Healthcare Costs Should Be Clear
Learn More About Transparency in Healthcare
Everyone should be able to understand the costs for healthcare services. We know our members want to be engaged in their healthcare decisions, and knowing costs upfront helps members make the best decision for themselves and their family. That’s why Physicians Health Plan (PHP) 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 PHP members have access to a cost estimating tool through the PHP 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 healthcare data in a way that works for you! PHP partners with 1UpHealth, a leader in interoperability technology, to give you access to your healthcare 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 healthcare 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 healthcare providers to create a more complete picture of your health and healthcare.
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 healthcare 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 healthcare 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.
PHP’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:
1UpHealth reviews and approves the apps that PHP members can use to access their PHP health information. Below is the list of currently approved apps, which are available in the app store.
b.well
OneRecord
myFHR
Health X Change
Mpowered
OneRecord
PHP takes 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 PHP to limit which apps you share your 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. In some instances, 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 health plans, healthcare clearinghouses, and healthcare providers who conduct certain financial and administrative transactions electronically. PHP is subject to HIPAA.
- Are third-party apps covered by HIPAA? Most third-party apps will not be covered by HIPAA 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).
What Should I Do If I think An App Has Used My Information Inappropriately?
If you believe your data through a third-party app was used inappropriately or breached, there are resources available to help you.
- Contact PHP’s Compliance Department at 866.747.2667 or by completing a report at MyComplianceReport.com. You will need the PHP access code to access this site. The PHP access code is PYHP.
- You should contact the Office for Civil Rights (OCR) and file a complaint through their complaint portal. The link to this portal is here: Office for Civil Rights.
- 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 your data through the Federal Trade Commission through this link: How Websites and Apps Collect and Use Your Information.
