Transparency in Coverage

In the proposed rules, under 26 CFR 54.9815-2715A3(b)(4), 29 CFR 2590.715-2715A3(b)(4), and 45 CFR 147.212(b)(4) (which the Departments proposed to be redesignated from paragraph (b)(3) as discussed in preamble section III.C.7. of the proposed rule), the Departments proposed to add new paragraphs to specify timing requirements for publishing each machine-readable file. In particular, the Departments proposed to amend redesignated paragraph (b)(4)(i) to require plans and issuers to update and post the In-network Rate and Allowed Amount Files required under paragraphs (b)(1)(i) and (ii), respectively, quarterly rather than monthly, beginning on the first day of the calendar-year quarter following the applicability date under paragraph (c)(1). The Departments sought comment on the benefits, drawbacks, and potential impact of the proposed change in the reporting cadence for the In- network Rate Files and the potential impact of the proposed change in reporting cadence for the Allowed Amount File. After considering comments on the proposal, the Departments are finalizing the timing requirements for the In-network Rate and Allowed Amount Files as proposed. The Departments are not finalizing the proposed timing requirements for the Change-log File; therefore, proposed paragraph (b)(4)(iii) is not being finalized, and proposed paragraphs (b)(4)(iv) through (vi) are finalized at paragraphs (b)(4)(iii) through (v), respectively. The Departments are also finalizing the timing for the Utilization File with modification, requiring it to be updated and posted annually beginning July 1, 2028. The Departments are finalizing the timing of the Taxonomy File and the Text File as proposed.

The majority of commenters on this proposal were generally supportive. Supportive commenters stated that the quarterly change would (1) reduce regulatory, administrative, and compliance burden; (2) decrease data churn; (3) stabilize data architecture; (4) free up resources for higher quality data preparation; and (5) create a more sustainable process while preserving price transparency objectives and the usefulness of the data. A commenter agreed that the proposed shift to quarterly reporting is reasonable but emphasized the general principle that patients, employers, and researchers deserve timely access to the data.

Most commenters who supported quarterly reporting for the In- network Rate File also supported quarterly reporting for the Allowed Amount File. A commenter supported quarterly reporting specifically for the Allowed Amount File but opined that while the shift reduces the frequency of file generation, the addition of utilization data increases the scope of the files, and that the net operational burden would likely be comparable to or less than current requirements. Several commenters supported quarterly reporting as an improvement to data usability, noting that the monthly reporting cadence creates noise, duplicates data, and makes it difficult to identify pricing trends or conduct longitudinal analyses. These commenters shared that monthly updates overtake some users' ability to process large files with little added value since negotiated rates generally do not change month to month. Commenters shared that a quarterly cadence would provide more stable, consistent snapshots, allowing consumers of the data to process fewer, more substantive updates rather than repeatedly ingesting largely identical datasets while reducing file bloat.

The Departments agree with commenters that the change to a quarterly reporting cadence for the In-network Rate and Allowed Amount Files will reduce the administrative burden on plans, issuers, and service providers. As the Departments explained in the preamble to the proposed rules, shifting to a quarterly reporting cadence for these files will help lower data storage and hosting costs, decrease bandwidth needs, and reduce ongoing maintenance expenses.\103\ The Departments acknowledge and share the principle that patients, employers, and researchers deserve timely access to the data and find that the quarterly cadence strikes the appropriate balance between reducing significant operational burden of monthly reporting on plans and issuers and maintaining sufficiently current data. The Departments also agree that the reduced cadence will provide file users with more time to analyze the data, as some file users have shared they have difficulty keeping up with the pace of downloading and ingesting the file data monthly.\104\

\103\ 90 FR 60432, 60464 (December 23, 2025).

\104\ Id.

Several commenters noted that the quarterly cadence provides plans and issuers additional time for validation and quality assurance before posting, improving the overall accuracy, quality, and completeness of the data. Commenters explained that the current monthly cadence does not provide plans and issuers with sufficient time to review and correct their files before the next update cycle, increasing the likelihood of errors and incomplete submissions. These commenters stated that a quarterly cadence may lead to fewer incomplete or broken files, higher overall file quality, and a decreased likelihood of inadvertent reporting errors. On the other hand, a commenter stated that monthly reporting gives plans and issuers the opportunity to identify and correct errors within a shorter window, and that under a quarterly reporting schedule, errors could leave file users without accurate information for an extended period.

The Departments anticipate that allowing plans and issuers two additional months between disclosures will ultimately result in improvements to the overall accuracy, quality, and completeness of the files. The additional time between reporting cycles will give plans and issuers more opportunity to review their files and conduct quality assurance, which may reduce errors prior to posting. Additionally, as discussed in section III.C.8.d. of this preamble concerning the Text File, the Departments are finalizing the proposal to require plans and issuers to provide, in prominent locations, an email address for an individual or group dedicated to receiving and responding to inquiries and issues related to the machine-readable files. While the quarterly cadence reduces the number of opportunities for correcting errors since there are fewer reporting cycles, the Text File requirement improves the ability of file users to reach the appropriate parties to address those corrections in a timely manner.

A few commenters expressed conditional support for quarterly reporting for the In-network Rate File, contingent on the concurrent finalization of standardized Change-log Files, specifically stating that the effectiveness of the quarterly file updates fully depend on how they are structured and implemented and that the combination of quarterly reporting

and a quarterly Change-log File would provide the right balance by allowing users to easily identify changes without having to download files monthly.

The Departments are not finalizing the Change-log File requirement for the reasons described in section III.C.8.a. of this preamble. Nevertheless, the Departments have determined that the quarterly reporting cadence is still optimal even without the Change-log File, due to the infrequency of data changes and the operational burden of monthly reporting, as discussed in the preamble to the proposed rules. The Departments find the changes being finalized in these rules collectively will significantly improve user experience, reduce processing time and effort, and make the files more accessible to the intended users of these files.

Commenters who opposed the proposed reduction in reporting frequency were primarily concerned that prices and provider networks can change more frequently than quarterly and that the proposal would introduce or worsen staleness in the data and reduce its reliability and usefulness. A commenter noted that the most meaningful rate updates tend to occur in February, July, August, and October, and that a quarterly cadence could delay visibility into those updates by up to 3 months, as contract negotiations follow a cadence that is better captured through monthly reporting. Another commenter expressed concern that newly contracted providers may appear in provider directories before their negotiated rates are reflected in the machine-readable files, warning that a quarterly cadence would lengthen these gaps. A few commenters expressed concern that a quarterly reporting schedule would result in outdated or inaccurate price estimates for consumers, with a commenter pointing to potential gaps in the internet-based self- service tool information required under 26 CFR 54.9815-2715A2(b)(1), 29 CFR 2590.715-2715A2(b)(1), and 45 CFR 147.211(b)(1).

