Proposed Rules on Coverage and Transparency and Final Rules on Hospital Price Transparency - Bim Group

Proposed Rules on Coverage and Transparency and Final Rules on Hospital Price Transparency

On November 15, 2019, the Internal Revenue Service (IRS), Department of Labor (DOL), and the Department of Health and Human Services (HHS) (collectively, Departments) released proposed rules on coverage transparency.

The proposed rules seek to give an estimate of plan participants’ potential cost-sharing liability for covered items and services they might receive from a particular health care provider. The proposed rules require group health plans and insurance issuers in the individual and group markets to disclose cost-sharing information and negotiated rates.

The proposed rules would also allow issuers that encourage participants to shop for lower cost services to take credit for “shared savings” payments they provide to participants in their medical loss ratio (MLR) calculations. HHS released a fact sheet regarding the proposed rules.

The Departments also issued final rules on price transparency requirements for hospitals. The final rules establish requirements for hospitals to create, update, and make public a list of their standard charges, including payer-specific negotiated charges, for the items and services they provide. HHS released a fact sheet regarding the final rules.

The final rules on hospital price transparency are effective on January 1, 2021.

HHS issued a press release regarding the proposed rules and the final rules.

The proposed rules regarding disclosure of cost-sharing information and public disclosure of negotiated rates and allowed amounts would become effective for plan years beginning on or after one year after final rules are issued. The proposed rule regarding the medical loss ratio (MLR) calculation would become effective beginning with the 2020 MLR reporting year.

Public comment on the proposed rules is due on January 14, 2020. After considering public comments, the Departments will issue final rules.

Download our full Advisor for a summary of the coverage transparency proposed rules affecting group health plans and issuers.


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