,,ii #aai? ,,congress #a/ ,session ,s4 #cchi ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,decemb] #i1 #bjbe,mr4 ,m>%all introduc$ ! foll[+ bill2 :i* 0 read twice & ref]r$ to ! ,committee on ,f9ance ,a ,,bill ,to l[] heal? c>e co/s = ,am]icans4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,l[]+ ,heal? ,c>e ,co/s = ,am]icans ,act4 7b7 ,table ( cont5ts ,! table ( cont5ts = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4,,title ,i--,g5]al provisions,sec4 #aja4 ,m9imum mon?ly premium paym5ts4,sec4 #ajb4 ,requir+ biometric & ,,id v]ification4,sec4 #ajc4 ,facilitat+ enrollm5t 9 & paym5t into ,heal?c>e ,af=dability ,acc\nts4,sec4 #ajd4 ,heal?c>e ,af=dability ,acc\nts4,sec4 #aje4 ,ext5sion ( tempor>y enhanc$ premium cr$its4,sec4 #ajf4 ,special rules relat+ to cov]age ( abortion s]vices4,sec4 #ajg4 ,special rules relat+ to cr$it = plans cov]+ abortion s]vices4,sec4 #ajh4 ,report+ ( heal? insurance cov]age4,sec4 #aji4 ,exclusion ( g5d] transition proc$ures f cov]age "u qualifi$ heal? plans4,sec4 #aaj4 ,fund+ co/ %>+ r$uction paym5ts4,sec4 #aaa4 ,waiv]s = ,/ate innovation4,,title ,,ii--,hospital transp>5cy requirements,sec4 #bja4 ,/r5g!n+ hospital price transp>5cy requirem5ts4,sec4 #bjb4 ,increas+ price transp>5cy ( cl9ical diagno/ic laboratory te/s4,sec4 #bjc4 ,imag+ transp>5cy4,sec4 #bjd4 ,ambulatory surgical c5t] price transp>5cy requirem5ts4,sec4 #bje4 ,/r5g!n+ heal? cov]age transp>5cy requirem5ts4,sec4 #bjf4 ,increas+ gr\p heal? plan access to heal? data4,sec4 #bjg4 ,ov]sight ( adm9i/rative s]vice provid]s4,sec4 #bjh4 ,/ate preemption only 9 ev5t ( conflict4,sec4 #bji4 ,requirem5t = explanation ( b5efits4,sec4 #baj4 ,provision ( itemiz$ bills4 ,i ,g5]al provisions #aja4 ,m9imum mon?ly premium paym5ts 7a7 ,9 g5]al ,section #cf;,b7b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#d7 ,limitation ,not)/&+ p>agraphs 7#b7 & 7#c71 9 no case %all ! premium assi/ance am\nt ) respect to any cov]age mon? exce$ ! excess 7if any7 ( ! am\nt det]m9$ "u p>agraph 7#b77;,a7 ov]-- 7,a7 9 ! case ( a taxpay] ^: h\sehold income 7express$ z a p]c5t ( ! pov]ty l9e7 is less ?an #bjj p]c5t1 #aj1 7,b7 9 ! case ( a taxpay] ^: h\sehold income 7express$ z a p]c5t ( ! pov]ty l9e7 is n less ?an #bjj p]c5t1 & less ?an #cjj p]c5t1 #bj1 7,c7 9 ! case ( a taxpay] ^: h\sehold income 7express$ z a p]c5t ( ! pov]ty l9e7 is n less ?an #cjj p]c5t1 & less ?an #djj p]c5t1 #cj1 & 7,d7 9 ! case ( a taxpay] ^: h\sehold income 7express$ z a p]c5t ( ! pov]ty l9e7 is n less ?an #djj p]c5t1 #dj4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjbe4 #ajb4 ,requir+ biometric & ,,id v]ification ,section #adaa7;b77#a7 ( ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjha7;b77#a77 is am5d$-- 7#a7 9 subp>agraph 7,a71 by /rik+ 2 & & ins]t+ a semicolon2 7#b7 by r$esignat+ subp>agraph 7,b7 z subp>agraph 7,c72 & 7#c7 by ins]t+ aft] subp>agraph 7,a7 ! foll[+3 7,b7 gov]nm5t-issu$ photo id5tification = ea* enrollee ov] ! age ( #ah1 & any o!r docum5tation z ! ,adm9i/rator ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices may require = purposes ( enrollm5t v]ification2 & 4 #ajc4 ,facilitat+ enrollm5t 9 & paym5t into ,heal?c>e ,af=dability ,acc\nts 7a7 ,9 g5]al ,section #acaa ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjca7 is am5d$-- 7#a7 9 subsection 7b77#a7-- 7,a7 9 subp>agraph 7,b71 by /rik+ & at ! end2 7,b7 by r$esignat+ subp>agraph 7,c7 z subp>agraph 7,d72 & 7,c7 by ins]t+ aft] subp>agraph 7,b7 ! foll[+3 7,c7 9 ! case ( plan ye>s beg9n+ aft] ,decemb] #ca1 #bjbf1 & be=e ,janu>y #a1 #bjcb1 facilitates enrollm5t 9 ,heal?c>e ,af=dability ,acc\nts describ$ 9 section #bbc7;i7 ( ! ,int]nal ,rev5ue ,code ( #aihf1 = qualifi$ individuals :o pur*ase qualifi$ heal? plans & are eligible = premium tax cr$its "u section #cf;,b2 & 2 7#b7 by add+ at ! end ( subsection 7c7 ! foll[+3 7#h7 ,enrollm5t 9 ,heal?c>e ,af=dability ,acc\nts ,! ,secret>y %all e/abli% a proc$ure = notify+ qualifi$ individuals :o pur*ase qualifi$ heal? plans & :o are eligible = a premium tax cr$it "u section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf ( ! ne$ to enroll 9 a ,heal?c>e ,af=dability ,acc\nt describ$ 9 section #bbc7;i7 ( su* ,code1 9 ord] to receive su* cr$it1 = plan ye>s beg9n+ aft] ,decemb] #ca1 #bjbf1 & be=e ,janu>y #a1 #bjcb4 2 & 7#c7 9 subsection 7d77#d77;,g71 by ins]t+ 1 &1 = plan ye>s beg9n+ aft] ,decemb] #ca1 #bjbf1 & be=e ,janu>y #a1 #bjcb1 make available to any individual qualify+ = su* a tax cr$it1 a l9k to ! application on ! website ( ! ,dep>tm5t ( ! ,treasury = enrollm5t 9 a ,heal?c>e ,af=dability ,acc\nt describ$ 9 section #bbc7;i7 ( ! ,int]nal ,rev5ue ,code ( #aihf be=e ! semicolon at ! end4 7b7 ,paym5t ( premium tax cr$its into ,heal?c>e ,af=dability ,acc\nts ,section #adab ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjhb7 is am5d$-- 7#a7 9 subsection 7a77#c7-- 7,a7 by /rik+ ! ,secret>y ( ! ,treasury makes advance paym5ts & ins]t+ 8! ,secret>y ( ! ,treasury-- 7,a7 except z provid$ 9 subp>agraph 7,b71 makes advance paym5ts 2 7,b7 by /rik+ ! p]iod at ! end & ins]t+ 1 &2 & 7,c7 by add+ at ! end ! foll[+ new subp>agraph3 7,b7 9 ! case ( a plan ye> beg9n+ aft] ,decemb] #ca1 #bjbf1 & be=e ,janu>y #a1 #bjcb1 makes advance paym5ts-- 7i7 ( su* premium tax cr$it into ! ,heal?c>e ,af=dability ,acc\nt ma9ta9$ "u section #bbc7;i7 ( ! ,int]nal ,rev5ue ,code ( #aihf = ea* individual eligible = su* cr$it2 & 7ii7 ( su* co/-%>+ r$uctions to ! issu]s ( ! qualifi$ heal? plans 9 ord] to r$uce ! premiums payable by individuals eligible = su* co/-%>+ r$uctions4 2 & 7#b7 9 subsection 7c77#b7-- 7,a7 by /rik+ ,! ,secret>y & ins]t+ ,except z provid$ 9 subp>agraph 7,c71 ! ,secret>y2 & 7,b7 by add+ at ! end ! foll[+ new subp>agraph3 7,c7 ,paym5t ( premium tax cr$it into ,heal?c>e ,af=dability ,acc\nts ,9 ! case ( plan