Compliance Toolkit

The protections for participants and their beneficiaries in the Patient Protection and Affordable Care Act (ACA) were expanded by the Consolidated Appropriations Act, 2021 (CAA) for Group Health Plans (GHPs) and individual health insurance coverage. The No Surprises Act is included in the CAA. These changes include additional reporting and disclosures requirements for employers sponsoring GHPs, insurers, and others (e.g., consultants, brokers, and agents) providing services to GHPs and individual health insurance.
The CAA applies to grandfathered GHPs. 

Most of these changes will not be applicable until 2022, some are scheduled to apply sooner, and others do not apply until 2023 or 2024. The CAA makes many changes to the Internal Revenue Code (IRC), the Employee Retirement Income Security Act (ERISA), and the Public Health Service Act (PHSA). In addition, in keeping with the theme of transparency, near the end of 2020 the Departments of Labor (DOL), Treasury, and Health and Human Services (HHS) issued the final “Transparency in Coverage” regulations, which include their own set of new disclosure requirements for GHPs and individual health insurance. It is critical that plan sponsors, participants, and other interested parties have a basic understanding of this CAA (including the No Surprises Act provisions) as well as the Transparency in Coverage regulations because they will require amendments to vendor contracts, plan documents, and Summary Plan Descriptions and are likely to increase plan expenses in the next several years. In addition, those covered under GHPs and individual health insurance will have access to much more information to make more informed decisions.

The Consolidated Appropriations Act (CAA) and the new Transparency in Coverage regulations present many significant compliance challenges to group health plans and individual health insurance coverage and their sponsors, insurers, third party administrators, consultants, brokers, agencies, and others who sponsor, issue, or provide services to group health plans and individual health insurance coverage. This comprehensive Compliance Toolkit serves as a reference and tool to guide the compliance process.

**** Find all mentioned exhibits and attachments to referenced articles by downloading them below.

Consolidated Appropriations Act Compliance

Prevention of Surprise Bills for Patients Seeking Care from an Emergency Room or Freestanding Emergency Care Facility

When an individual seeks treatment at an emergency department, he or she cannot control whether the health care provider providing treatment, or the related facility services and their health care providers providing treatments, are in his or her health plan network. To reduce the number of unexpected bills from out-of-network health care providers that individuals often receive after seeking emergency care, the new surprise billing provisions provide that the amounts paid for emergency care will now (i) be treated as in-network for calculating reimbursement, (ii) must be provided without prior authorization, and (iii) will be treated as in-network treatment provisions until the individual is stabilized, and if certain requirements are satisfied as discussed below.

These rules apply to group health plans, health insurers offering group or individual health insurance coverage (including grandfathered plans), and applicable healthcare facilities and providers. GHPs include both insured and self-insured plans, private employment based GHPs subject to Employee Retirement Income Security Act (ERISA), non-federal governmental plans (such as plans sponsored by states and local governments), church plans, and traditional indemnity plans. Individual health insurance coverage includes exchange and non-exchange plans and student health insurance coverage. It does not apply to health reimbursement arrangements, short-term limited-duration insurance or retiree-only plans and stand-alone dental and vision plans and employee assistance programs (EAPs). Applicable healthcare facilities include hospitals, hospital outpatient departments, critical access hospitals and ambulatory surgical centers. The Department of Health and Human Services (HHS) sought comment on adding other types of facilities to include, such as urgent care centers.

GHPs, health insurers, health providers and health facilities are required to make publicly available, post on a public website of the plan or issuer, and include on each explanation of benefits for an item or service with respect to which the requirements under section 9816 of the Internal Revenue Code (the Code), section 716 of the Employee Retirement Income Security Act (ERISA), and section 2799A-1 of the Public Health Service Act (PHS Act) apply, information in plain language on:

(1) the restrictions on balance billing in certain circumstances,
(2) any applicable state law protections against balance billing,
(3) the requirements under Code section 9816, ERISA section 716, and PHS Act section 2799A-1, and
(4) information on contacting appropriate state and federal agencies in the case that an individual believes that a provider or facility has violated the restrictions against balance billing.

A Model Notice, “Model Disclosure Notice Regarding Patient Protections Against Surprise Billing,” is included in the Toolkit as Attachment 2.
An out-of-network provider shall only be permitted to bill an individual more than the in-network cost-sharing amount for care provided after the participant is stabilized and certain conditions are met and if the provider gives the individual notice of the provider’s network status and delivers to the individual or their health plan an estimate of charges within certain specified timeframes and obtains individual does not seem to necessarily be the intent, but the final rule doesn’t elaborate. Similarly, can the GHP elect to change the basis from year to year?

Note: This new process also applies to out-of-network providers of non-emergency Services at In-Network Facilities and air ambulance services. The restriction is effective for plan years beginning on or after January 1, 2022.

Prevention of Surprise Bills for Patients Seeking Care from an Emergency Room or Freestanding Emergency Care Facility
The Sample Language provided in Exhibits 3 through 5 may be used by an employer, an insurer, or a third-party administrator to amend its plan documents, insurance policies, Summary Plan Descriptions, and Administrative Services Agreements.

  • Sample Language – Plan Document Provisions (Exhibit 3)
  • Sample Language – Summary Plan Description Provisions (Exhibit 4)
  • Sample Language – Administrative Services Agreement Provisions (Exhibit 5)
  • Attachment 2, the Model Notice “Model Disclosure Notice Regarding Patient Protections Against Surprise Billing”, may be used by an employer, insurer, or third-party administrator to inform participants of its policy regarding balance billing. It should be provided to participants before the beginning of plan years beginning on or after January 1, 2022. Attachment 1 contains:
    • Instructions for Providers and Facilities
    • Instructions for Group Health Plans and Health Insurance Issuers
    • Your Rights and Protections Against Surprise Medical Bills (the actual Model Notice)
  • Attachment 3 is to be used by a provider or facility to obtain approval from a participant for any charges for out-of- network services. The provider or facility should provide a plan, insurer, or third-party administrator a copy of the Model Consent Form that has been executed by the participant. Attachment 2 contains:
    • Instructions
    • Model Standard Notice and Consent Form “Standard Notice and Consent Documents Under the No Surprises Act”
  • Exhibit 6 is a Sample Notice to be used by an GHP, insurer, or TPA to inform a provider or facility that it is denying payment for the amount contained in its bill and will apply the Qualified Payment Amount (QPA) to the billed item or service.
  • The Compliance Tool, Summary of State Laws Prohibiting Balance Billing (Exhibit 7), summarizes the state laws on balance billing applicable to insured GHPs and individual insurance (including student health insurance). A GHP, insurer, or TPA should review these summaries before determining any payment in the indicated state. Another Compliance Tool, Summary Table of State Laws Prohibiting Balance Billing (Attachment 4), is attached as well to provide a quick reference for state balance billing laws.

