Transparency in Coverage

Section IV.A. of this preamble outlines the quantified costs associated with updating cost-sharing disclosures to reflect Federal balance billing protections, as described in 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 Departments assume that plans and issuers have already developed self-service tools and will only need to revise the statement to state that out-of-network providers may engage in balance billing, subject to applicable State and Federal laws. Although these

updates build on existing infrastructure, the Departments estimate that all plans (or TPAs on behalf of plans) and issuers will incur a one- time cost for minor technical modifications, with a total burden of 251 hours and an associated cost of approximately $45,934.

Section IV.A. of this preamble also outlines the quantified costs associated with providing the cost-sharing information, as described in 26 CFR 54.9815-2715A2(b)(1), 29 CFR 2590.715-2715A2(b)(1), and 45 CFR 147.211(b)(1), over the phone, as finalized in paragraph 26 CFR 54.9815-2715A2(b)(2)(iii), 29 CFR 2590.715-2715A2(b)(2)(iii), and 45 CFR 147.211(b)(2)(iii). As discussed in more detail in section IV.A. of this preamble, the Departments have provided both lower impact and higher impact cost estimates to account for varying call times. The Departments estimate that all plans (or TPAs on behalf plans) and issuers will incur a total, low-range, annual ongoing time burden of 585,000 hours with an associated estimated cost of $27,202,500, and a total, high-range, burden of 1,300,000 hours with and associated estimated cost of $60,450,000, to provide pricing information by phone.

The Departments have determined that plans and issuers will leverage their existing customer service call center infrastructure to provide cost-sharing information over the phone to reduce or eliminate any one-time burden and cost. While the Departments have determined many plans (or TPAs on behalf of plans) and issuers already provide some level of real-time phone-based cost-sharing information, they recognize that some plans and issuers may need to alter existing or develop new infrastructure and could incur additional one-time burden and cost to meet these requirements.

The Departments also anticipate that providing phone-based access will increase call duration and require plans (or TPAs on behalf of plans) and issuers to train customer service representatives and supervisors, resulting in a one-time burden of 277,472 hours and an estimated total cost of approximately $14,597,802.

The Departments assume that most self-insured group health plans will rely on TPAs to fulfill these requirements and that TPAs typically serve multiple clients, allowing for economies of scale, which could result in a lower burden and cost. Additionally, the Departments acknowledge that plans and issuers might choose to upgrade their communication systems voluntarily, such as adding mobile call features or real-time texting, which could involve upfront implementation costs but may also result in operational efficiencies or cost savings over time. However, the Departments are not able to estimate the extent to which plans and issuers may pursue such voluntary upgrades or the associated costs or savings.

The Departments recognize that expanding access to personalized pricing data, particularly via phone, may increase the risk of potential exposure of PHI and PII. As with internet-based disclosures, additional investments in security infrastructure, staff training on data protection, and consumer privacy tools may be necessary to mitigate the risk of unauthorized access or breaches. According to HIPAA Journal's 2025 Healthcare Data Breach Report, hundreds of millions of individuals were affected by health care data breaches involving 500 or more records reported to the Department of Health and Human Services Office for Civil Rights.\177\ The report noted that, in 2024, a new record was set, with over 289 million individuals having their protected health information exposed or impermissibly disclosed. The report also stated that more than 700 large health care data breaches continue to be reported annually, with breaches plateauing in the range of 700 to 750 incidents per year, approximately two large health care data breaches per day. In 2025 alone, at least 61.5 million individuals had their protected health information exposed or impermissibly disclosed through reported breaches. As a result, complying with these provisions may necessitate additional safeguards to protect PHI and PII during phone-based interactions.

\177\ Steve Adler, 2025 Healthcare Data Breach Report, The HIPAA Journal (February 13, 2026), https://www.hipaajournal.com/2025-healthcare-data-breach-report/.

The Departments requested comment on these burden and cost estimates, including assumptions on disclosures to reflect Federal balance billing protections, call duration, customer service staffing, and the extent to which plans (or TPAs on behalf of plans) and issuers are already equipped to provide real-time cost-sharing information by phone. The Departments received numerous comments which are discussed in more detail in section IV.A. of this preamble.

While not quantified in this analysis, the Departments acknowledge that State regulators may incur administrative costs to review, monitor, or enforce compliance with these additional requirements. The Departments requested comment on any potential State-level impacts and any other burdens and costs that could be incurred by entities that would be affected by the provision of these final rules. No comments were received on these issues. 3. Requirements for Public Disclosure Under 26 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212

The following paragraphs describe the non-quantified benefits, as well as the quantified costs and cost savings of the final requirements to the disclosure of information related to in-network rates and historical out-of-network allowed amounts through machine-readable files. a. Non-Quantified Benefits (1) Stronger Market Leverage for Plans and Issuers

By requiring more streamlined, meaningful, and clear disclosure of in-network rates and detailed out-of-network data, the provisions in these final rules will better enable plans and issuers to compare their in-network rates and out-of-network coverage with those of competitors. The addition of contextual files, including the Taxonomy File and Utilization File, is expected to enhance the practical value of this data, helping plans and issuers see not just raw prices but also provider specialties, actual in-network utilization, and historical changes in rate information.

This will support plans and issuers in identifying gaps, trends, and outliers within their own networks and relative to the market. This enhanced transparency is expected to strengthen their ability to negotiate lower reimbursement rates with providers based on knowing what those providers have negotiated with other payers that are similarly situated within the market for the same items or services with other plans and issuers that are similarly situated within the market. However, as noted in section V.D.2.a.(3). of this preamble, the Departments also recognize the potential for this information to drive rates up if providers learn they are being paid less than other providers and use that information to seek higher negotiated rates.

By enhancing the transparency of out-of-network allowed amounts and historical billed charges, these provisions may facilitate broader adoption of private health insurance market reference-based pricing strategies. Specifically, the final requirements related to the Allowed Amount File are expected to provide the

public with clearer information on what out-of-network providers charge. This additional transparency can help plans, issuers, and other file users better identify lower-cost providers and benchmark reasonable prices, ultimately supporting strategies where participants, beneficiaries, or enrollees pay the difference when selecting higher- cost providers in circumstances where they have a meaningful choice among providers.

Plans and issuers may use such reference-based pricing structures to guide participants, beneficiaries, and enrollees toward lower-cost providers. While the Departments recognize that reference-based pricing may not apply uniformly (for example, some plans offer exemptions based on clinical need or geographic limitations), it has generally led to cost reductions. For instance, combining price transparency with reference-based pricing has led to significant shifts in consumer choice of facility, resulting in a 27 percent reduction in the average price paid per laboratory test and a 13 percent reduction in the average price paid per imaging test.\178\

\178\ Christopher Whaley, Timothy Brown, & James Robinson, Consumer responses to price transparency alone versus price transparency combined with reference pricing, 5 American Journal of Health Economics 227, 249 (2019).

The Departments also expect that these final rules may facilitate more efficient improvements to plan design by making pricing information more accessible, standardized, and usable. With clearer information on negotiated rates, out-of-network allowed amounts, billed charges, provider specialties, utilization, and historical changes in rate information, plans and issuers may be better positioned to assess relative prices across providers, services, and markets and to refine network design, benefit design, and cost-sharing structures accordingly. In the absence of these disclosure requirements, higher- priced plans, issuers, and providers may have little incentive to disclose pricing information in a consistent and usable format, which can limit transparency and hinder the ability of other market participants to identify inefficiencies, evaluate alternative options. (2) Enhanced Regulatory Oversight, Market Monitoring, and Fiscal Effects

The Departments expect State and Federal regulators to gain efficiencies and insights from the data reporting pursuant to the amended disclosure requirements in these final rules. The final provisions will give regulators access to more streamlined, usable, and actionable in-network rates and out-of-network data, which may support more informed oversight of premium rate filings by enabling more effective monitoring of market trends and price variations. The final provisions may also help States monitor rates to identify collusive behaviors, as well as help establish benchmarks for negotiations with providers as part of State oversight activities related to coverage programs, ultimately strengthening regulatory oversight and promoting more competitive markets.

Recent analysis of proposed Federal price transparency legislation also illustrates that price transparency may have the potential to increase Federal revenue. One analysis estimated that the Patients Deserve Price Tags Act \179\ could generate approximately $122 billion in additional Federal revenue over the 2026 through 2035 period, with estimates ranging from approximately $25 billion to $270 billion.\180\ The analysis assumes that reductions in employer-sponsored insurance spending would reduce premiums and, over time, increase taxable wages, resulting in additional Federal income and payroll tax revenue. The estimated price effect was based on quantified effects from seven studies examining price transparency, reference pricing, and payment cap interventions in U.S. health care, with the range reflecting variation in the estimated effects across those studies. Although this analysis evaluates a broader set of price transparency policies and therefore cannot be used to estimate the fiscal effects of these final rules, it illustrates a potential mechanism through which the enhanced transparency requirements finalized in these rules could have broader economic and fiscal effects. To the extent these final rules increase competition and reduce health care spending and employer-sponsored insurance premiums, some of those reductions could ultimately be reflected in higher taxable wages and associated Federal tax revenues. The Departments have not quantified these potential effects.

\179\ Patients Deserve Price Tags Act, S. 2355, 119th Congress (2025), https://www.congress.gov/bill/119th-congress/senate-bill/2355.

\180\ Daniel Arnold & Christopher Whaley, Patients Deserve Price Tags: Independent Cost Savings Estimate, Center for Advancing Health Policy Through Research, Brown University School of Public Health (May 29, 2026), https://repository.library.brown.edu/studio/item/bdr:7dgwbwgp/.

(3) Increased Understanding and Empowered Consumers

These final rules aim to empower participants, beneficiaries, and enrollees by increasing transparency around what plans and issuers reimburse providers for covered items and services. By providing access to clearer, more streamlined, and more specific in-network rates, historical out-of-network allowed amounts, and billed charges, file users and ultimately health care consumers may be better equipped to understand how their choices of coverage and providers affect their costs. This transparency is expected to support more informed consumer decision-making when comparing plans or selecting providers.

Adding supporting contextual information to accompany the data is expected to enhance overall usability for third-party developers and other file users. As stated in the preamble to the 2020 final rules, the Departments expected third-party developers and other innovators to use the machine-readable file data to create “easy-to-use internet- based tools and mobile applications that will present information to laypersons in easy-to-understand, plain language that is sufficiently concise and well-organized,” \181\ which will allow “consumers to consider price as a factor when making meaningful comparisons between different coverage options and providers.” \182\

\181\ 85 FR 72158, 72169 (November 12, 2020).

\182\ Id. at 72210.

The Departments are encouraged by the consumer-facing tools that have been built since implementation of the 2020 final rules and look forward to additional growth in this space following implementation of the enhancements in these final rules. b. Costs

This section of the preamble provides both quantitative and qualitative analysis of the costs and cost savings associated with the Departments' final revisions to the requirements that plans and issuers make information regarding in-network negotiated rates and out-of- network allowed amounts available through machine-readable files on a public website. (1) Quantified Costs

Section IV.B. of this preamble outlines the quantified costs associated with requirements for public disclosure of in-network rates and allowed amount data for covered items and services from in- and out-of-network providers, as described under 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212.

