Departments Issue Checklist for Surprise Billing IDR Process

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This update was originally published by Larry Grudzien.

The Departments of IRS, DOL, and HHS (the “Departments”) recently issued a checklist of federal independent dispute resolution (IDR) and related requirements to help plan sponsors and insurers understand their obligations when processing claims for items and services that fall within the scope of the surprise medical billing protections of the No Surprises Act.

The Departments have received a number of questions and complaints regarding group health plan and  health insurance issuer requirements for making initial payments or sending notices of denial of  payment to nonparticipating providers, facilities, and providers of air ambulance services for items and  services for which the No Surprises Act balance billing protections apply.

Most questions and  complaints received to date by the No Surprises Help Desk relate to requirements to:

  • Send an initial payment or notice of denial of payment within 30 calendar days after the provider or facility submits a bill or a claim;
  • Provide the disclosures required with these initial payments or denials (such as the Qualifying Payment Amount (QPA), a contact telephone number, and email address); and
  • Provide information about the 30-business-day open negotiation period.

For example, the Departments have received complaints that some plans and issuers are requiring providers and facilities to initiate the open negotiation period through a private issuer hosted web portal which may not allow for the submission of the standard open negotiation initiation notice to  initiate open negotiation as described under federal regulations.

This checklist is intended to help plans and issuers understand their obligations and comply with key requirements of the No Surprises Act when processing claims for items and services that fall within the scope of the new surprise billing protections for emergency services, non-emergency services performed by nonparticipating providers at participating health care facilities, and air ambulance services furnished by nonparticipating providers of air ambulance services(“qualified IDR item(s) or service(s)”).

Please note this is not an exhaustive list of No Surprises Act requirements.

Click here to access the checklist

Carrier Updates Regarding the Transparency in Coverage Rules and Machine Readable Files

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The “Transparency in Coverage” final rules passed on October 28, 2020, requires health insurers and group health plans to create machine readable files (MRF) and member friendly cost estimation tools to be phased in throughout 2022, 2023, and 2024. The timeline is as follows:

  • July 1, 2022: Requires carriers, TPAs, and PBMs to publish two MRFs on a publicly available website displaying in-network and out-of-network rates for covered services. These files follow CMS guidance and are not meant for consumer-friendly search, but rather for a computer system to do further processing without human intervention.
  • January 1, 2023: Plans and payers must make available an online cost estimation tool for 500 “shoppable” services. Employers will be required to post the information or “link” with their plan’s information.
  • January 1, 2024: Plans and payers must make available an online cost estimation tool for all covered services.

We have put together a comprehensive resource with the latest updates and communications from our carrier partners. Click here to download the document.

Please reach out to your Cornerstone representative with any questions.

PCORI Fees Due to IRS No Later Than August 1, 2022

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Fees to fund the Patient-Centered Outcomes Research Institute (PCORI) are due to the IRS no later than August 1, 2022, from employers who sponsor certain self-insured health plans such as Level Funded and Health Reimbursement Arrangements (HRAs) that are not treated as excepted benefits.

How to Pay PCORI Fees
Employers that sponsor certain self-insured health plans (Level Funded) must report and pay the required PCORI fees via IRS Form 720 along with HRA plans, Quarterly Federal Excise Tax Return. Complete Part II, line 133. Employers should note “2nd Quarter” on the 720 form.

Click here to access the updated 720 form.

The fee applies to each Plan year that ends after October 1, 2012, and before October 1, 2029. “Plan year” refers to the plan year for your Level Funded Medical Plans or an HRA plan. Generally the plan year and the coverage period are the same. As an example, if your HRA benefit resets each January 1, your HRA plan year and your coverage period are generally a calendar year and end December 31.

Plan Year Ending Date Fee
October 1, 2020 – September 30, 2021 $2.66
October 1, 2021 – September 30, 2022 $2.79

There are three available methods that can be used to determine the average number of lives covered under a plan for the policy year. For an HRA plan it is acceptable to use the number of subscribers only. The most commonly used method for determining the fee for your Level Funded plan is the “Snapshot Method”.

