Health plan Price transparency Provider reimbursement rate

Enforcement of one of the final Coverage Transparency Rules (“TiC Rules”) begins July 1, 2022. The rule requires plans and issuers to make public machine-readable files that will disclose rates in the network and off-grid. authorized amounts and fees charged for plan or policy years beginning on or after January 1, 2022.


Over the past two years, several laws and regulations have been passed that require health plans and health insurance issuers to provide or disclose various types of information to plan members and the public. These mandates include the TiC rules, the No Surprises Act (NSA), and the Consolidated Appropriations Act of 2021 (CAA). On August 20, 2021, the U.S. Departments of Treasury, Labor, and Health and Human Services (the “Departments”) released a joint FAQ (the “FAQ”) intended to address various reporting requirements under these mandates and to recognize that some of them are duplicative or overlapping. In the FAQ, the departments postponed the application of several requirements under these new laws and regulations, including the postponement of the application of the requirement under the TiC rules to make certain plan information publicly available. in a machine-readable file format until July 1, 2022.

Foley & Lardner LLP has previously published several articles on the details of these mandates, including overviews of the TiC rules here and here, a detailed discussion of the regulations implementing the NSA, and a checklist for plan sponsors noting the requirements. applicable under the TiC rules and the CAA.

In light of ongoing questions about the applicability of the TiC rules, Foley has created a summary table that includes information on the requirements applied as of July 1, 2022, as well as any other requirements under the TiC rules.

What plans need to do to comply by July 1, 2022

To meet the requirements of the TiC rules which will be applied from July 1, 2022, plans and issuers must create two files: one to disclose the prices of suppliers on the network for covered items and services and another to disclose the amounts authorized out-of-network and fees charged for covered items and services. Both files must be machine-readable, which means they must conform to a non-proprietary open standard format such as XML or JSON and be made available over HTTPS. Formats such as PDF or DOCX are not acceptable file formats.

For the file disclosing network information, the file should contain the following data elements to each coverage option offered by the plan:

  1. The name and identifier (for exampleHIOS);

  2. Each billing code (for example, CPT) with a plain language description of the code; and

  3. All applicable rates, including negotiated rates, rate schedules, or derived amounts (for exampleprices by reconciliation with service providers or prices allocated for internal purposes).

If a service is part of a bundled payment, a plan is permitted to disclose the full dollar amount bundled under a single billing code, as long as it is consistent with the actual reimbursement process and the plan lists all services and items included as part of the bundle.

For the file disclosing off-network information, the file must contain the following data elements to each coverage option offered by the plan:

  1. The name and identifier (for exampleHIOS);

  2. Each billing code (for example, CPT) with a plain language description of the code; and

  3. Unique out-of-network amounts authorized (in dollars) for each out-of-network provider (with identifier, for exampleNPI) and fees charged for services or items during the 90-day period beginning 180 days prior to the file’s posting date.

For confidentiality reasons, data relating to a particular item or service should be omitted when there are fewer than 20 different payment requests associated with the billing code for that item or service.

TiC rules also require plans and issuers to provide information on negotiated rates and historical net prices of covered prescription drugs; however, the application of this requirement has been deferred pending further consideration of how this requirement overlaps with prescription drug reporting requirements under the CAA.

Once created, the files must be posted on a website accessible to the public and accessible free of charge to anyone. No conditions may be imposed on access to the files, such as creating a user account, password or other credentials or submitting personally identifiable information to access the file .

Files should be updated monthly and clearly indicate the date they were most recently updated. File schemas are available on the GitHub website.

Action steps

In practice, the bulk of the work associated with meeting these requirements will generally fall to issuers (for example, health insurance funds) and third party administrators (“TPA”). For fully insured plans, legal liability may be transferred to the health insurance company if set out in a written agreement. For self-funded plans, the plan sponsor remains liable even if reporting obligations are outsourced to TPAs ​​(although the service contract may contain indemnification provisions).

Plan sponsors should check with their insurers and TPAs ​​to ensure everything is on track to meet requirements by July 1, 2022.

Carriers, TPAs, and other plan service providers should have already started collecting data and using GitHub schemas, and should prepare to make these files publicly available by July 1, 2022.

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