Voglio sapere a riguardo di…

36960

Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations
Subpart DSurprise Billing and Transparency Requirements Sec.
2590.7161 Basis and scope.
2590.7162 Applicability.
2590.7163 Definitions.
2590.7164 Preventing surprise medical bills for emergency services.
2590.7165 Preventing surprise medical bills for non-emergency services performed by nonparticipating providers at certain participating facilities.
2590.7166 Methodology for calculating qualifying payment amount.
2590.7167 Complaints process for surprise medical bills regarding group health plans and group health insurance coverage.
2590.7171 Preventing surprise medical bills for air ambulance services.
2590.722 Choice of health care professional.

Subpart DSurprise Billing and Transparency Requirements 2590.7161

Basis and scope.

a Basis. Sections 2590.7161
through 2590.722 implement section 716722 of ERISA.
b Scope. This part establishes standards for group health plans and health insurance issuers offering group health insurance coverage with respect to surprise medical bills, transparency in health care coverage, and additional patient protections.
2590.7162

Applicability.

a In general. The requirements in 2590.7164 through 2590.7167, 2590.7171, and 2590.722 apply to group health plans and health insurance issuers offering group health insurance coverage including grandfathered health plans as defined in 2590.715
1251, except as specified in paragraph b of this section.
b Exceptions. The requirements in 2590.7164 through 2590.7167, 2590.7171, and 2590.722 do not apply to the following:
1 Excepted benefits as described in 2590.732.
2 Short-term, limited-duration insurance as defined in 2590.7012.
3 Health reimbursement arrangements or other account-based group health plans as described in 2590.7152711d.

jbell on DSKJLSW7X2PROD with RULES2

2590.7163

Definitions.

The definitions in this part apply to 2590.716 through 2590.722, unless otherwise specified. In addition, for purposes of 2590.716 through 2590.722, the following definitions apply:
Air ambulance service means medical transport by a rotary wing air ambulance, as defined in 42 CFR

VerDate Sep<11>2014

20:26 Jul 12, 2021

Jkt 253001

414.605, or fixed wing air ambulance, as defined in 42 CFR 414.605, for patients.
Cost sharing means the amount a participant or beneficiary 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-of-network 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 2590.716
4c1.
Emergency services has the meaning given the term in 2590.7164c2.
Health care facility, with respect to a group health plan or group 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 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 2590.7164c2i.
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 2590.7164c2ii are included as emergency services, that does not have a contractual relationship directly or indirectly with a group health plan or group 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 health
PO 00000

Frm 00089

Fmt 4701

Sfmt 4700

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 2590.7164, 2590.7165, and 2590.7171 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 2560.5031 of this chapter.
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;
2590.7164b3ivA, 2590.716
5c3, or 2590.7171b4i; or 45
CFR 149.110b3ivA, 149.120c3, or 149.130b4i, as applicable, or is agreed on through negotiations with respect to such item or service, such agreed on amount; or ii If the nonparticipating provider or nonparticipating emergency facility and the plan or issuer enter into the independent dispute resolution IDR
process under section 9816c or 9817b of the Internal Revenue Code, section 716c or 717b of ERISA, or section 2799A1c or 2799A2b of the PHS
Act, as applicable, and do not agree before the date on which a certified IDR
entity makes a determination with respect to such item or service under such subsection, the amount of such determination; or 3 In a State that has an All-Payer Model Agreement under section 1115A
of the Social Security Act that applies with respect to the plan or issuer; the nonparticipating provider or
E:FRFM13JYR2.SGM

13JYR2