SUPPORT FOR CLIENTS
Regulatory Compliance
COMPLIANCE WITH SISCO
As a partner in your ERISA self-funded health plan, SISCO is committed to assisting in compliance with the requirements of the Consolidated Appropriations Act (CAA) and the Transparency in Coverage Rule (TiC). The information provided outlines the requirements of the CAA and TiC, your health plan obligations, and how SISCO can help.
ACA Reporting
In accordance with the Affordable Care Act's employer shared responsibility provision, self-insured employers who sponsor self-insured group health plans are required to offer minimum essential coverage to their full-time employees. Health plans providing minimum essential coverage during a calendar year must report certain information to the IRS.
Although it is the responsibility of the group health plan to meet these reporting requirements, SISCO does assist in providing some of the necessary monthly and annual reporting for group health plans to reference in their reporting efforts. If you have additional questions or want to learn more about the reporting SISCO provides for our group health plans, please reach out to your dedicated SISCO representative. If you don’t have a dedicated representative, provide your contact information in the form below and one of our representatives will follow up.
1095 Tax Forms
SISCO assists clients by providing monthly and annual 1095 compliance reports that includes showing coverage information for all members and dependents for the applicable time frame. SISCO does not generate 1095 tax forms on behalf of clients, and we do not give tax guidance. If you have specific questions on completing the form, we recommend you speak to your tax advisor.
If you don’t have a dedicated representative, provide your contact information in the form below and one of our representatives will follow up.
Additional reference material on this topic:
Employer Shared Responsibility Provisions | Internal Revenue Service (irs.gov)
Consolidated Appropriations Act, 2021 (CAA)
The No Surprises Act (NSA), enacted as part of the Consolidated Appropriations Act, 2021 (CAA), includes transparency provisions requiring group health plans, including grandfathered plans, and health insurance carriers to submit certain information about prescription drug and health care spending to the federal government (DOL, HHS and Treasury).
As a partner in your ERISA self-funded health plan, SISCO is committed to assisting in compliance with these requirements. The below checklist is intended to help you understand what data and information you need to prepare to meet legislation guidelines.
Mental Health Parity
Date: Beginning February 10, 2021
Who: All group health plans and issuers offering group or individual health insurance coverage.
What: Requires group/individual health plans and Medicaid managed care organizations to perform, document and to provide, upon request, comparative analyses of the design and application of non-quantitative treatment limitations (NQTL). Requires these analyses be made available to state and federal authorities upon request, as well as other relevant information including the factors used to determine the NQTL, the evidentiary standards used to determine the NQTL and the results of the analyses. Requires HHS to request no fewer than 20 of these comparative analyses per year.
SISCO's Role: SISCO reviews all plan documents to provide recommendations to clients on mental health parity requirements. SISCO will also assist the plan to complete the Department of Labor self-assessment tool and provide a recommendation for actuarial partners to work with for a formal assessment. In the event of an audit, SISCO can provide recommendations to a third-party actuarial partner to assist with reporting necessary to satisfy an audit.
Insurance ID Cards
Date: Plan or policy years beginning on or after January 1, 2022
Who: All group health plans and issuers offering group or individual health insurance coverage.
What: Requires group and individual health plans to identify the amount of in-network and out-of-network deductibles, the in-network and out-of-network out-of-pocket maximum limitations, and a telephone number and Internet website address on insurance cards, through which individuals may seek consumer assistance information
SISCO's Role: SISCO has and will continue to issue new ID cards for all health plans effective 1/1/2022 to comply with the CAA requirements. All members will receive a new card and the new card will be available online at www.siscoconnect.com.
Provider Directories
Date: Plan or policy years beginning on or after January 1, 2022
Who: All group health plans and issuers offering group or individual health insurance coverage.
What: Requires plans to establish a response protocol to respond to current member network questions within one business day and retain the communication for at least two years.
Requires plans to maintain a provider directory available to consumers online that includes a list of the in-network providers and facilities along with certain information, including the name, address, specialty, phone number and digital contact information for the provider or facility.
If a member provides documentation that they received incorrect information about a provider’s network status prior to a visit, provides for the patient to be responsible only for the in-network cost-sharing amount and for the visit to apply to the member’s deductible or out-of-pocket maximum, if applicable.
Plans are required to include certain disclosures on their website and on each applicable explanation of benefits.
SISCO's Role: SISCO complies with requirements for networks maintained by SISCO and will continue to work with third party networks to ensure health plans comply.
Gag Clauses
Date: Beginning December 27, 2021
Due Date: Plan or policy years beginning on or after December 27, 2021
Who: All group health plans and issuers offering group or individual health insurance coverage.
