Consolidated Appropriations Act (CAA)
In late December 2020, Congress passed the Consolidated Appropriations Act (CAA). This law was designed to help reduce some barriers within the healthcare industry. Providers and health insurance companies are required to put several measures in place including making the cost of care available on Plan and provider websites, eliminate surprise billing, and provide continuity of care when a provider/facility leaves the network. These changes apply to individual and group health plans (grandfathered and non-grandfathered). Many elements of the CAA went into effect on Jan. 1, 2022, though some were delayed while the federal government worked out details of the requirements.
Below you will find a brief description of key points of the CAA and additional frequently asked questions that may be helpful to you. We also have a high-level overview that can be printed.
- Members
- General Info
- ID Cards
- Balance billing: Surprise bills must be covered at in-network rates
- Provider directories/Continuity of Care
- Price comparison tools
- Good-faith estimates/Advanced Explanation of Benefits (EOBs)
- Pharmacy reporting procedures
- Mental health parity
- Employer Groups
- General Info
- ID Cards
- Balance billing: Surprise bills must be covered at in-network rates
- Provider directories/Continuity of Care
- Price comparison tools
- Good-faith estimates/Advanced Explanation of Benefits (EOBs)
- Pharmacy reporting procedures
- Mental health parity
- Gag Clause Attestation
- Providers
- Balance billing: Surprise bills must be covered at in-network rates
- Provider directories/Continuity of Care
- Price comparison tools
- Good-faith estimates/Advanced Explanation of Benefits (EOBs)
- Pharmacy reporting procedures
- Mental health parity
What plans does the CAA rule apply to?
The federal law applies to individual, small group, and large group fully insured markets and self-insured group plans, including grandfathered plans and transitional relief plans. Coverage offered through the exchange (healthcare.gov) and for federal employees through the Federal Employees Health Benefits Program is also covered by the surprise billing law. Self-funded plans and Level Funded plans are also included.
Excepted benefits* and short-term limited duration insurance are excluded.
At this time, BCBSKS understands that the requirements of the CAA do not apply to coverage under Medicare Advantage (MA) or Medicare Part D. Medicare-specific provisions in the CAA are primarily applicable to FFS Medicare. However, some requirements may ultimately have some downstream effect to MA - e.g. physician fee schedule changes. BCBSKS is monitoring for any CMS guidance that is issued related to this Act and will implement any additional requirements as it relates to our MA and Medicare Part D plans if/when directed.
The No Surprises Act still applies for groups that don’t have out of network coverage.
*Excepted benefits are:
- those not considered health care coverage
- those that are limited benefits such as dental and vision,
- specific disease or illness coverage such as hospital indemnity
- and supplemental policies to Medicare or Armed Forces health care coverage
Beginning on and after January 1, 2022, as plans renew, new ID cards will be issued and must include:
- Plan deductibles for network and out-of-network deductible amounts.
- Maximum limits on out-of-pocket costs including network and out-of-network limits, as applicable.
- Phone number and web address for a member to get assistance including help to find a network provider.
Which of the following plans will require new ID cards to be issued?
We will reissue all ID cards upon renewal for all health insurance plans, with two exceptions. Medigap plans and Senior plans (through the State Employee Health Program) will not receive new ID cards.
Will every ID card need to be replaced with the new format or will maintenance ID cards and online cards suffice? When will the new cards need to be issued?
Cards will be updated and issued upon renewal to existing members and new members that change plans, prior to the plan effective or renewal date as is our normal business practice. BCBSKS will not proactively issue new cards to all members prior to Jan. 1, 2022. Existing members that wish to have a new ID card prior to their renewal date will be able to download an electronic version or request a new card via https://www.bcbsks.com/blue-access/login. A customer may request a full reissuance of ID cards if they so choose.
Download a helpful, one-page guide to understanding surprise medical bills.
Health plans must negotiate surprise medical bills on behalf of patients who receive emergency services rendered by out-of-network providers/facilities, air ambulance services, and services provided by out-of-network providers at in-network hospitals or facilities. The new law lifts the burden off patients, so they are held harmless and not balance billed for provider charges that exceed the in-network rate.
The law includes prohibitions on balance billing, a settlement process for disputes between health insurers or group health plans and out-of-network providers, and coordination with state surprise billing laws.
The law applies to medical bills related to:
- Out-of-network emergency covered services at a hospital or free-standing facility.
- Covered items and services provided by an out-of-network health care provider at an in-network facility.
- Out-of-network air ambulance items and services.
The law applies to emergency services at out-of-network hospitals and free-standing emergency facilities, out-of-network providers at in-network facilities, and out-of-network air ambulance carriers. Providers are prohibited from balance billing patients for these services. In addition, out-of-network providers of ancillary services at an in-network facility are also prohibited from balance billing patients. Ancillary services are those for emergency medicine, anesthesiology, pathology, radiology, neonatology, and laboratory and diagnostic services, and where there is not an in-network provider available.
The No Surprises Act establishes an Independent Dispute Resolution (IDR) process, also referred to as arbitration, to resolve disputes between out-of-network providers and insurers/health plans and prohibits balance billing by out-of-network providers with certain exceptions. The law does not apply if the member chooses to receive items and services from an out-of-network provider.
