Know Before You Owe: New Rules Expand Health Plan Price Transparency Requirements

Seyfarth Synopsis: The Departments of Labor, Treasury, and Health and Human Services (the “Departments”) have finalized significant revisions to the Transparency in Coverage regulations (the “Amendments”). The Amendments require telephone access to personalized cost sharing information upon request, substantially restructure the machine readable file framework, and align certain Transparency in Coverage requirements with overlapping No Surprises Act obligations. The changes will be implemented on a staggered basis beginning in 2027. 

Background

The Transparency in Coverage regulations were originally finalized in 2020 and established requirements for health plans to: (1) establish an online self-service tool that could estimate cost-sharing requirements for certain health care services, and (2) publish public, machine readable files disclosing in-network negotiated rates, out-of-network allowed amounts, and billed charges. Since then, implementation has been subject to delayed enforcement timelines, evolving agency guidance, and efforts to coordinate the Transparency in Coverage requirements with overlapping requirements under the No Surprises Act obligations.

For additional background, see our earlier legal updates discussing the original Transparency in Coverage final rule (here), subsequent implementation relief and delayed compliance deadlines (here), and agency guidance addressing Transparency in Coverage and No Surprises Act implementation issues (here).

The latest Amendments include significant revisions to the Transparency in Coverage framework, and seek to reduce file size, improve data usability, add contextual information, and better align Transparency in Coverage reporting with Hospital Price Transparency requirements.

Cost-Sharing Information Now Just a Phone Call Away

One issue left open by earlier guidance was how the Transparency in Coverage and No Surprises Act price comparison requirements would ultimately fit together. The Amendments aim to resolve that issue. Specifically, plans and issuers must make personalized cost sharing information available:

• Through the existing internet based self-service tool;
• On paper upon request; and
• By telephone upon request.

Notably, upon request, plans and issuers must provide personalized cost sharing information by telephone using the customer assistance number appearing on the participant's identification card. Plans and issuers may cap the number of providers for which a caller may request cost-sharing information at 20 per operational day, provided they inform the caller of the limit. The Amendments also confirm that compliance with these Transparency in Coverage disclosure requirements satisfies the federal No Surprises Act price comparison tool requirements. This eliminates the potential need to maintain two separate tools containing substantially similar information. Grandfathered plans and coverage, which generally are not subject to the Transparency in Coverage regulations, may use the same disclosure standards to satisfy the corresponding No Surprises Act requirement.

Balance Billing Disclosure

The Amendments update the balance billing statement accompanying personalized cost sharing information to reflect the federal protections enacted under the No Surprises Act. Plans and issuers generally must explain that a cost estimate may not include additional amounts an out-of-network provider is permitted to bill under applicable federal or state law.

Breaking Down Bundled Costs

The Amendments also clarify how plans and issuers must respond to certain requests involving bundled arrangements and preventive services. For a bundled payment arrangement that includes components with separate cost sharing, plans and issuers generally must provide an estimate for the requested item or service and each component carrying a separate cost sharing liability. If a plan or issuer cannot determine whether a requested service is being sought for preventive or nonpreventive purposes, it generally must display the cost sharing liability applicable for nonpreventive purposes unless the request can be categorized more precisely.

Streamlining the Machine Readable Files: In-Network Rates Go Network-Wide

Under the existing framework, In-Network Rate Files generally are organized by plan or policy. Going forward, plans and issuers must prepare one In-Network Rate File for each provider network they maintain or contract with. Because multiple plans and policies frequently use the same provider network and negotiated rates, the Departments expect network level reporting to reduce duplication and decrease both the number and size of the files.

Each In-Network Rate File must include:

• The common provider network name and a provider network identifier;
• Identifying information for each coverage option using the network, including the applicable Health Insurance Oversight System identifier or Employer Identification Number;
• The product type for each coverage option, such as HMO or PPO; and
• The required billing codes, descriptions, provider information, and applicable rates.

The Amendments also address contracts under which an in-network provider is paid a percentage of billed charges. A percentage may be reported only if the contract provides for payment as a percentage of billed charges and the plan or issuer cannot determine a dollar amount before the bill is generated. If a dollar amount can be calculated prospectively, the rate must continue to be reported as a dollar amount.

Removing Unlikely Provider-Service Combinations

The Departments found that machine-readable files have sometimes listed rates for services a provider is unlikely to perform because organization-level rates can be associated with every provider regardless of specialty. Going forward, plans and issuers must exclude combinations unlikely to result in payment (such as a rate for a podiatrist performing heart surgery) using their existing specialty-based claims rules.

Transparency Is No Longer Just About Publishing Rates

The Departments concluded that negotiated rate information alone often lacked sufficient context to be useful. As a result, plans and issuers will be required to publish several new contextual files designed to support and explain the information contained in the In-Network Rate Files. The Taxonomy File and Utilization File are new requirements that did not appear in the original 2020 regulations.

