If a new federal rule withstands politics and potential court challenges, U.S. health care prices may finally be freed from their historic black box.
The Centers for Medicare & Medicaid Services (CMS), along with the Departments of Labor and the Treasury, issued the Transparency in Coverage final rule Oct. 29 requiring most private health plans to disclose pricing and cost-sharing information so Americans will know in advance how much they will have to pay for prescription drugs, medical devices and other health care products and services.
Under the rule, non-grandfathered health plans must offer an online shopping tool, beginning Jan. 1, 2023, that allows consumers to see the negotiated rate between their provider and their plan, as well as a personalized estimate of their out-of-pocket cost for 500 of the most “shoppable” health care items and services.
By the next year, the shopping tools must be expanded to show the costs for the remaining procedures, drugs, durable medical equipment and other health care items or services that may be needed.
Another provision of the rule requires plans to make standardized and regularly updated data files publicly available by Jan. 1, 2022. CMS envisions entrepreneurs, researchers and developers using the data to create private-sector solutions to help patients make decisions about their care.
For instance, the data could be used by technology companies to create additional price comparison tools and portals to incentivize competition and by researchers to analyze how health care prices are set, CMS said.
(Plans that were in existence as of March 23, 2010, when the Affordable Care Act became law, are exempt from the rule as long as they maintain their grandfathered status.)
“With this information available to the public, there can finally be pressure on those that price gouge consumers when they are at their most vulnerable,” CMS said. It added that the rule “will drive innovation, support informed, price-conscious decision-making, and promote competition in the health care industry.”
Given the implementation dates and the fact that the requirements are an administrative rule rather than law, a new administration could withdraw or alter them.
Another rule issued this week by CMS, Labor and the Treasury will ensure most Americans incur no cost when it comes to getting vaccinated against COVID-19, at least for the duration of the public health emergency.
The interim final rule released Oct. 28 clarifies that any vaccine licensed by the FDA or granted an emergency use authorization will be covered under Medicare as a preventive vaccine at no cost to beneficiaries.
Intended to remove regulatory barriers and ensure consistent coverage and payment for the administration of a vaccine, the rule also “implements provisions of the CARES Act that ensure swift coverage of a COVID-19 vaccine by most private health insurance plans without cost sharing from both in and out-of-network providers,” CMS said.
Providers can be reimbursed for administering the vaccine to individuals without insurance through the Health Resources and Services Administration’s Provider Relief Fund. And state Medicaid and Children’s Health Insurance Program agencies must provide vaccine administration with no cost sharing for most beneficiaries during the public health emergency. However, states may have to evaluate cost-sharing policies once the emergency ends, CMS said.
Another provision in the rule requires providers who perform a COVID-19 diagnostic test to post their cash prices online. If they don’t, they could face civil monetary penalties.
Along with the rule, CMS released a set of toolkits for providers, states and insurers to help them prepare to swiftly administer a vaccine once one is available. In addition, CMS said it is working to increase reimbursement for new COVID-19 treatments that are approved or authorized by the FDA.
The interim rule will be open for comment for 30 days once it is published in the Federal Register.