7#aa77;,a7 ) respect to su* item or s]vice1 provid] or facility1 & plan1 ! am\nt det]m9$ 9 accordance ) su* law2 7,b7 subject to subp>agraphs 7,c7 & 7,d71 9 ! case su* ,/ate does n h 9 effect su* a law1 an am\nt t is ! m$ian contract$ rate = su* item or s]vice = su* ye>2 7,c7 9 ! case su* ,/ate is describ$ 9 p>agraph 7#aa77;,c7 ) respect to su* item or s]vice s furni%$1 ! am\nt t ! ,/ate approves "u su* sy/em = su* item or s]vice s furni%$2 or 7,d7 9 ! case su* heal? plan is a self-insur$ gr\p heal? plan & 9 ! case ( a ,/ate ) an agreem5t ) su* plan 9 effect z ( ! date ( ! enactm5t ( ! ,consum] ,protections ,aga9/ ,surprise ,m$ical ,bills ,act ( #bjbj1 t provides = a me?od = det]m9+ ! total am\nt payable "u su* heal? plan ) respect to su* item or s]vice furni%$ by su* provid] or facility1 su* am\nt det]m9$ 9 accordance ) su* me?od4 7#ac7 ,/abilize ,! t]m to /abilize1 ) respect to an em]g5cy m$ical condition1 has ! mean+ give 9 section #ahfg7;e77#c77;,a7 ( ! ,social ,security ,act4 7#ad7 ,co/-%>+ ,! t]m co/-%>+ includes copaym5ts1 co9surance1 & d$uctibles4 7l7 ,paym5t to provid] or facility ,9 ! case ( any paym5t requir$ to be made by a heal? plan pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a7 to a nonp>ticiapt+ provid] or nonp>ticipat+ facility = an item or s]vice1 su* paym5t %all be made to su* provid] or facility & n to ! individual receiv+ su* item or s]vice4 4 7#b7 ,con=m+ am5dm5ts 7,a7 ,application provisions ,section #ihae7;a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7i7 9 p>agraph 7#a71 by /rik+ 7z am5d$ by ! ,pati5t ,protection & ,af=dable ,c>e ,act7 & ins]t+ 7o!r ?an1 ) respect to a plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbb1 ! provisions ( section #bgai;,a ( su* ,act72 & 7ii7 9 p>agraph 7#b71 by ins]t+ 7o!r ?an1 ) respect to a plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbb1 ! provisions ( section #bgai;,a ( su* ,act7 aft] ! fir/ occurr5ce ( su* "p ,a4 7,b7 ,application to retiree-only plans ,section #ihca7;a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by ins]t+ 7o!r ?an1 ) respect to a gr\p heal? plan describ$ 9 p>agraph 7#b71 ! requirem5ts ( section #ihaf7 be=e %all n apply4 7#c7 ,cl]ical am5dm5t ,! table ( sections = su* sub*apt] is am5d$ by add+ at ! end ! foll[+ new items3 ,sec4 #ihae4 ,additional m>ket re=ms4 ,sec4 #ihaf4 ,pati5t protections4 4 7#d7 ,effective date ,! am5dm5ts made by ?is subsection %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb4 7c7 ,employee ,retirem5t ,income ,security ,act ( #aigd 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[+ new section3 #gaf4 ,pati5t protections 7a7 ,*oice ( heal? c>e pr(essional ,if a 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 ,co/-,%>+ & paym5t ( em]g5cy s]vices 7#a7 ,9 g5]al ,if a heal? plan provides or cov]s any b5efits ) respect to s]vices 9 an em]g5cy dep>tm5t ( a hospital &1 = plan ye> #bjbb or a subsequ5t plan ye>1 ) respect to em]g5cy s]vices 9 an indep5d5t free/&+ em]g5cy dep>tm5t1 ! plan %all cov] em]g5cy s]vices-- 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+ facility t is an em]g5cy dep>tm5t ( a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t 79 ?is subsection ref]r$ to z a p>ticipat+ em]g5cy facility7 ) 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+ facility t is an em]g5cy dep>tm5t ( a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t-- 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 is n great] ?an ! requirem5t t w\ld apply if su* s]vices 7 furni%$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility1 z applicable2 7iii7 su* co/-%>+ requirem5t is calculat$ z if ! contract$ rate = su* s]vices if furni%$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility 7 equal to ! recogniz$ am\nt = su* s]vices2 7iv7 ! heal? plan pays to su* provid] or facility1 respectively1 ! am\nt by :i* ! out-(-network rate = su* s]vices exce$s ! co/-%>+ am\nt = su* s]vices 7z det]m9$ 9 accordance ) clauses 7ii7 & 7iii772 & 7v7 any d$uctible or out-(-pocket maximum t w\ld apply if su* s]vices 7 furni%$ by a p>ticipat+ provid] or a p>ticipat+ em]g5cy facility %all be ! d$uctible or out-(-pocket maximum t applies2 & 7,d7 )\t reg>d to any o!r t]m or condition ( su* cov]age 7o!r ?an exclusion or coord9ation ( b5efits1 or an affiliation or wait+ p]iod1 p]mitt$ "u section #bgjd ( ! ,public ,heal? ,s]vice ,act1 includ+ z incorporat$ pursuant to section #gae & section #ihae ( ! ,int]nal ,rev5ue ,code ( #aihf1 & o!r ?an applicable co/-%>+74 7#b7 ,audit process & rulemak+ process = m$ian contract$ rates 7,a7 ,audit process 7i7 ,9 g5]al ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 coord9ation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ! ,treasury & 9 consultation ) ! ,national ,association ( ,insurance ,commission]s1 %all e/abli% ?r\gh rulemak+ a process1 9 accordance ) clause 7ii71 "u :i* heal? plans are audit$ by ! ,secret>y to ensure t-- 7,i7 su* plans are 9 compliance ) ! requirem5t ( apply+ a m$ian contract$ rate "u ?is section2 & 7,,ii7 t su* m$ian contract$ rate s appli$ satisfies ! def9ition "u subsection 7k77#h7 ) respect to ! ye> involv$4 7ii7 ,audit samples ,"u ! process e/abli%$ pursuant to clause 7i71 ! ,secret>y-- 7,i7 %all conduct audits describ$ 9 su* clause ( a sample ( heal? plans2 & 7,,ii7 may audit any heal? plan if ! ,secret>y has receiv$ any compla9t ab\t su* plan t involves ! compliance ( ! plan ) ! requirem5t describ$ 9 su* clause4 7,b7 ,rulemak+ ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 coord9ation ) ! ,secret>y ( ! ,treasury & ! ,secret>y ( ,heal? & ,human ,s]vices1 %all e/abli% ?r\gh rulemak+-- 7i7 ! me?odology ! sponsor or issu] ( a heal? plan %all use to det]m9e ! m$ian contract$ rate1 :i* %all acc\nt = relevant paym5t adju/m5ts t take into acc\nt facility type t are o!rwise tak5 into acc\nt = purposes ( det]m9+ paym5t am\nts ) respect to p>ticipat+ facilities2 & 7ii7 ! in=mation su* sponsor or issu] %all %>e ) ! nonp>ticipat+ provid] involv$ :5 mak+ su* a det]m9ation4 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 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$iatrics z ! *ild's prim>y c>e provid] if su* provid] p>ticipates 9 ! network ( ! plan4 7#b7 ,con/ruction ,no?+ 9 p>agraph 7#a7 %all be con/ru$ to waive any exclusions ( cov]age "u ! t]ms & conditions ( ! plan ) respect to cov]age ( p$iatric c>e4 7d7 ,pati5t access to ob/etrical & gynecological c>e 7#a7 ,g5]al rights 7,a7 ,direct access ,a heal? plan describ$ 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 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 heal? plan describ$ 9 ?is p>agraph is a 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 ! 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 7k7 ,def9itions ,= purposes ( ?is section3 7#a7 ,contract$ rate ,! t]m contract$ rate means1 ) respect to a heal? plan & a heal? c>e provid] or heal? c>e facility furni%+ an item or s]vice to a b5efici>y or p>ticipant ( su* plan1 ! agre$ ^u total paym5t am\nt 7inclusive ( any co/-%>+7 to su* provid] or facility = su* item or s]vice4 7#b7 ,dur+ a visit ,! t]m dur+ a visit %all1 ) respect to an individual :o is furni%$ items & s]vices at a p>ticipat+ facility1 include equipm5t & devices1 telem$ic9e s]vices1 imag+ s]vices1 laboratory s]vices1 preop]ative & po/op]ative s]vices1 & su* o!r items & s]vices z ! ,secret>y may specify furni%$ to su* individual1 reg>dless ( :e!r or n ! provid] furni%+ su* items or s]vices is at ! facility4 7#c7 ,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#d7 ,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#e7 ,em]g5cy s]vices 7,a7 ,9 g5]al ,! t]m em]g5cy s]vices1 ) respect to an em]g5cy m$ical condition1 means-- 7i7 a m$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$ical condition2 & 7ii7 )9 ! capabilities ( ! /aff & facilities available at ! hospital or ! indep5d5t free/&+ em]g5cy dep>tm5t1 z applicable1 su* fur!r m$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 ! pati5t 7reg>dless ( ! dep>tm5t ( ! hospital 9 :i* su* fur!r exam9ation or treatm5t is furni%$74 7,b7 ,inclusion ( additional s]vices ,9 ! case ( an individual enroll$ 9 a heal? plan :o is furni%$ s]vices describ$ 9 subp>agraph 7,a7 by a provid] or hospital or indep5d5t free/&+ em]g5cy dep>tm5t to /abilize su* individual ) respect to an em]g5cy m$ical condition1 ! t]m em]g5cy s]vices %all include1 9 addition to ^? describ$ 9 subp>agraph 7,a71 items & s]vices furni%$ z "p ( outpati5t obs]vation or an inpati5t or outpati5t /ay dur+ a visit 9 :i* su* individual is s /abiliz$ ) respect to su* em]g5cy condition if-- 7i7 su* items & s]vices w\ld o!rwise be cov]$ "u su* plan if furni%$ by a p>ticipat+ provid] or p>ticipat+ facility2 & 7ii7 su* items & s]vices are furni%$-- 7,i7 to ma9ta91 improve1 or resolve ! individual's /abilization ) respect to su* condition1 unless any circum/ance describ$ 9 subp>agraph 7,c7 has occurr$ ) respect to su* individual be=e su* items & s]vices are furni%$2 or 7,,ii7 = any purpose n describ$ 9 subclause 7,i71 unless ea* ( ! crit]ia describ$ 9 subp>agraph 7,d7 h be5 met ) respect to su* individual & su* item or s]vice4 7,c7 ,circum/ances ,= purposes ( subp>agraph 7,b77ii77,i71 a circum/ance describ$ 9 ?is subp>agraph is any ( ! foll[+1 ) respect to an individual :o is a b5efici>y1 p>ticipant1 or enrollee ( a heal? plan :o is furni%$ s]vices describ$ 9 subp>agraph 7,a7 by a hospital or indep5d5t free/&+ em]g5cy dep>tm5t ) respect to an em]g5cy m$ical condition3 7i7 ,a p>ticipat+ provid]1 ) respect to su* plan1 ) privileges at ! hospital or indep5d5t free/&+ em]g5cy dep>tm5t assumes responsibility = ! c>e ( ! individual4 7ii7 ,a p>ticipat+ provid]1 ) respect to su* plan1 assumes responsibility = ! c>e ( ! individual ?r\gh transf] ( ! individual4 7iii7 ,! heal? plan & ! provid] treat+ su* individual at ! hospital or indep5d5t free/&+ em]g5cy dep>tm5t = su* condition rea* an agreem5t conc]n+ ! c>e = ! individual4 7iv7 ,! individual is dis*>g$4 7,d7 ,sign$ notice crit]ia ,= purposes ( subp>agraph 7,b77ii77,,ii71 ! crit]ia describ$ 9 ?is subp>agraph1 ) respect to an individual & an item or s]vice furni%$ by a nonp>ticipat+ provid] or nonp>ticipat+ facility t is a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t1 are ! foll[+3 7i7 ,a writt5 notice 7z specifi$ by ! ,secret>y & 9 a cle> & und]/&able mann]7 is provid$ by su* provid] or facility to su* individual1 be=e su* item or s]vice is furni%$1 t includes ! foll[+ in=mation3 7,i7 ,t su* provid] or facility is a nonp>ticipat+ provid] or nonp>ticipat+ facility 7z applicable74 7,,ii7 ,to ! ext5t practicable1 ! e/imat$ am\nt t su* nonp>ticipat+ facility or nonp>ticipat+ provid] may *>ge ! individual = su* item or s]vice4 7,,iii7 ,a /atem5t t ! individual may seek su* item or s]vice f a provid] t is a p>ticipat+ provid] or a hospital or indep5d5t free/&+ em]g5cy dep>tm5t t is a p>ticipat+ facility & a li/1 if feasible1 ( p>ticipat+ facilities or p>ticipat+ provid]s1 z applicable1 :o are able to furni% su* item or s]vice4 7ii7 ,su* individual is 9 a condition to receive 7z det]m9$ 9 accordance ) guidance issu$ by ! ,secret>y7 ! in=mation describ$ 9 clause 7i7 & to confirm notice ( receipt ( su* notice1 9 accordance ) applicable ,/ate law4 7iii7 ,! individual signs & dates su* notice confirm+ receipt ( ! notice be=e su* item or s]vice is furni%$4 7#f7 ,heal? plan ,! t]m heal? plan means a gr\p heal? plan & heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p m>ket & includes a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act7 t is su* a plan or cov]age4 7#g7 ,indep5d5t free/&+ em]g5cy dep>tm5t ,! t]m indep5d5t free/&+ em]g5cy dep>tm5t means a heal? c>e facility t-- 7,a7 is geographically sep>ate & di/9ct & lic5s$ sep>ately f a hospital "u applicable ,/ate law2 & 7,b7 provides em]g5cy s]vices4 7#h7 ,m$ian contract$ rate 7,a7 ,9 g5]al ,subject to subp>agraph 7,b71 ! t]m m$ian contract$ rate means1 ) respect to a heal? plan-- 7i7 = an item or s]vice furni%$ dur+ #bjbb1 ! m$ian ( ! contract$ rates recogniz$ by ! sponsor or issu] ( su* plan 7det]m9$ ) respect to all su* plans ( su* sponsor or su* issu] t are )9 ! same l9e ( bus9ess 7z specifi$ 9 subp>agraph 7,c77 z ! plan involv$7 z ! total maximum paym5t "u su* plans 9 #bjai = ! same or a simil> item or s]vice t is provid$ by a provid] or facility 9 ! same or simil> specialty & provid$ 9 ! geographic region 7e/abli%$ 7& updat$1 z appropriate7 by ! ,secret>y1 9 consultation ) ! ,national ,association ( ,insurance ,commission]s7 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u subsection 7b77#b77;,b71 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] #bjai1 #bjbj1 & #bjba2 7ii7 = an item or s]vice furni%$ dur+ #bjbc or a subsequ5t ye> ?r\gh #bjbf1 ! m$ian contract$ rate = ! 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>2 7iii7 = an item or s]vice furni%$ dur+ a rebas+ ye> 7z def9$ 9 subp>agraph 7,d771 ! m$ian ( ! contract$ rates recogniz$ by ! sponsor or issu] ( su* plan 7det]m9$ ) respect to all su* plans ( su* sponsor or issu] t are )9 ! same l9e ( bus9ess 7z specifi$ 9 subp>agraph 7,c77 z ! plan involv$7 z ! total maximum paym5t "u su* plans 9 su* ye> = ! same or a simil> item or s]vice t is provid$ by a provid] or facility 9 ! same or simil> specialty & provid$ 9 ! geographic region 7z e/abli%$ pursuant to clause 7i77 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u subsection 7b77#b77;,b72 & 7iv7 = an item or s]vice furni%$ dur+ any ( ! #d ye>s foll[+ a rebas+ ye>1 ! m$ian contract$ rate = ! 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,b7 ,use ( sub/itute rate 9 case ( insuffici5t data 7i7 ,9 g5]al ,9 ! case ! sponsor or issu] ( a heal? plan has insuffici5t in=mation 7z specifi$ by ! ,secret>y7 to calculate ! m$ian ( ! contract$ rates 9 accordance ) subp>agraph 7,a7 = a ye> = an item or s]vice furni%$ 9 a p>ticul> geographic region 7z e/abli%$ pursuant to subp>agraph 7,a77i77 by a type ( provid] or facility1 ! sub/itute rate 7z def9$ 9 clause 7ii77 = su* item or s]vice %all be deem$ to be ! m$ian contract$ rate = su* item or s]vice furni%$ 9 su* region dur+ su* ye> by su* a provid] or facility = su* ye> "u su* subp>agraph 7,a7 = su* plan4 7ii7 ,sub/itute rate ,= purposes ( clause 7i71 ! t]m sub/itute rate means1 ) respect to an item or s]vice furni%$ by a provid] or facility 9 a geographic region 7e/abli%$ pursuant to subp>agraph 7,a77i77 dur+ a ye> = :i* a heal? plan is requir$ to make paym5t pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a7-- 7,i7 if suffici5t in=mation 7z specifi$ by ! ,secret>y7 exi/s to det]m9e ! m$ian ( ! contract$ rates recogniz$ by all heal? plans (f]$ 9 ! same l9e ( bus9ess 7z specifi$ 9 subp>agraph 7,c77 by any gr\p heal? plan = su* an item or s]vice furni%$ 9 su* region by su* a provid] or facility dur+ su* ye> us+ a database or o!r s\rce ( in=mation det]m9$ appropriate by ! ,secret>y1 su* m$ian2 & 7,,ii7 if su* suffici5t in=mation does n exi/1 ! m$ian ( ! contract$ rates recogniz$ by all heal? plans (f]$ 9 ! same l9e ( bus9ess 7z specifi$ 9 subp>agraph 7,c77 by any gr\p heal? plan = su* an item or s]vice furni%$ 9 a simil>ly situat$ geographic region 7z det]m9$ by ! ,secret>y7 ) su* suffici5t in=mation by su* a provid] or facility dur+ su* ye> us+ su* a database or su* o!r s\rce ( in=mation4 ,! ,secret>y %all develop a me?odology = det]m9+ a sub/itute rate bas$ on a simil>ly situat$ heal? plan t is n a ,f$]al heal? c>e program 7z def9$ 9 section #aabh;,b7f7 ( ! ,social ,security ,act7 9 ! case a sub/itute rate is n calculable "u ! previ\s s5t5ce ) respect to an item or s]vice4 7,c7 ,l9e ( bus9ess ,a l9e ( bus9ess specifi$ 9 ?is subp>agraph is "o ( ! foll[+3 7i7 ,! small gr\p m>ket4 7ii7 ,! l>ge gr\p m>ket4 7iii7 ,9 ! case ( a self-insur$ gr\p heal? plan1 o!r self-insur$ gr\p heal? plans4 7,d7 ,rebas+ ye> def9$ ,= purposes ( subp>agraph 7,a71 ! t]m rebas+ ye> means #bjbg & e #e ye>s !reaft]4 7#i7 ,nonp>ticipat+ facility2 p>ticipat+ facility 7,a7 ,nonp>ticipat+ facility ,! t]m nonp>ticipat+ facility means1 ) respect to an item or s]vice & a heal? plan1 a heal? c>e facility describ$ 9 subp>agraph 7,b77ii7 t does n h a contractual relation%ip ) ! plan = furni%+ su* item or s]vice4 7,b7 ,p>ticipat+ facility 7i7 ,9 g5]al ,! t]m p>ticipat+ facility means1 ) respect to an item or s]vice & a heal? plan1 a heal? c>e facility describ$ 9 clause 7ii7 t has a contractual relation%ip ) ! plan = furni%+ su* item or s]vice4 7ii7 ,heal? c>e facility describ$ ,a heal? c>e facility describ$ 9 ?is clause is ea* ( ! foll[+3 7,i7 ,a hospital 7z def9$ 9 #ahfa7;e7 ( ! ,social ,security ,act71 includ+ an em]g5cy dep>tm5t ( a hospital4 7,,ii7 ,a critical access hospital 7z def9$ 9 section #ahfa7mm77#a7 ( su* ,act74 7,,iii7 ,an ambulatory surgical c5t] 7z describ$ 9 section #ahcc7;i77#a77;,a7 ( su* ,act74 7,,iv7 ,a laboratory4 7,v7 ,a radiology facility or imag+ c5t]4 7,,vi7 ,an indep5d5t free/&+ em]g5cy dep>tm5t4 7,,vii7 ,any o!r facility specifi$ by ! ,secret>y4 7#aj7 ,nonp>ticipat+ provid]s2 p>ticipat+ provid]s 7,a7 ,nonp>ticipat+ provid] ,! t]m nonp>ticipat+ provid] means1 ) respect to an item or s]vice & a heal? plan1 a physician or o!r heal? c>e provid] :o does n h a contractual relation%ip ) ! plan = furni%+ su* item or s]vice "u ! plan4 7,b7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] means1 ) respect to an item or s]vice & a heal? plan1 a physician or o!r heal? c>e provid] :o has a contractual relation%ip ) ! plan = furni%+ su* item or s]vice "u ! plan4 7#aa7 ,out-(-network rate ,! t]m out-(-network rate means1 ) respect to an item or s]vice furni%$ 9 a ,/ate dur+ a ye> to a p>ticipant or b5efici>y ( a heal? plan receiv+ su* item or s]vice f a nonp>ticipat+ provid] or facility-- 7,a7 subject to subp>agraphs 7,c7 & 7,d71 9 ! case su* ,/ate has 9 effect a ,/ate law t provides = a me?od = det]m9+ ! total am\nt payable "u su* heal? plan regulat$ by su* ,/ate ) respect to su* item or s]vice furni%$ by su* provid] or facility1 su* am\nt det]m9$ 9 accordance ) su* law2 7,b7 subject to subp>agraphs 7,c7 & 7,d71 9 ! case su* ,/ate does n h 9 effect su* a law ) respect to su* item or s]vice1 plan1 & provid] or facility-- 7i7 subject to clause 7ii71 if ! provid] or facility 7z applicable7 & su* plan agree on an am\nt ( paym5t 7includ+ if agre$ on ?r\gh op5 negotiations "u subsection 7j77#a77 ) respect to su* item or s]vice1 su* agre$ on am\nt2 or 7ii7 if su* provid] or facility 7z applicable7 & su* plan ent] ! m$iat$ dispute process "u subsection 7j7 & d n s agree be=e ! date on :i* a select$ indep5d5t entity 7z def9$ 9 p>agraph 7#c7 ( su* subsection7 makes a det]m9ation ) respect to su* item or s]vice "u su* subsection1 ! am\nt ( su* det]m9ation2 7,c7 9 ! case su* ,/ate has 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%$2 or 7,d7 9 ! case su* heal? plan is a self-insur$ gr\p heal? plan & 9 ! case ( a ,/ate ) an agreem5t ) su* plan 9 effect z ( ! date ( ! enactm5t ( ! ,consum] ,protections ,aga9/ ,surprise ,m$ical ,bills ,act ( #bjbj1 t provides = a me?od = det]m9+ ! total am\nt payable "u su* heal? plan ) respect to