• Taxonomy File. Explains the specialty based rules used to determine which provider and service combinations appear in the In-Network Rate File.
• Utilization File. Identifies providers that submitted claims and received reimbursement for covered items and services during the applicable reporting period.
• Text File. Identifies where machine readable files are located and provides contact information for questions regarding those files.

The Departments also declined to finalize two proposals: a Change Log File that would have tracked changes between In-Network Rate Files and a requirement to report enrollment totals for each coverage option represented in an In-Network Rate File.

Expanded Out-of-Network Pricing Disclosures

The existing Out-of-Network Allowed Amount Files frequently contain limited or no reportable information. To address these gaps, the Amendments change both the level of aggregation and the amount of historical claims information that must be reported. Key changes include:

• Market level reporting. Allowed Amount Files generally must be organized by health insurance market rather than by individual plan or policy.
• Lower claims threshold. The reporting threshold decreases from 20 claims to 11 claims, meaning more out-of-network reimbursement data will appear in the public files.
• Longer reporting period. The reporting period increases from 90 days to six months.
• Longer lookback period. The lookback period increases from 180 days to nine months.

Special Aggregation Rules for Self-Insured Plans

The Amendments also provide additional flexibility for self-insured plans. Subject to specified conditions, service providers may aggregate reporting across multiple self-insured plans when preparing certain machine readable files. The Departments expect this approach to reduce duplication and simplify reporting for plans relying on common vendors or provider networks.

Plans and Issuers Must Attest to the Accuracy of Public Disclosures

A recurring concern following implementation of the original requirements was whether the publicly disclosed pricing information was complete and accurate. The Amendments require plans and issuers to attest that each machine-readable file includes all required information and is true, accurate, and complete to the best of their knowledge and belief.

The allocation of responsibility depends on the underlying arrangement:

• If an insured plan has a written agreement requiring the issuer to provide the required information and the issuer fails to comply, the issuer, rather than the plan, violates the applicable requirement.
• By contrast, a plan or issuer contracts with another third party, including a TPA, the plan or issuer generally remains responsible if that third party fails to comply.

This distinction is particularly important for self-insured plan sponsors. Although a TPA may prepare, host, aggregate, and attest to the files, using a vendor does not necessarily transfer the plan’s regulatory responsibility.

Putting Pricing Files Within Reach

Plans and issuers must publish a Text File identifying where machine readable files are located, include a monitored email address for questions regarding those files, provide a footer link labeled “Price Transparency” or “Transparency in Coverage,” and ensure the files remain publicly accessible without barriers such as passwords, user accounts, or CAPTCHA requirements.

Quarterly Reporting and Standardized File Formats

The Amendments reduce the reporting frequency for In-Network Rate Files and Out-of-Network Allowed Amount Files from monthly to quarterly and require use of a single nonproprietary, open standards file format specified through agency guidance. The Departments currently intend to designate JSON for most machine readable files.

Prescription Drug Files Coming in 2027

The Departments will begin developing the initial parameters for the Prescription Drug File in November 2026 and expect to finalize it in May 2027. Plans and issuers will be expected to publish Prescription Drug Files beginning in December 2027 and monthly thereafter. The new attestation, accessibility, and file-location requirements also apply to the Prescription Drug File.

Effective Dates

The regulations were published in the Federal Register on October 6, 2026, and become effective on December 7, 2026. The substantive requirements apply on a staggered basis.

• January 1, 2027: Participant disclosure Amendments, including the new telephone disclosure requirements, apply for plan years (and policy years in the individual market) beginning on or after this date.
• March 6, 2027 (five months after publication): Amendments affecting the In-Network Rate Files and Out-of-Network Allowed Amount Files become applicable.
• September 6, 2027 (eleven months after publication): The Taxonomy File, Utilization File, Text File, and related contextual disclosure requirements become applicable.
• July 1, 2028: The first Utilization Files must be posted.

Employer Takeaways

Although carriers, TPAs, and other service providers will implement many of the operational changes, employer plan sponsors should begin discussing implementation with their vendors now. Employers should focus on:

• Vendor readiness for the restructured machine readable file framework and new contextual files;
• Responsibility for preparing, reviewing, and making the required attestations;
• Whether vendors intend to use the aggregation rules for multiple self-insured plans and how plan information will remain identifiable;
• Readiness to provide accurate personalized cost-sharing information by telephone upon request via the phone number listed on ID cards;
•  Negotiate carrier, TPA, and other vendor agreements to clearly assign responsibility for compliance, require prompt correction of errors and cooperation with regulatory inquiries, and allocate liability for vendor noncompliance; and
• Review and document fiduciary governance obligations with respect to vendor compliance.

If you have questions regarding these Amendments or their impact on your health plan, please contact your Seyfarth attorney or any member of Seyfarth’s Employee Benefits and Executive Compensation Team.