Regulatory Updates

Final Rule on Transparency In Healthcare Coverage

November 11, 2020 – In response to President Trump’s Executive Order, Improving Price and Quality Transparency in American Healthcare to Put Patients First, the IRS, Department of Labor, and Department of Health and Human Services have jointly issued a Transparency In Coverage final rule. This guidance is intended to make healthcare price information accessible to consumers and other stakeholders to permit comparison-shopping.

The final rule requires that most healthcare plans make available to participants, beneficiaries, and enrollees (or their authorized representative) personalized out-of-pocket cost information, and the underlying negotiated rates for all covered healthcare items and services, including prescription drugs, through an Internet-based, self-service tool and in paper form upon request.

The guidance also requires most healthcare plans to make available to the public, including stakeholders such as consumers, researchers, employers, and third-party developers, three separate machine-readable files that include detailed pricing information. The detailed pricing information is to include 1) negotiated rates for all covered items and services between the plan or issuer and in-network providers; 2) historical payments to, and billed charges from, out-of-network providers; and 3) in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level.