Transparency in Coverage

For the reasons stated in the preamble, the Department of the Treasury amends 26 CFR part 54 as set forth below:

PART 54--PENSION EXCISE TAXES

0 1. The authority citation for part 54 continues to read as follows:

Authority: 26 U.S.C. 7805, unless otherwise noted. * * * * *

0 2. Section 54.9815-2715A1 is amended by-- 0 a. Redesignating paragraphs (a)(2)(xi) through (xxii) as paragraphs (a)(2)(xii) through (xxiii), respectively; and 0 b. Adding new paragraph (a)(2)(xi).

The addition reads as follows:

Sec. 54.9815-2715A1 Transparency in coverage--definitions.

(a) * * *

(2) * * *

(xi) Health insurance market means, irrespective of the State, one of the following:

(A) The individual market, as defined in 45 CFR 144.103 (other than short-term, limited-duration insurance or individual health insurance coverage that consists solely of excepted benefits, as defined in 45 CFR 148.220).

(B) The large group market, as defined in 45 CFR 144.103 (other than coverage that consists solely of excepted benefits, as defined in Sec. 54.9831-1(c)).

(C) The small group market, as defined in 45 CFR 144.103 (other than coverage that consists solely of excepted benefits, as defined in Sec. 54.9831-1(c)).

(D) For purposes of self-insured group health plans (other than account-based plans, as defined in Sec. 54.9815-2711(d)(6)(i), and plans that consist solely of excepted benefits, as defined in Sec. 54.9831-1(c)), all self-insured group health plans maintained by the plan sponsor. * * * * *

0 3. Section 54.9815-2715A2 is amended by-- 0 a. Revising paragraphs (b)(1)(i)(A) and (B), (b)(1)(vii)(A), and (b)(2)(ii) introductory text; 0 b. Redesignating paragraph (b)(2)(ii)(D) as paragraph (b)(2)(iv); 0 c. Adding paragraph (b)(2)(iii); 0 d. Revising newly redesignated paragraph (b)(2)(iv); 0 e. Revising paragraphs (b)(3)(i) and (ii) and (c)(1); and 0 f. Adding paragraph (c)(7).

The revisions and additions read as follows:

Sec. 54.9815-2715A2 Transparency in coverage--required disclosures to participants and beneficiaries.

* * * * *

(b) * * *

(1) * * *

(i) * * *

(A) If the request for cost-sharing information relates to items and services that are provided within a bundled payment arrangement, and the bundled payment arrangement includes items or services that have a separate cost-sharing liability, the group health plan or health insurance issuer must provide estimates of the cost-sharing liability for the requested covered item or service, as well as an estimate of the cost-sharing liability for each of the items and services in the bundled payment arrangement that have separate cost-sharing liabilities. While plans and issuers are not required to provide estimates of cost-sharing liability for a bundled payment arrangement where the cost-sharing is imposed separately for each item and service included in the bundled payment arrangement, nothing prohibits plans or issuers from providing estimates for multiple items and services in situations where such estimates could be relevant to participants or beneficiaries, as long as the plan or issuer also discloses information about the relevant items or services individually, as required in paragraph (b)(1)(v) of this section.

(B) For requested items and services that are recommended preventive services under section 2713 of the Public Health Service Act (PHS Act), if the group health plan or health insurance issuer cannot determine whether the request is for preventive or non-preventive purposes, the plan or issuer must display the cost-sharing liability that applies for non-preventive purposes. As an alternative, a plan or issuer may allow a participant or beneficiary to request cost-sharing information for the specific preventive or non-preventive item or service by including terms such as “preventive,” “non-preventive,” or “diagnostic” as a means to request the most accurate cost-sharing information. * * * * *

(vii) * * *

(A) A statement that the cost-sharing information provided pursuant to this paragraph (b)(1) does not account for potential additional amounts in situations where applicable State or Federal law allow out- of-network providers to bill participants or beneficiaries for the difference between a provider's billed charges and the sum of the amount collected from the group health plan or health insurance issuer and from the participants or beneficiaries in the form of a copayment, coinsurance, or deductible amount (the difference referred to as balance billing). This statement is not required if the State in which the item or service was furnished prohibits all out-of-network providers from balance billing for all items and services payable by the plan or issuer; * * * * *

(2) * * *

(ii) Paper method. Information provided under this paragraph (b) must be made available in plain language, without a fee, in paper form at the request of the participant or beneficiary. In responding to such a request, the group health plan or health insurance issuer may limit the number of providers with respect to which cost-sharing information for covered items and services is provided to no fewer than 20 providers per request. The plan or issuer is required to: * * * * *

(iii) Phone method. Information provided under this paragraph (b) must be made available at the request of the participant or beneficiary via a telephone number indicated on any physical or electronic plan or insurance identification card issued to a participant or beneficiary through which a consumer may seek customer assistance pursuant to Code section 9816(e). Such information must be accurate at the time of the request and must be provided at the time of the request. In responding to such a request, the group health plan or health insurance issuer may limit the number of providers with respect to which cost-sharing information for covered items and services is provided to no fewer

than 20 providers per day. The plan or issuer is required to:

(A) Disclose the applicable provider-per-day limit to the participant or beneficiary; and

(B) Provide the cost-sharing information, in accordance with the requirements in paragraphs (b)(2)(i)(A) through (C) of this section.

(iv) Alternative method. In circumstances where participants and beneficiaries request disclosure other than by the internet-based self- service tool, paper, or phone (for example, by email) group health plans and health insurance issuers may provide the disclosure through alternative means and satisfy the requirements of this section, provided the participant or beneficiary agrees that such disclosure through such means is sufficient to satisfy the request and the plan or issuer meets the timing requirements established under paragraph (b)(2)(ii)(C) of this section for paper method disclosure.

(3) * * *

(i) Special rule for insured group health plans. To the extent coverage under a group health plan consists of group health insurance coverage, the plan satisfies the requirements of this paragraph (b) if the plan requires the health insurance issuer offering the coverage to provide the information required by this paragraph (b) in compliance with this section under a written agreement. Accordingly, if an issuer and a plan sponsor enter into a written agreement under which the issuer agrees to provide the information required under this paragraph (b) in compliance with this section, and the issuer fails to do so, then the issuer, but not the plan, violates the transparency disclosure requirements of this paragraph (b).

(ii) Other contractual arrangements. A group health plan or health insurance issuer may satisfy the requirements under this paragraph (b) by entering into a written agreement under which another party (such as a pharmacy benefit manager or other third-party) provides the information required by this paragraph (b) in compliance with this section. Notwithstanding the preceding sentence, if a plan or issuer chooses to enter into such an agreement and the party with which it contracts fails to provide the information in compliance with this paragraph (b), the plan or issuer violates the transparency disclosure requirements of this paragraph (b).

(c) * * *

(1) This section applies for plan years beginning on or after January 1, 2027. Until the applicability date in the preceding sentence, plans and issuers are required to continue to comply with Sec. 54.9815-2715A2, revised as of April 1, 2025. * * * * *

(7) A group health plan or health insurance issuer that provides to the participant or beneficiary the information required under paragraph (b)(1) of this section, in accordance with the method and format requirements set forth in paragraph (b)(2) of this section, satisfies the requirements set forth in Code section 9819, ERISA section 719, and PHS Act section 2799A-4. * * * * *

0 4. Section 54.9815-2715A3 is amended by-- 0 a. Revising and republishing paragraph (b); and 0 f. Revising paragraph (c)(1).

The revisions and republications read as follows:

Sec. 54.9815-2715A3 Transparency in coverage--requirements for public disclosure.

* * * * *

(b) Requirements for public disclosure of in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for covered items and services, negotiated rates and historical net prices for covered prescription drugs, and contextual information. A group health plan or health insurance issuer must make available on an internet website the information required under paragraphs (b)(1) and (2) of this section in machine-readable files, in accordance with the method and format requirements described in paragraph (b)(3) of this section, and that are updated as required under paragraph (b)(4) of this section.

