,i #aai? ,,congress #b;d ,session ,h4 ,r4 #hcbd ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,april #af1 #bjbf,mr4 ,burlison 7= himself & ,mr4 ,b>rett7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committees on ,ways & ,means1 ,education & ,work=ce1 ! ,judici>y1 ,arm$ ,s]vices1 ,vet]ans' ,affairs1 & ,=eign ,affairs1 = 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 ( #aihf to increase ! limitations on contributions to heal? sav+s acc\nts1 to am5d ! ,public ,heal? ,s]vice ,act to provide = hospital & insur] price transp>5cy1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,great ,am]ican ,heal?c>e ,plan4 7b7 ,table ( cont5ts ,! table ( cont5ts = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4 ,title ,i--,heal? ,sav+s ,acc\nts ,sec4 #aja4 ,%ort title4 ,sec4 #ajb4 ,increase 9 contribution limitations4 ,sec4 #ajc4 ,fre$om f m&ate4 ,sec4 #ajd4 ,am\nts paid = heal? insurance or direct prim>y c>e s]vice arrangem5t4 ,sec4 #aje4 ,special rule = c]ta9 m$ical exp5ses incurr$ be=e e/abli%m5t ( acc\nt4 ,sec4 #ajf4 ,adm9i/rative error correction be=e due date ( return4 ,sec4 #ajg4 ,all[+ ,,hsa rollov] to *ild or p>5t ( acc\nt hold]4 ,sec4 #ajh4 ,cov]age = am\nts paid = heal?y food1 vitam9s1 diet>y supplem5ts1 & sports & fitness exp5ses4 ,sec4 #aji4 ,equival5t bankruptcy protections = heal? sav+s acc\nts z retirem5t funds4 ,sec4 #aaj4 ,satisfaction ( employ] m&ate ?r\gh heal? sav+s acc\nt contributions4 ,sec4 #aaa4 ,rollov]s f heal? c>e ,f,s,as & ,h,r,as p]mitt$4 ,sec4 #aab4 ,qualifi$ g5]al contributions to heal? sav+s acc\nts4 ,sec4 #aac4 ,*>itable contributions to heal? sav+s acc\nts4 ,sec4 #aad4 ,am\nts paid = heal? c>e %>+ m9i/ry4 ,title ,,ii--,heal? ,m>ketplace = ,all ,sec4 #bja4 ,%ort title4 ,sec4 #bjb4 ,heal? m>ketplace pools deem$ an employ] = purposes ( (f]+ gr\p heal? plans or gr\p heal? insurance cov]age4 ,sec4 #bjc4 ,con=m+ am5dm5ts4 ,title ,,iii--,/r5g!n+ ,hospital & ,insur] ,price ,transp>5cy ,sec4 #cja4 ,%ort title4 ,sec4 #cjb4 ,/r5g!n+ hospital price transp>5cy requirem5ts4 ,sec4 #cjc4 ,increas+ price transp>5cy ( cl9ical diagno/ic laboratory te/s4 ,sec4 #cjd4 ,imag+ transp>5cy4 ,sec4 #cje4 ,ambulatory surgical c5t] price transp>5cy requirem5ts4 ,sec4 #cjf4 ,/r5g!n+ heal? cov]age transp>5cy requirem5ts4 ,sec4 #cjg4 ,increas+ gr\p heal? plan access to heal? data4 ,sec4 #cjh4 ,ov]sight ( adm9i/rative s]vice provid]s4 ,sec4 #cji4 ,/ate preemption only 9 ev5t ( conflict4 ,sec4 #caj4 ,requirem5t = explanation ( b5efits4 ,sec4 #caa4 ,provision ( itemiz$ bills4 ,title ,,iv--,protect+ ,pati5t ,access to ,canc] & ,complex ,!rapies ,sec4 #dja4 ,%ort title4 ,sec4 #djb4 ,rebate by manufactur]s = select$ drugs & biological products subject to maximum fair price negotiation4 ,title ,v--,exp&$-access ,prescription ,drugs ,sec4 #eja4 ,exp&$-access prescription drugs4 ,sec4 #ejb4 ,gov]nm5t sponsor$ programs4 ,i ,heal? ,sav+s ,acc\nts #aja4 ,%ort title ,?is title may be cit$ z ! ,heal? ,sav+s ,acc\nts ,= ,all ,act ( #bjbf4 #ajb4 ,increase 9 contribution limitations 7a7 ,9 g5]al ,subsection 7b7 ( section #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7#a7 9 p>agraph 7#a71 by /rik+ ! sum ( & all t foll[s ?r\gh ! p]iod & ins]t+ an am\nt equal to ! applicable doll> am\nt "u p>agraph 7#a77;,b7 ( section #djb7;g7 7z adju/$ pursuant to p>agraph 7#d7 ( su* section7 ) respect to su* taxable ye>41 7#b7 by /rik+ p>agraphs 7#b71 7#c71 7#e71 7#g71 & 7#h71 7#c7 by ins]t+ aft] p>agraph 7#a7 ! foll[+3 7#b7 ,additional contributions = individuals #ej or old] ,9 ! case ( an individual :o has atta9$ age #ej be=e ! close ( ! taxable ye>1 ! am\nt ( ! limitation "u p>agraph 7#a7 %all be increas$ by an am\nt equal to ! applicable doll> am\nt "u subp>agraph 7,b77i7 ( section #dad7v77#b7 7z adju/$ pursuant to subp>agraph 7,c7 ( su* section74 1 7#d7 9 p>agraph 7#d71 by /rik+ ! flu% matt] foll[+ subp>agraph 7,c71 & 7#e7 by r$esignat+ p>agraphs 7#d7 & 7#f7 z p>agraphs 7#c7 & 7#d71 respectively4 7b7 ,con=m+ am5dm5ts 7#a7 ,subp>agraph 7,a7 ( section #bbc7;d77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ ! sum (-- & all t foll[s ?r\gh ! p]iod & ins]t+ ! am\nt det]m9$ "u subsection 7b77#a744 7#b7 ,subsection 7g77#a7 ( section #bbc ( su* ,code is am5d$-- 7,a7 by /rik+ 7b77#b71 7c77#b77;,a71 & & ins]t+ 7c77#b77;,a7 &11 7,b7 by am5d+ subp>agraph 7,b7 to read z foll[s3 7,b7 ! co/-(-liv+ adju/m5t det]m9$ "u section #a7;f77#c7 = ! cal5d> ye> 9 :i* su* taxable ye> beg9s det]m9$ by sub/itut+ cal5d> ye> #bjjc = cal5d> ye> #bjaf 9 subp>agraph 7,a77ii7 !re(4 1 & 7,c7 by /rik+ 7b77#b71 7c77#a77;,e77ii77,,ii71 & ins]t+ 7c77#a77;,e77ii77,,ii74 7#c7 ,section #bf7;b77#b77,s7 ( su* ,code is am5d$ by /rik+ 1 #bbc7;b77#h77;,b77i77,,ii714 7#d7 ,section #djh7;d77#i77;,c77i77,i7 ( su* ,code is am5d$ by /rik+ comput$ on ! basis ( ! type ( cov]age "u ! high d$uctible heal? plan cov]+ ! individual4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #ajc4 ,fre$om f m&ate 7a7 ,9 g5]al ,section #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by section #ajb1 is fur!r am5d$ by /rik+ subsections 7c7 & 7g7 & by r$esignat+ subsections 7d71 7e71 7f71 & 7h7 z subsections 7c71 7d71 7e71 & 7f71 respectively4 7b7 ,con=m+ am5dm5ts 7#a7 ,subsection 7a7 ( section #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ to read z foll[s3 7a7 ,d$uction all[$ ,9 ! case ( an individual1 !re %all be all[$ z a d$uction = ! taxable ye> an am\nt equal to ! aggregate am\nt paid 9 ca% dur+ su* taxable ye> by or on behalf ( su* individual to a heal? sav+s acc\nt ( su* individual4 4 7#b7 ,subsection 7c77#a77;,a7 ( section #bbc ( su* ,code1 z am5d$ by section #ajb & r$esignat$ by subsection 7a71 is fur!r am5d$ by /rik+ subsection 7f77#d7 & ins]t+ subsection 7e77#d74 7#c7 ,subp>agraph 7,u7 ( section #bf7;b77#b7 ( su* ,code1 z am5d$ by section #ajb1 is fur!r am5d$ by /rik+ section #bbc7;f77#d7 & ins]t+ section #bbc7;e77#d74 7#d7 ,sections #ce7;g77#c71 #bbj7;f77#e77;,a71 #hdh7;e77#a77;,b77v71 #digc7;a77#e71 & #fjea7;a77#ab7 ( su* ,code are ea* am5d$ by /rik+ section #bbc7;d7 ea* place x appe>s & ins]t+ section #bbc7;c74 7#e7 ,section #ajf7;d77#a7 ( su* ,code is am5d$-- 7,a7 by /rik+ :o is an eligible individual 7z def9$ 9 section #bbc7;c77#a771 & 7,b7 by /rik+ section #bbc7;d7 & ins]t+ section #bbc7;c74 7#f7 ,section #ajf7;e7 ( su* ,code is am5d$-- 7,a7 by /rik+ p>agraphs 7#c7 & 7#d7 & by r$esignat+ p>agraph 7#e7 z p>agraph 7#d71 7,b7 by ins]t+ aft] p>agraph 7#b7 ! foll[+ new p>agraph3 7#c7 ,treatm5t z rollov] contribution ,a qualifi$ ,,hsa di/ribution %all be treat$ z a rollov] contribution describ$ 9 section #bbc7;e77#e74 1 & 7,c7 by /rik+ to any eligible individual cov]$ "u a high d$uctible heal? plan ( ! employ] 9 p>agraph 7#d77;,b77ii7 7z s r$esignat$7 & ins]t+ to any employee ) respect to :om a heal? sav+s acc\nt has be5 e/abli%$4 7#g7 ,section #djh7;d77#i77;,a7 ( su* ,code is am5d$ by /rik+ :o is an eligible individual 7z def9$ 9 section #bbc7;c77 &4 7#h7 ,section #hgg;,a7g77#f7 ( su* ,code is am5d$ by /rik+ #bbc7;f77#d7 & ins]t+ #bbc7;e77#d74 7#i7 ,section #digc7;g7 ( su* ,code is am5d$-- 7,a7 by /rik+ section #bbc7;d7 & ins]t+ section #bbc7;c71 7,b7 9 p>agraph 7#a71 by /rik+ or #bbc7;f77#e7 & ins]t+ or #bbc7;e77#e71 7,c7 9 p>agraph 7#b77;,a71 by /rik+ section #bbc7;f77#b7 & ins]t+ section #bbc7;e77#b71 & 7,d7 9 ! flu% matt] at ! end1 by /rik+ section #bbc7;f77#c7 & ins]t+ section #bbc7;e77#c74 7#aj7 ,section #dige ( su* ,code is am5d$-- 7,a7 9 subsection 7c77#f7-- 7i7 by /rik+ section #bbc7;d7 & ins]t+ section #bbc7;c71 & 7ii7 by /rik+ section #bbc7;e77#b7 & ins]t+ section #bbc7;d77#b71 & 7,b7 9 subsection 7e77#a77;,e71 by /rik+ section #bbc7;d7 & ins]t+ section #bbc7;c74 7#aa7 ,subsection 7b7 ( section #dihj;,g ( su* ,code is am5d$ to read z foll[s3 7b7 ,rules & requirem5ts 7#a7 ,9 g5]al ,an employ] meets ! requirem5ts ( ?is subsection = any cal5d> ye> if ! employ] makes available comp>able contributions to ! heal? sav+s acc\nts ( all comp>able p>ticipat+ employees = ea* cov]age p]iod dur+ su* cal5d> ye>4 7#b7 ,comp>able contributions 7,a7 ,9 g5]al ,= purposes ( p>agraph 7#a71 ! t]m comp>able contributions means contributions-- 7i7 :i* are ! same am\nt1 or 7ii7 if ! employees are cov]$ by a heal? plan1 :i* are ! same p]c5tage ( ! annual d$uctible limit "u ! plan cov]+ ! employees4 7,b7 ,"p-ye> employees ,9 ! case ( an employee :o is employ$ by ! employ] = only a portion ( ! cal5d> ye>1 a contribution to ! heal? sav+s acc\nt ( su* employee %all be treat$ z comp>able if x is an am\nt :i* be>s ! same ratio to ! comp>able am\nt 7det]m9$ )\t reg>d to ?is subp>agraph7 z su* portion be>s to ! entire cal5d> ye>4 7#c7 ,comp>able p>ticipat+ employees ,= purposes ( p>agraph 7#a71 ! t]m comp>able p>ticipat+ employees means all employees :o are cov]$ 7if at all7 "u ! same heal? plan ( ! employ] & h ! same category ( cov]age4 ,= purposes ( ! prec$+ s5t5ce1 ! categories ( cov]age are self-only & family cov]age4 7#d7 ,"p-"t employees 7,a7 ,9 g5]al ,p>agraph 7#c7 %all be appli$ sep>ately ) respect to "p-"t employees & o!r employees4 7,b7 ,"p-"t employee ,= purposes ( subp>agraph 7,a71 ! t]m "p-"t employee means any employee :o is cu/om>ily employ$ = few] ?an #cj h\rs p] week4 4 7#ab7 ,section #dihj;,g7d7 ( su* ,code is am5d$ by /rik+ section #dihj;,e & ins]t+ ?is section4 7#ac7 ,section #ffic7;a77#b77;,c7 ( su* ,code is am5d$ by /rik+ section #bbc7;h7 & ins]t+ section #bbc7;f74 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #ajd4 ,am\nts paid = heal? insurance or direct prim>y c>e s]vice arrangem5t 7a7 ,9 g5]al ,p>agraph 7#b7 ( section #bbc7;c7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z r$esignat$ by section #ajc1 is am5d$-- 7#a7 9 subp>agraph 7,a71 by ins]t+ or pursuant to an arrangem5t "u :i* an individual is provid$ cov]age re/rict$ to prim>y c>e s]vices 9 ex*ange = a fix$ p]iodic fee or paym5t = prim>y c>e s]vices aft] m5/rual c>e products1 7#b7 by /rik+ subp>agraphs 7,b7 & 7,c71 & 7#c7 by r$esignat+ subp>agraph 7,d7 z subp>agraph 7,b74 7b7 ,con=m+ am5dm5t ,p>agraph 7#b7 ( section #bbc7;c7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ! prec$+ sections ( ?is ,act1 is fur!r am5d$ by /rik+ & any dep5d5t 7z def9$ 9 section #aeb1 det]m9$ )\t reg>d to subsections 7b77#a71 7b77#b71 & 7d77#a77;,b7 !re(7 ( su* individual & ins]t+ any dep5d5t 7z def9$ 9 section #aeb1 det]m9$ )\t reg>d to subsections 7b77#a71 7b77#b71 & 7d77#a77;,b7 !re(7 ( su* individual1 & any *ild 7z def9$ 9 section #aeb7;f77#a77 ( su* individual :o has n atta9$ ! age ( #bg be=e ! end ( su* individual's taxable ye>4 7c7 ,te*nical am5dm5ts 7#a7 ,section #bbj7;d77#b77;,a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ section #bbc7;d77#b77;,d7 & ins]t+ section #bbc7;c77#b77;,b74 7#b7 ,subsection 7f7 ( section #ajf ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by /rik+ section #bbc7;d77#b77;,d7 & ins]t+ section #bbc7;c77#b77;,b74 7d7 ,effective dates 7#a7 ,9 g5]al ,! am5dm5ts made by subsections 7a7 & 7b7 %all apply ) respect to am\nts paid aft] ! date ( ! enactm5t ( ?is ,act 9 taxable ye>s beg9n+ aft] su* date4 7#b7 ,te*nical am5dm5ts ,! am5dm5ts made by subsection 7c7 %all apply ) respect to taxable ye>s beg9n+ aft] ! date ( enactm5t ( ?is ,act4 #aje4 ,special rule = c]ta9 m$ical exp5ses incurr$ be=e e/abli%m5t ( acc\nt 7a7 ,9 g5]al ,p>agraph 7#b7 ( section #bbc7;c7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ & r$esignat$ by ! prec$+ sections ( ?is ,act1 is fur!r am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,c7 ,c]ta9 m$ical exp5ses incurr$ be=e e/abli%m5t ( acc\nt treat$ z qualifi$ ,an exp5se %all n fail to be treat$ z a qualifi$ m$ical exp5se solely because su* exp5se 0 incurr$ be=e ! e/abli%m5t ( ! heal? sav+s acc\nt if su* exp5se 0 incurr$-- 7i7 dur+ ei!r-- 7,i7 ! taxable ye> 9 :i* ! heal? sav+s acc\nt 0 e/abli%$1 or 7,,ii7 ! prec$+ taxable ye>1 9 ! case ( a heal? sav+s acc\nt e/abli%$ aft] ! taxable ye> 9 :i* su* exp5se 0 incurr$ b be=e ! "t prescrib$ by law = fil+ ! return = su* taxable ye> 7n includ+ ext5sions !re(71 & 7ii7 = m$ical c>e :i* 7b = ! fact t x 0 incurr$ be=e ! e/abli%m5t ( ! acc\nt7 o!rwise meets ! requirem5ts ( ! prec$+ subp>agraphs4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #ajf4 ,adm9i/rative error correction be=e due date ( return 7a7 ,9 g5]al ,p>agraph 7#d7 ( section #bbc7;e7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ & r$esignat$ by ! prec$+ sections ( ?is ,act1 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,d7 ,exception = adm9i/rative errors correct$ be=e due date ( return ,subp>agraph 7,a7 %all n apply if any paym5t or di/ribution is made to correct an adm9i/rative1 cl]ical1 or payroll contribution error & if-- 7i7 su* di/ribution is receiv$ by ! individual on or be=e ! la/ day prescrib$ by law 7includ+ ext5sions ( "t7 = fil+ su* individual's return = su* taxable ye>1 & 7ii7 su* di/ribution is accompani$ by ! am\nt ( net income attributable to su* contribution4 ,any net income describ$ 9 clause 7ii7 %all be includ$ 9 ! gross income ( ! individual = ! taxable ye> 9 :i* x is receiv$4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all take effect on ! date ( ! enactm5t ( ?is ,act4 #ajg4 ,all[+ ,,hsa rollov] to *ild or p>5t ( acc\nt hold] 7a7 ,9 g5]al ,p>agraph 7#h77;,a7 ( section #bbc7;e7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z r$esignat$ by ! prec$+ sections ( ?is ,act1 is am5d$-- 7#a7 by ins]t+ 1 *ild1 p>5t1 or gr&p>5t aft] surviv+ sp\se1 7#b7 by ins]t+ 1 *ild1 p>5t1 or gr&p>5t1 z ! case may be1 aft] ! sp\se1 7#c7 by ins]t+ 1 *ild1 p>5t1 or gr&p>5t aft] sp\se 9 ! head+ !re(1 & 7#d7 by add+ at ! end ! foll[+3 ,9 ! case ( a *ild :o acquires su* b5efici>y's int]e/ & ) respect to :om a d$uction "u section #aea is all[able to ano!r taxpay] = a taxable ye> beg9n+ 9 ! cal5d> ye> 9 :i* su* individual's taxable ye> beg9s1 su* heal? sav+s acc\nt %all be treat$ z a heal? sav+s acc\nt ( su* *ild44 7b7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #ajh4 ,cov]age = am\nts paid = heal?y food1 vitam9s1 diet>y supplem5ts1 & sports & fitness exp5ses 7a7 ,9 g5]al ,p>agraph 7#b7 ( section #bbc7;c7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ! prec$+ provisions ( ?is ,act1 is am5d$-- 7#a7 9 subp>agraph 7,a71 by add+ at ! end ! foll[+ new s5t5ce3 ,= purposes ( ?is subp>agraph1 am\nts paid = qualifi$ wellness exp5ses %all be treat$ z paid = m$ical c>e1 b only to ! ext5t t su* am\nts paid ) respect to ea* individual describ$ 9 ! fir/ s5t5ce ( ?is subp>agraph d n exce$ #ajj p] mon? 9 ! case ( a heal? sav+s acc\nt ! balance ( :i* does n exce$ #e1jjj2 #aej p] mon? 9 ! case ( a heal? sav+s acc\nt ! balance ( :i* exce$s #e1jjj b does n exce$ #aj1jjj2 & #bjj p] mon? 9 ! case ( a heal? sav+s acc\nt ! balance ( :i* exce$s #aj1jjj41 & 7#b7 by add+ at ! end ! foll[+3 7,d7 ,qualifi$ wellness exp5ses 7i7 ,9 g5]al ,= purposes ( ?is p>agraph1 ! t]m qualifi$ wellness exp5ses means am\nts paid = heal?y food1 vitam9s1 diet>y supplem5ts 7z def9$ 9 section #bja7;ff7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cba7;ff7771 or qualifi$ sports & fitness exp5ses4 7ii7 ,heal?y food ,! t]m heal?y food means any individual food :i* meets ! crit]ia ( section #aja4fe7;d77#c77;i7 ( title #ba1 ,code ( ,f$]al ,regulations 7or any successor regulations74 7iii7 ,qualifi$ sports & fitness exp5ses 7,i7 ,9 g5]al ,! t]m qualifi$ sports & fitness exp5ses means am\nts paid exclusively = ! sole purpose ( p>ticipat+ 9 a physical activity1 includ+-- 7aa7 = memb]%ip at a fitness facility1 7bb7 = p>ticipation or in/ruction 9 physical ex]cise or physical activity1 or 7cc7 = equipm5t us$ 9 a program 7includ+ a self-direct$ program7 ( physical ex]cise or physical activity1 includ+ a we>able fitness track]4 7,,ii7 ,fitness facility ,= purposes ( subclause 7,i77aa71 ! t]m fitness facility means a facility-- 7aa7 :i* provides in/ruction 9 a program ( physical ex]cise1 (f]s facilities = ! pres]vation1 ma9t5ance1 enc\ragem5t1 or developm5t ( physical fitness1 or s]ves z ! site ( su* a program ( a ,/ate or local gov]nm5t or an organization describ$ 9 section #eja7;c77#c7 & exempt f tax "u section #eja7;a71 7bb7 :i* is n a private club own$ & op]at$ by its memb]s1 7cc7 :i* does n (f] golf1 hunt+1 sail+1 or rid+ facilities1 7dd7 ! heal? or fitness compon5t ( :i* is n incid5tal to its ov]all function & purpose1 & 7ee7 :i* is fully compliant ) ! ,/ate ( jurisdiction & ,f$]al anti-discrim9ation laws4 7,,iii7 ,treatm5t ( ex]cise videos1 etc ,videos1 books1 & simil> mat]ials %all be treat$ z describ$ 9 subclause 7,i77bb7 if ! cont5t ( su* mat]ials con/itutes in/ruction 9 a program ( physical ex]cise or physical activity4 7,,iv7 ,limitations relat$ to sports & fitness equipm5t ,am\nts paid = equipm5t describ$ 9 subclause 7,i77cc7 %all be treat$ z qualifi$ sports & fitness exp5ses only-- 7aa7 if su* equipm5t is utiliz$ exclusively = p>ticipation 9 fitness1 ex]cise1 sport1 or o!r physical activity1 & 7bb7 9 ! case ( am\nts paid = app>el or footwe>1 if su* app>el or footwe> is ( a type t is necess>y =1 & is n us$ = any purpose o!r ?an1 a specific physical activity4 4 7b7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #aji4 ,equival5t bankruptcy protections = heal? sav+s acc\nts z retirem5t funds 7a7 ,9 g5]al ,section #ebb ( title #aa1 ,unit$ ,/ates ,code1 is am5d$ by add+ at ! end ! foll[+ new subsection3 7r7 ,treatm5t ( heal? sav+s acc\nts ,= purposes ( ?is section1 any heal? sav+s acc\nt 7z describ$ 9 section #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf7 %all be treat$ 9 ! same mann] z an individual retirem5t acc\nt describ$ 9 section #djh ( su* ,code4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to cases comm5c+ "u title #aa1 ,unit$ ,/ates ,code1 aft] ! date ( ! enactm5t ( ?is ,act4 #aaj4 ,satisfaction ( employ] m&ate ?r\gh heal? sav+s acc\nt contributions 7a7 ,9 g5]al ,section #dihj;,h ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subsection3 7e7 ,contributions to heal? sav+s acc\nts 7#a7 ,9 g5]al ,an (f] to make a contribution ( #dej p] mon? to an employee's heal? sav+s acc\nt %all be treat$ = purposes ( ?is section z an (f] to enroll 9 m9imum ess5tial cov]age "u an eligible employ]-sponsor$ plan = su* mon?4 7#b7 ,treatm5t z af=dable cov]age ,any employee (f]$ a contribution describ$ 9 p>agraph 7#a7 by any employ] = any mon? %all n be treat$ z describ$ 9 subsection 7b77#a77;,b7 ) respect to su* employ] = su* mon?4 4 7b7 ,application ( exclusion = employ] contributions to heal? sav+s acc\nts ,section #ajf7;d7 ( su* ,code is am5d$-- 7#a7 by r$esignat+ p>agraphs 7#b7 & 7#c7 z p>agraphs 7#c7 & 7#d71 respectively1 & 7#b7 by ins]t+ aft] p>agraph 7#a7 ! foll[+ new p>agraph3 7#b7 ,limitation ,9 ! case ( an employee ^: employ] makes a contribution ( at lea/ #dej p] mon? to su* employee's heal? sav+s acc\nt1 p>agraph 7#a7 %all apply to su* a contribution only if su* employee is enroll$ 9 heal? c>e cov]age = su* mon?4 4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to mon?s beg9n+ 9 taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #aaa4 ,rollov]s f heal? c>e ,f,s,as & ,h,r,as p]mitt$ 7a7 ,9 g5]al ,section #ajf ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subsection3 7h7 ,,fsa & ,,hra rollov]s to heal? sav+s acc\nts 7#a7 ,9 g5]al ,a plan %all n fail to be treat$ z a heal? flexible sp5d+ arrangem5t or heal? reimbursem5t arrangem5t "u ?is section or section #aje m]ely because su* plan provides = a qualifi$ ,,hsa rollov] di/ribution4 7#b7 ,qualifi$ ,,hsa rollov] di/ribution ,= purposes ( ?is subsection1 ! t]m qualifi$ ,,hsa rollov] di/ribution means any portion ( a b5efici>y's unus$ balance ( a heal? flexible sp5d+ arrangem5t or heal? reimbursem5t arrangem5t at ! end ( any plan ye> 7or su* o!r times z ! ,secret>y may provide7 :i* is transf]r$ 9 a direct tru/ee-to-tru/ee transf] to a heal? sav+s acc\nt ( su* b5efici>y4 7#c7 ,treatm5t z ,,hsa rollov] contribution ,= purposes ( ?is title1 a qualifi$ ,,hsa rollov] di/ribution %all be treat$ z a contribution describ$ 9 section #bbc7;e77#e74 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #aab4 ,qualifi$ g5]al contributions to heal? sav+s acc\nts 7a7 ,9 g5]al ,section #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ! prec$+ provisions ( ?is ,act1 is am5d$-- 7#a7 9 subsection 7c77#a77;,a71 by ins]t+ or a qualifi$ g5]al contribution1 aft] section #bbj7;f77#e711 & 7#b7 9 subsection 7e7-- 7,a7 9 p>agraph 7#c77;,b71 by ins]t+ 1 or a qualifi$ g5]al contribution aft] section #bbj7;f77#e71 & 7,b7 by add+ at ! end ! foll[+ new p>agraph3 7#i7 ,qualifi$ g5]al contribution ,= purposes ( ?is section-- 7,a7 ,9 g5]al ,! t]m qualifi$ g5]al contribution means any contribution :i*-- 7i7 is made by ! ,secret>y pursuant to a g5]al fund+ contribution1 7ii7 is made to ! heal? sav+s acc\nt ( an acc\nt b5efici>y 9 ! qualifi$ class ( acc\nt b5efici>ies specifi$ 9 ! g5]al fund+ contribution1 & 7iii7 is 9 an am\nt :i* is equal to ! ratio (-- 7,i7 ! am\nt ( su* g5]al fund+ contribution1 to 7,,ii7 ! numb] ( acc\nt b5efici>ies 9 su* qualifi$ class4 7,b7 ,g5]al fund+ contribution ,! t]m g5]al fund+ contribution means a contribution :i*-- 7i7 is made by-- 7,i7 an entity describ$ 9 section #agj7;c77#a7 7o!r ?an a possession ( ! ,unit$ ,/ates or a political subdivision !re(7 or an ,indian tribal gov]nm5t1 or 7,,ii7 an organization describ$ 9 section #eja7;c77#c7 & exempt f tax "u section #eja7;a71 & 7ii7 :i* specifies a qualifi$ class ( acc\nt b5efici>ies to :om su* contribution is to be di/ribut$4 7,c7 ,qualifi$ class 7i7 ,9 g5]al ,! t]m qualifi$ class means any ( ! foll[+3 7,i7 ,all acc\nt b5efici>ies4 7,,ii7 ,all acc\nt b5efici>ies :o reside 9 "o or m ,/ates or o!r qualifi$ geographic areas specifi$ by ! t]ms ( ! g5]al fund+ contribution4 7ii7 ,qualifi$ geographic area ,! t]m qualifi$ geographic area means any geographic area 9 :i* n less ?an #e1jjj acc\nt b5efici>ies reside & :i* is designat$ by ! ,secret>y z a qualifi$ geographic area "u ?is clause4 4 7b7 ,exclusion f gross income 7#a7 ,9 g5]al ,"p ,,iii ( sub*apt] ,b ( *apt] #a ( su* ,code is am5d$ by ins]t+ be=e section #adj ! foll[+ new section3 #aci,m4 ,qualifi$ g5]al contributions to heal? sav+s acc\nts 7a7 ,9 g5]al ,gross income ( an acc\nt b5efici>y %all n include any qualifi$ g5]al contribution to a heal? sav+s acc\nt ( ! acc\nt b5efici>y4 7b7 ,def9itions ,any t]m us$ 9 ?is section :i* is us$ 9 section #bbc %all h ! mean+ giv5 su* t]m "u section #bbc4 4 7#b7 ,cl]ical am5dm5t ,! table ( sections = "p ,,iii ( sub*apt] ,b ( *apt] #a ( su* ,code is am5d$ by ins]t+ be=e ! item relat+ to section #adj ! foll[+ new item3 ,sec4 #aci,m4 ,qualifi$ g5]al contributions to heal? sav+s acc\nts4 4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #aac4 ,*>itable contributions to heal? sav+s acc\nts 7a7 ,9 g5]al ,section #bbc7;c77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ! prec$+ provisions ( ?is ,act1 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,f7 ,! tru/ee provides ! acc\nt b5efici>y ) a ,,url 7or o!r simil> %>eable l9k7 :i* all[s any organization describ$ 9 section #eja7;c77#c7 & exempt f tax "u section #eja7;a7 to make contributions to ! acc\nt on ! acc\nt b5efici>y's behalf4 ,any su* contribution %all be tak5 into acc\nt z a *>itable contribution = purposes ( section #agj to ! ext5t t ! aggregate am\nt ( su* contributions f ea* su* organization = any taxable ye> does n exce$ #e1jjj4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 #aad4 ,am\nts paid = heal? c>e %>+ m9i/ry 7a7 ,9 g5]al ,section #bbc7;c77#b77;,a7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 z am5d$ by ! prec$+ provisions ( ?is ,act1 is am5d$ by add+ at ! end ! foll[+ new s5t5ce3 ,= purposes ( ?is subp>agraph1 am\nts paid by a memb] ( a heal? c>e %>+ m9i/ry 7z def9$ 9 section #ejjj;,a7d77#b77;,b77ii7 )\t reg>d to subclause 7,,iv7 !re(7 = ! %>+ ( m$ical exp5ses among memb]s1 or adm9i/rative fees ( su* m9i/ry1 %all be treat$ z paid = m$ical c>e44 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ! date ( ! enactm5t ( ?is ,act4 ,,ii ,heal? ,m>ketplace = ,all #bja4 ,%ort title ,?is title may be cit$ z ! ,heal? ,m>ketplace = ,all ,act ( #bjbf4 #bjb4 ,heal? m>ketplace pools deem$ an employ] = purposes ( (f]+ gr\p heal? plans or gr\p heal? insurance cov]age 7a7 ,def9ition ( employ] ,section #c7e7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajjb7e77 is am5d$ by add+ at ! end ! foll[+3 ,su* t]m %all be deem$ to include1 = purposes ( (f]+ a gr\p heal? plan 7z def9$ 9 section #gcc7;a77#a77 or gr\p heal? insurance cov]age 7z def9$ 9 section #gcc7;b77#d77 7:i*1 not)/&+ any o!r provision ( law1 may include su* a plan or cov]age cov]+ prescription or nonprescription drugs z ! only b5efit (f]$ by ! plan or cov]age 9 accordance ) section #gcf7;b77#e77;,b771 any entity t meets ! requirem5ts "u section #gcf7;b744 7b7 ,gr\p heal? plans & gr\p heal? insurance cov]age ,"p #g ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aaha et seq47 is am5d$ by add+ at ! end ! foll[+3 #gcf4 ,heal? m>ketplace pools deem$ an employ] = purposes ( (f]+ gr\p heal? plans or gr\p heal? insurance cov]age 7a7 ,9 g5]al ,an entity 7ref]r$ to 9 ?is section z a heal? m>ketplace pool7 t meets ! requirem5ts "u subsection 7b7 %all be deem$ an employ] "u section #c7e7 = purposes ( (f]+ a gr\p heal? plan or gr\p heal? insurance cov]age 7:i*1 not)/&+ any o!r provision ( law1 may include su* a plan or cov]age cov]+ prescription or nonprescription drugs z ! only b5efit (f]$ by ! plan or cov]age 9 accordance ) subsection 7b77#e77;,b774 7b7 ,requirem5ts = heal? m>ketplace pools ,! requirem5ts "u ?is subsection are ea* ( ! foll[+3 7#a7 ,organization ,! heal? m>ketplace pool %all-- 7,a7 be =m$ & ma9ta9$ 9 good fai? = a purpose t includes ! =mation ( a risk pool 9 ord] to (f] gr\p heal? insurance cov]age or a gr\p heal? plan to its memb]s2 & 7,b7 n condition memb]%ip 9 ! heal? m>ketplace pool on any heal? /atus-relat$ factor relat+ to an individual 7includ+ an employee ( an employ] or a dep5d5t ( an employee74 7#b7 ,(f]+ gr\p heal? plans & gr\p heal? insurance cov]age 7,a7 ,diff]5t gr\ps 7i7 ,9 g5]al ,! heal? m>ketplace pool1 :i* may be 9 conjunction ) a heal? insurance issu] t (f]s gr\p heal? insurance cov]age ?r\gh ! heal? m>ketplace pool1 %all make available a gr\p heal? plan or gr\p heal? insurance cov]age to all memb]s ( ! heal? m>ketplace pool 7&1 9 ! case ( memb]s t are employ]s1 employees ( ! employ]s7 at rates t-- 7,i7 are e/abli%$ by ! heal? m>ketplace pool1 or a heal? insurance issu] contract+ ) su* heal? m>ketplace pool1 on a policy or product specific basis2 & 7,,ii7 subject to sections #gja & #gjb1 may v>y = individuals cov]$ ?r\gh ! heal? m>ketplace pool4 7ii7 ,p]missible cov]age = dep5d5ts ,su* gr\p heal? plan or gr\p heal? insurance cov]age may be made available "u clause 7i7 to any dep5d5ts ( memb]s ( ! heal? m>ketplace pool or dep5d5ts ( employees ( employ]s t are su* memb]s4 7,b7 ,nondiscrim9ation 9 cov]age (f]$ 7i7 ,9 g5]al ,subject to clause 7ii71 ! heal? m>ketplace pool may n (f] cov]age "u a gr\p heal? plan or gr\p heal? insurance cov]age to a memb] ( ! heal? m>ketplace pool unless ! same cov]age is (f]$ to all su* memb]s ( ! heal? m>ketplace pool4 7ii7 ,con/ruction ,no?+ 9 ?is subsection %all be con/ru$ z requir+ a heal? insurance issu] or gr\p heal? plan to provide cov]age outside ! s]vice area ( ! issu] or plan1 or prev5t+ a heal? insurance issu] or gr\p heal? plan f und]writ+ or f exclud+ or limit+ ! cov]age on any individual1 subject to ! requirem5ts "u sections #gja & #gjb4 7,c7 ,assumption ( risk ,! heal? m>ketplace pool may provide-- 7i7 gr\p heal? insurance cov]age ?r\gh a contract ) a heal? insurance issu]2 or 7ii7 a gr\p heal? plan ?r\gh self-insurance4 7#c7 ,geographic areas ,no?+ 9 ?is subsection %all be con/ru$ z prev5t+ ! e/abli%m5t & op]ation ( m ?an #a heal? m>ketplace pool 9 a geographic area or z limit+ ! numb] ( heal? m>ketplace pools t may op]ate 9 any area4 7#d7 ,provision ( adm9i/rative s]vices to pur*as]s ,! heal? m>ketplace pool may provide adm9i/rative s]vices = memb]s4 ,su* s]vices may include acc\nt+1 bill+1 & enrollm5t in=mation4 7#e7 ,drug cov]age ,! gr\p heal? plan or gr\p heal? insurance cov]age (f]$ by ! heal? m>ketplace pool may (f]-- 7,a7 drug cov]age1 includ+ cov]age ( ov]-!-c\nt] drugs1 9 comb9ation ) o!r b5efits cov]$ by ! gr\p heal? plan or gr\p heal? insurance cov]age2 or 7,b7 not)/&+ any o!r provision ( law1 drug cov]age1 includ+ cov]age ( ov]-!-c\nt] drugs1 z ! only b5efit cov]$ by ! gr\p heal? plan or gr\p heal? insurance cov]age4 7#f7 ,memb]s 7,a7 ,9 g5]al ,) respect to an individual :o is a memb] ( ! heal? m>ketplace pool-- 7i7 ! individual may enroll = cov]age "u ! gr\p heal? plan or gr\p heal? insurance cov]age (f]$ by ! heal? m>ketplace pool 7includ+1 if applicable1 enrollm5t = cov]age = a dep5d5t ( su* individual72 or 7ii7 ! employ] ( ! individual may enroll ! individual = cov]age "u ! gr\p heal? plan or gr\p heal? insurance cov]age (f]$ by ! heal? m>ketplace pool 7includ+1 if applicable1 enrollm5t = cov]age = a dep5d5t ( su* individual74 7,b7 ,eligibility ,an individual %all be eligible to be a memb] ( ! heal? m>ketplace pool if su* individual is-- 7i7 a memb] ( an entity t e/abli%es or jo9s ! heal? m>ketplace pool 7or a dep5d5t ( su* a memb]1 z applicable72 7ii7 an employee ( a memb] ( an entity describ$ 9 clause 7i7 7or a dep5d5t ( su* an employee1 z applicable72 or 7iii7 an employee ( an entity 7or a dep5d5t ( su* an employee1 z applicable7 controll$ by a memb] ( an entity describ$ 9 clause 7i74 7,c7 ,rules = enrollm5t ,no?