New requirements for payers under CMS' Transparency in Coverage rule took effect Jan. 1.
Since July 1, 2022, payers have been required to disclose in-network provider rates for covered items and services; out-of-network allowed amounts and billed charges for all covered items and services; and negotiated rates and historical net prices for covered prescription drugs administered by providers.
In 2023, payers were required to provide an internet-based price comparison tool that allows members to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers for 500 items and services. For 2024, price comparison tools must include all services, including prescription drugs.
Plans subject to the new rule include individual and group plans (self-insured and level-funded). Those not subject include account-based group plans (HRAs, FSAs, HSAs). Payers not in compliance could face fines of up to $100 per day for each violation and for each individual affected by the violation.