Proposed Rule2025-23693
Transparency in Coverage
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
December 23, 2025
Issuing agencies
Treasury DepartmentInternal Revenue ServiceLabor DepartmentEmployee Benefits Security AdministrationHealth and Human Services Department
Abstract
These proposed rules set forth proposed requirements that would amend the regulations under the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code regarding price transparency reporting requirements for non-grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage. Specifically, these proposed rules would improve the standardization, accuracy, and accessibility of public pricing disclosures in line with the goals of the Executive Order 14221. With respect to the in-network rate and out-of-network allowed amount machine-readable files, these proposed rules would achieve these goals by adding new contextual files and additional data elements like product type, network name, and enrollment counts; changing the reporting level for aggregation of data; removing in-network rates for unlikely provider-to-service mappings; increasing the reporting period and lowering the claims threshold for out-of-network historical data; and reducing the reporting cadence. These proposed rules would also improve the findability of all of the publicly disclosed machine- readable files required under the Transparency in Coverage rules, including the prescription drug file, by requiring a text file and footer with website URLs and contact information for the files. These proposed rules would also require pricing information that is made available through an online consumer tool and paper (upon request), to also be made available by phone, and establish that the 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 these proposed rules).
Full Text
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[Federal Register Volume 90, Number 244 (Tuesday, December 23, 2025)]
[Proposed Rules]
[Pages 60432-60518]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2025-23693]
[[Page 60431]]
Vol. 90
Tuesday,
No. 244
December 23, 2025
Part IV
Department of the Treasury
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Internal Revenue Service
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26 CFR Part 54
Department of Labor
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Employee Benefits Security Administration
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29 CFR Part 2590
Department of Health and Human Services
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45 CFR Part 147
Transparency in Coverage; Proposed Rule
Federal Register / Vol. 90 , No. 244 / Tuesday, December 23, 2025 /
Proposed Rules
[[Page 60432]]
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DEPARTMENT OF THE TREASURY
Internal Revenue Service
26 CFR Part 54
[REG-107111-25]
RIN 1545-BQ55
DEPARTMENT OF LABOR
Employee Benefits Security Administration
29 CFR Part 2590
RIN 1210-AC30
DEPARTMENT OF HEALTH AND HUMAN SERVICES
45 CFR Part 147
[CMS-9882-P]
RIN 0938-AV64
Transparency in Coverage
AGENCY: Internal Revenue Service, Department of the Treasury; Employee
Benefits Security Administration, Department of Labor; Centers for
Medicare & Medicaid Services, Department of Health and Human Services.
ACTION: Proposed rule.
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SUMMARY: These proposed rules set forth proposed requirements that
would amend the regulations under the Public Health Service Act, the
Employee Retirement Income Security Act of 1974, and the Internal
Revenue Code regarding price transparency reporting requirements for
non-grandfathered group health plans and health insurance issuers
offering non-grandfathered group and individual health insurance
coverage. Specifically, these proposed rules would improve the
standardization, accuracy, and accessibility of public pricing
disclosures in line with the goals of the Executive Order 14221. With
respect to the in-network rate and out-of-network allowed amount
machine-readable files, these proposed rules would achieve these goals
by adding new contextual files and additional data elements like
product type, network name, and enrollment counts; changing the
reporting level for aggregation of data; removing in-network rates for
unlikely provider-to-service mappings; increasing the reporting period
and lowering the claims threshold for out-of-network historical data;
and reducing the reporting cadence. These proposed rules would also
improve the findability of all of the publicly disclosed machine-
readable files required under the Transparency in Coverage rules,
including the prescription drug file, by requiring a text file and
footer with website URLs and contact information for the files. These
proposed rules would also require pricing information that is made
available through an online consumer tool and paper (upon request), to
also be made available by phone, and establish that the 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 these
proposed rules).
DATES: To be assured consideration, comments must be received at one of
the addresses provided below by February 23, 2026.
ADDRESSES: Written comments may be submitted to the addresses specified
below. Any comment that is submitted will be shared among the
Department of the Treasury, the Department of Labor, the Department of
Health and Human Services (the Departments), and the Office of
Personnel Management. Please do not submit duplicates.
Comments will be made available to the public. Warning: Do not
include any personally identifiable information (such as name, address,
or other contact information) or confidential business information that
you do not want publicly disclosed. Comments are posted on the internet
exactly as received and can be retrieved by most internet search
engines. No deletions, modifications, or redactions will be made to the
comments received, as they are public records. Comments may be
submitted anonymously.
In commenting, please refer to file code CMS-9882-P. Because of
staff and resource limitations, the Departments cannot accept comments
by facsimile (FAX) transmission.
Comments, including mass comment submissions, must be submitted in
one of the following three ways (please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments on this
regulation to <a href="http://www.regulations.gov">http://www.regulations.gov</a>. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-9882-P, P.O. Box 8016,
Baltimore, MD 21244-8016.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-9882-P, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Kendra May or Jeremy Rotner, Centers
for Medicare and Medicaid Services, (301) 492-4293.
Elizabeth Schumacher or Sharon Aguirre, Employee Benefits Security
Administration, (202) 693-8335.
Alexander Krupnick, Internal Revenue Service, Department of the
Treasury, (202) 317-5500.
Individuals interested in obtaining information from the Department
of Labor (DOL) concerning employment-based health coverage laws may
call the Employee Benefits Security Administration (EBSA) Toll-Free
Hotline at 1-866-444-EBSA (3272) or visit the DOL's website
(<a href="http://www.dol.gov/agencies/ebsa">www.dol.gov/agencies/ebsa</a>). In addition, information from the
Department of Health and Human Services (HHS) on private health
insurance coverage and coverage provided by non-Federal governmental
group health plans can be found on the Centers for Medicare & Medicaid
Services (CMS) website (<a href="http://www.cms.gov/marketplace">http://www.cms.gov/marketplace</a>), information on
health care reform can be found at <a href="http://www.healthcare.gov">http://www.healthcare.gov</a>, and
information on surprise medical bills can be found at <a href="http://www.cms.gov/nosurprises">http://www.cms.gov/nosurprises</a>.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. The Departments post all
comments received before the close of the comment period on the
following website as soon as possible after they have been received:
<a href="http://www.regulations.gov">http://www.regulations.gov</a>. Follow the search instructions on that
website to view public comments. The Departments will not post on
<a href="http://Regulations.gov">Regulations.gov</a> public comments that make threats to individuals or
institutions or suggest that the commenter will take actions to harm an
individual. The Departments continue to encourage individuals not to
submit duplicative comments. The
[[Page 60433]]
Departments will post acceptable comments from multiple unique
commenters even if the content is identical or nearly identical to
other comments. The Departments encourage commenters to include
supporting facts, research, and evidence in their comments. When doing
so, commenters are encouraged to provide citations to the materials
referenced, including active hyperlinks. Likewise, commenters who
reference materials that have not been published are encouraged to
upload relevant data collection instruments, data sets, and detailed
findings as a part of their comment. Providing such citations and
documentation will assist the Departments in analyzing the comments.
Plain Language Summary: In accordance with 5 U.S.C. 553(b)(4), a
plain language summary of this rule may be found at <a href="https://www.regulations.gov/">https://www.regulations.gov/</a>.
I. Executive Summary
A. Purpose
The Departments of Labor, Health and Human Services (HHS), and the
Treasury (collectively, the Departments) issued proposed requirements
in the 2019 Transparency in Coverage proposed rules (2019 proposed
rules) \1\ and finalized the rules in 2020 (the 2020 final rules).\2\
The rules aimed to provide consumers with price and benefit information
that would enable them to better evaluate health care options and make
cost-conscious decisions; reduce surprises in consumers' out-of-pocket
costs for health care services; create a competitive dynamic that would
begin to narrow price differences for the same services in the same
health care markets; foster innovation by providing industry the
information necessary to support informed, price-conscious consumers in
the health care market; and, over time, potentially lower overall
health care costs.\3\
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\1\ 84 FR 65464 (November 27, 2019).
\2\ 85 FR 72158 (November 12, 2020).
\3\ 85 FR 72158, 72160 (November 12, 2020).
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The public disclosures made pursuant to the 2020 final rules led to
the release of an enormous amount of previously hidden pricing data.
However, post-implementation, the Departments continue to receive
feedback from users of the machine-readable files emphasizing the need
to address certain gaps in reporting and shrink file size by reducing
duplication and removing unnecessary data. Since the finalization of
the 2020 final rules, the Departments have also received feedback from
many interested parties about the myriad ways in which plans and
issuers contract with providers for items and services that impact the
usability of the data disclosed under the rules.
On February 25, 2025, President Trump issued Executive Order 14221,
``Making America Healthy Again by Empowering Patients With Clear,
Accurate, and Actionable Healthcare Pricing Information'' (Executive
Order 14221).\4\ Among other things, Executive Order 14221 directs the
Departments to take all necessary and appropriate action, including
issuing proposed regulatory action to promote more transparency in
health care pricing information. In line with the goals of Executive
Order 14221, the Departments propose several amendments to the 2020
final rules to improve the standardization, accuracy, and accessibility
of pricing information.
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\4\ Exec. Order No. 14221, 90 FR 11005 (February 28, 2025).
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Based on internal assessment and external feedback from interested
parties, the Departments have identified three main barriers to fully
achieving the goals of the 2020 final rules: inaccessibility due to the
size of the machine-readable files, ambiguity regarding some of the
data disclosures due to a lack of contextual information alongside the
raw data, and misalignment with the ``2019 Medicare and Medicaid
Programs: CY 2020 Hospital Outpatient PPS Policy Changes and Payment
Rates and Ambulatory Surgical Center Payment System Policy Changes and
Payment Rates. Price Transparency Requirements for Hospitals To Make
Standard Charges Public'' rule \5\ (2019 Hospital Price Transparency
rule) that makes comparing data across disclosures challenging.
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\5\ 84 FR 65524 (November 27, 2019).
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The Departments understand that the large size of many of the
required machine-readable files, particularly the in-network rate
machine-readable file (In-network Rate File), is the most prominent
challenge with working with the machine-readable files. Academics and
researchers,\6\ data engineers,\7\ health plans and health insurance
issuers,\8\ and members of Congress \9\ have stated that these large
file sizes create several problems for file users seeking to open and
analyze the files, as well as for health plans and health insurance
issuers reporting that amount of data. For file users, the amount of
data to sift through monthly requires significant resources and time.
Smaller datasets are easier to analyze and cheaper to maintain. For
plans and issuers, large files have large data storage, maintenance,
and bandwidth costs. The amount of data being generated monthly can
also lead to increased errors in the files, making it difficult for
plans and issuers to ensure they are compliant with the disclosure
requirements and for file users to be confident in the integrity of the
data being reported. Reducing the collective burden from large file
sizes and making it easier for all users to work with the data in the
machine-readable files are among the driving goals of these proposed
rules.
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\6\ Christopher Whaley, Neeraj Radhakrishnan, Michael Richards,
Kosali Simon, et al., Understanding Health Care Price Variation:
Evidence from Transparency-in-Coverage Data, 3 Health Affairs
Scholar 2 (2025), <a href="https://doi.org/10.1093/haschl/qxaf011">https://doi.org/10.1093/haschl/qxaf011</a>;
Michael E. Chernew, Sabrina Corlette, Kelly Davenport,
Fran[ccedil]ois de Brantes, et al., Transparency in Coverage:
Recommendations for Improving Access to and Usability of Health Plan
Price Data (2022), Georgetown University, <a href="https://georgetown.app.box.com/s/1ezsggz1c7smsaexkr8rght15sokgusl">https://georgetown.app.box.com/s/1ezsggz1c7smsaexkr8rght15sokgusl</a>.
\7\ Adam Geitgey, A Petabyte of Health Insurance Prices per
Month, Turquoise Health (July 11, 2023), <a href="https://blog.turquoise.health/a-petabyte-of-health-insurance-rates-a-month/">https://blog.turquoise.health/a-petabyte-of-health-insurance-rates-a-month/</a>.
\8\ United Health Care, Transparency in coverage, <a href="https://transparency-in-coverage.uhc.com/">https://transparency-in-coverage.uhc.com/</a> (last visited Dec. 8, 2025).
(``Files are in a JSON format and may contain millions of lines of
data and be up to 1 terabyte (TB) in size. Please consider your
system's capacity and memory when downloading these files.'')
\9\ Maggie Hassan & Michael Braun, Letter to CMS Administrator
Chiquita Brooks-LaSure (Mar. 6, 2023), <a href="https://www.hassan.senate.gov/imo/media/doc/tic.pdf">https://www.hassan.senate.gov/imo/media/doc/tic.pdf</a>.
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With the 2020 final rules, the Departments expected the public
disclosure of pricing information related to health care items and
services to help both uninsured and insured individuals in their health
care and health coverage purchasing decisions. As stated in the
preamble to the 2020 final rules, research indicates that having access
to pricing information can increase consumers' overall satisfaction and
provide opportunities for education and engagement on health care
pricing.\10\
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\10\ 85 FR 72158 (November 21, 2020).
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Price transparency enables consumers to evaluate health care
options and make cost-conscious decisions, allowing for the possibility
of a competitive dynamic that may narrow price dispersion for the same
items and services in the same health care markets and put downward
pressure on prices and potentially lower overall health care costs.\11\
Since the publication of the 2020 final rules, researchers have
continued to analyze price transparency in health care with the benefit
of access to the data provided largely by the machine-readable files.
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\11\ 85 FR 72158, 72159 (November 12, 2020).
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[[Page 60434]]
Some researchers have identified significant potential cost-savings
across the health insurance landscape through greater use of the
machine-readable file data.\12\ Recent discussions extol the potential
benefits of price transparency, echoing the reasons the Departments
emphasized in the 2020 final rules. These include effects on the demand
for health care by ``guiding patients to lower-priced providers'' and
to the supply side by ``promot[ing] price competition among
providers,'' \13\ as well as benefits to employers to ``redesign health
benefits and inform purchasing decisions.'' \14\ One analysis
emphasized a range of benefits, from ``optimizing current contracts''
to ``increasing the accuracy of performance assumptions, market
analysis, and strategic value.'' \15\ Early analyses of the potential
financial and economic impacts of the 2020 final rules show promise for
fulfilling the goals the Departments articulated in the 2020 final
rules of ``facilitating a market-driven heath care system by giving
consumers of health care services data that will enable consumers to
make fully informed, cost-conscious decisions when choosing health
care.'' \16\
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\12\ Stephen T. Parente, Estimating the Impact of New Health
Price Transparency Policies, 60 The Journal of Health Care
Organization, Provision, and Financing (Feb. 17, 2023);
David N. Bernstein & John R. Crowe, Price Transparency in United
States' Health Care: A Narrative Policy Review of the Current State
and Way Forward, 61 Inquiry (2024).
\13\ Juan Carvajal, Christopher Ody, & Christopher Whaley, The
Relationship Between Pricing Transparency and Price Competition in
the US Health Care Industry (Nov. 5, 2024), <a href="https://www.analysisgroup.com/globalassets/insights/publishing/2024_aba_article_relationship_between_pricing_transparency.pdf">https://www.analysisgroup.com/globalassets/insights/publishing/2024_aba_article_relationship_between_pricing_transparency.pdf</a>.
\14\ Christopher Whaley & Austin Frakt, If Patients Don't Use
Available Health Service Pricing Information, Is Transparency Still
Important?, 24 AMA Journal of Ethics 995 (Nov. 2022.
\15\ Sarun Charumilind, Shubham Singhal, Oleg Bestsennyy, Erica
Coe, et al., How Price Transparency Could Affect US Healthcare
Markets), McKinsey (Apr. 2, 2024), <a href="https://www.mckinsey.com/industries/healthcare/our-insights/how-price-transparency-could-affect-us-healthcare-markets">https://www.mckinsey.com/industries/healthcare/our-insights/how-price-transparency-could-affect-us-healthcare-markets</a>.
\16\ 85 FR 72158, 72171 (November 12, 2020).
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While the machine-readable file requirements of the 2020 final
rules and the 2019 Hospital Price Transparency rule do not require the
exact same disclosures, they have similar goals and some overlapping
data. Therefore, it can be useful to review studies of hospital
machine-readable files for lessons learned and outcomes that may
translate to the plan and issuer machine-readable file disclosures. One
study using hospital data found that ``choosing plans from the largest
insurer in the local market is more likely to result in lower
negotiated rates than from other plans,'' which can lead to reduced
costs for the ``growing number of self-insured employers engaged in
direct contracts with hospitals.'' \17\ One county government used
hospital data in this manner to reduce its health costs by over 40
percent.\18\ Tools allowing comparison of the hospital data recently
began populating the internet. The Departments are also aware of app
developers conducting similar analyses of the data from plan and issuer
disclosures and offering them to consumers (both individuals and
employers). The Departments expect that continued analyses and
development of consumer-facing tools and services will result in
similar savings opportunities achieved from studying the hospital
machine-readable files.
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\17\ Yang Wang, Michael E. Chernew, Leemore S. Dafny, Maximilian
J. Pany, et al., Do Insurers with Greater Market Power Negotiate
Consistently Lower Prices for Hospital Care? Evidence From Hospital
Price Transparency Data, 29 Medical Care Research & Review (Aug. 18,
2023).
\18\ Sara Hansard, One County Combed Hospital Data to Slash
Health Plan Costs 43 Percent (Feb. 6, 2023), Bloomberg, <a href="https://news.bloomberglaw.com/health-law-and-business/employer-health-plan-eyes-43-savings-from-payment-data-audits">https://news.bloomberglaw.com/health-law-and-business/employer-health-plan-eyes-43-savings-from-payment-data-audits</a>.
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However, the success of these analyses and the effectiveness of
consumer-facing tools depend on the usability of the machine-readable
files. Large file sizes, lack of clarity, and data of limited use
hamper efforts to build tools that can be brought to market. These
proposed changes, if finalized, would contribute to making the files
easier to digest and analyze, reduce challenges for existing tool
developers, and open the market to additional tool and app developers.
The Departments seek to address the limitations of the machine-
readable files through these proposed rules as well as through updates
to the machine-readable file form and manner requirements as detailed
in technical implementation guidance. As a first step towards
addressing these limitations, on May 22, 2025, the Departments
announced in FAQs Part 70 the intention to release schema version 2.0
(Schema 2.0), which will implement revised technical requirements for
the In-network Rate File and out-of-network allowed amounts and billed
charges machine-readable file (Allowed Amount File).\19\ However, the
Departments also recognize that more substantive requirements are
needed to clarify the data being published and to give users more
confidence in the data. Feedback from interested parties demonstrates
that, while the raw data from the machine-readable files presents
valuable information and opportunities for analysis, additional
contextual information is needed to supplement the in-network rates and
out-of-network allowed amounts and billed charges disclosed in the
machine-readable files. Additional contextual information would allow
users to understand changes in pricing over time, promote more accurate
reporting, and make pricing information more meaningful and accessible
overall. Therefore, the Departments are issuing these proposed rules as
a next step to addressing these concerns.
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\19\ U.S. Department of Labor, U.S. Department of Health & Human
Services & U.S. Department of the Treasury, Frequently Asked
Questions About Affordable Care Act Implementation Part 70 (May 22,
2025), <a href="https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-70">https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-70</a>.
