Transparency in coverage

Estimate your health costs using the cost estimator tool that matches your health plan. You may estimate in-network and out-of-network provider costs for inpatient procedures, diagnostic procedures, labs tests, and outpatient costs. 

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is balance billing, sometimes called “surprise billing”?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible as defined in your Summary Plan Description (SPD). You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care – like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You’re protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, and coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must:
  • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, contact The Department of Health and Human Services (HHS) No Surprises Help Desk at 1-800-985-3059.

Visit the Center for Medicare and Medicaid Services website for more information about your rights under federal law.

Starting July 1, 2022, to comply with the Transparency in Coverage rule, you’ll need to add the link to this website to your health plan's public website, or if this is not available, use your public website.

Along with the link, employers may include the following recommended language:

This link leads to the machine-readable files that are made available in response to the federal Transparency in Coverage Rule and includes negotiated service rates and out-of-network allowed amounts between health plans and healthcare providers. The machine-readable files are formatted to allow researchers, regulators, and application developers to access and analyze data more easily.

What is a machine-readable file?

A machine-readable file (MRF) is 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. These files follow the Centers for Medicare & Medicaid Services (CMS) defined layout and are in the CMS-approved format (JSON). These files are not meant for a consumer-friendly search of rates, benefits, or cost-sharing.

Stated by CMS, the primary intent for releasing these cost data files is to provide opportunities for detailed research studies and data analysis, as well as offer third-party developers and innovators the ability to create private-sector solutions to help drive additional price comparison in the health care market.

What are the employer requirements of the rule?

The text of the Transparency in Coverage Final Rule, says group health plans must create and publish machine-readable files (MRFs) that contain detailed pricing information, including:

1. Network negotiated rates for all items and services
2. Historical payments to, and billed from charges from out-of-network providers

Group health plans are required to make these files available to the public from an open-access internet website effective July 1, 2022.

To comply with the rule, group health plans must link to this website by copying this URL.

Do I need to download the MRF?

To be compliant with the rule, group health plans only need to make the link to this page available on the group's health plan site or on the employer's public site. If you choose to download the file, you may need to contact your IT department.

How often will data be updated?

The regulation requires the files to be updated monthly. As such, new files will be posted on the first day of each month.

What if an employer does not have a publicly available website?

The rule requires the group health plan (the employer) to make the link to this page available on a publicly accessible website. While the website need not be that of the group health plan itself, it is unclear how the group health plan would disclose the location of these machine-readable files in the absence of a website. To that end, any employer without a website should discuss the matter with its own legal counsel or technical resources.