New Price Transparency Rules: What Employers and Consultants Need to Know

On Oct. 29, 2020, the federal government issued new healthcare price transparency rules that apply to both self-insured employers and payers. These rules include a mandate and deadlines to give group benefits plan members access to a healthcare price transparency tool.

Bill Kampine, Healthcare Bluebook co-founder and senior vice president, is a nationally recognized expert on healthcare price and quality transparency. He was invited by the Centers for Medicare and Medicaid Services (CMS) to provide input during the rule-making process. Kampine also authored his company’s formal response to the draft rules.

Dave Luby, Quantum Health senior vice president, Client Experience, recently spoke with Kampine to discuss what employers and consultants should know about the new requirements.

Q: What’s the background behind these new transparency rules?

A: In the 2017-2018 time frame, leaders in Congress and the White House had strong interest in giving employers and consumers more transparency into healthcare costs and, with that, greater control over their spend. When Senate leaders saw political barriers to passing new legislation, the U.S. Department of Health and Human Services (HHS) looked at what administrative rule‐making authority was available under existing law — namely, the Affordable Care Act (ACA). Based on ACA language, HHS proposed a set of rules intended to make price transparency tools and data more widely available. After a period of public comment — comment that was historically extensive (more than 25,000 pages) — the final rules were published in late October.

Q: In a nutshell, what do the rules require of self-insured employers?

A: There are two main requirements that directly affect employers: First, starting Jan. 1, 2023, they must provide members with a consumer-friendly online tool for accessing cost information. The system must provide both in-network and out-of-network prices for providers and facilities; show a member’s accumulating balances toward deductible and out-of-pocket limits; and present an out-of-pocket estimate for each service. Second, self-insured employers and carriers who offer group plans must publish and share their in-network, out-of-network and pharmacy cost data in machine-readable file formats. The intent is to make pricing data accessible for academics, regulators, policymakers and even entrepreneurs, so they can use it for research and analysis. The assumption is that an employer will have their third-party administrator (TPA) or other payer partner submit these required data files. The first deadline for publishing this data is Jan. 1, 2022.

Q: The big news is the transparency tool mandate. What else should employers know about it?

A: As written, the rules apply to all self-insured employers. There are no exceptions based on group size or other criteria. The rules take effect in two stages: Effective Jan. 1, 2023, the tool must give consumers prices on 500 medical services and procedures. By Jan. 1, 2024, the tool must provide cost information on all services. The rules require that a price for each service be published regardless of whether a claim has been filed on each service. Traditionally, cost information has been based on filed claims.

Q: When you say, “as written,” it sounds as though you believe the rules aren’t set in stone.

A: There’s a chance they could be changed, amended or delayed, especially with the recent changes in presidential administration and congressional leadership. Also, because the ACA remains a focus of legal challenges, there’s a chance the entire law could be overturned. That would eliminate the statutory authority on which the rules are based. Those caveats aside, self-insured employers should still assume they’ll be required to comply with the rules.

Q: What would you recommend benefits leaders focus on at this point?

A: If you have a transparency tool and partner that you and your members are happy with, confirm with that partner or your TPA that they will be able to meet the new requirements, including the first data publishing deadline coming up early next year. If you don’t have a partner who provides a transparency tool, find one as soon as possible. You’ll want to consider it a minimum requirement that they be able to meet the new rules. The spirit of cost transparency — and what these rules are designed to support — is an easy, effective user experience that empowers consumers with the data they need to make informed healthcare choices.

Q: Do you consider these new rules a help or a hindrance to cost transparency?

A: Employers and members want to know what healthcare is going to cost. Now it’s no longer a matter of whether they’ll have access to that information, but when. A key value Quantum Health provides for clients is that, regardless of which transparency tool they have, you’ll support its utilization and guide members to high-quality, cost-effective in-network providers. Meanwhile, Healthcare Bluebook and others in our category are committed to driving this movement forward with innovative, easier-to-use tools for employers and consumers. I see the rules as a positive for all stakeholders on the purchasing side of healthcare.

For more on the new transparency rules, including a fact sheet and the final rules language, visit the CMS website.