su* item or s]vice furni%$ by su* provid] or facility1 su* am\nt det]m9$ 9 accordance ) su* me?od4 7#ab7 ,recogniz$ am\nt ,! t]m recogniz$ am\nt means1 ) respect to an item or s]vice furni%$ 9 a ,/ate dur+ a ye> to a p>ticipant or b5efici>y ( a heal? plan by a nonp>ticipat+ provid] or nonp>ticipat+ facility-- 7,a7 subject to subp>agraphs 7,c7 & 7,d71 9 ! case su* ,/ate has 9 effect a law describ$ 9 p>agraph 7#aa77;,a7 ) respect to su* item or s]vice1 provid] or facility1 & plan1 ! am\nt det]m9$ 9 accordance ) su* law2 7,b7 subject to subp>agraphs 7,c7 & 7,d71 9 ! case su* ,/ate does n h 9 effect su* a law1 an am\nt t is ! m$ian contract$ rate = su* item or s]vice = su* ye>2 7,c7 9 ! case su* ,/ate is describ$ 9 p>agraph 7#aa77;,c7 ) respect to su* item or s]vice s furni%$1 ! am\nt t ! ,/ate approves "u su* sy/em = su* item or s]vice s furni%$2 or 7,d7 9 ! case su* heal? plan is a self-insur$ gr\p heal? plan & 9 ! case ( a ,/ate ) an agreem5t ) su* plan 9 effect z ( ! date ( ! enactm5t ( ! ,consum] ,protections ,aga9/ ,surprise ,m$ical ,bills ,act ( #bjbj1 t provides = a me?od = det]m9+ ! total am\nt payable "u su* heal? plan ) respect to su* item or s]vice furni%$ by su* provid] or facility1 su* am\nt det]m9$ 9 accordance ) su* me?od4 7#ac7 ,/abilize ,! t]m to /abilize1 ) respect to an em]g5cy m$ical condition1 has ! mean+ give 9 section #ahfg7;e77#c77;,a7 ( ! ,social ,security ,act74 7#ad7 ,co/-%>+ ,! t]m co/-%>+ includes copaym5ts1 co9surance1 & d$uctibles4 7l7 ,paym5t to provid] or facility ,9 ! case ( any paym5t requir$ to be made by a heal? plan pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a7 to a nonp>ticiapt+ provid] or nonp>ticipat+ facility = an item or s]vice1 su* paym5t %all be made to su* provid] or facility & n to ! individual receiv+ su* item or s]vice4 4 7#b7 ,con=m+ am5dm5t 7,a7 ,application provisions ,section #gae7;a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;d7a77 is am5d$-- 7i7 9 p>agraph 7#a71 by /rik+ 7z am5d$ by ! ,pati5t ,protection & ,af=dable ,c>e ,act7 & ins]t+ 7o!r ?an1 ) respect to a plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbb1 ! provisions ( section #bgai;,a ( su* ,act72 & 7ii7 9 p>agraph 7#b71 by ins]t+ 7o!r ?an1 ) respect to a plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbb1 ! provisions ( section #bgai;,a ( su* ,act7 aft] ! fir/ occurr5ce ( su* "p ,a4 7,b7 ,application to retiree-only plans ,section #gcb7;a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aaia;a7a77 is am5d$ by /rik+ section #gaa & ins]t+ sections #gaa & #gaf4 7#c7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by ins]t+ aft] ! item relat+ to section #gad ! foll[+ new items3 ,sec4 #gae4 ,additional m>ket re=ms4 ,sec4 #gaf4 ,pati5t protections4 4 7#d7 ,effective date ,! am5dm5ts made by ?is subsection %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb4 #c4 ,consum] protections ?r\gh requirem5ts on heal? plans to prev5t surprise m$ical bills = non-em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities 7a7 ,,phsa am5dm5ts 7#a7 ,9 g5]al ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 z am5d$ by section #b7;a71 is fur!r am5d$ by ins]t+ be=e subsection 7k7 ! foll[+ new subsection3 7e7 ,co/-,%>+ & paym5t ( non-,em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities 7#a7 ,9 g5]al ,subject to p>agraph 7#b71 9 ! case ( items or s]vices 7o!r ?an em]g5cy s]vices to :i* subsection 7b7 applies or items & s]vices to :i* subsection 7i7 applies7 furni%$ to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan by a nonp>ticipat+ provid] dur+ a visit 7z def9$ by ! ,secret>y 9 accordance ) subsection 7k77#b77 at a p>ticipat+ facility1 if su* items & s]vices w\ld o!rwise be cov]$ "u su* plan if furni%$ by a p>ticipat+ provid]1 ! plan-- 7,a7 %all n impose on su* p>ticipant1 b5efici>y1 or enrollee a co/-%>+ am\nt = 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]2 7,b7 %all calculate su* co/-%>+ am\nt z if ! contract$ rate = su* s]vices if furni%$ by a p>ticipat+ provid] 7 equal to ! recogniz$ am\nt = su* items & s]vices2 7,c7 %all pay to su* provid] furni%+ su* items & s]vices to su* p>ticipant1 b5efici>y1 or enrollee ! am\nt by :i* ! out-(-network rate = su* items & s]vices 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 apply ! d$uctible or out-(-pocket maximum1 if any1 t w\ld apply if su* s]vices 7 furni%$ by a p>ticipat+ provid]4 7#b7 ,exception ,p>agraph 7#a7 %all n apply to a heal? plan 9 ! case ( items or s]vices furni%$ to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan by a nonp>ticipat+ provid] dur+ a visit 7z s def9$ by ! ,secret>y 9 accordance ) subsection 7k77#b77 at a p>ticipat+ facility if ! requirem5t describ$ 9 p>agraph 7#a7 ( section #aaej;,c7b7 ( ! ,social ,security ,act does n apply ) respect to su* provid] & su* items & s]vices due to ! application ( p>agraph 7#b7 ( su* section4 4 7#b7 ,effective date ,! am5dm5t made by p>agraph 7#a7 %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb4 7b7 ,,irc am5dm5ts 7#a7 ,9 g5]al ,section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf1 z add$ by section #b7;b71 is am5d$ by ins]t+ be=e subsection 7k7 ! foll[+ new subsection3 7e7 ,co/-,%>+ & paym5t ( non-,em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities 7#a7 ,9 g5]al ,subject to p>agraph 7#b71 9 ! case ( items or s]vices 7o!r ?an em]g5cy s]vices to :i* subsection 7b7 applies or items & s]vices to :i* subsection 7i7 applies7 furni%$ to a p>ticipant or b5efici>y ( a heal? plan by a nonp>ticipat+ provid] dur+ a visit 7z def9$ by ! ,secret>y 9 accordance ) subsection 7k77#b77 at a p>ticipat+ facility1 if su* items & s]vices w\ld o!rwise be cov]$ "u su* plan if furni%$ by a p>ticipat+ provid]1 ! plan-- 7,a7 %all n impose on su* p>ticipant or b5efici>y a co/-%>+ am\nt = 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]2 7,b7 %all calculate su* co/-%>+ am\nt z if ! contract$ rate = su* s]vices if furni%$ by a p>ticipat+ provid] 7 equal to ! recogniz$ am\nt = su* items & s]vices2 7,c7 %all pay to su* provid] furni%+ su* items & s]vices to su* p>ticipant or b5efici>y ! am\nt by :i* ! out-(-network rate = su* items & s]vices 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 apply ! d$uctible or out-(-pocket maximum1 if any1 t w\ld apply if su* s]vices 7 furni%$ by a p>ticipat+ provid]4 7#b7 ,exception ,p>agraph 7#a7 %all n apply to a heal? plan 9 ! case ( items or s]vices furni%$ to a p>ticipant or b5efici>y ( a heal? plan by a nonp>ticipat+ provid] dur+ a visit 7z s def9$ by ! ,secret>y 9 accordance ) subsection 7k77#b77 at a p>ticipat+ facility if ! requirem5t describ$ 9 p>agraph 7#a7 ( section #aaej;,c7b7 ( ! ,social ,security ,act does n apply ) respect to su* provid] & su* items & s]vices due to ! application ( p>agraph 7#b7 ( su* section4 4 7#b7 ,effective date ,! am5dm5ts made by p>agraph 7#a7 %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb4 7c7 ,,erisa am5dm5ts 7#a7 ,9 g5]al ,section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 z add$ by section #b7;c71 is am5d$ by ins]t+ be=e subsection 7k7 ! foll[+ new subsection3 7e7 ,co/-,%>+ & paym5t ( non-,em]g5cy s]vices p]=m$ by nonp>ticipat+ provid]s at c]ta9 p>ticipat+ facilities 7#a7 ,9 g5]al ,subject to p>agraph 7#b71 9 ! case ( items or s]vices 7o!r ?an em]g5cy s]vices to :i* subsection 7b7 applies or items & s]vices to :i* subsection 7i7 applies7 furni%$ to a p>ticipant or b5efici>y ( a heal? plan by a nonp>ticipat+ provid] dur+ a visit 7z def9$ by ! ,secret>y 9 accordance ) subsection 7k77#b77 at a p>ticipat+ facility1 if su* items & s]vices w\ld o!rwise be cov]$ "u su* plan if furni%$ by a p>ticipat+ provid]1 ! plan-- 7,a7 %all n impose on su* p>ticipant or b5efici>y a co/-%>+ am\nt = 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]2 7,b7 %all calculate su* co/-%>+ am\nt z if ! contract$ rate = su* s]vices if furni%$ by a p>ticipat+ provid] 7 equal to ! recogniz$ am\nt = su* items & s]vices2 7,c7 %all pay to su* provid] furni%+ su* items & s]vices to su* p>ticipant or b5efici>y ! am\nt by :i* ! out-(-network rate = su* items & s]vices 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 apply ! d$uctible or out-(-pocket maximum1 if any1 t w\ld apply if su* s]vices 7 furni%$ by a p>ticipat+ provid]4 7#b7 ,exception ,p>agraph 7#a7 %all n apply to a heal? plan 9 ! case ( items or s]vices furni%$ to a p>ticipant or b5efici>y ( a heal? plan by a nonp>ticipat+ provid] dur+ a visit 7z s def9$ by ! ,secret>y 9 accordance ) subsection 7k77#b77 at a p>ticipat+ facility if ! requirem5t describ$ 9 p>agraph 7#a7 ( section #aaej;,c7b7 ( ! ,social ,security ,act does n apply ) respect to su* provid] & su* items & s]vices due to ! application ( p>agraph 7#b7 ( su* section4 4 7#b7 ,effective date ,! am5dm5ts made by p>agraph 7#a7 %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb4 #d4 ,consum] protections ?r\gh application ( heal? plan ext]nal review 9 cases ( c]ta9 surprise m$ical bills ,section #bgai7;b77#a7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai7;b77#a77 is am5d$-- 7#a7 by /rik+ at a m9imum1 includes & ins]t+ at a m9imum-- 7,a7 includes 2 7#b7 by /rik+ at ! end or & ins]t+ &2 & 7#c7 by add+ at ! end ! foll[+ new subp>agraph3 7,b7 beg9n+ n lat] ?an ,janu>y #a1 #bjbb1 applies su* ext]nal review process ) respect to any adv]se det]m9ation by su* plan or issu] "u subsection 7b7 ( section #bgai;,a1 subsection 7e7 ( su* section1 or subsection 7i7 ( su* section1 includ+ ) respect to :e!r an item or s]vice t is ! subject to su* a det]m9ation is an item or s]vice to :i* su* subsection 7b71 7e71 or 7i7 applies2 or 4 #e4 ,consum] protections ?r\gh heal? plan transp>5cy requirem5ts 7a7 ,,phsa am5dm5ts ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 z am5d$ by sections #b7;a7 & #c7;a71 is fur!r am5d$ by ins]t+ be=e subsection 7k7 ! foll[+ new subsections3 7f7 ,provid] directory requirem5ts 7#a7 ,9 g5]al ,beg9n+ n lat] ?an ,janu>y #a1 #bjbb1 ea* heal? plan %all-- 7,a7 e/abli% ! v]ification process describ$ 9 p>agraph 7#b72 7,b7 e/abli% ! response protocol describ$ 9 p>agraph 7#c72 7,c7 e/abli% ! database describ$ 9 p>agraph 7#d72 & 7,d7 include 9 any directory 7o!r ?an ! database describ$ 9 subp>agraph 7,c77 conta9+ provid] directory in=mation ) respect to su* plan ! in=mation describ$ 9 p>agraph 7#e74 7#b7 ,v]ification process ,! v]ification process describ$ 9 ?is p>agraph is1 ) respect to a heal? plan1 a process-- 7,a7 "u :i* su* plan v]ifies & updates ! provid] directory in=mation includ$ on ! database describ$ 9 p>agraph 7#d7 ( su* plan (-- 7i7 n less frequ5tly ?an once e #ij days1 a r&om sample ( at lea/ #aj p]c5t ( heal? c>e provid]s & heal? c>e facilities includ$ 9 su* database2 & 7ii7 any su* provid] or su* facility includ$ 9 su* database t has n submitt$ any claim to su* plan dur+ a #ab-mon? p]iod2 7,b7 t e/abli%es a proc$ure = ! removal f su* database ( su* a provid] or facility ) respect to :i* su* plan has be5 unable to v]ify su* in=mation dur+ a p]iod specifi$ by ! plan2 & 7,c7 t provides = ! update ( su* database )9 #b bus9ess days ( su* plan receiv+ f su* a provid] or facility in=mation pursuant to section #aaej;,d ( ! ,social ,security ,act4 7#c7 ,response protocol ,! response protocol describ$ 9 ?is p>agraph is1 9 ! case ( an individual enroll$ 9 a heal? plan :o reque/s in=mation ?r\gh a telephone call or email on :e!r a heal? c>e provid] or heal? c>e facility has a contractual relation%ip to furni% items & s]vices "u su* plan1 a protocol "u :i* su* plan-- 7,a7 responds to su* individual z soon z practicable1 & 9 no case lat] ?an #a bus9ess day aft] su* call or email is receiv$1 ?r\gh a writt5 electronic or pap] 7z reque/$ by su* individual7 communication2 & 7,b7 reta9s su* communication 9 su* individual's file = at lea/ #b ye>s foll[+ su* response4 7#d7 ,database ,! database describ$ 9 ?is p>agraph is1 ) respect to a heal? plan1 a database on ! public website ( su* plan or issu] t conta9s-- 7,a7 a li/ ( ea* heal? c>e provid] & heal? c>e facility ) :i* su* plan has a contractual relation%ip = furni%+ items & s]vices "u su* plan2 & 7,b7 provid] directory in=mation ) respect to ea* su* provid] & facility4 7#e7 ,in=mation ,! in=mation describ$ 9 ?is p>agraph is1 ) respect to a directory conta9+ provid] directory in=mation ) respect to a heal? plan1 a notification t su* in=mation conta9$ 9 su* directory 0 accurate z ( ! date ( publication ( su* directory & t an individual enroll$ "u su* plan %\ld consult ! database describ$ 9 p>agraph 7#d7 ) respect to su* plan or contact su* plan to obta9 ! mo/ curr5t provid] directory in=mation ) respect to su* plan4 7#f7 ,def9ition ,= purposes ( ?is section1 ! t]m provid] directory in=mation includes1 ) respect to a heal? plan1 ! "n1 address1 specialty1 & telephone numb] ( ea* heal? c>e provid] or heal? c>e facility ) :i* su* plan has a contractual relation%ip = furni%+ items & s]vices "u su* plan4 7g7 ,disclosure on pati5t protections aga9/ balance bill+ ,beg9n+ n lat] ?an ,janu>y #a1 #bjbb1 ea* heal? plan %all make publicly available1 po/ on a website ( su* plan available to individuals enroll$ "u su* plan1 & include on ea* explanation ( b5efits = an item or s]vice ) respect to :i* ! requirem5ts "u subsection 7b71 7e71 or 7i7 applies-- 7#a7 in=mation 9 pla9 language on-- 7,a7 ! requirem5ts & prohibitions appli$ "u section #aaej;,c ( ! ,social ,security ,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 ) respect to :i* su* a provid] is a nonp>ticipat+ provid] or facility is a nonp>ticipat+ facility1 ) respect to su* plan1 = furni%+ su* item or s]vice aft] receiv+ paym5t f ! plan = 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 & 7i72 & 7#b7 in=mation 9 pla9 language on contact+ appropriate ,/ate & ,f$]al ag5cies 9 ! case t an individual believes t su* a heal? plan1 provid]1 or facility has violat$ any requirem5t describ$ 9 p>agraph 7#a7 ) respect to su* individual4 4 7b7 ,,irc am5dm5ts ,section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf1 z add$ by section #b7;b7 & am5d$ by section #c7;b71 is fur!r am5d$ by ins]t+ be=e subsection 7k7 ! foll[+ new subsections3 7f7 ,provid] directory requirem5ts 7#a7 ,9 g5]al ,beg9n+ n lat] ?an ,janu>y #a1 #bjbb1 ea* heal? plan %all-- 7,a7 e/abli% ! v]ification process describ$ 9 p>agraph 7#b72 7,b7 e/abli% ! response protocol describ$ 9 p>agraph 7#c72 7,c7 e/abli% ! database describ$ 9 p>agraph 7#d72 & 7,d7 include 9 any directory 7o!r ?an ! database describ$ 9 subp>agraph 7,c77 conta9+ provid] directory in=mation ) respect to su* plan ! in=mation describ$ 9 p>agraph 7#e74 7#b7 ,v]ification process ,! v]ification process describ$ 9 ?is p>agraph is1 ) respect to a heal? plan1 a process-- 7,a7 "u :i* su* plan v]ifies & updates ! provid] directory in=mation includ$ on ! database describ$ 9 p>agraph 7#d7 ( su* plan (-- 7i7 n less frequ5tly ?an once e #ij days1 a r&om sample ( at lea/ #aj p]c5t ( heal? c>e provid]s & heal? c>e facilities includ$ 9 su* database2 & 7ii7 any su* provid] or su* facility includ$ 9 su* database t has n submitt$ any claim to su* plan dur+ a #ab-mon? p]iod2 7,b7 t e/abli%es a proc$ure = ! removal f su* database ( su* a provid] or facility ) respect to :i* su* plan has be5 unable to v]ify su* in=mation dur+ a p]iod specifi$ by ! plan2 & 7,c7 t provides = ! update ( su* database )9 #b bus9ess days ( su* plan receiv+ f su* a provid] or facility in=mation pursuant to section #aaej;,d ( ! ,social ,security ,act4 7#c7 ,response protocol ,! response protocol describ$ 9 ?is p>agraph is1 9 ! case ( an individual enroll$ 9 a heal? plan :o reque/s in=mation ?r\gh a telephone call or email on :e!r a heal? c>e provid] or heal? c>e facility has a contractual relation%ip to furni% items & s]vices "u su* plan1 a protocol "u :i* su* plan-- 7,a7 responds to su* individual z soon z practicable1 & 9 no case lat] ?an #a bus9ess day aft] su* call or email is receiv$1 ?r\gh a writt5 electronic or pap] 7z reque/$ by su* individual7 communication2 & 7,b7 reta9s su* communication 9 su* individual's file = at lea/ #b ye>s foll[+ su* response4 7#d7 ,database ,! database describ$ 9 ?is p>agraph is1 ) respect to a heal? plan1 a database on ! public website ( su* plan or issu] t conta9s-- 7,a7 a li/ ( ea* heal? c>e provid] & heal? c>e facility ) :i* su* plan has a contractual relation%ip = furni%+ items & s]vices "u su* plan2 & 7,b7 provid] directory in=mation ) respect to ea* su* provid] & facility4 7#e7 ,in=mation ,! in=mation describ$ 9 ?is p>agraph is1 ) respect to a directory conta9+ provid] directory in=mation ) respect to a heal? plan1 a notification t su* in=mation conta9$ 9 su* directory 0 accurate z ( ! date ( publication ( su* directory & t an individual enroll$ "u su* plan %\ld consult ! database describ$ 9 p>agraph 7#d7 ) respect to su* plan or contact su* plan to obta9 ! mo/ curr5t provid] directory in=mation ) respect to su* plan4 7#f7 ,def9ition ,= purposes ( ?is section1 ! t]m provid] directory in=mation includes1 ) respect to a heal? plan1 ! "n1 address1 specialty1 & telephone numb] ( ea* heal? c>e provid] or heal? c>e facility ) :i* su* plan has a contractual relation%ip = furni%+ items & s]vices "u su* plan4 7g7 ,disclosure on pati5t protections aga9/ balance bill+ ,beg9n+ n lat] ?an ,janu>y #a1 #bjbb1 ea* heal? plan %all make publicly available1 po/ on a website ( su* plan available to individuals enroll$ "u su* plan1 & include on ea* explanation ( b5efits = an item or s]vice ) respect to :i* ! requirem5ts "u subsection 7b71 7e71 or 7i7 applies-- 7#a7 in=mation 9 pla9 language on-- 7,a7 ! requirem5ts & prohibitions appli$ "u section #aaej;,c ( ! ,social ,security ,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>ticipant or b5efici>y ( su* plan ) respect to :i* su* a provid] is a nonp>ticipat+ provid] or facility is a nonp>ticipat+ facility1 ) respect to su* plan1 = furni%+ su* item or s]vice aft] receiv+ paym5t f ! plan = su* item or s]vice & any applicable co/-%>+ paym5t f su* p>ticipant or b5efici>y2 & 7,c7 ! requirem5ts appli$ "u subsections 7b71 7e71 & 7i72 & 7#b7 in=mation 9 pla9 language on contact+ appropriate ,/ate & ,f$]al ag5cies 9 ! case t an individual believes t su* a heal? plan1 provid]1 or facility has violat$ any requirem5t describ$ 9 p>agraph 7#a7 ) respect to su* individual4 4 7c7 ,,erisa am5dm5ts ,section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 z add$ by section #b7;c7 & am5d$ by section #c7;c71 is fur!r am5d$ by ins]t+ be=e subsection 7k7 ! foll[+ new subsections3 7f7 ,provid] directory requirem5ts 7#a7 ,9 g5]al ,beg9n+ n lat] ?an ,janu>y #a1 #bjbb1 ea* heal? plan %all-- 7,a7 e/abli% ! v]ification process describ$ 9 p>agraph 7#b72 7,b7 e/abli% ! response protocol describ$ 9 p>agraph 7#c72 7,c7 e/abli% ! database describ$ 9 p>agraph 7#d72 & 7,d7 include 9 any directory 7o!r ?an ! database describ$ 9 subp>agraph 7,c77 conta9+ provid] directory in=mation ) respect to su* plan ! in=mation describ$ 9 p>agraph 7#e74 7#b7 ,v]ification process ,! v]ification process describ$ 9 ?is p>agraph is1 ) respect to a heal? plan1 a process-- 7,a7 "u :i* su* plan v]ifies & updates ! provid] directory in=mation includ$ on ! database describ$ 9 p>agraph 7#d7 ( su* plan (-- 7i7 n less frequ5tly ?an once e #ij days1 a r&om sample ( at lea/ #aj p]c5t ( heal? c>e provid]s & heal? c>e facilities includ$ 9 su* database2 & 7ii7 any su* provid] or su* facility includ$ 9 su* database t has n submitt$ any claim to su* plan dur+ a #ab-mon? p]iod2 7,b7 t e/abli%es a proc$ure = ! removal f su* database ( su* a provid] or facility ) respect to :i* su* plan has be5 unable to v]ify su* in=mation dur+ a p]iod specifi$ by ! plan2 & 7,c7 t provides = ! update ( su* database )9 #b bus9ess days ( su* plan receiv+ f su* a provid] or facility in=mation pursuant to section #aaej;,d ( ! ,social ,security ,act4 7#c7 ,response protocol ,! response protocol describ$ 9 ?is p>agraph is1 9 ! case ( an individual enroll$ 9 a heal? plan :o reque/s in=mation ?r\gh a telephone call or email on :e!r a heal? c>e provid] or heal? c>e facility has a contractual relation%ip to furni% items & s]vices "u su* plan1 a protocol "u :i* su* plan-- 7,a7 responds to su* individual z soon z practicable1 & 9 no case lat] ?an #a bus9ess day aft] su* call or email is receiv$1 ?r\gh a writt5 electronic or pap] 7z reque/$ by su* individual7 communication2 & 7,b7 reta9s su* communication 9 su* individual's file = at lea/ #b ye>s foll[+ su* response4 7#d7 ,database ,! database describ$ 9 ?is p>agraph is1 ) respect to a heal? plan1 a database on ! public website ( su* plan or issu] t conta9s-- 7,a7 a li/ ( ea* heal? c>e provid] & heal? c>e facility ) :i* su* plan has a contractual relation%ip = furni%+ items & s]vices "u su* plan2 & 7,b7 provid] directory in=mation ) respect to ea* su* provid] & facility4 7#e7 ,in=mation ,! in=mation describ$ 9 ?is p>agraph is1 ) respect to a directory conta9+ provid] directory in=mation ) respect to a heal? plan1 a notification t su* in=mation conta9$ 9 su* directory 0 accurate z ( ! date ( publication ( su* directory & t an individual enroll$ "u su* plan %\ld consult ! database describ$ 9 p>agraph 7#d7 ) respect to su* plan or contact su* plan to obta9 ! mo/ curr5t provid] directory in=mation ) respect to su* plan4 7#f7 ,def9ition ,= purposes ( ?is section1 ! t]m provid] directory in=mation includes1 ) respect to a heal? plan1 ! "n1 address1 specialty1 & telephone numb] ( ea* heal? c>e provid] or heal? c>e facility ) :i* su* plan has a contractual relation%ip = furni%+ items & s]vices "u su* plan4 7g7 ,disclosure on pati5t protections aga9/ balance bill+ ,beg9n+ n lat] ?an ,janu>y #a1 #bjbb1 ea* heal? plan %all make publicly available1 po/ on a website ( su* plan available to individuals enroll$ "u su* plan1 & include on ea* explanation ( b5efits = an item or s]vice ) respect to :i* ! requirem5ts "u subsection 7b71 7e71 or 7i7 applies-- 7#a7 in=mation 9 pla9 language on-- 7,a7 ! requirem5ts & prohibitions appli$ "u section #aaej;,c ( ! ,social ,security ,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>ticipant or b5efici>y ( su* plan ) respect to :i* su* a provid] is a nonp>ticipat+ provid] or facility is a nonp>ticipat+ facility1 ) respect to su* plan1 = furni%+ su* item or s]vice aft] receiv+ paym5t f ! plan = su* item or s]vice & any applicable co/-%>+ paym5t f su* p>ticipant or b5efici>y2 & 7,c7 ! requirem5ts appli$ "u subsections 7b71 7e71 & 7i72 & 7#b7 in=mation 9 pla9 language on contact+ appropriate ,/ate & ,f$]al ag5cies 9 ! case t an individual believes t su* a heal? plan1 provid]1 or facility has violat$ any requirem5t describ$ 9 p>agraph 7#a7 ) respect to su* individual4 4 #f4 ,consum] protections ?r\gh heal? plan requirem5t = fair & hone/ advance co/ e/imate 7a7 ,,phsa am5dm5t ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 z am5d$ by sections #b7;a71 #c7;a71 & #e7;a71 is fur!r am5d$ by ins]t+ be=e subsection 7k7 ! foll[+ new subsections3 7h7 ,advanc$ explanation ( b5efits ,beg9n+ on ,janu>y #a1 #bjbb1 ea* heal? plan %all1 ) respect to a notification submitt$ "u section #aaej;,d7b77#b77;,a7 ( ! ,social ,security ,act by a heal? c>e provid] or heal? c>e facility1 respectively1 to ! heal? plan = a p>ticipant1 b5efici>y1 or enrollee "u su* heal? plan s*$ul$ to receive an item or s]vice f ! provid] or facility1 n lat] ?an #a bus9ess day 7or1 9 ! case su* item or s]vice 0 s s*$ul$ at lea/ #aj bus9ess days be=e su* item or s]vice is to be furni%$ 7or 9 ! case su* notification 0 made pursuant to a reque/ by su* p>ticipant1 b5efici>y1 or enrollee71 #c bus9ess days7 aft] ! date on :i* ! heal? plan receives su* notification1 provide to ! p>ticipant1 b5efici>y1 or enrollee 7?r\gh mail or electronic means1 z reque/$ by ! p>ticipant1 b5efici>y1 or enrollee7 a notification 79 cle> & und]/&able language7 includ+ ! foll[+3 7#a7 ,:e!r or n ! provid] or facility is a p>ticipat+ provid] or a p>ticipat+ facility ) respect to ! heal? plan ) respect to ! furni%+ ( su* item or s]vice &-- 7,a7 9 ! case ! provid] or facility is a p>ticipat+ provid] or facility ) respect to ! heal? plan ) respect to ! furni%+ ( su* item or s]vice1 ! contract$ rate "u su* plan = su* item or s]vice2 & 7,b7 9 ! case ! provid] or facility is a nonp>ticipat+ provid] or facility ) respect to su* plan1 a description ( h[ su* individual may obta9 in=mation on provid]s & facilities t1 ) respect to su* heal? plan1 are p>ticipat+ provid]s & facilities4 7#b7 ,! good fai? e/imate includ$ 9 ! notification receiv$ f ! provid] or facility4 7#c7 ,a good fai? e/imate ( ! am\nt ! heal? plan is responsible = pay+ = items & s]vices includ$ 9 ! e/imate describ$ 9 p>agraph 7#b74 7#d7 ,a good fai? e/imate ( ! am\nt ( any co/-%>+ 7includ+ ) respect to ! d$uctible & any copaym5t or co9surance obligation7 = :i* ! p>ticipant1 b5efici>y1 or enrollee w\ld be responsible = su* item or s]vice 7z ( ! date ( su* notification74 7#e7 ,a good fai? e/imate ( ! am\nt t ! p>ticipant1 b5efici>y1 or enrollee has incurr$ t[>d meet+ ! limit ( ! f9ancial responsibility 7includ+ ) respect to d$uctibles & out-(-pocket maximums7 "u ! heal? plan 7z ( ! date ( su* notification74 7#f7 ,9 ! case su* item or s]vice is subject to a m$ical managem5t te*nique 7includ+ concurr5t review1 prior au?orization1 & /ep-!rapy or fail-fir/ protocols7 = cov]age "u ! heal? plan1 a disclaim] t cov]age = su* item or s]vice is subject to su* m$ical managem5t te*nique4 7#g7 ,a disclaim] t ! in=mation provid$ 9 ! notification is only an e/imate bas$ on ! items & s]vices reasonably expect$1 at ! "t ( s*$ul+ 7or reque/+7 ! item or s]vice1 to be furni%$ & is subject to *ange4 7#h7 ,a /atem5t t ! individual may seek su* an item or s]vice f a provid] t is a p>ticipat+ provid] or a facility t is a p>ticipat+ facility & a li/ ( p>ticipat+ facilities1 or ( p>ticipat+ provid]s1 z applicable1 :o are able to furni% su* items & s]vices involv$4 7#i7 ,any o!r in=mation or disclaim] ! heal? plan det]m9es appropriate t is consi/5t ) in=mation & disclaim]s requir$ "u ?is section4 7i7 ,co/-,%>+ & paym5t = s]vices provid$ bas$ on reliance on incorrect provid] network in=mation 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb1 9 ! case ( an item or s]vice furni%$ to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan by a nonp>ticipat+ provid] or a nonp>ticipat+ facility1 if su* item or s]vice w\ld o!rwise be cov]$ "u su* plan if furni%$ by a p>ticipat+ provid] or p>ticipat+ facility & if ei!r ( ! crit]ia describ$ 9 p>agraph 7#b7 applies ) respect to su* p>ticipant1 b5efici>y1 or enrollee & item or s]vice1 ! plan-- 7,a7 %all n impose on su* enrollee a co/-%>+ am\nt = su* item or s]vice s furni%$ t is great] ?an ! co/-%>+ am\nt t w\ld apply "u su* plan _h su* item or s]vice be5 furni%$ by a p>ticipat+ provid]2 7,b7 %all calculate su* co/-%>+ am\nt z if ! contract$ rate = su* item or s]vice furni%$ by su* a p>ticipat+ provid] or facility 7 equal to-- 7i7 ! mo/ rec5t 7z ( ! date su* item or s]vice 0 furni%$7 contract$ rate 9 effect betwe5 su* provid] or facility & su* plan = su* item or s]vice furni%$ "u su* plan1 if any2 or 7ii7 if no contract$ rate describ$ 9 clause 7i7 exi/s1 ! recogniz$ am\nt = su* item or s]vice2 7,c7 %all pay to su* nonp>ticipat+ provid] or facility furni%+ su* item or s]vice to su* p>ticipant1 b5efici>y1 or enrollee ! am\nt by :i*-- 7i7 if a contract$ rate describ$ 9 subp>agraph 7,b77i7 exi/s1 ! mo/ rec5t 7z ( ! date su* item or s]vices 0 furni%$7 su* rate2 or 7ii7 if no contract$ rate describ$ 9 su* subp>agraph exi/s1 ! out-(-network rate2 = su* items & s]vices 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 apply ! d$uctible or out-(-pocket maximum1 if any1 t w\ld apply if su* s]vices 7 furni%$ by a p>ticipat+ provid] or a p>ticipat+ facility4 7#b7 ,crit]ia describ$ ,= purposes ( p>agraph 7#a71 ! crit]ia describ$ 9 ?is p>agraph1 ) respect to an item or s]vice furni%$ to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan by a nonp>ticipat+ provid] or a nonp>ticipat+ facility1 are ! foll[+3 7,a7 ,! p>ticipant1 b5efici>y1 or enrollee receiv$ a notification "u subsection 7h7 ) respect to su* item & s]vice to be furni%$ & su* notification provid$ in=mation t ! provid] 0 a p>ticipat+ provid] or facility 0 a p>ticipat+ facility1 ) respect to ! plan = furni%+ su* item or s]vice4 7,b7 ,a notification 0 n provid$1 9 accordance ) subsection 7h71 to ! p>ticipant1 b5efici>y1 or enrollee1 & ! p>ticipant1 b5efici>y1 or enrollee reque/$ ?r\gh ! response protocol ( ! plan "u subsection 7f77#c7 in=mation on :e!r ! provid] 0 a p>ticipat+ provid] or facility 0 a p>ticipat+ facility ) respect to ! plan = furni%+ su* item or s]vice & 0 in=m$ ?r\gh su* protocol t ! provid] 0 su* a p>ticipat+ provid] or facility 0 su* a p>ticipat+ facility4 4 7b7 ,,irc am5dm5ts ,section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf1 z add$ by section #b7;b7 & am5d$ by sections #c7;b7 & #e7;b71 is fur!r am5d$ by ins]t+ be=e subsection 7k7 ! foll[+ new subsections3 7h7 ,advanc$ explanation ( b5efits ,beg9n+ on ,janu>y #a1 #bjbb1 ea* heal? plan %all1 ) respect to a notification submitt$ "u section #aaej;,d7b77#b77;,a7 ( ! ,social ,security ,act by a heal? c>e provid] or heal? c>e facility1 respectively1 to ! heal? plan = a p>ticipant or b5efici>y "u su* heal? plan s*$ul$ to receive an item or s]vice f ! provid] or facility1 n lat] ?an #a bus9ess day 7or1 9 ! case su* item or s]vice 0 s s*$ul$ at lea/ #aj bus9ess days be=e su* item or s]vice is to be furni%$ 7or 9 ! case su* notification 0 made pursuant to a reque/ by su* p>ticipant or b5efici>y71 #c bus9ess days7 aft] ! date on :i* ! heal? plan receives su* notification1 provide to ! p>ticipant or b5efici>y 7?r\gh mail or electronic means1 z reque/$ by ! p>ticipant or b5efici>y7 a notification 79 cle> & und]/able language7 includ+ ! foll[+3 7#a7 ,:e!r or n ! provid] or facility is a p>ticipat+ provid] or a p>ticipat+ facility ) respect to ! heal? plan ) respect to ! furni%+ ( su* item or s]vice &-- 7,a7 9 ! case ! provid] or facility is a p>ticipat+ provid] or facility ) respect to ! heal? plan ) respect to ! furni%+ ( su* item or s]vice1 ! contract$ rate "u su* plan = su* item or s]vice2 & 7,b7 9 ! case ! provid] or facility is a nonp>ticipat+ provid] or facility ) respect to su* plan1 a description ( h[ su* individual may obta9 in=mation on provid]s & facilities t1 ) respect to su* heal? plan1 are p>ticipat+ provid]s & facilities4 7#b7 ,! good fai? e/imate includ$ 9 ! notification receiv$ f ! provid] or facility4 7#c7 ,a good fai? e/imate ( ! am\nt ! heal? plan is responsible = pay+ = items & s]vices includ$ 9 ! e/imate describ$ 9 p>agraph 7#b74 7#d7 ,a good fai? e/imate ( ! am\nt ( any co/-%>+ 7includ+ ) respect to ! d$uctible & any copaym5t or co9surance obligation7 = :i* ! p>ticipant or b5efici>y w\ld be responsible = su* item or s]vice 7z ( ! date ( su* notification74 7#e7 ,a good fai? e/imate ( ! am\nt t ! p>ticipant or b5efici>y has incurr$ t[>d meet+ ! limit ( ! f9ancial responsibility 7includ+ ) respect to d$uctibles & out-(-pocket maximums7 "u ! heal? plan 7z ( ! date ( su* notification74 7#f7 ,9 ! case su* item or s]vice is subject to a m$ical managem5t te*nique 7includ+ concurr5t review1 prior au?orization1 & /ep-!rapy or fail-fir/ protocols7 = cov]age "u ! heal? plan1 a disclaim] t cov]age = su* item or s]vice is subject to su* m$ical managem5t te*nique4 7#g7 ,a disclaim] t ! in=mation provid$ 9 ! notification is only an e/imate bas$ on ! items & s]vices reasonably expect$1 at ! "t ( s*$ul+ 7or reque/+7 ! item or s]vice1 to be furni%$ & is subject to *ange4 7#h7 ,a /atem5t t ! individual may seek su* an item or s]vice f a provid] t is a p>ticipat+ provid] or a facility t is a p>ticipat+ facility & a li/ ( p>ticipat+ facilities1 or ( p>ticipat+ provid]s1 z applicable1 :o are able to furni% su* items & s]vices involv$4 7#i7 ,any o!r in=mation or disclaim] ! heal? plan det]m9es appropriate t is consi/5t ) in=mation & disclaim]s requir$ "u ?is section4 7i7 ,co/-,%>+ & paym5t = s]vices provid$ bas$ on reliance on incorrect provid] network in=mation 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb1 9 ! case ( an item or s]vice furni%$ to a p>ticipant or b5efici>y ( a heal? plan by a nonp>ticipat+ provid] or a nonp>ticipat+ facility1 if su* item or s]vice w\ld o!rwise be cov]$ "u su* plan if furni%$ by a p>ticipat+ provid] or p>ticipat+ facility & if ei!r ( ! crit]ia describ$ 9 p>agraph 7#b7 applies ) respect to su* p>ticipant or b5efici>y & item or s]vice1 ! plan-- 7,a7 %all n impose on su* enrollee a co/-%>+ am\nt = su* item or s]vice s furni%$ t is great] ?an ! co/-%>+ am\nt t w\ld apply "u su* plan _h su* item or s]vice be5 furni%$ by a p>ticipat+ provid]2 7,b7 %all calculate su* co/-%>+ am\nt z if ! contract$ rate = su* item or s]vice furni%$ by su* a p>ticipat+ provid] or facility 7 equal to-- 7i7 ! mo/ rec5t 7z ( ! date su* item or s]vice 0 furni%$7 contract$ rate 9 effect betwe5 su* provid] or facility & su* plan = su* item or s]vice furni%$ "u su* plan1 if any2 or 7ii7 if no contract$ rate describ$ 9 clause 7i7 exi/s1 ! recogniz$ am\nt = su* item or s]vice2 7,c7 %all pay to su* nonp>ticipat+ provid] or facility furni%+ su* item or s]vice to su* p>ticipant or b5efici>y ! am\nt by :i*-- 7i7 if a contract$ rate describ$ 9 subp>agraph 7,b77i7 exi/s1 ! mo/ rec5t 7z ( ! date su* item or s]vices 0 furni%$7 su* rate2 or 7ii7 if no contract$ rate describ$ 9 su* subp>agraph exi/s1 ! out-(-network rate2 = su* items & s]vices 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 apply ! d$uctible or out-(-pocket maximum1 if any1 t w\ld apply if su* s]vices 7 furni%$ by a p>ticipat+ provid] or a p>ticipat+ facility4 7#b7 ,crit]ia describ$ ,= purposes ( p>agraph 7#a71 ! crit]ia describ$ 9 ?is p>agraph1 ) respect to an item or s]vice furni%$ to a p>ticipant or b5efici>y ( a heal? plan by a nonp>ticipat+ provid] or a nonp>ticipat+ facility1 are ! foll[+3 7,a7 ,! p>ticipant or b5efici>y receiv$ a notification "u subsection 7h7 ) respect to su* item & s]vice to be furni%$ & su* notification provid$ in=mation t ! provid] 0 a p>ticipat+ provid] or facility 0 a p>ticipat+ facility1 ) respect to ! plan = furni%+ su* item or s]vice4 7,b7 ,a notification 0 n provid$1 9 accordance ) subsection 7h71 to ! p>ticipant or b5efici>y & ! p>ticipant or b5efici>y reque/$ ?r\gh ! response protocol ( ! plan "u subsection 7f77#c7 in=mation on :e!r ! provid] 0 a p>ticipat+ provid] or facility 0 a p>ticipat+ facility ) respect to ! plan = furni%+ su* item or s]vice & 0 in=m$ ?r\gh su* protocol t ! provid] 0 su* a p>ticipat+ provid] or facility 0 su* a p>ticipat+ facility4 4 7c7 ,,erisa am5dm5ts ,section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 z add$ by section #b7;c7 & am5d$ by sections #c7;c7 & #e7;c71 is fur!r am5d$ by ins]t+ be=e subsection 7k7 ! foll[+ new subsections3 7h7 ,advanc$ explanation ( b5efits ,beg9n+ on ,janu>y #a1 #bjbb1 ea* heal? plan %all1 ) respect to a notification submitt$ "u section #aaej;,d7b77#b77;,a7 ( ! ,social ,security ,act by a heal? c>e provid] or heal? c>e facility1 respectively1 to ! heal? plan = a p>ticipant or b5efici>y "u su* heal? plan s*$ul$ to receive an item or s]vice f ! provid] or facility1 n lat] ?an #a bus9ess day 7or1 9 ! case su* item or s]vice 0 s s*$ul$ at lea/ #aj bus9ess days be=e su* item or s]vice is to be furni%$ 7or 9 ! case su* notification 0 made pursuant to a reque/ by su* p>ticipant or b5efici>y71 #c bus9ess days7 aft] ! date on :i* ! heal? plan receives su* notification1 provide to ! p>ticipant or b5efici>y 7?r\gh mail or electronic means1 z reque/$ by ! p>ticipant or b5efici>y7 a notification 79 cle> & und]/&able language7 includ+ ! foll[+3 7#a7 ,:e!r or n ! provid] or facility is a p>ticipat+ provid] or a p>ticipat+ facility ) respect to ! heal? plan ) respect to ! furni%+ ( su* item or s]vice &-- 7,a7 9 ! case ! provid] or facility is a p>ticipat+ provid] or facility ) respect to ! heal? plan ) respect to ! furni%+ ( su* item or s]vice1 ! contract$ rate "u su* plan = su* item or s]vice2 & 7,b7 9 ! case ! provid] or facility is a nonp>ticipat+ provid] or facility ) respect to su* plan1 a description ( h[ su* individual may obta9 in=mation on provid]s & facilities t1 ) respect to su* heal? plan1 are p>ticipat+ provid]s & facilities4 7#b7 ,! good fai? e/imate includ$ 9 ! notification receiv$ f ! provid] or facility4 7#c7 ,a good fai? e/imate ( ! am\nt ! heal? plan is responsible = pay+ = items & s]vices includ$ 9 ! e/imate describ$ 9 p>agraph 7#b74 7#d7 ,a good fai? e/imate ( ! am\nt ( any co/-%>+ 7includ+ ) respect to ! d$uctible & any copaym5t or co9surance obligation7 = :i* ! p>ticipant or b5efici>y w\ld be responsible = su* item or s]vice 7z ( ! date ( su* notification74 7#e7 ,a good fai? e/imate ( ! am\nt t ! p>ticipant or b5efici>y has incurr$ t[>d meet+ ! limit ( ! f9ancial responsibility 7includ+ ) respect to d$uctibles & out-(-pocket maximums7 "u ! heal? plan 7z ( ! date ( su* notification74 7#f7 ,9 ! case su* item or s]vice is subject to a m$ical managem5t te*nique 7includ+ concurr5t review1 prior au?orization1 & /ep-!rapy or fail-fir/ protocols7 = cov]age "u ! heal? plan1 a disclaim] t cov]age = su* item or s]vice is subject to su* m$ical managem5t te*nique4 7#g7 ,a disclaim] t ! in=mation provid$ 9 ! notification is only an e/imate bas$ on ! items & s]vices reasonably expect$1 at ! "t ( s*$ul+ 7or reque/+7 ! item or s]vice1 to be furni%$ & is subject to *ange4 7#h7 ,a /atem5t t ! individual may seek su* an item or s]vice f a provid] t is a p>ticipat+ provid] or a facility t is a p>ticipat+ facility & a li/ ( p>ticipat+ facilities1 or ( p>ticipat+ provid]s1 z applicable1 :o are able to furni% su* items & s]vices involv$4 7#i7 ,any o!r in=mation or disclaim] ! heal? plan det]m9es appropriate t is consi/5t ) in=mation & disclaim]s requir$ "u ?is section4 7i7 ,co/-,%>+ & paym5t = s]vices provid$ bas$ on reliance on incorrect provid] network in=mation 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb1 9 ! case ( an item or s]vice furni%$ to a p>ticipant or b5efici>y ( a heal? plan by a nonp>ticipat+ provid] or a nonp>ticipat+ facility1 if su* item or s]vice w\ld o!rwise be cov]$ "u su* plan if furni%$ by a p>ticipat+ provid] or p>ticipat+ facility & if ei!r ( ! crit]ia describ$ 9 p>agraph 7#b7 applies ) respect to su* p>ticipant or b5efici>y & item or s]vice1 ! plan-- 7,a7 %all n impose on su* enrollee a co/-%>+ am\nt = su* item or s]vice s furni%$ t is great] ?an ! co/-%>+ am\nt t w\ld apply "u su* plan _h su* item or s]vice be5 furni%$ by a p>ticipat+ provid]2 7,b7 %all calculate su* co/-%>+ am\nt z if ! contract$ rate = su* item or s]vice furni%$ by su* a p>ticipat+ provid] or facility 7 equal to-- 7i7 ! mo/ rec5t 7z ( ! date su* item or s]vice 0 furni%$7 contract$ rate 9 effect betwe5 su* provid] or facility & su* plan = su* item or s]vice furni%$ "u su* plan1 if any2 or 7ii7 if no contract$ rate describ$ 9 clause 7i7 exi/s1 ! recogniz$ am\nt = su* item or s]vice2 7,c7 %all pay to su* nonp>ticipat+ provid] or facility furni%+ su* item or s]vice to su* p>ticipant or b5efici>y ! am\nt by :i*-- 7i7 if a contract$ rate describ$ 9 subp>agraph 7,b77i7 exi/s1 ! mo/ rec5t 7z ( ! date su* item or s]vices 0 furni%$7 su* rate2 or 7ii7 if no contract$ rate describ$ 9 su* subp>agraph exi/s1 ! out-(-network rate2 = su* items & s]vices 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 apply ! d$uctible or out-(-pocket maximum1 if any1 t w\ld apply if su* s]vices 7 furni%$ by a p>ticipat+ provid] or a p>ticipat+ facility4 7#b7 ,crit]ia describ$ ,= purposes ( p>agraph 7#a71 ! crit]ia describ$ 9 ?is p>agraph1 ) respect to an item or s]vice furni%$ to a p>ticipant or b5efici>y ( a heal? plan by a nonp>ticipat+ provid] or a nonp>ticipat+ facility1 are ! foll[+3 7,a7 ,! p>ticipant or b5efici>y receiv$ a notification "u subsection 7h7 ) respect to su* item & s]vice to be furni%$ & su* notification provid$ in=mation t ! provid] 0 a p>ticipat+ provid] or facility 0 a p>ticipat+ facility1 ) respect to ! plan = furni%+ su* item or s]vice4 7,b7 ,a notification 0 n provid$1 9 accordance ) subsection 7h71 to ! p>ticipant or b5efici>y & ! p>ticipant or b5efici>y reque/$ ?r\gh ! response protocol ( ! plan "u subsection 7f77#c7 in=mation on :e!r ! provid] 0 a p>ticipat+ provid] or facility 0 a p>ticipat+ facility ) respect to ! plan = furni%+ su* item or s]vice & 0 in=m$ ?r\gh su* protocol t ! provid] 0 su* a p>ticipat+ provid] or facility 0 su* a p>ticipat+ facility4 4 #g4 ,det]m9ation ?r\gh op5 negotiation & m$iation ( out-(-network rates to be paid by heal? plans 7a7 ,,phsa am5dm5t ,section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;a71 z am5d$ by sections #b7;a71 #c7;a71 #e7;a71 & #f7;a71 is fur!r am5d$ by ins]t+ be=e subsection 7k7 ! foll[+ new subsection3 7j7 ,det]m9ation ( out-(-,network rates ,to be paid by heal? plans 7#a7 ,det]m9ation ?r\gh op5 negotiation 7,a7 ,9 g5]al ,) respect to an item or s]vice furni%$ 9 a ye> by a nonp>ticipat+ provid] or a nonp>ticipat+ facility1 ) respect to a heal? plan1 9 a ,/ate describ$ 9 subp>agraph 7,b7 ( subsection 7k77#aa7 ) respect to su* plan & provid] or facility1 & = :i* a paym5t is requir$ to be made by ! heal? plan pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a71 ! provid] or facility 7z applicable7 or plan may1 dur+ ! #cj-;day p]iod beg9n+ on ! day ! provid] or facility receives a response f ! plan reg>d+ a claim = paym5t = su* item or s]vice1 initiate op5 negotiations "u ?is p>agraph betwe5 su* provid] or facility & plan = purposes ( det]m9+1 dur+ ! op5 negotiation p]iod1 an am\nt agre$ on by su* provid] or facility1 respectively1 & su* plan = paym5t 7includ+ any co/-%>+7 = su* item or s]vice4 ,= purposes ( ?is subsection1 ! op5 negotiation p]iod1 ) respect to an item or s]vice1 is ! #cj-;day p]iod beg9n+ on ! date ( initiation ( ! negotiations ) respect to su* item or s]vice4 7,b7 ,ex*ange ( in=mation ,9 c>ry+ out negotiations initiat$ "u subp>agraph 7,a71 ) respect to an item or s]vice describ$ 9 su* subp>agraph furni%$ 9 a ye>1 n lat] ?an ! fif? bus9ess day ( ! op5 negotiation p]iod describ$ 9 su* subp>agraph ) respect to su* item or s]vice-- 7i7 ! heal? plan t is p>ty to su* negotiations %all notify ! provid] or facility t is p>ty to su* negotiations ( ! m$ian contract$ rate = su* item or s]vice & ye>2 & 7ii7 su* provid] or facility %all notify su* heal? plan (-- 7,i7 ! m$ian ( ! total am\nt ( reimbursem5t 7includ+ any co/-%>+7 paid1 = ! mo/ rec5t ye> = :i* in=mation is available1 to su* provid] or facility = furni%+ su* item or s]vice to a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan t1 at ! "t su* item or s]vice 0 furni%$1 _h a contract 9 effect ) su* provid] or facility ) respect to ! furni%+ ( su* item or s]vice2 7,,ii7 9 ! case t in=mation describ$ 9 subclause 7,i7 is n available1 su* in=mation z specifi$ by ! ,secret>y2 & 7,,iii7 any additional in=mation specifi$ by ! ,secret>y4 7,c7 ,access+ m$iat$ dispute process 9 case ( fail$ negotiations ,9 ! case ( op5 negotiations pursuant to subp>agraph 7,a71 ) respect to an item or s]vice1 t d n result 9 a det]m9ation ( an am\nt ( paym5t = su* item or s]vice by ! la/ day ( ! op5 negotiation p]iod describ$ 9 su* subp>agraph ) respect to su* item or s]vice1 ! provid] or facility 7z applicable7 or heal? plan t 0 p>ty to su* negotiations may1 dur+ ! #b-;day p]iod beg9n+ on ! day aft] su* op5 negotiation p]iod1 initiate ! m$iat$ dispute process "u p>agraph 7#b7 ) respect to su* item or s]vice4 ,! m$iat$ dispute process %all be initiat$ by a p>ty pursuant to ! previ\s s5t5ce by submission to ! o!r p>ty & to ! ,secret>y ( a notification 7conta9+ su* in=mation z specifi$ by ! ,secret>y7 & = purposes ( ?is subsection1 ! date ( initiation ( su* process %all be ! date ( su* submission or su* o!r date specifi$ by ! ,secret>y pursuant to regulations t is n lat] ?an ! date ( receipt ( su* notification by bo? ! o!r p>ty & ! ,secret>y4 7#b7 ,m$iat$ dispute process available 9 case ( fail$ op5 negotiations 7,a7 ,e/abli%m5t ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 coord9ation ) ! ,secret>y ( ! ,treasury & ! ,secret>y ( ,labor1 %all e/abli% a process 79 ?is subsection ref]r$ to z ! m$iat$ dispute process7 "u :i*1 9 ! case ( an item or s]vice ) respect to :i* a provid] or facility 7z applicable7 or heal? plan submits a notification "u p>agraph 7#a77;,c7 79 ?is subsection ref]r$ to z a qualifi$ m$iat$ dispute item or s]vice71 an entity select$ "u p>agraph 7#c7 det]m9es1 subject to subp>agraph 7,b7 & 9 accordance ) ! succe$+ provisions ( ?is subsection1 ! am\nt ( paym5t "u ! heal? plan = su* item or s]vice furni%$ by su* provid] or facility4 7,b7 ,au?ority to cont9ue negotiations ,"u ! m$iat$ dispute process1 9 ! case t ! p>ties to a det]m9ation = a qualifi$ m$iat$ dispute item or s]vice agree on a paym5t am\nt = su* item or s]vice dur+ su* process b be=e ! date on :i* ! entity select$ ) respect to su* det]m9ation "u p>agraph 7#c7 makes su* det]m9ation1 su* am\nt %all be treat$ = purposes ( subsection 7k77#aa77;,b7 z ! am\nt agre$ to by su* p>ties = su* item or s]vice4 ,9 ! case ( an agreem5t describ$ 9 ! previ\s s5t5ce1 ! m$iat$ dispute process %all provide = a me?od to det]m9e h[ to allocate betwe5 ! p>ties to su* det]m9ation ! paym5t ( ! comp5sation ( ! entity select$ ) respect to su* det]m9ation4 7#c7 ,selection "u m$iat$ dispute process ,"u ! m$iat$ dispute process1 ! ,secret>y %all1 ) respect to ! det]m9ation ( ! am\nt ( paym5t "u ?is subsection ( a qualifi$ m$iat$ dispute item or s]vice1 provide = a me?od-- 7,a7 t all[s ! p>ties to su* det]m9ation to jo9tly select1 n lat] ?an ! la/ day ( ! #c-;day p]iod foll[+ ! date ( ! initiation ( ! process ) respect to su* item or s]vice1 = purposes ( mak+ su* det]m9ation1 an entity c]tifi$ "u p>agraph 7#g7 t-- 7i7 is n a p>ty to su* det]m9ation or an employee or ag5t ( su* a p>ty2 7ii7 does n h a mat]ial familial1 f9ancial1 or pr(essional relation%ip ) su* a p>ty2 & 7iii7 does n o!rwise h a conflict ( int]e/ ) su* a p>ty 7z det]m9$ by ! ,secret>y72 & 7,b7 t requires1 9 ! case su* p>ties d n make su* selection by su* la/ day1 ! ,secret>y to1 n lat] ?an #f days aft] su* date ( initiation-- 7i7 select su* an entity t satisfies clauses 7i7 ?r\gh 7iii7 ( subp>agraph 7,a72 & 7ii7 provide notification ( su* selection to ! provid] or facility 7z applicable7 & ! heal? plan p>ty to su* det]m9ation4 ,an entity select$ pursuant to ! previ\s s5t5ce to make a det]m9ation describ$ 9 su* s5t5ce %all be ref]r$ to 9 ?is subsection z ! select$ indep5d5t entity ) respect to su* det]m9ation4 7#d7 ,treatm5t ( consid]ation ( multiple items & s]vices 7,a7 ,9 g5]al ,"u ! m$iat$ dispute process1 ! ,secret>y %all specify crit]ia "u :i* multiple qualifi$ m$iat$ dispute items & s]vices are p]mitt$ to be consid]$ jo9tly z "p ( a s+le det]m9ation by an entity = purposes ( enc\rag+ ! effici5cy 7includ+ m9imiz+ co/s7 ( ! m$iat$ dispute process4 ,su* items & s]vices may be s consid]$ only if-- 7i7 su* items & s]vices to be includ$ 9 su* det]m9ation are furni%$ by ! same provid] or facility2 7ii7 paym5t = su* items & s]vices is requir$ to be made by ! same heal? plan2 & 7iii7 su* items & s]vices are relat$ to ! treatm5t ( a simil> condition4 7,b7 ,treatm5t ( bundl$ paym5ts ,9 c>ry+ out subp>agraph 7,a71 ! ,secret>y %all provide t1 9 ! case ( items & s]vices :i* are includ$ by a provid] or facility z "p ( a bundl$ paym5t1 su* items & s]vices includ$ 9 su* bundl$ paym5t may be "p ( a s+le det]m9ation "u ?is subsection4 7,c7 ,waiv] ( deadl9es ,= purposes ( p]mitt+ jo9t consid]ation ( qualifi$ m$iat$ dispute items & s]vices z "p ( a s+le det]m9ation "u ! crit]ia specifi$ pursuant to subp>agraph 7,a71 ! ,secret>y may waive any deadl9e specifi$ 9 ?is subsection4 7#e7 ,det]m9ation ( paym5t am\nt 7,a7 ,9 g5]al ,n lat] ?an #cj days aft] ! date ( initiation ( ! m$iat$ dispute resolution1 ) respect to a qualifi$ m$iat$ dispute item or s]vice1 ! select$ indep5d5t entity ) respect to a det]m9ation "u ?is subsection = su* item or s]vice %all-- 7i7 tak+ into acc\nt only ! consid]ations specifi$ 9 subp>agraph 7,c77i71 select "o ( ! (f]s submitt$ "u subp>agraph 7,b7 to be ! am\nt ( paym5t = su* item or s]vice det]m9$ "u ?is subsection = purposes ( subsection 7b77#a71 7e77#a71 or 7i77#a71 z applicable2 & 7ii7 notify ! provid] or facility & ! heal? plan p>ty to su* det]m9ation ( ! (f] select$ "u clause 7i74 7,b7 ,submission ( (f]s ,n lat] ?an #aj days aft] ! date ( initiation ( ! m$iat$ dispute resolution ) respect to a det]m9ation = a qualifi$ m$iat$ dispute item or s]vice1 ! provid] or facility & ! heal? plan p>ty to su* det]m9ation %all ea* submit to ! select$ indep5d5t entity-- 7i7 an (f] = a paym5t am\nt "u = su* item or s]vice furni%$ by su* provid] or facility2 7ii7 in=mation relat+ to su* (f]2 & 7iii7 su* o!r in=mation z reque/$ by ! select$ indep5d5t entity4 7,c7 ,consid]ations 7i7 ,9 g5]al ,= purposes ( subp>agraph 7,a71 ! consid]ations specifi$ 9 ?is subp>agraph1 ) respect to a det]m9ation = a qualifi$ m$iat$ dispute item or s]vice1 are ! foll[+3 7,i7 ,! m$ian contract$ rate = su* item or s]vice4 7,,ii7 ,subject to clause 7ii71 in=mation t is submitt$ pursuant to subp>agraph 7,b74 7ii7 ,treatm5t ( c]ta9 consid]ations ,9 mak+ a det]m9ation ) respect to a qualifi$ m$iat$ dispute item or s]vice pursuant to subp>agraph 7,a77i71 a select$ indep5d5t entity may n take into acc\nt usual & cu/om>y *>ges = ! item or s]vice nor *>ges bill$ by ! provid] or facility = ! item or s]vice4 7#f7 ,select$ indep5d5t entity comp5sation 7,a7 ,9 g5]al ,n lat] ?an #e days aft] receiv+ a notification describ$ 9 p>agraph 7#e77;,a77ii7 f a select$ indep5d5t entity ) respect to ! det]m9ation ( a paym5t am\nt = a qualifi$ m$iat$ dispute item or s]vice1 ! p>ty to su* det]m9ation ^: (f] submitt$ "u p>agraph 7#e77;,b7 0 n select$ by ! entity %all pay to su* entity a fee 9 comp5sation = ! s]vices ( su* entity 9 accordance ) ! guidel9es on su* comp5sation e/abli%$ by ! ,secret>y "u subp>agraph 7,b74 7,b7 ,guidel9es on comp5sation ,= purposes ( subp>agraph 7,a71 ! ,secret>y %all e/abli% guidel9es ) respect to ! comp5sation ( a select$ indep5d5t entity = ! s]vices ( su* entity ) respect to det]m9ations "u ! m$iat$ dispute process4 ,su* guidel9es %all provide t su* comp5sation reimburses ! entity = at lea/ ! co/s ( su* entity 9 p]=m+ ! duties ( ! entity "u ! m$iat$ dispute process4 7#g7 ,c]tification ( entities 7,a7 ,9 g5]al ,! ,secret>y %all e/abli% or recognize a process to c]tify 7includ+ rec]tification (7 entities "u ?is p>agraph4 ,su* process %all ensure t an entity s c]tifi$-- 7i7 has 7directly or ?r\gh contracts or o!r arrangem5ts7 suffici5t m$ical1 legal1 & o!r exp]tise & suffici5t /aff+ to make det]m9ations describ$ 9 p>agraph 7#b7 on a timely basis2 7ii7 is n-- 7,i7 a heal? plan1 provid]1 or facility2 7,,ii7 an affiliate or a subsidi>y ( a heal? plan1 provid]1 or facility2 or 7,,iii7 an affiliate or subsidi>y ( a pr(essional or trade association ( heal? plans or ( provid]s or facilities2 7iii7 c>ries out ! responsibilities ( su* an entity 9 accordance ) ?is subsection2 7iv7 meets appropriate indicators ( fiscal integrity2 7v7 ma9ta9s ! confid5tiality 79 accordance ) regulations promulgat$ by ! ,secret>y7 ( individually id5tifiable heal? in=mation obta9$ 9 ! c\rse ( conduct+ su* det]m9ations2 7vi7 does n "u ! m$iat$ dispute process c>ry out any det]m9ation ) respect to :i* ! entity w\ld n pursuant to clause 7i71 7ii71 or 7iii7 ( p>agraph 7#c77;,a7 be eligible = selection2 & 7vii7 meets su* o!r requirem5ts z det]m9$ appropriate by ! ,secret>y4 7,b7 ,p]iod ( c]tification ,subject to subp>agraph 7,c71 ea* c]tification 7includ+ a rec]tification7 ( an entity "u ! process describ$ 9 subp>agraph 7,a7 %all be = a #e-ye> p]iod4 7,c7 ,revocation ,a c]tification ( an entity "u ?is p>agraph may be revok$ "u ! process describ$ 9 subp>agraph 7,a7 if ! entity has a patt]n or practice ( noncompliance ) any ( ! requirem5ts describ$ 9 su* subp>agraph4 7,d7 ,petition = d5ial or )drawal ,! process describ$ 9 subp>agraph 7,a7 %all ensure t an individual1 provid]1 facility1 or heal? plan may petition = a d5ial ( a c]tification or a revocation ( a c]tification ) respect to an entity "u ?is p>agraph = failure ( meet+ a requirem5t ( ?is subsection4 7,e7 ,suffici5t numb] ( entities ,! process describ$ 9 subp>agraph 7,a7 %all ensure t a suffici5t numb] ( entities are c]tifi$ "u ?is p>agraph to ensure ! timely & effici5t provision ( det]m9ations describ$ 9 p>agraph 7#b74 7,f7 ,provision ( in=mation 7i7 ,9 g5]al ,an entity c]tifi$ "u ?is p>agraph %all provide to ! ,secret>y1 9 su* mann] z ! ,secret>y may require & on a qu>t]ly basis 7z specifi$ by ! ,secret>y71 su* in=mation z ! ,secret>y det]m9es appropriate to assure compliance ) ! requirem5ts describ$ 9 subp>agraph 7,a7 & to monitor & assess ! det]m9ations made by su* entity & to ensure ! abs5ce ( bias 9 mak+ su* det]m9ations4 ,su* in=mation %all include in=mation describ$ 9 clause 7ii7 b %all n include individually id5tifiable heal? in=mation4 7ii7 ,in=mation to be includ$ ,! in=mation describ$ 9 ?is clause ) respect to an entity is ! foll[+3 7,i7 ,! numb] ( paym5t det]m9ations describ$ 9 p>agraph 7#b7 made by su* entity1 disaggregat$ by-- 7aa7 ! l9e ( bus9ess 7z specifi$ 9 subsection 7k77#h77;,c77 ( ! heal? plans p>ty to su* det]m9ations2 & 7bb7 ! type ( provid]s & facilities p>ty to su* det]m9ations4 7,,ii7 ,a description ( ea* item or s]vice includ$ 9 ea* su* det]m9ation4 7,,iii7 ,! am\nt ( ea* (f] submitt$ to ! entity = ea* su* det]m9ation4 7,,iv7 ,! am\nt ( ea* su* det]m9ation4 7,v7 ,! l5g? ( "t 9 mak+ ea* su* det]m9ation4 7,,vi7 ,! comp5sation paid to su* entity ) respect to ea* su* det]m9ation4 7,,vii7 ,any o!r in=mation specifi$ by ! ,secret>y4 7#h7 ,adm9i/rative fee 7,a7 ,9 g5]al ,ea* p>ty to a det]m9ation to :i* an entity is select$ "u p>agraph 7#c7 9 a ye> %all pay to ! ,secret>y1 at su* "t & 9 su* mann] z specifi$ by ! ,secret>y1 a fee = p>ticipat+ 9 ! m$iat$ dispute process ) respect to su* det]m9ation 9 an am\nt describ$ 9 subp>agraph 7,b7 = su* ye>4 7,b7 ,am\nt ( fee ,! am\nt describ$ 9 ?is subp>agraph = a ye> is an am\nt e/abli%$ by ! ,secret>y 9 a mann] su* t ! total am\nt ( fees paid "u ?is p>agraph = su* ye> is e/imat$ to be equal to ! am\nt ( exp5ditures e/imat$ to be made by ! ,secret>y = su* ye> 9 c>ry+ out ! m$iat$ dispute process4 7#i7 ,secret>ial report2 publication ( in=mation 7,a7 ,secret>ial report ,beg9n+ n lat] ?an ,july #a1 #bjbc1 ! ,secret>y %all1 9 coord9ation ) ! ,secret>y ( ! ,treasury & ! ,secret>y ( ,labor1 p]iodically /udy & submit to ,congress a report on-- 7i7 ! ext5t to :i* ! paym5t am\nt det]m9$ "u ?is subsection = an item or s]vice furni%$ 9 a ye> 7or o!rwise agre$ to by a heal? plan & provid] or facility = purposes ( det]m9+ paym5t by ! plan to ! provid] or facility pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a77 diff]s f ! m$ian contract$ rate = su* item or s]vice & ye>1 includ+ ! numb] ( times su* det]m9$ 7or agre$ to7 am\nt exce$s su* m$ian contract$ rate2 & 7ii7 ! effect ( su* diff]5ce on ! co/-%>+ = su* item or s]vice = a p>ticipant1 b5efici>y1 or enrollee ( a heal? plan4 7,b7 ,publication ( in=mation ,beg9n+ ) ,july #a1 #bjbc1 & = ea* cal5d> qu>t] !reaft]1 ! ,secret>y %all1 9 coord9ation ) ! ,secret>y ( ! ,treasury & ! ,secret>y ( ,labor1 make publicly available a summ>y ( ! foll[+3 7i7 ,! in=mation describ$ 9 subclauses 7,i7 ?r\gh 7,v7 ( clause 7ii7 ( p>agraph 7#g77;,f7 t 0 submitt$ to ! ,secret>y "u clause 7i7 ( su* p>agraph dur+ su* qu>t]4 7ii7 ,! am\nt ( exp5ditures made by ! ,secret>y dur+ su* ye> to c>ry out ! m$iat$ dispute process4 7iii7 ,! total am\nt ( fees paid "u p>agraph 7#h7 dur+ su* qu>t]4 7iv7 ,! total am\nt ( comp5sation paid to select$ indep5d5t entities "u p>agraph 7#f7 dur+ su* qu>t]4 4 7b7 ,,irc am5dm5ts ,section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf1 z add$ by section #b7;b7 & am5d$ by sections #c7;b71 #e7;b71 & #f7;b71 is fur!r am5d$ by ins]t+ be=e subsection 7k7 ! foll[+ new subsection3 7j7 ,det]m9ation ( out-(-,network rates ,to be paid by heal? plans 7#a7 ,det]m9ation ?r\gh op5 negotiation 7,a7 ,9 g5]al ,) respect to an item or s]vice furni%$ 9 a ye> by a nonp>ticipat+ provid] or a nonp>ticipat+ facility1 ) respect to a heal? plan1 9 a ,/ate describ$ 9 subp>agraph 7,b7 ( subsection 7k77#aa7 ) respect to su* plan & provid] or facility1 & = :i* a paym5t is requir$ to be made by ! heal? plan pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a71 ! provid] or facility 7z applicable7 or plan may1 dur+ ! #cj-;day p]iod beg9n+ on ! day ! provid] or facility receives a response f ! plan reg>d+ a claim = paym5t = su* item or s]vice1 initiate op5 negotiations "u ?is p>agraph betwe5 su* provid] or facility & plan = purposes ( det]m9+1 dur+ ! op5 negotiation p]iod1 an am\nt agre$ on by su* provid] or facility1 respectively1 & su* plan = paym5t 7includ+ any co/-%>+7 = su* item or s]vice4 ,= purposes ( ?is subsection1 ! op5 negotiation p]iod1 ) respect to an item or s]vice1 is ! #cj-;day p]iod beg9n+ on ! date ( initiation ( ! negotiations ) respect to su* item or s]vice4 7,b7 ,ex*ange ( in=mation ,9 c>ry+ out negotiations initiat$ "u subp>agraph 7,a71 ) respect to an item or s]vice describ$ 9 su* subp>agraph