Payor contracting can seem daunting, particularly for new companies and innovative organizations that are unfamiliar with the nuances of providing a product to health insurers and health maintenance organizations. Navigating regulatory considerations and payor contract complexities requires a solid understanding of the basics. During this webinar, McDermott Partners Gregory Mitchell, Mimi Alexandre, and Erin Kelly discussed some key principles of payor contracting.
The Mental Health Parity and Addiction Equity Act (MHPAEA) generally requires group health plans and health insurance issuers to ensure that financial requirements (such as copays and deductibles), quantitative treatment limitations (such as visit limits), and nonquantitative treatment limitations (such as prior authorization and concurrent review) applicable to mental health or substance use disorder (MH/SUD) benefits are generally no more restrictive than the requirements or limitations applied to medical/surgical (M/S) benefits. The Consolidated Appropriations Act, 2021 imposed further obligations in the case of nonquantitative treatment limitations (NQTLs), which are the subject of final regulations issued in September 2024. (We explained the final regulations here.)
Among many other things, the final regulations establish a two-part test that applies to NQTLs consisting of:
The relevant data evaluation requirement has proven especially challenging for self-funded group health plans of every size, as third-party administrators fail, refuse, or are otherwise unable to provide the information necessary to comply. There may be another option, however.
The final regulations do not specify the data set on which compliance with the relevant data requirement is tested. Rather, the regulations, which apply to both plans and issuers, seem to assume that the plans test on the basis of plan data, and issuers test on the basis of the issuer’s corresponding block of business. In their informal remarks at trade and industry conferences, representatives of the US Department of Labor (DOL), expressing their own views and not those of the DOL, have acknowledged that they are aware of and are considering their options related to the proper testing data set.
Some large carriers have shared the NQTL analysis that they previously prepared for their fully insured groups with the self-funded group to whom they provide administrative services. Presumably, this will give their self-funded groups a starting point. Many self-funded groups, particularly smaller groups, are not inclined to modify the standard set of NQTLs offered by their carriers/administrative-service-only (ASO) providers. If these groups were allowed to test based on the carrier’s corresponding book of business, a good deal of the work would be done. This would also have the salutary effect of exerting market pressure [...]
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On December 5, 2024, the US Department of Health and Human Services Office for Civil Rights issued a “Dear Colleague” letter reiterating obligations that covered entities have under the May 2024 final rule related to language access requirements under Section 1557 of the Affordable Care Act. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in covered health programs and activities. The final rule strengthened many protections against discrimination in healthcare, including rules for providing language assistance to individuals with limited English proficiency (LEP) or disability. This Dear Colleague letter had the goal of outlining key requirements to ensure that covered entities provide meaningful language access to individuals in time for the June 5, 2025, deadline for full implementation.
With the 2025 plan year right around the corner, this is the ideal time for plan sponsors to ensure that plan operations comply with evolving legislative and regulatory requirements. This client alert highlights important regulatory changes that will impact retirement plans and health and welfare plans in the coming year.
Read more here.The 2024 election results will create significant tailwinds for Republican legislative and regulatory priorities in US Congress, federal agencies, and state houses across the country. This client alert considers the outlook for pharmacy regulation under the second incoming Trump administration and a unified Republican Congress, as well as state-level pharmacy policies that may advance as Republican public policy momentum builds.
In this recently recorded webinar, McDermott+’s Debbie Curtis and Rodney Whitlock discuss the outcomes of the 2024 election, potential healthcare policy changes under the new administration and Congress, and the implications of election outcomes on healthcare policy heading into the lame duck session and in 2025.
On November 18, 2024, the Internal Revenue Service (IRS) released Internal Revenue Bulletin 2024-47, which includes proposed regulations designed to ensure that non-grandfathered group health plans and insurance issuers provide an accessible exceptions process for preventive services, allowing coverage without cost sharing if deemed medically necessary by an individual’s provider.
Learn more about new IRS guidance in the latest Weekly IRS Roundup published by McDermott’s Tax Group.
Will President-elect Donald Trump seek to repeal the Affordable Care Act once more, or will his administration opt for smaller-scale changes to the law? In this article, Alden Bianchi shares his predictions on the actions the incoming administration and Republicans may consider as they take control of the White House and Congress.
On October 29, 2024, the US Department of Justice (DOJ) issued a proposed rule to implement US President Joe Biden’s Executive Order (EO) 14117. This order aims to prevent countries of concern from accessing Americans’ sensitive personal data and US-government-related data. The proposal specifically includes health data as a category of sensitive personal data that could be exploited. Health insurers, service providers to health plans, and healthcare providers should review this proposed rule closely.
The Consolidated Appropriations Act (CAA), 2023 (Public Law 117-328), extended certain key virtual care flexibilities instituted during the COVID-19 public health emergency through December 31, 2024. This includes the telehealth safe harbor for health savings account-eligible high deductible health plans. Without congressional action, these waivers and flexibilities will end on December 31, 2024.
Read the latest update from McDermott+ for more information on these policies, relevant regulatory and congressional action, and the likelihood of further extensions before the end of this year.
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