Transparency in Coverage: New for ’22

transparency in coverage

Healthcare costs are expected to trend higher by about 6.5 percent this year. COVID-19 and mental health care will drive the increase, among other health issues. But some relief is already here. Effective January 1, the No Surprises Act aims to protect patients after a service or product has already been provided by banning certain out-of-network billings and educating patients on how to question charges. The Transparency in Coverage rule, also now in effect, will help patients before a service or product is given by providing accurate cost-sharing estimates from different providers in real time. This allows patients to both understand how costs for covered health care items and services are determined by their plan, and also shop and compare health care costs before receiving care.

We’ve summarized the Transparency in Coverage Final Rule Fact Sheet from the Centers for Medicare and Medicaid Services (CMS) below.

Transparency in coverage for health plan members

Grandfathered health insurance plans (those in existence as of March 23, 2010) in individual and group markets must provide personalized information for all covered items and services. This includes out-of-pocket costs, negotiated rates, and so on. The information must be available in an internet-based tool. If a member asks for a paper copy, that has to be made available as well. Reviewing this information before a visit can help patients compare providers and treatments to get the help they need at a lower cost.

Transparency in coverage for the public

Non-grandfathered health insurance plans in individual and group markets must publish price data in three machine-readable files, including:

  • Negotiated rates for all covered items/services available from in-network providers
  • Historical data related to out-of-network providers
  • In-network negotiated prices and historical net prices for covered prescriptions

Important deadlines

Plan sponsors are required to meet the following Transparency in Coverage deadlines:

  • January 1, 2022: Provide public, machine-readable file with in-network rates, out-of-network allowed amounts and prescription drug pricing
  • January 1, 2023: Publish personalized, internet-based price data for 500 pre-selected items and services
  • January 1, 2024: Add pricing data for all other items, services, and drugs to the existing data

Although the deadline was January 1, CMS has announced that it will not enforce the 2022 requirement until July 1. Learn more here.

Significance for employers

Employers provide healthcare benefits to help create a healthy, productive, loyal staff. How effectively these benefits meet those goals relies in large part on the extent that employees use and are happy with them. Both the No Surprises Act and Transparency in Coverage rule should help employees keep their out-of-pocket costs as low as possible. When those costs can’t be avoided altogether, employer-sponsored FSA, HRA or HSA accounts (as available) can help even more. Happy employees are productive employees. And productive employees make happy employers. For more information, talk with your benefits broker or third-party benefits administrator (TPA).

DataPath, Inc. is the longest running solutions provider in the benefits administration industry. The company is also the creator of the award-winning employee education and engagement program, The Adventures of Captain Contributor.

Home » Transparency in Coverage: New for ’22