Price Transparency and Interoperability

In October 2020, the Federal government issued the Transparency in Coverage rule for health plans and health insurers to increase the availability of healthcare cost information for individual and most group plans. The new regulation includes a phased approach to developing cost transparency services and is a foundation for future additional price transparency requirements, including the Price Transparency Tool and the Advanced Explanation of Benefits. 

The first item in the Price Transparency in Coverage rule requires that machine-readable pricing files be made publicly available. These files provide negotiated rates for items and services with our in-network providers and allowed amounts based on historical payments to out-of-network providers.

We have provided links to machine-readable files in JSON format, as required by CMS. They may be extremely large (more than 100GB and up to 1TB) and will require a special application to open. The machine-readable files will be updated monthly to ensure accuracy of the data and reflect changes in pricing and regulatory requirements.

From the list below, find the plan type to access the associated in-network rate files or out-of-network historical payments.

The machine-readable files are a work in progress and will be posted as they are available. If you don’t see your plan, please check back. Also, files will be updated monthly to reflect changes in pricing/payment and regulatory requirements.

In 2023, PHP will be working to enhance our online cost estimation service to meet the next series of transparency rule requirements, including calculating a "real time" estimate of your out-of-pocket costs for a wide variety of covered services.

Developers interested in creating an account should visit 1UpHealth.

We will continue to ensure we are meeting all requirements within this ruling as they are issued. 

What is Transparency in Coverage?
CMS is requiring all health insurance plans to make in-network and out-of-network pricing for covered services available to the public in the form of a machine-readable file. In addition, a price comparison tool that includes 500 services, must be made available by Jan. 1, 2023

What is a machine-readable file (MRF)?
A machine-readable file (MRF) contains network and out-of-network pricing rates for covered services, and can only be opened by using a specialized computer application.

Where can I access machine-readable files?
You can find links to the machine-readable files above under the Machine-Readable Pricing Files header. The files can be up to a TB in size, so we recommend caution when trying to download them. The files will be in JSON format, and since it requires a specialized application to open the files, we recommend seeking assistance from your organization's IT department..

Where can I find pricing for the prescription drug list (PDL)?
The Transparency in Coverage rule does require prescription drug costs, however at this time, CMS has delayed the requirement to add them. Please be assured that we will comply with all CMS requirements.

In 2020, the Centers for Medicare and Medicaid Services (CMS) developed rules to help people access their health insurance information more easily. CMS has worked for multiple years to connect different parts of the healthcare system to help patients build a complete picture of their healthcare. This concept is called interoperability.

Interoperability allows different health information systems and organizations to work together to help ensure effective healthcare communications. Insurance companies are required to provide certain health information, such as claims, provider directories, laboratory, and other clinical information, in a digital, shareable format. Interoperability allows you to access your health information on a mobile or other electronic device in a secure way for personal use. For example, you could show your information to health care providers to create a more complete picture of your health and healthcare.

Your information will not be automatically shared: you will have control over who has access to your data.

If you have purchased individual coverage through the ACA Marketplace, your plan is covered under these new rules. Healthcare providers are also working to become more interconnected and have their own interoperability requirements. Check with your provider to see what they are doing for interoperability.

Your PHP information (claims, provider directories and other details) is already available to you in your secure MyPHP Member Portal and on the secure MyPHP app. Interoperability allows you to access this same information from different health insurance companies through one app.

You can also allow other apps or websites to view your information. This may be more convenient than logging into the PHP website, and you will be able to connect multiple health insurance companies to one app. However, once your information is connected to an app not associated with PHP, this information is no longer protected by HIPAA.

PHP partners with a company called 1UpHealth, to develop interoperability resources that enable apps to access PHP data. Currently, there are two approved apps; OneRecord and CareEvolution. You can purchase these apps through the app store.

Developers interested in creating an account with 1UpHealth should visit 1UpHealth

PHP takes information security very seriously. The new rules give every member the right to share their personal health information with whoever they choose, and some apps may not have the same security measures as us.

The rules do not allow PHP to limit which apps you share your information with. It is up to you to decide if an app is trustworthy. It is a good idea to read the security policy of any entity you share your information with.

However, PHP is still looking out for you. When you connect with an app, you may see warnings if an app does not meet our requirements. If you see a warning, proceed with caution! Your information may not be safe.

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) enforces the HIPAA Privacy, Security, and Breach Notification Rules, and the Patient Safety Act and Rule.

You can find more information about patient rights under HIPAA and who is obligated to follow HIPAA here:
HHS.gov/HIPAA/For-Individuals/Guidance-Materials-for-Consumers/index.html

To learn more about filing a complaint with OCR under HIPAA, visit:
HHS.gov/HIPAA/Filing-a-Complaint/index.html

Individuals can file a complaint with OCR using the OCR complaint portal:
OCRPortal.HHS.gov/OCR/smartscreen/main.jsf

Individuals can file a complaint with the FTC using the FTC complaint assistant:
ReportFraud.FTC.gov/#/Assistant