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.
Qualifying Payment Amount (QPA), Member Cost Sharing, and Provider Payment
For plans that utilize provider networks, WebTPA has completed the implementation of our WebTPA QPA, which we have begun to apply to surprise billing services to determine the member cost sharing amount and the initial payment to a provider. We are starting to receive information from various network partners on their QPA process and fee structure to assess whether we will be able to offer an option of QPA values to clients as we move further into 2022. For the time being, please know that the current status is that we have a process in place to ensure that your plan is compliant with the surprise billing process outlined in the NSA.
Surprise Billing Notice
The Surprise Billing Notice explains to members their rights regarding surprise balance billing. These notices are mailed along with member EOBs for NSA-protected claims and the notice is posted on WebTPA’s public website.
Independent Dispute Resolution (IDR)
WebTPA will facilitate the IDR process and the external appeal process for surprise billing protected claims.
On January 1, 2022, the Federal Independent Dispute Resolution (IDR) Process Guidance for Certified IDR Entities became available. The document includes information on how the parties to a payment dispute may initiate the process and how to request an extension of certain time periods for extenuating circumstances. It also addresses the requirements that certified IDR entities must follow in making a payment determination and the process for revocation of IDR certification. The complete document can be viewed here. Please note that any fees associated with the IDR process and charged by the certified IDR entities will be directly charged back to clients. We will continue to share additional information on how this process will work and how the fees will be assessed once we have more information.
Summary Plan Documents (SPDs) and Summary of Material Modification (SMM)
For those SPDs that WebTPA produces on behalf of clients, 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.
Mental Health Parity and Addiction and Equity Act (MHPAEA) Comparative Analysis
Recently the Departments of the Treasury, Labor, and Health and Human Services jointly issued a report to Congress, which offers valuable insight into the departments’ approach to enforcing the MHPAEA and, in particular, the requirement to document an analysis that compares nonquantitative treatment limitations (NQTLs) that apply to benefits for mental health and substance use disorders to those that apply to medical and surgical expenses. Along with the clear message of expecting health plans to have a well-documented NQTL comparative analysis in place prior to any request that the departments make for the information, it details measures taken to strengthen enforcement of MHPAEA requirements and it requests Congress to enact legislation that can further enhance their enforcement efforts. The full document can be viewed here.
WebTPA will coordinate the supply of utilization management NQTL analysis, if such services are provided by Communitas or American Health Holdings, but additional NQTLs such as network adequacy and prescription formulary design should be obtained from a plan’s PBM and network partner(s) respectively. In addition, we are currently working on updating and improving Communitas’ comparative analysis based on recent DOL guidance and will be able to share this analysis upon request.
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. 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). The files will be posted on WebTPA’s website specifically by client and we are actively engaged currently in outlining the web page designs needed and coordinating with network partners on how the in-network files will be made available prior to the July deadline.
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.
Coverage for COVID-19 Over-the-Counter (OTC) Diagnostic Testing
On Monday, January 10, the Biden Administration released FAQs Part 51 regarding the expanded coverage requirement for at-home COVID-19 tests that carry the FDA’s authorization, but do not include the involvement of a health care provider. The requirements apply to tests purchased on or after January 15, 2022 and encourage plans to adopt a direct coverage option by reimbursing sellers directly without requiring participants to provide upfront payment and seek reimbursement.
FAQs Part 52 clarifies that a direct-to-consumer program can include online or telephone ordering and may be provided through a pharmacy or other retailer, the plan directly, or any other entity on behalf of the plan. If a plan opts to provide in-person coverage through a preferred retailer that also maintains an online website that will ship tests directly to participants, the website is sufficient to meet the direct-to-consumer shipping requirement.
Plans may discourage fraudulent behavior by disallowing reimbursement for tests that are purchased online via direct person-to-person transactions, as well as from sellers that use online auction or resale marketplaces.
All rules apply to FDA-approved at-home COVID-19 tests that are authorized to be self-administered and self-read, rather than at-home tests that require a laboratory or other healthcare provider to process the results. Those types of tests are subject to the general rules that apply to coverage for COVID-19 testing with the involvement of a healthcare provider.
If a participant mistakenly seeks reimbursement from his or her health FSA, HRA, or HSA for at-home COVID-19 tests that are later reimbursed from his or her major medical plan, he or she will need to correct the erroneous reimbursement or distribution in accordance with the plan administrator’s procedures (and, in the case of an HSA, the generally applicable HSA rules regarding non-qualified medical expenses).
For those plans who have opted for medical plan reimbursement of these tests, we offer a manual claims submission process on the member portal, where a member may complete a claim form and submit it to WebTPA for reimbursement when they have paid out-of-pocket for eligible tests. For those who have selected a direct coverage model, we understand that the majority of plans are coordinating with their Pharmacy Benefit Managers (PBM) and contracted pharmacies. We thank you all for working with us during the very short implementation timeframe given for this new coverage to ensure that we were ready to assist your members and able to document the plan’s intent from an administrative perspective.
We will continue to provide you regulatory updates as they become available as we believe 2022 will be another active year for regulatory items. Thank you!