Effective for plan years beginning on or after 1/1/23, the No Surprises Act requires the provision of a tool to estimate cost-sharing information that members can access, via the Internet, for a specific healthcare service among providers in a particular geographic region during the plan year.
 
The Transparency in Coverage Rule requires a web tool (available to members) making certain information available for:

• 500 items and services identified by the federal government, effective for plan years beginning on or after 1/1/23
• all other items and services, effective for plan years beginning on or after 1/1/24

How we responded
Effective Dec. 1, 2022, employees covered under self-funded health benefit plans administered by Star Marketing and Administration, Inc., can shop online for medical procedures provided by doctors and facilities in their area to find high-quality, affordable care and get an out-of-pocket cost estimate. Via Healthcare Bluebook^TM, green, yellow and red color signs will help guide covered employees to the right care

The Consolidated Appropriations Act, 2021, (CAA) requires insurance companies and employer-based health benefit plans to submit information about prescription drug costs for a two-year period (2020 and 2021) by Dec. 27, 2022. Star Marketing and Administration, Inc., will submit this data so plans do not need to, but we are requesting input from sponsors of group plans in order to complete this accurately on their behalf. 

To help self-funded plans comply with this CAA provision, we are asking employers to submit their group health plan number reported on IRS Form 5500, if applicable, by Oct. 21, 2022. An email will be sent to employers on Oct. 7, 2022, with the request.

The data submitted will help: identify major drivers of increases in prescription drug and healthcare spending; explain how prescription drug rebates impact premiums and out-of-pocket costs; and promote transparency in prescription drug pricing. Drug data will be consolidated at the state level and individual plan information will not be identifiable.

For plan years beginning Jan. 1, 2022, the Transparency in Coverage Final Rule requires non-grandfathered, employer-sponsored group health benefit plans to disclose information in machine-readable files on a public website and to update them monthly. Files are required for in-network rates and out-of-network allowed amounts and billed amounts. The rule allows for a link to the information that must be posted to a public website by July 1, 2022. The link will be sent to employers with a plan administered by Star Marketing and Administration, Inc., on June 22, 2022.

Allows certain members who are continuing care patients to elect, if their provider/facility loses PPO network status, to continue receiving in-network benefits for the care from that provider/facility.
 
A Continuing Care Patient is defined as someone who is:

• undergoing a course of treatment from a provider or facility for a serious and complex condition;
• undergoing a course of institutional or inpatient care;
• scheduled to undergo nonelective surgery;
• pregnant and undergoing a course of treatment for the pregnancy; or terminally ill.

Must provide access to PPO network provider database on plan’s website.
 
Note: Electronic provider information is now available through networks directly. Links to available PPO networks are located on our website. PPO networks are responsible for the accuracy and maintenance of their databases and directories.

Must provide clear information on deductibles and out-of-pocket limits, along with a telephone number and website address for consumer assistance on ID cards.
 
Note: Members of health benefit plans administered by Star Marketing and Administration, Inc., will receive an updated ID card showing the out-of-pocket maximum at the start of their new plan year beginning on or after 1/1/22.

A federal process has been established to resolve disputes regarding plan out-of-network payments for emergency services provided by nonparticipating providers/facilities/air ambulances and for non-emergency services furnished by certain nonparticipating providers/facilities at participating healthcare facilities. Process deadlines provided below.⁴

Unless notice and consent (see below) is satisfied⁵, a member’s cost share for non-emergency care at an in-network facility by an out-of-network healthcare provider will be calculated using the lesser of: the billed amount or the median of the applicable contracted rates. The cost-share amount will be applied to the in-network deductible and in-network out-of-pocket limit. Ultimate payments by the plan may be subject to independent dispute resolution.

Most out-of-network providers⁵ must notify a member that they are not in the patient’s PPO network and obtain the patient’s written consent before providing non-emergency care.

Standard Notice and Consent Documents Under the No Surprises Act

Cost share for out-of-network emergency care will be calculated using the lesser of: the billed amount or the median of the applicable contracted rates. The cost-share amount will be applied to the in-network deductible and in-network out-of-pocket limit. Ultimate payments by the plan may be subject to independent dispute resolution.  
  

Must be revised to meet requirements.

Note: Members of a health benefit plan administered by Star Marketing and Administration, Inc., will receive an updated plan document at the start of their new plan year beginning on or after 1/1/22.

 Out-of-network providers are prohibited from balance billing for certain types of services:

• Out-of-network emergency care
• Certain types of care by an out-of-network provider at an in-network facility
• Out-of-network air ambulance services

Model Disclosure Notice: Patient Protections Against Surprise Billing

Note: This provision applies to our major medical plan designs with a PPO network.

Prior authorization cannot be applied to emergency care provided by emergency departments and freestanding emergency-care facilities.

Note: We already support compliance with this provision: Our plan designs do not require prior authorization for emergency care.

If a member is transported by an out-of-network air ambulance, cost sharing must be calculated using the lesser of: the billed amount or the median of the applicable contracted rates. The cost-share amount will be applied to the in-network deductible and in-network out-of-pocket maximum. Ultimate payments by the plan may be subject to independent dispute resolution.

Must provide good-faith estimate of cost of healthcare services and members’ cost-share responsibilities. (No Surprises Act)

Providers and facilities must provide a good-faith estimate for individuals enrolled in a health plan and seeking to submit a claim for scheduled items or services to their plan or coverage. (Consolidated Appropriations Act, 2021)

Must publish machine-readable files containing prescription drug pricing on a public website. (Transparency in Coverage Rule )