No Surprises Act/Transparency Under the Consolidated Appropriations Act, 2021

The No Surprises Act (NSA), signed into law as part of the Consolidated Appropriations Act, 2021 (CAA), establishes federal standards to protect patients with health benefits coverage from “surprise” medical bills that may arise when receiving care from certain out-of-network providers and ancillary providers. Under the NSA, patients will only be responsible for paying the in-network amount for covered services. The federal NSA does not preempt more restrictive state laws prohibiting surprise medical bills.

• When out-of-network providers bill members directly for the difference between the total amount they billed and what the member’s health insurance company or health plan actually paid is called balance billing, or surprise billing. Surprise billing is more likely to occur in emergency situations where members may not get to choose the provider.
• Effective with January 1, 2022, health plan effective dates, the No Surprises Act offers members protection against balance/surprise billing for the following:
  • Emergency care – from in-network or out-of-network providers
  • Non-emergency care – from out-of-network providers at in-network facilities
  • Air ambulance service – from out-of-network providers
• NSA legislation applies to both grandfathered and non-grandfathered Individual, Small Group, Level Funded and Large Group Fully Insured markets and Self-Insured (ASO) Group plans. It does not apply to Medicare and other programs that already offer safeguards against surprise billing.
• The NSA does not apply if a member voluntarily chooses to use an out-of-network provider and receives notice and signs a consent.

In late 2020, the Departments of Health and Human Services (HHS), Labor (DOL) and the Treasury finalized the Transparency in Coverage (TIC) rule which requires health insurers and group health plans to make health plan pricing information accessible to consumers, allowing for easy comparison shopping. The rule also requires insurers and group health plans to provide publicly available machine-readable files that include in-network negotiated payment rates and historical out-of-network charges for covered items and services, including prescriptions drugs. Data in machine-readable files must be updated monthly.

Enforcement on these changes has been delayed at this time, but Medical Mutual is already working to make sure we’re fully compliant.

The Advanced EOB (Explanation of Benefits) requirement of the No Surprises Act (NSA) is designed to give members advanced notice of how much they may have to pay out of pocket for healthcare tests and procedures. This requirement is projected to be a January 1, 2023, deliverable.

Here's how Medical Mutual will comply:

In preparation to deliver on this requirement by January 2023, Medical Mutual is working with multiple vendors regarding real-time claims adjudication. We are also awaiting release of expected Electronic Data Interchange (EDI) transaction types from Health and Human Services (HHS). This information will support the submission of procedural data from healthcare providers to health plans to facilitate the Advanced EOB. Medical Mutual expects these pre-service Explanation of Benefits (EOB) to closely mirror our existing EOBs but will rely heavily upon electronic delivery through the My Health Plan (MHP) portal to give members results in advance of their scheduled procedures.

For plans with effective dates on or after January 1, 2022, some health plan members may request to continue receiving care from a provider or facility who is no longer in their plan’s provider network. Under the No Surprises Act, the plan or issuer must provide timely notification to the member that the provider is leaving their plan’s network and inform them of their right to request continued transitional care from that provider at the same in-network benefit level. The election may last until the earlier of 90 days (starting on the date their plan or issuer notifies them of the change in network status); or the date on which such individual is no longer a continuing care patient with the provider or facility.

Here’s how Medical Mutual will comply:

Medical Mutual reviews continuation of care requests for individuals whose health care provider is terminated from the network based on medical necessity and in accordance with all applicable statutes and regulations.

Members will be eligible for continuing care when their current care involves the following:

• Serious and complex conditions.
• Course of institutional or inpatient care.
• Scheduled nonelective surgery including post-operative care.
• Course of treatment for pregnancy.
• Terminally ill patients.

IF the delay of such treatment will cause harm to the member, we will review and approve an out-of-network waiver if no other adequate in-network options exist until such time we can find adequate substitution to provide continuity of care. With an approved waiver, members may continue to see their provider at the in-network benefit level for up to 90 days after receiving written notice from Medical Mutual, or until treatment related to their condition is completed (whichever is less).

The Consolidated Appropriations Act (CAA) and Transparency in Coverage (TIC) rule require that insurers and group health plans offer price comparison information to members via a web-based cost-transparency tool. The tool must allow enrollees to compare costs across participating providers in a geographic region for specific items and services. The tool must also show members the amount they would be responsible for paying (cost-share) for having a specific service or item done by a specified provider.

Originally, the CAA and TIC rules were published with different target dates for making the cost transparency tool available. A recent update has aligned the rules so that they both require the tool be online by 2023. This update was issued in FAQ 49.

The CAA and TIC rules have different requirements for what services and items should be in the tool. It is possible that this will be resolved with future guidance from the federal agencies.

Here’s how Medical Mutual will comply:

Medical Mutual supports actionable price and quality transparency for consumers and has been forward-thinking with our offerings. We already offer a web and mobile tool that allows members to review price and quality of care information online. The information can also be provided over the phone.

Medical Mutual is working on improving and expanding our existing tools and will meet the TIC and CAA customer price transparency tool requirements by the specified dates. We will also help our self-funded clients meet this requirement by making the tool available to their members.

Insurers and group health plans must create and publish machine-readable files with rate information per the Transparency in Coverage (TIC) rule.

Starting July 1, 2022, you can find the file for our active plans here.

These files will be updated monthly and include negotiated rates for all in-network providers, and allowed amounts and historical billed charges for out-of-network providers. At this time, the TIC rule’s requirement to post pharmacy cost information has been deferred to an undetermined time.

