Proposed Rule on Price and Cost Sharing

Required disclosures to participants and beneficiaries

The federal government is proposing a rule that would require self-funded, non-grandfathered employer-based group health plans and health insurers offering non-grandfathered group and individual health coverage to disclose cost-sharing information to participants, beneficiaries and enrollees upon request.

The Transparency in Coverage proposed rule was released by the U.S. Departments of Health and Human Services, Labor and the Treasury in late November 2019. Comments are due in mid-January, and the rules would be effective one year after the effective date of the final rule.

Under the proposed rule, plans and insurers would be required to provide consumers the following:

  • Real-time, personalized access to cost-sharing information, including an estimate of cost-sharing liability for a requested covered item or service provided by a provider through an internet-based, self-service tool and in paper form, at a consumer’s request.

Such information is calculated based on the following:

  1. Accumulated amounts the participant or beneficiary has incurred to date;
  2. Negotiated rate, reflected as a dollar amount, for an in-network provider for the requested covered item or service;
  3. Out-of-network allowed amount for the requested covered item or service, if the request for cost-sharing information is for a covered item or service furnished by an out-of-network provider.
  • If a participant or beneficiary requests information for an item or service subject to a bundled payment arrangement, a list of such items and services for which cost-sharing information is disclosed;
  • If applicable, notification that coverage of a specific item or service is subject to a prerequisite;
  • A notice that out-of-network providers may bill participants or beneficiaries for the difference between a provider’s bill charges and the sum of the amount collected from the plan or insurer and from the patient in the form of a copayment or coinsurance amount (balance bill), and that the cost-sharing information provided does not account for these potential additional amounts;
  • A statement that the actual charges for a participant’s or beneficiary’s covered item or service may be different from an estimate of cost-sharing liability provided, depending on the actual items or services the participant or beneficiary receives at the point of care;
  • A statement that the estimate of cost-sharing liability for a covered item or service is not a guarantee that benefits will be provided for that item or service; and
  • Any additional information, including other disclaimers, that the plan or insurer determines is appropriate, provided the additional information does not conflict with the required information described above.

According to the Centers for Medicare & Medicaid Services, this information helps consumers by providing accurate estimates of out-of-pocket costs they must pay to meet their plans’ deductible, copay or co-insurance requirements. In addition, it creates opportunities for researchers, employers and other developers to build new tools to help consumers.

Requirements for public disclosure of in-network provider negotiated rates and out-of-network allowed amounts

Under the proposed rule, group health plans and health insurers would be required to publish monthly on an internet website the following information in two machine-readable files.

  1. A machine-readable file on negotiated rates would include:
    • The name and EIN or HIOS identifier, as applicable, for each plan option or coverage offered by a health insurer or group health plan;
    • A billing code or other code used by the group health plan or health insurer to identify covered items or services for purposes of claims adjudication and payment, and a plan language description for each billing code; and
    • Negotiated rates that are:
      • Reflected as dollar amounts, with respect to each covered item or service under the plan or coverage that is furnished by an in-network provider;
      • Associated with the National Provider Identifier (NPI) for each in-network provider; and
      • Associated with the last date of the contract term for each provider-specific negotiated rate that applies to each covered item or service, including rates for both individual items and services and items and services in a bundled payment arrangement.
  2. A machine-readable file on out-of-network allowed-amounts that would include:
    • Same as above;
    • Same as above; and
    • Unique out-of-network allowed amounts (reflected as a dollar amount) with respect to covered items or services furnished by an out-of-network provider during the 90-day time period that begins 180 days prior to the publication date of the machine-readable file (excluding amounts where there are fewer than 10 different claims for payments).
  3. The proposed rule would require the machine-readable files to use a non-proprietary, open format (such as JSON, XML or CSV) to be identified in technical implementation guidance and to comply with other guidance published after the proposal is finalized, including non-proprietary file formats and the schema (a description of the manner in which the date should be organized and arranged) for the file.

More on applicability

The proposed rule would not apply to account-based group health plans, including most health reimbursement arrangements (HRAs). Please note the proposed rule would apply to a qualified small employer health reimbursement arrangement, which is not an account-based plan.