Category: Pharmacy Reporting
Compliance Toolkit Fourth Quarterly Update Released
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?
Ordering
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.
Available Support
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.
Webinar Replay: A “Dope” Response to Pharmacy Transparency
Watch a replay of the third webinar in Humaculture, Inc.’s Hidden Opportunities, Strategic Compliance Series, which focuses on why the new pharmacy transparency law will not increase transparency; will increase costs, administration, and litigation risk; and how to effectively respond.
Presenters
- Steve Cyboran, ASA, MAAA, FCA, CEBS, actuary and strategy consultant
- Wes Rogers, Humaculturist® and strategy consultant
- Jack Towarnicky, LLM, JD, MBA, CEBS, attorney, strategy and compliance consultant
- Scott McKibbin, strategy and pharmacy consultant
Objective
Beyond basic compliance, this series addresses how to strategically leverage the No Surprises Act to create a competitive financial advantage for both the plan sponsor and plan participants. This session focuses on leveraging Acquisition Cost Based Pharmacy Pricing as well as Behavioral Design and Messaging as an example of a strategic action organizations can take to optimize this compliance opportunity.
Pharmacy Transparency Key Takeaways
During this session, participants will learn:
- Transparency is a misnomer – New rules don’t provide transparency
- Pharmacy is likely to continue to be rather “opaque”
- The conundrum – mere compliance will likely increase costs, administration, and litigation risk
- How to use Acquisition Cost Based Pharmacy Pricing as well as Behavioral Design and Messaging as examples of strategic actions to:
- Avoid what can be avoided
- Provide true transparency with pharmacy benefits
- Empower consumers to make better, more clinically appropriate decisions
- Communicate all negatives as the result of compliance
- Inform/educate consumers (before they become patients)
Available Support
We are available to support you in your strategy, design, compliance, financial, and monitoring needs. To that end, our team of consultants, including actuaries, clinicians, behavioral health, pharmacy, and legal resources are available to guide you through the compliance process. Please contact us: [email protected].
Watch
Watch the Hidden Opportunities: Preserving the Harvest…Leveraging HSAs Webinar Replay below, or via Rumble or YouTube.
Hidden Opportunities, A Strategic Compliance Series: A “Dope” Response to Pharmacy Transparency
You can now access a replay of this webinar here.
Join us on Thursday, March 17 from 12:00 to 12:30 CST for the third webinar in Humaculture, Inc.’s Hidden Opportunities, Strategic Compliance Series, to learn why the new pharmacy transparency law will not increase transparency; will increase costs, administration, and litigation risk; and how to effectively respond.
Presenters
- Steve Cyboran, ASA, MAAA, FCA, CEBS, actuary and strategy consultant
- Wes Rogers, Humaculturist® and strategy consultant
- Jack Towarnicky, LLM, JD, MBA, CEBS, attorney, strategy and compliance consultant
- Scott McKibbin, strategy and pharmacy consultant
Objective
Beyond basic compliance, this series addresses how to strategically leverage the No Surprises Act and Transparency in Coverage to create a competitive advantage for both the employer and employees. In this session we will include a focus on leveraging Acquisition Cost Based Pharmacy Pricing as well as Behavioral Design and Messaging as an example of a strategic action organizations can take to optimize this compliance opportunity.
Pharmacy Transparency Key Takeaways
During this session, participants will learn:
- Transparency is a misnomer – New rules don’t provide transparency
- Pharmacy is likely to continue to be rather “opaque”
- The conundrum – mere compliance will likely increase costs, administration, and litigation risk
- How to use Acquisition Cost Based Pharmacy Pricing as well as Behavioral Design and Messaging as examples of strategic actions to:
- Avoid what can be avoided
- Provide true transparency with pharmacy benefits
- Empower consumers to make better, more clinically appropriate decisions
- Communicate all negatives as the result of compliance
- Inform/educate consumers (before they become patients)
Compliance Toolkit First Quarterly Update Released
The Compliance Toolkit first quarterly update was released on January 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 April 30, 2022 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 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. is conducting a strategic compliance webinar series on the third Thursday of the month 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 is 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?
Ordering
You can purchase the Compliance Toolkit for only $450 by responding to this email and we will invoice you for the purchase price. Contact us to order your own copy or to ask any questions.
Available Support
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.
Compliance Toolkit Overview Webinar Replay: Learn About Humaculture’s CAA and Transparency Compliance Toolkit
This Compliance Toolkit Overview Webinar Replay will help you understand the Toolkit contents and how to use each aspect effectively to help meet the compliance requirements. The video addresses questions from the participants in the original webinar.
