In case you haven’t heard, the IRS, Department of Labor, and Department of Health and Human Services have issued the Transparency in Coverage rule. But what exactly is it? In simple terms, it means employer-sponsored group health plans and health insurance issuers in the individual and group markets are going to be required to make cost-sharing information available upon request to members, their beneficiaries, or enrollees.

Starting July 1st, 2022* employer-sponsored group health plans and health insurance issuers will have to provide:

• Negotiated rates for all covered items and services between the plan and in-network providers.

• Historical payments to, and billed charges from, out-of-network providers.

• In-network negotiated rates and historical net prices for all covered prescription drugs by plans.

• A self-service tool for enrollees to get personalized out-of-pocket cost estimates for care. 

So how does all that affect TPAs?

As a TPA, you can expect many of your clients will come to you with questions, and also look to you for solutions in becoming compliant with the Transparency in Coverage rules. This means that TPAs need to become well-versed in the rule details to design solutions for compliance. If they don’t, TPAs stand to lose clients, revenue, and credibility.

What solutions can TPAs provide to their clients?

Solutions should be customized to TPAs’ specific clients, but solutions exist already that meet some of the compliance requirements. For example, a simple answer to “how do we create a self-service tool for people to see personalized out-of-pocket cost estimates?” is to partner with a company that’s already created this tool. If you’re a TPA or health plan reading this, lucky you, we've already created a platform for people to shop and compare medical care and medications based on their coverage. If you want to get a head start on your journey to compliance with the Transparency in Coverage rule, request a demo here of the PointHealthTech Smart Healthcare Platform!

Other solutions will be more customized and hands-on. TPAs with clients who want to be compliant by January 1st, 2022 should already be working with those clients to collect historical payments and negotiated rates to get started on what will surely be a lot of work.‍

Things to think about.

There are still a lot of questions and uncertainties about this new rule. Especially on the specifics of how employer-sponsored group health plans and health insurance issuers in the individual and group markets can be compliant with the rule. TPAs can help find the answer to “how” by thinking of solutions now and meeting with clients to determine the best course of action. If anyone is hoping the rule won’t happen, don’t hold your breath. A lot of hospitals hoped for the same thing when the Hospital Price Transparency rule came up, but it went into effect on January 1st. Plus, the new administration has continued to enforce that rule. Not to mention, noncompliance with the rule could lead to a possible fine of $100 per member per day. Possibly more. It's highly likely that the Transparency in Coverage rule will also happen, so it’s best to start preparing sooner rather than later.

Transparency in Coverage TPA Survey

Curious about how prepared other TPAs are for the Transparency in Coverage rule and what they are doing about it? Us too! To help us all understand how TPAs are approaching Transparency in Coverage, we are surveying a select group about their knowledge and preparation for the new rules.

We would love to include your insights in the survey. Your responses will be kept confidential and the results will be reported back to participating TPAs in aggregate.

The survey is less than 20 questions and should take no more than 5 minutes to complete on your computer or mobile device.

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*The original publication stated the Transparency in Coverage rule would go into effect on January 1st, 2022. This blog was updated on August 24th, 2021 to reflect the updated enforcement date of July 1st, 2022 for the Transparency in Coverage rule from CMS.