Transparency in Coverage (TIC) Final Rules
In October 2020, the Departments of Health and Human Services, Labor, and Treasury released the Transparency in Coverage Final Rules (TIC). TIC requires that:
- Non-grandfathered health plans disclose, on a public website, three machine-readable files disclosing health care rates. The machine-readable files (MRF) must (i) contain provider rates for covered items and services, (ii) out-of-network allowed amounts and billed charges for covered items and services, and (iii) negotiated rates and historical net prices for covered prescription drugs. The files for (i) and (ii) must be made public beginning on July 1, 2022 (delayed from January 1, 2022); implementation of the third file has been postponed and no new date has been released.
- Health plans make price comparison information available through a web-based self-service tool and in paper form upon request for 500 items and services, for plan years beginning on or after January 1, 2023. Health plans must expand those tools to cover all items and services by January 1, 2024.
The Consolidated Appropriations Act (CAA)
On December 27, 2020, the Consolidated Appropriations Act (CAA) was signed into law. The CAA includes extensive transparency reforms, including some that appeared to overlap with TIC rules, but with more aggressive deadlines. The CAA represents the most significant changes to the private insurance market since the Affordable Care Act. The law:
- Requires plans to develop and make available price transparency tools, good faith estimates and an advanced explanation of benefits • Restricts “surprise billing”
- Prohibits “gag clauses” in healthcare contracts
- Adds new mandates for ID cards, provider directories and continuity of care.
We’ve enclosed some Frequently Asked Questions regarding these new changes. You can download them below: