Transparency in Coverage Final Rule Rewrites US Payer Price Files

The Transparency in Coverage final rule published today rewrites the machine-readable price files that US group health plans and health insurance issuers must post publicly, and it moves the reporting cycle from monthly to quarterly. The Internal Revenue Service, the Employee Benefits Security Administration and the Centers for Medicare and Medicaid Services issued the joint rule, which takes effect 60 days after publication in the Federal Register. It carries three document numbers: TD 10058, CMS-9882-F and RIN 0938-AV64.

The rule amends the 2020 Transparency in Coverage requirements (85 FR 72158, 12 November 2020), which released a large volume of previously hidden pricing data. The preamble names three barriers that kept the 2020 rules short of their goals: files too large to be usable, raw rates published without context, and misalignment with the Hospital Price Transparency rules that made comparisons across disclosures difficult.

Executive Order 14221, signed on 25 February 2025, directed the Departments to act on healthcare pricing transparency, and the proposed rules followed on 23 December 2025 (90 FR 60432). The Departments received comments from 132 commenters. Consumer groups, employers, issuers, third-party administrators, researchers and technology vendors disagreed about the timetable: several data users asked for a faster start, while plans and issuers asked for 18 to 24 months.

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What the Transparency in Coverage final rule changes

Three groups of changes matter for anyone who works with the data. The In-network Rate File and the Allowed Amount File change shape and content. New files add background that the raw rates never carried. The consumer disclosure rules add the telephone.

For the In-network Rate File, plans and issuers must organize data at the provider network level rather than the plan level, and include a common provider network name and a provider network identifier. Both rate files gain a product type element. Payers must report dollar amounts except where a contract pays only percentage-of-billed charges, an arrangement the preamble says left those rows unusable.

The Departments also require payers to drop in-network rates for provider-to-service combinations that are unlikely to occur, such as a podiatrist billing for heart surgery, and to publish a Taxonomy File so that users can check whether a provider’s specialty matches the service. A new Utilization File lets users test whether a recorded rate was ever paid.

Out-of-network data gets more claims and a longer lookback

The Allowed Amount File must now be aggregated by health insurance market type, and a self-insured group health plan may allow a third party to file one aggregated file on its behalf. The minimum claims threshold falls from 20 claims to 11, which the Departments aligned with the CMS cell suppression policy. The lookback period rises from 180 days to nine months, and the reporting period rises from 90 days to six months. The Departments expect the longer window to lift the number of service and provider combinations that clear the reporting threshold.

Contextual files: utilization, taxonomy and text

Three new files accompany the rate files. The Utilization File is published annually and carries a binary indicator of whether a service was used, based on roughly 12 months of claims. The Taxonomy File is published quarterly and lists provider taxonomy codes. The Text File gives the source page URL, direct links to the machine-readable files and point-of-contact details, and payers must update it within seven calendar days of a change to that information. File content itself sits outside that seven-day rule.

Two proposals did not survive. The Departments dropped the proposed Change-log File and did not finalize a requirement to report enrollment totals, both of which commenters flagged as burdensome.

A website footer requirement applies across every publicly disclosed machine-readable file, including the prescription drug file. Payers must post URLs in the footer so that users can find the files from the plan or issuer website. The prescription drug file itself awaits separate implementation. The Departments issued a request for information on it on 2 June 2025 (90 FR 23303) and say they plan to begin work in short order.

What the rule costs and what it saves

One-time costs total $399,747,381, and annual costs run to $80,439,626. The largest single build item is the Utilization File, at $175,037,782. Across all plans and issuers, the Departments put first-year implementation costs, covering one-time build and first-year running costs, at $480.2 million.

Annual savings of $254,934,840 outweigh those costs. Most of the savings come from cutting network egress costs, at $171,126,000 a year, and storage costs, at $73,317,600 a year, both consequences of publishing files quarterly instead of monthly. Reduced data cleaning adds $9,147,120, and easier file location adds $1,344,120.

From the second year onward the Departments project net savings of about $174.5 million a year. Using a perpetual horizon and a 7 percent discount rate, they put the present value of those savings at $1.73 billion in 2024 dollars and the annualized figure at $121.1 million. The accounting table reports net annualized savings between $89,750,876 and $124,302,294 at a 3 percent discount rate, and between $83,378,704 and $118,028,167 at 7 percent. The Departments classify the rule as a deregulatory action under Executive Order 14192.

What the changes mean for pricing data users

For employers, researchers and health economics teams, the practical effect is a smaller and better labelled data set published four times a year instead of twelve. The contextual files answer questions the raw rates could not: whether a provider plausibly furnishes a service, whether a rate was ever paid, and which network a rate belongs to. The lower claims threshold and longer lookback add out-of-network volume that earlier files suppressed, which widens the base for price variation studies.

The trade-off sits in comparability. Payers must rebuild files around provider networks and market types, so a historical series built on plan-level monthly files will not line up cleanly with the new quarterly ones. Analysts tracking negotiated rates over time will need to rebase their baselines instead of splicing the two series together.

The Departments also flag two costs they could not quantify: possible increases in health care costs or reduced provider discounts if greater price transparency pushes prices toward convergence, and privacy and cybersecurity costs tied to protecting personal health information in the newly aggregated files.

Where this fits in wider US pricing policy

The rule lands alongside other federal pricing measures, including drug price transparency rulemaking, most-favoured-nation drug pricing and healthcare pricing regulation models borrowed from other countries. The machine-readable files have been live since 2022, and the changes now finalised decide what that data looks like for the rest of the decade.

Source: Transparency in Coverage, final rule, Federal Register document 2026-20447, scheduled for publication on 6 October 2026. federalregister.gov/d/2026-20447