How does this new rule affect me?
While BCBSKS contracts with most hospitals and providers in our state, there could be occasions where you go seek emergency care at an in-network facility but are seen and treated by a provider who is out-of-network. In those cases, BCBSKS will now cover the care received by that provider at in-network rates.
BCBSKS cannot impose out-of-network member cost-sharing (co-pays, deductibles) requirements that are greater than those applied to in-network services (e.g., if your BCBSKS plan has a 10% co-insurance for in-network services, the co-insurance for out-of-network services cannot exceed 10%). Also, out-of-network cost-sharing must be applied to in-network deductibles and cost-sharing limits.
How does the No Surprises Act require coverage for out-of-network services including air ambulance?
BCBSKS will cover the same out-of-network items/services as it does in-network items/services regardless of whether they are provided by a non-participating provider/facility, subject to the requirements for cost-sharing (co-pays and deductibles), payment amounts, and dispute resolution. This includes all covered items/services in connection with the visit to the facility even if that care is provided outside of the facility (e.g., laboratory and telemedicine services).
If BCBSKS has a network of participating providers and covers any air ambulance benefits, BCBSKS must cover services provided by an out-of-network air ambulance carrier, even if BCBSKS does not have any in-network air ambulance carriers, subject to the requirements for cost-sharing, payment amounts, and dispute resolution.
Are there any restrictions or plan terms that change what out-of-network services are covered?
Coverage for emergency services must be provided without any prior authorization requirements or with administrative requirements or coverage limits that are more restrictive than those applicable to in-network emergency services.
Coverage for emergency services must be provided without regard to any other term or condition of the plan or coverage except for: (a) the exclusion or coordination of benefits when it’s not consistent with any benefits for emergency services); (b) any affiliation or waiting period or (c) any applicable cost-sharing requirements.
BCBSKS cannot deny benefits for a member with an emergency medical condition that receives emergency services, based on a general plan exclusion that applies to non-emergency items/services (e.g., denying emergency treatment for a dependent pregnant woman based on a general exclusion for dependent maternity care).
How is cost sharing handled for out-of-network emergency, out-of-network air ambulance or out-of-network service at an in-network facility when member has no choice?
In cases of extreme emergency, there will be times when you are unable to tell emergency providers where you would like to receive treatment. For situations like these, where the patient has no control over where they receive care, BCBSKS will not make a member pay out-of-network cost-sharing if it is a higher amount than what would be typical for their cost-sharing on in-network services. For example, if a member’s plan requires 10% co-insurance for in-network services, the co-insurance for out-of-network services cannot exceed 10%. In addition, out-of-network cost-sharing must be applied to in-network deductibles and cost-sharing limits.
When can a provider balance bill an individual?
Patients may be balanced billed for out-of-network non-ancillary services at an in-network facility if the provider:
- informs the patient in advanced that they are out-of-network,
- provides an estimate of the charges, and
- secures a written acknowledgement from the patient that they received the notice and understand any cost-sharing will be applied to their out-of-network limits.
Ancillary services are those for emergency medicine, anesthesiology, pathology, radiology, neonatology, and laboratory.
What are my rights and protections against surprise medical bills?
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing, or balance billing.
What is balance billing (sometimes called surprise billing)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. Out-of-network describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called balance billing. This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. Surprise billing is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Emergency services - If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center - When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in‑network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the Kansas Insurance Department at https://insurance.kansas.gov/ . You can also visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
What is the process if BCBSKS and the out-of-network provider/facility do not agree on the rates the provider/facility bills?
BCBSKS negotiates and agrees upon rates in advance with in-network facilities and providers. It is what we do to help protect our members from paying more for their care than they should. These negotiations do not take place with out-of-network facilities and providers until after a service is provided.
Included in the ACA is an independent dispute resolution (IDR) process, sometimes called a arbitration, which was established to determine the provider reimbursement amount if the health insurer or group health plan and the out-of-network provider are unable to negotiate a reimbursement rate (and if there is not a state law methodology to establish the reimbursement amount). The most important thing for our members to know about this is that once the IDR process concludes, the provider cannot balance bill, or send a bill to the patient for the remainder that was not covered by BCBSKS.
Health plans must keep their provider directories up to date and verify they are accurate no less than 90 days to ensure that members can access accurate information about in-network providers/facilities. BCBSKS is also begin-networking a new policy of responding to provider/facility networking questions from our members within one business day. When a members calls or inquires to customer service as to if a particular provider or facility is in the BCBSKS network, we will respond within one business day to ensure our members have timely access to the information they need.
BCBSKS must notify individuals when a provider/facility leaves its network and must provide related transitional continuity of care to patients in some circumstances. For patients receiving certain types of ongoing care from affected providers or facilities, health plans must provide up to 90-days of transitional coverage (or until treatment ends) by those providers, at in-network rates. Such transitional coverage is generally available for patients being treated for serious/complex health conditions, inpatient care, non-elective surgery, pregnancy and terminal illness.
How do I find out if a provider or facility is in network?
You can search to find in-network providers on our website. Here you can search by location and specialty. You can also call our Customer Service Center for this information toll free at 1-800-432-3990 and you will receive a verified response within one business day.
