To ensure compliance with the Transparency in Coverage rule, Benefit Fund Administrators should adhere to this checklist:

• Understand the Requirements for Grandfathered Plans: It’s surprising when some learn that Grandfathered plans are generally subject to the requirements of the Consolidated Appropriations Act (CAA) that, among other things, includes transparency in coverage and pricing. Due the complexity in interpreting these analougues requirements it is advisable to consult with your compliance or legal team on whether TiC requirements apply to your plan.
• Machine-Readable Files: Ensure public accessibility of machine-readable files detailing in-network rates, out-of-network allowed amounts, and prescription drug pricing. If linking to your TPA or ASO’s site, ensure those links are directed toward active, public-facing websites.
• Internet Pricing Tool for all Services: Ensure the internet pricing tool available to your members offers real-time cost-sharing information for all services. If working with a TPA/ASO confirm they provide the necessary disclosures to include all covered items and services as part of the self-service online tool.
• Data Accuracy: Verify the accuracy and completeness of all disclosed information. This requires auditing and spot-checking data files and tools against fee schedules and price lists.
• Member Education: Educate members on utilizing transparency tools to understand their health plan benefits to lower out-of-pocket costs. This can involve reaching members through different communication channels.
• Compliance Documentation: Maintain documentation of compliance efforts and updates for regulatory review.
• Feedback Mechanism: To ensure the pricing tool is serving your member’s needs, establish a system for receiving and addressing member feedback on the transparency tools.

Viveka Health: Your Transparency in Coverage Partner

All the items in this checklist represent only a portion of the compliance items Fund Administrators must consider. Viveka Health has the knowledge, guidance, and tools to assist your Fund Office in all aspects of Transparency in Coverage and related Laws. Please reach out to us with any questions or concerns.