---
kind: "section"
citation: "42 U.S.C. § 300gg–111"
title: "42"
title_heading: "The Public Health and Welfare"
number: "300gg–111"
heading: "Preventing surprise medical bills"
release: "119-102"
date: "2026-07-12"
url: "https://uscodex.org/usc/42/300gg-111"
units:
  - "Chapter 6A — Public Health Service"
  - "Subchapter XXV — Requirements Relating to Health Insurance Coverage"
  - "Part D — Additional Coverage Provisions"
---

# §300gg–111. Preventing surprise medical bills

- (a) **Coverage of emergency services—**
  - (1) **In general—** If a [group health plan](/usc/42/300bb–8.md?p=1), or a [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5), provides or covers any benefits with respect to [services](/usc/42/201.md?p=a) in an emergency department of a [hospital](/usc/42/300s–3.md?p=1) or with respect to emergency [services](/usc/42/201.md?p=a) in an independent freestanding emergency department (as defined in [paragraph (3)(D)](#a-3-D)), the plan or issuer shall cover emergency [services](/usc/42/201.md?p=a) (as defined in [paragraph (3)(C)](#a-3-C))—
    - (A) without the need for any prior authorization determination;
    - (B) whether the [health care provider](/usc/42/300aa–33.md?p=1) furnishing such [services](/usc/42/201.md?p=a) is a participating [provider](/usc/42/299b–21.md?p=8) or a participating emergency facility, as applicable, with respect to such [services](/usc/42/201.md?p=a);
    - (C) in a manner so that, if such [services](/usc/42/201.md?p=a) are provided to a [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee by a nonparticipating [provider](/usc/42/299b–21.md?p=8) or a nonparticipating emergency facility—
      - (i) such [services](/usc/42/201.md?p=a) will be provided without imposing any requirement under the plan or coverage for prior authorization of [services](/usc/42/201.md?p=a) or any limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency [services](/usc/42/201.md?p=a) received from participating [providers](/usc/42/299b–21.md?p=8) and participating emergency facilities with respect to such plan or coverage, respectively;
      - (ii) the cost-sharing requirement is not greater than the requirement that would apply if such [services](/usc/42/201.md?p=a) were provided by a participating [provider](/usc/42/299b–21.md?p=8) or a participating emergency facility;
      - (iii) such cost-sharing requirement is calculated as if the total amount that would have been charged for such [services](/usc/42/201.md?p=a) by such participating [provider](/usc/42/299b–21.md?p=8) or participating emergency facility were equal to the recognized amount (as defined in [paragraph (3)(H)](#a-3-H)) for such [services](/usc/42/201.md?p=a), plan or coverage, and year;
      - (iv) the [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2), respectively—
        - (I) not later than 30 calendar days after the bill for such [services](/usc/42/201.md?p=a) is transmitted by such [provider](/usc/42/299b–21.md?p=8) or facility, sends to the [provider](/usc/42/299b–21.md?p=8) or facility, as applicable, an initial payment or notice of denial of payment; and
        - (II) pays a total plan or coverage payment directly to such [provider](/usc/42/299b–21.md?p=8) or facility, respectively (in accordance, if applicable, with the timing requirement described in [subsection (c)(6)](#c-6)) that is, with application of any initial payment under [subclause (I)](#a-1-C-iv-I), equal to the amount by which the out-of-network rate (as defined in [paragraph (3)(K)](#a-3-K)) for such [services](/usc/42/201.md?p=a) exceeds the cost-sharing amount for such [services](/usc/42/201.md?p=a) (as determined in accordance with clauses [(ii)](#a-1-C-ii) and [(iii)](#a-1-C-iii)) and year; and
      - (v) any cost-sharing payments made by the [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee with respect to such emergency [services](/usc/42/201.md?p=a) so furnished shall be counted toward any in-network deductible or out-of-pocket maximums applied under the plan or coverage, respectively (and such in-network deductible and out-of-pocket maximums shall be applied) in the same manner as if such cost-sharing payments were made with respect to emergency [services](/usc/42/201.md?p=a) furnished by a participating [provider](/usc/42/299b–21.md?p=8) or a participating emergency facility; and
    - (D) without regard to any other term or condition of such coverage (other than exclusion or coordination of benefits, or an affiliation or waiting period, permitted under [section 300gg–3 of this title](/usc/42/300gg–3.md), including as incorporated pursuant to [section 1185d of title 29](/usc/29/1185d.md) and [section 9815 of title 26](/usc/26/9815.md), and other than applicable cost-sharing).
  - (2) **Audit process and regulations for qualifying payment amounts—**
    - (A) **Audit process—**
      - (i) **In general—** Not later than October 1, 2021, the [Secretary](/usc/42/201.md?p=c), in consultation with the [Secretary](/usc/42/201.md?p=c) of Labor and the [Secretary](/usc/42/201.md?p=c) of the Treasury, shall establish through rulemaking a process, in accordance with [clause (ii)](#a-2-A-ii), under which [group health plans](/usc/42/300bb–8.md?p=1) and [health insurance issuers](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) are audited by the [Secretary](/usc/42/201.md?p=c) or [applicable State authority](/usc/42/300gg–91.md?p=d-1) to ensure that—
        - (I) such plans and coverage are in compliance with the requirement of applying a qualifying payment amount under this section; and
        - (II) such qualifying payment amount so applied satisfies the definition under [paragraph (3)(E)](#a-3-E) with respect to the year involved, including with respect to a [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) described in [clause (ii)](#a-2-A-ii) of such [paragraph (3)(E)](#a-3-E).
      - (ii) **Audit samples—** Under the process established pursuant to [clause (i)](#a-2-A-i), the [Secretary](/usc/42/201.md?p=c)—
        - (I) shall conduct audits described in such clause, with respect to a year (beginning with 2022), of a sample with respect to such year of claims data from not more than 25 [group health plans](/usc/42/300bb–8.md?p=1) and [health insurance issuers](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5); and
        - (II) may audit any [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) if the [Secretary](/usc/42/201.md?p=c) has received any complaint or other information about such plan or coverage, respectively, that involves the compliance of the plan or coverage, respectively, with either of the requirements described in subclauses [(I)](#a-2-A-ii-I) and [(II)](#a-2-A-ii-II) of such clause.
      - (iii) **Reports—** Beginning for 2022, the [Secretary](/usc/42/201.md?p=c) shall annually submit to Congress a report on the number of plans and issuers with respect to which audits were conducted during such year pursuant to this subparagraph.
    - (B) **Rulemaking—** Not later than July 1, 2021, the [Secretary](/usc/42/201.md?p=c), in consultation with the [Secretary](/usc/42/201.md?p=c) of Labor and the [Secretary](/usc/42/201.md?p=c) of the Treasury, shall establish through rulemaking—
      - (i) the methodology the [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) shall use to determine the qualifying payment amount, differentiating by [individual market](/usc/42/300gg–91.md?p=e-1-A), [large group market](/usc/42/300gg–91.md?p=e-3), and [small group market](/usc/42/300gg–91.md?p=e-5);
      - (ii) the information such plan or issuer, respectively, shall share with the nonparticipating [provider](/usc/42/299b–21.md?p=8) or nonparticipating facility, as applicable, when making such a determination;
      - (iii) the geographic regions applied for purposes of this subparagraph, taking into account access to items and [services](/usc/42/201.md?p=a) in rural and underserved areas, including health professional shortage areas, as defined in [section 254e of this title](/usc/42/254e.md); and
      - (iv) a process to receive complaints of [violations](/usc/42/2000e–16a.md?p=c) of the requirements described in subclauses [(I)](#a-2-A-i-I) and [(II)](#a-2-A-i-II) of subparagraph (A)(i) by [group health plans](/usc/42/300bb–8.md?p=1) and [health insurance issuers](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5).

      Such rulemaking shall take into account payments that are made by such plan or issuer, respectively, that are not on a fee-for-[service](/usc/42/201.md?p=a) basis. Such methodology may account for relevant payment adjustments that take into account quality or facility type (including higher acuity settings and the case-mix of various facility types) that are otherwise taken into account for purposes of determining payment amounts with respect to participating facilities. In carrying out [clause (iii)](#a-2-B-iii), the [Secretary](/usc/42/201.md?p=c) shall consult with the National Association of Insurance Commissioners to establish the geographic regions under such clause and shall periodically update such regions, as appropriate, taking into account the findings of the report submitted under [section 109(a)](/usc/42/109.md) of the No Surprises Act.

