Final Rule Boosts Price Transparency & Addresses the MLR

The Departments of Health and Human Services, Labor, and Treasury issued a final rule that requires almost all health insurance companies and self-insured plans to disclose pricing and cost-sharing information. 

The MLR
Insurers that encourage members to use services from lower-cost/higher-value providers can take credit for shared-savings payments in their medical loss ratio (MLR) calculations beginning with the 2020 MLR reporting year.

Price Transparency
More than 200 million Americans with private-sector insurance (individual and group) will have access to real-time price information, including cost-sharing, so they know how much care will cost them before going in for treatment.

Through a shopping tool available through their plan or insurance company, consumers will be able to see the negotiated rate between their doctor and their plan or insurer, as well as an out-of-pocket cost estimate for procedures, drugs, durable medical equipment, and any other item or service they may need.

Plans will also have to make a data file publicly available, which would reveal what something costs under a member’s current plan, under a competitor’s health plan, or for the uninsured. The requirement for the publicly available data files will take effect for plan or policy years beginning on or after January 1, 2022. Plans and issuers must make cost-sharing information available for 500 specified items and services for plan or policy years beginning on or after January 1, 2023, and must make cost-sharing information available for all items and services for plan or policy years beginning on or after January 1, 2024.