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No Surprises Act - Coggle Diagram

- - - - (i) such items and services are furnished by the same provider/facility
      - (ii) payment for such items and services is required to be made by the same plan/insurer
      - (iv) such items and services were furnished during the 30 day period following the date on which the first item or service included wit hrespect to such determination was furnished or an alternative period under the regs (for use in limited situations such as by the consent of the parties or in the case of low-volume items and services)
      - (iii) such items nad services are related to the treatment of a similar condition; and
  - - - (i) has (directly or through contracts or other arrangements) sufficient medical, legal, and other expertise and sufficient staffing to make determinations described in paragraph (5) on a timely basis
      - (ii) is not (I) a GHP/GHC, provider, or facility, (II) an affiliate or a subsidiary of an entity in (I), or (III) an affiliate or subsidiary of a professional or trade associatoin of an entity in (I)
      - (iii) carries out the responsibility of such an entity in acordance with this subsection
      - (iv) meets appropriate indicators of fiscal integrity
      - (v) maintains the confidentiality (in accordance with regs) of individually identifiable health information obtained in the course of conducting such determinations
      - (vi) does not under the IDR process carry out any determination with respect to which the entity would not, pursuant to (F)(i), be eligible for selection
      - (vii) meets such other requirements as determined appropriate by the Secretaries.
    - - (i) that allows the GHP/GHC and the nonparticipating provider/facility involved in a notification under (1)(B) to jointly select, not later than the last day of the 3-business day period following the date of the initiation of the process, an entity certified under this paragraph that (I) is not a party to such determination or an employee or agent of such party; (II) does not have a material familial, financial, or professional relationship with such party; and (III) does not otherwise have a conflict of interest with such a party (as determined by regs)
      - (ii) that requires, in the case such parties do not make such selection by the last day, the Secretaries to, not later than 6 business days after such date of initiation (I) select such an entity that satisfies (i)(I)-(III); and (II) provide notification of such selection to the parties.
  - - - (i) shall each sumbit to the CIDRE
        
        (I) an offer for a payment amount for such item or service furnished by such provider/facility; and (II) such information as requested by the CIDRE relating to such offer
      - (ii) may each submit to the CIDRE with respect to such determination any information relating to such offer submitted by either party, including information relating to any circumstance described in (C)(ii).
    - - (i) In General. In determining which offer is the payment to be applied, the CIDRE shall consider (I) the Qualifying Payment Amounts for hte applicable year for items or services that are comparable to the qualified IDR item or service and that are furnished in the same geographic region (defined by regs); and (II) subject to (D), information on any circumstance described in (ii), such information as requested by the CIDRE relating to a party's submitted offer, and any additional information provided relating to additional circumstances below
      - (ii) Additional Circumstances.
        
        (I) The level of training, experience, and quality and outcomes measurements of hte provider/facility that furnished such item or service
        
        (II) The market share held by the nonparticipating provider/facility or that of the plan or issuer in the geographic region in which the item or service was provided.
        
        (III) The acuity of the individual receiving such item or service or the complexity of furnishing such item or service to such individual
        
        (IV) The teaching status, case mix, and scope of services of the nonparticipating facility that furnished such item or service
        
        (V) Demonstrations of good faith efforts (or lack thereof) made by either party to enter into network agreements and, if applicable, contracted rates between the parties during the previous 4 plan years.
    - - (i) In General. A determination of a CIDRE (I) shall be binding up on the parties involved, in the absence of a fraudulent claim or evidence of misrepresentation of facts presented to the IDR entity involved regarding such claim; ad (II) shall not be subject to judicial review, except in a case described in 9 USC 10(a)(1)-(4).
      - (ii) Suspension of Certain Subsequent IDR Requests. In the case of a determination of a CIDRE, the party that submitted such notirication may not submit during the 90-day period following such determination a subsequent notification under (1)(B) involving the same other party to such notification with respect to such an item or service that was the subject of such initial notification.
      - (iii) Subsequent Submission of Requests Permitted. In the case of a notification that is not permitted to be submitted (purusant to (ii) above), if the end of the open negotiation period that would otherwise apply if not for the 90-day suspension, the IDR initiating process in (1)(B) shall be applied so that instead of having 4 days after open negotiation to initiate IDR, the parties have a 30-day period beginning on the day after the last day of such 90-day suspension period.
      - (iv) The DOL, HHS, and Treasury shall jointly examine the impact of the suspension in (ii) and whether it delays payment determinations or impatcs early, alternative resolutoin of claims (such as thorugh open negotiations), and shall submit to Congress, not later than 2 years after the effective date of (ii), an interim report (and within 4 years, a final report) on whether any GHPs/GHCs have a pattern or practice of routine denial, low payment, or down-coding of claims, or otherwise abuse the 90-day period described in such clause, including recommendations on ways to discourage such a pattern or practice.
- - - - (A) without need for prior authorization
      - (B) whether the provider and/or facility are participating
      - (C) emergency services provided by nonparticipating provider/facility:
        
