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Price Transparency Requirements for Health Plans Finalized

For CEOs, CFOs, chief legal counsel, government relations executives, finance staff

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The Centers for Medicare & Medicaid Services (CMS) – along with the Departments of Labor and Treasury — has issued a final rule that establishes several new price transparency requirements for health plans. The final rule builds on the finalized price transparency requirements for hospitals and reflects President Trump’s June 24 executive order.  

The final rule applies to non-grandfathered group health plans (those not in existence prior to passage of the Affordable Care Act) and health insurers offering non-grandfathered health plans in the individual and group markets.  

Specifically, the rule will require these plans and insurers to make available to participants, beneficiaries, and enrollees personalized out-of-pocket cost information for all covered health care items and services through an internet-based self-service tool and in paper form, upon request. An initial list of 500 shoppable services will be required to be available via the internet-based self-service tool for plan years that begin on or after Jan. 1, 2023. The remainder of all items and services will be required for these self-service tools for plan years that begin on or after Jan. 1, 2024. 

In addition, these plans and insurers must make available to the public — including stakeholders such as consumers, researchers, employers, and third-party developers — detailed pricing information through three separate machine-readable files containing: 

  • The in-network negotiated rates with their network providers for all covered items and services 
  • Historical payments to, and billed charges from, out-of-network providers 
  • The in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level  

These files are required to be made public for plan years that begin on or after Jan. 1, 2022. 

In addition, CMS finalizes changes to medical loss ratio requirements that would allow issuers offering plans that incentivize enrollees to shop for services from lower-cost, high-value providers to “share savings” in their medical loss ratio calculations. 

More information is available in a CMS fact sheet.