  - (3) **Definitions—** In this part and part E:
    - (A) **Emergency department of a hospital—** The term “emergency department of a [hospital](/usc/42/300s–3.md?p=1)” includes a [hospital](/usc/42/300s–3.md?p=1) outpatient department that provides emergency [services](/usc/42/201.md?p=a) (as defined in [subparagraph (C)(i)](#a-3-C-i)).
    - (B) **Emergency medical condition—** The term “emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in clause [(i)](/usc/42/1867.md), [(ii)](/usc/42/1867.md), or [(iii)](/usc/42/1867.md) of section 1867(e)(1)(A) of the Social Security Act [[42 U.S.C. 1395dd(e)(1)(A)](/usc/42/1395dd.md?p=e-1-A)].
    - (C) **Emergency services—**
      - (i) **In general—** The term “emergency [services](/usc/42/201.md?p=a)”, with respect to an emergency medical condition, means—
        - (I) a medical screening examination (as required under section 1867 of the Social Security Act [[42 U.S.C. 1395dd](/usc/42/1395dd.md)], or as would be required under such section if such section applied to an independent freestanding emergency department) that is within the capability of the emergency department of a [hospital](/usc/42/300s–3.md?p=1) or of an independent freestanding emergency department, as applicable, including ancillary [services](/usc/42/201.md?p=a) routinely available to the emergency department to evaluate such emergency medical condition; and
        - (II) within the capabilities of the staff and facilities available at the [hospital](/usc/42/300s–3.md?p=1) or the independent freestanding emergency department, as applicable, such further medical examination and [treatment](/usc/42/11851.md?p=11) as are required under [section 1395dd of this title](/usc/42/1395dd.md), or as would be required under such section if such section applied to an independent freestanding emergency department, to stabilize the patient (regardless of the department of the [hospital](/usc/42/300s–3.md?p=1) in which such further examination or [treatment](/usc/42/11851.md?p=11) is furnished).
      - (ii) **Inclusion of additional services—**
        - (I) **In general—** For purposes of this subsection and [section 300gg–131 of this title](/usc/42/300gg–131.md), in the case of a [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee who is enrolled in a [group health plan](/usc/42/300bb–8.md?p=1) or group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) offered by a [health insurance issuer](/usc/42/300gg–91.md?p=b-2) and who is furnished [services](/usc/42/201.md?p=a) described in [clause (i)](#a-3-C-i) with respect to an emergency medical condition, the term “emergency [services](/usc/42/201.md?p=a)” shall include, unless each of the conditions described in [subclause (II)](#a-3-C-ii-II) are met, in addition to the items and [services](/usc/42/201.md?p=a) described in [clause (i)](#a-3-C-i), items and [services](/usc/42/201.md?p=a)—
          - (aa) for which benefits are provided or covered under the plan or coverage, respectively; and
          - (bb) that are furnished by a nonparticipating [provider](/usc/42/299b–21.md?p=8) or nonparticipating emergency facility (regardless of the department of the [hospital](/usc/42/300s–3.md?p=1) in which such items or [services](/usc/42/201.md?p=a) are furnished) after the [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the [services](/usc/42/201.md?p=a) described in [clause (i)](#a-3-C-i) are furnished.
        - (II) **Conditions—** For purposes of [subclause (I)](#a-3-C-ii-I), the conditions described in this subclause, with respect to a [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee who is stabilized and furnished additional items and [services](/usc/42/201.md?p=a) described in [subclause (I)](#a-3-C-ii-I) after such stabilization by a [provider](/usc/42/299b–21.md?p=8) or facility described in [subclause (I)](#a-3-C-ii-I), are the following;
          - (aa) Such [provider](/usc/42/299b–21.md?p=8) or facility determines such individual is able to travel using nonmedical transportation or nonemergency medical transportation.
          - (bb) Such [provider](/usc/42/299b–21.md?p=8) furnishing such additional items and [services](/usc/42/201.md?p=a) satisfies the notice and consent criteria of [section 300gg–132(d) of this title](/usc/42/300gg–132.md?p=d) with respect to such items and [services](/usc/42/201.md?p=a).
          - (cc) Such individual is in a condition to receive (as determined in accordance with guidelines issued by the [Secretary](/usc/42/201.md?p=c) pursuant to rulemaking) the information described in [section 300gg–132 of this title](/usc/42/300gg–132.md) and to provide informed consent under such section, in accordance with applicable [State](/usc/42/201.md?p=f) law.
          - (dd) Such other conditions, as specified by the [Secretary](/usc/42/201.md?p=c), such as conditions relating to coordinating care transitions to participating [providers](/usc/42/299b–21.md?p=8) and facilities.
    - (D) **Independent freestanding emergency department—** The term “independent freestanding emergency department” means a health care facility that—
      - (i) is geographically separate and distinct and licensed separately from a [hospital](/usc/42/300s–3.md?p=1) under applicable [State](/usc/42/201.md?p=f) law; and
      - (ii) provides any of the emergency [services](/usc/42/201.md?p=a) (as defined in [subparagraph (C)(i)](#a-3-C-i)).
    - (E) **Qualifying payment amount—**
      - (i) **In general—** The term “qualifying payment amount” means, subject to clauses [(ii)](#a-3-E-ii) and [(iii)](#a-3-E-iii), with respect to a sponsor of a [group health plan](/usc/42/300bb–8.md?p=1) and [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5)—
        - (I) for an item or [service](/usc/42/201.md?p=a) furnished during 2022, the median of the contracted rates recognized by the plan or issuer, respectively (determined with respect to all such plans of such sponsor or all such coverage offered by such issuer that are offered within the same insurance market (specified in subclause [(I)](#a-3-E-iv-I), [(II)](#a-3-E-iv-II), [(III)](#a-3-E-iv-III), or [(IV)](#a-3-E-iv-IV) of clause (iv)) as the plan or coverage) as the total maximum payment (including the cost-sharing amount imposed for such item or [service](/usc/42/201.md?p=a) and the amount to be paid by the plan or issuer, respectively) under such plans or coverage, respectively, on January 31, 2019, for the same or a similar item or [service](/usc/42/201.md?p=a) that is provided by a [provider](/usc/42/299b–21.md?p=8) in the same or similar specialty and provided in the geographic region in which the item or [service](/usc/42/201.md?p=a) is furnished, consistent with the methodology established by the [Secretary](/usc/42/201.md?p=c) under [paragraph (2)(B)](#a-2-B), increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over 2019, such percentage increase over 2020, and such percentage increase over 2021; and
        - (II) for an item or [service](/usc/42/201.md?p=a) furnished during 2023 or a subsequent year, the qualifying payment amount determined under this clause for such an item or [service](/usc/42/201.md?p=a) furnished in the previous year, increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over such previous year.
      - (ii) **New plans and coverage—** The term “qualifying payment amount” means, with respect to a sponsor of a [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) in a geographic region in which such sponsor or issuer, respectively, did not offer any [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance coverage](/usc/42/300gg–91.md?p=b-1) during 2019—
        - (I) for the first year in which such [group health plan](/usc/42/300bb–8.md?p=1), [group health insurance coverage](/usc/42/300gg–91.md?p=b-4), or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5), respectively, is offered in such region, a rate (determined in accordance with a methodology established by the [Secretary](/usc/42/201.md?p=c)) for items and [services](/usc/42/201.md?p=a) that are covered by such plan or coverage and furnished during such first year; and
        - (II) for each subsequent year such [group health plan](/usc/42/300bb–8.md?p=1), [group health insurance coverage](/usc/42/300gg–91.md?p=b-4), or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5), respectively, is offered in such region, the qualifying payment amount determined under this clause for such items and [services](/usc/42/201.md?p=a) furnished in the previous year, increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over such previous year.
      - (iii) **Insufficient information; newly covered items and services—** In the case of a sponsor of a [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) that does not have sufficient information to calculate the median of the contracted rates described in [clause (i)(I)](#a-3-E-i-I) in 2019 (or, in the case of a newly covered item or [service](/usc/42/201.md?p=a) (as defined in [clause (v)(III)](#a-3-E-v-III)), in the first coverage year (as defined in [clause (v)(I)](#a-3-E-v-I)) for such item or [service](/usc/42/201.md?p=a) with respect to such plan or coverage) for an item or [service](/usc/42/201.md?p=a) (including with respect to [provider](/usc/42/299b–21.md?p=8) type, or amount, of claims for items or [services](/usc/42/201.md?p=a) (as determined by the [Secretary](/usc/42/201.md?p=c)) provided in a particular geographic region (other than in a case with respect to which [clause (ii)](#a-3-E-ii) applies)) the term “qualifying payment amount”—
        - (I) for an item or [service](/usc/42/201.md?p=a) furnished during 2022 (or, in the case of a newly covered item or [service](/usc/42/201.md?p=a), during the first coverage year for such item or [service](/usc/42/201.md?p=a) with respect to such plan or coverage), means such rate for such item or [service](/usc/42/201.md?p=a) determined by the sponsor or issuer, respectively, through use of any database that is determined, in accordance with rulemaking described in [paragraph (2)(B)](#a-2-B), to not have any conflicts of interest and to have sufficient information reflecting allowed amounts paid to a [health care provider](/usc/42/300aa–33.md?p=1) or facility for relevant [services](/usc/42/201.md?p=a) furnished in the applicable geographic region (such as a [State](/usc/42/201.md?p=f) all-payer claims database);
