Understanding the Consolidated Appropriations Act, 2021 (CAA)

Summary: The No Surprises Act (NSA), part of CAA, is a significant step towards protecting consumers from certain unexpected medical bills. This act, effective Jan. 1, 2022, addresses issues related to balance billing for emergency services, and certain non-emergency services provided at in-network facilities.

Key Provisions for Employers:

• Protection from Balance Billing: Members will not receive surprise bills for emergency services from out-of-network providers and non-emergency services provided by out-of-network providers at in-network facilities.
  
  
• Out-of-network Cost Sharing: Emergency services will now be based on in-network rates. For air ambulance services and non-emergency services provided by out-of-network providers at in-network facilities, cost sharing will be calculated based on a recognized amount or a qualifying payment amount, whichever is less.
  
  
• Dispute Resolution: A new Independent Dispute Resolution (IDR) process has been established to resolve payment disputes between providers and plans, including for air ambulance services, without involving the member.
  
  
• Transparency and Consent: For certain non-emergency services, out-of-network providers may balance bill if they follow a specific notice process and obtain the member’s consent. All Explanation of Benefits (EOBs) will include a new disclosure about balance billing protections.

Action Required: No immediate action is required from groups. BCBSND has updated our systems to fully comply with the No Surprises Act.

Summary: With the Continuity of Care regulation, members currently undergoing treatment for serious and complex medical conditions, chronic illnesses, non-elective surgeries or pregnancy can maintain their care regimen even if their health care provider’s network status changes. This became effective for plan years starting on or after Jan. 1, 2022.

Who this applies to: This applies to fully insured and self-funded group health plans, as well as those with individual policies. This does not apply to grandfathered plans.

Action Required: Members will receive a notification letter and continuity of care form if they are seeing a provider who goes from participating to non-participating and must complete the Request for Continuity of Care form to initiate the process of continuity of care.

Summary: Reliable provider information at your fingertips is important. With the Provider Directory Information Accuracy regulation, BCBSND has implemented new measures for maintaining the accuracy of our provider directories. Providers are required to review and confirm the accuracy of their directory information every 90 days. The accuracy requirements have been in place for plan years beginning on or after Jan. 1, 2022. 

Who this applies to: This applies to fully insured and self-funded group health plans, as well as those with individual policies. This does not apply to grandfathered plans.

Action Required: No action is required. BCBSND will maintain and promptly update any changes submitted by providers within 48 hours to ensure our directory reflects the most current information. 

Summary: BCBSND has enhanced cost-sharing transparency for our members with the latest updates to our members’ ID cards. This change took place both physical and digitally, allowing members to easily access cost-sharing details beginning for plan years on or after Jan. 1, 2022.

Now Visible on ID Cards:

• Deductible Details – this includes both in-network and out-of-network.
  
  
• Out-of-Pocket Maximums – includes any out-of-pocket maximums.
  
  
• Contact Information – the phone number and website for members to use to seek assistance.

Who this applies to: This applies to fully insured and self-funded group health plans, as well as those with individual policies and grandfathered plans.

Action Required: BCBSND has issued new ID Cards to members at the time of their plan renewal. We advise employers to inform their teams to anticipate the arrival of new ID Cards. 

Summary: BCBSND will be providing annual reports on air ambulance services to the Department of Health and Human Services (HHS).

Reporting Information Inclusions:

• Claims data for air ambulance services detailed by:
  

- Whether services were for emergent or non-emergent care.

- Whether the provider of services is part of an independent program or part of some other program.

- Whether the services were furnished in a rural or urban area.

- Whether the provider of air ambulance services has a contract with the plan to furnish such services.

- Any other information requested by HHS.

Who this applies to: This applies to fully insured and self-funded group health plans, as well as those with individual policies. This does not apply to grandfathered plans.

Action Required: No action is required. BCBSND will handle all aspects of the data collection and submission process to HHS. 

Summary: BCBSND and groups must annually submit a Gag Clause Prohibition Compliance Attestation (GCPCA) to the Departments of Labor, Health and Human Services (HHS) and the Treasury, collectively.

Learn more at the Centers for Medicare and Medicaid Services’ (CMS) website: Gag Clause Prohibition Compliance Attestation.

The GCPCA is an attestation of compliance with the Internal Revenue Code, Employee Retirement Income Security Act and Public Health Service Act.

Who this applies to: This applies to fully insured group health plans and self-funded group health plans. BCBSND will file the attestation on behalf of fully insured and self-funded groups.  

Attestation Updates: BCBSND performs attestation on behalf of fully insured and self-funded groups for each annual attestation period.

Summary: BCBSND will annually report by June 1 for the prior calendar year, plan specific prescription drug spending and medical cost to the Departments of Health and Human Services, Labor and Treasury Departments.

Who this applies to: This applies to fully insured and self-funded group health plans, as well as those with individual policies and grandfathered plans.

Action Required: No action is required. BCBSND will reach out to health plans if supporting information is needed.

Summary: BCBSND ensures compliance with the MHPAEA by providing mental health and substance use disorder (MH/SUD) benefits that are no more restrictive than the medical and surgical benefits offered under our health plans. This commitment guarantees that individuals seeking mental health and addiction services receive equitable coverage and access comparable to those seeking medical and surgical care.

Who this applies to: This applies to fully insured and self-funded group health plans, as well as those with individual policies. This does not apply to grandfathered plans.

Regulatory Adherence: BCBSND conducts comparative analyses and maintains documents regarding its standard processes, strategies, and evidentiary standards supporting compliance with MHPAEA for its fully insured and self-funded lines of business. These analyses ensure that the non-quantitative treatment limitations (NQTLs)and quantitative treatment limitations (QTLs) applied to MH/SUD benefits are comparable to those applied to medical and surgical benefits.

Action Required: BCBSND will provide a summary of its most current comparative analyses upon request.

The federal government has delayed the implementation of Advanced Explanation of Benefits (EOBs) until further guidance is provided.