Sec. 6. Strengthening health coverage transparency requirements
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Section 1311(e)(3)(C) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18031(e)(3)(C) ) is amended— by striking The Exchange and inserting the following: The Exchange ; in clause (i), as inserted by paragraph (1)— by striking participating provider and inserting provider ; by inserting shall include the information specified in clause
(ii)and after such information ; by striking an Internet website and inserting a self-service tool that meets the requirements of clause
(iii); and by striking and such other and all that follows through the period and inserting or, at the option such individual, through a paper or phone disclosure (as selected by such individual and provided at no cost to such individual) that meets such requirements as the Secretary may specify. ; and by adding at the end the following new clauses: For purposes of clause (i), the information specified in this clause is, with respect to benefits available under a health plan for an item or service furnished by a health care provider, the following: If such provider is a participating provider with respect to such item or service, the in-network rate (as defined in subparagraph (F)) for such item or service. If such provider is not described in subclause (I), the maximum allowed amount for such item or service. The amount of cost sharing (including deductibles, copayments, and coinsurance) that the individual will incur for such item or service (which, in the case such item or service is to be furnished by a provider described in subclause (II), shall be calculated using the maximum amount described in such subclause). The amount the individual has already accumulated with respect to any deductible or out of pocket maximum under the plan (broken down, in the case separate deductibles or maximums apply to separate individuals enrolled in the plan, by such separate deductibles or maximums, in addition to any cumulative deductible or maximum). In the case such plan imposes any frequency or volume limitations with respect to such item or service (excluding medical necessity determinations), the amount that such individual has accrued towards such limitation with respect to such item or service. Any prior authorization, concurrent review, step therapy, fail first, or similar requirements applicable to coverage of such item or service under such plan. For purposes of clause (i), a self-service tool established by a health plan meets the requirements of this clause if such tool— is based on an internet website; provides for real-time responses to requests described in such clause; is updated in a manner such that information provided through such tool is timely and accurate; allows such a request to be made with respect to an item or service furnished by— a specific provider that is a participating provider with respect to such item or service; all providers that are participating providers with respect to such plan and such item or service; or a provider that is not described in item (bb); provides that such a request may be made with respect to an item or service through use of the billing code for such item or service or through use of a descriptive term for such item or service; and holds a member harmless for the amount of any difference in excess of the amount of the individual’s responsibility generated by the self-service tool and the amount ultimately billed or charged to the individual. . Section 1311(e)(3) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18031(e)(3) ) is amended by adding at the end the following new subparagraphs: Not later than January 1, 2025, and every month thereafter, each health plan shall submit to the Exchange, the Secretary, the State insurance commissioner, and make available to the public, the rate and payment information described in clause
(ii)in accordance with clause (iii). For purposes of clause (i), the rate and payment information described in this clause is, with respect to a health plan, the following: With respect to each item or service for which benefits are available under such plan (expressed as a dollar amount), including prescription drugs, identified by CPT, HCPCS, DRG, NDC, or other applicable nationally recognized identifier, including any applicable code modifiers, and accompanied by a brief description of the item or service, the in-network rate in effect as of the date of the submission of such information with each provider (identified by national provider identifier) that is a participating provider with respect to such item or service, other than such a rate in effect with a provider that has submitted no claims for such item or service to such plan. With respect to each drug (identified by National Drug Code, J-code, or other commonly recognized billing code used for drugs) for which benefits are available under such plan: The in-network rate (expressed as a dollar amount), including the individual and total amounts for any bundled rates, in effect as of the first day of the month in which such information is made public with each provider that is a participating provider with respect to such drug. The historical net price paid by such plan (net of rebates, discounts, and price concessions) (expressed as a dollar amount) for such drug dispensed or administered during the 90-day period beginning 180 days before such date of submission to each provider that was a participating provider with respect to such drug, broken down by each such provider (identified by national provider identifier), other than such an amount paid to a provider that has submitted no claims for such drug to such plan. With respect to each item or service for which benefits are available under such plan (expressed as a dollar amount), identified by CPT, DRG, HCPCS, NDC, or other applicable nationally recognized