Transparency in Coverage

Under section 1311(e)(3) of the Patient Protection and Affordable Care Act, as implemented by regulations at 45 CFR 155.1040(a) and 156.220, health insurance issuers seeking certification of a health plan as a QHP must make accurate and timely disclosures of certain information to the appropriate Health Insurance Marketplace (also known as Exchange), the Secretary of HHS, and the state insurance commissioner, and make it available to the public. Section 2715A of the PHS Act, as added by the Patient Protection and Affordable Care Act, extends the transparency reporting provisions under section 1311(e)(3) to non-grandfathered group health plans and health insurance issuers offering group or individual coverage, except that a plan or coverage not offered through an Exchange shall only be required to submit such information to the Secretary of HHS and state insurance commissioner, and make the information public.

Key Changes for PY2023: 
  • The deadline for submitting Transparency in Coverage data and the Claims Payment Policies and Other Information URL is now aligned with QHP certification and will be due on June 15, 2022. 
  • The instructions for entering data into the Issuer Level and Plan Level tabs of the Transparency in Coverage Template now include information regarding expected values for specific columns.
  • There are four new data value validations included in the Plan Level tab of the Transparency in Coverage Template. These include: 
    • The value reported for “Issuer Level Claims Received” on the Issuer Level tab is greater than or equal to the sum of claims received across all Plan IDs on the Plan Level tab.
    • The value reported for “Issuer Level Claims Denied” on the Issuer Level tab is greater than or equal to the sum of claims denied reported across all Plan IDs on the Plan Level tab.
    • The value reported for “Issuer Level Claims Denied” on the Issuer Level tab is greater than or equal to the number of “Issuer Level Internal Appeals Filed” in Calendar Year 2021.
    • The sum of Plan Level reasons for denied claims (columns D, E, F, G, H, and I) is greater than or equal to the Reported Claims Denied (column C) for each Plan ID. 
  • If you are new to the Exchange and select No for ‘Was This Issuer On The Exchange in 2021,’ then you will not be required to complete the Plan Level Data tab of the Transparency in Coverage Template. 
  • If you are returning to the Exchange and select Yes for “Was This Issuer On The Exchange in 2021,’ then you will be required to complete the Plan Level Data tab of the Transparency in Coverage Template. 
  • Off-Exchange-only plan IDs no longer need to be entered in the Plan Level tab of the Transparency in Coverage Template.
  • NOTE: CMS has clarified definitions and expectations for reporting claims received, claims denied, and reasons for denied claims data. The instructions now contain examples to help illustrate these clarifications. 

Tips for the Transparency in Coverage Section

  • Transparency in Coverage QHP Certification Submission Tips
  • If you are applying to offer on-Exchange plans for PY2023 but did not offer on-Exchange plans in PY2021, you must still submit a Transparency in Coverage Template. 
  • Do not include off-Exchange-only plans in the Plan Level tab of the Transparency in Coverage Template.
  • Required data elements are identified by an asterisk (*) next to the field name. Complete a separate template for each unique HIOS Issuer ID.
  • Use only the tabs provided in the Transparency in Coverage Template. Do not add additional tabs, rows, or columns. Separate templates should be submitted for each unique HIOS Issuer ID.
  • Enter all on-Exchange plan-level data in the Plan Level Data tab. One plan ID should be captured in each row. Each plan ID listed should be a distinct 14-character ID. 
  • Check the templates for completeness and data validity before you submit by clicking Validate on the Issuer Level Data tab. 
  • The Claims Payment Policies and Other Information URL will be collected in the Supplemental Submission Module (SSM) in HIOS and must be active and compliant with URL requirements at the time of initial submission.
  • If you are submitting via HIOS, you must upload the completed template to the Benefits and Service Area Module of HIOS by the required deadline.
  • If you are submitting via SERFF, submit one identical Transparency in Coverage Template containing all plan IDs in each submission binder. For example, if you submit an Individual Market binder and a SHOP Market binder, include both the Individual Market plan IDs and the SHOP Market plan IDs in one Transparency in Coverage Template and submit it in each binder. 

Application Resources