Transparency in Coverage Rule
The Transparency in Coverage Rule, finalized in 2020, requires insurers and group health plans, including self-funded clients, to post price and cost-sharing information to plan participants and enrollees.
The Center for Medicare and Medicaid Services (CMS) believes that making pricing information publicly available “strengthens the work of health care stakeholders that provide care, promote access to care, or otherwise aim to protect consumers and the health care system” because, with information on pricing, “these health care stakeholders can better fulfill each of the unique roles they play to improve America's health care system for consumers … researchers can better assess the cost-effectiveness of various treatments; state regulators can better review issuers' proposed rate increases; patient advocates can better help guide patients through care plans; employers can adopt incentives for consumers to choose more cost-effective care; and entrepreneurs can develop tools that help doctors better engage with patients.”
The Rule contains two key provisions, outlined below.
Provision 1: Machine-Readable File Access
On July 1, 2022, Sanford Health Plan began posting 2 machine-readable files. The files, which are updated monthly, contain pricing information for covered items and services in JSON file format. Below, you’ll find (1) an in-network machine-readable file with rates between Sanford Health Plan and in-network providers for all covered items and services and (2) an out-of-network machine-readable file with the allowed amounts for and billed charges from out-of-network providers.
This pricing information can be used by third parties, including researchers and app developers, to help consumers better understand the costs associated with their health care. The machine-readable files are not intended for consumer-friendly searches of rates, benefits or cost-sharing; specific technology may be needed to download and read these files given their size and complexity.
This aligns with the CMS vision that “third-party developers and other entities will download, process, and compile this data, creating more advanced price transparency tools that will help consumers shop among plans and providers, as well as giving the broader public information on patterns in health care costs and generate opportunities for innovation.”
Provision 2: Price Comparison Tool
Beginning January 1, 2023, Sanford Health Plan began offering a web-based, self-service price comparison tool. Members can log into their member portal within MyChart, view the “Insurance” section and choose “Shopping Tool” from the menu. Cost information can also be requested in paper form by contacting customer service.
The purpose of this tool is to provide our members with improved access to health care price information so they can compare prices and better estimate potential out-of-pocket costs.
To learn more about the Transparency in Coverage Rule, visit the CMS website or contact customer service at (800) 752-5863 from 8 a.m. to 5 p.m., Monday through Friday.
Machine Readable Files
Machine-readable-files in JSON format are provided below and updated monthly. Please reference the index file to navigate to the correct in-network-rates file for your needs. In-Network files will contain pricing information for covered items and services for in-network provider rates. Out-of-Network or the Allowed Amount file will contain historical payments to out-of-network providers for billed charges.
Disclaimer: The machine readable files below are made available in response to the federal Transparency in Coverage Rule. This material is not intended for consumer-friendly search of rates, benefits or cost-sharing. These files may be as large as one Terabyte (TB).
To learn more, visit the Centers for Medicare & Medicaid Services information page or contact our customer service team at (800) 752-5863 from 8 a.m. to 5 p.m., Monday through Friday.