+ 9 ?is p>agraph %all preclude ! heal? m>ketplace pool f e/abli%+ rules ( enrollm5t & re5rollm5t ( memb]s4 ,su* rules %all be appli$ consi/5tly to all memb]s )9 ! heal? m>ketplace pool & %all n be bas$ 9 any mann] on heal? /atus-relat$ factors 9 accordance ) sections #gja & #gjb4 7c7 ,det]m9ation ( employ] & jo9t employ] /atus ,p>ticipat+ 9 or facilitat+ a gr\p heal? plan or gr\p heal? insurance cov]age "u ?is section %all n be con/ru$ z e/abli%+ "u any ,f$]al or ,/ate law-- 7#a7 an employ] relation%ip = any purpose o!r ?an (f]+ ! gr\p heal? plan or gr\p heal? insurance cov]age2 or 7#b7 a jo9t employ] relation%ip = any purpose4 7d7 ,def9ition ,9 ?is section1 ! t]m dep5d5t1 z appli$ to a gr\p heal? plan or gr\p heal? insurance cov]age (f]$ 9 a ,/ate1 %all h ! mean+ appli$ to su* t]m ) respect to su* plan or cov]age "u ! ,/ate law apply+ to su* plan or cov]age4 ,su* t]m may include ! sp\se & *ildr5 ( ! individual involv$ 9 accordance ) su* ,/ate law4 4 #bjc4 ,con=m+ am5dm5ts ,section #c ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajjb7 is am5d$-- 7#a7 9 p>agraph 7#f71 by ins]t+ be=e ! p]iod 1 except 7) respect to an entity meet+ ! requirem5ts "u section #gcf7;b77 su* t]m includes any memb] ( su* entity2 7#b7 9 p>agraph 7#ba7-- 7,a7 9 subp>agraph 7,a71 by /rik+ subp>agraph 7,b7 & ins]t+ subp>agraphs 7,b7 & 7,c72 & 7,b7 by add+ at ! end ! foll[+3 7,c7 ,) respect to a p]son t is a memb] ( an entity 7ref]r$ to 9 section #gcf & ?is subp>agraph z a heal? m>ketplace pool7 t meets ! requirem5ts ( section #gcf7;b7 & (f]s a gr\p heal? plan 7z def9$ 9 section #gcc7;a77#a77 or gr\p heal? insurance cov]age 7z def9$ 9 section #gcc7;b77#d77 7:i*1 not)/&+ any o!r provision ( law1 may include su* a plan or cov]age cov]+ prescription or nonprescription drugs z ! only b5efit (f]$ by ! plan or cov]age71 memb]%ip 9 ! heal? m>ketplace pool %all n by itself cause ! p]son to be a fiduci>y ) respect to ! gr\p heal? plan or gr\p heal? insurance cov]age4 2 & 7#c7 9 p>agraph 7#dj77;,a7-- 7,a7 9 clause 7ii71 by /rik+ 1 or & ins]t+ 12 7,b7 9 clause 7iii71 by /rik+ ! p]iod & ins]t+ 1 or2 & 7,c7 by add+ at ! end ! foll[+3 7iv7 z a gr\p heal? plan 7z def9$ 9 section #gcc7;a77#a771 or gr\p heal? insurance cov]age 7z def9$ 9 section #gcc7;b77#d771 (f]$ by an entity meet+ ! requirem5ts "u section #gcf7;b7 7:i*1 not)/&+ any o!r provision ( law1 may include su* an entity (f]+ su* a plan or cov]age cov]+ prescription or nonprescription drugs z ! only b5efit (f]$ by ! plan or cov]age74 4 ,,iii ,/r5g!n+ ,hospital & ,insur] ,price ,transp>5cy #cja4 ,%ort title ,?is title may be cit$ z ! ,pati5ts ,des]ve ,price ,tags ,act4 #cjb4 ,/r5g!n+ hospital price transp>5cy requirem5ts 7a7 ,9 g5]al ,section #bgah7;e7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7;e77 is am5d$ to read z foll[s3 7e7 ,/&>d hospital *>ges 7#a7 ,9 g5]al 7,a7 ,disclosure ( /&>d *>ges ,ea* hospital %all1 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u subp>agraph 7,c71 on a mon?ly basis compile & make public 7)\t subscription & free ( *>ge7-- 7i7 all ( ! hospital's /&>d *>ges 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = ea* item & s]vice furni%$ by su* hospital2 & 7ii7 hospital /&>d *>ge in=mation1 includ+ ! in=mation describ$ 9 subp>agraph 7,b71 9 a consum]-fri5dly =mat 7z specifi$ by ! ,secret>y71 t includes-- 7,i7 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]vices ?r\gh ,decemb] #ca1 #bjbg1 aft] :i* ! hospital's prices %all include all %oppable s]vices2 & 7,,ii7 ) 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%$4 7,b7 ,/&>d *>ges describ$ ,= purposes ( subp>agraph 7,a71 /&>d *>ges means3 7i7 ,a pla9 language description ( ea* item or s]vice1 accompani$ by any applicable bill+ codes1 includ+ modifi]s1 us+ commonly recogniz$ bill+ code sets1 includ+ ! ,curr5t ,proc$ural ,t]m9ology code1 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! diagnosis-relat$ gr\p1 ! ,national ,drug ,code1 & o!r nationally recogniz$ id5tifi]4 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% price 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 ! m9imum ca% price accept$ by ! hospital f self-pay individuals = su* item or s]vice1 express$ z a doll> am\nt1 z well z1 ) respect to prices made public pursuant to subp>agraph 7,a77ii71 a l9k to a consum]-fri5dly docum5t t cle>ly expla9s ! hospital's *>ity c>e policy74 ,! hospital %all accept ! disc\nt$ ca% price z paym5t 9 full f any pati5t t *ooses to pay 9 ca% )\t reg>d to ! pati5t's cov]age4 7iv7 ,! pay]-specific negotiat$ *>ges1 express$ z a doll> am\nt & cle>ly associat$ ) ! "n ( ! applicable ?ird p>ty pay] & "n ( ea* plan1 t apply to ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 ,if ! *>ges are bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! hospital also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r t]ms1 s*$ules1 exhibits1 data1 or o!r in=mation ref]5c$ 9 any su* contract z %all be requir$ to det]m9e & disclose ! negotiat$ *>ge4 7v7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges = ea* su* item or s]vice1 express$ z a non-z]o doll> am\nt4 7vi7 ,any o!r additional in=mation ! ,secret>y may require = ! purpose ( improv+ ! accuracy (1 or enabl+ consum]s to easily und]/& & comp>e1 /&>d *>ges & prices = an item or s]vice1 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is subsection4 ,9 ! case ( /&>d *>ges & prices = an item or s]vice includ$ z "p ( a bundl$1 p] diem1 episodic1 or o!r simil> arrangem5t1 ! in=mation describ$ 9 ?is subp>agraph %all be made available z det]m9$ appropriate by ! ,secret>y4 7,c7 ,uni=m me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbg1 ! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = hospitals to use 9 compil+ & mak+ public /&>d *>ges pursuant to subp>agraph 7,a77i7 & a /&>d1 uni=m me?od & =mat = su* hospitals to use 9 compil+ & mak+ public prices pursuant to subp>agraph 7,a77ii74 ,su* me?ods & =mats %all-- 7i7 9 ! case ( su* me?od & =mat = mak+ public /&>d *>ges pursuant to subp>agraph 7,a77i71 ensure t su* *>ges are made available 9 a ma*9e-readable spread%eet =mat2 7ii7 meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges & prices2 & 7iii7 be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#b7 ,no deem$ compliance ,! availability ( a price e/imator tool %all n be consid]$ to deem compliance ) or o!rwise vitiate ! requirem5ts ( p>agraph 7#a77;,a77ii7 or any o!r requirem5ts ( ?is section4 ,fur!rmore1 ! use ( an e/imator tool %all n be us$ = purposes ( compliance ) any provisions 9 ?is section4 7#c7 ,monitor+ compliance ,! ,secret>y %all1 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* hospital's compliance ) ?is subsection is review$ n less frequ5tly ?an once e ye>4 7#d7 ,atte/ation ,a s5ior (ficial f ea* hospital 7! ,*ief ,executive ,(fic]1 ,*ief ,f9ancial ,(fic]1 or an (ficial ( equival5t s5iority7 %all atte/ to ! accuracy & complet5ess ( ! disclosures made 9 accordance ) ! hospital price transp>5cy requirem5ts set =? 9 ?is regulation4 ,su* atte/ation %all be deem$ to be mat]ial to paym5t f ! ,f$]al ,gov]nm5t to ! hospital4 7#e7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( a hospital t fails to comply ) ! requirem5ts ( ?is subsection1 n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s1 ! ,secret>y %all submit to su* hospital a notification ( su* det]m9ation1 :i* %all include a reque/ = a corrective action plan to comply ) su* requirem5ts4 7,b7 ,civil monet>y p5alty 7i7 ,9 g5]al ,9 addition to any o!r en=cem5t actions or p5alties t may apply "u ano!r provision ( law1 a hospital t has receiv$ a reque/ = a corrective action plan "u subp>agraph 7,a7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #de days aft] su* reque/ is made %all be subject to a civil monet>y p5alty ( an am\nt specifi$ by ! ,secret>y = ea* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* hospital 0 n comply+ ) su* requirem5ts7 dur+ :i* su* failure 0 ongo+4 ,su* am\nt %all n exce$-- 7,i7 9 ! case ( a hospital ) #cj or few] b$s1 #cjj p] day2 7,,ii7 9 ! case ( a hospital ) m ?an #cj b$s b few] ?an #aja b$s1 #ab4ej p] b$ p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #ae p] b$ p] day72 7,,iii7 9 ! case ( a hospital ) m ?an #ajj b$s b few] ?an #cja b$s1 #ag4ej p] b$ p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #bj p] b$ p] day72 7,,iv7 9 ! case ( a hospital ) m ?an #cjj b$s b few] ?an #eja b$s1 #bj p] b$ p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #be p] b$ p] day72 & 7,v7 9 ! case ( a hospital ) m ?an #ejj b$s1 #be p] b$ p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #ce p] b$ p] day74 7ii7 ,increase au?ority ,9 apply+ ?is subp>agraph ) respect to violations occurr+ 9 #bjbh 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 hospital "u clause 7i77,i72 7,,ii7 ! limitations on ! p] b$ p] day am\nt ( any p5alty applicable "u any ( subclauses 7,,ii7 ?r\gh 7,v7 ( clause 7i72 & 7,,iii7 ! limitation on ! increase ( any p5alty appli$ "u clause 7iii7 pursuant to ! am\nts specifi$ 9 subclause 7,,ii7 ( su* clause4 7iii7 ,p]si/5t noncompliance 7,i7 ,9 g5]al ,9 ! case ( a hospital 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 ! am\nt specifi$ 9 subclause 7,,ii7 ) respect to su* hospital & may require su* hospital to complete su* additional corrective actions plans z ! ,secret>y may specify4 7,,ii7 ,specifi$ am\nt ,= purposes ( subclause 7,i71 ! am\nt specifi$ 9 ?is subclause is1 ) respect to a hospital-- 7aa7 ) m ?an #cj b$s b few] ?an #aja b$s1 an am\nt t is n less ?an #ejj1jjj & n m ?an #a1jjj1jjj2 7bb7 ) m ?an #ajj b$s b few] ?an #cja b$s1 an am\nt t is great] ?an #a1jjj1jjj & n m ?an #b1jjj1jjj2 7cc7 ) m ?an #cjj b$s b few] ?an #eja b$s1 an am\nt t is great] ?an #b1jjj1jjj & n m ?an #d1jjj1jjj2 & 7dd7 ) m ?an #ejj b$s1 an am\nt t is n less ?an #e1jjj1jjj & n m ?an #aj1jjj1jjj4 7iv7 ,provision ( te*nical assi/ance ,! ,secret>y may1 to ! ext5t practicable1 provide te*nical assi/ance relat+ to compliance ) ! provisions ( ?is section to hospitals reque/+ su* assi/ance4 7v7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is subp>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7,c7 ,no waiv] ,! ,secret>y %all n grant or ext5d any waiv]1 delay1 toll+1 or o!r mitigation ( a civil monet>y p5alty = violation ( ?is subsection4 7#f7 ,def9itions ,= purposes ( ?is subsection3 7,a7 ,disc\nt$ ca% price ,! t]m disc\nt$ ca% price means ! m9imum *>ge1 exclusive ( any hospital or ?ird-p>ty pay] assi/ance1 t ! hospital accepts f an individual :o pays ca%1 or ca% equival5t1 = a hospital-furni%$ item or s]vice1 )\t reg>d to pati5t cov]age1 z paym5t 9 full4 7,b7 ,gross *>ge ,! t]m gross *>ge means ! *>ge = an individual item or s]vice t is reflect$ on a hospital's *>gema/]1 abs5t any disc\nts4 7,c7 ,hospital ,! t]m hospital means a hospital 7z def9$ 9 section #ahfa7;e7 ( ! ,social ,security ,act71 a critical access hospital 7z def9$ 9 section #ahfa7mmm77#a7 ( ! ,social ,security ,act71 or a rural em]g5cy hospital 7z def9$ 9 section #ahfa7kkk7 ( ! ,social ,security ,act71 toge!r ) any p>5t1 subsidi>y1 or o!r affiliat$ provid] or suppli] ( heal? c>e items & s]vices )\t reg>d to :e!r su* p>5t1 subsidi>y1 or o!r affiliat$ provid] or suppli] op]ates "u sep>ate lic5sure1 c]tification1 or designation4 7,d7 ,pay]-specific negotiat$ *>ge ,! t]m pay]-specific negotiat$ *>ge means ! *>ge t a hospital has negotiat$ ) a ?ird p>ty pay] = an item or s]vice4 7,e7 ,%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,f7 ,?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 7#g7 ,rulemak+ ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7b7 ,effective date 7#a7 ,9 g5]al ,! am5dm5t made by subsection 7a7 %all apply beg9n+ ,janu>y #a1 #bjbg4 7#b7 ,cont9u$ applicability ( rules = previ\s ye>s ,no?+ 9 ! am5dm5t made by ?is section may be con/ru$ z affect+ ! applicability ( ! regulations codifi$ at "p #ahj ( title #de1 ,code ( ,f$]al ,regulations1 be=e ,janu>y #a1 #bjbf4 7c7 ,cont9u$ applicability ( /ate law ,! provisions ( ?is ,act %all n sup]s$e any provision ( ,/ate law t e/abli%es1 implem5ts1 or cont9ues 9 effect any requirem5t or prohibition relat$ to heal? c>e price transp>5cy1 except to ! ext5t t su* requirem5t or prohibition prev5ts ! application ( a requirem5t or prohibition ( ?is ,act4 #cjc4 ,increas+ price transp>5cy ( cl9ical diagno/ic laboratory te/s ,section #bgah ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7 is am5d$ by add+ at ! end ! foll[+3 7f7 ,cl9ical diagno/ic laboratory price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,july #a1 #bjbh1 an applicable laboratory %all-- 7,a7 make publicly available 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 s furni%es2 & 7,b7 ensure t su* in=mation is updat$ n less frequ5tly ?an mon?ly1 if !re h be5 any *anges to su* in=mation4 7#b7 ,in=mation describ$ ,= purposes ( p>agraph 7#a71 ! in=mation describ$ 9 ?is p>agraph is1 ) respect to an applicable laboratory & a specifi$ cl9ical diagno/ic laboratory te/1 ! foll[+3 7,a7 ,a pla9 language description ( ea* item or s]vice1 accompani$ by any applicable bill+ codes1 includ+ modifi]s1 us+ commonly recogniz$ bill+ code sets1 includ+ ! ,curr5t ,proc$ural ,t]m9ology code1 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! diagnosis-relat$ gr\p1 ! ,national ,drug ,code1 & o!r nationally recogniz$ id5tifi]4 7,b7 ,! gross *>ge express$ z a doll> am\nt1 = ea* su* item or s]vice4 7,c7 ,! disc\nt$ ca% price 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 ! m9imum ca% price accept$ by ! laboratory f self-pay individuals = su* item or s]vice :5 provid$ 9 su* sett+s = ! previ\s ?ree ye>s1 express$ z a doll> am\nt1 z well z1 ) respect to prices made public pursuant to subp>agraph 7,a77ii71 a l9k to a consum]-fri5dly docum5t t cle>ly expla9s ! laboratory's *>ity c>e policy74 ,! laboratory %all accept ! disc\nt$ or m9imum ca% price z paym5t 9 full f any pati5t t *ooses to pay 9 ca% )\t reg>d to ! pati5t's cov]age4 7,d7 ,! pay]-specific negotiat$ *>ges1 express$ z a doll> am\nt & cle>ly associat$ ) ! "n ( ! applicable ?ird p>ty pay] & "n ( ea* plan1 t apply to ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 ,if ! *>ges are bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! cl9ical diagno/ic laboratory also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r t]ms1 s*$ules1 exhibits1 data1 or o!r in=mation ref]5c$ 9 any su* contract z %all be requir$ to det]m9e & disclose ! negotiat$ *>ge4 7,e7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges = ea* su* item or s]vice1 express$ z a non-z]o doll> am\nt4 7,f7 ,any o!r additional in=mation ! ,secret>y may require = ! purpose ( improv+ ! accuracy (1 or enabl+ consum]s to easily und]/& & comp>e1 /&>d *>ges & prices = an item or s]vice1 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is subsection4 ,9 ! case ( /&>d *>ges & prices = an item or s]vice includ$ z "p ( a bundl$1 p] diem1 episodic1 or o!r simil> arrangem5t1 ! in=mation describ$ 9 ?is subp>agraph %all be made available z det]m9$ appropriate by ! ,secret>y4 7#c7 ,uni=m me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbh1 ! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = applicable laboratories to use 9 compil+ & mak+ public in=mation pursuant to p>agraph 7#a74 ,su* me?od & =mat %all-- 7,a7 include a ma*9e-readable spread%eet =mat conta9+ ! in=mation describ$ 9 p>agraph 7#b7 = all items & s]vices furni%$ by ea* laboratory2 7,b7 meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* in=mation2 & 7,c7 be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#d7 ,inclusion ( ancill>y s]vices ,any price or rate = a specifi$ cl9ical diagno/ic laboratory te/ available to be furni%$ by an applicable laboratory made publicly available 9 accordance ) p>agraph 7#a7 %all include ! price or rate = any ancill>y item or s]vice 7includ+ specim5 collection s]vices1 specim5 transport1 c5trifugation1 aliquot+1 label+1 requisition process+1 & /&>d result report+ s]vices7 t w\ld cu/om>ily & r\t9ely be furni%$ by su* laboratory z "p ( su* te/1 z specifi$ by ! ,secret>y4 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 if su* laboratory cont9ues to fail to comply ) su* p>agraph aft] ! date t is #ij days aft] su* notification is s5t1 ! ,secret>y may impose a civil monet>y p5alty 9 an am\nt n to exce$ #cjj = ea* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* laboratory 0 fail+ to comply ) su* p>agraph7 dur+ :i* su* failure is ongo+4 7,b7 ,increase au?ority ,9 apply+ ?is p>agraph ) respect to violations occurr+ 9 #bjbi or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! p] day limitation on civil monet>y p5alties "u subp>agraph 7,a77ii74 7,c7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 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#f7 ,provision ( te*nical assi/ance ,! ,secret>y %all1 to ! ext5t practicable1 provide te*nical assi/ance relat+ to compliance ) ! provisions ( ?is subsection to applicable laboratories reque/+ su* assi/ance4 7#g7 ,def9itions ,9 ?is subsection3 7,a7 ,applicable laboratory ,! t]m applicable laboratory means a laboratory z su* t]m is def9$ 9 section #dic4b1 ( title #db1 ,code ( ,f$]al ,regulations 7or a successor regulation71 except t su* t]m does n include a laboratory ) respect to :i* /&>d *>ges & prices = specifi$ cl9ical diagno/ic laboratory te/s furni%$ by su* laboratory are made available by a hospital pursuant to subsection 7e7 ( ?is section4 7,b7 ,disc\nt$ ca% price ,! t]m disc\nt$ ca% price means ! *>ge t applies to an individual :o pays ca%1 or ca% equival5t1 = an item or s]vice4 7,c7 ,gross *>ge ,! t]m gross *>ge means ! *>ge = an individual item or s]vice t is reflect$ on an applicable laboratory's *>gema/]1 abs5t any disc\nts4 7,d7 ,pay]-specific negotiat$ *>ge ,! t]m pay]-specific negotiat$ *>ge means ! *>ge t an applicable laboratory has negotiat$ ) a ?ird p>ty pay] = an item or s]vice4 7,e7 ,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 7z describ$ 9 subsection 7e7 ( ?is section71 o!r ?an su* a te/ t is only available to be furni%$ by a s+le provid] ( s]vices or suppli]4 7,f7 ,?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 7#h7 ,rulemak+ ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 #cjd4 ,imag+ transp>5cy ,section #bgah ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah71 z am5d$ by section #cjc1 is fur!r am5d$ by add+ at ! end ! foll[+3 7g7 ,imag+ s]vices price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,july #a1 #bjbh1 ea* provid] ( s]vices or suppli] t furni%es a specifi$ imag+ s]vice1 o!r ?an su* a provid] or suppli] ) respect to :i* /&>d *>ges & prices = su* s]vices furni%$ by su* provid] or suppli] are made available by a hospital pursuant to subsection 7e71 %all-- 7,a7 make publicly available 79 accordance ) p>agraph 7#c77 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 p>agraph is1 ) respect to a provid] ( s]vices or suppli] & a specifi$ imag+ s]vice1 ! foll[+3 7,a7 ,a pla9 language description ( ea* item or s]vice1 accompani$ by any applicable bill+ codes1 includ+ modifi]s1 us+ commonly recogniz$ bill+ code sets1 includ+ ! ,curr5t ,proc$ural ,t]m9ology code1 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! diagnosis-relat$ gr\p1 ! ,national ,drug ,code1 & o!r nationally recogniz$ id5tifi]s4 7,b7 ,! gross *>ge express$ z a doll> am\nt1 = ea* su* item or s]vice4 7,c7 ,! disc\nt$ ca% price 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 ! m9imum ca% price accept$ by ! provid] ( s]vices or suppli] f self-pay individuals = su* item or s]vice :5 provid$ 9 su* sett+s = ! previ\s ?ree ye>s1 express$ z a doll> am\nt1 z well z1 ) respect to prices made public pursuant to subp>agraph 7,a77ii71 a l9k to a consum]-fri5dly docum5t t cle>ly expla9s ! provid] ( s]vices or suppli]'s *>ity c>e policy74 ,! provid] ( s]vices or suppli] %all accept ! disc\nt$ or m9imum ca% price z paym5t 9 full f any pati5t t *ooses to pay 9 ca% )\t reg>d to ! pati5t's cov]age4 7,d7 ,! pay]-specific negotiat$ *>ges1 express$ z a doll> am\nt & cle>ly associat$ ) ! "n ( ! applicable ?ird p>ty pay] & "n ( ea* plan1 t apply to ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 ,if ! *>ges are bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! provid] or suppli] also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r t]ms1 s*$ules1 exhibits1 data1 or o!r in=mation ref]5c$ 9 any su* contract z %all be requir$ to det]m9e & disclose ! negotiat$ *>ge4 7,e7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges = ea* su* item or s]vice1 express$ z a non-z]o doll> am\nt4 7,f7 ,any o!r additional in=mation ! ,secret>y may require = ! purpose ( improv+ ! accuracy (1 or enabl+ consum]s to easily und]/& & comp>e1 /&>d *>ges & prices = an item or s]vice1 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is subsection4 ,9 ! case ( /&>d *>ges & prices = an item or s]vice includ$ z "p ( a bundl$1 p] diem1 episodic1 or o!r simil> arrangem5t1 ! in=mation describ$ 9 ?is subp>agraph %all be made available z det]m9$ appropriate by ! ,secret>y4 7#c7 ,uni=m me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbh1 ! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = provid]s ( s]vices & suppli]s to use 9 mak+ public in=mation describ$ 9 p>agraph 7#b74 ,any su* me?od & =mat %all-- 7,a7 include a ma*9e-readable spread%eet =mat conta9+ ! in=mation describ$ 9 p>agraph 7#b7 = all items & s]vices furni%$ by ea* provid] ( s]vices & suppli] describ$ 9 p>agraph 7#a72 7,b7 meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* in=mation2 & 7,c7 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 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* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* provid] or suppli] 0 fail+ to comply ) su* p>agraph7 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 #bjbh 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 ( ! ,social ,security ,act 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 ,no au?ority to waive or r$uce p5alty ,! ,secret>y %all n grant or ext5d any waiv]1 delay1 toll+1 or o!r mitigation ( a civil monet>y p5alty = violation ( ?is subsection4 7,e7 ,provision ( te*nical assi/ance ,! ,secret>y %all1 to ! ext5t practicable1 provide te*nical assi/ance relat+ to compliance ) ! provisions ( ?is subsection to provid]s ( s]vices & suppli]s reque/+ su* assi/ance4 7,f7 ,cl>ification ( nonapplicability ( o!r en=cem5t provisions ,not)/&+ any o!r provision ( ?is title1 ?is p>agraph %all be ! sole means ( en=c+ ! provisions ( ?is subsection4 7#f7 ,specifi$ imag+ s]vice def9$ ,! t]m specifi$ imag+ s]vice means an imag+ s]vice t is a ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice 7z describ$ 9 subsection 7e774 7#g7 ,rulemak+ ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 #cje4 ,ambulatory surgical c5t] price transp>5cy requirem5ts ,section #bgah ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah71 z am5d$ by section #cjd1 is fur!r am5d$ by add+ at ! end ! foll[+3 7h7 ,ambulatory surg]y c5t] transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,july #a1 #bjbh1 ea* specifi$ ambulatory surgical c5t] %all comply ) ! price transp>5cy requirem5t describ$ 9 p>agraph 7#b74 7#b7 ,requirem5t describ$ 7,a7 ,9 g5]al ,a specifi$ ambulatory surgical c5t]1 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u subp>agraph 7,c71 %all compile & make public 7)\t subscription & free ( *>ge71 = ea* ye>-- 7i7 "o or m li/s1 9 a ma*9e-readable =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 9 a consum]-fri5dly =mat 7z specifi$ by ! ,secret>y7 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 includ$ on ! li/ describ$ 9 subsection 7e7 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 7z describ$ 9 clause 7ii77 t is n furni%$ by ! ambulatory surgical c5t]1 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 made public by a specifi$ ambulatory surgical c5t]1 ! foll[+3 7i7 ,a description ( ea* item or s]vice1 accompani$ by ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! national drug code1 or o!r id5tifi] us$ 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 ! m9imum ca% price accept$ by ! specifi$ ambulatory surgical c5t] f self-pay individuals = su* item or s]vice :5 provid$ 9 su* sett+s = ! previ\s ?ree ye>s1 express$ z a doll> am\nt1 z well z1 ) respect to prices made public pursuant to subp>agraph 7,a77ii71 a l9k to a consum]-fri5dly docum5t t cle>ly expla9s ! provid] ( s]vices or suppli]'s *>ity c>e policy74 ,! specifi$ ambulatory surgical c5t] %all accept ! disc\nt$ ca% price z paym5t 9 full f any pati5t t *ooses to pay 9 ca% )\t reg>d to ! pati5t's cov]age4 7iv7 ,! pay]-specific negotiat$ *>ges1 express$ z a doll> am\nt & cle>ly associat$ ) ! "n ( ! applicable ?ird p>ty pay] & "n ( ea* plan1 t apply to ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 ,if ! *>ges are bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! ambulatory surgical c5t] also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r t]ms1 s*$ules1 exhibits1 data1 or o!r in=mation ref]5c$ 9 any su* contract z %all be requir$ to det]m9e & disclose ! negotiat$ *>ge4 7v7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges = ea* su* item or s]vice1 express$ z a non-z]o doll> am\nt4 7vi7 ,any o!r additional in=mation ! ,secret>y may require = ! purpose ( improv+ ! accuracy (1 or enabl+ consum]s to easily und]/& & comp>e1 /&>d *>ges & prices = an item or s]vice1 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is subsection4 7,c7 ,uni=m me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbh1 ! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = specifi$ ambulatory surgical c5t]s to use 9 mak+ public /&>d *>ges pursuant to subp>agraph 7,a77i7 & a /&>d1 uni=m me?od & =mat = su* c5t]s to use 9 mak+ public prices pursuant to subp>agraph 7,a77ii74 ,any su* me?od & =mat %all-- 7i7 9 ! case ( su* *>ges made public by an ambulatory surgical c5t]1 ensure t su* *>ges are made available 9 a ma*9e-readable =mat2 7ii7 meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges & prices2 & 7iii7 be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#c7 ,no deem$ compliance ,! availability ( a price e/imator tool %all n be consid]$ to deem compliance ) or o!rwise vitiate ! requirem5ts ( ?is subsection 7aa74 ,fur!rmore1 ! use ( an e/imator tool %all n be us$ = purposes ( compliance ) any provisions 9 ?is subsection4 7#d7 ,monitor+ compliance ,! ,secret>y %all1 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$ ambulatory surgical c5t]'s compliance ) ?is subsection is review$ n less frequ5tly ?an once e ye>4 7#e7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( a specifi$ 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 ,a specifi$ 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* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* hospital 0 n comply+ ) su* requirem5ts7 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 #bjbh or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! limitation on ! p] day am\nt ( any p5alty applicable to a specifi$ ambulatory surgical c5t] "u clause 7i74 7iii7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 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 ,no au?ority to waive or r$uce p5alty ,! ,secret>y %all n grant or ext5d any waiv]1 delay1 toll+1 or o!r mitigation ( a civil monet>y p5alty = violation ( ?is subsection4 7#f7 ,provision ( te*nical assi/ance ,! ,secret>y %all1 to ! ext5t practicable1 provide te*nical assi/ance relat+ to compliance ) ! provisions ( ?is subsection to specifi$ ambulatory surgical c5t]s reque/+ su* assi/ance4 7#g7 ,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 ,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,c7 ,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,d7 ,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,e7 ,%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,f7 ,specifi$ ambulatory surgical c5t] ,! t]m specifi$ ambulatory surgical c5t] means an ambulatory surgical c5t] ) respect to :i* a hospital 7or any p]son ) an own]%ip or control int]e/ 7z def9$ 9 section #aabd7;a77#c7 ( ! ,social ,security ,act7 9 a hospital7 is a p]son ) an own]%ip or control int]e/ 7z s def9$74 7,g7 ,?ird p>ty pay] ,! t]m ?ird p>ty pay] means an entity t is1 by /atute1 contract1 or agreem5t1 legally responsible = paym5t ( a claim = a heal? c>e item or s]vice4 7#h7 ,rulemak+ ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 #cjf4 ,/r5g!n+ heal? cov]age transp>5cy requirem5ts 7a7 ,transp>5cy 9 cov]age ,section #acaa7;e77#c77;,c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjca7;e77#c77;,c77 is am5d$-- 7#a7 by /rik+ ,! ,ex*ange & ins]t+ ! foll[+3 7i7 ,9 g5]al ,! ,ex*ange 2 7#b7 9 clause 7i71 z ins]t$ by p>agraph 7#a7-- 7,a7 by /rik+ p>ticipat+ provid] & ins]t+ provid]2 7,b7 by ins]t+ %all include ! in=mation specifi$ 9 clause 7ii7 & aft] su* in=mation2 7,c7 by /rik+ an ,int]net website & ins]t+ a self-s]vice tool t meets ! requirem5ts ( clause 7iii72 & 7,d7 by /rik+ & su* o!r & all t foll[s ?r\gh ! p]iod & ins]t+ or1 at ! option su* individual1 ?r\gh a pap] or phone disclosure 7z select$ by su* individual & provid$ at no co/ to su* individual7 t meets su* requirem5ts z ! ,secret>y may specify42 & 7#c7 by add+ at ! end ! foll[+ new clauses3 7ii7 ,specifi$ in=mation ,= purposes ( clause 7i71 ! in=mation specifi$ 9 ?is clause is1 ) respect to b5efits available "u a heal? plan = an item or s]vice furni%$ by a heal? c>e provid]1 ! foll[+3 7,i7 ,if su* provid] is a p>ticipat+ provid] ) respect to su* item or s]vice1 ! 