Transparency in Coverage

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 include 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, included in 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 qualified health plans 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.

Title I of Division BB of the Consolidated Appropriations Act of 2021, which included 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, section 107 of the No Surprises Act added new section 9816(e) of the Code, section 716(e) of ERISA, and section 2799A-1(e) of the PHS Act, which contain requirements for plans and 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 9819 of the Code, section 719 of ERISA, and section 2799A-4 of the PHS Act, 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.

On June 24, 2019, President Trump issued Executive Order 13877, “Improving Price and Quality Transparency in American Healthcare to Put Patients First.” \11\ Executive Order 13877 sought to improve transparency in health care and empower patients to make fully informed decisions about their health care. As Executive Order 13877 noted, “patients often lack both access to useful price and quality information and the incentives to find low-cost, high-quality care.” The “opaque pricing structures” may harm the market by protecting “powerful special interest groups, such as large hospital systems and insurance companies” while “leav[ing] patients and taxpayers worse off than would a more transparent system.” \12\

\11\ Exec. Order No. 13877, 84 FR 30849 (June 27, 2019).

\12\ Id.

Executive Order 13877 directed the Departments to take action that would combat this issue by making meaningful price and quality information more broadly available to more Americans, thereby increasing competition, innovation, and value in the health care system. Specifically, section 3(b) of Executive Order 13877 directed the Secretaries of the Departments to issue an advance notice of proposed rulemaking, consistent with applicable law, soliciting comment on a proposal to require health care providers, health insurance issuers, and self-insured group health plans to provide or facilitate access to information about expected out-of-pocket costs for items or services to patients before they receive care.

To fulfill their responsibility under Executive Order 13877, the Departments proposed \13\ and subsequently finalized the Transparency in Coverage rules in the 2020 final rules.\14\ 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.

\13\ 84 FR 65464 (November 27, 2019).

\14\ 85 FR 72158 (November 12, 2020).

The 2020 final rules required non-grandfathered health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage to disclose cost-sharing information for all covered items and services to participants, beneficiaries, and enrollees through an internet-based self-service tool or, if requested by the individual, on paper. Those provisions of the 2020 final rules implemented paragraph (C) of section 1311(e)(3) of the Affordable Care Act.

The 2020 final rules also required non-grandfathered plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage to disclose on a public website three separate machine-readable files containing certain information regarding health care pricing under the plan or coverage. Those 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, implemented 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 implemented the requirement in section 1311(e)(3)(A)(vii) of the Affordable Care Act that require issuers of qualified health plans (QHPs) 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 was appropriate under section 1311(e)(3)(A)(ix) of the Affordable Care Act.

After the 2020 final rules were issued, interested parties used GitHub and other forums to bring to the Departments' attention specific questions related to implementation and compliance. In response, the Departments have issued Frequently Asked Questions (FAQs) \15\ and technical guidance.\16\

\15\ U.S. Department of Labor, U.S. Department of Health & Human Services & U.S. Department of the Treasury, FAQs About Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 49 (August 20, 2021), available at https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf and https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-49; FAQs About Affordable Care Act Implementation Part 53 (April 19, 2022), available at https://www.cms.gov/files/document/faq-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 (September 27, 2023), available at https://www.cms.gov/files/document/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.

\16\ Centers for Medicare & Medicaid Services, Transparency in Coverage, GitHub, available at https://github.com/CMSgov/price-transparency-guide (last visited June 15, 2026).

On February 25, 2025, President Trump issued Executive Order 14221,\17\ “Making America Healthy Again by Empowering Patients With Clear, Accurate, and Actionable Healthcare Pricing Information.” Executive Order 14221 stated that “[m]aking America healthy again will require empowering individuals with the best information possible to inform their life and healthcare choices” with the goal to “make more meaningful price information available to patients to support a more competitive, innovative, affordable, and higher quality healthcare system.” To that end, the Executive Order directs the Departments to “promote universal access to clear and accurate healthcare prices[;] . . . to improve existing price transparency requirements; increase enforcement of price transparency requirements; and identify opportunities to further empower patients with meaningful price information, potentially including through the expansion of existing price transparency requirements.” \18\

\17\ Exec. Order No. 14221, 90 FR 11005 (February 28, 2025).

\18\ Id.

Section 3 of Executive Order 14221 directs the Secretaries of the Departments to rapidly implement and enforce the health care price transparency regulations issued pursuant to Executive Order 13877,\19\ including action to: “(a) require the disclosure of the actual prices of items and services, not estimates; (b) issue updated guidance or proposed regulatory action ensuring pricing information is standardized and easily comparable across hospitals and health plans; and (c) issue guidance or proposed regulatory action updating enforcement policies designed to ensure compliance with the transparent reporting of complete, accurate, and meaningful data.” \20\ To fulfill their responsibility under Executive Order 14221, on December 23, 2025, the Departments published the proposed rules to amend the 2020 final rules.

\19\ Exec. Order No. 13877, 84 FR 30849 (June 27, 2019).

\20\ Exec. Order No. 14221, 90 FR 11005 (February 25, 2025).

The Departments received comments from 132 commenters in response to the proposed rules from a wide variety of interested parties, including private citizens; consumer and advocacy organizations; employers and other plan sponsors; health information technology, health care consulting, and health care staffing companies; health care providers and facilities, and health systems; health insurance issuers; service providers, including third-party administrators (TPAs); trade and professional associations; and researchers and academics. Many commenters provided detailed feedback on multiple aspects of the proposed rules and in response to various specific comment solicitations included in the preamble to the proposed rules.

The Departments received many comments expressing general support for the proposed rules, stating that the proposals would help control health care costs and empower consumers to make more informed decisions by improving the accuracy and usability of Transparency in Coverage data, reducing administrative burden for plans and issuers, and aligning with the Hospital Price Transparency requirements. The Departments also received many comments supporting technical and structural changes, including moving to network-level reporting, standardizing file structures, requiring additional contextual information, moving to a quarterly reporting cadence, requiring footer links to the location of the machine-readable files, and excluding from the data set providers who are unlikely to provide services typically outside their scope of practice. The Departments also received several comments supporting alignment with the Hospital Price Transparency requirements, stating that such alignment would reduce duplication, facilitate comparisons, and support more meaningful analyses of health care cost drivers. The Departments respond to these comments in section III. of this preamble.

The Departments also received several comments expressing general disagreement with the proposed rules and concern with the Departments' broader approach to Transparency in Coverage, stating that the proposals leave significant gaps that would undermine the goals of the statute. Several commenters expressed concern that the proposed rules could reduce competition in concentrated health insurance markets and place insufficient emphasis on quality as a factor in health care decision-making and suggested that the Departments work directly with physicians and other providers to inform price transparency. The Departments also received several comments stating that, despite the proposed improvements, fundamental issues of machine-readable file incompleteness, ambiguity, and usability would persist and continue to hinder data interpretation. In addition, several commenters did not support the proposed rules because they believed the proposals would increase costs and administrative burden for group health plans, particularly small and regional plans, and make the machine-readable files more complex for users to access. The Departments also received several comments expressing concern that the proposed rules favor researchers and academics over the development of consumer decision- support tools and focus on price without including quality or outcomes data needed to inform consumer decision-making.

The Departments received many comments suggesting additional ways in which the Departments could use their statutory authority to strengthen the Transparency in Coverage requirements, particularly by reducing barriers to accessibility and improving data usability. The Departments received a few comments recommending standardized, plain- language, consumer-facing summaries that translate machine-readable file data into estimated out-of-pocket costs, including deductible status, coinsurance, and network tier information. The Departments also received a few comments noting that issuers relying on TPAs to comply with Transparency in Coverage requirements may face barriers to accessing their own data. A few commenters recommended requiring the establishment of a unified national standards authority, creation of a national database compiling machine-readable file rates, and expansion of reporting requirements to additional payers or coverage programs, such as Medicaid managed care plans and Medicare Advantage plans.

Many commenters requested the Departments increase their enforcement activity, including through an increased use of audits, warning letters, corrective action plans, and monetary fines. Additionally, a commenter encouraged the Departments to take steps to publicly disclose information related to non-compliance warnings, corrective action plans, and civil money penalties, similar to existing enforcement protocols under the Hospital Price Transparency requirements.

The Departments respond to these comments in more detail in the relevant subsections of section III. of this preamble. The Departments recognize that plans and issuers may need to examine contracts with TPAs to identify if changes are necessary to enable access to the data required under these final rules. The Departments are not requiring standardized summaries of estimated out-of-pocket costs, including deductible status, coinsurance, and network tier information, because the data in the machine-readable files are rates and historic billed charges only and cannot reflect an individual consumer's personalized estimated cost-sharing liability, including accumulators and deductible progress. Requiring this information to be made available in the machine-readable files would be duplicative of the personalized cost- sharing information available through the internet-based self-service tool.\23\ Nevertheless, the Departments anticipate that researchers, employers, and other file users will use the machine-readable file data to analyze and compare health care prices and that third-party developers will build tools and apps that make the information more accessible and useful to consumers and other purchasers of health care, thereby promoting greater transparency for the broader public benefit.

\23\ 26 CFR 54.9815-2715A2(b)(2)(i), 29 CFR 2590.715- 2715A2(b)(2)(i), and 45 CFR 147.211(b)(2)(i).

The Departments appreciate commenters' suggestion to create a national database of compiled machine-

readable file negotiated rates and allowed amounts, but note that plans and issuers have been posting their files in an established manner for more than four years, creating consistency in their operations and for the public in finding the files. Additionally, findability will be further enhanced through the Text File as discussed in section III.C.8.d. of this preamble and the footer requirement as discussed in section III.C.10. of this preamble. Creating a new system to submit such information to the Departments would be overly burdensome in light of the other new requirements in these final rules. Further, rules regarding Medicaid managed-care and Medicare Advantage plans are beyond the scope of section 2715A of the PHS Act and these final rules.