        - (II) for an item or [service](/usc/42/201.md?p=a) furnished in a subsequent year (before the first sufficient information year (as defined in [clause (v)(II)](#a-3-E-v-II)) for such item or [service](/usc/42/201.md?p=a) with respect to such plan or coverage), means the rate determined under [subclause (I)](#a-3-E-iii-I) or this subclause, as applicable, for such item or [service](/usc/42/201.md?p=a) for the year previous to such subsequent year, increased by the percentage increase in the consumer price index for all urban consumers (United States city average) over such previous year;
        - (III) for an item or [service](/usc/42/201.md?p=a) furnished in the first sufficient information year for such item or [service](/usc/42/201.md?p=a) with respect to such plan or coverage, has the meaning given the term qualifying payment amount in [clause (i)(I)](#a-3-E-i-I), except that in applying such clause to such item or [service](/usc/42/201.md?p=a), the reference to “furnished during 2022” shall be treated as a reference to furnished during such first sufficient information year, the reference to “in 2019”[^1] shall be treated as a reference to such sufficient information year, and the increase described in such clause shall not be applied; and
        - (IV) for an item or [service](/usc/42/201.md?p=a) furnished in any year subsequent to the first sufficient information year for such item or [service](/usc/42/201.md?p=a) with respect to such plan or coverage, has the meaning given such term in [clause (i)(II)](#a-3-E-i-II), except that in applying such clause to such item or [service](/usc/42/201.md?p=a), the reference to “furnished during 2023 or a subsequent year” shall be treated as a reference to furnished during the year after such first sufficient information year or a subsequent year.
      - (iv) **Insurance market—** For purposes of [clause (i)(I)](#a-3-E-i-I), a health insurance market specified in this clause is one of the following:
        - (I) The [individual market](/usc/42/300gg–91.md?p=e-1-A).
        - (II) The [large group market](/usc/42/300gg–91.md?p=e-3) (other than plans described in [subclause (IV)](#a-3-E-iv-IV)).
        - (III) The [small group market](/usc/42/300gg–91.md?p=e-5) (other than plans described in [subclause (IV)](#a-3-E-iv-IV)).
        - (IV) In the case of a self-insured [group health plan](/usc/42/300bb–8.md?p=1), other self-insured [group health plans](/usc/42/300bb–8.md?p=1).
      - (v) **Definitions—** For purposes of this subparagraph:
        - (I) **First coverage year—** The term “first coverage year” means, with respect to a [group health plan](/usc/42/300bb–8.md?p=1) or group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) offered by a [health insurance issuer](/usc/42/300gg–91.md?p=b-2) and an item or [service](/usc/42/201.md?p=a) for which coverage is not offered in 2019 under such plan or coverage, the first year after 2019 for which coverage for such item or [service](/usc/42/201.md?p=a) is offered under such plan or [health insurance coverage](/usc/42/300gg–91.md?p=b-1).
        - (II) **First sufficient information year—** The term “first sufficient information year” means, with respect to a [group health plan](/usc/42/300bb–8.md?p=1) or group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) offered by a [health insurance issuer](/usc/42/300gg–91.md?p=b-2)—
          - (aa) in the case of an item or [service](/usc/42/201.md?p=a) for which the plan or coverage does not have sufficient information to calculate the median of the contracted rates described in [clause (i)(I)](#a-3-E-i-I) in 2019, the first year subsequent to 2022 for which the sponsor or issuer has such sufficient information to calculate the median of such contracted rates in the year previous to such first subsequent year; and
          - (bb) in the case of a newly covered item or [service](/usc/42/201.md?p=a), the first year subsequent to the first coverage year for such item or [service](/usc/42/201.md?p=a) with respect to such plan or coverage for which the sponsor or issuer has sufficient information to calculate the median of the contracted rates described in [clause (i)(I)](#a-3-E-i-I) in the year previous to such first subsequent year.
        - (III) **Newly covered item or service—** The term “newly covered item or [service](/usc/42/201.md?p=a)” means, with respect to a [group health plan](/usc/42/300bb–8.md?p=1) or group or individual [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering [health insurance coverage](/usc/42/300gg–91.md?p=b-1), an item or [service](/usc/42/201.md?p=a) for which coverage was not offered in 2019 under such plan or coverage, but is offered under such plan or coverage in a year after 2019.
    - (F) **Nonparticipating emergency facility; participating emergency facility—**
      - (i) **Nonparticipating emergency facility—** The term “nonparticipating emergency facility” means, with respect to an item or [service](/usc/42/201.md?p=a) and a [group health plan](/usc/42/300bb–8.md?p=1) or group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) offered by a [health insurance issuer](/usc/42/300gg–91.md?p=b-2), an emergency department of a [hospital](/usc/42/300s–3.md?p=1), or an independent freestanding emergency department, that does not have a contractual relationship directly or indirectly with the plan or issuer, respectively, for furnishing such item or [service](/usc/42/201.md?p=a) under the plan or coverage, respectively.
      - (ii) **Participating emergency facility—** The term “participating emergency facility” means, with respect to an item or [service](/usc/42/201.md?p=a) and a [group health plan](/usc/42/300bb–8.md?p=1) or group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) offered by a [health insurance issuer](/usc/42/300gg–91.md?p=b-2), an emergency department of a [hospital](/usc/42/300s–3.md?p=1), or an independent freestanding emergency department, that has a contractual relationship directly or indirectly with the plan or issuer, respectively, with respect to the furnishing of such an item or [service](/usc/42/201.md?p=a) at such facility.
    - (G) **Nonparticipating providers; participating providers—**
      - (i) **Nonparticipating provider—** The term “nonparticipating [provider](/usc/42/299b–21.md?p=8)” means, with respect to an item or [service](/usc/42/201.md?p=a) and a [group health plan](/usc/42/300bb–8.md?p=1) or group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) offered by a [health insurance issuer](/usc/42/300gg–91.md?p=b-2), a physician or other [health care provider](/usc/42/300aa–33.md?p=1) who is acting within the scope of practice of that [provider](/usc/42/299b–21.md?p=8)’s license or certification under applicable [State](/usc/42/201.md?p=f) law and who does not have a contractual relationship with the plan or issuer, respectively, for furnishing such item or [service](/usc/42/201.md?p=a) under the plan or coverage, respectively.
      - (ii) **Participating provider—** The term “participating [provider](/usc/42/299b–21.md?p=8)” means, with respect to an item or [service](/usc/42/201.md?p=a) and a [group health plan](/usc/42/300bb–8.md?p=1) or group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) offered by a [health insurance issuer](/usc/42/300gg–91.md?p=b-2), a physician or other [health care provider](/usc/42/300aa–33.md?p=1) who is acting within the scope of practice of that [provider](/usc/42/299b–21.md?p=8)’s license or certification under applicable [State](/usc/42/201.md?p=f) law and who has a contractual relationship with the plan or issuer, respectively, for furnishing such item or [service](/usc/42/201.md?p=a) under the plan or coverage, respectively.
    - (H) **Recognized amount—** The term “recognized amount” means, with respect to an item or [service](/usc/42/201.md?p=a) furnished by a nonparticipating [provider](/usc/42/299b–21.md?p=8) or nonparticipating emergency facility during a year and a [group health plan](/usc/42/300bb–8.md?p=1) or group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) offered by a [health insurance issuer](/usc/42/300gg–91.md?p=b-2)—
      - (i) subject to [clause (iii)](#a-3-H-iii), in the case of such item or [service](/usc/42/201.md?p=a) furnished in a [State](/usc/42/201.md?p=f) that has in effect a specified [State](/usc/42/201.md?p=f) law with respect to such plan, coverage, or issuer, respectively; such a nonparticipating [provider](/usc/42/299b–21.md?p=8) or nonparticipating emergency facility; and such an item or [service](/usc/42/201.md?p=a), the amount determined in accordance with such law;
      - (ii) subject to [clause (iii)](#a-3-H-iii), in the case of such item or [service](/usc/42/201.md?p=a) furnished in a [State](/usc/42/201.md?p=f) that does not have in effect a specified [State](/usc/42/201.md?p=f) law, with respect to such plan, coverage, or issuer, respectively; such a nonparticipating [provider](/usc/42/299b–21.md?p=8) or nonparticipating emergency facility; and such an item or [service](/usc/42/201.md?p=a), the amount that is the qualifying payment amount (as defined in [subparagraph (E)](#a-3-E))[^2] for such year and determined in accordance with rulemaking described in [paragraph (2)(B)](#a-2-B))[^2] for such item or [service](/usc/42/201.md?p=a); or
      - (iii) in the case of such item or [service](/usc/42/201.md?p=a) furnished in a [State](/usc/42/201.md?p=f) with an All-Payer Model Agreement under section 1115A of the Social Security Act [[42 U.S.C. 1315a](/usc/42/1315a.md)], the amount that the [State](/usc/42/201.md?p=f) approves under such system for such item or [service](/usc/42/201.md?p=a) so furnished.
    - (I) **Specified State law—** The term “specified [State](/usc/42/201.md?p=f) law” means, with respect to a [State](/usc/42/201.md?p=f), an item or [service](/usc/42/201.md?p=a) furnished by a nonparticipating [provider](/usc/42/299b–21.md?p=8) or nonparticipating emergency facility during a year and a [group health plan](/usc/42/300bb–8.md?p=1) or group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) offered by a [health insurance issuer](/usc/42/300gg–91.md?p=b-2), a [State](/usc/42/201.md?p=f) law that provides for a method for determining the total amount payable under such a plan, coverage, or issuer, respectively (to the extent such [State](/usc/42/201.md?p=f) law applies to such plan, coverage, or issuer, subject to [section 1144 of title 29](/usc/29/1144.md)) in the case of a [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee covered under such plan or coverage and receiving such item or [service](/usc/42/201.md?p=a) from such a nonparticipating [provider](/usc/42/299b–21.md?p=8) or nonparticipating emergency facility.
    - (J) **Stabilize—** The term “to stabilize”, with respect to an emergency medical condition (as defined in [subparagraph (B)](#a-3-B)), has the meaning give[^3] in section 1867(e)(3) of the Social Security Act ([42 U.S.C. 1395dd(e)(3)](/usc/42/1395dd.md?p=e-3)).
