Consolidated Appropriations Act and Transparency in Coverage Final Rule

Status: Blue Shield will collect pharmacy benefit and drug cost data between February 19, 2025, and April 19, 2025. Groups should use the link and web key sent via email or log onto Employer Connection to complete the survey.

Summary: Section 204 (division BB) requires health plans and employer-sponsored plans to report data on prescription drug spending and premium data.

Information must be submitted to the Centers for Medicare and Medicaid Services each year, covering data from the previous plan year.

To meet the June 1 deadline, Blue Shield needs to receive the Healthcare Spending Survey from Small Groups and Large Groups by April 19.

Status: Blue Shield will collect medical loss ratio data until March 31, 2025. Groups should use the link and web key sent via email to complete the survey.

Summary: The Affordable Care Act (ACA) requires health plans to spend a minimum percentage (80-85%) of premium revenue on medical claims and health care quality improvement efforts, known as the medical loss ratio (MLR). This limits the amount health insurance companies can spend on administrative expenses and profits.

The TCFR 45 CFR section 158 allows health plans to include, in the numerator of their MLR, certain “shared savings” payments that are offered to encourage enrollees to shop for higher-value, lower-cost plans.

To accurately calculate MLR rebates, Blue Shield must collect group size information from groups with 150 and fewer employees. This includes all Small Groups and some Large Groups.

Status: Blue Shield successfully submitted the annual gag clauses attestation to the CMS on December 12, 2024.

Summary: Section 202 (division BB) prohibits gag clauses in provider contracts to allow members, plan sponsors, and referring providers to see cost and quality data on providers.

A gag clause is a provision in a contract between the health plan and provider that restricts how much information a provider can share with an enrollee. Health plans are required to submit an annual attestation of compliance confirming their provider contracts do not include any gag clauses. By default, Blue Shield submits the gag clauses attestation to the CMS on behalf of fully-insured groups that have all their provider networks with Blue Shield (e.g. the group does not have any provider networks such as behavioral health with a third party annually by mid-December.

Self-funded ASO groups that have all their provider networks with Blue Shield, are given the option to have Blue Shield submit the gag clauses attestation on their behalf to the CMS. A survey is sent out to impacted groups annually at the end of Q3 to collect this information.

Self-Funded ASO groups with any provider networks carved out with a third party and all Shared Advantage/Shared Advantage Plus groups are responsible for submitting the attestation to the CMS themselves and may use the compliance statement sent via email communications.

Status: Blue Shield has prepared comparative analyses, in compliance with existing MHPAEA requirements. These analyses apply to all fully insured and self-funded plans for which Blue Shield underwrites and/or administers both medical and surgical benefits and mental health and substance use disorder benefits. For self-funded clients, Blue Shield is prepared to assist in a manner that is consistent with its role as a third-party administrator but does not manage MHPAEA compliance overall for clients.

We are aware of the 2024 MHPAEA Final Rules (“Final Rules”) and are working in good faith to implement the requirements of the made and we intend to comply with the requirements by the stated applicability dates.

Summary: The 2008 MHPAEA requires employer sponsored group health plans and issuers to provide mental health and substance use disorder benefits (MH/SUD) in parity with medical/surgical benefits (M/S) in terms of cost-sharing, quantitative treatment limitations, and non-quantitative treatment limitations (NQTLs).

Section 203 (division BB) requires plans and issuers to provide a comparative analysis demonstrating NQTL parity. This comparative analysis must include definitions of each NQTL and the benefits to which it applies; factors and standards used to support application of NQTLs; and analysis and conclusions showing that application of any NQTL to MH/SUD benefits is no more stringent than the application to M/S benefits.

Status: Blue Shield notifies impacted members who qualify for continuity of care protections with the option to continue transitional care from that provider. Members can find the latest information and application forms here on our Continuity of Care page.

Resources: Impact Chart - California vs. Federal Requirements (PDF, 27 KB)

Summary: Section 113 (division BB) requires continuation of care for patients in the middle of serious and complex care (detailed on this page) in the case when their provider's contract expires or is terminated. This also applies to members whose employer sponsored health plan changes or is terminated. In these scenarios, members will have the option to continue receiving care for 90 days or until the treatment concludes, whichever is sooner. The health plan is required to notify impacted and eligible, individuals of the option to continue receiving care.

