Transparency in Coverage

Issuing agencies

Abstract

These final rules set forth requirements that 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 final rules are intended to improve the standardization, accuracy, and accessibility of public pricing disclosures in line with the goals of Executive Order 14221, "Making America Healthy Again by Empowering Patients With Clear, Accurate, and Actionable Healthcare Pricing Information." With respect to the In- network Rate and out-of-network Allowed Amount machine-readable files, these final rules aim to achieve these goals by adding new contextual files and additional data elements like product type, provider network name, and provider network identifier; 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 final rules also aim to improve the findability of all publicly disclosed machine-readable files required under the Transparency in Coverage rules, including the prescription drug file, by requiring a text file containing contact information for the files, and a footer with website URLs. These final rules also require pricing information that is made available through an online consumer tool and on 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 final rules).

Full Text

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<title>Federal Register, Volume 91 Issue 192 (Tuesday, October 6, 2026)</title>
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[Federal Register Volume 91, Number 192 (Tuesday, October 6, 2026)]
[Rules and Regulations]
[Pages 63748-63867]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2026-20447]



[[Page 63747]]

Vol. 91

Tuesday,

No. 192

October 6, 2026

Part III





Department of the Treasury





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Internal Revenue Service





Department of Labor





Employee Benefits Security Administration





Department of Health and Human Services





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26 CFR Part 54

29 CFR Part 2590

45 CFR Part 147





Transparency in Coverage; Final Rule

Federal Register / Vol. 91, No. 192 / Tuesday, October 6, 2026 / 
Rules and Regulations

[[Page 63748]]


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DEPARTMENT OF THE TREASURY

Internal Revenue Service

26 CFR Part 54

[TD 10058]
RIN 1545-BR51

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-F]
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: Final rule.

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SUMMARY: These final rules set forth requirements that 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 final rules are intended to improve the 
standardization, accuracy, and accessibility of public pricing 
disclosures in line with the goals of Executive Order 14221, ``Making 
America Healthy Again by Empowering Patients With Clear, Accurate, and 
Actionable Healthcare Pricing Information.'' With respect to the In-
network Rate and out-of-network Allowed Amount machine-readable files, 
these final rules aim to achieve these goals by adding new contextual 
files and additional data elements like product type, provider network 
name, and provider network identifier; 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 final rules also aim to improve the 
findability of all publicly disclosed machine-readable files required 
under the Transparency in Coverage rules, including the prescription 
drug file, by requiring a text file containing contact information for 
the files, and a footer with website URLs. These final rules also 
require pricing information that is made available through an online 
consumer tool and on 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 final rules).

DATES: These regulations are effective on December 7, 2026.

FOR FURTHER INFORMATION CONTACT: Kendra May or Jeremy Rotner, Centers 
for Medicare and Medicaid Services, (301) 492-4293.
    Colin Harmeyer or David Sydlik, 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:

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 under the 2020 final rules led to the 
release of an enormous amount of previously hidden pricing data. 
However, post-implementation, the Departments received feedback from 
users of the machine-readable files emphasizing the need to address 
certain gaps in reporting, shrink file size by reducing duplication and 
removing unnecessary data, and improve the usability of the files.
    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. 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 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.\5\ The Departments plan to begin working to 
implement the prescription drug file in short order.
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    \4\ Exec. Order No. 14221, 90 FR 11005 (February 28, 2025).
    \5\ 90 FR 23303 (June 2, 2025).
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    To address statutory requirements and fulfill their responsibility 
under Executive Order 14221, the Departments proposed to amend certain 
requirements of the 2020 final rules in the December

[[Page 63749]]

23, 2025, Transparency in Coverage proposed rules (the proposed 
rules).\6\ The proposed rules addressed what the Departments identified 
as three main barriers to fully achieving the goals of the 2020 final 
rules: inaccessibility due to the large size of the machine-readable 
files, data ambiguity due to lack of contextual information alongside 
the raw data, andareas of misalignment with the Hospital Price 
Transparency rules \7\ that make comparing data across disclosures 
challenging. The proposed rules' Executive Summary further discussed 
the need for price transparency, including how it would benefit 
employers leveraging the data to lower their health care costs and app 
developers conducting analyses to offer pricing tools to individuals 
and employers, in addition to past regulatory and sub-regulatory action 
(section I.A.).\8\
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    \6\ 90 FR 60432 (December 23, 2025).
    \7\ 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, 84 FR 
65524 (November 27, 2019); Medicare Program: Hospital Outpatient 
Prospective Payment and Ambulatory Surgical Center Payment Systems 
and Quality Reporting Programs; Price Transparency of Hospital 
Standard Charges; Radiation Oncology Model, 86 FR 63458 (November 
16, 2021); Medicare Program: Hospital Outpatient Prospective Payment 
and Ambulatory Surgical Center Payment Systems; Quality Reporting 
Programs; Payment for Intensive Outpatient Services in Hospital 
Outpatient Departments, Community Mental Health Centers, Rural 
Health Clinics, Federally Qualified Health Centers, and Opioid 
Treatment Programs; Hospital Price Transparency; Changes to 
Community Mental Health Centers Conditions of Participation, Changes 
to the Inpatient Prospective Payment System Medicare Code Editor; 
Rural Emergency Hospital Conditions of Participation Technical 
Correction, 88 FR 81540 (November 22, 2023); Medicare Program: 
Hospital Outpatient Prospective Payment and Ambulatory Surgical 
Center Payment Systems; Quality Reporting Programs; Overall Hospital 
Quality Star Rating; Hospital Price Transparency; and Notice of 
Closure of a Teaching Hospital and Opportunity To Apply for 
Available Slots, 90 FR 53448 (November 25, 2025).
    \8\ 90 FR 60432 (December 23, 2025).
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    After consideration of public comment to the proposed rules and to 
address the need for regulatory action, the Departments are finalizing 
these rules pursuant to the authority under section 2715A of the Public 
Health Service (PHS) Act, included in 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).\9\ 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).
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    \9\ Except that under section 2715A of the PHS Act, a plan or 
coverage that is not offered through the Exchange is only required 
to submit information to the applicable Secretary and the State 
insurance commissioner, and to make such information available to 
the public.
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    The Departments are also finalizing 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, which added Code section 9819, ERISA section 719, and PHS Act 
section 2799A-4, requires group health plans and health insurance 
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 Costs and Cost Savings

BILLING CODE 3510-60-P
[GRAPHIC] [TIFF OMITTED] TR06OC26.021


[[Page 63750]]


[GRAPHIC] [TIFF OMITTED] TR06OC26.022


[[Page 63751]]


[GRAPHIC] [TIFF OMITTED] TR06OC26.023

BILLING CODE 3510-60-C

II. Background
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    \10\ For purposes of the Summary of Annual Cost Savings table 
and Executive Order 14192, negative values reflect reductions in 
costs with respect to monetized cost savings.
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A. 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 include 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, included in 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 qualified health plans 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.
    Title I of Division BB of the Consolidated Appropriations Act of 
2021, which included 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, section 107 of the No Surprises Act added new section 
9816(e) of the Code, section 716(e) of ERISA, and section 2799A-1(e) of 
the PHS Act, which contain requirements for plans and 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 9819 of 
the Code, section 719 of ERISA, and section 2799A-4 of the PHS Act, 
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.

[[Page 63752]]

B. Executive Orders and Regulations

    On June 24, 2019, President Trump issued Executive Order 13877, 
``Improving Price and Quality Transparency in American Healthcare to 
Put Patients First.'' \11\ 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 ``opaque pricing structures'' may harm the market by protecting 
``powerful special interest groups, such as large hospital systems and 
insurance companies'' while ``leav[ing] patients and taxpayers worse 
off than would a more transparent system.'' \12\
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    \11\ Exec. Order No. 13877, 84 FR 30849 (June 27, 2019).
    \12\ Id.
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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 \13\ and subsequently finalized the Transparency 
in Coverage rules in the 2020 final rules.\14\ 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.
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    \13\ 84 FR 65464 (November 27, 2019).
    \14\ 85 FR 72158 (November 12, 2020).
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    The 2020 final rules required 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. Those provisions of the 2020 final rules 
implemented paragraph (C) of section 1311(e)(3) of the Affordable Care 
Act.
    The 2020 final rules also required 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. Those 
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, implemented 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 
implemented the requirement in section 1311(e)(3)(A)(vii) of the 
Affordable Care Act that require issuers of qualified health plans 
(QHPs) 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 was appropriate under section 1311(e)(3)(A)(ix) of 
the Affordable Care Act.
    After the 2020 final rules were issued, interested parties used 
GitHub and other forums to bring to the Departments' attention specific 
questions related to implementation and compliance. In response, the 
Departments have issued Frequently Asked Questions (FAQs) \15\ and 
technical guidance.\16\
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    \15\ 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), available at <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/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-49">https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-49</a>; FAQs About Affordable Care Act 
Implementation Part 53 (April 19, 2022), available at <a href="https://www.cms.gov/files/document/faq-part-53.pdf">https://www.cms.gov/files/document/faq-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>; FAQs About Affordable Care Act Implementation Part 61 
(September 27, 2023), available at <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>.
    \16\ Centers for Medicare & Medicaid Services, Transparency in 
Coverage, GitHub, available at <a href="https://github.com/CMSgov/price-transparency-guide">https://github.com/CMSgov/price-transparency-guide</a> (last visited June 15, 2026).
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    On February 25, 2025, President Trump issued Executive Order 
14221,\17\ ``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.'' \18\
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    \17\ Exec. Order No. 14221, 90 FR 11005 (February 28, 2025).
    \18\ 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,\19\ 
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.'' \20\ To fulfill their 
responsibility under Executive Order 14221, on December 23, 2025, the 
Departments published the proposed rules to amend the 2020 final rules.
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    \19\ Exec. Order No. 13877, 84 FR 30849 (June 27, 2019).
    \20\ Exec. Order No. 14221, 90 FR 11005 (February 25, 2025).
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C. Statutory Background for Enforcement With Regard to the Affordable 
Care Act and the No Surprises Act

    The enforcement responsibilities of HHS and the States, with 
respect to oversight of 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

[[Page 63753]]

D of title XXVII of the PHS Act. Under this framework, HHS has 
enforcement authority over issuers in a State if the State indicates it 
cannot or will not enforce a provision (or provisions) of part A or D 
of title XXVII of the PHS Act, or 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.\21\ HHS also has primary enforcement authority with respect to the 
same provisions over non-Federal governmental plans, such as those 
sponsored by State and local government employers.\22\
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    \21\ See PHS Act section 2723(a)(2) and (b)(1)(A); 45 CFR 
150.203.
    \22\ PHS Act section 2723(b)(1)(B).
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    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.

D. Public Comments Received in Response to the Proposed Rules

    The Departments received comments from 132 commenters in response 
to the proposed rules from a wide variety of interested parties, 
including private citizens; consumer and advocacy organizations; 
employers and other plan sponsors; health information technology, 
health care consulting, and health care staffing companies; health care 
providers and facilities, and health systems; health insurance issuers; 
service providers, including third-party administrators (TPAs); trade 
and professional associations; and researchers and academics. Many 
commenters provided detailed feedback on multiple aspects of the 
proposed rules and in response to various specific comment 
solicitations included in the preamble to the proposed rules.
    The Departments received many comments expressing general support 
for the proposed rules, stating that the proposals would help control 
health care costs and empower consumers to make more informed decisions 
by improving the accuracy and usability of Transparency in Coverage 
data, reducing administrative burden for plans and issuers, and 
aligning with the Hospital Price Transparency requirements. The 
Departments also received many comments supporting technical and 
structural changes, including moving to network-level reporting, 
standardizing file structures, requiring additional contextual 
information, moving to a quarterly reporting cadence, requiring footer 
links to the location of the machine-readable files, and excluding from 
the data set providers who are unlikely to provide services typically 
outside their scope of practice. The Departments also received several 
comments supporting alignment with the Hospital Price Transparency 
requirements, stating that such alignment would reduce duplication, 
facilitate comparisons, and support more meaningful analyses of health 
care cost drivers. The Departments respond to these comments in section 
III. of this preamble.
    The Departments also received several comments expressing general 
disagreement with the proposed rules and concern with the Departments' 
broader approach to Transparency in Coverage, stating that the 
proposals leave significant gaps that would undermine the goals of the 
statute. Several commenters expressed concern that the proposed rules 
could reduce competition in concentrated health insurance markets and 
place insufficient emphasis on quality as a factor in health care 
decision-making and suggested that the Departments work directly with 
physicians and other providers to inform price transparency. The 
Departments also received several comments stating that, despite the 
proposed improvements, fundamental issues of machine-readable file 
incompleteness, ambiguity, and usability would persist and continue to 
hinder data interpretation. In addition, several commenters did not 
support the proposed rules because they believed the proposals would 
increase costs and administrative burden for group health plans, 
particularly small and regional plans, and make the machine-readable 
files more complex for users to access. The Departments also received 
several comments expressing concern that the proposed rules favor 
researchers and academics over the development of consumer decision-
support tools and focus on price without including quality or outcomes 
data needed to inform consumer decision-making.
    The Departments received many comments suggesting additional ways 
in which the Departments could use their statutory authority to 
strengthen the Transparency in Coverage requirements, particularly by 
reducing barriers to accessibility and improving data usability. The 
Departments received a few comments recommending standardized, plain-
language, consumer-facing summaries that translate machine-readable 
file data into estimated out-of-pocket costs, including deductible 
status, coinsurance, and network tier information. The Departments also 
received a few comments noting that issuers relying on TPAs to comply 
with Transparency in Coverage requirements may face barriers to 
accessing their own data. A few commenters recommended requiring the 
establishment of a unified national standards authority, creation of a 
national database compiling machine-readable file rates, and expansion 
of reporting requirements to additional payers or coverage programs, 
such as Medicaid managed care plans and Medicare Advantage plans.
    Many commenters requested the Departments increase their 
enforcement activity, including through an increased use of audits, 
warning letters, corrective action plans, and monetary fines. 
Additionally, a commenter encouraged the Departments to take steps to 
publicly disclose information related to non-compliance warnings, 
corrective action plans, and civil money penalties, similar to existing 
enforcement protocols under the Hospital Price Transparency 
requirements.
    The Departments respond to these comments in more detail in the 
relevant subsections of section III. of this preamble. The Departments 
recognize that plans and issuers may need to examine contracts with 
TPAs to identify if changes are necessary to enable access to the data 
required under these final rules. The Departments are not requiring 
standardized summaries of estimated out-of-pocket costs, including 
deductible status, coinsurance, and network tier information, because 
the data in the machine-readable files are rates and historic billed 
charges only and cannot reflect an individual consumer's personalized 
estimated cost-sharing liability, including accumulators and deductible 
progress. Requiring this information to be made available in the 
machine-readable files would be duplicative of the personalized cost-
sharing information available through the internet-based self-service 
tool.\23\ Nevertheless, the Departments anticipate that researchers, 
employers, and other file users will use the machine-readable file data 
to analyze and compare health care prices and that third-party 
developers will build tools and apps that make the information more 
accessible and useful to consumers and other purchasers of health care, 
thereby promoting greater transparency for the broader public benefit.
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    \23\ 26 CFR 54.9815-2715A2(b)(2)(i), 29 CFR 2590.715-
2715A2(b)(2)(i), and 45 CFR 147.211(b)(2)(i).
---------------------------------------------------------------------------

    The Departments appreciate commenters' suggestion to create a 
national database of compiled machine-

