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On November 12, 2020, the U.S. Departments of Health and Human Services (HHS), Labor and Treasury issued a Final Rule called Transparency in Coverage (the Rule). The Rule is intended to enable the public to have access to health coverage information that can be used to understand health care pricing. This would potentially enhance market competition and lower health care costs.

At a high level, the Rule requires certain health plans to:

• Make select rate and pricing information available through machine-readable files on July 1, 2022.
   
• Provide members with personalized costs, by service, including estimates of out-of-pocket (OOP) costs starting January 1, 2023.

Yes. The Rule does not apply to:

• Medicare Advantage plans
• Medicare Supplement plans
• Medicaid MCO coverage
• Vision- or dental-only plans
• Grandfathered health plans
• Short-term, limited-duration insurance

Group account customers should consult with their legal counsel to determine if their health plan is excluded from the Rule.

There is a three-year, phased approach for affected health plans and issuers to comply with the Rule.

Plans and issuers must provide:

• Public access to the machine-readable files for plan (or policy) years that begin on or after July 1, 2022.
   
• Cost information to members for 500 specified items and services for plan (or policy) years that begin on or after January 1, 2023.
   
• Cost information to members for all covered items and services for plan (or policy) years that begin on or after January 1, 2024.

The Rule is intended to accomplish two things:

1. Disclose the following information to the public through standardized machine-readable files, which will be updated on a monthly basis:
   • In-network (INN) provider negotiated rates
   • Historical out-of-network (OON) allowed amounts and billed charges

   The historical data must reflect the 90-day period that begins 180 days prior to the publication of the machine-readable files.

2. Disclose cost information upon request from members, including an estimate of the member’s cost for covered medical items or services, as well as prescription medicines. This information can be provided through an online tool and if requested, on paper within two business days.

The Rule applies to:

• Fully insured commercial market individual and group health plans
• Self-insured health plans
• Qualified Health Plans (QHP)
• Federal Employees Health Benefits Program