Benefits and Compensation

Rules for QHP Transparency Soon Will Apply to Employers

Insurers and plan sponsors soon will have to report to the government (and list on a web page) their policies on: out-of-network liability and balance billing; enrollee claim submission; claims and denials; recoupment of overpayments; medical necessity; prior authorization; drug exception timeframes; explanations of benefits; and coordination of benefits.

Guidance HHS published on Aug. 12 addresses requirements for qualified health plans sold on exchanges. Although the QHP requirements take effect for 2016 policies, very similar rules soon (after an official rulemaking process) will apply to employer plan sponsors and group policy issuers selling outside of exchanges.

Under the guidance, health plans must submit data to comply with ACA transparency requirements, and employer-sponsors of non-grandfathered health plans will have similar burdens soon.

Issuers of QHPs must disclose information to health insurance exchanges, HHS and state insurance commissioners, and make the information public. Insurers selling coverage on state-based and federally run exchanges using the website will start submitting data first. These requirements will take effect for QHPs starting in the 2016 plan year.

On an HHS web page, the agency placed: (1) a fact sheet describing the transparency requirements; (2) the data collection checklist; and (3) the display checklist.

Non-grandfathered group health plans and insurers offering group or individual coverage outside an exchange will soon have to collect, display and submit similar transparency data to HHS, state commissioners and the public (upon request). They will not have to report it to an exchange, a fact already mentioned in FAQs about the Affordable Care Act Implementation: Part XV.

HHS and the U.S. Departments of Labor and the Treasury will propose a version of this rule that will apply to non-grandfathered group health plans and insurers, and finalize it after notice and comment.

Other areas that have to be reported include enrollment data, financial data, data on rating practices, information on cost-sharing and payments for out-of-network coverage.

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