,i #aai? ,,congress #b;d ,session ,h4 ,r4 #ifde ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,july #ac1 #bjbf ,mr4 ,smi? ( ,miss\ri introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committees on ,ways & ,means1 & ,education & ,work=ce1 = 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 heal? c>e price transp>5cy1 & = o!r purposes4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,heal? ,c>e ,price ,c]ta9ty = ,all ,am]icans ,act4 #b4 ,requir+ c]ta9 facilities "u ! ,m$ic>e program to disclose c]ta9 in=mation relat+ to *>ges & prices 7a7 ,9 g5]al ,"p ,e ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #ahii;,d4 ,heal? c>e provid] price transp>5cy 7a7 ,hospitals 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a1 #bjbg1 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* hospital-- 7i7 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u subp>agraph 7,c71 compile & make public 7)\t subscription & free ( *>ge71 & update n less frequ5tly ?an annually 7or at su* great] frequ5cy z may be specifi$ by ! ,secret>y7-- 7,i7 all ( ! hospital's /&>d *>ges 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = ea* item & s]vice furni%$ by su* hospital2 7,,ii7 in=mation-- 7aa7 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 & 7bb7 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%$2 7ii7 po/ 9 a publicly accessible location ( su* hospital 79 a =m & mann] specifi$ by ! ,secret>y7 ! disc\nt$ ca% price1 z applicable1 express$ z a doll> am\nt1 = ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is furni%$ by ! hospital :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+ 7or1 9 ! case no disc\nt$ ca% price is available = su* s]vice1 ! m$ian ca% price *>g$ by ! hospital to self-pay individuals = su* s]vice :5 provid$ 9 su* sett+s = ! previ\s ?ree ye>s1 express$ z a doll> am\nt72 & 7iii7 submit to ! ,secret>y 79 a =m & mann] specifi$ by ! ,secret>y & on an annual basis7 an atte/ation1 sign$ by ! *ief executive (fic]1 *ief f9ancial (fic]1 or o!r comp>able (ficial 7z specifi$ by ! ,secret>y7 ( su* hospital1 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 commonly recogniz$ bill+ code sets1 includ+ ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! diagnosis-relat$ gr\p1 ! national drug code1 or o!r applicable id5tifi] det]m9$ appropriate by ! ,secret>y4 7ii7 ,= ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t & outpati5t dep>tm5t sett+s-- 7,i7 ! gross *>ge1 z applicable1 express$ z a doll> am\nt2 7,,ii7 ea* pay]-specific negotiat$ *>ge 9 effect betwe5 su* hospital & a ?ird p>ty pay]1 express$ z a doll> am\nt2 7,,iii7 ! deid5tifi$ maximum & m9imum pay]-specific negotiat$ *>ges 9 effect betwe5 su* hospital & any ?ird p>ty pay]2 & 7,,iv7 ! disc\nt$ ca% price1 z applicable1 express$ z a doll> am\nt 7or1 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\nt74 7iii7 ,) 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 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]vice 7:i* may include1 9 ! case t *>ges describ$ 9 clause 7iii7 = an item or s]vice are unable to be express$ z a doll> am\nt1 su* in=mation relat+ to pa/ all[$ *>ges = su* item or s]vice z may be specifi$ by ! ,secret>y71 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is subsection4 ,9 ! case ( /&>d *>ges & prices = an item or s]vice includ$ z "p ( a bundl$1 p] diem1 episodic1 or o!r simil> arrangem5t1 ! in=mation describ$ 9 ?is subp>agraph %all be made available z det]m9$ appropriate by ! ,secret>y4 7,c7 ,uni=m me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbh1 ! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = specifi$ hospitals to use 9 compil+ & mak+ public /&>d *>ges pursuant to subp>agraph 7,a77i77,i7 & a /&>d1 uni=m me?od & =mat = su* hospitals to use 9 compil+ & mak+ public prices pursuant to subp>agraph 7,a77i77,,ii74 ,su* me?ods & =mats-- 7i7 %all1 9 ! case ( su* me?od & =mat = mak+ public-- 7,i7 /&>d *>ges pursuant to subp>agraph 7,a77i77,i71 ensure t su* *>ges are made available 9 a ma*9e-readable =mat 7or a successor te*nology specifi$ by ! ,secret>y72 & 7,,ii7 prices pursuant to subp>agraph 7,a77i77,,ii71 ensure t su* prices are made available 9 a consum]-fri5dly =mat 7z 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,d7 ,deem$ compliance ) %oppable s]vices requirem5t = hospitals ) a price e/imator tool 7i7 ,9 g5]al ,be=e ! effective date ( regulations implem5t+ ! provisions ( sections #bgii;,a-#a7;f7 & #bgii;,b-#f ( ! ,public ,heal? ,s]vice ,act 7relat+ to advanc$ explanations ( b5efits71 includ+ regulations on e/abli%+ data transf] /&>ds to effectuate su* provisions1 a specifi$ hospital %all be deem$ to h compil$ & made public in=mation describ$ 9 subp>agraph 7,a77i77,,ii7 7relat+ to %oppable s]vices7 9 accordance ) a me?od & =mat specifi$ by ! ,secret>y "u subp>agraph 7,c7 if su* hospital ma9ta9s a price e/imator tool describ$ 9 clause 7ii74 7ii7 ,price e/imator tool describ$ ,= purposes ( clause 7i71 a price e/imator tool describ$ 9 ?is subp>agraph is1 ) respect to a specifi$ hospital1 a tool t meets ! foll[+ requirem5ts3 7,i7 ,su* tool all[s an individual to imm$iately obta9 a price e/imate 7tak+ into acc\nt :e!r su* individual is cov]$ "u any plan1 cov]age1 or program describ$ 9 subclause 7,,iv77cc77 & ! disc\nt$ ca% price *>g$ by a specifi$ hospital = ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is furni%$ by su* hospital1 & = ea* additional %oppable s]vice z su* hospital may select1 su* t price e/imates are available ?r\gh su* tool = at lea/ #cjj %oppable s]vices 7or = all su* s]vices1 if su* hospital furni%es few] ?an #cjj %oppable s]vices74 7,,ii7 ,su* tool all[s an individual to obta9 su* an e/imate by bill+ code & by s]vice description4 7,,iii7 ,su* tool is prom95tly display$ on ! public int]net website ( su* hospital4 7,,iv7 ,su* tool does n require an individual seek+ su* an e/imate to create an acc\nt or o!rwise input p]sonal in=mation1 except t su* tool may require t su* individual provide in=mation specifi$ by ! ,secret>y1 :i* may include ! foll[+3 7aa7 ,! "n ( su* individual4 7bb7 ,! date ( bir? ( su* individual4 7cc7 ,9 ! case su* individual is cov]$ "u a gr\p heal? plan1 gr\p or individual heal? insurance cov]age1 a ,f$]al heal? c>e program1 or ! program e/abli%$ "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code1 an id5tify+ numb] assign$ by su* plan1 cov]age1 or program to su* individual4 7dd7 ,9 ! case ( an individual describ$ 9 item 7cc71 an indication z to :e!r su* individual is ! prim>y insur$ individual "u su* plan1 cov]age1 or program 7&1 if su* individual is n ! prim>y insur$ individual1 a description ( ! individual's relation%ip to su* prim>y insur$ individual74 7ee7 ,any o!r in=mation specifi$ by ! ,secret>y4 7,v7 ,su* tool conta9s a /atem5t confirm+ ! accuracy & complet5ess ( in=mation pres5t$ ?r\gh su* tool z ( ! date su* reque/ is made4 7,,vi7 ,su* tool meets any o!r requirem5t specifi$ by ! ,secret>y4 7#c7 ,monitor+ compliance ,! ,secret>y %all e/abli% processes to monitor & assess specifi$ hospitals' compliance ) ?is subsection4 ,su* processes %all ensure t ea* specifi$ hospital's compliance ) ?is subsection is review$ n less frequ5tly ?an once e #c ye>s & 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$s1 #cdb p] day2 7,,ii7 9 ! case ( a specifi$ hospital ) m ?an #cj b$s b few] ?an #eej b$s1 #aa p] b$ p] day2 & 7,,iii7 9 ! case ( a specifi$ hospital ) #eej b$s or m1 #f1bgg p] day4 7ii7 ,increase au?ority ,9 apply+ ?is subp>agraph ) respect to failures to comply occurr+ 9 #bjbi or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase-- 7,i7 ! limitation on ! p] day am\nt ( any p5alty applicable to a specifi$ hospital "u subclause 7,i7 or 7,,iii7 ( clause 7i72 7,,ii7 ! limitations on ! p] b$ p] day am\nt ( any p5alty applicable "u clause 7i77,,ii72 & 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 ,9 g5]al ,subject to subclause 7,,ii71 ! ,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 area 7z def9$ by ! ,f$]al ,(fice ( ,rural ,heal? ,policy = ! purpose ( rural heal? grant programs adm9i/]$ by su* ,(fice7 or an und]s]v$ area if ! ,secret>y det]m9es t imposition ( su* p5alty w\ld result 9 an imm$iate ?reat to access to c>e = individuals 9 ! s]vice area ( su* hospital4 7,,ii7 ,limitation on application ,! ,secret>y may n elect to waive a p5alty "u subclause 7,i7 ) respect to a specifi$ 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 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 unique or unexpect$ ev5t74 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 7,c7 ,publication ( hospital price transp>5cy in=mation ,beg9n+ on ,janu>y #a1 #bjbh1 ! ,secret>y %all make publicly available on ! 