Transparency in Coverage Rule and Consolidated Appropriations Act Overview & FAQs

Note: These FAQs are updated frequently. Please check Administrators page for more updates.

Overview

On Nov. 12, 2020, the federal government issued the Transparency in Coverage Rule (TCR) to make health care prices more available and transparent to consumers. The aim of this rule is to enhance market competition and help lower health care prices.

HMSA continually works to ensure compliance with regulations in accordance with the final rulings and effective dates. Guidance and rules from government agencies will provide further clarity or improvements. We continue to take action and assess what can be done to continue our compliance efforts based on reasonable assumptions and the information available to us.

Key highlights of the mandates and how HMSA complies or will comply, along with the FAQs, are listed below. All responses have been given to the best of our ability at the time of publication.

If an effective date has not been identified or occurs in the future, the compliance dates and requirements of the respective mandate may be subject to change pending further federal agency rules. We’ll continue to update this document as more information becomes available to ensure that you receive the latest compliance requirements and regulatory deadlines.

Mandates	Details
Public Disclosure of Rates via Machine-readable Files Effective July 1, 2022 See Section 2 for additional information.	HMSA makes monthly machine-readable files (MRF) publicly available including: Negotiated rates with HMSA participating providers. Historical billed charges and allowed amounts paid to nonparticipating providers.
Disclosure of Personalized Out-of-pocket Costs Effective Jan. 1, 2023, & Jan. 1, 2024 See Section 3 for additional information.	HMSA offers price comparison tools to provide members with personalized out-of-pocket costs and price comparisons for covered items and services. Members have access to: Out-of-pocket cost estimates and network participation guidance by telephone. An online price comparison tool with cost comparisons across providers, and within a plan year and geographic region.
Advanced Explanation of Benefits Effective date pending final ruling by CMS. See Section 4 for additional information.	HMSA will provide a good-faith cost estimate for service billing codes provided by a provider or facility when final regulations are issued. Government agencies have deferred the effective date of the Advanced Explanation of Benefits mandate until further notice.
Provider Directories Effective Jan. 1, 2022	HMSA has up-to-date provider directories available to consumers online or within one business day of an inquiry. Providers are responsible for maintaining and updating their provider data to remain on HMSA’s provider directory. HMSA has established a user-friendly way for providers to verify their information. This verification process occurs every 90 days. HMSA may remove a provider from the directory if the required verification is not completed. If a member chooses a provider based on erroneous data, HMSA ensures that they are only responsible for amounts as if they received services/items from a participating provider.
Surprise Billing Effective Jan. 1, 2022	HMSA members are protected from surprise medical bills that could arise during an emergency situation when care is provided at an out-of-network facility or in situations when nonemergency services are provided by out-of-network providers at in-network facilities. HMSA members are responsible only for in-network cost-sharing amounts (including deductibles) in emergency situations and certain nonemergency situations where they don’t have the ability to choose an in-network provider. Members can request external review of adverse benefit determinations related to the No Surprises Act, including whether the regulation applies to a service. The surprise billing requirement also outlines the process for resolving payment disputes between a nonparticipating provider or facility and a health plan. If either party cannot agree on the payment amount for an out-of-network service experienced by a patient, they can initiate a new federal independent dispute resolution process. HMSA facilitates claims negotiation and engagement in the independent dispute resolution process on behalf of individuals, fully insured, and self-funded groups.
CAA Mental Health Parity Requirements Effective Feb. 10, 2021	Upon request by the Tri-agency regulators, HMSA must provide a comparative analysis of the design and application of NonQuantitative Treatment Limitations (NQTLs) related to medical/surgical versus mental health/substance use disorder benefits at the plan level. NQTLs include, but are not limited to, the following: Medical management standards that limit or exclude benefits based on medical necessity, medical appropriateness, or if the treatment is experimental or investigative (including standards for concurrent review). Formulary design for prescription drugs. Network tier design. Fail-first policies or step-therapy protocols. (e.g., refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective.) Exclusions based on failure to complete a course of treatment. Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of services that are a benefit of the plan. Self-funded group health plans are responsible for ensuring compliance with mental health parity requirements. The group will need to perform their own comparative analyses for their plan and remains responsible for all obligations to comply with the law.
Changes to Membership Cards Effective Jan. 1, 2025	As of Jan. 1, 2025, HMSA updated the membership cards to include: The amount of the medical in-network and out-of-network deductibles. The medical in-network and out-of-network out-of-pocket maximum. HMSA continues to include a phone number and website address for assistance, as well as a QR code on membership cards, which takes members to a webpage that displays the above-mentioned medical deductible and out-of-pocket maximums, and links to additional resources. To access this information, members can scan the QR code with their smartphones or other smart devices.
Continuity of Care Effective Jan. 1, 2022	If a contract between HMSA and a provider or facility is terminated, members may have an opportunity to elect continuity of care. We’ll inform members of their ability to elect treatment continuation. If a member meets eligibility requirements, we’ll work with the provider on continued treatment as required by the Consolidated Appropriations Act (CAA).
Reporting on Pharmacy Benefits and Drug Costs (RxDC) report See section 5 for additional information.	HMSA must submit a report annually on prescription drugs and health care spending to the federal government. The report is due annually on or before June 1.
Air Ambulance Reporting See section 6 for additional information.	HMSA will comply with the requirements once the final rules are published.
Gag Clause Prohibition Compliance Attestation See section 7 for additional information.	HMSA submitted the initial attestation Dec. 15, 2023, for the Dec. 27, 2020, through Nov. 1, 2023, reporting period. For each subsequent reporting year, HMSA will submit the attestation on or before Dec. 31.

Mandates

Details

Public Disclosure of Rates via Machine-readable Files

Effective July 1, 2022

See Section 2 for additional information.

HMSA makes monthly machine-readable files (MRF) publicly available including:

Negotiated rates with HMSA participating providers.
Historical billed charges and allowed amounts paid to nonparticipating providers.

Disclosure of Personalized Out-of-pocket Costs

Effective Jan. 1, 2023, & Jan. 1, 2024

See Section 3 for additional information.

HMSA offers price comparison tools to provide members with personalized out-of-pocket costs and price comparisons for covered items and services. Members have access to:

Out-of-pocket cost estimates and network participation guidance by telephone.
An online price comparison tool with cost comparisons across providers, and within a plan year and geographic region.

Advanced Explanation of Benefits

Effective date pending final ruling by CMS.

See Section 4 for additional information.

HMSA will provide a good-faith cost estimate for service billing codes provided by a provider or facility when final regulations are issued. Government agencies have deferred the effective date of the Advanced Explanation of Benefits mandate until further notice.

Provider Directories

Effective Jan. 1, 2022

HMSA has up-to-date provider directories available to consumers online or within one business day of an inquiry. Providers are responsible for maintaining and updating their provider data to remain on HMSA’s provider directory.

HMSA has established a user-friendly way for providers to verify their information.
This verification process occurs every 90 days.
HMSA may remove a provider from the directory if the required verification is not completed. If a member chooses a provider based on erroneous data, HMSA ensures that they are only responsible for amounts as if they received services/items from a participating provider.

Surprise Billing

Effective Jan. 1, 2022

HMSA members are protected from surprise medical bills that could arise during an emergency situation when care is provided at an out-of-network facility or in situations when nonemergency services are provided by out-of-network providers at in-network facilities. HMSA members are responsible only for in-network cost-sharing amounts (including deductibles) in emergency situations and certain nonemergency situations where they don’t have the ability to choose an in-network provider.

Members can request external review of adverse benefit determinations related to the No Surprises Act, including whether the regulation applies to a service.
The surprise billing requirement also outlines the process for resolving payment disputes between a nonparticipating provider or facility and a health plan. If either party cannot agree on the payment amount for an out-of-network service experienced by a patient, they can initiate a new federal independent dispute resolution process.
HMSA facilitates claims negotiation and engagement in the independent dispute resolution process on behalf of individuals, fully insured, and self-funded groups.