(1) Required information. Machine-readable files required under this paragraph (b) that are made available to the public by a group health plan or health insurance issuer must include:

(i) An in-network rate machine-readable file for each provider network maintained or contracted by a group health plan or health insurance issuer that includes the required information under this paragraph (b)(1)(i) for all covered items and services under each coverage option offered by the plan or issuer that uses such provider network, except for prescription drugs that are subject to a fee-for- service reimbursement arrangement, which must be reported in the prescription drug machine-readable file pursuant to paragraph (b)(1)(iii) of this section. Each in-network rate machine-readable file must include:

(A) The common provider network name;

(B) The provider network identifier;

(C) For each coverage option offered by a group health plan or health insurance issuer that uses such provider network, the name; the Health Insurance Oversight System (HIOS) identifier, or, if no HIOS identifier is available, the Employer Identification Number (EIN); and the product type (for example, including but not limited to health maintenance organization or preferred provider organization);

(D) A billing code, which in the case of prescription drugs must be a national drug code (NDC), and a plain language description for each billing code for each covered item or service included in the machine- readable file;

(E) For each covered item or service included in the machine- readable file, all applicable rates, which may include one or more of the following: Negotiated rates, underlying fee schedule rates, or derived amounts. If a group health plan or health insurance issuer does not use negotiated rates for provider reimbursement, then the plan or issuer should disclose derived amounts to the extent these amounts are already calculated in the normal course of business. If the plan or issuer uses underlying fee schedule rates for calculating cost sharing, then the plan or issuer should include the underlying fee schedule rates in addition to the negotiated rate or derived amount. Applicable rates, including for both individual items and services and items and services in a bundled payment arrangement, must be:

(1) Reflected as dollar amounts, with respect to each covered item or service that is furnished by an in-network provider. If the negotiated rate is subject to change based upon participant or beneficiary-specific characteristics, these dollar amounts should be reflected as the base negotiated rate applicable to the item or service prior to adjustments for participant or beneficiary-specific characteristics. For contractual arrangements under which a group health plan or health insurance issuer agrees to pay an in-network provider a percentage of billed charges and is not able to assign a dollar amount to an item or service prior to a bill being generated, plans and issuers must report a percentage number, in lieu of a dollar amount, in a form and manner as specified in guidance issued by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services.

(2) Associated with the National Provider Identifier (NPI), Tax

Identification Number (TIN), and Place of Service Code for each in- network provider, except those specified in paragraph (b)(1)(i)(F) of this section;

(3) Associated with the last date of the contract term or expiration date for each provider-specific applicable rate that applies to each covered item or service; and

(4) Indicated with a notation where a reimbursement arrangement other than a standard fee-for-service model (such as capitation or a bundled payment arrangement) applies.

(F) A group health plan or health insurance issuer must exclude from each file under paragraph (b)(1)(i) of this section a provider and their negotiated rate (provider-rate combination) for an item or service if the plan or issuer determines it is unlikely that the provider would be reimbursed for the item or service given that provider's specialty according to the plan's or issuer's internal provider taxonomy or other internal rules used during the claims adjudication process.

(ii) For each health insurance market, as defined in Sec. 54.9815- 2715A1(a)(2)(xi), in which a group health plan or health insurance issuer offers a plan or coverage, an out-of-network allowed amount machine-readable file, including:

(A) For each coverage option offered by a group health plan or health insurance issuer in such health insurance market, the name and the HIOS identifier, or, if no HIOS identifier is available, the EIN; and the product type (for example, including but not limited to health maintenance organization or preferred provider organization);

(B) A billing code, which in the case of prescription drugs must be an NDC, and a plain language description for each billing code for each covered item or service under any coverage option offered by a group health plan or health insurance issuer in such health insurance market; and

(C) Aggregated unique out-of-network allowed amounts and billed charges with respect to each covered item or service under any coverage option offered by a group health plan or health insurance issuer in such health insurance market furnished by out-of-network providers during the 6-month time period that begins 9 months prior to the publication date of the machine-readable file (except that a plan or issuer must omit such data in relation to a particular item or service when compliance with this paragraph (b)(1)(ii)(C) would require the plan or issuer to report payment of out-of-network allowed amounts in connection with fewer than 11 different claims for payment of that item or service in a single health insurance market). Consistent with paragraph (c)(3) of this section, nothing in this paragraph (b)(1)(ii)(C) requires the disclosure of information that would violate any applicable health information privacy law. Each unique out-of- network allowed amount must be:

(1) Reflected as a dollar amount, with respect to each covered item or service that is furnished by an out-of-network provider; and

(2) Associated with the NPI, TIN, and Place of Service Code for each out-of-network provider.

(iii) A prescription drug machine-readable file, including:

(A) For each coverage option offered by a group health plan or health insurance issuer, the name and the 14-digit HIOS identifier, or, if the 14-digit HIOS identifier is not available, the 5-digit HIOS identifier, or, if no HIOS identifier is available, the EIN;

(B) The NDC and the proprietary and nonproprietary name assigned to the NDC by the Food and Drug Administration (FDA) for each covered item or service that is a prescription drug under each coverage option offered by a plan or issuer;

(C) The negotiated rates which must be:

(1) Reflected as a dollar amount, with respect to each NDC that is furnished by an in-network provider, including an in-network pharmacy or other prescription drug dispenser;

(2) Associated with the NPI, TIN, and Place of Service Code for each in-network provider, including each in-network pharmacy or other prescription drug dispenser; and

(3) Associated with the last date of the contract term for each provider-specific negotiated rate that applies to each NDC; and

(D) Historical net prices that are:

(1) Reflected as a dollar amount, with respect to each NDC that is furnished by an in-network provider, including an in-network pharmacy or other prescription drug dispenser;

(2) Associated with the NPI, TIN, and Place of Service Code for each in-network provider, including each in-network pharmacy or other prescription drug dispenser; and

(3) Associated with the 90-day time period that begins 180 days prior to the publication date of the machine-readable file for each provider-specific historical net price that applies to each NDC (except that a group health plan or health insurance issuer must omit such data in relation to a particular NDC and provider when compliance with this paragraph (b)(1)(iii)(D) would require the plan or issuer to report payment of historical net prices calculated using fewer than 20 different claims for payment). Consistent with paragraph (c)(3) of this section, nothing in this paragraph (b)(1)(iii)(D) requires the disclosure of information that would violate any applicable health information privacy law.

(iv) In each machine-readable file required under paragraphs (b)(1)(i) through (iii), and (b)(2)(i) and (ii) of this section, a plan or issuer:

(A) Must attest the following: To the best of its knowledge and belief, this plan or issuer has included all applicable information in accordance with the requirements of 26 CFR 54.9815-2715A3, and the information encoded is true, accurate, and complete as of the date in the file.

(B) Must encode the name of the plan's or issuer's chief executive officer, president, or senior official designated to oversee the encoding of true, accurate, and complete data as directed in paragraph (b)(1)(iv)(A) of this section.

(C) May satisfy the requirements of paragraphs (b)(1)(iv)(A) and (B) of this section by entering into a written agreement under which another party (such as a third-party administrator) makes the attestation required in paragraph (b)(1)(iv)(A) of this section on behalf of the plan or issuer and encodes the name of the other party's chief executive officer, president, or senior official designated to oversee the encoding of true, accurate, and complete data as directed in paragraph (b)(1)(iv)(A) of this section, only if the plan or issuer has entered into an agreement with the other party to provide the information in this paragraph (b) pursuant to the special rules in paragraph (b)(5) of this section.

(2) Required contextual files. A group health plan or health insurance issuer must make available in a machine-readable format:

(i) A utilization file, for each in-network rate machine-readable file specified in paragraph (b)(1)(i) of this section, that includes, for the most recent plan year that ends at least 6 months prior to the date the utilization file is made available as specified in paragraph (b)(4)(iii) of this section:

(A) Items and services covered under the plans or policies included in the files prepared as specified in paragraph (b)(1)(i) of this section for which a claim has been submitted and reimbursed (or would be reimbursed but for cost-sharing liability), in whole or in part; and

(B) Each in-network provider identified by the NPI, TIN, and Place of

Service Code who was reimbursed (or would be reimbursed but for cost- sharing liability), in whole or in part, for a claim for each covered item or service included as specified in paragraph (b)(2)(i)(A) of this section.

(ii) A taxonomy file, for each in-network rate machine-readable file prepared as specified in paragraph (b)(1)(i) of this section, which includes the group health plan's or health insurance 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, as described in paragraph (b)(1)(i)(F) of this section. The information provided in the taxonomy file must be expressed as pairings of items and services (represented by billing codes) with provider specialties (represented by specialty codes which are derived from the Health Care Provider Taxonomy code set established by the National Uniform Claim Committee (NUCC)). Plans and issuers must use their internal provider taxonomy or other internal rules to determine whether to exclude certain provider-rate combinations from the in-network rate machine-readable file as specified in paragraph (b)(1)(i)(F) of this section.

(iii) A plain text file in a .txt format in the root folder (that is, the top-level directory on an electronic file system) of a group health plan's or health insurance issuer's website that includes:

(A) The source page URL for the internet website that hosts the machine-readable files required under paragraphs (b)(1) and (2) of this section;

(B) A direct link to the URL for the machine-readable files required under paragraphs (b)(1) and (2) of this section; and

(C) Point-of-contact information, including a monitored email address for an individual or group dedicated to receiving and responding to inquiries and issues related to the machine-readable files required under paragraphs (b)(1) and (2) of this section. This contact information (whether an individual or group) must be prominently displayed on the same website where the machine-readable files are made available and kept updated per the requirements in paragraph (b)(4)(v) of this section.

(3) Required method and format for disclosing information to the public. (i) Unless otherwise required by this section, the machine- readable files described in paragraphs (b)(1) and (2) of this section must be available in a single, non-proprietary, open-standards format, in a form and manner specified in guidance issued by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services.

(ii) The machine-readable files described in paragraphs (b)(1) and (2) of this section must be publicly available and accessible to any person, automated script, or web crawler free of charge and without conditions, such as establishment of a user account, password, submission of personally identifiable information or other credentials, or blocking server configurations or firewalls to access the file.

