The No Surprise Billing Act, which was included in the omnibus spending bill passed at the end of 2020, contains numerous provisions that impact group health plans-- including one regarding cost transparency. For plan years beginning on or after January 1, 2022, health plans must provide participants an advanced explanation of benefits (EOB) prior to scheduled care or upon request.
The advanced EOB must contain information about whether the provider is in- or out-of-network. Additionally, the EOB must include estimates of the cost of services, the amount the plan is responsible for paying, the amount the participant is responsible for paying, and the amount the participant has incurred toward his or her out-of-pocket maximum and deductible. If the service is subject to medical management techniques, such as step therapy or prior authorization, the EOB must include a disclaimer stating so. Finally, the EOB must include a disclaimer that all information included are estimates.
Generally, health plans must provide these EOBs within 3 business days for services scheduled 10 or more business days after the request, or within 1 business day for services scheduled less than 10 days from the request. However, the Department of Health and Human Services has the ability to alter those deadlines for services deemed to have low utilization or significant cost variations.