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Transparency in Coverage and No Surprises Act Overview

Transparency in Coverage and No Surprises Act Overview

in Important Notices by UHA Health Insurance

There are federal laws which provide a variety of mandates that will impact UHA, its members and other stakeholders soon.  These laws include the Transparency in Coverage Rule (TiC) and the No Surprises Act (NSA).  Some of the requirements of these laws overlap but the purpose for both is to provide consumers with cost information about medical services and to protect consumers from certain surprise medical bills.

Highlights of Mandates

Changes to ID Cards

UHA will be providing you a new ID card at the end of 2021.  The ID card will include more information such as [fill in] and a QR code that will display the plans in-network and out-of-network deductibles and the in-network and out-of-network out-of-pocket maximum.

Price comparison Tool

The price comparison tool will provide UHA members with personalized out-of-pocket costs and price comparisons for specific items or bundled services.  Generally, the tool allows members to:

  • Search based on billing code or description.
  • Review any accumulated deductible or other out-of-pocket expenditures to date.
  • Receive cost estimates.
  • Review factors that impact the cost, such as service location or drug dosage.

Originally scheduled to be available on January 1, 2022, the federal Departments of Labor, Health and Human Services, and the Treasury are deferring enforcement of the requirement that an insurer make available a price comparison tool (by internet, over the phone, and by paper) before a plan year begins on or after January 1, 2023.

Provider Directories

Requires up-to-date participating provider directories to be available online or within one business day of questions regarding a participating provider and their information or status with UHA.  This mandate goes into effect on January 1, 2022.

Advanced Explanation of Benefits (AEOB)

The AEOB will provide cost estimates for services that are scheduled at least three days in advance, based on service billing codes provided by a provider or facility.  Originally scheduled to be available on January 1, 2022, the federal Departments of Labor, Health and Human Services, and the Treasury are deferring enforcement of the requirement that an insurer make available an AEOB until further notice.

Surprise Billing

Protects UHA members from balance billing by non-participating providers in certain specific situations.  Generally, this protection occurs when emergency services are provided or when non-emergency services are provided by a non-participating provider in a participating facility.  In addition, the member may expect the applicable benefits, deductible, and maximum out of pocket cost to be applied at the participating provider benefit level for these services.

Continuity of Care

The law requires UHA to notify members when a provider or facility leaves UHA’s network while the provider or facility is providing ongoing care to a member.  In certain situations, UHA must also provide transitional coverage for up to 90 days or until treatment ends (whichever is earlier) at in-network rates. 

Public Disclosure of Rates Through Machine-Readable Files (MRFs)

The three MRFs include files that provide information on (1) in-network rates, (2) out-of-network historical rates, and (3) prescription drugs.  Data in the MRFs are to be used by the Centers for Medicare and Medicaid Services or other third parties, for example, to guide patients to more cost-effective alternatives for care.  Originally scheduled to be available on January 1, 2022, the federal Departments of Labor, Health and Human Services, and the Treasury are deferring enforcement of the requirements to publish files (1) and (2) until July 1, 2022.  File (3) prescription drugs will be deferred until further notice from the federal Departments.

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