Enforcement, Penalties, and Litigation Risk

are applicable to group health plans are added to the Code, PHSA, and ERISA and will be subject to the same general enforcement structure as the ACA coverage mandates. States retain primary enforcement authority over fully insured plans, subject to federal enforcement by HHS if a state fails to substantially enforce a provision. HHS also has jurisdiction over self-funded governmental plans.

The DOL has enforcement authority over plans subject to ERISA. Under the Code, a $100 per day per affected person excise tax may apply in the case of noncompliance by private sector plans and church plans. Provisions applicable to providers are added to the PHSA and are subject to primary enforcement at the state level and potential federal enforcement. The DOL is specifically authorized to coordinate with states and HHS regarding violations of provider requirements for GHPs and conduct investigations as appropriate.

The Act also requires the DOL to establish a process to audit health plans for compliance with the various provisions of the Act. The agencies are also required to provide a system for receiving complaints from participants about noncompliance with the Act. In addition, the Act provides 500 million dollars to fund implementation of the Act, including enforcement and health plan audits.

A violation of the No Surprises Act may result in a state enforcement action or federal civil monetary penalties of up to $10,000 per violation.
The types of providers and payers that will be impacted by this transformation are more far-reaching than one may expect, including:

  • Emergency room physicians
  • Providers that a patient typically doesn’t select such as hospitalist, radiologist, anesthesiologist, pathologist, or neonatologist
  • Air ambulance companies
  • Most out-of-network providers
  • Group health plans and group and individual health insurance coverage offered by health insurance issuers, including insured and self-insured plans

Hospital price transparency helps Americans know what a hospital charges for the items and services they provide. CMS takes seriously concerns it has heard from consumers that hospitals are not making clear, accessible pricing information available online, as they have been required to do since January 1, 2021.

CMS proposes to increase the penalty for some hospitals that do not comply with Hospital Price Transparency final rule. Specifically, CMS is proposing to set a minimum civil monetary penalty of $300/day that would apply to smaller hospitals with a bed count of 30 or fewer and apply a penalty of $10/bed/day for hospitals with a bed count greater than 30, not to exceed a maximum daily dollar amount of $5,500.

Under this proposed approach, for a full calendar year of noncompliance, the minimum total penalty amount would be $109,500 per hospital, and the maximum total penalty amount would be $2,007,500 per hospital.

Apart from the potential penalties, the new law and regulations make new information available to covered individuals, the public, and attorneys. It is likely this will prompt litigation, and a good faith compliance effort will be extremely helpful to avoid excessive losses form litigation.

Additionally, several states are now beginning to require licensing for PBMs. The licensing requirements often contain disclosure requirements regarding compensation the PBMs pay to brokers, consultants, and other service providers.

IDR

The open negotiation period then runs 30 business days from the date of the notice. Importantly, the IDR process cannot be started until the 30-business-day negotiation period is over. The written open negotiation period notice may be sent by mail. The notice may also be sent electronically if the following two conditions are met: 1) the initiating party has a good faith belief that the electronic method is readily accessible by the other party; and 2) the notice is provided in paper form free of charge, upon request.

Initiation of IDR Process
If the provider and health plan or insurer have not reached an agreement during the 30-day open negotiation period, then either party may initiate the IDR process within 4 business days. This 4-business-day period begins on the 31st business day after the start of the open negotiation period and is triggered by the initiating party sending a notice of IDR initiation to the other party. The initiating party must also furnish the notice of IDR initiation to the Departments on the same day the notice is sent through a Federal IDR portal available at https://www.nsa-idr.cms.gov.

The notice of IDR initiation must include the Qualifying Payment Amount (QPA), the initiating party’s preferred certified IDR entity, and the items or services being disputed. This notice may be sent by mail. The notice may also be sent electronically if the following two conditions are met: 1) the initiating party has a good faith belief that the electronic method is readily accessible by the other party; and 2) the notice is provided in paper form free of charge, upon request. The IFR provided a Model Notice, “Notice of IDR Initiation” (Attachment 13), which the initiating party is required to use.
The party that initiates the IDR process is prohibited from taking the same party to arbitration for the same or similar item or service for 90 days following a decision. Also, a party make not initiate the IDR process if the party knows or should reasonably know that the notice and consent provisions were properly followed for an item or service.

Selection and Notice of IDR Entity
The parties can agree to the selection of a certified IDR entity (as specified in the Notice of IDR Initiation) within 3 business days of the initiation of the IDR process. If no party objects and there are no conflicts of interest, then that entity will serve as the IDR entity. If a party objects to the selection of the IDR entity, then the party must explain its objection and propose another certified IDR entity. A party can object to the alternative. This process can continue for 3 business days. The parties must notify the Departments through the IDR portal. The notice must include, among other things, the name and IDR entity number and an attestation that the IDR entity does not have a conflict of interest.

The IFR includes an appendix listing the data elements to be included in the Notice of IDR Entity. This appendix is included in the Toolkit as a Model Compliance Tool, “IFR Appendix 1 Selection of Certified IDR Entity Data Elements” (Attachment 14).

If the parties cannot agree upon the selection of a certified IDR entity, they must notify the Departments within 4 business days after IDR initiation through the IDR portal. The Departments will then select a certified IDR entity at random within 6 days of the IDR initiation.

Notice of Agreement
The parties may continue to negotiate and reach an agreement before a final determination is made by the IDR entity under the IDR process. If an agreement is reached, then the parties must notify the Departments through the IDR portal within 3 business days. The notice must include the agreed out-of-network rate and the certified IDR entity fee and allocation if not split equally. The plan or insurer must then pay any balance to the out-of-network provider within 30 business days of the date of the agreement. If there is an agreement reached, the parties must submit a Notice of Agreement through the IDR portal. The IFR includes an appendix listing the data elements to be included in the Notice of
Agreement. The appendix is included in the Toolkit as a Model Compliance Tool, “Notice of Agreement
Data Elements” (Attachment 15).