[[Page 63754]]

readable file negotiated rates and allowed amounts, but note that plans 
and issuers have been posting their files in an established manner for 
more than four years, creating consistency in their operations and for 
the public in finding the files. Additionally, findability will be 
further enhanced through the Text File as discussed in section 
III.C.8.d. of this preamble and the footer requirement as discussed in 
section III.C.10. of this preamble. Creating a new system to submit 
such information to the Departments would be overly burdensome in light 
of the other new requirements in these final rules. Further, rules 
regarding Medicaid managed-care and Medicare Advantage plans are beyond 
the scope of section 2715A of the PHS Act and these final rules.
    A commenter noted that some payers have not meaningfully updated 
machine-readable file data in years and warned that without an 
enforcement mechanism tied to update frequency, the quarterly cadence 
risks allowing widespread noncompliance to persist.
    A commenter recommended that the Departments clarify the distinct 
role of States and the Federal Government and their jurisdictions in 
enforcement responsibility. Another commenter recommended that the 
Departments assign primary enforcement authority to a Federal entity, 
such as the Center for Consumer Information and Insurance Oversight 
(CCIIO), to improve compliance with the Transparency in Coverage 
requirements. Another commenter encouraged the Departments to increase 
coordination with State departments of insurance.
    A commenter requested that the Departments create a safe harbor or 
non-enforcement policy for employers who report non-compliance to the 
Departments, given that many health insurance purchasers hire service 
providers to handle their machine-readable file responsibilities. 
Another commenter wanted the Departments to require owners of the 
provider networks to share a complete and accurate set of health claims 
data with a self-insured plan sponsor and their service providers. A 
commenter requested that the Departments defer to States when 
regulating ERISA plans, as well as strengthen enforcement authority 
over ERISA plan administrators. A few commenters encouraged the 
Departments to establish new enforcement procedures, and one of these 
commenters criticized the Departments for relying on a discretion-based 
enforcement approach. A commenter encouraged the Departments to 
increase coordination with State departments of insurance.
    The Departments look forward to the reforms put forth by these 
final rules helping achieve the promise of price transparency to 
empower Americans and lower costs. The Departments agree that 
enforcement of the Transparency in Coverage requirements is critical to 
the ongoing usefulness of the published data and share commenters' 
concerns about plans and issuers failing to maintain updated and 
accurate files as required. The Departments also recognize that there 
is continued public interest in learning about compliance and 
enforcement actions with respect to the Transparency in Coverage 
requirements.
    The Departments have been engaged in compliance and enforcement 
efforts since the 2020 final rules requirements became effective. With 
the implementation of these final rules, the Departments will 
prioritize compliance and enforcement through existing authorities and 
will work to ensure that any enforcement actions will be transparent to 
the public.
    Under chapter 100 of the Code, Part 7 of ERISA, and title XXVII of 
the PHS Act, as applicable, the Departments may require corrective 
actions and impose civil monetary penalties, or seek equitable or other 
forms of remedial relief \24\ through voluntary compliance or 
otherwise, to the extent permitted under applicable law, when the 
Departments find violations through market conduct examinations and 
investigations of plans and issuers within their jurisdiction.
---------------------------------------------------------------------------

    \24\ Including under ERISA section 502(a)(5).
---------------------------------------------------------------------------

    With respect to the commenter who requested clarity on which 
entities have enforcement authority, the Departments reiterate the 
applicable jurisdictions of enforcement authority stated at the 
beginning of section II.C. of this preamble. The Department of Labor 
has primary enforcement authority over ERISA plans. State regulators 
maintain enforcement authority over health insurance coverage offered 
by health insurance issuers in the group and individual markets unless 
the State notifies HHS that it has not enacted legislation to enforce 
or HHS determines that a State has failed to substantially enforce such 
requirements, as described in section 2723(a)(2) of the PHS Act and 
implementing regulations under 45 CFR 150 subpart B. HHS has direct 
enforcement authority over non-Federal governmental plans in all 
jurisdictions.
    In response to the commenter who requested that the Departments 
require owners of provider networks to share a complete and accurate 
set of health claims data with a self-insured plan sponsor and their 
service providers, the Departments remind plans and issuers of the 
prohibitions on gag clauses under the Consolidated Appropriations Act, 
2021. Specifically, section 9824 of the Code, section 724 of ERISA, and 
section 2799A-9(a)(1) of the PHS Act prohibit group health plans and 
health insurance issuers offering group health insurance coverage from 
entering into an agreement with a health care provider, network or 
association of providers, TPA, or other service provider offering 
access to a network of providers that would directly or indirectly 
restrict the plan or issuer from electronically accessing de-identified 
claims and encounter information or data for each participant, 
beneficiary, or enrollee in the plan or coverage upon request, 
consistent with certain Federal privacy regulations.\25\
---------------------------------------------------------------------------

    \25\ As added by section 201 of title II (Transparency) of 
division BB of the Consolidated Appropriations Act, 2021.
---------------------------------------------------------------------------

    With respect to the commenter who expressed concerns about 
employers' and self-insured plans' ability to comply with the 
requirements of these final rules, the Departments point to the special 
rules as finalized in this rule at 26 CFR 54.9815-2715A3(b)(5), 29 CFR 
2590.715-2715A3(b)(5), and 45 CFR 147.212(b)(5), which articulate 
responsibility for group plans that enter into a written agreement with 
a health insurance issuer or a third party to provide the required 
machine-readable file information. If a self-insured plan sponsor is 
concerned that the plan's TPA may not be capable of fulfilling the 
requirements of the rule on its behalf, the plan should take all 
necessary steps to address such concern in its contract with the TPA.
    The Departments received one comment seeking confirmation that, as 
stated in the preamble to the 2020 final rules,\26\ ``denominational 
health plans'' are outside the scope of the Transparency in Coverage 
requirements. In the preamble to the 2020 final rules, the Departments 
stated that all plans subject to section 2715A of the PHS Act must 
comply with the rule's requirements. The Departments also stated that 
section 2715A of the PHS Act applies to group health plans and health 
insurance issuers offering group or individual health insurance 
coverage and not to, among others, ``denominational health plans,'' 
without defining the term. These final rules do not exclude 
denominational health plans that are church plans within the

[[Page 63755]]

meaning of section 3(33) of ERISA and section 414(e) of the Code 
because church plans are group health plans and the Departments have 
concluded that the statute provides no authority to exclude them.
---------------------------------------------------------------------------

    \26\ 85 FR 72158, 72252 (November 12, 2020).
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    Many commenters wanted the Departments to focus enforcement not 
just on whether the machine-readable files are being made publicly 
available, but to ensure that the data contained within the files are 
complete and accurate. Another commenter recommended Department-hosted 
``connectathon'' events to validate Transparency in Coverage data. Many 
commenters urged stronger accountability for the validity and accuracy 
of the data by including attestation requirements, with commenters 
stating that, without such safeguards, the data would be of limited 
value to consumers.
    In addition to the above enforcement tools, the Departments are 
finalizing an attestation requirement as an additional step to address 
the concerns about the accuracy of the information provided and help 
ensure its validity. The Departments discuss this and respond to the 
above comments in more detail in section III.C.7. of this preamble.
    Many commenters submitted comments that were not within the scope 
of the policies proposed under the proposed rules, including comments 
on requirements related to the 2019 Hospital Price Transparency 
rule,\27\ Advanced Explanation of Benefits,\28\ the claims review 
process and timeline, enforcement of the No Surprises Act balance 
billing protections,\29\ price transparency for Medicare plans, future 
rulemaking plans on additional price transparency policies, and quality 
data transparency.
---------------------------------------------------------------------------

    \27\ 83 FR 41141 (August 17, 2018).
    \28\ Public Law 116-260 (Dec. 27, 2020).
    \29\ Title I of Division BB of the Consolidated Appropriations 
Act, 2021.
---------------------------------------------------------------------------

    After reviewing the comments received, the Departments are 
finalizing the proposed rules, with some changes in response to 
comments, as described in more detail later in this preamble, to make 
pricing information more accurate, more accessible, and more 
actionable.

E. Technical Amendments

    These final rules include 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 
referred to those entities more than once in the same paragraph, the 
terms ``plan'' and ``issuer'' were used after the initial instance. 
However, that convention was not applied evenly.
    Therefore, in the proposed rules, the Departments proposed 
technical amendments to align the terms used to describe those entities 
with that convention in paragraphs (b)(1)(i)(A), (b)(1)(i)(B), 
(b)(2)(ii), (b)(3)(i), and (b)(3)(ii) of the internet-based self-
service tool disclosure requirements in 26 CFR 54.9815-2715A2, 29 CFR 
2590.715-2715A2, and 45 CFR 147.211; and paragraphs (b)(1)(i)(D), 
(b)(5)(i), and (b)(5)(ii) the machine-readable file disclosure 
requirements in 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 
CFR 147.212. The Departments did not receive any comments on these 
technical amendments and are therefore finalizing them as proposed. 
These changes are technical in nature and do not affect the rights or 
obligations of any plan, issuer, or other entity.
    In addition, the Departments proposed to modify 26 CFR 54.9815-
2715A3(b)(3)(ii), 29 CFR 2590.715-2715A3(b)(3)(ii), and 45 CFR 
147.212(b)(3)(ii) to clarify, as written elsewhere in paragraphs 
(b)(3)(i) and (b)(3)(iii), the machine-readable files being described 
are in paragraphs (b)(1) and (2) of the section.
    For consistency with Department of the Treasury and Department of 
Labor regulations, HHS is amending the section heading of 45 CFR 
147.211 to ``Transparency in coverage--required disclosures to 
participants, beneficiaries, and enrollees'' instead of ``Transparency 
in coverage--required disclosures to participants, beneficiaries, or 
enrollees.''

III. Overview of the Final Rules

A. Definitions

    To support proposed amendments to the Allowed Amount File provision 
(discussed in more detail in section III.C.6. of this preamble) and to 
promote consistency in data organization, the Departments proposed to 
add new paragraphs 26 CFR 54.9815-2715A1(a)(2)(xi), 29 CFR 2590.715-
2715A1(a)(2)(x), and 45 CFR 147.210(a)(2)(xi) to define the term 
``health insurance market'' and to redesignate the paragraphs that 
follow accordingly.\30\ The Departments proposed that ``health 
insurance market'' would mean, irrespective of State, one of the 
following:
---------------------------------------------------------------------------

    \30\ 90 FR 60432, 60442 (December 23, 2025) (proposing 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; and to redesignate paragraphs (a)(2)(x) through (xxi) as 
paragraphs (a)(2)(xi) through (xxii) under 29 CFR 2590.715-2715A1).
---------------------------------------------------------------------------

    <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.
    The Departments sought comment on this proposed definition. After 
consideration of public comments, the Departments are finalizing this 
definition with modifications that add cross-reference citations to the 
relevant definitions of excepted benefits for additional clarity. 
Specifically, the Departments are adding a cross-reference to the 
definition of excepted benefits in 45 CFR 148.220 to 26 CFR 54.9815-
2715A1(a)(2)(xi)(A), 29 CFR 2590.715-2715A1(a)(2)(x)(A), and 45 CFR 
147.210(a)(2)(xi)(A). This definition of the term applies to coverage 
in the individual health insurance market. The Departments also are 
adding a cross-reference to the definition of excepted benefits in 26 
CFR 54.9831-1(c), 29 CFR 2590.732(c), or 45 CFR 146.145(b) to 26 CFR 
54.9815-2715A1(a)(2)(xi)(B) through (D), 29 CFR 2590.715-
2715A1(a)(2)(x)(B) through (D), and 45 CFR 147.210(a)(2)(xi)(B) through 
(D), respectively. This definition of the term applies to group health 
plans.
    Several commenters supported the Departments' proposed definition 
of ``health insurance market'' for the purposes of the proposed 
amendments to the Allowed Amount File provision. These commenters 
expressed that clearly and consistently defining the health insurance 
market categories

[[Page 63756]]

would reduce ambiguity and variability in reporting. A few commenters 
also noted that delineating four separate markets and requiring 
separate out-of-network Allowed Amount machine-readable files for each 
market would support the comparability of the files and enable more 
accurate evaluation of affordability, network adequacy, and cost 
drivers across the system. A few commenters highlighted that this 
proposed definition aligns concepts of the Transparency in Coverage 
requirements with requirements included in the No Surprises Act. 
Another commenter stated that the proposed definition would provide 
additional information to the public about negotiated rates as they are 
anchored in qualifying payment amount (QPA) calculations and provide 
better insight to the Federal agencies tasked with enforcing QPA 
calculation requirements.
    The Departments agree with commenters that the definition of the 
term ``health insurance market'' promotes consistent data organization 
across plans and issuers in the market-level Allowed Amount Files, for 
which the Departments are finalizing requirements, as discussed in 
section III.C.6. of this preamble, with modifications to cross-
reference the relevant definitions of excepted benefits for clarity. 
The Departments also agree that clearly delineating each market 
included in the definition and requiring separate machine-readable 
files for each market supports the analytic value of these files.
    A commenter disagreed with the Departments' proposed definition of 
``health insurance market.'' The commenter expressed that including 
self-insured group health plans in the definition would lead to 
confusion for those plans as well as file users given the variability 
in State definitions of this term. The commenter recommended that self-
insured group health plans be defined as ``self-insured'' separately 
from ``health insurance market.'' Additionally, another commenter 
recommended that the Departments use the term ``health coverage 
market'' rather than ``health insurance market'' given that the 
proposed definition includes self-insured group health plans.
    The Departments acknowledge the commenter's concern about confusion 
regarding the variability in State definitions of the term, ``health 
insurance market.'' However, these final rules specify that the 
definition of ``health insurance market'' for the purposes of 
organizing the Allowed Amount Files is established ``irrespective of 
the State.'' Additionally, the Departments are not aware of any 
confusion among self-insured group health plans based on a similar 
definition of ``insurance market'' included in the method for 
calculating the QPA at 26 CFR 54.9816-6(a)(8), 29 CFR 2590.716-6(a)(8), 
and 45 CFR 149.140(a)(8).\31\ The Departments have determined that 
employing similar definitions for purposes of calculating the QPA under 
the No Surprises Act and for the Transparency in Coverage regulations 
reduces burden on interested parties that must fulfill reporting 
requirements under both regulatory frameworks. To further clarify the 
definition, the Departments have added cross-reference citations to the 
relevant definitions of excepted benefits. Therefore, the Departments 
are finalizing the definition with those modifications.
---------------------------------------------------------------------------

    \31\ 90 FR 60432, 60442 (December 23, 2025).
---------------------------------------------------------------------------

B. Requirements for Disclosing Cost-Sharing Information to 
Participants, Beneficiaries, and Enrollees

1. Balance Billing Protection Statement
    The Departments proposed to amend the balance billing protection 
statement that plans and issuers are currently required to include 
along with the required cost-sharing disclosures 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). 
The proposed amendments would require language in the balance billing 
protection 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 were 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 balance 
billing protection statement language was finalized in the 2020 final 
rules. This balance billing protection 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.
    The Departments sought comment on this proposal. After 
consideration of public comments, the Departments are finalizing the 
amendments to the balance billing protection statement as proposed.
    Several commenters supported the proposed amendment to the balance 
billing protection statement language for the self-service tool. These 
commenters mentioned that this amendment would clarify patients' No 
Surprises Act protections and any remaining balance billing risk, 
giving patients clearer, actionable information to support informed 
decisions.
    The Departments agree with commenters that amending the balance 
billing protection statement clarifies the protections patients have at 
both the State and Federal level and informs them of the potential for 
additional cost-sharing when using the self-service tool for estimates 
from an out-of-network provider.
    A commenter opposed requiring plans and issuers to amend the 
balance billing protection statement. The commenter noted that 
statements should inform rather than overwhelm consumers, as excessive 
notifications can obscure cost information and reduce comprehension. A 
few other commenters requested flexibility in the wording plans and 
issuers are allowed to use and recommended the Departments allow plans 
and issuers to continue using existing disclaimer language, which 
currently communicates the core point that cost-sharing estimates may 
not reflect additional amounts that an out-of-network provider may bill 
when permitted by applicable law.
    The Departments have determined that this balance billing 
protection statement increases comprehension by informing patients of 
the limits of the balance billing protections they may have under State 
and Federal laws, which will help mitigate unexpected health care costs 
when seeing an out-of-network provider. The Departments also note that 
the balance billing protection statement is an existing requirement and 
these final rules only amend the existing language to more accurately 
reflect consumers' rights under the No Surprises Act, which was not yet 
enacted when the current language in this statement was finalized in 
the 2020 final rules. The Departments also recognize that plans and 
issuers have existing balance billing protection statement language. 
The Departments note that paragraph (b)(1)(vii) does not require 
disclaimers to be reproduced verbatim. Plans and issuers may

