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Thompson Hine LLP, a full-service business law firm with approximately 400 lawyers in 8 offices, was ranked number 1 in the category “Most innovative North American law firms: New working models” by The Financial Times and was 1 of 7 firms shortlisted for The American Lawyer’s inaugural Legal Services Innovation Award. The firm has been recognized by the National Law Journal as a Legal Technology Trailblazer and featured by Bloomberg for its innovative service delivery models, which drive accuracy and predictability. The firm’s commitment to innovation is embodied in Thompson Hine SmartPaTHTM – a smarter way to work – predictable, efficient and aligned with client goals. For more information, please visit ThompsonHine.com and ThompsonHine.com/SmartPaTH.

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The <a href="https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CMS-Transparency-in-Coverage-9915F.pdf" target="_blank" rel="noopener">final rule on health plan price transparency</a>, issued by the U.S. Departments of Health and Human Services, Treasury and Labor in late October, imposes new disclosure requirements on group health plans. While the requirements do not go into effect until 2022, plan sponsors will need to act in the coming months to prepare for compliance.

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Which group health plans are subject to the rule?

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The rule applies to self-insured and fully insured medical and prescription drug plans. It does not apply to grandfathered health plans, retiree-only plans, excepted benefits (such as limited-scope dental and vision benefits) or certain other arrangements that are exempted from the Affordable Care Act’s market reform provisions.

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In general, group health plans and health insurers in the individual and group markets will be required to disclose and make readily available certain cost-sharing and pricing information beginning in 2022.

Publicly available disclosure of negotiated and historical pricing information

Effective for plan years beginning on or after January 1, 2022

Covered plans and issuers must make available to the public three machine-readable files (i.e., digital files that can be used for further processing of data) that include detailed pricing information for all covered items and services, including encounters, procedures, medical tests, supplies, durable medical equipment, prescription drugs and fees (including facility fees).

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Plans cannot charge a fee to access the files or require individuals to establish a user account or submit any personally identifiable information to access the files.

The files must be updated monthly and include the date of the most recent update. Specific technical instructions will be provided in separate guidance.

Disclosure of estimated cost-sharing information to covered participants and beneficiaries

Effective for plan years beginning on or after January 1, 2023

In addition to the information that must be made publicly available, plans also must make available to participants, beneficiaries and enrollees (or their authorized representatives) personalized out-of-pocket cost-sharing information and underlying negotiated rates for covered health care items and services. This information must be provided through an internet-based self-service tool and, upon request, in paper form.

The information required to be provided includes estimated cost-sharing liability, amounts already accumulated toward the covered individual’s deductible and out-of-pocket maximum, in-network rates, out-of-network allowed amounts, a list of items and services combined under a bundled payment, notice of prerequisites for coverage (such as prior authorization) and certain other specific disclosures (such as a reminder of the possibility of balance billing).

There are 500 items and services identified in the preamble to the final rule that must be available for searching by the first day of the plan year that begins in 2023. All remaining covered items and services must be available for searching by the first day of the plan year that begins in 2024.

Can plan sponsors rely on third-party service providers or insurers for compliance?

The final rule anticipates that plan sponsors will seek to rely on third-party service providers to do much of the heavy lifting with respect to gathering data and creating and updating the required databases and files. Where a fully insured plan contracts with the insurer or other third party (such as a health care clearinghouse) to provide the required information, the insurer or third party will be responsible for any noncompliance. However, self-insured plan sponsors will remain responsible for compliance (and noncompliance) even if they contract with third parties to provide the required disclosures.

What steps should a plan sponsor take now?

Compliance with the final rule will be a matter of contract negotiation for most plan sponsors.

Julia Ann Love 216.566.5686 <a href="mailto:Julia.Love@ThompsonHine.com">Julia.Love@ThompsonHine.com</a>

Kim Wilcoxon 513.352.6524 <a href="mailto:Kim.Wilcoxon@ThompsonHine.com">Kim.Wilcoxon@ThompsonHine.com</a>

Beth A. Mandel 513.352.6695 <a href="mailto:Beth.Mandel@ThompsonHine.com">Beth.Mandel@ThompsonHine.com</a>

or any member of our <a href="https://www.thompsonhine.com/services/employee-benefits-amp-executive-compensation" target="_blank" rel="noopener">Employee Benefits &amp; Executive Compensation</a> group.

This advisory bulletin may be reproduced, in whole or in part, with the prior permission of Thompson Hine LLP and acknowledgment of its source and copyright. This publication is intended to inform clients about legal matters of current interest. It is not intended as legal advice. Readers should not act upon the information contained in it without professional counsel. This document may be considered attorney advertising in some jurisdictions.

https://admin.thompsonhine.com/wp-content/uploads/2022/04/Employee_Benefits_Update_-_Preparing_for_Compliance_with_the_Final_Price_Transparency_Regulations.pdf

Preparing for Compliance with the Final Price Transparency Regulations

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