Ultimately, it is the responsibility of the member to verify the network status at the time services are rendered. We encourage members to access our online directories for the most current network information. Claims are processed according to the network status of the provider in our system. If that status is incorrect and the claim is appealed, we investigate to ensure we have the correct status. If not, we would reprocess the claim.
Which providers are required to be included in an updated directory?
The medical / surgical / physical, vision, dental, and behavioral directories are all included. A pharmacy directory is not required.
If a member asks about the status of a specific provider, does that guarantee that the provider is in network when the member goes for care?
If a member calls BCBSKS to expressly confirm that a specific provider is in network, BCBSKS will confirm the status and send a written or electronic confirmation which is good for a specified number of days. This will mean if the information was conveyed in error, we would cover the benefit at in-network benefit level based on the confirmation. However, the written response and confirmation doesn’t apply when the member calls for other reasons such as changing their PCP, to check on benefits, or ask general information about provider type (e.g., who are the cardiologists or gastroenterologists in the network), or can you provide a list of facilities or surgical centers. For those general calls, the member should confirm with the provider or directory prior to the visit if they are in network.
What is required under CAA regarding continuity of care?
The CAA allows certain patients the opportunity to continue care if their provider (doctor) or facility (hospital) is no longer in the BCBSKS network due to a change health plans or the provider/facility leaving the network. BCBSKS must permit members who are continuing care patients with an opportunity to request an election to continue to have benefits provided under the plan/coverage under the same terms and conditions as they would have been covered had no change occurred for up to a maximum of 90 days. The timing starts on the date a notice of the right to elect continuing care is provided to the member and ends the date on which the patient is no longer undergoing continuing care by that provider or facility, up to a maximum of 90 days.
Continuing care includes the following:
- Serious and complex conditions
- Course of institutional or inpatient care
- Scheduled nonelective surgery including post-operative care
- Course of treatment for pregnancy
- Terminally ill patients
When does continuity of care apply to self-funded plans?
Continuity of care may apply when a provider is no longer in the network. The member then has the right to request continuity of care for certain health care situations which, if authorized, would end after 90 days or the date the person is no longer under care.
It does not apply to plan changes or if the health plan moves to another plan administrator that does not have the provider in network. At that time if the plan had a transition of care program that would apply.
How does BCBSKS identify members that may be eligible for continuity of care under the CAA?
BCBSKS will send a letter to all members who are impacted by either loss of coverage, a change in health plans or a provider who is no longer a part of our network. Members who may be eligible will receive an opt-in form with this notification. The form must be filled out and submitted to BCBSKS.
Health plans must provide price comparison tools both online and by phone for members to compare expected cost-sharing amounts for covered services. While an extension was offered by the Federal Government, BCBSKS will begin the rollout of our new price comparison tool in early 2022.
How will you use price transparency as an opportunity to improve customer experience?
BCBSKS is committed to improving the experience of our members. We have an existing cost comparison tool on our website and have worked over the last year to improve this tool. We believe that our members should have a choice as to where they receive their care. This choice can be fueled by many things – location, prestige of a provider or facility and even cost. That’s why we are proud to have the largest network of providers of any Kansas insurance company, giving our members the ability to choose. With our new cost comparison tool, our members have more control than ever on where they choose to seek care.
New requirements on good-faith estimates and advanced Explanation of Benefits (EOBs) have been postponed by the federal government pending additional guidance expected to be issued in 2022.
Health plans are required to report on pharmacy benefits and drug costs. Plans will be required to annually report several plan details to the Departments of Health and Human Services, Labor and the United States Treasury. Pharmacy Benefit and Cost Reporting implementation dates are moved pending additional guidance. Plans are encouraged to prepare to meet the pharmacy benefits and cost reporting requirements by December 27, 2022.
Health plans are required to strengthen parity in mental health and substance use disorder benefits. Under the new requirements, individual and group health plans, including self-funded group health plans, must conduct and document a comparative analysis of their non-quantitative treatment limits (processes, strategies, standards, or other criteria that limit the scope or duration of benefits for services provided under the plan) for mental health, substance use disorder and medical surgical benefits. The new mental health parity requirements went into effect on February 10, 2021.
What plans does the CAA rule apply to?
The federal law applies to individual, small group, and large group fully insured markets and self-insured group plans, including grandfathered plans and transitional relief plans. Coverage offered through the exchange (healthcare.gov) and for federal employees through the Federal Employees Health Benefits Program is also covered by the surprise billing law. Self-funded plans and Level Funded plans are also included.
Excepted benefits* and short-term limited duration insurance are excluded.
At this time, BCBSKS understands that the requirements of the CAA do not apply to coverage under Medicare Advantage (MA) or Medicare Part D. Medicare-specific provisions in the CAA are primarily applicable to FFS Medicare. However, some requirements may ultimately have some downstream effect to MA - e.g. physician fee schedule changes. BCBSKS is monitoring for any CMS guidance that is issued related to this Act and will implement any additional requirements as it relates to our MA and Medicare Part D plans if/when directed.
The No Surprises Act still applies for groups that don’t have out of network coverage.
