Transparency in Coverage: Status Update, May 2022
The Transparency in Coverage Rule was issued in 2020 by the Department of Health and Human Services (HHS), and features a phased-in approach for compliance and enforcement.
The first requirement applies to plan sponsors, and the enforcement date has been delayed until July 1, 2022. Under this phase, all ‘issuers’ of health insurance will need to publish three ‘machine readable files’ (MFRs):
The first file will show negotiated rates for all covered items and services between the plan or issuer and in-network providers.
The second file will show the historical payments and billed charges from out-of-network providers (historical payments must have a minimum of twenty entries).
The third file will detail the in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level. Plans and issuers will display these data files in a standardized format and will provide monthly updates.
By July 1, Employers are required to post a link to their carrier’s MRFs on their public website. The purpose of this phase is to grant access to researchers and app developers to assist consumers understand costs associated with health care.
In January 2023, health plans must provide out of pocket cost information for an initial list of 500 services, as determined by HHS, that is accessible to beneficiaries using a ‘searchable’ internet based self service tool. A paper copy of this information will also be required upon request. In January 2024, an expanded list of services will be added to the requirement. At this time it appears that like the MRFs, insurance carriers will produce this tool, and employers will provide access to this tool on the public websites.
The final rule can be viewed in its entirety here.