Summary The Fifth Circuit Court of Appeals recently upheld regulations defining the qualifying payment amount (QPA). The QPA is a key factor in determining how much individuals and health plans must pay out-of-network providers in certain situations, where the individual does not have a choice to receive services in-network. The Upshot The Bottom Line The [&hellip… Continue Reading »
Summary The rules in the Consolidated Appropriations Act that aim to eliminate much of the surprise from billings by out-of-network providers in particular situations are the subject of continued controversy. The Upshot The Bottom Line If upheld, the district court’s decisions will likely result in higher costs for plans and patients, but there remains much [&hellip… Continue Reading »
Summary The Departments of Labor, Health and Human Services, and the Treasury have proposed regulations under the Mental Health Parity Act that build on prior guidance to set forth requirements for an extremely detailed analysis of how a health plan’s nonquantitative treatment limitations (NQTLs) for mental health and substance use disorder benefits compare to those [&hellip… Continue Reading »
Summary On July 25, 2023, the Departments of Labor, Treasury, and Health & Human Services (the Departments) released joint proposed regulations and other guidance under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (the MHPAEA). This alert provides a high-level summary of the much-anticipated guidance; a more detailed analysis of [&hellip… Continue Reading »
Summary By December 31, 2023, health plans and insurers must submit an attestation of compliance with the anti-gag rules of the Consolidated Appropriations Act, 2021 (CAA). The rules apply to all agreements entered into on or after the date that the CAA was enacted (December 27, 2020), and the first attestation applies retroactively to that [&hellip… Continue Reading »
Summary The Departments of Labor, Health and Human Services, and the Treasury have issued guidance that coordinates application of the No Surprise Billing rules under the Consolidated Appropriations Act, 2021, with the cost-sharing limits under the Affordable Care Act and the requirement to provide access to cost information through an internet-based self-service tool under the [&hellip… Continue Reading »
Health plan sponsors and health insurers will need to report prescription drug and other health plan costs (RxDC reporting) for 2022 by June 1, 2023. Unlike the RxDC reporting requirements for 2020 and 2021, this deadline is not expected to be delayed. Plan sponsors and insurers will benefit from the relaxation of some of the [&hellip… Continue Reading »
Summary The Departments of Labor, Health and Human Services, and the Treasury have issued guidance on how health plans and insurers may attest to their compliance with the anti-gag rules of the Consolidated Appropriations Act, 2021 (CAA). The Upshot The Bottom Line By December 31, 2023, health plans and insurers must submit an attestation of [&hellip… Continue Reading »
Summary The U.S. District Court in the Eastern District of Texas vacated certain provisions of the No Surprises regulations that it found inappropriately placed a “thumb on the scale,” and limited the discretion of arbitrators. The Upshot The Bottom Line The court decision provides another victory to out-of-network providers under the No Surprises rules, but it may [&hellip… Continue Reading »
Summary The Consolidated Appropriations Act, 2021, (CAA) and transparency regulations introduced major changes to health benefit plans. These changes continue to evolve with some requirements just now taking effect. The Upshot The Bottom Line The CAA introduced requirements that affect how much plans must pay in certain surprise situations, how plans must document compliance with [&hellip… Continue Reading »
With little time to spare before the provisions expired, Congress has extended, and President Biden is set to sign into law, an important safe harbor that allows plan sponsors to continue offering reduced-cost telehealth services without disrupting the ability to contribute to health savings accounts (HSAs). The extension is part of the $1.7 trillion Consolidated [&hellip… Continue Reading »
In a new set of Frequently Asked Questions, the U.S. Departments of Labor, Health and Human Services, and the Treasury provide significant relief to health plan sponsors and insurers seeking to report on expenditures for prescription drugs and other health care items and services in compliance with the Consolidated Appropriations Act, 2021. The new guidance has [&hellip… Continue Reading »
