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Transparency in Coverage Final Rules: Key Changes and Compliance Deadlines for Plan Sponsors

Published: 6 min read

By: HUB’s EB Compliance Team

The Departments of Health and Human Services (“HHS”), Labor (“DOL”), and the Treasury (collectively, the “Departments”) have published final rules amending the Transparency in Coverage (“TiC”) regulations originally finalized in 2020. The final rules respond to Executive Order 14221, “Making America Healthy Again by Empowering Patients With Clear, Accurate, and Actionable Healthcare Pricing Information,” and are intended to make the machine-readable files required under the TiC rules smaller, more standardized, and easier to use, while also expanding how plans must disclose cost-sharing information directly to participants, beneficiaries, and enrollees.

The changes arrive on three separate timelines, so plan sponsors should begin mapping out which requirements apply when, and should start conversations with carriers and third-party administrators (“TPAs”) now.

Background on the Transparency in Coverage Requirements

The Affordable Care Act (“ACA”) requires non-grandfathered group health plans and health insurance issuers to comply with the ACA’s price transparency provisions. The 2020 final rules implementing this requirement required plans and issuers to post three monthly machine-readable files — an In-Network Rate File, an Out-of-Network Allowed Amount File, and a Prescription Drug File — beginning in July 2022. The rules also required plans and issuers to make cost-sharing information available to participants through an online self-service tool or on paper upon request, beginning in January 2023.

Since implementation, the Departments have identified recurring barriers to the usefulness of the disclosed data, including large file sizes, a lack of context accompanying the raw rate data, and inconsistencies with the separate Hospital Price Transparency rule that complicate side-by-side comparisons. The final rules amend the Departments’ existing Transparency in Coverage regulations to address these concerns.

Key Changes to the Machine-Readable Files

The final rules make several changes to the In-Network Rate File and Out-of-Network Allowed Amount File:

  1. Network-level reporting. Plans and issuers must prepare one In-Network Rate File per provider network they maintain or contract with, rather than one per plan or policy, reducing duplication where multiple plans share the same negotiated rates.
  2. New Taxonomy and Utilization Files. Plans and issuers must exclude provider-rate combinations that a provider would be unlikely to be reimbursed for given its specialty, post a new Taxonomy File documenting the internal rules used to make that determination, and post a new Utilization File listing providers who submitted and were reimbursed for at least one claim in the most recent plan or policy year ending six months before the file is posted.
  3. Allowed Amount File changes. The claims-reporting threshold is lowered from 20 to 11 claims; the reporting period is expanded from 90 days to six months and the lookback period from 180 days to nine months; and data must be aggregated by health insurance market type (individual, small group, large group, and self-insured).
  4. New data elements. Both files must now include the plan’s or policy’s product type (e.g., HMO, PPO), and the In-Network Rate File must include a common provider network name and network identifier.
  5. Findability requirements. Plans and issuers must post a plain-text (.txt) Text File identifying the location of all required machine-readable files and a monitored contact email, plus add a footer link labeled “Price Transparency” or “Transparency in Coverage” on their website’s home page. These findability requirements also extend to the prescription drug machine-readable file.
  6. Single file format. All machine-readable files other than the Text File must be published in JSON format, as specified in forthcoming technical implementation guidance.
  7. Attestation. Each In-Network Rate, Allowed Amount, Taxonomy, and Utilization File must include an attestation that the information is true, accurate, and complete. Plans and issuers must also encode, in each of those files as well as in the Prescription Drug File, the name of the plan’s or issuer’s chief executive officer, president, or other senior official designated to oversee the encoding of the data.
  8. Reduced posting cadence. The In-Network Rate and Allowed Amount Files must be updated and posted quarterly rather than monthly, which CMS estimates will generate approximately $174.5 million in annual net cost savings to plans and issuers beginning in the second year of implementation.

Changes to Disclosures for Participants, Beneficiaries, and Enrollees

The final rules also amend the cost-sharing disclosure requirements that plans and issuers owe directly to participants, beneficiaries, and enrollees. Plans and issuers must now make the same cost-sharing estimates and notices currently available through the internet-based self-service tool or on paper also available by telephone, upon request, using the same phone number already required on insurance identification cards under Federal law. Plans and issuers may limit phone-based disclosures to no fewer than 20 providers per day, mirroring the existing limit that applies to paper requests.

The Departments have confirmed that satisfying this phone-disclosure requirement also satisfies the separate price-comparison-guidance-by-phone obligation under the No Surprises Act (“NSA”) — including for grandfathered group health plans and issuers offering grandfathered coverage that are not otherwise subject to the TiC rules. The final rules separately amend the balance billing protection statement that must accompany the self-service tool disclosures to reflect the Federal balance billing protections enacted under the NSA. Plans and issuers may continue to use existing disclaimer language so long as it conveys the required substance in plain language; the statement is not required to be reproduced verbatim.

Applicability Dates and Action Items

The final rules take effect on December 7, 2026, but the substantive compliance obligations phase in on three separate timelines. Plan sponsors — particularly those with self-insured plans that rely on TPAs to prepare the machine-readable files — should take the following steps:

  1. Track the three applicability dates:
    1. Plan years beginning on or after January 1, 2027 – This is the deadline for the participant-disclosure amendments (including the phone disclosure and the revised balance billing statement).
    2. Early March 2027 (five months after publication) – This is the deadline for the network-level reporting, the 11-claim threshold, the expanded reporting/lookback periods, the market-type aggregation, and the quarterly posting requirement.
    3. Early September 2027 (eleven months after publication) – This is the deadline for the new Taxonomy, Utilization, and Text File requirements.
  2. Contact issuers and TPAs to confirm their timeline for reorganizing In-Network Rate Files by provider network, moving to JSON-only formatting, and building the Taxonomy and Utilization Files. Remember that self-insured plan sponsors remain legally responsible for compliance even when a service provider prepares the files.
  3. Confirm that customer service vendors can deliver cost-sharing estimates by phone, using the existing identification-card phone number, before the plan’s 2027 plan-year start date.
  4. Update self-service tool notices and any paper disclosures to reflect the amended balance billing protection statement language before the applicable plan year begins.
  5. Identify who within the organization, an issuer representative, or a TPA representative that will serve as the designated senior official for the new attestation requirement, plus confirm how that person’s name will be encoded in each required file.
  6. Confirm that the plan’s or issuer’s website will include the required Text File and the “Price Transparency” or “Transparency in Coverage” footer link by the applicable deadline.

The Departments project that these changes will meaningfully reduce the size and complexity of the Transparency in Coverage disclosures while improving the accuracy and usability of the underlying data. Because compliance responsibility rests with the plan sponsor even where a TPA or issuer prepares the required files, plan sponsors should begin reviewing service agreements now to confirm that vendors are prepared to meet each applicability date discussed above.

If you have any questions, please contact your HUB advisor. View more compliance articles in our Compliance Directory.

NOTICE OF DISCLAIMER

Neither Hub International Limited nor any of its affiliated companies is a law or accounting firm, and therefore they cannot provide legal or tax advice. The information herein is provided for general information only and is not intended to constitute legal or tax advice as to an organization’s or individual’s specific circumstances. It is based on Hub International’s understanding of the law as it exists on the date of this publication. Subsequent developments may result in this information becoming outdated or incorrect and Hub International does not have an obligation to update this information. You should consult an attorney, accountant, or other legal or tax professional regarding the application of the general information provided here to your organization’s specific situation in light of your or your organization’s particular needs.