Due to the methodologies used to capture this data, and the complex required format, these Machine Readable Files are intended for use in technical analysis rather than by consumers in making decisions. Further, the methodology used to prepare these files may be different than that of other payers with the same requirements.

Medical Mutual has a current cost estimator tool on My Health Plan that can be used by members to compare costs of procedures and services by network providers. Additionally, our cost tool is being enhanced as we constantly work to improve our members’ experience and be complaint, and a new version will be available starting on January 1, 2023.

Effective with plan years beginning on or after Jan. 1, 2022, No Surprises Act (NSA) legislation requires group health plans and insurance companies to notify members about their rights and protections related to surprise medical billing. This notice must be publicly available, posted on the group health plan’s or insurance company’s public website, and included on member Explanation of Benefits (EOB). Medical Mutual will use the Department of Labor’s model notice for guidance.

Here’s how Medical Mutual will comply:

Notice of Rights and Protections Against Surprise Medical Bills can be found on our public website at the link at the bottom of the page.

Starting Jan. 1, 2022, our electronic EOBs – available through My Health Plan, our secure member website and member mobile app, will include this notice at the bottom of the document. Printed EOBs for applicable claims will include the scannable QR code below. Members can scan the QR code with their mobile device to access an online copy of this required information.

No Surprises Act (NSA) legislation requires health insurance plans to include, in clear writing, the following information on any physical or electronic ID cards:

• Any applicable medical deductibles
• Any applicable medical out-of-pocket amounts
• Telephone number and website where members can seek assistance

In addition, Ohio law requires additional changes, such as adding an indicator on the front of the ID card to let providers know if the plan is governed by the Ohio Department of Insurance or another entity.

Here’s how Medical Mutual will comply:

• Medical Mutual has modified our member ID cards to meet the above requirements.
• The newly designed NSA ID cards will be issued to all members before the end of 2022. Members will receive new ID cards when their group renews or makes benefit changes.
• Groups not making a benefit change will receive updated member IDs at the end of their plan year month or early the following month.
• Once new ID cards have been printed, an electronic version (ecard) will be available on My Health Plan, the MedMutual mobile app, Availity and EmployerLink.
• Members should continue to use their current ID card until they receive their new card in the mail. At that time, they should destroy their old card and start using their new one right away

The Consolidated Appropriations Act (CAA) allows the Departments of Health and Human Services (HHS), Labor (DOL) and the Treasury, sometimes referred to as the Tri-Agencies, to conduct audits of plans and require the plans to produce non-quantitative treatment limitation (NQTL) analysis for purpose of demonstrating compliance with The Mental Health Parity and Addition Equity Act (MHPAEA). This CAA provision went into effect in Q1 2021.

Under the CAA, health plans and insurers must:

• Perform and document comparative analyses of the design and application of NQTLs within mental health/substance use disorder (MH/SUD) and medical/surgical (M/S) benefits.
• NQTL documentation typically includes a side-by-side analysis of M/S and MH/SUD NQTL, which could include prior authorization, concurrent review, retrospective review, network adequacy, credentialing, etc.
• NQTLs applied to MH/SUD benefits must be comparable to and applied no more stringently than those NQTLs applied to M/S benefits.
• Federal or state regulators may request this documentation.
• Self-funded customers should meet with their legal counsel to review MHPAEA requirements and documentation specific to their plan designs.
• This reporting requirement does not impact the Quantitative Treatment Limit testing (i.e., cost-sharing, day or treatment limits).

Here’s how Medical Mutual will comply:

This CAA provision went into effect in Q1 2021.

Medical Mutual will continue to assist customers who receive notice from the federal agency advising that they will be conducting a Regulatory MHPAEA Audit on their plan. We will continue to help customers respond to questions, gather information, and finalize their NQTL audit response.

No Surprises Act (NSA) legislation sets member cost-sharing at in-network levels and requires providers to work with the member’s health insurance company or health plan to negotiate the total amount the provider will be paid.

The legislation includes a process for resolving payment disputes in the event providers and insurers/health plans fail to reach an agreement.

Here’s how Medical Mutual will comply:

• This Independent Dispute Resolution (IDR) process brings in a third-party, known as an independent dispute resolution entity, to determine the final payment amount.
• The provider or facility and the health plan will each submit a payment offer to the IDR entity, agreeing to accept the final payment amount as determined by the IDR entity.
• Payment must be made within 30 business days of the decision.
• Medical Mutual has chosen to partner with Zelis to support this process. They will manage the payment dispute arbitration process on our behalf. 

Insurers and self-funded health plans are required to provide up-to-date provider directories on a public facing website beginning with plan and policy years on or after January 1, 2022. The Consolidated Appropriations Act (CAA) requires insurers and health plans to have a process to verify provider geographic information and a process to respond to member requests related to a provider’s network status. The print directory must include a notification that the directory was accurate on the date of publication and that the member should consult the database for the most current information.

Here’s how Medical Mutual will comply:

• Medical Mutual will manage provider network requirements for their network providers. Providers will be required to attest to the following data every 90 days:
  • Name
  • Address
  • Specialty
  • Telephone number
  • Digital contract
• Medical Mutual will follow established guidance to remove providers who fail to attest to their data from the directory.
• Medical Mutual will follow established guidance to update, remove or add new provider data within the expected timeframe.