Compliance Date: 1/1/2022
Who Needs to Take Action: Health plans
Summary: Protects members from being responsible for amounts over their in-network cost-sharing (including deductibles) in situations that include:
- Out-of-network emergency services related to an emergency condition
- Certain non-emergency services delivered by an out-of-network provider at an in-network facility
- Out-of-network air ambulance services (if the plan covers in-network air ambulance services)
Members also have the right to request an external review in situations involving surprise billing and cost-sharing protections.
Read more about surprise billing regulations
Compliance Date: 1/1/2022 (enforcement deferred to 1/1/2023)
Who Needs to Take Action: Health plans
Summary: Requires health plans to provide members the ability, via phone or the plan’s website, to compare cost sharing for services rendered by in-network providers.
Compliance Date: 3/31/2023
Who Needs to Take Action: Health plans
Summary: Requires submission of two years of air ambulance claims data to Health and Human Services, the Department of Labor, and the Department of the Treasury. These agencies will be responsible for publishing a comprehensive report from all health plans.
Read more about air ambulance reporting regulations
Compliance Date: 1/1/2022
Who Needs to Take Action: Health plans
Summary: Requires that member ID cards include both in-network and out-of-network deductible and out-of-pocket maximum limits. The ID card must also include a phone number and website where members can get additional help.
Read more about ID card regulations (PDF)Open a PDF
Compliance Date: Pending further rulemaking
Who Needs to Take Action: Health plans
Summary: Requires health plans to provide members with a good faith estimate of expected charges and an Advanced Explanation of Benefits (AEOB) upon notification by a provider of scheduled services, or at a member’s request.
Read more about good faith estimate and AEOB regulations (PDF)Open a PDF
Compliance Date: 1/1/2022
Who Needs to Take Action: Health plans
Summary: Requires health plans to provide a continuation of in-network coverage with a provider, when that provider’s network status changes at the time a member is (1) undergoing a course of treatment for a serious and complex condition or pregnancy; (2) undergoing a course of institutional or inpatient care; (3) scheduled for non-elective surgery (including post-operative care); or (4) terminally ill. Coverage must be provided for up 90 days or until the member is no longer receiving continuing care, whichever comes first.
Compliance Date: 1/1/2022
Who Needs to Take Action: Health plans
Summary: Requires health plans to maintain an online directory of participating providers and verify and update the directory. Plans must also establish a process to respond to members’ requests (by phone or on the website) for the participating status of a provider, and ensure members are only responsible for in-network costs if they rely on inaccurate information provided by the plan.
Read more about provider directory regulations (PDF)Open a PDF
Compliance Date: 2/10/2021
Who Needs to Take Action: Health plans
Summary: Requires health plans to perform, document, and provide comparative analyses of the design and application of non-quantitative treatment limitations (NQTLs) when the plan provides both medical/surgical benefits and mental health/substance use disorder benefits and imposes NQTLs on mental health/substance use disorder benefits. These results must be made available to federal and state agencies, upon request.
The Mental Health Parity and Addiction Equity Act (MHPAEA) currently requires health plans apply any non-quantitative treatment limitations in parity between medical/surgical benefits and mental health/substance use disorder benefits.
Read more about mental health parity regulations (PDF)Open a PDF
Compliance Date: 12/27/2021; reporting to Health and Human Services on 7/1/2023 and after
Who Needs to Take Action: Health plans
Summary: Requires health plans to disclose information about direct and indirect agent and broker compensation to individuals who shop for, purchase, or renew coverage. Health plans must report specific information to Health and Human Services annually.
Read more about agent and broker fee disclosure regulations
Compliance Date: 12/27/2021
Who Needs to Take Action: Health plans
Summary: Requires health plans to disclose information about direct and indirect compensation of $1,000 or more received for brokerage or consulting services. This disclosure must be made to the “responsible plan fiduciary” of groups covered under the Employee Retirement Income Security Act (ERISA) in advance of a new arrangement, or before an existing arrangement is extended or renewed.
Read more about agent and broker fee disclosure regulations
Compliance Date: 1/1/2022
Who Needs to Take Action: Health plans
Summary: Prohibits health plans from entering into contracts with providers and third-party administrators that restrict the disclosure of provider-specific cost or quality information. Plans must provide annual attestation of compliance.
Read more about gag clause regulations (PDF)Open a PDF
Compliance Date: 12/27/2022
Who Needs to Take Action: Health plans
Summary: Requires health plans to report annual data on drug utilization, spending, and rebates to Health and Human Services, the Department of Labor, and the Department of the Treasury. Reporting must include total spending on health care services by type. No confidential or trade secret information will be made public.
Read more about pharmacy reporting regulations (PDF)Open a PDF
Compliance Date: 1/1/2022
Who Needs to Take Action: Health plans
Summary: Expands existing patient protections to apply to grandfathered and self-funded groups. Health plans that require designation of a primary care provider (PCP) must allow members to choose any available physician as a PCP, including the choice of a pediatrician for a child’s PCP. Health plans must also allow women to see an OB/GYN without prior authorization. Members must be notified of these protections.
GDPR Notification Content