,i #aah? ,,congress #a/ ,session ,h4 ,r4 #dhbb ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,july #bd1 #bjbc,mr4 ,smi? ( ,miss\ri introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committees on ,ways & ,means1 ,education & ! ,work=ce1 & ! ,budget1 = 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 improve price transp>5cy ) respect to c]ta9 heal? c>e s]vices1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,heal? ,c>e ,price ,transp>5cy ,act ( #bjbc4 7b7 ,table ( ,cont5ts ,! table ( cont5ts = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4,title ,i--,heal? ,c>e ,price ,transp>5cy = ,patients,sec4 #aja4 ,requir+ c]ta9 facilities "u ! ,m$ic>e program to disclose c]ta9 in=mation relat+ to *>ges & prices4,sec4 #ajb4 ,promot+ gr\p heal? plan price transp>5cy4,sec4 #ajc4 ,ov]sight ( ph>macy b5efits manag] s]vices4,sec4 #ajd4 ,reports on heal? c>e transp>5cy tools & data requirem5ts4,sec4 #aje4 ,report on integration 9 ,m$ic>e4,title ,,ii--,fair ,prices = ,patients,sec4 #bja4 ,limitation on co/ %>+ to net price am\nt "u ,m$ic>e "p ,d4,sec4 #bjb4 ,requir+ a sep>ate id5tification numb] & an atte/ation = ea* (f-campus outpati5t dep>tm5t ( a provid]4,sec4 #bjc4 ,p>ity 9 ,m$ic>e paym5ts = hospital outpati5t dep>tm5t s]vices furni%$ (f-campus4,title ,,iii--,pati5t-,focus$ ,investments,sec4 #cja4 ,e/abli%+ requirem5ts ) respect to ! use ( prior au?orization "u ,m$ic>e ,advantage plans4,sec4 #cjb4 ,ext5sion ( c]ta9 direct sp5d+ r$uctions4 ,i ,heal? ,c>e ,price ,transp>5cy = ,pati5ts #aja4 ,requir+ c]ta9 facilities "u ! ,m$ic>e program to disclose c]ta9 in=mation relat+ to *>ges & prices 7a7 ,9 g5]al ,"p ,e ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #ahii;,c4 ,heal? c>e provid] price transp>5cy 7a7 ,hospital price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbf1 ea* specifi$ hospital 7z def9$ 9 p>agraph 7#f77 t receives paym5t "u ?is title = furni%+ items & s]vices %all comply ) ! price transp>5cy requirem5t describ$ 9 p>agraph 7#b74 7#b7 ,requirem5t describ$ 7,a7 ,9 g5]al ,= purposes ( p>agraph 7#a71 ! price transp>5cy requirem5t describ$ 9 ?is p>agraph is1 ) respect to a specifi$ hospital1 t su* hospital1 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u subp>agraph 7,c71 compile & make public 7)\t subscription & free ( *>ge7 = ea* ye>-- 7i7 "o or m li/s1 9 a =mat specifi$ by ! ,secret>y 7:i* may be a ma*9e-readable =mat71 ( ! hospital's /&>d *>ges 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = ea* item & s]vice furni%$ by su* hospital2 & 7ii7 in=mation 9 a consum]-fri5dly =mat 7z specifi$ by ! ,secret>y7-- 7,i7 on ! hospital's prices 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = z _m ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vices t are furni%$ by ! hospital1 & z _m additional hospital-select$ %oppable s]vices 7or all su* additional s]vices1 if su* hospital furni%es few] ?an #cjj %oppable s]vices7 z may be necess>y = a comb9$ total ( at lea/ #cjj %oppable s]vices2 & 7,,ii7 t includes1 ) respect to ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is n furni%$ by ! hospital1 an indication t su* s]vice is n s furni%$4 7,b7 ,in=mation describ$ ,= purposes ( subp>agraph 7,a71 ! in=mation describ$ 9 ?is subp>agraph is1 ) respect to /&>d *>ges & prices 7z applicable7 made public by a specifi$ hospital1 ! foll[+3 7i7 ,a description ( ea* item or s]vice1 accompani$ by1 z applicable1 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! diagnosis-relat$ gr\p1 ! national drug code1 or o!r id5tifi] us$ or approv$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 7ii7 ,! gross *>ge1 express$ z a doll> am\nt1 = ea* su* item or s]vice1 :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 7iii7 ,! disc\nt$ ca% price1 express$ z a doll> am\nt1 = ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+ 7or1 9 ! case no disc\nt$ ca% price is available = an item or s]vice1 ! m$ian price *>g$ by ! hospital = su* item or s]vice :5 provid$ 9 su* sett+s = ! previ\s ?ree ye>s1 express$ z a doll> am\nt74 7iv7 ,any o!r in=mation ! ,secret>y may require = purposes ( promot+ public aw>5ess ( specifi$ hospital /&>d *>ges or prices 9 advance ( receiv+ an item or s]vice f su* a hospital1 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is section4 ,su* in=mation may include any curr5t pay]-specific negotiat$ *>ges1 cle>ly associat$ ) ! "n ( ! ?ird p>ty pay] & plan & express$ z a doll> am\nt1 t apply to ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 7,c7 ,me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbf1 ! ,secret>y %all e/abli% "o or m me?ods & =mats = specifi$ facilities to use 9 compil+ & mak+ public /&>d *>ges & prices 7z applicable7 pursuant to subp>agraph 7,a74 ,any su* me?od & =mat-- 7i7 may be simil> to any template made available by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices z ( ! date ( ! enactm5t ( ?is subp>agraph2 7ii7 %all meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges & prices2 & 7iii7 %all be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#c7 ,deem$ compliance ) %oppable s]vices requirem5t = hospitals ) a price e/imator tool 7,a7 ,9 g5]al ,) respect to ea* ye> until ! effective date ( regulations implem5t+ ! provisions ( sections #bgii;,a-#a7;f7 & #bgii;,b-#f ( ! ,public ,heal? ,s]vice ,act 7relat+ to advanc$ explanations ( b5efits71 includ+ regulations on e/abli%+ data transf] /&>ds to effectuate su* provisions1 a specifi$ hospital %all be deem$ to h compli$ ) ! requirem5t describ$ 9 p>agraph 7#b77;,a77ii77,i7 7relat+ to %oppable s]vices7 if su* hospital ma9ta9s a price e/imator tool describ$ 9 subp>agraph 7,b74 7,b7 ,price e/imator tool describ$ ,= purposes ( subp>agraph 7,a71 ! price e/imator tool describ$ 9 ?is subp>agraph is1 ) respect to a specifi$ hospital1 a tool t meets ! foll[+ requirem5ts3 7i7 ,su* tool all[s an individual to imm$iately obta9 a price e/imate 7tak+ into acc\nt :e!r su* individual is cov]$ "u any plan1 cov]age1 or program describ$ 9 clause 7iv77,,iii77 & ! disc\nt$ ca% price *>g$ by a specifi$ hospital1 = ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is furni%$ by su* hospital1 & = ea* additional %oppable s]vice z su* hospital may select1 su* t price e/imates are available ?r\gh su* tool = at lea/ #cjj %oppable s]vices 7or = all su* s]vices1 if su* hospital furni%es few] ?an #cjj %oppable s]vices74 7ii7 ,su* tool all[s an individual to obta9 su* an e/imate by bill+ code & by s]vice description4 7iii7 ,su* tool is prom95tly display$ on ! public int]net website ( su* hospital4 7iv7 ,su* tool does n require an individual seek+ su* an e/imate to create an acc\nt or o!rwise input p]sonal in=mation1 except t su* tool may require t su* individual provide in=mation specifi$ by ! ,secret>y1 :i* may include ! foll[+3 7,i7 ,! "n ( su* individual4 7,,ii7 ,! date ( bir? ( su* individual4 7,,iii7 ,9 ! case su* individual is cov]$ "u a gr\p heal? plan1 gr\p or individual heal? insurance cov]age1 a ,f$]al heal? c>e program1 or ! program e/abli%$ "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code1 an id5tify+ numb] assign$ by su* plan1 cov]age1 or program to su* individual4 7,,iv7 ,9 ! case ( an individual describ$ 9 subclause 7,,iii71 an indication z to :e!r su* individual is ! prim>y insur$ individual "u su* plan1 cov]age1 or program 7&1 if su* individual is n ! prim>y insur$ individual1 a description ( ! individual's relation%ip to su* prim>y insur$ individual74 7,v7 ,any o!r in=mation specifi$ by ! ,secret>y4 7v7 ,su* tool conta9s a /atem5t confirm+ ! accuracy & complet5ess ( in=mation pres5t$ ?r\gh su* tool z ( ! date su* reque/ is made4 7vi7 ,su* tool meets any o!r requirem5t specifi$ by ! ,secret>y4 7#d7 ,monitor+ compliance ,! ,secret>y %all1 ?r\gh notice & comm5t rulemak+ & 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 e/abli% a process to monitor compliance ) ?is subsection4 ,su* process %all ensure t ea* specifi$ hospital's compliance ) ?is subsection is review$ n less frequ5tly ?an once e #c ye>s4 7#e7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( a specifi$ hospital t fails to comply ) ! requirem5ts ( ?is subsection-- 7i7 ! ,secret>y %all notify su* hospital ( su* failure n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s2 & 7ii7 ^u reque/ ( ! ,secret>y1 ! hospital %all submit to ! ,secret>y1 n lat] ?an #de days aft] ! date ( su* reque/1 a corrective action plan to comply ) su* requirem5ts4 7,b7 ,civil monet>y p5alty 7i7 ,9 g5]al ,9 addition to any o!r en=cem5t actions or p5alties t may apply "u ano!r provision ( law1 a specifi$ hospital t has receiv$ a notification "u subp>agraph 7,a77i7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* notification 7or1 9 ! case ( su* a hospital t has submitt$ a corrective action plan describ$ 9 subp>agraph 7,a77ii7 9 response to a reque/ s describ$1 by ! date t is #ij days aft] ! ,secret>y id5tifies ! failure ( su* hospital to satisfactorily complete su* corrective action plan7 %all be subject to a civil monet>y p5alty ( an am\nt specifi$ by ! ,secret>y = ea* subsequ5t day dur+ :i* su* failure is ongo+4 ,su* am\nt %all n exce$-- 7,i7 9 ! case ( a specifi$ hospital t is a hospital or critical access hospital ) #cj or few] b$s1 #cjj p] day2 & 7,,ii7 9 ! case ( any specifi$ hospital & except z provid$ 9 clause 7iii71 #b1jjj1jjj = a #a-ye> p]iod4 7ii7 ,increase au?ority ,9 apply+ ?is subp>agraph ) respect to violations occurr+ 9 #bjbg or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase-- 7,i7 ! limitation on ! p] day am\nt ( any p5alty applicable to a specifi$ hospital t is a hospital or critical access hospital ) #cj or few] b$s "u clause 7i77,i72 7,,ii7 ! limitation on ! am\nt ( any p5alty applicable = a #a-ye> p]iod "u clause 7i77,,ii72 & 7,,iii7 ! limitation on ! increase ( any p5alty appli$ "u clause 7iii74 7iii7 ,p]si/5t noncompliance ,9 ! case ( a specifi$ hospital 7o!r ?an a specifi$ hospital t is a hospital or critical access hospital ) #cj or few] b$s7 t ! ,secret>y has det]m9$ to be kn[+ly & willfully noncompliant ) ! provisions ( ?is subsection two or m times dur+ a #a-ye> p]iod1 ! ,secret>y may increase any p5alty o!rwise applicable "u ?is subp>agraph by n m ?an #a1jjj1jjj & may require su* hospital to complete su* additional corrective actions plans z ! ,secret>y may specify4 7iv7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is subp>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7v7 ,au?ority to waive or r$uce p5alty ,! ,secret>y may waive or r$uce any p5alty o!rwise applicable ) respect to a specifi$ hospital "u ?is subp>agraph if ! ,secret>y det]m9es t imposition ( su* p5alty w\ld result 9 a significant h>d%ip = su* hospital 7su* z 9 ! case ( a hospital locat$ 9 a rural or und]s]v$ area :]e imposition ( su* p5alty may result 91 or contribute to1 a lack ( access to c>e = individuals 9 su* area74 7,c7 ,publication ( hospital price transp>5cy in=mation ,beg9n+ on ,janu>y #a1 #bjbf1 ! ,secret>y %all make publicly available on ! public website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices in=mation ) respect to compliance ) ! requirem5ts ( ?is subsection & en=cem5t activities und]tak5 by ! ,secret>y "u ?is subsection4 ,su* in=mation %all be updat$ n less ?an annually & include1 ) respect to ea* ye>-- 7i7 ! numb] ( reviews ( compliance ) ?is subsection und]tak5 by ! ,secret>y2 7ii7 ! numb] ( notifications describ$ 9 subp>agraph 7,a77i7 s5t by ! ,secret>y2 7iii7 ! id5tify ( ea* specifi$ hospital t 0 s5t su* a notification & a description ( ! nature ( su* hospital's noncompliance ) ?is subsection2 7iv7 ! am\nt ( any civil monet>y p5alty impos$ on su* hospital "u subp>agraph 7,b72 7v7 :e!r su* hospital subsequ5tly came into compliance ) ?is subsection2 & 7vi7 any o!r in=mation z det]m9$ by ! ,secret>y4 7#f7 ,def9itions ,= purposes ( ?is subsection3 7,a7 ,disc\nt$ ca% price ,! t]m disc\nt$ ca% price means ! *>ge t applies to an individual :o pays ca%1 or ca% equival5t1 = a specifi$ hospital-furni%$ item or s]vice4 7,b7 ,f$]al heal? c>e program ,! t]m ,f$]al heal? c>e program has ! mean+ giv5 su* t]m 9 section #aabh;,b4 7,c7 ,gross *>ge ,! t]m gross *>ge means ! *>ge = an individual item or s]vice t is reflect$ on a specifi$ hospital's *>gema/]1 abs5t any disc\nts4 7,d7 ,gr\p heal? plan2 gr\p heal? insurance cov]age2 individual heal? insurance cov]age ,! t]ms gr\p heal? plan1 gr\p heal? insurance cov]age1 & individual heal? insurance cov]age h ! mean+ giv5 su* t]ms 9 section #bgia ( ! ,public ,heal? ,s]vice ,act4 7,e7 ,pay]-specific negotiat$ *>ge ,! t]m pay]-specific negotiat$ *>ge means ! *>ge t a specifi$ hospital has negotiat$ ) a ?ird p>ty pay] = an item or s]vice4 7,f7 ,%oppable s]vice ,! t]m %oppable s]vice means a s]vice t c be s*$ul$ by a heal? c>e consum] 9 advance & includes all ancill>y items & s]vices cu/om>ily furni%$ z "p ( su* s]vice4 7,g7 ,specifi$ hospital ,! t]m specifi$ hospital means a hospital 7z def9$ 9 section #ahfa7;e771 a critical access hospital 7z def9$ 9 section #ahfa7mmm77#a771 or a rural em]g5cy hospital 7z def9$ 9 section #ahfa7kkk774 7,h7 ,?ird p>ty pay] ,! t]m ?ird p>ty pay] means an entity t is1 by /atute1 contract1 or agreem5t1 legally responsible = paym5t ( a claim = a heal? c>e item or s]vice4 7b7 ,ambulatory surgical c5t] price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbh1 ea* ambulatory surgical c5t] t receives paym5t "u ?is title = furni%+ items & s]vices %all comply ) ! price transp>5cy requirem5t describ$ 9 p>agraph 7#b74 7#b7 ,requirem5t describ$ 7,a7 ,9 g5]al ,= purposes ( p>agraph 7#a71 ! price transp>5cy requirem5t describ$ 9 ?is subsection is1 ) respect to an ambulatory surgical c5t]1 t su* surgical c5t] 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u subp>agraph 7,c771 compile & make public 7)\t subscription & free ( *>ge71 = ea* ye>-- 7i7 "o or m li/s1 9 a =mat specifi$ by ! ,secret>y1 ( ! ambulatory surgical c5t]'s /&>d *>ges 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = ea* item & s]vice furni%$ by su* surgical c5t]2 7ii7 in=mation on ! ambulatory surgical c5t]'s prices 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = z _m ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vices t are furni%$ by su* surgical c5t]1 & z _m additional ambulatory surgical c5t]-select$ %oppable s]vices 7or all su* additional s]vices1 if su* surgical c5t] furni%es few] ?an #cjj %oppable s]vices7 z may be necess>y = a comb9$ total ( at lea/ #cjj %oppable s]vices2 7iii7 ) respect to ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is n furni%$ by ! ambulatory surgical c5t]1 an indication t su* s]vice is n s furni%$2 & 7iv7 any additional in=mation specifi$ by ! ,secret>y4 7,b7 ,in=mation describ$ ,= purposes ( subp>agraph 7,a71 ! in=mation describ$ 9 ?is subp>agraph is1 ) respect to /&>d *>ges & prices 7z applicable7 made public by an ambulatory surgical c5t]1 ! foll[+3 7i7 ,a description ( ea* item or s]vice1 accompani$ by1 z applicable1 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! diagnosis-relat$ gr\p1 ! national drug code1 or o!r id5tifi] us$ or approv$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 7ii7 ,! gross *>ge1 express$ z a doll> am\nt1 = ea* su* item or s]vice4 7iii7 ,! disc\nt$ ca% price1 express$ z a doll> am\nt1 = ea* su* item or s]vice 7or1 9 ! case no disc\nt$ ca% price is available = an item or s]vice1 ! gross *>ge = su* item or s]vice = ! previ\s ?ree ye>s1 express$ z a doll> am\nt74 7iv7 ,any o!r in=mation ! ,secret>y may require t is n duplicative ( any o!r report+ requirem5t "u ?is subsection = purposes ( promot+ public aw>5ess ( ambulatory surgical c5t] prices 9 advance ( receiv+ an item or s]vice f su* an ambulatory surgical c5t]1 :i* may include any curr5t pay]-specific negotiat$ *>ges1 cle>ly associat$ ) ! "n ( ! ?ird p>ty pay] & plan & express$ z a doll> am\nt1 t applies to ea* su* item or s]vice4 7,c7 ,me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbh1 ! ,secret>y %all e/abli% "o or m me?ods & =mats = ambulatory surgical c5t]s to use 9 mak+ public /&>d *>ges & prices 7z applicable7 pursuant to subp>agraph 7,a74 ,any su* me?od & =mat-- 7i7 may be simil> to any template made available by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices z ( ! date ( ! enactm5t ( ?is p>agraph2 7ii7 %all meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges & prices2 & 7iii7 %all be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#c7 ,deem$ compliance ) %oppable s]vices requirem5t = ambulatory surgical c5t]s ) a price e/imator tool 7,a7 ,9 g5]al ,an ambulatory surgical c5t] %all be deem$ to h compli$ ) ! requirem5t describ$ 9 subsection 7b77#b77;,a7 7relat+ to %oppable s]vices7 if su* surgical c5t] ma9ta9s a price e/imator tool describ$ 9 subp>agraph 7,b74 7,b7 ,price e/imator tool describ$ ,= purposes ( subp>agraph 7,a71 ! price e/imator tool describ$ 9 ?is subp>agraph is1 ) respect to an ambulatory surgical c5t]1 a tool t meets ! foll[+ requirem5ts3 7i7 ,su* tool all[s an individual to imm$iately obta9 a price e/imate 7tak+ into acc\nt :e!r su* individual is cov]$ "u any plan1 cov]age1 or program describ$ 9 clause 7iv77,,iii77 = ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is furni%$ by su* surgical c5t]1 & = ea* additional %oppable s]vice z su* surgical c5t] may select1 su* t price e/imates are available ?r\gh su* tool = at lea/ #cjj %oppable s]vices 7or = all su* s]vices1 if su* surgical c5t] furni%es few] ?an #cjj %oppable s]vices74 7ii7 ,su* tool all[s an individual to obta9 su* an e/imate by bill+ code & by s]vice description4 7iii7 ,su* tool is prom95tly display$ on ! public int]net website ( su* ambulatory surgical c5t]4 7iv7 ,su* tool does n require an individual seek+ su* an e/imate to create an acc\nt or o!rwise input p]sonal in=mation1 except t su* tool may require t su* individual provide in=mation specifi$ by ! ,secret>y1 :i* may include ! foll[+3 7,i7 ,! "n ( su* individual4 7,,ii7 ,! date ( bir? ( su* individual4 7,,iii7 ,9 ! case su* individual is cov]$ "u a gr\p heal? plan1 gr\p or individual heal? insurance cov]age1 a ,f$]al heal? c>e program1 or ! program e/abli%$ "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code1 an id5tify+ numb] assign$ by su* plan1 cov]age1 or program to su* individual4 7,,iv7 ,9 ! case ( an individual describ$ 9 subclause 7,,iii71 an indication z to :e!r su* individual is ! prim>y insur$ individual "u su* plan1 cov]age1 or program 7&1 if su* individual is n ! prim>y insur$ individual1 a description ( ! individual's relation%ip to su* prim>y insur$ individual74 7,v7 ,any o!r in=mation specifi$ by ! ,secret>y4 7v7 ,su* tool conta9s a /atem5t confirm+ ! accuracy & complet5ess ( in=mation pres5t$ ?r\gh su* tool z ( ! date su* reque/ is made4 7vi7 ,su* tool meets any o!r requirem5t specifi$ by ! ,secret>y4 7#d7 ,monitor+ compliance ,! ,secret>y %all1 ?r\gh notice & comm5t rulemak+ & 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 e/abli% a process to monitor compliance ) ?is subsection4 ,su* process %all ensure t ea* ambulatory surgical c5t]'s compliance ) ?is subsection is review$ n less frequ5tly ?an once e #c ye>s4 7#e7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( an ambulatory surgical c5t] t fails to comply ) ! requirem5ts ( ?is subsection-- 7i7 ! ,secret>y %all notify su* ambulatory surgical c5t] ( su* failure n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s2 & 7ii7 ^u reque/ ( ! ,secret>y1 ! ambulatory surgical c5t] %all submit to ! ,secret>y1 n lat] ?an #de days aft] ! date ( su* reque/1 a corrective action plan to comply ) su* requirem5ts4 7,b7 ,civil monet>y p5alty 7i7 ,9 g5]al ,9 addition to any o!r en=cem5t actions or p5alties t may apply "u ano!r provision ( law1 an ambulatory surgical c5t] t has receiv$ a notification "u subp>agraph 7,a77i7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* notification 7or1 9 ! case ( an ambulatory surgical c5t] t has submitt$ a corrective action plan describ$ 9 subp>agraph 7,a77ii7 9 response to a reque/ s describ$1 by ! date t is #ij days aft] su* submission7 %all be subject to a civil monet>y p5alty ( an am\nt specifi$ by ! ,secret>y = ea* subsequ5t day dur+ :i* su* failure is ongo+ 7n to exce$ #cjj p] day74 7ii7 ,increase au?ority ,9 apply+ ?is subp>agraph ) respect to violations occurr+ 9 #bjbg or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! limitation on ! p] day am\nt ( any p5alty applicable to an ambulatory surgical c5t] "u clause 7i74 7iii7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is subp>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7iv7 ,au?ority to waive or r$uce p5alty ,! ,secret>y may waive or r$uce any p5alty o!rwise applicable ) respect to an ambulatory surgical c5t] "u ?is subp>agraph if ! ,secret>y det]m9es t imposition ( su* p5alty w\ld result 9 a significant h>d%ip = su* ambulatory surgical c5t] 7su* z 9 ! case ( an ambulatory surgical c5t] locat$ 9 a rural or und]s]v$ area :]e imposition ( su* p5alty may result 91 or contribute to1 a lack ( access to c>e = individuals 9 su* area74 7#f7 ,def9itions ,= purposes ( ?is section3 7,a7 ,disc\nt$ ca% price ,! t]m disc\nt$ ca% price means ! *>ge t applies to an individual :o pays ca%1 or ca% equival5t1 = a item or s]vice furni%$ by an ambulatory surgical c5t]4 7,b7 ,f$]al heal? c>e program ,! t]m ,f$]al heal? c>e program has ! mean+ giv5 su* t]m 9 section #aabh;,b4 7,c7 ,gross *>ge ,! t]m gross *>ge means ! *>ge = an individual item or s]vice t is reflect$ on a specifi$ surgical c5t]'s *>gema/]1 abs5t any disc\nts4 7,d7 ,gr\p heal? plan2 gr\p heal? insurance cov]age2 individual heal? insurance cov]age ,! t]ms gr\p heal? plan1 gr\p heal? insurance cov]age1 & individual heal? insurance cov]age h ! mean+ giv5 su* t]ms 9 section #bgia ( ! ,public ,heal? ,s]vice ,act4 7,e7 ,pay]-specific negotiat$ *>ge ,! t]m pay]-specific negotiat$ *>ge means ! *>ge t a specifi$ surgical c5t] has negotiat$ ) a ?ird p>ty pay] = an item or s]vice4 7,f7 ,%oppable s]vice ,! t]m %oppable s]vice means a s]vice t c be s*$ul$ by a heal? c>e consum] 9 advance & includes all ancill>y items & s]vices cu/om>ily furni%$ z "p ( su* s]vice4 7,g7 ,?ird p>ty pay] ,! t]m ?ird p>ty pay] means an entity t is1 by /atute1 contract1 or agreem5t1 legally responsible = paym5t ( a claim = a heal? c>e item or s]vice4 7c7 ,imag+ s]vices price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbe1 ea* provid] ( s]vices & suppli] t receives paym5t "u ?is title = furni%+ a specifi$ imag+ s]vice %all-- 7,a7 make publicly available 79 a =m & mann] specifi$ by ! ,secret>y7 on an ,int]net website ! in=mation describ$ 9 p>agraph 7#b7 ) respect to ea* su* s]vice t su* provid] ( s]vices or suppli] furni%es2 & 7,b7 ensure t su* in=mation is updat$ n less frequ5tly ?an annually4 7#b7 ,in=mation describ$ ,= purposes ( p>agraph 7#a71 ! in=mation describ$ 9 ?is subsection is1 ) respect to a provid] ( s]vices or suppli] & a specifi$ imag+ s]vice1 ! foll[+3 7,a7 ,! disc\nt$ ca% price = su* s]vice 7or1 if no su* price exi/s1 ! gross *>ge = su* s]vice74 7,b7 ,if requir$ by ! ,secret>y1 ! deid5tifi$ m9imum negotiat$ rate 9 effect betwe5 su* provid] or suppli] & any gr\p heal? plan or gr\p or individual heal? insurance cov]age = su* s]vice & ! deid5tifi$ maximum negotiat$ rate 9 effect betwe5 su* provid] or suppli] & any su* plan or cov]age = su* s]vice4 7#c7 ,me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbh1 ! ,secret>y %all e/abli% "o or m me?ods & =mats = ea* provid] ( s]vices & suppli] to use 9 compil+ & mak+ public /&>d *>ges & prices 7z applicable7 pursuant to p>agraph 7#a74 ,any su* me?od & =mat-- 7,a7 may be simil> to any template made available by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices z ( ! date ( ! enactm5t ( ?is subsection2 7,b7 %all meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges & prices2 & 7,c7 %all be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#d7 ,monitor+ compliance ,! ,secret>y %all1 ?r\gh notice & comm5t rulemak+ & 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 e/abli% a process to monitor compliance ) ?is subsection4 7#e7 ,specification ( s]vices ,n lat] ?an ,janu>y #a1 #bjbe1 ! ,secret>y %all publi% a li/ ( at lea/ #ej imag+ s]vices t ! ,secret>y det]m9es are %oppable 7or all su* s]vices1 if ! ,secret>y det]m9es t few] ?an #ej su* s]vices are %oppable7 betwe5 provid]s ( s]vices & suppli]s ( su* s]vices4 ,! ,secret>y %all update su* li/ z det]m9$ appropriate by ! ,secret>y4 7#f7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case t ! ,secret>y det]m9es t a provid] ( s]vices or suppli] is n 9 compliance ) p>agraph 7#a7-- 7i7 n lat] ?an #cj days aft] su* det]m9ation1 ! ,secret>y %all notify su* provid] or suppli] ( su* det]m9ation2 7ii7 ^u reque/ ( ! ,secret>y1 su* provid] or suppli] %all submit to ! ,secret>y1 n lat] ?an #de days aft] ! date ( su* reque/1 a corrective action plan to comply ) su* p>agraph2 & 7iii7 if su* provid] or suppli] cont9ues to fail to comply ) su* p>agraph aft] ! date t is #ij days aft] su* notification is s5t 7or1 9 ! case ( su* a provid] or suppli] t has submitt$ a corrective action plan describ$ 9 clause 7ii7 9 response to a reque/ s describ$1 aft] ! date t is #ij days aft] su* submission71 ! ,secret>y may impose a civil monet>y p5alty 9 an am\nt n to exce$ #cjj = ea* subsequ5t day dur+ :i* su* failure to comply or failure to submit is ongo+4 7,b7 ,increase au?ority ,9 apply+ ?is p>agraph ) respect to violations occurr+ 9 #bjbg or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! am\nt ( ! civil monet>y p5alty "u subp>agraph 7,a77iii74 7,c7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is p>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7,d7 ,au?ority to waive or r$uce p5alty ,! ,secret>y may waive or r$uce any p5alty o!rwise applicable ) respect to a provid] ( s]vices or suppli] "u ?is subp>agraph if ! ,secret>y det]m9es t imposition ( su* p5alty w\ld result 9 a significant h>d%ip = su* provid] or suppli] 7su* z 9 ! case ( a provid] or suppli] locat$ 9 a rural or und]s]v$ area :]e imposition ( su* p5alty may result 91 or contribute to1 a lack ( access to c>e = individuals 9 su* area74 7,e7 ,cl>ification ( nonapplicability ( o!r en=cem5t provisions ,not)/&+ any o!r provision ( ?is title1 ?is p>agraph %all be ! sole means ( en=c+ ! provisions ( ?is subsection4 7#g7 ,def9itions ,9 ?is subsection3 7,a7 ,gr\p heal? plan2 gr\p heal? insurance cov]age2 individual heal? insurance cov]age ,! t]ms gr\p heal? plan1 gr\p heal? insurance cov]age1 & individual heal? insurance cov]age h ! mean+ giv5 su* t]ms 9 section #bgia ( ! ,public ,heal? ,s]vice ,act4 7,b7 ,specifi$ imag+ s]vice ! t]m specifi$ imag+ s]vice means an imag+ s]vice t is includ$ on ! li/ publi%$ by ! ,secret>y "u subsection 7e74 7d7 ,cl9ical laboratory price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbe1 ea* applicable laboratory t receives paym5t "u ?is title = furni%+ a specifi$ cl9ical diagno/ic laboratory te/ %all-- 7,a7 make publicly available 79 a mann] & =m specifi$ by ! ,secret>y7 on an ,int]net website ! in=mation describ$ 9 p>agraph 7#b7 ) respect to ea* su* specifi$ cl9ical diagno/ic laboratory te/ t su* laboratory is s available to furni%2 & 7,b7 ensure t su* in=mation is updat$ n less frequ5tly ?an annually4 7#b7 ,in=mation describ$ ,= purposes ( p>agraph 7#a71 ! in=mation describ$ 9 ?is subsection is1 ) respect to an applicable laboratory & a specifi$ cl9ical diagno/ic laboratory te/1 ! foll[+3 7,a7 ,! disc\nt$ ca% price = su* te/ 7or1 if no su* price exi/s1 ! gross *>ge = su* te/74 7,b7 ,if requir$ by ! ,secret>y1 ! deid5tifi$ m9imum negotiat$ rate 9 effect betwe5 su* laboratory & any gr\p heal? plan or gr\p or individual heal? insurance cov]age = su* te/ & ! deid5tifi$ maximum negotiat$ rate 9 effect betwe5 su* laboratory & any su* plan or cov]age = su* te/4 7#c7 ,me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbh1 ! ,secret>y %all e/abli% "o or m me?ods & =mats = ea* provid] ( s]vices & suppli] to use 9 compil+ & mak+ public /&>d *>ges & prices 7z applicable7 pursuant to p>agraph 7#a74 ,any su* me?od & =mat-- 7,a7 may be simil> to any template made available by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices z ( ! date ( ! enactm5t ( ?is subsection2 7,b7 %all meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges & prices2 & 7,c7 %all be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#d7 ,monitor+ compliance ,! ,secret>y %all1 ?r\gh notice & comm5t rulemak+ & 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 e/abli% a process to monitor compliance ) ?is subsection4 7#e7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case t ! ,secret>y det]m9es t an applicable laboratory is n 9 compliance ) p>agraph 7#a7-- 7i7 n lat] ?an #cj days aft] su* det]m9ation1 ! ,secret>y %all notify su* laboratory ( su* det]m9ation2 7ii7 ^u reque/ ( ! ,secret>y1 su* laboratory %all submit to ! ,secret>y1 n lat] ?an #de days aft] su* reque/ is s5t1 a corrective action plan to comply ) su* subsection2 & 7iii7 if su* laboratory cont9ues to fail to comply ) su* p>agraph aft] ! date t is #ij days aft] su* notification is s5t 7or1 9 ! case ( su* a laboratory t has submitt$ a corrective action plan describ$ 9 clause7ii7 9 response to a reque/ s describ$1 aft] ! date t is #ij days aft] su* submission71 ! ,secret>y may impose a civil monet>y p5alty 9 an am\nt n to exce$ #cjj = ea* subsequ5t day dur+ :i* su* failure to comply is ongo+4 7,b7 ,increase au?ority ,9 apply+ ?is p>agraph ) respect to violations occurr+ 9 #bjbg or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! am\nt ( ! civil monet>y p5alty "u subp>agraph 7,a77iii74 7,c7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is p>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7,d7 ,au?ority to waive or r$uce p5alty ,! ,secret>y may waive or r$uce any p5alty o!rwise applicable ) respect to an applicable laboratory "u ?is p>agraph if ! ,secret>y det]m9es t imposition ( su* p5alty w\ld result 9 a significant h>d%ip = su* laboratory 7su* z 9 ! case ( an applicable laboratory locat$ 9 a rural or und]s]v$ area :]e imposition ( su* p5alty may result 91 or contribute to1 a lack ( access to c>e = individuals 9 su* area74 7,e7 ,cl>ification ( nonapplicability ( o!r en=cem5t provisions ,not)/&+ any o!r provision ( ?is title1 ?is subsection %all be ! sole means ( en=c+ ! provisions ( ?is section4 7#f7 ,def9itions ,9 ?is subsection3 7,a7 ,applicable laboratory ,! t]m applicable laboratory has ! mean+ giv5 su* t]m 9 section #dad4ejb1 ( title #db1 ,code ( ,f$]al ,regulations 7or any successor regulation74 7,b7 ,gr\p heal? plan2 gr\p heal? insurance cov]age2 individual heal? insurance cov]age ,! t]ms gr\p heal? plan1 gr\p heal? insurance cov]age1 & individual heal? insurance cov]age h ! mean+ giv5 su* t]ms 9 section #bgia ( ! ,public ,heal? ,s]vice ,act4 7,c7 ,specifi$ cl9ical diagno/ic laboratory te/ ,! t]m specifi$ cl9ical diagno/ic laboratory te/ means a cl9ical diagno/ic laboratory te/ t is includ$ on ! li/ ( %oppable s]vices specifi$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices pursuant to section #ahj4fj ( title #de1 ,code ( ,f$]al ,regulations 7or a successor regulation71 o!r ?an su* a te/ t is an advanc$ diagno/ic laboratory te/ 7z def9$ 9 section #ahcd;,a7d77#e774 4 7b7 ,publication ( hospital compliance ) price transp>5cy requirem5ts ,section #ahhf ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7u7 ,publication ( hospital compliance ) price transp>5cy requirem5ts 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbf1 ! ,secret>y %all1 = ea* hospital ) respect to :i* ! ,secret>y has conduct$ a review ( su* hospital's compliance ) ! provisions ( section #ahii;,c7a7 & f\nd su* hospital noncompliant ) su* provisions-- 7,a7 indicate su* noncompliance on su* hospital's entry on ! ,hospital ,comp>e int]net website 7or a successor website72 & 7,b7 specify :e!r su* hospital-- 7i7 submitt$ a corrective action plan describ$ 9 subsection 7a77#e77;,a77ii7 ( su* section 7&1 if s1 ! date su* plan 0 receiv$ by ! ,secret>y72 or 7ii7 0 subject to a civil monet>y p5alty impos$ "u subsection 7a77#e77;,b7 ( su* section 7&1 if s1 ! date ( ! imposition ( su* p5alty & ! am\nt ( su* p5alty74 7#b7 ,additions & updates ,! ,secret>y %all update any specification describ$ 9 subp>agraph 7,a7 or 7,b7 ( p>agraph 7#a7 ) respect to su* hospital-- 7,a7 9 ! case ( ! specification describ$ 9 su* p>agraph 7#a77;,a71 z soon z practicable aft] s5d+ ! notification describ$ 9 section #ahii;,c7a77#e77;,a77i72 & 7,b7 9 ! case ( ! specification describ$ 9 su* p>agraph 7#a77;,b77ii71 z soon z practicable