Flash Summary: Final Price Transparency Rules for Health Plans
Just shy of a year since the proposed rules were announced, the Trump administration today shared the final version of health plan price transparency mandates (CMS-9915-F) that, among other new requirements, insists that private insurers post real-time, personalized cost estimates for members.
The full document is 556 pages, so we are still reviewing, but have an initial high-level summary and insights.
- The first requirement is for three machine-readable files will be required for plans effective on Jan. 1, 2022.
- Negotiated rates for all covered items and services, for in-network providers
- Historical OON billed amounts and payments, subject to minimum payment volumes for privacy protection
- Historical and negotiated rates for prescription drugs per pharmacy
- Secondly, starting on Jan. 1, 2023, plans will need on demand (online and paper) price transparency.
- Needs to be personalized, and include out-of-pocket (OOP) estimates
- Year one needs to cover 500 defined shoppable services and by Jan. 1, 2024, needs to expand to all services
- Must show negotiated rates even if those rates are not the basis for determining OOP
- Needs to include prescription drug transparency
We’re gratified that CMS considered industry feedback to focus on shoppable services. While that focused scope is only in the first year, it will give plans and transparency leaders like HealthSparq time and experience to provide context and guidance for consumers on how to understand this information.
HealthSparq’s Price Transparency Solution is Poised to Meet the New Rules
HealthSparq is well positioned to help plans meet these mandates. We’ve been helping our clients with transparency for many years. The rule even recognizes that many health plans already offer these kinds of tools, but that consumers aren’t aware. They “strongly encourage plans and issuers to develop educational and outreach materials to promote awareness that self-service tools exist, where to find them on the plan’s or issuer’s website, how to use the tool.” We agree.
The new rules outline a few areas, like machine-readable requirements that will require some modifications, but we are already providing the personalized cost estimates to health plan members. We’re reviewing the list of 500 services now, and already provide estimates for the vast majority of them in our core product. One example of changes HealthSparq will make to our offering is to show negotiated rates even if they’re not the basis for the OOP estimate. This is a minor change and is in line with what we were expecting to support. We will begin working with our plans to determine the best means of obtaining this data for use in the experience.
We are strongly supportive of the goals these rules are meant to accomplish. And now we know the final details of the floor these rules establish. These rules provide a foundation to evolve our transparency solution and continue to support helping people make smarter health care choices.