Health Plan Price Transparency
Health Plan Price Transparency Rules and Regulations
In an effort to promote healthcare price transparency in the United States, federal agencies have issued regulations that impose compliance mandates on health insurers and employer-sponsored group health plans. Group health plans are subject to the following:
- Transparency in Coverage Rule: A provision of the Patient Protection and Affordable Care Act, this rule aims to lower healthcare costs by requiring plans to disclose their rates and other price information for all covered billable services.
- Consolidated Appropriations Act, 2021 (CAA): The CAA imposes a variety of transparency-related requirements on group health plans, such as no gag clauses, continuity of care, provider directory consumer protections, and the Prescription Drug Data Collection (RxDC) submission requirement.
These laws and regulations have bipartisan support, and it is expected that future administrations will continue implementing health plan price transparency legislation.
What are the Transparency Requirements for Group Health Plans?
While fully-insured plans can assign responsibility to insurers, self-insured group health plans are directly responsible for compliance and face significant penalties for failures.
Group health plans are required to:
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Publish Machine-Readable Files (MRFs)
Plans must post MRFs on a public website disclosing in-network negotiated rates and out-of-network allowed amounts. Plans must continue to update the MRFs every month to ensure the files remain accurate.
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Submit Information About Prescription Drugs and Healthcare Spending
As a part of RxDC, multiple data files must be submitted annually by plans to the Centers for Medicare & Medicaid Services, including one file with premium/premium equivalent data, one file with medical spending by category and six files with various prescription drug data elements
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Comply With Other Transparency Provisions
Additional transparency requirements, including an online price comparison tool, will continue to roll out in the coming years.
How Aon Can Help
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Annual RxDC Submission Support
- Overall Project Management: We provide oversight of the annual RxDC submission with all applicable current and termed vendors to facilitate and document the timely submission of required reports.
- Preparation and Submission: When applicable, Aon experts will populate and submit your premium and life years data file (D1) and plan information data file (P2) and the appropriate narrative responses.
- Sample Contract Language: We provide sample contract language for your legal counsel to use with your medical third-party administrator (TPA) and pharmacy benefit manager.
- Additional Support and Guidance: In more complex plan structure situations, Aon will deliver you additional support and guidance through an expert team.
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Health Plan Transparency Hub and Toolkit
- Customized Website and Support: If an employer is required to post MRFs and/or would like to demonstrate compliance with all links in one place, Aon can host an employer-specific website with applicable logos. This support includes coordinating with vendors to receive links to MRFs posted on the public website, updating the links to ensure full disclosure and compliance when there are changes to a medical third-party administrator (TPA) or plan benefits and maintaining a monthly log to track whether MRFs are accessible and populated.
- Compliance Timeline: We provide a tailored timeline of when transparency provisions apply to an employer’s plans.
- Step-by-Step Checklist: Our detailed checklist helps ensure the completion of all transparency-related compliance tasks.
- Reference Guide: The comprehensive and straightforward reference guide has legal citations that walk through the details of these requirements.
- Sample Contracts and Communications: Aon provides sample contract language for the employer’s legal counsel and a summary of material modification to communicate applicable changes to participants.
- Technical Support: We offer ongoing technical support from Aon’s legal consultants, actuaries and technology specialists through webinars, Q&A sessions and community information sharing.
- Guidance on Evolving Regulations and Guidance: Requirements are still changing, and the Toolkit will be updated as federal agencies release new guidance and TPAs implement the requirements.
Two
To help organizations fulfill the employer group health insurance requirement, Aon developed two health plan price transparency solutions to simplify the process and ensure compliance with regulations.
