Update to the Surprise Billing Legislation from Late 2020

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In late 2020, we reported the good news that the State of Ohio has passed legislation to curtail “surprise billing.” This was great news given that many of the major carriers in the state were paying claims out-of-network for peripheral services related to emergencies, anesthesia, radiology, and pathology services, which are not subject to patient choice in most instances.

The appeals process for these non-network claims to be paid at the in-network benefit level also became more stringent causing a lot of member, client, and broker dissatisfaction, expense, and time to resolve. The new state-based legislation opened pathways to require both insurance companies and providers to come to an agreement on reasonable payments to remove this burden on patients going forward.

The state legislation, however, did not impact air ambulances because they are regulated by the Federal Aviation Administration. While playing a critical role in life and death situations, air ambulances have extremely high costs, which in turn have become a huge patient burden since nearly all are run by out-of-network providers. After the insurance companies paid these claims out-of-network and up to the “reasonable and customary” amount, a Health Affairs study published in April 2020 found that patients received balance bills with a median cost of $21,698!

While there is a lot of frustration and debate about the most recent coronavirus relief package signed by Congress, the $900-billion deal included a nugget that will genuinely help patients in this situation, though not until 2022. The provision forbids surprise bills from hospitals, doctors, and air ambulances. Starting in 2022, providers and insurers will have to settle bills through arbitration under Federal law as well.

The next year will still present challenges for patients who need air transportation. In the meantime, our recourse as brokers is to help members in these situations as much as possible. We must place pressure on insurers to negotiate arrangements that don’t penalize members and on elected officials when and if those negotiations fall through.

Check out this article from Kaiser Health News for additional information about updates to cost transparency.

Resources

https://www.claimsjournal.com/news/national/2021/01/04/301271.htm

https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.01484

What are the “Transparency in Coverage Regulations”?

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Initially proposed in 2019, a final rule released on October 29, 2020, by the Department of Health and Human Services (HHS), the Department of Labor (DOL), and the Department of the Treasury delivered on President Trump’s executive order on Improving Price and Quality Transparency in American Healthcare to Put Patients First. These regulations are intended to improve price transparency, as required by the Affordable Care Act (ACA).

Transparency in coverage refers to an ACA provision that requires health plans and insurers to disclose certain cost-sharing information to participants, beneficiaries, enrollees, and, in some cases, the public through an internet-based self-service tool and, upon request, in paper form. These disclosures are required for an initial list of 500 items and services for plan years that begin on or after January 1, 2023, with all items and services to be disclosed for plan years that begin on or after January 1, 2024. The requirements apply to most fully insured and self-insured group health plans, and to insurers, but “Grandfathered” health plans, excepted benefits, and short-term limited duration insurance are exempt. HRAs, health FSAs are generally exempt as well. It is important to note that “Grandmothered” health plans are required to comply.

Here are some highlights:

  • Estimated Cost-Sharing. Plans and insurers must disclose the estimated amount that the individual must pay for a covered item or service under the plan’s terms (including deductibles, coinsurance, and copayments).
  • Accumulated Amounts. The amount of financial responsibility that an individual has already incurred when the request for cost-sharing information is made (i.e., deductible or out-of-pocket limit) must also be disclosed.
  • In-Network Negotiated Rates. Plans and insurers must also disclose the amount they or a third-party administrator have contractually agreed to pay an in-network provider for a covered item or service, such as negotiated rates (including for prescription drugs) and underlying fee schedules that result from using a formula (e.g., 150 percent of the Medicare rate) as a dollar amount.
  • Out-of-Network Allowed Amount. The maximum amount that would be paid for an item or service furnished by an out-of-network provider.
  • Items and Services List. A list of the covered items and services must be disclosed when an item or service is subject to a bundled payment arrangement.
  • Notice of Prerequisites to Coverage. Individuals must receive a notice informing them that a specific item or service may be subject to a “prerequisite,” which is defined as concurrent review, prior authorization, and step-therapy or fail-first protocols.
  • Disclosure Notice. A notice with several specific disclosures, including a statement about balance billing and disclaimers about differences in actual and estimated charges.
  • Public Disclosures. Plans and insurers must make extensive price transparency disclosures to the public in machine-readable files updated monthly. The disclosures must show negotiated rates for covered items and services between the plan or insurer and in-network providers, as well as historical payments to, and billed charges from, out-of-network providers. (In a change from the proposal, a separate machine-readable file must set forth prescription drug information.) These disclosures are required for plan years beginning on or after January 1, 2022.

