How to Make the Best Out of New Transparency Rules

Health Benefits are a very popular feature of a pay package and constitute a major reason for choosing- or leaving an employer.

Transparency-in-Coverage (TiC) Final Rules and No Surprises Act: Find your way in the regulatory maze

In a time of labor shortage, it’s then important for the employer to make the most of the dollars spent offering these benefits.

The No Surprises Act, signed into law on December 27, 2020, and a part of Title I of the CAA 2021, requires health plans and self-insured employers to maintain up to date in-network provider directories and to disclose detailed pricing and cost-sharing information to consumers and other stakeholders.

The Transparency-in-Coverage (TiC) Final Rules, jointly issued by three administrations in November 2020, are now part of Title II of the same CAA 2021. They take two approaches to make pricing information publicly accessible:

Employers will have to make publicly available three machine-readable files, updated monthly, including:

  • In-network provider lists with negotiated rates of 500 medical items and services
  • Historical out-of-network allowed amounts,
  • Drug pricing (enforcement deferred pending further rulemaking),

The machine-readable file requirements are applicable for plan years beginning on or after January 1, 2022, but law enforcement by HHS has been delayed to July 1., 2022.

As of today, only a very small percentage (4%!) of hospitals have made these data publicly available, and CMS postponed the implementation date to July 1, 2022.

Employers will also have to review hospital prices —including negotiated rates and rebates— disclosed in 2021 under the final transparency regulation for hospitals.

    As of today, only a very small percentage (4%!) of hospitals have made these data publicly available, and CMS postponed the implementation date to July 1, 2022.

    In fact, most employers will have to work with vendors to ensure compliance, particularly with regards to two major issues:

    • Obtaining prices since most don’t have the data required by the new rules;
    • Processing, formatting and publishing the monthly disclosures and updates.

    There is another, more thorough approach to consider: digital self-serve tools won’t work for all consumers. Presenting complex concepts like bundled care and cumulative treatment limitations will raise questions. And hence, providing human support —clinical and benefits experts who can help individuals navigate not just cost of care transparency, but their entire personal health journey— will be very helpful while not mandatory.

    A 2018 report from the HCCI (Health Care Cost Institute) shows that the top 5%, tagged “Top-Spenders”, cost over 50% of a health Plan total spending!

    This can be a way to turn these new regulations into a tool to better manage costs while enhancing the experience of plan members. As you probably know, costs are concentrated on a small number of high-spending plan members.

    People with 2 or more chronic conditions represent less than 6% of plan members, but carry high average costs.

    A priority of any cost containment solution is to look at the specific needs of “Top-spenders.”

    Helping these persons better utilize what the plan has to offer, providing them with the information they need to make informed choices could be the solution to make the best out of what many consider a new regulatory burden, adding to a very complex legislative body.

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