Transparency in Coverage (TCR) and Consolidated Appropriations Act (CAA) Overview

Public disclosure of rates via machine-readable files (MRFs)

FAQs [PDF]

In compliance with the Public Disclosure of Negotiated Rates mandate, HMSA will make monthly MRFs publicly available to view, which include:

• In-network negotiated rates with HMSA providers.
• Historical payments to out-of-network providers and their billed charges.
• In-network rates and historical net prices for covered prescription drugs

While the effective date is still January 1, 2022, In-network / Out-of-Network files enforcement has been delayed until July 1, 2022. The drug file requirement has been delayed until further guidance is issued.

Personalized disclosure of out-of-pocket costs (Cost Tool)

FAQs [PDF]

In compliance with the TCR and the CAA, HMSA will offer a price comparison tool to provide members with personalized out-of-pocket costs and price comparisons for specific items or bundled services. The tool must:

• Permit members to search based on billing code or description.
• Inform members of any accumulated deductible or other out-of-pocket expenditures
• to date.
• List any factors that impact the cost, such as service location or drug dosage.
• Provide cost estimates in paper format at the member’s request

Enforcement delayed until January 1, 2023.

Advanced explanation of benefits (AEOB)

FAQs [PDF]

In compliance with the CAA, HMSA will perform, document and to provide comparative analyses of the design and application of non-quantitative treatment limitations (NQTL), upon request from regulators.

The reporting requirement for the Mental Health Parity NQTL Analysis became effective on February 10, 2021.

In compliance with the CAA, brokers and consultants must disclose to group health plans compensation they receive for brokerage services or consulting.

• Applies beginning one year after the date of enactment (Dec. 27), but exempts brokerage and consulting contracts executed prior to the applicability date.