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    Gag clause attestation ensures plan sponsors have access to cost and quality data

    Authored by Bukaty Companies on April 24, 2023

    Many provisions within the Consolidated Appropriations Act (CAA), adopted in December 2022, are designed to bring greater cost transparency to the cost of medical care. A new CAA gag prohibition rule in effect today restricts health plans and carriers from entering into agreements with providers, third-party administrators (TPAs) and pharmacy benefit managers (PBM) that effectively block access to quality and cost data and prohibits sharing such data with business associates. The limited access to claims and cost data is often a source of frustration for plan sponsors looking to better understand health care costs and member health outcomes.

    The first attestation must be submitted to the Department of Health and Human Services (HHS) by December 31, 2023, and annually thereafter by December 31. The requirement applies to fully insured and self-funded group health plans, both Employee Retirement Income Security Act (ERISA) and non-ERISA plans, regardless of grandfathered status under the Affordable Care Act. Vision, dental, and other excepted benefits, such as accident and disability plans, are exempt from the attestation requirement. Account-based plans, like health flexible spending accounts or health reimbursement arrangements are also exempt.

    While the attestation requirement is the responsibility of the group health plan, FAQs released by the Department of Labor, HHS and IRS clarify that an entity other than the group health plan can submit the attestation.

    In preparation for the December 27 attestation deadline, plan sponsors should 1) confirm any existing or future plan-related agreements with TPAs, PBMs and provider networks are stripped of any noncompliant language, 2) fully insured plans should confirm that attestation will be submitted by the carrier, and 3) self-funded plans should determine if their TPA or other service provider will submit the attestation on their behalf, and to obtain a written agreement confirming the obligation.


    Blog Category: Compliance