We understand that group health plans must provide participants with new price comparison tools beginning in January. Can you please explain these requirements?

Effective for plan years beginning on or after January 1, 2023, the Transparency in Coverage Final Rule (TiC) requires most group health plans and carriers to make personalized out-of-pocket cost information available to participants through an internet-based self-service tool or in paper format (upon request). The requirements do not apply to grandfathered plans, account-based plans (e.g., HRAs and FSAs) and excepted benefits (e.g., stand-alone dental and vision benefits).

The purpose of the self-service tool is to provide participants with real-time, accurate estimates of their cost-sharing liability for healthcare items and services from different providers. This information may help participants to understand how costs for covered items and services are determined by their plan and to shop and compare healthcare costs prior to receiving care.

Specifically, the internet self-service tool must provide a participant with the following information:

• An estimate of the participant’s cost-sharing liability for a requested covered item or service.
• Accumulated amounts to date that the participant has incurred towards the plan deductible and out-of-pocket limit.
• The in-network (INN) rate (expressed as a dollar amount) and if applicable, the fee schedule for an INN provider’s services.
• The out-of-network (OON) allowed amount if the request is for an OON provider’s services.
• If the request involves a bundled payment arrangement, a list of the items and services for which the cost-sharing information is being disclosed.
• Any prerequisites (e.g., pre-authorization, concurrent review, step therapy or first-fail protocols) applicable to an item or service.

The information must be provided in plain language and be accompanied by a notice that reflects certain disclosures. Amongst other items, the notice must indicate that the cost-sharing is only an estimate, not a guarantee of coverage, and that participants may still be balanced billed for OON services.

Participants must be able to conduct a search using the tool by entering a descriptive term (e.g., rapid flu test) or billing code, provider name and other factors relevant to determine cost-sharing (e.g., facility name, service location). Where there are multiple results for in-network services, the search must allow participants to reorder information by geographic proximity and estimated cost-sharing amount. If information is requested in paper form, it must be mailed not later than two business days after the request is received.

Importantly, the TiC provided phased-in effective dates for the internet self-service tool requirement. An initial list of 500 “shoppable” items and services must be made available through the tool for plan years beginning on or after January 1, 2023. The current list of 500 items and services is available on the CMS website: CMS 500 Items and Services List for Price Comparison Tool. The list will be updated quarterly. For plan years beginning on or after January 1, 2024, all items and services, including prescription drugs and durable medical equipment (e.g., blood testing strips for diabetics), must be made available.

Employers that sponsor group health plans should consult with their carriers or third-party administrators (TPAs) to ensure the implementation of the self-service tool requirement, including any instructional materials for participants, is on schedule. Like the other TiC requirement (the machine-readable file disclosures), it is anticipated that employers will contract with their carriers and TPAs to assist with fulfilling the requirements. Fully insured plans can contract with their carrier to assume liability for the tool disclosures. Self-insured plans can contract with TPAs or other vendors but remain responsible for satisfying the requirements. It is advisable for employers to engage counsel in the contracting process.

For further information regarding the TiC and self-service tool requirements, please review the Transparency in Coverage Final Rule.