Price Transparency and Interoperability
Health Care Costs Should Be Clear
Learn More About Transparency in Health Care
Everyone should be able to understand the costs for health care services. We know our members want to be engaged in their health care decisions, and knowing costs upfront helps members make the best decision for themselves and their family. That’s why University of Michigan Health Plan (UM Health Plan) is making it easier to find these costs.
In October 2020, the Federal government issued the Transparency in Coverage rule for health plans and health insurers to increase the availability of healthcare cost information for individual and most group plans. The new regulation includes a phased approach to developing cost transparency services and is a foundation for future additional price transparency requirements.
All UM Health Plan members have access to a cost estimating tool through the member portal. This will show you your estimated cost (potential deductible, copay, coinsurance amounts) of covered health services and is based on your benefit plan and claims processed to date. You can save or print your results. Please be aware that the information provided is only an estimate based on the date you request the cost and benefit limitations, prior authorization and our plan requirements are not included in the estimate.
The Transparency in Coverage rule requires that health plans make machine-readable pricing files publicly available. These files provide negotiated rates for items and services with our in-network providers and allowed amounts based on historical payments to out-of-network providers.
We have provided links to machine-readable files in JSON format, as required by CMS. They may be extremely large (more than 100GB and up to 1TB) and will require a special application to open. The machine-readable files will be updated monthly to ensure accuracy of the data and reflect changes in pricing and regulatory requirements.
From the list below, find the plan type to access the associated in-network rate files or out-of-network historical payments.
Interoperability allows you to share your health information with third-party applications so that you can use your health care data in a way that works for you! University of Michigan Health Plan partners with 1UpHealth, a leader in interoperability technology, to give you access to your health care data.
What is Interoperability?
In 2020, the Centers for Medicare and Medicaid Services (CMS) developed rules to help people access their health insurance information more easily. This concept is called interoperability. The rule is called the CMS Interoperability and Patient Access Rule. If you have purchased individual coverage through the ACA Marketplace, your plan is covered under these new rules. You can learn more about the CMS Patient Access Rule here: CMS-9115-F
Interoperability allows different health information systems and organizations to work together to help ensure effective health care communications. Health plans must provide certain health information, such as claims, provider directories, laboratory, and other clinical information, in a digital, shareable format. Interoperability allows you to access your health information on a mobile or other electronic device securely for personal use through an app. For example, you could show your information to health care providers to create a more complete picture of your health and health care.
Your information will not be automatically shared. You are the owner of your data and have control over who has access to it.
How Does Interoperability work?
Interoperability uses FHIR® (pronounced fire) as a data exchange standard for health care information using modern web technologies. FHIR® was developed by HL7, a Standards Development Organization. FHIR® is based on modern web technologies that software developers can easily use, without in-depth health care domain knowledge. FHIR® resources are open source and available to any developer, which allows for limitless connections to applications (apps), providers, payers, and patients. Information on FHIR® can be found here: HL7 FHIR R4(Version 4.0.1)
Developers interested in creating an account with 1UpHealth should visit 1UpHealth Overview for Developers.
University of Michigan Health Plan’s Patient Access API & Provider Directory API capabilities statement outlines the supported resources and function names. This information can be found here: https://api.phpfhir.com/r4/metadata. Documentation surrounding API syntax, function/operations, parameters and examples queries can be found in the 1upHealth API References page. The capability statement overview can be found here: FHIR Server Capability Statement
Other information regarding errors can be found through the links below:
How can I keep my health information Safe?
UM Health Plan takes health information security very seriously. The new rules give every member the right to share their personal health information with whoever they choose, and some apps may not have the same security measures as us.
The rules do not allow UM Health Plan to limit which apps you share your health information with. It is up to you to decide if an app is trustworthy. Here are some things to keep in mind when deciding which app you will use:
- Review the app’s Privacy Policy and/or Terms of Service. You should feel comfortable asking whether the third-party app has a Privacy Policy and/or Terms of Service. Sometimes, the app's privacy and security language may be in the app's Terms of Service and not a separate Privacy Policy. If the app does not have a Privacy Policy, you should evaluate the possible risks in moving forward with the app.
- What are my rights under the Health Insurance Portability and Accountability Act (HIPAA), and who must follow HIPAA? The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) enforces the HIPAA Privacy, Security, and Breach Notification rules and the Patient Safety Act and Rule.
- The HIPAA Privacy Rule covers the following entities or organizations:
- Health plans, including health insurance companies, HMOs, company health plans, and certain government programs that pay for health care, such as Medicare and Medicaid. UM Health Plan is subject to the HIPAA privacy rules.
- Most health care providers, including those that conduct certain business electronically, such as billing your health insurance, include doctors, clinics, hospitals, psychologists, chiropractors, nursing homes, pharmacies, and dentists.
- Health Care Clearinghouses, which are entities that process nonstandard health information they receive from another entity into a standard (i.e. standard electronic format or data content) or visa versa.
- The HIPAA Privacy Rule does not cover these types of entities or organizations.
- Life insurers
- Employers
- Workers compensation carriers
- Most schools and school districts
- Many state agencies like child protective service agencies
- Most law enforcement agencies
- Many maniple offices
- Learn more about rights under HIPAA and who is obligated to follow HIPAA.
- You can also read more about HIPAA here: HIPAA FAQs for individuals.
- Are third-party apps covered by HIPAA? HIPAA will not cover most third-party apps because they are not affiliated with entities governed by the HIPAA Privacy Rule. Third-party apps likely fall under the Federal Trade Commission (FTC)'s jurisdiction and the protections provided by the FTC Act. Among other things, the FTC Act protects against deceptive acts (e.g., if an app shares personal data without permission despite having a privacy policy stating that it will not do so).
- Learn more from the FTC about mobile app privacy and security.
What should I do if I think my health information is being misused or if an app has not protected it?
The U.S. Department of Health and Human Services (HHS) Office for Civil Rights(OCR) enforces HIPAA Privacy, Security and Breach Notification. If you believe your health information isn’t being protected or your rights under HIPAA are being denied, you can:
- File a complaint with UM Health Plan. Contact the plan’s Compliance Department at 866-747-2667 or complete a report at MyComplianceReport.com. You will need an access code to access this site. The UM Health Plan access code is PYHP.
- You should contact the OCR and file a complaint through their complaint portal. The link to this portal is here: Office for Civil Rights
If you believe your data through a third-party app was misused or breached, resources are available to help you.
- In addition to contacting the OCR, you can also report fraud through the Federal Trade Commission. The link to this site is here: Federal Trade Commission.
- You can learn more about how apps and websites track and use data through the Federal Trade Commission through this link: How Websites and Apps Collect and Use Your Information.
