CMS Adopts New Price Transparency Rule for COVID-19 Test Providers and Insurers

COVID-19 test providers are the target of a new price transparency requirement, along with health insurers. On Nov. 6, the Centers for Medicare and Medicaid Services (CMS) finalized a new price transparency requirement that these entities provide detailed pricing information on key services. For providers of COVID-19 testing, the rules are already in effect. The new rule expands on a Trump administration transparency rule requiring hospitals to post their rates online. That rule, adopted in late 2019, is set to go into effect on Jan. 1, 2019, unless it is blocked by the courts. A lawsuit challenging the hospital price transparency rule was rejected at the district court level, but it is under appeal.

The new Interim Final Rule requires that providers of COVID-19 tests publish online their cash prices for COVID-19 testing services. The rule follows up on a provision found in Section 3202(b) of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The new requirement allows CMS to provide a warning, seek a correct action plan, or impose civil monetary penalties for non-compliance.

The provisions affecting healthcare plans should also be of interest to the laboratory community. Beginning Jan. 1, 2022, healthcare insurers will be required to make regular updates on their negotiated rates to in-network providers and historically allowed amounts for out-of-network providers in a standardized, machine readable file. Beginning Jan. 1, 2023, health insurers will be required to provide plan participants, beneficiaries and enrollees (or their authorized representative) personalized out-of-pocket cost information on an initial list of 500 shoppable services, over 100 of which are laboratory or pathology services. By Jan. 1, 2024, the transparency requirements will be expanded to require healthcare plans and insurers to provide cost-sharing information and negotiated rates on all covered health care items and services, including laboratory tests.

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