Consistent with the President’s Executive Order 14221, “Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information,” on Dec. 19, 2025, the Centers for Medicare & Medicaid Services, in partnership with the Department of Labor and the Department of the Treasury (collectively, the Departments) jointly proposed changes to the payer price transparency regulations to improve the accessibility of pricing disclosures to participants, beneficiaries, and enrollees, and the standardization and reliability of the public pricing disclosures from non-grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage.
These proposed changes build on the historic disclosure requirements the Departments issued in the Transparency in Coverage final rules on November 12, 2020 (the 2020 final rules) in line with the President’s June 24, 2019, Executive Order (EO) 13877, “Improving Price and Quality Transparency in American Healthcare to Put Patients First.”
This fact sheet discusses the proposed provisions of the Transparency in Coverage proposed rule (CMS-9882-P) that would amend the 2020 final rules. The proposed rule can be accessed via the Federal Register at: https://www.federalregister.gov/public-inspection/2025-23693/transparency-in-coverage.
Under current rules, non-grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage are required to post machine-readable files monthly for each plan or coverage they offer—an In-network Rate File disclosing in-network rates for all covered items and services, an Allowed Amount File disclosing out-of-network allowed amounts and the associated billed charges, and a prescription drug file disclosing in-network rates and historic net prices for covered items and services. These requirements became applicable in July 2022.[1]
Improved Standardization, Accuracy, And Accessibility of the In-network Rate and Out-of-Network Allowed Amount Machine-Readable Files
Based on internal assessment and external stakeholder feedback over the last three years of implementation, the Departments have identified three main barriers to fully achieving the goals of the 2020 final rules: inaccessibility due to the large size of the machine-readable files, data ambiguity due to lack of contextual information alongside the raw data, and areas of misalignment with the Hospital Price Transparency rule that make comparing data across disclosures challenging.
Reducing The Number and Size of Machine-Readable Files and Increasing Accessibility to Make Data More Meaningful
The primary cause of large In-network Rate File sizes is the inclusion of providers associated with negotiated rates for items or services they would be unlikely to furnish (e.g., rates for podiatrists to perform heart surgery). This occurs because payer-provider contracts often account for all items and services for all their providers, irrespective of clinical specialty.
To address these unlikely provider-rate combinations, the proposed rules include proposals to: 1) require group health plans and health insurance issuers to exclude from their In-network Rate Files provider-rate combinations for items and services for providers that would be unlikely to be reimbursed for the item or service given that provider's area of specialty. The proposal would require plans and issuers to determine which providers to exclude by using their internal provider taxonomy mappings used in the claims adjudication process; 2) require payers to post the internal provider taxonomy mapping they used to prepare the In-network Rate File; and 3) require plans and issuers to post a new file called a Utilization File for each In-network Rate File which would include all providers who have submitted and received reimbursement for at least one claim for a covered item or service over the 12-month period ending 6 months before the posting of the file.
To reduce duplicative data, the Departments propose to change the level at which group health plans and health insurance issuers must report data in the In-network Rate file. Under this proposal, plans and issuers would be required to prepare one In-network Rate File for each provider network they maintain or contract with rather than for each plan or policy they offer, as files are currently being prepared. Because it is very common for multiple policies offered by the same issuer (and many times across different issuers) to leverage the same provider networks with the same negotiated rates, requiring network-level reporting would streamline how rates are reported, reducing both the number and size of In-network Rate Files.
Further, reporting of in-network rates at the network level would also align with how the Hospital Price Transparency data is typically reported. Aligning payer and hospital data reporting would help normalize data across different systems, improve consistency, and make comparisons between the payer and hospital machine-readable files easier for users of the files.
Making Data More Usable
The Departments have received feedback and observed in compliance reviews that many group health plans and health insurance issuers include limited or no data in their Allowed Amount Files, which may be due in part to the current 20-claims threshold for reporting. This has limited transparency of out-of-network pricing information to patients and limits what researchers, academics, and developers can analyze. The Departments include three proposals to address insufficient data: 1) require payers to aggregate their Allowed Amount Files by insurance market type (large group, small group, individual, and self-insured); 2) lower the claims threshold from 20 to 11 claims; 3) increase the period of reporting from 90 days to 6 months and the lookback period from 180 days to 9 months.
Taken together, the Departments expect these proposals, if finalized, will result in the disclosure of much more out-of-network data, as it will be easier to reach an 11-claim threshold when data is aggregated by market type and the reporting period is over twice as long. Further, the Departments understand from stakeholder feedback that out-of-network allowed amounts across plans and policies are most aligned by market type, and providing this data at the market-type level would allow users to make comparisons of allowed amounts for plans within the same market, as preferred by researchers and academics.
The Departments also propose to require the inclusion of additional data elements to provide context around the data being reported. These include proposing that group health plans and health insurance issuers be required to report 1) the plan’s or policy’s product type (e.g., HMO, PPO, etc.) for each plan or policy represented in an In-network Rate File and Allowed Amount File, 2) a numerical enrollment count for each plan or policy represented in In-network Rate File and Allowed Amount File, and 3) the common network name associated with the provider network represented in the In-network Rate File.
In addition, the Departments propose to require group health plans and health insurance issuers to publicly disclose a new Change-log machine-readable file which would reflect changes in data from one In-network Rate File (under these proposed rules, prepared for a specific provider network) to the publishing of the next In-network Rate File. Therefore, rather than downloading and analyzing each set of newly posted In-network Rate files, users would only need to look at the Change-log File to determine which new files they need to examine from one reporting period to the next.
Make Data Easier to Locate
The proposed rules include two proposals to help users locate the machine-readable files. First, the Departments propose to require a plain text file (.txt file) located in the root folder of a payer’s website with information on the specific location of the machine-readable files as well as contact information including a name and email address for those that are responsible for the machine-readable files. In addition, the Departments propose to require group health plans and health insurance issuers to add a link in the footer of the home page of the plan’s or issuer’s website titled “Price Transparency” or “Transparency in Coverage” that routes directly to the publicly available web page that hosts the machine-readable files to allow for a standardized and predictable navigation path for users seeking the files. Together, these requirements would aid in the automation of locating and downloading the machine-readable files as well as providing a point of contact for the machine-readable files for questions or if clarification is needed on the data within the files. These proposals would also apply to the prescription drug machine-readable file. These proposals would and align with current requirements under the Hospital Price Transparency rules.
Reducing Stakeholder Burden
The Departments also propose to require plans and issuers to update and post the In-network Rate and Allowed Amount Files quarterly rather than monthly to help lower data storage and hosting costs, decrease bandwidth needs, and reduce ongoing maintenance expenses. Plans, issuers, and researchers have indicated that, since provider networks and rates do not change significantly from month-to-month, switching to a quarterly reporting cadence would not lead to a significant reduction in meaningful data. This reduced reporting cadence may also provide more time to analyze the data, 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. This change in reporting cadence along with the reduction of both the size and number of machine-readable files would reduce the current burden associated with preparing, ingesting, analyzing, and storing the public disclosures.
Solicit Comment on Adopting a Single File Format in Technical Implementation Guidance
Current rules require group health plans and health insurance issuers to publish their machine-readable files in “any non-proprietary, open format,” such as JSON, XML, or CSV, as specified through technical implementation guidance, which allows the Departments flexibility to adapt file formats to new and emerging technologies. The preamble to these proposed rules discusses the Departments’ intention to restrict the file type to one format in its technical implementation guidance in order to promote standardization between payers’ files. This includes a discussion of the Departments’ view of the relative pros and cons associated with the JSON format, the current format of over 90% of the MRFs, and the CSV format, for which the Departments have received recent support from certain researchers who are more accustomed to analyzing data in that format. The Departments solicit comment on the proposal to require payers to use a single file format in regulation, and, if finalized, in naming JSON or CSV as that single format.
Applicability Dates
The Departments propose that the proposed amendments to the machine-readable file provisions would 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.
Disclosures to Participants, Beneficiaries, and Enrollees: Internet-based Self-service Tool
Currently, the 2020 final rules require group health plans and health insurance issuers to make available cost-sharing information to participants, beneficiaries, and enrollees through an online self-service tool or paper, upon request. This cost-sharing information must be accompanied by several notices that provide critical explanatory information and indicate the limitations of the data being disclosed. These rules were applicable starting January 2023. Since the publication of the 2020 final rules, the No Surprises Act enacted several provisions requiring plans and issuers to make pricing information more transparent to consumers, including a requirement that plans and issuers make available cost-sharing information through an internet-based tool, as well as over the phone. The Departments indicated their view in guidance issued August 2021,[2] subsequent to the passage of the No Surprises Act, that the internet-based tools were largely duplicative but the No Surprises Act required cost-sharing information to also be provided over the phone. Therefore, the Departments propose to require that the same information required to be disclosed under the Transparency in Coverage rules be required to be communicated over the phone, upon request, to satisfy the No Surprises Act cost-sharing tool provision. The Departments also propose amendments to the notice requirement related to potential balance billing not captured in cost-sharing information to account for new federal protections against balance billing in certain circumstances.
Applicability Dates
The Departments propose that the proposed amendments to the self-service internet-based tool provisions would apply for plan years (in the individual market, policy years) beginning on or after January 1, 2027.
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[1] On September 27, 2023, the Departments released Affordable Care Act FAQs Part 61, announcing that they would enforce the prescription drug machine-readable requirement “on a case-by-case basis, as the facts and circumstances warrant.” 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. See 90 FR 23303 (June 2, 2025).
[2] See FAQs About Affordable Care Act Implementation Part 49, Q3 (Aug. 20, 2021), available at https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf.