Transparency in Coverage

2) 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

he 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)

cessary 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

s 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

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)

nt 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)

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

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

axonomy 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

877 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[;] . .

er 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

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

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

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

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

PA, 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)

tatement 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

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

gnated 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

mers 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)

r 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

ment 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

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

art 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

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

parency-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

n-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

s. 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)

d 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)

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

15A1(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

ntracting: 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

pe

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

xample, 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

ts have determined that adding a product type to the Allowed Amount Files would allow file users to compare how historical provider reimbursements differ based on product type. Disclosing product type data in the Allowed Amount Files would enable more accurate and actionable comparisons for employers, researchers, and regulators so they can understand true market pricing for specific product types. In addition, not only could users of these data make comparisons of allowed amounts across different product types for a specific service for a single payer, they could also make comparisons for the same service based on product type across different payers. For example, an employer or plan sponsor offering a PPO plan could benchmark their out-of-network costs specifically against other PPO plans in the market, rather than a generalized average that includes potentially lower-cost HMOs, and they could use this information to make future plan coverage determinations. Furthermore, with allowed amounts tied to product type, employers and plan sponsors would better understand the actual tradeoffs in plan design—that is, not just premiums and network access, but also how much the plan will pay when employees go out-of-network. One study on out-of-network behavioral health care in employer-sponsored coverage observed that balance billing was higher for HMO enrollees versus non-HMO enrollees. 77 With the inclusion of data on plan type, employers could use historical allowed amounts segmented by plan type to evaluate the level of financial protection offered for out-of-network services.

77 See Sarah A. Friedman, Hao Xu, Fernando Azocar & Susan L. Ettner, Quantifying Balance Billing for Out-of-Network Behavioral Health Care in Employer-Sponsored Insurance, 73 Psychiatric Services 1019 (2022).

The Departments acknowledge that product type is often used in the fully insured market, typically to comply with laws that apply to insured products

ase negotiated rate applicable to the item or service prior to adjustments for participant, beneficiary, or enrollee-specific characteristics. While there are alternative reimbursement arrangements that do not have a dollar amount associated with particular items and services before the item or service is furnished, a dollar amount can still be determined in some instances under these arrangements. Accordingly, in the preamble to the 2020 final rules, the Departments provided a list of alternative reimbursement arrangements and summarized general reporting expectations for these arrangements, while acknowledging that the list was not exhaustive, as there may be other alternative reimbursement or contracting arrangements in use. 79 Specifically, the Departments summarized the general reporting expectations, including for bundled payment arrangements and capitation arrangements (including sole capitation arrangements and partial capitation arrangements), reference-based pricing without a defined network, reference-based pricing with a defined network, and value-based purchasing. For example, the preamble to the 2020 final rules clarified that for payment arrangements under which adjustments are made after care is provided, the plan or issuer should disclose the base negotiated rate before adjustments are applied. 80

79 Id.

80 85 FR 72158, 72228 (November 12, 2020).

After the 2020 final rules were issued, interested parties used GitHub 81 and other forums to raise to the Departments' attention alternative payment arrangements under which reporting a current and accurate dollar amount for items and services in the In-network Rate File before the item or service is furnished may not be possible and requested guidance from the Departments on how to meet the disclosure requirements for such arrangements

nterested parties used GitHub 81 and other forums to raise to the Departments' attention alternative payment arrangements under which reporting a current and accurate dollar amount for items and services in the In-network Rate File before the item or service is furnished may not be possible and requested guidance from the Departments on how to meet the disclosure requirements for such arrangements. Specifically, interested parties questioned the Departments on how to report dollar amounts for negotiated rates that result from certain “percentage-of-billed-charges” contract arrangements, under which a dollar amount can be determined only retrospectively because the agreement between the plan or issuer and the in-network provider states that the plan or issuer will pay a fixed percentage of the billed charges. It is the Departments' understanding that these types of arrangements are not uncommon for certain types of items or services (such as low-volume procedures or high-cost, outlier inpatient care).

81 GitHub Users, GitHub Discussion: If negotiated rate is based on percentage of charge—then how would this be reported in the in-network file? #23, GitHub, https://github.com/CMSgov/price-transparency-guide/discussions/23 (last updated Apr. 15, 2022); GitHub Users, GitHub Discussion: Percentage of Billed Charges #315, GitHub, https://github.com/CMSgov/price-transparency-guide/discussions/315 (last visited Dec. 8, 2025); GitHub Users, GitHub Discussion: Using Claims History for In-Network File when unable to extract rates (that is percent of billed charges) #197, GitHub, https://github.com/CMSgov/price-transparency-guide/discussions/197 (last updated Sep. 30, 2022)

Discussion: Percentage of Billed Charges #315, GitHub, https://github.com/CMSgov/price-transparency-guide/discussions/315 (last visited Dec. 8, 2025); GitHub Users, GitHub Discussion: Using Claims History for In-Network File when unable to extract rates (that is percent of billed charges) #197, GitHub, https://github.com/CMSgov/price-transparency-guide/discussions/197 (last updated Sep. 30, 2022).

On April 19, 2022, the Departments issued FAQs Part 53 82 to provide an enforcement safe harbor for satisfying the reporting requirements for plans and issuers that use an alternative payment arrangement that does not permit them to derive with accuracy specific dollar amounts contracted for covered items and services in advance of the provision of that item or service, or that otherwise cannot disclose specific dollar amounts according to the file formatting requirements as provided in the Departments' technical implementation guidance through GitHub. This guidance further advised that for contractual arrangements under which a plan or issuer agrees to pay an in-network provider a percentage of billed charges and is not able to assign a dollar amount to an item or service prior to a bill being generated, plans and issuers may report a percentage number, in lieu of a dollar amount.

82 U.S. Department of Labor, U.S. Department of Health & Human Services & U.S. Department of the Treasury, FAQs about Affordable Care Act Implementation Part 53 (April 19, 2022), https://www.cms.gov/files/document/faqs-part-53.pdf and https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-53

/faqs-about-affordable-care-act-implementation-part-61.pdf and https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-61.

Since issuing the guidance in 2023, the Departments have continued to receive feedback from interested parties that arrangements where a dollar amount is unable to be determined in advance are not uncommon and should be reflected in the data. Therefore, the Departments propose to amend redesignated 26 CFR 54.9815-2715A3(b)(1)(i)(D)( 1 ), 29 CFR 2590.715-2715A3(b)(1)(i)(D)( 1 ), and 45 CFR 147.212(b)(1)(i)(D)( 1 ) to state that applicable rates must be reflected as dollar amounts, with respect to each covered item or service that is furnished by an in-network provider, except for contractual arrangements under which a group health plan or health insurance issuer agrees to pay an in-network provider a percentage of billed charges and is not able to assign a dollar amount to an item or service prior to a bill being generated. In these instances, plans and issuers must report a percentage number, in lieu of a dollar amount, in a form and manner as specified in guidance issued by the Departments.

While the Departments recognize the importance of allowing plans and issuers to disclose non-dollar amount rates when a dollar amount is unknown in advance, the Departments reiterate that plans and issuers must disclose rates as a dollar amount whenever a dollar amount can be calculated in advance, including when a negotiated base rate can be calculated prior to adjustments. Further, the Departments emphasize that this proposed change, if finalized, would permit plans and issuers to disclose an applicable rate in a non-dollar amount only in instances where the applicable rate is a percentage of billed charges and expect that plans and issuers report all other applicable rates as dollar amounts consistent with the form and manner specified in guidance issued by the Departments.

The Departments seek comment on this proposal.

4

if finalized, would permit plans and issuers to disclose an applicable rate in a non-dollar amount only in instances where the applicable rate is a percentage of billed charges and expect that plans and issuers report all other applicable rates as dollar amounts consistent with the form and manner specified in guidance issued by the Departments.

The Departments seek comment on this proposal.

4. Enrollment Totals

The Departments propose to add new 26 CFR 54.9815-2715A3(b)(1)(i)(E), 29 CFR 2590.715-2715A3(b)(1)(i)(E), and 45 CFR 147.212(b)(1)(i)(E) requiring plans and issuers to include in each In-network Rate File, current numerical enrollment totals, as of the date the file is posted, for each coverage option offered by a plan or issuer represented in the In-network Rate File. Such numerical enrollment totals must include the number of participants, beneficiaries, and enrollees (including all dependents) in the coverage option offered by a plan or issuer.

Affordable Care Act sections 1311(e)(3)(A)(iii) and (iv) require health plans seeking certification as a qualified health plan to submit to the Exchange, the Secretary, the State insurance commissioner, and make available to the public, accurate and timely disclosure of data on enrollment and disenrollment. PHS Act section 2715A, incorporated into ERISA section 715 and Code section 9815, gives the Departments the statutory authority to require a plan or coverage that is not offered through an Exchange to submit the information required under Affordable Care Act section 1311(e)(3) to the Secretary and the relevant State's insurance commissioner, and to make that information available to the public. However, the 2020 final rules do not require the disclosure of enrollment data

nts understand that plans and issuers then compare the NUCC provider taxonomy code and billing code included from the claim against their internal provider taxonomy mappings to determine if the claim can proceed through the next step of the payment adjudication process.

