Week in Washington: Transparency, Legislation Updates, and Regulation Round Up

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Week in Washington: Transparency, Legislation Updates, and Regulation Round Up


Two different transparency rules are out there:  a final rule that directly affects hospitals and a proposed rule that affects insurers. A few highlights are below. Given the likelihood of litigation, it is not expected that either regulation will result in extensive data availability in the near term. 

Hospital Transparency Rule (Hospital Outpatient Prospective Payment System Policy Change)

What Is It? The rule requires hospitals disclose standard charges (negotiated rates) online in a machine readable format of 70 to 300 “shoppable” charges. These charges must be associated with a particular billing code (e.g., CPT, HCPCS, etc.).

Who does it Affect? Hospitals

When is it Scheduled to Go into Effect? January 2021

Outlook: This will not be implemented in January 2021. Several prominent hospitals and hospital associations have publicly promised to litigate this rule (which could take several years). However some hospitals may comply as litigation goes on.

Key Links:  You can find the rule here 

Insurer Transparency Rule (Transparency in Coverage Proposed Rule)

What Is It? This is a proposed rule that will require insurers to disclose 1) negotiated rates for in-network providers and historical out of network allowed amounts in machine-readable formats on their websites and 2) provide cost-sharing information to enrollees (essentially an EOB but beforehand). CMS requested information on the technology requirements around sharing the cost-sharing information (specifically if it should be required to include open API). Finally the rule allows issuers to credit “shared savings (innovative designs to encourage consumers to shop for lower-cost providers) in MLR calculations for the 2020 MLR reporting year.

Who does it Affect? Individual and group plans (essentially major medical commercial insurance with a few exceptions. Note this includes self-insured.)

When is it Scheduled to Go into Effect? One year after the rule is finalized (no defined date).

Outlook: Unclear. The ACA does provide extensive statutory authority on commercial plans in the area of transparency. However, there is expected pushback from interested stakeholders. Given this is a proposed rule, changes should be expected before it’s finalized and it may take longer (i.e., until after the election) to finalize.

Key Links:  You can find the rule here

Legislation Update

There are a number of potential legislative issues that Congress is currently considering. Currently under consideration include prescription drug changes, surprise billing changes, and suspending various ACA taxes (e.g., Health Insurance Tax). Congress passed a spending bill that would keep the government open until December 20th.  Assuming President Trump signs the budget stop-gap, this would mean it is extremely likely that any legislation that will be passed has a deadline of December 20th.  It is very likely that Congress will adjourn following the December 20th deadline and no major legislation will be considered until after the 2020 election. 

Medicaid Updates

Tennessee officially submitted their Medicaid waiver that would turn their program into a block grant program.  Interestingly one of the major changes the state made from the proposed waiver is that money saved from the block grant would not need to be reinvested into the TennCare (Medicaid) program. If approved this may open an avenue for states not only to block grant their Medicaid program but divert Medicaid funds to other state budget needs. 

ACA Updates

CMS released enrollment in Healthcare.gov states after Week 3. To date, enrollment in Exchanges where HHS is operating is down about 12%, with several states having enrollment down in excess of 20%. The enrollment shortfall is occurring among returning enrollees, although most new enrollment occurs at the end of Open Enrollment. 

Other Reg Watch

Axios gives a good recap of regulations currently sitting at OMB including: international price indexing for drugs, drug importation from Canada, faster coverage by Medicare of breakthrough technologies, ACA Payment Notice, and changes to electronic record requirements.

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