Plans that are based on Referenced Based Pricing:
Referenced Based Pricing plans do not negotiate pricing with providers. Instead, the Plan pays a percentage over Medicare rates. Typically this percentage is 120% - 140% over the Medicare rate but may be adjusted as needed. Medicare rates can be found at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo These rates may be influenced by modifiers, geographic location and changes to the Medicare rates.
The Departments of the Treasury, Labor, and Health and Human Services (the Departments) have issued the Transparency in Coverage final rules (85 FR 72158) on November 12, 2020. The final rules require non-grandfathered group health plans and health insurance issuers in the individual and group markets (plans and issuers) to disclose certain pricing information. Under the final rules a plan or issuer must disclose in-network negotiated rates and billed out-of-network allowed rates through two machine-readable files posted on an internet website.
Plans and issuers are required to make these files public for plan policy years beginning with 2022. This material is for information only. This is provided for informational purposes only, is subject to change and does not guarantee eligibility or coverage. You should call 1 (800) 845-7629 for more information regarding coverage and your member responsibility.
Machine readable files are updated monthly.
Important note: Some of the files, available via the links below, are in JSON format and may be as large as one Terabyte (TB) in file size, which has significant system requirements for use. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The machine readable files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
Understanding the Data
Machine-readable files published adhere to the technical implementation guide and schema version 1.0.0 published by CMS at https://github.com/CMSgov/price-transparency-guide.