As your general agency partner, we want to provide the most updated and relevant industry information that could affect your business and your clients. As always, please reach out to us with any questions.

Check out this article from Kaiser Health News for additional information about updates to cost transparency.

Required Health Plan Coverage for Pfizer-BioNTech COVID-19 Vaccine

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This post was originally published by the Centers for Medicare and Medicaid Services.

Required Health Plan Coverage for Pfizer-BioNTech COVID-19 Vaccine

On December 11, 2020, the U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID-19 Vaccine for the prevention of COVID-19 in individuals 16 years of age and older. Review Pfizer’s Fact Sheet for Healthcare Providers Administering Vaccine (Vaccination Providers) regarding the limitations of authorized use.

On December 12, 2020, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) issued an interim recommendation for use of the Pfizer-BioNTech COVID-19 vaccine for persons 16 years of age and older in the U.S. population under the FDA’s EUA. On December 13, 2020, the recommendation made by the ACIP was adopted by the CDC Director and published in the CDC’s Morbidity and Mortality Weekly Report.

Under the CARES Act and implementing interim final regulations, non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage must cover, without cost sharing, COVID-19 immunizations for which recommendations of the ACIP have been adopted by the Director of the CDC, starting 15 business days after the date an applicable recommendation is made by the ACIP.

Vaccines Information on the CDC Website

CDC has made available a wealth of information about the COVID-19 vaccine at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html .  These resources may be useful for communicating with your enrollees. Specifically, you can access information about who gets vaccinated first, what to expect at the vaccine appointment, benefits of getting vaccinated, the safety of vaccines, and more.

For issuers who are integrated with health systems or communicating with your health systems, you can also check out the CDC’s COVID-19 Vaccination Communication Toolkit for medical centers, clinics and clinicians at:  https://www.cdc.gov/vaccines/covid-19/health-systems-communication-toolkit.html. CDC is planning on publishing additional toolkits in the future.

Anthem Will Issue MLR Rebates in August

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In an effort to ease the financial burden of the COVID-19 pandemic, Anthem will fast-track the annual medical loss ratio (MLR) rebates that groups and individual members typically receive in late September to August.

The medical loss ratio provision of the Affordable Care Act (ACA) encourages health plans to spend most of the premium dollars they collect on health care costs rather than overhead. It’s a ratio of insurance claims costs to insurance premiums, and is expressed as a percentage.

In the fully insured small group and individual markets, the MLR provision requires plans to spend at least 80 percent of premium income on health care claims and quality improvement. In the fully insured large group market, it requires at least 85 percent. In markets where Anthem doesn’t meet the minimum ratio, they are required to issue rebates to employer groups and individual members. ASO plans and stop-loss insurance are excluded from the rebates.

Anthem groups and individuals in 8 states will receive rebates this year.

Anthem will send rebate checks to employer groups and individual members along with a federally mandated notice that explains MLR and how it is calculated. They are also mandated to notify employees of the groups that receive rebate checks.

ACA rules require that employers either distribute the rebate among their employees covered by the rebated plan or use it to lower premiums in the next plan year. Rebate distributions must be made within three months of the policyholder’s receipt of the rebate. Group plans that are subject to Employee Retirement Income Security Act (ERISA) laws may also use the rebate funds to pay current plan premiums.

View this FAQ for more details on the rebates.

Contact your Cornerstone representative with any questions.

Employee Benefit Extensions for the COVID-19 Pandemic: COBRA, FSA, HRA, and More

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This post was submitted by Navia Benefit Solutions. In February 2020, FlexBank Administrators, a trusted and tenured provider of pre-tax benefits, COBRA administration, and compliance solutions, announced its partnership with Navia Benefit Solutions, a nationwide consumer-directed benefits provider of health, life, and compliance solutions.