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The disclosure requirements under the Transparency in Coverage
rules represent just one prong in a multipronged approach to promote
greater transparency and understanding of costs and pricing in the
health care and the health insurance market. The 2020 final rules must
be viewed within the context of other regulatory and statutory changes,
such as the Hospital Price Transparency initiative, as well as Title I
of Division BB of the Consolidated Appropriations Act, 2021 (CAA), also
known as the No Surprises Act, and its consumer protections against
surprise billing, its requirements for a good faith estimate, advanced
explanation of benefits, and more accurate provider directories. With
respect to the Hospital Price Transparency and the Transparency in
Coverage initiatives in particular, section 3(b) of Executive Order
14221 instructed the Departments to ``issue updated guidance or
proposed regulatory action ensuring pricing information is standardized
and easily comparable across hospitals and health plans.'' \20\ The
Departments received encouraging feedback that ``commercial prices
disclosed in the TiC [Transparency in Coverage] data are mostly
comparable to those disclosed by hospitals in compliance with the
hospital price transparency rule and to Marketscan [sic] claims data.''
\21\
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However, other interested parties have noted that, despite the
consistency of the raw data across hospital and plan and issuer
machine-readable files, there are other challenges in comparing the
information between the two sets of machine-readable files.\22\
Therefore, the Departments intend in these proposed rules, along with
Schema 2.0, to help align the Hospital Price Transparency reporting
requirements and the 2020 final rules, as well as to fulfill the
directive under Executive Order 14221.
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\20\ Exec. Order No. 14221, 90 FR 11005, 11006 (February 28,
2025).
\21\ Yang Wang, Michael Meiselbach, Gerard Anderson & Ge Bai,
Hospital Pricing Information Consistent Between Transparency-In-
Coverage Data and Other Commercial Data Sources, 42 Health Affairs
(2023), <a href="https://www.healthaffairs.org/content/forefront/hospital-pricing-information-consistent-between-transparency-coverage-data-and-other">https://www.healthaffairs.org/content/forefront/hospital-pricing-information-consistent-between-transparency-coverage-data-and-other</a>. Information on MarketScan data can be found at <a href="https://www.merative.com/documents/merative-marketscan-research-databases">https://www.merative.com/documents/merative-marketscan-research-databases</a>.
\22\ Nikki Tong, Price Transparency Proposal Leaves Room for
Improvement, Experts Say, Fierce Healthcare (Aug. 1, 2023), <a href="https://www.fiercehealthcare.com/providers/price-transparency-proposal-leaves-room-improvement">https://www.fiercehealthcare.com/providers/price-transparency-proposal-leaves-room-improvement</a>; Jing Jiang, Mengqi Jiang & Ge Bai,
Enforcing Hospital Price Transparency: Lessons from CMS Actions,
Health Affairs Forefront (Dec. 3, 2024), <a href="https://www.healthaffairs.org/content/forefront/enforcing-hospital-price-transparency-lessons-cms-actions">https://www.healthaffairs.org/content/forefront/enforcing-hospital-price-transparency-lessons-cms-actions</a>.
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Additionally, to better inform a response to Executive Order 14221,
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 in the
2020 final rules.\23\
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\23\ 90 FR 23303 (June 2, 2025).
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Building off of the 2020 final rules, the Departments propose these
rules pursuant to the authority under Section 2715A of the Public
Health Service (PHS) Act, incorporated into section 715 of the Employee
Retirement Income Security Act (ERISA) and section 9815 of the Internal
Revenue Code (Code), which provide that non-grandfathered group health
plans and health insurance issuers offering non-grandfathered group or
individual health insurance coverage must comply with section
1311(e)(3) of the Patient Protection and Affordable Care Act
(Affordable Care Act). This section of the Affordable Care Act
addresses transparency in health coverage and imposes certain reporting
and disclosure requirements on health plans that are seeking
certification as qualified health plans (QHPs) that may be offered on
an Exchange (as defined by section 1311(b)(1) of the Affordable Care
Act).
The Departments also propose these rules pursuant to the authority
under the No Surprises Act, which amended chapter 100 of the Code, Part
7 of ERISA, and title XXVII of the PHS Act. Among other protections,
the No Surprises Act provides Federal protections against surprise
billing by limiting out-of-network cost sharing and prohibiting balance
billing in many of the circumstances in which surprise bills most
frequently arise. Section 114 of the No Surprises Act added Code
section 9819, ERISA section 719, and PHS Act section 2799A-4, which
require plans and issuers to offer price comparison guidance by
telephone and make a ``price comparison tool'' available on the plan's
or issuer's website.
B. Summary of the Major Provisions
1. Transparency in Coverage--Definitions
The 2020 final rules include definitions at 26 CFR 54.9815-
2715A1(a)(2); 29 CFR 2590.715-2715A1(a)(2); and 45 CFR 147.210(a)(2).
These proposed rules, if finalized, would add a definition of the term
health insurance market for purposes of amendments to 26 CFR 54.9815-
2715A3(b)(1)(ii), 29 CFR 2590.715-2715A3(b)(1)(ii), and 45 CFR
147.212(b)(1)(ii) that would require group health plans and health
insurance issuers offering group or individual health insurance
coverage to make an out-of-network allowed amount machine-readable file
available for each health insurance market in which the plan or issuer
offers a plan or coverage. Under 26 CFR 54.9815-2715A1 and 45 CFR
147.210, the Departments propose to redesignate paragraphs (a)(2)(xi)
through (xxii) as paragraphs (a)(2)(xii) through (xxiii), respectively,
and add a new paragraph (a)(2)(xi) with the new definition. Under 29
CFR 2590.715-2715A1, the Departments propose to redesignate paragraphs
(a)(2)(x) through (xxi) as paragraphs (a)(2)(xi) through (xxii) and add
a new paragraph (a)(2)(x) with the new definition.
2. Transparency in Coverage--Required Disclosures to Participants,
Beneficiaries, or Enrollees
The 2020 final rules at 26 CFR 54.9815-2715A2; 29 CFR 2590.715-
2715A2; and 45 CFR 147.211 require non-grandfathered group health plans
and health insurance issuers offering non-grandfathered coverage in the
group and individual markets to make cost-sharing information available
to participants, beneficiaries, and enrollees through an internet-based
self-service tool (self-service tool), and in paper form, upon request.
The Departments propose to amend paragraph (b)(1)(vii)(A) of this
section to require the disclaimer, described in that paragraph, to
state that the cost-sharing information does not account for potential
additional amounts in situations where applicable State and Federal law
allow out-of-network providers to balance bill participants,
beneficiaries, and enrollees. This proposed amendment reflects the
existence of the Federal balance billing protections set forth in the
No Surprises Act, which was not in effect when (b)(1)(vii)(A) was
finalized in the 2020 final rules. The Departments also propose to
clarify that the disclaimer is not required if the State in which the
item or service was furnished prohibits all out-of-network providers
from balance billing for all items and services payable by the plan or
issuer.
In addition, the Departments propose to add a new paragraph at
(b)(2)(iii) under this section to require plans and issuers to make
available to participants, beneficiaries, and enrollees the cost-
sharing estimates and other disclosures required under paragraph (b)(1)
via a telephone number to implement requirements under section 9819 of
the Code, section 719 of ERISA, and PHS Act Section 2799A-4, as added
by section 114 of the No Surprises Act.\24\ The Departments propose to
require a telephone number through which a consumer may seek customer
assistance which would be required to be the same number that Code
section 9816(e), ERISA section 716(e), and PHS Act section 2799A-1(e),
as added by section 107 of the No Surprises Act requires be indicated
on any physical or electronic plan or insurance identification card
issued to a participant, beneficiary, or enrollee. The Departments also
propose to redesignate paragraph (b)(2)(ii)(D) as new paragraph
(b)(2)(iv) and amend redesignated paragraph (b)(2)(iv) to remove phone
as an alternative means by which a participant, beneficiary, or
enrollee can request the disclosures required under paragraph (b)(1).
---------------------------------------------------------------------------
\24\ 42 U.S.C. 300gg-111(e)(3); 29 U.S.C. 1185e(e)(3); 26 U.S.C.
9819. U.S. Department of Labor, U.S. Department of Health & Human
Services & U.S. Department of the Treasury, FAQs about Affordable
Care Act and Consolidated Appropriations Act, 2021 Implementation
Part 49 (August 20, 2021), <a href="https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf">https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf</a> and <a href="https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf">https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf</a>.
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The Departments also propose to add a new paragraph (c)(7) stating
that plans and issuers satisfy the requirements set forth in Code
section 9819, ERISA section 719, and PHS Act section 2799A-4 regarding
the price comparison tool by providing the information to participants,
beneficiaries, and enrollees set forth in paragraph (b)(1) as amended
in accordance with the method and format requirements set forth in
paragraph (b)(2), as amended.\25\
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\25\ While PHS Act section 2715A does not apply to grandfathered
health plans and health insurance issuers offering grandfathered
individual and group health insurance coverage, section 9819 of the
Code, section 719 of ERISA, and section 2799A-4 of the PHS Act do
apply to grandfathered health plans and issuers offering
grandfathered health insurance coverage.
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[[Page 60436]]
3. Transparency in Coverage--Requirements for Public Disclosure
The Transparency in Coverage final rules at 26 CFR 54.9815-2715A3;
29 CFR 2590.715-2715A3; and 45 CFR 147.212 require non-grandfathered
group health plans and health insurance issuers offering non-
grandfathered group and individual health insurance coverage to
disclose on a public website, in the format of machine-readable files,
information regarding in-network provider rates for covered items and
services, out-of-network allowed amounts and billed charges for covered
items and services, and negotiated rates and historical net prices for
covered prescription drugs.
The Departments propose a number of amendments that would apply to
the disclosure of information required under paragraphs (b)(1) and
(b)(2). First, the Departments propose to amend the introductory
paragraph of (b) to reference new requirements for the public
disclosure of contextual information and to redesignate paragraphs
(b)(2) through (b)(3) as paragraphs (b)(3) through (b)(4),
respectively, and add a new paragraph (b)(2) describing the proposed
contextual information disclosure requirements for the In-network Rate
File. The Departments also propose to add two new paragraphs,
(b)(2)(iv) and (b)(3)(iii), to help users more easily locate the public
disclosures made pursuant to these proposed rules by requiring plans
and issuers to post a plain text file in a .txt format (Text File) in
the root folder of the plan or issuer's website and a specific internet
domain as a link in the footer on the home page of the plan's or
issuer's website. The Departments are also considering a standardized
file format for all machine-readable files. The Departments also
propose to amend the required information at redesignated paragraph
(b)(1)(i)(B) and paragraph (b)(1)(ii)(A) to remove the requirement to
report a specific number of digits of the Health Insurance Oversight
System (HIOS) identifier (ID) that are required for each coverage
option and to add a requirement to disclose the product type associated
with the plan or policy in the In-network Rate Files and the Allowed
Amount Files. The Departments also propose to amend the special rules
to prevent unnecessary duplication in current paragraph (b)(4) by
redesignating paragraph (b)(4)(i) as paragraph (b)(5)(i), redesignating
paragraph (b)(4)(ii) as paragraph (b)(5)(ii), redesignating paragraph
(b)(4)(iii) as paragraph (b)(5)(iv), and adding paragraph (b)(5)(iii).
In new paragraph (b)(5)(iii), the Departments propose to permit self-
insured group health plans under certain circumstances to allow another
party, such as a service provider, with which they have an agreement as
described in paragraph (b)(5)(ii), to make available in a single In-
network Rate File as required under paragraph (b)(1)(i), the
information required under paragraph (b)(1)(i) for more than one plan,
insurance policy, or contract (including those offered by different
plan sponsors with which the other party has an agreement) and across
different health insurance markets. The Departments also propose to
amend newly redesignated paragraph (b)(5)(iv) to permit self-insured
group health plans under certain circumstances to allow another party
with which they have an agreement to aggregate the Allowed Amount Files
required under paragraph (b)(1)(ii) for more than one self-insured
group health plan, including those offered by different plan sponsors.
Finally, the Departments propose to amend newly redesignated
paragraph (b)(4) by adding new paragraphs to specify the timing
requirements for each machine-readable file required as proposed under
these rules. As related to the public disclosures generally, proposed
paragraph (b)(4)(i) would amend the required reporting frequency for
the In-network Rate and Allowed Amount Files under paragraphs (b)(1)(i)
and (b)(1)(ii) from monthly to quarterly but would not propose any
changes to the monthly reporting frequency for the prescription drug
file required under paragraph (b)(1)(iii). Newly redesignated paragraph
(b)(4)(vi) proposes to require the Text File proposed under new
paragraph (b)(2)(iv) to be posted beginning on the first day of the
calendar-year quarter following the applicability date under paragraph
(c)(1) and updated and posted as soon as practicable but no later than
7 calendar days following a change in any of the information required
under redesignated paragraph b)(2)(iv).
The amendments contained in these proposed rules generally modify
requirements related to the In-network Rate Files and the Allowed
Amount Files. However, several proposed amendments would amend
requirements related to the prescription drug machine-readable files,
specifically: the requirement that plans and issuers must include a
Text File in the root folder of a plan's or issuer's website as
described in proposed paragraphs (b)(2)(iv) (section III.C.7.d. of this
preamble) and the requirements related to the method and format for
disclosing information to the public as described in proposed
redesignated paragraph (b)(3) (section III.C.9. of this preamble). The
Departments note in each applicable section when a proposal would
modify requirements related to the prescription drug machine-readable
files.
4. Public Disclosure of In-Network Rates
With respect to the disclosure of in-network rates specifically, to
reduce duplicate in-network rate data, the Departments propose to amend
26 CFR 54.9815-2715A3(b)(1)(i), 29 CFR 2590.715-2715A3(b)(1)(i), and 45
CFR 147.212(b)(1)(i) to require plans and issuers to make an In-network
Rate File available for each provider network maintained or contracted
by the plan or issuer. As part of this proposal, the Departments
propose to redesignate paragraphs (b)(1)(i)(A) through (C) as
paragraphs (b)(1)(i)(B) through (D), respectively, and add a new
paragraph (b)(1)(i)(A) requiring each In-network Rate File to include
the common provider network name for which negotiated rate information
is included in that file.
The Departments also propose to amend redesignated paragraph
(b)(1)(i)(D)(1) to require in-network rates to be reflected as a dollar
amount except for contractual arrangements under which plans and
issuers agree to pay an in-network provider a percentage of billed
charges and are not able to assign a dollar amount to an item or
service prior to a bill being generated. The Departments also propose
to add new paragraph (b)(1)(i)(E), requiring each In-network Rate File
to include current enrollment totals, as of the date the file is
posted, for each plan or coverage option offered by a plan or issuer
that uses that file's provider network.
The Departments also propose in new paragraph (b)(1)(i)(F) to
require plans and issuers to exclude any provider and their negotiated
rate (provider-rate combination) for an item or service, if the
provider is unlikely to be reimbursed for the item or service given
that provider's area of specialty, according to the plan's or issuer's
internal provider taxonomy used during the claims adjudication process.
The Departments also propose to amend newly redesignated paragraph
(b)(1)(i)(D)(2) to account for this proposed required exclusion.
The Departments also propose to require plans and issuers to post
several contextual machine-readable files under new paragraph (b)(2)
that would help file users better understand the public
[[Page 60437]]
disclosures required in the In-network Rate Files under paragraph
(b)(1)(i). This proposal would mean plans and issuers would be required
to prepare new contextual files for each In-network Rate File prepared
pursuant to these proposed rules. In particular, the Departments
propose to require a change-log file (``Change-log File'') at new
paragraph (b)(2)(i), which would identify any changes made to the
required information described in paragraph (b)(1)(i) in the In-network
Rate File since the last posted In-network Rate File.
The Departments also propose to require a utilization file
(``Utilization File'') at new paragraph (b)(2)(ii), which would
document, for the 12-month period that ends 6 months prior to the
publication date of each Utilization File, all items and services
covered under the plans or policies represented in the In-network Rate
File prepared pursuant to proposed amended paragraph (b)(1)(i) for
which a claim has been submitted and reimbursed. The Utilization File
would also include each in-network provider identified by the National
Provider Identifier (NPI), Tax Identification Number (TIN), and Place
of Service Code who was reimbursed, in whole or in part, for a claim
for each covered item or service included in such file.
The Departments also propose to require plans and issuers to
publish a taxonomy file (``Taxonomy File'') at new paragraph
(b)(2)(iii) which would include their internal provider taxonomy that
matches items and services (represented by a billing code) with
provider specialties (represented by specialty codes that are derived
from the Health Care Provider Taxonomy \26\ code set established by the
National Uniform Claim Committee (NUCC)) to determine if the plan or
issuer should deny reimbursement for an item or service because it was
not furnished by a provider in an appropriate specialty.
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\26\ National Uniform Claim Committee, Health Care Provider
Taxonomy, <a href="https://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40">https://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40</a> (last visited Dec. 8, 2025).
---------------------------------------------------------------------------
Finally, the Departments propose to add timing requirements for the
proposed new contextual files under redesignated paragraph (b)(4). With
respect to the contextual files that related to the In-network Rate
Files under paragraph (b)(1)(i), under proposed paragraph (b)(4)(iii),
the Change-log File proposed at paragraph (b)(2)(i) would be required
to be posted beginning on the first day of the calendar-year quarter
following the date on which the first In-network Rate File is required
to be posted under paragraph (b)(4)(i), and updated and posted
quarterly whether or not there are changes to that file since it was
last posted. Under proposed paragraph (b)(4)(iv), the Utilization File
proposed at paragraph (b)(2)(ii) would be required to be posted
beginning on the first day of the calendar-year quarter following the
applicability date under paragraph (c)(1) and updated annually after
the initial posting. Lastly, under proposed paragraph (b)(4)(v), the
Taxonomy File proposed at paragraph (b)(2)(iii) would be required to be
posted beginning on the first day of the calendar-year quarter
following the applicability date under paragraph (c)(1) and updated and
posted quarterly if changes to the internal provider taxonomy impact
the information required in the machine-readable file required under
paragraph (b)(1)(i).
5. Public Disclosure of Out-of-Network Allowed Amounts
The Departments propose to make several amendments to 26 CFR
54.9815-2715A3(b)(1)(ii), 29 CFR 2590.715-2715A3(b)(1)(ii), and 45 CFR
147.212(b)(1)(ii) to increase the amount of historical claims data
available in the Allowed Amount Files. These amendments would require
plans and issuers to report out-of-network allowed amounts and billed
charges at the health insurance market level, rather than the plan or
policy level, lower the threshold for including claims in the Allowed
Amount File from 20 to 11 different claims per item or service, and
increase the reporting period from 90 days to 6 months and the lookback
period from 180 days to 9 months.
6. Severability
The 2020 final rules included severability clauses to emphasize the
Departments' intent that, to the extent a reviewing court holds that
any provision of the final rules is unlawful, the remaining rules
should take effect and be given the maximum effect permitted by law.
The 2020 final rules provide that any provision held to be invalid or
unenforceable by its terms, or as applied to any person or
circumstance, or stayed pending further agency action, shall be
severable from the relevant section and shall not affect the remainder
thereof or the application of the provision to persons not similarly
situated or to dissimilar circumstances. The Departments are not
modifying this language in the 2020 final rules and clarify that these
clauses continue to apply and would extend to the amendments proposed
in these rules, if finalized.
7. Technical Amendments
The Departments propose a series of technical amendments to the way
group health plans and health insurance issuers offering group or
individual health insurance coverage are referenced in 26 CFR 54.9815-
2715A2 and 54.9815-2715A3, 29 CFR 2590.715-2715A2 and 2590.715-2715A3,
and 45 CFR 147.211 and 147.212. In the 2020 final rules, the
Departments generally adopted the convention of referring to those
entities using the terms ``group health plan'' and ``health insurance
issuer'' throughout the regulations, except that where the Departments
refer to those entities more than once in the same paragraph, the terms
``plan'' and ``issuer'' are used after the initial instance. However,
that convention was not applied evenly.