  1. Actual Count Method: A plan sponsor may determine the average number of lives covered under a plan for a plan year by adding the totals of lives covered for each day of the play year and dividing that total by the total number of days in the plan year.
  2. Snapshot Method: A plan sponsor may determine the average number of lives covered under an applicable self-insured health plan for a plan year based on the total number of lives covered on one date (or more dates if an equal number of dates is used in each quarter) during the first, second or third month of each quarter, and dividing that total by the number of dates on which a count was made.
  3. Form 5500 Method: An eligible plan sponsor may determine the average number of lives covered under a plan for a plan year based on the number of participants reported on the Form 5500, Annual Return/Report of Employee Benefit Plan, or the Form 5500-SF, Short Form Annual Return/Report of Small Employee Benefit Plan.

Payments should be made payable to the U.S. Treasury and sent by August 1, 2022, to the address below:

Department of the Treasury
Internal Revenue Service
Ogden, UT 84201-0009

The following documents accompany this notice:

Tools to Assist you by Carrier:

All Savers®

All Savers posts the employer group’s membership information to the employer website. The employer group is required to complete and file the IRS Form 720. For general questions please contact All Savers Broker Services at 1-866-405-7174.

Humana Level Funded

Humana provides a snapshot report that shows the monthly membership employers will need when filing the PCORI. It is an employer report (instructions below). As a broker, the employer may grant you access if they want you to pull it for them.

Click here to review the instructions.

Aetna Funding Advantage

This link takes you to the Aetna Funding Advantage PCORI Fee Estimator Tool. This tool gives you guidance on calculating the PCORI fees for this group.

 

**Anthem OH SOCA MEWA, Anthem KY Chamber Advantage, Anthem IN Chamber Health Alliance, MMO COSE MEWA, Humana KY Chamber and UHC MEWA have built the PCORI fees into the premiums, therefore, you will not need to file and pay any additional fees.

Appropriations Bill Restores Telehealth Exemption for HDHPs for Remainder of 2022

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Congress has passed and the President has signed government funding legislation called the Consolidated Appropriations Act, 2022 (CAA-22). The CAA-22 temporarily and prospectively extends rules regarding access to telehealth services in the health savings account (HSA) context that were enacted in March 2020 in response to COVID-19.

As background, the CARES Act amended the HSA rules under the Internal Revenue Code (Code) to state that a high-deductible health plan (HDHP) could provide telehealth and other remote care services without first meeting the plan’s minimum deductible under Code Section 223(c)(2).

Under the CARES Act provision, however, a health plan did not fail to be treated as an HDHP merely because it did not have a deductible for telehealth and other remote care services for plan years beginning on or before December 31, 2021. An individual covered under this type of health plan could contribute to an HSA.

This provision was effective on the CARES Act’s enactment date (March 27, 2020), but could be applied retroactively to January 1, 2020 (IRS Notice 2020-29).

The CAA-22 prospectively extends this CARES Act rule by making it applicable for for the last nine months of 2022. for months beginning:

  • After March 31, 2022.
  • Before January 1, 2023.

The relief does not apply for the first three months of 2022 so some plans (e.g., calendar-year plans) must still apply their minimum deductible to telehealth and other remote care services during those months. Plans with 2021 plan years that started on or after April 1, 2021, should be unaffected by the three-month gap that affects other plans, because their CARES Act relief will not expire until those plan years end.

For a copy of the legislation, please click on the link below:

Consolidated Appropriations Act, 2022, Pub. L. No. __ (2022)

Available at https://www.congress.gov/117/bills/hr2471/BILLS-117hr2471enr.pdf

2022 Department of Labor Compliance Penalty Chart

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According to HR Service, Inc., the U.S. Department of Labor has published its final rule to adjust for inflation the civil monetary penalties assessed or enforced by the Department, pursuant to the Federal Civil Penalties Inflation Adjustment Act of 1990. The Inflation Adjustment Act requires the Department to annually adjust its civil money penalty levels for inflation no later than January 15 of each year.

