,i  #aah? ,,congress  #a/ ,session  ,h4 
,r4 #dije  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,july #bf1 #bjbc,mr4  
,fitzpatrick 7= himself & ,ms4 ,lee (   
,nevada7 introduc$ ! foll[+ bill2 :i* 0 
ref]r$ to ! ,committee on ,en]gy &      
,comm]ce1 & 9 addition to ! ,committees 
on ,education & ! ,work=ce1 & ,ways &   
,means1 = a p]iod to be subsequ5tly     
det]m9$ by ! ,speak]1 9 ea* case =      
consid]ation ( su* provisions z fall )9 
! jurisdiction ( ! committee conc]n$  ,a
 ,,bill  ,to am5d ! ,int]nal ,rev5ue    
,code ( #aihf1 ! ,public ,heal? ,s]vice 
,act1 & ! ,employee ,retirem5t ,income  
,security ,act ( #aigd to promote gr\p  
heal? plan price transp>5cy4  #a4 ,%ort 
title ,?is ,act may be cit$ z ! ,heal?  
,insurance ,price ,transp>5cy ,act (    
#bjbc4  #b4 ,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#bf ,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 ( ?is section1 
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 ( ?is section1 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 ,act 7#db  
,u4,s4,c4 #ahjaa7;e777 %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$+      
s5t5ce4  7#e7 ,atte/ation ,ea* gr\p     
heal? plan %all po/1 along ) rate &     
paym5t in=mation made public by su*     
plan1 an atte/ation t su* in=mation is  
complete & accurate4  7c7 ,def9itions ,9
 ?is p>agraph3 7#a7 ,p>ticipat+ provid] 
,! t]m p>ticipat+ provid] has ! mean+   
giv5 su* t]m 9 section #ihaf4  7#b7     
,9-network rate ,! t]m 9-network rate   
means1 ) respect to a heal? plan & an   
item or s]vice furni%$ 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 ( ?is section1 
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 ( ?is section1 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 ,act 7#db  
,u4,s4,c4 #ahjaa7;e777 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$+ s5t5ce4  7#e7 ,atte/ation ,ea* 
gr\p heal? plan & gr\p or individual    
heal? insurance cov]age %all po/1 along 
) rate & paym5t in=mation made public by
 su* plan or cov]age1 an atte/ation t   
su* in=mation is complete & accurate4   
7c7 ,def9itions ,9 ?is p>agraph3 7#a7   
,p>ticipat+ provid] ,! t]m p>ticipat+   
provid] has ! mean+ giv5 su* t]m 9      
section #bgia;,a-#a7;a77#c77;,g77ii74   
7#b7 ,9-network rate ,! t]m 9-network   
rate means1 ) respect to a heal? plan or
 cov]age & an item or s]vice furni%$ 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 ( ?is section1 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 ( ?is section1 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 ,act 7#db  
,u4,s4,c4 #ahjaa7;e777 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$+ s5t5ce4  7#e7      
,atte/ation ,ea* gr\p heal? plan & gr\p 
heal? insurance cov]age %all po/1 along 
) rate & paym5t in=mation made public by
 su* plan or cov]age1 an atte/ation t   
su* in=mation is complete & accurate4   
7c7 ,def9itions ,9 ?is p>agraph3 7#a7   
,p>ticipat+ provid] ,! t]m p>ticipat+   
provid] has ! mean+ giv5 su* t]m 9      
section #bgia;,a-#a7;a77#c77;,g77ii74   
7#b7 ,9-network rate ,! t]m 9-network   
rate means1 ) respect to a heal? plan or
 cov]age & an item or s]vice furni%$ 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,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