Consolidated Appropriations Act of 2021 and Transparency in Coverage Rule: What you need to know (FAQs)

Asuris is implementing CAA requirements via multiple work streams. Due to the complexity and breadth of requirements, work streams are being driven at the enterprise level. We will continue to provide updates on each individual workstream and our collective progress as the information becomes available.

Asuris will provide appropriately timed updates to brokers, employers and members through our regular communications channels as final CAA rules are issued: Producer News (monthly), Employer News (quarterly) and Member News (monthly). We will also create a standing CAA compliance web page with updated FAQs on asuris.com.

Yes. We confirm we are prepared to comply with this requirement.

We are evaluating any impacts for contracts with plan sponsors and will work with plan sponsors to incorporate contract changes, when necessary.

Fully insured rates for 2022 are filed and approved. We will evaluate long-term costs associated with these new requirements, and will adjust rates in future years, as needed.

Asuris does not believe our contract language interferes in the ability of our clients to comply with CAA’s disclosure requirements. We will work with groups directly on any contractual language concerns.

The following plans and reimbursement accounts are exempt from the rule:

• Excepted benefits (e.g. standalone vision, dental, and hearing plans), when not integrated with an applicable medical plan
• Retiree only plans
• Short term limited duration (STLD) plans
• Medicare plans
• Medicaid plans
• Flexible Spending Accounts (FSA), Health Reimbursement Accounts (HRA) and Health Savings Accounts (HSA)

For plan years beginning on and after July 1, 2022, insurers and plans must make available to the public, among other data, negotiated prices and historical net plan allowable amounts for all covered items and services, including prescription drugs.

For plan years beginning on and after January 1, 2023, insurers and plans must provide members with benefit cost estimator tools that enable members to understand and compare their personalized out-of-pocket costs for covered in-network (INN) and out-of-network (OON) services in real-time. The tool must contain prices on the 500 items, services, and prescriptions drugs identified in the final rule. The list contains primarily medical items and services for January 1, 2023. Beginning with plan years starting on and after January 1, 2024, the list will be expanded to contain all covered medical items, services and drugs, enabling members and consumers to understand and compare their personalized out-of-pocket costs for all INN and OON services in real-time.

The rule applies to health insurers in the group and individual markets, and group health plans. Health insurers are responsible for implementing the requirements for fully insured group and individual health plans. Self-funded group health plans may contract with third-party administrators to implement some or all requirements of the rule. The rule also applies to exchange plans and Transitional Relief plans (sometimes called “grandmother” coverage) plans.

The following plans and reimbursement accounts are exempt from the rule:

• Legacy (sometimes called “grandfathered”) plans
• Excepted benefits (e.g. standalone vision, dental, and hearing plans), when not integrated with an applicable medical plan
• Retiree only plans
• Short term limited duration (STLD) plans
• Flexible Spending Accounts (FSA), Health Reimbursement Accounts (HRA) and Health Savings Accounts (HSA)
• Medicare plans
• Medicaid plans

Legacy plans in place prior to enactment of the Affordable Care Act (ACA), are exempt from the rule, as well as many ACA requirements, provided no significant changes are made to the plan design. Health plans are required to disclose whether they consider themselves a legacy plan. Transitional Relief plans became effective after the ACA enactment and do not comply with certain ACA provisions. Federal regulators have allowed these plans to renew under a nonenforcement policy on an annual basis if the plans are otherwise permitted by state law. Customers should consult their own counsel on whether a plan is not covered. When integrated with an applicable medical plan, excepted benefits such as standalone dental or vision coverage are subject to the rule.

Non-ERISA self-funded plans are impacted and must meet both the machine-readable file (MRF) and price comparison tool requirements. Clients should consult their legal counsel for additional guidance.

Tribal health plans that are organized under ERISA or the Public Health Services Act (PHSA), are subject to transparency requirements. Clients should consult their legal counsel for additional guidance.

Yes. An insurer or third-party administrator (TPA) may support the compliance requirements for a self-funded group health plan.

