CMS Releases Updated Rules on Payer Transparency and Pricing

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CMS Releases Updated Rules on Payer Transparency and Pricing

On October 29, CMS finalized its Transparency in Coverage rule. The final rule is part of a larger effort to ensure price transparency across the healthcare sector. The Transparency in Coverage rule moves to require significant public disclosures of the prices of items and services by private health insurers.

The final rule has two key components:

  • Requires group health plans and health insurance issuers in the individual and group markets to disclose to all participants/beneficiaries/enrollees cost-sharing information for covered items and services.
    • This requirement will be phased in, with cost-sharing information for 500 “shoppable” services to be provided starting January 1, 2023, and cost-sharing for all items and services to be provided staring January 1, 2024.
    • This information will be provided through self-service tools provided to individual participants/beneficiaries/enrollees and in paper form.
  • Requires plans and issuers to disclose the following pricing information to the public:
    • Payment rates negotiated between plans/issuers and providers for all covered items and services.
    • Amounts allowed by plans/issuers for items and services furnished by out-of-network providers.
    • Prescription drug pricing information.

To read the full rule see here: Transparency in Coverage rule.