Capitol Benefits Group News & Updates
Upcoming Webinar: Preparing for a DOL Health Plan Audit
DOL audits are stressful and time-consuming, and ERISA violations can be costly. Please join us for our upcoming webinar on and learn how to be prepared and organized to reduce employer’s liabilities and successfully pass a DOL health plan audit.
Register for this webinar taking place on October 12, 2022 at 12PM CDT here.
2023 Medicare Part B Premium and Deductible
Medicare Part B rates have been released. The standard monthly premium for Medicare Part B enrollees will be $164.90 for 2023, a decrease of $5.20 from $170.10 in 2022. The annual deductible for all Medicare Part B beneficiaries is $226 in 2023, a decrease of $7 from the annual deductible of $233 in 2022.
Medicare Part D Coverage Notices Due Mid-October
The October 14, 2022 deadline by which plan sponsors that offer prescription drug coverage to provide notices of creditable or non-creditable coverage to Medicare-eligible individuals is fast approaching. Coverage that is deemed creditable is expected to cover, on average, at least as much as the standard Medicare Part D prescription drug plan, whereas non-creditable coverage falls below this threshold.
Plan sponsors are required to provide such notices to the following individuals by the October 14 deadline:
Retirees and their dependents
Active employees who qualify for Medicare and their dependents
COBRA participants who qualify for Medicare and their dependents
The Medicare Part D annual enrollment period begins October 15 and runs through December 7 for coverage that will begin on January 1, 2023. Prior to the enrollment period, plan sponsors must specify whether an individual’s prescription drug coverage is creditable or non-creditable. The annual deadline to provide coverage notices applies to all plans that offer prescription drug coverage, regardless of plan size, employer size, or grandfathered status. Plan sponsors can provide the required notice along with annual enrollment materials as long as the notice is “prominent and conspicuous.” This can be as a separate mailing or provided electronically if the participants have daily access to the plan sponsor’s electronic information system as part of their work duties.
If the notices are mailed to participants, a single notice can be provided to a covered Medicare individual and their dependents, unless it is known that a spouse or dependent resides at a different address than the participant. CMS has provided model notices on their website; plan sponsors should carefully review and customize these notices to ensure they accurately reflect plan provisions. In addition to providing Medicare-eligible individuals with annual notices of prescription drug coverage status, all plan sponsors are responsible for disclosing whether such plan is creditable or non-creditable to the Centers for Medicare and Medicaid Services (CMS). The plan sponsor has 60 days after the beginning of each plan year to complete the Creditable Coverage Disclosure Form on the CMS Creditable Coverage website.
Please note, Capitol Benefits Group (CBG) provides support to all group clients for benefits compliance requirements. Here is a list of applicable notice requirements for the calendar year. Upon review, please feel free to reach out to your assigned CBG representative if you require an updated notice or additional information.
Medical Loss Ratio Rebate Guidelines
Many sponsors of fully insured health plans either already have or will soon receive checks from their insurance carriers, along with a notice informing them that the check is a medical loss ratio (MLR) rebate. Plan sponsors should receive these checks by September 30, 2022. The MLR rules implemented as part of health care reform are designed to ensure that insurance carriers spend no more than a specified percentage of premiums collected on overhead-type expenses. Carriers must issue a rebate check in cases when this percentage is exceeded.
Plan sponsors who receive MLR rebates generally have a fiduciary duty to handle the funds in accordance with certain guidelines.
Additional Guidance Issued on Surprise Billing Protections
The Consolidated Appropriations Act of 2021 (CAA) introduced numerous protections against surprise billing for plan participants that impact group health plans, health insurance issuers, and providers. The federal Departments of Health and Human Services, Labor, and Treasury recently released a document discussing frequently asked questions (FAQs) about these surprise billing protections that provides clarity on a number of topics within the regulations. The key points from this guidance are outlined below.
Application to Reference Based Pricing Plans
It has been unclear how the surprise billing rules apply to plans without networks, such as reference-based pricing plans. The new guidance clarifies that:
The surprise billing rules apply to plans without networks;
Plans without networks need to protect against balance billing for emergency care and air ambulance services; and
Plans without networks do not need to comply with the surprise billing rules as they relate to non-emergency out-of-network services provided at in-network facilities.
In other words, participants covered by such plans can still receive balance bills for non-emergency care, but not for emergency care or covered air ambulance services.
In cases where there is no network, the “in-network” rate for this purpose is determined based on the first of the following, as applicable:
All-Payer Model Agreement
Specific state law
The lesser of the billed charge or the qualified payment amount (QPA).
Plans Without Out-of-Network Coverage
The FAQs affirm and clarify that the surprise billing protections apply to closed network plans, such as HMOs and EPOs, if the plan covers these items generally. This is the case even if the plan does not typically provide coverage for out-of-network items or services. As a result, many plans that do not typically offer out-of-network coverage will be required offer such coverage for the items and services subject to the surprise billing protections.
Applicability to Air Ambulance Services
The CAA does not require that plans cover air ambulance services. However, if a plan does cover air ambulance services, then the surprise billing protections apply when service is rendered by an out-of-network air ambulance provider. Of note, if the plan only covers emergency air ambulance services, the CAA’s protections would not also extend to non-emergent air ambulance services. When a plan does cover air ambulance services, the surprise balance billing protections apply even when the participant is picked up outside of the United States
Application to Behavioral Health Crisis Facilities
Out-of-network behavioral health facilities that (1) are either part of a hospital’s emergency department or geographically distinct from a hospital, (2) have a state license designating them as capable of providing emergency care services, and (3) provide behavioral health crisis response services are subject to the CAA’s surprise billing protections. This means that plan participants who receive emergency care from these facilities cannot receive surprise bills.
Notice and Disclosure Requirements
The CAA requires group health plans and insurance carriers to notify plan participants about various balance billing protections available to them. These notices should be posted on the plan’s website (or the website of a plan vendor pursuant to a written agreement) and included on each explanation of benefits for applicable covered items or services.
Calculating Qualifying Payment Amounts (QPAs)
The FAQs specify that:
Plans and issuers can calculate separate QPAs for each provider specialty if the plan’s/issuer’s contracted rates for service codes vary based on provider specialty; and
Self-funded groups that offer multiple plan options managed by multiple TPAs can calculate their QPAs separately per plan option.
Nuances of the Independent Dispute Resolution Process
Providers must wait until they receive an initial payment or a notice of denial of payment from the plan/insurer to start the Federal independent dispute resolution process. This is true even if the plan or insurer fails to comply with their obligation to send the initial payment or a notice of payment denial within 30 calendar days of receiving the bill from the provider.
The FAQs also note that:
An initial payment does not need to be the full QPA for an item or service, but it must be an amount that could reasonably be considered full payment;
Notices of denials of payment must (1) be in writing and (2) explain why the payment is being denied; and
Payment denials differ inherently from benefit denials because payment denials may be disputed through the Federal IDR process, whereas benefit denials due to adverse benefit determinations can be disputed through the plan’s claims and appeals process.
These FAQs indicate that guidance surrounding the CAA’s surprise billing protections may evolve further as parties engage with the Federal IDR process. We will continue to notify you of relevant updates as they become available.
The content herein is provided for general information purposes only, and does not constitute, legal, tax, or other advice or opinions on any matters. This information has been taken from sources which we believe to be reliable, but there is no guarantee as to its accuracy.
Webinar Archive
This webinar will discuss some of the seemingly endless list of issues that management will face as it navigates hybrid and remote work arrangements.
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