Stay in the know
WebTPA is committed to keeping its clients up to date on federal healthcare policies and legislation. Here you will find our interpretation of said legislation and how these statutes may impact your health plan.
Publicly Available, Machine-Readable Files
In-Network Rates and Historical Out-of-Network Allowed Amounts
To meet transparency requirements effective July 1, 2022, WebTPA will assist plan sponsors in making the two machine-readable files available (in-network rates for covered services or item covered by the plan, historical billed charges from out-of-network providers and the allowable amount of such charges considered by the plan).
COVID-19 Emergencies to End
The COVID-19 National Health Emergency and Public Health Emergency (PHE) were to expire on March 1 and April 11, 2023, respectively. The Biden Administration is extending the expiration date to May 11, 2023, to align with its commitment to give a minimum of 60 days' notice prior to the end of the emergencies. Group health plans and issuers are studying what this means for medical plan related coverages and processes.
CAA Prescription Data Collection Reporting
This notice provides information regarding WebTPA’s plans to assist our clients with their CAA Section 204 reporting obligations. We previously shared an overview of the reporting requirements, and we asked a few questions pertaining to your Plan’s submission of the various files. We have also been communicating with many of the PBM partners that our clients utilize to ensure that we are in sync with how they intend to submit data on behalf of our joint clients. Please note that this particular reporting exercise is largely prescription drug data, so the data that WebTPA will be able to provide in support of our clients, will be rather limited in scope.
ACA and IRS Dollar Limits
The U.S. Department of Health and Human Services (HHS) finalized an increase in the annual limit on cost-sharing for essential health benefits for non-grandfathered plans that apply to plan years beginning on or after January 1, 2023.
CAA Rx Reporting
The Consolidated Appropriations Act, 2021 (CAA) requires plans and issuers to submit information regarding the costs of prescription drugs and other health care services each year to the Center for Medicare & Medicaid Services (CMS). The rule generally applies to group health plans and health insurance issuers offering group or individual health insurance coverage. The term ‘‘group health plan’’ encompasses both self-funded and insured health plan, including employer-sponsored group health plans subject to ERISA, non-federal governmental plans (such as plans sponsored by states and local governments) subject to the Public Health Services (PHS) Act, and church plans subject to the Internal Revenue Code. Individual health insurance coverage includes student health insurance coverage. Plans consisting only of HIPAA excepted benefits do not have to comply.
Supreme Court Decision Supports Group Health Plans Cost-Containment Strategies for Dialysis Payments
On June 21, 2022, the U.S. Supreme Court found in favor of the group health plan in the case of DaVita v. Marietta Hospital, finding that the Marietta Hospital Employee Health Benefit Plan did not violate the Medicare Secondary Payer Act (MSPA) in limiting dialysis payments to DaVita. The court held that the plan does not discriminate against patients with end-stage renal disease (ESRD), as it offers the same level of coverage for all patients with kidney disease.
Upcoming PCORI Deadlines
At the end of 2021, the IRS raised the fee that insurers and sponsors of self-insured health plans pay annually to fund the federal Patient-Centered Outcomes Research Institute (PCORI) trust fund.
IDR Portal and Machine-Readable Files FAQ
On Friday, April 15, the Center for Medicare & Medicaid Services (CMS) launched the online IDR portal. The portal is a tool available to nonparticipating providers and health plans, after a 30-business day open negotiation period, when they are not able to agree on the out-of-network rate for services provided. The process is a part of the new consumer protections against surprise out-of-network balance billing, effective January 2022, under the No Surprises Act (NSA).
Court Ruling on No Surprises Act Independent Dispute Resolution Procedures
On Feb. 23, 2022, the U.S. District Court for the Eastern District of Texas granted a motion for summary judgment in favor of the Texas Medical Association (TMA), which contended that the Independent Dispute Resolution (IDR) process laid out in the Interim Final Rule Part II conflicted with the No Surprises Act’s statutory requirements.
End of 2021 Compliance Update
WebTPA is committed to keeping its clients up to date on federal healthcare policies and legislation. Below are two updates to kick off 2022.
No Surprises Act Status Update
As we enter the second month of 2022, we are sharing a status update on continued compliance efforts related to No Surprises Act and other regulatory requirements and recent notices.
End of Year NSA Compliance Updates
As many of the No Surprise Act (NSA) requirements are effective on or after January 1, 2022 for group health plans and issuers, we are providing a status update on our efforts to assist your plan with compliance.
Independent Dispute Resolution Process
On September 30, 2021, the U.S. Departments of Health and Human Services (HHS), Labor and Treasury (collectively, the Departments) along with the Office of Management and Budget released “Requirements Related to Surprise Billing: Part II,” to provide additional guidance on the Consolidated Appropriations Act (CAA).