How We’re Helping Your Plan Comply
Updated 11/27/23
EVHC is currently preparing the services and capabilities needed to support and assist Plan Sponsors in complying with these requirements. View the sections below for more information on each topic.
QUICK LINK: Member Rights and Protections Notice
Please note: Federal guidance regarding the Transparency in Coverage Rule and the Consolidated Appropriations Act, 2021, which includes the No Surprises Act, continues to be revised and updated; check back for updates. The below summary reflects EVHC's current plans as of the date of this publication. Please reach out to your EVHC client manager with questions. EVHC does not provide legal advice. We recommend our clients and Plan Sponsors consult their legal counsel to ensure their plans are compliant with the applicable laws.
Under the Consolidated Appropriations Act (CAA), health insurers offering group or individual health coverage and self-funded (ASO) group health plans are required to report data annually regarding prescription drugs and healthcare spending to the Departments of Health and Human Services, Labor, and Treasury (Tri-Agencies). This information must be submitted through a web portal set up by the Centers for Medicare & Medicaid Services (CMS).
Going forward, medical and pharmacy data reporting will be required annually by June 1.
Some of the information you will be asked to provide includes:
PBMs should be expected to submit the following data on employers’ behalf:
Reporting Instructions
Going forward, medical and pharmacy data reporting will be required annually by June 1.
How We Support You
We will submit the following information on behalf of our active clients:- P2 Group health plan list
- D1 Premium and life-years
- D2 Spending by category
- Narrative response (medical plan portion)
Some of the information you will be asked to provide includes:
- 5500 plan number(s) (ERISA plan number)
- Stoploss data
- Annual amount of stoploss premium
- Name and EIN of stoploss carrier
- If we pay the stoploss premium on your behalf, this information is NOT needed.
- Other ASO/TPA fees paid by the health plan directly to external vendors, NOT including what is paid to or by us
- Average monthly premium amount paid by members and the employer (excluding what the member pays)
- Carveout/external PBM vendor name and EIN
- Carveout/external wellness vendor name and EIN
- Carveout/external behavioral health vendor name and EIN
- Vendor name(s) and EIN(s) of group health plans offered to employees by a company other us, if applicable
PBM Reporting Expectations
It is important that employers ensure their PBMs will be reporting and filing the required data on behalf of their plans. If your PBM is Cigna, CVS Caremark, Elixir, or Southern Scripts, and we hold the contract, please reach out to your client manager to learn more. There may be additional fees assessed by the PBM.PBMs should be expected to submit the following data on employers’ behalf:
- D3 Top 50 Most Frequent Brand Drugs
- D4 Top 50 Most Costly Drugs
- D5 Top 50 Drugs by Spending Increase
- D6 RX Totals
- D7 RX Rebates by Therapeutic Class
- D8 RX Rebates for the Top 25 Drugs
- Narrative Response (PBM portion)
Reporting Instructions
This legislation is intended to protect patients from balance billing for “surprise” bills by limiting the amount patients will pay. Surprise bills are incurred when a patient does not have the opportunity to choose an in-network provider and is therefore responsible for charges over the Plan’s “allowed amount.” The No Surprises Act defines these types of services as:
In general, if a member chooses to have non-emergency services from an out-of-network provider, the provider must disclose in advance the fact that it is out-of-network, and if the patient signs the consent, the legislation does not apply.
Certain ancillary providers, such as radiologists, anesthesiologists, pathologists, and neonatologists are always subject to the legislation and cannot provide notice and obtain consent from the patient to waive the protections from the No Surprises Act.
The patient cost-share for surprise bills will be calculated using the median network rate for the applicable service in the applicable geographic region, defined as the qualified payment amount (QPA). Providers cannot collect more from the patient than the patient’s cost share.
Providers can negotiate with the self-funded health benefit plan if they believe they should be paid more for their service. If the health benefit plan and the provider are not able to reach an agreement, the legislation includes an Independent Dispute Resolution (IDR) process using baseball style arbitration to determine the final reimbursement amount.