Therefore, in the internet-based self-service tool disclosure
requirements in 26 CFR 54.9815-2715A2, 29 CFR 2590.715-2715A2, and 45
CFR 147.211, the Departments propose technical amendments to paragraphs
(b)(1)(i)(A), (b)(1)(i)(B), (b)(2)(ii), (b)(3)(i), and (b)(3)(ii) that
would bring the terms used to describe those entities in line with that
convention. In the machine-readable file disclosure requirements in 26
CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212, the
Departments propose amendments to redesignated paragraph (b)(1)(i)(D),
(b)(5)(i), and (b)(5)(ii) that would bring the terms used to describe
those entities in line with that convention. These paragraphs are
otherwise unchanged. These proposed changes are technical in nature and
would not affect the rights or obligations of any plan, issuer, or
other entity.
C. Summary of Costs and Benefits
[[Page 60438]]
[GRAPHIC] [TIFF OMITTED] TP23DE25.047
[[Page 60439]]
[GRAPHIC] [TIFF OMITTED] TP23DE25.048
[[Page 60440]]
[GRAPHIC] [TIFF OMITTED] TP23DE25.049
II. Background
A. Executive Orders
On June 24, 2019, President Trump issued Executive Order 13877,
``Improving Price and Quality Transparency in American Healthcare to
Put Patients First.'' \27\ Executive Order 13877 sought to improve
transparency in health care and empower patients to make fully informed
decisions about their health care. As Executive Order 13877 noted,
``patients often lack both access to useful price and quality
information and the incentives to find low-cost, high-quality care.''
The lack of this information is widely understood to be one of the root
problems causing dysfunction within America's health care system,
``generally leav[ing] patients and taxpayers worse off than would a
more transparent system.''
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\27\ Exec. Order No. 13877, 84 FR 30849 (June 27, 2019).
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Executive Order 13877 directed the Departments to take action that
would combat this issue by making meaningful price and quality
information more broadly available to more Americans, thereby
increasing competition, innovation, and value in the health care
system. Specifically, section 3(b) of Executive Order 13877 directed
the Secretaries of the Departments to issue an advance notice of
proposed rulemaking, consistent with applicable law, soliciting comment
on a proposal to require health care providers, health insurance
issuers, and self-insured group health plans to provide or facilitate
access to information about expected out-of-pocket costs for items or
services to patients before they receive care.
To fulfill their responsibility under Executive Order 13877, the
Departments proposed \28\ and subsequently finalized the Transparency
in Coverage rules in the 2020 final rules.\29\ The 2020 final rules
published by the Departments on November 12, 2020, implemented section
2715A of the PHS Act, which requires group health plans and health
insurance issuers offering group or individual health insurance
coverage to comply with section 1311(e)(3) of the Affordable Care Act.
As described more fully elsewhere in this preamble, these provisions
address transparency in health coverage and require plans and issuers
to make certain information available to the public.
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\28\ 84 FR 65464 (November 27, 2019).
\29\ 85 FR 72158 (November 12, 2020).
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On February 25, 2025, President Trump issued Executive Order
14221,\30\ ``Making America Healthy Again by Empowering Patients With
Clear, Accurate, and Actionable Healthcare Pricing Information.''
Executive Order 14221 stated that ``[m]aking America healthy again will
require empowering individuals with the best information possible to
inform their life and healthcare choices'' with the goal to ``make more
meaningful price information available to patients to support a more
competitive, innovative, affordable, and higher quality healthcare
system.'' To that end, the Executive Order directs the Departments to
``promote universal access to clear and accurate healthcare prices[;] .
. . to improve existing price transparency requirements; increase
enforcement of price transparency requirements; and identify
opportunities to further empower patients with meaningful price
information, potentially including through the expansion of existing
price transparency requirements.'' \31\
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\30\ Exec. Order No. 14221, 90 FR 11005 (February 28, 2025).
\31\ Id.
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Section 3 of Executive Order 14221 directs the Secretaries of the
Departments to rapidly implement and enforce the health care price
transparency regulations issued pursuant to Executive Order 13877,\32\
[[Page 60441]]
including action to: ``(a) require the disclosure of the actual prices
of items and services, not estimates; (b) issue updated guidance or
proposed regulatory action ensuring pricing information is standardized
and easily comparable across hospitals and health plans; and (c) issue
guidance or proposed regulatory action updating enforcement policies
designed to ensure compliance with the transparent reporting of
complete, accurate, and meaningful data.'' \33\ In line with these
directives, the Departments are publishing these proposed rules with
amendments to the regulations issued under the 2020 final rules.\34\
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\32\ Exec. Order No. 13877, 84 FR 30849 (June 27, 2019).
\33\ Exec. Order No. 14221, 90 FR 11005 (February 28, 2025).
\34\ 85 FR 72158 (November 12, 2020).
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B. Statutory Background and Enactment of the Affordable Care Act and
the No Surprises Act
The Patient Protection and Affordable Care Act (Pub. L. 111-148)
was enacted on March 23, 2010, and the Health Care and Education
Reconciliation Act of 2010 (Pub. L. 111-152) was enacted on March 30,
2010 (collectively the Affordable Care Act). As relevant here, the
Affordable Care Act reorganized, amended, and added to the provisions
of part A of title XXVII of the PHS Act relating to health coverage
requirements for group health plans and health insurance issuers. The
term group health plan includes both insured and self-insured group
health plans.
The Affordable Care Act also added section 715 to ERISA and section
9815 to the Code to incorporate the provisions of part A of title XXVII
of the PHS Act, PHS Act sections 2701 through 2728, into ERISA and the
Code, making them applicable to group health plans and health insurance
issuers providing coverage in connection with group health plans.
Section 2715A of the PHS Act, incorporated into section 715 of
ERISA and section 9815 of the Code, provides that plans and issuers
must comply with section 1311(e)(3) of the Affordable Care Act, which
addresses transparency in health coverage and imposes certain reporting
and disclosure requirements for health plans that are seeking
certification as QHPs that may be offered on an Exchange. A plan or
coverage that is not offered through an Exchange (as defined by section
1311(b)(1) of the Affordable Care Act) is required to submit the
information required to the relevant Secretary and the relevant State's
insurance commissioner, and to make that information available to the
public.
The 2020 final rules require non-grandfathered health plans and
health insurance issuers offering non-grandfathered group or individual
health insurance coverage to disclose cost-sharing information for all
covered items and services to participants, beneficiaries, and
enrollees through an internet-based self-service tool or, if requested
by the individual, on paper. These provisions of the 2020 final rules
implement paragraph (C) of section 1311(e)(3) of the Affordable Care
Act.
The 2020 final rules also require non-grandfathered plans and
health insurance issuers offering non-grandfathered group or individual
health insurance coverage to disclose on a public website three
separate machine-readable files containing certain information
regarding health care pricing under the plan or coverage. The machine-
readable file disclosure requirements are intended to make health care
pricing information accessible and useful to consumers and other
interested parties (including employers, and other purchasers of health
care),\35\ support efforts to lower health care costs by driving
competition,\36\ and to supplement State transparency efforts.\37\
These provisions of the 2020 final rules requiring plans and issuers to
disclose in-network negotiated rates, out-of-network allowed amounts
and the associated billed charges, and negotiated rates and historical
net prices for prescription drugs implement paragraph (A) of section
1311(e)(3) of the Affordable Care Act. In particular, the provisions
requiring the disclosure of out-of-network allowed amounts specifically
implement the requirement in section 1311(e)(3)(A)(vii) of the
Affordable Care Act to provide information on ``payments with respect
to any out-of-network coverage.'' In addition, the Secretary of HHS
determined that requiring disclosure of payment information on in-
network rates and prescription drugs is appropriate under section
1311(e)(3)(A)(ix) of the Affordable Care Act.
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\35\ 85 FR 72158, 72160-61 (November 12, 2020).
\36\ 85 FR 72158, 72161-62 (November 12, 2020).
\37\ 85 FR 72158, 72162-63 (November 12, 2020).
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The No Surprises Act added new provisions applicable to plans and
issuers in Subchapter B of chapter 100 of the Code, Part 7 of ERISA,
and Parts D and E of title XXVII of the PHS Act. As relevant here, the
No Surprises Act added new sections 9816(a)-(b) and 9817(a) of the
Code, sections 716(a)-(b) and 717(a) of ERISA, and sections 2799A-1,
2799A-2, 2799B-1, 2799B-2, 2799B-3, and 2799B-5 of the PHS Act, which
protect participants, beneficiaries, and enrollees in group health
plans and group and individual health insurance coverage from balance
bills by prohibiting nonparticipating providers, facilities, and
providers of air ambulance services from billing or holding liable
individuals for an amount that exceeds in-network cost sharing
determined in accordance with the No Surprises Act's cost-sharing
limitations in circumstances where the cost-sharing limitations apply.
The No Surprises Act also added new section 9816(e) of the Code,
section 716(e) of ERISA, and sections 2799A-1(e) of the PHS Act, which
contain requirements for applicable group health plans or issuers to
include certain information, in clear writing, on any physical or
electronic plan or insurance identification card issued to the
participants or beneficiaries in the plan or coverage. This information
includes any deductible applicable to such plan or coverage, any out-
of-pocket maximum limitation applicable to such plan or coverage, and a
telephone number and internet website address through which such
individual may seek consumer assistance information.
Further, section 114 of the No Surprises Act added section 2799A-4
of the PHS Act, section 9819 of the Code, and section 719 of ERISA,
which require plans and issuers to: offer price comparison guidance by
telephone and make available on the internet website of the plan or
issuer a price comparison tool that (to the extent practicable) allows
an individual enrolled under such plan or coverage, with respect to
such plan year, such geographic region, and participating providers
with respect to such plan or coverage, to compare the amount of cost
sharing that the individual would be responsible for paying under such
plan or coverage with respect to the furnishing of a specific item or
service by any such provider.
C. Statutory Background for Enforcement With Regards to the Affordable
Care Act and the CAA of 2021
The enforcement responsibilities of HHS and the States with respect
to oversight of health insurance issuer compliance with the Federal
insurance market reforms are set forth in the PHS Act. Pursuant to
section 2723(a)(1) of the PHS Act, as amended by the No Surprises Act,
states have primary enforcement authority over health insurance issuers
regarding the provisions of Parts A and D of title XXVII of the PHS
Act. Under this framework, HHS has enforcement
[[Page 60442]]
authority over issuers in a State if the Secretary of HHS makes a
determination that the State is failing to substantially enforce a
provision (or provisions) of Part A or D of title XXVII of the PHS
Act.\38\
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\38\ See section 2723(a)(2) and (b)(1)(A) of the PHS Act; 45 CFR
150.203.
---------------------------------------------------------------------------
The Departments of Labor and the Treasury generally have primary
enforcement authority over private sector employment-based group health
plans. The Internal Revenue Service (IRS) has jurisdiction over certain
church plans. HHS also has primary enforcement authority over non-
Federal governmental plans, such as those sponsored by state and local
government employers.\39\
---------------------------------------------------------------------------
\39\ Section 2723(b)(1)(B) of the PHS Act.
---------------------------------------------------------------------------
The Departments will generally use existing processes to ensure
compliance with the Code, ERISA, and PHS Act requirements that apply to
group health plans and health insurance issuers. HHS's enforcement
procedures related to the PHS Act Federal insurance market reforms are
set forth in section 2723 of the PHS Act and 45 CFR 150.101 et seq.,
including bases for initiating investigations, performing market
conduct examinations, and imposing civil money penalties. Section 504
of ERISA provides DOL with investigatory authority to determine whether
any person has violated or is about to violate any provision of ERISA
or any regulation or order thereunder.
D. Consultation With and Input From Interested Parties
The Departments have been in regular consultation with interested
parties since publishing the 2019 proposed rules. In addition to the
thousands of comments received on the 2019 proposed rules, following
the publication of the 2020 final rules, the Departments continued to
engage in consultation with interested parties and collaboration about
implementation of the 2020 final rules through technical implementation
discussions on GitHub (an online hosting platform for development and
source code management that permits version control), webinars, emails,
and an inquiry management system, as well as other informal compliance
assistance efforts and meetings with interested parties. This period of
collaboration with interested parties led to the finalization of an
initial technical format for disclosures (Schema 1.0) that was
finalized on March 1, 2022, and became applicable on July 1, 2022. The
Departments also regularly review news articles and research
publications discussing the 2020 final rules and have received written
and verbal recommendations from plans and issuers, data engineers, and
researchers and academics.\40\
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\40\ Supra note 8, 9, 10, and 11.
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On May 22, 2025, the Departments released FAQs Part 70 on Schema
2.0, which states the Departments' intention to issue revised technical
reporting requirements for the In-network Rate File and Allowed Amount
File for group health plans and health insurance issuers, and the
applicability date for implementation.\41\ FAQs Part 70 requested
interested parties to provide feedback through GitHub on how best to
address the revised technical reporting requirements. These
improvements respond to feedback from interested parties and are
designed to reduce unnecessary or duplicative data fields and make cost
information easier for consumers to understand and use.
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\41\ U.S. Department of Labor, U.S. Department of Health & Human
Services & U.S. Department of the Treasury, FAQs About Affordable
Care Act Implementation Part 70 (May 22, 2025), <a href="https://www.cms.gov/files/document/aca-faqs-part-70.pdf">https://www.cms.gov/files/document/aca-faqs-part-70.pdf</a> and <a href="https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-70">https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-70</a>.
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Additionally, on June 2, 2025, the Departments issued an RFI \42\
regarding the prescription drug machine-readable file requirement
seeking comment and recommendations on the prescription drug price
disclosure requirements. More specifically, the RFI requested comments
and recommendations to help inform implementation of the prescription
drug file disclosure requirements, including information on existing
prescription drug file data elements, the ability of health plans to
access necessary data for reporting, as well as state approaches and
innovation.\43\
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\42\ See 90 FR 23303 (June 2, 2025).
\43\ Id.
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The Departments considered all public input received as they
developed the policies in these proposed rules, with the exception of
prescription drug RFI comments. However, the Departments received these
prescription drug RFI comments and are separately taking them into
consideration to evaluate how to implement the Transparency in Coverage
prescription drug disclosure requirements in technical implementation
guidance or future rulemaking.
III. Provisions of the Proposed Regulations
A. Definitions
The Departments propose to define the term health insurance market
for purposes of proposed amendments to the Allowed Amount File
provision at 26 CFR 54.9815-2715A3(b)(1)(ii), 29 CFR 2590.715-
2715A3(b)(1)(ii), and 45 CFR 147.212(b)(1)(ii) (discussed in more
detail in section III.C.6. of this preamble), which would require group
health plans and health insurance issuers offering group or individual
health insurance coverage to make an out-of-network allowed amount
machine-readable file available for each health insurance market in
which plans and issuers offer a plan or coverage. Establishing a
standardized definition of the term health insurance market for this
purpose would promote consistent data organization across plans and
issuers in these market-level Allowed Amount Files.
The Departments propose to redesignate paragraphs (a)(2)(xi)
through (xxii) as paragraphs (a)(2)(xii) through (xxiii) under 26 CFR
54.9815-2715A1 and 45 CFR 147.210, respectively, and add a new
paragraph (a)(2)(xi) with the new definition. The Departments also
propose to redesignate paragraphs (a)(2)(x) through (xxi) as paragraphs
(a)(2)(xi) through (xxii) under 29 CFR 2590.715-2715A1, and to add a
new paragraph (a)(2)(x) with the new definition. Under this proposal,
health insurance market would mean, irrespective of the State, one of
the following:
<bullet> The individual market, as defined in 45 CFR 144.103 (other
than short-term, limited-duration insurance or individual health
insurance coverage that consists solely of excepted benefits).
<bullet> The large group market, as defined in 45 CFR 144.103
(other than coverage that consists solely of excepted benefits).
<bullet> The small group market, as defined in 45 CFR 144.103
(other than coverage that consists solely of excepted benefits).
<bullet> For purposes of self-insured group health plans (other
than account-based plans, as defined in 26 CFR 54.9815-2711(d)(6)(i),
29 CFR 2590.715-2711(d)(6)(i), and 45 CFR 147.126(d)(6)(i), and plans
that consist solely of excepted benefits), all self-insured group
health plans maintained by the plan sponsor.
For consistency, this definition would largely align with the
definition of the term ``insurance market'' for the purposes of the
methodology for calculating the qualifying payment amount (QPA) at 26
CFR 54.9816-6(a)(8), 29 CFR 2590.716-6(a)(8), and 45 CFR 149.140(a)(8).
As background, Code section 9816(a)(3)(E), ERISA section 716(a)(3)(E),
and PHS Act 2799A-1(a)(3)(E), as added by section 103 of the
[[Page 60443]]
No Surprises Act, generally defines the QPA as ``the median of the
contracted rates recognized by the plan or issuer, respectively
(determined with respect to all such plans of such sponsor or all such
coverage offered by such issuer that are offered within the same
insurance market (specified in subclause (I), (II), (III), or (IV) of
clause (iv)) as the plan or coverage) . . . under such plans or
coverage, respectively, on January 31, 2019,'' subject to other
criteria and increased for inflation. Paragraph (a)(3)(E)(iv)(III) of
the Code and ERISA and paragraph (a)(3)(E)(iv)(IV) of the PHS Act,
provide that in the case of a self-insured group health plan, a health
insurance market is ``other self-insured group health plans.''
When interpreting the definition of QPA for purposes of
establishing a methodology for calculating the QPA, the Departments
defined ``insurance market'' with respect to self-insured group health
plans to include, ``at the option of the plan sponsor, all self-insured
group health plans administered by the same entity (including a third
party administrator (TPA) contracted by the plan), to the extent
otherwise permitted by law, that is responsible for calculating the
qualifying payment amount on behalf of the plan.'' \44\ In other words,
the interim final rules permitted plan sponsors to use either rates
from only their own plans or rates from all plans administered by their
TPA to calculate QPAs. However, this language has been vacated by the
United States District Court for the Eastern District of Texas on the
basis that the No Surprises Act specifies that QPAs must be calculated
using the rates of ``all such plans of such sponsor.'' \45\ Therefore,
the United States District Court for the Eastern District of Texas
interpreted the No Surprises Act to restrict aggregation in that manner
for the purpose of calculating the QPA.
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\44\ 86 FR 36954 (July 13, 2021).
\45\ Texas Medical Association, a trade association representing
more than 56,000 Texas physicians and medical students; Dr. Adam
Corley, a Tyler, Texas physician; Tyler Regional Hospital, LLC, a
hospital in Tyler, Texas; LifeNet, Inc.; East Texas Air One, LLC;
Rocky Mountain Holdings, LLC; and Air Methods Corporation v. United
States Department of Health & Human Services, U.S. Department of
Labor, U.S. Department of the Treasury, and the Office of Personnel
Management, No. 6:22-cv-450-JDK (E.D. Tex. August 24, 2023) (TMA
III) (vacating portions of 26 CFR 54.9816-6T(a)(8)(iv), 29 CFR
2590.716-6(a)(8)(iv), and 45 CFR 149.140(a)(8)(iv). The Department
of Justice did not appeal the vacatur of this specific provision and
it remains in place. See also FAQs About Affordable Care Act and
Consolidated Act, 2021 Implementation Part 71 (July 30, 2025).
<a href="https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-71">https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-71</a> (until the Fifth Circuit issues its
en banc decision, extending enforcement relief for plans and issuers
that use a QPA calculated using a good faith, reasonable
interpretation of the methodology in place before the district court
decision, for items and services furnished before February 1, 2026).
