The Departments of Health and Human Services, Labor and the Treasury previously finalized a Transparency in Coverage rule that requires health plans to create a patient-facing price comparison tool and post publicly available machine-readable files that include negotiated rates for covered services for in-network providers; historical payments to and charges from out-of-network providers for covered items and services; and negotiated rates for in-network prescription drugs.
The data in machine-readable files must be updated monthly. The Departments have indicated the CAA’s Price Comparison Tool and Cost-Estimator requirements are largely duplicative of the Transparency in Coverage rule. The Departments will issue rulemaking in 2022 to reconcile the duplicative requirements and provide additional direction for the first publication years.
Spotlight mandate: Machine-readable files
The intent of this regulation is to provide health care pricing information that supports more informed decisions for receiving care.
BCBSND will provide the following machine-readable files, which are files where data is formatted in a way that can be processed by a computer, online:
- In-network provider rates for covered services
- Out-of-network allowed amounts and billed charges for covered services
- Negotiated rates and historical net prices for in-network prescription drugs
- A drug’s net price equals its list price minus all rebates, discounts and fees
BCBSND will provide public access to machine-readable files that provide in-network provider rates; out-of-network allowed amounts and billed charges for covered services; and in-network prescription drug pricing information.
Who it applies to: Fully insured group health plans, self-funded group health plans and individual policies—including all grandfathered plans.
Effective date: Plan years beginning on or after July 1, 2022, for in-network provider rates for covered services and for out-of-network allowed amounts and billed charges for covered services. Plan and policy years beginning after July 1, 2022, must be posted in the month in which the plan or policy year begins. The requirement to publish negotiated rates and historical prices for in-network prescriptions drugs has been delayed indefinitely, pending further rulemaking.
BCBSND will continue to monitor future rule making and coordinate with any self-funded clients with unique provider rates.