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Transparency Machine-Readable File Requirement | Keenan

July 02, 2022 by Amy Donovan

Beginning today, the Consolidated Appropriations Act of 2021 (CAA) requires non-grandfathered major medical group health plans and insurance carriers to disclose detailed pricing information in two separate machine-readable files (MRFs). Under the CAA’s corresponding Transparency in Coverage rules (TiC Final Rules) jointly published by the U.S. Department of Labor (DOL), Health and Human Services and U.S. Treasury (together the tri-agencies), these two MRFs must be posted by the plan on a public website that is freely accessible with no log-in required. These TiC requirements do not apply to grandfathered plans, excepted benefits, or account-based plans, such as HRAs, FSAs, and HSAs.

As you receive notice of the posting of these MRFs from your insurance carrier, broker, consultant or TPA, we anticipate you may have some questions.

What is a machine-readable file?

The TiC Final Rules define a “machine-readable file” as “a digital representation of data or information in a file that can be imported or read by a computer system for further processing without human intervention, while ensuring no semantic meaning is lost.” They are intended to be easily read by computers, and not necessarily by humans. Examples of machine-readable formats include, but are not limited to, .XML, .JSON and .CSV formats.

What is the purpose of posting these files?

The MRFs are extremely large files that are intended for data analytics to source the information to identify trends and develop industry efficiencies. The hope is that more available data will lead to lower costs.

Should I share these links with my employees?

You may, but there is no current legal requirement for you to do so. MRF files are not intended to be a member-utilized resource. The member-facing tool created by the CAA is the “Transparency Portal” that will be available on and after January 1, 2023, that allows members to price-compare various so-called “shoppable services” covered by the Plan.

Do we have to post these files somewhere on our website?

The tri-agencies guidance on this point has been confusing to many employers for a number of reasons. First of all, the TiC Final Rule places the obligation for posting on the Plan, not the employer. For fully-insured employers, their group health insurance carriers will post the link. For self-funded plans, the employer does not usually establish a public-facing website for the group health plan.

On June 17, 2022, the Centers for Medicare and Medicaid Services (CMS) posted the following Q&A on its “Technical Clarifications” web page:

“Question #37: May a group health plan that does not have its own website satisfy the requirements of the TiC Final Rules with respect to posting the Allowed Amount file and the In-network Rate file on a public website of the plan, if the plan’s service provider posts the Allowed Amount file and the In-network rate file on its public website on behalf of the group health plan?(New 6/17/22)

Answer #37: If a group health plan does not have a public website, the plan may satisfy the requirements for posting the Allowed Amount file and the In-Network file by entering into a written agreement under which a service provider (such as a TPA) posts the Allowed Amount file and the In-network Rate file on its public website on behalf of the plan. However, if a plan enters into an agreement under which a service provider agrees to post the Allowed Amount file and the In-network Rate file on its public website on behalf of the plan, and the service provider fails to do so, the plan violates these disclosure requirements. The Departments intend to follow up with the issuance of formal guidance soon.”

So, an employer may under this guidance delegate the posting duty to their TPA or other service provider, pursuant to their written contract. Employers that rely on this guidance should check to ensure that the up-to-date links are being posted in accordance with the regulations. Alternatively, an employer can post the links on its own public website.

About Amy Donovan
Amy is AP Keenan's Vice President of Legislative and Regulatory Affairs, authoring the firm's Briefings and position papers on legislation, regulation, and litigation that impact the firm and its clients.