# Transparency in Coverage > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/fr%3A2025-23693 ## Record - **Collection:** Federal Register - **Document type:** Proposed Rule - **Published:** December 23, 2025 - **Citation:** 90 FR 60432 ## Text DEPARTMENT OF THE TREASURY Internal Revenue Service 26 CFR Part 54 [REG-107111-25] RIN 1545-BQ55 DEPARTMENT OF LABOR Employee Benefits Security Administration 29 CFR Part 2590 RIN 1210-AC30 DEPARTMENT OF HEALTH AND HUMAN SERVICES 45 CFR Part 147 [CMS-9882-P] RIN 0938-AV64 Transparency in Coverage AGENCY: Internal Revenue Service, Department of the Treasury; Employee Benefits Security Administration, Department of Labor; Centers for Medicare & Medicaid Services, Department of Health and Human Services. ACTION: Proposed rule. SUMMARY: These proposed rules set forth proposed requirements that would amend the regulations under the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code regarding price transparency reporting requirements for non-grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage. Specifically, these proposed rules would improve the standardization, accuracy, and accessibility of public pricing disclosures in line with the goals of the Executive Order 14221. With respect to the in-network rate and out-of-network allowed amount machine-readable files, these proposed rules would achieve these goals by adding new contextual files and additional data elements like product type, network name, and enrollment counts; changing the reporting level for aggregation of data; removing in-network rates for unlikely provider-to-service mappings; increasing the reporting period and lowering the claims threshold for out-of-network historical data; and reducing the reporting cadence. These proposed rules would also improve the findability of all of the publicly disclosed machine-readable files required under the Transparency in Coverage rules, including the prescription drug file, by requiring a text file and footer with website URLs and contact information for the files. These proposed rules would also require pricing information that is made available through an online consumer tool and paper (upon request), to also be made available by phone, and establish that the satisfaction of such requirement also satisfies the requirements of section 114 of the No Surprises Act (including for grandfathered group health plans and health insurance issuers offering grandfathered group and individual health insurance coverage that are not otherwise subject to these proposed rules). DATES: To be assured consideration, comments must be received at one of the addresses provided below by February 23, 2026. ADDRESSES: Written comments may be submitted to the addresses specified below. Any comment that is submitted will be shared among the Department of the Treasury, the Department of Labor, the Department of Health and Human Services (the Departments), and the Office of Personnel Management. Please do not submit duplicates. Comments will be made available to the public. Warning: Do not include any personally identifiable information (such as name, address, or other contact information) or confidential business information that you do not want publicly disclosed. Comments are posted on the internet exactly as received and can be retrieved by most internet search engines. No deletions, modifications, or redactions will be made to the comments received, as they are public records. Comments may be submitted anonymously. In commenting, please refer to file code CMS-9882-P. Because of staff and resource limitations, the Departments cannot accept comments by facsimile (FAX) transmission. Comments, including mass comment submissions, must be submitted in one of the following three ways (please choose only one of the ways listed): 1. Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the “Submit a comment” instructions. 2. By regular mail. You may mail written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-9882-P, P.O. Box 8016, Baltimore, MD 21244-8016. Please allow sufficient time for mailed comments to be received before the close of the comment period. 3. By express or overnight mail. You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-9882-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850. For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section. FOR FURTHER INFORMATION CONTACT: Kendra May or Jeremy Rotner, Centers for Medicare and Medicaid Services, (301) 492-4293. Elizabeth Schumacher or Sharon Aguirre, Employee Benefits Security Administration, (202) 693-8335. Alexander Krupnick, Internal Revenue Service, Department of the Treasury, (202) 317-5500. Individuals interested in obtaining information from the Department of Labor (DOL) concerning employment-based health coverage laws may call the Employee Benefits Security Administration (EBSA) Toll-Free Hotline at 1-866-444-EBSA (3272) or visit the DOL's website ( www.dol.gov/agencies/ebsa ). 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 ( http://www.cms.gov/marketplace ), information on health care reform can be found at http://www.healthcare.gov, and information on surprise medical bills can be found at http://www.cms.gov/nosurprises. SUPPLEMENTARY INFORMATION: Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. The Departments post all comments received before the close of the comment period on the following website as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that website to view public comments. The Departments will not post on Regulations.gov public comments that make threats to individuals or institutions or suggest that the commenter will take actions to harm an individual. The Departments continue to encourage individuals not to submit duplicative comments. The Departments will post acceptable comments from multiple unique commenters even if the content is identical or nearly identical to other comments. The Departments encourage commenters to include supporting facts, research, and evidence in their comments. When doing so, commenters are encouraged to provide citations to the materials referenced, including active hyperlinks. Likewise, commenters who reference materials that have not been published are encouraged to upload relevant data collection instruments, data sets, and detailed findings as a part of their comment. Providing such citations and documentation will assist the Departments in analyzing the comments. Plain Language Summary: In accordance with 5 U.S.C. 553(b)(4), a plain language summary of this rule may be found at https://www.regulations.gov/. 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 1 84 FR 65464 (November 27, 2019). 2 85 FR 72158 (November 12, 2020). 3 85 FR 72158, 72160 (November 12, 2020). The public disclosures made pursuant to the 2020 final rules led to the release of an enormous amount of previously hidden pricing data. However, post-implementation, the Departments continue to receive feedback from users of the machine-readable files emphasizing the need to address certain gaps in reporting and shrink file size by reducing duplication and removing unnecessary data. Since the finalization of the 2020 final rules, the Departments have also received feedback from many interested parties about the myriad ways in which plans and issuers contract with providers for items and services that impact the usability of the data disclosed under the rules. On February 25, 2025, President Trump issued Executive Order 14221, “Making America Healthy Again by Empowering Patients With Clear, Accurate, and Actionable Healthcare Pricing Information” (Executive Order 14221). 4 Among other things, Executive Order 14221 directs the Departments to take all necessary and appropriate action, including issuing proposed regulatory action to promote more transparency in health care pricing information. In line with the goals of Executive Order 14221, the Departments propose several amendments to the 2020 final rules to improve the standardization, accuracy, and accessibility of pricing information. 4 Exec. Order No. 14221, 90 FR 11005 (February 28, 2025). Based on internal assessment and external feedback from interested parties, the Departments have identified three main barriers to fully achieving the goals of the 2020 final rules: inaccessibility due to the size of the machine-readable files, ambiguity regarding some of the data disclosures due to a lack of contextual information alongside the raw data, and misalignment with the “2019 Medicare and Medicaid Programs: CY 2020 Hospital Outpatient PPS Policy Changes and Payment Rates and Ambulatory Surgical Center Payment System Policy Changes and Payment Rates. Price Transparency Requirements for Hospitals To Make Standard Charges Public” rule 5 (2019 Hospital Price Transparency rule) that makes comparing data across disclosures challenging. 5 84 FR 65524 (November 27, 2019). The Departments understand that the large size of many of the required machine-readable files, particularly the in-network rate machine-readable file (In-network Rate File), is the most prominent challenge with working with the machine-readable files. Academics and researchers, 6 data engineers, 7 health plans and health insurance issuers, 8 and members of Congress 9 have stated that these large file sizes create several problems for file users seeking to open and analyze the files, as well as for health plans and health insurance issuers reporting that amount of data. For file users, the amount of data to sift through monthly requires significant resources and time. Smaller datasets are easier to analyze and cheaper to maintain. For plans and issuers, large files have large data storage, maintenance, and bandwidth costs. The amount of data being generated monthly can also lead to increased errors in the files, making it difficult for plans and issuers to ensure they are compliant with the disclosure requirements and for file users to be confident in the integrity of the data being reported. Reducing the collective burden from large file sizes and making it easier for all users to work with the data in the machine-readable files are among the driving goals of these proposed rules. 6 Christopher Whaley, Neeraj Radhakrishnan, Michael Richards, Kosali Simon, et al., Understanding Health Care Price Variation: Evidence from Transparency-in-Coverage Data, 3 Health Affairs Scholar 2 (2025), https://doi.org/10.1093/haschl/qxaf011; Michael E. Chernew, Sabrina Corlette, Kelly Davenport, François de Brantes, et al., Transparency in Coverage: Recommendations for Improving Access to and Usability of Health Plan Price Data (2022), Georgetown University, https://georgetown.app.box.com/s/1ezsggz1c7smsaexkr8rght15sokgusl. 7 Adam Geitgey, A Petabyte of Health Insurance Prices per Month, Turquoise Health (July 11, 2023), https://blog.turquoise.health/a-petabyte-of-health-insurance-rates-a-month/. 8 United Health Care, Transparency in coverage, https://transparency-in-coverage.uhc.com/ (last visited Dec. 8, 2025). (“Files are in a JSON format and may contain millions of lines of data and be up to 1 terabyte (TB) in size. Please consider your system's capacity and memory when downloading these files.”) 9 Maggie Hassan & Michael Braun, Letter to CMS Administrator Chiquita Brooks-LaSure (Mar. 6, 2023), https://www.hassan.senate.gov/imo/media/doc/tic.pdf. With the 2020 final rules, the Departments expected the public disclosure of pricing information related to health care items and services to help both uninsured and insured individuals in their health care and health coverage purchasing decisions. As stated in the preamble to the 2020 final rules, research indicates that having access to pricing information can increase consumers' overall satisfaction and provide opportunities for education and engagement on health care pricing. 10 10 85 FR 72158 (November 21, 2020). Price transparency enables consumers to evaluate health care options and make cost-conscious decisions, allowing for the possibility of a competitive dynamic that may narrow price dispersion for the same items and services in the same health care markets and put downward pressure on prices and potentially lower overall health care costs. 11 Since the publication of the 2020 final rules, researchers have continued to analyze price transparency in health care with the benefit of access to the data provided largely by the machine-readable files. 11 85 FR 72158, 72159 (November 12, 2020). Some researchers have identified significant potential cost-savings across the health insurance landscape through greater use of the machine-readable file data. 12 Recent discussions extol the potential benefits of price transparency, echoing the reasons the Departments emphasized in the 2020 final rules. These include effects on the demand for health care by “guiding patients to lower-priced providers” and to the supply side by “promot[ing] price competition among providers,” 13 as well as benefits to employers to “redesign health benefits and inform purchasing decisions.” 14 One analysis emphasized a range of benefits, from “optimizing current contracts” to “increasing the accuracy of performance assumptions, market analysis, and strategic value.” 15 Early analyses of the potential financial and economic impacts of the 2020 final rules show promise for fulfilling the goals the Departments articulated in the 2020 final rules of “facilitating a market-driven heath care system by giving consumers of health care services data that will enable consumers to make fully informed, cost-conscious decisions when choosing health care.” 16 12 Stephen T. Parente, Estimating the Impact of New Health Price Transparency Policies, 60 The Journal of Health Care Organization, Provision, and Financing (Feb. 17, 2023); David N. Bernstein & John R. Crowe, Price Transparency in United States' Health Care: A Narrative Policy Review of the Current State and Way Forward, 61 Inquiry (2024). 13 Juan Carvajal, Christopher Ody, & Christopher Whaley, The Relationship Between Pricing Transparency and Price Competition in the US Health Care Industry (Nov. 5, 2024), https://www.analysisgroup.com/globalassets/insights/publishing/2024_aba_article_relationship_between_pricing_transparency.pdf. 14 Christopher Whaley & Austin Frakt, If Patients Don't Use Available Health Service Pricing Information, Is Transparency Still Important?, 24 AMA Journal of Ethics 995 (Nov. 2022. 15 Sarun Charumilind, Shubham Singhal, Oleg Bestsennyy, Erica Coe, et al., How Price Transparency Could Affect US Healthcare Markets ), McKinsey (Apr. 2, 2024), https://www.mckinsey.com/industries/healthcare/our-insights/how-price-transparency-could-affect-us-healthcare-markets. 