Delays in Transparency Rule and No Surprises Act

On August 20, 2021, the Department of Labor, U.S. Department of Health and Human Services and Internal Revenue Service (“the agencies”) issued FAQ guidance Part49 on the implementation of transparency in coverage regulations (Transparency Rule and No Surprises Act).

As background, the Transparency Rule and No Surprise Act final regulations were issued in November 2020. These regulations required health plans and insurers to publicly disclose price information in machine-readable files for plan years beginning on or after January 1, 2022.

The original effective date for these requirements was for plan years beginning on or after January 1, 2022; however, enforcement of these requirements has been delayed until July 2022 and dates thereafter.

What’s Delayed?

  • Machine-readable files and in-network and out-of-network rates
    • Enforcement deferred until July 1, 2022 — requirement to publicly disclose machine-readable files for in-network rates and out-of-network allowed amounts and billed charges.
  • Pharmacy benefits and drug costs reporting
    • Defer enforcement of the first reporting deadline of December 27, 2021, or the second reporting deadline of June 1, 2022, pending the issuance of regulations or further guidance. The agencies strongly encourage plans and insurers to start working to ensure they will be able to begin reporting 2020 and 2021 data by December 27, 2022.
  • Advanced explanation of benefits (“EOB”)
    • The agencies intend to propose rulemaking “in the future” to provide guidance on how providers and facilities submit estimated charges, including “establishing appropriate data transfer standards.”
  • Pricing comparison tool
    • The agencies intend to propose regulations addressing whether compliance with the transparency in coverage regulations satisfies the Consolidated Appropriations Act 2021 (“CAA”) requirements and requiring of price comparison information to be available by phone. The agencies defer enforcement of the price comparison requirement to plan years beginning on or after January 1, 2023.

The agencies do not expect rulemaking to implement these CAA requirements until after the January 1, 2022 effective date for the following:

  • ID cards
  • No gag-clause rule and attestation
  • Provider directory
  • Balance-billing disclosure to participants
  • Continuity of care

What to Expect?

Plan sponsors (health plans, insurers or administrators) are expected to actively work on the implementation of the provisions that are in effect on or after January 1, 2022, such as the provisions regarding payment of emergency services and protection of participants from balance billing. During the implementation of these provisions, health plans are expected to act in good faith, reasonable interpretation of the law. Therefore, it is highly recommended to document any efforts to comply with these requirements. It is important for plan sponsors to stay informed by reviewing the proposed delays and upcoming provisions that have not been delayed. Stay tuned for further updates and developments.

Author: Brittanee Ann Ramos | [email protected]

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