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 ,cl9ical diagno/ic laboratory s]vices 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 available1 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u p>agraph 7#c71 ! 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 update su* in=mation n less frequ5tly ?an annually 7or at su* great] frequ5cy z ! ,secret>y may specify72 7,c7 submit to ! ,secret>y on an annual basis an atte/ation1 sign$ by ! *ief executive (fic]1 *ief f9ancial (fic]1 or o!r comp>able (ficial 7z specifi$ by ! ,secret>y7 ( su* laboratory1 t all su* in=mation is complete & accurate2 & 7,d7 po/ 9 a publicly accessible location ( su* laboratory 79 a =m & mann] specifi$ by ! ,secret>y7 ! disc\nt$ ca% price1 z applicable1 express$ z a doll> am\nt1 = ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is furni%$ by ! laboratory 7or1 9 ! case no disc\nt$ ca% price is available = su* s]vice1 ! m$ian ca% price *>g$ by ! laboratory to self-pay individuals = su* s]vice = ! previ\s ?ree ye>s1 express$ z a doll> am\nt74 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 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 ,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 ,monitor+ compliance ,! ,secret>y %all1 ?r\gh notice & comm5t rulemak+1 e/abli% a process to monitor compliance ) ?is subsection4 7#f7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case t ! ,secret>y det]m9es t an applicable laboratory is n 9 compliance ) ! requirem5ts ( p>agraph 7#a7-- 7i7 n lat] ?an #cj days aft] su* det]m9ation1 ! ,secret>y %all notify su* laboratory ( 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 made772 & 7ii7 9 ! case ( a laboratory t does n receive a reque/ = a corrective action plan z "p ( a notification "u clause 7i7-- 7,i7 ! ,secret>y %all1 n lat] ?an #ij days aft] su* notification is s5t1 det]m9e :e!r su* laboratory is 9 compliance ) su* requirem5ts2 & 7,,ii7 if ! ,secret>y det]m9es "u subclause 7,i7 t su* laboratory is n 9 compliance ) su* requirem5ts1 ! ,secret>y %all ei!r-- 7aa7 submit to su* laboratory 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* laboratory 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 ,an applicable laboratory t has receiv$ a reque/ = a corrective action plan "u clause 7i7 or 7ii7 ( subp>agraph 7,a7 & fails to comply ) ! requirem5ts ( p>agraph 7#a7 by ! date t is #ij days aft] su* reque/ is made1 & an applicable laboratory ) 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 9 an am\nt n to exce$ #cjj = 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 7,c7 ,increase au?ority ,9 apply+ ?is p>agraph ) respect to failures to comply 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,b74 7,d7 ,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,e7 ,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 an applicable laboratory "u ?is p>agraph if ! ,secret>y det]m9es t imposition ( su* p5alty w\ld result 9 an imm$iate ?reat to access to c>e = individuals 9 ! s]vice area ( su* laboratory4 7ii7 ,limitation ,! ,secret>y may n elect to waive or r$uce a p5alty "u clause 7i7 ) respect to an applicable laboratory m ?an #c times 9 a #aj ye> p]iod4 7,f7 ,h>d%ip exemption ,not)/&+ any limit on ! waiv] or r$uction ( a p5alty "u subp>agraph 7,e71 ! ,secret>y may waive any p5alty ) respect to an applicable laboratory on a case-by-case basis if ! ,secret>y det]m9es t a circum/ance exi/s int]f]+ ) su* laboratory's ability to comply ) ! provisions ( ?is subsection 7su* z a natural disa/] 7z def9$ 9 section #fjb7;a7 ( ! ,rob]t ,t4 ,/af=d ,disa/] ,relief & ,em]g5cy ,assi/ance ,act71 a public heal? em]g5cy1 or o!r unique or unexpect$ ev5t74 7#g7 ,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#h7 ,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 subsection 7a72 or 7ii7 an ambulatory surgical c5t] pursuant to subsection 7d74 7,b7 ,specifi$ cl9ical diagno/ic laboratory te/ ! t]m specifi$ cl9ical diagno/ic laboratory te/ means a cl9ical diagno/ic laboratory te/ t is includ$ on ! li/ ( %oppable s]vices specifi$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices 7z describ$ 9 subsection 7a77#b77;,a77i77,,ii771 o!r ?an an advanc$ diagno/ic laboratory te/ 7z def9$ 9 section #ahcd;,a7d77#e774 7c7 ,imag+ s]vices 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 7a7 or an ambulatory surgical c5t] pursuant to subsection 7d71 %all-- 7,a7 make publicly available1 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u p>agraph 7#c71 ! 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 updat$ su* in=mation n less frequ5tly ?an annually 7or at su* great] frequ5cy z ! ,secret>y may specify72 7,c7 submit to ! ,secret>y on an annual basis an atte/ation1 sign$ by ! *ief executive (fic]1 *ief f9ancial (fic]1 or o!r comp>able (ficial 7z specifi$ by ! ,secret>y7 ( su* provid] or suppli]1 t all su* in=mation is complete & accurate2 & 7,d7 po/ 9 a publicly accessible location ( su* provid] or suppli] 79 a =m & mann] specifi$ by ! ,secret>y7 ! disc\nt$ ca% price1 z applicable1 express$ z a doll> am\nt1 = ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is furni%$ by ! provid] or suppli] 7or1 9 ! case no disc\nt$ ca% price is available = su* s]vice1 ! m$ian ca% price *>g$ by ! provid] or suppli] to self-pay individuals = su* s]vice = ! previ\s ?ree ye>s1 express$ z a doll> am\nt74 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 ) ! requirem5ts ( p>agraph 7#a7-- 7i7 n lat] ?an #cj days aft] su* det]m9ation1 ! ,secret>y %all notify su* provid] or suppli] ( 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 made772 & 7ii7 9 ! case ( a provid] ( s]vices or suppli] t does n receive a reque/ = a corrective action plan z "p ( a notification "u clause 7i7-- 7,i7 ! ,secret>y %all1 n lat] ?an #ij days aft] su* notification is s5t1 det]m9e :e!r su* provid] or suppli] is 9 compliance ) su* requirem5ts2 & 7,,ii7 if ! ,secret>y det]m9es "u subclause 7,i7 t su* provid] or suppli] is n 9 compliance ) su* requirem5ts1 ! ,secret>y %all ei!r-- 7aa7 submit to su* provid] or suppli] 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* provid] or suppli] 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 ,a provid] ( s]vices or suppli] t has receiv$ a reque/ = a corrective action plan "u clause 7i7 or 7ii7 ( subp>agraph 7,a7 & fails to comply ) ! requirem5ts ( p>agraph 7#a7 by ! date t is #ij days aft] su* reque/ is made1 & a provid] ( s]vices or suppli] ) 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 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 n comply+ ) su* requirem5ts7 dur+ :i* su* failure 0 ongo+4 7,c7 ,increase au?ority ,9 apply+ ?is p>agraph ) respect to failures to comply 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,b74 7,d7 ,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,e7 ,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 p>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,f7 ,h>d%ip exemption ,not)/&+ any limit on ! waiv] or r$uction ( a p5alty "u subp>graph 7,e71 ! ,secret>y may waive any p5alty ) respect to a provid] ( s]vices or suppli] on a case-by-case basis if ! ,secret>y det]m9es t a circum/ance exi/s int]f]+ ) su* provid]'s or suppli]'s ability to comply ) ! provisions ( ?is subsection 7su* z a natural disa/] 7z def9$ 9 section #fjb7;a7 ( ! ,rob]t ,t4 ,/af=d ,disa/] ,relief & ,em]g5cy ,assi/ance ,act71 a public heal? em]g5cy1 or o!r unique or unexpect$ ev5t74 7,g7 ,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 ,def9ition ,9 ?is subsection1 ! 