Transparency in Coverage Rule

In 2020, the Federal Government finalized “Transparency in Coverage” Rule, which requires health insurers and group health plans, including self-funded clients, to provide cost-sharing data to consumers via:

• Machine-readable files: Machine-readable files must be published on a publicly available site based on the enforcement date of July 1, 2022, for plan years beginning on or after Jan. 1, 2022. These files provide pricing data for covered items and services based on in-network negotiated payment rates and historical out-of-network allowed amounts.
• Consumer price transparency tool: This online tool for members will include personalized, real-time, cost-share estimates for covered services and items, including pharmacy. Paper versions must be available upon request from BCBS. For plan years beginning on or after Jan 1, 2023, the online tool must provide cost-share estimates for 500 shoppable services. For plan years beginning on or after Jan. 1, 2024, the online tool must provide cost-share estimates for all covered services.

Transparency in Coverage Consumer Price Transparency Tool

Starting with plan years beginning on or after January 1, 2023, insurers and plans must make an online price transparency tool available for 500 shoppable items, services and drugs identified in the final rule. All covered items, services, and drugs are required to be included in the consumer price transparency tool for plan years that begin on or after January 1, 2024.

Consumers will be able to get real-time estimates of their cost-sharing liability for health care items and services from different providers. The tool requirements allow the members to understand how costs for covered health care items and services are determined by their plan.

The tool provides personalized out-of-pocket cost information as well as the underlying negotiated rates and allowed amounts for all covered health care items and services including prescription drugs.

Resources for Transparency in Coverage