A commenter noted that some payers have not meaningfully updated machine-readable file data in years and warned that without an enforcement mechanism tied to update frequency, the quarterly cadence risks allowing widespread noncompliance to persist.

A commenter recommended that the Departments clarify the distinct role of States and the Federal Government and their jurisdictions in enforcement responsibility. Another commenter recommended that the Departments assign primary enforcement authority to a Federal entity, such as the Center for Consumer Information and Insurance Oversight (CCIIO), to improve compliance with the Transparency in Coverage requirements. Another commenter encouraged the Departments to increase coordination with State departments of insurance.

A commenter requested that the Departments create a safe harbor or non-enforcement policy for employers who report non-compliance to the Departments, given that many health insurance purchasers hire service providers to handle their machine-readable file responsibilities. Another commenter wanted the Departments to require owners of the provider networks to share a complete and accurate set of health claims data with a self-insured plan sponsor and their service providers. A commenter requested that the Departments defer to States when regulating ERISA plans, as well as strengthen enforcement authority over ERISA plan administrators. A few commenters encouraged the Departments to establish new enforcement procedures, and one of these commenters criticized the Departments for relying on a discretion-based enforcement approach. A commenter encouraged the Departments to increase coordination with State departments of insurance.

The Departments look forward to the reforms put forth by these final rules helping achieve the promise of price transparency to empower Americans and lower costs. The Departments agree that enforcement of the Transparency in Coverage requirements is critical to the ongoing usefulness of the published data and share commenters' concerns about plans and issuers failing to maintain updated and accurate files as required. The Departments also recognize that there is continued public interest in learning about compliance and enforcement actions with respect to the Transparency in Coverage requirements.

The Departments have been engaged in compliance and enforcement efforts since the 2020 final rules requirements became effective. With the implementation of these final rules, the Departments will prioritize compliance and enforcement through existing authorities and will work to ensure that any enforcement actions will be transparent to the public.

Under chapter 100 of the Code, Part 7 of ERISA, and title XXVII of the PHS Act, as applicable, the Departments may require corrective actions and impose civil monetary penalties, or seek equitable or other forms of remedial relief \24\ through voluntary compliance or otherwise, to the extent permitted under applicable law, when the Departments find violations through market conduct examinations and investigations of plans and issuers within their jurisdiction.

\24\ Including under ERISA section 502(a)(5).

With respect to the commenter who requested clarity on which entities have enforcement authority, the Departments reiterate the applicable jurisdictions of enforcement authority stated at the beginning of section II.C. of this preamble. The Department of Labor has primary enforcement authority over ERISA plans. State regulators maintain enforcement authority over health insurance coverage offered by health insurance issuers in the group and individual markets unless the State notifies HHS that it has not enacted legislation to enforce or HHS determines that a State has failed to substantially enforce such requirements, as described in section 2723(a)(2) of the PHS Act and implementing regulations under 45 CFR 150 subpart B. HHS has direct enforcement authority over non-Federal governmental plans in all jurisdictions.

In response to the commenter who requested that the Departments require owners of provider networks to share a complete and accurate set of health claims data with a self-insured plan sponsor and their service providers, the Departments remind plans and issuers of the prohibitions on gag clauses under the Consolidated Appropriations Act, 2021. Specifically, section 9824 of the Code, section 724 of ERISA, and section 2799A-9(a)(1) of the PHS Act prohibit group health plans and health insurance issuers offering group health insurance coverage from entering into an agreement with a health care provider, network or association of providers, TPA, or other service provider offering access to a network of providers that would directly or indirectly restrict the plan or issuer from electronically accessing de-identified claims and encounter information or data for each participant, beneficiary, or enrollee in the plan or coverage upon request, consistent with certain Federal privacy regulations.\25\

\25\ As added by section 201 of title II (Transparency) of division BB of the Consolidated Appropriations Act, 2021.

With respect to the commenter who expressed concerns about employers' and self-insured plans' ability to comply with the requirements of these final rules, the Departments point to the special rules as finalized in this rule at 26 CFR 54.9815-2715A3(b)(5), 29 CFR 2590.715-2715A3(b)(5), and 45 CFR 147.212(b)(5), which articulate responsibility for group plans that enter into a written agreement with a health insurance issuer or a third party to provide the required machine-readable file information. If a self-insured plan sponsor is concerned that the plan's TPA may not be capable of fulfilling the requirements of the rule on its behalf, the plan should take all necessary steps to address such concern in its contract with the TPA.

The Departments received one comment seeking confirmation that, as stated in the preamble to the 2020 final rules,\26\ “denominational health plans” are outside the scope of the Transparency in Coverage requirements. In the preamble to the 2020 final rules, the Departments stated that all plans subject to section 2715A of the PHS Act must comply with the rule's requirements. The Departments also stated that section 2715A of the PHS Act applies to group health plans and health insurance issuers offering group or individual health insurance coverage and not to, among others, “denominational health plans,” without defining the term. These final rules do not exclude denominational health plans that are church plans within the

meaning of section 3(33) of ERISA and section 414(e) of the Code because church plans are group health plans and the Departments have concluded that the statute provides no authority to exclude them.

\26\ 85 FR 72158, 72252 (November 12, 2020).

Many commenters wanted the Departments to focus enforcement not just on whether the machine-readable files are being made publicly available, but to ensure that the data contained within the files are complete and accurate. Another commenter recommended Department-hosted “connectathon” events to validate Transparency in Coverage data. Many commenters urged stronger accountability for the validity and accuracy of the data by including attestation requirements, with commenters stating that, without such safeguards, the data would be of limited value to consumers.

In addition to the above enforcement tools, the Departments are finalizing an attestation requirement as an additional step to address the concerns about the accuracy of the information provided and help ensure its validity. The Departments discuss this and respond to the above comments in more detail in section III.C.7. of this preamble.

Many commenters submitted comments that were not within the scope of the policies proposed under the proposed rules, including comments on requirements related to the 2019 Hospital Price Transparency rule,\27\ Advanced Explanation of Benefits,\28\ the claims review process and timeline, enforcement of the No Surprises Act balance billing protections,\29\ price transparency for Medicare plans, future rulemaking plans on additional price transparency policies, and quality data transparency.

\27\ 83 FR 41141 (August 17, 2018).

\28\ Public Law 116-260 (Dec. 27, 2020).

\29\ Title I of Division BB of the Consolidated Appropriations Act, 2021.

After reviewing the comments received, the Departments are finalizing the proposed rules, with some changes in response to comments, as described in more detail later in this preamble, to make pricing information more accurate, more accessible, and more actionable.

These final rules include a series of technical amendments to the way group health plans and health insurance issuers offering group or individual health insurance coverage are referenced in 26 CFR 54.9815- 2715A2 and 54.9815-2715A3, 29 CFR 2590.715-2715A2 and 2590.715-2715A3, and 45 CFR 147.211 and 147.212. In the 2020 final rules, the Departments generally adopted the convention of referring to those entities using the terms “group health plan” and “health insurance issuer” throughout the regulations, except that where the Departments referred to those entities more than once in the same paragraph, the terms “plan” and “issuer” were used after the initial instance. However, that convention was not applied evenly.

Therefore, in the proposed rules, the Departments proposed technical amendments to align the terms used to describe those entities with that convention in paragraphs (b)(1)(i)(A), (b)(1)(i)(B), (b)(2)(ii), (b)(3)(i), and (b)(3)(ii) of the internet-based self- service tool disclosure requirements in 26 CFR 54.9815-2715A2, 29 CFR 2590.715-2715A2, and 45 CFR 147.211; and paragraphs (b)(1)(i)(D), (b)(5)(i), and (b)(5)(ii) the machine-readable file disclosure requirements in 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212. The Departments did not receive any comments on these technical amendments and are therefore finalizing them as proposed. These changes are technical in nature and do not affect the rights or obligations of any plan, issuer, or other entity.

In addition, the Departments proposed to modify 26 CFR 54.9815- 2715A3(b)(3)(ii), 29 CFR 2590.715-2715A3(b)(3)(ii), and 45 CFR 147.212(b)(3)(ii) to clarify, as written elsewhere in paragraphs (b)(3)(i) and (b)(3)(iii), the machine-readable files being described are in paragraphs (b)(1) and (2) of the section.

For consistency with Department of the Treasury and Department of Labor regulations, HHS is amending the section heading of 45 CFR 147.211 to “Transparency in coverage--required disclosures to participants, beneficiaries, and enrollees” instead of “Transparency in coverage--required disclosures to participants, beneficiaries, or enrollees.”

To support proposed amendments to the Allowed Amount File provision (discussed in more detail in section III.C.6. of this preamble) and to promote consistency in data organization, the Departments proposed to add new paragraphs 26 CFR 54.9815-2715A1(a)(2)(xi), 29 CFR 2590.715- 2715A1(a)(2)(x), and 45 CFR 147.210(a)(2)(xi) to define the term “health insurance market” and to redesignate the paragraphs that follow accordingly.\30\ The Departments proposed that “health insurance market” would mean, irrespective of State, one of the following:

\30\ 90 FR 60432, 60442 (December 23, 2025) (proposing to redesignate paragraphs (a)(2)(xi) through (xxii) as paragraphs (a)(2)(xii) through (xxiii) under 26 CFR 54.9815-2715A1 and 45 CFR 147.210; and to redesignate paragraphs (a)(2)(x) through (xxi) as paragraphs (a)(2)(xi) through (xxii) under 29 CFR 2590.715-2715A1).

The individual market, as defined in 45 CFR 144.103 (other than short-term, limited-duration insurance or individual health insurance coverage that consists solely of excepted benefits).

The large group market, as defined in 45 CFR 144.103 (other than coverage that consists solely of excepted benefits).

The small group market, as defined in 45 CFR 144.103 (other than coverage that consists solely of excepted benefits).

