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Transparency in Coverage

Welcome to UPMC Health Plan’s Transparency in Coverage information and download page for commercial health plans.

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

Frequently Asked Questions

How many files will UPMC Health Plan be posting?
UPMC Health Plan will post a table of contents file (compliant with CMS schema 1.0) that contains plan information and a corresponding, fully qualified domain name where the in-network rate data and out-of-network allowed amount data can be downloaded.

Requirements related to providing drug pricing information have been delayed. Accordingly, pharmacy rate files will not be included until indicated by updated guidance.
What is an MRF? In what format will the data be posted?
An MRF is a machine-readable file. CMS has developed a required schema—v1.0—that has JSON and XML options for the in-network rates and out-of-network allowed amount files. UPMC Health Plan’s MRFs will be in the JSON schema.

More information on CMS schemas.
Who are the files for? Should consumers download the transparency files?
According to CMS, “This pricing information can be used by third parties—such as researchers and app developers—to help consumers better understand the costs associated with their health care.” Additionally, the CMS schemas are intended as MRFs and targeted for machine ingestion rather than consumer download. UPMC Health Plan recommends that members with cost-related questions use our cost estimator tool (described above) or call Member Services.
How large are the MRFs?
File sizes will vary based on network composition, out-of-network claim volumes, and more. However, the CMS schema is intended to support extremely large data sets targeted for machine ingestion.
Is a sample of the MRFs available?
Yes, CMS has provided MRF samples to support schema v1.0.