Employers as plan sponsors have several Consolidated Appropriations Act (CAA) and other health plan transparency provisions to ensure are being handled on their behalf.  In FAQ Part 49, regulators had officially identify which provisions are delayed.  The time has come where virtually all of the requirements are applicable except for advance good faith estimates and corresponding advance EOBs.  The table below is intended to help stay organized on which requirements need written confirmation now from the insurer/TPA/PBM that all obligations are being handled.

 

Requirement Statutory Date Extension

No Surprise Billing: Group health plans (and their insurers) and providers of out-of-network emergency room, out-of-network air ambulance, and out-of-network services as part of care at an in-network facility must:

  • Treat the member as obtaining in-network care and charge normal in-network cost-sharing, with no balance billing to the member;
  • Follow federal guidelines for developing a qualifying payment amount (QPA) with timely payment to the out-of-network provider;
  • Negotiate QPA disputes for 30 days between plan and provider;
  • Timely file a request for independent dispute resolution (IDR) and pay applicable fees if agreement cannot be reached on a qualifying claim;
  • Timely provide the IDR arbitrator a best and final offer with all supporting documentation;
  • Abide by all terms of the final binding arbitration decision; and
  • Provide required notices for all the above.
1/1/22

 

No extension.  See the rules here:

Dec 2023 IDR Fees Rule

Gag Clause Prohibition and Compliance Attestation: Medical plans must not have provider or service contracts with gag clauses prohibiting the sharing of certain information with the plan sponsor or their designated business associates, and must certify compliance via annual attestation 12/27/20

(the date the CAA was enacted was the date health plans could no longer enter into contracts with prohibited gag clauses)

No extension.

  • Use reasonable good faith measures to ensure the plan does not enter into contracts with prohibited gag clauses.  We are hopeful to get guidance on what to do when agreements do contain prohibited gag clauses and/or insurer/TPA/PBM will not confirm.
  • First attestation due by 12/31/23

Subsequent attestations due annually by 12/31

Machine Readable Files on Plan’s Public Website: Non-grandfathered employer health plans must provide three machine readable files updated monthly on their public website disclosing:

  • INN: In-network provider negotiated rates for all services (including complicated percentage of billed charges amounts),
  • OON: Historical out-of-network billed and allowed charges (must have at least 20 entries in order to maintain patient privacy), and
  • Rx: Negotiated rates and historical net prices for all prescription drugs (with pharmacy location detail).
Plan year beginning on/after 1/1/22

INN and OON:

  • Plan years beginning 1/1/22 through 6/30/22 must comply as of 7/1/22
  • No delay for plan years beginning on/after 7/1/22

Rx: FAQs Part 61 removed an indefinite extension as of 11/3/23, must start verifying the carrier/TPA/PBM are in compliance once implementation guidance is issued.

Price Comparison Tool: Medical plans must maintain a price comparison tool via phone and web and provide a paper copy upon request Plan year beginning on/after 1/1/22 Extended to plan year beginning on/after 1/1/23

Accurate Provider Directories: Medical plans must maintain accurate provider directories on their website which are updated within two business days of a provider/facility change and are verified every 90 days, and maintain records for two years after each request for network information to prove they responded to each and every phone/mail/email/web request within one business day.

  • If a member relies on provider participation data from the means discussed above that turned out to be inaccurate, the plan will likely have to honor the claim as in-network
  • Print directories should indicate it’s accurate as of the date of publication along with instructions on how to retrieve/request the most current information
Plan year beginning on/after 1/1/22

No extension. Use reasonable good faith measures to comply.

Continuity of Care: When a plan terminates a contract with a provider or a provider leaves a network, they must communicate with patients under continuing care for terminal conditions or serious, complex medical conditions about the change in network status and an option to continue care for up to 90 days as if the provider had remained in-network. Plan year beginning on/after 1/1/22 No extension.  Use reasonable good faith measures to comply. Any additional stipulations resulting from future rulemaking will specify a future applicability date.
ID Cards: Medical plans must clearly disclose on physical and electronic ID cards the in- and out-of-network deductible and out-of-pocket requirements along with the phone and website for consumer assistance determining network provider participation Plan year beginning on/after 1/1/22

No extension. Use reasonable good faith measures to comply.

Online Self-Service Tool for 500 Shoppable Services: Non-grandfathered plans must provide an online self-service tool enabling members to evaluate:

  • The negotiated in-network price and maximum out-of-network plan payment allowed for 500 shoppable services,
  • A real-time estimate of their total out-of-pocket costs (accounting for deductibles and OOP already met to date) before actually getting those medical services,
  • Pre-authorization, step therapy, and other pre-service requirements,
  • Warnings that these are estimates only and balance billing may be possible, and

Provide a paper copy upon request.

Plan year beginning on/after 1/1/23 No extension.  Plans are also to provide a phone number to call for additional assistance.
Online Self-Service Tool for All Shoppable Services: Non-grandfathered plans must provide the self-service real-time estimate services above for all services, not just the initial list of 500 shoppable services Plan year beginning on/after 1/1/24

No extension. Plans are also to provide a phone number to call for additional assistance.

 

Annual RxDC Reporting: In addition, RxDC reporting is required annually by 6/1.  Your carrier, TPA, and/or PBM should submit this reporting for you, but it’s possible they will send you a survey in the first few months of the new year which must be answered in order for them to provide everything needed.  They mainly need to know how much the employees paid in premiums for medical/Rx coverage in calendar year 2023 vs. how much the employer paid in premiums.

 

IMA will continue to monitor regulator guidance and offer meaningful, practical, timely information.

This material should not be considered as a substitute for legal, tax and/or actuarial advice. Contact the appropriate professional counsel for such matters. These materials are not exhaustive and are subject to possible changes in applicable laws, rules, and regulations and their interpretations.

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