CareFirst - Mandates & Legislation Updates for January 2023

Here are the most important updates for CareFirst mandates and legislation in January 2023. 

Federal, State Requests for Mental Health Parity and Addiction Equity Act Compliance - New and Important Changes

As part of the Consolidated Appropriations Act (CAA), insurers and group health plans are required to provide to federal and state authorities, upon request, a detailed comparative nonquantitative treatment limitation (NQTL) analysis regarding compliance for mental health parity. This provision became effective on February 10, 2021.

The NQTL comparative analysis, which will demonstrate compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA), includes a written description of the plan's options and terms of coverage by all mental health or substance use disorder (MH/SUD) or medical/surgical (M/S) benefits classification, including relevant NQTL information based on the following six categories: inpatient in-network, inpatient out-of-network, outpatient in-network, outpatient out-of-network, prescription drugs, and emergency care.

CareFirst has established a process to gather NQTL information for both fully insured and self-insured accounts based on benefits and their classification. The factors and evidence used to support the standards determine that the NQTLs will apply to MH/SUD benefits and M/S benefits.

• CareFirst will complete the comparative analysis for fully insured plans. If a request is received from a Regulator or other eligible requestor, CareFirst will provide the comparative analysis to that party.
• Upon a self-insured account’s request, CareFirst will provide a populated Microsoft Word template that contains information necessary to prepare the NQTL comparative analysis for utilization management, network management and pharmacy for carved-in products. Self-insured accounts will be responsible for completing the comparative analysis, determining if their plan is MHPAE compliant, and responding to any requests they may receive from the Department of Labor (DOL).

REMINDER: If speaking to an external customer, please state as follows: I cannot provide legal advice, and any information provided should not be interpreted as legal advice. 

For more information, please contact MHPAEA Compliance Support at MHPAEA_NQTL@carefirst.com. 

Mental Health Parity has evolved, changes are noted below. 

New Parity Visitor Center

To help you find more information on Mental Health Parity, we’ve developed a Parity Visitor Center where you can:

• Access the MHP NQTL Intake Request form to submit a request for NQTL information
• Find parity tools and training information
• Review or download the Data Use Agreement (DUA) template
• Upload documents

Frequently Asked Questions—NQTL

What are NQTLs?

NQTLs include (but are not necessarily limited to) the following: 

• Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative
• Prior authorization or ongoing authorization requirements
• Concurrent review standards
• Formulary design for prescription drugs
• For a plan with multiple network tiers (such as preferred providers and participating providers), network tier design
• Standards for provider admission to participate in a network
• Provider reimbursement rates
• Plan or issuer methods for determining usual, customary and reasonable charges
• Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as fail-first policies or step therapy protocols)
• Exclusions of specific treatments for certain conditions
• Restrictions on applicable provider billing codes
• Standards for providing access to out-of-network providers
• Exclusions based on failure to complete a course of treatment
• Restrictions based on geographic location, facility type, provider specialty and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage

What will CareFirst provide for fully insured accounts? 

Fully insured accounts are not obligated to demonstrate their plan’s compliance. As the insurer, CareFirst is the accountable entity and is responsible for providing the applicable regulatory body with the NQTL comparative analysis if requested. If a fully insured account requests the NQTL analysis, the account should be provided with the following statement:

“[ACCOUNT NAME] has purchased a fully insured health insurance plan. Fully insured health insurance plans are regulated by state Departments of Insurance. The insurance issuer, CareFirst BCBS, is responsible for ensuring that the fully insured plans it markets comply with the Mental Health Parity and Addiction Equity Act and responding to state regulator inquiries. Please contact your account manager if you have any additional questions or concerns.”

If a fully insured account has additional questions, sales associates should contact their legal counsel.

Why can’t CareFirst do the comparative analysis for self-insured accounts?

CareFirst is not providing this service at this time. Additionally, under MHPAEA, the plan sponsor of the self-insured group is legally responsible for ensuring that its plan complies with the law. CareFirst will assist by providing the underlying plan information that is necessary for the account to conduct this analysis.

What is the timeframe for completing NQTL comparative information and/or analysis?

• Self-insured standard NQTL comparative information—approximately 2 weeks
• Self-insured non-standard NQTL comparative information, which includes the account template and/or set of questions—approximately 5 weeks

What does an account need to sign before CareFirst releases NQTL information?

Sales Consultants will be required to confirm that the accounts have a signed Administrative Service Agreement (ASA) on file for the plan year that governs the plan before information is released.

What information must plans and issuers make available in response to the Department of Labor’s requests for documentation of their comparative analyses? 

The U.S. Department of Labor has advised that plans and issuers should ensure that comparative analyses are sufficiently specific, detailed, and reasoned to demonstrate whether the processes, strategies, evidentiary standards or other factors used in developing and applying NQTL are comparable and applied no more stringently to mental health or substance use disorder benefits than to medical/surgical benefits, as described further below. 

To that end, a general statement of compliance, coupled with a conclusory reference to broadly stated processes, strategies, evidentiary standards or other factors, is insufficient to meet this statutory requirement.

Who can request NQTL information besides regulators? 

CareFirst will provide the NQTL information to the plan sponsor or, upon the plan sponsor’s request, a third party that is retained by the plan sponsor to conduct the MHPAEA analysis. Additionally, a beneficiary and/or their authorized representative in a self-insured plan may request the information from the plan sponsor.

What should sales associates communicate to a broker who asks CareFirst for the NQTL analysis for self-insured health plans?