As noted in the proposed rules, the Departments recognize that negotiated rates between issuers and health care organizations tend to change slowly over time and the quarterly reporting cadence would not meaningfully affect the accuracy of reported rates in the In-network Rate File for these entities.\105\ Contracts generally last a year or more, with some multi-year contracts lasting 2 to 5 years.\106\ Further, industry experience indicates that because only a small percentage of contracts change monthly, historical machine-readable file data continues to provide reasonable insights even when not updated on a monthly basis.\107\ Although the Departments acknowledge the concern that meaningful rate updates may occur in February, July, August, and October, and that a quarterly cadence could delay visibility into those updates, the Departments find that any harm of a potential lag in data would be outweighed by the significant burden reduction and other reporting efficiencies achieved by moving from monthly to quarterly reporting. As such, the Departments have determined negotiated rates between health care organizations and issuers should not significantly change from month to month, so the proposed quarterly reporting cadence would not meaningfully affect the accuracy of reported rates in the In-network Rate File for these entities.\108\ Further, while the Departments acknowledge the concern that newly contracted providers may appear in provider directories before their negotiated rates are reflected in the machine-readable files, the Departments encourage consumers to use the internet-based self-service tool for current and accurate provider participation and cost-sharing information, as this tool is maintained independently from the machine-readable files and is subject to separate requirements.

\105\ Id.

\106\ Id.

\107\ Matthew Robben, MRF Processing Notes--October Edition, Serif Health (October 20, 2023), available at https://www.serifhealth.com/blog/mrf-processing-notes-october-edition.

\108\ 90 FR 60432, 60464 (December 23, 2025).

Neither the 2020 final rules, nor these final rules, require plans and issuers to use the data in the machine-readable files to generate cost-sharing estimates for the internet-based self-service tool and the Departments remind plans and issuers that the cost-sharing information required to be provided to participants, beneficiaries, and enrollees at their request through an internet-based self-service tool under 26 CFR 54.9815-2715A2(b)(1), 29 CFR 2590.715-2715A2(b)(1), and 45 CFR 147.211(b)(1) must be accurate at the time the request is made. A group health plan or health insurance issuer that provides inaccurate information, including because it relied on outdated machine-readable file data to populate its internet-based self-service tool, is out of compliance. Additionally, the Departments recognize the role third- party developers play in building consumer-facing tools and apps using machine-readable file data to ultimately make the data accessible and meaningful to consumers, and the Departments have concluded that the quarterly cadence does not undermine consumers' ability to shop for care using these apps.

A commenter opposed the quarterly reporting cadence, stating that for injectable drugs and other items with volatile pricing, prices change from month to month, sometimes significantly, and that reducing the reporting frequency would further widen the gap between the rates available in the files and the corresponding transaction prices.

The Departments did not propose to amend the reporting cadence for the prescription drug machine-readable file. To the extent injectable drugs and other items with volatile pricing are not subject to a fee- for-service arrangement (and are therefore required to be included in an In-network Rate File), the Departments have determined that the quarterly cadence is appropriate because the rates required in the In- network Rate File are established through contractual arrangements that do not change with the same frequency as prescription drugs subject to a fee-for-service arrangement.

Several commenters shared alternatives to the reporting cadence that were not monthly or quarterly. A few commenters recommended that the Departments consider requiring reporting every 6 months, stating that payers typically do not update rates more frequently than semi- annually and that semi-annual reporting would be more cost-efficient while still providing relevant and up-to-date data without substantially undermining accuracy or transparency. A few commenters recommended requiring the machine-readable files to be updated more frequently than quarterly in certain situations, such as by providing a parallel mechanism for more frequent updates where network changes occur or by requiring updates to negotiated rates within 30 days of a contract amendment, termination, or renewal. A commenter recommended maintaining the monthly reporting cadence until the burden impacts of schema changes can be assessed.

The Departments acknowledge the range of alternative reporting cadences suggested by commenters but find that the quarterly cadence strikes the most appropriate balance, as it is not excessively burdensome on plans and issuers while still maintaining sufficiently current data. The Departments find that while the quarterly cadence accomplishes a substantial burden reduction compared to monthly reporting, the incremental

burden reduction from moving to a semi-annual reporting cadence would not justify the impact to the timeliness of the data, as the period between updates would double from three to 6 months and risk mid-year contract changes going unreported for a longer period.

Further, deferring reductions to reporting frequency until after recommended structural schema changes are implemented would require plans and issuers to perform rework, thereby increasing the burden associated with the reporting cadence. Accordingly, the Departments are not adopting these alternatives.

A few commenters recommended that the files should be required to be posted on a specific day during the reporting period. A commenter recommended requiring files to be posted on the first of the second month of each calendar quarter, rather than the first of the first month of each calendar quarter, because machine-readable files posted around January 1 of each year reflect negotiated rates from the previous year. Another commenter recommended requiring a first of the month posting to ensure consistency and to provide a more predictable timeframe for error correction.

While the Departments agree with the underlying rationale for requiring first-of-the-month posting to ensure consistency, the Departments are not adopting a monthly cadence and instead are applying this same timing principle to the quarterly cadence, requiring files to be posted on the first day of each calendar-year quarter (January 1, April 1, July 1, and October 1). The Departments note that the rates published in the In-network Rate File are prospective, reflecting negotiated rates established through annual contracts that are in effect at the start of the applicable period and therefore do not result in data lag. The Departments are also not adopting the recommendation to shift the posting deadline to the first day of the second month of each quarter. As discussed in section III.C.4. of this preamble, the Departments are not finalizing the requirement to include numerical enrollment totals in the In-network Rate File. Because enrollment totals will not be required in the In-network Rate File, the Departments have determined that the remaining data elements can be compiled and validated for reporting on the first day of the calendar- year quarter without any expected data lag.

The Departments proposed in paragraph (b)(4)(ii) that the prescription drug machine-readable file would be required to be updated monthly, which would retain the requirement under current paragraph (b)(1)(iii). A few commenters supported keeping the prescription drug machine-readable file reporting cadence as monthly given the greater frequency of drug price changes. A commenter recommended the Departments require plans and issuers to post their prescription drug files once per year, at the beginning of their plan year, stating that more frequent reporting does not benefit consumers evaluating plans and their networks.

As stated in the preamble of the 2020 final rules, drug prices can fluctuate as often as daily,\109\ so the Departments agree with commenters that a monthly cadence for the prescription drug file is more appropriate than a quarterly cadence. While an annual cadence might be sufficient for broad consumer understanding of network benefits, the goals of the prescription drug file are to provide consumers with pricing data and to reveal--for the first time--the pricing complexity of the prescription drug distribution chain. The Departments are also considering comments received on the request for information regarding the Prescription Drug Machine-Readable File Requirement in the Transparency in Coverage final rules \110\ and are separately taking them into consideration to evaluate how to implement the Transparency in Coverage prescription drug disclosure requirements.

\109\ 85 FR 72158, 72244 (November 12, 2020).

\110\ 90 FR 23303 (June 2, 2025).

The Departments proposed to require at proposed paragraph (b)(4)(iii) that plans and issuers update the Change-log File under proposed paragraph (b)(2)(i) on the same day that each In-network Rate File described in paragraph (b)(1)(i) is required to be updated, except for the first In-network Rate File for which there would be no changes to report. The group health plan or health insurance issuer would be required to post their first Change-log File beginning on the first day of the calendar-year quarter following the date on which the first In- network Rate File would be required to be posted under paragraph (b)(4)(i). The Departments proposed to require that if there are no changes to an In-network Rate File since it was updated last, a Change- log File would still be required to be posted at that time indicating there are no changes for that quarter.

While there were many commenters who supported the proposal for a Change-log File and its quarterly posting, many commenters opposed the Change-log File requirement noting the potential for large file sizes, operational challenges, and the administrative and financial burden of creating the files, as well as concerns about the limited value these files might ultimately provide to file users. For these and other reasons described in section III.C.8.a. of this preamble, the Departments are not finalizing the proposal to require plans and issuers to make available a Change-log File for each In-network Rate File and are therefore not finalizing the proposed timing requirements for the Change-log File in proposed paragraph (b)(4)(iii).

