27 presentation slides. "The purpose of this presentation is to: [1] Provide an overview of the provisions related to the Mental Health Parity and Addiction Equity Act (MHPAEA) added by the Consolidated Appropriations Act, 2021 (CAA); [2] Discuss how the new provisions apply to non-Fed plans; and [3] Introduce MHPAEA resources and compliance tools."

163 pages. "These proposed rules would implement certain provisions of the No Surprises Act that would increase transparency by requiring group health plans and health insurance issuers in the group and individual markets, and FEHB carriers, to submit certain information about air ambulance services to [HHS, Treasury and OPM], as applicable, and by requiring providers of air ambulance services to submit certain information to the Secretaries of HHS and Transportation. These proposed rules also include HHS-only proposed rules that would increase transparency by requiring a health insurance issuer offering individual health insurance coverage or short-term, limited-duration insurance to disclose to policyholders and to report to HHS any direct or indirect compensation provided by the issuer to an agent or broker associated with enrolling individuals in such coverage. These proposed rules would also provide the process by which HHS would investigate complaints and potential violations ... and, if warranted, take enforcement action, including the imposition of civil money penalties, against providers and facilities, including providers of air ambulance services.... These proposed rules would also establish the process by which HHS would impose civil money penalties if a provider of air ambulance services fails to submit some or all required data to HHS." [Also see CMS Press Release and Fact Sheet]

"This report reviews ... evidence on the number of air ambulance providers and suppliers, utilization rates by patients, and average costs, as well as the potential for balance billing for air ambulance transport, particularly for privately insured and uninsured patients."

20 pages. "This notice provides guidance to employers on the requirement to report the following qualified sick leave wages and qualified family leave wages (qualified leave wages) paid to employees for leave provided in 2021: [1] Qualified leave wages under the [FFCRA] as amended by the ... Consolidated Appropriations Act ... paid for leave provided to employees beginning January 1, 2021, through March 31, 2021. [2] Qualified leave wages under ... the American Rescue Plan Act of 2021 (ARP) ... paid for leave provided to employees beginning April 1, 2021, through September 30, 2021.... This reporting provides employees who are also self-employed with information necessary for properly claiming qualified sick leave equivalent or qualified family leave equivalent credits for the 2021 taxable year[.]"

"The FAQs announce that enforcement of certain provisions that apply to group health plans, health insurance issuers, and health care providers and facilities will be delayed ... [F]or those CAA provisions that are not being delayed -- requirements related to ID cards, provider directory, continuity of care, balance billing disclosures, and gag clause prohibitions -- the FAQs direct plans to use a good faith, reasonable interpretation of the CAA to comply."

"[The delay] is great news for plan sponsors, who seemed unable to obtain contract provisions from third-party administrators (TPAs) that stated the TPA would comply with these rules.... [P]laintiffs' lawyers [may] use this information as the basis to bring lawsuits claiming that plans are overcharging participants for healthcare coverage.... [H]ow drugs are priced remains in a black box for most employers. This information would allow an employer to compare what its health plan paid for prescription drugs against another employer health plan."

"While the new guidance doesn't change the law, it clarifies several provisions of the CAA, and ... delays enforcement of the following healthcare price transparency rules: [1] The requirement to disclose new advanced EOBs ... [2] The requirement to implement a 'price comparison tool' ... [3] The requirement to report drug cost information to federal regulators ... [4] The requirement to disclose to the public health plan pricing information related to in-network rates, out-of-network allowed costs, and prescription drug prices."

"On August 20, 2021, the DOL published FAQs Part 49 announcing the extension of the compliance dates for a few -- but far from all -- of the new group health plan mandates under the Tri-Department transparency regulations and the Consolidated Appropriations Act (CAA)." [A chart lists the requirements with original and extended compliance dates.]

"The regulations and statutory provisions ... mandate substantial disclosure obligations and reporting requirements of health care providers, health plans, and health insurers. The FAQs released on August 20 relate to the communication and reporting obligations and not the restrictions on charges, balance billing and cost-sharing obligations addressed in the Interim Final Regulations. The FAQs provide transitional non-enforcement relief from numerous new disclosure rules."

"The government recognizes that the [transparency in coverage (TIC)] regulations require an online shopping tool for plan years beginning on or after January 1, 2023 -- and the CAA also has similar-but-separate requirements.... The government intends to propose rulemaking requiring the same pricing information that is available online and in paper form (under the TIC regulations) will also be required by telephone. Additionally, the government will not enforce the CAA price comparison requirements until the plan year beginning on or after January 1, 2023 -- to align the compliance date of the TIC regulations with the compliance date of the CAA."