For In-network Rate Files, these final rules require plans and issuers to create a separate file for each provider

network, allow rates to be expressed as a percentage of billed charges when certain conditions are met, disclose the common provider network name, the provider network identifier, the product type of each plan or policy whose rates are included in the file and publish Taxonomy Files, and exclude providers unlikely to be reimbursed based on their scope of practice as well as allowing service providers to organize In-network Rate Files across multiple self-insured group health plans. The Departments estimate that all plans (or TPAs on behalf of plans) and issuers will incur a combined total one-time burden of 636,979 hours on the low end and 675,584 hours on the high end, with associated costs of approximately $107,027,465 and $113,178,175, respectively.\183\ While these provisions involve a one-time cost to modify existing processes, the Departments expect that, once these updates are implemented, the ongoing burden related to these changes will be minimal, beyond current costs for monitoring and maintaining these processes.

\183\ The low-end estimate is calculated as: 289,536 hours ($51,671,077) [organizing files by provider network] + 48,256 hours ($7,688,387) [including product type in the In-network Rate and Allowed Amount Files] + 9,651 hours ($1,537,678) [reporting dollar amounts except for only “percent-of-billed charges” payments] + 289,536 hours ($46,130,323) [excluding certain providers from the In-network Rate Files and publishing Taxonomy Files] = 636,979 hours and $107,027,465. The high-end estimate is calculated as: 289,536 hours ($51,671,077) [organizing files by provider network] + 48,256 hours ($7,688,387) [including product type in the In-network Rate and Allowed Amount Files] + 48,256 hours ($7,688,387) [reporting dollar amounts except for only “percent-of-billed charges” payments] + 289,536 hours ($46,130,323) [excluding certain providers from the In-network Rate Files and publishing Taxonomy Files] = 675,584 hours and $113,178,175.

For Allowed Amount Files, these final rules require data reporting at the market level instead of the individual plan or policy level, lowering the claims threshold from 20 to 11, extending the reporting period from 90 days to 6 months, and increasing the lookback period from 180 days to 9 months to enhance the robustness of historical data. The Departments estimate that all plans (or TPAs on behalf of plans) and issuers will incur a one-time burden of 96,512 hours, with associated costs of approximately $15,376,774. Lowering the claims threshold to 11 is expected to require only minor system adjustments, and the Departments anticipate minimal ongoing costs for maintaining and monitoring compliance. Similarly, extending the lookback and reporting periods are not expected to impose a significant additional burden, as the Departments expect only minimal system modifications to be needed, with associated costs absorbed into the routine system maintenance activities that plans (or TPAs on behalf of plans) and issuers already perform in the normal course of business. Ongoing costs for aggregating out-of-network Allowed Amount Files by market type are also expected to be minimal.

In addition, these final rules require plans and issuers to post several contextual machine-readable files: a Utilization File and a Text File, each with specific update and posting requirements. The Departments estimate a one-time burden of 1,061,632 hours for all plans (or TPAs on behalf of plans) and issuers, with associated costs of approximately $180,394,198 to implement the Utilization File requirements and add a Text File. The Departments further estimate an ongoing annual burden of 57,304 hours (costing approximately $9,552,155) to update the Utilization File and 45,240 hours (costing approximately $7,475,608) to respond to machine-readable file inquiries to improve discoverability and accessibility of the machine-readable files.

Once the initial implementation of the machine-readable file requirements is complete, the Departments expect ongoing updates to require minimal effort. While the Departments estimate ongoing costs associated with maintaining the Utilization File, as discussed in section IV.B.10. of this preamble, the Departments do not expect the Text File, the excluded-provider requirements, publication of the Taxonomy File, or the requirement to include a link to the internet domain hosting the machine-readable files on the website footer is expected to result in minimal ongoing costs beyond routine maintenance activities associated with existing machine-readable file reporting processes.

The Departments requested comment and data on how to better quantify these costs and have considered the comments received, which are addressed in section IV.B. of this preamble.

In addition, these final rules require plans and issuers to make machine-readable files available in a single non-proprietary, open- standards format, as specified in guidance issued by the Departments. The Departments estimate a one-time burden of 25,636 hours for plans (or TPAs on behalf of plans) and issuers, with associated costs of approximately $4,483,653 to implement this requirement, and do not anticipate ongoing costs, as this reflects a one-time update for a limited number of plans and issuers.

Finally, these final rules require plans and issuers to attest, to the best of their knowledge and belief, to the accuracy and completeness of the information contained in their machine-readable files. As discussed in section IV.B.14. of this preamble, the Departments estimate that plans (or TPAs on behalf of plans) and issuers will incur a one-time burden of 39,208 hours, with associated costs of approximately $5,046,281, to implement this requirement. The Departments further estimate an ongoing annual burden of 21,112 hours, with associated costs of approximately $2,961,863, to prepare, update, and maintain the required attestations each year.

In addition, because the Departments are adopting a phased implementation approach in these final rules, under which certain requirements become applicable 5 months after publication in the Federal Register (Phase 1), while others become applicable 11 months after publication (Phase 2), plans and issuers are expected to require additional resources during the overlap period. These activities include planning and design systems development, file creation and testing, operational coordination, and other implementation activities. As discussed in section IV.B.15. of this preamble, the Departments estimate an additional one-time burden of 435,259 hours for plans (or TPAs on behalf of plans) and issuers, with associated costs of approximately $66,624,563 to implement this requirement, and do not anticipate any recurring costs because the phased approach affects only the timing and sequencing of one-time implementation activities. (2) Cost savings (a) Reduced Data Cleaning and Integration Costs for Third-Party Developers and Other File Users

The Departments have determined that by reducing the complexity and inconsistency of data that currently require extensive data processing and reconciliation, these final rules will make machine-readable data both easier to locate and easier to process for third-party developers and other file users, such as academics, researchers, data engineers, and plans and issuers. These final rules will do this by requiring plans and issuers to publish contextual files including a Taxonomy File and a Utilization File; report at the provider network level rather than the plan or policy level; exclude providers that have in-network rates for items or services for which they are unlikely to

be reimbursed; add common provider network names and provider network identifiers, and product types; and standardize file locations with a Text File and footer links. The Departments anticipate that much of the burden currently involved in cleaning and processing the machine- readable files will be eliminated, since the files will contain more accurate data in smaller sizes. This is expected to reduce the time and resources that third-party developers and other file users spend removing duplicative and irrelevant data, which in turn will decrease the computational resources required for data cleaning and integration, further reducing overall costs.

In particular, the Departments estimate that the finalized provisions to require network-level reporting and specifying product types will meaningfully reduce data cleaning and integration costs for approximately 300 third-party developers and other file users,\184\ including research shops and consultancies. Specifically, network-level reporting as finalized is expected to save about 40 hours per quarterly reporting cycle, or 160 hours annually. The inclusion of product types is expected to save an estimated 20 hours per quarterly cycle, or 80 hours annually. Together, these provisions are expected to save about 240 hours of analyst time per year for each third-party developer or other file user. Using a median hourly wage of $112.01 for a Business Analyst,\185\ the Departments estimate total annual labor savings across all 300 third-party developers and other file users to be approximately $8.1 million.\186\

\184\ This estimate is based on discussions with a sample of third-party developers and other file users. From these discussions, the Departments estimated a total of approximately 300 third-party developers and other file users consuming the public disclosures associated with these rules.

\185\ U.S. General Services Administration, Pricing Intelligence Suite, CALC information and wage rates, https://buy.gsa.gov/pricing/ (last visited August13, 2026).

\186\ The total estimated annual labor savings is calculated by multiplying the 240 hours saved per third-party developer or other file user by the 300 affected users and the average hourly wage of $112.01 (240 x 300 x $112.01 = $8.1 million).

In addition, by requiring plans and issuers to exclude provider- rate combinations for items and services for which a provider is unlikely to be reimbursed, the Departments estimate a substantial reduction in the data volume that will be disclosed, compared to current volumes, leading to lower computational costs when processing the files. Assuming industry-wide disclosures currently total roughly 1,000,000 gigabytes (GB), equivalent to 1 petabyte (PB) \187\ in size per month, the exclusion of these provider-rate combinations is expected to reduce file sizes by about 70 percent \188\ to an estimated size of 300,000 GBs. While most cost savings will be associated with algorithms that process the data, which will reflect much higher actual computation savings, an absolute baseline can still be established.

\187\ Christopher Whaley, Nandita Radhakrishnan, Michael Richards, Kosali Simon, et al., Understanding Health Care Price Variation: Evidence from Transparency-in-Coverage Data, 3 Health Affairs Scholar 2 (2025), https://doi.org/10.1093/haschl/qxaf011.

\188\ This estimate is based on internal analysis of existing data and feedback from interested parties. External sources, such as Serif Health, report rates exceeding 80 percent. Salman Mukhi, Zombie Hunting: Filtering Approaches for Price Transparency Data (Sep. 20, 2024), https://www.serifhealth.com/blog/zombie-hunting-filtering-approaches-for-price-transparency-data.

Assuming an average compute cost of $0.015 per GB RAM-hour for general purpose usage,\189\ the baseline monthly compute cost for 1 PB is estimated at roughly $334 \190\ with an annual cost savings of $4,008. With a 70 percent reduction in file size, monthly compute costs are expected to decrease to approximately $100, yielding a monthly cost savings of $234, corresponding to an estimated annual savings of approximately $2,808 per third-party developer or other file user. Across 300 third-party developers and other file users, this equates to total annual cost savings of approximately $842,400.

\189\ Amazon Web Services, Amazon EC2 On-Demand Pricing, https://aws.amazon.com/ec2/pricing/on-demand (last accessed May 5, 2026).

\190\ This is calculated using AWS t4g.xlarge throughput of 720 GB/hour and 16 GB of RAM. Total hours = Total data/Throughput = 1,000,000GB/720GB per hour [ap] 1,388.89 hours; GB-RAM-hours = RAM x Hours = 16GB x 1,388.89 hours [ap] 22,222 GB-RAM-hours; Total cost = GB-RAM-hours x Price per GB-RAM-hour = 22,222 x $0.015 [ap] $333.33.

These final rules shift the reporting frequency from monthly to quarterly for In-network Rate and Allowed Amount Files, reducing the total computational needs accordingly. This change reduces total annual downloads from 3,600 (300 third-party developers and users x 12 months) to 1,200 (300 third-party developers and users x 4 months), or an average of 100 downloads per month to be processed. Under quarterly reporting, the estimated annual industry-wide computational costs for the optimized files are estimated to be $120,000.\191\ Relative to the monthly baseline, this cadence change combined with the file-size reduction yields an estimated $1,082,400 in total annual computational cost savings. Of this amount, approximately $842,400 is attributable to file-size optimization, while an additional $240,000 \192\ results from the reduction in reporting frequency.

\191\ Total computational costs for new files (300,000 GB) processed quarterly are calculated as $100 x 1,200 downloads per year = $120,000.

\192\ This is calculated by subtracting the total annual compute cost under quarterly reporting ($120,000) from the total annual compute cost under monthly reporting ($360,000): $360,000-$120,000 = $240,000.

The Departments have determined that together these final provisions are expected to result in total annual savings of roughly $9.2 million ($8.1 million in labor savings plus $1.1 million in industry-wide storage cost savings from the shift to quarterly reporting) for third-party developers and other users of price transparency data, while supporting the intended goal of making price data more usable and actionable.

The Departments also expect that other finalized provisions, including the addition of common provider network names, provider network identifiers, the Taxonomy File, and the Utilization File, will further improve the usability and accessibility of the machine-readable files. However, the Departments did not separately quantify the savings associated with these provisions.