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In contrast, the language of PHS Act section 2715A neither requires
nor prohibits disclosure of information described in the Affordable
Care Act section 1311(e)(3) to be aggregated by any specific market.
Therefore, in order to avoid confusion between the insurance market
applicable to the Allowed Amount File and the insurance market
applicable to the definition of QPA, which is subject to the holding of
TMA III, the Departments propose to use the term ``health insurance
market,'' rather than ``insurance market,'' for purposes of organizing
the Allowed Amount File. The Departments note that to the extent self-
insured group health plans use an entity to administer the plan, the
aggregation rules described in proposed 26 CFR 54.9815-
2715A3(b)(5)(iv), 29 CFR 2590.715-2715A3(b)(5)(iv), and 45 CFR
147.212(b)(5)(iv) would allow the entity to aggregate out-of-network
allowed amounts for more than one plan offered by a self-insured group
health plan sponsor the entity administers, including those offered by
self-insured group health plan sponsors. For clarity, the Departments
also propose to include cross-references to the market-wide definitions
in 45 CFR 144.103 where applicable.
The Departments understand that the term health insurance market is
not generally used to refer to self-insured group health plans.
However, for purposes of uniformity in the definition, to facilitate a
more streamlined and uniformed disclosure of Allowed Amount File, and
for ease of reference, the Departments propose that for purposes of
self-insured group health plans (other than account-based plans, as
defined in 26 CFR 54.9815-2711(d)(6)(i), 29 CFR 2590.715-2711(d)(6)(i),
and 45 CFR 147.126(d)(6)(i) of this subchapter, and plans that consist
solely of excepted benefits), health insurance market would mean all
self-insured group health plans maintained by the plan sponsor.
The Departments seek comment on this proposed definition.
B. Requirements for Disclosing Cost-Sharing Information to
Participants, Beneficiaries, and Enrollees
1. Disclaimer on Balance Billing
The Departments propose to amend the balance billing protection
notice that plans and issuers are currently required to include along
with the required cost-sharing information to participants,
beneficiaries, and enrollees under 26 CFR 54.9815-2715A2(b)(1)(vii)(A),
29 CFR 2590.715-2715A2(b)(1)(vii)(A), and 45 CFR 147.211(b)(1)(vii)(A).
These proposed amendments would require a statement that the cost-
sharing information in the self-service tool does not account for
potential additional amounts in situations where applicable State and
Federal law allow out-of-network providers to bill participants,
beneficiaries, or enrollees for the difference between a provider's
billed charges and the sum of the amount collected from the plan or
issuer and the amount collected from the participant, beneficiary, or
enrollee in the form of a copayment, coinsurance, or deductible amount
(the difference referred to as balance billing). These changes are
being proposed to reflect the existence of the Federal balance billing
protections set forth in the No Surprises Act, which were not yet
enacted when the current disclaimer language was finalized in the 2020
final rules. This statement would not be required if the State in which
the item or service was furnished prohibits all out-of-network
providers from balance billing for all items and services payable by
the group health plan or health insurance issuer.
Currently, under paragraph (b)(1) of this section, plans and
issuers must disclose certain cost-sharing information to participants,
beneficiaries, and enrollees, including, under paragraph (b)(1)(i), an
estimate of the participant's, beneficiary's, or enrollee's cost-
sharing liability for a requested covered item or service from a
particular provider or providers. Paragraph (b)(1)(iv) requires, in
part, that if the request is for cost-sharing information for an out-
of-network provider, the plan or issuer must disclose an out-of-network
allowed amount or any other rate that the group health plan or health
insurance issuer will pay for the requested covered item or service. As
discussed in the 2020 final rules,\46\ because cost estimates cannot
account for potential balance billing by an out-of-network provider,
current rules under paragraph (b)(1)(vii) require plans and issuers to
include a notice with a number of statements, including, under
paragraph (b)(1)(vii)(A), that out-of-network providers may bill
participants, beneficiaries, or enrollees for the difference between a
provider's billed charges and the sum of the amount collected from the
plan or issuer and the amount collected from the participant,
beneficiary, or enrollee in the form of a
[[Page 60444]]
copayment or coinsurance amount (the difference often referred to as
balance billing) and that these estimates do not account for those
potential additional amounts. Because there were existing State laws
prohibiting balance billing to some extent, as discussed in the 2020
final rules,\47\ the current rules only require this statement if
balance billing is permitted under State law.
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\46\ 85 FR 72158, 72201 (November 12, 2020).
\47\ 85 FR 72158, 72201 (November 12, 2020).
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Shortly after the 2020 final rules were published, the CAA, 2021,
which included the No Surprises Act, was signed into law on December
27, 2020. The No Surprises Act added provisions that apply to group
health plans and health insurance issuers offering group or individual
health insurance coverage, including certain limitations on cost
sharing for emergency services and for non-emergency services provided
by nonparticipating providers with respect to visits to certain
participating health care facilities.\48\ The No Surprises Act also
added certain limitations on cost sharing for air ambulance services
provided by out-of-network air ambulance providers.\49\ Additionally,
the No Surprises Act added that cost-sharing payments for emergency
services, non-emergency services furnished by a nonparticipating
provider in a participating health care facility, and air ambulance
services furnished by a nonparticipating provider must be counted
toward any in-network deductible or out-of-pocket maximums applied
under the plan or coverage (including the annual limitation on cost
sharing under section 2707(b) of the PHS Act) (as applicable),
respectively (and these in-network deductibles and out-of-pocket
maximums must be applied) in the same manner as if such cost-sharing
payments were made with respect to services furnished by a
participating provider or facility.\50\
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\48\ Codified in Code section 9816, ERISA section 716, and PHS
Act section 2799A-1.
\49\ Codified in Code section 9817, ERISA section 717, and PHS
Act section 2799A-2.
\50\ Codified in Code sections 9816 and 9817, ERISA sections 716
and 717, and PHS Act sections 2799A-1 and 2799A-2.
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In addition to the new provisions applicable to plans and issuers,
the No Surprises Act added a new Part E to title XXVII of the PHS Act
establishing requirements applicable to health care providers,
facilities, and providers of air ambulance services. Specifically, the
No Surprises Act added new PHS Act sections 2799B-1, 2799B-2, 2799B-3,
and 2799B-5, which protect participants, beneficiaries, and enrollees
in group health plans and group and individual health insurance
coverage offered by health insurance issuers from balance bills by
generally prohibiting nonparticipating providers, facilities, and
providers of air ambulance services from billing or holding liable
individuals for an amount that exceeds in-network cost sharing
determined in accordance with the No Surprises Act's cost-sharing
limitations in circumstances where the cost-sharing limitations apply.
Given that after the passage of the No Surprises Act, all
participants, beneficiaries, and enrollees of group health plans and
group and individual health insurance coverage are now protected from
certain balance billing under Federal law, the Departments propose to
amend the balance billing protection notice provision under paragraph
(b)(1)(vii)(A) to require a statement that the cost-sharing information
provided pursuant to paragraph (b)(1)(i) does not account for potential
additional amounts in situations where applicable State and Federal law
allow out-of-network providers to bill participants, beneficiaries, or
enrollees, for the difference between a provider's billed charges and
the sum of the amount collected from the plan or issuer and from the
participant, beneficiary, or enrollee in the form of a copayment,
coinsurance, or deductible amount (the difference referred to as
balance billing). Because there are circumstances under which
participants, beneficiaries, and enrollees can be balance billed under
current Federal law and State balance billing laws, the Departments
propose to clarify that this disclaimer is not required only if the
State in which the item or service is to be furnished prohibits all
out-of-network providers from balance billing for all items and
services payable by the group health plan or health insurance issuer.
The Departments understand that no States currently categorically
prohibit balance billing under all circumstances. Therefore, requiring
plans and issuers in States without such categorical prohibitions to
include this disclaimer would provide an additional layer of
transparency for consumers. It would also maintain flexibility for
plans and issuers to not include the notice if the State in which the
plan or issuer is disclosing cost-sharing information to a participant,
beneficiary, or enrollee does, subsequent to the finalization of these
proposed rules, pass a law to which all providers are subject that
prohibits balance billing for all items and services payable by the
plan or issuer.
The Departments seek comment on this proposal.
2. New Required Method and Format for Disclosing Information to
Participants, Beneficiaries, or Enrollees
The Departments propose to add new 26 CFR 54.9815-
2715A2(b)(2)(iii), 29 CFR 2590.715-2715A2(b)(2)(iii), and 45 CFR
147.211(b)(2)(iii) to require plans and issuers to make available to
participants, beneficiaries, and enrollees, at their request, the cost-
sharing estimates and other disclosures required under 26 CFR 54.9815-
2715A2(b)(1), 29 CFR 2590.715-2715A2(b)(1), and 45 CFR 147.211(b)(1)
via a phone number. Under this proposal, the information required via a
phone number would be required to be accurate at the time of the
request and provided at the time of the request. Plans and issuers
would be required to use the same telephone number that Code section
9816(e), ERISA section 716(e), and PHS Act section 2799A-1(e), as added
by section 107 of the No Surprises Act,\51\ require be indicated on any
physical or electronic plan or insurance identification (ID) card
issued to participants, beneficiaries, and enrollees for obtaining
customer assistance. The Departments also propose to redesignate
paragraph (b)(2)(ii)(D) as new paragraph (b)(2)(iv) and amend paragraph
(b)(2)(iv) to remove phone as an example of an alternative means for
providing the disclosures by which a participant, beneficiary, or
enrollee may request the disclosures required described in paragraph
(b)(1) because providing the disclosures by a phone number would be
required, as specified previously. If this new requirement is finalized
as proposed, plans and issuers would be required to make available
cost-sharing estimates via the internet-based self-service tool, a
phone number, and paper upon request.
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\51\ U.S. Department of Labor, U.S. Department of Health & Human
Services & U.S. Department of the Treasury, FAQs about Affordable
Care Act and Consolidated Appropriations Act, 2021 Implementation
Part 49 (August 20, 2021), <a href="https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf">https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf</a> and <a href="https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf">https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf</a>.
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The 2020 final rules at paragraph (b)(2) allow plans and issuers to
satisfy the disclosure requirements of paragraph (b)(1) through a self-
service tool, via paper, or through an alternative means such as phone
or email, provided the participant, beneficiary, or enrollee agrees
that disclosure through such means is sufficient to satisfy the request
and the request is fulfilled at least as rapidly as required for the
paper method. However, disclosure by such alternative means is not
required.
[[Page 60445]]
While the Departments have determined that the No Surprises Act's
price comparison tool (codified at Code section 9819, ERISA section
719, and the PHS Act section 2799A-4) and self-service tool required
under the 2020 final rules are largely duplicative, as discussed in
more detail in section III.B.3. of this preamble, the requirements of
Code section 9819, ERISA section 719, and the PHS Act section 2799A-4
expand the requirements for the disclosure of cost-sharing information
in the 2020 final rules in one prominent way. Specifically, Code
section 9819, ERISA section 719, and the PHS Act section 2799A-4
require group health plans and health insurance issuers offering group
or individual health insurance coverage to ``offer price comparison
guidance by telephone.''
The Departments intend for these proposed rules to satisfy the
requirements of the No Surprises Act to require price comparison
guidance via a telephone number, as set forth in Code section 9819,
ERISA section 719, and PHS Act section 2799A-4. Further, implementing
this requirement would respond to feedback the Departments have
received from participants, beneficiaries, and enrollees since the
publication of the 2020 final rules, indicating a limited ability to
receive cost-sharing information over the phone when requested from
plans and issuers. Requiring plans and issuers to provide cost-sharing
information in this way would further promote the price transparency
goals of providing accurate, real-time pricing to consumers, and making
that information accessible to more consumers.
To achieve these goals, these proposed rules add paragraph
(b)(2)(iii), proposing to require plans and issuers to make available
to participants, beneficiaries, and enrollees the cost-sharing
estimates and other disclosures required under paragraph (b)(1), via
phone, at the time requested and accurate at the time of their request.
In addition, at paragraph (b)(2)(iii), the Departments propose to
allow plans and issuers to limit the number of providers with respect
to which cost-sharing information for covered items and services is
provided to no fewer than 20 providers per day and, to require plans
and issuers to disclose the applicable provider-per-day limit to the
participant, beneficiary, or enrollee when the request for information
is made. A similar 20 provider limit currently applies with respect to
paper requests at 26 CFR 54.9815-2715A2(b)(2)(ii), 29 CFR 2590.715-
2715A2(b)(2)(ii), and 45 CFR 147.211(b)(2)(ii). In the 2020 final
rules, the Departments determined based on comments that ``limiting
paper request to 20 providers per request is a reasonable approach to
balancing the burdens on plans and issuers with the benefits of
providing consumers with enough information to be able to compare cost
and provider options.'' \52\ The Departments have determined that the
process by which plans and issuers would generate information
responsive to requests for receiving cost-sharing information over the
phone should be similar to the process for generating such information
to deliver via paper, given the practicalities of generating a response
on paper and over the phone. Therefore, the Departments propose to
adopt the limitations for paper disclosure at 26 CFR 54.9815-
2715A2(b)(2)(ii), 29 CFR 2590.715-2715A2(b)(2)(ii), and 45 CFR
147.211(b)(2)(ii) for phone disclosure such that plans and issuers may
limit the number of providers with respect to which cost-sharing
information for covered items and services is provided to no fewer than
20 providers per day and, plans and issuers would be required to
disclose the applicable provider-per-day limit to the participant,
beneficiary, or enrollee when the request for information is made. This
proposal is intended to balance the added burden to plans and issuers
of this additional method of delivery with ensuring that participants,
beneficiaries, and enrollees that opt to receive cost-sharing
information over the phone have access to the same information as those
that request such information via the paper method. The Departments
note that nothing in these proposed rules precludes a participant,
beneficiary, or enrollee from obtaining cost-sharing information from
more than one method, consistent with the requirements for each method.
Similarly, for consistency with the requirements for the paper method
of delivery under the 2020 final rules, the Departments also propose to
require plans and issuers to satisfy requests for cost-sharing
information over the phone at the time of the phone call in order to
ensure that participants, beneficiaries, and enrollees receive
information as quickly as possible.
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\52\ 85 FR 72158, 72207 (November 12, 2020).
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Accordingly, the Departments propose to require plans and issuers
to make available to participants, beneficiaries, and enrollees the
cost-sharing estimates and other disclosures described in paragraph
(b)(1) via phone at the time of the request and accurate at the time of
the request, and in accordance with the method and format requirements
in paragraphs (b)(2)(i)(A) through (C).
The Departments are also proposing to require health plans and
health insurance issuers to make cost-sharing estimates and other
disclosures available over the phone at a number designated on the ID
card for individuals to seek assistance. Code section 9816(e), ERISA
section 716(e), and PHS Act section 2799A-1(e) (insurance ID card
requirements), as added by section 107 of the No Surprises Act,
separately require plans and issuers to include in clear writing, on
any physical or electronic plan or insurance identification card issued
to participants, beneficiaries, or enrollees, certain information
including a phone number and website address for individuals to seek
consumer assistance. Therefore, plans and issuers are already required
to have a phone number designated on any physical or electronic plan or
insurance identification card and, under this proposal, plans and
issuers should make available cost-sharing estimates and other
disclosures at the request of the participant or beneficiary via such
phone number, if finalized. These provisions apply with respect to plan
years (in the individual market, policy years) beginning on or after
January 1, 2022.\53\ The Departments expect that requiring plans and
issuers to use an existing phone number would allow them to leverage
existing workflows and would make it easier for participants,
beneficiaries, and enrollees to obtain the cost information they are
seeking.
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\53\ U.S. Department of Labor, U.S. Department of Health & Human
Services & U.S. Department of the Treasury, FAQs About Affordable
Care Act and Consolidated Appropriations Act, 2021 Implementation
Part 49 (Aug. 20, 2021), <a href="https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf">https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf</a> and <a href="https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf">https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf</a>. FAQ Part 49 provided that, pending any
implementing rulemaking, the Departments would not deem a plan or
issuer to be out of compliance with ID card requirements where a
plan or issuer includes on any ID card, among other things, a
telephone number and website address for individuals to seek
consumer assistance and access additional applicable deductibles and
maximum out-of-pocket limits.
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The Departments request comment on whether this proposal should
include phone service standards to ensure that consumers have access to
timely and reliable information. In particular, the Departments request
comment on what such standards should include and what parameters
should be applied to each criterion. The Departments also request
comment on whether there are other relevant Federal, State, or local
[[Page 60446]]
standards for phone service quality or any industry practices that the
Departments should consider.
3. Compliance With PHS Act Section 2799A-4, ERISA Section 719, and Code
Section 9819
The Departments propose to add new 26 CFR 54.9815-2715A2(c)(7), 29
CFR 2590.715-2715A2(c)(7), and 45 CFR 147.211(c)(7) stating that a plan
or issuer satisfies the requirements of Code section 9819, ERISA
section 719, and the PHS Act section 2799A-4, as added by section 114
of the No Surprises Act by providing the information required under
paragraph (b)(1) of this section to participants, beneficiaries, and
enrollees in accordance with the method and format requirements
specified in paragraph (b)(2) of this section.
The 2020 final rules added 26 CFR 54.9815-2715A2(b)(1) and (b)(2),
29 CFR 2590.715-2715A2(b)(1) and (b)(2), and 45 CFR 147.211(b)(1) and
(b)(2), which created a comprehensive set of requirements for plan and
issuer disclosure of cost-sharing information through an internet-based
self-service tool, and in paper form, upon request.\54\ Paragraph
(b)(1) of the 2020 final rules requires the disclosure of cost-sharing
information, which is accurate at the time the request is made, with
respect to a participant's, beneficiary's, or enrollee's cost-sharing
liability for covered items and services, and which must reflect any
cost-sharing reductions the enrollee would receive.
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\54\ 26 CFR 54.9815-2715A2(b)(1) and (2), 29 CFR
2590.2715A2(b)(1) and (2), and 45 CFR 147.211(b)(1) and (2).
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Under paragraph (b)(2) of the 2020 final rules, disclosures must be
made available through a self-service tool on an internet website that
provides real-time responses based on cost-sharing information that is
accurate at the time of the request, in plain language, without a fee,
or in paper form, at the user's request. This paragraph requires
certain functionality to make searching using the self-service tool
easier, including searching by billing code or descriptive term, and
refining and reordering search results based on geographic proximity of
in-network providers, and the amount of the participant's,
beneficiary's, or enrollee's estimated cost-sharing liability for the
covered item or service, to the extent the search for cost-sharing
information for covered items or services returns multiple results.\55\
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\55\ 26 CFR 54.9815-2715A2(b)(2)(i), 29 CFR
2590.2715A2(b)(2)(i), and 45 CFR 147.211(b)(2)(i).
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Code section 9819, ERISA section 719, and PHS Act section 2799A-4,
as added by section 114 of the No Surprises Act, require plans and
issuers to offer price comparison guidance by telephone and make
available on the plan's or issuer's website a ``price comparison tool''
that allows individuals enrolled under such plan or coverage offered by
the plan or issuer to compare the amount of cost sharing that the
individual would be responsible for paying for an item or service
furnished by an in-network provider (hereinafter ``No Surprises Act
price comparison tool''). This requirement was applicable with respect
to plan years (and in the individual market, policy years) beginning on
or after January 1, 2022.
