,i #aai? ,,congress #b;d ,session ,h4 ,r4 #icic ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,june #bc1 #bjbf,mr4 ,gu?rie 7= himself & ,mr4 ,pallone7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committees on ,ways & ,means1 & ,education & ,work=ce1 = 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 promote price transp>5cy 9 ! heal? c>e sector4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,l[] ,co/s1 ,m ,transp>5cy ,act ( #bjbf4 #b4 ,hospital price transp>5cy 7a7 ,m$ic>e 7#a7 ,9 g5]al ,"p ,e ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #ahii;,d4 ,hospital price transp>5cy 7a7 ,transp>5cy requirem5t 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbh1 ea* specifi$ hospital t receives paym5t "u ?is title = furni%+ items & s]vices %all comply ) ! price transp>5cy requirem5t describ$ 9 p>agraph 7#b74 7#b7 ,requirem5t describ$ 7,a7 ,9 g5]al ,= purposes ( p>agraph 7#a71 ! price transp>5cy requirem5t describ$ 9 ?is p>agraph is1 ) respect to a specifi$ hospital1 t su* hospital1 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u subp>agraph 7,c71 compile & make public 7)\t subscription & free ( *>ge7 = ea* ye>-- 7i7 all ( ! hospital's /&>d *>ges 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = ea* item & s]vice furni%$ by su* hospital2 7ii7 in=mation 9 a consum]-fri5dly =mat 7z specifi$ by ! ,secret>y7-- 7,i7 on ! hospital's prices 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = z _m ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vices t are furni%$ by ! hospital1 & z _m additional hospital-select$ %oppable s]vices 7or all su* additional s]vices1 if su* hospital furni%es few] ?an #cjj %oppable s]vices7 z may be necess>y = a comb9$ total ( at lea/ #cjj %oppable s]vices2 & 7,,ii7 t includes1 ) respect to ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is n furni%$ by ! hospital1 an indication t su* s]vice is n s furni%$2 7iii7 ea* type #b national provid] id5tifi] associat$ ) ! hospital or a unit ( ! hospital2 & 7iv7 an atte/ation t all in=mation made public pursuant to ?is subp>agraph is complete & accurate4 7,b7 ,in=mation describ$ ,= purposes ( subp>agraph 7,a71 ! in=mation describ$ 9 ?is subp>agraph is1 ) respect to /&>d *>ges & prices1 z applicable1 made public by a specifi$ hospital1 ! foll[+3 7i7 ,a pla9 language description 7z specifi$ by ! ,secret>y7 ( ea* item or s]vice1 accompani$ by1 z applicable1 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! diagnosis-relat$ gr\p1 ! national drug code1 or o!r id5tifi] us$ or approv$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 7ii7 ,! gross *>ge1 z applicable1 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 ,= ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t & outpati5t dep>tm5t sett+s-- 7,i7 ! disc\nt$ ca% price1 z applicable1 express$ z a doll> am\nt2 or 7,,ii7 9 ! case no disc\nt$ ca% price is available = su* item or s]vice1 ! m$ian ca% price *>g$ by ! hospital 7n includ+ *>ity c>e7 to self-pay individuals = su* item or s]vice :5 provid$ 9 su* sett+s = ! previ\s ?ree ye>s1 express$ z a doll> am\nt4 7iv7 ,) 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 policy t includes1 if applicable1 any slid+ scale paym5t /ructure employ$ = det]m9+ prices4 7v7 ,! pay]-specific negotiat$ *>ges1 z applicable1 cle>ly associat$ ) ! "n ( ! ?ird p>ty pay] & plan & express$ z a doll> am\nt1 t apply to ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 7vi7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges1 z applicable1 = ea* su* item or s]vice1 n includ+ any su* *>ge t is #j4 7vii7 ,any o!r additional in=mation ! ,secret>y may require 79 consultation ) /akehold]s7 = ! 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$ 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-- 7i7 %all1 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 =mat 7or a successor te*nology specifi$ by ! ,secret>y72 7ii7 may be simil> to any template made available by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices z ( ! date ( ! enactm5t ( ?is subp>agraph2 7iii7 %all meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges & prices2 & 7iv7 %all be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#c7 ,monitor+ compliance ,! ,secret>y %all e/abli% processes to monitor & assess specifi$ hospitals' compliance ) ?is subsection4 ,su* processes %all include processes relat+ to ! foll[+3 7,a7 ,! evaluation & analysis ( compla9ts made by individuals or o!r entities relat+ to su* hospitals' compliance ) ?is subsection4 7,b7 ,! use ( audits to ensure su* hospitals' compliance ) ?is subsection4 7,c7 ,! obta9+ ( additional in=mation f su* hospitals to det]m9e su* hospitals' compliance ) ?is subsection 7z det]m9$ appropriate by ! ,secret>y74 7#d7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( a specifi$ hospital t fails to comply ) ! requirem5ts ( ?is subsection-- 7i7 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]m9ation 7:i* may include1 z det]m9$ appropriate by ! ,secret>y1 a reque/ = a corrective action plan 7to be submitt$ n lat] ?an #de days aft] su* reque/ is made7 to comply ) su* requirem5ts72 & 7ii7 9 ! case ( a hospital t does n receive a reque/ = a corrective action plan z "p ( a notification submitt$ by ! ,secret>y "u clause 7i7-- 7,i7 ! ,secret>y %all1 n lat] ?an #fj days aft] su* notification is s5t1 det]m9e :e!r su* hospital is 9 compliance ) su* requirem5ts2 & 7,,ii7 if ! ,secret>y det]m9es "u subclause 7,i7 t su* hospital is n 9 compliance ) su* requirem5ts1 ! ,secret>y %all ei!r-- 7aa7 submit to su* hospital a reque/ = a corrective action plan 7to be submitt$ n lat] ?an #de days aft] su* reque/ is made7 to comply ) su* requirem5ts2 or 7bb7 if ! ,secret>y det]m9es t su* hospital has n tak5 mean+ful actions to come into compliance s9ce su* notification 0 s5t1 impose a civil monet>y p5alty 9 accordance ) subp>agraph 7,b74 7,b7 ,civil monet>y p5alty 7i7 ,9 g5]al ,subject to clause 7vii71 9 addition to any o!r en=cem5t actions or p5alties t may apply "u ano!r provision ( ,f$]al law1 a specifi$ hospital t has receiv$ a reque/ = a corrective action plan "u clause 7i7 or 7ii7 ( subp>agraph 7,a7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* reque/ is made 7or1 if su* hospital has submitt$ su* a corrective action plan n lat] ?an #de days aft] ! date su* reque/ 0 made1 by ! date t is #ij days aft] ! date ( ! submission ( su* corrective action plan71 & a specifi$ hospital ) respect to :i* ! ,secret>y has made a det]m9ation describ$ 9 clause 7ii77,,ii77bb7 ( su* subp>agraph1 %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$-- 7,i7 9 ! case ( a specifi$ hospital ) #cj or few] b$s1 #cjj p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #djj p] day72 7,,ii7 9 ! case ( a specifi$ 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 specifi$ hospital ) m ?an #ajj b$s b few] ?an #bja b$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 specifi$ hospital ) m ?an #bjj 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 specifi$ 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 #bjbi or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase-- 7,i7 ! limitation on ! p] day am\nt ( any p5alty applicable to a specifi$ hospital "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 ! am\nts specifi$ 9 clause 7iii77,,ii74 7iii7 ,p]si/5t noncompliance 7,i7 ,9 g5]al ,9 ! case ( a specifi$ hospital 7o!r ?an a specifi$ hospital ) #cj or few] b$s7 t ! ,secret>y has det]m9$ to be kn[+ly & willfully noncompliant ) ! provisions ( ?is subsection = two or m #f-mon? p]iods dur+ any #c-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 specifi$ 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$s1 & am\nt t is n less ?an #e1jjj1jjj & n m ?an #aj1jjj1jjj4 7iv7 ,au?ority to waive or r$uce p5alty 7,i7 ,hospitals locat$ 9 rural or und]s]v$ areas 7aa7 ,9 g5]al ,subject to item 7bb71 ! ,secret>y may waive any p5alty1 or r$uce any p5alty by n m ?an #ge p]c5t1 o!rwise applicable "u ?is subp>agraph ) respect to a specifi$ hospital locat$ 9 a rural or und]s]v$ area if ! ,secret>y c]tifies t imposition ( su* p5alty w\ld result 9 an imm$iate ?reat to access to c>e = individuals 9 ! s]vice area ( su* hospital4 7bb7 ,limitation on application ,! ,secret>y may n elect to waive a p5alty "u item 7aa7 ) respect to a specifi$ hospital m ?an once 9 a #f-ye> p]iod & may n elect to r$uce su* a p5alty ) respect to su* a hospital m ?an once 9 su* a p]iod4 ,no?+ 9 ! prec$+ s5t5ce %all be con/ru$ z prohibit+ ! ,secret>y f bo? waiv+ & r$uc+ a p5alty ) respect to a specifi$ hospital dur+ a #f-ye> p]iod4 7,,ii7 ,r$uction if he>+ waiv$ ,! ,secret>y may r$uce any p5alty o!rwise applicable "u ?is subp>agraph 7z r$uc$1 if applicable1 "u subclause 7,i77 by n m ?an #ce p]c5t if ! specifi$ hospital t is ! subject ( su* p5alty agrees to waive any "r ( su* hospital to a he>+ be=e an adm9i/rative law judge ) respect to ! imposition ( su* p5alty4 7v7 ,h>d%ip exemption ,not)/&+ any limit on ! waiv] or r$uction ( a p5alty "u clause 7iv71 ! ,secret>y may waive any p5alty ) respect to a specifi$ hospital on a case-by-case basis if ! ,secret>y det]m9es t a circum/ance exi/s int]f]+ ) su* hospital's ability to comply ) ! provisions ( ?is subsection 7su* z a natural disa/] 7z def9$ 9 section #fjb7;a7 ( ! ,rob]t ,t4 ,/af=d ,disa/] ,relief & ,em]g5cy ,assi/ance ,act71 a public heal? em]g5cy1 or o!r simil> or unexpect$ cata/rophe or simil> situation74 7vi7 ,provision ( te*nical assi/ance ,! ,secret>y %all1 to ! ext5t practicable1 provide te*nical assi/ance relat+ to compliance ) ! provisions ( ?is subsection to specifi$ hospitals reque/+ su* assi/ance4 7vii7 ,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 7viii7 ,nonduplication ( c]ta9 p5alties 7,i7 ,9 g5]al ,! ,secret>y may n subject a specifi$ hospital to a civil monet>y p5alty "u ?is subp>agraph ) respect to noncompliance ) ! provisions ( ?is subsection = a p]iod if ! ,secret>y has impos$ a civil monet>y p5alty on su* hospital "u section #bgah7;f7 ( ! ,public ,heal? ,s]vice ,act = failure to comply ) ! provisions ( su* section = su* p]iod4 7,,ii7 ,prioritization ,9 ! case ( a hospital t ! ,secret>y det]m9es to be 9 violation ( ! provisions ( ?is subsection & ( section #bgah7;f7 ( ! ,public ,heal? ,s]vice ,act1 ! ,secret>y %all impose p5alties z prescrib$ 9 su* section #bgah7;f7 9 lieu ( any p5alties prescrib$ 9 ?is subsection4 7,c7 ,publication ( hospital price transp>5cy in=mation ,beg9n+ on ,janu>y #a1 #bjbh1 ! ,secret>y %all make publicly available on ! public website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices in=mation ) respect to compliance ) ! requirem5ts ( ?is subsection & en=cem5t activities und]tak5 by ! ,secret>y "u ?is subsection4 ,su* in=mation %all be updat$ 9 real "t 7if practicable7 & include-- 7i7 ! numb] ( reviews ( compliance ) ?is subsection und]tak5 by ! ,secret>y2 7ii7 ! numb] ( notifications describ$ 9 subp>agraph 7,a77i7 s5t by ! ,secret>y2 7iii7 ! id5tity ( ea* specifi$ hospital t 0 s5t su* a notification & a description ( ! nature ( su* hospital's noncompliance ) ?is subsection2 7iv7 ! am\nt ( any civil monet>y p5alty impos$ on su* hospital "u subp>agraph 7,b72 7v7 :e!r su* hospital subsequ5tly came into compliance ) ?is subsection2 7vi7 any waiv]s or r$uctions ( p5alties made pursuant to a c]tification by ! ,secret>y "u subp>agraph 7,b77iv71 includ+-- 7,i7 ! "n ( any specifi$ hospital t receiv$ su* a waiv] or r$uction2 7,,ii7 ! doll> am\nt ( ea* su* p5alty s waiv$ or r$uc$2 & 7,,iii7 ! rationale = ! grant+ ( ea* su* waiv] or r$uction1 b only to ! ext5t t su* rationale does n make public comm]cially s5sitive in=mation2 & 7vii7 any o!r in=mation z det]m9$ by ! ,secret>y4 7b7 ,ensur+ accessibility ?r\gh implem5tation ,9 implem5t+ ?is section1 ! ,secret>y %all ?r\gh rulemak+ ensure t a hospital mak+ public *>ges & prices pursuant to ?is section takes reasonable /eps 7z specifi$ by ! ,secret>y7 to ensure ! accessibility ( su* *>ges & in=mation to individuals ) limit$ ,engli% pr(ici5cy4 ,su* /eps may include ! hospital's provision ( int]pretation s]vices or ! hospital's provision ( translations ( *>ges & in=mation4 7c7 ,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 = an item or s]vice4 7#b7 ,gross *>ge ,! t]m gross *>ge means ! *>ge = an individual item or s]vice t is reflect$ on a specifi$ hospital's *>gema/] or provid] ( s]vice or suppli]'s1 z applicable1 *>gema/] 7or simil> li/ ( prices71 abs5t any disc\nts4 7#c7 ,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#d7 ,%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#e7 ,specifi$ hospital ,! t]m specifi$ hospital means a hospital 7z def9$ 9 section #ahfa7;e771 a critical access hospital 7z def9$ 9 section #ahfa7mmm77#a771 or a rural em]g5cy hospital 7z def9$ 9 section #ahfa7kkk774 7#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 4 7#b7 ,rule ( con/ruction ,no?+ 9 ! am5dm5ts made by ?is subsection may be con/ru$ to imp$e1 prohibit1 or prev5t ! ,secret>y ( ,heal? & ,human ,s]vices f implem5t+1 execut+1 c>ry+ out1 or en=c+ ! requirem5ts ( section #bgah7;f7 ( ! ,public ,heal? ,s]vice ,act4 7b7 ,,phsa 7#a7 ,9 g5]al ,section #bgah ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7f7 ,hospital transp>5cy requirem5t 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbh1 ea* hospital op]at+ )9 ! ,unit$ ,/ates 7includ+ a specifi$ hospital 7z def9$ 9 section #ahii;,d ( ! ,social ,security ,act77 %all comply ) ! price transp>5cy requirem5t describ$ 9 p>agraph 7#b74 7#b7 ,requirem5t describ$ 7,a7 ,9 g5]al ,= purposes ( p>agraph 7#a71 ! price transp>5cy requirem5t describ$ 9 ?is p>agraph is1 ) respect to a hospital1 t su* hospital1 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u subp>agraph 7,c71 compile & make public 7)\t subscription & free ( *>ge7 = ea* ye>-- 7i7 all ( ! hospital's /&>d *>ges 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = ea* item & s]vice furni%$ by su* hospital2 7ii7 in=mation 9 a consum]-fri5dly =mat 7z specifi$ by ! ,secret>y7-- 7,i7 on ! hospital's prices 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = z _m ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vices t are furni%$ by ! hospital1 & z _m additional hospital-select$ %oppable s]vices 7or all su* additional s]vices1 if su* hospital furni%es few] ?an #cjj %oppable s]vices7 z may be necess>y = a comb9$ total ( at lea/ #cjj %oppable s]vices2 & 7,,ii7 t includes1 ) respect to ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is n furni%$ by ! hospital1 an indication t su* s]vice is n s furni%$2 7iii7 ea* type #b national provid] id5tifi] associat$ ) ! hospital or a unit ( ! hospital2 & 7iv7 an atte/ation t all in=mation made public pursuant to ?is subp>agraph is complete & accurate4 7,b7 ,in=mation describ$ ,= purposes ( subp>agraph 7,a71 ! in=mation describ$ 9 ?is subp>agraph is1 ) respect to /&>d *>ges & prices1 z applicable1 made public by a hospital1 ! foll[+3 7i7 ,a pla9 language description 7z specifi$ by ! ,secret>y7 ( ea* item or s]vice1 accompani$ by1 z applicable1 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! diagnosis-relat$ gr\p1 ! national drug code1 curr5t proc$ure t]m9ology codes1 or o!r id5tifi] us$ or approv$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 7ii7 ,! gross *>ge1 z applicable1 express$ z a doll> am\nt 7z specifi$ by ! ,secret>y71 = ea* su* item or s]vice1 :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 7iii7 ,= ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t & outpati5t dep>tm5t sett+s-- 7,i7 ! disc\nt$ ca% price1 z applicable1 express$ z a doll> am\nt2 or 7,,ii7 9 ! case no disc\nt$ ca% price is available = su* item or s]vice1 ! m$ian ca% price *>g$ by ! hospital 7n includ+ *>ity c>e7 to self-pay individuals = su* item or s]vice :5 provid$ 9 su* sett+s = ! previ\s ?ree ye>s1 express$ z a doll> am\nt4 7iv7 ,) 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 policy t includes1 if applicable1 any slid+ scale paym5t /ructure employ$ = det]m9+ prices4 7v7 ,! pay]-specific negotiat$ *>ges1 z applicable1 cle>ly associat$ ) ! "n ( ! ?ird p>ty pay] & plan & express$ z a doll> am\nt1 t apply to ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 7vi7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges1 z applicable1 = ea* su* item or s]vice1 n includ+ any su* *>ge t is #j4 7vii7 ,any o!r additional in=mation ! ,secret>y may require 79 consultation ) /akehold]s7 = ! 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 = 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-- 7i7 %all1 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 =mat 7or a successor te*nology specifi$ by ! ,secret>y72 7ii7 may be simil> to any template made available by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices z ( ! date ( ! enactm5t ( ?is subp>agraph2 7iii7 %all meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges & prices2 & 7iv7 %all be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#c7 ,monitor+ compliance ,! ,secret>y %all e/abli% processes to monitor & assess specifi$ hospitals' compliance ) ?is subsection4 ,su* processes %all include processes relat+ to ! foll[+3 7,a7 ,! evaluation & analysis ( compla9ts made by individuals or o!r entities relat+ to su* hospitals' compliance ) ?is subsection4 7,b7 ,! use ( audits to ensure su* hospitals' compliance ) ?is subsection4 7,c7 ,! obta9+ ( additional in=mation f su* hospitals to det]m9e su* hospitals' compliance ) ?is subsection 7z det]m9$ appropriate by ! ,secret>y74 7#d7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( a hospital t fails to comply ) ! requirem5ts ( ?is subsection-- 7i7 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]m9ation 7:i* may include1 z det]m9$ appropriate by ! ,secret>y1 a reque/ = a corrective action plan 7to be submitt$ n lat] ?an #de days aft] su* reque/ is made7 to comply ) su* requirem5ts72 & 7ii7 9 ! case ( a hospital t does n receive a reque/ = a corrective action plan z "p ( a notification submitt$ by ! ,secret>y "u clause 7i7-- 7,i7 ! ,secret>y %all1 n lat] ?an #fj days aft] su* notification is s5t1 det]m9e :e!r su* hospital is 9 compliance ) su* requirem5ts2 & 7,,ii7 if ! ,secret>y det]m9es "u subclause 7,i7 t su* hospital is n 9 compliance ) su* requirem5ts1 ! ,secret>y %all ei!r-- 7aa7 submit to su* hospital a reque/ = a corrective action plan 7to be submitt$ n lat] ?an #de days aft] su* reque/ is made7 to comply ) su* requirem5ts2 or 7bb7 if ! ,secret>y det]m9es t su* hospital has n tak5 mean+ful actions to come into compliance s9ce su* notification 0 s5t1 impose a civil monet>y p5alty 9 accordance ) subp>agraph 7,b74 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 ( ,f$]al law1 a hospital t has receiv$ a reque/ = a corrective action plan "u clause 7i7 or 7ii7 ( subp>agraph 7,a7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* reque/ is made 7or1 if su* hospital has submitt$ su* a corrective action plan n lat] ?an #de days aft] ! date su* reque/ 0 made1 by ! date t is #ij days aft] ! date ( ! submission ( su* corrective action plan71 & a hospital ) respect to :i* ! ,secret>y has made a det]m9ation describ$ 9 clause 7ii77,,ii77bb7 ( su* subp>agraph1 %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] 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 #djj p] b$ p] day72 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$s b few] ?an #bja b$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 #bjj 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 #bjbi 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 ! am\nts specifi$ 9 clause 7iii77,,ii74 7iii7 ,p]si/5t noncompliance 7,i7 ,9 g5]al ,9 ! case ( a hospital 7o!r ?an a hospital ) #cj or few] b$s7 t ! ,secret>y has det]m9$ to be kn[+ly & willfully noncompliant ) ! provisions ( ?is subsection = two or m #f-mon? p]iods dur+ any #c-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$s1 & am\nt t is n less ?an #e1jjj1jjj & n m ?an #aj1jjj1jjj4 7iv7 ,au?ority to waive or r$uce p5alty 7,i7 ,hospitals locat$ 9 rural or und]s]v$ areas 7aa7 ,9 g5]al ,subject to item 7bb71 ! ,secret>y may waive any p5alty1 or r$uce any p5alty by n m ?an #ge p]c5t1 o!rwise applicable "u ?is subp>agraph ) respect to a hospital locat$ 9 a rural or und]s]v$ area if ! ,secret>y c]tifies t imposition ( su* p5alty w\ld result 9 an imm$iate ?reat to access to c>e = individuals 9 ! s]vice area ( su* hospital4 7bb7 ,limitation on application ,! ,secret>y may n elect to waive a p5alty "u item 7aa7 ) respect to a hospital m ?an once 9 a #f-ye> p]iod & may n elect to r$uce su* a p5alty ) respect to su* a hospital m ?an once 9 su* a p]iod4 ,no?+ 9 ! prec$+ s5t5ce %all be con/ru$ z prohibit+ ! ,secret>y f bo? waiv+ & r$uc+ a p5alty ) respect to a hospital dur+ a #f-ye> p]iod4 7,,ii7 ,r$uction if he>+ waiv$ ,! ,secret>y may r$uce any p5alty o!rwise applicable "u ?is subp>agraph 7z r$uc$1 if applicable1 "u subclause 7,i77 by n m ?an #ce p]c5t if ! specifi$ hospital t is subject ( su* p5alty agrees to waive any "r ( su* hospital to a he>+ be=e an adm9i/rative law judge ) respect to ! imposition ( su* p5alty4 7v7 ,provision ( te*nical assi/ance ,! ,secret>y %all1 to ! ext5t practicable1 provide te*nical assi/ance relat+ to compliance ) ! provisions ( ?is subsection to hospitals reque/+ su* assi/ance4 7vi7 ,h>d%ip exemption ,not)/&+ any limit on ! waiv] or r$uction ( a p5alty "u clause 7iv71 ! ,secret>y may waive any p5alty ) respect to a hospital on a case-by-case basis if ! ,secret>y det]m9es t a circum/ance exi/s int]f]+ ) su* hospital's ability to comply ) ! provisions ( ?is subsection 7su* z a natural disa/] 7z def9$ 9 section #fjb7;a7 ( ! ,rob]t ,t4 ,/af=d ,disa/] ,relief & ,em]g5cy ,assi/ance ,act71 a public heal? em]g5cy1 or o!r simil> or unexpect$ cata/rophe or simil> situation74 7vii7 ,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 7viii7 ,nonduplication ( p5alties 7,i7 ,9 g5]al ,! ,secret>y may n subject a hospital to a civil monet>y p5alty "u ?is subp>agraph ) respect to noncompliance ) ! provisions ( ?is subsection = a p]iod if ! ,secret>y has impos$ a civil monet>y p5alty on su* hospital "u section #ahii;,d ( ! ,social ,security ,act = failure to comply ) ! provisions ( su* section = su* p]iod4 7,,ii7 ,prioritization ,9 ! case ( a hospital t ! ,secret>y det]m9es to be 9 violation ( ! provisions ( ?is subsection & ( section #ahii;,d ( ! ,social ,security ,act1 ! ,secret>y %all impose p5alties z prescrib$ 9 ?is subsection 9 lieu ( any p5alties prescrib$ 9 su* section #ahii;,d4 7,c7 ,publication ( hospital price transp>5cy in=mation ,beg9n+ on ,janu>y #a1 #bjbh1 ! ,secret>y %all make publicly available on ! public website ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices in=mation ) respect to compliance ) ! requirem5ts ( ?is subsection & en=cem5t activities und]tak5 by ! ,secret>y "u ?is subsection4 ,su* in=mation %all be updat$ 9 real "t 7if practicable7 & include-- 7i7 ! numb] ( reviews ( compliance ) ?is subsection und]tak5 by ! ,secret>y2 7ii7 ! numb] ( notifications describ$ 9 subp>agraph 7,a77i7 s5t by ! ,secret>y2 7iii7 ! id5tity ( ea* hospital t 0 s5t su* a notification & a description ( ! nature ( su* hospital's noncompliance ) ?is subsection2 7iv7 ! am\nt ( any civil monet>y p5alty impos$ on su* hospital "u subp>agraph 7,b72 7v7 :e!r su* hospital subsequ5tly came into compliance ) ?is subsection2 7vi7 any waiv]s or r$uctions ( p5alties made pursuant to a c]tification by ! ,secret>y "u subp>agraph 7,b77iv71 includ+-- 7,i7 ! "n ( any hospital t receiv$ su* a waiv] or r$uction2 7,,ii7 ! doll> am\nt ( ea* su* p5alty s waiv$ or r$uc$2 & 7,,iii7 ! rationale = ! grant+ ( ea* su* waiv] or r$uction1 b only to ! ext5t t su* rationale does n make public comm]cially s5sitive in=mation2 & 7vii7 any o!r in=mation z det]m9$ by ! ,secret>y4 7#e7 ,ensur+ accessibility ?r\gh implem5tation ,9 implem5t+ ?is subsection1 ! ,secret>y %all ?r\gh rulemak+ ensure t a hospital mak+ public *>ges & prices pursuant to ?is section takes reasonable /eps 7z specifi$ by ! ,secret>y7 to ensure ! accessibility ( su* *>ges & in=mation to individuals ) limit$ ,engli% pr(ici5cy4 ,su* /eps may include ! hospital's provision ( int]pretation s]vices or ! hospital's provision ( translations ( *>ges & in=mation4 7#f7 ,def9itions ,= purposes ( ?is subsection3 7,a7 ,disc\nt$ ca% price ,! t]m disc\nt$ ca% price means ! *>ge t applies to an individual :o pays ca%1 or ca% equival5t1 = a hospital-furni%$ item or s]vice4 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 ,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,d7 ,%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,e7 ,?