CAA & Transparency Regulations - The "Man" Behind the Curtain

Transparency Regulations were issued by the Departments of Labor, Health and Human Services and the Treasury (Departments) in November 2020. A month later, the Consolidated Appropriations Act, 2021 (CAA) was signed into law. Following in August 2021, the Departments released FAQ guidance addressing several CAA requirements. These new requirements are designed to increase health care transparency and protect consumers against surprise billing. Let’s take a summary tour through the deadlines set forth.

Prohibition on Gag Clauses

applies immediately on December 27, 2020

A gag clause could directly or indirectly restrict/prevent insurers from making price or quality information available to patients or other third parties. This also includes preventing a pharmacist from disclosing cost information to patients. Under the CAA, insurers and group health plans cannot enter into agreements with providers that restrict their ability to disclose provider-specific cost or quality of care information. The provision also states that electronic deidentified claims and encounter information or data for enrollees cannot be restricted, with respect to applicable privacy regulations. Beginning in 2022, attestations will begin to be collected, focusing on the enforcement of compliance with the ban on gag clauses.

Broker Compensation Disclosure

generally applies to contracts beginning, extended or renewed on or after December 27, 2021

Section 202 of the CAA requires brokerage and consulting firms to disclose, in writing, the amount of compensation (direct and indirect) we anticipate receiving during your plan year ($1,000 or more). This disclosure applies to medical, dental and vision plans only, however Rose Street Advisors has made the decision to disclose all compensation received related to all benefit plans we service for you. This requirement does not apply to plans not subject to ERISA or plans that have a fee-for-service compensation model.

Ban on Balance Billing

applies to plan years beginning on or after January 1, 2022

Group Health Plans and Health Insurance Insurers are required to provide protection against balance billing and out-of-network cost sharing like emergency services and air ambulance services by non-participating providers. It also protects nonemergency services provided by non-participating providers at participating facilities. Members will find notice of these protections on an Explanation of Benefits (EOB) for an item or service when it applies.

Transparency in ID Cards

applies to plan years beginning on or after January 1, 2022

Health Insurance Insurers were mandated to provide updated physical and/or electronic ID Cards that include applicable out-of-network deductibles, out-of-pocket maximums, and contact information for individuals seeking assistance.

Continuity of Care

applies to plan years beginning on or after January 1, 2022

This new rule states a Health Insurance Issuer must offer an enrollee the opportunity to elect a transitional period of continued care with a provider whose participation in an applicable network ends while the enrollee is in a course of treatment for a medical condition.

Provider Directory Accuracy

applies to plan years beginning on or after January 1, 2022

In recent years, it is not uncommon to have a Physician listed In-Network, only to confirm that the Provider contract has ended and they are no longer a participating Provider. Health Plans and Insurers must now maintain provider directories on their public website. If inaccurate information is found, a covered individual cannot be required to pay more than in-network cost shares.

Machine Readable Files

initially set for January 1, 2022 then delayed until July 1, 2022

Fully Insured Insurers and Self-Funded Employers must disclose detailed service pricing information on their public website through three phases. • Phase One: In-Network provider negotiated rates for covered items and services (In-Network Rate File) • Phase Two: Historical payments to and billed charges from out-of-network providers (Allowed Amount File) • Phase Three: In-network negotiated rates and historical net prices for covered prescription drugs (Prescription Drug File)

Prescription Drug Cost Reporting

initially required by December 27, 2021, and extended until December 27, 2022

Insurers and Group Health Plans must provide data on pharmacy benefits and drug costs to federal regulators an on annual basis. The gathered information will then be used to provide publicly available reports on a bi-annual basis reviewing prescription drug reimbursements, pricing trends, and how much prescription drugs impact premium increases or decreases. By December 27, 2022, Insurers and Group Health Plans must be prepared to submit information for both 2020 and 2021.

Price Comparison Tool

applies to plan years beginning on or after January 1, 2023

Insurers and Group Health Plans are required to provide an internet-based self-service tool to disclose to the public the price comparison information and cost-sharing estimates. This tool cannot require someone to have a subscription, login, or charge fees to access the data. Upon request, information must also be provided in paper form or over the phone. The price comparison tool is being released in two phases. • Phase One: By January 1, 2023 at least 500 specific shoppable items, services and drugs identified by the Departments must be       available on the price comparison tool. • Phase Two: By January 1, 2024 all items, services and drugs must be available on the price comparison tool.

Advanced EOBs

delayed until further notice

Group Health Plans and Insurers must provide an advanced EOB to covered individuals highlighting details of the estimate of expected cost of services. This comes after receiving a good faith estimate of charges for those services from a health care provider or facility. For more information, please contact your Relationship Manager or our office at infor@rosestreetadvisors.com or 269.552.3200.

Several of these requirements are currently using a good faith, reasonable interpretation of the law until the Departments issue further regulations.