February 21, 2024
On February 2, 2024, the Departments of Labor/Employee Benefits Security Administration (DOL/EBSA), Health and Human Services/Centers for Medicare and Medicaid Services (HHS/CMS) and Treasury/Internal Revenue Service (Treasury/IRS) – collectively, the Tri-Departments – issued Affordable Care Act (ACA) FAQ Part 65 which starts with background on the Final Transparency in Coverage (TiC) rules’ requirements regarding a plan’s provision of a self-service tool for individuals to search for and receive an accurate estimate of cost-sharing for all covered items and services (effective January 1, 2024).
Key Action
Work with plan partners and vendors to ensure any cost-sharing information for items or services that may be implicated by the FAQ has appropriate notice and disclosure in the search results generated.
The guidance goes on to acknowledge that in certain circumstances plans may utilize past paid claims data in order to determine the estimate for future coverage and payments, and that for items and services with extremely low utilization the plan may not have adequate paid claim experience to provide an accurate estimate. The Tri-Departments then define a low utilization/claims history level under which plans may rely on narrow flexibility in producing and displaying self-service cost-sharing results in the provided tool, along with additional contact information for the individual to inquire further.
Summary
ACA FAQ Part 65 generally provides:
The single FAQ provides some flexibility for instances where there may be some concern about the accuracy of the estimate because of low utilization and thus a low number of past claims to use.
- If cost-sharing information would be based on past claims data (versus a prospective negotiated rate) and
- If there have been fewer than 20 different claims (meeting certain requirements) for such items and/or services in the past three years.
Then the plan may be able to indicate in the self-service tool that the item or service is covered but that the specific cost estimate is not available, and encourage the user to contact the plan/issuer for more information.
What’s Next?
In general, employer plans sponsors are working with partners/vendors to provide the required self-service tool and may wish to check-in and confirm whether any of the results from their self-service tool would fall within the definition and be better conveyed using the flexibility outlined by the Tri-Departments.
If you have questions, comments, or concerns about these or other regulatory and compliance issues, please contact us.
We provide this material for informational purposes only; it is not a substitute for legal advice.
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