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 4 7#b7 ,con=m+ am5dm5ts ,section #bgah ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7 is am5d$-- 7,a7 9 subsection 7b77#c71 by ins]t+ 7o!r ?an ! provisions ( subsection 7f77 aft] ?is section2 & 7,b7 9 subsection 7e71 by add+ at ! end ! foll[+ new s5t5ce3 ,! prec$+ provisions ( ?is subsection %all n apply beg9n+ on ,janu>y #a1 #bjbh44 7#c7 ,rule ( con/ruction ,no?+ 9 ! am5dm5ts made by ?is subsection may be con/ru$ to imp$e1 prohibit1 or prev5t ! ,secret>y ( ,heal? & ,human ,s]vices f implem5t+1 execut+1 c>ry+ out1 or en=c+ ! requirem5ts ( section #ahii;,d ( ! ,social ,security ,act4 #c4 ,cl9ical diagno/ic laboratory te/ price transp>5cy ,section #ahdf ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#b7 is am5d$-- 7#a7 9 ! head]1 by ins]t+ & additional requirem5ts aft] sanctions2 & 7#b7 by add+ at ! end ! foll[+ new subsection3 7c7 ,price transp>5cy requirem5t 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbh1 any applicable laboratory t receives paym5t "u ?is title = furni%+ any specifi$ cl9ical diagno/ic laboratory te/ "u ?is title %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 annually2 & 7,c7 include on ! website describ$ 9 subp>agraph 7,a7 an atte/ation t all su* in=mation is complete & accurate4 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 ! disc\nt$ ca% price = su* te/ 7or1 if no su* price exi/s1 ! gross *>ge = su* te/74 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-- 7,a7 may be simil> to any template made available by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices 7z describ$ 9 section #ahii;,d7a77#b77;,c77ii772 7,b7 %all meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* in=mation2 & 7,c7 %all be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#d7 ,inclusion ( ancill>y s]vices ,any price or *>ge = a specifi$ cl9ical diagno/ic laboratory te/ furni%$ by an applicable laboratory made publicly available 9 accordance ) p>agraph 7#a7 %all include ! price or *>ge 7z applicable7 = any ancill>y item or s]vice 7su* z specim5 collection s]vices7 t w\ld normally 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 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 has ! mean+ giv5 su* t]m 9 section #dad4ejb1 ( 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-- 7i7 a specifi$ hospital pursuant to section #ahii;,d2 7ii7 a hospital pursuant to section #bgah7;f7 ( ! ,public ,heal? ,s]vice ,act2 or 7iii7 an ambulatory surgical c5t] pursuant to section #ahcd7;bb74 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/] 7or simil> li/ ( prices71 abs5t any disc\nts4 7,d7 ,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 section #ahii;,d7a77#b77;,a77ii77,i771 o!r ?an an advanc$ diagno/ic laboratory te/ 7z def9$ 9 section #ahcd;,a7d77#e774 7,e7 ,specifi$ hospital ,! t]m specifi$ hospital has ! mean+ giv5 su* t]m 9 section #ahii;,d4 4 #d4 ,imag+ price transp>5cy ,section #ahii;,d ( ! ,social ,security ,act1 z add$ by section #b1 is am5d$-- 7#a7 by r$esignat+ subsections 7b7 & 7c7 z subsections 7c7 & 7d71 respectively2 7#b7 by ins]t+ aft] subsection 7a7 ! foll[+ new subsection3 7b7 ,imag+ s]vices price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbh1 ea* provid] ( s]vices & suppli] t receives paym5t "u ?is title = furni%+ 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 specifi$ hospital pursuant to subsection 7a71 a hospital pursuant to section #bgah7;f7 ( ! ,public ,heal? ,s]vice ,act1 or an ambulatory surgical c5t] pursuant to section #ahcd7;bb71 %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 annually2 & 7,c7 include on ! website describ$ 9 subp>agraph 7,a7 an atte/ation t all su* in=mation is complete & accurate4 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 ! disc\nt$ ca% price = su* s]vice 7or1 if no su* price exi/s1 ! gross *>ge = su* s]vice74 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-- 7,a7 may be simil> to any template made available by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices 7z describ$ 9 subsection 7a77#b77;,c77ii772 7,b7 %all meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* in=mation2 & 7,c7 %all be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#d7 ,monitor+ compliance ,! ,secret>y %all1 ?r\gh notice & comm5t rulemak+1 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 #bjbi or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! am\nt ( ! civil monet>y p5alty "u subp>agraph 7,a77iii74 7,c7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is p>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7,d7 ,au?ority to waive or r$uce p5alty 7i7 ,9 g5]al ,subject to clause 7ii71 ! ,secret>y may waive or r$uce any p5alty o!rwise applicable ) respect to a provid] ( s]vices or suppli] "u ?is subp>agraph if ! ,secret>y det]m9es t imposition ( su* p5alty w\ld result 9 an imm$iate ?reat to access to c>e = individuals 9 ! s]vice area ( su* provid] or suppli]4 7ii7 ,limitation ,! ,secret>y may n elect to waive or r$uce a p5alty "u clause 7i7 ) respect to a specific provid] ( s]vices or suppli] m ?an #c times 9 a #aj ye> p]iod4 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 2 & 7#c7 9 subsection 7d71 z s r$esignat$ by p>agraph 7#a71 by add+ at ! end ! foll[+ new p>agraph3 7#e7 ,specifi$ imag+ s]vice ! t]m specifi$ imag+ s]vice means an imag+ s]vice t is includ$ on ! li/ ( ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vices 7z describ$ 9 subsection 7a77#b77;,a77ii77,i774 4 #e4 ,ambulatory surgical c5t] price transp>5cy ,section #ahcd ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7bb7 ,ambulatory surgical c5t] price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbh1 ea* ambulatory surgical c5t] t receives paym5t "u ?is title = furni%+ items & s]vices %all comply ) ! price transp>5cy requirem5t describ$ 9 p>agraph 7#b74 7#b7 ,requirem5t describ$ 7,a7 ,9 g5]al ,= purposes ( p>agraph 7#a71 ! price transp>5cy requirem5t describ$ 9 ?is subsection is1 ) respect to an ambulatory surgical c5t]1 t su* surgical c5t] 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u subp>agraph 7,c71 compile & make public 7)\t subscription & free ( *>ge71 = ea* ye>-- 7i7 all ( ! 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 7z specifi$ by ! ,secret>y7 t are furni%$ by su* surgical c5t]1 & z _m additional ambulatory surgical c5t]-select$ %oppable s]vices 7or all su* additional s]vices1 if su* surgical c5t] furni%es few] ?an #cjj %oppable s]vices7 z may be necess>y = a comb9$ total ( at lea/ #cjj %oppable s]vices2 7iii7 ) respect to ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is n furni%$ by ! ambulatory surgical c5t]1 an indication t su* s]vice is n s furni%$2 & 7iv7 an atte/ation t all /&>d *>ges describ$ 9 clause 7i71 in=mation describ$ 9 clause 7ii71 & indications describ$ 9 clause 7iii7 are complete & accurate4 7,b7 ,in=mation describ$ ,= purposes ( subp>agraph 7,a71 ! in=mation describ$ 9 ?is subp>agraph is1 ) respect to /&>d *>ges & prices1 z applicable1 made public by an ambulatory surgical c5t]1 ! foll[+3 7i7 ,a pla9 language description 7z specifi$ by ! ,secret>y7 ( ea* item or s]vice1 accompani$ by1 z applicable1 ! ,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 z applicable1 express$ z a doll> am\nt1 = ea* su* item or s]vice4 7iii7 ,= ea* su* item or s]vice-- 7,i7 ! disc\nt$ ca% price1 z applicable1 express$ z a doll> am\nt2 or 7,,ii7 9 ! case no disc\nt$ ca% price is available = an item or s]vice1 ! m$ian ca% price *>g$ to self-pay individuals = su* item or s]vice = ! previ\s ?ree ye>s1 express$ z a doll> am\nt4 7iv7 ,any o!r additional in=mation ! ,secret>y may require 79 consultation ) /akehold]s7 = ! 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 = 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-- 7i7 %all1 9 ! case ( su* *>ges made public by an ambulatory surgical c5t]1 ensure t su* *>ges are made available 9 a ma*9e-readable =mat 7or successor te*nology72 7ii7 may be simil> to any template made available by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices 7z describ$ 9 section #ahii;,d7a77#b77;,c77ii772 7iii7 %all meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges & prices2 & 7iv7 %all be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#c7 ,monitor+ compliance ,! ,secret>y %all e/abli% processes to monitor & assess ambulatory surgical c5t]s' compliance ) ?is subsection4 ,su* processes %all include processes relat+ to ! foll[+3 7,a7 ,! evaluation & analysis ( compla9ts made by individuals or o!r entities relat+ to su* c5t]s' compliance ) ?is subsection4 7,b7 ,! use ( audits to ensure su* c5t]s' compliance ) ?is subsection4 7,c7 ,! obta9+ ( additional in=mation f su* c5t]s to det]m9e su* c5t]s' compliance ) ?is subsection 7z det]m9$ appropriate by ! ,secret>y74 7#d7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( an ambulatory surgical c5t] t fails to comply ) ! requirem5ts ( ?is subsection-- 7i7 ! ,secret>y %all notify su* ambulatory surgical c5t] ( su* failure n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s2 & 7ii7 ^u reque/ ( ! ,secret>y1 ! ambulatory surgical c5t] %all submit to ! ,secret>y1 n lat] ?an #de days aft] ! date ( su* reque/1 a corrective action plan to comply ) su* requirem5ts4 7,b7 ,civil monet>y p5alty 7i7 ,9 g5]al ,9 addition to any o!r en=cem5t actions or p5alties t may apply "u ano!r provision ( ,f$]al law1 an ambulatory surgical c5t] t has receiv$ a notification "u subp>agraph 7,a77i7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* notification 7or1 9 ! case ( an ambulatory surgical c5t] t has submitt$ a corrective action plan describ$ 9 subp>agraph 7,a77ii7 9 response to a reque/ s describ$ & has fail$ to comply ) su* requirem5ts 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* c5t] 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 #bjbi or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! limitation on ! p] day am\nt ( any p5alty applicable to an ambulatory surgical c5t] "u clause 7i74 7iii7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is subp>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7iv7 ,au?ority to waive or r$uce p5alty 7,i7 ,c5t]s locat$ 9 rural or und]s]v$ areas 7aa7 ,9 g5]al ,subject to item 7bb71 ! ,secret>y may waive any p5alty1 or r$uce any p5alty by n m ?an #ge p]c5t1 o!rwise applicable "u ?is subp>agraph ) respect to an ambulatory surgical c5t] locat$ 9 a rural or und]s]v$ area if ! ,secret>y c]tifies t imposition ( su* p5alty w\ld result 9 an imm$iate ?reat to access to c>e = individuals 9 ! s]vice area ( su* c5t]4 7bb7 ,limitation on application ,! ,secret>y may n elect to waive a p5alty "u item 7aa7 ) respect to an ambulatory surgical c5t] m ?an once 9 a #f-ye> p]iod & may n elect to r$uce su* a p5alty ) respect to su* a c5t] m ?an once 9 su* a p]iod4 ,no?