The Blue Cross and Blue Shield of Nebraska board of directors has named Jeff Russell as the company’s new president and CEO, effective June 26. Read more
Transparency in Coverage Rule/Consolidated Appropriations Act, 2021
March 13, 2023 -- The Transparency in Coverage Rule (TCR) was released in October 2020. In December 2020, the Consolidated Appropriations Act, 2021 (CAA) was signed into law.
- Making certain cost and claims data available through posted machine-readable files
- Establishing an internet-based, self-service tool to allow members to get real-time, accurate estimates of cost-sharing liability for specific services, furnished by specific providers, at specific locations
- Ending surprise medical bills, including those for air ambulance services
- Increasing transparency for group health plans, including added language on insurance cards, advance explanations of benefits (EOBs), price comparison tools and up-to-date provider directories
- Ensuring continuity of care when a provider or a facility leaves a network
- Strengthening mental health and substance use disorder parity requirements
- Requiring reporting for pharmacy benefits and drug costs
The CAA requires health plans offering group or individual health insurance coverage to begin submitting information about prescription drugs and health care spending to the Department of Health and Human Services (HHS), Department of Labor and Department of the Treasury.
As the next due date for pharmacy benefits reporting approaches (June 1, 2023), Blue Cross and Blue Shield of Nebraska (BCBSNE) has important updates on its compliance efforts.
Who does this apply to?
- Health Insurance issuers offering individual market coverage, including:
- Student health plans
- Plans sold through the Exchange
- Plans sold exclusively outside the Exchange
- Individual coverage issued through an association
- Fully insured and self-funded group health plans including:
- Non-federal governmental plans, such as plans sponsored by state and local government
- Church plans that are subject to Internal Revenue Code
- FEHB plans
Report due dates
- CY2022 report is due June 1, 2023
- All future reports are due by June 1 following the reference year
What BCBSNE is doing
Fully insured and level funded groups and individual products
BCBSNE will submit the following files in conjunction with our pharmacy benefits manager (PBM), Prime Therapeutics (Prime), for our individual plans and fully insured and level funded groups:
- P1. Individual and student market plan list
- P2. Group health plan list
- D1. Premium and Life-Years
- 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: Rx Totals
- D7: Rx Rebates by Therapeutic Class
- D8: Rx Rebates for the Top 25 Drugs
ASO Groups
BCBSNE will submit the following files in conjunction with our PBM, Prime, for our ASO groups with carve in pharmacy benefits:
- P2. Group health plan list
- D1. Premium and Life Years
- 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: Rx Totals
- D7: Rx Rebates by Therapeutic Class
- D8: Rx Rebates for the Top 25 Drugs
Instructions for ASOs with carve in pharmacy benefits through Prime:
ASOs with carve in through Prime will receive a survey from their BCBSNE account management team where they can submit the required information for the P2 and D1 reports. If the group elects to submit these reports themselves, BCBSNE will provide the group with the information it submits in the P2 report. If a group elects to submit the D1 report themselves, the group does not need to respond to BCBSNE’s survey.
Files BCBSNE will submit on behalf of ASOs with a pharmacy benefits manager other than Prime:
- P2. Group health plan list
- D1. Premium and Life Years
- D2. Spending by Category
Instructions for ASOs with a pharmacy benefits manager other than Prime:
The ASO and/or their PBM must submit files P2 and D3-D8 to be compliant with section 204 of the CAA. BCBSNE will submit P2, D1 and D2 reports on your behalf. If requested, BCBSNE will also provide the group with the information it submits in the P2 report.
Please note: If a group works with other TPAs, it’s their responsibility to file appropriately in compliance with section 204 of the CAA.
As part of the Transparency in Coverage Rule (TCR), health plans and self-funded groups are required to post certain cost and claims data through machine-readable files (MRFs) to a public website starting July 1, 2022.
To meet the mandate requirements, BCBSNE will post MRFs monthly on this public website: NebraskaBlue.com/MRFs
- MRFs will be available starting July 1, 2022, and will be updated monthly.
- Per TCR requirements, these files are in a machine-readable JSON format.
Requirements for self-funded plans (including level-funded):
- To comply with the TCR, self-funded groups must post this link on their public website by July 1, 2022: NebraskaBlue.com/MRFs
- To meet the requirements, the link must be publicly available and easily accessible.
- Once self-funded groups have posted the link on their website, their responsibility is complete.
- Self-funded groups who do not have a website should consult their legal counsel. BCBSNE does not provide legal guidance.
- Self-funded groups may wish to use the following language to accompany the MRFs link on their website:
Blue Cross and Blue Shield of Nebraska publishes machine-readable files on behalf of [insert group name]. View the machine-readable files here: NebraskaBlue.com/MRFs
- TCR Prescription Drug Machine-Readable File: The Departments of Labor, Health and Human Services (HHS) and the Treasury (collectively, "the Departments") will defer enforcement pending notice-and-comment rulemaking.
