The price comparison tool: what employer plans must offer.
Participants can ask their plan for an estimate of what a service will cost them. Plans must provide it through an online tool or on paper, and the carrier or administrator usually runs it.
What the rule requires.
Cost Sharing On Request
On request, a plan must give an enrolled participant or beneficiary an estimate of their cost sharing for a covered item or service. That lets a participant see what the plan expects them to pay before scheduling care. Employers usually rely on the carrier or administrator to produce these estimates, so it helps to know who handles requests.
An Online Tool
The plan must offer an internet self-service tool that is free, in plain language, and based on information accurate at the time of the request. Employees should be able to reach it from a member portal without calling anyone. Ask your carrier or administrator where the tool lives, whether it needs a login, and how employees will be pointed to it.
Paper On Request
Participants can ask for free paper copies. A plan can cap a response at no fewer than 20 providers if it discloses the limit, and must mail the information within 2 business days. Keep a short note of how employees should ask, such as a phone number or request form, so the process is easy to find. Confirm how paper requests are tracked and who responds.
Phase-In
For plan years beginning on or after January 1, 2023 the rule covered a set of 500 items and services. For plan years beginning on or after January 1, 2024 it covers all covered items and services. Dates and scope can change through later guidance, so confirm the current requirements for your plan year with your carrier, administrator, or benefits counsel before relying on this summary for planning.
Who Is Excluded
Grandfathered plans, health reimbursement arrangements and other account-based plans, and short-term limited duration insurance are excluded. Plans in these categories may still have other disclosure duties, and a plan’s status can change at renewal. Check with counsel or your carrier whether your own arrangement is covered or excluded.
A Written Agreement Can Cover It
An insured plan can meet the rule if its issuer provides the information under a written agreement, and a plan may also use another party, such as a pharmacy benefit manager. The plan remains responsible even then, so the agreement should say clearly who builds the tool, who answers requests, and who corrects errors. Have benefits counsel review it and keep a signed copy with your plan records.
What participants should see.
Estimated Cost Sharing
An estimate of the participant’s liability for the service, based on their plan. Employees see it as the dollar amount they would likely owe after the plan pays its share. It depends on factors such as deductible progress, copays, and coinsurance, so it is an estimate and not a guarantee of final cost.
Accumulated Amounts
How much of the deductible and out-of-pocket maximum the participant has already met. This matters because the same service costs a participant less once the deductible is met. The tool should reflect what the person has already paid this plan year, including amounts counted under a family deductible.
In-Network Rate
The negotiated rate in dollars, and the underlying fee schedule rate if it differs. This is the price the plan has negotiated with the provider for the service. Employees often see only a copay, so seeing the negotiated rate can help them understand why prices differ between providers.
Out-Of-Network Allowed Amount
The allowed amount in dollars, or a more accurate rate where one is available. It is the most the plan will count toward an out-of-network service, which may be lower than what the provider bills. Employees should understand the provider may be able to bill the difference where the law allows.
Bundled Payments And Prerequisites
For bundled payments, the items in the bundle, and notice when coverage requires a prerequisite. A bundled payment covers a group of related services for one price, such as a procedure and its follow-up care. Employees should be able to see what is included and whether approval is needed before care is scheduled.
Plain Language Notices
Notice that out-of-network providers may balance bill where state law permits it, that actual charges may differ, that an estimate is not a guarantee of benefits, and whether copay assistance counts toward the deductible and out-of-pocket maximum. Review the wording shown in the tool with your carrier so employees are not misled about what they may owe.
Search By Code Or Name
Participants must be able to search in-network cost sharing by billing code or description, by provider name, and by other factors such as location. A good test is to search for a familiar service by plain name, then by code, and confirm both return sensible results.
Sort By Cost And Distance
Multiple results must be sortable by proximity and estimated cost. Employees comparing care often balance cost and convenience. Check that the tool lets someone see lower-cost options and nearby options in one list, and that sorting works on a phone as well as a computer.
Preventive Services
If the plan cannot tell whether a request is for a preventive service, it shows the non-preventive cost sharing. Employees who expect a preventive visit to cost nothing may see a higher number than expected, so explain how your plan treats preventive care and where to confirm coverage.
Source: 29 CFR 2590.715-2715A2.
What plan sponsors can do.
Confirm Who Provides The Tool
Ask the carrier or administrator to confirm it provides the online tool for your plan. A short email or call is usually enough. Ask whether the tool covers all covered services and your specific plan design, and keep the reply with your compliance records.
Get The Agreement In Writing
If another party provides the tool, the plan violates the rule if that party fails to comply, so keep the arrangement documented. Ask your carrier or administrator to put responsibilities in writing, covering who builds the tool, who handles errors, and who answers employee requests, and file it with your plan records.
Test It
Try a few common services to see whether the tool works the way your employees will use it. Search for a routine office visit, a common imaging test, and a prescription, then compare the results with a recent explanation of benefits. Note anything confusing, missing, or slow, and share it with your carrier.
Check The Paper Process
Confirm how a participant asks for paper copies and that the 2 business day mailing is met. Ask who receives requests, how the response is tracked, and whether the plan can meet the mailing deadline. A short written procedure helps whoever answers employee questions point people to the right place.
Tell Employees Where It Is
Share the link and login steps in your enrollment materials. Add the link and short login steps to your open enrollment guide, intranet, and new-hire materials. Employees are more likely to use a tool they have seen once before they need it for a decision.
Review It At Renewal
Make the tool part of your renewal conversation with the carrier. Ask whether the tool has changed, whether employee complaints suggest problems, and whether it will work for any new plan options. A yearly check is far easier than finding a gap in the middle of the plan year.
Three questions to settle.
Who Runs The Tool
Ask the carrier or administrator to confirm in writing. A written confirmation names who is responsible if something goes wrong, and it is easy to file with your plan records. If the carrier shares responsibility with another vendor, ask for that arrangement to be described too.
Does It Cover All Services
Confirm that it covers all covered items and services. Ask whether any services are excluded or still being added, such as specialty, behavioral health, or prescription items, and when the full list will be available. Note the answer in your compliance file for the plan year.
What Is The Paper Process
Ask how participants request paper and how fast it is mailed. Request the process in writing, including the contact point, the response time, and any limit on the number of providers per request. Share it with whoever fields employee questions so requests are not lost.
Common Questions About The Price Comparison Tool
Does the employer have to build the tool?
No. An insured plan meets the rule if its issuer provides the information under a written agreement. If the issuer fails, the issuer violates the rule, not the plan.
What if our plan is self-funded?
A plan may use a written agreement with another party such as a pharmacy benefit manager. If that party fails to comply, the plan violates the rule.
Do account-based plans have to offer it?
No. Health reimbursement arrangements and other account-based group health plans are excluded.
Is paper available?
Yes. Participants can ask for free paper copies, mailed within 2 business days.
Can CFH help?
We can help you confirm who provides the tool and gather the agreement for your plan documents.
Is this legal advice?
No. This page summarizes the regulation. Your attorney can advise on your specific plan.
Laws and rules referenced
29 C.F.R. § 2590.715-2715A2 and § 2590.715-2715A3 — Transparency in coverage: price comparison disclosures to participants and the public machine-readable files.
This tool gives estimates for education, not tax or legal advice. Rules change, so confirm your situation with a qualified advisor.
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