Notice of Offer
If there still is no agreement, then each party must submit an offer along with supporting documentation within 10 business days of selecting an IDR entity. The offer must list both a dollar amount and a percentage of the qualifying payment amount (QPA) and any additional information
requested by the IDR entity. Providers and facilities must provide information relating to size and practice specialty. GHPs and insurers must disclose their coverage area, relevant geographic area and whether the plan is insured of self-funded. If batched items or services have different QPAs, the parties should provide these different QPAs. The Notice of Offer and any information requested by the IDR
entity must be submitted through the IDR portal. There is an appendix listing the data element that should be included in the Notice of Offer. This appendix is included in the Toolkit as a Model Compliance Tool, “Notice of Offer Data Elements” (Attachment 16).
Determination of Payment The IDR entity must select one of the offers (and cannot compromise) within 30 business days and provide a written decision to the parties through the IDR portal. The decision is binding on all parties in the absence of fraud or intentional misrepresentation of material facts. The decision is generally not
subject to judicial review unless there is fraud.
In determining the out-of-network rate, the IDR entity must start with a presumption the QPA is the most appropriate amount to use and thus the offer closest to the QPA should be used. The presumption can only be rebutted if the parties submit credible information that clearly demonstrates that the QPA is materially different from the appropriate out-of-network rate. QPA means the plan’s median contracted rate for the same or similar service in the same geographic region in the same insurance market. With
respect to additional factors such the provider’s level of experience and training or quality measurements, the information will have to clearly demonstrate that the QPA does not account for these factors in order to rebut the presumption. For example, the mere fact that a provider has 30 years of experience versus 10 years is not generally enough to rebut the presumption that the QPA is the
appropriate out-of-network rate. If the certified IDR entity does not choose the offer closest to the QPA, then the decision must include the underlying rationale for determining the out-of-network rate.
The IDR entity cannot consider billed charges, usual and customary charges or public payer rates including Medicare, Medicaid and Tricare or basing payment on a proportion of these amounts such as
150% of Medicare rates.
There is an appendix listing the data elements that should be included in the written decision from the IDR entity. This appendix is included in the Toolkit as a Model Compliance Tool, “IFR Appendix 6 Certified IDR Entity’s Written Decision of Payment Determination Data Elements (Attachment 21). Batching Multiple Claims Multiple claims may be batched together in a single IDR process, provided the claims are from a single 30-day period (or 90-day suspension period) and involve the same provider or facility, the same plan or insurer, and the same or similar items and services agreement. If there is an agreement reached, the parties must submit a Notice of Agreement through the IDR portal. The IFR includes an appendix listing the data elements to be included in the Notice of Agreement. The appendix is included in the Toolkit as a Model Compliance Tool, “Notice of Agreement
Data Elements” (Attachment 15).

Notice of Offer
If there still is no agreement, then each party must submit an offer along with supporting documentation within 10 business days of selecting an IDR entity. The offer must list both a dollar amount and a percentage of the qualifying payment amount (QPA) and any additional information
requested by the IDR entity. Providers and facilities must provide information relating to size and
practice specialty. GHPs and insurers must disclose their coverage area, relevant geographic area and whether the plan is insured of self-funded. If batched items or services have different QPAs, the parties should provide these different QPAs. The Notice of Offer and any information requested by the IDR entity must be submitted through the IDR portal. There is an appendix listing the data element that should be included in the Notice of Offer. This appendix is included in the Toolkit as a Model Compliance Tool, “Notice of Offer Data Elements” (Attachment 16).
Determination of Payment The IDR entity must select one of the offers (and cannot compromise) within 30 business days and provide a written decision to the parties through the IDR portal. The decision is binding on all parties in the absence of fraud or intentional misrepresentation of material facts. The decision is generally not
subject to judicial review unless there is fraud.
In determining the out-of-network rate, the IDR entity must start with a presumption the QPA is the most appropriate amount to use and thus the offer closest to the QPA should be used. The presumption can only be rebutted if the parties submit credible information that clearly demonstrates that the QPA is materially different from the appropriate out-of-network rate. QPA means the plan’s median contracted rate for the same or similar service in the same geographic region in the same insurance market. With
respect to additional factors such the provider’s level of experience and training or quality measurements, the information will have to clearly demonstrate that the QPA does not account for these factors in order to rebut the presumption. For example, the mere fact that a provider has 30 years of experience versus 10 years is not generally enough to rebut the presumption that the QPA is the
appropriate out-of-network rate. If the certified IDR entity does not choose the offer closest to the QPA,
then the decision must include the underlying rationale for determining the out-of-network rate.
The IDR entity cannot consider billed charges, usual and customary charges or public payer rates including Medicare, Medicaid and Tricare or basing payment on a proportion of these amounts such as
150% of Medicare rates.
There is an appendix listing the data elements that should be included in the written decision from the IDR entity. This appendix is included in the Toolkit as a Model Compliance Tool, “IFR Appendix 6 Certified IDR Entity’s Written Decision of Payment Determination Data Elements (Attachment 21). Batching Multiple Claims Multiple claims may be batched together in a single IDR process, provided the claims are from a single 30-day period (or 90-day suspension period) and involve the same provider or facility, the same plan or insurer, and the same or similar items and services.

There are two fees for the parties under the IDR process. The first fee is an administrative fee intended to reimburse the Departments for their costs. For 2022, the administrative fee will be $50. Each party will pay this fee to the IDR entity which will then remit the fee to the government.
There is also a fee paid to the IDR entity. These fees are determined by the IDR entity but must generally be within a pre-determined range. For 2022, this range is $200 to $500 for a single determination and $268 to $670 for batched determinations.

The IDR fee is submitted to the IDR entity which will then hold the fees in an escrow or trust account. At the end of the IDR process, the fee from the winning party will be refunded and the IDR entity retains the fee from the losing party. For batched determinations, if there are an equal number, the fee will be split evenly, otherwise the party with the fewest determinations is considered the losing party. If the parties reach an agreement during the IDR process, the fees will be split evenly unless the parties otherwise agree.

The Departments will publish information on IDR payment determinations quarterly. The IDR Entities must submit reports to the Departments monthly. This will enable plans, insurers, providers and the public to follow and assess the results. The goal is to increase transparency and make the process more efficient and predictable.
The reports will include the following:

• Number of notices of IDR initiation
• Size of provider practices
• Number of final determinations
• Description of items and services subject to final determinations including billing codes
• Geographic region
• Offers submitted expressed as dollar amount and percentage of QPA
• Whether accepted offer was from provider or plan/insurer
• Rationale for selecting offer
• Addition information submitted by parties
• Number of days between IDR entity selection and selection of payment
• IDR entity fee

The IFR includes an appendix listing all the data elements for the reporting. This appendix is included in the Toolkit as a Model Compliance Tool, “IFR Appendix 5 Entity Reporting Data Elements” (Attachment 19).

As noted above, there are various time frames that must be followed before and during the IDR process such as allowing 4 business days after the open negotiation period to initiate the IDR process. The IFR provides that in the case of extenuating circumstances, the Departments may, on a case-by-case basis at their discretion, provide for an extension of time due to matters beyond the control of the parties or for good cause. The example in the IFR indicates an extension would be warranted where a natural disaster impedes efforts by plans, insurers, or providers to comply with the terms of the IFR. The IFR provides a form to be used to request an extension of time. This form is included in the Toolkit as a Model Form,
“Request for Extension of Federal IDR Process Time Periods Due to Extenuating Circumstances (Attachment 20).

The Departments are accepting applications to be a certified IDR entity until November 1, 2021 in order to be certified by January 1, 2022. The IFR provides an appendix which lists the data elements for this
purpose. This appendix is included in the Toolkit as a Model Compliance Tool, “IFR Appendix 4 Entity Certification Data Elements” (Attachment 17). The Departments will certify IDR entities on a rolling basis. An IDR entity will need to have personal with experience in managed care, claims processing, billing and coding, arbitration and health care law and must have sufficient staff to render timely decisions. The IFR includes detailed rules for determining whether an IDR entity has a conflict-of-interest.

For example, certified IDR entities and their employees cannot be associated with health plans, insurers, providers or facilities or their affiliates. The IDR entities must also meet various security and privacy requirements which have been modeled after the requirements under HIPAA.

IDR entities will be certified for five years, and they must maintain compliance with the requirements during that time period. The IFR allows individuals and regulated entities to petition the Departments
for a denial or revocation of certification. The IFR provides a form, included here as the Model Form “Petition to Deny or Revoke IDR Certification”

(Attachment 18), which must be used for this purpose.

How to Comply

  • Attachment 11 is a Model Compliance Tool, “Supporting Statement for Paperwork Reduction Act 1995: Independent Dispute Resolution Process.”
  • Attachment 12 is a Model Notice, “Open Negotiation Notice”, that must be used by a provider if the provider wishes to negotiate the amount paid for a service.
  • Attachment 13 is a Model Notice, “Notice of IDR Initiation”, that must be used by the GHP/insurer or the provider to initiate the ODR process if neither party has reached an agreement during the 30-day open negotiation process.
  • Attachment 14 is a Model Compliance Tool, “IFR Appendix 1 Selection of Certified IDR Entity Data Elements”, that includes the data elements required for IDR certification.
  • Attachment 15 is a Model Compliance Tool, “IFR Appendix 2 Notice of Agreement Data Elements”, that specifies the data elements that must be included in a Notice of Agreement if the parties reach an agreement before the conclusion of the IDR process.
  • Attachment 16 is a Model Compliance Tool, “IFR Appendix 3 Notice of Offer Data Elements” that includes the data elements that must be included in the required offer that each party must submit, if there is no agreement, within ten business days of selecting an IDR entity.
  • Attachment 17 is a Model Compliance Tool, “IFR Appendix 4 Entity Certification Data Elements” that contains the data elements that are require for IDR certification.
  • Attachment 18 is a Model Form, “Petition to Deny or Revoke IDR Certification” that must be used if an individual would like to have an IDR entity decertified.
  • Attachment 19 is a Model Compliance Tool, “IFR Appendix 5 Entity Reporting Data Elements” that includes the data elements required for the IDR entities quarterly report of payment determinations.
  • Attachment 20 is a Model Form, “Request for Extension of Federal IDR Process Time Periods Due to Extenuating Circumstances” that must be used to request an extension of time in the otherwise specified time periods of the IDR process.
  • Attachment 21 is a Model Compliance Tool, “IFR Appendix 6 Certified IDR Entity’s Written Decision of Payment Determination Data Elements”

To Download Attachments, see below.

The CAA adds new provisions to protect access to pediatricians, obstetricians, and gynecologists as primary care providers. The CAA expands on similar existing provisions in the Affordable Care Act (ACA) as incorporated into the Public Health Service Act (PHS Act). Direct access to pediatricians, obstetricians, and gynecologists as an individual’s primary care provider is now part of ERISA and the Internal Revenue Code and is no longer part of the addition to the PHS Act holding the ACA provisions.

How to Comply – Choice of Health Care Provider
Exhibit 17, Exhibit 18, and Exhibit 19 contain Sample Language that may be modified as appropriate and used by a GHP, insurer, or TPA to amend its plan document, insurance policy, summary plan description, or administrative services agreement.

The Patient Protection and Affordable Care Act (ACA) contained a provision that prohibited discrimination against “any willing provider.” No federal agencies ever issued regulations implementing this provision, and instead stated that the statutory language was sufficiently clear. Congress apparently did not agree, as the CAA requires that the agencies propose regulations no later than January 1, 2022, and issue final regulations no later than six months after comments are received. Until guidance is issued, it is unclear what this means for GHPs and insurers.

How to Comply – Protections Against Provider Discrimination
The Compliance Toolkit will be updated once guidance is issued. Exhibit 20, Exhibit 21, and Exhibit 22 will likely contain Sample Language that may be modified as appropriate and used by a GHP, insurer, or TPA to amend its plan document, insurance policy, summary plan description, or administrative services agreement.

For the first plan or policy year beginning on or after January 1, 2022, certain patients in the midst of a course of medical care will have new protections. These new protections will apply if a plan participant or beneficiary is a continuing care patient receiving care from a network provider for (1) a serious and complex condition, (2) a course of institutional or inpatient care from a provider or facility, (3) a non elective surgery from the provider or facility, including receipt of post-operative care with respect to a surgery, (4) pregnancy and is undergoing a course of treatment for the pregnancy, or (5) a determined terminal illness and is receiving treatment for such illness from a provider or facility, and such provider or facility’s contract to be a network provider terminates or expires for any reason other than fraud by such provider or facility, then the following requirements must be met:

• A participant who is a continuing care patient must receive notice that the provider or facility is leaving the network and he or she may be protected for continuing care at the time the provider or facility’s contract terminates and inform such enrolled individual of his or her right to elect continued transitional care from such provider or facility.
• A participant must be provided with an opportunity to notify the plan or insurer of the individual’s need for transitional care.
• A participant must be allowed to elect to continue to have the benefits provided under such plan or such coverage under the same terms and conditions as would have applied and with respect to such items and services as would have been covered under such plan had the provider or facility’s contract not terminated.