*Excepted benefits are:
- those not considered health care coverage
- those that are limited benefits such as dental and vision,
- specific disease or illness coverage such as hospital indemnity
- and supplemental policies to Medicare or Armed Forces health care coverage
Beginning on and after January 1, 2022, as plans renew, new ID cards will be issued and must include:
- Plan deductibles for network and out-of-network deductible amounts.
- Maximum limits on out-of-pocket costs including network and out-of-network limits, as applicable.
- Phone number and web address for a member to get assistance including help to find a network provider.
Which of the following plans will require new ID cards to be issued?
We will reissue all ID cards upon renewal for all health insurance plans, with two exceptions. Medigap plans and Senior plans (through the State Employee Health Program) will not receive new ID cards.
Will every ID card need to be replaced with the new format or will maintenance ID cards and online cards suffice? When will the new cards need to be issued?
Cards will be updated and issued upon renewal to existing members and new members that change plans, prior to the plan effective or renewal date as is our normal business practice. BCBSKS will not proactively issue new cards to all members prior to Jan. 1, 2022. Existing members that wish to have a new ID card prior to their renewal date will be able to download an electronic version or request a new card via https://www.bcbsks.com/blue-access/login. A customer may request a full reissuance of ID cards if they so choose.
Download a helpful, one-page guide to understanding surprise medical bills.
Health plans must negotiate surprise medical bills on behalf of patients who receive emergency services rendered by out-of-network providers/facilities, air ambulance services, and services provided by out-of-network providers at in-network hospitals or facilities. The new law lifts the burden off patients, so they are held harmless and not balance billed for provider charges that exceed the in-network rate.
The law includes prohibitions on balance billing, a settlement process for disputes between health insurers or group health plans and out-of-network providers, and coordination with state surprise billing laws.
The law applies to medical bills related to:
- Out-of-network emergency covered services at a hospital or free-standing facility.
- Covered items and services provided by an out-of-network health care provider at an in-network facility.
- Out-of-network air ambulance items and services.
The law applies to emergency services at out-of-network hospitals and free-standing emergency facilities, out-of-network providers at in-network facilities, and out-of-network air ambulance carriers. Providers are prohibited from balance billing patients for these services. In addition, out-of-network providers of ancillary services at an in-network facility are also prohibited from balance billing patients. Ancillary services are those for emergency medicine, anesthesiology, pathology, radiology, neonatology, and laboratory and diagnostic services, and where there is not an in-network provider available.
The No Surprises Act establishes an Independent Dispute Resolution (IDR) process, also referred to as arbitration, to resolve disputes between out-of-network providers and insurers/health plans and prohibits balance billing by out-of-network providers with certain exceptions. The law does not apply if the member chooses to receive items and services from an out-of-network provider.
How does this new rule affect me?
While BCBSKS contracts with most hospitals and providers in our state, there could be occasions where you go seek emergency care at an in-network facility but are seen and treated by a provider who is out-of-network. In those cases, BCBSKS will now cover the care received by that provider at in-network rates.
BCBSKS cannot impose out-of-network member cost-sharing (co-pays, deductibles) requirements that are greater than those applied to in-network services (e.g., if your BCBSKS plan has a 10% co-insurance for in-network services, the co-insurance for out-of-network services cannot exceed 10%). Also, out-of-network cost-sharing must be applied to in-network deductibles and cost-sharing limits.
How does the No Surprises Act require coverage for out-of-network services including air ambulance?
BCBSKS will cover the same out-of-network items/services as it does in-network items/services regardless of whether they are provided by a non-participating provider/facility, subject to the requirements for cost-sharing (co-pays and deductibles), payment amounts, and dispute resolution. This includes all covered items/services in connection with the visit to the facility even if that care is provided outside of the facility (e.g., laboratory and telemedicine services).
If BCBSKS has a network of participating providers and covers any air ambulance benefits, BCBSKS must cover services provided by an out-of-network air ambulance carrier, even if BCBSKS does not have any in-network air ambulance carriers, subject to the requirements for cost-sharing, payment amounts, and dispute resolution.
Are there any restrictions or plan terms that change what out-of-network services are covered?
Coverage for emergency services must be provided without any prior authorization requirements or with administrative requirements or coverage limits that are more restrictive than those applicable to in-network emergency services.
Coverage for emergency services must be provided without regard to any other term or condition of the plan or coverage except for: (a) the exclusion or coordination of benefits when it’s not consistent with any benefits for emergency services); (b) any affiliation or waiting period or (c) any applicable cost-sharing requirements.
BCBSKS cannot deny benefits for a member with an emergency medical condition that receives emergency services, based on a general plan exclusion that applies to non-emergency items/services (e.g., denying emergency treatment for a dependent pregnant woman based on a general exclusion for dependent maternity care).
How is cost sharing handled for out-of-network emergency, out-of-network air ambulance or out-of-network service at an in-network facility when member has no choice?
In cases of extreme emergency, there will be times when you are unable to tell emergency providers where you would like to receive treatment. For situations like these, where the patient has no control over where they receive care, BCBSKS will not make a member pay out-of-network cost-sharing if it is a higher amount than what would be typical for their cost-sharing on in-network services. For example, if a member’s plan requires 10% co-insurance for in-network services, the co-insurance for out-of-network services cannot exceed 10%. In addition, out-of-network cost-sharing must be applied to in-network deductibles and cost-sharing limits.