        (i) must be provided without any requirement or limitation more restrictive than reqs and limitations on participating providers/facilities
        
        (ii) cost-sharing requirement cannot be greater than if provider/facility were participating;
        
        (iii) cost-sharing requirement is calculated as if the total amount that would have been charged by the provider/facility were equal to the Recognized Amount;
        
        (iv) the group health plan/insurer: (I) sends provider/facility sends initial payment or notice of denial of payment not later than 30 calendar days after provider/facility transmits bill [29 CFR 2590.716-4: or other time frames specified by state law or all-payer agreement. 30 days begins on date the plan receives the info necessary to decide a claim for payment]; and (II) pays a payment directly to provider/facility (in accordance with timing requirement in (c)(6), specified state law, or all-payer agreement) that is equal to the amount by which the Out-of-Network Rate exceeds the cost-sharing amount from (ii) and (iii) above less any initial payment made; and
        
        (v) any cost-sharing payments made shall be counted toward any in-network dedcutible or OOPM as if the provider/facility were participating
      - (D) without regard to any other term or condition of such coverage (other than exclusion or coordination of benefits, PHSA 2704-compliant waiting period, and applicable cost-sharing).
      - 29 CFR 2590.716-4: (4) without limiting what constitutes an emergency medical condition solely on the basis of diagnosis codes. Defines "emergency medical condition" and "emergency services" with reference to SSA 1867 (24 USC 1395dd(e)(1)(A)). Emergency services includes services furnished by a nonparticipating emergency provider/facility after the P/B is stabilized and as part of outpatient observation or in/out-patient stay with respect to the visit in which the emergency services are furnished.
    - - (C) Emergency Services
        
        (ii)(I) includes items and services (aa) covered by the plan and (bb) furnished by the nonparticipating provider/facility after the patient is stabilized and as part of outpatient observation or an in-patient or out-patient stay unless...
        
        (ii)(II)(aa) such provider/facility determines the individual is able to travel using nonmedical/nonemergency transportation; (bb) such provider/facility furnishing the additional items and services satisfies the notice and consent requirements of PHSA 2799B-2(d); the individual is in a condition to receive (under the regs) the information and to provide informed consent in accordance with applicable state law; (dd) any additional regulatory requirements are met.
      - (E) Qualifying Payment Amount
        
        (i)(I) 2022: the median of the contracted rates with respect to all GHPs of plan sponsor or all group health insurance issued by insurer that are offered within the same insurance market [(E)(iv): [PHSA: individual], large group, small group, or self-funded GHPs] as the total maximum payment (including cost-sharing imposed) on January 31, 2019 for the same or similar service [29 CFR 2590.716-6: same service code, or comparable code under a different code system] provided by a provider in the same or similar specialty [Reg: as identified by the plan/issuer consistent with their usual business practice, except that air ambulance is a single provider specialty] and provided in the same geographic region [defined in 29 CFR 2590.716-6], increased by the % increase in the consumer price index for all urban consumers (US city average) over 2019, 2020, and 2021.
        
        (i)(II) 2023 and later: the qualifying payment amount determined above for the previous year, increased by the % increase in the consumer price index for all urban consumers (US city average) over such previous year.
        
        (ii) New plans and coverage (if sponsor/insurer did not offer any GHP/GHC in such geographic area in 2019): (I) for the first year of coverage in such region, a rate determined by regulation; and (II) for each subsequent year, the amount determined in the previous year, increased by the % increase in the consumer price index for all urban consumers (US city average) over such previous year.
        
        (iii) Insuffucient information in 2019; newly covered items and services in a particular geographic region after 2019: (I) 2022, the first year of coverage for a newly covered item or service, or the first sufficient information year: the rate determined by the sponsor or insurer through any database that is determined under the regs to not have any conflicts of interest and to have sufficient information reflecting allowed amounts paid to providers/facilities for relevant services in the geographical region (such as a state all-payer claims database); (II) subsequent years: the rate determined under (I) for the previous year, increased by the % increase in the consumer price index for all urban consumers (US city average) over such previous year.
        
        29 CFR 2590.716-6: The database must be (i) a state all-payer claims database, or (ii) a third-party database not affiliated with any health insurer, health care provider/facility, or air ambulance, under IRC 52(a), (b) and 414(m), (o) rules that has sufficient info on IN amounts paid by health plans in the geo region and can distinguish them with other rates (OON, Medicare, CHIP). Regs contain lots of rules about median calculations.
      - (H) Recognized Amount, with respect to a covered item or service furnished by a nonparticipating provider/facility: (i) amount determined by Specified State Law, if the state in which the item or service was furnished has such a law; (ii) in a state with no such law, the Qualifying Payment Amount; or (iii) if furnished in a state with an All-Payer Model Agreement under Social Security Act 1115A, the amount that the state approves under such system for such item or service.
        
