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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations
Management and Budget and published by the U.S. Census Bureau, in the State, and one region consisting of all other portions of the State, determined based on the point of pick-up as defined in 42
CFR 414.605.
B If a plan or issuer does not have sufficient information to calculate the median of the contracted rates described in paragraph b of this section for an air ambulance service provided in a geographic region described in paragraph a7iiA of this section, one region consisting of all metropolitan statistical areas, as described by the U.S.
Office of Management and Budget and published by the U.S. Census Bureau, in each Census division and one region consisting of all other portions of the Census division, as described by the U.S. Census Bureau, determined based on the point of pick-up as defined in 42
CFR 414.605.
8 Insurance market is, irrespective of the State, one of the following:
i The individual market other than short-term, limited-duration insurance or individual health insurance coverage that consists solely of excepted benefits.
ii The large group market other than coverage that consists solely of excepted benefits.
iii The small group market other than coverage that consists solely of excepted benefits.
iv In the case of a self-insured group health plan, all self-insured group health plans other than account-based plans, as defined in 2590.715
2711d6i, and plans that consist solely of excepted benefits of the same plan sponsor, or at the option of the plan sponsor, all self-insured group health plans administered by the same entity including a third-party administrator contracted by the plan, to the extent otherwise permitted by law, that is responsible for calculating the qualifying payment amount on behalf of the plan.
9 Modifiers mean codes applied to the service code that provide a more specific description of the furnished item or service and that may adjust the payment rate or affect the processing or payment of the code billed.
10 Newly covered item or service means an item or service for which coverage was not offered in 2019 under a group health plan or group health insurance coverage offered by a health insurance issuer, but that is offered under the plan or coverage in a year after 2019.
11 New service code means a service code that was created or substantially revised in a year after 2019.

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12 Provider in the same or similar specialty means the practice specialty of a provider, as identified by the plan or issuer consistent with the plans or issuers usual business practice, except that, with respect to air ambulance services, all providers of air ambulance services are considered to be a single provider specialty.
13 Same or similar item or service means a health care item or service billed under the same service code, or a comparable code under a different procedural code system.
14 Service code means the code that describes an item or service using the Current Procedural Terminology CPT
code, Healthcare Common Procedure Coding System HCPCS, or DiagnosisRelated Group DRG codes.
15 Sufficient information means, for purposes of determining whether a group health plan or health insurance issuer offering group health insurance coverage has sufficient information to calculate the median of the contracted rates described in paragraph b of this section i The plan or issuer has at least three contracted rates on January 31, 2019, to calculate the median of the contracted rates in accordance with paragraph b of this section; or ii For an item or service furnished during a year after 2022 that is used to determine the first sufficient information year A The plan or issuer has at least three contracted rates on January 31 of the year immediately preceding that year to calculate the median of the contracted rates in accordance with paragraph b of this section; and B The contracted rates under paragraph a15iiA of this section account or are reasonably expected to account for at least 25 percent of the total number of claims paid for that item or service for that year with respect to all plans of the sponsor or the administering entity as provided in paragraph a8iv of this section, if applicable or all coverage offered by the issuer that are offered in the same insurance market.
16 Qualifying payment amount means, with respect to a sponsor of a group health plan or health insurance issuer offering group health insurance coverage, the amount calculated using the methodology described in paragraph c of this section.
17 Underlying fee schedule rate means the rate for a covered item or service from a particular participating provider, providers, or facility that a group health plan or health insurance issuer uses to determine a participants or beneficiarys cost-sharing liability for
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the item or service, when that rate is different from the contracted rate.
b Methodology for calculation of median contracted rate1 In general.
The median contracted rate for an item or service is calculated by arranging in order from least to greatest the contracted rates of all group health plans of the plan sponsor or the administering entity as provided in paragraph a8iv of this section, if applicable or all group health insurance coverage offered by the issuer in the same insurance market for the same or similar item or service that is provided by a provider in the same or similar specialty or facility of the same or similar facility type and provided in the geographic region in which the item or service is furnished and selecting the middle number. If there are an even number of contracted rates, the median contracted rate is the average of the middle two contracted rates. In determining the median contracted rate, the amount negotiated under each contract is treated as a separate amount.
If a plan or issuer has a contract with a provider group or facility, the rate negotiated with that provider group or facility under the contract is treated as a single contracted rate if the same amount applies with respect to all providers of such provider group or facility under the single contract.
However, if a plan or issuer has a contract with multiple providers, with separate negotiated rates with each particular provider, each unique contracted rate with an individual provider constitutes a single contracted rate. Further, if a plan or issuer has separate contracts with individual providers, the contracted rate under each such contract constitutes a single contracted rate even if the same amount is paid to multiple providers under separate contracts.
2 Calculation rules. In calculating the median contracted rate, a plan or issuer must:
i Calculate the median contracted rate with respect to all plans of such sponsor or the administering entity as provided in paragraph a8iv of this section, if applicable or all coverage offered by such issuer that are offered in the same insurance market;
ii Calculate the median contracted rate using the full contracted rate applicable to the service code, except that the plan or issuer must A Calculate separate median contracted rates for CPT code modifiers 26 professional component and TC technical component;
B For anesthesia services, calculate a median contracted rate for the
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