‘‘(B) OBSTETRICAL AND GYNECOLOGICAL 
CARE.—A health plan described in paragraph 
(2) shall treat the provision of obstetrical and 
gynecological care, and the ordering of related 
obstetrical and gynecological items and services, 
pursuant to the direct access described under 
subparagraph (A), by a participating health 
care professional who specializes in obstetrics or 
gynecology as the authorization of the primary 
care provider. 
‘‘(2) APPLICATION OF PARAGRAPH.—A health 
plan described in this paragraph is a health plan 
that— 
‘‘(A) provides coverage for obstetric or 
gynecologic care; and 
‘‘(B) requires the designation by a partici-
pant or beneficiary of a participating primary 
care provider. 
‘‘(3) CONSTRUCTION.—Nothing in paragraph 
(1) shall be construed to— 
‘‘(A) waive any exclusions of coverage 
under the terms and conditions of the plan with 
respect to coverage of obstetrical or gyneco-
logical care; or 
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‘‘(B) preclude the health plan involved 
from requiring that the obstetrical or gyneco-
logical provider notify the primary care health 
care professional or the plan of treatment deci-
sions. 
‘‘(k) DEFINITIONS.—For purposes of this section: 
‘‘(1) CONTRACTED
RATE.—The term ‘con-
tracted rate’ means, with respect to a health plan 
and a health care provider or health care facility fur-
nishing an item or service to a beneficiary or partici-
pant of such plan, the agreed upon total payment 
amount (inclusive of any cost-sharing) to such pro-
vider or facility for such item or service. 
‘‘(2) DURING
A
VISIT.—The term ‘during a 
visit’ shall, with respect to an individual who is fur-
nished items and services at a participating facility, 
include equipment and devices, telemedicine services, 
imaging services, laboratory services, preoperative 
and postoperative services, and such other items and 
services as the Secretary may specify furnished to 
such individual, regardless of whether or not the 
provider furnishing such items or services is at the 
facility. 
‘‘(3) EMERGENCY
DEPARTMENT
OF
A
HOS-
PITAL.—The term ‘emergency department of a hos-
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pital’ includes a hospital outpatient department that 
provides emergency services. 
‘‘(4) 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), (ii), or 
(iii) of section 1867(e)(1)(A) of the Social Security 
Act. 
‘‘(5) EMERGENCY SERVICES.— 
‘‘(A) IN GENERAL.—The term ‘emergency 
services’, with respect to an emergency medical 
condition, means— 
‘‘(i) a medical screening examination 
(as required under section 1867 of the So-
cial Security Act, 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 or 
of an independent freestanding emergency 
department, as applicable, including ancil-
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lary services 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 
or the independent freestanding emergency 
department, as applicable, such further 
medical examination and treatment as are 
required under section 1867 of such Act, 
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 de-
partment of the hospital in which such fur-
ther examination or treatment is fur-
nished). 
‘‘(B) INCLUSION
OF
ADDITIONAL
SERV-
ICES.—In the case of an individual enrolled in 
a health plan who is furnished services de-
scribed in subparagraph (A) by a provider or 
hospital or independent freestanding emergency 
department to stabilize such individual with re-
spect to an emergency medical condition, the 
term ‘emergency services’ shall include, in addi-
tion to those described in subparagraph (A), 
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items and services furnished as part of out-
patient observation or an inpatient or out-
patient stay during a visit in which such indi-
vidual is so stabilized with respect to such 
emergency condition if— 
‘‘(i) such items and services would 
otherwise be covered under such plan if 
furnished by a participating provider or 
participating facility; and 
‘‘(ii) such items and services are fur-
nished— 
‘‘(I) to maintain, improve, or re-
solve the individual’s stabilization with 
respect to such condition, unless any 
circumstance described in subpara-
graph (C) has occurred with respect 
to such individual before such items 
and services are furnished; or 
‘‘(II) for any purpose not de-
scribed in subclause (I), unless each 
of the criteria described in subpara-
graph (D) have been met with respect 
to such individual and such item or 
service. 
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‘‘(C) CIRCUMSTANCES.—For purposes of 
subparagraph (B)(ii)(I), a circumstance de-
scribed in this subparagraph is any of the fol-
lowing, with respect to an individual who is a 
beneficiary, participant, or enrollee of a health 
plan who is furnished services described in sub-
paragraph (A) by a hospital or independent 
freestanding emergency department with re-
spect to an emergency medical condition: 
‘‘(i) A participating provider, with re-
spect to such plan, with privileges at the 
hospital or independent freestanding emer-
gency department assumes responsibility 
for the care of the individual. 
‘‘(ii) A participating provider, with re-
spect to such plan, assumes responsibility 
for the care of the individual through 
transfer of the individual. 
‘‘(iii) The health plan and the pro-
vider treating such individual at the hos-
pital or independent freestanding emer-
gency department for such condition reach 
an agreement concerning the care for the 
individual. 
‘‘(iv) The individual is discharged. 
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‘‘(D) SIGNED NOTICE CRITERIA.—For pur-
poses of subparagraph (B)(ii)(II), the criteria 
described in this subparagraph, with respect to 
an individual and an item or service furnished 
by a nonparticipating provider or nonpartici-
pating facility that is a hospital or an inde-
pendent freestanding emergency department, 
are the following: 
‘‘(i) A written notice (as specified by 
the Secretary and in a clear and under-
standable manner) is provided by such pro-
vider or facility to such individual, before 
such item or service is furnished, that in-
cludes the following information: 
‘‘(I) That such provider or facil-
ity is a nonparticipating provider or 
nonparticipating facility (as applica-
ble). 
