Transparency in Coverage Rules
What is Transparency in Coverage?
Transparency in Coverage rules require health insurance carriers and health plans to publicly publish large amounts of healthcare data using a Machine-Readable File (MRF) format. This format permits anyone in the U.S. with a “machine” (computer) to read the files without requiring special software, formatting, passwords, or other identifying information. The purpose is twofold:
- To provide historical cost data on in-network and out-of-network care to consumers and;
- To allow researchers, regulators, data aggregators, and IT specialists to analyze this information and even create apps that allow consumers to understand their healthcare costs.
Why is Transparency in Coverage Important?
To create a standard so consumers, providers and facilities can understand healthcare pricing and shopping. The first step in this process requires data, i.e., the Machine-Readable File data. The files must separately contain information on:
- In-network negotiated rates for covered items and services
- Historical payments and billed charges from out-of-network providers
- Pharmacy information (this requirement is delayed until further notice)
Which party, the carrier or the health plan (employer), is responsible for posting and maintaining the files?
The responsibility for posting and maintaining the files may differ among fully insured plans and self-insured health plans. Below is the latest guidance, which is subject to change, and is not intended as legal or tax advice.
TIC Process By Plan Type
Fully Insured Health Plans:
If the issuer (carrier) includes in their agreements that they will host the files, the group does not need to publicly post a link to the files on their employer website unless the carrier requests it. For example, Cigna is asking all fully insured plans to publicly post the link on the employer’s website.
Self-Insured Health Plans:
A self-funded health plan should post the link to any third-party administrator files on their public employer website, as the plan/employer are considered the issuer of coverage.
Note: If a self-funded plan is “unbundled,” and utilizes separate vendors for services under the plan (i.e., separate vendors for pharmacy benefit management, employee assistance programs, or health plan benefits), then the plan must post those separate vendor links or host the files themselves.
In posting a link to the carrier/vendor site, please consider using language such as: "This link leads to the machine-readable files that are made available in response to the federal Transparency in Coverage Rule. The machine-readable files are formatted to provide access to the public, including consumers, researchers, regulators, and application developers to access and analyze the data."
Below is the current information we have received from each carrier, and we will continue to update this page on a regular basis as information becomes available.
Carrier Machine-Readable File Links
Trustmark will provide each client a link to a table of contents containing the applicable MRFs for their plans. Plan Sponsors should then post the link on their public website.
BLUE CROSS BLUE SHIELD NORTH CAROLINA
Information included on this page is not intended to be tax or legal advice. Information provided is for illustrative purposes only. Please refer to your legal counsel for any questions related to your specific situation.
Filed Under: Benefits Briefs