    - (K) **Out-of-network rate—** The term “out-of-network rate” means, with respect to an item or [service](/usc/42/201.md?p=a) furnished in a [State](/usc/42/201.md?p=f) during a year to a [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee of a [group health plan](/usc/42/300bb–8.md?p=1) or group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) offered by a [health insurance issuer](/usc/42/300gg–91.md?p=b-2) receiving such item or [service](/usc/42/201.md?p=a) from a nonparticipating [provider](/usc/42/299b–21.md?p=8) or nonparticipating emergency facility—
      - (i) subject to [clause (iii)](#a-3-K-iii), in the case of such item or [service](/usc/42/201.md?p=a) furnished in a [State](/usc/42/201.md?p=f) that has in effect a specified [State](/usc/42/201.md?p=f) law with respect to such plan, coverage, or issuer, respectively; such a nonparticipating [provider](/usc/42/299b–21.md?p=8) or nonparticipating emergency facility; and such an item or [service](/usc/42/201.md?p=a), the amount determined in accordance with such law;
      - (ii) subject to [clause (iii)](#a-3-K-iii), in the case such [State](/usc/42/201.md?p=f) does not have in effect such a law with respect to such item or [service](/usc/42/201.md?p=a), plan, and [provider](/usc/42/299b–21.md?p=8) or facility—
        - (I) subject to [subclause (II)](#a-3-K-ii-II), if the [provider](/usc/42/299b–21.md?p=8) or facility (as applicable) and such plan or coverage agree on an amount of payment (including if such agreed on amount is the initial payment sent by the plan under [subsection (a)(1)(C)(iv)(I)](#a-1-C-iv-I), [subsection (b)(1)(C)](#b-1-C), or [section 300gg–112(a)(3)(A) of this title](/usc/42/300gg–112.md?p=a-3-A), as applicable, or is agreed on through open negotiations under [subsection (c)(1)](#c-1)) with respect to such item or [service](/usc/42/201.md?p=a), such agreed on amount; or
        - (II) if such [provider](/usc/42/299b–21.md?p=8) or facility (as applicable) and such plan or coverage enter the independent dispute resolution process under [subsection (c)](#c) and do not so agree before the date on which a certified IDR entity (as defined in [paragraph (4)](#c-4) of such subsection) makes a determination with respect to such item or [service](/usc/42/201.md?p=a) under such subsection, the amount of such determination; or
      - (iii) in the case such [State](/usc/42/201.md?p=f) has an All-Payer Model Agreement under section 1115A of the Social Security Act [[42 U.S.C. 1315a](/usc/42/1315a.md)], the amount that the [State](/usc/42/201.md?p=f) approves under such system for such item or [service](/usc/42/201.md?p=a) so furnished.
    - (L) **Cost-sharing—** The term “cost-sharing” includes copayments, coinsurance, and deductibles.
- (b) **Coverage of non-emergency services performed by nonparticipating providers at certain participating facilities—**
  - (1) **In general—** In the case of items or [services](/usc/42/201.md?p=a) (other than emergency [services](/usc/42/201.md?p=a) to which [subsection (a)](#a) applies) for which any benefits are provided or covered by a [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) furnished to a [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee of such plan or coverage by a nonparticipating [provider](/usc/42/299b–21.md?p=8) (as defined in [subsection (a)(3)(G)(i)](#a-3-G-i)) (and who, with respect to such items and [services](/usc/42/201.md?p=a), has not satisfied the notice and consent criteria of [section 300gg–132(d) of this title](/usc/42/300gg–132.md?p=d)) with respect to a visit (as defined by the [Secretary](/usc/42/201.md?p=c) in accordance with [paragraph (2)(B)](#b-2-B)) at a participating health care facility (as defined in [paragraph (2)(A)](#b-2-A)), with respect to such plan or coverage, respectively, the plan or coverage, respectively—
    - (A) shall not impose on such [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee a cost-sharing requirement for such items and [services](/usc/42/201.md?p=a) so furnished that is greater than the cost-sharing requirement that would apply under such plan or coverage, respectively, had such items or [services](/usc/42/201.md?p=a) been furnished by a participating [provider](/usc/42/299b–21.md?p=8) (as defined in [subsection (a)(3)(G)(ii)](#a-3-G-ii));
    - (B) shall calculate such cost-sharing requirement as if the total amount that would have been charged for such items and [services](/usc/42/201.md?p=a) by such participating [provider](/usc/42/299b–21.md?p=8) were equal to the recognized amount (as defined in [subsection (a)(3)(H)](#a-3-H)) for such items and [services](/usc/42/201.md?p=a), plan or coverage, and year;
    - (C) not later than 30 calendar days after the bill for such [services](/usc/42/201.md?p=a) is transmitted by such [provider](/usc/42/299b–21.md?p=8), shall send to the [provider](/usc/42/299b–21.md?p=8) an initial payment or notice of denial of payment;
    - (D) shall pay a total plan or coverage payment directly, in accordance, if applicable, with the timing requirement described in [subsection (c)(6)](#c-6), to such [provider](/usc/42/299b–21.md?p=8) furnishing such items and [services](/usc/42/201.md?p=a) to such [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee that is, with application of any initial payment under [subparagraph (C)](#b-1-C), equal to the amount by which the out-of-network rate (as defined in [subsection (a)(3)(K)](#a-3-K)) for such items and [services](/usc/42/201.md?p=a) involved exceeds the cost-sharing amount imposed under the plan or coverage, respectively, for such items and [services](/usc/42/201.md?p=a) (as determined in accordance with subparagraphs [(A)](#b-1-A) and [(B)](#b-1-B)) and year; and
    - (E) shall count toward any in-network deductible and in-network out-of-pocket maximums (as applicable) applied under the plan or coverage, respectively, any cost-sharing payments made by the [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee (and such in-network deductible and out-of-pocket maximums shall be applied) with respect to such items and [services](/usc/42/201.md?p=a) so furnished in the same manner as if such cost-sharing payments were with respect to items and [services](/usc/42/201.md?p=a) furnished by a participating [provider](/usc/42/299b–21.md?p=8).
  - (2) **Definitions—** In this section:
    - (A) **Participating health care facility—**
      - (i) **In general—** The term “participating health care facility” means, with respect to an item or [service](/usc/42/201.md?p=a) and a [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5), a health care facility described in [clause (ii)](#b-2-A-ii) that has a direct or indirect contractual relationship with the plan or issuer, respectively, with respect to the furnishing of such an item or [service](/usc/42/201.md?p=a) at the facility.
      - (ii) **Health care facility described—** A health care facility described in this clause, with respect to a [group health plan](/usc/42/300bb–8.md?p=1) or group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5), is each of the following:
        - (I) A [hospital](/usc/42/300s–3.md?p=1) (as defined in 1861(e) of the Social Security Act [[42 U.S.C. 1395x(e)](/usc/42/1395x.md?p=e)]).
        - (II) A [hospital](/usc/42/300s–3.md?p=1) outpatient department.
        - (III) A critical access [hospital](/usc/42/300s–3.md?p=1) (as defined in [section 1861(mm)(1)](/usc/42/1861.md) of such Act [[42 U.S.C. 1395x(mm)(1)](/usc/42/1395x.md?p=mm-1)]).
        - (IV) An ambulatory surgical center described in section 1833(i)(1)(A) of such Act [[42 U.S.C. 1395l(i)(1)(A)](/usc/42/1395l.md?p=i-1-A)].
        - (V) Any other facility, specified by the [Secretary](/usc/42/201.md?p=c), that provides items or [services](/usc/42/201.md?p=a) for which coverage is provided under the plan or coverage, respectively.
    - (B) **Visit—** The term “visit” shall, with respect to items and [services](/usc/42/201.md?p=a) furnished to an individual at a health care facility, include equipment and devices, telemedicine [services](/usc/42/201.md?p=a), imaging [services](/usc/42/201.md?p=a), laboratory [services](/usc/42/201.md?p=a), preoperative and postoperative [services](/usc/42/201.md?p=a), and such other items and [services](/usc/42/201.md?p=a) as the [Secretary](/usc/42/201.md?p=c) may specify, regardless of whether or not the [provider](/usc/42/299b–21.md?p=8) furnishing such items or [services](/usc/42/201.md?p=a) is at the facility.
- (c) **Determination of out-of-network rates to be paid by health plans; independent dispute resolution process—**
  - (1) **Determination through open negotiation—**
    - (A) **In general—** With respect to an item or [service](/usc/42/201.md?p=a) furnished in a year by a nonparticipating [provider](/usc/42/299b–21.md?p=8) or a nonparticipating facility, with respect to a [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5), in a [State](/usc/42/201.md?p=f) described in [subsection (a)(3)(K)(ii)](#a-3-K-ii) with respect to such plan or coverage and [provider](/usc/42/299b–21.md?p=8) or facility, and for which a payment is required to be made by the plan or coverage pursuant to subsection [(a)(1)](#a-1) or [(b)(1)](#b-1), the [provider](/usc/42/299b–21.md?p=8) or facility (as applicable) or plan or coverage may, during the 30-day period beginning on the day the [provider](/usc/42/299b–21.md?p=8) or facility receives an initial payment or a notice of denial of payment from the plan or coverage regarding a claim for payment for such item or [service](/usc/42/201.md?p=a), initiate open negotiations under this paragraph between such [provider](/usc/42/299b–21.md?p=8) or facility and plan or coverage for purposes of determining, during the open negotiation period, an amount agreed on by such [provider](/usc/42/299b–21.md?p=8) or facility, respectively, and such plan or coverage for payment (including any cost-sharing) for such item or [service](/usc/42/201.md?p=a). For purposes of this subsection, the open negotiation period, with respect to an item or [service](/usc/42/201.md?p=a), is the 30-day period beginning on the date of initiation of the negotiations with respect to such item or [service](/usc/42/201.md?p=a).
