No Surprises Act / Transparency in Coverage Final Rule – 2023 Updates
Wellfleet continues to implement processes to conform to requirements articulated in the No Surprises Act (“NSA”) (passed in the Consolidated Appropriations Act of 2021) and Transparency in Coverage Final Rule (“TICFR”) published on November 12, 2020, by the Departments of Labor (DOL), Health and Human Services (HHS) and Treasury (collectively referred to as “Departments”). While the NSA and TICFR are applicable to all fully-insured ACA-compliant health plans, they are NOT applicable to self-funded student health plans. Even though the NSA does not apply to self-funded student plans, certain state surprise billing laws may apply to self-funded plans (for example, New Hampshire regulations RSA 420-O:3, III(c), RSA 329:31-b, RSA 420-J:1-3, and RSA 420-J:8).
Throughout 2022, Wellfleet performed a rolling implementation of the following NSA rules. These changes were implemented in alignment with plan effective dates in 2022, meeting the federal requirements for these rules:
- Balance Billing Disclosures – Health plans are required to make publicly available, post on a public website, and provide to individuals a notice regarding balance billing protections under the NSA. Wellfleet will make the model notice available through plan websites and member EOBs.
- Cost Sharing – When members receive Emergency Services, or certain non-emergency Treatment by an Out-of-Network Provider at an In-Network Facility, the cost sharing responsibility will be calculated based on the total amount that would have been charged for the services by an In-Network Provider or Facility. This is known as the Recognized Amount. Cost share for these claims will also count towards the member’s in-network deductible and in-network out-of-pocket maximum.
- Emergency Services – The NSA modifies the definition of emergency medical conditions and prohibits insurers/health plans from requiring prior authorization for Emergency Services.
- Identification Cards – Identification cards must include plan deductibles and out-of-pocket maximums for In-Network and Out-of-Network Services. Wellfleet will update ID card templates for all groups to include this information.
- Qualified Payment Amount (QPA) and Independent Dispute Resolution (IDR) – The No Surprises Act designates that health plans must apply a QPA to reimburse providers for Out-of-Network services covered under the Act. QPA means the median Negotiated Charge for (a) the same or similar services; (b) furnished in the same or similar facility; (c) by a provider of the same or similar specialty; (d) in the same or similar geographic area. The legislation outlines an independent dispute resolution (IDR) process to resolve reimbursement disputes between payors and providers. Wellfleet has developed processes to ensure that QPA amounts are used for provider reimbursement and member cost share calculation.
July 2022 TICFR Requirement- Machine-Readable Files:
- Machine-Readable Files (MRFs) – Beginning 7/1/22, Wellfleet made Machine-Readable Files publicly available through our website. Health Plans and Issuers are required to share this information with the public, including MRFs containing provider network negotiated (in-network) rates, and MRFs containing out-of-network claim data. These files are posted in JSON format to adhere to government specifications, meaning the files are not generally directly usable by members. The JSON-formatted files do however make data available for researchers or application developers. A “table of contents” file is also available for users to leverage in conformity with CMS standards and schema published on the Github Price Transparency Guide. The Wellfleet URL to access our table of contents files, allowed amounts file, or individual network MRFs, is:
If a researcher is interested in negotiated rates for the PPO network that their school or employer is covered by, they will want to download the individual in-network MRF for that network. Researchers reviewing out-of-network claim data should use the allowed amount MRF, which contains out-of-network claim data being reported via our (multiple plan) allowed amounts MRF file.
December 2022/January 2023 NSA/TICFR Requirements:
- NSA requirement: Pharmacy Benefits and Drug Costs Reporting – The first annual RxDC (Pharmacy Data Collection) reporting was required to be delivered to CMS (HIOS) by 12/27/22. This included a wide variety of pharmacy data for reference years 2020 and 2021. Wellfleet completed timely upload of the file(s) in HIOS for both our fully-insured business and on behalf of employer groups that we were TPA for during the 2020-2021 reference years.
- TICFR requirement: Online Self-Service Tool for Personalized Cost-Sharing Information (500 services) – a minimum of 500 services must be available in an online tool allowing members to compare pricing of the 500 services by provider in their geographic area. Wellfleet has partnered with Zelis, Inc. to meet this requirement with the Sapphire S365 cost comparison tool. This tool is available to members of our fully-insured student health plans upon plan effective date (beginning on or after 1/1/23).
Additional No Surprises Act Requirements to be implemented in 2023:
- Air Ambulance Reporting– The final rule for this deliverable has not been published by the government, and many requirements remain unknown. For example, where to upload the report and the final file layout all remain unknown.
- Broker Commission Reporting– The final rule for this deliverable has not been published by the government, and many requirements remain unknown. For example, where to upload the report and the final file layout all remain unknown.
- Remaining services incorporated into the Online Self-Service Tool for Personalized Cost-Sharing Information (beyond the initial 500 services) (1/1/24)
Consistent with the Berkshire Code of Business Conduct and Ethics, Wellfleet is committed to complying with all federal and state surprise billing laws, for both its fully-insured and self-funded lines of business.