The Departments requested comment on the estimated potential cost and time savings from streamlining and standardizing the machine- readable files, and on whether these provisions would effectively result in reduced data processing burdens and costs for users. The Departments did not receive any comments on these estimates. (b) Reduced Storage Costs for Plans, Issuers, Third-Party Developers, and Other Files Users

The Departments anticipate that the finalized provisions will result in storage cost savings for plans, issuers, third-party developers, and other file users by significantly decreasing the total volume of data needed to generate, store, and make the files available for download. These provisions will minimize data duplication and reduce both the number and size of the machine-readable files by changing the reporting cadence for both the In-network Rate File and the Allowed Amount File from monthly to quarterly, requiring reporting of negotiated rates at the provider network level rather than the plan or policy level, and excluding provider-rate combinations in the In- network Rate File for certain items and services.

The Departments have determined that these changes will lower ongoing storage, backup, and processing costs for the In-network Rate File, making it

easier and more cost-effective for third-party developers and other file users to download, build, and manage consumer-facing price comparison tools based on the machine-readable data.

As noted in section V.D.3.b.(2).(a). of this preamble, researchers have estimated that the combined monthly file sizes across industry for the In-network Rate Files are over 1 PB. The Departments estimate that the finalized provisions will reduce file sizes by approximately 70 percent, lowering the monthly data volume from about 1,000,000 GB to approximately 300,000 GB.

Using Amazon Web Services (AWS) S3 pricing as a benchmark, $0.023 per GB for the first 50 TB, $0.022 per GB for the next 450 TB, and $0.021 per GB beyond that,\193\ storing 1 PB worth of data will result in an estimated baseline monthly storage cost savings of roughly $22,583 with an annual cost savings of approximately $270,996. With a 70 percent reduction in file size, monthly storage costs are expected to decrease to approximately $6,651 ($79,812 annually), yielding a monthly cost savings of $15,932 and an estimated annual cost savings of approximately $191,184. These cost savings are expected to apply for all plans and issuers.

\193\ Amazon Web Services, Amazon S3 pricing, https://aws.amazon.com/s3/pricing/ (last accessed May 5, 2026).

Assuming 300 third-party developers and other file users download the files each month, total annual storage costs under current file size assumptions are estimated to be approximately $81,298,800.\194\ With the 70 percent file-size reduction, the annual cost for all 300 third-party developers and other file users is expected to decrease to $23,943,600.\195\ This results in an annual storage cost savings of roughly $57,355,200 \196\ for the 300 third-party developers and other file users as result of file-size optimizations.

\194\ This is calculated by multiplying the current yearly cost to download multiplied by the number of third-party developers and other file users: $270,996 x 300 = $81,298,800.

\195\ This figure is calculated by multiplying the annual cost per user after the file-size reduction ($79,812) by the number of third-party developers and other file users (300): $79,812 x 300 = $23,943,600.

\196\ Annual storage savings of $57,355,200 is calculated by subtracting the total annual cost after file-size reduction ($23,943,600) from the total annual cost under current file-size assumptions ($81,298,800): $81,298,800-$23,943,600 = $57,355,200.

In addition, because these final rules also shift the reporting frequency from monthly to quarterly, total storage needs and corresponding savings are expected to be reduced accordingly. Under quarterly reporting, annual industry-wide storage cost for the reduced file size for the In-network Rate Files is estimated at $7,981,200.\197\ Relative to the monthly baseline, this cadence change combined with the file-size reduction is expected to yield about $73,317,600 in total annual storage cost savings.\198\ Of this amount, approximately $57,355,200 in storage cost savings can be attributed to file-size optimization, while an additional $15,962,400 is attributable to the reduction in reporting frequency.

\197\ This is calculated by multiplying the reduced monthly storage cost ($6,651) by 4 quarterly reports and 300 third-party developers and other files: $6,651 x 4 x 300 = $7,981,200.

\198\ This is calculated by subtracting the total storage costs for the new, quarterly file downloads ($7,981,200) from the total storage costs for the current monthly downloads ($81,298,800): $81,298,800-$7,981,200 = $73,317,600.

The Departments requested comment on the assumptions made and the estimated storage cost savings for plans and issuers, third-party developers, and other users from reducing data volume. The Departments did not receive any comments on these estimates. (c) Reduced Network Egress Costs for Plans and Issuers

In addition to the estimated savings from reduced storage requirements, the Departments anticipate that the final provisions would also lead to a reduction in bandwidth network costs for plans and issuers associated with making their machine-readable files available for download.

Using the estimates developed and discussed in section V.D.3.b.(2).(b). of this preamble, for the In-network Rate File, and applying AWS egress costs, which are fees for data transferred from AWS to the public internet, as a benchmark--the first 100 GB are free, followed by $0.09 per GB for the first 50 TB, $0.085 per GB for the next 40 TB, $0.07 per GB for the next 100 TB, and $0.05 per GB for any amount exceeding 150 TB \199\--the Departments estimate a monthly tiered egress cost of transferring 1 PB data to be approximately $53,800 with an estimated annual cost of roughly $645,600. With a 70 percent reduction in file size to 300,000 GB, monthly data transfer egress costs are expected to decrease to about $18,795, with estimated annual costs of approximately $225,600. This is expected to yield a monthly cost savings of $35,005 and annual cost savings of approximately $420,060 for all plans and issuers. These cost estimates assume a single data transfer, or download, each month.

\199\ Amazon Web Services, Amazon EC2 On-Demand Pricing, https://aws.amazon.com/ec2/pricing/on-demand/ (last accessed May 5, 2026).

The Departments expect that the files will be downloaded by many third-party developers and other file users. Assuming 300 third-party developers and other file users download the files each month, total annual egress costs under current file size assumptions are estimated to be nearly $194 million.\200\ With the optimized file size estimates, the costs are expected to be reduced by about $68 million annually,\201\ yielding total industry-wide cost savings of $126 million annually.\202\

\200\ At current file sizes, data transfer cost estimates are approximately $53,800 per month for 1 PB data. The Departments assume that 300 third-party developers and other file users each download one file per month (12 annually), resulting in 3,600 total downloads per year. Based on a cost of $53,800 per download, the estimated annual cost is approximately $193,680,000 ($53,800 x 3,600).

\201\ This is calculated as follows: Estimated size data transfer cost estimates for optimized files are $18,795 per month for transferring 300,000 GB. The Departments assume that 300 third- party developers and other file users each download one file per month (3,600 downloads each year). At this rate, the total annual cost is estimated at $67,662,000 ($18,795 x 3,600).

\202\ Estimated annual size data transfer cost savings are calculated by subtracting the total annual cost for the optimized 300TB files ($67,662,000) from the total annual cost for the original 1PB files ($193,680,000): $193,680,000-$67,662,000 = $126,018,000.

Similar to reduced storage costs for plans and issuers discussed in section V.D.3.b.(2).(b). of this preamble, these final rules shift the reporting frequency from monthly to quarterly, which is expected to reduce total egress needs and corresponding costs. This change reduces total annual downloads from 3,600 (300 third-party developers and other file users x 12 months) to 1,200 (300 third-party developers and other file users x 4 months), or an average of 100 downloads per month. Under quarterly reporting, annual industry-wide egress costs for the optimized files are estimated to be about $22.6 million.\203\ Relative to the monthly baseline, this cadence change combined with the file- size reduction is expected to yield about $171 million in total annual cost savings.\204\ Of this amount, approximately $126 million egress cost savings is attributable to file-size optimization, while the additional $45

million results from the reduction in reporting frequency.

\203\ Total network costs for transferring new files (300,000 GB) on a quarterly basis are calculated by multiplying the monthly cost per file transfer ($18,795) by the total annual downloads (1,200): $18,795 x 1,200 downloads per year = $22,554,000.

\204\ Total network cost savings are calculated by subtracting the total annual network costs for the new files downloaded quarterly ($22,554,000) from the total annual costs for the current monthly downloads ($193,680,000): $193,680,000-$22,554,000 = $171,126,000.

The Departments requested comment on the assumptions made and anticipated egress cost savings for plans and issuers from reducing data volume and reporting cadence. The Departments did not receive any comments on these estimates. (d) Reduced Time Locating the Files for Third-Party Developers and Other File Users The Departments' decision to require plans and issuers to include a standardized Text File and to place a link to the web page that hosts the files in a footer on the plan's or issuer's home page are expected to make it easier for third-party developers and other file users, who currently face challenges navigating plan or issuer websites to find their machine-readable files, to more efficiently locate and access the data needed for their applications and analyses.

The time savings from locating files primarily stems from the requirement that plans and issuers include a standardized Text File that includes, among other things, the source page URL for the internet website that hosts the machine-readable files and a direct link to the URL for the machine-readable files, as well as the requirement that plans and issuers include a footer link in certain prominent locations that links directly to the internet website that hosts the machine- readable files. Additionally, the change from monthly to quarterly reporting is expected to reduce the number of times a file user will need to locate the In-network Rate and Allowed Amount Files to find updated information.

Together, the Departments estimate that these changes are expected to save about 10 hours of labor \205\ quarterly (or 40 hours annually) for each third-party developer or file user, reflecting the reduced need to manually track down and verify file locations. Using an average hourly wage of $112.01 for a Business Analyst,\206\ the Departments estimate that the total annual labor cost savings for all third-party developers and other file users will amount to approximately $1.3 million.\207\

\205\ The estimated 10 hours saved annually per organization is based on the assumption that, for each update, organizations review the prior month's links to locate files, and only a subset of those files requires additional effort to determine their posting location.

\206\ U.S. General Services Administration, Pricing Intelligence Suite, CALC information and wage rates, https://buy.gsa.gov/pricing/ (last visited August 13, 2026).

\207\ The total annual labor savings estimate is derived as follows: each of the approximately 300 third-party developers and other file users is estimated to save 10 hours of labor per quarterly reporting cycle as a result of the proposed standardized Text File and footer link, which facilitate easier file location. With four reporting cycles per year, this equates to 40 hours saved annually per third-party developer or other file user. Applying an average hourly wage for a Business Analyst of $112.01 results in an estimated annual savings of approximately $4,480 per third-party developer or other file user (40 hours x $112.01). When aggregated across the estimated 300 third-party developers and other file users, the total annual labor savings amount to approximately $1,344,120.

The Departments requested comment on the assumptions and estimated burden and cost savings from making the machine-readable files easier to locate through standardized links. The Departments did not receive any comments on these estimates.

The Departments have determined that the provisions of these final rules will help reduce administrative complexity and advance the objective of making price transparency data more accessible, efficient, and actionable for participants, beneficiaries, and enrollees.

As shown in Table 42, the final provisions are expected to generate total annual cost savings of approximately $255 million for plans, issuers, third-party developers, and other users. [GRAPHIC] [TIFF OMITTED] TR06OC26.064

(3) Non-Quantified Costs for Public Disclosure of In-Network Provider Rates

These final provisions are expected to introduce meaningful improvements to the quality, clarity, and usability of In-network Rate Files, such as requiring files to be organized by provider network rather than by plan or policy, allowing for percentage-of-billed charges reporting when the dollar amount is not known in advance, adding contextual files like Taxonomy and Utilization Files, and excluding certain provider-rate combinations if it is unlikely that a provider would be reimbursed for an item or service given that provider's area of specialty. While these improvements are intended to help file users, tool developers, and regulators better navigate and interpret rate data, they may also create non-quantified operational and market-level costs for plans and issuers.

Specifically, plans and issuers may face additional administrative and compliance costs from producing and maintaining more standardized machine-readable files. This may involve internal quality reviews, greater coordination across business units, as well as potential redesign of existing automated processes to create network-specific files and include new required data fields.

