ACA Implementation FAQ Part 65 Addresses Cost Estimate Disclosure and Insufficient Past Claims Data

The Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury released Affordable Care Act (ACA) FAQs Part 65 explaining how plans and issuers comply with Transparency in Coverage (TiC) cost-sharing disclosure requirements for items and services with extremely low utilization when a cost estimate is based on claims data. In cases where rates for items and services are not negotiated as prospective dollar rates—for example, in percentage-of-billed-charges arrangements—cost estimates may be based only on past claims data. Occasionally, past data may be limited for items or services with very low utilization and therefore may result in less predictive and less accurate cost estimates. 

Question: How should plans and issuers comply with the cost-sharing disclosure requirements of the TiC Final Rules with regard to items and services with extremely low utilization when a cost estimate is based on claims data rather than prospective rates?

Answer: To ensure that consumers receive accurate cost-sharing information, the Departments are likely to exercise their discretion, on a case-by-case basis, not to bring enforcement actions against plans and issuers that fail to include in their self-service tool (or in paper form, upon request) or fail to provide over the phone cost-sharing information for items and services for which a cost estimate for such items and services would need to be based on past claims data and for which there have been fewer than 20 different claims in total over the past three years. 

For these items and services, the plan or issuer should indicate on the self-service tool that the item or service is covered, but that a specific cost estimate is not available pursuant to the TiC Final Rules because of insufficient data. 

The self-service tool should encourage the participant, beneficiary, or enrollee to contact the plan or issuer for more information on the item’s or service’s cost-sharing requirements. In cases where the participant, beneficiary, or enrollee contacts a plan or issuer to request such information, the Departments encourage the plan or issuer to provide any available relevant benefits information, such as information available on the Summary of Benefits and Coverage or the portion of the cost of the item or service for which the participant, beneficiary, or enrollee will be responsible. The Departments remind plans and issuers that cost-sharing information for all other covered items and services must be made available through a self-service tool (and in paper form, upon request) as well as over the phone.