,i #aai? ,,congress #b;d ,session ,h4 ,r4 #ajghh ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,octob] #i1 #bjbf,mr4 ,pallone 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 title ,,xxvii ( ! ,public ,heal? ,s]vice ,act1 ! ,int]nal ,rev5ue ,code ( #aihf1 & ! ,employee ,retirem5t ,income ,security ,act ( #aigd to make c]ta9 adju/m5ts to ! surprise m$ical bill+ requirem5ts = private heal? insurance4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,l[] ,premiums1 ,fa/] ,paym5ts ,act4 #b4 ,adju/+ surprise m$ical bill+ requirem5ts 7a7 ,am5dm5ts to ! ,public ,heal? ,s]vice ,act 7#a7 ,elim9at+ indep5d5t dispute resolution process 7,a7 ,9 g5]al ,section #bgii;,a-#a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa7 is am5d$-- 7i7 9 subsection 7a7-- 7,i7 9 p>agraph 7#a77;,c77iv7-- 7aa7 9 subclause 7,i71 by ins]t+ ) respect to su* s]vices furni%$ be=e ,janu>y #a1 #bjbh1 be=e n lat] ?an2 & 7bb7 9 subclause 7,,ii71 by ins]t+ 7or1 ) respect to su* s]vices = :i* ! out-(-network rate is ! qualify+ paym5t am\nt = su* s]vices1 n lat] ?an #cj days aft] ! bill = su* s]vices is transmitt$ by su* provid] or facility7 aft] subsection 7c77#f72 & 7,,ii7 9 p>agraph 7#c77,k77ii7-- 7aa7 9 subclause 7,i71 by /rik+ subject to subclause 7,,ii7 & ins]t+ ) respect to items & s]vices furni%$ be=e ,janu>y #a1 #bjbh-- 7aa7 subject to item 7bb7 2 7bb7 by r$esignat+ subclause 7,,ii7 z item 7bb72 & 7cc7 by add+ at ! end ! foll[+ new subclause3 7,,ii7 ) respect to items & s]vices furni%$ on or aft] ,janu>y #a1 #bjbh1 ! qualify+ paym5t am\nt 7z def9$ 9 subp>agraph 7,e7 = su* ye> & det]m9$ 9 accordance ) rulemak+ describ$ 9 p>agraph 7#b77;,b77 = su* item or s]vice2 or 2 7ii7 9 subsection 7b77#a7-- 7,i7 9 subp>agraph 7,c71 by ins]t+ ) respect to su* s]vices furni%$ be=e ,janu>y #a1 #bjbh1 be=e n lat] ?an2 & 7,,ii7 9 subp>agraph 7,d71 by ins]t+ 7or1 ) respect to su* s]vices = :i* ! out-(-network rate is ! qualify+ paym5t am\nt = su* s]vices1 n lat] ?an #cj days aft] ! bill = su* s]vices is transmitt$ by su* provid]7 aft] subsection 7c77#f72 & 7iii7 9 subsection 7c7-- 7,i7 9 p>agraph 7#a77;,a71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg1 aft] 9 a ye>2 & 7,,ii7 9 p>agraph 7#g7-- 7aa7 9 subp>agraph 7,a71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg aft] subsequ5t ye>2 & 7bb7 9 subp>agraph 7,c71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg aft] subsequ5t ye>4 7,b7 ,air ambulance s]vices ,section #bgii;,a-#b ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aab7 is am5d$-- 7i7 9 subsection 7a77#c7-- 7,i7 9 subp>agraph 7,a71 by ins]t+ ) respect to su* s]vices furni%$ be=e ,janu>y #a1 #bjbh1 be=e n lat] ?an2 & 7,,ii7 9 subp>agraph 7,b71 by ins]t+ 7or1 ) respect to su* s]vices = :i* ! out-(-network rate is ! qualify+ paym5t am\nt = su* s]vices1 n lat] ?an #cj days aft] ! bill = su* s]vices is transmitt$ by su* provid]7 aft] subsection 7b77#f72 & 7ii7 9 subsection 7b7-- 7,i7 9 p>agraph 7#a77;,a71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg1 aft] 9 a ye>2 & 7,,ii7 9 p>agraph 7#g7-- 7aa7 9 subp>agraph 7,a71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg aft] subsequ5t ye>2 & 7bb7 9 subp>agraph 7,c71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg aft] subsequ5t ye>4 7#b7 ,adju/+ calculation ( qualify+ paym5t am\nt 7,a7 ,9 g5]al ,section #bgii;,a-#a7;a77#c77;,e7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa7;a77#c77;,e77 