Traditional Medical Plans without a provider network

[Ginger228]

@shaselton @shaselton-usds
Hi,
We still have traditional plans - comprehensive, hospital, and major medical. The products do not have In-Network or Out of Network benefits. Should these plans be excluded from Transparency in Coverage?

If there aren't any participating or non-participating providers to list for either the INN or AA MRF.

Thanks in advance.

[CKreklow]

Our interpretation here is that the distinction between in-network and out-of-network is just the presence of a contract agreement, it does not implicate member benefits. Do you not have a network applied to the plans that allows you to use negotiated rates with some providers?

We still apply networks to these plans, and any provider with a contract in that network goes to the in-network file. All the claims priced without reference to a contractual agreement are going to the allowed amount file (subject to aggregation and the claim threshold of course).

In the case where we had a plan with 100% U&C pricing, I believe we would intend to report an empty in-network file and put all the data in the allowed amounts file.

[Ginger228]

@shaselton @shaselton Should an empty INN MRF be created for these plans or no INN at all.

[shaselton-usds]

@Ginger228 If the plan does not have any contracts with any providers/networks for any items/services and follows these types of arrangements, then you wouldn't need to produce an in-network file. There would be no information there because you don't have any contracts to disclose.

So, does your plan have contractual in-network provider rates for covered items and services?

[Ginger228]

We do not have contractual in-network provider rates for our traditional indemnity product (major medical, hospitalization, or comprehensive).