ye>s beg9n+ aft] ,decemb] #ca1 #bjbf1 & be=e ,janu>y #a1 #bjca1 ! ,secret>y ( ! ,treasury %all make ! advance paym5t "u ?is section ( any premium tax cr$it all[$ "u section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf to ! ,heal?c>e ,af=dability ,acc\nt ( ! applicable individual on a mon?ly basis 7or su* o!r p]iodic basis z ! ,secret>y may provide74 4 #ajd4 ,heal?c>e ,af=dability ,acc\nts 7a7 ,9 g5]al ,section #bbc ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subsection3 7i7 ,heal?c>e ,af=dability ,acc\nts ,= purposes ( ?is section-- 7#a7 ,9 g5]al ,9 ! case ( a ,heal?c>e ,af=dability ,acc\nt1 ?is section %all be appli$ z provid$ 9 p>agraphs 7#c7 ?r\gh 7#g74 7#b7 ,heal?c>e ,af=dability ,acc\nt ,! t]m ,heal?c>e ,af=dability ,acc\nt means a heal? sav+s acc\nt1 det]m9$ z provid$ 9 ?is subsection4 7#c7 ,treatm5t ( transf]r$ contributions ,am\nts transf]r$ to a ,heal?c>e ,af=dability ,acc\nt pursuant to section #adab ( ! ,pati5t ,protection & ,af=dable ,c>e ,act %all n be tak5 into acc\nt 9 det]m9+ ! d$uction all[$ by subsection 7a74 7#d7 ,acc\nt mu/ be only ,,hsa ( individual 7,a7 ,9 g5]al ,an individual :o has a ,heal?c>e ,af=dability ,acc\nt %all n be treat$ z an eligible individual ) respect to any heal? sav+s acc\nt o!r ?an su* ,heal?c>e ,af=dability ,acc\nt4 7,b7 ,rollov] ( exi/+ acc\nt p]mitt$ ,an individual on ^: behalf a ,heal?c>e ,af=dability ,acc\nt is e/abli%$ may roll ov] ! balance ( any o!r heal? sav+s acc\nt ( ! individual to su* ,heal?c>e ,af=dability ,acc\nt accord+ to ! rules ( subsection 7f77#e74 7#e7 ,no rollov]s p]mitt$ ,except z provid$ 9 p>agraph 7#d77;,b71 subsection 7f77#e7 %all n apply & no am\nt %all be contribut$ f a ,heal?c>e ,af=dability ,acc\nt to any heal? sav+s acc\nt o!r ?an a ,heal?c>e ,af=dability ,acc\nt4 7#f7 ,re/riction on use ( am\nts ,no am\nts 9 a ,heal?c>e ,af=dability ,acc\nt may be us$ to pay = any-- 7,a7 g5d] transition proc$ures1 or 7,b7 abortion4 7#g7 ,def9itions ,= purposes ( p>agraph 7#f7-- 7,a7 ,g5d] transition proc$ure 7i7 ,9 g5]al ,! t]m g5d] transition proc$ure means any hormonal or surgical int]v5tion = ! purpose ( g5d] transition1 includ+-- 7,i7 gonadotrop9-releas+ hormone 7,gn,r,h7 agoni/s or o!r pub]ty-block+ or suppress+ drugs to /op or delay normal pub]ty2 7,,ii7 te/o/]one1 e/rog51 proge/]one1 or o!r &rog5s to an individual at doses t are supraphysiologic to :at w\ld normally be produc$ endog5\sly 9 a heal?y individual ( ! same age & sex2 7,,iii7 ca/ration2 7,,iv7 or*iectomy2 7,v7 scrotopla/y2 7,,vi7 implantation ( erection or te/icul> pro/heses2 7,,vii7 vasectomy2 7,,viii7 hy/]ectomy2 7,,ix7 oophorectomy2 7,x7 ov>iectomy2 7,,xi7 recon/ruction ( ! fix$ "p ( ! ure?ra ) or )\t a metoidiopla/y or a phallopla/y2 7,,xii7 metoidiopla/y2 7,,xiii7 p5ectomy2 7,,xiv7 phallopla/y2 7,,xv7 vag9opla/y2 7,,xvi7 clitoropla/y2 7,,xvii7 vag9ectomy2 7,,xviii7 vulvopla/y2 7,,xix7 r$uction ?yro*ondropla/y2 7,,xx7 *ondrol>yngopla/y2 7,,xxi7 ma/ectomy2 7,,xxii7 tubal ligation2 7,,xxiii7 /]ilization2 7,,xxiv7 any pla/ic1 cosmetic1 or ae/hetic surg]y t fem9izes or mascul9izes ! facial or o!r physiological features ( an individual2 7,,xxv7 any placem5t ( *e/ implants to create fem99e brea/s2 7,,xxvi7 any placem5t ( fat or artificial implants 9 ! gluteal region2 7,,xxvii7 augm5tation mammopla/y2 7,,xxviii7 liposuction2 7,,xxix7 lip(ill+2 7,,xxx7 voice surg]y2 7,,xxxi7 hair recon/ruction2 7,,xxxii7 pectoral implants2 & 7,,xxxiii7 ! removal ( any o!rwise heal?y or non-diseas$ body "p or tissue4 7ii7 ,exclusions ,! t]m g5d] transition proc$ure does n include ! foll[+ :5 furni%$ to an individual by a heal? c>e provid] ) ! cons5t ( su* individual or1 if applicable1 su* individual's p>5ts or legal gu>dian3 7,i7 ,s]vices to individuals born ) a m$ically v]ifiable disord] ( sex developm5t1 includ+ an individual ) ext]nal sex *>act]i/ics t are irresolvably ambigu\s1 su* z an individual born ) #df ,,xx *romosomes ) virilization1 an individual born ) #df ,,xy *romosomes ) und]virilization1 or an individual born hav+ bo? ov>ian & te/icul> tissue4 7,,ii7 ,s]vices provid$ :5 a physician has o!rwise diagnos$ a disord] ( sexual developm5t 9 :i* ! physician has det]m9$ ?r\gh g5etic or bio*emical te/+ t ! individual does n h normal sex *romosome /ructure1 sex /]oid hormone production1 or sex /]oid hormone action = a heal?y individual ( ! same sex & age4 7,,iii7 ,! treatm5t ( any infection1 injury1 disease1 or disord] t has be5 caus$ by or exac]bat$ by ! p]=mance ( g5d] transition proc$ures1 :e!r or n ! g5d] transition proc$ure 0 p]=m$ 9 accordance ) ,/ate & ,f$]al law or :e!r or n fund+ = ! g5d] transition proc$ure is p]missible "u ?is section4 7,,iv7 ,any proc$ure und]tak5 because ! individual suff]s f a physical disord]1 physical injury1 or physical illness 7b n m5tal1 behavioral1 or emotional di/ress or a m5tal1 behavioral1 or emotional disord]7 t w\ld1 z c]tifi$ by a physician1 place ! individual 9 imm95t dang] ( dea? or impairm5t ( major bodily function1 unless ! proc$ure is p]=m$4 7,v7 ,pub]ty suppression or block+ prescription drugs = ! purpose ( normaliz+ pub]ty = a m9or exp]i5c+ precoci\s pub]ty4 7,,vi7 ,male circumcision4 7,b7 ,g5d] transition ,! t]m g5d] transition means ! process 9 :i* an individual goes f id5tify+ ) or pres5t+ z 8 or h] sex to id5tify+ ) or pres5t+ a self-proclaim$ id5tity t does n correspond ) or is diff]5t f 8 or h] sex1 & may be accompani$ ) social1 legal1 or physical *anges4 7,c7 ,sex ,! t]m sex1 :5 ref]r+ to an individual's sex1 means to ref] to ei!r male or female1 z biologically det]m9$4 7,d7 ,female ,! t]m female1 :5 us$ to ref] to a natural p]son1 means an individual :o naturally has1 _h1 w h1 or w\ld h1 b = a cong5ital anomaly1 hi/orical accid5t1 or int5tional or un9t5tional disruption1 ! reproductive sy/em