The Ghost in the Machine (Readable Files): Proposed Transparency in Coverage Amendments Attempt to Shed Additional Light on Health Plan Data

The push to health care transparency continues.[1]  During the first Trump administration, the Centers for Medicare and Medicaid Services (“CMS”), with the Department of Labor (“DOL”) and the Department of the Treasury/Internal Revenue Service (“IRS”) (collectively, “the Departments”) implemented the 2020 Transparency in Coverage Final Rule (“2020 Final Rule”).  Those rules generally require group health plans and health insurance issuers offering individual and group coverage to provide a cost-sharing tool through which individuals may receive estimates of cost-sharing obligations for items and services covered under their plan.  They also require public disclosure—through machine-readable files (“MRF”)—of in-network provider rates and out-of-network allowed amounts for items and services covered by the plan.

The new Transparency in Coverage Proposed Rule (“Proposed Rule”), builds on the 2020 Final Rule and purports to reduce the volume and reporting frequency for most health plan MRFs, although complying with the rule will likely result in at least a one-time increase in burden and costs.[2]  The Administration frames the Proposed Rule as a pivot from “data quantity” to “data quality,” explicitly targeting large and unwieldy MRFs and requiring the removal of clinically implausible “ghost rates” for services unlikely to be performed.  The Proposed Rule seeks to address two key areas: (1) MRF usability challenges; and (2) consumer price comparison tool improvements. 

For MRFs,[3] the Departments focuses on:

• File Size: Reducing large and difficult-to-navigate MRFs;
• Context: Reducing data ambiguity due to a lack of contextual information (e.g., active vs. inactive providers); and
• Alignment: Creating consistency across Hospital Price Transparency rules, to improve cross-file comparisons.[4]

GROOM INSIGHT: The Departments continue to envision third-party developers and other entities downloading, processing, and aggregating health pricing data, thus enabling the creation of more sophisticated price‑transparency tools. The Departments believe that these tools—including advanced analytics platforms and AI‑driven agents—may enhance the consumer shopping experience, provide insight into health care cost trends, and foster innovation in the health care market.

The Proposed Rule also seeks to align existing requirements for consumer price comparison tools with related No Surprises Act (“NSA”) disclosure requirements under the Consolidated Appropriations Act, 2021 (“CAA”).  In addition to providing cost-sharing information through internet-based self-service tools and on paper upon request, the Proposed Rule would also require plans and issuers to provide cost-sharing information by telephone.   

Summary of Key Proposed Changes

A. Public Disclosure Requirements

 1. All MRFs

In the Proposed Rule, the Departments seek to enhance standardization and usability of MRFs in part by proposing contextual files in addition to raw pricing data.  There are four types of contextual files in the Proposed Rule. The only file that applies to all MRFs is the Text File.  The Departments intend to issue technical guidance (and seek input) for In-Network and Allowed Amount MRFs on GitHub and via FAQs. 

Text Files – New –The Departments propose requiring plans and issuers to post a plain text file in .txt format (“Text File”) in the root folder (the top-level directory on an electronic file system) of a plan’s or issuer’s website that includes source page URL information and links for the internet website that hosts MRFs, as well as point-of-contact information for an individual who can address MRF-related inquiries and issues.  

Standardized File Format – No change – the Proposed Rule does not make any changes to the required format for publishing MRFs.  Instead, the Departments seek input on whether to name JavaScript Object Notation (“JSON”) or Comma Separate Value(s) (“CSV”) as the standardized file format for all MRFs in rulemaking or technical implementation guidance.  The Departments also reiterate a request for comment regarding a requirement that plans and issuers provide rate information through a publicly accessible Application Programming Interface (“API”) that would align with the CMS Interoperability and Prior Authorization Final Rule.[5]

GROOM INSIGHT: In the preamble, the Departments acknowledged that JSON and CSV appeal to different groups and users, and each platform has benefits and drawbacks. The desire to standardize reporting of health care pricing appears to outweigh the impact of reducing flexibility for plans and issuers.

Website Posting Requirements – Codification of previous guidance – Many employer-sponsored ERISA plans do not currently maintain a separate dedicated internet page for their group health plans.  In response, the Departments propose allowing a plan or issuer to satisfy the disclosure requirements by entering into a written agreement under which another party posts the MRFs on its public website on behalf of the plan or issuer.  This amendment would codify FAQs Part 55 and extend it to apply to issuers for consistency.

