October 29, 2020, the Departments of Health and Human Services, Labor and the Treasury, issued the Transparency in Coverage final rule (see Fact Sheet). The Final Rule establishes requirements for the disclosure on group health plans and health insurers in the individual and group markets. First, they must provide cost-sharing information to enrolled individuals through an online tool on their website and in paper form (upon request). This part of the rule will be phased in beginning on or after January 1, 2023.
Second, most non-grandfathered group health plans or health insurers offering non-grandfathered coverage must disclose pricing information in three machine-readable files for 1) rates for in-network providers; 2) billed charges and allowed amounts for out-of-network providers during a specified period; and 3) prices for prescription drugs during a specified period. This part of the rule will go into effect beginning in 2022.
Third, insurers can claim credit towards their medical loss ratio (MLR) for “shared savings” when an enrollee selects a lower-cost, higher-value provider. This provision applies beginning with the 2020 MLR reporting year.