We will support Plan Sponsors by identifying these surprise bills and adjudicating them using the QPA. We also support the IDR process by working with the applicable vendor delivering this service for our clients. In some cases, the network is managing the process. Where the network is not managing the process, we are utilizing Multiplan’s services.
The member’s explanation of benefits for these services includes the required disclosure notice of a patient’s rights under the No Surprises Act; this notice is also posted on our website so clients can access and link to it as the legislation requires plans to post it on their public website.
The provider explanation of payment for these services includes the required information on how providers can initiate the open negotiation process.
Coverage for true emergency services and certain services rendered by out-of-network providers at network facilities must be reviewed to ensure that these services are covered at the in-network level. Beginning with plan years starting 1/1/22, we are reviewing applicable client medical plans and recommending necessary plan changes.
Client benefit plan documents and Summary Plan Descriptions are being reviewed and updated to support compliance with the law.
- Out-of-network air ambulance services
- Out-of-network services received at an in-network facility
- Out-of-network emergency services
In general, if a member chooses to have non-emergency services from an out-of-network provider, the provider must disclose in advance the fact that it is out-of-network, and if the patient signs the consent, the legislation does not apply.
Certain ancillary providers, such as radiologists, anesthesiologists, pathologists, and neonatologists are always subject to the legislation and cannot provide notice and obtain consent from the patient to waive the protections from the No Surprises Act.
The patient cost-share for surprise bills will be calculated using the median network rate for the applicable service in the applicable geographic region, defined as the qualified payment amount (QPA). Providers cannot collect more from the patient than the patient’s cost share.
Providers can negotiate with the self-funded health benefit plan if they believe they should be paid more for their service. If the health benefit plan and the provider are not able to reach an agreement, the legislation includes an Independent Dispute Resolution (IDR) process using baseball style arbitration to determine the final reimbursement amount.
How We Support You
We will support Plan Sponsors by identifying these surprise bills and adjudicating them using the QPA. We also support the IDR process by working with the applicable vendor delivering this service for our clients. In some cases, the network is managing the process. Where the network is not managing the process, we are utilizing Multiplan’s services. The member’s explanation of benefits for these services includes the required disclosure notice of a patient’s rights under the No Surprises Act; this notice is also posted on our website so clients can access and link to it as the legislation requires plans to post it on their public website.
The provider explanation of payment for these services includes the required information on how providers can initiate the open negotiation process.
Coverage for true emergency services and certain services rendered by out-of-network providers at network facilities must be reviewed to ensure that these services are covered at the in-network level. Beginning with plan years starting 1/1/22, we are reviewing applicable client medical plans and recommending necessary plan changes.
Client benefit plan documents and Summary Plan Descriptions are being reviewed and updated to support compliance with the law.
Plan Sponsors must provide access to up-to-date provider databases on a public-facing website beginning with plan years on or after January 1, 2022. Each network/vendor is responsible for managing provider network requirements for their contracted providers.
We currently include links to applicable network databases from our portal. We recommend that clients add the links to their websites. Our customer service will support member requests related to a provider’s network status.
How We Support You
We currently include links to applicable network databases from our portal. We recommend that clients add the links to their websites. Our customer service will support member requests related to a provider’s network status. Upon plan year effective date, when a network provider or facility terminates from the network, certain patients must be notified of the termination and have the opportunity to request to continue care from that provider or facility at the in-network benefit level. This continuation of care will end the earlier of 90 days after the request or the date the patient is no longer undergoing continuing care.
We work with the networks to receive regular updates of provider terminations and evaluate claims history and pre-certification records to identify and notify the impacted members of their right to continue care and in-network benefits. We are receiving and recording continuous care elections and adjudicating claims accordingly.
We have implemented processes to notify your members when one of their providers is leaving the network. To ensure efficient and timely communication for this process and the anticipated advance EOB process, we ask that you make every effort to include employee email addresses on your eligibility file. This will ensure prompt delivery of notifications to your employees.
