Background

To prevent unexpected medical expenses, the CAA mandates that health plans and issuers send participants, beneficiaries, or enrollees an AEOB notification in easily understood language upon receiving a “good faith estimate” from a provider or facility. The initial phase of implementation involved issuing regulations in 2021 regarding good faith estimates for uninsured (or self-pay) individuals, which are currently operational. However, federal agencies acknowledged (in FAQ guidance) the challenges in establishing the technical framework to transmit these estimates from providers and facilities to plans and issuers. Consequently, enforcement of this mandate was postponed pending further rulemaking.

Content Requirements

The AEOB is required to contain the following details:

  1. The provider or facility’s network status;
  2. The agreed-upon rate for the service or item; for providers or facilities not in the network, it should provide guidance on accessing information about participating ones;
  3. The good faith estimate provided by the provider;
  4. An estimated amount the plan is obligated to pay, along with any cost-sharing responsibilities;
  5. Clarifications on whether coverage is influenced by medical management techniques.
CMS Progress

CMS is collaborating with agencies throughout the U.S. Departments of Health and Human Services, Labor, and the Treasury, along with the Office of Personnel Management (OPM), to gradually introduce the good faith estimate and AEOB mandates. This phased strategy, as stated by CMS, enables meticulous research and cooperation, ensuring each phase is well-informed and bolstered by suitable technical protocols for data exchange between providers and payers. The CMS guidance does not provide a specific timeline for implementation.

CMS Research

In addition to soliciting feedback through requests for information, CMS undertook a study on the business and technological requisites within the healthcare sector, along with the capabilities of providers and payers. Following this examination, researchers advised the Departments and the OPM to propose a unified data exchange standard. This standard would facilitate the submission of good faith estimates by payers and the transmission of AEOBs from payers to providers. The study suggested that the new standards might be necessary to guarantee the effective execution of the AEOB mandates.

Action Steps

At this time, plans and issuers are not required to furnish AEOBs. They should, however, stay vigilant for regulatory directives, including updates on implementation schedules and potential new transmission standards for AEOBs. CMS offers a webpage dedicated to regulations and guidance, which consolidates all recent developments for easy reference.