America's Benefit Specialist October 2023

GAG-CLAUSE PROHIBITION ATTESTATION REQUIREMENTS: ARE YOUR CLIENTS READY TO COMPLY?

By Dorothy Cociu, RHU, REBC, GBA, RPA President, Advanced Benefit Consulting & Insurance Services Fullerton, California dmcociu@advancedbenefitconsulting.com

comply), we now have the end-of-the-year filing requirement for the CAA’s gag-clause prohibitions and attestations. Hopefully, this isn’t the first time you or your clients are hearing about this requirement. Yes, it is another require ment within CMS’ HIOS portal, but the good news is that it’s not as difficult as the RxDC submission process. But I will get to the process later. Let’s start from the beginning. What does this all actually mean? Basically, it means that employer-sponsored group health plans and issuers (like insurance companies and HMOs) cannot have any “gag clauses” in their contracts that directly or indirectly restrict specific data and information that a plan or issuer can make available to another party in their contracts. BACKGROUND The CAA was one of the largest bills ever passed by Congress, and had several years of requirements for health plans, plan sponsors, issuers, PBMs, TPAs and more. One of the last provi sions of the CAA is the prohibition on gag clauses in provider

Another year, another new federal requirement for health plans and employers that sponsor them. So what is it this year? Besides of course the CAA’s RxDC filing requirements in HIOS (originally due December 2022, but pushed back to Jan uary 31, 2023, for reference years 2020 and 2021, and June 1, 2023, for 2022 reference years, which had employers, brokers, TPAs, pharmacy benefit managers and more scrambling to A “GAG CLAUSE” UNDER THE CAA PROHIBITS RESTRICTIONS ON THE DISCLOSURE OF PROVIDER-SPECIFIC COST OR QUALITY OF CARE INFORMATION OR DATA.

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