The No Surprises Act and Transparency in Coverage Rules

The Departments of Labor, Health and Human Services (HHS), and the Treasury (collectively, the Departments) jointly released information regarding the No Surprises Act (NSA) and Transparency in Coverage (TiC) Rules.

We continue to monitor these rules as they are subject to change. Please consult with your legal or other advisor as needed.

This notice was last updated on June 24, 2022; is based on HWMG’s interpretation; does not represent financial, tax, or legal advice; and is subject to future review and modification.

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Highlights

Mental health parity describes the equal treatment of mental health conditions and substance use disorders in health plans. HWMG will provide a Non-Quantitative Treatment Limitations Comparative analysis to the DOL or HHS, upon request.

Requires new service provider disclosure requirements for brokerage and consulting services, and requires group health plan fiduciaries to take action if they do not receive these disclosures. Disclosure is required only if the service provider receives $1,000 or more.

Requires deductible and out-of-pocket maximum information on physical or electronic member ID cards. In December 2021, HWMG distributed new ID cards containing a QR code for online viewing of deductible and out-of-pocket maximum information. Here’s how to view the QR code information on the ID card:

  1. Open the camera app on your mobile device.
  2. Point your camera at the QR code on your ID card.
  3. Tap the pop-up link to the website that appears on your screen.
  4. Your device will automatically open the website, where you can view your deductibles and out-of-pocket maximums.

Requires health plans to update and verify the accuracy of provider directory information at least every 90 days and establish a protocol for responding to requests from enrollees about a provider’s network participation status.

Prohibits balance billing of members and protects against surprise billing when receiving out-of-network emergency services, out-of-network nonemergency services at an in-network facility, or out-of-network air ambulance healthcare services. There are some exceptions based on member consent.

Also requires health plans to make publicly available and include on applicable explanation of benefits (EOBs) information about balance billing restrictions, state law protections, and appropriate agency contacts in case an individual believes a provider or facility has violated such restrictions.

HWMG has posted a surprise billing disclosure notice which will be included with all medical EOBs to members about their rights and protections against surprise medical bills.

Requires health plans to use a qualifying payment amount (QPA) to determine the amount members are required to pay for certain out-of-network services. The QPA will also be used to determine the initial plan payment for non-emergency services rendered by out-of-network providers at certain in-network facilities.

Requires continuity of services for certain health plan enrollees, defined as “continuing care patients,” when there is a change in the provider network. Such patients will receive timely notification of the change and have up to 90 days of continued coverage at in-network cost-sharing to allow for transition of care to an in-network provider.

Requires health plans to disclose via machine-readable files on a public website information regarding in-network provider rates for covered items/services and out-of-network allowed amounts and billed charges for covered items/services. Learn more.

Requires health plans to submit to the Departments data related to prescription drug expenditures.

Requires health plans to make price information available to enrollees through an internet-based self-service tool, in paper, and via telephone with respect to covered items/services. This information must be available beginning January 1, 2023 for certain items and services, and January 1, 2024 for the remainder.

Requires health plans to send participants an Advance Explanation of Benefits (AEOB) with cost estimates on services scheduled at least three days in advance. This requirement is deferred to an unspecified date.

Please reach out to HWMG’s Customer Service Center at (808) 941-4622, toll-free at (808) 941-4622, or via email if you have questions about any of the above.