If a broker requests the NQTL analysis, the broker should be provided the following statement:

“At this time, CareFirst is not conducting the NQTL comparative analysis for self-insured group health plans. CareFirst has established a process by which it will, upon request, provide the underlying documents/information necessary for the self-insured group health plan to conduct the NQTL analysis. If the group would like to request this information, please submit a request to [Sales Name and Title], and the information will be provided to the plan sponsor or a third party they designate to perform the comparative analysis.”

What does a third party with which CareFirst shares or exchanges data relating to MHPAEA need to sign before CareFirst releases NQTL information?

There is now an updated CareFirst Data Usage Agreement (DUA) specifically for these MHPAEA disclosures that must be signed and on file for every third party with which CareFirst shares or exchanges data relating to MHPAEA. The consultants may already have a signed DUA in place.

In these cases, the consultant must only complete the Data Extract Schedule (DES), which is the last page of the agreement. 

For any third party for which CareFirst does not currently have a DUA in place, both the DUA and updated DES documents must be signed and filed prior to any exchange of data. This MHPAEA DUA does not replace any existing DUA on file and is only applicable for this process only.

The DUA can be found on the Sales Resource Guide.

Is there a specific format in which the NQTL comparative analysis is required to be documented?

The DOL has not provided a standard template, data format or exact details on what needs to be provided if requested. However, the DOL has provided high-level guidelines of the minimum information that should be provided to determine if a plan is MHPAEA compliant.

How does a plan complete the comparative analysis?

CareFirst cannot advise on the specifics of how the comparative analysis is performed. The Department of Labor has provided a tool for group health plans to validate self-compliance against the MHPAEA rules. The tool can be found on the Department of Labor/EBSA website under Mental Health Parity: DOL Self Compliance Tool for MHPAEA. 

Where should sales associates go if they have more questions about NQTL Comparative Analysis? 

The Department of Labor has resources and additional information on its website: Mental Health and Substance Use Disorder Parity | U.S. Department of Labor (dol.gov). 

Who can sales associates contact for more information on the MHPAEA amendments included in the CAA that apply to group health plans and health insurance issuers? 

Contact the Department of Labor at www.askebsa.dol.gov or 866-444-3272. You may also contact Health and Human Services at marketconduct@cms.hhs.gov. You may also wish to consult your legal counsel.

For more information

Please contact MHPAEA Compliance Support at MHPAEA_NQTL@carefirst.com

CAA & Transparency in Coverage Updates: RxDC Reporting, Cost Sharing and Federal IDR Fees Prescription Drug and Healthcare Spending Reports (RxDC)

On December 23, 2022, the Department of Health and Human Services (HHS), the Department of Labor (DOL), and the Department of the Treasury (collectively, the Departments) released FAQs about Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation (Set 56). The document offers updated guidance for the initial submission of the RxDC reporting that provided a submission grace period through January 31, 2023. The Departments clearly stated that they would not consider a plan or issuer to be out of compliance provided that a good faith submission of the 2020 and 2021 data is made on or before that date. 

Due to this flexibility, CareFirst opted to delay our submission to allow for some additional internal data validation. As stated in the previous RxDC article, CareFirst will not send a mass communication to groups confirming the submission once complete. For questions about whether a group’s data is included in our submission, please refer to the information provided in the articles that went out in October 2022 and December 2022. 

Consumer Transparency Cost Sharing Information Requirements

CareFirst supports meaningful transparency efforts that help consumers make informed healthcare decisions. We go beyond price to integrate quality and wellness by leveraging our digital tools to provide the personalized, value-driven experience consumers want and need. Meaningful transparency supports high-value healthcare decision-making, leading to better outcomes and lower care costs. 

CAA and TIC regulations require health insurers and group health plans to provide an internet based, self-service, cost-transparency tool to enrollees starting in January 2023. The tool must have personalized out-of-pocket cost information and the underlying negotiated rates for 500 covered healthcare items and services included in the CMS requirements. Health plans must expand those tools to cover all items and services by January 2024. 

CareFirst will use our Treatment Cost Estimator (TCE) tool, powered by Sapphire Digital and available through My Account, to meet this requirement for most of our commercial business. Members can already use TCE to access individualized cost estimates for many common healthcare services. The TCE functionality is being enhanced to provide the ability to search for services by billing code and to display refined cost estimates based on our negotiated rates with providers (when applicable) for all 500 services required by CMS. All members with access to My Account will have a seamless update to their experience for the enhanced TCE functionality once it goes live. 

Unfortunately, Sapphire Digital has encountered some critical defects in the testing phase for the enhanced functionality that have delayed the deployment. This delay is impacting all Sapphire Digital clients, not just CareFirst. Production deployment is currently expected in mid to late January.

Beginning the first week of January, CareFirst Administrators (CFA) and National Capital Area Services (NCAS) clients will have access to a similar tool powered by Perspecta. 

In 2023, CareFirst will continue to explore opportunities in partnership with our shared administration accounts that need additional support to make tools available to their members.

Members can also obtain this personalized cost information by phone if they call Member Services using the number on the back of their ID card. Our customer service team will assist them and provide a copy of the information electronically or by mail upon request.

No Surprises Act: 2023 Federal Independent Dispute Resolution (IDR) Fees

On December 23, 2022, the Department of Health and Human Services (HHS), the Department of Labor (DOL), and the Department of the Treasury (collectively, the Departments) released the Amendment to the Calendar Year 2023 Fee Guidance for the Federal Independent Dispute Resolution (IDR) Process under the No Surprises Act: Change in Administrative Fee.

Beginning on January 1, 2023, the non-refundable fee assessed to both the initiating and non-initiating parties of a Provider-Payer dispute will increase from $50 to $350. Additionally, the Departments published an updated list of certified IDR entity fees. 

For more information

If you have any questions, please contact your CareFirst Account Consultant or you can speak to your Amwins Connect Sales Representative.