In November 2020, the U.S. Department of Health & Human Services (HHS), Department of Labor, and Department of the Treasury issued the Transparency in Coverage Rule. Based on Affordable Care Act (ACA) requirements, it mandates payers:
- Post machine-readable files (MRFs) that list in-network rates and out-of-network allowed amounts on a publicly available website by July 1, 2022
- Provide members with an online cost estimator tool that allows them to look up their out-of-pocket costs for health care services beginning in 2023
Kaiser Permanente is committed to providing price transparency in their interactions with customers and members. Kaiser Permanente already provides multiple price transparency tools for:
- Brokers, consultants, and employers — Client and group specific reports are available based on claims data, clinical data, employee engagement, and aggregate data. To be HIPAA compliant, there are group size requirements that vary depending on the report. Reach out to your account representative to learn more about the tools that are available to you.
- Members — The machine-readable files are not intended to represent member out-of-pocket costs. Each member's cost share is based on their unique plan benefits. The best way for Kaiser Permanente members to estimate their out-of-pocket health care costs before getting care from Kaiser Permanente providers is to use the cost estimator tool on kp.org (requires sign on).
The links on Transparency In Pricing Machine-Readable Files | Kaiser Permanente are to machine-readable files (MRFs) that comply with the federal Transparency in Coverage rule. The files will be made public for plan years that begin on or after January 1, 2022 and will be refreshed monthly.
The inclusion of providers and information on the MRFs is based on the requirements of the federal Transparency in Coverage rule, its definition of "in-network provider", and sub-regulatory guidance such as the Transparency in Coverage schema Version 1.0.0 and FAQs issued by the U.S. Departments of Labor, Health and Human Services and Treasury. The MRFs should not be used instead of provider directories, health plan coverage documents, or cost estimate tools and communications. CERTAIN SERVICES ARE SUBJECT TO MEDICAL MANAGEMENT, SUCH AS REFERRAL AND/OR PRIOR AUTHORIZATION REQUIREMENTS. To determine whether such requirements apply to the services that a member is seeking, they should consult a coverage document such as the applicable Evidence of Coverage (EOC), Certificate of Insurance (COI) or Membership Agreement. For member-specific questions, members can contact Kaiser Permanente Member Services (800-464-4000).
For questions, please contact your B&P Sales Rep – 888.722.3373.