‘‘(II) To the extent practicable, 
the estimated amount that such non-
participating facility or nonpartici-
pating provider may charge the indi-
vidual for such item or service. 
‘‘(III) A statement that the indi-
vidual may seek such item or service 
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from a provider that is a participating 
provider or a hospital or independent 
freestanding emergency department 
that is a participating facility and a 
list, if feasible, of participating facili-
ties or participating providers, as ap-
plicable, who are able to furnish such 
item or service. 
‘‘(ii) Such individual is in a condition 
to receive (as determined in accordance 
with guidance issued by the Secretary) the 
information described in clause (i) and to 
confirm notice of receipt of such notice, in 
accordance with applicable State law. 
‘‘(iii) The individual signs and dates 
such notice confirming receipt of the notice 
before such item or service is furnished. 
‘‘(6) HEALTH PLAN.—The term ‘health plan’ 
means a group health plan, including any group 
health plan that is a grandfathered health plan (as 
defined in section 1251(e) of the Patient Protection 
and Affordable Care Act). 
‘‘(7) INDEPENDENT
FREESTANDING
EMER-
GENCY DEPARTMENT.—The term ‘independent free-
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standing emergency department’ means a health 
care facility that— 
‘‘(A) is geographically separate and dis-
tinct and licensed separately from a hospital 
under applicable State law; and 
‘‘(B) provides emergency services. 
‘‘(8) MEDIAN CONTRACTED RATE.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the term ‘median contracted rate’ 
means, with respect to a health plan— 
‘‘(i) for an item or service furnished 
during 2022, the median of the contracted 
rates recognized by the sponsor of such 
plan (determined with respect to all such 
plans of such sponsor that are within the 
same line of business (as specified in sub-
paragraph (C)) as the plan involved) as the 
total maximum payment under such plans 
in 2019 for the same or a similar item or 
service that is provided by a provider or fa-
cility in the same or similar specialty and 
provided in the geographic region (estab-
lished (and updated, as appropriate) by the 
Secretary, in consultation with the Na-
tional Association of Insurance Commis-
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sioners) in which the item or service is fur-
nished, consistent with the methodology es-
tablished by the Secretary under sub-
section (b)(2)(B), increased by the percent-
age increase in the consumer price index 
for all urban consumers (United States 
city average) over 2019, 2020, and 2021; 
‘‘(ii) for an item or service furnished 
during 2023 or a subsequent year through 
2026, the median contracted rate for the 
previous year, increased by the percentage 
increase in the consumer price index for all 
urban consumers (United States city aver-
age) over such previous year; 
‘‘(iii) for an item or service furnished 
during a rebasing year (as defined in sub-
paragraph (D)), the median of the con-
tracted rates recognized by the sponsor of 
such plan (determined with respect to all 
such plans of such sponsor that are within 
the same line of business (as specified in 
subparagraph (C)) as the plan involved) as 
the total maximum payment under such 
plans in such year for the same or a simi-
lar item or service that is provided by a 
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provider or facility in the same or similar 
specialty and provided in the geographic 
region (as established pursuant to clause 
(i)) in which the item or service is fur-
nished, consistent with the methodology es-
tablished by the Secretary under sub-
section (b)(2)(B); and 
‘‘(iv) for an item or service furnished 
during any of the 4 years following a re-
basing year, the median contracted rate for 
the previous year, increased by the per-
centage increase in the consumer price 
index for all urban consumers (United 
States city average) over such previous 
year. 
‘‘(B) USE OF SUBSTITUTE RATE IN CASE 
OF INSUFFICIENT DATA.— 
‘‘(i) IN
GENERAL.—In the case the 
sponsor of a health plan has insufficient 
information (as specified by the Secretary) 
to calculate the median of the contracted 
rates in accordance with subparagraph (A) 
for a year for an item or service furnished 
in a particular geographic region (as estab-
lished pursuant to subparagraph (A)(i)) by 
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a type of provider or facility, the substitute 
rate (as defined in clause (ii)) for such 
item or service shall be deemed to be the 
median contracted rate for such item or 
service furnished in such region during 
such year by such a provider or facility for 
such year under such subparagraph (A) for 
such plan. 
‘‘(ii) SUBSTITUTE
RATE.—For pur-
poses of clause (i), the term ‘substitute 
rate’ means, with respect to an item or 
service furnished by a provider or facility 
in a geographic region (established pursu-
ant to subparagraph (A)(i)) during a year 
for which a health plan is required to make 
payment pursuant to subsection (b)(1), 
(e)(1), or (i)(1)— 
‘‘(I) if sufficient information (as 
specified by the Secretary) exists to 
determine the median of the con-
tracted rates recognized by all health 
plans offered in the same line of busi-
ness (as specified in subparagraph 
(C)) by any group health plan for 
such an item or service furnished in 
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such region by such a provider or fa-
cility during such year using a data-
base or other source of information 
determined appropriate by the Sec-
retary, such median; and 
‘‘(II) if such sufficient informa-
tion does not exist, the median of the 
contracted rates recognized by all 
health plans offered in the same line 
of business (as specified in subpara-
graph (C)) by any group health plan 
for such an item or service furnished 
in a similarly situated geographic re-
gion (as determined by the Secretary) 
with such sufficient information by 
such a provider or facility during such 
year using such a database or such 
other source of information. 
The Secretary shall develop a methodology 
for determining a substitute rate based on 
a similarly situated health plan that is not 
a Federal health care program (as defined 
in section 1128B(f) of the Social Security 
Act) in the case a substitute rate is not 
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