General News
Published April 20, 2021
Excludes
grandfathered plans, Medicare, personal funding accounts, vision-only, and
dental-only plans
On October 29, 2020, the Department of Health and Human
Services (HHS), the Department of Labor, and the Department of the Treasury
jointly released the final Transparency
in Coverage ruling, which implements the section 1311(e)(3) of the Affordable
Care Act. The rule requires group health plans and health insurers to post
in-network and out-of-network rates they negotiate with providers that must be
in a machine-readable format. Insurers must also develop online price
transparency tools to give consumers and other stakeholders cost-sharing
information.
Please be aware there
are currently multiple regulations that have many similar requirements to the
Transparency in Coverage rule; for example, the Surprise
Balance Billing and the Consolidated
Appropriations Act. The information
in this article is specific to the Transparency in Coverage ruling only.
What will Premera do and when?
Premera has a standard process for implementing all new requirements
that impact us and our customers. Implementation efforts have begun, and we
have a company-wide, cross-functional team working as part of an implementation
project to ensure we are in compliance with all aspects of the new
requirements. Per the new requirements, here are the timelines Premera will
follow.
Public Access Requirement
The Public Access Requirement goes into effect for plan
years (policy years in the individual market) beginning on or after January
1, 2022. Group Health plans and health insurers must make three separate
machine-readable files publicly available. The files must be updated monthly
and include the following detailed pricing information:
- In network: Negotiated rates for all covered items and services between the plan or issuer and in-network providers.
- Out of network: Historical payments to, and billed charges from, out-of-network providers.
- Prescription drugs: In-network negotiated rates and historical net prices for all covered prescription drugs at the pharmacy location level.
The Cost-Sharing Information Requirement
The Cost-Sharing Information Requirement makes available
personalized out-of-pocket cost information, and the underlying negotiated
rates, for services through an internet-based self-service tool and in paper
form upon request. The Cost-Sharing Information Requirement goes into effect
for plan (or policy) years beginning on or after:
- January 1, 2023 for estimates concerning 500 specific items and services; and
- January 1, 2024 for estimates on all items and services covered by the plan.
This month, Premera will communicate with [provider and]
employer groups to ensure clarity on this new ruling and to share more
information about the final Transparency
in Coverage ruling.