A participant shall continue to receive such transitional coverage beginning on the date he or she receives notice of the contract termination and continue until the earlier of 90 days after his or her receipt of such notice, or the date such individual is no longer qualified as a continuing care patient under the definition above with respect to that health care provider or facility. The health care provider caring for the continuing care patient is required to accept payment from such plan for services and items furnished to the continuing care patient as payment in full for such items and services and to maintaining compliance with all policies, procedures, and quality standards imposed by the plan.

How to Comply – Continuity of Care
Exhibit 23, Exhibit 24, and Exhibit 25 contain Sample Language that may be modified as appropriate and used by a GHP, insurer, or TPA to amend its plan document, insurance policy, summary plan description, or administrative services agreement.

Exhibit 26 is a Sample Notice, “Termination from the Network Notice,” that must be provided by the GHP, insurer, or TPA to the participant informing him or her that a provider or facility as left the network and explain the rights the participant has as a continuing care patient.

Exhibit 27 is a Sample Notice, “Notice for the Need for Transitional Care,” that a GHP, insurer, or TPA should provide to a participant. The participant must complete the notice and return it to the GHP, insurer, or TPA informing them that he or she qualifies as a continuing care patient and is requesting additional care.

Health Plan Identification Card Contents
Effective for plan or policy years beginning on or after January 1, 2022, group and individual health plan identification cards must include the coverage in-network and out-of-network deductibles, out-of-pocket maximums, a telephone number, and a website address through which the participants may seek consumer assistance information, including which hospitals and urgent care centers have a contractual relationship with the plan.

Advanced Explanation of Benefits (EOB) Requirements
Beginning with the first plan year beginning on or after January 1, 2022, when any health care provider notifies a group or individual health plan that a participant or beneficiary is scheduled to receive services, the plan must notify the participant no later than one business day after receiving such notice (the deadline varies depending on when the service is scheduled as compared to when the notice is received) in clear and understandable language whether or not the health care provider or facility is an in-network provider for the plan.

In addition, the advanced explanation of benefits is required to be provided to the participant or beneficiary and must include all of the following information:

Whether or not the provider or facility is in-network with respect to the health plan for the item or service and, if in network, the contracted rate or coverage (based on the billing and diagnostic codes provided by the provider or facility) and if it is out-of-network, then a description of how the individual may obtain information on providers and facilities that are in-network, if any.

• The good faith estimate included in the notification received from the provider or facility based on such codes.
• A good faith estimate of the amount the plan is responsible for and the amount of any covered individual cost sharing (including with respect to the deductible and any copayment or coinsurance obligation (as of the date of the notification).

A good faith estimate of the amount that the covered individual has incurred toward meeting the limit of the financial responsibility (including with respect to deductibles and out-of-pocket maximums) under the plan (as of the date of such notification).

• If the item or service is subject to a medical management technique (including concurrent review, prior authorization, and step-therapy or fail-first protocols) for coverage, a disclaimer that the coverage is subject to that medical management technique.
• A disclaimer that the information provided in the notification is only an estimate based on the items and services reasonably expected, at the time of scheduling (or requesting) the item or service, to be furnished and is subject to change.
• Any other information or disclaimer the plan determines appropriate that is consistent with information and disclaimers required under this section of the Act.

Under the CAA, the above notice must be provided not later than 1 business day after the provider or facility gives notice to the health plan or, if the item or service was scheduled in time, then at least 10 business days before the item or service is to be furnished. If the notification was made pursuant to an covered individual request, then the time is 3 business days after the date on which the plan receives the notification.

The Secretary may modify these timing requirements in the case of specified items and services (i.e., one that has low utilization or significant variation in costs such as when furnished as part of complex treatment) but any modification made by the Secretary may not result in the provision of the notification after the person has been furnished the items or services.

How to Comply – Advanced Explanation of Benefits (EOB) Requirements

Exhibit 29 is a Sample Form, “Advanced EOB,” that must be provided to a participant by a GHP, insurer, or TPA (beginning in 2022) before any services are rendered to a participant.

For plan years beginning on or after January 1, 2022, a health plan is required to offer price comparison guidance by telephone and make available on its website a price comparison tool that (to the extent practicable) allows an covered individual, for the plan year, geographic region, and its participating providers, to compare the amount of cost sharing that the covered individual would be responsible for paying with respect to the furnishing of a specific item or service by any such provider.

How To Comply – Price Comparison Tool for In-Network Services Required

Exhibit 30 is a Compliance Tool that a GHP, insurer, or TPA can follow to create a Price Comparison tool according to the requirements of the CAA.

Effective for plan years beginning on or after January 1, 2022, each health plan must establish: (i) a verification process; (ii) a response protocol; and (iii) a provider database and include in any directory (other than the database) specified provider directory information. Under the verification process, the health plan—not less frequently than once every 90 days—must verify and update the provider directory information in a database.

It must establish a procedure for the removal from the database of a provider or facility if the plan has been unable to verify the information during a period specified by the health plan. The database must be updated within 2 business days of the health plan receiving information that a provider or facility has changed its network status. Group health plans will need to enhance website information and other communication
Health care providers and facilities are now required to put in place a business process to provide timely updates to provider directories at both the beginning and termination of a network relationship.

If a health care provider or facility bills a patient greater than the in-network rate and the individual pays the bill, the health care provider is required to repay the individual the amount paid in excess of the in-network rate for the services or treatment with interest at the rate specified by the Secretary of HHS.

How to Comply – Provider Directory Information Improvement

Exhibit 31 is a Compliance Tool that a GHP, insurer, or TPA can use to address all aspects of the new requirements for preparing and maintaining provider directories

Additional Transparency Requirements in the CAA

Effective December 27, 2020, Plans cannot enter into any agreement with healthcare providers, networks of providers, TPAs, or others who offer access to a network of providers if that contract would, directly or indirectly, preclude the GHP or insurer from:

• Disclosing provider-specific cost or quality-of-care information or data, through a consumer engagement tool or other means, to referring providers, the plan sponsor, covered individuals, or individuals eligible to become covered individuals;
• Electronically accessing de-identified claims information (in accordance with HIPAA, GINA and the ADEA); and
• Sharing the above information with a business associate.

