Price transparency

Deadline Approaching: Transparency in Coverage Final Rule

The day has finally arrived. Well, almost.

Today is June 29, 2022, which means that the first phase of the Transparency in Coverage Final Rule will be enforceable in just 2 days. So, what’s required of health plans on July 1, 2022, and what will happen if they don’t do it? Keep reading to find out.

First, let’s level-set on the three phases of the Transparency in Coverage Final Rule and the deadlines:

  1. Machine readable files (MRFs) for in-network and allowed amount rates, July 1, 2022
  2. Internet-based price comparison tool, January 1, 2023
  3. Machine readable files of negotiated rates of prescription drugs, deadline delayed indefinitely

Now, let’s discuss what’s required for the July 1 deadline – the machine readable files for in-network rates and allowed amounts. To learn more about the other components of the Transparency in Coverage Final Rule, check out this article.

Q: Who is required to publish the machine readable files?

A: Health plans – inclusive of self-funded and fully insured employers and insurance carriers – are required to publish the MRFs. If a self-funded employer uses a Third Party Administrator (TPA) to administer their plan, the TPA is responsible for publishing the MRFs (although the self-funded employer is the one that’s legally liable). Grandfathered plans are exempt from the Transparency in Coverage Ruling.

Q: What needs to be included in the machine readable files?

A: The in-network MRF should have rates for all the covered items and services between the plan and in-network providers. The allowed amount MRF should have the allowed amounts for out-of-network providers, including billed charges. For examples and more specifics about the MRFs, you can check out the CMS’ Price Transparency Guide on GitHub.

Q: Where do the machine readable files need to be published?

A: The MRFs need to be published on a public website and be available free of charge for anybody to access.

Q: What will happen if a health plan does not publish the machine readable files?

A: Failure to comply can lead to a hefty penalty of $100 per member per day.

Q: How often do the MRFs need to be updated?

A: Both MRFs (in-network and allowed amount) are required to be updated on a monthly basis and be inclusive of data from a 90-day period starting 180 days prior to the date it was published.

If you have any other questions about what’s required by July 1 or other components of the Transparency in Coverage Final Rule, you can find more details here or shoot us a note.

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