HR Service has created a penalty adjustment chart for 2022 for your reference that you can download here.

Contact your Cornerstone broker advisor with any questions.

OSHA and Legislative Updates Regarding the Vaccine-or-Test Rule

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The U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) recently announced that it is withdrawing its temporary vaccination and testing emergency standard, following the Supreme Court’s temporary block of the federal vaccination mandate. The initial intent of the mandate was “aimed to protect unvaccinated employees of large employers with 100 or more employees from workplace exposure to coronavirus.”

Additionally, a Supreme Court vote of 6-3 blocked the vaccine-or-test requirement for large employers. However, the Biden administration requested that the mandate remain for health care workers in facilities receiving Medicare and Medicaid funding.

Contact your Cornerstone representative with any questions.

Resources

SCOTUS Blocks Employer Vaccine Mandate, But Keeps It For Health Care Workers (BenefitsPro)

OSHA Officially Withdraws Vaccine-or-Test Rule (BenefitsPro)

Humana COVID-19 At-Home Testing Updates

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Beginning January 15, 2022, Humana will cover over-the-counter COVID-19 at-home test kits for members.

As announced by the U.S. Department of Health and Human Services group health plans will cover the cost of at-home, over-the-counter COVID-19 test kits beginning on January 15. This new policy will cover eight test kits per month, for all covered members, at no out-of-pocket cost.

Humana will offer commercial group members two options to get at-home, OTC COVID-19 test kits at no-cost:

  1. Pay the full amount for the test up-front and get reimbursed, and
  2. Have the pharmacy staff process the at-home OTC COVID-19 test kit as a claim and receive payment directly from Humana at no cost to them.

Please read the FAQ below for details and contact your Cornerstone representative with any questions.

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UnitedHealthcare to Cover COVID-19 At-Home Tests, Small Business Market Segment Update

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On Jannuary 10, 2022, the Departments of Labor, Treasury and Health and Human Services released guidance to support the Administration’s directive that health insurers and group health plans cover, subject to certain criteria, the cost of FDA-authorized or approved over-the-counter (OTC) COVID-19 at home tests beginning on January 15, 2022.

On January 15, 2022, UnitedHealthcare began covering most commercial individual and group health plan members’ FDA-authorized or approved over-the-counter COVID-19 at home tests without a doctor’s prescription or clinical assessment. This COVID-19 at home test benefit includes up to eight tests per member per 30 days.

UnitedHealthcare fully insured and level-funded individual and group health plan members will have two ways that they can receive reimbursement for these COVID-19 at home test kits.

  1. Preferred Retailers — UnitedHealthcare has developed and deployed a solution of Preferred Retailers for coverage of over-the-counter COVID-19 at home test kits. A Preferred Retailer is a pharmacy that UnitedHealthcare has made arrangement with to provide an OTC COVID-19 at home tests at no cost to the member at time of purchase or later. The list of Preferred Retailers and their websites may be found in the Preferred Retailer list on uhc.com. UnitedHealthcare is working to add additional Preferred Retailers.
  2. Other retailers or online — If the member purchases a COVID-19 at home test at any in-store or online retailer other than at the in-store pharmacy counter, they may submit purchase receipt(s) for reimbursement at the UnitedHealthcare member portal for a maximum reimbursement of $12 per test. Many COVID-19 tests are sold as a two-pack so that means the test pack would be reimbursed at $24 ($12 for each test).

A member must be a UnitedHealthcare commercial individual or group health plan member and have UnitedHealthcare’s Pharmacy benefit to purchase over-the-counter COVID-19 at home tests at the Preferred Retailer at no cost using their UnitedHealthcare member ID card. As mentioned earlier, the member may also purchase and then submit a receipt for reimbursement at the retail location of their choice.

Other self-funded customers will receive a communication shortly that will outline the program and options for their business and members.

Contact your Cornerstone representative with any questions.

