Three End-of-Year Transparency Deadlines to Remember
The Transparency Rules are a collection of regulations and statutory provisions intended to improve the health care industry and protect consumers.
Some hopeful results include:
- improving costs through increasing transparency and increasing competition,
- creating cost savings for both the consumer and the employers,
- protecting and helping consumers make more informed health care decisions,
- achieving improved health outcomes,
- and driving innovation.
The transparency rules fall into two main categories: the Transparency in Coverage Final Rules (TiCFR) and the Consolidated Appropriations Act (CAA).
Underneath the CAA umbrella, there are three separate rules that address transparency:
- CAA No Surprises Act (NSA)
- CAA Transparency in Coverage rules (not to be confused with the TiCFR),
- CAA Mental Health Parity and Equity Act (MHPAEA) reports
All of these rules are sometimes referred to collectively and generally, as the Transparency Rules.
The Transparency Rules add:
- additional disclosure obligations and reporting requirements for health insurers/carriers/TPAs,
- health care providers,
- and group health plans (and the employers that sponsor those plans).
An employer that sponsors a group health plan should be aware of three upcoming end of year deadlines, each of which is described in more detail in this article.
Pharmacy Benefits & Drug Costs Report (RxDC)
- December 27, 2022 is due date for the report covering 2020 and 2021 data.
Participant-Level Transparency in Coverage (TiCFR)
- By the first day of the plan year starting on or after January 1, 2023.
Notice Regarding Patient Protections Against Surprise Billing
- By the first day of the plan year starting on or after January 1, 2023.
Pharmacy Benefits and Drug Costs Report (RxDC)
The CAA Transparency in Coverage provisions, commonly referred to as the Prescription Drug Data Collection (RxDC) report, require all employer-sponsored medical plans, both fully insured and self-insured plans, to submit each year a new annual prescription drug and health care spending report.
Reporting for the 2020 and 2021 calendar years is due December 27, 2022 and then reporting will be due each June 1, for subsequent calendar years.
For example, absent any extensions, the second report containing 2022 data is due June 1, 2023.
There are separate TiCFR rules that require similar disclosure to participants, but that rule has been delayed given the overlapping requirements under the CAA.
The RxDC report includes the following data:
P File
For group health plans, this will be a P2 file.
D Files
- D1 Premium and Life-Years (see pages 20 to 23 in CMS instructions)
- D2 Spending by Category (see pages 23 to 30 in CMS instructions)
- D3 Top 50 Most Frequent Brand Drugs
- D4 Top 50 Most Costly Drugs
- D5 Top 50 Drugs by Spending Increase
- D6 Rx Totals
- D7 Rx Rebates by Therapeutic Class
- D8 Rx Rebates for the Top 25 Drugs
Narrative Response
This is a Word or PDF document where the 8 questions/topics are answered in narrative form.
The reports are submitted to the DOL, HHS and Treasury (the Departments) through a web portal set up by the DOL’s Centers for Medicare & Medicaid Services (CMS).
Generally, employers that sponsor fully insured plans will rely on their insurance carrier to submit the report but may be asked to provide some basic information.
These employers should coordinate with their third-party administrator (TPA) or pharmacy benefit manager (PBM) to assist and make sure the report is completed on the plan’s behalf. Typically, the TPA will complete P2, D1-D2 and the PBM will complete D3-D8.
Remember, employers maintain responsibility for complying with this rule even when others are acting on their behalf.
Price Comparison Tool for Participants
The Transparency in Coverage Final Rules (TiCFR) require group health plans, starting with their 2023 plan year, to offer an internet-based price comparison tool disclosing a (preliminary) list of 500 shoppable items and services.
All remaining items and services must be added to this tool by their 2024 plan year. This information must also be available over the telephone and/or in paper form.
The tool provides consumers with real-time cost estimates from different providers for covered items and services to enable shopping and comparing prices before receiving care.
A very similar price comparison tool is also required under the CAA.
To minimize compliance burdens and duplication, the Departments (DOL, HHS, IRS) aligned the effective dates and suggested possible proposed regulations that would allow compliance with the TiCFR rules to also satisfy compliance with the CAA No Surprises Act, as long as access via telephone (as required by the CAA) is also provided.
January 1, 2023 • TiCFR
Private disclosure to participants, first 500 items and services listed, remaining items added to list by 2024.
January 1, 2023 • CAA No Surprises Act
Price cost-sharing comparison tool for participants by phone and website (original effective date 1/1/22).
Most employers that sponsor group health plans will rely on their carrier or third-party administrator (TPA) to develop and maintain the internet price comparison tool as well as provide information via paper or over the phone.
Employers should confirm that their carrier or TPA is on track for compliance by 2023.
Remember employers maintain responsibility for complying with this rule even when others are acting on their behalf.
Notice Regarding Patient Protections Against Surprise Billing
The CAA No Surprises Act (NSA) seeks to protect patients from surprise billing including those who get emergency care and certain non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.
Participants who are enrolled in an employer sponsored group health plan must be notified of their rights and protections against surprise medical bills through the model notice or alternatively, a notice that includes:
- the restrictions on providers and facilities regarding balance billing in certain circumstances,
- any applicable state law protections against balance billing, and
- information on contacting appropriate state and federal agencies in the case that an individual believes that a provider or facility has violated the restrictions against balance billing.
All employers that maintain a public website for their group health plan (different than a public facing website) should post the new “version 2” notice on that site by the first day of the plan year beginning on or after January 1, 2023.
Employers without a public group health plan website should be able to rely on their carrier (if group health plan is insured) or their TPA (if the group health plan is self/level funded) to post this notice on the carrier/TPA public website for the plan.
Remember, employers maintain responsibility for complying with this rule even when others are acting on their behalf.
Although it is not required, some employers that want to ensure their employees understand their rights and protections under this rule are also voluntarily including the model notice in their annual notices packets provided at open enrollment and at hire for eligible employees.
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