t at "s po9t produces1 transports1 & utilizes eggs = f]tilization4 7,e7 ,male ,! t]m male1 :5 us$ to ref] to a natural p]son1 means an individual :o naturally has1 _h1 w h1 or w\ld h1 b = a cong5ital anomaly1 hi/orical accid5t1 or int5tional or un9t5tional disruption1 ! reproductive sy/em t at "s po9t produces1 transports1 & utilizes sp]m = f]tilization4 7,f7 ,abortion 7i7 ,9 g5]al ,! t]m abortion means-- 7,i7 drugs or proc$ures us$ ) ! prim>y int5t to end ! life ( ! human be+ 9 ! womb1 7,,ii7 pre-viable deliv]y n describ$ 9 clause 7ii71 & 7,,iii7 po/-viable deliv]y ) int5tional dea? ( ! fetus4 7ii7 ,exclusions ,su* t]m does n include-- 7,i7 sep>ation ( ! "m & h] embryo or fetus to prev5t ! "m's dea? or imm$iate irrev]sible bodily h>m1 :i* _c be mitigat$ 9 any o!r way1 7,,ii7 treatm5t ( ectopic or mol> pregnancy1 7,,iii7 treatm5t ( misc>riage1 or 7,,iv7 any s]vice describ$ 9 clause 7i7 9 ! case ( a pregnancy :i* is ! result ( an act ( rape or ince/4 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjbf4 #aje4 ,ext5sion ( tempor>y enhanc$ premium cr$its 7a7 ,9 g5]al ,clause 7iii7 ( section #cf;,b7b77#c77;,a7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7#a7 by /rik+ ,janu>y #a1 #bjbf & ins]t+ ,janu>y #a1 #bjcb1 & 7#b7 by /rik+ #bjbe 9 ! head+ & ins]t+ #bjca4 7b7 ,h\sehold income limitation ,section #cf;,b7c77#a77;,e7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$-- 7#a7 by /rik+ rule = #bjba ?r\gh #bjbe4--;,9 ! case ( & ins]t+ ! foll[+3 8rules = #bjba ?r\gh #bjca4-- 7i7 ,9 g5]al ,9 ! case ( 1 & 7#b7 by add+ at ! end ! foll[+ new clause3 7ii7 ,special rule = #bjbg ?r\gh #bjca ,9 ! case ( any taxable ye> beg9n+ aft] ,decemb] #ca1 #bjbf1 & be=e ,janu>y #a1 #bjcb1 subp>agraph 7,a7 %all be appli$ by sub/itut+ #gjj p]c5t = #djj p]c5t4 4 7c7 ,phas$[n ( enhanc$ am\nts ,subp>agraph 7,a7 ( section #cf;,b7b77#c7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new clause3 7iv7 ,phas$[n ( enhanc$ am\nts 7,i7 ,9 g5]al ,9 ! case ( a taxable ye> beg9n+ aft] ,decemb] #ca1 #bjbg1 ! premium assi/ance am\nt det]m9$ "u ?is subsection 7)\t reg>d to ?is clause7 %all be r$uc$ by an am\nt equal to ! phas$[n p]c5tage ( ! enhanc$ am\nt4 7,,ii7 ,enhanc$ am\nt ,= purposes ( subclause 7,i71 ! t]m enhanc$ am\nt means ! excess1 if any1 ( ! premium assi/ance am\nt det]m9$ "u ?is subsection 7)\t reg>d to ?is clause7 ov] ! premium assi/ance am\nt :i* w\ld be s det]m9$ if clause 7iii7 did n apply = ! taxable ye>4 7,,iii7 ,phas$[n p]c5tage ,= purposes ( subclause 7,i71 ! phas$[n p]c5tage is-- 7aa7 #bj p]c5t1 9 ! case ( a taxable ye> beg9n+ aft] ,decemb] #ca1 #bjbg1 & be=e ,janu>y #a1 #bjbi1 7bb7 #dj p]c5t1 9 ! case ( a taxable ye> beg9n+ aft] ,decemb] #ca1 #bjbh1 & be=e ,janu>y #a1 #bjcj1 7cc7 #fj p]c5t1 9 ! case ( a taxable ye> beg9n+ aft] ,decemb] #ca1 #bjbi1 & be=e ,janu>y #a1 #bjca1 & 7dd7 #hj p]c5t1 9 ! case ( a taxable ye> beg9n+ aft] ,decemb] #ca1 #bjcj1 & be=e ,janu>y #a1 #bjcb4 4 7d7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjbe4 #ajf4 ,special rules relat+ to cov]age ( abortion s]vices 7a7 ,9 g5]al ,section #acjc7;b7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjbc7;b77 is am5d$-- 7#a7 9 p>agraph 7#b7-- 7,a7 by am5d+ subp>agraph 7,a7 to read z foll[s3 7,a7 ,prohibition on ! use ( ,f$]al funds ,if a qualifi$ heal? plan provides cov]age ( s]vices describ$ 9 p>agraph 7#a77;,b77i71 ! issu] ( ! plan %all n use any am\nt attributable to any co/-%>+ r$uction "u section #adjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7& ! am\nt 7if any7 ( ! advance paym5t ( ! r$uction "u section #adab74 2 7,b7 9 subp>agraph 7,b77i77,i71 by /rik+ cr$its & co/-%>+ r$uctions describ$ 9 subp>agraph 7,a7 & ins]t+ co/-%>+ r$uctions describ$ 9 subp>agraph 7,a7 & premium tax cr$its "u section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf1 & ! am\nt1 if any1 ( ! advance paym5t ( su* cr$it "u section #adab2 & 7#b7 by am5d+ p>agraph 7#c7 to read z foll[s3 7#c7 ,rules relat+ to notice 7,a7 ,notice ,a qualifi$ heal? plan t provides = cov]age ( ! s]vices describ$ 9 p>agraph 7#a77;,b77i7 %all1 at ! "t ( enrollm5t1 provide notice to enrollees-- 7i7 t ! plan includes su* cov]age2 7ii7 ! am\nt ( ! premium *>g$ = su* cov]age2 & 7iii7 t su* am\nt is n eligible = ! premium tax cr$it "u section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf4 7,b7 ,disclosures 7i7 ,9 g5]al ,! issu] ( a plan describ$ 9 subp>agraph 7,a7 %all include ! cov]age ( s]vices describ$ 9 p>agraph 7#a77;,b77i7 z "p ( ! summ>y ( b5efits & cov]age explanation = ! plan1 z applicable4 7ii7 ,comp>ative in=mation ,if "o or m plans describ$ 9 subp>agraph 7,a7 are (f]$ ?r\gh an ,ex*ange 9 a ,/ate1 ! ,ex*ange %all include 9 any /&>diz$ =mat = pres5t+ heal? b5efits plan options to pot5tial enrollees1 comp>ative in=mation on plan cov]age ( su* s]vices4 4 7b7 ,effective date ,! am5dm5ts made by subsection 7a7 %all apply ) respect to plan ye>s beg9n+ aft] ,decemb] #ca1 #bjbf4 #ajg4 ,special rules relat+ to cr$it = plans cov]+ abortion s]vices 7a7 ,9 g5]al ,p>agraph 7#c7 ( section #cf;,b7b7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,f7 ,special rule = abortion cov]age ,if a qualifi$ heal? plan (f]s cov]age ( abortion 7z def9$ 9 section #bbc7;i77#g77;,f771 ! portion ( ! premium = ! plan prop]ly allocable 7"u rules prescrib$ by ! ,secret>y ( ,heal? & ,human ,s]vices7 to su* cov]age %all n be tak5 into acc\nt 9 det]m9+ ei!r ! mon?ly premium or ! adju/$ mon?ly premium "u p>agraph 7#b74 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjbf4 #ajh4 ,report+ ( heal? insurance cov]age 7a7 ,9 g5]al ,subclause 7,,ii7 ( section #fjee7;b77#a77;,b77iii7 ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ to read z foll[s3 7,,ii7 9 ! case ( a qualifi$ heal? plan-- 7aa7 ! am\nt ( ! plan premium1 7bb7 if ! plan provid$ cov]age ( s]vices describ$ 9 subsection 7b77#a7 ( section #acjc ( ! ,pati5t ,protection & ,af=dable ,c>e ,act1 ! am\nt ( ! plan premium attributable to su* cov]age 7calculat$ z describ$ 9 subsection 7b77#b77;,b7 ( su* section71 & 7cc7 ! am\nt 7if any7 ( any advance paym5t "u section #adab ( ! ,pati5t ,protection & ,af=dable ,c>e ,act ( any premium tax cr$it "u section #cf;,b ) respect to su* cov]age1 & 4 7b7 ,effective date ,! am5dm5t made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjbf4 #aji4 ,exclusion ( g5d] transition proc$ures f cov]age "u qualifi$ heal? plans 7a7 ,9 g5]al ,section #acja7;a77#a7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjba7;a77#a77 is am5d$-- 7#a7 9 subp>agraph 7,b71 by /rik+ & aft] ! semicolon2 7#b7 9 subp>agraph 7,c77iv71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7#c7 by add+ at ! end ! foll[+3 7,d7 does n provide cov]age = g5d] transition proc$ures4 4 7b7 ,def9ition ( g5d] transition proc$ure ,section #acja ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjba7 is am5d$ by add+ at ! end ! foll[+3 7c7 ,def9itions relat+ to g5d] transition proc$ures 7#a7 ,g5d] transition proc$ure 7,a7 ,9 g5]al ,= purposes ( subsection 7a77#a77;,d71 ! t]m g5d] transition proc$ure means any hormonal or surgical int]v5tion = ! purpose ( g5d] transition1 includ+-- 7i7 gonadotrop9-releas+ hormone 7,gn,r,h7 agoni/s or o!r pub]ty-block+ or suppress+ drugs to /op or delay normal pub]ty2 7ii7 te/o/]one1 e/rog51 proge/]one1 or o!r &rog5s to an individual at doses t are supraphysiologic to :at w\ld normally be produc$ endog5\sly 9 a heal?y individual ( ! same age & sex2 7iii7 ca/ration2 7iv7 or*iectomy2 7v7 scrotopla/y2 7vi7 implantation ( erection or te/icul> pro/heses2 7vii7 vasectomy2 7viii7 hy/]ectomy2 7ix7 oophorectomy2 7x7 ov>iectomy2 7xi7 recon/ruction ( ! fix$ "p ( ! ure?ra ) or )\t a metoidiopla/y or a phallopla/y2 7xii7 metoidiopla/y2 7xiii7 p5ectomy2 7xiv7 phallopla/y2 7xv7 vag9opla/y2 7xvi7 clitoropla/y2 7xvii7 vag9ectomy2 7xviii7 vulvopla/y2 7xix7 r$uction ?yro*ondropla/y2 7xx7 *ondrol>yngopla/y2 7xxi7 ma/ectomy2 7xxii7 tubal ligation2 7xxiii7 /]ilization2 7xxiv7 any pla/ic1 cosmetic1 or ae/hetic surg]y t fem9izes or mascul9izes ! facial or o!r physiological features ( an individual2 7xxv7 any placem5t ( *e/ implants to create fem99e brea/s2 7xxvi7 any placem5t ( fat or artificial implants 9 ! gluteal region2 7xxvii7 augm5tation mammopla/y2 7xxviii7 liposuction2 7xxix7 lip(ill+2 7xxx7 voice surg]y2 7xxxi7 hair recon/ruction2 7xxxii7 pectoral implants2 & 7xxxiii7 ! removal ( any o!rwise heal?y or non-diseas$ body "p or tissue4 7,b7 ,exclusions ,= purposes ( subsection 7a77#a77;,d71 ! t]m g5d] transition proc$ure does n include ! foll[+ :5 furni%$ to an individual by a heal? c>e provid] ) ! cons5t ( su* individual or1 if applicable1 su* individual's p>5ts or legal gu>dian3 7i7 ,s]vices to individuals born ) a m$ically v]ifiable disord] ( sex developm5t1 includ+ an individual ) ext]nal sex *>act]i/ics t are irresolvably ambigu\s1 su* z an individual born ) #df ,,xx *romosomes ) virilization1 an individual born ) #df ,,xy *romosomes ) und]virilization1 or an individual born hav+ bo? ov>ian & te/icul> tissue4 7ii7 ,s]vices provid$ :5 a physician has o!rwise diagnos$ a disord] ( sexual developm5t 9 :i* ! physician has det]m9$ ?r\gh g5etic or bio*emical te/+ t ! individual does n h normal sex *romosome /ructure1 sex /]oid hormone production1 or sex /]oid hormone action = a heal?y individual ( ! same sex & age4 7iii7 ,! treatm5t ( any infection1 injury1 disease1 or disord] t has be5 caus$ by or exac]bat$ by ! p]=mance ( g5d] transition proc$ures1 :e!r or n ! g5d] transition proc$ure 0 p]=m$ 9 accordance ) ,/ate & ,f$]al law or :e!r or n fund+ = ! g5d] transition proc$ure is p]missible "u ?is section4 7iv7 ,any proc$ure und]tak5 because ! individual suff]s f a physical disord]1 physical injury1 or physical illness 7b n m5tal1 behavioral1 or emotional di/ress or a m5tal1 behavioral1 or emotional disord]7 t w\ld1 z c]tifi$ by a physician1 place ! individual 9 imm95t dang] ( dea? or impairm5t ( major bodily function1 unless ! proc$ure is p]=m$4 7v7 ,pub]ty suppression or block+ prescription drugs = ! purpose ( normaliz+ pub]ty = a m9or exp]i5c+ precoci\s pub]ty4 7vi7 ,male circumcision4 7#b7 ,relat$ t]ms ,= purposes ( p>agraph 7#a73 7,a7 ,female ,! t]m female1 :5 us$ to ref] to a natural p]son1 means an individual :o naturally has1 _h1 w h1 or w\ld h1 b = a cong5ital anomaly1 hi/orical accid5t1 or int5tional or un9t5tional disruption1 ! reproductive sy/em t at "s po9t produces1 transports1 & utilizes eggs = f]tilization4 7,b7 ,g5d] transition ,! t]m g5d] transition means ! process 9 :i* an individual goes f id5tify+ ) or pres5t+ z 8 or h] sex to id5tify+ ) or pres5t+ a self-proclaim$ id5tity t does n correspond ) or is diff]5t f 8 or h] sex1 & may be accompani$ ) social1 legal1 or physical *anges4 7,c7 ,male ,! t]m male1 :5 us$ to ref] to a natural p]son1 means an individual :o naturally has1 _h1 w h1 or w\ld h1 b = a cong5ital anomaly1 hi/orical accid5t1 or int5tional or un9t5tional disruption1 ! reproductive sy/em t at "s po9t produces1 transports1 & utilizes sp]m = f]tilization4 7,d7 ,sex ,! t]m sex1 :5 ref]r+ to an individual's sex1 means to ref] to ei!r male or female1 z biologically det]m9$4 4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply ) respect to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbf4 #aaj4 ,fund+ co/ %>+ r$uction paym5ts ,section #adjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjga7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7h7 ,fund+ 7#a7 ,9 g5]al ,!re are appropriat$ out ( any monies 9 ! ,treasury n o!rwise appropriat$ su* sums z may be necess>y = purposes ( mak+ paym5ts "u ?is section = plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbf4 7#b7 ,limitation 7,a7 ,9 g5]al ,! am\nts appropriat$ "u p>agraph 7#a7 may n be us$ = purposes ( mak+ paym5ts "u ?is section = a qualifi$ heal? plan t provides heal? b5efit cov]age t includes cov]age ( abortion4 7,b7 ,exception ,subp>agraph 7,a7 %all n apply to paym5ts = a qualifi$ heal? plan t provides cov]age ( abortion only if necess>y to save ! life ( ! "m or if ! pregnancy is a result ( an act ( rape or ince/4 4 #aaa4 ,waiv]s = ,/ate innovation 7a7 ,/reaml9+ ! ,/ate application process ,section #accb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjeb7 is am5d$-- 7#a7 9 subsection 7a77#a77;,c71 by /rik+ ! law & ins]t+ a law or has 9 effect a c]tification2 & 7#b7 9 subsection 7b77#b7-- 7,a7 9 ! p>agraph head+1 by ins]t+ or c]tify aft] law2 7,b7 9 subp>agraph 7,a7-- 7i7 by /rik+ ,a law & ins]t+ ! foll[+3 7i7 ,laws ,a law 2 & 7ii7 by add+ at ! end ! foll[+3 7ii7 ,c]tifications ,a c]tification describ$ 9 ?is p>agraph is a docum5t1 sign$ by ! ,gov]nor ( ! ,/ate1 t c]tifies t su* ,gov]nor has ! au?ority "u exi/+ ,f$]al & ,/ate law to take action "u ?is section1 includ+ implem5tation ( ! ,/ate plan "u subsection 7a77#a77;,b74 2 & 7,c7 9 subp>agraph 7,b7-- 7i7 9 ! subp>agraph head+1 by /rik+ ( opt out2 & 7ii7 by /rik+ may repeal a law & all t foll[s ?r\gh ! p]iod at ! end & ins]t+ ! foll[+3 8may t]m9ate ! au?ority provid$ "u ! waiv] ) respect to ! ,/ate by-- 7i7 repeal+ a law describ$ 9 subp>agraph 7,a77i72 or 7ii7 t]m9at+ a c]tification describ$ 9 subp>agraph 7,a77ii71 ?r\gh a c]tification = su* t]m9ation sign$ by ! ,gov]nor ( ! ,/ate4 4 7b7 ,giv+ ,/ates m fund+ flexibility1 ,to e/abli% re9surance1 invisible high-,risk pools1 insurance /ability funds1 & o!r programs 7#a7 ,/ate grants "u waiv]s ,section #accb7;a7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjeb7;a77 is am5d$-- 7,a7 9 p>agraph 7#c7-- 7i7 9 ! fir/ s5t5ce-- 7,i7 by ins]t+ or w\ld qualify = a r$uc$ portion ( aft] w\ld n qualify =2 7,,ii7 by ins]t+ 1 or ! ,/ate w\ld n qualify = or w\ld qualify = a r$uc$ portion ( basic heal? program funds "u section #acca1 aft] subtitle ,e2 7,,iii7 by ins]t+ 1 or basic heal? program funds ! ,/ate w\ld h receiv$1 aft] ?is title2 & 7,,iv7 by ins]t+ or = implem5t+ ! basic heal? program e/abli%$ "u section #acca be=e ! p]iod2 7ii7 9 ! second s5t5ce1 by ins]t+ be=e ! p]iod 1 & ) respect to p>ticipation 9 ! basic heal? program & funds provid$ to su* o!r ,/ates "u section #acca2 & 7iii7 by add+ aft] ! second s5t5ce ! foll[+3 ,a ,/ate may reque/ t all (1 or any portion (1 su* aggregate am\nt ( su* cr$its1 r$uctions1 or funds be paid to ! ,/ate z describ$ 9 ! fir/ s5t5ce42 7,b7 by r$esignat+ p>agraphs 7#d71 7#e71 & 7#f7 z p>agraphs 7#e71 7#f71 & 7#g71 respectively2 & 7,c7 by ins]t+ aft] p>agraph 7#c7 ! foll[+3 7#d7 ,f$]al fund+ = invisible high-risk pool & re9surance programs 7,a7 ,allocations ,n lat] ?an #de days aft] ! date ( enactm5t ( ! ,l[]+ ,heal? ,c>e ,co/s = ,am]icans ,act1 ! ,secret>y1 9 consultation ) ! ,national ,association ( ,insurance ,commission]s1 %all specify an allocation me?odology = det]m9+ ! am\nt ( funds appropriat$ "u section #b7;a77#b77;,b7 ( ! ,l[]+ ,heal? ,c>e ,co/s = ,am]icans ,act = a fiscal ye> to be allocat$ = ea* ,/ate = purposes ( subp>agraph 7,b7 & section #b7;a77#b77;,c7 ( ! ,l[]+ ,heal? ,c>e ,co/s = ,am]icans ,act4 7,b7 ,/ate grants ,f am\nts appropriat$ "u section #b7;a77#b77;,b7 ( ! ,l[]+ ,heal? ,c>e ,co/s = ,am]icans ,act = a fiscal ye>1 ! ,secret>y %all aw>d grants to ,/ates = ea* ( fiscal ye>s #bjbg ?r\gh #bjcj1 9 am\nts det]m9$ 9 accordance ) ! allocation me?odology "u subp>agraph 7,a71 = ! foll[+ purposes3 7i7 ,= fiscal ye> #bjbg1 = adm9i/rative co/s ( ! ,/ate associat$ ) prep>+ & submitt+ in=mation describ$ 9 subsection 7a77#a77;,b7 t includes an invisible high-risk pool or re9surance program t meets ! requirem5ts ( subsection 7g77#b71 or co/s associat$ ) ! e/abli%m5t ( su* invisible high-risk pool or re9surance program4 7ii7 ,= ea* ( fiscal ye>s #bjbh1 #bjbi1 & #bjcj1 = ! e/abli%m5t or ma9t5ance ( invisible high-risk pools & re9surance programs t meet ! requirem5ts ( subsection 7g77#b7 & = :i* ! ,/ate has receiv$ a waiv] "u ?is section4 7,c7 ,budget neutrality ,funds aw>d$ to a ,/ate "u a grant aw>d$ "u subp>agraph 7,b7 %all n be tak5 into acc\nt = purposes ( det]m9+ "u p>agraph 7#a7 :e!r ! ,/ate waiv] is budget neutral1 or det]m9+ "u subsection 7b77#a7 :e!r ! ,/ate waiv] increases ! ,f$]al deficit4 4 7#b7 ,appropriations 7,a7 ,9 g5]al ,!re are au?oriz$ to be appropriat$1 & !re are appropriat$1 to ! ,secret>y ( ,heal? & ,human ,s]vices1 = ! purposes describ$ 9 section #accb7;a77#d77;,b7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act & subp>agraph 7,c71 out ( any funds 9 ! ,treasury n o!rwise appropriat$-- 7i7 #ejj1jjj1jjj = fiscal ye> #bjbg2 & 7ii7 #e1jjj1jjj1jjj = ea* ( fiscal ye>s #bjbh1 #bjbi1 & #bjcj4 7,b7 ,available until exp5d$ ,am\nts appropriat$ "u ?is p>agraph %all rema9 available until exp5d$4 7#c7 ,default ,f$]al safegu>d 7,a7 ,9 g5]al ,= purposes ( plan ye> #bjbf1 9 ! case ( a ,/ate t does n1 by a date specifi$ by ! ,secret>y ( ,heal? & ,human ,s]vices 7ref]r$ to 9 ?is p>agraph z ! ,secret>y71 9 consultation ) ! ,national ,association ( ,insurance ,commission]s1 h 9 effect a waiv] "u section #accb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjeb7 t includes an invisible high-risk pool or re9surance program t meets ! requirem5ts ( subsection 7g77#b7 ( su* section #accb1 ! ,secret>y %all1 f am\nts appropriat$ "u subp>agraph 7,b71 use ! allocation det]m9$ = ! ,/ate "u subsection 7a77#d77;,b7 ( su* section #accb = plan ye> #bjbf = ! purpose describ$ 9 clause 7ii7 = su* ,/ate4 7,b7 ,requir$ use = m>ket /abilization paym5ts to issu]s ,! ,secret>y %all use any allocation = a ,/ate made pursuant to clause 7i7 to provide inc5tives to appropriate entities to ent] into arrangem5ts ) ! ,/ate to help /abilize premiums = heal? insurance cov]age 9 ! individual m>ket 9 su* ,/ate by provid+ paym5ts to su* appropriate entities us+ paym5t p>amet]s & a me?odology det]m9$ by ! ,secret>y4 7c7 ,ensur+ pati5t access to m flexible heal? plans ,section #accb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjeb7 is am5d$-- 7#a7 9 subsection 7a77#a77;,c71 by /rik+ subsection 7b77#b7 & ins]t+ subsection 7b77#c72 & 7#b7 9 subsection 7b7-- 7,a7 9 p>agraph 7#a7-- 7i7 9 subp>agraph 7,b71 by /rik+ at lea/ z af=dable & ins]t+ ( comp>able af=dability1 includ+ = l[-income individuals1 individuals ) s]i\s heal? ne$s1 & o!r vuln]able populations12 & 7ii7 by am5d+ subp>agraph 7,d7 to read z foll[s3 7,d7 7i7 w n increase ! ,f$]al deficit ov] ! t]m ( ! waiv]2 & 7ii7 w n increase ! ,f$]al deficit ov] ! t]m ( ! #aj-ye> budget plan submitt$ "u subsection 7a77#a77;,b77ii74 2 7,b7 by r$esignat+ p>agraph 7#b7 7z am5d$ by p>agraph 7#a77 z p>agraph 7#c72 & 7,c7 by ins]t+ aft] p>agraph 7#a7 ! foll[+3 7#b7 ,budget>y effect 7,a7 ,9 g5]al ,9 det]m9+ :e!r a ,/ate plan submitt$ "u subsection 7a7 meets ! deficit neutrality requirem5ts ( p>agraph 7#a77;,d71 ! ,secret>y may take into consid]ation ! direct budget>y effect ( ! provisions ( su* plan on s\rces ( ,f$]al fund+ o!r ?an ! fund+ describ$ 9 subsection 7a77#c74 7,b7 ,limitation ,a det]m9ation made by ! ,secret>y "u subp>agraph 7,a7-- 7i7 %all n be con/ru$ to affect any waiv] process or /&>ds or t]ms & conditions 9 effect on ! date ( enactm5t ( ! ,l[]+ ,heal? ,c>e ,co/s = ,am]icans ,act "u title ,,xi1 ,,xviii1 ,,xix1 or ,,xxi ( ! ,social ,security ,act1 or any o!r ,f$]al law relat+ to ! provision ( heal? c>e items or s]vices2 & 7ii7 %all be made )\t reg>d to any *anges 9 policy ) respect to any waiv] process or provision ( heal? c>e items or s]vices describ$ 9 clause 7i74 4 7d7 ,provid+ exp$it$ approval ( ,/ate waiv]s ,section #accb7;d7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjeb7;d77 is am5d$-- 7#a7 9 p>agraph 7#a7 by /rik+ #ahj & ins]t+ #abj2 & 7#b7 by add+ at ! end ! foll[+3 7#c7 ,exp$it$ det]m9ation 7,a7 ,9 g5]al ,) respect to any application "u subsection 7a77#a7 submitt$ on or aft] ! date ( enactm5t ( ! ,l[]+ ,heal? ,c>e ,co/s = ,am]icans ,act or any su* application submitt$ prior to su* date ( enactm5t & "u review by ! ,secret>y on su* date ( enactm5t1 ! ,secret>y %all make a det]m9ation on su* application1 us+ ! crit]ia = approval o!rwise applicable "u ?is section1 n lat] ?an #de days aft] ! receipt ( su* application1 & %all all[ ! public notice & comm5t at ! ,/ate & ,f$]al levels describ$ "u subsection 7a77#e7 to occur concurr5tly if su* ,/ate application-- 7i7 is submitt$ 9 response to an urg5t situation1 ) respect to areas 9 ! ,/ate t ! ,secret>y det]m9es are at risk = excessive premium increases or hav+ no heal? plans (f]$ 9 ! applicable heal? insurance m>ket = ! curr5t or foll[+ plan ye>2 7ii7 is = a waiv] t is ! same or sub/antially simil> to a waiv] t ! ,secret>y already has approv$ = ano!r ,/ate2 or 7iii7 is = a waiv] t includes an invisible high-risk pool or re9surance program describ$ 9 subp>agraph 7,a71 7,b71 or 7,d7 ( subsection 7g77#b74 7,b7 ,approval 7i7 ,urg5t situations 7,i7 ,provisional approval ,a waiv] approv$ "u ! exp$it$ det]m9ation process "u subp>agraph 7,a77i7 %all be 9 effect = a p]iod ( #c ye>s1 unless ! ,/ate reque/s a %ort] duration4 7,,ii7 ,full approval ,subject to ! requirem5ts = approval o!rwise applicable "u ?is section1 n lat] ?an #a ye> be=e ! expiration ( a provisional waiv] p]iod describ$ 9 subclause 7,i7 ) respect to an application describ$ 9 subp>agraph 7,a77i71 ! ,secret>y %all make a det]m9ation on :e!r to ext5d ! approval ( su* waiv] = ! full t]m ( ! waiv] reque/$ by ! ,/ate1 = a total approval p]iod n to exce$ #f ye>s4 ,! ,secret>y may reque/ additional in=mation z ! ,secret>y det]m9es appropriate to make su* det]m9ation4 7ii7 ,approval ( same or simil> applications ,an approval ( a waiv] "u subp>agraph 7,a77ii7 %all be subject to ! t]ms ( subsection 7e74 7,c7 ,,gao /udy ,n lat] ?an #e ye>s aft] ! date ( enactm5t ( ! ,l[]+ ,heal? ,c>e ,co/s = ,am]icans ,act1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct a review ( all waiv]s approv$ pursuant to subp>agraph 7,a77ii7 to evaluate :e!r su* waiv]s met ! requirem5ts ( subsection 7b77#a7 & :e!r ! applications %\ld h qualifi$ = su* exp$it$ process4 4 7e7 ,provid+ c]ta9ty = ,/ate-,bas$ re=ms ,section #accb7;e7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjeb7;e77 is am5d$ by /rik+ ,no waiv] & all t foll[s ?r\gh ! p]iod at ! end & ins]t+ ! foll[+3 8,a waiv] "u ?is section-- 7#a7 %all be 9 effect = a p]iod ( #f ye>s unless ! ,/ate reque/s a %ort] duration2 7#b7 may be r5ew$1 subject to ! ,/ate meet+ ! crit]ia = approval o!rwise applicable "u ?is section1 = unlimit$ additional #f-ye> p]iods ^u application by ! ,/ate2 & 7#c7 may n be susp5d$ or t]m9at$1 9 :ole or 9 "p1 by ! ,secret>y at any "t be=e ! date ( expiration ( ! waiv] p]iod 7includ+ any r5ewal p]iod "u p>agraph 7#b771 unless ! ,secret>y det]m9es t ! ,/ate mat]ially fail$ to comply ) ! t]ms & conditions ( ! waiv]4 4 7f7 ,guidance & regulations ,section #accb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjeb7 is am5d$-- 7#a7 by add+ at ! end ! foll[+3 7f7 ,guidance & regulations 7#a7 ,9 g5]al ,) respect to c>ry+ out ?is section1 ! ,secret>y %all-- 7,a7 issue guidance1 n lat] ?an #fj days aft] ! date ( enactm5t ( ! ,l[]+ ,heal? ,c>e ,co/s = ,am]icans ,act1 t includes initial examples ( model ,/ate plans t meet ! requirem5ts = approval "u ?is section2 & 7,b7 p]iodically review ! guidance issu$ "u subp>agraph 7,a7 &1 :5 appropriate1 issue additional examples ( model ,/ate plans t meet ! requirem5ts = approval "u ?is section1 :i* may include-- 7i7 ,/ate plans e/abli%+ re9surance or invisible high-risk pool arrangem5ts = purposes ( cov]+ ! co/ ( high-risk individuals2 7ii7 ,/ate plans exp&+ insur] p>ticipation1 access to af=dable heal? plans1 network adequacy1 & heal? plan options ov] ! entire applicable heal? insurance m>ket 9 ! ,/ate2 7iii7 waiv]s enc\rag+ or requir+ heal? plans 9 su* ,/ate to deploy value-bas$ insurance designs :i* /ructure enrollee co/-%>+ & o!r heal? plan design elem5ts to enc\rage enrollees to consume high-value cl9ical s]vices2 7iv7 ,/ate plans all[+ = significant v>iation 9 heal? plan b5efit design2 or 7v7 any o!r ,/ate plan z ! ,secret>y det]m9es appropriate4 7#b7 ,rescission ( previ\s regulations & guidance ,beg9n+ on ! date ( enactm5t ( ! ,l[]+ ,heal? ,c>e ,co/s = ,am]icans ,act1 ! regulations promulgat$ & ! guidance issu$ "u ?is section prior to ! date ( enactm5t ( ! ,l[]+ ,heal? ,c>e ,co/s = ,am]icans ,act %all h no =ce or effect4 2 & 7#b7 9 subsection 7a77#e7 7z r$esignat$ by p>agraph 7#b77;,a77ii77-- 7,a7 9 subp>agraph 7,a71 by ins]t+ 1 z applicable be=e ! p]iod2 & 7,b7 9 subp>agraph 7,b71 by /rik+ ,n lat] ?an #ahj days aft] ! date ( enactm5t ( ?is ,act1 ! ,secret>y %all & ins]t+ ,! ,secret>y may4 7g7 ,invisible high-,risk pools & re9surance programs ,section #accb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjeb71 z am5d$ by p>agraph 7#f71 is fur!r am5d$ by add+ at ! end ! foll[+3 7g7 ,invisible high-,risk pools & re9surance programs 7#a7 ,fund+ ,) respect to a ,/ate t has receiv$ a waiv] "u ?is section to e/abli% an invisible high-risk pool or re9surance program describ$ 9 p>agraph 7#b71 ! ,/ate may fund su* program1 9 :ole or 9 "p1 us+ "o or bo? ( ! foll[+3 7,a7 ,am\nts receiv$ ?r\gh a grant describ$ 9 subsection 7a77#d77;,b74 7,b7 ,all (1 or a portion (1 ! paym5ts made to ! ,/ate z describ$ 9 subsection 7a77#c71 consi/5t ) ! in=mation ! ,/ate provides "u subsection 7a77#a77;,b74 7#b7 ,program design ,an invisible high-risk pool or re9surance program describ$ 9 ?is p>agraph is a program t meets any ( ! foll[+3 7,a7 ,an invisible high-risk pool1 z def9$ by ! ,/ate1 "u :i* heal? insurance issu]s1 ) respect to designat$ individuals :o exp]i5ce high] ?an av]age heal? co/s z det]m9$ by ! ,/ate1 & are enroll$ 9 heal? insurance cov]age (f]$ 9 ! individual m>ket1 c$e risk to ! pool1 )\t affect+ ! premium paid by ! designat$ individuals or _! t]ms ( cov]age4 ,) respect to su* pool1 ! ,/ate1 or an entity op]at+ ! pool on behalf ( ! ,/ate1 %all e/abli%-- 7i7 ! premium am\nt ! c$+ issu] %all pay to ! re9surance pool2 7ii7 ! applicable atta*m5t po9ts or co9surance p]c5tages if ! c$+ issu] reta9s any portion ( ! risk "u c$$ policies2 & 7iii7 ! me*anism by :i* high-risk individuals are designat$ = cession to ! pool1 :i* may include a li/ ( designat$ high-co/ heal? conditions4 7,b7 ,a re9surance program1 z def9$ by ! ,/ate1 t assumes a portion ( ! risk = individuals :o exp]i5ce high] ?an av]age heal? co/s1 z det]m9$ by ! ,/ate1 9 a mann] sub/antially simil> to ! re9surance program t op]at$ 9 ! ,/ate 9 accordance ) section #acda4 7,c7 ,a re9surance program e/abli%$ by ! ,/ate n o!rwise describ$ 9 ?is p>agraph4 7,d7 ,a program bas$ on ano!r ,/ate's re9surance program-- 7i7 describ$ 9 subp>agraph 7,a71 7,b71 or 7,c71 = :i* an application has be5 approv$ "u ?is subsection2 or 7ii7 :i* 0 implem5t$ prior to ,septemb] #a1 #bjbe1 & :i* ! ,secret>y det]m9es meets ! requirem5ts ( subp>agraph 7,a74 4 7h7 ,applicability ,! am5dm5ts made by ?is ,act to section #accb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjeb7-- 7#a7 ) respect to applications = waiv]s "u su* section #accb submitt$ aft] ! date ( enactm5t ( ?is ,act & applications = su* waiv]s submitt$ prior to su* date ( enactm5t & "u review by ! ,secret>y on ! date ( enactm5t1 %all take effect on ! date ( enactm5t ( ?is ,act2 & 7#b7 ) respect to applications = waiv]s approv$ "u su* section #accb be=e ! date ( enactm5t ( ?is ,act1 %all n require reconsid]ation ( :e!r su* applications meet ! requirem5ts ( su* section #accb1 except t1 at ! reque/ ( a ,/ate1 ! ,secret>y %all recalculate ! am\nt ( fund+ provid$ "u subsection 7a77#c7 ( su* section4 7i7 ,cl>ify+ budget neutrality ,section #accb7;a77#a77;,b7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7#db ,u4,s4,c4 #ahjeb7;a77#a77;,b77 is am5d$-- 7#a7 9 clause 7i71 by ins]t+ 1 includ+1 z applicable1 a description ( ! ,/ate's plan to use any am\nts aw>d$ to ! ,/ate "u p>agraph 7#d7 to support an invisible high-risk pool or re9surance program consi/5t ) subsection 7g7 & su* in=mation ab\t su* program z ! ,secret>y may require be=e ! semicolon2 & 7#b7 9 clause 7ii71 by ins]t+ ov] bo? ! t]m ( ! propos$ waiv] & ! t]m ( ! #aj-ye> budget plan aft] ,gov]nm5t4 ,,ii ,hospital transp>5cy requirem5ts #bja4 ,/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 #bjbf4 7c7 ,cont9u$ applicability ( /ate law ,! provisions ( ?is title %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 title4 #bjb4 ,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 #bjc4 ,imag+ transp>5cy ,section #bgah ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#ah71 z am5d$ by section #bjb1 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 #bjd4 ,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 #bjc1 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 #bje4 ,/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 #gbaeh71 be=e ,janu>y #a1 #bjbf4 #bjf4 ,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 #bjg4 ,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 ,,cfr p>ts #afj & #afd1 subp>ts ,a & ,e74 7#c7 ,disclosure & r$isclosure 7,a7 ,9 g5]al ,a gr\p heal? plan receiv+ in=mation "u p>agraph 7#a7 may disclose su* in=mation