9-network rate 7z def9$ 9 subp>agraph 7,f77 = su* item or s]vice4 7,,ii7 ,if su* provid] is n describ$ 9 subclause 7,i71 ! maximum all[$ doll> am\nt = su* item or s]vice4 7,,iii7 ,! am\nt ( co/ %>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! individual w incur = su* item or s]vice 7:i*1 9 ! case su* item or s]vice is to be furni%$ by a provid] describ$ 9 subclause 7,,ii71 %all be calculat$ us+ ! maximum am\nt describ$ 9 su* subclause74 7,,iv7 ,! am\nt ! individual has already accumulat$ ) respect to any d$uctible or out-(-pocket maximum "u ! plan 7brok5 d[n1 9 ! case sep>ate d$uctibles or maximums apply to sep>ate individuals enroll$ 9 ! plan1 by su* sep>ate d$uctibles or maximums1 9 addition to any cumulative d$uctible or maximum74 7,v7 ,9 ! case su* plan imposes any frequ5cy or volume limitations ) respect to su* item or s]vice 7exclud+ m$ical necessity det]m9ations71 ! am\nt t su* individual has accru$ t[>ds su* limitation ) respect to su* item or s]vice4 7,,vi7 ,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 7iii7 ,self-s]vice tool ,= purposes ( clause 7i71 a self-s]vice tool e/abli%$ by a heal? plan meets ! requirem5ts ( ?is clause if su* tool-- 7,i7 is bas$ on an int]net website2 7,,ii7 provides = real-"t responses to reque/s describ$ 9 su* clause2 7,,iii7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is timely & accurate2 7,,iv7 all[s su* a reque/ to be made ) respect to an item or s]vice furni%$ by-- 7aa7 a specific provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7bb7 all provid]s t are p>ticipat+ provid]s ) respect to su* plan & su* item or s]vice2 or 7cc7 a provid] t is n describ$ 9 item 7bb72 7,v7 provides t su* a reque/ may be made ) respect to an item or s]vice ?r\gh use (-- 7aa7 ! bill+ code = su* item or s]vice2 or 7bb7 ?r\gh use ( a descriptive t]m = su* item or s]vice to produce a li/ ( bill+ code options f :i* ! individual selects to indicate ! subject matt] items or s]vices2 & 7,,vi7 holds a memb] h>mless = ! am\nt ( any diff]5ce 9 excess ( ! am\nt ( ! individual's responsibility g5]at$ by ! self-s]vice tool & ! am\nt ultimately bill$ or *>g$ to ! individual4 4 7b7 ,disclosure ( additional in=mation ,section #acaa7;e77#c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjca7;e77#c77 is am5d$ by add+ at ! end ! foll[+ new subp>agraphs3 7,e7 ,rate & paym5t in=mation 7i7 ,9 g5]al ,n lat] ?an ,janu>y #a1 #bjbh1 & e mon? !reaft]1 ea* heal? plan %all submit to ! ,ex*ange1 ! ,secret>y1 ! ,/ate insurance commission]1 & make available to ! public1 ! rate & paym5t in=mation describ$ 9 clause 7ii7 9 accordance ) clause 7iii74 7ii7 ,rate & paym5t in=mation describ$ ,= purposes ( clause 7i71 ! rate & paym5t in=mation describ$ 9 ?is clause is1 ) respect to a heal? plan1 ! foll[+3 7,i7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan 7express$ z a doll> am\nt71 includ+ prescription drugs1 id5tifi$ by ,,cpt1 ,,hcpcs1 ,,drg1 ,,ndc1 or o!r applicable nationally recogniz$ id5tifi]1 includ+ any applicable code modifi]s1 & accompani$ by a brief description ( ! item or s]vice1 ! 9-network rate 9 effect z ( ! date ( ! submission ( su* in=mation ) ea* provid] 7id5tifi$ by national provid] id5tifi]7 t is a p>ticipat+ provid] ) respect to su* item or s]vice1 o!r ?an su* a rate 9 effect ) a provid]-- 7aa7 t has submitt$ no claims2 & 7bb7 expects to receive no claims 9 ! !n applicable cal5d> ye> = su* item or s]vice to su* plan4 7,,ii7 ,) respect to ea* drug 7id5tifi$ by ,national ,drug ,code1 ,j-code1 or o!r commonly recogniz$ bill+ code us$ = drugs7 = :i* b5efits are available "u su* plan3 7aa7 ,! 9-network rate 7express$ z a doll> am\nt71 includ+ ! individual & total am\nts = any bundl$ rates1 9 effect z ( ! fir/ day ( ! mon? 9 :i* su* in=mation is made public ) ea* provid] t is a p>ticipat+ provid] ) respect to su* drug4 7bb7 ,! hi/orical net price paid by su* plan 7net ( rebates1 disc\nts1 & price concessions7 7express$ z a doll> am\nt7 = su* drug disp5s$ or adm9i/]$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( submission to ea* provid] t 0 a p>ticipat+ provid] ) respect to su* drug1 brok5 d[n by ea* su* provid] 7id5tifi$ by national provid] id5tifi]71 o!r ?an su* an am\nt paid to a provid] t has submitt$ no claims = su* drug to su* plan4 7,,iii7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan 7express$ z a doll> am\nt71 id5tifi$ by ,,cpt1 ,,drg1 ,,hcpcs1 ,,ndc1 or o!r applicable nationally recogniz$ id5tifi]1 includ+ any applicable code modifi]s1 & accompani$ by a brief description ( ! item or s]vice1 ! am\nt bill$ or *>g$ by ! provid]1 & ! am\nt all[$ by ! plan1 = ea* su* item or s]vice furni%$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( submission by ea* provid] t 0 n a p>ticipat+ provid] ) respect to su* item or s]vice1 brok5 d[n by ea* su* provid] 7id5tifi$ by national provid] id5tifi]71 o!r ?an items & s]vices ) respect to :i* no claims = su* item or s]vice 7 submitt$ to su* plan dur+ su* p]iod4 7iii7 ,mann] ( submission ,rate & paym5t in=mation requir$ to be submitt$ & made available "u ?is subp>agraph %all be s submitt$ & s made available z foll[s3 7,i7 ,in=mation %all be conta9$ 9 #c sep>ate ma*9e-readable files correspond+ to ! in=mation describ$ 9 ea* ( subclauses 7,i7 ?r\gh 7,,iii7 ( clause 7ii7 t meet su* requirem5ts z specifi$ by ! ,secret>y ?r\gh rulemak+1 9 consultation ) ! ,secret>ies ( ,labor & ! ,treasury to apply comp>able requirem5ts to gr\p heal? plans & to entities provid+ b5efit managem5t or o!r ?ird-p>ty adm9i/ration s]vices on a contractual basis ) a gr\p heal? plan4 7,,ii7 ,requirem5ts specifi$ by ! ,secret>y ?r\gh rulemak+ %all ensure t3 7aa7 ,su* files are limit$ to an appropriate size1 are made available 9 a widely available =mat t all[s = in=mation conta9$ 9 su* files to be comp>$ across heal? plans1 & are accessible to individuals at no co/ & )\t ! ne$ to e/abli% a us] acc\nt or provid] o!r cr$5tials4 7bb7 ,! rates1 am\nts1 & prices to be disclos$ include contractual t]ms conta9+ calculation =mulae1 pric+ me?odologies1 & o!r in=mation necess>y to det]m9e ! doll> value ( reimbursem5t4 7cc7 ,ea* su* file includes ea* ( ! foll[+ data elem5ts3 7,,aa7 ,a num]ical id5tifi] = ! gr\p heal? plan &_/or heal? insurance issu] 7su* z a ,heal? ,insurance ,ov]sight ,sy/em id5tifi]74 7,,bb7 ,a pla9-language description ( ! item or s]vice 7includ+1 = drugs1 ! propriet>y & nonpropriet>y "n assign$74 7,,cc7 ,! bill+ code1 includ+ any applicable modifi]s1 associat$ ) su* item or s]vice1 includ+ ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 diagnosis-relat$ gr\p1 national drug code1 or o!r commonly recogniz$ code set4 7,,dd7 ,! place ( s]vice code4 7,,ee7 ,! ,national ,provid] ,id5tifi] or provid] ,tax ,id5tification ,numb]4 7,,iii7 ,! rate & paym5t in=mation disclos$ "u subclauses 7,i7 ?r\gh 7,,iii7 ( clause 7ii7 %all be sep>ately del9eat$ = ea* item or s]vice1 reg>dless ( :e!r su* item or s]vice is reimburs$ z a "p ( a bundle1 episode1 or o!r gr\p+ ( items & s]vices4 7,,iv7 ,an (fic] or executive ( compet5t au?ority %all atte/ to ! accuracy & complet5ess ( in=mation submitt$ & made available "u ?is subp>agraph4 ,su* atte/ation %all be subject to en=cem5t "u subp>agraph 7,h7 &1 :]e applicable1 %all be deem$ mat]ial to paym5ts f ! ,f$]al ,gov]nm5t receiv$ by ! gr\p heal? plan or heal? insurance issu]4 7,v7 ,regulations promulgat$ pursuant to ?is section %all provide t3 7aa7 ,! ,secret>y %all audit ! ?ree ma*9e-readable files requir$ by subp>agraph 7,e77ii7 po/$ by no few] ?an #bj gr\p heal? plans or heal? insurance issu]s4 7bb7 ,! ,secret>y ( ,labor %all audit ! ?ree ma*9e-readable files requir$ by subp>agraph 7,e77ii7 po/$ by no few] ?an #bjj gr\p heal? plans or s]vice provid]s furni%+ ?ird-p>ty adm9i/rator s]vices to a gr\p heal? plan4 7cc7 ,f9d+s1 conclusions1 & en=cem5t actions tak5 bas$ on audits ( ! ma*9e-readable files %all be report$ annually to ,congress no lat] ?an ,july #a ( ! cal5d> ye> dur+ :i* ! files 7 audit$4 ,su* report to ,congress %all be accessible to ! public4 7iv7 ,us] guide ,ea* heal? plan %all make available to ! public in/ructions writt5 9 pla9 language expla9+ h[ individuals may se>* = in=mation describ$ 9 clause 7ii7 9 files submitt$ 9 accordance ) clause 7iii74 7,f7 ,def9itions ,9 ?is p>agraph3 7i7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] has ! mean+ giv5 su* t]m 9 section #bgii;,a-#a ( ! ,public ,heal? ,s]vice ,act4 7ii7 ,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 ,if ! rate is bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! heal? plan also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r t]ms1 s*$ules1 exhibits1 data1 or o!r in=mation ref]5c$ 9 any su* contract z %all be requir$ to det]m9e & disclose ! negotiat$ rate4 7,g7 ,applicability to acc\ntable c>e organizations ,an applicable ,,aco p>ticipat+ 9 ! ,m$ic>e ,%>$ ,sav+s ,program1 z def9$ 9 ,section #ahii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;jjj71 %all be subject to ! requirem5ts ( ?is p>agraph z if su* applicable ,,aco is a gr\p heal? plan or heal? insurance issu]4 7,h7 ,en=cem5t 7i7 ,9 g5]al ,ea* ye>1 ! ,secret>y %all audit ! ?ree ma*9e-readable files requir$ by subp>agraph 7,e77ii7 po/$ by no few] ?an #bj gr\p heal? plans or heal? insurance issu]s4 7ii7 ,notification & reque/ = corrective action ,9 ! case ( a heal? plan t fails to comply ) ! requirem5ts ( ?is subsection1 n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s1 ! ,secret>y %all submit to su* heal? plan a notification ( su* det]m9ation1 :i* %all include a reque/ = a corrective action plan to comply ) su* requirem5ts4 7iii7 ,civil monet>y p5alty ,a heal? plan t has receiv$ a reque/ = a corrective action plan "u clause 7ii7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* reque/ is made %all be subject to a civil monet>y p5alty ( an am\nt specifi$ by ! ,secret>y = ea* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* laboratory 0 fail+ to comply ) su* p>agraph7 dur+ :i* su* failure 0 ongo+4 ,su* am\nt %all n exce$ #cjj p] memb] p] day or #aj1jjj1jjj1 :i*ev] is less]4 7,i7 ,rulemak+ ,! ,secret>y %all implem5t subp>agraphs 7,e7 ?r\gh 7,h7 ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7c7 ,effective date 7#a7 ,9 g5]al ,! am5dm5ts made by subsections 7a7 & 7b7 %all apply beg9n+ ,janu>y #a1 #bjbg4 7#b7 ,cont9u$ applicability ( rules = previ\s ye>s ,no?+ 9 ! am5dm5ts made by ?is section 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$4 ,reg4 #gbaeh7 be=e ,janu>y #a1 #bjbg4 #cjg4 ,increas+ gr\p heal? plan access to heal? data 7a7 ,gr\p heal? plan access to in=mation 7#a7 ,9 g5]al ,p>agraph 7#b7 ( section #djh7;b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aajh7;b77 is am5d$ by add+ at ! end ! foll[+ new subp>agraphs3 7,c7 ,no contract or arrangem5t = s]vices1 & no ext5sion or r5ewal ( su* contract or arrangem5t1 betwe5 a gr\p heal? plan 7z t t]m is def9$ 9 section #gcc7;a7 ( ?is title7 & p>ty 9 int]e/1 includ+ a heal? c>e provid] 7:i* = purposes ( ?is subp>agraph1 includes a heal? c>e facility71 network or association ( provid]s1 s]vice provid] (f]+ access to a network ( provid]s1 or ?ird-p>ty adm9i/rator 7collectively ref]r$ to z ,cov]$ ,s]vice ,provid]s71 is reasonable )9 ! mean+ ( ?is p>agraph unless su* contract or arrangem5t-- 7i7 all[s ! responsible plan fiduci>y 7z t t]m is def9$ 9 subp>agraph 7,b77ii77,i77ee77 access to all claims & enc\nt] in=mation or data1 & any docum5tation support+ claim paym5ts1 includ+1 b n limit$ to1 m$ical records & policy docum5ts1 or in=mation or data describ$ 9 section #gbd7;a77#a77;,b7 to-- 7,i7 enable su* entity to comply ) ! t]ms ( ! plan & any applicable law2 & 7,,ii7 det]m9e ! accuracy or reasonabl5ess ( paym5t2 & 7ii7 does n-- 7,i7 unreasonably limit or delay access1 z det]m9$ by ! ,secret>y b 9 any ev5t n long] ?an #ae days1 to su* in=mation or data2 7,,ii7 limit ! volume ( claims & enc\nt] in=mation or data t ! gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 or a bus9ess associate ( su* plan may access dur+ an audit or pursuant to any reque/ = su* in=mation or data2 7,,iii7 limit ! disclosure ( pric+ t]ms = value-bas$ paym5t arrangem5ts or capitat$ paym5t arrangem5ts1 includ+-- 7aa7 paym5t calculations & =mulas2 7bb7 quality measures2 7cc7 contract t]ms2 7dd7 paym5t am\nts2 7ee7 measurem5t p]iods = all inc5tives2 & 7ff7 o!r paym5t me?odologies us$ by an entity1 includ+ a heal? c>e provid] 7includ+ a heal? c>e facility71 network or association ( provid]s1 s]vice provid] (f]+ access to a network ( provid]s1 or ?ird-p>ty adm9i/rator2 7,,iv7 limit ! disclosure ( ov]paym5ts & ov]paym5t recov]y t]ms2 7,v7 limit ! "r ( ! gr\p heal? plan1 ! plan sponsor1 or ! plan adm9i/rator ( su* plan to select an auditor or def9e audit scope or frequ5cy2 7,,vi7 o!rwise limit or unduly delay ! gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 or a bus9ess associate ( su* plan f access+ claims & enc\nt] in=mation or data 9 a daily bat*2 7,,vii7 limit ! disclosure ( fees *>g$ to ! gr\p heal? plan relat$ to plan adm9i/ration & claims process+1 includ+ r5egotiation fees1 access fees1 repric+ fees1 or enhanc$ review fees2 7,,viii7 limit ! "r ( ! gr\p heal? plan1 ! plan sponsor1 or ! plan adm9i/rator to reque/ action on any suspect claim paym5ts2 or 7,,ix7 limit public disclosure ( de-id5tifi$ or aggregate in=mation4 7,d7 7i7 ,cov]$ ,s]vice ,provid]s %all provide in=mation or data "u ?is p>agraph 9 a mann] consi/5t ) ! privacy & security regulations promulgat$ "u ! ,heal? ,insurance ,portability & ,acc\ntability ,act 7ref]r$ to 9 ?is subp>agraph z ,,hipaa74 7ii7 ,a gr\p heal? plan t receives a disclosure f a p>ty 9 int]e/ pursuant to subp>agraph 7,b7 or 7,c7 %all comply ) ! privacy & security regulations promulgat$ "u ,,hipaa4 7iii7 ,no?+ 9 ?is subp>agraph %all be con/ru$ to modify ! requirem5ts = ! creation1 receipt1 ma9t5ance1 or transmission ( protect$ heal? in=mation "u ! ,,hipaa privacy regulation 7z def9$ 9 section #aahj7;b77#c7 ( ! ,social ,security ,act7 z !y apply directly or indirectly to an entity pursuant to ?is p>agraph4 7iv7 ,?is subp>agraph %all n be read to abridge or limit ! disclosure requirem5ts "u ?is p>agraph or to impose additional privacy or security requirem5ts on ,cov]$ ,s]vice ,provid]s or plan sponsors4 7,e7 ,a gr\p heal? plan receiv+ in=mation or data "u ?is p>agraph may disclose su* in=mation only 9 a mann] t is consi/5t ) ! ,heal? ,insurance ,portability & ,acc\ntability ,act 7,,hipaa7 & ! privacy & security regulations promulgat$ !reund]1 reg>dless ( _! direct or indirect applicability to ! plan or any entities t c\ld be or are bus9ess associates4 7,f7 ,in=mation made available "u ?is section %all con=m to ! foll[+ /&>ds3 7i7 ,all claims f a heal?c>e provid] %all be made to ! gr\p heal? plan 9 accordance ) transaction /&>ds adopt$ by regulation "u ,,hipaa1 z foll[s3 7,i7 ,in/itutional1 pr(essional1 & d5tal claims %all be 9 ,,asc ,x#ab,n #hcg =mat or any subsequ5t /&>d4 7,,ii7 ,ph>macy claims %all be 9 ! ,national ,c\ncil = ,prescription ,drug ,programs 7,,ncpdp7 =mat or any subsequ5t /&>d4 7,,iii7 ,! files %all be unmodifi$ copies ( ! files s5t f ! provid]4 ,9 ! ev5t t pap] claims are s5t by ! provid]1 !y %all be conv]t$ to ! appropriate /&>d electronic =mat4 ,files %all be accessible to ! plan at no co/ to ! gr\p heal? plan4 7ii7 ,all claim paym5t 7or ,,eft1 electronic funds transf]7 & electronic remittance advice 7,,era7 notices s5t by a ,cov]$ ,s]vice ,provid] %all be made available to ! gr\p heal? plan z ,,asc ,x#ab,n #hce files 9 accordance ) /&>ds adopt$ by regulation "u ,,hipaa4 ,! files %all be unmodifi$ copies ( ! files s5t by ! ,cov]$ ,s]vice ,provid] to ! heal?c>e provid]4 ,files %all be accessible at no co/ to ! gr\p heal? plan4 7iii7 ,! contractual t]ms conta9+ calculation =mulae1 pric+ me?odologies1 & o!r in=mation us$ to det]m9e ! doll> value ( reimbursem5t4 7iv7 ,all non-claim co/s %all be itemiz$ & made available to ! gr\p heal? plan 9 real "t ?r\gh a web-bas$ portal1 ?r\gh an ,,api1 & ?r\gh a d[nloadable ,,csv file4 7,g7 ,! ,secret>y %all implem5t subp>agraphs 7,c7 ?r\gh 7,f7 ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7#b7 ,civil en=cem5t ,subsection 7c7 ( section #ejb ( su* ,act 7#bi ,u4,s4,c4 #aacb7 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ac7 ,9 ! case ( an agreem5t betwe5 a gr\p heal? plan 7z def9$ 9 section #gcc7;a771 ! plan sponsor ( su* plan 7z def9$ 9 section #c7af77;,b771 or ! plan adm9i/rator ( su* plan 7z def9$ 9 section #c7af77;,a77 & a heal? c>e provid] 7:i*1 = purposes ( ?is p>agraph1 includes a heal? c>e facility71 network or association ( provid]s1 s]vice provid] (f]+ access to a network or association ( provid]s1 or ?ird-p>ty adm9i/rator1 t violates ! provisions ( section #gbd1 ! ,secret>y may assess a civil p5alty aga9/ su* provid]1 network or association1 s]vice provid] (f]+ access to a network or association ( provid]s1 ?ird-p>ty adm9i/rator1 or o!r s]vice provid] 9 ! am\nt ( #aj1jjj = ea* day dur+ :i* su* violation cont9ues4 ,su* p5alty %all be 9 addition to o!r p5alties z may be prescrib$ by law4 4 7#c7 ,exi/+ provisions void ,section #daj ( su* ,act 7#bi ,u4,s4,c4 #aaaj7 is am5d$ by add+ at ! end ! foll[+3 7c7 ,any provision 9 an agreem5t or in/rum5t %all be void z aga9/ public policy if su* provision-- 7#a7 unduly delays or limits a gr\p heal? plan 7z def9$ 9 section #gcc7;a771 ! plan sponsor ( su* plan 7z def9$ 9 section #c7af77;,b771 or ! plan adm9i/rator ( su* plan 7z def9$ 9 section #c7af77;,a77 f access+ ! claims & enc\nt] in=mation or data describ$ 9 section #gbd7;a77#a77;,b72 or 7#b7 violates ! requirem5ts ( section #djh7;b77#b77;,c74 4 7#d7 ,te*nical am5dm5t ,clause 7i7 ( section #djh7;b77#b77;,b7 ( su* ,act is am5d$ by /rik+ ?is clause & ins]t+ ?is p>agraph4 7b7 ,updat$ atte/ation = price & quality in=mation ,section #gbd7;a77#c7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahem7a77#c77 is am5d$ to read z foll[s3 7#c7 ,atte/ation 7,a7 ,9 g5]al ,subject to subp>agraph 7,c71 a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all annually submit to ! ,secret>y an atte/ation t su* plan or issu] ( su* cov]age is 9 compliance ) ! requirem5ts ( ?is subsection4 ,su* atte/ation %all also include a /atem5t v]ify+ t-- 7i7 ! in=mation or data describ$ "u subp>agraphs 7,a7 & 7,b7 ( p>agraph 7#a7 is available ^u reque/ & provid$ to ! gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 or ! bus9ess associate ( su* plan1 or ! issu] 9 a timely mann]2 & 7ii7 !re are no t]ms 9 ! agreem5t "u su* p>agraph 7#a7 t directly or indirectly re/rict or unduly delay a gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 a bus9ess associate ( su* plan1 or ! issu] f audit+1 review+1 or o!rwise access+ su* in=mation4 7,b7 ,limitation on submission ,subject to clause 7ii71 a gr\p heal? plan or issu] (f]+ gr\p heal? insurance cov]age may n ent] into an agreem5t ) a ?ird-p>ty adm9i/rator or o!r s]vice provid] to submit ! atte/ation requir$ "u subp>agraph 7,a74 7,c7 ,exception ,9 ! case ( a gr\p heal? plan or issu] (f]+ gr\p heal? insurance cov]age t is unable to obta9 ! in=mation or data ne$$ to submit ! atte/ation requir$ "u subp>agraph 7,a71 su* plan or issu] may submit a writt5 /atem5t 9 lieu ( su* atte/ation t includes-- 7i7 an explanation ( :y su* plan or issu] 0 unsuccessful 9 obta9+ su* in=mation or data1 includ+ :e!r su* plan1 ! plan sponsor1 or ! plan adm9i/rator or issu] 0 limit$ or prev5t$ f audit+1 review+1 or o!rwise access+ su* in=mation or data2 7ii7 a description ( ! ef=ts made by ! gr\p heal? plan1 ! plan sponsor1 or ! plan adm9i/rator to remove any gag clause provisions f ! agreem5t "u p>agraph 7#a72 & 7iii7 a description ( any response by ! ?ird-p>ty adm9i/rator or o!r s]vice provid] ) respect to ef=ts to comply ) ! atte/ation requirem5t "u subp>agraph 7,a71 includ+ ! "n ( ! ?ird-p>ty adm9i/rator or o!r s]vice provid]4 4 7c7 ,effective date ,! am5dm5ts made by subsections 7a7 & 7b7 %all apply ) respect to a plan beg9n+ ) ! fir/ plan ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ?is ,act4 #cjh4 ,ov]sight ( adm9i/rative s]vice provid]s 7a7 ,,erisa am5dm5ts 7#a7 ,9 g5]al ,subp>t ,b ( "p #g ( subtitle ,b ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajba et seq47 is am5d$ by add+ at ! end ! foll[+3 #gbg4 ,ov]sight ( adm9i/rative s]vice provid]s 7a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #b ye>s aft] ! date ( enactm5t ( ?is section1 no agreem5t betwe5 a gr\p heal? plan 7z def9$ 9 section #gcc7;a771 ! plan sponsor ( su* plan 7z def9$ 9 section #c7af77;,b771 ! plan adm9i/rator ( su* plan 7z def9$ 9 section #c7af77;,a771 or a bus9ess associate ( su* plan 7z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations71 7or heal? insurance issu] (f]+ gr\p heal? insurance cov]age 9 connection ) su* a plan71 & a heal? c>e provid]1 network or association ( provid]s1 ?ird-p>ty adm9i/rator1 s]vice provid] (f]+ access to a network ( provid]s1 or any o!r ?ird p>ty 7ea* ref]r$ to z a heal? plan s]vice provid]7 is p]missible if su* agreem5t limits 7or delays beyond ! applicable report+ p]iod describ$ 9 subsection 7b77#a77 ! disclosure ( in=mation to gr\p heal? plans 9 su* a mann] t prev5ts su* plan1 issu]1 or entity f provid+ ! in=mation describ$ 9 subsection 7b74 7b7 ,requir$ disclosures 7#a7 ,cont5ts & frequ5cy ,) respect to plan ye>s beg9n+ on or aft] ! date t is #b ye>s aft] ! date ( enactm5t ( ?is section1 n less frequ5tly ?an qu>t]ly1 a heal? plan s]vice provid] %all provide to ! gr\p heal? plan or heal? insurance issu] ! foll[+ in=mation at no co/ to ! gr\p heal? plan or heal? insurance issu]3 7,a7 ,! in=mation describ$ 9 section #gbd7;a77#a77;,b74 7,b7 ,any contractual & subcontractual calculation me?odologies1 pric+ or fee s*$ules1 or o!r =mulae us$ to det]m9e reimbursem5t am\nts to provid]s & subcontractors1 includ+ me?odologies1 s*$ules1 fee /ructures1 & any appli$ adju/m5ts or modifi]s1 ) su* in=mation provid$ 9 a mann] suffici5tly detail$ to enable ! gr\p heal? plan or heal? insurance issu] to accurately assess1 v]ify1 & ensure compliance ) ! t]ms ( any contractual & subcontractual agreem5t gov]n+ ! reimbursem5t am\nts4 7,c7 ,! total am\nt receiv$ or expect$ to be receiv$ by ! heal? plan s]vice provid] or its subcontractors 9 provid] or suppli] rebates1 fees1 alt]native disc\nts1 & all o!r remun]ation includ+ am\nts held 9 escr[ or v>iance acc\nts t has be5 paid or is to be paid = claims incurr$ & adm9i/rative s]vices includ+ data sales or network paym5ts4 7,d7 ,! total am\nt paid or expect$ to be paid by ! heal? plan s]vice provid] or to subcontractors 9 rebates1 fees1 contractual arrangem5ts1 & all o!r remun]ation t has be5 paid or is expect$ to be paid = adm9i/rative & o!r s]vices4 7,e7 ,all paym5t data & reconciliation in=mation relat$ to alt]native comp5sation arrangem5ts includ+ acc\ntable c>e organizations1 value-bas$ programs1 %>$ sav+s programs1 inc5tive comp5sation1 bundl$ paym5ts1 capitation arrangem5ts1 p]=mance paym5ts1 & any o!r reimbursem5t or paym5t models1 :]e ! gr\p heal? plan or heal? insurance issu] paid fees1 incurr$ obligations1 or made paym5ts 9 connection ) ! gr\p heal? plan relat$ to su* arrangem5ts4 7#b7 ,privacy requirem5ts 7,a7 ,9 g5]al ,heal? plan s]vice provid]s %all provide ! in=mation or data "u p>agraph 7#a7 consi/5t ) ! privacy1 security1 & brea* notification regulations at p>ts #afj & #afd ( title #de1 ,code ( ,f$]al ,regulations1 promulgat$ "u subtitle ,f ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 subtitle ,d ( ! ,heal? ,in=mation ,te*nology = ,cl9ical ,heal? ,act ( #bjji1 & section #aahj ( ! ,social ,security ,act1 & %all re/rict ! use & disclosure ( su* in=mation accord+ to su* privacy1 security1 & brea* notification regulations4 ,an entity t receives a disclosure f a p>ty 9 int]e/ pursuant to subp>agraph 7,b7 or 7,c7 %all comply ) ! privacy & security regulations promulgat$ "u ,,hipaa4 7,b7 ,re/rictions ,a gr\p heal? plan %all comply ) section #afd4ejd7;f7 ( title #de1 ,code ( ,f$]al ,regulations 7or a successor regulation71 & a plan sponsor %all act 9 accordance ) ! t]ms ( ! agreem5t describ$ 9 su* section4 7,c7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to modify ! requirem5ts = ! creation1 receipt1 ma9t5ance1 or transmission ( protect$ heal? in=mation "u ! ,,hipaa privacy regulations 7#de ,,cfr p>ts #afj & #afd1 subp>ts ,a & ,e74 7#c7 ,disclosure & r$isclosure 7,a7 ,9 g5]al ,a gr\p heal? plan receiv+ in=mation "u p>agraph 7#a7 may disclose su* in=mation only-- 7i7 to ! entity f :i* ! in=mation 0 receiv$ or to t entity's bus9ess associates or to ! gr\p heal? plan's bus9ess associates z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations72 or 7ii7 z p]mitt$ by ! ,,hipaa ,privacy ,rule 7#de ,,cfr p>ts #afj & #afd1 subp>ts ,a & ,e74 7,b7 ,availability ( in=mation ,to ! ext5t ! in=mation requir$ by ?is subsection is made available to ! heal? insurance issu] (f]+ gr\p heal? insurance 9 connection ) a gr\p heal? plan1 ! heal? insurance issu] %all make su* in=mation available1 at ! same "t1 9 ! same =mat1 & at no co/1 to ! gr\p heal? plan4 7,c7 ,failure to provide ,! obligation to provide in=mation pursuant to ?is subsection %all exi/ not)/&+ ! pres5ce ( any =mal data-%>+ agreem5t betwe5 ! p>ties4 ,failure to provide ! requir$ in=mation z specifi$ %all con/itute a violation ( ?is ,act & ! ,secret>y %all initiate en=cem5t action "u section #ejb )9 #ij days ( becom+ aw>e ( a violation ( ?is section1 except t no?+ 9 ?is section %all be con/ru$ to limit ! ,secret>y's exi/+ au?ority "u ! ,act4 7#d7 ,data =mat /&>ds ,all data & in=mation provid$ pursuant to ?is subsection %all comply ) ! foll[+ /&>ds3 7,a7 ,all claims f a heal?c>e provid] %all be made to ! gr\p heal? plan 9 accordance ) transactions /&>ds adopt$ "u ,,hipaa1 z foll[s3 7i7 ,in/itutional1 pr(essional1 & d5tal claims & adju/m5ts to ^! claims %all be 9 ,,asc ,x#ab,n #hcg =mat1 z transmitt$ by ! provid]1 or1 9 ! case ( pap] claims1 conv]t$ to ! ,,asc ,x#ab,n #hcg electronic =mat4 7ii7 ,prescription drug claims %all be 9 ! ,national ,c\ncil = ,prescription ,drug ,programs 7,,ncpdp7 =mat1 z transmitt$ by ! provid]1 or 9 ! case ( pap] claims1 conv]t$ to ! ,,ncpdp electronic =mat4 7iii7 ,su* data %all be provid$ at no co/ to ! gr\p heal? plan4 7,b7 ,all claim paym5t 7or ,,eft1 electronic funds transf]7 & electronic remittance advice 7,,era7 in=mation s5t by a heal? plan s]vice provid] %all be provid$ to ! gr\p heal? plan or heal? insurance issu] 9 ! ,,asc ,x#ab,n #hce =mat 9 accordance ) transaction /&>ds adopt$ "u ,,hipaa1 unmodifi$ f ! =m 9 :i* x 0 transmitt$ to ! heal?c>e provid]4 ,su* in=mation %all be provid$ at no co/ to ! gr\p heal? plan or heal? insurance issu]4 7,c7 ,! ,secret>y may modify ! /&>ds set =? 9 ?is p>agraph z necess>y to align ) any *anges adopt$ by ! ,secret>y ( ,heal? & ,human ,s]vices pursuant to ! au?ority provid$ "u section #aagc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;d-#b74 7c7 ,prohibit$ contractual provisions ,any provision 9 an agreem5t betwe5 a gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 or a bus9ess associate ( su* plan or a heal? insurance issu] & a heal? plan s]vice provid] t unduly delays or limits a gr\p heal? plan's or heal? insurance issu]'s access to in=mation describ$ 9 ?is section or t re/ricts ! =mat or tim+ ( ! provision ( su* in=mation 9 a mann] t is inconsi/5t ) ! requirem5ts ( ?is section %all be prohibit$ &1 if a gr\p heal? plan or heal? insurance issu] ent]s into su* agreem5t1 %all be deem$ void z aga9/ public policy4 7d7 ,p5alties = non-,compliance ,any failure by a heal? plan s]vice provid] to comply ) ! requirem5ts ( ?is section %all result 9 ! imposition ( a civil p5alty ( #ajj1jjj = ea* day ! violation cont9ues1 9 addition to any o!r p5alties prescrib$ by law4 7e7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7#b7 ,p5alty 7,a7 ,9 g5]al ,section #ejb7;a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aacb7;a77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ad7 ,! ,secret>y may assess a civil p5alty aga9/ any p]son ( #ajj1jjj p] day = ea* violation by any p]son ( section #gbg4 4 7,b7 ,te*nical am5dm5t ,p>agraph 7#f7 ( section #ejb7;a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aacb7;a77 is am5d$ by /rik+ or 7#i7 & ins]t+ x ) ! phrase 7#i71 7#ac71 or 7#ad74 7b7 ,,phsa am5dm5ts 7#a7 ,9 g5]al ,"p ,d ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa et seq47 is am5d$ by add+ at ! end ! foll[+3 #bgii;,a-#ab4 ,ov]sight ( adm9i/rative s]vice provid]s 7a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ?is section1 no agreem5t betwe5 a gr\p heal? plan t is a self-fund$1 non-,f$]al plan1 z def9$ 9 section #bgia7;d77#h77;,c7 7#db ,u4,s4,c4 #cjj;gg-#ia7;d77#h77;,c771 & a heal? c>e provid]1 network or association ( provid]s1 ?ird-p>ty adm9i/rator1 s]vice provid] (f]+ access to a network ( provid]s1 or any o!r ?ird p>ty 7ea* ref]r$ to 9 ?is section z a heal? plan s]vice provid]7 is p]missible if su* agreem5t limits 7or delays beyond ! applicable report+ p]iod describ$ 9 subsection 7b77#a77 ! disclosure ( in=mation to gr\p heal? plans 9 su* a mann] t prev5ts su* plan1 issu]1 or entity f provid+ ! in=mation describ$ 9 subsection 7b74 7b7 ,requir$ disclosures 7#a7 ,cont5ts & frequ5cy ,) respect to plan ye>s beg9n+ on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ?is section1 n less frequ5tly ?an qu>t]ly1 a heal? plan s]vice provid] %all provide to ! gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan ! foll[+ in=mation at no co/ to ! plan3 7,a7 ,! in=mation describ$ 9 section #bgii;,a-#i7;a77#a77;,b7 7#db ,u4,s4,c4 #cjj;gg-#aai7;a77#a77;,b774 7,b7 ,any contractual & subcontractual calculation me?odologies1 pric+ or fee s*$ules1 or o!r =mulae us$ to det]m9e reimbursem5t am\nts to provid]s & subcontractors1 includ+ me?odologies1 s*$ules1 fee /ructures1 & any appli$ adju/m5ts or modifi]s1 ) su* in=mation provid$ 9 a mann] suffici5tly detail$ to enable ! gr\p heal? plan to accurately assess1 v]ify1 & ensure compliance ) ! t]ms ( any contractual & subcontractual agreem5t gov]n+ ! reimbursem5t am\nts4 7,c7 ,! total am\nt receiv$ or expect$ to be receiv$ by ! heal? plan s]vice provid] or its