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Transparency in Coverage

Overview and faq

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 cost-sharing data to consumers.

Machine-readable files:

The Transparency in Coverage (TiC) rule requires that all 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.


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. 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


Centivo’s commitment to supporting our clients

Compliance for our self-insured Plan Sponsors is an essential principle for Centivo. We intend to assist our Plan Sponsors in their compliance with the very complex Transparency in Coverage regulations and support our Plan Sponsors by providing the MRFs 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. 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 will make the MRFs accessible on 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 of August 1, 2022, or later, Centivo will make the MRFs accessible on or before their plan year effective date.

 

What MRFs will we see posted by Centivo?
Centivo will post 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.

 

What MRFs will we see posted by Centivo?

Centivo will generate, host and/or provide 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 will host and/or provide links to the files as they are received from the repricing network. The MRFs will 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 will provide 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?

Centivo will work with each Plan Sponsor in supporting their compliance efforts as outlined in the group’s Administrative Services Agreement (ASA).

 

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 a self-service online tool which discloses personalized cost-sharing information and negotiated rates for 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.