Transparency Rule & No Surprises Act Chart

August 3, 2021

The No Surprises Act was signed into law December 27, 2020, as part of the Consolidated Appropriations Act of 2021 to protect participants in health benefit plans from surprise medical bills for emergency and non-emergency medical care, including air ambulance services. The No Surprises Act applies to employer-sponsored group health plans, including self-funded plans, fully insured plans, and grandfathered plans. It does not apply to HRA plans (or other account-based plans), voluntary dental and vision plans administered under a separate policy or agreement, or retiree-only plans. 

The Transparency Rule was signed into law November 12, 2020 and requires plans and insurance issuers to disclose cost-sharing information, negotiated rates for in-network providers, and allowed amounts for out-of-network providers. The Transparency Rule applies to employer-sponsored group health plans and health insurance issuers in the group and individual market. It does not apply to grandfathered health plans, HRA/HSA Plans, retiree only plans, or voluntary dental and vision plans administered under a separate policy or agreement. A self-insured plan can delegate compliance with the Transparency Rule to a third-party administrator (TPA) but will be liable for the TPA’s non-compliance. Sponsors of fully insured plans are permitted to enter into a written agreement delegating compliance to the health insurance issuer; the issuer will then be liable for noncompliance. 

Limited guidance regarding out-of-network (OON) emergency and balance-billing was published on July 13, 2021. The July guidance stated that the federal government intends to issue regulations regarding transparency in plan and insurance identification cards, continuity of care, accuracy of provider network directories, prohibition on gag clauses, and pharmacy benefit and drug cost reporting. However, rulemaking regarding some of these provisions might not occur until after January 1, 2022. Regulations issued after January 1, 2022 will include a prospective applicability date that provides plans, issuers, providers, and facilities a reasonable amount of time to comply with new or clarified requirements. Until such regulations are issued plan sponsors are expected to implement the requirements of the No Surprises Act and Transparency Rule using a good faith, reasonable interpretation.

Please click here to view a chart with more information on the requirements and effective dates of the No Surprises Act and Transparency Rule.

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