What: Prohibits gag clauses on cost and quality information in payer-provider contracting.
Precludes commercial health plans from entering into contracts with providers that prohibit payers from disclosing provider-specific cost or quality information to referring providers, the plan sponsor, enrollees and individuals eligible to become enrollees.
Precludes contract terms prohibiting payers from electronically accessing de-identified claims and encounter information for each enrollee, upon request of the payer to the provider. Information requests include, on a per claim basis, financial information such as the allowed amount, provider name and clinical designation, service codes or any other data element included in the claim or encounter transaction.
Precludes contract terms from prohibiting sharing of information detailed in this section with HIPAA business associates.
SISCO's Role: SISCO has updated its applicable contracts to meet the requirements of this section. SISCO has also offered all clients the ability to permit SISCO to submit the Gag Clause Attestation. All clients who have had active self-funded medical coverage with SISCO since 2020 were included in the Gag Clause Attestation submitted in December 2023.
No Surprises Act (NSA)
Date: Plan or policy years beginning on or after January 1, 2022.
Who: All group health plans and issuers offering group or individual health insurance coverage.
What: Provides for patients to be responsible for only in-network cost-sharing amounts, including deductibles, in emergency situations and certain non-emergency situations (including air ambulance providers).
SISCO's Role: SISCO has established operations to be compliant with the No Surprise Act provisions. Model notices are included in all plan documents and in all explanation of benefits. Additionally all claims related to No Surprise Act are priced thru our vendor relationships at the qualified payment amount to be compliant with NSA provisions.
Prior Authorization of OB/GYN Services
Date: Plan or policy years beginning on or after January 1, 2022.
Who: All group health plans and issuers offering group or individual health insurance coverage.
What: Group health plans and health insurance issuers continue to be prohibited from requiring prior authorization for obstetrical and gynecological care, including the ordering of related OB/GYN items and services.
SISCO's Role: SISCO is in compliance with this provision
Machine Readable Files
Date: Plan or policy years beginning on or after January 1, 2022. Compliance enforcement began on July 1, 2022.
Who: All group health plans and issuers offering group or individual health insurance coverage.
What: Requires group health plans and health insurance issuers to publicly post machine-readable files for in-network rates, out-of-network allowed amounts and billed charges. This provision previously included prescription drug negotiated rates and historical prices, but this portion of the provision has been delayed indefinitely.
SISCO's Role: SISCO has partnered with each network partner to make in-network rates available, as well as making our own network and out-of-network rates publicly available for our health plan partners. SISCO has created a weblink specific to every client that includes their applicable Machine Readable Files. It is the client’s responsibility to post this on their publicly available website.
Price Comparison Tool
Date: Plan or policy years beginning on or after January 1, 2022; however, enforcement of this provision was deferred until January 1, 2023.
Who: All group health plans and issuers offering group or individual health insurance coverage.
What: Requires group health plans and health insurance issuers to maintain a “price comparison tool” available via phone and website that allows enrolled individuals and participating providers to compare cost-sharing for items and services by any participating provider.
SISCO's Role: SISCO will offer health plan clients options through third party relationships to be compliant by 1/1/2023.
Pharmacy Benefits and Drug Costs Reporting
Prescription Drug Data Collection (RxDC)
The No Surprises Act (NSA), enacted as part of the Consolidated Appropriations Act, 2021 (CAA), includes transparency provisions requiring group health plans, including grandfathered plans, and health insurance carriers to submit certain information about prescription drug and health care spending to the federal government (DOL, HHS and Treasury).
This is now an annual obligation and the reports for the 2023 calendar year must be
electronically submitted to the Centers for Medicare & Medicaid Services (CMS) by June 01,2024. Most self-insured health plans need to rely heavily on their vendors such as their Third-Party Administrator (TPA) and/or Pharmacy Benefit Manager (PBM) to provide the data necessary.
SISCO will continue to assist our self-funded health plans during this round of reporting, due June 1, 2024. This filing will be related to the 2023 plan years. Like last year, SISCO will process and submit the P2 Group Health Plan and the D2 Spend by Category data. New this reporting round, health plans need to provide health plan premium averages. SISCO requested this information from each health plan and if a response was provided (due date April 15, 2024), SISCO will submit this information on behalf of the client. If SISCO does not receive a timely or complete response on the premium averages, we will not submit the premium data portion on behalf of the client.
SISCO has worked with the PBM partners to determine the PBM submission responsibilities. See below for a breakdown of responsibilities by PBM.
