,,ii ,cal5d> ,no4 #ebb #aai? ,,congress #b;d ,session ,s4 #bcee ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,july #ag1 #bjbe,mr4 ,m>%all 7= himself1 ,mr4 ,hick5loop]1 ,mr4 ,grassley1 ,ms4 ,hassan1 ,mr4 ,%eehy1 ,ms4 ,ern/1 ,ms4 ,baldw91 ,mr4 ,mor5o1 ,mr4 ,scott ( ,florida1 ,mr4 ,kim1 ,mr4 ,hu/$1 ,ms4 ,blunt ,ro*e/]1 ,mr4 ,tub]ville1 ,ms4 ,lummis1 ,mr4 ,coons1 ,mr4 ,mull91 ,mr4 ,book]1 ,mr4 ,wel*1 ,mr4 ,pet]s1 ,ms4 ,w>r51 ,mr4 ,arm/rong1 ,mr4 ,kelly1 ,mr4 ,s*mitt1 ,mr4 ,fett]man1 & ,mr4 ,gallego7 introduc$ ! foll[+ bill2 :i* 0 read twice & ref]r$ to ! ,committee on ,heal?1 ,education1 ,labor1 & ,p5sions ,july #bg1 #bjbf,report$ by ,mr4 ,cassidy1 ) an amendment,strike out all aft] ! enact+ clause & ins]t ! "p pr9t$ 9 italic ,a ,,bill ,to am5d ! ,public ,heal? ,s]vice ,act to provide = hospital & insur] price transp>5cy4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,pati5ts ,des]ve ,price ,tags ,act4 #b4 ,/r5g!n+ hospital price transp>5cy requirem5ts 7a7 ,9 g5]al ,section #bgah7;e7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7;e77 is am5d$ to read z foll[s3 7e7 ,/&>d hospital *>ges 7#a7 ,9 g5]al 7,a7 ,disclosure ( /&>d *>ges ,ea* hospital %all1 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u subp>agraph 7,c71 on a mon?ly basis compile & make public 7)\t subscription & free ( *>ge7-- 7i7 all ( ! hospital's /&>d *>ges 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = ea* item & s]vice furni%$ by su* hospital2 & 7ii7 hospital /&>d *>ge in=mation1 includ+ ! in=mation describ$ 9 subp>agraph 7,b71 9 a consum]-fri5dly =mat 7z specifi$ by ! ,secret>y71 t includes-- 7,i7 z _m ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vices t are furni%$ by ! hospital1 & z _m additional hospital-select$ %oppable s]vices 7or all su* additional s]vices1 if su* hospital furni%es few] ?an #cjj %oppable s]vices7 z may be necess>y = a comb9$ total ( at lea/ #cjj %oppable s]vices ?r\gh ,decemb] #ca1 #bjbf1 aft] :i* ! hospital's prices %all include all %oppable s]vices2 & 7,,ii7 ) respect to ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice t is n furni%$ by ! hospital1 an indication t su* s]vice is n s furni%$4 7,b7 ,/&>d *>ges describ$ ,= purposes ( subp>agraph 7,a71 /&>d *>ges means3 7i7 ,a pla9 language description ( ea* item or s]vice1 accompani$ by any applicable bill+ codes1 includ+ modifi]s1 us+ commonly recogniz$ bill+ code sets1 includ+ ! ,curr5t ,proc$ural ,t]m9ology code1 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! diagnosis-relat$ gr\p1 ! ,national ,drug ,code1 & o!r nationally recogniz$ id5tifi]4 7ii7 ,! gross *>ge1 express$ z a doll> am\nt1 = ea* su* item or s]vice1 :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 7iii7 ,! disc\nt$ ca% price express$ z a doll> am\nt1 = ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+ 7or1 9 ! case no disc\nt$ ca% price is available = an item or s]vice1 ! m9imum ca% price accept$ by ! hospital f self-pay individuals = su* item or s]vice1 express$ z a doll> am\nt1 z well z1 ) respect to prices made public pursuant to subp>agraph 7,a77ii71 a l9k to a consum]-fri5dly docum5t t cle>ly expla9s ! hospital's *>ity c>e policy74 ,! hospital %all accept ! disc\nt$ ca% price z paym5t 9 full f any pati5t t *ooses to pay 9 ca% )\t reg>d to ! pati5t's cov]age4 7iv7 ,! pay]-specific negotiat$ *>ges1 express$ z a doll> am\nt & cle>ly associat$ ) ! "n ( ! applicable ?ird p>ty pay] & "n ( ea* plan1 t apply to ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 ,if ! *>ges are bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! hospital also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r t]ms1 s*$ules1 exhibits1 data1 or o!r in=mation ref]5c$ 9 any su* contract z %all be requir$ to det]m9e & disclose ! negotiat$ *>ge4 7v7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges = ea* su* item or s]vice1 express$ z a non-z]o doll> am\nt4 7vi7 ,any o!r additional in=mation ! ,secret>y may require = ! purpose ( improv+ ! accuracy (1 or enabl+ consum]s to easily und]/& & comp>e1 /&>d *>ges & prices = an item or s]vice1 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is subsection4 ,9 ! case ( /&>d *>ges & prices = an item or s]vice includ$ z "p ( a bundl$1 p] diem1 episodic1 or o!r simil> arrangem5t1 ! in=mation describ$ 9 ?is subp>agraph %all be made available z det]m9$ appropriate by ! ,secret>y4 7,c7 ,uni=m me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbf1 ! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = hospitals to use 9 compil+ & mak+ public /&>d *>ges pursuant to subp>agraph 7,a77i7 & a /&>d1 uni=m me?od & =mat = su* hospitals to use 9 compil+ & mak+ public prices pursuant to subp>agraph 7,a77ii74 ,su* me?ods & =mats %all-- 7i7 9 ! case ( su* me?od & =mat = mak+ public /&>d *>ges pursuant to subp>agraph 7,a77i71 ensure t su* *>ges are made available 9 a ma*9e-readable spread%eet =mat2 7ii7 meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges & prices2 & 7iii7 be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#b7 ,no deem$ compliance ,! availability ( a price e/imator tool %all n be consid]$ to deem compliance ) or o!rwise vitiate ! requirem5ts ( p>agraph 7#a77;,a77ii7 or any o!r requirem5ts ( ?is section4 ,fur!rmore1 ! use ( an e/imator tool %all n be us$ = purposes ( compliance ) any provisions 9 ?is ,section4 7#c7 ,monitor+ compliance ,! ,secret>y %all1 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 e/abli% a process to monitor compliance ) ?is subsection4 ,su* process %all ensure t ea* hospital's compliance ) ?is subsection is review$ n less frequ5tly ?an once e ye>4 7#d7 ,atte/ation ,a s5ior (ficial f ea* hospital 7! ,*ief ,executive ,(fic]1 ,*ief ,f9ancial ,(fic]1 or an (ficial ( equival5t s5iority7 %all atte/ to ! accuracy & complet5ess ( ! disclosures made 9 accordance ) ! hospital price transp>5cy requirem5ts set =? 9 ?is regulation4 ,su* atte/ation %all be deem$ to be mat]ial to paym5t f ! ,f$]al ,gov]nm5t to ! hospital4 7#e7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( a hospital t fails to comply ) ! requirem5ts ( ?is subsection1 n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s1 ! ,secret>y %all submit to su* hospital a notification ( su* det]m9ation1 :i* %all include a reque/ = a corrective action plan to comply ) su* requirem5ts4 7,b7 ,civil monet>y p5alty 7i7 ,9 g5]al ,9 addition to any o!r en=cem5t actions or p5alties t may apply "u ano!r provision ( law1 a hospital t has receiv$ a reque/ = a corrective action plan "u subp>agraph 7,a7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #de days aft] su* reque/ is made %all be subject to a civil monet>y p5alty ( an am\nt specifi$ by ! ,secret>y = ea* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* hospital 0 n comply+ ) su* requirem5ts7 dur+ :i* su* failure 0 ongo+4 ,su* am\nt %all n exce$-- 7,i7 9 ! case ( a hospital ) #cj or few] b$s1 #cjj p] day2 7,,ii7 9 ! case ( a hospital ) m ?an #cj b$s b few] ?an #aja b$s1 #ab4ej p] b$ p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #ae p] b$ p] day72 7,,iii7 9 ! case ( a hospital ) m ?an #ajj b$s b few] ?an #cja b$s1 #ag4ej p] b$ p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #bj p] b$ p] day72 7,,iv7 9 ! case ( a hospital ) m ?an #cjj b$s b few] ?an #eja b$s1 #bj p] b$ p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #be p] b$ p] day72 & 7,v7 9 ! case ( a hospital ) m ?an #ejj b$s1 #be p] b$ p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #ce p] b$ p] day74 7ii7 ,increase au?ority ,9 apply+ ?is subp>agraph ) respect to violations occurr+ 9 #bjbg or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase-- 7,i7 ! limitation on ! p] day am\nt ( any p5alty applicable to a hospital "u clause 7i77,i72 7,,ii7 ! limitations on ! p] b$ p] day am\nt ( any p5alty applicable "u any ( subclauses 7,,ii7 ?r\gh 7,v7 ( clause 7i72 & 7,,iii7 ! limitation on ! increase ( any p5alty appli$ "u clause 7iii7 pursuant to ! am\nts specifi$ 9 subclause 7,,ii7 ( su* clause4 7iii7 ,p]si/5t noncompliance 7,i7 ,9 g5]al ,9 ! case ( a hospital t ! ,secret>y has det]m9$ to be kn[+ly & willfully noncompliant ) ! provisions ( ?is subsection two or m times dur+ a #a-ye> p]iod1 ! ,secret>y may increase any p5alty o!rwise applicable "u ?is subp>agraph by ! am\nt specifi$ 9 subclause 7,,ii7 ) respect to su* hospital & may require su* hospital to complete su* additional corrective actions plans z ! ,secret>y may specify4 7,,ii7 ,specifi$ am\nt ,= purposes ( subclause 7,i71 ! am\nt specifi$ 9 ?is subclause is1 ) respect to a hospital-- 7aa7 ) m ?an #cj b$s b few] ?an #aja b$s1 an am\nt t is n less ?an #ejj1jjj & n m ?an #a1jjj1jjj2 7bb7 ) m ?an #ajj b$s b few] ?an #cja b$s1 an am\nt t is great] ?an #a1jjj1jjj & n m ?an #b1jjj1jjj2 7cc7 ) m ?an #cjj b$s b few] ?an #eja b$s1 an am\nt t is great] ?an #b1jjj1jjj & n m ?an #d1jjj1jjj2 & 7dd7 ) m ?an #ejj b$s1 & am\nt t is n less ?an #e1jjj1jjj & n m ?an #aj1jjj1jjj4 7iv7 ,provision ( te*nical assi/ance ,! ,secret>y may1 to ! ext5t practicable1 provide te*nical assi/ance relat+ to compliance ) ! provisions ( ?is section to hospitals reque/+ su* assi/ance4 7v7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is subp>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7,c7 ,no waiv] ,! ,secret>y %all n grant or ext5d any waiv]1 delay1 toll+1 or o!r mitigation ( a civil monet>y p5alty = violation ( ?is subsection4 7#f7 ,def9itions ,= purposes ( ?is subsection3 7,a7 ,disc\nt$ ca% price ,! t]m disc\nt$ ca% price means ! m9imum *>ge1 exclusive ( any hospital or ?ird-p>ty pay] assi/ance1 t ! hospital accepts f an individual :o pays ca%1 or ca% equival5t1 = a hospital-furni%$ item or s]vice1 )\t reg>d to pati5t cov]age1 z paym5t 9 full4 7,b7 ,gross *>ge ,! t]m gross *>ge means ! *>ge = an individual item or s]vice t is reflect$ on a hospital's *>gema/]1 abs5t any disc\nts4 7,c7 ,hospital ,! t]m hospital means a hospital 7z def9$ 9 section #ahfa7;e7 ( ! ,social ,security ,act71 a critical access hospital 7z def9$ 9 section #ahfa7mmm77#a7 ( ! ,social ,security ,act71 or a rural em]g5cy hospital 7z def9$ 9 section #ahfa7kkk7 ( ! ,social ,security ,act71 toge!r ) any p>5t1 subsidi>y1 or o!r affiliat$ provid] or suppli] ( heal? c>e items & s]vices )\t reg>d to :e!r su* p>5t1 subsidi>y1 or o!r affiliat$ provid] or suppli] op]ates "u sep>ate lic5sure1 c]tification1 or designation4 7,d7 ,pay]-specific negotiat$ *>ge ,! t]m pay]-specific negotiat$ *>ge means ! *>ge t a hospital has negotiat$ ) a ?ird p>ty pay] = an item or s]vice4 7,e7 ,%oppable s]vice ,! t]m %oppable s]vice means a s]vice t c be s*$ul$ by a heal? c>e consum] 9 advance & includes all ancill>y items & s]vices cu/om>ily furni%$ z "p ( su* s]vice4 7,f7 ,?ird p>ty pay] ,! t]m ?ird p>ty pay] means an entity t is1 by /atute1 contract1 or agreem5t1 legally responsible = paym5t ( a claim = a heal? c>e item or s]vice4 7#g7 ,rulemak+ ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7b7 ,effective date 7#a7 ,9 g5]al ,! am5dm5t made by subsection 7a7 %all apply beg9n+ ,janu>y #a1 #bjbf4 7#b7 ,cont9u$ applicability ( rules = previ\s ye>s ,no?+ 9 ! am5dm5t made by ?is section may be con/ru$ z affect+ ! applicability ( ! regulations codifi$ at "p #ahj ( title #de1 ,code ( ,f$]al ,regulations1 be=e ,janu>y #a1 #bjbe4 7c7 ,cont9u$ applicability ( /ate law ,! provisions ( ?is ,act %all n sup]s$e any provision ( ,/ate law t e/abli%es1 implem5ts1 or cont9ues 9 effect any requirem5t or prohibition relat$ to heal? c>e price transp>5cy1 except to ! ext5t t su* requirem5t or prohibition prev5ts ! application ( a requirem5t or prohibition ( ?is ,act4 #c4 ,increas+ price transp>5cy ( cl9ical diagno/ic laboratory te/s ,section #bgah ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah7 is am5d$ by add+ at ! end ! foll[+3 7f7 ,cl9ical diagno/ic laboratory price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,july #a1 #bjbg1 an applicable laboratory %all-- 7,a7 make publicly available on an int]net website ! in=mation describ$ 9 p>agraph 7#b7 ) respect to ea* su* specifi$ cl9ical diagno/ic laboratory te/ t su* laboratory s furni%es2 & 7,b7 ensure t su* in=mation is updat$ n less frequ5tly ?an mon?ly1 if !re h be5 any *anges to su* in=mation4 7#b7 ,in=mation describ$ ,= purposes ( p>agraph 7#a71 ! in=mation describ$ 9 ?is p>agraph is1 ) respect to an applicable laboratory & a specifi$ cl9ical diagno/ic laboratory te/1 ! foll[+3 7,a7 ,a pla9 language description ( ea* item or s]vice1 accompani$ by any applicable bill+ codes1 includ+ modifi]s1 us+ commonly recogniz$ bill+ code sets1 includ+ ! ,curr5t ,proc$ural ,t]m9ology code1 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! diagnosis-relat$ gr\p1 ! ,national ,drug ,code1 & o!r nationally recogniz$ id5tifi]4 7,b7 ,! gross *>ge express$ z a doll> am\nt1 = ea* su* item or s]vice4 7,c7 ,! disc\nt$ ca% price express$ z a doll> am\nt1 = ea* su* item or s]vice 7or1 9 ! case no disc\nt$ ca% price is available = an item or s]vice1 ! m9imum ca% price accept$ by ! laboratory f self-pay individuals = su* item or s]vice :5 provid$ 9 su* sett+s = ! previ\s ?ree ye>s1 express$ z a doll> am\nt1 z well z1 ) respect to prices made public pursuant to subp>agraph 7,a77ii71 a l9k to a consum]-fri5dly docum5t t cle>ly expla9s ! laboratory's *>ity c>e policy74 ,! laboratory %all accept ! disc\nt$ or m9imum ca% price z paym5t 9 full f any pati5t t *ooses to pay 9 ca% )\t reg>d to ! pati5t's cov]age4 7,d7 ,! pay]-specific negotiat$ *>ges1 express$ z a doll> am\nt & cle>ly associat$ ) ! "n ( ! applicable ?ird p>ty pay] & "n ( ea* plan1 t apply to ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 ,if ! *>ges are bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! cl9ical diagno/ic laboratory also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r t]ms1 s*$ules1 exhibits1 data1 or o!r in=mation ref]5c$ 9 any su* contract z %all be requir$ to det]m9e & disclose ! negotiat$ *>ge4 7,e7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges = ea* su* item or s]vice1 express$ z a non-z]o doll> am\nt4 7,f7 ,any o!r additional in=mation ! ,secret>y may require = ! purpose ( improv+ ! accuracy (1 or enabl+ consum]s to easily und]/& & comp>e1 /&>d *>ges & prices = an item or s]vice1 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is subsection4 ,9 ! case ( /&>d *>ges & prices = an item or s]vice includ$ z "p ( a bundl$1 p] diem1 episodic1 or o!r simil> arrangem5t1 ! in=mation describ$ 9 ?is subp>agraph %all be made available z det]m9$ appropriate by ! ,secret>y4 7#c7 ,uni=m me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbg1 ! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = applicable laboratories to use 9 compil+ & mak+ public in=mation pursuant to p>agraph 7#a74 ,su* me?od & =mat %all-- 7,a7 include a ma*9e-readable spread%eet =mat conta9+ ! in=mation describ$ 9 p>agraph 7#b7 = all items & s]vices furni%$ by ea* laboratory2 7,b7 meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* in=mation2 & 7,c7 be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#d7 ,inclusion ( ancill>y s]vices ,any price or rate = a specifi$ cl9ical diagno/ic laboratory te/ available to be furni%$ by an applicable laboratory made publicly available 9 accordance ) p>agraph 7#a7 %all include ! price or rate = any ancill>y item or s]vice 7includ+ specim5 collection s]vices1 specim5 transport1 c5trifugation1 aliquot+1 label+1 requisition process+1 & /&>d result report+ s]vices7 t w\ld cu/om>ily & r\t9ely be furni%$ by su* laboratory z "p ( su* te/1 z specifi$ by ! ,secret>y4 7#e7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case t ! ,secret>y det]m9es t an applicable laboratory is n 9 compliance ) p>agraph 7#a7-- 7i7 n lat] ?an #cj days aft] su* det]m9ation1 ! ,secret>y %all notify su* laboratory ( su* det]m9ation2 & 7ii7 if su* laboratory cont9ues to fail to comply ) su* p>agraph aft] ! date t is #ij days aft] su* notification is s5t1 ! ,secret>y may impose a civil monet>y p5alty 9 an am\nt n to exce$ #cjj = ea* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* laboratory 0 fail+ to comply ) su* p>agraph7 dur+ :i* su* failure is ongo+4 7,b7 ,increase au?ority ,9 apply+ ?is p>agraph ) respect to violations occurr+ 9 #bjbh or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! p] day limitation on civil monet>y p5alties "u subp>agraph 7,a77ii74 7,c7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is p>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7#f7 ,provision ( te*nical assi/ance ,! ,secret>y %all1 to ! ext5t practicable1 provide te*nical assi/ance relat+ to compliance ) ! provisions ( ?is subsection to applicable laboratories reque/+ su* assi/ance4 7#g7 ,def9itions ,9 ?is subsection3 7,a7 ,applicable laboratory ,! t]m applicable laboratory means a laboratory z su* t]m is def9$ 9 section #dic4b1 ( title #db1 ,code ( ,f$]al ,regulations 7or a successor regulation71 except t su* t]m does n include a laboratory ) respect to :i* /&>d *>ges & prices = specifi$ cl9ical diagno/ic laboratory te/s furni%$ by su* laboratory are made available by a hospital pursuant to subsection 7e7 ( ?is section4 7,b7 ,disc\nt$ ca% price ,! t]m disc\nt$ ca% price means ! *>ge t applies to an individual :o pays ca%1 or ca% equival5t1 = an item or s]vice4 7,c7 ,gross *>ge ,! t]m gross *>ge means ! *>ge = an individual item or s]vice t is reflect$ on an applicable laboratory's *>gema/]1 abs5t any disc\nts4 7,d7 ,pay]-specific negotiat$ *>ge ,! t]m pay]-specific negotiat$ *>ge means ! *>ge t an applicable laboratory has negotiat$ ) a ?ird p>ty pay] = an item or s]vice4 7,e7 ,specifi$ cl9ical diagno/ic laboratory te/ ,! t]m specifi$ cl9ical diagno/ic laboratory te/ means a cl9ical diagno/ic laboratory te/ t is includ$ on ! li/ ( %oppable s]vices specifi$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices 7z describ$ 9 subsection 7e7 ( ?is section71 o!r ?an su* a te/ t is only available to be furni%$ by a s+le provid] ( s]vices or suppli]4 7,f7 ,?ird p>ty pay] ,! t]m ?ird p>ty pay] means an entity t is1 by /atute1 contract1 or agreem5t1 legally responsible = paym5t ( a claim = a heal? c>e item or s]vice4 7#h7 ,rulemak+ ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 #d4 ,imag+ transp>5cy ,section #bgah ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah71 z am5d$ by section #c1 is fur!r am5d$ by add+ at ! end ! foll[+3 7g7 ,imag+ s]vices price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,july #a1 #bjbg1 ea* provid] ( s]vices or suppli] t furni%es a specifi$ imag+ s]vice1 o!r ?an su* a provid] or suppli] ) respect to :i* /&>d *>ges & prices = su* s]vices furni%$ by su* provid] or suppli] are made available by a hospital pursuant to subsection 7e71 %all-- 7,a7 make publicly available 79 accordance ) p>agraph 7#c77 on an int]net website ! in=mation describ$ 9 p>agraph 7#b7 ) respect to ea* su* s]vice t su* provid] ( s]vices or suppli] furni%es2 & 7,b7 ensure t su* in=mation is updat$ n less frequ5tly ?an annually4 7#b7 ,in=mation describ$ ,= purposes ( p>agraph 7#a71 ! in=mation describ$ 9 ?is p>agraph is1 ) respect to a provid] ( s]vices or suppli] & a specifi$ imag+ s]vice1 ! foll[+3 7,a7 ,a pla9 language description ( ea* item or s]vice1 accompani$ by any applicable bill+ codes1 includ+ modifi]s1 us+ commonly recogniz$ bill+ code sets1 includ+ ! ,curr5t ,proc$ural ,t]m9ology code1 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! diagnosis-relat$ gr\p1 ! ,national ,drug ,code1 & o!r nationally recogniz$ id5tifi]4 7,b7 ,! gross *>ge express$ z a doll> am\nt1 = ea* su* item or s]vice4 7,c7 ,! disc\nt$ ca% price express$ z a doll> am\nt1 = ea* su* item or s]vice 7or1 9 ! case no disc\nt$ ca% price is available = an item or s]vice1 ! m9imum ca% price accept$ by ! provid] ( s]vices or suppli] f self-pay individuals = su* item or s]vice :5 provid$ 9 su* sett+s = ! previ\s ?ree ye>s1 express$ z a doll> am\nt1 z well z1 ) respect to prices made public pursuant to subp>agraph 7,a77ii71 a l9k to a consum]-fri5dly docum5t t cle>ly expla9s ! provid] ( s]vices or suppli]'s *>ity c>e policy74 ,! provid] ( s]vices or suppli] %all accept ! disc\nt$ or m9imum ca% price z paym5t 9 full f any pati5t t *ooses to pay 9 ca% )\t reg>d to ! pati5t's cov]age4 7,d7 ,! pay]-specific negotiat$ *>ges1 express$ z a doll> am\nt & cle>ly associat$ ) ! "n ( ! applicable ?ird p>ty pay] & "n ( ea* plan1 t apply to ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 ,if ! *>ges are bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! provid] or suppli] also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r t]ms1 s*$ules1 exhibits1 data1 or o!r in=mation ref]5c$ 9 any su* contract z %all be requir$ to det]m9e & disclose ! negotiat$ *>ge4 7,e7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges = ea* su* item or s]vice1 express$ z a non-z]o doll> am\nt4 7,f7 ,any o!r additional in=mation ! ,secret>y may require = ! purpose ( improv+ ! accuracy (1 or enabl+ consum]s to easily und]/& & comp>e1 /&>d *>ges & prices = an item or s]vice1 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is subsection4 ,9 ! case ( /&>d *>ges & prices = an item or s]vice includ$ z "p ( a bundl$1 p] diem1 episodic1 or o!r simil> arrangem5t1 ! in=mation describ$ 9 ?is subp>agraph %all be made available z det]m9$ appropriate by ! ,secret>y4 7#c7 ,uni=m me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbg1 ! