From fostering a workplace culture centered on supporting the physical, emotional, career and financial wellbeing of employees to ensuring that benefit programs are compliant with local, state and federal requirements, effectively protecting the wellbeing of your employees connects directly to protecting the wellbeing of your organization overall. Compliance Connections delivers monthly, actionable guidance designed to help you manage and optimize the connections between the compliance of your benefits and human resources programs to overall organizational wellbeing. This edition focuses on transparency requirements under the Patient Protection and Affordable Care Act (ACA) and the Consolidated Appropriations Act, 2021 (CAA), both of which are intended to provide additional protections from balance billing and to help consumers obtain information about health costs prior to receiving medical care. Below are some important action steps employers should keep in mind when seeking to understand and implement applicable requirements.
Determine which new transparency provisions apply. The ACA regulations refer to "transparency in coverage" with a focus on personalized cost-sharing information. The CAA's transparency requirements range from provider directory information to new identification card requirements. The ACA's transparency in coverage requirements apply to non-grandfathered group health plans and health insurance issuers offering non-grandfathered coverage in the group and individual markets. However, the CAA's provisions do not contain an exclusion for non-grandfathered coverage. Employers may wish to opt-in to the ACA's requirements if otherwise not required to comply. Regardless, it is important to understand which law triggers a particular requirement. Which new transparency requirements apply to your major medical plan?
Provide verified and updated provider directory information. The CAA requires specific provider directory disclosures. For plan years beginning on or after January 1, 2022, group health plans must establish databases on public websites for those plans that contain both: (1) lists of each health care provider and health care facility with which the applicable plan has a direct or indirect contractual relationship for furnishing items and services under the plan, and (2) provider directory information with respect to each such provider and facility. Plans will likely have to lean on their TPA or insurer to provide the updated information and potentially the actual database, so plan sponsors should clarify responsibilities in time for their compliance deadlines. What additional steps does your plan need to take to comply with the upcoming provider directory requirements?
Verify that new plan identification cards will contain necessary information. For plan years beginning on or after January 1, 2022, plan identification cards issued to participants and beneficiaries must include the following: (1) any deductible applicable to such plan or coverage; (2) any out-of-pocket maximum limitation applicable to such plan or coverage; and (3) a telephone number and Internet website address through which an individual may seek consumer assistance information. If the information is not specifically included on an identification card, the obligation may be met by including a source to obtain the information on the card, such as a TPA's web address. Plan sponsors should verify that their insurers or TPAs will meet these obligations. What information, if any, should be added to your plan identification cards to meet new disclosure requirements?
Avoid surprises associated with surprise billing. The Departments of the Treasury, Labor, and Health and Human Services issued two sets of what will be a series of regulations implementing the surprise medical billing provisions of the CAA. (That portion of the CAA is also referred to as the "No Surprises Act" or NSA.) The NSA is intended to protect participants, beneficiaries, and enrollees in group health plans (and group and individual health insurance coverage) from "surprise" balance billing when they receive specified emergency care (generally from out-of-network providers or facilities). Balance billing refers to the practice of out-of-network providers billing patients for the difference between (1) the provider's billed charges, and (2) the amount collected from the plan or insurer, plus the amount collected from the patient in the form of cost sharing (such as a copayment, coinsurance, or amounts paid toward a deductible). The requirements generally apply to three categories of healthcare: (1) the provision of emergency services by a nonparticipating emergency facility or a nonparticipating provider; (2) non-emergency services furnished by out-of-network providers in in-network facilities, and (3) air ambulance services provided by out-of-network providers. The new rules address payment amounts and independent dispute resolution when reimbursement amounts are not agreed upon and apply to plan (and policy) years that begin on or after January 1, 2022. What work does your plan need to do to prepare for new surprise billing requirements?
Work with your vendors to prepare for IDR. Beginning in 2022, plans will also be subject to new independent dispute resolution (IDR) requirements in situations involving surprise billing under the NSA. Under applicable regulations, IDR will apply when negotiations between individuals, plans, or health insurers and out-of-network providers (including facilities and air ambulance providers) do not result in an agreement on payment for specific items and services provided to a patient under circumstances where NSA protections apply. The IDR process does not apply to situations where a State All-Payer Model Agreement or Specified State Law applies. Although employers will not likely be directly involved in IDR, they will likely bear administrative costs passed along by TPAs or insurers and receive questions from employees and their family members, and should thus be familiar with general IDR requirements. What updates are needed for your vendor contracts to reflect new rules and associated costs?
This is a preview edition of Compliance Connections, a monthly publication produced by Gallagher's Compliance Consulting Practice. For five more action steps, contact your Gallagher representative or visit our Compliance Resources page to subscribe and receive the full version of this publication each month.
Compliance is a series of actions, not a final destination. As a trusted advisor, Gallagher has developed this Compliance Connections series to help you pursue a path through employee benefits compliance issues as part of an overall continuing compliance plan. Plan sponsors should carefully evaluate their health and welfare plans to determine if they are in compliance with both federal and state law. If you have any questions about one or more of the compliance requirements listed above, or would like additional information on how Gallagher constantly monitors laws and regulations impacting employee benefits in order to support plan sponsors in their compliance efforts, please contact your Gallagher representative.
The intent of this analysis is to provide you with general information. It does not necessarily fully address all your organization's specific issues. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific issues should be addressed by your organization's general counsel or an attorney who specializes in this practice area.