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I Can See Right through You! Health Transparency Rules Result in Increased Scrutiny of Provider Fees

September 19, 2023 (4 min read)

Many employers provide their employees with health coverage—the Affordable Care Act making it more likely. Enter the Consolidated Appropriations Act, 2021 (CAA), bringing new rules on surprise billing and price transparency. Employers spend time negotiating with their insured plan providers, or self-insured plan-third-party administrators, deciding on pricing. And, courtesy of the CAA and newly issued transparency regulations, employers now have access to (or should have) ample data not previously available providing them with insight to health plan pricing. Some employers are especially unhappy with the results and are challenging these vendors in court. 

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Related Content

  • Transparency Disclosure Rules for Group Health Plans
    Reference the rules that require health plans and insurers to provide a substantial amount of cost, coverage, provider, and other coverage information to eligible and covered individuals and make rate information publicly available. They apply for most employer-sponsored group health plans (both self-funded and fully insured) as well as to health insurance policies in the individual and group markets. Many of the new requirements became effective on January 1, 2022.
  • Transparency Reporting and Compliance Rules for Group Health Plans
    Review the new reporting and other requirements for employer group health plans enacted under the No Surprises Act and other provisions of the CAA. The reporting measures require affected entities to provide substantial amounts of information to oversight agencies to help the agencies, lawmakers, and other stakeholders better understand the factors driving prescription drug and other health care coverage costs as well as to help assess broader trends in the health care market and the effectiveness of transparency and balance billing reforms.
  • Transparency in Coverage, No Surprises Act, and Consolidated Appropriations Act, 2021, Requirements Checklist
    Use these charts to review the requirements for health plans, health insurance issuers, and providers regarding transparency, balance billing, and other matters imposed under (1) the Transparency in Coverage rules (extending rules of the Affordable Care Act); (2) the No Surprises Act (enacted as Title I of Division BB of the CAA (Pub. L. No. 116-260)); and (3) additional rules enacted under CAA, Division BB, Title II.

Practical Guidance Updates 
Featuring the latest updates from your Practical Guidance account.    

  • Employee Benefits & Executive Compensation Key Legal Developments Tracker
    Stay informed on new developments.
    • Retirement Plans. IRS announces a two-year administrative transition period for the SECURE 2.0 Act requirement that catch-up contributions made on behalf of certain eligible participants are to be designated as Roth contributions. That section was statutorily scheduled to apply to taxable years beginning after December 31, 2023; the IRS now paused that rule until taxable years beginning after December 31, 2025. R.S. Notice 2023-62.
    • Retirement Plans. The American Bar Association posted a summary of the May 3, 2023, meeting between PBGC representatives and members of ABA’s Joint Committee on Employee Benefits (JCEB). Among the topics discussed, PBGC addressed common errors detected in standard termination audits and reported that PBGC has approved 78 initial/supplemental applications for the PBGC’s Special Financial Assistance Program (SFA) since introduction of the SFA program. ABA, Joint Committee on Employee Benefits Report on May 3, 2023, Session with PBGC.
    • Health and Welfare Plans. IRS issues a 2024 index adjustment for Affordable Care Act contribution percentages used to determine affordability under the ACA employer shared responsibility mandate that applies to applicable large employers (ALEs). The required contribution percentage for ALEs will decrease in 2024 to 8.39% (down from 9.12% for 2023). Under R.C. Section 36B, individuals are eligible for a premium tax credit if their employer does not offer them affordable coverage that provides minimum value (that is, the premiums exceed the required contribution percentage multiplied by household income). Plus, under I.R.C Section 4980H, ALEs can be responsible for employer shared responsibility payments for any month when: (1) the ALE fails to offer full-time employees and their dependents minimum essential coverage (MEC), and (2) it offers full-time employees a MEC that is unaffordable. ­­Rev. Proc. 2023-29.
  • Generative Artificial Intelligence (AI) Resource Kit is a collection of current guidance on generative AI, ChatGPT, and similar tools.

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