Transparency of Coverage Requirements – Compliance Deadline Approaches | FordHarrison

Summary: For health plans, machine-readable files, containing in-network provider charges and out-of-network authorized amounts and charges, must be posted on a public website by July 1, 2022.


The public disclosure requirement is required under the “Transparency in Coverage” Final Rules (“TiC Rules”) issued in November 2020 by the Internal Revenue Service, Department of Labor and Department of Health and Human Services social (“Agencies”). The TiC Rules are intended to implement the cost transparency requirements imposed by the Affordable Care Act. TiC’s final rules apply to non-grandfathered group health plans and insurers offering non-grandfathered coverage and require cost-sharing disclosures to be made available by most health plans and insurers. Shortly after the release of the final TiC rules, the Internal Revenue Service, Department of Labor, and Department of Health and Human Services (the “Departments”) jointly issued regulations clarifying the transparency of coverage requirements , which will be applied from 1 July. , 2022. This disclosure requirement does not apply to plans grandfathered under the Affordable Care Act, with the exception of benefits (stand-alone dental and visual plans and on-site medical clinics), separate plans ‘retirees only’, ministries sharing health care, short-term, time-limited contracts. (STLDI) and account-based plans like Health Reimbursement Arrangements (HRA) and Flexible Healthcare Spending Accounts (FSA).

In accordance with regulations, most health plans and insurers in the individual and group markets are required to disclose rates negotiated by in-network providers as well as historical out-of-network amounts allowed and charges billed to providers. Plans and insurers must also disclose network-negotiated rates and historical net prices for all prescription drugs covered at the pharmacy level as specified by departments. Specifically, the information required above must be posted on a public website and, upon request, personalized cost-sharing information must be disclosed to participants, beneficiaries, or registrants.

After the final TiC rules were finalized, the Consolidated Appropriations Act (CAA) was published, imposing new transparency requirements on plans and issuers, including prescription drug reporting. It has been noted that many of the CAA requirements contain duplicate and overlapping reporting requirements for prescription drugs. For example, under the TiC Final Rule and the CAA, plans and issuers must publicly publish price information for all covered prescription drugs by January 1, 2022. To address the overlap, departments have published Frequently Asked Questions.

Plan sponsor requirements under the TiC Final Rule

The required disclosures must be made by means of three machine-readable files (MRFs) posted on a public website in a standardized format. Insurers can publish information for fully insured plans. For self-funded plans, third-party administrators may publish information with the plan sponsor. Regulations require MRFs to be updated monthly and indicate the date of the last update, thus allowing the public to access information about health insurance coverage that can be used to understand health care pricing. health. MRFs cannot require registration or exist behind a firewall and must be publicly available free of charge.

Due date

The regulations required FRMs to be made public for plan years beginning on or after January 1, 2022. However, the ministries postponed enforcement of the requirement until July 1, 2022. For plan years starting between January 1, 2022 and July 1, 2022, files must be posted no later than July 1, 2022. For plan years starting after July 1, 2022, files must be posted in the month in which the plan year begins. However, it is recommended that MRFs be posted no later than July 1, 2022 for all plan years (calendar and non-calendar). Departments have deferred enforcement of the MRF requirement for prescription drug pricing pending the development of new rules.

Trust in good faith

The TiC Final Rule provides some protection for good faith compliance. Under the final rule, a group health insurance plan that acts in “good faith” and with “due diligence” will not fail to comply solely because it makes an error or omission in the requirement. of disclosure. Moreover, a plan or insurer will fail to comply only because, despite its good faith and due diligence, its website is temporarily inaccessible (for example, for the public disclosure obligation). The final rule further states that to take advantage of these protections, the plan or issuer must make the information available as soon as possible. Plan sponsors must prepare a deliberate written compliance plan to demonstrate good faith efforts and due diligence if they are unable to fully comply with disclosure requirements by July 1, 2022.

If the required disclosure is provided by a third party (for example, a third party administrator) and the third party is non-compliant, the plan will not be non-compliant unless it knows or reasonably should have known that the information provided is incomplete. or incorrect.

Next steps for plan sponsors

To ensure compliance, plan sponsors must confirm in writing that insurers and/or third parties obtain and publish the information. Plan sponsors must confirm that all links provided by the insurer or PTA include the appropriate MRFs and that the content and accessibility requirements of the regulations are met. Plan sponsors should determine whether the MRF should be posted on the plan website for self-funded plans or on the third-party administrator or both.

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