Federal changes providers should know about in the new year

There are two federal changes that impact the health care industry, effective January 1, 2022: the No Surprises Act (as part of the Consolidated Appropriations Act of 2021) and the Transparency in Coverage rule. Both directly apply to commercial and self-insured coverage. Continue reading to learn more about how these federal changes can impact you as a provider.

The No Surprises Act has many touchpoints with the provider community, to address surprise billing, update member ID cards, and make new provider directory updates. See below for sections of the No Surprises Act that have the most direct impact on you and your operations.

  • Balance Billing Members: The No Surprises Act protects members from ‘balance billing’ for three scenarios:
    • Emergency Room Care
    • Certain professional services rendered by a Non-Participating provider during admission at a Participating Facility (unless a patient consents); and
    • Out-of-Network Air Ambulance transportation (not ground ambulance)

These services should be covered as in-network and include a requirement that health plans make a qualified payment directly to the out-of-network provider.

  • QPA and IDR requirements: To also help prevent members from receiving unexpected bills for certain services, a new payment called a QPA (Qualifying Payment Amount) and IDR (Independent Dispute Resolution) requirements have been established. Out of Network Providers rendering qualifying (ER, air ambulance, or care by a non-participating provider at an in-network facility) services may now be reimbursed via a QPA methodology, and may include an external rate open negotiation and a new federally regulated Independent Dispute Resolution (IDR) if they disagree with the payment.
  • Member ID cards: To help members better understand their cost-sharing responsibilities, plans have updated ID cards to reflect their in-network and out-of-network deductible—and their maximum out-of-pocket requirements. These changes will roll out throughout 2022.
  • Provider Directory: Beginning January 1, 2022, new federal requirements in the No Surprises Act have placed greater importance on provider directory accuracy. Health plans will be required to verify provider directory information every 90 days and remove providers from directories if unable to validate the accuracy of a provider’s information.
  • Cost estimator: Both the Transparency in Coverage final rule and the No Surprise Act include similar requirements for a price comparison tool for real-time estimates of cost-share for covered items and services—with different effective dates (the No Surprises Act was January 1, 2022). In recognition of the duplication, the federal government will defer enforcement of the No Surprises Act to plan year January 1, 2023, to align with the Transparency in Coverage requirements. Massachusetts has required a cost estimator since 2012, and we are leveraging our existing cost estimator tool for this new federal requirement as federal details emerge.
  • Advance Explanation of Benefits (AEOB): To keep patients informed prior to certain services, a member will be able to request a pre-service cost estimate after scheduling a service with their provider. AllWays Health Partners offers an interim process for 1/1/22 as the final federal rules have not been published.
  • Prescription Costs & Impact on Premium: This new reporting requirement, among other things, identifies high-cost drugs and their impact on commercial premiums; it will be submitted to the federal government. This report will be due 12/27/2022 based on pending guidance that has yet to be finalized.
  • Provider gag clauses: This requirement ensures that provider contracts do not include ‘gag clauses’ that would interfere with certain requirements within the No Surprises Act and Transparency in Coverage regarding access to provider-specific cost and quality data. The Transparency in Coverage rule has two main requirements on health plans:
    • Cost Calculator: These are personalized, real-time estimates of out-of-pocket costs for covered items and services via an internet-based tool (and paper upon request) before enrollees seek care.
    • Public Display of Machine Readable Files: Two machine-readable files, in-network rates, and historical allowed amounts are available on our website as of 07/01/2022. The prescription drug machine-readable file is deferred pending future federal rulemaking.

For more information, visit cms.gov

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