16 85 FR 72158, 72171 (November 12, 2020). While the machine-readable file requirements of the 2020 final rules and the 2019 Hospital Price Transparency rule do not require the exact same disclosures, they have similar goals and some overlapping data. Therefore, it can be useful to review studies of hospital machine-readable files for lessons learned and outcomes that may translate to the plan and issuer machine-readable file disclosures. One study using hospital data found that “choosing plans from the largest insurer in the local market is more likely to result in lower negotiated rates than from other plans,” which can lead to reduced costs for the “growing number of self-insured employers engaged in direct contracts with hospitals.” 17 One county government used hospital data in this manner to reduce its health costs by over 40 percent. 18 Tools allowing comparison of the hospital data recently began populating the internet. The Departments are also aware of app developers conducting similar analyses of the data from plan and issuer disclosures and offering them to consumers (both individuals and employers). The Departments expect that continued analyses and development of consumer-facing tools and services will result in similar savings opportunities achieved from studying the hospital machine-readable files. 17 Yang Wang, Michael E. Chernew, Leemore S. Dafny, Maximilian J. Pany, et al., Do Insurers with Greater Market Power Negotiate Consistently Lower Prices for Hospital Care? Evidence From Hospital Price Transparency Data, 29 Medical Care Research & Review (Aug. 18, 2023). 18 Sara Hansard, One County Combed Hospital Data to Slash Health Plan Costs 43 Percent (Feb. 6, 2023), Bloomberg, https://news.bloomberglaw.com/health-law-and-business/employer-health-plan-eyes-43-savings-from-payment-data-audits. However, the success of these analyses and the effectiveness of consumer-facing tools depend on the usability of the machine-readable files. Large file sizes, lack of clarity, and data of limited use hamper efforts to build tools that can be brought to market. These proposed changes, if finalized, would contribute to making the files easier to digest and analyze, reduce challenges for existing tool developers, and open the market to additional tool and app developers. The Departments seek to address the limitations of the machine-readable files through these proposed rules as well as through updates to the machine-readable file form and manner requirements as detailed in technical implementation guidance. As a first step towards addressing these limitations, on May 22, 2025, the Departments announced in FAQs Part 70 the intention to release schema version 2.0 (Schema 2.0), which will implement revised technical requirements for the In-network Rate File and out-of-network allowed amounts and billed charges machine-readable file (Allowed Amount File). 19 However, the Departments also recognize that more substantive requirements are needed to clarify the data being published and to give users more confidence in the data. Feedback from interested parties demonstrates that, while the raw data from the machine-readable files presents valuable information and opportunities for analysis, additional contextual information is needed to supplement the in-network rates and out-of-network allowed amounts and billed charges disclosed in the machine-readable files. Additional contextual information would allow users to understand changes in pricing over time, promote more accurate reporting, and make pricing information more meaningful and accessible overall. Therefore, the Departments are issuing these proposed rules as a next step to addressing these concerns. 19 U.S. Department of Labor, U.S. Department of Health & Human Services & U.S. Department of the Treasury, Frequently Asked Questions About Affordable Care Act Implementation Part 70 (May 22, 2025), https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-70. The disclosure requirements under the Transparency in Coverage rules represent just one prong in a multipronged approach to promote greater transparency and understanding of costs and pricing in the health care and the health insurance market. The 2020 final rules must be viewed within the context of other regulatory and statutory changes, such as the Hospital Price Transparency initiative, as well as Title I of Division BB of the Consolidated Appropriations Act, 2021 (CAA), also known as the No Surprises Act, and its consumer protections against surprise billing, its requirements for a good faith estimate, advanced explanation of benefits, and more accurate provider directories. With respect to the Hospital Price Transparency and the Transparency in Coverage initiatives in particular, section 3(b) of Executive Order 14221 instructed the Departments to “issue updated guidance or proposed regulatory action ensuring pricing information is standardized and easily comparable across hospitals and health plans.” 20 The Departments received encouraging feedback that “commercial prices disclosed in the TiC [Transparency in Coverage] data are mostly comparable to those disclosed by hospitals in compliance with the hospital price transparency rule and to Marketscan [sic] claims data.” 21 However, other interested parties have noted that, despite the consistency of the raw data across hospital and plan and issuer machine-readable files, there are other challenges in comparing the information between the two sets of machine-readable files. 22 Therefore, the Departments intend in these proposed rules, along with Schema 2.0, to help align the Hospital Price Transparency reporting requirements and the 2020 final rules, as well as to fulfill the directive under Executive Order 14221. 20 Exec. Order No. 14221, 90 FR 11005, 11006 (February 28, 2025). 21 Yang Wang, Michael Meiselbach, Gerard Anderson & Ge Bai, Hospital Pricing Information Consistent Between Transparency-In-Coverage Data and Other Commercial Data Sources, 42 Health Affairs (2023), https://www.healthaffairs.org/content/forefront/hospital-pricing-information-consistent-between-transparency-coverage-data-and-other. Information on MarketScan data can be found at https://www.merative.com/documents/merative-marketscan-research-databases. 22 Nikki Tong, Price Transparency Proposal Leaves Room for Improvement, Experts Say, Fierce Healthcare (Aug. 1, 2023), https://www.fiercehealthcare.com/providers/price-transparency-proposal-leaves-room-improvement; Jing Jiang, Mengqi Jiang & Ge Bai, Enforcing Hospital Price Transparency: Lessons from CMS Actions, Health Affairs Forefront (Dec. 3, 2024), https://www.healthaffairs.org/content/forefront/enforcing-hospital-price-transparency-lessons-cms-actions. Additionally, to better inform a response to Executive Order 14221, on June 2, 2025, the Departments published a Request for Information (RFI) seeking the public's input on ways to effectively implement or amend the prescription drug machine-readable file requirement in the 2020 final rules. 23 23 90 FR 23303 (June 2, 2025). Building off of the 2020 final rules, the Departments propose these rules pursuant to the authority under Section 2715A of the Public Health Service (PHS) Act, incorporated into section 715 of the Employee Retirement Income Security Act (ERISA) and section 9815 of the Internal Revenue Code (Code), which provide that non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage must comply with section 1311(e)(3) of the Patient Protection and Affordable Care Act (Affordable Care Act). This section of the Affordable Care Act addresses transparency in health coverage and imposes certain reporting and disclosure requirements on health plans that are seeking certification as qualified health plans (QHPs) that may be offered on an Exchange (as defined by section 1311(b)(1) of the Affordable Care Act). The Departments also propose these rules pursuant to the authority under the No Surprises Act, which amended chapter 100 of the Code, Part 7 of ERISA, and title XXVII of the PHS Act. Among other protections, the No Surprises Act provides Federal protections against surprise billing by limiting out-of-network cost sharing and prohibiting balance billing in many of the circumstances in which surprise bills most frequently arise. Section 114 of the No Surprises Act added Code section 9819, ERISA section 719, and PHS Act section 2799A-4, which require plans and issuers to offer price comparison guidance by telephone and make a “price comparison tool” available on the plan's or issuer's website. B. Summary of the Major Provisions 1. Transparency in Coverage—Definitions The 2020 final rules include definitions at 26 CFR 54.9815-2715A1(a)(2); 29 CFR 2590.715-2715A1(a)(2); and 45 CFR 147.210(a)(2). These proposed rules, if finalized, would add a definition of the term health insurance market for purposes of amendments to 26 CFR 54.9815-2715A3(b)(1)(ii), 29 CFR 2590.715-2715A3(b)(1)(ii), and 45 CFR 147.212(b)(1)(ii) that would require group health plans and health insurance issuers offering group or individual health insurance coverage to make an out-of-network allowed amount machine-readable file available for each health insurance market in which the plan or issuer offers a plan or coverage. Under 26 CFR 54.9815-2715A1 and 45 CFR 147.210, the Departments propose to redesignate paragraphs (a)(2)(xi) through (xxii) as paragraphs (a)(2)(xii) through (xxiii), respectively, and add a new paragraph (a)(2)(xi) with the new definition. Under 29 CFR 2590.715-2715A1, the Departments propose to redesignate paragraphs (a)(2)(x) through (xxi) as paragraphs (a)(2)(xi) through (xxii) and add a new paragraph (a)(2)(x) with the new definition. 2. Transparency in Coverage—Required Disclosures to Participants, Beneficiaries, or Enrollees The 2020 final rules at 26 CFR 54.9815-2715A2; 29 CFR 2590.715-2715A2; and 45 CFR 147.211 require non-grandfathered group health plans and health insurance issuers offering non-grandfathered coverage in the group and individual markets to make cost-sharing information available to participants, beneficiaries, and enrollees through an internet-based self-service tool (self-service tool), and in paper form, upon request. The Departments propose to amend paragraph (b)(1)(vii)(A) of this section to require the disclaimer, described in that paragraph, to state that the cost-sharing information does not account for potential additional amounts in situations where applicable State and Federal law allow out-of-network providers to balance bill participants, beneficiaries, and enrollees. This proposed amendment reflects the existence of the Federal balance billing protections set forth in the No Surprises Act, which was not in effect when (b)(1)(vii)(A) was finalized in the 2020 final rules. The Departments also propose to clarify that the disclaimer is not required if the State in which the item or service was furnished prohibits all out-of-network providers from balance billing for all items and services payable by the plan or issuer. In addition, the Departments propose to add a new paragraph at (b)(2)(iii) under this section to require plans and issuers to make available to participants, beneficiaries, and enrollees the cost-sharing estimates and other disclosures required under paragraph (b)(1) via a telephone number to implement requirements under section 9819 of the Code, section 719 of ERISA, and PHS Act Section 2799A-4, as added by section 114 of the No Surprises Act. 24 The Departments propose to require a telephone number through which a consumer may seek customer assistance which would be required to be the same number that Code section 9816(e), ERISA section 716(e), and PHS Act section 2799A-1(e), as added by section 107 of the No Surprises Act requires be indicated on any physical or electronic plan or insurance identification card issued to a participant, beneficiary, or enrollee. The Departments also propose to redesignate paragraph (b)(2)(ii)(D) as new paragraph (b)(2)(iv) and amend redesignated paragraph (b)(2)(iv) to remove phone as an alternative means by which a participant, beneficiary, or enrollee can request the disclosures required under paragraph (b)(1). 24 42 U.S.C. 300gg-111(e)(3); 29 U.S.C. 1185e(e)(3); 26 U.S.C. 9819. U.S. Department of Labor, U.S. Department of Health & Human Services & U.S. Department of the Treasury, FAQs about Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 49 (August 20, 2021), https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf and https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf. The Departments also propose to add a new paragraph (c)(7) stating that plans and issuers satisfy the requirements set forth in Code section 9819, ERISA section 719, and PHS Act section 2799A-4 regarding the price comparison tool by providing the information to participants, beneficiaries, and enrollees set forth in paragraph (b)(1) as amended in accordance with the method and format requirements set forth in paragraph (b)(2), as amended. 25 25 While PHS Act section 2715A does not apply to grandfathered health plans and health insurance issuers offering grandfathered individual and group health insurance coverage, section 9819 of the Code, section 719 of ERISA, and section 2799A-4 of the PHS Act do apply to grandfathered health plans and issuers offering grandfathered health insurance coverage. 