Mar 10, 2021
- Large Group
- Small Group
- Individual
Recent regulations focus on price and quality transparency
We believe part of making healthcare simpler means empowering members’ decisions with information that balances the cost and quality of services. Anthem will expand the amount of information provided to members and clients in response to the Consolidated Appropriations Act (CAA) and transparency rule from the Tri-Agencies (U.S. Departments of Health and Human Services, Labor, and Treasury).
“No Surprises Act”
The CAA includes the “No Surprises Act” with regulations intended to help protect consumers from surprise billing. The law includes requirements for all types of employer plans, including self-funded employers and health insurance issuers in the Individual and Group markets.
- For fully insured employers subject to state law, states will be working to harmonize existing state requirements with the new federal legislation.
- For self-funded employers subject to federal ERISA regulations, the federal framework will apply.
Numerous provisions are included in the CAA, the majority of which become effective January 1, 2022. The provisions include:
- COVID-19 testing and vaccines
- Surprise medical billing/air ambulance bills
- Provider directories
- Advance cost estimate and explanation of benefits (EOB)
- Insurance cards
- Broker and consultant compensation disclosure
- Mental health and substance use disorder parity
- Price comparison tool
- Gag clauses
- Pharmacy benefits and drug cost reporting
Health Plan Price Transparency Rule
In October 2020, the Tri-Agencies released a final rule in response to an executive order designed to improve price and quality transparency.
This final rule applies to commercially insured, non-grandfathered, Group health plans and to issuers offering non-grandfathered health insurance coverage in the Individual and Group markets. Requirements will be phased in over three years starting in January 2022.
- For plan years that begin on or after January 1, 2022 – Plans and issuers must make three separate machine-readable files in a standardized format available to the public, including stakeholders such as consumers, researchers, employers, and third-party developers. The three files must be placed on a publicly available website and updated monthly.
- Negotiated in-network provider rates for all covered items and services
- Historical payments to, and billed charges from, out-of-network providers
- In-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level.
- Beginning January 1, 2023 – Plans and issuers must make personalized out-of-pocket cost information and the underlying negotiated rates for 500 covered healthcare items and services, including prescription drugs, available to participants, beneficiaries, and enrollees. This information must be available through an internet-based self-service tool and in paper form upon request.
- Beginning January 1, 2024 – Health plans must expand their transparency tools to encompass all covered items and services.
Implementation and regulatory compliance
Anthem is committed to full compliance along with the timely implementation and execution of the regulations for our fully insured and self-insured employer groups. We are continuing to monitor the CAA and transparency rule as they move through the regulatory process and will provide guidance and updates as more information becomes available.
If you have any questions, please contact your Anthem representative.