On October 29, 2020, the Departments of Health and Human Services (HHS), Treasury, and Labor issued the “transparency in coverage” final rule. This rule imposes new requirements on group health plans to disclose cost-sharing estimates at the request of an enrollee and publicly release negotiated rates for in-network providers, historical out of network allowed amounts and billed charges, and drug pricing information. The rule applies to non-grandfathered self-insured and fully insured plans. Grandfathered health plans and stand-alone dental and vision plans are not impacted by this rule. The goal of the rule is to allow enrollees to estimate their cost-sharing before receiving healthcare services and to encourage shopping and price competition among providers.

The rule applies to self-insured group health plans and fully insured health insurers in the individual and group markets. The rules make it clear that in health plans sponsored by employers, the employers are the parties responsible for providing this information to plan participants and ensuring that it is adequately presented. Although employers are allowed to contract with insurers or third party administrators to provide this information, employers remain liable in the event the required information is not provided.

There are three effective dates within the rules:

January 1, 2022 – Health plans must disclose 1) rates for in-network providers; 2) billed charges and allowed amounts for out-of-network providers during a specific period; and 3) prices for prescription drugs during a specified period.

January 1, 2023 – Health plans must provide cost-sharing information to enrolled individuals through an online tool on their websites and in paper form for a list of 500 items and services identified by the Departments.

January 1, 2024 – Health plans must include all items and services (beyond the initial 500) on their cost-sharing website.

Diversified Group has assembled a team to explore and evaluate web-based transparency tool options that might be available and the amount of hosted data needed for our client’s to be in compliance. At this point we are still reviewing the Final Transparency Rule. We will continue to update you as this issue evolves. In the meantime, please feel free to reach out to the Diversified Group’s compliance team with any questions:

Dave Follansbee, VP of Operations and Compliance
dfollansbee@diversifiedgb.com or (860) 295-6531

Laura Williams, Business Development and Compliance Consultant
lwilliams@diversifiedgb.com or (860) 612-8644

DG Compliance