85 The NUCC establishes and maintains standard provider taxonomy codes, which are used to define a provider's area of specialty. Provider taxonomy codes are ten characters in length structured into three distinct “levels” including provider grouping, classification, and area of specialization. See National Uniform Claim Committee, Health Care Provider Taxonomy, https://www.nucc.org/index.php/code-sets-mainmenu-41/provider-taxonomy-mainmenu-40 (last visited Dec. 8, 2025).

86 See 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).

87 See 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).

The Departments have observed that several third-party data aggregation vendors successfully demonstrated various methods to efficiently filter existing machine-readable file content by utilizing NUCC provider taxonomy codes, demonstrating these codes can help determine whether a provider is likely going to be eligible for reimbursement for a specific service or procedure. 88 Therefore, the Departments have determined this may be a viable approach to excluding certain provider-rate combinations.

88 See Sameer Mukhi, Zombie Hunting: Filtering Approaches for Price Transparency Data, Serif Health Blog (Sept. 20, 2024), https://www.serifhealth.com/blog/zombie-hunting-filtering-approaches-for-price-transparency-data/; Matt Najarian, Clinically Implausible Rates Are Getting the Boot, Turquoise Health Blog (Aug. 30, 2023), https://blog.turquoise.health/clinically-implausible-rates-are-getting-the-boot/

Sameer Mukhi, Zombie Hunting: Filtering Approaches for Price Transparency Data, Serif Health Blog (Sept. 20, 2024), https://www.serifhealth.com/blog/zombie-hunting-filtering-approaches-for-price-transparency-data/; Matt Najarian, Clinically Implausible Rates Are Getting the Boot, Turquoise Health Blog (Aug. 30, 2023), https://blog.turquoise.health/clinically-implausible-rates-are-getting-the-boot/.

The 2020 final rules at 26 CFR 54.9815-2715A3(b)(1)(i)(C)(1), 29 CFR 2590.715-2715A3(b)(1)(i)(C)(1), and 45 CFR 147.212(b)(1)(i)(C)(1) require plans and issuers to disclose all applicable rates for in-network providers, including negotiated rates, underlying fee schedule rates, or derived amounts, to the extent they may be used for purposes of determining provider reimbursement or cost-sharing for in-network providers. The 2020 final rules do not specify any exclusions to this requirement. As a result, the Departments have observed and have received feedback that In-network Rate Files often include negotiated rates for providers for items and services that those providers would not likely be reimbursed for because the items and services are outside their specialty (for example, a mental health provider billing for knee replacement). 89 The Departments understand that plans and issuers frequently negotiate applicable rates at the provider organization level (such as large multi-specialty physician groups or integrated health systems) for every provider who is a member of that organization, regardless of whether that

provider would be likely to be reimbursed for that item or service.

89 See Sameer Mukhi, Zombie Hunting: Filtering Approaches for Price Transparency Data, Serf Health Blog (Sept. 20, 2024), https://www.serifhealth.com/blog/zombie-hunting-filtering-approaches-for-price-transparency-data/.

Under the 2020 final rules, these rates are required to be disclosed

r services that providers are unlikely to perform or be reimbursed for—because they fall outside their specialty—would significantly reduce the size of the In-network Rate Files. This significant decrease in file size would also reduce the storage space and computer processing resources needed to generate, store, and analyze In-network Rate Files, reducing burden for file producers and users alike.

Therefore, the Departments propose to revise the content requirements for the In-network Rate File to require plans and issuers to exclude provider-rate combinations for an item or service if the provider would be unlikely to be reimbursed for the item or service given the provider's area of specialty, according to the plan's or issuer's internal provider taxonomy that is typically used during the claims adjudication process.

In order for users of the In-network Rate Files to understand how plans and issuers constructed the files according to this new proposed requirement, the Departments also propose to add new 26 CFR 54.9815-2715A3(b)(2)(iii), 29 CFR 2590.715-2715A3(b)(2)(iii), and 45 CFR 147.212(b)(2)(iii), to require plans and issuers to publish a taxonomy machine-readable file. As discussed in more detail in section III.C.7. of this preamble, this new machine-readable file would disclose the mapping of billing codes to internal provider taxonomy codes, providing transparency into how plans and issuers determined which provider-rate combinations for covered items and services have been excluded from the In-network Rate Files based on the plan's or issuer's taxonomy rules.

The Departments seek comment on all aspects of this proposal. The Departments are particularly interested in feedback from interested parties on whether there are plans or issuers that do not map provider specialties to billing codes within their claims adjudication process or use different code sets, and whether there could be a way to standardize the provider specialty mapping to billing code process

20 final rules at paragraph (b)(1)(ii)(C) require plans and issuers to disclose on a public website a machine-readable file that includes, among other things, each unique out-of-network allowed amount with respect to covered items or services furnished by a particular out-of-network provider during the 90-day time period that begins 180 days prior to the publication date of the Allowed Amount File. In addition, plans and issuers must omit such data in relation to a particular item or service and provider when including it would require the plan or issuer to report payment of out-of-network allowed amounts in connection with fewer than 20 different claims for payments for an item or service under a single plan or coverage. 97 Current rules at paragraph (b)(4)(iii) also permit, but do not require, plans and issuers to satisfy the public disclosure requirements of paragraph (b)(1)(ii) by making available out-of-network allowed amount data that has been aggregated to include information from more than one plan or policy, under certain circumstances.

97 26 CFR 54.9815-2715A3(b)(1)(ii)(C), 29 CFR 2590.715-2715A3(b)(1)(ii)(C), and 45 CFR 147.212(b)(1)(ii)(C).

a. Reducing the Claims Threshold

Initially, the Departments established the 20-claims threshold to limit the possibility that individual participants, beneficiaries, and enrollees may be identified through the public disclosure of historical allowed amount data. In the 2019 proposed rules, the Departments proposed to require plans and issuers to omit out-of-network allowed amounts from the Allowed Amount File in relation to a particular item or service and provider when including this data would require the plan or issuer to report payment of out-of-network allowed amounts in connection with fewer than 10 different claims for payments

allowed amount data. In the 2019 proposed rules, the Departments proposed to require plans and issuers to omit out-of-network allowed amounts from the Allowed Amount File in relation to a particular item or service and provider when including this data would require the plan or issuer to report payment of out-of-network allowed amounts in connection with fewer than 10 different claims for payments. 98 The Departments requested comment on whether a higher minimum claims threshold, such as a threshold of 20 claims, would better mitigate privacy concerns and minimize complexity in complying with Federal or State privacy laws without compromising the integrity of the compiled information. 99 As discussed in the 2020 final rules, some commenters expressed concerns about maintaining Health Insurance Portability and Accountability Act (HIPAA) protections on the Allowed Amount File due to the small number of claims associated with specific items and services for out-of-network providers. 100 Several commenters stated that the threshold of 10 different claims to require public disclosure of unique historical allowed amounts would be too low to protect consumers' protected health information. Based on commenters' concerns, the Departments determined that increasing the claims threshold from 10 to 20 claims in the 2020 final rules would better balance the policy goal of transparency with the need to protect participants, beneficiaries, and enrollees from the possibility of being re-identified through the data included in the Allowed Amount File. 101

98 84 FR 65464, 65481 (November 27, 2019).

99 Id.

100 85 FR 72158, 72233 (November 12, 2020).

101 Id

price of an item or service in the context of an arms-length transaction between a provider and a plan or issuer who have not negotiated the rate, and where there is therefore no discount associated with the advantage to a provider of being “in network.” 105 Employers and plan sponsors can use this data to benchmark costs, refine benefit designs, and negotiate more effectively with administrators. Health care providers and service providers can use it to estimate what they might be reimbursed and what their patients or their participants, beneficiaries, or enrollees, respectively, might be charged for out-of-network care. 106

105 Zack Cooper, Hao Nguyen, Nathan Shekita & Fiona Scott Morton, Out-of-Network Billing and Negotiated Payments for Hospital-Based Physicians, 39 Health Affairs 24 (2020) (published Dec. 16, 2019), https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00507.

106 Rebecca Hodes, Demystifying “Allowed Amounts” in Out-of-Network Billing, Mentaya Blog (Apr. 1, 2025), https://www.mentaya.com/blog/demystifying-allowed-amounts-in-out-of-network-billing.

