Transparency in Coverage Final Rule Requires Insurance Disclosure to Consumers

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On October 29, 2020, HHS, the Department of Labor, and the Department of Treasury (the Departments) jointly issued a final rule requiring health plans to disclose price and cost-sharing information to participants, beneficiaries, enrollees and the general public. This rule builds upon prior price transparency rules requiring hospitals to disclose their standard charges, including negotiated rates with third-party payers.

This final price transparency rule applicable to health plans includes two approaches to make more healthcare price information accessible to consumers:

  • Most non-grandfathered group health plans and health insurance issuers will be required to disclose to participants, beneficiaries, and enrollees, their personalized out-of-pocket cost information, and the underlying negotiated rates, for all covered healthcare items and services, including prescription drugs, through an internet-based self-service tool and in paper form upon request. Beginning January 1, 2023, health plans will be required to publish an initial pricing list of 500 shoppable services, as determined by the Departments, that must be disclosed on the health plan’s website using a self-service tool. Beginning January 1, 2024, health plans will be required to disclose pricing information for all remaining items and services using the same online self-service tool.
  • Beginning January 1, 2022, most non-grandfathered group health plans and health insurance issuers must disclose on their websites three separate machine-readable files that include detailed pricing information for all covered items and services offered to enrollees. The first file must show negotiated rates for all covered items and services between the plan or issuer and in-network providers. The second file must show both the historical payments to, and billed charges from, out-of-network providers. The third file must detail the in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level.

This final rule is the latest effort by the Trump administration to increase what is known as price transparency in health care. A copy of the executive order on “Improving Price and Quality Transparency in American Healthcare to Put Patients First” can be found here. Additional information regarding the final rule on hospital price transparency can be found in the Health Headlines November 18, 2019 article entitled “CMS Finalizes Rule on Hospital Price Transparency and HHS Proposes New Rule on Health Plan Price Transparency.”

A copy of the October 29, 2020 final rule can be found here, and the CMS fact sheet can be found here.

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