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 PY2024:
  • The deadline for submitting Transparency in Coverage data and the Claims Payment Policies and Other Information URL is now aligned with QHP certification; both will be due on June 14, 2023. The Issuer Level and Plan Level data tabs now require that in- and out-of-network claims receipt and denial data are reported separately.
  • There are two new Issuer Level data fields for resubmitted in- and out-of-network claims.
  • There are two new Plan Level data fields for resubmitted in- and out-of-network claims.
  • There are four new Plan Level data fields for claim denial reasons:
    • Number of Plan Level Claims with Date of Service (DOS) in 2022 That Were Also Denied Due to Enrollee Benefit Limit Reached in Calendar Year 2022
    • Number of Plan Level Claims with DOS in 2022 That Were Also Denied Due to Member Not Covered During All or Part of Date of Service in Calendar Year 2022
    • Number of Plan Level Claims with DOS in 2022 That Were Also Denied Due to Investigational, Experimental, or Cosmetic Procedure in Calendar Year 2022
    • Number of Plan Level Claims with DOS in 2022 That Were Also Denied for Administrative Reasons in Calendar Year 2022.
  • 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

  • If you are applying to offer on-Exchange plans for PY2024 but did not offer on-Exchange plans in PY2022, 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.
  • 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.
  • 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. Note that this is different from the process used for other templates submitted as part of the QHP application and certification process, wherein each binder should include a unique template.
Application Resources