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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations ii For an item or service other than items or services described in paragraphs c1iii through vii of this section furnished during 2023 or a subsequent year, the plan or issuer must calculate the qualifying payment amount by increasing the qualifying payment amount determined under paragraph c1i of this section, for such an item or service furnished in the immediately preceding year, by the percentage increase as published by the Department of the Treasury and the Internal Revenue Service.
A The percentage increase for any year after 2022 will be published in guidance by the Internal Revenue Service. The Department of the Treasury and Internal Revenue Service will calculate the percentage increase using the CPIU published by the Bureau of Labor Statistics of the Department of Labor.
B For purposes of this paragraph c1ii, the CPIU for each calendar year is the average of the CPIU as of the close of the 12-month period ending on August 31 of the calendar year, rounded to 10 decimal places.
C The combined percentage increase for any year will be calculated as CPI
U present year/CPIU prior year.
iii For anesthesia services furnished during 2022, the plan or issuer must calculate the qualifying payment amount by first increasing the median contracted rate for the anesthesia conversion factor as determined in accordance with paragraph b of this section for the same or similar item or service under such plans or coverage, respectively, on January 31, 2019, in accordance with paragraph c1i of this section referred to in this section as the indexed median contracted rate for the anesthesia conversion factor.
The plan or issuer must then multiply the indexed median contracted rate for the anesthesia conversion factor by the sum of the base unit, time unit, and physical status modifier units of the participant, beneficiary, or enrollee to whom anesthesia services are furnished to determine the qualifying payment amount.
A The base units for an anesthesia service code are the base units for that service code specified in the most recent edition as of the date of service of the American Society of Anesthesiologists Relative Value Guide.
B The time unit is measured in 15minute increments or a fraction thereof.
C The physical status modifier on a claim is a standard modifier describing the physical status of the patient and is used to distinguish between various levels of complexity of the anesthesia services provided, and is expressed as a
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unit with a value between zero 0 and three 3.
D The anesthesia conversion factor is expressed in dollars per unit and is a contracted rate negotiated with the plan or issuer.
iv For anesthesia services furnished during 2023 or a subsequent year, the plan or issuer must calculate the qualifying payment amount by first increasing the indexed median contracted rate for the anesthesia conversion factor, determined under paragraph c1iii 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 that amount by the sum of the base unit, time unit, and physical status modifier units for the participant, beneficiary, or enrollee to whom anesthesia services are furnished to determine the qualifying payment amount.
v For air ambulance services billed using the air mileage service codes A0435 and A0436 that are furnished during 2022, the plan or issuer must calculate the qualifying payment amount for services billed using the air mileage service codes by first increasing the median contracted rate as determined in accordance with paragraph b of this section, in accordance with paragraph c1i of this section referred to in this section as the indexed median air mileage rate.
The plan or issuer must then multiply the indexed median air mileage rate by the number of loaded miles provided to the participant, beneficiary, or enrollee to determine the qualifying payment amount.
A The air mileage rate is expressed in dollars per loaded mile flown, is expressed in statute miles not nautical miles, and is a contracted rate negotiated with the plan or issuer.
B The number of loaded miles is the number of miles a patient is transported in the air ambulance vehicle.
C The qualifying payment amount for other service codes associated with air ambulance services is calculated in accordance with paragraphs c1i and ii of this section.
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
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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, beneficiary, or enrollee 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 or individual 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, group health insurance coverage, or individual 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, group health insurance coverage, or individual health insurance coverage, respectively, is offered in the region, the plan or issuer must calculate the qualifying payment amount by increasing the qualifying 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
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