For purposes of self-insured group health plans (other than account-based plans, as defined in 26 CFR 54.9815-2711(d)(6)(i), 29 CFR 2590.715-2711(d)(6)(i), and 45 CFR 147.126(d)(6)(i), and plans that consist solely of excepted benefits), all self-insured group health plans maintained by the plan sponsor.

The Departments sought comment on this proposed definition. After consideration of public comments, the Departments are finalizing this definition with modifications that add cross-reference citations to the relevant definitions of excepted benefits for additional clarity. Specifically, the Departments are adding a cross-reference to the definition of excepted benefits in 45 CFR 148.220 to 26 CFR 54.9815- 2715A1(a)(2)(xi)(A), 29 CFR 2590.715-2715A1(a)(2)(x)(A), and 45 CFR 147.210(a)(2)(xi)(A). This definition of the term applies to coverage in the individual health insurance market. The Departments also are adding a cross-reference to the definition of excepted benefits in 26 CFR 54.9831-1(c), 29 CFR 2590.732(c), or 45 CFR 146.145(b) to 26 CFR 54.9815-2715A1(a)(2)(xi)(B) through (D), 29 CFR 2590.715- 2715A1(a)(2)(x)(B) through (D), and 45 CFR 147.210(a)(2)(xi)(B) through (D), respectively. This definition of the term applies to group health plans.

Several commenters supported the Departments' proposed definition of “health insurance market” for the purposes of the proposed amendments to the Allowed Amount File provision. These commenters expressed that clearly and consistently defining the health insurance market categories

would reduce ambiguity and variability in reporting. A few commenters also noted that delineating four separate markets and requiring separate out-of-network Allowed Amount machine-readable files for each market would support the comparability of the files and enable more accurate evaluation of affordability, network adequacy, and cost drivers across the system. A few commenters highlighted that this proposed definition aligns concepts of the Transparency in Coverage requirements with requirements included in the No Surprises Act. Another commenter stated that the proposed definition would provide additional information to the public about negotiated rates as they are anchored in qualifying payment amount (QPA) calculations and provide better insight to the Federal agencies tasked with enforcing QPA calculation requirements.

The Departments agree with commenters that the definition of the term “health insurance market” promotes consistent data organization across plans and issuers in the market-level Allowed Amount Files, for which the Departments are finalizing requirements, as discussed in section III.C.6. of this preamble, with modifications to cross- reference the relevant definitions of excepted benefits for clarity. The Departments also agree that clearly delineating each market included in the definition and requiring separate machine-readable files for each market supports the analytic value of these files.

A commenter disagreed with the Departments' proposed definition of “health insurance market.” The commenter expressed that including self-insured group health plans in the definition would lead to confusion for those plans as well as file users given the variability in State definitions of this term. The commenter recommended that self- insured group health plans be defined as “self-insured” separately from “health insurance market.” Additionally, another commenter recommended that the Departments use the term “health coverage market” rather than “health insurance market” given that the proposed definition includes self-insured group health plans.

The Departments acknowledge the commenter's concern about confusion regarding the variability in State definitions of the term, “health insurance market.” However, these final rules specify that the definition of “health insurance market” for the purposes of organizing the Allowed Amount Files is established “irrespective of the State.” Additionally, the Departments are not aware of any confusion among self-insured group health plans based on a similar definition of “insurance market” included in the method for calculating the QPA at 26 CFR 54.9816-6(a)(8), 29 CFR 2590.716-6(a)(8), and 45 CFR 149.140(a)(8).\31\ The Departments have determined that employing similar definitions for purposes of calculating the QPA under the No Surprises Act and for the Transparency in Coverage regulations reduces burden on interested parties that must fulfill reporting requirements under both regulatory frameworks. To further clarify the definition, the Departments have added cross-reference citations to the relevant definitions of excepted benefits. Therefore, the Departments are finalizing the definition with those modifications.

\31\ 90 FR 60432, 60442 (December 23, 2025).

The Departments proposed to amend the balance billing protection statement that plans and issuers are currently required to include along with the required cost-sharing disclosures to participants, beneficiaries, and enrollees under 26 CFR 54.9815-2715A2(b)(1)(vii)(A), 29 CFR 2590.715-2715A2(b)(1)(vii)(A), and 45 CFR 147.211(b)(1)(vii)(A). The proposed amendments would require language in the balance billing protection statement that the cost-sharing information in the self- service tool does not account for potential additional amounts in situations where applicable State and Federal law allow out-of-network providers to bill participants, beneficiaries, or enrollees for the difference between a provider's billed charges and the sum of the amount collected from the plan or issuer and the amount collected from the participant, beneficiary, or enrollee in the form of a copayment, coinsurance, or deductible amount (the difference referred to as balance billing). These changes were proposed to reflect the existence of the Federal balance billing protections set forth in the No Surprises Act, which were not yet enacted when the current balance billing protection statement language was finalized in the 2020 final rules. This balance billing protection statement would not be required if the State in which the item or service was furnished prohibits all out-of-network providers from balance billing for all items and services payable by the group health plan or health insurance issuer.

The Departments sought comment on this proposal. After consideration of public comments, the Departments are finalizing the amendments to the balance billing protection statement as proposed.

Several commenters supported the proposed amendment to the balance billing protection statement language for the self-service tool. These commenters mentioned that this amendment would clarify patients' No Surprises Act protections and any remaining balance billing risk, giving patients clearer, actionable information to support informed decisions.

The Departments agree with commenters that amending the balance billing protection statement clarifies the protections patients have at both the State and Federal level and informs them of the potential for additional cost-sharing when using the self-service tool for estimates from an out-of-network provider.

A commenter opposed requiring plans and issuers to amend the balance billing protection statement. The commenter noted that statements should inform rather than overwhelm consumers, as excessive notifications can obscure cost information and reduce comprehension. A few other commenters requested flexibility in the wording plans and issuers are allowed to use and recommended the Departments allow plans and issuers to continue using existing disclaimer language, which currently communicates the core point that cost-sharing estimates may not reflect additional amounts that an out-of-network provider may bill when permitted by applicable law.

The Departments have determined that this balance billing protection statement increases comprehension by informing patients of the limits of the balance billing protections they may have under State and Federal laws, which will help mitigate unexpected health care costs when seeing an out-of-network provider. The Departments also note that the balance billing protection statement is an existing requirement and these final rules only amend the existing language to more accurately reflect consumers' rights under the No Surprises Act, which was not yet enacted when the current language in this statement was finalized in the 2020 final rules. The Departments also recognize that plans and issuers have existing balance billing protection statement language. The Departments note that paragraph (b)(1)(vii) does not require disclaimers to be reproduced verbatim. Plans and issuers may

continue to use existing disclaimer language to the extent that the language includes the required balance billing information as set forth in these final rules and is written in plain language, as defined in 26 CFR 54.9815-2715A1(a)(2)(xxi), 29 CFR 2590.715-2715A1(a)(2)(xx), and 45 CFR 147.210(a)(2)(xxi). This requirement is designed to ensure that each plan's or issuer's balance billing protection statement accurately describe the scope of the No Surprises Act balance billing protections. The Departments have determined that the balance billing protection statement as amended by these final rules sufficiently informs patients of their potential for additional costs when seeing an out-of-network provider. 2. New Required Method and Format for Disclosing Information to Participants, Beneficiaries, and Enrollees

The Departments proposed to add new 26 CFR 54.9815- 2715A2(b)(2)(iii), 29 CFR 2590.715-2715A2(b)(2)(iii), and 45 CFR 147.211(b)(2)(iii) to require plans and issuers to make available to participants, beneficiaries, and enrollees, at their request, the cost- sharing estimates and other disclosures required under 26 CFR 54.9815- 2715A2(b)(1), 29 CFR 2590.715-2715A2(b)(1), and 45 CFR 147.211(b)(1) via a telephone number. Under the proposal, the information required via a telephone number would be required to be accurate at the time of the request and provided at the time of the request. Plans and issuers would be required to use the same telephone number that Code section 9816(e), ERISA section 716(e), and PHS Act section 2799A-1(e), as added by section 107 of the No Surprises Act, require be indicated on any physical or electronic plan or insurance identification card issued to participants, beneficiaries, and enrollees for obtaining customer assistance. The Departments also proposed to redesignate paragraph (b)(2)(ii)(D) as new paragraph (b)(2)(iv) and amend paragraph (b)(2)(iv) to remove phone as an example of an alternative means for providing the disclosures by which a participant, beneficiary, or enrollee may request the disclosures required in paragraph (b)(1), because providing the disclosures by telephone is newly required under these rules.

In the proposed rules, the Departments also indicated their intention for these proposals to satisfy the No Surprises Act requirement that plans and issuers provide price comparison guidance by telephone, as set forth in Code section 9819, ERISA section 719, and PHS Act section 2799A-4. The Departments further explained that 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.

In addition, at paragraph (b)(2)(iii), the Departments proposed to allow group health plans and health insurance issuers to limit the number of providers, about which cost-sharing information for covered items and services is provided, to no fewer than 20 providers per day. The Departments also proposed to require plans and issuers that choose to apply the 20 providers-per-day limit to disclose such limitation to the participant, beneficiary, or enrollee when the request for information is made for disclosures by phone. A similar 20-provider limit was already in place with respect to paper requests at 26 CFR 54.9815-2715A2(b)(2)(ii), 29 CFR 2590.715-2715A2(b)(2)(ii), and 45 CFR 147.211(b)(2)(ii). The Departments noted in the proposed rules that nothing precludes a participant, beneficiary, or enrollee from obtaining cost-sharing information from more than one method, consistent with the requirements for each method. Similarly, for consistency with the requirements for the paper method of delivery under the 2020 final rules, the Departments proposed to require plans and issuers to satisfy requests for cost-sharing information over the phone at the time of the request, and in accordance with the method and format requirements in paragraphs (b)(2)(i)(A) through (C), to ensure that participants, beneficiaries, and enrollees receive information as quickly as possible.

