The Consolidated Appropriations Act and Consumer Protections Related to Transparency in Health Care and Surprise Billing
The federal Consolidated Appropriations Act (CAA) sets up new protections for customers related to transparency in health care and surprise billing. In implementing the CAA requirements, EmblemHealth continues to enhance our customers’ experiences, expand our health care capabilities, and ultimately promote better health outcomes.
EmblemHealth’s customers entrust us with their access to care. We have many new customer tools available today, and we are on course to fulfill the CAA’s full requirements—even as the implementation continues to develop and evolve.
Below are activities EmblemHealth has underway to provide customers with the consumer protections called for by the CAA and other transparency-related laws.
TRANSPARENCY – COST CALCULATORS
EmblemHealth currently offers a cost calculator tool for its members, and plans to offer an enhanced, internet-based self-service cost calculator in 2023. The tool will be available on our member portal and customers will be informed about how to access the tool before it is completed. Members will be able to save a PDF copy of the information they view in the online tool on the website or member portal. Members will also be able to contact EmblemHealth Customer Service if they have difficulty using the tool, or if they would like a paper copy mailed to them.
TRANSPARENCY – MACHINE READABLE FILES
EmblemHealth is making available machine-readable files containing pricing information for in-network health care services and the allowed amounts for out-of-network health care services. Prescription drug pricing information will be made available when additional regulatory guidance is issued. EmblemHealth will post the files in a JSON format on its public website and will update them monthly. Customers will be able to view or download the available machine-readable files by clicking Pricing Information in our public website footer.
NO SURPRISES ACT
EmblemHealth continues to review the No Surprises Act and the evolving regulatory guidance related to paying for Emergency Services, Non-Emergency Services, and Air Ambulance Services under the CAA. We are introducing compliant processes as we learn more from the regulators. State surprise billing laws may also continue to apply for insured business in certain instances.
EmblemHealth will require providers to bill and submit claims according to any No Surprises Act requirements. We will update member contracts and certificates of coverage to meet state and federal laws and related regulatory guidance upon plan renewal. EmblemHealth will continue to implement any additional No Surprises Act requirements issued in the future.
SPECIFIC NO SURPRISES ACT REQUIREMENTS:
EmblemHealth notified its contracted providers in July 2021 to remove any direct or indirect prohibitions on the disclosure of pricing and quality data (“gag clause”). This includes electronic access to de-identified claims and encounter data for each member, and the ability to share this data consistent with applicable privacy regulations.
NEW ID CARDS
EmblemHealth is updating our members’ ID cards to include in-network and out-of-network deductibles and out-of-pocket maximums. Updated ID cards will be issued to members upon plan renewal in all affected lines of business, unless the customer has requested an alternate approach.
ADVANCED EXPLANATION OF BENEFITS (EOBs)
The federal government is expected to issue additional rules for this requirement. EmblemHealth continues to monitor regulatory developments in this area and will implement this requirement in a timely manner once they are released.
CONTINUITY OF CARE
EmblemHealth is leveraging existing notice processes to meet the federal and updated state requirements to ensure the quality of our members' care is best managed and transitioned when a provider or facility network relationship changes.
PHARMACY REPORTING REQUIREMENTS [For Plans with Prescription Drug Benefits]
The federal government issued interim final rules for these requirements with reporting for 2020 and 2021 due by December 27, 2022, and then by June 1 of each year thereafter. EmblemHealth will implement these reporting requirements in a timely manner and plans to submit aggregate data by state and market segment.
Recognizing the significant operational challenges in complying with these complex reporting requirements, the federal government is providing a submission grace period through January 31, 2023, for submission of the 2020 and 2021 reports. EmblemHealth and its vendor Express Scripts are using this extra time to address some data files issues and conduct additional quality checks.
ACCURACY OF PROVIDER DIRECTORY INFORMATION
The CAA establishes standards related to provider directories that are intended to protect members from surprise billing and improve the accuracy of provider directory information. To meet these requirements, EmblemHealth will:
- Routinely compare provider directory data with provider data compiled by the State, if any;
- Ask providers to verify their data through attestations and CAQH data at least every 90 days;
- Suppress a provider’s information from the online directory if the provider’s data cannot be verified 180 days after the last verification date; and
- Update our provider directory information within two (2) business days of receiving a complete update.
MENTAL HEALTH PARITY REQUIREMENTS
EmblemHealth conducts comprehensive comparative analyses to demonstrate compliance with Mental Health Parity requirements. We assess the processes, strategies, evidentiary standards, or other factors used to administer mental health and/or substance use disorder benefits to ensure they are comparable to and applied no more stringently than the processes, strategies, evidentiary standards, or other factors used to administer medical or surgical benefits.
DISCLAIMER: EmblemHealth updates are intended to provide general information and assistance. They do not constitute medical, legal or tax advice. Please contact your medical, legal and tax advisors on any questions you have concerning these new requirements. Nothing in these updates constitute a binding obligation of EmblemHealth with respect to any matter discussed. In addition to federal law, states may have additional or differing requirements. These rules do not apply to all of our products.