furni%$ 9 a ye>1 n lat] ?an ! fif? bus9ess day ( ! op5 negotiation p]iod describ$ 9 su* subp>agraph ) respect to su* item or s]vice-- 7i7 ! heal? plan t is p>ty to su* negotiations %all notify ! provid] or facility t is p>ty to su* negotiations ( ! m$ian contract$ rate = su* item or s]vice & ye>2 & 7ii7 su* provid] or facility %all notify su* heal? plan (-- 7,i7 ! m$ian ( ! total am\nt ( reimbursem5t 7includ+ any co/-%>+7 paid1 = ! mo/ rec5t ye> = :i* in=mation is available1 to su* provid] or facility = furni%+ su* item or s]vice to a p>ticipant or b5efici>y ( a heal? plan t1 at ! "t su* item or s]vice 0 furni%$1 _h a contract 9 effect ) su* provid] or facility ) respect to ! furni%+ ( su* item or s]vice2 7,,ii7 9 ! case t in=mation describ$ 9 subclause 7,i7 is n available1 su* in=mation z specifi$ by ! ,secret>y2 & 7,,iii7 any additional in=mation specifi$ by ! ,secret>y4 7,c7 ,access+ m$iat$ dispute process 9 case ( fail$ negotiations ,9 ! case ( op5 negotiations pursuant to subp>agraph 7,a71 ) respect to an item or s]vice1 t d n result 9 a det]m9ation ( an am\nt ( paym5t = su* item or s]vice by ! la/ day ( ! op5 negotiation p]iod describ$ 9 su* subp>agraph ) respect to su* item or s]vice1 ! provid] or facility 7z applicable7 or heal? plan t 0 p>ty to su* negotiations may1 dur+ ! #b-;day p]iod beg9n+ on ! day aft] su* op5 negotiation p]iod1 initiate ! m$iat$ dispute process "u p>agraph 7#b7 ) respect to su* item or s]vice4 ,! m$iat$ dispute process %all be initiat$ by a p>ty pursuant to ! previ\s s5t5ce by submission to ! o!r p>ty & to ! ,secret>y ( a notification 7conta9+ su* in=mation z specifi$ by ! ,secret>y7 & = purposes ( ?is subsection1 ! date ( initiation ( su* process %all be ! date ( su* submission or su* o!r date specifi$ by ! ,secret>y pursuant to regulations t is n lat] ?an ! date ( receipt ( su* notification by bo? ! o!r p>ty & ! ,secret>y4 7#b7 ,m$iat$ dispute process available 9 case ( fail$ op5 negotiations 7,a7 ,e/abli%m5t ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 coord9ation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ,labor1 %all e/abli% a process 79 ?is subsection ref]r$ to z ! m$iat$ dispute process7 "u :i*1 9 ! case ( an item or s]vice ) respect to :i* a provid] or facility 7z applicable7 or heal? plan submits a notification "u p>agraph 7#a77;,c7 79 ?is subsection ref]r$ to z a qualifi$ m$iat$ dispute item or s]vice71 an entity select$ "u p>agraph 7#c7 det]m9es1 subject to subp>agraph 7,b7 & 9 accordance ) ! succe$+ provisions ( ?is subsection1 ! am\nt ( paym5t "u ! heal? plan = su* item or s]vice furni%$ by su* provid] or facility4 7,b7 ,au?ority to cont9ue negotiations ,"u ! m$iat$ dispute process1 9 ! case t ! p>ties to a det]m9ation = a qualifi$ m$iat$ dispute item or s]vice agree on a paym5t am\nt = su* item or s]vice dur+ su* process b be=e ! date on :i* ! entity select$ ) respect to su* det]m9ation "u p>agraph 7#c7 makes su* det]m9ation1 su* am\nt %all be treat$ = purposes ( subsection 7k77#aa77;,b7 z ! am\nt agre$ to by su* p>ties = su* item or s]vice4 ,9 ! case ( an agreem5t describ$ 9 ! previ\s s5t5ce1 ! m$iat$ dispute process %all provide = a me?od to det]m9e h[ to allocate betwe5 ! p>ties to su* det]m9ation ! paym5t ( ! comp5sation ( ! entity select$ ) respect to su* det]m9ation4 7#c7 ,selection "u m$iat$ dispute process ,"u ! m$iat$ dispute process1 ! ,secret>y %all1 ) respect to ! det]m9ation ( ! am\nt ( paym5t "u ?is subsection ( a qualifi$ m$iat$ dispute item or s]vice1 provide = a me?od-- 7,a7 t all[s ! p>ties to su* det]m9ation to jo9tly select1 n lat] ?an ! la/ day ( ! #c-;day p]iod foll[+ ! date ( ! initiation ( ! process ) respect to su* item or s]vice1 = purposes ( mak+ su* det]m9ation1 an entity c]tifi$ "u p>agraph 7#g7 t-- 7i7 is n a p>ty to su* det]m9ation or an employee or ag5t ( su* a p>ty2 7ii7 does n h a mat]ial familial1 f9ancial1 or pr(essional relation%ip ) su* a p>ty2 & 7iii7 does n o!rwise h a conflict ( int]e/ ) su* a p>ty 7z det]m9$ by ! ,secret>y72 & 7,b7 t requires1 9 ! case su* p>ties d n make su* selection by su* la/ day1 ! ,secret>y to1 n lat] ?an #f days aft] su* date ( initiation-- 7i7 select su* an entity t satisfies clauses 7i7 ?r\gh 7iii7 ( subp>agraph 7,a72 & 7ii7 provide notification ( su* selection to ! provid] or facility 7z applicable7 & ! heal? plan p>ty to su* det]m9ation4 ,an entity select$ pursuant to ! previ\s s5t5ce to make a det]m9ation describ$ 9 su* s5t5ce %all be ref]r$ to 9 ?is subsection z ! select$ indep5d5t entity ) respect to su* det]m9ation4 7#d7 ,treatm5t ( consid]ation ( multiple items & s]vices 7,a7 ,9 g5]al ,"u ! m$iat$ dispute process1 ! ,secret>y %all specify crit]ia "u :i* multiple qualifi$ m$iat$ dispute items & s]vices are p]mitt$ to be consid]$ jo9tly z "p ( a s+le det]m9ation by an entity = purposes ( enc\rag+ ! effici5cy 7includ+ m9imiz+ co/s7 ( ! m$iat$ dispute process4 ,su* items & s]vices may be s consid]$ only if-- 7i7 su* items & s]vices to be includ$ 9 su* det]m9ation are furni%$ by ! same provid] or facility2 7ii7 paym5t = su* items & s]vices is requir$ to be made by ! same heal? plan2 & 7iii7 su* items & s]vices are relat$ to ! treatm5t ( a simil> condition4 7,b7 ,treatm5t ( bundl$ paym5ts ,9 c>ry+ out subp>agraph 7,a71 ! ,secret>y %all provide t1 9 ! case ( items & s]vices :i* are includ$ by a provid] or facility z "p ( a bundl$ paym5t1 su* items & s]vices includ$ 9 su* bundl$ paym5t may be "p ( a s+le det]m9ation "u ?is subsection4 7,c7 ,waiv] ( deadl9es ,= purposes ( p]mitt+ jo9t consid]ation ( qualifi$ m$iat$ dispute items & s]vices z "p ( a s+le det]m9ation "u ! crit]ia specifi$ pursuant to subp>agraph 7,a71 ! ,secret>y may waive any deadl9e specifi$ 9 ?is subsection4 7#e7 ,det]m9ation ( paym5t am\nt 7,a7 ,9 g5]al ,n lat] ?an #cj days aft] ! date ( initiation ( ! m$iat$ dispute resolution1 ) respect to a qualifi$ m$iat$ dispute item or s]vice1 ! select$ indep5d5t entity ) respect to a det]m9ation "u ?is subsection = su* item or s]vice %all-- 7i7 tak+ into acc\nt only ! consid]ations specifi$ 9 subp>agraph 7,c77i71 select "o ( ! (f]s submitt$ "u subp>agraph 7,b7 to be ! am\nt ( paym5t = su* item or s]vice det]m9$ "u ?is subsection = purposes ( subsection 7b77#a71 7e77#a71 or 7i77#a71 z applicable2 & 7ii7 notify ! provid] or facility & ! heal? plan p>ty to su* det]m9ation ( ! (f] select$ "u clause 7i74 7,b7 ,submission ( (f]s ,n lat] ?an #aj days aft] ! date ( initiation ( ! m$iat$ dispute resolution ) respect to a det]m9ation = a qualifi$ m$iat$ dispute item or s]vice1 ! provid] or facility & ! heal? plan p>ty to su* det]m9ation %all ea* submit to ! select$ indep5d5t entity-- 7i7 an (f] = a paym5t am\nt "u = su* item or s]vice furni%$ by su* provid] or facility2 7ii7 in=mation relat+ to su* (f]2 & 7iii7 su* o!r in=mation z reque/$ by ! select$ indep5d5t entity4 7,c7 ,consid]ations 7i7 ,9 g5]al ,= purposes ( subp>agraph 7,a71 ! consid]ations specifi$ 9 ?is subp>agraph1 ) respect to a det]m9ation = a qualifi$ m$iat$ dispute item or s]vice1 are ! foll[+3 7,i7 ,! m$ian contract$ rate = su* item or s]vice4 7,,ii7 ,subject to clause 7ii71 in=mation t is submitt$ pursuant to subp>agraph 7,b74 7ii7 ,treatm5t ( c]ta9 consid]ations ,9 mak+ a det]m9ation ) respect to a qualifi$ m$iat$ dispute item or s]vice pursuant to subp>agraph 7,a77i71 a select$ indep5d5t entity may n take into acc\nt usual & cu/om>y *>ges = ! item or s]vice nor *>ges bill$ by ! provid] or facility = ! item or s]vice4 7#f7 ,select$ indep5d5t entity comp5sation 7,a7 ,9 g5]al ,n lat] ?an #e days aft] receiv+ a notification describ$ 9 p>agraph 7#e77;,a77ii7 f a select$ indep5d5t entity ) respect to ! det]m9ation ( a paym5t am\nt = a qualifi$ m$iat$ dispute item or s]vice1 ! p>ty to su* det]m9ation ^: (f] submitt$ "u p>agraph 7#e77;,b7 0 n select$ by ! entity %all pay to su* entity a fee 9 comp5sation = ! s]vices ( su* entity 9 accordance ) ! guidel9es on su* comp5sation e/abli%$ by ! ,secret>y "u subp>agraph 7,b74 7,b7 ,guidel9es on comp5sation ,= purposes ( subp>agraph 7,a71 ! ,secret>y %all e/abli% guidel9es ) respect to ! comp5sation ( a select$ indep5d5t entity = ! s]vices ( su* entity ) respect to det]m9ations "u ! m$iat$ dispute process4 ,su* guidel9es %all provide t su* comp5sation reimburses ! entity = at lea/ ! co/s ( su* entity 9 p]=m+ ! duties ( ! entity "u ! m$iat$ dispute process4 7#g7 ,c]tification ( entities 7,a7 ,9 g5]al ,! ,secret>y %all e/abli% or recognize a process to c]tify 7includ+ rec]tification (7 entities "u ?is p>agraph4 ,su* process %all ensure t an entity s c]tifi$-- 7i7 has 7directly or ?r\gh contracts or o!r arrangem5ts7 suffici5t m$ical1 legal1 & o!r exp]tise & suffici5t /aff+ to make det]m9ations describ$ 9 p>agraph 7#b7 on a timely basis2 7ii7 is n-- 7,i7 a heal? plan1 provid]1 or facility2 7,,ii7 an affiliate or a subsidi>y ( a heal? plan1 provid]1 or facility2 or 7,,iii7 an affiliate or subsidi>y ( a pr(essional or trade association ( heal? plans or ( provid]s or facilities2 7iii7 c>ries out ! responsibilities ( su* an entity 9 accordance ) ?is subsection2 7iv7 meets appropriate indicators ( fiscal integrity2 7v7 ma9ta9s ! confid5tiality 79 accordance ) regulations promulgat$ by ! ,secret>y7 ( individually id5tifiable heal? in=mation obta9$ 9 ! c\rse ( conduct+ su* det]m9ations2 7vi7 does n "u ! m$iat$ dispute process c>ry out any det]m9ation ) respect to :i* ! entity w\ld n pursuant to clause 7i71 7ii71 or 7iii7 ( p>agraph 7#c77;,a7 be eligible = selection2 & 7vii7 meets su* o!r requirem5ts z det]m9$ appropriate by ! ,secret>y4 7,b7 ,p]iod ( c]tification ,subject to subp>agraph 7,c71 ea* c]tification 7includ+ a rec]tification7 ( an entity "u ! process describ$ 9 subp>agraph 7,a7 %all be = a #e-ye> p]iod4 7,c7 ,revocation ,a c]tification ( an entity "u ?is p>agraph may be revok$ "u ! process describ$ 9 subp>agraph 7,a7 if ! entity has a patt]n or practice ( noncompliance ) any ( ! requirem5ts describ$ 9 su* subp>agraph4 7,d7 ,petition = d5ial or )drawal ,! process describ$ 9 subp>agraph 7,a7 %all ensure t an individual1 provid]1 facility1 or heal? plan may petition = a d5ial ( a c]tification or a revocation ( a c]tification ) respect to an entity "u ?is p>agraph = failure ( meet+ a requirem5t ( ?is subsection4 7,e7 ,suffici5t numb] ( entities ,! process describ$ 9 subp>agraph 7,a7 %all ensure t a suffici5t numb] ( entities are c]tifi$ "u ?is p>agraph to ensure ! timely & effici5t provision ( det]m9ations describ$ 9 p>agraph 7#b74 7,f7 ,provision ( in=mation 7i7 ,9 g5]al ,an entity c]tifi$ "u ?is p>agraph %all provide to ! ,secret>y1 9 su* mann] z ! ,secret>y may require & on a qu>t]ly basis 7z specifi$ by ! ,secret>y71 su* in=mation z ! ,secret>y det]m9es appropriate to assure compliance ) ! requirem5ts describ$ 9 subp>agraph 7,a7 & to monitor & assess ! det]m9ations made by su* entity & to ensure ! abs5ce ( bias 9 mak+ su* det]m9ations4 ,su* in=mation %all include in=mation describ$ 9 clause 7ii7 b %all n include individually id5tifiable heal? in=mation4 7ii7 ,in=mation to be includ$ ,! in=mation describ$ 9 ?is clause ) respect to an entity is ! foll[+3 7,i7 ,! numb] ( paym5t det]m9ations describ$ 9 p>agraph 7#b7 made by su* entity1 disaggregat$ by-- 7aa7 ! l9e ( bus9ess 7z specifi$ 9 subsection 7k77#h77;,c77 ( ! heal? plans p>ty to su* det]m9ations2 & 7bb7 ! type ( provid]s & facilities p>ty to su* det]m9ations4 7,,ii7 ,a description ( ea* item or s]vice includ$ 9 ea* su* det]m9ation4 7,,iii7 ,! am\nt ( ea* (f] submitt$ to ! entity = ea* su* det]m9ation4 7,,iv7 ,! am\nt ( ea* su* det]m9ation4 7,v7 ,! l5g? ( "t 9 mak+ ea* su* det]m9ation4 7,,vi7 ,! comp5sation paid to su* entity ) respect to ea* su* det]m9ation4 7,,vii7 ,any o!r in=mation specifi$ by ! ,secret>y4 7#h7 ,adm9i/rative fee 7,a7 ,9 g5]al ,ea* p>ty to a det]m9ation to :i* an entity is select$ "u p>agraph 7#c7 9 a ye> %all pay to ! ,secret>y1 at su* "t & 9 su* mann] z specifi$ by ! ,secret>y1 a fee = p>ticipat+ 9 ! m$iat$ dispute process ) respect to su* det]m9ation 9 an am\nt describ$ 9 subp>agraph 7,b7 = su* ye>4 7,b7 ,am\nt ( fee ,! am\nt describ$ 9 ?is subp>agraph = a ye> is an am\nt e/abli%$ by ! ,secret>y 9 a mann] su* t ! total am\nt ( fees paid "u ?is p>agraph = su* ye> is e/imat$ to be equal to ! am\nt ( exp5ditures e/imat$ to be made by ! ,secret>y = su* ye> 9 c>ry+ out ! m$iat$ dispute process4 7#i7 ,secret>ial report2 publication ( in=mation 7,a7 ,secret>ial report ,beg9n+ n lat] ?an ,july #a1 #bjbc1 ! ,secret>y %all1 9 coord9ation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ,labor1 p]iodically /udy & submit to ,congress a report on-- 7i7 ! ext5t to :i* ! paym5t am\nt det]m9$ "u ?is subsection = an item or s]vice furni%$ 9 a ye> 7or o!rwise agre$ to by a heal? plan & provid] or facility = purposes ( det]m9+ paym5t by ! plan to ! provid] or facility pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a77 diff]s f ! m$ian contract$ rate = su* item or s]vice & ye>1 includ+ ! numb] ( times su* det]m9$ 7or agre$ to7 am\nt exce$s su* m$ian contract$ rate2 & 7ii7 ! effect ( su* diff]5ce on ! co/-%>+ = su* item or s]vice = a p>ticipant or b5efici>y ( a heal? plan4 7,b7 ,publication ( in=mation ,beg9n+ ) ,july #a1 #bjbc1 & = ea* cal5d> qu>t] !reaft]1 ! ,secret>y %all1 9 coord9ation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ,labor1 make publicly available a summ>y ( ! foll[+3 7i7 ,! in=mation describ$ 9 subclauses 7,i7 ?r\gh 7,v7 ( clause 7ii7 ( p>agraph 7#g77;,f7 t 0 submitt$ to ! ,secret>y "u clause 7i7 ( su* p>agraph dur+ su* qu>t]4 7ii7 ,! am\nt ( exp5ditures made by ! ,secret>y dur+ su* ye> to c>ry out ! m$iat$ dispute process4 7iii7 ,! total am\nt ( fees paid "u p>agraph 7#h7 dur+ su* qu>t]4 7iv7 ,! total am\nt ( comp5sation paid to select$ indep5d5t entities "u p>agraph 7#f7 dur+ su* qu>t]4 4 7c7 ,,erisa am5dm5ts ,section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 z add$ by section #b7;c7 & am5d$ by sections #c7;c71 #e7;c71 & #f7;c71 is fur!r am5d$ by ins]t+ be=e subsection 7k7 ! foll[+ new subsection3 7j7 ,det]m9ation ( out-(-,network rates ,to be paid by heal? plans 7#a7 ,det]m9ation ?r\gh op5 negotiation 7,a7 ,9 g5]al ,) respect to an item or s]vice furni%$ 9 a ye> by a nonp>ticipat+ provid] or a nonp>ticipat+ facility1 ) respect to a heal? plan1 9 a ,/ate describ$ 9 subp>agraph 7,b7 ( subsection 7k77#aa7 ) respect to su* plan & provid] or facility1 & = :i* a paym5t is requir$ to be made by ! heal? plan pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a71 ! provid] or facility 7z applicable7 or plan may1 dur+ ! #cj-;day p]iod beg9n+ on ! day ! provid] or facility receives a response f ! plan reg>d+ a claim = paym5t = su* item or s]vice1 initiate op5 negotiations "u ?is p>agraph betwe5 su* provid] or facility & plan = purposes ( det]m9+1 dur+ ! op5 negotiation p]iod1 an am\nt agre$ on by su* provid] or facility1 respectively1 & su* plan = paym5t 7includ+ any co/-%>+7 = su* item or s]vice4 ,= purposes ( ?is subsection1 ! op5 negotiation p]iod1 ) respect to an item or s]vice1 is ! #cj-;day p]iod beg9n+ on ! date ( initiation ( ! negotiations ) respect to su* item or s]vice4 7,b7 ,ex*ange ( in=mation ,9 c>ry+ out negotiations initiat$ "u subp>agraph 7,a71 ) respect to an item or s]vice describ$ 9 su* subp>agraph furni%$ 9 a ye>1 n lat] ?an ! fif? bus9ess day ( ! op5 negotiation p]iod describ$ 9 su* subp>agraph ) respect to su* item or s]vice-- 7i7 ! heal? plan t is p>ty to su* negotiations %all notify ! provid] or facility t is p>ty to su* negotiations ( ! m$ian contract$ rate = su* item or s]vice & ye>2 & 7ii7 su* provid] or facility %all notify su* heal? plan (-- 7,i7 ! m$ian ( ! total am\nt ( reimbursem5t 7includ+ any co/-%>+7 paid1 = ! mo/ rec5t ye> = :i* in=mation is available1 to su* provid] or facility = furni%+ su* item or s]vice to a p>ticipant or b5efici>y ( a heal? plan t1 at ! "t su* item or s]vice 0 furni%$1 _h a contract 9 effect ) su* provid] or facility ) respect to ! furni%+ ( su* item or s]vice2 7,,ii7 9 ! case t in=mation describ$ 9 subclause 7,i7 is n available1 su* in=mation z specifi$ by ! ,secret>y2 & 7,,iii7 any additional in=mation specifi$ by ! ,secret>y4 7,c7 ,access+ m$iat$ dispute process 9 case ( fail$ negotiations ,9 ! case ( op5 negotiations pursuant to subp>agraph 7,a71 ) respect to an item or s]vice1 t d n result 9 a det]m9ation ( an am\nt ( paym5t = su* item or s]vice by ! la/ day ( ! op5 negotiation p]iod describ$ 9 su* subp>agraph ) respect to su* item or s]vice1 ! provid] or facility 7z applicable7 or heal? plan t 0 p>ty to su* negotiations may1 dur+ ! #b-;day p]iod beg9n+ on ! day aft] su* op5 negotiation p]iod1 initiate ! m$iat$ dispute process "u p>agraph 7#b7 ) respect to su* item or s]vice4 ,! m$iat$ dispute process %all be initiat$ by a p>ty pursuant to ! previ\s s5t5ce by submission to ! o!r p>ty & to ! ,secret>y ( a notification 7conta9+ su* in=mation z specifi$ by ! ,secret>y7 & = purposes ( ?is subsection1 ! date ( initiation ( su* process %all be ! date ( su* submission or su* o!r date specifi$ by ! ,secret>y pursuant to regulations t is n lat] ?an ! date ( receipt ( su* notification by bo? ! o!r p>ty & ! ,secret>y4 7#b7 ,m$iat$ dispute process available 9 case ( fail$ op5 negotiations 7,a7 ,e/abli%m5t ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y1 9 coord9ation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ! ,treasury1 %all e/abli% a process 79 ?is subsection ref]r$ to z ! m$iat$ dispute process7 "u :i*1 9 ! case ( an item or s]vice ) respect to :i* a provid] or facility 7z applicable7 or heal? plan submits a notification "u p>agraph 7#a77;,c7 79 ?is subsection ref]r$ to z a qualifi$ m$iat$ dispute item or s]vice71 an entity select$ "u p>agraph 7#c7 det]m9es1 subject to subp>agraph 7,b7 & 9 accordance ) ! succe$+ provisions ( ?is subsection1 ! am\nt ( paym5t "u ! heal? plan = su* item or s]vice furni%$ by su* provid] or facility4 7,b7 ,au?ority to cont9ue negotiations ,"u ! m$iat$ dispute process1 9 ! case t ! p>ties to a det]m9ation = a qualifi$ m$iat$ dispute item or s]vice agree on a paym5t am\nt = su* item or s]vice dur+ su* process b be=e ! date on :i* ! entity select$ ) respect to su* det]m9ation "u p>agraph 7#c7 makes su* det]m9ation1 su* am\nt %all be treat$ = purposes ( subsection 7k77#aa77;,b7 z ! am\nt agre$ to by su* p>ties = su* item or s]vice4 ,9 ! case ( an agreem5t describ$ 9 ! previ\s s5t5ce1 ! m$iat$ dispute process %all provide = a me?od to det]m9e h[ to allocate betwe5 ! p>ties to su* det]m9ation ! paym5t ( ! comp5sation ( ! entity select$ ) respect to su* det]m9ation4 7#c7 ,selection "u m$iat$ dispute process ,"u ! m$iat$ dispute process1 ! ,secret>y %all1 ) respect to ! det]m9ation ( ! am\nt ( paym5t "u ?is subsection ( a qualifi$ m$iat$ dispute item or s]vice1 provide = a me?od-- 7,a7 t all[s ! p>ties to su* det]m9ation to jo9tly select1 n lat] ?an ! la/ day ( ! #c-;day p]iod foll[+ ! date ( ! initiation ( ! process ) respect to su* item or s]vice1 = purposes ( mak+ su* det]m9ation1 an entity c]tifi$ "u p>agraph 7#g7 t-- 7i7 is n a p>ty to su* det]m9ation or an employee or ag5t ( su* a p>ty2 