Therefore, to increase the volume of allowed amount data available, the Departments propose to amend paragraph (b)(1)(ii)(C) to lower the minimum claims threshold for a particular item or service under a single plan or coverage to 11 different claims for a particular item or service in a single health insurance market. The proposed 11-claims threshold would align with the CMS cell suppression policy, which sets minimum thresholds for the display of CMS data by researchers or other custodians of CMS data sets, such as Limited Data Set (LDS) files. 107 The policy stipulates that

no cell (such as admittances, discharges, patients, services, etc.) containing a value of 1 to 10 can be reported directly

ce market. The proposed 11-claims threshold would align with the CMS cell suppression policy, which sets minimum thresholds for the display of CMS data by researchers or other custodians of CMS data sets, such as Limited Data Set (LDS) files. 107 The policy stipulates that

no cell (such as admittances, discharges, patients, services, etc.) containing a value of 1 to 10 can be reported directly. 108 This policy is a safeguard designed to prevent the identification of individual Medicare or Medicaid beneficiaries when CMS data is shared publicly 109 and helps ensure compliance with Federal privacy laws, such as HIPAA, by reducing the risk of re-identification of individuals from aggregated data.

107 Centers for Medicare & Medicaid Services, Limited Data Set (LDS) Files, https://www.cms.gov/data-research/files-for-order/data-disclosures-and-data-use-agreements-duas/limited-data-set-lds (last modified July 7, 2025); Research Data Assistance Center (ResDAC), CMS Cell Size Suppression Policy (Jan. 26, 2024), https://resdac.org/articles/cms-cell-size-suppression-policy.

108 Id.

109 Id.

The Departments have determined that the proposed 11-claims threshold, combined with the proposal to require reporting by health insurance market type discussed later in this section of the preamble, would provide sufficient protection against the disclosure of sensitive patient information. Under the proposal to require reporting by health insurance market type, data disclosed in the Allowed Amount Files would not be directly associated with a single plan or policy when two or more plans or policies are aggregated into one file (as discussed in more detail later in this section of the preamble). Instead, the data would be aggregated to a broader health insurance market type (such as “individual market” or “large group market”)

ealth insurance market type, data disclosed in the Allowed Amount Files would not be directly associated with a single plan or policy when two or more plans or policies are aggregated into one file (as discussed in more detail later in this section of the preamble). Instead, the data would be aggregated to a broader health insurance market type (such as “individual market” or “large group market”). For example, a unique allowed amount and billed charge for a given item or service furnished by a given provider might be associated with “Large Group Market offered by Insurer A,” rather than “Insurer A's Employer X Gold PPO Plan.” This high-level aggregation would provide a strong shield for patient privacy.

Additionally, the Departments also note that, as specified in current paragraph (b)(1)(ii)(C), disclosure of such information would not be required if doing so would violate applicable health information privacy laws. This is consistent with paragraph (c)(3), which specifies that, among other things, nothing in 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, or 45 CFR 147.212 alters or otherwise affects a plan's or issuer's duty to comply with requirements under other applicable State or Federal laws, including those governing the privacy or security of information required to be disclosed under this section.

As such, the Departments have determined that lowering the claims threshold in this way would strike a better balance between protecting sensitive health information and allowing for a more comprehensive and useful dataset to support the end goals of price transparency.

Lastly, the Departments propose to delete “and provider” from the parenthetical language in (b)(1)(ii)(C) to more clearly specify that the claims threshold pertains to the number of claims for an item or service overall for the file, not the number of claims for an item or service from a particular provider

would be required to include in the Allowed Amount File allowed amounts and billed charges with respect to covered items or services furnished by out-of-network providers during the 6-month time period that begins 9 months prior to the publication date of the file. This amendment would increase the reporting period from 90 days to 6 months and increase the lookback period from 180 days to 9 months. In the preamble to the 2020 final rules, the Departments noted that they would monitor the implementation of the lookback period for the Allowed Amount Files and may revisit it if the 90-day reporting period and 180-day lookback period failed to yield sufficient out-of-network data on allowed amounts. 111 By approximately doubling the reporting period from 90 days to 6 months and shifting the lookback period from 180 days to 9 months, the Departments expect that more out-of-network claims for items and services would meet the required threshold for reporting requirements, meaning there would be more data to populate the Allowed Amount Files.

111 85 FR 72158, 72230 (November 12, 2020).

The Departments welcome comment on all aspects of this proposal. The Departments are also particularly interested in feedback on the impact of the proposed amendment to the required reporting cadence (proposed to be quarterly as discussed in section III.C.10. of this preamble) on the proposed changes to the lookback period. For example, since the proposed quarterly reporting period would require reporting 6 months' worth of data every 3 months, the Departments seek comment on whether a potential duplication of out-of-network allowed amounts across multiple files would present any difficulties for the analysis of the data, such as calculating averages or annual amounts.

c

e market type—specifically (1) individual market, (2) large group market, (3) small group market, and (4) self-insured group health plans maintained by the same plan sponsor—provides a structured approach to organizing and analyzing claims data. Interested parties suggested that this categorization would be useful because pricing dynamics and reimbursement rates tend to vary by

market segments. 112 Therefore, the Departments expect that organizing out-of-network allowed amounts in this way would facilitate a more comprehensive assessment of the volume and characteristics of out-of-network claims and enhance the data's utility for users by aligning it with the distinct pricing structures and regulatory environments of each market type. It would also make comparing allowed amounts for plans and policies within the same market easier for file users.

112 There is evidence of consistent alignment within market types and significant divergence between market types when comparing allowed amounts relative to a common benchmark (Medicare). This pattern holds even for in-network prices. Out-of-network allowed amounts often derive from similar underlying cost structures. Caroline Hanson, Ian McCarthy, Eamon Molloy & Karen Stockley, Providers Paid Substantially Less by Marketplace Nongroup Insurers Than by Employer Small-Group Plans, 2021, 43 Health Affairs 1672 (Dec. 20, 2024), https://www.healthaffairs.org/doi/10.1377/hlthaff.2024.00913.

If this proposed amendment is finalized, the Departments also anticipate a significant reduction in the overall number of Allowed Amount Files (since these would be reported at the market level, rather than at the plan level), even as those data files become more populated. Additionally, this approach would further protect patient privacy, as discussed earlier in this section of the preamble, because data aggregated across two or more plans or policies would not be directly associated with a single plan or policy

of Allowed Amount Files (since these would be reported at the market level, rather than at the plan level), even as those data files become more populated. Additionally, this approach would further protect patient privacy, as discussed earlier in this section of the preamble, because data aggregated across two or more plans or policies would not be directly associated with a single plan or policy.

On the other hand, the Departments acknowledge that requiring market-level aggregation may limit or eliminate the ability of file users to map specific allowed amounts and billed charges to an individual plan or policy. However, plans and issuers would still be required under paragraph (b)(1)(ii)(A) to disclose information about the plans or policies whose allowed amounts are included in each file. Therefore, file users would be able to determine which plans or policies have allowed amounts included in the Allowed Amount File, even if they would be unable to match a specific out-of-network allowed amount to a particular plan or policy. The Departments have determined that the advantages of having more populated Allowed Amount Files at the market level would outweigh the drawbacks of missing plan-level data. The Departments seek comment on what additional information might be limited or lost by aggregating allowed amount and billed charges data by health insurance market type, and the potential importance of that information to price transparency. The Departments also invite comments more broadly on the proposal to require reporting of out-of-network allowed amount data by health insurance market type.

Lastly, the Departments are also proposing special aggregation rules for self-insured group health plans, which are described in more detail in section III.C.11. of this preamble. The Departments request comment on all aspects of these proposals. For a discussion of the Departments' proposal to amend paragraph (b)(1)(ii)(A) related to disclosing HIOS IDs and product types in Allowed Amount Files, see section III.C.2

ents are also proposing special aggregation rules for self-insured group health plans, which are described in more detail in section III.C.11. of this preamble. The Departments request comment on all aspects of these proposals. For a discussion of the Departments' proposal to amend paragraph (b)(1)(ii)(A) related to disclosing HIOS IDs and product types in Allowed Amount Files, see section III.C.2. of this preamble.

7. Contextual Files: Change-log, Utilization, Taxonomy, and Text

The Departments propose to require plans and issuers to publicly disclose, through machine-readable files, additional contextual information that would help file users better understand the public disclosures required under paragraph (b)(1)(i). These files, which include a Change-log File, Utilization File, and Taxonomy File would contain information about the data within the In-network Rate and Allowed Amount Files. The Departments also propose to require a contextual machine-readable file to help users find the In-Network Rate, Allowed Amount, and prescription drug machine-readable files required under paragraph (b)(1) and new paragraph (b)(2) of this section, which the Departments are proposing to identify as a Text File. 113 In particular, the Departments propose to amend 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212 to redesignate paragraphs (b)(2) through (4) as paragraphs (b)(3) through (5), respectively, and to add new paragraph (b)(2) to require contextual files. Specifically, the Departments propose to add new paragraphs (b)(2)(i) through (iv) requiring: a Change-log File at paragraph (b)(2)(i), a Utilization File at paragraph (b)(2)(ii), a Taxonomy File at paragraph (b)(2)(iii), and a Text File at paragraph (b)(2)(iv)

ates, out-of-network allowed amounts and the associated billed charges and negotiated rates and historic net prices for prescription drugs. In the 2020 final rules, the Departments recognized the necessity of public disclosure of health care pricing information due to the variation in health care prices across the health care industry and the complexity of health insurance and health plan coverage. 114

114 The 2020 final rules stated that “many consumers do not fully comprehend the basics of health coverage, much less the more complex facets of the health care system that can affect an individual's out-of-pocket cost for items and services, including: Its specialized billing codes and payment processes; the various specialized terms used in plan and coverage contracts and related documents (such as copayment and coinsurance); and the various billing and payment structures plans and issuers use to compensate providers and assign cost-sharing liability to individuals (for example, bundled payment arrangements).” 85 FR 72158, 72210 (November 12, 2020).

