Consolidated Appropriations Act (CAA): Pharmacy Data Reporting Update
Under the CAA, group health plans (fully-insured and self-funded) and health insurance issuers offering group or individual health insurance coverage must report plan-specific prescription drug spending and medical cost data annually to the Departments of Health and Human Services (HHS), Labor, and the Treasury. The first report (for 2020 and 2021 data) is required by Dec. 27, 2022, and then by June 1 thereafter of the calendar year immediately following the “reference year”, which is the calendar year of the data contained within the prescription drug data collection (RxDC) report.
For the initial filing, Blue Cross is offering to report this data, on behalf of its fully-insured and self-funded accounts, for benefits which it administers. For those accounts that Blue Cross does not administer prescription drug coverage, we will provide support for some of the required reports, but the account is responsible for working with their pharmacy benefit manager (PBM) to ensure all other necessary reports are submitted.
For more information about what accounts need to do, please visit RX Data Reporting section of our CAA/TCR Overview.
Regulatory Update: Medical Loss Ratio Rebates
We’ll be distributing Medical Loss Ratio (MLR) rebates to impacted small group account holders this year. Please review the MLR letter(s) that you’ll receive by mail for more details about how this applies to you and your employees. We’re also notifying impacted employee subscribers by mail, postmarked between September 15 - 30, 2022.
Rebates will be issued no later than September 30, 2022.
If you have any questions, please contact your account executive.
The Transparency in Coverage Rule (TCR) and Machine-Readable Files
Under the Transparency in Coverage Rule, issued in November 2020, health plans are required to disclose in-network provider negotiated rates and historical out-of-network allowed amounts through machine-readable files (MRFs) on a publicly available website by July 1, 2022. This provision affects health insurance issuers in the individual and group markets as well as fully insured group health plans and self-funded accounts.
We’re currently working to become compliant as of July 1, 2022. At that time, members will be able to access this information at
Complete details about implementation of this MRF provision, other provisions of the Transparency in Coverage Rule and the Consolidated Appropriations Act (CAA) are available here.
If you have any questions, contact your account executive.
Important Employer Surveys: Medical Loss Ratios and Employer Group Size
In July, fully insured Blue Cross Blue Shield of Massachusetts accounts will receive one or both of the following surveys in the mail:
- The Patient Protection and Affordable Care Act (PPACA) survey, which allows us to calculate medical loss ratios (MLR) accurately for the small- and large-employer group segments. If MLR standards aren't met, we'll issue premium rebates to the applicable employers.
- The federal Medicare Secondary Payer (MSP) survey, which allows us to annually track an account's total number of employees. This will help us determine whether Medicare or an employer group health plan pays for an employee's health claims first, based on MSP laws.
It's important that you respond as soon as possible. These surveys help determine the size of each of our accounts, so we can calculate our medical loss ratio, establish which accounts are eligible to receive a rebate in 2023, and ensure that your employees' claims are processed properly.
Which Survey(s) You’ll Receive
|Fully insured accounts||The PPACA survey
The MSP survey
|Accounts that canceled coverage with Blue Cross in 2021||The PPACA survey|
If you have any questions, please contact your account executive. For more information about these surveys, medical loss ratios, or MSP rules, please see:
Members to Receive Updated ID Cards With New Cost Information
Being transparent to our members about health care costs is of the utmost importance to us. That’s why we’re now including deductible and maximum out-of-pocket cost information on all member ID cards. Updated cards will be issued beginning in May 2022. Members whose plans have a renewal date between January 1 and May 31, 2022, will be issued new cards by the end of June. Members, whose plans are renewing with changes from June 1, 2022 onwards, will receive updated ID cards prior to their anniversary date. Members, whose plans are renewing with no changes from June 1, 2022 onwards, will receive updated ID cards in the month following their anniversary date.
Along with the card, members will be sent an insert informing them of the new change. You can see the insert here. Members who want to learn more about their health care costs can sign in to their MyBlue account at bluecrossma.org, or open the MyBlue app.
These changes also ensure that we’re supporting compliance with the Consolidated Appropriations Act (CAA). Learn more here about our response to the CAA as well as the Transparency in Coverage Rule (TCR) and Machine Readable Files.
If you have any questions, contact your account executive.
Transparency in Coverage Rule and the Consolidated Appropriations Act Update
Blue Cross Blue Shield of Massachusetts continues to actively plan our support of and compliance with the required capabilities for applicable provisions in both the Transparency in Coverage Rule and the Consolidated Appropriations Act. We've made significant operational progress and we're implementing a good-faith response as we strive towards meeting compliance standards. We'll adjust our approach as we receive further clarification and/or changes to the regulations from the federal government.
We have updated our overview and FAQs document which outlines how we will ensure compliance with new requirements.
