EMPLOYEE RESOURCES
Transparency in Coverage
Public Display Requirements Overview for Blue Cross NC Employer Groups
June 2022
The following is a summary provided for convenience and is not intended as legal advice. Customers should consult with their attorney for advice specific to their needs. This document and the policies contained within are subject to change at any time without prior notice.
Under the Transparency in Coverage Rule, health insurance issuers and group health plans1 must produce and maintain public machine-readable files (in the JSON format) with all in- network rates and historical allowed amounts for out-of-network providers (collectively referred to as the “Files”).2 Each rate posted in the Files must be reported by individual billing code for each coverage type and for each provider at a specific site of service. Files must be publicly available, accessible to any person free of charge, without conditions and updated monthly.
The Transparency in Coverage Rule applies to Affordable Care Act (ACA) non-grandfathered plans and transitional plans3. These requirements do not apply to grandfathered plans4, excepted benefits5, retiree-only plans, short term limited duration plans, or Flexible Spending Accounts, Health Reimbursement Accounts and Health Savings Accounts. Customers should consult their own legal counsel on whether their plan is covered.
Files include:
- In-Network Rate File: Includes plan name, billing codes for all covered items and services, provider identifiers, place of service, negotiated rates associated with each provider for each item or service, as well as rates that support alternative payment models for each network provider.
- Out-of-Network Historical Rates File: Includes plan name, billing codes for all covered items and services, provider identifiers, place of service, unique allowed amounts and billed charges paid to out-of-network providers during the defined look-back period, which is the 90-day period beginning 180 days prior to publication of the file.6
How Blue Cross NC will support the machine-readable files requirement
- Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will produce machine- readable files containing in-network rates and out-of-network historical rates. The Files will include in-network rates and out-of-network historical rates for providers in North Carolina and other states. The Files will be updated monthly. The Files will contain a very significant amount of data (estimated at 1 Terabyte per file).
- Blue Cross NC will host Files on its publicly available website, at https://www.bluecrossnc.com/about-us/policies-and-best-practices/transparency- coverage-mrf#. (This website will be live on July 1, 2022.)
- The Files will be publicly available and posted free of charge without having to establish a user account, password or other credentials. (Blue Cross NC does not intend to charge additional fees to self-funded groups for these Files.)
- Blue Cross NC will produce Files for ACA non-grandfathered plans and transitional plans. Data for grandfathered plans are not subject to these requirements and will not be publicly available.
- The Transparency in Coverage Rule requires group health plans to make the Files available on a publicly available internet site. Employer groups may post the relevant URL below to their own public website to satisfy the requirements of the Transparency in Coverage rule.
o For fully-insured groups:
Blue Cross NC will create, host, and update the Files on behalf of fully-insured groups. Blue Cross NC is also in the process of updating its fully-insured group contracts to accommodate the nature of this responsibility. Fully-insured contracts must be reviewed and approved by the North Carolina Department of Insurance before any changes may take effect. Once the changes are approved, we will update groups accordingly.
1 Self-insured group health plans may enter an agreement with third-party administrators to perform the functions required under the rule, but group health plans will remain legally responsible. Please see more on this below.
2 Agencies required an additional file to display costs of covered prescription drugs, but they have since deferred enforcement of the Prescription Drug File until further rulemaking is completed.
3 Transitional plans are plans that became effective between March 23, 2010, when the ACA was signed, and October 2013, when the regulations went into effect. Transitional plans do not meet ACA requirements but are allowed by federal law. The plans cannot be sold to new customers.
4 Grandfathered plans are plans that were effective prior to the March 23, 2010, enactment of the ACA and have been renewed annually since then.
5 E.g, standalone vision, dental, and hearing plans