subcontractors 9 provid] or suppli] rebates1 fees1 alt]native disc\nts1 & all o!r remun]ation includ+ am\nts held 9 escr[ or v>iance acc\nts t has be5 paid or is to be paid = claims incurr$ & adm9i/rative s]vices includ+ data sales or network paym5ts4 7,d7 ,! total am\nt paid or expect$ to be paid by ! heal? plan s]vice provid] or to subcontractors 9 rebates1 fees1 contractual arrangem5ts1 & all o!r remun]ation t has be5 paid or is expect$ to be paid = adm9i/rative & o!r s]vices4 7,e7 ,all paym5t data & reconciliation in=mation relat$ to alt]native comp5sation arrangem5ts includ+ acc\ntable c>e organizations1 value-bas$ programs1 %>$ sav+s programs1 inc5tive comp5sation1 bundl$ paym5ts1 capitation arrangem5ts1 p]=mance paym5ts1 & any o!r reimbursem5t or paym5t models1 :]e ! gr\p heal? plan paid fees1 incurr$ obligations1 or made paym5ts 9 connection ) ! gr\p heal? plan relat$ to su* arrangem5ts4 7#b7 ,privacy requirem5ts 7,a7 ,9 g5]al ,heal? plan s]vice provid]s %all provide ! in=mation or data "u p>agraph 7#a7 consi/5t ) ! privacy1 security1 & brea* notification regulations at p>ts #afj & #afd ( title #de1 ,code ( ,f$]al ,regulations1 promulgat$ "u subtitle ,f ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 subtitle ,d ( ! ,heal? ,in=mation ,te*nology = ,cl9ical ,heal? ,act ( #bjji1 & section #aahj ( ! ,social ,security ,act1 & %all re/rict ! use & disclosure ( su* in=mation accord+ to su* privacy1 security1 & brea* notification regulations4 ,an entity t receives a disclosure f a p>ty 9 int]e/ pursuant to subp>agraph 7,b7 or 7,c7 %all comply ) ! privacy & security regulations promulgat$ "u ,,hipaa4 7,b7 ,re/rictions ,a gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan %all comply ) section #afd4ejd7;f7 ( title #de1 ,code ( ,f$]al ,regulations 7or a successor regulation71 & a plan sponsor %all act 9 accordance ) ! t]ms ( ! agreem5t describ$ 9 su* section4 7,c7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to modify ! requirem5ts = ! creation1 receipt1 ma9t5ance1 or transmission ( protect$ heal? in=mation "u ! ,,hipaa privacy regulations 7#de ,,cfr p>ts #afj & #afd1 subp>ts ,a & ,e74 7#c7 ,disclosure & r$isclosure 7,a7 ,9 g5]al ,a gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan receiv+ in=mation "u p>agraph 7#a7 may disclose su* in=mation only-- 7i7 to ! entity f :i* ! in=mation 0 receiv$ or to t entity's bus9ess associates z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations72 or 7ii7 z p]mitt$ by ! ,,hipaa ,privacy ,rule 7#de ,,cfr p>ts #afj & #afd1 subp>ts ,a & ,e74 7,b7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to prev5t a gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan1 or a heal? plan s]vice provid] provid+ s]vices ) respect to su* a plan1 f plac+ reasonable re/rictions on ! public disclosure ( ! in=mation describ$ 9 p>agraph 7#a71 except t su* plan or entity may n re/rict disclosure ( su* in=mation to ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 ! ,dep>tm5t ( ! ,treasury1 or ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates4 7,c7 ,failure to provide ,! obligation to provide in=mation pursuant to ?is subsection %all exi/ not)/&+ ! pres5ce ( any =mal data-%>+ agreem5t betwe5 ! p>ties4 ,failure to provide ! requir$ in=mation z specifi$ %all con/itute a violation ( ?is ,act & ! ,secret>y %all initiate en=cem5t action "u section #bgbc7;b7 7#db ,u4,s4,c4 #cjj;gg-#bb7;b77 )9 #ij days ( becom+ aw>e ( a violation ( ?is section1 except t no?+ 9 ?is section %all be con/ru$ to limit ! ,secret>y's exi/+ au?ority "u ?is ,act4 7#d7 ,data =mat /&>ds ,all data & in=mation provid$ pursuant to ?is subsection %all comply ) ! foll[+ /&>ds3 7,a7 ,all claims f a heal?c>e provid] %all be made to ! gr\p heal? plan 9 accordance ) /&>ds adopt$ "u ,,hipaa at section #afb4aaja ( title #de1 ,code ( ,f$]al ,regulations1 z foll[s3 7i7 ,in/itutional1 pr(essional1 & d5tal claims & adju/m5ts to ^! claims %all be provid$ to ! gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan 9 ! ,,asc ,x#ab,n #hcg =mat4 7ii7 ,prescription drug claims %all be 9 ! ,national ,c\ncil = ,prescription ,drug ,programs 7,,ncpdp7 =mat4 7iii7 ,! files %all be unmodifi$ copies ( ! files s5t f ! provid]4 ,9 ! ev5t t pap] claims are s5t by ! provid]1 !y %all be conv]t$ to ! appropriate /&>d electronic =mat4 ,su* data %all be provid$ at no co/ to ! gr\p heal? plan4 7,b7 ,all claim paym5t 7or ,,eft1 electronic funds transf]7 & electronic remittance advice 7,,era7 in=mation s5t by a heal? plan s]vice provid] %all be provid$ to ! gr\p heal? plan or heal? insurance issu] 9 ! ,,asc ,x#ab,n #hce =mat1 9 accordance ) /&>ds adopt$ "u ,,hipaa at section #afb4afjb ( title #de1 ,code ( ,f$]al ,regulations1 unmodifi$ f ! =m 9 :i* x 0 transmitt$ to ! heal?c>e provid]4 ,su* in=mation %all be provid$ at no co/ to ! gr\p heal? plan4 7,c7 ,! ,secret>y may modify ! /&>ds set =? 9 ?is p>agraph z necess>y to align ) any *anges adopt$ by ! ,secret>y pursuant to ! au?ority provid$ "u section #aagc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;d-#b74 7c7 ,prohibit$ contractual provisions ,any provision 9 an agreem5t t unduly delays or limits a gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan's access to in=mation describ$ 9 ?is section or t re/ricts ! =mat or tim+ ( ! provision ( su* in=mation 9 a mann] t is inconsi/5t ) ! requirem5ts ( ?is section %all be prohibit$ &1 if a self-fund$1 non-,f$]al gov]nm5tal plan ent]s into su* agreem5t1 %all be deem$ void z aga9/ public policy4 7d7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7#b7 ,p5alty ,section #bgbc7;b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#bb7;b77 is am5d$ by add+ at ! end ! foll[+3 7#d7 ,en=cem5t au?ority relat+ to heal? plan s]vice provid]s ,not)/&+ any provisions to ! contr>y1 ! ,secret>y may assess a p5alty aga9/ a heal? plan s]vice provid]1 z def9$ 9 section #bgii;,a-#ab7;a7 7#db ,u4,s4,c4 #cjj;gg-#aba7;a771 ( #ajj1jjj p] day = ea* violation ( su* section1 pursuant to sub/antially simil> processes & proc$ures z ^? set =? 9 section #bgbc7;b77#b77;,d7 ?r\gh 7,g7 7#db ,u4,s4,c4 #cjj;gg-#aba7;b77#b77;,d7 ?r\gh 7,g774 4 #cji4 ,/ate preemption only 9 ev5t ( conflict ,! provisions ( sections #cjb ?r\gh #cje 7includ+ ! am5dm5ts made by su* sections7 %all n sup]s$e any provision ( ,/ate law :i* e/abli%es1 implem5ts1 or cont9ues 9 effect any requirem5t or prohibition relat$ to heal? c>e price transp>5cy1 includ+ hospital1 cl9ical diagno/ic laboratory te/s1 imag+ s]vices1 & ambulatory surgical c5t]1 except to ! ext5t t su* requirem5t or prohibition prev5ts ! application ( a requirem5t or prohibition ( su* sections 7or am5dm5t74 ,no?+ 9 ?is section %all be con/ru$ to affect gr\p heal? plans e/abli%$ "u ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or alt] ! application ( section #ead ( su* ,act 7#bi ,u4,s4,c4 #aadd74 #caj4 ,requirem5t = explanation ( b5efits 7a7 ,,phsa ,am5dm5ts 7#a7 ,em]g5cy s]vices ,section #bgii;,a-#a7;f77#a77;,c7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa7;f77#a77;,c77 is am5d$ to read z foll[s3 7,c7 ,a good fai? e/imate ( ! am\nt ! plan or cov]age is responsible = pay+ = items & s]vices includ$ 9 ! e/imate describ$ 9 subp>agraph 7,b71 includ+ a pla9 language description ( ea* item or s]vice & all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 4 7#b7 ,explanation ( b5efits ,section #bgii;,a-#a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa7 is am5d$ by add+ at ! end ! foll[+3 7g7 ,explanation ( b5efits 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbg1 ea* gr\p heal? plan1 or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all1 )9 #de days ( receiv+ any reque/ = paym5t = an item or s]vice "u ! plan1 provide to ! p>ticipant1 b5efici>y1 or enrollee 7?r\gh mail or electronic means1 z reque/$ by ! p>ticipant1 b5efici>y1 or enrollee7 a notification 79 cle> & und]/&able language & utiliz+ sub/antially ! same =mat z ! advanc$ explanation ( b5efits requir$ by subsection 7f7 to enable comp>ison7 includ+ ! foll[+3 7,a7 ,:e!r or n ! provid] or facility is a p>ticipat+ provid] or a p>ticipat+ facility ) respect to ! plan or cov]age ) respect to ! furni%+ ( su* item or s]vice4 7,b7 ,an itemiz$ explanation ( b5efits t includes ! foll[+3 7i7 ,a pla9 language description ( ea* item or s]vice4 7ii7 ,all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 7iii7 ,! am\nt ! plan or cov]age is responsible = pay+ = ea* item or s]vice4 7iv7 ,! am\nt ( any co/-%>+ = :i* ! p>ticipant1 b5efici>y1 or enrollee is responsible = ea* item or s]vice 7z ( ! date ( su* notification74 7v7 ,! am\nt t ! p>ticipant1 b5efici>y1 or enrollee has incurr$ t[>d meet+ ! limit ( ! f9ancial responsibility 7includ+ ) respect to d$uctibles & out-(-pocket maximums7 "u ! plan or cov]age 7z ( ! date ( su* notification74 7vi7 ,! site ( ea* item or s]vice4 7#b7 ,=mat ,if applicable1 ! notification describ$ 9 p>agraph 7#a7 may be provid$ 9 conjunction )1 or z "p (1 a notice ( a claim det]m9ation or o!r communication requir$ by section #bgai7;a7 7#db ,u4,s4,c4 #cjj;gg-#ai7;a771 or regulations !reund]4 7h7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7b7 ,,irc am5dm5ts 7#a7 ,em]g5cy s]vices ,section #ihaf7;f77#a77;,c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ to read z foll[s3 7,c7 ,a good fai? e/imate ( ! am\nt ! plan is responsible = pay+ = items & s]vices includ$ 9 ! e/imate describ$ 9 subp>agraph 7,b71 includ+ a pla9 language description ( ea* item or s]vice & all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 4 7#b7 ,explanation ( b5efits ,section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+3 7g7 ,explanation ( b5efits 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbg1 ea* gr\p heal? plan %all1 )9 #de days ( receiv+ any reque/ = paym5t = an item or s]vice "u ! plan1 provide to ! p>ticipant or b5efici>y 7?r\gh mail or electronic means1 z reque/$ by ! p>ticipant or b5efici>y7 a notification 79 cle> & und]/&able language & utiliz+ sub/antially ! same =mat z ! advanc$ explanation ( b5efits requir$ by subsection 7f7 to enable comp>ison7 includ+ ! foll[+3 7,a7 ,:e!r or n ! provid] or facility is a p>ticipat+ provid] or a p>ticipat+ facility ) respect to ! plan ) respect to ! furni%+ ( su* item or s]vice4 7,b7 ,an itemiz$ explanation ( b5efits t includes ! foll[+3 7i7 ,a pla9 language description ( ea* item or s]vice4 7ii7 ,all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 7iii7 ,! am\nt ! plan is responsible = pay+ = ea* item or s]vice4 7iv7 ,! am\nt ( any co/-%>+ = :i* ! p>ticipant or b5efici>y is responsible = ea* item or s]vice 7z ( ! date ( su* notification74 7v7 ,! am\nt t ! p>ticipant or b5efici>y has incurr$ t[>d meet+ ! limit ( ! f9ancial responsibility 7includ+ ) respect to d$uctibles & out-(-pocket maximums7 "u ! plan 7z ( ! date ( su* notification74 7vi7 ,! site ( ea* item or s]vice4 7#b7 ,=mat ,if applicable1 ! notification describ$ 9 p>agraph 7#a7 may be provid$ 9 conjunction )1 or z "p (1 a notice ( a claim det]m9ation or o!r communication requir$ by section #ejc ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd or regulations !reund]4 7h7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7c7 ,,erisa am5dm5ts 7#a7 ,em]g5cy s]vices ,section #gaf7;f77#a77;,c7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;e7f77#a77;,c77 is am5d$ to read z foll[s3 7,c7 ,a good fai? e/imate ( ! am\nt ! heal? plan is responsible = pay+ = items & s]vices includ$ 9 ! e/imate describ$ 9 subp>agraph 7,b71 includ+ a pla9 language description ( ea* item or s]vice & all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 4 7#b7 ,explanation ( b5efits ,section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;e7 is am5d$ by add+ at ! end ! foll[+3 7g7 ,explanation ( b5efits 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbg1 ea* gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all1 )9 #de days ( receiv+ any reque/ = paym5t = an item or s]vice "u ! plan1 provide to ! p>ticipant or b5efici>y 7?r\gh mail or electronic means1 z reque/$ by ! p>ticipant or b5efici>y7 a notification 79 cle> & und]/&able language & utiliz+ sub/antially ! same =mat z ! advanc$ explanation ( b5efits requir$ by subsection 7f7 to enable comp>ison7 includ+ ! foll[+3 7,a7 ,:e!r or n ! provid] or facility is a p>ticipat+ provid] or a p>ticipat+ facility ) respect to ! plan or cov]age ) respect to ! furni%+ ( su* item or s]vice4 7,b7 ,an itemiz$ explanation ( b5efits t includes ! foll[+3 7i7 ,a pla9 language description ( ea* item or s]vice4 7ii7 ,all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 7iii7 ,! am\nt ! plan or cov]age is responsible = pay+ = ea* item or s]vice4 7iv7 ,! am\nt ( any co/-%>+ = :i* ! p>ticipant or b5efici>y is responsible = ea* item or s]vice 7z ( ! date ( su* notification74 7v7 ,! am\nt t ! p>ticipant or b5efici>y has incurr$ t[>d meet+ ! limit ( ! f9ancial responsibility 7includ+ ) respect to d$uctibles & out-(-pocket maximums7 "u ! plan or cov]age 7z ( ! date ( su* notification74 7vi7 ,! site ( ea* item or s]vice4 7#b7 ,=mat ,if applicable1 ! notification describ$ 9 p>agraph 7#a7 may be provid$ 9 conjunction )1 or z "p (1 a notice ( a claim det]m9ation or o!r communication requir$ by section #ejc or regulations !reund]4 7h7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 #caa4 ,provision ( itemiz$ bills ,"p ,e ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aca et seq47 is am5d$ by add+ at ! end ! foll[+3 #bgii;,b-#aj4 ,provid] requirem5ts = itemiz$ bills 7a7 ,requirem5ts 7#a7 ,itemiz$ bill & o!r in=mation requir$ 7,a7 ,9 g5]al ,a heal? c>e provid] or heal? c>e facility t reque/s paym5t f an individual aft] provid+ a heal? c>e item or s]vice to ! pati5t %all include ) su* reque/ a writt51 itemiz$ bill ( ! co/ ( ea* reasonably expect$ item or s]vice ! heal? c>e provid] or heal? c>e facility provid$ to ! individual1 includ+ teleheal? visits or visits by o!r electronic means4 ,! heal? c>e provid] or heal? c>e facility %all provide ! itemiz$ bill n lat] ?an #cj days aft] ! heal? c>e provid] or heal? c>e facility receiv$ a f9al paym5t on ! provid$ s]vice or supply f a ?ird p>ty4 7,b7 ,requir$ in=mation ,= ea* item or s]vice provid$ by ! heal? c>e provid] or facility or = :i* ! heal? c>e provid] or facility is bill+ ! individual1 ! itemiz$ bill mu/ include-- 7i7 a pla9 language description ( ea* di/9ct heal? c>e item or s]vice2 7ii7 all applicable bill+ codes = ea* di/9ct heal? c>e item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$2 7iii7 ! price & bill$ am\nt1 if diff]5t1 ( ea* di/9ct heal? c>e item or s]vice or if ! provid] or facility is (f]+ b9d+1 all-9 prices = bundl$ items & s]vices1 ! total b9d+ price = bundl$ items & s]vices & bill$ am\nt2 7iv7 any paym5ts made to ! heal? c>e provid] or heal? c>e facility by or on behalf ( ! individual 7includ+ paym5ts by any heal? plan or insurance7 = any heal? c>e item or s]vice cov]$ 9 ! itemiz$ bill2 7v7 in=mation ab\t ! availability ( language-assi/ance s]vices = individuals ) limit$ ,engli% pr(ici5cy 7,,lep72 7vi7 ! id5tification ( an (fice or individual at ! heal? c>e provid] or heal? c>e facility1 includ+ phone numb] & email address1 t %all be able to discuss ! specific details ( ! itemiz$ /atem5t & be au?oriz$ to make appropriate *anges !reto2 & 7vii7 in=mation ab\t ! heal? c>e provid]'s or heal? c>e facility's *>ity c>e policies & in/ructions on h[ to apply = *>ity c>e4 7#b7 ,collections actions 7,a7 ,9 g5]al ,a heal? c>e provid] or heal? c>e facility %all n take any collections actions aga9/ an individual-- 7i7 = any provid$ heal? c>e item or s]vice unless ! heal? c>e provid] or heal? c>e facility has compli$ ) p>agraph 7#a72 or 7ii7 ) respect to any items or s]vices = :i* ! am\nt appe>+ on an itemiz$ bill describ$ above 9 p>agraph 7#a7 exce$s ! am\nt disclos$ pursuant to ,f$]al heal? c>e price transp>5cy regulations1 includ+ "p #ahj ( title #de1 ,code ( ,f$]al ,regulations1 or provid$ 9 a good fai? e/imate t complies ) section #bgii;,b-#f ( ?is ,act & section #adi4faj ( title #de1 ,code ( ,f$]al ,regulations1 or ano!r good fai? e/imate provid$ by a heal? c>e entity cov]$ "u ?is section b n o!rwise cov]$ "u su* section #bgii;,b-#f unless ! provid] or facility docum5ts t ! additional items or s]vices 7 m$ically necess>y due to un=ese5 complications or a pati5t-initiat$ *ange1 & c\ld n reasonably h be5 anticipat$4 7,b7 ,burd5 ( pro( ,! burd5 ( pro( "u subp>agraph 7,a77ii7 %all re/ ) ! provid]1 & abs5t ! docum5tation describ$ 9 su* subp>agraph1 ! good fai? e/imate %all be b9d+4 7b7 ,failure ,to comply 7#a7 ,p5alties ,! ,secret>y %all impose p5alties on any heal? c>e provid] or heal? c>e facility t fails to comply ) ! requirem5ts ( ?is section 9 an am\nt n to exce$ #aj1jjj = ea* in/ance ( failure to comply4 7#b7 ,presumption 9 favor ( individual ,if a heal? c>e provid] or heal? c>e facility fails to comply ) ! requirem5ts ( ?is section1 ! presumption %all be t *>ges 7 sub/antially 9 excess ( ! good fai? e/imate 7z set =? 