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Section 112 (division BB) requires providers to send a good faith estimate of their “expected” charges for furnishing an item or service to an enrollee to the health plan and for the health plans to send the estimate and other information to the enrollees.

Market impact of this provision effects Individual Family Plan (IFP), Small Business Markets (SBM), Core, Premier, Administrative Services Only (ASO) and Shared Advantage (SA) lines of business.

 

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Section 116 (division BB) requires that health plans maintain an accurate and up-to-date directory and database of in-network providers and facilities and provide members with an accurate directory online anytime, or offline within one day of request.

Market impact of this provision effects Individual Family Plan (IFP), Small Business Markets (SBM), Core, Premier, Administrative Services Only (ASO) and Shared Advantage (SA) lines of business.

 

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Section 107 (division BB) requires health plans to display specific plan information on physical and digital member ID cards in clear writing. Specifically, cards must display any deductibles and any out-of-pocket maximum limitations applicable to the plan, as well as telephone number and website address for further assistance.

Market impact of this provision effects Individual Family Plan (IFP), Small Business Markets (SBM), Core, Premier, Administrative Services Only (ASO), Shared Advantage (SA), and Medicare Supplement lines of business.

 

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The 2008 MHPAEA requires employer sponsored group health plans and issuers to provide mental health and substance use disorder benefits (MH/SUD) in parity with medical/surgical benefits (M/S) in terms of cost-sharing, quantitative treatment limitations, and non-quantitative treatment limitations (NQTLs).

Section 203 of CAA requires plans and issuers provide a comparative analysis demonstrating NQTL parity. This comparative analysis process must include definitions of each NQTL and the benefits to which it applies; factors and standards used to support application of NQTLs; and analysis and conclusions showing that application of any NQTL to MH/SUD benefits is no more stringent than the application to M/S benefits.

Market impact of this provision effects Individual Family Plan (IFP), Small Business Markets (SBM), Core, Premier, and Administrative Services Only (ASO) lines of business.

Please see the notices attached for additional information:

MHPAEA Update for Small Business (1-100)

MHPAEA Update for Large Groups (101+)

SBM Broker Alert - Mental Health Parity (8/13)

XLOB Broker Alert - Mental Health Parity (8/13)

Frequently Asked Questions

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Section 133 (division BB) protects members from unexpected out-of-network costs by requiring that members only be responsible for in-network cost-sharing amounts in emergency and certain non-emergency situations where members do not have the ability to choose an in-network provider. 

Section also prohibits providers from balance billing members, except in limited situations with member notice and consent, and states that any out-of-network expenses for the services covered will accumulate toward a member’s in-network deductible and out-of-pocket maximum.

Market impact of this provision effects Individual Family Plan (IFP), Small Business Markets (SBM), Core, Premier, Administrative Services Only (ASO) and Shared Advantage (SA) lines of business.

 

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This provision overlaps between CAA Price Comparison Tool and TCFR Cost Sharing Estimator Tool.

CAA Plan Comparison Tool section 114 requires that group health plans and insurance issuers maintain a “price comparison tool” available via phone and website that allows members and participating providers to compare cost-sharing for items and services by any participating provider.

TCFR Cost Sharing Estimator Tool requires that group health plans and insurance issues make available to members, personalized out-of-pocket cost information for covered items and services, through a self-service tool and in paper within 2 days upon request. 

TFCR Machine Readable File provision requires three types of files to be available to make information useful for the average consumer (e.g. .XML excel file); In-network rates; out-of-network allowed amounts; and prescription drug in-network rates.

Market impact of this provision effects Individual Family Plan (IFP), Small Business Markets (SBM), Core, Premier, Administrative Services Only (ASO) and Shared Advantage (SA) lines of business.

 

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Section 113 (division BB) requires employer sponsored health plans and payers to continue providing in-network care for individuals who are undergoing treatment for a serious and complex conditions, pregnancy, inpatient care, non-elective surgery, or terminal illness even when an in-network provider or facility leaves the network, for 90 days or until the treatment concludes, whichever is sooner. 

Market impact of this provision effects Individual Family Plan (IFP), Small Business Markets (SBM), Core, Premier, Administrative Services Only (ASO) and Shared Advantage (SA) lines of business.

 

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The Medical Loss Ratio (MLR) provision ensures that a minimum percent of health insurance premiums are used to pay claims and limits the amount health insurance companies can spend on administrative expenses and profits. The Affordable Care Act (ACA) requires that 80% - 85% of premium dollars be spent on medical care.

The MLR Shared Savings provision allows payers to include, in the numerator of their MLR, certain “shared savings” payments that are offered to encourage enrollees to shop for higher-value, lower-cost plans. 

Market impact of this provision effects Individual Family Plan (IFP), Small Business Markets (SBM), Core, and Premier lines of business.