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Brown & Brown — Conference Presentation (September 2022)
33 slides from Brown & Brown's conference presentation, Sep 15, 2022
Slide 1: This Webinar Will Start Momentarily
This Webinar Will Start Momentarily. Thank you for joining us!
Slide 2: Clearing the Air on Transparency Regulations
Clearing the Air on Transparency Regulations September 15, 2022 Presented By: Presented by the Regulatory and Scott Wold and Cindy Niesen Legislative Strategy Group
Slide 3: Disclaimer
DISCLAIMER Brown & Brown, Inc. and all its affiliates, do not provide legal, regulatory or tax guidance, or advice. If legal advice counsel or representation is needed, the services of a legal professional should be sought. The information in this document is intended to provide a general overview o
Slide 4: Agenda
Agenda 1 Basic Overview Transparency Requirements 2 Machine-Readable Files 3 Prescription Drug Reporting 4 Price Comparison Tool BROWN & BROWN | 4
Slide 5: Overview of Transparency Requirements
Overview of Transparency Requirements
Slide 6: Two Sources of Rules
Two Sources of Rules Affordable Care Act No Surprises Act • Publicly Available Machine-Readable Files • Prohibition on Gag Clauses (discussed later) • Health Plan ID Card Enhancements • Price Comparison Tool (discussed later) • Continuity of Care Requirements • Reflected in the final Transparency in
Slide 7: Compliance Dates
Compliance Dates Prohibition on Gag Clauses – 12/27/20 Health Plan ID Card Enhancements – PY beginning on or after 1/1/22 Continuity of Care Requirements – PY beginning on or after 1/1/22 Provider Directory Requirements – PY beginning on or after 1/1/22 Surprise Medical Bills – PY beginning on or af
Slide 8: Machine-Readable Files
Machine-Readable Files
Slide 9: Publicly Available Machine-Readable Files
Publicly Available Machine-Readable Files Files are for public, not plan participants or employees • No specific notice requirement for employees or participants Form and content requirements • Standardized format • Three separate machine-readable files: 1. Negotiated rates between plan and in-netwo
Slide 10: Publicly Available Machine-Readable Files: Who Must Comply
Publicly Available Machine-Readable Files W H O M U S T C O M P LY ? Applies to: Does not apply to: • Non-grandfathered Group Health Plans, • Grandfathered health plans including: • Group health plans that are excepted benefits: • Employer-sponsored plans • Most dental and vision plans • Multiemploy
Slide 11: Publicly Available Machine-Readable Files: Who Must Comply
Publicly Available Machine-Readable Files W H O M U S T C O M P LY ? For group health plans, the requirement • For self-insured plans, the group health plan may applies to both group health plan and, if fully satisfy the law’s requirements by entering into a written agreement under which another par
Slide 12: Publicly Available Machine-Readable Files: Other Issues
Publicly Available Machine-Readable Files OTHER ISSUES If files will be published on the insurance carrier’s or TPA’s website, is a link required? • In discussing one of the two machine-readable files, the regulations state: “However, if a plan . . . chooses not to also host the file separately on i
Slide 13: Publicly Available Machine-Readable Files: Additional Guidance on Links
Publicly Available Machine-Readable Files OTHER ISSUES Additional Guidance on Links • FAQs About ACA and CAA Part 55 issued 8/15/22 » Q/A22: If a group health plan does not have its own public website, nothing in the TiC Final Rules requires the plan to create its own website for the purposes of pro
Slide 14: RxDC Reporting
RxDC Reporting
Slide 15: General Overview of Requirements
General Overview of Requirements • Added to ERISA, Internal Revenue Code and PHSA by CAA of 2021 • Interim Final Regulations issued 11/23/21 » https://www.govinfo.gov/content/pkg/FR-2021-11-23/pdf/2021-25183.pdf • CMS published filing instructions; most recently updated in June 2022 » https://regtap
Slide 16: General Overview of Requirements
General Overview of Requirements • Applies to fully insured and self-insured group health plans, but: » Does not apply to HIPAA excepted benefits (e.g., most dental and vision plans; fixed indemnity plans; disease-specific insurance) » Does not apply to account-based plans (e.g., HRAs and health FSA
Slide 17: General Overview of Requirements
General Overview of Requirements • Using a third party (e.g., insurance carrier, TPA, PBM, etc.) » Regulations allow fully insured group health plans » Instructions indicate that multiple reporting entities to shift all responsibility to carrier if carrier agrees can submit reports on behalf of a gr
Slide 18: What Information Must Be Reported
What Five General Categories of Information Information ▪ Plan List – File P2 Must Be ▪ Premiums and Life Years (Covered Lives) – File D1 Reported ▪ Medical Spending by Category – File D2 ▪ Rx Cost Information – Files D3-D8 ▪ Narratives Carriers, TPAs and PBMs that file on behalf of group health pla