[[Page 63757]]

continue to use existing disclaimer language to the extent that the 
language includes the required balance billing information as set forth 
in these final rules and is written in plain language, as defined in 26 
CFR 54.9815-2715A1(a)(2)(xxi), 29 CFR 2590.715-2715A1(a)(2)(xx), and 45 
CFR 147.210(a)(2)(xxi). This requirement is designed to ensure that 
each plan's or issuer's balance billing protection statement accurately 
describe the scope of the No Surprises Act balance billing protections. 
The Departments have determined that the balance billing protection 
statement as amended by these final rules sufficiently informs patients 
of their potential for additional costs when seeing an out-of-network 
provider.
2. New Required Method and Format for Disclosing Information to 
Participants, Beneficiaries, and Enrollees
    The Departments proposed 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 telephone number. Under the proposal, the information required 
via a telephone 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, require be indicated on any 
physical or electronic plan or insurance identification card issued to 
participants, beneficiaries, and enrollees for obtaining customer 
assistance. The Departments also proposed 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 in paragraph (b)(1), 
because providing the disclosures by telephone is newly required under 
these rules.
    In the proposed rules, the Departments also indicated their 
intention for these proposals to satisfy the No Surprises Act 
requirement that plans and issuers provide price comparison guidance by 
telephone, as set forth in Code section 9819, ERISA section 719, and 
PHS Act section 2799A-4. The Departments further explained that 
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.
    In addition, at paragraph (b)(2)(iii), the Departments proposed to 
allow group health plans and health insurance issuers to limit the 
number of providers, about which cost-sharing information for covered 
items and services is provided, to no fewer than 20 providers per day. 
The Departments also proposed to require plans and issuers that choose 
to apply the 20 providers-per-day limit to disclose such limitation to 
the participant, beneficiary, or enrollee when the request for 
information is made for disclosures by phone. A similar 20-provider 
limit was already in place 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). The Departments noted in the proposed rules that 
nothing 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 proposed to require plans 
and issuers to satisfy requests for cost-sharing information over the 
phone at the time of the request, and in accordance with the method and 
format requirements in paragraphs (b)(2)(i)(A) through (C), to ensure 
that participants, beneficiaries, and enrollees receive information as 
quickly as possible.
    The Departments clarify that the 20-provider limit applies 
separately to the paper and phone methods. Accordingly, a plan or 
issuer must disclose cost-sharing information for no fewer than 20 
providers by paper per day and no fewer than 20 providers by phone per 
day, if both are requested. However, there may be overlap with respect 
to the provider information provided via either method, to the extent a 
participant requests cost-sharing information both on paper and by 
phone for any of the same providers. There is no additional requirement 
that a plan or issuer avoid duplicative responses in that situation.
    The Departments requested comment on whether this proposal should 
include phone service standards to ensure that consumers have access to 
timely and reliable information, including, in particular, what such 
standards should include and what parameters should be applied to each 
criterion. The Departments also requested comment on whether there are 
other relevant Federal, State, or local standards for phone service 
quality or any industry practices that the Departments should consider. 
After consideration of public comments, the Departments are finalizing 
these requirements as proposed, with minor, non-substantive edits to 
improve clarity.
    Many commenters supported the Departments' proposal to require 
plans and issuers to make available to participants, beneficiaries, and 
enrollees, at their request, cost sharing estimates and other required 
disclosures by phone, noting that this approach aligns with existing 
obligations under the No Surprises Act, enhances transparency, and 
supports consumers' ability to plan for out-of-pocket costs and make 
more informed decisions about their health care. Several commenters 
emphasized that adding a phone option would help address barriers faced 
by consumers with limited internet access or lower digital literacy, 
including individuals residing in rural areas, and appreciated the 
Departments' efforts to provide multiple ways for individuals to obtain 
cost sharing information as a means of promoting equity and reducing 
disparities in access to health care pricing information. A commenter, 
while supportive of the proposal, expressed concern that this 
requirement could lead to higher plan costs that may ultimately be 
passed on to consumers in the form of increased premiums, and 
encouraged the Departments to explore a unified data center to handle 
phone requests. Another commenter expressed support for multi-modal 
access to price comparison tools, including digital platforms and 
telephonic assistance, but recommended that such access relies on a 
shared data architecture rather than parallel compliance builds, with a 
unified information backbone that feeds both digital and phone-based 
interfaces without duplicating reporting structures.
    The Departments agree that aligning the Transparency in Coverage 
and the No Surprises Act requirements reduces regulatory burden for 
group health plans and health insurance issuers and minimizes confusion 
among payers and consumers regarding two overlapping statutory 
obligations. The Departments

[[Page 63758]]

also agree that the phone method of disclosing cost-sharing estimates 
helps address access concerns by providing an additional method for 
participants, beneficiaries, and enrollees, including those with lower 
digital literacy, limited internet access, and disparate geographic 
location, to obtain cost-sharing information and other required 
disclosures. The Departments are not pursuing a unified data center to 
handle phone requests in order to allow each plan or issuer to pursue 
its own approach to providing cost-sharing estimates over the phone. 
The Departments acknowledge concerns about potential increases in plan 
costs but have determined that the benefits of improved access to cost-
sharing information justify any potential increases in costs, which the 
Departments expect would be marginal given that plans and issuers can 
rely on existing customer service processes to satisfy the requirement.
    The Departments further emphasize that nothing in these final rules 
requires plans and issuers to build separate data systems or back-end 
infrastructure to support the requirements of the Transparency in 
Coverage disclosures to participants, beneficiaries, and enrollees 
across the required methods. The cost-sharing information required to 
be disclosed via phone is the same information required to be disclosed 
through the internet-based self-service tool and in paper form. Plans 
and issuers may use the same underlying data systems to generate cost-
sharing information across all three modalities, provided the 
information disclosed meets the requirements of paragraph (b)(1) and 
(2), including that it is accurate at the time of the request.
    A few commenters expressed concerns about the proposed 20-provider-
per-day limit for phone disclosures. These commenters stated that 
verbally conveying cost-sharing estimates for up to 20 providers during 
a single call would be impracticable and time-intensive, and could 
increase the likelihood of consumer confusion, undermining the intended 
consumer experience. One of those commenters further noted that the 
higher limit could trigger unpredictable call volumes that reduce 
service quality for all callers. Some other commenters recommended that 
the Departments limit the requests to no more than 3 to 5 providers per 
phone call, while another commenter recommended a limit of 10 providers 
per business day, stating that this approach would better align with 
the practical constraints of phone-based interactions while still 
providing a meaningful ability for participants, beneficiaries, and 
enrollees to compare provider options.
    In the 2020 final rules, the Departments established a limit of no 
fewer than 20 providers per request for paper-based disclosures. The 
Departments have determined the phone disclosure limit should be 
consistent with the paper limit to ensure that these primary 
alternatives to the internet-based self-service tool ensure consumers 
receive the same level of access to cost-sharing information regardless 
of whether they request it by paper or phone because the information is 
likely sourced in the same manner and only shared differently with the 
requestor, by paper, or read over the phone. Reducing the phone limit 
below the paper limit would create a disparity in access to information 
between these two comparable request-based methods that would 
disadvantage consumers who rely on the phone-based method, including 
those with limited digital literacy or limited internet access. The 
Departments acknowledge the possibility of consumer confusion from 
having to navigate through up to 20 providers over the phone, but plans 
and issuers are encouraged to work with consumers to provide cost-
sharing estimates in the best way for each individual consumer, 
including reminding them that information is available by paper, or 
email, upon request. The Departments further clarify that the 20-
provider-per-day limit applies on a per-operational-day basis--that is, 
per day on which the plans or issuers customer service call center is 
open and available to receive calls.
    The Departments emphasize that the 20-provider limit, if adopted by 
a plan or issuer, will not necessarily result in cost-sharing 
information being provided for 20 providers on every call. It 
represents a maximum limit plans and issuers may impose for 
participants, beneficiaries, and enrollees who request information. The 
Departments expect that most consumers will seek relatively 
straightforward information, such as their out-of-pocket costs for a 
service from a specific provider or within a limited geographic area. 
The Departments agree with commenters about the possibility that some 
phone interactions may result in longer engagements, depending on the 
number of providers requested. However, the direct engagement afforded 
through phone interaction also provides an opportunity to ensure the 
consumer better understands the data and how to use it.
    Several commenters opposed adopting additional phone-based service 
standards, stating that plans and issuers are already subject to 
customer service expectations, contractual requirements, and applicable 
State and Federal oversight. A commenter noted the difficulty of 
evaluating this proposal given that the Departments did not specify the 
standards under consideration and expressed concern that additional 
prescriptive requirements could increase cost and complexity without 
improving consumer access to pricing estimates. The commenter 
recommended not requiring plans to provide cost estimates on a 24-hour 
basis but rather allow plans and issuers to align hours of operation 
with existing customer service hours. Another commenter stated that the 
ability to fulfill requests by phone varies widely based on plan scale, 
technical capabilities, and the complexity of requests, and that 
promulgating one-size-fits-all standards would cause unintended 
consequences, wasteful expenditure, and administrative burden. A 
commenter expressed confidence that plans would take reasonable steps 
to provide the required information within reasonable timelines taking 
into consideration the facts and circumstances of plan administration 
and capabilities. Conversely, another commenter encouraged the 
Departments to finalize additional phone-based service standards and 
consider establishing clear performance expectations, such as tracking 
and reporting call wait times, to ensure that phone-based access is 
reliable and meets consumer needs.
    The Departments agree with commenters that plans and issuers are 
already subject to customer service expectations, contractual 
requirements, and State oversight applicable to their overall consumer 
assistance operations. The Departments therefore decline to finalize 
additional standards beyond those proposed. The Departments have 
determined that plans and issuers are best positioned to set their own 
additional customer service standards, including based on standards 
they may already have in place for handling calls to the customer 
assistance number on the plan's or policy's identification card. 
Requiring additional standards, such as hours of operation, would 
likely be duplicative and unnecessarily burdensome.
    A commenter requested that the Departments clearly articulate what 
operational change is required, noting that the proposal appears to 
formalize, and potentially expand, expectations for providing phone-
based cost-sharing information. The commenter urged the Departments to 
clarify whether the proposed regulatory change codifies

[[Page 63759]]

existing practice or creates new obligations, stating that such 
clarification would allow plans and issuers to assess whether they are 
already in compliance with this requirement.
    In the 2020 final rules, the Departments finalized phone-based 
cost-sharing disclosure as an optional means of providing the 
information required under paragraph (b)(1). Following enactment of the 
No Surprises Act, which requires plans and issuers to offer price 
comparison guidance by phone under Code section 9819, ERISA section 
719, and PHS Act section 2799A-4, the Departments stated in FAQs Part 
49 \32\ that they expected to propose rulemaking requiring that the 
same pricing information that is available through the online tool or 
in paper form also be provided over the telephone upon request. These 
final rules codify that expectation by incorporating the phone 
disclosure requirement into the Transparency in Coverage regulations. 
For plans and issuers already providing cost-sharing information by 
phone consistent with the No Surprises Act and the guidance set forth 
in FAQs Part 49, this rule provides regulatory clarity by establishing 
a single, consolidated set of requirements across the online, paper, 
and phone disclosure modalities.
---------------------------------------------------------------------------

    \32\ 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), available at <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>.
---------------------------------------------------------------------------

    A commenter highlighted potential challenges regarding the 
operational readiness of service providers to provide real-time, 
accurate cost-sharing information, including potential underestimation 
of call volumes. Additionally, the commenter cautioned that service 
providers are likely to pass compliance costs onto plans through 
increased administrative fees rather than absorbing these reasonable 
costs.
    As stated in prior rulemaking, including the 2020 final rules, and 
reiterated in the proposed rules, the obligation to comply with the 
disclosure requirements under 26 CFR 54.9815-2715A2, 29 CFR 2590.715-
2715A2, and 45 CFR 147.211 rests with the group health plan or health 
insurance issuer offering coverage, even when the plan or issuer 
contracts with a service provider to perform certain functions on its 
behalf. The Departments recognize that service providers operating on 
behalf of plans and issuers may incur costs associated with 
implementing these requirements and may recover those costs through 
administrative fees. As discussed in section IV.A. of this preamble, 
the Departments assume that self-insured group health plans will rely 
on service providers to implement these requirements and, accordingly, 
estimate the costs of these changes as costs to plans' service 
providers. In addition, the Departments expect any resulting increases 
in administrative fees to be limited because the final requirements 
largely build on existing infrastructure, systems, and processes, 
including internet-based self-service tools that many plans, issuers, 
and service providers have already developed.
    A few commenters raised issues outside the scope of the phone-based 
disclosure provision. A commenter noted that the accuracy of consumer-
facing tools ultimately depends on the quality of the underlying 
machine-readable file data. Another commenter recommended that these 
final rules establish dispute protections for insured individuals who 
rely on phone-based cost-sharing estimates, similar to the good faith 
estimate protections available to uninsured individuals under the No 
Surprises Act. An additional commenter recommended that the Departments 
acknowledge in this preamble that price transparency is a necessary but 
insufficient condition for cost discipline and that the competitive 
benefit of transparency data depends on incentive alignment among 
intermediaries.
    The Departments appreciate these comments but note that they are 
outside the scope of the phone disclosure provision finalized in this 
rule.
3. Compliance With Code Section 9819, ERISA Section 719, and PHS Act 
Section 2799A-4
    The Departments proposed 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 
group health plan or health insurance 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 Departments also proposed that grandfathered health plans and 
issuers offering grandfathered individual and group 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 sought comment on all aspects of this proposal. 
After consideration of public comments, the Departments are finalizing 
these provisions as proposed.
    A few commenters strongly supported the Departments' proposal to 
treat compliance with the Transparency in Coverage cost-sharing 
disclosure requirements as satisfying the No Surprises Act price 
comparison tool obligations under Code section 9819, ERISA section 719, 
and PHS Act section 2799A-4. These commenters stated that requiring 
plans and issuers to build two separate self-service tools would impose 
significant unnecessary operational burdens and duplicate 
infrastructure costs. A commenter noted that a single, unified self-
service tool would be an administrative simplification that would allow 
health plans and issuers to direct implementation resources toward 
improving the availability and accuracy of cost-sharing estimates made 
available through their existing self-service tools. Other commenters 
emphasized that a single tool would prevent considerable consumer 
confusion and support a more consistent consumer experience across 
channels. Another commenter supported the proposed alignment of the 
Federal statutory requirements and noted appreciation that State law 
variations need not be addressed within this provision.
    The Departments agree that maintaining two functionally equivalent 
but separately administered self-service tools would impose significant 
burdens on plans and issuers without a corresponding benefit to 
consumers. The Departments also agree that subjecting plans and issuers 
to overlapping regulatory obligations to build separate tools offering 
substantially similar information would be administratively inefficient 
and contrary to the consumer-oriented goals of these statutes.
    The Departments note that the policy finalized in this provision is 
limited to the alignment of Federal requirements, and specifically, 
that plans and issuers providing the information in accordance with the 
Transparency in Coverage cost-sharing disclosure requirement 
regulations satisfies the Federal price comparison tool mandates set 
forth in Code section 9819, ERISA section 719, and PHS Act section 
2799A-4, including for grandfathered group health plans and health 
insurance issuers offering grandfathered group and individual health 
insurance coverage

[[Page 63760]]

that are not otherwise subject to such requirements. The Departments 
clarify that satisfying the overlapping Federal statutory requirements 
does not alter, address, or preempt applicable State laws. Pursuant to 
section 2724(a) of the PHS Act, and consistent with the framework 
established in the 2020 final rules, State laws regulating health 
insurance issuers are not preempted except to the extent they prevent 
the application of Federal requirements. Therefore, health insurance 
issuers must continue to independently comply with any applicable State 
laws.
    A commenter recommended that the Departments expand the tool 
requirements to mandate the disclosure of policies regarding the 
treatment of cost-sharing assistance. Specifically, the commenter 
requested that the Departments require group health plans and health 
insurance issuers to disclose the use of accumulator adjustment 
programs (AAPs), copay maximizers, and alternative funding programs 
(AFPs). The commenter also stated that providing this information would 
help patients and employers avoid benefit designs that may negatively 
impact patient access, adherence, and outcomes.
    The Departments have determined that adding new, substantive 
disclosure elements to the Transparency in Coverage and No Surprises 
Act requirements, such as specific flags for AAPs, copay maximizers, or 
AFPs, is outside the scope of this rulemaking. The purpose of this 
provision is to align the existing operational requirements of the 
Transparency in Coverage and No Surprises Act tools, not to introduce 
new data elements. The Departments note that, under existing 
Transparency in Coverage regulations, plans and issuers are already 
required to provide a notice in plain language with the internet-based 
self-service tool disclosures that includes a statement ``disclosing 
whether the plan counts copayment assistance and other third-party 
payments in the calculation of the participant's, beneficiary's, or 
enrollee's deductible and out-of-pocket maximum.'' \33\
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    \33\ 26 CFR 54.9815-2715A2(b)(1)(vii)(D), 29 CFR 2590.715-
2715A2(b)(1)(vii)(D), and 45 CFR 147.211(b)(1)(vii)(D).
---------------------------------------------------------------------------

4. Applicability
    The Departments proposed 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 paragraphs (b)(1)(i)(A), (b)(1)(i)(B), 
(b)(1)(vii)(A), (b)(2)(ii), (b)(3)(i), and (b)(3)(ii) and new 
paragraphs (b)(2)(iii) and (iv), and (c)(7) of these sections 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 these sections would continue to apply.
    The Departments sought comment on this proposed applicability date. 
After consideration of comments, the Departments are finalizing the 
proposed applicability date but modifying the proposed language at 26 
CFR 54.9815-2715A2(c)(1), 29 CFR 2590.715-2715A2(c)(1), and 45 CFR 
147.211(c)(1) to convey that all provisions of these sections apply for 
plan years (in the individual market, for policy years) beginning on or 
after January 1, 2027, and until such date, plans and issuers must 
comply with 26 CFR 54.9815-2715A3 revised as of April 1, 2025, 29 CFR 
2590.715-2715A3 revised as of July 1, 2025, and 45 CFR 147.211, revised 
as of October 1, 2025.
    A few commenters commented on this proposal. A commenter supported 
the proposed applicability date as providing adequate implementation 
time, while a few other commenters recommended the Departments extend 
the applicability date, which commenters variously recommended delaying 
an additional 6 months or 12 months, to allow sufficient time to 
implement the operations, systems, vendor, and training changes 
necessary to comply with the new requirements. A few additional 
commenters stated that a fixed applicability date of plan or policy 
years beginning on or after January 1, 2027--depending on when the 
final rule is published in 2026--could result in insufficient time for 
group health plans and health insurance issuers to update their 
workflows to implement these provisions.
    The Departments considered the proposed applicability date in light 
of the timing of the publication of these final rules. The Departments 
have determined that because the balance billing protection statement 
changes required under this section add to a preexisting disclosure 
requirement in accordance with current paragraph (b)(1)(vii)(A) \34\ 
they require minimal additional time and effort. Furthermore, because 
group health plans and health insurance issuers already have customer 
service phone infrastructure in place, the Departments have determined 
the applicability date in these final rules allows sufficient time for 
implementation.
---------------------------------------------------------------------------

    \34\ 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), available at <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>.
---------------------------------------------------------------------------

    With regard to the requirement that plans and issuers make 
available via phone the cost-sharing estimates and other disclosures 
required under paragraph (b)(1) of this section, the Departments 
acknowledge that plans and issuers will need to make operational 
changes and train customer service representatives to comply with these 
requirements. However, as the Departments stated in the preamble to the 
proposed rules, plans and issuers have been anticipating that this 
method of disclosure would be required since 2021, when the Departments 
announced their intention to propose rules requiring that the same 
pricing information that is available through the Transparency in 
Coverage internet-based self-service tool or in paper form, as 
described in 26 CFR 54.9815-2715A2(b)(2), 29 CFR 2590.715-2715A2(b)(2), 
and 45 CFR 147.211(b)(2), must also be provided over the phone upon 
request, pursuant to Code section 9819, ERISA section 719, and PHS Act 
section 2799A-4, as added by section 114 of the No Surprises Act.\35\ 
Therefore, the Departments expect many plans and issuers have already 
made progress toward meeting this requirement since then.
---------------------------------------------------------------------------

    \35\ See 90 FR 60432, 60446 (December 23, 2025); see also 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), available at https://www.cms.gov/CCIIO/Resources/Fact-
Sheets-and-FAQs/Downloads/FAQs-Part-49.pdf 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>.
---------------------------------------------------------------------------

    Additionally, as the Departments noted in the preamble to the 
proposed rules, group health plans and health insurance issuers are 
already required to include a telephone number through which 
participants, beneficiaries, and enrollees may seek consumer assistance 
information on physical or electronic plan or insurance identification 
cards under 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.\36\ Because new paragraph (b)(2)(iii) requires plans and issuers 
to leverage that existing telephone number to provide the required 
cost-sharing estimates and other disclosures, the Departments expect 
that much of the operations and systems, as well as vendors associated 
with the existing telephone number can

[[Page 63761]]

be leveraged for this purpose as well. For these reasons, the 
Departments are finalizing the applicability date as proposed to ensure 
consumers can timely access price comparison information over the 
phone.
---------------------------------------------------------------------------

    \36\ See 90 FR 60432, 60447 (December 23, 2025).
---------------------------------------------------------------------------

    Therefore, after consideration of these comments, the Departments 
have determined that the proposed applicability date for the amendments 
to paragraphs (b)(1)(i)(A), (b)(1)(i)(B), (b)(1)(vii)(A), (b)(2)(ii), 
(b)(3)(i), and (b)(3)(ii) and new paragraphs (b)(2)(iii), (b)(2)(iv), 
and (c)(7), is appropriate and reasonable.

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 In-network Rate File provision in the 2020 final rules 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 an 
internet 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 proposed 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 
instead of for each coverage option offered by a group health plan or 
health insurance issuer. This proposed change was 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 Price Transparency rules \37\ under 45 CFR part 180.
---------------------------------------------------------------------------

    \37\ 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, 84 FR 
65524 (November 27, 2019); Medicare Program: Hospital Outpatient 
Prospective Payment and Ambulatory Surgical Center Payment Systems 
and Quality Reporting Programs; Price Transparency of Hospital 
Standard Charges; Radiation Oncology Model, 86 FR 63458 (November 
16, 2021); Medicare Program: Hospital Outpatient Prospective Payment 
and Ambulatory Surgical Center Payment Systems; Quality Reporting 
Programs; Payment for Intensive Outpatient Services in Hospital 
Outpatient Departments, Community Mental Health Centers, Rural 
Health Clinics, Federally Qualified Health Centers, and Opioid 
Treatment Programs; Hospital Price Transparency; Changes to 
Community Mental Health Centers Conditions of Participation, Changes 
to the Inpatient Prospective Payment System Medicare Code Editor; 
Rural Emergency Hospital Conditions of Participation Technical 
Correction, 88 FR 81540 (November 22, 2023); Medicare Program: 
Hospital Outpatient Prospective Payment and Ambulatory Surgical 
Center Payment Systems; Quality Reporting Programs; Overall Hospital 
Quality Star Rating; Hospital Price Transparency; and Notice of 
Closure of a Teaching Hospital and Opportunity To Apply for 
Available Slots, 90 FR 53448 (November 25, 2025).
---------------------------------------------------------------------------

    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 proposed 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 report the common 
provider network name for which negotiated rate information is 
included. To allow file users to cross-reference a particular plan or 
policy of interest to its in-network rates, the Departments proposed to 
amend redesignated paragraph (b)(1)(i)(B) to require plans and issuers 
to identify, for each provider network for which the group health plan 
or health insurance issuer must publish an In-network Rate File, each 
of the plan's or issuer's coverage options that use that network. The 
Departments also proposed 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. Finally, the Departments proposed 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.
    The Departments solicited comment on all aspects of these proposed 
requirements. After consideration of public comments, the Departments 
are finalizing these provisions largely as proposed, except that the 
Departments are adding in new paragraph (b)(1)(i)(B) a requirement that 
group health plans and health insurance issuers report a provider 
network identifier, which further redesignates proposed paragraphs 
(b)(1)(i)(B) through (D) as paragraphs (b)(1)(i)(C) through (E), 
respectively.
    Many commenters supported the proposal to require one In-network 
Rate File per provider network (instead of per plan or policy) because 
commenters believe network-level organization would eliminate 
duplicative rates repeated across many health plans, substantially 
reduce file size and file counts, make data easier to download and 
process, better reflect how negotiated rates are operationally managed, 
better align payer disclosures with Hospital Price Transparency files, 
improve usability for employers and purchasers, and help clinicians 
understand network structures and track rate changes over time.
    The Departments agree that organizing the In-network Rate File by 
provider network instead of individual plan or policy will result in 
the benefits commenters identified. As stated in the proposed rules, 
the size of the In-network Rate File can be highly dependent on how it 
is organized. Where multiple plans share the same negotiated rates 
under an umbrella provider network, organizing the In-network Rate 
Files by provider network rather than by each individual plan or policy 
in most cases decreases the size of the files, often significantly, 
while still maintaining data integrity. It likely also reduces the 
total number of In-network Rate Files because research indicates that 
there are far more plans and policies offered than there are distinct, 
separately managed provider networks.\38\ Together, these anticipated 
reductions are expected to ease the processing burden on both file 
producers and file users and increase the usability for employers and 
purchasers. The Departments also agree with the commenters' assertion 
that network-level organization better reflects how negotiated rates 
are operationally managed, better aligns with hospital machine-readable 
files' data, and could help the public understand network structures 
and track rate changes over time.
---------------------------------------------------------------------------

    \38\ See Jane M. Zhu, Yuehan Zhang, & Daniel Polsky, Networks in 
ACA Marketplaces Are Narrower for Mental Health Care Than for 
Primary Care, 36 Health Affairs 9 (September 5, 2017), available at 
<a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0325">https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0325</a> 
(finding, based on 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). 
The proposed rules included citations with incorrect authors' names. 
Those citations have been corrected in these final rules.
---------------------------------------------------------------------------

    In the proposed rules, the Departments sought comment on whether 
additional limitations on what constitutes a separate provider network 
should be required. Many commenters recommended the Departments adopt a

[[Page 63762]]

clear, prescriptive definition of ``provider network'' (including what 
constitutes a distinct network) because they were concerned that 
inconsistent payer interpretations would undermine comparability, 
complicate enforcement, and limit the usability of network-level 
reporting. A few commenters provided examples of the variability in 
issuer network definitions and contracting practices to illustrate the 
potential impacts of inconsistent network definitions (for example, 
issuers may define networks at the product level, geographically, or by 
line of business). Other commenters expressed concern that, without 
guardrails and clear definitions, network-level reporting could become 
overly fragmented or otherwise inconsistent. These commenters suggested 
that over-segmentation could mean a proliferation of small network 
files (potentially increasing overall file volume), under-segmentation 
could mean the inclusion of rates that do not apply to many enrollees, 
and inconsistent naming could prevent reliable cross-payer comparison. 
A few commenters also recommended that the Departments require plans 
and issuers to clearly indicate whether a file represents a base 
network or a derived network, while another commenter recommended that 
the Departments require a standardized network hierarchy or precedence 
field and/or logic to be reported to resolve overlapping networks.
    The Departments did not define ``provider network'' in the proposed 
rules but instead instructed plans and issuers to define what 
constitutes a separate provider network according to their current 
business practices.\39\ This is because, while the Departments 
acknowledge the possibility of variability among provider network 
definitions and a potential reduction in comparability among files, 
these provisions are intended to facilitate analysis of the reported 
data based on the provider network structures as designed by plans and 
issuers, rather than require a one-size-fits-all approach.
---------------------------------------------------------------------------

    \39\ 90 FR 60432, 60448 (December 23, 2025).
---------------------------------------------------------------------------

    However, the Departments also acknowledge the possibility of over- 
and under-segmentation where plans and issuers rely solely on their 
current business practices without further guidance. Thus, in response 
to commenters seeking more clarity on what constitutes a provider 
network, under these final rules, the Departments clarify that each 
network should represent a single collection of contracted providers 
and corresponding in-network rates within a defined structure and 
represent the providers and rates for any member who accesses services 
while in-network. If variations among either participating providers or 
in-network rates exist, those variations constitute a separate network 
(for example, a derived network, which is a separate provider network 
that is leased from another issuer) and should therefore be reflected 
in a separate In-network Rate File. Lastly, the Departments recognize 
that networks can be layered, necessitating that base and derived 
networks be identified appropriately, and that other network 
hierarchies can exist as well. The Departments will specify an approach 
for reporting these network variations through future technical 
implementation guidance.
    Regarding the proposal to require plans and issuers to include the 
common provider network name as part of their In-network Rate Files, 
the Departments sought 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. Several commenters supported the requirement to include the 
common provider network name but expressed concern that relying 
primarily on provider network names may create ambiguity because payers 
may use different names (for example, one internal and one external) 
for the same network or similar names for different networks. A few 
commenters agreed that the network naming conventions should align with 
the external, consumer-facing marketing name of the network rather than 
an internal or publicly unknown name. A commenter recommended that the 
Departments publish guidance on network naming conventions to reduce 
ambiguity and facilitate cross-payer analysis. Several commenters 
recommended that the Departments require a standardized network 
identifier (or require a supplemental network identifier in addition to 
the common provider network name), because an identifier would support 
accurate aggregation and comparison, prevent users from treating 
distinct networks as interchangeable, and improve the ability to link 
negotiated rates to plan design information and other datasets.
    The Departments agree that the common provider network name should 
be an external name most familiar to participants, beneficiaries, 
enrollees, and the public, as currently described in technical 
implementation guidance.\40\ As noted in the proposed rules, the 
purpose of this requirement is to help file users identify specific 
provider networks, and provider network names used solely within a plan 
or issuer's internal operations are unlikely to be meaningful or 
recognizable to file users.\41\ The Departments acknowledge commenters' 
concerns that relying on provider network names alone would create 
ambiguity because plans and issuers may use different names for the 
same network or similar names for different networks. However, the 
Departments are not inclined to direct how plans and issuers must name 
their networks, and support allowing plans and issuers freedom to 
maintain existing provider network names and to create new ones within 
their own existing frameworks. Requiring changes to provider network 
naming could cause downstream confusion for group health plan sponsors 
and consumers.
---------------------------------------------------------------------------

    \40\ GitHub Users, GitHub Discussion: In-Network File #897, 
GitHub, available at <a href="https://github.com/CMSgov/price-transparency-guide/blob/master/schemas/in-network-rates/README.md#provider-reference-object">https://github.com/CMSgov/price-transparency-guide/blob/master/schemas/in-network-rates/README.md#provider-reference-object</a> (last updated January 8, 2026).
    \41\ 90 FR 60432, 60448 (December 23, 2025).
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    The Departments agree that a second network identifier, in addition 
to the common provider network name, could help relieve ambiguity by 
allowing file users to identify distinct networks that use the same or 
similar names, thus supporting accurate aggregation of in-network rates 
across multiple plans or policies that use the same network, and 
linking to other datasets. To that end, the Departments are finalizing 
at new paragraph (b)(1)(i)(B) the requirement that plans and issuers 
disclose a provider network identifier, in addition to the common 
provider network name. The Departments expect plans and issuers to use 
the existing network identifier used for internal tracking, which the 
Departments expect would be minimally burdensome to disclose. 
Instructions on how a plan or issuer may report the network identifier 
if no network identifier already exists will be provided through future 
technical implementation guidance.
    A few commenters recommended that CMS convene a working group to 
standardize a network-identification process for networks and 
associated plans, similar to how Vehicle Identification Numbers for 
cars are created and managed. Under this recommendation, commenters 
explained, CMS would create a standard for network identification and 
assign, register, and manage these identifiers. Creating, 
standardizing, and managing a network identifier process is beyond the 
scope of these final rules; however, the Departments acknowledge that 
there

