QUESTION: We’ve heard that our company’s group health plan must make public transparency disclosures that include MRFs. What are MRFs, and how often do they have to be updated?
ANSWER: The agencies use the acronym “MRF” to refer to the machine-readable files that must be made public as part of the ACA’s price transparency requirement. Under implementing regulations issued in November 2020, most health plans and insurers in the individual and group markets must make transparency in coverage (TiC) cost-sharing disclosures that include (1) in-network provider negotiated rates, (2) historical out-of-network allowed amounts for providers, and (3) in-network negotiated rates and historical net prices for all covered prescription drugs at the pharmacy-location level (see our Checkpoint article). The regulations required the files to be made public for plan years that begin on or after January 1, 2022. However, shortly after the TiC regulations were finalized, Congress enacted additional transparency requirements that overlap with the TiC regulations (see our Checkpoint article). Consequently, the agencies deferred enforcement of the requirements for in-network and out-of-network rates until July 1, 2022. Enforcement of the prescription drug disclosures is deferred indefinitely, pending additional rulemaking (see our Checkpoint article).
The in-network and out-of-network rate disclosures must be made through three MRFs posted on an internet website in a standardized format, updated monthly. The regulations define MRF to mean a digital representation of data or information in a file that can be imported or read by a computer system for further processing without human intervention, while ensuring no semantic meaning is lost. Each MRF must use a non-proprietary, open format to be identified in technical implementation guidance (for example, JSON, XML, CSV). A PDF file, for example, would not meet this definition due to its proprietary nature. The MRFs are also required to comply with technical, non-substantive implementation guidance to be provided by the agencies. The TiC regulations identify the required data elements. The disclosures are intended to allow the public to access health insurance coverage information that can be used to understand health care pricing.
In addition to the public disclosures in the MRFs, the TiC regulations also require plans and insurers to disclose individualized cost-sharing information to a participant, beneficiary, or enrollee (or his or her authorized representative) upon request, including an estimate of the individual’s cost-sharing liability for covered items or services furnished by a particular provider. These disclosures, which must be available through an internet-based self-service tool and on paper, are required for an initial list of 500 items and services for plan years that begin on or after January 1, 2023, with all items and services to be disclosed for plan years that begin on or after January 1, 2024 (see our Checkpoint Question of the Week).
For more information, see EBIA’s Health Care Reform manual at Section XXXVII.D (“Transparency in Coverage Cost-Sharing Disclosures”). See also EBIA’s Self-Insured Health Plans manual at Section XXVIII.H (“Transparency in Coverage Cost-Sharing Disclosures”).
Contributing Editors: EBIA Staff.
