The Consolidated Appropriations Act (CAA) of 2021 and the Transparency in Coverage Final Rule will impact many of our members starting Jan. 1, 2022. As providers caring for our members, you may be impacted as well.
Here are highlights of changes we are making. This isn’t a comprehensive review of all requirements. Some details may change if the federal government issues additional regulations or guidance. Watch News and Updates for more information and consult with your own legal advisors for information on obligations that may apply to you.
Provider Directory (plan years beginning on or after Jan. 1, 2022)
CAA requires provider directory information to be verified every 90 days. Providers and insurers have roles in fulfilling this requirement to maintain an accurate directory. Learn more.
ID Cards (plan years beginning on or after Jan. 1, 2022)
The CAA requires that member ID cards include deductible information and out-of-pocket maximums. We will provide new electronic cards for all members. Learn more.
Continuity of Care (plan years beginning on or after Jan. 1, 2022)
Most of our group and fully insured plans include a period of continuity of care at in-network reimbursement rates when a provider leaves our networks. The new legislation also requires continuity of care for affected members when:
- A provider’s network status changes
- A group health plan changes health insurance issuer, resulting in the member no longer having access to a participating provider in our network.
Surprise Billing Provisions of No Surprises Act (NSA) (plan years beginning on or after Jan. 1, 2022)
Under NSA, most out-of-network providers will no longer be allowed to balance bill patients for:
- Emergency services (learn about the updated definition of emergency services)
- Out-of-network care during a visit to an in-network facility
- Out-of-network air ambulance services, if patients' benefit plan covers in-network air ambulance services
No Surprises Act (NSA) – Downcoding Explanations
As part of ensuring we’re appropriately reimbursing for our members’ care, there are some situations in which we may recode a claim. We notify nonparticipating providers when we do this on the provider claim summary. Under the U.S. Departments of Health and Human Services, Labor and the Treasury Requirements Related to Surprise Billing: Final Rules, we are in the process of updating that notice for items and services subject to the NSA requirements.
Gag Clauses (effective Dec. 27, 2020)
CAA prohibits health insurers and group health plans from agreements with providers that include gag clauses related to provider cost and quality information. If any of our contracts include such CAA gag clause language, the contract language will be remediated, and in the interim, the language will be considered unenforceable as a matter of law.
Machine-Readable Files
Health insurers are required to publicly display certain health care price information via machine-readable files on their websites beginning in 2022. These machine-readable files will include negotiated rates with in-network providers, allowed amounts for out-of-network providers and may include prescription-drug pricing. Learn more.
More About the Legislation
Congress passed the CAA in December 2020. It includes the No Surprises Act (NSA), which addresses surprise medical billing for certain services. It also has requirements for health insurers and group health plans to provide information and tools for consumers to better navigate their health care.
The Departments of Health and Human Services (HHS), Labor and Treasury (the Departments) released the Transparency in Coverage Final Rule in October 2020. The rule requires certain health care price information to be made available to help consumers and other stakeholders make health care decisions.
Note: On Aug. 20, 2021, the Departments issued guidance in the form of frequently asked questions to address the implementation of aspects of the Transparency in Coverage Final Rule and the CAA. Specifically, the Departments indicated that they are delaying their enforcement of certain provisions. We are evaluating this guidance and will provide updates as needed.