The Departments clarify that the 20-provider limit applies separately to the paper and phone methods. Accordingly, a plan or issuer must disclose cost-sharing information for no fewer than 20 providers by paper per day and no fewer than 20 providers by phone per day, if both are requested. However, there may be overlap with respect to the provider information provided via either method, to the extent a participant requests cost-sharing information both on paper and by phone for any of the same providers. There is no additional requirement that a plan or issuer avoid duplicative responses in that situation.

The Departments requested comment on whether this proposal should include phone service standards to ensure that consumers have access to timely and reliable information, including, in particular, what such standards should include and what parameters should be applied to each criterion. The Departments also requested 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. After consideration of public comments, the Departments are finalizing these requirements as proposed, with minor, non-substantive edits to improve clarity.

Many commenters supported the Departments' proposal to require plans and issuers to make available to participants, beneficiaries, and enrollees, at their request, cost sharing estimates and other required disclosures by phone, noting that this approach aligns with existing obligations under the No Surprises Act, enhances transparency, and supports consumers' ability to plan for out-of-pocket costs and make more informed decisions about their health care. Several commenters emphasized that adding a phone option would help address barriers faced by consumers with limited internet access or lower digital literacy, including individuals residing in rural areas, and appreciated the Departments' efforts to provide multiple ways for individuals to obtain cost sharing information as a means of promoting equity and reducing disparities in access to health care pricing information. A commenter, while supportive of the proposal, expressed concern that this requirement could lead to higher plan costs that may ultimately be passed on to consumers in the form of increased premiums, and encouraged the Departments to explore a unified data center to handle phone requests. Another commenter expressed support for multi-modal access to price comparison tools, including digital platforms and telephonic assistance, but recommended that such access relies on a shared data architecture rather than parallel compliance builds, with a unified information backbone that feeds both digital and phone-based interfaces without duplicating reporting structures.

The Departments agree that aligning the Transparency in Coverage and the No Surprises Act requirements reduces regulatory burden for group health plans and health insurance issuers and minimizes confusion among payers and consumers regarding two overlapping statutory obligations. The Departments

also agree that the phone method of disclosing cost-sharing estimates helps address access concerns by providing an additional method for participants, beneficiaries, and enrollees, including those with lower digital literacy, limited internet access, and disparate geographic location, to obtain cost-sharing information and other required disclosures. The Departments are not pursuing a unified data center to handle phone requests in order to allow each plan or issuer to pursue its own approach to providing cost-sharing estimates over the phone. The Departments acknowledge concerns about potential increases in plan costs but have determined that the benefits of improved access to cost- sharing information justify any potential increases in costs, which the Departments expect would be marginal given that plans and issuers can rely on existing customer service processes to satisfy the requirement.

The Departments further emphasize that nothing in these final rules requires plans and issuers to build separate data systems or back-end infrastructure to support the requirements of the Transparency in Coverage disclosures to participants, beneficiaries, and enrollees across the required methods. The cost-sharing information required to be disclosed via phone is the same information required to be disclosed through the internet-based self-service tool and in paper form. Plans and issuers may use the same underlying data systems to generate cost- sharing information across all three modalities, provided the information disclosed meets the requirements of paragraph (b)(1) and (2), including that it is accurate at the time of the request.

A few commenters expressed concerns about the proposed 20-provider- per-day limit for phone disclosures. These commenters stated that verbally conveying cost-sharing estimates for up to 20 providers during a single call would be impracticable and time-intensive, and could increase the likelihood of consumer confusion, undermining the intended consumer experience. One of those commenters further noted that the higher limit could trigger unpredictable call volumes that reduce service quality for all callers. Some other commenters recommended that the Departments limit the requests to no more than 3 to 5 providers per phone call, while another commenter recommended a limit of 10 providers per business day, stating that this approach would better align with the practical constraints of phone-based interactions while still providing a meaningful ability for participants, beneficiaries, and enrollees to compare provider options.

In the 2020 final rules, the Departments established a limit of no fewer than 20 providers per request for paper-based disclosures. The Departments have determined the phone disclosure limit should be consistent with the paper limit to ensure that these primary alternatives to the internet-based self-service tool ensure consumers receive the same level of access to cost-sharing information regardless of whether they request it by paper or phone because the information is likely sourced in the same manner and only shared differently with the requestor, by paper, or read over the phone. Reducing the phone limit below the paper limit would create a disparity in access to information between these two comparable request-based methods that would disadvantage consumers who rely on the phone-based method, including those with limited digital literacy or limited internet access. The Departments acknowledge the possibility of consumer confusion from having to navigate through up to 20 providers over the phone, but plans and issuers are encouraged to work with consumers to provide cost- sharing estimates in the best way for each individual consumer, including reminding them that information is available by paper, or email, upon request. The Departments further clarify that the 20- provider-per-day limit applies on a per-operational-day basis--that is, per day on which the plans or issuers customer service call center is open and available to receive calls.

The Departments emphasize that the 20-provider limit, if adopted by a plan or issuer, will not necessarily result in cost-sharing information being provided for 20 providers on every call. It represents a maximum limit plans and issuers may impose for participants, beneficiaries, and enrollees who request information. The Departments expect that most consumers will seek relatively straightforward information, such as their out-of-pocket costs for a service from a specific provider or within a limited geographic area. The Departments agree with commenters about the possibility that some phone interactions may result in longer engagements, depending on the number of providers requested. However, the direct engagement afforded through phone interaction also provides an opportunity to ensure the consumer better understands the data and how to use it.

Several commenters opposed adopting additional phone-based service standards, stating that plans and issuers are already subject to customer service expectations, contractual requirements, and applicable State and Federal oversight. A commenter noted the difficulty of evaluating this proposal given that the Departments did not specify the standards under consideration and expressed concern that additional prescriptive requirements could increase cost and complexity without improving consumer access to pricing estimates. The commenter recommended not requiring plans to provide cost estimates on a 24-hour basis but rather allow plans and issuers to align hours of operation with existing customer service hours. Another commenter stated that the ability to fulfill requests by phone varies widely based on plan scale, technical capabilities, and the complexity of requests, and that promulgating one-size-fits-all standards would cause unintended consequences, wasteful expenditure, and administrative burden. A commenter expressed confidence that plans would take reasonable steps to provide the required information within reasonable timelines taking into consideration the facts and circumstances of plan administration and capabilities. Conversely, another commenter encouraged the Departments to finalize additional phone-based service standards and consider establishing clear performance expectations, such as tracking and reporting call wait times, to ensure that phone-based access is reliable and meets consumer needs.

The Departments agree with commenters that plans and issuers are already subject to customer service expectations, contractual requirements, and State oversight applicable to their overall consumer assistance operations. The Departments therefore decline to finalize additional standards beyond those proposed. The Departments have determined that plans and issuers are best positioned to set their own additional customer service standards, including based on standards they may already have in place for handling calls to the customer assistance number on the plan's or policy's identification card. Requiring additional standards, such as hours of operation, would likely be duplicative and unnecessarily burdensome.

A commenter requested that the Departments clearly articulate what operational change is required, noting that the proposal appears to formalize, and potentially expand, expectations for providing phone- based cost-sharing information. The commenter urged the Departments to clarify whether the proposed regulatory change codifies

existing practice or creates new obligations, stating that such clarification would allow plans and issuers to assess whether they are already in compliance with this requirement.

In the 2020 final rules, the Departments finalized phone-based cost-sharing disclosure as an optional means of providing the information required under paragraph (b)(1). Following enactment of the No Surprises Act, which requires plans and issuers to offer price comparison guidance by phone under Code section 9819, ERISA section 719, and PHS Act section 2799A-4, the Departments stated in FAQs Part 49 \32\ that they expected to propose rulemaking requiring that the same pricing information that is available through the online tool or in paper form also be provided over the telephone upon request. These final rules codify that expectation by incorporating the phone disclosure requirement into the Transparency in Coverage regulations. For plans and issuers already providing cost-sharing information by phone consistent with the No Surprises Act and the guidance set forth in FAQs Part 49, this rule provides regulatory clarity by establishing a single, consolidated set of requirements across the online, paper, and phone disclosure modalities.

\32\ U.S. Department of Labor, U.S. Department of Health & Human Services & U.S. Department of the Treasury, FAQs About Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 49 (August 20, 2021), available at 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.

A commenter highlighted potential challenges regarding the operational readiness of service providers to provide real-time, accurate cost-sharing information, including potential underestimation of call volumes. Additionally, the commenter cautioned that service providers are likely to pass compliance costs onto plans through increased administrative fees rather than absorbing these reasonable costs.

As stated in prior rulemaking, including the 2020 final rules, and reiterated in the proposed rules, the obligation to comply with the disclosure requirements under 26 CFR 54.9815-2715A2, 29 CFR 2590.715- 2715A2, and 45 CFR 147.211 rests with the group health plan or health insurance issuer offering coverage, even when the plan or issuer contracts with a service provider to perform certain functions on its behalf. The Departments recognize that service providers operating on behalf of plans and issuers may incur costs associated with implementing these requirements and may recover those costs through administrative fees. As discussed in section IV.A. of this preamble, the Departments assume that self-insured group health plans will rely on service providers to implement these requirements and, accordingly, estimate the costs of these changes as costs to plans' service providers. In addition, the Departments expect any resulting increases in administrative fees to be limited because the final requirements largely build on existing infrastructure, systems, and processes, including internet-based self-service tools that many plans, issuers, and service providers have already developed.

A few commenters raised issues outside the scope of the phone-based disclosure provision. A commenter noted that the accuracy of consumer- facing tools ultimately depends on the quality of the underlying machine-readable file data. Another commenter recommended that these final rules establish dispute protections for insured individuals who rely on phone-based cost-sharing estimates, similar to the good faith estimate protections available to uninsured individuals under the No Surprises Act. An additional commenter recommended that the Departments acknowledge in this preamble that price transparency is a necessary but insufficient condition for cost discipline and that the competitive benefit of transparency data depends on incentive alignment among intermediaries.

