The goal of the new Transparency in Coverage rules is to make key pricing and quality information easily available to healthcare consumers. These regulations affect non-grandfathered group health plans, individual insurance providers, and non-governmental health plans. They’ll go into effect over the next three years with the following milestones:
- By January 1, 2022: Post machine-readable files outlining in-network rates, out-of-network allowed amounts, and prescription drug pricing on the internet.
- By January 1, 2023: Provide an internet-based self-service tool that lists personalized, out-of-pocket cost estimates and other price-related data for 500 pre-determined items and services.
- By January 1, 2024: Expand the internet-based tool to include all covered items, services, and prescription drugs in addition to the original 500.
With over 10 years of experience creating innovative solutions to meet the needs of the market and help navigate the complexities of care, Castlight is well-positioned to assist both employer plan sponsors and insurance issuers with rapidly interpreting and responding to these transparency regulations.
Over the past decade, Castlight has become a leader in healthcare navigation. Our world-class digital platform and team of clinical and benefits experts help members connect with the right care at the right time. Transparency is one of the many factors it takes to empower, engage, and activate someone in their personal healthcare journey.
Fortunately, when it comes to transparency, we’re already at a huge advantage. In the early days of Castlight, we developed deep data expertise in order to equip members with the information needed to make the most informed healthcare decisions. In establishing and mastering the following fundamentals, Castlight became an industry pioneer in transparency.
- Provider Directory: Castlight’s unified provider directory consists of 910,000 physicians. Using our own machine learning model, we regularly validate the accuracy of the provider network information received from multiple sources and claims.
- Cost Estimates: Even before the federal transparency rules were developed, Castlight used an algorithm that combines multiple sources with individual-level data to provide accurate out-of-pocket estimates, 90% of which fall within a 10% error margin.
- Provider Quality: We leverage 30 third-party quality sources — like CMS and IQVIA — and supplement them with Castlight’s proprietary quality score, allowing us to reflect the quality for 94% of physicians and 93% of acute care hospitals in the U.S.
- User Ratings : By adding member ratings and third-party reviews covering around 90% of the unified provider directory, we further enable members to make informed decisions.
- SmartMatch: Created by Castlight, SmartMatch curates a personalized list of top providers based on cost, quality, convenience, and relevance to a member’s profile and preferences. Members can still search all in-network providers, but SmartMatch gives them a head start, lessens the cognitive burden, and increases engagement.
Castlight’s Transparency in Coverage Solutions
We believe Castlight is the most prepared to lead compliance with these regulations for three main reasons: We were the first comprehensive transparency solution and have invested significant capital in advancing our capabilities in this space; we have seen it all when it comes to data management and are prepared to accommodate even the most complex pricing data scenarios; we have already built the complementary features that drive personalized engagement and real value in transparency.
Here’s how Castlight’s strong transparency foundation will help plan sponsors and issuers become and remain compliant with these new rules.
Machine Readable Files
The organization and ongoing maintenance of these files will likely be a substantial administrative challenge for plan sponsors and issuers and place a strain on their internal capacity and resources. To ease the burden, Castlight will offer a product-service hybrid including the following components:
- Access: We’ll design a data spec aligned with the machine-readable file format, which will live on GitHub and allow for easier extraction of required data elements.
- Organize: Our product team will provide expert guidance on how to best organize pricing data from disparate sources and methods.
- Post: Following CMS requirements, we’ll build and post the files in the JSON format.
- Update: We’ll establish a monthly reconciliation process with each plan sponsor and issuer.
- Report: We’ll provide a reporting module to track when the data is publicly accessed.
Internet-Based Self-Service Tool
This solution is Castlight’s current transparency and care guidance experience — when members use Castlight to search for a provider, they see cost estimates, quality scores, and patient ratings. We had this down to a science before the rule came about, and we’ll continue to invest in it as part of our navigation solution.
We’re working on two modifications that will align our existing solution with the exact Transparency in Coverage specifications. The first update is to the way the tool behaves. Today, our platform allows members to search for care by using common language descriptive terms like “asthma” and “dermatologist,” and it also makes sense of items and services typically bundled together in common episodes of care. For example, if someone searches “knee replacement surgery,” they’ll see everything included in the cost estimate.
The investment to build this logic already takes cost transparency from a line-item by line-item approach to a more holistic and user-friendly view of cost. The transparency regulations will not cancel out this substantial value. To comply with the letter of the rule, we’ll add the ability to search by CPT code and by a combination of CPT code and provider name. While it’s not common for the average consumer to know a specific CPT code, let alone search for it, this functionality is required for compliance.
The second modification is to the content provided with each search. Currently, Castlight’s system shares out-of-pocket estimates based on historical claims feeds, direct rate sheets, and our proprietary cost-sharing liability algorithm. To adhere to the new rules, we’ll start also displaying the underlying determinants of those estimated out-of-pocket costs, such as in-network rates, out-of-network allowed amounts, and more.
The bottom line with this Transparency in Coverage component is that Castlight’s existing care guidance technology is the solution to assist with compliance and will allow plan sponsors and issuers to skip the monumental cost, time, and effort it takes to build a solution from scratch.
We’re excited to help our customers in this way so they can continue innovating for their populations. However, we want to be clear that we will (and already do) go far beyond transparency in order to create a healthcare navigation experience consumers actually want to engage with, one that’s personalized to each user and employs several methods to help them find and engage with the best care. We cover that here.
In addition, though it’s completely separate from Transparency in Coverage — and less prescriptive and detailed — the No Surprises Act is equally important. Among other transparency-related provisions, it requires health plans to offer a price comparison tool similar to the internet-based self-service tool required by Transparency in Coverage. In a follow-up post, we’ll explain this act further, including how it’s different from the new transparency rules and how Castlight will help address it.