Introducing the No Surprises Act of the Consolidated Appropriations Act
Beginning January 1, 2022, members of fully insured and self-insured accounts may see billing changes due to the federal No Surprises Act.
About the No Surprises Act
The No Surprises Act, which was enacted as part of the Consolidated Appropriations Act (“CAA”) in late 2020, provides new federal consumer protections against balance billing for certain medical bills under certain circumstances. For example, claims subject to the Act may occur in emergency situations when a member can’t control who is involved in their care, in non-emergency situations when a member schedules a visit at an in-network facility but is unexpectedly treated by an out-of-network provider, or when out-of-network air ambulance services are provided for services that would have been covered if the air ambulance provider was in-network.*
Member Cost Share
For medical bills subject to the No Surprises Act outside of Massachusetts, member cost share must be calculated based on the applicable Recognized Amount, which the Act defines as:
- an amount determined by an applicable All-Payer Model Agreement, or
- if there’s no applicable All-Payer Model Agreement, an amount determined by a specified state law, or
- if there’s no applicable All-Payer Model Agreement or specified state law, the lesser of the amount billed by the provider or facility, and the Qualifying Payment Amount (QPA), which is generally the median contracted rate for the item or service in the geographic region.
Member cost share for Massachusetts medical bills covered under the No Surprises Act will be based on whichever of the following amounts is lower:
- the amount billed by the provider or facility
- the Blue Cross Blue Shield of Massachusetts QPA
Payment to Non-Participating Providers
All claims subject to the No Surprises Act must be paid to the provider, not the member. Pending Division of Insurance (DOI) approval for fully insured accounts, we’re changing the payment methodology used to pay non-participating providers for all bills subject to the Act. This includes ERAP (emergency, radiology, anesthesiology, pathology) claims, which we’ve been paying at charge to prevent members from being balance billed.
For Massachusetts claims covered by the Act, we’ll pay providers the lesser of charges or QPA. For out-of-state claims, we’ll pay providers the applicable Recognized Amount.
Negotiation and Independent Dispute Resolution (IDR)
The federal law also includes provisions allowing providers to request negotiation of the payor’s payment for bills subject to the No Surprises Act, and if negotiation fails, either party can initiate an Independent Dispute Resolution (IDR) process, also known as arbitration, to determine the allowed payment amount. Both parties submit their best offer, and one offer is approved. The decision of the IDR entity is binding. Members will not be involved at any point in the negotiation and IDR processes. Those processes take place between the provider, the payor, and the IDR entity.
As a result of the negotiation and IDR processes, the rate of payment to the provider could be adjusted post-payment. Regardless of any change to the provider’s payment amount, member cost share, which constitutes the member’s maximum liability, is the same as described above.
Notice and Consent
There are limited circumstances set forth in the law that allow providers to balance bill members for certain types of services covered by the No Surprises Act. Providers must provide proper notice to the member of the provider’s non-participating status at least 72 hours in advance of service delivery, and the member must provide written consent to be balance billed. The notice and consent provisions do not apply to all medical services included in the statute or to all provider types. The member is not required to provide written consent.
We’ll post disclosures that outline our members’ rights and protections under the No Surprises Act at bluecrossma.org/disclaimer/member-rights in late December. The Explanation of Benefits (EOB) we send to members when we pay bills covered by the law will also direct members to this information.
As the regulations supporting the No Surprises Act continue to evolve, we’ll update you on any related changes.
If you have any questions, please contact your account executive.
*Ground ambulance claims aren’t included under the No Surprises Act.
Transparency in Coverage Rule (TCR) and the Consolidated Appropriations Act (CAA)
On Aug. 20, 2021, the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury jointly released guidance in the form of Frequently Asked Questions (FAQs) to clarify the requirements and timelines for implementation of certain provisions within the Transparency in Coverage (TCR) and Consolidated Appropriations Act (CAA).
In general, the FAQ delays enforcement of certain provisions of the TCR and CAA and takes a good faith compliance approach to other provisions. This is a positive update by the federal government as it will allow health plans and issuers more flexibility in implementing key aspects of the requirements. BCBSMA is currently reviewing the updates provided in the FAQs and will update our customers as to whether there will be any changes to previously announced approaches and paths to compliance. We are working to update our external FAQ document which is available on our account and broker portals and will include updates to our approach in the next edition in the next few weeks.
There are several critical updates we would highlight that are included in the updated FAQ including:
Enforcement of machine-readable files (Transparency in Coverage Final Rule)
Prescription drug file
The Departments will defer enforcement of the requirement within TCR Final Rules that plans/issuers must include the negotiated rates and historical net prices for covered prescription drugs in their public machine-readable files (MRFs) while it considers, through future notice/comment rulemaking, whether the prescription drug MRF requirement remains appropriate.