    - (B) **Accessing independent dispute resolution process in case of failed negotiations—** In the case of open negotiations pursuant to [subparagraph (A)](#c-1-A), with respect to an item or [service](/usc/42/201.md?p=a), that do not result in a determination of an amount of payment for such item or [service](/usc/42/201.md?p=a) by the last day of the open negotiation period described in such subparagraph with respect to such item or [service](/usc/42/201.md?p=a), the [provider](/usc/42/299b–21.md?p=8) or facility (as applicable) or [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) that was party to such negotiations may, during the 4-day period beginning on the day after such open negotiation period, initiate the independent dispute resolution process under [paragraph (2)](#c-2) with respect to such item or [service](/usc/42/201.md?p=a). The independent dispute resolution process shall be initiated by a party pursuant to the previous sentence by submission to the other party and to the [Secretary](/usc/42/201.md?p=c) of a notification (containing such information as specified by the [Secretary](/usc/42/201.md?p=c)) and for purposes of this subsection, the date of initiation of such process shall be the date of such submission or such other date specified by the [Secretary](/usc/42/201.md?p=c) pursuant to [regulations](/usc/42/201.md?p=d) that is not later than the date of receipt of such notification by both the other party and the [Secretary](/usc/42/201.md?p=c).
  - (2) **Independent dispute resolution process available in case of failed open negotiations—**
    - (A) **Establishment—** Not later than 1 year after December 27, 2020, the [Secretary](/usc/42/201.md?p=c), jointly with the [Secretary](/usc/42/201.md?p=c) of Labor and the [Secretary](/usc/42/201.md?p=c) of the Treasury, shall establish by regulation one independent dispute resolution process (referred to in this subsection as the “IDR process”) under which, in the case of an item or [service](/usc/42/201.md?p=a) with respect to which a [provider](/usc/42/299b–21.md?p=8) or facility (as applicable) or [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) submits a notification under [paragraph (1)(B)](#c-1-B) (in this subsection referred to as a “qualified IDR item or [service](/usc/42/201.md?p=a)”), a certified IDR entity under [paragraph (4)](#c-4) determines, subject to [subparagraph (B)](#c-2-B) and in accordance with the succeeding provisions of this subsection, the amount of payment under the plan or coverage for such item or [service](/usc/42/201.md?p=a) furnished by such [provider](/usc/42/299b–21.md?p=8) or facility.
    - (B) **Authority to continue negotiations—** Under the independent dispute resolution process, in the case that the parties to a determination for a qualified IDR item or [service](/usc/42/201.md?p=a) agree on a payment amount for such item or [service](/usc/42/201.md?p=a) during such process but before the date on which the entity selected with respect to such determination under [paragraph (4)](#c-4) makes such determination under [paragraph (5)](#c-5), such amount shall be treated for purposes of [subsection (a)(3)(K)(ii)](#a-3-K-ii) as the amount agreed to by such parties for such item or [service](/usc/42/201.md?p=a). In the case of an agreement described in the previous sentence, the independent dispute resolution process shall provide for a method to determine how to allocate between the parties to such determination the payment of the compensation of the entity selected with respect to such determination.
    - (C) **Clarification—** A nonparticipating [provider](/usc/42/299b–21.md?p=8) may not, with respect to an item or [service](/usc/42/201.md?p=a) furnished by such [provider](/usc/42/299b–21.md?p=8), submit a notification under [paragraph (1)(B)](#c-1-B) if such [provider](/usc/42/299b–21.md?p=8) is exempt from the requirement under subsection (a) of [section 300gg–132 of this title](/usc/42/300gg–132.md) with respect to such item or [service](/usc/42/201.md?p=a) pursuant to [subsection (b)](/usc/42/300gg–132.md?p=b) of such section.
  - (3) **Treatment of batching of items and services—**
    - (A) **In general—** Under the IDR process, the [Secretary](/usc/42/201.md?p=c) shall specify criteria under which multiple qualified IDR dispute items and [services](/usc/42/201.md?p=a) are permitted to be considered jointly as part of a single determination by an entity for purposes of encouraging the efficiency (including minimizing costs) of the IDR process. Such items and [services](/usc/42/201.md?p=a) may be so considered only if—
      - (i) such items and [services](/usc/42/201.md?p=a) to be included in such determination are furnished by the same [provider](/usc/42/299b–21.md?p=8) or facility;
      - (ii) payment for such items and [services](/usc/42/201.md?p=a) is required to be made by the same [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2);
      - (iii) such items and [services](/usc/42/201.md?p=a) are related to the [treatment](/usc/42/11851.md?p=11) of a similar condition; and
      - (iv) such items and [services](/usc/42/201.md?p=a) were furnished during the 30 day[^4] period following the date on which the first item or [service](/usc/42/201.md?p=a) included with respect to such determination was furnished or an alternative period as determined by the [Secretary](/usc/42/201.md?p=c), for use in limited situations, such as by the consent of the parties or in the case of low-volume items and [services](/usc/42/201.md?p=a), to encourage procedural efficiency and minimize health plan and [provider](/usc/42/299b–21.md?p=8) administrative costs.
    - (B) **Treatment of bundled payments—** In carrying out [subparagraph (A)](#c-3-A), the [Secretary](/usc/42/201.md?p=c) shall provide that, in the case of items and [services](/usc/42/201.md?p=a) which are included by a [provider](/usc/42/299b–21.md?p=8) or facility as part of a bundled payment, such items and [services](/usc/42/201.md?p=a) included in such bundled payment may be part of a single determination under this subsection.
  - (4) **Certification and selection of IDR entities—**
    - (A) **In general—** The [Secretary](/usc/42/201.md?p=c), in consultation with the [Secretary](/usc/42/201.md?p=c) of Labor and [Secretary](/usc/42/201.md?p=c) of the Treasury, shall establish a process to certify (including to recertify) entities under this paragraph. Such process shall ensure that an entity so certified—
      - (i) has (directly or through contracts or other arrangements) sufficient medical, legal, and other expertise and sufficient staffing to make determinations described in [paragraph (5)](#c-5) on a timely basis;
      - (ii) is not—
        - (I) a [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5), [provider](/usc/42/299b–21.md?p=8), or facility;
        - (II) an affiliate or a subsidiary of such a [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2), [provider](/usc/42/299b–21.md?p=8), or facility; or
        - (III) an affiliate or subsidiary of a professional or trade association of such [group health plans](/usc/42/300bb–8.md?p=1) or [health insurance issuers](/usc/42/300gg–91.md?p=b-2) or of [providers](/usc/42/299b–21.md?p=8) or facilities;
      - (iii) carries out the responsibilities of such an entity in accordance with this subsection;
      - (iv) meets appropriate indicators of fiscal integrity;
      - (v) maintains the confidentiality (in accordance with [regulations](/usc/42/201.md?p=d) promulgated by the [Secretary](/usc/42/201.md?p=c)) of individually identifiable health information obtained in the course of conducting such determinations;
      - (vi) does not under the IDR process carry out any determination with respect to which the entity would not pursuant to subclause [(I)](#c-4-F-i-I), [(II)](#c-4-F-i-II), or [(III)](#c-4-F-i-III) of subparagraph (F)(i) be eligible for selection; and
      - (vii) meets such other requirements as determined appropriate by the [Secretary](/usc/42/201.md?p=c).
    - (B) **Period of certification—** Subject to [subparagraph (C)](#c-4-C), each certification (including a recertification) of an entity under the process described in [subparagraph (A)](#c-4-A) shall be for a 5-year period.
    - (C) **Revocation—** A certification of an entity under this paragraph may be revoked under the process described in [subparagraph (A)](#c-4-A) if the entity has a pattern or practice of noncompliance with any of the requirements described in such subparagraph.
    - (D) **Petition for denial or withdrawal—** The process described in [subparagraph (A)](#c-4-A) shall ensure that an individual, [provider](/usc/42/299b–21.md?p=8), facility, or [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) may petition for a denial of a certification or a revocation of a certification with respect to an entity under this paragraph for failure of meeting a requirement of this subsection.
    - (E) **Sufficient number of entities—** The process described in [subparagraph (A)](#c-4-A) shall ensure that a sufficient number of entities are certified under this paragraph to ensure the timely and efficient provision of determinations described in [paragraph (5)](#c-5).
    - (F) **Selection of certified IDR entity—** The [Secretary](/usc/42/201.md?p=c) shall, with respect to the determination of the amount of payment under this subsection of an item or [service](/usc/42/201.md?p=a), provide for a method—
      - (i) that allows for the [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) and the nonparticipating [provider](/usc/42/299b–21.md?p=8) or the nonparticipating emergency facility (as applicable) involved in a notification under [paragraph (1)(B)](#c-1-B) to jointly select, not later than the last day of the 3-business day period following the date of the initiation of the process with respect to such item or [service](/usc/42/201.md?p=a), for purposes of making such determination, an entity certified under this paragraph that—
        - (I) is not a party to such determination or an [employee](/usc/42/300gg–91.md?p=d-5) or agent of such a party;
        - (II) does not have a material familial, financial, or professional relationship with such a party; and
        - (III) does not otherwise have a conflict of interest with such a party (as determined by the [Secretary](/usc/42/201.md?p=c)); and
      - (ii) that requires, in the case such parties do not make such selection by such last day, the [Secretary](/usc/42/201.md?p=c) to, not later than 6 business days after such date of initiation—
        - (I) select such an entity that satisfies subclauses [(I)](#c-4-F-i-I) through [(III)](#c-4-F-i-III) of clause (i));[^2] and
        - (II) provide notification of such selection to the [provider](/usc/42/299b–21.md?p=8) or facility (as applicable) and the plan or issuer (as applicable) party to such determination.