The Departments announced on August 20, 2021, in FAQs Part 49 that
the price comparison methods required by the No Surprises Act price
comparison tool are largely duplicative of the self-service tool
component of the 2020 final rules except that the information under the
No Surprises Act price comparison tool must also be provided over the
telephone upon request.\56\ Therefore, the Departments indicated they
intended to propose rulemaking requiring that the same pricing
information that is available through the self-service tool or in paper
form, as described in the 2020 final rules, must also be provided over
the phone upon request. The Departments also announced that, as an
exercise of enforcement discretion, they would defer enforcement of the
requirement that plans and issuers make available a price comparison
tool by internet website, in paper form, or telephone pursuant to the
No Surprises Act until plan years (or in the individual market, policy
years) beginning on or after January 1, 2023, to align the enforcement
date of the No Surprises Act price comparison disclosure requirements
with the enforcement date of the self-service tool described in the
2020 final rules.
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\56\ U.S. Department of Labor, U.S. Department of Health & Human
Services & U.S. Department of the Treasury, FAQs About Affordable
Care Act and Consolidated Appropriations Act, 2021 Implementation
Part 49 (Aug. 20, 2021), <a href="https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf">https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf</a> and <a href="https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf">https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf</a>.
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Further, the Departments announced their intention to propose
rulemaking and seek public comment regarding whether compliance with
the self-service tool requirements of the 2020 final rules should
satisfy the analogous requirements set forth Code section 9819, ERISA
section 719, and PHS Act section 2799A-4. Plans and issuers have built
and developed tools to comply with the requirements of the 2020 final
rules and have anticipated, since the release of FAQs Part 49, that the
Departments would propose in a future rulemaking that plans and issuers
satisfy the No Surprises Act price comparison tool requirement by
providing the required disclosures to participants, beneficiaries, and
enrollees through the self-service tool as required in paragraphs
(b)(1) and (2) of the 2020 final rules. Given this, the Departments
have determined that requiring plans and issuers to build a second
self-service tool would impose significant unnecessary burden and cause
considerable confusion for consumers on the purposes of the two tools.
Thus, it is appropriate that compliance with the self-service tool
described in the 2020 final rules and as amended in these proposed
rules should satisfy compliance with the No Surprises Act price
comparison tool requirements.
Therefore, as discussed in section II.B.2. of this preamble, to
align with the No Surprises Act price comparison tool requirements the
Departments propose to require in new paragraph (b)(2)(iii) that plans
and issuers make available to participants, beneficiaries, and
enrollees the cost-sharing information and other disclosures required
under paragraph (b)(1) via the same telephone number that Code section
9816(e), ERISA section 716(e), and PHS Act section 2799A-1(e), as added
by section 107 of the No Surprises Act, requires be indicated on any
physical or electronic plan or insurance identification card issued to
a participant, beneficiary, or enrollee for obtaining customer
assistance. The Departments also propose at new paragraph (c)(7) that a
group plan or health insurance issuer satisfies the requirements of
Code section 9819, ERISA section 719, and PHS Act section 2799A-4 by
providing the information required in paragraph (b)(1) to participants,
beneficiaries, and enrollees in accordance with the method and format
requirements specified in paragraph (b)(2).
The Departments acknowledge that, while PHS Act section 2715A does
not apply to grandfathered health plans and health insurance issuers
offering grandfathered individual and group health insurance coverage,
Code section 9819, ERISA section 719, and PHS Act section 2799A-4 do.
The Departments have also stated that the requirements of PHS Act
section 2715A are largely duplicative to those of Code section 9819,
ERISA section 719, and PHS Act section 2799A-4, except that the former
does not require information to be disclosed by phone. Therefore, if
this rule is finalized, grandfathered health plans and issuers offering
grandfathered
[[Page 60447]]
health insurance coverage may comply with the requirements of PHS Act
2715A, as codified in 26 CFR 54.9815-2715A2, 29 CFR 2590.716-2715A2 and
45 CFR 147.211, to satisfy the requirements of Code section 9819, ERISA
section 719, and PHS Act section 2799A-4. The Departments request
comments on whether any additional provisions are necessary to assist
grandfathered health plans and health insurance issuers in complying
with the requirements of 26 CFR 54.9815-2715A2, 29 CFR 2590.716-2715A2
and 45 CFR 147.211. The Departments seek comment on all aspects of this
proposal.
4. Applicability
The Departments propose to revise 26 CFR 54.9815-2715A2(c)(1), 29
CFR 2590.715-2715A2(c)(1), and 45 CFR 147.211(c)(1) to state that the
proposed amendments to (b)(1)(vii)(A), and new paragraphs (b)(2)(iii),
(b)(2)(iv), and (c)(7) of this section would apply for plan years (in
the individual market, policy years) beginning on or after January 1,
2027. Until such time, the current provisions of paragraph (b) of this
section continue to apply.
With respect to proposed provisions at new paragraph (b)(2)(iii),
the Departments understand that most plans and issuers already have in
place a consumer assistance telephone number for participants,
beneficiaries, and enrollees to receive benefit information pursuant to
Code section 9816(e), ERISA section 716(e), and PHS Act section 2799A-
1(e), as added by section 107 of the No Surprises Act, and as clarified
in previously issued guidance.\57\ Because plans and issuers can
leverage the operations of an existing consumer assistance phone
number, the Departments have determined that the proposed applicability
date appropriately balances the need for improved access to cost-
sharing estimates for consumers who wish to access this information
over the phone with the time necessary for plans and issuers to make
the administrative and operational changes to implement this proposal.
Similarly, because most plans are already required to disclose the
balance billing disclosures under the 2020 final rules, the Departments
have determined that the proposed applicability date for new paragraph
(b)(1)(vii)(A) that would amend the balance billing disclosure is
appropriate and reasonable.
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\57\ U.S. Department of Labor, U.S. Department of Health & Human
Services & U.S. Department of the Treasury, FAQs About Affordable
Care Act and Consolidated Appropriations Act, 2021 Implementation
Part 49 (Aug. 20, 2021), <a href="https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf">https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf</a> and <a href="https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/affordable-care-act-faqs-49-2021.pdf">https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/affordable-care-act-faqs-49-2021.pdf</a>.
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The Departments propose to make new paragraph (c)(7) applicable for
plan years (in the individual market, policy years) beginning on or
after January 1, 2027. The Departments selected this date because once
plans and issuers are required to provide cost-sharing information by
phone on the same date pursuant to proposed new paragraph (b)(2)(iii),
it would be reasonable for the Departments to consider a plan or
issuer's compliance with paragraphs (b)(1) and (2) to constitute
compliance with the No Surprises Act price comparison tool as required
by Code section 9819, ERISA section 719, and PHS Act section 2799A-4.
The Departments seek comment on this proposed applicability date
for these proposed provisions.
C. Requirements for Public Disclosure of In-Network Rates and
Historical Allowed Amount Data for Covered Items and Services From In-
and Out-of-Network Providers
1. Provider Network-Level Reporting for the In-Network Rate Files
The current In-network Rate File provision at 26 CFR 54.9815-
2715A3(b)(1)(i), 29 CFR 2590.715-2715A3(b)(1)(i), and 45 CFR
147.212(b)(1)(i) requires plans and issuers to make available on a
public website a machine-readable file that discloses in-network
provider rates for covered items and services, with the exception of
prescription drugs that are subject to a fee-for-service reimbursement
arrangement. The Departments propose to amend the introductory language
of paragraph (b)(1)(i) to require plans and issuers to make available
an In-network Rate File for each provider network maintained or
contracted by the group health plan or health insurance issuer. This
proposed change is intended to reduce the size and total number of In-
network Rate Files, allow file users to more efficiently aggregate and
analyze the data, and align reporting more closely to how data is
typically reported by hospitals pursuant to the Hospital 2019 and 2023
Price Transparency rules \58\ under 45 CFR part 180.
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\58\ 84 FR 65524 (November 17, 2019) and 88 FR 81540 (November
22, 2023).
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a. Reducing File Size
As discussed in section I.A. of this preamble, file size is the
most common concern that the Departments have heard from interested
parties regarding the current In-network Rate Files. These files are
often very large, making them challenging for users to download,
analyze, and store.\59\ In-network Rate File sizes often represent many
terabytes of data a month for a single issuer,\60\ and many exceed most
local storage and processing capabilities.\61\ Additionally, each
issuer may have hundreds of separate files for each plan or coverage it
offers, making aggregation and analysis highly resource intensive.\62\
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\59\ See Fred Diamond, Payers' Price Transparency Data Still Not
User-Friendly, Say Researchers (Feb. 7, 2023), <a href="https://www.fiercehealthcare.com/payers/health-insurance-plans-price-transparency-data-still-not-user-friendly-say-researchers">https://www.fiercehealthcare.com/payers/health-insurance-plans-price-transparency-data-still-not-user-friendly-say-researchers</a>; See
alsoDavid Muhlestein, Improving Price Transparency Data:
Recommendations From Practice, Health Affairs. (Mar. 19, 2025),
<a href="https://www.healthaffairs.org/content/forefront/improving-price-transparency-data-recommendations-practice">https://www.healthaffairs.org/content/forefront/improving-price-transparency-data-recommendations-practice</a>.
\60\ See David Muhlestein, Improving Price Transparency Data:
Recommendations from Practice, Health Affairs (Mar. 19, 2025),
<a href="https://www.healthaffairs.org/content/forefront/improving-price-transparency-data-recommendations-practice">https://www.healthaffairs.org/content/forefront/improving-price-transparency-data-recommendations-practice</a>.
\61\ See Aileen Y. Choi, Karen Manthe-Cohen, & Robert J. Rosso,
Technical Challenges with Private Health Insurance Price
Transparency Data, Congressional Research Service (June 13, 2025),
<a href="https://www.congress.gov/crs-product/R48570">https://www.congress.gov/crs-product/R48570</a>.
\62\ See Aileen Y. Choi, Karen Manthe-Cohen, & Robert J. Rosso,
Technical Challenges with Private Health Insurance Price
Transparency Data, Congressional Research Service (June 13, 2025),
<a href="https://www.congress.gov/crs-product/R48570">https://www.congress.gov/crs-product/R48570</a>.
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The Departments have determined that the size of the In-network
Rate File can be highly dependent on how it is organized. 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.\63\ This means that when plans and issuers
organize In-network Rate Files by plan ID, they often repeat the same
negotiated rates across multiple plan files, which leads to significant
duplicative data throughout the In-network Rate Files. The Departments
have received consistent feedback about the challenges related to file
size, and some of that feedback has suggested that the disclosure
requirements be amended to organize In-network Rate Files by provider
network, whereby each file would contain all rates negotiated by the
reporting entity for that provider network, rather than having a file
for each plan ID.\64\
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\63\ See Lester Adler, Michael Fiedler, & Benjamin Ippolito,
Assessing Recent Health Care Proposals from the House Committee on
Energy and Commerce (May 25, 2023), <a href="https://www.brookings.edu/articles/assessing-recent-health-care-proposals-from-the-house-committee-on-energy-and-commerce">https://www.brookings.edu/articles/assessing-recent-health-care-proposals-from-the-house-committee-on-energy-and-commerce</a>.
\64\ See Mark Robben, Learnings from MRF Land, Serif Health
(Mar. 31, 2023), <a href="https://www.serifhealth.com/blog/learnings-from-mrf-land">https://www.serifhealth.com/blog/learnings-from-mrf-land</a>; Georgetown University, Transparency in Coverage:
Recommendations for Improving Access to and Usability of Health Plan
Price Data (Jan. 9, 2023), <a href="https://georgetown.app.box.com/s/1ezsggz1c7smsaexkr8rght15sokgusl">https://georgetown.app.box.com/s/1ezsggz1c7smsaexkr8rght15sokgusl</a>.
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[[Page 60448]]
Currently, the technical implementation guidance for the In-network
Rate File allows plans and issuers flexibility to leverage a Table of
Contents File to combine common negotiated rates across multiple In-
network Rate Files, rather than publishing negotiated rates
individually for each plan ID. This allows issuers to avoid duplicating
prices within and across plans by linking the files for each plan that
uses a given provider network to an underlying file of in-network
prices.\65\ Interested parties report that this reduces the total
amount of data that must be analyzed to estimate market-level
prices.\66\ Many plans and issuers currently leverage this
optimization. The Departments conducted an internal analysis in 2024
that sampled In-network Rate Files market wide and found that 83
percent of issuers sampled were leveraging a Table of Contents to
organize their files.
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\65\ See Lester Adler, Michael Fiedler, & Benjamin Ippolito,
Assessing Recent Health Care Proposals from the House Committee on
Energy and Commerce (May 25, 2023), <a href="https://www.brookings.edu/articles/assessing-recent-health-care-proposals-from-the-house-committee-on-energy-and-commerce">https://www.brookings.edu/articles/assessing-recent-health-care-proposals-from-the-house-committee-on-energy-and-commerce</a>.
\66\ Id.
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The Departments agree that where multiple plans share the same
negotiated rates under an umbrella provider network, organizing the In-
network Rate Files by provider network would decrease the size of the
files, often significantly while still maintaining data integrity.
Therefore, to standardize this method of organizing files across all
plans and issuers, the Departments propose to amend the introductory
language of paragraph (b)(1)(i) to require plans and issuers to make an
In-network Rate File available for each provider network maintained or
contracted by the plan or issuer. This approach would also reduce the
total number of In-network Rate Files because there are far more plans
and policies available than there are distinct, separately managed
provider networks.\67\
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\67\ See Jianhui Zhu, Yuting Zhang, & Daniel Polsky, Networks in
ACA Marketplaces Are Narrower for Mental Health Care Than for
Primary Care, 36 Health Affairs 9 (Sept. 2017). (Researchers found
that, using 2016 <a href="http://HealthCare.gov">HealthCare.gov</a> data, 531unique provider networks
were used by 281 different issuers, covering 5,022 qualified health
plans in the Federally-facilitated Marketplaces).
---------------------------------------------------------------------------
To make it easier for file users to determine in advance of
downloading a provider network-level In-network Rate File whether it
contains data of interest to them, the Departments propose to
redesignate paragraphs (b)(1)(i)(A) through (C) as paragraphs
(b)(1)(i)(B) through (D), respectively, and add a new paragraph
(b)(1)(i)(A) requiring each In-network Rate File to include the common
provider network name for which negotiated rate information is
included. The Departments seek comment on whether there is another term
or code, in addition to or instead of the common provider network name,
that would help producers or file users identify specific provider
networks. The Departments expect plans and issuers to define what
constitutes a separate provider network according to their current
business practices. The Departments solicit comments on whether
additional limitations on what constitutes a separate provider network
should be required.
In order to maintain the connection of rates to plans under this
proposal, as further discussed in section III.C.2. of this preamble,
the Departments also propose to amend redesignated paragraph
(b)(1)(i)(B) to require plans and issuers to identify, for each
provider network for which the plan or issuer must publish an In-
network Rate File, each of the plan's or issuer's coverage options that
use that network. This would allow file users to cross reference the
rates for a particular plan or policy of interest to its in-network
rates.
The Departments also propose conforming amendments to redesignated
paragraphs (b)(1)(i)(C) and (D). Specifically, the Departments propose
to amend redesignated paragraph (b)(1)(i)(C) to specify that each In-
network Rate File must include a billing code and a plain language
description for each covered item or service included in the file,
rather than under each coverage option offered by plans and
issuers.\68\ The Departments propose to amend redesignated paragraph
(b)(1)(i)(D) to specify that all applicable rates must be included for
each covered item or service included in the file, rather than for all
items or services the plan or issuer covers, since not all applicable
rates for items or services the plan or issuer covers are negotiated
under a given provider network. Since plans and issuers would be
required to make an In-network Rate File available for each provider
network they maintain or contract with, they would ultimately still be
required to disclose all applicable rates for items or services they
cover, but those rates may not all be reported in every In-network Rate
File organized by provider network.
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\68\ ``Plain language'' means ``written and presented in a
manner calculated to be understood by the average participant,
beneficiary, or enrollee'' under current 26 CFR 54.9815-
2715A1(a)(2)(xx), 29 CFR 2590.715-2715A1(a)(2)(xix), and 45 CFR
147.210(a)(2)(xx) (redesignated as 26 CFR 54.9815-2715A1(a)(2)(xxi),
29 CFR 2590.715-2715A1(a)(2)(xx), and 45 CFR 147.210(a)(2)(xxi)
under these proposed rules).
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The Departments are also proposing special aggregation rules for
self-insured group health plans, which is described in more detail in
section III.C.11. of this preamble.
b. Other Improvements for File Users
The Departments have determined that, overall, provider network-
level files would simplify data aggregation and analysis for
researchers and other groups interested in analyzing specific provider
networks, which is important to facilitate consumer's plan selection
decisions. For example, the Departments understand that organizing In-
network Rate Files by network would make it easier for employers and
plan sponsors to analyze the negotiated rates of different networks to
make informed decisions about which plans to offer their employees,
potentially favoring networks with more competitive pricing, in
addition to opening the door for employers to bring health care
purchasing decisions in house through direct contracting with provider
groups.\69\ This proposal may be of particular benefit to smaller
employers, who have historically had less leverage to negotiate
directly with providers due to lower patient volume, by empowering them
with access to network-level pricing data for negotiations.
---------------------------------------------------------------------------
\69\ See Samuel Haitoff, Jay Puthumana, Abhishek Dama, Yang
Wang, et al., Employer-Provider Direct Contracting: Practice and
Policy, Health Affairs Forefront (Apr. 1, 2025), <a href="https://www.healthaffairs.org/content/forefront/employer-provider-direct-contracting-practice-and-policy">https://www.healthaffairs.org/content/forefront/employer-provider-direct-contracting-practice-and-policy</a>; See also Cynthia A. Fisher & Arthur
B. Laffer, Healthcare Price Transparency and Competition: How Real
Price Transparency Can Reduce American Healthcare Costs More Than $1
Trillion Annually and Extend Life Expectancy (Oct. 2023), <a href="https://static1.squarespace.com/static/60065b8fc8cd610112ab89a7/t/652f0429f8ca6d62668bb43d/1697580073561/PRA_Fisher-Laffer+Healthcare+Price+Transparency+Paper_FINAL.pdf">https://static1.squarespace.com/static/60065b8fc8cd610112ab89a7/t/652f0429f8ca6d62668bb43d/1697580073561/PRA_Fisher-Laffer+Healthcare+Price+Transparency+Paper_FINAL.pdf</a>; See also
Christopher Whaley, Geetika Sachdev, Michael Bartlett, & Ge Bai,
It's Time for Employers to Bring Health Care Decisions In-House,
Health Affairs Forefront (Sept. 22, 2022), <a href="https://www.healthaffairs.org/content/forefront/s-time-employers-bring-health-care-decisions-in-house">https://www.healthaffairs.org/content/forefront/s-time-employers-bring-health-care-decisions-in-house</a>.
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Similarly, organizing in-network rate information by provider
network would help service providers advise clients on network
selection and cost management strategies. Likewise, researchers,
academics, and policymakers would be better positioned to analyze
pricing variations across different providers, specialties, and
geographic areas within the same provider network and between
[[Page 60449]]
different networks that may inform policy interventions aimed at cost
containment and market regulations.
The Departments understand that State insurance regulators may also
be able to use network-level data to inform and improve rate review
processes, optimize public option plans, and potentially guide
antitrust enforcement.\70\ Currently, State regulators may review unit
cost and utilization trends submitted by issuers as part of their rate
review process. Access to more consumable provider rates by network and
product type in the In-network Rate Files may make it easier for
regulators to validate unit cost trends, and to use those trends to
assess the reasonableness of premium increases. Also, the reduction of
duplicative data in the In-network Rate Files may make it easier for
States to monitor rates to identify collusive behaviors, as well as
help establish benchmarks for negotiations with providers as part of
State oversight activities related to coverage programs.
