On Oct. 29, 2020, the Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury (Departments) issued a final rule regarding transparency in coverage that imposes new transparency requirements on group health plans and health insurers in the individual and group markets. These provisions only apply to non-grandfathered coverage, including both insured and self-insured group health plan sponsors.
This final rule was issued in response to an executive order issued on June 24, 2019, aimed at improving price and quality transparency in health care.
Health Care Transparency Provisions
Specifically, the final rule requires plans and issuers to disclose:
- Price and cost-sharing information to participants, beneficiaries and enrollees upon request: Personalized cost-sharing information must be made available through an internet-based self-service tool and in paper form upon request. An initial list of 500 shoppable services will be required for plan years beginning on or after Jan. 1, 2023. The remainder of all items and services will be required for plan years beginning on or after Jan. 1, 2024.
- In-network provider-negotiated rates and historical out-of-network allowed amounts on their website: For plan years beginning on or after Jan. 1, 2022, plans and issuers will also be required to disclose on a public website their in-network negotiated rates, billed charges and allowed amounts paid for out-of-network providers, and the negotiated rate and historical net price for prescription drugs.
The final rule also allows issuers that share savings with consumers resulting from consumers shopping for lower-cost, higher-value services, to take credit for those “shared savings” payments in their medical loss ratio (MLR) calculations.
The final rule will require plans and issuers to disclose the personalized price and cost-sharing information to consumers.
Important Dates
January 1, 2022
Detailed pricing information must be made public for plan years beginning on or after Jan. 1, 2022.
January 1, 2023
A list of 500 shoppable services must be available via the internet-based self-service tool for plan years beginning on or after Jan. 1, 2023.
January 1, 2024
The remainder of all items and services is required for plan years beginning on or after Jan. 1, 2024.
This Legal Update is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. ©2020 Zywave, Inc. All rights reserved.
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