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 7a77i77,,ii774 7d7 ,ambulatory surgical c5t]s 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* c5t]-- 7i7 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u subp>agraph 7,c71 compile & make public 7)\t subscription & free ( *>ge71 & update n less frequ5tly ?an annually 7or at su* great] frequ5cy z may be specifi$ by ! ,secret>y7-- 7,i7 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 7,,ii7 in=mation on ! ambulatory surgical c5t]'s prices 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = z _m ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vices 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 & 7,,iii7 ) 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%$2 7ii7 submit to ! ,secret>y on an annual basis an atte/ation1 sign$ by ! *ief executive (fic]1 *ief f9ancial (fic]1 or o!r comp>able (ficial 7z specifi$ by ! ,secret>y7 ( su* c5t]1 t all in=mation made public pursuant to ?is subp>agraph is complete & accurate2 & 7iii7 po/ 9 a publicly accessible location ( su* c5t] 79 a =m & mann] specifi$ by ! ,secret>y7 ! disc\nt$ ca% price1 z applicable1 express$ z a doll> am\nt1 = ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is furni%$ by ! c5t] 7or1 9 ! case no disc\nt$ ca% price is available = su* s]vice1 ! m$ian ca% price *>g$ by ! c5t] to self-pay individuals = su* s]vice = ! previ\s ?ree ye>s1 express$ z a doll> am\nt74 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 commonly recogniz$ bill+ code sets1 includ+ ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! national drug code1 or o!r applicable id5tifi] det]m9$ appropriate by ! ,secret>y4 7ii7 ,= ea* su* item or s]vice-- 7,i7 ! gross *>ge1 z applicable1 express$ z a doll> am\nt2 7,,ii7 ea* pay]-specific negotiat$ *>ge 9 effect betwe5 su* c5t] & a ?ird p>ty pay]1 express$ z a doll> am\nt2 7,,iii7 ! deid5tifi$ maximum & m9imum pay]-specific negotiat$ *>ges 9 effect betwe5 su* c5t] & any ?ird p>ty pay]2 & 7,,iv7 ! disc\nt$ ca% price1 z applicable1 express$ z a doll> am\nt 7or1 9 ! case no disc\nt$ ca% price is available = an item or s]vice1 ! m$ian ca% price *>g$ to self-pay individuals 7n includ+ *>ity c>e7 = su* item or s]vice = ! previ\s ?ree ye>s1 express$ z a doll> am\nt74 7iii7 ,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 ,9 ! case ( /&>d *>ges & prices = an item or s]vice includ$ z "p ( a bundl$1 p] diem1 episodic1 or o!r simil> arrangem5t1 ! in=mation describ$ 9 ?is subp>agraph %all be made available z det]m9$ appropriate by ! ,secret>y4 7,c7 ,uni=m me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbh1 ! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = 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 (-- 7,i7 /&>d *>ges made public by an ambulatory surgical c5t] "u subp>agraph 7,a77i71 ensure t su* *>ges are made available 9 a ma*9e-readable =mat 7or successor te*nology72 & 7,,ii7 prices made public by an ambulatory surgical c5t] "u subp>agraph 7,a77ii71 ensure t su* prices are made available 9 a consum]-fri5dly =mat 7z specifi$ by ! ,secret>y72 7ii7 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 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,d7 ,deem$ compliance ) %oppable s]vices requirem5t = c5t]s ) a price e/imator tool 7i7 ,9 g5]al ,be=e ! effective date ( regulations implem5t+ ! provisions ( sections #bgii;,a-#a7;f7 & #bgii;,b-#f ( ! ,public ,heal? ,s]vice ,act 7relat+ to advanc$ explanations ( b5efits71 includ+ regulations on e/abli%+ data transf] /&>ds to effectuate su* provisions1 a specifi$ hospital %all be deem$ to h compil$ & made public in=mation describ$ 9 subp>agraph 7,a77i77,,ii7 7relat+ to %oppable s]vices7 9 accordance ) a me?od & =mat specifi$ by ! ,secret>y "u subp>agraph 7,c7 if su* hospital ma9ta9s a price e/imator tool describ$ 9 clause 7ii74 7ii7 ,price e/imator tool describ$ ,= purposes ( clause 7i71 a price e/imator tool describ$ 9 ?is subp>agraph is1 ) respect to an ambulatory surgical c5t]1 a tool t meets ! foll[+ requirem5ts3 7,i7 ,su* tool all[s an individual to imm$iately obta9 a price e/imate 7tak+ into acc\nt :e!r su* individual is cov]$ "u any plan1 cov]age1 or program describ$ 9 subclause 7,,iv77cc77 & ! disc\nt$ ca% price *>g$ by an ambulatory surgical c5t] = ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is furni%$ by su* c5t]1 & = ea* additional %oppable s]vice z su* c5t] may select1 su* t price e/imates are available ?r\gh su* tool = at lea/ #cjj %oppable s]vices 7or = all su* s]vices1 if su* hospital furni%es few] ?an #cjj %oppable s]vices74 7,,ii7 ,su* tool all[s an individual to obta9 su* an e/imate by bill+ code & by s]vice description4 7,,iii7 ,su* tool is prom95tly display$ on ! public int]net website ( su* c5t]4 7,,iv7 ,su* tool does n require an individual seek+ su* an e/imate to create an acc\nt or o!rwise input p]sonal in=mation1 except t su* tool may require t su* individual provide in=mation specifi$ by ! ,secret>y1 :i* may include ! foll[+3 7aa7 ,! "n ( su* individual4 7bb7 ,! date ( bir? ( su* individual4 7cc7 ,9 ! case su* individual is cov]$ "u a gr\p heal? plan1 gr\p or individual heal? insurance cov]age1 a ,f$]al heal? c>e program1 or ! program e/abli%$ "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code1 an id5tify+ numb] assign$ by su* plan1 cov]age1 or program to su* individual4 7dd7 ,9 ! case ( an individual describ$ 9 item 7cc71 an indication z to :e!r su* individual is ! prim>y insur$ individual "u su* plan1 cov]age1 or program 7&1 if su* individual is n ! prim>y insur$ individual1 a description ( ! individual's relation%ip to su* prim>y insur$ individual74 7ee7 ,any o!r in=mation specifi$ by ! ,secret>y4 7,v7 ,su* tool conta9s a /atem5t confirm+ ! accuracy & complet5ess ( in=mation pres5t$ ?r\gh su* tool z ( ! date su* reque/ is made4 7,,vi7 ,su* tool meets any o!r requirem5t specifi$ by ! ,secret>y4 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 t ! ,secret>y det]m9es t an ambulatory surgical c5t] is n 9 compliance ) ! requirem5ts ( p>agraph 7#a7-- 7i7 n lat] ?an #cj days aft] su* det]m9ation1 ! ,secret>y %all notify su* c5t] ( 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 made772 & 7ii7 9 ! case ( an ambulatory surgical c5t] t does n receive a reque/ = a corrective action plan z "p ( a notification "u clause 7i7-- 7,i7 ! ,secret>y %all1 n lat] ?an #ij days aft] su* notification is s5t1 det]m9e :e!r su* c5t] is 9 compliance ) su* requirem5ts2 & 7,,ii7 if ! ,secret>y det]m9es "u subclause 7,i7 t su* c5t] is n 9 compliance ) su* requirem5ts1 ! ,secret>y %all ei!r-- 7aa7 submit to su* c5t] 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* c5t] 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 ,an ambulatory surgical c5t] t has receiv$ a reque/ = a corrective action plan "u clause 7i7 or 7ii7 ( subp>agraph 7,a7 & fails to comply ) ! requirem5ts ( p>agraph 7#a7 by ! date t is #ij days aft] su* reque/ is made1 & an ambulatory surgical c5t] ) 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 9 an am\nt n to exce$ #cjj = ea* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* c5t] 