(iii) The source page URL for the internet website that hosts the machine-readable files required under paragraphs (b)(1) and (2) of this section must be included as a link in the footer on the home page of the group health plan's or health insurance issuer's website, as well as any page of the website that features a footer, that is labeled “Price Transparency” or “Transparency in Coverage” and links directly to the publicly available web page that hosts the link to the machine-readable files.

(iv) The group health plan or health insurance issuer may satisfy the requirements of paragraph (b)(3)(iii) of this section by entering into a written agreement under which another party (such as a third- party administrator) posts the machine-readable files described in paragraphs (b)(1) and (2) of this section on its public website on behalf of the plan or issuer, including if the plan or issuer does not have a website. However, if the files are posted on a service provider's website, and the plan or issuer maintains a public website but chooses not to host the files separately on its own public website, it must provide a link on its own public website to the location where the files are made publicly available.

(4) Timing. A group health plan or health insurance issuer must update the machine-readable files in accordance with the following timeframes and clearly indicate the date that the files were most recently updated:

(i) The in-network rate and out-of-network allowed amount machine- readable files required by paragraphs (b)(1)(i) and (ii) of this section must be updated and posted quarterly on the first day of each calendar-year quarter beginning with the first calendar-year quarter following the applicability date under paragraph (c)(1) of this section;

(ii) The prescription drug machine-readable file required by paragraph (b)(1)(iii) of this section must be updated monthly;

(iii) The utilization machine-readable file required under paragraph (b)(2)(i) of this section must be posted beginning on July 1, 2028, and updated and posted on an annual basis thereafter;

(iv) The taxonomy machine-readable file required under paragraph (b)(2)(ii) of this section must be updated and posted quarterly on the first day of each calendar-year quarter beginning with the first calendar-year quarter following the applicability date under paragraph (c)(1) of this section. If there are no changes to the taxonomy that affect the information required in the machine-readable file required under paragraph (b)(1)(i) of this section in a subsequent quarter, the taxonomy file is still required to be posted but not updated for that quarter; and

(v) The text file required by paragraph (b)(2)(iii) of this section must be posted on the first day of the first calendar-year quarter following the applicability date under paragraph (c)(1) of this section and subsequently updated and posted as soon as practicable but no later than 7 calendar days following a change in any of the information required under paragraph (b)(2)(iii) of this section.

(5) Special rules to prevent unnecessary duplication--(i) Special rule for insured group health plans. To the extent coverage under a group health plan consists of group health insurance coverage, the plan satisfies the requirements of this paragraph (b) if the plan requires the health insurance issuer offering the coverage to provide the information under a written agreement. Accordingly, if an issuer and a plan sponsor enter into a written agreement under which the issuer agrees to provide, on behalf of the plan, the information required under this paragraph (b) in compliance with this section, and the issuer fails to do so, then the issuer, but not the plan, violates the transparency disclosure requirements of this paragraph (b).

(ii) Other contractual arrangements. A group health plan or health insurance issuer may satisfy the requirements under this paragraph (b) by entering into a written agreement under which another party (such as a third-party administrator or health care claims clearinghouse) will provide, on behalf of the plan or issuer, the information required by this paragraph (b) in compliance with this section. Notwithstanding the preceding sentence, if a plan or issuer chooses to enter into such an agreement and the party with which it contracts fails to provide the information in compliance with this paragraph (b), the plan or issuer violates the transparency disclosure requirements of this paragraph (b).

(iii) Special rule for self-insured group health plans with respect to the disclosure of in-network rate machine-readable files. A self- insured group health plan that enters into an agreement with another party described in paragraph (b)(5)(ii) of this section may permit such other party to make available in a single in-network rate machine- readable file as required under paragraph (b)(1)(i) of this section the information required under paragraph (b)(1)(i) of this section for each provider network used by more than one plan, insurance policy, or contract (including those offered by different plan sponsors with which that other party has an agreement) and across different health insurance markets if--

(A) Each in-network rate machine-readable file made available for a provider network includes the required information under paragraph (b)(1)(i) of this section for all covered items and services under each plan, insurance policy, or contract that uses the same provider network for which the in-network rate machine-readable file is made available; and

(B) Each of the self-insured group health plan's utilization and taxonomy machine-readable files include the information required under paragraphs (b)(2)(i) and (ii) of this section, respectively, for the same plans, insurance policies, or contracts (including those offered by different plan sponsors and across different health insurance markets, if applicable) represented in the corresponding in-network rate machine-readable files specified in paragraph (b)(1)(i) of this section.

(iv) Special rule for self-insured group health plans with respect to the disclosure of out-of-network allowed amount machine-readable files. A self-insured group health plan that enters into an agreement with another party described in paragraph (b)(5)(ii) of this section may permit such other party to make available the information required under paragraph (b)(1)(ii) of this section in a single out-of-network allowed amount file for more than one self-insured group health plan (including those offered by different plan sponsors with which the other party has an agreement), provided that the out-of-network allowed amount and billed charge data described in paragraph (b)(1)(ii)(C) of this section in relation to a particular item or service is omitted if it would require disclosure of out-of-network allowed amounts in connection with fewer than 11 different claims for payment of such item or service across all of the plans (including those offered by different plan sponsors) included in the out-of-network machine- readable file.

(c) * * *

(1)(i) Until the applicability date specified in paragraph (c)(1)(ii) of this section, plans and issuers are required to continue to comply with Sec. 54.9815-2715A3, revised as of April 1, 2025.

(ii) The provisions of this section apply beginning March 6, 2027, except that paragraphs (b)(2), (b)(3)(iii), and (b)(4)(iii) through (v) of this section apply beginning September 6, 2027. * * * * *

For the reasons stated in the preamble, the Department of Labor amends 29 CFR part 2590 as set forth below:

PART 2590--RULES AND REGULATIONS FOR GROUP HEALTH PLANS

0 5. The authority citation for part 2590 continues to read as follows:

Authority: 29 U.S.C. 1027, 1059, 1135, 1161-1168, 1169, 1181- 1183, 1181 note, 1185, 1185a-n, 1191, 1191a, 1191b, and 1191c; sec. 101(g), Pub. L. 104-191, 110 Stat. 1936; sec. 401(b), Pub. L. 105- 200, 112 Stat. 645 (42 U.S.C. 651 note); sec. 512(d), Pub. L. 110- 343, 122 Stat. 3881; sec. 1001, 1201, and 1562(e), Pub. L. 111-148, 124 Stat. 119, as amended by Pub. L. 111-152, 124 Stat. 1029; Division M, Pub. L. 113-235, 128 Stat. 2130; Pub. L. 116-260, 134 Stat. 1182; Secretary of Labor's Order 1-2011, 77 FR 1088 (Jan 9, 2012).

0 6. Section 2590.715-2715A1 is amended by-- 0 a. Redesignating paragraphs (a)(2)(x) through (xxi) as paragraphs (a)(2)(xi) through (xxii), respectively; and 0 b. Adding new paragraph (a)(2)(x).

The addition reads as follows:

Sec. 2590.715-2715A1 Transparency in coverage--definitions.

(a) * * *

(2) * * *

(x) Health insurance market means, irrespective of the State, one of the following:

(A) The individual market, as defined in 45 CFR 144.103 (other than short-term, limited-duration insurance or individual health insurance coverage that consists solely of excepted benefits, as defined in 45 CFR 148.220).

(B) The large group market, as defined in 45 CFR 144.103 (other than coverage that consists solely of excepted benefits, as defined in Sec. 2590.732(c)).

(C) The small group market, as defined in 45 CFR 144.103 (other than coverage that consists solely of excepted benefits, as defined in Sec. 2590.732(c)).

(D) For purposes of self-insured group health plans (other than account-based plans, as defined in Sec. 2590.715-2711(d)(6)(i), and plans that consist solely of excepted benefits, as defined in Sec. 2590.732(c)), all self-insured group health plans maintained by the plan sponsor. * * * * *

0 7. Section 2590.715-2715A2 is amended by-- 0 a. Revising paragraphs (b)(1)(i)(A) and (B), (b)(1)(vii)(A), and (b)(2)(ii) introductory text; 0 b. Redesignating paragraph (b)(2)(ii)(D) as paragraph (b)(2)(iv); 0 c. Adding paragraph (b)(2)(iii); 0 d. Revising newly redesignated paragraph (b)(2)(iv); 0 e. Revising paragraphs (b)(3)(i) and (ii) and (c)(1); and 0 f. Adding paragraph (c)(7).

The revisions and additions read as follows:

Sec. 2590.715-2715A2 Transparency in coverage--required disclosures to participants and beneficiaries.

