Transparency in Coverage Rule/Consolidated Appropriations Act, 2021

Nov. 16, 2021 -- 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
  • 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 The rules will not be published before the compliance date.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 furnish our providers with ongoing updates on our progress.


Updates to Support Our Providers

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 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. 

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® on the front will be issued to our members through 2022. 

 

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:

Sample ID Card

QR Code is a registered trademark of DENSO WAVE INCORPORATED.

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.