        29 CFR 2590.716-3: clarifies that (ii) is the lesser of the qualifying payment amount or the billed amount.
      - (I) Specified State Law: a state law that provides a method for determining the total amount payable under a plan (to the extent the state law is not preempted by ERISA 514) in the case of a patient receiving an item or service from a nonparticipating provider/facility.
        
        29 CFR 2590.716-3: A GHP that opts into such a specified state law must do so for all items and services to which the specified state law applies and in a manner determined by the applicable state authority, and must prominently dispaly in its plan materials describing the coverage of OON services a statment that the plan has opted into the specified state law, identify the relevant state (or states), and include a general description of the items and services provided by nonparticipating facilities and providers that are covered by a specified state law. "State" includes American territories and DC.
      - (K) Out-of-Network Rate: (i) in a state with a Specified State Law, the amount determined by such law; (ii) in a state with no such law, (I) the amount agreed upon in open negotiations; or (II) the IDR entity's determined amount; (iii) in a state with an All-Payer Model Agreement under Social Security Act 1115A, the amount that the state approves under such system for such item or service.
      - (L) Cost-Sharing: includes copayments, coinsurance, and deductibles
        
        29 CFR 2590.716-3: the amount a participant or beneficiary is responsibile for paying for a covered item or service under the terms of the GHP/GHC. Does not include amounts paid towards premiums, balance billing by OON providers, or the cost of items or services that are not covered under a GHP/GHC.
      - Participating health care facility: includes a single case agreement between a facility and a plan/issuer that is used to address unique situations in which a P/B requires services that typically occur OON. 29 CFR 2590.716-3.
    - - (A) shall not impose on such patient a cost-sharing requirement that is greater than the requirement that would apply under the plan had such items or services been furnished by a participating provider
      - (B) shall cacluclate such cost-sharing requirement as if the total amount that would have been charged for such items and services by a participating provider were equal to the Recognized Amount.
      - (C) not later than 30 calendar days after the bill for such items and services is transmitted by the provider, shall send the provider an initial payment or notice of denial of payment. [29 CFR 2590.716-5: or other timeline in a specified state law or all-payer agreement. 30-day period begins on the date the plan/issuer receives the info necessary to decide a claim for payment.]
      - (D) shall pay a total plan or coverage payment directly (in accordance, if applicable, with the timing req described in subsection (c)(6), specified state law, or all-payer agreement), to such provder, with application of any initial payment under (C), equal to the amount by which the Out-of-Network Rate for such items and services exceeds the cost-sharing amount imposed under the plan or coverage for such items and services, less any initial payment amount made.
      - (E) shall count toward any in-network deductible and in-network out-of-pocket maximums applied under the plan, any cost-sharing payments made by the patient with respect to such items and services in the same manner as if such cost-sharing payments were with respect to items and services furnished by a participating provider.
    - - (B) Visit: shall include equipment and devices, telemedicine services, imaging services, laboratory services, properative and postoperative services, and such other items and services specified in the regs, regardless of whether or not the provider furnishing such items or services is at the facility.
  - - - (1)(A) A GHP/GHC that covers OBGYN care and requires PCP designation may not require authorization or referral by the plan, insurer, or any person (including a PCP) in the case of a female participant or beneficiary who seeks coverage for OBGYN care provided by a participating health care professional who specializes in obstetrics or gynecology. Such professional shall otherwise adhere t osuch plan's or insurer's policies and procedures, including procedures regarding referrals and obtanining prior authorization and providing services pursuant to a treatment plan (if any) approved by the plan.
      - (1)(B) A GHP/GHC that covers OBGYN care and requires PCP designation shall treat the provision of OBGYN care, and the ordering of related OBGYN items and services, pursuant to the direct access described under subparagraph (A), by a participating health care professional who specializes in obstetrics or gynecology as the authorization of the PCP.
      - (3) Nothing in paragraph (1) shall be construed to (A) waive any exclusions of coverage under the terms and conditions of the plan/coverage with respect to OBGYN care; or (B) preclude the GHP/insurer from requiring that the OBGYN provider notify the PCP or the plan or treatment decisions.
- - - - (2) Ancillary Servcies Described [these are subect to balance billing ban and hold harmless req, even if notice and consent is satisfied]
        
        (A) subject to (3) below, items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology, whether or not provided by a physician or non-physician practitioner, and items and services provided by assistant surgeons, hospitals, and intensivists
        
        (B) subject to (3) below, diagnostic services (including radiology and lab services)
        
        (C) items and services provided by such other specialty practitioners specified in HHS regs
        