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\70\ Colorado's State law mandates insurers provide in-network
allowed amounts data tailored for State-specific analyses. See
Colorado Rev. Statutes Sec. 10-16-168(4); Medical Group Management
Association, Unlocking the Potential of Healthcare Price
Transparency Data (Dec. 5, 2024), <a href="https://www.mgma.com/articles/unlocking-the-potential-of-healthcare-price-transparency-data">https://www.mgma.com/articles/unlocking-the-potential-of-healthcare-price-transparency-data</a>
(noting that Colorado uses price transparency data ``to inform rate
reviews, optimize [its] public option plans, and potentially guide
antitrust enforcement,'' according to Colorado Insurance
Commissioner Michael Conway); See also Sabrina Corlette, The Health
Plan Price Transparency Files Are a Mess: States Can Help Make Them
Better, Health Affairs Forefront (May 5, 2023), <a href="https://chirblog.org/the-health-plan-price-transparency-data-files-are-a-mess-states-can-help-make-them-better">https://chirblog.org/the-health-plan-price-transparency-data-files-are-a-mess-states-can-help-make-them-better</a>.
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c. Better Alignment With Hospital Price Transparency Reporting
Organizing in-network rates by provider network would also promote
standardization and streamlined comparison of pricing information
across hospitals and health plans, consistent with Executive Order
14221.\71\ As discussed in section I.A. of this preamble, many
interested parties have called for better alignment among Federal price
transparency requirements to avoid consumer confusion and duplication
of effort.\72\
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\71\ Exec. Order No. 14221, 90 FR 11005 (February 28, 2025).
\72\ See American Hospital Association, Fact Sheet: Hospital
Price Transparency (Feb. 24, 2023), <a href="https://www.aha.org/fact-sheets/2023-02-24-fact-sheet-hospital-price-transparency">https://www.aha.org/fact-sheets/2023-02-24-fact-sheet-hospital-price-transparency</a>.
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Currently, the Hospital Price Transparency machine-readable files
required under 45 CFR part 180 generally disclose rates at the provider
network level.\73\ By contrast, rates disclosed pursuant to the 2020
final rules are currently disclosed at the more granular plan or policy
level, which presents complications for data matching. For example, a
single set of Hospital Price Transparency rates negotiated between a
plan and a hospital system could appear multiple times, under several
different plan names, in an issuer's current In-network Rate Files,
without any reference to the provider network name in the Hospital
Price Transparency file. Standardization of price disclosures for
providers, plans, issuers, and procedures at the same level would allow
for more accurate comparisons between the different types of
transparency files.
---------------------------------------------------------------------------
\73\ 45 CFR 180.50.
---------------------------------------------------------------------------
The Departments seek comment on all aspects of these proposals.
2. HIOS Identifier and Product Type
The Departments propose to amend the identifying coverage
information that plans and issuers must disclose in the In-network Rate
Files at redesignated 26 CFR 54.9815-2715A3(b)(1)(i)(B), 29 CFR
2590.715-2715A3(b)(1)(i)(B), and 45 CFR 147.212(b)(1)(i)(B), and in the
Allowed Amount Files at 26 CFR 54.9815-2715A3(b)(1)(ii)(A), 29 CFR
2590.715-2715A3(b)(1)(ii)(A), and 45 CFR 147.212 (b)(1)(ii)(A).
Specifically, the Departments propose to remove the requirement for
plans and issuers to report the 14-digit Health Insurance Oversight
System (HIOS) identifier (ID) or, if the 14-digit HIOS ID is not
available, the 5-digit HIOS ID, and instead require them to report the
HIOS identifier associated with each coverage option for which data is
being reported in a form and manner as specified in guidance issued by
the Departments. The Departments also propose to add a requirement for
plans and issuers to report the product type (for example, Health
Maintenance Organization (HMO) or Preferred Provider Organization
(PPO)) associated with the coverage option for which data is being
reported.
The 2020 final rules require plans and issuers to include their 14-
digit HIOS ID in the In-network Rate File and Allowed Amount File
unless the plan or issuer does not have a 14-digit HIOS ID available,
in which case the plan or issuer must include the HIOS ID at the 5-
digit issuer level.\74\ If a plan or issuer does not have a HIOS ID, it
must use its Employer Identification Number (EIN). The Departments
received significant comments on GitHub about requiring the 14-digit
HIOS ID,\75\ stating that this requirement would result in an enormous
amount of redundant data because provider rates are not established
based on distinct plan designs, but rather they are applied across
multiple plan offerings. The Departments have determined that the
number of HIOS digits that plans and issuers must report is a technical
implementation detail that should be removed from regulation and set
forth in technical implementation guidance to better maintain the
Departments' flexibility to determine appropriate technical reporting
requirements and to make refinements in response to changes in
technology or health care industry business practice. This is in line
with the Departments' general approach as described in the preamble to
the 2020 final rules, to provide specific technical direction in
separate technical implementation guidance, rather than in rulemaking,
in order to keep pace with and respond to technological
developments.\76\ The Departments propose to amend the reporting
requirements to specify that for each applicable coverage option
offered by a group health plan or health insurance issuer, the plan or
issuer must report the name and the HIOS identifier, or, if no HIOS
identifier is available, the EIN.
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\74\ The 14-digit HIOS ID is comprised of the following: (1)
issuer's ID number (first 5 digits, for example, 12345), (2)
issuer's State abbreviation (next 2 digits, for example, WA); (3)
issuer's three-digit Product ID (next 3 digits, for example, 001);
and (4) a four-digit sequence number that is the ``Component ID''
(last 4 digits, for example, 0001). Thus, HIOS ID at the 14-digit
level would be 12345WA0010001, 10 digits would be 12345WA001, 7
digits would be 12345WA, and 5 digits would be 12345.
\75\ See GitHub Users, GitHub Discussion: Updating to allow for
reporting at the 10-digit HIOS level vs the 14-digit level #447,
GitHub, <a href="https://github.com/CMSgov/price-transparency-guide/pull/447#issuecomment-1102946004">https://github.com/CMSgov/price-transparency-guide/pull/447#issuecomment-1102946004</a> (last updated Apr. 19, 2022); See also
GitHub Users, GitHub Discussion: In-Network-Rates File: Schema and
Definition of Plan Name and HIOS/EIN #44, GitHub, <a href="https://github.com/CMSgov/price-transparency-guide/discussions/44#discussioncomment-645647">https://github.com/CMSgov/price-transparency-guide/discussions/44#discussioncomment-645647</a> (last updated Mar. 28, 2022).
\76\ 85 FR 72158, 72221 (November 12, 2020).
---------------------------------------------------------------------------
In addition to the HIOS digit amendment, the Departments propose to
amend redesignated paragraph (b)(1)(i)(B) and amend paragraph
(b)(1)(ii)(A) to newly require plans and issuers to report the product
type for each applicable coverage option offered by a plan or issuer in
the In-network Rate File and Allowed Amount File, respectively. The
Departments have received feedback that requiring plans and issuers to
disclose health plan product types (for example, HMO, PPO) would
promote more meaningful transparency around the health care pricing
information disclosed in the In-
[[Page 60450]]
network Rate and Allowed Amount Files. The Departments agree with this
feedback, as product types dictate the fundamental relationship between
the payer and the provider regarding patient access and volume, which
are key leverage points in contract negotiations over rates. For
example, in instances where HMOs may have narrow networks, providers
contracting with such HMOs are likely to see increased patient volume,
which may encourage such providers to contract at a lower rate with the
HMO than they might with a PPO that is less likely to result in higher
patient volume. Product types also dictate the fundamental relationship
between payer and patient, with differences, for example, related to
patient choice, cost-sharing responsibilities, and accessibility.
Additionally, the Departments have heard from interested parties
that although negotiated rates under a provider network are typically
consistent across plans and policies with respect to a specific item or
service and a specific provider, these rates may differ based on
product type. As such, interested parties have stated that requiring
plans and issuers to include the product type for each applicable
coverage option offered by the plan or issuer in the In-network Rate
File would allow users to account for those differences.
In addition to providing context on how prospective rates differ,
the Departments have determined that adding a product type to the
Allowed Amount Files would allow file users to compare how historical
provider reimbursements differ based on product type. Disclosing
product type data in the Allowed Amount Files would enable more
accurate and actionable comparisons for employers, researchers, and
regulators so they can understand true market pricing for specific
product types. In addition, not only could users of these data make
comparisons of allowed amounts across different product types for a
specific service for a single payer, they could also make comparisons
for the same service based on product type across different payers. For
example, an employer or plan sponsor offering a PPO plan could
benchmark their out-of-network costs specifically against other PPO
plans in the market, rather than a generalized average that includes
potentially lower-cost HMOs, and they could use this information to
make future plan coverage determinations. Furthermore, with allowed
amounts tied to product type, employers and plan sponsors would better
understand the actual tradeoffs in plan design--that is, not just
premiums and network access, but also how much the plan will pay when
employees go out-of-network. One study on out-of-network behavioral
health care in employer-sponsored coverage observed that balance
billing was higher for HMO enrollees versus non-HMO enrollees.\77\ With
the inclusion of data on plan type, employers could use historical
allowed amounts segmented by plan type to evaluate the level of
financial protection offered for out-of-network services.
---------------------------------------------------------------------------
\77\ See Sarah A. Friedman, Hao Xu, Fernando Azocar & Susan L.
Ettner, Quantifying Balance Billing for Out-of-Network Behavioral
Health Care in Employer-Sponsored Insurance, 73 Psychiatric Services
1019 (2022).
---------------------------------------------------------------------------
The Departments acknowledge that product type is often used in the
fully insured market, typically to comply with laws that apply to
insured products. The Departments also acknowledge that the definitions
of these product types may differ from State to State and seek comment
on whether that would present difficulties for plans and issuers in
determining which product type to indicate. The Departments also seek
comment on whether possible inconsistency between State definitions of
certain product types would cause confusion among file users. Under
ERISA, self-insured plans are not currently required to be identified
by product type and these traditional classifications may not
necessarily apply or otherwise accurately describe a self-insured
benefit arrangement. As such, the Departments seek comment on whether
self-insured plans generally identify benefit package options by
product type, whether there is any existing nomenclature that self-
insured plans could use to accurately identify the type of benefit
arrangement being offered, and whether it is practical to extend this
requirement to self-insured plans.
3. Percentage-of-Billed-Charges Arrangements
The Departments propose to amend redesignated 26 CFR 54.9815-
2715A3(b)(1)(i)(D)(1), 29 CFR 2590.715-2715A3(b)(1)(i)(D)(1), and 45
CFR 147.212(b)(1)(i)(D)(1) (redesignated from paragraph (b)(1)(i)(C)(1)
as discussed in section III.C.1. of this preamble) of the In-network
Rate Files provision to require that in-network rates must be reflected
as a dollar amount except for contractual arrangements under which a
plan or issuer agrees to pay an in-network provider a percentage of
billed charges and is not able to assign a dollar amount to an item or
service prior to a bill being generated. In such circumstances, plans
and issuers must report a percentage number, in lieu of a dollar
amount, in the form and manner as specified in guidance issued by the
Departments.
Paragraph (b)(1)(i)(C) of the current In-network Rate File
provision requires plans and issuers to publish all applicable rates,
which may include one or more of the following: negotiated rates,
underlying fee schedule rates, or derived amounts for all covered items
and services in the In-network Rate File. The Departments specified in
the preamble to the 2020 final rules that the In-network Rate File
requirement applies to plans and issuers regardless of the type of
payment model or models under which they provide reimbursement.\78\
---------------------------------------------------------------------------
\78\ 85 FR 72158, 72226 (November 12, 2020).
---------------------------------------------------------------------------
Under the 2020 final rules, paragraph (b)(1)(i)(C)(1) of the In-
network Rate File provision requires that rates must be reflected in
the In-network Rate File as dollar amounts and if the rate is subject
to change based upon participant, beneficiary, or enrollee-specific
characteristics, that these dollar amounts should be reflected as the
base negotiated rate applicable to the item or service prior to
adjustments for participant, beneficiary, or enrollee-specific
characteristics. While there are alternative reimbursement arrangements
that do not have a dollar amount associated with particular items and
services before the item or service is furnished, a dollar amount can
still be determined in some instances under these arrangements.
Accordingly, in the preamble to the 2020 final rules, the Departments
provided a list of alternative reimbursement arrangements and
summarized general reporting expectations for these arrangements, while
acknowledging that the list was not exhaustive, as there may be other
alternative reimbursement or contracting arrangements in use.\79\
Specifically, the Departments summarized the general reporting
expectations, including for bundled payment arrangements and capitation
arrangements (including sole capitation arrangements and partial
capitation arrangements), reference-based pricing without a defined
network, reference-based pricing with a defined network, and value-
based purchasing. For example, the preamble to the 2020 final rules
clarified that for payment arrangements under which adjustments are
made after care is provided, the plan or issuer should disclose the
base negotiated rate before adjustments are applied.\80\
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\79\ Id.
\80\ 85 FR 72158, 72228 (November 12, 2020).
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[[Page 60451]]
After the 2020 final rules were issued, interested parties used
GitHub \81\ and other forums to raise to the Departments' attention
alternative payment arrangements under which reporting a current and
accurate dollar amount for items and services in the In-network Rate
File before the item or service is furnished may not be possible and
requested guidance from the Departments on how to meet the disclosure
requirements for such arrangements. Specifically, interested parties
questioned the Departments on how to report dollar amounts for
negotiated rates that result from certain ``percentage-of-billed-
charges'' contract arrangements, under which a dollar amount can be
determined only retrospectively because the agreement between the plan
or issuer and the in-network provider states that the plan or issuer
will pay a fixed percentage of the billed charges. It is the
Departments' understanding that these types of arrangements are not
uncommon for certain types of items or services (such as low-volume
procedures or high-cost, outlier inpatient care).
---------------------------------------------------------------------------
\81\ GitHub Users, GitHub Discussion: If negotiated rate is
based on percentage of charge--then how would this be reported in
the in-network file? #23, GitHub, <a href="https://github.com/CMSgov/price-transparency-guide/discussions/23">https://github.com/CMSgov/price-transparency-guide/discussions/23</a> (last updated Apr. 15, 2022);
GitHub Users, GitHub Discussion: Percentage of Billed Charges #315,
GitHub,<a href="https://github.com/CMSgov/price-transparency-guide/discussions/315">https://github.com/CMSgov/price-transparency-guide/discussions/315</a> (last visited Dec. 8, 2025); GitHub Users, GitHub
Discussion: Using Claims History for In-Network File when unable to
extract rates (that is percent of billed charges) #197, GitHub,
<a href="https://github.com/CMSgov/price-transparency-guide/discussions/197">https://github.com/CMSgov/price-transparency-guide/discussions/197</a>
(last updated Sep. 30, 2022).
---------------------------------------------------------------------------
On April 19, 2022, the Departments issued FAQs Part 53 \82\ to
provide an enforcement safe harbor for satisfying the reporting
requirements for plans and issuers that use an alternative payment
arrangement that does not permit them to derive with accuracy specific
dollar amounts contracted for covered items and services in advance of
the provision of that item or service, or that otherwise cannot
disclose specific dollar amounts according to the file formatting
requirements as provided in the Departments' technical implementation
guidance through GitHub. This guidance further advised that for
contractual arrangements under which a plan or issuer agrees to pay an
in-network provider a percentage of billed charges and is not able to
assign a dollar amount to an item or service prior to a bill being
generated, plans and issuers may report a percentage number, in lieu of
a dollar amount.
---------------------------------------------------------------------------
\82\ U.S. Department of Labor, U.S. Department of Health & Human
Services & U.S. Department of the Treasury, FAQs about Affordable
Care Act Implementation Part 53 (April 19, 2022), <a href="https://www.cms.gov/files/document/faqs-part-53.pdf">https://www.cms.gov/files/document/faqs-part-53.pdf</a> and <a href="https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-53">https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-53</a>.
---------------------------------------------------------------------------
On September 27, 2023, the Departments clarified in FAQs Part 61
\83\ that whether a plan or issuer is able to comply with the
requirement to disclose certain rates as dollar amounts is a fact-
specific determination and that the Departments would exercise
enforcement discretion with respect to this requirement on a case-by-
case basis, without any categorical ``safe harbor.'' The Departments
instructed plans and issuers that are unable to determine dollar
amounts for the applicable rate element to continue to follow the
existing technical implementation guidance on GitHub.
---------------------------------------------------------------------------
\83\ U.S. Department of Labor, U.S. Department of Health & Human
Services & U.S. Department of the Treasury, FAQs about Affordable
Care Act Implementation Part 61 (September 27, 2023), <a href="https://www.cms.gov/files/document/faqs-about-affordable-care-act-implementation-part-61.pdf">https://www.cms.gov/files/document/faqs-about-affordable-care-act-implementation-part-61.pdf</a> and <a href="https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-61">https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-61</a>.
---------------------------------------------------------------------------
Since issuing the guidance in 2023, the Departments have continued
to receive feedback from interested parties that arrangements where a
dollar amount is unable to be determined in advance are not uncommon
and should be reflected in the data. Therefore, the Departments propose
to amend redesignated 26 CFR 54.9815-2715A3(b)(1)(i)(D)(1), 29 CFR
2590.715-2715A3(b)(1)(i)(D)(1), and 45 CFR 147.212(b)(1)(i)(D)(1) to
state that applicable rates must be reflected as dollar amounts, with
respect to each covered item or service that is furnished by an in-
network provider, except for contractual arrangements under which a
group health plan or health insurance issuer agrees to pay an in-
network provider a percentage of billed charges and is not able to
assign a dollar amount to an item or service prior to a bill being
generated. In these instances, plans and issuers must report a
percentage number, in lieu of a dollar amount, in a form and manner as
specified in guidance issued by the Departments.
While the Departments recognize the importance of allowing plans
and issuers to disclose non-dollar amount rates when a dollar amount is
unknown in advance, the Departments reiterate that plans and issuers
must disclose rates as a dollar amount whenever a dollar amount can be
calculated in advance, including when a negotiated base rate can be
calculated prior to adjustments. Further, the Departments emphasize
that this proposed change, if finalized, would permit plans and issuers
to disclose an applicable rate in a non-dollar amount only in instances
where the applicable rate is a percentage of billed charges and expect
that plans and issuers report all other applicable rates as dollar
amounts consistent with the form and manner specified in guidance
issued by the Departments.
The Departments seek comment on this proposal.
4. Enrollment Totals
The Departments propose to add new 26 CFR 54.9815-
2715A3(b)(1)(i)(E), 29 CFR 2590.715-2715A3(b)(1)(i)(E), and 45 CFR
147.212(b)(1)(i)(E) requiring plans and issuers to include in each In-
network Rate File, current numerical enrollment totals, as of the date
the file is posted, for each coverage option offered by a plan or
issuer represented in the In-network Rate File. Such numerical
enrollment totals must include the number of participants,
beneficiaries, and enrollees (including all dependents) in the coverage
option offered by a plan or issuer.
Affordable Care Act sections 1311(e)(3)(A)(iii) and (iv) require
health plans seeking certification as a qualified health plan to submit
to the Exchange, the Secretary, the State insurance commissioner, and
make available to the public, accurate and timely disclosure of data on
enrollment and disenrollment. PHS Act section 2715A, incorporated into
ERISA section 715 and Code section 9815, gives the Departments the
statutory authority to require a plan or coverage that is not offered
through an Exchange to submit the information required under Affordable
Care Act section 1311(e)(3) to the Secretary and the relevant State's
insurance commissioner, and to make that information available to the
public. However, the 2020 final rules do not require the disclosure of
enrollment data.