The agreement can allow the provider or network to include reasonable restrictions on public disclosure of the information. A GHP must submit an annual attestation to HHS that the plan is in compliance with these requirements. Gag clauses are in many TPA agreements. For example, the TPA agreement may state that the Plan will pay at the “PPO Rates” but those rates and how they are determined are categorized as “proprietary information” or “confidential information.”

The CAA requires new disclosures for brokers and other consultants providing services to certain group health plans. Under the CAA, “covered service providers” must disclose their “direct” and “indirect” compensation above $1,000 received during the term of the contract or arrangement to a responsible plan fiduciary of a “covered health plan.”

The basis for indirect compensation, consisting of a text field allowing entry of what the grounds for the indirect compensation were (for example, a bonus or incentive).
• Other information specified by HHS, for example:
distinguishing between STLDI and individual health insurance coverage;
listing the appointment arrangement duration; and
stating the number of plans an agent sold. To ensure that reported information reflects the full amount of compensation received by agents and brokers, an insurer would need to include compensation arrangements:

• Directly between the insurer and the writing agent or broker.
• From the insurer to the writing agent or broker involving any intermediary organizations in connection with the sale of STLDI or individual health insurance coverage.

Examples of intermediary organizations involved in the sale, placement, or renewal of relevant coverage include:

• General lines agencies.
• Marketing organizations.

The required reporting would need to be submitted to HHS each year by the last business day of July of the calendar year following the applicable reporting period. For non-calendar year policies, insurers would need to split the agent and broker compensation between the reports for two calendar years.

Under a statutory a transition rule, the reporting requirements would not apply to contracts executed between health insurers that offer STLDI and individual health insurance coverage before December 27, 2021. Under the proposed regulations, as a result, the reporting requirements would apply to contracts executed between an agent or broker and an insurer offering STLDI or individual health insurance coverage on or after December 27, 2021.

How to Comply – Brokers and Consultants Required to Disclose Direct and Indirect Compensation to Plan

Exhibit 33 is a Sample Form that that brokers, consultants or other service providers can use to report direct and indirect compensation related to GHPs. Exhibit 34 is a Sample Form that a broker, consultant, or other service providers can use to report direct and indirect compensation related to individual insurance coverage. Exhibit 35 is a Sample Report that an insurer can use to fulfill its reporting requirement to HHS.

The Secretaries of HHS, Labor, and Treasury are directed to issue a compliance program guidance document to help improve compliance with the mental health parity and substance abuse disorder protections under the Mental Health Parity and Addiction Equity Act. The document shall provide de-identified examples of previous findings of compliance and noncompliance with nonquantitative treatment limitations and deficient information disclosures, and descriptions of violations discovered in investigations.

The CAA requires that group and individual health plans providing mental health or substance abuse disorder benefits and imposing any Non-Quantitative Treatment Limitations (NQTLs) on such benefits (i.e., restrictions not tied to dollar value or frequency) must perform and document a comparative analysis.

The comparative analysis is required to contain the following information (copied directly from the legislation):
1. The specific plan or coverage terms or other relevant terms regarding the NQTLs and a description of all mental health or substance use disorder and medical or surgical benefits to which each such term applies in each respective benefit classification;
2. The factors used to determine that the NQTLs will apply to mental health or substance use disorder benefits and medical or surgical benefits;
3. The evidentiary standards used for the factors identified in clause (2), when applicable, provided that every factor shall be defined, and any other source or evidence relied upon to design and apply the NQTLs to mental health or substance use disorder benefits and medical or surgical benefits;
4. The comparative analyses demonstrating that the processes, strategies, evidentiary standards, and other factors used to apply the NQTLs to mental health or substance use disorder benefits, as written and in operation, are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, and other factors used to apply the NQTLs to medical or surgical benefits in the benefits classification; and
5. The specific findings and conclusions reached by the group health plan or health insurer with respect to the health insurance coverage, including any results of the analyses described in this subparagraph that indicate that the plan or coverage is or is not in compliance with this section.

Beginning 45 days after the legislation goes into effect (in early February 2021), the comparative analysis must be made available to the applicable state or federal agency upon request.

The analysis does not need to be sent anywhere, but it should be kept in a file for audit purposes in case it is ever requested. If an agency audit of the analysis determines that any NQTL does not comply with the parity requirements, the plan may be required to take corrective action to bring the plan into compliance. If the plan fails to do so in a timely manner, the agency will notify enrolled individuals of the non-compliance and may also include the plan in a public report along with other non-compliant plans.

For fully-insured plans, the carrier is primarily responsible for ensuring the plan design and claims processing comply with the MHPAEA, and the carrier should prepare this comparative analysis and handle any audit of such analysis if requested.

Some carriers are already subject to such requirements and audits at the state level. For self-funded plans, the Third-Party Administrator (TPA) will likely take responsibility for this new requirement, or at least assist with it.

For self-funded plans, the employer is primarily responsible for compliance with MHPAEA requirements. The TPA may have some fiduciary responsibility depending upon the terms of the contract for services and the TPA’s role in plan design and claims processing, so it would make sense for the TPAs to assist with this comparative analysis, but employers cannot automatically assume that it will be handled by the TPA.

  • Attachment 5 is a Model Compliance Tool, “Self-compliance Tool for the Mental Health Parity and Addition Equity Act (MHPAEA)”, is a guide provided by the DOL to assist GHPs, insurers, state regulators, TPAs and others determine whether a GHP or health insurance issuer complies with the Mental Health Parity and Addiction Equity Act (MHPAEA) and additional related requirements. This tool was released by The U.S. Department of Labor’s Employee Benefits Security Administration (EBSA).
  • Attachment 6 is another Model Compliance Tool, “Warning Signs: Plan or Policy Non-Quantitative Treatment Limitations (NQTLs) that Require Additional Analysis to Determine Mental Health Parity Compliance,” that focuses on NQTLs and how to identify provisions that will require inquiry beyond the plan/policy terms in order to determine compliance with mental health parity requirements.
  • Attachment 7 is a Model Compliance Tool, “FAQs About Mental Health and Substance Use Disorder Parity Implementation and the Consolidated Appropriations Act, 2021,” that provides additional guidance through FAQs to better understand the compliance requirements. It contains frequently asked questions and answers that the DOL, HHS, and the Treasury have jointly prepared to help stakeholders understand these amendments.
  • Attachment 8 is a Model Compliance Tool, “Fact Sheet FY 2020 MHPAEA Enforcement,” that summarizes EBSA’s and CMS’s investigations and public inquiries related to MHPAEA during FY 2020. This fact sheet does not report ongoing investigations that were open but not closed during FY 2020. These cases will be reported in a subsequent report for the FY in which these cases are closed. Multi-year investigations are not uncommon with respect to complex MHPAEA issues, especially for investigations that involve large service providers (such as issuers, third-party administrators, and managed behavioral health organizations).
  • Attachment 9 is a Compliance Tool, “MHPAEA Comparative and Fee Analysis Tool”, that contains the necessary information to inventory and record the comparative analysis required to comply. Once the spreadsheet is populated and the coverage provisions and limits have been evaluated it can be used to prepare any necessary reporting. The tool follows the requirements outlined in the Self-compliance tool (Attachment 4).