There is also a risk that improving the transparency of negotiated rates may cause some providers to raise their prices if they discover they are paid less than their peers. This response could contribute to price convergence rather than sustained downward pressure on costs, an effect observed in some transparency studies, where high prices fall slightly but lower prices rise, ultimately reducing overall savings. For instance, one study found that although price transparency has helped narrow price variation in health care, it has not consistently lowered overall prices. According to the study, the highest prices fell by 6.3 percent, while the lowest prices rose by 3.4 percent, and mid- range prices decreased only slightly by 1.1 percent.\208\ While the study does not address the effect on average prices, these findings suggest that transparency can pressure high-cost providers to reduce prices but may also lead lower-cost providers to increase prices. A 2020 study also suggests that price transparency could facilitate tacit collusion, resulting in higher prices in markets that are not perfectly competitive, such as health care. In these markets, there are fewer sellers and higher barriers to entry for new competitors.\209\

\208\ Forrest Xiao, The Healthcare Cost Conundrum: Prices are Stabilizing. Why are Expenses Still Rising?, Turquoise Health (October 31, 2024), https://blog.turquoise.health/the-healthcare-cost-conundrum/.

\209\ Robert Graboyes & Jessica McBirney, Price Transparency in Healthcare: Apply With Caution, Mercatus Center, George Mason University (August 19, 2020), https://www.mercatus.org/system/files/graboyes-price-transparency-mercatus-research-v1.pdf.

Another potential cost stemming from increased transparency due to improvements in In-network Rate Files is the impact on a plan's or issuer's ability or incentive to develop and maintain a robust provider network. A provider network consists of health care providers that have entered into agreements with plans or issuers to deliver care at a negotiated rate, which the provider accepts as full payment. Plans and issuers often prefer their participants, beneficiaries, and enrollees to use in-network providers, as these providers meet the health plan's quality standards and agree to lower rates in exchange for the patient volume they will receive by being part of the network.\210\ Some plans and issuers use narrow networks, which include a more limited group of providers. While these networks offer fewer in-network options to participants, beneficiaries and enrollees, they often result in lower monthly premiums and reduced out-of-pocket costs.\211\ The Departments recognize that publicly disclosing negotiated rates may reduce the incentive for providers to enter into such contractual agreements, particularly in narrow networks, if they know those rates will be made public or if they are being offered lower than market rates. This could, in turn, limit network options available to plans and issuers.

\210\ Elizabeth Davis, Health insurance provider network overview, Verywell Health (updated January 13, 2026), https://www.verywellhealth.com/health-insurance-provider-network-1738750.

\211\ Tracy Anderman, What to know about narrow network health insurance plans, Consumer Reports (Nov. 23, 2018), https://www.consumerreports.org/health-insurance/what-to-know-about-narrow-network-health-insurance-plans.

Smaller issuers may be disproportionately affected by the improved transparency of negotiated rates, as they may be unable to match the higher rates that larger issuers can offer. In turn, smaller issuers may be forced to contract only with lower-cost providers, potentially leading to narrower networks and affecting participant, beneficiary, and enrollee access to care. Such network constraints may also make it more difficult for these issuers to fully comply with network adequacy standards described at 45 CFR 156.230 or applicable State standards. Ultimately, while the purpose of improving price transparency is to empower participants, beneficiaries, and enrollees and enhance market efficiency, the Departments acknowledge that these final provisions could, in some cases, reduce the ability or incentive of plans and issuers, especially smaller ones, to build and maintain robust networks that satisfy quality and access requirements. (4) Non-Quantified Costs for Public Disclosure of Out-of-Network Allowed Amounts

The Departments recognize the potential costs arising from the expansion of data in the Allowed Amount Files. These may include the increased complexity and administrative burden of managing and reporting a larger volume of data over extended reporting and lookback periods, as well as at the broader health insurance market level rather than at the plan or policy level. Additionally, to account for the expanded handling of detailed claims data, plans and issuers may face additional expenses for enhanced cybersecurity measures and compliance with data privacy regulations. These potential costs are difficult to quantify given current data limitations, but the Departments acknowledge that they represent important considerations associated with implementing these final provisions.

The Departments requested comment and data on the potential magnitude of these non-quantified costs, including legal, operational, and network impacts, and how they may affect plan and issuer implementation, including information that may assist the Departments in estimating any additional burden and cost. However, the Departments did not receive comments that primarily addressed or provided information that would assist the Departments in quantifying these specific non-quantified costs. 4. Summary of Transfers

The requirements of these final rules, as discussed in section III. of this preamble, require plans and issuers to enhance the accuracy and usability of pricing information through improved machine-readable files, expand cost-sharing disclosure methods (including phone access), and streamline reporting requirements. As a result of these final requirements, the Departments expect various transfers to occur between plans and issuers; providers; participants, beneficiaries, and enrollees; and the Federal government. While the precise magnitude of these transfers is difficult to quantify due to varying market conditions and consumer behaviors, the directional effects and distributional impacts can be analyzed conceptually. a. Transfer From Higher-Cost to Lower-Cost Providers

If participants, beneficiaries, and enrollees gain easier access to pricing information through enhanced machine-readable files and phone- based cost-sharing estimates, some consumers may switch from higher- cost to lower-cost providers for comparable services. This transfer occurs as consumer cost preferences result in shifts from providers who charge what consumers feel are above-market rates, to those offering what the consumer feels to be more competitive pricing. The magnitude of this transfer is expected to depend on several factors such as the degree of price variation between providers, consumer price sensitivity,

and relationships between consumers and providers.

Some evidence shows that in competitive markets, price ranges may narrow as lower-cost providers raise their prices to align with higher- cost competitors, potentially increasing costs.\212\ Disclosing negotiated rates can enable providers to match each other's prices, which may further limit cost reductions or even lead to higher overall prices despite the increased transparency.\213\ However, in some instances, increased transparency may lead higher-cost providers to face new pressure to lower costs, potentially decreasing costs.\214\

\212\ Forrest Xiao, The Healthcare Cost Conundrum: Prices are Stabilizing. Why are Expenses Still Rising?, Turquoise Health (October 31, 2024), https://blog.turquoise.health/the-healthcare-cost-conundrum/.

\213\ David N. Bernstein & Jonathan R. Crowe, Price Transparency in United States' Health Care: A Narrative Policy Review of the Current State and Way Forward, 61 INQUIRY: The Journal of Health Care Organization, Provision, and Financing (2024).

\214\ Yujie Feng, Price Transparency in Healthcare: Bargaining Incentives and Patient Responses, 102 Journal of Health Economics (2025).

The Departments acknowledge that this transfer may be partially offset by potential price convergence effects, where lower-cost providers may increase their prices toward market averages once pricing becomes more transparent. However, the net effect is expected to favor more efficient providers and create competitive pressure for cost reduction across the market. b. Transfer From Providers to Consumers Through Reduced Out-of-Pocket Spending

If consumers use enhanced pricing information to select lower-cost providers, their out-of-pocket expenses for health care services are expected to decrease, representing a transfer from the provider to the consumer. This transfer is facilitated by these final requirements to make cost-sharing information available by phone, which may particularly benefit populations who face barriers to using online tools, including older adults, individuals with disabilities, and those with limited internet access.

By expanding access to personalized pricing information, these consumers may make more cost-conscious health care decisions, resulting in lower deductibles, copayments, and coinsurance amounts. The magnitude of this transfer could vary significantly based on individual utilization patterns, plan design, and the availability of lower-cost alternatives within their provider networks. This shift is consistent with empirical findings that greater price transparency can help consumers make more cost-effective choices and encourage market competition.\215\

\215\ Zach Y. Brown, Equilibrium Effects of Health Care Price Information, 101 Review of Economics and Statistics 4 (2019); Christopher Whaley, Timothy Brown, & James Robinson, Consumer Responses to Price Transparency Alone Versus Price Transparency Combined with Reference Pricing, 5 American Journal of Health Economics 227 (2019).

If enhanced price transparency leads to systematic shifts toward lower-cost providers and overall reductions in health care spending, plans and issuers may experience lower claims costs, which could eventually translate to reduced premiums for participants, beneficiaries, and enrollees. That is, as plans and issuers experience lower medical costs due to participant, beneficiary, and enrollee price shopping, competitive pressure may lead to premium reductions to attract and retain enrollees. However, the magnitude of this transfer is expected to depend on several factors, including the degree of competition across different market segments and geographic areas (for example, urban vs. rural markets) and the rate at which consumer utilization patterns change. d. Transfer From Plans and Issuers to Federal Government Through Reduced Premium Tax Credit (PTC)

If enhanced price transparency leads to lower premiums in the individual insurance market, PTC amounts would decline, resulting in reduced Federal PTC spending. Because the premium contributions for PTC-eligible consumers are generally determined as a percentage of household income, these consumers' out-of-pocket premium contributions would remain unchanged despite a reduction in PTC amounts. The magnitude of this transfer is expected to depend on the extent to which price transparency leads to competitive pressure and overall premium reductions, as well as the number of PTC-eligible consumers affected. For subsidized consumers, the net effect may be largely neutral, since their required premium contributions are based on income rather than plan cost; however, if they choose a lower-cost plan as premiums decrease, they could experience a net benefit. On the other hand, unsubsidized consumers would generally experience a positive impact from any premium reductions. e. Transfer From Federal Government to Plans and Issuers Through Increased PTCs

Although the balance of the available evidence suggests that enhanced price transparency is more likely to reduce health care costs, the Departments also recognize that prices and premiums could increase in certain markets or as a result of implementation costs. To the extent that these effects increase premiums in the individual market, Federal PTC spending could increase, resulting in a potential transfer from the Federal government to plans and issuers through increased PTC payments. Such transfer could occur, for example, if the costs of implementing enhanced machine-readable file requirements, phone-based cost-sharing tools, and other transparency measures result in increased premiums. The magnitude and direction of any such transfer would depend on the extent to which these effects increase individual market premiums and corresponding PTC amounts.

The Departments also recognize potential Federal fiscal effects in the employer-sponsored insurance market. To the extent that these final rules result in higher premiums for employer-sponsored coverage, employers may increase spending on health benefits. If higher employer health benefit costs result in lower taxable wages, Federal income and payroll tax revenues could decrease. Conversely, to the extent that these final rules contribute to lower employer-sponsored premiums and higher taxable wages, Federal tax revenues could increase. The Departments consider these potential effects to be additional Federal fiscal effects rather than transfers to plans and issuers. The Departments acknowledge uncertainty in both the magnitude and timing of these potential transfers and Federal fiscal effects. However, the available empirical evidence generally suggests that greater price transparency is more likely to place downward pressure on health care prices and spending rather than resulting in increases. One study estimated that insurer price transparency could reduce medical expenditures for the privately insured population by approximately 6.9 percent, with estimated annual savings ranging from $17.6 billion to $80.7 billion.\216\ Recent evidence on

price convergence also suggests that reductions in higher negotiated rates may exceed increases in lower negotiated rates. As discussed in section V.D.3.a.(3). of this preamble, one analysis of negotiated rates for 37 common health care services at 234 unique hospitals across the 10 largest U.S. metropolitan areas found that higher-priced rates declined by 6.3 percent annually, while lower-priced rates increased by 3.4 percent annually, resulting in lower overall prices.\217\

\216\ Stephen T. Parente, Estimating the impact of new health price transparency policies, 60 Inquiry: The Journal of Health Care Organization, Provision, and Financing, (2023), https://journals.sagepub.com/doi/pdf/10.1177/00469580231155988.

