New rule would compel health plans to disclose out-of-pocket costs
A proposed rule would require employer-sponsored health plans to provide plan enrollees with cost estimates from different providers.
One of the big unknowns in health care coverage is always how much any given incident will cost the consumer out of pocket. And a new rule proposed by federal agencies, set to be published in the Federal Register November 27, would require employer-sponsored group health plans to provide plan enrollees with estimates of their out-of-pocket expenses for services from different health care providers.
According to the Society for Human Resource Management, the information would be available to enrollees via an online self-service tool so people could shop around before they get care, instead of being hit with the final total after the fact. Comments are due by January 14, 2020.
Related: How much do families spend on out-of-pocket health care costs?
It’s expected that insurers will oppose the plan, according to Carrie B. Cherveny, senior vice president of strategic client solutions for global insurance brokerage Hub International’s risk services division, who told SHRM that “the rules around public disclosure will likely be opposed by health insurance carriers who view their price negotiation as confidential and part of the service that they provide as carriers.”
Cherveny also said that insurers will probably go to court to challenge the rules, just as hospital systems are expected to do on price disclosure rules affecting them.
Employers might not be too happy about the proposal by the departments of Health and Human Services, Labor and the Treasury, either, according to Susan Nash, a partner at law firm Winston & Strawn in Chicago.
Nash said that although employers generally welcome actions to improve price transparency, they “may balk at the cost of preparing the online or mobile app-based cost-estimator tools, or purchasing such tools from vendors.”
And since the information will be plan-specific, they’ll also have to coordinate more closely with “third-party administrators, pharmacy benefit managers, [and] disease management, behavioral health, utilization review, and other specialty vendors and [the process] will require amendments to existing agreements.”
While plans grandfathered under the Affordable Care Act will be exempt, all others will have to provide out-of-pocket costs for all covered health care items and services available to enrollees via a self-service website (available on paper if requested, in a format similar to an explanation of benefits notice). They will also have to make publicly available the in-network rates they negotiate with the plan’s network providers, in addition to past payments already made to out-of-network providers—and update the information monthly.
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