is am5d$-- 7i7 9 clause 7i7-- 7,i7 9 subclause 7,i71 by /rik+ & at ! end2 7,,ii7 9 subclause 7,,ii7-- 7aa7 by ins]t+ be=e #bjbh aft] or a subsequ5t ye>2 & 7bb7 by /rik+ ! p]iod at ! end & ins]t+ a semicolon2 & 7,,iii7 by add+ at ! end ! foll[+ new subclauses3 7,,iii7 = an item or s]vice furni%$ dur+ #bjbh1 ! m$ian ( ! contract$ rates recogniz$ by ! plan or issu]1 respectively 7det]m9$ only ) respect to su* plan or su* cov]age71 z ! total paym5t 7includ+ ! co/-%>+ am\nt impos$ = su* item or s]vice & ! am\nt to be paid by ! plan or issu]1 respectively1 & ! av]age expect$ am\nt ( any inc5tive-bas$ or retroactive paym5ts or paym5t adju/m5ts1 includ+ risk-%>+ paym5ts1 bonuses1 & p5alties7 "u su* plan or cov]age1 respectively1 on ,janu>y #ca1 #bjai1 = ! same or a simil> item or s]vice t is provid$ by a provid] 9 ! same specialty & provid$ 9 ! geographic region 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u p>agraph 7#b71 exclud+ any su* rate 9 effect ) a provid] t did n furni% su* item or s]vice dur+ ! plan ye> conta9+ ,janu>y #ca1 #bjai1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] #bjai & su* p]c5tage increase = ea* ( ye>s #bjbj ?r\gh #bjbg2 & 7,,iv7 = an item or s]vice furni%$ dur+ #bjbi or a subsequ5t ye>1 ! qualify+ paym5t am\nt det]m9$ "u ?is clause = su* an item or s]vice furni%$ 9 ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 2 7ii7 9 clause 7ii7-- 7,i7 9 ! text prec$+ subclause 7,i71 by ins]t+ 9 a ye> be=e #bjbh be=e 9 a geographic region2 7,,ii7 9 subclause 7,,ii71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 7,,iii7 by r$esignat+ subclauses 7,i7 & 7,,ii7 z items 7aa7 & 7bb71 respectively1 & adju/+ ! m>g9s accord+ly2 7,,iv7 by /rik+ means1 ) respect to & ins]t+ ! foll[+3 means-- 7,i7 ) respect to 2 & 7,v7 by add+ at ! end ! foll[+ new subclause3 7,,ii7 ) respect to a sponsor ( a gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age 9 #bjbh or a subsequ5t ye> t su* sponsor or issu]1 respectively1 did n (f] dur+ #bjai-- 7aa7 = ! fir/ ye> 9 :i* su* gr\p heal? plan1 gr\p heal? insurance cov]age1 or individual heal? insurance cov]age1 respectively1 is (f]$1 a rate 7det]m9$ 9 accordance ) a me?odology e/abli%$ by ! ,secret>y7 = items & s]vices t are cov]$ by su* plan or cov]age & furni%$ dur+ su* fir/ ye>2 & 7bb7 = ea* subsequ5t ye> su* gr\p heal? plan1 gr\p heal? insurance cov]age1 or individual heal? insurance cov]age1 respectively1 is (f]$1 ! qualify+ paym5t am\nt det]m9$ "u ?is clause = su* items & s]vices furni%$ 9 ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 2 7iii7 9 clause 7iii7-- 7,i7 9 ! matt] prec$+ subclause 7,i71 by ins]t+ 7or clause 7i77,,iii71 z applicable7 aft] describ$ 9 clause 7i77,i72 7,,ii7 9 subclause 7,,iii7-- 7aa7 by /rik+ or cov]age1 has & ins]t+ ! foll[+3 or cov]age-- 7aa7 9 ! case t su* fir/ suffici5t in=mation ye> is a ye> be=e #bjbh1 has 2 & 7bb7 by add+ at ! end ! foll[+ new item3 7bb7 9 ! case t su* fir/ suffici5t in=mation ye> is #bjbh or a subsequ5t ye>1 has ! mean+ giv5 ! t]m qualify+ paym5t am\nt 9 clause 7i77,,iii71 except t 9 apply+ su* clause to su* item or s]vice1 ! ref]5ce to furni%$ dur+ #bjbh %all1 = fir/ suffici5t in=mation ye>s subsequ5t to #bjbh1 be treat$ z a ref]5ce to furni%$ dur+ su* fir/ suffici5t in=mation ye>1 ! ref]5ce to ,janu>y #ca1 #bjai %all be treat$ z a ref]5ce to ! fir/ day ( su* fir/ suffici5t in=mation ye>1 & ! increase describ$ 9 su* clause %all n be appli$2 & 2 & 7,,iii7 9 subclause 7,,iv7-- 7aa7 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 7bb7 by /rik+ or cov]age1 has & ins]t+ ! foll[+3 or cov]age-- 7aa7 9 ! case t su* fir/ suffici5t in=mation ye> is a ye> be=e #bjbh1 has 2 & 7cc7 by add+ at ! end ! foll[+ new item3 7bb7 9 ! case t su* fir/ suffici5t in=mation ye> is #bjbh or a subsequ5t ye>1 has ! mean+ giv5 su* t]m 9 clause 7i77,,iv71 except t 9 apply+ su* clause to su* item or s]vice1 ! ref]5ce to furni%$ dur+ #bjbi or a subsequ5t ye> %all1 = fir/ suffici5t in=mation ye>s subsequ5t to #bjbh1 be treat$ z a ref]5ce to furni%$ dur+ ! ye> aft] su* fir/ suffici5t in=mation ye> or a subsequ5t ye>4 2 & 7iv7 9 clause 7v77,,ii7-- 7,i7 9 item 7aa71 by ins]t+ 7or clause 7i77,,iii71 z applicable7 aft] describ$ 9 clause 7i77,i72 & 7,,ii7 9 item 7bb71 by ins]t+ 7or clause 7i77,,iii71 z applicable7 aft] describ$ 9 clause 7i77,i74 7,b7 ,updat$ rulemak+ ,section #bgii;,a-#a7;a77#b77;,b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa7;a77#b77;,b77 is am5d$-- 7i7 by r$esignat+ clauses 7i7 ?r\gh 7iv7 z subclauses 7,i7 ?r\gh 7,,iv71 respectively1 & adju/+ ! m>g9s accord+ly2 7ii7 by /rik+ ,n lat] ?an & ins]t+ ! foll[+3 7i7 ,initial rulemak+ ,n lat] ?an 2 7iii7 by ins]t+ be=e ,su* rulemak+ ! foll[+ new clause3 7ii7 ,updat$ rules 7,i7 ,9 g5]al ,n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is clause1 ! ,secret>y1 9 consultation ) ! ,secret>y ( ,labor & ! ,secret>y ( ! ,treasury1 %all update ! rules issu$ "u clause 7i7 to revise ! me?odology ! gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all use to det]m9e ! qualify+ paym5t am\nt = an item or s]vice furni%$ dur+ #bjbh or a subsequ5t ye>4 7,,ii7 ,exp$it$ rulemak+ ,! ,secret>y may promulgate an int]im f9al rule to c>ry out ?is clause4 2 7iv7 by /rik+ ,su* rulemak+ & ins]t+ ! foll[+3 7iii7 ,guidel9es ,! initial rulemak+ "u clause 7i71 & ! updat$ rules "u clause 7ii71 2 7v7 by /rik+ ,9 c>ry+ out clause 7iii7 & ins]t+ ,9 c>ry+ out clause 7i77,,iii72 & 7vi7 by add+ at ! end ! foll[+ new clause3 7vi7 ,judicial review ,!re %all be no judicial review ( ! me?odology = det]m9+ ! qualify+ paym5t am\nt e/abli%$ "u ?is subp>agraph4 4 7,c7 ,annual audits ,section #bgii;,a-#a7;a77#b77;,a7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa7;a77#b77;,a77 is am5d$-- 7i7 9 clause 7ii7-- 7,i7 9 subclause 7,i7-- 7aa7 by /rik+ a ye> 7beg9n+ ) #bjbb7 & ins]t+ ea* ye> beg9n+ ) #bjbb & end+ ) #bjbg2 7bb7 by /rik+ su* clause1 ) & ins]t+3 su* clause-- 7aa7 ) 2 & 7cc7 by add+ at ! end ! foll[+ new item3 7bb7 ) respect to #bjbh & ea* subsequ5t ye>1 ( a sample ) respect to su* ye> ( claims data f n less ?an #be gr\p heal? plans & heal? insurance issu]s (f]+ gr\p or individual heal? insurance cov]age2 & 2 & 7,,ii7 9 subclause 7,,ii71 by /rik+ may & ins]t+ %all2 & 7ii7 9 clause 7iii7-- 7,i7 by ins]t+ 7&1 beg9n+ = #bjbh1 %all make publicly available7 aft] submit to ,congress2 7,,ii7 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 7,,iii7 by /rik+ on ! numb] & ins]t+3 on-- 7,i7 ! numb] 2 & 7,,iv7 by add+ at ! end ! foll[+ new subclause3 7,,ii7 ! f9d+s ( ea* su* audit4 4 7b7 ,am5dm5ts to ! ,int]nal ,rev5ue ,code ( #aihf 7#a7 ,elim9at+ indep5d5t dispute resolution process 7,a7 ,9 g5]al ,section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7i7 9 subsection 7a7-- 7,i7 9 p>agraph 7#a77;,c77iv7-- 7aa7 9 subclause 7,i71 by ins]t+ ) respect to