Price Transparency

Transparency in Coverage Machine Readable Files

Machine-readable files 7/1/22 launch.

The machine-readable files should be accessible on a freely available internet website. Users are not obligated to create a user account, password, or any other credentials, and there’s no need for the submission of personal identifying information, such as a name, email address, or telephone number.

· Files must adhere to specifications concerning font size, accessibility, and security settings.

· The option to post files on a third-party site is permissible.

· Files must not be in PDF or Excel format; instead, they will be published in JSON.

Machine-readable files within the network comprise negotiated rates for all covered items and services at the plan level, encompassing all medical codes and contracted rates, organized by provider.

For out-of-network data in machine-readable files, allowed amounts for covered items and services are delineated based on billed charges, including historical amounts. The provision of files is not mandatory if there are fewer than 20 claims for a service by a specific provider.

MotivHealth generates and releases files wherever access to data is available on behalf of customers, unless otherwise instructed by the client. The publicly accessible MotivHealth website is https://motivhealth.com/machinereadablefiles (accessible as of July 1, 2022). Customers are welcome to include a link to the MotivHealth site on their own websites.

The customers must publish the files monthly to their own publicly available website. Customers are able to retrieve their machine-readable files by July 1, 2022, and monthly thereafter.

Transparency in Coverage Consumer Price

Starting with plan years beginning on or after January 1, 2023, insurers and plans must make an online price transparency tool available for 500 shoppable items, services and drugs identified in the final rule. All covered items, services, and drugs are required to be included in the consumer price transparency tool for plan years that begin on or after January 1, 2024.

Consumers will be able to get real-time estimates of their cost-sharing liability for health care items and services from different providers. The tool requirements allow the members to understand how costs for covered health care items and services are determined by their plan.

The tool must make available personalized out-of-pocket cost information as well as the underlying negotiated rates and allowed amounts for all covered health care items and services including prescription drugs. The information must be available through an internet-based self-service tool. A paper form of the estimate is available via contact with customer service