While price disclosures required in the 2020 final rules contributed to a broader understanding of the data that drives plan and issuer payments for health care items and services, the intervening years demonstrated that additional context is necessary to promote a fuller understanding of health care industry pricing dynamics. These proposed additional files would help make the data disclosures of the machine-readable files required under paragraph (b)(1) more meaningful and accessible, which would promote greater transparency in health care pricing information. Under this proposal, plans and issuers would be required to prepare a Change-log File, a Utilization File, and a Taxonomy File for each In-network Rate File prepared pursuant to these proposed rules, and a single Text File to facilitate locating the other machine-readable files required under these proposed rules

ents propose to require, in new 26 CFR 54.9815-2715A3(b)(2)(i), 29 CFR 2590.715-2715A3(b)(2)(i), and 45 CFR 147.212(b)(2)(i), that plans and issuers must make available, in a machine-readable format, a Change-log File for each In-network Rate File, that identifies any changes made to the required information in the In-network Rate File since the immediately preceding published In-network Rate File. The proposed Change-log File would be required to be publicly posted in the form as specified in guidance issued by the Departments, consistent with redesignated and amended paragraph (b)(3) and discussed in section III.C.9. of this preamble. It would be required to be posted in accordance with the timing requirements proposed at redesignated paragraph (b)(4)(iii) and discussed in section III.C.10. of this preamble. Specifically, it would be required to be posted on the first day of the calendar-year quarter following the date on which the first In-network Rate File would be required to be posted under proposed paragraph (b)(4)(i). 115 The purpose of the proposed Change-log File would be to assist all file users in identifying changes to the required information in the In-network Rate File from one reporting period to the next. Pursuant to the proposed requirement to publish the In-network Rate File described at (b)(1)(i) quarterly, the updated Change-log File would also be required to be published quarterly, indicating whether or not there were changes.

115 See Table 2 for an example.

The total amount of information contained in every plan's and issuer's set of machine-readable files is extremely large, 116 creating challenges for file users of all backgrounds in ingesting and analyzing the information. Therefore, rather than downloading and analyzing each set of newly posted files to determine if there have been any changes to the required information in a plan's or issuer's In-network Rate File, file users would only need to look at the Change-log File to determine which new files they need to examine

ile: items and services covered under the plans or policies included in the files prepared as specified in proposed amended paragraph (b)(1)(i) for which a claim has been submitted and reimbursed, in whole or in part, and 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 as specified in paragraph (b)(2)(ii)(A) of this section. The Utilization File would be required to be published in the form and manner specified in proposed redesignated paragraph (b)(3) and discussed in section III.C.9. of this preamble and in accordance with the timing requirements proposed at redesignated paragraph (b)(4)(iv) and discussed in section III.C.10. of this preamble. Specifically, it would be required to be updated and posted annually beginning on the first day of the calendar-year quarter following the applicability date under paragraph (c)(1). Plans and issuers would be required to update and post the Utilization File in accordance with the timing requirements proposed at redesignated paragraph (b)(4)(iv) and discussed in section III.C.10. of this preamble.

The Departments have determined that the Utilization File would provide important insights, both as a stand-alone dataset, as well as in combination with the In-network Rate File. On its own, the Utilization File would reveal which providers are actively serving enrollees and delivering covered items and services within a plan's or issuer's network. If a provider appears in a plan's or issuer's In-network Rate File but does not appear in the plan's or issuer's Utilization File, then users may reasonably conclude that that provider, despite having a negotiated rate, has had no recent interactions with that plan's or issuer's participants, beneficiaries, or enrollees

rates to actual utilization would become more widely and consistently available to users of the Transparency in Coverage pricing data. Finally, the Utilization Files would act as an important qualifier to the data disclosed in the In-network Rate Files, by providing a strong indication of the degree to which negotiated rates are used by providers to deliver actual services to health plan enrollees.

117 Sameer Mukhi, Zombie Hunting: Filtering Approaches for Price Transparency Data, Serf Health Blog (Sept. 20, 2024), https://www.serifhealth.com/blog/zombie-hunting-filtering-approaches-for-price-transparency-data/.

Under this proposed requirement, plans and issuers would not be required to disclose the number of times that any given provider submitted a claim for any particular item or service, but rather only that a given provider submitted and was reimbursed, partially or in whole, for at least one claim for a covered item or service during the reporting period. The Departments have determined this appropriately balances the need for additional transparency around which in-network providers are actively providing a covered item or service with the burden on plans and issuers associated with extracting data from a claims data repository. The Departments recognize that because plans and issuers would not be required to disclose the number of items and services performed by specific providers, the Utilization File would be limited in its ability to address some research questions that might be of interest to some interested parties. As such, the Departments request comment on whether the inclusion of the volume of items and services performed by an in-network provider would be a valuable addition to the Utilization File. The Departments also request comment on whether additional data elements, such as metrics analyzing a plan or overall percentage of providers with zero utilization for the lookback period should be included in order to make it easier for file users to examine provider network adequacy

me of items and services performed by an in-network provider would be a valuable addition to the Utilization File. The Departments also request comment on whether additional data elements, such as metrics analyzing a plan or overall percentage of providers with zero utilization for the lookback period should be included in order to make it easier for file users to examine provider network adequacy. The Departments also request comment on the burden to plans and issuers to produce a Utilization File with claims volume and any additional metrics included in the files, as well as comments on how to mitigate these concerns.

The Departments are also proposing at 26 CFR 54.9815-2715A3(b)(2)(ii), 29 CFR 2590.715-2715A3(b)(2)(ii), and 45 CFR 147.212(b)(2)(ii), to require the Utilization File to include data for the 12-month period that ends 6 months prior to the publication date of each Utilization File, to allow for enough time for plans and issuers to complete the claims processing lifecycle including pre-claim submission, pre-claim payment, and payment determination and collection. 118 This figure is obtained from research suggesting that claims that take the longest to resolve can take up to 75 days to reach payment determination. 119 While 75 days is considerably shorter than 6 months, due to the lack of available metrics on the time it takes payers to complete payment to providers, the Departments propose a longer lookback period to ensure the Utilization File captures all applicable payments.

118 FinThrive, Understanding the Claims Lifecycle: A Step-by-Step Guide (Nov. 26, 2024), https://finthrive.com/blog/understanding-the-claims-lifecycle-a-step-by-step-guide.

119 Rajiv Chandawarkar, Prakash Nadkarni, Elizabeth Barmash, Stephany Thomas, et al., Revenue Cycle Management: The Art and the Science, 12 Plastic and Reconstructive Surgery Global Open 7 (July 2, 2024).

The Departments request comment on this lookback period.

c

proposed redesignated paragraph (b)(3) and discussed in section III.C.9. of this preamble. Additionally, and as discussed in section III.C.10. of this preamble, the Departments propose to

add paragraph (b)(4)(v) to require plans and issuers to post an updated Taxonomy File quarterly beginning on the first day of the calendar-year quarter following the applicability date under paragraph (c)(1). If there are no changes to the taxonomy that affect the information required in the machine-readable file required under (b)(1)(i) in a subsequent quarter, the posted Taxonomy File would not be required to be updated for that quarter.

The Taxonomy File would provide transparency into how plans and issuers determine whether to exclude certain provider-rate combinations from an In-network Rate File. As explained in section III.C.5. of this preamble, the Departments are proposing to require plans and issuers to exclude from each In-network Rate File a provider-rate combination for an item or service, if the provider would be 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. This is because rates for such items and services generally do not provide useful information to users of the In-network Rate File, and excluding them would improve the reliability of the data reported and significantly reduce the file size.

The Departments have determined that it is necessary to give plans and issuers specific guidance for how to exclude provider-rate combinations for items and services for which the provider would not likely be reimbursed given their practice area of specialty, rather than leaving it to each plan and issuer to determine how to exclude such information. Accordingly, the Departments have determined that plans and issuers should be required to post their internal provider taxonomy mappings in the Taxonomy File

displayed on the same website where the machine-readable files are made available and be kept updated per the requirements in paragraph (b)(4)(vi) of this section. This information would allow users to more easily locate the plan's or issuer's machine-readable files, increasing both automated and non-automated access to the machine-readable files. Additionally, and as discussed in section III.C.10. of this preamble, the Departments propose to add paragraph (b)(4)(vi) to require plans and issuers to post a Text File beginning on the first day of the calendar-year quarter following the applicability date under paragraph (c)(1) and subsequently update the Text File as soon as practicable but not later than 7 calendar days following a change in any of the information required under paragraph (b)(2)(iv) of this section.

