Recently, a bipartisan duo of United States Senators sent a letter to the Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure, asking the agency to update its regulations to “ensure that there is true health plan transparency and compliance” in the Transparency in Coverage (TiC) rule.
As the letter from Maggie Hassan and Mike Braun notes, the TiC rule was issued by CMS in July 2022, and it requires health insurance companies to publicly publish in- and out-of-network rates for health care plans that they offer. The hope was that employers, policymakers, and others would be able to “identify unreasonable prices and excessive increases,” which would ultimately lead to lower prices for consumers and patients.
After the July 2022 requirements, on January 1, 2023, additional requirements went into effect, including the requirement of an internet-based price comparison tool (also available by phone or paper form upon request) by which consumers can receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider(s) for 500 items and services. Cost estimates are required to be provided in real-time based on cost-sharing information that should be accurate at the time of the request. The final stage will go into effect on January 1, 2024, when the internet-based price comparison tool will need to allow an individual to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider(s) for all items and services.
However, the letter says that while some insurance companies have complied with the rules, “others may be relying on gaps to evade accountability,” including providing information in an “indecipherable structure,” omitting pricing information, or putting the information into files that are too large for anything short of a supercomputer to process. The letter also states that the way the system is currently set up “makes cross-plan comparisons challenging,” as each plan may be formatting or structuring their data differently. Further, there is no central repository that the public can go to and find plan data.
To that end, Senators Hassan and Braun cited some of the options CMS has at this point to improve the data accessibility, usability, and quality so that employers, policymakers, and others are able to use the data in the way it is intended. Some solutions include limiting the file sizes, creating a standardized reporting template, reducing the frequency of reporting, and requiring a clear organizational system and standardized labeling. Just these changes along would “allow the public to use the data more effectively, while simplifying the reporting process for plans.”
CMS has the ability to take enforcement action against plans and issuers that do not comply with the rule, including requiring corrective action plans and imposing civil monetary penalty of up to $100 per day (adjusted annually) for each violation and for each individual affected by the violation.
The Senators also suggest that CMS increase its enforcement efforts and target plans that provide low-quality data or no data at all. Random audits may “result in better usability” and enforcement would “help ensure that remaining noncompliant plans follow the law.”