America's Benefit Specialist March 2023

BENEFIT REPORTING

another party (such as a third-party administrator or health care-claims clearinghouse) will provide the information. But if the third-party fails to provide the information, the plan violates the reporting requirement. Monahan said, “If you are self-funded, then you can out source it to one or more outside vendors, but you need to have a written agreement with each of those outside vendors to make sure they agree to be in compliance. “Here is the little twist for self-funded entities: Although you’re required to enter into a written agreement, if you do so and the third parties fail to perform, unlike with a fully insured plan, the employer still remains responsible and could still be found to be liable. So you need that written agreement.” Note that the form of the written agreement is not defined by the regulations. Be sure to cover liability protections in your written agreements. Particularly for self-funded plans, review the full agreement to ensure it provides the protec tions the plan and employer needs. “You can combine and have one written agreement to address all of these mandates, RxDC, TiC, self-service tool and air-ambulance reporting, or you can break them up,” said Monahan. “They haven’t specified what form the written agreement needs to be in. We have seen written contracts, we have seen amendments, we have seen email confirma tion of amendments, etc., so they take different forms.” ACTION ITEMS FOR EMPLOYERS For all plans: Be sure to calendar compliance dates. The initial Rx reporting date is December 27, 2022, and annual dates for 2022 and after calendar years will be June 1 after the calendar year ends. For fully insured plans: Enter into a written agreement with issuer, and provide any plan-level or other data required by issuer. For self-funded plans: Self-funded plans must either com ply or outsource to a TPA or ASO. If outsourcing, they need to enter into a written agreement to assure that they timely provide any plan-level or other data required by the third party. They need the written agreements to lessen employer liability, period. It is important to note that the written agreement require ment also applies to the TiC Final Rule (both MRF and online self-service tool mandates) and the CAA air-ambulance re

porting requirement. Our ABC contracts include all of these items and allows us to customize for each client and delete unneeded items in each circumstance. You may have already been receiving some emails or other correspondence from your carriers, administrators or PBMs on this. Do not ignore them. Monahan said, “It’s very prudent to reach out to your car rier. Don’t assume they are going to reach out to you. Take the affirmative step, reach out to them, offer them a contract or amendment and see where they stand on this, and then move forward, and keep that paper trail. Then, if any ques tions ever arise, you can establish the steps you took to try and meet your fiduciary obligations in the administration of your group health plan, and you did the best you could to make sure you were in compliance with the rules. Keep a copy of these records and hold on to them.” I hope your eyes will indeed reflect knowledge and under standing on these topics in the months to come. Best of luck with it all, and happy reporting! Sources: ACA FAQs, Part 49 www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-sur prises-act; www.cms.gov/nosurprises www.cms.gov/files/document/model-disclosure-notice-pa tient-protections-against-surprise-billing-providers-facili ties-health.pdf www.cms.gov/nosurprises/policies-and-resources/overview-of rules-fact-sheets www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insur ance-Protections/Prescription-Drug-Data-Collection Dorothy Cociu is the president of Advanced Benefit Consulting in Anaheim, California. Advanced Benefit Consulting & Aditi Group offer privacy and security training, consulta tion and implementation system assistance, as well as risk-assessment services on an ongoing basis. Author’s Note: I’d like to thank Marilyn Monahan of Monahan Law Office for her assistance with this article and our related seminars and webinars.

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