The Departments appreciate these comments but note that they are outside the scope of the phone disclosure provision finalized in this rule. 3. Compliance With Code Section 9819, ERISA Section 719, and PHS Act Section 2799A-4

The Departments proposed 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 group health plan or health insurance 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 Departments also proposed that grandfathered health plans and issuers offering grandfathered individual and group 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 sought comment on all aspects of this proposal. After consideration of public comments, the Departments are finalizing these provisions as proposed.

A few commenters strongly supported the Departments' proposal to treat compliance with the Transparency in Coverage cost-sharing disclosure requirements as satisfying the No Surprises Act price comparison tool obligations under Code section 9819, ERISA section 719, and PHS Act section 2799A-4. These commenters stated that requiring plans and issuers to build two separate self-service tools would impose significant unnecessary operational burdens and duplicate infrastructure costs. A commenter noted that a single, unified self- service tool would be an administrative simplification that would allow health plans and issuers to direct implementation resources toward improving the availability and accuracy of cost-sharing estimates made available through their existing self-service tools. Other commenters emphasized that a single tool would prevent considerable consumer confusion and support a more consistent consumer experience across channels. Another commenter supported the proposed alignment of the Federal statutory requirements and noted appreciation that State law variations need not be addressed within this provision.

The Departments agree that maintaining two functionally equivalent but separately administered self-service tools would impose significant burdens on plans and issuers without a corresponding benefit to consumers. The Departments also agree that subjecting plans and issuers to overlapping regulatory obligations to build separate tools offering substantially similar information would be administratively inefficient and contrary to the consumer-oriented goals of these statutes.

The Departments note that the policy finalized in this provision is limited to the alignment of Federal requirements, and specifically, that plans and issuers providing the information in accordance with the Transparency in Coverage cost-sharing disclosure requirement regulations satisfies the Federal price comparison tool mandates set forth in Code section 9819, ERISA section 719, and PHS Act section 2799A-4, including for grandfathered group health plans and health insurance issuers offering grandfathered group and individual health insurance coverage

that are not otherwise subject to such requirements. The Departments clarify that satisfying the overlapping Federal statutory requirements does not alter, address, or preempt applicable State laws. Pursuant to section 2724(a) of the PHS Act, and consistent with the framework established in the 2020 final rules, State laws regulating health insurance issuers are not preempted except to the extent they prevent the application of Federal requirements. Therefore, health insurance issuers must continue to independently comply with any applicable State laws.

A commenter recommended that the Departments expand the tool requirements to mandate the disclosure of policies regarding the treatment of cost-sharing assistance. Specifically, the commenter requested that the Departments require group health plans and health insurance issuers to disclose the use of accumulator adjustment programs (AAPs), copay maximizers, and alternative funding programs (AFPs). The commenter also stated that providing this information would help patients and employers avoid benefit designs that may negatively impact patient access, adherence, and outcomes.

The Departments have determined that adding new, substantive disclosure elements to the Transparency in Coverage and No Surprises Act requirements, such as specific flags for AAPs, copay maximizers, or AFPs, is outside the scope of this rulemaking. The purpose of this provision is to align the existing operational requirements of the Transparency in Coverage and No Surprises Act tools, not to introduce new data elements. The Departments note that, under existing Transparency in Coverage regulations, plans and issuers are already required to provide a notice in plain language with the internet-based self-service tool disclosures that includes a statement “disclosing whether the plan counts copayment assistance and other third-party payments in the calculation of the participant's, beneficiary's, or enrollee's deductible and out-of-pocket maximum.” \33\

\33\ 26 CFR 54.9815-2715A2(b)(1)(vii)(D), 29 CFR 2590.715- 2715A2(b)(1)(vii)(D), and 45 CFR 147.211(b)(1)(vii)(D).

The Departments proposed 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 paragraphs (b)(1)(i)(A), (b)(1)(i)(B), (b)(1)(vii)(A), (b)(2)(ii), (b)(3)(i), and (b)(3)(ii) and new paragraphs (b)(2)(iii) and (iv), and (c)(7) of these sections 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 these sections would continue to apply.

The Departments sought comment on this proposed applicability date. After consideration of comments, the Departments are finalizing the proposed applicability date but modifying the proposed language at 26 CFR 54.9815-2715A2(c)(1), 29 CFR 2590.715-2715A2(c)(1), and 45 CFR 147.211(c)(1) to convey that all provisions of these sections apply for plan years (in the individual market, for policy years) beginning on or after January 1, 2027, and until such date, plans and issuers must comply with 26 CFR 54.9815-2715A3 revised as of April 1, 2025, 29 CFR 2590.715-2715A3 revised as of July 1, 2025, and 45 CFR 147.211, revised as of October 1, 2025.

A few commenters commented on this proposal. A commenter supported the proposed applicability date as providing adequate implementation time, while a few other commenters recommended the Departments extend the applicability date, which commenters variously recommended delaying an additional 6 months or 12 months, to allow sufficient time to implement the operations, systems, vendor, and training changes necessary to comply with the new requirements. A few additional commenters stated that a fixed applicability date of plan or policy years beginning on or after January 1, 2027--depending on when the final rule is published in 2026--could result in insufficient time for group health plans and health insurance issuers to update their workflows to implement these provisions.

The Departments considered the proposed applicability date in light of the timing of the publication of these final rules. The Departments have determined that because the balance billing protection statement changes required under this section add to a preexisting disclosure requirement in accordance with current paragraph (b)(1)(vii)(A) \34\ they require minimal additional time and effort. Furthermore, because group health plans and health insurance issuers already have customer service phone infrastructure in place, the Departments have determined the applicability date in these final rules allows sufficient time for implementation.

\34\ U.S. Department of Labor, U.S. Department of Health & Human Services & U.S. Department of the Treasury, FAQs About Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 49 (August 20, 2021), available at 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.

With regard to the requirement that plans and issuers make available via phone the cost-sharing estimates and other disclosures required under paragraph (b)(1) of this section, the Departments acknowledge that plans and issuers will need to make operational changes and train customer service representatives to comply with these requirements. However, as the Departments stated in the preamble to the proposed rules, plans and issuers have been anticipating that this method of disclosure would be required since 2021, when the Departments announced their intention to propose rules requiring that the same pricing information that is available through the Transparency in Coverage internet-based self-service tool or in paper form, as described in 26 CFR 54.9815-2715A2(b)(2), 29 CFR 2590.715-2715A2(b)(2), and 45 CFR 147.211(b)(2), must also be provided over the phone upon request, pursuant to Code section 9819, ERISA section 719, and PHS Act section 2799A-4, as added by section 114 of the No Surprises Act.\35\ Therefore, the Departments expect many plans and issuers have already made progress toward meeting this requirement since then.

\35\ See 90 FR 60432, 60446 (December 23, 2025); see also U.S. Department of Labor, U.S. Department of Health & Human Services & U.S. Department of the Treasury, FAQs about Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 49 (August 20, 2021), available at 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.

Additionally, as the Departments noted in the preamble to the proposed rules, group health plans and health insurance issuers are already required to include a telephone number through which participants, beneficiaries, and enrollees may seek consumer assistance information on physical or electronic plan or insurance identification cards under 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.\36\ Because new paragraph (b)(2)(iii) requires plans and issuers to leverage that existing telephone number to provide the required cost-sharing estimates and other disclosures, the Departments expect that much of the operations and systems, as well as vendors associated with the existing telephone number can

be leveraged for this purpose as well. For these reasons, the Departments are finalizing the applicability date as proposed to ensure consumers can timely access price comparison information over the phone.

\36\ See 90 FR 60432, 60447 (December 23, 2025).

Therefore, after consideration of these comments, the Departments have determined that the proposed applicability date for the amendments to paragraphs (b)(1)(i)(A), (b)(1)(i)(B), (b)(1)(vii)(A), (b)(2)(ii), (b)(3)(i), and (b)(3)(ii) and new paragraphs (b)(2)(iii), (b)(2)(iv), and (c)(7), is appropriate and reasonable.

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

The In-network Rate File provision in the 2020 final rules 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 an internet 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 proposed 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 instead of for each coverage option offered by a group health plan or health insurance issuer. This proposed change was 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 Price Transparency rules \37\ under 45 CFR part 180.

\37\ 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, 84 FR 65524 (November 27, 2019); Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Price Transparency of Hospital Standard Charges; Radiation Oncology Model, 86 FR 63458 (November 16, 2021); Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Payment for Intensive Outpatient Services in Hospital Outpatient Departments, Community Mental Health Centers, Rural Health Clinics, Federally Qualified Health Centers, and Opioid Treatment Programs; Hospital Price Transparency; Changes to Community Mental Health Centers Conditions of Participation, Changes to the Inpatient Prospective Payment System Medicare Code Editor; Rural Emergency Hospital Conditions of Participation Technical Correction, 88 FR 81540 (November 22, 2023); Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Overall Hospital Quality Star Rating; Hospital Price Transparency; and Notice of Closure of a Teaching Hospital and Opportunity To Apply for Available Slots, 90 FR 53448 (November 25, 2025).

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 proposed 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 report the common provider network name for which negotiated rate information is included. To allow file users to cross-reference a particular plan or policy of interest to its in-network rates, the Departments proposed to amend redesignated paragraph (b)(1)(i)(B) to require plans and issuers to identify, for each provider network for which the group health plan or health insurance issuer must publish an In-network Rate File, each of the plan's or issuer's coverage options that use that network. The Departments also proposed 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. Finally, the Departments proposed 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.

The Departments solicited comment on all aspects of these proposed requirements. After consideration of public comments, the Departments are finalizing these provisions largely as proposed, except that the Departments are adding in new paragraph (b)(1)(i)(B) a requirement that group health plans and health insurance issuers report a provider network identifier, which further redesignates proposed paragraphs (b)(1)(i)(B) through (D) as paragraphs (b)(1)(i)(C) through (E), respectively.

