Transparency Rules for Self-Funded Health Plans


What are the transparency requirements for a self-funded health plan?  How does the Transparency in Coverage (TiC) Rule differ from the No Surprises Act under the Consolidated Appropriations Act, 2021 (CAA)?  The following brief summary answers these questions.

TiC under PPACA

  • Final Rule released in October 2020 by the Departments of HHS, Labor, and Treasury
  • Requires non-grandfathered group health plans to disclose, on a public Website, information regarding (1) in-network rates for covered items and services; (2) out-of-network allowed amounts and billed charges for covered items and services; and (3) negotiated rates and historical net prices for covered prescription drugs – in three separate machine-readable files
  • May include negotiated rates, underlying fee schedule rates, or derived amounts for all covered items and services in the in-network rate file
  • Enforcement of requirement for machine-readable files disclosing in-network and out-of-network data effective 7/1/22
  • Enforcement of requirement for machine-readable files disclosing prescription drugs deferred until further notice
  • Price-comparison tool and cost-estimating tool (first 500 services) effective 1/1/23
  • Cost-estimating tool (remaining services) effective 1/1/24
  • Model notice required when covered participant requests cost-sharing information in paper form (may also be incorporated into Internet-based self-service tool)

Transparency under No Surprises Act

  • Part of CAA passed by Congress in December 2020
  • Health plans must publicly display certain health-care price information* via machine-readable files on their Websites beginning in 2022 (*negotiated rates with in-network providers and allowed amounts for out-of-network providers; may include prescription-drug pricing)
  • Price-comparison tool effective 1/1/23 to align with TiC (future regulations may be issued to merge CAA requirements with TiC)
  • Prescription drug cost reporting due 12/27/22 for 2020 and 2021 data (6/1 thereafter)
  • Air-ambulance claims data due 3/31/23 for 2022 data and 3/30/24 for 2023 data (only two calendar years of reporting required)

Contact ASR Health Benefits at (616) 957-1751 or (800) 968-2449 for more information.