Compliance With The CAA’s Gag Clause Prohibition

The Consolidated Appropriations Act (CAA) of 2021 made a number of federal changes to the U.S. health care system, with the goal of increasing transparency.

One of the most immediate changes was the prohibition of gag clauses in contracts between insurance plans, insurance issuers, and providers.

Gag clauses are contractual provisions that restrict plans or issuers from sharing provider-specific cost information or quality-of-care information with patients, other providers, or plan sponsors. They can also prevent plans or issuers from electronically sharing de-identified claims data and other encounter information with patients and providers.

The CAA’s gag clause prohibition was designed to ensure that patients have access to the information they need to make informed decisions about their care, especially regarding costs. The prohibition also allows the entirety of the CAA’s transparency changes to function.

The gag clause prohibition went into effect on December 27, 2020, but the requirement for plans/issuers to contest their compliance with the law does not go in effect until December 31, 2023. The Gag Clause Prohibition Compliance Attestation is due on 12/31 annually and must be submitted by group health plans (fully insured and self-funded) and insurance issuers. The requirement does not apply to excepted benefits, Account-based plans, standalone Dental plans, or Vision plans.

Self-funded group plans have the greatest burden with this requirement. Employers with such plans may attest themselves or may contract with their Pharmacy Benefits Managers (PBM), Third-Party Administrators (TPA), or Administrative Services Only (ASO) coordinators to facilitate the attestation. Reports must be submitted using CMS’s Health Insurance Oversight System (HIOS), and special HIOS registration is required.

For fully insured group plans, both the insurance issuer and the plan are considered to be in compliance when the insurance issuer makes its annual attestation. In other words, when the fully insured health insurance carriers inevitably make and file these attestations, both the plan and its sponsors will be in compliance. In general, employers with fully insured group health plans do not need to act unless otherwise notified by the carrier.

 

Source Link

Recommended Articles

Annual Employee Benefits Compliance Responsibilities On January 1st

The start of each year marks an important date for employers as they face annual compliance responsibilities related to their health plans, the Affordable Care Act (ACA), and COBRA. Staying on top of these regulations is crucial for compliance and to avoid significant non-compliance penalties.

Read More

AI in Healthcare: Calls for Stricter Standards Amid OpenAI Leadership Shuffle

Recent disruptions in OpenAI’s top brass have sparked intense dialogue within the healthcare sector, emphasizing the urgent need for robust standards governing the implementation of generative AI technologies. With Microsoft recruiting former OpenAI executives Sam Altman and Greg Brockman, concerns are growing that few corporations may soon dictate the trajectory of healthcare AI, potentially molding ...

Read More

2024 FSA, HSA, and HDHP Plan Limits

A health Flexible Spending Account (FSA) is an employer-sponsored benefit that allows eligible employees to save pre-tax dollars to pay for qualified medical expenses. Employees can elect a specific dollar amount, up to a certain limit, to set aside annually.

Read More

Proposals On PBMs And Medical Devices Advanced By House Subcommittee

The House Committee on Energy and Commerce health subcommittee pushed forward 21 proposals on Tuesday, some of which will restrict the power of pharmacy benefit managers (PBMs). Democrats supported many of the proposals put forward by Republicans, including legislation reining in PBMs that had support from 60 organizations representing patients, providers, pharmacists, small businesses and ...

Read More
arrowcaret-downclosefacebook-squarehamburgerinstagram-squarelinkedin-squarepauseplaytwitter-squareyoutube-square