How We Support You
We work with the networks to receive regular updates of provider terminations and evaluate claims history and pre-certification records to identify and notify the impacted members of their right to continue care and in-network benefits. We are receiving and recording continuous care elections and adjudicating claims accordingly.We have implemented processes to notify your members when one of their providers is leaving the network. To ensure efficient and timely communication for this process and the anticipated advance EOB process, we ask that you make every effort to include employee email addresses on your eligibility file. This will ensure prompt delivery of notifications to your employees.
The No Surprises Act requires that, for plan years beginning on or after 1/1/22, online and printed ID cards include in-network and out-of-network deductibles, out-of-pocket maximums, and a telephone number and website address where members may obtain support, including network information.
We implemented the required changes to both electronic and physical ID cards at the start of each client’s plan year beginning on or after January 1, 2022. All electronic versions of the cards are being updated prior to the start of your plan year beginning 1/1/22 and after. Any physical cards issued after that date will include the new version of the card.
Additionally, pre-certification authorization requirements for emergencies must be removed. However, we are including a request to call so our healthcare management staff can continue to provide services when the client utilizes our services.
How We Support You
We implemented the required changes to both electronic and physical ID cards at the start of each client’s plan year beginning on or after January 1, 2022. All electronic versions of the cards are being updated prior to the start of your plan year beginning 1/1/22 and after. Any physical cards issued after that date will include the new version of the card.Additionally, pre-certification authorization requirements for emergencies must be removed. However, we are including a request to call so our healthcare management staff can continue to provide services when the client utilizes our services.
Federal law prohibits group health plans and health insurers offering group and individual health insurance coverage from entering into contracts that contain “gag” clauses, or provisions that restrict the group health plan/insurer from disclosing and sharing certain cost or quality of care data or other information to participants, plan sponsors, or referring providers, or restrict the plan or insurer from sharing such information with a business associate (consistent with applicable privacy regulations).
Health insurers offering group or individual coverage, and fully insured and self-funded health plans (ERISA, Non-ERISA, grandfathered and non-grandfathered) must submit this attestation, unless someone submits it on their behalf.
The first attestation is due by December 31, 2023, covering the period beginning December 27, 2020, or the effective date of the applicable plan or coverage (if later), through the date of attestation. Subsequent attestations are due by December 31 of each year thereafter.
We WILL submit the attestation on the client’s behalf for:
If a client wishes to opt out of us submitting gag clause attestation on their behalf for this upcoming submission, they must contact their client manager to opt-out in writing by 11/1/2023. If no opt-out request is received by this date, we will submit on their behalf.
View the CMS summary on this topic, with additional resources including FAQs, submission instructions and templates.
Health insurers offering group or individual coverage, and fully insured and self-funded health plans (ERISA, Non-ERISA, grandfathered and non-grandfathered) must submit this attestation, unless someone submits it on their behalf.
Deadlines
The first attestation is due by December 31, 2023, covering the period beginning December 27, 2020, or the effective date of the applicable plan or coverage (if later), through the date of attestation. Subsequent attestations are due by December 31 of each year thereafter.
How We Support You
We WILL submit the attestation on the client’s behalf for:
- Medical plans – for networks where we hold the network contract (example Aetna, Cigna, Highmark, Anthem)
- Prescription plans – for PBMs where we hold the network contract (example CVS, Elixir, Cigna, Southern Scripts)
- Terminated clients as of the filing in December
- Medical/PBM/behavioral health networks that are on a direct contract basis with the client.
- Domestic networks
- Clients that opt-out of this reporting by the specified deadline (see details below)
If a client wishes to opt out of us submitting gag clause attestation on their behalf for this upcoming submission, they must contact their client manager to opt-out in writing by 11/1/2023. If no opt-out request is received by this date, we will submit on their behalf.
View the CMS summary on this topic, with additional resources including FAQs, submission instructions and templates.
Plan Sponsors must provide an external review process to determine if the plan correctly determined whether the service provided is subject to the No Surprises Act.
