- Posted by Jessica Waltman
- On November 2, 2020
The Trump Administration released two eagerly anticipated final regulations on October 29, 2020. One spells out health care price transparency requirements for health insurance carriers and employers that sponsor group health plans. The other rule addresses mandatory coverage requirements for COVID-19 tests and vaccines.
The new transparency rule requires all health insurance carriers and businesses that offer non-grandfathered group coverage to disclose a significant amount of health plan price information to the public and even more data to plan participants. The hope is that this data will help improve understanding of health care pricing and potentially dampen the rise in health care spending.
A critical point to understand about this regulation is that while virtual no employer could independently implement these transparency requirements if the company offers fully-insured coverage, the rule does assign them equal liability with their health insurance carrier. Businesses that provide self-funded or level-funded major medical coverage retain ultimate compliance responsibility. Employers with fully-insured group coverage can transfer full liability to their health insurance issuer as part of their coverage contract. However, there will likely be a premium impact due to the transfer of risk. The rule allows companies that offer group insurance through self-funded and level-funded plans to contract with their third-party administrator or another vendor to fulfill their transparency obligations. These employer groups can ask for indemnification via their vendor contracts but still retain ultimate compliance responsibility.
The three major tasks for health insurance carriers and employer group health plans must complete are as follows, broken down by due date:
- Due January 1, 2022—Make three machine-readable data files of health care price information available online and maintain the data. The first file must contain all in-network provider negotiated rates, the second data on historical out-of-network allowed amounts, and the third prescription drug pricing information.
- Due for all plan and policy years beginning on or after January 1, 2023— Make sure that plan participants can access personalized cost estimates for 500 designated shoppable services before they incur a claim. Plan participants must have access to a website with all of the required information, and they must also be able to request paper copies. The information that must be shared includes:
- Estimated cost-sharing liability for specific procedures and conditions;
- The amount of cost-sharing liability a participant has incurred to date relative to their maximum out-of-pocket limit and any deductible;
- The negotiated rate the carrier or group plan has agreed to pay an in-network provider for the specific covered service the plan participant is considering;
- The maximum reimbursement amount that the carrier or group plan would pay to an out-of-network provider for a particular service;
- An explanation of any prerequisite for the person’s specific coverage request, such as step therapy or a preauthorization; and
- A notice that warns about balance-billing to explain that the plan is merely providing personalized estimates and actual costs may vary.
- Due for all plan and policy years beginning on or after January 1, 2024—Plan participants must be able to access all required personalized cost estimate data listed above before they incur a claim for ALL covered providers and services. This information must be easily accessible online, and participants may request paper copies if needed.
The final regulation also gives fully-insured health plans some medical loss ratio relief for sharing value-based care savings with enrollees.
COVID-19 Coverage Rule
The COVID-19 coverage interim final regulation provides clarity regarding the federal legislation enacted last Spring that requires all health plans to cover COVID-19 diagnostic testing without imposing cost-sharing and medical management requirements for as long as the COVID-19 public health emergency period lasts. The rules cover COVID-19 testing, including in vitro tests, which encompass “diagnostic” and “antibody” testing and incorporates molecular, antigen, and serological testing. The coverage mandate also applies to “related services,” which include those provided during urgent care center visits, in-person and telehealth office visits, and emergency room visits that result in the order of a COVID-19 test.
The new rule requires testing providers to make the “cash price” of their services readily available. This “cash price” should be the amount an individual would pay for the services if they were uninsured, must be posted on a publicly accessible section of the provider’s website.
The regulation also addresses how plans must cover qualifying COVID-19 vaccines. The CARES Act requires all non-grandfathered health plans to cover qualified coronavirus preventive services without cost-sharing. This rule expands upon the ACA’s general requirement that preventive care is paid for on a first-dollar basis, but with several key distinctions.
- Unlike other preventive care services, COVID-19 vaccines must be covered on a first-dollar basis even if an out-of-network provider provides the vaccine. Plans must reimburse out-of-network vaccine providers “in an amount that is reasonable, as determined in comparison to prevailing market rates for such service.”
- It will not be necessary for the United States Preventive Services Taskforce and the Advisory Committee on Immunization Practices classify a COVID-19 vaccine as appropriate for “routine use” to meet the definition of “qualifying coronavirus preventive services.” That means plans will be able to cover COVID-19 vaccines on a first-dollar basis right away.
- The regulation specifies that health plans must consider an approved COVID-19 vaccine as part of the plan’s preventive care coverage within 15 business days of a formal federal recommendation.
It is also worth noting that the special rules for qualifying coronavirus preventive services only apply during the public health emergency. However, even after the Secretary of Health and Human Services declares the public health emergency to be over, COVID-19 vaccinations will likely remain a recommended service by the United States Preventive Services Taskforce and the Advisory Committee on Immunization Practices and thereby covered under the ACA’s general preventive service rules.