Final Rule regarding Transparency in Coverage for Health Care Services

 

Seyfarth Comments: The final Transparency in Coverage Rule was published jointly by the Departments of Health and Human Services, Treasury, and Labor on November 12, 2020. The Rule aims to increase transparency in cost-sharing for patients by requiring non-grandfathered group health plans and insurance issuers to publish certain healthcare price information estimates. The Rule takes effect January 11, 2021, with staggered effective dates for required disclosures through January 1, 2024.

The Transparency in Coverage Rule attempts to execute on the Trump Administration’s executive order on Improving Price and Quality Transparency in American Healthcare to Put Patients First, issued on June 24, 2019. The final Rule requires certain disclosures regarding prices and cost-sharing information for certain healthcare items and services provided by non-grandfathered group health plans and insurance issuers. The Rule generally applies to traditional health plan coverage, and does not apply to account-based group health plans (such as HRAs, including individual coverage HRAs, or health FSAs), excepted benefits, or short-term limited-duration insurance.

The Rule requires two categories of disclosures: disclosures to the public, and disclosures to plan participants.

Public Disclosures

For plan years beginning on or after January 1, 2022, group health plans and insurance issuers will be required to publicly disclose health care pricing information on an internet website, which must be updated monthly. In general, plans and issuers will have to disclose:

• In-network provider negotiated rates for covered items and services;
• Historical data showing billed and allowed amounts for covered items or services, including prescription drugs, furnished by out-of-network providers; and
• Negotiated rates and historical net prices for prescription drugs furnished by in-network providers.

Participant Disclosures

Under the participant disclosure requirements, group health plans and issuers must provide certain personalized cost-sharing information to participants and beneficiaries in advance and upon request. The disclosures must be available both using an internet-based self-service tool and on paper if requested. The required disclosures must include the following information:

• The estimated cost-sharing liability for a requested covered item or service;
• Accumulated amounts, including unreimbursed amounts the participant or beneficiary has paid toward meeting his or her individual deductible and/or out-of-pocket limit (and if enrolled in other than self-only coverage, amounts incurred toward meeting the other than self-only coverage deductible or out-of-pocket limit);
• In-network negotiated rates for covered items and services;
• Out-of-network allowed amounts, or any other rate that provides a more accurate estimate of what the plan or issuer will pay for the requested covered item or service;
• Lists of covered items and services that are part of a bundled payment arrangement;
• Notice of items and/or services subject to a “prerequisite,” which is defined as concurrent review, prior authorization, and step-therapy or fail-first protocols that must be satisfied before the plan or issuer will cover the item or service (not including medical necessity determinations or other medical management techniques); and
• A disclosure notice that includes: balance billing provisions, possible variations in actual charges, a disclosure that the estimated cost-sharing liability is not a guarantee, the application of copayment assistance and/or third-party payments, and any other information deemed appropriate. A model notice is available on the Department of Labor’s website: https://www.dol.gov/sites/dolgov/files/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/transparency-in-coverage-draft-model-disclosure.pdf
• Due to the extensive nature of the required disclosures, the Departments include a staggered schedule for providing the required participant disclosures under the Rule. For plan years beginning on or after January 1, 2023, plans must make this information available for 500 items and services listed in the Rule, and for plan years beginning on or after January 1, 2024, plans must make the information available for all items and services.

 Compliance

A group health plan may satisfy the disclosure requirements by entering into a written agreement with its third-party administrator (TPA), whereby the TPA will provide the information required by the Rule. Notably, if the TPA fails to provide the information required by the Rule, the plan remains responsible for noncompliance.

A plan or issuer will not fail to comply with the disclosure requirements if, while acting in good faith and with reasonable diligence: i) it makes an error or omission and corrects the information as soon as practicable; or ii) its internet website is temporarily inaccessible, provided it makes the information available as soon as practicable.

The extensive disclosures required by the Rule have been greeted with much criticism, in particular by the insurance industry. Litigation and other challenges to the Rule are anticipated. In particular, there are concerns that the Rule will impede the ability of service providers and drug companies to negotiate prices. Accordingly, the final Rule contains a severability clause so if a court holds any provision of the Rule to be unlawful, the remaining provisions will survive.

Seyfarth will continue to track further developments regarding the Rule. Also, be sure to sign up for our blog, Beneficially Yours, for further discussion of employee benefits topics and updates at https://www.beneficiallyyours.com/.