We currently have an external review process in place that will be utilized for claims that are subject to the No Surprises Act.
How We Support You
We currently have an external review process in place that will be utilized for claims that are subject to the No Surprises Act. Compensation to brokers and service providers in connection with services provided to a group health plan must be disclosed to the Plan Sponsor or insurer. Brokers, consultants, and other service providers subject to the law must provide such disclosure as required by law.
We disclose such compensation when applicable in our administrative services agreement and will continue to do so.
How We Support You
We disclose such compensation when applicable in our administrative services agreement and will continue to do so.For plan years beginning January 1, 2022, and after, group health plans are required to create and publish machine-readable files on a public site and update them monthly. The files are required for in-network rates and out-of-network allowed amounts and billed amounts. Enforcement of this requirement has been delayed from January 1, 2022 to July 1, 2022.
Implementation of the prescription drug machine-readable files has been delayed indefinitely pending additional guidance.
We will provide each client a link to a table of contents containing the applicable MRFs for their plans. Plan Sponsors should then post the link on their public website.
Implementation of the prescription drug machine-readable files has been delayed indefinitely pending additional guidance.
How We Support You
We will provide each client a link to a table of contents containing the applicable MRFs for their plans. Plan Sponsors should then post the link on their public website.The Transparency in Coverage Rule requires that members be provided with benefit cost estimator tools (by Internet website or paper) that help members estimate their out-of-pocket costs and compare costs for covered network and out-of-network services. A similar cost comparison tool (by Internet website or telephone) for services from a network provider is required under the No Surprises Act.
The Departments have deferred enforcement of the price comparison tool under the No Surprises Act until plan years beginning on or after January 1, 2023, to align with the Transparency in Coverage rule.
Beginning January 1, 2023, the tool required under the Transparency in Coverage Rule must include 500 identified items and services. In 2024, the tools must provide costs for all covered medical items and services for network and out-of-network services.
The Departments intend to propose rulemaking and seek public comment regarding:
Clients who already have Healthcare Bluebook will receive expanded services to include network filtering and integrated deductible and out-of-pocket accumulator data to obtain a more meaningful estimate of out-of-pocket expenses.
Beginning 1/1/23, all clients who do not have this service from another source will receive this service to deliver the required price lookup and price comparison capabilities.
The Departments have deferred enforcement of the price comparison tool under the No Surprises Act until plan years beginning on or after January 1, 2023, to align with the Transparency in Coverage rule.
Beginning January 1, 2023, the tool required under the Transparency in Coverage Rule must include 500 identified items and services. In 2024, the tools must provide costs for all covered medical items and services for network and out-of-network services.
The Departments intend to propose rulemaking and seek public comment regarding:
- Whether compliance with Internet-based self-service tool requirements of the Transparency in Coverage Rule satisfy requirements in the No Surprises Act
- That the same pricing information available through the online tool or in paper form, as described in the Transparency in Coverage Rule, be provided over the phone, upon request, as required by the No Services Act
How We Support You
We will support Plan Sponsors when networks are not providing such service or clients have multiple network tiers by providing the required price transparency/cost comparison tool through Healthcare Bluebook.Clients who already have Healthcare Bluebook will receive expanded services to include network filtering and integrated deductible and out-of-pocket accumulator data to obtain a more meaningful estimate of out-of-pocket expenses.
Beginning 1/1/23, all clients who do not have this service from another source will receive this service to deliver the required price lookup and price comparison capabilities.
The No Surprises Act requires providers to confirm coverage and send a notice to the health plan of the patient’s estimated costs associated with services scheduled three or more days in advance. The health plan must send an advance EOB to the member through the mail or email.
We will support Plan Sponsors with this service pending additional forthcoming guidance.
How We Support You
We will support Plan Sponsors with this service pending additional forthcoming guidance.We will be communicating the applicable fees to our clients and brokers in April 2022, with the compliance fees effective on July 1, 2022.