By David Zanze, Executive Vice President of Western Growers Assurance Trust
On December 27, 2020, the Consolidated Appropriations Act (CAA) was signed into law. The CAA represents the most significant changes to the private insurance market since the Affordable Care Act and includes extensive transparency reform, which protects patients against unexpected or “surprise” medical bills.
What do these changes mean for health plan participants?
According to a recent report from the Office of the Assistant Secretary for Planning and Evaluation (ASPE), nearly one in five patients who go to the emergency room, have an elective surgery, or give birth in a hospital receive surprise bills, with average costs ranging from $750 to $2,600.
The legislation aims to give patients transparency and financial peace of mind when seeking care. Here are some changes health plan participants can expect:
• Out-of-Network Care: Patients may not be billed more than the network cost-sharing amount for services received from a non-participating facility or non-participating emergency room unless the patient receives notice of a provider’s non-network status in advance and consents to the non-network treatment and cost.
• Pre-Authorization Not Required: Plans may not require pre-authorization for emergency services.
• Patient Deductible: Out-of-network surprise bills will be applied to the patient’s network deductible.
• Continuity of Care: If a provider changes network status (i.e., leaves the plan’s network), patients with certain needs may continue care with the provider for up to 90 days at network cost sharing rates to allow for a transition of care to a network provider.
• Inaccurate Network Directories: If a patient provides documentation that he or she was provided inaccurate information from a plan or insurer about a provider’s network status prior to treatment, the patient will only be responsible for the in-network cost-sharing amount.
• ID Cards: The CAA requires health plans to provide information on ID cards regarding the amount of the in-network and out-of-network deductibles, the in-network and out-of-network out-of-pocket maximum limitations, and a telephone number and Internet website address through which individuals may seek consumer assistance information.
New transparency rules also try to provide health plan participants with enough information to help lower the risk of receiving surprise medical bills. Plans are required to provide participants an Advanced Explanation of Benefits (AEB) once a participant receives a “good faith” cost estimate for an item or service from a health care provider/facility. The AEB must show, among other things:
• the amount the plan must pay, and any cost sharing the participant must pay
• whether the coverage for the item or service is subject to medical management techniques
• and if out-of-network, information on how the participant can learn more about in-network providers/facilities offering the same item or service
There may be instances when a member relies on inaccurate network directory information prior to treatment and receives services from a provider who is no longer a member of the network. In these instances, the plan is required to pay the claims at the in-network rate.
The No Surprises Act also prohibits plan sponsors from entering an agreement with a provider, provider network, third-party administrator or other service providers that could restrict the plan from furnishing provider-specific cost or quality of care information.
We’ve created some Frequently Asked Questions regarding these new changes and what they mean for patients and health plans: www.wgat.com/news/faqs-transparency/
WGAT will continue to keep its members updated on any significant changes that will affect your WGAT health plans so you can keep your valued workers healthy and productive. If you don’t have a WGAT plan, you can contact Western Growers Insurance Services for more information and see how it can help you better manage your health care costs. You can reach a sales team member at (800) 333-4WGA.
In addition to serving as executive vice president of Western Growers Assurance Trust, David Zanze is the president of Pinnacle Claims Management, Inc.