The Consolidated Appropriations Act

The No Surprises Act protects patients from “surprise” bills in certain situations where a provider bills a member for the difference between what the insurer paid and the amount the provider bills (“balance bill”). The No Surprises Act prevents providers from balance billing patients in two situations—emergency services and services delivered at in-network facilities by out-of-network providers, including labs.

When a claim is received from an out-of-network provider, the insurer has 30 days to deny or pay the claim. If the provider is dissatisfied with the payment received, the insurer and the provider must engage in 30 days of “good faith negotiation.” If that is unsuccessful, either the insurer or the provider can initiate the “independent dispute resolution” (IDR) process, which will determine the final payment amount for the claim. This amount is binding on the insurer and the provider, and such awards can only be challenged in court under limited circumstances. Regardless of what happens at the IDR, the member pays no more than the initially calculated cost-share. The member is not involved in the IDR process at all.  

There are limited situations where certain providers can ask patients to waive their rights under the CAA and we anticipate the need for member support to ensure that providers do not seek a waiver when they are prohibited from doing so.

How does this affect your employees?

When the protections are triggered, patients are responsible for no more than in-network cost-sharing amounts, including deductibles, co-insurance and co-pays. 

What is Blue Cross required to do? 

Blue Cross will ensure procedures are in place to timely pay or deny claims and help ensure that your employees are benefitting from the full protection of the new law.  We will handle the IDR process and will advocate for your employees if out-of-network providers are not following the law. 

IDR (Independent Dispute Resolution) Process Policy

Notice of Open Negotiation

Health plans must identify on insurance cards the amount of the in-network and out-of-network deductibles, the in-network and out-of-network out-of-pocket maximum, and a phone number and website address for consumer assistance information. 

How does this affect your employees? 

Your employees and their dependents will receive new ID cards each year upon their renewal. Please let them know they can expect new cards.  

What is Blue Cross required to do? 
We have added fields to the ID card to help your employees understand their in-network and out-of-network cost-sharing amounts. Our ID cards already display the customer service team’s phone number and our website address. This will remain in place.

Health insurance issuers are required to maintain a “price comparison tool” available via phone and website that allows enrolled individuals to compare cost-sharing for items and services by any participating provider.

How does this affect your employees? 

Please encourage your employees to create an account on our Member Resource Center. Once they have an account, they can log in and use the tool to estimate the cost of upcoming care.

What is Blue Cross required to do? 

We have a price-comparison tool available today on our Member Resource Center. Members can access our price comparison tool by signing into our Member Resource Center or by calling our customer service team at (800) 247-2583.  

The CAA requires that health plans establish a verification process to confirm provider directory information at least every 90 days. Health plans must establish a response protocol to respond to member network questions within one business day and retain communications for at least two years.

How does this affect your employees? 

If a member provides documentation that they received incorrect provider information related to whether or not the provider is in-network, the member will only be responsible for in-network cost-sharing. If this happens, please encourage your employees to contact our customer service team at (800) 247-2583. 

What is Blue Cross required to do? 

We will ensure our provider directory management and processes will be compliant with this requirement. 

What are network providers required to do? 

Network providers are obligated to update Blue Cross provider directory information and protect their patients from harm resulting from incorrect information.

The CAA requires health plans to document comparative analyses of the design and application of nonquantitative treatment limits (NQTLs) applied to medical and mental health benefit. The NQTL analysis must be made available to state and federal authorities upon request.

How does this affect your employees? 

The NQTL analysis will be made available to employees upon request. 

What is Blue Cross required to do? 

Blue Cross is committed to meeting or exceeding mental health and physical health parity standards. We have taken the necessary steps to ensure you remain compliant with federal mental health parity requirements.

Although not part of the CAA, the Transparency in Coverage (TCR) rule requires that health plans share negotiated prices for services in publicly available “machine-readable files.”

View our Machine Readable Files webpage for more details.

How does this affect your employees? 

This will not affect your employees. 

What is Blue Cross required to do? 

We are publishing these prices on behalf of our groups. Current configuration rules require the posting of many terabytes of data (a trillion bytes), with storage costs ranging in the millions of dollars. As such, this aspect of the TCR rule remains under consideration while work underway at the federal level addresses storage cost concerns. 

While delayed pending formal rulemaking, the Advanced Explanation of Benefits will provide greater price transparency and allow for greater financial planning for health care consumers. 

How does this affect your employees?

Once this process is put in place, your employees will see greater transparency about how much medical services cost and who pays what over the course of time for care. It will help people estimate the cost of care and provide insight into the way the health care system works.

What are network providers required to do? 

The CAA requires providers and facilities to estimate the charge for a scheduled service when an appointment is made or shortly thereafter. Once a provider has produced a cost estimate for a scheduled service, providers must communicate the estimate to Blue Cross. 

What is Blue Cross required to do? 

Once Blue Cross receives an estimate from a provider or request from a member, we must deliver information to the member including: 

• Our cost estimate (both how much the provider will receive and the member’s cost-share)
• Where the member is in their deductible and out-of-pocket maximum
• Whether provider is in-network
• Whether the service is subject to prior approval 
• What the member’s accumulated cost-share is currently

By June 1st of each year, plans and issuers must report certain prescription drug data from the prior calendar year. Data will include information on coverage, number of participants, the 50 most frequently dispensed brand drugs, total paid claims for these drugs, and the impact of rebates on premiums and fees.

On an annual basis, employer groups and health insurance issuers must submit information about the average monthly premiums paid by employees versus employers. The government believes that this information is important to understanding the impact of prescription drug costs on premiums for employers versus employees.

What is Blue Cross required to do? 
We will be providing the reporting for employers & groups that use Vermont Blue Rx as their pharmacy benefit manager. If your organization uses a pharmacy benefit manager other than Vermont Blue Rx, you need to work directly with that pharmacy benefit manager to produce the required reports.

Blue Cross will also report the health plan premium information – fully-insured employer groups, Blue Edge groups, and Blue Edge Business groups will be asked to provide this information to us for the reporting needs.

Each year, groups and insurers are required to report certain information concerning stop loss coverage.

What is Blue Cross required to do?
We will be providing reporting to the Centers of Medicare and Medicaid Services (CMS) on behalf of the groups we manage stop loss coverage for.

If Blue Cross does not manage your stop loss coverage, you or your stop-loss insurer are required to report this information to CMS by December 27, 2024. For more information about this, view our CAA document for Administrative Services Only (ASO) employer groups or view the CMS CAA document (see Section 204 of Division BB). For assistance with additional questions, contact your stop-loss carrier.

Under the CAA, plans and insurers are prohibited from entering into agreements with providers, networks, and other entities that restrict the plan or insurer from the following:

• providing provider-specific cost or quality of care information or data to necessary parties
• electronically accessing de-identified claims data
• sharing any information, consistent with applicable privacy regulations

Each year, groups and insurers are required to submit a Gag Clause Prohibition Compliance Attestation.

What are group health plans required to do?
For this initial reporting period in December 2023, Blue Cross VT will be submit the Gag Clause Prohibition Compliance Attestation to the Centers of Medicare and Medicaid Services (CMS) on behalf of our employer groups. The first round of reporting is due by December 31, 2023 and will cover the period beginning December 27, 2020 through the date of attestation.

More information about the Gag Clause compliance attestation can be found via the CMS User Manual.

What is Blue Cross required to do?
On behalf of our employer groups, we will submit the Gag Clause Prohibition Compliance Attestation to CMS.