CAA Pharmacy Benefit Manager Submission Details
Amwins RX: AmWins RX will fulfill their reporting obligations and will file directly to CMS on a client-by-client basis. Reach out to your dedicated representative at AmWins RX with additional questions.
CIGNA: CIGNA will provide reporting for the remaining 6 data files for all claims processed
through their system for the reference year. CIGNA will be assessing a fee for the reporting and reporting will be sent through SISCO for each client to file to CMS.
CVS: CVS will fulfill their reporting obligations and will file directly to CMS on a client-by-client basis. Reach out to your dedicated representative at CVS with additional questions.
Elixir: Elixir will submit the remaining 6 data files for all claims processed through their system for the reference year. Elixir will be assessing a fee for the reporting.
Express Scripts: Express Script will fulfill their reporting obligations and will send reporting directly to the client to file to CMS. Reach out to your dedicated representative at Express Scripts with additional questions.
Magellan: Magellan will file the initial report for the reference year directly to CMS. Reach out to your dedicated representative at Magellan with additional questions.
Maxor: Maxor will file data to CMS and will notify the client of submission once completed. Please contact your dedicated representative at Maxor with additional questions.
MedOne: MedOne will provide reporting for the remaining 6 data files for all claims processed through their system for the reference year. MedOne will be assessing a fee for the reporting and reporting will send reports directly to the client. Please contact your dedicated representative at MedOne with additional questions.
Optum RX: Optum will provide reporting for the remaining 6 data files for all claims processed through their system for the reference year. Optum RX will assess a fee for the reporting and reporting will be sent through SISCO for each client to file to CMS.
ProAct: ProAct will fulfill their reporting obligations and will file directly to CMS on a client-byclient basis. Please reach out to your dedicated ProAct Representative with additional questions.
RXBenefits: RXBenefits will fulfill their reporting obligations and will file directly to CMS on a client-by-client basis. Please reach out to your dedicated RXBenefits representative with additional questions.
Serve You: Serve You will be providing reporting for the remaining 6 data files for all claims processed through their system for the reference year. Serve You reporting will be sent through SISCO for each client to file to CMS.
True RX: True Rx will fulfill their reporting obligations and will file directly to CMS on a client-byclient basis. Please reach out to your dedicated True RX representative with additional questions.
US-Rx Care: US-Rx Care will be filing the remaining 6 data files for all claims processed through their system for the reference years at the TPA, state and market level segment (not at individual client level). Please reach out to your dedicated US-Rx Care representative with additional questions.
Ventegra: Ventegra will be work directly with individual clients to determine if client or Ventegra will submit to CMS. Please reach out to your dedicated Ventegra representative with additional questions.
Welldyne: Welldyne will fulfill their reporting obligations and will file directly to CMS on a client-by-client basis. Data will be aggregated at a market segment and state level and a narrative file will be provided as well. Please reach out to your dedicated Welldyne representative with additional questions.
Additional details can be found at the Center for Medicare & Medicaid Services (CMS) website by clicking the following link: Center for Medicare & Medicaid Services CAA Reporting
Broker and Consultant Compensation Disclosure
Date: December 27, 2021. Contracts executed and certain contracts renewed after December 27, 2021, by a health insurance issuer will be subject to the disclosure requirements.
Who: Issuers offering individual health insurance coverage and Short-Term, Limited Duration Insurance (STLDI) coverage.
What: For individual health insurance coverage and STLDI coverage, a health insurance issuer must disclose to enrollees, and report to the Department of Health and Human Services (HHS), any direct or indirect compensation that the issuer pays to an agent or broker associated with plan selection and enrolling individuals in the coverage.
SISCO's Role: SISCO is in compliance with this provision.
Continuity of Care
Date: Plan or policy years beginning on or after January 1, 2022.
Who: All group health plans and issuers offering group or individual health insurance coverage.
What: Requires a group health plan or health insurance issuer to provide 90 days of continued, in-network care for continuing care patients if a provider or facility leaves the network. Continuing care patients generally are individuals who are undergoing treatment for a serious and complex condition, pregnant, receiving inpatient care, scheduled for non-elective surgery, or terminally ill.
The group health plan or health insurance issuer is to notify continuing care patients if their providers or facilities leave the network and provide the option to continue care for the lesser of 90 days or until the individual is no longer a continuing care patient.
Providers subject to this provision are to continue accepting in-network payment as payment in full and otherwise comply with all policies, procedures and quality standards imposed by the plan or issuer for the continuing care patient.
SISCO's Role: SISCO has updated protocol to ensure compliance with this provision