Navigating Health Plan Transparency: Employer Responsibilities

Reporting Requirements

File RxDC report by June 1 of each year

Health plans must submit annual prescription drug and health care spending reports (RxDC) to the federal government by June 1 for the previous year. These reports require detailed plan, enrollment, premium, and benefit information, and may involve multiple third parties. A submission is complete once all required files are provided, regardless of who submits them.

• Contact your plan’s issuer, third party administrator (TPA), or pharmacy benefit manager (PBM) early each year to confirm who will submit the RxDC files;
• Respond promptly to any information requests;
• Review your agreement to ensure reporting is covered; Monitor compliance for self-insured plans.

Submit gag clause attestation by December 31 of each year

Health plans may not enter contracts with providers, TPAs, or service partners that include “gag clauses” restricting access to provider price or quality information. Each year, plans must submit an attestation of compliance by December 31, unless a fully insured plan’s issuer submits it on their behalf.

• Review contracts to ensure they do not include prohibited gag clauses;
• Confirm with your issuer, TPA, or PBM who will submit the required attestation each year;
• For self-insured plans, ensure downstream agreements prohibit gag clauses and address reporting duties;
• Monitor provider compliance

Employers that submit their own attestation should follow the latest federal instructions.

Disclosure Requirements

Post MRFs and make monthly updates

Health plans must post three machine-readable files online: in-network negotiated rates, out-of-network allowed amounts, and (once implemented) prescription drug prices. These files must be updated monthly and available to the public at no cost.

• Verify your issuer or third-party posts and updates In-network Rate and Allowed Amount Files monthly;
• Ensure agreements outline these posting responsibilities;
• Monitor compliance for self-insured plans;
• Stay updated on new MRF transparency guidance.

Provide a self-service price comparison tool

Health plans must provide an online tool for participants to compare real-time costs for covered services, including prescriptions, and offer paper versions upon request.

• Make sure your issuer or third-party provides the required price comparison tool
• Make sure the agreement includes the responsibility for providing the tool;
• Remains compliant for self-insured plans.

Post balance billing notice

Health plans must protect participants from balance billing and unexpected out-of-network costs for emergency services, air ambulance, and certain nonemergency care. Plans must post a notice of these protections and include it with any applicable EOBs. A federal model notice is available but not required.

• Confirm your issuer or TPA posts the balance billing notice online;
• Ensure the agreement addresses the responsibility for posting this notice;
• Monitor compliance with this posting requirement.

Provide advanced EOBs (delayed)

The requirement to provide advanced EOBs based on good-faith estimates from providers is delayed until further guidance is issued.

Monitor guidance regarding the implementation of the advanced EOB requirement.