Yes. The rule did not alter existing state and federal privacy or security requirements, including the Health Insurance Portability and Accountability Act (HIPAA). The transparency final rule does not require the public disclosure of any protected personal health information (PHI).

States will have primary enforcement authority, with HHS being responsible for enforcement if a state fails to do so. Group health plans subject to ERISA are subject to enforcement by the DOL.

As of February 2021, groups and insurers are required to provide NQTL analyses when requested by federal regulators. We continue to monitor for instances in which NQTL audits are conducted, and will incorporate additional information into our existing processes.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPEA) has been effect since 2010 and health plans have been required to ensure parity with Non-Quantitative Treatment Limit for many years. Additionally, subsequent regulations have required health plans to provide certain disclosures including processes, strategies, evidentiary standard, and other factors used to apply NQTLs.

The CAA added an additional disclosure requirement that includes a comparative analysis that addresses the specific plan or coverage terms relevant to the NQTL; the factors and evidentiary standards used to determine the NQTL; a comparative analysis of the NQTL; and the specific findings and conclusions of the analysis. In further guidance, the Tri-Agencies stated that the “Self-Compliance Tool for the Mental Health Parity and Addiction Equity Act (MHPAEA)” provided by the US Department of Labor (DOL), which contains a six-step analysis for health plan NQTLs will meet the disclosure requirements of the CAA.

In compliance with the requirements of the CAA, Asuris has developed the “Mental Health Parity and Addition Equity Act Non-Quantitative Treatment Analysis Disclosure” booklet. The information provided in the booklet and the format used are modeled after the “Self-Compliance Tool for the Mental Health Parity and Addiction Equity Act (MHPAEA)” provided by the US Department of Labor (DOL), which the DOL as stated in subsequent guidance meets the requirements of the health plan disclosure requirements within CAA.

The purpose of the booklet is to demonstrate the compliance of Asuris standard plans with MHPAEA by analyzing each plan NQTL using the six-step analysis developed by the US Department of Labor through the Self-Compliance Tool.
Please note that Asuris will update the booklet, along with other documents referenced within as process, procedures and regulatory requirements are updated and clarified.

Asuris will provide specific supporting documentation referenced in the booklet upon request, and when formally requested by a member, provider, or regulator as part of an audit, in compliance with the CAA.

The NQTL analysis Asuris has conducted is based on Asuris standard fully insured plans, and applies to all Asuris commercial lines of business, across all states in which Asuris issues insured health plans.

For self-funded plans, plan sponsors are responsible for ensuring their plans are compliant with any applicable state and federal laws. Accordingly, the Asuris “Mental Health Parity and Addition Equity Act Non-Quantitative Treatment Analysis Disclosure” is for informational purposes only in connection with self-funded plans administered by Asuris. As such, self-funded plans may need to perform additional analyses, particularly for customized plans.

Asuris will provide specific supporting documentation referenced in the booklet upon request, and when formally requested by a member, provider, or regulator as part of an audit, in compliance with the CAA. If a state or federal regulator initiates a MHPAEA audit of an employer group client, Asuris will work in partnership with the client to provide appropriate and up-to-date documentation in relation to the services Asuris provides in support of the audit.

The booklet is confidential and contains Asuris' Proprietary Materials. All information contained in the booklet is subject to the applicable provisions contained within any contract between the rightful recipient and Asuris. Therefore, group clients will need to abide by any confidential information requirements contained in their contract with Asuris. The booklet is considered a regulatory document subject to confidentiality contract provisions and not marketing material, therefore it should not be dispersed as such.

The federal balance billing law goes into effect at the beginning of plan/policy years on or after January 1, 2022, so the law is in effect for new groups with January 1, 2022 effective dates, and upon renewal for groups that renew on or after January 1, 2022. If a group has yet to renew in 2022, the balance billing protections are not in effect for that group until their renewal date.

We are applying the NSA at the ERISA plan year instead of the group’s renewal date. The law requires it to be applied at plan year. For groups that renew mid-year, the NSA would have started for them on Jan. 1, 2022. If they have a Apr. 1 plan year, the NSA doesn’t apply until then.

