New Rules on Health-Care Price Transparency and Coverage for COVID-19 Vaccines

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ON OCTOBER 28, the U.S. Department of Health and Human Services (HHS), the U.S. Department of Labor, and the U.S. Department of the Treasury released the coverage transparency final rule. Building on earlier administration actions requiring hospitals to disclose standard charges and negotiated rates with third-party payers, this new rule includes two requirements aimed at increasing health-care price transparency in the commercial market.

First, health plans and payers will be required to provide participants, beneficiaries, and enrollees with personalized out-of-pocket cost information, and the underlying negotiated rates, for all covered health-care items, services, and prescription drugs. Plans and payers must provide cost-sharing information through an Internet-based self-service tool and in paper form upon request.

Second, the rule requires payers and plans to post three data files for public use:

  • Negotiated rates for all covered items and services between the plan or payer and in-network providers
  • Historical payments to, and billed charges from, out-of-network providers
  • In-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level.

These files are required to be made public for plan years that begin on or after January 1, 2022.

Learn more about the coverage transparency rule.

The Centers for Medicare & Medicaid Services (CMS) also released its fourth COVID-19 interim final rule. This rule requires U.S. Food and Drug Administration–approved COVID-19 vaccines to be provided at no cost to beneficiaries enrolled in Medicare and Medicare Advantage. Medicaid beneficiaries can receive the vaccine at no cost only during the public health emergency, and most private payers will also be required to provide the vaccine at no cost. Additionally, CMS is continuing efforts around transparency by requiring all providers who perform a COVID-19 diagnostic test to post their prices online.

Learn more about the fourth COVID-19 interim final rule.

Bookmark ASCO in Action and ASCO Practice Central to stay up-to-date as these rules are implemented. 

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