Transparency in Coverage
Posted: May 5, 2022
Health plan price transparency helps consumers know the cost of a covered item or service before receiving care. Beginning July 1, 2022, most group health plans and issuers of group or individual health insurance will begin posting pricing information for covered items and services. This pricing information can be used by third parties, such as researchers and app developers to help consumers better understand the costs associated with their health care. More requirements will go into effect starting on January 1, 2023, and January 1, 2024 which will provide additional access to pricing information and enhance consumers’ ability to shop for the health care that best meet their needs.
Making pricing information available to the public
In three stages, most group health plans and issuers of group or individual health insurance are required to disclose pricing information.
1. Machine-Readable Files containing the following sets of costs for items and services
· In-Network Rate File: rates for all covered items and services between the plan or issuer and in-network providers.
· Allowed Amount File: allowed amounts for, and billed charges from, out-of-network providers.
2. Internet-based price comparison tool (or disclosure on paper, upon request) allowing an individual to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers, for 500 items and services.
3. Internet-based price comparison tool (or disclosure on paper, upon request) allowing an individual to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers, for all items and services.
Stay tuned for more! Phase 2 and Phase 3 go into effect in 2023 and 2024.
By plan or policy years beginning on or after January 1, 2023, most group health plans and issuers of group or individual health insurance coverage are required to disclose personalized pricing information for all covered items and service to their participants, beneficiaries, and enrollees through an online consumer tool, or in paper form, upon request. Cost estimates must be provided in real-time based on cost-sharing information that is accurate at the time of the request.
Enforcement
Beginning July 1, 2022, CMS will enforce applicable price transparency requirements. For plans and issuers that are subject to CMS’s enforcement authority and do not comply, we may take several enforcement actions, including: requiring corrective actions and/or imposing a civil money penalty up to $100 per day, adjusted annually under 45 CFR part 102, for each violation and for each individual affected by the violation.
For additional details on enforcement refer to 45 CFR part 150, subpart B and C and for information on appealing a proposed civil money penalty refer to 45 CFR part 150, subpart D.
Originally posted on CMS.gov