aft] ! imposition ( a civil monet>y p5alty describ$ 9 su* p>agraph4 4 7c7 ,con=m+ am5dm5t ,section #bgah7;e7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7;e77 is am5d$ by add+ at ! end ! foll[+ new s5t5ce3 ,! prec$+ s5t5ce %all n apply beg9n+ ,janu>y #a1 #bjbf44 7d7 ,fund+ 7#a7 ,9 g5]al ,9 addition to funds o!rwise available1 out ( any moneys 9 ! ,treasury n o!rwise appropriat$1 !re are appropriat$ #aj1jjj1jjj = fiscal ye> #bjbd1 to rema9 available until exp5d$1 = purposes (-- 7,a7 implem5t+ ! am5dm5t made by ?is subsection 7a72 & 7,b7 monitor+ ! compliance ( entities ) su* am5dm5t4 7#b7 ,report on exp5ditures ,n lat] ?an #e ye>s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all submit to ! ,committee on ,ways & ,means & ! ,committee on ,en]gy & ,comm]ce ( ! ,h\se ( ,repres5tatives & ! ,committee on ,f9ance ( ! ,s5ate a report t-- 7,a7 describes activities und]tak5 fund$ ?r\gh funds made available "u p>agraph 7#a71 includ+ a specification ( ! am\nt ( su* funds exp5d$ = ea* su* activity2 & 7,b7 id5tifies all entities ) :i* ! ,secret>y has ent]$ into contracts = purposes ( implem5t+ ! am5dm5t made by ?is subsection 7a71 monitor+ compliance ( entities ) su* am5dm5t1 or provid+ te*nical assi/ance to entities to promote compliance ) su* am5dm5t4 7e7 ,implem5tation 7#a7 ,accessibility ,9 implem5t+ section #ahii;,c7a77#b77;,a77ii7 ( ! ,social ,security ,act 7z add$ by subsection 7a771 ! ,secret>y ( ,heal? & ,human ,s]vices %all ?r\gh rulemak+ ensure t in=mation made available pursuant to su* am5dm5t by an entity is s made available 9 pla91 easily und]/&able language & t su* entity provides access to su* int]pretation s]vices1 translations1 & o!r assi/ive s]vices to make su* in=mation accessible to individuals ) limit$ ,engli% pr(ici5cy & individuals ) disabilities4 7#b7 ,te*nical assi/ance ,! ,secret>y ( ,heal? & ,human ,s]vices %all1 to ! ext5t practicable1 provide te*nical assi/ance to entities mak+ public /&>d *>ges & prices 7z applicable7 pursuant to ! am5dm5t made by subsection 7a74 #ajb4 ,promot+ gr\p heal? plan price transp>5cy 7a7 ,price transp>5cy requirem5ts 7#a7 ,,irc 7,a7 ,9 g5]al ,section #ihai ( ! ,int]nal ,rev5ue ,code ( #aihf 7#bf4 ,u4,s4,c4 #ihaf7 is am5d$ to read z foll[s3 #ihai4 ,price transp>5cy requirem5ts 7a7 ,co/ %>+ transp>5cy 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #b ye>s aft] ! date ( ! enactm5t ( ! ,heal? ,c>e ,price ,transp>5cy ,act ( #bjbc1 a gr\p heal? plan %all p]mit individuals to le>n ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 "u ! individual's plan or cov]age t ! individual w\ld be responsible = pay+ ) respect to ! furni%+ ( a specific item or s]vice by a provid] 9 a timely mann] ^u ! reque/ ( ! individual4 ,at a m9imum1 su* in=mation %all include ! in=mation specifi$ 9 p>agraph 7#b7 & %all be made available to su* individual ?r\gh a self-s]vice tool t meets ! requirem5ts ( p>agraph 7#c7 or1 at ! option ( su* individual1 ?r\gh a pap] disclosure or phone or o!r electronic disclosure 7z select$ by su* individual & provid$ at no co/ to su* individual7 t meets su* requirem5ts z ! ,secret>y may specify4 7#b7 ,specifi$ in=mation ,= purposes ( p>agraph 7#a71 ! in=mation specifi$ 9 ?is p>agraph is1 ) respect to an item or s]vice = :i* b5efits are available "u a gr\p heal? plan furni%$ by a heal? c>e provid] to a p>ticipant or b5efici>y ( su* plan1 ! foll[+3 7,a7 ,if su* provid] is a p>ticipat+ provid] ) respect to su* item or s]vice1 ! 9-network rate 7z def9$ 9 subsection 7c77 = su* item or s]vice4 7,b7 ,if su* provid] is n describ$ 9 subp>agraph 7,a71 ! maximum all[$ am\nt = su* item or s]vice4 7,c7 ,! e/imat$ am\nt ( co/ %>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! p>ticipant or b5efici>y w incur = su* item or s]vice 7:i*1 9 ! case su* item or s]vice is to be furni%$ by a provid] describ$ 9 subp>agraph 7,b71 %all be calculat$ us+ ! maximum am\nt describ$ 9 su* subp>agraph74 7,d7 ,! am\nt ! p>ticipant or b5efici>y has already accumulat$ ) respect to any d$uctible or out ( pocket maximum1 :e!r = items & s]vices furni%$ by a p>ticipat+ provid] or = items & s]vices furni%$ by a provid] t is n a p>ticipat+ provid]1 "u ! plan 7brok5 d[n1 9 ! case sep>ate d$uctibles or maximums apply to sep>ate p>ticipants & b5efici>ies enroll$ 9 ! plan1 by su* sep>ate d$uctibles or maximums1 9 addition to any cumulative d$uctible or maximum74 7,e7 ,9 ! case su* plan imposes any frequ5cy or volume limitations ) respect to su* item or s]vice 7exclud+ m$ical necessity det]m9ations71 ! am\nt t su* p>ticipant or b5efici>y has accru$ t[>ds su* limitation ) respect to su* item or s]vice4 7,f7 ,any prior au?orization1 concurr5t review1 /ep !rapy1 fail fir/1 or simil> requirem5ts applicable to cov]age ( su* item or s]vice "u su* plan4 ,! ,secret>y may provide t in=mation describ$ 9 any ( subp>agraphs 7,a7 ?r\gh 7,f7 n be treat$ z in=mation specifi$ 9 ?is p>agraph1 & specify additional in=mation t %all be treat$ z in=mation specifi$ 9 ?is p>agraph1 if det]m9$ appropriate by ! ,secret>y4 7#c7 ,self-s]vice tool ,= purposes ( p>agraph 7#a71 a self-s]vice tool e/abli%$ by a gr\p heal? plan meets ! requirem5ts ( ?is p>agraph if su* tool-- 7,a7 is bas$ on an ,int]net website2 7,b7 provides = real-"t responses to reque/s describ$ 9 p>agraph 7#a72 7,c7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is timely & accurate at ! "t su* reque/ is made2 7,d7 all[s su* a reque/ to be made ) respect to an item or s]vice furni%$ by-- 7i7 a specific provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7ii7 all provid]s t are p>ticipat+ provid]s ) respect to su* item or s]vice2 or 7iii7 a provid] t is n describ$ 9 clause 7ii72 7,e7 provides t su* a reque/ may be made ) respect to an item or s]vice ?r\gh use ( ! bill+ code = su* item or s]vice or ?r\gh use ( a descriptive t]m = su* item or s]vice2 & 7,f7 meets any o!r requirem5t det]m9$ appropriate by ! ,secret>y4 ,! ,secret>y may require su* tool1 z a condition ( comply+ ) subp>agraph 7,e71 to l9k multiple bill+ codes to a s+le descriptive t]m if ! ,secret>y det]m9es t ! bill+ codes to be s l9k$ correspond to simil> items & s]vices4 7b7 ,rate & paym5t in=mation 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #b ye>s aft] ! date ( ! enactm5t ( ! ,heal? ,c>e ,price ,transp>5cy ,act ( #bjbc1 ea* gr\p heal? plan 7o!r ?an a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act7 %all1 n less frequ5tly ?an once e #c mon?s 7or1 9 ! case ( in=mation describ$ 9 p>agraph 7#b77;,b71 n less frequ5tly ?an mon?ly71 make available to ! public ! rate & paym5t in=mation describ$ 9 p>agraph 7#b7 9 accordance ) p>agraph 7#c74 7#b7 ,rate & paym5t in=mation describ$ ,= purposes ( p>agraph 7#a71 ! rate & paym5t in=mation describ$ 9 ?is p>agraph is1 ) respect to a gr\p heal? plan1 ! foll[+3 7,a7 ,) respect to ea* item or s]vice 7o!r ?an a drug7 = :i* b5efits are available "u su* plan1 ! 9-network rate 9 effect ) ea* provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice1 o!r ?an su* a rate 9 effect ) a provid] t1 dur+ ! #a-ye> p]iod end+ #aj bus9ess days be=e ! date ( ! publication ( su* in=mation1 did n submit any claim = su* item or s]vice to su* plan4 7,b7 ,) respect to ea* drug 7id5tifi$ by national drug code7 = :i* b5efits are available "u su* plan1 ! av]age am\nt paid by su* plan 7net ( rebates1 disc\nts1 & price concessions7 = su* drug disp5s$ or adm9i/]$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( publication to ea* provid] t 0 a p>ticipat+ provid] ) respect to su* drug1 brok5 d[n by ea* su* provid]1 o!r ?an su* an am\nt paid to a provid] t1 dur+ su* p]iod1 submitt$ few] ?an #bj claims = su* drug to su* plan4 7,c7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan1 ! am\nt bill$1 & ! am\nt all[$ by ! plan1 = ea* su* item or s]vice furni%$ dur+ ! #ij-;day p]iod specifi$ 9 subp>agraph 7,b7 by a provid] t 0 n a p>ticipat+ provid] ) respect to su* item or s]vice1 brok5 d[n by ea* su* provid]1 o!r ?an items & s]vices ) respect to :i* few] ?an #bj claims = su* item or s]vice 7 submitt$ to su* plan dur+ su* p]iod4 7#c7 ,mann] ( publication ,rate & paym5t in=mation requir$ to be made available "u ?is subsection %all be s made available 9 doll> am\nts ?r\gh #c sep>ate ma*9e-readable files 7or any successor te*nology1 su* z application program int]face te*nology1 det]m9$ appropriate by ! ,secret>y7 correspond+ to ! in=mation describ$ 9 ea* ( subp>agraphs 7,a7 ?r\gh 7,c7 ( p>agraph 7#b7 t meet su* requirem5ts z specifi$ by ! ,secret>y4 ,su* requirem5ts %all ensure t su* files are limit$ to an appropriate size1 d n include disclosure ( unnecess>y duplicative in=mation conta9$ 9 o!r files made available "u ?is subsection1 are made available 9 a widely-available =mat ?r\gh a publicly-available website t all[s = in=mation conta9$ 9 su* files to be comp>$ across gr\p heal? plans1 & are accessible to individuals at no co/ & )\t ! ne$ to e/abli% a us] acc\nt or provide o!r cr$5tials4 7#d7 ,us] in/ructions ,ea* gr\p heal? plan %all make available to ! public in/ructions writt5 9 pla9 language expla9+ h[ individuals may se>* = in=mation describ$ 9 p>agraph 7#b7 9 files submitt$ 9 accordance ) p>agraph 7#c74 ,! ,secret>y %all develop & publi% a template t su* a plan may use 9 develop+ in/ructions = purposes ( ! prec$+ s5t5ce4 7#e7 ,atte/ation ,ea* gr\p heal? plan %all po/1 along ) rate & paym5t in=mation made public by su* plan1 an atte/ation t su* in=mation is complete & accurate4 7c7 ,def9itions ,9 ?is section3 7#a7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] has ! mean+ giv5 su* t]m 9 section #ihaf4 7#b7 ,9-network rate ,! t]m 9-network rate means1 ) respect to a heal? plan & an item or s]vice furni%$ by a provid] t is a p>ticipat+ provid] ) respect to su* plan & item or s]vice1 ! contract$ rate 9 effect betwe5 su* plan & su* provid] = su* item or s]vice4 4 7,b7 ,cl]ical am5dm5t ,! item relat+ to section #ihai ( ! table ( sections = sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ to read z foll[s3 ,sec4 #ihai4 ,price transp>5cy requirem5ts4 4 7#b7 ,,phsa ,section #bgii;,a-#d ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aad7 is am5d$ to read z foll[s3 #bgii;,a-#d4 ,price transp>5cy requirem5ts 7a7 ,co/ %>+ transp>5cy 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #b ye>s aft] ! date ( ! enactm5t ( ! ,heal? ,c>e ,price ,transp>5cy ,act ( #bjbc1 a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all p]mit individuals to le>n ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 "u ! individual's plan or cov]age t ! individual w\ld be responsible = pay+ ) respect to ! furni%+ ( a specific item or s]vice by a provid] 9 a timely mann] ^u ! reque/ ( ! individual4 ,at a m9imum1 su* in=mation %all include ! in=mation specifi$ 9 p>agraph 7#b7 & %all be made available to su* individual ?r\gh a self-s]vice tool t meets ! requirem5ts ( p>agraph 7#c7 or1 at ! option ( su* individual1 ?r\gh a pap] disclosure or phone or o!r electronic disclosure 7z select$ by su* individual & provid$ at no co/ to su* individual7 t meets su* requirem5ts z ! ,secret>y may specify4 7#b7 ,specifi$ in=mation ,= purposes ( p>agraph 7#a71 ! in=mation specifi$ 9 ?is p>agraph is1 ) respect to an item or s]vice = :i* b5efits are available "u a gr\p heal? plan or gr\p or individual heal? insurance cov]age furni%$ by a heal? c>e provid] to a p>ticipant or b5efici>y ( su* plan1 or enrollee 9 su* cov]age1 ! foll[+3 7,a7 ,if su* provid] is a p>ticipat+ provid] ) respect to su* item or s]vice1 ! 9-network rate 7z def9$ 9 subsection 7c77 = su* item or s]vice4 7,b7 ,if su* provid] is n describ$ 9 subp>agraph 7,a71 ! maximum all[$ am\nt = su* item or s]vice4 7,c7 ,! e/imat$ am\nt ( co/ %>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! p>ticipant or b5efici>y w incur = su* item or s]vice 7:i*1 9 ! case su* item or s]vice is to be furni%$ by a provid] describ$ 9 subp>agraph 7,b71 %all be calculat$ us+ ! maximum am\nt describ$ 9 su* subp>agraph74 7,d7 ,! am\nt ! p>ticipant1 b5efici>y1 or enrollee has already accumulat$ ) respect to any d$uctible or out ( pocket maximum1 :e!r = items & s]vices furni%$ by a p>ticipat+ provid] or = items & s]vices furni%$ by a provid] t is n a p>ticipat+ provid]1 "u ! plan or cov]age 7brok5 d[n1 9 ! case sep>ate d$uctibles or maximums apply to sep>ate p>ticipants1 b5efici>ies or enrollees enroll$ 9 ! plan or cov]age1 by su* sep>ate d$uctibles or maximums1 9 addition to any cumulative d$uctible or maximum74 7,e7 ,9 ! case su* plan or cov]age imposes any frequ5cy or volume limitations ) respect to su* item or s]vice 7exclud+ m$ical necessity det]m9ations71 ! am\nt t su* p>ticipant1 b5efici>y1 or enrollee has accru$ t[>ds su* limitation ) respect to su* item or s]vice4 7,f7 ,any prior au?orization1 concurr5t review1 /ep !rapy1 fail fir/1 or simil> requirem5ts applicable to cov]age ( su* item or s]vice "u su* plan or cov]age4 ,! ,secret>y may provide t in=mation describ$ 9 any ( subp>agraphs 7,a7 ?r\gh 7,f7 n be treat$ z in=mation specifi$ 9 ?is p>agraph1 & specify additional in=mation t %all be treat$ z in=mation specifi$ 9 ?is p>agraph1 if det]m9$ appropriate by ! ,secret>y4 7#c7 ,self-s]vice tool ,= purposes ( p>agraph 7#a71 a self-s]vice tool e/abli%$ by a gr\p heal? plan or gr\p or individual heal? insurance cov]age meets ! requirem5ts ( ?is p>agraph if su* tool-- 7,a7 is bas$ on an ,int]net website2 7,b7 provides = real-"t responses to reque/s describ$ 9 p>agraph 7#a72 7,c7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is timely & accurate at ! "t su* reque/ is made2 7,d7 all[s su* a reque/ to be made ) respect to an item or s]vice furni%$ by-- 7i7 a specific provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7ii7 all provid]s t are p>ticipat+ provid]s ) respect to su* item or s]vice2 or 7iii7 a provid] t is n describ$ 9 clause 7ii72 7,e7 provides t su* a reque/ may be made ) respect to an item or s]vice ?r\gh use ( ! bill+ code = su* item or s]vice or ?r\gh use ( a descriptive t]m = su* item or s]vice2 & 7,f7 meets any o!r requirem5t det]m9$ appropriate by ! ,secret>y4 ,! ,secret>y may require su* tool1 z a condition ( comply+ ) subp>agraph 7,e71 to l9k multiple bill+ codes to a s+le descriptive t]m if ! ,secret>y det]m9es t ! bill+ codes to be s l9k$ correspond to simil> items & s]vices4 7b7 ,rate & paym5t in=mation 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #b ye>s aft] ! date ( ! enactm5t ( ! ,heal? ,c>e ,price ,transp>5cy ,act ( #bjbc1 ea* gr\p heal? plan 7o!r ?an a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act7 or gr\p or individual heal? insurance cov]age1 %all1 n less frequ5tly ?an once e #c mon?s 7or1 9 ! case ( in=mation describ$ 9 p>agraph 7#b77;,b71 n less frequ5tly ?an mon?ly71 make available to ! public ! rate & paym5t in=mation describ$ 9 p>agraph 7#b7 9 accordance ) p>agraph 7#c74 7#b7 ,rate & paym5t in=mation describ$ ,= purposes ( p>agraph 7#a71 ! rate & paym5t in=mation describ$ 9 ?is p>agraph is1 ) respect to a gr\p heal? plan or gr\p or individual heal? insurance cov]age1 ! foll[+3 7,a7 ,) respect to ea* item or s]vice 7o!r ?an a drug7 = :i* b5efits are available "u su* plan or cov]age1 ! 