* * * * *

(b) * * *

(1) * * *

(i) * * *

(A) If the request for cost-sharing information relates to items and services that are provided within a bundled payment arrangement, and the bundled payment arrangement includes items or services that have a separate cost-sharing liability, the group health plan or health insurance issuer must provide estimates of the cost-sharing liability for the requested covered item or service, as well as an estimate of the cost-sharing liability for each of the items and services in the bundled payment arrangement that have separate cost-sharing liabilities. While plans and issuers are not required to provide estimates of cost-sharing liability for a bundled payment arrangement where the cost-sharing is imposed separately for each item and service included in the bundled payment arrangement, nothing prohibits plans or issuers from providing estimates for multiple items and services in situations where such estimates could be relevant to participants or beneficiaries, as long as the plan or issuer also discloses information about the relevant items or services individually, as required in paragraph (b)(1)(v) of this section.

(B) For requested items and services that are recommended preventive services under section 2713 of the Public Health Service Act (PHS Act), if

the group health plan or health insurance issuer cannot determine whether the request is for preventive or non-preventive purposes, the plan or issuer must display the cost-sharing liability that applies for non-preventive purposes. As an alternative, a plan or issuer may allow a participant or beneficiary to request cost-sharing information for the specific preventive or non-preventive item or service by including terms such as “preventive,” “non-preventive,” or “diagnostic” as a means to request the most accurate cost-sharing information. * * * * *

(vii) * * *

(A) A statement that the cost-sharing information provided pursuant to this paragraph (b)(1) does not account for potential additional amounts in situations where applicable State or Federal law allow out- of-network providers to bill participants or beneficiaries for the difference between a provider's billed charges and the sum of the amount collected from the group health plan or health insurance issuer and from the participants or beneficiaries in the form of a copayment, coinsurance, or deductible amount (the difference referred to as balance billing). This statement is not required if the State in which the item or service was furnished prohibits all out-of-network providers from balance billing for all items and services payable by the plan or issuer; * * * * *

(2) * * *

(ii) Paper method. Information provided under this paragraph (b) must be made available in plain language, without a fee, in paper form at the request of the participant or beneficiary. In responding to such a request, the group health plan or health insurance issuer may limit the number of providers with respect to which cost-sharing information for covered items and services is provided to no fewer than 20 providers per request. The plan or issuer is required to: * * * * *

(iii) Phone method. Information provided under this paragraph (b) must be made available at the request of the participant or beneficiary via a telephone number indicated on any physical or electronic plan or insurance identification card issued to a participant or beneficiary through which a consumer may seek customer assistance pursuant to ERISA section 716(e). Such information must be accurate at the time of the request and must be provided at the time of the request. In responding to such a request, the group health plan or health insurance issuer may limit the number of providers with respect to which cost-sharing information for covered items and services is provided to no fewer than 20 providers per day. The plan or issuer is required to:

(A) Disclose the applicable provider-per-day limit to the participant or beneficiary; and

(B) Provide the cost-sharing information, in accordance with the requirements in paragraphs (b)(2)(i)(A) through (C) of this section.

(iv) Alternative method. In circumstances where participants and beneficiaries request disclosure other than by the internet-based self- service tool, paper, or phone (for example, by email) group health plans and health insurance issuers may provide the disclosure through alternative means and satisfy the requirements of this section, provided the participant or beneficiary agrees that such disclosure through such means is sufficient to satisfy the request and the plan or issuer meets the timing requirements established under paragraph (b)(2)(ii)(C) of this section for paper method disclosure.

(3) * * *

(i) Special rule for insured group health plans. To the extent coverage under a group health plan consists of group health insurance coverage, the plan satisfies the requirements of this paragraph (b) if the plan requires the health insurance issuer offering the coverage to provide the information required by this paragraph (b) in compliance with this section under a written agreement. Accordingly, if an issuer and a plan sponsor enter into a written agreement under which the issuer agrees to provide the information required under this paragraph (b) in compliance with this section, and the issuer fails to do so, then the issuer, but not the plan, violates the transparency disclosure requirements of this paragraph (b).

(ii) Other contractual arrangements. A group health plan or health insurance issuer may satisfy the requirements under this paragraph (b) by entering into a written agreement under which another party (such as a pharmacy benefit manager or other third-party) provides the information required by this paragraph (b) in compliance with this section. Notwithstanding the preceding sentence, if a plan or issuer chooses to enter into such an agreement and the party with which it contracts fails to provide the information in compliance with this paragraph (b), the plan or issuer violates the transparency disclosure requirements of this paragraph (b).

(c) * * *

(1) This section applies for plan years beginning on or after January 1, 2027. Until the applicability date in the preceding sentence, plans and issuers are required to continue to comply with Sec. 2590.715-2715A2, revised as of July 1, 2025. * * * * *

(7) A group health plan or health insurance issuer that provides to the participant or beneficiary the information required under paragraph (b)(1) of this section, in accordance with the method and format requirements set forth in paragraph (b)(2) of this section, satisfies the requirements set forth in Code section 9819, ERISA section 719, and PHS Act section 2799A-4. * * * * *

0 8. Section 2590.715-2715A3 is amended by-- 0 a. Revising and republishing paragraph (b); and 0 b. Revising paragraph (c)(1).

The revisions and republications read as follows:

Sec. 2590.715-2715A3 Transparency in coverage--requirements for public disclosure.

* * * * *

(b) Requirements for public disclosure of in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for covered items and services, negotiated rates and historical net prices for covered prescription drugs, and contextual information. A group health plan or health insurance issuer must make available on an internet website the information required under paragraphs (b)(1) and (2) of this section in machine-readable files, in accordance with the method and format requirements described in paragraph (b)(3) of this section, and that are updated as required under paragraph (b)(4) of this section.

(1) Required information. Machine-readable files required under this paragraph (b) that are made available to the public by a group health plan or health insurance issuer must include:

(i) An in-network rate machine-readable file for each provider network maintained or contracted by a group health plan or health insurance issuer that includes the required information under this paragraph (b)(1)(i) for all covered items and services under each coverage option offered by the plan or issuer that uses such provider network, except for prescription drugs that are subject to a fee-for- service

reimbursement arrangement, which must be reported in the prescription drug machine-readable file pursuant to paragraph (b)(1)(iii) of this section. Each in-network rate machine-readable file must include:

(A) The common provider network name;

(B) The provider network identifier;

(C) For each coverage option offered by a group health plan or health insurance issuer that uses such provider network, the name; the Health Insurance Oversight System (HIOS) identifier, or, if no HIOS identifier is available, the Employer Identification Number (EIN); and the product type (for example, including but not limited to health maintenance organization or preferred provider organization);

(D) A billing code, which in the case of prescription drugs must be a national drug code (NDC), and a plain language description for each billing code for each covered item or service included in the machine- readable file;

(E) For each covered item or service included in the machine- readable file, all applicable rates, which may include one or more of the following: Negotiated rates, underlying fee schedule rates, or derived amounts. If a group health plan or health insurance issuer does not use negotiated rates for provider reimbursement, then the plan or issuer should disclose derived amounts to the extent these amounts are already calculated in the normal course of business. If the plan or issuer uses underlying fee schedule rates for calculating cost sharing, then the plan or issuer should include the underlying fee schedule rates in addition to the negotiated rate or derived amount. Applicable rates, including for both individual items and services and items and services in a bundled payment arrangement, must be:

(1) Reflected as dollar amounts, with respect to each covered item or service that is furnished by an in-network provider. If the negotiated rate is subject to change based upon participant or beneficiary-specific characteristics, these dollar amounts should be reflected as the base negotiated rate applicable to the item or service prior to adjustments for participant or beneficiary-specific characteristics. For contractual arrangements under which a group health plan or health insurance issuer agrees to pay an in-network provider a percentage of billed charges and is not able to assign a dollar amount to an item or service prior to a bill being generated, plans and issuers must report a percentage number, in lieu of a dollar amount, in a form and manner as specified in guidance issued by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services.

(2) Associated with the National Provider Identifier (NPI), Tax Identification Number (TIN), and Place of Service Code for each in- network provider, except those specified in paragraph (b)(1)(i)(F) of this section;

(3) Associated with the last date of the contract term or expiration date for each provider-specific applicable rate that applies to each covered item or service; and

(4) Indicated with a notation where a reimbursement arrangement other than a standard fee-for-service model (such as capitation or a bundled payment arrangement) applies.

(F) A group health plan or health insurance issuer must exclude from each file under paragraph (b)(1)(i) of this section a provider and their negotiated rate (provider-rate combination) for an item or service if the plan or issuer determines it is unlikely that the provider would be reimbursed for the item or service given that provider's specialty according to the plan's or issuer's internal provider taxonomy or other internal rules used during the claims adjudication process.