On April 29, 2020, the Department of Labor, Revenue, and Treasury (the “Departments”) issued benefit extensions for certain group health plans, disability and other welfare plans, and pension plans during the COVID-19 National Emergency.

The goal of the benefit extensions is to minimize the possibility of individuals losing benefits because of a failure to comply with an applicable timeframe.

There are eight benefit timeframes that have been extended. We go into detail about each one below and provide examples to illustrate how the benefit extensions will work. You can also download our benefit extensions infographic for a snapshot of the extensions and new timeframes.

Navia COVID-19 Timeline Extensions

Outbreak Period

The term “Outbreak Period” is used to define the period of time affected by the extensions.

  • The Outbreak Period started on March 1, 2020 when President Trump declared a National Emergency in response to COVID-19.
  • The Outbreak Period will end 60 days AFTER the National Emergency is declared over.
  • For example, the National Emergency became effective March 1, 2020 and if President Trump announces on May 31, 2020 that the National Emergency is over, the Outbreak Period will be March 1 to July 31, 2020 (National Emergency timeline plus 60 days).

The Outbreak Period goes from the beginning of the national emergency through the end of the 60 days after the national emergency is declared over. During the Outbreak Period , standard election and filing time frames are essentially on “pause” and then resume after the Outbreak Period ends.

Timeframe Extensions Disregard the “Outbreak Period”

On March 13, 2020, President Trump issued the Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak and by separate letter declared a national emergency under the Stafford Act effective March 1, 2020.

As a result of the National Emergency, the Departments recognized that participants and beneficiaries covered by group health plans, disability or other employee welfare benefit plans, and employee pension plans may find it difficult to meet or comply with certain pre-established timeframes. Similarly, the Departments recognized that group health plans may have difficulty in complying with certain notice obligations.

Essentially, this guidance requires benefit plans to disregard the period from March 1, 2020 until sixty (60) days after the announced end of the National Emergency, or such other date announced by the Agencies in a future notice (the “Outbreak Period”).  To the extent there are different Outbreak Period end dates for different parts of the country, the Departments will issue additional guidance.

8 New Benefit Extensions and How they Work

Please note the date used in the examples for the “end of the national emergency” is just an example date to help illustrate how the extension timeframes work. We do not yet know when the end of the emergency will be declared.

(1) HIPAA special enrollment period

Generally, group health plans (GHPs) must allow individuals to enroll in the GHP if enrollment is requested within 30 days of the occurrence of the event (or within 60 days, in the case of the special enrollment rights added by the Children’s Health Insurance Program Re-authorization Act of 2009).

Example: Assume the end of the national emergency is April 30, 2020. During open enrollment, Randy declines coverage in his employer’s GHP.  On March 31, 2020, Randy’s wife gives birth.  Randy would like to enroll himself, his wife, and his child in his employer’s plan.  Open enrollment does not begin until November 15, 2020.  Since the timeframe beginning March 1, 2020, through the Outbreak period is disregarded, Randy now has until July 29, 2020, to enroll, provided that he pays the premiums for any period of coverage.  Practical Point: If Randy waits until July 29, 2020, to exercise his special enrollment rights, neither the employer or the carrier would know to provide coverage to Randy and his family until his election is made. 

(2) COBRA Election Period

COBRA generally provides a qualified beneficiary 60 days to elect COBRA continuation coverage under a group health plan.

Example: Assume the end of the Outbreak Period is June 30, 2020.  Sandy is terminated on February 25, 2020.  Sandy’s specific rights notice is mailed on March 1, 2020.  Sandy’s 60-day COBRA election period would end on April 29, 2020 but since the timeframe beginning March 1, 2020, through the Outbreak Period is disregarded, Sandy has until August 29, 2020 to elect COBRA.

<<Need help managing COBRA? Learn how Navia can help>>

(3) COBRA Premium Payments

COBRA continuation coverage may be terminated for failure to pay premiums timely. A premium is considered timely paid if it is made not later than 30 days after the first day of the coverage period.

