Agencies Publish Interim Final Regulations Regarding Surprise Billing Arbitration
October 12, 2021
On September 30, 2021, HHS, the DOL and the Treasury Department released Part II of interim final rules implementing the No Surprise Billing Act (the Act) that was part of the Consolidated Appropriations Act, 2021 passed by Congress in late 2020. This set of interim rules focus on the independent dispute resolution process (IDR) between the payer and provider outlined in the Act, good faith cost estimates for the uninsured, the dispute resolution process for patients and providers, and rights to external review. Part I of these rules was published in July and is discussed in our July 7, 2021, article in Compliance Corner.
An interim final rule is a rule that an agency promulgates when it finds that it has good cause to issue a final rule without first issuing a proposed rule. Although interim rules are often effective as of the date of their publication, they will have a comment period after which the interim rule may be amended in response to public comments. In this case, the interim final rules are effective 60 days from the date they are published in the Federal Register. The 60 days serve as the comment period for the interim final rules.
The rules describing the IDR process are effective beginning January 1, 2022. They apply to out-of-network providers, facilities, providers of air ambulance services, plans, and issuers in the group and individual markets who need to determine the out-of-network rate for those items and services for which balance billing was prohibited under Part I of the rules.
Under these rules, payers and out-of-network providers have 30 days to negotiate privately to resolve a payment dispute. This “open negotiation” period starts when a provider notifies the payer in writing of its desire to initiate proceedings within 30 days of initial payment or denial from the payer. If the parties fail to settle the matter in that time, then either party can begin the IDR process within four days after the initial 30-day window closes. The parties then may jointly select a certified independent dispute resolution entity (which must certify that it has no conflict of interest with either party) to resolve the dispute (the “arbiter”). Note that if the parties cannot agree to an arbiter, then federal officials will select one.
Once the arbiter is selected, the parties will submit their offers for payment along with supporting documentation. The arbiter works from the presumption that the qualified payment amount (QPA) is the appropriate out-of-network amount for the item or service. The QPA is the insurance plan's median contracted rate for the same or similar service in an area, so the offer of payment closest to the QPA will usually be awarded. However, the arbiter must consider any credible documentation submitted to it by a party, and if it clearly demonstrates that the value of the item or service is materially different from the QPA, then the arbiter can deviate from the offer closest to the presumptive amount. The arbiter has 30 days to issue a binding written determination selecting one of the parties’ offers as the out-of-network payment amount. It should be noted that while both parties pay an administrative fee at the beginning of the IDR, the winning party gets this fee refunded.
The rules also provide a process to follow to become a certified independent dispute resolution entity. Applications must be submitted by November 1, 2021, if an entity wishes to be certified by January 1, 2022. More information about the process can be found here.
Good Faith Estimates for the Uninsured
The rules also require providers and facilities to provide a good faith estimate of the expected charges for items and services to an uninsured individual (or individuals that choose to pay for the item or service themselves). The good faith estimate must include expected charges for the items or services that are reasonably expected to be provided together with the primary item or service, including items or services that may be provided by other providers and facilities.
Since it will take time for providers and facilities to develop procedures for determining good faith estimates and providing them to the uninsured, HHS will exercise its enforcement discretion in situations where a good faith estimate provided to an uninsured (or self-pay) individual does not include expected charges from other providers and facilities that are involved in the individual’s care, for good faith estimates provided to uninsured (or self-pay) individuals from January 1, 2022, through December 31, 2022.
Dispute Resolution Process for Patients and Providers
When an uninsured individual receives a good faith estimate, but the ultimate bill is a substantially higher amount (which is defined in Part I of these rules, but generally is an amount at least $400 more than the good faith estimate), then Part II provides a dispute resolution process by which the uninsured individual can challenge the billing.
Part II expands on rules previously issued by the Departments regarding external review of claims and appeals. The original rules require plans to provide an external review process that claimants can follow when they receive final internal adverse benefit determinations. The new rules allow claimants to follow this process when they receive determinations that involve whether a plan or issuer is complying with the surprise billing and cost-sharing protections under the Act and its implementing regulations as well. The new rules also extend this requirement to grandfathered plans, but only to the extent that a claimant receives a determination related to the Act.
Employers should be aware of these new regulations, as they would have an impact on how self-insured plans are administered as well as how carriers interact with providers in fully insured plans.