(ii) For each health insurance market, as defined in Sec. 2590.715-2715A1(a)(2)(x), in which a group health plan or health insurance issuer offers a plan or coverage, an out-of-network allowed amount machine-readable file, including:

(A) For each coverage option offered by a group health plan or health insurance issuer in such health insurance market, the name and the HIOS identifier, or, if no HIOS identifier is available, the EIN; and the product type (for example, including but not limited to health maintenance organization or preferred provider organization);

(B) A billing code, which in the case of prescription drugs must be an NDC, and a plain language description for each billing code for each covered item or service under any coverage option offered by a group health plan or health insurance issuer in such health insurance market; and

(C) Aggregated unique out-of-network allowed amounts and billed charges with respect to each covered item or service under any coverage option offered by a group health plan or health insurance issuer in such health insurance market furnished by out-of-network providers during the 6-month time period that begins 9 months prior to the publication date of the machine-readable file (except that a plan or issuer must omit such data in relation to a particular item or service when compliance with this paragraph (b)(1)(ii)(C) would require the plan or issuer to report payment of out-of-network allowed amounts in connection with fewer than 11 different claims for payment of that item or service in a single health insurance market). Consistent with paragraph (c)(3) of this section, nothing in this paragraph (b)(1)(ii)(C) requires the disclosure of information that would violate any applicable health information privacy law. Each unique out-of- network allowed amount must be:

(1) Reflected as a dollar amount, with respect to each covered item or service that is furnished by an out-of-network provider; and

(2) Associated with the NPI, TIN, and Place of Service Code for each out-of-network provider.

(iii) A prescription drug machine-readable file, including:

(A) For each coverage option offered by a group health plan or health insurance issuer, the name and the 14-digit HIOS identifier, or, if the 14-digit HIOS identifier is not available, the 5-digit HIOS identifier, or, if no HIOS identifier is available, the EIN;

(B) The NDC, and the proprietary and nonproprietary name assigned to the NDC by the Food and Drug Administration (FDA), for each covered item or service under each coverage option offered by a plan or issuer that is a prescription drug;

(C) The negotiated rates which must be:

(1) Reflected as a dollar amount, with respect to each NDC that is furnished by an in-network provider, including an in-network pharmacy or other prescription drug dispenser;

(2) Associated with the NPI, TIN, and Place of Service Code for each in-network provider, including each in-network pharmacy or other prescription drug dispenser; and

(3) Associated with the last date of the contract term for each provider-specific negotiated rate that applies to each NDC; and

(D) Historical net prices that are:

(1) Reflected as a dollar amount, with respect to each NDC that is furnished by an in-network provider, including an in-network pharmacy or other prescription drug dispenser;

(2) Associated with the NPI, TIN, and Place of Service Code for each in-network provider, including each in-network pharmacy or other prescription drug dispenser; and

(3) Associated with the 90-day time period that begins 180 days prior to the publication date of the machine-

readable file for each provider-specific historical net price that applies to each NDC (except that a group health plan or health insurance issuer must omit such data in relation to a particular NDC and provider when compliance with this paragraph (b)(1)(iii)(D) would require the plan or issuer to report payment of historical net prices calculated using fewer than 20 different claims for payment). Consistent with paragraph (c)(3) of this section, nothing in this paragraph (b)(1)(iii)(D) requires the disclosure of information that would violate any applicable health information privacy law.

(iv) In each machine-readable file required under paragraphs (b)(1)(i) through (iii), and (b)(2)(i) and (ii) of this section, a plan or issuer:

(A) Must attest the following: To the best of its knowledge and belief, this plan or issuer has included all applicable information in accordance with the requirements of 29 CFR 2590.715-2715A3, and the information encoded is true, accurate, and complete as of the date in the file.

(B) Must encode the name of the plan's or issuer's chief executive officer, president, or senior official designated to oversee the encoding of true, accurate, and complete data as directed in paragraph (b)(1)(iv)(A) of this section.

(C) May satisfy the requirements of paragraphs (b)(1)(iv)(A) and (B) of this section by entering into a written agreement under which another party (such as a third-party administrator) makes the attestation required in paragraph (b)(1)(iv)(A) of this section on behalf of the plan or issuer and encodes the name of the other party's chief executive officer, president, or senior official designated to oversee the encoding of true, accurate, and complete data as directed in paragraph (b)(1)(iv)(A) of this section, only if the plan or issuer has entered into an agreement with the other party to provide the information in this paragraph (b) pursuant to the special rules in paragraph (b)(5) of this section.

(2) Required contextual files. A group health plan or health insurance issuer must make available in a machine-readable format:

(i) A utilization file, for each in-network rate machine-readable file specified in paragraph (b)(1)(i) of this section, that includes, for the most recent plan year that ends at least 6 months prior to the date the utilization file is made available as specified in paragraph (b)(4)(iii) of this section:

(A) Items and services covered under the plans or policies included in the files prepared as specified in paragraph (b)(1)(i) of this section for which a claim has been submitted and reimbursed (or would be reimbursed but for cost-sharing liability), in whole or in part; and

(B) Each in-network provider identified by the NPI, TIN, and Place of Service Code who was reimbursed (or would be reimbursed but for cost-sharing liability), in whole or in part, for a claim for each covered item or service included as specified in paragraph (b)(2)(i)(A) of this section.

(ii) A taxonomy file, for each in-network rate machine-readable file prepared as specified in paragraph (b)(1)(i) of this section, which includes the group health plan's or health insurance 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, as described in paragraph (b)(1)(i)(F) of this section. The information provided in the taxonomy file must be expressed as pairings of items and services (represented by billing codes) with provider specialties (represented by specialty codes which are derived from the Health Care Provider Taxonomy code set established by the National Uniform Claim Committee (NUCC)). Plans and issuers must use their internal provider taxonomy or other internal rules to determine whether to exclude certain provider-rate combinations from the in-network rate machine-readable file as specified in paragraph (b)(1)(i)(F) of this section.

(iii) A plain text file in a .txt format in the root folder (that is, the top-level directory on an electronic file system) of a group health plan's or health insurance issuer's website that includes:

(A) The source page URL for the internet website that hosts the machine-readable files required under paragraphs (b)(1) and (2) of this section;

(B) A direct link to the URL for the machine-readable files required under paragraphs (b)(1) and (2) of this section; and

(C) Point-of-contact information, including a monitored email address for an individual or group dedicated to receiving and responding to inquiries and issues related to the machine-readable files required under paragraphs (b)(1) and (2) of this section. This contact information (whether an individual or group) must be prominently displayed on the same website where the machine-readable files are made available and kept updated per the requirements in paragraph (b)(4)(v) of this section.

(3) Required method and format for disclosing information to the public. (i) Unless otherwise required by this section, the machine- readable files described in paragraphs (b)(1) and (2) of this section must be available in a single, non-proprietary, open-standards format, in a form and manner specified in guidance issued by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services.

(ii) The machine-readable files described in paragraphs (b)(1) and (2) of this section must be publicly available and accessible to any person, automated script, or web crawler free of charge and without conditions, such as establishment of a user account, password, submission of personally identifiable information or other credentials, or blocking server configurations or firewalls to access the file.

(iii) The source page URL for the internet website that hosts the machine-readable files required under paragraphs (b)(1) and (2) of this section must be included as a link in the footer on the home page of the group health plan's or health insurance issuer's website, as well as any page of the website that features a footer, that is labeled “Price Transparency” or “Transparency in Coverage” and links directly to the publicly available web page that hosts the link to the machine-readable files.

(iv) The group health plan or health insurance issuer may satisfy the requirements of paragraph (b)(3)(iii) of this section by entering into a written agreement under which another party (such as a third- party administrator) posts the machine-readable files described in paragraphs (b)(1) and (2) of this section on its public website on behalf of the plan or issuer, including if the plan or issuer does not have a website. However, if the files are posted on a service provider's website, and the plan or issuer maintains a public website but chooses not to host the files separately on its own public website, it must provide a link on its own public website to the location where the files are made publicly available.

(4) Timing. A group health plan or health insurance issuer must update the machine-readable files in accordance with the following timeframes and clearly indicate the date that the files were most recently updated:

(i) The in-network rate and out-of-network allowed amount machine- readable files required by paragraphs (b)(1)(i) and (ii) of this section must be updated and posted quarterly on the first day of each calendar-year quarter beginning with the first calendar-year quarter following the applicability date under paragraph (c)(1) of this section;

(ii) The prescription drug machine-readable file required by paragraph (b)(1)(iii) of this section must be updated monthly;

(iii) The utilization machine-readable file required under paragraph (b)(2)(i) of this section must be posted beginning on July 1, 2028, and updated and posted on an annual basis thereafter;

(iv) The taxonomy machine-readable file required under paragraph (b)(2)(ii) of this section must be updated and posted quarterly on the first day of each calendar-year quarter beginning with the first calendar-year quarter following the applicability date under paragraph (c)(1) of this section. If there are no changes to the taxonomy that affect the information required in the machine-readable file required under paragraph (b)(1)(i) of this section in a subsequent quarter, the taxonomy file is still required to be posted but not updated for that quarter; and

(v) The text file required by paragraph (b)(2)(iii) of this section must be posted on the first day of the first calendar-year quarter following the applicability date under paragraph (c)(1) of this section and subsequently updated and posted as soon as practicable but no later than 7 calendar days following a change in any of the information required under paragraph (b)(2)(iii) of this section.

(5) Special rules to prevent unnecessary duplication--(i) Special rule for insured group health plans. To the extent coverage under a group health plan consists of group health insurance coverage, the plan satisfies the requirements of this paragraph (b) if the plan requires the health insurance issuer offering the coverage to provide the information under a written agreement. Accordingly, if an issuer and a plan sponsor enter into a written agreement under which the issuer agrees to provide, on behalf of the plan, the information required under this paragraph (b) in compliance with this section, and the issuer fails to do so, then the issuer, but not the plan, violates the transparency disclosure requirements of this paragraph (b).

