Transparency in Coverage

On November 12, 2020, the Departments of Health and Human Services, Labor and the Treasury finalized the Transparency in Coverage Rule that requires health insurers and group health plans to disclose detailed pricing information in 3 separate machine-readable files (MRFs).

Specifically, the following information must be disclosed:

  1. In-network Rate File – In-network provider negotiated rates for covered items and services
  2. Allowed Amount File – Historical payments to and billed charges from out-of- network providers
  3. Prescription Drug File – In-network negotiated rates and historical net prices for covered prescription drugs – this
    particular MRF requirement is delayed until further notice.

Because Florida Blue is the Health Insurance Provider for St. Johns County School District’s self-funded medical plan, the required MRFs will be made available on Florida Blue’s Transparency in Coverage web page beginning July 1, 2022.

What are machine-readable files (MRFs)?

The Transparency in Coverage Final Rules define ‘”machine-readable file’” as a digital representation of data or information in a file that can be imported or read by a computer system for further processing without human intervention while ensuring no lost semantic meaning. This ensures the MRF can be imported or read by a computer system without those processes resulting in alterations to the ways data and commands are presented in the file.

The Final Rules require each MRF to use a nonproprietary, open format that will be identified in technical implementation
guidance—for example, JavaScript Object Notation (JSON), Extensible Markup Language (XML) or Comma Separate
Value(s) (CSV). A PDF file would not meet this definition due to its proprietary nature.

Important Notes About the MRFs

  • These files are extremely large (minimum file size is 20 GB) and are designed to allow researchers, regulators, and application developers with data related to payment rates for health care services.
  • Due to the size of these files, an individual’s ability to view or download these files will be dependent on their hardware, browser, and internet speed.
  • The data on these files do not reflect the application of benefits or cost-sharing (deductibles, copayments, coinsurance) for a specific health plan.
  • Each MRF uses a standard data format and schema (JSON) defined by federal agencies.
  • All MRFs will only include rates for benefits that Florida Blue or Truli for Health administers – rates for benefits that are “carved out” to other vendors (i.e., pharmacy) will have to be obtained from that vendor.
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