The CAA updated the Employee Retirement Income Security Act, the Public Health Services Act and the Internal Revenue Code to require group health plans to report certain information related to prescription drugs to the secretaries of the departments of Health and Human Services, Labor, and the Treasury, including:

• The plan year, number of covered individuals and each state in which the plan is offered.
• The top 50 brand prescription drugs paid for by the plan, and the total number of paid claims for each drug.
• The top 50 most expensive prescription drugs paid for by the plan by total annual spending, and the annual amount spent by the plan for each drug.
• The 50 prescription drugs with the greatest increase in plan expenditures since the prior plan year, and the change in amounts spent for each drug.
• The total spending on health care services by plan, broken down into specific categories, including hospital costs, primary care costs, specialty care costs and prescription drug costs. Average monthly premiums paid by employers and by participants.
• The effect on premiums by rebates and fees paid by drug manufacturers to the plan or its administrators or service providers, including any reduction in premiums and out-of-pocket costs associated with the rebates and fees.

The agencies, along with the Office of Personnel Management, will use the reported information to analyze trends in overall spending on prescription drugs and other health care services by employers that sponsor self-funded health plans and by insurers that provide fully insured health plans. The agencies said they will then publish the analysis in a format that will enable plans and issuers to negotiate fairer rates and ultimately lower costs for participants, beneficiaries, and covered individuals.

Under CAA, the first reporting would be due December 27, 2021, with reporting due each June thereafter. Enforcement of this requirement to report by December 27,2021 or the second deadline or reporting on June 2022 has been delayed pending the issuance of regulations or further guidance. The first report will be due December 27, 2022.

How to Comply – Pharmacy Benefit and Drug Cost Reporting and Other Reporting Requirements

Attachment 10 is a Compliance Tool that contains a sample of a report that an employer, insurer or third- party administrator must make to the Departments of Health and Human Services, Labor, and the Treasury.

How to Comply

  • Attachment 11 is a Model Compliance Tool, “Supporting Statement for Paperwork Reduction Act 1995: Independent Dispute Resolution Process.”
  • Attachment 12 is a Model Notice, “Open Negotiation Notice”, that must be used by a provider if the provider wishes to negotiate the amount paid for a service.
  • Attachment 13 is a Model Notice, “Notice of IDR Initiation”, that must be used by the GHP/insurer or the provider to initiate the ODR process if neither party has reached an agreement during the 30-day open negotiation process.
  • Attachment 14 is a Model Compliance Tool, “IFR Appendix 1 Selection of Certified IDR Entity Data Elements”, that includes the data elements required for IDR certification.
  • Attachment 15 is a Model Compliance Tool, “IFR Appendix 2 Notice of Agreement Data Elements”, that specifies the data elements that must be included in a Notice of Agreement if the parties reach an agreement before the conclusion of the IDR process.
  • Attachment 16 is a Model Compliance Tool, “IFR Appendix 3 Notice of Offer Data Elements” that includes the data elements that must be included in the required offer that each party must submit, if there is no agreement, within ten business days of selecting an IDR entity.
  • Attachment 17 is a Model Compliance Tool, “IFR Appendix 4 Entity Certification Data Elements” that contains the data elements that are require for IDR certification.
  • Attachment 18 is a Model Form, “Petition to Deny or Revoke IDR Certification” that must be used if an individual would like to have an IDR entity decertified.
  • Attachment 19 is a Model Compliance Tool, “IFR Appendix 5 Entity Reporting Data Elements” that includes the data elements required for the IDR entities quarterly report of payment determinations.
  • Attachment 20 is a Model Form, “Request for Extension of Federal IDR Process Time Periods Due to Extenuating Circumstances” that must be used to request an extension of time in the otherwise specified time periods of the IDR process.
  • Attachment 21 is a Model Compliance Tool, “IFR Appendix 6 Certified IDR Entity’s Written Decision of Payment Determination Data Elements”

To Download Attachments, see below.

The CAA adds new provisions to protect access to pediatricians, obstetricians, and gynecologists as primary care providers. The CAA expands on similar existing provisions in the Affordable Care Act (ACA) as incorporated into the Public Health Service Act (PHS Act). Direct access to pediatricians, obstetricians, and gynecologists as an individual’s primary care provider is now part of ERISA and the Internal Revenue Code and is no longer part of the addition to the PHS Act holding the ACA provisions.

How to Comply – Choice of Health Care Provider
Exhibit 17, Exhibit 18, and Exhibit 19 contain Sample Language that may be modified as appropriate and used by a GHP, insurer, or TPA to amend its plan document, insurance policy, summary plan description, or administrative services agreement.

The Patient Protection and Affordable Care Act (ACA) contained a provision that prohibited discrimination against “any willing provider.” No federal agencies ever issued regulations implementing this provision, and instead stated that the statutory language was sufficiently clear. Congress apparently did not agree, as the CAA requires that the agencies propose regulations no later than January 1, 2022, and issue final regulations no later than six months after comments are received. Until guidance is issued, it is unclear what this means for GHPs and insurers.

How to Comply – Protections Against Provider Discrimination
The Compliance Toolkit will be updated once guidance is issued. Exhibit 20, Exhibit 21, and Exhibit 22 will likely contain Sample Language that may be modified as appropriate and used by a GHP, insurer, or TPA to amend its plan document, insurance policy, summary plan description, or administrative services agreement.