        (D) items and services provided by a nonparticipating provider if there is no participating provider who can furnish such item or service at such facility
      - (3) Exception. The HHS Secretary may, through rulemaking, establish a list (and update such list periodically) of advanced diagnostic lab tests, which shall not be incuded as an ancillary service in (2) and with respect to which (a) above [balance billing ban and hold harmless req] would apply.
    - - (1) In General. A nonparticipating provider/facility satisfies the notice and consent criteria if it:
        
        (A) in the case that the patient makes an appointment to be furnished such items or services at least 72 hours prior to the date on which the individual is to be furnished such items or services, provides to the patient (or authorized rep) not later than 72 hours prior to the date on which the individual is furnished such items or services (or, in the case that the patient makes such an appointment within 72 hours of when such items or services to be furnished, provides to the patient (or authorized rep) on such date the appointment is made), a written notice in paper or electronic form, as selected by the patient (and including electronic notification as practicable) specified in the HHS reg not later than July 1, 2021, that
        
        (i) contains the information required under (2) below
        
        (ii) clearly states that consent to receive such items and services from such nonparticipating provider/facility is optional and that the patient may instead seek care from a participating provider/facility, in which case the cost-sharing responsibility of the patient would not exceed such responsibility that would apply to such item or service frunished by a participating provider
        
        (iii) is available in the 15 most common languages in the geographic region of the applicable facility
        
        (B) obtains from the patient the consent described in (3) below to be treated by a nonparticipating provider/facility
        
        (C) provides a signed copy of such consent to the patient through mail or email (as selected by the patient)
      - (2) Information Required Under Written Notice. For purposes of (1)(A)(i), the information required in the notice is each of the following
        
        (A) Notification that the provider/facility is a nonparticipating provider/facility with respect to the health plan
        
        (B) Notification of the good faith estimated amount that such provider or facility may charge the patient for such items and services involved, including a notification that the provision of such estimate or consent to be treated under (3) does not constitute a contract with respect to the charges estimated for such items and services.
        
        (C) In the case of a nonparticipating provider in a participating facility, a list of any participatin gproviders at the facility who are able to furnish such items and services involved and notificatoin that the patient may be referred, at their option, to such a participating provider
        
        (D) Information about whether prior authorization or other care management limitations may be required in advance of recieving such items or services at the facility.
      - (3) Consent Described to Be Treated by a Nonparticipating Provider/Facility. For purposes of (1)(B), the consent described in this paragraph is a document specified by the HHS Secretary, in consultation with the DOL Secretary, through guidance that shall be signed by the patient before such items or services are furnished and that
        
        (A) acknowledges (in clear and understandable language) that the patient has been (i) provided with the written notice under (1)(A); (ii) informed that the payment of such charge by the patient may not accrue toward meeting any limitation that the plan or coverage places on cost-sharing, including an explanation that such payment may not apply to an in-network deductible applied under the plan; and (iii) provided the opportunity to receive the written notice under (1)(A) in the form selected by the patient
        
        (B) documents the date on which the patient received the written notice in (1)(A) and the date on which the individual signed such consent to be furnished such items or services by such provider/facility.
      - (4) The consent descried in (3) above shall constitute only consent to the receipt of the information provided pursuant to this subsection and shall not constitute a contractual agreement of the patient to any estimated charge or amount included in such information.
  - - - (1) the reqs and prohibitions of such provider/facility under 2799B-1 and 2799B-2 (balance billing bans)
      - (2) any other applicable state law reqs on privder/facility regarding the amounts such proivder/facility may, with respect to an item or servie, charge a patient enrolled in a GHP or group or individual health insurance with respect to which the provider/facility does not have a contractual relationship (network agreement)
      - (3) information on contacting appropriate state and federal agencies in the case that an individual believes that such provider/facility has violated any req desribed in (1) or (2) with respect to such individual
  - - - (1) State Authority. Each state may require a provider/facility (including a provider of air ambulance services) subject to the requirements of this part (NSA added Part D- Additional Coverage Protections to PHSA Title XXVII) to satisfy such reqs applicable to the provider/facility
      - (2) Failure to Implement Requirements. In the case of a determination by the HHS Secretary that a state has failed to substantially enforce the reqs to which paragraph (1) applies with respect to providers/facilities in the state, the HHS shall enforce such reqs under (b) below insofar as they relate to violations of such reqs occurring in such state.
      - (3) Notification of Applicable Secreatary. A state may notify the HHS, DOL, or Treasury, as applicable, of violations of 2799B-1, 2799B-2, or 2799B-5 and any enforcement actions taken against providers/facilities as a result of such violatoins, including the disposition of any such enforcement actions.
    - - (1) In General. If a provider/facility is found by the HHS to be in violation of a req to which (a)(1) above applies, the HHS [only? -- this provision was only to the PHSA] may apply a civil monetary penalty with respect to such provider/facility (including air ambulance) in an amount not to exceed $10,000 per violation.
      - (2) Limitation. (b)(1) above shall apply to the enforcement of a provision specified in (a)(1) only as provided in (a)(2) (in the case of a state's failure to enforce the reqs in (a)(1)).
      - (3) Complaint Process. The HHS, shall, thorugh rulemaking, establish a process to receive consumer complaints of violations of such provisions and provide a response to such complaints within 60 days of receipt of such complaints.
      - (4) Exception. The HHS shall waive the penalties in (1) with respect to a facility/provider/air amulance who does not knowingly ivolate and should not have reasonably known it violated one of the three relevant PHSA sections, if such facility/provider/air ambulance within 30 days of the violatoin withdraws the bill that was in violation of such provision and reimbuses the health plan or enrollee in an an amount equal to the difference between the amount billed and the amount allowed to be billed under the provision, plus interest, at an interest rate determined by the HHS.
- - - - (1) In General. A plan shall meet the reqs of (2) below, in the case of an individual with benefits under a GHP/GHC and with respect to a health care provider/facility that has a contractual relationship with such plan or such issuer (as applicable) for furnishing items and services under such plan, if, while such individual is a continuing care patient:
        
