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Transparency in Coverage Rules In Effect as of July 1

Healthcare plans can be complicated, and trigger confusion for consumers. In particular, many participants in healthcare plans experience difficulty detangling the details of their plans with regard to healthcare service pricing and their own out-of-pocket spending. The Transparency in Coverage rules created by the federal government in 2020 were designed to answer critical questions regarding price and quality of healthcare services, with changes rolling out through 2024. A deadline for one important milestone was set for July 1 of this year.

As of July 1, cost-sharing data must be provided to consumers via machine-readable files that shall be published on a publicly available website.

What is the purpose of the machine-readable files? These files must be provided by the health insurance company to consumers, and should detail pricing information for covered items and services according to in-network negotiated rates along with historical data on out-of-network amounts that have been allowed.

In the future, a third file must disclose prescription drug rates and historical costs. However, the requirement for release of this file has been delayed due to the need for further guidance.

Information within all applicable files must be updated monthly.

What else is required of healthcare plan providers? When publishing the required information, healthcare plan providers must pay careful attention to regulations regarding:

  • The required font size, accessibility, and security settings
  • Files must not be PDF or Excel format
  • Published data must include negotiated rates for all covered items and services for each plan level, relating to all medical codes, and including all contracted rates and providers
  • Out-of-network files must include allowed amounts for items and services, based on billed charges and historically allowed amounts
  • If there are fewer than 20 out-of-network claims for a service by a provider, the information is not required to be included

What do consumers need to do? The required files must be made available on a publicly-accessible website. Consumers will not be required to establish a user account, password, or any other credentials in order to access this information. The website must not require users to submit any personal information.

Consumers should check with their health insurance provider to learn where the required files will be published, and ask their healthcare plan representative for assistance with interpreting the data when necessary.

Again, the above requirements all relate to machine-readable files which must be published by July 1, 2022. Both group plan sponsors and individuals should contact their healthcare plan representatives if they have any questions.

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