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UCare, a nonprofit health plan serving Minnesota and western Wisconsin, has tapped healthcare guidance and transparency technology company HealthSparq on a price transparency solution months before the Centers for Medicare and Medicaid Services rule goes into effect for payers..
The partnership is to give members more personalized and accurate cost estimates for healthcare services for the roughly 600,000 members served by UCare.
The health plan expects that once the tech solution is implemented, it will make it easier for patients to plan for the financial aspects of their healthcare, and offer them a digital experience.
HealthSparq is also promising to deliver insights to members with its Treatment Timelines tool, which estimates both the time care will take and all the costs involved from evaluation through recovery for complex care such as surgeries.
WHAT’S THE IMPACT
Top-of-mind for UCare is compliance with the Centers for Medicare and Medicaid Services’ self-service mandates for health plans, which go into effect in 2023. The October 2020 CMS final rule requires that members have access to online price transparency tools.
According to CMS, beginning July 1, most group health plans and issuers of group or individual health insurance will begin posting pricing information for covered items and services.
This pricing information can be used by third parties, such as researchers and app developers, to help consumers better understand the costs associated with their care.
More requirements will go into effect starting on January 1, 2023 and January 1, 2024, which will provide additional access to pricing information and ostensibly enhance consumers’ ability to shop for the healthcare that best meets their needs.
By plan or policy years beginning on or after January 1, 2023, most group health plans and issuers of group or individual health insurance coverage will be required to disclose personalized pricing information for all covered items and service to their participants, beneficiaries and enrollees through an online consumer tool, or in paper form on request.
Cost estimates must be provided in real-time based on cost-sharing information that is accurate at the time of the request, said CMS.
For health plans and insurers, the key provisions include making pricing information available to the public, including in-network rates and allowed amounts in machine-readable files and providing an internet-based price comparison tool. Beneficiaries should be left with an understanding of their out-of-pocket expenses so they can effectively shop for items and services, CMS said.
Controversially, the final rule also requires plans and issuers to disclose in-network provider negotiated rates, as well as historical out-of-network allowed amounts and drug pricing information.
The Department of Health and Human Services also finalized amendments to its medical loss ratio program in the rule that allows issuers offering group or individual health insurance coverage to receive credit in their MLR calculations for savings they share with enrollees that result from the enrollees shopping for, and receiving care from, lower-cost, higher-value providers
For plans that don’t comply, CMS may take enforcement actions in a number of ways, such as requiring corrective actions and/or imposing a civil monetary penalty of up to $100 per day for each violation and each individual affected by the violation.
THE LARGER TREND
Hospitals have their own price transparency requirements, but a recent survey from patientrightsadvocate.org found that, to date, just 14.3% of 1,000 hospitals are compliant with the rule.
About 38% of the hospitals surveyed posted a sufficient amount of negotiated rates, but more than half were not compliant in other criteria of the rule, such as rates by each insurer and named plan. At the same time, just 0.5% of hospitals owned by the three largest hospital systems in the country – HCA Healthcare, CommonSpirit Health, and Ascension – were in compliance.
The most prevalent omission tagged as “noncompliance” was not posting, or the incomplete posting of negotiated prices for each item and service clearly associated with all of the payers and plans accepted by the hospital.
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