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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations
services described in paragraph b of this section, the plan or issuer must cover the items and services when furnished by a nonparticipating provider in accordance with paragraph c of this section.
b Items and services described. The items and services described in this paragraph b are items and services other than emergency services furnished to a participant, beneficiary, or enrollee by a nonparticipating provider with respect to a visit at a participating health care facility, unless the provider has satisfied the notice and consent criteria of 149.420c through i with respect to such items and services.
c Coverage requirements. In the case of items and services described in paragraph b of this section, the plan or issuer 1 Must not impose a cost-sharing requirement for the items and services that is greater than the cost-sharing requirement that would apply if the items or services had been furnished by a participating provider.
2 Must calculate the cost-sharing requirements as if the total amount that would have been charged for the items and services by such participating provider were equal to the recognized amount for the items and services.
3 Not later than 30 calendar days after the bill for the items or services is transmitted by the provider or in cases where the recognized amount is determined by a specified State law or All-Payer Model Agreement, such other timeframe as specified under the State law or All-Payer Model Agreement, must determine whether the items and services are covered under the plan or coverage and, if the items and services are covered, send to the provider an initial payment or a notice of denial of payment. For purposes of this paragraph c3, 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 items or services.
4 Must pay a total plan or coverage payment directly to the nonparticipating provider that is equal to the amount by which the out-of-network rate for the items and services involved exceeds the cost-sharing amount for the items and services as determined in accordance with paragraphs c1 and 2 of this section, less any initial payment amount made under paragraph c3 of this section. The total plan or coverage payment must be made in accordance with the timing requirement described in section 2799A1c6 of the PHS Act, or in cases where the out-of-network rate is determined under a specified
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State law or All-Payer Model Agreement, such other timeframe as specified by the State law or All-Payer Model Agreement.
5 Must count any cost-sharing payments made by the participant, beneficiary, or enrollee toward any innetwork deductible and in-network outof-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-of-pocket maximums must be applied in the same manner as if such cost-sharing payments were made with respect to items and services furnished by a participating provider.
d Applicability date. The provisions of this section are applicable with respect to plan years in the individual market, policy years beginning on or after January 1, 2022.
149.130 Preventing surprise medical bills for air ambulance 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 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 149.140 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
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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 2799A2b6 of the PHS Act, or in cases where the outof-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 in the individual market, policy years beginning on or after January 1, 2022.
149.140 Methodology for calculating qualifying payment amount.

a Definitions. For purposes of this section, the following definitions apply:
1 Contracted rate means the total amount including cost sharing that a group health plan or health insurance issuer has contractually agreed to pay a participating provider, facility, or provider of air ambulance services for covered items and services, whether directly or indirectly, including through a third-party administrator or pharmacy benefit manager. Solely for purposes of this definition, a single case agreement, letter of agreement, or other similar arrangement between a provider, facility, or air ambulance provider and a plan or issuer, used to supplement the network of the plan or coverage for a specific participant, beneficiary, or enrollee in unique circumstances, does not constitute a contract.
2 Derived amount has the meaning given the term in 147.210 of this subchapter.
3 Eligible database means i A State all-payer claims database;
or
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