Transparency in Coverage (& Pricing) – checking in on payer response

Transparency in Coverage (& Pricing) – checking in on payer response

Friday July 1, 2022 was the implementation date for a key part of CMS-9915-F Transparency in Coverage (TiC), a Final Rule issued jointly by multiple government agencies: IRS, DOL, CMS and HHS. If you aren’t already familiar with that rule, I’ve provided a high-level summary below and there are plenty of excellent explainers available elsewhere. The primary focus of this article is a review of how payers have (or have not) begun to comply with the requirements.

Who, What Where, How: Phase 1 Requirement under TiC Rule

• Why: Lower costs by making payer-provider rates transparent
• Who: Individual, Group, and Self-insured medical plans
• What: Payment rates for all services for ALL in-network providers AND “out of network” allowed amounts and historical billed charges from out of network providers. This data is mapped to the specific provider NPI and EIN; services and items are designated by code and description (CPT?, HCPCS, DRG, APC, NDC, etc.)
• How: Machine Readable Files (JSON, XML) downloadable without any kind of log in
• Where: On each individual payer’s website*

*While this rule is a huge step, requiring payers to publish the data on their own websites, instead of requiring them to report to CMS (the way Medicare Administrative Contractors do with Local Coverage Determinations and Articles, as providers are required to do with quality data) means that gathering and making meaning out of this data will be a SIGNIFICANT project. If you are curious, CMS says that they will enforce this, and can impose corrective actions and civil money penalty of $100 per day for failure to meet, so the teeth on this are NOT sharp.

Where: Payer Website Publication of Machine Readable Files

So, let’s do a quick check in on how top payers are doing with meeting this deadline. I haven’t taken the time to open and explore each file, but I have confirmed publication of the file and that the basic index/table of contents makes sense. The table below is a snapshot from 7/1/2022.

??How: Sample Screenshots

If you go to explore these files, you will find a wide variance in how payers have attempted to meet (and may be failing to meet) this requirement. Here are some screenshots from early in July 2022, including viewing the source JSON code and an example of allowable amounts converted to XLS for a tiny sample.

Who: Overview of Individual, Group Medical Plans, and Self-insured medical plans

• Rule applies to: Health insurance issuers in the individual and group market: Fully insured group health plans, self-funded individual plans, Qualified Health Plan (QHP) issuers, and the Federal Employees Health Benefits Program.
• The rule does not apply to: Medicare Advantage, Medicare Supplement, Medicaid MCO coverage, plans that offer only dental or vision insurance.

?According to the Covered Lives data available from Policy Reporter as of 7/1/2022, this rule impacts over 150M covered lives, and the top payers with the plan types required to meet TiC rules are the big payers you would expect: United Healthcare, Anthem, Aetna, HCSC, Cigna, Kaiser Permanente and the big Blues (Illinois, Texas, Michigan and the Federal Employee plan).

What: Transparency in Coverage Regulatory Requirement

This is NOT meant to be an exhaustive regulatory review, but here is a high level view through the lens of considering the impact of TiC on professionals who need payer intelligence.

Friday July 1, 2022 was the implementation date for a key part of CMS-9915-F Transparency in Coverage (TiC), a Final Rule issued jointly by multiple government agencies: IRS, DOL, CMS and HHS. This rule applies to specific set of medical insurance payers (see list below) and includes 2 key transparency obligations:

1 – Insurers must disclose payment rates and drug pricing information on the internet in machine-readable files (MRFs) that meet very specific formatting requirements and

2 – Insurers must disclose cost-sharing liability for services directly to enrollees in an online tool (as well as by paper or telephone if requested).

As intended, this rule should create transparent information that allows consumers to understand cost of care, make informed decisions, and enhance market competition to ultimately lower health care prices. Of course, it isn’t that simple. Because insurers create multiple plans and those plans have both in-network negotiated rates with specific sets of providers and rules for out-of-network allowed amounts, this data is voluminous and complex.

The implementation is in 3 stages: Machine Readable Files for plan began Friday July 1, 2022; Cost sharing information for 500 specified items begins on or after January 1, 2023 and cost sharing information for ALL covered items and services begins on or after January 1, 2024.

Also there have been some developments since the passage of CMS-9915-F. Most importantly, another rule issued under 2021 Consolidated Appropriations Act (CAA) mandated prescription drug reporting that was duplicative, so implementation was delayed until July 1, 2022 (from the original January 1, 2022 requirement).