Transparency in Coverage Final Rule and Other Regulatory Highlights Health Plans Need To Know

Maggie BrownOctober 30, 2020

Transparency in Coverage Final Rule

On October 29th, the Transparency in Coverage Final Rule was released and will be published in the Federal Register. We reviewed the Proposed Rule which impacts health plans, which would require health plans to provide personalized out-of-pocket cost information for all covered healthcare items and services.  This information that a health plan must post to its website includes in-network negotiated rates and out-of-network historical payment amounts using a very specific format at regular intervals. So basically, negotiated rates would be transparent to the world. Insurers that incentivize consumers by encouraging them to shop for services from lower cost and higher value providers will be allowed to use the shared savings in the MLR calculations.

The timeline of the Final Rule begins in 2022 and we will review the 500-plus page document in the next few days and begin to develop the HealthEdge Compliance Requirements and Position Statements. 

  • 2022 -Plans must post in-network negotiated provider rates, out-of-network coverage rates, and in-network drug pricing in a machine-readable format
  • 2023- Plans must offer an online shopping tool or similar platform that includes an out-of-pocket cost estimate and negotiated prices for 500 of the "most shoppable" services
  • 2024- The online shopping tool is extended to all services

The Final Rule also allows the plan to include in the numerator of the MLR any shared savings payments the issuer has made to an enrollee as a result of the enrollee choosing to obtain health care from a lower-cost, higher-value provider, beginning in the 2020 MLR reporting year.

In addition, because of the provider world's current state, specifically hospitals, some clients are concerned about the Hospital Price Transparency final rule that becomes effective January 1, 2021. Hospitals will have to put the prices of their most common services on their website. 

ONC and CMS interoperability rules

The Patient Access API and Provider Directory API will be enforced in mid-2021. 

Right now, plans are likely focused on the current member portal technology that they have and how to leverage that for the patient access and provider directory APIs—the data will be similar, but the access points will be different. Many plans are also wondering about authentication and authorization management, meaning how a plan can ensure that they are only releasing information to the correct third party under the member's consent. 

A much heavier lift for health plans will be the payer-to-payer data exchange that will be enforced in 2022. At this point, it is unlikely that plans are looking to achieve the ingestion of payer-to-payer data. They are focused on the extraction and sending of the information. The ingestion is the more complex, requiring a look at how the information will benefit the member’s care by creating a continuum that can be used to guide the member’s care decisions.

HealthEdge is currently looking at the known data requirements in CMS recommended companion guides —CARIN Alliance Blue Button® Framework and Common Payer Consumer Data Set (CPCDS) and others.  We are assessing changes to the API and monitoring future requirements to ensure all data available from our technology is in the appropriate formats for their use.  We have plans to address the business use cases for the use of the received data in early 2021.

We are in the CMS world at the moment, and these requirements will impact Impacts Medicare Advantage (MA), Medicaid, CHIP, and Qualified Health Plan (QHP) issuers on the Federally-Facilitated Exchanges (FFEs).

Information Blocking

Going hand-in-hand with interoperability, the Information Blocking final rule goes into effect on November 2, 2020. This rule prohibits health providers, technology vendors, health information exchanges, and health information networks from practices that inhibit the exchange, use, or access to electronic health information (EHI). There are some exceptions that the federal government has put into place.

Although payers may not fit neatly into any of these categories, they do hold information that interoperability is trying to put into members' hands. We will continue to monitor updates and the potential impact this rule could have on payers. 

Additional news

In other news, discussions are ongoing between the National Committee on Vital and Health Statistics' (NCVHS) and the Department of Health and Human Services on adopting a newer version of the X12N HIPAA EDI Transactions. At some point in the next few years, we can anticipate moving all of our EDI transactions to a newer version of the X12 rolls. 

The final item is the CMS Annual Enrollment Period. On November 2 and November 3, CMS will conduct its CMS-generated rollover processing, a big deal for health plans. Some health plans may hit some bumps in the road and need our immediate attention and we are ready to support our customers. 

About the Author

Maggie Brown

Maggie Brown, Regulatory Compliance Manager

Maggie Brown has over 30 years of leadership experience in healthcare and insurance marketplace. Maggie transitioned from health plan management roles to implementing core business solutions for numerous health plans around the country. With the enactment of HIPAA, the Balanced Budget Act, and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 she focused on how to ensure a health plan could implement key technology solutions, meeting the needs of their members, while being compliant in a rapidly changing regulatory environment. Maggie has led implementations for government programs at both new and established managed care companies. Maggie holds a Doctor of Religious Arts degree with a major in Pastoral Psychology.

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