Many commenters supported the proposal to require one In-network Rate File per provider network (instead of per plan or policy) because commenters believe network-level organization would eliminate duplicative rates repeated across many health plans, substantially reduce file size and file counts, make data easier to download and process, better reflect how negotiated rates are operationally managed, better align payer disclosures with Hospital Price Transparency files, improve usability for employers and purchasers, and help clinicians understand network structures and track rate changes over time.

The Departments agree that organizing the In-network Rate File by provider network instead of individual plan or policy will result in the benefits commenters identified. As stated in the proposed rules, the size of the In-network Rate File can be highly dependent on how it is organized. Where multiple plans share the same negotiated rates under an umbrella provider network, organizing the In-network Rate Files by provider network rather than by each individual plan or policy in most cases decreases the size of the files, often significantly, while still maintaining data integrity. It likely also reduces the total number of In-network Rate Files because research indicates that there are far more plans and policies offered than there are distinct, separately managed provider networks.\38\ Together, these anticipated reductions are expected to ease the processing burden on both file producers and file users and increase the usability for employers and purchasers. The Departments also agree with the commenters' assertion that network-level organization better reflects how negotiated rates are operationally managed, better aligns with hospital machine-readable files' data, and could help the public understand network structures and track rate changes over time.

\38\ See Jane M. Zhu, Yuehan Zhang, & Daniel Polsky, Networks in ACA Marketplaces Are Narrower for Mental Health Care Than for Primary Care, 36 Health Affairs 9 (September 5, 2017), available at https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0325 (finding, based on 2016 HealthCare.gov data, 531unique provider networks were used by 281 different issuers, covering 5,022 qualified health plans in the Federally-facilitated Marketplaces). The proposed rules included citations with incorrect authors' names. Those citations have been corrected in these final rules.

In the proposed rules, the Departments sought comment on whether additional limitations on what constitutes a separate provider network should be required. Many commenters recommended the Departments adopt a

clear, prescriptive definition of “provider network” (including what constitutes a distinct network) because they were concerned that inconsistent payer interpretations would undermine comparability, complicate enforcement, and limit the usability of network-level reporting. A few commenters provided examples of the variability in issuer network definitions and contracting practices to illustrate the potential impacts of inconsistent network definitions (for example, issuers may define networks at the product level, geographically, or by line of business). Other commenters expressed concern that, without guardrails and clear definitions, network-level reporting could become overly fragmented or otherwise inconsistent. These commenters suggested that over-segmentation could mean a proliferation of small network files (potentially increasing overall file volume), under-segmentation could mean the inclusion of rates that do not apply to many enrollees, and inconsistent naming could prevent reliable cross-payer comparison. A few commenters also recommended that the Departments require plans and issuers to clearly indicate whether a file represents a base network or a derived network, while another commenter recommended that the Departments require a standardized network hierarchy or precedence field and/or logic to be reported to resolve overlapping networks.

The Departments did not define “provider network” in the proposed rules but instead instructed plans and issuers to define what constitutes a separate provider network according to their current business practices.\39\ This is because, while the Departments acknowledge the possibility of variability among provider network definitions and a potential reduction in comparability among files, these provisions are intended to facilitate analysis of the reported data based on the provider network structures as designed by plans and issuers, rather than require a one-size-fits-all approach.

\39\ 90 FR 60432, 60448 (December 23, 2025).

However, the Departments also acknowledge the possibility of over- and under-segmentation where plans and issuers rely solely on their current business practices without further guidance. Thus, in response to commenters seeking more clarity on what constitutes a provider network, under these final rules, the Departments clarify that each network should represent a single collection of contracted providers and corresponding in-network rates within a defined structure and represent the providers and rates for any member who accesses services while in-network. If variations among either participating providers or in-network rates exist, those variations constitute a separate network (for example, a derived network, which is a separate provider network that is leased from another issuer) and should therefore be reflected in a separate In-network Rate File. Lastly, the Departments recognize that networks can be layered, necessitating that base and derived networks be identified appropriately, and that other network hierarchies can exist as well. The Departments will specify an approach for reporting these network variations through future technical implementation guidance.

Regarding the proposal to require plans and issuers to include the common provider network name as part of their In-network Rate Files, the Departments sought 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. Several commenters supported the requirement to include the common provider network name but expressed concern that relying primarily on provider network names may create ambiguity because payers may use different names (for example, one internal and one external) for the same network or similar names for different networks. A few commenters agreed that the network naming conventions should align with the external, consumer-facing marketing name of the network rather than an internal or publicly unknown name. A commenter recommended that the Departments publish guidance on network naming conventions to reduce ambiguity and facilitate cross-payer analysis. Several commenters recommended that the Departments require a standardized network identifier (or require a supplemental network identifier in addition to the common provider network name), because an identifier would support accurate aggregation and comparison, prevent users from treating distinct networks as interchangeable, and improve the ability to link negotiated rates to plan design information and other datasets.

The Departments agree that the common provider network name should be an external name most familiar to participants, beneficiaries, enrollees, and the public, as currently described in technical implementation guidance.\40\ As noted in the proposed rules, the purpose of this requirement is to help file users identify specific provider networks, and provider network names used solely within a plan or issuer's internal operations are unlikely to be meaningful or recognizable to file users.\41\ The Departments acknowledge commenters' concerns that relying on provider network names alone would create ambiguity because plans and issuers may use different names for the same network or similar names for different networks. However, the Departments are not inclined to direct how plans and issuers must name their networks, and support allowing plans and issuers freedom to maintain existing provider network names and to create new ones within their own existing frameworks. Requiring changes to provider network naming could cause downstream confusion for group health plan sponsors and consumers.

\40\ GitHub Users, GitHub Discussion: In-Network File #897, GitHub, available at https://github.com/CMSgov/price-transparency-guide/blob/master/schemas/in-network-rates/README.md#provider-reference-object (last updated January 8, 2026).

\41\ 90 FR 60432, 60448 (December 23, 2025).

The Departments agree that a second network identifier, in addition to the common provider network name, could help relieve ambiguity by allowing file users to identify distinct networks that use the same or similar names, thus supporting accurate aggregation of in-network rates across multiple plans or policies that use the same network, and linking to other datasets. To that end, the Departments are finalizing at new paragraph (b)(1)(i)(B) the requirement that plans and issuers disclose a provider network identifier, in addition to the common provider network name. The Departments expect plans and issuers to use the existing network identifier used for internal tracking, which the Departments expect would be minimally burdensome to disclose. Instructions on how a plan or issuer may report the network identifier if no network identifier already exists will be provided through future technical implementation guidance.

A few commenters recommended that CMS convene a working group to standardize a network-identification process for networks and associated plans, similar to how Vehicle Identification Numbers for cars are created and managed. Under this recommendation, commenters explained, CMS would create a standard for network identification and assign, register, and manage these identifiers. Creating, standardizing, and managing a network identifier process is beyond the scope of these final rules; however, the Departments acknowledge that there

may be a benefit to having a standardized network identification process and may take it into further consideration.

Many commenters recommended a clear mapping of plans to provider networks, expressing concern that information could be lost in the transition from plan-level reporting to network-level reporting. Several of these commenters recommended requiring the Table of Contents File to identify the provider networks associated with a given plan. A few commenters suggested plans could be identified using the Employer Identification Number (EIN) and a few other commenters noted Health Insurance Oversight System (HIOS) identifiers (IDs) and group numbers could also identify correct plans and networks. Lastly, a few commenters suggested the Departments provide links to provider directories along with other required plan data.

The Departments agree that retaining plan-level data is essential to the usability of the In-network Rate File. The Table of Contents File is expected in the current technical implementation guidance (also referred to as Schema 2.0) if more than one plan or policy offered by an issuer or plan sponsor shares the same in-network rates. The Departments decline to require the Table of Contents File in regulation in order to maintain the Departments' flexibility to collaborate with industry on technical specifications for most efficiently reporting the required data under the In-network Rate file. For this new organization of the In-network Rate File by provider network as finalized in these rules, the Departments expect--and plan to clarify in future technical implementation guidance--that the In-network Rate File only includes data about contracted providers and their rates. All of the data for plans or policies that use that network (including HIOS, EINs, and group numbers, as appropriate) will be captured in the Table of Contents File, which serves as an external reference to the In-network Rate File. This approach allows seamless mapping of plans and policies to provider networks, while preventing inflated file sizes for the In- network Rate File. Lastly, while the Departments recognize the potential value in providing a link to provider directories because they can help consumers understand provider availability and access, the purpose of the In-network Rate File is to disclose contracted rates for providers by network, not to connect to consumer-facing provider directory information.

A commenter recommended that the In-network Rate Files explicitly exclude “rental networks” used solely to supplement a plan's primary network, stating that it would exponentially increase file size while providing information relevant to only a small fraction of utilization. The commenter requested the Departments clarify if plans may limit In- network Rate File disclosures to their primary contracted networks and if they are not required to include secondary rental network arrangements. Another commenter recommended the Departments specify which payer holds the contracts with providers for each network agreement represented by the In-network Rate Files, to help researchers understand each payer's relative market influence. Another commenter recommended the Departments clarify that network-level In-network Rate Files may be partitioned into multiple files or segments, suggesting that plans and issuers may face storage and bandwidth constraints when hosting files that represent large or national networks.

The Departments reiterate that an In-network Rate File must be published for each provider network maintained or contracted by the group health plan or health insurance issuer. Whether that network is rented or owned does not change the plan's or issuer's responsibility to publish rates for that provider network as the network is attached to the product(s) marketed by the plan or issuer and for which there is enrollment. This allows files to be developed independently across multiple provider networks--whether rented or owned--without expanding or increasing In-network Rate File size exponentially. The Departments also acknowledge the potential value to file users of disclosing when networks are owned versus rented but are not finalizing a requirement to include that data element at this time in order to maintain flexibility to engage with industry through GitHub on this issue. However, the Departments may consider adding an optional contextual “rented vs. owned” data element to identify network ownership in future technical implementation guidance. Further, both the 2020 final rules and these final rules, as well as Schema 2.0, allow plans and issuers to segment large files when necessary. The Departments recognize that this flexibility is particularly valuable for plans and issuers with large or national networks and intend to maintain it in future iterations of the schema.