[[Page 63763]]

may be a benefit to having a standardized network identification 
process and may take it into further consideration.
    Many commenters recommended a clear mapping of plans to provider 
networks, expressing concern that information could be lost in the 
transition from plan-level reporting to network-level reporting. 
Several of these commenters recommended requiring the Table of Contents 
File to identify the provider networks associated with a given plan. A 
few commenters suggested plans could be identified using the Employer 
Identification Number (EIN) and a few other commenters noted Health 
Insurance Oversight System (HIOS) identifiers (IDs) and group numbers 
could also identify correct plans and networks. Lastly, a few 
commenters suggested the Departments provide links to provider 
directories along with other required plan data.
    The Departments agree that retaining plan-level data is essential 
to the usability of the In-network Rate File. The Table of Contents 
File is expected in the current technical implementation guidance (also 
referred to as Schema 2.0) if more than one plan or policy offered by 
an issuer or plan sponsor shares the same in-network rates. The 
Departments decline to require the Table of Contents File in regulation 
in order to maintain the Departments' flexibility to collaborate with 
industry on technical specifications for most efficiently reporting the 
required data under the In-network Rate file. For this new organization 
of the In-network Rate File by provider network as finalized in these 
rules, the Departments expect--and plan to clarify in future technical 
implementation guidance--that the In-network Rate File only includes 
data about contracted providers and their rates. All of the data for 
plans or policies that use that network (including HIOS, EINs, and 
group numbers, as appropriate) will be captured in the Table of 
Contents File, which serves as an external reference to the In-network 
Rate File. This approach allows seamless mapping of plans and policies 
to provider networks, while preventing inflated file sizes for the In-
network Rate File. Lastly, while the Departments recognize the 
potential value in providing a link to provider directories because 
they can help consumers understand provider availability and access, 
the purpose of the In-network Rate File is to disclose contracted rates 
for providers by network, not to connect to consumer-facing provider 
directory information.
    A commenter recommended that the In-network Rate Files explicitly 
exclude ``rental networks'' used solely to supplement a plan's primary 
network, stating that it would exponentially increase file size while 
providing information relevant to only a small fraction of utilization. 
The commenter requested the Departments clarify if plans may limit In-
network Rate File disclosures to their primary contracted networks and 
if they are not required to include secondary rental network 
arrangements. Another commenter recommended the Departments specify 
which payer holds the contracts with providers for each network 
agreement represented by the In-network Rate Files, to help researchers 
understand each payer's relative market influence. Another commenter 
recommended the Departments clarify that network-level In-network Rate 
Files may be partitioned into multiple files or segments, suggesting 
that plans and issuers may face storage and bandwidth constraints when 
hosting files that represent large or national networks.
    The Departments reiterate that an In-network Rate File must be 
published for each provider network maintained or contracted by the 
group health plan or health insurance issuer. Whether that network is 
rented or owned does not change the plan's or issuer's responsibility 
to publish rates for that provider network as the network is attached 
to the product(s) marketed by the plan or issuer and for which there is 
enrollment. This allows files to be developed independently across 
multiple provider networks--whether rented or owned--without expanding 
or increasing In-network Rate File size exponentially. The Departments 
also acknowledge the potential value to file users of disclosing when 
networks are owned versus rented but are not finalizing a requirement 
to include that data element at this time in order to maintain 
flexibility to engage with industry through GitHub on this issue. 
However, the Departments may consider adding an optional contextual 
``rented vs. owned'' data element to identify network ownership in 
future technical implementation guidance. Further, both the 2020 final 
rules and these final rules, as well as Schema 2.0, allow plans and 
issuers to segment large files when necessary. The Departments 
recognize that this flexibility is particularly valuable for plans and 
issuers with large or national networks and intend to maintain it in 
future iterations of the schema.
    Some commenters opposed the proposal to require an In-network Rate 
File for each provider network maintained or contracted by the group 
health plan or health insurance issuer. A commenter expressed concern 
that the proposal could require plans to create more machine-readable 
files as any change for a given plan, in either the in-network 
providers or their rates, would be seen as a new network and would 
require a new In-network Rate File. Another commenter stated that 
network-level files would reduce the precision of the data where the 
common provider network name is not granular enough to denote rate 
variation across employer-sponsored plans, narrow and tiered networks, 
point-solution carve-outs, and regional plan variants. Another 
commenter requested that the Departments permit voluntary reporting at 
the network level and allow plans and issuers to continue reporting In-
network Rate Files at the plan level. Lastly, a commenter stated the 
network should be defined at the rate level as opposed to the provider 
level to better align with the hospital machine-readable files.
    The Departments acknowledge that the proposal could cause plans to 
create more machine-readable files if they over-segment their provider 
networks; however, the Departments' clarification earlier in this 
section of this preamble that a provider network should reflect a 
single collection of contracted providers and corresponding in-network 
rates should guide appropriate segmentation. Similarly, this 
clarification should guide the approach to rate variations and--along 
with the required provider network identifier--should lessen the risk 
of reduced data precision due to relying on the common provider network 
name alone. In addition, organizing the In-network Rate File by 
provider network is a primary focus of these final rules, and all plans 
and issuers will be required to reorganize their In-network Rate Files 
in this manner to ensure consistency and comparability across the 
files, improve the usefulness of the data, and reduce file size. 
Lastly, the Hospital Price Transparency machine-readable files required 
under 45 CFR part 180 identify the standard charge rates a hospital has 
established with each payer. Aligning with the Hospital Price 
Transparency requirements would standardize price disclosures, allowing 
researchers and other file users to more accurately cross-reference and 
compare information. For these reasons, the Departments have determined 
this to be the preferred approach for reorganizing the In-network Rate 
File.
    A few commenters made additional recommendations to the Departments 
regarding the In-network Rate File. A

[[Page 63764]]

commenter recommended that the Departments require plans and issuers to 
report data by provider type, stating that provider type data 
comparisons--such as assessing mental health and substance use care 
access and analyzing insurers' parity compliance--are necessary for 
understanding rates, but these comparisons are not possible without 
making provider types available. Another commenter expressed concern 
that many duplicate rates exist for the same service in the In-network 
Rate Files and recommended the Departments provide adequate 
differentiation of these rates. Several commenters also recommended 
contextual data elements to be added to the In-network Rate File that 
they believed would increase the precision of reported rates such as 
modifiers, multipliers, conditional clauses, outlier payment 
methodologies, outlier thresholds, carve-outs, bundled payment logic, 
capitation and global payment models, uniform service classifications, 
standard billing code types, and details on pricing and reimbursement 
methodologies especially for alternative reimbursement arrangements not 
supported by the schema. A few commenters asserted that inpatient 
outlier costs account for $100 billion in annual health care spending.
    The Departments appreciate these commenters' recommendations and 
recognize that some of these contextual data elements could provide 
additional nuance to the rates, while others could address gaps in 
specificity. These suggested elements are implementation details best 
addressed in technical implementation guidance given they are highly 
fact specific. Current technical implementation guidance already 
addresses modifiers, multipliers, bundled arrangements, capitation and 
global payment models, uniform service classifications, standard 
billing code types, and details on pricing and reimbursement 
methodologies. Further technical guidance will be provided to instruct 
plans and issuers to provide individual rate details on items that 
could otherwise be obscured or inappropriately summarized within the 
In-network Rate Files, such as for certain multipliers and uniform 
service classifications. Conditional clauses are not currently captured 
within the structure of the machine-readable file schemas because they 
generally apply at the contract level rather than to a specific item or 
service. While the current technical implementation guidance does not 
address a standardized method for disclosure of outliers, wherein rates 
may change at high dollar thresholds, the Departments intend to provide 
additional guidance for Schema 3.0 to accommodate these arrangements, 
including stop-loss provisions, which are contractual terms designed to 
protect against excessively high billed charges. Disclosure of these 
provisions can provide greater transparency into how negotiated rates 
may be adjusted or applied in atypical or unusually high-cost 
scenarios.
    The Departments also recognize the complexity of reporting carve-
outs and are considering whether additional technical implementation 
guidance would improve consistency in reporting these arrangements. The 
Departments recognize that grouping provider types (for example, 
physician, nurse practitioner, etc.) together can make rates ambiguous. 
The Departments intend to address the means of referencing these 
provider types to their appropriate rates within the In-network Rate 
File through future technical implementation guidance in collaboration 
with industry to determine the most efficient approach. The Departments 
encourage interested parties to continue to engage the Departments on 
additional technical modifications to the In-network Rate File 
reporting on GitHub. Subsequent technical improvements will be 
addressed in future technical implementation guidance.
    Lastly, as a clarification regarding plans without defined 
networks, as stated in the preamble to the 2020 rules, the Departments 
expect there will be no In-network Rate File for these types of 
arrangements because the plan or issuer does not have in-network 
providers as defined in these final rules.\42\ Plans without defined 
networks will still be required to publish Allowed Amount Files.
---------------------------------------------------------------------------

    \42\ 85 FR 72158, 72228 (November 12, 2020).
---------------------------------------------------------------------------

2. HIOS Identifier and Product Type
    In the proposed rules, the Departments proposed 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 proposed to remove 
the requirement for plans and issuers to report the 14-digit HIOS ID 
or, if the 14-digit HIOS ID is not available, the 5-digit HIOS ID, and 
instead require them to report the HIOS ID 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 did 
not propose to change the requirement that if no HIOS ID is available, 
plans and issuers must report the EIN. The Departments also proposed 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 Departments solicited comment on these proposed 
requirements. After consideration of comments, the Departments are 
finalizing these requirements largely as proposed, with the technical 
modification discussed in section III.C.1. of this preamble to 
redesignate proposed paragraph (b)(1)(i)(B) as paragraph 
(b)(1)(i)(C).The Departments are also adding a clarification that HMO 
and PPO are examples of product types and not an exhaustive list. Many 
commenters who submitted feedback on this proposal generally supported 
removing the 14-digit HIOS ID specificity from these final rules. A 
commenter interpreted the Departments' proposal to remove HIOS digit 
specificity as a proposal to remove the HIOS ID requirement altogether, 
stating that the 14-level HIOS ID is invaluable. Another commenter 
expressed concern that without the 14-digit HIOS ID, it would be hard 
to identify prices for individual health plans. The commenter 
recommended that plans and issuers include a crosswalk between networks 
and HIOS IDs in their Table of Contents Files, and when multiple rates 
exist within a network for the same service delivered by the same 
provider, the different HIOS IDs corresponding to each unique rate 
should be clearly identified. Yet another commenter requested that the 
Departments require plans and issuers to disclose the EIN of each 
company that purchases group health insurance coverage on the Small 
Business Health Options Program Marketplace, along with the HIOS Plan 
ID of coverage.
    Under these final rules, plans and issuers are still required to 
report the HIOS ID, if they have a HIOS ID, to identify the plan or 
coverage. The Departments clarify that the addition of the common 
provider network name field, as discussed in section III.C.1. of this 
preamble, is a complement to the network-level reporting requirement 
for the In-network Rate Files and does not replace the HIOS ID as the 
primary identifier for group or individual health insurance coverage. 
The Departments

[[Page 63765]]

have determined that the 14-digit HIOS ID--the most granular 
identifier--is not always necessary to identify a coverage option. The 
Departments currently specify the number of HIOS digits in technical 
implementation guidance and plan to continue doing so at a level of 
granularity that best supports accurate plan identification while 
reducing duplicative data, which is a determination the Departments 
make in collaboration with the GitHub community. As explained in the 
proposed rules, the Departments have determined that this approach, 
rather than specifying the number of digits in regulation, better 
maintains 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.\43\ 
The Departments anticipate limited risk that health plans will be 
unable to be identified, given that all plan data is currently captured 
in the Table of Contents File, which allows plans and issuers to 
combine common negotiated rates across multiple In-network Rate Files 
rather than publishing negotiated rates individually for each plan ID.
---------------------------------------------------------------------------

    \43\ 90 FR 60432, 60449 (December 23, 2025).
---------------------------------------------------------------------------

    The Departments also acknowledge the value of capturing the EINs of 
small employers that purchase group health insurance coverage through 
the Small Business Health Options Program as the EIN would serve as the 
identifier when a HIOS ID may not be available but are not finalizing 
such a requirement at this time. The Departments are mindful that 
including additional requirements at this time could jeopardize plans' 
and issuers' ability to meet the implementation timelines being 
finalized in this rule and have determined it is appropriate to first 
assess the impact of the provisions being finalized before including 
additional data elements that could increase plan and issuer burden. 
The Departments will explore possible ways to implement this in the 
future.
    With regard to the proposed requirement that plans and issuers 
include the product type of each plan or policy represented in an In-
network Rate File, the Departments sought comment on whether possible 
inconsistency between State definitions of certain product types would 
present difficulties for plans and issuers in determining which product 
type to indicate or cause confusion among file users. The Departments 
also sought 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.
    All commenters who provided feedback on the product type proposal 
supported it. A few commenters recommended that product type be 
included at the network level, not the plan or coverage option level, 
to minimize the likelihoods of duplicative data and increased file 
size. A few other commenters recommended that the Departments develop 
consistent definitions of different product types to ensure consistency 
in reporting. A commenter noted that terms like HMO or PPO can mean 
different things depending on context--in some cases, referring 
strictly to cost-sharing and referral mechanics at the plan level and, 
in others, reflecting a distinct network construct. The commenter 
recommended that the Departments clarify this distinction and provide a 
structured approach to ensure that product type is consistently 
represented as either a plan attribute, a network attribute, or both, 
where appropriate. Additionally, the commenter recommended that, with 
respect to self-funded employer plans, the Departments should encourage 
alignment with commonly accepted State-level product definitions to the 
extent feasible. The commenter shared that in the ERISA context, where 
self-insured plans are not formally required to be identified by 
product type, adopting a standardized nomenclature would improve 
consistency, reduce file user confusion, and enhance parity across 
fully-insured and self-funded arrangements.
    The Departments acknowledge that group health plans and health 
insurance issuers may use product type inconsistently, as terms such as 
HMO or PPO can vary in meaning depending on context. Although HHS 
regulations at 45 CFR 144.103 (providing a definition for ``product'') 
and 45 CFR 147.106(e)(3)(ii) (providing exceptions to guaranteed 
renewability requirements for uniform modifications of coverage) 
reference ``product network types,'' such as HMO, PPO, exclusive 
provider organization (EPO), point of service (POS), or indemnity, the 
Departments consider product type for purposes of these final rules to 
be a coverage option designation rather than a network-level 
designation. While the Departments do not define product type in these 
final rules, the Departments clarify here that terms such as HMO and 
PPO are examples of product types and are meant to be illustrative and 
non-exhaustive, given that plans and issuers may use other terms 
consistent with their own business practices and as required by 
applicable State law. These terms serve as meaningful indicators of 
benefit design structure at the plan or policy level, even where the 
precise meaning of these terms may vary depending on context. The 
Departments also understand that the vast majority of self-insured 
ERISA plans, which are not subject to State law definitions, use common 
labels such as HMO and PPO to describe their benefit offerings, as 
these terms are widely recognized and readily understood by employees. 
To that end, the Departments intend to develop future technical 
implementation guidance that will allow plans and issuers to select 
from a list of common product types and determine an alternative for 
reporting if there is no common product type to accurately describe the 
benefit offering.
    After considering the public comments received, the Departments are 
finalizing the amendment to redesignated 26 CFR 54.9815-
2715A3(b)(1)(i)(C), 29 CFR 2590.715-2715A3(b)(1)(i)(C), and 45 CFR 
147.212(b)(1)(i)(C), and 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) with the 
minor technical and clarifying amendments described above.
3. Percentage-of-Billed-Charges Arrangements
    The Departments proposed 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 require that in-network rates must be 
reflected as dollar amounts 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 would be required to report a 
percentage number, in lieu of a dollar amount, in the form and manner 
as specified in guidance issued by the Departments. The Departments 
solicited comment on this proposed requirement. After consideration of 
comments, the Departments are finalizing this requirement as proposed; 
however, other amendments to this section further redesignate this 
paragraph as paragraph (b)(1)(i)(E)(1).
    In the proposed rules, the Departments explained that, although

