Transparency in Coverage Machine-Readable File Enforcement Begins July 1st, Who is Really Responsible?

Insights | Transparency in Coverage Machine-Readable File Enforcement Begins July 1st, Who is Really Responsible?

As the deadline for enforcement of the Transparency in Coverage Final Rule’s requirement to post machine-readable files draws near, many employers still find themselves a bit confused as to what is really required.  A portion of the rule requires non-grandfathered group health plans and health insurers to make three machine-readable files publicly available including:

  • Negotiated rates for all covered items and services between the plan and in-network providers;
  • Historical billed charges and payments to out of network providers; and
  • In-network negotiated rates and net prices for all covered prescriptions drugs (currently on hold).   

While compliance is (or was) required for the first plan year beginning on or after January 1, 2022, guidance released late last summer extended the enforcement date for plan years beginning January through June to July 1st and put the prescription drug component of the requirement on hold indefinitely.  Since then, insurers and claims administrators alike have been working to support clients in compliance, but the message hasn’t always been clear.   Following is what employers need to know:

Public Posting Requirement

Files must be made publicly available and posted to a public website, but this does not necessarily mean that the files must be made available on the plan sponsor’s landing page.  Posting to a public page providing information about company careers and benefits may be appropriate.  Files must be made available free of charge without condition.  This means that any requirement to create an account, provide credentials, or provide other information like name or address is prohibited.   

How to Comply

Fully-insured and self-funded and level-funded plan sponsors may host the files on their public websites. Both fully-insured plan sponsors and self-funded or level-funded plans may also satisfy the requirement by entering into a written agreement with their insurer or third-party administrator to provide and post the files.  However, the difference for self-funded and level-funded plan sponsors is that they are ultimately responsible for compliance.    

Employer Action Items

Fully-insured employers should enter into a written agreement with their carrier to provide and post the files on their behalf.   Self-insured employers should determine how their third-party administrator can help support compliance – most vendors are hosting the files and providing clients direct links to their websites.  Self-insured employers should then take the following actions:

  • Determine where to host the link on their public website;
  • Work with their IT or website host to have the link added to the website; and
  • Review their administrative agreements and work with legal counsel to negotiate compliance support into contracts moving forward.

To be cautious, a fully insured plan sponsor may also post the files to their public website to ensure their compliance with the rule.

Please reach out to your HORAN representative with additional questions at 800.544.8306.

 

The information contained in this document is informational only and is not intended as, nor should it be construed as, legal or accounting advice. Neither HORAN nor its consultants provide legal, tax nor accounting advice of any kind. We make no legal representation, nor do we take legal responsibility of any kind regarding regulatory compliance. Please consult your counsel for a definitive interpretation of current statute and regulation and their impact on you and your organization.