- TCR In-Network and Out-of-Network Machine-Readable Files: The Departments are deferring enforcement until July 1, 2022, for plan years beginning on or after Jan. 1, 2022. This is a six-month extension.
- TCR Price Comparison Tool: Enforcement deferred until Jan. 1, 2023.
- CAA Price Comparison Tool and Telephone Access: The Departments will defer enforcement until Jan. 1, 2023. We anticipate future rulemaking will align with the TCR.
- CAA Advanced Explanation of Benefits: The Departments are deferring enforcement pending future rulemaking.
- CAA Reporting on Pharmacy Benefits and Drug Costs: The Departments will defer pending future rulemaking or guidance.
- CAA Plan ID Card Deductibles, Out-of-Pocket Limitations: The Departments will issue new rules, but the Jan. 1, 2022, deadline did not change. Issuers/plans should demonstrate good faith compliance.
- CAA Provider Directory: Good faith compliance beginning Jan. 1, 2022, pending notice-and-comment rulemaking.
- CAA Balance Billing Disclosures (No Surprises Act): Good faith compliance beginning Jan. 1, 2022.
- CAA Continuity of Care: The Jan. 1, 2022, effective date did not change. The rules will not be published before the compliance date. Plans should use good faith compliance.
- CAA Grandfathered Health Plans: We believe there are some provisions in the CAA that do not apply to grandfathered plans.
BCBSNE has a strategic plan in place
We are actively working toward compliance with the provisions in the TCR and the CAA. As final regulations are released, we will provide our brokers and employer groups with ongoing updates on our progress.
Assistance for self-funded groups
BCBSNE will help support our self-funded groups in their compliance efforts. More details and specifics regarding the scope of this assistance will be communicated after the final regulations have been issued.
Updates to Support Our Brokers and Group Leaders
The requirements apply to:
- Individual policies
- Small group plans
- Large group plans, including self-insured plans
- Federal Employee Health Benefit Plan (FEP)
The requirements do not apply to:
- Grandfathered plans
- Any group health plan or individual coverage in relation to the provision of excepted benefit
- HRAs or other account-based group health plans
- Short-term limited duration (STLD) insurance
- Medicare Advantage plans, Medicaid MCO or CHIP
- Encouragement to consumers to shop for services
- Public disclosure of rates in machine-readable files
- Personalized disclosure of out-of-pocket costs
The Departments have deferred enforcement on this requirement, so we are awaiting further guidance.
Unless the requirements are specified for Medicare and Medicaid Managed Care Organizations (MMCOs), the CAA requirements apply to:
- Individual policies
- Small group plans
- Large group plans, including self-insured plans
The applicability of the CAA varies by component for:
- FEP
- Grandfathered plans
- Price comparison tools
- Advance EOBs
- Surprise billing
- Air ambulance
- Provider directories
- Mental health parity
- Changes to member ID cards
- Broker and consultant compensation disclosure
The No Surprises Act protects consumers from getting surprise bills from out-of-network providers or facilities for medical care received from out-of-network providers or facilities in emergency situations (to include emergency and related post-stabilization services), nonemergency services provided by a nonparticipating provider in a participating facility, and air ambulance services. This federal mandate applies to all individual policies, fully insured group health plans and both ERISA and non-ERISA self-funded groups, where the state law does not apply.
Legislative Bill 997 (LB997), also known as Nebraska’s Out-of-Network Emergency Medical Care Act, keeps consumers from getting surprise bills from out-of-network providers or facilities for emergency medical services. Facilities are defined as a general acute hospital, satellite emergency department or ambulatory surgical center licensed pursuant to the Health Care Facility Licensure Act. Effective Jan. 1, 2021, providers in Nebraska may not balance bill patients for medical care received from out-of-network providers or facilities in emergency situations. This state mandate applies to all fully insured plans and non-ERISA groups.
The Interim Final Rule related to the No Surprises Act was released by the federal government in July 2021. Both laws will apply depending on the plan type, situation, providers and treatment being sought.
To comply with the ID card mandates, and make it easier for members and providers to find information about covered benefits, new ID cards with a Quick Response (QR) Code® will be issued upon renewal* for groups with effective dates of Jan. 1, 2022, and after.
Please note:
- The QR code will link to the member’s specific Schedule of Benefits Summary. By scanning the QR code, both the member and provider can access information about in-network and out-of-network deductibles and out-of-pocket maximums.
- The cards will also include a phone number and website URL for member service.
- Current member ID numbers will not change.
Here is a sample of our new ID card:
QR Code is a registered trademark of DENSO WAVE INCORPORATED.