The “Transparency in Coverage” final rule was posted on Oct. 29 and published in the Federal Register on Nov. 12 by the Department of Health and Human Services (HHS), the Department of Labor, and the Department of Treasury in response to President Trump’s price and quality transparency executive order issued in June 2019.

The requirements give consumers tools to evaluate pricing information from their health care payer plans to improve transparency in health care pricing and to encourage competition. The following will be required by insurers to disclose on a public website to support innovation and informed, price-conscious decision-making:

  • In-network negotiated rates
  • Billed charges and allowed amounts paid for out-of-network providers
  • Negotiated rate and historical net price for prescription drugs

Two approaches were included to make this health care pricing available to consumers and stakeholders for easy comparison-shopping. The first includes personalized out-of-pocket cost information, and the underlying negotiated rates, for all covered health care items and services. Initially, 500 shoppable services will be made available on Jan. 1, 2023, with the remainder becoming available on Jan. 1, 2024.

The second approach requires insurers to provide three separate machine-readable files that include the pricing information below beginning Jan. 1, 2022:

  • 1st file – negotiated rates for all covered items
  • 2nd file – historical payments to and billed charges from out-of-network providers
  • 3rd file – in-network negotiated rates and historical net prices for all prescription drugs).

HHS encourages clinicians interested in “shared savings” to inform their patients of these new tools.

View the CMS transparency in coverage fact sheet for more information. Read more clinical resources news from the AASM.