In October 2020, the Health and Human Services, Labor and Treasury Departments (the Departments) finalized the Transparency in Coverage (TIC) rules. These rules arm healthcare consumers with pricing and quality information, empowering them to make informed decisions about their medical care. Before the July 1, 2022 enforcement date, plan sponsors should coordinate participant communications and informational access with insurance carriers and third-party administrators.
What are the Transparency in Coverage Rules? The TIC rules require public and plan participant disclosures about health care services. Over the next few years, these rules will be implemented in phases that start with public posting of pricing data and progress to personalized access to coverage costs for individual plan members.
What are the Public Disclosure Requirements? To follow the Public Disclosure phase by July 1, 2022, plans and insurance carriers must produce two files—one to disclose in-network provider rates for covered services and another to show out-of-network allowed amounts and billed charges. Both files must be “machine-readable,” conforming to a non-proprietary, open standard format (such as XML) and made available via HTTPS. Formats such as PDF or DOCX are not acceptable according to the TIC Rules. Plan sponsors should confirm the formats and availability of these files with carriers and administrators who host this information.
The Public Disclosure phase of the TIC rules, requires health plans and insurance carriers to make the following electronic file information available to the public:
- In-network provider negotiated rates for all covered items and services;
- Historical data that shows both billed and allowed amounts for all covered items and services set by out-of-network providers, including prescription drugs, and
- Negotiated rates and historical net prices for prescription drugs set by in-network providers.
What are the Plan Participant Disclosure Requirements? By January 1, 2023, health plans and carriers must supply the following detail for 500 shoppable services, such as lab tests, imaging services, elective surgical procedures and preventative screenings such as dexascans, colonoscopies and mammograms:
- Estimated cost-sharing: How much a patient is expected to pay for an item or service;
- Accumulated amounts: How much a patient has contributed to their deductible and out-of-pocket maximum, in addition to how close they are to any treatment limitations;
- Negotiated rates: The dollar amount a plan or issuer has agreed to pay an in-network provider for an item, service, or prescription, in addition to underlying fee schedules;
- Out-of-network allowed amount: The maximum amount (or a best estimate) that a plan or issuer will pay for an out-of-network item or service;
- Items and services list: Everything that’s covered in a bundled payment agreement;
- Coverage prerequisites: A notice alerting patients to the fact that a certain item or service requires a prerequisite, such as a prior authorization or step therapy, and
- Disclosure notices: Notices must include balance billing details, a disclaimer about the difference between actual and estimated charges, and whether or not co-payment assistance and other third-party payments are included in calculations for a patient’s deductible and out-of-pocket maximums.
What will Plans and Carriers do for Participants in 2024? The final phase of the TIC Rules, beginning January 1, 2024 will allow plan participants to view the above-mentioned cost details, for all items and services (in addition to the 500 original services already mentioned), via an online self-service tool and, if requested, paper format.
Please do not hesitate to contact your Salus Group team member if you have questions regarding TIC Rules.