The departments of Labor, Health and Human Services, and the Treasury have issued Affordable Care Act (ACA) FAQ Part 65 to provide guidance on the cost-sharing disclosure requirements under the Transparency in Coverage (TiC) rules. Under the TiC final rules, non-grandfathered group health plans and health insurers must disclose individualized cost-sharing and pricing information to participants, beneficiaries and enrollees through an internet-based self-service tool and in paper form, upon request, as well as over the phone.[1] The guidance covers scenarios when it is not possible to give an accurate cost-sharing estimate due to extremely low utilization of a particular item or service.
In the FAQ guidance, the departments advise they are likely to exercise discretion, on a case-by-case basis, when considering a case where an employer-sponsored group health plan or health insurer fails to provide a requested cost estimate for an item or service if 1) the estimate would need to be based on claims data, and 2) the claims data available consists of fewer than 20 different claims in total over the past three years.
In such cases of low utilization, the plan or insurer should indicate on the self-service tool that the item or service is covered but that there is insufficient data for a specific cost estimate. The tool should also direct the individual to contact the plan or insurer for more information on the cost sharing. If the individual does so, the plan or insurer is encouraged to provide any available relevant benefit information — such as information from the summary of benefits and coverage (SBC) or the portion of the cost of the item or service for which the individual will be responsible.
Plans and insurers are also reminded that cost-sharing information for all other covered items and services must be made available through a self-service tool (and in paper form, upon request) as well as over the phone.
Under the TiC final rules, the plan or insurer must provide cost-sharing information for covered items or services in connection with in-network providers and the allowed amount for covered items or services provided by out-of-network providers. The disclosure for an item or service in the internet-based self-service tool must be an accurate estimate at the time the request is made. While the estimates for items or services are largely based on contracted rates, plans and insurers may use analytics such as past claims data to produce more accurate cost estimates.
These disclosure requirements first applied to 500 specified items and services for plan or policy years beginning on or after January 1, 2023, and expanded to all covered items and services for plan or policy years starting on or after January 1, 2024. FAQ Part 65 does not change any timing related to the TiC’s cost-sharing disclosure requirements.
