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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations 149.30

Definitions.

Subpart BProtections against Balance Billing for the Group and Individual Health Insurance Markets 149.110 Preventing surprise medical bills for emergency services.
149.120 Preventing surprise medical bills for non-emergency services performed by nonparticipating providers at certain participating facilities.
149.130 Preventing surprise medical bills for air ambulance services.
149.140 Methodology for calculating qualifying payment amount.
149.150 Complaints process for surprise medical bills regarding group health plans and group and individual health insurance coverage.
Subpart CReserved Subpart DAdditional Patient Protections 149.310 Choice of health care professional.
Subpart EHealth Care Provider, Health Care Facility, and Air Ambulance Service Provider Requirements 149.410 Balance billing in cases of emergency services.
149.420 Balance billing in cases of nonemergency services performed by nonparticipating providers at certain participating health care facilities.
149.430 Provider and facility disclosure requirements regarding patient protections against balance billing.
149.440 Balance billing in cases of air ambulance services.
149.450 Complaints process for balance billing regarding providers and facilities.
Authority: 42 U.S.C. 300gg111 through 300gg139, as amended.

Subpart AGeneral Provisions 149.10

Basis and scope.

a Basis. This part implements parts D and E of title XXVII of the PHS Act.
b Scope. This part establishes standards for group health plans, health insurance issuers offering group or individual health insurance coverage, health care providers and facilities, and providers of air ambulance services with respect to surprise medical bills, transparency in health care coverage, and additional patient protections.

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149.20

Applicability.

a In general. 1 The requirements in subparts B and D of this part apply to group health plans and health insurance issuers offering group or individual health insurance coverage including grandfathered health plans as defined in 147.140 of this subchapter, except as specified in paragraph b of this section.
2 The requirements in subpart E of this part apply to health care providers, health care facilities, and providers of air ambulance services.

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b Exceptions. The requirements in subparts B and D of this part do not apply to the following:
1 Excepted benefits as described in 146.145 and 148.220 of this subchapter.
2 Short-term, limited-duration insurance as defined in 144.103 of this subchapter.
3 Health reimbursement arrangements or other account-based group health plans as described in 147.126d of this subchapter.
149.30

Definitions.

The definitions in part 144 of this subchapter apply to this part, unless otherwise specified. In addition, for purposes of this part, the following definitions apply:
Air ambulance service means medical transport by a rotary wing air ambulance, as defined in 42 CFR
414.605, or fixed wing air ambulance, as defined in 42 CFR 414.605, for patients.
Cost sharing means the amount a participant, beneficiary, or enrollee is responsible for paying for a covered item or service under the terms of the group health plan or health insurance coverage. Cost sharing generally includes copayments, coinsurance, and amounts paid towards deductibles, but does not include amounts paid towards premiums, balance billing by out-ofnetwork providers, or the cost of items or services that are not covered under a group health plan or health insurance coverage.
Emergency department of a hospital includes a hospital outpatient department that provides emergency services.
Emergency medical condition has the meaning given the term in 149.110c1.
Emergency services has the meaning given the term in 149.110c2.
Health care facility, with respect to a group health plan or group or individual health insurance coverage, in the context of non-emergency services, is each of the following:
1 A hospital as defined in section 1861e of the Social Security Act;
2 A hospital outpatient department;
3 A critical access hospital as defined in section 1861mm1 of the Social Security Act; and 4 An ambulatory surgical center described in section 1833i1A of the Social Security Act.
Independent freestanding emergency department means a health care facility not limited to those described in the definition of health care facility with respect to non-emergency services that
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1 Is geographically separate and distinct and licensed separately from a hospital under applicable State law; and 2 Provides any emergency services as described in 149.110c2i.
Nonparticipating emergency facility means an emergency department of a hospital, or an independent freestanding emergency department or a hospital, with respect to services that pursuant to 149.110c2ii are included as emergency services, that does not have a contractual relationship directly or indirectly with a group health plan or group or individual health insurance coverage offered by a health insurance issuer, with respect to the furnishing of an item or service under the plan or coverage, respectively.
Nonparticipating provider means any physician or other health care provider who does not have a contractual relationship directly or indirectly with a group health plan or group or individual health insurance coverage offered by a health insurance issuer, with respect to the furnishing of an item or service under the plan or coverage, respectively.
Notice of denial of payment means, with respect to an item or service for which benefits subject to the protections of 149.110 through 149.130 are provided or covered, a written notice from the plan or issuer to the health care provider, facility, or provider of air ambulance services, as applicable, that payment for such item or service will not be made by the plan or coverage and which explains the reason for denial.
The term notice of denial of payment does not include a notice of benefit denial due to an adverse benefit determination as defined in 29 CFR
2560.5031.
Out-of-network rate means, with respect to an item or service furnished by a nonparticipating provider, nonparticipating emergency facility, or nonparticipating provider of air ambulance services 1 Subject to paragraph 3 of this definition, in a State that has in effect a specified State law, the amount determined in accordance with such law;
2 Subject to paragraph 3 of this definition, in a State that does not have in effect a specified State law i Subject to paragraph 2ii of this definition, if the nonparticipating provider or nonparticipating emergency facility and the plan or issuer agree on an amount of payment including if the amount agreed upon is the initial payment sent by the plan or issuer under 26 CFR 54.98164Tb3ivA, 54.98165Tc3, or 54.98171Tb4i;
29 CFR 2590.7164b3ivA, 2590.7165c3, or 2590.7171b4i;

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