New directive delays certain dates of entry into force of CAA and other health benefits | Ogletree, Deakins, Nash, Smoak & Stewart, PC



New regulatory guidance from three federal agencies that enforce private sector benefits laws will make 2021 employer to-do lists slightly, but only slightly, more manageable by 2022.

Most importantly, the Frequently Asked Questions (FAQs) guidelines delay many of the more difficult compliance requirements in 2021 and 2022 under the Consolidated Appropriations Act, 2021 (CAA) and the Patient Protection and Affordable Care Act (ACA). ): so-called “advanced explanations of benefits” (EOB) providing good faith estimates of reimbursable expenses for scheduled medical services; a “price comparison tool” to allow participants to compare cost sharing amounts for specific network providers; detailed information on the cost of drugs that were to be reported to federal regulators in December 2021; and public price disclosures for network tariffs, authorized off-grid costs, and prescription drug prices.

The FAQ guide, released on August 20, 2021 by the US Department of Labor, the US Department of Health and Human Services, and the US Department of the Treasury, also provides helpful clarification or clarification related to other key compliance elements. 2021 health benefits for employers. , including gag clauses, identity cards, continuity of care requirements and provider directories.

The FAQ guidelines do not delay or offer further relief related to new surprise medical billing requirements under the No Surprises Act, which was enacted as part of the CAA and is expected to come into effect on January 1, 2022. , or equity in mental health and addiction equity. Law “comparative analysis” required by the CAA, which is already in force.

Here’s a summary of the top takeaways for employers in the new FAQ guide.

Advanced EOBs

Under the No Surprises Act, plans are required to provide good faith estimates of expected vendor charges for a specific scheduled service, as well as good faith estimates of the cost sharing that would apply to a participant, and the amount already committed for any limits of liability. This was originally scheduled to come into effect on January 1, 2022, but the guidelines say agencies will defer enforcement until regulations are published on those plan disclosures and the disclosures required by medical providers. (question 6)

Price comparison tool and public price disclosures

Under the No Surprises Act, plans are required to offer online tools and telephone support to allow participants to compare cost-sharing amounts for specific network providers in a specific region. Separately, under the ACA, plans are required to offer three “machine-readable files” on a public website covering network rates, off-network allowable amounts, and prescription drug prices. The requirements of the No Surprises Act and the ACA were both scheduled to come into force on January 1, 2022. The guidelines extend the date of entry into force of the requirements of the No Surprises Act to January 1, 2023, and the requirements of the ‘On-grid and off-grid ACA. to July 1, 2022. The ACA prescription drug requirement is delayed until agencies issue regulations on the issue. (Questions 1-3)

Drug cost report

The CAA requires employer plans to provide agencies with very detailed information on the cost of prescription drugs, including the 50 most commonly covered drugs by plan, the 50 most expensive drugs by plan, and total health care spending for each plan. each scheme divided into specific categories. Initial reports were to be provided to agencies by December 27, 2021, and then by June 1, 2022. Agencies will defer application of the 2021 and 2022 reports until they issue additional guidance, although agencies “encourage strongly the plans ”. to prepare to report data for plan years 2020 and 2021 no later than December 27, 2022. (Question 12)

Gagging clauses

Under the CAA, plans cannot enter into network agreements or other agreements that would prevent them from making available to providers or participants information on the costs or quality of provider-specific care, d ” electronically access anonymized claims and dating information for each participant (in accordance with privacy laws), or sharing any of these types of information with partners commercial. Plans must certify to agencies annually that they do not have such clauses in their agreements. This requirement came into effect with the enactment of the CAA on December 27, 2020 and is not changed by the FAQ guidelines. The agencies have indicated that additional guidance is forthcoming on how the plans will attest to compliance. (question 7)

Insurance cards

Under the No Surprises Act, plans must update physical or electronic insurance cards to include network and off-network deductibles, disbursement limits, and consumer assistance contact information. This is expected to take effect on January 1, 2022, a date unchanged by FAQ guidelines. The directives specify, however, that the agencies will take into account both the data actually present on the cards and the data “made available thanks to the information provided on the identity card”. (question 4)

Continuity of care

Under the No Surprises Act, when a provider or network contract is terminated, plans must take steps to protect inpatients or other continuing care patients. This requirement will take effect on January 1, 2022. The guidelines state that agencies intend to issue formal regulations on this requirement, but will not do so until the effective date. Until these regulations come into effect, the plans will be subject to a standard of good faith compliance. (question 10)

Supplier directories

Under the No Surprises Act, plans must take several steps to improve supplier directories, such as updating them at least every 90 days and informing participants more quickly if a particular supplier is on the network. These requirements will come into effect on January 1, 2022, and the guidelines do not change that. Agencies indicate that they intend to issue formal regulations in the future and may also have specific additional guidance on the required disclosure of balance billing information. (Questions 8 and 9)


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