Surprise Health Plans!
The recently enacted Covid Relief bill that was signed into law on December 27, 2020 not only provides further relief in regard to the impact of the COVID-19 pandemic, but also also adopted a number of new substantive laws that impact health plans and providers, including the No Surprises Act (the “Act”). More specifically, the No Surprises Act contains several requirements related to price transparency and provider directories that impact health plans effective January 1, 2022 (1).
In general, the Act attempts to protect consumers who see out of network (“OON”) providers by capping their responsibility for cost sharing to what it would have been if they were treated by an in-network provider. As a result, consumers will be protected from surprise bills in situations where they have little or no control over who provides their care. The Act also establishes a dispute resolution and arbitration process for health plans to resolve payment disputes with OON providers.
In addition, as summarized below, the Act contains several other provisions that are helpful for protecting consumers from surprise medical bills, including certain transparency requirements for health plans.
Internet Based Price Comparison Tool
For plan years beginning on or after January 1, 2022, health plans must offer price comparison guidance by telephone through a tool like our member services log-in feature which enables member services professionals to view the same options as the member is seeing so as to guide the member effectively. It will also require plans to make available, on the plan’s website, a price comparison tool like CareSelect’s Cost Add-on. This feature must allow an enrollee, with respect to the applicable plan year, geographic region, and participating providers, to compare the amount of cost-sharing that the individual would be responsible for paying under the plan with respect to the furnishing of a specific service by any such provider.
It is important to note that this requirement is one year earlier than the Self-Service Internet Tool requirements under the Transparency in Coverage regulations, as summarized here.
Database of Contracted Providers
For plan years beginning on or after January 1, 2022, health plans must:
- establish a database on a public website listing each provider/facility that has a direct or indirect contractual relationship under the plan, including the:
- Name; address, specialty, telephone number, and digital contact information of the provider/facility;
- establish a regular verification process for the providers/facilities listed in the provider directory;
- establish a response protocol for individuals who request information on whether a provider/facility has a contractual relationship with the health plan; and
- provide information about print directories being accurate as of the date of publication and directing individuals to the database on the public website to obtain the most current provider directory information.
If an enrollee receives erroneous information through the database, provider directory, or response protocol that a provider/facility is a participating provider/facility, the health plan must not impose out-of-network cost-sharing, deductibles, or out-of-pocket maximum amounts on the enrollee.
Provider Directories
Effective January 1, 2022, health plans must ensure provider directories are current and accurate, with regular verification of provider contract status and updates required at least once every 90 days. Providers are required to submit regular updates to group health plans and insurers to assist with their verification and update process, including notice of material changes to their provider directory information. The database of provider directories must be updated within 2 business days of the Health Plan receiving such data.
Health Plans must also respond to enrollees about a provider’s network status within one business day of a request and establish a database of in-network providers. If a patient provides documentation that they received incorrect information from a plan about a provider’s network status prior to a visit, the patient will only be responsible for the in-network cost-sharing amount.
Advanced Explanation of Benefits
For plan years beginning on or after January 1, 2022, health plans must provide an “Advanced Explanation of Benefits” to enrollees for scheduled services (through mail or electronic means), which includes:
- notification of a provider/facility’s network participation status;
- the contracted rate of a participating provider/facility;
- a description of how the enrollee may obtain information on participating providers/facilities;
- a good faith estimate of expected charges from a nonparticipating provider/facility;
- a good faith estimate of the amount the plan or coverage is responsible for paying with respect to services provided by nonparticipating providers/facilities;
- a good faith estimate of the enrollee’s cost-sharing responsibility;
- a good faith estimate of the amount the enrollee has incurred toward meeting financial responsibility limits (e.g., deductibles, out-of-pocket maximums);
- a disclaimer if the service is subject to medical management techniques (e.g., concurrent review, prior authorization, step-therapy or fail-first protocols); and
- a disclaimer that such information is only an estimate.
Prohibition on Gag Clauses in Contracts
Health plans may not enter into an agreement with a health care provider, network or association of providers, third-party administrator, or other service provider offering access to a network of providers that would directly or indirectly restrict the health plans from:
- providing provider-specific cost or quality of care information or data, through a consumer engagement tool or any other means, to referring providers, the plan sponsor, enrollees, or individuals eligible to become enrollees of the plan or coverage;
- electronically accessing de-identified claims and encounter information or data for each enrollee in the plan or coverage, upon request and consistent with HIPAA, GINA, and the ADA on a per claim basis—
- financial information, such as the allowed amount, or any other claim-related financial obligations included in the provider contract;
- provider information, including name and clinical designation;
- service codes; or
- any other data element included in claim or encounter transactions; or
- sharing such information or data, or directing that such data be shared, with a business associate.
Insurance Cards
For plan years beginning on or after January 1, 2022, health plans must include on insurance cards issued to enrollees any in-network and out-of-network deductible and out-of-pocket maximum limitations applicable to the plan or coverage.
Health plans must also have a telephone number and website address where enrollees can seek consumer assistance information, such as information related to hospitals and urgent care facilities that have in effect a contractual relationship with such plan or coverage for furnishing items and services under such plan or coverage.
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(1) All requirements under the Act impact both health insurance issuers and group health plans. Medicare and Medicaid plans are excluded from the requirements of the Act.