Transparency in Coverage Machine-Readable Files

Overview
Insurers and plans will be required to make available to the public, pricing files to be updated monthly, effective for plan years on and after January 1, 2022.

Enforcement date for in and out of network machine readable files is July 1, 2022
Enforcement date for the pharmacy machine-readable file is delayed pending further rule-making

Federal rules
Excerpt from the original Full Final Rule
Dated November 12, 2020

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“3. Requirements for Public Disclosure of In-network Provider Rates for Covered Items and Services, Out-of-network Allowed Amounts and Prescription Drug Pricing Information Through Machine-readable Files under 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212.”

Excerpt from Final Rule Fact Sheet
Dated October 29, 2020

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“Group health plans or health insurance issuers offering non-grandfathered health insurance coverage in the individual and group markets will be required to make available to the public, including stakeholders such as consumers, researchers, employers, and third-party developers, three separate machine-readable files that include detailed pricing information.

• The first file will show negotiated rates for all covered items and services between the plan or issuer and in-network providers. (Note: enforcement delayed until 7/1/22 per FAQS ABOUT AFFORDABLE CARE ACT AND CONSOLIDATED APPROPRIATIONS ACT, 2021 IMPLEMENTATION PART 49 (PDF)- Opens in a new window)

• The second file will show both the historical payments to, and billed charges from, out-of-network providers. Historical payments must have a minimum of twenty entries in order to protect consumer privacy. (Note: enforcement delayed until 7/1/22 per FAQS ABOUT AFFORDABLE CARE ACT AND CONSOLIDATED APPROPRIATIONS ACT, 2021 IMPLEMENTATION PART 49 (PDF)- Opens in a new window)

• The third file will detail the in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level. (Note: delayed pending further rulemaking, per FAQS ABOUT AFFORDABLE CARE ACT AND CONSOLIDATED APPROPRIATIONS ACT, 2021 IMPLEMENTATION PART 49 (PDF)- Opens in a new window)

Plans and issuers will display these data files in a standardized format and will provide monthly updates. This data will provide opportunities for detailed research studies, data analysis, and offer third party developers and innovators the ability to create private sector solutions to help drive additional price comparison and consumerism in the health care market. These files are required to be made public for plan years that begin on or after January 1, 2022.”

To learn more, go to the Blue Cross Blue Shield page (click here to redirect to the external site)