Over the past few year years, several laws and regulations have been passed that require health plans and health insurance carriers to disclose health care costs and other related information to both plan members and the public in an effort to increase health care cost transparency. This transparency will assist individuals to make informed health care decisions. These new laws and regulations include the Transparency in Coverage Final Rules, finalized November 2020, and the Consolidated Appropriations Act of 2021 (CAA), signed into law in December 2020 (together known as “transparency rules”).
Read on for important information that pertains to group health plan requirements under these transparency rules and the important upcoming compliance deadline of July 1, 2022.
The transparency rules require group health plans to publish on a public website the following information using two separate machine-readable files (MRFs):
In-network rates, including negotiated rates for all covered services and items between the plan/carrier and in-network providers.
Out-of-network allowed amounts paid to, and billed charges from, out-of-network providers for all covered services and items within a 90-day period.
Group health plans must ensure that the MRFs are posted on a public website by July 1, 2022.
“Public Website” Requirement
The MRFs must be publicly available on a group health’s plan’s public website, free of charge, without requiring a plan participant to log-in with user account credentials, including a password. Practically, many plans will provide a link on their public company website to their carrier and/or TPA website with the MRFs.
These MRFs must be updated monthly and clearly indicate the date they were most recently updated.
The MRF requirements under the transparency rules do not apply to the following plans:
Grandfathered plans
Account-based plans (FSAs, HRAs)
Excepted benefits (dental and vision plans)
Retiree-only plans
Since plan carriers and third-party administrators (TPAs) are in the best position to create and update the MRFs, group health plans must rely on them for compliance with these requirements. Some carriers and TPAs have already communicated these MRF requirements to group health plans via email and letters with information on next steps.
Fully-Insured Plans: Rely on the plan’s medical carrier for full compliance with the MRF requirements under the transparency requirements by entering into a written agreement with the carrier to satisfy these requirements.
Self-Funded Plans: Self-funded plans are legally responsible for complying with the MRF requirements. This includes the employer, as the self-funded plan sponsor, posting information regarding access to the MRFs on its public website. Practically, self-funded plans must rely on their TPA to comply with the obligations of these requirements, including access and updates to the MRFs. Self-funded plans are advised to amend their agreements with their TPA to reflect required obligations by both parties.
Since the July 1, 2022 deadline for these MRFs to be posted on a public company website is coming up quickly, group health plans are advised to work with their carriers or TPAs to comply with these transparency rules.
Review other important transparency rules provisions and effective dates for group health plans in a reference chart detailed here.
The transparency rules also include the No Surprises Act, which prohibits “balance billing” or “surprise medical bills” by providers and facilities for most emergency services, certain non-emergency services, and air ambulance services. Click here for a Risk Strategies article with more information.
Reach out to your Risk Strategies account team with any additional questions.