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CMS Finalizes Transparency in Coverage Rule: What happens next?

The final component of the Trump Administration’s Executive Order issued in 2019 on Health Care Price Transparency was announced on October 30th when the Centers for Medicare and Medicaid Services (CMS) along with the Departments of Labor and the Department of the Treasury delivered the Transparency in Coverage Final Rule (CMS- 9915 –P) requiring health insurers and self-insured health plans to disclose pricing and cost-sharing information. If all goes as planned, starting in 2023, health plans must provide a consumer-friendly transparency tool that allows consumers to see how much a medical procedure or service costs before scheduling treatment.

But the road to implementation is long and costly for insurance companies and third-party administrators (TPAs). To break it down, let’s start with an overview of the rule.

At a Glance
The Transparency in Coverage Rule is the third and final component of the 2019 executive order that includes the Rx Rule and the Hospital Price Transparency Rule and outlines the following deadlines and requirements for health plans and TPAs:

  1. January 1, 2022. Health plans must make publicly available files with the price paid to each provider for specific services. The files must include in-network, out of network and Rx prices, and must be updated monthly.
  2. January 1, 2023. Health plans are required to offer an online shopping tool that will allow consumers to see the negotiated rate between their provider and their plan, along with a personalized estimate of their out-of-pocket cost for 500 of the most shoppable items and services.
  3. January 1, 2024. These shopping tools will be required to show the costs for the remaining procedures, drugs, durable medical equipment and any other item or service needed.

Bluebook’s Response
As the industry leader in cost and quality navigation, Bluebook leadership was invited by senior policy makers and administrators to share input and feedback during the rulemaking process., Healthcare Bluebook (Bluebook) issued the following statement:

Healthcare Bluebook supports any effort to promote greater transparency around healthcare costs. As the nation’s first and largest provider of healthcare transparency and navigation solutions to state and municipal employers, self-insured Fortune 500 employers and third-party administrators, we know firsthand the value of delivering transparent cost and quality information.

Over the past two years, our experts have been called upon by federal legislators and policy makers, and we are proud to have had the opportunity to share input and knowledge during the Transparency in Coverage rule making process. We have been actively engaging our clients in a planning dialogue as we awaited final rules. Our teams are already documenting potential additional requirements for our platform and developing a cost schedule and cost model. We will be ready to help our clients meet the requirements in the final rule. In the meantime, we welcome clients to reach out to their Bluebook contacts with any specific questions or concerns. We believe this is an important win for consumers and employers and will help deliver a clearer picture of healthcare costs to support better decision-making.

Bluebook is closely examining the final ruleset and modifying its platform to meet the new transparency mandate so that we are prepared to help our clients meet the rule’s conditions.

"Because of our insight into quality and cost navigation and our history of developing consumer-friendly transparency solutions, Healthcare Bluebook is in a unique position to ensure that our TPA clients remain fully compliant. We have lessons learned from over a decade of doing this work. Our focus is to take complex information and make it easy for consumers to understand," said Bluebook Co-Founder and Senior Vice President, Bill Kampine.

What Happens Next?
While the requirements are intended to empower consumers to shop and compare costs between specific providers before receiving care, they are costly mandates for insurance plan providers and TPAs.

Bluebook anticipates legal challenges from the payors and or American Health Insurance Plans (AHIP, the advocacy / lobbying group for most payors). For detailed information, see the AHIPs 57-page comment letter on the rule. CMS has also posted a Transparency in Coverage Fact Sheet for quick reference.

Recap
Bluebook is being extremely proactive in response to the rules and its requirements with a team in place to track and document potential added requirements for our platform.

Additionally:

  • We are actively engaged in planning discussions with our TPA clients to ensure compliance and meet deadlines.
  • Through our policy relationships in Washington, we continue to monitor the guidance from the Departments on implementation of the final rules, incorporate insights and share guidance back with our clients.
  • Our product team has already completed the first phase of platform updates to meet some of the final requirements. We are currently reviewing all details of the final rules and working with our clients to help them ensure compliance.

Finally, the media have been actively reaching out to Bluebook for our insight and commentary. We are honored to be called upon to share information that may be helpful and provide guidance to consumers, employers, health plans and TPAs.

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