Fully insured plans, self-insured plans, and the Federal Employee Plan. The federal mandate will also apply to legacy plans. The plans excluded from the federal mandate include Medicare Supplement (MediGap) and Medicare Advantage plans. Dental and vision plans are also excluded.

No, the No Surprises Act does not apply to retiree-only plans.

The notice of member rights titled “Your Rights and Protections Against Surprise Medical Bills” has been added to the 2022 member benefit booklets. This provides a high-level overview of the protections and definitions associated with federal balance billing.

Yes, as of 1/1/22. It’s also included with every EOB. We are also working to implement a solution whereby the notice will be included only with applicable EOBs, i.e. those that are subject to balance billing protections.

Yes, we will provide support to reimburse OON providers and facilities when balance billing is prohibited.

The U.S. Departments of Health and Human Services, Labor, and Treasury have developed a list of Certified Independent Resolution Entities (CIDRES) to resolve disputes between providers, facilities, air ambulance providers and group health plans. We will work with any CIDRE as needed.

We have identified the Asuris groups and their expected 2022 renewal dates and have configured them into our claims workflows. Once a group reaches the beginning of their ERISA plan year, they will begin to receive their balance billing benefit. We are monitoring claims to ensure they are correctly processing claims eligible for NSA protections. For example, a claim with a date of service prior to the group’s 2022 ERISA plan year would not be flagged as NSA-eligible, and therefore would be processed without NSA protections.

An Asuris cross-functional team reviews claims activity on a daily basis and works through questions and issues in real time. Additionally, we are working to implement claims status reporting for Regence leadership to ensure these requirements receive ongoing focus.

In some circumstances we may be pending claims for short periods of time.

We will issue claim adjustments, not vouchers.

Health insurers (including self-funded groups) are required to report data for air ambulance claims incurred in 2022 and 2023 to the Department of Health and Human Services (HHS). The deadline for reporting 2022 data, originally March 31, 2023, has been postponed pending the issuance of final reporting rules.

For more information about air ambulance claims data reporting please see the CMS air ambulance reporting fact sheet.

Yes. The federal and Washington laws differ in the following ways:

Emergency Services

• Both Washington and Federal law apply to coverage for services in an emergency department of a hospital or freestanding emergency facility, whether in- or out-of-network.
• Federal law requires carriers to cover services in an emergency department of a hospital, regardless of any plan exclusions that exist (Ex., dependent maternity).
• The federal law also applies to post stabilization services with respect to the visit in which the emergency room services are furnished. This may include any additional items and services that are covered under a plan and furnished by a non-participating provider/facility after the patient is stabilized and as part of an outpatient observation or inpatient/outpatient regardless of where the services are provided in the hospital.

Out-of-Network Services performed at In-Network Facilities

• Both Washington and Federal law applies to coverage for services performed at the following in-network facilities when performed by an out-of-network provider: hospital emergency room, inpatient and outpatient hospital and ambulatory surgical centers. The federal law also includes critical access hospitals, inpatient psychiatric and rehabilitation facilities, and independent freestanding facilities, as long as they are able to provide emergency services.
• Washington and Federal law require carriers to hold members harmless from balance billing when non-emergency services are provided by out-of-network providers for surgical and ancillary services including, surgery, anesthesiology, pathology, radiology, hospitalists and laboratory. Federal law also included: intensivist, neonatology, whether or not provided by a physician or nonphysician practitioner, and items and services provided by assistant surgeons.

Air Ambulance

• Federal law requires patients to be held harmless from surprise bills for out-of-network air ambulance services.

Misc.

• Both Washington and Federal law require carriers to provide members a notice to explain member rights under balance billing. For fully insured and self-funded groups who opted into Washington balance billing, they will receive the Washington notice that will include both Washington and federal language. Self-funded groups will use the federal notice. The notices will be placed on the Asuris website and in most member benefit booklets. Although Washington law does not require the notice to be included with member EOBs, the Federal law does; therefore, the plan specific notice (FI or SF) will be attached to member EOBs if it reflects services that meet balance billing requirements (ex., emergency services).
• Although the federal law allows for a provider to acquire a notice and consent in certain situations, Washington law is prohibiting providers from attaining a notice and consent to balance bill patients. Therefore, if the service and provider are covered under Washington balance billing protections, a provider is not able to ask the patient for consent in those situations.
• Both the Washington and federal laws have a provider dispute resolution process. Washington has provided guidance their law will supersede the federal law.

