Exciting announcement: Flume Health Raises $30M Series A To Redefine Health Plan Administration Learn more

Transparency in Coverage

The Transparency in Coverage Final Rules (the TiC Final Rules) require health insurers and Group Health Plans, including self-funded Plans, to disclose on a public website information regarding in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for covered items and services, and negotiated rates and historical net prices for covered prescription drugs in three separate machine-readable files.

Machine-readable files (MRFs) must be published on a publicly available site based on the enforcement date of July 1, 2022, for plan years beginning on or after Jan. 1, 2022.  These files provide pricing data for covered items and services based on in-network negotiated payment rates and historical out-of-network allowed amounts.  The third machine-readable file for prescription drug rates and historical costs has been delayed pending further guidance.

Publicly available MRFs
Note: This page is intended to meet the compliance requirements for the Transparency in Coverage Act.  Per that legislation, this page and these files are designed to be read by machines.  Some of these files are very large so downloads may require substantial system resources.

The TiC Final Rules also require plans and issuers to make price comparison information available to participants, beneficiaries, and enrollees through an internet-based self-service tool and in paper form, upon request. The online Price Transparency tool for members must include personalized, real-time, cost-share estimates for covered services and items, including pharmacy. For plan years beginning on or after Jan 1, 2023, the online tool must provide cost-share estimates for 500 shoppable services. For plan years beginning on or after Jan. 1, 2024, the online tool must provide cost-share estimates for all covered services.