Transparency in Coverage
Key claim: Most employer health plans and insurers must publish more standardized, easier-to-find public price files and also give the same cost information by phone, not just online or on paper.
Abstract
(Rule · Treasury Department, Internal Revenue Service, Labor Department, Employee Benefits Security Administration, Health and Human Services Department) These final rules set forth requirements that amend the regulations under the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code regarding price transparency reporting requirements for non- grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage. Specifically, these final rules are intended to improve the standardization, accuracy, and accessibility of public pricing disclosures in line with the goals of Executive Order 14221, “Making America Healthy Again by Empowering Patients With Clear, Accurate, and Actionable Healthcare Pricing Information.” With respect to the In- network Rate and out-of-network Allowed Amount machine-readable files, these final rules aim to achieve these goals by adding new contextual files and additional data elements like product type, provider network name, and provider network identifier; changing the reporting level for aggregation of data; removing in-network rates for unlikely provider- to-service mappings; increasing the reporting period and lowering the claims threshold for out-of-network historical data; and reducing the reporting cadence. These final rules also aim to improve the findability of all publicly disclosed machine-readable files required under the Transparency in Coverage rules, including the prescription drug file, by requiring a text file containing contact information for the files, and a footer with website URLs. These final rules also require pricing information that is made available through an online consumer tool and on paper (upon request), to also be made available by phone, and establish that the satisfaction of such requirement also satisfies the requirements of section 114 of the No Surprises Act (including for grandfathered group health plans and health insurance issuers offering grandfathered group and individual health insurance coverage that are not otherwise subject to these final rules).
Why this matters
Transparency in Coverage is the main federal mechanism forcing commercial health plans to publish negotiated prices and member cost-sharing data, and these final rules make those disclosures more usable by standardizing the public price files and requiring telephone access to the same information. For patients, that affects how easily they can compare prices before care; for plans and third-party vendors, it reshapes the compliance baseline for price transparency.