It is recommended that self-funded groups who opted-into a state law opt-out. The federal law provides the same protections as the state law specific to emergency services and ancillary services provided by an out-of-network provider at an in-network facility. However, the federal law provides additional provisions, such as post stabilization and air ambulance.

If the self-funded group remains opted into the state balance billing law, it can create member and provider confusion. This can occur because of the overlap between the state and federal laws. Members may not be aware of what law applies for the particular services they receive. For example: A member visits a Washington out-of-network emergency room (state law applies) and is then admitted to the hospital for stabilization services (federal law applies). When the hospital files the claim with the carrier, the payment to the hospital will contain two reimbursement rates: the commercially reasonable rate for the emergency services (state law) and qualified payment amount for the stabilization services (federal law). If the out-of-network hospital wants to dispute the rate paid, they would have to file two disputes – one with the OIC for the emergency services and one with CMS for the stabilization services.

This also creates more complex processes for Asuris as the claims system will need to be configured to identify whether the self-funded group is opted-in or -out of the state balance billing law. In the example above, the carrier’s claims processing system will need to determine which rate applies to the various line items contained on the hospital claim, the state’s commercially reasonable rate or the qualified payment amount.

We will administer continuity of care, as required, if a contracted provider leaves our network.

As a provider signals intent to leave our provider network, we identify patients of that provider on the basis of claims, and provide notice to impacted members of their provider’s changing network status, as well as their right to continue care with that provider.

Yes, we will administer transitional care.

Yes. We currently provide access to provider directories on our websites, and will continue to do so. We understand the requirement to honor in-network cost sharing if a member receives from Asuris incorrect information about their provider's network status. We will ensure in-network cost sharing is honored for any members in accordance with applicable laws and regulations.

ASO groups have the compliance obligation under the CAA. Asuris assumes responsibility for administering the provider directory requirements to the extent that it relates to providing an accurate and comprehensive directory of providers in the Asuris network. Asuris is not responsible for administering the provider directory requirements in connection with providers outside of the Asuris network, including when an ASO carves out PBM and non-network providers.

Although the member ID cards will be new, our process for producing and issuing them on or before their effective date isn’t changing, and our standard renewal deadlines aren’t changing.

The administrative fees for 2022 have already been finalized and there will be no additional fees added.

New member ID cards are required to be distributed to new and renewing group members beginning with January 1, 2022 effective dates.

New member ID cards will be reissued in connection with the group’s renewal date (or ERISA plan year start date, if different than renewal date) in 2022.

Users will be able to access the MRF query landing page below by clicking on the ‘TIC Machine-Readable Files’ link at the bottom of every public-facing page on asuris.com. In addition, groups will be able to copy https://www.asuris.com/transparency-in-coverage/ and embed it on their own websites.

There is no special information required for someone to access MRFs on asuris.com/employer/resources/caa-tic-rule. MRFs for groups can be accessed by clicking on the appropriate line of business link for self-funded or fully insured groups. Clicking each link will produce a combined MRF result that includes all employer group health plans and networks associated with the line of business selected.

MRFs for a specific self-funded or fully insured groups of 51+ can be searched on asuris.com/employer/resources/caa-tic-rule by typing the group’s Employer Identification Number (EIN) in the search field window and clicking the ‘Get by EIN’ button. Separate MRFs for fully insured small (1-50) groups are not available at the plan level; they are aggregated and combined with all fully insured groups’ MRFs. Users can access these MRFs by clicking on the fully insured link in the table at the top of asuris.com/employer/resources/caa-tic-rule.