9-network rate 9 effect ) ea* provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice1 o!r ?an su* a rate 9 effect ) a provid] t1 dur+ ! #a-ye> p]iod end+ #aj bus9ess days be=e ! date ( ! publication ( su* in=mation1 did n submit any claim = su* item or s]vice to su* plan or cov]age4 7,b7 ,) respect to ea* drug 7id5tifi$ by national drug code7 = :i* b5efits are available "u su* plan1 ! av]age am\nt paid by su* plan or cov]age 7net ( rebates1 disc\nts1 & price concessions7 = su* drug disp5s$ or adm9i/]$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( publication to ea* provid] t 0 a p>ticipat+ provid] ) respect to su* drug1 brok5 d[n by ea* su* provid]1 o!r ?an su* an am\nt paid to a provid] t1 dur+ su* p]iod1 submitt$ few] ?an #bj claims = su* drug to su* plan or cov]age4 7,c7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan or cov]age1 ! am\nt bill$1 & ! am\nt all[$ by ! plan or cov]age1 = ea* su* item or s]vice furni%$ dur+ ! #ij-;day p]iod specifi$ 9 subp>agraph 7,b7 by a provid] t 0 n a p>ticipat+ provid] ) respect to su* item or s]vice1 brok5 d[n by ea* su* provid]1 o!r ?an items & s]vices ) respect to :i* few] ?an #bj claims = su* item or s]vice 7 submitt$ to su* plan or cov]age dur+ su* p]iod4 7#c7 ,mann] ( publication ,rate & paym5t in=mation requir$ to be made available "u ?is subsection %all be s made available 9 doll> am\nts ?r\gh #c sep>ate ma*9e-readable files 7or any successor te*nology1 su* z application program int]face te*nology1 det]m9$ appropriate by ! ,secret>y7 correspond+ to ! in=mation describ$ 9 ea* ( subp>agraphs 7,a7 ?r\gh 7,c7 ( p>agraph 7#b7 t meet su* requirem5ts z specifi$ by ! ,secret>y4 ,su* requirem5ts %all ensure t su* files are limit$ to an appropriate size1 d n include disclosure ( unnecess>y duplicative in=mation conta9$ 9 o!r files made available "u ?is subsection1 are made available 9 a widely-available =mat ?r\gh a publicly-available website t all[s = in=mation conta9$ 9 su* files to be comp>$ across gr\p heal? plans & gr\p & individual heal? insurance cov]age1 & are accessible to individuals at no co/ & )\t ! ne$ to e/abli% a us] acc\nt or provide o!r cr$5tials4 7#d7 ,us] in/ructions ,ea* gr\p heal? plan & gr\p or individual heal? insurance cov]age %all make available to ! public in/ructions writt5 9 pla9 language expla9+ h[ individuals may se>* = in=mation describ$ 9 p>agraph 7#b7 9 files submitt$ 9 accordance ) p>agraph 7#c74 ,! ,secret>y %all develop & publi% a template t su* a plan or cov]age may use 9 develop+ in/ructions = purposes ( ! prec$+ s5t5ce4 7#e7 ,atte/ation ,ea* gr\p heal? plan & gr\p or individual heal? insurance cov]age %all po/1 along ) rate & paym5t in=mation made public by su* plan or cov]age1 an atte/ation t su* in=mation is complete & accurate4 7c7 ,def9itions ,9 ?is section3 7#a7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] has ! mean+ giv5 su* t]m 9 section #bgia;,a-#a7;a77#c77;,g77ii74 7#b7 ,9-network rate ,! t]m 9-network rate means1 ) respect to a heal? plan or cov]age & an item or s]vice furni%$ by a provid] t is a p>ticipat+ provid] ) respect to su* plan & item or s]vice1 ! contract$ rate 9 effect betwe5 su* plan or cov]age & su* provid] = su* item or s]vice4 4 7#c7 ,,erisa 7,a7 ,9 g5]al ,section #gai ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;h7 is am5d$ to read z foll[s3 #gai4 ,price transp>5cy requirem5ts 7a7 ,co/ %>+ transp>5cy 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #b ye>s aft] ! date ( ! enactm5t ( ! ,heal? ,c>e ,price ,transp>5cy ,act ( #bjbc1 a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all p]mit individuals to le>n ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 "u ! individual's plan or cov]age t ! individual w\ld be responsible = pay+ ) respect to ! furni%+ ( a specific item or s]vice by a provid] 9 a timely mann] ^u ! reque/ ( ! individual4 ,at a m9imum1 su* in=mation %all include ! in=mation specifi$ 9 p>agraph 7#b7 & %all be made available to su* individual ?r\gh a self-s]vice tool t meets ! requirem5ts ( p>agraph 7#c7 or1 at ! option ( su* individual1 ?r\gh a pap] disclosure or phone or o!r electronic disclosure 7z select$ by su* individual & provid$ at no co/ to su* individual7 t meets su* requirem5ts z ! ,secret>y may specify4 7#b7 ,specifi$ in=mation ,= purposes ( p>agraph 7#a71 ! in=mation specifi$ 9 ?is p>agraph is1 ) respect to an item or s]vice = :i* b5efits are available "u a gr\p heal? plan or gr\p heal? insurance cov]age furni%$ by a heal? c>e provid] to a p>ticipant or b5efici>y ( su* plan1 or enrollee 9 su* cov]age1 ! foll[+3 7,a7 ,if su* provid] is a p>ticipat+ provid] ) respect to su* item or s]vice1 ! 9-network rate 7z def9$ 9 subsection 7c77 = su* item or s]vice4 7,b7 ,if su* provid] is n describ$ 9 subp>agraph 7,a71 ! maximum all[$ am\nt = su* item or s]vice4 7,c7 ,! e/imat$ am\nt ( co/ %>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! p>ticipant or b5efici>y w incur = su* item or s]vice 7:i*1 9 ! case su* item or s]vice is to be furni%$ by a provid] describ$ 9 subp>agraph 7,b71 %all be calculat$ us+ ! maximum am\nt describ$ 9 su* subp>agraph74 7,d7 ,! am\nt ! p>ticipant1 b5efici>y1 or enrollee has already accumulat$ ) respect to any d$uctible or out ( pocket maximum1 :e!r = items & s]vices furni%$ by a p>ticipat+ provid] or = items & s]vices furni%$ by a provid] t is n a p>ticipat+ provid]1 "u ! plan or cov]age 7brok5 d[n1 9 ! case sep>ate d$uctibles or maximums apply to sep>ate p>ticipants1 b5efici>ies or enrollees enroll$ 9 ! plan or cov]age1 by su* sep>ate d$uctibles or maximums1 9 addition to any cumulative d$uctible or maximum74 7,e7 ,9 ! case su* plan or cov]age imposes any frequ5cy or volume limitations ) respect to su* item or s]vice 7exclud+ m$ical necessity det]m9ations71 ! am\nt t su* p>ticipant1 b5efici>y1 or enrollee has accru$ t[>ds su* limitation ) respect to su* item or s]vice4 7,f7 ,any prior au?orization1 concurr5t review1 /ep !rapy1 fail fir/1 or simil> requirem5ts applicable to cov]age ( su* item or s]vice "u su* plan or cov]age4 ,! ,secret>y may provide t in=mation describ$ 9 any ( subp>agraphs 7,a7 ?r\gh 7,f7 n be treat$ z in=mation specifi$ 9 ?is p>agraph1 & specify additional in=mation t %all be treat$ z in=mation specifi$ 9 ?is p>agraph1 if det]m9$ appropriate by ! ,secret>y4 7#c7 ,self-s]vice tool ,= purposes ( p>agraph 7#a71 a self-s]vice tool e/abli%$ by a gr\p heal? plan or gr\p heal? insurance cov]age meets ! requirem5ts ( ?is p>agraph if su* tool-- 7,a7 is bas$ on an ,int]net website2 7,b7 provides = real-"t responses to reque/s describ$ 9 p>agraph 7#a72 7,c7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is timely & accurate at ! "t su* reque/ is made2 7,d7 all[s su* a reque/ to be made ) respect to an item or s]vice furni%$ by-- 7i7 a specific provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7ii7 all provid]s t are p>ticipat+ provid]s ) respect to su* item or s]vice2 or 7iii7 a provid] t is n describ$ 9 clause 7ii72 7,e7 provides t su* a reque/ may be made ) respect to an item or s]vice ?r\gh use ( ! bill+ code = su* item or s]vice or ?r\gh use ( a descriptive t]m = su* item or s]vice2 & 7,f7 meets any o!r requirem5t det]m9$ appropriate by ! ,secret>y4 ,! ,secret>y may require su* tool1 z a condition ( comply+ ) subp>agraph 7,e71 to l9k multiple bill+ codes to a s+le descriptive t]m if ! ,secret>y det]m9es t ! bill+ codes to be s l9k$ correspond to simil> items & s]vices4 7b7 ,rate & paym5t in=mation 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #b ye>s aft] ! date ( ! enactm5t ( ! ,heal? ,c>e ,price ,transp>5cy ,act ( #bjbc1 ea* gr\p heal? plan 7o!r ?an a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act7 or gr\p heal? insurance cov]age1 %all1 n less frequ5tly ?an once e #c mon?s 7or1 9 ! case ( in=mation describ$ 9 p>agraph 7#b77;,b71 n less frequ5tly ?an mon?ly71 make available to ! public ! rate & paym5t in=mation describ$ 9 p>agraph 7#b7 9 accordance ) p>agraph 7#c74 7#b7 ,rate & paym5t in=mation describ$ ,= purposes ( p>agraph 7#a71 ! rate & paym5t in=mation describ$ 9 ?is p>agraph is1 ) respect to a gr\p heal? plan or gr\p heal? insurance cov]age1 ! foll[+3 7,a7 ,) respect to ea* item or s]vice 7o!r ?an a drug7 = :i* b5efits are available "u su* plan or cov]age1 ! 9-network rate 9 effect ) ea* provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice1 o!r ?an su* a rate 9 effect ) a provid] t1 dur+ ! #a-ye> p]iod end+ #aj bus9ess days be=e ! date ( ! publication ( su* in=mation1 did n submit any claim = su* item or s]vice to su* plan or cov]age4 7,b7 ,) respect to ea* drug 7id5tifi$ by national drug code7 = :i* b5efits are available "u su* plan1 ! av]age am\nt paid by su* plan or cov]age 7net ( rebates1 disc\nts1 & price concessions7 = su* drug disp5s$ or adm9i/]$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( publication to ea* provid] t 0 a p>ticipat+ provid] ) respect to su* drug1 brok5 d[n by ea* su* provid]1 o!r ?an su* an am\nt paid to a provid] t1 dur+ su* p]iod1 submitt$ few] ?an #bj claims = su* drug to su* plan or cov]age4 7,c7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan or cov]age1 ! am\nt bill$1 & ! am\nt all[$ by ! plan or cov]age1 = ea* su* item or s]vice furni%$ dur+ ! #ij-;day p]iod specifi$ 9 subp>agraph 7,b7 by a provid] t 0 n a p>ticipat+ provid] ) respect to su* item or s]vice1 brok5 d[n by ea* su* provid]1 o!r ?an items & s]vices ) respect to :i* few] ?an #bj claims = su* item or s]vice 7 submitt$ to su* plan or cov]age dur+ su* p]iod4 7#c7 ,mann] ( publication ,rate & paym5t in=mation requir$ to be made available "u ?is subsection %all be s made available 9 doll> am\nts ?r\gh #c sep>ate ma*9e-readable files 7or any successor te*nology1 su* z application program int]face te*nology1 det]m9$ appropriate by ! ,secret>y7 correspond+ to ! in=mation describ$ 9 ea* ( subp>agraphs 7,a7 ?r\gh 7,c7 ( p>agraph 7#b7 t meet su* requirem5ts z specifi$ by ! ,secret>y4 ,su* requirem5ts %all ensure t su* files are limit$ to an appropriate size1 d n include disclosure ( unnecess>y duplicative in=mation conta9$ 9 o!r files made available "u ?is subsection1 are made available 9 a widely-available =mat ?r\gh a publicly-available website t all[s = in=mation conta9$ 9 su* files to be comp>$ across gr\p heal? plans & gr\p & individual heal? insurance cov]age1 & are accessible to individuals at no co/ & )\t ! ne$ to e/abli% a us] acc\nt or provide o!r cr$5tials4 7#d7 ,us] in/ructions ,ea* gr\p heal? plan & gr\p heal? insurance cov]age %all make available to ! public in/ructions writt5 9 pla9 language expla9+ h[ individuals may se>* = in=mation describ$ 9 p>agraph 7#b7 9 files submitt$ 9 accordance ) p>agraph 7#c74 ,! ,secret>y %all develop & publi% a template t su* a plan or cov]age may use 9 develop+ in/ructions = purposes ( ! prec$+ s5t5ce4 7#e7 ,atte/ation ,ea* gr\p heal? plan & gr\p heal? insurance cov]age %all po/1 along ) rate & paym5t in=mation made public by su* plan or cov]age1 an atte/ation t su* in=mation is complete & accurate4 7c7 ,def9itions ,9 ?is section3 7#a7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] has ! mean+ giv5 su* t]m 9 section #gaf7;a77#c77;,g77ii74 7#b7 ,9-network rate ,! t]m 9-network rate means1 ) respect to a heal? plan or cov]age & an item or s]vice furni%$ by a provid] t is a p>ticipat+ provid] ) respect to su* plan & item or s]vice1 ! contract$ rate 9 effect betwe5 su* plan or cov]age & su* provid] = su* item or s]vice4 4 7,b7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by /rik+ ! item relat+ to section #gai & ins]t+ ! foll[+ new item3 ,sec4 #gai4 ,price transp>5cy requirem5ts4 4 7b7 ,accessibility ?r\gh implem5tation ,9 implem5t+ ! am5dm5ts made by subsection 7a71 ! ,secret>y ( ! ,treasury1 ! ,secret>y ( ,heal? & ,human ,s]vices1 & ! ,secret>y ( ,labor %all take reasonable /eps to ensure ! accessibility ( in=mation made available pursuant to su* am5dm5ts1 includ+ reasonable /eps to ensure t su* in=mation is provid$ 9 pla91 easily und]/&able language & t int]pretation1 translations1 & assi/ive s]vices are provid$ by gr\p heal? plans & heal? insurance issu]s (f]+ gr\p or individual heal? insurance cov]age to make su* in=mation accessible to ^? ) limit$ ,engli% pr(ici5cy & ^? ) disabilities4 7c7 ,cont9u$ applicability ( rules = previ\s ye>s ,no?+ 9 ! am5dm5ts made by subsection 7a7 may be con/ru$ z affect+ ! applicability ( ! rule entitl$ ,transp>5cy 9 ,cov]age publi%$ by ! ,dep>tm5t ( ! ,treasury1 ! ,dep>tm5t ( ,labor1 & ! ,dep>tm5t ( ,heal? & ,human ,s]vices on ,novemb] #ab1 #bjbj 7#he ,f$4 ,reg4 #gbaeh7 = any plan ye> beg9n+ be=e ! date t is #b ye>s aft] ! date ( ! enactm5t ( ?is ,act4 #ajc4 ,ov]sight ( ph>macy b5efits manag] s]vices 7a7 ,,irc 7#a7 ,9 g5]al ,sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+3 #ihbf4 ,ov]sight ( ph>macy b5efits manag] s]vices 7a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #c ye>s aft] ! date ( enactm5t ( ?is section1 a gr\p heal? plan1 or an entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( su* a plan1 %all n ent] into a contract ) a drug manufactur]1 di/ributor1 :olesal]1 subcontractor1 rebate aggregator1 or any associat$ ?ird p>ty t limits ! disclosure ( in=mation to plan sponsors 9 su* a mann] t prev5ts ! plan1 or an entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( a plan1 f mak+ ! report describ$ 9 subsection 7b74 7b7 ,annual report 7#a7 ,9 g5]al ,) respect to plan ye>s beg9n+ on or aft] ! date t is #c ye>s aft] ! date ( enactm5t ( ?is section1 = ea* su* plan ye>1 a gr\p heal? plan1 or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( su* a plan1 %all submit to ! plan sponsor 7z def9$ 9 section #c7af77;,b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd7 ( su* plan a report 9 a ma*9e-readable =mat4 ,ea* su* report %all include1 ) respect to su* plan provid$ = su* plan ye>-- 7,a7 to ! ext5t feasible1 in=mation collect$ f drug manufactur]s 7or an entity adm9i/]+ copay assi/ance on behalf ( su* manufactur]s7 by su* plan 7or entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( su* plan7 on ! total am\nt ( copaym5t assi/ance doll>s paid1 or copaym5t c>ds appli$1 t 7 fund$ by ! drug manufactur] ) respect to ! p>ticipants & b5efici>ies 9 su* plan2 7,b7 a li/ ( ea* drug cov]$ by su* plan t 0 disp5s$ dur+ ! plan ye>1 includ+1 ) respect to ea* su* drug dur+ su* plan ye>-- 7i7 ! br& "n1 *emical entity1 & ,national ,drug ,code2 7ii7 ! numb] ( p>ticipants & b5efici>ies = :om ! drug 0 disp5s$ dur+ ! plan ye>1 ! total numb] ( prescription claims = ! drug 7includ+ orig9al prescriptions & refills71 & ! total numb] ( dosage units ( ! drug disp5s$ across ! plan ye>1 disaggregat$ by disp5s+ *annel 7su* z retail1 mail ord]1 or specialty ph>macy72 7iii7 ! :olesale acquisition co/1 li/$ z co/ p] days supply & co/ p] pill1 or 9 ! case ( a drug 9 ano!r =m1 p] dosage unit2 7iv7 ! total out-(-pocket sp5d+ by p>ticipants & b5efici>ies on su* drug1 includ+ p>ticipant & b5efici>y sp5d+ ?r\gh copaym5ts1 co9surance1 & d$uctibles2 7v7 = any drug = :i* gross sp5d+ ( ! gr\p heal? plan exce$$ #aj1jjj dur+ ! plan ye>-- 7,i7 a li/ ( all o!r drugs 9 ! same !rapeutic category or class1 includ+ br& "n drugs & biological products & g5]ic drugs or biosimil> biological products t are 9 ! same !rapeutic category or class z su* drug2 & 7,,ii7 ! rationale = ! =mul>y placem5t ( su* drug 9 t !rapeutic category or class1 if applicable2 7vi7 ! am\nt receiv$1 or expect$ to be receiv$1 f drug manufactur]s 9 rebates1 fees1 alt]native disc\nts1 or o!r remun]ation = claims incurr$ = su* drug dur+ ! plan ye>2 7vii7 ! total net sp5d+1 aft] d$uct+ rebates1 price concessions1 alt]native disc\nts or o!r remun]ation f drug manufactur]s1 by ! heal? plan on su* drug2 & 7viii7 ! net price p] c\rse ( treatm5t or s+le fill1 su* z a #cj-;day supply or #ij-;day supply1 incurr$ by ! heal? plan & its p>ticipants & b5efici>ies aft] manufactur] rebates1 fees1 & o!r remun]ation = su* drug disp5s$ dur+ ! plan ye>2 7,c7 a li/ ( ea* !rapeutic category or class ( drugs t 7 disp5s$ "u ! heal? plan dur+ ! plan ye>1 &1 ) respect to ea* su* !rapeutic category or class ( drugs1 dur+ ! plan ye>-- 7i7 total gross sp5d+ by ! plan1 be=e manufactur] rebates1 fees1 or o!r manufactur] remun]ation2 7ii7 ! numb] ( p>ticipants & b5efici>ies :o 7 disp5s$ a drug cov]$ by su* plan 9 t category or class1 brok5 d[n by ea* su* drug 7id5tifi$ by ,national ,drug ,code72 7iii7 if applicable to t category or class1 a description ( ! =mul>y ti]s & utilization managem5t 7su* z prior au?orization or /ep !rapy7 employ$ = drugs 9 t category or class2 & 7iv7 ! total out-(-pocket sp5d+ by p>ticipants & b5efici>ies1 includ+ p>ticipant & b5efici>y sp5d+ ?r\gh copaym5ts1 co9surance1 & d$uctibles2 7,d7 total gross sp5d+ on prescription drugs by ! plan dur+ ! plan ye>1 be=e rebates & o!r manufactur] fees or remun]ation2 7,e7 total am\nt receiv$1 or expect$ to be receiv$1 by ! heal? plan 9 drug manufactur] rebates1 fees1 alt]native disc\nts1 & all o!r remun]ation receiv$ f ! manufactur] or any ?ird p>ty1 o!r ?an ! plan sponsor1 relat$ to utilization ( drug or drug sp5d+ "u t heal? plan dur+ ! plan ye>2 7,f7 ! total net sp5d+ on prescription drugs by ! heal? plan dur+ ! plan ye>2 & 7,g7 am\nts paid directly or indirectly 9 rebates1 fees1 or any o!r type ( remun]ation to brok]s1 consultants1 advisors1 or any o!r individual or firm = ! ref]ral ( ! gr\p heal? plan's bus9ess to ! ph>macy b5efits manag]4 7#b7 ,privacy requirem5ts ,entities provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan %all provide in=mation "u p>agraph 7#a7 9 a mann] consi/5t ) ! privacy1 security1 & brea* notification regulations promulgat$ "u section #bfd7;c7 ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 & %all re/rict ! use & disclosure ( su* in=mation accord+ to su* privacy regulations4 7#c7 ,disclosure & r$isclosure 7,a7 ,limitation to bus9ess associates ,a gr\p heal? plan receiv+ a report "u p>agraph 7#a7 may disclose su* in=mation only to bus9ess associates ( su* plan z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations74 7,b7 ,cl>ification reg>d+ public disclosure ( in=mation ,no?