Recently, HHS, IRS, and DOL issued proposed regulations that, if finalized, will substantially expand the health care pricing information that group health plans must make available to both plan participants and the public. Specifically, the agencies propose the following:

Participant cost-sharing information 

• Self-insured and insured group health plans must provide plan participants and beneficiaries with cost-sharing information in advance, including (but not limited to):
• Estimated deductibles, coinsurance, and copayment amounts for covered medical services, medications, and medical devices, at the provider level;
• Amounts accrued to individuals’ deductibles, out-of-pocket maximums, and treatment limits;
• Negotiated rates—expressed as a dollar amount—that form the basis for participants’ coinsurance and deductible obligations;
• Maximum out-of-network allowed amounts for items and services furnished by out-of-network providers, including participants’ cost-sharing liabilities; and
• Items and services included in bundled payments. 

Public disclosure of negotiated rates

Self-insured and insured group health plans must make public, in an electronic format, their in-network negotiated rates and historical allowed amounts for covered items and services furnished by out-of-network providers. This information must be updated on a monthly basis and include:

• Names and identifiers for each group health plan or plan option;
• Billing codes for all covered items and services, at the provider level; and
• Out-of-network allowed amounts for all covered items and services, at the provider level.

Specific proposals for data that plans must make public are available here and here. For now, the regulations anticipate that for capitation, ACO, or direct contracting arrangements, group health plans will need to disclose at least participant cost-sharing amounts. More details will be available at a later date.

What happens next?

In the coming weeks and months, the agencies will consider comments from the public and continue to develop guidance on the format and content of the above disclosures. Specifically:

• The comment period is slated to close on January 14, 2020. The Business Group will submit comments and welcomes input from members.
• After the comment period closes, the agencies will finalize the regulations.
• The agencies propose that these requirements go into effect for the plan year beginning 1 year after the agencies issue final regulations.

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Articles & Guides Coverage Expansion Compliance