0 n comply+ ) su* requirem5ts7 dur+ :i* su* failure 0 ongo+4 7ii7 ,increase au?ority ,9 apply+ ?is subp>agraph ) respect to failures to comply 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 "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$uce p5alty 7,i7 ,9 g5]al ,subject to subclause 7,,ii71 ! ,secret>y may waive any p5alty1 or r$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$iate ?reat to access to c>e = individuals 9 ! s]vice area ( su* surgical c5t]4 7,,ii7 ,limitation on application ,! ,secret>y may n elect to waive a p5alty "u subclause 7,i7 ) respect to an ambulatory surgical c5t] m ?an once 9 a #f-ye> p]iod & may n elect to r$uce su* a p5alty ) respect to su* a surgical 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$uc+ a p5alty ) respect to an ambulatory surgical c5t] dur+ a #f-ye> p]iod4 7v7 ,h>d%ip exemption ,not)/&+ any limit on ! waiv] or r$uction ( a p5alty "u clause 7iv71 ! ,secret>y may waive any p5alty ) respect to an ambulatory surgical c5t] on a case-by-case basis if ! ,secret>y det]m9es t a circum/ance exi/s int]f]+ ) su* c5t]'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 unique or unexpect$ ev5t74 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 7e7 ,ensur+ accessibility ?r\gh implem5tation ,9 implem5t+ ?is section1 ! ,secret>y %all ?r\gh rulemak+ ensure t a provid] ( s]vices or suppli] 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 ! provision ( int]pretation s]vices or ! provision ( translations ( *>ges & in=mation4 7f7 ,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 an applicable laboratory 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 = an item or s]vice4 4 7b7 ,con=m+ am5dm5t ,section #bgah7;e7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7;e77 is am5d$ by add+ at ! end ! foll[+ new s5t5ce3 ,! prec$+ provisions ( ?is subsection %all n apply beg9n+ on ,janu>y #a1 #bjbh44 #c4 ,heal? cov]age price transp>5cy 7a7 ,price transp>5cy requirem5ts 7#a7 ,,irc 7,a7 ,9 g5]al ,section #ihai ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 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 #bjbi 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 #bjbi4 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 #bjbi1 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 ,o!r in=mation det]m9$ appropriate by ! ,secret>y4 7#c7 ,self-s]vice tool ,= purposes ( p>agraph 7#a71 a self-s]vice tool e/abli%$ by a gr\p heal? plan meets ! requirem5ts ( ?is p>agraph if su* tool-- 7,a7 is bas$ on an int]net website 7or successor te*nology specifi$ by ! ,secret>y72 7,b7 is made available 9 pla9 language at no co/2 7,c7 provides = real-"t responses to reque/s describ$ 9 p>agraph 7#a72 7,d7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is timely & accurate at ! "t su* reque/ is made2 7,e7 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 nonspecific provid]s locat$ 9 a relevant geographic region t are n p>ticipat+ provid]s ) respect to su* item or s]vice2 7,f7 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,g7 meets any o!r requirem5t det]m9$ appropriate by ! ,secret>y1 includ+ requirem5ts to ensure ! accessibility & usability ( in=mation provid$ ?r\gh su* tool4 7c7 ,rate & paym5t in=mation 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbi1 ea* gr\p heal? plan 7o!r ?an a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act7 or a *ur* plan 7z def9$ 9 section #dad7;e777 %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]vice 7o!r ?an1 9 ! case t su* plan provides b5efits = su* item or s]vice only :5 furni%$ by a specific type ( provid]1 su* a p>ticipat+ provid] :o is n su* type ( provid] 7ref]r$ to 9 ?is subp>agraph z an exclud$ provid]772 & 7ii7 ) respect to ea* su* p>ticipat+ provid] 7o!r ?an a provid] t is an exclud$ provid] ) respect to su* item or s]vice71 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 = :i* paym5t 0 made 79 :ole or 9 "p7 "u su* plan4 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 = :i*1 dur+ su* p]iod1 few] ?an #aa claims 7 made "u su* plan4 ,9 det]m9+ ! numb] ( claims made "u su* plan ) respect to an item or s]vice dur+ su* p]iod = purposes ( ! prec$+ s5t5ce1 su* numb] %all be deem$ to include all claims = su* item or s]vice made dur+ su* p]iod "u all gr\p heal? plans (f]$ 9 ! same insurance m>ket 7specifi$ 9 subclause 7,i71 7,,ii71 7,,iii71 ( section #ihaf7;a77#c77;,e77iv77 by ! sponsor ( ! plan at issue4 ,9 ! case t a specific doll> am\nt = an 9-network rate requir$ to be made available pursuant to ?is subsection ) respect to an item or s]vice _c be det]m9$ prospectively on ! basis t su* rate is det]m9$ z a p]c5tage ( ! bill$ *>ges = su* item or s]vice1 su* p]c5tage & ! m$ian am\nt recogniz$ by su* plan z paym5t = su* item or s]vice ) respect to claims = su* item or s]vice submitt$ by p>ticipat+ provid]s dur+ ! p]iod describ$ 9 subp>agraph 7,a77ii7 %all be report$ by su* plan 9 lieu ( su* rate4 ,su* plan %all id5tify t su* m$ian am\nt repres5ts an e/imate ( su* 9-network rate = su* item or s]vice4 7#c7 ,mann] ( publication 7,a7 ,9 g5]al ,rate & paym5t in=mation requir$ 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 guidance71 includ+ requirem5ts relat+ to :e!r su* in=mation %\ld be s made available on ! plan or cov]age level1 ) respect to individual provid] networks1 or aggregat$ 9 su* mann] z specifi$ by ! ,secret>y4 ,su* requirem5ts %all ensure t su* files are limit$ to an appropriate size1 d n include disclosure ( unnecess>y duplicative in=mation conta9$ 9 o!r files made available "u ?is subsection1 are made available 9 a widely available =mat ?r\gh a publicly available website t all[s = in=mation conta9$ 9 su* files to be comp>$ across gr\p heal? plans & gr\p 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$5tials or und]take o!r /eps z may be specifi$ by ! ,secret>y4 7,b7 ,tim+ ,rate & paym5t in=mation describ$ 9 p>agraph 7#b7 %all be made public on a qu>t]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$+ s5t5ce4 7#e7 ,summ>y ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbi1 ea* gr\p heal? plan %all make public a data file1 9 a mann] t ensures t su* file may be easily d[nload$ & 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 ,a gr\p heal? plan %all annually submit to ! ,secret>y an atte/ation1 sign$ by ! *ief executive (fic]1 *ief f9ancial (fic]1 or o!r comp>able (ficial 7z specifi$ by ! ,secret>y7 ( su* plan1 ( su* plan's compliance ) ! provisions ( ?is section & t in=mation made available "u ?is section is true1 accurate1 & complete4 ,su* atte/ation %all1 except 9 ! case ( a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act7 or a *ur* plan 7z def9$ 9 section #dad7;e771 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 ,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 rate & paym5t in=mation is made public by su* plan "u subsection 7c7-- 7,a7 a contract is 9 effect betwe5 an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( su* plan & 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 ! 