Agencies propose updates to transparency in coverage requirements

The Departments of Labor, Health and Human Services, and the Treasury recently issued newly proposed regulations that amend the existing Transparency in Coverage final regulations issued on November 12, 2020 (the 2020 Final Regulations).

Under the 2020 Final Regulations, non-grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage are required to post machine-readable files (MRFs) monthly for each plan or coverage they offer. This includes:

• An in-network rate file disclosing in-network rates for all covered items and services
• An allowed amount file disclosing out-of-network allowed amounts and the associated billed charges
• A prescription drug file disclosing in-network rates and historic net prices for covered items and services

The newly proposed regulations build on the 2020 Final Regulations and include several changes to improve the accessibility of pricing disclosures to participants, beneficiaries and enrollees as well as the standardization and reliability of the public pricing disclosures.

Proposed amendments

The proposed amendments to improve the standardization, accuracy and accessibility of the in-network rate and out-of-network allowed amount MRFs are outlined below.

Make data more meaningful

The newly proposed regulations would reduce the number and size of MRFs and increase accessibility. Group health plans and health insurance issuers would be required to:

• Exclude from their in-network rate files provider-rate combinations for items and services for providers that would be unlikely to be reimbursed for the item or service given that provider's area of specialty
• Require payers to post the internal provider taxonomy mapping they used to prepare the in-network rate file
• Require plans and issuers to post a new file called a utilization file for each in-network rate file, which would include all providers who have submitted and received reimbursement for at least one claim for a covered item or service over the 12-month period ending six months before the posting of the file

In addition, the Departments propose to change the level at which group health plans and health insurance issuers must report data in the in-network rate file. Plans and issuers would also be required to prepare one in-network rate file for each provider network they maintain or contract with rather than for each plan or policy they offer.

Make data more usable

The Departments observed that many group health plans and health insurance issuers include limited or no data in their allowed amount files. This reduces transparency of out-of-network pricing information to patients and limits what researchers, academics and developers can analyze. To address this, the Departments propose to:

• Require payers to aggregate their allowed amount files by insurance market type (large group, small group, individual and self-insured)
• Lower the claims threshold from 20 to 11 claims
• Lengthen the reporting period from 90 days to six months and the lookback period from 180 days to nine months

The Departments also propose requiring additional data elements as context around the data being reported. These include:

• The plan’s or policy’s product type (e.g., health maintenance organization, preferred provider organization) for each plan or policy represented in an in-network rate file and allowed amount file
• A numerical enrollment count for each plan or policy represented in an in-network rate file and allowed amount file
• The common network name associated with the provider network represented in the in-network rate file

Make data easier to locate

Two proposals aim to help users locate the MRFs:

• Require a plain text file (.txt file) located in the root folder of a payer’s website with information on the specific location of the MRFs as well as contact information, including a name and email address for those who are responsible
• Require group health plans and health insurance issuers to add a link in the footer of the home page of the plan’s or issuer’s website titled “Price Transparency” or “Transparency in Coverage” that routes directly to the publicly available web page that hosts the MRFs to allow for a standardized and predictable navigation path for users seeking the files

Reduce stakeholder burden

The proposed regulations would also require plans and issuers to update and post the in-network rate and allowed amount files quarterly rather than monthly to help lower data storage and hosting costs, decrease bandwidth needs and reduce ongoing maintenance expenses.

Disclosures to participants, beneficiaries and enrollees

Group health plans and health insurance issuers are required to make available cost-sharing information to participants, beneficiaries and enrollees through an online self-service tool or via paper, upon request. The Departments previously indicated that the internet-based tools were largely duplicative, but the No Surprises Act required cost-sharing information to also be provided over the phone. Therefore, the Departments propose to require that the same information that must be disclosed under the Transparency in Coverage rules also be required to be communicated over the phone, upon request, to satisfy the No Surprises Act cost-sharing tool provision. The Departments also propose amendments to the notice requirement related to potential balance billing not captured in cost-sharing information to account for new federal protections against balance billing in certain circumstances.

Going forward

As proposed, the amendments to the MRF requirements would apply 12 months following the date of publication of the final regulations in the Federal Register. The proposed applicable date for the amendments to the self-service internet-based tool provisions would apply for plan years beginning on or after January 1, 2027. Group health plan sponsors should closely monitor the proposed regulations and prepare for any potential changes.