Read More

Impending Deadline for Health Plans to Publish Machine-Readable Files

Beginning July 1, machine-readable files (MRFs) for in-network and out-of-network health care services are required to be publicly disclosed.

This is the initial step in enforcement under the Transparency in Coverage (TiC) rules and is part of the larger federal effort to improve transparency in the cost of health care services. Originally, the enforcement deadline was January 1, 2022 and also included disclosures related to prescription drugs, but this was deferred pending additional rule making. Since the release of the TiC rule, the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury (Departments) adopted an enforcement safe harbor to clarify reporting for arrangements where a specific dollar amount cannot be determined. With the deadline around the corner, this safe harbor should alleviate some of the compliance efforts in meeting this disclosure obligation. Below is a quick overview of what is required:

Enforcement Deadline July 1, 2022 for plan years beginning on or after January 1, 2022. For plan years beginning after July 1, 2022, posting is the month the plan year begins
Application Non-grandfathered group health plans and health insurance issuers in individual and group markets (not applicable to grandfathered plans, excepted benefits, and account-based plans such as HRAs, FSAs, and HSAs)
Type of Data Posting of MRFs on a public website with the following data:
• In-network negotiated rates with providers
• Out-of-network allowed amounts and billed charges
In-network negotiated rates and historical prices for prescription drugs (delayed pending future rulemaking)

Data in MRFs must be updated monthly for accuracy and indicate the date last updated
Public Posting Requirement 1. Freely accessible without charge
2. Login credentials not required
3. Personal identifiable information such as name, email address or phone number not required

The TiC rules do not discuss where the information must be posted. Plans and issuers may determine the location based on where it is most accessible for the intended user.
Nonduplication Rule Fully-Insured Plan: A fully-insured group health plan will satisfy the MRF requirements if the issuer offering the coverage is required to provide the information according to a written agreement with the plan. If the issuer fails to provide full and timely information, then the issuer has violated the TiC disclosure requirements.

Self-Insured Plan: A self-insured group health may enter into a written agreement under which another party (e.g., TPA or health care claims clearinghouse) will post the MRFs publicly but the plan remains liable and must continue to monitor the other party for compliance.

The MRF can be hosted on another party’s website, but what is unclear is whether a plan sponsor must also provide a link on their own public website. The TiC rules suggest that if a plan or issuer chooses not to also host the file separately on its own website, it must provide a link on its own public website to where the file is publicly available. Additional guidance would be helpful.
In-Network Rate Safe Harbor Report rates as percentage instead of a dollar amount (use the Departments’ formatting requirements)

OR

Use open text field with description of formula, variables, methodology, and other necessary information needed to understand the arrangement (can only be used if the Department’s technical implementation guidance does not support the arrangement)
Enforcement The Centers for Medicare and Medicaid Services (CMS) may require corrective actions and/or impose a civil monetary penalty up to $100 per day (adjusted annually) per violation and per affected individual.

Looking for more information and guidance around implementing the Transparency in Coverage rule? Read more here: Departments Issue Transparency in Coverage Final Rule.

Share

Top