120 As previously mentioned, proposed paragraph (b)(2)(iv) (relating to the proposed requirement to include a plain text file in a .txt format in the root folder of a plan's or issuer's website) and (b)(3) (relating to the method and format for disclosing information to the public) of 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212 applies to the prescription drug machine-readable files.

The Departments have observed and received feedback from interested parties that locating the files on a plan's or issuer's website can be difficult. To assist the public, CMS provided guidance on how to locate machine-readable files on the Transparency in Coverage website. 121 However, in considering how to improve both automated and non-automated access to the machine-readable files, the Departments have determined it is appropriate to require a standardized Text File at a consistent location (specifically, the root folder of the plan's or issuer's website), which would provide a direct link to the machine-readable files as opposed to the current approach of having to locate the correct web page within the website

tomated and non-automated access to the machine-readable files, the Departments have determined it is appropriate to require a standardized Text File at a consistent location (specifically, the root folder of the plan's or issuer's website), which would provide a direct link to the machine-readable files as opposed to the current approach of having to locate the correct web page within the website. If a plan or issuer does not have a website, they can satisfy this requirement by entering into a written agreement under which another party (such as a TPA) posts the Text File in the root folder on its public website on behalf of the plan or issuer pursuant to proposed paragraph (b)(3)(iv).

121 Centers for Medicare & Medicaid Services, Use of Pricing Information Published Under the Transparency in Coverage Final Rule, https://www.cms.gov/priorities/healthplan-price-transparency/overview/use-pricing-information-published-under-transparency-coverage-final-rule (last modified Aug. 14, 2025).

Further, the Departments also received feedback regarding the difficulty of contacting plans and issuers to alert them to problems with their machine-readable files or to ask for additional information or clarifying context. Contact information for someone at the plan or issuer who is familiar with the details of the machine-readable files would allow the public to reach out for assistance with accessing or utilizing the machine-readable files.

Therefore, the Departments propose to require the Text File to include plan or issuer point-of-contact information, who could help in verifying the contents of the machine-readable files and respond to requests for assistance related to accessing and utilizing the machine-

readable files. The Departments also propose to require that the point-of-contact information be posted prominently on the same web page where the machine-readable files are located to further reduce the difficulty file users have faced in reaching out to plans and issuers for assistance

propose these new requirements in accordance with Executive Order 14221 Section 3(b), which directs the Departments to “issue updated guidance or proposed regulatory action ensuring pricing information is standardized and easily comparable across hospitals and health plans.” 122 CMS added new requirements to the 2019 Hospital Price Transparency rule 123 in the 2023 Hospital Price Transparency rule. 124 The 2023 Hospital Price Transparency rule, 125 which went into effect on January 1, 2024, requires certain hospitals to include a Text File in the root folder of the hospital's public website that includes a direct link to the hospital's machine-readable file containing standard charge information and a link in the footer on its website that links directly to the publicly available web page that hosts the link to the machine-readable file. In proposing to adopt a similar requirement, the Departments would align this requirement with the 2023 Hospital Price Transparency rule 126 requirement to improve machine-readable file accessibility for the public. Based on feedback on this similar provision for the 2023 Hospital Price Transparency rule, 127 the Departments have determined this would be a relatively simple, low burden change, and that the increased benefits to the public outweigh the costs.

122 Centers for Medicare & Medicaid Services, Use of Pricing Information Published Under the Transparency in Coverage Final Rule, https://www.cms.gov/priorities/healthplan-price-transparency/overview/use-pricing-information-published-under-transparency-coverage-final-rule (last modified Aug. 14, 2025).

123 84 FR 65524 (November 17, 2019).

124 88 FR 81540 (November 22, 2023).

125 Id.

126 88 FR 81540, 82112 (November 22, 2023).

127 88 FR 81540 (November 22, 2023)

134 See Exec. Order No. 13877, 84 FR 30849 (June 27, 2019).

The Departments have received feedback in support of specifying either JSON or CSV formats. Both JSON and CSV formats have benefits and drawbacks, and each serves different audiences. JSON is a widely adopted industry standard that allows the machine-readable file data to be accessible to various users and adaptable to various use-cases. In the 2020 final rules, the Departments noted that the machine-readable files' primary benefit to health care consumers will be the availability of web-based tools and mobile applications developed for consumer use by third-party developers, aggregation, and analysis conducted by researchers, and oversight efforts by regulators. The required machine-readable files will be optimal for ingestion, data aggregation, and data analysis, all of which are functions performed by third-party internet-based developers, researchers, and regulators who use large data sets in a manner that will lead to benefits for consumers.” 135 In the 3 years since the publication of the machine-readable file requirements, the Departments have observed the creation of a number of web-based tools developed for consumer use by third-party developers. These developers provided feedback on the benefits and drawbacks of various file formats but largely indicated a preference for using JSON due to its flexibility and adaptability.

135 85 FR 72158, 72240 (November 12, 2020).

It is the Departments' understanding that JSON's suitability for the broad, high-volume disclosures required pursuant to the Transparency in Coverage rules stems in part from its ability to effectively handle different stages of the process by which raw data is transformed into more user-friendly outputs

JSON due to its flexibility and adaptability.

135 85 FR 72158, 72240 (November 12, 2020).

It is the Departments' understanding that JSON's suitability for the broad, high-volume disclosures required pursuant to the Transparency in Coverage rules stems in part from its ability to effectively handle different stages of the process by which raw data is transformed into more user-friendly outputs. This data process, known as Extract, Transform, and Load (ETL), begins with raw data gathered (“extracted”) from a range of sources; then cleaned and standardized (“transformed”) into a selected format; and then loaded into a repository or database for subsequent uses (and ultimately, for downstream analysis). Different file formats are best suited for different stages of the ETL process. An optimal file format for the machine-readable files would accurately represent the data's underlying relationships through the file format's organizational structure, ensure efficient storage and processing of the data, and make the data accessible to a variety of users with diverse use cases. As applied to the machine-readable files, JSON's strength is its capacity to handle all stages of the ETL process. It is also lightweight and effective for the extraction step from raw data, and it is highly flexible for both the initial transformation step and subsequent transformation of machine-readable file data by downstream users. The widespread use of JSON for the machine-readable files is expected given the advantages of JSON in the data extraction stage, and in efficiently representing the underlying complex relationships in machine-readable file data. Additionally, JSON is widely adopted by industry and government as a common means of data exchanges, and enjoys native support for most programming languages, meaning that these languages and tools already “speak” JSON, limiting the time and effort required to work with JSON-formatted files

n stage, and in efficiently representing the underlying complex relationships in machine-readable file data. Additionally, JSON is widely adopted by industry and government as a common means of data exchanges, and enjoys native support for most programming languages, meaning that these languages and tools already “speak” JSON, limiting the time and effort required to work with JSON-formatted files.

The Departments have also received feedback that many file users, especially researchers, prefer to work with the machine-readable file data in CSV format due to its relative simplicity and accessibility, and that they migrate the data from JSON to CSV in order to conduct analyses. For example, CSV files can include a header row specifying the titles of each subsequent column in the file for visual simplicity. CSV files are highly portable and can be loaded into commonly used tools that do not require engineering capability such as Microsoft Excel and may be a more familiar format to a wider audience than JSON.

The Departments recognize that both of these file formats have limitations. A JSON format requires users to have some data engineering sophistication to interact with the machine-readable files directly—capabilities and resources that many individuals and organizations may not have. Additionally, working with JSON may require more computing resources than some other formats to process. Other file formats may have attributes that suit the needs of certain users of the machine-readable files better than JSON does. However, the drawback with using CSV or any row-based tabular flat file structure for machine-readable file publishing and consumption of the amount of data that is being generated pursuant to the Transparency in Coverage requirements is that it makes it challenging for a file user with a standard personal computer to load and work with it effectively

ng information. The Departments are of the view that specifying a single format presents an important part of fully realizing the goals of price transparency and Executive Orders 13877 and 14221. 137 The Departments seek comment on specifying a single, non-proprietary open-source format for the machine-readable files and on the relevant benefits and burdens associated with the CSV and JSON formats. The Departments also seek comment on the

Departments' position that specifying a single format in technical implementation guidance, as opposed to regulation, is advisable to maintain maximum flexibility to change formats more quickly to keep pace with technological changes.

137 See Exec. Order No. 13877, 84 FR 30849 (June 27, 2019); See also Exec. Order No. 14221, 90 FR 11005 (February 28, 2025).

Additionally, in recognition of the developments of electronic data transfer systems since the publication of the 2020 final rules and in anticipation of future developments of new technologies, the Departments are revisiting the request for comment made in the 2019 proposed rules regarding a requirement that plans and issuers provide rate information through a publicly accessible API that would comply with standards defined by the Departments. 138 In light of the publication of the CMS Interoperability and Prior Authorization Final Rule, 139 the Departments seek comment on whether the required information in paragraphs (b)(1) and (2) should be required to be disclosed through an electronic data transfer technology, such as a publicly accessible API, as well as what standards should apply. The Departments also seek comment on whether the use of a standards-based API would benefit consumers, developers of consumer-facing applications, and other entities seeking to access this data.

