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As if 2020 didn’t gift health plans enough regulation fun, the year closed out with another surprise—the ‘No Surprises Act’ that was part of the ‘Consolidated Appropriations Act, 2021’ (HR 133) a $2.3 trillion piece of legislation that includes $900 billion in federal funding and relief for COVID-19. While the ‘No Surprises Act’ legislation is largely to bolster protections for consumers against surprise and balance billing in health care, it also includes specific health plan requirements for price transparency and provider directories. Here are the highlights we are reviewing for our plan partners.

RELATED: Watch AHIP webinar, Making Costs Clear: Beyond Price Transparency Mandates.

Providing members with online price transparency

Starting with plan years beginning on or after January 1, 2022, group and individual health plans must offer personalized price comparison guidance by phone and website (Section 114). This requirement is a year earlier than the Transparency in Coverage final rule  requirement. In the No Surprises Act, plans must provide members with the ability to compare the amount of their cost shares for a specific item or service by any provider for their plan year and in their geographic region. While more specifics of how plans must implement should be forthcoming, price transparency tools, like HealthSparq One, already provide out-of-pocket pricing to support members when comparing their cost sharing requirements for covered services.

Improving the availability and accuracy of provider data

For group and individual plans with plan years starting in 2022, the legislation (in Section 116) requires plans to establish a database of direct and in-direct contracted providers and facilities. The data needs to be shared on a public website for member access. Directory information is defined as name, address, specialty, telephone number, and digital contact information of each contracted provider or facility. Printed directories must have a notification that data was accurate as of the publication date and that members should consult the online directory, or database, for the most current provider directory information.

The legislation also outlines requirements for maintaining up-to-date provider information. Specifically, plans must verify provider directory information at least every 90 days and establish a procedure to remove providers without verification and when they are no longer in-network. Provider data must be updated within two business days of receipt. And, if a member receives incorrect information that a provider is in-network when they are not, the member would only be responsible for the in-network cost-sharing amount for the covered service.

Providing EOBs in advance of appointment

Health plans must also provide members with an “Advanced Explanation of Benefits” for scheduled services (Section 111). This would include the provider/facility network status and estimates of charges, contracted rates based on the billing and diagnostic codes, and member cost-sharing amounts. The estimate must also include disclaimers related to medical management (such as concurrent review, prior authorization, and step-therapy or fail-first protocols), reasonable expectation of items and services that is subject to change, and any other disclaimers the plan deems appropriate.

HealthSparq is well positioned to help plans meet the requirements of the legislation. We’ve been supporting plans and their members with provider directories and out-of-pocket price transparency for years. While the detailed rules to implement this legislation are forthcoming, HealthSparq fully intends to support these new requirements starting on 1/1/2022.  To learn more about HealthSparq’s proven capabilities, request a demo today.