Within the last year, Congress and the Departments of Treasury, Labor, and Health and Human Services have issued a host of new rules that aim to improve healthcare cost transparency and encourage consumer engagement. In October 2020, the departments released final rules on the Transparency in Coverage requirements that apply to group health plans. Subsequently, in December 2020, Congress passed a variety of additional plan transparency requirements under the Consolidated Appropriations Act of 2021 (CAA), some of which overlap with the departments' rules.

Many of these new requirements have already taken effect or will soon go into effect for the 2022 plan year. With the rollout of the No Surprises Act (NSA), new requirements for member ID cards and Advanced Explanation of Benefits (AEOB) communications have also been introduced.

Member ID Requirements

For plan years beginning January 2022 or later, NSA now requires that member ID cards (both electronic and print) include the following:

• In-network (INN) deductible
• Out-of-network (OON) deductible
• Out-of-pocket maximum limit
• Telephone number for member assistance
• Website URL for member assistance
• Information on where to find INN providers

To summarize: An ID card (paper or electronic) must be provided to plan participants with any deductible and out-of-pocket maximums applicable to their plan, as well as a phone number and website where they can seek consumer assistance information.

Advanced EOB (AEOB) Requirements

NSA has also introduced a requirement for AEOBs (applicable to all services, in- and out-of-network, by providers and facilities). AEOBs must be provided whenever an appointment is made for services and also whenever requested by the member, even without an appointment.

For every scheduled service and upon member request, the payer must provide the member with an AEOB that includes:

• Whether the provider or facility is a participating provider (INN) and the contracted rate for the item or service
• If the provider or facility is OON: a description on how to find information on INN providers
• Good faith estimates for each of the following:
  • Provider billed charges (sent by the provider)
  • Amount the payer is responsible for paying
  • Member's cost-share responsibility
  • Amount the member has incurred toward meeting deductibles and OOP maximums
• A disclaimer that coverage is subject to medical management, if applicable
• Any other applicable information or disclaimer

To summarize: Providers must ask patients whether they are enrolled in a group health plan and, if so, provide an estimate of the expected charges to the patient's insurer. After receiving the estimate, plans must provide an advanced EOB to the plan participant that informs them whether the provider/facility is in-network, of what the plan will pay, and of any cost-sharing requirements.

How Your Vendor Can Help

Your ID card communications should be able to deliver NSA-ready cards on behalf your clients by designing templates to each payer's compliance specifications and the required fields as detailed above.

Using client-provided data, your partner should be able to work with payers to create NSA-ready templates for AEOBs (in both print and digital format), while supporting increased EOB/AEOB volume and distinguishing between pre-service estimates and claims for received care.

Moreover, your vendor should help you leverage AEOBs for strategic pre-service communication to members through:

• Custom messaging or inserts
• Steerage to INN providers
• Promotion of educational resources and wellness programs

In Conclusion

The No Surprises Act impacts all healthcare organizations, from large health plans and systems to small medical offices and individual providers. As such, leaders across the healthcare industry must directly understand the details of the legislation prior to implementation or have a trusted advisor with legislative expertise who can guide them to appropriate solutions.

From the patient-facing Advanced Explanation of Benefits through to adjudication, arbitration and settlement, alignment with the NSA requirements will require organizations to adapt internal capabilities, outsource solutions, or find some combination of the two. Companies may have to alter their infrastructure and processes to administer all aspects of the law.

And according to proprietary research, providing accurate Advanced Explanation of Benefits (AEOBs) to member-patients and meeting the tight post-service timeline in which providers and insurers must complete adjudication, remediation, and arbitration will be the most challenging areas for organizations to tackle, particularly for substantial claims.

For access to additional information, visit Zelis' No Surprises Act Information Hub.