Departments Release Final Rule on Transparency in Coverage

The Centers for Medicare & Medicaid Services (CMS), the Department of Labor (DOL) and the Department of the Treasury jointly released a final rule amending the rules under the Public Health Service Act, the Employee Retirement Income Security Act of 1974 (ERISA), and the Internal Revenue Code regarding price transparency reporting requirements for non-grandfathered group health plans, intended to improve the standardization, accuracy, and accessibility of public pricing disclosures in line with the goals of Executive Order 14221, “Making America Healthy Again by Empowering Patients With Clear, Accurate, and Actionable Healthcare Pricing Information.”

Regarding the in-network rate and out-of-network allowed amount machine-readable files, the final rules address:

• Adding new contextual files and additional data elements like product type, provider network name, and provider network identifier
• Changing the reporting level for aggregation of data
• Removing in-network rates for unlikely provider-to-service mappings
• Increasing the reporting period and lowering the claims threshold for out-of-network historical data; and reducing the reporting cadence
• Requiring dollar amount rates for “Percentage-of-Billed-Charges Arrangements”
• Improving the findability of all publicly disclosed machine-readable files required by requiring a text file containing contact information for the files, and a footer with website URLs
• Requiring pricing information that is made available through an online consumer tool and on paper (upon request), to also be made available by phone, and establish that the satisfaction of such requirement also satisfies the requirements of section 114 of the No Surprises Act (including for grandfathered group health plans that are not otherwise subject to these final rules).

The regulations are effective 60 days after official publication in the Federal Register.