9 section #bgii;,b-#f7 = ! purpose ( any pati5t-provid] dispute1 includ+ 9 accordance ) section #bgii;,b-#g & regulations promulgat$ !reund]4 7c7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 ,,iv ,protect+ ,pati5t ,access to ,canc] & ,complex ,!rapies #dja4 ,%ort title ,?is title may be cit$ z ! ,protect+ ,pati5t ,access to ,canc] & ,complex ,!rapies ,act4 #djb4 ,rebate by manufactur]s = select$ drugs & biological products subject to maximum fair price negotiation 7a7 ,ma9ta9+ paym5ts "u "p ,b bas$ on ,,asp#f ,section #ahdg;,a7b77#a77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c;a7b77#a77;,b77 is am5d$ by /rik+ or 9 ! case ( su* a drug or biological product t is a select$ drug & all t foll[s ?r\gh ! semicolon & ins]t+ a semicolon4 7b7 ,rebate by manufactur]s = select$ drugs & biological products subject to maximum fair price negotiation 7#a7 ,9 g5]al ,section #ahdg;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c;a7 is am5d$-- 7,a7 by r$esignat+ subsection 7j7 z subsection 7k72 & 7,b7 by ins]t+ aft] subsection 7i7 ! foll[+ new subsection3 7j7 ,rebate by manufactur]s = select$ drugs & biological products subject to maximum fair price negotiation 7#a7 ,requirem5ts 7,a7 ,secret>ial provision ( in=mation ,n lat] ?an #f mon?s aft] ! end ( ea* cal5d> qu>t] beg9n+ on or aft] ! fir/ day ( ! initial price applicability p]iod 7z def9$ 9 section #aaia7;b77#b771 ! ,secret>y %all1 = ea* select$ drug 7z def9$ 9 section #aaib7;c77 ( ea* manufactur] ) an agreem5t "u section #aaic = :i* a maximum fair price is 9 effect & = :i* paym5t may be made "u ?is "p1 report to ea* manufactur] ( su* select$ drug ! foll[+ = su* cal5d> qu>t] dur+ su* price applicability p]iod3 7i7 ,in=mation on ! total numb] ( units ( ! bill+ & paym5t code = su* select$ drug furni%$ "u ?is "p dur+ su* cal5d> qu>t]4 7ii7 ,in=mation on ! sum (-- 7,i7 ! am\nt 7if any7 by :i*-- 7aa7 ! ,,asp#f paym5t am\nt 7z def9$ 9 p>agraph 7#e77 = su* drug & cal5d> qu>t]1 less ! ,,asp#f co9surance am\nt = su* drug & cal5d> qu>t]2 exce$s 7bb7 ! ,,mfp#f paym5t am\nt 7z s def9$7 = su* drug & cal5d> qu>t]1 less ! ,,mfp#f co9surance am\nt = su* drug & cal5d> qu>t]2 & 7,,ii7 ! am\nt 7if any7 by :i*-- 7aa7 ! ,,asp#f co9surance am\nt 7z def9$ 9 p>agraph 7#e77 = su* drug & cal5d> qu>t]2 exce$s 7bb7 ! ,,mfp#f co9surance am\nt 7z s def9$7 = su* drug & cal5d> qu>t]4 7iii7 ,! rebate am\nt specifi$ "u subp>agraph 7,b7 = su* drug & cal5d> qu>t]4 7,b7 ,manufactur] requirem5t ,= ea* cal5d> qu>t] beg9n+ on or aft] ! fir/ day ( ! initial price applicability p]iod 7z def9$ 9 section #aaia7;b77#b771 ! manufactur] ( a select$ drug %all1 = su* drug1 n lat] ?an #cj days aft] ! date ( receipt f ! ,secret>y ( ! in=mation describ$ 9 subp>agraph 7,a7 = su* cal5d> qu>t]1 provide to ! ,secret>y a rebate t is equal to ! am\nt specifi$ 9 subp>agraph 7,a77ii7 multipli$ by ! numb] ( units specifi$ 9 subp>agraph 7,a77i7 = su* drug = su* cal5d> qu>t]4 ,! rebate requir$ "u ?is subp>agraph %all be 9 addition to any o!r rebates requir$ "u ?is title or title ,,xix1 includ+ ! paym5ts requir$ "u subsections 7h7 & 7i74 7#b7 ,calculation ( b5efici>y co9surance bas$ on mfp#f 7,a7 ,9 g5]al ,subject to subp>agraph 7,b71 9 ! case ( a select$ drug ) respect to :i* a rebate is paid "u ?is subsection-- 7i7 ! am\nt ( any co9surance applicable "u ?is "p to an individual to :om su* drug is furni%$ dur+ a cal5d> qu>t] %all be equal to ! ,,mfp#f co9surance am\nt2 & 7ii7 ! am\nt ( su* co9surance = su* cal5d> qu>t] %all be appli$ z a p]c5t1 z det]m9$ by ! ,secret>y1 to ! paym5t am\nt t w\ld o!rwise apply "u subsection 7b77#a77;,b74 7,b7 ,cl>ification reg>d+ application ( inflation rebate ,if a rebate is requir$ "u subsection 7i7 ) respect to a select$ drug = a cal5d> qu>t]1 ! less] ( ! am\nt ( co9surance comput$ "u subp>agraph 7,a7 or ! co9surance comput$ "u subsection 7i77#e7 %all apply = su* drug & cal5d> qu>t]4 7#c7 ,rebate deposits ,am\nts paid z rebates "u p>agraph 7#a77;,b7 %all be deposit$ into ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund e/abli%$ "u section #ahda4 7#d7 ,civil money p5alty ,! civil money p5alty e/abli%$ "u p>agraph 7#g7 ( subsection 7i7 %all apply to ! failure to comply ) ?is subsection 9 ! same mann] z su* p5alty applies to failures to comply ) ! requirem5ts "u p>agraph 7#a77;,b7 ( subsection 7i74 7#e7 ,def9itions ,9 ?is subsection1 ) respect to a select$ drug = a cal5d> qu>t] dur+ a price applicability p]iod3 7,a7 ,,asp#f co9surance am\nt ,! ,,asp#f co9surance am\nt is equal to #bj p]c5t ( ! ,,asp#f paym5t am\nt4 7,b7 ,,asp#f paym5t am\nt ,! ,,asp#f paym5t am\nt is equal to #ajf p]c5t ( ! am\nt det]m9$ "u p>agraph 7#d7 ( subsection 7b7 = su* drug dur+ su* cal5d> qu>t]4 7,c7 ,,mfp#f co9surance am\nt ,! ,,mfp#f co9surance am\nt is equal to #bj p]c5t ( ! ,,mfp#f paym5t am\nt4 7,d7 ,,mfp#f paym5t am\nt ,! ,,mfp#f paym5t am\nt is equal to #ajf p]c5t ( ! maximum fair price 7z def9$ 9 section #aaia7;c77#b77 applicable = su* drug dur+ su* cal5d> qu>t]4 7#f7 ,cl>ification ,no?+ 9 "p ,e ( title ,,xi or ?is subsection %all be con/ru$ to require a manufactur] to provide select$ drugs at maximum fair prices o!r ?an ?r\gh ! rebate requir$ "u ?is subsection4 4 7#b7 ,am\nts payable2 co/-%>+ ,section #ahcc7;a77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77#a77 is am5d$-- 7,a7 9 subp>agraph 7,g71 by /rik+ subsection 7i77#i7 & ins]t+ p>agraphs 7#i7 & 7#aj7 ( subsection 7i72 7,b7 9 subp>agraph 7,s71 by /rik+ subp>agraph 7,,ee7 & ins]t+ subp>agraphs 7,,ee7 & 7,,ii72 7,c7 by /rik+ & 7,,hh7 & ins]t+ 7,,hh72 & 7,d7 by ins]t+ be=e ! semicolon at ! end ! foll[+3 1 & 7,,ii7 ) respect to a select$ drug 7z def9$ 9 section #aaib7;c77 t is subject to a rebate "u section #ahdg;,a7j71 ! am\nts paid %all be equal to ! p]c5t ( ! paym5t am\nt o!rwise det]m9$ "u section #ahdg;,a7b77#a77;,b7 t equals ! diff]5ce betwe5 7i7 #ajj p]c5t1 & 7ii7 ! p]c5t appli$ "u section #ahdg;,a7j77#b77;,a77ii74 7#c7 ,,asc con=m+ am5dm5ts ,section #ahcc7;i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7i77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#aa7 ,9 ! case ( a select$ drug 7z def9$ 9 section #aaib7;c771 subject to a rebate "u section #ahdg;,a7j7 = :i* paym5t "u ?is subsection is n packag$ into a paym5t = a s]vice furni%$ on or aft] ! initial price applicability ye> = ! select$ drug "u ! revis$ paym5t sy/em "u ?is subsection1 9 lieu ( calculation ( co9surance & ! am\nt ( paym5t o!rwise applicable "u ?is subsection1 ! provisions ( section #ahdg7;j77#b7 & p>agraph 7#a77;,,ii7 ( subsection 7a71 %all1 z det]m9$ appropriate by ! ,secret>y1 apply "u ?is subsection 9 ! same mann] z su* provisions ( section #ahdg;,a7j77#b7 & subsection 7a7 apply "u su* section & subsection4 4 7#d7 ,,opps con=m+ am5dm5t ,section #ahcc7t77#h7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#h77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,g7 ,select$ drugs subject to rebate ,9 ! case ( a select$ drug 7z def9$ 9 section #aaib7;c771 subject to a rebate "u section #ahdg;,a7j7 = :i* paym5t "u ?is subsection is n packag$ into a paym5t = a cov]$ ,,opd s]vice 7or gr\p ( s]vices7 furni%$ on or aft] ! initial price applicability ye> = ! select$ drug1 & ! paym5t = su* drug is ! same z ! am\nt = a cal5d> qu>t] "u section #ahdg;,a7b77#a77;,b71 "u ! sy/em "u ?is subsection1 9 lieu ( ! calculation ( ! copaym5t am\nt & ! am\nt o!rwise applicable "u ?is subsection 7o!r ?an ! application ( ! limitation describ$ 9 subp>agraph 7,c771 ! provisions ( section #ahdg;,a7j77#b7 & p>agraph 7#a77;,,ii7 ( subsection 7a71 %all1 z det]m9$ by ! ,secret>y apply "u ?is section 9 ! same mann] z su* provisions ( section #ahdg;,a7j77#b7 & subsection 7a7 apply "u su* section & subsection4 4 7#e7 ,exclusion ( select$ drug mfp rebates f asp calculation ,section #ahdg;,a7c77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c;a7c77#c77 is am5d$ by /rik+ subsection 7i7 & ins]t+ subsection 7i71 subsection 7j74 7#f7 ,coord9ation ) m$icaid rebate in=mation disclosures ,section #aibg7;b77#c77;,d77i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acifr-#h7;b77#c77;,d77i77 is am5d$ by /rik+ & ! rebate & ins]t+ & ! rebates4 7#g7 ,provision ( rebates ,section #aaic7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;f-#b7;a77 is am5d$-- 7,a7 9 p>agraph 7#a71 by /rik+ subp>agraph 7,b7 & ins]t+ ! foll[+3 7,b7 by pay+ rebates 9 accordance ) section #ahdg;,a7j72 2 7,b7 9 p>agraph 7#b71 by /rik+ subp>agraph 7,b7 & ins]t+ ! foll[+3 7,b7 by pay+ rebates 9 accordance ) section #ahdg;,a7j72 2 & 7,c7 9 p>agraph 7#c71 by /rik+ subp>agraph 7,b7 & ins]t+ ! foll[+3 7,b7 by pay+ rebates 9 accordance ) section #ahdg;,a7j72 4 7c7 ,con=m+ am5dm5ts 7#a7 ,section #ahdg;,a7i77#e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#c;a7i77#e77 is am5d$1 9 ! matt] prec$+ subp>agraph 7,a7-- 7,a7 by /rik+ ,9 ! case & ins]t+ ,subsection to subsection 7j77#b77;,b71 9 ! case2 & 7,b7 by /rik+ 7or1 9 ! case ( a "p ,b rebatable drug t is a select$ drug 7z def9$ 9 section #aaib7;c771 ! paym5t am\nt describ$ 9 subsection 7b77#a77;,b7 = su* drug72 & 7#b7 ,section #ahcc7;a77#a77;,,ee7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77#a77;,,ee77 is am5d$-- 7,a7 by /rik+ 7or1 9 ! case ( a "p ,b rebatable drug t is a select$ drug 7z def9$ 9 section #aaib7;c7 = :i*1 ! paym5t am\nt describ$ 9 section #ahdg;,a7b77#a77;,b77 = su* drug = su* qu>t]2 & 7,b7 by /rik+ or section #ahdg;,a7b77#a77;,b71 z applicable14 ,v ,exp&$-access ,prescription ,drugs #eja4 ,exp&$-access prescription drugs 7a7 ,9 g5]al ,section #ejc7;b7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cec7;b77 is am5d$ by add+ at ! end ! foll[+3 7#f7 ,exp&$-access prescription drugs 7,a7 ,e/abli%m5t ( li/ ,! ,secret>y %all e/abli% & ma9ta9 a li/ ( exp&$-access prescription drugs4 7,b7 ,designation ,! ,secret>y %all designate su* exp&$-access prescription drugs bas$ on safety data1 evid5ce ( l[ risk1 & suitability = assessm5t 9 a ph>macy or simil> sett+ 7su* z c]ta9 antibiotics = m9or infections1 antivirals1 hormonal !rapies1 & ma9t5ance drugs = *ronic conditions74 7,c7 ,disp5s+ & adm9i/]+ ,not)/&+ p>agraph 7#a71 an exp&$-access prescription drug may be disp5s$ & adm9i/]$ by a cov]$ individual aft] conduct+ an appropriate pati5t assessm5t consi/5t ) protocols to be issu$ by ! ,secret>y4 7,d7 ,rulemak+ ,n lat] ?an #abj days aft] ! date ( enactm5t ( ?is p>agraph1 ! ,secret>y %all issue su* regulations ?r\gh notice-&-comm5t rulemak+ z may be necess>y to c>ry out ?is p>agraph1 includ+-- 7i7 to e/abli% & ma9ta9 ! li/ "u subp>agraph 7,a72 & 7ii7 to issue protocols "u subp>agraph 7,c74 7,e7 ,preemption 7i7 ,9 g5]al ,except z provid$ 9 clause 7ii71 no ,/ate or political subdivision ( a ,/ate may e/abli%1 en=ce1 or cont9ue 9 effect ) respect to an exp&$-access prescription drug any provision ( law or legal requirem5t1 includ+ ) respect to lic5sure ( a cov]$ individual1 t is diff]5t f1 or is 9 conflict )1 any requirem5t applicable "u ?is p>agraph4 7ii7 ,/ate opt-out au?ority ,! prohibition 9 clause 7i7 %all n apply 9 ! case ( a ,/ate 7exclud+ a political subdivision !re(7 t has 9 effect a law explicitly prohibit+ or limit+ ! prescrib+ or disp5s+ ( an exp&$-access prescription drug by a cov]$ individual4 7,f7 ,cov]$ individual def9$ ,9 ?is p>agraph1 ! t]m cov]$ individual means an individual :o is lic5s$ "u applicable ,/ate law z-- 7i7 a ph>maci/2 7ii7 an advanc$ practice regi/]$ nurse2 7iii7 an advanc$ practice provid]2 7iv7 a physician assi/ant2 or 7v7 su* o!r heal? c>e pr(essional1 z may be specifi$ by ! ,secret>y4 4 7b7 ,congressional report ,n lat] ?an #b ye>s aft] ! date ( enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all submit to ,congress a report on ! implem5tation (1 & ,/ate opt-outs "u1 p>agraph 7#f7 ( section #ejc7;b7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cec7;b77 7z add$ by subsection 7a774 #ejb4 ,gov]nm5t sponsor$ programs 7a7 ,requirem5t ,! ,presid5t %all take su* /eps z are necess>y to ensure t ea* ,gov]nm5t sponsor$ program includes cov]age = exp&$-access prescription drugs adm9i/]$ by cov]$ individuals to b5efici>ies ( ! program4 7b7 ,preemption ,a cov]$ individual may adm9i/] exp&$-access prescription drugs pursuant to subsection 7a7 reg>dless ( a provision ( law or legal requirem5t 9 ! ,/ate ( ! cov]$ individual reg>d+ ! lic5sure or scope-(-practice ( ! individual4 7c7 ,def9itions ,9 ?is section3 7#a7 ,! t]m cov]$ individual has ! mean+ giv5 t t]m 9 section #ejc7;b77#f7 ( ! ,f$]al ,food1 ,drug1 & ,cosmetic ,act 7#ba ,u4,s4,c4 #cec7;b77#f771 z add$ by section #eja ( ?is ,act4 7#b7 ,! t]m exp&$-access prescription drugs means drugs cov]$ "u su* section #ejc7;b77#f74 7#c7 ,! t]m ,gov]nm5t sponsor$ program means any cov]age describ$ 9 section #ejjj;,a7f77#a77;,a7 ( ! ,int]nal ,rev5ue ,code ( #aihf4