Regulations are slated to take effect over the next few years that will greatly increase the transparency requirements for group health plans. The regulations issued under the Trump administration will require health insurers in the individual and group health markets to disclose cost-sharing information upon request, make cost-sharing information available on their websites and disclose negotiated rates with in-network providers.
The rules are designed to help health plan enrollees choose the plan that is best for them and their family, as well as to give them a full picture of what they can expect to pay for services as part of their deductibles, copays and coinsurance. There are a few different parts to the rules: one focuses on personalized cost-sharing information and another focuses on other pricing and information that insurers are required to post health plan transparency information on their websites.
Personalized cost-sharing information
The new rules require health plans to provide personalized estimates for enrollees upon request, so they can calculate their potential out-of-pocket expenses prior to receiving medical treatment.
The following must be provided to a plan enrollee upon inquiry ahead of receiving care:
Cost-sharing liability
This covers how much the enrollee would have to pay out of pocket under their plan for deductibles, coinsurance and copays for a specific medical service. These estimates must be specific to the individual that’s inquiring and not a general estimate.
Accumulated out-of-pocket payments
Enrollees can inquire to their health plans about how much they’ve paid out towards their deductibles and their plan’s out-of-pocket maximums as of the date requested.
In-network rates
Upon request, the plan must divulge how much the enrollee will have to pay out of pocket in relation to the rates it has negotiated for a specific procedure by an in-network provider. The plan or insurer must disclose the negotiated rate, expressed as a dollar amount, even if it is not the rate the plan or insurer uses to calculate cost-sharing liability. The plans must also disclose out-of-pocket liability for an individual as well as the negotiated rates for prescription drugs. The health insurer does not have to disclose drug discounts or rebates as part of the inquiry.
Out-of-network allowed amount
The insurer must disclose the maximum amount its plan will pay for an “item or service” from an out-of-network provider.
Notice of prerequisites to coverage
If the service the enrollee is inquiring about prior authorization, concurrent review or step-therapy, the insurer must include this information in the answer to the request.
This part of the regulation will take effect in two phases:
- 1/1/2023: Insurers will be required to provide personalized cost-sharing information on 500 specific services.
- 1/1/2024: Insurers will be required to provide personalized cost-sharing information on all specific services.
Publicly available cost-sharing information
The new regulations also require health plans (not including grandfathered ones) and health insurers to post on their websites machine-readable files with detailed pricing information.
The website must include the following information, which has to be updated on a monthly basis:
- Rates for all covered items and services that the plan has negotiated with its in-network providers.
- Historical payments the insurer has made to out-of-network providers, as well as the billed charges.
- The plan’s in-network negotiated rates and historical net prices for all covered prescription drugs at the pharmacy location level.
