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Transparency in Coverage Final Rule Fact Sheet (CMS-9915-F) | CMS

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the coverage transparency final rule released today by the department of health and human services (hhs), the department of labor and the department of the treasury (the departments) complies with president trump’s executive order on improving price and quality transparency in American health care to put patients first.[1] this final rule is a historic step in putting health care pricing information in the hands of consumers and other stakeholders, furthering the administration’s goal of ensuring consumers have the critical information they need to make decisions informed about medical care.

The requirements of this rule will provide consumers with the necessary tools to access pricing information through their health plans. This rule builds on previous actions the administration has taken to increase pricing transparency by giving patients access to hospital pricing information. The administration has already finalized the requirements for hospitals to disclose their standard charges, including negotiated rates with third-party payers. the requirements in the final coverage transparency rule will reduce the secrecy behind health care pricing with the goal of creating more competition in the private health care industry.

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For too long, Americans have been in the dark about the cost of their health care until they get services and get a bill. This rule will require most group health plans and health insurance issuers in the group and individual market to disclose price and cost-sharing information to participants, beneficiaries, and enrollees. The departments are finalizing a requirement to give consumers real-time, personalized access to cost-sharing information, including an estimate of their cost-sharing responsibility, through a web-based self-service tool. this requirement will allow consumers to shop and compare costs between specific providers before receiving care. Through this final rule, plans and issuers will also be required to disclose on a public website their in-network negotiated rates, billed charges and allowable amounts paid by out-of-network providers, and the negotiated rate and historical net price of prescription drugs. . Making this information publicly available will drive innovation, support informed and price-conscious decision-making, and promote competition in the health care industry.

make health care pricing information accessible to consumers

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This final rule includes two approaches to making health care price information accessible to consumers and other interested parties, allowing for easy comparison shopping.

  • First, most grandfathered group health plans[2] and health insurance issuers that offer grandfathered health insurance coverage in the individual and group markets will be required to make available to Participants, beneficiaries, and enrollees (or their authorized representative) personalized information about out-of-pocket costs and underlying negotiated rates for all covered health care items and services, including prescription drugs, through a web-based self-service tool and in printed format upon request. For the first time, most consumers will be able to get accurate, real-time estimates of their cost-sharing responsibility for health care items and services from different providers in real time, allowing them to understand how the costs of items and services Covered health care services are determined by your plan, and also shop around and compare health care costs before you get care. an initial list of 500 purchasable services as determined by the departments shall be available through the web-based self-service tool for plan years beginning on or after January 1, 2023. the remainder of all items and services will be required for these self-service tools for plan years beginning on or after January 1, 2024.
  • second, most grandfathered group health plans or health insurance issuers that offer grandfathered health insurance coverage in the individual and group markets will be required to make available to the public, including interested parties , such as consumers, researchers, employers, and third-party developers, three separate machine-readable files that include detailed pricing information. The first file will show the negotiated rates for all covered items and services between the plan or issuer and in-network providers. the second file will show historical payments and billed charges from out-of-network providers. historical payments must have a minimum of twenty entries to protect consumer privacy. and finally, the third file will detail in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level. plans and issuers will display these data files in a standardized format and provide monthly updates. this data will provide opportunities for detailed research studies, data analysis, and offer third-party developers and innovators the ability to create private sector solutions to help drive additional comparison shopping and consumerism in the healthcare market. these files must be made public for plan years beginning on or after January 1, 2022.
  • In this rule, hhs will also enable issuers that empower and incentivize consumers through plans that include provisions that encourage consumers to purchase services from lower-cost, higher-value providers, and share the resulting savings. with consumers, to take credit for such “shared savings” payments in their medical loss ratio (MLR) calculations. HHS will allow this to ensure that issuers are not required to pay MLR rebates based on a plan design that would provide a benefit to consumers that is not currently captured in any existing MLR income or expense category. hhs believes this change will preserve the legally required value consumers receive for coverage under the mlr program, while encouraging issuers to offer new or different value-based plan designs that support competition and participation. of the consumer in the health care market.

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