Module 5: Participant Response To Health Plan Pricing Flashcards
What protections are established for consumers of medical services from no surprises act?
Protects people under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out of network providers at in work facilities, and services from out of network air ambulance service providers.
What are the protections for non-insured individuals or those who elect self pay have under no surprise act?
The act ensures they receive a good faith estimate of how much the care will cost before the care is provided.
What is risk premium?
The max amount that individuals are willing to pay to avoid consequences of an uncertain loss.
What is a loading fee?
The actual amount that is paid over the expected loss. Includes admin cost, reserves, and profits.
What kind of information does the transparency in coverage requires non grandfathered group health plans and health insurance issuers offering non grandfathered coverage in group and individual markets?
Disclose in public website:
- in network provider rates for covered items and services
- out of network allowed amounts and billed charges for covered items and services
- negotiated rates
- historical net prices for covered prescription drugs in 3 separate machine readable files
What are the transparency in coverage final rules as they relate to price comparison tools?
TIC final rules require plans and issuers to make price comparison info available to participants, beneficiaries and enrollees through an internet-based self service tool and in paper form, upon request.
- 500 items and services identified by departments on or after 1/1/23
- all covered items and services for a plan or policy on or after 1/1/24.
What are the additional requirements for price comparison functionality that the CAA (consolidated appropriation act) imposed in addition to price comparison tools identified in TiC final rules?
CAA required all plans and issuers to offer price comparison guidance by phone and make available on the plans or issuers website, a price comparison tool that allows members to compare the amount of cost sharing under their plan. This was required on or after 1/1/ 2022.
What did the CAA mandate any modifications to insurance ID cards?
CAA requires plans and issuers of ID cards to include in clear writing on any physical and electronic IDs:
- applicable deductibles
- applicable out of pocket maximums
- phone number and website for members to seek consumer assistance
- effective on or after 1/1/2022
Under CAA, who receives the good faith estimate from health providers regarding the expected cost of services?
CAA required providers and facilities upon an individual scheduling or items or services or upon request:
- to inquire if individual is enrolled in a health plan
- provide notification of the good faith estimate of expected charges, including those provided by another facility
- expected billing and diagnostic codes for items and services
- if individual is enrolled in a plan, notice provided to their plan
- if individual is not enrolled in a plan, provider must provide to individual
Per CAA, what are the requirements on plan sponsors to provide an advance explanation of benefits?
CAA requires plans and issuers, upon receiving a good faith estimate to send a participant, beneficiary, or enrolled (via mail or electronic means) and advanced explanation of benefits notification in clear and understandable language. This includes:
- network status of the provider or facility
- contracted rate for item or service
- if provider or facility is OON, a description of how the member can obtain info on participating providers and facilities
- the good faith estimate received from the provider
- a good faith estimate of the amount the plan or coverage is responsible for paying
- the amount of any cost sharing the member would be responsible for
- disclaimers indicating whether coverage is subject to any medical management techniques
- provision applied on or after 1/1/2022
Summarize the CAA’s prohibition on gag clauses as they relate to plan sponsors
CAA prohibits plans and issuers from entering into an agreement with a provider, network or association of providers, 3rd party admin or other service provider offering access to a network of providers that would directly or indirectly restrict the plan or issuer from:
- providing provider specific cost or quality of care info or data to referring providers or members
- electronically accessing de-identified claims and encounter data for each member
- sharing info consistent with applicable privacy regulations
In addition, plans and issuers must annually submit to the departments an attestation of compliance with these requirements. Effective on or after 12/27/2020.
What are the legal standards imposed on plan sponsors to improve accuracy or provider directory info?
If a member receives inaccurate info of a participating provider, then the plan is not allowed to charge more than the in network cost sharing amounts, and that amount must count towards any in network deductibles and out of pocket max.
This is effective on or after 1/1/2022.
What is meant by continuity of care and when does it apply to a health plan participant?
ERISA, as amended by the CAA, established continuity of care protections for group and ind plans members.
These protections ensure continuity of care in instances when terminations of certain contractual relationships result in changes in provider or facility network status.
These were applicable on or after 1/1/2022.
Does the CAA include an exception to grandfathered plans?
No, the ACA clarified that the new and re-codified patient protection provisions of the CAA, including related to choice of health care professional, apply to grandfathered health plans.
