Transparency in Coverage overview
In 2020, The Departments (HHS, DOL and Department of Treasury) finalized the “Transparency in Coverage” rule, which requires health insurers and group health plans, including self-funded clients, to provide network and cost-sharing data to consumers in the following forms:
1. Machine-readable rate files, which must be made available to the general public
2. An interactive cost-estimator tool, which must be made available to plan participants
1. Machine-readable files:
The Transparency in Coverage (TiC) rule requires that all self-insured health plans produce and post the following Machine-Readable Files (MRFs) on a publicly facing website. The files must provide pricing data for covered items and services as follows:
- In-network negotiated rates for covered services
- Historical out-of-network payments to and billed charges from providers
- Prescription Drug Rate files and historical costs files (Note: Until further guidance is published by the Departments, the Prescription Drug Rate files and historical costs files are delayed.)
The compliance deadline depends on your plan year effective date:
- For Plan Sponsors with a plan year effective date between January 1, 2022, and July 1, 2022, the compliance deadline is July 1, 2022.
- For Plan Sponsors with a plan year effective date of August 1, 2022, or later, the compliance deadline coincides with the plan year effective date.
Information in the MRFs must be updated and published monthly.
About the files
The Files have specific requirements regarding font size, accessibility and security settings and can be published in various languages. Centivo will be using JSON as recommended on CMS’s GitHub site.
2. Cost-estimator tool:
The Transparency in Coverage (TiC) rule also requires all self-insured health plans with policy years beginning on or after January 1, 2023, to disclose personalized cost-sharing information and negotiated rates for 500 covered items and services to their members.
A plan participant may enter the name of a covered item or service and a provider, and then receive an estimate of their out-of-pocket cost. The goal of this requirement is to help members better understand their health benefits and costs.
The tool must include the ability to:
- Provide an estimate that is accurate at the time of the request (e.g., using a member’s current accumulator status and plan design).
- Search for all in-network providers and then filter/reorder on those results for both cost and proximity to a ZIP code.
- Include disclaimers, like pre-authorization or referral required, or progress towards certain visit limits.
- Search all covered items and services (for January 1, 2024).
Plan Sponsor action items
Plan Sponsors (self-insured plans) must take action to comply with the requirements from The Departments based on the plan year.
Machine readable rate files
The Plan Sponsor MRFs can be hosted on a third-party site, however, in order to comply, Centivo strongly advises the Plan Sponsor to provide a link to the MRFs from its own public website. Plan Sponsors who fail to publish a link from their own website may face penalties. The Plan Sponsor needs to ensure the following:
1. There is a link to the MRFs on their public website.
2. The website needs to be a public facing site and cannot require a login.
3. Access to the files must be free of charge.
4. The website cannot require the end user to submit any personal identifying information.
No action required at this time.
Centivo’s commitment to supporting our clients
Compliance for our self-insured Plan Sponsors is an essential principle for Centivo. We assist our Plan Sponsors in their compliance with the very complex Transparency in Coverage regulations and support our Plan Sponsors by providing the MRFs and cost-estimator tool as required by The Departments.
Frequently Asked Questions (FAQ)
As a Plan Sponsor, what do I need to do?
Plan Sponsors are ultimately responsible for compliance with posting the machine-readable files (MRFs) on their public site and developing a cost-estimator tool. See above under “Plan Sponsor action items” for an outline of the Plan Sponsor responsibilities.
When will Centivo provide the MRFs as outlined in the Transparency in Coverage rule on behalf of Plan Sponsors?
Centivo made the MRFs accessible before July 1, 2022 for Plan Sponsors with a plan year effective date between January 1, 2022, and July 1, 2022, as required by the regulations. For Plan Sponsors with a plan year effective date after July 1, 2022, Centivo will make the MRFs accessible on or before their plan year effective date.
What MRFs will we see posted by Centivo?
Centivo posts MRFs in JSON format for each network:
1. In-Network Negotiated Rates File (labeled: in-network-rates)
2. Out-of-Network Allowed Amounts File (labeled: allowed-amounts)
The recommended browsers for accessing the files are Chrome, Firefox and Microsoft Edge.
How does Centivo manage the MRFs and ensure compliance?
Centivo generates, hosts and/or provides links to all MRFs for each Plan Sponsor on their custom site (updated monthly), accessible via the Plan Sponsor’s specific URL. If the Plan Sponsor is utilizing a network Centivo does not reprice claims for, Centivo hosts and/or provides links to the files as they are received from the repricing network. The MRFs include the pricing for the 90-day time-period that begins 180 days prior to the file publication date.
How will I be able to locate my specific Plan’s MRFs?
Centivo provides each Plan Sponsor with a link to their custom URL where their MRFs are posted for posting on their company website.
What is the penalty to the Plan Sponsor for failing to be compliant?
The Department of Labor may take several enforcement actions against Plan Sponsors that are non-compliant, including levying fines and other penalties.
Will Centivo charge customers for creating and managing the MRFs and cost-estimator tool?
Centivo will work with each Plan Sponsor in supporting their compliance efforts as outlined in the group’s Administrative Services Agreement (ASA).
How will the cost-estimator tool be available to members?
The cost-estimator tool will be accessible to Centivo members via the Centivo app and member portal.
What are the additional phases to the Transparency in Coverage rule?
The Transparency in Coverage rule is being rolled out in three phases:
- Phase 1: Requirement to post MRFs as outlined above, effective July 1, 2022
- Phase 2: Requirement for the cost-estimator tool which discloses 500 “shoppable” items, services and prescription drugs, effective January 1, 2023
- Phase 3: Requirement for a self-service online tool which discloses personalized cost-sharing information and negotiated rates for all covered items, services and prescription drugs, effective January 1, 2024
Centivo will be supporting Plan Sponsors in complying with all three phases of the Transparency in Coverage rule.