only-- 7i7 to ! entity f :i* ! in=mation 0 receiv$ or to t entity's bus9ess associates or to ! gr\p heal? plan's bus9ess associates z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations72 or 7ii7 z p]mitt$ by ! ,,hipaa ,privacy ,rule 7#de ,,cfr p>ts #afj & #afd1 subp>ts ,a & ,e74 7,b7 ,availability ( in=mation ,to ! ext5t ! in=mation requir$ by ?is subsection is made available to ! heal? insurance issu] (f]+ gr\p heal? insurance 9 connection ) a gr\p heal? plan1 ! heal? insurance issu] %all make su* in=mation available1 at ! same "t1 9 ! same =mat1 & at no co/1 to ! gr\p heal? plan4 7,c7 ,failure ,to provide ,! obligation to provide in=mation pursuant to ?is subsection %all exi/ not)/&+ ! pres5ce ( any =mal data-%>+ agreem5t betwe5 ! p>ties4 ,failure to provide ! requir$ in=mation z specifi$ %all con/itute a violation ( ?is ,act & ! ,secret>y %all initiate en=cem5t action "u section #ejb )9 #ij days ( becom+ aw>e ( a violation ( ?is section1 except t no?+ 9 ?is section %all be con/ru$ to limit ! ,secret>y's exi/+ au?ority "u ! ,act4 7#d7 ,data =mat /&>ds ,all data & in=mation provid$ pursuant to ?is subsection %all comply ) ! foll[+ /&>ds3 7,a7 ,all claims f a heal?c>e provid] %all be made to ! gr\p heal? plan 9 accordance ) transactions /&>ds adopt$ "u ,,hipaa1 z foll[s3 7i7 ,in/itutional1 pr(essional1 & d5tal claims & adju/m5ts to ^! claims %all be 9 ,,asc ,x#ab,n #hcg =mat1 z transmitt$ by ! provid]1 or1 9 ! case ( pap] claims1 conv]t$ to ! ,,asc ,x#ab,n #hcg electronic =mat4 7ii7 ,prescription drug claims %all be 9 ! ,national ,c\ncil = ,prescription ,drug ,programs 7,,ncpdp7 =mat1 z transmitt$ by ! provid]1 or 9 ! case ( pap] claims1 conv]t$ to ! ,,ncpdp electronic =mat4 7iii7 ,su* data %all be provid$ at no co/ to ! gr\p heal? plan4 7,b7 ,all claim paym5t 7or ,,eft1 electronic funds transf]7 & electronic remittance advice 7,,era7 in=mation s5t by a heal? plan s]vice provid] %all be provid$ to ! gr\p heal? plan or heal? insurance issu] 9 ! ,,asc ,x#ab,n #hce =mat 9 accordance ) transaction /&>ds adopt$ "u ,,hipaa1 unmodifi$ f ! =m 9 :i* x 0 transmitt$ to ! heal?c>e provid]4 ,su* in=mation %all be provid$ at no co/ to ! gr\p heal? plan or heal? insurance issu]4 7,c7 ,! ,secret>y may modify ! /&>ds set =? 9 ?is p>agraph z necess>y to align ) any *anges adopt$ by ! ,secret>y ( ,heal? & ,human ,s]vices pursuant to ! au?ority provid$ "u section #aagc ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;d-#b74 7c7 ,prohibit$ contractual provisions ,any provision 9 an agreem5t betwe5 a gr\p heal? plan1 ! plan sponsor1 ! plan adm9i/rator1 or a bus9ess associate ( su* plan or a heal? insurance issu] & a heal? plan s]vice provid] t unduly delays or limits a gr\p heal? plan's or heal? insurance issu]'s access to in=mation describ$ 9 ?is section or t re/ricts ! =mat or tim+ ( ! provision ( su* in=mation 9 a mann] t is inconsi/5t ) ! requirem5ts ( ?is section %all be prohibit$ &1 if a gr\p heal? plan or heal? insurance issu] ent]s into su* agreem5t1 %all be deem$ void z aga9/ public policy4 7d7 ,p5alties = non-,compliance ,any failure by a heal? plan s]vice provid] to comply ) ! requirem5ts ( ?is section %all result 9 ! imposition ( a civil p5alty ( #ajj1jjj = ea* day ! violation cont9ues1 9 addition to any o!r p5alties prescrib$ by law4 7e7 ,regulations ,! ,secret>y %all implem5t ?is section ?r\gh notice & comm5t rulemak+ 9 accordance ) section #eec ( title #e1 ,unit$ ,/ates ,code4 4 7#b7 ,p5alty 7,a7 ,9 g5]al ,section #ejb7;c7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aacb7;c771 z am5d$ by section #bjf1 is fur!r 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+ 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;,c71 & 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;,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 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 7p>ts #afj & #afd ( title #de1 ,code ( ,f$]al ,regulations74 7#c7 ,disclosure & r$isclosure 7,a7 ,9 g5]al ,a gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan receiv+ in=mation "u p>agraph 7#a7 may disclose su* in=mation only-- 7i7 to ! entity f :i* ! in=mation 0 receiv$ or to t entity's bus9ess associates z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations72 or 7ii7 z p]mitt$ by ! ,,hipaa ,privacy ,rule 7#de ,,cfr p>ts #afj & #afd1 subp>ts ,a & ,e74 7,b7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to prev5t a gr\p heal? plan t is a self-fund$1 non-,f$]al gov]nm5tal plan1 or a heal? plan s]vice provid] provid+ s]vices ) respect to su* a plan1 f plac+ reasonable re/rictions on ! public disclosure ( ! in=mation describ$ 9 p>agraph 7#a71 except t su* plan or entity may n re/rict disclosure ( su* in=mation to ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 ! ,dep>tm5t ( ! ,treasury1 or ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates4 7,c7 ,failure to provide ,! obligation to provide in=mation pursuant to ?is subsection %all exi/ not)/&+ ! pres5ce ( any =mal data-%>+ agreem5t betwe5 ! p>ties4 ,failure to provide ! requir$ in=mation z specifi$ %all con/itute a violation ( ?is ,act & ! ,secret>y %all initiate en=cem5t action "u section #bgbc7;b7 )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 ,act4 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;a71 ( #ajj1jjj p] day = ea* violation ( su* section1 pursuant to sub/antially simil> processes & proc$ures z ^? set =? 9 subp>agraphs 7,d7 ?r\gh 7,g7 ( section #bgbc7;b77#b74 4 #bjh4 ,/ate preemption only 9 ev5t ( conflict ,! provisions ( sections #bja ?r\gh #bjd 7includ+ ! am5dm5ts made by su* sections7 %all n sup]s$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 #bji4 ,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 #baj4 ,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