CMS Releases Proposed Price Transparency Rules for Payers: An Initial Take

New proposed rules for insurers were released today by the Centers for Medicare & Medicaid Services (CMS) designed, in large part, to increase price transparency.

Our core business is delivering provider directories and cost estimation solutions to health plans that empower people to make smarter health care choices and have more control over their health care costs. We are reviewing the proposed rules to assess exactly how we will ensure our clients meet these mandates. You can access the complete (221 pages!) proposal here. We fully support efforts to deliver greater transparency to people using the health care system.

Already Meeting Proposed Rules

Our HealthSparq One® out-of-pocket cost transparency capabilities in their existing form appear to already meet the proposed rules stating that consumers must have access to “personalized out-of-pocket cost information for all covered health care items and services through an internet-based self-service tool.” This allows people to “shop and compare costs for health care before receiving care,” using descriptive terms and billing codes, with quality care information, and based on their unique insurance benefit design and deductible status. We can even help payers deliver this valuable information to providers, who can then share the information with patients as they develop treatment plans.

There is also language focused on incentivizing consumers to shop for care and select lower-cost, high-value providers. Earlier this year,  the State of Virginia announced the creation of a regulatory framework around health plan sponsored cost comparison incentive programs and now we see CMS proposing a framework for health plans to financially incent members to shop for lower cost care. Our HealthSparq Rewards solution – a shopping incentive program that overlays our cost transparency offering – already meets the Virginia state regulations, and based on our initial review of the CMS proposed rules, those as well. Additionally, it appears that payments under these incentive programs will not negatively impact MLR calculations.

New Areas of Focus

The proposal also states that insurers “would be required to 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.” The inclusion of out-of-network cost data would be a new undertaking for us, and we are evaluating these new rules.  However, as with our already announced FHIR-based interoperability API services, we will be strongly advocating for the development of FHIR standards for these. We are actively involved in HL7’s Da Vinci working group on price transparency.

Finally, the inclusion of prescription price transparency is an important one. It is a capability we offer today, with our partner MedSavvy, and will be exploring the rules in more detail.

Comments are due to CMS within the next 60 days. Please reach out to me with your thoughts on the proposed rules. We’d like to hear about your planned comments or questions on working with HealthSparq to address these rules.