Transparency in Coverage

What exactly is the Transparency in Coverage - Public Access Requirement?

On October 29, 2020, the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury jointly released the Transparency in Coverage final rule. One of the requirements of the rule that group health plans and issuers must meet is to make certain price information accessible to plan participants and other stakeholders. This is known as the Public Access Requirement. 

The Public Access Requirement is the first of three specific requirements that must be implemented. Group health plans and issuers must make three separate machine-readable files (MRF) publicly available, free of charge by the enforcement deadline of July 1, 2022. The files are updated monthly and include the following detailed pricing information:

  • In network: Negotiated rates for all covered items and services between the plan or issuer and in-network providers.
  • Out of network: Historical payments to, and billed charges from, out-of-network providers. Files are not required if there are fewer than 20 claims for a service for a provider.
  • Prescription drugs: In-network negotiated rates and historical net prices for all covered prescription drugs at the pharmacy location level (this requirement is delayed pending further rulemaking).

Purpose of the machine-readable files (MRF)

To provide raw data in a specific format that can be read by machines without requiring manipulation or other human intervention. 

They are not intended to be user friendly or easily understood by the average consumer; however, they are an intermediate step that lays the groundwork for a consumer-facing experience, powered by this data, to inform your employees’ decision making.

Accessing the MRF files:

As a convenience, Premera has made the machine-readable files available to self-funded employers using the Machine-readable files link. Please note the files will not include carved out services and no data will be available in the file until July 1, 2022.