CMS Started to Enforce Applicable Price Transparency Requirements

by  Amanda Ballif
Aug 1st, 2022

Beginning July 1, 2022, CMS started to enforce applicable price transparency requirements because of the Trump Administration's historic price transparency requirement in 2019 to increase competition and lower healthcare costs for all Americans.

For plans and issuers that are subject to CMS's enforcement authority and do not comply, they may take several enforcement actions, including: requiring corrective actions and/or imposing a civil money penalty up to $100 per day, adjusted annually under 45 CFR part 102, for each violation and for each individual affected by the violation.

Most group health plans and issuers of group or individual health insurance are required to disclose pricing information because of the Trump administration policy in three stages. These are the three stages: 

1. Machine-Readable Files containing the following sets of costs for items and services: 

• • In-Network Rate File: rates for all covered items and services between the plan or issuer and in-network providers.

  • Allowed Amount File: allowed amounts for, and billed charges from, out-of-network providers.

2. Internet-based price comparison tool (or disclosure on paper, upon request) allowing an individual to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers, for 500 items and services.

3. Internet-based price comparison tool (or disclosure on paper, upon request) allowing an individual to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers, for all items and services.

Tip: Stay tuned for more! Phase 2 and Phase 3 go into effect in 2023 and 2024

By plan or policy years beginning on or after January 1, 2023, most group health plans and issuers of group or individual health insurance coverage are required to disclose personalized pricing information for all covered items and service to their participants, beneficiaries, and enrollees through an online consumer tool, or in paper form, upon request. Cost estimates must be provided in real-time based on cost-sharing information that is accurate at the time of the request.

Enforcement: For additional details on enforcement refer to 45 CFR part 150, subpart B and C and for information on appealing a proposed civil money penalty refer to 45 CFR part 150, subpart D.

Resources and additional reading:.

• The Transparency in Coverage Final Rules (TiC)
• The frequently asked question (FAQ) 
• The CMS GitHub website – CMSgov/price-transparency-guide
• Transparency in Coverage Final Rule Fact Sheet (CMS-9915-F)
• Compliance Alert: Machine-Readable TiC File Requirement Is Looming
• How much health insurers pay for almost everything is about to go public
• Trump Administration Announces Historic Price Transparency Requirements to Increase Competition and Lower Healthcare Costs for All Americans