The Consolidated Appropriations Act (CAA), No Surprises Act (NSA), and the Transparency in Coverage (TiC) final rule impose several requirements on group health plans.
- For a fully-insured plan, the carrier will typically handle the requirements.
- For a self-funded plan, the responsibility of compliance lies with the employer as the plan sponsor. However, many of the requirements force employers to rely on their third-party administrator (TPA) and others to implement appropriate measures to comply.
The following is a checklist of the various requirements to assist employers who offer self-funded group health plans in determining which items the TPA will handle on their behalf and which things the employer is responsible for handling on their own (or for finding another solution).
Employers should review contracts with service providers to ensure that compliance obligations related to surprise billing, transparency and reporting requirements are clearly assigned and that costs for compliance, if any, are clarified. Contracts should include appropriate indemnification or liability protections for the employer if the service provider fails to comply with applicable requirements. Employers should also maintain documentation demonstrating due diligence in monitoring compliance.
Compliance Checklist
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1. No Gag Clause in Provider Contracts
All gag clauses must be removed from relevant provider contracts, and group health plans must submit an annual attestation of compliance. The attestation is due by December 31st each year.
- Confirm that all existing contracts with service providers in connection with administering the group health plan do not contain any gag clauses
- Confirm in writing (in the contract or otherwise) that the service provider(s) will submit an annual attestation of compliance each year
2. ID Cards / Provider Directory Accuracy
ID cards must include additional required information, including deductible and copay details.
Accurate provider directory information must be available online and by telephone, and the information is required to be verified and updated at least every 90 days. If an individual is provided inaccurate information by the provider directory stating that the provider or facility was a participating provider or facility, the plan may apply cost-sharing only equal to or less than it would for a participating provider or facility and must count such cost-sharing amounts toward any in-network deductible or maximum OOP.
- Confirm the TPA will provide ID cards with the required information
- Confirm the TPA will maintain an accurate provider directory OR will assume liability if the employer’s plan is required to pay more due to provider directory inaccuracies
3. Surprise Billing Rules (Balance Billing Protection)
Balance billing generally is not permitted for: (i) out-of-network emergency services; (ii) out-of-network providers in an in-network facility; and (iii) out-of-network air ambulance services. Plan participants may only be asked to pay the in-network rates, and the plan must pay the difference as negotiated with the provider.
A model notice communicating this protection must be posted on the plan’s public-facing website and must also be included with all explanations of benefits (EOBs).
- Confirm surprise billing protections are addressed in the group health plan’s summary plan description (SPD)
- Confirm the TPA will process claims in accordance with the surprise billing requirements
- Confirm to what extent the TPA will negotiate with providers to get a fair price for the services, potentially using the independent dispute resolution (IDR) process, and any costs associated with such negotiations
- Confirm the TPA will include the model notice, or something similar, on their public-facing website and on all EOBs
4. Service Provider Compensation Disclosure
Service providers to group health plans subject to ERISA that expect to receive $1,000 or more in direct or indirect compensation must provide a written disclosure describing the compensation and services provided to the plan.
- Confirm that service providers receiving $1,000 or more in compensation have provided the required written disclosure of services and compensation
- Maintain copies of the compensation disclosures for plan documentation purposes and be sure to use the information provided to confirm that the plan sponsor is making responsible, reasonable choices about vendor selection and plan asset spending
5. Continuity of Care
When a provider or facility is no longer in-network or covered under the plan, participants must be permitted to continue care for up to 90 days under the same terms and conditions that were in place prior to the change in network or coverage.
- Confirm that upon a network change, the TPA will identify and notify affected individuals and provide an opportunity for participants to request transitional care
6. Health Plan Data Machine-Readable Files
Group health plans must make machine-readable files (MRFs) publicly available that disclose pricing information. These files generally include: (i) in-network rate information for covered items and services; (ii) out-of-network allowed amounts and billed charges; (iii) internal provider taxonomy mapping or other rules supporting the pricing disclosures; (iv) provider utilization information; and (v) a text file with the source page URL that hosts the MRF and contact information for the MRF.
Except for the text file MRF, all MRF files should be published in JavaScript Object Notation (JSON). The files must be publicly accessible through a website, with a homepage footer link titled "Price Transparency" or "Transparency in Coverage" directing users to the disclosures. Plans must also maintain a monitored email address for inquiries regarding the files.
The TiC final rule issued in October 2026 provides a phased implementation approach during 2027 and 2028 for the required file formats and reporting content described above. Additional FAQs released around the same time indicate that technical schemas and implementation specifications for prescription drug MRFs are expected in late 2027.
- Confirm the TPA will post the MRFs in the specified format on their public website and update the files in accordance with applicable timelines, including quarterly updates for in-network rate and out-of-network allowed amount files and annual updates for provider utilization information
- Confirm the TPA will maintain the required homepage footer link ("Price Transparency" or "Transparency in Coverage") and monitored email address for inquiries regarding the files
- Confirm the TPA will attest to the accuracy and completeness of the data provided in the machine-readable files
7. Prescription Drug Cost (RxDC) Reporting
A plan list file and 8 data files, along with narratives, containing certain information about the plan’s prescription drug and health care spending must be submitted annually to CMS. It is possible the information required will need to be gathered from several different sources (e.g., TPA, PBM, and other service providers).
- Confirm which data files applicable service providers will submit on behalf of the plan and whether they will incorporate information from other vendors or need any information from the employer
- If any service providers will not handle their portion of the reporting, confirm how the plan information will be shared to allow the employer to report
8. Price Comparison Tool / Cost-Sharing Disclosures
Personalized cost-sharing information for covered health care items and services from each provider must be provided through an internet-based self-service tool and by telephone, and by paper upon request. If applicable, the tool must also include a balance billing disclosure where participants may be responsible for additional amounts.
The cost-sharing disclosure requirements originate from the TiC rules. The No Surprises Act also has a similar requirement of a price comparison tool. A single tool that complies with the TiC rules can fulfill both obligations.
- Confirm the TPA will provide a web-based price comparison tool as well as making the information available by phone or on paper upon request with appropriate balance billing disclosures
9. Advanced Explanation of Benefit (EOB) – Delayed indefinitely
Plans must provide an advanced notification of a good faith estimate of expected charges to participants.
