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Transparency in Coverage Rule: Overview & Healthcare Pricing Comparison Tools

healthcare price transparency tools

We are nearing the 1/1/23 requirement for health plans to provide online shopping/price comparison on health plan member portals for around 500 services. This is part of the Transparency in Coverage Rule.

Members will be able to sign into their health plan member portal with their credentials – select a provider, select one of 500 services/procedures, and get back a personalized view of the cost that factors in their cost sharing and negotiated rate elements. With this, members get a clear understanding of what a service will cost with that provider. With this personalized view, members can make an educated decision about the cost of their healthcare services & procedures.

How is this different?

Health plans currently have a pricing tool that shows basic prices – such as an office visit, cardiologist visit, or echocardiogram. However, it’s not personalized. With this new requirement, members will have full transparency. They will understand what the cost for the service will be based on their specific benefit plan, which providers are in network, and where they’re at in their particular plan (deductible, max out of pocket).

Which plans are included?

All commercial plans must meet this requirement. This includes all individual and family plans on/off the exchange. This does not apply to Medicare or Medicaid.

What does this mean?

This is an exciting step forward toward healthcare becoming more digital and patient-centric. It also aligns with the soon-to-come Advanced Explanation of Benefits.

For example, say you have a knee injury and need replacement surgery. As of 1/1/23, with the Transparency in Coverage requirements, you’ll be able to log into your health plan portal and compare prices for that procedure. A broader scope of shoppable services must be made available to you in 2024

Advanced EOB

The Advanced EOB will be the next generation of this service. With the Advanced EOB your physician would request one from your health plan with the specific codes for that knee surgery. This Advanced EOB tells you, if you have this service with this provider and everything matches, this would be your benefit. It’s like getting your EOB before you even decide to have the surgery. Versus today, where you get the knee surgery and then some time after you get your EOB, and know your cost share.

Pricing Transparency & HealthEdge – The Wave toward Digital

HealthEdge is on the forefront of pricing transparency and enabling health plans to empower members to make educated decisions about their health. HealthEdge has had tools in place for several years to consume the items and services and based on the member and provider return personalized cost sharing information. HealthEdge’s suite of products provide accurate real-time data – the backbone of pricing transparency. 

About the Author

Maggie Brown has over 30 years of leadership experience in healthcare and insurance marketplace. Maggie transitioned from health plan management roles to implementing core business solutions for numerous health plans around the country. With the enactment of HIPAA, the Balanced Budget Act, and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 she focused on how to ensure a health plan could implement key technology solutions, meeting the needs of their members, while being compliant in a rapidly changing regulatory environment. Maggie has led implementations for government programs at both new and established managed care companies. Maggie holds a Doctor of Religious Arts degree with a major in Pastoral Psychology.