Transparency in Coverage: Recommendations* for Improving Access to

and Usability of Health Plan Price Data

On July 1, 2022, federal rules required health insurance plans and issuers to publicly post their
in-network provider reimbursement rates for all covered items as well as allowed amounts and
billed charges for out-of-network items and services. These requirements represent a dramatic
step forward for health care price transparency in the U.S. Greater insight into health care
prices can be a critical tool for understanding the drivers of health system costs and targeting
strategies to lower cost growth. Employers can leverage knowledge about provider prices to
design cost-efficient, high value provider networks. Researchers can leverage the data to gain a
greater understanding of system costs. This in turn can help policymakers and regulators target,
design, and implement policies to improve the affordability of coverage.
However, although many plans and issuers have complied with the federal Transparency in
Coverage (TiC) rules, at significant cost—estimated at over $3 billion in the first year alone—
multiple problems have rendered the published data largely inaccessible and unusable. It would
be a shame to squander this significant investment, which ultimately will result in higher
premiums for policyholders, given the potential value of this data.
The good news is that many of the access and usability problems stem from the technical
specifications provided by the Centers for Medicare & Medicaid Services (CMS). Most can be
fixed through administrative action and better enforcement, with minimum cost burdens for
plans and issuers.

Major Problems with the Transparency in Coverage Data

The following issues pose significant challenges to the accessibility and utility of the TiC
requirements. The result is that the targeted end users – employers, researchers, regulators
and policymakers – cannot achieve the cost containment goals that greater transparency seeks
to achieve. For example:

• The pricing data posted by plans and issuers is hard to find and comprehend. There is no
central repository, and there is a large degree of duplication and irrelevance in the
pricing data.
• Many data files are too large to access without a supercomputer.
• The variation in file types and structures that plans and issuers are using makes it
challenging to access the data using the same file processing script.
To put it in lay terms, trying to locate a single provider in the TiC files is akin to trying to find a
single word in a very large dictionary that isn’t in alphabetical order. This is in part because
there is very little summary information or index information available.
In many cases, the data posted by plans and issuers is of questionable quality. For example,
there is evidence that the data presented in the files inadequately accounts for the variation in
contractual arrangements between providers and payers. More oversight and enforcement are
likely needed to ensure that the pricing data accurately reflects negotiated and out-of-network
rates.

Proposed Potential Solutions

CMS can improve the accessibility and usability of the data through the following actions:

• Reduce data redundancy by:

o Requiring the use of relational databases or file structures, to identify where
there are the same (or very similar) negotiated rates or limiting the posted files
to unique network arrangements and associated fee schedules, providing users
with the ability to crosswalk to the employer identification numbers (EIN) to
which the network arrangement applies
 Alternatively, consider creating a file structure that allows insurers to
post one rate for a service or provider if different plans (self-insured,
large-group fully insured, individual, etc) share the same rate.
o Requiring a flag in the in-network file to denote providers with 20 or more
services performed in the last year (a similar threshold is required for the out-of-
network files)
o Reducing frequency of reporting from monthly to quarterly or even biannually.
This has the advantage of both giving users more time to analyze the data and
reducing the compliance burden on issuers
• Improve accessibility by:
o Requiring a clear library index (or “augmented index file”) and standardized
labeling of files so that users can see what provider/service codes are in each file
o Maintaining a repository of issuers in compliance with the rule and include links
to their data sources; issuers not in compliance should also be publicly identified
o Imposing a file size limit to ensure that files are not unreasonably large. While
ultimately each plan or issuer would still need to publish the same volume of
data, requiring them to post a greater number of smaller files will enable users
with standard computing capacity to download and use the data
o Requiring issuers to use the same file type across all users, to enable the use of a
single, standard, and open-source code to access the information
• Improve usability by:
o Requiring clearer and standardized labels (file names) on each file (i.e., standard
labels for network type, the services included, service area, etc.)
o Require standardized conventions for and inclusion of providers’ National
Provider Identifiers (NPIs)
• Improve data quality by:
 o Reviewing a random sampling of files to assess data quality during each posting
period. Issuers with poor data quality should be required to take corrective
action
o Providing a public-facing portal and reporting template for users to submit
potential violations of the TiC posting requirements and flag potential data
quality problems
o Convene and maintaining a standing group of technical experts to advise CMS on
ways to improve accessibility and data quality, with the goal of ensuring that the
agency is continually striving to ensure that the published data meets the needs
of researchers, regulators, and purchasers
Congress may also want to consider requiring HHS to produce an annual report that leverages
the newly available price data to provide legislators and other stakeholders with critical
information about the drivers of health system costs.
*These recommendations have been developed through consultation with:
Dr. Michael Chernew, PhD
Leonard D. Schaeffer Professor
Department of Health Care Policy
Harvard Medical School

Sabrina Corlette, JD
Research Professor and Co-Director
Center on Health Insurance Reforms
Georgetown University McCourt School of Public Policy

Karen Davenport, MPA

Senior Research Fellow
Center on Health Insurance Reforms
Georgetown University McCourt School of Public Policy

François de Brantes
Senior Partner
HVC Incentives Advisory Group

Katherine Hempstead, PhD

Senior Policy Advisor
Robert Wood Johnson Foundation

Morgan Henderson, PhD

Principal Data Scientist
The Hilltop Institute at UMBC
Emma Hoo
Director, Value-Based Purchasing
Purchaser Business Group on Health

Daniel Kurowski, MPH

Director of Government Data and Analytics
Health Care Cost Institute

Katie Martin, MPA

President and CEO
Health Care Cost Institute

Aditi Sen, PhD

Director of Research and Policy
Health Care Cost Institute

Kosali Simon, PhD

Distinguished Professor
Paul H. O’Neill School of Public and Environmental Affairs
Indiana University

Christopher Whaley, PhD

Economist
RAND Corporation

If you have any questions about the above recommendations, please contact Sabrina Corlette
at Sabrina.corlette@georgetown.edu or (202) 687-3003.