[[Page 63766]]

the 2020 final rules \44\ generally require rates to be reported as 
dollar amounts regardless of payment model, interested parties 
identified ongoing challenges with certain alternative reimbursement 
arrangements, most notably with ``percentage-of-billed-charges'' 
contracts, under which a dollar amount cannot be determined 
prospectively because payment is defined as a fixed percentage of 
charges that are not known until after a claim is generated. In FAQs 
Part 53, the Departments established an enforcement safe harbor 
permitting percentage-based reporting for such alternative payment 
arrangements when dollar amounts could not be derived with 
accuracy.\45\ In FAQs Part 61, the Departments rescinded the statement 
of enforcement discretion provided in FAQs Part 53 and clarified that 
the ability to report dollar amounts is a fact-specific determination 
and that enforcement discretion would be exercised on a case-by-case 
basis, without a categorical safe harbor, while also directing plans 
and issuers to continue following existing technical implementation 
guidance.\46\ In response to continued feedback and the need for 
greater clarity and consistency in reporting, the Departments proposed 
to amend the In-network Rate File requirements to permit plans and 
issuers to report a percentage of billed charges in limited 
circumstances in the form and manner specified in guidance, while 
continuing to require dollar-based reporting wherever a dollar amount 
can be determined prospectively.
---------------------------------------------------------------------------

    \44\ 85 FR 72158, 72226 (November 12, 2020).
    \45\ 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), available at 
<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>.
    \46\ 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), available at 
<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/ouractivities/resource-center/faqs/aca-part-61">https://www.dol.gov/agencies/ebsa/about-ebsa/ouractivities/resource-center/faqs/aca-part-61</a>; Centers 
for Medicare & Medicaid Services, Transparency in Coverage, GitHub, 
<a href="https://github.com/CMSgov/price-transparency-guide/blob/master/schemas/in-network-rates/README.md#additional-notes-1">https://github.com/CMSgov/price-transparency-guide/blob/master/schemas/in-network-rates/README.md#additional-notes-1</a> (last updated 
January 8, 2026).
---------------------------------------------------------------------------

    Many commenters supported the proposal to require that in-network 
rates be reflected as dollar amounts except for contractual 
arrangements under which the 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. 
These commenters stated that the proposed exception would preserve 
contractual accuracy while providing a pragmatic solution that removes 
ambiguity and prevents the disclosure of misleading dollar figures. 
Additionally, commenters highlighted that this proposal aligns with 
current guidance that recognizes situations where a precise dollar 
amount cannot be determined in advance.
    The Departments agree with commenters that requiring in-network 
rates to be reflected as dollar amounts except for certain specific 
arrangements can remove ambiguity, preserve contractual accuracy, and 
prevent the disclosure of misleading dollar figures. The goal of these 
transparency disclosures is to reveal how group health plans' and 
health insurance issuers' contractual arrangements are currently 
structured, rather than trying to standardize a one-size-fits-all 
approach.
    Several commenters offered alternatives to reporting only a 
percentage under these arrangements, stating that the proposed 
exception would provide limited value and would be inconsistently 
implemented without additional context. A few commenters recommended 
requiring plans and issuers to pair any reported percentage with 
dollar-based context derived from historical experience, such as 
historical price averages, average and median paid amounts over a 12-
month lookback period or percentile-based allowed amounts, and 
estimated dollar amounts as required in the Hospital Price Transparency 
rules,\47\ to make the information usable and comparable. A commenter 
recommended that plans and issuers be required to provide the average 
billed amount for a particular provider group along with the percentage 
number. Another commenter recommended that the Departments allow 
reporting of percentages when historical claims data for a service does 
not meet the minimum volume threshold necessary to support a reliable 
dollar estimate, rather than publishing an estimated dollar amount that 
may not reflect an accurate payment experience and could confuse users 
and potentially erode data integrity.
---------------------------------------------------------------------------

    \47\ 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, 84 FR 
65524 (November 27, 2019); Medicare Program: Hospital Outpatient 
Prospective Payment and Ambulatory Surgical Center Payment Systems 
and Quality Reporting Programs; Price Transparency of Hospital 
Standard Charges; Radiation Oncology Model, 86 FR 63458 (November 
16, 2021); Medicare Program: Hospital Outpatient Prospective Payment 
and Ambulatory Surgical Center Payment Systems; Quality Reporting 
Programs; Payment for Intensive Outpatient Services in Hospital 
Outpatient Departments, Community Mental Health Centers, Rural 
Health Clinics, Federally Qualified Health Centers, and Opioid 
Treatment Programs; Hospital Price Transparency; Changes to 
Community Mental Health Centers Conditions of Participation, Changes 
to the Inpatient Prospective Payment System Medicare Code Editor; 
Rural Emergency Hospital Conditions of Participation Technical 
Correction, 88 FR 81540 (November 22, 2023); Medicare Program: 
Hospital Outpatient Prospective Payment and Ambulatory Surgical 
Center Payment Systems; Quality Reporting Programs; Overall Hospital 
Quality Star Rating; Hospital Price Transparency; and Notice of 
Closure of a Teaching Hospital and Opportunity To Apply for 
Available Slots, 90 FR 53448 (November 25, 2025).
---------------------------------------------------------------------------

    The Departments acknowledge the limitations of reporting an in-
network rate only as a percentage and appreciate the suggestions to add 
additional claims-based data elements to provide context and clarity 
for percentage-of-billed-charges reporting. The Departments also 
acknowledge the commenter's suggestion to allow plans and issuers to 
disclose percentage-based rates when historical claims data for a 
service does not meet a minimum volume threshold. However, the 
Departments have determined that calculating a dollar-based value 
derived from historical claims, such as averages, estimates, or 
medians, would add considerable complexity to the In-network Rate File. 
The In-network Rate File is intended to contain prospective data for a 
specific time period to accurately reflect what payer-provider 
contractual arrangements look like. If the Departments were to require 
plans and issuers to include retrospective claims data from other 
systems into the In-network Rate File, it would add considerable burden 
to create the file. In addition, the information could reduce the 
usability of the file, as it would result in the file including both 
prospective data and historical billed charges that may not reflect 
future billed charges. This could create confusion about which data in 
the In-network Rate File reflects current contractual arrangements, as 
historical claims data is meant to be reflected in the Allowed Amount 
File only. Additionally, in contrast with the Hospital Price 
Transparency reporting approach where there is a singular provider (the 
hospital), calculating averages or medians across a large volume of 
providers with different billed charges is unlikely to provide 
meaningful or actionable information for file users.
    A few commenters did not support the proposal, asserting that 
allowing an exception to reporting a dollar amount would result in 
disclosures that are confusing and not actionable. These commenters 
indicated that percentages

[[Page 63767]]

are difficult to interpret without the underlying billed charge, which 
is often unavailable, and therefore this type of disclosure would limit 
meaningful comparisons across plans and providers. A commenter 
expressed that posting negotiated rates as a percentage of billed 
charges directly undermines the intended purpose of the price 
transparency goals and that for a percentage-of-billed-charges rate to 
be meaningful, hospitals would have to disclose the price for that same 
service in their hospital pricing files. Another commenter expressed 
concern that allowing percentage-only reporting would create a 
transparency loophole and shift the burden to users to cross-reference 
other sources to estimate actual prices.
    The Departments acknowledge these comments regarding the 
interpretability of percentage-of-billed-charges reporting without the 
availability of a billed charge amount. The Departments have determined 
that it is appropriate to codify the exception to reporting a dollar 
amount as specified in existing technical implementation guidance.\48\ 
Since issuing this guidance, 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.\49\ Requiring plans and issuers to 
generate estimated dollar amounts when only a percentage of billed 
charges is available prospectively would introduce significant 
variability and limit the accuracy of the reported amount given 
differing underlying payment methodologies. In turn, this limited 
accuracy may impose more burden on users to interpret these amounts. 
The Departments understand that disclosing percentages without billed 
charges limits users' ability to view the base dollar amount a plan or 
issuer agrees to pay a provider, and thus limits price transparency in 
that manner. However, the Departments have determined that permitting 
this exception offers more transparency into plan and issuer activity 
than potentially imprecise estimates derived through various means. The 
Departments reiterate that plans and issuers must disclose rates as a 
dollar amount whenever a dollar amount can be calculated in advance, 
and the exception only applies under this narrow circumstance.
---------------------------------------------------------------------------

    \48\ Centers for Medicare & Medicaid Services, Transparency in 
Coverage Price Transparency Guide, In-network Rates Negotiated Price 
Object, GitHub, available at <a href="https://github.com/CMSgov/price-transparency-guide/tree/master/schemas/in-network-rates#negotiated-price-object">https://github.com/CMSgov/price-transparency-guide/tree/master/schemas/in-network-rates#negotiated-price-object</a> (last visited August 21, 2026).
    \49\ 90 FR 60432, 60451 (December 23, 2025).
---------------------------------------------------------------------------

    Finally, a few commenters recommended that the Departments codify 
the open text field guidance as described in FAQs Part 53 for 
alternative reimbursement arrangements.\50\ While the Departments are 
not codifying the ``additional information'' field--also known as the 
open text field--in these final rules because it is an optional field 
for use only when applicable, the Departments clarify that the 
additional information field remains in the schema to allow plans and 
issuers to describe additional context to their contracting 
arrangements, including payment formulas or methodologies, if they 
cannot otherwise be captured in the existing standardized data elements 
of the schema.
---------------------------------------------------------------------------

    \50\ 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-ebs">https://www.dol.gov/agencies/ebsa/about-ebs</a>.
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4. Enrollment Totals
    The Departments proposed 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) to require group health plans and health insurance 
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 would include the number of 
participants, beneficiaries, and enrollees (including all dependents) 
in the coverage option offered by a plan or issuer. In the proposed 
rules, the Departments explained that in response to feedback received 
since the publication of the 2020 final rules, additional data 
elements, such as plan enrollment numbers, 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, 
would be in line with the goals stated in the 2020 final rules.\51\ The 
Departments solicited comment on the feasibility of including the 
enrollment total as of the date the file is posted, whether an 
enrollment total on a different specified date would be more feasible 
for file producers and more useful to data users, and on the proposal 
in general.
---------------------------------------------------------------------------

    \51\ 85 FR 72158, 72161 (November 12, 2020); see also Gary 
Claxton, Lynne Cotter, & Shameek Rakshit, Challenges with Effective 
Price Transparency Analyses, Peterson-KFF Health System Tracker 
(February 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>.
---------------------------------------------------------------------------

    After consideration of comments, the Departments are not finalizing 
the proposal to include numerical enrollment totals in the In-network 
Rate File.
    Several commenters supported requiring group health plans and 
health insurance issuers to include the number of participants, 
beneficiaries, and enrollees (including dependents) for each coverage 
option represented in the In-network Rate File. These commenters stated 
that such enrollment data would improve the analytical usefulness of 
the files by providing more consistent contextual information about the 
reach of benefit arrangements, supporting analysis of market power and 
pricing trends, enabling comparison across plans and coverage options, 
and helping purchasers identify appropriate benchmark groups.
    A few commenters recommended that the Departments consider 
including county-level enrollment counts to help researchers, 
regulators, and businesses to better understand relative market power 
and act upon enrollment data. A commenter urged the Departments to 
review methodologies on county-level enrollment as used in Medicare 
Advantage plans to see how they could be applied to the In-network Rate 
Files. Commenters also recommended clarifying enrollment attribution by 
limiting the total to individuals directly enrolled with the reporting 
plan or issuer to help avoid confusion arising from collaborative 
agreements across separate payer entities who share provider networks, 
and that multiple plans and issuers can provide a single member with 
network access.
    Several commenters recommended reporting enrollment totals in the 
Table of Contents File or other plan level metadata rather than within 
each In-network Rate File, stating that a centralized approach would 
provide a more consistent reporting location, reduce duplication and 
reconciliation burden, and simplify implementation for plans and 
service providers. A commenter further recommended quarterly updates to 
the Table of Contents File and adding a standardized enrollment total 
field to the reporting plan object.
    Several commenters did not support requiring plans and issuers to 
include the number of participants, beneficiaries, and enrollees 
(including dependents) for each plan or coverage option represented in 
the In-network Rate File. The commenters noted that enrollment and rate 
data reside in separate, incompatible systems, making

[[Page 63768]]

compliance operationally impracticable and adding complexity in 
reconciling the data since member-level systems are not available for 
machine-readable file generation. Another commenter expressed concern 
that requiring exact enrollment totals may create operational burden 
and reporting instability. The commenter noted that enrollment figures 
are inherently fluid and difficult to measure precisely at a single 
point in time and therefore recommended allowing rounded estimates to 
balance transparency goals with administrative feasibility, data 
consistency, and comparability across plans and issuers.
    Finally, a commenter recommended that the Departments convene a 
structured workgroup of interested parties on enrollment reporting to 
support implementation and help troubleshoot operational issues prior 
to issuing final guidance for reporting enrollment totals.
    The Departments agree with commenters' assessment of the 
operational difficulties in reporting enrollment numbers at the plan 
level and are also concerned that the differences in data systems, 
reporting methodologies, and reconciliation processes could increase 
the likelihood of inconsistent or inaccurate reporting across plans and 
issuers, thereby reducing the reliability and comparability of the data 
for users. After further consideration, the Departments are concerned 
that the potential value for certain uses of the enrollment counts are 
outweighed by the significant operational burden associated with 
implementing this requirement and updating the enrollment numbers 
quarterly, and potential unintended consequences to plans, issuers, and 
other businesses that could result from the disclosure of enrollment 
trends.
    A few commenters supported requiring plans and issuers to include 
in each In-network Rate File current numerical enrollment totals ``as 
of'' the file posting date for each coverage option offered by a plan 
or issuer represented in the file. The commenters believed the ``as 
of'' file posting date is the clearest and most administratively 
feasible reference point for both file producers and data users. A few 
commenters recommended allowing a set date for reporting enrollment 
totals and recommended the date be the first day of the month preceding 
the filing quarter. The commenters believed this would reduce 
operational burden while still providing useful context for users. 
Another commenter urged the Departments to require annual enrollment 
reporting if it is infeasible or overly burdensome for plans and 
issuers to include enrollment totals as of the file posting date. A 
commenter recommended that the Departments set the enrollment total 
``as of'' report date to the posting date of the previous In-network 
Rate File because they believed retrospective reporting would balance 
minimal uncertainty with offering users a more accurate representation.
    Conversely, a few commenters did not support requiring plans and 
issuers to include enrollment totals as of any specific date for group 
health plans. The commenters noted that the enrollment total comprises 
multiple numbers that are built on separate data sources and requires 
time to compile, making near real-time reporting difficult.
    A few commenters also expressed that enrollment numbers may be 
outdated by days or weeks which could mislead users, that enrollment 
totals are not necessary for an individual member to make provider cost 
comparisons, and that the information provides limited practical value 
for consumers. A few other commenters mentioned data accuracy concerns, 
which they believed would also increase the potential for 
misinterpretation. A commenter did not believe enrollment totals would 
fulfill the Departments' goal to enable users to build analytically 
sound and accurate comparisons of plans and issuers' enrollment data, 
nor would it reduce file size. Another commenter noted that enrollment 
data is already available for individual and small groups under the 
Unified Rate Review Template public use files.
    The Departments have considered alternative reporting approaches, 
including in response to comments explaining that enrollment 
information is maintained in separate systems from other machine-
readable file data and would need to be appended to the In-network Rate 
File. After consideration of those alternatives, the Departments agree 
with commenters who expressed concern that point-in-time enrollment 
reporting could quickly become outdated or misleading due to frequent 
enrollment fluctuations and retroactive eligibility adjustments. The 
Departments also agree that requiring the reporting of enrollment 
totals could increase operational complexity and create challenges 
related to data accuracy, consistency, and comparability across 
reporting entities. In addition, the Departments agree with commenters' 
concerns regarding the limited practical utility of enrollment 
information for consumers, while acknowledging that consumers are not 
typically the primary users of the In-network Rate Files. The 
Departments further recognize that publicly available sources may 
already provide certain enrollment-related information for portions of 
the health insurance market. For example, under the Prescription Drug 
Data Collection (RxDC) requirement, plans and issuers are required to 
report the number of participants, beneficiaries, and enrollees, as 
applicable, covered on the last day of the reference year for each plan 
or coverage.\52\ The Departments acknowledge this requires only annual 
reporting of the previous year's enrollment totals, whereas the 
Transparency in Coverage proposed requirement would require quarterly 
reporting of enrollment numbers which would increase the operational 
complexity and data validity challenges as previously mentioned.
---------------------------------------------------------------------------

