Health Plan Price Transparency Rules and Regulations
In an effort to promote healthcare price transparency in the United States, federal agencies have issued new regulations that impose compliance mandates on health insurers and employer-sponsored group health plans. Group health plans are subject to:
- Transparency in Coverage Rule: A provision of the Patient Protection and Affordable Care Act, this rule aims to lower healthcare costs by requiring plans to disclose their rates and other price information for all covered billable services.
- Consolidated Appropriations Act, 2021 (CAA): The CAA imposes a variety of transparency-related requirements on group health plans, such as no gag clauses, continuity of care, provider directory consumer protections, and the upcoming prescription, medical, wellness and premium data submission requirement, also referred to as RxDC.
These laws and regulations have bipartisan support, and it is expected that future administrations will continue implementing health plan price transparency legislation.
What Are the Transparency Requirements for Group Health Plans?
While fully-insured plans can assign responsibility to insurers, self-insured group health plans are directly responsible for compliance and face significant penalties for failures. Group health plans are required to:
Publish Machine-Readable Files (MRFs)Plans must post MRFs on a public website disclosing:
- In-network negotiated rates with providers
- Out-of-network allowed amounts
- Prescription drug prices (Note: the prescription drug file has been delayed indefinitely)
Create an Online Price Comparison ToolPlans must provide an online price comparison tool for plan participants to determine the cost of medical items, services and prescription drugs.
Comply With Other Transparency ProvisionsPlans must comply with other transparency requirements under CAA and the No Surprises Act that become applicable for plan years beginning in 2022.
How Can Aon Help Employers Prepare for Health Plan Price Transparency?
To help organizations comply with employer group health insurance requirements, Aon developed the Health Plan Transparency Hub and Toolkit. It includes:
Customized Website and Support
If an employer is required to post MRFs and/or would like to demonstrate compliance with all links in one place, Aon can host an employer-specific website with applicable logos. This support includes:
- Coordinating with vendors to receive links to MRFs posted on the public website.
- Updating the links to ensure full disclosure and compliance when there are changes to a medical third-party administrator (TPA) or plan benefits.
- Maintaining a monthly log to track whether MRFs are accessible and populated.
We provide a tailored timeline of when transparency provisions apply to an employer’s plans.
Our detailed checklist helps ensure the completion of all transparency-related compliance tasks.
The comprehensive and straightforward reference guide has legal citations that walk through the details of these requirements.
Sample Contracts and Communications
Aon provides sample contract language for the employer’s legal counsel and a summary of material modification to communicate applicable changes to participants.
We offer ongoing technical support from Aon’s legal consultants, actuaries and technology specialists through webinars, Q&A sessions and community information sharing.
Guidance on Evolving Regulations and Guidance
Requirements are still changing, and the Toolkit will be updated as federal agencies release new guidance and TPAs implement the requirements.