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The Internal Revenue Service (IRS), the Employee Benefits Security Administration (EBSA), and the U.S. Department of Health and Human Services (HHS) have proposed rules on price transparency reporting requirements. The proposed rules would amend existing rules under the Public Health Service Act, the Employee Retirement Income Security Act (ERISA), and the Internal Revenue Code.
The proposed rules would affect non-grandfathered group health plans and health insurance companies that offer non-grandfathered group and individual health insurance plans. The purpose of the proposed rules is to provide more standardized, accurate, and accessible pricing transparency for the public. Among the changes are adding new data elements, changing reporting levels, increasing reporting periods, and reducing reporting frequency. Other amendments would improve the ability to locate publicly disclosed machine-readable files required by the Transparency in Coverage rules. As per the No Surprises Act, this pricing information would be available to consumers through an online consumer portal, as well as via hard copies and phone upon request.
According to a press release from the Centers for Medicare & Medicaid Services (CMS), the proposed rules are intended to build on the 2020 Transparency in Coverage final rules, as well as Executive Order 14221, "Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information." The proposed rules would generally take effect 12 months after publication of the final rules in the Federal Register. However, amendments to the rules concerning the self-service internet-based tool provisions would apply for all plan years beginning on or after January 1, 2027.
Reducing the Data and Making It More Accessible
Under the current rules, which took effect in July 2022, health plans and insurance companies subject to these rules must post monthly machine-readable files for each plan or coverage they offer. These files include an "In-Network Rate File," which discloses in-network rates for all covered items and services, an "Allowed Amount File," which discloses out-of-network allowed amounts and the associated billed charges, and a prescription drug file that contains in-network rates and historic net prices for covered items and services.
The federal agencies proposing these rules intend to fully achieve the goals in the 2020 final rules referenced above by addressing the current inaccessibility of required files due to their size, ambiguity due to a lack of contextual information for the raw data, and misalignment with the Hospital Price Transparency rule, which makes comparing data more difficult.
One way the proposed rules reduce the number and size of machine-readable files is by eliminating data on providers associated with items or services they are unlikely to provide from the In-Network Rate Files. Plans would determine which data to exclude based on their internal provider taxonomy mappings, post the mapping they use, and post a new file entitled "Utilization File" for each "In-Network Rate File." The new file would include all providers that submitted and received reimbursement for at least one claim for a covered item or service over the past year, ending six months before the date of posting the file. The proposed rules also would avoid duplicative data by requiring plans to prepare one "In-Network Rate File" for each provider network they maintain or contract with, rather than one file for each plan or policy they offer.
Proposed changes to the "Allowed Amount Files" include requiring the aggregation of these files by insurance market type, i.e., large group, small group, individual, and self-insured. The claims threshold for reporting in these files would decrease from 20 to 11 claims, and the reporting period would increase from 90 days to 6 months, with the lookback period increasing from 180 days to 9 months.
Another change would include requiring plans to report the product type, a numerical enrollment count, and the common network name used with the provider network for each plan or policy in the files. Plans also would be required to publicly disclose a new Change-long machine-readable file reflecting changes in data from one "In-Network Rate File" to the next.
Making Data Easier to Locate
The proposed rules would require each payer's website to include a plain-text file in the root folder that specifies the location of the machine-readable files and the contact information for those responsible for them. Plans also would need to add a link to the home pages of their websites titled "Price Transparency" or "Transparency in Coverage," that directly routes users to the machine-readable files.
Reducing Burdens on Plans and Insurance Companies
To reduce data-reporting burdens on plans and insurance companies, the proposed rules would require them to update and post the required files quarterly rather than monthly.
Adopting a Single File Format
Current rules allow plans and insurance companies to publish their machine-readable files in any "non-proprietary, open format." The federal agencies intend to adopt a single format for the required files to promote standardization. Therefore, they are soliciting comments on the proposal and the best format to use.
The Internet-Based Self-Service Tool
The 2020 final rules currently require plans and health insurance companies to make cost-sharing information available to the public through an online self-service tool or, upon request, in paper form. However, the No Surprises Act contains several provisions designed to make pricing information more transparent to consumers, including over-the-phone pricing, which the 2020 final rules do not require. Therefore, the federal agencies are proposing that the same information required under the Transparency in Coverage rules be available, upon request, over the phone to satisfy the requirements of the No Surprises Act. Finally, amended rules would reflect new federal protections against balance billing in some circumstances.
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