Following a 2019 executive order issued by then President Trump, three regulatory departments worked together to issue two rules designed to increase medical care price
transparency and increase competition among hospitals and health plans.
In the intervening years, hospitals and health plans have been preparing to meet the requirements. Starting with plan years that begin on or after January 1, 2023, the most
consumer friendly of the requirements will ensure health plans provide members cost-sharing information on 500 health care items and services through an internet based,
self-service tool and in paper form upon request. The following year, cost sharing data for the remainder of health care items and services must be made available. Self-funded and level-funded plans will need to confirm if third-party administrators (TPAs) and carriers intend to fulfill the obligation on their behalf.
This upcoming requirement builds on previous actions that health plans and hospitals were required to take to comply with federal regulations. Most recently, health plans or issuers were required to post machine-readable files (MRFs) on a public website starting July 1, 2022, detailing
• negotiated rates for items and services between the plan or issuer; and
• historical payments to and billed charges from out-of-network providers.
Once additional rulemaking is completed, a third file must be posted containing in-network negotiated rates and historical net prices for all covered prescription drugs by
plan or issuer at the pharmacy level. The data in these files is better suited for use by researchers and third-party developers rather than consumers.
For fully insured groups, most carriers (issuers) are fulfilling the MRF website posting requirement. Carriers vary in their interpretation of the rule. Click here to see a summary of carrier positions regarding posting obligations by plan funding type.
Hospitals have been subject to an element of the transparency in pricing rule starting in January 2021, when it was required to publicly post negotiated rates for health care
procedures on hospital websites. Lack of compliance prompted the Centers for Medicare and Medicaid Services (CMS) to issue increased penalties for noncompliance.
There are more requirements ahead, such as Advanced Explanation of Benefits, that health plans must address to improve health care price transparency. Bukaty Companies will continue to keep you informed and prepared.