Requirements Related to Surprise Billing; Part II »
Proposed Rules Issued on Air Ambulance Services Reporting under the CAA
September 28, 2021
On September 16, 2021, the Departments of Labor, Health and Human Services, and the Treasury (collectively, “agencies”) jointly published proposed rules regarding the implementation of provisions of the Consolidated Appropriations Act, 2021 (CAA), including the No Surprises Act. Among other items, the regulations address required reporting of air ambulance services by group health plans (including grandfathered plans), insurers and providers.
The No Surprises Act prohibits surprise billing of participants for certain out-of-network healthcare services, including air ambulance services, provided under particular circumstances. To increase price transparency, the No Surprises Act also requires group health plans, insurers and air ambulance providers to submit certain information to the agencies, including claims data about air ambulance services. The purpose of the data collection is to provide the regulators with a more complete understanding of air ambulance services provided across the industry. HHS is then required to issue a comprehensive public report summarizing the data and providing an assessment of certain aspects and characteristics of the air ambulance market.
Under the proposed rules, plans and insurers would be required to provide the following information regarding air ambulance claims: whether the services were provided on an emergency basis; whether the service provider is part of a hospital-owned or sponsored program, municipality-sponsored program, hospital independent partnership (hybrid) program, independent program, or tribally operated program in Alaska; whether the transport originated in a rural or urban area; the type of aircraft used for the transport (fixed-wing or rotary-wing air ambulance); and whether the provider of the air ambulance service has a contract with the plan or issuer to provide air ambulance services. Additionally, the plans and insurers would need to submit certain claims-level data, including: the date of service, billing and procedural codes, information about each air transport (such as loaded miles and whether the transport was inter-facility), and claims adjudication and payment information. HHS intends to match this claims-level data with information submitted by the air ambulance providers to complete the analysis necessary to fulfill the public reporting requirement.
The information would be submitted to HHS for a period of two calendar years, beginning with 2022. The 2022 calendar year data would be due by March 31, 2023, and the 2023 calendar year data would be due by March 30, 2024.
To streamline the process and avoid unnecessary duplication of reporting, an insured plan could enter a written agreement with the insurer, under which the insurer could assume responsibility for providing the necessary data on the plan’s behalf. In such case, if the insurer fails to timely report, the insurer (and not the plan) would be in violation of the requirements. Although a self-insured plan could contract with a third-party administrator for assistance, the ultimate reporting obligation remains with the plan.
The proposed rules also provide guidance for insurers regarding broker compensation disclosures for individual health insurance or short-term, limited-duration insurance. (The guidance does not address compensation disclosures in the group health plan context.) To satisfy the transparency provisions of the CAA, insurers are required to make disclosures to enrollees and submit reports to HHS regarding direct and indirect compensation provided by an insurer to a broker associated with enrolling the individuals in such coverage. The proposed rules define direct and indirect compensation, explain that the required disclosures would include the commission schedule and structure for any compensation not captured by this schedule, and discuss the timing of the disclosures (e.g., upon enrollment, renewal or invoicing). HHS proposes that these new requirements apply to contracts executed between brokers and insurers on or after December 27, 2021.
Furthermore, the rules propose amendments to existing regulations to clarify the complaint investigation process, potential investigations with respect to nonfederal governmental plans, and the imposition of civil monetary penalties against plans and insurers.
Sponsors of group health plans should be aware of the proposed rules and should consult with their insurers or service providers regarding implementation of the air ambulance services reporting requirements. Comments regarding the proposed regulations can be submitted through October 18, 2021.
Requirements Related to Air Ambulance Services, Agent and Broker Disclosures, and Provider Enforcement »
IRS Provides Guidance on Reporting Qualified Sick and Family Leave Wages
September 14, 2021
On September 7, 2021, the IRS issued Notice 2021-53. This notice provides guidance on how to report the amount of qualified sick and family leave wages paid to employees for leave taken in 2021 on Form W-2. This guidance includes considerations for such leave taken in accordance with the FFCRA, as amended by the CARES Act, and the American Rescue Plan Act (ARPA).
