Refresher on CAA and Transparency Provisions to Date

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.

No extension.  See the rules here:

• July 2021 IFR Part I
• Oct 2021 IFR Part II
• Aug 2022 Final Rule
• Oct 2023 IDR Proposed Rule

Dec 2023 IDR Fees Rule

(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).

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.

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

No extension. Use reasonable good faith measures to comply.

No extension. Use reasonable good faith measures to comply.

• 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.

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