Comment and response document

Transparency in Coverage Summary of 60-day Comments
Category
Timing

Comment Summary
Clarify the timing of when the URLs go live for
the general public.
Accelerate the implementation process.

Provide the final data elements and format at
least six months in advance of the submission
deadline.

Scope of data
collection

Reporting requirements should be consistent
for all group plans including those sold on and
off the Marketplaces, individual, small group,
grandfathered, large group, and self-insured.

Collect of data such as race, ethnicity, gender,
sexual orientation, age, health status,
disability, geographic location, enrollee
income, and primary language to support
evidence-based policymaking that addresses
health disparities.

Response
We will provide further guidance and training on the
process and timing once we finalize the package.
We expect this to happen sometime in 2016.
CMS seeks to balance the need to provide the
public with accurate information and provide issuers
with adequate time to collect and provide data. We
do not believe it is possible to display the
information any sooner. However, based on
comments received, we are proposing to accelerate
the phased-in approach by collecting and displaying
additional information in year 2 (2017).
CMS intends to provide sufficient time for issuer
submission. CMS will also provide instructions and
guidance on submitting the information. Because
the proposed first year’s data collection is limited,
CMS does not believe that six months is required.
CMS plans to implement a phased in approach and
will consult with the Departments of Labor and
Treasury. In addition, HHS, the Department of
Labor, and the Department of Treasury intend to
propose transparency reporting rules for non-QHP
issuers and non-grandfathered group health plans,
and those rules may differ from the rules for QHP
issuers and will take into account differences in
markets, and other relevant factors.
These data elements might be valuable, particularly
for researchers and to inform policymaking, and we
may consider adding these data elements in a
future PRA package. Issuers do not currently collect
all of this information, however. We also have
concerns about collecting information regarding
some of these factors, as applicants and enrollees

Transparency in Coverage Summary of 60-day Comments

Using EDGE server data for the ACA’s riskmitigation programs could be used for
transparency purposes as well.

are not required to report all of this information. We
will consider this suggestion for the second phase
of implementation.
The EDGE server does not contain data that could
be used for transparency purposes.

Do not require submission/display of data
Revised Appendix A specifies what applies to
elements for stand-alone dental plans (SADPs) SADPs.
that do not apply to dental.
Develop common definitions to ensure the
data collected are accurately represented.
Implement controls to ensure the secure
transfer of data from issuers to CMS.

Display plan level data.

Data display

Oversight

Display data in user friendly format such as the
Public Use Files (PUF), not a landscape
format.
Transparency data collected should be used
for oversight and enforcement purposes.

CMS will add common definitions to the data
collection process.
Initially, issuers will send information to a secure
email address. CMS has used this approach with
other data collections. Ultimately, we intend to
integrate data collection with qualified health plan
(QHP) certification.
Displaying data at the issuer level provides more
comprehensive information that we believe is more
meaningful to consumers. Displaying information at
the plan level could result in displaying data
anomalies due to low enrollment in a particular plan.
We will consider whether to display certain
elements at the plan level as part of phase II (likely
2019 and beyond).
CMS intends to display the data using a public use
file (PUF).
As noted in the Supporting Statement, CMS does
not intend to use the data for oversight purposes at

Transparency in Coverage Summary of 60-day Comments

Provide information to State commissioners
relevant to their state.
Out-of-network Collect information on cost-sharing and
coverage
payments with respect to any out-of-network
coverage.
Data on claims Do not display information on claims denials at
denials
this time.

Issuers should report paid and unpaid claims
data by age and income, with diagnosis and
service codes.

Claims
payment

Post plan performance measures of claims
payment timeliness

Collection of website link for claims payments
only is insufficient.
Report additional claims data.
Pending
claims/grace
periods

Reporting should indicate if the pending claim
is in the grace period.

this time. However, we may do so in the future, as
part of phase II (likely 2019 and beyond).
Information will be made available to States for
public view.
CMS is not collecting this information at this time,
due to cost fluctuation for out-of-network services.
In our phased in approach, we will initially collect
claims denial and internal and external appeals
figures. We consider this data collection element to
be useful to consumers.
CMS will consider this approach or a similar
approach for phase II. We note that requiring such
reporting is likely to be labor-intensive and want to
provide sufficient time for issuers to ensure their
systems are capable of this type of reporting.
We will consider this for the future. We note that the
MCAS requires similar reporting. We will wait for
finalization of the MCAS before requiring this of
issuers, so as not to duplicate efforts.
CMS is using a phased approach. We fully intend
to collect additional data as part of phase II.
CMS will determine what additional data elements
would be useful to consumers for phase II.
We are not proposing to require issuers to report on
specific claims that fall in the grace period; we are
asking issuers to provide consumers information on
grace periods and pending claims policies. We will
consider this suggestion for phase II.

Transparency in Coverage Summary of 60-day Comments
Retroactive
denials

Remove the retroactive denial category and
add claims denials category only.
Commenter supports our proposal not to
collect claims denial information at this time.

Data on rating
practices

Disenrollment
data

We think it is important for consumers to know
claims can be denied retroactively, so that they are
aware of the potential for further financial liability.
We appreciate the comment and will move forward
with a phased in approach.

No proprietary or confidential information
should be released to the public.
Data should not be made available until after
the completion of the QHP certification
process.
Utilize this information to indicate whether a
plan’s premium was determined unreasonable
and to link to additional rate-review
information.

We do not propose releasing any confidential or
proprietary information.
CMS intends to display the existing Unified Rate
Review (URR) data.

Display data via the URRT.

We are not proposing to display separately. We
currently display the data via the URRT.
This data element will be posted in 2017.

Disenrollment data should be collected and
posted in 2017.
Disenrollment data should be presented only
after studies have been conducted assessing
reviewer responses.

Reports should reflect the age and significant
medical diagnosis associated with each
disenrollment.

CMS (and States) already use the information
collected on the Unified Rate Review Template
(URRT) to determine whether rates are
unreasonable. CMS and States are already
required to make rating information available to the
public by providing a link to the rate filing
justifications.

The proposal for collection and display of
disenrollment data takes into account concerns
raised during the 60-day comment period. For
phase I, issuers will report overall disenrollment
figures.
As noted above, we intend to require issuers to
provide reason codes for disenrollments as part of
phase II. At that time, we will consider the feasibility
of this suggestion. However, we think it is unlikely
that there are medical diagnoses attributable to

Transparency in Coverage Summary of 60-day Comments

Information on
enrollee and
participation
rights

Modify to indicate whether the dis-enrolled
individual was in a premium grace period
immediately prior to disenrollment.
Analyze these data in light of ACA
nondiscrimination standards.

each disenrollment. For example, people may
disenroll because they move to a different area or
become eligible for other coverage.
We will consider this for phase II.

States have primary responsibility for form review
and for ensuring that issuers meet market wide
standards, including non-discrimination standards.
As part of QHP certification in the Federallyfacilitated Marketplaces (FFMs), CMS currently
reviews plans for discriminatory benefit design.
Drug
Do not include this information until there has
The drug exceptions process is in our regulations,
exceptions
been time to see how state insurance
and issuers are expected to follow it. Issuertimeframes
regulators decide to proceed with incorporating provided information must be accurate.
and enrollment the drug exceptions process into the external
responsibilities appeals process, if at all.
Periodic
financial
disclosure

Provide information indicating whether each
issuer displayed on the site owed medical-loss
ratio rebates in the prior year.

Because this information is currently available on
the CCIIO website: at
https://www.cms.gov/CCIIO/Resources/DataResources/mlr.html, we do not intend to duplicate
this reporting requirement.