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.
ID Cards
WebTPA is coordinating the issuance of physical 2022 ID cards with the added required information and will be wrapping up the requested client reprints between now and year end. Temporary ID cards are also posted on the member portal as “images”. As we move forward into 2022, subsequent renewal months will be receiving ID card reprints in compliance with NSA provisions.
Member Cost Sharing, Qualifying Payment Amount (QPA), and Independent Dispute Resolution (IDR)
WebTPA’s selected vendor will calculate the QPA and we will apply the QPA to determine the member cost sharing. We will facilitate the Independent Dispute Resolution (IDR) process and the external appeal process as it concerns surprise billing protections. This process is underway and will be in place as of January 2022.
Summary Plan Documents (SPDs) and Summary of Material Modification (SMM)
For those SPDs that we produce, we are incorporating NSA-compliant language within full SPD restatements or SMMs. For SPDs we do not produce, we encourage clients to seek outside legal assistance to ensure appropriate NSA-compliant language is incorporated.
Surprise Billing Notice
The Surprise Billing Notice explains to members their rights regarding balance billing. These notices will be mailed along with member EOBs for NSA-protected claims and will also be posted to the website by the end of the year.
Continuity of Care
We are ready to timely furnish notice to those enrollees receiving ongoing care from a provider/facility leaving the plan network. Such notices will be furnished to those individuals receiving treatment for serious or complex health conditions, institutional or inpatient care, nonelective surgery, pregnancy, and care for terminal illness.
Network Provider Directory Accuracy
Several communications have been sent to provider networks, to ensure that they are aware of and can assist with the directory requirements. We typically receive this type of data from the network directly or in many cases, simply link from our website to the online search hosted by the network.
Reporting on Pharmacy Benefits and Prescription Drug Costs
We will provide plan-related information required to be reported, to the extent we maintain such information. A large amount of the reporting requirement is dependent on the PBM.
Anti-Transparency Gag Clauses
Our contracts with PPO Networks for plan or contract year beginning in or after 2022, will be compliant with the prohibition on restricting the plan’s access to, and ability to share, price and quality information.
Publicly Available, Machine-Readable Files (In-Network Rates and Historical Out-of-Network Allowed Amounts)
The effective date of this requirement has been delayed until July 1, 2022. We 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). The files will be posted specifically by client.
If you have questions about the delivery of the above requirements, please contact your Account Executive. Previous WebTPA Compliance Updates regarding surprise billing protections and transparency are available on our website: https://www.webtpa.com/blog.