(ii) Other contractual arrangements. A group health plan or health insurance issuer may satisfy the requirements under this paragraph (b) by entering into a written agreement under which another party (such as a third-party administrator or health care claims clearinghouse) will provide, on behalf of the plan or issuer, the information required by this paragraph (b) in compliance with this section. Notwithstanding the preceding sentence, if a plan or issuer chooses to enter into such an agreement and the party with which it contracts fails to provide the information in compliance with this paragraph (b), the plan or issuer violates the transparency disclosure requirements of this paragraph (b).

(iii) Special rule for self-insured group health plans with respect to the disclosure of in-network rate machine-readable files. A self- insured group health plan that enters into an agreement with another party described in paragraph (b)(5)(ii) of this section may permit such other party to make available in a single in-network rate machine- readable file as required under paragraph (b)(1)(i) of this section the information required under paragraph (b)(1)(i) of this section for each provider network used by more than one plan, insurance policy, or contract (including those offered by different plan sponsors with which that other party has an agreement) and across different health insurance markets if--

(A) Each in-network rate machine-readable file made available for a provider network includes the required information under paragraph (b)(1)(i) of this section for all covered items and services under each plan, insurance policy, or contract that uses the same provider network for which the in-network rate machine-readable file is made available; and

(B) Each of the self-insured group health plan's utilization and taxonomy machine-readable files include the information required under paragraphs (b)(2)(i) and (ii) of this section, respectively, for the same plans, insurance policies, or contracts (including those offered by different plan sponsors and across different health insurance markets, if applicable) represented in the corresponding in-network rate machine-readable files specified in paragraph (b)(1)(i) of this section.

(iv) Special rule for self-insured group health plans with respect to the disclosure of out-of-network allowed amount machine-readable files. A self-insured group health plan that enters into an agreement with another party described in paragraph (b)(5)(ii) of this section may permit such other party to make available the information required under paragraph (b)(1)(ii) of this section in a single out-of-network allowed amount file for more than one self-insured group health plan (including those offered by different plan sponsors with which the other party has an agreement), provided that the out-of-network allowed amount and billed charge data described in paragraph (b)(1)(ii)(C) of this section in relation to a particular item or service is omitted if it would require disclosure of out-of-network allowed amounts in connection with fewer than 11 different claims for payment of such item or service across all of the plans (including those offered by different plan sponsors) included in the out-of-network machine- readable file.

(c) * * *

(1)(i) Until the applicability date specified in paragraph (c)(1)(ii) of this section, plans and issuers are required to continue to comply with 29 CFR 2590.715-2715A3 revised as of July 1, 2025.

(ii) The provisions of this section apply beginning March 6, 2027, except that paragraphs (b)(2), (b)(3)(iii), and (b)(4)(iii) through (v) of this section apply beginning September 6, 2027. * * * * *

For the reasons stated in the preamble, the Department of Health and Human Services amends 45 CFR part 147 as set forth below:

PART 147--HEALTH INSURANCE REFORM REQUIREMENTS FOR THE GROUP AND INDIVIDUAL HEALTH INSURANCE MARKETS

0 9. The authority citation for part 147 is revised to read as follows:

Authority: 42 U.S.C. 300gg through 300gg-63, 300gg-91, 300gg- 92, and 300gg-114, as amended.

0 10. Section 147.210 is amended by-- 0 a. Redesignating paragraphs (a)(2)(xi) through (xxii) as paragraphs (a)(2)(xii) through (xxiii), respectively; and 0 b. Adding paragraph (a)(2)(xi).

The addition reads as follows:

Sec. 147.210 Transparency in coverage--definitions.

(a) * * *

(2) * * *

(xi) Health insurance market means, irrespective of the State, one of the following:

(A) The individual market, as defined in Sec. 144.103 (other than short-term, limited-duration insurance or individual health insurance coverage that consists solely of excepted benefits, as defined in Sec. 148.220).

(B) The large group market, as defined in Sec. 144.103 (other than coverage that consists solely of excepted benefits, as defined in Sec. 146.145(b)).

(C) The small group market, as defined in Sec. 144.103 (other than coverage that consists solely of excepted benefits, as defined in Sec. 146.145(b)).

(D) For purposes of self-insured group health plans (other than account-based plans, as defined in Sec. 147.126(d)(6)(i),

and plans that consist solely of excepted benefits, as defined in Sec. 146.145(b)), all self-insured group health plans maintained by the plan sponsor. * * * * *

0 11. Section 147.211 is amended by-- 0 a. Revising paragraphs (b)(1)(i)(A) and (B), (b)(1)(vii)(A), and (b)(2)(ii) introductory text; 0 b. Redesignating paragraph (b)(2)(ii)(D) as paragraph (b)(2)(iv); 0 c. Adding paragraph (b)(2)(iii); 0 d. Revising newly redesignated paragraph (b)(2)(iv); 0 e. Revising paragraphs (b)(3)(i) and (ii) and (c)(1); and 0 f. Adding paragraph (c)(7).

The revisions and additions read as follows:

Sec. 147.211 Transparency in coverage--required disclosures to participants, beneficiaries, and enrollees.

* * * * *

(b) * * *

(1) * * *

(i) * * *

(A) If the request for cost-sharing information relates to items and services that are provided within a bundled payment arrangement, and the bundled payment arrangement includes items or services that have a separate cost-sharing liability, the group health plan or health insurance issuer must provide estimates of the cost-sharing liability for the requested covered item or service, as well as an estimate of the cost-sharing liability for each of the items and services in the bundled payment arrangement that have separate cost-sharing liabilities. While plans and issuers are not required to provide estimates of cost-sharing liability for a bundled payment arrangement where the cost-sharing is imposed separately for each item and service included in the bundled payment arrangement, nothing prohibits plans or issuers from providing estimates for multiple items and services in situations where such estimates could be relevant to participants, beneficiaries, or enrollees, as long as the plan or issuer also discloses information about the relevant items or services individually, as required in paragraph (b)(1)(v) of this section.

(B) For requested items and services that are recommended preventive services under section 2713 of the Public Health Service Act (PHS Act), if the group health plan or health insurance issuer cannot determine whether the request is for preventive or non-preventive purposes, the plan or issuer must display the cost-sharing liability that applies for non-preventive purposes. As an alternative, a plan or issuer may allow a participant, beneficiary, or enrollee to request cost-sharing information for the specific preventive or non-preventive item or service by including terms such as “preventive,” “non- preventive,” or “diagnostic” as a means to request the most accurate cost-sharing information. * * * * *

(vii) * * *

(A) A statement that the cost-sharing information provided pursuant to this paragraph (b)(1) does not account for potential additional amounts in situations where applicable State or Federal law allow out- of-network providers to bill participants, beneficiaries, or enrollees for the difference between a provider's billed charges and the sum of the amount collected from the group health plan or health insurance issuer and from the participants, beneficiaries, or enrollees in the form of a copayment, coinsurance, or deductible amount (the difference referred to as balance billing). This statement is not required if the State in which the item or service was furnished prohibits all out-of- network providers from balance billing for all items and services payable by the plan or issuer; * * * * *

(2) * * *

(ii) Paper method. Information provided under this paragraph (b) must be made available in plain language, without a fee, in paper form at the request of the participant, beneficiary, or enrollee. In responding to such a request, the group health plan or health insurance issuer may limit the number of providers with respect to which cost- sharing information for covered items and services is provided to no fewer than 20 providers per request. The plan or issuer is required to: * * * * *

(iii) Phone method. Information provided under this paragraph (b) must be made available at the request of the participant, beneficiary, or enrollee via a telephone number indicated on any physical or electronic plan or insurance identification card issued to a participant, beneficiary, or enrollee through which a consumer may seek customer assistance pursuant to section 2799A-1(e)(3) of the PHS Act. Such information must be accurate at the time of the request and must be provided at the time of the request. In responding to such a request, the group health plan or health insurance issuer may limit the number of providers with respect to which cost-sharing information for covered items and services is provided to no fewer than 20 providers per day. The plan or issuer is required to:

(A) Disclose the applicable provider-per-day limit to the participant, beneficiary, or enrollee; and

(B) Provide the cost-sharing information, in accordance with the requirements in paragraphs (b)(2)(i)(A) through (C) of this section.

(iv) Alternative method. In circumstances where participants, beneficiaries, and enrollees request disclosure other than by the internet-based self-service tool, paper, or phone (for example, by email) group health plans and health insurance issuers may provide the disclosure through alternative means and satisfy the requirements of this section, provided the participant, beneficiary, or enrollee agrees that such disclosure through such means is sufficient to satisfy the request and the plan or issuer meets the timing requirements established under paragraph (b)(2)(ii)(C) of this section for paper method disclosure.