  An entity selected pursuant to the previous sentence to make a determination described in such sentence shall be referred to in this subsection as the “certified IDR entity” with respect to such determination.

  - (5) **Payment determination—**
    - (A) **In general—** Not later than 30 days after the date of selection of the certified IDR entity with respect to a determination for a qualified IDR item or [service](/usc/42/201.md?p=a), the certified IDR entity shall—
      - (i) taking into account the considerations specified in [subparagraph (C)](#c-5-C), select one of the offers submitted under [subparagraph (B)](#c-5-B) to be the amount of payment for such item or [service](/usc/42/201.md?p=a) determined under this subsection for purposes of subsection [(a)(1)](#a-1) or [(b)(1)](#b-1), as applicable; and
      - (ii) notify the [provider](/usc/42/299b–21.md?p=8) or facility and the [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) party to such determination of the offer selected under [clause (i)](#c-5-A-i).
    - (B) **Submission of offers—** Not later than 10 days after the date of selection of the certified IDR entity with respect to a determination for a qualified IDR item or [service](/usc/42/201.md?p=a), the [provider](/usc/42/299b–21.md?p=8) or facility and the [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) party to such determination—
      - (i) shall each submit to the certified IDR entity with respect to such determination—
        - (I) an offer for a payment amount for such item or [service](/usc/42/201.md?p=a) furnished by such [provider](/usc/42/299b–21.md?p=8) or facility; and
        - (II) such information as requested by the certified IDR entity relating to such offer; and
      - (ii) may each submit to the certified IDR entity with respect to such determination any information relating to such offer submitted by either party, including information relating to any circumstance described in [subparagraph (C)(ii)](#c-5-C-ii).
    - (C) **Considerations in determination—**
      - (i) **In general—** In determining which offer is the payment to be applied pursuant to this paragraph, the certified IDR entity, with respect to the determination for a qualified IDR item or [service](/usc/42/201.md?p=a) shall consider—
        - (I) the qualifying payment amounts (as defined in [subsection (a)(3)(E)](#a-3-E)) for the applicable year for items or [services](/usc/42/201.md?p=a) that are comparable to the qualified IDR item or [service](/usc/42/201.md?p=a) and that are furnished in the same geographic region (as defined by the [Secretary](/usc/42/201.md?p=c) for purposes of such subsection) as such qualified IDR item or [service](/usc/42/201.md?p=a); and
        - (II) subject to [subparagraph (D)](#c-5-D), information on any circumstance described in [clause (ii)](#c-5-C-ii), such information as requested in [subparagraph (B)(i)(II)](#c-5-B-i-II), and any additional information provided in [subparagraph (B)(ii)](#c-5-B-ii).
      - (ii) **Additional circumstances—** For purposes of [clause (i)(II)](#c-5-C-i-II), the circumstances described in this clause are, with respect to a qualified IDR item or [service](/usc/42/201.md?p=a) of a nonparticipating [provider](/usc/42/299b–21.md?p=8), nonparticipating emergency facility, [group health plan](/usc/42/300bb–8.md?p=1), or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) of group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) the following:
        - (I) The level of training, experience, and quality and outcomes measurements of the [provider](/usc/42/299b–21.md?p=8) or facility that furnished such item or [service](/usc/42/201.md?p=a) (such as those endorsed by the consensus-based entity authorized in section 1890 of the Social Security Act [[42 U.S.C. 1395aaa](/usc/42/1395aaa.md)]).
        - (II) The market share held by the nonparticipating [provider](/usc/42/299b–21.md?p=8) or facility or that of the plan or issuer in the geographic region in which the item or [service](/usc/42/201.md?p=a) was provided.
        - (III) The acuity of the individual receiving such item or [service](/usc/42/201.md?p=a) or the complexity of furnishing such item or [service](/usc/42/201.md?p=a) to such individual.
        - (IV) The teaching status, case mix, and scope of [services](/usc/42/201.md?p=a) of the nonparticipating facility that furnished such item or [service](/usc/42/201.md?p=a).
        - (V) Demonstrations of good faith efforts (or lack of good faith efforts) made by the nonparticipating [provider](/usc/42/299b–21.md?p=8) or nonparticipating facility or the plan or issuer to enter into network agreements and, if applicable, contracted rates between the [provider](/usc/42/299b–21.md?p=8) or facility, as applicable, and the plan or issuer, as applicable, during the previous 4 plan years.
    - (D) **Prohibition on consideration of certain factors—** In determining which offer is the payment to be applied with respect to qualified IDR items and [services](/usc/42/201.md?p=a) furnished by a [provider](/usc/42/299b–21.md?p=8) or facility, the certified IDR entity with respect to a determination shall not consider usual and customary charges, the amount that would have been billed by such [provider](/usc/42/299b–21.md?p=8) or facility with respect to such items and [services](/usc/42/201.md?p=a) had the provisions of section [300gg–131](/usc/42/300gg–131.md) or [300gg–132](/usc/42/300gg–132.md) of this title (as applicable) not applied, or the payment or reimbursement rate for such items and [services](/usc/42/201.md?p=a) furnished by such [provider](/usc/42/299b–21.md?p=8) or facility payable by a public payor, including under the Medicare [program](/usc/42/274l–1.md?p=4) under title XVIII of the Social Security Act [[42 U.S.C. 1395](/usc/42/1395.md) et seq.], under the Medicaid [program](/usc/42/274l–1.md?p=4) under title XIX of such Act [[42 U.S.C. 1396](/usc/42/1396.md) et seq.], under the Children’s Health Insurance [Program](/usc/42/274l–1.md?p=4) under title XXI of such Act [[42 U.S.C. 1397aa](/usc/42/1397aa.md) et seq.], under the TRICARE [program](/usc/42/274l–1.md?p=4) under [chapter 55](/usc/10/chstA-ptII-ch55.md) of title 10, or under chapter 17 of title 38.
    - (E) **Effects of determination—**
      - (i) **In general—** A determination of a certified IDR entity under [subparagraph (A)](#c-5-A)—
        - (I) shall be binding upon the parties involved, in the absence of a fraudulent claim or evidence of misrepresentation of facts presented to the IDR entity involved regarding such claim; and
        - (II) shall not be subject to judicial review, except in a case described in any of paragraphs (1) through (4) of [section 10(a) of title 9](/usc/9/10.md?p=a).
      - (ii) **Suspension of certain subsequent IDR requests—** In the case of a determination of a certified IDR entity under [subparagraph (A)](#c-5-A), with respect to an initial notification submitted under [paragraph (1)(B)](#c-1-B) with respect to qualified IDR items and [services](/usc/42/201.md?p=a) and the two parties involved with such notification, the party that submitted such notification may not submit during the 90-day period following such determination a subsequent notification under such paragraph involving the same other party to such notification with respect to such an item or [service](/usc/42/201.md?p=a) that was the subject of such initial notification.
      - (iii) **Subsequent submission of requests permitted—** In the case of a notification that pursuant to [clause (ii)](#c-5-E-ii) is not permitted to be submitted under [paragraph (1)(B)](#c-1-B) during a 90-day period specified in such clause, if the end of the open negotiation period specified in [paragraph (1)(A)](#c-1-A), that but for this clause would otherwise apply with respect to such notification, occurs during such 90-day period, such [paragraph (1)(B)](#c-1-B) shall be applied as if the reference in such paragraph to the 4-day period beginning on the day after such open negotiation period were instead a reference to the 30-day period beginning on the day after the last day of such 90-day period.
      - (iv) **Reports—** The [Secretary](/usc/42/201.md?p=c), jointly with the [Secretary](/usc/42/201.md?p=c) of Labor and the [Secretary](/usc/42/201.md?p=c) of the Treasury, shall examine the impact of the application of [clause (ii)](#c-5-E-ii) and whether the application of such clause delays payment determinations or impacts early, alternative resolution of claims (such as through open negotiations), and shall submit to Congress, not later than 2 years after the date of implementation of such clause an interim report (and not later than 4 years after such date of implementation, a final report) on whether any [group health plans](/usc/42/300bb–8.md?p=1) or [health insurance issuers](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) or types of such plans or coverage have a pattern or practice of routine denial, low payment, or down-coding of claims, or otherwise abuse the 90-day period described in such clause, including recommendations on ways to discourage such a pattern or practice.
    - (F) **Costs of independent dispute resolution process—** In the case of a notification under [paragraph (1)(B)](#c-1-B) submitted by a nonparticipating [provider](/usc/42/299b–21.md?p=8), nonparticipating emergency facility, [group health plan](/usc/42/300bb–8.md?p=1), or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) and submitted to a certified IDR entity—
      - (i) if such entity makes a determination with respect to such notification under [subparagraph (A)](#c-5-A), the party whose offer is not chosen under such subparagraph shall be responsible for paying all fees charged by such entity; and
      - (ii) if the parties reach a settlement with respect to such notification prior to such a determination, each party shall pay half of all fees charged by such entity, unless the parties otherwise agree.
  - (6) **Timing of payment—** The total plan or coverage payment required pursuant to subsection [(a)(1)](#a-1) or [(b)(1)](#b-1), with respect to a qualified IDR item or [service](/usc/42/201.md?p=a) for which a determination is made under [paragraph (5)(A)](#c-5-A) or with respect to an item or [service](/usc/42/201.md?p=a) for which a payment amount is determined under open negotiations under [paragraph (1)](#c-1), shall be made directly to the nonparticipating [provider](/usc/42/299b–21.md?p=8) or facility not later than 30 days after the date on which such determination is made.
  - (7) **Publication of information relating to the IDR process—**
    - (A) **Publication of information—** For each calendar quarter in 2022 and each calendar quarter in a subsequent year, the [Secretary](/usc/42/201.md?p=c) shall make available on the public website of the Department of Health and Human [Services](/usc/42/201.md?p=a)—
      - (i) the number of notifications submitted under [paragraph (1)(B)](#c-1-B) during such calendar quarter;
      - (ii) the size of the [provider](/usc/42/299b–21.md?p=8) [practices](/usc/42/17061.md?p=19) and the size of the facilities submitting notifications under [paragraph (1)(B)](#c-1-B) during such calendar quarter;
      - (iii) the number of such notifications with respect to which a determination was made under [paragraph (5)(A)](#c-5-A);
      - (iv) the information described in [subparagraph (B)](#c-7-B) with respect to each notification with respect to which such a determination was so made;
      - (v) the number of times the payment amount determined (or agreed to) under this subsection exceeds the qualifying payment amount, specified by items and [services](/usc/42/201.md?p=a);
      - (vi) the amount of expenditures made by the [Secretary](/usc/42/201.md?p=c) during such calendar quarter to carry out the IDR process;