+ 9 ! prec$+ s5t5ce %all be con/ru$ z prohibit+ ! ,secret>y f bo? waiv+ & r$uc+ a p5alty ) respect to an ambulatory surgical c5t] dur+ a #f-ye> p]iod4 7,,ii7 ,r$uction if he>+ waiv$ ,! ,secret>y may r$uce any p5alty o!rwise applicable "u ?is subp>agraph 7z r$uc$1 if applicable1 "u subclause 7,i77 by n m ?an #ce p]c5t if ! ambulatory surgical c5t] t is ! subject ( su* p5alty agrees to waive any "r ( su* c5t] to a he>+ be=e an adm9i/rative law judge ) respect to ! imposition ( su* p5alty4 7#e7 ,provision ( te*nical assi/ance ,! ,secret>y %all1 to ! ext5t practicable1 provide te*nical assi/ance relat+ to compliance ) ! provisions ( ?is subsection to ambulatory surgical c5t]s reque/+ su* assi/ance4 7#f7 ,def9itions ,= purposes ( ?is subsection3 7,a7 ,disc\nt$ ca% price ,! t]m disc\nt$ ca% price means ! *>ge t applies to an individual :o pays ca%1 or ca% equival5t1 = an 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 an ambulatory surgical c5t]'s *>gema/]1 abs5t any disc\nts4 7,c7 ,%oppable s]vice ,! t]m %oppable s]vice means a s]vice t c be s*$ul$ by a heal? c>e consum] 9 advance & includes all ancill>y items & s]vices cu/om>ily furni%$ z "p ( su* s]vice4 4 #f4 ,heal? cov]age price transp>5cy 7a7 ,price transp>5cy requirem5ts 7#a7 ,,irc 7,a7 ,9 g5]al ,section #ihai ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7i7 9 ! head]1 by /rik+ ,ma9t5ance ( price comp>ison tool & ins]t+ ,transp>5cy 9 cov]age2 7ii7 by /rik+ ,a gr\p heal? plan & ins]t+ ! foll[+3 7a7 ,ma9t5ance ( price comp>ison tool = plan ye>s be=e #bjbh 7#a7 ,9 g5]al ,a gr\p heal? plan 2 7iii7 9 subsection 7a71 z ins]t$ by clause 7ii71 by add+ at ! end ! foll[+ new p>agraph3 7#b7 ,sunset ,p>agraph 7#a7 %all n apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbh4 2 & 7iv7 by add+ at ! end ! foll[+ new subsections3 7b7 ,co/-%>+ transp>5cy 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbh1 a gr\p heal? plan %all provide a p>ticipant or b5efici>y1 9 a timely mann] ^u reque/ ( ! p>ticipant or b5efici>y1 in=mation on ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 "u ! p>ticipant or b5efici>y's plan t ! p>ticipant or b5efici>y w\ld be responsible = pay+ ) respect to ! furni%+ ( a specific item or s]vice by a provid]4 ,at a m9imum1 su* in=mation %all include ! in=mation specifi$ 9 p>agraph 7#b7 & %all be made available to su* p>ticipant or b5efici>y ?r\gh a self-s]vice tool t meets ! requirem5ts ( p>agraph 7#c7 or1 at ! option ( su* p>ticipant or b5efici>y1 ?r\gh a pap] disclosure or phone or o!r electronic disclosure 7z select$ by su* p>ticipant or b5efici>y & provid$ at no co/ to su* p>ticipant or b5efici>y7 t meets su* requirem5ts z ! ,secret>y may specify4 7#b7 ,specifi$ in=mation ,= purposes ( p>agraph 7#a71 ! in=mation specifi$ 9 ?is p>agraph is1 ) respect to an item or s]vice = :i* b5efits are available "u a gr\p heal? plan furni%$ by a heal? c>e provid] to a p>ticipant or b5efici>y ( su* plan1 ! foll[+3 7,a7 ,if su* provid] is a p>ticipat+ provid] ) respect to su* item or s]vice1 ! 9-network rate = su* item or s]vice4 7,b7 ,if su* provid] is n a p>ticipat+ provid] ) respect to su* item or s]vice1 ! maximum all[$ am\nt or o!r doll> am\nt t su* plan w recognize z paym5t = su* item or s]vice1 along ) a notice t su* p>ticipant or b5efici>y may be liable = additional *>ges4 7,c7 ,! e/imat$ am\nt ( co/ %>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! p>ticipant or b5efici>y w incur = su* item or s]vice 7:i*1 9 ! case su* item or s]vice is to be furni%$ by a provid] describ$ 9 subp>agraph 7,b71 %all be calculat$ us+ ! maximum all[$ am\nt or o!r doll> am\nt describ$ 9 su* subp>agraph74 7,d7 ,! am\nt ! p>ticipant or b5efici>y has already accumulat$ ) respect to any d$uctible or out ( pocket maximum "u ! plan 7brok5 d[n1 9 ! case sep>ate d$uctibles or maximums apply to a p>ticipant & su* p>ticipant's b5efici>ies enroll$ 9 ! plan1 by su* sep>ate d$uctibles or maximums1 9 addition to any cumulative d$uctible or maximum74 7,e7 ,9 ! case su* plan imposes any frequ5cy or volume limitations ) respect to su* item or s]vice 7exclud+ m$ical necessity det]m9ations71 ! am\nt t su* p>ticipant or b5efici>y has accru$ t[>ds su* limitation ) respect to su* item or s]vice4 7,f7 ,any prior au?orization1 concurr5t review1 /ep !rapy1 fail fir/1 or simil> requirem5ts applicable to cov]age ( su* item or s]vice "u su* plan4 7,g7 ,any f9ancial inc5tives 7su* z any cr$it1 paym5t1 or o!r b5efit provid$ by su* plan7 available to ! p>ticipant or b5efici>y ) respect to su* item or s]vice furni%$ by su* provid] kn[n at ! "t su* reque/ is made4 7,h7 ,9 ! case su* item or s]vice is an applicable spread price drug disp5s$ by a ph>macy-- 7i7 a specification t su* item or s]vice is su* an applicable spread price drug2 7ii7 ! am\nt ( ! diff]5ce 7if any7 betwe5 ! specifi$ paym5t am\nt = su* drug s disp5s$ by su* ph>macy & ! specifi$ reimbursem5t am\nt = su* drug s disp5s$ by su* ph>macy2 7iii7 a pla9 language /atem5t specifi$ by ! ,secret>y t expla9s ! concept ( spread pric+ & h[ su* item's /atus z su* an applicable spread price drug may impact ! am\nt su* plan pays = su* drug & co/ %>+ am\nts = su* drug describ$ 9 subp>agraph 7,c72 & 7iv7 a pla9 language /atem5t specifi$ by ! ,secret>y in=m+ ! p>ticipant or b5efici>y ( ! p>ticipant's or b5efici>y's ability to obta9 a summ>y docum5t relat+ to drug pric+ in=mation describ$ 9 section #ihbf7;b77#b77;,b77ii74 7#c7 ,self-s]vice tool ,= purposes ( p>agraph 7#a71 a self-s]vice tool e/abli%$ by a gr\p heal? plan meets ! requirem5ts ( ?is p>agraph if su* tool-- 7,a7 is bas$ on an ,int]net website 7or successor te*nology specifi$ by ! ,secret>y72 7,b7 provides = real-"t responses to reque/s describ$ 9 p>agraph 7#a72 7,c7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is timely & accurate at ! "t su* reque/ is made2 7,d7 all[s su* a reque/ to be made ) respect to an item or s]vice furni%$ by-- 7i7 a specific provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7ii7 all provid]s t are p>ticipat+ provid]s ) respect to su* item or s]vice2 or 7iii7 a provid] locat$ 9 a relevant geographic region t is n a p>ticipat+ provid] ) respect to su* item or s]vice2 7,e7 provides t su* a reque/ may be made ) respect to an item or s]vice ?r\gh use ( ! bill+ code = su* item or s]vice or ?r\gh use ( a descriptive t]m = su* item or s]vice2 & 7,f7 meets any o!r requirem5t det]m9$ appropriate by ! ,secret>y1 includ+ requirem5ts to ensure ! accessibility & usability ( in=mation provid$ ?r\gh su* tool4 ,! ,secret>y may require su* tool1 z a condition ( comply+ ) subp>agraph 7,e71 to l9k multiple bill+ codes to a s+le descriptive t]m if ! ,secret>y det]m9es t ! bill+ codes to be s l9k$ correspond to simil> items & s]vices4 7c7 ,rate & paym5t in=mation 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbh1 ea* gr\p heal? plan 7o!r ?an a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act77 %all make available to ! public ! rate & paym5t in=mation describ$ 9 p>agraph 7#b7 9 accordance ) p>agraph 7#c74 7#b7 ,rate & paym5t in=mation describ$ ,= purposes ( p>agraph 7#a71 ! rate & paym5t in=mation describ$ 9 ?is p>agraph is1 ) respect to a gr\p heal? plan1 ! foll[+3 7,a7 ,) respect to ea* item or s]vice 7o!r ?an a drug7 = :i* b5efits are available "u su* plan-- 7i7 ! 9-network rate 7express$ z a doll> am\nt7 9 effect z ( ! date on :i* su* in=mation is made public ) ea* provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7ii7 ) respect to ea* su* provid]1 an indication ( :e!r1 dur+ ! #a-ye> p]iod beg9n+ #ah mon?s be=e ! date su* in=mation is made public1 su* provid] submitt$ a claim = su* item or s]vice to su* plan2 & 7iii7 9 ! case t su* plan provides b5efits = su* item or s]vice only :5 furni%$ by a specific type ( provid]1 a specification ( ea* type ( provid] t may furni% su* item or s]vice "u su* plan2 7,b7 ,) respect to ea* drug 7id5tifi$ by national drug code7 = :i* b5efits are available "u su* plan-- 7i7 ! 9-network rate 7express$ z a doll> am\nt7 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* drug2 7ii7 ! av]age am\nt paid by su* plan 7acc\nt+ =1 9 a mann] det]m9$ appropriate by ! ,secret>y1 rebates1 disc\nts1 price concessions1 & any o!r remun]ation specifi$ by ! ,secret>y7 = su* drug disp5s$ or adm9i/]$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( publication to ea* provid] t 0 a p>ticipat+ provid] ) respect to su* drug1 brok5 d[n by ea* su* provid]1 unless few] ?an #bj claims = su* drug 7 submitt$ to su* plan dur+ su* p]iod2 & 7iii7 9 ! case su* drug is an applicable spread price drug disp5s$ by a ph>macy-- 7,i7 a specification t su* drug is su* an applicable spread price drug2 & 7,,ii7 = ea* ph>macy t has a contractual relation%ip = disp5s+ su* drug "u su* plan1 a specification ( ! diff]5ce 7if any7 betwe5 ! specifi$ paym5t am\nt = su* drug s disp5s$ by su* ph>macy & ! specifi$ reimbursem5t am\nt = su* drug s disp5s$ by su* ph>macy4 7,c7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan1 ! am\nt bill$1 & ! am\nt all[$ by ! plan1 = ea* su* item or s]vice furni%$ dur+ ! #f-mon? p]iod beg9n+ #i mon?s be=e ! date su* in=mation is made public by a provid] t 0 n a p>ticipat+ provid] ) respect to su* item or s]vice1 brok5 d[n by ea* su* provid]1 o!r ?an su* an am\nt ) respect to an item or s]vice furni%$ by a provid] t1 dur+ su* p]iod1 submitt$ few] ?an #aa claims = su* item or s]vice to su* plan4 7#c7 ,mann] ( publication 7,a7 ,9 g5]al ,rate & paym5t in=mation requir$ to be made available "u ?is subsection %all be s made available 9 doll> am\nts ?r\gh sep>ate ma*9e-readable files 7& any successor te*nology1 z applicable1 su* z application programm+ int]face te*nology1 det]m9$ appropriate by ! ,secret>y7 correspond+ to ! in=mation describ$ 9 ea* ( subp>agraphs 7,a7 ?r\gh 7,c7 ( p>agraph 7#b7 t meet su* requirem5ts z specifi$ by ! ,secret>y 7:i* may be s specifi$ ?r\gh subregulatory guidance74 ,su* requirem5ts %all ensure t su* files are limit$ to an appropriate size1 d n include disclosure ( unnecess>y duplicative in=mation conta9$ 9 o!r files made available "u ?is subsection1 are made available 9 a widely available =mat ?r\gh a publicly available website t all[s = in=mation conta9$ 9 su* files to be comp>$ across gr\p heal? plans & gr\p or individual heal? insurance cov]age1 & are accessible to individuals at no co/ & )\t ! ne$ to e/abli% a us] acc\nt or provide o!r cr$5tials4 7,b7 ,tim+ ,rate & paym5t in=mation-- 7i7 describ$ 9 subp>agraph 7,a7 or 7,b7 ( p>agraph 7#b7 %all be made public on a qu>t]ly basis2 & 7ii7 describ$ 9 subp>agraph 7,c7 ( p>agraph 7#b7 %all be made public on a mon?ly basis4 7#d7 ,us] in/ructions ,ea* gr\p heal? plan %all make available to ! public in/ructions writt5 9 pla9 language expla9+ h[ individuals may se>* = in=mation describ$ 9 p>agraph 7#b7 9 files submitt$ 9 accordance ) p>agraph 7#c74 ,! ,secret>y %all develop & publi% ?r\gh subregulatory guidance a template t su* a plan may use 9 develop+ in/ructions = purposes ( ! prec$+ s5t5ce4 7#e7 ,summ>y ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbh1 ea* gr\p heal? plan %all make public a data file1 9 a mann] t ensures t su* file may be easily d[nload$ & read by /&>d spread%eet s(tw>e & t meets su* requirem5ts z e/abli%$ by ! ,secret>y1 conta9+ a summ>y ( all rate & paym5t in=mation made public by su* plan ) respect to su* plan dur+ su* plan ye>4 ,su* file %all include ! foll[+3 7,a7 ,! mean1 m$ian1 & int]qu>tile range ( ! 