CAA Mental Health Parity Requirements

Effective Feb. 10, 2021

Upon request by the Tri-agency regulators, HMSA must provide a comparative analysis of the design and application of NonQuantitative Treatment Limitations (NQTLs) related to medical/surgical versus mental health/substance use disorder benefits at the plan level.

NQTLs include, but are not limited to, the following:

Medical management standards that limit or exclude benefits based on medical necessity, medical appropriateness, or if the treatment is experimental or investigative (including standards for concurrent review).
Formulary design for prescription drugs.
Network tier design.
Fail-first policies or step-therapy protocols. (e.g., refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective.)
Exclusions based on failure to complete a course of treatment.
Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of services that are a benefit of the plan.

Self-funded group health plans are responsible for ensuring compliance with mental health parity requirements. The group will need to perform their own comparative analyses for their plan and remains responsible for all obligations to comply with the law.

Changes to Membership Cards

Effective Jan. 1, 2025

As of Jan. 1, 2025, HMSA updated the membership cards to include:

The amount of the medical in-network and out-of-network deductibles.
The medical in-network and out-of-network out-of-pocket maximum.

HMSA continues to include a phone number and website address for assistance, as well as a QR code on membership cards, which takes members to a webpage that displays the above-mentioned medical deductible and out-of-pocket maximums, and links to additional resources. To access this information, members can scan the QR code with their smartphones or other smart devices.

Continuity of Care

Effective Jan. 1, 2022

If a contract between HMSA and a provider or facility is terminated, members may have an opportunity to elect continuity of care. We’ll inform members of their ability to elect treatment continuation. If a member meets eligibility requirements, we’ll work with the provider on continued treatment as required by the Consolidated Appropriations Act (CAA).

Reporting on Pharmacy Benefits and Drug Costs (RxDC) report

See section 5 for additional information.

HMSA must submit a report annually on prescription drugs and health care spending to the federal government. The report is due annually on or before June 1.

Air Ambulance Reporting

See section 6 for additional information.

HMSA will comply with the requirements once the final rules are published.

Gag Clause Prohibition Compliance Attestation

See section 7 for additional information.

HMSA submitted the initial attestation Dec. 15, 2023, for the Dec. 27, 2020, through Nov. 1, 2023, reporting period. For each subsequent reporting year, HMSA will submit the attestation on or before Dec. 31.

Updated

Does the TCR or CAA impact the Health Insurance Portability and Accountability Act or other security or privacy rules?

No. The rule doesn’t alter existing state and federal privacy or security requirements, including requirements under HIPAA. Neither the TCR nor CAA require public disclosure of protected personal health information.

Updated

What government agencies oversee these mandates?

The departments overseeing the TCR and CAA include:

The Internal Revenue Service (IRS), Department of the Treasury.
The Employee Benefits Security Administration (EBSA), Department of Labor.
The Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS).
The agencies referenced under the CAA include the Hawaii Department of Health and Human Services, the Department of Labor, and the Department of the Treasury.

Updated

Who do the mandates apply to?

The TCR and CAA apply to health insurers in the individual and group markets and to group health plans, including the Federal Employee Health Benefit (FEHB) program. Certain groups or types of benefits are not subject to the public disclosure of rates via MRFs, the cost tool, and Advanced Explanation of Benefits (AEOB).

See Sections 2, 3, and 4 for more information.

Updated

Will there be additional administrative costs or fees?

At this time, there are no administrative costs or fees associated with these mandates. Self-funded groups can expect timely and relevant information regarding potential administrative costs as more details become available. Please discuss any concerns with your HMSA representative.

Updated

Will the mandates impact group rates?

At this time, there are no administrative costs or fees associated with these mandates. Please discuss this with your HMSA representative.

Updated

Where can I find up-to-date information on what HMSA is doing related to the TCR?

For updated information, please visit: hmsa.com/employers/service-center/administrators/transparency-in-coverage-rule-and-consolidated-appropriations-act/.
CMS Transparency in Coverage webpage: cms.gov/healthplan-price-transparency.
CMS Transparency in Coverage – Final Rule Fact Sheet: cms.gov/newsroom/fact-sheets/transparency-coverage-final-rule-fact-sheet-cms-9915-f.
Consolidated Appropriations Act: congress.gov/bill/116th-congress/house-bill/133/text.

