Transparency in Coverage Rule – Online self-service tools for 1/1/24 

November 7, 2023

Impact: Commercial and HIM

In May, Prime communicated an update on the Transparency in Coverage Rule (TiC) (CMS 9915-F) which requires non-grandfathered Commercial and HIM health plans to create online “self-service” search tools that contain real-time, member-specific information on member’s cost-sharing for covered items and services, including prescription drugs. At that time, we committed to providing an update on our progress to satisfy the requirements with

On-track (1/1/2024):

  • Provide the ability to sort drug cost by pharmacy quotes on MyPrime in order of member’s cost share.
  • Make content changes on MyPrime to outline member cost-sharing liability, copay/deductible status reflected as cost-sharing liability, and language that preventive services may not be subject to cost-sharing.
  • Display member accumulated amounts on MyPrime based on paid claims.
  • Provide members, from health plans who have delegated member service calls to Prime, the ability to call the Contact Center and request cost-sharing information be provided to them via paper method. An optional service for clients who don’t delegate member service calls was communicated in early October.

Out of Network Risk:

Out of network claims make up a proportionally small number of the total number of claims processed and as such, Prime’s self-service tool is designed to prioritize the display of in-network pharmacies, as those would be the primary search goals of the member.

Due to the TiC online cost estimator requirements being new to the industry and with the idea that additional guidance may be issued in the future, Prime Legal and Compliance are comfortable with the direction of providing/surfacing the AWP amount to the member as a good faith solution to provide a reasonably accurate estimate of what the plan would pay through a member reimbursement request (paper claim) and the member’s cost share liability for the out-of-network requirements. Our assessment takes into consideration that this information only applies to non-contracted pharmacies, the out-of-network providers.

  • With Senior and Executive leadership backing, Prime has landed on a solution to display the Average Wholesale Price (AWP) to members who price medications at OON pharmacies.
  • For out of network inquiries, members must search by specific pharmacy name, which for out-of-network pharmacies, will return the AWP.
  • The AWP would be revealed to the member as the highest potential cost share the member may realize for OON claims.
  • This solution is accurate and ensures members understand that they will be required to pay the full price of medications at point of sale before submitting a paper claim.
  • Prime is developing disclaimers for the Out-of-network search results.
  • Our estimated delivery is Q1 2024; we intend to share more details about our delivery as they become available.

Machine Readable File:

In late September, the tri-agencies (HHS, Department of Labor and Treasury) issued a new Machine-Readable File (MRF) FAQ document which rescinds the August 2021 MRF FAQ, with the Departments remarking that they are rescinding the enforcement discretion, and they do not intend to engage in any further rulemaking. Therefore, this FAQ guidance is the first step in moving to enforce the drug reporting requirements.  The agencies must begin the process of formulating guidance on the technical requirements for, and format of, the MRF.

While there is no indication of when that guidance will be released, Prime has begun working to determine system needs and capabilities to support the development of the pharmacy MRF.  Prime will provide updates as guidance is released or updated.

TIC Next steps

  • Out-of-network timelines will be shared in the coming weeks as the delivery team finishes other components of the Transparency in Coverage mandate.
  • Prime’s compliance partners will continue to monitor the federal Machine-Readable File component for scope requirements and timelines.
  • Prime can share mock-ups of MyPrime designs and provide demos of the new functionality as needed.

If you have questions, please reach out to your Prime/Magellan Rx client account team representative.