Federal Agencies Adopt Rule Mandating Health Plan Price Transparency
By Joey Berlin

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A number of health plans will be required to be more transparent about coverage pricing starting in early 2021 after the recent adoption of a rule by three federal agencies.

The final rule will require most health plans that came into existence after passage of the Affordable Care Act to provide “personalized out-of-pocket cost information, and the underlying negotiated rates, for all covered health care items and services, including prescription drugs, through an internet-based self-service tool and in paper form upon request,” CMS said in a fact sheet on the changes.

The rule takes effect Jan. 11. Initially, plans that begin on or after Jan. 1, 2023, will be required to have the internet self-service tool display a list of 500 “shoppable services,” as determined by the three agencies: the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury.

The same price transparency rules for all other items and services will be required for plan years that begin on or after Jan. 1, 2024.

For plan years beginning on or after the first day of 2022, the same plans also will be required to disclose several pieces of “detailed pricing information” in three files posted on the internet:

  • In-network negotiated rates for physicians and other health care professionals;
  • Historical out-of-network allowed amounts, including payments to and billed charges from out-of-network physicians and other health care professionals; and
  • In-network negotiated rates and historical net prices for all covered prescription drugs.

Posting those files will allow the public “to have access to health coverage information that can be used to understand health care pricing and potentially dampen the rise in health care spending,” said the rule summary in the Nov. 12 Federal Register. Plans must update the three files monthly.

CMS recently adopted a similar rule mandating certain price transparency requirements for hospitals. That rule survived a court challenge earlier this year and will go into effect Jan. 1, 2021.

Last Updated On

November 24, 2020

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Joey Berlin

Associate Editor

(512) 370-1393
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Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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