When can a provider balance bill an individual?
Patients may be balanced billed for out-of-network non-ancillary services at an in-network facility if the provider:
- informs the patient in advanced that they are out-of-network ,
- provides an estimate of the charges, and
- secures a written acknowledgement from the patient that they received the notice and understand any cost-sharing will be applied to their out-of-network limits.
Ancillary services are those for emergency medicine, anesthesiology, pathology, radiology, neonatology, and laboratory.
What are my rights and protections against surprise medical bills?
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing, or balance billing.
What is balance billing (sometimes called surprise billing)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. Out-of-network describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called balance billing. This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. Surprise billing is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Emergency services - If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center - When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in‑network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the Kansas Insurance Department at https://insurance.kansas.gov/ . You can also visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
What is the process if BCBSKS and the out-of-network provider/facility do not agree on the rates the provider/facility bills?
BCBSKS negotiates and agrees upon rates in advance with in-network facilities and providers. It is what we do to help protect our members from paying more for their care than they should. These negotiations do not take place with out-of-network facilities and providers until after a service is provided.
Included in the ACA is an independent dispute resolution (IDR) process, sometimes called a arbitration, which was established to determine the provider reimbursement amount if the health insurer or group health plan and the out-of-network provider are unable to negotiate a reimbursement rate (and if there is not a state law methodology to establish the reimbursement amount). The most important thing for our members to know about this is that once the IDR process concludes, the provider cannot balance bill, or send a bill to the patient for the remainder that was not covered by BCBSKS.
Health plans must keep their provider directories up to date and verify they are accurate no less than 90 days to ensure that members can access accurate information about in-network providers/facilities. BCBSKS is also begin-networking a new policy of responding to provider/facility networking questions from our members within one business day. When a members calls or inquires to customer service as to if a particular provider or facility is in the BCBSKS network, we will respond within one business day to ensure our members have timely access to the information they need.
BCBSKS must notify individuals when a provider/facility leaves its network and must provide related transitional continuity of care to patients in some circumstances. For patients receiving certain types of ongoing care from affected providers or facilities, health plans must provide up to 90-days of transitional coverage (or until treatment ends) by those providers, at in-network rates. Such transitional coverage is generally available for patients being treated for serious/complex health conditions, inpatient care, non-elective surgery, pregnancy and terminal illness.
How do I find out if a provider or facility is in network?
You can search to find in-network providers on our website. Here you can search by location and specialty. You can also call our Customer Service Center for this information toll free at 1-800-432-3990 and you will receive a verified response within one business day.
Ultimately, it is the responsibility of the member to verify the network status at the time services are rendered. We encourage members to access our online directories for the most current network information. Claims are processed according to the network status of the provider in our system. If that status is incorrect and the claim is appealed, we investigate to ensure we have the correct status. If not, we would reprocess the claim.
Which providers are required to be included in an updated directory?
The medical / surgical / physical, vision, dental, and behavioral directories are all included. A pharmacy directory is not required.
If a member asks about the status of a specific provider, does that guarantee that the provider is in network when the member goes for care?
If a member calls BCBSKS to expressly confirm that a specific provider is in network, BCBSKS will confirm the status and send a written or electronic confirmation which is good for a specified number of days. This will mean if the information was conveyed in error, we would cover the benefit at in-network benefit level based on the confirmation. However, the written response and confirmation doesn’t apply when the member calls for other reasons such as changing their PCP, to check on benefits, or ask general information about provider type (e.g., who are the cardiologists or gastroenterologists in the network), or can you provide a list of facilities or surgical centers. For those general calls, the member should confirm with the provider or directory prior to the visit if they are in network.
What is required under CAA regarding continuity of care?
The CAA allows certain patients the opportunity to continue care if their provider (doctor) or facility (hospital) is no longer in the BCBSKS network due to a change health plans or the provider/facility leaving the network. BCBSKS must permit members who are continuing care patients with an opportunity to request an election to continue to have benefits provided under the plan/coverage under the same terms and conditions as they would have been covered had no change occurred for up to a maximum of 90 days. The timing starts on the date a notice of the right to elect continuing care is provided to the member and ends the date on which the patient is no longer undergoing continuing care by that provider or facility, up to a maximum of 90 days.
Continuing care includes the following:
- Serious and complex conditions
- Course of institutional or inpatient care
- Scheduled nonelective surgery including post-operative care
- Course of treatment for pregnancy
- Terminally ill patients
When does continuity of care apply to self-funded plans?
Continuity of care may apply when a provider is no longer in the network. The member then has the right to request continuity of care for certain health care situations which, if authorized, would end after 90 days or the date the person is no longer under care.
It does not apply to plan changes or if the health plan moves to another plan administrator that does not have the provider in network. At that time if the plan had a transition of care program that would apply.
How does BCBSKS identify members that may be eligible for continuity of care under the CAA?
BCBSKS will send a letter to all members who are impacted by either loss of coverage, a change in health plans or a provider who is no longer a part of our network. Members who may be eligible will receive an opt-in form with this notification. The form must be filled out and submitted to BCBSKS.