(3) * * *

(i) Special rule for insured group health plans. To the extent coverage under a group health plan consists of group health insurance coverage, the plan satisfies the requirements of this paragraph (b) if the plan requires the health insurance issuer offering the coverage to provide the information required by this paragraph (b) in compliance with this section under a written agreement. Accordingly, if an issuer and a plan sponsor enter into a written agreement under which the issuer agrees to provide the information required under this paragraph (b) in compliance with this section, and the issuer fails to do so, then the issuer, but not the plan, violates the transparency disclosure requirements of this paragraph (b).

(ii) Other contractual arrangements. A group health plan or health insurance issuer may satisfy the requirements under this paragraph (b) by entering into a written agreement under which another party (such as a pharmacy benefit manager or other third-party) provides the information required by this paragraph (b) in compliance with this section. Notwithstanding the preceding sentence, if a plan or issuer chooses to enter into such an agreement and the party with which it contracts fails to provide the information in compliance with this paragraph (b), the plan or issuer violates the transparency disclosure requirements of this paragraph (b).

(c) * * *

(1) This section applies for plan years (in the individual market, for policy years) beginning on or after January 1,

2027. Until the applicability date in the preceding sentence, plans and issuers are required to continue to comply with Sec. 147.211, revised as of October 1, 2025. * * * * *

(7) A group health plan or health insurance issuer that provides to the participant, beneficiary or enrollee the information required under paragraph (b)(1) of this section, in accordance with the method and format requirements set forth in paragraph (b)(2) of this section, satisfies the requirements set forth in Code section 9819, ERISA section 719, and PHS Act section 2799A-4. * * * * *

0 12. Section 147.212 is amended by-- 0 a. Revising and republishing paragraph (b); and 0 b. Revising paragraph (c)(1).

The revisions and republications read as follows:

Sec. 147.212 Transparency in coverage--requirements for public disclosure.

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(b) Requirements for public disclosure of in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for covered items and services, negotiated rates and historical net prices for covered prescription drugs, and contextual information. A group health plan or health insurance issuer must make available on an internet website the information required under paragraphs (b)(1) and (2) of this section in machine-readable files, in accordance with the method and format requirements described in paragraph (b)(3) of this section, and that are updated as required under paragraph (b)(4) of this section.

(1) Required information. Machine-readable files required under this paragraph (b) that are made available to the public by a group health plan or health insurance issuer must include:

(i) An in-network rate machine-readable file for each provider network maintained or contracted by a group health plan or health insurance issuer that includes the required information under this paragraph (b)(1)(i) for all covered items and services under each coverage option offered by the plan or issuer that uses such provider network, except for prescription drugs that are subject to a fee-for- service reimbursement arrangement, which must be reported in the prescription drug machine-readable file pursuant to paragraph (b)(1)(iii) of this section. Each in-network rate machine-readable file must include:

(A) The common provider network name;

(B) The provider network identifier;

(C) For each coverage option offered by a group health plan or health insurance issuer that uses such provider network, the name; the Health Insurance Oversight System (HIOS) identifier, or, if no HIOS identifier is available, the Employer Identification Number (EIN); and the product type (for example, including but not limited to health maintenance organization or preferred provider organization);

(D) A billing code, which in the case of prescription drugs must be a national drug code (NDC), and a plain language description for each billing code for each covered item or service included in the machine- readable file;

(E) For each covered item or service included in the machine- readable file, all applicable rates, which may include one or more of the following: Negotiated rates, underlying fee schedule rates, or derived amounts. If a group health plan or health insurance issuer does not use negotiated rates for provider reimbursement, then the plan or issuer should disclose derived amounts to the extent these amounts are already calculated in the normal course of business. If the plan or issuer uses underlying fee schedule rates for calculating cost sharing, then the plan or issuer should include the underlying fee schedule rates in addition to the negotiated rate or derived amount. Applicable rates, including for both individual items and services and items and services in a bundled payment arrangement, must be:

(1) Reflected as dollar amounts, with respect to each covered item or service that is furnished by an in-network provider. If the negotiated rate is subject to change based upon participant, beneficiary, or enrollee-specific characteristics, these dollar amounts should be reflected as the base negotiated rate applicable to the item or service prior to adjustments for participant, beneficiary, or enrollee-specific characteristics. For contractual arrangements under which a group health plan or health insurance issuer agrees to pay an in-network provider a percentage of billed charges and is not able to assign a dollar amount to an item or service prior to a bill being generated, plans and issuers must report a percentage number, in lieu of a dollar amount, in a form and manner as specified in guidance issued by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services.

(2) Associated with the National Provider Identifier (NPI), Tax Identification Number (TIN), and Place of Service Code for each in- network provider, except those specified in paragraph (b)(1)(i)(F) of this section;

(3) Associated with the last date of the contract term or expiration date for each provider-specific applicable rate that applies to each covered item or service; and

(4) Indicated with a notation where a reimbursement arrangement other than a standard fee-for-service model (such as capitation or a bundled payment arrangement) applies.

(F) A group health plan or health insurance issuer must exclude from each file under paragraph (b)(1)(i) of this section a provider and their negotiated rate (provider-rate combination) for an item or service if the plan or issuer determines it is unlikely that the provider would be reimbursed for the item or service given that provider's specialty according to the plan's or issuer's internal provider taxonomy or other internal rules used during the claims adjudication process.

(ii) For each health insurance market, as defined in Sec. 147.210(a)(2)(xi), in which a group health plan or health insurance issuer offers a plan or coverage, an out-of-network allowed amount machine-readable file, including:

(A) For each coverage option offered by a group health plan or health insurance issuer in such health insurance market, the name and the HIOS identifier, or, if no HIOS identifier is available, the EIN; and the product type (for example, including but not limited to health maintenance organization or preferred provider organization);

(B) A billing code, which in the case of prescription drugs must be an NDC, and a plain language description for each billing code for each covered item or service under any coverage option offered by a group health plan or health insurance issuer in such health insurance market; and

(C) Aggregated unique out-of-network allowed amounts and billed charges with respect to each covered item or service under any coverage option offered by a group health plan or health insurance issuer in such health insurance market furnished by out-of-network providers during the 6-month time period that begins 9 months prior to the publication date of the machine-readable file (except that a plan or issuer must omit such data in relation to a particular item or service when compliance with this paragraph (b)(1)(ii)(C) would require the plan or issuer to report payment of out-of-network allowed amounts in connection with fewer than 11 different claims for

payment of that item or service in a single health insurance market). Consistent with paragraph (c)(3) of this section, nothing in this paragraph (b)(1)(ii)(C) requires the disclosure of information that would violate any applicable health information privacy law. Each unique out-of-network allowed amount must be:

(1) Reflected as a dollar amount, with respect to each covered item or service that is furnished by an out-of-network provider; and

(2) Associated with the NPI, TIN, and Place of Service Code for each out-of-network provider.

(iii) A prescription drug machine-readable file, including:

(A) For each coverage option offered by a group health plan or health insurance issuer, the name and the 14-digit HIOS identifier, or, if the 14-digit HIOS identifier is not available, the 5-digit HIOS identifier, or, if no HIOS identifier is available, the EIN;

(B) The NDC, and the proprietary and nonproprietary name assigned to the NDC by the Food and Drug Administration (FDA), for each covered item or service that is a prescription drug under each coverage option offered by a plan or issuer;

(C) The negotiated rates which must be:

(1) Reflected as a dollar amount, with respect to each NDC that is furnished by an in-network provider, including an in-network pharmacy or other prescription drug dispenser;

(2) Associated with the NPI, TIN, and Place of Service Code for each in-network provider, including each in-network pharmacy or other prescription drug dispenser; and

(3) Associated with the last date of the contract term for each provider-specific negotiated rate that applies to each NDC; and

(D) Historical net prices that are:

(1) Reflected as a dollar amount, with respect to each NDC that is furnished by an in-network provider, including an in-network pharmacy or other prescription drug dispenser;

(2) Associated with the NPI, TIN, and Place of Service Code for each in-network provider, including each in-network pharmacy or other prescription drug dispenser; and

(3) Associated with the 90-day time period that begins 180 days prior to the publication date of the machine-readable file for each provider-specific historical net price that applies to each NDC (except that a group health plan or health insurance issuer must omit such data in relation to a particular NDC and provider when compliance with this paragraph (b)(1)(iii)(D) would require the plan or issuer to report payment of historical net prices calculated using fewer than 20 different claims for payment). Consistent with paragraph (b)(3) of this section, nothing in this paragraph (b)(1)(iii)(D) requires the disclosure of information that would violate any applicable health information privacy law.

(iv) In each machine-readable file required under paragraphs (b)(1)(i) through (iii), and (b)(2)(i) and (ii) of this section, a plan or issuer:

(A) Must attest the following: To the best of its knowledge and belief, this plan or issuer has included all applicable information in accordance with the requirements of 45 CFR 147.212, and the information encoded is true, accurate, and complete as of the date in the file.

(B) Must encode the name of the plan's or issuer's chief executive officer, president, or senior official designated to oversee the encoding of true, accurate, and complete data as directed in paragraph (b)(1)(iv)(A) of this section.