7ii7 does n h a mat]ial familial1 f9ancial1 or pr(essional relation%ip ) su* a p>ty2 & 7iii7 does n o!rwise h a conflict ( int]e/ ) su* a p>ty 7z det]m9$ by ! ,secret>y72 & 7,b7 t requires1 9 ! case su* p>ties d n make su* selection by su* la/ day1 ! ,secret>y to1 n lat] ?an #f days aft] su* date ( initiation-- 7i7 select su* an entity t satisfies clauses 7i7 ?r\gh 7iii7 ( subp>agraph 7,a72 & 7ii7 provide notification ( su* selection to ! provid] or facility 7z applicable7 & ! heal? plan p>ty to su* det]m9ation4 ,an entity select$ pursuant to ! previ\s s5t5ce to make a det]m9ation describ$ 9 su* s5t5ce %all be ref]r$ to 9 ?is subsection z ! select$ indep5d5t entity ) respect to su* det]m9ation4 7#d7 ,treatm5t ( consid]ation ( multiple items & s]vices 7,a7 ,9 g5]al ,"u ! m$iat$ dispute process1 ! ,secret>y %all specify crit]ia "u :i* multiple qualifi$ m$iat$ dispute items & s]vices are p]mitt$ to be consid]$ jo9tly z "p ( a s+le det]m9ation by an entity = purposes ( enc\rag+ ! effici5cy 7includ+ m9imiz+ co/s7 ( ! m$iat$ dispute process4 ,su* items & s]vices may be s consid]$ only if-- 7i7 su* items & s]vices to be includ$ 9 su* det]m9ation are furni%$ by ! same provid] or facility2 7ii7 paym5t = su* items & s]vices is requir$ to be made by ! same heal? plan2 & 7iii7 su* items & s]vices are relat$ to ! treatm5t ( a simil> condition4 7,b7 ,treatm5t ( bundl$ paym5ts ,9 c>ry+ out subp>agraph 7,a71 ! ,secret>y %all provide t1 9 ! case ( items & s]vices :i* are includ$ by a provid] or facility z "p ( a bundl$ paym5t1 su* items & s]vices includ$ 9 su* bundl$ paym5t may be "p ( a s+le det]m9ation "u ?is subsection4 7,c7 ,waiv] ( deadl9es ,= purposes ( p]mitt+ jo9t consid]ation ( qualifi$ m$iat$ dispute items & s]vices z "p ( a s+le det]m9ation "u ! crit]ia specifi$ pursuant to subp>agraph 7,a71 ! ,secret>y may waive any deadl9e specifi$ 9 ?is subsection4 7#e7 ,det]m9ation ( paym5t am\nt 7,a7 ,9 g5]al ,n lat] ?an #cj days aft] ! date ( initiation ( ! m$iat$ dispute resolution1 ) respect to a qualifi$ m$iat$ dispute item or s]vice1 ! select$ indep5d5t entity ) respect to a det]m9ation "u ?is subsection = su* item or s]vice %all-- 7i7 tak+ into acc\nt only ! consid]ations specifi$ 9 subp>agraph 7,c77i71 select "o ( ! (f]s submitt$ "u subp>agraph 7,b7 to be ! am\nt ( paym5t = su* item or s]vice det]m9$ "u ?is subsection = purposes ( subsection 7b77#a71 7e77#a71 or 7i77#a71 z applicable2 & 7ii7 notify ! provid] or facility & ! heal? plan p>ty to su* det]m9ation ( ! (f] select$ "u clause 7i74 7,b7 ,submission ( (f]s ,n lat] ?an #aj days aft] ! date ( initiation ( ! m$iat$ dispute resolution ) respect to a det]m9ation = a qualifi$ m$iat$ dispute item or s]vice1 ! provid] or facility & ! heal? plan p>ty to su* det]m9ation %all ea* submit to ! select$ indep5d5t entity-- 7i7 an (f] = a paym5t am\nt "u = su* item or s]vice furni%$ by su* provid] or facility2 7ii7 in=mation relat+ to su* (f]2 & 7iii7 su* o!r in=mation z reque/$ by ! select$ indep5d5t entity4 7,c7 ,consid]ations 7i7 ,9 g5]al ,= purposes ( subp>agraph 7,a71 ! consid]ations specifi$ 9 ?is subp>agraph1 ) respect to a det]m9ation = a qualifi$ m$iat$ dispute item or s]vice1 are ! foll[+3 7,i7 ,! m$ian contract$ rate = su* item or s]vice4 7,,ii7 ,subject to clause 7ii71 in=mation t is submitt$ pursuant to subp>agraph 7,b74 7ii7 ,treatm5t ( c]ta9 consid]ations ,9 mak+ a det]m9ation ) respect to a qualifi$ m$iat$ dispute item or s]vice pursuant to subp>agraph 7,a77i71 a select$ indep5d5t entity may n take into acc\nt usual & cu/om>y *>ges = ! item or s]vice nor *>ges bill$ by ! provid] or facility = ! item or s]vice4 7#f7 ,select$ indep5d5t entity comp5sation 7,a7 ,9 g5]al ,n lat] ?an #e days aft] receiv+ a notification describ$ 9 p>agraph 7#e77;,a77ii7 f a select$ indep5d5t entity ) respect to ! det]m9ation ( a paym5t am\nt = a qualifi$ m$iat$ dispute item or s]vice1 ! p>ty to su* det]m9ation ^: (f] submitt$ "u p>agraph 7#e77;,b7 0 n select$ by ! entity %all pay to su* entity a fee 9 comp5sation = ! s]vices ( su* entity 9 accordance ) ! guidel9es on su* comp5sation e/abli%$ by ! ,secret>y "u subp>agraph 7,b74 7,b7 ,guidel9es on comp5sation ,= purposes ( subp>agraph 7,a71 ! ,secret>y %all e/abli% guidel9es ) respect to ! comp5sation ( a select$ indep5d5t entity = ! s]vices ( su* entity ) respect to det]m9ations "u ! m$iat$ dispute process4 ,su* guidel9es %all provide t su* comp5sation reimburses ! entity = at lea/ ! co/s ( su* entity 9 p]=m+ ! duties ( ! entity "u ! m$iat$ dispute process4 7#g7 ,c]tification ( entities 7,a7 ,9 g5]al ,! ,secret>y %all e/abli% or recognize a process to c]tify 7includ+ rec]tification (7 entities "u ?is p>agraph4 ,su* process %all ensure t an entity s c]tifi$-- 7i7 has 7directly or ?r\gh contracts or o!r arrangem5ts7 suffici5t m$ical1 legal1 & o!r exp]tise & suffici5t /aff+ to make det]m9ations describ$ 9 p>agraph 7#b7 on a timely basis2 7ii7 is n-- 7,i7 a heal? plan1 provid]1 or facility2 7,,ii7 an affiliate or a subsidi>y ( a heal? plan1 provid]1 or facility2 or 7,,iii7 an affiliate or subsidi>y ( a pr(essional or trade association ( heal? plans or ( provid]s or facilities2 7iii7 c>ries out ! responsibilities ( su* an entity 9 accordance ) ?is subsection2 7iv7 meets appropriate indicators ( fiscal integrity2 7v7 ma9ta9s ! confid5tiality 79 accordance ) regulations promulgat$ by ! ,secret>y7 ( individually id5tifiable heal? in=mation obta9$ 9 ! c\rse ( conduct+ su* det]m9ations2 7vi7 does n "u ! m$iat$ dispute process c>ry out any det]m9ation ) respect to :i* ! entity w\ld n pursuant to clause 7i71 7ii71 or 7iii7 ( p>agraph 7#c77;,a7 be eligible = selection2 & 7vii7 meets su* o!r requirem5ts z det]m9$ appropriate by ! ,secret>y4 7,b7 ,p]iod ( c]tification ,subject to subp>agraph 7,c71 ea* c]tification 7includ+ a rec]tification7 ( an entity "u ! process describ$ 9 subp>agraph 7,a7 %all be = a #e-ye> p]iod4 7,c7 ,revocation ,a c]tification ( an entity "u ?is p>agraph may be revok$ "u ! process describ$ 9 subp>agraph 7,a7 if ! entity has a patt]n or practice ( noncompliance ) any ( ! requirem5ts describ$ 9 su* subp>agraph4 7,d7 ,petition = d5ial or )drawal ,! process describ$ 9 subp>agraph 7,a7 %all ensure t an individual1 provid]1 facility1 or heal? plan may petition = a d5ial ( a c]tification or a revocation ( a c]tification ) respect to an entity "u ?is p>agraph = failure ( meet+ a requirem5t ( ?is subsection4 7,e7 ,suffici5t numb] ( entities ,! process describ$ 9 subp>agraph 7,a7 %all ensure t a suffici5t numb] ( entities are c]tifi$ "u ?is p>agraph to ensure ! timely & effici5t provision ( det]m9ations describ$ 9 p>agraph 7#b74 7,f7 ,provision ( in=mation 7i7 ,9 g5]al ,an entity c]tifi$ "u ?is p>agraph %all provide to ! ,secret>y1 9 su* mann] z ! ,secret>y may require & on a qu>t]ly basis 7z specifi$ by ! ,secret>y71 su* in=mation z ! ,secret>y det]m9es appropriate to assure compliance ) ! requirem5ts describ$ 9 subp>agraph 7,a7 & to monitor & assess ! det]m9ations made by su* entity & to ensure ! abs5ce ( bias 9 mak+ su* det]m9ations4 ,su* in=mation %all include in=mation describ$ 9 clause 7ii7 b %all n include individually id5tifiable heal? in=mation4 7ii7 ,in=mation to be includ$ ,! in=mation describ$ 9 ?is clause ) respect to an entity is ! foll[+3 7,i7 ,! numb] ( paym5t det]m9ations describ$ 9 p>agraph 7#b7 made by su* entity1 disaggregat$ by-- 7aa7 ! l9e ( bus9ess 7z specifi$ 9 subsection 7k77#h77;,c77 ( ! heal? plans p>ty to su* det]m9ations2 & 7bb7 ! type ( provid]s & facilities p>ty to su* det]m9ations4 7,,ii7 ,a description ( ea* item or s]vice includ$ 9 ea* su* det]m9ation4 7,,iii7 ,! am\nt ( ea* (f] submitt$ to ! entity = ea* su* det]m9ation4 7,,iv7 ,! am\nt ( ea* su* det]m9ation4 7,v7 ,! l5g? ( "t 9 mak+ ea* su* det]m9ation4 7,,vi7 ,! comp5sation paid to su* entity ) respect to ea* su* det]m9ation4 7,,vii7 ,any o!r in=mation specifi$ by ! ,secret>y4 7#h7 ,adm9i/rative fee 7,a7 ,9 g5]al ,ea* p>ty to a det]m9ation to :i* an entity is select$ "u p>agraph 7#c7 9 a ye> %all pay to ! ,secret>y1 at su* "t & 9 su* mann] z specifi$ by ! ,secret>y1 a fee = p>ticipat+ 9 ! m$iat$ dispute process ) respect to su* det]m9ation 9 an am\nt describ$ 9 subp>agraph 7,b7 = su* ye>4 7,b7 ,am\nt ( fee ,! am\nt describ$ 9 ?is subp>agraph = a ye> is an am\nt e/abli%$ by ! ,secret>y 9 a mann] su* t ! total am\nt ( fees paid "u ?is p>agraph = su* ye> is e/imat$ to be equal to ! am\nt ( exp5ditures e/imat$ to be made by ! ,secret>y = su* ye> 9 c>ry+ out ! m$iat$ dispute process4 7#i7 ,secret>ial report2 publication ( in=mation 7,a7 ,secret>ial report ,beg9n+ n lat] ?an ,july #a1 #bjbc1 ! ,secret>y %all1 9 coord9ation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ! ,treasury1 p]iodically /udy & submit to ,congress a report on-- 7i7 ! ext5t to :i* ! paym5t am\nt det]m9$ "u ?is subsection = an item or s]vice furni%$ 9 a ye> 7or o!rwise agre$ to by a heal? plan & provid] or facility = purposes ( det]m9+ paym5t by ! plan to ! provid] or facility pursuant to subsection 7b77#a71 7e77#a71 or 7i77#a77 diff]s f ! m$ian contract$ rate = su* item or s]vice & ye>1 includ+ ! numb] ( times su* det]m9$ 7or agre$ to7 am\nt exce$s su* m$ian contract$ rate2 & 7ii7 ! effect ( su* diff]5ce on ! co/-%>+ = su* item or s]vice = a p>ticipant or b5efici>y ( a heal? plan4 7,b7 ,publication ( in=mation ,beg9n+ ) ,july #a1 #bjbc1 & = ea* cal5d> qu>t] !reaft]1 ! ,secret>y %all1 9 coord9ation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ,labor1 make publicly available a summ>y ( ! foll[+3 7i7 ,! in=mation describ$ 9 subclauses 7,i7 ?r\gh 7,v7 ( clause 7ii7 ( p>agraph 7#g77;,f7 t 0 submitt$ to ! ,secret>y "u clause 7i7 ( su* p>agraph dur+ su* qu>t]4 7ii7 ,! am\nt ( exp5ditures made by ! ,secret>y dur+ su* ye> to c>ry out ! m$iat$ dispute process4 7iii7 ,! total am\nt ( fees paid "u p>agraph 7#h7 dur+ su* qu>t]4 7iv7 ,! total am\nt ( comp5sation paid to select$ indep5d5t entities "u p>agraph 7#f7 dur+ su* qu>t]4 4 7d7 ,rule ( con/ruction ,no?+ 9 ?is ,act1 or ! am5dm5t made by ?is ,act1 %all be con/ru$ z remov+ any obligation ( a heal? plan 7z def9$ 9 subsection 7k77#f7 ( section #bgai;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ai;,a71 z am5d$ by ?is ,act7 to provide paym5t to a heal? c>e provid] or heal? c>e facility = items & s]vices furni%$ by su* provid] or facility to an individual enroll$ 9 su* plan4 #h4 ,prohibit+ balance bill+ practices by provid]s = em]g5cy s]vices1 = s]vices furni%$ by nonp>ticipat+ provid] at p>ticipat+ facility1 & 9 c]ta9 cases ( mis9=mation 7a7 ,no balance bill+ ,"p ,a ( title ,,xi ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acja et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #aaej;,c4 ,prohibition on c]ta9 balance bill+ practices 7a7 ,em]g5cy s]vices ,9 ! case ( an individual ) b5efits "u a gr\p heal? plan or heal? insurance cov]age (f]$ 9 ! gr\p or individual m>ket :o is furni%$ 9 a plan ye> t beg9s on or aft] ,janu>y #a1 #bjbb1 em]g5cy s]vices ) respect to an em]g5cy m$ical condition dur+ a visit at an em]g5cy dep>tm5t ( a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t-- 7#a7 if ! hospital or indep5d5t free/&+ em]g5cy dep>tm5t does n h a contractual relation%ip ) su* plan or cov]age = furni%+ su* s]vices1 ! hospital or indep5d5t free/&+ em]g5cy dep>tm5t %all n bill1 & %all n hold liable1 ! individual = a paym5t am\nt = su* em]g5cy s]vices s furni%$ t is m ?an ! co/-%>+ am\nt = su* s]vices 7z det]m9$ 9 accordance ) section #bgai;,a7b7 ( ! ,public ,heal? ,s]vice ,act1 section #gaf7;b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihaf7;b7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z applicable72 & 7#b7 a heal? c>e provid] )\t a contractual relation%ip ) su* plan or cov]age = furni%+ su* s]vices %all n bill1 & %all n hold liable1 su* individual = a paym5t am\nt = su* s]vices furni%$ to su* individual by su* provid] ) respect to su* em]g5cy m$ical condition & visit = :i* ! individual receives em]g5cy s]vices at ! em]g5cy dep>tm5t ( ! hospital or indep5d5t free/&+ em]g5cy dep>tm5t t is m ?an ! co/-%>+ am\nt = su* s]vices furni%$ by ! provid] 7z det]m9$ 9 accordance ) section #bgai;,a7b7 ( ! ,public ,heal? ,s]vice ,act1 section #gaf7;b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihaf7;b7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z applicable74 7b7 ,s]vices furni%$ by nonp>ticipat+ provid] at p>ticipat+ facility 7#a7 ,9 g5]al ,subject to p>agraph 7#b71 9 ! case ( an individual ) b5efits "u a heal? plan :o is furni%$ items or s]vices 7o!r ?an em]g5cy s]vices to :i* subsection 7a7 applies or items & s]vices to :i* subsection 7c7 applies7 9 a plan ye> t1 ) respect to su* plan or su* cov]age 7z applicable71 beg9s on or aft] ,janu>y #a1 #bjbb1 at a p>ticipat+ facility by a nonp>ticipat+ provid]1 su* provid] %all n bill1 & %all n hold liable1 su* individual = a paym5t am\nt = su* an item or s]vice furni%$ by su* provid] dur+ a visit at su* facility t is m ?an ! co/-%>+ am\nt = su* item or s]vice 7z det]m9$ 9 accordance ) section #bgai;,a7e7 ( ! ,public ,heal? ,s]vice ,act1 section #gaf7;e7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihaf7;e7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z applicable74 7#b7 ,exception 9 case notice provid$ ,p>agraph 7#a7 %all n apply ) respect to items & s]vices 7o!r ?an items & s]vices describ$ 9 p>agraph 7#c77 furni%$ to an individual enroll$ 9 a gr\p heal? plan or 9 heal? insurance cov]age (f]$ 9 ! gr\p or individual m>ket by a heal? c>e provid] t does n h a contractual relation%ip ) su* plan or cov]age = furni%+ su* items & s]vices if ! foll[+ crit]ia are met3 7,a7 ,a writt5 notice 7z specifi$ by ! ,secret>y & 9 cle> & und]/&able language7 is provid$ by ! provid] to su* individual1 n lat] ?an #dh h\rs be=e su* items & s]vices are to be s furni%$1 t includes ! foll[+ in=mation3 7i7 ,a /atem5t v]ify+ t ! provid] does n h su* a relation%ip ) su* plan or cov]age4 7ii7 ,! e/imat$ am\nt t su* provid] may *>ge ! individual = su* items & s]vices4 7iii7 ,a /atem5t t ! individual may seek su* items or s]vices f a heal? c>e provid] t does h su* a contractual relation%ip & a li/1 if feasible1 ( provid]s ) su* a relation%ip :o are able to furni% su* items & s]vices involv$4 7,b7 ,on ! date su* item or s]vice is to be furni%$1 be=e su* item or s]vice is s furni%$1 ! individual signs & dates su* notice confirm+ receipt ( ! notice & cons5t ( ! individual to be s furni%$ su* items & s]vices4 7,c7 ,a copy ( su* sign$ & dat$ notice is provid$ by ! provid] to ! plan or cov]age4 7#c7 ,items & s]vices describ$ ,! items & s]vices describ$ 9 ?is p>agraph are items & s]vices furni%$ by a specifi$ provid] 7z def9$ 9 subsection 7f77#c774 7c7 ,reliance on incorrect provid] in=mation ,9 ! case ( an individual :o is furni%$ items or s]vices by a heal? c>e provid] or heal? c>e facility = :i* a gr\p heal? plan or heal? insurance issu] is requir$ to make paym5t "u section #bgai;,a7i7 ( ! ,public ,heal? ,s]vice ,act1 section #gaf7;i7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihaf7;i7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 su* provid] or facility %all n bill1 & %all n hold liable1 su* individual = a paym5t am\nt = su* an item or s]vice t is m ?an ! co/-%>+ am\nt = su* item or s]vice 7z det]m9$ 9 accordance ) section #bgai;,a7i7 ( ! ,public ,heal? ,s]vice ,act1 section #gaf7;i7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihaf7;i7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z applicable74 7d7 ,compliance ) requirem5ts "u op5 negotiation & m$iat$ dispute resolution processes ,a heal? c>e provid] or heal? c>e facility %all comply ) any requirem5t impos$ on su* provid] or facility1 respectively1 "u section #bgai;,a7j7 ( ! ,public ,heal? ,s]vice ,act1 #ihaf7;j7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 or #gaf7;j7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd4 7e7 ,p5alty 7#a7 ,9 g5]al ,any heal? c>e provid] or heal? c>e facility 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 ,! provisions ( section #aabh;,a 7o!r ?an subsection 7a71 subsection 7b71 ! fir/ s5t5ce ( subsection 7c77#a71 & subsection 7o77 %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$+ "u subsection 7a7 ( su* section4 7f7 ,def9itions ,= purposes ( ?is section & sections #aaej;,d & #aaej;,e3 7#a7 ,! t]ms dur+ a visit1em]g5cy dep>tm5t ( a hospital1 em]g5cy m$ical condition1 em]g5cy s]vices1 indep5d5t free/&+ em]g5cy dep>tm5t1 nonp>ticipat+ provid]1 nonp>ticipat+ facility1 p>ticipat+ facility1 p>ticipat+ provid] h ! mean+s giv5 su* t]ms1 respectively1 9 section #bgai;,a7k7 ( ! ,public ,heal? ,s]vice ,act4 7#b7 ,! t]ms gr\p heal? plan1 gr\p m>ket1 heal? insurance issu]1 heal? insurance cov]age1 & individual m>ket h ! mean+s giv5 su* t]ms1 respectively1 9 section #bgia ( ! ,public ,heal? ,s]vice ,act4 7#c7 ,! t]m specifi$ provid]1 ) respect to an individual ) b5efits "u a gr\p heal? plan or heal? insurance cov]age & a hospital ) a contractual relation%ip ) su* plan or cov]age = furni%+ items & s]vices-- 7,a7 means an ancill>y heal? c>e provid]1 includ+ em]g5cy m$ic9e provid]s or suppli]s1 ane/hesiologi/s1 pa?ologi/s1 radiologi/s1 neonatologi/s1 assi/ant surgeons1 hospitali/s1 int5sivi/s1 or o!r provid]s det]m9$ by ! ,secret>y 7includ+ provid]s :o furni% simil> items & s]vices z ! provid]s specifi$ 9 ?is p>agraph72 & 7,b7 includes1 ) respect to an item or s]vice1 any heal? c>e provid] furni%+ su* item or s]vice at su* hospital if !re is no heal? c>e provid] at su* hospital :o c furni% su* item or s]vice :o has su* a relation%ip ) su* plan or cov]age = furni%+ su* item or s]vice4 4 7b7 ,provid] directory2 pati5t-,provid] dispute resolution process ,"p ,a ( title ,,xi ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acja et seq471 z am5d$ by subsection 7a71 is fur!r am5d$ by add+ at ! end ! foll[+ new sections3 #aaej;,d4 ,pati5t protections aga9/ surprise bill+ ?r\gh transp>5cy 7a7 ,submission ( in=mation to heal? plans ( c]ta9 provid] in=mation ,beg9n+ n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is section1 ea* heal? c>e provid] & heal? c>e facility %all e/abli% a process "u :i* su* provid] or facility transmits1 to ea* heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age & gr\p heal? plan ) :i* su* provid] or suppli] has 9 effect a contractual relation%ip = furni%+ items & s]vices "u su* cov]age or su* plan1 provid] directory in=mation 7z def9$ 9 section #bgai;,a7f77#f7 ( ! ,public ,heal? ,s]vice ,act1 section #gaf7;f77#f7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or section #ihaf7;f77#f7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z applicable7 ) respect to su* provid] or facility1 z applicable4 ,su* provid] or facility %all s transmit su* in=mation to su* issu] (f]+ su* cov]age or su* gr\p heal? plan-- 7#a7 :5 !re are any mat]ial *anges 7includ+ a *ange 9 address1 telephone numb]1 or o!r contact in=mation7 to su* provid] directory in=mation ( ! provid] or facility ) respect to su* cov]age (f]$ by su* issu] or ) respect to su* plan2 & 7#b7 at any o!r "t 7includ+ ^u ! reque/ ( su* issu] or plan7 det]m9$ appropriate by ! provid]1 facility1 or ! ,secret>y4 7b7 ,provision ( in=mation ^u reque/ & = s*$ul$ appo9tm5ts ,ea* heal? c>e provid] & heal? c>e facility %all1 beg9n+ ,janu>y #a1 #bjbb1 9 ! case ( an individual :o s*$ules an item or s]vice to be furni%$ to su* individual by su* provid] or facility at lea/ #c bus9ess days be=e ! date su* item or s]vice is to be s furni%$1 n lat] ?an #a bus9ess day aft] ! date ( su* s*$ul+ 7or1 9 ! case ( su* an item or s]vice s*$ul$ at lea/ #aj bus9ess days be=e ! date su* item or s]vice is to be s furni%$ 7or if reque/$ by ! individual71 n lat] ?an #c bus9ess days aft] ! date ( su* s*$ul+ or su* reque/7-- 7#a7 inquire if su* individual is enroll$ 9 a gr\p heal? plan1 gr\p or individual heal? insurance cov]age (f]$ by a heal? insurance issu]1 or a ,f$]al heal? c>e program 7& if is s enroll$ 9 su* plan or cov]age1 seek+ to h a claim = su* item or s]vice submitt$ to su* plan or cov]age72 & 7#b7 provide a notification 79 cle> & und]/&able language7 ( ! good fai? e/imate ( ! expect$ *>ges = furni%+ su* item or s]vice 7includ+ any item or s]vice t is reasonably expect$ to be provid$ 9 conjunction ) su* s*$ul$ item or s]vice7 to-- 7,a7 9 ! case ! individual is enroll$ 9 su* a plan or su* cov]age 7& is seek+ to h a claim = su* item or s]vice submitt$ to su* plan or cov]age71 su* plan or issu] ( su* cov]age2 & 7,b7 9 ! case ! individual is n describ$ 9 subp>agraph 7,a7 & n enroll$ 9 a ,f$]al heal? c>e program1 ! individual4 7c7 ,cont9uity ( c>e ,a heal? c>e provid] or heal? c>e facility %all1 9 ! case ( an individual furni%$ items & s]vices by su* provid] or facility = :i* cov]age is provid$ "u a gr\p heal? plan or gr\p or individual heal? insurance cov]age pursuant to section #bgcj ( su* ,act1 section #ihag ( ! ,int]nal ,rev5ue ,code ( #aihf1 or section #gag ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd-- 7#a7 accept paym5t f su* plan or su* issu] 7z applicable7 7& co/-%>+ f su* individual1 if applicable1 9 accordance ) subsection 7a77#b77;,c7 ( su* section #bgcj1 #ihag1 or #gag7 = su* items & s]vices z paym5t 9 full = su* items & s]vices2 & 7#b7 cont9ue to adh]e to all policies1 proc$ures1 & quality /&>ds impos$ by su* plan or issu] ) respect to su* individual & su* items & s]vices 9 ! same mann] z if su* t]m9ation _h n occurr$4 7d7 ,limitation ,beg9n+ on ,janu>y #a1 #bjbb1 a heal? c>e provid] or heal? c>e facility may n initiate a process to seek reimbursem5t ( paym5t = items & s]vices furni%$ to an individual enroll$ 9 a gr\p heal? plan or heal? insurance cov]age (f]$ 9 ! gr\p or individual m>ket m ?an #a ye> aft] ! date on :i* su* items & s]vices 7 s furni%$4 7e7 ,p5alty 7#a7 ,g5]al p5alty 7,a7 ,9 g5]al ,except z provid$ 9 p>agraph 7#b71 any heal? c>e provid] or heal? c>e facility 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 ,! provisions ( section #aabh;,a 7o!r ?an subsection 7a71 subsection 7b71 ! fir/ s5t5ce ( subsection 7c77#a71 & subsection 7o77 %all apply ) respect to a civil monet>y p5alty impos$ "u ?is p>agraph 9 ! same mann] z su* provisions apply ) respect to a p5alty or proce$+ "u subsection 7a7 ( su* section4 7#b7 ,provid] directory in=mation p5alty 7,a7 ,9 g5]al ,ea* heal? c>e provid] or heal? c>e facility t fails to transmit in=mation z requir$ "u subsection 7a7 %all be subject to a civil monet>y p5alty ( #a1jjj = ea* day su* provid] or facility 7z applicable7 fails to s transmit su* in=mation4 7,b7 ,application ( provisions ,! provisions ( section #aabh;,a 7o!r ?an subsection 7a71 subsection 7b71 ! fir/ s5t5ce ( subsection 7c77#a71 subsection 7d71 & subsection 7o77 %all apply ) respect to a civil monet>y p5alty impos$ "u ?is p>agraph 9 ! same mann] z su* provisions apply ) respect to a p5alty or proce$+ "u subsection 7a7 ( su* section4 #aaej;,e4 ,pati5t-provid] dispute resolution 7a7 ,9 g5]al ,n lat] ?an ,july #a1 #bjba1 ! ,secret>y %all e/abli% a process 79 ?is subsection ref]r$ to z ! pati5t-provid] dispute resolution process7 "u :i* an un9sur$ individual1 ) respect to an item or s]vice1 :o receiv$1 pursuant to section #aaej;,d7b71 f a heal? c>e provid] or heal? c>e facility a good-fai? e/imate ( ! expect$ *>ges = furni%+ su* item or s]vice to su* individual & :o aft] be+ furni%$ su* item or s]vice by su* provid] or facility is bill$ by su* provid] or facility = su* item or s]vice = *>ges t are sub/antially 9 excess ( su* e/imate1 may seek a det]m9ation f a select$ dispute resolution entity = ! *>ges to be paid by su* individual 79 lieu ( su* am\nt s bill$7 to su* provid] or facility = su* item or s]vice4 ,= purposes ( ?is subsection1 ! t]m un9sur$ individual means1 ) respect to an item or s]vice1 an individual :o does n h b5efits = su* item or s]vice "u a gr\p heal? plan1 heal? insurance cov]age (f]$ 9 ! gr\p or individual m>ket by a heal? insurance issu]1 ,f$]al heal? c>e program 7z def9$ 9 section #aabh;,b7f771 or a heal? b5efits plan "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code 7or an individual :o has b5efits = su* item or s]vice "u a gr\p heal? plan or heal? insurance cov]age (f]$ 9 ! gr\p or individual m>ket by a heal? insurance issu]1 b :o does n seek to h a claim = su* item or s]vice submitt$ to su* plan or cov]age74 7b7 ,selection ( entities ,"u ! pati5t-provid] dispute resolution process1 ! ,secret>y %all1 ) respect to a det]m9ation s\ght by an individual "u subsection 7a71 ) respect to *>ges to be paid by su* individual to a heal? c>e provid] or heal? c>e facility describ$ 9 su* p>agraph = an item or s]vice furni%$ to su* individual by su* provid] or facility1 provide =-- 7#a7 a me?od to select to make su* det]m9ation an entity c]tifi$ "u subsection 7d7 t-- 7,a7 is n a p>ty to su* det]m9ation or an employee or ag5t ( su* p>ty2 7,b7 does n h a mat]ial familial1 f9ancial1 or pr(essional relation%ip ) su* a p>ty2 & 7,c7 does n o!rwise h a conflict ( int]e/ ) su* a p>ty 7z det]m9$ by ! ,secret>y72 & 7#b7 ! provision ( a notification ( su* selection to ! individual & ! provid] or facility 7z applicable7 p>ty to su* det]m9ation4 ,an entity select$ pursuant to ! previ\s s5t5ce to make a det]m9ation describ$ 9 su* s5t5ce %all be ref]r$ to 9 ?is subsection z ! select$ dispute resolution entity ) respect to su* det]m9ation4 7c7 ,adm9i/rative fee ,! ,secret>y %all e/abli% a fee to p>ticipate 9 ! pati5t-provid] dispute resolution process 9 su* a mann] z to n create a b>ri] to an un9sur$ individual's access to su* process4 7d7 ,c]tification ,! ,secret>y %all e/abli% or recognize a process to c]tify entities "u ?is subp>agraph4 ,su* process %all ensure t an entity s c]tifi$ satisfies at lea/ ! crit]ia specifi$ 9 section #bgai;,a7j77#g7 ( ! ,public ,heal? ,s]vice ,act4 4 #i4 ,additional consum] protections 7a7 ,public ,heal? ,s]vice ,act ,subp>t ,,ii ( "p ,a ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aa et seq47 is am5d$ by add+ at ! end ! foll[+ new sections3 #bgcj4 ,cont9uity ( c>e 7a7 ,ensur+ cont9uity ( c>e ) respect to t]m9ations ( c]ta9 contractual relation%ips result+ 9 *anges 9 provid] network /atus 7#a7 ,9 g5]al ,9 ! case ( an individual ) b5efits "u a gr\p heal? plan or gr\p or individual heal? insurance cov]age (f]$ by a heal? insurance issu] & ) respect to a heal? c>e provid] or facility t has a contractual relation%ip ) su* plan or su* issu] 7z applicable7 = furni%+ items & s]vices "u su* plan or su* cov]age1 if1 :ile su* individual is a cont9u+ c>e pati5t 7z def9$ 9 subsection 7b77 ) respect to su* provid] or facility-- 7,a7 su* contractual relation%ip is t]m9at$ 7z def9$ 9 subsection 7b772 7,b7 b5efits provid$ "u su* plan or su* heal? insurance cov]age ) respect to su* provid] or facility are t]m9at$ because ( a *ange 9 ! t]ms ( ! p>ticipation ( su* provid] or facility 9 su* plan or cov]age2 or 7,c7 a contract betwe5 su* gr\p heal? plan & a heal? insurance issu] (f]+ heal? insurance cov]age 9 connection ) su* plan is t]m9at$1 result+ 9 a loss ( b5efits provid$ "u su* plan ) respect to su* provid] or facility2 ! plan or issu]1 respectively1 %all meet ! requirem5ts ( p>agraph 7#b7 ) respect to su* individual4 7#b7 ,requirem5ts ,! requirem5ts ( ?is p>agraph are t ! plan or issu]-- 7,a7 notify ea* individual enroll$ "u su* plan or cov]age :o is a cont9u+ c>e pati5t ) respect to a provid] or facility at ! "t ( a t]m9ation describ$ 9 p>agraph 7#a7 affect+ su* provid] or facility on a timely basis ( su* t]m9ation & su* individual's "r to elect cont9u$ transitional c>e f su* provid] or facility "u ?is section2 7,b7 provide su* individual ) an opportunity to notify ! plan or issu] ( ! individual's ne$ = transitional c>e2 & 7,c7 p]mit ! pati5t to elect to cont9ue to h b5efits provid$ "u su* plan or su* cov]age1 "u ! same t]ms & conditions z w\ld h appli$ & ) respect to su* items & s]vices z w\ld h be5 cov]$ "u su* plan or cov]age _h su* t]m9ation n occurr$1 ) respect to ! c\rse ( treatm5t furni%$ by su* provid] or facility relat+ to su* individual's /atus z a cont9u+ c>e pati5t dur+ ! p]iod beg9n+ on ! date on :i* ! notice "u subp>agraph 7,a7 is provid$ & end+ on ! e>li] (-- 7i7 ! #ij-;day p]iod beg9n+ on su* date2 or 7ii7 ! date on :i* su* individual is no long] a cont9u+ c>e pati5t ) respect to su* provid] or facility4 7b7 ,def9itions ,9 ?is section3 7#a7 ,cont9u+ c>e pati5t ,! t]m cont9u+ c>e pati5t means an individual :o1 ) respect to a provid] or facility-- 7,a7 is und]go+ a c\rse ( treatm5t = a s]i\s & complex condition f ! provid] or facility2 7,b7 is und]go+ a c\rse ( in/itutional or inpati5t c>e f ! provid] or facility2 7,c7 is s*$ul$ to und]go nonelective surg]y f ! provid]1 includ+ receipt ( po/op]ative c>e f su* provid] or facility ) respect to su* a surg]y2 7,d7 is pregnant & und]go+ a c\rse ( treatm5t = ! pregnancy f ! provid] or facility2 or 7,e7 is or 0 det]m9$ to be t]m9ally ill 7z det]m9$ "u section #ahfa7;dd77#c77;,a7 ( ! ,social ,security ,act7 & is receiv+ treatm5t = su* illness f su* provid] or facility4 7#b7 ,s]i\s & complex condition ,! t]m s]i\s & complex condition means1 ) respect to a p>ticipant1 b5efici>y1 or enrollee "u a gr\p heal? plan or heal? insurance cov]age-- 7,a7 9 ! case ( an acute illness1 a condition t is s]i\s en\gh to require specializ$ m$ical treatm5t to avoid ! reasonable possibility ( dea? or p]man5t h>m2 or 7,b7 9 ! case ( a *ronic illness or condition1 a condition t is-- 7i7 is life-?reat5+1 deg5]ative1 pot5tially disabl+1 or cong5ital2 & 7ii7 requires specializ$ m$ical c>e ov] a prolong$ p]iod ( "t4 7#c7 ,t]m9at$ ,! t]m t]m9at$ includes1 ) respect to a contract1 ! expiration or nonr5ewal ( ! contract1 b does n include a t]m9ation ( ! contract = failure to meet applicable quality /&>ds or = fraud4 #bgca4 ,in=mation requir$ to be includ$ on heal? insurance memb]%ip c>ds ,9 ! case ( a gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age t provides a physical or electronic c>d indicat+ memb]%ip 9 su* plan or cov]age to an individual enroll$ "u su* plan or cov]age1 su* gr\p heal? plan or issu] %all include on su* c>d ea* ( ! foll[+3 7#a7 ,! ne>e/ hospital to ! prim>y resid5ce ( su* individual t has 9 effect a contractual relation%ip ) su* plan or cov]age = furni%+ items & s]vices "u su* plan or cov]age4 7#b7 ,a telephone numb] or ,int]net website address ?r\gh :i* su* individual may seek consum] assi/ance in=mation1 su* z in=mation relat$ to hospitals & urg5t c>e facilities t h 9 effect a contractual relation%ip ) su* plan or cov]age = furni%+ items & s]vices "u su* plan or cov]age4 7#c7 ,any d$uctible applicable to su* individual4 7#d7 ,any out-(-pocket maximum applicable to su* individual4 7#e7 ,any co/-%>+ obligation applicable to su* individual = a visit at an em]g5cy dep>tm5t1 or urg5t c>e facility1 t has 9 effect a contractual relation%ip ) su* plan or cov]age = furni%+ items & s]vices "u su* plan or cov]age4 #bgcb4 ,ma9t5ance ( price comp>ison tool ,9 connection ) ! (f]+ ( a gr\p heal? plan or gr\p or individual heal? insurance cov]age 9 a geographic region = a plan ye>1 a plan sponsor or heal? insurance issu]1 respectively1 %all employ an individual to (f] price comp>ison guidance1 or make available on an ,int]net website a price comp>ison tool1 t 7to ! ext5t practicable7 all[s an individual enroll$ "u su* plan or cov]age1 ) respect to su* plan ye> & su* geographic region1 to comp>e ! am\nt 7det]m9$ by hi/oric claims data ( p>ticipat+ provid]s ) respect to su* plan or cov]age7 ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! individual w\ld be responsible = pay+ "u su* plan or cov]age ) respect to ! furni%+ ( a specific item or s]vice by any su* provid]4 4 7b7 ,int]nal ,rev5ue ,code 7#a7 ,9 g5]al ,sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ! previ\s sections1 is fur!r am5d$ by add+ at ! end ! foll[+ new sections3 #ihag4 ,cont9uity ( c>e 7a7 ,ensur+ cont9uity ( c>e ) respect to t]m9ations ( c]ta9 contractual relation%ips result+ 9 *anges 9 provid] network /atus 7#a7 ,9 g5]al ,9 ! case ( an individual ) b5efits "u a gr\p heal? plan & ) respect to a heal? c>e provid] or facility t has a contractual relation%ip ) su* plan = furni%+ items & s]vices "u su* plan1 if1 :ile su* individual is a cont9u+ c>e pati5t 7z def9$ 9 subsection 7b77 ) respect to su* provid] or facility-- 7,a7 su* contractual relation%ip is t]m9at$ 7z def9$ 9 p>agraph 7b772 7,b7 b5efits provid$ "u su* plan ) respect to su* provid] or facility are t]m9at$ because ( a *ange 9 ! t]ms ( ! p>ticipation ( su* provid] or facility 9 su* plan2 or 7,c7 a contract betwe5 su* gr\p heal? plan & a heal? insurance issu] (f]+ heal? insurance cov]age 9 connection ) su* plan is t]m9at$1 result+ 9 a loss ( b5efits provid$ "u su* plan ) respect to su* provid] or facility2 ! plan %all meet ! requirem5ts ( p>agraph 7#b7 ) respect to su* individual4 7#b7 ,requirem5ts ,! requirem5ts ( ?is p>agraph are t ! plan-- 7,a7 notify ea* individual enroll$ "u su* plan :o is a cont9u+ c>e pati5t ) respect to a provid] or facility at ! "t ( a t]m9ation describ$ 9 p>agraph 7#a7 affect+ su* provid] on a timely basis ( su* t]m9ation & su* individual's "r to elect cont9u$ transitional c>e f su* provid] or facility "u ?is section2 7,b7 provide su* individual ) an opportunity to notify ! plan ( ! individual's ne$ = transitional c>e2 & 7,c7 p]mit ! pati5t to elect to cont9ue to h b5efits provid$ "u su* plan1 "u ! same t]ms & conditions z w\ld h appli$ & ) respect to su* items & s]vices z w\ld h be5 cov]$ "u su* plan _h su* t]m9ation n occurr$1 ) respect to ! c\rse ( treatm5t furni%$ by su* provid] or facility relat+ to su* individual's /atus z a cont9u+ c>e pati5t dur+ ! p]iod beg9n+ on ! date on :i* ! notice "u subp>agraph 7,a7 is provid$ & end+ on ! e>li] (-- 7i7 ! #ij-;day p]iod beg9n+ on su* date2 or 7ii7 ! date on :i* su* individual is no long] a cont9u+ c>e pati5t ) respect to su* provid] or facility4 7b7 ,def9itions ,9 ?is section3 7#a7 ,cont9u+ c>e pati5t ,! t]m cont9u+ c>e pati5t means an individual :o1 ) respect to a provid] or facility-- 7,a7 is und]go+ a c\rse ( treatm5t = a s]i\s & complex condition f ! provid] or facility2 7,b7 is und]go+ a c\rse ( in/itutional or inpati5t c>e f ! provid] or facility2 7,c7 is s*$ul$ to und]go nonelective surg]y f ! provid] or facility1 includ+ receipt ( po/op]ative c>e f su* provid] or facility ) respect to su* a surg]y2 7,d7 is pregnant & und]go+ a c\rse ( treatm5t = ! pregnancy f ! provid] or facility2 or 7,e7 is or 0 det]m9$ to be t]m9ally ill 7z det]m9$ "u section #ahfa7;dd77#c77;,a7 ( ! ,social ,security ,act7 & is receiv+ treatm5t = su* illness f su* provid] or facility4 7#b7 ,s]i\s & complex condition ,! t]m s]i\s & complex condition means1 ) respect to a p>ticipant1 b5efici>y1 or enrollee "u a gr\p heal? plan-- 7,a7 9 ! case ( an acute illness1 a condition t is s]i\s en\gh to require specializ$ m$ical treatm5t to avoid ! reasonable possibility ( dea? or p]man5t h>m2 or 7,b7 9 ! case ( a *ronic illness or condition1 a condition t-- 7i7 is life-?reat5+1 deg5]ative1 pot5tially disabl+1 or cong5ital2 & 7ii7 requires specializ$ m$ical c>e ov] a prolong$ p]iod ( "t4 7#c7 ,t]m9at$ ,! t]m t]m9at$ includes1 ) respect to a contract1 ! expiration or nonr5ewal ( ! contract1 b does n include a t]m9ation ( ! contract = failure to meet applicable quality /&>ds or = fraud4 #ihah4 ,in=mation requir$ to be includ$ on heal? insurance memb]%ip c>ds ,9 ! case ( a gr\p heal? plan t provides a physical or electronic c>d indicat+ memb]%ip 9 su* plan to an individual enroll$ "u su* plan1 su* gr\p heal? plan %all include on su* c>d ea* ( ! foll[+3 7#a7 ,! ne>e/ hospital to ! prim>y resid5ce ( su* individual t has 9 effect a contractual relation%ip ) su* plan = furni%+ items & s]vices "u su* plan4 7#b7 ,a telephone numb] or ,int]net website address ?r\gh :i* su* individual may seek consum] assi/ance in=mation1 su* z in=mation relat$ to hospitals & urg5t c>e facilities t h 9 effect a contractual relation%ip ) su* plan = furni%+ items & s]vices "u su* plan4 7#c7 ,any d$uctible applicable to su* individual4 7#d7 ,any out-(-pocket maximum applicable to su* individual4 7#e7 ,any co/-%>+ obligation applicable to su* individual = a visit at an em]g5cy dep>tm5t1 or urg5t c>e facility1 t has 9 effect a contractual relation%ip ) su* plan = furni%+ items & s]vices "u su* plan4 #ihai4 ,ma9t5ance ( price comp>ison tool ,9 connection ) ! (f]+ ( a gr\p heal? plan 9 a geographic region = a plan ye>1 a plan sponsor %all employ an individual to (f] price comp>ison guidance1 or make available on an ,int]net website a price comp>ison tool1 t 7to ! ext5t practicable7 all[s an individual enroll$ "u su* plan1 ) respect to su* plan ye> & su* geographic region1 to comp>e ! am\nt 7det]m9$ by hi/oric claims data ( p>ticipat+ provid]s ) respect to su* plan7 ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! individual w\ld be responsible = pay+ "u su* plan ) respect to ! furni%+ ( a specific item or s]vice by any su* provid]4 4 7#b7 ,con=m+ am5dm5t ,section #ihae7;a7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by section #b7;b71 is fur!r am5d$-- 7,a7 9 p>agraph 7#a71 by /rik+ section #bgai;,a & ins]t+ section #bgai;,a1 #bgcj1 #bgca1 or #bgcb2 & 7,b7 9 p>agraph 7#b71 by /rik+ section #bgai;,a & ins]t+ section #bgai;,a1 #bgcj1 #bgca1 or #bgcb4 7#c7 ,cl]ical am5dm5t ,! table ( sections = su* sub*apt]1 z am5d$ by section #b7;b71 is fur!r am5d$ by add+ at ! end ! foll[+ new items3 ,sec4 #ihag4 ,cont9uity ( c>e4 ,sec4 #ihah4 ,in=mation requir$ to be includ$ on heal? insurance memb]%ip c>ds4 ,sec4 #ihai4 ,ma9t5ance ( price comp>ison tool4 4 7c7 ,employee ,retirem5t ,income ,security ,act 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 seq471 z am5d$ by section #b7;c71 is fur!r am5d$ by add+ at ! end ! foll[+ new sections3 #gag4 ,cont9uity ( c>e 7a7 ,ensur+ cont9uity ( c>e ) respect to t]m9ations ( c]ta9 contractual relation%ips result+ 9 *anges 9 provid] network /atus 7#a7 ,9 g5]al ,9 ! case ( an individual ) b5efits "u a gr\p heal? plan or heal? insurance cov]age (f]$ by a heal? insurance issu] 9 connection ) a gr\p heal? plan & ) respect to a heal? c>e provid] or facility t has a contractual relation%ip ) su* plan