The Transparency in Coverage (TiC) rule is gaining more attention as the deadline to post a public link to certain machine-readable data files is July 1, 2022.

The requirement to post machine-readable files begins July 1, 2022. The TiC requires group health plans and health insurance issuers to disclose on a public website detailed pricing information in three separate machine-readable files (MRFs). The following must be disclosed:

• The In-Network Rate File – All applicable rates paid to in-network providers for all covered items and services (including negotiated rates, underlying fee schedules, etc.):
• The Allowed Amount File – Billed charges and allowed amounts for covered items and services provided by out-of-network providers; and
• The Prescription Drug File – Negotiated rates and historical prices for prescription drugs furnished by in-network providers. – this file has been delayed indefinitely

Non-grandfathered group health plans, regardless of number of participants must comply.

• Fully insured plans: the carrier/insurer is responsible for creating and hosting the files. Employers should follow the guidance of their health insurance carrier regarding posting requirements.

• Self-insured plans: the TPA will need to produce the files and link to where the files are hosted. However, self-insured medical plans are faced with a lack of clear guidance on whether files hosted on a the TPA’s public website are enough to comply. For those employers wanting to take a conservative approach, the safest course of action would be to post the link to the files on its own public website.  We are hopeful that more guidance will be released to provide clarity for group health plan sponsors.

For fully insured plans, the insurer will or may have already connected with your employer for guidance and instruction. We recommend following the guidance of your carrier.

For self-insured plans, an employer will need to connect with their TPA to ensure they will provide a link to the file on your behalf so that your employer can post on its public website.

The files are not meant for plan participants, rather, the machine-readable files are formatted to allow researchers, regulators, and application developers to access and analyze data easily.

These files are not member-friendly; however, member-friendly tools will be available in 2023 and 2024 per the Federal transparency efforts.

The law does not require that the group health plan notify its participants of the availability of these files.

For more information, contact INSURICA today.

This article is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel or an insurance professional for appropriate advice. © 2022 Zywave, Inc. All rights reserved.