In response to an executive order presented in June 2019, the Department of Labor (DOL), Health and Human Services (HHS) and the Treasury have issued a final rule regarding coverage transparency. The rule imposes new transparency requirements on group health plans and health insurers in the individual and group markets.
The final rule applies to non-grandfathered coverage, including insured and self-insured group health plan sponsors, and requests:
- Individual and group markets to disclose cost-sharing information upon request to a participant, beneficiary, or enrollee (or their authorized representative), which should include an estimate of the individual’s cost-sharing liability for covered items or services furnished by a particular provider. This personalized cost-sharing information must be made available through an internet-based self-service tool and in paper form. An initial list of 500 shoppable services will be required for plan years beginning on or after January 1, 2023, while the remainder will be required for 2024.
- Plans and issuers to disclose in-network provider negotiated rates, historical out-of-network allowed amounts, and drug pricing information through three machine-readable files online for plan years beginning on or after January 1, 2022.
The rule also indicates that issuers that share savings with consumers, or allow consumers to shop for lower-cost, higher-value services, can take credit for those shared savings in their medical loss ratio (MLR) calculations.
Essentially, the final rule will allow the public to have access to health coverage information, which will help patients understand healthcare pricing, tiers of services and potentially combat the rise in healthcare spending.
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