Reporting of Product type  – New –  The Departments also propose to add a requirement for plans and issuers to report the product type (e.g., Health Maintenance Organization (“HMO”) or Preferred Provider Organization (“PPO”)) associated with the coverage option for which data is being reported. 

• This requirement does not apply to prescription drug MRFs.

HIOS Identifier Modifications – Amendment – Pending future technical guidance, the Departments propose removing the specific digit requirements and instead require that plans and issuers report the name of each applicable coverage option “and the HIOS identifier, or, if no HIOS identifier is available, the EIN…” 

• This requirement does not apply to prescription drug MRFs.

2. In-Network Rate MRFs

The Proposed Rule includes three contextual file requirements that apply only to In-Network Rate MRFs. 

• Change-log File: This file would identify modifications to required information from one reporting period to the next.
• Utilization File: This file would contain claims data for items and services covered under the plans or policies included in the MRFs for a defined prior period.
• Taxonomy File: This file would map items and services to provider specialties to identify rates for a treatment that are clinically implausible (negotiated rates for providers for services for which they would be unlikely to be reimbursed), which are also referred to as “ghost” or “zombie” rates. 

Network-Level Reporting –  New – This change would require posting separate files for each provider network, which the Departments believe would also address requests for better alignment with Hospital Price Transparency Reporting.  Plans and issuers would be expected to define what constitutes a separate provider network according to their current business practices. 

Elimination of “Ghost” Rates – New – The Departments propose adding a requirement for plans and issuers to exclude provider-rate combinations for an item or service if the provider would be unlikely to be reimbursed for the item or service given the provider’s area of specialty.  The Departments believe that excluding these “ghost” rates that are not likely to result in a reimbursement will reduce file size.  If finalized as proposed, the rule will require plans and issuers to identify “ghost” rates using their internal provider taxonomy file.

Percentage of Billed Charges – Codification of previous guidance – Plans and issuers must disclose rates as a dollar amount whenever a dollar amount can be calculated in advance, including when a negotiated base rate can be calculated before adjustments.  This proposed provision codifies previous guidance.[6]  This proposed change, if finalized, would permit plans and issuers to disclose an applicable rate in a non-dollar amount only whenthe applicable rate is a percentage of billed charges and expect that plans and issuers report all other applicable rates as dollar amounts. 

Enrollment Totals – New – The Proposed Rule would require that each In-network Rate File include current numerical enrollment totals, as of the date the file is posted, for each coverage option offered by a plan or issuer represented in the In-network Rate File. Such enrollment totals must include the number of participants, beneficiaries, and enrollees (including all dependents) in the coverage option offered by a plan or issuer.

Special Rule for Self-insured Group Health Plans – New – The Proposed Rule includes a special rule for self-insured group health plans that satisfy certain conditions.  The Departments observed that In-network Rate Files may include information about plans, insurance policies, and contracts across health insurance markets, as a service provider may use the same provider network across multiple service lines (e.g., self-insured group health plans, fully-insured group health plans and/or individual health insurance coverage).  Under the Proposed Rule, these service providers would already be required to disclose an In-network Rate MRF.  The Departments would allow a self-insured group health plan to permit its service provider to include plans and coverage offered in different health insurance markets in the same In-network Rate MRF, to the extent they use the same provider network.

The option would be available only to self-insured group health plans that satisfy the following conditions:

• each In-network Rate MRF made available for a provider network must include information 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 MRF is made available; and

• each proposed contextual file (all of which must be made available for each In-network Rate MRF) must include data from the same plans, insurance policies, or contracts (including those offered by different plan sponsors and across different health insurance markets, if applicable) that are represented in the corresponding In-network Rate MRF.

Under this proposal, a self-insured group health plan that contracts with another party that takes advantage of the special rule would not be permitted to publish (either itself or by contracting with another party) the corresponding contextual files only with respect to its own plans.

GROOM INSIGHT:  Self-insured group health plans will remain liable for compliance failures even if they contract with and depend on third-party administrators (“TPAs”) and issuers to implement this Proposed Rule, if finalized.  Self-insured group health plans will need to carefully review and work with TPAs and issuers to update administrative services agreement and contracts to ensure compliance.  We also recommend that self-insured group health plans review indemnification clauses to ensure that they continue to be sufficient.

3. OON Allowed Amounts MRFs

The Departments are proposing five important changes for OON allowed amounts, including a new definition. 

