FAQs issued on ACA transparency in coverage requirements

The departments of Labor, Health and Human Services, and the Treasury have issued ACA FAQs Part 61 providing guidance on the Transparency in Coverage (TiC) requirements under the Affordable Care Act (ACA).

Background

Specifically, the TiC final rules issued on November 12, 2020, require non-grandfathered group health plans and health insurance issuers in the individual and group markets to disclose on a public website:

• In-network rates for covered items and services
• Out-of-network allowed amounts and billed charges for covered items and services
• Negotiated rates and historical net prices for covered prescription drugs in three separate machine readable files^[1]

On August 20, 2021, the departments announced they would defer enforcement of the requirement to publish machine-readable files related to prescription drugs due to concerns of an overlap with reporting requirements for prescription drugs under section 204 of the Consolidated Appropriations Act, 2021 (referred to as Prescription Drug Data Collection or RxDC).

In addition, on April 19, 2022, the departments provided a blanket enforcement safe harbor for satisfying the TiC reporting requirements for plans and issuers with reimbursement arrangements under which specific dollar amounts for covered items and services cannot accurately be determined. In issuing the guidance, the departments made clear that discretion would be used in enforcing the reporting requirement in circumstances where it is extremely difficult or impossible for a plan or issuer to determine and report an exact dollar amount for an item or service before it is provided, such as with “percentage-of-billed-charges” contracts.

ACA FAQs Part 61

In the new FAQ guidance, the departments have determined there is no meaningful conflict between the RxDC reporting requirements and the TiC final rules. As a result, the TiC final rules’ prescription drug machine-readable file requirement will be enforced, and the blanket enforcement safe harbor has been eliminated. Instead, the departments will exercise enforcement discretion on a case-by-case basis.

Going forward

Employer plan sponsors should begin working with their third-party administrators, carriers and pharmacy benefit managers to prepare for meeting the requirements to publish the prescription drug machine-readable files.

The departments intend to develop technical requirements and an implementation timeline in future guidance for plans that relied on the enforcement safe harbor.

Footnote

1. For more information on the machine-readable file requirements, see “Q&A: Final rule on health care transparency,” Insider, November 2020. Return to article undo