9-network rate1 & ! am\nt all[$ = an item or s]vice :5 n furni%$ by a p>ticipat+ provid]1 9 effect z ( ! fir/ day ( su* plan ye> = ea* item or s]vice 7id5tifi$ by pay] id5tifi] approv$ or us$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices7 = :i* b5efits are available "u ! plan1 brok5 d[n by ! type ( provid] furni%+ ! item or s]vice & by ! geographic area 9 :i* su* item or s]vice is furni%$4 7,b7 ,tr5ds 9 paym5t rates = su* items & s]vices ov] su* plan ye>1 includ+ an id5tification ( in/ances 9 :i* su* rates h increas$1 decreas$1 or rema9$ ! same4 7,c7 ,! "n ( su* plan1 a description ( ! type ( network ( p>ticipat+ provid]s us$ by su* plan1 & a description ( :e!r su* plan is self-insur$ or fully-insur$4 7,d7 ,= ea* item or s]vice :i* is paid z "p ( a bundl$ or capitat$ rate-- 7i7 a description ( ! =mulae1 pric+ me?odologies1 or o!r in=mation us$ to calculate ! paym5t rate = su* rate2 & 7ii7 a li/ ( ! items & s]vices includ$ 9 su* rate4 7,e7 ,! p]c5tage ( items & s]vices t are paid = on a fee-=-s]vice basis & ! p]c5tage ( items & s]vices t are paid = z "p ( a bundl$ rate1 capitat$ paym5t rate1 or o!r alt]native paym5t model4 7d7 ,atte/ation ,ea* gr\p heal? plan %all annually submit to ! ,secret>y an atte/ation ( su* plan's compliance ) ! provisions ( ?is section4 ,su* atte/ation %all include a l9k to ! website 7or o!r successor te*nology7 :]e rate & paym5t in=mation requir$ to be made public "u subsection 7c7 may be access$4 7e7 ,accessibility ,a gr\p heal? plan %all take reasonable /eps 7z specifi$ by ! ,secret>y7 to ensure t in=mation provid$ 9 response to a reque/ describ$ 9 subsection 7b71 & rate & paym5t in=mation made public "u subsection 7c71 is provid$ 9 pla91 easily und]/&able language & t int]pretation1 translations1 & assi/ive s]vices are provid$ to ^? ) limit$ ,engli% pr(ici5cy & ^? ) disabilities4 7f7 ,,pbm disclosure ( applicable spread price drugs ,an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( a gr\p heal? plan %all disclose to su* plan1 at su* "t & 9 su* mann] z specifi$ by ! ,secret>y to ensure t in=mation provid$ "u subsection 7b7 & rate & paym5t in=mation made public "u subsection 7c7 is timely & accurate-- 7#a7 a li/ ( drugs 7id5tifi$ by national drug codes7 = :i* b5efits are available "u su* plan t are applicable spread price drugs2 & 7#b7 ) respect to ea* drug includ$ on su* li/ & ea* ph>macy ) a contractual relation%ip = furni%+ su* drug "u su* plan1 a specification ( ! diff]5ce 7if any7 betwe5 ! specifi$ paym5t am\nt = su* drug s disp5s$ by su* ph>macy & ! specifi$ reimbursem5t am\nt = su* drug s disp5s$ by su* ph>macy4 7g7 ,def9itions ,9 ?is section3 7#a7 ,applicable spread price drug ,! t]m applicable spread price drug means1 ) respect to a gr\p heal? plan1 a drug = :i* b5efits are available "u su* plan & ) respect to :i*1 at ! "t a disclosure describ$ 9 subsection 7f7 is requir$ to be made by an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( su* plan-- 7,a7 a contract is 9 effect betwe5 su* entity & a ph>macy = ! disp5s+ ( su* drug "u su* plan2 & 7,b7 ! specifi$ paym5t am\nt = su* drug s disp5s$ is less ?an ! specifi$ reimbursem5t am\nt = su* drug s disp5s$4 7#b7 ,9-network rate ,! t]m 9-network rate means1 ) respect to a gr\p heal? plan & an item or s]vice furni%$ by a provid] t is a p>ticipat+ provid] ) respect to su* plan & item or s]vice1 ! contract$ rate 7reflect$ z a doll> am\nt7 9 effect betwe5 su* plan & su* provid] = su* item or s]vice1 reg>dless ( :e!r su* rate is calculat$ bas$ on a set am\nt1 a fee s*$ule1 or an am\nt d]iv$ f ano!r am\nt1 or a =mula1 or o!r me?od4 7#c7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] means1 ) respect to an item or s]vice & a gr\p heal? plan1 a physician or o!r heal? c>e provid] 7z def9$ 9 p>agraph 7#d77 :o is act+ )9 ! scope ( practice ( t provid]'s lic5se or c]tification "u applicable ,/ate law & :o has a contractual relation%ip ) ! plan = furni%+ su* item or s]vice "u ! plan4 7#d7 ,provid] ,! t]m provid] includes a heal? c>e facility & a ph>macy4 7#e7 ,specifi$ paym5t am\nt ,! t]m specifi$ paym5t am\nt means1 ) respect to a drug to be disp5s$ by a ph>macy to a p>ticipant or b5efici>y ( a gr\p heal? plan :]e su* ph>macy has 9 effect a contract ) an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( su* plan = ! disp5s+ ( su* drug "u su* plan1 ! am\nt t su* entity has agre$ to pay su* ph>macy = ! +r$i5t co/s & any applicable disp5s+ fee = su* drug 7or ! am\nt t su* entity has agre$ to pay su* ph>macy = su* drug "u any o!r comp5sation /ructure specifi$ by ! ,secret>y7 "u su* contract1 tak+ into acc\nt any co/ %>+ requirem5t applicable to su* drug & p>ticipant or b5efici>y4 7#f7 ,specifi$ reimbursem5t am\nt ,! t]m specifi$ reimbursem5t am\nt means1 ) respect to a drug to be disp5s$ by a ph>macy to a p>ticipant or b5efici>y ( a gr\p heal? plan :]e su* ph>macy has 9 effect a contract ) an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( su* plan = ! disp5s+ ( su* drug "u su* plan1 t am\nt t su* plan has agre$ to pay to su* entity = ! +r$i5t co/s & any applicable disp5s+ fee = su* drug 7or ! am\nt t su* plan has agre$ to pay su* entity = su* drug "u any o!r comp5sation /ructure specifi$ by ! ,secret>y71 tak+ into acc\nt any co/ %>+ requirem5t applicable to su* drug & p>ticipant or b5efici>y4 4 7,b7 ,cl]ical am5dm5t ,! item relat+ to section #ihai ( ! table ( sections = sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ to read z foll[s3 ,sec4 #ihai4 ,transp>5cy 9 cov]age4 4 7#b7 ,,phsa ,section #bgii;,a-#d ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aad7 is am5d$-- 7,a7 9 ! head]1 by /rik+ ,ma9t5ance ( price comp>ison tool & ins]t+ ,transp>5cy 9 cov]age2 7,b7 by /rik+ ,a gr\p heal? plan & ins]t+ ! foll[+3 7a7 ,ma9t5ance ( price comp>ison tool = plan ye>s be=e #bjbh 7#a7 ,9 g5]al ,a gr\p heal? plan 2 7,c7 9 subsection 7a71 z ins]t$ by subp>agraph 7,b71 by add+ at ! end ! foll[+ new p>agraph3 7#b7 ,sunset ,p>agraph 7#a7 %all n apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbh4 2 & 7,d7 by add+ at ! end ! foll[+ new subsections3 7b7 ,co/-%>+ transp>5cy 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbh1 a gr\p heal? plan & a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all provide a p>ticipant1 b5efici>y1 or enrollee1 9 a timely mann] ^u reque/ ( ! p>ticipant1 b5efici>y1 or enrollee1 in=mation on ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 "u ! p>ticipant1 b5efici>y1 or enrollee's plan or cov]age t ! p>ticipant1 b5efici>y1 or enrollee w\ld be responsible = pay+ ) respect to ! furni%+ ( a specific item or s]vice by a provid]4 ,at a m9imum1 su* in=mation %all include ! in=mation specifi$ 9 p>agraph 7#b7 & %all be made available to su* p>ticipant1 b5efici>y1 or enrollee ?r\gh a self-s]vice tool t meets ! requirem5ts ( p>agraph 7#c7 or1 at ! option ( su* p>ticipant1 b5efici>y1 or enrollee1 ?r\gh a pap] disclosure or phone or o!r electronic disclosure 7z select$ by su* individual & provid$ at no co/ to su* individual7 t meets su* requirem5ts z ! ,secret>y may specify4 7#b7 ,specifi$ in=mation ,= purposes ( p>agraph 7#a71 ! in=mation specifi$ 9 ?is p>agraph is1 ) respect to an item or s]vice = :i* b5efits are available "u a gr\p heal? plan or gr\p or individual heal? insurance cov]age furni%$ by a heal? c>e provid] to an individual enroll$ "u su* plan or cov]age1 ! foll[+3 7,a7 ,if su* provid] is a p>ticipat+ provid] ) respect to su* item or s]vice1 ! 9-network rate = su* item or s]vice4 7,b7 ,if su* provid] is n a p>ticipat+ provid] ) respect to su* item or s]vice1 ! maximum all[$ am\nt or o!r doll> am\nt t su* plan or cov]age w recognize z paym5t = su* item or s]vice1 along ) a notice t su* individual may be liable = additional *>ges4 7,c7 ,! e/imat$ 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 subp>agraph 7,b71 %all be calculat$ us+ ! maximum all[$ am\nt or o!r doll> am\nt describ$ 9 su* subp>agraph74 7,d7 ,! am\nt ! individual has already accumulat$ ) respect to any d$uctible or out ( pocket maximum "u ! plan or cov]age 7brok5 d[n1 9 ! case sep>ate d$uctibles or maximums apply to individuals enroll$ 9 ! plan or cov]age1 by su* sep>ate d$uctibles or maximums1 9 addition to any cumulative d$uctible or maximum74 7,e7 ,9 ! case su* plan 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,f7 ,any prior au?orization1 concurr5t review1 /ep !rapy1 fail fir/1 or simil> requirem5ts applicable to cov]age ( su* item or s]vice "u su* plan or cov]age4 7,g7 ,any f9ancial inc5tives 7su* z any cr$it1 paym5t1 or o!r b5efit provid$ by su* plan or issu]7 available to ! individual ) respect to su* item or s]vice furni%$ by su* provid] kn[n at ! "t su* reque/ is made4 7,h7 ,9 ! case su* item or s]vice is an applicable spread price drug disp5s$ by a ph>macy-- 7i7 a specification t su* item or s]vice is su* an applicable spread price drug2 7ii7 ! am\nt ( ! diff]5ce 7if any7 betwe5 ! specifi$ paym5t am\nt = su* drug s disp5s$ by su* ph>macy & ! specifi$ reimbursem5t am\nt = su* drug s disp5s$ by su* ph>macy2 7iii7 a pla9 language /atem5t specifi$ by ! ,secret>y t expla9s ! concept ( spread pric+ & h[ su* item's /atus z su* an applicable spread price drug may impact ! am\nt su* plan or cov]age pays = su* drug & co/ %>+ am\nts = su* drug describ$ 9 subp>agraph 7,c72 & 7iv7 except 9 ! case ( individual heal? insurance cov]age1 a pla9 language /atem5t specifi$ by ! ,secret>y in=m+ ! p>ticipant or b5efici>y ( ! p>ticipant's or b5efici>y's ability to obta9 a summ>y docum5t relat+ to drug pric+ in=mation describ$ 9 section #bgii;,a-#aa7;b77#b77;,b77ii74 7#c7 ,self-s]vice tool ,= purposes ( p>agraph 7#a71 a self-s]vice tool e/abli%$ by a gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age meets ! requirem5ts ( ?is p>agraph if su* tool-- 7,a7 is bas$ on an int]net website 7or successor te*nology specifi$ by ! ,secret>y72 7,b7 provides = real-"t responses to reque/s describ$ 9 p>agraph 7#a72 7,c7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is timely & accurate at ! "t su* reque/ is made2 7,d7 all[s su* a reque/ to be made ) respect to an item or s]vice furni%$ by-- 7i7 a specific provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7ii7 all provid]s t are p>ticipat+ provid]s ) respect to su* item or s]vice2 or 7iii7 a provid] locat$ 9 a relevant geographic region t is n a p>ticipat+ provid] ) respect to su* item or s]vice2 7,e7 provides t su* a reque/ may be made ) respect to an item or s]vice ?r\gh use ( ! bill+ code = su* item or s]vice or ?r\gh use ( a descriptive t]m = su* item or s]vice2 & 7,f7 meets any o!r requirem5t det]m9$ appropriate by ! ,secret>y1 includ+ requirem5ts to ensure ! accessibility & usability ( in=mation provid$ ?r\gh su* tool4 ,! ,secret>y may require su* tool1 z a condition ( comply+ ) subp>agraph 7,e71 to l9k multiple bill+ codes to a s+le descriptive t]m if ! ,secret>y det]m9es t ! bill+ codes to be s l9k$ correspond to simil> items & s]vices4 7c7 ,rate & paym5t in=mation 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbh1 ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age 7o!r ?an a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act77 %all make available to ! public ! rate & paym5t in=mation describ$ 9 p>agraph 7#b7 9 accordance ) p>agraph 7#c74 7#b7 ,rate & paym5t in=mation describ$ ,= purposes ( p>agraph 7#a71 ! rate & paym5t in=mation describ$ 9 ?is p>agraph is1 ) respect to a gr\p heal? plan or gr\p or individual heal? insurance cov]age1 ! foll[+3 7,a7 ,) respect to ea* item or s]vice 7o!r ?an a drug7 = :i* b5efits are available "u su* plan or cov]age1-- 7i7 ! 