The No Surprises Act and Transparency in Coverage Rules

Mental health parity describes the equal treatment of mental health conditions and substance use disorders in health plans. HMAA will provide a Non-Quantitative Treatment Limitations Comparative analysis to the DOL or HHS, upon request.

Requires deductible and out-of-pocket maximum information on physical or electronic member ID cards. HMAA’s ID cards contain a QR code for online viewing of deductible and out-of-pocket maximum information. Here’s how to view the QR code information on the ID card:

1. Open the camera app on your mobile device.
2. Point your camera at the QR code on your ID card.
3. Tap the pop-up link to the website that appears on your screen.
4. Your device will automatically open the website, where you can view your deductibles and out-of-pocket maximums.

Requires health plans to update and verify the accuracy of provider directory information at least every 90 days and establish a protocol for responding to requests from enrollees about a provider’s network participation status.

Prohibits balance billing of members and protects against surprise billing when receiving out-of-network emergency services, out-of-network nonemergency services at an in-network facility, or out-of-network air ambulance healthcare services. There are some exceptions based on member consent.

Also requires health plans to make publicly available and include on applicable explanation of benefits (EOBs) information about balance billing restrictions, state law protections, and appropriate agency contacts in case an individual believes a provider or facility has violated such restrictions.

HMAA’s surprise billing disclosure notice is included with all medical EOBs to members about their rights and protections against surprise medical bills.

Requires health plans to use a qualifying payment amount (QPA) to determine the amount members are required to pay for certain out-of-network services. The QPA will also be used to determine the initial plan payment for non-emergency services rendered by out-of-network providers at certain in-network facilities.

Requires continuity of services for certain health plan enrollees, defined as “continuing care patients,” when there is a change in the provider network. Such patients will receive timely notification of the change and have up to 90 days of continued coverage at in-network cost-sharing to allow for transition of care to an in-network provider.

Requires health plans to disclose via machine-readable files on a public website information regarding in-network provider rates for covered items/services and out-of-network allowed amounts and billed charges for covered items/services. Learn more.

Requires health plans to make price information available to enrollees through an internet-based self-service tool, in paper, and via telephone with respect to certain covered items/services by January 1, 2023 and other items/services by January 1, 2024.

HMAA provides price information to its members via https://zconnect.zakipointhealth.com. You can also download the zConnect Health app from the Apple App or Google Play store. You will need to enter a group code which is your HMAA policy number with “HI-” at the beginning and register a new account.

Requires health plans to send participants an Advance Explanation of Benefits (AEOB) with cost estimates on services scheduled at least three days in advance. This requirement is deferred to an unspecified date.