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Transparency in Coverage

Beginning July 1st, 2022, the Transparency in Coverage Rules (TIC Rules) requires MediExcel Health Plan to disclose on its public website, information regarding in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for covered items and services, as well as negotiated rates and historical net prices for covered prescription drugs, in separate machine-readable files (MRF.)

 

These MRFs are formatted to allow easy access and data analysis by researchers, regulators, and application developers. While these files are accessible to all, the files are large and written in JSON, which is a machine-readable language that is not easily interpreted or searchable. For questions about this requirement, email claims@mediexcel.com.

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In-network

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Out-of-network

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Prescription Drug Reporting

The following information is provided regarding the compliance of prescription drug data collection (RxDC) reporting by MediExcel Health Plan.

 

Prescription drug data collection (RxDC) reporting begins on December 27, 2022. RxDC reporting is based on the interim final rule with comments (IFC), entitled “Prescription Drug and Health Care Spending,” required under section 204 of Title II (Transparency) of Division BB of the Consolidated Appropriations Act, 2021 (CAA.)*  Federal Departments will issue biennial public reports on prescription drug pricing trends and the impact of prescription drug costs on premiums and out-of-pocket costs starting in 2023. These reports are expected to enhance transparency and shed light on how prescription drugs contribute to the growth of healthcare spending and the cost of health coverage in the U.S.

The IFC requires plans and issuers in the group (such as MediExcel Health Plan), and individual markets to submit certain information on prescription drugs and other health care spending to the Departments annually.

 

The IFC provides that health insurers generally will be required to submit this information aggregated at the state/market level, rather than separately for each plan (see Title 26 Chapter I Subchapter D Part 54 §54.9825-5T.)** 

 

To ensure that the Federal Departments can conduct meaningful data analysis and identify prescription drug trends, the IFC further provides uniform standards and definitions, including for identifying prescription drugs regardless of the dosage strength, package size, or mode of delivery.

 

Previously, MediExcel Health Plan had been providing prescription drug utilization data to the State of California. However, because MediExcel Health Plan’s prescription drugs are mainly rendered in Mexico, (99.9%) the prescription drug data provided to California was not useful for purposes of data aggregation. As a result, the State of California has exempted MediExcel Health Plan (as it is licensed under Health and Safety Code Section 1351.2) from reporting prescription drug utilization as per Health and Safety Code Section 1385.02.

 

https://www.cms.gov/newsroom/fact-sheets/prescription-drug-and-health-care-spending-interim-final-rule-request-comments

** https://www.ecfr.gov/current/title-26/chapter-I/subchapter-D/part-54/section-54.9825-5T

Price Comparison Tool

Please note that this Price Comparison Tool (PCT) is required under Federal laws and rules (Consolidated Appropriations Act (CAA) and Transparency in Coverage Rule (TCR)). The Federal Centers for Medicare & Medicaid Services (CMS) has established a listing of 500 shoppable items and services (https://www.cms.gov/healthplan-price-transparency/resources/500-items-services) in which health plans are required to provide the member’s cost-sharing responsibility. There are two unique aspects regarding MediExcel Health Plan (MEHP). 1) The vast majority of the covered healthcare items and services are only rendered in Mexico. The only category of health care services that may be covered by MEHP in the U.S. pertains to emergency and urgent care services. 2) The vast majority of MEHP-covered healthcare services are copay-related and not coinsurance.

 

For purposes of complying with federal PCT requirements, MEHP is providing the 500 shoppable items and services as if rendered in the U.S. Only those shoppable items and services that can be provided on an urgent and emergency care basis shall have a cost component. Those shoppable items and services that do not have an urgent or emergency care basis in the U.S. will reflect the status of not being covered in the PCT. In addition to utilizing the PCT to obtain price comparison information, a member can also contact our Member Services team at (619) 365-4346, or via e-mail at memberservices@mediexcel.com, for the requested information.

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