138 See 84 FR 65464, 65483 (November 27, 2019).

139 See 89 FR 8758 (February 24, 2024).

9. Required Method and Format for Disclosing Information to the Public

As discussed in section III.C.7

rrently written) must be available in a form and manner as specified in guidance issued by the Departments; and third, the Departments propose to amend redesignated paragraph (b)(3)(ii) to ensure that the machine-readable files remain publicly accessible to automated scripts and web crawlers as well as human users and that blocking server configurations or firewalls cannot be used to impede access. The Departments also propose to add paragraph (iv) at redesignated 26 CFR 54.9815-2715A3(b)(3), 29 CFR 2590.715-2715A3(b)(3), and 45 CFR 147.212(b)(3), allowing a group health plan or health insurance issuer to satisfy the disclosure requirements of paragraph (b)(3)(iii) by entering into a written agreement under which another party posts the machine-readable files on its public website on behalf of the plan or issuer. However, if the files are posted on a service provider's website and the plan or issuer maintains a public website but chooses not to host the files separately on its own public website, it must provide a link on its own public website to the location where the files are made publicly available. This requirement applies to a public website maintained by the plan or issuer and does not apply to a public website maintained by an employer or plan sponsor.

140 As previously mentioned, proposed paragraph (b)(3) (relating to the method and format for disclosing information to the public) of 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212 applies to the prescription drug machine-readable files.

The 2020 final rules at 26 CFR 54.9815-2715A3(b)(2), 29 CFR 2590.715-2715A3(b)(2), and 45 CFR 147.212(b)(2) require plans and issuers to make the machine-readable files described in paragraph (b) of that section available and accessible to any person on a public website in a form and manner as specified in guidance issued by the Departments

dized hyperlinks in the footer of a plan's or issuer's website home page, as well as any other page on their website that features a footer, in order to aid file users in the automated and non-automated retrieval of machine-readable files by creating a predictable navigation path to internal web pages that host the machine-readable files posted pursuant to the Transparency in Coverage requirements. Additionally, the Departments propose to amend the existing requirement that the machine-readable files described in paragraphs (b)(1) and (2) must be publicly available and accessible to any person free of charge and without conditions, to specify that they must be publicly available and accessible to any person, automated scripts, or web crawlers free of charge and without conditions such as establishment of a user account, password, submission of personally identifiable information or other credentials, or blocking server configurations or firewalls to access the file. Requiring the machine-readable files to be available to both human and automated users more directly aligns with the purpose of the files being machine-readable. Examples of conditions include a “captcha,” 142 a 403 error, 143 or limits on the number of downloads allowed by a user or at a time.

142 See IBM, What is a CAPTCHA ?, https://www.ibm.com/think/topics/captcha (last visited Dec. 8, 2025). (“CAPTCHA stands for `completely automated public Turing test to tell computers and humans apart.' It refers to various authentication methods that validate users as humans, not bots, by presenting a challenge that is simple for humans but difficult for machines.”)

143 See Mozilla, 403 Error, https://developer.mozilla.org/en-US/docs/Web/HTTP/Reference/Status/403 (last updated July 4, 2025)

025). (“CAPTCHA stands for `completely automated public Turing test to tell computers and humans apart.' It refers to various authentication methods that validate users as humans, not bots, by presenting a challenge that is simple for humans but difficult for machines.”)

143 See Mozilla, 403 Error, https://developer.mozilla.org/en-US/docs/Web/HTTP/Reference/Status/403 (last updated July 4, 2025). (“The HTTP 403 Forbidden client error response status code indicates that the server understood the request but refused to process it.”)

Once a human user or automated web crawler arrives at the website of the plan or issuer, they would be able to identify the specific location of the files. The Departments have determined that making this information more easily accessible to automated searches and data aggregation would help third parties to develop tools that further assist the public in understanding this information and capturing it in a meaningful way for making informed health care decisions. Moreover, the Departments have determined that this requirement would be simple for plans and issuers to implement, because plans

and issuers commonly link to other information in their website footer. In addition, using a standardized label for the link in the footer would make the location of the machine-readable files easier to identify by individual consumers manually searching for such files.

Both this proposed requirement and the proposed contextual machine-readable Text File as discussed in section III.C.7.d. of this preamble, are intended to improve both automated and manual location of the machine-readable files on a plan's or issuer's website. While the Text File will enhance automated searching more so than manual searching, the footer links would assist manual searching more so than automated searching as individuals are likely to first examine a footer for web page navigation. Thus, these proposed requirements would complement each other and improve overall accessibility

mployer or plan sponsor. This proposed new paragraph also moves part of current 26 CFR 54.9815-2715A3(b)(4)(iii), 29 CFR 2590.715-2715A3(b)(4)(iii), and 45 CFR 147.212(b)(4)(iii) addressing plans or issuers who do not have a website to new paragraph (b)(3)(iv) for clarity and alignment with other proposed changes.

144 See 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 55 (Aug. 19, 2022), https://www.cms.gov/files/document/faqs-part-55.pdf and https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-55.

The Departments recognize that many employer-sponsored ERISA plans do not currently maintain a separate dedicated internet page for their group health plans or have an internet website at all. This proposed new paragraph would codify FAQs Part 55 145 and extend it to apply to issuers, and recognize the hardship for impacted group health plans, especially for smaller employers. The Departments are proposing this extension to issuers because they were not covered under the guidance in FAQs Part 55 and this would make the requirements consistent across all entities subject to the requirements of paragraph (b)(3)(iii).

145 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 55 (Aug 19, 2022), https://www.cms.gov/files/document/faqs-part-55.pdf and https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-55

nts of paragraph (b)(3)(iii).

145 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 55 (Aug 19, 2022), https://www.cms.gov/files/document/faqs-part-55.pdf and https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-55.

The Departments also propose to amend paragraph (b)(3)(i) at redesignated 26 CFR 54.9815-2715A3(b)(3), 29 CFR 2590.715-2715A3(b)(3), and 45 CFR 147.212(b)(3) to require that the proposed method and format requirements for disclosing information to the public would apply to both the machine-readable files under paragraph (b)(1) and the contextual machine-readable files under new paragraph (b)(2).

Finally, as with the public disclosure requirements in the 2020 final rules, the Departments intend to continue to issue form and manner requirements for the machine-readable files specified in technical guidance in the form of sample file schemas and data attributes on GitHub. 146 The technical guidance for the machine-readable files, in the form of schemas, 147 will be updated when appropriate as the Departments receive feedback from the community and interested parties. Additionally, guidance on applicability timelines for new schema requirements and implementation of policy requirements will continue to be posted in the form of Frequently Asked Questions. 148 Table 2 summarizes the technical guidance documents that the Departments expect to publish pursuant to the finalization of these proposed rules. The Departments encourage interested parties to submit all questions and issues on GitHub, as it enables a centralized response and helps to efficiently identify and address common concerns across interested parties.

146 Centers for Medicare & Medicaid Services, Price Transparency Guide, https://github.com/CMSgov/price-transparency-guide (last updated Oct. 1, 2025)

o quarterly, to help lower data storage and hosting costs, decrease bandwidth needs, and reduce ongoing maintenance expenses. The Departments have received feedback that a reduced reporting cadence may also provide more time to analyze the data, 149 as some file users have informed the Departments that they have difficulty keeping up with the pace of downloading and ingesting the file data monthly.

149 See Michael Chernew, Sabrina Corlette, Kevin 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.

With respect to In-network Rate File data, interested parties have indicated that negotiated rates between issuers and health care organizations (for example, hospital systems)—in contrast to individual providers—tend to change slowly over time because contracts generally last a year or more, with some multi-year contracts lasting 2 to 5 years. As such, the Departments have determined negotiated rates between health care organizations and issuers should not significantly change from month to month, so the proposed quarterly reporting cadence would not meaningfully affect the accuracy of reported rates in the In-network Rate File for these entities.

The Departments acknowledge that the accuracy of rates at the individual provider level are more likely to be affected by the proposed quarterly reporting cadence, though not significantly. The Departments understand that individual providers can regularly move in and out of relationships with the institutions that employ them (for example, hospital systems, group medical practices); 150 thus, reported rates at the individual provider level may be less accurate with a change from monthly to quarterly reporting

ted by the proposed quarterly reporting cadence, though not significantly. The Departments understand that individual providers can regularly move in and out of relationships with the institutions that employ them (for example, hospital systems, group medical practices); 150 thus, reported rates at the individual provider level may be less accurate with a change from monthly to quarterly reporting. More specifically, the turnover of individual providers within the roster of a large provider organization (like specialist physicians associated with a hospital system) means that the reporting of negotiated rates that “flow down” to the individual providers might become increasingly out of date, given a longer cadence for the reporting requirement. One recent study that quantified physician turnover rates due to retirements and shifts in practice affiliations suggested an annual turnover rate of 7.6 percent in 2018. 151 Given that this relatively low annual percentage would translate to an even smaller quarterly turnover rate, the Departments have determined that under the proposed change in reporting cadence, negotiated rates for individual providers would likely become only somewhat less accurate because there would be more providers who terminate employment with their parent organizations during the extended reporting interval.