Some commenters opposed the proposal to require an In-network Rate File for each provider network maintained or contracted by the group health plan or health insurance issuer. A commenter expressed concern that the proposal could require plans to create more machine-readable files as any change for a given plan, in either the in-network providers or their rates, would be seen as a new network and would require a new In-network Rate File. Another commenter stated that network-level files would reduce the precision of the data where the common provider network name is not granular enough to denote rate variation across employer-sponsored plans, narrow and tiered networks, point-solution carve-outs, and regional plan variants. Another commenter requested that the Departments permit voluntary reporting at the network level and allow plans and issuers to continue reporting In- network Rate Files at the plan level. Lastly, a commenter stated the network should be defined at the rate level as opposed to the provider level to better align with the hospital machine-readable files.

The Departments acknowledge that the proposal could cause plans to create more machine-readable files if they over-segment their provider networks; however, the Departments' clarification earlier in this section of this preamble that a provider network should reflect a single collection of contracted providers and corresponding in-network rates should guide appropriate segmentation. Similarly, this clarification should guide the approach to rate variations and--along with the required provider network identifier--should lessen the risk of reduced data precision due to relying on the common provider network name alone. In addition, organizing the In-network Rate File by provider network is a primary focus of these final rules, and all plans and issuers will be required to reorganize their In-network Rate Files in this manner to ensure consistency and comparability across the files, improve the usefulness of the data, and reduce file size. Lastly, the Hospital Price Transparency machine-readable files required under 45 CFR part 180 identify the standard charge rates a hospital has established with each payer. Aligning with the Hospital Price Transparency requirements would standardize price disclosures, allowing researchers and other file users to more accurately cross-reference and compare information. For these reasons, the Departments have determined this to be the preferred approach for reorganizing the In-network Rate File.

A few commenters made additional recommendations to the Departments regarding the In-network Rate File. A

commenter recommended that the Departments require plans and issuers to report data by provider type, stating that provider type data comparisons--such as assessing mental health and substance use care access and analyzing insurers' parity compliance--are necessary for understanding rates, but these comparisons are not possible without making provider types available. Another commenter expressed concern that many duplicate rates exist for the same service in the In-network Rate Files and recommended the Departments provide adequate differentiation of these rates. Several commenters also recommended contextual data elements to be added to the In-network Rate File that they believed would increase the precision of reported rates such as modifiers, multipliers, conditional clauses, outlier payment methodologies, outlier thresholds, carve-outs, bundled payment logic, capitation and global payment models, uniform service classifications, standard billing code types, and details on pricing and reimbursement methodologies especially for alternative reimbursement arrangements not supported by the schema. A few commenters asserted that inpatient outlier costs account for $100 billion in annual health care spending.

The Departments appreciate these commenters' recommendations and recognize that some of these contextual data elements could provide additional nuance to the rates, while others could address gaps in specificity. These suggested elements are implementation details best addressed in technical implementation guidance given they are highly fact specific. Current technical implementation guidance already addresses modifiers, multipliers, bundled arrangements, capitation and global payment models, uniform service classifications, standard billing code types, and details on pricing and reimbursement methodologies. Further technical guidance will be provided to instruct plans and issuers to provide individual rate details on items that could otherwise be obscured or inappropriately summarized within the In-network Rate Files, such as for certain multipliers and uniform service classifications. Conditional clauses are not currently captured within the structure of the machine-readable file schemas because they generally apply at the contract level rather than to a specific item or service. While the current technical implementation guidance does not address a standardized method for disclosure of outliers, wherein rates may change at high dollar thresholds, the Departments intend to provide additional guidance for Schema 3.0 to accommodate these arrangements, including stop-loss provisions, which are contractual terms designed to protect against excessively high billed charges. Disclosure of these provisions can provide greater transparency into how negotiated rates may be adjusted or applied in atypical or unusually high-cost scenarios.

The Departments also recognize the complexity of reporting carve- outs and are considering whether additional technical implementation guidance would improve consistency in reporting these arrangements. The Departments recognize that grouping provider types (for example, physician, nurse practitioner, etc.) together can make rates ambiguous. The Departments intend to address the means of referencing these provider types to their appropriate rates within the In-network Rate File through future technical implementation guidance in collaboration with industry to determine the most efficient approach. The Departments encourage interested parties to continue to engage the Departments on additional technical modifications to the In-network Rate File reporting on GitHub. Subsequent technical improvements will be addressed in future technical implementation guidance.

Lastly, as a clarification regarding plans without defined networks, as stated in the preamble to the 2020 rules, the Departments expect there will be no In-network Rate File for these types of arrangements because the plan or issuer does not have in-network providers as defined in these final rules.\42\ Plans without defined networks will still be required to publish Allowed Amount Files.

\42\ 85 FR 72158, 72228 (November 12, 2020).

In the proposed rules, the Departments proposed 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 proposed to remove the requirement for plans and issuers to report the 14-digit HIOS ID or, if the 14-digit HIOS ID is not available, the 5-digit HIOS ID, and instead require them to report the HIOS ID 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 did not propose to change the requirement that if no HIOS ID is available, plans and issuers must report the EIN. The Departments also proposed 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 Departments solicited comment on these proposed requirements. After consideration of comments, the Departments are finalizing these requirements largely as proposed, with the technical modification discussed in section III.C.1. of this preamble to redesignate proposed paragraph (b)(1)(i)(B) as paragraph (b)(1)(i)(C).The Departments are also adding a clarification that HMO and PPO are examples of product types and not an exhaustive list. Many commenters who submitted feedback on this proposal generally supported removing the 14-digit HIOS ID specificity from these final rules. A commenter interpreted the Departments' proposal to remove HIOS digit specificity as a proposal to remove the HIOS ID requirement altogether, stating that the 14-level HIOS ID is invaluable. Another commenter expressed concern that without the 14-digit HIOS ID, it would be hard to identify prices for individual health plans. The commenter recommended that plans and issuers include a crosswalk between networks and HIOS IDs in their Table of Contents Files, and when multiple rates exist within a network for the same service delivered by the same provider, the different HIOS IDs corresponding to each unique rate should be clearly identified. Yet another commenter requested that the Departments require plans and issuers to disclose the EIN of each company that purchases group health insurance coverage on the Small Business Health Options Program Marketplace, along with the HIOS Plan ID of coverage.

Under these final rules, plans and issuers are still required to report the HIOS ID, if they have a HIOS ID, to identify the plan or coverage. The Departments clarify that the addition of the common provider network name field, as discussed in section III.C.1. of this preamble, is a complement to the network-level reporting requirement for the In-network Rate Files and does not replace the HIOS ID as the primary identifier for group or individual health insurance coverage. The Departments

have determined that the 14-digit HIOS ID--the most granular identifier--is not always necessary to identify a coverage option. The Departments currently specify the number of HIOS digits in technical implementation guidance and plan to continue doing so at a level of granularity that best supports accurate plan identification while reducing duplicative data, which is a determination the Departments make in collaboration with the GitHub community. As explained in the proposed rules, the Departments have determined that this approach, rather than specifying the number of digits in regulation, better maintains the Departments' flexibility to determine appropriate technical reporting requirements and to make refinements in response to changes in technology or health care industry business practice.\43\ The Departments anticipate limited risk that health plans will be unable to be identified, given that all plan data is currently captured in the Table of Contents File, which allows plans and issuers to combine common negotiated rates across multiple In-network Rate Files rather than publishing negotiated rates individually for each plan ID.

\43\ 90 FR 60432, 60449 (December 23, 2025).

The Departments also acknowledge the value of capturing the EINs of small employers that purchase group health insurance coverage through the Small Business Health Options Program as the EIN would serve as the identifier when a HIOS ID may not be available but are not finalizing such a requirement at this time. The Departments are mindful that including additional requirements at this time could jeopardize plans' and issuers' ability to meet the implementation timelines being finalized in this rule and have determined it is appropriate to first assess the impact of the provisions being finalized before including additional data elements that could increase plan and issuer burden. The Departments will explore possible ways to implement this in the future.

With regard to the proposed requirement that plans and issuers include the product type of each plan or policy represented in an In- network Rate File, the Departments sought comment on whether possible inconsistency between State definitions of certain product types would present difficulties for plans and issuers in determining which product type to indicate or cause confusion among file users. The Departments also sought comment on whether self-insured plans generally identify benefit package options by product type, whether there is any existing nomenclature that self-insured plans could use to accurately identify the type of benefit arrangement being offered, and whether it is practical to extend this requirement to self-insured plans.

All commenters who provided feedback on the product type proposal supported it. A few commenters recommended that product type be included at the network level, not the plan or coverage option level, to minimize the likelihoods of duplicative data and increased file size. A few other commenters recommended that the Departments develop consistent definitions of different product types to ensure consistency in reporting. A commenter noted that terms like HMO or PPO can mean different things depending on context--in some cases, referring strictly to cost-sharing and referral mechanics at the plan level and, in others, reflecting a distinct network construct. The commenter recommended that the Departments clarify this distinction and provide a structured approach to ensure that product type is consistently represented as either a plan attribute, a network attribute, or both, where appropriate. Additionally, the commenter recommended that, with respect to self-funded employer plans, the Departments should encourage alignment with commonly accepted State-level product definitions to the extent feasible. The commenter shared that in the ERISA context, where self-insured plans are not formally required to be identified by product type, adopting a standardized nomenclature would improve consistency, reduce file user confusion, and enhance parity across fully-insured and self-funded arrangements.