        (A) such contractual relationship is terminated
        
        (B) benefits provided under such plan with respect to such provider/facility are terminated because of a change in the terms of the participation of the provider/facility in such plan
        
        (C) a contract between such GHP/insurer in connection with such plan is terminated, resulting in a loss of benefits provided under such plan with respect to such provider/facility
      - (2) Requirements. The plan/insurer must:
        
        (A) notify each individual enrolled under such plan who is a continuing care patient with respect to a provider/facility at the time of a terminatoin described in (1) affecting such provider/facility on a timely basis of such termination and such individual's right to elect continued transitional care from such provider/facility
        
        (B) provide such individual with an opportunity to notify the plan/insurer of the individual's need for transitional care
        
        (C) permit the patient to elect to continue to have benefits provided under such plan, under the same terms and conditions as would have applied and with respect to such items and services as would have been covered under such plan had the termination not occurred, with respect to the course of treatment furnished during the period beginning on the date on which the notice under (AA) is provided and ending on the earlier of
        
        (i) the 90-day period beginning on such date
        
        (ii) the date on which such individual is no longer a continuing care patient with respect to such provider or facility.
    - - (1) Continuing Care Patient (NSA pg. 323)
      - (3) "Terminated" includes the expiration or nonrenewal of a contract but does not include a termination of the contract for failure to meet applicable quality standards or for fraud.
- - - - (2) such cost-sharing amounts shall be counted towards the in-network deducitble and in-network OOPM amount under the plan for the plan year (and such in-network deductible shall be applied) with respect to such items and services so furnished in the same manner as if such cost-sharing payments were made for items furnished by a participating provider
      - (3) the GHP/insurer shall
        
        (A) send provider initial payment or notice of denial of payment not later than 30 calendar days after provider transmits bill
        
        (B) pay a total payment directly to provider that is equal to the amount by which the Out-of-Network Rate (defined in 716(a)(3)(K)) exceeds the cost-sharing amount from (1) and (2) above
      - (1) the cost-sharing req with respect to such services shall be the same req that would apply if such services were provided by such participating provider, and any coinsurance or deductible shall be based on rates that would appl for such services if they were furnished by a participating provider
    - - (1) Determination Through Open Negotiation
        
        (A) In General. With respect to an item or service furnished in a year by a nonparticipating provider, with respect to a GHP for which a payment is required to be made under (a)(3) above, the provider or plan may, during the 30-day period beginning on the day the provider receives an initial payment or a notice of denial of payment from the plan regarding a claim for payment for such item or service, initiate open negotiations for purposes of determining an amount agreed on by both parties. For purposes of this subsection, the open negotiation period, with respect to air ambulance services, is the 30-day period beginning on the date of initiation of the negotiations.
        
        (B) Accessing Independent Dispute Resolution Process in Case of Failed Negotiations. In the case of open negotiations pursuant to (A) that do not result in a determination of a payment amount by the last day of the open negotiation period, the provider or GHP may, during the 4-day period beginning on the day after such open negotiation period, initiate the IDR process. The IDR process shall be initiated by a party by submission to the other party and to the DOL, HHS, and Treasury of a notification (containing information specified by regs). For purposes of this subsection, the date of initiation of such process shall be the date of such submission or such other datespecified by regs that is not later than the date of receipt of such notification by both the other party and Secretaries.
      - (2) Independent Dispute Resolution Process Available in Case of Failed Open Negotiations
        
        (A) Establishment. Not later than 1 year after the enactment of this subsection, the DOL, HHS, and Treasury shall jointly establish by regulation the IDR process.
        