\217\ Turquoise Health, Is Price Transparency Helping? (2024), https://turquoise.health/resources/reports/is-price-transparency-helping-white-paper.

At the same time, other empirical studies have found that price transparency may result in upward price adjustments in certain markets. One randomized controlled trial evaluating a statewide outpatient price transparency tool found a 0.75 percent increase in billed charges, concentrated among lower-priced providers.\218\ Another study examining state-mandated hospital price disclosure in Massachusetts and North Carolina found increases in outpatient imaging prices following disclosure of insurer-specific negotiated prices, with larger increases in markets with greater provider concentration.\219\ These findings suggest that the effects of price transparency may vary depending on market conditions, provider responses, consumer behavior, and how price transparency requirements are implemented.

\218\ Kayleigh Barnes, Sherry A. Glied, Benjamin R. Handel & Grace Kim, The Impact of Price Transparency in Outpatient Provider Markets, National Bureau of Economic Research, Working Paper No. 32580 (2024), https://doi.org/10.3386/w32580.

\219\ Tong Guo, Xinyao Kong & Yanwen Wang, Mandating Transparency: Evidence from Hospital Price Disclosure (Mar. 25, 2026) (unpublished manuscript), SSRN, https://doi.org/10.2139/ssrn.6869224.

Given the limited empirical evidence specifically related to the transparency enhancements included in these final rules, the Departments have not quantified the magnitude of this potential transfer or the potential Federal tax revenue effects described above. Federal PTC expenditures could increase if the final requirements result in higher individual market premiums or decrease if the requirements contribute to lower premiums. Federal tax revenues could decrease if the final requirements result in higher employer-sponsored insurance premiums and associated reductions in taxable wages, or increase if the requirements contribute to lower employer-sponsored insurance premiums and associated increases in taxable wages.

The Departments requested comment on these potential transfers, including possible effects related to provider price convergence and market dynamics. Several commenters generally supported enhanced price transparency and stated that greater access to pricing information could help reduce health care costs. However, commenters did not specifically address potential transfers or provide information that would enable the Departments to quantify the potential transfers discussed in this section. 5. Uncertainty Analysis

The Departments recognize that the assumptions underlying the estimated costs and cost savings described in sections IV.A., IV.B., and V.D.3.b. of this preamble involve a degree of uncertainty. Differences in plan and issuer size, internal systems, and workflows may affect the resources required to implement these final requirements. The quality, structure, and reporting practices of existing files could also shape the extent of savings realized by third-party developers and other users. In addition, labor costs, technical implementation needs, and the pace of adopting new practices are likely to vary across the industry. External factors, such as market behavior, regulatory changes, or shifts in the number of file users, may further influence the overall impacts.

The Departments requested comment on uncertainties and welcomed data or information that could improve the accuracy of the estimates or help identify ways to address potential variability. Although several commenters raised concerns regarding implementation burden and operational complexity more generally, the Departments did not receive comments or data specifically addressing the sources of uncertainty identified, or otherwise materially reducing the uncertainty associated with these estimates. 6. Regulatory Review Cost Estimation

To comply with these final rules, affected entities must first review and understand the regulatory requirements. While plans and issuers are ultimately responsible for meeting these final requirements, the Departments expect, as assumed elsewhere, that the burden of compliance will fall primarily on issuers and TPAs, with only the largest self-insured plans likely to assume this responsibility directly. While the Departments do not have specific data on how many large, self-insured plans will opt to comply independently, such plans are expected to incur similar costs and burdens as issuers and TPAs in developing compliant tools and reviewing these final rules. Therefore, for purposes of estimating regulatory review costs, the Departments assume that a total of 1,508 issuers and plans (or TPAs on behalf of plans) will take on these responsibilities.

Additionally, the Departments expect States to review these final rules to prepare for oversight and enforcement duties. If these final rules impose administrative costs on private entities, such as the time required to review and interpret these final rules, the Departments estimate the costs associated with regulatory review. Given the difficulty in precisely determining how many entities will undertake such a review, the Departments assume that all plans (or TPAs on behalf of plans) and issuers, and States will need to review these final rules to comply.

The Departments acknowledge that this assumption may overstate or understate actual costs, as not all entities may conduct an in-depth review, and some may rely on external counsel or consultants. Nonetheless, the Departments have determined that using the total number of plans, issuers, and States provides a reasonable basis for estimating the regulatory review burden.

Using data from the Bureau of Labor Statistics' Occupational Employment and Wage Statistics,\220\ the Departments assume that plans (or TPAs on behalf of plans) and issuers will rely on a Computer and Information Systems Manager (Code 11-3021) and a Lawyer (Code 23-1011) to review and interpret these final rules. For States, a Compliance Officer (Code 13-1041) is assumed to perform this task. Assuming an average reading speed of 200 words per minute and using BLS median wage data (including a 100 percent increase to account for the cost of fringe benefits and other indirect costs), the Departments estimate that each issuer or TPA will require approximately 4.4 hours of review by a Computer and Information Systems Manager (at $164.62 per hour) and 8.9 hours by a Lawyer (at $145.34 per hour). Based on these assumptions, the combined labor cost for all 1,508 issuers and plans (or TPAs on behalf of plans) is approximately $3,047,412.\221\

\220\ U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics (OEWS) Tables (May 2024), https://www.bls.gov/oes/current/oes_stru.htm.

\221\ The estimated review time is based on an approximately 385-page final rule containing approximately 106,523 words. Assuming an average reading speed of 200 words per minute for double-spaced text, the Departments estimate that it would take approximately 533 minutes, or 8.9 hours, to review the entire final rule. The Departments assume that a Lawyer will review the entire final rule (8.9 hours), while a Computer and Information Systems Manager will review approximately half of the final rule (4.4 hours), reflecting the portions most relevant to technical and implementation requirements. Thus, each issuer or TPA is estimated to incur approximately 13.3 hours of review. Applying hourly wage rates of $145.34 for a Lawyer and $164.62 for a Computer and Information Systems Manager results in an estimated labor cost of approximately $2,021 per issuer or TPA, or approximately $3,047,412 across all 1,508 issuers and TPAs. The final page and word counts may vary as the final rule is prepared for publication; however, the Departments do not expect such variations to materially affect the estimated regulatory review burden or cost.

For States, it is estimated that a Compliance Officer will need approximately 8.9 hours (at $75.40 per hour) to review these final rules, resulting in a total cost of $34,135 across all 50 States and the District of Columbia. Accordingly, the total combined estimated cost of regulatory review for all plans, issuers, and State departments of insurance is approximately $3,081,547.\222\

\222\ The Departments assume that a Compliance Officer will review the entire final rule (8.9 hours), using the review-time methodology described above, as State departments of insurance may need to understand the scope of the final requirements, assess their implications for regulated issuers, and determine how the requirements may affect State regulatory oversight and compliance activities. Applying an hourly wage rate of $75.40 for a Compliance Officer results in an estimated labor cost of approximately $669 per State, or approximately $34,135 across all 50 States and the District of Columbia. Combined with the approximately $3,047,412 in estimated review costs for issuers and plans (or TPAs on behalf of plans), the total estimated cost of reviewing the final rule is approximately $3,081,547.

The Departments considered adding a new content element under the In-network Rate File requirements at 26 CFR 54.9815-2715A3(b)(1), 29 CFR 2590.715-2715A3(b)(1), and 45 CFR 147.212(b)(1) requiring disclosure of claims volume for each negotiated rate for each provider for each item and service as an additional or alternative method of providing contextual plan and coverage usage information. The Departments also considered requiring plans and issuers in the Utilization File at 26 CFR 54.9815-2715A3(b)(2)(i), 29 CFR 2590.715- 2715A3(b)(2)(i), and 45 CFR 147.212(b)(2)(i) to disclose the number of times that any given provider submitted a claim for any particular item or service. The Departments requested comment on this alternative.

Many commenters recommended that the Departments amend the proposed Utilization File to include claims volumes instead of a binary indicator of whether a claim for an item or service was reimbursed. These commenters identified the potential benefits for researchers, purchasers, and other file users in approaching contract negotiations and conducting more complex analyses, such as weighting prices by utilization to examine spending, focusing analyses on high-volume services, and distinguishing outlier prices. A few commenters encouraged the Departments to consult with interested parties on the best method for introducing claims volume into the Utilization File. A commenter suggested that group plans, their vendor partners, and issuers, already process and link historical claims data for the Allowed Amount File. Several commenters also noted that claims volume would help verify the exclusion of unlikely provider-rate combinations in the In-network Rate File.

Many commenters offered methods for the Departments to implement a requirement that claims volume be disclosed, including raw counts, aggregated counts, or volume bands. A few commenters recognized the privacy concerns related to associating providers with a small number of claims and suggested either that provider groups with between zero and ten cases should be categorized as “10 or fewer” or be suppressed entirely. Alternatively, they recommended that the Departments establish an enrollment threshold below which utilization data would be reported at the market-type level rather than the plan or network level. As another alternative, a commenter recommended the Departments require plans and issuers to publish a percentage of providers with zero utilization during a lookback period, rather than discrete counts. Another commenter stated that combining claims volume with the owner of the provider network's own internal taxonomy would negate the need for the Taxonomy File. A commenter wanted the additional data attributes of average charged amount, average remittance amount, denial count, and denial rate. Another commenter suggested including how many times the provider group has been reimbursed for a procedure during the lookback period.

Several commenters had a variety of recommendations for how to implement claims volume. These include clearly defining provider groups as a combination of TINs with their associated NPIs that collectively contract rates with the insurer; including claims volume at the provider group level instead of the provider level; including location- specific information; requiring plans and issuers to use a single provider reference route and a single identifier type (ideally NPI); reporting data by market type; requiring NPIs at the Type 1 level for the rendering/servicing provider and requiring disclosure of the service facility location for professional claims; structuring the utilization indicator (as claims volume) at the same structural level at which a negotiated rate object is connected to a provider reference group; implementing a provider support collection within the negotiated rate object, keyed or indexed by provider reference, where each entry contains support metrics such as historical claim count and lookback period; and expanding the provider reference object to convert each NPI into a structured NPI object that includes attributes such as specialty, credentials, and practice locations, which could then be referenced by the negotiated price object to indicate when prices vary based on specialty.

Many commenters opposed the use of claims volumes in the Utilization File. A commenter stated that it would make the Utilization File redundant because the claims-based standard would screen out provider-service pairings that have not resulted in reimbursement. A few commenters cited privacy concerns, with one noting that, for smaller group health plans, making public claims volume by provider and place of service for every item and service would have the potential to reveal sensitive, protected health information. A commenter noted that it would be very administratively burdensome.

The Departments acknowledge the potential benefits to different types of file users of including claims volume in the Utilization File or the In-network Rate File but are not finalizing such a requirement due to privacy concerns, the added burden to plans and issuers, and the potential to significantly increase the size of the Utilization Files. The Departments appreciate the recommendations for mitigating privacy concerns, but have determined that, even with such approaches, patients could remain exposed to a significant level of risk. In addition, the Departments are not convinced that claims volume information would provide greater value to file users in verifying the unlikely provider- rate exclusions in the In-network Rate File than a binary indicator, which is the approach the Departments are finalizing, as discussed in section III.C.5. of this preamble. Claims volume would be a large quantity of data for both plans and issuers to add to the files

(and continue to host on their servers) and for users to sift through, and for the purposes of understanding whether a provider is appropriately removed from the In-network Rate File, a claim volume of 100 provides the same usage indication as a claim volume of one. Therefore, the Departments are not finalizing requirements to disclose claims volume in either the In-network Rate File or the Utilization File. 2. Excluded Information

The Departments considered two alternative approaches to the final requirement that plans and issuers exclude from each In-network Rate File provider-rate combinations for an item or service for which a provider is unlikely to be reimbursed based on the provider's area of specialty, as determined using the plan's or issuer's internal provider taxonomy or other internal rules used to determine if the plan or issuer should deny reimbursement for an item or service based on the provider's specialty during the claims adjudication process.

