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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations
sufficient information to calculate the median of the contracted rates described in paragraph b of this section in 2019
or, in the case of a newly covered item or service, in the first coverage year for such item or service with respect to such plan or coverage if the plan or issuer does not have sufficient information for an item or service provided in a geographic region i For an item or service furnished during 2022 or, in the case of a newly covered item or service, during the first coverage year for the item or service with respect to the plan or coverage, the plan or issuer must calculate the qualifying payment amount by first identifying the rate that is equal to the median of the in-network allowed amounts for the same or similar item or service provided in the geographic region in the year immediately preceding the year in which the item or service is furnished or, in the case of a newly covered item or service, the year immediately preceding such first coverage year determined by the plan or issuer, respectively, through use of any eligible database, and then increasing that rate by the percentage increase in the CPIU over such preceding year. For purposes of this section, in cases in which an eligible database is used to determine the qualifying payment amount with respect to an item or service furnished during a calendar year, the plan or issuer must use the same database for determining the qualifying payment amount for that item or service furnished through the last day of the calendar year, and if a different database is selected for some items or services, the basis for that selection must be one or more factors not directly related to the rate of those items or services such as sufficiency of data for those items or services.
ii For an item or service furnished in a subsequent year before the first sufficient information year for such item or service with respect to such plan or coverage, the plan or issuer must calculate the qualifying payment amount by increasing the qualifying payment amount determined under paragraph c3i of this section or this paragraph c3ii, as applicable, for such item or service for the year immediately preceding such subsequent year, by the percentage increase in CPI
U over such preceding year;
iii For an item or service furnished in the first sufficient information year for such item or service with respect to such plan or coverage, the plan or issuer must calculate the qualifying payment amount in accordance with paragraph c1i, iii, or v of this section, as applicable, except that in applying such
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paragraph to such item or service, the reference to furnished during 2022 is treated as a reference to furnished during such first sufficient information year, the reference to in 2019 is treated as a reference to such sufficient information year, and the increase described in such paragraph is not applied; and iv For an item or service furnished in any year subsequent to the first sufficient information year for such item or service with respect to such plan or coverage, the plan or issuer must calculate the qualifying payment amount in accordance with paragraph c1ii, iv, or vi of this section, as applicable, except that in applying such paragraph to such item or service, the reference to furnished during 2023 or a subsequent year is treated as a reference to furnished during the year after such first sufficient information year or a subsequent year.
4 New service codes. In the case of a plan or issuer that does not have sufficient information to calculate the median of the contracted rates described in paragraph b of this section and determine the qualifying payment amount under paragraphs c1 through 3 of this section because the item or service furnished is billed under a new service code i For an item or service furnished during 2022 or, in the case of a newly covered item or service, during the first coverage year for the item or service with respect to the plan or coverage, the plan or issuer must identify a reasonably related service code that existed in the immediately preceding year and A If the Centers for Medicare &
Medicaid Services has established a Medicare payment rate for the item or service billed under the new service code, the plan or issuer must calculate the qualifying payment amount by first calculating the ratio of the rate that Medicare pays for the item or service billed under the new service code compared to the rate that Medicare pays for the item or service billed under the related service code, and then multiplying the ratio by the qualifying payment amount for an item or service billed under the related service code for the year in which the item or service is furnished.
B If the Centers for Medicare &
Medicaid Services has not established a Medicare payment rate for the item or service billed under the new service code, the plan or issuer must calculate the qualifying payment amount by first calculating the ratio of the rate that the plan or issuer reimburses for the item or service billed under the new service
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code compared to the rate that the plan or issuer reimburses for the item or service billed under the related service code, and then multiplying the ratio by the qualifying payment amount for an item or service billed under the related service code.
ii For an item or service furnished in a subsequent year before the first sufficient information year for such item or service with respect to such plan or coverage or before the first year for which an eligible database has sufficient information to a calculate a rate under paragraph c3i of this section in the immediately preceding year, the plan or issuer must calculate the qualifying payment amount by increasing the qualifying payment amount determined under paragraph c4i of this section or this paragraph c4ii, as applicable, for such item or service for the year immediately preceding such subsequent year, by the percentage increase in CPI
U over such preceding year;
iii For an item or service furnished in the first sufficient information year for such item or service with respect to such plan or coverage or the first year for which an eligible database has sufficient information to calculate a rate under paragraph c3i of this section in the immediately preceding year, the plan or issuer must calculate the qualifying payment amount in accordance with paragraph c3 of this section.
d Information to be shared about qualifying payment amount. In cases in which the recognized amount with respect to an item or service furnished by a nonparticipating provider, nonparticipating emergency facility, or nonparticipating provider of air ambulance services is the qualifying payment amount, the plan or issuer must provide in writing, in paper or electronic form, to the provider or facility, as applicable 1 With each initial payment or notice of denial of payment under 149.110, 149.120, or 149.130:
i The qualifying payment amount for each item or service involved;
ii A statement to certify that, based on the determination of the plan or issuer A The qualifying payment amount applies for purposes of the recognized amount or, in the case of air ambulance services, for calculating the participants, beneficiarys, or enrollees cost sharing; and B Each qualifying payment amount shared with the provider or facility was determined in compliance with this section;
iii A statement that if the provider or facility, as applicable, wishes to
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