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$-- 7,a7 9 ! head]1 by /rik+ ,ma9t5ance ( price comp>ison tool & ins]t+ ,transp>5cy 9 cov]age2 7,b7 by /rik+ ,a gr\p heal? plan & ins]t+ ! foll[+3 7a7 ,ma9t5ance ( price comp>ison tool = plan ye>s be=e #bjbi 7#a7 ,9 g5]al ,a gr\p heal? plan 2 7,c7 9 subsection 7a71 z ins]t$ 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 #bjbi4 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 #bjbi1 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 ,o!r in=mation det]m9$ appropriate by ! ,secret>y4 7#c7 ,self-s]vice tool ,= purposes ( p>agraph 7#a71 a self-s]vice tool e/abli%$ by a gr\p heal? plan or 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 is made available 9 pla9 language at no co/2 7,c7 provides = real-"t responses to reque/s describ$ 9 p>agraph 7#a72 7,d7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is timely & accurate at ! "t su* reque/ is made2 7,e7 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 nonspecific provid]s locat$ 9 a relevant geographic region t are n p>ticipat+ provid]s ) respect to su* item or s]vice2 7,f7 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,g7 meets any o!r requirem5t det]m9$ appropriate by ! ,secret>y1 includ+ requirem5ts to ensure ! accessibility & usability ( in=mation provid$ ?r\gh su* tool4 7c7 ,rate & paym5t in=mation 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbi1 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 ,act7 & o!r ?an su* an issu] (f]+ gr\p heal? insurance cov]age 9 connection ) a *ur* plan 7z def9$ 9 section #dad7;e7 ( ! ,int]nal ,rev5ue ,code ( #aihf77 %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]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]vice 7o!r ?an1 9 ! case t su* plan or cov]age provides b5efits = su* item or s]vice only :5 furni%$ by a specific type ( provid]1 su* a p>ticipat+ provid] :o is n su* type ( provid] 7ref]r$ to 9 ?is subp>agraph z an exclud$ provid]772 & 7ii7 ) respect to ea* su* p>ticipat+ provid] 7o!r ?an a provid] t is an exclud$ provid] ) respect to su* item or s]vice71 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]age = :i* paym5t 0 made 79 :ole or 9 "p7 "u su* plan or cov]age4 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 ! plan or cov]age1 = 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 = :i*1 dur+ su* p]iod1 few] ?an #aa claims 7 made "u su* plan or cov]age4 ,9 det]m9+ ! numb] ( claims made "u su* plan or cov]age ) respect to an item or s]vice dur+ su* p]iod = purposes ( ! prec$+ s5t5ce1 su* numb] %all be deem$ to include all claims = su* item or s]vice made dur+ su* p]iod "u all gr\p heal? plans & heal? insurance cov]age (f]$ 9 ! same insurance m>ket 7specifi$ 9 subclause 7,i71 7,,ii71 7,,iii71 or 7,,iv7 ( section #bgii;,a-#a7;a77#c77;,e77iv77 by ! sponsor or issu] 7z applicable7 ( ! plan or cov]age at issue4 ,9 ! case t a specific doll> am\nt = an 9-network rate requir$ to be made available pursuant to ?is subsection ) respect to an item or s]vice _c be det]m9$ prospectively on ! basis t su* rate is det]m9$ z a p]c5tage ( ! bill$ *>ges = su* item or s]vice1 su* p]c5tage & ! m$ian am\nt recogniz$ by su* plan or cov]age z paym5t = su* item or s]vice ) respect to claims = su* item or s]vice submitt$ by p>ticipat+ provid]s dur+ ! p]iod describ$ 9 subp>agraph 7,a77ii7 %all be report$ by su* plan 9 lieu ( su* rate4 ,su* plan or cov]age %all id5tify t su* m$ian am\nt repres5ts an e/imate ( su* 9-network rate = su* item or s]vice4 7#c7 ,mann] ( publication 7,a7 ,9 g5]al ,rate & paym5t in=mation requir$ 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 guidance71 includ+ requirem5ts relat+ to :e!r su* in=mation %\ld be s made available on ! plan or cov]age level1 ) respect to individual provid] networks1 or aggregat$ 9 su* mann] z specifi$ by ! ,secret>y4 ,su* requirem5ts %all ensure t su* files are limit$ to an appropriate size1 d n include disclosure ( unnecess>y duplicative in=mation conta9$ 9 o!r files made available "u ?is subsection1 are made available 9 a widely-available =mat ?r\gh a publicly-available website t all[s = in=mation conta9$ 9 su* files to be comp>$ across gr\p heal? plans & gr\p 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$5tials4 7,b7 ,tim+ ,rate & paym5t in=mation describ$ 9 p>agraph 7#b7 %all be made public on a qu>t]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$+ s5t5ce4 7#e7 ,summ>y ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbi1 ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all make public a data file1 9 a mann] t ensures t su* file may be easily d[nload$ & 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/ation1 sign$ by ! *ief executive (fic]1 *ief f9ancial (fic]1 or o!r comp>able (ficial 7z specifi$ by ! ,secret>y7 ( su* plan or issu]1 ( su* plan's or cov]age's compliance ) ! provisions ( ?is section & t in=mation made available "u ?is section is true1 accurate1 & complete4 ,su* atte/ation %all1 except 9 ! case ( a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act7 or 9 ! case ( su* an issu] (f]+ gr\p heal? insurance cov]age 9 connection ) a *ur* plan 7z def9$ 9 section #dad7;e7 ( ! ,int]nal ,rev5ue ,code ( #aihf71 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 ,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 rate & paym5t in=mation is made public by su* plan "u subsection 7c7-- 7,a7 a contract is 9 effect betwe5 an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( su* plan or cov]age & 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 ! 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$-- 7i7 9 ! head]1 by /rik+ ,ma9t5ance ( price comp>ison tool & ins]t+ ,transp>5cy 9 cov]age2 7ii7 by /rik+ ,a gr\p heal? plan & ins]t+ ! foll[+3 7a7 ,ma9t5ance ( price comp>ison tool = plan ye>s be=e #bjbi 7#a7 ,9 g5]al ,a gr\p heal? plan 2 7iii7 9 subsection 7a71 z ins]t$ 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 #bjbi4 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 #bjbi1 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 ,o!r in=mation det]m9$ appropriate by ! ,secret>y4 7#c7 ,self-s]vice tool ,= purposes ( p>agraph 7#a71 a self-s]vice tool e/abli%$ by a gr\p heal? plan or 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 is made available 9 pla9 language at no co/2 7,c7 provides = real-"t responses to reque/s describ$ 9 p>agraph 7#a72 7,d7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is timely & accurate at ! "t su* reque/ is made2 7,e7 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 nonspecific provid]s locat$ 9 a relevant geographic region t are n p>ticipat+ provid]s ) respect to su* item or s]vice2 7,f7 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,g7 meets any o!r requirem5t det]m9$ appropriate by ! ,secret>y1 includ+ requirem5ts to ensure ! accessibility & usability ( in=mation provid$ ?r\gh su* tool4 7c7 ,rate & paym5t in=mation 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbi1 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]vice 7o!r ?an1 9 ! case t su* plan or cov]age provides b5efits = su* item or s]vice only :5 furni%$ by a specific type ( provid]1 su* a p>ticipat+ provid] :o is n su* type ( provid] 7ref]r$ to 9 ?is subp>agraph z an exclud$ provid]772 & 7ii7 ) respect to ea* su* p>ticipat+ provid] 7o!r ?an a provid] t is an exclud$ provid] ) respect to su* item or s]vice71 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]age = :i* paym5t 0 made 79 :ole or 9 "p7 "u su* plan or cov]age4 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 ! plan or cov]age1 = 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 = :i*1 dur+ su* p]iod1 few] ?an #aa claims 7 made "u su* plan or cov]age4 ,9 det]m9+ ! numb] ( claims made "u su* plan or cov]age ) respect to an item or s]vice dur+ su* p]iod = purposes ( ! prec$+ s5t5ce1 su* numb] %all be deem$ to include all claims = su* item or s]vice made dur+ su* p]iod "u all gr\p heal? plans & heal? insurance cov]age (f]$ 9 ! same insurance m>ket 7specifi$ 9 subclause 7,i71 7,,ii71 7,,iii71 or 7,,iv7 ( section #gaf7;a77#c77;,e77iv77 by ! sponsor or issu] 7z applicable7 ( ! plan or cov]age at issue4 ,9 ! case t a specific doll> am\nt = an 9-network rate requir$ to be made available pursuant to ?is subsection ) respect to an item or s]vice _c be det]m9$ prospectively on ! basis t su* rate is det]m9$ z a p]c5tage ( ! bill$ *>ges = su* item or s]vice1 su* p]c5tage & ! m$ian am\nt recogniz$ by su* plan or cov]age z paym5t = su* item or s]vice ) respect to