150 Cf. Code section 9820(a)(2), ERISA section 720(a)(2), and PHS Act section 2799A-5(a)(2) (requiring plans and issuers to verify and update their provider directory database not less frequently than once every 90 days, and to remove providers and facilities which have the plan or issuer has been unable to verify).

151 Amelia M. Bond, Lawrence P. Casalino, Ming Tai-Seale, Matthew A. Unruh, et al., Physician Turnover in the United States, 175 Annals of Internal Medicine 896, 903 (2023)

(requiring plans and issuers to verify and update their provider directory database not less frequently than once every 90 days, and to remove providers and facilities which have the plan or issuer has been unable to verify).

151 Amelia M. Bond, Lawrence P. Casalino, Ming Tai-Seale, Matthew A. Unruh, et al., Physician Turnover in the United States, 175 Annals of Internal Medicine 896, 903 (2023).

Notwithstanding the potential for some of the data in the files to be less accurate, particularly with respect to individual providers, the Departments expect the benefits of quarterly reporting to outweigh these potential limitations, given that for the majority of use cases for the In-network Rate Files, the proposed change in reporting cadence would have only minimal impact on the ability to use the data for reasonable analytic purposes and would significantly reduce burdens both on producers and file users. For example, for a file user that analyzes aggregated rates between plans or issuers and health care organizations and compares reimbursement for orthopedic services in the same geographic market between two issuers, the impact of individual providers (who all share the same rates) moving in and out of health care systems would be immaterial.

The Departments request comment on the benefits, drawbacks, and potential impact of the proposed change in reporting cadence for the In-network Rate Files.

The Departments have also determined there would be no loss in data value by changing the reporting cadence from monthly to quarterly for the Allowed Amount File under paragraph (b)(1)(ii) since the data represents a historical snapshot that would continue to be captured in its entirety. The Departments seek comment on the potential impact of the proposed change in reporting cadence for the Allowed Amount File.

The Departments are not proposing to change the monthly reporting cadence for the prescription drug machine-readable file under paragraph (b)(1)(iii) in proposed paragraph (b)(4)(ii)

Rate File since it was updated last, a Change-log File would still be required to be posted at that time indicating there are no changes for that quarter.

152 See Table 3 for an example.

The Departments also propose to require at proposed paragraph (b)(4)(iv) that the Utilization File described in proposed new paragraph (b)(2)(ii) be updated and posted every 12 months after the initial posting. The Utilization File would be required to be initially posted on the first day of the calendar-year quarter following the applicability date under paragraph (c)(1) and annually on the same date thereafter. The Departments have determined that an annual cadence for this file is sufficient to illustrate provider reimbursement for corresponding items and services and appropriately balances the benefit of having recent historical data with the burden on plans and issuers to extract data from their claims systems annually.

The Departments also propose to require at proposed paragraph (b)(4)(v) that plans and issuers update the Taxonomy File prepared pursuant to proposed paragraph (b)(2)(iii) and post such file beginning on the first day of the calendar-year quarter following the applicability date under paragraph (c)(1). This would help to ensure file users have all necessary information to assess the data disclosed through the In-network Rate Files as described under paragraph (b)(1)(i) and to provide clarity around what data was excluded from the In-network Rate Files pursuant to the new proposed requirement to exclude certain information under new paragraph (b)(1)(i)(F). If there are no changes to the taxonomy that impact the information required to be included in the In-network Rate File from one quarter to the next, the posted Taxonomy File would not be required to be updated

time for plans and issuers to make the required update.

EP23DE25.051

The Departments seek comment on these proposed timing requirements.

11. Special Rules To Prevent Unnecessary Duplication

The Departments propose in 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212 to redesignate paragraph (b)(4)(i) as paragraph (b)(5)(i) and redesignate paragraph (b)(4)(ii) as paragraph

(b)(5)(ii)—each without any substantive changes to the existing policy in the 2020 final rules. The Departments also propose to redesignate and amend paragraph (b)(4)(iii), which permits aggregation of out-of-network allowed amounts in certain circumstances, as paragraph (b)(5)(iv) and to add new paragraph (b)(5)(iii) to include similar permissions with respect to in-network rates.

In new paragraph (b)(5)(iii), the Departments propose, under certain conditions, to allow self-insured group health plans to permit another party (pursuant to a contract) to make available in a single In-network Rate File, the information required under paragraph (b)(1)(i) for multiple plans, insurance policies, and contracts, including those offered by different plan sponsors with which the other party contracts and across markets that share the same provider network. 153 Similarly, in redesignated paragraph (b)(5)(iv), the Departments propose amendments that would allow, under certain conditions, self-insured group health plans to permit another party (pursuant to a contract) to make available in a single Allowed Amount File the information required under paragraph (b)(1)(ii) for more than one self-insured group health plan, including those offered by different plan sponsors with which the other party contracts

the Departments propose amendments that would allow, under certain conditions, self-insured group health plans to permit another party (pursuant to a contract) to make available in a single Allowed Amount File the information required under paragraph (b)(1)(ii) for more than one self-insured group health plan, including those offered by different plan sponsors with which the other party contracts. The Departments also propose two amendments to redesignated paragraph (b)(5)(iv) to account for proposed amendments to the Allowed Amount File requirements in paragraph (b)(1)(ii): (1) to require that the minimum claims threshold apply across multiple self-insured group health plans whose information is included in a single Allowed Amount File, as described in proposed paragraph (b)(5)(iv), rather than for each such individual self-insured group health plan, and (2) to revise the minimum claims threshold to 11-claims in accordance with proposed paragraph (b)(1)(ii)(C). Lastly, the Departments propose amendments to better organize and streamline requirements in redesignated paragraph (b)(5)(iv) which do not affect any substantive rights or obligations.

153 For the purposes of this section III.C.11, the term “health insurance market” refers to the definition in proposed 25 CFR 54.9815-2715A1, 29 CFR 2590.715.2715A1, and 45 CFR 147.210 as described in section III.A of these proposed rules.

a. Special Rule for Self-Insured Group Health Plans With Respect to the Disclosure of In-Network Rate Files

In new paragraph (b)(5)(iii), the Departments propose to permit In-network Rate Files, which for self-insured group health plans under the proposed amendments to paragraph (b)(1)(i) would have been required to be made available at the plan sponsor level, to instead be made available at the service provider level for each provider network used by the self-insured group health plan

work Rate Files

In new paragraph (b)(5)(iii), the Departments propose to permit In-network Rate Files, which for self-insured group health plans under the proposed amendments to paragraph (b)(1)(i) would have been required to be made available at the plan sponsor level, to instead be made available at the service provider level for each provider network used by the self-insured group health plan. This In-network Rate File could include such information for more than one self-insured group health plan with which the other party has an agreement, as well as other policies and contracts offered by the other party acting as a health insurance issuer, that uses the same provider network. This In-network Rate File may also include the relevant information from plans or coverage in different health insurance markets, as described below.

As discussed in section III.C.1 of this preamble, the Departments propose to amend 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 organization by provider network would reduce file size and the overall number of files and make more meaningful information available to file users. Under this proposal, each self-insured group health plan would be required to make available an In-network Rate File for each provider network it maintains. For self-insured group health plans that are administered by the same service provider and use the same provider network, this approach would require duplicate In-network Rate Files that include the same negotiated rates under the same provider network for each self-insured group health plan using that network

quired to make available an In-network Rate File for each provider network it maintains. For self-insured group health plans that are administered by the same service provider and use the same provider network, this approach would require duplicate In-network Rate Files that include the same negotiated rates under the same provider network for each self-insured group health plan using that network. Therefore, to further the goals of reducing duplicative rates and simplifying analysis for file users, the Departments propose in paragraph (b)(5)(iii) to permit and encourage self-insured group health plans to allow another party with which they contract, such as a service provider, to make available an In-network Rate File for each provider network used by more than one self-insured plan.

