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With an increasingly tight labor market, offering employee medical and group health plans has become a necessity for any employer wanting to attract and retain employees. These already costly benefits are accompanied by complicated government regulations that require employer compliance.

The departments of Health and Human Services, Labor, and Treasury have released new Transparency in Coverage (TIC) rules that put several additional compliance burdens on group health plan sponsors. Employers must make public disclosures of in-network and out-of-network rates by July 1, 2022.

To meet that deadline, plan sponsors should have already received from their carriers and third-party administrators (TPA) the necessary information in the proper format to comply with the new rules.

Additionally, employers are required to provide “machine readable files” (MRF) that reveal in-network rates, out-of-network charges, and information relating to prescription drug coverage. The first MRF must disclose a plan’s negotiated rates for covered items and services for all in-network providers. The second MRF must show the historical payments and billed charges from out-of-network providers. This file should include at least 20 historical entries to help protect individual participant privacy.

Although most medical insurance companies should be prepared to help businesses meet these requirements, it is still important for an employer who sponsors health plans to make sure the TIC and MRF are in total compliance.

The MRF must include:

  1. Each group medical plan must include the insurer Health Insurance Oversight (HIOS) identifier or, if none, the employer identification number (EIN).
  2. A billing code (e.g., Current Procedural Terminology (CPT) code, Healthcare Common Procedure Coding System (HCPCS) code, Diagnosis-Related Group (DRG) code, National Drug Code (NDC), or any other common payer identifier, as well as a plain-language description for each billing code.
  3. The In-Network Rate MRF must show:
  • In-network rates for each item or service provided by in-network providers.
  • Negotiated rates, fee-schedule rates used to determine cost-sharing, or derived amounts-whichever rate is applicable to the plan.
  • The TIC rules allow plan sponsors to contract with a carrier, TPA, or other third party to produce and house the information for a plan.

Be aware it is the employer that will remain responsible for any failures.

 

The Allowed Amount MRF must show:

  1. Out-of-network allowed amounts and billed charges with respect to covered items or services, furnished by out-of-network providers during the 90-day period starting 180 days prior to the MRF publication date.
  2. The plan must omit data for a particular item or service and provider when the plan or insurer would be reporting on payment of out-of-network allowed amounts for fewer than 20 different claims for payment under a single plan or coverage. These amounts must be expressed as dollar amounts and associated with the NPI, Taxpayer Identification Number, and Place of Service Code for each network provider.
  3. Plan sponsors must update the MRFs at least monthly. So, they should establish processes to coordinate regularly with the carrier.
  4. The appropriate departments require the files be posted to a public website that consumers can use without providing individually identifiable information. The website cannot require passwords, account setup, login credentials, or any other barriers to accessing the required information.

In this instance, the insurance carrier will be responsible for any MRF failure required in writing to ensure a plan’s compliance. Employers and insurance carriers should carefully review indemnification provisions in all relevant vendor service agreements.

 

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A New Path to HR Bliss – Trusted for more than 30 years, Employer Advantage frees you from the administrative and compliance burdens of having employees so you can focus on your business success. Versatile enough for companies of all sizes, our unique service combines comprehensive management of your employee administration and compliance with the latest software solutions, tailored to meet your individual needs and company culture. Our full-service management of Human Resourcespayrollhealth and benefits, workplace safety, and more enhances your profitability while reducing the costs and risks associated with employment law compliance. We provide your employees with top-notch assistance and benefits that help you increase productivity, save time and money, and attract and retain a talented workforce. And for small and mid-sized businesses, we bring you economy of scale with access to Fortune 500-level benefits, specialty assistance, and savings that would not be possible to attain on your own. Headquartered in the Midwest and serving more than 500 companies and 10,000 worksite employees throughout the country, Employer Advantage is an IRS-Certified Professional Employer Organization (PEO) (CPEO). Experienced, certified, and trusted. www.EmployerAdvantage.com

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