Background: The past 12 months have been focused on due dates for promoting health plan cost transparency brought on by two federal transparency efforts: the CMS Transparency in Coverage (TiC) Final Rule and the No Surprises Act included in the CAA, 2021 legislation. Bolton first wrote about these efforts here.
Employers have already noticed enhanced ID cards, publicly posted machine readable files, prescription drug cost reporting due in late December, and the latest is focused on a medical cost transparency tool that will help plan participants shopping and planning for medical services.
The price comparison tool must be available for plan years beginning on or after January 1, 2023, with respect to 500 items and services that were identified by the agencies in Table 1 in the preamble to the TiC Final Rule which can be found here. For plan years beginning on or after January 1, 2024, the price comparison tool must be available for all covered items and services.
The tool will allow an individual to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers. The information must also be made available by phone or paper upon request from the plan participant.
How will employers comply?
Fully insured group health plans will need to rely on their carrier to develop and implement the cost comparison tools. Most carriers have a version of this tool and are in the process of expanding the tool to meet the TiC requirements.
Self-insured group health plans will need to rely on their Third Party Administrators (TPAs) to develop this tool. Most TPAs have a version of this tool and are working to make the necessary updates, but it’s unclear if TPAs will charge an additional cost to maintain standards found in the TiC and CAA rules.
When will plan participants have access to the 500 shoppable services in the cost comparison tool? Starting on the Plan or Policy year beginning on or after January 1, 2023. For example, a group health plan that renews on March 1, 2023 must ensure the tool is available on that date.
What should employers do next? Employers should work with their benefits broker to ensure its group health plan will comply by the effective date.
(Bolton IMA will continue to monitor regulator guidance and offer meaningful, practical, timely information. This material should not be considered as a substitute for legal, tax and/or actuarial advice. Contact the appropriate professional counsel for such matters. These materials are not exhaustive and are subject to possible changes in applicable laws, rules, and regulations and their interpretations.)