Further, the Departments propose that these In-network Rate Files may include information about plans, insurance policies, and contracts across health insurance markets, since a service provider may use the same provider network for multiple self-insured group health plans it administers and also for multiple fully-insured group health plans or individual health insurance coverage it offers as a health insurance issuer. Such a service provider, when acting as a health insurance issuer, would already be required under the Departments' proposed amendments to paragraph (b)(1)(i) to disclose an In-network Rate File for that provider network that includes negotiated rate information for the fully-insured group health plans it offers across the small group and large group markets, as well as any individual policies it offers in the individual market, to the extent those plans or policies use that same provider network. Under new paragraph (b)(5)(iii), a self-insured group health plan could permit its service provider to include plans and coverage offered in different health insurance markets in the same In-network Rate File, to the extent they use the same provider network

le for each In-network Rate File, as discussed in section III.C.7. of this preamble, under proposed new paragraphs (b)(2)(i), (ii) and (iii), respectively), include data from the same plans, insurance policies, or contracts (including those offered by different plan sponsors and across different health insurance markets, if applicable) that are represented in the corresponding In-network Rate File. This is because, as discussed in section III.C.7. of this preamble, for the Change-log, Utilization, and Taxonomy Files to be meaningful, they must directly correspond to the disclosures in the In-network Rate Files for which they are made available. Under this proposal, a self-insured group health plan that contracts with another party that takes

advantage of the special rule would not be permitted to publish (either itself or by contracting with another party) the corresponding Change-log, Utilization, and Taxonomy Files only with respect to its own plans.

b. Special Rule for Self-Insured Group Health Plans With Respect to the Disclosure of Out-of-Network Allowed Amount Files

As described above, the Departments propose in 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212 to redesignate paragraph (b)(4)(iii) as paragraph (b)(5)(iv), and to amend redesignated paragraph (b)(5)(iv) to state that a self-insured group health plan may permit another party with which it contracts, such as a service provider, to include the required allowed amount and billed charge information in a single Allowed Amount File for more than one self-insured group health plan, including those offered by different plan sponsors with which the other party contracts, provided certain conditions are met

to state that a self-insured group health plan may permit another party with which it contracts, such as a service provider, to include the required allowed amount and billed charge information in a single Allowed Amount File for more than one self-insured group health plan, including those offered by different plan sponsors with which the other party contracts, provided certain conditions are met.

For improved readability, the Departments propose to move the condition currently described in paragraph (b)(4)(iii) (related to application of the claims threshold to the Allowed Amount File) into new paragraph (b)(5)(iv) and to amend it to align with the Departments' proposed revisions to the claims threshold in paragraph (b)(1)(ii).

Under paragraph (b)(4)(iii) of the 2020 final rules, group health plans and health insurance issuers are currently permitted to satisfy the Allowed Amount File disclosure requirements in paragraph (b)(1)(ii) by contracting with an issuer, service provider, or other party to make available out-of-network allowed amount data that has been aggregated to include information from more than one plan, policy, or contract (provided that the claims threshold described in paragraph (b)(1)(ii)(C) is met independently for each item or service and for each plan or coverage included in an aggregated Allowed Amount File). These plans, policies, or contracts may be across multiple health insurance markets.

As discussed in section III.C.6 of this preamble, the Departments now propose to amend paragraph (b)(1)(ii) to require all plans and issuers to aggregate out-of-network allowed amount data across the plans or coverage they offer in each health insurance market. For example, an issuer offering six plans in the small group market and four in the individual market would be required to make available two Allowed Amount Files: one that aggregates allowed amounts across the issuer's six small group market plans and another that aggregates allowed amounts across its four individual market plans

)(ii). If finalized as proposed, 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 be defined as all self-insured group health plans maintained by the plan sponsor. Therefore, proposed paragraph (b)(1)(ii) would require self-insured group health plans to aggregate out-of-network allowed amount data across the plans offered by the same plan sponsor (that is, in the same health insurance market), but would not permit aggregation across more than one plan sponsor. The Departments have determined that allowing aggregation of allowed amount data only across self-insured group health plans offered by different plan sponsors maintains the market division grouping necessary to make the data more actionable for research and analysis as discussed in section III.C.6 of this preamble. As such, proposed paragraph (b)(5)(iv) states that a self-insured group health plan that enters into an agreement with another party described in paragraph (b)(5)(ii) may permit such other party to make available the information required under paragraph (b)(1)(ii) in a single out-of-network allowed amount file for more than one self-insured group health plan, including those offered by different plan sponsors with which the other party contracts. This would mean that a self-insured group health plan may permit their service provider or other party with which they contract to include their required allowed amount and billed charges information in a single Allowed Amount File along with allowed amount and billed charges information from more than one self-insured group health plan, including those offered by different plan sponsors (that is, in different health insurance markets)

ilable. The Departments have determined that this provision more logically belongs in redesignated paragraph (b)(3) concerning the method and format for disclosing information to the public. As such, the Departments propose to move it to new paragraph (b)(3)(iv) with proposed amendments that are discussed in section III.C.9. of this preamble.

The Departments seek comment on these proposals.

12. Applicability

The Departments propose to require under paragraph (c)(1)that the proposed amendments to the provisions of paragraph (b) of 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212 apply 12 months following the date of publication of the final regulations in the Federal Register . The Departments are proposing this applicability date to ensure that all plans and issuers begin following the updated set of technical requirements at the same time. Until such time, the current provisions of paragraph (b) continue to apply.

Based on initial implementation experience, the Departments have determined that the proposed applicability date appropriately balances the need for achieving increased usability of the machine-readable file data in a timely manner with the time necessary for both file developers and other users to collaborate with the Departments on GitHub and for plans and issuers to make the operational and systems changes to implement these proposals.

The Departments seek comment on this proposed applicability date, including whether 12 months following publication of final regulations provides enough time for plans and issuers to comply with the amended provisions of paragraph (b) and whether there are particular challenges in complying with such applicability date compared to an applicability date based on plan or policy year.

IV

ta reflects only base wages. The Departments determined that CALC's occupation-specific data better aligns with the skill sets and job functions necessary for implementing the requirements in these proposed rules and therefore provides a more suitable basis for estimating labor costs. Table 6 presents the fully burdened mean hourly wage and occupations used in the Departments' estimates.

158 U.S. General Services Administration, Pricing Intelligence Suite, CALC information and wage rates, https://buy.gsa.gov/pricing/ (last visited Dec. 8, 2025).

EP23DE25.054

C. ICRs Regarding Requirements for Disclosures to Participants, Beneficiaries, or Enrollees Under 26 CFR 54.9815-2715A2, 29 CFR 2590.715-2715A2, and 45 CFR 147.211

As discussed previously in this preamble, the Departments propose several amendments to the 2020 final rules to improve price transparency and strengthen consumer protections for participants, beneficiaries, and enrollees. First, the Departments propose revising the disclaimer required under paragraph (b)(1)(vii)(A) to clarify 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. These revisions reflect the Federal balance billing protections introduced by the No Surprises Act, which were not in effect when the original provision was finalized. These proposed revisions aim to ensure that participants, beneficiaries, and enrollees understand that cost-sharing estimates disclosed through their plan's or issuer's self-service tool may not account for additional amounts owed to out-of-network providers.

In addition, the Departments propose adding a new paragraph (b)(2)(iii) requiring plans and issuers to make cost-sharing information available by telephone, consistent with requirements under the No Surprises Act

red Health Insurance? Most Very Large Employers Self-Insure, Verywell Health (November 9, 2024), https://www.verywellhealth.com/what-is-self-insured-health-insurance-and-how-is-it-regulated-4688567.

As also noted in section VI.C.3. of this preamble, the Departments estimate that approximately 1,375 issuers 160 and 205 TPAs 161 (a total of 1,580 entities) would implement the proposed requirements. The Departments acknowledge that actual costs may vary depending on factors such as the volume of providers and items or services for which cost-sharing information must be disclosed, and whether plans (or TPAs on behalf of plans) and issuers already have tools that fully or partially meet the proposed requirements or can be readily adapted. The Departments welcome comment on the assumptions and inputs used to develop these burden and cost estimates.

160 The Departments' estimate of the number of health insurance companies and the number of issuers (issuer/State combinations) is based on medical loss ratio reports submitted by issuers for the 2023 reporting year. Centers for Medicare & Medicaid Services, Medical Loss Ratio Data and System Resources (December 23, 2024), https://www.cms.gov/CCIIO/Resources/Data-Resources/mlr.

161 Non-issuer TPAs based on data derived from the 2016 Benefit Year reinsurance program contributions.

The Departments also assume that plans (or TPAs on behalf of plans) have

already built self-service tools and would only be required to revise the disclaimer stating that out-of-network providers may engage in balance billing, subject to applicable State and Federal laws. Although these updates build on existing infrastructure, they would require a one-time cost for minor technical modifications including editing disclosure text, testing for quality assurance, and implementing the update. The Departments estimate that, on average, each issuer or TPA would require 10 minutes (approximately 0.17 hours) of a Senior Application Developer's time (at $143 per hour) to update the disclosure

tes build on existing infrastructure, they would require a one-time cost for minor technical modifications including editing disclosure text, testing for quality assurance, and implementing the update. The Departments estimate that, on average, each issuer or TPA would require 10 minutes (approximately 0.17 hours) of a Senior Application Developer's time (at $143 per hour) to update the disclosure. As shown in Table 7, across all 1,580 issuers and TPAs, the total one-time burden is estimated at 263 hours, with an associated cost of approximately $37,657.

EP23DE25.055

a. High Impact for Providing Cost-Sharing Information Via P

This text is long and has been trimmed here. Open the source document for the complete record.