Posting MRF's (Machine-Readable Files) to comply with new Transparency in Coverage Rules; Abortion Rider Updates & Legal Ramifications

July 1 Deadline for Posting MRF's

The Transparency in Coverage Final Rules (TiC Final Rules) require group health plans and health insurance issuers to disclose on a public website detailed pricing information in three separate machine-readable files (MRFs). Specifically, the following information must be disclosed:

• First file: In-network provider negotiated rates for covered items and services (the “In-network Rate File”);
• Second file:Historical payments to and billed charges from out-of-network providers (the “Allowed Amount File”); and
• Third file:?In-network negotiated rates and historical net prices for covered prescription drugs (the “Prescription Drug File”)—this particular MRF requirement is delayed until further notice.

The files must be publicly available and accessible free of charge without any restrictions. Please reach out with further questions on making these file accessible to employees!

Action Steps

Most employers will rely on their insurance carriers and third-party administrators (TPAs) to provide the MRFs. The TiC Final Rules allow fully-insured employers to shift legal responsibility for the MRFs to their carriers if this arrangement is described in a written agreement. Self-insured employers can use their TPAs (or other service providers) for the MRFs if this is set forth in a written agreement. Still, these employers remain legally liable for compliance under the TiC Final Rules.

The TiC Final Rules suggest that self-insured employers may be required to post a link on their websites to where the MRFs are publicly available, but this is not clearly addressed in the Final Rules. Additional guidance from federal agencies on this topic would be helpful.

Employers should confirm that written agreements addressing MRFs are in place with their carriers and TPAs and that these files will be available by the applicable deadline.

Massachusetts Carrier Links to MRF's (Thanks to the RG Team!)

• Blue Cross/Blue Shield of MA
• Harvard Pilgrim Health Care
• Tufts Health Plan
• Allways Health Plan
• United Healthcare

Content Elements for All MRFs?

The following content elements are required to be included in the three MRFs:

• Name and identifier for each coverage option: Plans and issuers must include their Health Insurance Oversight System (HIOS) ID at the 14-digit product level. If the plan or issuer does not have a HIOS ID at the plan or product level, the plan or issuer must use the HIOS ID at the five-digit issuer level. If a plan or issuer does not have a HIOS ID, it must use its EIN.
• Billing codes: This includes a Current Procedural Terminology (CPT) code, a Healthcare Common Procedure Coding System (HCPCS) code, a Diagnosis Related Group (DRG), a National Drug Code (NDC) or another common payer identifier used by a plan or issuer (for example, a hospital revenue code). In the case of prescription drugs, plans may only use the NDC as the billing code type. Plain language descriptions of the billing codes must also be provided.
• In-network applicable amounts, out-of-network allowed amounts, or negotiated rates and historical net prices for prescription drugs: This will depend on the type of file (in-network amounts for the In-Network Rate File, allowed amounts and historical billed charges for the Allowed Amount File, or negotiated rates and historical net prices for the Prescription Drug File). For all MRFs, the specific pricing information within each file must be associated with the provider’s national provider identifier, tax identification number and a Place of Service Code, although the provider’s name is not required to be included. Historical payments must have a minimum of 20 entries to protect consumer privacy.

Timing:?Plans and issuers must update the information required to be included in each MRF on a monthly basis to ensure it remains accurate and must clearly indicate the date the files were most recently updated.

For the full Compliance Bulletin on transparency with MRF's please email [email protected]

Implications to adding Abortion Riders back to your Plan

Consult with Legal Counsel

We are seeing carriers begin to roll out Reproductive Travel Riders in Massachusetts. For the carrieres that have it available, there is an attestation to complete and a member reimbursement form for those employees that may live in states where abortion is still illegal and need to travel for care. HOWEVER...?

If the plan is sitused in a state that does not prohibit abortions or coverage for abortions, but a participant lives in a state that has a prohibition on abortions, then the state law would have to be evaluated, but it may be possible for the plan to cover abortions and travel for such abortions performed outside the state where the participant resides.

Some carriers who insure plans in states where abortion is legal are requesting the state insurance agencies to approve riders for employers to add travel benefits for participants who reside in states where abortion may be illegal or unavailable. This does not absolve the employer of needing to meet and understand the criminal implications, if any, for allowing participants to travel outside their state to obtain abortions, and it is likely the carriers will ask employers to indemnify them.

Conclusion

While there are several options for employers, each option requires careful evaluation of any applicable state law, which varies among the states that limit or prohibit abortions. Employers should work with experienced counsel when determining the best approach for their employees so as to understand all potential civil, criminal, or insurance law implications, and avoid any potential legal, unintended consequences to the company or its employees.

Please reach out for entire Legal Notice from our partners at Barrow Weatherhead Lent LLP. If you do not have legal counsel, myself or the RG Team can connect you with an ERISA attorney that can explain implications for adding this rider to your plan.