Proposed Rule on Healthcare Transparency to Affect Some Employer Plans

On June 24, 2019, President Trump signed an executive order aimed at improving price and quality transparency in healthcare. Click here for more information.

On November 15, 2019, the Department of Labor (DOL), Health and Human Services (HHS) and the Treasury (Departments) issued a proposed rule regarding transparency in coverage that would impose new transparency requirements on group health plans and health insurers in the individual and group markets.

The proposed rule would require plans and issuers to disclose:

  • Cost-sharing estimates to participants, beneficiaries and enrollees upon request; and
  • In-network provider-negotiated rates and historical out-of-network allowed amounts on their website.

How the Executive Order Impacts Consumers

By granting better access to information regarding the price and quality of healthcare goods and services, the executive order will enhance patients’ ability to choose the healthcare that best fits their needs; as well as grant patients more control over their healthcare resources and protect them from surprise medical bills.

Additionally, under the executive order, the aforementioned Departments will now require healthcare providers, health insurance issuers, and self-insured group health plans to provide information about expected out-of-pocket costs for items and services prior to patients receiving care.

How the Healthcare Transparency Proposed Rule Impacts Employer Plans

The following two approaches of this proposed rule are intended to make healthcare price information accessible to consumers and other stakeholders, allowing for easy comparison-shopping.

The first approach would require each non-grandfathered group health plan or health insurance issuer offering non-grandfathered health insurance coverage in the individual and group markets to disclose personalized out-of-pocket cost information for all covered healthcare items and services. This includes estimates of the individual’s cost-sharing liability for healthcare for different providers. This would be provided to participants via an internet-based self-service tool and in paper form.

The second approach would require each non-grandfathered group health plan or health insurance issuer offering non-grandfathered health insurance coverage in the individual and group markets to disclose to the public the in-network negotiated rates with their network providers and historical payments of allowed amounts to out-of-network providers through standardized, regularly updated machine-readable files.

The proposed rule would also allow issuers that share savings with consumers that result from consumers shopping for lower-cost, higher-value services, to take credit for those “shared savings” payments in their medical loss ratio (MLR) calculations.

For more information, click here.


Questions? Contact the Creative Benefits Team at 866-306-0200 or solutions@creativebenefitsinc.com.