At Homestead, we’ve been closely following developments regarding the federal No Surprises Act (NSA) and Transparency in Coverage (TiC) rulings, particularly as they relate to self-funded health plans and the impact on our clients and members. Below, we have gathered all the necessary information that could impact self-funded health plans, as well as what actions we’re taking to remain compliant – and help our clients remain compliant – with these regulatory updates, including:

• What is the No Surprises Act and Transparency in Coverage Rule?
• What do these rulings do, as they relate to self-funded health plans?
• What is Homestead doing?

What is No Surprises Act (NSA) and Transparency in Coverage Rule (TiC)?

The No Surprises Act (NSA) was signed into law by Congress and took effect on January 1, 2022, to establish federal protections from surprise medical costs after receiving care from an out-of-network provider or facility.  The NSA and TiC require multiple initiatives intended to increase transparency around the cost of healthcare so that members can make informed decisions and be protected from unexpected costs. Various portions of these rules will be implemented nationally over the next 1-2 years.

What do these rulings do, as they relate to self-funded health plans?

• Ensure ID cards reflect in-network and out-of-network deductibles and out-of-pocket limits
• Establish Qualified Payable Amounts (QPA) for emergency and air ambulance claims
  • The QPA is based on a median in-network rate so a patient doesn’t face high out-of-network charges when they receive emergency treatment
  • The QPA is used to determine member responsibility (i.e., coinsurance, co-pays)
• Create an Independent Dispute Resolution (IDR) Process that includes the QPA as a factor in resolving the dispute
  • Providers may negotiate their emergency and air ambulance claim payments utilizing the IDR process
  • Regardless of what the provider is paid, the member responsibility does not change
• Improve Provider Directories
  • Provider directories will be updated regularly to ensure accuracy
  • Directories will be standardized to provide uniform contact information
• Ensure Continuous Care benefits when network status changes
  • For members receiving chronic care, benefits are protected for up to 90 days when a provider’s network status changes
• Require Machine Readable Files (MRFs) for network contracts and historical paid allowed amounts*
  • Contract details for providers and facilities for each plan will be provided in an “In-Network MRF” to provide transparency on the potential cost for covered services
  • Historical data for each plan will be provided in an “Allowed Amounts MRF” to provide historical costs for services not otherwise covered by a contract
    • Data will only be provided if the plan has at least 20 claims for that service to maintain member privacy
  • These files must be publicly accessible by health plans to ensure complete transparency, and must be published July 1, 2022.
• Lead to the development of online “shopping” tools for healthcare services
  • Shows an estimate of the cost of healthcare services for providers
  • Reflects members’ estimated out-of-pocket responsibility with consideration to accumulators and limits.

*Please note: these files are in a fixed format established by the federal government to gather data for planned consumer-focused tools. These files are not considered user friendly, but will be eventually used as part of the online “shopping” tools mentioned above.

What is Homestead doing?

• Phase 1:
  • As groups renew, we have been updating member ID cards to reflect the new requirements
  • We have expanded our balance billing defense support to include the IDR process/open negotiations for emergency and air ambulance claims (please note that this is only a small percentage of group claims)
  • We are tweaking our current provider directory to fully meet the federal requirements
  • We are creating Machine Readable Files access on behalf of our clients. This has included working with multiple networks as applicable.
• Phase 2:
  • We are developing a shopping tool that will work with our enhanced provider directory and the machine readable files to provide estimates of anticipated healthcare costs by January 1, 2023.