Guidance to Congress on Health Care Price Transparency Legislation
Steps Congress should take to extend and strengthen the current rules
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Executive Summary
A package of bipartisan health policies is currently moving through the U.S. House of Representatives to strengthen federal price transparency requirements on providers and health plans. The House proposals would largely put two Trump-era rules in federal statute: the hospital price transparency rule and the health plan price transparency rule known as Transparency in Coverage. As Congress continues to work on price transparency, the preamble discussions from these two rules offer the first and best place to look for guidance. These principles and objectives are outlined in this report. Using this as a guide, the report recommends steps Congress should take to extend and strengthen the current rules.
The main goal of the price transparency rules is to deliver more affordable health care. While this goal may be simply and strongly stated, the federal rules were also guided by a more detailed set of principles and objectives aimed more pointedly at ensuring patients and those who support patients can ultimately access the pricing information they need when they need it.
Key principles and objectives
Prices should be disclosed to give consumers the information they need to hold health
plans and providers accountable and push them to innovate better ways to deliver coverage and care.
- Prices should be disclosed publicly to strengthen the ability of other entities to develop tools and resources to support health care consumers.
- All hospitals should be required to report pricing information.
- All health plans should be required to report pricing information.
- Patients should have access to pricing information for all health care items and services.
- Patients should have access to all the information they need when they sit down with their provider to make the best health care decisions. This objective was further supported by the following more specific objectives.
- Patients should have access to real-time pricing and cost-sharing information.
- Pricing and cost-sharing information should reflect the explanation of benefits a patient will receive from their health plan.
- Pricing information should be provided in dollar amounts, not percentages or formulas.
- Health plans should provide patients with their most accurate estimate for out-of-network costs.
- Patients should be able to access all the rate information necessary to estimate their cost sharing for in-network care.
- Price transparency information should be easily accessible to researchers, software developers and other health innovators that are positioned to use the information to help consumers.
- Price transparency should not require hospitals or health plans to change how they do business.
- Consumers should not need to depend on third parties.
Recommendations
- Use the federal rules as the foundation for legislation to build up a more robust set of price transparency policies.
- Expand the hospital price transparency requirements to more care settings and to care provided in hospitals by providers who are not employed by the hospital.
- Require hospitals to disclose information through the data files in a standardized format.
- Move closer to real-time disclosure of pricing and cost-sharing information.
- Make pricing and cost sharing information easily accessible to a patient’s authorized representative.
- Provide the authority to extend key interoperability policies that CMS implemented through rulemaking in recent years to all health plans subject to Affordable Care Act (ACA) individual and group market reforms.
- Align price transparency requirements with the requirements of the No Surprises Act.