On Sept. 27, 2023, the Departments of Labor, Health and Human Service, and the Treasury (Departments) issued Frequently Asked Questions (FAQs), ending certain enforcement relief related to the transparency requirement for posting machine-readable files (MRFs).

The FAQs end the enforcement delay for posting MRFs related to prescription drug pricing. The Departments intend to provide an implementation timeline for this requirement in the future. The FAQs also end the enforcement of safe harbor for health plans and health insurance issuers that use alternative reimbursement arrangements and cannot express in-network rates as dollar amounts.

Going forward, the Departments will exercise enforcement discretion for these arrangements on a case-by-case basis.

Highlights

• Non-grandfathered health plans and issuers must publicly post three MRFs regarding in-network provider rates, out-of-network allowed amounts and billed charges, and prescription drug rates and prices.
• The Departments have ended an enforcement delay for posting the prescription drug file. Future guidance will specify a timeline for complying with this requirement.
• The Departments have also ended an enforcement safe harbor related to disclosing certain in-network pricing.

MRF posting requirement

Beginning July 1, 2022, the Transparency in Coverage Final Rules require non-grandfathered health plans and issuers to disclose on a public website detailed pricing information in three separate MRFs. Specifically, the following MRFs are required:

• In-network Rate File: In-network provider negotiated rates for covered items and services.
• Allowed Amount File: Historical payments to and billed charges from out-of-network providers.
• Prescription Drug File: In-network negotiated rates and historical net prices for covered prescription drugs.

Most employers rely on their insurance carriers and third-party administrators to provide and post the MRFs.

Enforcement delay–prescription drug file

In August 2021, the Departments issued FAQs that delayed the requirement to post a Prescription Drug File, pending further guidance. The Departments temporarily delayed enforcing this posting requirement to assess whether it conflicts with the new prescription drug reporting requirement created by the Consolidated Appropriations Act, 2021, which is known as RxDC reporting.

The Departments have now determined there is no “meaningful conflict” between the Prescription Drug File and RxDC reporting. Thus, the Departments’ latest FAQs rescind the enforcement delay for posting the Prescription Drug File. The FAQs state that the Departments intend to issue additional guidance to address technical requirements and provide an implementation timeline for posting the Prescription Drug File for plans and issuers that relied on the enforcement delay.

Enforcement safe harbor–in-network rate file

In April 2022, the Departments issued FAQs providing an enforcement safe harbor for the In-network Rate File when alternative reimbursement arrangements do not allow plans and issuers to express in-network rates as dollar amounts. The latest FAQs rescind this safe harbor, stating that the Departments did not intend to provide a categorical exception to the MRF posting requirements.

The FAQs clarify that whether a plan or issuer can comply with the requirement to disclose certain rates as dollar amounts is a fact-specific determination. Thus, the Departments intend to exercise enforcement discretion with respect to this requirement on a case-by-case basis.

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Provided by Christensen Group Insurance. This Legal Update is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice. ©Zywave, Inc. All rights reserved.