health insurance meeting

From Amerihealth NJ:

Health care and health insurance are among the most regulated industries in the U.S., making compliance a crucial requirement for success. AmeriHealth New Jersey has a strong track record of compliance to local, state, and federal guidelines, and we are working to comply with the new Consolidated Appropriations Act (CAA) and Transparency in Coverage Rule (TCR) requirements.

We have been focused on transparency for our members for years, and we are now further sharpening our efforts related to transparency and accountability pertaining to the recent legislation for which we have developed an enterprise-wide implementation program to ensure requirements are met.

We have a cross-functional team that is working closely with key vendors to outline the requirements and implement solutions. We are working closely with legislators and AHIP as information about these laws is still being finalized.

Recent Transparency requirements

The new legislation comes to us in two parts, the Consolidated Appropriations Act (CAA) and the Transparency in Coverage Rule (TCR).

1. Consolidated Appropriations Act (CAA):

The CAA is a $1.4 trillion legislative package that includes COVID‑19-related relief for physicians and provides funding for health care-related government operations through the end of fiscal year 2021. The CAA also bans balance billing in various situations, including for emergency services. Key highlights of the CAA include:

  • Advanced EOBs to help covered members understand their anticipated out of pocket costs;
  • Protections against surprise billing;
  • Broker and Consultant compensation disclosures;
  • A continuity of care provision for network changes;
  • Disclosure of deductible and out of pocket maximums on ID cards;
  • Price comparison tool;
  • and mental health parity provisions, effective January 1, 2022.

For an overview of all of the CAA provisions please visit the Milliman website.

2. Transparency in Coverage Rule (TCR):

Finalized in October 2020 by the U.S. Departments of Health and Human Services, Treasury, and Labor, the TCR includes requirements for health plans to disclose cost‑sharing estimates, post negotiated in-networks rates, and post other historical out-of-network charges and pricing information. The TCR requires insurers to create online consumer tools, including personalized information regarding members’ cost‑sharing responsibilities for covered items and services.

A key provision of the TCR required by January 1, 2022 is related to Public Disclosures: Insurers and self‑funded employers must make available on a public website through three machine-readable files negotiated rates for covered services with in‑network providers; historical OON allowed amounts and billed charges, and in‑network negotiated rates and historical prices for all covered prescription drugs.

Insurers will be required to update this information monthly.

Continued focus on Transparency to enhance the member experience

Each day, AmeriHealth New Jersey strives to help our members better understand and maximize their benefits, make informed health care decisions, improve their health and well-being, and have a positive experience interacting with us.

We will be in compliance with the transparency-related requirements by the required effective dates. We also plan to communicate directly with digitally engaged AmeriHealth New Jersey members about these transparency-related changes, unless directed otherwise by certain self‑funded customers.

We will provide additional information and updates on a routine basis with you about the mandated changes through future bulletins.

Questions? Contact your Total Benefit Solutions, Inc account manager at (215)355-2121