The Consolidated Appropriations Act (CAA) prohibits health plans from entering into contracts that would restrict the plan from:
- Offering provider-specific cost or quality of care information to referring providers, the plan sponsor, plan participants, or persons eligible to become plan participants. The statute contemplates that this information would be delivered through a “consumer engagement tool” or “any other means”.
- Electronically accessing de-identified claims data for each plan participant upon request on a per claim basis including:
- Financial information such as the allowed amount and any other claim-related financial obligations in the provider contract;
- Provider information, including name and clinical designation;
- Services codes; and
- Any other data element included in the transaction.
The contract cannot prevent this data from being shared or directing that the data be shared with a plan’s business associates. However, a network may place reasonable restrictions on public disclosure of the information.
Plans must submit an annual attestation to the government that they are in compliance with this rule.
It is unclear when this rule will apply to any given plan. By its terms, it seems to govern only prospective contracts; not existing ones. The question of what happens when an existing agreement is renewed or modified remains to be answered.
However, plans currently negotiating new network agreements or contemplating doing so, will likely need to take account of these requirements.
There appears to be tension between making the information available to plan participants and others, and the ability of a network to place reasonable restrictions on public disclosure.