The FFCRA required employers with fewer than 500 employees to provide emergency paid sick leave (EPSL) and extended FMLA (EFMLA) for those employees for specific reasons relating to the pandemic. The employers had to front the cost of that leave; however, they were reimbursed for those costs by obtaining a tax credit. The CARES Act extended these leaves to March 31, 2021, but it became voluntary. Similarly, the ARPA extended the voluntary leaves until September 31, 2021, allowed employees to use EPSL for reasons related to the vaccine, and expanded the reasons employees could take EFMLA. More information on the ARPA amendments to these leaves can be found in this article in the March 16, 2021, edition of Compliance Corner.
The notice makes clear that employers must report these wages to employees in one of two ways: either on Form W-2, Box 14, or in a separate statement provided with the Form W-2. The guidance provides employers with model language to use as part of the Instructions for Employee for the Form W-2 or on the separate statement provided with the Form W-2.
Employers that chose to extend EPSL and EFMLA to their employees should be aware of this notice.
IRS Notice 2021-53 »
IRS Publishes the ACA’s Affordability Percentage and Individual’s Premium Tax Credit Table for 2022
September 14, 2021
On August 30, 2021, the IRS published Rev. Proc. 2021-36, which provides the 2022 premium tax credit (PTC) table and the employer contribution percentage requirements applicable for plan years beginning in calendar year 2022.
The ACA's (also known as the "employer mandate") require an employer to provide affordable, minimum value coverage to its full-time employees. The IRS's required contribution percentage is used to determine whether an employer-sponsored health plan offers an individual "affordable" coverage, and the affordability percentage is adjusted for inflation each year. In addition, the ACA also provides a refundable PTC, based on household income, to help individuals and families afford health insurance through affordable insurance exchanges. The IRS provides the PTC percentage table for individuals to calculate their PTC.
For 2022, the ACA's affordability percentage will decrease to 9.61% (down from 9.83% in 2021). For the employer mandate and affordability, this means that an employee's required premium contribution toward single-only coverage under an employer-sponsored group health plan can be no more than 9.61% of the federal poverty line or of an employee's W2 income or rate of pay (depending on which of the three affordability safe harbors the employer is relying upon).
In addition, the existing ACA premium tax credit was expanded in March 2021 by the ARPA for taxable years 2021 and 2022. The adjusted percentage for 2022 is the same as for 2021, and ranges from zero to 8.5%. The 2022 PTC table used to determine an individual's eligibility can be found in the IRS revenue procedure document.
The revenue procedure is effective for plan years beginning on and after December 31, 2021.
Employers should be mindful of the upcoming 2022 affordability percentages and make sure that the premium offerings for 2022 continue to be affordable for full-time employees, so as to avoid any employer shared responsibility penalties. The penalties related to employer shared responsibility remain the law (despite the fact that the ACA's individual mandate was repealed in 2019).
Revenue Procedure 2021-36 »
IRS Releases Two Letters Concerning HSAs and HDHPs
September 14, 2021
On June 25, 2021, the IRS released two information letters responding to the inquiries regarding whether the HSA excessive employer contribution error can be corrected and what amounts are counted toward the minimum annual deductible for an HDHP when a discount, rebate or coupon was provided for healthcare services or products. (Letters 2021-0008 and 2021-0014)
The first letter (2021-0008) addresses situations when an employer made excessive contributions to an employee’s HSA beyond the annual HSA contribution limit, as well as when an HSA custodian failed to provide a corrected Form 5948-SA.
The letter reminds that when an employer contributes more than the annual limit to an employee’s HSA inadvertently, the employer may correct the error. Specifically, at the employer’s option, the employer may ask the custodian to return the excess amount to the employer. If the employer does not recover the excess amount, the employer must include the amount on the employee’s Form W-2 as wages for the year the employer made contributions. Though it was not described in the letter, keep in mind that the excess contributions and net income attributable to such excess contributions need to be returned before the account holder’s federal income tax return filing deadline (including extensions) in order to avoid the 6% excise tax. (Reference: IRS Notice 2008-59, Q&A-24).
The letter also advises that the account holder should contact the custodian to obtain a corrected Form 5948-SA. As a reference, while taxpayers should keep a copy of Form 5498-SA, Form W-2 also shows HSA contributions. It also states that HSAs may be governed by ERISA and that the account holder may contact the DOL for information about applicable fiduciary responsibilities.
