Senators push CMS to close price transparency loopholes
The lawmakers say that while some insurance companies are complying with CMS' rule, others may be relying on gaps to evade accountability.
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Senators Maggie Hassan (D-N.H.) and Mike Braun (R-Ind.) are pressing the Centers for Medicare and Medicaid Services to update its regulations and close loopholes they say allow health insurers to avoid price transparency requirements.
CMS issued the Transparency in Coverage rule in July 2022, requiring health insurance companies to publicly post their in-network and out-of-network rates for the healthcare plans they offer. Broadly, the senators are supportive of the rule, which they say takes "important steps" toward improving price transparency by allowing researchers, policymakers and employers to identify unreasonable prices and excessive increases, thus helping to lower prices.
However, Hassan and Braun are concerned that remaining "technical loopholes" have resulted in insurance companies publishing data that does not align with the intent of the CMS rule. In a letter to CMS last week, they said that, while some insurance companies are complying with CMS' rule, others may be relying on gaps to evade accountability.
"According to reports, insurance companies have provided information in an indecipherable structure, omitted important pricing information, and stuffed the information into files too large for anything but a supercomputer to process," they wrote.
They also said CMS has not created a publicly accessible repository for plan data, meaning employers and researchers have been unable to use the data to assess the drivers of high healthcare costs and to target solutions.
WHAT'S THE IMPACT?
The two senators said there are administrative actions CMS can take to improve data quality and accessibility. The agency could limit file sizes, for example, or create standardized reporting templates, reduce the frequency of reporting and require a clear organizational system and standardized labeling.
"These changes would allow the public to use the data more effectively, while simplifying the reporting process for plans," they wrote.
They added that CMS should consider pairing those reforms with increased enforcement efforts, with an eye toward plans that provide no or low-quality data.
"Randomly auditing the quality of plan data would result in better usability, and additional enforcement would help ensure that remaining noncompliant plans follow the law," they wrote.
THE LARGER TREND
Under the Transparency in Coverage rule, price transparency tools were formally required beginning on January 1. Published machine-readable files are part of a requirement that kicked in for payers on July 1, 2022. These files provide pricing data for covered items and services based on in-network negotiated payment rates and historical out-of-network allowed amounts.
Now, with transparency tools mandated, "patients should be able to access an estimation of their cost of care," said Carol Skenes, payer and provider strategist at Turquoise Health. "Copay, coinsurance, deductibles and the rest will be similar to the machine readable files – the end goal is to give the patient an idea of how much they'll be required to pay."
Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com