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = provid]s ( s]vices & suppli]s to use 9 mak+ public in=mation describ$ 9 p>agraph 7#b74 ,any su* me?od & =mat %all-- 7,a7 include a ma*9e-readable spread%eet =mat conta9+ ! in=mation describ$ 9 p>agraph 7#b7 = all items & s]vices furni%$ by ea* provid] ( s]vices & suppli] describ$ 9 p>agraph 7#a72 7,b7 meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* in=mation2 & 7,c7 be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#d7 ,monitor+ compliance ,! ,secret>y %all1 ?r\gh notice & comm5t rulemak+ & 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 e/abli% a process to monitor compliance ) ?is subsection4 7#e7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case t ! ,secret>y det]m9es t a provid] ( s]vices or suppli] is n 9 compliance ) p>agraph 7#a7-- 7i7 n lat] ?an #cj days aft] su* det]m9ation1 ! ,secret>y %all notify su* provid] or suppli] ( su* det]m9ation2 7ii7 ^u reque/ ( ! ,secret>y1 su* provid] or suppli] %all submit to ! ,secret>y1 n lat] ?an #de days aft] ! date ( su* reque/1 a corrective action plan to comply ) su* p>agraph2 & 7iii7 if su* provid] or suppli] cont9ues to fail to comply ) su* p>agraph aft] ! date t is #ij days aft] su* notification is s5t 7or1 9 ! case ( su* a provid] or suppli] t has submitt$ a corrective action plan describ$ 9 clause 7ii7 9 response to a reque/ s describ$1 aft] ! date t is #ij days aft] su* submission71 ! ,secret>y may impose a civil monet>y p5alty 9 an am\nt n to exce$ #cjj = ea* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* provid] or suppli] 0 fail+ to comply ) su* p>agraph7 dur+ :i* su* failure to comply or failure to submit is ongo+4 7,b7 ,increase au?ority ,9 apply+ ?is p>agraph ) respect to violations occurr+ 9 #bjbg or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! am\nt ( ! civil monet>y p5alty "u subp>agraph 7,a77iii74 7,c7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is p>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7,d7 ,no au?ority to waive or r$uce p5alty ,! ,secret>y %all n grant or ext5d any waiv]1 delay1 toll+1 or o!r mitigation ( a civil monet>y p5alty = violation ( ?is subsection4 7,e7 ,provision ( te*nical assi/ance ,! ,secret>y %all1 to ! ext5t practicable1 provide te*nical assi/ance relat+ to compliance ) ! provisions ( ?is subsection to provid]s ( s]vices & suppli]s reque/+ su* assi/ance4 7,f7 ,cl>ification ( nonapplicability ( o!r en=cem5t provisions ,not)/&+ any o!r provision ( ?is title1 ?is p>agraph %all be ! sole means ( en=c+ ! provisions ( ?is subsection4 7#f7 ,specifi$ imag+ s]vice def9$ ! t]m specifi$ imag+ s]vice means an imag+ s]vice t is a ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice 7z describ$ 9 subsection 7e774 7#g7 ,rulemak+ ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 #e4 ,ambulatory surgical c5t] price transp>5cy requirem5ts ,section #bgah ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah71 z am5d$ by section #d1 is fur!r am5d$ by add+ at ! end ! foll[+3 7h7 ,ambulatory surg]y c5t] transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,july #a1 #bjbg1 ea* specifi$ ambulatory surgical c5t] %all comply ) ! price transp>5cy requirem5t describ$ 9 p>agraph 7#b74 7#b7 ,requirem5t describ$ 7,a7 ,9 g5]al ,a specifi$ ambulatory surgical c5t]1 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u subp>agraph 7,c71 %all compile & make public 7)\t subscription & free ( *>ge71 = ea* ye>-- 7i7 "o or m li/s1 9 a ma*9e-readable =mat specifi$ by ! ,secret>y1 ( ! ambulatory surgical c5t]'s /&>d *>ges 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = ea* item & s]vice furni%$ by su* surgical c5t]2 7ii7 in=mation 9 a consum]-fri5dly =mat 7z specifi$ by ! ,secret>y7 on ! ambulatory surgical c5t]'s prices 7includ+ ! in=mation describ$ 9 subp>agraph 7,b77 = z _m ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vices includ$ on ! li/ describ$ 9 subsection 7e7 t are furni%$ by su* surgical c5t]1 & z _m additional ambulatory surgical c5t]-select$ %oppable s]vices 7or all su* additional s]vices1 if su* surgical c5t] furni%es few] ?an #cjj %oppable s]vices7 z may be necess>y = a comb9$ total ( at lea/ #cjj %oppable s]vices2 & 7iii7 ) respect to ea* ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vice 7z describ$ 9 clause 7ii77 t is n furni%$ by ! ambulatory surgical c5t]1 an indication t su* s]vice is n s furni%$4 7,b7 ,in=mation describ$ ,= purposes ( subp>agraph 7,a71 ! in=mation describ$ 9 ?is subp>agraph is1 ) respect to /&>d *>ges & prices made public by a specifi$ ambulatory surgical c5t]1 ! foll[+3 7i7 ,a description ( ea* item or s]vice1 accompani$ by ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 ! national drug code1 or o!r id5tifi] us$ or approv$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 7ii7 ,! gross *>ge1 express$ z a doll> am\nt1 = ea* su* item or s]vice4 7iii7 ,! disc\nt$ ca% price1 express$ z a doll> am\nt1 = ea* su* item or s]vice 7or1 9 ! case no disc\nt$ ca% price is available = an item or s]vice1 ! m9imum ca% price accept$ by ! specifi$ ambulatory surgical c5t] f self-pay individuals = su* item or s]vice :5 provid$ 9 su* sett+s = ! previ\s ?ree ye>s1 express$ z a doll> am\nt1 z well z1 ) respect to prices made public pursuant to subp>agraph 7,a77ii71 a l9k to a consum]-fri5dly docum5t t cle>ly expla9s ! provid] ( s]vices or suppli]'s *>ity c>e policy74 ,! specifi$ ambulatory surgical c5t] %all accept ! disc\nt$ ca% price z paym5t 9 full f any pati5t t *ooses to pay 9 ca% )\t reg>d to ! pati5t's cov]age4 7iv7 ,! pay]-specific negotiat$ *>ges1 express$ z a doll> am\nt & cle>ly associat$ ) ! "n ( ! applicable ?ird p>ty pay] & "n ( ea* plan1 t apply to ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 ,if ! *>ges are bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! ambulatory surgical c5t] also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r t]ms1 s*$ules1 exhibits1 data1 or o!r in=mation ref]5c$ 9 any su* contract z %all be requir$ to det]m9e & disclose ! negotiat$ *>ge4 7v7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges = ea* su* item or s]vice1 express$ z a non-z]o doll> am\nt4 7vi7 ,any o!r additional in=mation ! ,secret>y may require = ! purpose ( improv+ ! accuracy (1 or enabl+ consum]s to easily und]/& & comp>e1 /&>d *>ges & prices = an item or s]vice1 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is subsection4 7,c7 ,uni=m me?od & =mat ,n lat] ?an ,janu>y #a1 #bjbg1 ! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = specifi$ ambulatory surgical c5t]s to use 9 mak+ public /&>d *>ges pursuant to subp>agraph 7,a77i7 & a /&>d1 uni=m me?od & =mat = su* c5t]s to use 9 mak+ public prices pursuant to subp>agraph 7,a77ii74 ,any su* me?od & =mat %all-- 7i7 9 ! case ( su* *>ges made public by an ambulatory surgical c5t]1 ensure t su* *>ges are made available 9 a ma*9e-readable =mat2 7ii7 meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges & prices2 & 7iii7 be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#c7 ,no deem$ compliance ,! availability ( a price e/imator tool %all n be consid]$ to deem compliance ) or o!rwise vitiate ! requirem5ts ( ?is subsection 7aa74 ,fur!rmore1 ! use ( an e/imator tool %all n be us$ = purposes ( compliance ) any provisions 9 ?is subsection4 7#d7 ,monitor+ compliance ,! ,secret>y %all1 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 e/abli% a process to monitor compliance ) ?is subsection4 ,su* process %all ensure t ea* specifi$ ambulatory surgical c5t]'s compliance ) ?is subsection is review$ n less frequ5tly ?an once e ye>4 7#e7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( a specifi$ ambulatory surgical c5t] t fails to comply ) ! requirem5ts ( ?is subsection-- 7i7 ! ,secret>y %all notify su* ambulatory surgical c5t] ( su* failure n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s2 & 7ii7 ^u reque/ ( ! ,secret>y1 ! ambulatory surgical c5t] %all submit to ! ,secret>y1 n lat] ?an #de days aft] ! date ( su* reque/1 a corrective action plan to comply ) su* requirem5ts4 7,b7 ,civil monet>y p5alty 7i7 ,9 g5]al ,a specifi$ ambulatory surgical c5t] t has receiv$ a notification "u subp>agraph 7,a77i7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* notification 7or1 9 ! case ( an ambulatory surgical c5t] t has submitt$ a corrective action plan describ$ 9 subp>agraph 7,a77ii7 9 response to a reque/ s describ$1 by ! date t is #ij days aft] su* submission7 %all be subject to a civil monet>y p5alty ( an am\nt specifi$ by ! ,secret>y = ea* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* hospital 0 n comply+ ) su* requirem5ts7 dur+ :i* su* failure is ongo+ 7n to exce$ #cjj p] day74 7ii7 ,increase au?ority ,9 apply+ ?is subp>agraph ) respect to violations occurr+ 9 #bjbg or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! limitation on ! p] day am\nt ( any p5alty applicable to a specifi$ ambulatory surgical c5t] "u clause 7i74 7iii7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is subp>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7iv7 ,no au?ority to waive or r$uce p5alty ,! ,secret>y %all n grant or ext5d any waiv]1 delay1 toll+1 or o!r mitigation ( a civil monet>y p5alty = violation ( ?is subsection4 7#f7 ,provision ( te*nical assi/ance ,! ,secret>y %all1 to ! ext5t practicable1 provide te*nical assi/ance relat+ to compliance ) ! provisions ( ?is subsection to specifi$ ambulatory surgical c5t]s reque/+ su* assi/ance4 7#g7 ,def9itions ,= purposes ( ?is section3 7,a7 ,disc\nt$ ca% price ,! t]m disc\nt$ ca% price means ! *>ge t applies to an individual :o pays ca%1 or ca% equival5t1 = a item or s]vice furni%$ by an ambulatory surgical c5t]4 7,b7 ,gross *>ge ,! t]m gross *>ge means ! *>ge = an individual item or s]vice t is reflect$ on a specifi$ surgical c5t]'s *>gema/]1 abs5t any disc\nts4 7,c7 ,gr\p heal? plan2 gr\p heal? insurance cov]age2 individual heal? insurance cov]age ,! t]ms gr\p heal? plan1 gr\p heal? insurance cov]age1 & individual heal? insurance cov]age h ! mean+ giv5 su* t]ms 9 section #bgia ( ! ,public ,heal? ,s]vice ,act4 7,d7 ,pay]-specific negotiat$ *>ge ,! t]m pay]-specific negotiat$ *>ge means ! *>ge t a specifi$ surgical c5t] has negotiat$ ) a ?ird p>ty pay] = an item or s]vice4 7,e7 ,%oppable s]vice ,! t]m %oppable s]vice means a s]vice t c be s*$ul$ by a heal? c>e consum] 9 advance & includes all ancill>y items & s]vices cu/om>ily furni%$ z "p ( su* s]vice4 7,f7 ,specifi$ ambulatory surgical c5t] ,! t]m specifi$ ambulatory surgical c5t] means an ambulatory surgical c5t] ) respect to :i* a hospital 7or any p]son ) an own]%ip or control int]e/ 7z def9$ 9 section #aabd7;a77#c7 ( ! ,social ,security ,act7 9 a hospital7 is a p]son ) an own]%ip or control int]e/ 7z s def9$74 7,g7 ,?ird p>ty pay] ,! t]m ?ird p>ty pay] means an entity t is1 by /atute1 contract1 or agreem5t1 legally responsible = paym5t ( a claim = a heal? c>e item or s]vice4 7#h7 ,rulemak+ ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 #f4 ,/r5g!n+ heal? cov]age transp>5cy requirem5ts 7a7 ,transp>5cy 9 cov]age ,section #acaa7;e77#c77;,c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjca7;e77#c77;,c77 is am5d$-- 7#a7 by /rik+ ,! ,ex*ange & ins]t+ ! foll[+3 7i7 ,9 g5]al ,! ,ex*ange 2 7#b7 9 clause 7i71 z ins]t$ by p>agraph 7#a7-- 7,a7 by /rik+ p>ticipat+ provid] & ins]t+ provid]2 7,b7 by ins]t+ %all include ! in=mation specifi$ 9 clause 7ii7 & aft] su* in=mation2 7,c7 by /rik+ an ,int]net website & ins]t+ a self-s]vice tool t meets ! requirem5ts ( clause 7iii72 & 7,d7 by /rik+ & su* o!r & all t foll[s ?r\gh ! p]iod & ins]t+ or1 at ! option su* individual1 ?r\gh a pap] or phone disclosure 7z select$ by su* individual & provid$ at no co/ to su* individual7 t meets su* requirem5ts z ! ,secret>y may specify42 & 7#c7 by add+ at ! end ! foll[+ new clauses3 7ii7 ,specifi$ in=mation ,= purposes ( clause 7i71 ! in=mation specifi$ 9 ?is clause is1 ) respect to b5efits available "u a heal? plan = an item or s]vice furni%$ by a heal? c>e provid]1 ! foll[+3 7,i7 ,if su* provid] is a p>ticipat+ provid] ) respect to su* item or s]vice1 ! 9-network rate 7z def9$ 9 subp>agraph 7,f77 = su* item or s]vice4 7,,ii7 ,if su* provid] is n describ$ 9 subclause 7,i71 ! maximum all[$ doll> am\nt = su* item or s]vice4 7,,iii7 ,! am\nt ( co/ %>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! individual w incur = su* item or s]vice 7:i*1 9 ! case su* item or s]vice is to be furni%$ by a provid] describ$ 9 subclause 7,,ii71 %all be calculat$ us+ ! maximum am\nt describ$ 9 su* subclause74 7,,iv7 ,! am\nt ! individual has already accumulat$ ) respect to any d$uctible or out ( pocket maximum "u ! plan 7brok5 d[n1 9 ! case sep>ate d$uctibles or maximums apply to sep>ate individuals enroll$ 9 ! plan1 by su* sep>ate d$uctibles or maximums1 9 addition to any cumulative d$uctible or maximum74 7,v7 ,9 ! case su* plan imposes any frequ5cy or volume limitations ) respect to su* item or s]vice 7exclud+ m$ical necessity det]m9ations71 ! am\nt t su* individual has accru$ t[>ds su* limitation ) respect to su* item or s]vice4 7,,vi7 ,any prior au?orization1 concurr5t review1 /ep !rapy1 fail fir/1 or simil> requirem5ts applicable to cov]age ( su* item or s]vice "u su* plan4 7iii7 ,self-s]vice tool ,= purposes ( clause 7i71 a self-s]vice tool e/abli%$ by a heal? plan meets ! requirem5ts ( ?is clause if su* tool-- 7,i7 is bas$ on an int]net website2 7,,ii7 provides = real-"t responses to reque/s describ$ 9 su* clause2 7,,iii7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is timely & accurate2 7,,iv7 all[s su* a reque/ to be made ) respect to an item or s]vice furni%$ by-- 7aa7 a specific provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7bb7 all provid]s t are p>ticipat+ provid]s ) respect to su* plan & su* item or s]vice2 or 7cc7 a provid] t is n describ$ 9 item 7bb72 7,v7 provides t su* a reque/ may be made ) respect to an item or s]vice ?r\gh use (-- 7aa7 ! bill+ code = su* item or s]vice2 or 7bb7 ?r\gh use ( a descriptive t]m = su* item or s]vice to produce a li/ ( bill+ code options f :i* ! individual selects to indicate ! subject matt] items or s]vices2 & 7,,vi7 holds a memb] h>mless = ! am\nt ( any diff]5ce 9 excess ( ! am\nt ( ! individual's responsibility g5]at$ by ! self-s]vice tool & ! am\nt ultimately bill$ or *>g$ to ! individual4 4 7b7 ,disclosure ( additional in=mation ,section #acaa7;e77#c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjca7;e77#c77 is am5d$ by add+ at ! end ! foll[+ new subp>agraphs3 7,e7 ,rate & paym5t in=mation 7i7 ,9 g5]al ,n lat] ?an ,janu>y #a1 #bjbg1 & e mon? !reaft]1 ea* heal? plan %all submit to ! ,ex*ange1 ! ,secret>y1 ! ,/ate insurance commission]1 & make available to ! public1 ! rate & paym5t in=mation describ$ 9 clause 7ii7 9 accordance ) clause 7iii74 7ii7 ,rate & paym5t in=mation describ$ ,= purposes ( clause 7i71 ! rate & paym5t in=mation describ$ 9 ?is clause is1 ) respect to a heal? plan1 ! foll[+3 7,i7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan 7express$ z a doll> am\nt71 includ+ prescription drugs1 id5tifi$ by ,,cpt1 ,,hcpcs1 ,,drg1 ,,ndc1 or o!r applicable nationally recogniz$ id5tifi]1 includ+ any applicable code modifi]s1 & accompani$ by a brief description ( ! item or s]vice1 ! 9-network rate 9 effect z ( ! date ( ! submission ( su* in=mation ) ea* provid] 7id5tifi$ by national provid] id5tifi]7 t is a p>ticipat+ provid] ) respect to su* item or s]vice1 o!r ?an su* a rate 9 effect ) a provid]-- 7aa7 t has submitt$ no claims2 & 7bb7 expects to receive no claims 9 ! !n applicable cal5d> ye> = su* item or s]vice to su* plan4 7,,ii7 ,) respect to ea* drug 7id5tifi$ by ,national ,drug ,code1 ,j-code1 or o!r commonly recogniz$ bill+ code us$ = drugs7 = :i* b5efits are available "u su* plan3 7aa7 ,! 9-network rate 7express$ z a doll> am\nt71 includ+ ! individual & total am\nts = any bundl$ rates1 9 effect z ( ! fir/ day ( ! mon? 9 :i* su* in=mation is made public ) ea* provid] t is a p>ticipat+ provid] ) respect to su* drug4 7bb7 ,! hi/orical net price paid by su* plan 7net ( rebates1 disc\nts1 & price concessions7 7express$ z a doll> am\nt7 = su* drug disp5s$ or adm9i/]$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( submission to ea* provid] t 0 a p>ticipat+ provid] ) respect to su* drug1 brok5 d[n by ea* su* provid] 7id5tifi$ by national provid] id5tifi]71 o!r ?an su* an am\nt paid to a provid] t has submitt$ no claims = su* drug to su* plan4 7,,iii7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan 7express$ z a doll> am\nt71 id5tifi$ by ,,cpt1 ,,drg1 ,,hcpcs1 ,,ndc1 or o!r applicable nationally recogniz$ id5tifi]1 includ+ any applicable code modifi]s1 & accompani$ by a brief description ( ! item or s]vice1 ! am\nt bill$ or *>g$ by ! provid]1 & ! am\nt all[$ by ! plan1 = ea* su* item or s]vice furni%$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( submission by ea* provid] t 0 n a p>ticipat+ provid] ) respect to su* item or s]vice1 brok5 d[n by ea* su* provid] 7id5tifi$ by national provid] id5tifi]71 o!r ?an items & s]vices ) respect to :i* no claims = su* item or s]vice 7 submitt$ to su* plan dur+ su* p]iod4 7iii7 ,mann] ( submission ,rate & paym5t in=mation requir$ to be submitt$ & made available "u ?is subp>agraph %all be s submitt$ & s made available z foll[s3 7,i7 ,in=mation %all be conta9$ 9 #c sep>ate ma*9e-readable files correspond+ to ! in=mation describ$ 9 ea* ( subclauses 7,i7 ?r\gh 7,,iii7 ( clause 7ii7 t meet su* requirem5ts z specifi$ by ! ,secret>y ?r\gh rulemak+1 9 consultation ) ! ,secret>ies ( ,labor & ! ,treasury to apply comp>able requirem5ts to gr\p heal? plans & to entities provid+ b5efit managem5t or o!r ?ird-p>ty adm9i/ration s]vices on a contractual basis ) a gr\p heal? plan4 7,,ii7 ,requirem5ts specifi$ by ! ,secret>y ?r\gh rulemak+ %all ensure t3 7aa7 ,su* files are limit$ to an appropriate size1 are made available 9 a widely available =mat t all[s = in=mation conta9$ 9 su* files to be comp>$ across heal? plans1 & are accessible to individuals at no co/ & )\t ! ne$ to e/abli% a us] acc\nt or provid] o!r cr$5tials4 7bb7 ,! rates1 am\nts1 & prices to be disclos$ include contractual t]ms conta9+ calculation =mulae1 pric+ me?odologies1 & o!r in=mation necess>y to det]m9e ! doll> value ( reimbursem5t4 7cc7 ,ea* su* file includes ea* ( ! foll[+ data elem5ts3 7,,aa7 ,a num]ical id5tifi] = ! gr\p heal? plan &_/or heal? insurance issu] 7su* z a ,heal? ,insurance ,ov]sight ,sy/em id5tifi]74 7,,bb7 ,a pla9-language description ( ! item or s]vice 7includ+1 = drugs1 ! propriet>y & nonpropriet>y "n assign$74 7,,cc7 ,! bill+ code1 includ+ any applicable modifi]s1 associat$ ) su* item or s]vice1 includ+ ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 diagnosis-relat$ gr\p1 national drug code1 or o!r commonly recogniz$ code set4 7,,dd7 ,! place ( s]vice code4 7,,ee7 ,! ,national ,provid] ,id5tifi] or provid] ,tax ,id5tification ,numb]4 7,,iii7 ,! rate & paym5t in=mation disclos$ "u subclauses 7,i7 ?r\gh 7,,iii7 ( clause 7ii7 %all be sep>ately del9eat$ = ea* item or s]vice1 reg>dless ( :e!r su* item or s]vice is reimburs$ z a "p ( a bundle1 episode1 or o!r gr\p+ ( items & s]vices4 7,,iv7 ,an (fic] or executive ( compet5t au?ority %all atte/ to ! accuracy & complet5ess ( in=mation submitt$ & made available "u ?is subp>agraph4 ,su* atte/ation %all be subject to en=cem5t "u subp>agraph 7,h7 &1 :]e applicable1 %all be deem$ mat]ial to paym5ts f ! ,f$]al ,gov]nm5t receiv$ by ! gr\p heal? plan or heal? insurance issu]4 7,v7 ,regulations promulgat$ pursuant to ?is section %all provide t3 7aa7 ,! ,secret>y %all audit ! ?ree ma*9e-readable files requir$ by subp>agraph 7,e77ii7 po/$ by no few] ?an #bj gr\p heal? plans or heal? insurance issu]s4 7bb7 ,! ,secret>y ( ,labor %all audit ! ?ree ma*9e-readable files requir$ by subp>agraph 7,e77ii7 po/$ by no few] ?an #bjj gr\p heal? plans or s]vice provid]s furni%+ ?ird-p>ty adm9i/rator s]vices to a gr\p heal? plan4 7cc7 ,f9d+s1 conclusions1 & en=cem5t actions tak5 bas$ on audits ( ! ma*9e-readable files %all be report$ annually to ,congress no lat] ?an ,july #a ( ! cal5d> ye> dur+ :i* ! files 7 audit$4 ,su* report to ,congress %all be accessible to ! public4 7iv7 ,us] guide ,ea* heal? plan %all make available to ! public in/ructions writt5 9 pla9 language expla9+ h[ individuals may se>* = in=mation describ$ 9 clause 7ii7 9 files submitt$ 9 accordance ) clause 7iii74 7,f7 ,def9itions ,9 ?is p>agraph3 7i7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] has ! mean+ giv5 su* t]m 9 section #bgii;,a-#a ( ! ,public ,heal? ,s]vice ,act4 7ii7 ,9-network rate ,! t]m 9-network rate means1 ) respect to a heal? plan & an item or s]vice furni%$ by a provid] t is a p>ticipat+ provid] ) respect to su* plan & item or s]vice1 ! contract$ rate 9 effect betwe5 su* plan & su* provid] = su* item or s]vice4 ,if ! rate is bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! heal? plan also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r t]ms1 s*$ules1 exhibits1 data1 or o!r in=mation ref]5c$ 9 any su* contract z %all be requir$ to det]m9e & disclose ! negotiat$ rate4 7,g7 ,applicability to acc\ntable c>e organizations ,an applicable ,,aco p>ticipat+ 9 ! ,m$ic>e ,%>$ ,sav+s ,program1 z def9$ 9 ,section #ahii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;jjj71 %all be subject to ! requirem5ts ( ?is p>agraph z if su* applicable ,,aco is a gr\p heal? plan or heal? insurance issu]4 7,h7 ,en=cem5t 7i7 ,9 g5]al ,ea* ye>1 ! ,secret>y %all audit ! ?ree ma*9e-readable files requir$ by subp>agraph 7,e77ii7 po/$ by no few] ?an #bj gr\p heal? plans or heal? insurance issu]s4 7ii7 ,notification & reque/ = corrective action ,9 ! case ( a heal? plan t fails to comply ) ! requirem5ts ( ?is subsection1 n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s1 ! ,secret>y %all submit to su* heal? plan a notification ( su* det]m9ation1 :i* %all include a reque/ = a corrective action plan to comply ) su* requirem5ts4 7iii7 ,civil monet>y p5alty ,a heal? plan t has receiv$ a reque/ = a corrective action plan "u clause 7ii7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* reque/ is made %all be subject to a civil monet>y p5alty ( an am\nt specifi$ by ! ,secret>y = ea* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* laboratory 0 fail+ to comply ) su* p>agraph7 dur+ :i* su* failure 0 ongo+4 ,su* am\nt %all n exce$ #cjj p] memb] p] day or #aj1jjj1jjj1 :i*ev] is less]4 7,i7 ,rulemak+ ,! ,secret>y %all implem5t subp>agraphs 7,e7 ?r\gh 7,h7 ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7c7 ,effective date 7#a7 ,9 g5]al ,! am5dm5ts made by subsections 7a7 & 7b7 %all apply beg9n+ ,janu>y #a1 #bjbf4 7#b7 ,cont9u$ applicability ( rules = previ\s ye>s ,no?