Section 2: Public disclosure of rates via machine-readable files

Health plans and issuers must make MRFs available to the public that contain provider pricing information for items and services that are covered under non-grandfathered plans in individual and group markets.

Under the regulation, service billing codes such as the Current Procedural Terminology code, Health Common Procedure Coding System code, Diagnosis-related Group code, or other common identifiers must be used to identify each item or service. The reported provider rates for each covered item and service must include all participating providers and their contract negotiated rates as well as their allowed amounts and billed charges paid to nonparticipating providers three to six months before the file publication date. Participating and nonparticipating rates must be reported in separate files.

This data must be reported in the specified machine-readable format that is detailed in the final ruling’s technical implementation guide and the data must be updated and published on a publicly accessible website each month.

To view HMSA’s machine-readable files, please click the link below:
hmsa.com/help-center/transparency-in-coverage-machine-readable-files/.

Frequently asked questions:

Updated

What is a machine-readable file format?

A machine-readable file is a digital representation of information that follows predefined rules that allow a computer system to import and analyze the files without human intervention.

Files created by HMSA are in JavaScript Object Notation (JSON) format and all other file requirements follow current technical implementation guide file schemas available on GitHub.

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How large is a transparency MRF?

We’re expecting each HMSA-produced machine-readable file to remain under 1TB.

Updated

Who can use the data and for what purpose?

Anyone can use it, including consumers, researchers, employers, CMS, or other third parties. MRF data is mandated to be available to the public at no charge without any restrictions. HMSA doesn’t control this data.

Updated

What are the information technology requirements for transmitting files and posting MRFs?

CMS did not specify requirements or mechanisms to transmit or post files in the transparency final ruling or the MRF technical guide on GitHub. Organizations should seek internal technical guidance to determine the best solutions based on their needs and technical capabilities.

Updated

How does HMSA support compliance with monthly reporting requirements for MRFs?

HMSA provides compliant MRFs on hmsa.com for impacted health plans. These files follow technical requirements defined in the final rulings, including the latest available technical specifications (file schemas) on GitHub. We continue tracking with lawmakers and industry leaders to stay informed about changes to existing requirements and the latest industry standards for compliance with federal regulations.

Updated

Does HMSA have recommendations for users who are experiencing issues when accessing HMSA’s MRFs?

Yes. Every month, HMSA validates that our newly published MRFs are publicly accessible from various web browsers and endpoints. If you’re experiencing issues, we recommend taking the following actions:

Clear browser cache and search history.
Use the Incognito/Private Search mode for your web browser.
Try a different web browser.
Verify that your local device and web settings do not restrict downloads.
Verify that URLs were copied and pasted to the web browser exactly as they were reported in the table of contents.
Check your local folders where downloaded files are stored, as downloads may initiate without any notification.

Note: HMSA isn’t responsible for users’ local capabilities that could impact individual user’s experience when accessing MRFs, including issues with local hardware or network, browser settings, or storage capacity.

Updated

Can HMSA work directly with individual groups or third-party vendors on behalf of groups that wish to host MRFs on an alternate website and/or consolidate HMSA’s data with data from other sources?

Yes. It’s HMSA’s commitment and priority to ensure our good-faith compliance with MRFs in a manner that’s equitable to impacted stakeholders starting on the federally mandated enforcement date and monthly thereafter.

Based on the complexity and level of effort involved with this requirement, HMSA isn’t able to support individual partner requests in addition to our own efforts to meet this requirement. HMSA’s machine-readable file data is available to the public at no charge and without any restrictions as mandated. HMSA doesn’t control our data files and it may be used by anyone including consumers, researchers, employers, CMS, or other third parties. Anyone can access, use, consolidate, or host MRFs for applicable HMSA plans.

Updated

Does HMSA charge customers for creating the MRFs?

We don’t anticipate any administrative costs or fees associated with this mandate. However, we may assess fees in the future.

Updated

What is HMSA’s MRF record keeping and retention policy?

