On April 19, 2022, the Departments of Labor, Health and Human Services, and Treasure (Tri-Agencies) issued new guidance in the form of two FAQs regarding the Transparency in Coverage (TIC) rules.

Background

• The TIC rules were originally issued in November 2020, covering implementation of price transparency requirements under the Affordable Care Act (ACA). The rules require plans and plan issuers to provide information, for plan years beginning on or after January 1, 2022, in three publicly posted, machine-readable files:
  • In-network rates
  • Out-of-network allowed amounts and billed charges
  • Negotiated rates and historical net prices for prescription drugs
• Enforcement of the requirements for the first two machine-readable files was delayed until July 1, 2022. Enforcement of the requirements for the prescription drug file has been deferred indefinitely pending further rulemaking.

New Guidance

• The TIC rules require that rates, which may include negotiated rates, underlying fee schedule rates, or derived amounts, be expressed in dollar amounts. The guidance provides further clarity with respect to situations where it may not be possible for plans to report rates in advance as dollar amounts because providers are not reimbursed on a fee-for-service basis.
• For plans that report rates as a percentage of billed charges or in another alternative arrangement, the guidance offers two safe harbors:
  • Rates may be reported as a percentage rather than as a dollar amount, subject to specific formatting requirements.
  • If rates are reported in a different reimbursement arrangement that is not supported by Centers for Medicare and Medicaid Services (CMS) technical implementation guidance, plans may use an open text field to provide a description of the formula, variables, methodology, and any other information necessary to understand the reimbursement arrangement.