On October 29, 2020, HHS, the Department of Labor, and the Department of Treasury (the Departments) jointly issued a final rule requiring health plans to disclose price and cost-sharing information to participants, beneficiaries, enrollees and the general public. This rule builds upon prior price transparency rules requiring hospitals to disclose their standard charges, including negotiated rates with third-party payers.
In addition, the Consolidated Appropriations Act, 2021 was signed into law at the end of 2020 and includes the No Surprises Act, which prohibits hospitals and doctors from issuing surprise medical bills for certain healthcare services. The No Surprises Act includes open negotiation and Independent Dispute Resolution (IDR) procedures for health plans and out-of-network healthcare facilities and providers to determine applicable payment rates. Although portions of the CAA are effective at different points in time, the majority of the No Surprises Act provisions will take effect for plan years on or after 1/1/2022.
As the legislation requirements are either already here or fast approaching, WebTPA has categorized our contributing efforts into related workstreams. Each identified workstream includes a WebTPA Lead and subsequent Team, consisting of multiple departments needed to complete our tasks. Each separate workstream is in the process of completing their own Kick-Off Meeting, to further familiarize themselves with the details of the Act that are available at this time. Our execution and our goals may adapt, as rules and further details, possibly available this summer, are received from the Departments on a continuing basis.
Below are the workstreams identified and the general scope of each.
Plans must include deductibles and out-of-pocket maximums on ID cards. WebTPA is communicating with existing ID card vendors to agree on requirements and begin establishing rollout timelines.
Provider Directory Assistance
Plans must establish a public site which lists participating providers and facilities. The database is to be updated at least every 90 days and remove any providers or facilities that are no longer participating. In addition, print directories requirements exist. Plans must also respond within one business day to a participant who requests information regarding whether a provider or facility is in-network and save the communication in the participant’s file for at least two years.
Once a service has been scheduled with a provider, doctors and hospitals must send notice of eligibility, coverage, benefits, and network participation to individuals. WebTPA is researching available details on receiving notification of scheduled services and the Provider Notices workstream connects closely with the Advanced Explanation of Benefits workstream.
Advanced Explanation of Benefits
Plans must provide participants, upon request, with an advanced EOB for scheduled services that generally explains the estimated costs for the item or service and the applicable cost-sharing requirements. As the Advanced EOB has 8 required elements, WebTPA will be reviewing the format, the data to be communicated, and the delivery methods.
Member Cost-Sharing of Emergency, Certain Non-Emergency, and Air Ambulance Services
Member cost-sharing for specific services, which may have been at out-of-network benefit levels in the past, must be applied to the in-network cost-sharing amounts and benefit levels. This requirement impacts WebTPA’s claim paying system and quoting of benefits.
Timely Out-of-Network Payment or Denial and Independent Dispute Resolution (IDR) Process
Within 30 days of receiving a claim, plans must send an out-of-network payment or denial. If a provider is not satisfied with the payment or the denial, they may initiate open negotiations up to 30 days after receipt and the negotiations period lasts 30 days. If an agreement is not reached during the 30-day negotiations period, either party can initiate the Independent Dispute Resolution (IDR) process. IDR takes place in front of an independent, unbiased entity which features binding “baseball style” arbitration. WebTPA is researching this requirement, and awaiting more detail from regulators later this summer.
Continuity of Care
Each continuing care patient must be notified of a provider’s termination and the patient’s right to elect continued transitional care from such provider or facility, for up to 90 days from the date the notice was provided to the individual.
Mental Health Parity and Addiction Equity Act (MHPAEA) Non-Quantitative Treatment Limitations (NQTLs)
Plans should perform and document "a comparative analysis of the nonquantitative treatment limitations which apply to mental health or substance use disorder benefits.” WebTPA believes it will only be able to assist with a comparative analysis on portions of the NQTL’s, specifically those related to Utilization Review including pre-cert, medical necessity and concurrent care. Clients may need to coordinate with their brokers, PPO networks and PBMs regarding NQTL’s surrounding network access, formulary structure, etc.
TPAs must disclose full direct and indirect compensation and allow the plan 60 days to consider the costs. Health plans are required to notify DOL if they do not receive this information. WebTPA is researching the details of this requirement and will determine details of this notice.
Price Comparison Tool
Plans must offer price comparison guidance by phone and a price comparison tool online for participants to compare cost-sharing amounts for specific items and services furnished by a provider. WebTPA is working with an outside vendor to assist our clients with compliance, and will be providing details on the cost of deploying this tool with renewal pricing for 2022.
Transparency in Coverage
Plans will be required to disclose personalized out-of-pocket cost information and underlying negotiated rates, for all covered healthcare items and services, including prescription drugs, through an internet-based self-service tool and in paper form upon request. They will also be required to publish an initial pricing list of 500 shoppable services that must be disclosed on the health plan’s website using a self-service tool. Eventually, they will be required to disclose pricing information for all remaining items and services using the same online self-service tool. Plans must also disclose on their websites three separate machine-readable files that include detailed in-network, out-of-network, and prescription drug pricing information for all covered items and services offered to enrollees. WebTPA will be coordinating with PPO networks and an outside vendor to bring plans into compliance.
In conclusion, we have several departments involved in the study of the requirements and active discussions are ongoing. We plan to provide monthly updates across all workstreams and our first monthly update, provided in May, will include scope summaries for each workstream.