Appendix 1: Transparency in Coverage Model Notice; Appendix 2: Negotiated Rate Machine-Readable File Data Elements; Appendix 3: The Allowed Amount Machine-Readable File Data Elements
In conjunction with proposed “transparency in coverage” regulations requiring group health plans and insurers to make extensive price and cost-sharing disclosures (see our Checkpoint article), the DOL has posted three appendices containing a proposed model disclosure notice and proposed negotiated rate and allowed amount data elements for required disclosures under the regulations. Here are highlights:
Model Notice. Under the proposed regulations, plans or insurers must provide an estimate of an individual’s cost-sharing liability for a covered item or service, including the underlying information necessary to calculate the estimate, a notice of required prerequisites for the item or service, and an explanation of any limitations that apply to the cost-sharing estimate. According to the agencies, the proposed model notice in Appendix 1 would satisfy the notice requirements with respect to prerequisites and the limitations of the estimate. A plan or insurer may use the model notice when a participant, beneficiary, or enrollee requests cost-sharing information in paper form or may incorporate the model language into an Internet-based self-service tool. The model notice, in Q&A format, explains the purpose of the notice, defines key terms, cautions recipients about limitations of the cost estimate, and (if applicable) describes prerequisites imposed by the plan such as preauthorization, concurrent review, or fail-first requirements. The notice may be modified, provided the modification does not conflict with the information required to be provided under the regulations. Use of the model notice is encouraged but not mandatory.
Negotiated Rate Data Elements. The proposed regulations would require plans and insurers to disclose in-network provider negotiated rates (the contracted amounts in-network providers are paid for covered items and services) through a machine-readable file posted on the Internet. Appendix 2 identifies proposed data elements to be included in the file such as identification of the entity publishing the file, general information about the plan and providers, and details about negotiated rates and services provided.
Allowed Amount Data Elements. The proposed regulations also would require plans and insurers to disclose—in a machine-readable file—allowed amounts for out-of-network providers. Appendix 3 identifies the proposed data elements, including general information about the reporting entity, plan, providers, and services provided, and detailed historical information about the plan’s out-of-network allowed amounts. As proposed, the file must list the dollar amount for each unique allowed amount that the plan or insurer paid for a covered item or service furnished by an out-of-network provider during the 90-day period beginning 180 days prior to the publication date of the machine-readable file. The allowed amount would be reported as the aggregate of the actual amount the plan or insurer paid to the provider for an item or service, plus the participant’s, beneficiary’s, or enrollee’s share of the cost. To protect patient privacy, out-of-network allowed amount information would not be reported for services and providers for which there were fewer than ten different claims for payment.
EBIA Comment: The agencies have requested comments on all aspects of the proposed regulations, including the proposed model notice and data elements. Comments may be submitted electronically or by mail and must be received by January 14, 2020. For more information, see EBIA’s Health Care Reform manual at Section XXXVI.F (“‘Transparency in Coverage’ Reporting and Cost-Sharing Disclosures”), EBIA’s Self-Insured Health Plans manual at Section XXVIII.A (“Overview of Participant Disclosure Requirements”), and EBIA’s Consumer-Driven Health Care manual at Section V.E (“Summary of Effects of Health Care Reform on Account-Based Plans”).
Contributing Editors: EBIA Staff.