Application Delays for Group Health Plan Compliance – Food, Drugs, Healthcare, Life Sciences

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1 Machine readable files. Under the Final Rules on Transparency of Coverage (“TiC Final Rules”), non-grandfathered group health insurance plans and issuers offering non-grandfathered health insurance coverage in the group and individual markets are required to disclose, by means of machine-readable files (i.e. representations of data or information in files that can be imported or read by computers for further processing without human intervention), (1) on-network provider rates for covered items and services, (2) off-network authorized amounts and charges billed for covered items and services, and (3) negotiated and historical net drug prices prescription covered. These data must be displayed on the public websites of the plans or issuers. See a related discussion of drug benefit reporting requirements under the CAA in # 10 below. Compliance with TiC’s final rules was required for plan years beginning on or after January 1, 2022. Application of prescription drug price disclosure requirement under TiC’s final rules is postponed to a later undisclosed date pending development of further notice and comments, due to overlapping requirements declarations added by the CAA.

The application of the disclosure requirements of on-network tariffs and off-grid authorized amounts and invoiced fees is delayed until July 1, 2022.

2 Price comparison tools. Plans and issuers are required under TiC’s final rules to make price comparison information available to participants through a self-service online tool and in hard copy upon request. Under the CAA, plans and issuers are required to make similar information available to plan members by telephone. Under TiC’s final rules, compliance for 500 specified items and services was required for plan years beginning on or after January 1, 2023 and January 1, 2024 for all other items. The similar requirement under the CAA was in effect for plan years beginning on or after January 1, 2022. Acknowledging that the price comparison requirements under the TiC and CAA Final Rules are “largely redundant” with the exception of the ability to receive such information over the phone, the application of both laws is delayed until as of January 1, 2023. The ministries intend to propose rules requiring that the same TiC tariff information available through the online self-service tool, in paper form, and also by telephone on request. 3 Insurance identity cards. Under the CAA, plans and issuers are required to include on insurance ID cards information about any applicable deductible, the maximum limit payable, as well as the phone number and website through which participants can access consumer help information. Plan years starting on or after January 1, 2022. Delayed indefinitely. Departments plan to issue additional implementation guidelines, but until then good faith compliance is required. 4 Good faith estimate.Under the CAA, when a person schedules items or services, vendors and facilities are required to provide a good faith estimate of expected charges. This estimate should also be provided upon request and include expected billing and diagnostic codes. The provider must also pass this information on to the person’s health plan. Plan years starting on or after January 1, 2022. Delayed indefinitely. Departments plan to issue additional implementation guidelines, but until then good faith compliance is required. 5 Advanced explanation of benefits. Plans and issuers are required under the CAA to provide planing participants at least 3 business days in advance with an Advanced Explanation of Benefits (“EOB”) detailing, among other things, whether the provider or the installation is networked, the good faith estimate received from the supplier (described above) and an estimate of the participant’s cost-sharing obligation. Plan years starting on or after January 1, 2022. Delayed indefinitely. Due to the complexities inherent in administering the good faith estimate requirement described directly above, application is also delayed until further guidance is issued. 6 Prohibition of gag clauses. The CAA prohibits plans and issuers from entering into agreements with healthcare providers (or a network of providers), third-party administrators, or other service providers that would prevent those parties from disclosing specific pricing information or quality, including anonymized information, or certain complaint information (in accordance with HIPAA). December 27, 2020 Delayed indefinitely. Departments plan to issue additional implementation guidelines, but until then good faith compliance is required. 7 Supplier directories. Plans and issuers are required to maintain an up-to-date and accurate supplier directory and establish a protocol for responding to participant inquiries regarding the status of a supplier in the network. Under the CAA, if an attendee receives incorrect information through the database or response protocol, they cannot be held responsible for a cost-sharing amount greater than the cost-sharing amount that would have been charged for the same items and services provided by a network provider or apply off-network caps. Plan years starting on or after January 1, 2022. Delayed indefinitely. Departments plan to issue additional implementation guidelines, but until then good faith compliance is required. 8 Balance billing information. The CAA also requires plans and issuers to notify plan members through public websites and on each EOB that balance billing for certain emergency services is prohibited. Plan years starting on or after January 1, 2022. Delayed indefinitely. Ministries issued guidance in July 2021 and plan to issue additional implementation guidance, but until then good faith compliance is required. A template disclosure notice is available here. 9 Continuity of care. CAA protects participants undergoing treatment for serious or complex conditions, residential or inpatient care, treatment related to pregnancy, or having scheduled non-elective treatment or terminally ill participants from immediate loss of life. coverage in the event of a change in the status of supplier or establishment in the network. The CAA imposes a notification requirement of changes to a provider’s or facility’s network status, and in some cases the participant must be provided with continuous coverage for up to 90 days at the network rate. Plan years starting on or after January 1, 2022. Delayed indefinitely. Departments plan to issue additional implementation guidelines, but until then good faith compliance is required. ten Reports on drug benefits and drug costs. Under the CAA, plans and issuers are required to submit to government departments a wide range of information on prescription drug benefits and drug costs. The information required includes a list of the 50 most frequently dispensed and paid for prescription drugs under the plan, the 50 most expensive prescription drugs covered by the plan, and the 50 most expensive prescription drugs. plan compared to the previous plan year reported on. In addition, plans and issuers are also required to report to departments the total expenses and costs for various services and items and the total premiums broken down by member and employer payments, among other data. The CAA has two reporting deadlines, December 27, 2021 and June 1, 2022 (with regular reporting by June 1 of each subsequent year). Delayed indefinitely. Recognizing the “significant operational challenges” in complying with these reporting requirements, disclosure is delayed until new guidance is issued. However, plans and issuers are “strongly encouraged” to prepare for compliance by December 27, 2022 for 2020 and 2021 data.


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