Plans and issuers requirements and resources

The Consolidated Appropriations Act, 2021 (CAA) established protections for consumers related to surprise billing and transparency in health care. Resources to help plans and issuers navigate these new rules and requirements are listed below.

Some documents on this page include guidance pertaining to rules that have been vacated by Texas Medical Association, et al. v. United States Department of Health and Human Services, Case No. 6:23-cv-59-JDK or Texas Medical Association, et al. v. United States Department of Health and Human Services, Case No. 6:22-cv-450-JDK. These decisions vacated rules related to batching of IDR disputes, the administrative fee amount for IDR disputes, requirements related to the timeframe for sending an initial payment or notice of denial of payment, the methodology for calculating qualifying payment amounts (QPAs), and/or provisions pertaining to air ambulance disputes. Please review the opinions in the cases cited above for further information on which provisions of the regulations and guidance were vacated and the notes on our website about applicable guidance. Disregard those specific sections of these documents to the extent inconsistent with the court’s opinions.

Resources

• No Surprises Act Qualifying Payment Amount (QPA) Methodology. Information for plans and issuers on the QPA under the No Surprises Act and information on the QPA audit authority and process. QPA Calculation Methodology (PDF) and Recorded Presentation (YouTube). 
• No Surprises Act Remittance Advice Remark Codes (RARCs). Information for plans and issuers on RARCs related to the No Surprises Act. RARCs Related to the No Surprises Act (PDF).
• Federal Independent Dispute Resolution (IDR) Applicability Chart. Chart to help determine whether the Federal IDR process, a state law, or an All-Payer Model Agreement applies for determining out-of-network rates. Chart for Determining Applicability for the Federal IDR Process (PDF) (PDF).
• Federal IDR Checklist for Plans and Issuers. A resource to help plans and issuers understand their obligations and comply with key requirements of the No Surprises Act when processing claims for items and services that fall within the scope of the new surprise billing protections. Federal IDR Process - Checklist of requirements for group health plans and group and individual health insurance issuers (PDF) (PDF).
• CAA Enforcement Letters. A summary of each state’s enforcement structure of the Public Health Service Act provisions, as extended or added by the CAA, as well as information on whether the federal IDR process and the federal patient-provider dispute resolution process apply in each state and in what circumstances. All CAA Enforcement Letters are posted on the CCIIO CAA page under “Enforcement.”
• Mental Health Parity and Addiction Equity Act (MHPAEA). Overview of the provisions related to MHPAEA added by the CAA, how the new provisions apply to plans and issuers, and MHPAEA resources and compliance tools. Non-Federal Governmental Plans and NQTL Comparative Analysis Reviews for MHPAEA Compliance (PDF) and Health Insurance Issuers and NQTL Comparative Analysis Reviews for MHPAEA Compliance (PDF) (PDF).
• Prescription Drug Data Collection (RxDC). Resources to help plans and issuers comply with the prescription drug data collection requirements of the CAA. RxDC resources page.
• Gag Clause Prohibition Compliance Attestation (GCPCA). Resources to help plans and issuers comply with the gag clause prohibition compliance attestation (GCPCA) requirements of the CAA. GCPCA resources page.