Example: Assume the end of the Outbreak Period is July 31, 2020.  Jim is enrolled and making timely payments on COBRA as of March 31, 2020.  He does not make April’s premium payment within the 30-day payment grace period.  Because the 30-day grace period is disregarded through the Outbreak Period, Jim has until August 30, 2020 to make April, May, June, July, and August’s premium payments.

(4) COBRA Notices – Qualifying Event

Notice requirements prescribe time periods for individuals to notify the plan of certain qualifying events or a determination of disability.  Notice requirements also prescribe the time period for employers to notify the plan of certain qualifying events.

Example: Assume the end of the Outbreak Period is September 30, 2020. Bob is enrolled in COBRA with his spouse Tricia.  Bob and Tricia divorce on April 1, 2020.  Bob has the obligation to notify the plan sponsor/administrator of the divorce within 60 days which will trigger a dependent level COBRA offer for Tricia.  Because the 60-day notice requirement is disregarded through the Outbreak Period, Bob has until November 29, 2020 to notify the plan sponsor/administrator of the divorce.

(5) Benefit Plan Claims Filing Procedure Timeframe (FSA/HRA)

The date within which individuals must file a claim under the plan’s claims procedures.

Example: Employer, Teresa Co., provides her employees an FSA benefit.  Teresa Co.’s plan runs January through December with a ninety-day claims run-out period ending March 31, 2020.  The national emergency is effective March 1, 2020.  In this example assume the national emergency ends May 31, 2020.  As of March 1, 2020, Teresa Co’s participants had 30 days until the claims run-out deadline—due to the guidance, that timeframe is disregarded until the end of the national emergency plus 60 days.  Therefore, plan participants new claims run-out deadline is August 29, 2020.  August 29, 2020, is reached by assuming May 31, 2020, is end of the national emergency, plus 60 days, plus the 30 days disregarded from March to March 31st.

(6) ERISA Adverse Benefit Determination Appeals Deadlines

The date within which claimants may file an appeal of an adverse benefit determination under the plan’s claims procedure.

FSA Example 1: Assume the end of the national emergency is May 31, 2020.  Tim, an FSA participant, receives a denial of his FSA claim on March 15, 2020.  Tim normally has 180 days from March 15, 2020, to file an appeal.  Since the timeframe beginning March 1, 2020, through the Outbreak period is disregarded, Tim now has until January 26, 2021 to file his appeal.  In this example the January 26, 2021, is determined by assuming the end of the national emergency is May 31, 2020.  Add sixty more days to get to July 30, 2020 (the outbreak period) plus the 180 days to appeal.

HRA Example: Assume the end of the national emergency is April 30, 2020. Bob, an HRA participant, receives a denial of his HRA claim on January 28, 2020.  Bob normally has 180 days from January 28, 2020, to appeal his denial.  Since the timeframe beginning March 1, 2020, through the Outbreak period is disregarded, Bob now has until November 24, 2020, to file his appeal.  In this example November 24, 2020, is determined by assuming the end of the national emergency is April 30, 2020, plus sixty days, plus 148 days (180 – 32 days following January 28 to March 1st). 

(7)  ERISA External Review

The date within which claimants may file a request for an external review after receipt of an adverse benefit determination or final internal adverse benefit determination.

Example: Assume the national emergency ends April 30, 2020. Megan receives a denial on March 15, 2020.  Normally, Megan has four months from March 15, 2020, to file a request for external review.  Since the timeframe beginning March 1, 2020, through the Outbreak period is disregarded, Megan now has until October 29, 2020, to file her request.  In this example October 29, 2020, is determined by assuming the end of the national emergency is April 30, 2020, plus sixty days, plus four months.

(8) Deadline to Submit Additional Information for External Review

The date within which a claimant may file information to perfect a request for external review upon a finding that the request was not complete.

Example: Assume the national emergency ends April 30, 2020. Natalie receives notice of an incomplete external review request on March 15, 2020.  Normally, Natalie has four months from March 15, 2020 to perfect her request.  Since the timeframe beginning March 1, 2020, through the Outbreak period is disregarded, Natalie has until October 29, 2020, to perfect her request.  In this example October 29, 2020, is determined by assuming the end of the national emergency is April 30, 2020, plus sixty days, plus four months.

