The Transparency in Coverage Final Rules (TiC Final Rules) require group health plans and health insurance issuers to disclose on a public website detailed pricing information in three separate machine-readable files (MRFs). Specifically, the following information must be disclosed:
The files must be publicly available and accessible free of charge without any restrictions.
Most employers will rely on their insurance carriers and third-party administrators (TPAs) to provide the MRFs. The TiC Final Rules allow fully-insured employers to shift legal responsibility for the MRFs to their carriers if this arrangement is described in a written agreement. Self-insured employers can use their TPAs (or other service providers) for the MRFs if this is set forth in a written agreement. Still, these employers remain legally liable for compliance under the TiC Final Rules.
The TiC Final Rues suggest that self-insured employers may be required to post a link on their websites to where the MRFs are publicly available, but this is not clearly addressed in the Final Rules. Additional guidance from federal agencies on this topic would be helpful.
Employers should confirm that written agreements addressing MRFs are in place with their carriers and TPAs and that these files will be available by the applicable deadline.
Machine-readable Files (MRFs)
The In-network Rates, Allowed Amounts, and Prescription Drug Files must be disclosed as machine-readable files. The TiC Final Rules define ‘‘machine-readable file’’ as a digital representation of data or information in a file that can be imported or read by a computer system for further processing without human intervention while ensuring no lost semantic meaning. This ensures the MRF can be imported or read by a computer system without those processes resulting in alterations to the ways data and commands are presented in the file.
A plan or issuer’s file will be acceptable so long as it:
The TiC Final Rules anticipate that plan sponsors will rely on their carriers or service providers, such as TPAs for self-insured plans, to satisfy the MRF disclosure requirements. Accordingly, the TiC Final Rules include a special rule to streamline the provision of the required disclosures and avoid unnecessary duplication. The special rule has different implications depending on the type of plan:
Content Elements for All MRFs
The following content elements are required to be included in the three MRFs:
Name and identifier for each coverage option: Plans and issuers must include their Health Insurance Oversight System (HIOS) ID at the 14-digit product level. If the plan or issuer does not have a HIOS ID at the plan or product level, the plan or issuer must use the HIOS ID at the five-digit issuer level. If a plan or issuer does not have a HIOS ID, it must use its EIN.
Timing: Plans and issuers must update the information required to be included in each MRF on a monthly basis to ensure it remains accurate and must clearly indicate the date the files were most recently updated.
The Departments of Labor, Health and Human Services, and the Treasury (collectively, the Departments) have been providing technical guidance for plans and issuers to assist in developing the MRFs.
GitHub Implementation Guidance
The Departments’ technical implementation guidance will be available online through GitHub, a website and cloud-based service that helps developers store and manage their code as well as track and control changes to their code. The Departments’ goal in using GitHub is to facilitate a collaborative effort that allows plans and issuers to meet the public disclosure requirements of the TiC Final Rules while addressing their unique IT system, issuer and plan attributes.
To the extent a plan or issuer’s unique attributes (for example, IT system, plan benefit design or reimbursement model) are not addressed sufficiently through the technical implementation guidance, the Departments intend to provide targeted technical assistance to ensure all plans and issuers are able to meet their public disclosure requirements. The technical implementation guidance will provide instructions on obtaining this technical assistance should the need arise.
The guidance hosted on GitHub will include a file’s repository set of “schemas,” which are descriptions of how the data should be organized and arranged. Plans and issuers will be able to access the GitHub schemas at any time and collaborate with the Departments in real-time.
April 2022 Technical Guidance
On April 19, 2022, the Departments issued FAQs providing an enforcement safe harbor for in-network rates that are not expressed as a dollar amount:
According to the Departments, they will monitor the implementation of the MRF requirements and may revisit this safe harbor in the future. In addition, this safe harbor will not apply to a particular alternative reimbursement arrangement if the Departments determine the particular arrangement can sufficiently disclose a dollar amount. The Departments encourage the continued utilization of GitHub to submit suggestions on ways the schema should support alternative reimbursement arrangements.
Source: U.S. Department of Labor
This Compliance Bulletin is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice.