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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 (Updated April 2022)

UHA provided you a new ID card at the end of 2021.  The ID card included more information such as displaying your medical plan’s annual deductible and maximum out-of-pocket costs, and a contact number and website for you to reach us if you need assistance.

Another new feature we’ve included for your convenience is a QR code which takes you to our member portal, where you can log in to:

  • View your specific plan benefits, such as your drug plan information
  • View or print a digital copy of your member ID card
  • Track your claims

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

By January 1, 2023 UHA will make available an internet-based self-service tool and in paper form upon request for the 500 shoppable services.

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. 

Prescription Drug Data Collection (RxDC)

Under the Consolidated Appropriations Act (CAA), insurance companies and employer-based health plans must submit information about prescription drugs and health care spending. This data submission is called the RxDC report. The Rx stands for prescription drug and the DC stands for data collection.

The Centers for Medicare and Medicaid Services is collecting the RxDC report on behalf of the Departments of Health and Human Services, the Department of Labor, the Department of Treasury, and the Office of Personnel Management.

The December 27, 2021, report date had a delayed enforcement until December 27, 2022. After the reporting, the December reports will be required by June 1, each year.

The report includes general information identifying the insurer or plan as follows:

  • Enrollment and premium information, including average monthly premiums paid by employees and the employer
  • Total health care spending, broken down by type of cost (e.g., hospital care, primary care, specialty care, prescription drugs, and other medical costs including wellness services) by enrollees and by employer or insurer
  • Prescription drug spending by enrollees and employers or insurer
  • 50 most frequently dispensed brand prescription drugs
  • 50 costliest prescription drugs by total annual spending
  • 50 prescription drugs with the greatest increase in plan or coverage expenditures from the prior year
  • Prescription drug rebates, fees, and other remuneration paid by drug manufacturers to the plan or issuer in each therapeutic class of drugs, as well as for each of the 25 drugs that yielded the highest amount of rebates
  • Impact of prescription drug rebates, fees, and other remuneration paid by prescription drug manufacturers on premiums and out-of-pocket costs

The guidance provides uniform standards and definitions, including standards for identifying prescription drugs regardless of the dosage strength, package size, or mode of delivery. The uniform standards for submitting data are intended to allow the Tri-Agencies and U.S. Office of Personnel Management (OPM) to conduct meaningful data analysis and identify prescription drug trends.

UHA will submit the report and required data for prescription drugs and medical coverage provided by UHA. Reporting will be aggregated at the state/market level, rather than separately for each UHA customer. We will not accept requests for UHA customers to submit the report and data themselves.

Public Disclosure of Rates Through Machine-Readable Files (MRFs)
Updated June 2022

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 will provide opportunities for detailed research studies, data analysis, and offer third party developers and innovators the ability to create private sector solutions to help drive additional price comparison and consumerism in the health care market. UHA MRFs (1) and (2) are available here. File (3) prescription drugs will be deferred until further notice from the federal departments.

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