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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations
vi For air ambulance services billed using the air mileage service codes A0435 and A0436 that are furnished during 2023 or a subsequent year, the plan or issuer must calculate the qualifying payment amount by first increasing the indexed median air mileage rate, determined under paragraph c1v of this section for such services furnished in the immediately preceding year, in accordance with paragraph c1ii of this section. The plan or issuer must then multiply the indexed median air mileage rate by the number of loaded miles provided to the participant or beneficiary to determine the qualifying payment amount.
vii For any other items or services for which a plan or issuer generally determines payment for the same or similar items or services by multiplying a contracted rate by another unit value, the plan or issuer must calculate the qualifying payment amount using a methodology that is similar to the methodology required under paragraphs c1iii through vi of this section and reasonably reflects the payment methodology for same or similar items or services.
2 New plans and coverage. With respect to a sponsor of a group health plan or health insurance issuer offering group health insurance coverage in a geographic region in which the sponsor or issuer, respectively, did not offer any group health plan or health insurance coverage during 2019
i For the first year in which the group health plan or group health insurance coverage, respectively, is offered in such region A If the plan or issuer has sufficient information to calculate the median of the contracted rates described in paragraph b of this section, the plan or issuer must calculate the qualifying payment amount in accordance with paragraph c1 of this section for items and services that are covered by the plan or coverage and furnished during the first year; and B If the 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 item or service provided in a geographic region, the plan or issuer must determine the qualifying payment amount for the item or service in accordance with paragraph c3i of this section.
ii For each subsequent year the group health plan or group health insurance coverage, respectively, is offered in the region, the plan or issuer must calculate the qualifying payment amount by increasing the qualifying
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payment amount determined under this paragraph c2 for the items and services furnished in the immediately preceding year, in accordance with paragraph c1ii, iv, or vi of this section, as applicable.
3 Insufficient information; newly covered items and services. In the case of a plan or issuer that does not have sufficient information to calculate the median of the contracted rates described in paragraph b of this section in 2019
or, in the case of a newly covered item or service, in the first coverage year for such item or service with respect to such plan or coverage if the plan or issuer does not have sufficient information for an item or service provided in a geographic region i For an item or service furnished during 2022 or, in the case of a newly covered item or service, during the first coverage year for the item or service with respect to the plan or coverage, the plan or issuer must calculate the qualifying payment amount by first identifying the rate that is equal to the median of the in-network allowed amounts for the same or similar item or service provided in the geographic region in the year immediately preceding the year in which the item or service is furnished or, in the case of a newly covered item or service, the year immediately preceding such first coverage year determined by the plan or issuer, respectively, through use of any eligible database, and then increasing that rate by the percentage increase in the CPIU over such preceding year. For purposes of this section, in cases in which an eligible database is used to determine the qualifying payment amount with respect to an item or service furnished during a calendar year, the plan or issuer must use the same database for determining the qualifying payment amount for that item or service furnished through the last day of the calendar year, and if a different database is selected for some items or services, the basis for that selection must be one or more factors not directly related to the rate of those items or services such as sufficiency of data for those items or services.
ii For an item or service furnished in a subsequent year before the first sufficient information year for such item or service with respect to such plan or coverage, the plan or issuer must calculate the qualifying payment amount by increasing the qualifying payment amount determined under paragraph c3i of this section or this paragraph c3ii, as applicable, for such item or service for the year immediately preceding such subsequent
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year, by the percentage increase in CPI
U over such preceding year;
iii For an item or service furnished in the first sufficient information year for such item or service with respect to such plan or coverage, the plan or issuer must calculate the qualifying payment amount in accordance with paragraph c1i, iii, or v of this section, as applicable, except that in applying such paragraph to such item or service, the reference to furnished during 2022 is treated as a reference to furnished during such first sufficient information year, the reference to in 2019 is treated as a reference to such sufficient information year, and the increase described in such paragraph is not applied; and iv For an item or service furnished in any year subsequent to the first sufficient information year for such item or service with respect to such plan or coverage, the plan or issuer must calculate the qualifying payment amount in accordance with paragraph c1ii, iv, or vi of this section, as applicable, except that in applying such paragraph to such item or service, the reference to furnished during 2023 or a subsequent year is treated as a reference to furnished during the year after such first sufficient information year or a subsequent year.
4 New service codes. In the case of a plan or issuer that does not have sufficient information to calculate the median of the contracted rates described in paragraph b of this section and determine the qualifying payment amount under paragraphs c1 through 3 of this section because the item or service furnished is billed under a new service code i For an item or service furnished during 2022 or, in the case of a newly covered item or service, during the first coverage year for the item or service with respect to the plan or coverage, the plan or issuer must identify a reasonably related service code that existed in the immediately preceding year and A If the Centers for Medicare &
Medicaid Services has established a Medicare payment rate for the item or service billed under the new service code, the plan or issuer must calculate the qualifying payment amount by first calculating the ratio of the rate that Medicare pays for the item or service billed under the new service code compared to the rate that Medicare pays for the item or service billed under the related service code, and then multiplying the ratio by the qualifying payment amount for an item or service billed under the related service code for
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