On August 19, 2022, frequently asked questions related to the Transparency in Coverage Final Rules (TiC Final Rules) and the No Surprises Act (NSA) section of the Consolidated Appropriations Act (CAA) were released jointly by the Departments of Labor, Health and Human Services (HHS) and the Treasury (collectively, the Departments). The FAQs clarify certain items pertaining to balance billing and disclosure requirements under the NSA and the TiC Final Rules, including posting requirements for machinereadable files (MRFs). This release is contained in the publication FAQs About Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 55 (FAQ – Part 55).

FAQ – Part 55 addresses the NSA and the TiC Final Rules in two separate and distinct sections. Therefore, this article also addresses each of these topics separately beginning with the TiC Final Rules followed by clarifications related to the NSA. For ease of reference, these sections also include important background information into the TiC Final Rules and the NSA.

Transparency in Coverage Rules

Background

The Transparency in Coverage Final Rules (TiC Final Rules) require non-grandfathered group health plans and individual health insurance issuers to disclose information related to the in-network rates for covered items/services, out-of-network allowed amounts and billed charges for items/services and negotiated rates and historical net prices for covered prescription drugs. This information must be contained in separate MRFs and posted on the health plan’s public website as of the later of July 1, 2022, or the first day of the plan year beginning on or after January 1, 2022. The requirement to post an MRF containing prescription drug information has been postponed indefinitely.

Under the TiC Final Rules, price comparison information must be made available to participants, beneficiaries and enrollees through an internet-based self service tool and by telephone (and made available in paper form, upon request). For all plan years beginning on or after January 1, 2023, a list of 500 items and services identified by the Departments in Table 1 of the preamble to the TiC Final Rules must be made available. Thereafter, a list of all covered items and services of a plan/policy must be disclosed through the internet-based self-service tool to participants, beneficiaries and enrollees for all plan years beginning on or after January 1, 2024.

FAQ – Part 55: Clarification on Transparency in Coverage Rules – Machine-Readable Files

FAQ – Part 55 provides plans and issuers greater clarity as to the rules surrounding the requirement to make certain machine-readable files available on a public website. As a reminder, certain machine-readable files related to the plan must be posted on the health plan’s public website. This requirement is effective as of the later of July 1, 2022, or the first day of the plan year beginning on or after January 1, 2022.

For self-funded plans, a plan sponsor may satisfy its posting requirement by entering into a written agreement with a service provider (such as a third-party administrator (TPA)) that posts the information on the service provider’s/TPA’s public website. The ability to delegate the responsibility to a service provider applies regardless of whether the plan sponsor has a public website for its health plan.

Regulatory and Legislative Strategy Group