Transparency in Coverage Rule/Consolidated Appropriations Act, 2021
Nov. 9, 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.
The Consolidated Appropriations Act of 2021, Section 201, requires that a group health plan or insurer may not enter into an agreement with a health care provider, network or association of providers, Third Party Administrator (TPA), or other service provider offering access to a network of providers that would directly or indirectly restrict a group health plan or insurer from providing provider-specific cost or quality of care information or data, electronically accessing de-identified claims and encounter information or data for each enrollee or sharing that information or data with a business associate.
The insurer or health plan must submit an attestation (formal confirmation) of compliance, annually on or before Dec. 31, beginning with Dec. 31, 2023.
To ensure that Group Health Plans for which Blue Cross and Blue Shield of Nebraska (BCBSNE) provides TPA services comply with this requirement, BCBSNE:
- Will file the required Group Health Plan attestations on behalf of all Groups (at TIN level in BCBSNE system) prior to Dec. 31, 2023, and annually thereafter.
- Will not attest to any services carved out (e.g., Pharmacy Benefits), as it does not control the carved-out service contracts.
- If your plan has pharmacy services carved out, your BCBSNE account executive will reach out to confirm with you.
If a Group Health Plan prefers to file its own attestation, it must notify BCBSNE each calendar year of its intention to do so, to prevent duplication.
- 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 about prescription drug and health care spending
The CAA requires health plans offering group or individual health insurance coverage to submit information about prescription drug and health care spending to the Department of Health and Human Services, Department of Labor and Department of the Treasury.
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
The report for the previous calendar year is due by June 1 of the following year. For example, the calendar year 2023 report is due by June 1, 2024.
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.
To meet the mandate requirements, BCBSNE will post MRFs monthly on this public website: NebraskaBlue.com/MRFs
- MRFs 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: 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
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
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.
General Notice to Group Health Plans (GHPs)
How does the federal No Surprises Act apply to Nebraska’s Out-of-Network Emergency Medical Care Act (LB997)?
No Surprises Act
The Interim Final Rule related to the No Surprises Act was released by the federal government in July 2021. The 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.
In this rulemaking, the Department of Health and Human Services (HHS), the Department of Labor (DOL), and the Department of the Treasury (collectively, the Departments) are issuing interim final rules with largely parallel provisions that apply to group health plans and health insurance issuers offering group or individual health insurance coverage.
Nebraska’s Out-of-Network Emergency Medical Care Act
Legislative Bill 997 (LB997), also known as Nebraska’s Out-of-Network Emergency Medical Care Act, passed in 2020. This 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.
Both the No Surprises Act and LB997 will apply depending on the plan type, situation, providers and treatment being sought.
What this means for you:
As an ERISA GHP, in October 2020, you were given the choice to opt out of the LB997
provision, effective Jan. 1, 2021, for coverage of emergency services provided by an out-of-network provider at an in-network level. However, whether or not you opted out of the provision, you will now be required to adhere to the No Surprises Act for emergency services effective for your plan year beginning on and after Jan. 1, 2022. In addition to covering out-of-network emergency services at an in-network level per state law, the No Surprises Act extends the in-network level of coverage to post-stabilization services related to emergency services, non-emergency services from nonparticipating providers at participating facilities and air ambulance services from nonparticipating providers of air ambulance services.
As a non-ERISA GHP, you will continue to be subject to LB997 for coverage of emergency services; however, in addition to covering these out-of-network emergency services at an in-network level of benefits, the No Surprises Act extends this in-network level of benefits to post-stabilization services related to emergency services, non-emergency services from nonparticipating providers at participating facilities and air ambulance services from nonparticipating providers of air ambulance services.
Air Ambulance Services
The Interim Final Rule related to the No Surprises Act also protects individuals from surprise medical bills for air ambulance services furnished by nonparticipating providers and non-emergency services furnished by nonparticipating providers at participating facilities in certain circumstances.
Section 105 of the No Surprises Act added section 9817 of the Code, section 717 of ERISA, and section 2799A-2 of the Public Health Service (PHS) Act to address surprise air ambulance bills. According to the act, these provisions apply to consumers who receive services from a nonparticipating provider of air ambulance services, meaning medical transport by a rotary-wing air ambulance, as defined in 42 CFR 414.605, or fixed-wing air ambulance, as defined in 42 CFR 414.605. The Interim Final Rule applies these provisions where a plan or coverage generally has a network of participating providers and provides or covers any benefits for air ambulance services, even if the plan or coverage does not have in its network any providers of air ambulance services. With respect to air ambulance services furnished by nonparticipating providers (including inter-facility transports), plans and issuers must comply with the requirements regarding cost sharing, payment amounts and processes for resolving billing disputes described elsewhere in the act, if such services would be covered if provided by a participating provider with respect to such plan or coverage.
What this means for you:
For all GHPs, upon plan years beginning and after Jan. 1, 2022, you must cover emergency and non-emergency air ambulance services for out-of-network providers at the in-network level of benefits if you cover these services for in-network providers. If an air ambulance service would not be covered for an in-network provider, then it need not be covered for an out-of-network provider.
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® are issued upon renewal*.
Please note:
- The QR code links 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 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.
Please contact a member of your BCBSNE sales account team if you have any questions.