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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations
State health benefits risk pool means a State health benefits risk pool within the meaning of 54.98014a1vii.
Travel insurance means insurance coverage for personal risks incident to planned travel, which may include, but is not limited to, interruption or cancellation of trip or event, loss of baggage or personal effects, damages to accommodations or rental vehicles, and sickness, accident, disability, or death occurring during travel, provided that the health benefits are not offered on a stand-alone basis and are incidental to other coverage. For this purpose, the term travel insurance does not include major medical plans that provide comprehensive medical protection for travelers with trips lasting 6 months or longer, including, for example, those working overseas as an expatriate or military personnel being deployed.
Waiting period means waiting period within the meaning of 54.9815
2708b.
Par. 7. Section 54.98152719AT is added to read as follows:

54.98152719AT
temporary.

Patient protections
ab Reserved c Applicability date. The provisions of this section are applicable to group health plans and health insurance issuers for plan years beginning before January 1, 2022. See also 54.98164T
through 54.98167T, 54.98171T, and 54.98221T for rules applicable with respect to plan years beginning on or after January 1, 2022.
Par. 8. Sections 54.98161T, 54.9816
2T, 54.98163T, 54.98164T, 54.9816
5T, 54.98166T, 54.98167T, 54.9817
1T, and 54.98221T are added to read as follows:

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Sec.
54.98161T Basis and scope temporary.
54.98162T Applicability temporary.
54.98163T Definitions temporary.
54.98164T Preventing surprise medical bills for emergency services temporary.
54.98165T Preventing surprise medical bills for non-emergency services performed by nonparticipating providers at certain participating facilities temporary.
54.98166T Methodology for calculating qualifying payment amount temporary.
54.98167T Complaints process for surprise medical bills regarding group health plans temporary.
54.98171T Preventing surprise medical bills for air ambulance services temporary.
54.98221T Choice of health care professional temporary.

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54.98161T
temporary.

Basis and scope
a Basis. This section and 54.98162T through 54.98167T, 54.98171T, and 54.98221T implement subchapter B of chapter 100 of the Internal Revenue Code of 1986.
b Scope. This part establishes standards for group health plans with respect to surprise medical bills, transparency in health care coverage, and additional patient protections.
54.98162T

Applicability temporary.

a In general. The requirements in 54.98164T through 54.98167T, 54.98171T, and 54.98221T apply to group health plans including grandfathered health plans as defined in 54.98151251T, except as specified in paragraph b of this section.
b Exceptions. The requirements in 54.98164T through 54.98167T, 54.98171T, and 54.98221T do not apply to the following:
1 Excepted benefits as described in 54.98311c.
2 Short-term, limited-duration insurance as defined in 54.98012.
3 Health reimbursement arrangements or other account-based group health plans as described in 54.98152711d.
54.98163T

Definitions temporary.

The definitions in 54.98012T apply to 54.98164T through 54.98167T, 54.98171T, and 54.98221T unless otherwise specified. In addition, for purposes of 54.98164T through 54.98167T, 54.98171T, and 54.9822
1T, 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 54.9816
4Tc1.
Emergency services has the meaning given the term in 54.98164Tc2.

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Health care facility, with respect to a group health plan, in the context of nonemergency 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 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 54.98164Tc2i.
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 54.98164Tc2ii are included as emergency services, that does not have a contractual relationship directly or indirectly with a group health plan, with respect to the furnishing of an item or service under the plan.
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, with respect to the furnishing of an item or service under the plan.
Notice of denial of payment means, with respect to an item or service for which benefits subject to the protections of 54.98164T, 54.98165T, and 54.98171T are provided or covered, a written notice from the plan 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 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;

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