      - (vii) the total amount of fees paid under [paragraph (8)](#c-8) during such calendar quarter; and
      - (viii) the total amount of compensation paid to certified IDR entities under [paragraph (5)(F)](#c-5-F) during such calendar quarter.
    - (B) **Information—** For purposes of [subparagraph (A)](#c-7-A), the information described in this subparagraph is, with respect to a notification under [paragraph (1)(B)](#c-1-B) by a nonparticipating [provider](/usc/42/299b–21.md?p=8), nonparticipating emergency facility, [group health plan](/usc/42/300bb–8.md?p=1), or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5)—
      - (i) a description of each item and [service](/usc/42/201.md?p=a) included with respect to such notification;
      - (ii) the geography in which the items and [services](/usc/42/201.md?p=a) with respect to such notification were provided;
      - (iii) the amount of the offer submitted under [paragraph (5)(B)](#c-5-B) by the [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) (as applicable) and by the nonparticipating [provider](/usc/42/299b–21.md?p=8) or nonparticipating emergency facility (as applicable) expressed as a percentage of the qualifying payment amount;
      - (iv) whether the offer selected by the certified IDR entity under [paragraph (5)](#c-5) to be the payment applied was the offer submitted by such plan or issuer (as applicable) or by such [provider](/usc/42/299b–21.md?p=8) or facility (as applicable) and the amount of such offer so selected expressed as a percentage of the qualifying payment amount;
      - (v) the category and practice specialty of each such [provider](/usc/42/299b–21.md?p=8) or facility involved in furnishing such items and [services](/usc/42/201.md?p=a);
      - (vi) the identity of the health plan or [health insurance issuer](/usc/42/300gg–91.md?p=b-2), [provider](/usc/42/299b–21.md?p=8), or facility, with respect to the notification;
      - (vii) the length of time in making each determination;
      - (viii) the compensation paid to the certified IDR entity with respect to the settlement or determination; and
      - (ix) any other information specified by the [Secretary](/usc/42/201.md?p=c).
    - (C) **IDR entity requirements—** For 2022 and each subsequent year, an IDR entity, as a condition of certification as an IDR entity, shall submit to the [Secretary](/usc/42/201.md?p=c) such information as the [Secretary](/usc/42/201.md?p=c) determines necessary to carry out the provisions of this subsection.
    - (D) **Clarification—** The [Secretary](/usc/42/201.md?p=c) shall ensure the public reporting under this paragraph does not contain information that would disclose privileged or confidential information of a [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) or of a [provider](/usc/42/299b–21.md?p=8) or facility.
  - (8) **Administrative fee—**
    - (A) **In general—** Each party to a determination under [paragraph (5)](#c-5) to which an entity is selected under [paragraph (3)](#c-3)[^5] in a year shall pay to the [Secretary](/usc/42/201.md?p=c), at such time and in such manner as specified by the [Secretary](/usc/42/201.md?p=c), a fee for participating in the IDR process with respect to such determination in an amount described in [subparagraph (B)](#c-8-B) for such year.
    - (B) **Amount of fee—** The amount described in this subparagraph for a year is an amount established by the [Secretary](/usc/42/201.md?p=c) in a manner such that the total amount of fees paid under this paragraph for such year is estimated to be equal to the amount of expenditures estimated to be made by the [Secretary](/usc/42/201.md?p=c) for such year in carrying out the IDR process.
  - (9) **Waiver authority—** The [Secretary](/usc/42/201.md?p=c) may modify any deadline or other timing requirement specified under this subsection (other than the establishment date for the IDR process under [paragraph (2)(A)](#c-2-A) and other than under [paragraph (6)](#c-6)) in cases of extenuating circumstances, as specified by the [Secretary](/usc/42/201.md?p=c), or to ensure that all claims that occur during a 90-day period described in [paragraph (5)(E)(ii)](#c-5-E-ii), but with respect to which a notification is not permitted by reason of such paragraph to be submitted under [paragraph (1)(B)](#c-1-B) during such period, are eligible for the IDR process.
- (d) **Certain access fees to certain databases—** In the case of a sponsor of a [group health plan](/usc/42/300bb–8.md?p=1) or [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) that, pursuant to [subsection (a)(3)(E)(iii)](#a-3-E-iii), uses a database described in such subsection to determine a rate to apply under such subsection for an item or [service](/usc/42/201.md?p=a) by reason of having insufficient information described in such subsection with respect to such item or [service](/usc/42/201.md?p=a), such sponsor or issuer shall cover the cost for access to such database.
- (e) **Transparency regarding in-network and out-of-network deductibles and out-of-pocket limitations—** A [group health plan](/usc/42/300bb–8.md?p=1) or a [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) and providing or covering any benefit with respect to items or [services](/usc/42/201.md?p=a) shall include, in clear writing, on any physical or electronic plan or insurance identification card issued to the [participants](/usc/42/300gg–91.md?p=d-11), [beneficiaries](/usc/42/300gg–91.md?p=d-2), or enrollees in the plan or coverage the following:
  - (1) Any deductible applicable to such plan or coverage.
  - (2) Any out-of-pocket maximum limitation applicable to such plan or coverage.
  - (3) A telephone number and Internet website address through which such individual may seek consumer assistance information, such as information related to [hospitals](/usc/42/300s–3.md?p=1) and urgent care facilities that have in effect a contractual relationship with such plan or coverage for furnishing items and [services](/usc/42/201.md?p=a) under such plan or coverage[^6]
- (f) **Advanced explanation of benefits—**
  - (1) **In general—** For plan years beginning on or after January 1, 2022, each [group health plan](/usc/42/300bb–8.md?p=1), or a [health insurance issuer](/usc/42/300gg–91.md?p=b-2) offering group or [individual health insurance coverage](/usc/42/300gg–91.md?p=b-5) shall, with respect to a notification submitted under [section 300gg–136 of this title](/usc/42/300gg–136.md) by a [health care provider](/usc/42/300aa–33.md?p=1) or health care facility to the plan or issuer for a [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee under plan or coverage scheduled to receive an item or [service](/usc/42/201.md?p=a) from the [provider](/usc/42/299b–21.md?p=8) or facility (or authorized representative of such [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee), not later than 1 business day (or, in the case such item or [service](/usc/42/201.md?p=a) was so scheduled at least 10 business days before such item or [service](/usc/42/201.md?p=a) is to be furnished (or in the case of a request made to such plan or coverage by such [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee), 3 business days) after the date on which the plan or coverage receives such notification (or such request), provide to the [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee (through mail or electronic means, as requested by the [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee) a notification (in clear and understandable language) including the following:
    - (A) Whether or not the [provider](/usc/42/299b–21.md?p=8) or facility is a participating [provider](/usc/42/299b–21.md?p=8) or a participating facility with respect to the plan or coverage with respect to the furnishing of such item or [service](/usc/42/201.md?p=a) and—
      - (i) in the case the [provider](/usc/42/299b–21.md?p=8) or facility is a participating [provider](/usc/42/299b–21.md?p=8) or facility with respect to the plan or coverage with respect to the furnishing of such item or [service](/usc/42/201.md?p=a), the contracted rate under such plan or coverage for such item or [service](/usc/42/201.md?p=a) (based on the billing and diagnostic codes provided by such [provider](/usc/42/299b–21.md?p=8) or facility); and
      - (ii) in the case the [provider](/usc/42/299b–21.md?p=8) or facility is a nonparticipating [provider](/usc/42/299b–21.md?p=8) or facility with respect to such plan or coverage, a description of how such individual may obtain information on [providers](/usc/42/299b–21.md?p=8) and facilities that, with respect to such plan or coverage, are participating [providers](/usc/42/299b–21.md?p=8) and facilities, if any.
    - (B) The good faith estimate included in the notification received from the [provider](/usc/42/299b–21.md?p=8) or facility (if applicable) based on such codes.
    - (C) A good faith estimate of the amount the plan or coverage is responsible for paying for items and [services](/usc/42/201.md?p=a) included in the estimate described in [subparagraph (B)](#f-1-B).
    - (D) A good faith estimate of the amount of any cost-sharing for which the [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee would be responsible for such item or [service](/usc/42/201.md?p=a) (as of the date of such notification).
    - (E) A good faith estimate of the amount that the [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee has incurred toward meeting the limit of the financial responsibility (including with respect to deductibles and out-of-pocket maximums) under the plan or coverage (as of the date of such notification).
    - (F) In the case such item or [service](/usc/42/201.md?p=a) is subject to a medical management technique (including concurrent review, prior authorization, and step-therapy or fail-first protocols) for coverage under the plan or coverage, a disclaimer that coverage for such item or [service](/usc/42/201.md?p=a) is subject to such medical management technique.
    - (G) A disclaimer that the information provided in the notification is only an estimate based on the items and [services](/usc/42/201.md?p=a) reasonably expected, at the time of scheduling (or requesting) the item or [service](/usc/42/201.md?p=a), to be furnished and is subject to change.
    - (H) Any other information or disclaimer the plan or coverage determines appropriate that is consistent with information and disclaimers required under this section.
  - (2) **Authority to modify timing requirements in the case of specified items and services—**
    - (A) **In general—** In the case of a [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee scheduled to receive an item or [service](/usc/42/201.md?p=a) that is a specified item or [service](/usc/42/201.md?p=a) (as defined in [subparagraph (B)](#f-2-B)), the [Secretary](/usc/42/201.md?p=c) may modify any timing requirements relating to the provision of the notification described in [paragraph (1)](#f-1) to such [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee with respect to such item or [service](/usc/42/201.md?p=a). Any modification made by the [Secretary](/usc/42/201.md?p=c) pursuant to the previous sentence may not result in the provision of such notification after such [participant](/usc/42/300gg–91.md?p=d-11), [beneficiary](/usc/42/300gg–91.md?p=d-2), or enrollee has been furnished such item or [service](/usc/42/201.md?p=a).
    - (B) **Specified item or service defined—** For purposes of [subparagraph (A)](#f-2-A), the term “specified item or [service](/usc/42/201.md?p=a)” means an item or [service](/usc/42/201.md?p=a) that has low utilization or significant variation in costs (such as when furnished as part of a complex [treatment](/usc/42/11851.md?p=11)), as specified by the [Secretary](/usc/42/201.md?p=c).

