Transparency in Coverage Gets a Major Refresh: What Employers Need to Know

The Departments of Labor, Health and Human Services, and the Treasury (the Departments) recently released newly finalized Transparency in Coverage (TiC) Final Rules. They build on the original 2020 regulations and advance recent federal efforts to give consumers clearer, more actionable healthcare pricing information.

Why the Rule Matters

The original TiC rules required health plans and carriers to publish extensive pricing data in public machine-readable files (MRFs) and to offer cost-sharing information through consumer-facing tools.

Those requirements increased access to pricing data, but regulators found many disclosures too large and complex to be useful. The new rules aim to make price transparency more accessible, standardized, and actionable.

Key Changes Employers Should Understand

1. Smaller, More Useful In-Network Rate Files

Under the prior rules, plans often reported negotiated rates for provider-service combinations that would never occur in practice. For example, rates for a podiatrist to perform heart surgery.

The final rule lets plans and issuers exclude these unlikely combinations based on internal provider taxonomy and claims-adjudication rules. Plans must also publish:

• A new Taxonomy File explaining the methodology used; and
• A new Utilization File identifying providers who actually submitted reimbursed claims during the relevant period

The result should be smaller files that better reflect real-world utilization and negotiated rates.

2. Reporting Shifts from the Plan Level to the Network Level

Because many health plans utilize the same provider networks and negotiated rates, regulators concluded that a separate file for each plan creates unnecessary duplication. Going forward, plans and issuers generally will publish a single in-network rate file for each provider network rather than one for every health plan.

3. Expanded Out-of-Network Pricing Data

Regulators also found that out-of-network pricing disclosures often lacked enough data to be meaningful. The final rule:

• Reduces the reporting threshold from 20 claims to 11 claims;
• Requires aggregation by market type (i.e., large group, small group, individual, and self-insured); and
• Expands the amount of out-of-network data disclosed publicly
  
  

4. Easier Access to Transparency Files

Finding TiC files has often been its own challenge. To simplify access, plans and issuers must now:

• Publish a standardized text file identifying where the machine-readable files are located;
• Provide a monitored contact email for transparency-related inquiries; and
• Add a website footer link labeled "Price Transparency" or "Transparency in Coverage" that directs users to the relevant disclosures
  
  

5. Quarterly Instead of Monthly Updates

Many stakeholders argued that monthly updates created a substantial administrative burden without producing meaningful new information. The final rule responds by reducing the update frequency for in-network and out-of-network files from monthly to quarterly.

6. New Accuracy and Accountability Requirements

Plans and issuers must now attest that disclosed information is complete, accurate, and compliant with the regulations. Each machine-readable file must also identify the senior executive responsible for overseeing the accuracy of the disclosed data.

Changes to Consumer Cost-Sharing Tools

The final rule also expands member-facing pricing requirements. Plans currently must provide cost-sharing information through an online self-service tool and, upon request, in paper form. Under the new rules, plans must also make this information available by telephone upon request. For employers, this means vendors and administrators supporting transparency tools may need operational enhancements before the requirement applies.

Key Compliance Dates

The final rule becomes effective 60 days after publication in the Federal Register. CMS set several phased implementation dates:

• In-network and out-of-network file changes apply five months after publication;
• Taxonomy, utilization, and text-file requirements apply 11 months after publication; and
• Consumer tool and telephone-request requirements apply for plan years beginning on or after January 1, 2027.

A Note for Self-Funded Plans

Self-funded plan sponsors should pay particular attention to these requirements. While a plan can rely on its TPA to prepare and post the required machine-readable files, the plan ultimately remains responsible for compliance. The new rules also require each file to include an attestation that the information is true, accurate, and complete, along with identification of the senior executive responsible for overseeing the submission. A TPA can handle this attestation on the plan’s behalf if the appropriate written agreement is in place. However, assigning this responsibility to a TPA does not shift the plan’s underlying compliance obligation. Self-funded employers should review their TPA agreements to confirm who will handle the attestation and that the TPA is responsible for providing complete, accurate, and timely files.

What Employers Should Do Now

Most employers will rely on carriers, third-party administrators, and transparency vendors to implement these changes. Even so, plan sponsors should still take several proactive steps:

1. Discuss implementation timelines with carriers and TPAs.
2. Confirm vendor readiness for the new reporting and attestation requirements.
3. Evaluate whether transparency data can be leveraged more effectively in population health and cost-containment initiatives.
4. Review participant communication strategies regarding available price-shopping tools.

The Bottom Line

The latest TiC regulations are less about creating new transparency mandates and more about making existing ones usable. By shrinking file size, improving standardization, expanding meaningful disclosures, and strengthening accountability, regulators are trying to turn vast amounts of pricing data into a resource that employers, researchers, and consumers can actually use to make more informed healthcare decisions.