This year, Foley’s Health Benefits Practice has released multiple alerts on several of the new group health plan requirements set forth by the Consolidated Appropriations Act of 2021 (CAA) and the Transparency in Coverage (TiC) regulations under the Affordable Care Act (ACA). To review all of the major CAA and TiC requirements, you can access our checklist for plan sponsors here and our checklist for plan service providers here. This article summarizes the new CAA and TiC reporting requirements with deadlines that are soon approaching.
Prescription Drug Data Collection (RxDC) for 2020 and 2021 Data – December 27, 2022. As summarized in our previous articles here (plan sponsor perspective) and here (plan service provider perspective), RxDC reports for the 2020 and 2021 calendar years are due in a matter of days (December 27, 2022). The regulators – specifically, the Centers for Medicare & Medicaid Services (CMS) – have provided numerous instructions, templates, and other materials to help reporting entities complete this RxDC reporting. CMS’ reporting instructions provide a step-by-step walk-through of the required data files. CMS also recently issued several FAQs addressing issues that reporting entities have been experiencing with the data files, including when an employer-provided health plan uses multiple vendors (e.g., two third party administrators). Reporting entities should already have their accounts set up on the Health Insurance Oversight System (HIOS) portal and should be prepared to finalize the RxDC data files for submission. CMS informally indicated that the HIOS portal will remain open until January 31, 2023 to accept 2020 and 2021 data files, but the regulators have not yet issued any sort of official extension or non-enforcement relief beyond December 27, 2022.
Self-Service Price Comparison Tool – January 1, 2023. As summarized in our article here, the CAA and TiC regulations require group health plans to provide certain plan member disclosures upon request, including in the form of a self-service price comparison tool. On a high level, the rules require a group health plan to establish an online self-service tool that allows plan members to search for specific services covered under the plan at specific health care providers, and the tool must provide pre-service, real-time information such as whether the provider is in-network or out-of-network under the plan, whether a cost-share (e.g., copay, coinsurance, or deductible) applies for that service, the member’s current deductible and out-of-pocket maximum accumulated amounts, and whether prior authorization is needed for the service. By January 1, 2023, the tool must address 500 commonly covered services, and then must address all covered services by January 1, 2024.
Air Ambulance Cost Reporting – March 31, 2023. As summarized in our article here, the CAA requires group health plans to report specific air ambulance claim data. Currently, the requirements are set forth in a Proposed Rule (as discussed in our previous article). The Proposed Rule provides that group health plans must submit their air ambulance claim reports for the 2022 calendar year by March 31, 2023. Given that the requirements are currently only in proposed form and we have received little guidance from the regulators on how this reporting will be conducted, it is possible that this reporting deadline will be extended or the rule will be modified in its final state. However, at this time, we understand that this deadline still applies and the reporting requirements must be met as specified in the Proposed Rule.
RxDC Reporting for 2022 Data – June 1, 2023. RxDC reporting (summarized above) for the 2022 calendar year is due June 1, 2023, so there is not much of a break between the reporting for the 2020 and 2021 calendar years and the 2022 calendar year.
The Foley Health Benefits Practice has been advising employers, health plans, insurance carriers, third party administrators, pharmacy benefit managers, point solution companies, and other health plan service providers on these requirements. Our team is happy to assist as companies work through these requirements for the very first time.
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