## Footnotes

[^1]: See References in Text note below.
[^2]: Closing parentheses so in original.
[^3]: So in original. Probably should be “given”.
[^4]: So in original. Probably should be “30-day”.
[^5]: So in original. Probably should be “paragraph (4)”.
[^6]: So in original. Probably should be followed by a period.

## Source credit

(July 1, 1944, ch. 373, title XXVII, § 2799A–1, as added and amended Pub. L. 116–260, div. BB, title I, §§ 102(a)(1), 103(a), 107(a), 111(a), Dec. 27, 2020, 134 Stat. 2759, 2797, 2858, 2861.)

## Notes

### Editorial Notes

### References in Text

Section 109(a) of the No Surprises Act, referred to in subsec. (a)(2)(B), is section 109(a) of Pub. L. 116–260, div. BB, title I, Dec. 27, 2020, 134 Stat. 2859, which is not classified to the Code.

The phrase “in 2019”, referred to in subsec. (a)(3)(E)(iii)(III), does not appear in cl. (i)(I) of subsec. (a)(3)(E). However, subsec. (a)(3)(E)(iii)(III) of section 9816 of Title 26, Internal Revenue Code, which contains text similar to that in this subclause, refers to the phrase “on January 31, 2019”, which does appear in cl. (i)(I).

The Social Security Act, referred to in subsec. (c)(5)(D), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Titles XVIII, XIX, and XXI of the Act are classified generally to subchapters XVIII (§ 1395 et seq.), XIX (§ 1396 et seq.), and XXI (§ 1397aa et seq.), respectively, of chapter 7 of this title. For complete classification of this Act to the Code, see section 1305 of this title and Tables.

### Amendments

2020—Subsecs. (c), (d). Pub. L. 116–260, § 103(a), added subsec. (c) and redesignated former subsec. (c) as (d).

Subsec. (e). Pub. L. 116–260, § 107(a), added subsec. (e).

Subsec. (f). Pub. L. 116–260, § 111(a), added subsec. (f).

### Statutory Notes and Related Subsidiaries

### Effective Date of 2020 Amendment

Amendment by section 107(a) of div. BB of Pub. L. 116–260 applicable with respect to plan years beginning on or after Jan. 1, 2022, see section 107(d) of div. BB of Pub. L. 116–260, set out as a note under section 9816 of Title 26, Internal Revenue Code.

### Effective Date

Section applicable with respect to plan years beginning on or after Jan. 1, 2022, see section 102(e) of div. BB of Pub. L. 116–260, set out as an Effective Date of 2020 Amendment note under section 8902 of Title 5, Government Organization and Employees.