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Regulatory Highlights: Recent Updates Impacting Payers

Interoperability remains front and center for compliance. HealthEdge continues to focus on the Patient Access API, which has an enforcement date of July 1, 2021. All of the data required for our clients’ compliance is in our data warehouse. Our HealthRules Payer customers can use the Common Payer Consumer Data Set (CPCDS) to move their data from our data warehouse to the HL7-FHIR-enabled solution. We are creating a patient access data mapping document to enable our customers to easily collect the data elements required by the CPCDS.

Also with a July 1, 2021 enforcement date is the Provider Directory API.  The data within HealthRules Payer can support this requirement, but it is likely plans will use the system of record they use today to produce their Directories.  HealthEdge will address following the Patient Access API.

Effective January 1, 2022, the Transparency in Coverage Final Rule will require all payers to post three machine-readable files (MRFs) to their public website every month, including in-network negotiated provider rates, in-network drug pricing, and out-of-network coverage rates. HealthEdge is working on the high-level requirement to map the data they need to create the in-network and out-of-network provider rate files every month.

Key provisions of the Consolidated Appropriations Act—which went into effect on December 27, 2020— impact payers.

The No Surprises Act includes federal protections against surprise medical bills from out-of-network providers for emergency services, including air ambulances. The Act also applies to out-of-network providers when the patient is at an in-network facility unless the patient agrees prior to the services.  Under this act, cost-sharing amounts are capped at those that apply to in-network services, providers cannot send bills for any higher amounts, and there is an arbitration process to resolve payment disputes between insurers and providers. The act borrows from the enforcement and state preemption frameworks from HIPAA and the ACA. There is also a clause for the Continuity of Care when a health care provider drops from an insurer or group health plan’s network.

This all becomes effective January 1, 2022, so we expect to see activity related to the No Surprises Act ramp up soon. The Tri Agencies must issue a new rule to implement these provisions, allow for at least 60 days for comments, and then have a six-month runway for implementation. They will also need to generate and authenticate data and reporting, particularly around these air ambulance providers and the insurer, and conduct studies on the effect on provider consolidation, health care costs, and access to care across the lines of business. The federal government will also need to issue several different reports, as defined in the Act.

The CAA also includes Transparency Rules requiring health plans to have a price comparison tool, available online and by phone, that will compare cost-sharing amounts for certain items or services at any provider. The intent is to improve disclosure of cost-sharing requirements by listing plan-specific deductibles and out-of-pocket maximums on insurance cards alongside a phone number and website where an individual can ask about network status.

There is also an “advanced” explanation of benefits. When a provider notifies the health plan that an enrollee is scheduled to receive health care services, the plan must send an advanced explanation of benefits that indicates if the provider is in- or out-of-network and includes estimated costs and disclaimers.

The CAA also includes protocols related to provider directory updates. Health plans must update provider directory information at least every 90 days and remove any providers with information that cannot be verified. They also must respond to enrollees about a provider’s network status within one business day of their request. If the provider directory is not up to date and the employer enrollees relied on inaccurate information, the health plan must treat the member as if they went to an in-network provider.

When it comes to the price comparison tool, advanced explanation of benefits, and provider directory, HealthEdge will continue to monitor the agencies for rulemaking and prepare to  support and enable compliance with these components.

The government is granting some funds for states to establish All-Payer Claims Database (APCD) which is a voluntary program to collect health care claims data from payers. Right now, 21 states have established or in the process of implementing APCDs, and 11 more states have indicated a very strong interest.

The states cannot require TPAs or self-funded group health plans to contribute data. The Secretary of Labor will provide guidance regarding the data collection process and standardized reporting formats because the APCD hits all lines of business.

Lastly, we have two proposed rules in the comment period. First, the comment period for the proposed modifications to the HIPAA Privacy Rule to support and remove barriers to coordinated care and individual engagement ends on March 22, 2021. The proposed changes align with the current interoperability and transparency rules aimed at becoming more member-centric in the release of information. We also have Medicare and Medicaid Programs, Contract Year 2021 and 2022 Policy and Technical Changes, which comes out every year for CMS programs. The comment period ends April 6, 2021.

HealthEdge works with our clients to help them achieve full compliance with the laws, rules, and standards when these regulations impact our products and services.

About the Author

Maggie Brown has over 30 years of leadership experience in healthcare and insurance marketplace. Maggie transitioned from health plan management roles to implementing core business solutions for numerous health plans around the country. With the enactment of HIPAA, the Balanced Budget Act, and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 she focused on how to ensure a health plan could implement key technology solutions, meeting the needs of their members, while being compliant in a rapidly changing regulatory environment. Maggie has led implementations for government programs at both new and established managed care companies. Maggie holds a Doctor of Religious Arts degree with a major in Pastoral Psychology.