Anthem Members Will be Reimbursed for Over-the-Counter COVID-19 Tests

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A recent announcement from the federal government intends to increase access to COVID-19 testing. As of January 15, 2022, members can get reimbursed by their health plan without cost share for the costs of over-the-counter diagnostic COVID-19 tests until the end of the Coronavirus Public Health Emergency. Diagnostic tests are performed if members are experiencing COVID-19 symptoms or have been recently exposed.

When should an employee take a test?

The Centers for Disease Control and Prevention (CDC) provides guidelines for who should get a diagnostic test and when based on their current health vaccination status and history of infection.

Where can employees find a test?

  • Visit COVIDtests.gov for information on free tests that may be available through government programs.
  • Anthem has a limited number of at-home diagnostic test kits available for certain members to order online. Log in using the Sydney Health mobile app (see attached flyer for details) or at anthem.com. If the member is eligible to order an at-home test, they will see an option to place an order.
  • Employees can still use in-person diagnostic COVID-19 testing sites. These may include their doctor’s office, a pharmacy or health clinic, or an urgent care center. They can use our  COVID-19 Test Site Finder to find a testing location close to them.
  • Over-the-counter diagnostic tests can be purchased online, at a local pharmacy, or from a big-box store.

Can employees visit the emergency room for a test?

As hospitals and emergency departments are overwhelmed, employees should avoid going to the emergency room (ER) to be tested. They should only visit the ER or call 911 if they’re experiencing life-threatening symptoms.

How are the over-the-counter tests covered?

From January 15, 2022, until the end of the Coronavirus Public Health Emergency, each member on a group plan can get up to eight over-the-counter tests each month. If they purchase a test kit that includes two rapid tests, that will count as two of their eight covered tests.

How will employees be reimbursed?

Members will be reimbursed for over-the-counter COVID-19 diagnostic tests purchased on or after January 15, 2022.  The member may have to pay out of pocket at the time of purchase but should keep their receipt and submit a claim online.  The member will log in to anthem.com and following the steps in the attached document titled How Members File for At-Home COVID Test Reimbursement.

 

Click this link to find Anthem’s COVID-19 resource site with more information on the over-the-counter kits.

Contact your Cornerstone representative with any questions.

Supreme Court Blocks Vaccine Mandate for Large Businesses, Allows it for Health Care Workers

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Please note:  The Supreme Court has ruled this as a stay for how this was written. If OSHA or the Biden Administration were to re-write this mandate in a more acceptable form, then it could go into effect in the future.

The U.S. Supreme Court issued two highly anticipated rulings on Thursday, temporarily blocking a Biden administration COVID-19 vaccine mandate for large employers but allowing a separate rule applying only to health care workers at facilities receiving federal funding.

The high court settled the matter concerning large employers in a 6-3 decision to block the rule that would have been issued by the Occupational Safety and Health Administration, with the three liberal justices dissenting.

“OSHA has never before imposed such a mandate. Nor has Congress. Indeed, although Congress has enacted significant legislation addressing the COVID–19 pandemic, it has declined to enact any measure similar to what OSHA has promulgated here,” the majority opinion stated.

As for health care facilities, the court ruled 5-4 to uphold for now the rule administered by the Department of Health and Human Services, with Justices Clarence Thomas, Samuel Alito, and Neil Gorsuch dissenting.

“Both Medicare and Medicaid are administered by the Secretary of Health and Human Services, who has general statutory authority to promulgate regulations ‘as may be necessary to the efficient administration of the functions with which [he] is charged.’ One such function — perhaps the most basic, given the Department’s core mission — is to ensure that the health care providers who care for Medicare and Medicaid patients protect their patients’ health and safety,” the majority stated.

The rulings take effect immediately and will remain in place until legal challenges over their constitutionality are resolved through the justice system, and possibly through the Supreme Court.

A mandate targeting half the U.S. workforce

The administration’s employer mandate, announced by senior officials in early November, with an original effective date of Jan. 4, targets about 84 million U.S. workers, or roughly half of the U.S. workforce. Its deadline for employers to require masking was extended to Jan. 10. Full compliance, which the court’s decision now renders renders unenforceable, had been extended to Feb. 9.

Contact your Cornerstone representative with any questions.

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