+ 9 ! am5dm5ts made by ?is section may be con/ru$ z affect+ ! applicability ( ! rule entitl$ ,transp>5cy 9 ,cov]age publi%$ by ! ,dep>tm5t ( ! ,treasury1 ! ,dep>tm5t ( ,labor1 & ! ,dep>tm5t ( ,heal? & ,human ,s]vices on ,novemb] #ab1 #bjbj 7#he ,f$4 ,reg4 #gbaeh7 be=e ,janu>y #a1 #bjbf4 #g4 ,increas+ gr\p heal? plan access to heal? data 7a7 ,gr\p heal? plan access to in=mation 7#a7 ,9 g5]al ,p>agraph 7#b7 ( section #djh7;b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aajh7;b77 is am5d$ by add+ at ! end ! foll[+ new subp>agraphs3 7,c7 ,no contract or arrangem5t = s]vices1 & no ext5sion or r5ewal ( su* contract or arrangem5t1 betwe5 a gr\p heal? plan 7z t t]m is def9$ 9 section #gcc7;a7 ( ?is title7 & p>ty 9 int]e/1 includ+ a heal? c>e provid] 7:i* = purposes ( ?is subp>agraph1 includes a heal? c>e facility71 network or association ( provid]s1 s]vice provid] (f]+ access to a network ( provid]s1 ?ird-p>ty adm9i/rator1 or ph>macy b5efit manag] 7collectively ref]r$ to z ,cov]$ ,s]vice ,provid]s71 is reasonable )9 ! mean+ ( ?is p>agraph unless su* contract or arrangem5t-- 7i7 all[s ! responsible plan fiduci>y 7z t t]m is def9$ 9 subp>agraph 7,b77ii77,i77ee77 access to all claims & enc\nt] in=mation or data1 & any docum5tation support+ claim paym5ts1 includ+1 b n limit$ to1 m$ical records & policy docum5ts1 or in=mation or data describ$ 9 section #gbd7;a77#a77;,b7 to-- 7,i7 enable su* entity to comply ) ! t]ms ( ! plan & any applicable law2 & 7,,ii7 det]m9e ! accuracy or reasonabl5ess ( paym5t2 & 7ii7 does n-- 7,i7 unreasonably limit or delay access1 z det]m9$ by ! ,secret>y b 9 any ev5t n long] ?an #ae days1 to su* in=mation or data2 7,,ii7 limit ! volume ( claims & enc\nt] in=mation or data t ! gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 or a bus9ess associate ( su* plan may access dur+ an audit or pursuant to any reque/ = su* in=mation or data2 7,,iii7 limit ! disclosure ( pric+ t]ms = value-bas$ paym5t arrangem5ts or capitat$ paym5t arrangem5ts1 includ+-- 7aa7 paym5t calculations & =mulas2 7bb7 quality measures2 7cc7 contract t]ms2 7dd7 paym5t am\nts2 7ee7 measurem5t p]iods = all inc5tives2 & 7ff7 o!r paym5t me?odologies us$ by an entity1 includ+ a heal? c>e provid] 7includ+ a heal? c>e facility71 network or association ( provid]s1 s]vice provid] (f]+ access to a network ( provid]s1 ?ird-p>ty adm9i/rator1 or ph>macy b5efit manag]2 7,,iv7 limit ! disclosure ( ov]paym5ts & ov]paym5t recov]y t]ms2 7,v7 limit ! "r ( ! gr\p heal? plan1 ! plan sponsor1 or ! plan adm9i/rator ( su* plan to select an auditor or def9e audit scope or frequ5cy2 7,,vi7 o!rwise limit or unduly delay ! gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 or a bus9ess associate ( su* plan f access+ claims & enc\nt] in=mation or data 9 a daily bat*2 7,,vii7 limit ! disclosure ( fees *>g$ to ! gr\p heal? plan relat$ to plan adm9i/ration & claims process+1 includ+ r5egotiation fees1 access fees1 repric+ fees1 or enhanc$ review fees2 7,,viii7 limit ! "r ( ! gr\p heal? plan1 ! plan sponsor1 or ! plan adm9i/rator to reque/ action on any suspect claim paym5ts2 or 7,,ix7 limit public disclosure ( de-id5tifi$ or aggregate in=mation4 7,d7 7i7 ,cov]$ ,s]vice ,provid]s %all provide in=mation or data "u ?is p>agraph 9 a mann] consi/5t ) ! privacy & security regulations promulgat$ "u ! ,heal? ,insurance ,portability & ,acc\ntability ,act 7ref]r$ to 9 ?is subp>agraph z ,,hipaa74 7ii7 ,a gr\p heal? plan t receives a disclosure f a p>ty 9 int]e/ pursuant to subp>agraph 7,b7 or 7,c7 %all comply ) ! privacy & security regulations promulgat$ "u ,,hipaa4 7iii7 ,no?+ 9 ?is subp>agraph %all be con/ru$ to modify ! requirem5ts = ! creation1 receipt1 ma9t5ance1 or transmission ( protect$ heal? in=mation "u ! ,,hipaa privacy regulation 7z def9$ 9 section #aahj7;b77#c7 ( ! ,social ,security ,act7 z !y apply directly or indirectly to an entity pursuant to ?is p>agraph4 7iv7 ,?is subp>agraph %all n be read to abridge or limit ! disclosure requirem5ts "u ?is p>agraph or to impose additional privacy or security requirem5ts on ,cov]$ ,s]vice ,provid]s or plan sponsors4 7,e7 ,a gr\p heal? plan receiv+ in=mation or data "u ?is p>agraph may disclose su* in=mation only 9 a mann] t is consi/5t ) ! ,heal? ,insurance ,portability & ,acc\ntability ,act 7,,hipaa7 & ! privacy & security regulations promulgat$ !reund]1 reg>dless ( _! direct or indirect applicability to ! plan or any entities t c\ld be or are bus9ess associates4 7,f7 ,in=mation made available "u ?is section %all con=m to ! foll[+ /&>ds3 7i7 ,all claims f a heal?c>e provid] %all be made to ! gr\p heal? plan 9 accordance ) transaction /&>ds adopt$ by regulation "u ,,hipaa1 z foll[s3 7,i7 ,in/itutional1 pr(essional1 & d5tal claims %all be 9 ,,asc ,x#ab,n #hcg =mat or any subsequ5t /&>d4 7,,ii7 ,ph>macy claims %all be 9 ! ,national ,c\ncil = ,prescription ,drug ,programs 7,,ncpdp7 =mat or any subsequ5t /&>d4 7,,iii7 ,! files %all be unmodifi$ copies ( ! files s5t f ! provid]4 ,9 ! ev5t t pap] claims are s5t by ! provid]1 !y %all be conv]t$ to ! appropriate /&>d electronic =mat4 ,files %all be accessible to ! plan at no co/ to ! gr\p heal? plan4 7ii7 ,all claim paym5t 7or ,,eft1 electronic funds transf]7 & electronic remittance advice 7,,era7 notices s5t by a ,cov]$ ,s]vice ,provid] %all be made available to ! gr\p heal? plan z ,,asc ,x#ab,n #hce files 9 accordance ) /&>ds adopt$ by regulation "u ,,hipaa4 ,! files %all be unmodifi$ copies ( ! files s5t by ! ,cov]$ ,s]vice ,provid] to ! heal?c>e provid]4 ,files %all be accessible at no co/ to ! gr\p heal? plan4 7iii7 ,! contractual t]ms conta9+ calculation =mulae1 pric+ me?odologies1 & o!r in=mation us$ to det]m9e ! doll> value ( reimbursem5t4 7iv7 ,all non-claim co/s %all be itemiz$ & made available to ! gr\p heal? plan 9 real "t ?r\gh a web-bas$ portal1 ?r\gh an ,,api1 & ?r\gh a d[nloadable ,,csv file4 7,g7 ,! ,secret>y %all implem5t subp>agraphs 7,c7 ?r\gh 7,f7 ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7#b7 ,civil en=cem5t ,subsection 7c7 ( section #ejb ( su* ,act 7#bi ,u4,s4,c4 #aacb7 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ac7 ,9 ! case ( an agreem5t betwe5 a gr\p heal? plan 7z def9$ 9 section #gcc7;a771 ! plan sponsor ( su* plan 7z def9$ 9 section #c7af77;,b771 or ! plan adm9i/rator ( su* plan 7z def9$ 9 section #c7af77;,a77 & a heal? c>e provid] 7:i*1 = purposes ( ?is p>agraph1 includes a heal? c>e facility71 network or association ( provid]s1 s]vice provid] (f]+ access to a network or association ( provid]s1 ?ird-p>ty adm9i/rator1 or ph>macy b5efit manag]1 t violates ! provisions ( section #gbd1 ! ,secret>y may assess a civil p5alty aga9/ su* provid]1 network or association1 s]vice provid] (f]+ access to a network or association ( provid]s1 ?ird-p>ty adm9i/rator1 ph>macy b5efit manag]1 or o!r s]vice provid] 9 ! am\nt ( #aj1jjj = ea* day dur+ :i* su* violation cont9ues4 ,su* p5alty %all be 9 addition to o!r p5alties z may be prescrib$ by law4 4 7#c7 ,exi/+ provisions void ,section #daj ( su* ,act 7#bi ,u4,s4,c4 #aaaj7 is am5d$ by add+ at ! end ! foll[+3 7c7 ,any provision 9 an agreem5t or in/rum5t %all be void z aga9/ public policy if su* provision-- 7#a7 unduly delays or limits a gr\p heal? plan 7z def9$ 9 section #gcc7;a771 ! plan sponsor ( su* plan 7z def9$ 9 section #c7af77;,b771 or ! plan adm9i/rator ( su* plan 7z def9$ 9 section #c7af77;,a77 f access+ ! claims & enc\nt] in=mation or data describ$ 9 section #gbd7;a77#a77;,b72 or 7#b7 violates ! requirem5ts ( section #djh7;b77#b77;,c74 4 7#d7 ,te*nical am5dm5t ,clause 7i7 ( section #djh7;b77#b77;,b7 ( su* ,act is am5d$ by /rik+ ?is clause & ins]t+ ?is p>agraph4 7b7 ,updat$ atte/ation = price & quality in=mation ,section #gbd7;a77#c7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahem7a77#c77 is am5d$ to read z foll[s3 7#c7 ,atte/ation 7,a7 ,9 g5]al ,subject to subp>agraph 7,c71 a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all annually submit to ! ,secret>y an atte/ation t su* plan or issu] ( su* cov]age is 9 compliance ) ! requirem5ts ( ?is subsection4 ,su* atte/ation %all also include a /atem5t v]ify+ t-- 7i7 ! in=mation or data describ$ "u subp>agraphs 7,a7 & 7,b7 ( p>agraph 7#a7 is available ^u reque/ & provid$ to ! gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 or ! bus9ess associate ( su* plan1 or ! issu] 9 a timely mann]2 & 7ii7 !re are no t]ms 9 ! agreem5t "u su* p>agraph 7#a7 t directly or indirectly re/rict or unduly delay a gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 a bus9ess associate ( su* plan1 or ! issu] f audit+1 review+1 or o!rwise access+ su* in=mation4 7,b7 ,limitation on submission ,subject to clause 7ii71 a gr\p heal? plan or issu] (f]+ gr\p heal? insurance cov]age may n ent] into an agreem5t ) a ?ird-p>ty adm9i/rator or o!r s]vice provid] to submit ! atte/ation requir$ "u subp>agraph 7,a74 7,c7 ,exception ,9 ! case ( a gr\p heal? plan or issu] (f]+ gr\p heal? insurance cov]age t is unable to obta9 ! in=mation or data ne$$ to submit ! atte/ation requir$ "u subp>agraph 7,a71 su* plan or issu] may submit a writt5 /atem5t 9 lieu ( su* atte/ation t includes-- 7i7 an explanation ( :y su* plan or issu] 0 unsuccessful 9 obta9+ su* in=mation or data1 includ+ :e!r su* plan1 ! plan sponsor1 or ! plan adm9i/rator or issu] 0 limit$ or prev5t$ f audit+1 review+1 or o!rwise access+ su* in=mation or data2 7ii7 a description ( ! ef=ts made by ! gr\p heal? plan1 ! plan sponsor1 or ! plan adm9i/rator to remove any gag clause provisions f ! agreem5t "u p>agraph 7#a72 & 7iii7 a description ( any response by ! ?ird-p>ty adm9i/rator or o!r s]vice provid] ) respect to ef=ts to comply ) ! atte/ation requirem5t "u subp>agraph 7,a71 includ+ ! "n ( ! ?ird-p>ty adm9i/rator or o!r s]vice provid]4 4 7c7 ,effective date ,! am5dm5ts made by subsections 7a7 & 7b7 %all apply ) respect to a plan beg9n+ ) ! fir/ plan ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ?is ,act4 #h4 ,ov]sight ( adm9i/rative s]vice provid]s 7a7 ,,erisa am5dm5ts 7#a7 ,9 g5]al ,subp>t ,b ( "p #g ( subtitle ,b ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajba et seq47 is am5d$ by add+ at ! end ! foll[+3 #gbf4 ,ov]sight ( adm9i/rative s]vice provid]s 7a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #b ye>s aft] ! date ( enactm5t ( ?is section1 no agreem5t betwe5 a gr\p heal? plan 7z def9$ 9 section #gcc7;a771 ! plan sponsor ( su* plan 7z def9$ 9 section #c7af77;,b771 ! plan adm9i/rator ( su* plan 7z def9$ 9 section #c7af77;,a771 or a bus9ess associate ( su* plan 7z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations71 7or heal? insurance issu] (f]+ gr\p heal? insurance cov]age 9 connection ) su* a plan71 & a heal? c>e provid]1 network or association ( provid]s1 ?ird-p>ty adm9i/rator1 s]vice provid] (f]+ access to a network ( provid]s1 ph>macy b5efit manag]s1 or any o!r ?ird p>ty 7ea* ref]r$ to z a heal? plan s]vice provid]7 is p]missible if su* agreem5t limits 7or delays beyond ! applicable report+ p]iod describ$ 9 subsection 7b77#a77 ! disclosure ( in=mation to gr\p heal? plans 9 su* a mann] t prev5ts su* plan1 issu]1 or entity f provid+ ! in=mation describ$ 9 subsection 7b74 7b7 ,requir$ disclosures 7#a7 ,cont5ts & frequ5cy ,) respect to plan ye>s beg9n+ on or aft] ! date t is #b ye>s aft] ! date ( enactm5t ( ?is section1 n less frequ5tly ?an qu>t]ly1 a heal? plan s]vice provid] %all provide to ! gr\p heal? plan or heal? insurance issu] ! foll[+ in=mation at no co/ to ! gr\p heal? plan or heal? insurance issu]3 7,a7 ,! in=mation describ$ 9 section #gbd7;a77#a77;,b74 7,b7 ,any contractual & subcontractual calculation me?odologies1 pric+ or fee s*$ules1 or o!r =mulae us$ to det]m9e reimbursem5t am\nts to provid]s & subcontractors1 includ+ me?odologies1 s*$ules1 fee /ructures1 & any appli$ adju/m5ts or modifi]s1 ) su* in=mation provid$ 9 a mann] suffici5tly detail$ to enable ! gr\p heal? plan or heal? insurance issu] to accurately assess1 v]ify1 & ensure compliance ) ! t]ms ( any contractual & subcontractual agreem5t gov]n+ ! reimbursem5t am\nts4 7,c7 ,! total am\nt receiv$ or expect$ to be receiv$ by ! heal? plan s]vice provid] or its subcontractors 9 provid] or suppli] rebates1 fees1 alt]native disc\nts1 & all o!r remun]ation includ+ am\nts held 9 escr[ or v>iance acc\nts t has be5 paid or is to be paid = claims incurr$ & adm9i/rative s]vices includ+ data sales or network paym5ts4 7,d7 ,! total am\nt paid or expect$ to be paid by ! heal? plan s]vice provid] or to subcontractors 9 rebates1 fees1 contractual arrangem5ts1 & all o!r remun]ation t has be5 paid or is expect$ to be paid = adm9i/rative & o!r s]vices4 7,e7 ,all paym5t data & reconciliation in=mation relat$ to alt]native comp5sation arrangem5ts includ+ acc\ntable c>e organizations1 value-bas$ programs1 %>$ sav+s programs1 inc5tive comp5sation1 bundl$ paym5ts1 capitation arrangem5ts1 p]=mance paym5ts1 & any o!r reimbursem5t or paym5t models1 :]e ! gr\p heal? plan or heal? insurance issu] paid fees1 incurr$ obligations1 or made paym5ts 9 connection ) ! gr\p heal? plan relat$ to su* arrangem5ts4 7#b7 ,privacy requirem5ts 7,a7 ,9 g5]al ,heal? plan s]vice provid]s %all provide ! in=mation or data "u p>agraph 7#a7 consi/5t ) ! privacy1 security1 & brea* notification regulations at p>ts #afj & #afd ( title #de1 ,code ( ,f$]al ,regulations1 promulgat$ "u subtitle ,f ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 subtitle ,d ( ! ,heal? ,in=mation ,te*nology = ,cl9ical ,heal? ,act ( #bjji1 & section #aahj ( ! ,social ,security ,act1 & %all re/rict ! use & disclosure ( su* in=mation accord+ to su* privacy1 security1 & brea* notification regulations4 ,an entity t receives a disclosure f a p>ty 9 int]e/ pursuant to subp>agraph 7,b7 or 7,c7 %all comply ) ! privacy & security regulations promulgat$ "u ,,hipaa4 7,b7 ,re/rictions ,a gr\p heal? plan %all comply ) section #afd4ejd7;f7 ( title #de1 ,code ( ,f$]al ,regulations 7or a successor regulation71 & a plan sponsor %all act 9 accordance ) ! t]ms ( ! agreem5t describ$ 9 su* section4 7,c7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to modify ! requirem5ts = ! creation1 receipt1 ma9t5ance1 or transmission ( protect$ heal? in=mation "u ! ,,hipaa privacy regulations 7#de ,c4,f4,r4 p>ts #afj & #afd1 subp>ts ,a & ,e74 7#c7 ,disclosure & r$isclosure 7,a7 ,9 g5]al ,a gr\p heal? plan receiv+ in=mation "u p>agraph 7#a7 may disclose su* in=mation only-- 7i7 to ! entity f :i* ! in=mation 0 receiv$ or to t entity's bus9ess associates or to ! gr\p heal? plan's bus9ess associates z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations72 or 7ii7 z p]mitt$ by ! ,,hipaa ,privacy ,rule 7#de ,c4,f4,r4 p>ts #afj & #afd1 subp>ts ,a & ,e74 7,b7 ,availability ( in=mation ,to ! ext5t ! in=mation requir$ by ?is subsection is made available to ! heal? insurance issu] (f]+ gr\p heal? insurance 9 connection ) a gr\p heal? plan1 ! heal? insurance issu] %all make su* in=mation available1 at ! same "t1 9 ! same =mat1 & at no co/1 to ! gr\p heal? plan4 7,c7 ,failure to provide ,! obligation to provide in=mation pursuant to ?is subsection %all exi/ not)/&+ ! pres5ce ( any =mal data-%>+ agreem5t betwe5 ! p>ties4 ,failure to provide ! requir$ in=mation z specifi$ %all con/itute a violation ( ?is ,act & ! ,secret>y %all initiate en=cem5t action "u section #ejb )9 #ij days ( becom+ aw>e ( a violation ( ?is section1 except t no?+ 9 ?is section %all be con/ru$ to limit ! ,secret>y's exi/+ au?ority "u ! ,act4 7#d7 ,data =mat /&>ds ,all data & in=mation provid$ pursuant to ?is subsection %all comply ) ! foll[+ /&>ds3 7,a7 ,all claims f a heal?c>e provid] %all be made to ! gr\p heal? plan 9 accordance ) transactions /&>ds adopt$ "u ,,hipaa1 z foll[s3 7i7 ,in/itutional1 pr(essional1 & d5tal claims & adju/m5ts to ^! claims %all be 9 ,,asc ,x#ab,n #hcg =mat1 z transmitt$ by ! provid]1 or1 9 ! case ( pap] claims1 conv]t$ to ! ,,asc ,x#ab,n #hcg electronic =mat4 7ii7 ,prescription drug claims %all be 9 ! ,national ,c\ncil = ,prescription ,drug ,programs 7,,ncpdp7 =mat1 z transmitt$ by ! provid]1 or 9 ! case ( pap] claims1 conv]t$ to ! ,,ncpdp electronic =mat4 7iii7 ,su* data %all be provid$ at no co/ to ! gr\p heal? plan4 7,b7 ,all claim paym5t 7or ,,eft1 electronic funds transf]7 & electronic remittance advice 7,,era7 in=mation s5t by a heal? plan s]vice provid] %all be provid$ to ! gr\p heal? plan or heal? insurance issu] 9 ! ,,asc ,x#ab,n #hce =mat 9 accordance ) transaction /&>ds adopt$ "u ,,hipaa1 unmodifi$ f ! =m 9 :i* x 0 transmitt$ to ! heal?c>e provid]4 ,su* in=mation %all be provid$ at no co/ to ! gr\p heal? plan or heal? insurance issu]4 7,c7 ,! ,secret>y may modify ! /&>ds set =? 