Disclosure and tool operational criteria: Plans and issuers must implement internet-based self-service tools and related disclosures in a way that ensures accessibility, security, timeliness, and consumer usability, and must make required machine-readable files publicly available as specified in the final rules. The Departments adopt operational expectations to support accurate, plain-language cost-sharing estimates and public pricing disclosures while recognizing implementation burdens and providing phased compliance where specified.
Self-service tool delivery and access: The self-service tool must be made available via an internet website with a fully responsive design so it is accessible on desktop and mobile devices. Plans and issuers may also offer a mobile application but are not required to do so. Plans and issuers must provide the cost-sharing information in paper form upon request and may limit paper responses to results for up to 20 providers per request. Other non-internet delivery methods (for example, phone or e-mail) are permitted if the participant, beneficiary, or enrollee agrees and the response is provided at least as rapidly as required for paper.
Search and input capabilities: The self-service tool must allow users to request cost-sharing information by entering a specific in-network provider name together with a billing code (such as CPT/HCPCS) or a plain-language descriptive term. The tool should also accept other relevant inputs including location of service (e.g., ZIP code), facility name, dosage for drugs, and should support searches by descriptive terms to accommodate users unfamiliar with billing codes. The tool is not required to support simultaneous multi-parameter search combinations but may do so.
Scope and phased implementation for the tool: Plans and issuers must include cost-sharing information for the 500 specified items and services in the self-service tool for plan/policy years beginning on or after January 1, 2023, and must expand the tool to cover all items and services for plan/policy years beginning on or after January 1, 2024. Plans and issuers may provide additional items or bundled estimates beyond the required set so long as individual-item estimates are also available where cost sharing is assessed separately.
Content and calculation of estimates: The self-service tool must disclose the following content elements for each requested covered item or service: (1) an estimated dollar amount of the individual's cost-sharing liability (including deductible, coinsurance, and copayments) computed using applicable in-network rates, out-of-network allowed amounts, and individual-specific accumulators (deductible and out-of-pocket status); (2) accumulated amounts toward deductible and out-of-pocket limits (including amounts applicable to self-only and other-than-self-only coverage as applicable); (3) in-network rates, including negotiated rate and, where applicable and different, the underlying fee schedule rate used to determine cost-sharing liability; (4) out-of-network allowed amount (or $0 where no reimbursement is provided); (5) a list of items and services included in any bundled payment arrangement when relevant; (6) notices of prerequisites for coverage (e.g., prior authorization, step therapy) when applicable; and (7) a plain-language disclosure notice describing limitations of the estimate, potential for balance billing (only when balance billing is permitted under state law), whether third-party/copay assistance counts toward accumulators, and whether an item may be preventive and thus subject to no cost sharing in some circumstances. Estimates should be rendered as a dollar amount; plans and issuers may also optionally present low/high ranges or ancillary averages in addition to the required single-dollar estimate.
Use of rates and alternative payment arrangements: Cost-sharing estimates must be calculated based on the rates or fee schedules that determine the participant's, beneficiary's, or enrollee's liability. Where plans use an underlying fee schedule (e.g., for capitated or other alternative reimbursement models), the tool must use the current underlying fee schedule rate to calculate cost sharing and must disclose that underlying fee schedule rate when it differs from the negotiated rate. Negotiated rates must be displayed even if not used to calculate cost sharing.
Bundled services and itemization: If cost sharing is assessed separately for distinct items within an episode of care, the tool must disclose separate cost-sharing liabilities for those distinct items. If a single bundled cost-sharing obligation applies to the enrollee (e.g., one copayment for the bundle), the plan or issuer may provide a bundled estimate but must also disclose the constituent items where they are relevant and available.
Paper delivery and request limits: For paper requests, plans and issuers must provide the required content elements, may limit results to 20 providers per request, and must fulfill non-paper requested delivery formats (e.g., phone, e-mail) at least as rapidly as the paper method if the enrollee agrees to that means.
Plain language and consumer-facing presentation: All disclosures to participants, beneficiaries, and enrollees must be presented in plain language formatted to be understood by the average enrollee. Plans and issuers should avoid technical jargon and include clear definitions or tooltips for necessary technical terms. Descriptive plain-language labels for billing codes are required to aid comprehension.
Privacy, security, and accessibility: The self-service tool and any related internet interfaces must implement reasonable and appropriate safeguards for privacy and data security consistent with applicable federal and state law. Tools must be accessible to individuals with disabilities following applicable accessibility standards and must not rely on proprietary software to deliver required machine-readable or consumer-facing information.
Timeliness, timestamps, and notices of validity: Cost-sharing responses must reflect accurate information at the time of the request. Plans and issuers should include a timestamp showing when the estimate was generated and may include an expiration date for the estimate or a notice directing the user to contact the plan for updates. Paper notices may include date and time stamps to reflect when the estimate was produced.
Provider directories and geographic proximity: Tools should enable consumers to choose providers by proximity (for example, by entering ZIP code), and may allow selection of search radius or preference for home versus work location. For out-of-network provider requests, the tool must display the out-of-network allowed amount, percentage of billed charges, or other applicable rate metric as used by the plan.
Limitations, disclaimers, and state law interactions: The plain-language notice must explain that estimates are not guarantees of payment or coverage, may differ from final claims-based amounts due to services rendered, claims processing, or unforeseen clinical developments, and that balance-billing statements are required only where balance billing is permitted under applicable state law. Plans and issuers may use model notice language or provide state-specific detail as needed.
Third-party tools and vendor compliance: Plans and issuers may fulfill the self-service tool requirement by making available a third-party tool (including PBM or vendor tools) provided the tool meets all regulatory content, operational, security, accessibility, and timeliness requirements and the plan or issuer remains responsible for compliance.
Machine-readable public files operational criteria: Machine-readable files containing in-network negotiated rates, historical out-of-network allowed amounts and billed charges, and negotiated rates and historical net prices for prescription drugs must be published on an internet website in a non-proprietary, machine-readable format (as specified in the regulations). These files must be updated at the cadence required by the final rules (for example, monthly where applicable) and include plain-language descriptions for each billing code to support public and developer use. The Departments require these public files for all covered items and services without a phased-in limitation for machine-readable file disclosure.
Reasonable flexibility and phased compliance: Where the final rules provide phased-in scope for the self-service tool (first-year 500 items then all items), plans and issuers should use the phased timeline to build compliant operational capabilities. The Departments recognize implementation burdens and allow reasonable operational flexibility for how plans and issuers meet these operational criteria so long as the regulatory content, accessibility, and security requirements are satisfied.