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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations
membership booklet, outline of coverage, or other evidence of coverage the plan or issuer provides to participants or beneficiaries;
vii Documents regarding the facts in the complaint in the possession of, or otherwise attainable by, the complainant; or viii Any other information DOL may need to make a determination of facts for an investigation.
3 DOL will make reasonable efforts consistent with agency practices to notify the complainant of the outcome of the complaint after the submission is processed through appropriate methods as determined by DOL. A complaint is considered processed after DOL has reviewed the complaint and accompanying information and made an outcome determination. Based on the nature of the complaint and the plan or issuer involved, DOL may i Refer the complainant to another appropriate Federal or State resolution process;
ii Notify the complainant and make reasonable efforts to refer the complainant to the appropriate State or Federal regulatory authority if DOL
receives a complaint where another entity has enforcement jurisdiction over the plan or issuer;
iii Refer the plan or issuer for an investigation for enforcement action; or iv Provide the complainant with an explanation of the resolution of the complaint and any corrective action taken.

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2590.7171 Preventing surprise medical bills for air ambulance services.

a In general. If a group health plan or a health insurance issuer offering group health insurance coverage provides or covers any benefits for air ambulance services, the plan or issuer must cover such services from a nonparticipating provider of air ambulance services in accordance with paragraph b of this section.
b Coverage requirements. A plan or issuer described in paragraph a of this section must provide coverage of air ambulance services in the following manner 1 The cost-sharing requirements with respect to the services must be the same requirements that would apply if the services were provided by a participating provider of air ambulance services.
2 The cost-sharing requirement must be calculated as if the total amount that would have been charged for the services by a participating provider of air ambulance services were equal to the lesser of the qualifying payment amount as determined in accordance with
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2590.7166 or the billed amount for the services.
3 The cost-sharing amounts must be counted towards any in-network deductible and in-network out-of-pocket maximums including the annual limitation on cost sharing under section 2707b of the PHS Act as applicable applied under the plan or coverage and the in-network deductible and out-ofpocket maximums must be applied in the same manner as if the cost-sharing payments were made with respect to services furnished by a participating provider of air ambulance services.
4 The plan or issuer must i Not later than 30 calendar days after the bill for the services is transmitted by the provider of air ambulance services, determine whether the services are covered under the plan or coverage and, if the services are covered, send to the provider an initial payment or a notice of denial of payment. For purposes of this paragraph b4i, the 30-calendar-day period begins on the date the plan or issuer receives the information necessary to decide a claim for payment for the services.
ii Pay a total plan or coverage payment directly to the nonparticipating provider furnishing such air ambulance services that is equal to the amount by which the out-of-network rate for the services exceeds the cost-sharing amount for the services as determined in accordance with paragraphs b1
and 2 of this section, less any initial payment amount made under paragraph b4i of this section. The total plan or coverage payment must be made in accordance with the timing requirement described in section 717b6 of ERISA, or in cases where the out-of-network rate is determined under a specified State law or All-Payer Model Agreement, such other timeframe as specified by the State law or All-Payer Model Agreement.
c Applicability date. The provisions of this section are applicable with respect to plan years beginning on or after January 1, 2022.
2590.722 Choice of health care professional.

a Choice of health care professional1 Designation of primary care provideri In general. If a group health plan, or a health insurance issuer offering group health insurance coverage, requires or provides for designation by a participant or beneficiary of a participating primary care provider, then the plan or issuer must permit each participant or beneficiary to designate any participating primary care provider who
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is available to accept the participant or beneficiary. In such a case, the plan or issuer must comply with the rules of paragraph a4 of this section by informing each participant of the terms of the plan or health insurance coverage regarding designation of a primary care provider.
ii Construction. Nothing in paragraph a1i of this section is to be construed to prohibit the application of reasonable and appropriate geographic limitations with respect to the selection of primary care providers, in accordance with the terms of the plan or coverage, the underlying provider contracts, and applicable State law.
iii Example. The rules of this paragraph a1 are illustrated by the following example:
A Facts. A group health plan requires individuals covered under the plan to designate a primary care provider. The plan permits each individual to designate any primary care provider participating in the plans network who is available to accept the individual as the individuals primary care provider. If an individual has not designated a primary care provider, the plan designates one until the individual has made a designation. The plan provides a notice that satisfies the requirements of paragraph a4 of this section regarding the ability to designate a primary care provider.
B Conclusion. In this Example, the plan has satisfied the requirements of paragraph a of this section.
2 Designation of pediatrician as primary care provideri In general. If a group health plan, or a health insurance issuer offering group health insurance coverage, requires or provides for the designation of a participating primary care provider for a child by a participant or beneficiary, the plan or issuer must permit the participant or beneficiary to designate a physician allopathic or osteopathic who specializes in pediatrics including pediatric subspecialties, based on the scope of that providers license under applicable State law as the childs primary care provider if the provider participates in the network of the plan or issuer and is available to accept the child. In such a case, the plan or issuer must comply with the rules of paragraph a4 of this section by informing each participant in the individual market, primary subscriber of the terms of the plan or health insurance coverage regarding designation of a pediatrician as the childs primary care provider.
ii Construction. Nothing in paragraph a2i of this section is to be construed to waive any exclusions of
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