3. Transparency in Coverage—Requirements for Public Disclosure The Transparency in Coverage final rules at 26 CFR 54.9815-2715A3; 29 CFR 2590.715-2715A3; and 45 CFR 147.212 require non-grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage to disclose on a public website, in the format of machine-readable files, information regarding in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for covered items and services, and negotiated rates and historical net prices for covered prescription drugs. The Departments propose a number of amendments that would apply to the disclosure of information required under paragraphs (b)(1) and (b)(2). First, the Departments propose to amend the introductory paragraph of (b) to reference new requirements for the public disclosure of contextual information and to redesignate paragraphs (b)(2) through (b)(3) as paragraphs (b)(3) through (b)(4), respectively, and add a new paragraph (b)(2) describing the proposed contextual information disclosure requirements for the In-network Rate File. The Departments also propose to add two new paragraphs, (b)(2)(iv) and (b)(3)(iii), to help users more easily locate the public disclosures made pursuant to these proposed rules by requiring plans and issuers to post a plain text file in a .txt format (Text File) in the root folder of the plan or issuer's website and a specific internet domain as a link in the footer on the home page of the plan's or issuer's website. The Departments are also considering a standardized file format for all machine-readable files. The Departments also propose to amend the required information at redesignated paragraph (b)(1)(i)(B) and paragraph (b)(1)(ii)(A) to remove the requirement to report a specific number of digits of the Health Insurance Oversight System (HIOS) identifier (ID) that are required for each coverage option and to add a requirement to disclose the product type associated with the plan or policy in the In-network Rate Files and the Allowed Amount Files. The Departments also propose to amend the special rules to prevent unnecessary duplication in current paragraph (b)(4) by redesignating paragraph (b)(4)(i) as paragraph (b)(5)(i), redesignating paragraph (b)(4)(ii) as paragraph (b)(5)(ii), redesignating paragraph (b)(4)(iii) as paragraph (b)(5)(iv), and adding paragraph (b)(5)(iii). In new paragraph (b)(5)(iii), the Departments propose to permit self-insured group health plans under certain circumstances to allow another party, such as a service provider, with which they have an agreement as described in paragraph (b)(5)(ii), to make available in a single In-network Rate File as required under paragraph (b)(1)(i), the information required under paragraph (b)(1)(i) for more than one plan, insurance policy, or contract (including those offered by different plan sponsors with which the other party has an agreement) and across different health insurance markets. The Departments also propose to amend newly redesignated paragraph (b)(5)(iv) to permit self-insured group health plans under certain circumstances to allow another party with which they have an agreement to aggregate the Allowed Amount Files required under paragraph (b)(1)(ii) for more than one self-insured group health plan, including those offered by different plan sponsors. Finally, the Departments propose to amend newly redesignated paragraph (b)(4) by adding new paragraphs to specify the timing requirements for each machine-readable file required as proposed under these rules. As related to the public disclosures generally, proposed paragraph (b)(4)(i) would amend the required reporting frequency for the In-network Rate and Allowed Amount Files under paragraphs (b)(1)(i) and (b)(1)(ii) from monthly to quarterly but would not propose any changes to the monthly reporting frequency for the prescription drug file required under paragraph (b)(1)(iii). Newly redesignated paragraph (b)(4)(vi) proposes to require the Text File proposed under new paragraph (b)(2)(iv) to be posted beginning on the first day of the calendar-year quarter following the applicability date under paragraph (c)(1) and updated and posted as soon as practicable but no later than 7 calendar days following a change in any of the information required under redesignated paragraph b)(2)(iv). The amendments contained in these proposed rules generally modify requirements related to the In-network Rate Files and the Allowed Amount Files. However, several proposed amendments would amend requirements related to the prescription drug machine-readable files, specifically: the requirement that plans and issuers must include a Text File in the root folder of a plan's or issuer's website as described in proposed paragraphs (b)(2)(iv) (section III.C.7.d. of this preamble) and the requirements related to the method and format for disclosing information to the public as described in proposed redesignated paragraph (b)(3) (section III.C.9. of this preamble). The Departments note in each applicable section when a proposal would modify requirements related to the prescription drug machine-readable files. 4. Public Disclosure of In-Network Rates With respect to the disclosure of in-network rates specifically, to reduce duplicate in-network rate data, the Departments propose to amend 26 CFR 54.9815-2715A3(b)(1)(i), 29 CFR 2590.715-2715A3(b)(1)(i), and 45 CFR 147.212(b)(1)(i) to require plans and issuers to make an In-network Rate File available for each provider network maintained or contracted by the plan or issuer. As part of this proposal, the Departments propose to redesignate paragraphs (b)(1)(i)(A) through (C) as paragraphs (b)(1)(i)(B) through (D), respectively, and add a new paragraph (b)(1)(i)(A) requiring each In-network Rate File to include the common provider network name for which negotiated rate information is included in that file. The Departments also propose to amend redesignated paragraph (b)(1)(i)(D)( 1 ) to require in-network rates to be reflected as a dollar amount except for contractual arrangements under which plans and issuers agree to pay an in-network provider a percentage of billed charges and are not able to assign a dollar amount to an item or service prior to a bill being generated. The Departments also propose to add new paragraph (b)(1)(i)(E), requiring each In-network Rate File to include current enrollment totals, as of the date the file is posted, for each plan or coverage option offered by a plan or issuer that uses that file's provider network. The Departments also propose in new paragraph (b)(1)(i)(F) to require plans and issuers to exclude any provider and their negotiated rate (provider-rate combination) for an item or service, if the provider is unlikely to be reimbursed for the item or service given that provider's area of specialty, according to the plan's or issuer's internal provider taxonomy used during the claims adjudication process. The Departments also propose to amend newly redesignated paragraph (b)(1)(i)(D)( 2 ) to account for this proposed required exclusion. The Departments also propose to require plans and issuers to post several contextual machine-readable files under new paragraph (b)(2) that would help file users better understand the public disclosures required in the In-network Rate Files under paragraph (b)(1)(i). This proposal would mean plans and issuers would be required to prepare new contextual files for each In-network Rate File prepared pursuant to these proposed rules. In particular, the Departments propose to require a change-log file (“Change-log File”) at new paragraph (b)(2)(i), which would identify any changes made to the required information described in paragraph (b)(1)(i) in the In-network Rate File since the last posted In-network Rate File. The Departments also propose to require a utilization file (“Utilization File”) at new paragraph (b)(2)(ii), which would document, for the 12-month period that ends 6 months prior to the publication date of each Utilization File, all items and services covered under the plans or policies represented in the In-network Rate File prepared pursuant to proposed amended paragraph (b)(1)(i) for which a claim has been submitted and reimbursed. The Utilization File would also include each in-network provider identified by the National Provider Identifier (NPI), Tax Identification Number (TIN), and Place of Service Code who was reimbursed, in whole or in part, for a claim for each covered item or service included in such file. The Departments also propose to require plans and issuers to publish a taxonomy file (“Taxonomy File”) at new paragraph (b)(2)(iii) which would include their internal provider taxonomy that matches items and services (represented by a billing code) with provider specialties (represented by specialty codes that are derived from the Health Care Provider Taxonomy 26 code set established by the National Uniform Claim Committee (NUCC)) to determine if the plan or issuer should deny reimbursement for an item or service because it was not furnished by a provider in an appropriate specialty. 26 National Uniform Claim Committee, Health Care Provider Taxonomy, https://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40 (last visited Dec. 8, 2025). Finally, the Departments propose to add timing requirements for the proposed new contextual files under redesignated paragraph (b)(4). With respect to the contextual files that related to the In-network Rate Files under paragraph (b)(1)(i), under proposed paragraph (b)(4)(iii), the Change-log File proposed at paragraph (b)(2)(i) would be required to be posted beginning on the first day of the calendar-year quarter following the date on which the first In-network Rate File is required to be posted under paragraph (b)(4)(i), and updated and posted quarterly whether or not there are changes to that file since it was last posted. Under proposed paragraph (b)(4)(iv), the Utilization File proposed at paragraph (b)(2)(ii) would be required to be posted beginning on the first day of the calendar-year quarter following the applicability date under paragraph (c)(1) and updated annually after the initial posting. Lastly, under proposed paragraph (b)(4)(v), the Taxonomy File proposed at paragraph (b)(2)(iii) would be required to be posted beginning on the first day of the calendar-year quarter following the applicability date under paragraph (c)(1) and updated and posted quarterly if changes to the internal provider taxonomy impact the information required in the machine-readable file required under paragraph (b)(1)(i). 5. Public Disclosure of Out-of-Network Allowed Amounts The Departments propose to make several amendments to 26 CFR 54.9815-2715A3(b)(1)(ii), 29 CFR 2590.715-2715A3(b)(1)(ii), and 45 CFR 147.212(b)(1)(ii) to increase the amount of historical claims data available in the Allowed Amount Files. These amendments would require plans and issuers to report out-of-network allowed amounts and billed charges at the health insurance market level, rather than the plan or policy level, lower the threshold for including claims in the Allowed Amount File from 20 to 11 different claims per item or service, and increase the reporting period from 90 days to 6 months and the lookback period from 180 days to 9 months. 6. Severability The 2020 final rules included severability clauses to emphasize the Departments' intent that, to the extent a reviewing court holds that any provision of the final rules is unlawful, the remaining rules should take effect and be given the maximum effect permitted by law. The 2020 final rules provide that any provision held to be invalid or unenforceable by its terms, or as applied to any person or circumstance, or stayed pending further agency action, shall be severable from the relevant section and shall not affect the remainder thereof or the application of the provision to persons not similarly situated or to dissimilar circumstances. The Departments are not modifying this language in the 2020 final rules and clarify that these clauses continue to apply and would extend to the amendments proposed in these rules, if finalized. 7. Technical Amendments The Departments propose a series of technical amendments to the way group health plans and health insurance issuers offering group or individual health insurance coverage are referenced in 26 CFR 54.9815-2715A2 and 54.9815-2715A3, 29 CFR 2590.715-2715A2 and 2590.715-2715A3, and 45 CFR 147.211 and 147.212. In the 2020 final rules, the Departments generally adopted the convention of referring to those entities using the terms “group health plan” and “health insurance issuer” throughout the regulations, except that where the Departments refer to those entities more than once in the same paragraph, the terms “plan” and “issuer” are used after the initial instance. However, that convention was not applied evenly. Therefore, in the internet-based self-service tool disclosure requirements in 26 CFR 54.9815-2715A2, 29 CFR 2590.715-2715A2, and 45 CFR 147.211, the Departments propose technical amendments to paragraphs (b)(1)(i)(A), (b)(1)(i)(B), (b)(2)(ii), (b)(3)(i), and (b)(3)(ii) that would bring the terms used to describe those entities in line with that convention. In the machine-readable file disclosure requirements in 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212, the Departments propose amendments to redesignated paragraph (b)(1)(i)(D), (b)(5)(i), and (b)(5)(ii) that would bring the terms used to describe those entities in line with that convention. These paragraphs are otherwise unchanged. These proposed changes are technical in nature and would not affect the rights or obligations of any plan, issuer, or other entity. C. Summary of Costs and Benefits EP23DE25.047 EP23DE25.048 EP23DE25.049 II. Background A. Executive Orders On June 24, 2019, President Trump issued Executive Order 13877, “Improving Price and Quality Transparency in American Healthcare to Put Patients First.” 27 Executive Order 13877 sought to improve transparency in health care and empower patients to make fully informed decisions about their health care. As Executive Order 13877 noted, “patients often lack both access to useful price and quality information and the incentives to find low-cost, high-quality care.” The lack of this information is widely understood to be one of the root problems causing dysfunction within America's health care system, “generally leav[ing] patients and taxpayers worse off than would a more transparent system.” 27 Exec. Order No. 13877, 84 FR 30849 (June 27, 2019). Executive Order 13877 directed the Departments to take action that would combat this issue by making meaningful price and quality information more broadly available to more Americans, thereby increasing competition, innovation, and value in the health care system. Specifically, section 3(b) of Executive Order 13877 directed the Secretaries of the Departments to issue an advance notice of proposed rulemaking, consistent with applicable law, soliciting comment on a proposal to require health care providers, health insurance issuers, and self-insured group health plans to provide or facilitate access to information about expected out-of-pocket costs for items or services to patients before they receive care. To fulfill their responsibility under Executive Order 13877, the Departments proposed 28 and subsequently finalized the Transparency in Coverage rules in the 2020 final rules. 29 The 2020 final rules published by the Departments on November 12, 2020, implemented section 2715A of the PHS Act, which requires group health plans and health insurance issuers offering group or individual health insurance coverage to comply with section 1311(e)(3) of the Affordable Care Act. As described more fully elsewhere in this preamble, these provisions address transparency in health coverage and require plans and issuers to make certain information available to the public. 