Transparency in coverage data

For additional information about the Transparency in Coverage Rule, please visit the Centers for Medicare and Medicaid Services website. You can also review our Frequently Asked Questions (FAQs) below.
 
In addition, Mass General Brigham Health Plan commercial members have access to a variety of resources for understanding health care costs. This includes our cost estimator tool for tracking cost sharing and viewing payments within your plan, which can be accessed through the Mass General Brigham Health Plan Member app and Member portal. Please note: machine-readable files can include provider reimbursement rates for services that may have restrictions within your specific plan.

Click here to access machine-readable files for Mass General Brigham Health Plan plans. Please note: to use the machine-readable files, the member should use an appropriate online JSON tool to format the data.

 *Multiplan (PHCS) wrap provider in-network only applies to the state of New Hampshire, therefore, please refrain from using this file in its entirety and use these rates for providers in the state of New Hampshire only.

**Multiplan/Data iSight out-of-network provider network only applies to the states of Massachusetts and New Hampshire, therefore, please refrain from using this file in its entirety and use these rates for providers in Massachusetts and New Hampshire states only.

Download a PDF version of this FAQ.

What are machine-readable files?
As part of the federal Transparency in Coverage Rule, health insurers and self-funded group health plans or employer-sponsored plans are required to publicly display information, called machine-readable files. These files are updated monthly and include in-network negotiated provider rates and out-of-network provider allowed amounts.

What is included in machine-readable files?
These files include a Table of Contents, as well as in-network negotiated provider rates and out-of-network provider allowed amounts that each contain vendor file references.

What is included in the Table of Contents?
The Table of Contents (TOC) includes an index of the in-network negotiated provider rates and out-of-network provider amounts based on a given plan and product line.

What is an in-network rate?
An in-network rate is the amount that a health insurer has agreed to pay a contracted provider for healthcare services. As part of the Transparency in Coverage Rule, these rate files include negotiated rates, underlying fee schedule rates used to determine cost sharing, or derived amounts, according to the rate that is applicable to the health insurer’s reimbursement model.

What is an out-of-network allowed amount?
An out-of-network allowed amount is the maximum payment that a health insurer will pay for a healthcare service from a non-participating provider. As part of the Transparency in Coverage Rule, these rate files include the allowed amount for those items and services, including each unique amount associated with the individual provider.

When will machine-readable files be available?
In compliance with federal guidance related to the Transparency in Coverage Rule, machine-readable files became publicly available on July 1, 2022, and will be generated on a monthly basis moving forward.
 

Download a PDF version of this FAQ.
 
What are prescription drug spending reports?
As part of the No Surprises Act, group health plans and health insurance issuers are required to submit information about prescription drug spending starting in late 2022. These reports outline prescription drug expenses for medical and retail pharmacy claims for the previous two calendar years.
 
What is included in prescription drug spending reports?
These reports are required to include information on the most frequently dispensed and costly drugs, as well as prescription drug rebates.
 
How is Mass General Brigham Health Plan supporting prescription drug spending reports?
Mass General Brigham Health Plan is committed to working with commercial accounts and consultants to submit prescription drug spending reports. Please see below for the list of information that we are able to provide as part of the CMS report template and codes.
 
For accounts that include prescription drug coverage administered through Mass General Brigham Health Plan, we will work in collaboration with CVS Caremark to compile and submit the following data reports and narrative responses:

• P1 – Individual and Student Market Plan List
• P2 – Group Health Plan List
• D1 – Premium and Life Years
• D2 – Drugs Covered under Hospital or Medical Benefits
• D3 – Top 50 Most Frequent Brand Drugs
• D4 – Top 50 Most Costly Drugs
• D5 – Top 50 Drugs by Spending Increase
• D6 – Pharmacy Totals
• D7 – Pharmacy Rebates by Therapeutic Class
• D8 – Pharmacy Rebates for the Top 25 Drugs
• Employer Size for Self-Funded Plans
• Wellness Services
• Drugs Missing from the CMS Crosswalk
• Drugs Covered under Hospital or Medical Benefits
• Prescription Drug Rebate Descriptions
• Allocation Methods for Prescription Drug Rebates
• Impact of Prescription Drug Rebates

 
For accounts that do not include prescription drug coverage administered through Mass General Brigham Health Plan, we can submit the following data reports and narrative responses:

• P2 – Group Health Plan List*
• D1 – Premium and Life Years
• D2 – Drugs Covered under Hospital or Medical Benefits
• Employer Size for Self-Funded Plans
• Wellness Services
• Please note, we cannot support the following data as we do not have full access to retail pharmacy data for self-insured accounts with the Pharmacy Benefits Manager carved out:
  • D3 – Top 50 Most Frequent Brand Drugs
  • D4 – Top 50 Most Costly Drugs
  • D5 – Top 50 Drugs by Spending Increase
  • D6 – Pharmacy Totals
  • D7 – Pharmacy Rebates by Therapeutic Class
  • D8 – Pharmacy Rebates for the Top 25 Drugs
  • Drugs Missing from the CMS Crosswalk
  • Prescription Drug Rebate Descriptions
  • Allocation Methods for Prescription Drug Rebates
  • Impact of Prescription Drug Rebates

 
*Please note, the P2 report attestations are limited to benefits administered by Mass General Brigham Health Plan.
 
For general inquiries about Mass General Brigham Health Plan’s prescription drug spending reports, who should I contact?
You can contact our Broker & Account Services team via email at HealthPlanBrokerandAccountSupport@mgb.org or call us at 866-643-8392. 
 
How often are the prescription drug spending reports required to be submitted?
In compliance with regulatory guidelines, the prescription drug spending reports are required to be submitted on a periodic basis.