The Departments proposed to require at paragraph (b)(4)(iv) that the Utilization File described in proposed new paragraph (b)(2)(ii) be updated and posted every 12 months after the initial posting. As discussed further in section III.C.8.b. of this preamble, the Departments are finalizing the Utilization File requirement with a modification to the lookback period to be for the most recent plan year (in the individual market, policy year) that ends at least 6 months prior to the date the Utilization File is made available and with a modification to the initial posting to begin on July 1, 2028.

The Departments did not receive comments on the proposed timing of the Utilization File. However, the Departments are finalizing an annual July 1 reporting cadence for the Utilization File in renumbered paragraph (b)(4)(iii) to account for finalizing the Utilization File lookback period in relation to a plan or policy year. Because most plans and coverage begin their new plan or policy year on January 1, requiring the file to be posted annually on July 1 means that files for most plans and policies will be posted 6 months following the end of the applicable plan or policy year. This allows plans and issuers a 6- month window, as proposed, to complete the claims processing lifecycle, including pre-claim submission, pre-claim payment, payment determination and collection, and prepare the file for posting.\111\ For plans and policies that do not run from January 1 to December 31, the window to prepare the file for posting will be longer than 6 months. For example, the Utilization File for a plan that begins on July 1, 2028, and ends on June 30, 2029, is required to be posted on July 1, 2030. This approach strikes a balance between allowing plans and issuers sufficient time to gather the required information and prepare it for posting, and ensuring that Utilization Files for all plans and issuers will be updated or posted on the same

day, regardless of plan or policy year, so that file users know when to expect updates and can easily locate the most recent file.

\111\ See 90 FR 60432, 60458 (December 23, 2025).

The Departments proposed to require at paragraph (b)(4)(v) that plans and issuers update the Taxonomy File under paragraph (b)(2)(iii) and post such file beginning on the first day of the calendar-year quarter following the applicability date under paragraph (c)(1)(ii). If there are no changes to the taxonomy that impact the information required to be included in the In-network Rate File from one quarter to the next, the Taxonomy File would not be required to be updated. The Departments are finalizing the timing of the posting of the Taxonomy File in renumbered paragraph (b)(4)(iv) with a modification to specify that if there are no changes to the taxonomy that affect the information required in the machine-readable file required under paragraph (b)(1)(i) in a subsequent quarter, the Taxonomy File is still required to be posted, but not updated for that quarter.

A commenter recommended requiring the Taxonomy File to be updated whenever a plan's or issuer's internal taxonomy changes to guarantee the public has the most up-to-date information. While the Departments recognize the importance of accurate and timely taxonomy information, the Departments have determined that a plan's or issuer's internal taxonomy is unlikely to change to a significant degree between quarters and that the requirement to update the Taxonomy File with changes in the subsequent quarter sufficiently balances the burdens of updating and maintaining the file with the timeliness of accurate information. Additionally, the Taxonomy File is meant to provide additional context to the In-network Rate File, which is updated more frequently through a quarterly reporting cadence.

However, the Departments intended that the Taxonomy File would be required to be posted each quarter, even if there are no changes to the taxonomy that affect the information required in the In-network Rate File. To ensure that the regulation is clear on this point, the Departments are finalizing renumbered paragraph (b)(4)(iv) to specify that plans and issuers are required to post a Taxonomy File on a quarterly basis, even if there is no data to be updated from the prior quarter. This is a clarification, rather than a substantive modification. It will ensure that an accurate Taxonomy File can always be linked to the most recently published In-network Rate File, giving file users confidence that they can match information between the two files.

Finally, the Departments proposed in new paragraph (b)(4)(vi) to require that the Text File required under proposed paragraph (b)(2)(iv) of this section be initially posted on the first day of the calendar- year quarter following the applicability date under paragraph (c)(1) and updated and posted within 7 calendar days following a change in any of the information required under paragraph (b)(2)(iv). The Departments requested comment on whether 7 calendar days following a change provides sufficient time for plans and issuers to make the required update. The Departments are finalizing the timing to post the Text File at renumbered paragraph (b)(4)(v) as proposed.

A commenter sought clarification on whether the requirement would apply solely to changes in file location and contact information, or whether it would also require off-cycle or ad-hoc updates to file content outside the proposed quarterly cadence for In-network Rate Files, for example, when a rate changes or a new provider is contracted.

The Departments clarify that the 7-calendar-day update requirement under paragraph (b)(4)(v) will apply only to changes in the information required under paragraph (b)(2)(iii), specifically, the source page URL, the direct link to the machine-readable files, and the point-of- contact information. This requirement does not apply to updates to the content of other machine-readable files themselves.

After considering the public comments, the Departments are finalizing the amendment to redesignated paragraph (b)(4)(i) through (ii) as proposed. The Departments are not finalizing the requirement to provide a Change-log File and therefore are not finalizing the timing to provide a Change-log File as proposed in paragraph (b)(4)(iii). As a result, the Departments are finalizing paragraphs (b)(4)(iv) through (vi) at paragraphs (b)(4)(iii) through (v). The Departments are finalizing with modification the timing for the Utilization File at redesignated paragraph (b)(4)(iii) so that it must be updated and posted annually beginning on July 1, 2028. The Departments are finalizing with modification the timing of the Taxonomy File at redesignated paragraph (b)(4)(iv) and finalizing the Text File at redesignated paragraph (b)(4)(v) as proposed. See Table 2 for example initial and subsequent posting dates.

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The Departments proposed in 26 CFR 54.9815-2715A3, 29 CFR 2590.715- 2715A3, and 45 CFR 147.212 to redesignate paragraphs (b)(4)(i) and (ii) as paragraphs (b)(5)(i) and (ii), respectively--each without any substantive changes to the existing policy established in the 2020 final rules. The Departments also proposed to add new paragraph (b)(5)(iii) to propose, under certain conditions, to allow self-insured group health plans to permit another party (pursuant to a contract) to make available in a single In-network Rate File, the information required under paragraph (b)(1)(i) for multiple plans, insurance policies, and contracts, including those offered by different plan sponsors with which the other party contracts and across health insurance markets that share the same provider network. In new paragraph (b)(5)(iii)(A), the Departments proposed the first condition, which is that each In-network Rate File made available for a provider network must include the required information under paragraph (b)(1)(i) for all covered items and services under each plan, insurance policy, or contract that uses the same provider network for which the In- network Rate File is made available. In new paragraph (b)(5)(iii)(B), the Departments proposed the second condition, which is that each proposed Change-log, Utilization, and Taxonomy File must include data from the same plans, insurance policies, or contracts that are represented in the corresponding In-network Rate File.

The Departments also proposed to redesignate certain language from current paragraph (b)(4)(iii) as paragraph (b)(5)(iv) and amend it to allow, under certain conditions, self-insured group health plans to permit another party (under a written agreement) to make available in a single Allowed Amount File the information required under paragraph (b)(1)(ii) for more than one self-insured group health plan, including those offered by different plan sponsors with which the other party contracts. For consistency in the application of the 11-claims threshold specified in paragraph (b)(1)(ii)(C), the Departments proposed in new paragraph (b)(5)(iv) that in order for a self-insured group health plan to take advantage of the special rule in that paragraph, the proposed 11-claim threshold must be applied to the aggregated data set.