        (B) Authority to Continue Negotiations. Under the IDR process, in the case that the parties to a determination for a qualified IDR air ambulance service agree on a payment amount during such process but before the determination date, such amount shall be treated as the agreed upon Out-of-Network Rate (under ERISA 716(a)(3)(K)(ii)(I)). In such a case, the IDR process shall provide for a method to determine how to allocate between the parties the payment of the compensation of the IDR entity.
        
        (C) Clarification. A nonparticipating provider may not submit a notification under (1)(B) if such provider is exempt from the requirement under PHSA 2799B-2(a) [notice and consent exception to provider balance billing ban] with respect to such item or service.
      - (3) Treatment of Batching of Services. The provisions of ERISA 716(c)(3) shall apply with respect to a notification submitted under this subsection wit hrespect to air ambulance services in teh same manner and to the same extent such provisions apply with respect to a notification submitted under ERISA 716(c).
      - (4) IDR Entities. (A) An IDR entity is certified under this subsection if it is a CIDRE under ERISA 716(c)(4). (B). The provisions of ERISA 716(c)(4)(F) shall apply with respect to selecting a CIDRE for air ambulance disputes.
      - (5) Payment Determination.
        
        (A) In General. Not later than 30 days after the date of selection of the CIDRE with respect to a determination for a qualified IDR air ambulance service, the CIDRE shall (i) taking into account the considerations specified in (C), select one of the offers submitted under (B) to be the amount of payment for such service; and (ii) notify the provider or facility and the GHP/GHC party to such determination of the offer selected under (i).
        
        (B) Submission of Offers. Not later than 10 days after the date of selection of the CIDRE with respect to a determination for a qualified IDR air ambulance service, the provider and GHP/GHC party to such determination
        
        (i) shall each sumbit to the CIDRE:
        
        (I) an offer for a payment amount for such item or service furnished by such provider/facility; and (II) such information as requested by the CIDRE relating to such offer
        
        (ii) may each submit to the CIDRE with respect to such determination any information relating to such offer submitted by either party, including information relating to any circumstance described in (C)(ii).
        
        (C) Considerations in Detail
        
        (ii) Adittional Circumstances. For purposes of (i)(II), the circumstances described in this clause are:
        
        (I) The quality and outcomes measurements of the provider that furnished such services
        
        (II) The activity of hte individual receiving such services or the complexity of furnishing such services to such individual
        
        (III) The training, experience, and quality of the medical personnel that furnished such services
        
        (IV) Ambulance vehicle type, including the clinical capacity level of such vehicle
        
        (VI) Demonstrations of good faith efforts (or lack of good faith efforts) made by the nonparticipating provider/facility or the plan/issuer to enter int network agreements and, if applicable, contracted rates between the provider and the plan/issuer during the previous 4 plan years
        
        (i) In General. In determining which offer is the payment to be applied, the CIDRE shall consider (I) the Qualifying Payment Amounts for the applicable year for items or services that are comparable to the qualified IDR air ambulance service and that are furnished in the same geographic region (defined by regs); and (II) subject to (iii), information on any circumstance described in (ii), such information as requested by the CIDRE relating to a party's submitted offer, and any additional information provided relating to additional circumstances below
        
        (D) Prohibition on Consideration of Certain Factors. In determining which offer is the payment to be applied with respect to qualified IDR air ambulance services furnished by a provider, the CIDRE shall not consider usual and customary charges, the amount that would have been billed by such provider or facility with respect to such services had PHSA 2799B-5 [air ambulance balance billing ban and hold harmless req] not applied, or the payment or reimbursement rate for such items and services furnished by such provider/facility payable by a public payor, including Medicare, Medicaid, CHIP, or TRICARE.
        
        (D) Effects of Determination. The provisions of ERISA 716(c)(5)(E) shall apply with respect to a determination of a CIDRE under (A) in the same manner.
        
        (E) Costs of Independent Dispute Resolution Process. The provisions of ERISA 716(c)(5)(F) shall apply to a notificatoin made under this subsection under (A) in the same manner and to the same extent.
      - (6) Timing of Payment. The total plan payment required by (a)(3) for air ambulance claims for which a determination is made under (5)(A) or under open negotiations in (1), shall be made directly to the nonparticipating provider/facility not later than 30 days after the date on which such determination is made.
      - (7) Publication of Information Relating to the IDR Process [on DOL, HHS, IRS websites]
      - (8) Administrative Fee.
        
        (A) In general. Each party to a determination under (5) in a year shall pay to the Secretaries, at such time and in such manner as specified by regs, a fee for participating in the IDR process with respect to such determination and in an amount described in (B) below for such year.
        
