Through the Looking Glass: The Price Transparency Rule in 2023

Hospital Transparency Rule

With the market rapidly changing and prices constantly going up, people across the nation are increasingly taking notice of their line items. As such, to be more transparent in the medical field, the Centers for Medicare and Medicaid Services adopted the Hospital Transparency Rule, which has been divided into four separate stages. The first began on January 1, 2021 and required hospitals to disclose any negotiated prices for services and items. This was followed by the second stage which recently took effect on July 1, 2022. This requires many group health plans and issuers of health insurance coverage to clearly disclose in a public manner information relating to in-network rates for covered services and items and amounts charged for out-of-network providers. In addition, there are particular requirements for the presentation of this information, such as where it is posted and the type of files used to disclose the data, to ensure public access and greater transparency in the commercial medical market.

This is a massive undertaking and thus takes a great deal of time to accomplish, so the Rule has been divided into several stages, each with different effective dates. So, the third stage of the Rule is set to take effect on January 1, 2023. This stage will focus on cost-sharing as well and requires group health plans and health insurance issuers to provide detailed reports to all participants and beneficiaries on cost-sharing information for 500 defined services and items. These services and items include essential services like routine office visits for patients, imaging, lab work, and cancer screenings, to name a few. The cost estimates for these items should take into consideration a member’s deductibles and any out of-pocket maximums. These estimates should be made available to all participants, beneficiaries, and enrollees in either a digital manner or in paper upon request of the individual. Also, the estimates should be based on real- time and should be accurate at the time of the request.

This stage of the Transparency Rule will likely bring more significant changes than the previous stages. As will the following stage, which is set to take effect on January 1, 2024, which will expand the cost transparency information requirement of 500 defined services and items to include all covered services and items. The year 2023 will bring about many changes in the medical industry and will be viewed as a transition period to more transparency. Contact us at Jolley Law Group with any questions regarding these upcoming stages.

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