Transparency in Coverage

  • Transparency in Coverage Final Rule – Public access requirement

    On October 29, 2020, the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury jointly released the final Transparency in Coverage final rule, which implements the section 1311(e)(3) of the AffordableCare Act. The rule requires that group health plans and issuers offering coverage in the group and individual markets post in-network and out-of-network rates they negotiate with providers that must be in a machine-readable format. Issuers and grouphealth plans must also develop online price transparency tools to give consumers and other stakeholders cost-sharing information. The rule excludes grandfathered plans, Medicare, personal funding accounts, vision-only, and dental-only plans. 

    Please be aware the Consolidated Appropriations Act has transparency requirements that are similar to the Transparency in Coverage rule. The information below is specific to the Transparency in Coverage rule only. 

    Machine readable files and the public access requirement

    The Public Access Requirement goes into effect for plan years on or after January 1, 2022 and is the first of three specific requirements that must be implemented. Group Health plans and issuers offering coverage in the group and individual markets must make three separate machine-readable files publicly available, free of charge based on the enforcement date of July 1, 2022. The files must be updated monthly and include the following detailed pricing information:

    • In network: Negotiated rates for all covered items and services between the plan or issuer and in-network providers.
    • Out of network: Historical payments to, and billed charges from, out-of-network providers. Files are not required if there are fewer than 20 claims for a service for a provider.
    • Prescription drugs: In-network negotiated rates and historical net prices for all covered prescription drugs at the pharmacy location level (delayed pending further rulemaking).

    The purpose of these files is to provide raw data in a specific format that can be read by machines without requiring manipulation or other human intervention. These files are not intended to be user friendly or easily understood by the average consumer.

    Our publicly available website is https://lifewise.sapphiremrfhub.com


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