Feb 23, 2022
The No Surprises, Continuity of Care, and Provider Directories provisions of the Consolidated Appropriations Act (CAA) of 2021 went into effect last month. Here is what you need to know to support your Blue Shield of California clients.
Surprise Billing
The No Surprises Act, aimed at protecting members from unanticipated out-of-network medical bills, outlines an array of requirements and processes impacting providers and health plans.
Under this provision, members are only responsible for in-network cost-sharing amounts for out-of-network services rendered in the following scenarios: 1) certain ancillary services provided by out-of-network providers at in-network facilities such as care received during emergencies at emergency departments and also during air ambulance transport, and 2) out-of-network care provided at in-network facilities without a provider notification to the patient including a good faith estimate of services and the patient’s informed consent.
The provision also outlines an Independent Dispute Resolution (IDR) process for out-of-network billing disputes if providers and health plans are unable to reach an agreement on an out-of-network Qualifying Payment Amount (QPA). The Biden Administration shared last year that a health plan’s median contract rate for an item or service is the appropriate out-of-network payment amount for the IDR unless credible evidence is submitted otherwise. Blue Shield is aware of the IDR process and is prepared to comply with the requirements set forth by the Centers for Medicare and Medicaid Services (CMS) in the case it must partake in an IDR with a provider.
There are many helpful resources on Surprise Billing provided by the CMS including fact sheets, the IDR process, and consumer protection that can be found on www.cms.gov/nosurprises.
Continuity of Care
Continuity of Care (CoC) legislation is meant to ensure continuation of care for patients in the middle of complex care in the case when their provider’s contract is terminated.*
Under CAA laws, continuing care patients can stay with a terminated Provider* if receiving treatment for pregnancy, a serious and complex condition, or a terminal illness. Inpatients and individuals scheduled for non-elective surgery may also stay with a terminated Provider. Providers must continue care until treatment ends or 90 days after notice of termination is received, whichever is sooner, and also must accept payment, follow policies and procedures, and meet quality standards as if the expired contract were still in place.
Federal requirements for continuity of care, which are stricter than California’s, must be incorporated into self-funded plans. California employers are not mandated to provide state CoC completion of covered services for self-funded groups. Blue Shield offers Self-Funded Employer Groups to enroll in both state and federal mandates. Please refer to this FAQs document for additional information.
Provider Directories
The Provider Directories provision of the CAA requires payers to establish a verification process to confirm provider directory information at least every 90 days, including removing providers or facilities that are non-responsive. Additionally, the provision requires updating directory information within 48 contiguous hours of receiving information from a provider or facility, not including weekends and holidays.
Blue Shield successfully deployed, and is now compliant with, the additional Provider Directories requirements. These include requirements that plans must also develop a protocol to respond to member network questions within one business day, and that members who receive inaccurate information that a provider is in-network can only be liable for in-network cost-sharing. Members can find the most up to date provider information using the Blue Shield Find a Doctor tool or by calling the Customer Care number on their Blue Shield member ID card.
Blue Shield teams are closely following and preparing to implement the transparency provisions of the CAA that are pending future rulemaking. Blue Shield has carefully evaluated provisions such as Insurance ID Cards, Broker Compensation Disclosure, Mental Health Parity and Addiction Equity, and Gag Clauses, that previously went into effect to meet timely compliance. They continue to pursue solutions to meet additional requirements of these mandates and will provide updates accordingly.
You can reference the Blue Shield Mandates page on Broker Connection for more information and updates, including summaries and FAQs for the CAA. Blue Shield is closely following all regulatory guidance and working to implement requirements to meet timely compliance. They will share more information on how these changes will impact you and their members as it becomes available.
* Unless the Provider is terminated for reasons other than fraud or failure to meet quality standards.