Finally, the Departments proposed to redesignate other language from current paragraph (b)(4)(iii) as paragraph (b)(3)(iv), which would provide that the plan or issuer may enter into a written agreement with another party (such as a service provider) to post the machine-readable files on its public website on behalf of the plan or issuer, including if the plan or issuer does not have a website. However, if the files are posted on a service provider's website, and the plan or issuer maintains a public website but chooses not to host the files separately on its own public website, it must provide a link on its own public website to the location where the files are made publicly available. Because the Departments determined that this provision more logically belongs in redesignated paragraph (b)(3), the Departments proposed to move it to new paragraph (b)(3)(iv) with proposed amendments that are explained in section III.C.10. of this preamble.

After consideration of comments, the Departments are finalizing these amendments as proposed, with the following modifications: (1) The Departments are removing the reference to the Change-log File in paragraph (b)(5)(iii)(B), which is not being finalized, as discussed in section III.C.8.a. of this preamble; and (2) the Departments are finalizing certain non-substantive language edits to paragraphs (b)(5)(i) through (iii) to ensure clarity and consistency throughout the regulatory text.

Several commenters expressed support for the proposal in proposed paragraph (b)(5)(iii) to allow a self-insured group health plan to enter into an agreement with a service provider to make available an In-network Rate File

for each provider network used by more than one plan, insurance policy, or contract (including those offered by different plan sponsors with which the service provider has an agreement) and across different health insurance markets, subject to certain conditions, asserting that doing so will reduce total file count, eliminate duplication, and improve analysis. One of these commenters noted that it is appropriate that the contextual files include data for the same aggregated set of plans.

The Departments agree with commenters and reiterate the statement in the proposed rules that allowing self-insured group health plans to permit another party with which it contracts to combine In-network Rate File data by provider network and across different health insurance markets, subject to certain conditions, will reduce duplicate rate information and simplify analysis for file users.\112\ The Departments continue to expect that organizing data by provider network will reduce file size and the overall number of files and make more meaningful information available to file users. The Departments also agree that for the Utilization and Taxonomy Files to be meaningful, they must include information from the same plans, insurance policies, or contracts represented in the corresponding In-network Rate File, including, as applicable, those offered by different plan sponsors and across different health insurance markets. As discussed in section III.C.8.a. of this preamble, the Departments are not finalizing the Change-log File requirement in proposed paragraph (b)(2)(i). Therefore, the Departments are finalizing paragraph (b)(5)(iii)(B) only with respect to the Utilization and Taxonomy Files, which the Departments are finalizing as discussed in sections III.C.8.b. and III.C.8.c. of this preamble, respectively.

\112\ 90 FR 60432, 60466 (December 23, 2025).

A commenter recommended that the Departments ensure the proposals to allow self-funded plan data aggregation in the In-network Rate File do not create gaps in data coverage or accountability, while another commenter recommended there be traceability to the plans included in the aggregated file by including EINs or plan identifiers.

As discussed in section III.C.2., redesignated paragraph (b)(1)(i)(C) will require that an In-network Rate File includes an EIN if there is no HIOS ID available (as is the case for self-insured plans). The Departments acknowledge the commenter's concern about data gaps and confirm that all plan-level data, including the plan sponsor's EINs, will be populated in the Table of Contents File so that a user can identify the plans included in a combined file. As discussed in section III.C.1. of this preamble, Schema 2.0 currently expects plans and issuers to use a Table of Contents File if more than one plan or policy offered by a health insurance issuer or health plan shares the same in-network rates.

A commenter recommended that self-insured plan sponsors not be held liable for non-compliance when the plan sponsor is not the owner of the provider network, stating that the owner of the provider network produces a machine-readable file for a plan sponsor that is either “renting” the carrier's provider network or contracting with a third- party to access a provider network.

The Departments note that current paragraph (b)(4)(ii) (redesignated in these final rules as paragraph (b)(5)(ii)) specifies that if a plan or issuer contracts with another party (such as a service provider or health care claims clearinghouse) to disclose required machine-readable file information under paragraph (b) and the party with which it contracts fails to provide the information, the plan or issuer is considered to have violated the requirements of paragraph (b). The Departments did not propose and are not finalizing substantive changes to this requirement. As the Departments discussed in the 2020 final rules, plans and issuers are not required to enter into such agreements to comply with the public disclosure requirements of those final rules.\113\ If a plan or issuer chooses to do so, it is ultimately the responsibility of the plan or issuer to ensure that the service provider provides the information required by those final rules.\114\ This ensures the Departments retain a mechanism to enforce those final rules against the entities subject to their authority. Further, the Departments emphasize that this liability structure is standard for plans and issuers entering into written agreements to handle such responsibilities.\115\

\113\ 85 FR 72158, 72245 (November 12, 2020).

\114\ Id.

\115\ See 45 CFR 149.720(d)(2) (“Other contractual arrangements. A group health plan or health insurance issuer offering group or individual health insurance coverage may satisfy the requirements under paragraph (a) of this section by entering into a written agreement under which one or more other parties (such as health insurance issuers, pharmacy benefit managers, third-party administrators, or other third parties) report some or all of the information required under paragraph (a) of this section in compliance with this section. Notwithstanding the preceding sentence, if a group health plan or health insurance issuer chooses to enter into such an agreement and the party with which it contracts fails to provide the information in accordance with paragraph (a) of this section, the plan or issuer violates the reporting requirements of paragraph (a) of this section.”); see also 89 FR 77586, 77613 (September 23, 2024) (“Plans and issuers remain responsible for compliance with MHPAEA, and for ERISA-covered group health plans, fiduciaries, including TPAs or other service providers who are acting as fiduciaries, must work with plan sponsors and issuers to ensure that the plans and coverage they help establish and administer comply with the law.”).

A commenter requested the Departments confirm or consider revising the special rule for self-insured plans that use a vendor for in- network arrangements but also have supplemental carve-outs or other arrangements outside the standard network to be included in the aggregate reporting for the In-network Rate File.

The Departments encourage all self-insured group health plans that use the same provider networks to take advantage of the special rule in paragraph (b)(5)(iii) to streamline reporting. As discussed in section III.C.1. of this preamble, if variations among either participating providers or in-network rates exist, those variations constitute a separate provider network. The current technical implementation guidance allows a plan's information to be associated with multiple, layered provider networks that constitute the plan's complete coverage. This includes reflecting a base network with additional carve-out provider networks in their Table of Contents File.

Most commenters supported the proposal in redesignated paragraph (b)(5)(iv) to allow self-insured group health plans to permit another party with which it contracts, such as a service provider, to include the allowed amount and billed charge information required under paragraph (b)(1)(ii) in a single Allowed Amount File for more than one self-insured group health plan, including those offered by different plan sponsors with which the other party contracts, provided certain conditions are met. Commenters stated that the proposal would result in important simplification and cost-savings where multiple employer plan sponsors are all served by, and contracted with, the same vendor.

The Departments agree that the special rule in paragraph (b)(5)(iv) will allow streamlined reporting for self-insured group health plans while maintaining the market division grouping necessary to make the data more actionable for research and analysis as discussed in the proposed rules.\116\

\116\ 90 FR 60432, 60467 (December 23, 2025).

