Group Health Plan Transparency Requirements Under CAA (Pt.1)

Group Health Plan Transparency Requirements Under CAA (Pt.1)

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In December 2020, significant legislation was passed with the purpose of improving transparency in group health benefits offered by employers. These requirements were passed as part of the Consolidated Appropriations Act of 2021, commonly referred to as the CAA.

While the effective dates for many of the new transparency requirements have been delayed, the requirements listed below are already in effect or will be soon. Many of these requirements should already have been implemented by carriers (for fully insured plans) and TPAs (for self-insured plans) starting with the 2022 plan year. Requirements that are not already in effect are noted throughout.

Provider Directory Accuracy

Many of our clients have asked us to assist their employees who have mistakenly incurred out-of-network expenses even though they had good reason to think the provider was in-network. The CAA attempts to reduce this problem by requiring health plans to:

  • Regularly update and verify the accuracy of information in provider directories (both print and online); and
  • Accurately respond by phone and email to questions about a provider’s network status.

If a carrier or TPA incorrectly states that an out-of-network provider is in-network, then they will be required to pay out-of-network expenses incurred by a participant the same as if they were in-network.

ID Cards

Health plans are also required to provide more detailed information than has historically been provided on ID cards provided to plan participants. Specifically, cards must include:

  • Plan-specific deductibles and out-of-pocket maximums (This information could be provided electronically, such as through the use of a QR code on the card).
  • A phone number and website where employees can determine whether a provider is in-network or out-of-network (which are subject to the accuracy rules described above).

Most carriers and TPAs have already updated their ID cards to comply with this requirement for plan years starting in 2022. However, since final regulations haven’t yet been issued, additional changes to ID cards may be on the way in 2023.

Surprise Billing Requirements

The CAA’s “Surprise Billing” provisions offer perhaps the most significant new protections for employees against unexpected out-of-network charges. Very generally, group health plans are required to charge in-network rates for:

  • Emergency services obtained by plan participants at out-of-network hospitals and freestanding emergency facilities;
  • Care provided to participants by out-of-network providers at in-network healthcare facilities (whether on an emergency basis or not); and
  • Services provided to participants by out-of-network air ambulance carriers.

Plans must also provide a notice to participants describing these protections in more detail (sometimes called Balance Billing Notice). This should be included in the health insurance certificate (for fully insured plans) or summary plan description (for-self-insured plans), or it may be provided as part of an amendment or addendum.

Carriers and TPAs are also required to provide the notice in each Explanation of Benefits that contains an item or service to which the Surprise Billing protections apply.

“Gag Order” Prohibition

Group health plans insurers and plan sponsors are prohibited from entering into a provider network agreement that contains a “gag clause” regarding the cost of services and quality of care offered by healthcare providers in the network. These types of clauses have been relatively common in the past. Group health plans will also be required to file an annual attestation that they are not subject to any gag clause of this type with a governmental agency, likely the Department of Labor (DOL) or Department of Health and Human Services.

While the gag order prohibition is already in effect, the attestation requirement has been delayed. The Miller Group will let our clients know when a process is in place for the filing of attestations and any actions you may need to take.

  • For fully insured employers, we believe the attestation will be completed by the carrier.
  • Self-insured employers will likely be responsible for filing the attestation, but some TPAs may be willing to take on that responsibility.

More information to come after regulations regarding the attestation requirement have been issued!

Compensation Disclosures

The CAA requires group health plan sponsors to obtain information about the compensation paid to brokers and other entities that provide services to the plan. This includes medical, dental and vision coverages.

The Miller Group started providing disclosures regarding our compensation to clients with plan years beginning on or after February 1, 2022, and they will be updated annually. Yet our disclosure is only one piece of the puzzle. Employers also need to obtain information about what compensation other service providers, such as carriers, TPAs and wellness vendors, will receive. While this is ultimately the responsibility of the employer, The Miller Group is putting a process in place to help our clients obtain the required documents.

Mental Health Parity Analysis

Group health plans have long been required to meet detailed parity requirements in the coverage they provide for mental health services as compared to other health concerns. What’s new under the CAA is that plans are supposed to conduct a detailed analysis of their compliance with these requirements, which must be provided to the DOL, state regulators, and even plan participants on request.

While this might sound simple, it is not. To date, no guidance has been issued that clearly explains the exact content of such an analysis. In fact, none of the analyses that the DOL has reviewed so far were accepted as fully compliant.

While this requirement is technically in effect now, there is no hard deadline for completing the analysis. We are working on a process for clients who desire assistance.

  • For self-insured clients, you will need to use an external vendor to perform the analysis. Your account team will be contacting you in the near future about this option.
  • For fully insured employers, the major carriers have advised us they will provide the analysis to clients who receive a request from someone to whom they are legally required to provide it.
What’s Next?

This is the first of two articles highlighting the new CAA requirements. Next month, we’ll take a look at the requirements that have not yet taken effect and what we are doing to help our clients comply with them. These include:

  • Making certain health plan data available in “machine-readable files” on public websites (effective in July 2022)
  • Filing reports regarding prescription drug costs, drug rebates, and participant costs through a CMS portal (first filing due in December 2022)
  • Establishing a consumer price comparison tool (for plan years starting on or after January 1, 2023)
  • Providing Explanations of Benefits to participants who request them before moving forward with a particular medical service (currently delayed for an undetermined amount of time)

 

Julie Athey talks transparency health plan requirementsBy Julie Athey, J.D., Director of Compliance, The Miller Group

 

 

 

 

 

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