or su* issu] 7z applicable7 = furni%+ items & s]vices "u su* plan or su* cov]age1 if1 :ile su* individual is a cont9u+ c>e pati5t 7z def9$ 9 subsection 7b77 ) respect to su* provid] or facility-- 7,a7 su* contractual relation%ip is t]m9at$ 7z def9$ 9 p>agraph 7b772 7,b7 b5efits provid$ "u su* plan or su* heal? insurance cov]age ) respect to su* provid] or facility are t]m9at$ because ( a *ange 9 ! t]ms ( ! p>ticipation ( ! provid] or facility 9 su* plan or cov]age2 or 7,c7 a contract betwe5 su* gr\p heal? plan & a heal? insurance issu] (f]+ heal? insurance cov]age 9 connection ) su* plan is t]m9at$1 result+ 9 a loss ( b5efits provid$ "u su* plan ) respect to su* provid] or facility2 ! plan or issu]1 respectively1 %all meet ! requirem5ts ( p>agraph 7#b7 ) respect to su* individual4 7#b7 ,requirem5ts ,! requirem5ts ( ?is p>agraph are t ! plan or issu]-- 7,a7 notify ea* individual enroll$ "u su* plan or cov]age :o is a cont9u+ c>e pati5t ) respect to a provid] or facility at ! "t ( a t]m9ation describ$ 9 p>agraph 7#a7 affect+ su* provid] or facility on a timely basis ( su* t]m9ation & su* individual's "r to elect cont9u$ transitional c>e f su* provid] or facility "u ?is section2 7,b7 provide su* individual ) an opportunity to notify ! plan or issu] ( ! individual's ne$ = transitional c>e2 & 7,c7 p]mit ! pati5t to elect to cont9ue to h b5efits provid$ "u su* plan or su* cov]age1 "u ! same t]ms & conditions z w\ld h appli$ & ) respect to su* items & s]vices z w\ld h be5 cov]$ "u su* plan or cov]age _h su* t]m9ation n occurr$1 ) respect to ! c\rse ( treatm5t furni%$ by su* provid] or facility relat+ to su* individual's /atus z a cont9u+ c>e pati5t dur+ ! p]iod beg9n+ on ! date on :i* ! notice "u subp>agraph 7,a7 is provid$ & end+ on ! e>li] (-- 7i7 ! #ij-;day p]iod beg9n+ on su* date2 or 7ii7 ! date on :i* su* individual is no long] a cont9u+ c>e pati5t ) respect to su* provid] or facility4 7b7 ,def9itions ,9 ?is section3 7#a7 ,cont9u+ c>e pati5t ,! t]m cont9u+ c>e pati5t means an individual :o1 ) respect to a provid] or facility-- 7,a7 is und]go+ a c\rse ( treatm5t = a s]i\s & complex condition f ! provid] or facility2 7,b7 is und]go+ a c\rse ( in/itutional or inpati5t c>e f ! provid] or facility2 7,c7 is s*$ul$ to und]go nonelective surg]y f ! provide or facility1 includ+ receipt ( po/op]ative c>e f su* provid] or facility ) respect to su* a surg]y2 7,d7 is pregnant & und]go+ a c\rse ( treatm5t = ! pregnancy f ! provid] or facility2 or 7,e7 is or 0 det]m9$ to be t]m9ally ill 7z det]m9$ "u section #ahfa7;dd77#c77;,a7 ( ! ,social ,security ,act7 & is receiv+ treatm5t = su* illness f su* provid] or facility4 7#b7 ,s]i\s & complex condition ,! t]m s]i\s & complex condition means1 ) respect to a p>ticipant1 b5efici>y1 or enrollee "u a gr\p heal? plan or heal? insurance cov]age-- 7,a7 9 ! case ( an acute illness1 a condition t is s]i\s en\gh to require specializ$ m$ical treatm5t to avoid ! reasonable possibility ( dea? or p]man5t h>m2 or 7,b7 9 ! case ( a *ronic illness or condition1 a condition t-- 7i7 is life-?reat5+1 deg5]ative1 pot5tially disabl+1 or cong5ital2 & 7ii7 requires specializ$ m$ical c>e ov] a prolong$ p]iod ( "t4 7#c7 ,t]m9at$ ,! t]m t]m9at$ includes1 ) respect to a contract1 ! expiration or nonr5ewal ( ! contract1 b does n include a t]m9ation ( ! contract = failure to meet applicable quality /&>ds or = fraud4 #gah4 ,in=mation requir$ to be includ$ on heal? insurance memb]%ip c>ds ,9 ! case ( a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age t provides a physical or electronic c>d indicat+ memb]%ip 9 su* plan or cov]age to an individual enroll$ "u su* plan or cov]age1 su* gr\p heal? plan or issu] %all include on su* c>d ea* ( ! foll[+3 7#a7 ,! ne>e/ hospital to ! prim>y resid5ce ( su* individual t has 9 effect a contractual relation%ip ) su* plan or cov]age = furni%+ items & s]vices "u su* plan or cov]age4 7#b7 ,a telephone numb] or ,int]net website address ?r\gh :i* su* individual may seek consum] assi/ance in=mation1 su* z in=mation relat$ to hospitals & urg5t c>e facilities t h 9 effect a contractual relation%ip ) su* plan or cov]age = furni%+ items & s]vices "u su* plan or cov]age4 7#c7 ,any d$uctible applicable to su* individual4 7#d7 ,any out-(-pocket maximum applicable to su* individual4 7#e7 ,any co/-%>+ obligation applicable to su* individual = a visit at an em]g5cy dep>tm5t1 or urg5t c>e facility1 t has 9 effect a contractual relation%ip ) su* plan or cov]age = furni%+ items & s]vices "u su* plan or cov]age4 #gai4 ,ma9t5ance ( price comp>ison tool ,9 connection ) ! (f]+ ( a gr\p heal? plan or gr\p heal? insurance cov]age 9 a geographic region = a plan ye>1 a plan sponsor or heal? insurance issu]1 respectively1 %all employ an individual to (f] price comp>ison guidance1 or make available on an ,int]net website a price comp>ison tool1 t 7to ! ext5t practicable7 all[s an individual enroll$ "u su* plan or cov]age1 ) respect to su* plan ye> & su* geographic region1 to comp>e ! am\nt 7det]m9$ by hi/oric claims data ( p>ticipat+ provid]s ) respect to su* plan or cov]age7 ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! individual w\ld be responsible = pay+ "u su* plan or cov]age ) respect to ! furni%+ ( a specific item or s]vice by any su* provid]4 4 7#b7 ,con=m+ am5dm5t ,section #gae7;a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;d7a771 z am5d$ by section #b7;c71 is fur!r am5d$-- 7,a7 9 p>agraph 7#a71 by /rik+ section #bgai;,a & ins]t+ section #bgai;,a1 #bgcj1 #bgca1 or #bgcb2 & 7,b7 9 p>agraph 7#b71 by /rik+ section #bgai;,a & ins]t+ section #bgai;,a1 #bgcj1 #bgca1 or #bgcb4 7#c7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by ins]t+ aft] ! item relat+ to section #gaf ! foll[+ new items3 ,sec4 #gag4 ,cont9uity ( c>e4 ,sec4 #gah4 ,in=mation requir$ to be includ$ on heal? insurance memb]%ip c>ds4 ,sec4 #gai4 ,ma9t5ance ( price comp>ison tool4 4 7d7 ,effective date ,! am5dm5ts made by ?is section %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbb4 #aj4 ,report+ requirem5ts reg>d+ air ambulance s]vices 7a7 ,report+ requirem5ts = provid]s ( air ambulance s]vices 7#a7 ,9 g5]al ,a provid] ( air ambulance s]vices %all submit to ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ,transportation-- 7,a7 n lat] ?an ! date t is #ij days aft] ! la/ day ( ! fir/ plan ye> beg9n+ on or aft] ! date on :i* a f9al rule is promulgat$ pursuant to ! rulemak+ describ$ 9 subsection 7d71 ! in=mation describ$ 9 p>agraph 7#b7 ) respect to su* plan ye>2 & 7,b7 n lat] ?an ! date t is #ij days aft] ! la/ day ( ! plan ye> imm$iately succe$+ ! plan ye> describ$ 9 subp>agraph 7,a71 su* in=mation ) respect to su* imm$iately succe$+ plan ye>4 7#b7 ,in=mation describ$ ,= purposes ( p>agraph 7#a71 in=mation describ$ 9 ?is p>agraph1 ) respect to a provid] ( air ambulance s]vices1 is ea* ( ! foll[+3 7,a7 ,co/ data1 z det]m9$ appropriate by ! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) ! ,secret>y ( ,transportation1 = air ambulance s]vices furni%$ by su* provid]1 sep>at$ to ! maximum ext5t possible by air transportation co/s associat$ ) furni%+ su* air ambulance s]vices & co/s ( m$ical s]vices & supplies associat$ ) furni%+ su* air ambulance s]vices4 7,b7 ,! numb] & location ( all air ambulance bases op]at$ by su* provid]4 7,c7 ,! numb] & type ( aircraft op]at$ by su* provid]4 7,d7 ,! numb] ( air ambulance transports1 disaggregat$ by payor mix1 includ+ gr\p heal? plans1 heal? insurance issu]s1 & ,gov]nm5t payors4 7,e7 ,! numb] ( claims ( su* provid] t h be5 d5i$ paym5t by a gr\p heal? plan or heal? insurance issu] & ! reasons = any su* d5ials4 7,f7 ,! numb] ( em]g5cy & nonem]g5cy air ambulance transports1 disaggregat$ by air ambulance base & type ( aircraft4 7b7 ,report+ requirem5ts = gr\p heal? plans & heal? insurance issu]s 7#a7 ,9 g5]al ,ea* gr\p heal? plan & heal? insurance issu] (f]+ heal? insurance cov]age 9 ! individual or gr\p m>ket %all submit to ! ,secret>y ( ,heal? & ,human ,s]vices-- 7,a7 n lat] ?an ! date t is #ij days aft] ! la/ day ( ! fir/ plan ye> beg9n+ on or aft] ! date on :i* a f9al rule is promulgat$ pursuant to ! rulemak+ describ$ 9 subsection 7d71 ! in=mation describ$ 9 p>agraph 7#b7 ) respect to su* plan ye>2 & 7,b7 n lat] ?an ! date t is #ij days aft] ! la/ day ( ! plan ye> imm$iately succe$+ ! plan ye> describ$ 9 subp>agraph 7,a71 su* in=mation ) respect to su* imm$iately succe$+ plan ye>4 7#b7 ,in=mation describ$ ,= purposes ( p>agraph 7#a71 in=mation describ$ 9 ?is p>agraph1 ) respect to a gr\p heal? plan or a heal? insurance issu] (f]+ heal? insurance cov]age 9 ! individual or gr\p m>ket1 is ea* ( ! foll[+3 7,a7 ,claims data = air ambulance s]vices furni%$ by provid]s ( su* s]vices1 disaggregat$ by ea* ( ! foll[+ factors3 7i7 ,:e!r su* s]vices 7 furni%$ on an em]g5t or nonem]g5t basis4 7ii7 ,:e!r ! provid] ( su* s]vices is "p ( a hospital-own$ or sponsor$ program1 municipality-sponsor$ program1 hospital indep5d5t p>tn]%ip 7hybrid7 program1 or indep5d5t program4 7iii7 ,:e!r su* s]vices 7 furni%$ 9 a rural or urban area4 7iv7 ,! type ( aircraft 7su* z rotor transport or fix$ w+ transport7 us$ to furni% su* s]vices4 7v7 ,:e!r ! provid] ( su* s]vices has a contract ) ! plan or issu]1 z applicable1 to furni% su* s]vices "u ! plan or cov]age1 respectively4 7,b7 ,su* o!r in=mation reg>d+ provid]s ( air ambulance s]vices z ! ,secret>y ( ,heal? & ,human ,s]vices may specify4 7c7 ,publication ( compreh5sive report 7#a7 ,9 g5]al ,n lat] ?an ! date t is "o ye> aft] ! date describ$ 9 subsection 7b77#a77;,b71 ! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) ! ,secret>y ( ,transportation 7ref]r$ to 9 ?is section z ! ,secret>ies71 %all develop1 & make publicly available 7subject to p>agraph 7#c771 a compreh5sive report summ>iz+ ! in=mation submitt$ "u subsections 7a7 & 7b7 & includ+ ea* ( ! foll[+3 7,a7 ,! p]c5tage ( provid]s ( air ambulance s]vices t are "p ( a hospital-own$ or sponsor$ program1 municipality-sponsor$ program1 hospital-indep5d5t p>tn]%ip 7hybrid7 program1 or indep5d5t program4 7,b7 ,an assessm5t ( ! ext5t ( competition among provid]s ( air ambulance s]vices on ! basis ( price & s]vices (f]$1 & any *anges 9 su* competition ov] "t4 7,c7 ,an assessm5t ( ! av]age *>ges = air ambulance s]vices1 am\nts paid by gr\p heal? plans & heal? insurance issu]s (f]+ heal? insurance cov]age 9 ! individual or gr\p m>ket to provid]s ( air ambulance s]vices = furni%+ su* s]vices1 & am\nts paid out-(-pocket by consum]s1 & any *anges 9 su* am\nts paid ov] "t4 7,d7 ,an assessm5t ( ! pres5ce ( air ambulance bases 91 or ) ! capability to s]ve1 rural areas1 & ! relative gr[? 9 air ambulance bases 9 rural & urban areas ov] "t4 7,e7 ,any evid5ce ( gaps 9 rural access to provid]s ( air ambulance s]vices4 7,f7 ,! p]c5tage ( provid]s ( air ambulance s]vices t h contracts ) gr\p heal? plans or heal? insurance issu]s (f]+ heal? insurance cov]age 9 ! individual or gr\p m>ket to furni% su* s]vices "u su* plans or cov]age1 respectively4 7,g7 ,an assessm5t ( :e!r !re are in/ances ( unfair1 deceptive1 or pr$atory practices by provid]s ( air ambulance s]vices 9 collect+ paym5ts f pati5ts to :om su* s]vices are furni%$1 su* z ref]ral ( su* pati5ts to collections1 lawsuits1 & li5s or wage g>ni%m5t actions4 7,h7 ,an assessm5t ( :e!r !re are in/ances ( gr\p heal? plans or heal? insurance issu]s n provid+ sub/antial reasons = refus+ to ent] into contract negotiations ) provid]s ( air ambulance s]vices4 7,i7 ,an assessm5t ( :e!r !re are1 )9 ! air ambulance indu/ry1 in/ances ( unreasonable indu/ry conc5tration1 excessive m>ket dom9ation1 or o!r conditions t w\ld all[ at lea/ "o provid] ( air ambulance s]vices to unreasonably increase prices or exclude competition 9 air ambulance s]vices 9 a giv5 geographic region4 7,j7 ,an assessm5t ( ! frequ5cy ( pati5t balance bill+1 pati5t ref]rals to collections1 lawsuits to collect balance bills1 & li5s or wage g>ni%m5t actions by provid]s ( air ambulance s]vices z "p ( a collections process across hospital-own$ or sponsor$ programs1 municipality-sponsor$ programs1 hospital-indep5d5t p>tn]%ip 7hybrid7 programs1 or indep5d5t programs1 provid]s ( air ambulance s]vices op]at$ by public ag5cies 7su* z a ,/ate or c\nty heal? dep>tm5t71 & o!r indep5d5t provid]s ( air ambulance s]vices4 7,k7 ,an assessm5t ( ! frequ5cy ( claims appeals made by provid]s ( air ambulance s]vices to gr\p heal? plans or heal? insurance issu]s (f]+ heal? insurance cov]age 9 ! individual or gr\p m>ket ) respect to air ambulance s]vices furni%$ to enrollees ( su* plans or cov]age1 respectively4 7,l7 ,any o!r co/1 quality1 or o!r data relat+ to air ambulance s]vices or ! air ambulance indu/ry1 z det]m9$ necess>y & appropriate by ! ,secret>ies4 7#b7 ,o!r s\rces ( in=mation ,! ,secret>ies may incorporate in=mation f indep5d5t exp]ts or ?ird-p>ty s\rces 9 develop+ ! compreh5sive report requir$ "u p>agraph 7#a74 7#c7 ,protection ( propriet>y in=mation ,! ,secret>ies may n make publicly available "u ?is subsection any propriet>y in=mation4 7d7 ,rulemak+ ,n lat] ?an ! date t is "o ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) ! ,secret>y ( ,transportation1 %all1 ?r\gh notice & comm5t rulemak+1 specify ! =m & mann] 9 :i* reports describ$ 9 subsections 7a7 & 7b7 %all be submitt$ to su* ,secret>ies1 tak+ into consid]ation 7z applicable & to ! ext5t feasible7 any recomm5dations includ$ 9 ! report submitt$ by ! ,advisory ,committee on ,air ,ambulance & ,pati5t ,bill+ "u section #dah7;e7 ( ! ,,faa ,reau?orization ,act ( #bjah 7,public ,law #aae-bed2 #di ,u4,s4,c4 #dbcja note prec474 7e7 ,civil money p5alties 7#a7 ,9 g5]al ,subject to p>agraph 7#b71 a provid] ( air ambulance s]vices :o fails to submit all in=mation requir$ "u subsection 7a77#b7 by ! date describ$ 9 subp>agraph 7,a7 or 7,b7 ( subsection 7a77#a71 z applicable1 %all be subject to a civil money p5alty ( n m ?an #aj1jjj4 7#b7 ,exception ,9 ! case ( a provid] ( air ambulance s]vices t submits only "s ( ! in=mation requir$ "u subsection 7a77#b7 by ! date describ$ 9 subp>agraph 7,a7 or 7,b7 ( subsection 7a77#a71 z applicable1 ! ,secret>y ( ,heal? & ,human ,s]vices may waive ! civil money p5alty impos$ "u p>agraph 7#a7 if su* provid] demon/rates a good fai? ef=t 9 work+ ) ! ,secret>y to submit ! rema9+ in=mation requir$ "u subsection 7a77#b74 7#c7 ,proc$ure ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;a-#g;a71 o!r ?an subsections 7a7 & 7b7 & ! fir/ s5t5ce ( subsection 7c77#a71 %all apply to civil money p5alties "u ?is subsection 9 ! same mann] z su* provisions apply to a p5alty or proce$+ "u su* section4 7f7 ,unfair & deceptive practices & unfair me?ods ( competition ,! ,secret>y ( ,transportation may use any in=mation submitt$ "u subsection 7a7 9 det]m9+ :e!r a provid] ( air ambulance s]vices has violat$ section #dagab7;a7 ( title #di1 ,unit$ ,/ates ,code4 7g7 ,und]/&+ air ambulance quality & pati5t safety ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct a /udy & submit to ,congress a report on options to e/abli% quality1 pati5t safety1 s]vice reliability1 & cl9ical capability /&>ds = ea* cl9ical capability level ( air ambulances4 ,su* report %all include analysis & recomm5dations1 z appropriate1 to ,congress reg>d+ ea* ( ! foll[+ ) respect to air ambulance s]vices3 7#a7 ,qualifications ( diff]5t cl9ical capability levels & ti]+ ( su* levels4 7#b7 ,pati5t safety & quality /&>ds4 7#c7 ,options = improv+ s]vice reliability dur+ poor wea!r1 night conditions1 or o!r adv]se conditions4 7#d7 ,diff]5ces betwe5 air ambulance vehicle types1 s]vices1 & te*nologies1 & o!r flight capability /&>ds1 & ! impact ( su* diff]5ces on pati5t safety4 7#e7 ,cl9ical triage crit]ia = air ambulances4 7h7 ,def9itions ,9 ?is section1 ! t]ms gr\p heal? plan1 heal? insurance cov]age1 & heal? insurance issu] h ! mean+s giv5 su* t]ms 9 section #bgia ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ia74 #aa4 ,,gao report on effects ( legislation ,n lat] ?an #b ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report summ>iz+ ! effects ( ! provisions ( ?is ,act1 includ+ ! am5dm5ts made by su* provisions1 on *anges dur+ su* p]iod 9 heal? c>e provid] networks ( gr\p heal? plans & heal? insurance cov]age (f]$ by a heal? insurance issu] 9 ! gr\p or individual m>ket1 9 fee s*$ules & am\nts = heal? c>e s]vices1 & to contract$ rates "u su* plans or cov]age4 ,su* report %all-- 7#a7 to ! ext5t practicable1 sample a /ati/ically significant gr\p ( national heal? c>e provid]s2 & 7#b7 exam9e-- 7,a7 provid] network p>ticipation1 includ+ nonp>ticipat+ provid]s furni%+ items & s]vices at p>ticipat+ facilities2 7,b7 heal? c>e provid] gr\p network p>ticipation1 includ+ specialty1 size1 & own]%ip2 & 7,c7 ! impact ( ,/ate surprise bill+ laws & network adequacy /&>ds on p>ticipation ( heal? c>e provid]s & facilities 9 provid] networks ( gr\p heal? plans & ( heal? insurance cov]age (f]$ by heal? insurance issu]s 9 ! gr\p or individual m>ket4 #ab4 ,transitional rule all[+ d$uction = surprise bill+ exp5ses bel[ ,,agi floor 7a7 ,9 g5]al ,section #bac ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subsection3 7g7 ,transitional rule all[+ d$uction = surprise bill+ exp5ses bel[ ,,agi floor 7#a7 ,9 g5]al ,9 addition to ! d$uction all[$ by subsection 7a7 = any taxable ye>1 !re %all be all[$ z a d$uction an am\nt equal to ! less] (-- 7,a7 ! excess (-- 7i7 ! surprise bill+ exp5ses :i* w\ld be all[$ z a d$uction = su* taxable ye> "u subsection 7a7 if su* subsection 7 appli$ )\t reg>d to ! limitation bas$ on ! taxpay]'s adju/$ gross income1 ov] 7ii7 #fjj1 or 7,b7 ! applicable p]c5tage ( ! taxpay]'s adju/$ gross income4 7#b7 ,surprise bill+ exp5ses ,= purposes ( ?is subsection1 ! t]m surprise bill+ exp5ses means exp5ses paid = m$ical c>e ( an individual :o is a p>ticipant1 b5efici>y1 or enrollee 9 a gr\p heal? plan or 9 gr\p or individual heal? insurance cov]age (f]$ by a heal? insurance issu] 7z su* t]ms are def9$ 9 section #bgia ( ! ,public ,heal? ,s]vice ,act71 if-- 7,a7 b5efits are provid$ = su* m$ical c>e "u su* plan or cov]age1 & 7,b7 su* m$ical c>e-- 7i7 is furni%$ by a provid] )\t a contractual relation%ip ) su* plan or cov]age ) respect to ! furni%+ ( su* m$ical c>e dur+ a visit at a facility ) a contractual relation%ip ) su* plan or cov]age1 or 7ii7 is furni%$ 9 an em]g5cy dep>tm5t ( a hospital or an indep5d5t free/&+ em]g5cy dep>tm5t4 7#c7 ,applicable p]c5tage ,= purposes ( ?is section1 ! t]m applicable p]c5tage means1 ) respect to any taxpay] = any taxable ye>1 ! p]c5tage 9 effect "u subsection 7a7 ) respect to su* taxpay] = su* taxable ye>4 7#d7 ,limitations ,surprise bill+ exp5ses %all be tak5 into acc\nt "u p>agraph 7#a7 only if su* exp5ses are paid dur+ ! p]iod beg9n+ on ,janu>y #a1 #bjbj1 & end+ on ! date :i* is #a ye> aft] ! day be=e ! date specifi$ 9 section #b7;a77#e7 ( ! ,consum] ,protections ,aga9/ ,surprise ,m$ical ,bills ,act ( #bjbj4 4 7b7 ,con=m+ am5dm5ts ,sections #aje7;f71 #afb7l77#c71 & #ggjb;,b7e77#b7 ( su* ,code are ea* am5d$ by /rik+ #bac7;a7 & ins]t+ #bac4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s end+ aft] ,decemb] #ca1 #bjai4