Transparency in Coverage Rule/Consolidated Appropriations Act, 2021

Sept. 15, 2021 -- The Transparency in Coverage (TCR) was released in October 2020. In December 2020, the Consolidated Appropriations Act, 2021 (CAA) was signed into law.

These federal mandates represent one of the largest pieces of legislation impacting the health insurance industry in U.S. history.  

The TCR is designed to make health care price information more transparent for consumers. The provisions include:

  • 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

The CAA includes funding for COVID-19 relief, as well as various other provisions such as health care-related mandates to protect consumers. The provisions include:

  • 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

BCBSNE has a strategic plan in place and is 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.

Provisions with deferred enforcement dates

  • 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. 

Provisions with original implementation dates in effect

  • 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. 

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

We are unable to comment as of now because the Departments are deferring enforcement of this rule pending further rulemaking.

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 Interim Final Rule related to the No Surprises Act was released from the federal government in July 2021. Both laws will apply depending on the plan type, situation, providers involved and treatment being sought. 
Upon request, BCBSNE will provide group health plans with a comparative analysis in compliance with the CAA’s requirements related to mental health parity non-quantitative treatment limitations (NQTLs). 
BCBSNE and BCBSA are mobilizing to execute the multiple requirements. Local BCBS companies will largely have responsibility for individually complying with the requirements. BCBSA will provide inter-plan support where necessary and will support us with analysis, best-practice sharing and implementation support. We are moving forward with coordinated solutions, while recognizing that additional clarity is still pending from the federal government on some of the specific requirements. 
Please contact a member of your BCBSNE sales or account management team.