Network Directory Health plans are required to verify, maintain, and update directories of network providers at least every 90 days. Enrollees who rely on incorrect information included in an out-of-date network directory may be protected from higher cost-sharing amounts. For example, if an enrollee receives treatment from a provider who is listed in an out-of-date directory as a network provider but has since left the network, claims must be paid at the network cost sharing amount. Continuity of Care If a provider changes network status, individuals identified as “continuing care patients” may continue care with the provider for up to 90 days at network cost-sharing rates to allow for a transition of care to a network provider. A continuing care patient is one who is: • undergoing a course of treatment for a serious and complex condition; • undergoing a course of institutional or in-patient care; • scheduled to undergo nonelective surgery, including receipt of postoperative care with respect to the surgery; • pregnant and receiving care for the pregnancy; or • receiving treatment for a terminal illness. Non-Quantitative Treatment Limitations (NQTL) Analysis The Mental Health Parity and Addiction Act of 2008 prohibits a health plan from imposing a non-quantitative treatment limitation (NQTL) on mental health or substance use disorder benefits based on medical appropriateness. NQTLs include preauthorization requirements, step-therapy requirements, credentialing requirements, medical necessity policies, and usual customary and reasonable determinations. Under the CAA, health plans must prepare—and provide to the Department of Labor upon request—a written analysis demonstrating that the plan’s NQTL requirements for mental health/substance abuse services are no more restrictive in design or operation than those for medical/surgical services. Prescription Drug and Medical Reporting Effective Dec. 27, 2022, and not later than June 1 of each year thereafter, plans must annually report detailed plan information, including: • The 50 most commonly prescribed brand drugs; • The 50 costliest prescription drugs; • The 50 prescription drugs with the greatest increase in plan expenditures; • Total spending on health care services by the plan; • The average monthly premium paid by employers on behalf of enrollees, and by the enrollees themselves; • The impact of drug manufacturer rebates, fees, and other remunerations health care premiums; and • Any reduction in premiums and out-of-pocket costs associated with rebates, fees, or other remuneration. Air Ambulance Reporting Insurers and self-funded plans will be required to report certain detailed claims information (including transport information, network status, and claim adjudication information) for air ambulance services. Reports for 2022 must be submitted by March 31, 2023.
No Surprises Act The No Surprises Act (“NSA”) protects consumers against unexpected or “surprise” medical bills by prohibiting balance billing for certain services and requiring notice and consent for others and requiring that the prohibition language be provided to consumers on the plan’s public website and on each EOB. The NSA prohibits facilities or providers from balance billing for more than the network cost-sharing amount for: • Emergency services received in a non-participating facility; • Certain ancillary services performed in a participating facility by out-of-network providers; • Services provided by a non-participating provider in a participating facility when there is no participating provider who can furnish such services; and • Services provided by a non-participating provider or facility without the patient’s informed consent. The NSA also creates a negotiation/resolution process to resolve disputes between health plans and out-of-network providers for balance billing-prohibited services. A new federal Independent Dispute Resolution (IDR) process requires disputing parties to engage in a 30-business day negotiation period to attempt to reach an agreement regarding the total out-of-network rate (including cost sharing); if no agreement is reach, either party may initiate the IDR process within four days. The IDR process is administered by an arbitrator who will take into consideration payment amounts offered by each party, as well as median contracted rate, level of training and experience of the provider, and other relevant factors. The arbitrator’s decision is binding and the losing party is responsible for paying the arbitrator’s fees. Each party will pay a $50 administrative fee. Expansion of External Review The scope of external review has been expanded to allow reviews of adverse benefit determinations that involve a finding the surprise billing protections are not applicable to the claim. What You Should Do Next If your company is a participating employer in Western Growers Assurance Trust or uses Pinnacle Claims Management, Inc. as its third-party administrator, all these requirements have been implemented or are in development for timely compliance by the applicable effective dates. If your company sponsors a self-insured plan and uses another third party administrator, work with your administrator to ensure that all these requirements are being addressed and your interests are protected. Remember, it is ultimately the employer’s responsibility to comply with these new requirements. If you have any questions or would like to learn more about these requirements, please contact Jonathan Alexander at jalexander@wgat.com Compliance Note: Western Growers Assurance Trust (“WGAT”), a multiple employer welfare arrangement, is implementing the transparency requirements imposed by the TIC and CAA. WGAT’s participating employers are not required to individually take any action to comply with these new requirements. Please note, WGAT’s plan year runs on a fiscal basis from July 1 st – June 30th, which impacts whenWGAT must comply with the requirements detailed above.
MAY | JUNE 2022
33
Western Grower & Shipper | www.wga.com
Made with FlippingBook. PDF to flipbook with ease