CAA Pharmacy Benefit and Healthcare Spending Reporting Deadline Approaching
Under the CAA, Section 204, insured and self-insured group health plans are required to report significant information regarding prescription drug and healthcare spending to the government. The 2020 and 2021 calendar year data submissions were due by December 27, 2022. However, under recently announced relief, a submission grace period was made available to employers who submitted the 2020 and 2021 data in good faith on or before January 31, 2023.
The data must be submitted to the Health Insurance Oversight System (HIOS) in files and formats specified by CMS. As applicable, employers should work closely with their carriers, third-party administrators, pharmacy benefit managers and other vendors to ensure the required information is timely and accurately provided. In some cases, employers that sponsor self-insured plans may need to submit data directly to HIOS. Detailed information regarding the reporting requirements, including instructions, FAQs and a HIOS portal user guide, is available on the CMS website.
Employers should be aware that the reporting of 2022 data is due by June 1, 2023 . Accordingly, carriers, TPAs and service providers submitting information on behalf of plans will be collecting required information from employers in advance of this deadline. Therefore, employers should respond promptly to requests for needed data, such as the average monthly premium paid by employers and employees, by any deadline set by the carrier, TPA or service provider. (Under limited regulatory relief, some plans were not required to report the average premium information for 2020 and 2021 but must do so for the 2022 reporting year.) Employers should also request written confirmation from the carrier, TPA or service provider of the timely submission.
Upcoming ACA Reporting Deadlines for Forms 1094/1095
Annual ACA reporting deadlines for employers that sponsored group health plans in 2022 are approaching.
Applicable large employers (ALEs) with 50 or more full-time employees (FTEs), including full-time equivalent employees, in the prior year who sponsored group health plans (whether insured or self-insured) must comply with IRC Section 6056 reporting in early 2023. Specifically, ALEs must complete and distribute Form 1095-C to full-time employees by March 2, 2023. The form should detail whether the employee was offered minimum value, affordable coverage during 2022. The forms may be mailed, electronically delivered or delivered by hand (although proof of delivery in some manner is recommended).
Employers who sponsored a self-insured plan during 2022 must comply with Section 6055 reporting in 2023. Self-insured employers with 50 or more FTEs must complete Section III of Form 1095-C detailing which months the employee (and any applicable spouse and dependents) had coverage under the employer’s plan. If the self-insured employer has fewer than 50 FTEs, it must complete and distribute a Form 1095-B with such information. Again, the forms must be delivered to employees by March 2, 2023.
If the self-insured employer has fewer than 50 FTEs, an alternative is available to distributing Form 1095-B to individuals. These small employers are permitted to post a clear and conspicuous notice on their website of the availability of the document and the necessary contact information to request it. Any such request must be fulfilled within 30 days. This posting alternative is not available for Form 1095-C.
Employers must also file the forms with the IRS by February 28, 2023, if filing by paper, and March 31, 2023, if filing electronically. The filing must include the transmittal Form 1094-C (if filing Forms 1095-C) or Form 1094-B (if filing Forms 1095-B).
Proposed March 31, 2023 CAA Air Ambulance Reporting Deadline Is Approaching
The CAA 2021 requires fully insured and self-insured group health plans to report specific air ambulance data for calendar years 2022 and 2023 to HHS. Under a 2021 proposed rule to begin implementing the requirement, the reporting of 2022 data is due by March 31, 2023. With no updated guidance from HHS since 2021’s proposed rule, the March 31, 2023, reporting date currently stands. As that deadline draws near, employers should contact their carriers or TPAs now regarding the reporting requirements.
Specifically, the proposed rule requires plans to report information for each air ambulance services claim received or paid for during the applicable reporting year. This information includes certain identification information for the plan/sponsor, the market segment (e.g., self-insured large group market), service date, specific healthcare billing codes, service provider information, transport information (including aircraft type, loaded miles, pick-up and drop-off zip codes) and whether the provider had a contract with the plan. Plans must also report specific claim adjudication information, including whether the claim was paid, denied, or appealed, and claim payment information, such as submitted charges, amounts paid and cost-sharing.
Many plan sponsors will likely rely upon their insurers and TPAs, who have access to the necessary data, to complete the required reporting. Sponsors of fully insured plans should confirm that their insurer will submit the required data on the plan’s behalf. Sponsors of self-insured plans should reach out to their TPA to determine if the TPA will submit data for the plan or if the sponsor will need to do so directly. Any agreed-upon reporting arrangements should be incorporated into a written contract so each party’s obligations are clear. Sponsors should also seek confirmation from the insurer or TPA when the reporting is timely completed.
