Update: Transparency in Coverage Rule

  • June 15, 2022

    Excludes grandfathered plans; Medicare; personal funding accounts; and vision-only and dental-only plans


    The Department of Health and Human Services (HHS), Department of Labor (DOL), and the Department of the Treasury deferred enforcement of the in-network and the out-of-network machine-readable files until July 1, 2022, and deferred enforcement of the prescription drug machine-readable file pending further rulemaking.

    For more information, you may review the final Transparency in Coverage rule.


    What is the Transparency in Coverage Rule?

    On October 29, 2020, the Department of Health and Human Services (HHS), the Department of Labor (DOL), and the Department of the Treasury jointly released the Transparency in Coverage final rule, which implements the section 1311(e)(3) of the Affordable Care Act. The rule includes two approaches to making healthcare price information more accessible to consumers. First, through machine-readable files, and second, through an internet-based, self-service tool with personalized out-of-pocket cost information.

    What will Premera do and when?

    Premera has a standard process for implementing all new requirements that impact us and our customers. Implementation efforts are underway, and we have a company-wide, cross-functional team working as part of an implementation project to ensure we are in compliance with all aspects of the rule as required on insured business. Premera is not responsible for self-funded (or OptiFlex) group health plan compliance but will include self-funded data as a convenience (excluding carved out benefits/services). Per the new requirements, the following information includes the timelines which Premera will follow.

    What is the Public Access Requirement?

    The Public Access Requirement instructs group health plans and health insurance issuers to publish machine-readable files on a publicly available site based on the enforcement date of July 1, 2022, for plan years beginning on or after January 1, 2022. The files must be updated monthly and include the following detailed pricing information:

    • In network: Negotiated rates for all covered items and services between the plan or issuer and in-network providers.
    • Out of network: Historical payments to, and billed charges from, out-of-network providers.
    • Prescription drugs: In-network negotiated rates and historical net prices for all covered prescription drugs at the pharmacy location level. (UPDATE: On hold, pending further rulemaking)

    What is the purpose of the machine-readable files?

    The purpose is to provide raw data in a Centers for Medicare & Medicaid Services (CMS)-specified format that can be read by machines without requiring manipulation or other human intervention. This work is an intermediate step that lays the groundwork for the implementation of a price comparison tool (available in 2023), which is a consumer-facing experience that is designed to help inform your employees’ decision-making. At this time, the files that will post in July are not available in a format that will be easily interpreted by the average consumer.

    Self-funded and OptiFlex Employers

    As a convenience, Premera will make the machine-readable files available to our self-funded employers and provide a link that can be used to access the files. Please note the files will not include carved-out services. The URL to the file site is https://premera.sapphiremrfhub.com. Employers may post the link on their sites early, but please note that no data will be available in the file until July 1, 2022.

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