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Brown & Brown — Conference Presentation (May 2024)
35 slides from Brown & Brown's conference presentation, May 16, 2024
Slide 1: This Webinar Will Start Momentarily
This Webinar Will Start Momentarily. Thank you for joining us!
Slide 2: Health Plan Transparency Requirements
Health Plan Transparency Requirements May 16, 2024 Presented By: Presented by the Regulatory and Cindy Niesen and Dan Brady 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 Transparency Requirements 2 Surprise Medical Billing 3 Price Comparison Tool 4 Prescription Drug Reporting 5 Gag Clause Attestations BROW N & BROW N | 4
Slide 5: Transparency Requirements
Transparency Requirements
Slide 6: Transparency Requirements - Overview
Transparency Requirements - Overview • ID Card Requirement • Group health plans with plan years beginning on or after 1/1/2022 • Must include the following information: IN/OON deductibles, OOP maximums, contact information for consumer assistance • Continuity of Care • Group health plans with plan y
Slide 7: Transparency Requirements - Overview
Transparency Requirements - Overview • In-Network Provider Directories » Group health plans with plan years beginning on or after 1/1/2022 » Plans and issuers must establish: 1. a database listing health care providers and facilities that have contracted with the provider network, 2. a process to ve
Slide 8: Transparency Rules
Transparency Rules Publicly Available Machine-Readable Files • One file must include the rates negotiated between the plan and in- network providers for all covered items and services; another file must include data showing the historical payments to, and billed charges from out-of-network providers
Slide 9: Surprise Medical Billing
Surprise Medical Billing
Slide 10: Surprise Medical Billing Rules
Surprise Medical Billing Rules • Effective for plan years beginning on or after January 1, 2022 • Rules generally apply to all group medical plans (also apply to health care providers) • In-network cost-sharing limitations for specific claims » Rules apply to three types of claims: o Out-of-network
Slide 11: Surprise Medical Billing Rules
Surprise Medical Billing Rules NOTICE REQUIREMENTS • Post information about rules on a public website of the plan or issuer ▪ If a plan does not have a public website, requirement can be satisfied by entering into a written agreement with a health insurance carrier or a third-party administrator (TP
Slide 12: Independent Dispute Resolution (IDR) Process
Independent Dispute Resolution (IDR) Process Background ▪ 2021 - the regulatory agencies published interim final regulations implementing the IDR process as part of the federal surprise billing rules ▪ Rules govern the amount a group health plan must pay the out-of-network provider/facility when the
Slide 13: Price Comparison Tool
Price Comparison Tool
Slide 14: Price Comparison Tool
Price Comparison Tool • Allows participants to compare the amount of cost-sharing that the individual would be responsible for paying under the plan when receiving a specific item or service by a particular provider • Self-service tool available on internet website (and by telephone per CAA) » Real-
Slide 15: Price Comparison Tool
Price Comparison Tool • Effective for plan years 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 • Effective for pl
Slide 16: 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 17: RxDC Reporting
RxDC Reporting
Slide 18: General Overview of RxDC Requirements
General Overview of RxDC Requirements • Added to ERISA, Internal Revenue Code and PHSA by CAA of 2021 • Generally due by June 1st of the year following the applicable reporting year (i.e., immediately preceding calendar year) • Applies to both grandfathered and non-grandfathered fully insured and se
Slide 19: Who is handling the reporting?
Who is handling the reporting? • Using a third party (e.g., insurance carrier, TPA, • Carrier/TPA/PBM will not have all this information PBM, etc.) (especially premium information) » Regulations allow fully insured group health » Plan sponsor may need to file D1 or provide plans to shift all respons
Slide 20: Multiple Reporting Entities
Multiple Reporting Entities Rules regarding multiple files • Instructions indicate that if there are multiple reporting entities that they should work together to submit only one data file of each type for the same plan, issuer, or carrier ▪ Ex: behavioral health benefit begins data submission with
Slide 21: What Information Must Be Reported
What Five General Categories of Information Information 1 Group Health Plan List – File P2 Must Be Premiums and Life Years (Covered Lives) – File D1 Reported 2 3 Medical Spending by Category – File D2 4 Rx Cost Information – Files D3-D8 5 Narratives Carriers, TPAs and PBMs that file on behalf of gro
Slide 22: 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 23: D1: Life Years and Premiums
D1: Life Years and Premiums Six Data Elements 1. Life Years = Average number of members (employees and dependents) throughout the year 3. Admin fees paid (aggregate for plan) • First, calculate total member months 4. Stop loss premium paid (aggregate for plan) » Count the number of members covered o
Slide 24: Data Files (D2 – D8)
Data Files (D2 – D8) D2 • Medical spending by category: hospital, primary care, specialty care, other medical costs and services, and medical benefit drugs (known amounts and estimated amounts) D3 through D8 • Top 50 Brand Drugs, Top 50 Most Costly Drugs, Top 50 Drugs by Spending Increase, Rx Totals
Slide 25: Updated RxDC Reporting Instructions (1/24)
Updated RxDC Reporting Instructions (1/24) • Key material changes: ▪ Beginning with RxDC reporting for the 2023 calendar year reference year, CMS will begin enforcing the previously-suspended aggregation restriction o Requires the most granular aggregation level that applies to all healthcare spendi
Slide 26: Updated RxDC Reporting Instructions (1/24)
Updated RxDC Reporting Instructions (1/24) Additional updates to RxDC Reporting instructions clarified how reporting entities should: ▪ Populate the benefit carve-out field in the P2 (Plan List) file ▪ Report information in prior years column in D5 file how to represent plans when the plan contribut
Slide 27: Penalties
Penalties • Regulatory agencies have not provided guidance regarding enforcement or potential penalties • RxDC reporting requirement added as Section 9825 of the Internal Revenue Code » Section 9825 is part of Chapter 100 » Section 4980D imposes an excise tax on any failure of a group health plan to
Slide 28: 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 User M
Slide 29: Summary
Summary • Plan sponsors need to determine whether carrier, TPA and/or PBM will be performing reporting on behalf of the plan ▪ If so, enter into a written agreement • Will all data files be covered by third-party reporting? ▪ If so, determine what information needs to be provided to carrier/TPA/PBM
Slide 30: Gag Clause Attestations
Gag Clause Attestations
Slide 31: General Overview of Gag Clause Attestation Requirements
General Overview of Gag Clause Attestation Requirements • Prohibition on gag clauses was effective December 27, 2020 • Applies to fully insured and self-insured group health plans, including plans subject to ERISA, non-Federal governmental plans and church plans » Does not apply to plans providing e
Slide 32: Recent Regulatory Guidance
Recent Regulatory Guidance FAQ About Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 57 • Issued February 23, 2023 • Provides examples of prohibited gag clauses » A provision in a contract between a TPA and group health plan indicating that the plan may not share in
Slide 33: Attestations
Attestations • A group health plan must annually submit to the DOL an attestation that it is complying with these • Third party can submit on behalf of group health plan requirements » Fully Insured – Submission by carrier constitutes • Deadline: A plan must attest each year by December compliance b
Slide 34: HRCI and SHRM Credits
HRCI and SHRM Credits This Program, ID No. 661709,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 35: 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