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CMS Proposed Rule on Transparency in Coverage Issued

The Centers for Medicare & Medicaid Service (CMS) — along with the Departments of Labor and Treasury — has issued a proposed rule that would establish a number of new price transparency requirements for health plans. The proposed rule is intended to build on newly finalized price transparency requirements for hospitals and reflects President Trump’s June 24 executive order.

The proposed rule would apply to non-grandfathered group health plans (those not in existence prior to passage of the Affordable Care Act) and health insurers offering non-grandfathered health plans in the individual and group markets. Specifically, the proposed rule would require these plans to:

  • Make available to participants, beneficiaries, and enrollees personalized out-of-pocket cost information for all covered health care items and services through an internet-based self-service tool and in paper form, upon request.
  • ​Make available to the public — including stakeholders such as consumers, researchers, employers, and third-party developers — the in-network negotiated rates with their network providers and historical payments of allowed amounts to out-of-network providers through standardized, regularly updated machine-readable files.

In addition, CMS proposes changes to medical loss ratio (MLR) requirements that would allow issuers offering plans that incentivize enrollees to shop for services from lower-cost, high-value providers to “share savings” in their MLR calculations.

The proposed rule also seeks comments on whether plans should be required to make cost-sharing information available through a standards-based application programming interface, and on how health care quality information could be incorporated into the price transparency information made available under the proposal.

CMS proposes that the health plan price transparency requirements would be effective one year following publication of a final rule. The MLR provision would be effective beginning with the 2020 MLR reporting year. More information is available in a CMS fact sheet.​


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