According to the Departments of Health and Human Services (HHS), Labor, and Treasury, full range of FDA-approved contraceptive services should be provided to the enrollees in the group health plans without cost sharing. However, eligible organizations that oppose to provide contraceptive services due to religious reasons are exempted from providing, arranging, and making payments for the services. Instead, they are required to notify their objection either to HHS or to their third party administrator (TPA).
The contraceptives services then must be provided by the TPA, which includes pharmacy benefit managers (PBMs) as well. Yet again, for getting coverage by the Federally Facilitated Marketplaces (FFM) to meet the cost of services, the TPA can make arrangement with a qualified health plan insurer.
CMS recently released a website (REGTAP.info) where insurers and TPAs can submit contraceptive claims paid by them in 2015. The website also has some of the Frequently Asked Questions about the working of the new process. No matter what, TPAs are required to submit a Notice of Intent Disclosure Form through the website between August 22 and September 20, 2016, and must also specify the total amount of eligible contraceptive claims paid by them.
FFM insurer would also need to mention their requests for the money paid or the amount agreed to pay to the TPM. Extra 15 percent administrative fees can be claimed by the FFM insurers who agreed to cover claims for TPAs.
Although TPAs are not paid any administrative fees, the extra 15 percent fee paid can be split between the insurer and the TPA on agreement with the insurer. TPAs and PBMs having same parent company as that of their FFM insurer, need not submit a separate form. The form submitted by their insurer would be sufficient.
The amount owed to the insurer by the CMS will be balanced with the amount owed by the insurer in the form of monthly user fees, starting from the fall of 2016. If the amount is not balanced with CMS’ owing money to the insurer, then the excess amount would be carried forward to the next year. The agency stated that they would consider reimbursing insurers by the first quarter of 2017 for the payments they made to the TPAs this year.