Transparency in Coverage Final Rules (CMS 9882-F)

Transparency in Coverage Final Rules (CMS 9882-F)

Introduction

Consistent with the President's Executive Order 14221 , "Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information," on October 5, 2026, the Department of Health and Human Services (through the Centers for Medicare & Medicaid Services), in partnership with the Departments of Labor and the Department of the Treasury (collectively, the Departments) jointly finalized changes to the Transparency in Coverage regulations to improve the accessibility of pricing disclosures to participants, beneficiaries, and enrollees, and the standardization and reliability of the public pricing disclosures from non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage.

These changes build on the historic disclosure requirements the Departments issued in the Transparency in Coverage final rules on Nov. 12, 2020 (the 2020 final rules) in line with the President's June 24, 2019, Executive Order (EO) 13877, "Improving Price and Quality Transparency in American Healthcare to Put Patients First" and EO 14221, "Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information."

This fact sheet discusses the provisions of the Transparency in Coverage final rules (CMS-9882-F) that amend the 2020 final rules. You can access the final rules in the Federal Register at: https://www.federalregister.gov/public-inspection/2026-20447/transparency-in-coverage

Under the 2020 final rules, non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage are required to post machine-readable files monthly for each plan or coverage they offer - an in-network rate file disclosing in-network rates for all covered items and services, an allowed amount file disclosing out-of-network allowed amounts and the associated billed charges for covered items and services, and a prescription drug file disclosing in-network rates and historical net prices for covered prescription drugs. These requirements became applicable in July 2022.¹

Improved Standardization, Accuracy, and Accessibility of the In-Network Rate and Out-of-Network Allowed Amount Machine-Readable Files

Based on internal assessment and external stakeholder feedback received since implementation began, the Departments have identified three main barriers to fully achieving the goals of the 2020 final rules: inaccessibility due to the large size of the machine-readable files, data ambiguity due to lack of contextual information alongside the raw data, and areas of misalignment with the Hospital Price Transparency rule that make comparing data across disclosures challenging.

Reducing the Number and Size of Machine-Readable Files and Increasing Accessibility to Make Data More Meaningful

A major driver of large in-network rate file sizes involves including provider-negotiated rates for items or services the provider is unlikely to furnish because of their specialty and the nature of the item or service (e.g., rates for podiatrists to perform heart surgery). This occurs because payer-provider contracts often negotiate rates at the provider organization level for every provider who is a member of the organization, regardless of clinical specialty.

To address these unlikely provider-rate combinations, the final rules include amendments to:

1. Require group health plans and health insurance issuers to exclude from their In-network Rate Files provider-rate combinations for items and services that providers would be unlikely to be reimbursed for given that provider's specialty area. The provision requires plans and issuers to determine which provider-rate combinations to exclude by using their internal provider taxonomies or other internal rules used during the claims adjudication process to determine if the provider should be reimbursed for the item or service given that provider's specialty;
2. Post the internal provider taxonomy mapping or other rules they used to prepare each In-network Rate File in a new file called the Taxonomy File; and
3. Post a new file called a Utilization File for each In-network Rate File, which will include all providers who have submitted and received reimbursement for at least one claim for a covered item or service for the most recent plan or policy year ending six months before the posting of the file.

To reduce duplicative data, the Departments finalized a change to the level at which group health plans and health insurance issuers must report data in the In-network Rate File. Under this provision, plans and issuers must prepare one In-network Rate File for each provider network they maintain or contract with, rather than for each plan or policy they offer, as required by the 2020 final rules. Because it is very common for multiple plans offered by the same issuer or administered by the same service provider to leverage the same provider networks with the same negotiated rates, requiring network-level reporting will streamline how rates are reported, reducing both the number and the size of In-network Rate Files.

Further, reporting in-network rates at the network level also aligns with how the Hospital Price Transparency data is typically reported. Aligning payer and hospital data reporting will help normalize data across different systems, improve consistency, and make comparisons between the payer and hospital machine-readable files easier for file users.

Improving Data Availability

The Departments have received feedback and observed that many group health plans and health insurance issuers include limited or no data in their Out-of-network Allowed Amount Files, which may be due, in part, to the current 20-claims threshold for reporting. This has limited the transparency of out-of-network pricing information to the public and, in turn, limited what researchers, academics, and developers can analyze. The Departments include three amendments for the Out-of-network Allowed Amount Files to address insufficient data: 1) require payers to aggregate their Allowed Amount Files by insurance market type (large group, small group, individual, and self-insured); 2) lower the claims threshold for reporting payment of out-of-network allowed amounts from 20 to 11 claims; and 3) increase the amount of out-of-network data disclosed to the public to better position researchers and academics to conduct analyses to inform the public.

Taken together, the Departments expect these amendments will significantly increase the amount of out-of-network data disclosed to the public. The barrier to meeting the 11-claim threshold will be lower, particularly when data is aggregated by market type and the reporting period is more than twice as long. Further, the Departments understand from stakeholder feedback that out-of-network allowed amounts across plans and policies are most aligned by market type. Providing this data at the market-type level will allow users to compare allowed amounts for plans within the same market, which, based on feedback, the Departments anticipate will better position researchers and academics to conduct analyses to inform the public.

The final rules also require additional data elements to provide context around the reported data. Group health plans and health insurance issuers will be required to report the plan's or policy's product type (e.g., HMO, PPO) for each plan or policy represented in an In-network Rate File and Out-of-network Allowed Amount File, as well as the common provider network name and network identifier associated with the provider network represented in the In-network Rate File.

Making Data Easier to Locate

The final rules include two provisions to help users locate the machine-readable files. First, plans and issuers will be required to publish a plain text file (.txt file) located in the root folder of the plan's or issuer's website (or under certain circumstances, for another party to publish the file on its public website on the plan's or issuer's behalf) with information on the specific location of the machine-readable files. This file must also include contact information, including a monitored email address for an individual or group dedicated to receiving and responding to inquiries and issues related to the machine-readable files. In addition, plans and issuers will be required to add a link in the footer of the homepage of their website titled "Price Transparency" or "Transparency in Coverage" that routes directly to the publicly available web page that hosts the machine-readable files. This will allow for a standardized and predictable navigation path for users trying to find the files. Together, these requirements will help automate locating and downloading the machine-readable files and provide a point of contact for questions about or clarification on the data within the files. These requirements will also apply to the prescription drug machine-readable file. These provisions align with current requirements under the Hospital Price Transparency rules.

Reducing Stakeholder Burden

Beginning in the second year of implementation and continuing thereafter, these final rules are expected to generate a net cost savings to plans and issuers of approximately $174.5 million annually, due in part to the reduced reporting cadence for certain machine-readable files. The Departments are requiring plans and issuers to update and post the In-network Rate and Out-of-network Allowed Amount Files quarterly rather than monthly to help lower data storage and hosting costs, decrease bandwidth needs, and reduce ongoing maintenance expenses. Plans, issuers, and researchers have indicated that, since provider networks and rates do not change significantly from month to month, switching to a quarterly reporting cadence will not lead to a significant reduction in meaningful data. This reduced reporting cadence will also provide more time for file users to analyze the data, as some file users have informed the Departments that they have difficulty keeping up with the pace of downloading and ingesting the file data monthly. This change in reporting cadence along with the reduction of both the size and number of machine-readable files will reduce the current burden associated with preparing, ingesting, analyzing, and storing the public disclosures.

Adopting a Single File Format in Technical Implementation Guidance

Currently, the 2020 final rules require group health plans and health insurance issuers to publish their machine-readable files in "any non-proprietary, open format," such as JSON, XML, or CSV, as specified through technical implementation guidance, which allows the Departments flexibility to adapt file formats to new and emerging technologies. To promote standardization across payers' files and remain consistent with current industry practice, the final rules require plans and issuers to use a single format. The Departments intend to specify the JSON format in guidance for all machine-readable files other than the text file, which is required to be published as a plain text (.txt) file.

Increasing Accuracy and Accountability Through Attestation

To improve the accuracy, reliability, and accountability of the disclosures in the machine-readable files, the Departments are requiring plans and issuers to attest, in each In-network Rate, Out-of-network Allowed Amount, Taxonomy, and Utilization machine-readable file, that to the best of its knowledge and belief, the plan or issuer has included all applicable information in accordance with the requirements, and the information encoded is true, accurate, and complete as of the date in the file. Plans and issuers must also encode, in each In-network Rate, Out-of-network Allowed Amount, Prescription Drug, Taxonomy, and Utilization machine-readable file, the name of the plan's or issuer's chief executive officer, president, or senior official designated to oversee the encoding of true, accurate, and complete data.

Applicability Dates

The final rules are effective 60 days after the date of publication in the Federal Register. The amendments related to the In-network Rate and Out-of-network Allowed Amount Files apply five months following the date of publication of the final regulations, while the amendments related to the new contextual files (taxonomy, utilization, and text) apply 11 months following the date of publication of the final regulations.

Disclosures to Participants, Beneficiaries, and Enrollees: Internet-Based Self-Service Tool

Currently, the 2020 final rules require group health plans and health insurance issuers to make available cost-sharing information to participants, beneficiaries, and enrollees through an online self-service tool or paper, upon request. This cost-sharing information must be accompanied by certain notices that provide critical explanatory information and indicate the limitations of the data being disclosed. These rules were applicable starting January 2023. Since the publication of the 2020 final rules, the No Surprises Act enacted several provisions requiring plans and issuers to make pricing information more transparent to consumers, including a requirement that plans and issuers make available cost-sharing information through an internet-based tool, as well as over the phone. These final rules require that the cost-sharing information required to be made available through an internet-based tool or on paper, upon request, under the 2020 Transparency in Coverage rules also be made available over the phone, upon request, to satisfy the No Surprises Act cost-sharing tool provision. The Departments also finalized that satisfaction of such requirement also satisfies the requirements of section 114 of the No Surprises Act (including for grandfathered group health plans and health insurance issuers offering grandfathered group and individual health insurance coverage that are not otherwise subject to the final rules). The Departments also amended the notice requirement to account for new federal protections against balance billing in certain circumstances.

Applicability Dates

The amendments to the internet-based self-service tool provisions apply for plan years (in the individual market, policy years) beginning on or after Jan. 1, 2027.

1. On Sept. 27, 2023, the Departments released Affordable Care Act FAQs Part 61 , announcing that they would enforce the prescription drug machine-readable requirement "on a case-by-case basis, as the facts and circumstances warrant." On June 2, 2025, the Departments published a Request for Information (RFI) seeking the public's input on ways to effectively implement or amend the prescription drug machine-readable file requirement.

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