Transparency in Coverage Rule
What is the Transparency in Coverage Rule?
The Transparency in Coverage Rule was issued in 2020 by the U.S Department of Health & Human Services, Department of Labor, and Department of the Treasury and enforced beginning 7/1/22. It requires health plans, (which includes employers who sponsor employee benefits plans) and health insurance issuers to publish two separate machine readable files (MRFs) as follows:
In Network: Negotiated rates for all covered items and services between the plan or issuer and in-network providers.
Out of Network: Allowed amount paid to, and billed charges from, out-of-network providers for all covered services within a 90-day period.
What will Cigna + Oscar do?
Cigna will be producing and hosting client-specific MRFs to assist our clients with compliance.
These files will be hosted by Cigna at no cost. No new charges will apply through the end of 2022 for standard delivery/hosting of MRFs. Charges for 2023 effective dates will be evaluated at a later date.
What if my company does not have a website?
If you do not have a public website, you do not need to develop one for the purposes of posting the files (or links to the files). You will be automatically opted into an agreement for Cigna to manage this on your behalf.
How to meet regulatory requirements:
To meet regulatory requirements, Cigna + Oscar recommends you take the following actions:
Please copy the following link and post it to your public website if you are an existing or new Cigna + Oscar small business customer. This is the link the general public can use to access the MRFs: https://www.cigna.com/legal/compliance/machine-readable-files
You can determine where on your public website you would like to place the link.
Per the regulation, anyone in the United States should be able to access this link on your website without any requirement such as a password, a fee or an age restriction.
Along with the link, please include the following recommended overview verbiage:
"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 more easily access and analyze data."
You may have trouble opening the machine readable files in the .JSON format on your own. It probably won’t make any sense for most people and needs special software to read them for the more technological individuals such as researchers, regulators and application developers who would use the information in the files.
You only need to follow this process once to establish the link. Cigna will update the files each month and this link will remain constant and always access the most up-to-date files.
Should you need assistance in further understanding this communication or generating a written agreement, please contact email@example.com or your broker.
Cigna + Oscar coverage is insured by Cigna Health and Life Insurance Company. CA: benefits administered by Oscar Health Administrators. Other states: benefits administered by Oscar Management Corporation. Pharmacy benefits provided by Express Scripts, Inc.