On November 11, Humaculture, Inc. released its Compliance Toolkit. Humaculture, Inc. designed the Toolkit to help you comply with Requirements Under the Consolidated Appropriations Act (“CAA”) and the New “Transparency in Coverage” Regulations. The Toolkit includes over one hundred and seventy-five (175) pages and contains over fifty-five (55) Exhibits and Attachments.
On December 14, 2021, Actuary Steve Cyboran, Wes Rogers, and Attorney Howard Lapin reviewed the contents of the Humaculture, Inc. Compliance Toolkit and explain how to use it to comply with the new requirements under the CAA and the “Transparency in Coverage” regulations.
This Webinar focuses on how to use the Compliance Toolkit, not the compliance requirements. To better understand the compliance requirements or download the presentation slides, please access our prior Blog Post.
Ordering
When you order the Compliance Toolkit, it will be provided to you in a Word file and can be easily branded for use with your clients.
How do I order? Contact us.
You can purchase the Compliance Toolkit for only $450 by responding to this email and we will invoice you for the purchase price.
The price includes quarterly updates through September 30, 2022 at no extra charge.
As soon as we receive your payment, we will send you a copy of the Compliance Toolkit.
If you would like to see a sample, please contact us and we will schedule time to review the Toolkit with you.
Questions? If you have any questions before or after ordering the Compliance Toolkit, please contact us.
Available Support
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.
Watch
Watch the Compliance Toolkit Webinar Replay below, or via Rumble.
Hidden Opportunities, A Strategic Compliance Series
Please join us on the third Thursday of the month over the next five months for our upcoming strategic compliance series. This series will focus on harnessing Hidden Opportunities in the No Surprises Act and Transparency in Coverage regulations.
In this webinar series we explore ways organizations can go beyond basic compliance and improve their “organizational soil” through a strategic response to the No Surprises Act and the Transparency in Coverage regulations. Our goal is 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?
For example, a knowledgeable horticulturist may use the high temperatures of the summer season, which are a normal part of the environment just as law and regulation are a normal part of the business environment, to solarize the soil. This is a low cost and simple process of spreading a plastic sheet over an area of soil to trap and intensify the sun’s energy. It is a process that works well to destroy weed seeds and pathogens. Similarly, a knowledgeable Humaculturist® can employ techniques to leverage laws and regulations to strategically improve the organization. This webinar series seeks to identify some of these techniques.
The topics for the upcoming series will include:
| Hidden Opportunities: No Surprises Act | |
| January 20, 2022 12:00-12:30 CST | Surpassing Mere Compliance – Including Reference Based Pricing |
| February 17, 2022 12:00-12:30 CST | Preserving the Harvest…Leveraging HSAs |
| Hidden Opportunities: Transparency | |
| March 17, 2022 12:00-12:30 CST | A “Dope” Response to Pharmacy Transparency |
| April 21, 2022 12:00-12:30 CST | Mental Health Parity…A Lucid Approach |
| May 19, 2022 12:00-12:30 CST | Pest Management, Minimizing Plan Losses through Fee Disclosure |
To view a video on the Humaculture, Inc. Compliance Toolkit that can help support your basic compliance efforts, click here.
Available Support
We are available to support you in your strategy, design, compliance, financial, and monitoring needs. To that end, our team of consultants, including actuaries, clinicians, behavioral health, pharmacy, and legal resources are available to guide you through the compliance process. Please contact us.
Compliance Toolkit Overview – Navigating Compliance with the Patchwork of New Transparency Laws and Regulations
View a replay of this webinar HERE.
Join us for a free 45 minute webinar on December 14, 2021 at 1:00 PM CST.
Actuary Steve Cyboran, Wes Rogers, and Attorney Howard Lapin will conduct a new free webinar to review the contents of the Compliance Toolkit and explain how to use it to comply with the new requirements under the CAA and the “Transparency in Coverage” regulations.
This Webinar focuses on how to use the Compliance Toolkit. To view the Webinar presenting details of the compliance requirements, or download the presentation slides, please access our prior Blog Post.
On November 11, Humaculture, Inc. released its Compliance Toolkit. Humaculture, Inc. designed the Toolkit to help you comply with Requirements Under the Consolidated Appropriations Act (“CAA”) and the New “Transparency in Coverage” Regulations. The Toolkit includes over one hundred and seventy-five (175) pages and contains over fifty-five (55) Exhibits and Attachments.
