In December, the Centers for Medicare and Medicaid Services (CMS), the Department of Labor, and the Department of the Treasury released the 2025 Transparency in Coverage Proposed Rule. The proposed rule aims to enhance the accessibility and usability of health plan pricing data. It addresses barriers such as large file sizes, a lack of context, and misalignment with other transparency regulations.
Background
The rule builds upon Section 1311(e)(3) of the Patient Protection and Affordable Care Act (ACA) and the Public Health Service (PHS) Act, which mandate transparency in health coverage. To implement these laws, the Departments of the Treasury, Labor, and Health and Human Services issued the original Transparency in Coverage final rules in November 2020. Executive Order 13877, issued by President Trump in June 2019, prompted these 2020 rules, which focused on putting patients first by improving price and quality transparency.
Addressing Technical and Usability Barriers
After the 2020 rules, researchers, data engineers, and Congress highlighted three main challenges:
- Inaccessibility Due to File Size: The machine-readable files (MRFs) required by current rules are often too large and unwieldy, sometimes reaching many terabytes in size. These massive datasets create significant burdens for users attempting to download and parse the information, and they result in high data storage and bandwidth costs for the plans and issuers reporting them.
- Lack of Context: Raw data lacked the necessary contextual information to make it meaningful for consumers and researchers.
- Misalignment: Requirements for payers were not aligned with the 2019 Hospital Price Transparency rule, making side-by-side comparisons of payer and provider data extremely difficult.
The new proposed rule aims to eliminate some of these errors by:
Enhancements to Machine-Readable Files (MRFs)
The proposal introduces several changes to streamline the data that health plans must disclose publicly:
Network-Level Reporting
Payers would report rates at the provider network level rather than for each individual plan, mirroring how hospitals already report data. This is intended to eliminate redundant data across thousands of plan-specific files.
Data Trimming
Payers must exclude provider-rate combinations for services that a provider is unlikely to furnish based on their specialty (e.g., gallbladder surgery rates for a psychiatrist). This is expected to significantly decrease the size of MRFs.
Reduced Update Frequency
The requirement for payers to refresh their in-network and out-of-network files would move from monthly to quarterly.
New Data Elements
MRFs would be required to include numerical enrollment totals, product types (e.g., HMO or PPO), and common provider network names.
New Contextual Files
To make the raw data more interpretable, the rule proposes three new supplementary files for each in-network rate file:
Change-log File
This file would identify specifically what data changed between the current and previous quarterly reporting periods.
Utilization File
This would list all providers who have received reimbursement for at least one claim over the previous 12 months. It helps users identify actively serving providers.
Taxonomy File
This file would disclose the payer’s internal specialty-to-billing-code mappings used to justify service exclusions.
Improved “Findability” of Data
The rule seeks to make files easier for automated tools and researchers to locate by:
- Requiring a plain text file (.txt) in the root folder of the payer’s website containing direct links to all MRF locations and a specific point of contact.
- Requiring a “Price Transparency” or “Transparency in Coverage” link in the footer of the payer’s homepage.
Changes to Out-of-Network (OON) Disclosures
To address gaps where plans currently report little or no OON data, the proposal would:
- Require plans to aggregate data at the health insurance market level (e.g., individual, small group, or large group) rather than the plan level.
- Lower the claims threshold for reporting from 20 claims to 11 claims.
- Increase the reporting period from 90 days to 6 months, with the lookback period expanding from 180 days to 9 months.
Expanded Consumer Access
The rule also impacts the self-service tools patients use to estimate costs:
Phone Access
The proposed rule would require plans to provide cost-sharing estimates via a phone number (found on the member’s ID card) upon request, in addition to existing online and paper methods.
No Surprises Act Alignment
Providers and health plans must update balance billing notices to reflect Federal protections, clarifying that estimates do not account for balance billing except where permitted by law.
Timeline
If finalized as written, the MRF changes would generally take effect 12 months after the date of publication of the final rule. The proposed updates to internet-based self-service tools and the phone disclosure requirement are scheduled to take effect on January 1, 2027. Public comments on the rule are due by February 23, 2026.
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