The first approach involved requiring plans and issuers to run each combination of provider and item or service as a mock claim and only including in the In-network Rate File those mock claims that passed validation edits for appropriateness of that provider to perform the service. This differs from the process described in section III.C.5. of this preamble because a mock claims process would have required plans and issuers to process each potential provider-rate combination through their claims adjudication systems, rather than relying on their internal mapping of billing codes to exclude providers. The Departments explained that the former method would establish a clear standard and provide meaningful information, resulting in smaller In-network Rate Files that are far more accessible and manageable, but would have involved a significant initial and ongoing administrative and financial burden. The Departments requested but did not receive comments on this proposed alternative and are not adopting this alternative due to the significant administrative and operational burden and the inability of file users to verify the mock claim exclusions.

Second, the Departments explored the idea of requiring plans and issuers to create In-network Rate Files using negotiated rates based solely on historical claims data by identifying providers who have submitted claims for specific items or services. This method would have the benefit of a clear and reliable metric, claims history, which can be verified and documented, to exclude provider-rate combinations. It would also be direct and straightforward for plans and issuers to implement. The Departments requested comment on this proposed alternative.

A few commenters proposed limiting provider-service pairings to those supported by at least one fully adjudicated claim within a specified lookback period. A few commenters noted that a historical claims-based exclusion approach could wrongfully exclude newly contracted providers or claims for items and services related to rare and complex treatments that are not used frequently.

The Departments are not finalizing this alternative after determining that, because the In-network Rate File includes prospective information, excluding providers based on historical data could confuse file users and potentially exclude newer providers that have no claims history as well as providers who furnish items and services infrequently for rare conditions. The Departments have also determined that a historical claims-based approach would be operationally complex and less effective than the finalized approach of utilizing taxonomy data to identify and exclude unlikely provider-rate combinations. For additional discussion regarding claims volume considerations related to the finalized the Utilization File requirements, see section V.E.1. of this preamble. 3. Data Retention

As noted in the proposed rules, the Departments considered requiring plans and issuers to retain and publicly post Transparency in Coverage machine-readable files for a specified period, including up to 7 years, to facilitate longitudinal analysis of pricing trends and contractual data. The Departments recognized that historical data could provide value for researchers, policymakers, and other users by supporting historical benchmarking and analysis of negotiated rate trends over time.

However, the Departments have determined that requiring long-term public retention of machine-readable files would impose significant operational and financial burden on plans and issuers.\223\ In particular, plans and issuers would need to maintain substantial additional data storage capacity, network bandwidth, indexing systems, and ongoing maintenance processes to support public access to large volumes of historical data. The Departments are also concerned that maintaining extensive archives of historical files could increase administrative complexity and create challenges related to data organization, discoverability, and long-term data integrity.

\223\ 90 FR 60432, 60502 (December 23, 2025).

The Departments sought comment on the relative burdens and benefits of requiring files to be publicly posted for a specific period, including 7 years; whether public retention of prior files would continue to provide value if combined with the other proposed changes; and what retention period would provide sufficient value for file users without imposing an undue burden on plans and issuers. The Departments did not propose and are not finalizing any data retention requirements at this time.

A few commenters recommended that the Departments require plans and issuers to retain or archive Transparency in Coverage machine-readable files for a specified period. These commenters suggested that, beyond other proposals to reduce the number and size of machine-readable files, requiring plans and issuers to retain or archive these files would promote accountability for negotiated rate trajectories and ensure that historical data is available for longitudinal analysis and enforcement. A few commenters recommended a 7-year retention period, while another commenter recommended a 3-year retention period. Conversely, a commenter opposed long-term public retention of the machine-readable files, pointing to the increased storage, hosting, and data management costs associated with long-term retention, particularly given the size and volume of machine-readable files and the addition of the new proposed file types. The commenter recommended that the Departments limit required retention periods to the minimum duration necessary to support file usability and regulatory objectives, while avoiding unnecessary cost and infrastructure burden.

After careful consideration, including additional analysis of the costs associated with long-term data retention, the Departments have concluded that the benefits would not justify the operational and storage burdens associated with maintaining large volumes of historical data for public access over the long term.

In the proposed rules, the Departments estimated that the size of the In-network Rate Files, the main driver of annual storage costs, would decrease by approximately 70 percent, lowering the industry-wide monthly data volume from 1 petabyte to

approximately 300,000 GB,\224\ based on the proposed changes to the In- network Rate File reporting cadence, structure, and content. The Departments are finalizing the proposed shift to a quarterly reporting cadence redesignated at 26 CFR 54.9815-2715A3(b)(4)(i), 29 CFR 2590.715-2715A3(b)(4)(i), and 45 CFR 147.212(b)(4)(i), reporting negotiated rates at the network level rather than plan and policy level 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), and excluding unlikely provider-rate combinations at 26 CFR 54.9815-2715A3(b)(1)(i)(F), 29 CFR 2590.715- 2715A3(b)(1)(i)(F), and 45 CFR 147.212(b)(1)(i)(F).

\224\ 90 FR 60496 (December 23, 2025).

Using AWS storage pricing ($0.023 per GB for the first 50 terabytes (TB), $0.022 per GB for the next 450 TB, and $0.021 per GB beyond that) as a benchmark, the monthly data storage cost for the initial 300,000 GB In-network Rate File across all plans and issuers is approximately $6,651. While a single quarter of data could cost approximately $6,651 per month to maintain, retaining a full year of quarterly disclosures (approximately 1,200,000 GB) would shift the majority of the storage into the lower-priced $0.021 per GB storage tier, resulting in an estimated annual storage cost of approximately $309,000.\225\

\225\ The estimated annual storage cost ofapproximately $309,000 is calculated by applying AWS storage pricing tiers to1,200,000 GB of quarterly disclosure data retained over a one-year period: (50,000 GB x $0.023 per GB x 12 months) + (450,000 GB x $0.022 per GB x 12 months) + (700,000 GB x $0.021 per GB x 12 months) = $13,800 + $118,800 + $176,400 = $309,000.

Although annual storage costs may appear modest under a one-year retention scenario, the burden increases substantially as data accumulates over multiple years. If the Departments were to require continuous retention of all In-network Rate files for a 7-year period, storage costs would compound significantly as the cumulative data volume steadily would continue to grow over time. By adding 300,000 GB of new data every quarter for 28 quarters, the industry-wide data footprint would grow to approximately 8.4 million GB (8.4 petabytes).\226\ Under this scenario, monthly storage costs alone would reach approximately $176,950 by the end of the 7-year period,\227\ resulting in estimated cumulative 7-year storage expenditures of approximately $7.71 million across all affected plans and issuers.\228\

\226\ The estimated cumulative storage volume of approximately 8.4 million GB is calculated by assuming 300,000 GB of new data is added each quarter over a 7-year period: 300,000 GB x 28 quarters = 8,400,000 GB (8.4 petabytes).

\227\ The estimated monthly storage cost of approximately $176,950 at the end of the 7-year period is calculated by applying AWS storage pricing tiers to 8,400,000 GB of cumulative data storage: (50,000 GB x $0.023 per GB) + (450,000 GB x $0.022 per GB) + (7,900,000 GB x $0.021 per GB) = $1,150 + $9,900 + $165,900 = $176,950.

\228\ The estimated cumulative 7-year storage expenditure of approximately $7.71 million is calculated as follows: (($6,650 estimated initial monthly storage cost + $176,950 estimated monthly storage cost at the end of year 7) / 2) x 84 months = approximately $7.71 million.

The Departments also acknowledge there are Federal data retention requirements such as regulations related to the Federal independent dispute resolution process that generally require that covered data is retained for a minimum of 6 years from the date of the data's creation.\229\ As such, if the Departments were to propose and finalize a similar data retention requirement regarding Transparency in Coverage, the cost associated with storing and maintaining quarterly data for the cumulative 6-year period could be significant. Therefore, due to this expected burden and additional feedback from commenters about this expected burden, the Departments did not propose and are not finalizing any data retention requirements at this time.

\229\ 26 CFR 54.9816-8(c)(viii), 29 CFR 2590.716-8(c)(viii), and 45 CFR 149.510(c)(viii).

The Departments indicated in FAQs Part 49 issued on August 20, 2021,\230\ that the price comparison methods required by the No Surprises Act (codified in Code section 9819, ERISA section 719, and PHS Act section 2799A-4) are largely duplicative of the self-service tool described in the 2020 final rules. Accordingly, the Departments indicated their intent to propose rulemaking and requested comment regarding whether compliance with the self-service tool requirements of the 2020 final rules satisfies the analogous requirements set forth in Code section 9819, ERISA section 719, and PHS Act section 2799A-4.

\230\ 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.

As noted in the proposed rules, the Departments considered requiring plans and issuers to develop a separate cost comparison tool to fulfill the requirements of the No Surprises Act, which could provide consumers another avenue to shop for services and make informed health care decisions. However, as explained in the proposed rules, the Departments determined that such a proposal would likely impose significant costs on plans and issuers for having to build an entirely new technical infrastructure, with little additional benefit for participants, beneficiaries, and enrollees, given that the provisions of the No Surprises Act largely duplicate the requirements of the Transparency in Coverage rules.

Additionally, the Departments noted that there would be a significant risk of public confusion, as participants, beneficiaries, and enrollees might be unsure of which tool to use, whether the tools serve different purposes, or whether search results will differ. Following implementation of the 2020 final rules, the Departments received feedback from plans and issuers indicating that participants, beneficiaries, and enrollees expressed similar concerns about confusion when plans and issuers transitioned from a legacy self-service tool to a tool that complied with the requirements of the 2020 final rules.

A commenter indicated that they appreciated the Departments' efforts to streamline price comparison tool requirements to avoid duplication. The Departments also did not receive any comments supporting a requirement for an additional self-service tool. The Departments note that consolidating the requirements into a single tool provides operational benefits, allowing plans and issuers to focus their resources on improving the availability and accuracy of cost- sharing information. Ultimately, this alignment promotes administrative efficiency and ensures a streamlined consumer experience for participants, beneficiaries, and enrollees. For the reasons related to burden and consumer confusion discussed in the proposed rules, the Departments are not finalizing an additional self-service tool.

The Regulatory Flexibility Act (RFA) (5 U.S.C. 601, et seq.) requires agencies to analyze options for regulatory relief of small entities, to prepare a final regulatory flexibility analysis, and to describe the impact of these final rules on small entities, unless the head of the agency can certify that the rule will not have a significant economic impact on a substantial number of small entities. The RFA generally defines a “small entity” as (1) a proprietary firm meeting the size standards of the Small Business Administration (SBA), (2) a not-for-profit organization that is not dominant in its field, or (3) a small government

jurisdiction with a population of less than 50,000. States and individuals are not included in the definition of “small entity.”

