A benefit broker's guide to managing CAA requirements on behalf of clients
As health insurance advisers, we know how complicated the Consolidated Appropriations Act of 2021 (CAA) will be for our clients to navigate.
The three trickiest areas fall into three buckets: transparency, accuracy of information and equal access to care. In order to keep from feeling boxed in by these challenges, let's unpack exactly what each area entails.
The ERISA requirement boils down to this: An employer must understand how vendors are being paid, ensure that members have adequate information to make informed decisions, and that there is equal access to physical and mental health care.
The most challenging aspect will be obtaining contracts and ascertaining that the employer has enough information to understand how the administrative services only (ASO) agreement works. Also top of mind is how it intersects with the PPO and PBM contracts, and affects their employees.
Other areas of equal importance include the pricing model, as well as network requirements and robustness. Of course, we can obtain a copy of the ASO agreement, and the forward-thinking among us can get our hands on the PBM contract, or make sure we move to a PBM that will actually share their contract. (Has anyone tried to get a copy of a PPO contract? I know someone who did and it arrived in his mailbox in an unidentified envelope!)
Let's assume that we will have significant challenges in obtaining those contracts. What else can we possibly do? Our firm has moved on to data scraping and analytics. There are resources that help you determine what a plan paid for services so you can see the variation. You can use this data to help your client understand the difference between payments and suggest payment models that might suit them better.
Accuracy of information
How often has a member thought a provider was in-network, only to learn later that they were not? This is especially true with anesthesiologists, radiologists and pathologists. Even if a member is diligent in ensuring their surgeon and facility are both in the network, they often have no control over who knocks them out, who reads any scans performed during the procedure, or who determines whether or not they have cancer. Surprise billing legislation on both state and federal levels is helping resolve some of the issues, but problems persist.
What about quality? One of the other requirements in the CAA is that the networks be kept up to date and employees be able to access both price and quality metrics.
We called one of our carriers to ask about a physician — just a list of a few primary care physicians actually taking patients. Our rep left the building and called us from a cell phone to tell us who was taking patients. We didn't even ask about quality.
We are a boutique firm, so maybe we don't have enough clout. However, when Walmart asks and the carrier refuses, do you think a regular employer without a million employees stands a chance of accessing this information?
Find another resource beyond Google that will help employees find high-quality care. We often help clients invest in effective care management, not traditional medical management, to guide members to high-quality care delivered at the appropriate facility. This conversation never revolves around cost. It is simply giving regular folks access to information to find a doctor with a quantifiable track record, not just good advertising or the one working in the hospital system.
Equal access to care
This is a thorny and highly subjective topic. It is also an area where employers — or brokers — have a lot of control.
The Mental Health Parity and Addiction Equality Act of 2008 required that group health plans offer mental health coverage equal to that of physical health. That meant equal access to providers, payment models and ease of access.
In the past few years, I am sure you have heard of something called an NQTL, which stands for non-quantitative treatment limitations. Started jointly by the Department of Labor, Department of Health and Human Services and Department of the Treasury, these audits review plans for mental health parity. They have a near 100% fail rate.
Since employers do not control the network, this puts them in an impossible position. An independent entity also can perform an NQTL audit, allowing the employer to show a good faith effort to comply. It might be the best possible solution right now.
Meanwhile, here are three steps to help your clients:
- Stay up to date on compliance! We have recently talked with a number of employers that have had no guidance on RxDC reporting, the data-collection portion of the CAA that deals with prescription coverage, NQTL audits or network transparency. Yes, the obligation belongs to the employer. You are their adviser and it is incumbent on you to advise them of the requirements and financial risks for non-compliance.
- Review current agreements for compliance with the new laws and understand that there will be times when neither you nor the client can control the contract. I would advise you to choose vendors with appropriate contracts, which sometimes takes time to complete.
- Advise the client on where they stand in meeting the requirements and the financial risks for non-compliance. The fines are substantial and will pierce the corporate veil.
These actions all seem simple to me, yet at the same time, incredibly complex. But by taking them, we can grow our businesses and help our clients do the right thing.