The Departments of the Treasury, Labor, and Health and Human Services (the Departments) have issued the Transparency in Coverage final rules (85 FR 72158) on November 12, 2020. The final rules require non-grandfathered group health plans and health insurance issuers in the individual and group markets (plans and issuers) to disclose certain pricing information.
Under this rule, health plans and insurers are required to post three machine-readable files (i.e., a digital representation of data or information in a file that can be imported into or read by a computer system for further processing) on a website:
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An In-Network Rate File: negotiated rates with in-network providers
In-network rates with respect to each item or service for in-network providers, including negotiated rates, underlying fee schedule rates used to determine cost-sharing, or derived amounts, whichever rate is applicable to their reimbursement model. If this rate is percentage based, the file must include the calculated dollar amount, or calculated dollar amount for each provider, identified by NPI, if rates differ by providers or network tier. The file must identify bundles of items or services by relevant code.
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An Out-of-Network Allowed File: historical billed charges and allowed amounts
The historical out-of-network allowed amounts for covered items or services and the billed charges for those items and services, including each unique amount, associated with the provider by NPI. If the rate is percentage based, the file must include the calculated dollar amount, and must disclose aggregate actual amounts paid, plus the individual’s share of the cost. The data in the file should encompass a 90-day period that begins 180 days prior to the publication date.
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In-Network Prescription Drug File
Negotiated rates and historical net prices connected to prescription drugs.
The information provided on this website does not, and is not intended to, constitute legal advice; instead, all information, content, and materials available on this site are for general informational purposes.
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