        (B) Amount of Fee. The amount for a year is an amount established by the Secretaries in a manner such that the total amount of fees paid for such year is estimated to be equal to the amount of expenditures estimated to be made by the Secretaries for such year in carrying out the IDR process.
- - - - (1) not later than the date that is 90 days after the last day of the first calendar year beginning on or after the date on which a final rule is promulgated pursuant to the rulemaking described in (d) below, information described in subsection (b) below with respect to such plan year
      - (2) not later than the date that is 90 days after the last day of the plan year immediately succeeding the calendar year immediately succeeding the calendar year described in (1) above, such information with respect to such immediately succeeding plan year.
    - - (1) claims data for air ambulance services furnished by providers of such services, disaggregated by each of the following factors:
        
        (A) Whether such services were furnished on an emergent or nonemergent basis
        
        (B) Whether the provider of such services is part of a hospital-owned or spopnsored program, municipality-sponsored program, hospital independent partnership (hybrid) program, independent program, or tribally operated program in Alaska.
        
        (C) Whether the transport in which the services were furnished originated in a rural or urban area
        
        (D) The type of aircraft (such as rotor transport or fixed wing transport) used to furnish such services
        
        (E) Whether the provider of such services has a contract with the plan/insurer, as applicable, to furnish such services under the plan
      - (2) such other informatoin regarding providers of air ambulances services as specified in the regs.
- - - - (A) in the case of an individual enrolled in such plan under (1), the plan
      - (B) in the case of an individual not enrolled in a plan under (1), the individual
- - - - (1) For plan years beginning on or after January 1, 2022, each GHP/GHC shall
        
        (C) establish the database described in (4) below
        
        (D) include in any directory (other than in (C)/(4)) containing provider directory information with respect to such plan the information described in (5) below
        
        (A) establish the verification process in (2) below
        
        (B) establish the response protocol described in (3) below
      - (2) Verification Process. A process:
        
        (A) under which, not less frequently than once every 90 days, such plan/insurer verifies and updates the provider directory information included on the database described in (4) below of such plan/insurer of each health care provider/facility included in such database
        
        (B) that establishes a procedure for the removal of such a provider/facility with respect to which such plan/insurer has been unable to verify such information during a period specified by the plan/insurer
        
        (C) that provides for the update of such database within 2 business days of such plan/insurer receiving from such a provider/facility information pursuant to PHSA 2799B-9
      - (3) Response Protocol. In the case of an individual enrolled under a GHP/GHC who requests information through a telephone call or electronic, web-based or internet-based means on whether a provider/facility has a contractual relationship to furnish items nad services under such plan, a protocol under such plan/insurer in the case such request is made through a telephone call
        
        (A) responds to such individual as soon as practicable and in no case later than 1 business day after such call is received, through a written electronic or print (as requested by such individual) communication
        
        (B) retains such communication in such individual's file for at least 2 years following such response
      - (4) Database must contain:
        
        (A) a list of each health care provider and facility with which such plan/insurer has a direct or indirect contractual relationship for furnishing items and services under such plan
        
        (B) provider directory information with respect to each such provider and facility
      - (5) Information. With respect to a print directory containing provider directory information with respect to a GHP/GHC, a notification that such information contained in such directory was accurate as of the date of publication of such directory and that an individual enrolled under such plan should consult the database described in (4) with respect to such plan or contact such plan/insurer to obtain the most current provider directory information with respect to such plan.
      - (6) Definition. "Provider directory information" includes the name, address, specialty, telephone number, and digital contact information of each health care provider/facility with which such plan/insurer has a contractual relatoinship for furnishing items and services under such plan.
      - (7) Rule of Construction. Nothing in this section shall be construed to preempt any provision of state law relating to health care provider directories, to the extent such state law provides to such plan/insurer, subject to ERISA 514.
    - - (1) In General. For plan years beginning on or after January 1, 2022, in the case of an item or service furnished to a patient enrolled in a GHP/GHC by a nonparticipating provider/facility, if such item or service would otherwise be covered under such plan if furnished by a participating provider/facility and if either of the criteria described in (2) below applies, the plan
        
        (A) shall not impose on such patient a cost-sharing amount for such item or service so furnished that is greater than the amount that would apply under such plan had such item or service been furnished by a participating provider
        
        (B) shall apply the deductible or OOPM that would apply if such services were furnished by a participating provder/facility
      - (2) Criteria Described
        
        (A) the patient received through a databse, provider directory, or response protocol described in (a) above information with respect to such item and service to be furnished and such information provided that the provider/facility was participaing with respect to the plan for furnishing such item or service
        
        (B) the information was not provided, in accordance with (a) above to the patient and the patient requested through the response protocol in (a)(3) of the plan information on whether the provider/facility was participating with respect to the plan for furnishing such item or service and was informed through such protocol that the provider/facility was participating
    - - (1) information in plan language on
        