11 pages.  12 Q&As addressing:

• Transparency in Coverage Machine-Readable Files
• Price Comparison Tools
• Transparency in Plan or Insurance Identification Cards
• Good Faith Estimate
• Advanced Explanation of Benefits
• Prohibition on Gag Clauses on Price and Quality Data
• Protecting Patients and Improving the Accuracy of Provider Directory Information
• Continuity of Care
• Grandfathered Health Plans
• Reporting on Pharmacy Benefits and Drug Costs

"The automatic enrollment provision of the PATH Act supersedes any state law that restricts the ability of a church plan to have an automatic contribution arrangement."

"Effective beginning January 1, 2022, the CAA prohibits plans and providers from billing patients more than in-network cost-sharing amounts in certain circumstances. The prohibition applies to both emergency care and certain non-emergency situations where patients do not have the ability to choose an in-network provider."

"The CAA requires that health plan participants receive an advance explanation of benefits (EOB) whenever they schedule a health care service at least three business days in advance. Participants are also able to request an advance EOB for a health care service whether or not the service has been scheduled."

"[S]ome states have already taken action against these balance billing practices by implementing various forms of consumer protection laws over recent years.... For fully insured plans, the insurance carriers will need to update the plans they issue to incorporate the new regulations and maintain compliance with both state and federal laws."

"The IFR is largely focused on how the surprise billing protections apply to group health plans and health insurance issuers, as well as how the Qualified Payment Amount (QPA) is calculated. There are some rules related to the initial payment for surprise billing claims from providers and notices of denial, as well as provider-focused rules. The IFR generally hews closely to the CAA's provisions and provides some clarity regarding the calculation of the QPA amount."

"Employers may want to note that the DOL will establish a process to administer complaints that health plans and insurers are violating the No Surprises Act rules. Though employees could file such complaints, it appears that providers would be more likely to use the new system. Options for the DOL under the new process include referring the plan or insurer for an investigation or for enforcement action."

"Along with the IFR, the Departments released model notices that group health plans and issuers (as well as providers and facilities) must make publicly available, post on a website, and include on each explanation of benefits and other related materials.... The regulations apply to group health plans and insurance issuers offering group or individual coverage, including grandfathered plans. The regulations do not apply to retiree-only plans; excepted benefits; short-term, limited duration insurance; health reimbursement accounts (HRAs); and other account-based group health plans (e.g., healthcare flexible spending accounts)."

"When does this rule apply? ... What plans are covered by the interim final rule? ... Major provisions of the interim final rule ... How is billing determined? ... What about cost sharing? ... What notices must providers and group or individual health plans give to patients?"

"The [qualifying payment amount (QPA)] will be used to cap a patient's cost-sharing responsibility for out-of-network care unless they have formally consented to be balance-billed ... Health plan payments then will be determined via either negotiations or an independent dispute resolution (IDR) process that will be spelled out in rulemaking later this year."

"[T]he DOL has already started to collect the [nonquantitative treatment limitation (NQTL)] analyses mandated by the [Consolidated Appropriations Act] and is already issuing findings letters based on their initial reviews.... [T]he level of detail demanded by regulators surrounding the evidentiary factors -- including numeric support for parity -- is very detailed, and has not typically been maintained by plans or issuers."

"The rule establishes time frames for initial payment/notice of denial (within 30 days of a bill being submitted), making a final benefit determination and payment (with 30 days of initial response), payment negotiations and initiating the independent dispute resolution process.... Plan sponsors will have until plan years beginning on or after January 1, 2022 to make sure that their plans comply with these new rules[.]"

"The new rules impose significant and detailed new notice obligations on the part of group healthcare plans, with one notice going to affected enrollees and another going to the out-of-network provider.... [The qualifying payment amount (QPA)], and how to calculate it, is the focus of most of the new rules' complexity and nuance.... The plan sponsor will want to take steps to ensure its plan's claim payor (the insurer or TPA) can make these calculations and do so correctly."

"[T]he DOL expects to focus on the following four NQTLs in its near-term enforcement efforts: [1] Prior authorization requirements for in-network and out-of-network inpatient services; [2] Concurrent review for in-network and out-of-network inpatient and outpatient services; [3] Standards for provider admission to participate in a network, including reimbursement rates; and [4] Out-of-network reimbursement rates (plan methods for determining usual, customary, and reasonable charges)."

"Most of the responsibility for these changes will fall on the carrier or third-party administrator/administrative services only provider (TPA). However, employers should confirm with their carriers and TPAs that they plan to implement these rules."