The second letter (2021-0014) responds to an inquiry about the benefits that can be provided by an HDHP before the minimum annual deductible is satisfied as well as the interaction of copay accumulator rules with the HDHP requirements. The letter reminds that an individual covered by an HDHP who also has a discount card, rebate or coupon for healthcare services or products, may still contribute to an HSA provided that the individual is required to pay the costs of the covered healthcare until the minimum annual deductible for the HDHP is satisfied. As an example, the letter states that if a manufacturer’s discount (including a rebate or coupon) reduces a drug’s cost from $1,000 to $600, the amount that may be credited toward satisfying the HDHP deductible is $600, not $1,000. (Reference: IRS Notice 2004-50, Q&A-9).
The letter also reiterates that HDHPs may not provide benefits other than for preventive care until the minimum deductible for that year is satisfied. The eligible “preventive” care is determined under Section 223, and state-law mandates do not change the outcome. For example, some states mandate male contraception and sterilization services. However, the letter affirms the previous guidance that state mandated benefits that are not included in Section 223 is not considered preventive for the purpose of an HDHP. (Reference: IRS Notice 2018-12).
Though these information letters provide helpful reminders of the existing rules, they do not outline the comprehensive guidance. The readers are recommended to verify any specific situation with the IRS Notices referenced in this section or consult with the legal or tax advisor.
IRS Letter 2021-0008 »
IRS Notice 2021-0014 »
IRS Reminds Taxpayers that COVID-19 Testing and PPE are Reimbursable under FSAs, HRAs and HSAs
September 14, 2021
On September 10, 2021, the IRS issued News Release 2021-181, which reminds taxpayers that the cost of COVID-19 home testing kits is a qualified medical expense and therefore eligible for reimbursement through a health FSA, HRA or HSA. A qualified medical expense is an expense related to the diagnosis, prevention or treatment of a health condition. Thus, the cost associated with the diagnosis of COVID-19 is a qualified medical expense.
Additionally, the cost of personal protective equipment (PPE), such as masks, hand sanitizer and sanitizing wipes used for the primary purpose of preventing the spread of COVID-19 is also a qualified medical expense eligible for reimbursement under a health FSA, HRA or HSA.
Employers and service providers that administer these plans should keep this guidance in mind when providing reimbursements.
News Release 2021-181 »
IRS Regulations Recapture Excess Employment Tax Credits under ARPA
September 14, 2021
On September 10, 2021, the Treasury Department released temporary regulations related to tax credits under the American Rescue Plan Act’s (ARPA’s) paid sick and family leave and employee retention provisions under the CARES Act. The rules are effective immediately but are applicable to all paid sick and family leave monies credited or refunded on or after April 1, 2021; and employee retention monies credited or refunded on or after July 1, 2021.
The guidance is technical in nature. Employers should carefully review with their accountants and tax specialists to understand the guidance and its impact on their assessed taxes.
An employer may not receive the employee retention credit for the same wages for which the employee receives the paid sick and family leave credit. For second quarter 2021, if an eligible employer receives the employee retention credit based on wages paid that are also qualified leave wages on which the employer may claim the paid sick and family leave credits, the employer must reduce any paid sick and family leave credits by the amount of the credit allowed under the CARES Act. For the third and fourth calendar quarters of 2021, any qualified leave wages eligible employers take into account for purposes of the paid sick and family leave credits may not be taken into account for purposes of the employee retention credit.
The paid sick and family leave credits are also reduced by the amount of the credit allowed under Section 41 (the credit for increasing research activities). In addition, any wages taken into account in determining paid sick and family leave credits cannot be taken into account as wages for purposes of the credits under Sections 45A (Indian Employment Credit), 45P (Employer Wage Credit for employees who are active-duty service members), and 45S (Paid Family and Medical Leave Credit).
Some employers received an advanced payment of the paid sick and family leave credit. Other employers received a refund if the amount of the credits exceeds their taxes for the quarter.
The new guidance provides that any credits claimed that exceeded the amount to which the employer was entitled and that were actually credited or refunded by the IRS are considered to be erroneous refunds. The IRS will collect these erroneous payments in the normal course of processing employment tax returns by treating the amounts as owed taxes (underpayment of taxes).