    \52\ See 29 CFR 2590.725-4(a)(3) and 45 CFR 149.740(a)(3); see 
also 26 CFR 54.9825-6T(a)(3) (expired).
---------------------------------------------------------------------------

    A few commenters recommended clarification regarding where 
enrollment totals should be reported in the machine-readable files to 
ensure consistency across plans and issuers and how the different 
machine-readable file production scenarios would handle the enrollment 
totals. A commenter urged the Departments to clarify which enrollment 
totals apply when an employer plan generates In-network Rate Files at a 
plan-level compared to when a vendor produces a network-level In-
network Rate File that includes the employer health plan's information. 
Specifically, the commenter questioned whether plan-level reporting 
should reflect overall plan enrollment or enrollment for a particular 
plan design option.
    The Departments acknowledge these requests for clarification but 
because the proposal to require numerical enrollment totals in the In-
network Rate File is not being finalized in these rules, such 
clarification is not necessary.
    A few commenters expressed concerns regarding how reporting 
enrollment totals could compromise sensitive business information and 
the ability for plans and issuers to negotiate fair rates. A commenter 
noted that providers and third parties already are using data from 
published machine-readable files in rate negotiations and expressed 
concern that adding enrollment data would increase the likelihood of 
that practice, allowing providers to further identify areas for 
leverage in rate negotiations. The commenter stated that increased 
costs related to such practices would be passed on to consumers, 
ultimately undermining the cost-containment goal of price transparency. 
A commenter

[[Page 63769]]

noted that without proper context, users of machine-readable files may 
incorrectly use enrollment figures to draw conclusions about provider 
networks or plan popularity, which could undermine, rather than 
enhance, meaningful transparency. A commenter expressed that the 
granularity of coverage-level enrollee reporting could raise privacy or 
competitive concerns for small employers. the commenter recommended a 
defined enrollment threshold to protect small populations without 
creating gaps in data for larger plans where privacy risk is 
negligible. A commenter recommended reporting enrollment at both the 
plan and network levels. Another commenter noted that network 
enrollment data information would better support employers with health 
benefit negotiations, which typically are done at the network level.
    The Departments carefully considered commenters' concerns that 
reporting enrollment totals could have unintended consequences that 
expose business vulnerabilities such as limiting ability to negotiate 
effectively--especially for smaller entities--and lead to higher prices 
for consumers. The Departments note that the intention of the In-
network Rate File is to reveal pricing by provider network. While 
enrollment counts might give context to prices, they are not directly 
price related. The Departments acknowledge comments recommending 
reporting at the network level instead of the coverage level, which 
could minimize the risk that parties would take advantage of enrollment 
information to negotiate higher rates. However, the Departments are 
persuaded that the operational, implementation, data reliability, and 
business vulnerability concerns raised by commenters outweigh the 
potential benefits of finalizing this proposal, regardless of how 
enrollment counts are reported. In particular, the Departments are 
concerned that requiring enrollment reporting could be unduly 
burdensome due to the separation of enrollment and rate data systems 
and may result in inconsistent or potentially misleading reporting. 
Accordingly, the Departments are not finalizing the proposed 
requirement to include enrollment totals in the In-network Rate Files.
5. Excluded Provider Information
    The Departments proposed 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 group health plans and health insurance 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 proposed 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 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. The Departments 
also proposed to amend 26 CFR 54.9815-2715A3(b)(1)(i)(E)(2), 29 CFR 
2590.715-2715A3(b)(1)(i)(E)(2), and 45 CFR 147.212(b)(1)(i)(E)(2) to 
direct plans and issuers not to include an in-network provider's 
National Provider Identifier (NPI), Tax Identification Number (TIN), 
and Place of Service Code if that in-network provider would be excluded 
as specified in paragraph (b)(1)(i)(F) of this section.
    The proposed rules set forth 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's or issuer's requirements for 
that item or service, the claim may be denied. For example, the 
Departments expect that a plan's 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 the standardized code set 
established by the National Uniform Claim Committee (NUCC) or their own 
model derived from it.\53\ The NUCC maintains standard provider 
taxonomy codes, which are used to define a provider's area of 
specialty.\54\ Provider taxonomy codes are ten characters in length 
structured into three distinct ``levels'' including provider grouping, 
classification, and area of specialization.\55\ 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. 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.
---------------------------------------------------------------------------

    \53\ 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, available at 
<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 May 4, 2026).
    \54\ See National Uniform Claim Committee, Health Care Provider 
Taxonomy, available at <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 May 4, 
2026).
    \55\ See id.
---------------------------------------------------------------------------

    The Departments sought comment on all aspects of this proposal and 
were 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 
also sought comment on whether there are alternative approaches to 
excluding any provider that has a rate for an item or service that 
interested parties consider not to be a meaningful rate. The 
Departments also requested feedback from interested parties on the 
relative burdens and benefits of alternative approaches to both 
producers and file users. The Departments were also interested in any 
concerns that parties may have with a proposal to require plans and 
issuers to make such exclusions at all.
    After consideration of public comments, the Departments are 
finalizing the requirements set forth at 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) and 26 CFR 54.9815-2715A3(b)(1)(i)(E)(2), 29 CFR 
2590.715-2715A3(b)(1)(i)(E)(2), and 45 CFR 147.212(b)(1)(i)(E)(2) as 
proposed, with one modification to require plans and issuers to exclude 
provider-rate combinations that are unlikely given the provider's 
specialty, according to either

[[Page 63770]]

the plan's or issuer's internal provider taxonomy or other internal 
rules used during the claims adjudication process.
    Many commenters supported the proposals that would remove unlikely 
provider-rate combinations to decrease file size and increase data 
reliability and usability by removing ``noise.'' These commenters 
indicated that plans and issuers already utilize internal controls to 
map provider specialty or taxonomy to billing codes for the purposes of 
preventing payments when an item or service in a claim is inconsistent 
with the submitting provider's credentials. A few commenters asserted 
that removing unlikely provider-rate combinations should help employers 
make better purchasing decisions. A few other commenters added that 
finalizing this proposal would lead to reduced costs for compliance and 
system maintenance, and that a logical removal of implausible 
combinations represents a standardization that enhances usability 
without sacrificing transparency.
    The Departments agree that requiring plans and issuers to exclude 
unlikely provider-rate combinations will lead to significant reductions 
in file size, increase the usability and reliability of the In-network 
Rate File data for providers, patients, and policymakers, and help 
employers make better purchasing decisions.
    A few commenters, while supportive of the proposal, expressed 
concerns about implementation and emphasized the importance of clear 
instructions to plans and issuers on how to conduct the required 
provider-rate exclusions to avoid over-exclusion. A commenter noted 
that the exclusions would be administratively burdensome for owners of 
provider networks to implement and requested that the Departments 
provide technical assistance to these owners. Another commenter pointed 
out the potential for the provider-rate exclusion to appear in a non-
standardized manner, given the potential differences in plans' and 
issuers' claims adjudication processes. A commenter requested that the 
Departments require plans and issuers to document the provider-rate 
combinations that are removed to increase the public's understanding of 
these exclusions. A few commenters encouraged the Departments to work 
with interested parties to identify the best way to design the 
parameters around provider-rate exclusions. Another commenter requested 
that the Departments go further and require plans and issuers to 
exclude negotiated rates from the In-network Rate File where plans or 
issuers have a reasonable belief that claims are no longer being 
submitted under the contract, including but not limited to instances 
where the plan or issuer has officially designated the contract as 
``dormant'' or some other related term. However, a commenter 
recommended that the Departments permit plans and issuers to include a 
provider in the rate file for a specific service even if the provider 
has not historically performed the service within the network reflected 
in the file, which may be the case when the provider is in a multi-
specialty group with combinations of TIN/EINs and NPIs. A commenter was 
concerned that implementor-defined taxonomy filters could result in 
data gaps, contributing to existing data usability issues.
    The Departments intend to address many of these concerns through 
future technical implementation guidance to afford the Departments 
flexibility to determine appropriate technical reporting requirements 
and to make refinements in response to changes in technology and health 
care industry business practices. This future technical implementation 
guidance--in the form of contextual data attributes within schemas--
will provide clear instructions to plans and issuers, and the iterative 
development process through community feedback on GitHub will allow 
file producers and file users to help the Departments minimize over-
exclusions and address non-standard arrangements. The Departments have 
determined that requiring plans and issuers to separately document the 
provider-rate combinations that are excluded from the In-network Rate 
File is unnecessary given that file users can verify the exclusions 
through examining the Taxonomy and Utilization Files, as discussed in 
section III.C.8. of this preamble. The Departments emphasize that the 
provider-rate exclusion must be based on the plan's or issuer's 
determination that it is unlikely a provider would be reimbursed for an 
item or service given that provider's specialty. This does not include 
an unlikely reimbursement based on other reasons, such as a dormancy 
period. A claims adjudication system relying on taxonomic specialties 
may still be able to reimburse for a claim submitted by a previously 
dormant provider if it meets the provider specialty-billing code 
mapping, regardless of a lack of recent claims.
    Additionally, the Departments note for clarity, that these final 
rules require a plan or issuer to exclude unlikely provider-rate 
combinations using its internal logic used during the claims 
adjudication process to determine whether to deny reimbursement for an 
item or service given the provider's specialty--whether that internal 
logic is an internal provider taxonomy or other internal rules used for 
this purpose. The ``internal provide taxonomy'' referenced in this 
requirement is distinct from the ``Taxonomy File'' referenced in the 
new requirement discussed in section III.C.8.c. of this preamble. The 
Taxonomy File must contain a plan's or issuer's internal logic used 
during the claims adjudication process to determine whether to deny 
reimbursement for an item or service given the provider's specialty--
again, using an internal provider taxonomy or other internal rules used 
for this purpose--but reflected as pairings of billing codes and NUCC 
codes. The Departments therefore expect that plans and issuers may need 
to convert their internal rules into data suitable to be submitted in 
the Taxonomy File.
    A commenter expressed concern that the proposed exclusion process 
would be used by issuers as a justification to improperly deny claims 
for the provision of services that may fall within a provider's lawful 
scope of practice but are not captured by the NUCC code set. The 
commenter requested that the Departments engage advanced practice 
provider organizations in reviewing and transparently validating the 
process used to determine which services are excluded for their 
respective specialties.
    The Departments clarify that a plan's or issuer's determination of 
whether a provider is unlikely to be reimbursed for an item or service 
based on the provider's specialty must be made consistent with 
applicable law. This clarification recognizes that other provisions of 
Federal or State law may limit the circumstances in which a plan or 
issuer may distinguish among providers based on specialty, licensure, 
certification, or similar characteristics. For example, section 2706(a) 
of the PHS Act generally prohibits discrimination with respect to 
participation under a plan or coverage against a health care provider 
acting within the scope of the provider's license or certification 
under applicable State law. However, validating the process used to 
determine which services are excluded for their respective specialties 
is beyond the scope of these rules, which do not require plans and 
issuers to make any changes their claim adjudication processes or any 
rules they use to determine whether to deny reimbursement given the 
provider's specialty.
    A commenter noted that the rule would prevent provider-rate 
combinations from other taxonomies being used as part of the process to

[[Page 63771]]

exclude unlikely provider-rate combinations but does not prevent 
posting a conversion factor or rate for procedures within the same 
specialty that are not performed and that this could lead to payers 
negotiating significantly lower rates with specialists for specific 
services they do not perform.
    The Departments agree that a provider's taxonomy defines what they 
may be reimbursed for, not what they actually furnish. The Utilization 
File addresses this gap by identifying providers who submitted claims 
and received reimbursement (or would have been reimbursed but for cost-
sharing liability) for items and services during the reporting period. 
This allows users to distinguish negotiated rates for items and 
services actually furnished from those that are not, without requiring 
plans to make service-level determinations about individual practices. 
The Departments will monitor whether the Utilization File serves this 
purpose effectively. The Departments also acknowledge that details 
about negotiated arrangements, such as conversion factors and rates, 
can vary among providers within the same specialty and could lead to 
ambiguous negotiated rates. To address this, the Departments continue 
to include an open text field in the schema to enable plans and issuers 
to clarify or account for these unique scenarios and will continue to 
evaluate the possibility of standardizing such arrangement details as 
the Departments monitor industry's implementation of the schema.
    A few commenters cautioned against utilizing overly rigid filtering 
requirements to determine whether a specific provider is unlikely to be 
reimbursed for an item or service. This is because a highly granular 
NPI level reporting would require splitting apart NPI array values and 
would significantly fragment the provider references attribute, 
particularly where a multi-specialty physician group shares a set of 
negotiated rates and is represented by a single provider reference 
object in the file.
    The Departments agree that the requirement to exclude unlikely 
provider-rate combinations may increase the technical complexity for 
reporting. Nevertheless, the Departments have determined that achieving 
the stated transparency goals of these rules requires this increased 
accuracy. The Departments intend to provide guidance for satisfying the 
requirement to exclude unlikely provider-rate combinations when 
contracts are negotiated for multiple provider groups through future 
technical implementation guidance in collaboration with industry to 
determine the most efficient approach.
    Many commenters opposed the proposal to require plans and issuers 
to exclude unlikely provider-rate combinations because of operational 
challenges and burden. Several of these commenters noted that many 
plans do not use a uniform specialty-to-billing-code rule for all 
providers that can easily be repurposed into machine-readable file 
filtering, which could lead to unintentionally excluding meaningful 
provider-rate combinations. Additionally, these commenters noted that 
some plans and issuers do not have taxonomy code-based claims systems 
(using the location of care, instead, for example) or that this logic 
is held by payment integrity vendors instead of the plan or issuer, and 
creating a logic to capture the many nuances in claims adjudication 
possibilities would lead to a complex and resource-intensive 
undertaking to both develop and maintain on an ongoing basis. A 
commenter explained that the applicability of NUCC taxonomy codes in 
claims adjudication may involve complex branching logic based on 
factors such as whether the rendering clinician is a physician or a 
non-physician practitioner, and whether the clinician is double board 
certified. Another commenter noted that claims adjudication relies on a 
combination of historical utilization patterns, adjudication rules, and 
post-service validation, and not a static, pre-service determination of 
which provider types may bill for a given code. A commenter identified 
State requirements which may require customization for a single 
issuer's inclusion/exclusion of certain provider-rate combinations. 
Another commenter recommended that plans be permitted to use third-
party data vendors or clinical appropriateness engines--not just their 
adjudication system--to identify and suppress irrelevant provider-rate 
combinations.
    The Departments recognize that there is no uniform claims 
adjudication system and that plans and issuers may have different 
approaches to ensuring that claims are not approved for items or 
services that are not furnished by a provider in an appropriate 
specialty. The Departments additionally understand that claims 
adjudication processes are not static and that a set of pre-service 
rules may not always align with the post-service result when applied to 
a claim. However, the Departments understand that all plans and issuers 
include as part of their claims adjudication process a method for 
determining 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, even though not all of these methods are organized as 
taxonomies that match billing codes with specialty codes. For example, 
the Departments expect that every plan and issuer has a process to 
ensure that it does not approve a claim for heart surgery performed by 
a podiatrist when the claim is otherwise identical to one submitted by 
a cardiac surgeon.
    To account for the fact that some plans and issuers use internal 
rules other than a provider taxonomy 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, the Departments 
are finalizing paragraph (b)(1)(i)(F) to specify that a plan or issuer 
must exclude from its In-network Rate File provider-rate combinations 
for items or services that are unlikely to be reimbursed based on the 
provider's specialty according either to the plan's or issuer's 
internal provider taxonomy or other internal rules used to determine if 
the plan or issuer should deny reimbursement for an item or service 
based on the provider's specialty during the claims adjudication 
process. The Departments are also finalizing redesignated paragraph 
(b)(2)(ii) to specify that the Taxonomy File must include a plan or 
issuer's internal provider taxonomy, or other internal rules, used to 
determine if the plan or issuer should deny reimbursement for an item 
or service given the provider's specialty.
    For plans and issuers using internal rules other than a provider 
taxonomy for determining whether to deny reimbursement due to provider 
specialty, the Departments expect that each method can be mapped to 
pairings of items and services with provider specialties, such that the 
plan or issuer can comply with the requirement to provide a Taxonomy 
File, as described in redesignated paragraph (b)(2)(ii). This mapping 
process will allow custom, internal provider taxonomies or other 
internal rules used to deny reimbursement given the provider's 
specialty, which may vary widely across plans and issuers, to be 
disclosed in a standardized format. As such, the Departments are 
requiring plans and issuers to document in the Taxonomy File a mapping 
of the relationships between items and services and provider 
specialties utilized in the claims adjudication process to the 
appropriate billing code and NUCC code, respectively, so file users can 
understand their unique approach to

