The Affordable Care Act contains broad provisions requiring health insurers and group health plans to make substantial amounts of information available to the public to facilitate transparency in health care pricing, and several recent Executive Orders have also focused on the availability of health pricing information. In 2020, under the authority of the Affordable Care Act, the Departments of Health and Human Services, Labor, and the Treasury issued transparency in coverage regulations (often referred to as the “TiC Rules”), which require most health plans and health insurance issuers in the group and individual markets (“Plans and Issuers”) to publicly disclose health plan pricing and cost sharing information. The first deadline under the TiC Rules was originally set for January 1, 2022, but was delayed to July 1, 2022 in part due to the enactment of the Consolidated Appropriation Act (which contained additional, and somewhat overlapping, transparency in coverage rules).
Specifically, by July 1, 2022, the TiC rules require that each Plan and Issuer make two “machine readable files” (or “MRFs”) of pricing information available on its public website. Generally speaking, the MRFs that must be available must include (1) the payment rates negotiated between plans or issuers and providers for all covered items and services (the “In-Network File”), and (2) the unique amounts a plan or issuer allowed, as well as the associated billed charged for covered items or services furnished by out-of-network providers during a specified time period (the “Out-of-Network File”). (The deadline for a third file, which must contain pricing information for prescription drugs, was originally January 1, 2022, and has been extended indefinitely pending coordination with similar requirements under the Consolidated Appropriations Act.) Plans and Issuers are not required to disclose information that would violate health privacy laws. The MRFs must be updated monthly and clearly note the date they were last updated. The MRFs must be in a non-proprietary, open-standards format that is “platform independent” and available to the public without restrictions that would impede re-use, such as a JSON file. Microsoft Word, Microsoft Excel, and PDF files are not acceptable because they are proprietary formats.
Group health plans have historically been able to satisfy many disclosure obligations through hard copy distributions, intranet postings and e-mails. That is not an option for the MRFs (though a paper form must be available on request). Each of the MRFs must be available to the public on a website without any access limitations—an individual may not be required to create a user account, password, or other credentials to access the MRFs. This means that a plan sponsor’s intranet is not an acceptable location for the MRFs.
In addition, while the rules permit a Plan or Issuer to contract with a third party to post the MRFs, the Plan or Issuer is still required to provide a link on “its own public website” to the MRFs. This most commonly arises when the third party administrator (TPA) has agreed to prepare, update, and host the MRFs for a self-insured plan. Simply having the MRFs available on a TPA’s website is not adequate. Rather, the “plan’s” public-facing website (or, presumably, the plan sponsor’s public-facing website) must contain a link to the MRFs.
If you have questions about these or any of the transparency in coverage requirements, contact a member of Mayer Brown’s Employee Benefits team.