At the end of 2020, Congress passed the Consolidated Appropriations Act (CAA) which includes a number of key provisions for health plans. Among them is the requirement that health plans offer a web-based price transparency tool that will communicate expected costs of various services provided in a health plan member’s service area. The tool must provide out-of-pocket costs for these services from in-network providers for the most recent plan year. The information in the tool must also be accessible by phone. Health plans are required to offer this service as of January 1, 2022.

The anticipated benefits of these requirements include lower costs for members, fewer surprises in billing – especially from out-of-network providers – and ultimately lower costs to the plans that underwrite these services.

Understandably, this law places a significant administrative burden on health plans. Although many third-party advisors and vendors are typically involved with health plans in the delivery of care, the onus is on health plans to coordinate this effort. For insured plans, the insurance carrier is responsible for meeting the price transparency obligation. For self-funded plans, the onus is on the plan’s third-party administrator.

The legislation also specifies providing patients with explanations of benefits in advance wherever possible, limitations on balance billing (“surprise billing”), and new requirements on member ID cards. The CAA exempts grandfathered plans – plans that existed at the time of the signing of the Affordable Care Act in March 2010 – but still applies to plan offerings developed since then, such as pharmacy and drug cost reporting. It also applies to any plan offerings that have changed substantially enough for them to lose their grandfathered status since 2010.

Blue Health Intelligence® (BHI®) has been working with a number of health plans to comply with the CAA law by Jan. 1, 2022.

Contact BHI to learn how your health plan can ensure compliance.