Consolidated Appropriations Act (CAA) requirements - Chapter 2, 2022 Administrative Guide

Advanced EOB Network Considerations

Consistent with the Consolidated Appropriations Act (CAA), we must provide information to our members about costs related to the services you provide them. You agree to help us provide them this information.

You will provide information about the rules on balance billing under this act, as well as any other state law that requires you to advise our members about what you may charge them after we pay you. In addition, you agree to provide contact information for appropriate state and federal agencies in case a member believes you have violated balance billing rules.

Continuity of Care

Health insurance issuers, plan sponsors and/or health care providers are required to comply with the Continuity of Care requirements under the CAA unless your participation agreement states otherwise.

Continuity of Care is provided in the following circumstances:

  1. Your participation agreement with us or between you and a downstream provider is terminated by us, a payer, you or a downstream provider.
  2. The terms of your network participation with us or a payer changed, and that change leads to certain members no longer receiving in-network coverage for your care.
  3. A fully insured group contract between us and a group health plan terminated and that termination leads to members no longer receiving in-network coverage for your care.

Under the CAA, Continuity of Care must be offered to members in your care or the care of your downstream contracted providers who are:

  1. Undergoing treatment for a serious and complex medical condition.
  2. Undergoing inpatient or institutional treatment.
  3. Scheduled to undergo nonelective surgery, including receipt of postoperative care with respect to such a surgery.
  4. Pregnant and receiving treatment related to the pregnancy.
  5. Terminally ill per the Social Security Act and receiving treatment for the terminal illness.

In accordance with the CAA, you must accept payment from us or a payer based on your participation agreement and negotiated rates for any services rendered pursuant to the Continuity of Care requirements under the CAA. Any care you render to a member under Continuity of Care is subject to our or any payer’s applicable policies, procedures and quality standards. You also acknowledge additional rights for Continuity of Care may be required under state or local law or as specifically required in your participation agreement with us.

Provider directory

Consistent with the CAA, we will verify information in our provider directory. You will provide us with accurate information and respond to our questions when you receive them. You will respond within any time period listed in the communication we send to you. We may remove health care providers and facilities from the provider directory if we can’t verify information.

CAA prohibition on gag clauses

Your participation agreement may include a confidentiality provision that lists information that neither party may disclose to a member, health care provider or other third party except as required by an agency of the government. You agree the CAA constitutes such a requirement by an agency of the government, and nothing in your participation agreement will be interpreted to supersede or conflict with the CAA. Specifically, your participation agreement will not be interpreted to directly or indirectly restrict us (as a health insurance issuer offering group and individual health insurance coverage) or a group health plan from:

  1. Providing provider-specific cost or quality of care information to referring health care providers or current and potential members.
  2.  Electronically accessing de-identified claims and encounter information for each member in the plan or coverage, upon request and consistent with the privacy regulations related to section 264(c) of the Health Insurance Portability and Accountability Act (HIPAA), the amendments made by the Genetic Information Nondiscrimination Act of 2008, and American with Disabilities Act of 1990. This includes, on a per claim basis the following:

a. Financial information

b. Provider information

c. Service codes

d. Any other data included in claim or encounter transactions

  1.  Sharing information with a business associate as defined in section 160.103 of title 45, Code of Federal Regulations (or successor regulations), consistent with HIPAA6, the amendments made by the Genetic Information Nondiscrimination Act of 2008, and the Americans with Disabilities Act of 1990.