A commenter supported the proposal that a self-insured group health plan may not take advantage of the special

rule under paragraph (b)(5)(iv) unless the proposed 11-claim threshold applies across all plans included in the Allowed Amount File. The commenter stated that allowing service providers to aggregate Allowed Amount Files across multiple self-insured group health plans offered by different sponsors, with the 11-claim threshold applied to the aggregated dataset rather than to each individual plan, would maximize out-of-network data volume, improve privacy protections, and reduce file proliferation.

The Departments agree with the commenter's anticipation of increased data volume and reiterate the expectation that this approach will better mitigate privacy concerns and minimize complexity in complying with Federal or State privacy laws as discussed in the proposed rules.\117\

\117\ Id. at 60455.

A commenter stated that the Departments should clarify how the claims threshold is measured if the self-insured plan has multiple service providers. The commenter recommended that the threshold be based only on the information that is within the service provider's control, such that no service provider should be required to aggregate data from another service provider to meet this threshold.

The Departments agree with the commenter that a determination as to whether allowed amount and billed charge data should be omitted based on the 11-claims threshold, as specified in paragraph (b)(5)(iv), should be based only on the information that is within a service provider's control, as requiring plans to ensure information is exchanged between service providers would be difficult and unnecessarily burdensome. 13. Applicability

The Departments proposed to require under paragraph (c)(1) that the proposed amendments to the provisions of paragraph (b) of 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212 would apply 12 months following the date of publication of the final regulations in the Federal Register. The Departments proposed this applicability date to ensure that all plans and issuers would begin following the updated set of technical requirements at the same time, rather than according to plan or policy year. The Departments sought comment on this proposed applicability date.

After consideration of comments, the Departments are modifying the proposed applicability date under paragraph (c)(1) such that that the provisions of this section will apply beginning 5 months following the date of publication of the final regulations in the Federal Register, which is March 6, 2027, except for the contextual files under paragraph (b)(2) and their timing requirements under paragraphs (b)(4)(iii) through (v), and the website footer requirements under paragraph (b)(3)(iii), which will apply beginning 11 months following the date of publication of the final regulations in the Federal Register, which is September 6, 2027. Until those applicability dates, plans and issuers are required to 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 147.212, revised as of October 1, 2025. These final rules give plans and issuers 5 months following publication of the final rule to implement the changes related to the In-network Rate File, Allowed Amount File, and attestations, and 11 months following publication of the final rule to implement the contextual files and the website footer.

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

A few commenters supported a 12-month transition as reasonable for interpreting requirements, updating mappings/designs, testing, and deploying, while also noting that implementation depends on technical guidance being available early enough to use that time effectively. However, many users of the data recommended making the applicability date earlier because they believed the Transparency in Coverage infrastructure has been operational since 2022 and the proposal largely refines existing requirements rather than requiring a “from-scratch” build. A few commenters reasoned that many proposed changes are mainly output restructuring or metadata additions (instead of new data generation), and that quarterly (vs. monthly) posting could offset operational burden. A few commenters recommended a shorter compliance runway (4 to 5 months) and stated it would create continuity with the recent 2026 OPPS Final Rule \118\ for hospital machine-readable file update timelines and is feasible because payers and vendors have matured development pipelines after prior schema changes. They asserted that plans and issuers should likewise be held to a similar timeline, which would mean the applicability date for changes included in these final rules should be 5 months after the final rules' publication date at most.

\118\ 90 FR 53448 (November 25, 2025).

The Departments agree that the final requirements are mainly refinements and restructuring of existing requirements and that the quarterly cadence should offset operational burden. Unlike the 2026 OPPS Final Rule,\119\ which sets forth all the development requirements in regulation, the Transparency in Coverage development process has two stages--the rule sets forth the requirements stating what information must be disclosed, while the GitHub platform sets forth the schemas, which are the technical specifications for how the required information should be disclosed with collaboration and input from the developer community. Thus, implementation of these technical specifications requires time following rule publication for technical implementation guidance development on GitHub and then additional time for plans and issuers to build the files once the schemas are finalized.

\119\ Id.

In response to the many requests from commenters to accelerate the applicability timeline, the Departments have determined that certain provisions should be applicable 5 months after the publication date of these final rules in the Federal Register. These include the changes to In-network Rate File at paragraph (b)(1)(i) and the Allowed Amount File at paragraph (b)(1)(ii) along with their special rules under paragraph (b)(5), and their timing under paragraph (b)(4)(i); as well as the attestations under paragraph (b)(1)(iv) and the required method and format provisions under paragraphs (b)(3)(i), (ii), and (iv).

The Departments have determined that the implementation timeline for the In-network Rate and Allowed Amount Files can be accelerated given that plans and issuers are already producing these files and the proposed amendments primarily refine and restructure existing requirements, making 5 months sufficient to accomplish both GitHub collaboration and the building of the files. In addition, the Departments have determined an accelerated applicability date is appropriate for the method and format provisions described in section III.C.10. of this preamble, which involve only basic website modifications.

Several plans and issuers opposed the 12-month applicability date following finalization of the rule and recommended an applicability date at least 18 months (and in one case 24 months) after release of final technical standards, rather than these final rules. These commenters reasoned the proposal introduces substantial operational workstreams (for example, changes in enrollment, the addition of new contextual files, structural modification to the existing machine- readable files, and time required for vendor or service provider coordination, including the design, development, testing, quality assurance, validation, and deployment of hosting and tooling updates), and that overlapping Federal requirements (interoperability, advanced explanations of benefits, new disclosure rules) compete for constrained technical resources. A few commenters added that these workforce constraints and vendor dependency chains limit how much timelines can be compressed without harming accuracy and reliability. A few commenters stated that plans and issuers cannot begin planning and development until all technical requirements, including Schema 3.0 data attributes, examples, and FAQs, are final. These commenters stated that late updates or changes to definitions, requirements, or technical guidance for Schema 1.0 and 2.0 required rework and created delays.

The Departments disagree that plans and issuers require 18 to 24 months following finalization of the schema requirements to implement these new provisions. Such an implementation runway would be significantly longer than that of the initial machine-readable file infrastructure following the 2020 final rules, which required a much larger effort to build. The Departments acknowledge that the proposed provisions impose new operational burden and that plans and issuers are subject to overlapping Federal requirements that may strain their personnel and infrastructure capacities. However, the Departments have determined that the applicability dates for these provisions are reasonable given that the new requirements are mainly refining and restructuring data, combined with the fact that the Departments are not finalizing the Change-log File or the enrollment totals provisions as described in sections III.C.8.a. and III.C.4., respectively, which commenters indicated would be operationally challenging.

The Departments are committed to making the data available to the public as soon as possible and have determined that the amendments to the machine-readable files can and should be fully implemented by the end of 2027. Since a 12-month applicability date would push implementation into 2028, the Departments are finalizing an 11-month applicability date to the new contextual files under paragraph (b)(2) and their timing under paragraph (b)(4)(iii) through (v), as well as the website footer under paragraph (b)(4)(iii). Eleven months provides plans and issuers adequate time to augment their workforce, if necessary, and aligns with the accelerated applicability recommended by many commenters for all files. The Departments disagree that plans and issuers cannot begin planning and development until all technical requirements, including Schema 3.0 data attributes, examples, and FAQs, are final. The intention of the Transparency in Coverage technical implementation process is to allow development to take place transparently--in real time with the GitHub community--as was the case following the publication of the 2020 final rules. Industry feedback on where and how data should be disclosed within the machine-readable files will inform the final specification, but file developers will have the initial draft schemas at the beginning of each phase's development window to start building towards. Development teams can begin planning data extraction from internal systems based on the known core elements, allowing implementation work to proceed in parallel with the technical implementation process. File developers do not need to wait until the very end of the process to start their builds; rather, development can and should begin before Schema 3.0 is formally finalized.