For the first plan or policy year beginning on or after January 1, 2022, certain patients in the midst of a course of medical care will have new protections. These new protections will apply if a plan participant or beneficiary is a continuing care patient receiving care from a network provider for (1) a serious and complex condition, (2) a course of institutional or inpatient care from a provider or facility, (3) a non elective surgery from the provider or facility, including receipt of post-operative care with respect to a surgery, (4) pregnancy and is undergoing a course of treatment for the pregnancy, or (5) a determined terminal illness and is receiving treatment for such illness from a provider or facility, and such provider or facility’s contract to be a network provider terminates or expires for any reason other than fraud by such provider or facility, then the following requirements must be met:

• A participant who is a continuing care patient must receive notice that the provider or facility is leaving the network and he or she may be protected for continuing care at the time the provider or facility’s contract terminates and inform such enrolled individual of his or her right to elect continued transitional care from such provider or facility.
• A participant must be provided with an opportunity to notify the plan or insurer of the individual’s need for transitional care.
• A participant must be allowed to elect to continue to have the benefits provided under such plan or such coverage under the same terms and conditions as would have applied and with respect to such items and services as would have been covered under such plan had the provider or facility’s contract not terminated.

A participant shall continue to receive such transitional coverage beginning on the date he or she receives notice of the contract termination and continue until the earlier of 90 days after his or her receipt of such notice, or the date such individual is no longer qualified as a continuing care patient under the definition above with respect to that health care provider or facility. The health care provider caring for the continuing care patient is required to accept payment from such plan for services and items furnished to the continuing care patient as payment in full for such items and services and to maintaining compliance with all policies, procedures, and quality standards imposed by the plan.

How to Comply – Continuity of Care
Exhibit 23, Exhibit 24, and Exhibit 25 contain Sample Language that may be modified as appropriate and used by a GHP, insurer, or TPA to amend its plan document, insurance policy, summary plan description, or administrative services agreement.

Exhibit 26 is a Sample Notice, “Termination from the Network Notice,” that must be provided by the GHP, insurer, or TPA to the participant informing him or her that a provider or facility as left the network and explain the rights the participant has as a continuing care patient.

Exhibit 27 is a Sample Notice, “Notice for the Need for Transitional Care,” that a GHP, insurer, or TPA should provide to a participant. The participant must complete the notice and return it to the GHP, insurer, or TPA informing them that he or she qualifies as a continuing care patient and is requesting additional care.

Health Plan Identification Card Contents
Effective for plan or policy years beginning on or after January 1, 2022, group and individual health plan identification cards must include the coverage in-network and out-of-network deductibles, out-of-pocket maximums, a telephone number, and a website address through which the participants may seek consumer assistance information, including which hospitals and urgent care centers have a contractual relationship with the plan.

Advanced Explanation of Benefits (EOB) Requirements
Beginning with the first plan year beginning on or after January 1, 2022, when any health care provider notifies a group or individual health plan that a participant or beneficiary is scheduled to receive services, the plan must notify the participant no later than one business day after receiving such notice (the deadline varies depending on when the service is scheduled as compared to when the notice is received) in clear and understandable language whether or not the health care provider or facility is an in-network provider for the plan.

In addition, the advanced explanation of benefits is required to be provided to the participant or beneficiary and must include all of the following information:

Whether or not the provider or facility is in-network with respect to the health plan for the item or service and, if in network, the contracted rate or coverage (based on the billing and diagnostic codes provided by the provider or facility) and if it is out-of-network, then a description of how the individual may obtain information on providers and facilities that are in-network, if any.

• The good faith estimate included in the notification received from the provider or facility based on such codes.
• A good faith estimate of the amount the plan is responsible for and the amount of any covered individual cost sharing (including with respect to the deductible and any copayment or coinsurance obligation (as of the date of the notification). A good faith estimate of the amount that the covered individual has incurred toward meeting the limit of the financial responsibility (including with respect to deductibles and out-of-pocket maximums) under the plan (as of the date of such notification).
• If the item or service is subject to a medical management technique (including concurrent review, prior authorization, and step-therapy or fail-first protocols) for coverage, a disclaimer that the coverage is subject to that medical management technique.
• A disclaimer that the information provided in the notification is only an estimate based on the items and services reasonably expected, at the time of scheduling (or requesting) the item or service, to be furnished and is subject to change.
• Any other information or disclaimer the plan determines appropriate that is consistent with information and disclaimers required under this section of the Act.

Under the CAA, the above notice must be provided not later than 1 business day after the provider or facility gives notice to the health plan or, if the item or service was scheduled in time, then at least 10 business days before the item or service is to be furnished. If the notification was made pursuant to an covered individual request, then the time is 3 business days after the date on which the plan receives the notification.

The Secretary may modify these timing requirements in the case of specified items and services (i.e., one that has low utilization or significant variation in costs such as when furnished as part of complex treatment) but any modification made by the Secretary may not result in the provision of the notification after the person has been furnished the items or services.

How to Comply – Advanced Explanation of Benefits (EOB) Requirements

Exhibit 29 is a Sample Form, “Advanced EOB,” that must be provided to a participant by a GHP, insurer, or TPA (beginning in 2022) before any services are rendered to a participant.

For plan years beginning on or after January 1, 2022, a health plan is required to offer price comparison guidance by telephone and make available on its website a price comparison tool that (to the extent practicable) allows an covered individual, for the plan year, geographic region, and its participating providers, to compare the amount of cost sharing that the covered individual would be responsible for paying with respect to the furnishing of a specific item or service by any such provider.

How To Comply – Price Comparison Tool for In-Network Services Required

Exhibit 30 is a Compliance Tool that a GHP, insurer, or TPA can follow to create a Price Comparison tool according to the requirements of the CAA.

Effective for plan years beginning on or after January 1, 2022, each health plan must establish: (i) a verification process; (ii) a response protocol; and (iii) a provider database and include in any directory (other than the database) specified provider directory information. Under the verification process, the health plan—not less frequently than once every 90 days—must verify and update the provider directory information in a database.

It must establish a procedure for the removal from the database of a provider or facility if the plan has been unable to verify the information during a period specified by the health plan. The database must be updated within 2 business days of the health plan receiving information that a provider or facility has changed its network status. Group health plans will need to enhance website information and other communication.

Health care providers and facilities are now required to put in place a business process to provide timely updates to provider directories at both the beginning and termination of a network relationship.

If a health care provider or facility bills a patient greater than the in-network rate and the individual pays the bill, the health care provider is required to repay the individual the amount paid in excess of the in-network rate for the services or treatment with interest at the rate specified by the Secretary of HHS.

How to Comply – Provider Directory Information Improvement

Exhibit 31 is a Compliance Tool that a GHP, insurer, or TPA can use to address all aspects of the new requirements for preparing and maintaining provider directories

Download Attachments/Exhibits Here

**You can find all mentioned exhibits and attachments to referenced articles by downloading them below.

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