28 84 FR 65464 (November 27, 2019). 29 85 FR 72158 (November 12, 2020). On February 25, 2025, President Trump issued Executive Order 14221, 30 “Making America Healthy Again by Empowering Patients With Clear, Accurate, and Actionable Healthcare Pricing Information.” Executive Order 14221 stated that “[m]aking America healthy again will require empowering individuals with the best information possible to inform their life and healthcare choices” with the goal to “make more meaningful price information available to patients to support a more competitive, innovative, affordable, and higher quality healthcare system.” To that end, the Executive Order directs the Departments to “promote universal access to clear and accurate healthcare prices[;] . . . to improve existing price transparency requirements; increase enforcement of price transparency requirements; and identify opportunities to further empower patients with meaningful price information, potentially including through the expansion of existing price transparency requirements.” 31 30 Exec. Order No. 14221, 90 FR 11005 (February 28, 2025). 31 Id. Section 3 of Executive Order 14221 directs the Secretaries of the Departments to rapidly implement and enforce the health care price transparency regulations issued pursuant to Executive Order 13877, 32 including action to: “(a) require the disclosure of the actual prices of items and services, not estimates; (b) issue updated guidance or proposed regulatory action ensuring pricing information is standardized and easily comparable across hospitals and health plans; and (c) issue guidance or proposed regulatory action updating enforcement policies designed to ensure compliance with the transparent reporting of complete, accurate, and meaningful data.” 33 In line with these directives, the Departments are publishing these proposed rules with amendments to the regulations issued under the 2020 final rules. 34 32 Exec. Order No. 13877, 84 FR 30849 (June 27, 2019). 33 Exec. Order No. 14221, 90 FR 11005 (February 28, 2025). 34 85 FR 72158 (November 12, 2020). B. Statutory Background and Enactment of the Affordable Care Act and the No Surprises Act The Patient Protection and Affordable Care Act (Pub. L. 111-148) was enacted on March 23, 2010, and the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152) was enacted on March 30, 2010 (collectively the Affordable Care Act). As relevant here, the Affordable Care Act reorganized, amended, and added to the provisions of part A of title XXVII of the PHS Act relating to health coverage requirements for group health plans and health insurance issuers. The term group health plan includes both insured and self-insured group health plans. The Affordable Care Act also added section 715 to ERISA and section 9815 to the Code to incorporate the provisions of part A of title XXVII of the PHS Act, PHS Act sections 2701 through 2728, into ERISA and the Code, making them applicable to group health plans and health insurance issuers providing coverage in connection with group health plans. Section 2715A of the PHS Act, incorporated into section 715 of ERISA and section 9815 of the Code, provides that plans and issuers must comply with section 1311(e)(3) of the Affordable Care Act, which addresses transparency in health coverage and imposes certain reporting and disclosure requirements for health plans that are seeking certification as QHPs that may be offered on an Exchange. A plan or coverage that is not offered through an Exchange (as defined by section 1311(b)(1) of the Affordable Care Act) is required to submit the information required to the relevant Secretary and the relevant State's insurance commissioner, and to make that information available to the public. The 2020 final rules require non-grandfathered health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage to disclose cost-sharing information for all covered items and services to participants, beneficiaries, and enrollees through an internet-based self-service tool or, if requested by the individual, on paper. These provisions of the 2020 final rules implement paragraph (C) of section 1311(e)(3) of the Affordable Care Act. The 2020 final rules also require non-grandfathered plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage to disclose on a public website three separate machine-readable files containing certain information regarding health care pricing under the plan or coverage. The machine-readable file disclosure requirements are intended to make health care pricing information accessible and useful to consumers and other interested parties (including employers, and other purchasers of health care), 35 support efforts to lower health care costs by driving competition, 36 and to supplement State transparency efforts. 37 These provisions of the 2020 final rules requiring plans and issuers to disclose in-network negotiated rates, out-of-network allowed amounts and the associated billed charges, and negotiated rates and historical net prices for prescription drugs implement paragraph (A) of section 1311(e)(3) of the Affordable Care Act. In particular, the provisions requiring the disclosure of out-of-network allowed amounts specifically implement the requirement in section 1311(e)(3)(A)(vii) of the Affordable Care Act to provide information on “payments with respect to any out-of-network coverage.” In addition, the Secretary of HHS determined that requiring disclosure of payment information on in-network rates and prescription drugs is appropriate under section 1311(e)(3)(A)(ix) of the Affordable Care Act. 35 85 FR 72158, 72160-61 (November 12, 2020). 36 85 FR 72158, 72161-62 (November 12, 2020). 37 85 FR 72158, 72162-63 (November 12, 2020). The No Surprises Act added new provisions applicable to plans and issuers in Subchapter B of chapter 100 of the Code, Part 7 of ERISA, and Parts D and E of title XXVII of the PHS Act. As relevant here, the No Surprises Act added new sections 9816(a)-(b) and 9817(a) of the Code, sections 716(a)-(b) and 717(a) of ERISA, and sections 2799A-1, 2799A-2, 2799B-1, 2799B-2, 2799B-3, and 2799B-5 of the PHS Act, which protect participants, beneficiaries, and enrollees in group health plans and group and individual health insurance coverage from balance bills by prohibiting nonparticipating providers, facilities, and providers of air ambulance services from billing or holding liable individuals for an amount that exceeds in-network cost sharing determined in accordance with the No Surprises Act's cost-sharing limitations in circumstances where the cost-sharing limitations apply. The No Surprises Act also added new section 9816(e) of the Code, section 716(e) of ERISA, and sections 2799A-1(e) of the PHS Act, which contain requirements for applicable group health plans or issuers to include certain information, in clear writing, on any physical or electronic plan or insurance identification card issued to the participants or beneficiaries in the plan or coverage. This information includes any deductible applicable to such plan or coverage, any out-of-pocket maximum limitation applicable to such plan or coverage, and a telephone number and internet website address through which such individual may seek consumer assistance information. Further, section 114 of the No Surprises Act added section 2799A-4 of the PHS Act, section 9819 of the Code, and section 719 of ERISA, which require plans and issuers to: offer price comparison guidance by telephone and make available on the internet website of the plan or issuer a price comparison tool that (to the extent practicable) allows an individual enrolled under such plan or coverage, with respect to such plan year, such geographic region, and participating providers with respect to such plan or coverage, to compare the amount of cost sharing that the individual would be responsible for paying under such plan or coverage with respect to the furnishing of a specific item or service by any such provider. C. Statutory Background for Enforcement With Regards to the Affordable Care Act and the CAA of 2021 The enforcement responsibilities of HHS and the States with respect to oversight of health insurance issuer compliance with the Federal insurance market reforms are set forth in the PHS Act. Pursuant to section 2723(a)(1) of the PHS Act, as amended by the No Surprises Act, states have primary enforcement authority over health insurance issuers regarding the provisions of Parts A and D of title XXVII of the PHS Act. Under this framework, HHS has enforcement authority over issuers in a State if the Secretary of HHS makes a determination that the State is failing to substantially enforce a provision (or provisions) of Part A or D of title XXVII of the PHS Act. 38 38 See section 2723(a)(2) and (b)(1)(A) of the PHS Act; 45 CFR 150.203. The Departments of Labor and the Treasury generally have primary enforcement authority over private sector employment-based group health plans. The Internal Revenue Service (IRS) has jurisdiction over certain church plans. HHS also has primary enforcement authority over non-Federal governmental plans, such as those sponsored by state and local government employers. 39 39 Section 2723(b)(1)(B) of the PHS Act. The Departments will generally use existing processes to ensure compliance with the Code, ERISA, and PHS Act requirements that apply to group health plans and health insurance issuers. HHS's enforcement procedures related to the PHS Act Federal insurance market reforms are set forth in section 2723 of the PHS Act and 45 CFR 150.101 et seq., including bases for initiating investigations, performing market conduct examinations, and imposing civil money penalties. Section 504 of ERISA provides DOL with investigatory authority to determine whether any person has violated or is about to violate any provision of ERISA or any regulation or order thereunder. D. Consultation With and Input From Interested Parties The Departments have been in regular consultation with interested parties since publishing the 2019 proposed rules. In addition to the thousands of comments received on the 2019 proposed rules, following the publication of the 2020 final rules, the Departments continued to engage in consultation with interested parties and collaboration about implementation of the 2020 final rules through technical implementation discussions on GitHub (an online hosting platform for development and source code management that permits version control), webinars, emails, and an inquiry management system, as well as other informal compliance assistance efforts and meetings with interested parties. This period of collaboration with interested parties led to the finalization of an initial technical format for disclosures (Schema 1.0) that was finalized on March 1, 2022, and became applicable on July 1, 2022. The Departments also regularly review news articles and research publications discussing the 2020 final rules and have received written and verbal recommendations from plans and issuers, data engineers, and researchers and academics. 40 40 Supra note 8, 9, 10, and 11. On May 22, 2025, the Departments released FAQs Part 70 on Schema 2.0, which states the Departments' intention to issue revised technical reporting requirements for the In-network Rate File and Allowed Amount File for group health plans and health insurance issuers, and the applicability date for implementation. 41 FAQs Part 70 requested interested parties to provide feedback through GitHub on how best to address the revised technical reporting requirements. These improvements respond to feedback from interested parties and are designed to reduce unnecessary or duplicative data fields and make cost information easier for consumers to understand and use. 41 U.S. Department of Labor, U.S. Department of Health & Human Services & U.S. Department of the Treasury, FAQs About Affordable Care Act Implementation Part 70 (May 22, 2025), https://www.cms.gov/files/document/aca-faqs-part-70.pdf and https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-70. Additionally, on June 2, 2025, the Departments issued an RFI 42 regarding the prescription drug machine-readable file requirement seeking comment and recommendations on the prescription drug price disclosure requirements. More specifically, the RFI requested comments and recommendations to help inform implementation of the prescription drug file disclosure requirements, including information on existing prescription drug file data elements, the ability of health plans to access necessary data for reporting, as well as state approaches and innovation. 43 42 See 90 FR 23303 (June 2, 2025). 