Under the Paperwork Reduction Act of 1995 (PRA), the Departments are required to provide notice in the Federal Register and solicit comment before an information collection request (ICR) is submitted to the Office of Management and Budget (OMB) for review and approval. These final rules contain ICRs that are subject to review by OMB. A description of these provisions is given in sections IV.A. and B. of this preamble, with estimates of the annual and one-time burdens summarized in Tables 35 and 36, respectively.

In the proposed rules, the Departments solicited public comment on the ICRs, including the following areas, as required by section 3506(c)(2)(A) of the PRA.

The need for the information collection and its usefulness in carrying out the proper functions of an agency, including whether the information shall have practical utility.

The accuracy of the Departments' estimate of the information collection burden, including the validity of the methodology and assumptions used.

The quality, utility, and clarity of the information to be collected.

Recommendations to minimize the information collection burden on the affected public, including automated collection techniques.

The Departments received several comments addressing these issues from plans and issuers, consumer and patient advocacy organizations, data analytics and informatics companies, and professional trade associations. A few commenters noted that burden estimates should better reflect real-world implementation costs and highlighted potential operational impacts associated with specific provisions, including changes to reporting thresholds and data requirements, as well as the need to account for continuous maintenance activities. A few other commenters also indicated that recurring burdens are undercounted, emphasizing that many requirements involve continuous maintenance and that some annual costs (such as those associated with Taxonomy Files) are not fully captured. A few commenters provided recommendations related to wage assumptions, consumer support burden estimates, and the overall methodology used to estimate burden. These comments, along with the Departments' responses, are discussed in sections IV.A. and IV.B. of this preamble.

Several commenters expressed concern that increased transparency requirements may create significant administrative and financial burdens that could be passed on to consumers in the form of higher premiums or costs if not paired with meaningful usability improvements. A few commenters noted that implementation burden could be substantial, potentially exceeding prior Transparency in Coverage updates, and recommended prioritizing high-value requirements and streamlining timelines and guidance.

The Departments acknowledge these concerns, including that estimated one-time implementation costs in the proposed rules may be substantial and that ongoing compliance may require additional effort and resources. After consideration of the comments regarding significant burden, the Departments have decided not to finalize certain requirements, including the requirement to add a Change-log File related to the In-network Rate File disclosures and the requirement to

include the current enrollment totals for each coverage option associated with the applicable In-network Rate File. As a result, these final rules reduce compliance burdens on plans and issuers while continuing to advance the Departments' underlying policy goals.

In addition, in response to public comments and as discussed in sections III.C.9. and III.C.7. of this preamble, respectively, the Departments are finalizing a requirement for plans and issuers to publish machine-readable files in a single non-proprietary, open- standards format, as well as a requirement to attest, to the best of their knowledge and belief, to the accuracy and completeness of the information contained in their machine-readable files. These requirements are intended to improve the consistency and reliability of machine-readable file disclosures while advancing the Departments' transparency objectives.

A commenter recommended applying stronger PRA-based burden governance, including evaluating the marginal utility of each requirement and conducting post-implementation reassessments. The Departments acknowledge this perspective but have determined that a requirement-by-requirement marginal utility analysis would be complex and impractical given data limitations and the interrelated nature of the provisions. The Departments acknowledge the value of post- implementation evaluation and will continue to consider interested parties' feedback and implementation experience in future policymaking efforts. In accordance with Executive Order 12866 \120\ and Executive Order 14192,\121\ the Departments have evaluated the overall costs, cost savings and benefits of these final rules and determined that they are expected to result in net cost savings over time, reflecting that aggregate cost savings outweigh the aggregate costs.

\120\ Exec. Order 12866, 58 FR 51735 (September 30, 1993).

\121\ Exec. Order 14192, 90 FR 9065 (January 31, 2025).

A commenter urged the Departments to consider the rule's impact on physicians, particularly solo and small physician practices, and explore future actions to address policies that may increase costs and limit access to care. The Departments acknowledge this concern but note that these final rules apply to plans and issuers rather than providers. The potential impact on applicable small entities is addressed in section V.F. of this preamble.

Taking these considerations into account, the Departments have evaluated these final rules in the broader context of their anticipated effects, including overall costs and benefits. The Departments have determined that these final rules will improve transparency and promote more efficient markets, support informed decision-making, and help mitigate potential cost pass-through to consumers over time. Furthermore, as discussed in section V.I. of this preamble, the Departments expect the requirements in these final rules to yield net cost savings over the long term. Therefore, the Departments have determined that these final rules, and the refinements made in response to comments, appropriately balance the goal of minimizing administrative burden with maximizing the impact and value of transparency requirements. Wage Estimates

To estimate wages, the Departments used data from the Contract Awarded Labor Category (CALC) database tool \122\ to calculate average labor costs associated with the burden and equivalent costs of the ICRs. The CALC tool was developed to assist acquisition professionals with market research and price analysis of labor categories under multiple U.S. General Services Administration and Veterans Administration (VA) contracts. While the Departments recognize that various methods exist for estimating fringe benefits and overhead costs, the CALC database was selected because, unlike Bureau of Labor Statistics (BLS) data, which is valuable for identifying broad labor market trends, the CALC tool is specifically designed to support market research for government procurement. It provides cost estimates for specific labor categories based on actual contract rates. More importantly, CALC data reflects fully burdened hourly rates, including both base pay and benefits, whereas BLS data reflects only base wages. The Departments determined that CALC's occupation-specific data better aligns with the skill sets and job functions necessary for implementing the requirements in these final rules and therefore provides a more suitable basis for estimating labor costs.

\122\ U.S. General Services Administration, Pricing Intelligence Suite, CALC information and wage rates, available at https://buy.gsa.gov/pricing/ (last visited August 13, 2026).

A few commenters recommended that the Departments' burden estimates reflect prevailing wage rates for relevant personnel. The Departments appreciate these comments and have revised the wage rate assumptions used in the burden estimates to better reflect prevailing market rates. The Departments have updated the wage assumptions used in the burden estimates by adopting median wages instead of the mean wages used in the proposed rules, as median wages are less influenced by outliers and better reflect typical compensation, resulting in more representative and reliable estimates of labor costs. Table 3 presents the fully burdened median hourly wage and occupations used in the Departments' estimates.

[GRAPHIC] [TIFF OMITTED] TR06OC26.025

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

In the proposed rules, the Departments proposed several amendments to the 2020 final rules to improve price transparency and strengthen consumer protections for participants, beneficiaries, and enrollees. Specifically, the Departments proposed revising the statement required under paragraph (b)(1)(vii)(A) to clarify that the cost-sharing information does not account for potential additional amounts in situations where applicable State and Federal law allow out-of-network providers to balance bill participants, beneficiaries, and enrollees. These revisions reflect the Federal balance billing protections introduced by the No Surprises Act, which were not in effect when the original provision was finalized.

The Departments are finalizing these revisions, as proposed. These changes will help ensure that participants, beneficiaries, and enrollees understand that cost-sharing estimates disclosed through their plan's or issuer's self-service tool may not account for additional amounts that could ultimately be owed to out-of-network providers.

