HHS requests info on explanation of benefits policy changes

The government wants feedback on how to regulate the advanced explanation of benefits and cost estimate provisions of the surprise billing ban, several departments announced in a request for information issued Wednesday.

The Health and Human Services, Treasury and Labor departments specifically ask for comments on the “good faith estimate” and advanced explanation of benefits provisions from the No Surprises Act.

Under that 2020 law, insurers are required to send beneficiaries explanations of their benefits upon request or when items or services are scheduled at least three days in advance. They must include information about whether providers are in-network, whether the items or services are subject to prior authorizations, and how much patients can expect to pay.

Most of the statute took effect in January. But regulators announced in August 2021 that they would delay the advanced explanation of benefits provision and requirement for good faith cost estimates for insured patients. Providers and insurers asked the departments for more time to develop the technical infrastructure to carry out these requirements, and for regulators to develop standards for data transfers between providers and insurers.

The request for information poses several questions about how cost estimates and benefit explanations should be transferred within the healthcare system and to patients. Regulators ask what they should consider when deciding whether to encourage Fast Healthcare Interoperability Resources-based interfaces and how they should address related privacy concerns. 

The departments ask for comments on whether providers should have to inform insurers when patients waive balance billing and cost-sharing protections. Regulators also ask how the No Surprises Act or state surprise billing laws should be reflected in explanations of benefits, whether diagnosis codes should be included, and what challenges underserved communities face that could affect benefits explanation preparation.  Additionally, policymakers ask about the potential economic impacts of the pending regulations.

Comments are due 60 days after the request for information is formally published in the Federal Register. HHS’ regulatory agenda indicates the department wants to propose a rule on the advanced explanation of benefits in or around January.

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