CMS Makes Updates to Transparency Mandates: First Look at What Health Plans Need to Know

New guidance was just issued by federal agencies for price transparency mandates. You can read all the details here. HealthSparq’s focus is delivering compliant transparency and guidance solutions to health plans and their members and we have been eagerly awaiting these updates. The federal guidance answers some important questions for health insurers and employer groups, and puts some compliance elements on pause. Here’s our initial take of the guidance: 

Public Disclosure of Rates 

Overview: Transparency in Coverage Final Rules mandated that non-grandfathered health plans in the group and individual insurance markets publicly disclose data. The mandate requires plans publish three files: in-network provider rates for covered items and services; out-of-network allowed amounts and billed charges for covered items and services; and negotiated rates and historical net prices for covered prescription drugs. These separate machine-readable files are to be updated monthly for plan years starting January 1, 2022. 

Federal guidance: Given the Consolidated Appropriations Act/No Surprises Act legislation and related prescription drug requirements passed at the end of 2020, the Departments will defer enforcement of machine-readable files for prescription drugs “while it considers, through notice-and-comment rulemaking, whether the prescription drug machine-readable file requirement remains appropriate.” At the same time, the Departments will enforce compliance for the in-network provider rates for covered items and services, out-of-network allowed amounts, and billed charges for covered items and services six months later, starting July 1, 2022.  

Price Transparency for Members 

Overview: Transparency in Coverage Final Rules mandated member access via online tool and print to cost shares for 500 covered items and services starting January 1, 2023, and all items and services starting January 1, 2024. Then, the No Surprises Act was passed in late 2020 that largely duplicated the online tool price transparency element with a deadline of January 1, 2022. However, the No Surprises Act mandated member access via online tool and phone.  

Federal guidance: Since plans expected to implement Transparency in Coverage phase one for access to 500 items and services starting January 1, 2023, the Departments will defer enforcement for price transparency until that date for online tool, phone, and print access to out-of-pocket pricing information for 500 items and services until January 1, 2023 to align the Transparency in Coverage and No Surprises Act requirements. Until that time, the Departments will focus on compliance assistance. The Departments also encourage states, the primary enforcers of the legislation, to take a similar approach.  

Grandfathered Plan Changes 

Overview: Grandfathered health plans were not subject to Transparency in Coverage mandates for price transparency due to Affordable Care Act provisions. Grandfathered health plans were subject to Consolidated Appropriations Act/No Surprises Act requirements.  

Federal guidance: The Departments confirmed grandfathered health plans are not excluded from the No Surprises Act. As such, they would likely be required to support price transparency, advanced explanation of benefits (AEOB), and provider data accuracy requirements, among other requirements outlined in the legislation.   

Explanation of Benefits in Advance of Care (AEOB) 

Overview: The No Surprises Act required plans to issue an AEOB upon receiving a good faith estimate of costs from providers for scheduled items and services electronically or by mail. There is a lot more detail to this requirement, but compliance was slated to start January 1, 2022. 

Federal guidance: The Departments received feedback on the challenges of developing the technical infrastructure necessary for providers and facilities to transmit the required information to plans. The Departments noted it is not likely compliance would be possible by January 1, 2022. They are undertaking notice and comment rulemaking, including establishing appropriate data transfer standards. Enforcement of the requirement is deferred. In the meantime, The Department of Health and Human Services will investigate whether interim solutions are feasible for insured consumers. 

Provider Data Accuracy 

Overview: The No Surprises Act built on current requirements for Medicare and Medicaid plans, as well as state laws, to support provider data accuracy for members. The legislation required plans establish a process to update and verify the accuracy of provider directory information and to establish a protocol for responding to requests about a provider’s network participation status. This effort worked in tandem with the new surprise billing requirements.  

Federal guidance: Rulemaking for the legislation will not happen before January 1, 2022. Until further rulemaking is issued, plans are “expected to implement these provisions using a good faith, reasonable interpretation of the statute.” Until rulemaking, the Departments will not find a plan out of compliance “as long as the plan or issuer imposes only a cost-sharing amount that is not greater than the cost-sharing amount that would be imposed for items and services furnished by a participating provider, and counts those cost-sharing amounts toward any deductible or out-of-pocket maximum, in a case when a participant, beneficiary, or enrollee receives items and services from a nonparticipating provider and the individual was provided inaccurate information by the plan or issuer under a provider directory or response protocol that stated that the provider or facility was a participating provider or participating facility.” 

HealthSparq remains committed to helping health plans comply with federal mandates. This guidance certainly provides some breathing room for plans to comply, but still plan to work with clients who want to comply early. We’ll be diving more deeply into the guidance and talking to health plans, so more to come.  

Our team has been providing transparency solutions to plans for years and believe the mandates provide a foundation for plans to build on and deliver differentiated experiences that guide members to the right care at the right time. We to be a voice for health plan members navigating our very complicated healthcare industry. Please reach out to learn more about our transparency and guidance solutions and how we can help your organization comply with federal mandates.