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Final Rule Requires Insurers to Post Negotiated Rates

October 30, 2020

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CONTACTS
Mary Mullaney, Director, Hospital Payment Policies

The Departments of Health and Human Services, Labor, and Treasury released the Transparency in Coverage final rule on Oct. 29 requiring private health plans to make public negotiated rates with providers. Health plans will also be required to provide consumers with personalized out-of-pocket cost information.

Beginning Jan. 1, 2022, most plans in the individual and group markets will be required to make personalized out-of-pocket cost information available to participants, beneficiaries, and enrollees. Those plans will also be required to make underlying negotiated rates available for all covered health care items and services, including prescription drugs, through an internet-based, self-service tool and in paper form upon request.

In addition, plans will be required to make three separate machine-readable files public that include detailed pricing information beginning Jan. 1, 2022. The first file will show negotiated rates for all covered items and services between the plan or issuer and in-network providers. The second file will show both the historical payments to, and the billed charges from, out-of-network providers. Historical payments must have a minimum of 20 entries to protect consumer privacy. The third file will list detailed in-network negotiated rates and historical net prices for all covered prescription drugs by the plan or issuer at the pharmacy location level. Plans and issuers will be required to display these data files in a standardized format and provide monthly updates.

Plans will also be required to post an initial list of 500 shoppable services as determined by the federal departments and make them available via an internet-based self-service tool for plan years that begin on or after Jan. 1, 2023. The remainder of all covered items and services will be required for these self-service tools for plan years that begin on or after Jan. 1, 2024.

A fact sheet is available here.

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