Consider attending this Webinar to understand the Toolkit contents and how to use each aspect effectively to help meet the compliance requirements. The Webinar will:
- Include a question and answer period,
- Be recorded, so you will be able to access the recording at anytime in the future, and
- Be limited to 500 participants.
After registering, you will receive a confirmation email containing information about how to join the webinar with a link to add an appointment to your calendar.
If you have any comments or questions regarding any of the above information, please do not hesitate to Contact Us.
Compliance Toolkit Available Now – Navigating Compliance with the Patchwork of New Transparency Laws and Regulations
Many of the new requirements in the Consolidated Appropriations Act and the New Transparency in Coverage Regulations are effective in 2022, and some were effective earlier this year. Humaculture, Inc.’s Compliance Toolkit is designed to support your compliance needs. View a replay of our webinar overview of the Compliance Toolkit here.
Are you ready?
Do you know what to do as an Employer, Insurer, or Third-Party Administrator for group and individual health plans?
The new law and regulations require many changes to plan documents, Summary Plan Descriptions, administrative services agreements, and claim procedures. In addition, new disclosures must be provided to covered individuals and new reporting must be submitted to several governmental agencies.
If you do not comply, the penalties for noncompliance can be severe, up to $100 per day per affected individual.
Compliance Toolkit Contents
To address the situation, Attorney Howard Lapin, Actuary Steve Cyboran, and I have created 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 one hundred and seventy-five (175) 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.
Notice: All items contained in the Compliance Toolkit comply with our current understanding of the requirements of the Consolidated Appropriations Act and the New Transparency in Coverage Regulations. The Sample Language, Model Language, Sample Reports, explanations, etc. have been prepared before all guidance has been released by the various governmental agencies. If any changes are required after any guidance is released, the Compliance Toolkit will be amended to reflect any changes (quarterly through September 30, 2022 at no additional cost). In addition, you are advised to seek legal counsel in the use of this Compliance Toolkit.
Webinar Reviewing the Compliance Toolkit
On December 14 at 1:00 pm we conduced 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. Don’t miss it!
Ordering
When you order the Compliance Toolkit, it will be provided to you in a Word file and can be easily branded for use with your clients.
How do I order? Contact us.
You can purchase the Compliance Toolkit for only $450 by responding to this email and we will invoice you for the purchase price.
The price includes quarterly updates through October 31, 2022 at no extra charge.
As soon as we receive your payment, we will send you a copy of the Compliance Toolkit.
If you would like to see a sample, please contact us and we will schedule time to review the Toolkit with you.
Questions? If you have any questions before or after ordering the Compliance Toolkit, please contact us.
Available Support
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.
Transparency Webinar Replay: Big Changes Coming! How to Comply with the Consolidated Appropriations Act (CAA) and Transparency in Coverage Rules!
A replay of and presentation deck for our July 20 Webinar is now available. This webinar addresses several new laws and regulations that significantly impact group health plans and individual insurance coverage. The Consolidated Appropriations Act (CAA), signed into law December 27, 2020, contained the No Surprises Act (NSA) and rules for the additional analysis required for Mental Health Parity (MHP). In addition, the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury (collectively, the Agencies) issued final “Transparency in Coverage” regulations requiring certain disclosures for group health plans and individual insurance.
Compliance Responsibility for Penalties
The following table summarizes the CAA, NSA, MHP, and Transparency in Coverage rules, including the responsible party, applicability, who will enforce the law or rules, and which party is subject to penalties. As of this date, there are still several uncertainties which we expect to be resolved as more guidance is made available by the DOL, HHS, and Treasury. We are working with the CMS oversight group to determine if, or how, these rules may, or may not, apply to self-funded student health plans.
| Insured Group Health | Self-Funded Group Health | Individual/Insured Student Health | Self-funded Student Health | |
| No Surprises Act | ||||
| Responsible Party | Uncertain | Employer | Uncertain | Uncertain |
| Applicability | Yes | Yes | Yes | Uncertain |
| Enforcement | State, then HHS | HHS, DOL, IRS | State, then HHS | Uncertain |
| Subject to Penalties | Uncertain | Employer | Uncertain | Uncertain |
| Transparency | ||||
| Responsible Party | Uncertain | Employer | Uncertain | Uncertain |
| Applicability | Yes, except Grandfathered Plans | Yes, except Grandfathered Plans | Yes | Uncertain |
| Enforcement | HHS, DOL, IRS | HHS, DOL, IRS | State, then HHS | Uncertain |
| Subject to Penalties | Uncertain | Employer | Uncertain | Uncertain |
| Mental Health Parity | ||||
| Responsible Party | Insurer | Employer | Insurer | MEC Plan Sponsor |
| Applicability | Yes | Yes | Yes | Maybe |
| Enforcement | State, then HHS | HHS, DOL, IRS | State, then HHS | State, perhaps |
| Subject to Penalties | Uncertain | Employer | Uncertain | Uncertain |
| Fee Disclosure | ||||
| Responsible Party | Service Provider1 | Service Provider1 | Insurer | Uncertain |
| Applicability | ERISA Plans | ERISA Plans | Yes | Uncertain |
| Enforcement | DOL | DOL | HHS | Uncertain |
| Subject to Penalties | Service Provider1 | Service Provider1 | Uncertain | Uncertain |
Why is transparency compliance important?
