The Consolidated Appropriations Act marks the biggest change in healthcare since the passage of the Affordable Care Act (ACA) in 2010. While the CAA may be complex and overwhelming, Imagine360 has the knowledge and resources to help clients and brokers navigate it. We’ve broken down the key points related to health insurance coverage and what they mean for employers and employees.
Telehealth services can continue as they have – for now.
At the start of the COVID-19 pandemic, specific restrictions on coverage and reimbursement for telehealth services were waived. Previously, telehealth was available for very limited services, but the waiver allowed for expansion into virtual primary care and mental healthcare. Typically, High-Deductible Health Plans (HDHPs) could not provide “first dollar coverage” for these telehealth services, meaning that the member needed to meet their deductible before their health plan would provide coverage. Regulations such as the CARES Act allowed health plans to provide first-dollar coverage for telehealth services.
The ability to use telehealth in these new ways was set to expire when the public health emergency ended. Thanks to the CAA, however, these services can still be covered through December 31, 2024, for plan years effective after December 31, 2022. This allows patients to continue to receive the virtual care they’ve come to rely on, and time for regulators to consider permanent changes.
However, because the law applies on a “plan year” basis, this can be tricky to operationalize for groups that renew later in the year. In addition, the HDHP first-dollar coverage relief is not automatic. Any HDHP plan that would like to take advantage of this option will need to ensure that their Plan Documents are updated to reflect first-dollar coverage for the telehealth services.
The NSA, which went into effect on January 1, 2022, protects patients from unexpected medical bills from out-of-network providers and facilities under specific circumstances. CAA 2023 did not make changes to this act.
The TiC Rule gives patients the tools they need to access pricing information through their health plans. This requires health insurers, including self-funded clients, to provide cost-sharing data to consumers through a consumer price estimator tool. CAA 2023 also did not make changes to this rule.
The Employee and Retiree Access to Justice Act / Mental Health Matters Act (HR 7780)
Also in this category is the Employee and Retiree Access to Justice Act / Mental Health Matters Act (HR 7780). If this bill to amend the Employee Retirement Income Security Act (ERISA) had passed, the law would have had several legal implications, including:
Allowing the Department of Labor to pursue civil lawsuits for mental health parity violations, versus existing non-compliance and enforcement penalties.
Banning the use of arbitration clauses and/or class action waivers in plan documents,
Eliminating the “abuse of discretion standard” that applies to benefit determinations, and forcing reviewing courts to apply the de novo standard of review to appeals of benefits claims. Eliminating this standard would prohibit a plan from using its discretionary authority to interpret a plan, leaving litigation as the only way to resolve issues.
The Restore Protections for Dialysis Patients Act (HR 8594, S4750) failed to make it into law
This piece, drafted by DaVita after its loss in the Supreme Court in June 2022, would have required plans to treat dialysis patients the same way as any other member with chronic medical conditions.
Had it passed, this legislation would have cost plan sponsors significantly more money. The Congressional Budget Office (CBO) report estimated the legislation would not only fail to generate savings, but would result in additional costs to the federal government. The CBO estimated the 10-year cost of this bill to the federal government at $8 billion, and the cost to employers at $40 billion.
The CAA is the government’s latest effort to add protections against surprise billing and create more transparency in healthcare, and it certainly won’t be the last. We will continue to monitor healthcare legislation and provide resources to help clients and brokers understand its implications for them. If you’re unsure how the CAA will impact you directly, contact Imagine360 and we can walk you through how it will affect your health plan.