HMSA backs up a minimum of 12 months of published files. If CMS offers specific guidance on retention policy requirements, we’ll adjust our retention period accordingly.
Since files are hosted on Amazon Web Services servers, on-demand web reporting can be generated to inventory files that have been hosted, uploaded, and downloaded.

Updated

Are grandfathered health plans included in this requirement?

No. Grandfathered health plans are not in scope for the MRF requirement. Other plans or types of benefits not subject to the mandate include:

Excepted benefits, such as standalone vision and dental plans.
Flexible spending accounts, health reimbursement accounts, and health savings accounts.
Medicare.
Medicaid.

Updated

How can I stay updated on HMSA’s plans for MRFs?

Please continue visiting this site for updates on MRF. If you have any questions, contact your HMSA representative.

Section 3: Disclosure of personalized out-of-pocket costs

Updated as of April 2026.

The price comparison tool (cost tool) gives members access to their out-of-pocket costs and negotiated rates for covered health care items and services. Members can get the information by phone, on the website, or in print to compare copayments and coinsurance for items and services from participating providers.

Effective Jan. 1, 2023, insurers and plans were required to make the cost tool available to commercial plan members for 500 shoppable items and services identified in the rule.

Effective Jan. 1, 2024, they were required to include all covered items and services.

Frequently asked questions:

Updated

What does “all items and services” mean?

As of Jan. 1, 2024, the cost tool mandate requires inclusion of all items and services that are benefits of a member’s HMSA health plan, including routine office visits and virtual care, urgent and emergent inpatient and outpatient care, medical tests and labs, diagnostic imaging, durable medical equipment, therapies, and more.

Updated

How does HMSA provide applicable pricing information to members?

HMSA partnered with Sapphire Digital, part of Zelis Corp., to implement their S365 platform as our online self-service cost tool. Users can use the platform to search pricing estimates for common “shoppable” procedures and other covered items and services as well as compare pricing among providers. S365 is available to beneficiaries who have HMSA commercial plans.

If a member would like to request pricing information by phone, they can call HMSA Customer Relations.

Updated

How does HMSA provide members with a Notice of Disclosure or inform members that prior authorization or other medical policies may be required for a service?

This information is available on the online cost tool or by phone from HMSA Customer Relations.

Updated

What search capabilities does the cost tool have?

Members can search for covered items and services by:

Billing code or descriptive term (e.g., rapid flu test).
Provider or facility name or specialty.
Categories of care (e.g., primary care services, women’s health, behavioral health, etc.).
Members can filter their search or prioritize results based on cost, available providers’ specialties, gender, and/or geographic proximity (e.g., geolocation, city, state, ZIP code, or island and distance in miles).

Updated

Are these pricing tools available to applicable members?

Yes. Members have had access to transparency web-based pricing tool since Jan. 1, 2023.

Members can also request pricing and network guidance from HMSA Customer Relations by phone.

Updated

Where can I find the internet-based, self-service cost tool?

The cost tool can be found by logging into My Account and selecting Procedure Cost Estimator from the Benefits drop-down. Users who want to access S365 must have a registered member profile so they can be allowed to access personalized benefit information, such as out-of-pocket costs and deductibles.

Updated

What’s the benefit of offering a cost tool?

Access to a cost tool may enhance the consumer experience with these benefits:

Enables members to evaluate health care options and make cost-conscious decisions.
Reduces potential surprises regarding the individual member’s out-of-pocket costs for health care services.
Potentially lowers overall health care costs by identifying the total cost of care, not only the member’s out-of-pocket expense.
Using the cost tool before treatment should reduce the number of surprise bills after the member’s treatment.

It’s important to note that prices should never be used as the sole criterion for choosing a physician or any other health care professional. Priority consideration should be given to the quality of services delivered and/or the effectiveness of the intervention.

Updated

Why is there a difference in pricing among providers who offer the same service?

Providers’ negotiated rates vary due to multiple factors, including credentials and level of education, quality, access needs, network adequacy, resource utilization, setting of care, and more. HMSA works with providers to ensure that we’re providing our members with access to affordable, high-quality health care.