Consistent with HHS guidance regarding consideration of small entities under the Regulatory Flexibility Act \231\ and with the approach adopted in prior HHS rulemakings, the Departments generally consider an economic impact to be “significant” if the rule's economic impacts represent 3 to 5 percent of the affected entities' revenues and consider a “substantial” number to be 5 percent or more of the affected small entities within an identified industry. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions.

\231\ Office of the Assistant Secretary for Planning and Evaluation, Guidance on Proper Consideration of Small Entities in Rulemakings of the U.S. Department of Health and Human Services (2023), https://aspe.hhs.gov/reports/proper-consideration-small-entities-rulemakings-us-dhhs.

As discussed in section V.F.5. of this preamble, the Departments estimate that most affected entities qualify as small entities based on SBA small business size standards for the purposes of this RFA. The data and conclusions presented in this section constitute the Departments' final regulatory flexibility analysis under the RFA. 1. Statement of Need for, and Objectives of, the Rules

These final rules amend and strengthen the existing Transparency in Coverage regulations under sections 1311(e)(3) and 2715A of the PHS Act (included in the Code by section 9815 of the Code and into ERISA by section 715 of ERISA) to enhance price transparency reporting requirements for non-grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage. Consistent with the goals of Executive Order 14221, these final rules aim to provide patients with clear, accurate, and actionable pricing information.\232\

\232\ Exec. Order No. 14221, 90 FR 11005 (February 28, 2025).

More broadly, these final rules amend the Transparency in Coverage requirements at 26 CFR 54.9815-2715A2, 29 CFR 2590.715-2715A2, and 45 CFR 147.211 to improve the quality, accuracy, and usability of publicly available pricing disclosures and cost-sharing information for participants, beneficiaries, and enrollees. The finalized provisions also amend 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, and 45 CFR 147.212 to improve the organization and standardization of machine- readable files, enhance provider network reporting, require additional contextual information to facilitate interpretation of pricing data, expand disclosures related to out-of-network allowed amounts, and improve the discoverability and usability of Transparency in Coverage data. In addition, these final rules amend 26 CFR 54.9815-2715A2(b), 29 CFR 2590.715-2715A2(b), and 45 CFR 147.211(b) to align certain disclosure requirements with protections established under the No Surprises Act and reduce duplicative reporting requirements.

By making pricing data more meaningful and accessible, these final rules are expected to help participants, beneficiaries, and enrollees better understand their potential costs, support more informed decision-making, and promote greater competition among health care providers and insurers. The Departments also expect that these improvements will facilitate more effective use of pricing data by researchers, policymakers, employers, third-party developers, and other interested parties seeking to evaluate pricing patterns, market dynamics, and health care costs over time.

It is the Departments' intention that implementation of these provisions will improve the transparency, accessibility, and usefulness of pricing and cost-sharing information for participants, beneficiaries, enrollees, providers, researchers, and other interested parties. 2. Summary of Significant Issues

The Departments received comments indicating that small and regional health plans may be disproportionately impacted by these requirements. A commenter stated that the investment required to support the proposed Change-log File would be especially burdensome for regional, not-for-profit plans with limited resources. Another commenter also noted that large national carriers are less likely to face similar challenges, as they have already invested in machine- readable file production infrastructure and maintain more complex contractual and reporting systems. The commenter also stated that machine-readable file requirements may impose greater technical burden on smaller carriers and regional plans that lack the infrastructure necessary to generate and maintain detailed machine-readable files at the required frequency. In addition, the commenter suggested that reducing or eliminating certain requirements could lessen compliance burden for smaller carriers, new market entrants, and self-funded plans while still achieving the transparency objectives of the rule.

The Departments acknowledge that these final rules may impose greater operational and implementation burden on certain small entities, particularly smaller and regional plans with more limited technical and administrative resources. 3. Steps Taken To Minimize Costs to Small Entities

The Departments have taken steps to reduce potential burden, including not finalizing the proposed Change-log File and enrollment data reporting, as well as refining underlying assumptions used in estimating burden to better reflect expected implementation costs and operational burden. The Departments are also adopting several provisions in these final rules that are intended to reduce operational burden across all plans and issuers, including smaller entities. In particular, the Departments highlight the decisions to reduce duplication and file size by allowing plans and issuers to aggregate and report information by provider network and market types, as well as the decision to extend reporting periods for certain files. The Departments expect these changes to reduce implementation and operational costs, particularly for plans and issuers with fewer resources and limited variability among the products offered to their client base. For example, smaller independent insurers may maintain fewer provider networks and products than larger insurers with more varied and complex provider network agreements and therefore may benefit more substantially from the ability to consolidate machine- readable file reporting by provider network and market type.

In these final rules, the Departments are also retaining and expanding policies enabling plans and issuers to enter into written agreements with service providers to aggregate, generate, and post machine-readable files and related text files. These policies enable smaller group health plans and health insurance issuers to outsource key compliance functions to service providers that are better equipped to manage these activities. Smaller health plans, including self- insured group health plans, may rely on service providers to manage their provider network agreements and claims processing, so relying on these service providers to manage the generation of these plans' machine-readable files may facilitate a more efficient path to compliance.

The regulatory alternatives considered in developing these final rules are discussed in section V.E. of this preamble. In evaluating these alternatives, the Departments considered their potential effects on small entities.

The Departments considered requiring plans and issuers to disclose claims volume in the In-network Rate File or Utilization File; requiring plans and issuers to use alternative methods for excluding unlikely provider-rate combinations from the In-network Rate File, including mock claims and historical claims data; requiring plans and issuers to retain machine-readable files long term; and requiring plans and issuers to develop of a separate price comparison tool to fulfill the requirements of the No Surprises Act. Although these alternatives could provide additional information, functionality, or analytical value, they would also impose additional administrative, technical, storage, and operational burdens on plans and issuers.

These additional burdens would likely disproportionately affect small entities that may have more limited technical, administrative, and financial resources. Accordingly, the Departments have determined that the approaches adopted in these final rules better balance the benefits of improved price information with minimizing unnecessary burden on small entities. 5. Affected Small Entities

These final rules affect health insurance issuers offering group or individual health insurance coverage.

For purposes of the RFA, the Departments have determined that health insurance companies are generally classified under the North American Industry Classification System (NAICS) code 524114 (Direct Health and Medical Insurance Carriers). According to SBA size standards, entities with average annual receipts of $47 million or less are considered small entities within this classification. Alternatively, some entities may fall under NAICS code 621491 (HMO Medical Centers), which has a size standard of $44.5 million or less in annual average receipts.

The Departments used the latest available data from the Census Bureau's Statistics of U.S. Businesses (SUSB) for 2022 \233\ and the applicable SBA small business size standards.\234\ Based on these data, the Departments estimate there are 1,217 affected firms across the relevant NAICS categories, of which 921 qualify as small entities under SBA standards, as shown in Table 43. The Departments use these estimates for purposes of the RFA analysis in these final rules. [GRAPHIC] [TIFF OMITTED] TR06OC26.065

As noted in section V.F. of this preamble, the Departments consider annual average economic impacts exceeding approximately 3 to 5 percent of revenues to constitute a significant economic impact on a substantial number of small entities. For purposes of this RFA analysis, the Departments evaluate whether compliance costs exceed approximately 3 to 5 percent of firm revenues to determine whether these final rules will have a significant economic impact on a substantial number of small entities. To conduct this analysis, the Departments analyzed revenue data for Direct Health and Medical Insurance Carriers and HMO Medical Centers that met the SBA small business size standards presented in Table 44, along with the implementation costs estimated in section IV. of this preamble.

\233\ U.S. Census Bureau, Statistics of U.S. Businesses (SUSB), https://www.census.gov/programs-surveys/susb.html (last visited May 8, 2026).

\234\ U.S. Small Business Administration, Table of Size Standards, https://www.sba.gov/document/support-table-size-standards (last visited May 8, 2026).

To assess the ratio of compliance costs to revenues, the Departments used the total number of firms classified as small entities based on the 2022 SUSB data (n=921). The Departments then categorized these firms by receipts-based size category and calculated the share of small firms within each category, as shown in the “Percent of Small Firms” column in Table 44. Using corresponding revenue data from the 2022 SUSB data, the Departments calculated average annual revenues for firms within each size category.

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For purposes of estimating annualized cost for each firm, the Departments estimate a high-end industry cost of approximately $480,187,007 during the first year as discussed in section IV. of this preamble. In addition, plans and issuers are expected to incur approximately $3,047,412 in cost to review and understand the regulatory requirements as described in section V.D. of this preamble for a total first-year cost of approximately $483,234,418. Assuming these costs are distributed evenly across all 1,303 issuers and 205 TPAs, the estimated average high-end one-time per-entity costs will be approximately $320,447. This equal allocation is a simplifying assumption and is not intended to suggest that each entity will incur the same costs. Actual costs may vary depending on entity size, existing technical and administrative infrastructure, and the degree of operational changes necessary to comply with the final requirements.

In the proposed rules,\235\ the Departments stated their expectation that fully-insured group health plans will rely on health insurance issuers whereas self-insured group health plans will depend on TPAs, including issuers providing administrative services only and non-issuer TPAs, to implement the requirements. The Departments also noted that some self-insured plans may choose to comply independently and would likely incur a similar hour burden. Accordingly, the estimated per-entity costs are intended to reflect the expected burden on issuers and TPAs responsible for implementing the final requirements on behalf of plans.

\235\ 90 FR 60432, 60504 (December 23, 2025).

To assess the ratio of compliance costs to revenues, the Departments divided the estimated annualized cost per firm by the average annual revenue for firms within each receipts-based size category and expressed the result as a percentage. This percentage, shown in the “Compliance Cost-to-Revenue Ratio” column in Table 45, represents the estimated compliance cost burden relative to revenue for small firms due to these final rules. The Departments consider a “significant” economic impact to be compliance costs that amount to approximately 3 to 5 percent or more of affected entities' total revenues.

Based on the estimated compliance cost-to-revenue ratios shown in Table 45, the Departments expect these final rules to impose a significant economic impact on a substantial number of small entities, particularly among firms in lower receipts-based size categories where estimated compliance costs exceed approximately 3 to 5 percent of annual revenues. Specifically, approximately 861 of the 921 small entities identified in this analysis fall within receipts-based size categories below $10 million in annual revenue, where the estimated compliance cost-to-revenue ratios meet or exceed the Departments' significance threshold.

[GRAPHIC] [TIFF OMITTED] TR06OC26.067

This conclusion differs from the assessment presented in the proposed rules, in which the Departments relied primarily on issuer- level MLR data to estimate the number of affected small entities and concluded that the proposed rules would not have a significant economic impact on a substantial number of small entities. In the proposed rules, the Departments used total premium revenue reported in MLR submissions to identify issuers below the applicable size threshold. The MLR-based analysis also accounted for whether entities were subsidiaries of larger organizations or had non-medical lines of business that could cause their total revenues to exceed the applicable SBA size standard. For purposes of these final rules, the Departments updated the analysis to rely on SUSB data and the applicable SBA size standards. SUSB data provide firm counts and receipts-based size categories by NAICS code, allowing the Departments to apply the relevant SBA size standards directly to firms in each of the relevant industries. The estimates derived from the two data sources are not directly comparable because the sources differ in scope, unit of analysis, and method of classifying small entities. The larger number of small entities identified using SUSB data reflects the broader firm- level scope of the final-rule analysis and does not indicate that the MLR data used in the proposed rules were inaccurate. As a result of this revised methodology and updated assumptions, the Departments estimate that these final rules may have a significant economic impact on a substantial number of small entities, particularly among entities in lower receipts-based size categories.