Searching by EIN will produce an MRF that’s specific to the EIN of the self-funded or fully insured 51+ employer group selected. Searching by line of business (e.g. self-funded or fully insured) will produce an expanded MRF that includes all the employer group health plans and networks associated with the line of business selected.

MRFs are searchable by EIN only for self-funded groups and fully insured groups of 51+. Fully insured small (1-50) groups’ MRFs are not searchable by EIN; small groups’ MRFs can be accessed by clicking on the fully insured link.

In addition, some groups’ plans are not covered by the Transparency in Coverage Rule. If a file request by EIN is out of scope, no search results will be shown. Users can consult the CMS rule for details on which plans are within scope.

Because the MRFs are intended to be used for data aggregation and research purposes, they are required to be generated in a very specific format mandated by CMS. The data in the MRFs will appear like lines of computer code text, and additional coding or other technical support will be required to make them user-friendly for human consumption.

No. There is no requirement for the data displayed in the MRFs to correspond directly with data displayed in the price comparison tool. While the MRFs will display in-network (INN) and out-of-network (OON) provider pricing information, the price comparison tool will display each member’s specific cost share.

Yes. When dental and/or vision are integrated with a customer’s medical plan, they are included.

It depends on whether the provider is classified and priced for the plan as INN or OON. If the secondary network providers are considered INN, their rates should be included in the INN file.

For groups with plan years that begin January 1, 2022 through July 1, 2022, the files were required to be publicly available by July 1, 2022. For groups with plan years beginning August 1, 2022 and thereafter, the files are required to be publicly available before the end of the month of their effective date.

Health insurers and issuers must provide detailed pricing data in two MRFs. The files must be available to users publicly at no cost, and they must be updated each month. Billing codes must be included, enabling the user to identify each item or service, such as:

• Current Procedural Terminology (CPT) code
• Health Common Procedure Coding System (HCPCS) code
• Diagnosis-Related Group (DRG) code or
• National Drug Code (NDC)
• Other common identifiers

• File One - In-Network Rates. This file must include negotiated rates for all covered INN items and services.
• File Two - Out-of-Network (Allowed) Historical Rates. File two must include both the billed charges from, and historical payments to, OON providers for all covered items, services, and prescription drugs. If a provider has fewer than 20 claims for a particular item or service during the reporting period, the data for these items and services are not required to be reported.
• The requirement for a third file containing prescription drug pricing data has been put on hold. This file was to include detailed historical net prices and INN negotiated rates for all covered prescription drugs by plan or issuer at the pharmacy location or other provider level. Additional rules and a new compliance enforcement date pertaining to prescription drug MRFs are expected to be issued in the future.

A standardized format is required for displaying the data. The Centers for Medicare and Medicaid Services (CMS) has issued guidance indicating PDF and Excel documents are not allowable file formats. Because the MRFs are intended to be used for data aggregation and research purposes, they are required to be generated in a very specific format as mandated by CMS. The data in the MRFs will appear like lines of computer code text, and additional coding will be required to make them user-friendly for human consumption.

It depends on the relationship we have with the client. If we have a contractual relationship with an employer, as with fully insured and self-funded groups who use Asuris networks, we will create, generate, and publish MRFs on behalf of customers unless otherwise directed by them. Self-funded groups with custom networks can discuss their specific TIC compliance needs with their AE.

Yes. Separate MRFs are required to be created, maintained and updated monthly representing contracted INN and OON pricing for each network. Because the same contracted network pricing often applies to multiple groups, MRFs that contain network rates contracted by more than one employer group will be used for all applicable groups. Note that only medical plans covered under the TIC Rule are included in the MRFs. If a file request by EIN or HIOS-id is out of scope, no search results will be shown. Users can consult the CMS rule for details on which plans are within scope.

We will waive any fees to customers associated with expenses that we incur for generating, hosting and maintaining MRFs on our website in 2022. This applies to both fully insured and self-funded groups. Any potential administrative fees for maintaining self-funded groups’ MRFs beyond 2022 are to be determined.

Asuris will publish updated MRFs on a monthly basis, replacing the prior month’s file each month. There is no requirement pertaining to retention or displaying of files from prior months.

