A Call to Action: Health Plans Must  Respond to New Rules 

In the coming months, employers and other group health plan sponsors will need to address a diverse and largely unheralded array of health plan requirements. Collectively, these new rules may constitute the largest set of compliance  obligations for health plans since the implementation of the Affordable Care Act. Most of the requirements are set  forth in provisions of the Consolidated Appropriations Act, which was signed into law in December 2020, but they also  include regulatory guidance published in late 2020 and throughout 2021. The new rules include: 

  • Requirements to disclose information about network, out-of-network, and prescription drug pricing in a  transparent manner 
  • Requirements to report to the federal government certain information about prescription drug pricing 
  • “No Surprises” rules that limit how much plan participants must pay in certain situations (such as emergencies) when they receive out-of-network care and that establish a process for determining how much plans must pay in  those situations 
  • An obligation to conduct an analysis that compares non-quantitative limits on coverage for mental health and  substance use disorders to similar limits on coverage for medical and surgical expenses 
  • A prohibition against entering into vendor contracts that inappropriately restrict the disclosure of information about  cost and the quality of care 
  • A requirement to obtain specific information from brokers and consultants when engaging them to provide services  for a health plan 

Some of these requirements are already in effect. Others will take effect near the end of 2021 or at the start of the next  plan year. The rules require action from those who maintain insured plans as well as those who sponsor self-funded  arrangements.*

Employers will not be able to meet these new requirements on their own. They will need the cooperation of their  vendors and should be seeking commitments from their insurers, third party administrators, brokers, and others to  provide the information and services necessary for compliance. Without this cooperation, health plans could be subject  to enforcement actions, monetary penalties, and possible litigation. 

The new rules are detailed, and guidance on a number of matters has yet to be issued. However, in a series of separate  briefings, we will aim to describe the fundamental requirements of the new rules, one-by-one, and suggest measures  that employers may take to bring their plans into compliance. Employers should promptly and carefully consider their  own courses of action and seek assistance in complying with the new rules, as appropriate. 

Lawyers at Ballard Spahr are working with the new rules and are prepared to assist you with questions that you may  have. Please contact Edward Leeds or Brian Pinheiro.  

*Certain types of plans—including most dental, vision, employee assistance plans, and individual account plans  (such as health flexible spending arrangements and health reimbursement arrangements)—will generally be  exempt from the new rules.