43 Id. The Departments considered all public input received as they developed the policies in these proposed rules, with the exception of prescription drug RFI comments. However, the Departments received these prescription drug RFI comments and are separately taking them into consideration to evaluate how to implement the Transparency in Coverage prescription drug disclosure requirements in technical implementation guidance or future rulemaking. III. Provisions of the Proposed Regulations A. Definitions The Departments propose to define the term health insurance market for purposes of proposed amendments to the Allowed Amount File provision at 26 CFR 54.9815-2715A3(b)(1)(ii), 29 CFR 2590.715-2715A3(b)(1)(ii), and 45 CFR 147.212(b)(1)(ii) (discussed in more detail in section III.C.6. of this preamble), which would require group health plans and health insurance issuers offering group or individual health insurance coverage to make an out-of-network allowed amount machine-readable file available for each health insurance market in which plans and issuers offer a plan or coverage. Establishing a standardized definition of the term health insurance market for this purpose would promote consistent data organization across plans and issuers in these market-level Allowed Amount Files. The Departments propose to redesignate paragraphs (a)(2)(xi) through (xxii) as paragraphs (a)(2)(xii) through (xxiii) under 26 CFR 54.9815-2715A1 and 45 CFR 147.210, respectively, and add a new paragraph (a)(2)(xi) with the new definition. The Departments also propose to redesignate paragraphs (a)(2)(x) through (xxi) as paragraphs (a)(2)(xi) through (xxii) under 29 CFR 2590.715-2715A1, and to add a new paragraph (a)(2)(x) with the new definition. Under this proposal, health insurance market would mean, irrespective of the State, one of the following: • 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). • The large group market, as defined in 45 CFR 144.103 (other than coverage that consists solely of excepted benefits). • The small group market, as defined in 45 CFR 144.103 (other than coverage that consists solely of excepted benefits). • For purposes of self-insured group health plans (other than account-based plans, as defined in 26 CFR 54.9815-2711(d)(6)(i), 29 CFR 2590.715-2711(d)(6)(i), and 45 CFR 147.126(d)(6)(i), and plans that consist solely of excepted benefits), all self-insured group health plans maintained by the plan sponsor. For consistency, this definition would largely align with the definition of the term “insurance market” for the purposes of the methodology for calculating the qualifying payment amount (QPA) at 26 CFR 54.9816-6(a)(8), 29 CFR 2590.716-6(a)(8), and 45 CFR 149.140(a)(8). As background, Code section 9816(a)(3)(E), ERISA section 716(a)(3)(E), and PHS Act 2799A-1(a)(3)(E), as added by section 103 of the No Surprises Act, generally defines the QPA as “the median of the contracted rates recognized by the plan or issuer, respectively (determined with respect to all such plans of such sponsor or all such coverage offered by such issuer that are offered within the same insurance market (specified in subclause (I), (II), (III), or (IV) of clause (iv)) as the plan or coverage) . . . under such plans or coverage, respectively, on January 31, 2019,” subject to other criteria and increased for inflation. Paragraph (a)(3)(E)(iv)(III) of the Code and ERISA and paragraph (a)(3)(E)(iv)(IV) of the PHS Act, provide that in the case of a self-insured group health plan, a health insurance market is “other self-insured group health plans.” When interpreting the definition of QPA for purposes of establishing a methodology for calculating the QPA, the Departments defined “insurance market” with respect to self-insured group health plans to include, “at the option of the plan sponsor, all self-insured group health plans administered by the same entity (including a third party administrator (TPA) contracted by the plan), to the extent otherwise permitted by law, that is responsible for calculating the qualifying payment amount on behalf of the plan.” 44 In other words, the interim final rules permitted plan sponsors to use either rates from only their own plans or rates from all plans administered by their TPA to calculate QPAs. However, this language has been vacated by the United States District Court for the Eastern District of Texas on the basis that the No Surprises Act specifies that QPAs must be calculated using the rates of “all such plans of such sponsor.” 45 Therefore, the United States District Court for the Eastern District of Texas interpreted the No Surprises Act to restrict aggregation in that manner for the purpose of calculating the QPA. 44 86 FR 36954 (July 13, 2021). 45 Texas Medical Association, a trade association representing more than 56,000 Texas physicians and medical students; Dr. Adam Corley, a Tyler, Texas physician; Tyler Regional Hospital, LLC, a hospital in Tyler, Texas; LifeNet, Inc.; East Texas Air One, LLC; Rocky Mountain Holdings, LLC; and Air Methods Corporation v. United States Department of Health & Human Services, U.S. Department of Labor, U.S. Department of the Treasury, and the Office of Personnel Management, No. 6:22-cv-450-JDK (E.D. Tex. August 24, 2023) ( TMA III ) (vacating portions of 26 CFR 54.9816-6T(a)(8)(iv), 29 CFR 2590.716-6(a)(8)(iv), and 45 CFR 149.140(a)(8)(iv). The Department of Justice did not appeal the vacatur of this specific provision and it remains in place. See also FAQs About Affordable Care Act and Consolidated Act, 2021 Implementation Part 71 (July 30, 2025). https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-71 (until the Fifth Circuit issues its en banc decision, extending enforcement relief for plans and issuers that use a QPA calculated using a good faith, reasonable interpretation of the methodology in place before the district court decision, for items and services furnished before February 1, 2026). In contrast, the language of PHS Act section 2715A neither requires nor prohibits disclosure of information described in the Affordable Care Act section 1311(e)(3) to be aggregated by any specific market. Therefore, in order to avoid confusion between the insurance market applicable to the Allowed Amount File and the insurance market applicable to the definition of QPA, which is subject to the holding of TMA III, the Departments propose to use the term “health insurance market,” rather than “insurance market,” for purposes of organizing the Allowed Amount File. The Departments note that to the extent self-insured group health plans use an entity to administer the plan, the aggregation rules described in proposed 26 CFR 54.9815-2715A3(b)(5)(iv), 29 CFR 2590.715-2715A3(b)(5)(iv), and 45 CFR 147.212(b)(5)(iv) would allow the entity to aggregate out-of-network allowed amounts for more than one plan offered by a self-insured group health plan sponsor the entity administers, including those offered by self-insured group health plan sponsors. For clarity, the Departments also propose to include cross-references to the market-wide definitions in 45 CFR 144.103 where applicable. The Departments understand that the term health insurance market is not generally used to refer to self-insured group health plans. However, for purposes of uniformity in the definition, to facilitate a more streamlined and uniformed disclosure of Allowed Amount File, and for ease of reference, the Departments propose that for purposes of self-insured group health plans (other than account-based plans, as defined in 26 CFR 54.9815-2711(d)(6)(i), 29 CFR 2590.715-2711(d)(6)(i), and 45 CFR 147.126(d)(6)(i) of this subchapter, and plans that consist solely of excepted benefits), health insurance market would mean all self-insured group health plans maintained by the plan sponsor. The Departments seek comment on this proposed definition. B. Requirements for Disclosing Cost-Sharing Information to Participants, Beneficiaries, and Enrollees 1. Disclaimer on Balance Billing The Departments propose to amend the balance billing protection notice that plans and issuers are currently required to include along with the required cost-sharing information to participants, beneficiaries, and enrollees under 26 CFR 54.9815-2715A2(b)(1)(vii)(A), 29 CFR 2590.715-2715A2(b)(1)(vii)(A), and 45 CFR 147.211(b)(1)(vii)(A). These proposed amendments would require a statement that the cost-sharing information in the self-service tool does not account for potential additional amounts in situations where applicable State and Federal law allow out-of-network providers to bill participants, beneficiaries, or enrollees for the difference between a provider's billed charges and the sum of the amount collected from the plan or issuer and the amount collected from the participant, beneficiary, or enrollee in the form of a copayment, coinsurance, or deductible amount (the difference referred to as balance billing). These changes are being proposed to reflect the existence of the Federal balance billing protections set forth in the No Surprises Act, which were not yet enacted when the current disclaimer language was finalized in the 2020 final rules. This statement would not be required if the State in which the item or service was furnished prohibits all out-of-network providers from balance billing for all items and services payable by the group health plan or health insurance issuer. Currently, under paragraph (b)(1) of this section, plans and issuers must disclose certain cost-sharing information to participants, beneficiaries, and enrollees, including, under paragraph (b)(1)(i), an estimate of the participant's, beneficiary's, or enrollee's cost-sharing liability for a requested covered item or service from a particular provider or providers. Paragraph (b)(1)(iv) requires, in part, that if the request is for cost-sharing information for an out-of-network provider, the plan or issuer must disclose an out-of-network allowed amount or any other rate that the group health plan or health insurance issuer will pay for the requested covered item or service. As discussed in the 2020 final rules, 46 because cost estimates cannot account for potential balance billing by an out-of-network provider, current rules under paragraph (b)(1)(vii) require plans and issuers to include a notice with a number of statements, including, under paragraph (b)(1)(vii)(A), that out-of-network providers may bill participants, beneficiaries, or enrollees for the difference between a provider's billed charges and the sum of the amount collected from the plan or issuer and the amount collected from the participant, beneficiary, or enrollee in the form of a copayment or coinsurance amount (the difference often referred to as balance billing) and that these estimates do not account for those potential additional amounts. Because there were existing State laws prohibiting balance billing to some extent, as discussed in the 2020 final rules, 47 the current rules only require this statement if balance billing is permitted under State law. 46 85 FR 72158, 72201 (November 12, 2020). 47 85 FR 72158, 72201 (November 12, 2020). Shortly after the 2020 final rules were published, the CAA, 2021, which included the No Surprises Act, was signed into law on December 27, 2020. The No Surprises Act added provisions that apply to group health plans and health insurance issuers offering group or individual health insurance coverage, including certain limitations on cost sharing for emergency services and for non-emergency services provided by nonparticipating providers with respect to visits to certain participating health care facilities. 48 The No Surprises Act also added certain limitations on cost sharing for air ambulance services provided by out-of-network air ambulance providers. 49 Additionally, the No Surprises Act added that cost-sharing payments for emergency services, non-emergency services furnished by a nonparticipating provider in a participating health care facility, and air ambulance services furnished by a nonparticipating provider must be counted toward any in-network deductible or out-of-pocket maximums applied under the plan or coverage (including the annual limitation on cost sharing under section 2707(b) of the PHS Act) (as applicable), respectively (and these in-network deductibles and out-of-pocket maximums must be applied) in the same manner as if such cost-sharing payments were made with respect to services furnished by a participating provider or facility. 50 48 Codified in Code section 9816, ERISA section 716, and PHS Act section 2799A-1. 49 Codified in Code section 9817, ERISA section 717, and PHS Act section 2799A-2. 50 Codified in Code sections 9816 and 9817, ERISA sections 716 and 717, and PHS Act sections 2799A-1 and 2799A-2. In addition to the new provisions applicable to plans and issuers, the No Surprises Act added a new Part E to title XXVII of the PHS Act establishing requirements applicable to health care providers, facilities, and providers of air ambulance services. Specifically, the No Surprises Act added new PHS Act sections 2799B-1, 2799B-2, 2799B-3, and 2799B-5, which protect participants, beneficiaries, and enrollees in group health plans and group and individual health insurance coverage offered by health insurance issuers from balance bills by generally prohibiting nonparticipating providers, facilities, and providers of air ambulance services from billing or holding liable individuals for an amount that exceeds in-network cost sharing determined in accordance with the No Surprises Act's cost-sharing limitations in circumstances where the cost-sharing limitations apply. Given that after the passage of the No Surprises Act, all participants, beneficiaries, and enrollees of group health plans and group and individual health insurance coverage are now protected from certain balance billing under Federal law, the Departments propose to amend the balance billing protection notice provision under paragraph (b)(1)(vii)(A) to require a statement that the cost-sharing information provided pursuant to paragraph (b)(1)(i) does not account for potential additional amounts in situations where applicable State and Federal law allow out-of-network providers to bill participants, beneficiaries, or enrollees, for the difference between a provider's billed charges and the sum of the amount collected from the plan or issuer and from the participant, beneficiary, or enrollee in the form of a copayment, coinsurance, or deductible amount (the difference referred to as balance billing). Because there are circumstances under which participants, beneficiaries, and enrollees can be balance billed under current Federal law and State balance billing laws, the Departments propose to clarify that this disclaimer is not required only if the State in which the item or service is to be furnished prohibits all out-of-network providers from balance billing for all items and services payable by the group health plan or health insurance issuer. The Departments understand that no States currently categorically prohibit balance billing under all circumstances. Therefore, requiring plans and issuers in States without such categorical prohibitions to include this disclaimer would provide an additional layer of transparency for consumers. It would also maintain flexibility for plans and issuers to not include the notice if the State in which the plan or issuer is disclosing cost-sharing information to a participant, beneficiary, or enrollee does, subsequent to the finalization of these proposed rules, pass a law to which all providers are subject that prohibits balance billing for all items and services payable by the plan or issuer. The Departments seek comment on this proposal. 