Complex care in the context of this provision refers to:

• Members with acute illnesses serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm.
• Members with chronic illness or condition that is (i) life-threatening, degenerative, potentially disabling, or congenital; and (ii) requires specialized medical care over a prolonged period of time.
• A member receiving a course of institutional or inpatient care from a provider.
• Nonelective surgery from the provider, including receipt of post-operative care with respect to surgery.
• Pregnancy, and when the member is undergoing a course of treatment for the pregnancy.
• Terminal illness and the member is receiving treatment for such illness from a provider.

Status: Blue Shield is compliant with the CAA & TCFR Treatment Cost Estimator Tool requirements to have all shoppable services available on the tool. Members can access the tool upon logging into their member portal via blueshieldca.com

Summary: There is some overlap between the requirements of the Price Comparison Tool under the CAA and the Price Transparency Tool under the Transparency in Coverage Final Rule (TCFR).

The TCFR Price Transparency Tool requires that group health plans and insurance issues make available to members personalized, out-of-pocket cost information for covered items and services through a self-service tool and in paper form within two days upon request. 

The CAA Price Comparison Tool section 114 (division BB) requires that group health plans and insurance issuers maintain a “price comparison tool” available via phone and website that allows members and participating providers to compare cost-sharing for items and services by any participating provider.

Status: Blue Shield posts data files required under the Machine Readable Files (MRF) provision on a monthly basis. The data files are hosted through an external vendor on our MRF page. This addresses the compliance obligation for fully-insured group plans.

Self-funded group plan sponsors need to post this link on their own websites for compliance purposes. Self-funded plans can choose where to publish the link on their site, but the link must be publicly available (no login or other requirements should be required to access the MRF files).

Resources: A webpage for MRF, publicly available to anyone visiting the Blue Shield home page, is available on our MRF page.

Summary: The TFCR Machine Readable File provision requires health plans and self-funded employer sponsored plans to publicly display in-network rates and out-of-network allowed amounts in a machine-readable file format.

Status: The Tri-Agencies announced deferred enforcement of this requirement because they need more information on the standards for data transfers between providers and health plans.

Summary: Section 111 (division BB) requires providers to send a good faith estimate of the “expected” amount that an item or service will cost the enrollee. Health plans to send the estimate and other information to members.

Status: Blue Shield is compliant with the surprise billing requirements of this provision. 

Resources: A notice (PDF, 87 KB) outlining member protections is available to members on our Regulatory notices page. 

Summary: Section 106 (division BB) protects members from unexpected out-of-network costs, It requires that members only be responsible for in-network cost-sharing amounts in emergency and certain non-emergency situations where members cannot choose an in-network provider. 

Providers are also prohibited from balance billing members, except in limited situations with member notice and consent. In addition, any out-of-network expenses for the services covered will accumulate toward a member’s in-network deductible and out-of-pocket maximum. This provision also establishes the Independent Dispute Resolution (IDR) process for provider billing disputes.

Status: Blue Shield is compliant. Blue Shield’s IFP applications and enrollment materials include disclosures on broker compensations. Blue Shield has no disclosure obligation for employer-sponsored group health plans.

Summary: Section 202 (division BB) requires brokers, agents, and consultants to disclose any direct or indirect compensation related to brokerage services or consulting to group health plan sponsors for Individual & Family Plans (IFP).

Health plans are required to disclose compensation information to enrollees and the Department of Health and Human Services (HHS) for individual health coverage and short-term or limited-duration coverage.

Status: Blue Shield is compliant. We included required information on member ID cards and reissued ID cards to all members upon enrollment or renewal in a 2022 plan.

Summary: Section 107 (division BB) requires health plans to clearly display the following information on physical and member ID cards: deductibles, any out-of-pocket maximum limitations applicable to the plan, and a telephone number and website address for further assistance.

Status: Blue Shield is compliant with the Provider Directories requirements.

Resources: Members can find the most up to date provider information using the Blue Shield Find a Doctor tool or by calling the Customer Care number on their Blue Shield member ID card.

Summary: Section 116 (division BB) requires that health plans maintain an accurate in-network provider directory and verify information every 90 days. This mandate also includes the requirement to respond to member network questions within one business day and in-network cost-sharing liability in the case that members receive inaccurate information that a provider is in-network.