No. The MRFs will have nothing at all to do with member identity. The MRF file for OON items and services will only represent providers’ contracts and allowable amounts; no PHI is included.

We are working to ensure that MRFs are available and consistent with the requirements. We are dedicated to working with our employer-sponsored health plan customers to discuss any specific reporting needs.

Because of the large data file size required to transmit all of our provider and Rx pricing data, a business decision has been made to provide MRF data to groups on demand, rather than in real time. When a MRF request is submitted on our publicly-accessible website, our system will generate the requested file at that time. File generation could take considerable time (e.g. up to 24 hours). The requestor will need to make allowances for this time in their request.

Because the MRFs are intended to be used for data aggregation and research purposes, they are required to be generated in a very specific format as mandated by the Centers for Medicare and Medicaid Services (CMS). We will publish JSON (Javascript Object Notation) files. The data in the MRFs will appear like lines of computer code text, and additional coding will be required to make them user-friendly for human consumption.

We intend to be compliant.

Files will be updated and available monthly in compliance with the rule. We will follow standard quality and control operations to ensure file and data accuracy as changes are identified. Standard and repeatable processes for file generation will be automated.

Yes, MRFs will continue to reflect the date of the last update.

We intend to comply with the regulatory implementation dates as stated previously: on or before July 1, 2022, MRFs containing costs for all covered services will be accessible.

Customers should follow the standard process and engage their Account Management Team for inquiries.

The MRF data will be publicly accessible by anyone in the public sphere, including members, consumers, researchers, employers and third-party developers. Once made public, Asuris cannot control or enforce any restrictions on how the data are used.

We will create MRFs for all fully insured plans. For self-funded customers using an Asuris network we will create MRFs as designated under the rule. We will waive any fees to customers associated with expenses that we incur for generating, hosting and maintaining MRFs on our website in 2022. This applies to both fully insured and self-funded groups. Any potential administrative fees for maintaining self-funded groups’ MRFs beyond 2022 are to be determined. Self-funded customers that have plans with custom networks should discuss their compliance needs with their Asuris representative. These requests will be considered on a case by case basis. We will report information regarding potential administrative costs as more details become available.

No. The rule requires files to be accessible free of charge to anyone, without requiring to user to have an account or submit any personal contact information.

VBA pricing is not required to be included. The pricing that is required will be fee-for-service or bundled arrangements, but will not factor-in the impact of upside/downside risk on pricing.

The requirement for generating, hosting and maintaining prescription drug MRFs has been put on hold pending further rulemaking. Previously, covered prescription drugs that are purchased on an INN basis were to be included in the INN Prescription Drug File, and those purchased OON would be included in the OON file. Data for each prescription drug was to include:

• each drug’s strength, dosage, and formulation level at the first 9-digit NDC level
• the negotiated cost for each INN pharmacy
• the pharmacy tax ID number (TIN), place of service code and NPI
• the issuer’s or health plan’s cost including any allocated price concessions, rebates, discounts, chargebacks, fees.

This is to be determined, since the requirement for prescription drug MRFs is on hold. Customers with PBM networks other than Prime who would like us to post MRFs on their behalf should discuss this with their Asuris representative. Requests will be considered on a case by case basis. Information concerning any potential administrative costs associated with posting third party PBM data will be provided to self-funded customers as more details become available.

Contracted virtual care platforms are network providers, so their rates will be included in the MRFs.

We will include data for any client specific network for which we pay the claims.

Yes. Because OON allowable amounts are based on backward-looking claims data, groups who term with Asuris and start with another carrier will need this past data to determine their future OON allowable amounts for a specified time period. We will maintain and provide OON MRFs in these cases for a runout period to be determined on a case by case basis with each group where the situation applies.

Yes. We will work to ensure our current cost comparison tool is modified as required to comply with both CAA regulations and TIC rule provisions.

We expect to incorporate data from third parties with whom Asuris has a contractual relationship. Asuris cannot verify the accuracy of data provided by a third party with whom we do not have a contractual arrangement. However, we will work with clients individually to understand the support they require, and try to accommodate.

