The Centers for Medicare & Medicaid Services (CMS), along with the Department of Labor and the Department of the Treasury, has proposed amendments to existing payer price transparency regulations. These changes aim to enhance accessibility and standardization of pricing disclosures for non-grandfathered group health plans and insurance issuers. The proposal follows President Biden's Executive Order 14221, which seeks to provide patients with clear healthcare pricing information.
The proposed rule, available on the Federal Register at https://www.federalregister.gov/public-inspection/2025-23693/transparency-in-coverage, builds upon previous rules established in November 2020 under Executive Order 13877. Current regulations require monthly updates of machine-readable files detailing in-network rates, out-of-network allowed amounts, and prescription drug prices. However, challenges such as large file sizes and data ambiguity have been identified.
To address these issues, CMS proposes several changes. One key proposal is to exclude unlikely provider-rate combinations from In-network Rate Files by using internal provider taxonomy mappings. Additionally, a new Utilization File would be introduced to list providers who have submitted claims over a specified period.
Further proposals include aggregating Allowed Amount Files by insurance market type and lowering the claims threshold from 20 to 11 claims. Reporting periods would also be extended from 90 days to six months. To improve usability, additional data elements like product type and enrollment count would be required.
The Departments suggest reducing reporting frequency from monthly to quarterly to ease data management burdens. They also propose requiring a single file format for all machine-readable files, seeking feedback on whether JSON or CSV should be used.
Finally, amendments are suggested for self-service tools providing cost-sharing information online or via phone as per the No Surprises Act requirements. The applicability date for these amendments is proposed for January 1, 2027.