2. New Required Method and Format for Disclosing Information to Participants, Beneficiaries, or Enrollees The Departments propose to add new 26 CFR 54.9815-2715A2(b)(2)(iii), 29 CFR 2590.715-2715A2(b)(2)(iii), and 45 CFR 147.211(b)(2)(iii) to require plans and issuers to make available to participants, beneficiaries, and enrollees, at their request, the cost-sharing estimates and other disclosures required under 26 CFR 54.9815-2715A2(b)(1), 29 CFR 2590.715-2715A2(b)(1), and 45 CFR 147.211(b)(1) via a phone number. Under this proposal, the information required via a phone number would be required to be accurate at the time of the request and provided at the time of the request. Plans and issuers would be required to use the same telephone number that Code section 9816(e), ERISA section 716(e), and PHS Act section 2799A-1(e), as added by section 107 of the No Surprises Act, 51 require be indicated on any physical or electronic plan or insurance identification (ID) card issued to participants, beneficiaries, and enrollees for obtaining customer assistance. The Departments also propose to redesignate paragraph (b)(2)(ii)(D) as new paragraph (b)(2)(iv) and amend paragraph (b)(2)(iv) to remove phone as an example of an alternative means for providing the disclosures by which a participant, beneficiary, or enrollee may request the disclosures required described in paragraph (b)(1) because providing the disclosures by a phone number would be required, as specified previously. If this new requirement is finalized as proposed, plans and issuers would be required to make available cost-sharing estimates via the internet-based self-service tool, a phone number, and paper upon request. 51 U.S. Department of Labor, U.S. Department of Health & Human Services & U.S. Department of the Treasury, FAQs about Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 49 (August 20, 2021), https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf and https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf. The 2020 final rules at paragraph (b)(2) allow plans and issuers to satisfy the disclosure requirements of paragraph (b)(1) through a self-service tool, via paper, or through an alternative means such as phone or email, provided the participant, beneficiary, or enrollee agrees that disclosure through such means is sufficient to satisfy the request and the request is fulfilled at least as rapidly as required for the paper method. However, disclosure by such alternative means is not required. While the Departments have determined that the No Surprises Act's price comparison tool (codified at Code section 9819, ERISA section 719, and the PHS Act section 2799A-4) and self-service tool required under the 2020 final rules are largely duplicative, as discussed in more detail in section III.B.3. of this preamble, the requirements of Code section 9819, ERISA section 719, and the PHS Act section 2799A-4 expand the requirements for the disclosure of cost-sharing information in the 2020 final rules in one prominent way. Specifically, Code section 9819, ERISA section 719, and the PHS Act section 2799A-4 require group health plans and health insurance issuers offering group or individual health insurance coverage to “offer price comparison guidance by telephone.” The Departments intend for these proposed rules to satisfy the requirements of the No Surprises Act to require price comparison guidance via a telephone number, as set forth in Code section 9819, ERISA section 719, and PHS Act section 2799A-4. Further, implementing this requirement would respond to feedback the Departments have received from participants, beneficiaries, and enrollees since the publication of the 2020 final rules, indicating a limited ability to receive cost-sharing information over the phone when requested from plans and issuers. Requiring plans and issuers to provide cost-sharing information in this way would further promote the price transparency goals of providing accurate, real-time pricing to consumers, and making that information accessible to more consumers. To achieve these goals, these proposed rules add paragraph (b)(2)(iii), proposing to require plans and issuers to make available to participants, beneficiaries, and enrollees the cost-sharing estimates and other disclosures required under paragraph (b)(1), via phone, at the time requested and accurate at the time of their request. In addition, at paragraph (b)(2)(iii), the Departments propose to allow plans and issuers to limit the number of providers with respect to which cost-sharing information for covered items and services is provided to no fewer than 20 providers per day and, to require plans and issuers to disclose the applicable provider-per-day limit to the participant, beneficiary, or enrollee when the request for information is made. A similar 20 provider limit currently applies with respect to paper requests at 26 CFR 54.9815-2715A2(b)(2)(ii), 29 CFR 2590.715-2715A2(b)(2)(ii), and 45 CFR 147.211(b)(2)(ii). In the 2020 final rules, the Departments determined based on comments that “limiting paper request to 20 providers per request is a reasonable approach to balancing the burdens on plans and issuers with the benefits of providing consumers with enough information to be able to compare cost and provider options.” 52 The Departments have determined that the process by which plans and issuers would generate information responsive to requests for receiving cost-sharing information over the phone should be similar to the process for generating such information to deliver via paper, given the practicalities of generating a response on paper and over the phone. Therefore, the Departments propose to adopt the limitations for paper disclosure at 26 CFR 54.9815-2715A2(b)(2)(ii), 29 CFR 2590.715-2715A2(b)(2)(ii), and 45 CFR 147.211(b)(2)(ii) for phone disclosure such that plans and issuers may limit the number of providers with respect to which cost-sharing information for covered items and services is provided to no fewer than 20 providers per day and, plans and issuers would be required to disclose the applicable provider-per-day limit to the participant, beneficiary, or enrollee when the request for information is made. This proposal is intended to balance the added burden to plans and issuers of this additional method of delivery with ensuring that participants, beneficiaries, and enrollees that opt to receive cost-sharing information over the phone have access to the same information as those that request such information via the paper method. The Departments note that nothing in these proposed rules precludes a participant, beneficiary, or enrollee from obtaining cost-sharing information from more than one method, consistent with the requirements for each method. Similarly, for consistency with the requirements for the paper method of delivery under the 2020 final rules, the Departments also propose to require plans and issuers to satisfy requests for cost-sharing information over the phone at the time of the phone call in order to ensure that participants, beneficiaries, and enrollees receive information as quickly as possible. 52 85 FR 72158, 72207 (November 12, 2020). Accordingly, the Departments propose to require plans and issuers to make available to participants, beneficiaries, and enrollees the cost-sharing estimates and other disclosures described in paragraph (b)(1) via phone at the time of the request and accurate at the time of the request, and in accordance with the method and format requirements in paragraphs (b)(2)(i)(A) through (C). The Departments are also proposing to require health plans and health insurance issuers to make cost-sharing estimates and other disclosures available over the phone at a number designated on the ID card for individuals to seek assistance. Code section 9816(e), ERISA section 716(e), and PHS Act section 2799A-1(e) (insurance ID card requirements), as added by section 107 of the No Surprises Act, separately require plans and issuers to include in clear writing, on any physical or electronic plan or insurance identification card issued to participants, beneficiaries, or enrollees, certain information including a phone number and website address for individuals to seek consumer assistance. Therefore, plans and issuers are already required to have a phone number designated on any physical or electronic plan or insurance identification card and, under this proposal, plans and issuers should make available cost-sharing estimates and other disclosures at the request of the participant or beneficiary via such phone number, if finalized. These provisions apply with respect to plan years (in the individual market, policy years) beginning on or after January 1, 2022. 53 The Departments expect that requiring plans and issuers to use an existing phone number would allow them to leverage existing workflows and would make it easier for participants, beneficiaries, and enrollees to obtain the cost information they are seeking. 53 U.S. Department of Labor, U.S. Department of Health & Human Services & U.S. Department of the Treasury, FAQs About Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 49 (Aug. 20, 2021), https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf and https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf. FAQ Part 49 provided that, pending any implementing rulemaking, the Departments would not deem a plan or issuer to be out of compliance with ID card requirements where a plan or issuer includes on any ID card, among other things, a telephone number and website address for individuals to seek consumer assistance and access additional applicable deductibles and maximum out-of-pocket limits. The Departments request comment on whether this proposal should include phone service standards to ensure that consumers have access to timely and reliable information. In particular, the Departments request comment on what such standards should include and what parameters should be applied to each criterion. The Departments also request comment on whether there are other relevant Federal, State, or local standards for phone service quality or any industry practices that the Departments should consider. 3. Compliance With PHS Act Section 2799A-4, ERISA Section 719, and Code Section 9819 The Departments propose to add new 26 CFR 54.9815-2715A2(c)(7), 29 CFR 2590.715-2715A2(c)(7), and 45 CFR 147.211(c)(7) stating that a plan or issuer satisfies the requirements of Code section 9819, ERISA section 719, and the PHS Act section 2799A-4, as added by section 114 of the No Surprises Act by providing the information required under paragraph (b)(1) of this section to participants, beneficiaries, and enrollees in accordance with the method and format requirements specified in paragraph (b)(2) of this section. The 2020 final rules added 26 CFR 54.9815-2715A2(b)(1) and (b)(2), 29 CFR 2590.715-2715A2(b)(1) and (b)(2), and 45 CFR 147.211(b)(1) and (b)(2), which created a comprehensive set of requirements for plan and issuer disclosure of cost-sharing information through an internet-based self-service tool, and in paper form, upon request. 54 Paragraph (b)(1) of the 2020 final rules requires the disclosure of cost-sharing information, which is accurate at the time the request is made, with respect to a participant's, beneficiary's, or enrollee's cost-sharing liability for covered items and services, and which must reflect any cost-sharing reductions the enrollee would receive. 54 26 CFR 54.9815-2715A2(b)(1) and (2), 29 CFR 2590.2715A2(b)(1) and (2), and 45 CFR 147.211(b)(1) and (2). Under paragraph (b)(2) of the 2020 final rules, disclosures must be made available through a self-service tool on an internet website that provides real-time responses based on cost-sharing information that is accurate at the time of the request, in plain language, without a fee, or in paper form, at the user's request. This paragraph requires certain functionality to make searching using the self-service tool easier, including searching by billing code or descriptive term, and refining and reordering search results based on geographic proximity of in-network providers, and the amount of the participant's, beneficiary's, or enrollee's estimated cost-sharing liability for the covered item or service, to the extent the search for cost-sharing information for covered items or services returns multiple results. 55 55 26 CFR 54.9815-2715A2(b)(2)(i), 29 CFR 2590.2715A2(b)(2)(i), and 45 CFR 147.211(b)(2)(i). Code section 9819, ERISA section 719, and PHS Act section 2799A-4, as added by section 114 of the No Surprises Act, require plans and issuers to offer price comparison guidance by telephone and make available on the plan's or issuer's website a “price comparison tool” that allows individuals enrolled under such plan or coverage offered by the plan or issuer to compare the amount of cost sharing that the individual would be responsible for paying for an item or service furnished by an in-network provider (hereinafter “No Surprises Act price comparison tool”). This requirement was applicable with respect to plan years (and in the individual market, policy years) beginning on or after January 1, 2022. The Departments announced on August 20, 2021, in FAQs Part 49 that the price comparison methods required by the No Surprises Act price comparison tool are largely duplicative of the self-service tool component of the 2020 final rules except that the information under the No Surprises Act price comparison tool must also be provided over the telephone upon request. 56 Therefore, the Departments indicated they intended to propose rulemaking requiring that the same pricing information that is available through the self-service tool or in paper form, as described in the 2020 final rules, must also be provided over the phone upon request. The Departments also announced that, as an exercise of enforcement discretion, they would defer enforcement of the requirement that plans and issuers make available a price comparison tool by internet website, in paper form, or telephone pursuant to the No Surprises Act until plan years (or in the individual market, policy years) beginning on or after January 1, 2023, to align the enforcement date of the No Surprises Act price comparison disclosure requirements with the enforcement date of the self-service tool described in the 2020 final rules. 