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In November 2020, the U.S. Department of Health & Human Services (HHS), Department of Labor, and Department of the Treasury issued the Transparency in Coverage Rule. Based on Affordable Care Act (ACA) requirements, it mandates payers:
- Post machine-readable files (MRFs) that list in-network rates and out-of-network allowed amounts on a publicly available website by July 1, 2022
- Provide members with an online cost estimator tool that allows them to look up their out-of-pocket costs for health care services beginning in 2023
Kaiser Permanente is committed to providing price transparency in our interactions with customers and members. We already provide multiple price transparency tools for:
- Brokers, consultants, and employers — Client and group specific reports are available based on claims data, clinical data, employee engagement, and aggregate data. To be HIPAA compliant, there are group size requirements that vary depending on the report. Reach out to your account representative to learn more about the tools that are available to you.
- Members — The machine-readable files are not intended to represent member out-of-pocket costs. Each member's cost share is based on their unique plan benefits. The best way for Kaiser Permanente members to estimate their out-of-pocket health care costs before getting care from Kaiser Permanente providers is to use the cost estimator tool on kp.org (requires sign on).
The links on this page are to machine-readable files (MRFs) that comply with the federal Transparency in Coverage rule. The files will be made public for plan years that begin on or after January 1, 2022 and will be refreshed monthly.
The inclusion of providers and information on the MRFs is based on the requirements of the federal Transparency in Coverage rule, its definition of "in-network provider", and sub-regulatory guidance such as the Transparency in Coverage schema Version 1.0.0 and FAQs issued by the U.S. Departments of Labor, Health and Human Services and Treasury. The MRFs should not be used instead of provider directories, health plan coverage documents, or cost estimate tools and communications. CERTAIN SERVICES ARE SUBJECT TO MEDICAL MANAGEMENT, SUCH AS REFERRAL AND/OR PRIOR AUTHORIZATION REQUIREMENTS. To determine whether such requirements apply to the services that you are seeking, you should consult your coverage document such as the applicable Evidence of Coverage (EOC), Certificate of Insurance (COI) or Membership Agreement. For member-specific questions, please contact Kaiser Permanente Member Services.
Important Information about the MRFs
Before accessing the MRFs, please review all of the following important information.
- The actual amounts paid to a contracted provider may differ from the rates listed on the MRFs due to member-specific characteristics and the use of modifiers, bundling, and the application of other contract terms and policies for a service provided to a specific member.
- The providers included, and rates listed within the MRFs, are subject to change retroactively based on ongoing negotiations with providers.
- For agreements with providers that use alternative reimbursement arrangements for items and services are not specified, Kaiser will rely on the enforcement safe harbor as set forth in FAQs About Affordable Care Act Implementation Part 53 (issued April 19, 2022).
- Payment based on Medicare allowable rates. Actual allowable amounts may differ from those listed in the MRFs based on actual claims and member-specific characteristics.
- Payment based on default rate/process. Certain provider agreements have, in addition to the specific contract rates listed for services and/or items within the MRFs, a default process for calculating payment for other services and/or items that may be covered and provided (e.g., a percent of billed charges). Such pricing provisions are not reflected within the MRFs.
- Inpatient bill code rates. The per diem negotiated rate within MRFs may change depending on the duration of an inpatient stay, with the MRFs at this time reporting the negotiated per diem rate applicable initially.
- Table of Contents. We are publishing all MRF files in accordance with the CMS schema. For a given region, some plans with an In Network Rate Machine Readable File may not have an associated Table of Contents file.
- For applicable rates found in agreements held by third parties with whom a Kaiser health plan/issuer is contracted (such as underlying fee schedule rates impacting cost sharing and network agreements) the In Network Rate Machine Readable File obtained from such a contracted third party and/or a link to their file will be published in the relevant Kaiser regional health plan's file(s) as applicable. Please reach out to the following entities for their In Network Files: Delta and Multiplan/PHCS.