9 ?is p>agraph z necess>y to align ) any *anges adopt$ by ! ,secret>y ( ,heal? & ,human ,s]vices pursuant to ! au?ority provid$ "u section #aagc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;d-#b74 7c7 ,prohibit$ contractual provisions ,any provision 9 an agreem5t betwe5 a gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 or a bus9ess associate ( su* plan or a heal? insurance issu] & a heal? plan s]vice provid] t unduly delays or limits a gr\p heal? plan's or heal? insurance issu]'s access to in=mation describ$ 9 ?is section or t re/ricts ! =mat or tim+ ( ! provision ( su* in=mation 9 a mann] t is inconsi/5t ) ! requirem5ts ( ?is section %all be prohibit$ &1 if a gr\p heal? plan or heal? insurance issu] ent]s into su* agreem5t1 %all be deem$ void z aga9/ public policy4 7d7 ,p5alties = non-,compliance ,any failure by a heal? plan s]vice provid] to comply ) ! requirem5ts ( ?is section %all result 9 ! imposition ( a civil p5alty ( #ajj1jjj = ea* day ! violation cont9ues1 9 addition to any o!r p5alties prescrib$ by law4 7e7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7#b7 ,p5alty 7,a7 ,9 g5]al ,section #ejb7;a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aacb7;a77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ad7 ,! ,secret>y may assess a civil p5alty aga9/ any p]son ( #ajj1jjj p] day = ea* violation by any p]son ( section #gbf4 4 7,b7 ,te*nical am5dm5t ,p>agraph 7#f7 ( section #ejb7;a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aacb7;a77 is am5d$ by /rik+ or 7#i7 & ins]t+ x ) ! phrase 7#i71 7#ac71 or 7#ad74 7b7 ,,phsa am5dm5ts 7#a7 ,9 g5]al ,"p ,d ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa et seq47 is am5d$ by add+ at ! end ! foll[+3 #bgii;,a-#aa4 ,ov]sight ( adm9i/rative s]vice provid]s 7a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ?is section1 no agreem5t betwe5 a gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan1 z def9$ 9 section #bgia7;d77#h77;,c7 7#db ,u4,s4,c4 #cjj;gg-#ia7;d77#h77;,c771 & a heal? c>e provid]1 network or association ( provid]s1 ?ird-p>ty adm9i/rator1 s]vice provid] (f]+ access to a network ( provid]s1 ph>macy b5efit manag]s1 or any o!r ?ird p>ty 7ea* ref]r$ to 9 ?is section z a heal? plan s]vice provid]7 is p]missible if su* agreem5t limits 7or delays beyond ! applicable report+ p]iod describ$ 9 subsection 7b77#a77 ! disclosure ( in=mation to gr\p heal? plans 9 su* a mann] t prev5ts su* plan1 issu]1 or entity f provid+ ! in=mation describ$ 9 subsection 7b74 7b7 ,requir$ disclosures 7#a7 ,cont5ts & frequ5cy ,) respect to plan ye>s beg9n+ on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ?is section1 n less frequ5tly ?an qu>t]ly1 a heal? plan s]vice provid] %all provide to ! gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan ! foll[+ in=mation at no co/ to ! plan3 7,a7 ,! in=mation describ$ 9 section #bgii;,a-#i7;a77#a77;,b7 7#db ,u4,s4,c4 #cjj;gg-#aai7;a77#a77;,b774 7,b7 ,any contractual & subcontractual calculation me?odologies1 pric+ or fee s*$ules1 or o!r =mulae us$ to det]m9e reimbursem5t am\nts to provid]s & subcontractors1 includ+ me?odologies1 s*$ules1 fee /ructures1 & any appli$ adju/m5ts or modifi]s1 ) su* in=mation provid$ 9 a mann] suffici5tly detail$ to enable ! gr\p heal? plan to accurately assess1 v]ify1 & ensure compliance ) ! t]ms ( any contractual & subcontractual agreem5t gov]n+ ! reimbursem5t am\nts4 7,c7 ,! total am\nt receiv$ or expect$ to be receiv$ by ! heal? plan s]vice provid] or its subcontractors 9 provid] or suppli] rebates1 fees1 alt]native disc\nts1 & all o!r remun]ation includ+ am\nts held 9 escr[ or v>iance acc\nts t has be5 paid or is to be paid = claims incurr$ & adm9i/rative s]vices includ+ data sales or network paym5ts4 7,d7 ,! total am\nt paid or expect$ to be paid by ! heal? plan s]vice provid] or to subcontractors 9 rebates1 fees1 contractual arrangem5ts1 & all o!r remun]ation t has be5 paid or is expect$ to be paid = adm9i/rative & o!r s]vices4 7,e7 ,all paym5t data & reconciliation in=mation relat$ to alt]native comp5sation arrangem5ts includ+ acc\ntable c>e organizations1 value-bas$ programs1 %>$ sav+s programs1 inc5tive comp5sation1 bundl$ paym5ts1 capitation arrangem5ts1 p]=mance paym5ts1 & any o!r reimbursem5t or paym5t models1 :]e ! gr\p heal? plan paid fees1 incurr$ obligations1 or made paym5ts 9 connection ) ! gr\p heal? plan relat$ to su* arrangem5ts4 7#b7 ,privacy requirem5ts 7,a7 ,9 g5]al ,heal? plan s]vice provid]s %all provide ! in=mation or data "u p>agraph 7#a7 consi/5t ) ! privacy1 security1 & brea* notification regulations at p>ts #afj & #afd ( title #de1 ,code ( ,f$]al ,regulations1 promulgat$ "u subtitle ,f ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 subtitle ,d ( ! ,heal? ,in=mation ,te*nology = ,cl9ical ,heal? ,act ( #bjji1 & section #aahj ( ! ,social ,security ,act1 & %all re/rict ! use & disclosure ( su* in=mation accord+ to su* privacy1 security1 & brea* notification regulations4 ,an entity t receives a disclosure f a p>ty 9 int]e/ pursuant to subp>agraph 7,b7 or 7,c7 %all comply ) ! privacy & security regulations promulgat$ "u ,,hipaa4 7,b7 ,re/rictions ,a gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan %all comply ) section #afd4ejd7;f7 ( title #de1 ,code ( ,f$]al ,regulations 7or a successor regulation71 & a plan sponsor %all act 9 accordance ) ! t]ms ( ! agreem5t describ$ 9 su* section4 7,c7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to modify ! requirem5ts = ! creation1 receipt1 ma9t5ance1 or transmission ( protect$ heal? in=mation "u ! ,,hipaa privacy regulations 7#de ,c4,f4,r4 p>ts #afj & #afd1 subp>ts ,a & ,e74 7#c7 ,disclosure & r$isclosure 7,a7 ,9 g5]al ,a gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan receiv+ in=mation "u p>agraph 7#a7 may disclose su* in=mation only-- 7i7 to ! entity f :i* ! in=mation 0 receiv$ or to t entity's bus9ess associates z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations72 or 7ii7 z p]mitt$ by ! ,,hipaa ,privacy ,rule 7#de ,c4,f4,r4 p>ts #afj & #afd1 subp>ts ,a & ,e74 7,b7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to prev5t a gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan1 or a heal? plan s]vice provid] provid+ s]vices ) respect to su* a plan1 f plac+ reasonable re/rictions on ! public disclosure ( ! in=mation describ$ 9 p>agraph 7#a71 except t su* plan or entity may n re/rict disclosure ( su* in=mation to ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 ! ,dep>tm5t ( ! ,treasury1 or ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates4 7,c7 ,failure to provide ,! obligation to provide in=mation pursuant to ?is subsection %all exi/ not)/&+ ! pres5ce ( any =mal data-%>+ agreem5t betwe5 ! p>ties4 ,failure to provide ! requir$ in=mation z specifi$ %all con/itute a violation ( ?is ,act & ! ,secret>y %all initiate en=cem5t action "u section #bgbc7;b7 7#db ,u4,s4,c4 #cjj;gg-#bb7;b77 )9 #ij days ( becom+ aw>e ( a violation ( ?is section1 except t no?+ 9 ?is section %all be con/ru$ to limit ! ,secret>y's exi/+ au?ority "u ?is ,act4 7#d7 ,data =mat /&>ds ,all data & in=mation provid$ pursuant to ?is subsection %all comply ) ! foll[+ /&>ds3 7,a7 ,all claims f a heal?c>e provid] %all be made to ! gr\p heal? plan 9 accordance ) /&>ds adopt$ "u ,,hipaa at section #afb4aaja ( title #de1 ,code ( ,f$]al ,regulations1 z foll[s3 7i7 ,in/itutional1 pr(essional1 & d5tal claims & adju/m5ts to ^! claims %all be provid$ to ! gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan 9 ! ,,asc ,x#ab,n #hcg =mat4 7ii7 ,prescription drug claims %all be 9 ! ,national ,c\ncil = ,prescription ,drug ,programs 7,,ncpdp7 =mat4 7iii7 ,! files %all be unmodifi$ copies ( ! files s5t f ! provid]4 ,9 ! ev5t t pap] claims are s5t by ! provid]1 !y %all be conv]t$ to ! appropriate /&>d electronic =mat4 ,su* data %all be provid$ at no co/ to ! gr\p heal? plan4 7,b7 ,all claim paym5t 7or ,,eft1 electronic funds transf]7 & electronic remittance advice 7,,era7 in=mation s5t by a heal? plan s]vice provid] %all be provid$ to ! gr\p heal? plan or heal? insurance issu] 9 ! ,,asc ,x#ab,n #hce =mat1 9 accordance ) /&>ds adopt$ "u ,,hipaa at section #afb4afjb ( title #de1 ,code ( ,f$]al ,regulations1 unmodifi$ f ! =m 9 :i* x 0 transmitt$ to ! heal?c>e provid]4 ,su* in=mation %all be provid$ at no co/ to ! gr\p heal? plan4 7,c7 ,! ,secret>y may modify ! /&>ds set =? 9 ?is p>agraph z necess>y to align ) any *anges adopt$ by ! ,secret>y pursuant to ! au?ority provid$ "u section #aagc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;d-#b74 7c7 ,prohibit$ contractual provisions ,any provision 9 an agreem5t t unduly delays or limits a gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan's access to in=mation describ$ 9 ?is section or t re/ricts ! =mat or tim+ ( ! provision ( su* in=mation 9 a mann] t is inconsi/5t ) ! requirem5ts ( ?is section %all be prohibit$ &1 if a self-fund$1 non-,f$]al gov]nm5tal plan ent]s into su* agreem5t1 %all be deem$ void z aga9/ public policy4 7d7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7#b7 ,p5alty ,section #bgbc7;b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#bb7;b77 is am5d$ by add+ at ! end ! foll[+3 7#d7 ,en=cem5t au?ority relat+ to heal? plan s]vice provid]s ,not)/&+ any provisions to ! contr>y1 ! ,secret>y may assess a p5alty aga9/ a heal? plan s]vice provid]1 z def9$ 9 section #bgii;,a-#aa7;a7 7#db ,u4,s4,c4 #cjj;gg-#aba7;a771 ( #ajj1jjj p] day = ea* violation ( su* section1 pursuant to sub/antially simil> processes & proc$ures z ^? set =? 9 section #bgbc7;b77#b77;,d7 ?r\gh 7,g7 7#db ,u4,s4,c4 #cjj;gg-#aba7;b77#b77;,d7 ?r\gh 7,g774 4 #i4 ,/ate preemption only 9 ev5t ( conflict ,! provisions ( sections #b ?r\gh #e 7includ+ ! am5dm5ts made by su* sections7 %all n sup]s$e any provision ( ,/ate law :i* e/abli%es1 implem5ts1 or cont9ues 9 effect any requirem5t or prohibition relat$ to heal? c>e price transp>5cy1 includ+ hospital1 cl9ical diagno/ic laboratory te/s1 imag+ s]vices1 & ambulatory surgical c5t]1 except to ! ext5t t su* requirem5t or prohibition prev5ts ! application ( a requirem5t or prohibition ( su* sections 7or am5dm5t74 ,no?+ 9 ?is section %all be con/ru$ to affect gr\p heal? plans e/abli%$ "u ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or alt] ! application ( section #ead ( su* ,act 7#bi ,u4,s4,c4 #aadd74 #aj4 ,requirem5t = explanation ( b5efits 7a7 ,,phsa ,am5dm5ts 7#a7 ,em]g5cy s]vices ,section #bgii;,a-#a7;f77#a77;,c7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa7;f77#a77;,c77 is am5d$ to read z foll[s3 7,c7 ,a good fai? e/imate ( ! am\nt ! plan or cov]age is responsible = pay+ = items & s]vices includ$ 9 ! e/imate describ$ 9 subp>agraph 7,b71 includ+ a pla9 language description ( ea* item or s]vice & all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 4 7#b7 ,explanation ( b5efits ,section #bgii;,a-#a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa7 is am5d$ by add+ at ! end ! foll[+3 7g7 ,explanation ( b5efits 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbf1 ea* gr\p heal? plan1 or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all1 )9 #de days ( receiv+ any reque/ = paym5t = an item or s]vice "u ! plan1 provide to ! p>ticipant1 b5efici>y1 or enrollee 7?r\gh mail or electronic means1 z reque/$ by ! p>ticipant1 b5efici>y1 or enrollee7 a notification 79 cle> & und]/&able language & utiliz+ sub/antially ! same =mat z ! advanc$ explanation ( b5efits requir$ by subsection 7f7 to enable comp>ison7 includ+ ! foll[+3 7,a7 ,:e!r or n ! provid] or facility is a p>ticipat+ provid] or a p>ticipat+ facility ) respect to ! plan or cov]age ) respect to ! furni%+ ( su* item or s]vice4 7,b7 ,an itemiz$ explanation ( b5efits t includes ! foll[+3 7i7 ,a pla9 language description ( ea* item or s]vice4 7ii7 ,all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 7iii7 ,! am\nt ! plan or cov]age is responsible = pay+ = ea* item or s]vice4 7iv7 ,! am\nt ( any co/-%>+ = :i* ! p>ticipant1 b5efici>y1 or enrollee is responsible = ea* item or s]vice 7z ( ! date ( su* notification74 7v7 ,! am\nt t ! p>ticipant1 b5efici>y1 or enrollee has incurr$ t[>d meet+ ! limit ( ! f9ancial responsibility 7includ+ ) respect to d$uctibles & out-(-pocket maximums7 "u ! plan or cov]age 7z ( ! date ( su* notification74 7vi7 ,! site ( ea* item or s]vice4 7#b7 ,=mat ,if applicable1 ! notification describ$ 9 p>agraph 7#a7 may be provid$ 9 conjunction )1 or z "p (1 a notice ( a claim det]m9ation or o!r communication requir$ by section #bgai7;a7 7#db ,u4,s4,c4 #cjj;gg-#ai7;a771 or regulations !reund]4 7h7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7b7 ,,irc am5dm5ts 7#a7 ,em]g5cy s]vices ,section #ihaf7;f77#a77;,c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ to read z foll[s3 7,c7 ,a good fai? e/imate ( ! am\nt ! plan is responsible = pay+ = items & s]vices includ$ 9 ! e/imate describ$ 9 subp>agraph 7,b71 includ+ a pla9 language description ( ea* item or s]vice & all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 4 7#b7 ,explanation ( b5efits ,section #ihaf ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+3 7g7 ,explanation ( b5efits 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbf1 ea* gr\p heal? plan %all1 )9 #de days ( receiv+ any reque/ = paym5t = an item or s]vice "u ! plan1 provide to ! p>ticipant or b5efici>y 7?r\gh mail or electronic means1 z reque/$ by ! p>ticipant or b5efici>y7 a notification 79 cle> & und]/&able language & utiliz+ sub/antially ! same =mat z ! advanc$ explanation ( b5efits requir$ by subsection 7f7 to enable comp>ison7 includ+ ! foll[+3 7,a7 ,:e!r or n ! provid] or facility is a p>ticipat+ provid] or a p>ticipat+ facility ) respect to ! plan ) respect to ! furni%+ ( su* item or s]vice4 7,b7 ,an itemiz$ explanation ( b5efits t includes ! foll[+3 7i7 ,a pla9 language description ( ea* item or s]vice4 7ii7 ,all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 7iii7 ,! am\nt ! plan is responsible = pay+ = ea* item or s]vice4 7iv7 ,! am\nt ( any co/-%>+ = :i* ! p>ticipant or b5efici>y is responsible = ea* item or s]vice 7z ( ! date ( su* notification74 7v7 ,! am\nt t ! p>ticipant or b5efici>y has incurr$ t[>d meet+ ! limit ( ! f9ancial responsibility 7includ+ ) respect to d$uctibles & out-(-pocket maximums7 "u ! plan 7z ( ! date ( su* notification74 7vi7 ,! site ( ea* item or s]vice4 7#b7 ,=mat ,if applicable1 ! notification describ$ 9 p>agraph 7#a7 may be provid$ 9 conjunction )1 or z "p (1 a notice ( a claim det]m9ation or o!r communication requir$ by section #ejc ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd or regulations !reund]4 7h7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7c7 ,,erisa am5dm5ts 7#a7 ,em]g5cy s]vices ,section #gaf7;f77#a77;,c7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;e7f77#a77;,c77 is am5d$ to read z foll[s3 7,c7 ,a good fai? e/imate ( ! am\nt ! heal? plan is responsible = pay+ = items & s]vices includ$ 9 ! e/imate describ$ 9 subp>agraph 7,b71 includ+ a pla9 language description ( ea* item or s]vice & all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 4 7#b7 ,explanation ( b5efits ,section #gaf ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;e7 is am5d$ by add+ at ! end ! foll[+3 7g7 ,explanation ( b5efits 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbf1 ea* gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all1 )9 #de days ( receiv+ any reque/ = paym5t = an item or s]vice "u ! plan1 provide to ! p>ticipant or b5efici>y 7?r\gh mail or electronic means1 z reque/$ by ! p>ticipant or b5efici>y7 a notification 79 cle> & und]/&able language & utiliz+ sub/antially ! same =mat z ! advanc$ explanation ( b5efits requir$ by subsection 7f7 to enable comp>ison7 includ+ ! foll[+3 7,a7 ,:e!r or n ! provid] or facility is a p>ticipat+ provid] or a p>ticipat+ facility ) respect to ! plan or cov]age ) respect to ! furni%+ ( su* item or s]vice4 7,b7 ,an itemiz$ explanation ( b5efits t includes ! foll[+3 7i7 ,a pla9 language description ( ea* item or s]vice4 7ii7 ,all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 7iii7 ,! am\nt ! plan or cov]age is responsible = pay+ = ea* item or s]vice4 7iv7 ,! am\nt ( any co/-%>+ = :i* ! p>ticipant or b5efici>y is responsible = ea* item or s]vice 7z ( ! date ( su* notification74 7v7 ,! am\nt t ! p>ticipant or b5efici>y has incurr$ t[>d meet+ ! limit ( ! f9ancial responsibility 7includ+ ) respect to d$uctibles & out-(-pocket maximums7 "u ! plan or cov]age 7z ( ! date ( su* notification74 7vi7 ,! site ( ea* item or s]vice4 7#b7 ,=mat ,if applicable1 ! notification describ$ 9 p>agraph 7#a7 may be provid$ 9 conjunction )1 or z "p (1 a notice ( a claim det]m9ation or o!r communication requir$ by section #ejc or regulations !reund]4 7h7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 #aa4 ,provision ( itemiz$ bills ,"p ,e ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aca et seq47 is am5d$ by add+ at ! end ! foll[+3 #bgii;,b-#aj4 ,provid] requirem5ts = itemiz$ bills 7a7 ,requirem5ts 7#a7 ,itemiz$ bill & o!r in=mation requir$ 7,a7 ,9 g5]al ,a heal? c>e provid] or heal? c>e facility t reque/s paym5t f an individual aft] provid+ a heal? c>e item or s]vice to ! pati5t %all include ) su* reque/ a writt51 itemiz$ bill ( ! co/ ( ea* reasonably expect$ item or s]vice ! heal? c>e provid] or heal? c>e facility provid$ to ! individual1 includ+ teleheal? visits or visits by o!r electronic means4 ,! heal? c>e provid] or heal? c>e facility %all provide ! itemiz$ bill n lat] ?an #cj days aft] ! heal? c>e provid] or heal? c>e facility receiv$ a f9al paym5t on ! provid$ s]vice or supply f a ?ird p>ty4 7,b7 ,requir$ in=mation ,= ea* item or s]vice provid$ by ! heal? c>e provid] or facility or = :i* ! heal? c>e provid] or facility is bill+ ! individual1 ! itemiz$ bill mu/ include-- 7i7 a pla9 language description ( ea* di/9ct heal? c>e item or s]vice2 7ii7 all applicable bill+ codes = ea* di/9ct heal? c>e item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$2 7iii7 ! price & bill$ am\nt1 if diff]5t1 ( ea* di/9ct heal? c>e item or s]vice or if ! provid] or facility is (f]+ b9d+1 all-9 prices = bundl$ items & s]vices1 ! total b9d+ price = bundl$ items & s]vices & bill$ am\nt2 7iv7 any paym5ts made to ! heal? c>e provid] or heal? c>e facility by or on behalf ( ! individual 7includ+ paym5ts by any heal? plan or insurance7 = any heal? c>e item or s]vice cov]$ 9 ! itemiz$ bill2 7v7 in=mation ab\t ! availability ( language-assi/ance s]vices = individuals ) limit$ ,engli% pr(ici5cy 7,,lep72 7vi7 ! id5tification ( an (fice or individual at ! heal? c>e provid] or heal? c>e facility1 includ+ phone numb] & email address1 t %all be able to discuss ! specific details ( ! itemiz$ /atem5t & be au?oriz$ to make appropriate *anges !reto2 & 7vii7 in=mation ab\t ! heal? c>e provid]'s or heal? c>e facility's *>ity c>e policies & in/ructions on h[ to apply = *>ity c>e4 7#b7 ,collections actions 7,a7 ,9 g5]al ,a heal? c>e provid] or heal? c>e facility %all n take any collections actions aga9/ an individual-- 7i7 = any provid$ heal? c>e item or s]vice unless ! heal? c>e provid] or heal? c>e facility has compli$ ) p>agraph 7#a72 or 7ii7 ) respect to any items or s]vices = :i* ! am\nt appe>+ on an itemiz$ bill describ$ above 9 p>agraph 7#a7 exce$s ! am\nt disclos$ pursuant to ,f$]al heal? c>e price transp>5cy regulations1 includ+ "p #ahj ( title #de1 ,code ( ,f$]al ,regulations1 or provid$ 9 a good fai? e/imate t complies ) section #bgii;,b-#f ( ?is ,act & section #adi4faj ( title #de1 ,code ( ,f$]al ,regulations1 or ano!r good fai? e/imate provid$ by a heal? c>e entity cov]$ "u ?is section b n o!rwise cov]$ "u su* section #bgii;,b-#f unless ! provid] or facility docum5ts t ! additional items or s]vices 7 m$ically necess>y due to un=ese5 complications or a pati5t-initiat$ *ange1 & c\ld n reasonably h be5 anticipat$4 7,b7 ,burd5 ( pro( ,! burd5 ( pro( "u subp>agraph 7,a77ii7 %all re/ ) ! provid]1 & abs5t ! docum5tation describ$ 9 su* subp>agraph1 ! good fai? e/imate %all be b9d+4 7b7 ,failure ,to comply 7#a7 ,p5alties ,! ,secret>y %all impose p5alties on any heal? c>e provid] or heal? c>e facility t fails to comply ) ! requirem5ts ( ?is section 9 an am\nt n to exce$ #aj1jjj = ea* in/ance ( failure to comply4 7#b7 ,presumption 9 favor ( individual ,if a heal? c>e provid] or heal? c>e facility fails to comply ) ! requirem5ts ( ?is section1 ! presumption %all be t *>ges 7 sub/antially 9 excess ( ! good fai? e/imate 7z set =? 9 section #bgii;,b-#f7 = ! purpose ( any pati5t-provid] dispute1 includ+ 9 accordance ) section #bgii;,b-#g & regulations promulgat$ !reund]4 7c7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,pati5ts ,des]ve ,price ,tags ,act4 #b4 ,/r5g!n+ hospital price transp>5cy ,title ,,xxvii ( ! ,public ,heal? ,s]vice ,act is am5d$ by ins]t+ aft] section #bgah 7#db ,u4,s4,c4 #cjj;gg-#ah7 ! foll[+3 #bgah;,a4 ,provid] price transp>5cy 7a7 ,def9itions ,9 ?is section3 7#a7 ,applicable imag+ s]vice provid] ,! t]m applicable imag+ provid] means a provid] ( s]vices or suppli] :o furni%es any imag+ s]vices to pati5ts1 includ+ an indep5d5t diagno/ic te/+ facility1 an outpati5t diagno/ic facility1 & any o!r imag+ c5t] designat$ by ! ,secret>y1 except t su* t]m does n include an imag+ s]vice provid] ) respect to :i* /&>d *>ges = specifi$ imag+ s]vice provid] s]vices furni%$ by su* s]vice provid] are made available by a hospital pursuant to subsection 7b7 or specifi$ ambulatory surgical c5t] pursuant to subsection 7e74 7#b7 ,applicable laboratory ,! t]m applicable laboratory means a laboratory z su* t]m is def9$ 9 section #dic4b1 ( title #db1 ,code ( ,f$]al ,regulations 7or a successor regulation71 except t su* t]m does n include a laboratory ) respect to :i* /&>d *>ges = specifi$ cl9ical diagno/ic laboratory te/s furni%$ by su* laboratory are made available by a hospital pursuant to subsection 7b7 or specifi$ ambulatory surgical c5t] pursuant to subsection 7e74 7#c7 ,disc\nt$ ca% price 7,a7 ,9 g5]al ,! t]m disc\nt$ ca% price means ! m9imum *>ge express$ z a doll> am\nt1 subject to subp>agraph 7,b71 t ! applicable s]vice provid] subject to ?is section accepts f an individual :o pays ca%1 or ca% equival5t1 = a furni%$ item or s]vice1 )\t reg>d to heal? insurance cov]age1 z paym5t 9 full4 7,b7 ,exclusions ,= purposes ( subp>agraph 7,a71 ! m9imum *>ge describ$ 9 su* subp>agraph1 ) respect to a furni%$ item or s]vice1 z applicable1 %all be calculat$ )\t tak+ into acc\nt any f9ancial assi/ance1 includ+ assi/ance attributable to *>ity c>e 79 ! case ( a hospital1 z su* t]m is us$ = purposes ( hospital co/ report+ "u title ,,xviii ( ! ,social ,security ,act71 or ?ird-p>ty assi/ance = su* item or s]vice4 7#d7 ,extraord9>y collection actions ,! t]m extraord9>y collection action has ! mean+ giv5 su* t]m = purposes ( section #eja7r7 ( ! ,int]nal ,rev5ue ,code ( #aihf4 7#e7 ,gross *>ge ,! t]m gross *>ge means ! *>ge = an individual item or s]vice t is reflect$ on a hospital's *>gema/] or simil> li/ ( prices facilitat$ by any o!r provid]1 z def9$ by ! ,secret>y1 abs5t any disc\nts4 7#f7 ,hospital ,! t]m hospital means an in/itution 9 any ,/ate 9 :i* ,/ate or applicable local law provides = ! lic5s+ ( hospitals1 t is lic5s$ z a hospital pursuant to su* law or is approv$1 by ! ag5cy ( su* ,/ate or locality responsible = lic5s+ hospitals1 z meet+ ! /&>ds e/abli%$ = su* lic5s+4 ,= purposes ( ?is p>agraph1 ! t]m ,/ate includes ea* ( ! sev]al ,/ates1 ! ,di/rict ( ,columbia1 ,pu]to ,rico1 ! ,virg9 ,isl&s1 ,guam1 ,am]ican ,samoa1 & ! ,nor!rn ,m>iana ,isl&s4 7#g7 ,pay]-specific negotiat$ *>ge ,! t]m pay]-specific negotiat$ *>ge means ! *>ge t a hospital has negotiat$ ) a ?ird-p>ty pay] = an item or s]vice4 7#h7 ,%oppable s]vice ,! t]m %oppable s]vice means a s]vice t c be s*$ul$ by a heal?c>e consum] 9 advance4 ,su* s]vices are r\t9ely provid$ 9 non-urg5t situations t d n require imm$iate action or att5tion to ! pati5t1 ?us all[+ pati5ts to price %op & s*$ule a s]vice at a "t t is conv5i5t = !m4 7#i7 ,specifi$ ambulatory surgical c5t] ,! t]m specifi$ ambulatory surgical c5t] means any di/9ct entity t op]ates exclusively = ! purpose ( provid+ surgical s]vices to pati5ts n requir+ hospitalization & 9 :i* ! expect$ duration ( s]vices w\ld n exce$ #bd h\rs foll[+ an admission1 except t su* t]m does n include a surgical c5t] ) respect to :i* /&>d *>ges = specifi$ ambulatory surgical c5t] s]vices furni%$ by su* surgical c5t] are made available by a hospital pursuant to subsection 7b74 7#aj7 ,specifi$ cl9ical diagno/ic laboratory te/ ,! t]m specifi$ cl9ical diagno/ic laboratory te/ means any cl9ical diagno/ic laboratory te/ or s]vice t is provid$ by ! applicable laboratory1 exclud+ advanc$ diagno/ic laboratory te/s 7z def9$ 9 section #ahcd;,a7d77#e7 ( ! ,social ,security ,act74 7#aa7 ,specifi$ imag+ s]vice ,! t]m specifi$ imag+ s]vice has ! mean+ giv5 to ! t]m radiology & c]ta9 o!r imag+ s]vices = purposes ( section #daa4cea ( title #db1 ,code ( ,f$]al ,regulations 7or successor regulations74 7#ab7 ,?ird p>ty pay] ,! t]m ?ird p>ty pay] means an entity t is1 by /atute1 contract1 or agreem5t1 legally responsible = paym5t ( a claim = a heal? c>e item or s]vice4 7b7 ,hospital price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a ( ! ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ! ,pati5ts ,des]ve ,price ,tags ,act1 ea* hospital %all1 9 accordance ) a me?od & =mat e/abli%$ by ! ,secret>y "u p>agraph 7#c71 on a qu>t]ly basis 7if !re h be5 any *anges to ! /&>d *>ges describ$ 9 subp>agraph 7#b7 compile & make publicly available on an int]net website 7)\t subscription & free ( *>ge7-- 7,a7 all ( ! hospital's /&>d *>ges = ea* item & s]vice furni%$ by su* hospital 9 a ma*9e-readable =mat 7or a successor te*nology specifi$ by ! ,secret>y72 7,b7 all ( ! hospital's /&>d *>ges 9 a consum]-fri5dly =mat 7z specifi$ by ! ,secret>y71 t includes-- 7i7 z _m ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices-specifi$ %oppable s]vices t are furni%$ by ! hospital1 & z _m additional hospital-select$ %oppable s]vices 7or all su* additional s]vices1 if su* hospital furni%es few] ?an #cjj %oppable s]vices7 z may be necess>y = a comb9$ total ( at lea/ #cjj %oppable s]vices ?r\gh ! ,janu>y #a describ$ 9 ?is subp>agraph1 aft] :i* ! hospital %all include all %oppable s]vices t ! hospital furni%es2 & 7ii7 ) 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 & 7,c7 ! "n & bus9ess address = ea* p]son or entity t1 ) respect to ! hospital-- 7i7 has an own]%ip or inve/m5t int]e/2 7ii7 has a controll+ int]e/2 7iii7 is a managem5t s]vices organization2 or 7iv7 is a significant equity inve/or4 7#b7 ,/&>d *>ges def9$ ,= purposes ( p>agraph 7#a71 ! t]m /&>d *>ges means ! foll[+3 7,a7 ,a pla9 language description ( ea* item & s]vice1 accompani$ by any applicable bill+ codes1 includ+ modifi]s1 us+ commonly recogniz$ bill+ code sets1 includ+-- 7i7 ! ,diagnosis ,relat$ ,gr\p2 7ii7 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code2 7iii7 ! ,national ,drug ,code2 & 7iv7 o!r applicable id5tifi]s z det]m9$ by ! ,secret>y 7or successor code sets74 7,b7 ,! gross *>ge1 express$ z a doll> am\nt1 = ea* su* item or s]vice1 :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 7,c7 ,! disc\nt$ ca% price4 7,d7 ,! pay]-specific negotiat$ *>ges1 express$ z a doll> am\nt & cle>ly associat$ ) ! "n ( ! applicable ?ird-p>ty pay] & "n ( ea* plan1 t apply to ea* su* item or s]vice :5 provid$ 91 z applicable1 ! inpati5t sett+ & outpati5t dep>tm5t sett+4 ,if ! *>ges are bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! hospital %all also disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r in=mation necess>y to det]m9e ! negotiat$ *>ge z a doll> am\nt4 7,e7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges = ea* su* item or s]vice1 express$ z a non-z]o doll> am\nt4 7,f7 ,! am\nt ( any facility fee1 z def9$ by ! ,secret>y1 or add-on *>ges t w be "p ( ! f9al paym5t am\nt1 9 addition to any in=mation t might help ! pati5t und]/& :5 a facility fee or add-on *>ge may apply & h[ to avoid su* *>ges4 7,g7 ,any o!r additional in=mation ! ,secret>y may require = ! purpose ( improv+ ! accuracy (1 or enabl+ consum]s to easily und]/& & comp>e1 /&>d *>ges = an item or s]vice1 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is subsection4 ,9 ! case ( /&>d *>ges = 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 ,! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = hospitals to use 9 compil+ & mak+ public in=mation describ$ 9 p>agraph 7#a74 ,su* me?od & =mat %all-- 7,a7 include a ma*9e-readable =mat 7or successor te*nology specifi$ by ! ,secret>y7 conta9+ ! in=mation describ$ 9 p>agraph 7#b7 = all items & s]vices furni%$ by ea* hospital2 7,b7 meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges2 & 7,c7 be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#d7 ,no deem$ compliance ,hospitals may (f] a price e/imator tool1 b ! availability ( su* a price e/imator tool %all n be consid]$ to deem compliance ) or o!rwise vitiate ! requirem5ts ( p>agraph 7#a77;,b7 or any o!r requirem5ts ( ?is subsection4 7#e7 ,monitor+ compliance ,! ,secret>y %all1 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 e/abli% a process to monitor compliance ) ?is subsection4 ,su* process %all ensure t ea* hospital's compliance ) ?is subsection is review$ n less frequ5tly ?an once e ye>4 7#f7 ,atte/ation ,a s5ior (ficial f ea* hospital 7! ,*ief ,executive ,(fic]1 ,*ief ,f9ancial ,(fic]1 or an (ficial ( equival5t s5iority7 %all atte/ to ! accuracy & complet5ess ( ! disclosures1 & any o!r atte/ations z requir$ by ! ,secret>y1 made 9 accordance ) ! hospital price transp>5cy requirem5ts bas$ on crit]ia e/abli%$ by ! ,secret>y4 7#g7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( a hospital t fails to comply ) ! requirem5ts ( ?is subsection1 n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s1 ! ,secret>y %all notify su* hospital ( su* det]m9ation1 :i* %all include a reque/ = a corrective action plan if applicable to comply ) su* requirem5ts4 7,b7 ,civil monet>y p5alty 7i7 ,9 g5]al ,9 addition to any o!r en=cem5t actions or p5alties t may apply "u ano!r provision ( law1 a hospital t has receiv$ a reque/ = a corrective action plan "u subp>agraph 7,a7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* reque/ is made %all be subject to a civil monet>y p5alty ( an am\nt specifi$ by ! ,secret>y = ea* day 7beg9n+ on ! day ! hospital 0 fir/ out ( compliance1 z det]m9$ by ! ,secret>y7 dur+ :i* su* failure 0 ongo+4 ,su* am\nt %all n exce$-- 7,i7 9 ! case ( a specifi$ hospital ) #cj or few] b$s1 #cjj p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #djj p] day72 7,,ii7 9 ! case ( a specifi$ hospital ) m ?an #cj b$s b few] ?an #aja b$s1 #ab4ej p] b$ p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #ae p] b$ p] day72 7,,iii7 9 ! case ( a specifi$ hospital ) m ?an #ajj b$s b few] ?an #bja b$s1 #ag4ej p] b$ p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #bj p] b$ p] day72 7,,iv7 9 ! case ( a specifi$ hospital ) m ?an #bjj b$s b few] ?an #eja b$s1 #bj p] b$ p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #be p] b$ p] day72 & 7,v7 9 ! case ( a specifi$ hospital ) m ?an #ejj b$s1 #be p] b$ p] day 7or1 9 ! case ( su* a hospital t has be5 noncompliant ) su* requirem5ts = a #a-ye> p]iod or long]1 beg9n+ ) ! fir/ day foll[+ su* #a-ye> p]iod1 #ce p] b$ p] day74 7ii7 ,increase au?ority ,9 apply+ ?is subp>agraph ) respect to hospitals t fail to comply 9 #bjbh or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase-- 7,i7 ! limitation on ! p] day am\nt ( any p5alty applicable to a hospital "u clause 7i77,i72 7,,ii7 ! limitations on ! p] b$ p] day am\nt ( any p5alty applicable "u any ( subclauses 7,,ii7 ?r\gh 7,v7 ( clause 7i72 & 7,,iii7 ! limitation on ! increase ( any p5alty appli$ "u clause 7iii7 pursuant to ! am\nts specifi$ 9 subclause 7,,ii7 ( su* clause4 7iii7 ,p]si/5t noncompliance 7,i7 ,9 g5]al ,9 ! case ( a hospital t ! ,secret>y has det]m9$ to be noncompliant ) ! provisions ( ?is subsection two or m times dur+ a #a-ye> p]iod 7z det]m9$ by ! ,secret>y71 ! ,secret>y may increase any p5alty o!rwise applicable "u ?is subp>agraph by ! am\nt specifi$ 9 subclause 7,,ii7 ) respect to su* hospital & may require su* hospital to complete su* additional corrective actions plans z ! ,secret>y may specify4 7,,ii7 ,specifi$ am\nt ,= purposes ( subclause 7,i71 ! am\nt specifi$ 9 ?is subclause is1 ) respect to a hospital-- 7aa7 ) m ?an #cj b$s b few] ?an #aja b$s1 an am\nt t is n less ?an #ejj1jjj & n m ?an #a1jjj1jjj2 7bb7 ) m ?an #ajj b$s b few] ?an #cja b$s1 an am\nt t is great] ?an #a1jjj1jjj & n m ?an #b1jjj1jjj2 7cc7 ) m ?an #cjj b$s b few] ?an #eja b$s1 an am\nt t is great] ?an #b1jjj1jjj & n m ?an #d1jjj1jjj2 & 7dd7 ) m ?an #ejj b$s1 & am\nt t is n less ?an #e1jjj1jjj & n m ?an #aj1jjj1jjj4 7iv7 ,provision ( te*nical assi/ance ,! ,secret>y may1 to ! ext5t practicable1 provide te*nical assi/ance relat+ to compliance ) ! provisions ( ?is section to hospitals reque/+ su* assi/ance4 7v7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is subp>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7,c7 ,no au?ority to waive or r$uce p5alty ,! ,secret>y %all n grant or ext5d any waiv]1 delay1 toll+1 or o!r mitigation ( a civil monet>y p5alty = fail+ to comply ) ! requirem5ts ( ?is subsection except :]e ! ,secret>y det]m9es t impos+ ! maximum civil monet>y p5alty1 includ+ p5alties = p]si/5t noncompliance1 w disrupt hospital op]ations 9 a mann] t impacts pati5t c>e4 ,! ,secret>y may reque/ docum5tation 9 su* =m & mann] z ! ,secret>y may require 9 ord] to evaluate impact on hospital op]ations4 7,d7 ,prohibition on extraord9>y collection ,9 addition to civil monet>y p5alties applicable "u subp>agraph 7,b7 & any o!r en=cem5t actions or p5alties t may apply "u any o!r provision ( law1 = a hospital t has receiv$ a reque/ = a corrective action plan "u subp>agraph 7,a7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* reque/1 t hospital or any o!r p]son or entity collect+ on behalf ( ! hospital %all-- 7i7 n take any extraord9>y collection actions aga9/ any pati5t or pati5t gu>antor = debt incurr$ by any pati5t on ! date or dates ( s]vice :5 ! hospital 0 n 9 compliance ) ! requirem5ts ( ?is subsection2 7ii7 cease any extraord9>y collection actions t h begun aga9/ any pati5t or pati5t gu>antor = debt incurr$ by any pati5t on ! date or dates ( s]vice :5 ! hospital 0 n 9 compliance ) ! requirem5ts ( ?is subsection2 & 7iii7 n take any extraord9>y collection actions aga9/ any pati5t or pati5t gu>antor = debt incurr$ by any pati5t on ! date or dates ( s]vice :5 ! hospital 0 n 9 compliance ) ! requirem5ts ( ?is subsection aft] ! hospital comes back into compliance ) ! requirem5ts ( ?is subsection4 7#h7 ,rulemak+ 7,a7 ,9 g5]al ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 7,b7 ,own]%ip in=mation ,9 promulgat+ regulations "u ?is p>agraph1 ! ,secret>y %all def9e ! individuals & organizations t mu/ be disclos$ "u p>agraph 7#a77;,c7 9 a mann] t h>monizes disclosure requirem5ts ) requirem5ts e/abli%$ "u section #aabd ( ! ,social ,security ,act & prioritizes ! disclosure ( individuals & organizations :o's own]%ip or managem5t relation%ip ) a hospital impacts op]ational1 f9ancial1 or cl9ical decision mak+ = su* hospital4 4 #c4 ,cl9ical diagno/ic laboratory price transp>5cy ,section #bgah;,a ( ! ,public ,heal? ,s]vice ,act1 z add$ by section #b1 is am5d$ by add+ at ! end ! foll[+3 7c7 ,cl9ical diagno/ic laboratory price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a ( ! ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ! ,pati5ts ,des]ve ,price ,tags ,act1 an applicable laboratory %all1 on a qu>t]ly basis 7if !re h be5 any *anges to ! /&>d *>ges describ$ 9 p>agraph 7#b77 compile & make publicly available on an int]net website 7)\t subscription & free ( *>ge7-- 7,a7 ! /&>d *>ges describ$ 9 p>agraph 7#b7 ) respect to ea* specifi$ cl9ical diagno/ic laboratory te/ t su* laboratory s furni%es2 & 7,b7 ! "n & bus9ess address = ea* p]son or entity t1 ) respect to ! laboratory-- 7i7 has an own]%ip or inve/m5t int]e/2 7ii7 has a controll+ int]e/2 7iii7 is a managem5t s]vices organization2 or 7iv7 is a significant equity inve/or4 7#b7 ,/&>d *>ges def9$ ,= purposes ( p>agraph 7#a71 ! t]m /&>d *>ges means1 ) respect to an applicable laboratory & a specifi$ cl9ical diagno/ic laboratory te/1 ! foll[+3 7,a7 ,a pla9 language description ( ea* item or s]vice1 accompani$ by any applicable bill+ codes 7includ+ modifi]s t mat]ially *ange ! price = insur]s or provid]s1 & t mat]ially *ange out-(-pocket co/s = consum]s7 us+ commonly recogniz$ bill+ code sets1 includ+-- 7i7 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code2 7ii7 ! ,national ,drug ,code2 or 7iii7 o!r applicable id5tifi] z det]m9$ by ! ,secret>y 7or successor code sets74 7,b7 ,! gross *>ge express$ z a doll> am\nt1 = ea* su* te/4 7,c7 ,! disc\nt$ ca% price4 7,d7 ,! pay]-specific negotiat$ *>ges1 express$ z a doll> am\nt & cle>ly associat$ ) ! "n ( ! applicable ?ird-p>ty pay] & "n ( ea* plan1 t apply to ea* su* te/4 ,if ! *>ges are bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! applicable laboratory also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r in=mation necess>y to det]m9e ! negotiat$ *>ge z a doll> am\nt4 7,e7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges = ea* su* item or s]vice1 express$ z a non-z]o doll> am\nt4 7,f7 ,any o!r additional in=mation ! ,secret>y may require = ! purpose ( improv+ ! accuracy (1 or enabl+ consum]s to easily und]/& & comp>e1 /&>d *>ges = an item or s]vice1 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is section4 ,9 ! case ( /&>d *>ges = 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 ,! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = applicable laboratories to use 9 compil+ & mak+ public in=mation pursuant to p>agraph 7#a74 ,su* me?od & =mat %all-- 7,a7 include a ma*9e-readable =mat 7or a successor te*nology specifi$ by ! ,secret>y7 conta9+ ! in=mation describ$ 9 p>agraph 7#b7 = all specifi$ cl9ical diagno/ic laboratory te/s furni%$ by ea* laboratory & ! own]%ip in=mation describ$ 9 p>agraph 7#a77;,b72 7,b7 meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* in=mation2 & 7,c7 be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#d7 ,monitor+ compliance ,! ,secret>y %all1 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 e/abli% a process to monitor compliance ) ?is subsection4 ,su* process %all ensure t ea* applicable laboratory's compliance ) ?is subsection is review$ n less frequ5tly ?an once e ye>4 7#e7 ,inclusion ( ancill>y s]vices ,any *>ge = a specifi$ cl9ical diagno/ic laboratory te/ furni%$ by an applicable laboratory made publicly available 9 accordance ) p>agraph 7#a7 %all include ! *>ge = any ancill>y item or s]vice 7su* z specim5 collection s]vices1 specim5 transport1 c5trifugation1 aliquot+1 label+1 requisition process+1 & /&>d result report+ s]vices7 t w\ld cu/om>ily & r\t9ely be furni%$ by su* laboratory z "p ( su* te/1 z specifi$ by ! ,secret>y4 7#f7 ,atte/ation ,a s5ior (ficial f ea* cl9ical diagno/ic laboratory 7! ,*ief ,executive ,(fic]1 ,*ief ,f9ancial ,(fic]1 or an (ficial ( equival5t s5iority7 %all atte/ to ! accuracy & complet5ess ( ! disclosures1 & any o!r atte/ations z requir$ by ! ,secret>y1 made 9 accordance ) ! cl9ical laboratory price transp>5cy requirem5ts bas$ on crit]ia e/abli%$ by ! ,secret>y4 7#g7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( an applicable laboratory t fails to comply ) ! requirem5ts ( ?is subsection-- 7i7 ! ,secret>y %all notify su* laboratory ( su* failure n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s2 & 7ii7 ^u reque/ ( ! ,secret>y1 su* laboratory %all submit to ! ,secret>y1 n lat] ?an #de days aft] ! date ( su* reque/1 a corrective action plan to comply ) su* requirem5ts4 7,b7 ,civil monet>y p5alty 7i7 ,9 g5]al ,an applicable laboratory t has receiv$ a notification "u subp>agraph 7,a77i7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* notification 7or1 9 ! case ( an applicable laboratory t has submitt$ a corrective action plan describ$ 9 subp>agraph 7,a77ii7 9 response to a reque/ s describ$1 by ! date t is #ij days aft] su* submission7 %all be subject to a civil monet>y p5alty ( an am\nt specifi$ by ! ,secret>y = ea* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* laboratory 0 n comply+ ) su* requirem5ts7 dur+ :i* su* failure is ongo+ 7n to exce$ #cjj p] day74 7ii7 ,increase au?ority ,9 apply+ ?is subp>agraph ) respect to an applicable laboratory t fails to comply ) ! requirem5ts ( ?is subsection 9 #bjbh or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! limitation on ! p] day am\nt ( any p5alty applicable to an applicable laboratory "u clause 7i74 7iii7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is subp>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7iv7 ,no au?ority to waive or r$uce p5alty ,! ,secret>y %all n grant or ext5d any waiv]1 delay1 toll+1 or o!r mitigation ( a civil monet>y p5alty = fail+ to comply ) ! requirem5ts ( ?is subsection except :]e ! ,secret>y det]m9es t impos+ ! maximum civil monet>y p5alty w disrupt applicable laboratory op]ations 9 a mann] t impacts pati5t c>e4 ,! ,secret>y may reque/ docum5tation 9 su* =m & mann] z ! ,secret>y may require 9 ord] to evaluate impact on applicable laboratory op]ations4 7#h7 ,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#i7 ,rulemak+ 7,a7 ,9 g5]al ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 7,b7 ,own]%ip in=mation ,9 promulgat+ regulations "u ?is p>agraph1 ! ,secret>y %all def9e ! individuals & organizations t mu/ be disclos$ "u p>agraph 7#a77;,c7 9 a mann] t h>monizes disclosure requirem5ts ) requirem5ts e/abli%$ "u section #aabd ( ! ,social ,security ,act & prioritizes ! disclosure ( individuals & organizations :o's own]%ip or managem5t relation%ip ) a hospital impacts op]ational1 f9ancial1 or cl9ical decision mak+ = su* hospital4 4 #d4 ,imag+ s]vices price transp>5cy ,section #bgah;,a ( ! ,public ,heal? ,s]vice ,act1 z am5d$ by section #c1 is fur!r am5d$ by add+ at ! end ! foll[+3 7d7 ,imag+ s]vices price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a ( ! ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ! ,pati5ts ,des]ve ,price ,tags ,act1 ea* applicable imag+ s]vice provid] %all1 on a qu>t]ly basis 7if !re h be5 any *anges to ! /&>d *>ges describ$ 9 p>agraph 7#b77 compile & make publicly available on an int]net website 7)\t subscription & free ( *>ge7-- 7,a7 ! /&>d *>ges describ$ 9 p>agraph 7#b7 ) respect to ea* su* specifi$ imag+ s]vice provid$ by su* provid]2 & 7,b7 ! "n & bus9ess address = ea* p]son or entity t1 ) respect to ! imag+ s]vices provid]-- 7i7 has an own]%ip or inve/m5t int]e/2 7ii7 has a controll+ int]e/2 7iii7 is a managem5t s]vices organization2 or 7iv7 is a significant equity inve/or4 7#b7 ,/&>d *>ges def9$ ,= purposes ( p>agraph 7#a71 ! t]m /&>d *>ges1 ) respect to an applicable imag+ s]vice provid] & a specifi$ imag+ s]vice1 means ! foll[+3 7,a7 ,a pla9 language description ( ea* item or s]vice1 accompani$ by any applicable bill+ codes 7includ+ modifi]s t mat]ially *ange ! price = insur]s or provid]s1 & t mat]ially *ange out-(-pocket co/s = consum]s7 us+ commonly recogniz$ bill+ code sets1 includ+-- 7i7 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code2 7ii7 ! ,national ,drug ,code2 or 7iii7 o!r applicable id5tifi] z det]m9$ by ! ,secret>y 7or successor code sets74 7,b7 ,! gross *>ge express$ z a doll> am\nt1 = ea* su* item or s]vice4 7,c7 ,! disc\nt$ ca% price4 7,d7 ,! pay]-specific negotiat$ *>ges1 express$ z a doll> am\nt & cle>ly associat$ ) ! "n ( ! applicable ?ird-p>ty pay] & "n ( ea* plan1 t apply to ea* su* s]vice4 ,if ! *>ges are bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! provid] or suppli] also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r in=mation necess>y to det]m9e ! negotiat$ *>ge z a doll> am\nt4 7,e7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges = ea* su* item or s]vice1 express$ z a non-z]o doll> am\nt4 7,f7 ,any o!r additional in=mation ! ,secret>y may require = ! purpose ( improv+ ! accuracy (1 or enabl+ consum]s to easily und]/& & comp>e1 /&>d *>ges & prices = an item or s]vice1 except in=mation t is duplicative ( any o!r report+ requirem5t "u ?is subsection4 ,9 ! case ( /&>d *>ges = 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 ,! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = applicable imag+ s]vice provid]s to use 9 mak+ public in=mation describ$ 9 p>agraph 7#a74 ,any su* me?od & =mat %all-- 7,a7 include a ma*9e-readable =mat 7z specifi$ by ! ,secret>y7 conta9+ ! in=mation describ$ 9 p>agraph 7#b7 = all specifi$ imag+ s]vices furni%$ by ea* applicable imag+ s]vice provid] & own]%ip in=mation describ$ 9 p>agraph 7#a77;,b72 7,b7 meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* in=mation2 & 7,c7 be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#d7 ,monitor+ compliance ,! ,secret>y %all1 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 e/abli% a process to monitor compliance ) ?is subsection4 7#e7 ,atte/ation ,a s5ior (ficial f ea* specifi$ imag+ s]vice provid] 7! ,*ief ,executive ,(fic]1 ,*ief ,f9ancial ,(fic]1 or an (ficial ( equival5t s5iority7 %all atte/ to ! accuracy & complet5ess ( ! disclosures1 & any o!r atte/ations z requir$ by ! ,secret>y1 made 9 accordance ) ! imag+ s]vice provid] price transp>5cy requirem5ts bas$ on crit]ia e/abli%$ by ! ,secret>y4 7#f7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( a specifi$ imag+ s]vice provid] t fails to comply ) ! requirem5ts ( ?is subsection-- 7i7 ! ,secret>y %all notify su* imag+ s]vice provid] ( su* failure n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s2 & 7ii7 ^u reque/ ( ! ,secret>y1 su* imag+ s]vice provid] %all submit to ! ,secret>y1 n lat] ?an #de days aft] ! date ( su* reque/1 a corrective action plan to comply ) su* requirem5ts4 7,b7 ,civil monet>y p5alty 7i7 ,9 g5]al ,a specifi$ imag+ s]vice provid] t has receiv$ a notification "u subp>agraph 7,a77i7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* notification 7or1 9 ! case ( a specifi$ imag+ s]vice provid] t has submitt$ a corrective action plan describ$ 9 subp>agraph 7,a77ii7 9 response to a reque/ s describ$1 by ! date t is #ij days aft] su* submission7 %all be subject to a civil monet>y p5alty ( an am\nt specifi$ by ! ,secret>y = ea* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* imag+ s]vice provid] 0 n comply+ ) su* requirem5ts7 dur+ :i* su* failure is ongo+ 7n to exce$ #cjj p] day74 7ii7 ,increase au?ority ,9 apply+ ?is subp>agraph ) respect to a specifi$ imag+ s]vice provid] t fails to comply ) ! requirem5ts ( ?is subsection 9 #bjbh or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! limitation on ! p] day am\nt ( any p5alty applicable to a specifi$ imag+ s]vice provid] "u clause 7i74 7iii7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is subp>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7iv7 ,no au?ority to waive or r$uce p5alty ,! ,secret>y %all n grant or ext5d any waiv]1 delay1 toll+1 or o!r mitigation ( a civil monet>y p5alty = fail+ to comply ) ! requirem5ts ( ?is subsection except :]e ! ,secret>y det]m9es t impos+ ! maximum civil monet>y p5alty w disrupt specifi$ imag+ s]vice provid] op]ations 9 a mann] t impacts pati5t c>e4 ,! ,secret>y may reque/ docum5tation 9 su* =m & mann] z ! ,secret>y may require 9 ord] to evaluate impact on specifi$ imag+ s]vice provid] op]ations4 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#h7 ,rulemak+ 7,a7 ,9 g5]al ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 7,b7 ,own]%ip in=mation ,9 promulgat+ regulations "u ?is p>agraph1 ! ,secret>y %all def9e ! individuals & organizations t mu/ be disclos$ "u p>agraph 7#a77;,c7 9 a mann] t h>monizes disclosure requirem5ts ) requirem5ts e/abli%$ "u section #aabd ( ! ,social ,security ,act & prioritizes ! disclosure ( individuals & organizations :o's own]%ip or managem5t relation%ip ) a hospital impacts op]ational1 f9ancial1 or cl9ical decision mak+ = su* hospital4 4 #e4 ,ambulatory surgical c5t] price transp>5cy ,section #bgah;,a ( ! ,public ,heal? ,s]vice ,act1 z am5d$ by section #d1 is fur!r am5d$ by add+ at ! end ! foll[+3 7e7 ,ambulatory surgical c5t] price transp>5cy 7#a7 ,9 g5]al ,beg9n+ ,janu>y #a ( ! ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ! ,pati5ts ,des]ve ,price ,tags ,act1 ea* specifi$ ambulatory surgical c5t] %all1 on a qu>t]ly basis 7if !re h be5 any *anges to ! /&>d *>ges describ$ 9 p>agraph 7#b771 compile & make publicly available on an int]net website 7)\t subscription & free ( *>ge7-- 7,a7 ! /&>d *>ges describ$ 9 p>agraph 7#b7 ) respect to ea* specifi$ s]vice furni%$ by su* surgical c5t]2 & 7,b7 ! "n & bus9ess address = ea* p]son or entity t1 ) respect to ! ambulatory surgical c5t]-- 7i7 has an own]%ip or inve/m5t int]e/2 7ii7 has a controll+ int]e/2 7iii7 is a managem5t s]vices organization2 or 7iv7 is a significant equity inve/or4 7#b7 ,/&>d *>ges def9$ ,= purposes ( p>agraph 7#a71 ! t]m /&>d *>ges ) respect to /&>d *>ges & prices made public by a specifi$ ambulatory surgical c5t] means ! foll[+3 7,a7 ,a pla9 language description ( ea* item or s]vice1 accompani$ by any applicable bill+ codes 7includ+ modifi]s t mat]ially *ange ! price = insur]s or provid]s1 & t mat]ially *ange out-(-pocket co/s = consum]s7 us+ commonly recogniz$ bill+ code sets1 includ+-- 7i7 ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code2 7ii7 ! ,national ,drug ,code2 or 7iii7 o!r applicable id5tifi] z det]m9$ by ! ,secret>y 7or successor code sets74 7,b7 ,! gross *>ge1 express$ z a doll> am\nt1 = ea* su* item or s]vice4 7,c7 ,! disc\nt$ ca% price4 7,d7 ,! pay]-specific negotiat$ *>ges1 express$ z a doll> am\nt & cle>ly associat$ ) ! "n ( ! applicable ?ird p>ty pay] & "n ( ea* plan1 t apply to ea* su* item or s]vice4 ,if ! *>ges are bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! ambulatory surgical c5t] also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r in=mation necess>y to det]m9e ! negotiat$ *>ge z a doll> am\nt4 7,e7 ,! de-id5tifi$ maximum & m9imum negotiat$ *>ges = ea* su* item or s]vice1 express$ z a non-z]o doll> am\nt4 7,f7 ,any o!r additional in=mation ! ,secret>y may require = ! purpose ( improv+ ! accuracy (1 or enabl+ consum]s to easily und]/& & comp>e1 /&>d *>ges & prices = an item or s]vice4 ,9 ! case ( /&>d *>ges = 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 ,! ,secret>y %all e/abli% a /&>d1 uni=m me?od & =mat = specifi$ ambulatory surgical c5t]s to use 9 compil+ & mak+ public in=mation pursuant to p>agraph 7#a74 ,su* me?od & =mat %all-- 7,a7 include a ma*9e-readable =mat 7or a successor te*nology specifi$ by ! ,secret>y7 conta9+ ! in=mation describ$ 9 p>agraph 7#b7 = all specifi$ s]vices furni%$ by ea* ambulatory surgical c5t] & = ! own]%ip in=mation describ$ 9 p>agraph 7#a77;,b72 7,b7 meet su* /&>ds z det]m9$ appropriate by ! ,secret>y 9 ord] to ensure ! accessibility & usability ( su* *>ges2 & 7,c7 be updat$ z det]m9$ appropriate by ! ,secret>y1 9 consultation ) /akehold]s4 7#d7 ,monitor+ compliance ,! ,secret>y %all1 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 e/abli% a process to monitor compliance ) ?is subsection4 ,su* process %all ensure t ea* specifi$ ambulatory surgical c5t]'s compliance ) ?is subsection is review$ n less frequ5tly ?an once e ye>4 7#e7 ,atte/ation ,a s5ior (ficial f ea* specifi$ ambulatory surgical c5t] 7! ,*ief ,executive ,(fic]1 ,*ief ,f9ancial ,(fic]1 or an (ficial ( equival5t s5iority7 %all atte/ to ! accuracy & complet5ess ( ! disclosures1 & any o!r atte/ations z requir$ by ! ,secret>y1 made 9 accordance ) ! ambulatory c5t] price transp>5cy requirem5ts bas$ on crit]ia e/abli%$ by ! ,secret>y4 7#f7 ,en=cem5t 7,a7 ,9 g5]al ,9 ! case ( a specifi$ ambulatory surgical c5t] t fails to comply ) ! requirem5ts ( ?is subsection-- 7i7 ! ,secret>y %all notify su* ambulatory surgical c5t] ( su* failure n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s2 & 7ii7 ^u reque/ ( ! ,secret>y1 su* ambulatory surgical c5t] %all submit to ! ,secret>y1 n lat] ?an #de days aft] ! date ( su* reque/1 a corrective action plan to comply ) su* requirem5ts4 7,b7 ,civil monet>y p5alty 7i7 ,9 g5]al ,a specifi$ ambulatory surgical c5t] t has receiv$ a notification "u subp>agraph 7,a77i7 & fails to comply ) ! requirem5ts ( ?is subsection by ! date t is #ij days aft] su* notification 7or1 9 ! case ( a specifi$ ambulatory surgical c5t] t has submitt$ a corrective action plan describ$ 9 subp>agraph 7,a77ii7 9 response to a reque/ s describ$1 by ! date t is #ij days aft] su* submission7 %all be subject to a civil monet>y p5alty ( an am\nt specifi$ by ! ,secret>y = ea* day 7beg9n+ ) ! day on :i* ! ,secret>y fir/ det]m9$ t su* ambulatory surgical c5t] 0 n comply+ ) su* requirem5ts7 dur+ :i* su* failure is ongo+ 7n to exce$ #cjj p] day74 7ii7 ,increase au?ority ,9 apply+ ?is subp>agraph ) respect to a specifi$ ambulatory surgical c5t] t fails to comply ) ! requirem5ts ( ?is subsection 9 #bjbh or a subsequ5t ye>1 ! ,secret>y may ?r\gh notice & comm5t rulemak+ increase ! limitation on ! p] day am\nt ( any p5alty applicable to a specifi$ ambulatory surgical c5t] "u clause 7i74 7iii7 ,application ( c]ta9 provisions ,! provisions ( section #aabh;,a ( ! ,social ,security ,act 7o!r ?an subsections 7a7 & 7b7 ( su* section7 %all apply to a civil monet>y p5alty impos$ "u ?is subp>agraph 9 ! same mann] z su* provisions apply to a civil monet>y p5alty impos$ "u subsection 7a7 ( su* section4 7iv7 ,no au?ority to waive or r$uce p5alty ,! ,secret>y %all n grant or ext5d any waiv]1 delay1 toll+1 or o!r mitigation ( a civil monet>y p5alty = fail+ to comply ) ! requirem5ts ( ?is subsection except :]e ! ,secret>y det]m9es t impos+ ! maximum civil monet>y p5alty w disrupt specifi$ ambulatory surgical c5t] op]ations 9 a mann] t impacts pati5t c>e4 ,! ,secret>y may reque/ docum5tation 9 su* =m & mann] z ! ,secret>y may require 9 ord] to evaluate impact on specifi$ ambulatory surgical c5t] op]ations4 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 specifi$ ambulatory surgical c5t]s reque/+ su* assi/ance4 7#h7 ,rulemak+ 7,a7 ,9 g5]al ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 7,b7 ,own]%ip in=mation ,9 promulgat+ regulations "u ?is p>agraph1 ! ,secret>y %all def9e ! individuals & organizations t mu/ be disclos$ "u p>agraph 7#a77;,c7 9 a mann] t h>monizes disclosure requirem5ts ) requirem5ts e/abli%$ "u section #aabd ( ! ,social ,security ,act & prioritizes ! disclosure ( individuals & organizations :o's own]%ip or managem5t relation%ip ) a hospital impacts op]ational1 f9ancial1 or cl9ical decision mak+ = su* hospital4 7f7 ,cont9u$ applicability ( ,/ate law ,! provisions ( ?is section %all n sup]s$e any provision ( ,/ate law t e/abli%es1 implem5ts1 or cont9ues 9 effect any requirem5t or prohibition relat$ to heal? c>e price transp>5cy1 except to ! ext5t t su* requirem5t or prohibition prev5ts ! application ( a requirem5t or prohibition ( ?is section4 4 #f4 ,/r5g!n+ heal? cov]age transp>5cy requirem5ts 7a7 ,transp>5cy 9 cov]age ,section #bgae;,a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ae;a7 is am5d$-- 7#a7 by /rik+ ,a ,gr\p heal? & ins]t+ ! foll[+3 7a7 ,9 g5]al ,a gr\p heal? 2 & 7#b7 by end+ at ! end ! foll[+3 7b7 ,additional transp>5cy requirem5ts 7#a7 ,specifi$ in=mation requir$ 7,a7 ,9 g5]al ,a gr\p heal? plan or heal? insurance issu] (f]+ cov]age 9 ! individual or gr\p m>ket %all provide to ea* p>ticipant1 b5efici>y1 or enrollee1 at ! "t ( enrollm5t 9 ! plan or cov]age1 ! in=mation describ$ 9 subp>agraph 7,b74 7,b7 ,in=mation requir$ ,= purposes ( subp>agraph 7,a71 ! in=mation specifi$ 9 ?is subp>agraph is1 ) respect to b5efits available "u ! plan or cov]age = an item or s]vice furni%$ by a heal? c>e provid]1 ! foll[+ 7or o!r in=mation z det]m9$ appropriate by ! ,secret>y73 7i7 ,if su* provid] is an 9-network provid] ) respect to su* item or s]vice1 ! 9-network rate 7z def9$ 9 p>agraph 7#e77 = su* item or s]vice4 7ii7 ,if su* provid] is n describ$ 9 clause 7i71 ! out-(-network all[$ am\nt 7z su* t]m is def9$ = purposes ( section #adg4baj7;a77#b77xvii7 ( title #de1 ,code ( ,f$]al ,regulation7 = su* item or s]vice t ! plan or cov]age w pay )\t reg>d to ! am\nt 9 clause 7iii74 7iii7 ,! am\nt ( co/-%>+ liability 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! individual w incur = su* item or s]vice bas$ on ! in=mation available to ! plan or cov]age at ! "t ! reque/ is made 7:i*1 9 ! case su* item or s]vice is to be furni%$ by a provid] describ$ 9 clause 7ii71 %all be calculat$ us+ ! maximum am\nt describ$ 9 su* clause74 7iv7 ,! accumulat$ am\nts ) respect to any d$uctible or out-(-pocket maximum "u ! plan or cov]age reflect$ 9 ! plan's or cov]age's records at ! "t ! reque/ is made 7brok5 d[n1 9 ! case sep>ate d$uctibles or maximums apply to sep>ate individuals enroll$ 9 ! plan or cov]age1 by su* sep>ate d$uctibles or maximums1 9 addition to any cumulative d$uctible or maximum74 7v7 ,9 ! case su* plan or cov]age imposes any frequ5cy or volume limitations ) respect to su* item or s]vice 7exclud+ m$ical necessity det]m9ations71 ! am\nt t su* individual has accru$ t[>ds su* limitation ) respect to su* item or s]vice reflect$ 9 ! plan's or cov]age's records at ! "t ! reque/ is made4 7vi7 ,in=mation ab\t any utilization managem5t requirem5ts1 su* z 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]age1 includ+ in=mation reg>d+ utilization managem5t practices & det]m9ations1 includ+ aggregate in=mation relat$ to approval & d5ial rates1 associat$ timel9es1 & appeals1 z det]m9$ appropriate by ! ,secret>y4 7,c7 ,self-s]vice tool ,= purposes ( subp>agraph 7,a71 a self-s]vice tool e/abli%$ by a heal? plan meets ! requirem5ts ( ?is subp>agraph if su* tool-- 7i7 is bas$ on an int]net website2 7ii7 provides = real-"t responses to reque/s describ$ 9 su* subp>agraph2 7iii7 is updat$ 9 a mann] su* t ! in=mation is accurate bas$ on ! in=mation available to ! plan or cov]age at ! "t ! reque/ is made2 7iv7 all[s su* a reque/ to be made = in=mation ) respect to an item or s]vice furni%$ by-- 7,i7 a specific provid] t is an 9-network provid] ) respect to su* item or s]vice2 or 7,,ii7 all provid]s t are 9-network provid]s ) respect to su* plan or cov]age & su* item or s]vice2 7v7 provides t su* a reque/ may be made = in=mation ) respect to an item or s]vice ?r\gh use (-- 7,i7 ! bill+ code = su* item or s]vice2 or 7,,ii7 ?r\gh use ( a descriptive t]m = su* item or s]vice2 & 7vi7 is made available 9 pla9 language1 )\t subscription or o!r fee4 7,d7 ,nonduplication ,a gr\p heal? plan or heal? insurance issu]s %all be deem$ to be 9 compliance ) ?is p>agraph if su* plan or issu] has a tool 9 place "u section #bgii;,a-#d4 7#b7 ,rate & paym5t in=mation 7,a7 ,9 g5]al ,beg9n+ ,janu>y #a ( ! ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ! ,pati5ts ,des]ve ,price ,tags ,act1 & e qu>t] !reaft] 7if !re h be5 any *anges to ! rate & paym5t in=mation describ$ 9 subp>agraphs 7,b7 & 7,c71 ea* gr\p heal? plan or heal? insurance issu] (f]+ cov]age 9 ! gr\p or individual m>ket %all make available to ! public1 ! rate & paym5t in=mation describ$ 9 subp>agraph 7,b7 9 accordance ) subp>agraph 7,c74 7,b7 ,rate & paym5t in=mation describ$ ,= purposes ( subp>agraph 7,a71 ! rate & paym5t in=mation describ$ 9 ?is subp>agraph is1 ) respect to a plan or cov]age1 ! foll[+3 7i7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan or cov]age1 exclud+ ^? includ$ 9 clause 7ii71 id5tifi$ by ,,cpt1 ,,hcpcs1 ,,drg1 or o!r applicable nationally recogniz$ id5tifi]1 includ+ any applicable code modifi]s1 & accompani$ by a pla9 language description ( ! item or s]vice1 ! 9-network rate 7express$ z a doll> am\nt or p]c5tage ( *>ges1 unless o!rwise specifi$ by ! ,secret>y71 includ+ ! individual & total am\nts = any bundl$ rates1 9 effect z ( ! date ( ! submission ( su* in=mation ) ea* provid] 7id5tifi$ by national provid] id5tifi]7 t is an 9-network provid] ) respect to su* item or s]vice1 o!r ?an su* a rate 9 effect ) a provid] t an issu] has det]m9$ bas$ on factors det]m9$ by ! ,secret>y 7su* z m$ical specialty7 t x is unlikely t ! provid] w\ld be reimburs$ = ! item or s]vice4 7ii7 ,) respect to ea* drug & biologic 7id5tifi$ by ,national ,drug ,code1 ,j-code1 or o!r commonly recogniz$ bill+ code us$ = drugs7 = :i* b5efits are available "u su* plan or cov]age1 ! 9-network rate 7express$ z a doll> am\nt or p]c5tage ( *>ges1 unless o!rwise specifi$ by ! ,secret>y7 9 effect z ( ! fir/ day ( ! qu>t] 9 :i* su* in=mation is made public ) ea* ph>macy or o!r prescription drug disp5s] t is an 9-network ph>macy or o!r prescription drug disp5s] ) respect to su* drug4 7iii7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan or cov]age 7express$ z a doll> am\nt71 id5tifi$ by ,,cpt1 ,,drg1 ,,hcpcs1 or o!r applicable nationally recogniz$ id5tifi]1 includ+ any applicable code modifi]s1 & accompani$ by a brief description ( ! item or s]vice1 ! am\nt bill$ or *>g$ by ! provid]1 & ! am\nt all[$ by ! plan or cov]age1 = ea* su* item or s]vice furni%$ dur+ a repres5tative lookback w9d[ e/abli%$ by ! ,secret>y by ea* provid] t 0 an out-(-network provid] ) respect to su* item or s]vice1 brok5 d[n by ea* su* provid] 7id5tifi$ by national provid] id5tifi]71 o!r ?an items & s]vices ) respect to :i* n few] ?an #aa claims = su* item or s]vice 7 submitt$ to su* plan dur+ su* p]iod4 7,c7 ,mann] ( submission ,rate & paym5t in=mation requir$ to be submitt$ & made available "u ?is p>agraph %all be s submitt$ & s made available z foll[s3 7i7 ,in=mation %all be conta9$ 9 at lea/ #c sep>ate ma*9e-readable files correspond+ to ! in=mation describ$ 9 ea* ( clauses 7i7 ?r\gh 7iii7 ( subp>agraph 7,b7 t meet su* requirem5ts z specifi$ by ! ,secret>y ?r\gh rulemak+1 9 consultation ) ! ,secret>ies ( ,labor & ! ,treasury1 to apply comp>able requirem5ts to gr\p heal? plans & heal? insurance cov]age & to entities provid+ b5efit managem5t or o!r ?ird-p>ty adm9i/ration s]vices on a contractual basis ) a gr\p heal? plan or cov]age4 7ii7 ,requirem5ts specifi$ by ! ,secret>y ?r\gh rulemak+ 7or subregulatory guidance7 %all ensure ! foll[+3 7,i7 ,su* files are made available 9 a widely available =mat t all[s = in=mation conta9$ 9 su* files to be comp>$ across plans & cov]age & are freely accessible to individuals at no co/ & )\t ! ne$ to e/abli% a us] acc\nt or provide o!r cr$5tials4 7,,ii7 ,ea* su* file includes ea* ( ! foll[+ data elem5ts3 7aa7 ,a num]ical id5tifi] = ! gr\p heal? plan or heal? insurance issu] 7su* z a ,heal? ,insurance ,ov]sight ,sy/em id5tifi]74 7bb7 ,a pla9-language description ( ! item or s]vice 7includ+1 = drugs1 ! propriet>y & nonpropriet>y "n assign$74 7cc7 ,! bill+ code1 includ+ any applicable modifi]s1 associat$ ) su* item or s]vice1 includ+ ! ,heal?c>e ,common ,proc$ure ,cod+ ,sy/em code1 diagnosis-relat$ gr\p1 national drug code1 or o!r commonly recogniz$ code set4 7dd7 ,! place ( s]vice code4 7ee7 ,! ,national ,provid] ,id5tifi] & provid] ,tax ,id5tification ,numb]4 7iii7 ,! rate & paym5t in=mation disclos$ "u clauses 7i7 ?r\gh 7iii7 ( subp>agraph 7,b7 %all be sep>ately del9eat$ = ea* item or s]vice1 reg>dless ( :e!r su* item or s]vice is reimburs$ z a "p ( a bundle1 episode1 or o!r gr\p+ ( items & s]vices4 7iv7 ,an (fic] or executive ( compet5t au?ority %all atte/ to ! accuracy & complet5ess ( in=mation submitt$ & made available "u ?is subp>agraph4 ,9 ! case ( a plan or cov]age t relies on a ?ird-p>ty adm9i/rator or o!r s]vice provid] to compile ! in=mation submitt$ & made available "u ?is subp>agraph1 su* plan or cov]age may satisfy ! requirem5t "u ?is clause by obta9+ su* an atte/ation f ! ?ird-p>ty adm9i/rator or o!r s]vice provid]4 ,su* atte/ation %all be subject to en=cem5t "u p>agraph 7#f74 7#c7 ,own]%ip in=mation ,beg9n+ ,janu>y #a ( ! ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ! ,pati5ts ,des]ve ,price ,tags ,act1 & e qu>t] !reaft] 7if !re h be5 any *anges 9 ! requir$ in=mation71 ea* gr\p heal? plan or heal? insurance issu] (f]+ cov]age 9 ! individual or gr\p m>ket %all submit to ! ,secret>y1 ! applicable ,/ate au?ority1 & make available to ! public1 ! "n & bus9ess address ( ea* p]son or entity t1 ) respect to su* plan or cov]age-- 7,a7 has an own]%ip or inve/m5t int]e/2 7,b7 has a controll+ int]e/2 7,c7 is a managem5t s]vices organization2 or 7,d7 is a significant equity inve/or4 7#d7 ,en=cem5t 7,a7 ,9 g5]al ,ea* ye>1 ! ,secret>y %all audit ! ma*9e-readable files requir$ by p>agraph 7#b77;,b7 po/$ by n few] ?an #ej gr\p heal? plans or heal? insurance issu]s = compliance ) =mat & accessibility /&>ds4 7,b7 ,notification & reque/ = corrective action ,9 ! case ( a gr\p heal? plan or heal? insurance issu] t fails to comply ) ! requirem5ts ( ?is p>agraph1 n lat] ?an #cj days aft] ! date on :i* ! ,secret>y det]m9es su* failure exi/s1 ! ,secret>y %all submit to su* plan or issu] a notification ( su* det]m9ation1 :i* %all include a reque/ = a corrective action plan to comply ) su* requirem5ts4 7,c7 ,civil monet>y p5alty ,a plan or issu] t has receiv$ a reque/ = a corrective action plan "u subp>agraph 7,b7 & fails to comply ) ! requirem5ts ( ?is p>agraph by ! date t is #cj days aft] su* reque/ is made %all be subject to a civil monet>y p5alty ( an am\nt specifi$ by ! ,secret>y = ea* day 7beg9n+ ) ! day on :i* su* heal? plan or heal? insurance issu] 0 fail+ to comply ) su* p>agraph7 dur+ :i* su* failure 0 ongo+4 ,su* am\nt %all n exce$ #cjj p] p>ticipant1 b5efici>y1 or cov]$ individual p] day or #aj1jjj1jjj1 :i*ev] is less]4 7#e7 ,def9itions ,9 ?is subsection3 7,a7 ,9-network provid] ,! t]m 9-network provid] has ! mean+ giv5 su* t]m 9 section #ed4ihae-bgae;,a#a7;a77#b77xii7 ( title #bf1 ,code ( ,f$]al ,regulations4 7,b7 ,9-network rate ,! t]m 9-network rate means1 ) respect to a heal? plan & an item or s]vice furni%$ by a provid] t is a p>ticipat+ provid] ) respect to su* plan & item or s]vice1 ! contract$ rate 9 effect betwe5 su* plan & su* provid] = su* item or s]vice4 ,if ! rate is bas$ on an algori?m1 p]c5tage ( ano!r am\nt1 or o!r =mula or crit]ia1 ! heal? plan also %all disclose su* algori?m1 p]c5tage1 =mula1 or crit]ia z set =? 9 its contract & any o!r t]ms1 s*$ules1 exhibits1 data1 or o!r in=mation ref]5c$ 9 any su* contract z %all be requir$ to det]m9e & disclose ! negotiat$ rate4 7#f7 ,rulemak+ 7,a7 ,9 g5]al ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 ,! ,secret>y may implem5t ! mann] ( submission ( data describ$ 9 p>agraph 7#b77;,c7 ?r\gh subregulatory guidance4 7,b7 ,regulations ,regulations promulgat$ pursuant to ?is subsection %all provide ! foll[+3 7i7 ,! ,secret>y %all annually audit ! ma*9e-readable files requir$ by p>agraph 7#b77;,b7 po/$ by n few] ?an #ej gr\p heal? plans or heal? insurance issu]s = compliance ) =mat & accessibility /&>ds4 7ii7 ,! ,secret>y ( ,labor %all annually audit ! ma*9e-readable files requir$ by p>agraph 7#b77;,b7 po/$ by n few] ?an #bej gr\p heal? plans or s]vice provid]s furni%+ ?ird-p>ty adm9i/rator s]vices to a gr\p heal? plan = compliance ) =mat & accessibility /&>ds4 7iii7 ,! ,secret>y ( ,heal? & ,human ,s]vices1 9 conjunction ) ! ,secret>y ( ,labor & ! ,secret>y ( ! ,treasury1 %all annually issue a report to ,congress t includes f9d+s1 conclusions1 & en=cem5t actions tak5 bas$ on audits ( ! ma*9e-readable files4 ,su* report %all be provid$ no lat] ?an ,july #a foll[+ ! cal5d> ye> dur+ :i* ! audits 7 complet$4 ,! ,secret>y ( ,heal? & ,human ,s]vices %all make su* report to ,congress accessible to ! public4 4 7b7 ,effective date 7#a7 ,9 g5]al ,! am5dm5ts made by subsections 7a7 & 7b7 %all apply beg9n+ ,janu>y #a ( ! ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ! ,pati5ts ,des]ve ,price ,tags ,act4 7#b7 ,cont9u$ applicability ( rules = previ\s ye>s ,no?+ 9 ! am5dm5ts made by ?is section may be con/ru$ z affect+ ! applicability ( ! rule entitl$ ,transp>5cy 9 ,cov]age publi%$ by ! ,dep>tm5t ( ! ,treasury1 ! ,dep>tm5t ( ,labor1 & ! ,dep>tm5t ( ,heal? & ,human ,s]vices on ,novemb] #ab1 #bjbj 7#he ,f$4 ,reg4 #gbaeh71 or am5dm5ts made to su* rule t are applicable be=e ! date ( enactm5t ( ! ,pati5ts ,des]ve ,price ,tags ,act4 #g4 ,increas+ gr\p heal? plan access to heal? data 7a7 ,gr\p heal? plan access to in=mation 7#a7 ,9 g5]al ,section #bgii;,a-#i ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aai7 is am5d$ by add+ at ! end ! foll[+3 7#a7 ,gr\p ,heal? ,plan ,access to ,in=mation 7,a7 ,9 g5]al ,no contract or arrangem5t = s]vices1 & no ext5sion or r5ewal ( su* contract or arrangem5t1 betwe5 a gr\p heal? plan t is (f]$ by a specifi$ l>ge employ] or t is a specifi$ l>ge plan 7z su* t]ms are def9$ 9 subp>agraph 7,f77 & a heal? c>e provid] 7:i* = purposes ( ?is subp>agraph1 includes a heal? c>e facility71 network or association ( provid]s1 s]vice provid] (f]+ access to a network ( provid]s1 ?ird-p>ty adm9i/rator1 heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age1 or ph>macy b5efit manag]1 or any entity act+ z an int]m$i>y betwe5 ! gr\p heal? plan & ! heal? c>e provid]1 network association ( provid]s1 s]vice provid] (f]+ access to a network or association ( provid]s 7includ+ a lic5s$ heal? insurance issu] or ?ird-p>ty adm9i/rator71 or ph>macy b5efit manag] 7collectively ref]r$ to 9 ?is subsection z ,cov]$ ,s]vice ,provid]s71 is reasonable )9 ! mean+ ( ?is subsection unless su* contract or arrangem5t-- 7i7 all[s ! responsible plan fiduci>y 7z t t]m is def9$ 9 section #djh7;b77#b77;,b77ii77,i77ee77 access to all claims & enc\nt] in=mation or data1 & any docum5tation support+ claim paym5ts1 includ+1 b n limit$ to1 m$ical records & policy docum5ts1 or in=mation or data describ$ 9 subsection 7a77#a77;,b7 to-- 7,i7 comply ) applicable law2 & 7,,ii7 det]m9e ! accuracy or reasonabl5ess ( claims paym5t2 & 7ii7 does n-- 7,i7 unreasonably limit or delay access1 z det]m9$ by ! ,secret>y b 9 any ev5t n long] ?an #ae days1 aft] a reque/ = access by a plan fiduci>y to su* in=mation or data2 7,,ii7 limit ! volume ( claims & enc\nt] in=mation or data t ! gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 or a bus9ess associate ( su* plan may access dur+ an audit or pursuant to any reque/ = su* in=mation or data2 7,,iii7 limit ! disclosure ( pric+ t]ms = value-bas$ paym5t arrangem5ts or capitat$ paym5t arrangem5ts1 includ+-- 7aa7 paym5t calculations & =mulas2 7bb7 quality measures2 7cc7 contract t]ms2 7dd7 paym5t am\nts2 7ee7 measurem5t p]iods = all inc5tives2 & 7ff7 o!r paym5t me?odologies us$ by an entity1 includ+ a heal? c>e provid] 7includ+ a heal? c>e facility71 network or association ( provid]s1 s]vice provid] (f]+ access to a network ( provid]s1 ?ird-p>ty adm9i/rator1 or ph>macy b5efit manag]2 7,,iv7 limit ! disclosure ( ov]paym5ts & ov]paym5t recov]y t]ms2 7,v7 limit ! "r ( ! gr\p heal? plan1 ! plan sponsor1 or ! plan adm9i/rator ( su* plan to select an auditor or def9e audit scope or frequ5cy2 7,,vi7 o!rwise limit or unduly delay ! gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 or a bus9ess associate ( su* plan f access+ claims & enc\nt] in=mation or data2 7,,vii7 limit ! disclosure ( fees *>g$ to ! gr\p heal? plan relat$ to plan adm9i/ration & claims process+1 includ+ r5egotiation fees1 access fees1 repric+ fees1 or enhanc$ review fees2 7,,viii7 limit ! "r ( ! gr\p heal? plan1 ! plan sponsor1 or ! plan adm9i/rator to reque/ action on any suspect claim paym5ts2 7,,ix7 limit public disclosure ( de-id5tifi$ or aggregate in=mation2 7,x7 limit ! disclosure (1 ) respect to a provid] t files claims "u su* plan1 :e!r a ,cov]$ ,s]vice ,provid]-- 7aa7 has an own]%ip or inve/m5t int]e/2 7bb7 has a controll+ int]e/2 7cc7 is a managem5t s]vices organization2 or 7dd7 is a significant equity inve/or2 or 7,,xi7 limit ! disclosure ( ! "n & address ( ea* p]son or entity t1 ) respect to ! heal? plan s]vice provid]-- 7aa7 has an own]%ip or inve/m5t int]e/2 7bb7 has a controll+ int]e/2 or 7cc7 is a significant equity inve/or4 7,b7 ,mann] ( provid+ in=mation or data 7i7 ,9 g5]al ,a ,cov]$ ,s]vice ,provid] %all provide in=mation or data "u ?is subsection 9 a mann] consi/5t ) ! privacy regulations promulgat$ "u section #acdjb7;a7 ( ! ,heal? ,in=mation ,te*nology = ,economic & ,cl9ical ,heal? ,act 7#db ,u4,s4,c4 #agicb7;a77 & consi/5t ) ! privacy regulations promulgat$ "u ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif 9 "p #afj & subp>ts ,a & ,e ( "p #afd ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations7 7ref]r$ to 9 ?is p>agraph z ! ,,hipaa privacy regulations7 & %all re/rict ! use & disclosure ( su* in=mation accord+ to su* privacy regulations & su* ,,hipaa privacy regulations4 ,a ,cov]$ ,s]vice ,provid] %all n be requir$ to disclose in=mation or data "u ?is subsection t c\ld reasonably id5tify a p>ticipant or b5efici>y ?r\gh individually id5tifiable heal? in=mation 7z su* t]m is def9$ "u ,,hipaa privacy regulations74 7ii7 ,additional requirem5ts ,9 c>ry+ out ?is subsection1 a ,cov]$ ,s]vice ,provid] %all comply ) section #afd4ejd7;f7 ( title #de1 ,code ( ,f$]al ,regulations 7or a successor regulation74 7iii7 ,rule ( con/ruction 7,i7 ,9 g5]al ,no?+ 9 ?is subsection %all be con/ru$ to modify ! requirem5ts = ! creation1 receipt1 ma9t5ance1 or transmission ( protect$ heal? in=mation "u ! ,,hipaa privacy regulations4 7,,ii7 ,civil rights laws ,no?+ 9 ?is subsection %all be con/ru$ to affect ! application ( any ,f$]al or ,/ate privacy or civil rights law1 includ+ ! ,,hipaa privacy regulations1 ! ,g5etic ,in=mation ,nondiscrim9ation ,act ( #bjjh 7,public ,law #aaj-bcc7 7includ+ ! am5dm5ts made by su* ,act71 ! ,am]icans ) ,disabilities ,act ( #aiij 7#db ,u4,s4,c4 #abaja et seq471 section #ejd ( ! ,rehabilitation ,act ( #aigc 7#bi ,u4,s4,c4 #gid71 section #aeeg ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahaaf71 title ,,vi ( ! ,civil ,rights ,act ( #aifd 7#db ,u4,s4,c4 #bjjj;d71 & title ,,vii ( ! ,civil ,rights ,act ( #aifd 7#db ,u4,s4,c4 #bjjj;e74 7iv7 ,writt5 notice ,ea* plan ye>1 a ,cov]$ ,s]vice ,provid] %all provide to ea* p>ticipant or b5efici>y writt5 notice in=m+ ! p>ticipant or b5efici>y ( ! requirem5t t ,cov]$ ,s]vice ,provid]s respond to reque/s to submit in=mation or data "u p>agraph 7#a71 z applicable1 :i* may include incorporat+ su* notification 9 plan docum5ts provid$ to ! p>ticipant or b5efici>y1 or provid+ individual notification4 7v7 ,cl>ification reg>d+ public disclosure ( in=mation ,no?+ 9 ?is subsection %all prev5t a ,cov]$ ,s]vice ,provid] f plac+ reasonable re/rictions on ! public disclosure ( ! in=mation or data describ$ 9 p>agraph 7#a71 except t su* ,provid] may n re/rict disclosure ( su* report to ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 or ! ,dep>tm5t ( ! ,treasury4 7vi7 ,limitation ,?is p>agraph %all n be con/ru$ to abridge or limit ! disclosure requirem5ts "u ?is subsection or to impose additional privacy or security requirem5ts on ,cov]$ ,s]vice ,provid]s or plan sponsors4 7,c7 ,limitation on disclosure ,a gr\p heal? plan receiv+ in=mation or data "u ?is subsection may disclose su* in=mation only 9 a mann] t is consi/5t ) ,,hipaa & ! privacy & security regulations promulgat$ !reund]1 reg>dless ( _! direct or indirect applicability to ! plan or any entities t c\ld be or are bus9ess associates4 ,a gr\p heal? plan 7& any bus9ess associate or o!r entity act+ on behalf ( su* plan7 may use su* in=mation or data only = purposes ( plan adm9i/ration & may n sell1 lic5se1 or o!rwise comm]cially exploit su* in=mation or data or provide su* in=mation or data to any ?ird p>ty t may take su* action4 7,d7 ,requirem5ts ( in=mation ,in=mation made available "u ?is subsection %all con=m to ! foll[+ /&>ds3 7i7 ,all claims f a heal?c>e provid] %all be made to ! gr\p heal? plan 9 accordance ) transaction /&>ds adopt$ by regulation "u ,,hipaa1 z foll[s3 7,i7 ,in/itutional1 pr(essional1 & d5tal claims %all be 9 ,,asc ,x#ab,n #hcg;,d =mat or any subsequ5t /&>d z e/abli%$ by ! ,secret>y4 7,,ii7 ,ph>macy claims %all be 9 ! ,national ,c\ncil = ,prescription ,drug ,programs 7,,ncpdp7 =mat or any subsequ5t /&>d z e/abli%$ by ! ,secret>y4 7,,iii7 ,! files %all be unmodifi$ copies ( ! files s5t f ! provid]1 or1 ^u reque/1 deliv]$ 9 a ma*9e readable =mat4 ,9 ! ev5t t pap] claims are s5t by ! provid]1 !y %all be conv]t$ to ! appropriate /&>d electronic =mat4 ,files %all be accessible to ! plan at no co/ to ! gr\p heal? plan4 7ii7 ,all claim paym5t 7or ,,eft1 electronic funds transf]7 & electronic remittance advice 7,,era7 notices s5t by a ,cov]$ ,s]vice ,provid] %all be made available to ! gr\p heal? plan z ,,asc ,x#ab,n #hce files 7or any o!r =mat z id5tifi$ by ! ,secret>y7 9 accordance ) /&>ds adopt$ by regulation "u ,,hipaa4 ,! files %all be unmodifi$ copies ( ! files s5t by ! ,cov]$ ,s]vice ,provid] to ! heal?c>e provid]4 ,files %all be accessible at no co/ to ! gr\p heal? plan4 7iii7 ,! contractual t]ms conta9+ paym5t calculations & =mulas1 pric+ me?odologies1 & o!r in=mation us$ to det]m9e ! doll> value ( reimbursem5t1 9 a =mat z specifi$ by ! ,secret>y4 7iv7 ,all non-claim co/s %all be itemiz$ & made available to ! gr\p heal? plan z reque/$ ?r\gh a web-bas$ portal1 ?r\gh an application program int]face 7,,api71 ?r\gh a d[nloadable ,comma-,sep>at$ ,value 7,,csv7 file1 &1 z appropriate1 ?r\gh o!r d[nloadable ma*9e-readable file types4 7,e7 ,implem5tation ,! ,secret>y %all implem5t ?is subsection ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 7,f7 ,def9itions 7i7 ,9 g5]al ,! provisions ( sections #djh & #daj ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd %all apply ) respect to t]ms us$ "u ?is subsection4 7ii7 ,specifi$ l>ge employ] ,9 ?is subsection1 ! t]m specifi$ l>ge employ] means1 9 connection ) a gr\p heal? plan 7includ+ gr\p heal? insurance cov]age (f]$ 9 connection ) su* a plan7 e/abli%$ or ma9ta9$ by a s+le employ]1 ) respect to a cal5d> ye> or a plan ye>1 z applicable1 an employ] :o employ$ an av]age ( at lea/ #ej employees on bus9ess days dur+ ! prec$+ cal5d> ye> or plan ye> & :o employs at lea/ #a employee on ! fir/ day ( ! cal5d> ye> or plan ye>4 7iii7 ,specifi$ l>ge plan ,9 ?is subsection1 ! t]m specifi$ l>ge plan means a gr\p heal? plan 7includ+ gr\p heal? insurance cov]age (f]$ 9 connection ) su* a plan7 e/abli%$ or ma9ta9$ by a plan sponsor describ$ 9 clause 7ii7 or 7iii7 ( section #c7af77;,b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd t _h an av]age ( at lea/ #ej p>ticipants on bus9ess days dur+ ! prec$+ cal5d> ye> or plan ye>1 z applicable4 4 7#b7 ,civil en=cem5t 7,a7 ,civil en=cem5t ,subsection 7c7 ( section #ejb ( su* ,act 7#bi ,u4,s4,c4 #aacb7 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ac7 7,a7 ,9 ! case ( an agreem5t betwe5 a gr\p heal? plan 7z def9$ 9 section #gcc7;a771 ! plan sponsor ( su* plan 7z def9$ 9 section #c7af77;,b771 or ! plan adm9i/rator ( su* plan 7z def9$ 9 section #c7af77;,a77 & a heal? c>e provid] 7:i*1 = purposes ( ?is p>agraph1 includes a heal? c>e facility71 network or association ( provid]s1 s]vice provid] (f]+ access to a network or association ( provid]s1 ?ird-p>ty adm9i/rator1 or ph>macy b5efit manag]1 t violates ! provisions ( section #gbd7;b71 ! ,secret>y may assess a civil p5alty aga9/ su* provid]1 network or association1 s]vice provid] (f]+ access to a network or association ( provid]s1 ?ird-p>ty adm9i/rator1 ph>macy b5efit manag]1 or o!r s]vice provid] 9 ! am\nt ( up to #aj1jjj = ea* day dur+ :i* su* violation cont9ues4 ,su* p5alty %all be 9 addition to o!r p5alties z may be prescrib$ by law4 7,b7 ,no?+ 9 subp>agraph 7,a7 %all be con/ru$ to p]mit ! ,secret>y to regulate heal? c>e provid]s act+ 9 _! capacity z m$ical organizations furni%+ items & s]vices to pati5ts4 4 7,b7 ,exi/+ provisions void ,section #daj ( su* ,act 7#bi ,u4,s4,c4 #aaaj7 is am5d$ by add+ at ! end ! foll[+3 7c7 ,any provision 9 an agreem5t or in/rum5t %all be void z aga9/ public policy if su* provision-- 7#a7 unduly delays or limits a gr\p heal? plan 7z def9$ 9 section #gcc7;a771 ! plan sponsor ( su* plan 7z def9$ 9 section #c7af77;,b771 or ! plan adm9i/rator ( su* plan 7z def9$ 9 section #c7af77;,a77 f access+ ! claims & enc\nt] in=mation or data describ$ 9 section #gbd7;b77#a77;,b72 or 7#b7 violates ! requirem5ts ( section #djh7;b77#b77;,c74 4 7,c7 ,te*nical am5dm5ts ,section #djh7;b77#b77;,b7 ( su* ,act 7#bi ,u4,s4,c4 #aajh7;b77#b77 is am5d$-- 7i7 9 clause 7i71 by /rik+ ?is clause & ins]t+ ?is p>agraph2 & 7ii7 by add+ at ! end ! foll[+3 7xi7 ,a contract or arrangem5t %all n be reasonable "u ?is subp>agraph if x fails to comply ) section #gbd7;b74 4 7b7 ,updat$ atte/ation = price & quality in=mation ,section #bgii;,a-#i7;a77#d7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aai7;a77#d77 is am5d$ to read z foll[s3 7#d7 ,atte/ation 7,a7 ,9 g5]al ,subject to subp>agraph 7,c71 a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all annually submit to ! ,secret>y an atte/ation t su* plan or issu] ( su* cov]age is 9 compliance ) ! requirem5ts ( ?is subsection4 ,su* atte/ation %all also include a /atem5t v]ify+ t-- 7i7 ! in=mation or data describ$ "u subp>agraphs 7,a7 & 7,b7 ( p>agraph 7#a7 is available ^u reque/ & provid$ to ! gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 or ! bus9ess associate ( su* plan1 or ! issu]1 z applicable1 9 a timely mann]2 & 7ii7 !re are no t]ms 9 ! agreem5t "u su* p>agraph 7#a7 t directly or indirectly re/rict or unduly delay a gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 a bus9ess associate ( su* plan1 or ! issu] f audit+1 review+1 or o!rwise access+ su* in=mation4 7,b7 ,limitation on submission ,a gr\p heal? plan or issu] (f]+ gr\p heal? insurance cov]age may n ent] into an agreem5t ) a ?ird-p>ty adm9i/rator or o!r s]vice provid] to submit ! atte/ation requir$ "u subp>agraph 7,a74 7,c7 ,exception ,9 ! case ( a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age t is unable to obta9 ! in=mation or data ne$$ to submit ! atte/ation requir$ "u subp>agraph 7,a71 su* plan or issu] may submit a writt5 /atem5t 9 lieu ( su* atte/ation t includes-- 7i7 an explanation ( :y su* plan or issu] 0 unsuccessful 9 obta9+ su* in=mation or data1 includ+ :e!r su* plan1 ! plan sponsor1 or ! plan adm9i/rator or issu] 0 limit$ or prev5t$ f audit+1 review+1 or o!rwise access+ su* in=mation or data2 7ii7 a description ( ! ef=ts made by ! gr\p heal? plan1 ! plan sponsor1 or ! plan adm9i/rator to remove any gag clause provisions f ! agreem5t "u p>agraph 7#a72 & 7iii7 a description ( any response by ! ?ird-p>ty adm9i/rator or o!r s]vice provid] ) respect to ef=ts to comply ) ! atte/ation requirem5t "u subp>agraph 7,a71 includ+ ! "n ( ! ?ird-p>ty adm9i/rator or o!r s]vice provid]4 4 7c7 ,effective date ,! am5dm5ts made by subsections 7a7 & 7b7 %all apply ) respect to a plan beg9n+ ) ! fir/ plan ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ?is ,act4 #h4 ,ov]sight ( adm9i/rative s]vice provid]s 7a7 ,,phsa am5dm5t ,"p ,d ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa et seq471 z am5d$ by section #fgja7;a7 ( ! ,consolidat$ ,appropriations ,act1 #bjbf1 is am5d$ by add+ at ! end ! foll[+3 #bgii;,a-#ab4 ,ov]sight ( adm9i/rative s]vice provid]s 7a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a ( ! ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ! ,pati5ts ,des]ve ,price ,tags ,act1 no agreem5t betwe5 a gr\p heal? plan t is (f]$ by a specifi$ l>ge employ] or t is a specifi$ l>ge plan 7z su* t]ms are def9$ 9 section #bgii;,a-#aa7;f77 or a heal? insurance issu] (f]+ individual or gr\p heal? cov]age 7t makes an election subject to subsection 7b77#e77 & a heal? insurance issu] t is op]at+ z a ?ird-p>ty adm9i/rator1 a heal? c>e provid]1 network or association ( provid]s1 ?ird-p>ty adm9i/rator1 s]vice provid] (f]+ access to a network ( provid]s1 ph>macy b5efit manag]s1 or any o!r ?ird p>ty 7ea* ref]r$ to 9 ?is section z a heal? plan s]vice provid]7 is p]missible if su* agreem5t limits 7or delays beyond ! applicable report+ p]iod describ$ 9 subsection 7b77#a77 ! disclosure ( in=mation to su* gr\p heal? plans & heal? insurance issu]s 9 a mann] t prev5ts any heal? plan s]vice provid] f provid+ ! in=mation describ$ 9 subsection 7b774 7b7 ,requir$ disclosures 7#a7 ,cont5ts & frequ5cy ,) respect to plan ye>s beg9n+ on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ?is section1 n less frequ5tly ?an qu>t]ly1 a heal? plan s]vice provid] %all provide to ! gr\p heal? or ! heal? insurance issu] (f]+ individual or gr\p heal? insurance cov]age ! foll[+ in=mation at no co/ to ! plan or issu]3 7,a7 ,! in=mation describ$ 9 section #bgii;,a-#i7;a77#a77;,b7 7#db ,u4,s4,c4 #cjj;gg-#aai7;a77#a77;,b774 7,b7 ,any contractual & subcontractual calculation me?odologies1 pric+ or fee s*$ules1 or o!r =mulae us$ to det]m9e reimbursem5t am\nts to provid]s & subcontractors1 includ+ me?odologies1 s*$ules1 fee /ructures1 & any appli$ adju/m5ts or modifi]s1 ) su* in=mation provid$ 9 a mann] suffici5tly detail$ to enable ! gr\p heal? plan or issu] to accurately assess1 v]ify1 & ensure compliance ) ! t]ms ( any contractual & subcontractual agreem5t gov]n+ ! reimbursem5t am\nts4 7,c7 ,! total am\nt receiv$ or expect$ to be receiv$ by ! heal? plan s]vice provid] or its subcontractors 9 provid] or suppli] rebates1 fees1 alt]native disc\nts1 & all o!r remun]ation includ+ am\nts held 9 escr[ or v>iance acc\nts t has be5 paid or is to be paid = claims incurr$ & adm9i/rative s]vices includ+ data sales or network paym5ts4 7,d7 ,! total am\nt paid or expect$ to be paid by ! heal? plan s]vice provid] to its subcontractors 9 rebates1 fees1 contractual arrangem5ts1 & all o!r remun]ation = adm9i/rative & o!r s]vices4 7,e7 ,all paym5t data1 calculation me?odologies1 & reconciliation in=mation relat$ to alt]native comp5sation arrangem5ts1 includ+ acc\ntable c>e organizations1 value-bas$ programs1 %>$ sav+s programs1 inc5tive comp5sation1 bundl$ paym5ts1 capitation arrangem5ts1 p]=mance paym5ts1 & any o!r reimbursem5t or paym5t models1 :]e ! gr\p heal? plan paid fees1 incurr$ obligations1 or made paym5ts 9 connection ) ! gr\p heal? plan or issu] relat$ to su* arrangem5ts4 7,f7 ,:e!r1 ) respect to a provid] t files claims "u su* plan or cov]age1 ! heal? plan s]vice provid]-- 7i7 has an own]%ip or inve/m5t int]e/2 7ii7 has a controll+ int]e/2 7iii7 is a managem5t s]vices organization2 or 7iv7 is a significant equity inve/or4 7,g7 ,! "n & bus9ess address = ea* p]son or entity t1 ) respect to ! heal? plan s]vice provid]-- 7i7 has an own]%ip or inve/m5t int]e/2 7ii7 has a controll+ int]e/2 or 7iii7 is a significant equity inve/or4 7#b7 ,mann] ( provid+ in=mation or data 7,a7 ,9 g5]al ,a heal? plan s]vice provid] %all provide in=mation or data "u p>agraph 7#a7 9 a mann] consi/5t ) ! privacy regulations promulgat$ "u section #acdjb7;a7 ( ! ,heal? ,in=mation ,te*nology = ,economic & ,cl9ical ,heal? ,act 7#db ,u4,s4,c4 #agicb7;a77 & consi/5t ) ! privacy regulations promulgat$ "u ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif 9 "p #afj & subp>ts ,a & ,e ( "p #afd ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations7 7ref]r$ to 9 ?is p>agraph z ! ,,hipaa privacy regulations7 & %all re/rict ! use & disclosure ( su* in=mation accord+ to su* privacy regulations & su* ,,hipaa privacy regulations4 7,b7 ,additional requirem5ts ,9 c>ry+ out ?is subsection1 a heal? plan s]vice provid] %all comply ) section #afd4ejd7;f7 ( title #de1 ,code ( ,f$]al ,regulations 7or a successor regulation74 7,c7 ,rule ( con/ruction 7i7 ,9 g5]al ,no?