Category: Affordable Care Act
The Compliance Toolkit fourth quarterly update was released on October 31, 2022 for changes since it was released on November 11, 2021. The Consolidated Appropriations Act (CAA), No Surprises Act, and Transparency in Coverage Final Rule Compliance toolkit will next be updated on or around January 31, 2023 if there are any updates required.
Compliance Toolkit First Quarterly Update
The Compliance Toolkit first quarterly update addresses:
- The Independent Dispute Resolution section was updated to include a section for the Revenue Procedure 2022-11 which published the percentage adjustment for median contracted rates.
- The Pharmacy Benefit and Drug Cost Reporting section was updated to include a section reflecting the guidance contained in the November 23, 2021 Prescription Drug and Health Care Spending Interim Final Rules, implementing Section 204, Title II, another phase of the transparency provisions of the Consolidated Appropriations Act (CAA) of 2021.
- The Direct and Indirect Compensation section was updated to reflect clarifying language and a section was added to address guidance contained in the Field Assistance Bulletin No. 2021-03 released by the Department of Labor (“DOL”) on December 30, 2021.
- Attachment 1: Compliance Tool – CAA and Transparency Financial Impact Analysis Tool was updated to reflect additional calculations.
- Attachment 9: Compliance Tool – MHPAEA Comparative and Fee Analysis Tool was updated to improve some of the functionality.
Compliance Toolkit Second Quarterly Update
The Compliance Toolkit second quarterly update addresses:
- The Initiation of IDR Process section was updated to indicate that online IDR portal was opened on April 15, 2022.
- The Determination of Payment section was updated to report a court case that invalidated the portion of the interim final rule relating to the presumption that the QPA is the most appropriate amount and a release of a Memorandum, withdrawing the portion of the interim final rule that was invalidated by the court.
- The Petition to Deny or Revoke IDR Certification was updated to report the release of IRS Notice 2022-11, which provides guidance on indexing “the qualifying payment” amount for items and services furnished in 2022 in the case of a group health plan or insurer that does not have enough information as of January 31, 2019, to calculate the median of the in-network contracted rates or in the case there are new items or services being furnished.
- The Fee Disclosure Related to Covered Group Health Plans Section was updated to remove duplicate sections.
- The Public Disclosure of Provider Fees Requirement section was updated to report the release of two new FAQs discussing the machine-readable files used for public disclosure.
Compliance Toolkit Third Quarterly Update
The Compliance Toolkit third quarterly update addresses:
- The “Independent Dispute Resolution (IDR) Procedures for Determining Certain Out-of-Network Rates to Be Paid by Group Health Plans” section has been updated to reflect the following:
- Departments jointly issued FAQ guidance adopting an enforcement safe harbor for health plans and insurers reporting certain types of in-network rates under the transparency in coverage.
- Departments jointly issued revised process guides for independent dispute resolution (IDR) under the No Surprises Act.
- Federal Court stays proceeding in case vacating Portions of No Surprises Act’s IDR Regulations
- Departments Jointly issued Checklist for Surprise Billing IDR Process
- Departments Issued Checklist for Surprises Billing IDR process
- The “Public Disclosure of Provider Fees Requirement” section was updated to clarify that the deadline for posting the Machine Readable Files is July 1, 2022.
Compliance Toolkit Fourth Quarterly Update
The Compliance Toolkit fourth quarterly update addresses:
- Federal Court vacated key portions of the interim final regulation implementing the independent dispute (IDR) provisions of the No Surprises Act relating to air ambulance services.
- The DOL, HHS and IRS finalized options of the No Surprise Act medical billing regulation covering the independent dispute resolution (IDR) process. These regulations first remove the provision that the court invalided and specify that certified IDR entities should select the offer that represents the value of the item or service under dispute after considering the QPA and all permissible information submitted by the parties. The regulation net expanded on the requirement that health plans and insurers disclosure to provided and facilities the QPA for items or services with each initial payment or notice of denial of payment.
- In connection with the release of the final Surprise Billing regulations, the Departments of Labor (“DOL”), Health and Human Services (“HHS”) and Treasury (collectively, the “Agencies”) released an extensive set of FAQs covering surprise billing and price transparency rules. The FAQs are wide-ranging, but provide important clarifications.
- CMS published more detailed reporting guidance along with reporting templates on its RxDC webpage for Prescription Drug reporting due on December 27, 2022. This guidance included the following:
- RxDC reporting instructions
- RxDC templates
- RxDC drug name and therapeutic class crosswalk
- CMS also revised the Model Disclosure Notice Regarding Patient Protections Against Surprise Billing and its instructions and the Standard Notice and Consent Documents Under the No Surprises Act to be used in 2022 and to be used in 2022 and beyond.
- Attachment 2 now reflects the recently released revised “Model Disclosure Notice Regarding Patient Protections Against Surprise Billing.”
- Attachment 3 now reflects the recently released revised “Standard Notice and Consent Documents Under the No Surprises Act.”
Compliance Toolkit Contents
To address the compliance needs of the industry, Humaculture, Inc. partnered with Attorneys Howard Lapin and Larry Grudzien to create a Compliance Toolkit to address all of the requirements in the new law and regulations. It contains over forty documents, including:
- A detailed explanation of the law and regulations;
- A compliance tool that highlights all of the required changes and what steps needed to be taken to comply;
- Sample provisions for plan documents, Summary Plan Descriptions, and administrative services agreements;
- All of the model notices that have to be provided to covered individuals;
- Sample notices that have to be provided to participants; and
- Sample disclosures and reports that have to be made to the governmental agencies.
There are over two hundred and eighty-five (285) pages of documents in this Compliance Toolkit. It has been specially designed for use by employers, insurers, brokers, and third-party administrator to help them effectively to comply with all of the requirements.
Webinar Reviewing the Compliance Toolkit
On December 14, 2021, we conducted a free webinar to review the Compliance Toolkit. We reviewed its contents and explained how it can be used to comply with the requirements. You can view the webinar here.
Hidden Opportunities, A Strategic Compliance Series
Humaculture, Inc. conducted a strategic compliance webinar series over the first five months of 2022 focusing on harnessing the Hidden Opportunities in the No Surprises Act and Transparency in Coverage Final Rule. Our goal was to help organizations create a competitive advantage. Does it make sense to expend limited resources to merely comply with the law and regulations, or is there a way to strategically “design the compliance away” while strategically differentiating the employee value proposition?
You can purchase the Compliance Toolkit, which includes quarterly updates through October 31, 2023, for only $450 by contacting us and we will invoice you for the purchase price. Contact us to order your own copy or to ask any questions.
We are available to support you in your compliance and financial needs. This Compliance Toolkit, including Financial Analysis Tools will help facilitate self compliance. Our team of consultants, including actuaries, clinicians, behavioral health, pharmacy, and legal resources are also available to guide you through the compliance process, or we can take the lead. We would be happy to have a conversation regarding your needs and can customize a proposal for the level and type of support you may need. Please contact us.