Progress Toward Advanced Explanation of Benefits (AEOB) Rulemaking and Implementation (Apr. 23, 2024)
Available at https://www.cms.gov/files/document/progress-aeob-rulemaking-implementation.pdf
HHS has released an update on its progress toward implementation of the Advanced Explanation of Benefits (AEOB). As background, transparency provisions in the Consolidated Appropriations Act, 2021 require health care providers to provide an individual’s health plan a good faith estimate (GFE) of the expected charges for furnishing an item or service (upon scheduling or at the participant’s request). (For uninsured or self-pay individuals, the provider must provide the GFE to the individual.) Upon receiving a provider’s GFE, health plans must send the participant or beneficiary an AEOB that includes the GFE and other information, such as the provider’s network status and an estimate of the amount the plan is required to pay. Although the GFE requirement began applying to uninsured individuals in 2022, the agencies deferred enforcement of the GFE and AEOB requirements for plans until regulations implementing the requirements are issued and applicable (see our article). At the time, the agencies advised that they intended to undertake rulemaking “in the future” to implement AEOBs, noting that the delays were attributed to complexities in developing technical infrastructure for transmission of data from providers to plans and insurers.
Explaining that it is working to implement the GFE and AEOB requirements in stages, HHS explains in this update that the agencies are incorporating lessons learned from implementing the uninsured GFE provisions, as well as industry feedback from the preliminary development of GFE and AEOB data exchange standards, to develop proposed rules on insured GFE and AEOB requirements. HHS notes that in a study it conducted of the health care industry’s business and technology needs and the capabilities of providers and payers, researchers recommended that HHS propose a single data exchange standard for the receipt of GFEs by payers and the transmission of AEOBs from payers to providers. The study suggested that existing technical standards may not be sufficient to meet the insured GFE and AEOB requirements; thus, new standards may need to be developed to ensure successful implementation.
EBIA Comment: This update is a very high-level summary of HHS’s progress with the AEOB. It does not include any discussion of the timeframe for implementation of this requirement for group health plans, although the need to develop new technical standards suggests further delay. For more information, see EBIA’s Health Care Reform manual at Section XXXVII.E (“Surprise Medical Billing Transparency Disclosures”), EBIA’s Self-Insured Health Plans manual at Section XXVIII.I (“Surprise Medical Billing Transparency Disclosures”), and EBIA’s ERISA Compliance manual at Section XXVI.F (“Transparency Disclosures for Group Health Plans”).
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