The Transparency in Coverage (TiC) rule is gaining more attention as the deadline to post a public link to certain machine-readable data files approaches. More and more insurers and plan issuers are addressing these with their customers causing a stir amongst group health plans.

What is it? The TiC rule is part of the federal transparency efforts we’ve talked about before here. The rule includes several new laws, one of which is the requirement that insurers and health plans must publicly post certain machine-readable files described here:

  • The In-Network Rate File – All applicable rates paid to in-network providers for all covered items and services (including negotiated rates, underlying fee schedules, etc.);
  • The Allowed Amount File – Billed charges and allowed amounts for covered items and services provided by out-of-network providers; and
  • The Prescription Drug File – Negotiated rates and historical prices for prescription drugs furnished by in-network providers. – this file has been delayed indefinitely

Who must comply? Non-grandfathered group health plans, regardless of number of participants.

  • Fully insured plans: the carrier/insurer is responsible for creating and hosting the files. Employers should follow the guidance of their health insurance carrier regarding posting requirements.

Note: Most carriers/insurers of fully insured plans appear to be taking responsibility for posting the files as well except Cigna. Please contact your benefits advisor for more information.

  • Self-insured plans: the TPA will need to produce the files and link to where the files are hosted. However,self-insured medical plans are faced with a lack of clear guidance on whether files hosted on a the TPA’s public website are enough to comply. For those employers wanting to take a conservative approach, the safest course of action would be to post the link to the files on its own public website.  We are hopeful that more guidance will be released to provide clarity for group health plan sponsors.

What action is needed? For fully insured plans, the insurer will or may have already connected with your employer for guidance and instruction. We recommend following the guidance of your carrier.

For self-insured plans, an employer will need to connect with their TPA to ensure they will provide a link to the file on your behalf so that your employer can post on its public website.

What is the purpose of these files? The files are not meant for plan participants, rather, the machine-readable files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.

These files are not member-friendly; however, member-friendly tools will be available in 2023 and 2024 per the Federal transparency efforts.

Do employers need to notify participants? The law does not require that the group health plan notify its participants of the availability of these files.

What is the deadline to comply? July 1, 2022

What if my employer doesn’t have a public website? It seems reasonable that an employer could rely on their insurer to post on their public website which is especially true for fully insured group health plans. Further DOL guidance would be welcome here.

Where can I learn more about the Federal Transparency Efforts? Click this link for a recording of the latest Bolton webinar on the topic.