Section 4: Advanced Explanation of Benefits

Among the provisions of the CAA is the requirement of an Advanced Explanation of Benefits, (AEOB), for scheduled services that includes a patient’s information regarding network inclusion, contracted rate for a given item or service, out-of-pocket estimates, estimates of incurred amounts toward a patient’s deductible/cost-sharing limits, and information on medical management requirements.

Government agencies have deferred the effective date of the Advanced Explanation of Benefits mandate until further notice.

Section 5: Prescription Drug Data Collection (RxDC) report for Fully Insured Employer Groups

Updated as of April 2026.

The CAA (Section 204) requires health plans issuers to annually report prescription drug and health care spending information to the Tri-agencies. The report must include information such as premium amounts, number of members enrolled in a plan, and pharmacy rebates. The report is due annually on or before June 1.

Frequently asked questions:

Updated

Does HMSA submit the Prescription Drug Data Collection report to CMS on behalf of employer groups?

Yes. HMSA agrees to good-faith compliance with the Prescription Drug Data Collection reporting requirements to the extent that it places duties on the insurer. We continue to work closely with our pharmacy benefits manager (PBM) to submit the required information annually in a timely manner.

Updated

Which reports does HMSA provide on behalf of employer groups?

HMSA continues to submit all required reports to CMS on behalf of its employer groups.

Updated

For the reports that you’ll submit on behalf of employer groups, do you submit the entire report or are there portions of any report that the group must submit?

HMSA submits all portions of the report for information and data that HMSA possesses on behalf of employer groups.

Updated

What’s the estimated timing and process for data collection?

HMSA mailed a letter in mid-March with instructions to fill out an online survey for monthly premium amounts and group size. The survey period closed on April 23, 2026.

Updated

When will HMSA file the report?

Reports are due annually by June 1. HMSA will submit the report on or before this date.

Updated

Will HMSA provide employers with a copy of the report?

No. HMSA aggregates employer information by marketing segment and is unable to provide a copy of their report.

Updated

For the D2 file and premium cost share information, does HMSA report this information at the client level or is the information aggregated?

HMSA aggregates D2 data and premium cost share information by the following market segments consistent with CMS guidelines:

- Individual.

- Student.

- Fully insured small group (50 employers or fewer).

- Fully insured large group (51 employees or more).

- Self-funded plans offered by large employers.

- Federal Employees Health Benefits Program.

Updated

If the group has a separate PBM, what reports does HMSA provide?

For groups with a separate Pharmacy Benefit Manager, HMSA submits D1 Premium and Life-Years and D2 Spending by Category to CMS. On the Group Health Plan List report (P2), HMSA indicates that the group is included on HMSA’s D1 and D2 reports and that the group is not included on HMSA’s D3-D8 reports that require PBM-related information.

Updated

What group health plan name and group plan number does HMSA use for the report?

HMSA uses the group name and group number from our source processing system. We also use the employer EIN that the employer group provided. CMS has indicated that they’ll use this information to identify and attribute the report to the appropriate employer group.

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When was the deadline to provide 2025 premium cost share information to HMSA?

Premium cost share information was due to HMSA via the CAA certification form by April 23, 2026.

Updated

If a group has additional questions about the premium cost share information collection process, what should they do?

Please refer to these FAQs for premium cost share information.

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What issuer or TPA information does HMSA use for this report?

Hawaii Medical Service Association.
EIN: 99-0040115.

Updated

How will an employer know that HMSA submitted the report?

Visit hmsa.com/employers/caacertification to view HMSA’s CAA Certification submission confirmation receipt after June 1 annually.

Updated

Does HMSA provide written confirmation that they’ll comply with Transparency in Coverage rules?

No written confirmation will be provided since, pursuant to 12.1 of the fully insured employer Group Plan Agreement, HMSA has agreed to comply with applicable laws, which we believe doesn’t require written confirmation.

Section 6: Air Ambulance Reporting

Updated as of May 2025.

The CAA No Surprises Act (Section 106) requires air ambulance providers, insurance companies, and employer-based health plans to submit information to federal regulators about air ambulance services provided to consumers. CMS will collect data to develop a public report on air ambulance services.