Health plans must provide price comparison tools both online and by phone for members to compare expected cost-sharing amounts for covered services. While an extension was offered by the Federal Government, BCBSKS will begin the rollout of our new price comparison tool in early 2022.
How will you use price transparency as an opportunity to improve customer experience?
BCBSKS is committed to improving the experience of our members. We have an existing cost comparison tool on our website and have worked over the last year to improve this tool. We believe that our members should have a choice as to where they receive their care. This choice can be fueled by many things – location, prestige of a provider or facility and even cost. That’s why we are proud to have the largest network of providers of any Kansas insurance company, giving our members the ability to choose. With our new cost comparison tool, our members have more control than ever on where they choose to seek care.
New requirements on good-faith estimates and advanced Explanation of Benefits (EOBs) have been postponed by the federal government pending additional guidance expected to be issued in 2022.
Beginning in 2022, the Consolidated Appropriations Act of 2021 required group health plans or health insurers, like Blue Cross and Blue Shield of Kansas (BCBSKS), to report data on health plan premiums and various healthcare spending categories, along with certain prescription drug information to the federal government. The report is known as the RxDC Pharmacy Report (RxDC). BCBSKS values the strong relationships we have with our groups, and we are here to help you through the data submission process.
- More information if your group is fully insured/level-funded.
- More information if your group is an ASO/Minimum Premium.
All information must be submitted through the BCBSKS web portal by April 23, 2025, for BCBSKS to submit this information to CMS on your behalf.
*The deadline for submission of RxDC data was 12 a.m., April 30. Blue Cross and Blue Shield of Kansas is no longer accepting submissions. Any information submitted after 12 a.m. on April 30 will not be included in our reporting to CMS and you will be required to submit this information on your own. Below are some helpful links and information from the CMS website for how to submit your data.
Beginning in 2022, the Consolidated Appropriations Act of 2021 requires group health plans or health insurers, like Blue Cross and Blue Shield of Kansas (BCBSKS), to report data on health plan premiums and various health care spending categories, along with certain prescription drug information, to the federal government. The report is known as the RxDC Pharmacy Report (RxDC). BCBSKS values the strong relationships we have with our groups, and we are here to help you through the data submission process.
This is a yearly requirement through the CAA. BCBSKS will reach out to groups in Q1 of each calendar year to begin collecting the necessary data.
Under the regulatory requirements of the Consolidated Appropriations Act (CAA), individual and group health plans, including self-funded group health plans, must conduct and document a comparative analysis of their non-quantitative treatment limits (processes, strategies, standards, or other criteria that limit the scope or duration of benefits for services provided under the plan) for mental health, substance use disorder and medical surgical benefits.
Fully Insured Plans — BCBSKS standard fully-insured plan designs and processes are designed to be parity-compliant.
Self-funded Plans – Self-funded plans are legally responsible for compliance with the mental health parity requirements, including Non-Quantitative Treatment Limitations (NQTL) analysis. BCBSKS will provide assistance in demonstrating Mental Health Parity NQTL compliance via documentation that shows compliant policies and procedures when a group receives an official request from a state or federal regulating entity. ASO groups should consult with their own legal counsel to have their plan document and summary plan descriptions reviewed and updated, as needed, as part of their Plan’s review of NQTL benefits.
What is the Mental Health Parity and Addiction Equity Act (MHPAEA)?
MHPAEA is a federal law that prevents individual and group health plans, and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits. Parity doesn’t require that mental health benefits be offered.
Can you describe how BCBSKS will support a self-funded customer?
For our self-funded clients, we provide the following support, when a group receives an official request from a state or federal regulating entity:
- We will assist ASO clients in meeting NQTL documentation requirements.
- Specifically, we will assist by providing documentation including any differences particular to the Plan that we found in our analysis.
- Should an ASO client receive a DOL audit request, they should let BCBSKS know immediately so that we work to provide documentation to assist the Plan with fulfilling their obligation to provide timely responses back to the regulator.
What are the key components of NQTL under Mental Health Parity?
Benefit limitations may include, but are not limited to, the following:
- Medical management standards based on medical necessity / appropriateness of services such as prior authorizations and concurrent review
- Formulary design
- Standards for provider participation in a network, including reimbursement rates
- Step therapy requirements
For all NQTLs identified, the benefit applied to mental health and substance use disorder benefits must be comparable to and applied no more stringently than those NQTLs applied to medical surgical benefits.
*Blue Cross and Blue Shield of Kansas filed the Gag Clause Attestation on Dec. 18 for fully insured and self-funded groups that met the criteria outlined in the letter and information below. If your group was not included, you will be required to submit this information on your own by Dec. 31. Below is a helpful link with information for how to submit your data.
What is the gag clause attestation law that groups must follow?
In December 2020, a federal law was enacted which prohibits groups and insurers offering group coverage from entering into agreements with providers, third-party administrators, or other service providers that restricts the group or group insurer from:
- providing provider-specific cost or quality of care information or data to referring providers, plan sponsors, members, or prospective members;
- electronically accessing de-identified claims and encounter information or data for each member in the plan or coverage, upon request and consistent with other privacy and federal laws; and
- sharing either of the above with a business associate and consistent with other privacy and federal laws.
