Jun 24, 2022
The Transparency in Coverage rule requires health plans and insurers to disclose pricing information
via MRF by July 1, 2022. Health plans must generate two MRFs that contain:
- Negotiated rates for in-network providers
- Billed charges and allowed amounts paid for out-of-network providers
The TiC final rule applies to non-grandfathered individual and group health plans. The rule does not apply to grandfathered plans or excepted benefits like stand-alone dental and vision coverage, Medicare supplement policies, hospital indemnity, and other similar limited benefit plans. The rule also doesn’t apply to programs outside of the commercial market like Medicare Advantage and Medicaid.
Aetna
Information will be published on Aetna.com on July 1, 2022, for fully insured (51-100) and small group
Aetna Funding Advantage (2-100) groups. By posting the MRFs for your small group Aetna Funding Advantage clients, Aetna is taking work off their plate. Aetna will update the files each month and this link will remain active with the most up-to-date
information.
Capital Blue Cross
On July 1, 2022, Capital Blue Cross will publish machine-readable files on their website in compliance with the Transparency in Coverage Final Rule. Once posted, you’ll be able to access them through this link. The publicly accessible files will include medical in-network rates and out-of-network allowed amounts for Capital Blue Cross and national networks. It is important to note that the machine-readable files will not appear until the files are populated sometime on July 1, 2022. If you click on the link before the data is released, you will be routed to MyCare Finder, their provider finder tool.
Employers may post the URL on their sites for users to access. The data files will be updated on the first of every month. Machine-readable files are a digital representation of data or information that can be imported or read into a computer system for further processing. The data is not meaningful at first glance without that process. Capital Blue Cross will not charge for use of the machine-readable files posted on their site. Those who wish to interpret the data will need to process and evaluate it on their own or use a third-party vendor.
CareFirst
July 1, 2022, CareFirst will publish Table of Contents (TOC) files for all plans effective on or after January 1, 2022, in the Legal & Mandates section of carefirst.com. Each TOC file will house all relevant plan data and the URL location information for where to download the appropriate files. CareFirst is on track to meet the July 1, 2022 deadline. The target date for the webpage to go live with the TOC files is June 29, 2022.
What about the machine-readable file for drug pricing that was required in the final rule? CareFirst will not host files for plans that use NetLease. The Departments released additional guidance in August 2021 that delayed the implementation of the two MRFs from January 1 to July 1, 2022, and put this third file for drug pricing on hold indefinitely, pending additional guidance at a later date.
How does a member use the file to look up pricing? Machine-readable files are meant to feed technology-based tools. They are not meant to be used by members to look up pricing. Members currently have access to the Treatment Cost Estimator Tool in My Account, and CareFirst is working on the necessary enhancements required by the final rule to be in place by January 1, 2023.
What is the 20-claim minimum rule related to the out-of-network file? For the out-of-network file, entities are required to report historical allowed amounts and billed charges for specific items and services by providers. To protect privacy, regulations require that this data be omitted if there are fewer than 20 different claims for a particular item or service and provider combination for a plan.
Is there a cost for hosting the machine-readable files? For 2022, they’re absorbing the costs for self-funded plans. However, their approach for 2023 and forward is still being considered.
Can a self-funded employer group host the machine-readable files on their company website? To meet the compliance date of July 1, 2022, CareFirst will host the files for all applicable plans. If a self-funded group wants to host the files on their website, they may reach out to their CareFirst Sales Consultant for more information.
What about CFA and NCAS groups? The files hosted by CareFirst will include a PPO file for CFA Blue and additional files sent to CareFirst for NCAS.
