Transparency in Coverage
In November 2020, the Federal Government finalized the Transparency in Coverage Rule. This rule is a historic step toward empowering consumers with the important information they need to make informed healthcare decisions. With this new rule, you will have the tools needed to access pricing information through your health plan.
The Transparency in Coverage Rule requires most group health plans and insurers to disclose price and cost-sharing information to participants, beneficiaries, and enrollees. You will be able to get accurate, real-time estimates of cost-sharing liability for healthcare items and services from different providers. This will help you to better understand how costs for covered health care items and services are determined by your plan and to shop and compare health care costs before choosing to receive care.
Under the new rule, health insurers and group health plans are required to provide cost-sharing information in two ways:
- Machine-readable files — Beginning January 1, 2023, and updated monthly thereafter, Meritain Health will publish two sets of data in machine-readable files: 1) pricing information for covered items and services based on in-network negotiated payment rates and 2) historical out-of-network allowed amounts.
- Consumer price transparency tool — Health insurers and group health plans are required to create online cost estimator tools that provide personalized, real-time information regarding members’ cost-sharing responsibilities for covered items and services. Cost-share estimates for 500 shoppable services will be available for plan years beginning on or after Jan. 1, 2023, and estimates for all covered services will be available for plan years beginning on or after Jan. 1, 2024. At that time, paper versions will also be available upon request.
Machine-Readable Files: Key Points
Health insurers and plans are required to provide cost-sharing information in the form of machine-readable files, which must be published and updated monthly and obey the following requirements:
- Machine-readable files must be available on an internet website free of charge.
- Users are not required to create an account, password, or other credentials.
- Users are not required to submit any personal identifying information such as a name, email address, or telephone number.
- In-network machine-readable files include negotiated rates for all covered items and services at the plan level, for all medical codes, for contracted rates, and by provider.
- Out-of-network machine-readable files include allowed amounts for covered items, services based on billed charges, and allowed amounts including historical amounts.
- Pricing data with fewer than 20 rows per provider per billing modifier are excluded.
Meritain Health creates and publishes files where everyone will have access to the data. KPI’s publicly available website is:
These files are updated on a monthly basis.
Price Transparency Tool: Key Points
Health insurers and plans are required to make a price transparency tool that gives members the ability to access real-time estimates of their cost-sharing liability for healthcare items and services from different providers. The tool is required to:
- Allow members to understand how costs for covered health care items and services are determined by their plan.
- Allow members to search based on billing code or description.
- Allow members to compare costs between in-network and out-of-network providers.
- Inform members of any accumulated deductible or other out-of-pocket costs.
- Identify factors that affect cost, such as service location or drug dosage.
- The data must be available through an internet-based self-service tool.
- A paper form of the estimate must be available through customer service.
The price transparency tool is required to make available personalized out-of-pocket cost information as well as the underlying negotiated rates and allowed amounts for all covered healthcare items and services. This tool is available through the Meritain Health Member portal under the Tools & Resources section.