Slide 19: Plan List
Plan List • P2 applies to group health plans • Must be submitted by any reporting entity that submits a file on behalf of a group health plan • Includes various pieces of plan identifying information (e.g., plan name, plan number, plan year, plan sponsor name, etc.) and information about issuer, TPA
Slide 20: Life Years and Premiums
Life Years and Premiums • File D1 • Carrier/TPA/PBM will not have all of this information • Life years = Average number of members (employees and dependents) throughout the • Plan sponsor may need to file D1 or provide year information to carrier/TPA/PBM » Instructions illustrate how to calculate •
Slide 21: Spending by Category
Spending by Category • File D2 • Report data related to the reference year for claims paid or received through March 31 of the following calendar year • Categories » Hospital » Primary care » Specialty care » Other medical costs and services » Medical benefit drugs: Known amounts » Medical benefit d
Slide 22: Spending by Category
Spending by Category File D2 • Other medical costs and services includes information regarding wellness spending • Prior version of instructions appeared to require submission of a broad range of wellness spending by plan sponsor • Revised instructions narrow scope of this reporting » File must incl
Slide 23: Prescription Drug Reporting
Prescription Drug Reporting • Files D3 through D8 » Top 50 Brand Drugs, Top 50 Most Costly Drugs, Top 50 Drugs by Spending Increase, Rx Totals, Rx Rebates by Therapeutic Class, Rx Rebates for the Top 25 Drugs • Does not include Rx drugs covered under a medical benefit (so no coordination needed betw
Slide 24: Narrative Response
Narrative Response • Seven specific narratives required » Employer size for self-funded plans – identify whether size was determined using actual counts or estimates; if estimates, describe estimation method » Net payments from federal/state reinsurance or cost-sharing reduction programs » Drugs mis
Slide 25: Filing Procedure
Filing Procedure • Submit data through the RxDC module in the Health Insurance Oversight System (HIOS) » Instructions for using the RxDC module are in the User Manual • Process for registering » Must have a HIOS account to file reports » Instructions for creating an account are in the HIOS Portal Us
Slide 26: Summary
Summary • Plan sponsors need to determine whether carrier, • Will all data files be covered by third-party reporting? TPA and/or PBM will be performing reporting on » If so, determine what information needs to be behalf of the plan provided to carrier/TPA/PBM for it to complete the » If so, enter in
Slide 27: Price Comparison Tool
Price Comparison Tool
Slide 28: Price Comparison Tool
Price Comparison Tool • Both final TiC regulations under the ACA and the CAA include this requirement • Final TiC regulations apply to same plans as MRF requirements (e.g., grandfathered plans, excepted benefits and account-based plans are excluded) • CAA applies more broadly because it applies to g
Slide 29: Price Comparison Tool
Price Comparison Tool Based on TiC regulations issued under the ACA • Self-service tools available on Internet website (and by telephone per CAA) » Real-time responses as of the date of the request » Must be provided in paper form upon request » Mobile app alone is insufficient » Searchable by: - Co
Slide 30: Price Comparison Tool
Price Comparison Tool • Starting with the first plan year beginning on or after January 1, 2023 » Must disclose cost-sharing and pricing for 500 specific items and services » List available at http://www.cms.gov/healthplan-price-transparency/resources/500-items-services » Updated quarterly • Startin
Slide 31: Price Comparison Tool
Price Comparison Tool Tool must provide the following information: 1. Estimated cost sharing liability ($) for a covered item 5. If the item or service is part of a bundled payment or service, including all items and services for which arrangement, a list of the items or services included in benefit
Slide 32: HRCI and SHRM Credits
HRCI and SHRM Credits This Program, ID No. 604506,has been approved for 1.00 HR (General) recertification credit hours toward aPHR™, aPHRi™, PHR®, PHRca®, SPHR®, GPHR®, PHRi™ and SPHRi™ recertification through HR Certification Institute® (HRCI®). Brown & Brown is recognized by SHRM to offer Professi
Slide 33: Find your solution at BBrown.com
Find your solution at BBrown.com DISCLAIMER: Brown & Brown, Inc. and all its affiliates, do not provide legal, regulatory or tax guidance, or advice. If legal advice counsel or representation is needed, the services of a legal professional should be sought. The information in this document is intend
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