In addition, the Departments proposed adding a new paragraph (b)(2)(iii) requiring plans and issuers to make cost-sharing information available by phone, consistent with requirements under the No Surprises Act. The Departments also proposed to require a telephone number for consumer assistance, as already required 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, to be indicated on any physical or electronic plan or insurance identification card issued to a participant, beneficiary, or enrollee.

The Departments are also finalizing these requirements as proposed. To reduce unnecessary administrative burden and prevent consumer confusion, providing the information as specified in paragraph (b)(1) and in the methods and formats as specified in paragraph (b)(2), as amended by these final rules, satisfies the price comparison tool requirements under section 114 of the No Surprises Act. These requirements apply to non-grandfathered group health plans and health insurance issuers offering non-grandfathered coverage in the group and individual markets.

As discussed in section V.C.3. of this preamble, the Departments assume that self-insured group health plans will depend on TPAs, including issuers providing administrative services only and non-issuer TPAs, to implement the requirements of these final rules. This assumption is based on the Departments' understanding that most self- insured group health plans already rely on TPAs to perform core administrative functions, such as enrollment and claims processing.\123\ For those self-insured plans that choose to develop their own internet-based self-service tools, the Departments assume that they will incur costs and burdens similar to those estimated for issuers and TPAs. Accordingly, the Departments use issuers and TPAs as the unit of analysis for estimating the cost of these changes.

\123\ Louise Norris, What is Self-Insured Health Insurance? Most Very Large Employers Self-Insure, Verywell Health (November 6, 2025), available at https://www.verywellhealth.com/what-is-self-insured-health-insurance-and-how-is-it-regulated-4688567.

The Departments also assume that issuers and TPAs have already developed internet-based self-service tools, originally required for plan or policy years beginning on or after January 1, 2023, and will only need to modify these existing systems to comply with the final provisions. The Departments acknowledge that some interactive voice response programming work may be necessary, but the Departments expect the associated cost to be minimal.

As also noted in section V.C.3. of this preamble, the Departments estimate that approximately 1,303 issuers \124\ and 205 TPAs \125\ (a total of 1,508 entities) are expected to implement these final requirements. The Departments

acknowledge that actual costs may vary depending on factors such as the volume of providers and items or services for which cost-sharing information must be disclosed, and whether plans (or TPAs on behalf of plans) and issuers already have tools that fully or partially meet the final requirements or can be readily adapted. However, the Departments note that, in 2021, they announced their intention to propose rulemaking requiring that the same pricing information provided through the Transparency in Coverage internet-based self-service tool or in paper form be provided via phone.\126\ Because the statutory requirements to offer price comparison guidance by telephone have been in place for plan years (in the individual market, policy years) beginning on or after January 1, 2022,\127\ the Departments expected that many plans and issuers had already made progress toward meeting this requirement since then.

\124\ The Departments' estimate of the number of health insurance companies and the number of issuers (issuer/State combinations) is based on medical loss ratio (MLR) reports submitted by issuers for the 2024 reporting year. Centers for Medicare & Medicaid Services, Medical Loss Ratio Data and System Resources (last updated Mar. 3, 2026), available at https://www.cms.gov/CCIIO/Resources/Data-Resources/mlr. Although the Departments' estimates in the proposed rules were based 2023 MLR data, the Departments have updated these estimates based on the latest available MLR data to improve their accuracy.

\125\ Estimated number of non-issuer TPAs, based on data derived from the 2016 Benefit Year Reinsurance Program contributions.

\126\ 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 49 (August 20, 2021), https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-49.pdf and https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-49.pdf.

\127\ Code section 9819, ERISA section 719, and PHS Act section 2799A-4.

The Departments also assume that plans (or TPAs on behalf of plans) have already built self-service tools and will only be required to revise the existing statement disclosing that out-of-network providers may engage in balance billing, subject to applicable State and Federal laws. Although these updates build on existing infrastructure, they are expected to require a one-time cost for minor technical modifications including editing statement text, testing for quality assurance, and implementing the update. The Departments estimate that, on average, each issuer or TPA will require 10 minutes (approximately 0.17 hours) \128\ of a Senior Application Developer's time (at $182.76 per hour) to update the statement. As shown in Table 4, across all 1,508 issuers and TPAs, the total one-time burden is estimated at 251 hours, with an associated cost of approximately $45,934.

\128\ Unless otherwise specified, all burden-hour estimates in section IV. of this preamble were developed using an IGCE framework. The IGCE framework provides a structured approach for estimating the resources necessary to implement and maintain regulatory requirements by identifying the anticipated activities, appropriate labor categories, level of effort, and operational and technical resources associated with each requirement. The Departments used this framework to develop reasonable assumptions regarding the personnel and hours necessary for plans and issuers to complete each information collection activity, taking into account the nature and complexity of the required tasks. Additional information regarding IGCE tools and resources is available through the U.S. General Services Administration. See U.S. General Services Administration, IGCE (Independent Government Cost Estimate), https://buy.gsa.gov/pricing/ (last visited August 13, 2026). [GRAPHIC] [TIFF OMITTED] TR06OC26.026

Under a scenario with increased call volume and duration (that is, high impact), the Departments anticipate that requiring cost-sharing information to also be accessible by phone could increase call volume and call duration to the plan's or issuer's customer support line. This anticipated increase may result from participants, beneficiaries, and enrollees who prefer verbal assistance or who have limited digital access or digital literacy.

In the proposed rules, the Departments estimated that, under high- and low-impact scenarios, a customer service representative would require 10 and 9 minutes per interaction, respectively, to provide the requested information and complete post-call documentation. However, a commenter expressed concern that these consumer-support burden assumptions are underestimated, noting that call center interactions are likely to be longer and more complex than estimated and that consumers typically compare fewer providers in practice.

The Departments acknowledge the commenter's concern that the consumer-support burden assumptions may be underestimated. However, the Departments have determined that the cost-sharing information requested over the phone is generally readily available through existing price comparison tools, and customer service representatives should be able to access and communicate that information without significant additional time.

Accordingly, the Departments have determined that the estimated average call duration of approximately 9 to 10 minutes, including post- call documentation, as presented in the proposed rules, is reasonable. The Departments recognize that call times may vary depending on the complexity of the inquiry; however, they have determined that, in many cases, consumers will seek relatively straightforward information, such as the cost of services from a specific provider and their expected out-of-pocket responsibility.

In addition, available data on customer service interactions related to health care services suggest that average call times are often shorter, typically ranging from approximately 4 to 8 minutes.\129\ Although commenters stated that cost-sharing inquiries may involve greater complexity than typical health plan customer service calls, the Departments have determined that the higher estimated average call duration reasonably accounts for inquiries involving cost-sharing estimates that may be more complex than routine customer service calls. Taken together, these considerations support the reasonableness of the Departments' estimated average call duration.

\129\ Available industry data indicate that average handle times for health care-related customer service calls generally range from approximately 4 to 8 minutes, with reported averages of about 4.4 minutes (Dialog Health, https://www.dialoghealth.com/post/healthcare-call-center-statistics), 6.6 minutes (SpinSci, https://spinsci.ai/resources/what-is-average-handle-time-aht-in-healthcare), and 6 to 8 minutes (Zendesk, https://www.zendesk.com/in/blog/customer-service/satisfaction/average-handle-time/).