+ 9 ?is subsection %all be con/ru$ to modify ! requirem5ts = ! creation1 receipt1 ma9t5ance1 or transmission ( protect$ heal? in=mation "u ! ,,hipaa privacy regulations4 7ii7 ,civil rights laws ,no?+ 9 ?is subsection %all be con/ru$ to affect ! application ( any ,f$]al or ,/ate privacy or civil rights law1 includ+ ! ,,hipaa privacy regulations1 ! ,g5etic ,in=mation ,nondiscrim9ation ,act ( #bjjh 7,public ,law #aaj-bcc7 7includ+ ! am5dm5ts made by su* ,act71 ! ,am]icans ) ,disabilities ,act ( #aiij 7#db ,u4,s4,c4 #abaja et seq471 section #ejd ( ! ,rehabilitation ,act ( #aigc 7#bi ,u4,s4,c4 #gid71 section #aeeg ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahaaf71 title ,,vi ( ! ,civil ,rights ,act ( #aifd 7#db ,u4,s4,c4 #bjjj;d71 & title ,,vii ( ! ,civil ,rights ,act ( #aifd 7#db ,u4,s4,c4 #bjjj;e74 7,d7 ,writt5 notice ,ea* plan ye>1 a heal? plan s]vice provid] %all provide to ea* p>ticipant or b5efici>y writt5 notice in=m+ ! p>ticipant or b5efici>y ( ! requirem5t = heal? plan s]vice provid]s to submit in=mation or data "u p>agraph 7#a71 z applicable1 :i* may include incorporat+ su* notification 9 plan docum5ts provid$ to ! p>ticipant or b5efici>y1 or provid+ individual notification4 7,e7 ,cl>ification reg>d+ public disclosure ( in=mation ,no?+ 9 ?is subsection %all prev5t a heal? plan s]vice provid] f plac+ reasonable re/rictions on ! public disclosure ( ! in=mation or data describ$ 9 p>agraph 7#a71 except t su* provid] may n re/rict disclosures "u subsection 7b77#a7 to ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 or ! ,dep>tm5t ( ! ,treasury4 7,f7 ,limitation ,?is p>agraph %all n be con/ru$ to abridge or limit ! disclosure requirem5ts "u ?is subsection or to impose additional privacy or security requirem5ts on heal? plan s]vice provid]s or plan sponsors4 7#c7 ,disclosure & r$isclosure 7,a7 ,9 g5]al ,a gr\p heal? plan or heal? insurance issu] (f]+ individual or gr\p cov]age receiv+ in=mation "u p>agraph 7#a7 may disclose su* in=mation only-- 7i7 to ! entity f :i* ! in=mation 0 receiv$ or to t entity's bus9ess associates z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations72 or 7ii7 z p]mitt$ by ! ,,hipaa ,privacy ,rule 7#de ,c4,f4,r4 "p #afj & subp>ts ,a & ,e ( "p #afd74 7,b7 ,availability ( in=mation ,to ! ext5t ! in=mation requir$ by ?is subsection is made available to ! heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 ! heal? insurance issu] %all make su* in=mation available1 at ! same "t1 9 ! same =mat1 & at no co/1 to ! gr\p heal? plan4 7,c7 ,limitation on use ( in=mation ,a gr\p heal? plan or heal? insurance issu] 7& any bus9ess associate or o!r entity act+ on behalf ( su* plan7 may use in=mation or data "u ?is p>agraph only = purposes ( plan adm9i/ration & may n sell1 lic5se1 or o!rwise comm]cially exploit su* in=mation or data or provide su* in=mation or data to any ?ird p>ty t may take su* action4 7,d7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to prev5t a gr\p heal? plan1 a heal? insurance issu]1 or a heal? plan s]vice provid] provid+ s]vices ) respect to su* a plan1 f plac+ reasonable re/rictions on ! public disclosure ( ! in=mation describ$ 9 p>agraph 7#a71 except t su* plan or entity may n re/rict disclosure ( su* in=mation to ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 ! ,dep>tm5t ( ! ,treasury1 or ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates4 7,e7 ,failure to provide ,! obligation to provide in=mation pursuant to ?is subsection %all exi/ not)/&+ ! pres5ce ( any =mal data-%>+ agreem5t betwe5 ! p>ties4 ,failure to provide ! requir$ in=mation z specifi$ %all con/itute a violation ( ?is ,act & ! ,secret>y %all initiate en=cem5t action "u section #bgbc7;b7 7#db ,u4,s4,c4 #cjj;gg-#bb7;b77 )9 #ij days ( becom+ aw>e ( a violation ( ?is section1 except t no?+ 9 ?is section %all be con/ru$ to limit ! ,secret>y's exi/+ au?ority "u ?is ,act4 7#d7 ,data =mat /&>ds ,all data & in=mation provid$ pursuant to ?is subsection %all comply ) ! foll[+ /&>ds3 7,a7 ,all claims f a heal?c>e provid] %all be made to ! gr\p heal? plan 9 accordance ) /&>ds adopt$ "u ,,hipaa z describ$ 9 subp>t ,k ( "p #afb ( title #de1 ,code ( ,f$]al ,regulations1 z foll[s3 7i7 ,in/itutional1 pr(essional1 & d5tal claims & adju/m5ts to ^! claims %all be provid$ to ! gr\p heal? plan or heal? insurance issu] 9 ! ,,asc ,x#ab,n #hcg =mat4 7ii7 ,prescription drug claims %all be 9 ! ,national ,c\ncil = ,prescription ,drug ,programs 7,,ncpdp7 =mat4 7iii7 ,! files %all be unmodifi$ copies ( ! files s5t f ! provid]4 ,9 ! ev5t t pap] claims are s5t by ! provid]1 !y %all be conv]t$ to ! appropriate /&>d electronic =mat4 ,su* data %all be provid$ at no co/ to ! gr\p heal? plan4 7,b7 ,all claim paym5t 7or ,,eft1 electronic funds transf]7 & electronic remittance advice 7,,era7 in=mation s5t by a heal? plan s]vice provid] %all be provid$ to ! gr\p heal? plan or heal? insurance issu] 9 ! ,,asc ,x#ab,n #hce =mat1 9 accordance ) /&>ds & op]at+ rules adopt$ "u ,,hipaa at subp>t ,p ( "p #afb ( title #de1 ,code ( ,f$]al ,regulations1 unmodifi$ f ! =m 9 :i* x 0 transmitt$ to ! heal?c>e provid]4 ,su* in=mation %all be provid$ at no co/ to ! gr\p heal? plan4 7,c7 ,! ,secret>y may modify ! /&>ds set =? 9 ?is p>agraph z necess>y to align ) any *anges adopt$ by ! ,secret>y pursuant to ! au?ority provid$ "u section #aagc ( ! ,social ,security ,act 7 #db ,u4,s4,c4 #acbj;d-#b74 7#e7 ,opt-9 = heal? insurance cov]age ,9 ! case ( a heal? insurance issu] (f]+ cov]age 9 ! individual or gr\p m>ket1 su* issu] may1 on an annual basis1 = plan ye>s beg9n+ on or aft] ! effective date ( ?is section1 elect to require a heal? plan s]vice provid] to submit to su* issu] a report t includes all ( ! in=mation describ$ 9 p>agraph 7#a74 7c7 ,prohibit$ contractual provisions ,any provision 9 an agreem5t t unduly delays or limits a gr\p heal? plan or issu]'s access to in=mation describ$ 9 ?is section or t re/ricts ! =mat or tim+ ( ! provision ( su* in=mation 9 a mann] t is inconsi/5t ) ! requirem5ts ( ?is section %all be prohibit$ &1 if a gr\p heal? plan or issu] ent]s into su* agreem5t1 %all be deem$ void z aga9/ public policy4 7d7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7b7 ,p5alty ,section #bgbc7;b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#bb7;b77 is am5d$ by add+ at ! end ! foll[+3 7#d7 ,en=cem5t au?ority relat+ to heal? plan s]vice provid]s ,not)/&+ any provisions to ! contr>y1 ! ,secret>y may assess a p5alty aga9/ a heal? plan s]vice provid]1 z def9$ 9 section #bgii;,a-#ab7;a7 7#db ,u4,s4,c4 #cjj;gg-#aba7;a771 ( #ajj1jjj p] day = ea* violation ( su* section1 pursuant to sub/antially simil> processes & proc$ures z ^? set =? 9 section #bgbc7;b77#b77;,d7 ?r\gh 7,g7 7#db ,u4,s4,c4 #cjj;gg-#aba7;b77#b77;,d7 ?r\gh 7,g774 4 7c7 ,,erisa am5dm5ts 7#a7 ,9 g5]al ,section #ejb7;c7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aacb7;c77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ad7 ,! ,secret>y may assess a civil p5alty aga9/ any p]son ( #ajj1jjj p] day = ea* violation by any p]son ( section #gbg4 4 7#b7 ,te*nical am5dm5t ,p>agraph 7#f7 ( section #ejb7;a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aacb7;a77 is am5d$ by /rik+ or 7#i7 & ins]t+ 7#i71 7#ac71 or 7#ad74 #i4 ,/ate preemption only 9 ev5t ( conflict ,! provisions ( section #bgah;,a ( ! ,public ,heal? ,s]vice ,act 7z add$ & am5d$ by ?is ,act7 %all n be con/ru$ to sup]s$e any provision ( ,/ate law :i* e/abli%es1 implem5ts1 or cont9ues 9 effect any requirem5t or prohibition relat$ to heal? c>e price transp>5cy1 includ+ = hospitals1 cl9ical diagno/ic laboratories1 provid] ( specifi$ imag+ s]vices1 & ambulatory surgical c5t]s 7z su* t]ms are def9$ 9 section #bgah;,a7a7 ( ! ,public ,heal? ,s]vice ,act71 except to ! ext5t t su* requirem5t or prohibition prev5ts ! application ( a requirem5t or prohibition ( su* sections 7or su* am5dm5ts74 ,no?+ 9 ?is section %all be con/ru$ to affect gr\p heal? plans e/abli%$ "u ! ,employee ,retirem5t ,income ,security ,act ( #aigd1 or alt] ! application ( section #ead ( su* ,act 7#bi ,u4,s4,c4 #aadd74 #aj4 ,requirem5t = explanation ( b5efits 7a7 ,advanc$ explanation ( b5efits ,section #bgii;,a-#a7;f7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa7;f77 is am5d$-- 7#a7 9 p>agraph 7#a7-- 7,a7 by /rik+ subp>agraph 7,c7 & ins]t+ ! foll[+3 7,c7 ,a good fai? e/imate ( ! am\nt ! plan or cov]age is responsible = pay+ = items & s]vices includ$ 9 ! e/imate describ$ 9 subp>agraph 7,b71 includ+ a pla9 language description ( ea* item or s]vice & all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 2 & 7,b7 by add+ at ! end ! foll[+ 7,i7 ,a notification t ! recipi5t may be held h>mless1 9 c]ta9 circum/ances1 if ! in=mation 9 ! advanc$ explanation ( b5efits does n mat* ! am\nt ! recipi5t is bill$4 2 & 7#b7 by add+ at ! end ! foll[+ 7#c7 ,hold h>mless 7,a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #a ye> aft] ! date on :i* ! ,secret>y implem5ts ?is section1 a p>ticipant1 b5efici>y1 or enrollee %all be held h>mless = any am\nt t is sub/antially 9 excess 7z def9$ by ! ,secret>y 9 a mann] consi/5t ) ! process describ$ 9 section #bgii;,b-#g7 ( ! e/imate g5]at$ by ! advanc$ explanation ( b5efits4 7,b7 ,no pati5t responsibility = excess *>ges ,a gr\p heal? plan or a heal? insurance issu] 9 ! gr\p or individual m>ket %all n hold a p>ticipant1 b5efici>y1 or enrollee responsible = excess *>ges describ$ 9 ?is p>agraph if su* excess is ! result ( cov]age or paym5t det]m9ations t diff] f projections made 9 ! advanc$ explanation ( b5efits at ! "t su* explanation 0 g5]at$4 7,c7 ,sub/antial excess ,a p>ticipant1 b5efici>y1 or enrollee %all n be held h>mless = excess am\nts if su* am\nts reflect ! co/ ( m$ically necess>y items or s]vices furni%$ bas$ on un=ese5 circum/ances t c\ld n h reasonably be5 anticipat$ by ! provid] or facility at ! "t ! good fai? e/imate 0 g5]at$ or by ! plan or issu] at ! "t ! advanc$ explanation ( b5efits 0 g5]at$4 4 7b7 ,good fai? e/imates ,section #bgii;,b-#f ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#acf7 is am5d$-- 7#a7 by /rik+ ,ea* heal? c>e & ins]t+ ! foll[+3 7a7 ,9 g5]al ,ea* heal? c>e 2 & 7#b7 by add+ at ! end ! foll[+3 7b7 ,hold h>mless 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ! date t is #a ye> aft] ! date on :i* ! ,secret>y implem5ts section #bgii;,a-#a7;f71 if an individual enroll$ 9 a gr\p heal? plan or heal? insurance cov]age 7& seeks to h a claim = an item or s]vice submitt$ to su* plan or cov]age7 is responsible = any am\nt t is sub/antially 9 excess 7z def9$ by ! ,secret>y 9 a mann] consi/5t ! process describ$ 9 section #bgii;,b-#g7 ( ! e/imate g5]at$ 9 ! advanc$ explanation ( b5efits describ$ 9 section #bgii;,a-#a7;f7 because ! f9al *>ges = items & s]vices 7 sub/antially 9 excess ( ! good fai? e/imate provid$ to ! plan or cov]age "u ?is section1 a provid] %all n bill ! pati5t = am\nts sub/antially 9 excess ( ! advanc$ explanation ( b5efits4 7#b7 ,sub/antial excess ,an individual seek+ to h a claim = an item or s]vice cov]$ by a gr\p heal? plan or heal? insurance cov]age %all n be held h>mless = excess am\nts if su* am\nts reflect ! co/ ( m$ically necess>y items or s]vices furni%$ bas$ on un=ese5 circum/ances t c\ld n h reasonably be5 anticipat$ by ! provid] or facility at ! "t ! good fai? e/imate 0 g5]at$ or by ! plan or issu] at ! "t ! advanc$ explanation ( b5efits 0 g5]at$4 4 7c7 ,explanation ( b5efits ,section #bgii;,a-#a ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa7 is am5d$ by add+ at ! end ! foll[+3 7g7 ,explanation ( b5efits 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on ,janu>y #a ( ! ye> t beg9s on or aft] ! date t is #a ye> aft] ! date ( enactm5t ( ! ,pati5ts ,des]ve ,price ,tags ,act1 ea* gr\p heal? plan1 or a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all1 )9 #de days ( receiv+ ! in=mation necess>y to decide a claim = paym5t 7z def9$ by ! ,secret>y7 = an item or s]vice "u ! plan or cov]age = :i* liability "u ! plan or cov]age has be5 det]m9$1 provide to ! p>ticipant1 b5efici>y1 or enrollee 7?r\gh mail or electronic means1 z reque/$ by ! p>ticipant1 b5efici>y1 or enrollee7 a notification 79 cle> & und]/&able language & utiliz+ sub/antially ! same =mat z ! advanc$ explanation ( b5efits requir$ by subsection 7f7 to enable comp>ison :5 an advanc$ explanation ( b5efits is provid$7 includ+ ! foll[+3 7,a7 ,:e!r or n ! provid] or facility is a p>ticipat+ provid] or a p>ticipat+ facility ) respect to ! plan or cov]age ) respect to ! furni%+ ( su* item or s]vice4 7,b7 ,an itemiz$ explanation ( b5efits t includes ! foll[+3 7i7 ,a pla9 language description ( ea* item or s]vice4 7ii7 ,all applicable bill+ codes = ea* item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets t are cle>ly id5tifi$4 7iii7 ,! am\nt ! plan or cov]age is responsible = pay+ = ea* item or s]vice4 7iv7 ,! am\nt ( any co/-%>+ = :i* ! p>ticipant1 b5efici>y1 or enrollee is responsible = ea* item or s]vice 7z ( ! date ( su* notification74 7v7 ,! am\nt t ! p>ticipant1 b5efici>y1 or enrollee has incurr$ t[>d meet+ ! limit ( ! f9ancial responsibility 7includ+ ) respect to d$uctibles & out-(-pocket maximums7 "u ! plan or cov]age 7z ( ! date ( su* notification74 7vi7 ,! type ( site ( ea* item or s]vice1 includ+ (fice1 facility1 or em]g5cy room4 7vii7 ,if applicable1 a description ( any discrepancies t exi/ betwe5 ! s]vices outl9$ 9 a pati5t's advanc$ explanation ( b5efits & ! explanation ( b5efits4 7viii7 ,! am\nt ( any facility fee or o!r pati5t *>ges t 7 add$ to ! f9al paym5t am\nt1 toge!r ) a pla9 language explanation ( ! fee1 if applicable4 7,c7 ,if ! provid] or facility is a p>ticipat+ provid] or facility ) respect to ! plan or cov]age ) respect to ! furni%+ ( su* item or s]vice1 ! contract$ rate "u su* plan or cov]age = su* item or s]vice4 7,d7 ,! *>ges submitt$ by ! provid] or facility = ea* item or s]vice4 7,e7 ,in=mation p]ta9+ to plan type1 z def9$ ! ,secret>y4 7#b7 ,=mat ,if applicable1 ! notification describ$ 9 p>agraph 7#a7 may be provid$ 9 conjunction )1 or z "p (1 a notice ( a claim det]m9ation or o!r communication requir$ by section #bgai7;a7 7#db ,u4,s4,c4 #cjj;gg-#ai7;a771 or regulations !reund]4 7h7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 #aa4 ,transp>5cy 9 bill+ 7a7 ,9 g5]al ,"p ,e ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aca et seq47 is am5d$ by add+ at ! end ! foll[+3 #bgii;,b-#aj4 ,pati5t access to complete bill+ in=mation 7a7 ,requirem5ts 7#a7 ,notice ( "r ( access to itemiz$ bills2 ,9 g5]al ,a heal? c>e provid] or heal? c>e facility t reque/s paym5t f an individual = provid+ a heal? c>e item or s]vice to ! pati5t %all include ) su* reque/ a writt5 notice ( ! individual's "r to reque/ an itemiz$ bill z "p ( ! individual's designat$ record set "u section #afd1ebd ( title #de1 ,code ( ,f$]al ,regulations 7or a successor regulation74 7#b7 ,requir$ in=mation ,a notice "u p>agraph 7#a7 %all provide-- 7,a7 a phone numb] & int]net website :]e an individual c make a reque/ = access to _! itemiz$ bill2 7,b7 in=mation ab\t ! availability ( language-assi/ance s]vices = individuals ) limit$ ,engli% pr(ici5cy 7,,lep72 & 7,c7 in=mation ab\t ! heal? c>e provid]'s or heal? c>e facility's *>ity c>e policies & in/ructions on h[ to apply = *>ity c>e4 7#c7 ,collections actions 7,a7 ,9 g5]al ,a heal? c>e provid] or heal? c>e facility %all n bill or take any collections actions aga9/ an individual-- 7i7 = any provid$ heal? c>e item or s]vice unless ! heal? c>e provid] or heal? c>e facility has compli$ ) p>agraph 7#a7 or section #acdje7;e77#d7 ( ! ,,hite* ,act2 or 7ii7 ) respect to any items or s]vices = :i* ! am\nt appe>+ on an itemiz$ bill describ$ above 9 p>agraph 7#a7 exce$s ! am\nt disclos$ pursuant to ,f$]al heal? c>e price transp>5cy regulations1 includ+ "p #ahj ( title #de1 ,code ( ,f$]al ,regulations1 or provid$ 9 a good fai? e/imate t complies ) section #bgii;,b-#f ( ?is ,act & section #adi4faj ( title #de1 ,code ( ,f$]al ,regulations1 or ano!r good fai? e/imate provid$ by a heal? c>e entity cov]$ "u ?is section b n o!rwise cov]$ "u su* section #bgii;,b-#f1 unless ! provid] or facility docum5ts t ! additional items or s]vices 7 m$ically necess>y due to un=ese5 complications or a pati5t-initiat$ *ange1 & c\ld n reasonably h be5 anticipat$4 7,b7 ,provid] requirem5t ,if a provid] fails to provide a docum5tation z requir$ "u subp>agraph 7,a77ii7 9 ! case ( items or s]vices1 ! good fai? e/imate describ$ 9 su* subp>agraph ) respect to su* items or s]vices %all be b9d+4 7b7 ,failure ,to comply 7#a7 ,p5alties ,! ,secret>y %all impose p5alties on any heal? c>e provid] or heal? c>e facility t fails to comply ) ! requirem5ts ( ?is section 9 an am\nt n to exce$ #aj1jjj = ea* in/ance ( failure to comply4 7#b7 ,presumption 9 favor ( individual ,if a heal? c>e provid] or heal? c>e facility fails to comply ) ! requirem5ts ( ?is section1 ! presumption %all be t *>ges 7 sub/antially 9 excess ( ! good fai? e/imate1 z set =? 9 section #bgii;,b-#f1 = ! purpose ( any pati5t-provid] dispute1 includ+ 9 accordance ) section #bgii;,b-#g & regulations promulgat$ !reund]4 7c7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7b7 ,/&>ds = access+ itemiz$ bills ,section #acdje7;e7 ( ! ,,hite* ,act 7#db ,u4,s4,c4 #agice7;e77 is am5d$-- 7#a7 9 p>agraph 7#b71 by /rik+ & at ! end2 7#b7 9 p>agraph 7#c71 by /rik+ ! p]iod & ins]t+ 2 &2 & 7#c7 by add+ at ! end1 ! foll[+3 7#d7 if ! individual makes a reque/ only = an itemiz$ copy ( a bill = s]vices provid$1 ! cov]$ entity or bus9ess associate %all-- 7,a7 make su* protect$ heal? in=mation available )9 #cj days ( su* reque/2 7,b7 n impose any fee = provid+ su* individual a copy ( _! in=mation2 & 7,c7 include 9 su* itemiz$ bill1 a pla9 language description ( ea* di/9ct heal? c>e item or s]vice1 all applicable bill+ codes = ea* di/9ct item or s]vice1 includ+ modifi]s1 us+ /&>d & commonly recogniz$ bill+ code sets1 ! price & bill$ am\nt1 if diff]5t1 ( ea* di/9ct item or s]vice4 4 #ab4 ,te*nical am5dm5ts 7a7 ,,erisa ,section #gae7;a77#a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;d7a77#a77 is am5d$ by ins]t+ & p>ts ,d & ,e ( ! ,public ,heal? ,s]vice ,act 7z am5d$ by ! ,pati5ts ,des]ve ,price ,tags ,act7 aft] ,af=dable ,c>e ,act74 7b7 ,int]nal ,rev5ue ,code ,section #ihae7;a77#a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by ins]t+ & p>ts ,d & ,e ( ! ,public ,heal? ,s]vice ,act 7z am5d$ by ! ,pati5ts ,des]ve ,price ,tags ,act7 aft] ,af=dable ,c>e ,act74 #ac4 ,implem5tation & en=cem5t fund+ 7a7 ,appropriation = ,secret>y ( ,labor ,!re are au?oriz$ to be appropriat$1 su* sums z may be necess>y = fiscal ye> #bjbf1 & ea* subsequ5t fiscal ye>1 to enable ! ,secret>y ( ,labor to c>ry out ?is ,act & ! am5dm5ts made by ?is ,act1 includ+ en=cem5t activities4 7b7 ,appropriation = ! ,secret>y ( ,heal? & ,human ,s]vices ,!re are au?oriz$ to be appropriat$1 su* sums z may be necess>y = fiscal ye> #bjbf1 & ea* subsequ5t fiscal ye>1 to enable ! ,secret>y ( ,heal? & ,human ,s]vices to c>ry out ! am5dm5ts made by ?is ,act1 includ+ implem5tation & en=cem5t activities4 ,july #bg1 #bjbf,report$ ) an am5dm5t