Recapture of Excess Employment Tax Credits Under the American Relief Plan Act of 2021 »
IRS Issues Letter Concerning FSA Reimbursement After Termination
August 31, 2021
On June 25, 2021, the IRS responded to an inquiry from a congresswoman on behalf of her constituent who was concerned that the unused balance in her health FSA was forfeited when she was terminated from her employment because her health FSA was determined not to be eligible for COBRA. She asked for clarification of existing IRS guidance regarding health FSAs and the COBRA requirements (Letter 2021-0004).
In the letter, the IRS confirmed existing guidance and reiterated general information pertaining to COBRA and health FSAs. Specifically, it outlines the situation in which COBRA is triggered and, if triggered, how the COBRA premium for a health FSA should be determined in light of carryover amounts.
COBRA coverage for an FSA is triggered if a participant experiences a COBRA qualifying event (e.g. termination or reduction in hours) and as of the date of the qualifying event the amount the participant may receive from their health FSA for the rest of the plan year exceeds the amount the FSA may require to be paid for the COBRA for the rest of that plan year. The IRS confirmed that any carryover amount is included in determining the amount of the benefit that a qualified beneficiary is entitled to receive during the remainder of the plan year in which a qualifying event occurs.
The below section from the IRS Letter 2021-0004 provides additional information:
If COBRA is available, the amount the participant may be able to receive as a reimbursement for medical care following termination of employment is generally:
- The carryover amount plus the amount of the health FSA contribution elected for the plan year, minus
- The amount the plan has reimbursed the employee as of the date of the qualifying event.
The amount that a participant may be required to pay for COBRA continuation coverage for the rest of the year does not include the carryover amount and is:
- The amount of the health FSA contribution elected for the plan year, minus
- The amount contributed to the health FSA as of the date of the qualifying event.
Furthermore, IRS Notice 2015-87 provides some examples and additional guidance that may be helpful in understanding these rules. Similar to the IRS letter described above, this notice did not provide any new guidance. However, it provides helpful reminders of the applicability of COBRA on health FSA and a carryover.
IRS Letter 2021-0004 »
IRS Notice 2015-87 »
FAQs Address Implementation of Group Health Plan Transparency Requirements
August 31, 2021
On August 20, 2021, the DOL, HHS and the Treasury jointly released FAQs regarding implementation of requirements under the Transparency in Coverage (the TiC) final rule and provisions of the Consolidated Appropriations Act of 2021 (the CAA), including the No Surprises Act. Importantly, the FAQs provide an update on the enforcement dates of provisions under these laws pending the issuance of regulatory guidance.
The TiC final rule was issued in 2020 and requires non-grandfathered group health plans to disclose in-network provider negotiated rates, historical out-of-network allowed amounts, and prescription drug pricing information to the public via machine-readable files posted to a website. Additionally, these plans must provide participants with personalized cost-sharing information for covered services via an online self-service tool. The rule includes phased-in effective dates from January 2022 through January 2024.
Subsequently, Congress passed the CAA in December 2020. This budgetary measure includes various provisions to address surprise billing and price transparency in the group health plan context. However, some of the CAA requirements duplicate the TiC requirements, but have different effective dates.
The FAQs address the overlapping TiC and CAA provisions. The guidance also sets expectations regarding the timing of implementing regulations and plan compliance in the interim.
Specifically, FAQs #1 and #2 focus upon the TiC machine-readable file requirements. Under the new guidance, the enforcement date for public posting of a plan’s in-network rates and out-of-network allowed amounts is extended from January 1, 2022, to July 1, 2022. The posting of the TiC prescription drug pricing file is deferred indefinitely pending a determination, through notice and comment rulemaking, of whether it remains necessary. (The CAA pharmacy benefit reporting provisions require plans to report some of the same prescription drug information to regulators.)
FAQ #3 speaks to the overlapping price comparison tool requirements under the TiC and CAA. Under the TiC, plans must make price comparison and cost sharing information available to participants through an internet-based self-service tool and in paper form, upon request. This requirement applies to 500 common items and services effective for plan years beginning on or after January 1, 2023, and for all items and services commencing for plan years beginning on or after January 1, 2024. The CAA requires plans to provide similar price comparison guidance by internet and phone for plan years beginning on or after January 1, 2022. The new guidance indicates that regulators intend to propose rules and seek comments as to whether compliance with the TiC pricing requirements, with the addition of fulfilling participant requests made by phone, would also satisfy the CAA requirements. Furthermore, the guidance indicates that enforcement of the CAA self-service tool requirement is postponed until plan years beginning on or after January 1, 2023, to align with the TiC effective date.