For group health plans, the penalty for non-compliance will be up to $100 per participant per day. For a group of 1,000 affected participants, the penalty could be about $36 million over the course of one year of non-compliance.
Available Support
We developed a Compliance Toolkit to facilitate self compliance, which is now available. Watch a replay of an overview webinar of the Compliance Toolkit. 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. Please contact us.
Mental Health Transparency Implications
Mental health and substance abuse disorders (MH/SUD) are a big issue as a result of the COVID-19 response, economic shut down, and social isolation resulting from the transition to virtual work and education. As a result, we have seen significant increases in depression, where rates of depression tripled, substance abuse, and opioid use, in particular, where related deaths are were up 80% in 2020 to 90k, expanding on over 40 years of exponential increases in mortality.
With the passage of the CAA transparency rules, health plans are immediately required to conduct a detailed Comparative Analysis of both financial and non-financial treatment limitations if an Agency or plan participant requests the analysis, report, and supporting documentation. The Agencies are ramping up staff to focus on compliance.
In addition to complying with MHP, we also recommend developing a plan to mitigate the behavioral health issues in your organization. Compliance alone will not likely address the impact on your employees. An effective approach will require a more sustainable approach focusing on a purposeful culture, a healthy culture, and cultural alignment of all reward and benefit programs.
The webinar addresses these topics in much greater detail.
Free Webinar: New Transparency Rule/No Surprises Act
This webinar can now be accessed from Here.
Our Humaculture, Inc. approach to partnering with the best and brightest continues to grow and produce successes for our clients and partners alike.
As part of our continued efforts to bring to you the best resources, we want to make you aware of a free webinar on July 20, 2021 at 1:00 PM CDT.
Please register Here for the webinar.
The Consolidated Appropriations Act and the “Transparency in Coverage” regulations are potential game changers, affecting how health plans set prices for services, negotiate provider contracts and pay for out-of-network emergency care, report information and provide disclosures to participants.
These substantial new requirements will be effective for plan years beginning on or after 2022.
Steve Cyboran, Chief Behavioral Officer and Actuary, and Wes Rogers, Chief Guidance Officer, at Humaculture, Inc., will join attorneys Howard Lapin and Larry Grudzien to conduct a new free webinar reviewing the requirements for the Consolidated Appropriation Act and the “Transparency in Coverage” regulations on July 20 at 1 PM CDT.
The Webinar will be 90 minutes in length, and will cover a lot of detail and answer questions like:
Preventing Surprise Billing:
- What new requirements will be imposed to prevent surprise billing?
General Transparency:
- What new requirements must be added to insurer and TPA contracts to meet the new transparency requirements?
- What new EOBs must be provided to participants before any scheduled care?
- What new services must be provided to a “continuing care patient”?
- What new price comparison guidance must to be provided by phone or Plan website to participants?
- What new advanced explanation of benefits must be provided to participants if requested for scheduled services?
- What new provider directories must be provided and how often must they be updated?
- What new disclosures must be made to the plan for broker, TPA and other vendor fees?
Mental Health Parity Transparency:
- What detailed comparative analysis must be provide to governmental agencies if the plan provides both medical/surgical benefits and mental health/substance abuse benefits?
Reporting:
- What new reporting must be made to governmental agencies on drug prices?
Transparency in Coverage:
- What information must a health plan publicly report on negotiated in-network and out-of-network amounts?
- What information must health plans provide to participants on cost sharing?
We will also provide suggested steps to comply with these new reporting and disclosure requirements.
To mitigate technical issues, we are limiting the registration for this webinar to 500.
This Webinar will include a question and answer period.
A copy of the slides will be provided for all who register. After registering, you will receive a confirmation email containing information about joining the webinar.
If you have any comments or questions regarding any of the above information, please do not hesitate to contact us.
