Benefits Compliance
Covia is committed to full compliance with federal laws and regulations concerning surprise billing and transparency in coverage. We are committed to helping you understand the legislation, the impact to our Team Members and Covia’s actions to be fully compliant with the legislation. Visit the links and attachments below for more information.
No Surprises Act Notice
The No Surprises Act (NSA), signed into law as part of the Consolidated Appropriations Act, 2021 (CAA), establishes federal standards to protect patients with health benefits coverage from “surprise” medical bills that may arise when receiving care from certain out-of-network providers and ancillary providers. Under the NSA, patients will only be responsible for paying the in-network amount for covered services. The federal NSA does not preempt more restrictive state laws prohibiting surprise medical bills.
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When out-of-network providers bill members directly for the difference between the total amount they billed and what the member’s health insurance company or health plan actually paid is called balance billing, or surprise billing. Surprise billing is more likely to occur in emergency situations where members may not get to choose the provider.
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Effective with January 1, 2022, health plan effective dates, the No Surprises Act offers members protection against balance/surprise billing for the following:
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Emergency care – from in-network or out-of-network providers
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Non-emergency care – from out-of-network providers at in-network facilities
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Air ambulance service – from out-of-network providers
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NSA legislation applies to both grandfathered and non-grandfathered Individual, Small Group, Level Funded and Large Group Fully Insured markets and Self-Insured (ASO) Group plans. It does not apply to Medicare and other programs that already offer safeguards against surprise billing.
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The NSA does not apply if a member voluntarily chooses to use an out-of-network provider and receives notice and signs a consent.
Transparency in Coverage - Machine Readable Files
The Departments of Health and Human Services (HHS), Labor (DOL) and the Treasury finalized the Transparency in Coverage (TIC) rule, which requires health insurers and group health plans to make health plan pricing information accessible to consumers, allowing for easy comparison shopping. The rule also requires insurers and group health plans to provide publicly available machine-readable files that include in-network negotiated payment rates and historical out-of-network charges for covered items and services. Starting July 1, 2022, you can find the machine readable files for our active plans here. These files will be updated monthly and include negotiated rates for all in-network providers, and allowed amounts and historical billed charges for out-of-network providers. At this time, the TIC rule’s requirement to post pharmacy cost information has been deferred to an undetermined time.
