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Home Employers Industry Insights for Employers and Brokers Informed on Reform Health Care Reform NewsTri-Agencies Finalize Transparency in Coverage Rule

Article | 30 October 2020

Tri-Agencies Finalize Transparency in Coverage Rule

On Oct. 29, 2020, the U.S. Departments of Health and Human Services, Labor, and Treasury (tri-agencies) released a prepublication version of a final rule on Transparency in Coverage. Initially proposed last year, the rule requires most group health plans and health insurance issuers in the individual and group markets to disclose price and cost-sharing information for all covered items and services to participants and enrollees. This rule is separate from a similar rule requiring hospitals to disclose price information set to take effect on Jan. 1, 2021. Both rules follow through on a 2019 Executive Order designed to increase price transparency for consumers and competition among all hospitals and health insurers.

Disclosing Cost-Sharing Information and Negotiated Rates
The final rule requires most group health plans and health insurance issuers in the individual and group markets to disclose cost-sharing information to customers upon request. The information must be available through a self-service tool online and, if requested, in paper form. The cost-sharing information must be made available for all procedures, medical tests, drugs, durable medical equipment, and any other item or service a customer may need for which the costs are payable, in whole or in part, under the terms of a plan or coverage. Calculations must consider all applicable forms of cost sharing – including deductibles, coinsurance requirements, and copayments – but do not include premiums, balance billing amounts for services received from out-of-network providers, or the cost of non-covered items or services.

In addition to providing personalized cost-sharing information, health plans and health insurers must also publicly disclose in-network provider negotiated rates and historical out-of-network allowed amounts online through two separate machine-readable files. A third file must also be posted to disclose negotiated rates with pharmacies and average historical net prices for prescription drugs, taking into account any rebates or discounts received. Historical pricing information must be provided for a 90-day period beginning 180 days prior to file publication.

Cigna believes health care consumers should have easy access to information that allows them to make better informed decisions. While we support and encourage meaningful and actionable price transparency, we believe public disclosure of negotiated rates would confuse consumers, result in higher prices for health care, and return the health care system to a fee-for-service orientation by encouraging focus on unit costs rather than quality and total cost of care.

Medical Loss Ratio Program Rules for Shared Savings Plans
Insurers that incentivize consumers with plan provisions that encourage the use of services from lower-cost, higher-value providers – and share the resulting savings with consumers – will be allowed to take credit for the “shared savings” payments in medical loss ratio (MLR) calculations beginning with the 2020 MLR reporting year.

Effective Dates
Effective Jan. 1, 2022, plans and issuers must make applicable data files publicly available. Personalized cost-sharing information must be made available for 500 services (as determined by the tri-agencies) beginning Jan.1, 2023, and cost-sharing information for all items and services are required beginning Jan. 1, 2024.

For more details on the final rule, review the information at these links:

  • Read the final rule [PDF]
  • Read the Centers for Medicare & Medicaid Services fact sheet

We encourage you to bookmark Informed on Reform, where we continuously update information on legislation and regulatory changes impacting health plans.


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