Consolidated Appropriations Act and Transparency in Coverage Final Rule

2/10/21

Blue Shield has completed the comparative analysis, for both self-funded and fully-insured, groups with both mental health and medical benefits carved-in with Blue Shield.

We are prepared to provide a comparative analysis, describing selected nonquantitative treatment limitations (NQTLs), for eligible groups, to  support  the application of the selected NQTLs to MH/SUD benefits upon request through your Account Manager.

1/1/22

Blue Shield is compliant with the surprise billing requirements of this provision and awaits further guidance regarding air ambulance reporting. 

Under this provision, members are only responsible for in-network cost-sharing amounts for out-of-network services rendered in certain scenarios outlined by the law. The law requires that members are kept out of any payment disputes and resolutions between the health plan and a provider. A notice outlining member protections is available to members on our Regulatory notices page. 

This provision also includes the reporting of air ambulance claims information. Blue Shield is working on creating this report for 2022 data due by March 31, 2023, however, we are awaiting final requirements from the CMS on the process to submit reports. 

1/1/22

Blue Shield is consistently identifying impacted members who qualify for continuity of care protections and is notifying them of the option to continue transitional care from that provider.

A member can request continuity of care by visiting blueshieldca.com and filling out the Continuity of Care Application. Please view the Request for Continuity of Care Services document for more details.

12/27/21

Blue Shield is Compliant. Blue Shield’s Individual & Family Plans applications and enrollment materials, now include verbiage disclosing information on broker compensations. Blue Shield has no disclosure obligation for employer-sponsored group health plans.

Gag Clauses Provision: 12/27/21

Attestation Submission: 12/31/2023

Blue Shield is compliant with the Gag Clauses provision and is preparing to submit the annual attestation of compliance to the Centers for Medicare and Medicaid Services (CMS) by the deadline.

Fully-Insured/Flex-Funded Groups

Blue Shield will be submitting an annual compliance attestation on behalf of all our fully-insured/flex-funded groups. This attestation will be for Blue Shield's provider contracts only. Groups that contract with a third party insurer besides Blue Shield will be responsible for coordinating an attestation submission for these other insurers' provider contracts.

Self-Funded ASO

Blue Shield will collect an agreement from self-funded ASO groups via an intake form to submit the attestation on the group's behalf. This option is only available to ASO groups that have all their provider networks with Blue Shield. Groups that contract with any providers - such as mental health or pharmacy providers- through a third party besides Blue Shield will be responsible for submitting their own attestation of compliance using Blue Shield's Confirmation of Compliance Statement below.

Self-Funded Shared Advantage/Shared Advantage Plus

Shared Advantage and Shared Advantage Plus groups will need to submit their own attestation to the CMS directly, using Blue Shield's Confirmation of Compliance Statement below.

Blue Shield's Confirmation of Compliance

Blue Shield of California confirms it is compliant with the federal Consolidated Appropriations Act, Section 201, Gag Clauses provision. We ensure our provider contracts exclude any gag clauses which prevent the sharing of cost and quality data.

Next reports due June 1, 2024 and annually thereafter

Blue Shield of California has successfully submitted CAA Section 204 reports to the Centers for Medicare and Medicaid Services (CMS). This submission included both information available to us as the health plan and information received from group plan sponsors via the D1 Premium Intake Form.

New reporting instruction released by the CMS allowed Blue Shield to omit the employer/employee premium contribution breakdown if it was not received and submit total premium paid for D1 on behalf of fully-insured groups with Blue Shield pharmacy benefits, even those who did not complete the D1 Intake Form. 

Pending
further
rulemaking

Blue Shield is awaiting further guidance. The Tri-Agencies announced deferred enforcement of this requirement until further rulemaking due to a need for more information on the standards for data transfers between providers and health plans. Blue Shield project teams continue to work on all other unimpacted requirements.

1/1/22

Blue Shield is compliant with the Provider Directories requirements. This includes a protocol to respond to member network questions within one business day and only in-network member cost-share liability in the case that members receive inaccurate information that a provider is in-network.
 
Members can find the most up to date provider information using the Blue Shield Find a Doctor tool or by calling the Customer Care number on their Blue Shield member ID card.

1/1/22

Blue Shield is compliant. We included required information on member ID cards and reissued ID cards to all members upon enrollment or renewal in a 2022 plan.

1/1/23 - 
500 services
1/1/24 -
all services

Blue Shield is working in good faith to implement the requirements of this provision and intends to comply with the requirements due by January 1, 2023.

The requirements for CAA price comparison tool overlap with that of TCFR cost sharing estimator tool. The Tri-Agencies have acknowledged this and combined the requirements of both mandates.

1/1/23 - 
500 services
1/1/24 -
all services

Blue Shield is working in good faith to implement the requirements of this provision and intends to comply with the requirements due by January 1, 2023.

The requirements for TCFR cost sharing estimator tool overlap with that of the CAA price comparison tool. The Tri-Agencies have acknowledged this and combined the requirements of both mandates.

7/1/22

Blue Shield has posted required data files under the Machine Readable Files (MRF) provision.

These files are hosted through an external vendor and available through this link:

​​​​​Blue Shield of California – Machine Readable Files

Blue Shield has addressed the compliance obligation of this provision as it applies to our fully-insured group plans.

Self-funded group plan sponsors need to post this link on their own websites for compliance purposes. If is up to the self-funded plan to determine where on its site to publish the link, but the link must be publicly available (no login or other requirements should be required to access the MRF files).

A webpage for MRF, publicly available to anyone visiting the Blue Shield home page, is available here.

7/31/21
2020 reporting
year

The Affordable Care Act (ACA) requires health plans to spend a minimum percentage of plan members' premium on medical expenses, known as the "Medical Loss Ratio (MLR)" or the "80/20 rule".

2022

We are now calculating 2022 rebates. If any rebates are owed, we will reach out to groups in the fall of 2023.