+ 9 ?is section prev5ts an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan f plac+ reasonable re/rictions on ! public disclosure ( ! in=mation conta9$ 9 a report describ$ 9 p>agraph 7#a71 except t su* entity may n re/rict disclosure ( su* report to ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 ! ,dep>tm5t ( ! ,treasury1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates1 or applicable ,/ate ag5cies4 7,c7 ,limit$ =m ( report ,! ,secret>y %all def9e ?r\gh rulemak+ a limit$ =m ( ! report "u p>agraph 7#a7 requir$ ( plan sponsors :o are drug manufactur]s1 drug :olesal]s1 or o!r direct p>ticipants 9 ! drug supply *a91 9 ord] to prev5t anti-competitive behavior4 7#d7 ,report to ,,gao ,a gr\p heal? plan1 or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan1 %all submit to ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates ea* ( ! fir/ #d reports submitt$ to a plan sponsor "u p>agraph 7#a7 ) respect to su* plan1 & o!r su* reports z reque/$1 9 accordance ) ! privacy requirem5ts "u p>agraph 7#b71 ! disclosure & r$isclosure /&>ds "u p>agraph 7#c71 ! /&>ds specifi$ pursuant to p>agraph 7#e71 & su* o!r in=mation t ! ,comptroll] ,g5]al det]m9es necess>y to c>ry out ! /udy "u section #ajc7;d7 ( ! ,heal? ,c>e ,price ,transp>5cy ,act ( #bjbc4 7#e7 ,/&>d =mat ,n lat] ?an #ah mon?s aft] ! date ( enactm5t ( ?is section1 ! ,secret>y %all specify ?r\gh rulemak+ /&>ds = entities requir$ to submit reports "u p>agraph 7#d7 to submit su* reports 9 a /&>d =mat4 7c7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to p]mit a gr\p heal? plan or o!r entity to re/rict disclosure to1 or o!rwise limit ! access (1 ! ,secret>y ( ! ,treasury to a report describ$ 9 subsection 7b77#a7 or in=mation relat$ to compliance ) subsection 7a7 or 7b7 by su* plan or o!r entity subject to su* subsections4 7d7 ,def9ition ,9 ?is section1 ! t]m :olesale acquisition co/ has ! mean+ giv5 su* t]m 9 section #ahdg;,a7c77#f77;,b7 ( ! ,social ,security ,act4 4 7#b7 ,cl]ical am5dm5t ,! table ( sections = sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new item3 ,sec4 #ihbf4 ,ov]sight ( ph>macy b5efits manag] s]vices4 4 7b7 ,,phsa ,title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et seq47 is am5d$-- 7#a7 9 "p ,d 7#db ,u4,s4,c4 #cjj;gg-#aaa et seq471 by add+ at ! end ! foll[+ new section3 #bgii;,a-#aa4 ,ov]sight ( ph>macy b5efits manag] s]vices 7a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #c ye>s aft] ! date ( enactm5t ( ?is section1 a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 or an entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( su* a plan or issu]1 %all n ent] into a contract ) a drug manufactur]1 di/ributor1 :olesal]1 subcontractor1 rebate aggregator1 or any associat$ ?ird p>ty t limits ! disclosure ( in=mation to plan sponsors 9 su* a mann] t prev5ts ! plan or issu]1 or an entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( a plan or issu]1 f mak+ ! report describ$ 9 subsection 7b74 7b7 ,annual report 7#a7 ,9 g5]al ,) respect to plan ye>s beg9n+ on or aft] ! date t is #c ye>s aft] ! date ( enactm5t ( ?is section1 = ea* su* plan ye>1 a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( su* a plan or an issu]1 %all submit to ! plan sponsor 7z def9$ 9 section #c7af77;,b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd7 ( su* plan or cov]age a report 9 a ma*9e-readable =mat4 ,ea* su* report %all include1 ) respect to su* plan or cov]age provid$ = su* plan ye>-- 7,a7 to ! ext5t feasible1 in=mation collect$ f drug manufactur]s 7or an entity adm9i/]+ copay assi/ance on behalf ( su* manufactur]s7 by su* plan or issu] 7or entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( su* plan or issu]7 on ! total am\nt ( copaym5t assi/ance doll>s paid1 or copaym5t c>ds appli$1 t 7 fund$ by ! drug manufactur] ) respect to ! p>ticipants1 b5efici>ies1 & enrollees 9 su* plan or cov]age2 7,b7 a li/ ( ea* drug cov]$ by su* plan or cov]age t 0 disp5s$ dur+ ! plan ye>1 includ+1 ) respect to ea* su* drug dur+ su* plan ye>-- 7i7 ! br& "n1 *emical entity1 & ,national ,drug ,code2 7ii7 ! numb] ( p>ticipants1 b5efici>ies1 & enrollees = :om ! drug 0 disp5s$ dur+ ! plan ye>1 ! total numb] ( prescription claims = ! drug 7includ+ orig9al prescriptions & refills71 & ! total numb] ( dosage units ( ! drug disp5s$ across ! plan ye>1 disaggregat$ by disp5s+ *annel 7su* z retail1 mail ord]1 or specialty ph>macy72 7iii7 ! :olesale acquisition co/1 li/$ z co/ p] days supply & co/ p] pill1 or 9 ! case ( a drug 9 ano!r =m1 p] dosage unit2 7iv7 ! total out-(-pocket sp5d+ by p>ticipants1 b5efici>ies1 & enrollees on su* drug1 includ+ p>ticipant1 b5efici>y1 & enrollee sp5d+ ?r\gh copaym5ts1 co9surance1 & d$uctibles2 7v7 = any drug = :i* gross sp5d+ ( ! gr\p heal? plan or heal? insurance cov]age exce$$ #aj1jjj dur+ ! plan ye>-- 7,i7 a li/ ( all o!r drugs 9 ! same !rapeutic category or class1 includ+ br& "n drugs & biological products & g5]ic drugs or biosimil> biological products t are 9 ! same !rapeutic category or class z su* drug2 & 7,,ii7 ! rationale = ! =mul>y placem5t ( su* drug 9 t !rapeutic category or class1 if applicable2 7vi7 ! am\nt receiv$1 or expect$ to be receiv$1 f drug manufactur]s 9 rebates1 fees1 alt]native disc\nts1 or o!r remun]ation = claims incurr$ = su* drug dur+ ! plan ye>2 7vii7 ! total net sp5d+1 aft] d$uct+ rebates1 price concessions1 alt]native disc\nts or o!r remun]ation f drug manufactur]s1 by ! heal? plan or heal? insurance cov]age on su* drug2 & 7viii7 ! net price p] c\rse ( treatm5t or s+le fill1 su* z a #cj-;day supply or #ij-;day supply1 incurr$ by ! heal? plan or heal? insurance cov]age & its p>ticipants1 b5efici>ies1 & enrollees1 aft] manufactur] rebates1 fees1 & o!r remun]ation = su* drug disp5s$ dur+ ! plan ye>2 7,c7 a li/ ( ea* !rapeutic category or class ( drugs t 7 disp5s$ "u ! heal? plan or heal? insurance cov]age dur+ ! plan ye>1 &1 ) respect to ea* su* !rapeutic category or class ( drugs1 dur+ ! plan ye>-- 7i7 total gross sp5d+ by ! plan or cov]age1 be=e manufactur] rebates1 fees1 or o!r manufactur] remun]ation2 7ii7 ! numb] ( p>ticipants1 b5efici>ies1 & enrollees :o 7 disp5s$ a drug cov]$ by su* plan or cov]age 9 t category or class1 brok5 d[n by ea* su* drug 7id5tifi$ by ,national ,drug ,code72 7iii7 if applicable to t category or class1 a description ( ! =mul>y ti]s & utilization managem5t 7su* z prior au?orization or /ep !rapy7 employ$ = drugs 9 t category or class2 & 7iv7 ! total out-(-pocket sp5d+ by p>ticipants1 b5efici>ies1 & enrollees1 includ+ p>ticipant1 b5efici>y1 & enrollee sp5d+ ?r\gh copaym5ts1 co9surance1 & d$uctibles2 7,d7 total gross sp5d+ on prescription drugs by ! plan or cov]age dur+ ! plan ye>1 be=e rebates & o!r manufactur] fees or remun]ation2 7,e7 total am\nt receiv$1 or expect$ to be receiv$1 by ! heal? plan or heal? insurance cov]age 9 drug manufactur] rebates1 fees1 alt]native disc\nts1 & all o!r remun]ation receiv$ f ! manufactur] or any ?ird p>ty1 o!r ?an ! plan sponsor1 relat$ to utilization ( drug or drug sp5d+ "u t heal? plan or heal? insurance cov]age dur+ ! plan ye>2 7,f7 ! total net sp5d+ on prescription drugs by ! heal? plan or heal? insurance cov]age dur+ ! plan ye>2 & 7,g7 am\nts paid directly or indirectly 9 rebates1 fees1 or any o!r type ( remun]ation to brok]s1 consultants1 advisors1 or any o!r individual or firm = ! ref]ral ( ! gr\p heal? plan's or heal? insurance issu]'s bus9ess to ! ph>macy b5efits manag]4 7#b7 ,privacy requirem5ts ,heal? insurance issu]s (f]+ gr\p heal? insurance cov]age & entities provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan %all provide in=mation "u p>agraph 7#a7 9 a mann] consi/5t ) ! privacy1 security1 & brea* notification regulations promulgat$ "u section #bfd7;c7 ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 & %all re/rict ! use & disclosure ( su* in=mation accord+ to su* privacy regulations4 7#c7 ,disclosure & r$isclosure 7,a7 ,limitation to bus9ess associates ,a gr\p heal? plan receiv+ a report "u p>agraph 7#a7 may disclose su* in=mation only to bus9ess associates ( su* plan z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations74 7,b7 ,cl>ification reg>d+ public disclosure ( in=mation ,no?+ 9 ?is section prev5ts a heal? insurance issu] (f]+ gr\p heal? insurance cov]age or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan f plac+ reasonable re/rictions on ! public disclosure ( ! in=mation conta9$ 9 a report describ$ 9 p>agraph 7#a71 except t su* issu] or entity may n re/rict disclosure ( su* report to ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 ! ,dep>tm5t ( ! ,treasury1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates1 or applicable ,/ate ag5cies4 7,c7 ,limit$ =m ( report ,! ,secret>y %all def9e ?r\gh rulemak+ a limit$ =m ( ! report "u p>agraph 7#a7 requir$ ( plan sponsors :o are drug manufactur]s1 drug :olesal]s1 or o!r direct p>ticipants 9 ! drug supply *a91 9 ord] to prev5t anti-competitive behavior4 7#d7 ,report to ,,gao ,a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan %all submit to ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates ea* ( ! fir/ #d reports submitt$ to a plan sponsor "u p>agraph 7#a7 ) respect to su* cov]age or plan1 & o!r su* reports z reque/$1 9 accordance ) ! privacy requirem5ts "u p>agraph 7#b71 ! disclosure & r$isclosure /&>ds "u p>agraph 7#c71 ! /&>ds specifi$ pursuant to p>agraph 7#e71 & su* o!r in=mation t ! ,comptroll] ,g5]al det]m9es necess>y to c>ry out ! /udy "u section #ajc7;d7 ( ! ,heal? ,c>e ,price ,transp>5cy ,act ( #bjbc4 7#e7 ,/&>d =mat ,n lat] ?an #ah mon?s aft] ! date ( enactm5t ( ?is section1 ! ,secret>y %all specify ?r\gh rulemak+ /&>ds = heal? insurance issu]s & entities requir$ to submit reports "u p>agraph 7#d7 to submit su* reports 9 a /&>d =mat4 7c7 ,en=cem5t 7#a7 ,9 g5]al ,not)/&+ section #bgbc1 ! ,secret>y1 9 consultation ) ! ,secret>y ( ,labor & ! ,secret>y ( ! ,treasury1 %all en=ce ?is section4 7#b7 ,failure to provide timely in=mation ,a heal? insurance issu] or an entity provid+ ph>macy b5efits managem5t s]vices t violates subsection 7a7 or fails to provide in=mation requir$ "u subsection 7b7 %all be subject to a civil monet>y p5alty 9 ! am\nt ( #aj1jjj = ea* day dur+ :i* su* violation cont9ues or su* in=mation is n disclos$ or report$4 7#c7 ,false in=mation ,a heal? insurance issu] or entity provid+ ph>macy b5efits managem5t s]vices t kn[+ly provides false in=mation "u ?is section %all be subject to a civil money p5alty 9 an am\nt n to exce$ #ajj1jjj = ea* item ( false in=mation4 ,su* civil money p5alty %all be 9 addition to o!r p5alties z may be prescrib$ by law4 7#d7 ,proc$ure ,! provisions ( section #aabh;,a ( ! ,social ,security ,act1 o!r ?an subsection 7a7 & 7b7 & ! fir/ s5t5ce ( subsection 7c77#a7 ( su* section %all apply to civil monet>y p5alties "u ?is subsection 9 ! same mann] z su* provisions apply to a p5alty or proce$+ "u section #aabh;,a ( ! ,social ,security ,act4 7#e7 ,waiv]s ,! ,secret>y may waive p5alties "u p>agraph 7#b71 or ext5d ! p]iod ( "t = compliance ) a requirem5t ( ?is section1 = an entity 9 violation ( ?is section t has made a good-fai? ef=t to comply ) ?is section4 7d7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to p]mit a heal? insurance issu]1 gr\p heal? plan1 or o!r entity to re/rict disclosure to1 or o!rwise limit ! access (1 ! ,secret>y ( ,heal? & ,human ,s]vices to a report describ$ 9 subsection 7b77#a7 or in=mation relat$ to compliance ) subsection 7a7 or 7b7 by su* issu]1 plan1 or o!r entity subject to su* subsections4 7e7 ,def9ition ,9 ?is section1 ! t]m :olesale acquisition co/ has ! mean+ giv5 su* t]m 9 section #ahdg;,a7c77#f77;,b7 ( ! ,social ,security ,act4 2 & 7#b7 9 section #bgbc ( su* ,act 7#db ,u4,s4,c4 #cjj;gg-#bb7-- 7,a7 9 subsection 7a7-- 7i7 9 p>agraph 7#a71 by ins]t+ 7o!r ?an subsections 7a7 & 7b7 ( section #bgii;,a-#aa7 aft] "p ,d2 & 7ii7 9 p>agraph 7#b71 by ins]t+ 7o!r ?an subsections 7a7 & 7b7 ( section #bgii;,a-#aa7 aft] "p ,d2 & 7,b7 9 subsection 7b7-- 7i7 9 p>agraph 7#a71 by ins]t+ 7o!r ?an subsections 7a7 & 7b7 ( section #bgii;,a-#aa7 aft] "p ,d2 7ii7 9 p>agraph 7#b77;,a71 by ins]t+ 7o!r ?an subsections 7a7 & 7b7 ( section #bgii;,a-#aa7 aft] "p ,d2 & 7iii7 9 p>agraph 7#b77;,c77ii71 by ins]t+ 7o!r ?an subsections 7a7 & 7b7 ( section #bgii;,a-#aa7 aft] "p ,d4 7c7 ,,erisa 7#a7 ,9 g5]al ,subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajba et seq47 is am5d$-- 7,a7 9 subp>t ,b ( "p #g 7#bi ,u4,s4,c4 #aahe et seq471 by add+ at ! end ! foll[+3 #gbf4 ,ov]sight ( ph>macy b5efits manag] s]vices 7a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #c ye>s aft] ! date ( enactm5t ( ?is section1 a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 or an entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( su* a plan or issu]1 %all n ent] into a contract ) a drug manufactur]1 di/ributor1 :olesal]1 subcontractor1 rebate aggregator1 or any associat$ ?ird p>ty t limits ! disclosure ( in=mation to plan sponsors 9 su* a mann] t prev5ts ! plan or issu]1 or an entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( a plan or issu]1 f mak+ ! report describ$ 9 subsection 7b74 7b7 ,annual report 7#a7 ,9 g5]al ,) respect to plan ye>s beg9n+ on or aft] ! date t is #c ye>s aft] ! date ( enactm5t ( ?is section1 = ea* su* plan ye>1 a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( su* a plan or an issu]1 %all submit to ! plan sponsor 7z def9$ 9 section #c7af77;,b77 ( su* plan or cov]age a report 9 a ma*9e-readable =mat4 ,ea* su* report %all include1 ) respect to su* plan or cov]age provid$ = su* plan ye>-- 7,a7 to ! ext5t feasible1 in=mation collect$ f drug manufactur]s 7or an entity adm9i/]+ copay assi/ance on behalf ( su* manufactur]s7 by su* plan or issu] 7or entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( su* plan or issu]7 on ! total am\nt ( copaym5t assi/ance doll>s paid1 or copaym5t c>ds appli$1 t 7 fund$ by ! drug manufactur] ) respect to ! p>ticipants1 b5efici>ies1 & enrollees 9 su* plan or cov]age2 7,b7 a li/ ( ea* drug cov]$ by su* plan or cov]age t 0 disp5s$ dur+ ! plan ye>1 includ+1 ) respect to ea* su* drug dur+ su* plan ye>-- 7i7 ! br& "n1 *emical entity1 & ,national ,drug ,code2 7ii7 ! numb] ( p>ticipants1 b5efici>ies1 & enrollees = :om ! drug 0 disp5s$ dur+ ! plan ye>1 ! total numb] ( prescription claims = ! drug 7includ+ orig9al prescriptions & refills71 & ! total numb] ( dosage units ( ! drug disp5s$ across ! plan ye>1 disaggregat$ by disp5s+ *annel 7su* z retail1 mail ord]1 or specialty ph>macy72 7iii7 ! :olesale acquisition co/1 li/$ z co/ p] days supply & co/ p] pill1 or 9 ! case ( a drug 9 ano!r =m1 p] dosage unit2 7iv7 ! total out-(-pocket sp5d+ by p>ticipants1 b5efici>ies1 & enrollees on su* drug1 includ+ p>ticipant1 b5efici>y1 & enrollee sp5d+ ?r\gh copaym5ts1 co9surance1 & d$uctibles2 7v7 = any drug = :i* gross sp5d+ ( ! gr\p heal? plan or heal? insurance cov]age exce$$ #aj1jjj dur+ ! plan ye>-- 7,i7 a li/ ( all o!r drugs 9 ! same !rapeutic category or class1 includ+ br& "n drugs & biological products & g5]ic drugs or biosimil> biological products t are 9 ! same !rapeutic category or class z su* drug2 & 7,,ii7 ! rationale = ! =mul>y placem5t ( su* drug 9 t !rapeutic category or class1 if applicable2 7vi7 ! am\nt receiv$1 or expect$ to be receiv$1 f drug manufactur]s 9 rebates1 fees1 alt]native disc\nts1 or o!r remun]ation = claims incurr$ = su* drug dur+ ! plan ye>2 7vii7 ! total net sp5d+1 aft] d$uct+ rebates1 price concessions1 alt]native disc\nts or o!r remun]ation f drug manufactur]s1 by ! heal? plan or heal? insurance cov]age on su* drug2 & 7viii7 ! net price p] c\rse ( treatm5t or s+le fill1 su* z a #cj-;day