Transparency in Coverage Rule Overview

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 and historical payments to and charges from out-of-network providers for covered items and services.

The posting of the machine readable file information occurred on July 1, 2022. The price comparison tool is required to be delivered by January 1, 2023.

Publicly Available Machine-Readable Files

The intent of this regulation is to provide health care pricing information that supports more informed decisions for receiving care.

The following machine-readable files, which are files where data is formatted in a way that can be processed by a computer, online can be found by visiting the machine-readable files website. Information available to the public is as follows:

  • In-network provider rates for covered services
  • Out-of-network allowed amounts and billed charges for covered services
  • A third requirement to publish machine readable files for certain prescription drug information has been delayed indefinitely by the federal government as it works to issue additional rules surrounding this requirement.

The information displayed in the files represents the rate Blue Cross and Blue Shield licensees have negotiated with their in-network providers for all covered items and services. This is not, however, an estimate of the cost members will be responsible paying for an item or service. Individual cost will vary depending upon the terms of the individual’s specific health insurance coverage and the structure of the reimbursement arrangement, if applicable. Blue Cross and Blue Shield licensees have made reasonable efforts to ensure that the data displayed in the files is complete and accurate at the time it is published. The data is refreshed each month.

Who it applies to: Fully insured group health plans, self-funded group health plans and individual policies, with the exception that this mandate does NOT apply to grandfathered health plans.

Patient-Facing Price Comparison Tool

By January 1, 2023, health plans are required to maintain a price comparison tool, available by phone and online, that allows members to compare cost-sharing amounts for items and services provided by participating providers.

BCBSND’s internet-based self-service price comparison tool will be offered online, by phone, and in paper upon request. The comparison tool will start with pricing information on the 500 most common shoppable services and will subsequently expand a year later to all covered services. The tool (to the extent practicable) will allow an enrolled member to search for and compare cost-sharing amounts for items and services based on geographic area, benefit plan, year, and participating providers.

Who it applies to: All members of fully insured group health plans, self-funded group health plans and individual policies will have access to the price comparison tool to estimate costs.

Machine-Readable Files FAQs

Patient-Facing Price Comparison Tool FAQs

BCBSND has created these FAQs to assist employers with understanding the requirements of the Transparency in Coverage regulation and the Consolidated Appropriations Act. The FAQs are not intended to be legal advice. BCBSND is committed to assisting employer groups with compliance, but BCBSND encourages employers to consult their own legal counsel with any specific issues or questions.