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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations ii Any third-party database which A Is not affiliated with, or owned or controlled by, any health insurance issuer, or a health care provider, facility, or provider of air ambulance services or any member of the same controlled group as, or under common control with, such an entity. For purposes of this paragraph a3iiA, the term controlled group means a group of two or more persons that is treated as a single employer under sections 52a, 52b, 414m, or 414o of the Internal Revenue Code of 1986, as amended;
B Has sufficient information reflecting in-network amounts paid by group health plans or health insurance issuers offering group or individual health insurance coverage to providers, facilities, or providers of air ambulance services for relevant items and services furnished in the applicable geographic region; and C Has the ability to distinguish amounts paid to participating providers and facilities by commercial payers, such as group health plans and health insurance issuers offering group or individual health insurance coverage, from all other claims data, such as amounts billed by nonparticipating providers or facilities and amounts paid by public payers, including the Medicare program under title XVIII of the Social Security Act, the Medicaid program under title XIX of the Social Security Act or a demonstration project under title XI of the Social Security Act, or the Childrens Health Insurance Program under title XXI of the Social Security Act.
4 Facility of the same or similar facility type means, with respect to emergency services, either i An emergency department of a hospital; or ii An independent freestanding emergency department.
5 First coverage year means, with respect to an item or service for which coverage is not offered in 2019 under a group health plan or group or individual health insurance coverage offered by a health insurance issuer, the first year after 2019 for which coverage for such item or service is offered under that plan or coverage.
6 First sufficient information year means, with respect to a group health plan or group or individual health insurance coverage offered by a health insurance issuer i In the case of an item or service for which the plan or coverage does not have sufficient information to calculate the median of the contracted rates described in paragraph b of this section in 2019, the first year after 2022
for which the plan or issuer has
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sufficient information to calculate the median of such contracted rates in the year immediately preceding that first year after 2022; and ii In the case of a newly covered item or service, the first year after the first coverage year for such item or service with respect to such plan or coverage for which the plan or issuer has sufficient information to calculate the median of the contracted rates described in paragraph b of this section in the year immediately preceding that first year.
7 Geographic region means i For items and services other than air ambulance services A Subject to paragraphs a7iB
and C of this section, one region for each metropolitan statistical area, as described by the U.S. Office of Management and Budget and published by the U.S. Census Bureau, in a State, and one region consisting of all other portions of the State.
B If a 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 described in paragraph a7iA of this section, one region consisting of all metropolitan statistical areas, as described by the U.S. Office of Management and Budget and published by the U.S. Census Bureau, in the State, and one region consisting of all other portions of the State.
C If a 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 described in paragraph a7iB of this section, one region consisting of all metropolitan statistical areas, as described by the U.S. Office of Management and Budget and published by the U.S. Census Bureau, in each Census division and one region consisting of all other portions of the Census division, as described by the U.S. Census Bureau.
ii For air ambulance services A Subject to paragraph a7iiB of this section, one region consisting of all metropolitan statistical areas, as described by the U.S. Office of Management and Budget and published by the U.S. Census Bureau, in the State, and one region consisting of all other portions of the State, determined based on the point of pick-up as defined in 42
CFR 414.605.
B If a 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 air ambulance service provided in a
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geographic region described in paragraph a7iiA of this section, one region consisting of all metropolitan statistical areas, as described by the U.S.
Office of Management and Budget and published by the U.S. Census Bureau, in each Census division and one region consisting of all other portions of the Census division, as described by the U.S. Census Bureau, determined based on the point of pick-up as defined in 42
CFR 414.605.
8 Insurance market is, irrespective of the State, one of the following:
i The individual market other than short-term, limited-duration insurance or individual health insurance coverage that consists solely of excepted benefits.
ii The large group market other than coverage that consists solely of excepted benefits.
iii The small group market other than coverage that consists solely of excepted benefits.
iv In the case of a self-insured group health plan, all self-insured group health plans other than account-based plans, as defined in 147.126d6i of this subchapter, and plans that consist solely of excepted benefits of the same plan sponsor, or at the option of the plan sponsor, all self-insured group health plans administered by the same entity including a third-party administrator contracted by the plan, to the extent otherwise permitted by law, that is responsible for calculating the qualifying payment amount on behalf of the plan.
9 Modifiers mean codes applied to the service code that provide a more specific description of the furnished item or service and that may adjust the payment rate or affect the processing or payment of the code billed.
10 Newly covered item or service means an item or service for which coverage was not offered in 2019 under a group health plan or group or individual health insurance coverage offered by a health insurance issuer, but that is offered under the plan or coverage in a year after 2019.
11 New service code means a service code that was created or substantially revised in a year after 2019.
12 Provider in the same or similar specialty means the practice specialty of a provider, as identified by the plan or issuer consistent with the plans or issuers usual business practice, except that, with respect to air ambulance services, all providers of air ambulance services are considered to be a single provider specialty.
13 Same or similar item or service means a health care item or service billed under the same service code, or
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