9-network rate 7express$ z a doll> am\nt7 9 effect z ( ! date on :i* su* in=mation is made public ) ea* provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7ii7 ) respect to ea* su* provid]1 an indication ( :e!r1 dur+ ! #a-ye> p]iod beg9n+ #ah mon?s be=e ! date su* in=mation is made public1 su* provid] submitt$ a claim = su* item or s]vice to su* plan or cov]age2 & 7iii7 9 ! case t su* plan or cov]age provides b5efits = su* item or s]vice only :5 furni%$ by a specific type ( provid]1 a specification ( ea* type ( provid] t may furni% su* item or s]vice "u su* plan or cov]age2 7,b7 ,) respect to ea* drug 7id5tifi$ by national drug code7 = :i* b5efits are available "u su* plan or cov]age-- 7i7 ! 9-network rate 7express$ z a doll> am\nt7 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* drug2 7ii7 ! av]age am\nt paid by su* plan or cov]age 7acc\nt+ =1 9 a mann] det]m9$ appropriate by ! ,secret>y1 rebates1 disc\nts1 price concessions1 & any o!r remun]ation specifi$ by ! ,secret>y7 = su* drug disp5s$ or adm9i/]$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( publication to ea* provid] t 0 a p>ticipat+ provid] ) respect to su* drug1 brok5 d[n by ea* su* provid]1 unless few] ?an #bj claims = su* drug 7 submitt$ to su* plan or cov]age dur+ su* p]iod2 & 7iii7 9 ! case su* drug is an applicable spread price drug disp5s$ by a ph>macy-- 7,i7 a specification t su* drug is su* an applicable spread price drug2 & 7,,ii7 = ea* ph>macy t has a contractual relation%ip = disp5s+ su* drug "u su* plan or cov]age1 a specification ( ! diff]5ce 7if any7 betwe5 ! specifi$ paym5t am\nt = su* drug s disp5s$ by su* ph>macy & ! specifi$ reimbursem5t am\nt = su* drug s disp5s$ by su* ph>macy4 7,c7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan or cov]age1 ! am\nt bill$1 & ! am\nt all[$ by ! plan1 = ea* su* item or s]vice furni%$ dur+ ! #f-mon? p]iod beg9n+ #i mon?s be=e ! date su* in=mation is made public by a provid] t 0 n a p>ticipat+ provid] ) respect to su* item or s]vice1 brok5 d[n by ea* su* provid]1 o!r ?an su* an am\nt ) respect to an item or s]vice furni%$ by a provid] t1 dur+ su* p]iod1 submitt$ few] ?an #aa claims = su* item or s]vice to su* plan or cov]age4 7#c7 ,mann] ( publication 7,a7 ,9 g5]al ,rate & paym5t in=mation requir$ to be made available "u ?is subsection %all be s made available 9 doll> am\nts ?r\gh sep>ate ma*9e-readable files 7& any successor te*nology1 z applicable1 su* z application programm+ int]face te*nology1 det]m9$ appropriate by ! ,secret>y7 correspond+ to ! in=mation describ$ 9 ea* ( subp>agraphs 7,a7 ?r\gh 7,c7 ( p>agraph 7#b7 t meet su* requirem5ts z specifi$ by ! ,secret>y 7:i* may be s specifi$ ?r\gh subregulatory guidance74 ,su* requirem5ts %all ensure t su* files are limit$ to an appropriate size1 d n include disclosure ( unnecess>y duplicative in=mation conta9$ 9 o!r files made available "u ?is subsection1 are made available 9 a widely-available =mat ?r\gh a publicly-available website t all[s = in=mation conta9$ 9 su* files to be comp>$ across gr\p heal? plans & gr\p or individual heal? insurance cov]age1 & are accessible to individuals at no co/ & )\t ! ne$ to e/abli% a us] acc\nt or provide o!r cr$5tials4 7,b7 ,tim+ ,rate & paym5t in=mation-- 7i7 describ$ 9 subp>agraph 7,a7 or 7,b7 ( p>agraph 7#b7 %all be made public on a qu>t]ly basis2 & 7ii7 describ$ 9 subp>agraph 7,c7 ( p>agraph 7#b7 %all be made public on a mon?ly basis4 7#d7 ,us] in/ructions ,ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all make available to ! public in/ructions writt5 9 pla9 language expla9+ h[ individuals may se>* = in=mation describ$ 9 p>agraph 7#b7 9 files submitt$ 9 accordance ) p>agraph 7#c74 ,! ,secret>y %all develop & publi% ?r\gh subregulatory guidance a template t su* a plan may use 9 develop+ in/ructions = purposes ( ! prec$+ s5t5ce4 7#e7 ,summ>y ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbh1 ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all make public a data file1 9 a mann] t ensures t su* file may be easily d[nload$ & read by /&>d spread%eet s(tw>e & t meets su* requirem5ts z e/abli%$ by ! ,secret>y1 conta9+ a summ>y ( all rate & paym5t in=mation made public by su* plan or issu] ) respect to su* plan or cov]age dur+ su* plan ye>4 ,su* file %all include ! foll[+3 7,a7 ,! mean1 m$ian1 & int]qu>tile range ( ! 9-network rate1 & ! am\nt all[$ = an item or s]vice :5 n furni%$ by a p>ticipat+ provid]1 9 effect z ( ! fir/ day ( su* plan ye> = ea* item or s]vice 7id5tifi$ by pay] id5tifi] approv$ or us$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices7 = :i* b5efits are available "u ! plan or cov]age1 brok5 d[n by ! type ( provid] furni%+ ! item or s]vice & by ! geographic area 9 :i* su* item or s]vice is furni%$4 7,b7 ,tr5ds 9 paym5t rates = su* items & s]vices ov] su* plan ye>1 includ+ an id5tification ( in/ances 9 :i* su* rates h increas$1 decreas$1 or rema9$ ! same4 7,c7 ,! "n ( su* plan1 a description ( ! type ( network ( p>ticipat+ provid]s us$ by su* plan or cov]age1 &1 9 ! case ( a gr\p heal? plan1 a description ( :e!r su* plan is self-insur$ or fully-insur$4 7,d7 ,= ea* item or s]vice :i* is paid z "p ( a bundl$ or capitat$ rate-- 7i7 a description ( ! =mulae1 pric+ me?odologies1 or o!r in=mation us$ to calculate ! paym5t rate = su* rate2 & 7ii7 a li/ ( ! items & s]vices includ$ 9 su* rate4 7,e7 ,! p]c5tage ( items & s]vices t are paid = on a fee-=-s]vice basis & ! p]c5tage ( items & s]vices t are paid = z "p ( a bundl$ rate1 capitat$ paym5t rate1 or o!r alt]native paym5t model4 7d7 ,atte/ation ,ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all annually submit to ! ,secret>y an atte/ation ( su* plan's or cov]age's compliance ) ! provisions ( ?is section4 ,su* atte/ation %all include a l9k to ! website 7or o!r successor te*nology7 :]e rate & paym5t in=mation requir$ to be made public "u subsection 7c7 may be access$4 7e7 ,accessibility ,a gr\p heal? plan & a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all take reasonable /eps 7z specifi$ by ! ,secret>y7 to ensure t in=mation provid$ 9 response to a reque/ describ$ 9 subsection 7b71 & rate & paym5t in=mation made public "u subsection 7c71 is provid$ 9 pla91 easily und]/&able language & t int]pretation1 translations1 & assi/ive s]vices are provid$ to ^? ) limit$ ,engli% pr(ici5cy & ^? ) disabilities4 7f7 ,,pbm disclosure ( applicable spread price drugs ,an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( a gr\p heal? plan or gr\p or individual heal? insurance cov]age %all disclose to su* plan or cov]age1 at su* "t & 9 su* mann] z specifi$ by ! ,secret>y to ensure t in=mation provid$ "u subsection 7b7 & rate & paym5t in=mation made public "u subsection 7c7 is timely & accurate-- 7#a7 a li/ ( drugs 7id5tifi$ by national drug codes7 = :i* b5efits are available "u su* plan t are applicable spread price drugs2 & 7#b7 ) respect to ea* drug includ$ on su* li/ & ea* ph>macy ) a contractual relation%ip = furni%+ su* drug "u su* plan or cov]age1 a specification ( ! diff]5ce 7if any7 betwe5 ! specifi$ paym5t am\nt = su* drug s disp5s$ by su* ph>macy & ! specifi$ reimbursem5t am\nt = su* drug s disp5s$ by su* ph>macy4 7g7 ,def9itions ,9 ?is section3 7#a7 ,applicable spread price drug ,! t]m applicable spread price drug means1 ) respect to a gr\p heal? plan or gr\p or individual heal? insurance cov]age1 a drug = :i* b5efits are available "u su* plan or cov]age & ) respect to :i*1 at ! "t a disclosure describ$ 9 subsection 7f7 is requir$ to be made by an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( su* plan or cov]age-- 7,a7 a contract is 9 effect betwe5 su* entity & a ph>macy = ! disp5s+ ( su* drug "u su* plan or cov]age2 & 7,b7 ! specifi$ paym5t am\nt = su* drug s disp5s$ is less ?an ! specifi$ reimbursem5t am\nt = su* drug s disp5s$4 7#b7 ,9-network rate ,! t]m 9-network rate means1 ) respect to a gr\p heal? plan or gr\p or individual heal? insurance cov]age & an item or s]vice furni%$ by a provid] t is a p>ticipat+ provid] ) respect to su* plan or cov]age & item or s]vice1 ! contract$ rate 7reflect$ z a doll> am\nt7 9 effect betwe5 su* plan or cov]age & su* provid] = su* item or s]vice1 reg>dless ( :e!r su* rate is calculat$ bas$ on a set am\nt1 a fee s*$ule1 or an am\nt d]iv$ f ano!r am\nt1 or a =mula1 or o!r me?od4 7#c7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age1 a physician or o!r heal? c>e provid] 7z def9$ 9 p>agraph 7#d77 :o is act+ )9 ! scope ( practice ( t provid]'s lic5se or c]tification "u applicable ,/ate law & :o has a contractual relation%ip ) ! plan or issu]1 respectively1 = furni%+ su* item or s]vice "u ! plan or cov]age1 respectively4 7#d7 ,provid] ,! t]m provid] includes a heal? c>e facility & a ph>macy4 7#e7 ,specifi$ paym5t am\nt ,! t]m specifi$ paym5t am\nt means1 ) respect to a drug to be disp5s$ by a ph>macy to a p>ticipant1 b5efici>y1 or enrollee ( a gr\p heal? plan or gr\p or individual heal? insurance cov]age :]e su* ph>macy has 9 effect a contract ) an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( su* plan or cov]age = ! disp5s+ ( su* drug "u su* plan or cov]age1 ! am\nt t su* entity has agre$ to pay su* ph>macy = ! +r$i5t co/s & any applicable disp5s+ fee = su* drug 7or ! am\nt t su* entity has agre$ to pay su* ph>macy = su* drug "u any o!r comp5sation /ructure specifi$ by ! ,secret>y7 "u su* contract1 tak+ into acc\nt any co/ %>+ requirem5t applicable to su* drug & p>ticipant1 b5efici>y1 or enrollee4 7#f7 ,specifi$ reimbursem5t am\nt ,! t]m specifi$ reimbursem5t am\nt means1 ) respect to a drug to be disp5s$ by a ph>macy to a p>ticipant1 b5efici>y1 or enrollee ( a gr\p heal? plan or gr\p or individual heal? insurance cov]age :]e su* ph>macy has 9 effect a contract ) an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( su* plan or cov]age = ! disp5s+ ( su* drug "u su* plan or cov]age1 t am\nt t su* plan or cov]age has agre$ to pay to su* entity = ! +r$i5t co/s & any applicable disp5s+ fee = su* drug 7or ! am\nt t su* plan or cov]age has agre$ to pay su* entity = su* drug "u any o!r comp5sation /ructure specifi$ by ! ,secret>y71 tak+ into acc\nt any co/ %>+ requirem5t applicable to su* drug & p>ticipant1 b5efici>y1 or enrollee4 4 7#c7 ,,erisa 7,a7 ,9 g5]al ,section #gai ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;h7 is am5d$-- 7i7 9 ! head]1 by /rik+ ,ma9t5ance ( price comp>ison tool & ins]t+ ,transp>5cy 9 cov]age2 7ii7 by /rik+ ,a gr\p heal? plan & ins]t+ ! foll[+3 7a7 ,ma9t5ance ( price comp>ison tool = plan ye>s be=e #bjbh 7#a7 ,9 g5]al ,a gr\p heal? plan 2 7iii7 9 subsection 7a71 z ins]t$ by clause 7ii71 by add+ at ! end ! foll[+ new p>agraph3 7#b7 ,sunset ,p>agraph 7#a7 %all n apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbh4 2 & 7iv7 by add+ at ! end ! foll[+ new subsections3 7b7 ,co/-,%>+ transp>5cy 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbh1 a gr\p heal? plan & a heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all provide a p>ticipant or b5efici>y1 9 a timely mann] ^u reque/ ( ! p>ticipant or b5efici>y1 in=mation on ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 "u ! p>ticipant or b5efici>y's plan or cov]age t ! p>ticipant or b5efici>y w\ld be responsible = pay+ ) respect to ! furni%+ ( a specific item or s]vice by a provid]4 ,at a m9imum1 su* in=mation %all include ! in=mation specifi$ 9 p>agraph 7#b7 & %all be made available to su* p>ticipant or b5efici>y ?r\gh a self-s]vice tool t meets ! requirem5ts ( p>agraph 7#c7 or1 at ! option ( su* p>ticipant or b5efici>y1 ?r\gh a pap] disclosure or phone or o!r electronic disclosure 7z select$ by su* p>ticipant or b5efici>y & provid$ at no co/ to su* p>ticipant or b5efici>y7 t meets su* requirem5ts z ! ,secret>y may specify4 7#b7 ,specifi$ in=mation ,= purposes ( p>agraph 7#a71 ! in=mation specifi$ 9 ?is p>agraph is1 ) respect to an item or s]vice = :i* b5efits are available "u a gr\p heal? plan or gr\p heal? insurance cov]age furni%$ by a heal? c>e provid] to a p>ticipant or b5efici>y ( su* plan or cov]age1 ! foll[+3 7,a7 ,if su* provid] is a p>ticipat+ provid] ) respect to su* item or s]vice1 ! 