Gag Clause Prohibition Compliance Attestation (GCPCA)
Group health plans (plans) and health insurance issuers offering group or individual health insurance coverage (issuers) must annually submit a Gag Clause Prohibition Compliance Attestation (GCPCA) to the Departments of Labor, Health and Human Services (HHS), and the Treasury (collectively, the Departments). A GCPCA is an attestation of compliance with Internal Revenue Code (Code) section 9824, Employee Retirement Income Security Act (ERISA) section 724, and Public Health Service (PHS) Act section 2799A-9, as added by the Consolidated Appropriations Act, 2021 (CAA) and as applicable. These provisions generally prohibit plans and issuers from entering into certain provider agreements that would prevent the disclosure of cost or quality of care information or data, and certain other information to active or eligible participants, beneficiaries, and enrollees of the plan or coverage, plan sponsors, or referring providers, or restrict the plan or issuer from sharing such information with a business associate, consistent with applicable privacy regulations. A health care provider, network or association of providers, or other service provider may place reasonable restrictions on the public disclosure of this information. These provisions became effective December 27, 2020. Group Health Cooperative of Eau Claire will complete the attestation annually by December 31st for all fully-insured employer groups.
Pharmacy Benefit and Drug Cost Reporting
Under the Consolidated Appropriations Act (CAA), insurance companies and employer-based health plans are required to report data annually regarding prescription drugs and health care spending to the Departments of Health and Human Services, Labor, and Treasury (Tri-Agencies). This information must be submitted through a web portal that is being set up by the Centers for Medicare & Medicaid Services (CMS)
For fully-insured employers who use Express Scripts, our pharmacy benefit manager (PBM), Group Health Cooperative of Eau Claire and Express Scripts will complete all reporting requirements by June 1 each year. Reporting requirements include the following:
- Enrollment and premium information, including average monthly premiums paid by employees and the employer
- Total health care spending, broken down by type of cost (e.g., hospital care, primary care, specialty care, prescription drugs, and other medical costs including wellness services) by enrollees and by employer or insurer
- Prescription drug spending by enrollees and employers or insurer
- 50 most frequently dispensed brand prescription drugs
- 50 costliest prescription drugs by total annual spending
- 50 prescription drugs with the greatest increase in plan or coverage expenditures from the prior year
- Prescription drug rebates, fees, and other remuneration paid by drug manufacturers to the plan or issuer in each therapeutic class of drugs, as well as for each of the 25 drugs that yielded the highest amount of rebates
- Impact of prescription drug rebates, fees, and other remuneration paid by prescription drug manufacturers on premiums and out-of-pocket costs
Mental Health Parity and Addiction Equity Act (MHPAEA)
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prohibits health plans and health insurance issuers from imposing barriers on access to mental health or substance use disorder (MH/SUD) benefits that do not apply to medical and surgical (M/S) benefits. MHPAEA’s parity requirements apply to financial requirements (such as deductibles, copayments and coinsurance), quantitative treatment limitations (such as day or visit limits) and nonquantitative treatment limitations (NQTLs), which generally limit the scope or duration of benefits (such as standards related to network composition). MHPAEA applies to group health plans sponsored by employers with more than 50 employees. However, insured health plans in the small group market must also comply with federal parity requirements for MH/SUD benefits. To ensure compliance with MHPAEA, Group Health Cooperative of Eau Claire completes an annual comparative analysis on our Commercial and Medicaid product lines to ensure coverage for mental health/substance use benefits are comparable to, and applied no more stringently to, coverage for medical and surgical benefits. Group Health Cooperative of Eau Claire currently has identified the following NQTLs in their annual review:
- Out of Network (OON) Geographic Restricts
- Medical Necessity Determinations
- Prior Authorization Requests
- Provider Credentialing
- Provider Reimbursement