The Transparency in Coverage Rule requires hospitals, health insurers and group health plans to provide various pricing files and tools to the public over the course of a multi-year rollout of health care cost data. As of January 2022, plans are required to post publicly available machine-readable files that include in-network negotiated payment rates and historical out-of-network charges for covered items and services, including prescriptions drugs. The rule does not apply to grandfathered plans, excepted benefit plans and short-term limited durations plans.
Today’s communication focuses specifically on the machine-readable files and how WebTPA can assist our group health plans in being compliant. The purpose of the files is to provide opportunities for detailed research studies and data analysis. The hope is that this data will assist independent developers and innovators to create private sector solutions, to drive price-conscious decision making in the health care industry. The files are not intended for individual members or consumers to search for procedures. This is part of the next phase being developed for 2023 and will include consumer facing, highly functional price comparison tools.
The three “machine readable” files are to be organized in the following format:
• In-Network Rates. Must show negotiated rates for all covered in-network items and services.
• Out-of-Network Historical Rates. Must show both the historical payments to, and billed charges from, out-of-network providers for all covered items and services. Data does not have to be reported if the provider has fewer than 20 claims for the item or service during the reporting period.
• Prescription Drugs. Must detail the in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level. The historical prices are for the 90-day time-period that begins 180 days prior to the file publication date.
The files must include billing codes used to identify the item or service such as the Current Procedural Terminology (CPT) code, Health Common Procedure Coding System (HCPCS) code, Diagnosis-Related Group (DRG) code or the National Drug Code (NDC) or other common identifiers.
Data is to be displayed in a standardized format, made available at no cost, and updated monthly. Because the files must be displayed publicly, a user cannot be required to establish a user account, password, or other credentials, nor to submit any personal identifying information such as a name, email address, or telephone number.
WebTPA is planning to host the files on our site for all of our clients who wish us to do so, but a group health plan should also provide a link on its own website to the location where the file is made publicly available. We have begun working with network vendors as well as our out-of- network repricing vendors to determine when files will be available and how they can be accessed on behalf of our clients. Since we do not own or require a specific PBM partner to be used by our clients, we’ll first reach out to any PBM vendor where we have a sizable volume of clients, but we do encourage you to talk with your PBM to determine if the data file for your pharmacy plans could be sent to WebTPA on your behalf or a link could be shared with WebTPA to access. This would be especially helpful if you work with a local or niche PBM partner that may be specific to your group health plan. If you have any questions about the next steps, please contact Account Management and we’ll help direct you to the right area or assist in answering your questions.