Biden Admin Issues New Price Transparency Rule for Insurers

  • The Biden administration — having already opted to keep Trump administration-era health care price transparency regulations on the books — has now issued a new set of transparency requirements aimed at health insurers specifically.

    The interim final rule with request for comments (IFC), titled “Prescription Drug and Health Care Spending,” will require group and individual market health plans as well as Federal Employees Health Benefits Program carriers to submit a wealth of prescription drug and health care spending data to the federal government no later than Dec. 27, 2022. At least one industry analyst doesn’t anticipate the regulation will have a particularly significant effect on health insurers — though that may not stop them from protesting.

    “We do not see any meaningful impact in the near term regarding this rule, especially as enforcement does not go into effect until December 2022 and details around pricing as a result of this rule would not come until June 2023 at the earliest,” Citi equities analyst Ralph Giacobbe advised investors on Nov. 18. “That said, we expect pushback from the industry, both related to the administrative burden and greater understanding of how the data will be used given sensitivities around competitive intel.”

    Major industry trade group AHIP did not respond to AIS Health’s request for comment by press time.

    According to a CMS fact sheet, the IFC will require health plans to submit the following information annually to HHS, the Dept. of Labor and the Treasury Dept.:

    • General information regarding the plan or coverage;
    • Enrollment and premium information, including average monthly premiums paid by employees versus employers;
    • Total health care spending, broken down by type of cost (hospital care, primary care, specialty care, prescription drugs, and other medical costs, including wellness services), including prescription drug spending by enrollees versus employers and issuers;
    • The 50 most frequently dispensed brand prescription drugs;
    • The 50 costliest prescription drugs by total annual spending;
    • The 50 prescription drugs with the greatest increase in plan or coverage expenditures from the previous year;
    • Prescription drug rebates, fees and other remuneration paid by drugmakers to the plan or issuer in each therapeutic class of drugs, as well as for each of the 25 drugs that yielded the highest amount of rebates; and
    • The impact of prescription drug rebates, fees and other remuneration on premiums and out-of-pocket costs.

    HHS and the Labor and Treasury departments will turn that information into biennial reports, starting in 2023, that detail “prescription drug pricing trends and the impact of prescription drug costs on premiums and out-of-pocket costs.” The IFC is the fourth regulation related to the No Surprises Act and transparency requirements outlined in the Consolidated Appropriations Act of 2021.

    Click here for a pdf of the full issue

  • Leslie Small

    Leslie has been reporting and editing in various journalism roles for nearly a decade. Most recently, she was the senior editor of FierceHealthPayer, an e-newsletter covering the health insurance industry. A graduate of Penn State University, she previously served in editing roles at newspapers in Pennsylvania, Virginia and Colorado.

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