Navia’s commitment to providing high-quality service has never been more important and we will continue to find ways to help during these difficult times. Please check back regularly for updates. Stay safe and healthy.

Surprise Billing Behind the Scenes

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In a Stanford study released in March of 2019, medical transport percentage of visits out of network was reported up to 42.8 percent between January 2010 and December of 2016. These incidents are far more common than the legislative, or perhaps insurance, communities are aware of or admit to. Out-of-network “balance billing,” or “surprise billing,” occurs mostly when a patient sees a provider who is not contracted with a given insurance carrier during the course of a treatment or procedure or in an emergency when they are transported, unknowingly, by an out-of-network service provider.

Federal legislation has three distinct bills at varying stages of discussion within committees, which may or may not pass and have certainly been delayed because of COVID-19.

House Energy and Commerce, Senate HELP House Ways and Means House Education and Labor
Arbitration For services above $750, or $25,000 for air ambulances, payers and providers could elect a baseball-style, binding arbitration process. The arbitrator is requires to consider certain information including training and experience of the provider, market share of both payer and provider and patient acuity. The party that imitates arbitration is barred from bringing the same party to arbitration for the same service for 90 days. A two-step process is created to resolve disputes, which have no minimum dollar figure. First, either party may initiate a 30-day negotiation period to exchange information and attempt resolution. Second, either party can initiate a mediation process with an independent third party. The payer and provider present final offers then. For disputes over services that cost more than $750, or $25,000 for air ambulances, payers and provider could enter into independent dispute resolution, an arbitration-type process, to determine payment for a service.
House Energy and Commerce, Senate HELP House Ways and Means House Education and Labor
Set Rates

 

 This proposal requires insurers to pay the median in-network rate in a given region for services under $750. There is no set rate for out-of-network services, but the third-party mediator will consider the median contract rate specific to the plan and for similar providers, services, and geographic areas during the resolution. A benchmark rate would be applied to care under $750. The rate would be set at the median in-network price for service in a given geography. The benchmark rate would apply for air ambulance disputes under $25,000.
Transparency Elements Prohibits out-of-network providers from sending a balance bill to patients unless the provider gives 72 hours notice of network status before the patient receives out-of-network care and the patient provides consent. This requires providers to publish certain in-network and out-of-network services and their price. Patients will receive a true and honest cost estimate before services are rendered, which include cost, what providers will deliver the service, and whether those providers are in-network. Prohibits certain out-of-network providers from sending a balance bill unless a notice is sent 72 hours in advance of the elective out-of-network procedure and patient signs a consent form. Requires providers and payers to provide a good faith estimate of the costs owed for a service within a certain geography.

In a somewhat covert move by Health and Human Services, hospitals receiving emergency funding may be banned from any surprise billing with regard to COVID-19. The language used by HHS was board and written with the intention to bar balance billing for actual or suspected COVID-19 cases. So does this mean everyone? The Trump administration has come out and stated that this means no COVID-19 related balance billing. More information will be understood as the terms and conditions of funding continue to be released. Of course with regard to COVID-19, a big question follows regarding transport companies who may have received funding as well.

States aren’t waiting on Federal legislation to pass. In OH, the Holmes Plan (SB198) would put an end to the burden resting on the patient. An out-of-network provider can accept the in-network insurance reimbursement or negotiate something acceptable to them from an insurance carrier. If both parties can’t agree, they go to arbitration where an independent third party will decide.

Ohio House Bill 388 unanimously passed after a deal was reached with medical carriers and providers creating a multi-step process to negotiate out of network payments. The provider can accept the highest in network reimbursement, the out of network rate, or the Medicare rate. If arbitration becomes necessary, the loser will reimburse 70 percent of the arbitration costs encouraging parties to accept negotiated rates before arbitration.

