CMS releases final price disclosure rule: 5 things to know

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CMS unveiled a final rule Oct. 29 that requires health plans to disclose the rates they negotiate with hospitals and other healthcare providers. 

Five things to know: 

1. The final rule requires health insurers to offer an online tool that provides members with personalized out-of-pocket cost information and the negotiated rates for all covered services and items, including prescription drugs. Health plans must also provide this information in paper form if it is requested. 

2. CMS said insurers will be required to provide a list of 500 shoppable services via the online tool for plan years that begin on or after Jan. 1, 2023. Insurers will be required to provide cost information for additional items and services for plan years that begin on or after Jan. 1, 2024. 

3. The final rule requires health insurers and group health plans to provide the public with three separate machine-readable files that include detailed pricing information. 

4. The first file will show negotiated rates for all covered items and services between the plan and in-network providers. The second file will show both the historical payments to and billed charges from out-of-network providers. The third file will detail in-network negotiated rates and historical net prices for all covered prescription drugs. These data files will be made public for plan years that begin on or after Jan. 1, 2022, and will be updated monthly. 

5. Insurers that offer plans that encourage the use of lower-cost, higher-value providers can take credit for "shared savings" payments in their medical loss ratio calculations. HHS said it believes this change will encourage insurers "to offer new or different value-based plan designs that support competition and consumer engagement in the healthcare market."

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