        (A) the requirements and prohibitions applied under PHSA 2799B-1 and 2799B-2 [balance billing prohibitions]
        
        (B) if provided for under applicable state law, any other reqs on providers/facilities regarding the amounts such providers/facilities may, with respect to an item or service,charge a patient with respect to whcih such a provider/facility does not have a contractual relationship for furnishing such item or service under the plan after receiving payment from the plan and any cost-sharing payment
        
        (C) the requirements applied under ERISA 716
      - (2) information on contacting appropriate state and federal agencies in the case that an individual believes that such a provider/facility has violated any requirement in (1)
- - - - (A) Whether or not the provider/facility is a participating provider/facility with respect to the plan and the furnishing of such item or service and
        
        (i) in the case of a participating provider/facility, the contracted rate under such plan for such item or service (based on the billing and diagnostic codes prvided by such provider/facility)
        
        (ii) in the case of a nonparticipating provider/facility with respect to such plan, a description of how such individual may obtain information on participating providers and facilities
      - (B) The good faith estimate included in the notification received from the provider or facility (if applicable) based on such codes
      - (C) A good faith estimate of the amount the health plan is responsible for paying for items and services included in the estimate described in (B) above
      - (D) A good faith estimate of the amount of any cost-sharing for which the patient would be responsible for such item or service (as of the date of such notification)
      - (E) A good faith estimate of the amount that the patient has incurred toward meeting the limit of the financial responsibility (including with respect to deductibles and OOPMs) under the plan (as of the date of the notification)
      - (F) In the case such item or service is subject to a medical management technique (including concurrent review, prior authorzation, and step-therapy or fail-first protocols) for coverage under the plan, a disclaimer that coverage for such item or service is subject to such technique.
      - (G) A disclaimer that the information in the notification is only an estimate based on the items and services reasonably expected, at the time of scheduling (or requesting) the item or services, and is subject to change
      - (H) Any other information or disclaimer the plan or coverage determines appropriate that is consistent with information and disclaimers required under this section.
    - - (A) In General. The DOL, IRS, and HHS may modify any timing requirements relating to the provision of the notification described in (1) with respect to a scheduled "specified item or service," as long as the modifciation does not result in the provision of such notification after the patient has been furnished the item or service.
      - (B) "Spcified item or service" means an item or service that has low utilization or significant variation in costs (such as when furnished as part of a complex treatment), as specified by the HHS, DOL, and IRS.
- - - - (1) In General. A GHP/GHC may not enter into an agreement with a health care provider, netowrk or association of providers, third-party administrator, or other service provider offering access to a network of providers that would directly or indirectly restrict a GHP/GHC from
        
        (A) providing provider-specific cost or quality of care information or data, through a consumer engagement tool or any other means, to referring providers, the plan sponsor, participants or beneficiaries, or individuals eligble to become participatns or beneficiaries
        
        (B) electronically accessing de-identified claims and encounter information or data for each participant or beneficiary in the plan or coverage, upon request and consistent with the privacy regulations promulgated pursuant to HIPAA 254(c), GINA, and the ADA, including on a per claim basis
        
        (i) financial information, such as the allowed amount, or any other claim-related financial obligations included in the provider contract
        
        (ii) provider information, including name and clinical designation
        
        (iii) service codes
        
        (iv) any other data element included in claim or encounter transactions
        
        (C) sharing information or data described in (A) or (B) , or directing that such data be shared, with a BAA [defined in 45 CFR 160.103]
      - (3) Attestation. A GHP/GHC shall annually submit to the DOL, HHS, and Treasury an attestation that such plan is in compliance with the reqs of this subsection.
- - - - (I) [Definitions] (NSA p. 382)
      - (II) For purposes of this subparagraph, a descriptoin of compensation or cost may be expressed as a monetary amount, formula, or a per capita charge for each enrollee or, if the compensation or cost cannot reasonably be expressed in such terms, by any other reasonable method, including a disclosure that additional compensation may be earned but may not be calculated at the time of contract if such disclosure includes a description of the circumstances under which the additional compensation may be earned and a reasonable and good faith estimate if the covered service provider cannot otherwise readily describe compensation or cost and explains the methodology and assumptions used to prepare such estimate. Any such description shall contain sufficient information to permit evaluation of the reasonableness of the compensation or cost
      - (III) No person or entity is a covered service provider solely on the basis of providing services as an affiliate or a subcontractor that is performing one or more of the services described in (I)(bb)(AA) or (BB)
    - - (I) A description of the services to be provided to the covered plan pursuant to the contract or arrangement
      - (II) If applicable, a statement that the covered service provider, an affiliate, or a subcontractor, will provide, or reasonably expects to provide, services pursuant to the contract or arrangement directly to the covered plan as a fiduciary (under ERISA 3(21))
      - (III) A description of all direct compensation, either in the aggregate or by service 387