We will continue to monitor for further guidance, including the issuance of final regulations. However, in the interim, sponsors, particularly those of self-insured plans, should reach out to discuss the air ambulance reporting requirements with their TPAs and service providers as soon as possible.
State Requires Plans to Cover Certain Gender-Affirming Care Services
February 28, 2023
On January 20, 2023, the Division of Insurance issued a Consumer Advisory that announced that plans issued in the state must cover certain gender-affirming care services starting in 2023. Gender-affirming care services are also included as an essential health benefit (EHB) in the state’s benchmark plan. The division also prepared a PDF guide for this coverage.
Employers with plans governed by the state or with policies that adopted the state’s benchmark plan should be aware of this new area of required coverage.
State Reminds Consumers of the Right to Receive Contraceptive Services at No Cost
February 28, 2023
On February 6, 2023, the Division of Insurance issued a Consumer Advisory reminding insurers regulated by the state of their obligation to cover contraceptive services to insureds at no cost. This obligation prohibits insurers from charging copayments, deductibles or coinsurance amounts to the individual seeking those services.
The ACA requires insurers to provide this coverage for a range of recommended preventative services (including tubal ligation surgery) and prohibits imposing any cost-sharing on insureds receiving those services. In addition, state law obligates insurers regulated by the state to allow for 12-month oral birth control prescriptions.
The division issued this advisory in response to complaints that consumers were asked to pay a portion of the costs associated with preventative services covered by the ACA. Employers with plans regulated by the state should be aware of this obligation.
State Publishes No Surprise Billing Guide
February 28, 2023
On January 10, 2023, the Department of Insurance and Financial Services published a consumer guide to help consumers in the state understand the state’s surprise billing law. Act 368, signed into law in 2020, prohibits out-of-network providers in the state from billing a patient for an amount greater than the applicable in-network coinsurance, copay or deductible. Instead, the out-of-network provider must submit a claim to the patient’s insurer for an amount established in the law. This prohibition generally applies to covered healthcare services provided by an out-of-network provider in an emergency. It also applies if an out-of-network provider bills a patient after treating them at a participating health facility and the patient did not have the ability or opportunity to choose an in-network provider.
The law also requires out-of-network providers to provide a disclosure before providing a non-emergency healthcare service. The disclosure must state that the patient’s health insurer may not provide coverage for all the scheduled healthcare services and that the patient may be responsible for the cost of the services. The disclosure must also state that the provider must provide a good faith estimate of the cost of the healthcare services and that there is a right to request an in-network provider. The disclosure directs the patient to their insurer for information on in-network services.
Employers with plans governed by the state should be aware of this law. Self-insured plans in the state are not subject to the state law but may be subject to the federal No Surprises Act.
New Jersey Temporary Workers’ Bill of Rights Enacted
February 28, 2023
On February 6, 2023, New Jersey Gov. Murphy signed into the law commonly called “The New Jersey Temporary Workers’ Bill of Rights (A1474 2R),” which requires temporary staffing agencies and their clients in certain industries to equalize the compensation and benefits of temporary workers with that of regular employees, provide each temporary worker with a detailed itemized statement of wage and deduction information and other requirements. The applicable industry includes food preparation and service, building and ground cleaning, transportation occupations, and construction.
Most of the law’s provisions will take effect on August 5, 2023, except the new hire notice requirement and non-retaliation provision will become effective on May 7, 2023.
The new law provides significant equal compensation protection to temporary workers, including the “average cost of benefits, or the cash equivalent thereof.” However, the law does not further define benefits for this purpose. Covered employers for temporary agencies or third-party clients should review this development with their employment counsel and monitor any updates to these new requirements.
New Special Enrollment Period for Pregnancy
February 28, 2023
Rhode Island now requires group health plans issued or renewed after January 1, 2023, to establish a new special enrollment period for pregnant individuals to enroll mid-year. The special enrollment period extends throughout the pregnancy. Coverage must be effective as of the first month the pregnant individual applies for coverage. It appears the event would apply to any individual eligible under the group health plan who becomes pregnant, including the employee, spouse, domestic partner or child.
Importantly, pregnancy is not a recognized qualifying event under Section 125. Therefore, if an employee adds coverage mid-year under this event, any associated contributions will likely need to be deducted on a post-tax basis.
This material was created by PPI Benefit Solutions to provide accurate and reliable information on the subjects covered but should not be regarded as a complete analysis of these subjects. It is not intended to provide specific legal, tax or other professional advice. The service of an appropriate professional should be sought regarding your individual situation. PPI does not offer tax or legal advice. "PPI®" is a service mark of Professional Pensions, Inc., a subsidiary of NFP Corp. (NFP). All rights reserved.