Health and Disability

Under the revised proposal, insurers may during 2016, and must during 2017 for the 2018 open enrollment period, provide CMS for display on its transparency website a URL that would link to insurer policies or information regarding:

• Out-of-network liability and balance billing (including information on exceptions for out-of-network liability, as for emergency services);
• How enrollees can submit claims in lieu of a provider if their provider fails to submit a bill;
• Grace periods and pending of claims during grace periods (including notice that enrollees could be ultimately liable for pended claims if they do not catch up on their premiums;
• Retroactive claims denials;
• Recoupment of overpayments by enrollees;
• Medical necessity and prior authorization timeframes and enrollee responsibilities;
• Drug exception (for obtaining non-formulary drugs) timeframes and enrollee responsibilities;
• Explanation of benefit (EOB) forms — what they are, when they are sent, and how they should be read and understood;
• Coordination of benefits; and
• Insurer contact information.