The US Federal government departments released mandates for Health Plans or Issuers to provide better transparency in coverage for consumers. Plans must disclose cost-sharing information to enrollees, beneficiaries, or participants related to the covered services. Issuers also need to publish in-network negotiated rates, historical out-of-network allowed amounts, and prescription drug pricing based on each provider's contracts and plans offered. The disclosed information will guide the consumers to make better decisions regarding services, providers, and their health. Health Plans need to integrate their internal systems to achieve compliance.

Milestones on the Timeline

Milestones on the Timeline
MLR Calculation Update

Effective with the 2020 MLR reporting year

Disclosure to Public

Applicable for Plan years beginning on or after
Jan 1, 2022

Disclosure to Enrollees

Jan 1, 2023 – Applicable to 500 Pre-defined items or services

Disclosure to Enrollees

Jan 1, 2024 – Applicable to
all items or services

Requirements

Seven Content Elements

Disclose cost-sharing information to enrollees

  • Estimated Cost-sharing Liability
  • Accumulated Amounts
  • Negotiated Rates
  • Out-of-network Allowed Amounts
  • List of Items and Services
  • Notice of Prerequisites
  • Disclosure Notice
Self-Service Tool

Share an estimate of cost-sharing details with enrollees via an internet website

Paper Form

Members can request cost-sharing information from health plans in paper form

In-network File

Disclose negotiated in-network rate every month based on contracts

Allowed Amount File

Disclose allowed amount and historical bill charges every month

Drug Prescription File

Disclose negotiated rate and historical net price every month

Medical Loss Ratio

Formula updated to credit health plans for “shared savings” payments

How Can You Achieve It?

To ensure that your solution fulfills future requirements, below are the vital elements you need to account for in your technology roadmap.

Enterprise Applications Integration

Authentication and Authorization

Content & Vocabulary Mappings

Data
Management

Error Handling

Audit

FHIR

We Can Help You With

Assessment

Compliance gap identification, and process blueprinting

Roadmap Planning

Chart out an execution plan with milestones

Implementation

Leverage technology to realize the roadmap

Go-Live and Support

Performance consistency and continuous improvement

Let’s Talk

Ensure your systems and processes are compliant with Transparency in Coverage!

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