- The Departments have acknowledged that the subsequent CAA requirements, particular to prescription drug reporting, significantly changed the regulatory landscape since the TCR Final Rules were adopted. The Departments recognized concern about potentially duplicative and overlapping reporting requirements for prescription drugs.
In-network rate and out-of-network allowed amount files
The Departments will defer enforcement of the TCR Final Rules’ requirement to publish in-network (IN) negotiated provider rates and the historical allowed amount payments to out-of-network (OON) providers until July 1, 2022. Given this updated guidance, BCBSMA will delay publishing the in-network and out-of-network files until July 1, 2022.
Following this six (6) month delay, the Departments intend to begin enforcement on July 1, 2022, for anniversary dates (in the individual market, policy years) on or after January 1, 2022.
For 2022 plan years and policy years beginning after July 1, 2022, plans and issuers should post the MRFs in the month in which the plan year (in the individual market, policy year) begins, consistent with the TCR Final Rules.
Price comparison tools
The regulations on price comparison tools outlined in the CAA have been determined to be duplicative of those that are outlined under the Transparency in Coverage final rule. Therefore, the consumer tool requirements will begin in alignment with existing TCR language for price comparison tools for the HHS-determined 500 items/services, on and after January 1, 2023.
- BCBSMA will continue its work to expand cost estimation to our Indemnity members and certain accounts which do not currently have access to our Estimate Costs tool and will add an additional 106 treatment categories effective January 1, 2022.
- Potential alignment is complicated given CAA’s added requirement that price information must be also be provided over the telephone upon request (not included in TCR).
- Therefore, the Departments intend to propose new rulemaking requiring within the TCR that the same pricing information that is available through the online tool or in paper form be also provided over the telephone upon request.
The Departments announced that plans and issuers should not expect further regulations pertaining to member ID cards prior to the 1/1/22 effective date. As such, the guidance requires good faith compliance beginning 1/1/22.
- Plans and Issuers will be considered to be in compliance with ID card requirements when the following information is provided on any physical or electronic ID card:
- The applicable major medical deductible and applicable out-of-pocket maximum, as well as a telephone number and website address for individuals to seek consumer assistance and access additional information pertaining to applicable deductibles and maximum out-of-pocket limits.
Good faith estimates
Given concerns around complexities of developing the technical infrastructure for transmission of the necessary data from providers and facilities to plans and issuers, the Departments now acknowledge that compliance around good faith estimates related to individuals who are enrolled in a health plan or coverage and are seeking to have a claim for the scheduled items or services submitted to the plan or coverage is likely not possible by January 1, 2022.
Therefore, the Departments will defer enforcement of this requirement until rulemaking to fully implement this requirement is adopted and applicable.
Given concerns from stakeholders regarding the ability to build good faith estimates as noted above, the Departments now acknowledge that AEOB compliance is likely not possible by 1/1/22.
- The Departments intend to develop a new notice and rulemaking process to implement this provision; until that time, Departments will defer enforcement of AEOBs.
- BCBSMA is reassessing our approach and next steps and will continue to keep our accounts and brokers updated on how we plan to move forward.
The Departments will not be issuing regulations addressing the prohibition of gag clauses, as they have noted that this section is self-implementing.
- Pending future guidance on how to submit attestations of compliance, plans and issuers are expected to implement the requirements prohibiting gag clauses using a good faith compliance approach.
Until further rulemaking is issued (after January 1, 2022), plans and issuers are expected to implement provider directory provisions using a good faith compliance approach.
- Pending any future implementing rulemaking, the Departments clarify that good faith compliance requires plans and issuers to impose in-network cost-sharing where a participant receives items or services from a nonparticipating provider and the participant was provided inaccurate information by the plan or issuer through a provider directory or other response protocol.
Continuity of care
Until rulemaking to fully implement these provisions is adopted and applicable, plans, issuers, providers, and facilities are expected to implement the requirements using a good faith compliance approach.
- The Departments note that any rulemaking to implement continuity of care provisions will include a prospective applicability date that provides plans, issuers, providers, and facilities with a “reasonable” amount of time to comply with any new requirements.
Reporting on Rx benefits and drug costs
The Departments now acknowledge the significant operational challenges that plans and issuers may encounter in complying with these reporting requirements by the statutory deadlines. The Departments anticipate that plans and issuers may also need additional time to modify contractual agreements to enable disclosure and transfer of the required data between various entities; to develop internal processes and procedures; and to identify, compile, prepare, and validate the required data.
- The Departments will defer enforcement of the requirement to report the specified information by the first deadline for reporting on December 27, 2021 and the second deadline for reporting on June 1, 2022, pending the issuance of regulations or further guidance.
- Until regulations or further guidance is issued, the Departments “strongly encourage” plans and issuers to start working to ensure that they are in a position to be able to begin reporting the required information with respect to 2020 and 2021 data by December 27, 2022.