Transparency in Healthcare

In 2020, as part of an effort to improve transparency in healthcare costs and help consumers make informed decisions about their care, the Federal Government issued the Transparency in Coverage Rule which requires health plans to provide clear healthcare cost information to members through:

• Machine-readable files (MRFs): Health plans must publish machine-readable files on a publicly available site, beginning July 1, 2022.  These files include pricing data for covered services and items based on in-network negotiated rates and historical out-of-network allowed amounts.  A third file that contains negotiated rates and historic pricing for prescription drugs is also included in the Transparency Rule. However, creation and publication of this file has been delayed pending further guidance. These files must be updated and published monthly. Publicly available MRF:
  • UCLA Health Medicare Advantage Principal Plan (HMO)
  • UCLA Health Medicare Advantage Prestige Plan (HMO)
• Consumer price transparency tool: Starting January 1, 2023, insurers and plans were required to provide an online tool with estimates for at least 500 shoppable health care items, services, and drugs. By January 1, 2024, the requirement extends to include all covered health care items and services. The tool will give consumers access to real-time cost-sharing estimates based on their plan, allowing them to compare costs for different providers. The information available will include not only personalized out-of-pocket estimates but also details about the underlying negotiated rates and allowed amounts for items and services, including prescription drugs. While the tool must be available online, if individuals prefer, they can request a paper form of their estimate by contacting customer service. Members can log in to MyChart to use our treatment cost calculator.

IMPORTANT NOTE: We have provided links to machine-readable files in JSON format and may be as large as one Terabyte (TB) in file size, which has significant system requirements for use. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The MFRs will be updated monthly to ensure accuracy of the data and reflect changes in pricing and regulatory requirements. However, they should not be used as a substitute for provider directories, health plan coverage documents, or cost estimation tools and communications. Certain services are subject to medical management, such as referral and/or prior authorization requirements. To determine if these requirements apply to the services that you are seeking, please refer to your Evidence of Coverage (EOC). For member-specific questions, please contact UCLA Health Medicare Advantage Member Services.