What is the Transparency in Coverage (TiC) Rule?

Self-funded plan sponsors are responsible for complying with the regulations. Aetna provided a unique URL (link) the plan sponsor could post on their website. The In-Network & Allowed Amount MRF will update monthly.

Fully insured and Small Group AFA, no action is needed. Aetna will post the required data on Aetna.com.

Self-funded plan sponsors should retain MRF data according to their data retention policy. For fully insured plan sponsors, Aetna will retain the MRFs according to our data retention policy.

Both MRFs contain the plan sponsor’s plan name, employer identification number (EIN), the reporting entity creating the MRF(s), billing codes, billing code description, CMS 2-digit place of service, provider’s tax identification (TIN), provider’s national provider identifier (NPI).

In-Network will contain the negotiated rates for covered items services, and the end date if applicable for the rate for all participating providers for the plan.

Allowed Amount will contain the allowed amounts for, and billed charges from the non-participating providers (out-of-network) to the relevant historical period (90 day of claim history) of the 20-claim threshold should be applied at the billing code level. 

The No Surprises Act (NSA) provides protections from surprise medical bills for coverage of emergency services, coverage of non-emergency services performed by out of network providers at in-network facilities, prohibits balance billing, establishes special rules for high deductible health plans, and applies external review requirements for surprise billing.

So, what does that mean? Let’s say an employee is on vacation and  suffers an injury and requires stitches. They go to the emergency room, have a couple tests done and get stitches. The hospital and all its providers are out of network (non-participating) for your benefit plan. The NSA requires that your claim is paid as if the hospital was in network, and the provider(s) are not allowed to balance bill you.

In some instances, the NSA requires non-participating providers to provide a notice and obtain consent when services are performed in a participating health care facility. An example of a situation where consent could be obtained if an employee chooses to have an elective procedure performed by a non-participating provider, but the facility it’s performed in is participating.  The notice and consent ensure you are aware of the potential charges you will be responsible for.  But there are exceptions:

• Emergent Services (emergency facility and all coverable services billed as emergent)
• Non-participating provider’s services when a participating provider was not available.
• Sudden emergency services not anticipated during care.
• Ancillary services, like emergency medicine, anesthesiology, pathology, radiology, and neonatology, whether provided by a physician or non-physician practitioner, and items and services provided by assistant surgeons, hospitalists, and intensivists.

In these situations, the non-participating provider is not allowed to seek consent for the charges and the employee is protected from any dollar amounts above their in-network cost share.

Independent Dispute Resolution (IDR) is an arbitration process to resolve NSA-eligible payment disputes between non-participating providers and Aetna.  It is required by the NSA and establishes an arbitration process by an external entity that will resolve eligible payment disputes for air ambulance, emergency services or non-emergency medical services provided by an out of network provider at a participating facility and health plans.

Aetna’s system is configured to apply Qualified Payment Amount (QPA) to NSA-eligible claims. Claims that apply the QPA have certain action codes to indicate payment.  Those action codes are included in our logic to identify the appropriate claims to charge the NSA-eligible per claim fee.

In late February 2023, the IRS, DOL and HHS issued a joint announcement detailing how group health plans are to comply with the gag clause attestation requirements, or Gag Clause Prohibition Compliance Attestations (GCPCA), established by the Consolidated Appropriations Act, 2021.

Employer-sponsored group health plans (both self-funded and fully insured) are prohibited from entering into agreements with a health care provider, network or association of providers, third-party administrator, or other service provider where the plan is restricted from accessing and sharing certain information. Employer-sponsored group health plans are also required to submit an annual attestation that the plan is in compliance with these requirements.

For the 2024 Gag Clause Prohibition Compliance Attestation (GCPCA) submission due by December 31, 2024, Aetna® will file on behalf of all self-funded (including Aetna Funding Advantage), insured and split-funded plan sponsors that had active coverage in 2024.

Aetna has conducted a review of our provider and vendor contracts and are confident that we are in compliance with the gag clause prohibition requirements. You can request a confirmation of compliance from Aetna by reaching out to your account manager.

Additional information regarding the Gag Clause Prohibition requirements can be found on the CMS website. On this site, plan sponsors can find Frequently Asked Questions, detailed instructions for submitting the attestations, a link to the reporting template, and a link directly to the web form for submission.

If you have additional questions, contact your account manager.