supply or #ij-;day supply1 incurr$ by ! heal? plan or heal? insurance cov]age & its p>ticipants1 b5efici>ies1 & enrollees1 aft] manufactur] rebates1 fees1 & o!r remun]ation = su* drug disp5s$ dur+ ! plan ye>2 7,c7 a li/ ( ea* !rapeutic category or class ( drugs t 7 disp5s$ "u ! heal? plan or heal? insurance cov]age dur+ ! plan ye>1 &1 ) respect to ea* su* !rapeutic category or class ( drugs1 dur+ ! plan ye>-- 7i7 total gross sp5d+ by ! plan or cov]age1 be=e manufactur] rebates1 fees1 or o!r manufactur] remun]ation2 7ii7 ! numb] ( p>ticipants1 b5efici>ies1 & enrollees :o 7 disp5s$ a drug cov]$ by su* plan or cov]age 9 t category or class1 brok5 d[n by ea* su* drug 7id5tifi$ by ,national ,drug ,code72 7iii7 if applicable to t category or class1 a description ( ! =mul>y ti]s & utilization managem5t 7su* z prior au?orization or /ep !rapy7 employ$ = drugs 9 t category or class2 & 7iv7 ! total out-(-pocket sp5d+ by p>ticipants1 b5efici>ies1 & enrollees1 includ+ p>ticipant1 b5efici>y1 & enrollee sp5d+ ?r\gh copaym5ts1 co9surance1 & d$uctibles2 7,d7 total gross sp5d+ on prescription drugs by ! plan or cov]age dur+ ! plan ye>1 be=e rebates & o!r manufactur] fees or remun]ation2 7,e7 total am\nt receiv$1 or expect$ to be receiv$1 by ! heal? plan or heal? insurance cov]age 9 drug manufactur] rebates1 fees1 alt]native disc\nts1 & all o!r remun]ation receiv$ f ! manufactur] or any ?ird p>ty1 o!r ?an ! plan sponsor1 relat$ to utilization ( drug or drug sp5d+ "u t heal? plan or heal? insurance cov]age dur+ ! plan ye>2 7,f7 ! total net sp5d+ on prescription drugs by ! heal? plan or heal? insurance cov]age dur+ ! plan ye>2 & 7,g7 am\nts paid directly or indirectly 9 rebates1 fees1 or any o!r type ( remun]ation to brok]s1 consultants1 advisors1 or any o!r individual or firm = ! ref]ral ( ! gr\p heal? plan's or heal? insurance issu]'s bus9ess to ! ph>macy b5efits manag]4 7#b7 ,privacy requirem5ts ,heal? insurance issu]s (f]+ gr\p heal? insurance cov]age & entities provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan %all provide in=mation "u p>agraph 7#a7 9 a mann] consi/5t ) ! privacy1 security1 & brea* notification regulations promulgat$ "u section #bfd7;c7 ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 & %all re/rict ! use & disclosure ( su* in=mation accord+ to su* privacy regulations4 7#c7 ,disclosure & r$isclosure 7,a7 ,limitation to bus9ess associates ,a gr\p heal? plan receiv+ a report "u p>agraph 7#a7 may disclose su* in=mation only to bus9ess associates ( su* plan z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations74 7,b7 ,cl>ification reg>d+ public disclosure ( in=mation ,no?+ 9 ?is section prev5ts a heal? insurance issu] (f]+ gr\p heal? insurance cov]age or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan f plac+ reasonable re/rictions on ! public disclosure ( ! in=mation conta9$ 9 a report describ$ 9 p>agraph 7#a71 except t su* issu] or entity may n re/rict disclosure ( su* report to ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 ! ,dep>tm5t ( ! ,treasury1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates1 or applicable ,/ate ag5cies4 7,c7 ,limit$ =m ( report ,! ,secret>y %all def9e ?r\gh rulemak+ a limit$ =m ( ! report "u p>agraph 7#a7 requir$ ( plan sponsors :o are drug manufactur]s1 drug :olesal]s1 or o!r direct p>ticipants 9 ! drug supply *a91 9 ord] to prev5t anti-competitive behavior4 7#d7 ,report to ,,gao ,a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan %all submit to ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates ea* ( ! fir/ #d reports submitt$ to a plan sponsor "u p>agraph 7#a7 ) respect to su* cov]age or plan1 & o!r su* reports z reque/$1 9 accordance ) ! privacy requirem5ts "u p>agraph 7#b71 ! disclosure & r$isclosure /&>ds "u p>agraph 7#c71 ! /&>ds specifi$ pursuant to p>agraph 7#e71 & su* o!r in=mation t ! ,comptroll] ,g5]al det]m9es necess>y to c>ry out ! /udy "u section #ajc7;d7 ( ! ,heal? ,c>e ,price ,transp>5cy ,act ( #bjbc4 7#e7 ,/&>d =mat ,n lat] ?an #ah mon?s aft] ! date ( enactm5t ( ?is section1 ! ,secret>y %all specify ?r\gh rulemak+ /&>ds = heal? insurance issu]s & entities requir$ to submit reports "u p>agraph 7#d7 to submit su* reports 9 a /&>d =mat4 7c7 ,en=cem5t 7#a7 ,9 g5]al ,not)/&+ section #ejb1 ! ,secret>y1 9 consultation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ! ,treasury1 %all en=ce ?is section4 7#b7 ,failure to provide timely in=mation ,a heal? insurance issu] or an entity provid+ ph>macy b5efits managem5t s]vices t violates subsection 7a7 or fails to provide in=mation requir$ "u subsection 7b7 %all be subject to a civil monet>y p5alty 9 ! am\nt ( #aj1jjj = ea* day dur+ :i* su* violation cont9ues or su* in=mation is n disclos$ or report$4 7#c7 ,false in=mation ,a heal? insurance issu] or entity provid+ ph>macy b5efits managem5t s]vices t kn[+ly provides false in=mation "u ?is section %all be subject to a civil money p5alty 9 an am\nt n to exce$ #ajj1jjj = ea* item ( false in=mation4 ,su* civil money p5alty %all be 9 addition to o!r p5alties z may be prescrib$ by law4 7#d7 ,proc$ure ,! provisions ( section #aabh;,a ( ! ,social ,security ,act1 o!r ?an subsection 7a7 & 7b7 & ! fir/ s5t5ce ( subsection 7c77#a7 ( su* section %all apply to civil monet>y p5alties "u ?is subsection 9 ! same mann] z su* provisions apply to a p5alty or proce$+ "u section #aabh;,a ( ! ,social ,security ,act4 7#e7 ,waiv]s ,! ,secret>y may waive p5alties "u p>agraph 7#b71 or ext5d ! p]iod ( "t = compliance ) a requirem5t ( ?is section1 = an entity 9 violation ( ?is section t has made a good-fai? ef=t to comply ) ?is section4 7d7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to p]mit a heal? insurance issu]1 gr\p heal? plan1 or o!r entity to re/rict disclosure to1 or o!rwise limit ! access (1 ! ,secret>y ( ,labor to a report describ$ 9 subsection 7b77#a7 or in=mation relat$ to compliance ) subsection 7a7 or 7b7 by su* issu]1 plan1 or o!r entity subject to su* subsections4 7e7 ,def9ition ,9 ?is section1 ! t]m :olesale acquisition co/ has ! mean+ giv5 su* t]m 9 section #ahdg;,a7c77#f77;,b7 ( ! ,social ,security ,act4 2 & 7,b7 9 section #ejb 7#bi ,u4,s4,c4 #aacb7-- 7i7 9 subsection 7a7-- 7,i7 9 p>agraph 7#f71 by /rik+ or 7#i7 & ins]t+ 7#i71 or 7#ac72 7,,ii7 9 p>agraph 7#aj71 by /rik+ at ! end or2 7,,iii7 9 p>agraph 7#aa71 at ! end by /rik+ ! p]iod & ins]t+ 2 or2 & 7,,iv7 by add+ at ! end ! foll[+ new p>agraph3 7#ab7 by ! ,secret>y1 9 consultation ) ! ,secret>y ( ,heal? & ,human ,s]vices1 & ! ,secret>y ( ! ,treasury1 to en=ce section #gbf4 2 7ii7 9 subsection 7b77#c71 by ins]t+ & subsections 7a77#ab7 & 7c77#ac7 be=e 1 ! ,secret>y is n2 & 7iii7 9 subsection 7c71 by add+ at ! end ! foll[+ new p>agraph3 7#ac7 ,secret>ial en=cem5t au?ority relat+ to ov]sight ( ph>macy b5efits manag] s]vices 7,a7 ,failure to provide timely in=mation ,! ,secret>y1 9 consultation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ! ,treasury1 may impose a p5alty aga9/ any gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 or entity provid+ ph>macy b5efits managem5t s]vices on behalf ( su* plan or cov]age1 t violates section #gbf7;a7 or fails to provide in=mation requir$ "u section #gbf7;b71 9 ! am\nt ( #aj1jjj = ea* day dur+ :i* su* violation cont9ues or su* in=mation is n disclos$ or report$4 7,b7 ,false in=mation ,! ,secret>y1 9 consultation ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ! ,treasury1 may impose a p5alty aga9/ a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? cov]age1 or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( su* plan or cov]age1 t kn[+ly provides false in=mation "u section #gbf 9 an am\nt n to exce$ #ajj1jjj = ea* item ( false in=mation4 ,su* p5alty %all be 9 addition to o!r p5alties z may be prescrib$ by law4 7,c7 ,waiv]s ,! ,secret>y may waive p5alties "u subp>agraph 7,a71 or ext5d ! p]iod ( "t = compliance ) a requirem5t ( section #gbf1 = an entity 9 violation ( su* section t has made a good-fai? ef=t to comply ) su* section4 4 7#b7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajja et seq47 is am5d$ by ins]t+ aft] ! item relat+ to section #gbe ! foll[+ new item3 ,sec4 #gbf4 ,ov]sight ( ph>macy b5efits manag] s]vices4 4 7d7 ,,gao /udy 7#a7 ,9 g5]al ,n lat] ?an #c ye>s aft] ! date ( enactm5t ( ?is ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report on-- 7,a7 ph>macy networks ( gr\p heal? plans1 heal? insurance issu]s1 & entities provid+ ph>macy b5efits managem5t s]vices "u su* gr\p heal? plan or gr\p or individual heal? insurance cov]age1 includ+ networks t h ph>macies t are "u common own]%ip 79 :ole or "p7 ) gr\p heal? plans1 heal? insurance issu]s1 or entities provid+ ph>macy b5efits managem5t s]vices or ph>macy b5efits adm9i/rative s]vices "u gr\p heal? plan or gr\p or individual heal? insurance cov]age2 7,b7 z x relates to ph>macy networks t include ph>macies "u common own]%ip describ$ 9 subp>agraph 7,a7-- 7i7 :e!r su* networks are design$ to enc\rage enrollees ( a plan or cov]age to use su* ph>macies ov] o!r network ph>macies = specific s]vices or drugs1 & if s1 ! reasons ! networks give = enc\rag+ use ( su* ph>macies2 & 7ii7 :e!r su* ph>macies are us$ by enrollees disproportionately m 9 ! aggregate or = specific s]vices or drugs comp>$ to o!r network ph>macies2 7,c7 :e!r gr\p heal? plans & heal? insurance issu]s (f]+ gr\p or individual heal? insurance cov]age h options to elect diff]5t network pric+ arrangem5ts 9 ! m>ketplace ) entities t provide ph>macy b5efits managem5t s]vices1 ! preval5ce ( elect+ su* diff]5t network pric+ arrangem5ts2 7,d7 ph>macy network design p>amet]s t enc\rage enrollees 9 ! plan or cov]age to fill prescriptions at mail ord]1 specialty1 or retail ph>macies t are :olly or p>tially-own$ by t issu] or entity2 & 7,e7 ! degree to :i* mail ord]1 specialty1 or retail ph>macies t disp5se prescription drugs to an enrollee 9 a gr\p heal? plan or heal? insurance cov]age t are "u common own]%ip 79 :ole or "p7 ) gr\p heal? plans1 heal? insurance issu]s1 or entities provid+ ph>macy b5efits managem5t s]vices or ph>macy b5efits adm9i/rative s]vices "u gr\p heal? plan or gr\p or individual heal? insurance cov]age receive reimbursem5t t is great] ?an ! m$ian price *>g$ to ! gr\p heal? plan or heal? insurance issu] :5 ! same drug is disp5s$ to enrollees 9 ! plan or cov]age by o!r ph>macies includ$ 9 ! ph>macy network ( t plan1 issu]1 or entity t are n :olly or p>tially own$ by ! heal? insurance issu] or entity provid+ ph>macy b5efits managem5t s]vices4 7#b7 ,requirem5t ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all ensure t ! report "u p>agraph 7#a7 does n conta9 in=mation t w\ld all[ a read] to id5tify a specific plan or entity provid+ ph>macy b5efits managem5t s]vices or o!rwise conta9 comm]cial or f9ancial in=mation t is privileg$ or confid5tial4 7#c7 ,def9itions ,9 ?is subsection1 ! 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 #ajd4 ,reports on heal? c>e transp>5cy tools & data requirem5ts 7a7 ,initial report ,n lat] ?an ,decemb] #ca1 #bjbd1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ! ,committees 7z def9$ 9 subsection 7d77 an initial report t-- 7#a7 id5tifies & describes heal? c>e transp>5cy tools & ,f$]al heal? c>e report+ requirem5ts 7z describ$ 9 subsection 7d77 t are 9 effect z ( ! date ( ! submission ( su* initial report1 includ+ ! frequ5cy ( reports ) respect to ea* su* requirem5t & :e!r any su* requirem5ts are duplicative2 7#b7 reviews h[ su* report+ requirem5ts are en=c$2 7#c7 analyzes :e!r ! public availability ( heal? c>e transp>5cy tools1 & ! publication ( data pursuant to su* report+ requirem5ts1 has-- 7,a7 be5 utiliz$ & valu$ by consum]s1 includ+ reasons = su* utilization 7or lack !re(72 & 7,b7 assi/$ heal? insurance plan sponsors & fiduci>ies improve b5efits1 l[] heal? c>e co/s = plan p>ticipants1 & meet fiduci>y requirem5ts2 7#d7 includes recomm5dations to ! ,committees1 ! ,secret>y ( ,heal? & ,human ,s]vices1 ! ,secret>y ( ,labor1 & ! ,secret>y ( ! ,treasury to-- 7,a7 improve ! effici5cy1 accuracy1 & usability ( heal? c>e transp>5cy tools2 7,b7 /reaml9e ,f$]al heal? c>e report+ requirem5ts to elim9ate duplicative requirem5ts & r$uce ! burd5 on entities requir$ to submit reports pursuant to su* provisions2 7,c7 improve ! accuracy & effici5cy ( su* reports :ile ma9ta9+ ! integrity & usability ( ! data provid$ by su* reports2 7,d7 address any gaps 9 data provid$ by su* reports2 & 7,e7 ensure t ! data & in=mation report$ is comp>able & usable to consum]s1 includ+ pati5ts1 plan sponsors1 & policy mak]s4 7b7 ,f9al report ,n lat] ?an ,decemb] #ca1 #bjbh1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ! ,committees a report t includes-- 7#a7 ! in=mation provid$ 9 ! initial report1 along ) any updates to su* in=mation2 & 7#b7 any new in=mation ) respect to heal? c>e transp>5cy tools t h be5 releas$ foll[+ ! submission ( su* initial report1 or new report+ requirem5ts 9 effect z ( ! date ( ! submission ( ! f9al report4 7c7 ,report on exp&+ price transp>5cy requirem5ts ,n lat] ?an ,decemb] #ca1 #bjbe1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates1 9 consultation ) ! ,secret>y ( ,heal? & ,human ,s]vices1 heal? c>e provid] gr\ps1 & pati5t advocacy gr\ps1 %all submit to ! ,committees a report t includes recomm5dations to exp& price transp>5cy report+ requirem5ts to additional c>e sett+s1 ) an emphasis on sett+s :]e %oppable s]vices 7z def9$ 9 subsection 7d77 are furni%$4 7d7 ,def9itions ,9 ?is section3 7#a7 ,committees ,! t]m ,committees means ! ,committee on ,ways & ,means1 ! ,committee on ,en]gy & ,comm]ce1 & ! ,committee on ,education & ! ,work=ce ( ! ,h\se ( ,repres5tatives1 & ! ,committee on ,f9ance & ! ,committee on ,heal?1 ,education1 ,labor1 & ,p5sions ( ! ,s5ate4 7#b7 ,f$]al heal? c>e report+ requirem5ts ,! t]m ,f$]al heal? c>e report+ requirem5ts includes regulatory & /atutory requirem5ts ) respect to ! report+ & publication ( heal? c>e price1 co/ access1 & quality data1 includ+ requirem5ts e/abli%$ by ! ,consolidat$ ,appropriations ,act ( #bjba 7,public ,law #aaf-bfj71 ?is ,act1 & o!r report+ & publication requirem5ts ) respect to transp>5cy 9 heal? c>e z id5tifi$ by ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates4 7#c7 ,%oppable s]vice ,! t]m %oppable s]vice means a s]vice t c be s*$ul$ by a heal? c>e consum] 9 advance & includes all ancill>y items & s]vices cu/om>ily furni%$ z "p ( su* s]vice4 #aje4 ,report on integration 9 ,m$ic>e 7a7 ,requir$ ,,ma & ,,pdp report+ 7#a7 ,,ma plans ,section #aheg7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;e77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#f7 ,requir$ disclosure ( c]ta9 in=mation relat+ to heal? c>e provid] own]%ip 7,a7 ,9 g5]al ,= plan ye> #bjbe & = e ?ird plan ye> !reaft]1 ea* ,,ma organization (f]+ an ,,ma plan "u ?is "p dur+ su* plan ye> %all submit to ! ,secret>y1 at a "t & 9 a mann] specifi$ by ! ,secret>y-- 7i7 ! taxpay] id5tification numb] = ea* heal? c>e provid] t 0 a specifi$ heal? c>e provid] ) respect to su* organization dur+ su* ye>2 7ii7 ! total am\nt ( inc5tive-bas$ paym5ts made to1 & ! total am\nt ( %>$ losses rec\pm5ts collect$ f1 su* specifi$ heal? c>e provid]s dur+ su* plan ye>2 & 7iii7 ! total am\nt ( inc5tive-bas$ paym5ts made to1 & ! total am\nt ( %>$ losses rec\pm5ts collect$ f1 provid]s ( s]vices & suppli]s n describ$ 9 clause 7ii7 dur+ su* plan ye>4 7,b7 ,def9ition ,= purposes ( ?is p>agraph1 ! t]m specifi$ heal? c>e provid] means1 ) respect to an ,,ma organization & a plan ye>1 a provid] ( s]vices or suppli] ) respect to :i* su* organization 7or any p]son ) an own]%ip or control int]e/ 7z def9$ 9 section #aabd7;a77#c77 9 su* organization7 is a p]son ) an own]%ip or control int]e/ 7z s def9$74 4 7#b7 ,prescription drug plans ,section #ahfj;,d-#ab7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aab7;b77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#i7 ,provision ( in=mation relat+ to ph>macy own]%ip 7,a7 ,9 g5]al ,= plan ye> #bjbe & = e ?ird plan ye> !reaft]1 ea* ,,pdp sponsor (f]+ a prescription drug plan "u ?is "p dur+ su* plan ye> %all submit to ! ,secret>y1 at a "t & 9 a mann] specifi$ by ! ,secret>y1 ! taxpay] id5tification numb] & ,national ,provid] ,id5tifi] = ea* ph>macy t 0 a specifi$ ph>macy ) respect to su* sponsor dur+ su* ye>4 7,b7 ,def9ition ,= purposes ( ?is