Transparency in applying coverage | Jackson Lewis CP


On April 19, 2022, the Departments of Labour, Health and Human Services and the Treasury released additional guidance as part of the final rules on transparency of coverage released in 2020. The guidance, implementation FAQs of the Affordable Care Act, Part 53, provide a safe haven for disclosing in-network health care costs that cannot be expressed in dollars. They also serve as a timely reminder of the July 1, 2022 deadline to begin enforcing the final rules.


Final rules require non-grandfathered health plans and health insurance issuers to publish cost information to participants, beneficiaries and enrollees of in-network and out-of-network health services through files machine-readable published on a public website. The final rules for this requirement are in effect for plan years beginning on or after January 1, 2022 (an additional requirement to disclose information about drug benefits and drug costs is deferred pending further guidance). The final rules require that all fees be expressed in dollars. After the publication of the final rules, plans and issuers pointed out that under certain alternative reimbursement methods, the costs in the network are calculated as a percentage of the fees charged. In these cases, dollar amounts cannot be determined in advance.

Safe Harbor FAQs

The FAQs provide a safe harbor for cost disclosure under a contractual agreement where the plan or transmitter agrees to pay a network provider a percentage of the billed fee and cannot assign a dollar amount before to provide the services. In this type of arrangement, they can declare the percentage instead of a dollar amount. The FAQs also provide that where the nature of the contractual arrangement requires the submission of additional information to describe the nature of the negotiated rate, plans and issuers may describe the formula, variables, methodology or other information necessary to understand the arrangement openly. text field. This is only permitted if the current technical specifications do not support disclosure via machine-readable files.

Public website requirements

These guidelines are quite narrow and primarily of interest to plans, issuers and third-party administrators responsible for the technical aspects of disclosure. Nonetheless, it is a useful reminder to plan sponsors that the July 1 deadline for implementing these requirements is fast approaching. Plan sponsors should remember that these machine-readable files must be posted on a public website. The final rules make it clear that the files should be accessible for free, without having to create a user account, password or other credentials and without submitting any personally identifying information such as a name. , email address or phone number. If a third-party website hosts the files, the plan or issuer must post a link to the location of the file on its own public website. Simply posting the files to an individual plan’s website or the plan sponsor’s corporate intranet does not meet these requirements. Regardless of how a plan chooses to comply, enforcement begins in two months.


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