FAQ #4 explains that the CAA requirement for plans to issue updated physical or electronic insurance identification cards remains effective for plan years beginning on or after January 1, 2022. The new cards issued to enrollees must reflect cost-sharing information, including applicable deductibles, out-of-pocket maximum limitations, and a telephone number and website address for assistance. Regulatory guidance will likely not be issued until after the effective date, so plans are expected to implement the ID card requirements using a good faith, reasonable interpretation of the law in the interim.
According to FAQs #5 and #6, enforcement of the CAA provisions that require plans to provide participants with good faith cost estimates of scheduled services or advance explanations of benefits are delayed pending the issuance of regulatory guidance. Such guidance is not anticipated prior to the January 1, 2022 effective dates.
FAQ #7 confirms that the CAA prohibition against gag clauses took effect upon the law’s enactment on December 27, 2020. As a result, plans must ensure that contract provisions regarding provider networks do not directly or indirectly restrict them from accessing cost and quality of care information and providing the information to participants or from electronically accessing de-identified participant claims data. The regulators intend to issue guidance to explain how plans should submit their attestations of compliance with this prohibition and anticipate beginning to collect such attestations starting in 2022.
FAQ #8 indicates that regulatory guidance on the CAA provider directory provisions will likely not be issued prior to the January 1, 2022, effective date. These provisions generally require plans to establish a process to update and verify the accuracy of provider directory information and respond to participant requests about a provider’s network participation status. Pending guidance, plans are expected to comply in good faith and would be deemed in compliance provided that any participants given inaccurate information about a provider’s network status are assessed only the in-network rates.
FAQ #9 explains that regulations addressing the CAA balance billing disclosure requirements will not be issued prior to the January 1, 2022, effective date. Until further guidance is issued, use of the model disclosure notice provided with the July 2021 Interim Final Rules on Surprise Billing will be considered good faith compliance, if all other applicable requirements are met.
Similarly, FAQ #10 indicates that guidance will not be issued regarding the CAA continuity of care provisions before the January 1, 2022, effective date. These provisions are designed to protect participants undergoing care for certain conditions and serious illnesses from unanticipated in-network provider terminations by the plan. Plans must comply in good faith in the interim.
FAQ #11 clarifies that although ACA grandfathered plans are exempt from the TiC requirements, these plans are subject to the transparency and No Surprises Act provisions of the CAA.
Finally, FAQ #12 provides that enforcement of the CAA pharmacy benefit reporting requirements will be deferred from December 27, 2021, to December 27, 2022, pending the issuance of regulations. However, plans are encouraged to start working to ensure they are in a position to report the required information with respect to 2020 and 2021 data by December 27, 2022.
Employers who sponsor group health plans should be aware of this important regulatory update. They should continue to work with their counsel and service providers to ensure compliance with the TiC and CAA provisions by the applicable enforcement dates.
FAQs About Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 49 »
CMS Updates MSP Reporting System
August 17, 2021
On June 28, 2021, CMS issued a technical alert regarding the inclusion of Part D information in the Section 111 Query Only Response File for Responsible Reporting Entities (RREs) that provide primary prescription drug information for purposes of Medicare Secondary Payer (MSP) Section 111 reporting.
The alert notifies group health plan RREs of changes being made to the Query Only Response File. The changes add fields 20 through 22 to account for current Part D enrollment information for a beneficiary. The new fields request information regarding the current Medicare Part D plan contractor number, plan enrollment date and plan termination date.
These changes are effective December 13, 2021. For additional information regarding RREs and reporting primary prescription drug information, see the article “CMS Issues Guidance Regarding Responsible Reporting Entities and Reporting Primary Prescription Drug Information” in the May 11, 2021, edition of Compliance Corner.
As a reminder, an RRE is usually the insurer for a fully insured plan, the third-party administrator for a self-insured plan and the plan administrator for a self-insured plan that self-administers. While employers are not usually the RRE, they should be aware of this guidance.
CMS Technical Alert »
MMSEA Section 111 MSP Mandatory Reporting GHP User Guide »