(C) May satisfy the requirements of paragraphs (b)(1)(iv)(A) and (B) of this section by entering into a written agreement under which another party (such as a third-party administrator) makes the attestation required in paragraph (b)(1)(iv)(A) of this section on behalf of the plan or issuer and encodes the name of the other party's chief executive officer, president, or senior official designated to oversee the encoding of true, accurate, and complete data as directed in paragraph (b)(1)(iv)(A) of this section, only if the plan or issuer has entered into an agreement with the other party to provide the information in this paragraph (b) pursuant to the special rules in paragraph (b)(5) of this section.

(2) Required contextual files. A group health plan or health insurance issuer must make available in a machine-readable format:

(i) A utilization file, for each in-network rate machine-readable file specified in paragraph (b)(1)(i) of this section, that includes, for the most recent plan year (in the individual market, policy year) that ends at least 6 months prior to the date the utilization file is made available as specified in paragraph (b)(4)(iii) of this section:

(A) Items and services covered under the plans or policies included in the files prepared as specified in paragraph (b)(1)(i) of this section for which a claim has been submitted and reimbursed (or would be reimbursed but for cost-sharing liability), in whole or in part; and

(B) Each in-network provider identified by the NPI, TIN, and Place of Service Code who was reimbursed (or would be reimbursed but for cost-sharing liability), in whole or in part, for a claim for each covered item or service included as specified in paragraph (b)(2)(i)(A) of this section.

(ii) A taxonomy file, for each in-network rate machine-readable file prepared as specified in paragraph (b)(1)(i) of this section, which includes the group health plan's or health insurance 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, as described in paragraph (b)(1)(i)(F) of this section. The information provided in the taxonomy file must be expressed as pairings of items and services (represented by billing codes) with provider specialties (represented by specialty codes which are derived from the Health Care Provider Taxonomy code set established by the National Uniform Claim Committee (NUCC)). Plans and issuers must use their internal provider taxonomy or other internal rules to determine whether to exclude certain provider-rate combinations from the in-network rate machine-readable file as specified in paragraph (b)(1)(i)(F) of this section.

(iii) A plain text file in a .txt format in the root folder (that is, the top-level directory on an electronic file system) of a group health plan's or health insurance issuer's website that includes:

(A) The source page URL for the internet website that hosts the machine-readable files required under paragraphs (b)(1) and (2) of this section;

(B) A direct link to the URL for the machine-readable files required under paragraphs (b)(1) and (2) of this section; and

(C) Point-of-contact information, including a monitored email address for an individual or group dedicated to receiving and responding to inquiries and issues related to the machine-readable files required under paragraphs (b)(1) and (2) of this section. This contact information (whether an individual or group) must be prominently displayed on the same website where the machine-readable files are made available and kept updated per the requirements in paragraph (b)(4)(v) of this section.

(3) Required method and format for disclosing information to the public. (i) Unless otherwise required by this section, the machine- readable files described in paragraphs (b)(1) and (2) of this section must be available in a single, non-proprietary, open-standards format, in a form and manner specified

in guidance issued by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services.

(ii) The machine-readable files described in paragraphs (b)(1) and (2) of this section must be publicly available and accessible to any person, automated script, or web crawler free of charge and without conditions, such as establishment of a user account, password, submission of personally identifiable information or other credentials, or blocking server configurations or firewalls to access the file.

(iii) The source page URL for the internet website that hosts the machine-readable files required under paragraphs (b)(1) and (2) of this section must be included as a link in the footer on the home page of the group health plan's or health insurance issuer's website, as well as any page of the website that features a footer, that is labeled “Price Transparency” or “Transparency in Coverage” and links directly to the publicly available web page that hosts the link to the machine-readable files.

(iv) The group health plan or health insurance issuer may satisfy the requirements of paragraph (b)(3)(iii) of this section by entering into a written agreement under which another party (such as a third- party administrator) posts the machine-readable files described in paragraphs (b)(1) and (2) of this section on its public website on behalf of the plan or issuer, including if the plan or issuer does not have a website. However, if the files are posted on a service provider's website, and the plan or issuer maintains a public website but chooses not to host the files separately on its own public website, it must provide a link on its own public website to the location where the files are made publicly available.

(4) Timing. A group health plan or health insurance issuer must update the machine-readable files in accordance with the following timeframes and clearly indicate the date that the files were most recently updated:

(i) The in-network rate and out-of-network allowed amount machine- readable files required by paragraphs (b)(1)(i) and (ii) of this section must be updated and posted quarterly on the first day of each calendar-year quarter beginning with the first calendar-year quarter following the applicability date under paragraph (c)(1) of this section;

(ii) The prescription drug machine-readable file required by paragraph (b)(1)(iii) of this section must be updated monthly;

(iii) The utilization machine-readable file required under paragraph (b)(2)(i) of this section must be posted beginning on July 1, 2028, and updated and posted on an annual basis thereafter;

(iv) The taxonomy machine-readable file required under paragraph (b)(2)(ii) of this section must be updated and posted quarterly on the first day of each calendar-year quarter beginning with the first calendar-year quarter following the applicability date under paragraph (c)(1) of this section. If there are no changes to the taxonomy that affect the information required in the machine-readable file required under paragraph (b)(1)(i) of this section in a subsequent quarter, the taxonomy file is still required to be posted but not updated for that quarter; and

(v) The text file required by paragraph (b)(2)(iii) of this section must be posted on the first day of the first calendar-year quarter following the applicability date under paragraph (c)(1) of this section and subsequently updated and posted as soon as practicable but no later than 7 calendar days following a change in any of the information required under paragraph (b)(2)(iii) of this section.

(5) Special rules to prevent unnecessary duplication--(i) Special rule for insured group health plans. To the extent coverage under a group health plan consists of group health insurance coverage, the plan satisfies the requirements of this paragraph (b) if the plan requires the health insurance issuer offering the coverage to provide the information under a written agreement. Accordingly, if an issuer and a plan sponsor enter into a written agreement under which the issuer agrees to provide, on behalf of the plan, the information required under this paragraph (b) in compliance with this section, and the issuer fails to do so, then the issuer, but not the plan, violates the transparency disclosure requirements of this paragraph (b).

(ii) Other contractual arrangements. A group health plan or health insurance issuer may satisfy the requirements under this paragraph (b) by entering into a written agreement under which another party (such as a third-party administrator or health care claims clearinghouse) will provide, on behalf of the plan or issuer, the information required by this paragraph (b) in compliance with this section. Notwithstanding the preceding sentence, if a plan or issuer chooses to enter into such an agreement and the party with which it contracts fails to provide the information in compliance with this paragraph (b), the plan or issuer violates the transparency disclosure requirements of this paragraph (b).

(iii) Special rule for self-insured group health plans with respect to the disclosure of in-network rate machine-readable files. A self- insured group health plan that enters into an agreement with another party described in paragraph (b)(5)(ii) of this section may permit such other party to make available in a single in-network rate machine- readable file as required under paragraph (b)(1)(i) of this section the information required under paragraph (b)(1)(i) of this section for each provider network used by more than one plan, insurance policy, or contract (including those offered by different plan sponsors with which that other party has an agreement) and across different health insurance markets if--

(A) Each in-network rate machine-readable file made available for a provider network includes the required information under paragraph (b)(1)(i) of this section for all covered items and services under each plan, insurance policy, or contract that uses the same provider network for which the in-network rate machine-readable file is made available; and

(B) Each of the self-insured group health plan's utilization and taxonomy machine-readable files include the information required under paragraphs (b)(2)(i) and (ii) of this section, respectively, for the same plans, insurance policies, or contracts (including those offered by different plan sponsors and across different health insurance markets, if applicable) represented in the corresponding in-network rate machine-readable files specified in paragraph (b)(1)(i) of this section.

(iv) Special rule for self-insured group health plans with respect to the disclosure of out-of-network allowed amount machine-readable files. A self-insured group health plan that enters into an agreement with another party described in paragraph (b)(5)(ii) of this section may permit such other party to make available the information required under paragraph (b)(1)(ii) of this section in a single out-of-network allowed amount file for more than one self-insured group health plan (including those offered by different plan sponsors with which the other party has an agreement), provided that the out-of-network allowed amount and billed charge data described in paragraph (b)(1)(ii)(C) of this section in relation to a particular item or service is omitted if it would require disclosure of out-of-network allowed amounts in connection with fewer than 11 different claims for payment of such item or service across all of the plans (including those offered by different plan sponsors) included in

the out-of-network machine-readable file.

(c) * * *

(1)(i) Until the applicability date specified in paragraph (c)(1)(ii) of this section, plans and issuers are required to continue to comply with Sec. 147.212 revised as of October 1, 2025.

(ii) The provisions of this section apply beginning March 6, 2027, except that paragraphs (b)(2), (b)(3)(iii), and (b)(4)(iii) through (v) of this section apply beginning September 6, 2027. * * * * * [FR Doc. 2026-20447 Filed 10-5-26; 8:45 am] BILLING CODE 4150-29-P; 4831-GV-P; 4169-69-P