Transparency in Coverage Final Rules (85 FR 72158)

The Departments of the Treasury, Labor and Health and Human Services issued the Transparency in Coverage final rules (85 FR 72158) on November 12, 2020.

The final rules require non-grandfathered group health plans and health insurance issuers in the individual and group markets to disclose certain pricing information. Under the final rules, a plan or issuer must disclose in-network negotiated rates and out-of-network allowed amounts through two Machine-readable Files (MRFs) posted on an internet website. The Departments deferred a third prescription drug MRF until future rulemaking occurs.

What this means 

• Carriers are now required to publish their negotiated contract rates for services provided.
• Even though they will be officially available and printed, the rates will still be subject to change at any time (Carriers cannot be locked in to those numbers precisely for every location).

Format and Future Updates

• MRFs will be published in a JSON format and will comply with the CMS schema.
• Table of Contents (TOC) files will be used. These files are an index that point to the location of the different in-network and allowed amount files.
• Carriers will continue to monitor regulatory developments and the CMS GitHub for technical guidance.

Notes

• Please note these may be very large data files. To download these files, an application designed to handled large data files may be recommended.
• These are complex files that are unlikely to be directly usable by a member. Members may want to access their health plan coverage materials instead, to learn more about their benefits.
• Pricing information may be subject to change between the date of the last file update and the next monthly file update.​​​

Questions

For any questions please contact your United Agencies representative for assistance, or contact our office for more info.