su* s]vices furni%$ be=e ,janu>y #a1 #bjbh1 be=e n lat] ?an2 & 7bb7 9 subclause 7,,ii71 by ins]t+ 7or1 ) respect to su* s]vices = :i* ! out-(-network rate is ! qualify+ paym5t am\nt = su* s]vices1 n lat] ?an #cj days aft] ! bill = su* s]vices is transmitt$ by su* provid] or facility7 aft] subsection 7c77#f72 & 7,,ii7 9 p>agraph 7#c77,k77ii7-- 7aa7 9 subclause 7,i71 by /rik+ subject to subclause 7,,ii7 & ins]t+ ) respect to items & s]vices furni%$ be=e ,janu>y #a1 #bjbh-- 7aa7 subject to item 7bb7 2 7bb7 by r$esignat+ subclause 7,,ii7 z item 7bb72 & 7cc7 by add+ at ! end ! foll[+ new subclause3 7,,ii7 ) respect to items & s]vices furni%$ on or aft] ,janu>y #a1 #bjbh1 ! qualify+ paym5t am\nt 7z def9$ 9 subp>agraph 7,e7 = su* ye> & det]m9$ 9 accordance ) rulemak+ describ$ 9 p>agraph 7#b77;,b77 = su* item or s]vice2 or 2 7ii7 9 subsection 7b77#a7-- 7,i7 9 subp>agraph 7,c71 by ins]t+ ) respect to su* s]vices furni%$ be=e ,janu>y #a1 #bjbh1 be=e n lat] ?an2 & 7,,ii7 9 subp>agraph 7,d71 by ins]t+ 7or1 ) respect to su* s]vices = :i* ! out-(-network rate is ! qualify+ paym5t am\nt = su* s]vices1 n lat] ?an #cj days aft] ! bill = su* s]vices is transmitt$ by su* provid]7 aft] subsection 7c77#f72 & 7iii7 9 subsection 7c7-- 7,i7 9 p>agraph 7#a77;,a71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg1 aft] 9 a ye>2 & 7,,ii7 9 p>agraph 7#g7-- 7aa7 9 subp>agraph 7,a71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg aft] subsequ5t ye>2 & 7bb7 9 subp>agraph 7,c71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg aft] subsequ5t ye>4 7,b7 ,air ambulance s]vices ,section #ihag ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7i7 9 subsection 7a77#c7-- 7,i7 9 subp>agraph 7,a71 by ins]t+ ) respect to su* s]vices furni%$ be=e ,janu>y #a1 #bjbh1 be=e n lat] ?an2 & 7,,ii7 9 subp>agraph 7,b71 by ins]t+ 7or1 ) respect to su* s]vices = :i* ! out-(-network rate is ! qualify+ paym5t am\nt = su* s]vices1 n lat] ?an #cj days aft] ! bill = su* s]vices is transmitt$ by su* provid]7 aft] subsection 7b77#f72 & 7ii7 9 subsection 7b7-- 7,i7 9 p>agraph 7#a77;,a71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg1 aft] 9 a ye>2 & 7,,ii7 9 p>agraph 7#g7-- 7aa7 9 subp>agraph 7,a71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg aft] subsequ5t ye>2 & 7bb7 9 subp>agraph 7,c71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg aft] subsequ5t ye>4 7#b7 ,adju/+ calculation ( qualify+ paym5t am\nt 7,a7 ,9 g5]al ,section #ihaf7;a77#c77;,e7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7i7 9 clause 7i7-- 7,i7 9 subclause 7,i71 by /rik+ & at ! end2 7,,ii7 9 subclause 7,,ii7-- 7aa7 by ins]t+ be=e #bjbh aft] or a subsequ5t ye>2 & 7bb7 by /rik+ ! p]iod at ! end & ins]t+ a semicolon2 & 7,,iii7 by add+ at ! end ! foll[+ new subclauses3 7,,iii7 = an item or s]vice furni%$ dur+ #bjbh1 ! m$ian ( ! contract$ rates recogniz$ by ! plan 7det]m9$ only ) respect to su* plan71 z ! total paym5t 7includ+ ! co/-%>+ am\nt impos$ = su* item or s]vice & ! am\nt to be paid by ! plan1 & ! av]age expect$ am\nt ( any inc5tive-bas$ or retroactive paym5ts or paym5t adju/m5ts1 includ+ risk-%>+ paym5ts1 bonuses1 & p5alties7 "u su* plan on ,janu>y #ca1 #bjai1 = ! same or a simil> item or s]vice t is provid$ by a provid] 9 ! same specialty & provid$ 9 ! geographic region 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u p>agraph 7#b71 exclud+ any su* rate 9 effect ) a provid] t did n