Background: The Federal Government has made significant efforts in bringing transparency to the healthcare market via the CMS Transparency in Coverage (TiC) Final Rule and the No Surprises Act (NSA) included in the CAA, 2021 legislation. Bolton first wrote about these efforts here.
The CMS TiC rule and the NSA are working in conjunction with each other to further the federal transparency efforts. While these efforts are largely expected to help consumers with healthcare spending, they do come with added administrative burden and complexity.
The agencies responsible for regulating the new federal transparency efforts have released clarifying FAQs which should help group health plans, providers and issuers to comply with the regulations.
Joint Agency FAQs
In FAQs Part 60, the Agencies addressed a few areas described below.
- The FAQs clarify that claims subject to the NSA (requiring the group health plans to apply cost-sharing for plan participants as if in-network) are subject to the ACA’s maximum out-of-pocket (MOOP) limitations, even if the services would otherwise be considered out-of-network.
- The FAQs clarify that any contractual arrangement with an air ambulance provider, direct or indirect, makes the air ambulance provider a “participating provider” for purposes of the NSA.
- The FAQs indicate that facility fees fall under the definition of “items and services” which are protected under the NSA (and subject to in-network cost-sharing) and must also be disclosed for cost comparison purposes under the TiC requirements (e.g., price transparency tools and any advanced explanation of benefits).
In addition to the FAQs, the Departments also included a statement making it clear that they’re aware and concerned that facility fees are being charged outside of hospital settings which results in increased costs.
The agencies report that “several states have taken or are considering taking action to prohibit, limit, or increase transparency around facility fees” and felt it was important to address that facility fees should be included for cost comparison purposes via the last Q&A.
Bolton will continue to monitor regulator guidance and offer meaningful, practical, timely information.
This article should not be considered as a substitute for legal, tax and/or actuarial advice. Contact the appropriate professional counsel for such matters. This article is not exhaustive and the content is subject to possible changes in applicable laws, rules, and regulations and their interpretations.