In Kentucky, the Alavarado Senate Bill (SB150) seeks to end the same thing, but with a slightly different approach. Kentucky would require the insurance commissioner to create a database of billed health care service charges. A similar arbitration program would be set up for insurers and providers to negotiate a price that is acceptable to both parties. A new bill has been introduced in the Senate (SB265) by Wil Shroder who believes that price transparency is needed to resolve the situation. More to follow on this proposal, however, in emergency situations where the dollar amounts are staggering for out-of-network surprise billing, there is no opportunity for an individual to verify the price of transport and treatment ahead of time.

Some argue in both states that while the bills have good intentions to alleviate cost shifting to members it would likely result in increased medical insurance premiums in the end. So it would seem like we may have a long way to go before this issue is resolved for those members that fall into the trap of surprise billing by out of network providers that they didn’t select during the course of their treatment.

Cornerstone is committed to keeping our broker partners informed of changes within the industry. Contact us today with any questions.

Source: Jack Hoadley, Beth Fuchs, and Kevin Lucia, “Update on Federal Surprise Billing Legislation: New Bills Contain Key Differences,” To the Point (blog), Commonwealth Fund, Feb. 20, 2020. https://doi.org/10.26099/35jk-h55

IRS Announces 2021 HSA Contribution Limits, HDHP Minimum Deductibles, and HDHP Out-of-Pocket Maximums

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The IRS has announced the 2021 cost-of-living adjusted limits for health savings accounts (HSAs) and high-deductible health plans (HDHPs). Here are the details:

  • HSA Contribution Limits. The 2021 annual HSA contribution limit is $3,600 for individuals with self-only HDHP coverage (up from $3,550 in 2020), and $7,200 for individuals with family HDHP coverage (up from $7,100 in 2020).
  • HDHP Minimum Deductibles. The 2021 minimum annual deductible is $1,400 for self-only HDHP coverage (unchanged from 2020) and $2,800 for family HDHP coverage (unchanged from 2020).
  • HDHP Out-of-Pocket Maximums. The 2021 limit on out-of-pocket expenses (including items such as deductibles, copayments, and coinsurance, but not premiums) is $7,000 for self-only HDHP coverage (up from $6,900 in 2020), and $14,000 for family HDHP coverage (up from $13,800 in 2020).

Contact your Cornerstone representative with any questions.

DOL Issues Benefit Extensions During COVID-19 National Emergency

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The Department of Labor, Revenue, and Treasury recently issued benefit extensions for certain group health plans, disability and other welfare plans, and pension plans during the COVID-19 National Emergency. The goal of the benefit extensions is to minimize the possibility of individuals losing benefits because of a failure to comply with an applicable timeframe.

Click here for more information.

Contact your Cornerstone representative with any questions.

The Supreme Court’s ACA Ruling and What it Might Mean

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According to ThinkAdvisor, the U.S. Supreme Court’s ACA ruling could “add some stability to the individual and family major medical insurance market, at a time the COVID-19 is shaking everything up.”

In an 8-1 decision by the court, Congress cannot cancel an agreement to pay insurers for participating in a program by simply zeroing out funding or the payments.

Read the full article here.

Contact your Cornerstone representative with any questions.

Ohio Insurance License Renewal and Continuing Education Relief During COVID-19

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The Ohio Department of Insurance recently announced that Governor DeWine signed House Bill 197, which includes relief to insurance license-holders whose license expires during the coronavirus pandemic.

This bill applies to any individual or business entity with an active license with the Ohio Department of Insurance, including major lines agents; limited line agents; title agents; title insurance marketing representatives; managing general agents; public insurance adjusters and agents; reinsurance intermediary brokers and managers; surety bail bond agents; surplus lines brokers; third party administrators; and viatical settlement brokers.

In summary, if a license is set to expire during the state of emergency, it will remain valid and can be renewed until no later than 90 days after the state of emergency ends or December 1, 2020, whichever comes first. All late fees will be waived and license holders do not need to take any actions to receive the extension.

The deadline for continuing education requirements has also been extended, though license holders are encouraged to continue their requirements to the best of their ability so as to not overwhelm the system when the state of emergency ends.

Any person who is in the process of obtaining their initial license will be allowed to sit for an examination past the 180-day expiration of their license education course completion certificate.

Contact your Cornerstone representative for more information.

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