Since the publication of the 2020 final rules, the Departments have
received feedback from interested parties on the importance of
additional data elements that would allow users to weigh different
plans and coverage options to understand their relative influence on
the overall landscape of pricing in health insurance, such as plan
enrollment numbers, in line with the goals stated in the 2020 final
rules.\84\ The Departments understand that requiring the reporting of
plan enrollment counts would enable file users to develop analytical
models that prioritize negotiated rates for health care
[[Page 60452]]
items and services based on the number of individuals covered by the
corresponding plan or coverage, thereby focusing analysis on prices
with the broadest impact on the insured population. Plans with higher
enrollments may have a larger impact on negotiated rates, due to
relative market power, approximate size of the overall market, and
other factors. Additionally, this contextual information would expand
opportunities to conduct analysis and compare rates across ``like''
plans. The Departments understand, based on feedback from interested
parties, that enrollment data would be particularly useful in analyzing
the small group and individual markets, where small differences may
have pronounced impacts on trends and patterns. The Departments are
specifying that the numerical enrollment totals must include the number
of participants, beneficiaries, and enrollees (including all
dependents) to distinguish from other reporting requirements plans and
issuers are required to comply with.
---------------------------------------------------------------------------
\84\ 85 FR 72158, 72161 (November 12, 2020); See Gary Claxton,
Lynne Cotter, & Shameek Rakshit, Challenges with Effective Price
Transparency Analyses, Peterson-KFF Health System Tracker (Feb. 25,
2025), <a href="https://www.healthsystemtracker.org/brief/challenges-with-effective-price-transparency-analyses/">https://www.healthsystemtracker.org/brief/challenges-with-effective-price-transparency-analyses/</a>.
---------------------------------------------------------------------------
Therefore, the Departments have determined that requiring
disclosure of this additional data in the In-network Rate File would
provide important context to the health care pricing information and
propose to require in new paragraph (b)(1)(i)(E) that plans and issuers
are required to disclose enrollment totals for each coverage option
they offer represented in the In-network Rate File. These proposed
rules would require that plans and issuers include enrollment totals as
of the date the In-network Rate File is posted. The Departments seek
comment on the feasibility of including the enrollment total as of the
date the file is posted and whether an enrollment total on a different
specified date would be more feasible for file producers and more
useful to the data users. The Departments also solicit comment on this
proposal in general.
5. Excluded Provider Information
The Departments propose to add new 26 CFR 54.9815-
2715A3(b)(1)(i)(F), 29 CFR 2590.715-2715A3(b)(1)(i)(F), and 45 CFR
147.212(b)(1)(i)(F) to the In-network Rate Files provision that would
require plans and issuers to exclude from each In-network Rate File a
provider and their negotiated rate (provider-rate combination) for an
item or service, if the plan or issuer determines it is unlikely that
such provider would be reimbursed for the item or service based on the
scope of the provider's license or area of specialty. The Departments
further propose that plans and issuers must make such a determination
using their internal provider taxonomy that is typically used during
the claims adjudication process. The Departments have determined that
excluding provider-rate combinations that are not likely to result in a
reimbursement is necessary to limit unnecessary information that
inflates file size and limits the accessibility of the data in the In-
network Rate File.
These proposed rules at paragraph (b)(1)(i)(F) would require plans
and issuers to use their internal provider taxonomy that is typically
used during the claims adjudication process to determine which
provider-rate combinations to exclude from the In-network Rate File.
The internal provider taxonomy is part of the claims adjudication
workflow, in which the plan or issuer assesses whether the billed item
or service (represented by a billing code) aligns with the specialty of
the rendering provider (represented by a provider taxonomy code). If
the specialty does not meet the plan or issuer's requirements for that
item or service, the claim may be denied. For example, the Departments
expect that a plan or issuer's internal provider taxonomy would be
unlikely to reimburse a claim submitted for a heart surgery submitted
from a podiatrist because the billing code associated with a heart
surgery would not match with a taxonomy code for a podiatrist.
The Departments understand that it is standard business practice
for the internal provider taxonomy maintained by a plan or issuer to
identify provider specialties using a standardized code set established
by the National Uniform Claim Committee (NUCC).\85\ The NUCC maintains
standard provider taxonomy codes, which are used to define a provider's
area of specialty.\86\ Provider taxonomy codes are ten characters in
length structured into three distinct ``levels'' including provider
grouping, classification, and area of specialization.\87\ The
Departments understand that when a provider submits a claim for
reimbursement to a plan or issuer, the provider must include their NUCC
code and the billing code for the item or service along with certain
other information. The Departments understand that plans and issuers
then compare the NUCC provider taxonomy code and billing code included
from the claim against their internal provider taxonomy mappings to
determine if the claim can proceed through the next step of the payment
adjudication process.
---------------------------------------------------------------------------
\85\ The NUCC establishes and maintains standard provider
taxonomy codes, which are used to define a provider's area of
specialty. Provider taxonomy codes are ten characters in length
structured into three distinct ``levels'' including provider
grouping, classification, and area of specialization. See National
Uniform Claim Committee, Health Care Provider Taxonomy, <a href="https://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40">https://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40</a> (last visited Dec. 8, 2025).
\86\ See National Uniform Claim Committee, Health Care Provider
Taxonomy, <a href="https://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40">https://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40</a> (last visited Dec. 8, 2025).
\87\ See National Uniform Claim Committee, Health Care Provider
Taxonomy, <a href="https://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40">https://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40</a> (last visited Dec. 8, 2025).
---------------------------------------------------------------------------
The Departments have observed that several third-party data
aggregation vendors successfully demonstrated various methods to
efficiently filter existing machine-readable file content by utilizing
NUCC provider taxonomy codes, demonstrating these codes can help
determine whether a provider is likely going to be eligible for
reimbursement for a specific service or procedure.\88\ Therefore, the
Departments have determined this may be a viable approach to excluding
certain provider-rate combinations.
---------------------------------------------------------------------------
\88\ See Sameer Mukhi, Zombie Hunting: Filtering Approaches for
Price Transparency Data, Serif Health Blog (Sept. 20, 2024), <a href="https://www.serifhealth.com/blog/zombie-hunting-filtering-approaches-for-price-transparency-data/">https://www.serifhealth.com/blog/zombie-hunting-filtering-approaches-for-price-transparency-data/</a>; Matt Najarian, Clinically Implausible
Rates Are Getting the Boot, Turquoise Health Blog (Aug. 30, 2023),
<a href="https://blog.turquoise.health/clinically-implausible-rates-are-getting-the-boot/">https://blog.turquoise.health/clinically-implausible-rates-are-getting-the-boot/</a>.
---------------------------------------------------------------------------
The 2020 final rules at 26 CFR 54.9815-2715A3(b)(1)(i)(C)(1), 29
CFR 2590.715-2715A3(b)(1)(i)(C)(1), and 45 CFR 147.212(b)(1)(i)(C)(1)
require plans and issuers to disclose all applicable rates for in-
network providers, including negotiated rates, underlying fee schedule
rates, or derived amounts, to the extent they may be used for purposes
of determining provider reimbursement or cost-sharing for in-network
providers. The 2020 final rules do not specify any exclusions to this
requirement. As a result, the Departments have observed and have
received feedback that In-network Rate Files often include negotiated
rates for providers for items and services that those providers would
not likely be reimbursed for because the items and services are outside
their specialty (for example, a mental health provider billing for knee
replacement).\89\ The Departments understand that plans and issuers
frequently negotiate applicable rates at the provider organization
level (such as large multi-specialty physician groups or integrated
health systems) for every provider who is a member of that
organization, regardless of whether that
[[Page 60453]]
provider would be likely to be reimbursed for that item or service.
---------------------------------------------------------------------------
\89\ See Sameer Mukhi, Zombie Hunting: Filtering Approaches for
Price Transparency Data, Serf Health Blog (Sept. 20, 2024), <a href="https://www.serifhealth.com/blog/zombie-hunting-filtering-approaches-for-price-transparency-data/">https://www.serifhealth.com/blog/zombie-hunting-filtering-approaches-for-price-transparency-data/</a>.
---------------------------------------------------------------------------
Under the 2020 final rules, these rates are required to be
disclosed. As a result, the Departments and interested parties have
observed that there are many provider-rate combinations that are not
meaningful for transparency purposes and impose unnecessary burden on
both producers and users of the In-network Rate File. This
overinclusion leads to significant file sizes, where In-network Rate
Files are consistently enlarged by the inclusion of these unlikely
provider-rate combinations. One early examination found that plans and
issuers were posting approximately a petabyte (PB) \90\ of information
each month, in part due to the inclusion of what it refers to as
``clinically implausible rates.'' \91\ In September 2024, the
Departments analyzed a subset of In-network Rate Files and discovered
that 73 percent of hematologists' negotiated rates were for 500 billing
codes for services for which they would be unlikely to be reimbursed
for. Another researcher reported that 96.5 percent of rates reported in
the In-network Rate Files were for services with respect to providers
who would be unlikely to be reimbursed for those services based on
their specialty.\92\ The Departments understand from feedback from
interested parties that excessive file size creates network bandwidth
and data storage problems for file producers and users alike, including
significant costs associated with hosting, downloading, or analyzing
significant amounts of data.
---------------------------------------------------------------------------
\90\ One petabyte (PB) is a unit of digital information equal to
1,000 terabytes (TB) in the decimal system (or 1,000,000 gigabytes
(GB)). In binary terms, which is sometimes used in computing, 1 PB
equals 1,024 terabytes.
\91\ Adam Geitgey, A Petabyte of Health Insurance Prices Per
Month, Turquoise Health Blog (July 11, 2023), <a href="https://blog.turquoise.health/a-petabyte-of-health-insurance-rates-a-month/">https://blog.turquoise.health/a-petabyte-of-health-insurance-rates-a-month/</a>.
\92\ See David Muhlestein, Improving Price Transparency Data:
Recommendations From Practice, Health Affairs Forefront (Mar. 19,
2025), <a href="https://www.healthaffairs.org/content/forefront/improving-price-transparency-data-recommendations-practice">https://www.healthaffairs.org/content/forefront/improving-price-transparency-data-recommendations-practice</a>.
---------------------------------------------------------------------------
In addition, the Departments understand that excess data of limited
use poses an unnecessary barrier to analyzing these files for users
seeking to understand health care price variation, and to carrying out
research on pricing data.\93\ For example, one researcher identified a
negotiated rate for a Caesarean section (C-section) for a neurological
institute that was almost ten times the median rate for a C-section in
that geographic region.\94\ The researcher identified that the
neurological institute must share the same rate for a C-section with
all the providers in their parent organization per their contract even
though neurologists would be unlikely to be reimbursed for a C-
section.\95\ These rates may distort patterns, averages, and medians
when conducting market-wide analyses, leading to an inaccurate
understanding of health care prices.\96\
---------------------------------------------------------------------------
\93\ See Gary Claxton, Lynne Cotter, & Shameek Rakshit,
Challenges with Effective Price Transparency Analyses, Peterson-KFF
Health System Tracker (Feb. 25, 2025), <a href="https://www.healthsystemtracker.org/brief/challenges-with-effective-price-transparency-analyses/">https://www.healthsystemtracker.org/brief/challenges-with-effective-price-transparency-analyses/</a>; See also David Muhlestein, Improving Price
Transparency Data: Recommendations From Practice, Health Affairs
Forefront (Mar. 19, 2025), <a href="https://www.healthaffairs.org/content/forefront/improving-price-transparency-data-recommendations-practice">https://www.healthaffairs.org/content/forefront/improving-price-transparency-data-recommendations-practice</a>.
\94\ See Adam Stein, Beyond the Trillion Prices: Pricing C-
Sections in America, D01thUb Blog (Oct. 13, 2022), <a href="https://www.dolthub.com/blog/2022-10-03-c-sections/">https://www.dolthub.com/blog/2022-10-03-c-sections/</a>.
\95\ Id.
\96\ See James Hines, Zombie Rates: A Data-Driven Approach to
Healthcare Price Transparency, Gigasheet Blog (Jan. 27, 2025),
<a href="https://www.gigasheet.com/post/price-transparency-zombie-rates">https://www.gigasheet.com/post/price-transparency-zombie-rates</a>.
---------------------------------------------------------------------------
The Departments recognize that the 2020 final rules specifying that
plans and issuers disclose all negotiated rates for all covered items
and services for all in-network providers have led to the disclosure of
rates beyond what was intended by the Departments. The Departments have
determined that excluding provider-rate combinations for services that
providers are unlikely to perform or be reimbursed for--because they
fall outside their specialty--would significantly reduce the size of
the In-network Rate Files. This significant decrease in file size would
also reduce the storage space and computer processing resources needed
to generate, store, and analyze In-network Rate Files, reducing burden
for file producers and users alike.
Therefore, the Departments propose to revise the content
requirements for the In-network Rate File to require plans and issuers
to exclude provider-rate combinations for an item or service if the
provider would be unlikely to be reimbursed for the item or service
given the provider's area of specialty, according to the plan's or
issuer's internal provider taxonomy that is typically used during the
claims adjudication process.
In order for users of the In-network Rate Files to understand how
plans and issuers constructed the files according to this new proposed
requirement, the Departments also propose to add new 26 CFR 54.9815-
2715A3(b)(2)(iii), 29 CFR 2590.715-2715A3(b)(2)(iii), and 45 CFR
147.212(b)(2)(iii), to require plans and issuers to publish a taxonomy
machine-readable file. As discussed in more detail in section III.C.7.
of this preamble, this new machine-readable file would disclose the
mapping of billing codes to internal provider taxonomy codes, providing
transparency into how plans and issuers determined which provider-rate
combinations for covered items and services have been excluded from the
In-network Rate Files based on the plan's or issuer's taxonomy rules.
The Departments seek comment on all aspects of this proposal. The
Departments are particularly interested in feedback from interested
parties on whether there are plans or issuers that do not map provider
specialties to billing codes within their claims adjudication process
or use different code sets, and whether there could be a way to
standardize the provider specialty mapping to billing code process. The
Departments are also interested in whether there are alternative
approaches to excluding any provider that has a rate for an item or
service that interested parties consider to not be a meaningful rate.
While the Departments have included a discussion of some potential
alternatives in section VI.D.2. of this preamble, the Departments are
interested in feedback from interested parties on the relative burdens
and benefits of alternative approaches to both producers and file
users. The Departments are also interested in any concerns that parties
may have with a proposal to require plans and issuers to make such
exclusions at all. For instance, do file users have concerns about
plans and issuers intentionally or inadvertently over-excluding
provider-rate combinations from the In-network Rate File? Additionally,
do file users recommend alternative approaches to best achieve the
goals of transparency as set out in the 2020 final rules? For example,
are there alternative approaches that will help meet the Departments'
goals of limiting unnecessary information that inflates file size,
without limiting the accessibility of the data, and promoting
meaningful transparency of in-network rate pricing information?
6. Out-of-Network Allowed Amount Machine-Readable File
The Departments propose to make several amendments to the Allowed
Amount File provision at 26 CFR 54.9815-2715A3(b)(1)(ii), 29 CFR
2590.715-2715A3(b)(1)(ii), and 45 CFR 147.212(b)(1)(ii) to increase the
amount of historical out-of-network claims data disclosed in the files,
including a proposal to lower the threshold for including claims from
20 to 11 different
[[Page 60454]]
claims per item or service, a proposal to increase the reporting period
from 90 days to 6 months, a proposal to increase the lookback period
from 180 days to 9 months, and a proposal to require reporting at the
health insurance market level, rather than the plan or policy level.
Lastly, the Departments propose to remove the phrase ``and provider''
from paragraph (b)(1)(ii)(C) to clarify that the claims threshold
pertains to the number of claims for an item or service overall for the
file, not the number of claims for an item or service from a particular
provider.
The 2020 final rules at paragraph (b)(1)(ii)(C) require plans and
issuers to disclose on a public website a machine-readable file that
includes, among other things, each unique out-of-network allowed amount
with respect to covered items or services furnished by a particular
out-of-network provider during the 90-day time period that begins 180
days prior to the publication date of the Allowed Amount File. In
addition, plans and issuers must omit such data in relation to a
particular item or service and provider when including it would require
the plan or issuer to report payment of out-of-network allowed amounts
in connection with fewer than 20 different claims for payments for an
item or service under a single plan or coverage.\97\ Current rules at
paragraph (b)(4)(iii) also permit, but do not require, plans and
issuers to satisfy the public disclosure requirements of paragraph
(b)(1)(ii) by making available out-of-network allowed amount data that
has been aggregated to include information from more than one plan or
policy, under certain circumstances.
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\97\ 26 CFR 54.9815-2715A3(b)(1)(ii)(C), 29 CFR 2590.715-
2715A3(b)(1)(ii)(C), and 45 CFR 147.212(b)(1)(ii)(C).
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a. Reducing the Claims Threshold
Initially, the Departments established the 20-claims threshold to
limit the possibility that individual participants, beneficiaries, and
enrollees may be identified through the public disclosure of historical
allowed amount data. In the 2019 proposed rules, the Departments
proposed to require plans and issuers to omit out-of-network allowed
amounts from the Allowed Amount File in relation to a particular item
or service and provider when including this data would require the plan
or issuer to report payment of out-of-network allowed amounts in
connection with fewer than 10 different claims for payments.\98\ The
Departments requested comment on whether a higher minimum claims
threshold, such as a threshold of 20 claims, would better mitigate
privacy concerns and minimize complexity in complying with Federal or
State privacy laws without compromising the integrity of the compiled
information.\99\ As discussed in the 2020 final rules, some commenters
expressed concerns about maintaining Health Insurance Portability and
Accountability Act (HIPAA) protections on the Allowed Amount File due
to the small number of claims associated with specific items and
services for out-of-network providers.\100\ Several commenters stated
that the threshold of 10 different claims to require public disclosure
of unique historical allowed amounts would be too low to protect
consumers' protected health information. Based on commenters' concerns,
the Departments determined that increasing the claims threshold from 10
to 20 claims in the 2020 final rules would better balance the policy
goal of transparency with the need to protect participants,
beneficiaries, and enrollees from the possibility of being re-
identified through the data included in the Allowed Amount File.\101\
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\98\ 84 FR 65464, 65481 (November 27, 2019).
\99\ Id.
\100\ 85 FR 72158, 72233 (November 12, 2020).
\101\ Id.
---------------------------------------------------------------------------
The Departments clarified in technical implementation guidance that
while a plan or issuer with fewer than 20 claims for a particular item
or service must omit information on payment of out-of-network allowed
amounts for that item or service, the Allowed Amount File must still be
produced pursuant to paragraph (b)(1)(ii)(C); however, information in
the file would be minimal due to the lack of information to
report.\102\ The Departments reasoned that the file must be created so
that file users know that the plan or issuer does not have any claims
that meet the 20-claims threshold, and that maintenance of such files
would be minimal.\103\
---------------------------------------------------------------------------
\102\ Centers for Medicare & Medicaid Services. Technical
Clarifications Question 23: After we compile all our allowed amounts
and billed charges for the Allowed Amount file, how do we adjust the
file to make sure we have taken into account the 20-claim
threshold?, <a href="https://www.cms.gov/priorities/healthplan-price-transparency/overview/resources/technical-clarification">https://www.cms.gov/priorities/healthplan-price-transparency/overview/resources/technical-clarification</a> (last
visited Dec. 8, 2025).
\103\ Centers for Medicare & Medicaid Services. Technical
Clarifications Question 15: If a plan does not meet the 20-claim
threshold for any of its allowed amounts, must a file be produced?,
<a href="https://www.cms.gov/priorities/healthplan-price-transparency/overview/resources/technical-clarification">https://www.cms.gov/priorities/healthplan-price-transparency/overview/resources/technical-clarification</a> (last visited Dec. 8,
2025).
