Watch the Replay: Making Care Costs Clear – Price Transparency Mandate

While our industry has been providing price transparency for years, the Transparency in Coverage rule mandates a new experience for commercial health plans. Our AHIP webinar last week, “Making Care Costs Clear Beyond Price Transparency Mandates,” shared not only details on the rule, but the gap between mandate and what people really need.

During the session, our audience poll highlighted the fact that many plans are just getting started or still reviewing the rule, with 75% of respondents falling into that category. To address where plans are today in their preparation, our experts walked through what’s included, but also what’s missing from the final rule, and our special guest from Capital BlueCross offered tips on how to get started.

Understanding the rule

While the rule document is quite long and has a lot more detail, it really boils down to a couple of requirements—showing data to the public and providing personalized data for members.

  • Publicly available data. Plans must provide data through three machine readable files. The files include negotiated rates for all covered items and services, for in-network providers, historical out-of-network billed amounts and payments (subject to minimum payment volumes for privacy protection), and prescription drugs rates for in-network providers and pharmacies. This requirement starts January 1, 2022.
  • Member-only disclosures. The rule requires online, self-service access to personalized information on member cost-sharing liability, including the amount someone is responsible paying for, including deductibles, co-insurance and co-payments, for covered items and services. Plans must provide this information online and via print for 500 items and services starting no later than January 1, 2023, and for all covered items and services starting January 1, 2024.

At the end of 2020, Congress also passed the long anticipated No Surprises Act. This legislation has requirements for plans for price transparency resources starting January 1, 2022. As the rules get established for these requirements, plans will need to adjust accordingly.

What members really need

Giving people access to personalized pricing information is something HealthSparq has specialized in for many years. People deserve to know what their care will cost. At the same time, people don’t want to “shop” for health care. Health care is confusing, even for those of us in the business. That’s why we need to make it easy for members to access the information they need.

How easy? People have high expectations for ease of use based on other online resources they use every day. In January 2021, we surveyed more than 1,000 consumers and 9 out of 10 of them they agreed that comparing prices of health care services should be as simple as comparing prices in retail. Plus, about the same amount of people want help saving on care and say that should be as easy as saving on groceries.

How plans can get ready to comply

Given that most plans are in the early phase of preparation, Tammy Little from Capital BlueCross shared insights on what her organization is doing to prepare for compliance. She noted how her team realized that “price transparency with the mandate is not something new–we already have the foundation for it. We’re just building on that.” Her advice to other plans is to “start thinking about member engagement and making it usable for members.”

She notes that people want to save, but they don’t always know HOW to save, so Capital BlueCross wants members to have more control over their care. They are providing HealthSparq One to members so they can not only search for procedure-level costs, but also plan for more complex care, like surgery. The plan also started taking advantage of the recommended medical loss ratio (MLR) credit with their launch of HealthSparq Rewards in 2020. In the rule, the government recommends plans share the savings from cost-effective providers used by members and is allowing this kind of financial incentive program to be credited in their MLR.

While your team may be focused on the specific of the mandate, it is important to remember that members need more than billing code search capabilities. They need guidance to understand what is relevant in their care and the best options. Watch the webinar to learn more. And reach out to chat with our price transparency experts to get started on going beyond the mandate.