Aug 27, 2021
The Consolidated Appropriations Act of 2021 (CAA), also called the “No Surprises Act” required all health insurance carriers and employers that offer group coverage to provide increased transparency in several areas, such as billing.
The Biden Administration recently delayed several of the requirements in the FAQ guidance issued on August 20, 2021
The original deadlines were December 27, 2021 for plan years effective January 1, 2022. Certain enforcement deadlines have been extended. In still some instances, a good faith compliance standard applies until implementation regulations are finalized.
The new requirements apply to all employer group health plans, including small and large group, grandfathered, and self-funded plans.
The following charts explain how deadlines have changed for employers, carriers, and, when applicable, health care providers.
| Requirements | Applicability | Enforcement Change | Other Important Notes |
|---|---|---|---|
| Price Data Disclosure: In-network reimbursement rates and out-of-network allowed amounts and billed charges: publish machine-readable files on a public website | Carriers* | Delayed until July 1, 2022. | - |
| Prescription Drug Costs and Pricing Data: publish machine-readable files on a public website | Carriers* | Delayed until further notice. | This requirement remains under review. |
| Price Comparison Tool for all enrollees and plan participants: publish an Internet-based tool | Carriers* | Enforcement deadline changed to January 1, 2023. | Since the requirement is largely duplicative of the internet-based self-service price disclosure requirement in the health plan transparency rule, consolidation is being considered. |
| Prescription Drug Costing Report: Disclose detailed plan pharmacy and claims cost data to the federal government on December 27, 2021, and every June 1 thereafter. | Carriers* | Delayed pending further guidance. | - |
| Advanced EOB: EOBs provided before members incur a claim and following the receipt of a good faith estimate of charges from the insured’s provider. | Carriers* | Delayed until the finalization of regulations. | This requirement remains under review. |
| Provider Good Faith Estimate: Provide a good faith estimate of expected charges when they schedule treatment and any items or services reasonably expected to be provided with the scheduled treatment, including those by another provider or facility. | Providers | Delayed until the finalization of regulations. | This requirement remains under review. |
Surprise Balance Billing Requirements: Types of Medical Service and Claims Affected:
|
Providers, Carriers* | No delay, effective for plans that start on or after January 1, 2022. Good faith and reasonable interpretation are expected until rules are final |
Group health plans have a disclosure requirement to follow starting with the 2022 plan year. The Biden Administration published a model disclosure form and directions in July of 2021. If group plan sponsors use it, they will be considered compliant. |
| No “Gag Clauses” in provider contract with group health plans and health insurance carriers. | Providers, Carriers* | No delay, effective December 27, 2021. | - |
| Provider Directory Accuracy: In-network provider directories accuracy | Carriers* | No delay, effective for plans that start on or after January 1, 2022. | If there is a network directory error and someone uses an out-of-network provider that they believed to be in-network due to the mistake, then the plan or issuer cannot require participants to pay any more than in-network cost sharing to be considered compliant. Also, the plan or issuer needs to count those cost-sharing amounts toward any deductible or out-of-pocket maximum. |
| Member ID Cards: Clear information on printed and electronic ID cards about deductibles and out-of-pocket maximum limitations, and telephone number and website address for individuals to seek consumer assistance. | Carriers* | No delay, effective for plans that start on or after January 1, 2022. Assume good faith until final guidelines are set. |
Plans and issuers are expected to implement the ID card requirements using a good faith, reasonable interpretation of the law. |
| Continuity of Care Protections | Carriers* | No delay, effective for plans that start on or after January 1, 2022. | When a provider or facility is no longer in-network or covered, participants must be permitted to elect continuing care for up to 90 days from that provider or facility under the same terms and conditions that were in place prior to the change in network or coverage. |
*Carriers and Group Health Plan Sponsors. Companies that self-fund their group coverage have sole responsibility for making sure the provisions of both the CAA and the transparency regulation are carried out.