---------------------------------------------------------------------------
Since the publication of the 2020 final rules, however, the
Departments have received feedback and observed that many plans and
issuers produce Allowed Amount Files with limited to no out-of-network
claims data, which the Departments have determined is due in part to
the 20-claims threshold. Given the limited data available, file users
are unable to perform meaningful analyses using out-of-network
data.\104\ This is because there are too many ``gaps'' in out-of-
network data in the file, which occur whenever there are fewer than 20
claims for a specific out-of-network item or service for a given plan.
---------------------------------------------------------------------------
\104\ Matthew Robben, Learnings from MRF Land, Serif Health Blog
(Mar. 31, 2023), <a href="https://www.serifhealth.com/blog/learnings-from-mrf-land">https://www.serifhealth.com/blog/learnings-from-mrf-land</a>.
---------------------------------------------------------------------------
Out-of-network price transparency data is vital for employers,
researchers, and regulators to analyze health care spending, benchmark
costs, and inform future policy decisions. This data offers new insight
into actual health care expenditures, including a window into the price
of an item or service in the context of an arms-length transaction
between a provider and a plan or issuer who have not negotiated the
rate, and where there is therefore no discount associated with the
advantage to a provider of being ``in network.'' \105\ Employers and
plan sponsors can use this data to benchmark costs, refine benefit
designs, and negotiate more effectively with administrators. Health
care providers and service providers can use it to estimate what they
might be reimbursed and what their patients or their participants,
beneficiaries, or enrollees, respectively, might be charged for out-of-
network care.\106\
---------------------------------------------------------------------------
\105\ Zack Cooper, Hao Nguyen, Nathan Shekita & Fiona Scott
Morton, Out-of-Network Billing and Negotiated Payments for Hospital-
Based Physicians, 39 Health Affairs 24 (2020) (published Dec. 16,
2019), <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00507">https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00507</a>.
\106\ Rebecca Hodes, Demystifying ``Allowed Amounts'' in Out-of-
Network Billing, Mentaya Blog (Apr. 1, 2025), <a href="https://www.mentaya.com/blog/demystifying-allowed-amounts-in-out-of-network-billing">https://www.mentaya.com/blog/demystifying-allowed-amounts-in-out-of-network-billing</a>.
---------------------------------------------------------------------------
Therefore, to increase the volume of allowed amount data available,
the Departments propose to amend paragraph (b)(1)(ii)(C) to lower the
minimum claims threshold for a particular item or service under a
single plan or coverage to 11 different claims for a particular item or
service in a single health insurance market. The proposed 11-claims
threshold would align with the CMS cell suppression policy, which sets
minimum thresholds for the display of CMS data by researchers or other
custodians of CMS data sets, such as Limited Data Set (LDS) files.\107\
The policy stipulates that
[[Page 60455]]
no cell (such as admittances, discharges, patients, services, etc.)
containing a value of 1 to 10 can be reported directly.\108\ This
policy is a safeguard designed to prevent the identification of
individual Medicare or Medicaid beneficiaries when CMS data is shared
publicly \109\ and helps ensure compliance with Federal privacy laws,
such as HIPAA, by reducing the risk of re-identification of individuals
from aggregated data.
---------------------------------------------------------------------------
\107\ Centers for Medicare & Medicaid Services, Limited Data Set
(LDS) Files, <a href="https://www.cms.gov/data-research/files-for-order/data-disclosures-and-data-use-agreements-duas/limited-data-set-lds">https://www.cms.gov/data-research/files-for-order/data-disclosures-and-data-use-agreements-duas/limited-data-set-lds</a> (last
modified July 7, 2025); Research Data Assistance Center (ResDAC),
CMS Cell Size Suppression Policy (Jan. 26, 2024), <a href="https://resdac.org/articles/cms-cell-size-suppression-policy">https://resdac.org/articles/cms-cell-size-suppression-policy</a>.
\108\ Id.
\109\ Id.
---------------------------------------------------------------------------
The Departments have determined that the proposed 11-claims
threshold, combined with the proposal to require reporting by health
insurance market type discussed later in this section of the preamble,
would provide sufficient protection against the disclosure of sensitive
patient information. Under the proposal to require reporting by health
insurance market type, data disclosed in the Allowed Amount Files would
not be directly associated with a single plan or policy when two or
more plans or policies are aggregated into one file (as discussed in
more detail later in this section of the preamble). Instead, the data
would be aggregated to a broader health insurance market type (such as
``individual market'' or ``large group market''). For example, a unique
allowed amount and billed charge for a given item or service furnished
by a given provider might be associated with ``Large Group Market
offered by Insurer A,'' rather than ``Insurer A's Employer X Gold PPO
Plan.'' This high-level aggregation would provide a strong shield for
patient privacy.
Additionally, the Departments also note that, as specified in
current paragraph (b)(1)(ii)(C), disclosure of such information would
not be required if doing so would violate applicable health information
privacy laws. This is consistent with paragraph (c)(3), which specifies
that, among other things, nothing in 26 CFR 54.9815-2715A3, 29 CFR
2590.715-2715A3, or 45 CFR 147.212 alters or otherwise affects a plan's
or issuer's duty to comply with requirements under other applicable
State or Federal laws, including those governing the privacy or
security of information required to be disclosed under this section.
As such, the Departments have determined that lowering the claims
threshold in this way would strike a better balance between protecting
sensitive health information and allowing for a more comprehensive and
useful dataset to support the end goals of price transparency.
Lastly, the Departments propose to delete ``and provider'' from the
parenthetical language in (b)(1)(ii)(C) to more clearly specify that
the claims threshold pertains to the number of claims for an item or
service overall for the file, not the number of claims for an item or
service from a particular provider. This change would reflect the
Departments' current policy (other than the proposed changes to this
paragraph discussed elsewhere in this section of the preamble), and is
proposed as a technical clarification.\110\ The parenthetical in
paragraph (b)(1)(ii)(C) would be revised to specify that a plan or
issuer must omit out-of-network allowed amount and billed charge data
in relation to a particular item or service if including it would
require the plan or issuer to report payment of out-of-network allowed
amounts in connection with fewer than 11 different claims for payment
of that item or service in a single health insurance market. The
Departments seek comment on this proposal.
---------------------------------------------------------------------------
\110\ Centers for Medicare & Medicaid Services. Technical
Clarifications Question 23: After we compile all our allowed amounts
and billed charges for the Allowed Amount file, how do we adjust the
file to make sure we have taken into account the 20-claim
threshold?, <a href="https://www.cms.gov/priorities/healthplan-price-transparency/overview/resources/technical-clarification">https://www.cms.gov/priorities/healthplan-price-transparency/overview/resources/technical-clarification</a> (last
visited Dec. 8, 2025).
---------------------------------------------------------------------------
b. Increasing the Reporting Period
The Departments also propose to amend paragraph (b)(1)(ii)(C) to
specify that plans and issuers would be required to include in the
Allowed Amount File allowed amounts and billed charges with respect to
covered items or services furnished by out-of-network providers during
the 6-month time period that begins 9 months prior to the publication
date of the file. This amendment would increase the reporting period
from 90 days to 6 months and increase the lookback period from 180 days
to 9 months. In the preamble to the 2020 final rules, the Departments
noted that they would monitor the implementation of the lookback period
for the Allowed Amount Files and may revisit it if the 90-day reporting
period and 180-day lookback period failed to yield sufficient out-of-
network data on allowed amounts.\111\ By approximately doubling the
reporting period from 90 days to 6 months and shifting the lookback
period from 180 days to 9 months, the Departments expect that more out-
of-network claims for items and services would meet the required
threshold for reporting requirements, meaning there would be more data
to populate the Allowed Amount Files.
---------------------------------------------------------------------------
\111\ 85 FR 72158, 72230 (November 12, 2020).
---------------------------------------------------------------------------
The Departments welcome comment on all aspects of this proposal.
The Departments are also particularly interested in feedback on the
impact of the proposed amendment to the required reporting cadence
(proposed to be quarterly as discussed in section III.C.10. of this
preamble) on the proposed changes to the lookback period. For example,
since the proposed quarterly reporting period would require reporting 6
months' worth of data every 3 months, the Departments seek comment on
whether a potential duplication of out-of-network allowed amounts
across multiple files would present any difficulties for the analysis
of the data, such as calculating averages or annual amounts.
c. Aggregating Data by Requiring Reporting by Market Type
Lastly, the Departments propose to amend the introductory language
in paragraph (b)(1)(ii) to require plans and issuers to aggregate their
allowed amount reporting at the health insurance market level (as
defined in proposed new 26 CFR 54.9815-2715A1(a)(2)(xi), 29 CFR
2590.715-2715A1(a)(2)(x), and 45 CFR 147.210(a)(2)(xi) and discussed in
section III.A. of this preamble). Specifically, under paragraph
(b)(1)(ii), plans and issuers would be required to make available an
Allowed Amount File for each health insurance market in which a plan or
coverage is offered. The Departments also propose to make conforming
amendments in paragraphs (b)(1)(ii)(A) through (C) to indicate that
each Allowed Amount File for a given health insurance market must
include information aggregated across the coverage options offered by
the plan or issuer in that market, rather than all coverage options
offered by the plan or issuer.
The Departments have received feedback from interested parties
indicating that aggregating health insurance out-of-network claims by
health insurance market type--specifically (1) individual market, (2)
large group market, (3) small group market, and (4) self-insured group
health plans maintained by the same plan sponsor--provides a structured
approach to organizing and analyzing claims data. Interested parties
suggested that this categorization would be useful because pricing
dynamics and reimbursement rates tend to vary by
[[Page 60456]]
market segments.\112\ Therefore, the Departments expect that organizing
out-of-network allowed amounts in this way would facilitate a more
comprehensive assessment of the volume and characteristics of out-of-
network claims and enhance the data's utility for users by aligning it
with the distinct pricing structures and regulatory environments of
each market type. It would also make comparing allowed amounts for
plans and policies within the same market easier for file users.
---------------------------------------------------------------------------
\112\ There is evidence of consistent alignment within market
types and significant divergence between market types when comparing
allowed amounts relative to a common benchmark (Medicare). This
pattern holds even for in-network prices. Out-of-network allowed
amounts often derive from similar underlying cost structures.
Caroline Hanson, Ian McCarthy, Eamon Molloy & Karen Stockley,
Providers Paid Substantially Less by Marketplace Nongroup Insurers
Than by Employer Small-Group Plans, 2021, 43 Health Affairs 1672
(Dec. 20, 2024), <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2024.00913">https://www.healthaffairs.org/doi/10.1377/hlthaff.2024.00913</a>.
---------------------------------------------------------------------------
If this proposed amendment is finalized, the Departments also
anticipate a significant reduction in the overall number of Allowed
Amount Files (since these would be reported at the market level, rather
than at the plan level), even as those data files become more
populated. Additionally, this approach would further protect patient
privacy, as discussed earlier in this section of the preamble, because
data aggregated across two or more plans or policies would not be
directly associated with a single plan or policy.
On the other hand, the Departments acknowledge that requiring
market-level aggregation may limit or eliminate the ability of file
users to map specific allowed amounts and billed charges to an
individual plan or policy. However, plans and issuers would still be
required under paragraph (b)(1)(ii)(A) to disclose information about
the plans or policies whose allowed amounts are included in each file.
Therefore, file users would be able to determine which plans or
policies have allowed amounts included in the Allowed Amount File, even
if they would be unable to match a specific out-of-network allowed
amount to a particular plan or policy. The Departments have determined
that the advantages of having more populated Allowed Amount Files at
the market level would outweigh the drawbacks of missing plan-level
data. The Departments seek comment on what additional information might
be limited or lost by aggregating allowed amount and billed charges
data by health insurance market type, and the potential importance of
that information to price transparency. The Departments also invite
comments more broadly on the proposal to require reporting of out-of-
network allowed amount data by health insurance market type.
Lastly, the Departments are also proposing special aggregation
rules for self-insured group health plans, which are described in more
detail in section III.C.11. of this preamble. The Departments request
comment on all aspects of these proposals. For a discussion of the
Departments' proposal to amend paragraph (b)(1)(ii)(A) related to
disclosing HIOS IDs and product types in Allowed Amount Files, see
section III.C.2. of this preamble.
7. Contextual Files: Change-log, Utilization, Taxonomy, and Text
The Departments propose to require plans and issuers to publicly
disclose, through machine-readable files, additional contextual
information that would help file users better understand the public
disclosures required under paragraph (b)(1)(i). These files, which
include a Change-log File, Utilization File, and Taxonomy File would
contain information about the data within the In-network Rate and
Allowed Amount Files. The Departments also propose to require a
contextual machine-readable file to help users find the In-Network
Rate, Allowed Amount, and prescription drug machine-readable files
required under paragraph (b)(1) and new paragraph (b)(2) of this
section, which the Departments are proposing to identify as a Text
File.\113\ In particular, the Departments propose to amend 26 CFR
54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212 to
redesignate paragraphs (b)(2) through (4) as paragraphs (b)(3) through
(5), respectively, and to add new paragraph (b)(2) to require
contextual files. Specifically, the Departments propose to add new
paragraphs (b)(2)(i) through (iv) requiring: a Change-log File at
paragraph (b)(2)(i), a Utilization File at paragraph (b)(2)(ii), a
Taxonomy File at paragraph (b)(2)(iii), and a Text File at paragraph
(b)(2)(iv).
---------------------------------------------------------------------------
\113\ As previously mentioned, several proposed amendments would
amend requirements related to the prescription drug machine-readable
files, specifically: the requirement that plans and issuers must
include a plain text file in a .txt format in the root folder of a
plan's or issuer's website as describe in proposed paragraphs
(b)(2)(iv) of 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45
CFR 147.212 (section III.C.7.d of this preamble) and the
requirements related to the method and format for disclosing
information to the public as described in proposed paragraph (b)(3)
of 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212
(section III.C.9 of this preamble).
---------------------------------------------------------------------------
The 2020 final rules at 26 CFR 54.9815-2715A3(b), 29 CFR 2590.715-
2715A3(b), and 45 CFR 147.212(b) require plans and issuers to make
available on a public internet website the disclosure of health care
pricing information in machine-readable files, in accordance with
specific manner and format requirements. In particular, the Departments
require plans and issuers to disclose in-network provider rates, out-
of-network allowed amounts and the associated billed charges and
negotiated rates and historic net prices for prescription drugs. In the
2020 final rules, the Departments recognized the necessity of public
disclosure of health care pricing information due to the variation in
health care prices across the health care industry and the complexity
of health insurance and health plan coverage.\114\
---------------------------------------------------------------------------
\114\ The 2020 final rules stated that ``many consumers do not
fully comprehend the basics of health coverage, much less the more
complex facets of the health care system that can affect an
individual's out-of-pocket cost for items and services, including:
Its specialized billing codes and payment processes; the various
specialized terms used in plan and coverage contracts and related
documents (such as copayment and coinsurance); and the various
billing and payment structures plans and issuers use to compensate
providers and assign cost-sharing liability to individuals (for
example, bundled payment arrangements).'' 85 FR 72158, 72210
(November 12, 2020).
---------------------------------------------------------------------------
While price disclosures required in the 2020 final rules
contributed to a broader understanding of the data that drives plan and
issuer payments for health care items and services, the intervening
years demonstrated that additional context is necessary to promote a
fuller understanding of health care industry pricing dynamics. These
proposed additional files would help make the data disclosures of the
machine-readable files required under paragraph (b)(1) more meaningful
and accessible, which would promote greater transparency in health care
pricing information. Under this proposal, plans and issuers would be
required to prepare a Change-log File, a Utilization File, and a
Taxonomy File for each In-network Rate File prepared pursuant to these
proposed rules, and a single Text File to facilitate locating the other
machine-readable files required under these proposed rules. Each
Change-log File would reflect changes in data from one In-network Rate
File (under these proposed rules, prepared for a specific provider
network) to the publishing of the next In-network Rate File; each
Utilization File would reflect utilized covered items and services
under the plans and policies represented in one In-network Rate File;
and each Taxonomy File would represent the mapping of billing codes to
internal provider taxonomy codes used as part of the claims
adjudication
[[Page 60457]]
process for the plans and policies represented in the In-network Rate
File. Each Text File would direct users to the location of the machine-
readable files required under paragraphs (b)(1) and (2) and provide
contact information for an individual who can address inquiries and
issues related to the required machine-readable files. To ensure this
data can be imported and read by a computer system directly, without
reliance on proprietary software, and to promote standardization, these
contextual files would also need to be machine-readable, in the form
and manner as specified in guidance pursuant to proposed re-designated
paragraph (b)(3)(i).
a. Change-log File
The Departments propose to require, in new 26 CFR 54.9815-
2715A3(b)(2)(i), 29 CFR 2590.715-2715A3(b)(2)(i), and 45 CFR
147.212(b)(2)(i), that plans and issuers must make available, in a
machine-readable format, a Change-log File for each In-network Rate
File, that identifies any changes made to the required information in
the In-network Rate File since the immediately preceding published In-
network Rate File. The proposed Change-log File would be required to be
publicly posted in the form as specified in guidance issued by the
Departments, consistent with redesignated and amended paragraph (b)(3)
and discussed in section III.C.9. of this preamble. It would be
required to be posted in accordance with the timing requirements
proposed at redesignated paragraph (b)(4)(iii) and discussed in section
III.C.10. of this preamble. Specifically, it would be required to be
posted on the first day of the calendar-year quarter following the date
on which the first In-network Rate File would be required to be posted
under proposed paragraph (b)(4)(i).\115\ The purpose of the proposed
Change-log File would be to assist all file users in identifying
changes to the required information in the In-network Rate File from
one reporting period to the next. Pursuant to the proposed requirement
to publish the In-network Rate File described at (b)(1)(i) quarterly,
the updated Change-log File would also be required to be published
quarterly, indicating whether or not there were changes.
---------------------------------------------------------------------------
\115\ See Table 2 for an example.
---------------------------------------------------------------------------
The total amount of information contained in every plan's and
issuer's set of machine-readable files is extremely large,\116\
creating challenges for file users of all backgrounds in ingesting and
analyzing the information. Therefore, rather than downloading and
analyzing each set of newly posted files to determine if there have
been any changes to the required information in a plan's or issuer's
In-network Rate File, file users would only need to look at the Change-
log File to determine which new files they need to examine. These
proposed rules would create efficiencies for file users by reducing the
amount of required data storage for file users and save time by
eliminating the need to review data that has not changed. This would
also allow researchers and other interested parties to more easily
track changes over time.
---------------------------------------------------------------------------
\116\ Gary Claxton, Lynne Cotter, & Shameek Rakshit, Challenges
with Effective Price Transparency Analyses, Peterson-KFF Health
System Tracker (Feb. 25, 2025), <a href="https://www.healthsystemtracker.org/brief/challenges-with-effective-price-transparency-analyses/">https://www.healthsystemtracker.org/brief/challenges-with-effective-price-transparency-analyses/</a>.
---------------------------------------------------------------------------
The Departments seek comment on how the Change-log File can be most
effective, including what machine-readable file format it should be
required to be published. The Departments also seek comment on if any
specific information should be required to be included, and if so, what
information should be required to be included in the Change-log File.
For example, the Departments are interested in feedback from interested
parties on whether the Change-log File should only identify the
information in the file that has changed between one reporting to the
next or if it should also identify how the specific informa
[…truncated; see source link]Indexed from Federal Register on December 23, 2025.
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