TRANSPARENCY IN COVERAGE FINAL RULE
Transparency in Coverage Final Rule
When the Transparency in Coverage final rule that was published in the Federal Register on November 12, 2020, Trustmark immediately began internal discussions regarding the outlined requirements, including the self-service tool and the machinereadable files.
Currently, we’re pursuing solutions to help our clients comply and will continue to publish updates as they become available. The final rule becomes effective on January 11, 2021, 60 days after its publication.
12/16/20 Update:
A final rule requiring transparency in healthcare pricing was released by the U.S. Departments of Labor, the Treasury and Health and Human Services. The final rule was published in the Federal Register on November 12, 2020. The final rule becomes effective 60 days after publication: January 11, 2021. Litigation is anticipated upon the publication of this rule. Trustmark will publish updates as they are available and will be pursuing solutions to help our clients comply. The regulations apply to self-funded and fully-insured, non-grandfathered plans. They do not apply to grandfathered plans or HRAs or other account-based plans. The regulations include:
- A requirement that group health plans and health insurance issuers, in the individual and group markets, disclose to participants, beneficiaries, or enrollees upon request, through a self-service tool made available by the plan or issuer on an Internet website, cost-sharing information for a covered item or service from a particular provider or providers, and
- A requirement that plans and issuers make such information available in paper form, upon request. The final rules adopt a three-year, phased-in approach with respect to the scope of the requirement to disclose cost-sharing information.
- A requirement that such plans and issuers disclose pricing information in machine-readable files to the public as explained below.
Self-service Tool Plans and issuers must make cost-sharing information available for 500 items and services identified by the departments for plan years beginning on or after January 1, 2023, and must make cost-sharing information available for all items and services for plan years beginning on or after January 1, 2024.
Machine-readable Files The regulations require that plans and issuers disclose pricing information to the public through three machine-readable files:
- One file requires disclosure of payment rates negotiated between plans or issuers and providers for all covered items and services.
- The second file will disclose the unique amounts a plan or issuer allowed, as well as associated billed charges, for covered items or services furnished by out-of-network providers during a specified time period.
- To reduce the complexity and burden of including prescription drug information in the negotiated rate machine-readable file, the final rules require a third file that will include pricing information for prescription drugs.
The final rules modify the applicability date for the machine-readable files to plan years beginning on or after January 1, 2022.
For a longer, more detailed summary of the Transparency in Coverage Final Rule, click here.