Overview
The Transparency in Coverage rule has prompted action to put patients first by improving price and quality transparency in American healthcare. The focus of this rule is to put healthcare price information in the hands of consumers and other stakeholders to ensure consumers are empowered with the critical information they need to make informed healthcare decisions. A summary of the requirements associated with the transparency regulations follows. MedCost also has prepared FAQs to offer insight into our efforts to meet these requirements and timelines.
Requirement #1 - Public Transparency Disclosures
Group health plans or health insurance issuers offering non-grandfathered health insurance coverage in the individual and group markets will be required to make available to the public three separate machine-readable files (MRFs) that include detailed pricing information. 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 both the historical payments to, and billed charges from, out-of-network providers. 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. Public disclosure of these files is required to be enforced by July 1, 2022. Note: The Pharmacy Pricing MRF requirement has been delayed indefinitely pending further regulatory guidance.
Requirement #2 - Self-Service Shopping Tool
Group health plans or health insurance issuers offering non-grandfathered health insurance coverage in the individual and group markets will be required to make available to participants, beneficiaries, and enrollees (or their authorized representative) personalized out-of-pocket cost information, and the underlying negotiated rates, for all covered health care items and services, including prescription drugs, through an internet-based self-service tool and in paper form upon request.
An initial list of 500 shoppable services, as determined by the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury, will be required to be available via the internet-based self-service tool for plan years that begin on or after January 1, 2023. The remainder of all items and services will be required for these self-service tools for plan years that begin on or after January 1, 2024.
Public Transparency Disclosures Frequently Asked Questions
Will MedCost build and manage the publicly accessible website with all required machine-readable files on behalf of its clients?
MedCost will house on a publicly accessible website the required machine-readable files on behalf of its employer clients.
In what format will the files be made public?
MedCost will release non-proprietary, open format files in accordance with the regulation.
How often will data be updated?
Data will be updated monthly in accordance with the Final Payer Transparency in Coverage Rule.
When will the platform be ready to launch?
MedCost intends to have the platform available in advance of the deadline for publishing the publicly accessible data under the final rule.
How will MedCost keep up to date with any changes to the repository?
The publicly accessible data will be updated monthly in accordance with the Final Payer Transparency in Coverage Rule. Applicable data from third parties will be published to the platform upon receipt, up to once monthly.
How will employers be able to direct inquiries to the website (i.e., can it be direct or via a link on the employer’s site)?
As this will be a publicly accessible site, we anticipate employers will be able to direct inquiries either directly or via a link on the MedCost site.
Self-Service Shopping Tool Frequently Asked Questions
Will MedCost offer a self-service shopping tool to employer clients for use by their health plan members?
MedCost will offer a self-service shopping tool to employers for their health plan members’ use that is designed to meet the requirements of both the Payer Transparency in Coverage rule’s self-service shopping tool and the No Surprises Act’s price comparison tool requirements.
When will the platform be ready to launch?
The specific timing of the product launch has not been finalized, but we intend to have the tool in place in advance of the deadlines set by the Final Payer Transparency in Coverage Rule and the No Surprises Act.
How does MedCost intend to handle requests for information by phone/email or requests for paper copies?
Employer questions regarding the Self-Service Shopping Tool can be directed to your MedCost Account Manager or Client Relations Specialist. Member requests for information should be directed to our Customer Service Contact Center at the number listed on the member’s ID card or through Live Chat on www.MedCost.com. MedCost will provide paper copies of price comparison information upon request within timelines established by the Final Payer Transparency in Coverage Rule.
Will there be a cost to employers for solutions that are designed to meet the requirements of the Final Payer Transparency in Coverage Rule?
To cover overhead and administrative responsibilities associated with these additional services, clients will see an increase in their 2022 compliance fee upon renewal.
Will MedCost support the employer’s communication with employees on these changes?
Yes. As with other plan communications, MedCost anticipates it would pass through printing and distributions costs incurred to support such functions.