BLUECONNECT
Commercial Brokers
New Cost Estimate Tools for Members
Beginning in January 2022, health insurers and group health plans are required to provide a price transparency tool that gives members the ability to access real-time estimates of their cost-sharing liability for health care items and services from different providers. The tool is required to:
  • Allow members to understand how costs for covered health care items and services are determined by their plan.
  • Allow members to search based on billing code or description.
  • Allow members to compare costs between in-network and out-of-network providers.
  • Inform members of any accumulated deductible or other out-of-pocket costs.
  • Identify factors that affect cost, such as service location or drug dosage.
  • The data must be available through an internet-based self-service tool.
  • A paper form of the estimate must be available through customer service.
The price transparency tool is required to make available personalized out-of-pocket cost information as well as the underlying negotiated rates and allowed amounts for all covered health care items and services. This will include prescription drugs when that part of the rule is finalized.

Transparency in Coverage Rules
Under Transparency in Coverage, there are two different kinds of required disclosures: public disclosures and plan participant disclosures. These rules will be implemented in phases, over the course of about three years, beginning with the public posting of pricing data and progressing to a more personalized transparency experience for plan members.

Timeline
January 1, 2022
Publicly disclose:
  • In-network provider negotiated rates
  • Historical allowed amounts for out-of-network providers
  • Access to public machine-readable files
January 1, 2023
Disclose to participants via online services tool:
  • Personalized, out-of-pocket cost estimates and other price related data for the identified 500 ‘shoppable’ services
January 1, 2024
Expand:
  • Expand online self-service tool to include cost estimates and other price related data for all covered items and services
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