56 U.S. Department of Labor, U.S. Department of Health & Human Services & U.S. Department of the Treasury, FAQs About Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 49 (Aug. 20, 2021), https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf and https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf. Further, the Departments announced their intention to propose rulemaking and seek public comment regarding whether compliance with the self-service tool requirements of the 2020 final rules should satisfy the analogous requirements set forth Code section 9819, ERISA section 719, and PHS Act section 2799A-4. Plans and issuers have built and developed tools to comply with the requirements of the 2020 final rules and have anticipated, since the release of FAQs Part 49, that the Departments would propose in a future rulemaking that plans and issuers satisfy the No Surprises Act price comparison tool requirement by providing the required disclosures to participants, beneficiaries, and enrollees through the self-service tool as required in paragraphs (b)(1) and (2) of the 2020 final rules. Given this, the Departments have determined that requiring plans and issuers to build a second self-service tool would impose significant unnecessary burden and cause considerable confusion for consumers on the purposes of the two tools. Thus, it is appropriate that compliance with the self-service tool described in the 2020 final rules and as amended in these proposed rules should satisfy compliance with the No Surprises Act price comparison tool requirements. Therefore, as discussed in section II.B.2. of this preamble, to align with the No Surprises Act price comparison tool requirements the Departments propose to require in new paragraph (b)(2)(iii) that plans and issuers make available to participants, beneficiaries, and enrollees the cost-sharing information and other disclosures required under paragraph (b)(1) via the same telephone number that Code section 9816(e), ERISA section 716(e), and PHS Act section 2799A-1(e), as added by section 107 of the No Surprises Act, requires be indicated on any physical or electronic plan or insurance identification card issued to a participant, beneficiary, or enrollee for obtaining customer assistance. The Departments also propose at new paragraph (c)(7) that a group plan or health insurance issuer satisfies the requirements of Code section 9819, ERISA section 719, and PHS Act section 2799A-4 by providing the information required in paragraph (b)(1) to participants, beneficiaries, and enrollees in accordance with the method and format requirements specified in paragraph (b)(2). The Departments acknowledge that, while PHS Act section 2715A does not apply to grandfathered health plans and health insurance issuers offering grandfathered individual and group health insurance coverage, Code section 9819, ERISA section 719, and PHS Act section 2799A-4 do. The Departments have also stated that the requirements of PHS Act section 2715A are largely duplicative to those of Code section 9819, ERISA section 719, and PHS Act section 2799A-4, except that the former does not require information to be disclosed by phone. Therefore, if this rule is finalized, grandfathered health plans and issuers offering grandfathered health insurance coverage may comply with the requirements of PHS Act 2715A, as codified in 26 CFR 54.9815-2715A2, 29 CFR 2590.716-2715A2 and 45 CFR 147.211, to satisfy the requirements of Code section 9819, ERISA section 719, and PHS Act section 2799A-4. The Departments request comments on whether any additional provisions are necessary to assist grandfathered health plans and health insurance issuers in complying with the requirements of 26 CFR 54.9815-2715A2, 29 CFR 2590.716-2715A2 and 45 CFR 147.211. The Departments seek comment on all aspects of this proposal. 4. Applicability The Departments propose to revise 26 CFR 54.9815-2715A2(c)(1), 29 CFR 2590.715-2715A2(c)(1), and 45 CFR 147.211(c)(1) to state that the proposed amendments to (b)(1)(vii)(A), and new paragraphs (b)(2)(iii), (b)(2)(iv), and (c)(7) of this section would apply for plan years (in the individual market, policy years) beginning on or after January 1, 2027. Until such time, the current provisions of paragraph (b) of this section continue to apply. With respect to proposed provisions at new paragraph (b)(2)(iii), the Departments understand that most plans and issuers already have in place a consumer assistance telephone number for participants, beneficiaries, and enrollees to receive benefit information pursuant to Code section 9816(e), ERISA section 716(e), and PHS Act section 2799A-1(e), as added by section 107 of the No Surprises Act, and as clarified in previously issued guidance. 57 Because plans and issuers can leverage the operations of an existing consumer assistance phone number, the Departments have determined that the proposed applicability date appropriately balances the need for improved access to cost-sharing estimates for consumers who wish to access this information over the phone with the time necessary for plans and issuers to make the administrative and operational changes to implement this proposal. Similarly, because most plans are already required to disclose the balance billing disclosures under the 2020 final rules, the Departments have determined that the proposed applicability date for new paragraph (b)(1)(vii)(A) that would amend the balance billing disclosure is appropriate and reasonable. 57 U.S. Department of Labor, U.S. Department of Health & Human Services & U.S. Department of the Treasury, FAQs About Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 49 (Aug. 20, 2021), https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf and https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/affordable-care-act-faqs-49-2021.pdf. The Departments propose to make new paragraph (c)(7) applicable for plan years (in the individual market, policy years) beginning on or after January 1, 2027. The Departments selected this date because once plans and issuers are required to provide cost-sharing information by phone on the same date pursuant to proposed new paragraph (b)(2)(iii), it would be reasonable for the Departments to consider a plan or issuer's compliance with paragraphs (b)(1) and (2) to constitute compliance with the No Surprises Act price comparison tool as required by Code section 9819, ERISA section 719, and PHS Act section 2799A-4. The Departments seek comment on this proposed applicability date for these proposed provisions. C. Requirements for Public Disclosure of In-Network Rates and Historical Allowed Amount Data for Covered Items and Services From In- and Out-of-Network Providers 1. Provider Network-Level Reporting for the In-Network Rate Files The current In-network Rate File provision at 26 CFR 54.9815-2715A3(b)(1)(i), 29 CFR 2590.715-2715A3(b)(1)(i), and 45 CFR 147.212(b)(1)(i) requires plans and issuers to make available on a public website a machine-readable file that discloses in-network provider rates for covered items and services, with the exception of prescription drugs that are subject to a fee-for-service reimbursement arrangement. The Departments propose to amend the introductory language of paragraph (b)(1)(i) to require plans and issuers to make available an In-network Rate File for each provider network maintained or contracted by the group health plan or health insurance issuer. This proposed change is intended to reduce the size and total number of In-network Rate Files, allow file users to more efficiently aggregate and analyze the data, and align reporting more closely to how data is typically reported by hospitals pursuant to the Hospital 2019 and 2023 Price Transparency rules 58 under 45 CFR part 180. 58 84 FR 65524 (November 17, 2019) and 88 FR 81540 (November 22, 2023). a. Reducing File Size As discussed in section I.A. of this preamble, file size is the most common concern that the Departments have heard from interested parties regarding the current In-network Rate Files. These files are often very large, making them challenging for users to download, analyze, and store. 59 In-network Rate File sizes often represent many terabytes of data a month for a single issuer, 60 and many exceed most local storage and processing capabilities. 61 Additionally, each issuer may have hundreds of separate files for each plan or coverage it offers, making aggregation and analysis highly resource intensive. 62 59 See Fred Diamond, Payers' Price Transparency Data Still Not User-Friendly, Say Researchers (Feb. 7, 2023), https://www.fiercehealthcare.com/payers/health-insurance-plans-price-transparency-data-still-not-user-friendly-say-researchers; See also David Muhlestein, Improving Price Transparency Data: Recommendations From Practice, Health Affairs. (Mar. 19, 2025), https://www.healthaffairs.org/content/forefront/improving-price-transparency-data-recommendations-practice. 60 See David Muhlestein, Improving Price Transparency Data: Recommendations from Practice, Health Affairs (Mar. 19, 2025), https://www.healthaffairs.org/content/forefront/improving-price-transparency-data-recommendations-practice. 61 See Aileen Y. Choi, Karen Manthe-Cohen, & Robert J. Rosso, Technical Challenges with Private Health Insurance Price Transparency Data, Congressional Research Service (June 13, 2025), https://www.congress.gov/crs-product/R48570. 62 See Aileen Y. Choi, Karen Manthe-Cohen, & Robert J. Rosso, Technical Challenges with Private Health Insurance Price Transparency Data, Congressional Research Service (June 13, 2025), https://www.congress.gov/crs-product/R48570. The Departments have determined that the size of the In-network Rate File can be highly dependent on how it is organized. It is very common for multiple plans offered by the same issuer or administered by the same service provider to leverage the same provider networks with the same negotiated rates. 63 This means that when plans and issuers organize In-network Rate Files by plan ID, they often repeat the same negotiated rates across multiple plan files, which leads to significant duplicative data throughout the In-network Rate Files. The Departments have received consistent feedback about the challenges related to file size, and some of that feedback has suggested that the disclosure requirements be amended to organize In-network Rate Files by provider network, whereby each file would contain all rates negotiated by the reporting entity for that provider network, rather than having a file for each plan ID. 64 63 See Lester Adler, Michael Fiedler, & Benjamin Ippolito, Assessing Recent Health Care Proposals from the House Committee on Energy and Commerce (May 25, 2023), https://www.brookings.edu/articles/assessing-recent-health-care-proposals-from-the-house-committee-on-energy-and-commerce. 64 See Mark Robben, Learnings from MRF Land, Serif Health (Mar. 31, 2023), https://www.serifhealth.com/blog/learnings-from-mrf-land; Georgetown University, Transparency in Coverage: Recommendations for Improving Access to and Usability of Health Plan Price Data (Jan. 9, 2023), https://georgetown.app.box.com/s/1ezsggz1c7smsaexkr8rght15sokgusl. Currently, the technical implementation guidance for the In-network Rate File allows plans and issuers flexibility to leverage a Table of Contents File to combine common negotiated rates across multiple In-network Rate Files, rather than publishing negotiated rates individually for each plan ID. This allows issuers to avoid duplicating prices within and across plans by linking the files for each plan that uses a given provider network to an underlying file of in-network prices. 65 Interested parties report that this reduces the total amount of data that must be analyzed to estimate market-level prices. 66 Many plans and issuers currently leverage this optimization. The Departments conducted an internal analysis in 2024 that sampled In-network Rate Files market wide and found that 83 percent of issuers sampled were leveraging a Table of Contents to organize their files. 65 See Lester Adler, Michael Fiedler, & Benjamin Ippolito, Assessing Recent Health Care Proposals from the House Committee on Energy and Commerce (May 25, 2023), https://www.brookings.edu/articles/assessing-recent-health-care-proposals-from-the-house-committee-on-energy-and-commerce. 66 Id. The Departments agree that where multiple plans share the same negotiated rates under an umbrella provider network, organizing the In-network Rate Files by provider network would decrease the size of the files, often significantly while still maintaining data integrity. Therefore, to standardize this method of organizing files across all plans and issuers, the Departments propose to amend the introductory language of paragraph (b)(1)(i) to require plans and issuers to make an In-network Rate File available for each provider network maintained or contracted by the plan or issuer. This approach would also reduce the total number of In-network Rate Files because there are far more plans and policies available than there are distinct, separately managed provider networks. 67 67 See Jianhui Zhu, Yuting Zhang, & Daniel Polsky, Networks in ACA Marketplaces Are Narrower for Mental Health Care Than for Primary Care, 36 Health Affairs 9 (Sept. 2017). (Researchers found that, using 2016 HealthCare.gov data, 531unique provider networks were used by 281 different issuers, covering 5,022 qualified health plans in the Federally-facilitated Marketplaces). To make it easier for file users to determine in advance of downloading a provider network-level In-network Rate File whether it contains data of interest to them, the Departments propose to redesignate paragraphs (b)(1)(i)(A) through (C) as paragraphs (b)(1)(i)(B) through (D), respectively, and add a new paragraph (b)(1)(i)(A) requiring each In-network Rate File to include the common provider network name for which negotiated rate information is included. The Departments seek comment on whether there is another term or code, in addition to or instead of the common provider network name, that would help producers or file users identify specific provider networks. The Departments expect plans and issuers to define what constitutes a separate provider network according to their current business practices. The Departments solicit comments on whether additional limitations on what constitutes a separate provider network should be required. In order to maintain the connection of rates to plans under this proposal, as further discussed in section III.C.2. of this preamble, the Departments also propose to amend redesignated paragraph (b)(1)(i)(B) to require plans and issuers to identify, for each provider network for which the plan or issuer must publish an In-network Rate File, each of the plan's or issuer's coverage options that use that network. This would allow file users to cross reference the rates for a particular plan or policy of interest to its in-network rates. The Departments also propose conforming amendments to redesignated paragraphs (b)(1)(i)(C) and (D). Specifically, the Departments propose to amend redesignated paragraph (b)(1)(i)(C) to specify that each In-network Rate File must include a billing code and a plain language description for each covered item or service included in the file, rather than under each coverage option offered by plans and issuers. 