p>agraph1 ! t]m specifi$ ph>macy means1 ) respect to an ,,pdp sponsor (f]+ a prescription drug plan & a plan ye>1 a ph>macy ) respect to :i*-- 7i7 su* sponsor 7or any p]son ) an own]%ip or control int]e/ 7z def9$ 9 section #aabd7;a77#c77 9 su* sponsor7 is a p]son ) an own]%ip or control int]e/ 7z s def9$72 or 7ii7 a ph>macy b5efit manag] (f]+ s]vices "u su* plan 7or any p]son ) an own]%ip or control int]e/ 7z s def9$7 9 su* sponsor7 is a p]son ) an own]%ip or control int]e/ 7z s def9$74 4 7b7 ,med,p,a,c reports ,"p ,e ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex et seq471 z am5d$ by section #aja1 is fur!r am5d$ by add+ at ! end ! foll[+ new section3 #ahii;,d4 ,reports on v]tical integration "u ,m$ic>e 7a7 ,9 g5]al ,n lat] ?an ,june #ae1 #bjbi1 & e #c ye>s !reaft]1 ! ,m$ic>e ,paym5t ,advisory ,commission %all submit to ,congress a report on ! /ate ( v]tical integration 9 ! heal? c>e sector dur+ ! applicable ye> ) respect to entities p>ticipat+ 9 ! ,m$ic>e program1 includ+ heal? c>e provid]s1 ph>macies1 prescription drug plan sponsors1 ,m$ic>e ,advantage organizations1 & ph>macy b5efit manag]s4 ,su* report %all include-- 7#a7 ) respect to ,m$ic>e ,advantage organizations1 ! evaluation describ$ 9 subsection 7b72 7#b7 ) respect to prescription drug plans1 ph>macy b5efit manag]s1 & ph>macies1 ! comp>isons & evaluations describ$ 9 subsection 7c72 7#c7 ) respect to ,m$ic>e ,advantage plans "u :i* b5efits are available = physician-adm9i/]$ drugs1 ! in=mation describ$ 9 subsection 7d72 & 7#d7 ! id5tifications describ$ 9 subsection 7e72 & 7#e7 an analysis ( ! impact ( su* integration on heal? c>e access1 price1 quality1 & outcomes4 7b7 ,m$ic>e ,advantage organizations ,= purposes ( subsection 7a77#a71 ! evaluation describ$ 9 ?is subsection is1 ) respect to ,m$ic>e ,advantage organizations & an applicable ye>1 an evaluation1 tak+ into acc\nt pati5t acuity & ! types ( areas s]vic$ by su* organization1 (-- 7#a7 ! av]age numb] ( qualify+ diagnoses made dur+ su* ye> ) respect to enrollees ( a ,m$ic>e ,advantage plan (f]$ by su* organization :o1 dur+ su* ye>1 receiv$ a heal? risk assessm5t f a specifi$ heal? c>e provid]2 7#b7 ! av]age risk score = su* enrollees :o receiv$ su* an assessm5t dur+ su* ye>2 7#c7 any relation%ip betwe5 su* risk scores = su* enrollees receiv+ su* an assessm5t f su* a provid] dur+ su* ye> & inc5tive paym5ts made to su* provid]s2 7#d7 ! av]age risk score = enrollees ( su* plan :o receiv$ any item or s]vice f a specifi$ heal? c>e provid] dur+ su* ye>2 7#e7 any relation%ip betwe5 ! risk scores ( enrollees "u su* plan & :e!r ! enrollees h receiv$ any item or s]vice f a specifi$ provid]2 & 7#f7 any relation%ip betwe5 ! risk scores ( enrollees "u su* plan t h receiv$ any item or s]vice f a specifi$ provid] & inc5tive paym5ts made "u ! plan to specifi$ provid]s4 7c7 ,prescription drug plans ,= purposes ( subsection 7a77#b71 ! comp>isons & evaluations describ$ 9 ?is subsection are1 ) respect to prescription drug plans & an applicable ye>1 ! foll[+3 7#a7 ,= ea* cov]$ "p ,d drug = :i* b5efits are available "u su* a plan1 a comp>ison ( ! av]age negotiat$ rate 9 effect ) specifi$ ph>macies ) su* rates 9 effect = 9-network ph>macies t are n specifi$ ph>macies4 7#b7 ,comp>isons ( ! foll[+3 7,a7 ,! total am\nt paid by ph>macy b5efit manag]s to specifi$ ph>macies = cov]$ "p ,d drugs & ! total am\nt s paid to ph>macies t are n specifi$ ph>macies = su* drugs4 7,b7 ,! total am\nt paid by su* sponsors to specifi$ ph>macy b5efit manag]s z reimbursem5t = cov]$ "p ,d drugs & ! total am\nt s paid to ph>macy b5efit manag]s t are n specifi$ ph>macy b5efit manag]s z su* reimbursem5t4 7,c7 ,fees paid "u by plan to specifi$ ph>macy b5efit manag]s comp>$ to su* fees paid to ph>macy b5efit manag]s t are n specifi$ ph>macy b5efit manag]s4 7#c7 ,an evaluation ( ! total am\nt ( direct & indirect remun]ation = cov]$ "p ,d drugs pass$ ?r\gh to prescription drug plan sponsors & ! total am\nt reta9$ by ph>macy b5efit manag]s 7includ+ entities "u contract ) su* a manag]74 7#d7 ,to ! ext5t t ! available data p]mits1 an evaluation ( fees *>g$ by rebate aggregators t are affiliat$ ) plan sponsors4 7d7 ,physician-,adm9i/]$ drugs ,= purposes ( subsection 7a77#c71 ! in=mation describ$ 9 ?is subsection is1 ) respect to physician-adm9i/]$ drugs = :i* b5efits are available "u a ,m$ic>e ,advantage plan dur+ an applicable ye>1 ! foll[+3 7#a7 ,) respect to ea* su* plan1 an id5tification ( ea* drug = :i* b5efits 7 available "u su* plan only :5 adm9i/]$ by a heal? c>e provid] t acquir$ su* drug f an affiliat$ ph>macy4 7#b7 ,an evaluation ( ! diff]5ce betwe5 ! total numb] ( drugs adm9i/]$ by a heal? c>e provid] t 7 acquir$ f affiliat$ ph>macies comp>$ to ! numb] ( su* drugs s adm9i/]$ t 7 acquir$ f ph>macies o!r ?an affiliat$ ph>macies1 & an evaluation ( ! diff]5ce 9 paym5ts = su* drugs s adm9i/]$ :5 acquir$ f a specifi$ ph>macy & :5 acquir$ f a ph>macy t is n a specifi$ ph>macy4 7#c7 ,an evaluation ( ! doll> value ( all su* drugs t 7 n s adm9i/]$ because ( a delay attributable to an affiliat$ ph>macy comp>$ to ! doll> value ( all su* drugs t 7 n s adm9i/]$ because ( a delay attributable to ph>macy t is n an affiliat$ ph>macy4 7#d7 ,! numb] ( enrollees adm9i/]$ su* a drug t 0 acquir$ f an affiliat$ ph>macy4 7#e7 ,! numb] ( enrollees furni%$ su* a drug t 0 acquir$ f a ph>macy t is n an affiliat$ ph>macy4 7e7 ,id5tifications ,= purposes ( subsection 7a77#d71 ! id5tifications describ$ 9 ?is subsection are1 ) respect to an applicable ye>1 id5tifications ( ea* heal? c>e entity p>ticipat+ "u ! ,m$ic>e program ) respect to :i* ano!r heal? c>e entity s p>ticipat+ is a p]son ) an own]%ip or control int]e/ 7z def9$ 9 section #aabd7;a77#c774 7f7 ,def9itions ,9 ?is section3 7#a7 ,affiliat$ ph>macy ,! t]m affiliat$ ph>macy means1 ) respect to a ,m$ic>e ,advantage plan (f]$ by a ,m$ic>e ,advantage organization1 a ph>macy ) respect to :i* su* organization 7or any p]son ) an own]%ip or control int]e/ 7z def9$ 9 section #aabd7;a77#c77 9 su* organization7 is a p]son ) an own]%ip or control int]e/ 7z s def9$74 7#b7 ,applicable ye> ,! t]m applicable ye> means1 ) respect to a report submitt$ "u subsection 7a71 ! fir/ cal5d> ye> beg9n+ at lea/ #d ye>s prior to ! date ( ! submission ( su* report4 7#c7 ,cov]$ "p ,d drug ,! t]m cov]$ "p ,d drug has ! mean+ giv5 su* t]m 9 section #ahfj;,d-#b7;e74 7#d7 ,direct & indirect remun]ation ,! t]m direct & indirect remun]ation has ! mean+ giv5 su* t]m 9 section #dbc4cjh ( title #db1 ,code ( ,f$]al ,regulations 7or any successor regulation74 7#e7 ,qualify+ diagnosis ,! t]m qualify+ diagnosis means1 ) respect to an enrollee ( a ,m$ic>e ,advantage plan1 a diagnosis t is tak5 into acc\nt 9 calculat+ a risk score = su* enrollee "u ! risk adju/m5t me?odology e/abli%$ by ! ,secret>y pursuant to section #ahec7;a77#c74 7#f7 ,risk score ,! t]m risk score means1 ) respect to an enrollee ( a ,m$ic>e ,advantage plan1 ! score calculat$ = su* individual us+ ! me?odology describ$ 9 p>agraph 7#e74 7#g7 ,physician-adm9i/]$ drug ,! t]m physician-adm9i/]$ drug means a drug furni%$ to an individual t1 _h su* individual be5 enroll$ "u "p ,b & n enroll$ "u "p ,c1 w\ld h be5 payable "u section #ahdb7o74 7#h7 ,specifi$ heal? c>e provid] ,! t]m specifi$ heal? c>e provid] means1 ) respect to a ,m$ic>e ,advantage plan (f]$ by a ,m$ic>e ,advantage organization1 a heal? c>e provid] ) respect to :i* su* organization 7or any p]son ) an own]%ip or control int]e/ 7z def9$ 9 section #aabd7;a77#c77 9 su* organization7 is a p]son ) an own]%ip or control int]e/ 7z s def9$74 7#i7 ,specifi$ ph>macy ,! t]m specifi$ ph>macy means1 ) respect to a prescription drug plan (f]$ by a prescription drug plan sponsor1 a ph>macy ) respect to :i*-- 7,a7 su* sponsor 7or any p]son ) an own]%ip or control int]e/ 7z def9$ 9 section #aabd7;a77#c77 9 su* sponsor7 is a p]son ) an own]%ip or control int]e/ 7z s def9$72 or 7,b7 a ph>macy b5efit manag] (f]+ s]vices "u su* plan 7or any p]son ) an own]%ip or control int]e/ 7z s def9$7 9 su* sponsor7 is a p]son ) an own]%ip or control int]e/ 7z s def9$74 7#aj7 ,specifi$ ph>macy b5efit manag] ,! t]m specifi$ ph>macy b5efit manag] means1 ) respect to a prescription drug plan (f]$ by a prescription drug plan sponsor1 a ph>macy b5efit manag] ) respect to :i* su* sponsor 7or any p]son ) an own]%ip or control int]e/ 7z def9$ 9 section #aabd7;a77#c77 9 su* sponsor7 is a p]son ) an own]%ip or control int]e/ 7z s def9$74 4 ,,ii ,fair ,prices = ,pati5ts #bja4 ,limitation on co/ %>+ to net price am\nt "u ,m$ic>e "p ,d 7a7 ,9 g5]al ,section #ahfj;,d-#b ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajb7 is am5d$-- 7#a7 9 subsection 7b7-- 7,a7 9 p>agraph 7#b77;,a71 by /rik+ 7#h7 & 7#i7 & ins]t+ 7#h71 7#i71 & 7#aj72 7,b7 9 p>agraph 7#i77;,b77ii71 by /rik+ ,= a plan ye> & ins]t+ ,subject to p>agraph 7#aj71 = a plan ye>2 & 7,c7 by add+ at ! end ! foll[+ new p>agraph3 7#aj7 ,limitation on co/ %>+ to net price am\nt 7,a7 ,9 g5]al ,= a plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbg1 ! cov]age provides b5efits = a supply ( a cov]$ "p ,d drug disp5s$ by a ph>macy1 = co/s 9 excess ( ! d$uctible specifi$ 9 p>agraph 7#a7 & prior to an individual rea*+ ! out-(-pocket ?re%old "u p>agraph 7#d71 ) co/-%>+ = a mon?'s supply t does n exce$ ! av]age net price = su* a supply ( su* drug dur+ su* plan ye> 7or1 if l[]1 ! applicable ca% price = su* a supply ( su* drug s disp5s$ by su* ph>macy74 7,b7 ,def9itions ,9 ?is p>agraph3 7i7 ,applicable ca% price ,! t]m applicable ca% price means1 ) respect to a supply ( a cov]$ "p ,d drug disp5s$ by a ph>macy1 ! price t su* ph>macy w\ld *>ge = su* supply ( su* drug disp5s$ to an individual )\t b5efits = su* drug "u any ,f$]al heal? c>e program 7z def9$ 9 section #aabh;,b71 a gr\p heal? plan or gr\p or individual heal? insurance cov]age 7z su* t]ms are def9$ 9 section #bgia ( ! ,public ,heal? ,s]vice ,act71 or ! program e/abli%$ "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code4 7ii7 ,av]age net price ,! t]m av]age net price means1 ) respect to a supply ( a cov]$ "p ,d drug1 a prescription drug plan1 & a plan ye>1 ! av]age am\nt paid "u su* plan 7includ+ any am\nts paid by an individual enroll$ "u su* plan z co/ %>+ = su* drug7 z paym5t = su* a supply ( su* drug disp5s$ dur+ su* ye>1 less any rebates or o!r =ms ( remun]ation receiv$ "u su* plan ) respect to su* drug4 2 & 7#b7 9 subsection 7c71 by add+ at ! end ! foll[+ new p>agraph3 7#g7 ,co/ %>+ limit$ to net price ,! cov]age is provid$ 9 accordance ) subsection 7b77#aj74 4 7b7 ,con=m+ am5dm5t to co/-,%>+ = l[-,income individuals ,section #ahfj;,d-#ad7;a77#a77;,d77iii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aad7;a77#a77;,d77iii77 is am5d$ by add+ at ! end ! foll[+ new s5t5ce3 ,= plan ye> #bjbg & subsequ5t plan ye>s1 ! copaym5t am\nt applicable "u ?is clause to a supply ( a cov]$ "p ,d drug disp5s$ to ! individual may n exce$ ! am\nt provid$ "u section #ahfj;,d-#b7;b77#aj744 7c7 ,,gao report ,n lat] ?an ,janu>y #a1 #bjbi1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report conta9+-- 7#a7 an analysis ( compliance ) ! am5dm5ts made by ?is section2 7#b7 an analysis ( en=cem5t ( su* am5dm5ts2 7#c7 recomm5dations ) respect to improv+ su* en=cem5t2 & 7#d7 recomm5dations relat+ to improv+ public disclosure1 & public aw>5ess (1 ! requirem5ts ( su* am5dm5ts4 #bjb4 ,requir+ a sep>ate id5tification numb] & an atte/ation = ea* (f-campus outpati5t dep>tm5t ( a provid] 7a7 ,9 g5]al ,section #ahcc7t7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#bc7 ,use ( unique heal? id5tifi]s2 atte/ation 7,a7 ,9 g5]al ,no paym5t may be made "u ?is subsection 7or "u an applicable paym5t sy/em pursuant to p>agraph 7#ba77 = items & s]vices furni%$ on or aft] ,janu>y #a1 #bjbf1 by an (f-campus outpati5t dep>tm5t ( a provid] 7z def9$ 9 subp>agraph 7,c77 unless-- 7i7 su* dep>tm5t has obta9$1 & su* items & s]vices are bill$ "u1 a /&>d unique heal? id5tifi] = heal? c>e provid]s 7z describ$ 9 section #aagc7;b77 t is sep>ate f su* id5tifi] = su* provid]2 & 7ii7 su* provid] has submitt$ to ! ,secret>y1 dur+ ! #b-ye> p]iod end+ on ! date su* items & s]vices are s furni%$1 an atte/ation t su* dep>tm5t is compliant ) ! requirem5ts describ$ 9 section #dac4fe ( title #db1 ,code ( ,f$]al ,regulations 7or a successor regulation74 7,b7 ,process = submission & review ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is p>agraph1 ! ,secret>y %all1 ?r\gh notice & comm5t rulemak+1 e/abli% a process = ea* provid] ) an (f-campus outpati5t dep>tm5t ( a provid] to submit an atte/ation pursuant to subp>agraph 7,a77ii71 & = ! ,secret>y to review ea* su* atte/ation & det]m9e1 ?r\gh site visits1 remote audits1 or o!r means 7z det]m9$ appropriate by ! ,secret>y71 :e!r su* dep>tm5t is compliant ) ! requirem5ts describ$ 9 su* subp>agraph4 7,c7 ,(f-campus outpati5t dep>tm5t ( a provid] def9$ ,= purposes ( ?is p>agraph1 ! t]m (f-campus outpati5t dep>tm5t ( a provid] means a dep>tm5t ( a provid] 7z def9$ 9 section #dac4fe ( title #db1 ,code ( ,f$]al ,regulations1 or any successor regulation7 t is n locat$-- 7i7 on ! campus 7z def9$ 9 su* section7 ( su* provid]2 or 7ii7 )9 ! di/ance 7describ$ 9 su* def9ition ( campus7 f a remote location ( a hospital facility 7z def9$ 9 su* section74 4 7b7 ,,hhs ,,oig analysis ,n lat] ?an ,janu>y #a1 #bjcj1 ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices %all submit to ,congress-- 7#a7 an analysis ( ! process e/abli%$ by ! ,secret>y ( ,heal? & ,human ,s]vices to conduct ! reviews & det]m9ations describ$ 9 section #ahcc7t77#bc77;,b7 ( ! ,social ,security ,act1 z add$ by subsection 7a7 ( ?is section2 & 7#b7 recomm5dations bas$ on su* analysis1 z ! ,inspector ,g5]al det]m9es appropriate4 #bjc4 ,p>ity 9 ,m$ic>e paym5ts = hospital outpati5t dep>tm5t s]vices furni%$ (f-campus 7a7 ,9 g5]al ,section #ahcc7t77#af7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#af77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,h7 ,p>ity 9 fee s*$ule am\nt = c]ta9 s]vices furni%$ by an (f-campus outpati5t dep>tm5t ( a provid] 7i7 ,9 g5]al ,subject to clause 7iii71 9 ! case ( specifi$ ,,opd s]vices 7z def9$ 9 clause 7v77 t are furni%$ dur+ #bjbe or a subsequ5t ye> by an (f-campus outpati5t dep>tm5t ( a provid] 7z def9$ 9 clause 7iv77 7or1 9 ! case ( an (f-campus outpati5t dep>tm5t ( a provid] t is a hospital describ$ 9 section #ahhf7;d77#a77;,b77v71 or is locat$ 9 a rural area or a heal? pr(essional %ortage area1 su* s]vices t are furni%$ dur+ #bjbf or a subsequ5t ye>71 !re %all be sub/itut$ = ! am\nt o!rwise det]m9$ "u ?is subsection = su* s]vice & ye> an am\nt equal to ! paym5t am\nt t w\ld h be5 payable "u ! applicable paym5t sy/em "u ?is "p 7o!r ?an "u ?is subsection7 _h su* s]vices be5 furni%$ by su* a dep>tm5t subject to su* paym5t sy/em pursuant to p>agraph 7#ba77;,c74 7ii7 ,n budget neutral implem5tation ,9 mak+ any budget neutrality adju/m5ts "u ?is subsection = #bjbe or a subsequ5t ye>1 ! ,secret>y %all n take into acc\nt ! r$uc$ exp5ditures t result f ! application ( ?is subp>agraph4 7iii7 ,transition ,! ,secret>y %all provide = a #d-ye> phase-9 ( ! application ( clause 7i71 ) clause 7i7 be+ fully applicable = specifi$ ,,opd s]vices beg9n+ ) #bjbh 7or 9 ! case ( an (f-campus outpati5t dep>tm5t ( a provid] t is a hospital describ$ 9 section #ahhf7;d77#a77;,b77v71 or is locat$ 9 a rural area or a heal? pr(essional %ortage area1 beg9n+ ) #bjbi74 7iv7 ,(f-campus dep>tm5t ( a provid] ,= purposes ( ?is subp>agraph1 ! t]m (f-campus outpati5t dep>tm5t ( a provid] means a dep>tm5t ( a provid] 7z def9$ 9 section #dac4fe7;a77#b7 ( title #db1 ,code ( ,f$]al ,regulations7 t is n locat$-- 7,i7 on ! campus 7z su* t]m is def9$ 9 su* section7 ( su* provid]2 or 7,,ii7 )9 ! di/ance 7describ$ 9 su* def9ition ( campus7 f a remote location ( a hospital facility 7z def9$ 9 su* section74 7v7 ,o!r def9itions ,= purposes ( ?is subp>agraph3 7,i7 ,designat$ ambulatory paym5t classification gr\p ,! t]m designat$ ambulatory paym5t classification gr\p means an ambulatory paym5t classification gr\p = drug adm9i/ration s]vices4 7,,ii7 ,heal? pr(essional %ortage area ,! t]m heal? pr(essional %ortage area has ! mean+ giv5 su* t]m 9 section #ccb7;a77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act4 7,,iii7 ,rural area ,! t]m rural area has ! mean+ giv5 su* t]m 9 section #ahhf7;d77#b77;,d74 7,,iv7 ,specifi$ ,,opd s]vices ,! t]m specifi$ ,,opd s]vices means cov]$ ,,opd s]vices assign$ to a designat$ ambulatory paym5t classification gr\p4 4 7b7 ,implem5tation ,section #ahcc7t77#ab7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#ab77 is am5d$-- 7#a7 9 subp>agraph 7,d71 by /rik+ & at ! end2 7#b7 9 subp>agraph 7,e71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7#c7 by add+ at ! end ! foll[+ new subp>agraph3 7,f7 ! det]m9ation ( any paym5t am\nt "u p>agraph 7#af77;,h71 includ+ ! transition "u clause 7iii7 ( su* p>agraph4 4 ,,iii ,pati5t-,focus$ ,inve/m5ts #cja4 ,e/abli%+ requirem5ts ) respect to ! use ( prior au?orization "u ,m$ic>e ,advantage plans 7a7 ,9 g5]al ,section #aheb ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7o7 ,prior au?orization requirem5ts 7#a7 ,9 g5]al ,9 ! case ( a ,m$ic>e ,advantage plan t imposes any prior au?orization requirem5t ) respect to any applicable item or s]vice 7z def9$ 9 p>agraph 7#e77 dur+ a plan ye>1 su* plan %all-- 7,a7 beg9n+ ) ! ?ird plan ye> beg9n+ aft] ! date ( ! enactm5t ( ?is subsection-- 7i7 e/abli% ! electronic prior au?orization program describ$ 9 p>agraph 7#b72 & 7ii7 meet ! enrollee protection /&>ds specifi$ pursuant to p>agraph 7#d72 & 7,b7 beg9n+ ) ! f\r? plan ye> beg9n+ aft] ! date ( ! enactm5t ( ?is subsection1 meet ! transp>5cy requirem5ts specifi$ 9 p>agraph 7#c74 7#b7 ,electronic prior au?orization program 7,a7 ,9 g5]al ,= purposes ( p>agraph 7#a77;,a71 ! electronic prior au?orization program describ$ 9 ?is p>agraph is a program t provides = ! secure electronic transmission (-- 7i7 a prior au?orization reque/ f a provid] ( s]vices or suppli] to a ,m$ic>e ,advantage plan ) respect to an applicable item or s]vice to be furni%$ to an individual & a response1 9 accordance ) ?is p>agraph1 f su* plan to su* provid] or suppli]2 & 7ii7 any atta*m5t relat+ to su* reque/ or response4 7,b7 ,electronic transmission 7i7 ,exclusions ,= purposes ( ?is p>agraph1 a facsimile1 a propriet>y pay] portal t does n meet /&>ds specifi$ by ! ,secret>y1 or an electronic =m %all n be treat$ z an electronic transmission describ$ 9 subp>agraph 7,a74 7ii7 ,/&>ds ,an electronic transmission describ$ 9 subp>agraph 7,a7 %all comply )-- 7,i7 applicable te*nical /&>ds adopt$ by ! ,secret>y pursuant to section #aagc2 & 7,,ii7 o!r requirem5ts to promote ! /&>dization & /reaml9+ ( electronic transactions "u ?is "p specifi$ by ! ,secret>y4 7iii7 ,deadl9e = specification ( additional requirem5ts ,n lat] ?an ,july #a1 #bjbd1 ! ,secret>y %all f9alize requirem5ts describ$ 9 clause 7ii77,,ii74 7,c7 ,real-"t decisions 7i7 ,9 g5]al ,subject to clause 7iv71 ! program describ$ 9 subp>agraph 7,a7 %all provide = real-"t decisions 7z def9$ by ! ,secret>y 9 accordance ) clause 7v77 by a ,m$ic>e ,advantage plan ) respect to prior au?orization reque/s = applicable items & s]vices id5tifi$ by ! ,secret>y pursuant to clause 7ii7 if su* reque/s are submitt$ ) all m$ical or o!r docum5tation requir$ by su* plan4 7ii7 ,id5tification ( items & s]vices 7,i7 ,9 g5]al ,= purposes ( clause 7i71 ! ,secret>y %all id5tify1 n lat] ?an ! date on :i* ! initial ann\ncem5t describ$ 9 section #ahec7;b77#a77;,b77i7 = ! ?ird plan ye> beg9n+ aft] ! date ( ! enactm5t ( ?is subsection is requir$ to be ann\nc$1 applicable items & s]vices = :i* prior au?orization reque/s are r\t9ely approv$4 7,,ii7 ,updates ,! ,secret>y %all consid] updat+ ! applicable items & s]vices id5tifi$ "u subclause 7,i7 bas$ on ! in=mation describ$ 9 p>agraph 7#c77;,a77i7 7if available & det]m9$ practicable to utilize by ! ,secret>y7 & any o!r in=mation det]m9$ appropriate by ! ,secret>y n less frequ5tly ?an bi5nially4 ,! ,secret>y %all ann\nce any su* update t is to apply ) respect to a plan ye> n lat] ?an ! date on :i* ! initial ann\ncem5t describ$ 9 section #ahec7;b77#a77;,b77i7 = su* plan ye> is requir$ to be ann\nc$4 7iii7 ,reque/ = in=mation ,! ,secret>y %all issue a reque/ = in=mation = purposes ( initially id5tify+ applicable items & s]vices "u clause 7ii77,i74 7iv7 ,exception = ext5uat+ circum/ances ,9 ! case ( a prior au?orization reque/ submitt$ to a ,m$ic>e ,advantage plan = an individual enroll$ 9 su* plan dur+ a plan ye> ) respect to an item or s]vice id5tifi$ by ! ,secret>y pursuant to clause 7ii7 = su* plan ye>1 su* plan may1 9 lieu ( provid+ a real-"t decision ) respect to su* reque/ 9 accordance ) clause 7i71 delay su* decision "u ext5uat+ circum/ances 7z specifi$ by ! ,secret>y71 provid$ t su* decision is provid$ no lat] ?an #gb h\rs aft] receipt ( su* reque/ 7or1 9 ! case t ! provid] ( s]vices or suppli] submitt+ su* reque/ has indicat$ t su* delay may s]i\sly jeop>dize su* individual's life1 heal?1 or ability to rega9 maximum function1 no lat] ?an #bd h\rs aft] receipt ( su* reque/74 7v7 ,def9ition ( real-"t decision ,9 e/abli%+ ! def9ition ( a real-"t decision = purposes ( clause 7i71 ! ,secret>y %all take into acc\nt curr5t m$ical practice1 te*nology1 heal? c>e indu/ry /&>ds1 & o!r relevant in=mation relat+ to h[ quickly a ,m$ic>e ,advantage plan may provide responses ) respect to prior au?orization reque/s4 7vi7 ,implem5tation ,! ,secret>y %all use notice & comm5t rulemak+ = ea* ( ! foll[+3 7,i7 ,e/abli%+ ! def9ition ( a real-"t decision = purposes ( clause 7i74 7,,ii7 ,updat+ su* def9ition4 7,,iii7 ,initially id5tify+ applicable items or s]vices pursuant to clause 7ii77,i74 7,,iv7 ,updat+ applicable items & s]vices s id5tifi$ z describ$ 9 clause 7ii77,,ii74 7#c7 ,transp>5cy requirem5ts 7,a7 ,9 g5]al ,= purposes ( p>agraph 7#a77;,b71 ! transp>5cy requirem5ts specifi$ 9 ?is p>agraph are1 ) respect to a ,m$ic>e ,advantage plan1 ! foll[+3 7i7 ,! plan1 annually & 9 a mann] specifi$ by ! ,secret>y1 %all submit to ! ,secret>y ! foll[+ in=mation3 7,i7 ,a li/ ( all applicable items & s]vices t 7 subject to a prior au?orization requirem5t "u ! plan dur+ ! previ\s plan ye>4 7,,ii7 ,! p]c5tage & numb] ( specifi$ reque/s 7z def9$ 9 subp>agraph 7,f77 approv$ dur+ ! previ\s plan ye> by ! plan 9 an initial det]m9ation & ! p]c5tage & numb] ( specifi$ reque/s d5i$ dur+ su* plan ye> by su* plan 9 an initial det]m9ation 7bo? 9 ! aggregate & categoriz$ by ea* item & s]vice74 7,,iii7 ,! p]c5tage & numb] ( specifi$ reque/s submitt$ dur+ ! previ\s plan ye> t 7 made ) respect to an item or s]vice id5tifi$ by ! ,secret>y pursuant to p>agraph 7#b77;,c77ii7 = su* plan ye>1 & ! p]c5tage & numb] ( su* reque/s t 7 subject to an exception "u p>agraph 7#b77;,c77iv7 7categoriz$ by ea* item & s]vice74 7,,iv7 ,! p]c5tage & numb] ( specifi$ reque/s submitt$ dur+ ! previ\s plan ye> t 7 made ) respect to an item or s]vice id5tifi$ by ! ,secret>y pursuant to p>agraph 7#b77;,c77ii7 = su* plan ye> t 7 approv$ 7categoriz$ by ea* item & s]vice74 7,v7 ,! p]c5tage & numb] ( specifi$ reque/s t 7 d5i$ dur+ ! previ\s plan ye> by ! plan 9 an initial det]m9ation & t 7 subsequ5tly appeal$4 7,,vi7 ,! numb] ( appeals ( specifi$ reque/s resolv$ dur+ ! prec$+ plan ye>1 & ! p]c5tage & numb] ( su* resolv$ appeals t result$ 9 approval ( ! furni%+ ( ! item or s]vice t 0 ! subject ( su* reque/1 categoriz$ by ea* applicable item & s]vice & categoriz$ by ea* level ( appeal 7includ+ judicial review74 7,,vii7 ,! p]c5tage & numb] ( specifi$ reque/s t 7 d5i$1 & ! p]c5tage & numb] ( specifi$ reque/s t 7 approv$1 by ! plan dur+ ! previ\s plan ye> ?r\gh ! utilization ( decision support te*nology1 artificial intellig5ce te*nology1 ma*9e-le>n+ te*nology1 cl9ical decision-mak+ te*nology1 or any o!r te*nology specifi$ by ! ,secret>y4 7,,viii7 ,! av]age & ! m$ian am\nt ( "t 79 h\rs7 t elaps$ dur+ ! previ\s plan ye> betwe5 ! submission ( a specifi$ reque/ to ! plan & a det]m9ation by ! plan ) respect to su* reque/ = ea* su* item & s]vice1 exclud+ any su* reque/s t 7 n submitt$ ) ! m$ical or o!r docum5tation requir$ to be submitt$ by ! plan4 7,,ix7 ,! p]c5tage & numb] ( specifi$ reque/s t 7 exclud$ f ! calculation describ$ 9 subclause 7,,viii7 bas$ on ! plan's det]m9ation t su* reque/s 7 n submitt$ ) ! m$ical or o!r docum5tation requir$ to be submitt$ by ! plan4 7,x7 ,in=mation on ea* occurr5ce dur+ ! previ\s plan ye> 9 :i*1 dur+ a surgical or m$ical proc$ure involv+ ! furni%+ ( an applicable item or s]vice ) respect to :i* su* plan _h approv$ a prior au?orization reque/1 ! provid] ( s]vices or suppli] furni%+ su* item or s]vice det]m9$ t a diff]5t or additional item or s]vice 0 m$ically necess>y1 includ+ a specification ( :e!r su* plan subsequ5tly approv$ ! furni%+ ( su* diff]5t or additional item or s]vice4 7,,xi7 ,a disclosure & description ( any te*nology describ$ 9 subclause 7,,vii7 t ! plan utiliz$ dur+ ! previ\s plan ye> 9 mak+ det]m9ations ) respect to specifi$ reque/s4 7,,xii7 ,! numb] ( grievances 7z describ$ 9 subsection 7f77 receiv$ by su* plan dur+ ! previ\s plan ye> t 7 relat$ to a prior au?orization requirem5t4 7,,xiii7 ,su* o!r in=mation z ! ,secret>y det]m9es appropriate4 7ii7 ,! plan %all provide-- 7,i7 to ea* provid] or suppli] :o seeks to ent] into a contract ) su* plan to furni% applicable items & s]vices "u su* plan1 ! li/ describ$ 9 clause 7i77,i7 & any policies or proc$ures us$ by ! plan = mak+ det]m9ations ) respect to prior au?orization reque/s2 7,,ii7 to ea* su* provid] & suppli] t ent]s into su* a contract1 access to ! crit]ia us$ by ! plan = mak+ su* det]m9ations & an itemization ( ! m$ical or o!r docum5tation requir$ to be submitt$ by a provid] or suppli] ) respect to su* a reque/2 & 7,,iii7 to an enrollee ( ! plan1 ^u reque/1 access to ! crit]ia us$ by ! plan = mak+ det]m9ations ) respect to prior au?orization reque/s = an item or s]vice4 7,b7 ,option = plan to provide c]ta9 additional in=mation ,z "p ( ! in=mation describ$ 9 subp>agraph 7,a77i7 provid$ to ! ,secret>y dur+ a plan ye>1 a ,m$ic>e ,advantage plan may elect to include in=mation reg>d+ ! p]c5tage & numb] ( specifi$ reque/s made ) respect to an individual & an item or s]vice t 7 d5i$ by ! plan dur+ ! prec$+ plan ye> 9 an initial det]m9ation bas$ on su* reque/s fail+ to demon/rate t su* individuals met ! cl9ical crit]ia e/abli%$ by su* plan to receive su* items or s]vices4 7,c7 ,regulations ,! ,secret>y %all1 ?r\gh notice & comm5t rulemak+1 e/abli% requirem5ts = ,m$ic>e ,advantage plans reg>d+ ! provision (-- 7i7 access to crit]ia describ$ 9 subp>agraph 7,a77ii77,,ii7 to provid]s ( s]vices & suppli]s 9 accordance ) su* subp>agraph2 & 7ii7 access to su* crit]ia to enrollees 9 accordance ) subp>agraph 7,a77ii77,,iii74 7,d7 ,publication ( in=mation ,! ,secret>y %all publi% in=mation describ$ 9 subp>agraph 7,a77i7 & subp>agraph 7,b7 on a public website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 ,su* in=mation %all be s publi%$ on an individual plan level & may 9 addition be aggregat$ 9 su* mann] z det]m9$ appropriate by ! ,secret>y4 7,e7 ,med,pac report ,n lat] ?an #c ye>s aft] ! date in=mation is fir/ submitt$ "u subp>agraph 7,a77i71 ! ,m$ic>e ,paym5t ,advisory ,commission %all submit to ,congress a report on su* in=mation t includes a descriptive analysis ( ! use ( prior au?orization4 ,z appropriate1 ! ,commission %\ld report on /ati/ics includ+ ! frequ5cy ( appeals & ov]turn$ decisions4 ,! ,commission %all provide recomm5dations1 z appropriate1 on any improvem5t t %\ld be made to ! electronic prior au?orization programs ( ,m$ic>e ,advantage plans4 7,f7 ,specifi$ reque/ def9$ ,= purposes ( ?is p>agraph1 ! t]m specifi$ reque/ means a prior au?orization reque/ made ) respect to an applicable item or s]vice4 7#d7 ,enrollee protection /&>ds ,= purposes ( p>agraph 7#a77;,a77ii71 ) respect to ! use ( prior au?orization by ,m$ic>e ,advantage plans = applicable items & s]vices1 ! enrollee protection /&>ds specifi$ 9 ?is p>agraph are-- 7,a7 ! adoption ( transp>5t prior au?orization programs develop$ 9 consultation ) enrollees & ) provid]s & suppli]s ) contracts 9 effect ) su* plans = furni%+ su* items & s]vices "u su* plans2 7,b7 all[+ = ! waiv] or modification ( prior au?orization requirem5ts bas$ on ! p]=mance ( su* provid]s & suppli]s 9 demon/rat+ compliance ) su* requirem5ts1 su* z adh]5ce to evid5ce-bas$ m$ical guidel9es & o!r quality crit]ia2 & 7,c7 conduct+ annual reviews ( su* items & s]vices = :i* prior au?orization requirem5ts are impos$ "u su* plans ?r\gh a process t takes into acc\nt input f enrollees & f provid]s & suppli]s ) su* contracts 9 effect & is bas$ on consid]ation ( prior au?orization data f previ\s plan ye>s & analyses ( curr5t cov]age crit]ia4 7#e7 ,applicable item or s]vice def9$ ,= purposes ( ?is subsection1 ! t]m applicable item or s]vice means1 ) respect to a ,m$ic>e ,advantage plan1 any item or s]vice = :i* b5efits are available "u su* plan1 o!r ?an a cov]$ "p ,d drug4 7#f7 ,reports to ,congress 7,a7 ,,gao ,n lat] ?an ! end ( ! f\r? plan ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is subsection1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report conta9+ an evaluation ( ! implem5tation ( ! requirem5ts ( ?is subsection & an analysis ( issues 9 implem5t+ su* requirem5ts fac$ by ,m$ic>e ,advantage plans4 7,b7 ,,hhs ,n lat] ?an ! end ( ! fif? plan ye> beg9n+ aft] ! date ( ! enactm5t ( ?is subsection1 & bi5nially !reaft] ?r\gh ! date t is #aj ye>s aft] su* date ( enactm5t1 ! ,secret>y %all submit to ,congress a report conta9+ a description ( ! in=mation submitt$ "u p>agraph 7#c77;,a77i7 dur+-- 7i7 9 ! case ( ! fir/ su* report1 ! f\r? plan ye> beg9n+ aft] ! date ( ! enactm5t ( ?is subsection2 & 7ii7 9 ! case ( a subsequ5t report1 ! #b plan ye>s prec$+ ! ye> ( ! submission ( su* report4 4 7b7 ,ensur+ timely responses = all prior au?orization reque/s submitt$ "u "p ,c ,section #aheb7;g7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77 is am5d$-- 7#a7 9 p>agraph 7#a77;,a71 by ins]t+ & 9 accordance ) p>agraph 7#f7 aft] p>agraph 7#c72 7#b7 9 p>agraph 7#c77;,b77iii71 by ins]t+ 7or1 subject to subsection 7o71 ) respect to prior au?orization reque/s submitt$ on or aft] ! fir/ day ( ! ?ird plan ye> beg9n+ aft] ! date ( ! enactm5t ( ! ,improv+ ,s5iors' ,timely ,access to ,c>e ,act ( #bjbc1 n lat] ?an #bd h\rs7 aft] #gb h\rs4 7#c7 by add+ at ! end ! foll[+ new p>agraph3 7#f7 ,timeframe = response to prior au?orization reque/s ,subject to p>agraph 7#c7 & subsection 7o71 9 ! case ( an organization det]m9ation made ) respect to a prior au?orization reque/ = an item or s]vice to be furni%$ to an individual submitt$ on or aft] ! fir/ day ( ! ?ird plan ye> beg9n+ aft] ! date ( ! enactm5t ( ?is p>agraph1 ! organization %all notify ! enrollee 7& ! physician involv$1 z appropriate7 ( su* det]m9ation no lat] ?an #g days 7or su* %ort] timeframe z ! ,secret>y may specify ?r\gh notice & comm5t rulemak+1 tak+ into acc\nt enrollee & /akehold] fe$back7 aft] receipt ( su* reque/4 4 7c7 ,rule ( con/ruction ,none ( ! am5dm5ts made by ?is section may be con/ru$ to affect ! f9alization ( ! propos$ rule entitl$ ,m$ic>e & ,m$icaid ,programs2 ,pati5t ,protection & ,af=dable ,c>e ,act2 ,advanc+ ,int]op]ability & ,improv+ ,prior ,au?orization ,processes = ,m$ic>e ,advantage ,organizations1 ,m$icaid ,manag$ ,c>e ,plans1 ,/ate ,m$icaid ,ag5cies1 ,*ildr5's ,heal? ,insurance ,program 7,,*ip7 ,ag5cies & ,,*ip ,manag$ ,c>e ,entities1 ,issu]s ( ,qualifi$ ,heal? ,plans on ! ,f$]ally ,facilitat$ ,ex*anges1 ,m]it-,bas$ ,inc5tive ,paym5t ,sy/em 7,,mips7 ,eligible ,cl9icians1 & ,eligible ,hospitals & ,critical ,access ,hospitals 9 ! ,m$ic>e ,promot+ ,int]op]ability ,program publi%$ on ,decemb] #ac1 #bjbb 7#hg ,f$4 ,reg4 #gfbch71 or application ( su* rule s f9aliz$1 = plan ye>s be=e ! ?ird plan ye> beg9n+ on or aft] ! date ( ! enactm5t ( ?is ,act4 #cjb4 ,ext5sion ( c]ta9 direct sp5d+ r$uctions ,section #bea;,a7#f77;,d7 ( ! ,balanc$ ,budget & ,em]g5cy ,deficit ,control ,act ( #aihe 7#ija;a7#f77;,d77 is am5d$-- 7#a7 9 clause 7i71 by /rik+ 2 & & ins]t+ a semicolon2 7#b7 9 clause 7ii71 by /rik+ second #f mon?s 9 :i* su* ord] is effective = su* fiscal ye>1 ! paym5t r$uction %all be #j p]c5t4 & ins]t+ #b mon? p]iod beg9n+ on ! day aft] ! la/ day ( ! p]iod describ$ 9 clause 7i7 9 :i* su* ord] is effective = su* fiscal ye>1 ! paym5t r$uction %all be #a4e p]c5t2 &2 & 7#c7 by add+ at ! end ! foll[+ new clause3 7iii7 ) respect to ! la/ #d mon?s 9 :i* su* ord] is effective = su* fiscal ye>1 ! paym5t r$uction %all be #j p]c5t4 4