On April 19, 2022, the DOL issued Part 53 of a series of FAQs concerning the ACA. Specifically, the FAQs cover the requirement under the Transparency in Coverage Rule (the Rule) to provide certain disclosures in machine-readable files.
The Departments of HHS, Treasury and Labor (the departments) promulgated the Rule on October 29, 2020. The Rule imposes new cost-sharing and pricing disclosure requirements upon group health plans and health insurers. Among other requirements, non-grandfathered group health plans and health insurance issuers offering non-grandfathered coverage must disclose, on a public website, information regarding in-network rates for covered items and services and out-of-network allowed amounts and billed charges for covered items and services in two separate machine-readable files. This requirement applies to plan years beginning on or after January 1, 2022, although the departments will defer enforcement of the requirements related to machine-readable files disclosing in-network and out-of-network data until July 1, 2022.
The departments have a framework that plans or issuers may use to disclose required information in a machine-readable format (a 'schema'). The FAQS cover situations when plans or issuers enter arrangements with providers that do not fit neatly into the schema, or do not provide the information the schema accounts for.
- [FAQ#1] Plans or issuers may enter contracts with in-network providers in which they agree to pay those in-network providers a percentage of billed charges. However, plans and issuers may not be able to assign a dollar amount to an item or service before the provider generates a bill pursuant to such arrangements. When disclosing those rates, plans and issuers may report a percentage number rather than a dollar amount.
- [FAQ#2] Plans or issuers may have arrangements with providers that the schema does not support, or they may have arrangements that require more information in order to describe them. Plans and issuers may disclose in an open text field a description of the formula, variables, methodology, or other information necessary to understand the arrangement.
Group health plan sponsors should be aware of this update and should work with their insurers and/or third-party administrators to ensure the machine-readable file disclosures are timely posted in accordance with applicable guidance.