[[Page 63772]]

excluding unlikely provider-rate combinations.
    The Departments recognize that plans and issuers will incur a 
burden associated with establishing a system and process to remove 
unlikely provider-rate combinations from the In-network Rate File. 
However, based on comments, the Departments have determined that the 
collective benefits to file producers and users from reduced file sizes 
and increased clarity and usability significantly outweigh the burdens 
incurred, as discussed in sections IV.B.5. and V.D. of this preamble, 
and reduced file size is a goal for which many interested parties, 
including plans and issuers, have advocated since the first machine-
readable files were published.
    The Departments illustrate below how the excluded provider-rate 
requirement would work vis-[agrave]-vis the Taxonomy File in the 
scenario raised by commenters wherein a plan's or issuer's adjudication 
process relies on a combination of historical utilization patterns, 
adjudication rules, and post-service validation and not a static, pre-
service determination of which provider types may bill for a given 
code.
    The Departments agree that adjudication systems differ and often 
leverage dynamic rules engines, clinical edit software, and post-
service validation rather than static, provider specialty lookup tables 
for each specialty and billing code combination. However, the goal of 
the Taxonomy File requirement is not to require plans and issuers to 
change their claim adjudication systems, nor is it to establish a 
standard system for denying reimbursement based on billing code-
specialty pairings. Rather, the Taxonomy File is designed to provide 
consumers of the machine-readable files with a standardized legend to 
interpret the rules logic applied within the In-network Rate File.
    Plans and issuers maintain the foundational data necessary to 
create the baseline Taxonomy File through things like provider 
credentialing records (which includes NPI and NUCC codes), pre-service 
determination or claim edit configurations, and historical claim 
databases. Where a plan relies on post-service adjudication, dynamic 
logic, or location of care, for example, rather than explicit taxonomy 
specialty edit rules, the plan can leverage the same empirical 
utilization patterns (for example, a 12-month lookback of historical 
claims data) combined with provider credentialing taxonomy sets to 
generate the required provider specialty-billing code pairings for the 
Taxonomy File.
    As an example, consider a plan or issuer that uses any combination 
of the following: mapping internal provider types to NUCC taxonomy 
codes; performing empirical analysis on historical claims data; and 
extracting explicit provider specialty deterministic claim edit rules 
or other claim edit rules that work to ensure that a provider is not 
reimbursed for furnishing an item or service that is inappropriate 
given the provider's specialty. To create a Taxonomy File from these 
internal rules, the plan or issuer would need to take the following 
steps. First, the plan or issuer would need to derive specialty to 
billing code combinations from any internal rules it uses to determine 
whether to deny a claim for an item or service because it was not 
furnished by a provider in an appropriate specialty. Then, the plan or 
issuer would need to create a Taxonomy File from the derived output by 
mapping the specialty to billing code combinations to pairings of NUCC 
codes and billing codes.
    As another example, for a plan or issuer that uses a payment 
integrity vendor or a clinical appropriateness engine as part of its 
claims adjudication process to deny reimbursement for an item or 
service because it was not furnished by a provider in an appropriate 
specialty, the taxonomic rules used by the vendor or engine are part of 
the plan's or issuer's internal provider taxonomy or other internal 
rules. Accordingly, any provider-rate combinations for items or 
services that are unlikely to be reimbursed given that provider's 
specialty pursuant to the vendor's or the clinical appropriateness 
engine's taxonomic rules must be excluded from the In-network Rate 
File. Similarly, those items or services and provider specialty 
combinations must be mapped to the appropriate billing code and 
baseline NUCC code and disclosed in the Taxonomy File. Note that, as 
discussed above, if the payment integrity vendor's or clinical 
appropriateness engine's rules used as part of the claims adjudication 
process are not already organized to associate items and services with 
provider specialties, those associations would first need to be derived 
from the rules before they can be mapped to billing codes and NUCC 
codes. The Departments expect the plan or issuer to work with such 
vendors to support the disclosure requirements. This may require 
contractual agreements between the parties to produce the required data 
in accordance with the required cadence. If a plan or issuer does not 
use a vendor or clinical appropriateness engine as part of its claims 
adjudication process for those purposes, then those tools are not part 
of the plan's or issuer's internal provider taxonomy or other internal 
rules and must not be used to determine which provider-rate 
combinations to exclude from the In-network Rate File or which billing 
code-NUCC code pairings to include in the Taxonomy File.
    In response to the commenter who noted that State requirements may 
require customization for an issuer's inclusion or exclusion of certain 
provider-rate combinations, the Departments assume that a plan's or 
issuer's internal provider taxonomy or other internal rules used to 
determine if the plan or issuer should deny reimbursement for an item 
or service based on the provider's specialty account for applicable 
State requirements that require or prohibit reimbursement for an item 
or service due to the specialty of the provider that furnished it. The 
Departments expect that those requirements must inform the plan's or 
issuer's provider-rate exclusions, and therefore they must be 
appropriately represented in the Taxonomy File.
    If the Departments become aware that there are plans and issuers 
whose claims adjudication processes do not have a way to deny 
reimbursement for an item or service because it was not furnished by a 
provider in an appropriate specialty, or whose internal provider 
taxonomy or other internal rules used to determine if the plan or 
issuer should deny reimbursement for an item or service given the 
provider's specialty cannot be mapped to unlikely provider-rate 
combinations or billing code-NUCC code pairings, the Departments will 
reconsider these requirements in the future to determine how such plans 
and issuers can comply.
    Many commenters also opposed the proposal to require plans and 
issuers to exclude unlikely provider-rate combinations because of the 
potential to leave file users confused and confronted with incomplete 
information. A commenter advised that a provider contract may include a 
global list of rates even though a provider only submits claims for 
some of the items and services on the list. The commenter described 
this as an example of a permissive taxonomic mapping where a plan or 
issuer contracts with a multi-specialty provider group for all service 
codes that would likely need to be included to accommodate the wide 
range of services potentially delivered. Another commenter demonstrated 
that these exclusions would hide rate negotiations and make it harder 
for the public to understand contracts between

[[Page 63773]]

payers and providers. A commenter noted that removing such combinations 
increases the likelihood that consumers may be incorrectly informed 
that a provider is out-of-network. Another commenter cited evidence 
from current machine-readable file data indicating that a taxonomy-only 
approach can be simultaneously over-inclusive and under-inclusive 
because specialty labels are imperfect proxies for actual service 
delivery patterns. Another commenter advised the Departments to conduct 
an analysis to better understand the implications of removing provider-
rate combinations based on plans' and issuers' internal taxonomy 
mapping on data quality and variance. A commenter recommended that the 
Departments not finalize any exclusion requirements and leave it to 
individual file users to apply plans' and issuers' Taxonomy Files to 
the In-network Rate Files to map out unlikely provider-rate 
combinations.
    The Departments recognize the possibility of permissive taxonomic 
mappings that may over-include provider specialties and claims 
adjudication systems and the potential for over- and under-exclusion of 
unlikely provider-rate combinations. However, the Departments note 
that, if a plan or issuer does maintain a permissive taxonomic mapping, 
it will be revealed in the Taxonomy File and potentially verified with 
the Utilization File. For example, under the current reporting 
requirements, a plan or issuer may include a negotiated rate in the In-
network Rate File for a podiatrist to perform a heart surgery even 
though the plan's claims adjudication system would be unlikely to 
process a reimbursement for that provider-service combination. Under 
these final rules, that provider-rate combination would likely appear 
in the Taxonomy File but would likely be excluded from the In-network 
Rate File because the plan's or issuer's internal provider taxonomy or 
other rules used during the claims adjudication process would likely 
not match podiatrists with heart surgery for purposes of reimbursement.
    This excluded provider-rate combination would also be unlikely to 
appear in the Utilization File because it is unlikely a podiatrist 
would have performed a heart surgery and been reimbursed for it. File 
users can use the Utilization File to verify whether a plan or issuer 
improperly excluded provider-rate combinations from the In-network 
File. Specifically, if a file user identifies in the Utilization File 
providers that were reimbursed (or would be reimbursed but for cost-
sharing liability, a modification from the proposed rule discussed in 
section III.C.8.b. of this preamble) for items or services for which 
they submitted claims during the plan or policy year, and these 
provider-rate combinations were included in the Taxonomy File but 
excluded from the In-network Rate file, that would indicate that the 
plan or issuer improperly excluded the provider-rate combination from 
the In-network Rate File. Additionally, the Departments note that the 
Utilization File is one tool for determining whether a provider is 
correctly identified as in-or out-of-network, alongside existing 
provider directories and other resources, and therefore requiring the 
removal of unlikely provider-rate combinations should not result in 
consumers receiving incorrect provider network information.
    The Departments acknowledge that requiring plans and issuers to 
remove unlikely provider-rate combinations from the In-network Rate 
File could diminish the public's understanding of contracts between 
plans and issuers and providers. However, as discussed in the 2020 
final rules, the In-network Rate File is meant to capture ``rates that 
are used to determine cost-sharing liability, which is essential 
information upon which consumers would need to rely to make health care 
purchasing decisions,'' \56\ and not necessarily every component of a 
contract. Removing unlikely provider-rate combinations is expected to 
help achieve that goal, as it will reduce file size which will make it 
easier for users of the file to obtain the rate information necessary 
to make informed health care purchasing decisions.
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    \56\ 85 FR 72158, 72227 (November 12, 2020).
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    The Departments do not agree that it is necessary to conduct an 
analysis of the impact of requiring plans and issuers to exclude 
unlikely provider-rate combinations and are instead taking into account 
information submitted by several commenters who conducted this type of 
analysis and revealed, in their comments to the proposed rules, 
significant file size reductions. As discussed in section IV.B.5. of 
the Collection of Information Requirements of these final rules, the 
Departments expect plans (or TPAs on behalf of plans) and issuers to be 
able to rely primarily on data they already maintain including listing 
their in-network providers together with the specialties of those 
providers, as well as the internal provider taxonomy or other internal 
rules used to determine if the plan or issuer should deny reimbursement 
for an item or service given the provider's specialty, which are needed 
to map provider specialties to the appropriate billing codes, as well 
as similar logic implemented within their claims adjudication systems 
to pend or deny claims that fall outside a provider's scope of 
practice. The Departments disagree that individual file users should 
have to apply Taxonomy Files to In-network Rate Files as an alternative 
to requiring plans and issuers to exclude unlikely provider-rate 
combinations, as this would retain large file sizes and impose 
unnecessary barriers to file users, who may not have the technological 
resources to conduct manual exclusions.
    A few commenters noted that many health plan and issuer cost 
estimator tools rely on In-network Rate Files to provide personalized 
cost information to consumers and requested that any provider-rate 
exclusions applied to the In-network Rate File (by any approach) also 
apply to issuers' cost calculator tools. A commenter requested that the 
Departments allow plans and issuers to respond to the excluded 
provider-service requests with a clear, consumer-friendly message 
indicating that an estimate is not available for that provider-service 
pairing.
    The 2020 final rules, as well as these final rules, do not require 
plans and issuers to use the data in the machine-readable files to 
generate cost-sharing estimates for the internet-based self-service 
tool. The results the internet-based self-service tool should generate 
are highly dependent on changing inputs (network status, deductible 
progress, etc.). The internet-based self-service tool's outputs are 
required to be accurate at the time of the participant's, 
beneficiary's, or enrollee's request under 26 CFR 54.9815-2715A2(b)(1), 
29 CFR 2590.715-2715A2(b)(1), and 45 CFR 147.211(b)(1), whereas the In-
network Rate and Allowed Amount Files will not reflect changes until 
the next quarter. As such, an internet-based self-service tool that 
relies on the latest file may be inaccurate during the three-month 
period between postings. If a plan or issuer chooses to utilize their 
machine-readable files to generate results for the internet-based self-
service tool, they are still obligated to ensure that the information 
required to be disclosed to participants, beneficiaries, and enrollees 
is accurate at the time the request is made. The Departments expect 
that each plan's or issuer's internet-based self-service tool will 
provide accurate responses, including not listing providers in search 
results for services those providers would not render, regardless of 
what information appears in the machine-readable files.
    Many commenters urged the Departments to consider alternative

[[Page 63774]]

approaches to removing unlikely provider-rate combinations, including, 
(1) several versions of a CMS-standardized specialty-to-code framework, 
(2) a hybrid approach combining TIN-level claims-based inclusion with 
provider specialty backstops and a more general exclusion process based 
on prior claims volume that would appear in the Utilization File, (3) 
adding a fee schedule object to the In-network Rate File schema which 
would expose the contractual relationship that produces unlikely 
provider-rate combinations, and (4) a mechanism which encompasses the 
scope of different provider specialties and which account for the 
evolving nature of health care service delivery. A few commenters 
expressed concern that regulators, brokers, and other data users may 
reach differing conclusions regarding whether plans and issuers are 
excluding the correct provider-rate combinations without a standardized 
exclusion policy. A few commenters requested that the Departments 
consider a standardized approach after monitoring the approaches plans 
and issuers use to determine which provider-rate combinations to 
exclude. A few commenters (both for the Excluded Provider Information 
and the Utilization File proposals) suggested limiting or excluding 
provider-rate combinations to those supported by at least one fully 
adjudicated claim within a specified lookback period or some variation 
of a claims-utilization based exclusion approach. The Departments 
address these comments in Alternatives Considered in section V.E.2. of 
this preamble.
    The Departments disagree that the alternative approaches to 
removing unlikely provider-rate combinations would be effective. In 
section III.C.8.c. of this preamble, the Departments discuss why a CMS-
standardized approach is unworkable at this time while acknowledging 
they intend to analyze the landscape of Taxonomy Files to determine if 
greater standardization is feasible and desirable in the future. The 
Departments have determined that a top-down standardized approach would 
result in under- and over-exclusions, which many commenters warned 
against, by trying to impose a one-size-fits-all approach on the 
significant differences among plans' and issuers' taxonomic and claims 
adjudication systems. The Departments also discuss the limitations of a 
claims-based process, which would include a hybrid approach, in section 
V.E.2. of this preamble. The Departments disagree with adding a fee 
schedule object to the In-network Rate File as it would not result in 
the desired file size reductions that excluding unlikely provider-rate 
combinations should achieve. The Departments will provide examples of 
excluding unlikely provider-rate combinations in technical 
implementation guidance and will continue to work with interested 
parties in the schema development process to support plans and issuers 
and file users in understanding how to implement this requirement.
6. Out-of-Network Allowed Amount Machine-Readable File
    The Departments proposed 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 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. The Departments also proposed 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. Lastly, the Departments proposed 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 solicited 
comments on these proposed amendments. Many commenters generally 
supported the proposed changes to the Allowed Amount File, noting that 
they would increase the amount and usefulness of out-of-network claims 
data. Commenters expressed that these changes would enhance 
transparency, improve the usability and organization of the machine-
readable files, and provide more meaningful visibility into out-of-
network reimbursement patterns at the market level. The Departments 
agree with these commenters. After consideration of public comments, 
the Departments are finalizing these amendments as proposed. A 
discussion of the specific proposed changes to the Allowed Amount File 
and comments received is below.
a. Reducing the Claims Threshold
    Since the publication of the 2020 final rules, 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.\57\ 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.
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    \57\ Matthew Robb

[…truncated; see source link]