CMS Completes Historic Price Transparency Initiative

BALTIMORE, Maryland, Oct. 30 -- The U.S. Department of Health and Human Services' Centers for Medicare and Medicaid Services issued the following news release on Oct. 29:

Today, under President Trump's leadership, the Centers for Medicare & Medicaid Services (CMS) along with the Departments of Labor and the Department of the Treasury issued a historic final rule on price transparency, helping to ensure every American knows how much their healthcare will cost in advance and allowing them to make fully informed and value-conscious decisions. The rule requires most private health plans, including group health plans and individual health insurance market plans to disclose pricing and cost-sharing information and fulfills a key element of President Trump's Executive Order on price and quality transparency.

"President Trump is solving longstanding problems in our healthcare system; hidden healthcare prices have produced a dysfunctional system that serves special interests but leaves patients out in the cold," said CMS Administrator Seema Verma. "Price transparency puts patients in control and supports competition on the basis of cost and quality which can rein in the high cost of care. CMS' action represents perhaps the most consequential healthcare reform in the last several decades."

Under this final rule, about 200 million Americans will gain access to real-time price information, enabling them to know how much their healthcare will cost them before going in for treatment. The rule requires group health plans and health insurance issuers in the individual and group markets to not only provide easy-to-understand personalized information on enrollee cost-sharing for healthcare services, but they must also publically disclose the rates they actually pay healthcare providers for specific services. This will allow for unprecedented price transparency that will benefit employers, providers, and patients to help drive down healthcare costs.

Starting on January 1, 2023the rule will require health plans to offer an online shopping tool that will allow 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 items and services. Then starting on January 1, 2024, these shopping tools will be required to show the costs for the remaining procedures, drugs, durable medical equipment and any other item or service they may need.

In addition, by January 1, 2022 this rule will require plans to make publicly available standardized and regularly updated data files, which would open new opportunities for research and innovation to drive improvements within the healthcare market. With this data, entrepreneurs, researchers, and developers will be able to create private sector solutions for patients to help them make decisions about their care. Further, people who are uninsured or shopping for health insurance will be able to understand how health care items and services are priced under health insurance coverage. Technology companies can create additional price comparison tools and portals that will further incentivize competition, as well as allow for unprecedented research studies and data analysis into how healthcare prices are set. 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.

Today's announcement builds on CMS' efforts over the past three years to promote price and quality transparency. Additional actions taken by CMS to promote price transparency and put the consumer back in control of their healthcare experience include:

* Requiring hospitals to post their standard pricing information online in a machine-readable format, updating it at least once a year.

* Requiring hospitals to make prices more transparent beginning in 2021.

* Launching the Procedure Price Lookup, which allows consumers to compare Medicare payments and copayments for certain procedures that are performed in both hospital outpatient departments and ambulatory surgical centers. In 2020, CMS also added physician fees to the tool, offering people with Medicare a more accurate prediction of the true out-of-pocket costs.

* Launching Care Compare, which includes visit cost estimate information for new and returning Medicare patients. Consumers searching for doctors and clinicians in Care Compare can see how much their visit may cost for specialists in their area to help inform their health care decisions.

* Making quality information available for the first time on all Exchange plans to help consumers compare their coverage choices.

* Launching a modernized and redesigned Medicare Plan Finder, the most used tool on Medicare.gov, allowing users to shop and compare Medicare Advantage and Part D plans and find information on extra benefits more easily.

* Creating Blue Button 2.0 so beneficiaries can securely connect their data to apps and other tools developed by innovative companies that can help them organize and share their claims data, find health plans, make care appointments, and check symptoms.

* Requiring hospitals and clinicians to be subject to potential payment reductions if they do not give patients access to their data.

* Giving patients access to their health information in a secure, understandable, user-friendly electronic format so they can make informed decisions about their healthcare.

* For the first time, releasing a robust repository of research-ready Transformed Medicaid Statistical Information System (T-MSIS) data files so that stakeholders can answer questions about Medicaid and Children's Health Insurance Program (CHIP) enrollment, services and payment.

* Introducing the first-ever Medicaid and CHIP Scorecard to provide much-needed transparency on how well Medicaid is serving its beneficiaries.

* Launching the Provider Data Catalog (PDC), which provides downloadable and interactive datasets like those currently available on data.Medicare.gov. The PDC employs an Application Programming Interface (API), allowing innovators in the field to easily access and analyze CMS' publicly reported data.

To ensure timely access to data during the coronavirus disease 2019 (COVID-19) Public Health Emergency (PHE) CMS also:

* Required all 15,417 Medicare and Medicaid nursing homes to report cases of COVID-19 to all residents, their families and the CDC.

* Issued monthly data snapshots on the impact of COVID-19 on Medicare beneficiaries.

* Released an enrollment trends report showing that thousands of Americans who lost job-based coverage during the COVID-19 PHE and were able to take advantage of a special enrollment period to enroll in a plan through HealthCare.gov.

* Released Medicaid and CHIP data on enrollment trends, telehealth utilization, and children's preventive care utilization during the PHE.

To view the fact sheet, click here: www.cms.gov/newsroom/fact-sheets/transparency-coverage-final-rule-fact-sheet-cms-9915-f

To view the final rule, click here: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CMS-Transparency-in-Coverage-9915F.pdf

To view the full list of CMS transparency accomplishments, click here: www.cms.gov/files/document/transparency-accomplishments.pdf