Agencies delay health plan transparency rules / no surprises | Hodgson Russ LLP



The Ministries of Labor, Health and Social Services, and the Treasury (collectively, the “Agencies”) have published Frequently Asked Questions (FAQs) regarding the implementation of certain provisions of the Consolidated Appropriations Act (CAA ). In the final days or 2020, the CAA was enacted, providing for a number of transparency obligations for health plans and their service providers. Recent guidelines have extended the deadline for applying several of these rules. Among the provisions affected by this new orientation, we can cite:

  • Coverage transparency of machine-readable files.

Final Coverage Transparency Rules require group health insurance plans to disclose information regarding network provider rates for covered services, authorized off-network amounts and charges for covered services, as well as negotiated rates and historical net prices for prescription drugs covered in three separate machine-readable files. The requirements for machine-readable files were to apply to plan years beginning on or after January 1, 2022. However, under these new guidelines, the Agencies will postpone the application of these applicable rules until July 1, 2022. Enforcement of regulations related to the publication of machine-readable files for the price of prescription drugs will be deferred pending further rules.

Under the CAA, group health insurance plans are required to offer price comparison advice over the phone and to make available a “price comparison tool” that allows a member to compare the amount. the cost sharing that he would pay for a specific item or service. This requirement applies to plan years starting on or after January 1, 2022. Under the new guidelines, the deadline for the CAA price comparison tool has been extended to plan years starting on or after January 1, 2023.

  • Advanced explanation of benefits

CAA requires plans to send an advanced benefit explanation notification to a participant in clear, understandable language. These provisions were to apply to plan years beginning on or after January 1, 2022. Under the new directives, the Agencies will postpone application until regulations to fully implement the requirements are adopted and enforceable. .

The CAA has established supplier directory standards. These arrangements generally require plans to verify the accuracy of supplier directory information and to establish a procedure for responding to requests from participants regarding a supplier’s participation status in the network. If a participant receives inaccurate information from the plan in the required supplier directory, the plan cannot impose a cost-sharing amount greater than the cost-sharing amount that would be charged for items and services provided by a participating supplier or provider. participating institution. While these provisions are applicable to plan years starting on or after January 1, 2022, additional rules will not be published until after the effective date. Until further guidance is issued, plans should implement these rules using a reasonable and good faith interpretation of the law.

The CAA has imposed a number of rules that will dramatically change the way group health insurance plans are administered. These FAQs provide interim guidance and may alter the timeline that plan sponsors may have developed to address the implementation of these new rules.

Affordable Care Act and Consolidated Appropriation Act 2021 FAQs Part 49 Implementation (Aug 20, 2021)


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