Summary The Departments of Labor, Treasury, and Health & Human Services have finalized regulations regarding the dispute resolution process implemented under the No Surprise Billing Rules in the Consolidated Appropriations Act. The Departments also have issued important FAQ guidance that addresses many other elements of the No Surprise Billing Rules. The Upshot The new final [&hellip… Continue Reading »
In a Memorandum Opinion and Order issued last week, a federal judge in the Eastern District of Texas vacated significant provisions in the regulations under the No Surprises Act. The order addresses the independent dispute resolution (IDR) process that health plans or providers may initiate to resolve differences about how much a health plan should pay for out-of-network [&hellip… Continue Reading »
Summary The Consolidated Appropriations Act, 2021 (CAA) requires group health plans and health insurers to submit information regarding the costs of prescription drug costs and other health care services each year to the federal government. This is the ninth briefing in Ballard Spahr’s series on the CAA and health transparency regulations. It was originally published [&hellip… Continue Reading »
Summary The Consolidated Appropriations Act (CAA) requires each group health plan and health insurer with a network of providers to maintain a database on a public website that lists the name, address, specialty, telephone number, and digital contact information for each provider that directly or indirectly participates in the network. These new standards are effective [&hellip… Continue Reading »
Addressing motions to dismiss, a district court in Texas has found that a provider may proceed with its lawsuit to recover the full amount of its charges for COVID-19 diagnostic testing under the FFCRA and CARES Act from an insurer. The FFCRA and CARES Act require health plans and insurers to pay the amount published by a [&hellip… Continue Reading »
Summary To help individuals better understand the costs they will bear for medical care, the Consolidated Appropriations Act (CAA) requires health plan ID cards to include clear information about deductibles and out-of-pocket maximum limitations as well as a telephone number and website address where enrollees can obtain additional information about their coverage. This is the [&hellip… Continue Reading »
Summary Under a new rule introduced by the Consolidated Appropriations Act, 2021 (CAA), a health plan or insurer must offer an enrollee the opportunity to elect a transitional period of continued care with a provider whose participation in the applicable network ends while the enrollee is in a course of treatment for certain medical conditions. [&hellip… Continue Reading »
Summary The Departments of the Treasury, Labor, and Health and Human Services jointly issued a report to Congress, fulfilling obligations that they have with regard to the Mental Health Parity and Addiction Equity Act (MHPAEA) and Consolidated Appropriations Act, 2021 (CAA). The report offers valuable insight into the departments’ approach to enforcing the MHPAEA and, [&hellip… Continue Reading »
Summary Health plan vendors sometimes impose contractual restrictions on the disclosure of data that they consider to be confidential or proprietary. A number of new rules aim to foster transparency and require disclosure of pricing and other information that might otherwise be subject to those restrictions. The Consolidated Appropriations Act, 2021 (CAA) prohibits a health [&hellip… Continue Reading »
Summary The Consolidated Appropriations Act, 2021 (CAA) requires the disclosure of information to ensure that brokers and certain consultants receive no more than reasonable compensation for their services. This is the fourth briefing in Ballard Spahr’s series on the Consolidated Appropriations Act, 2021 (CAA) and transparency regulations. It was originally was published in November 2021. [&hellip… Continue Reading »
Summary The IRS has extended certain deadlines relating to affordable housing projects with Low Income Housing Tax Credits (LIHTC) under Section 42 of the Internal Revenue Code of 1986, as amended (the Code) or financed with tax-exempt private activity bonds under Section 142(d) of the Code. The Upshot While COVID-19 disruptions continue, owners, operators, issuers, and state [&hellip… Continue Reading »
Summary New rules require group health plans and insurers to disclose pricing information in three phases. This is the third briefing in Ballard Spahr’s series on the Consolidated Appropriations Act, 2021 (CAA) and transparency regulations. It was originally published in November 2021. The first installment addressed the new No Surprises Rules. The second focused on Understanding the [&hellip… Continue Reading »
