Employee Benefits Compliance

FAQs Delay Transparency Rule Effective Dates; Clarifies Requirements For Plan Transparency for Costs and Provider Negotiated Rates

Recently released Frequently Asked Questions (FAQ) address several issues related to the Transparency in Coverage (TiC) regulation and the insurance plan and provider transparency regulations in the Consolidated Appropriations Act (CAA). The FAQs –

  • Delay the effective for some, but not all, provisions
  • Provides for provisions that will not have rules written prior to the stated effective date and related clarification that plans may use reasonable good faith interpretation of the rule in order to comply prior to receiving further guidance

See the below chart for details on the FAQs.

TiC RequirementOriginal Effective DateNew Date / Detail
Plan must post public machine-readable file for in-network provider ratesPlan years beginning on/after 1/1/2022Plan years 1/1/2022 – 6/30 the effective date is extended to 7/1/2022. No extension after 7/1.
Make public machine-readable file out-of-network allowed amounts/billed charges for covered itemsPlan years beginning on/after 1/1/2022Plan years 1/1/2022 – 6/30 the effective date is extended to 7/1/2022. No extension after 7/1.
Make public machine -readable file negotiated rates & historical net prices for covered prescription drugsPlan years beginning on/after 1/1/2022Effective date extended indefinitely pending revised regulations.
Plan must offer self-service price comparison tool for 500 shoppable covered items/servicesPlan years beginning on/after 1/1/2023Not extended; proposed addition of telephone number for assistance.
Plan must offer self-service price comparison tool for all covered items/servicesPlan years beginning on/after 1/1/2024Not extended; proposed addition of telephone number for assistance.
CAA RequirementOriginal Effective DateNew Date / Detail
Plan must offer price comparison toolPlan years beginning on/after 1/1/2022Duplicative of similar tool required under the TiC transparency rules. Line up rules by extending effective date of CAA so all similar provisions are effective 1/1/2023.
Plan must include deductibles and out-of-pocket max on insurance ID cardsPlan years on/after 1/1/2022Not extended. Good faith, reasonable interpretation of rule appropriate pending written sub-regulatory guidance; not expected prior to 1/1/2022.
Plan prohibited from gag clause contract provision for provider cost or quality data (contracts cannot ban obtaining this information as needed to comply with transparency provisions)12/27/2020Not extended. Use good faith, reasonable interpretation. Regulations expected on process for submitted attestations of compliance.
Provider and Plan must coordinate to provide advanced Explanation of Benefits to patient scheduling servicesPlan years on/after 1/1/2022Extended indefinitely pending regulations.
Provider must give patient good faith estimate of costs if no health insurance coverage / doesn’t intend to submit claim through insurance1/1/2022Not extended. Regulations expected prior to effective date.
Plan must apply in-network cost sharing to claim if participant relies on directory information that incorrectly identified provider as in-networkPlan years on/after 1/1/2022No extended. Use good faith, reasonable interpretation pending regulations not expected prior to effective date.
Plan must submit prescription drug information/costs to governmentFirst due by 12/27/2021 and subsequently by 6/1 annuallyDeadlines extended pending regulations. Expect to report 2020 & 2022 by 12/27/2022.

The Surprise Medical Billing rule was not delayed and will be effective January 1, 2022. For details on the surprise medical billing regulations, see the Leavitt Group article.

Conclusion

Plan sponsors should ensure they work with their Leavitt Group Trusted Advisor for employee benefits to understand the provisions applicable to your plan.  Be sure to consult the FAQs for full details. There are many provisions which will require use of a good faith, reasonable interpretation of the law as you understand it. The good news, is that the bulk of the work required for these provisions will rest with the insurer plans. Some self-funded plans will require additional work as these provisions come into play plan years 2022. Consult your Third-Party Administrator for coordination on any of these provisions.

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