Health Plan Price Transparency Rules and Regulations
In an effort to promote healthcare price transparency in the United States, federal agencies have issued 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 Prescription Drug Data Collection (RxDC) submission requirement.
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
Submit Information About Prescription Drugs and Healthcare SpendingAs part of RxDC, multiple data files must be submitted annually by plans to the Centers for Medicare & Medicaid Services, including:
- One file with premium/premium equivalent data
- One file with medical spending by category
- Six files with various prescription drug data elements
Comply With Other Transparency ProvisionsAdditional transparency requirements, including an online price comparison tool, will continue to roll out in the coming years.
How Can Aon Help Employers Prepare for Health Plan Price Transparency?
To help organizations fulfill the employer group health insurance requirements, Aon developed two health plan price transparency solutions to simplify the process and ensure compliance with the regulations.
Annual RxDC Submission Support
Overall Project Management
We provide oversight of the annual RxDC submission with all applicable current and termed vendors to facilitate and document timely submission of required reports.
Preparation and Submission
When applicable, Aon experts will populate and submit your premium & life years data file (D1) and plan information data file (P2), as well as the appropriate narrative responses.
Sample Contract Language
We provide sample contract language for your legal counsel to use with your medical third-party administrator (TPA) and pharmacy benefit manager.
Additional Support and Guidance
In more complex plan structure situations, Aon will deliver you additional support and guidance through an expert team.
Health Plan Transparency Hub and Toolkit
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.
With our support, employers can focus on their core business while Aon experts manage their health plan price transparency requirements.
To learn more about health plan price transparency rules and regulations, and how Aon can help your organization, please contact our team.