The law also requires groups and insurers offering group coverage to attest that they have not entered into any prohibited agreements after Dec. 27, 2023, and will not enter into any prohibited agreements in the future. The attestation must be completed annually.
Which groups will BCBSKS include in their attestation filing?
- Fully insured groups that did not request us not to submit on their behalf.
- Self-funded groups that submitted their required information to BCBSKS by Nov. 22, 2024.
Will BCBSKS report on behalf of all groups?
No, BCBSKS is not reporting on behalf of the following groups for BCBSKS providers and network of providers:
-
Any group that opts out of BCBSKS reporting on their behalf
- Any group that was a self-funded group at any point between Dec. 27, 2023, and Oct. 1, 2024, that does not affirmatively opt-in to BCBSKS attesting on their behalf
-
Any group that cancelled their BCBSKS insurance before Oct. 1, 2024 (some exceptions exist)
-
Any group that became a BCBSKS group after Oct. 1, 2024
-
Any group that only has BCBSKS benefits which are excepted from reporting (i.e., limited scope dental) per CMS instructions.
Where can I find more information?
If your group has questions about the gag clause attestation and how to report your compliance, you can find more information here: https://www.cms.gov/marketplace/about/oversight/other-insurance-protections/gag-clause-prohibition-compliance-attestation
My group is reporting on our own. Where can I find a statement from BCBSKS to submit my group’s attestation?
Groups that are reporting on their own may want or need a statement regarding BCBSKS’s compliance efforts with the gag clause prohibition. BCBSKS offers the following statement:
Blue Cross Blue Shield of Kansas’s Statement Regarding Compliance with Gag Clause Prohibition for the Attestation Due by Dec. 31, 2024
BCBSKS has made an effort to review and ensure relevant contracts follow federal law regarding the prohibition on gag clauses during the applicable timeframe. Based on these efforts, BCBSKS intends to attest that it is in compliance with the gag clause prohibition that is due by Dec. 31, 2024, for its providers and network of providers.
Health plans must negotiate surprise medical bills on behalf of patients who receive emergency services rendered by out-of-network providers/facilities, air ambulance services, and services provided by out-of-network providers at in-network hospitals or facilities. The new law lifts the burden off patients, so they are held harmless and not balance billed for provider charges that exceed the in-network rate.
The law includes prohibitions on balance billing, a settlement process for disputes between health insurers or group health plans and out-of-network providers, and coordination with state surprise billing laws.
The law applies to medical bills related to:
- Out-of-network emergency covered services at a hospital or free-standing facility.
- Covered items and services provided by an out-of-network health care provider at an in-network facility.
- Out-of-network air ambulance items and services.
The law applies to emergency services at out-of-network hospitals and free-standing emergency facilities, out-of-network providers at in-network facilities, and out-of-network air ambulance carriers. Providers are prohibited from balance billing patients for these services. In addition, out-of-network providers of ancillary services at an in-network facility are also prohibited from balance billing patients. Ancillary services are those for emergency medicine, anesthesiology, pathology, radiology, neonatology, and laboratory and diagnostic services, and where there is not an in-network provider available.
The No Surprises Act establishes an Independent Dispute Resolution (IDR) process, also referred to as arbitration, to resolve disputes between out-of-network providers and insurers/health plans and prohibits balance billing by out-of-network providers with certain exceptions. The law does not apply if the member chooses to receive items and services from an out-of-network provider.
When can a provider balance bill an individual?
Patients may be balanced billed for out-of-network non-ancillary services at an in-network facility if the provider
- informs the patient in advanced that they are out-of-network,
- provides an estimate of the charges, and
- secures a written acknowledgement from the patient that they received the notice and understand any cost-sharing will be applied to their out-of-network limits.
Ancillary services are those for emergency medicine, anesthesiology, pathology, radiology, neonatology, and laboratory.
What is the process if BCBSKS and the out-of-network provider/facility do not agree on the rates the provider/facility bills?
Included in the CAA is an independent dispute resolution (IDR) process, sometimes called arbitration, which was established to determine the provider reimbursement amount if the health insurer or group health plan and the out-of-network provider are unable to negotiate a reimbursement rate (and if there is not a state law methodology to establish the reimbursement amount).
Here’s how it will work:
- There is a 30-day negotiation period with the health plan to resolve disputes over reimbursement for out-of-network covered items and services. The negotiation period starts after the provider receives payment or a claim denial. Four days after the end of the 30-day negotiation period, if no agreement has been met, either BCBSKS or the provider can request an IDR. If the provider does not contact the health plan within 30 days of payment, the arbitration option is not available to them.
- Both parties must agree on an IDR entity, otherwise the Department of Health and Human Services will select an IDR entity. The offers are then submitted to the arbitrator.
- BCBSKS and the provider will make an offer reimbursement rate they believe to be fair and the IDR entity will chose either the BCBSKS offer or the provider offer. The party whose offer was not selected will pay any costs associated with the IDR process and the additional payment amount required. How that is covered by the self-funded customer is outlined in their plan agreement.
