May 5, 2022

 

Federal agencies had delayed enforcement of this requirement until July 1, 2022. This rule was effective with plans years beginning on, or after, January 1, 2022.

Most non-grandfathered group health plans or health insurance issuers offering non-grandfathered health insurance coverage in the individual and group markets — and self-funded plans — are required to make available to the public (including stakeholders such as consumers, researchers, employers, and third-party developers) three separate machine-readable files that include detailed pricing information.

 The data files:

  1. Must first show negotiated rates for all covered items and services between the plan or issuer and in-network providers;
  2. Must also show both the historical payments to, and billed charges from, out-of-network providers (historical payments must have a minimum of 20 entries in order to protect consumer privacy);
  3. The third file must detail the in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level. Note, this is postponed until further notice.

Self -funded plans and issuers must display these data files publicly — in a standardized format — and provide monthly updates.

What Does This Mean for Employers?

  • Employers that have yet to hear directly from their TPA or ASO will need to know their administrator’s status to provide a link for the machine-readable files by July 1.
  • Federal regulators have indicated a self-funded employer plan will satisfy the requirement if they post the TPA or ASO link to their own organizations’ public facing websites.
  • Self -funded plans are unable to create these machine-readable files and as such are totally reliant on their TPA or ASO to provide them.
  • TPAs and ASOs have indicated they will provide employers with a link to their files housing the required information.
  • A few TPA or ASO administrators recently announced their July 1 readiness to post a public link for the machine-readable files that clients may use.

Please contact your Apex account executive with questions and for more information.