Transparency in Coverage
Transparency in Coverage Rule
The “Transparency in Coverage Rule,” issued in 2020 by the US Departments of Health and Human Services, Labor, and Treasury, requires health insurers and group health plans for plan years beginning on or after January 1, 2022, to publish machine-readable files on a publicly available website by July 1, 2022.
These files, updated monthly, will provide pricing data for covered items and services based on:
- In-network negotiated payment rates at the plan level, for all medical codes, for contracted rates, and by provider.
- Out-of-network machine-readable files including allowed amounts for covered items, services based on billed charges, and allowed amounts including historical amounts.
- Prescription drug rates and historical costs (delayed pending further guidance from the Departments).
The machine-readable files are available on each plan’s website free of charge. Users are not required to establish a user account, password, or other credentials and does not require the user to submit any personal identifying information such as a name, email address, or telephone number.
Each health insurer and group health plan creates and publishes files where they have access to the data on behalf of customers unless otherwise directed by the client.
File Access
File access for plans offered to participating groups of California Schools VEBA are available through the following URLs provided:
For both UnitedHealthcare HMOs and UnitedHealthcare/UMR PPOs, please click on:
https://transparency-in-coverage.uhc.com
For Kaiser Permanente plans, please click on: https://healthy.kaiserpermanente.org/southern-california/front-door/machine-readable
For Cigna HMOs, please click on: https://www.cigna.com/legal/compliance/machine-readable-files
It should be noted that these files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data. These files are not intended for direct member use. Members should refer to their health plan coverage materials, or use their health plan’s online tools and provider directory, to learn about their benefits, medications, and providers (doctors and hospitals), respectively.
Price Comparison Tool
Curly-haired nurse showing online news to elderly lady
Effective January 1, 2023, plans and issuers must have price comparison information available with respect to an initial list of 500 identified items and services. This information must be made available through an internet-based self-service tool and in paper form, upon request.
Typically, consumers receive an Explanation of Benefits after receiving care, which details the prices charged by the provider, the plan’s contracted or negotiated rates, consumer cost-sharing obligations, and other information. Consumers will have access to this type of information before receiving care and can use it to compare prices and better estimate potential out-of-pocket costs.
Members can access their health plan’s available cost estimation tool via online portal applications with digital paperless preferences on file or email. Members can also contact the applicable customer service for their health plan and receive written cost share estimates by email or have a physical letter sent by mail.
These price comparison tools are available on each plan’s website free of charge. Users can access these tools by registering an account or using an already established user account, password, or other credentials.
For the plans offered to participating groups of California Schools VEBA, members can reference the following provided links to those tools and related materials:
United Healthcare HMO https://member.uhc.com/myuhc
UMR PPO https://member.umr.com
Kaiser HMO https://kp.org/costestimates
Express Scripts https://www.express-scripts.com
Cigna HMO https://my.cigna.com