The tool is required to provide enrollees or their authorized representatives personalized out-of-pocket cost information and underlying negotiated rates for all covered health care items and services, including prescription drugs. The information must be available online via self-service, over the phone, and in paper form upon request. Most consumers will be able to get real-time and accurate treatment estimates of their cost-sharing liability from providers. The tool will enable members to understand how costs for covered health care items and services are determined by their plan, and comparison shop estimated health care costs among multiple providers before receiving care.

The tool is required to be available for an initial specified list of 496 shoppable items, services and drugs identified in the rule starting with plan years beginning on or after January 1, 2023. Most of the required services will be medical in the first year. All covered items, services, and drugs are required to be included for plan years beginning on or after January 1, 2024.

CMS has published this list of the initial 496 shoppable items, services and drugs required to be included as of Jan. 1, 2023.

Beginning January 1, 2024, the cost comparison tool will expand to include all medical care covered by the insurer or plan, including charges for office visits, virtual care, medical tests, durable medical equipment, and prescription drugs.

Members must be able to search for covered items and services by billing code or descriptive term (e.g., rapid flu test); provider/pharmacy name; and other factors relevant to determine cost sharing (e.g., facility name, service location, network, tiering, dosage). The member will be able to adjust their search or prioritize the results based on geographic proximity of providers and the estimated cost share liability for the item/services/drug if there are multiple results. Information will be available at no cost through an internet self-service tool, and via mail or email sent to a member upon written request.

Data for generating cost estimates for the 496 required shoppable items, services and drugs will come from two sources: (1) our historical claims data, and (2) negotiated rates contained in our machine-readable files (MRFs). Members will be able to choose their estimates to be displayed based on historical claims or negotiated rates. Members’ cost-share accumulator data (deductible, coinsurance and copays) will be sourced from within our internal health plan systems to show estimated out-of-pocket costs.

Price comparison tools, and transparency in coverage rules, align with our cause to make health care more person-focused and economically sustainable. The tool will enable consumers to evaluate health care options and to make cost-conscious decisions; reduce potential surprises in relation to members' out-of-pocket costs for health care services; foster competition that may narrow price variability for the same items and services in the same health care markets; and potentially lower overall health care costs. We have provided these types of tools to support members’ efforts to lower their costs for several years.

The Advanced EOB (AEOB) requirement is on hold pending new rules on standards for data transfers for providers’ good-faith estimates (on which Advanced EOBs are to be based) and other matters.

We can currently provide single-claim estimates. Prior to enforcement of the AEOB provision being postponed, we were working to address multi-claim estimates. We’re engaging Availity as the pipeline to work with providers to send that information to us. Complex procedures involving multiple providers under a single treatment episode will require the scheduling provider to amass and send all the information to us. And we’re working with our digital team to create a process for members to request the same thing.

According to the Federal Register draft rulemaking is scheduled for March 2024.

This rule impacts group, Individual and Short-Term Limited Duration (STLD) plans. On the group side, brokers will be required to disclose commissions to group plan sponsors. On the Individual and STLD side, we will be required to disclose brokers’ commissions on Individual and Short-Term Limited Duration plans to Individual customers.

We will post brokers’ Individual and STLD commission schedules on a public-facing web page on asuris.com for plan applicants’ review both pre-sale and post-sale. Dental commissions will be included. Schedules will include commissions both in PMPM and annualized format.

According to CMS the purpose of RxDC reporting is to enable better understanding of health care spending overall, and specifically prescription drug price increases relative to total spending on health care services.

Issuers and sponsors of group health plans are required to report a plan list (P2) and the following eight sets of data (D1-8 files) to CMS annually:

• D1 premium and life years (including employer/employee premium splits, beginning in 2022)
• D2 spending by category
• D3 top 50 most frequent brand drugs
• D4 top 50 most costly drugs
• D5 top 50 drugs by spending increase
• D6 prescription drug totals
• D7 prescription drug rebates by therapeutic class
• D8 prescription drug rebates for the top 25 drugs

Yes. For information about how Asuris is implementing 2023 RxDC reporting for employer groups please read this Employer News article.

