Payer Patient Estimate Tools (PET)

The Centers for Medicare and Medicaid Services’ (CMS) Mandated Requirements

Transparency in Coverage (TiC) , aka the Final Rule that mandates payers disclose their prices, has put PET requirements into two phases. For both phases, upon request, payers and insurers must disclose cost-sharing info to Participants, Beneficiaries, and Enrollees (PBE)* via an online self-service tool (here at Turquoise Health, we call this the Patient Estimate Tool) so PBEs can access the following info:

  • Estimated Cost-Sharing Liability: Includes copay, coinsurance and deductibles
  • Accumulated Amounts: PBE’s remaining deductible and out-of-pocket amounts at the time of request
  • In-Network Rate: Payer contractual allowed amount
  • Out-of-Network Allowed Amount: Max amount a plan would pay for an item or service out of network
  • List of Items/Services subject to bundled payment arrangements 
  • Notice of prerequisites, if applicable: Concurrent review, prior authorization, or the step-therapy/fail-first approach of prescribing patients less expensive medication before more costly medication is authorized
  • Disclosure Notice: predetermined list of disclosures provided by CMS

*So many abbreviations!

Some requirements above overlap with requirements outlined as Good Faith Estimates (GFEs) and Advanced Explanation of Benefits (AEOBs) from the No Surprises Act, although there are some notable differences. This patient estimate tool focuses on the self-service aspect, meaning the PBE should be able to operate independently to receive the cost-sharing and other information. With GFEs and AEOBs, PBEs are reliant on providers and insurers to provide cost-sharing and charge information. 

TiC is also focused on cost-sharing estimates specifically for CPT Codes in Phase 1. The rates, cost, and disclosures within the PET must be written in approachable, easy-to-understand language PBEs can easily understand (defined as “plain language”) and PBEs must be able to request the information via paper form. For Phase 1, which went into effect on January 1, 2023, CMS published a list of 500 pre-determined CPT Codes required to be included in every patient estimate tool. Estimates for all other items and services must be available on the patient estimate tool for Phase 2, which goes into effect on January 1, 2024.