Transparency in Coverage - Mandate overview

Helping members understand estimated costs before receiving care:

• Insurers and group health plans are required to provide online consumer tools leveraging personalized information about member’s cost-sharing responsibilities for covered items and services.
• Web-based tool that allows members to:
  • Search on billing code or description
  • Compare costs across in-network and out-of-network providers
  • Display deductible status or other out-of-pocket expenditures to-date

The Transparency in Coverage Final Rule requires that health plans offer an internet-based self-service tool: 

• Plans must make available personalized out-of-pocket cost information for covered items and services
• The tool must provide real time estimates of a member’s cost-sharing liability that are personalized based on the member’s plan and coverage
• July 22, publishing two machine-readable files publicly: Negotiated Rates and Out-of-Network File
• Beginning 1/1/23, cost-estimator tools must include an initial list of 500 shoppable services (specified in the final rules).
• Beginning 1/1/24, cost-estimator tools must include an all-covered items and services 

The Transparency in Coverage Final Rule outlines 7 required content requirements for cost-sharing estimator tools:

• Estimated cost-sharing liability - the estimated amount for the covered service the member will be responsible for, including deductible, coinsurance, and copay, based on their plan coverage.
• Accumulator amounts – dollar amount incurred toward deductible, out of pocket max and treatment limits 
• In-network rates: provide the negotiated rate for the covered 500 items or services for any in-network provider – including in-network out of area providers – based on fee schedules – currently based on historical paid claims. 
• Out of network amounts: provide estimates of what the plan will pay and the member’s financial responsibility for services received from out of network providers.
• Bundled payments: list items/services included in bundled payment arrangements
• Prerequisites of coverage: Notify members at the time of the search if an item or service, covered under their plan, is subject to coverage prerequisites, such as prior authorization. 
• Disclosures notices: inform members of certain limitations of cost estimates, including out of network providers may balance bill; actual charges may vary from the estimate; estimate is not a guarantee of coverage; cost sharing may not apply to certain preventative services.

Tufts Health Plan members have access to an online cost transparency tool, Treatment Cost Estimator, to obtain cost estimates on health care services.  With the passage of federal mandates, the Transparency in Coverage final rule and CAA/No Surprises Act legislation, the tool will be updated in response to the regulations. For additional resources, visit cms.gov.