furni% su* item or s]vice dur+ ! plan ye> conta9+ ,janu>y #ca1 #bjai1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] #bjai & su* p]c5tage increase = ea* ( ye>s #bjbj ?r\gh #bjbg2 & 7,,iv7 = an item or s]vice furni%$ dur+ #bjbi or a subsequ5t ye>1 ! qualify+ paym5t am\nt det]m9$ "u ?is clause = su* an item or s]vice furni%$ 9 ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 2 7ii7 9 clause 7ii7-- 7,i7 9 ! text prec$+ subclause 7,i71 by ins]t+ 9 a ye> be=e #bjbh be=e 9 a geographic region2 7,,ii7 9 subclause 7,,ii71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 7,,iii7 by r$esignat+ subclauses 7,i7 & 7,,ii7 z items 7aa7 & 7bb71 respectively1 & adju/+ ! m>g9s accord+ly2 7,,iv7 by /rik+ means1 ) respect to & ins]t+ ! foll[+3 means-- 7,i7 ) respect to 2 & 7,v7 by add+ at ! end ! foll[+ new subclause3 7,,ii7 ) respect to a sponsor ( a gr\p heal? plan (f]$ 9 #bjbh or a subsequ5t ye> t su* sponsor did n (f] dur+ #bjai-- 7aa7 = ! fir/ ye> 9 :i* su* gr\p heal? plan is (f]$1 a rate 7det]m9$ 9 accordance ) a me?odology e/abli%$ by ! ,secret>y7 = items & s]vices t are cov]$ by su* plan & furni%$ dur+ su* fir/ ye>2 & 7bb7 = ea* subsequ5t ye> su* gr\p heal? plan is (f]$1 ! qualify+ paym5t am\nt det]m9$ "u ?is clause = su* items & s]vices furni%$ 9 ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 2 7iii7 9 clause 7iii7-- 7,i7 9 ! matt] prec$+ subclause 7,i71 by ins]t+ 7or clause 7i77,,iii71 z applicable7 aft] describ$ 9 clause 7i77,i72 7,,ii7 9 subclause 7,,iii7-- 7aa7 by /rik+ su* plan1 has & ins]t+ ! foll[+3 su* plan-- 7aa7 9 ! case t su* fir/ suffici5t in=mation ye> is a ye> be=e #bjbh1 has 2 & 7bb7 by add+ at ! end ! foll[+ new item3 7bb7 9 ! case t su* fir/ suffici5t in=mation ye> is #bjbh or a subsequ5t ye>1 has ! mean+ giv5 ! t]m qualify+ paym5t am\nt 9 clause 7i77,,iii71 except t 9 apply+ su* clause to su* item or s]vice1 ! ref]5ce to furni%$ dur+ #bjbh %all1 = fir/ suffici5t in=mation ye>s subsequ5t to #bjbh1 be treat$ z a ref]5ce to furni%$ dur+ su* fir/ suffici5t in=mation ye>1 ! ref]5ce to ,janu>y #ca1 #bjai %all be treat$ z a ref]5ce to ! fir/ day ( su* fir/ suffici5t in=mation ye>1 & ! increase describ$ 9 su* clause %all n be appli$2 & 2 & 7,,iii7 9 subclause 7,,iv7-- 7aa7 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 7bb7 by /rik+ su* plan1 has & ins]t+ ! foll[+3 su* plan-- 7aa7 9 ! case t su* fir/ suffici5t in=mation ye> is a ye> be=e #bjbh1 has 2 & 7cc7 by add+ at ! end ! foll[+ new item3 7bb7 9 ! case t su* fir/ suffici5t in=mation ye> is #bjbh or a subsequ5t ye>1 has ! mean+ giv5 su* t]m 9 clause 7i77,,iv71 except t 9 apply+ su* clause to su* item or s]vice1 ! ref]5ce to furni%$ dur+ #bjbi or a subsequ5t ye> %all1 = fir/ suffici5t in=mation ye>s subsequ5t to #bjbh1 be treat$ z a ref]5ce to furni%$ dur+ ! ye> aft] su* fir/ suffici5t in=mation ye> or a subsequ5t ye>4 2 & 7iv7 9 clause 7v77,,ii7-- 7,i7 9 item 7aa71 by ins]t+ 7or clause 7i77,,iii71 z applicable7 aft] describ$ 9 clause 7i77,i72 & 7,,ii7 9 item 7bb71 by ins]t+ 7or clause 7i77,,iii71 z applicable7 aft] describ$ 9 clause 7i77,i74 7,b7 ,updat$ rulemak+ ,section #ihaf7;a77#b77;,b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7i7 by r$esignat+ clauses 7i7 ?r\gh 7iv7 z subclauses 7,i7 ?r\gh 7,,iv71 respectively1 & adju/+ ! m>g9s accord+ly2 7ii7 by /rik+ ,n lat] ?an & ins]t+ ! foll[+3 7i7 ,initial rulemak+ ,n lat] ?an 2 7iii7 by ins]t+ be=e ,su* rulemak+ ! foll[+ new clause3 7ii7 ,updat$ rules 7,i7 ,9 g5]al ,n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is clause1 ! ,secret>y1 9 consultation ) ! ,secret>y ( ,labor & ! ,secret>y ( ,heal? & ,human ,s]vices1 %all update ! rules issu$ "u clause 7i7 to revise ! me?odology ! gr\p heal? plan %all use to det]m9e ! qualify+ paym5t am\nt = an item or s]vice furni%$ dur+ #bjbh or a subsequ5t ye>4 7,,ii7 ,exp$it$ rulemak+ ,! ,secret>y may promulgate an int]im f9al rule to c>ry out ?is clause4 2 7iv7 by /rik+ ,su* rulemak+ & ins]t+ ! foll[+3 7iii7 ,guidel9es ,! initial rulemak+ "u clause 7i71 & ! updat$ rules "u clause 7ii71 2 7v7 by /rik+ ,9 c>ry+ out clause 7iii7 & ins]t+ ,9 c>ry+ out clause 7i77,,iii72 & 7vi7 by add+ at ! end ! foll[+ new clause3 7vi7 ,judicial review ,!re %all be no judicial review ( ! me?odology = det]m9+ ! qualify+ paym5t am\nt e/abli%$ "u ?is subp>agraph4 4 7,c7 ,annual audits ,section #ihaf7;a77#b77;,a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7i7 9 clause 7ii7-- 7,i7 9 subclause 7,i7-- 7aa7 by /rik+ a ye> 7beg9n+ ) #bjbb7 & ins]t+ ea* ye> beg9n+ ) #bjbb & end+ ) #bjbg2 7bb7 by /rik+ su* clause1 ) & ins]t+3 su* clause-- 7aa7 ) 2 & 7cc7 by add+ at ! end ! foll[+ new item3 7bb7 ) respect to #bjbh & ea* subsequ5t ye>1 ( a sample ) respect to su* ye> ( claims data f n less ?an #be gr\p heal? plans2 & 2 & 7,,ii7 9 subclause 7,,ii71 by /rik+ may & ins]t+ %all2 & 7ii7 9 clause 7iii7-- 7,i7 by ins]t+ 7&1 beg9n+ = #bjbh1 %all make publicly available7 aft] submit to ,congress2 7,,ii7 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 7,,iii7 by /rik+ on ! numb] & ins]t+3 on-- 7,i7 ! numb] 2 & 7,,iv7 by add+ at ! end ! foll[+ new subclause3 7,,ii7 ! f9d+s ( ea* su* audit4 4 7c7 ,am5dm5ts to ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#a7 ,elim9at+ indep5d5t dispute resolution process 7,a7 ,9 g5]al ,section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;e7 is am5d$-- 7i7 9 subsection 7a7-- 7,i7 9 p>agraph 7#a77;,c77iv7-- 7aa7 9 subclause 7,i71 by ins]t+ ) respect to su* s]vices furni%$ be=e ,janu>y #a1 #bjbh1 be=e n lat] ?an2 & 7bb7 9 subclause 7,,ii71 by ins]t+ 7or1 ) respect to su* s]vices = :i* ! out-(-network rate is ! qualify+ paym5t am\nt = su* s]vices1 n lat] ?an #cj days aft] ! bill = su* s]vices is transmitt$ by su* provid] or facility7 aft] subsection 7c77#f72 & 7,,ii7 9 p>agraph 7#c77,k77ii7-- 7aa7 9 subclause 7,i71 by /rik+ subject to subclause 7,,ii7 & ins]t+ ) respect to items & s]vices furni%$ be=e ,janu>y #a1 #bjbh-- 7aa7 subject to item 7bb7 2 7bb7 by r$esignat+ subclause 7,,ii7 z item 7bb72 & 7cc7 by add+ at ! end ! foll[+ new subclause3 7,,ii7 ) respect to items & s]vices furni%$ on or aft] ,janu>y #a1 #bjbh1 ! qualify+ paym5t am\nt 7z def9$ 9 subp>agraph 7,e7 = su* ye> & det]m9$ 9 accordance ) rulemak+ describ$ 9 p>agraph 7#b77;,b77 = su* item or s]vice2 or 2 7ii7 9 subsection 7b77#a7-- 7,i7 9 subp>agraph 7,c71 by ins]t+ ) respect to su* s]vices furni%$ be=e ,janu>y #a1 #bjbh1 be=e n lat] ?an2 & 7,,ii7 9 subp>agraph 7,d71 by ins]t+ 7or1 ) respect to su* s]vices = :i* ! out-(-network rate is ! qualify+ paym5t am\nt = su* s]vices1 n lat] ?an #cj days aft] ! bill = su* s]vices is transmitt$ by su* provid]7 aft] subsection 7c77#f72 & 7iii7 9 subsection 7c7-- 7,i7 9 p>agraph 7#a77;,a71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg1 aft] 9 a ye>2 & 7,,ii7 9 p>agraph 7#g7-- 7aa7 9 subp>agraph 7,a71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg aft] subsequ5t ye>2 & 7bb7 9 subp>agraph 7,c71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg aft] subsequ5t ye>4 7,b7 ,air ambulance s]vices ,section #gag ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;f7 is am5d$-- 7i7 9 subsection 7a77#c7-- 7,i7 9 subp>agraph 7,a71 by ins]t+ ) respect to su* s]vices furni%$ be=e ,janu>y #a1 #bjbh1 be=e n lat] ?an2 & 7,,ii7 9 subp>agraph 7,b71 by ins]t+ 7or1 ) respect to su* s]vices = :i* ! out-(-network rate is ! qualify+ paym5t am\nt = su* s]vices1 n lat] ?an #cj days aft] ! bill = su* s]vices is transmitt$ by su* provid]7 aft] subsection 7b77#f72 & 7ii7 9 subsection 7b7-- 7,i7 9 p>agraph 7#a77;,a71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg1 aft] 9 a ye>2 & 7,,ii7 9 p>agraph 7#g7-- 7aa7 9 subp>agraph 7,a71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg aft] subsequ5t ye>2 & 7bb7 9 subp>agraph 7,c71 by ins]t+ end+ on or be=e ,decemb] #ca1 #bjbg aft] subsequ5t ye>4 7#b7 ,adju/+ calculation ( qualify+ paym5t am\nt 7,a7 ,9 g5]al ,section #gaf7;a77#c77;,e7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;e7a77#c77;,e77 is am5d$-- 7i7 9 clause 7i7-- 7,i7 9 subclause 7,i71 by /rik+ & at ! end2 7,,ii7 9 subclause 7,,ii7-- 7aa7 by ins]t+ be=e #bjbh aft] or a subsequ5t ye>2 & 7bb7 by /rik+ ! p]iod at ! end & ins]t+ a semicolon2 & 7,,iii7 by add+ at ! end ! foll[+ new subclauses3 7,,iii7 = an item or s]vice furni%$ dur+ #bjbh1 ! m$ian ( ! contract$ rates recogniz$ by ! plan or issu]1 respectively 7det]m9$ only ) respect to su* plan or su* cov]age71 z ! total paym5t 7includ+ ! co/-%>+ am\nt impos$ = su* item or s]vice & ! am\nt to be paid by ! plan or issu]1 respectively1 & ! av]age expect$ am\nt ( any inc5tive-bas$ or retroactive paym5ts or paym5t adju/m5ts1 includ+ risk-%>+ paym5ts1 bonuses1 & p5alties7 "u su* plan or cov]age1 respectively1 on ,janu>y #ca1 #bjai1 = ! same or a simil> item or s]vice t is provid$ by a provid] 9 ! same specialty & provid$ 9 ! geographic region 9 :i* ! item or s]vice is furni%$1 consi/5t ) ! me?odology e/abli%$ by ! ,secret>y "u p>agraph 7#b71 exclud+ any su* rate 9 effect ) a provid] t did n furni% su* item or s]vice dur+ ! plan ye> conta9+ ,janu>y #ca1 #bjai1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] #bjai & su* p]c5tage increase = ea* ( ye>s #bjbj ?r\gh #bjbg2 & 7,,iv7 = an item or s]vice furni%$ dur+ #bjbi or a subsequ5t ye>1 ! qualify+ paym5t am\nt det]m9$ "u ?is clause = su* an item or s]vice furni%$ 9 ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 2 7ii7 9 clause 7ii7-- 7,i7 9 ! text prec$+ subclause 7,i71 by ins]t+ 9 a ye> be=e #bjbh be=e 9 a geographic region2 7,,ii7 9 subclause 7,,ii71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 7,,iii7 by r$esignat+ subclauses 7,i7 & 7,,ii7 z items 7aa7 & 7bb71 respectively1 & adju/+ ! m>g9s accord+ly2 7,,iv7 by /rik+ means1 ) respect to & ins]t+ ! foll[+3 means-- 7,i7 ) respect to 2 & 7,v7 by add+ at ! end ! foll[+ new subclause3 7,,ii7 ) respect to a sponsor ( a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age 9 #bjbh or a subsequ5t ye> t su* sponsor or issu]1 respectively1 did n (f] dur+ #bjai-- 7aa7 = ! fir/ ye> 9 :i* su* gr\p heal? plan or gr\p heal? insurance cov]age1 respectively1 is (f]$1 a rate 7det]m9$ 9 accordance ) a me?odology e/abli%$ by ! ,secret>y7 = items & s]vices t are cov]$ by su* plan or cov]age & furni%$ dur+ su* fir/ ye>2 & 7bb7 = ea* subsequ5t ye> su* gr\p heal? plan or gr\p heal? insurance cov]age1 respectively1 is (f]$1 ! qualify+ paym5t am\nt det]m9$ "u ?is clause = su* items & s]vices furni%$ 9 ! previ\s ye>1 increas$ by ! p]c5tage increase 9 ! consum] price index = all urban consum]s 7,unit$ ,/ates city av]age7 ov] su* previ\s ye>4 2 7iii7 9 clause 7iii7-- 7,i7 9 ! matt] prec$+ subclause 7,i71 by ins]t+ 7or clause 7i77,,iii71 z applicable7 aft] describ$ 9 clause 7i77,i72 7,,ii7 9 subclause 7,,iii7-- 7aa7 by /rik+ or cov]age1 has & ins]t+ ! foll[+3 or cov]age-- 7aa7 9 ! case t su* fir/ suffici5t in=mation ye> is a ye> be=e #bjbh1 has 2 & 7bb7 by add+ at ! end ! foll[+ new item3 7bb7 9 ! case t su* fir/ suffici5t in=mation ye> is #bjbh or a subsequ5t ye>1 has ! mean+ giv5 ! t]m qualify+ paym5t am\nt 9 clause 7i77,,iii71 except t 9 apply+ su* clause to su* item or s]vice1 ! ref]5ce to furni%$ dur+ #bjbh %all1 = fir/ suffici5t in=mation ye>s subsequ5t to #bjbh1 be treat$ z a ref]5ce to furni%$ dur+ su* fir/ suffici5t in=mation ye>1 ! ref]5ce to ,janu>y #ca1 #bjai %all be treat$ z a ref]5ce to ! fir/ day ( su* fir/ suffici5t in=mation ye>1 & ! increase describ$ 9 su* clause %all n be appli$2 & 2 & 7,,iii7 9 subclause 7,,iv7-- 7aa7 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 7bb7 by /rik+ or cov]age1 has & ins]t+ ! foll[+3 or cov]age-- 7aa7 9 ! case t su* fir/ suffici5t in=mation ye> is a ye> be=e #bjbh1 has 2 & 7cc7 by add+ at ! end ! foll[+ new item3 7bb7 9 ! case t su* fir/ suffici5t in=mation ye> is #bjbh or a subsequ5t ye>1 has ! mean+ giv5 su* t]m 9 clause 7i77,,iv71 except t 9 apply+ su* clause to su* item or s]vice1 ! ref]5ce to furni%$ dur+ #bjbi or a subsequ5t ye> %all1 = fir/ suffici5t in=mation ye>s subsequ5t to #bjbh1 be treat$ z a ref]5ce to furni%$ dur+ ! ye> aft] su* fir/ suffici5t in=mation ye> or a subsequ5t ye>4 2 & 7iv7 9 clause 7v77,,ii7-- 7,i7 9 item 7aa71 by ins]t+ 7or clause 7i77,,iii71 z applicable7 aft] describ$ 9 clause 7i77,i72 & 7,,ii7 9 item 7bb71 by ins]t+ 7or clause 7i77,,iii71 z applicable7 aft] describ$ 9 clause 7i77,i74 7,b7 ,updat$ rulemak+ ,section #gaf7;a77#b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;e7a77#b77 is am5d$-- 7i7 by r$esignat+ subp>agraphs 7,a7 ?r\gh 7,d7 z clauses 7i7 ?r\gh 7iv71 respectively1 & adju/+ ! m>g9s accord+ly2 7ii7 by /rik+ ,n lat] ?an & ins]t+ ! foll[+3 7,a7 ,initial rulemak+ ,n lat] ?an 2 7iii7 by ins]t+ be=e ,su* rulemak+ ! foll[+ new clause3 7,b7 ,updat$ rules 7i7 ,9 g5]al ,n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is clause1 ! ,secret>y1 9 consultation ) ! ,secret>y ( ! ,treasury & ! ,secret>y ( ,heal? & ,human ,s]vices1 %all update ! rules issu$ "u subp>agraph 7,a7 to revise ! me?odology ! gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all use to det]m9e ! qualify+ paym5t am\nt = an item or s]vice furni%$ dur+ #bjbh or a subsequ5t ye>4 7ii7 ,exp$it$ rulemak+ ,! ,secret>y may promulgate an int]im f9al rule to c>ry out ?is subp>agraph4 2 7iv7 by /rik+ ,su* rulemak+ & ins]t+ ! foll[+3 7,c7 ,guidel9es ,! initial rulemak+ "u subp>agraph 7,a71 & ! updat$ rules "u subp>agraph 7,b71 2 7v7 by /rik+ ,9 c>ry+ out clause 7iii7 & ins]t+ ,9 c>ry+ out subp>agraph 7,a77iii72 & 7vi7 by add+ at ! end ! foll[+ new subp>agraph3 7,d7 ,judicial review ,!re %all be no judicial review ( ! me?odology = det]m9+ ! qualify+ paym5t am\nt e/abli%$ "u ?is p>agraph4 4