How the Price Transparency in Coverage Rule benefit those individuals insured by employer health plans?

With the Transparency in Coverage rule in effect, people can make more informed decisions and compare costs between specific providers. The rule currently applies to a wide range of services, such as hospitalizations, blood tests, and prescriptions; it will continue to expand over the next two years to include more services.?

By January 1, 2023, all plans must share the costs of the 500 most common health care items and services; by January 2024, plans must publicize the cost of every covered item and service. In addition, all insurance plans must provide an explanation of benefits (EOB) statement, with an estimate of the out-of-pocket costs for any medical services, before those services are provided, so that people can view the out-of-pocket costs ahead of time.?

The regulation requires insurers to inform people about the prices they have negotiated with in-network providers for all covered items and services. Also, for out-of-network providers, the EOB will include the maximum amount an insurer will pay for a given service (the allowed amount) and the amount that is charged by the provider (the billed amount). Insurers must update the costs on their EOBs at least once a month for accuracy. Insurers and several health tech companies are working on developing online tools so people can compare costs. In the meantime, requests for healthcare pricing information can be made directly to insurance providers.

Without price and cost information available, people often chose services without fully understanding how much their insurance would pay and how much they would be charged out of pocket. For example, if you needed a surgical procedure, it was difficult to find out how much you would be responsible for paying until after the procedure when you got the bill. You also were unlikely to know if you could have gotten the same procedure from a different provider for a lower price. Now, with Hospital Price Transparency and Transparency in Coverage rules, you can review health care pricing information beforehand and compare the costs among different providers.