Frequently asked question:

Updated

Will HMSA submit this report on behalf of fully insured employer group plans?

We’re awaiting final rules and/or guidance relating to the air ambulance reporting requirement from federal agencies. HMSA intends to fully comply with the requirements once they’re published. We will contact employer groups if information is required.

Section 7: Gag Clause Prohibition Compliance Attestation

Updated as of December 2025.

Section 201 of the CAA prohibits group health plans and health insurance issuers from entering into an agreement with a provider, network or association of providers; third-party administrator; or other service provider offering access to a network of providers that would directly or indirectly restrict the plan or issuer from:

Providing provider-specific cost or quality of care information or data to referring providers, the plan sponsor, participants, beneficiaries, or enrollees, or individuals eligible to become participants, beneficiaries, or enrollees of the plan.
Electronically accessing de-identified claims and encounter data for each participant, beneficiary, or enrollee.
Sharing such information consistent with applicable privacy regulations.

Group health plans and health insurance issuers must annually submit an attestation of compliance with these requirements to CMS.

Frequently asked questions:

What is a “gag clause”?

A contract term that restricts specific data and information that a plan or issuer can make available to another party. Gag clauses may be found in agreements with providers, TPAs, or service providers offering access to a provider network are prohibited under the Consolidated Appropriations Act of 2021.

Updated

What is the due date for the Gag Clause Prohibition Compliance Attestation?

The submission window closed on Dec. 10, 2025. HMSA submitted the attestation for 2025. You may view the submission receipt here [PDF].

Updated

Does HMSA complete the attestation on behalf of fully insured employer group plans?

Yes, HMSA submits the attestation on behalf of its fully insured employer groups.

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What is an ERISA Plan ID number?

The Employee Retirement Income Security Act (ERISA) Plan ID is a three-digit number used by the Department of Labor and the IRS to identify one employee welfare plan from another of a company’s benefit offerings.

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How can I tell if my group/account is an ERISA Plan?

Generally, your group health plan is governed by ERISA if you file a Form 5500 with the Department of Labor. You can also check with your accounting, finance, and/or legal departments.

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Where can I find my ERISA three-digit plan number?

It can be found on the plan’s Form 5500, which is filed with the Department of Labor.

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What is a Form 5500 and who is required/exempt from filing it?

You can find more information about Form 5500 at the Department of Labor website and also on the ADP website. Please check with your finance/accounting/legal department to confirm your group’s status.

What is a federal Employee Identification Number?

An employer identification number (EIN) is a nine-digit number assigned by the IRS. The IRS uses the number to identify taxpayers who are required to file various business tax returns.

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Where can I find my HMSA group number?

Please refer to the letter you received from HMSA regarding the Gag Clause Compliance; your group number is on the upper right-hand side under “Your immediate action is needed.”

Updated

My ERISA group account has multiple federal EINs. Do I have to submit information for all of them?

Yes, please submit a separate entry for unique EIN that is associated with your account.
If you have multiple ERISA plan numbers, please only select and submit one.

What will happen if I didn’t submit my group health plan information to HMSA?

HMSA will submit your group health plan with the information we currently have in our system, but it may be incomplete.

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My account is no longer active with HMSA. Why am I receiving this letter?

You’re receiving this letter because your group(s) were enrolled in a HMSA health plan in 2024-25 (even though the plans have since been canceled) and therefore falls into the date parameters set by CMS.

Updated

How will an employer know that HMSA submitted the attestation?

Visit hmsa.com/employers/caagagclause/ to view HMSA’s Gag Clause submission confirmation receipt after Dec. 31.

What issuer information will HMSA use for this report?

Hawaii Medical Service Association
EIN: 99-0040115

New

Will HMSA provide written confirmation that they’ll comply with Consolidated Appropriations Act for Gag Clause Prohibition Compliance Attestation?

For fully insured employer groups pursuant to 12.1 in the Group Plan Agreement, HMSA has already agreed to comply with applicable laws, which we believe doesn’t require written confirmation.