Some small plans and issuers may benefit from centralized functions that reduce the direct burden of compliance. In addition, based on 2024 MLR data, many of these entities are likely to have access to centralized administrative, operational, or compliance functions through affiliated parent organizations and may also have non-health lines of business that result in total revenues exceeding $47 million.\236\ As a result, the estimated per-entity impacts presented in this analysis may overstate the burden experienced by individual entities.

\236\ Based on data from MLR annual report for the 2024 MLR reporting year. See Centers for Medicare and Medicaid Services, Medical Loss Ratio Data and System Resources (last updated Mar. 3, 2026), 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.

The Departments also note that the analysis of impacts on small entities is based primarily on first-year implementation costs, which represent the largest share of the burden associated with these final rules as discussed in section IV. of this preamble. These first-year costs reflect one-time activities such as systems development, file creation and testing, operational coordination, and implementation planning. In subsequent years, plans and issuers are expected to incur primarily ongoing maintenance, reporting, and file update activities, which are substantially lower than the initial implementation burden. Accordingly, the Departments expect the economic impact of these final rules on small entities to decline significantly after the first year of implementation. 7. Duplication, Overlap, and Conflict With Other Rules and Regulations

The Departments do not anticipate that these final rules will duplicate, overlap, or conflict with other Federal rules or regulations. These final rules amend the Transparency in Coverage requirements to improve the quality, accuracy, and usability of pricing and cost-sharing disclosures, align certain requirements with protections established under the No Surprises Act, and reduce duplicative reporting requirements.

The Departments did not receive comments identifying any duplication, overlap, or conflict with other rules or regulations and conclude that these final rules do not create material

duplication, overlap, or conflict with other Federal requirements. 8. Small Rural Hospitals

Section 1102(b) of the Social Security Act (SSA) (42 U.S.C. 1302) requires agencies to prepare an RIA if a rule is expected to have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must align with the provisions of section 604 of the RFA. For purposes of section 1102(b) of the SSA, the Departments define a small rural hospital as a hospital that is located outside of a metropolitan statistical area with fewer than 100 beds.

While these final rules are not anticipated to directly regulate small rural hospitals, the Departments acknowledge that the transparency requirements in these final rules may have indirect effects on these facilities through potential changes in negotiated rates and patient cost-sharing, market dynamics that could impact hospital revenues, particularly given that rural providers typically operate with thinner profit margins than their urban counterparts. At the same time, the Departments recognize that rural hospitals may also face lower levels of competition in certain areas, which could limit the extent of any indirect effects that result from these final rules. Therefore, the Departments have determined that any indirect effects are not expected to rise to the level of a significant impact on the operations of a substantial number of small rural hospitals.

Executive Order 13132 establishes certain requirements that an agency must meet when it issues a final rule that imposes substantial direct costs on State and local governments, preempts State law, or otherwise has federalism implications. Federal agencies issuing regulations that have federalism implications must consult with States and local officials and describe the extent of their consultation and the nature of the concerns of States and local officials in the preamble to the regulation.

The Departments have determined these final rules may have federalism implications because they have direct effects on the States, the relationship between the Federal Government and States, or on the distribution of power and responsibilities among various levels of government relating to the disclosure of health insurance coverage information to consumers.

Under these final rules, all non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage, including non-Federal governmental plans as defined in section 2791(d)(8)(C) of the PHS Act, are required to enhance the accessibility and transparency of cost- sharing and pricing information for a participant, beneficiary, or enrollee (or an authorized representative on behalf of such individual). Specifically, plans and issuers need to update statements to reflect Federal balance billing protections, make cost-sharing estimates available by phone, and clarify how to meet the requirements for price comparison tools. These final rules also require improvements to the format and accessibility of machine-readable files, expansion of required data elements, and adjustments to posting frequency and structure to ensure pricing data is more usable and understandable for consumers.

Federal standards developed under section 2715A of the PHS Act do not preempt any related States' standards relating to health insurance issuers that require pricing information to be disclosed to participants, beneficiaries, or enrollees, or otherwise publicly disclosed, except to the extent that such State disclosure requirements prevent the application of a requirement under these final rules.

The Departments have determined that these final rules may have federalism implications based on the required disclosure of pricing information, as they are aware of at least 33 States that have passed some form of price transparency legislation, such as all-payer claims databases, consumer-facing price comparison tools, and right to shop programs, with varying requirements regarding the scope and level of disclosure.\237\ While some States provide prices for individual services, others report aggregated costs across providers or over time to reflect the cost of an episode of care. The methods of sharing this information also vary. For instance, California requires uninsured patients to receive price estimates upon request, whereas other States use websites or software applications to enable consumers to compare prices across providers. Only seven States have published pricing information of issuers on consumer-facing public websites.\238\ Therefore, these final rules may require plans and issuers to disclose more detailed pricing information than some State laws currently mandate.

\237\ National Conference of State Legislatures, Health Costs, Coverage and Delivery State Legislation Database, https://www.ncsl.org/health/health-costs-coverage-and-delivery-state-legislation (last updated May 19, 2026). To access the database, click “NCSL Database” and then filter under “Topic Search” for “Market” and then “Price Transparency and Cost Cont.” to see the total number of States that have adopted or enacted some form of price transparency legislation.

\238\ Melanie Evans, One State's Effort to Publicize Hospital Prices Brings Mixed Results, Wall Street Journal (June 26, 2019), https://www.wsj.com/articles/one-states-effort-to-publicize-hospital-prices-brings-mixed-results-11561555562.

In general, through section 514, ERISA supersedes State laws to the extent that they relate to any covered employee benefit plan but preserves State laws that regulate insurance, banking, or securities. Furthermore, the preemption provisions of section 731 of ERISA and section 2724 of the PHS Act (implemented in 29 CFR 2590.731(a) and 45 CFR 146.143(a)) apply so that the provisions of Part 7 of ERISA and title XXVII of the PHS Act (including the amendments made by the Affordable Care Act) are not to be “construed to supersede any provision of State law which establishes, implements, or continues in effect any standard or requirement solely relating to issuers in connection with group health insurance coverage except to the extent that such standard or requirement prevents the application of a `requirement' of a Federal standard.” The Departments have interpreted State law to “prevent the application” of a PHS Act provision where the State law makes it impossible for an issuer to comply with title XXVII of the PHS Act.\239\ The conference

report accompanying HIPAA indicates that this preemption is intended to be the “narrowest” preemption of State laws, and Health Care Financing Administration (HCFA) guidance similarly states that preemption is limited to the “narrowest” of circumstances.\240\ States may therefore continue to apply State law requirements to health insurance issuers so long as such requirements do not prevent the application of the Affordable Care Act requirements that are the subject of this rulemaking. Accordingly, States have significant latitude to impose requirements on health insurance issuers that are more restrictive than the Federal law.

\239\ 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 54 (July 28, 2022), https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-54.pdf and https://www.cms.gov/files/document/faqs-part-54.pdf.

\240\ HCFA Program Memorandum, The Relationship of Certain Types of State Laws to the Application of the Guaranteed Availability Requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in the Small Group Market, Program Memorandum/ Insurance Commissioners/Insurance Issuers, Transmittal No. 00-03 (June 2000), https://www.cms.gov/Regulations-and-Guidance/Health-Insurance-Reform/HealthInsReformforConsume/downloads/HIPAA-00-03.pdf.

In compliance with the requirement of Executive Order 13132, which requires agencies to examine closely any policies that may have federalism implications or limit the policy making discretion of the States, the Departments have engaged in efforts to consult with and work cooperatively with affected States. These efforts have included participation in conference calls and events hosted by the National Association of Insurance Commissioners (NAIC), as well as direct engagement with State insurance officials. The Departments intend to act in a similar fashion in enforcing the Affordable Care Act, including the provisions of section 2715A of the PHS Act. While drafting these final rules, the Departments attempted to balance the States' interests in regulating issuers with the goal of enhancing price transparency nationwide. By doing so, the Departments have complied with the requirements of Executive Order 13132.

The Departments requested comment on any potential effects these requirements on States, including any duplicative burdens between State and Federal requirements and ways to address such burdens, if applicable. The Departments did not receive any comments on these issues.

In accordance with the requirements set forth in section 8(a) of Executive Order 13132, and by the signatures affixed to these final rules, the Departments certify that the Department of the Treasury, Employee Benefits Security Administration, and CMS have complied with the requirements of Executive Order 13132 for these final rules in a meaningful and timely manner.

Executive Order 14192, titled “Unleashing Prosperity Through Deregulation,” was issued on January 31, 2025. Section 3(a) of Executive Order 14192 requires an agency, unless prohibited by law, to identify at least ten existing regulations to be repealed when the agency issues a new regulation. In furtherance of this requirement, section 3(c) of Executive Order 14192 requires that the new incremental costs associated with new regulations shall, to the extent permitted by law, be offset by the elimination of existing costs associated with prior regulations. A significant regulatory action (as defined in section 3(f) of Executive Order 12866) that would impose total costs greater than zero is considered an Executive Order 14192 regulatory action.

In the proposed rules, the Departments anticipated that these rules would qualify as an Executive Order 14192 regulatory action because total costs were estimated to be greater than zero for Executive Order 14192 accounting purposes. Upon further review, the Departments have determined that certain impacts erroneously characterized as quantified benefits are more appropriately classified as cost savings. These impacts correspond to categories of compliance costs and burdens that were calculated in the 2020 Transparency in Coverage final rules and that this rule would reduce or eliminate, including costs associated with the development, operation, maintenance, and updating of machine- readable files, as well as related data processing and reporting requirements. Because the quantified values reflect reductions in labor, computational, storage, data transfer, and other costs that plans, issuers, third-party developers, and other file users would otherwise incur to access, process, store, transmit, and maintain machine-readable file data, the Departments classify these impacts as cost savings for Executive Order 14192 accounting purposes.

Specifically, the Departments consider the estimated reductions in data cleaning and integration costs, storage costs and lower network egress expenses resulting from reducing the reporting frequency from monthly to quarterly to be cost savings for Executive Order 14192 accounting purposes. These savings are quantified and discussed in section V.D.3.c.(2). After incorporating this refinement, the Departments estimate that total costs are less than zero for Executive Order 14192 accounting purposes and therefore conclude that these rules are an Executive Order 14192 deregulatory action.

As indicated in section IV.D., these final rules will result in implementation costs of approximately $480.2 million for all plans and issuers, including both one-time implementation costs and first-year ongoing costs. Beginning in the second year and continuing thereafter, these final rules are expected to generate a net cost savings of approximately $174.5 million annually ($254.9 million in cost savings offset by $80.4 million in costs) across all plans and issuers. Using a perpetual time horizon and applying a 7 percent discount rate, the Departments estimate a present value (as of 2024) of net cost savings of approximately $1.73 billion (2024 dollars), assuming implementation begins in 2027 for all plans and issuers. On an annualized basis, the Departments estimate a net cost savings of approximately $121.1 million (2024 dollars) for all plans and issuers, discounted relative to 2024, at a 7 percent discount rate.

Although the rule will impose upfront implementation costs in the first year, the discounted value of cost savings exceeds the discounted value of costs over the period analyzed. Accordingly, the Departments conclude that these rules are an Executive Order 14192 deregulatory action for the purposes of meeting Executive Order 14192 requirements.

This final regulation is subject to the Congressional Review Act provisions of the Small Business Regulatory Enforcement Fairness Act of 1996 (5 U.S.C. 801 et seq.) and has been transmitted to the Congress and the Comptroller General for review.