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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations
or 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 nonparticipating emergency facility; and the item or service, the amount that the State approves under the All-Payer Model Agreement for the item or service.
Participating emergency facility means any 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 has a contractual relationship directly or indirectly with a group health plan or health insurance issuer offering group or individual health insurance coverage setting forth the terms and conditions on which a relevant item or service is provided to a participant, beneficiary, or enrollee under the plan or coverage, respectively. A single case agreement between an emergency facility and a plan or issuer that is used to address unique situations in which a participant, beneficiary, or enrollee requires services that typically occur out-of-network constitutes a contractual relationship for purposes of this definition, and is limited to the parties to the agreement.
Participating health care facility means any health care facility described in this section that has a contractual relationship directly or indirectly with a group health plan or health insurance issuer offering group or individual health insurance coverage setting forth the terms and conditions on which a relevant item or service is provided to a participant, beneficiary, or enrollee under the plan or coverage, respectively.
A single case agreement between a health care facility and a plan or issuer that is used to address unique situations in which a participant, beneficiary, or
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enrollee requires services that typically occur out-of-network constitutes a contractual relationship for purposes of this definition, and is limited to the parties to the agreement.
Participating provider means any physician or other health care provider who has a contractual relationship directly or indirectly with a group health plan or health insurance issuer offering group or individual health insurance coverage setting forth the terms and conditions on which a relevant item or service is provided to a participant, beneficiary, or enrollee under the plan or coverage, respectively.
Physician or health care provider means a physician or other health care provider who is acting within the scope of practice of that providers license or certification under applicable State law, but does not include a provider of air ambulance services.
Provider of air ambulance services means an entity that is licensed under applicable State and Federal law to provide air ambulance services.
Same or similar item or service has the meaning given the term in 149.140a13.
Service code has the meaning given the term in 149.140a14.
Qualifying payment amount has the meaning given the term in 149.140a16.
Recognized amount means, with respect to an item or service furnished by a nonparticipating provider or nonparticipating emergency facility 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, the lesser of i The amount that is the qualifying payment amount as determined in accordance with 149.140; or ii The amount billed by the provider or facility.
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 nonparticipating emergency facility; and the item or service, the amount that the State approves under the All-Payer Model Agreement for the item or service.
Specified State law means a State law that provides for a method for determining the total amount payable under a group health plan or group or individual health insurance coverage offered by a health insurance issuer to
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the extent such State law applies for an item or service furnished by a nonparticipating provider or nonparticipating emergency facility including where it applies because the State has allowed a plan that is not otherwise subject to applicable State law an opportunity to opt in, subject to section 514 of the Employee Retirement Income Security Act of 1974. A group health plan that opts in to such a specified State law must do so for all items and services to which the specified State law applies and in a manner determined by the applicable State authority, and must prominently display in its plan materials describing the coverage of out-of-network services a statement that the plan has opted into the specified State law, identify the relevant State or States, and include a general description of the items and services provided by nonparticipating facilities and providers that are covered by the specified State law.
State means each of the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
Treating provider is a physician or health care provider who has evaluated the individual.
Visit, with respect to items and services furnished to an individual at a health care facility, includes, in addition to items and services furnished by a provider at the facility, equipment and devices, telemedicine services, imaging services, laboratory services, and preoperative and postoperative services, regardless of whether the provider furnishing such items or services is at the facility.
Subpart BProtections Against Balance Billing for the Group and Individual Health Insurance Markets 149.110 Preventing surprise medical bills for emergency services.

a In general. If a group health plan, or a health insurance issuer offering group or individual health insurance coverage, provides or covers any benefits with respect to services in an emergency department of a hospital or with respect to emergency services in an independent freestanding emergency department, the plan or issuer must cover emergency services, as defined in paragraph c2 of this section, and this coverage must be provided 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 for emergency services in the following manner
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