The ACA’s approaches to deadlines for disclosing health plan prices

In 2020, the Centers for Medicare & Medicaid Services (CMS) released the TiC Final Rules, which, among other things, require non-grandparent health plans to publish certain information on a public website. plan prices in machine-readable files (MRFs) until July 1, 2022.

Many employers (both fully insured and self-insured) have questions about how to comply. In this customer signal, we provide compliance alternatives, although many third party insurers and administrators (TPAs) have already taken steps to ensure that employers comply.

TiC rules in brief

The disclosure requirements for TiC apply to insurers and most non-grandfather health group plans, including both insurance and self-insured plans. However, they do not apply to account-based plans (eg HRAs and FSAs), exempt benefits or short-term insurance for a limited period.

Generally speaking, the group health plans subject to the Final TiC Rules must disclose through three separate MRFs the following price information for each coverage option:

  1. The network provider has negotiated tariffs for all items and covered services

  2. Historically allowed amounts outside the network for suppliers and

  3. Negotiated rates and historical net prices for all prescription drugs covered at the pharmacy level

The MRF must be updated monthly and must clearly indicate the date on which the files were last updated. The guidelines, issued in late 2021, have delayed the requirements for prescription drugs indefinitely. Thus, only intranet and offline MRFs should be publicly available by July 1, 2022.

Hosting and publishing links to the MRF

According to the TiC Final Rules, MRFs must be published on a publicly accessible website accessible to anyone free of charge and without any conditions, such as the creation of a user account, password or other identifying information or the submission of personal information.

Fully insured plans

The final TiC rules allow fully insured plans to enter into a written agreement with the carrier to assume responsibility for complying with MRF requirements. Where such an agreement exists, it is the responsibility of the carrier, not the plan or the employer, to ensure that the MRF meets all the necessary requirements for form, content and public disclosure.

Self-insuring plans

The rules allow self-insured plans to contract with their TPA to prepare, host and update the MRF. However, unlike their fully insured counterparts, self-employed employers ultimately remain responsible for the TPA’s non-compliance with TiC requirements.

Few, if any, employers are able to gather the voluminous information needed to create an MRF and the infrastructure to host and update these large files (sometimes over terabytes of data). Most have to rely on their TPA to create and host files. The TPA must be able to publish the files and provide the employer with a link to the MRF, and then the employer must publish it on a public website.

The final TiC policy states that “if a plan or publisher chooses not to host the file separately on its own website, it must provide a link on its public website to the place where the file is publicly available ”(as noted above, fully insured plans can rely on their insurer to meet this requirement). The rules assume that the link must be published on website of the plan (not the employer), although most employers who do not have a separate health plan website comply by posting a link in the benefits or employment section of their company’s website. More guidance from CMS would be welcome on this, as well as how employers without a public website can comply.

In cases where the self-employed employer does not maintain a dedicated website for its group health plan, where a link to the publication of the MRF by the TPA may be added, it may consider one or more of the following compliance alternatives:

  • Create a special website or subpage for the plan. Employers who already have a public website can hire a provider to create a stand-alone website for their employee income plans, where the link can be published, or create a special subpage of the employer’s website plan.

  • Website of a TPA-sponsored plan. Some TPAs ​​may, in special cases (for example, when the employer does not have its own public website), be able to assist the employer in setting up a separate public website specific to the employer’s plan where the link can be published.

  • Post on the employer’s public website. A self-employed employer could publish the link to the MRF on its own public website. Ideally, the link would be published on a subpage where benefits are usually discussed, such as a career opportunities subpage. As noted earlier, this approach would meet the requirements of “publicly available”, but may not meet a strict reading of the rules, as the link is not published on the plan’s “own public website”. However, most self-supporting plans use this approach until further guidance is issued.

Steps for action

Group health plans that have not yet taken action need to act quickly. Fully insured plans should enter into a written agreement with their insurer, according to which the insurer agrees to publish the MRF on the insurer’s website and to assume responsibility for the requirements for disclosure of the MRF.

The sponsors of self-supporting plans must confirm that their TPAs ​​have prepared MRFs that meet the requirements that the files will be available and made available for publication on the plan site or will be published on a site hosted by the TPA, that the data will be available by the July 1 deadline and must post a link on the employer’s website to where the files are hosted.

The plan sponsor must also review all contracts with the TPA to determine the costs and requirements for providing information and / or publishing and hosting the MRF. Perhaps most importantly, they need to have identified and are ready to implement a solution to provide links to the publicly available website where this pricing information will be located.

An experienced health or compensation lawyer can provide guidance on specific steps that can be taken to ensure compliance with the TiC Final Rules.

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