The Departments acknowledge that group health plans and health insurance issuers may use product type inconsistently, as terms such as HMO or PPO can vary in meaning depending on context. Although HHS regulations at 45 CFR 144.103 (providing a definition for “product”) and 45 CFR 147.106(e)(3)(ii) (providing exceptions to guaranteed renewability requirements for uniform modifications of coverage) reference “product network types,” such as HMO, PPO, exclusive provider organization (EPO), point of service (POS), or indemnity, the Departments consider product type for purposes of these final rules to be a coverage option designation rather than a network-level designation. While the Departments do not define product type in these final rules, the Departments clarify here that terms such as HMO and PPO are examples of product types and are meant to be illustrative and non-exhaustive, given that plans and issuers may use other terms consistent with their own business practices and as required by applicable State law. These terms serve as meaningful indicators of benefit design structure at the plan or policy level, even where the precise meaning of these terms may vary depending on context. The Departments also understand that the vast majority of self-insured ERISA plans, which are not subject to State law definitions, use common labels such as HMO and PPO to describe their benefit offerings, as these terms are widely recognized and readily understood by employees. To that end, the Departments intend to develop future technical implementation guidance that will allow plans and issuers to select from a list of common product types and determine an alternative for reporting if there is no common product type to accurately describe the benefit offering.

After considering the public comments received, the Departments are finalizing the amendment to redesignated 26 CFR 54.9815- 2715A3(b)(1)(i)(C), 29 CFR 2590.715-2715A3(b)(1)(i)(C), and 45 CFR 147.212(b)(1)(i)(C), and 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) with the minor technical and clarifying amendments described above. 3. Percentage-of-Billed-Charges Arrangements

The Departments proposed 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 require that in-network rates must be reflected as dollar amounts except 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. In such circumstances, plans and issuers would be required to report a percentage number, in lieu of a dollar amount, in the form and manner as specified in guidance issued by the Departments. The Departments solicited comment on this proposed requirement. After consideration of comments, the Departments are finalizing this requirement as proposed; however, other amendments to this section further redesignate this paragraph as paragraph (b)(1)(i)(E)(1).

In the proposed rules, the Departments explained that, although

the 2020 final rules \44\ generally require rates to be reported as dollar amounts regardless of payment model, interested parties identified ongoing challenges with certain alternative reimbursement arrangements, most notably with “percentage-of-billed-charges” contracts, under which a dollar amount cannot be determined prospectively because payment is defined as a fixed percentage of charges that are not known until after a claim is generated. In FAQs Part 53, the Departments established an enforcement safe harbor permitting percentage-based reporting for such alternative payment arrangements when dollar amounts could not be derived with accuracy.\45\ In FAQs Part 61, the Departments rescinded the statement of enforcement discretion provided in FAQs Part 53 and clarified that the ability to report dollar amounts is a fact-specific determination and that enforcement discretion would be exercised on a case-by-case basis, without a categorical safe harbor, while also directing plans and issuers to continue following existing technical implementation guidance.\46\ In response to continued feedback and the need for greater clarity and consistency in reporting, the Departments proposed to amend the In-network Rate File requirements to permit plans and issuers to report a percentage of billed charges in limited circumstances in the form and manner specified in guidance, while continuing to require dollar-based reporting wherever a dollar amount can be determined prospectively.

\44\ 85 FR 72158, 72226 (November 12, 2020).

\45\ 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), available at 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.

\46\ 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 61 (September 27, 2023), available at https://www.cms.gov/files/document/faqs-about-affordable-care-act-implementation-part-61.pdf and https://www.dol.gov/agencies/ebsa/about-ebsa/ouractivities/resource-center/faqs/aca-part-61; Centers for Medicare & Medicaid Services, Transparency in Coverage, GitHub, https://github.com/CMSgov/price-transparency-guide/blob/master/schemas/in-network-rates/README.md#additional-notes-1 (last updated January 8, 2026).

Many commenters supported the proposal to require that in-network rates be reflected as dollar amounts except for contractual arrangements under which the 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. These commenters stated that the proposed exception would preserve contractual accuracy while providing a pragmatic solution that removes ambiguity and prevents the disclosure of misleading dollar figures. Additionally, commenters highlighted that this proposal aligns with current guidance that recognizes situations where a precise dollar amount cannot be determined in advance.

The Departments agree with commenters that requiring in-network rates to be reflected as dollar amounts except for certain specific arrangements can remove ambiguity, preserve contractual accuracy, and prevent the disclosure of misleading dollar figures. The goal of these transparency disclosures is to reveal how group health plans' and health insurance issuers' contractual arrangements are currently structured, rather than trying to standardize a one-size-fits-all approach.

Several commenters offered alternatives to reporting only a percentage under these arrangements, stating that the proposed exception would provide limited value and would be inconsistently implemented without additional context. A few commenters recommended requiring plans and issuers to pair any reported percentage with dollar-based context derived from historical experience, such as historical price averages, average and median paid amounts over a 12- month lookback period or percentile-based allowed amounts, and estimated dollar amounts as required in the Hospital Price Transparency rules,\47\ to make the information usable and comparable. A commenter recommended that plans and issuers be required to provide the average billed amount for a particular provider group along with the percentage number. Another commenter recommended that the Departments allow reporting of percentages when historical claims data for a service does not meet the minimum volume threshold necessary to support a reliable dollar estimate, rather than publishing an estimated dollar amount that may not reflect an accurate payment experience and could confuse users and potentially erode data integrity.

\47\ 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, 84 FR 65524 (November 27, 2019); Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Price Transparency of Hospital Standard Charges; Radiation Oncology Model, 86 FR 63458 (November 16, 2021); Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Payment for Intensive Outpatient Services in Hospital Outpatient Departments, Community Mental Health Centers, Rural Health Clinics, Federally Qualified Health Centers, and Opioid Treatment Programs; Hospital Price Transparency; Changes to Community Mental Health Centers Conditions of Participation, Changes to the Inpatient Prospective Payment System Medicare Code Editor; Rural Emergency Hospital Conditions of Participation Technical Correction, 88 FR 81540 (November 22, 2023); Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Overall Hospital Quality Star Rating; Hospital Price Transparency; and Notice of Closure of a Teaching Hospital and Opportunity To Apply for Available Slots, 90 FR 53448 (November 25, 2025).

The Departments acknowledge the limitations of reporting an in- network rate only as a percentage and appreciate the suggestions to add additional claims-based data elements to provide context and clarity for percentage-of-billed-charges reporting. The Departments also acknowledge the commenter's suggestion to allow plans and issuers to disclose percentage-based rates when historical claims data for a service does not meet a minimum volume threshold. However, the Departments have determined that calculating a dollar-based value derived from historical claims, such as averages, estimates, or medians, would add considerable complexity to the In-network Rate File. The In-network Rate File is intended to contain prospective data for a specific time period to accurately reflect what payer-provider contractual arrangements look like. If the Departments were to require plans and issuers to include retrospective claims data from other systems into the In-network Rate File, it would add considerable burden to create the file. In addition, the information could reduce the usability of the file, as it would result in the file including both prospective data and historical billed charges that may not reflect future billed charges. This could create confusion about which data in the In-network Rate File reflects current contractual arrangements, as historical claims data is meant to be reflected in the Allowed Amount File only. Additionally, in contrast with the Hospital Price Transparency reporting approach where there is a singular provider (the hospital), calculating averages or medians across a large volume of providers with different billed charges is unlikely to provide meaningful or actionable information for file users.

A few commenters did not support the proposal, asserting that allowing an exception to reporting a dollar amount would result in disclosures that are confusing and not actionable. These commenters indicated that percentages

are difficult to interpret without the underlying billed charge, which is often unavailable, and therefore this type of disclosure would limit meaningful comparisons across plans and providers. A commenter expressed that posting negotiated rates as a percentage of billed charges directly undermines the intended purpose of the price transparency goals and that for a percentage-of-billed-charges rate to be meaningful, hospitals would have to disclose the price for that same service in their hospital pricing files. Another commenter expressed concern that allowing percentage-only reporting would create a transparency loophole and shift the burden to users to cross-reference other sources to estimate actual prices.

The Departments acknowledge these comments regarding the interpretability of percentage-of-billed-charges reporting without the availability of a billed charge amount. The Departments have determined that it is appropriate to codify the exception to reporting a dollar amount as specified in existing technical implementation guidance.\48\ Since issuing this guidance, 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.\49\ Requiring plans and issuers to generate estimated dollar amounts when only a percentage of billed charges is available prospectively would introduce significant variability and limit the accuracy of the reported amount given differing underlying payment methodologies. In turn, this limited accuracy may impose more burden on users to interpret these amounts. The Departments understand that disclosing percentages without billed charges limits users' ability to view the base dollar amount a plan or issuer agrees to pay a provider, and thus limits price transparency in that manner. However, the Departments have determined that permitting this exception offers more transparency into plan and issuer activity than potentially imprecise estimates derived through various means. The Departments reiterate that plans and issuers must disclose rates as a dollar amount whenever a dollar amount can be calculated in advance, and the exception only applies under this narrow circumstance.

\48\ Centers for Medicare & Medicaid Services, Transparency in Coverage Price Transparency Guide, In-network Rates Negotiated Price Object, GitHub, available at https://github.com/CMSgov/price-transparency-guide/tree/master/schemas/in-network-rates#negotiated-price-object (last visited August 21, 2026).

\49\ 90 FR 60432, 60451 (December 23, 2025).

Finally, a few commenters recommended that the Departments codify the open text field guidance as described in FAQs Part 53 for alternative reimbursement arrangements.\50\ While the Departments are not codifying the “additional information” field--also known as the open text field--in these final rules because it is an optional field for use only when applicable, the Departments clarify that the additional information field remains in the schema to allow plans and issuers to describe additional context to their contracting arrangements, including payment formulas or methodologies, if they cannot otherwise be captured in the existing standardized data elements of the schema.

\50\ 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-ebs.