9-network rate = su* item or s]vice4 7,b7 ,if su* provid] is n a p>ticipat+ provid] ) respect to su* item or s]vice1 ! maximum all[$ am\nt or o!r doll> am\nt t su* plan or cov]age w recognize z paym5t = su* item or s]vice1 along ) a notice t su* p>ticipant or b5efici>y may be liable = additional *>ges4 7,c7 ,! e/imat$ am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! p>ticipant or b5efici>y w incur = su* item or s]vice 7:i*1 9 ! case su* item or s]vice is to be furni%$ by a provid] describ$ 9 subp>agraph 7,b71 %all be calculat$ us+ ! maximum all[$ am\nt or o!r doll> am\nt describ$ 9 su* subp>agraph74 7,d7 ,! am\nt ! p>ticipant or b5efici>y has already accumulat$ ) respect to any d$uctible or out ( pocket maximum "u ! plan or cov]age 7brok5 d[n1 9 ! case sep>ate d$uctibles or maximums apply to a p>ticipant & su* p>ticipant's b5efici>ies enroll$ 9 ! plan or cov]age1 by su* sep>ate d$uctibles or maximums1 9 addition to any cumulative d$uctible or maximum74 7,e7 ,9 ! case su* plan imposes any frequ5cy or volume limitations ) respect to su* item or s]vice 7exclud+ m$ical necessity det]m9ations71 ! am\nt t su* p>ticipant or b5efici>y has accru$ t[>ds su* limitation ) respect to su* item or s]vice4 7,f7 ,any prior au?orization1 concurr5t review1 /ep !rapy1 fail fir/1 or simil> requirem5ts applicable to cov]age ( su* item or s]vice "u su* plan or cov]age4 7,g7 ,any f9ancial inc5tives 7su* z any cr$it1 paym5t1 or o!r b5efit provid$ by su* plan or issu]7 available to ! p>ticipant or b5efici>y ) respect to su* item or s]vice furni%$ by su* provid] kn[n at ! "t su* reque/ is made4 7,h7 ,9 ! case su* item or s]vice is an applicable spread price drug disp5s$ by a ph>macy-- 7i7 a specification t su* item or s]vice is su* an applicable spread price drug2 7ii7 ! am\nt ( ! diff]5ce 7if any7 betwe5 ! specifi$ paym5t am\nt = su* drug s disp5s$ by su* ph>macy & ! specifi$ reimbursem5t am\nt = su* drug s disp5s$ by su* ph>macy2 7iii7 a pla9 language /atem5t specifi$ by ! ,secret>y t expla9s ! concept ( spread pric+ & h[ su* item's /atus z su* an applicable spread price drug may impact ! am\nt su* plan or cov]age pays = su* drug & co/ %>+ am\nts = su* drug describ$ 9 subp>agraph 7,c72 & 7iv7 a pla9 language /atem5t specifi$ by ! ,secret>y in=m+ ! p>ticipant or b5efici>y ( ! p>ticipant's or b5efici>y's ability to obta9 a summ>y docum5t relat+ to drug pric+ in=mation describ$ 9 section #gbf7;b77#b77;,b77ii74 7#c7 ,self-s]vice tool ,= purposes ( p>agraph 7#a71 a self-s]vice tool e/abli%$ by a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age meets ! requirem5ts ( ?is p>agraph if su* tool-- 7,a7 is bas$ on an int]net website 7or successor te*nology specifi$ by ! ,secret>y72 7,b7 provides = real-"t responses to reque/s describ$ 9 p>agraph 7#a72 7,c7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is timely & accurate at ! "t su* reque/ is made2 7,d7 all[s su* a reque/ to be made ) respect to an item or s]vice furni%$ by-- 7i7 a specific provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7ii7 all provid]s t are p>ticipat+ provid]s ) respect to su* item or s]vice2 or 7iii7 a provid] locat$ 9 a relevant geographic region t is n a p>ticipat+ provid] ) respect to su* item or s]vice2 7,e7 provides t su* a reque/ may be made ) respect to an item or s]vice ?r\gh use ( ! bill+ code = su* item or s]vice or ?r\gh use ( a descriptive t]m = su* item or s]vice2 & 7,f7 meets any o!r requirem5t det]m9$ appropriate by ! ,secret>y1 includ+ requirem5ts to ensure ! accessibility & usability ( in=mation provid$ ?r\gh su* tool4 ,! ,secret>y may require su* tool1 z a condition ( comply+ ) subp>agraph 7,e71 to l9k multiple bill+ codes to a s+le descriptive t]m if ! ,secret>y det]m9es t ! bill+ codes to be s l9k$ correspond to simil> items & s]vices4 7c7 ,rate & paym5t in=mation 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbh1 ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p heal? insurance cov]age 7o!r ?an a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act77 %all make available to ! public ! rate & paym5t in=mation describ$ 9 p>agraph 7#b7 9 accordance ) p>agraph 7#c74 7#b7 ,rate & paym5t in=mation describ$ ,= purposes ( p>agraph 7#a71 ! rate & paym5t in=mation describ$ 9 ?is p>agraph is1 ) respect to a gr\p heal? plan or gr\p heal? insurance cov]age1 ! foll[+3 7,a7 ,) respect to ea* item or s]vice 7o!r ?an a drug7 = :i* b5efits are available "u su* plan or cov]age-- 7i7 ! 9-network rate 7express$ z a doll> am\nt7 9 effect z ( ! date on :i* su* in=mation is made public ) ea* provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7ii7 ) respect to ea* su* provid]1 an indication ( :e!r1 dur+ ! #a-ye> p]iod beg9n+ #ah mon?s be=e ! date su* in=mation is made public1 su* provid] submitt$ a claim = su* item or s]vice to su* plan or cov]age2 & 7iii7 9 ! case t su* plan or cov]age provides b5efits = su* item or s]vice only :5 furni%$ by a specific type ( provid]1 a specification ( ea* type ( provid] t may furni% su* item or s]vice "u su* plan or cov]age2 7,b7 ,) respect to ea* drug 7id5tifi$ by national drug code7 = :i* b5efits are available "u su* plan or cov]age-- 7i7 ! 9-network rate 7express$ z a doll> am\nt7 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* drug2 7ii7 ! av]age am\nt paid by su* plan or cov]age 7acc\nt+ =1 9 a mann] det]m9$ appropriate by ! ,secret>y1 rebates1 disc\nts1 price concessions1 & any o!r remun]ation specifi$ by ! ,secret>y7 = su* drug disp5s$ or adm9i/]$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( publication to ea* provid] t 0 a p>ticipat+ provid] ) respect to su* drug1 brok5 d[n by ea* su* provid]1 unless few] ?an #bj claims = su* drug 7 submitt$ to su* plan or cov]age dur+ su* p]iod2 & 7iii7 9 ! case su* drug is an applicable spread price drug disp5s$ by a ph>macy-- 7,i7 a specification t su* drug is su* an applicable spread price drug2 & 7,,ii7 = ea* ph>macy t has a contractual relation%ip = disp5s+ su* drug "u su* plan or cov]age1 a specification ( ! diff]5ce 7if any7 betwe5 ! specifi$ paym5t am\nt = su* drug s disp5s$ by su* ph>macy & ! specifi$ reimbursem5t am\nt = su* drug s disp5s$ by su* ph>macy4 7,c7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan or cov]age1 ! am\nt bill$1 & ! am\nt all[$ by ! plan1 = ea* su* item or s]vice furni%$ dur+ ! #f-mon? p]iod beg9n+ #i mon?s be=e ! date su* in=mation is made public by a provid] t 0 n a p>ticipat+ provid] ) respect to su* item or s]vice1 brok5 d[n by ea* su* provid]1 o!r ?an su* an am\nt ) respect to an item or s]vice furni%$ by a provid] t1 dur+ su* p]iod1 submitt$ few] ?an #aa claims = su* item or s]vice to su* plan or cov]age4 7#c7 ,mann] ( publication 7,a7 ,9 g5]al ,rate & paym5t in=mation requir$ to be made available "u ?is subsection %all be s made available 9 doll> am\nts ?r\gh sep>ate ma*9e-readable files 7& any successor te*nology1 z applicable1 su* z application programm+ int]face te*nology1 det]m9$ appropriate by ! ,secret>y7 correspond+ to ! in=mation describ$ 9 ea* ( subp>agraphs 7,a7 ?r\gh 7,c7 ( p>agraph 7#b7 t meet su* requirem5ts z specifi$ by ! ,secret>y 7:i* may be s specifi$ ?r\gh subregulatory guidance74 ,su* requirem5ts %all ensure t su* files are limit$ to an appropriate size1 d n include disclosure ( unnecess>y duplicative in=mation conta9$ 9 o!r files made available "u ?is subsection1 are made available 9 a widely available =mat ?r\gh a publicly available website t all[s = in=mation conta9$ 9 su* files to be comp>$ across gr\p heal? plans & gr\p or individual heal? insurance cov]age1 & are accessible to individuals at no co/ & )\t ! ne$ to e/abli% a us] acc\nt or provide o!r cr$5tials4 7,b7 ,tim+ ,rate & paym5t in=mation-- 7i7 describ$ 9 subp>agraph 7,a7 or 7,b7 ( p>agraph 7#b7 %all be made public on a qu>t]ly basis2 & 7ii7 describ$ 9 subp>agraph 7,c7 ( p>agraph 7#b7 %all be made public on a mon?ly basis4 7#d7 ,us] in/ructions ,ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all make available to ! public in/ructions writt5 9 pla9 language expla9+ h[ individuals may se>* = in=mation describ$ 9 p>agraph 7#b7 9 files submitt$ 9 accordance ) p>agraph 7#c74 ,! ,secret>y %all develop & publi% ?r\gh subregulatory guidance a template t su* a plan may use 9 develop+ in/ructions = purposes ( ! prec$+ s5t5ce4 7#e7 ,summ>y ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbh1 ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all make public a data file1 9 a mann] t ensures t su* file may be easily d[nload$ & read by /&>d spread%eet s(tw>e & t meets su* requirem5ts z e/abli%$ by ! ,secret>y1 conta9+ a summ>y ( all rate & paym5t in=mation made public by su* plan or issu] ) respect to su* plan or cov]age dur+ su* plan ye>4 ,su* file %all include ! foll[+3 7,a7 ,! mean1 m$ian1 & int]qu>tile range ( ! 9-network rate1 & ! am\nt all[$ = an item or s]vice :5 n furni%$ by a p>ticipat+ provid]1 9 effect z ( ! fir/ day ( su* plan ye> = ea* item or s]vice 7id5tifi$ by pay] id5tifi] approv$ or us$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices7 = :i* b5efits are available "u ! plan or cov]age1 brok5 d[n by ! type ( provid] furni%+ ! item or s]vice & by ! geographic area 9 :i* su* item or s]vice is furni%$4 7,b7 ,tr5ds 9 paym5t rates = su* items & s]vices ov] su* plan ye>1 includ+ an id5tification ( in/ances 9 :i* su* rates h increas$1 decreas$1 or rema9$ ! same4 7,c7 ,! "n ( su* plan1 a description ( ! type ( network ( p>ticipat+ provid]s us$ by su* plan or cov]age1 &1 9 ! case ( a gr\p heal? plan1 a description ( :e!r su* plan is self-insur$ or fully-insur$4 7,d7 ,= ea* item or s]vice :i* is paid z "p ( a bundl$ or capitat$ rate-- 7i7 a description ( ! =mulae1 pric+ me?odologies1 or o!r in=mation us$ to calculate ! paym5t rate = su* rate2 & 7ii7 a li/ ( ! items & s]vices includ$ 9 su* rate4 7,e7 ,! p]c5tage ( items & s]vices t are paid = on a fee-=-s]vice basis & ! p]c5tage ( items & s]vices t are paid = z "p ( a bundl$ rate1 capitat$ paym5t rate1 or o!r alt]native paym5t model4 7d7 ,atte/ation ,ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all annually submit to ! ,secret>y an atte/ation ( su* plan's or cov]age's compliance ) ! provisions ( ?is section4 ,su* atte/ation %all include a l9k to ! website 7or o!r successor te*nology7 :]e rate & paym5t in=mation requir$ to be made public "u subsection 7c7 may be access$4 7e7 ,accessibility ,a gr\p heal? plan & a heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all take reasonable /eps 7z specifi$ by ! ,secret>y7 to ensure t in=mation provid$ 9 response to a reque/ describ$ 9 subsection 7b71 & rate & paym5t in=mation made public "u subsection 7c71 is provid$ 9 pla91 easily und]/&able language & t int]pretation1 translations1 & assi/ive s]vices are provid$ to ^? ) limit$ ,engli% pr(ici5cy & ^? ) disabilities4 7f7 ,,pbm disclosure ( applicable spread price drugs ,an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( a gr\p heal? plan or gr\p heal? insurance cov]age %all disclose to su* plan or cov]age1 at su* "t & 9 su* mann] z specifi$ by ! ,secret>y to ensure t in=mation provid$ "u subsection 7b7 & rate & paym5t in=mation made public "u subsection 7c7 is timely & accurate-- 7#a7 a li/ ( drugs 7id5tifi$ by national drug codes7 = :i* b5efits are available "u su* plan t are applicable spread price drugs2 & 7#b7 ) respect to ea* drug includ$ on su* li/ & ea* ph>macy ) a contractual relation%ip = furni%+ su* drug "u su* plan or cov]age1 a specification ( ! diff]5ce 7if any7 betwe5 ! specifi$ paym5t am\nt = su* drug s disp5s$ by su* ph>macy & ! specifi$ reimbursem5t am\nt = su* drug s disp5s$ by su* ph>macy4 7g7 ,def9itions ,9 ?is section3 7#a7 ,applicable spread price drug ,! t]m applicable spread price drug means1 ) respect to a gr\p heal? plan or gr\p heal? insurance cov]age1 a drug = :i* b5efits are available "u su* plan or cov]age & ) respect to :i*1 at ! "t a disclosure describ$ 9 subsection 7f7 is requir$ to be made by an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( su* plan or cov]age-- 7,a7 a contract is 9 effect betwe5 su* entity & a ph>macy = ! disp5s+ ( su* drug "u su* plan or cov]age2 & 7,b7 ! specifi$ paym5t am\nt = su* drug s disp5s$ is less ?an ! specifi$ reimbursem5t am\nt = su* drug s disp5s$4 7#b7 ,9-network rate ,! t]m 9-network rate means1 ) respect to a gr\p heal? plan or gr\p heal? insurance cov]age & an item or s]vice furni%$ by a provid] t is a p>ticipat+ provid] ) respect to su* plan or cov]age & item or s]vice1 ! contract$ rate 7reflect$ z a doll> am\nt7 9 effect betwe5 su* plan or cov]age & su* provid] = su* item or s]vice1 reg>dless ( :e!r su* rate is calculat$ bas$ on a set am\nt1 a fee s*$ule1 or an am\nt d]iv$ f ano!r am\nt1 or a =mula1 or o!r me?od4 7#c7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] means1 ) respect to an item or s]vice & a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 a physician or o!r heal? c>e provid] 7z def9$ 9 p>agraph 7#d77 :o is act+ )9 ! scope ( practice ( t provid]'s lic5se or c]tification "u applicable ,/ate law & :o has a contractual relation%ip ) ! plan or issu]1 respectively1 = furni%+ su* item or s]vice "u ! plan or cov]age1 respectively4 7#d7 ,provid] ,! t]m provid] includes a heal? c>e facility & a ph>macy4 7#e7 ,specifi$ paym5t am\nt ,! t]m specifi$ paym5t am\nt means1 ) respect to a drug to be disp5s$ by a ph>macy to a p>ticipant or b5efici>y ( a gr\p heal? plan or gr\p heal? insurance cov]age :]e su* ph>macy has 9 effect a contract ) an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( su* plan or cov]age = ! disp5s+ ( su* drug "u su* plan or cov]age1 ! am\nt t su* entity has agre$ to pay su* ph>macy = ! +r$i5t co/s & any applicable disp5s+ fee = su* drug 7or ! am\nt t su* entity has agre$ to pay su* ph>macy = su* drug "u any o!r comp5sation /ructure specifi$ by ! ,secret>y7 "u su* contract1 tak+ into acc\nt any co/ %>+ requirem5t applicable to su* drug & p>ticipant or b5efici>y4 7#f7 ,specifi$ reimbursem5t am\nt ,! t]m specifi$ reimbursem5t am\nt means1 ) respect to a drug to be disp5s$ by a ph>macy to a p>ticipant or b5efici>y ( a gr\p heal? plan or gr\p heal? insurance cov]age :]e su* ph>macy has 9 effect a contract ) an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( su* plan or cov]age = ! disp5s+ ( su* drug "u su* plan or cov]age1 t am\nt t su* plan or cov]age has agre$ to pay to su* entity = ! +r$i5t co/s & any applicable disp5s+ fee = su* drug 7or ! am\nt t su* plan or cov]age has agre$ to pay su* entity = su* drug "u any o!r comp5sation /ructure specifi$ by ! ,secret>y71 tak+ into acc\nt any co/ %>+ requirem5t applicable to su* drug & p>ticipant or b5efici>y4 4 7,b7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by /rik+ ! item relat+ to section #gai & ins]t+ ! foll[+ new item3 ,sec4 #gai4 ,transp>5cy 9 cov]age4 4 7b7 ,application programm+ int]face report ,n lat] ?an ,janu>y #a1 #bjbh1 & annually !reaft]1 ! ,secret>y ( ,heal? & ,human ,s]vices %all1 9 consultation ) ! ,(fice ( ! ,national ,coord9ator = ,heal? ,in=mation ,te*nology1 ,dep>tm5t ( ,labor1 ! ,dep>tm5t ( ! ,treasury1 & /akehold]s1 submit to ! ,h\se ,committees on ,education & ! ,work=ce1 ,en]gy & ,comm]ce1 & ,ways & ,means1 & ! ,s5ate ,committees on ,f9ance & ,heal?1 ,education1 ,labor1 & ,p5sions a report on ! use ( /&>ds-bas$ application programm+ int]faces 79 ?is subsection ref]r$ to z ,a,p,is7 to facilitate access to heal? c>e price transp>5cy in=mation & ! int]op]ability ( o!r m$ical in=mation4 ,su* report %all include an evaluation ( ! capacity ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 & ! ,dep>tm5t ( ! ,treasury to regulate & implem5t /&>ds relat$ to ,a,p,is & recomm5dations = improv+ su* capacity4 ,su* report %all include ! foll[+3 7#a7 ,a description ( curr5t use1 & propos$ use1 ( ,a,p,is "u ,f$]al rules to facilitate int]op]ability1 includ+ in=mation relat$ to capacity con/ra9ts )9 ! ag5cies1 b>ri]s to adoption1 privacy & security1 adm9i/rative burd5s & effici5cies1 c>e coord9ation1 & levels ( compliance4 7#b7 ,a description ( ! feasibility ( ag5cy p>ticipation 9 ! developm5t ( ,a,p,is to enable application access to price transp>5cy data "u ! am5dm5ts made by subsection 7a74 7#c7 ,a specification ( ! timel9e = :i* su* data /&>ds c be requir$ to make su* data accessible via an ,,api4 7#d7 ,an analysis ( ! b5efits & *all5ges ( implem5t+ /&>ds-bas$ ,a,p,is = price transp>5cy data1 includ+ ! ability = consum]s to access rate & paym5t in=mation & ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 "u ! consum]'s plan ?r\gh ?ird-p>ty int]net-bas$ tools & applications4 7#e7 ,an analysis ( ! impact t ,a,p,is :i* provide real-"t access to pric+ & co/-%>+ in=mation may h 9 increas+ ! am\nt ( s]vices %oppable = individuals1 su* z by /&>diz+ m heal? c>e sp5d via episode bundles4 7#f7 ,an analysis ( :i* heal? c>e items & s]vices may be useful "u ,,api1 su* z ^? = :i* prices *ange ) ! greate/ frequ5cy4 7#g7 ,an analysis ( ! co/ ( ,,api /&>ds implem5tation on issu]s1 employ]s1 & o!r private-sector entities4 7#h7 ,an analysis ( ! ability ( ,/ate regulators to en=ce ,,api /&>ds & ! co/s to ! ,f$]al ,gov]nm5t & ,/ates to regulate & en=ce ,,api /&>ds4 7#i7 ,an analysis ( ! int]action ) ,,api /&>ds & ,f$]al heal? in=mation privacy /&>ds4 7c7 ,provid] tool report 7#a7 ,9 g5]al ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act1 ,! ,secret>y ( ,heal? & ,human ,s]vices1 act+ ?r\gh ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices1 %all1 9 consultation ) /akehold]s1 conduct a /udy & submit to ! ,h\se ,committees on ,education & ! ,work=ce1 ,en]gy & ,comm]ce1 & ,ways & ,means1 & ! ,s5ate ,committees on ,f9ance & ,heal?1 ,education1 ,labor1 & ,p5sions a report on ! usefulness & feasibility ( ! e/abli%m5t ( a provid] tool by a gr\p heal? plan1 or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age1 9 facilitat+ ! provision ( in=mation made available pursuant to ! am5dm5ts made by subsection 7a74 ,su* report %all include ! foll[+3 7,a7 ,a description ( ! feasibility ( e/abli%+ a requirem5t = ! v>i\s types ( plans & cov]age to (f] su* a provid] tool1 includ+ any *all5ges to e/abli%+ a provid] tool us+ ! same te*nology plat=m z ! self-s]vice tool describ$ 9 su* am5dm5ts4 7,b7 ,an evaluation on ! usefulness ( a provid] tool to aid pati5t-decision mak+ & h[ su* tool w\ld coord9ate ) o!r in=mation available to a pati5t & _! provid] "u o!r ,f$]al requirem5ts 9 place or "u consid]ation4 7,c7 ,an evaluation ( :e!r ! in=mation provid$ by su* tool w\ld be duplicative ( ! advanc$ explanation ( b5efits requir$ "u ,f$]al law or any o!r exi/+ requirem5t4 7,d7 ,a description ( ! usability & expect$ utilization ( su* tool among provid]s1 includ+ among diff]5t provid] types4 7,e7 ,an analysis ( ! impact ( a provid] tool 9 value-bas$ c>e arrangem5ts4 7,f7 ,an analysis on ! pot5tial impact ( ! provid] tool on-- 7i7 pati5ts' out-(-pocket sp5d+2 7ii7 plan design1 includ+ impacts on co/-%>+ requirem5ts2 7iii7 c>e coord9ation & quality2 7iv7 plan premiums2 7v7 ov]all heal? c>e sp5d+ & utilization2 & 7vi7 heal? c>e access 9 rural areas4 7,g7 ,an analysis ( ! feasibility ( a provid] tool to include additional functionality to facilitate & improve ! adm9i/ration ( ! requirem5ts on provid]s to submit notifications to su* plan or cov]age "u section #bgii;,b-#f ( ! ,public ,heal? ,s]vice ,act & ! requirem5ts on su* plan or cov]age to provide an advanc$ explanation ( b5efits to individuals "u section #bgii;,a-#a7;f7 ( su* ,act4 7,h7 ,an analysis ( :i* heal? c>e items & s]vices1 w\ld be mo/ useful = provid]s utiliz+ a provid] tool4 7,i7 ,an analysis ( rulemak+ requir$ to ensure su* a tool complies ) f$]al heal? in=mation privacy /&>ds4 7,j7 ,an analysis ( ! burd5 & co/ ( ! creation ( a provid] tool by plans & cov]age on provid]s1 issu]s1 employ]s1 & o!r private-sector entities4 7,k7 ,an analysis ( ! ability ( /ate regulators to en=ce provid] tool /&>ds & ! co/s to ! ,dep>tm5t & /ates to regulate & en=ce provid] tool /&>ds4 7#b7 ,def9ition ,! t]m provid] tool means a tool design$ to facilitate ! provision ( in=mation made available pursuant to ! am5dm5ts made by subsection 7a7 & e/abli%$ by a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age t all[s provid]s to access ! in=mation su* plan or cov]age mu/ provide ?r\gh ! self-s]vice tool describ$ 9 su* am5dm5ts to an individual ) :om ! provid] is actively treat+ at ! "t ( su* reque/1 ^u ! reque/ ( ! provid]1 & ) ! cons5t ( su* individual4 7d7 ,reports 7#a7 ,compliance ,n lat] ?an ,janu>y #a1 #bjbi1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit to ,congress a report conta9+-- 7,a7 an analysis ( compliance ) ! am5dm5ts made by ?is section2 7,b7 an analysis ( en=cem5t ( su* am5dm5ts by ! ,secret>ies ( ,heal? & ,human ,s]vices1 ,labor1 & ! ,treasury2 7,c7 recomm5dations relat+ to improv+ su* en=cem5t2 & 7,d7 recomm5dations relat+ to improv+ public disclosure1 & public aw>5ess1 ( in=mation requir$ to be made available by gr\p heal? plans & heal? insurance issu]s pursuant to su* am5dm5ts4 7#b7 ,prices ,n lat] ?an ,janu>y #a1 #bjbi1 & bi5nially !reaft]1 ! ,secret>ies ( ,heal? & ,human ,s]vices1 ,labor1 & ! ,treasury %all jo9tly submit to ,congress a report conta9+ an assessm5t ( diff]5ces 9 negotiat$ prices 7& any tr5ds 9 su* prices7 9 ! private m>ket betwe5-- 7,a7 rural & urban areas2 7,b7 ! individual1 small gr\p1 & l>ge gr\p m>kets2 7,c7 consolidat$ & nonconsolidat$ heal? c>e provid] areas 7z specifi$ by ! ,secret>y ( ,heal? & ,human ,s]vices72 7,d7 nonpr(it & =-pr(it hospitals2 7,e7 nonpr(it & =-pr(it insur]s2 & 7,f7 insur]s s]v+ local or regional areas & insur]s s]v+ multi/ate or national areas4 7e7 ,quality report ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is subsection1 ! ,secret>ies ( ,heal? & ,human ,s]vices1 ,labor1 & ! ,treasury %all jo9tly submit to ,congress a report on ! feasibility ( includ+ data relat+ to ! quality ( heal? c>e items & s]vices ) ! price transp>5cy in=mation requir$ to be made available "u ! am5dm5ts made by subsection 7a74 ,su* report %all include recomm5dations = legislative & regulatory actions to id5tify appropriate metrics = assess+ & comp>+ quality ( c>e4 7f7 ,cont9u$ applicability ( rules = previ\s ye>s ,no?+ 9 ! am5dm5ts made by subsection 7a7 may be con/ru$ z affect+ ! applicability ( ! rule entitl$ ,transp>5cy 9 ,cov]age publi%$ by ! ,dep>tm5t ( ! ,treasury1 ! ,dep>tm5t ( ,labor1 & ! ,dep>tm5t ( ,heal? & ,human ,s]vices on ,novemb] #ab1 #bjbj 7#he ,f$4 ,reg4 #gbaeh71 = any plan ye> beg9n+ be=e ,janu>y #a1 #bjbh4