Commercial health plans are those that are available through an employer, as well as plans that can be purchased directly from an insurance company or on Pennie™. Commercial health plans exclude government-sponsored plans such as Medicare and Medicaid.
Information for Members and Consumers
Transparency in health care typically refers to access to information related to the cost of care. As of July 1, 2022, health insurers and group health plans are required to post “Transparency in Coverage” files including their contracted rates with providers. By Jan. 1, 2023, health insurers and group health plans must have a self-service shopping tool for up to 500 services.
UPMC Health Plan is committed to making cost information available to members. That’s why the Health Plan provides a tool that members can use to estimate the cost of shoppable services. The tool accesses members’ benefits and accounts to provide current, customized estimates of deductible, copayment, and cost-sharing information.
UPMC Health Plan members can access this tool via MyHealth OnLine (MHOL). To access the tool, members should:
- Log in to MHOL, then click Estimate and Explore Treatment Options in the center column.
- Click Go to Estimator.
- In the disclaimer pop-up window, click Accept.
Members can review our Medical Cost Estimator brochure for more information on our self-service tool and can also receive cost estimates by calling Member Services at the number on their member ID card.
Transparency in Coverage: Machine-Readable Files
The Transparency in Coverage Final Rule, issued on Nov. 12, 2020, sets forth requirements for group health plans and health insurance issuers to produce machine-readable files (MRFs) that disclose in-network negotiated rates and historical out-of-network allowed amounts by July 1, 2022. Requirements related to providing drug pricing information have been delayed.
Plans and issuers must also disclose cost-sharing information—including an estimate of an individual’s cost-sharing liability—for 500 covered items or services furnished by a particular provider beginning on Jan. 1, 2023 and for all covered items and services beginning January Jan. 1, 2024. For more information on Transparency in Coverage, please visit Health Plan Price Transparency | Centers for Medicare & Medicaid Services (CMS).
UPMC Health Plan is making MRFs—including in-network rates and out-of-network allowed amounts—available online in accordance with the Final Rule and updated timelines issued by the departments of Labor, Treasury, and Health and Human Services. The MRFs will be available to the public without restrictions that would impede reuse of the data. There will also be no charge for downloads or requirements for user accounts, passwords, other credentials, or any personal identifying information.
UPMC Health Plan produces MRFs in compliance with CMS specifications in JSON format.
How to Download
The table of contents file lists URLs for the MRFs by plan name. Downloads will be available as of July 1, 2022.
Download Table of Contents