claims = su* item or s]vice submitt$ by p>ticipat+ provid]s dur+ ! p]iod describ$ 9 subp>agraph 7,a77ii7 %all be report$ by su* plan or cov]age 9 lieu ( su* rate4 ,su* plan or cov]age %all id5tify t su* m$ian am\nt repres5ts an e/imate ( su* 9-network rate = su* item or s]vice4 7#c7 ,mann] ( publication 7,a7 ,9 g5]al ,rate & paym5t in=mation requir$ 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 guidance71 includ+ requirem5ts relat+ to :e!r su* in=mation %\ld be s made available on ! plan or cov]age level1 ) respect to individual provid] networks1 or aggregat$ 9 su* mann] z specifi$ by ! ,secret>y4 ,su* requirem5ts %all ensure t su* files are limit$ to an appropriate size1 d n include disclosure ( unnecess>y duplicative in=mation conta9$ 9 o!r files made available "u ?is subsection1 are made available 9 a widely available =mat ?r\gh a publicly available website t all[s = in=mation conta9$ 9 su* files to be comp>$ across gr\p heal? plans & gr\p 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$5tials4 7,b7 ,tim+ ,rate & paym5t in=mation describ$ 9 p>agraph 7#b7 %all be made public on a qu>t]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$+ s5t5ce4 7#e7 ,summ>y ,= ea* plan ye> beg9n+ on or aft] ,janu>y #a1 #bjbi1 ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all make public a data file1 9 a mann] t ensures t su* file may be easily d[nload$ & 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/ation1 sign$ by ! *ief executive (fic]1 *ief f9ancial (fic]1 or o!r comp>able (ficial 7z specifi$ by ! ,secret>y7 ( su* plan or issu]1 ( su* plan's or cov]age's compliance ) ! provisions ( ?is section & t in=mation made available "u ?is section is true1 accurate1 & complete4 ,su* atte/ation %all1 except 9 ! case ( a gr&fa!r$ heal? plan 7z def9$ 9 section #abea7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act71 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 ,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 rate & paym5t in=mation is made public by su* plan "u subsection 7c7-- 7,a7 a contract is 9 effect betwe5 an entity provid+ ph>macy b5efit managem5t s]vices on behalf ( su* plan or cov]age & 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 ! 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 #bjbi1 & 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$4 ,reg4 #gbaeh71 = any plan ye> beg9n+ be=e ,janu>y #a1 #bjbi4 #d4 ,in=mation on prescription drugs 7a7 ,,phsa 7#a7 ,9 g5]al ,"p ,d ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act is am5d$ by add+ at ! end ! foll[+ new section3 #bgii;,a-#ab4 ,in=mation on prescription drugs 7a7 ,9 g5]al ,a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all-- 7#a7 n re/rict1 directly or indirectly1 any ph>macy t disp5ses a prescription drug to an enrollee 9 ! plan or cov]age f in=m+ 7or p5alize su* ph>macy = in=m+7 an enrollee ( any diff]5tial betwe5 ! enrollee's out-(-pocket co/ "u ! plan or cov]age ) respect to acquisition ( ! drug & ! am\nt an individual w\ld pay = acquisition ( ! drug )\t us+ any gr\p heal? plan or heal? insurance cov]age2 & 7#b7 ensure t any entity t provides ph>macy b5efits managem5t s]vices "u a contract ) any su* heal? plan or heal? insurance cov]age does n1 ) respect to su* plan or cov]age1 re/rict1 directly or indirectly1 a ph>macy t disp5ses a prescription drug f in=m+ 7or p5alize su* ph>macy = in=m+7 an enrollee ( any diff]5tial betwe5 ! enrollee's out-(-pocket co/ "u su* plan or cov]age ) respect to acquisition ( ! drug & ! am\nt an individual w\ld pay = acquisition ( ! drug )\t us+ any gr\p heal? plan or heal? insurance cov]age4 7b7 ,def9ition ,= purposes ( ?is section1 ! t]m out-(-pocket co/1 ) respect to acquisition ( a drug1 means ! am\nt to be paid by ! enrollee "u ! plan or cov]age1 includ+ any co/-%>+ 7includ+ any d$uctible1 copaym5t1 or co9surance7 &1 z det]m9$ by ! ,secret>y1 any o!r exp5diture4 4 7#b7 ,con=m+ am5dm5t ,section #bgbi ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#bi7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7c7 ,sunset ,! prec$+ provisions ( ?is section %all n apply beg9n+ on ! date ( ! enactm5t ( ?is subsection4 4 7b7 ,,erisa 7#a7 ,9 g5]al ,subp>t ,b ( "p #g ( ,subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #gbg4 ,in=mation on prescription drugs 7a7 ,9 g5]al ,a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all-- 7#a7 n re/rict1 directly or indirectly1 any ph>macy t disp5ses a prescription drug to a p>ticipant or b5efici>y 9 ! plan or cov]age f in=m+ 7or p5alize su* ph>macy = in=m+7 a p>ticipant or b5efici>y ( any diff]5tial betwe5 ! p>ticipant's or b5efici>y's out-(-pocket co/ "u ! plan or cov]age ) respect to acquisition ( ! drug & ! am\nt an individual w\ld pay = acquisition ( ! drug )\t us+ any gr\p heal? plan or heal? insurance cov]age2 & 7#b7 ensure t any entity t provides ph>macy b5efits managem5t s]vices "u a contract ) any su* heal? plan or heal? insurance cov]age does n1 ) respect to su* plan or cov]age1 re/rict1 directly or indirectly1 a ph>macy t disp5ses a prescription drug f in=m+ 7or p5alize su* ph>macy = in=m+7 a p>ticipant or b5efici>y ( any diff]5tial betwe5 ! p>ticipant's or b5efici>y's out-(-pocket co/ "u su* plan or cov]age ) respect to acquisition ( ! drug & ! am\nt an individual w\ld pay = acquisition ( ! drug )\t us+ any gr\p heal? plan or heal? insurance cov]age4 7b7 ,def9ition ,= purposes ( ?is section1 ! t]m out-(-pocket co/1 ) respect to acquisition ( a drug1 means ! am\nt to be paid by ! p>ticipant or b5efici>y "u ! plan or cov]age1 includ+ any co/-%>+ 7includ+ any d$uctible1 copaym5t1 or co9surance7 &1 z det]m9$ by ! ,secret>y1 any o!r exp5diture4 4 7#b7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajja et seq47 is am5d$ by ins]t+ aft] ! item relat+ to section #gbf ! foll[+ new item3 ,sec4 #gbg4 ,in=mation on prescription drugs4 4 7c7 ,,irc 7#a7 ,9 g5]al ,sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+3 #ihbg4 ,in=mation on prescription drugs 7a7 ,9 g5]al ,a gr\p heal? plan %all-- 7#a7 n re/rict1 directly or indirectly1 any ph>macy t disp5ses a prescription drug to a p>ticipant or b5efici>y 9 ! plan f in=m+ 7or p5alize su* ph>macy = in=m+7 a p>ticipant or b5efici>y ( any diff]5tial betwe5 ! p>ticipant's or b5efici>y's out-(-pocket co/ "u ! plan ) respect to acquisition ( ! drug & ! am\nt an individual w\ld pay = acquisition ( ! drug )\t us+ any gr\p heal? plan or heal? insurance cov]age2 & 7#b7 ensure t any entity t provides ph>macy b5efits managem5t s]vices "u a contract ) any su* plan does n1 ) respect to su* plan or cov]age1 re/rict1 directly or indirectly1 a ph>macy t disp5ses a prescription drug f in=m+ 7or p5alize su* ph>macy = in=m+7 a p>ticipant or b5efici>y ( any diff]5tial betwe5 ! p>ticipant's or b5efici>y's out-(-pocket co/ "u ! plan ) respect to acquisition ( ! drug & ! am\nt an individual w\ld pay = acquisition ( ! drug )\t us+ any gr\p heal? plan or heal? insurance cov]age4 7b7 ,def9ition ,= purposes ( ?is section1 ! t]m out-(-pocket co/1 ) respect to acquisition ( a drug1 means ! am\nt to be paid by ! p>ticipant or b5efici>y "u ! plan1 includ+ any co/-%>+ 7includ+ any d$uctible1 copaym5t1 or co9surance7 &1 z det]m9$ by ! ,secret>y1 any o!r exp5diture4 4 7#b7 ,cl]ical am5dm5t ,! table ( sections = sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new item3 ,sec4 #ihbg4 ,in=mation on prescription drugs4 4 #e4 ,v]tical integration acc\ntability 7a7 ,requir$ ,,ma & ,,pdp report+ 7#a7 ,,ma plans ,section #aheg7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;e77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#f7 ,requir$ disclosure ( c]ta9 in=mation relat+ to heal? c>e provid] own]%ip 7,a7 ,9 g5]al ,= plan ye> #bjbh & = e ?ird plan ye> !reaft]1 ea* applicable ,,ma organization (f]+ an ,,ma plan "u ?is "p dur+ su* plan ye> %all submit to ! ,secret>y1 at a "t & 9 a mann] specifi$ by ! ,secret>y-- 7i7 ! taxpay] id5tification numb] = ea* heal? c>e provid] t 0 a specifi$ heal? c>e provid] ) respect to su* organization dur+ su* ye>2 7ii7 ! total am\nt ( inc5tive-bas$ paym5ts made ) respect to su* plan ye> to su* specifi$ heal? c>e provid]s t h 9 effect a f9ancial risk arrangem5t ) respect to su* plan ye>2 7iii7 ! total am\nt ( rec\pm5ts collect$ ) respect to su* plan ye> f su* specifi$ heal? c>e provid]s t h 9 effect a f9ancial risk arrangem5t ) respect to su* plan ye>2 7iv7 ! total am\nt ( inc5tive-bas$ paym5ts made ) respect to su* plan ye> to provid]s ( s]vices & suppli]s n t are n specifi$ heal? c>e provid]s & t h 9 effect a f9ancial risk arrangem5t ) respect to su* plan ye>2 & 7v7 ! total am\nt ( rec\pm5ts collect$ ) respect to su* plan ye> f su* provid]s ( s]vices & suppli]s t h 9 effect a f9ancial risk arrangem5t ) respect to su* plan ye>4 7,b7 ,def9itions ,= purposes ( ?is p>agraph3 7i7 ,applicable ,,ma organization ,! t]m applicable ,,ma organization means1 ) respect to a plan ye>1 an ,,ma organization ) at lea/ #be1jjj individuals enroll$ across all ,m$ic>e ,advantage plans (f]$ by su* organization dur+ su* plan ye>4 7ii7 ,specifi$ heal? c>e provid] ,! t]m specifi$ heal? c>e provid] means1 ) respect to an applicable ,,ma organization & a plan ye>1 a provid] ( s]vices or suppli] t-- 7,i7 is own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* ,,ma organization2 7,,ii7 has 9 effect a contract solely ) su* organization 7or ) an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* organization 7or t has 9 effect any comp>able arrangem5t ) su* organization77 = furni%+ items & s]vices2 7,,iii7 is a p>tn] "u a p>tn]%ip 7z def9$ 9 section #ggja7;a77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf7 ) su* organization 7or ) any an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* organization72 or 7,,iv7 ?r\gh contract1 own]%ip1 or o!rwise-- 7aa7 directly or indirectly controls1 is controll$ by1 or is "u common own]%ip ) su* organization 7or ) an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* organization72 7bb7 is "p ( a controll$ gr\p ( corporations "u section #aefc ( ! ,int]nal ,rev5ue ,code ( #aihf ) su* organization 7or ) any su* entity72 7cc7 is a p>ticipant 9 a lawful comb9ation "u :i* su* provid] or suppli] %>es sub/antial f9ancial risk 9 connection ) su* organization's op]ations 7or ) ! op]ations ( any su* entity72 or 7dd7 "p ( an affiliat$ s]vice gr\p "u section #dad ( su* ,code ) su* organization 7or ) any su* entity74 4 7#b7 ,prescription drug plans ,section #ahfj;,d-#ab7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aab7;b77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#i7 ,provision ( in=mation relat+ to ph>macy own]%ip 7,a7 ,9 g5]al ,= plan ye> #bjbh & = e ?ird plan ye> !reaft]1 ea* ,,pdp sponsor (f]+ a prescription drug plan "u ?is "p dur+ su* plan ye> %all submit to ! ,secret>y1 at a "t & 9 a mann] specifi$ by ! ,secret>y1 ! taxpay] id5tification numb] & ,national ,provid] ,id5tifi] = ea* ph>macy t 0 a specifi$ ph>macy ) respect to su* plan dur+ su* ye>4 7,b7 ,def9ition ,= purposes ( ?is p>agraph1 ! t]m specifi$ ph>macy means1 ) respect to a prescription drug plan (f]$ by a ,,pdp sponsor & a plan ye>1 a ph>macy t-- 7i7 is own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* sponsor2 7ii7 has 9 effect a contract solely ) su* sponsor 7or ) an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* sponsor 7or t has 9 effect any comp>able arrangem5t ) su* sponsor77 = disp5s+ cov]$ "p ,d drugs2 7iii7 is a p>tn] "u a p>tn]%ip 7z def9$ 9 section #ggja7;a77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf7 ) su* sponsor 7or ) any an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* sponsor72 or 7iv7 ?r\gh contract1 own]%ip1 or o!rwise-- 7,i7 directly or indirectly controls1 is controll$ by1 or is "u common own]%ip ) su* sponsor 7or ) an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* sponsor72 7,,ii7 is "p ( a controll$ gr\p ( corporations "u section #aefc ( ! ,int]nal ,rev5ue ,code ( #aihf ) su* sponsor 7or ) any su* entity72 7,,iii7 is a p>ticipant 9 a lawful comb9ation "u :i* su* provid] or suppli] %>es sub/antial f9ancial risk 9 connection ) su* sponsor's op]ations 7or ) ! op]ations ( any su* sponsor72 or 7,,iv7 "p ( an affiliat$ s]vice gr\p "u section #dad ( su* ,code ) su* sponsor 7or ) any su* entity74 4 7b7 ,reports on v]tical integration "u ,m$ic>e 7#a7 ,9 g5]al ,n lat] ?an ! fir/ ,june #ae occurr+ on or aft] ! date t is #b ye>s aft] ! ,secret>y ( ,heal? & ,human ,s]vices fir/ makes available in=mation submitt$ "u sections #aheg7;e77#f7 & #ahfj;,d-#ab7;b77#i7 ( ! ,social ,security ,act 7z add$ by p>agraphs 7#a7 & 7#b71 respectively1 ( subsection 7a77 to ! ,m$ic>e ,paym5t ,advisory ,commission1 & aga9 n lat] ?an #d ye>s aft] ! fir/ report is submitt$ "u ?is p>agraph1 ! ,m$ic>e ,paym5t ,advisory ,commission %all submit to ,congress a report on ! /ate ( v]tical integration 9 ! heal? c>e sector dur+ ! applicable ye> ) respect to entities p>ticipat+ 9 ! ,m$ic>e program "u "p ,c ( title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ba et seq47 or "p ,d ( su* title 7#db ,u4,s4,c4 #aciew-#aja et seq471 includ+ heal? c>e provid]s1 ph>macies1 prescription drug plan sponsors1 ,m$ic>e ,advantage organizations1 & ph>macy b5efit manag]s4 ,su* report %all include1 to ! ext5t practicable-- 7,a7 ) respect to ,m$ic>e ,advantage organizations1 ! evaluation describ$ 9 p>agraph 7#b72 7,b7 ) respect to prescription drug plans1 ph>macy b5efit manag]s1 & ph>macies1 ! comp>isons & summ>y describ$ 9 p>agraph 7#c72 7,c7 an assessm5t ( ! ,m$ic>e ,advantage organization & ,,pdp sponsor integration in=mation describ$ 9 p>agraph 7#d72 & 7,d7 an analysis ( ! impact ( su* integration on heal? c>e access1 price1 quality1 & outcomes4 7#b7 ,m$ic>e ,advantage organizations ,= purposes ( p>agraph 7#a77;,a71 ! evaluation describ$ 9 ?is p>agraph is1 ) respect to ,m$ic>e ,advantage organizations & an applicable ye>1 an evaluation1 tak+ into acc\nt pati5t acuity & ! types ( areas s]vic$ by su* organization1 (-- 7,a7 ! av]age numb] ( qualify+ diagnoses made dur+ su* ye> ) respect to enrollees ( a ,m$ic>e ,advantage plan (f]$ by su* organization :o1 dur+ su* ye>1 receiv$ a heal? risk assessm5t f a specifi$ heal? c>e provid]1 comp>$ to ! av]age numb] ( su* diagnoses made dur+ su* ye> ) respect to enrollees ( su* plan :o1 dur+ su* ye>1 did n receive su* an assessm5t f su* a provid]2 7,b7 ! av]age risk score = enrollees ( a ,m$ic>e ,advantage plan :o receiv$ su* an assessm5t f a specifi$ heal? c>e provid] dur+ su* ye> comp>$ to ! av]age risk score = enrollees ( su* plan :o did n receive su* an assessm5t f su* a provid] dur+ su* ye>2 7,c7 any relation%ip betwe5 risk scores = su* enrollees receiv+ su* an assessm5t f su* a provid] dur+ su* ye> & inc5tive-bas$ paym5ts made to su* provid]s2 7,d7 ! av]age risk score = enrollees ( su* plan :o receiv$ any item or s]vice f a specifi$ heal? c>e provid] dur+ su* ye> comp>$ to ! av]age risk score = enrollees ( su* plan :o did n receive any item or s]vice f su* a provid] dur+ su* ye>2 7,e7 any relation%ip betwe5 ! risk scores ( enrollees "u su* plan & :e!r ! enrollees h receiv$ any item or s]vice f a specifi$ provid]2 & 7,f7 any relation%ip betwe5 ! risk scores ( enrollees "u su* plan t h receiv$ any item or s]vice f a specifi$ provid] & inc5tive-bas$ paym5ts made "u ! plan to specifi$ provid]s4 7#c7 ,prescription drug plans ,= purposes ( p>agraph 7#a77;,b71 ! comp>isons & summ>y describ$ 9 ?is p>agraph are1 ) respect to prescription drug plans & an applicable ye>1 ! foll[+3 7,a7 ,= ea* cov]$ "p ,d drug = :i* b5efits are available "u su* a plan1 a comp>ison ( in=mation ab\t paym5ts submitt$ ) respect to su* plan "u section #ahfj;,d-#ab7;h77#a77;,c77i77,i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aab7;h77#a77;,c77i77,i77 ) respect to specifi$ ph>macies ) ! same su* in=mation ab\t paym5ts submitt$ by su* plan ) respect to 9-network ph>macies t are n specifi$ ph>macies4 7,b7 ,comp>isons ( ! foll[+3 7i7 ,! total am\nt paid by ph>macy b5efit manag]s to specifi$ ph>macies = cov]$ "p ,d drugs & ! total am\nt s paid to ph>macies t are n specifi$ ph>macies = su* drugs4 7ii7 ,! total am\nt paid by su* sponsors to specifi$ ph>macy b5efit manag]s z reimbursem5t = cov]$ "p ,d drugs & ! total am\nt s paid to ph>macy b5efit manag]s t are n specifi$ ph>macy b5efit manag]s z su* reimbursem5t4 7,c7 ,a summ>y ( ! total manufactur]-d]iv$ rev5ue reta9$ by ph>macy b5efit manag]s & any affiliates ( su* ph>macy b5efit manag]s 7z report$ "u section #ahfj;,d-#ab7;h77#a77;,c77i77,i77kk7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aab7;h77#a77;,c77i77,i77kk774 7#d7 ,m$ic>e ,advantage organization & ,,pdp sponsor integration in=mation ,= purposes ( p>agraph 7#a77;,c71 ! ,m$ic>e ,advantage organization & ,,pdp sponsor integration in=mation describ$ 9 ?is p>agraph is in=mation submitt$ "u sections #aheg7;e77#f7 & #ahfj;,d-#ab7;b77#i7 ( ! ,social ,security ,act 7z add$ by p>agraphs 7#a7 & 7#b71 respectively1 ( subsection 7a77 & section#ahfj;,d-#ab7;h7 ( su* ,act 7#db ,u4,s4,c4 #aciew-#aab7;h774 7#e7 ,def9itions ,9 ?is subsection3 7,a7 ,applicable ye> ,! t]m applicable ye> means-- 7i7 ) respect to ! fir/ report submitt$ "u p>agraph 7#a71 plan ye> #bjbh2 & 7ii7 ) respect to ! second report submitt$ "u p>agraph 7#a71 plan ye> #bjca4 7,b7 ,cov]$ "p ,d drug ,! t]m cov]$ "p ,d drug has ! mean+ giv5 su* t]m 9 section #ahfj;,d-#b7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajb7;e774 7,c7 ,qualify+ diagnosis ,! t]m qualify+ diagnosis means1 ) respect to an enrollee ( a ,m$ic>e ,advantage plan1 a diagnosis t is tak5 into acc\nt 9 calculat+ a risk score = su* enrollee "u ! risk adju/m5t me?odology e/abli%$ by ! ,secret>y pursuant to section #ahec7;a77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acjew-#bc7;a77#c774 7,d7 ,risk score ,! t]m risk score means1 ) respect to an enrollee ( a ,m$ic>e ,advantage plan1 ! score calculat$ = su* individual us+ ! me?odology describ$ 9 subp>agraph 7,e74 7,e7 ,specifi$ heal? c>e provid] ,! t]m specifi$ heal? c>e provid] means1 ) respect to a ,m$ic>e ,advantage plan (f]$ by a ,m$ic>e ,advantage organization1 a heal? c>e provid] t-- 7i7 is own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* organization2 7ii7 has 9 effect a contract solely ) su* organization 7or ) an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* organization 7or t has 9 effect any comp>able arrangem5t ) su* organization77 = furni%+ items & s]vices2 7iii7 is a p>tn] "u a p>tn]%ip 7z def9$ 9 section #ggja7;a77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf7 ) su* organization 7or ) any an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* organization72 or 7iv7 ?r\gh contract1 own]%ip1 or o!rwise-- 7,i7 directly or indirectly controls1 is controll$ by1 or is "u common own]%ip ) su* organization 7or ) an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* organization72 7,,ii7 is "p ( a controll$ gr\p ( corporations "u section #aefc ( ! ,int]nal ,rev5ue ,code ( #aihf ) su* organization 7or ) any su* entity72 7,,iii7 is a p>ticipant 9 a lawful comb9ation "u :i* su* provid] or suppli] %>es sub/antial f9ancial risk 9 connection ) su* organization's op]ations 7or ) ! op]ations ( any su* entity72 or 7,,iv7 "p ( an affiliat$ s]vice gr\p "u section #dad ( su* ,code ) su* organization 7or ) any su* entity74 7,f7 ,specifi$ ph>macy ,! t]m specifi$ ph>macy means1 ) respect to a prescription drug plan (f]$ by a prescription drug plan sponsor1 a ph>macy t-- 7i7 is own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* sponsor2 7ii7 has 9 effect a contract solely ) su* sponsor 7or ) an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* sponsor 7or t has 9 effect any comp>able arrangem5t ) su* sponsor77 = disp5s+ cov]$ "p ,d drugs2 7iii7 is a p>tn] "u a p>tn]%ip 7z def9$ 9 section #ggja7;a77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf7 ) su* sponsor 7or ) any an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* sponsor72 or 7iv7 ?r\gh contract1 own]%ip1 or o!rwise-- 7,i7 directly or indirectly controls1 is controll$ by1 or is "u common own]%ip ) su* sponsor 7or ) an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* sponsor72 7,,ii7 is "p ( a controll$ gr\p ( corporations "u section #aefc ( ! ,int]nal ,rev5ue ,code ( #aihf ) su* sponsor 7or ) any su* entity72 7,,iii7 is a p>ticipant 9 a lawful comb9ation "u :i* su* provid] or suppli] %>es sub/antial f9ancial risk 9 connection ) su* sponsor's op]ations 7or ) ! op]ations ( any su* entity72 or 7,,iv7 "p ( an affiliat$ s]vice gr\p "u section #dad ( su* ,code ) su* sponsor 7or ) any su* entity74 7,g7 ,specifi$ ph>macy b5efit manag] ,! t]m specifi$ ph>macy b5efit manag] means1 ) respect to a prescription drug plan (f]$ by a prescription drug plan sponsor1 a ph>macy b5efit manag] t-- 7i7 is own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* sponsor2 7ii7 has 9 effect a contract solely ) su* sponsor 7or ) an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* sponsor 7or t has 9 effect any comp>able arrangem5t ) su* sponsor77 = furni%+ ph>macy b5efit managem5t s]vices2 7iii7 is a p>tn] "u a p>tn]%ip 7z def9$ 9 section #ggja7;a77#b7 ( ! ,int]nal ,rev5ue ,code ( #aihf7 ) su* sponsor 7or ) any an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* sponsor72 or 7iv7 ?r\gh contract1 own]%ip1 or o!rwise-- 7,i7 directly or indirectly controls1 is controll$ by1 or is "u common own]%ip ) su* sponsor 7or ) an entity own$ by1 controll$ by1 or relat$ "u a common own]%ip /ructure ) su* sponsor72 7,,ii7 is "p ( a controll$ gr\p ( corporations "u section #aefc ( ! ,int]nal ,rev5ue ,code ( #aihf ) su* sponsor 7or ) any su* entity72 7,,iii7 is a p>ticipant 9 a lawful comb9ation "u :i* su* provid] or suppli] %>es sub/antial f9ancial risk 9 connection ) su* sponsor's op]ations 7or ) ! op]ations ( any su* entity72 or 7,,iv7 "p ( an affiliat$ s]vice gr\p "u section #dad ( su* ,code ) su* sponsor 7or ) any su* entity74 #f4 ,implem5tation fund+ 7a7 ,9 g5]al ,= ! purposes describ$ 9 subsection 7b71 !re are appropriat$1 9 addition to am\nts o!rwise available1 out ( am\nts 9 ! ,treasury n o!rwise appropriat$-- 7#a7 to ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ! ,treasury1 #fe1jjj1jjj = fiscal ye> #bjbg1 to rema9 available ?r\gh fiscal ye> #bjcb2 & 7#b7 to ! ,secret>y ( ,labor1 #ce1jjj1jjj = fiscal ye> #bjbg1 to rema9 available ?r\gh fiscal ye> #bjcb4 7b7 ,p]mitt$ purposes ,! purposes describ$ 9 ?is subsection are ! foll[+ purposes1 ins(> z su* purposes are to c>ry out ! provisions (1 includ+ ! am5dm5ts made by1 ?is title3 7#a7 ,prep>+1 draft+1 & issu+ propos$ & f9al regulations or int]im regulations4 7#b7 ,prep>+1 draft+1 & issu+ guidance & public in=mation4 7#c7 ,prep>+1 draft+1 & publi%+ reports4 7#d7 ,en=cem5t ( su* provisions4 7#e7 ,report+1 collection1 & analysis ( data4 7#f7 ,o!r adm9i/rative duties necess>y = implem5tation ( su* provisions4 7c7 ,transp>5cy ( implem5tation funds ,ea* ,secret>y describ$ 9 subsection 7a7 %all annually submit1 n lat] ?an ,septemb] #a/ ( ea* ye>1 to ! ,committees on ,en]gy & ,comm]ce1 on ,ways & ,means1 on ,education & ! ,work=ce1 & on ,appropriations ( ! ,h\se ( ,repres5tatives & ! ,committees on ,heal?1 ,education1 ,labor1 & ,p5sions1 on ,f9ance1 & on ,appropriations ( ! ,s5ate a report on funds exp5d$ pursuant to funds appropriat$ "u ?is section4