identifier, including any applicable code modifiers, and accompanied by a brief description of the item or service, the amount billed or charged by the provider, and the amount allowed by the plan, for each such item or service furnished during the 90-day period beginning 180 days before such date of submission by each provider that was not a participating provider with respect to such item or service, broken down by each such provider (identified by national provider identifier), other than items and services with respect to which no claims for such item or service were submitted to such plan during such period. Rate and payment information required to be submitted and made available under this subparagraph shall be so submitted and so made available as follows: Information shall be contained in 3 separate machine-readable files corresponding to the information described in each of subclauses
(I)through
(III)of clause
(ii)that meet such requirements as specified by the Secretary through rulemaking, in consultation with the Secretaries of Labor and the Treasury to apply comparable requirements to group health plans and to entities providing benefit management or other third-party administration services on a contractual basis with a group health plan. Requirements specified by the Secretary through rulemaking shall ensure that: Such files are limited to an appropriate size, are made available in a widely available format that allows for information contained in such files to be compared across health plans, and are accessible to individuals at no cost and without the need to establish a user account or provider other credentials. The rates, amounts, and prices to be disclosed include contractual terms containing calculation formulae, pricing methodologies, and other information necessary to determine the dollar value of reimbursement. Each such file includes each of the following data elements: A numerical identifier for the group health plan and/or health insurance issuer (such as a Health Insurance Oversight System identifier). A plain-language description of the item or service (including, for drugs, the proprietary and nonproprietary name assigned). The billing code, including any applicable modifiers, associated with such item or service, including the Healthcare Common Procedure Coding System code, diagnosis-related group, national drug code, or other commonly recognized code set. The place of service code. The National Provider Identifier or provider Tax Identification Number. The rate and payment information disclosed under subclauses
(I)through
(III)of clause
(ii)shall be separately delineated for each item or service, regardless of whether such item or service is reimbursed as a part of a bundle, episode, or other grouping of items and services. An officer or executive of competent authority shall attest to the accuracy and completeness of information submitted and made available under this subparagraph. Such attestation shall be deemed material to payments from the Federal Government received by the group health plan or health insurance issuer. Regulations promulgated pursuant to this section shall provide that: The Secretary shall audit the three machine-readable files required by subparagraph (E)(ii) posted by no fewer than 20 group health plans or health insurance issuers. The Secretary of Labor shall audit the three machine-readable files required by subparagraph (E)(ii) posted by no fewer than 200 group health plans or service providers furnishing third-party administrator services to a group health plan. Findings, conclusions, and enforcement actions taken based on audits of the machine-readable files shall be reported annually to Congress no later than July 1 of the calendar year during which the files were audited. Such report to Congress shall be accessible to the public. Each health plan shall make available to the public instructions written in plain language explaining how individuals may search for information described in clause
(ii)in files submitted in accordance with clause (iii). In this paragraph: The term participating provider has the meaning given such term in section 2799A–1 of the Public Health Service Act. The term in-network rate means, with respect to a health plan and an item or service furnished by a provider that is a participating provider with respect to such plan and item or service, the contracted rate in effect between such plan and such provider for such item or service. If the rate is based on an algorithm, percentage of another amount, or other formula or criteria, the health plan also shall disclose such algorithm, percentage, formula, or criteria as set forth in its contract and any other terms, schedules, exhibits, data, or other information referenced in any such contract as shall be required to determine and disclose the negotiated rate. An applicable ACO participating in the Medicare Shared Savings Program, as defined in Section 1899 of the Social Security Act (42 U.S.C. § 1395jjj), shall be subject to the requirements of this paragraph as if such applicable ACO is a group health plan or health insurance issuer. Each year, the Secretary shall audit the three machine-readable files required by subparagraph (E)(ii) posted by no fewer than 20 group health plans or health insurance issuers. . The amendments made by subsection
(a)shall apply beginning January 1, 2025. Nothing in the amendments made by this section may be construed as affecting the applicability of the rule entitled Transparency in Coverage published by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services on November 12, 2020 (85 Fed. Reg. 72158) before January 1, 2025.
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- 85 FR 72158
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Sec. 6
Strengthening health coverage transparency requirements
Fed. Reg.85 FR 72158
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