68 The Departments propose to amend redesignated paragraph (b)(1)(i)(D) to specify that all applicable rates must be included for each covered item or service included in the file, rather than for all items or services the plan or issuer covers, since not all applicable rates for items or services the plan or issuer covers are negotiated under a given provider network. Since plans and issuers would be required to make an In-network Rate File available for each provider network they maintain or contract with, they would ultimately still be required to disclose all applicable rates for items or services they cover, but those rates may not all be reported in every In-network Rate File organized by provider network. 68 “Plain language” means “written and presented in a manner calculated to be understood by the average participant, beneficiary, or enrollee” under current 26 CFR 54.9815-2715A1(a)(2)(xx), 29 CFR 2590.715-2715A1(a)(2)(xix), and 45 CFR 147.210(a)(2)(xx) (redesignated as 26 CFR 54.9815-2715A1(a)(2)(xxi), 29 CFR 2590.715-2715A1(a)(2)(xx), and 45 CFR 147.210(a)(2)(xxi) under these proposed rules). The Departments are also proposing special aggregation rules for self-insured group health plans, which is described in more detail in section III.C.11. of this preamble. b. Other Improvements for File Users The Departments have determined that, overall, provider network-level files would simplify data aggregation and analysis for researchers and other groups interested in analyzing specific provider networks, which is important to facilitate consumer's plan selection decisions. For example, the Departments understand that organizing In-network Rate Files by network would make it easier for employers and plan sponsors to analyze the negotiated rates of different networks to make informed decisions about which plans to offer their employees, potentially favoring networks with more competitive pricing, in addition to opening the door for employers to bring health care purchasing decisions in house through direct contracting with provider groups. 69 This proposal may be of particular benefit to smaller employers, who have historically had less leverage to negotiate directly with providers due to lower patient volume, by empowering them with access to network-level pricing data for negotiations. 69 See Samuel Haitoff, Jay Puthumana, Abhishek Dama, Yang Wang, et al., Employer-Provider Direct Contracting: Practice and Policy, Health Affairs Forefront (Apr. 1, 2025), https://www.healthaffairs.org/content/forefront/employer-provider-direct-contracting-practice-and-policy; See also Cynthia A. Fisher & Arthur B. Laffer, Healthcare Price Transparency and Competition: How Real Price Transparency Can Reduce American Healthcare Costs More Than $1 Trillion Annually and Extend Life Expectancy (Oct. 2023), https://static1.squarespace.com/static/60065b8fc8cd610112ab89a7/t/652f0429f8ca6d62668bb43d/1697580073561/PRA_Fisher-Laffer+Healthcare+Price+Transparency+Paper_FINAL.pdf; See also Christopher Whaley, Geetika Sachdev, Michael Bartlett, & Ge Bai, It's Time for Employers to Bring Health Care Decisions In-House, Health Affairs Forefront (Sept. 22, 2022), https://www.healthaffairs.org/content/forefront/s-time-employers-bring-health-care-decisions-in-house. Similarly, organizing in-network rate information by provider network would help service providers advise clients on network selection and cost management strategies. Likewise, researchers, academics, and policymakers would be better positioned to analyze pricing variations across different providers, specialties, and geographic areas within the same provider network and between different networks that may inform policy interventions aimed at cost containment and market regulations. The Departments understand that State insurance regulators may also be able to use network-level data to inform and improve rate review processes, optimize public option plans, and potentially guide antitrust enforcement. 70 Currently, State regulators may review unit cost and utilization trends submitted by issuers as part of their rate review process. Access to more consumable provider rates by network and product type in the In-network Rate Files may make it easier for regulators to validate unit cost trends, and to use those trends to assess the reasonableness of premium increases. Also, the reduction of duplicative data in the In-network Rate Files may make it easier for States to monitor rates to identify collusive behaviors, as well as help establish benchmarks for negotiations with providers as part of State oversight activities related to coverage programs. 70 Colorado's State law mandates insurers provide in-network allowed amounts data tailored for State-specific analyses. See Colorado Rev. Statutes § 10-16-168(4); Medical Group Management Association, Unlocking the Potential of Healthcare Price Transparency Data (Dec. 5, 2024), https://www.mgma.com/articles/unlocking-the-potential-of-healthcare-price-transparency-data (noting that Colorado uses price transparency data “to inform rate reviews, optimize [its] public option plans, and potentially guide antitrust enforcement,” according to Colorado Insurance Commissioner Michael Conway); See also Sabrina Corlette, The Health Plan Price Transparency Files Are a Mess: States Can Help Make Them Better, Health Affairs Forefront (May 5, 2023), https://chirblog.org/the-health-plan-price-transparency-data-files-are-a-mess-states-can-help-make-them-better. c. Better Alignment With Hospital Price Transparency Reporting Organizing in-network rates by provider network would also promote standardization and streamlined comparison of pricing information across hospitals and health plans, consistent with Executive Order 14221. 71 As discussed in section I.A. of this preamble, many interested parties have called for better alignment among Federal price transparency requirements to avoid consumer confusion and duplication of effort. 72 71 Exec. Order No. 14221, 90 FR 11005 (February 28, 2025). 72 See American Hospital Association, Fact Sheet: Hospital Price Transparency (Feb. 24, 2023), https://www.aha.org/fact-sheets/2023-02-24-fact-sheet-hospital-price-transparency. Currently, the Hospital Price Transparency machine-readable files required under 45 CFR part 180 generally disclose rates at the provider network level. 73 By contrast, rates disclosed pursuant to the 2020 final rules are currently disclosed at the more granular plan or policy level, which presents complications for data matching. For example, a single set of Hospital Price Transparency rates negotiated between a plan and a hospital system could appear multiple times, under several different plan names, in an issuer's current In-network Rate Files, without any reference to the provider network name in the Hospital Price Transparency file. Standardization of price disclosures for providers, plans, issuers, and procedures at the same level would allow for more accurate comparisons between the different types of transparency files. 73 45 CFR 180.50. The Departments seek comment on all aspects of these proposals. 2. HIOS Identifier and Product Type The Departments propose to amend the identifying coverage information that plans and issuers must disclose in the In-network Rate Files at redesignated 26 CFR 54.9815-2715A3(b)(1)(i)(B), 29 CFR 2590.715-2715A3(b)(1)(i)(B), and 45 CFR 147.212(b)(1)(i)(B), and in the Allowed Amount Files at 26 CFR 54.9815-2715A3(b)(1)(ii)(A), 29 CFR 2590.715-2715A3(b)(1)(ii)(A), and 45 CFR 147.212 (b)(1)(ii)(A). Specifically, the Departments propose to remove the requirement for plans and issuers to report the 14-digit Health Insurance Oversight System (HIOS) identifier (ID) or, if the 14-digit HIOS ID is not available, the 5-digit HIOS ID, and instead require them to report the HIOS identifier associated with each coverage option for which data is being reported in a form and manner as specified in guidance issued by the Departments. The Departments also propose to add a requirement for plans and issuers to report the product type (for example, Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO)) associated with the coverage option for which data is being reported. The 2020 final rules require plans and issuers to include their 14-digit HIOS ID in the In-network Rate File and Allowed Amount File unless the plan or issuer does not have a 14-digit HIOS ID available, in which case the plan or issuer must include the HIOS ID at the 5-digit issuer level. 74 If a plan or issuer does not have a HIOS ID, it must use its Employer Identification Number (EIN). The Departments received significant comments on GitHub about requiring the 14-digit HIOS ID, 75 stating that this requirement would result in an enormous amount of redundant data because provider rates are not established based on distinct plan designs, but rather they are applied across multiple plan offerings. The Departments have determined that the number of HIOS digits that plans and issuers must report is a technical implementation detail that should be removed from regulation and set forth in technical implementation guidance to better maintain the Departments' flexibility to determine appropriate technical reporting requirements and to make refinements in response to changes in technology or health care industry business practice. This is in line with the Departments' general approach as described in the preamble to the 2020 final rules, to provide specific technical direction in separate technical implementation guidance, rather than in rulemaking, in order to keep pace with and respond to technological developments. 76 The Departments propose to amend the reporting requirements to specify that for each applicable coverage option offered by a group health plan or health insurance issuer, the plan or issuer must report the name and the HIOS identifier, or, if no HIOS identifier is available, the EIN. 74 The 14-digit HIOS ID is comprised of the following: (1) issuer's ID number (first 5 digits, for example, 12345), (2) issuer's State abbreviation (next 2 digits, for example, WA); (3) issuer's three-digit Product ID (next 3 digits, for example, 001); and (4) a four-digit sequence number that is the “Component ID” (last 4 digits, for example, 0001). Thus, HIOS ID at the 14-digit level would be 12345WA0010001, 10 digits would be 12345WA001, 7 digits would be 12345WA, and 5 digits would be 12345. 75 See GitHub Users, GitHub Discussion: Updating to allow for reporting at the 10-digit HIOS level vs the 14-digit level #447, GitHub, https://github.com/CMSgov/price-transparency-guide/pull/447#issuecomment-1102946004 (last updated Apr. 19, 2022); See also GitHub Users, GitHub Discussion: In-Network-Rates File: Schema and Definition of Plan Name and HIOS/EIN #44, GitHub, https://github.com/CMSgov/price-transparency-guide/discussions/44#discussioncomment-645647 (last updated Mar. 28, 2022). 76 85 FR 72158, 72221 (November 12, 2020). In addition to the HIOS digit amendment, the Departments propose to amend redesignated paragraph (b)(1)(i)(B) and amend paragraph (b)(1)(ii)(A) to newly require plans and issuers to report the product type for each applicable coverage option offered by a plan or issuer in the In-network Rate File and Allowed Amount File, respectively. The Departments have received feedback that requiring plans and issuers to disclose health plan product types (for example, HMO, PPO) would promote more meaningful transparency around the health care pricing information disclosed in the In- network Rate and Allowed Amount Files. The Departments agree with this feedback, as product types dictate the fundamental relationship between the payer and the provider regarding patient access and volume, which are key leverage points in contract negotiations over rates. For example, in instances where HMOs may have narrow networks, providers contracting with such HMOs are likely to see increased patient volume, which may encourage such providers to contract at a lower rate with the HMO than they might with a PPO that is less likely to result in higher patient volume. Product types also dictate the fundamental relationship between payer and patient, with differences, for example, related to patient choice, cost-sharing responsibilities, and accessibility. Additionally, the Departments have heard from interested parties that although negotiated rates under a provider network are typically consistent across plans and policies with respect to a specific item or service and a specific provider, these rates may differ based on product type. As such, interested parties have stated that requiring plans and issuers to include the product type for each applicable coverage option offered by the plan or issuer in the In-network Rate File would allow users to account for those differences. In addition to providing context on how prospective rates differ, the Departments have determined that adding a product type to the Allowed Amount Files would allow file users to compare how historical provider reimbursements differ based on product type. Disclosing product type data in the Allowed Amount Files would enable more accurate and actionable comparisons for employers, researchers, and regulators so they can understand true market pricing for specific product types. In addition, not only could users of these data make comparisons of allowed amounts across different product types for a specific service for a single payer, they could also make comparisons for the same service based on product type across different payers. For example, an employer or plan sponsor offering a PPO plan could benchmark their out-of-network costs specifically against other PPO plans in the market, rather than a generalized average that includes potentially lower-cost HMOs, and they could use this information to make future plan coverage determinations. Furthermore, with allowed amounts tied to product type, employers and plan sponsors would better understand the actual tradeoffs in plan design—that is, not just premiums and network access, but also how much the plan will pay when employees go out-of-network. One study on out-of-network behavioral health care in employer-sponsored coverage observed that balance billing was higher for HMO enrollees versus non-HMO enrollees. 77 With the inclusion of data on plan type, employers could u [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/fr%3A2025-23693. Public record. Not legal advice.