Taking these factors and available evidence into account, the Departments continue to maintain that, under a high-impact scenario, for each issuer or TPA,

it will require 10 minutes \130\ for a customer service representative (at $46.50 per hour) to speak with each consumer and provide the requested information and complete post-call documentation. Under the high impact scenario estimate, the Departments estimate there will be 7.8 million calls annually,\131\ each issuer or TPA will receive approximately 5,172 calls per year, resulting in an estimated annual burden of 862 hours,\132\ with an estimated associated cost of approximately $40,086. As shown in Table 5, the Departments estimate that for all 1,508 issuers and TPAs, the estimated total ongoing annual burden will be approximately 1,300,000 hours, with an estimated associated cost of $60,450,000 annually.\133\

\130\ According to a 2012 report by the Healthcare Financial Management Association, the average handle time for call centers generally ranges from 7 to 8 minutes. For purposes of this analysis, the Departments assume an additional 2 minutes will be needed for call documentation, resulting in an average handle time of 9 to 10 minutes. Accordingly, the Departments use 9 minutes as the lower bound and 10 minutes as the upper bound to estimate the potential impact of increased call times under the proposed disclosure requirements. Healthcare Financial Management Association, Ask the Expert: Setting Industry Standards for Call Center Activities (October 25, 2012), available at https://www.hfma.org/revenue-cycle/kpis/7256/.

\131\ According to data from the Congressional Research Service, the total insured population in private/commercial insurance, including employer-sponsored and individual market coverage, is projected to be approximately 156 million in 2023 (of the estimated 304 million insured individuals in 2023, approximately 148 million are covered by public programs, including Medicare, Medicaid, VA Care, and TRICARE. The remaining 156 million are covered under private/commercial insurance, including both employer-sponsored and individual market plans). The Departments estimate 5 percent of total calls will be shopping-related calls per year under the high- call time scenario. This estimate is informed by a KFF study (https://www.kff.org/affordable-care-act/kff-survey-of-consumer-experiences-with-health-insurance/) in which 57 percent of adults contacted their insurance in 2023, with under 31 percent asking about out-of-pocket expenses--a subset of which could reasonably be considered shopping related calls. Considering that consumers contact plans via phone, online, in-person, or in writing, it was estimated that 25 percent of these contacts were by phone. Of these phone contacts, 10-20 percent of the 31 percent asking about out-of- pocket expenses were assumed to be shopping calls, resulting in an estimated range of 2.5 percent to 5 percent of total calls being shopping-related. Using the upper bound of 5 percent for the high- call time scenario, this results in approximately 7.8 million shopping-related calls per year. Congressional Research Service, U.S. Health Care Coverage and Spending (February 19, 2025), available at https://www.congress.gov/crs-product/IF10830.

\132\ This calculation distributes the total workload across all 1,508 issuers and TPAs. At the industry level, there are 7,800,000 high-call time calls per year, with an average handle time of 10 minutes per call, resulting in 78,000,000 total minutes (1,300,000 hours). To compute the per-entity workload, the total calls are divided by the number of issuers and TPAs: 7,800,000/1,508 [ap] 5,172 calls per entity per year. Multiplying the per-entity calls by the 10-minute average handle time gives 51,724 minutes annually per entity, which converts to approximately 862 hours (51,724/60).

\133\ Throughout sections IV. and V. of this preamble, differences between subtotals, totals, and percentage calculations may occur due to rounding. As a result, figures presented in tables and accompanying text may not sum precisely. [GRAPHIC] [TIFF OMITTED] TR06OC26.033

Under a scenario with less call volume and duration (that is, a lower-impact scenario), the Departments assume that a smaller subset of participants, beneficiaries, and enrollees will opt to request pricing information by phone. In this scenario, the Departments estimate that for each issuer or TPA it will take 9 minutes for a customer service representative (at $46.50 per hour) to speak with consumers and provide the requested information and complete post-call documentation. Assuming 3.9 million calls annually,\134\ each issuer or TPA will receive approximately 2,586 calls per year, resulting in an estimated annual burden of 388 hours \135\ with an estimated associated cost of approximately $18,039 per issuer or TPA. As shown in Table 6, across all 1,508 issuers and TPAs, the estimated total ongoing burden is approximately 585,000 hours, with a total annual cost of approximately $27,202,500.

\134\ According to data from the Congressional Research Service, the total insured population in private/commercial insurance, including employer-sponsored and individual market coverage, is projected to be approximately 156 million in 2023 (of the estimated 304 million insured individuals in 2023, approximately 148 million are covered by public programs, including Medicare, Medicaid, VA Care, and TRICARE. The remaining 156 million are covered under private/commercial insurance, including both employer-sponsored and individual market plans). The Departments estimate that 2.5 percent of total calls will be shopping-related calls per year under the low-call time scenario. This estimate is informed by a KFF study (https://www.kff.org/affordable-care-act/kff-survey-of-consumer-experiences-with-health-insurance/) in which 57 percent of adults contacted their insurance in 2023, with under 31 percent asking about out-of-pocket expenses--a subset of which could reasonably be considered shopping related calls. Considering that consumers contact plans via phone, online, in-person, or in writing, it was estimated that 25 percent of these contacts were by phone. Of these phone contacts, 10-20 percent of the 31 percent asking about out-of- pocket expenses were assumed to be shopping calls, resulting in an estimated range of 2.5 percent to 5 percent of total calls being shopping-related. Using the lower bound of 2.5 percent for the low- call time scenario, this results in approximately 3.9 million shopping-related calls per year. Congressional Research Service, U.S. Health Care Coverage and Spending (Feb. 19, 2025), available at https://www.congress.gov/crs-product/IF10830.

\135\ This calculation distributes the total workload across all 1,508 issuers and TPAs. At the industry level, there are 3,900,000 low-volume calls per year, with an average handle time of 9 minutes per call, resulting in 35,100,000 total minutes (585,000 hours). To compute the per-entity workload, the total calls are divided by the number of issuers and TPAs: 3,900,000/1,508 [ap] 2,586 calls per entity per year. Multiplying the per-entity calls by the 9-minute average handle time gives 23,276 minutes annually per entity, which converts to approximately 388 hours (23,276/60).

[GRAPHIC] [TIFF OMITTED] TR06OC26.027

Plans (or TPAs on behalf of plans) and issuers will also incur a one-time burden and cost to train customer service representatives and their supervisors on this phone requirement. The Departments assume this requirement will not necessitate hiring additional full-time staff. Instead, the Departments expect issuers and TPAs to rely on existing customer service representatives and supervisors for this task.

For each issuer or TPA, the Departments estimate that one training specialist will spend 8 hours (at $98.03 per hour) to train 20 customer service representatives (totaling 160 hours at $46.50 per hour) and two supervisors (totaling 16 hours at $91 per hour) on how to respond to participants, beneficiaries, and enrollees seeking pricing information by phone. This results in a one-time burden of 184 hours per issuer or TPA, with an estimated associated cost of $9,680. As shown in Table 7, for all 1,508 issuers and TPAs, the total estimated one-time training hour burden is 277,472 hours, with a corresponding cost of approximately $14,597,802. [GRAPHIC] [TIFF OMITTED] TR06OC26.028

The Departments anticipate that, in the future, ongoing training costs associated with these phone requirements will be included into existing onboarding programs for new employees and included in the regular annual training provided to current staff. The Departments did not receive any comments regarding the ongoing training costs associated with these requirements.