The Transparency in Coverage Final Rules require non-grandfathered group health plans and health insurance issuers offering non-grandfathered coverage in the group and individual markets to disclose on a public website information regarding in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for covered items and services, and negotiated rates and historical net prices for covered prescription drugs. By requiring the dissemination of price and benefit information directly to consumers and to the public, the transparency in coverage requirements are intended to provide the following consumer benefits:

• Enables consumers to evaluate health care options and to make cost-conscious decisions;

• Strengthens the support consumers receive from stakeholders that help protect and engage consumers;

• Reduces potential surprises in relation to individual consumers' out-of-pocket costs for health care services;

• Creates a competitive dynamic that may narrow price dispersion for the same items and services in the same health care markets; and

• Puts downward pressure on prices which, in turn, potentially lowers overall health care costs.

The goal of the final rules is to deliver these benefits to all consumers and health care stakeholders through greater transparency in coverage. CMS requires that the information be provided in three separate machine-readable files. The machine-readable file requirements are applicable to payment rates beginning on or after January 1, 2022. For example, Humana has recently released their rates via the Humana Data Exchange website (https://developers.humana.com/Cost-Transparency). In 2023 and 2024, CMS will require implementation of internet-based comparison tools that allow an individual to directly estimate their cost-sharing responsibility for a specific service from a specific provider. For more information on the Transparency in Coverage Final Rules, refer to the CMS website at https://www.cms.gov/healthplan-price-transparency/plans-and-issuers.

Implications

Although the intended goal is to provide consumers with more price transparency when making decisions on healthcare, the benefits of this new data are game-changing as it provides researchers and stakeholders involved in the economics of health several opportunities that were not always cost-efficient or available with existing datasets, including, but not limited:

• The ability to capture a much broader and diverse list of item and service payment rates from health plans not historically accessible

• Granularity into commercial (private, Medicare Advantage, Managed Medicaid, Workers' Compensation, etc.) plans rates

• Ability to differentiate rates across National, Regional, State plans and providers that are not standardized like Medicare

• The ability to fill evidence gaps when considering the heterogenous provider insurance mix across diseases

• A lens into the provider practice economics across both inpatient and outpatient settings of care

• A set of data points that often require costly and time-intensive claims analyses

• An opportunity to reduce assumptions and limitations related to economic models such as budget impact and cost-effectiveness

• A chance to design individualized-specific analyses that customer often request and rarely can be fulfilled

At QualiaBio, our team has been fast at work to develop a Health Plan and Insurer Price Transparency Database, which will combine payments rates for items and services across many of the most common health plans in the US. This database will be integrated into our existing Hospital Price Transparency database to optimize the data capture on the payment rates of items and services across the majority of US hospitals and health plans. Contact us to learn more about our existing existing analytics as well as upcoming planned analytics. We can be reached at [email protected].