Regulators Delay Certain Group Health Plan Transparency Deadlines

• Providing provider-specific cost or quality of care data, via consumer engagement tools or to referring providers, the plan sponsor, enrollees, or individuals eligible to enroll (the provider/network can, however, place “reasonable restrictions on the public disclosure” of such information)
• Accessing de-identified claim by claim data with detailed financial info (allowed amount or any other claim-related financial obligation included in the provider contract), provider info (name, clinical designation), service codes, or any other data element included in claim/encounter transactions
• Sharing all such data above (or directing sharing of that data) with a HIPAA business associate

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

• Use reasonable good faith measures to ensure the plan does not enter into contracts with prohibited gag clauses
• Regulators will soon provide the process for submitting the annually required attestations to begin in 2022

• If the individual does not have coverage, the provider is required to send such good faith estimate directly to the individual
• If the individual has coverage, the provider is required to send a good faith estimate of of the expected charges, along with the billing and diagnostic codes, to the individual’s plan

Extended indefinitely pending future rulemaking for situations where expenses will be submitted to a plan.  Any additional stipulations resulting from future rulemaking will specify a future applicability date.

• The participating provider’s contracted rate (based on the billing and diagnostic codes submitted)
• In the case of a non-participating provider, a description of how to obtain information on in-network provider access
• A good faith estimate from the provider based on the codes submitted
• A good faith estimate of the plan’s coverage amount, the member’s cost-sharing, and any deductible and out-of-pocket requirements already met as of the date of the notice
• Explanation of any medical management techniques applicable to these services
• A disclaimer this is a good faith estimate on items/services reasonably expected to be furnished, and is subject to change
• As well as any other valid disclaimers/information the plan deems appropriate to disclose

• INN: In-network provider negotiated rates for all services,
• 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 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: Extended indefinitely pending future rulemaking

• 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

• 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.