- In choosing either the BCBSKS offer or the provider offer, the IDR entity shall consider the median contracted rate for the item or service. In addition, the IDR entity may request information on the following in order to reach a decision:
- The level of training, experience, and quality and outcomes measurements of the provider or facility.
- The market share of the provider or facility and BCBSKS in the geographic area.
- The acuity of the patient’s condition.
- The teaching status, case mix, and scope of services of the facility.
- Demonstrations of good faith efforts by the provider or facility to participate in the BCBSKS network.
The IDR entity is specifically prohibited from considering billed charges, provider usual and customary fees, or government program rates like Medicare or Medicaid. There are federal rules and processes yet to be developed, and questions about scope and applicability as it relates to state laws.
Providers are not allowed to balance bill the patient for the remainder.
Health plans must keep their provider directories up to date and verify they are accurate no less than 90 days to ensure that members can access accurate information about in-network providers/facilities. BCBSKS is also begin-networking a new policy of responding to provider/facility networking questions from our members within one business day. When a members calls or inquires to customer service as to if a particular provider or facility is in the BCBSKS network, we will respond within one business day to ensure our members have timely access to the information they need.
BCBSKS must notify individuals when a provider/facility leaves its network and must provide related transitional continuity of care to patients in some circumstances. For patients receiving certain types of ongoing care from affected providers or facilities, health plans must provide up to 90-days of transitional coverage (or until treatment ends) by those providers, at in-network rates. Such transitional coverage is generally available for patients being treated for serious/complex health conditions, inpatient care, non-elective surgery, pregnancy and terminal illness.
Which providers are required to be included in an updated directory?
The medical / surgical / physical, vision, dental, and behavioral directories are all included. A pharmacy directory is not required.
What information is required to be in a directory under CAA?
The provider directory must include the following information for each health care provider or hospital/facility that the plan has a contractual relationship with to provide items and services under the plan’s coverage including
- Name
- Address
- Specialty
- Phone number
- Digital contact information (email address and/or website)
BCBSKS will continue to ask providers to verify their data through regular Availity attestations. If a provider’s data cannot be verified, the provider will be removed from the online provider directory. Once the data is verified the provider will be added back into the directory. Once BCBSKS receives updated information for a provider, it will be updated within two business days.
What is required under CAA regarding continuity of care?
The CAA allows certain patients the opportunity to continue care if their provider (doctor) or facility (hospital) is no longer in the BCBSKS network due to a change health plans or the provider/facility leaving the network. BCBSKS must permit members who are continuing care patients with an opportunity to request an election to continue to have benefits provided under the plan/coverage under the same terms and conditions as they would have been covered had no change occurred for up to a maximum of 90 days. The timing starts on the date a notice of the right to elect continuing care is provided to the member and ends the date on which the patient is no longer undergoing continuing care by that provider or facility, up to a maximum of 90 days.
Continuing care includes the following:
- Serious and complex conditions
- Course of institutional or inpatient care
- Scheduled nonelective surgery including post-operative care
- Course of treatment for pregnancy
- Terminally ill patients
Health plans must provide price comparison tools both online and by phone for members to compare expected cost-sharing amounts for covered services. While an extension was offered by the Federal Government, BCBSKS will begin the rollout of our new price comparison tool in early 2022.
New requirements on good-faith estimates and advanced Explanation of Benefits (EOBs) have been postponed by the federal government pending additional guidance expected to be issued in 2022.
Health plans are required to report on pharmacy benefits and drug costs. Plans will be required to annually report several plan details to the Departments of Health and Human Services, Labor and the United States Treasury. Pharmacy Benefit and Cost Reporting implementation dates are moved pending additional guidance. Plans are encouraged to prepare to meet the pharmacy benefits and cost reporting requirements by Dec. 27, 2022.
The RxDC report requires various files to be submitted for both fully insured and self-funded groups for coverage that is not carved out for BCBSKS. These files include both a listing of group health plans, as well as various data files:
The data reports required by CMS include:
P2: Group Health Plan List
D1: Premium and Life Years
D2: Spending by Category
D3: Top 50 Most Frequent Brand Drugs
D4: Top 50 Most Costly Drugs
D5: Top 50 Drugs by Spending Increase
D6: Rx Totals
D7: Rx Rebates by Therapeutic Class
D8: Rx Rebates for the Top 25 Drugs
Premium information (part of D1) will be reported for all groups that responded to the BCBSKS request for information. BCBSKS has worked with Prime Therapeutics to fulfill data reporting requirements for D3 thru D8 for all groups with Prime. BCBSKS and Prime Therapeutics as our Pharmacy Benefit Manager will also be submitting a narrative answer to cover any needed explanations of the data.
BCBSKS will not be sending out any notification of report submission until confirmation is received from CMS. We won't be providing detailed reports of data submitted as data was reported in aggregate form.
Health plans are required to strengthen parity in mental health and substance use disorder benefits. Under the new requirements, individual and group health plans, including self-funded group health plans, must conduct and document a comparative analysis of their non-quantitative treatment limits (processes, strategies, standards, or other criteria that limit the scope or duration of benefits for services provided under the plan) for mental health, substance use disorder and medical surgical benefits. The new mental health parity requirements went into effect on February 10, 2021.