The Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury jointly released the Transparency in Coverage final rule, which implements the section 1311(e)(3) of the Affordable Care Act (ACA). The rule requires group health plans and issuers offering coverage in the group and individual markets to disclose out-of-network and negotiated in-network rates with providers and post the rates online in a machine-readable format.
The rule aims to make healthcare pricing more transparent and accessible for consumers and other stakeholders, so they have the information they need to make, or assist others in making informed healthcare decisions. This excludes grandfathered plans, Medicare, Medicaid, personal funding accounts (HSAs, FSAs, and HRAs), vision-only, dental-only plans, and short-term, limited duration coverage.
This rule requires issuers and group health plans to disclose price and cost-sharing information to participants, beneficiaries, and enrollees through self-service tools.
Public machine-readable files (MRFs)
Group health plans and issuers offering coverage in the group and individual markets must make 3 separate machine-readable files available publicly, free of charge.
These 3 files must be updated monthly and include the following pricing information:
- In network: Negotiated rates with in-network providers for all covered items and services.
- Out of network: Historical billed or allowed amounts for out-of-network providers. Files and disclosures are not required for particular provider, item, or service. combinations with less than 20 claims under a single plan or coverage during the reporting period.
- Prescription drugs: In-network negotiated rates and historical net prices for all covered prescription drugs at the pharmacy location level (delayed pending further rulemaking).
The purpose of these files is to provide raw data in a specific format that can be read by machines without requiring manipulation or human intervention.
Note: These are comprehensive files as defined by the requirements provided by CMS. They are large in size and individual computer performance can impact the time and ability to download the files.