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Are You Ready for Transparency in Coverage Compliance?

By: Kaitlyn MacLeod, Esq.

Enforcement is almost here for one of the most cumbersome of the Transparency in Coverage obligations.

That’s right – plans need to post their Machine-Readable Files on a publicly available website beginning July 1st. Technically, this requirement went into effect on January 1st, but enforcement has been delayed until the summer. Non-grandfathered group health plans must publicly disclose information on in-network provider rates as well as out-of-network allowed amounts and billed charges for covered items and services. This requirement applies to all plan years that begin on or after January 1, 2022.

The enforcement date for the third Machine-Readable File on negotiated rates and historical net prices for covered prescription drugs has not yet been announced.

We’ve had a lot of questions popping up about these new compliance obligations and we’re here to set the record straight.

Can we post the Machine-Readable Files on our Member Portal?

No. These files must be publicly available – meaning that they cannot be behind a member login or paywall of any kind. The purpose of the public posting requirement is to keep consumers informed about their pricing options before they join a plan as well as once they enrolled.

Can groups host the actual Machine-Readable Files on the TPA’s Website?

So long as the plan posts a link on their own company website linking to the TPA’s webpage, this is allowable under the Allowed Amounts File rules. The rules are silent for the other two machine-readable files, but we recommend at the very least including the links to the publicly hosted files on the company’s own website.

What if the group doesn’t have at least 20 claims per type of service/item for the Allowed Amounts file?

The group still has to provide the Allowed Amounts file for all allowed amounts that do meet the 20 claims per type of service or item. If the item or service does not have at least 20 claims, the file will need to note that that service or item did not meet the threshold under the law to be reported.

If the group doesn’t have any services or items that meet the 20 claims threshold – the group still needs to provide a publicly available file noting that no services or items met the threshold.

What if the group has Multiple Network Vendors?

The plan must provide access to an in-network Machine-Readable File that contains information from all networks available under the plan. The plan can choose to either provide a URL linking to the external provider network file or include the various networks’ data in one Table of Contents file. Both of these options have particular requirements in their set up and we recommend referencing the CMS Technical Clarification for further details.

If you have any further questions on the Transparency in Coverage requirements, we are here to help. Contact us at pgcreferral@phiagroup.com.