Benefits Counselor ' May 2022

• Published date: 05 May 2022
• Subject Matter: Employment and HR, Retirement, Superannuation & Pensions, Health & Safety, Employee Benefits & Compensation
• Law Firm: Reinhart Boerner Van Deuren s.c.
• Author: Mr Employee Benefits Group

HEALTH PLAN DEVELOPMENTS

New Safe Harbor for Transparency In Coverage Rule's In-Network Machine-Readable File

The Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury (the Departments) recently announced a limited enforcement safe harbor for the in-network medical machine-readable file required under the Transparency in Coverage Final Rule (the Rule).

Under the Rule, non-grandfathered group health plans and health insurance issuers offering non-grandfathered coverage in the group and individual markets must disclose, on a public website, information regarding in-network provider rates in a machine-readable file. The Rule also requires plans and issuers to post machine-readable files for (1) out-of-network allowed amounts and billed charges; and (2) negotiated rates and historical net prices for prescription drugs. The Departments are not enforcing the in-network and out-of-network machine-readable file requirements until July 1, 2022, or the first month of the plan or policy year in 2022 if later. The file requirement for prescription drugs is pended until future rulemaking.

Pursuant to the Rule, machine-readable files must list rates in dollar amounts. However, under the new safe harbor plans and issuers that use "percentage-of-billed-charges" contracts with in-network providers for particular services can instead disclose the reimbursement percentage. The Departments determined that the safe harbor was necessary because under these types of contracts, the dollar amount cannot be known until the provider bills for the service, and the billed charge can vary. The Departments also extended a safe harbor to other in-network services for which providers are reimbursed under arrangements not supported by the Department's machine-readable file schema, or that need additional context to be understood. In those cases, plans and issuers may describe the arrangement in an open text field.

Agencies Publish Guidance on Federal IDR Process Under No Surprises Act

The Departments published guidance to clarify the independent dispute resolution (IDR) process for group health plans, health insurers and out-of-network providers under the No Surprises Act. The IDR process comes into play when the out-of-network providers do not agree with the amount the plan or issuer paid for services that the provider cannot balance bill to the patient under the No Surprises Act. The guidance is not binding, but provides information on the entire lifecycle of a disputed claim, from the steps that must precede IDR to its conclusion. Covered topics include:

• Plan or Issuer's Initial Payment or Claim Denial
• Open Negotiations
• Initiating the Federal IDR Process
• Selection of the Certified IDR Entity
• Submission of Offers and IDR Entity Fees
• Factors and Information Certified IDR Entities Must Consider
• Certified IDR Entity's Offer Selection and Written Decision
• Effect of the Determination
• Extensions of Time Periods
• Fees

The guidance also includes a chart summarizing the steps in the entire process and providing links to the standard notices required at different stages.

The Departments also published similar guidance for certified IDR entities. The guidance generally covers the same topics, but also discusses:

• Conflicts of Interest for Certified IDR Entities
• Determining Whether the Federal IDR Process Applies to the Dispute
• Recordkeeping and Reporting Requirements
• Confidentiality Requirements
• Revocation of Certification

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