Employer Checklist for New Health Plan Price Transparency Rules and CAA

Mental Health Parity Comparative Analyses

Plans imposing non-quantitative treatment limitations (NQTLs) on mental health or substance use disorder benefits must perform comparative analyses of the application of these NQTLs.  Must make analyses available to regulatory agencies upon request.  (CAA)

02/10/2021

None.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

Third Party Fee Disclosures

New requirement to avoid an ERISA prohibited transaction (similar to current retirement plan fee disclosures).  Covered service providers must provide this disclosure to responsible plan fiduciary.  (CAA)

12/27/2021

Good faith, reasonable interpretation.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

Public Pricing Information Disclosures

Plans must publicly disclose through three machine-readable files information regarding: in-network negotiated rates; out-of-network amounts allowed and associated billed charges; and prescription drug information.  Disclosures must be posted on a public website. (TiC Regulations)

Plan Years on or after 01/01/2022

Deferred enforcement for INNET/OON until 07/01/2022.

Rx enforcement was deferred until 9/27/2023 FAQ guidance; regulators soon to issue implementation timeline.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

Price Comparison Tool

Plans must offer price comparison guidance by phone and make a price comparison tool available online that allows an enrolled individual to compare cost-sharing for specific items and services.  Note this is similar, but not identical to, Self-Service Tool below. (CAA)

Plan Years on or after 01/01/2022

Deferred enforcement until plan year on or after 01/01/2023, to align with TiC requirement below. Future regulations may be issued to merge requirements.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

Pre-Service Cost-Sharing Disclosure and Self-Service Tool

Plans must disclose cost-sharing information upon request, including an estimate of cost-sharing liability for covered items pre-service.  Disclosure must be available through a self-service tool that allows for searching of factors that are relevant for cost-sharing determinations.  Must also be available upon request in paper form.  Note this is similar, but not identical to, the Price Comparison Tool above.  (TiC Regulations)

Plan Years on or after 01/01/2023 (500 items);

Plan Years on or after 01/01/2024 (full compliance)

None.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

Advanced Explanation of Benefits (EOB)

Plans must provide EOB to covered individuals in advance of a service.  Required within one-three business days after plan receives notification of a service from a health care provider or facility.  (CAA)

Plan Years on or after 01/01/2022

Deferred enforcement pending further rulemaking.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

Continuity of Care Protections and Notification

If plan’s contractual relationship with a participating provider or facility terminates or changes so that benefits provided in relation to a continuing care patient’s care is no longer provided, plan must provide patient notification and right to elect continued transitional care. (CAA)

Plan Years on or after 01/01/2022

Good faith, reasonable interpretation required.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

Provider Directory

Plans must create database listing providers with direct or indirect contractual relationship with plan. Plan must verify and update directory information every 90 days. If participant uses out-of-network provider based on misrepresentation that provider was in-network, plan must process and pay claim as if in-network. (CAA)

Plan Years on or after 01/01/2022

Good faith, reasonable interpretation required.

If misrepresent INNET status, no enforcement if treat cost-sharing as INNET.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

ID Card Disclosures

Plan physical and electronic ID cards must state deductible, out-of-pocket maximum, and contact information (phone and website) for consumer assistance information. (CAA)

Plan Years on or after 01/01/2022

Good faith, reasonable interpretation required.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

Removal of Gag Clauses

Plans may not enter into any agreement regarding access to a network of providers that would restrict the plan from providing provider-specific cost or quality of care information, accessing de-identified information or data, or sharing such information with a business associate.  Annual attestation of compliance must be submitted to CMS.  (CAA)

12/27/2020

First attestation must be submitted by 12/31/2023 (covering multiple years), then by each Dec. 31 thereafter.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

No Surprise Billing (Balance Bill Prohibition)

Plans must comply with new participant cost-sharing and nonparticipating provider payment requirements with respect to emergency services, nonemergency services provided by nonparticipating providers at participating facilities, and air ambulances; exceptions apply to certain services if participant provides consent. Expansion of ACA’s patient protections for emergency coverage (e.g., expanded definitions).  Expansion of external review to adverse determinations made involving surprise billing protections, and new independent dispute resolution process for providers.  New notice requirements on public website and in EOBs. (CAA and regulations)

Plan Years on or after 01/01/2022

For required disclosures, plans must use good faith, reasonable standard.

Use of model notice considered good faith.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

Prescription Drug Cost Reporting

Plans must submit prescription drug and plan spending information to HHS, DOL, and Treasury, including but not limited to top drugs dispensed, most costly drugs, rebate information, plan expense breakdowns, and plan premium information.  (CAA)

12/27/2021

Delayed. 2020 and 2021 reports are now due by 12/27/2022, and future year reports by June 1 thereafter.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

Air Ambulance Cost Reporting

Plans must report air ambulance claims data. Per proposed rules, 2022 data must be submitted by 3/31/2023; and 2023 data must be submitted by 3/30/2024. Only two calendar years of reporting. (CAA)

03/31/2023 per proposed rules

CMS delayed reporting until rules are finalized.

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date:

Choice of Health Care Professionals Patient Protections – Grandfathered Plans Only

(This rule is currently applicable to non-grandfathered plans under the ACA.) If plan requires a participant to designate a primary participating provider, then plan must allow participant to designate any participating provider who is available to accept such individual (also special rules for pediatricians with children and gynecologists for women).

Plan Years on or after 01/01/2022

None

Service Agreement Amendment required? Yes/No

Plan/SPD Amendment required? Yes/No

Other follow up required? Yes/No

Target Date: