On October 29, 2020, the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury jointly released the final Transparency in Coverage ruling, which implements the section 1311(e)(3) of the Affordable
Care Act. The rule requires health to post in-network and out-of-network rates in a machine-readable format. Health plans must also develop online price transparency tools to give consumers and other stakeholders cost-sharing information.
Please be aware there
are currently multiple regulations that have many similar requirements to the
Transparency in Coverage rule. The information in this article is
specific to the Transparency in Coverage ruling only.
What will Premera do and when?
Premera has a standard process for implementing all new requirements that impact us and our customers. Implementation efforts have begun, 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 new requirements. Per the new requirements, here are the timelines Premera will follow:
Public Access Requirement
The Public Access Requirement goes into effect beginning on or after January 1, 2022. Health plans must make three separate machine-readable files publicly available. The files must be updated monthly and include the following detailed
pricing information:
- In-network: 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 rates and historical net prices for all covered prescription drugs at the pharmacy location level.
The Cost-Sharing Information Requirement
The Cost-Sharing Information Requirement makes available personalized out-of-pocket cost information, and the underlying negotiated rates, for services through an internet-based self-service tool and in paper form upon request. The Cost-Sharing Information
Requirement goes into effect for plan (or policy) years beginning on or after:
- January 1, 2023 for estimates concerning 500 specific items and services; and
- January 1, 2024 for estimates on
all items and services covered by the plan.
What kind of data will be included?/h3>
- In-network: 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 rates and historical net prices for all covered prescription drugs at the pharmacy location level.
Premera will continue communicate with provider to ensure clarity on this new ruling and to share more information about the final Transparency
in Coverage ruling.