As health plan sponsors it is self-funded groups’ responsibility to ensure their compliance with RxDC reporting requirements. We do not accept RxDC data or combine data provided by other entities with the data we hold.

When directed by groups, we include in each group’s D1 (premium and life years) file information about the following benefits arrangements, where applicable:

• Carved-out PBM or specialty PBM entity
• A second (or more) TPA(s) that administered medical benefits or PBM benefits
• A stop-loss carrier other than or in addition to CBRM/RBSI

Where we are the sole administrator of a group’s benefits, and have written authorization from groups, we will prepare and submit the required reporting to CMS. However, where groups have carved out any portion of their medical, pharmacy or stoploss benefits, we cannot prepare and submit the data because we didn’t administer the benefits and cannot validate its accuracy. We will not accept RxDC data or combine data provided by other entities with the data we hold.

For information about how Asuris is implementing 2023 RxDC reporting for employer groups please read this Employer News article.

We will submit that RxDC data with the associated narrative responses. If a group does not authorize us to submit on their behalf, we will provide the group with their data (in the format required in the data submission instructions), including the associated narrative responses.

No and No. We will only prepare and submit reporting on behalf of groups when authorized to do so. Please see answer to the next question below for more details. There are no additional costs for our submitting reporting on behalf of groups for reference years 2020 through 2023.

For information about how Asuris is implementing 2023 RxDC reporting for employer groups please read this Employer News article.

It is each self-funded group’s obligation to comply with RxDC reporting requirements. We contact inactive self-funded groups via email to obtain their preference on the reporting of data for the benefits that we administered in the reference year. If the group wants us to submit reporting on their behalf we will do so as a courtesy, upon receiving their written authorization. If a group does not respond, or indicates their preference to self-report, we will provide them their data so that they can file it independently or through a TPA.

Yes. We will provide confirmation to groups and their producers via the first available Employer News and Producer News editions published after the reporting deadline.

Our P2 (plan list) files for self-funded groups are built using the following mapping schema:

Self-funded groups can have multiple TPAs and PBMs and those entities will be included in the TPA Name/EIN and PBM Name/EIN where applicable. Self-funded groups will be identified in the P2 file at the group or parent group level based on the makeup of the group.

For self-funded groups we reported life years and premium equivalents, including administrative fees and stop-loss premium (for fully insured groups we reported earned premium). Where we submit premium equivalent for self-funded groups, the amount is computed using costs that we bill each group based both on data we hold, and data that groups provide us that’s not contained within our systems:

• Medical claims costs
• PBM claims costs (if we hold the PBM)
• ASO administrative fees
• PBM administrative fees (if we hold the PBM)
• Stop-loss premium (CBRM, and RBSI if applicable)
• Stop-loss claims paid by the stoploss carrier (CBRM, and RBSI if applicable)
• Total Life Years
• Total Premium Equivalent Paid
• Average Employer Premium Equivalent Paid
• Average Employee Premium Equivalent Paid

Completing and submitting self-funded groups’ D1 file requires that groups sign and return their RxDC Reporting Authorization Form, and complete an RxDC Data Collection Form containing their Total Life Years, Average Employer Premium Equivalent Paid, Average Employee Premium Equivalent Paid, Total Premium Equivalent, Total ASO/TPA Admin Fees and Stop-loss Premium. We pass the data provided through to the RxDC data collection system hosted by CMS.

Asuris hereby confirms that the administrative services it provides to fully insured and self-funded customers are consistent with the gag clause prohibition requirements set forth in the Consolidated Appropriations Act, 2021 (PL 116 - 260), Division BB, Section 201: INCREASING TRANSPARENCY BY REMOVING GAG CLAUSES ON PRICE AND QUALITY INFORMATION.

We submitted a gag clause prohibition compliance attestation (GCPCA) on behalf of all fully insured employer groups, and self-funded groups that authorized us to do so. Upon submitting, CMS issued the following attestation confirmation number to us: 38158.