FAQS About Enforcement of The Affordable Care Act and Consolidated Appropriations Act

The Transparency in Coverage Final Rules (the TiC Final Rules) require non-grandfathered group health plans and health insurance issuers to disclose certain billing information for covered items and services on a public website. This includes in-network provider rates, allowed amounts for out-of-network services, billed charges, and negotiated rates and historical net prices for covered prescription drugs in three separate machine-readable files. This rule applies to issuers offering non-grandfathered coverage in the group and individual markets. Below are answers to two frequently asked questions regarding the enforcement of specific provisions of the Affordable Care Act (ACA) and specific provisions of Title I (the No Surprises Act) and Title II (Transparency) of Division BB of the Consolidated Appropriations Act, 2021 (the CAA).

FAQ 1: Will the Departments enforce the machine-readable file provisions in the TiC Final Rules?

Yes, but subject to two exceptions. Plans and issuers must create public machine-readable files disclosing in-network rates, out-of-network allowed amounts, and billed charges. However, the first exception allows the Departments, as an exercise of enforcement discretion, to defer enforcement of the TiC Final Rules’ requirement that plans and issuers publish machine-readable files relating to prescription drug pricing, pending further rulemaking. The second exception allows the Department, again as an exercise of enforcement discretion, to defer enforcement of the TiC Final Rules’ requirement to publish the remaining machine-readable files until July 1, 2022.

FAQ 2: Are plans and issuers required to make public the machine-readable files for in-network rates and out-of-network allowed amounts and billed charges for plan years (in the individual market, policy years) beginning on or after January 1, 2022?

There are several CAA provisions that plans and issuers must implement by January 1, 2022. It will take these issuers substantial time and effort to make the machine-readable files available in the form and manner required in the TiC Final Rules.

In recognition of this, the Departments will defer enforcement of these requirements to make public the machine-readable files for in-network rates, out-of-network allowed amounts, and billed charges, until July 1, 2022. This applies to plan or policy years beginning on or after January 1, 2022.

HBL has experience in all areas of benefits and employment law, offering a comprehensive solution to all your business benefits and HR/employment needs. We help ensure you are in compliance with the complex requirements of ERISA and the IRS code, as well as those laws that impact you and your employees. Together, we reduce your exposure to potential legal or financial penalties. Learn more by calling 470-571-1007.

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Hall Benefits Law, LLC

HBL offers employers comprehensive legal guidance on benefits in mergers and acquisitions, Employee Stock Ownership Plans (ESOPs), executive compensation, health and welfare benefits, healthcare reform, and retirement plans. We counsel a wide spectrum of clients including small, mid-sized, and large companies, 401(k) investment advisors, health insurance brokers, accountants, attorneys, and HR consultants, just to name a few. HBL is passionate about advising clients, and we are dedicated to our mission: to provide comprehensive, personalized, and practical ERISA and benefits legal solutions that exceed client expectations.

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