What is the Transparency in Coverage Rule?

In 2020, the federal government finalized the Transparency in Coverage Rule (TiC), which requires that health plans and insurers provide cost-sharing data to consumers. It does so mainly through machine-readable files (MRFs), which have three formats: in-network, out-of-network, and prescription drug prices. The first includes pricing data for covered in-network items and services, and the out-of-network file describes historical aggregated out-of-network allowed amounts and billed charges. The prescription drug prices file is currently indefinitely delayed and not publicly available. Additionally, there exists a consumer price transparency tool that provides real-time personalized cost-share estimates for all items and services.

How is the Transparency in Coverage Rule used?

Transparency in Coverage uses standard-format MRFs to provide the public with access to pricing data. The MRF must be available for free on a public website without any barriers (such as making an account, a password, or an ad wall). Anyone, including analysts and researchers, can access this data to see their pricing data and compare hospitals. These sites must be updated monthly and show the date of the most recent revision.

TiC also provides a consumer price transparency tool. For participants in a given health plan, this tool provides personalized cost-share estimates for covered services and items. As of 2024, this tool is mandated to cover all services and items. Upon request, it can be given in paper format.

FAQ

Do TiC include out-of-network costs?

The Tic looks at aggregated historical out-of-network allowed amounts and billed charges, meaning it does apply out-of-network.

How do I access the MRF?

There are two main ways to access an MRF. First, you can locate your insurer’s website, find a page on the site labeled “Price Transparency,” “Billing,” or something else in that category. Inside that section of the page, the insurer will likely have placed the MRF in a downloadable format, like .json or .csv. The alternative is to simply google, “[Insurance company] machine readable file” and let the search engine do the hard work for you.

Conclusion

We hope this article answered all your Transparency in Coverage Rule questions! At Fairdoc, we are here to inform you, assist you, and answer all your questions. If you have any inquiries for us, feel free to reach out, and stay tuned for future articles!