“Health Insurance Market” Definition – New – The Departments proposed adding a definition for “health insurance market” to clarify how OON Allowed Amount MRFs are organized and aggregated, and to ensure consistency across markets.  The definition is designed to distinguish the term “insurance market” as it was used for purposes of the methodology for calculating the qualifying payment amount (“QPA”) under the NSA and interpreted in Texas Med. Ass’n v. U.S. Dep’t of Health & Hum. Servs. (TMA III). 

The proposed insurance market definitions generally align with current law.  For self-funded plans, the definition would be “all self-insured group health plans of the same plan sponsor.” (emphasis added).  The definitions for insured and self-funded plan excludes account-based plans, excepted benefits, and short-term, limited duration insurance.

Expand Aggregation of Data by Market Type – Amendment –  The Departments would require all plans and issuers to aggregate OON Allowed Amount data across the plans or coverage they offer in each health insurance market.  Thus, generally self-insured group health plans would have to aggregate OON Allowed Amount data across the plans offered by the same plan sponsor, but would not permit aggregation across more than one plan sponsor.  There is a special aggregation rule for self-insured group health plans that meet certain conditions.

Reduce Minimum Claim Threshold from 20 to 11 Claims – Amendment – The 2020 Final Rule established a 20-claims minimum threshold for OON reporting, to protect the privacy of individuals receiving OON services.  The Departments have proposed to lower the claims threshold to 11 to address complaints regarding the insufficiency of OON claims data. 

Special Rule for Self-insured Group Health Plans – New –The Departments have determined that allowing aggregation of OON Allowed Amount data across self-insured group health plans offered by different plan sponsors maintains the market division grouping necessary to make the data more actionable for research and analysis.  Thus, the Departments propose that self-insured group health plans may enter contract with another party (e.g., TPA) to make the required information available in a single OON Allowed Amount MRF for more than one self-insured group health plan, including those offered by different plan sponsors.  This special rule would apply only to self-insured group health plans and not fully-insured group health plans or individual market coverage.

The Departments propose that a self-insured group health plan may not take advantage of the special rule unless the proposed 11-claim threshold applies across all plans included in the Allowed Amount File. Applying the threshold to aggregated data, especially when aggregated across multiple self-insured group health plans offered by different plan sponsors, would likely increase the amount of allowed amount data available because more services would likely exceed the 11-claim threshold.

Increase Reporting Period – Amendment –  The reporting period for OON would increase from 90 days to six months, with a historical lookback of nine months.  The Departments propose this significant increase to align with their expectation that there will be more OON data to populate if the amendment to reduce the minimum claims threshold is finalized.

4. Reporting Frequency & Timing

The 2020 Final Rule requires all plans and issuers to file MRFs monthly.  The Departments propose reducing reporting frequency to quarterly for the in-network and out-of-network data files.  Prescription drug pricing files would remain on a monthly schedule.

The Departments propose and seek comment on timing requirements related to the proposed file publication requirements, as follows:

5. Prescription Drug MRFs

In September 27, 2023, the Departments released ACA FAQs Part 61, announcing that they would enforce the prescription drug MRF requirement “on a case-by-case basis, as the facts and circumstances warrant.”  On June 2, 2025, the Departments published a Request for Information (“RFI”) seeking the public’s input on ways to effectively implement or amend the prescription drug MRF requirement in the 2020 final rules, including information on existing prescription drug file data elements, the ability of health plans to access necessary data for reporting, and innovation.

The Proposed Rule does not reflect public input related to the prescription drug RFI comments because the Departments are separately taking them into consideration to evaluate how to implement the Transparency in Coverage prescription drug disclosure requirements in technical implementation guidance or future rulemaking.

As explained above, not all components of the Proposed Rule impact prescription drug MRFs. The reporting cadence for prescription drug MRFs does not change.  The frequency of prescription drug MRFs remains monthly, while the In-Network Rate MRFs and OON Allowed Amount MRFs would change to quarterly if the Proposed Rule becomes final. 

The proposals that do impact all MRFs, including prescription drug MRFs, are:

• Contextual Files 
• Text Files
• Standardized Files
• Updated Method and Formats for Public Disclosures

GROOM INSIGHT:  The Administration continues to signal a strong focus on prescription drug transparency and reporting, reflected across several ongoing and emerging policy initiatives. This emphasis appears not only in Trump’s recent announcement regarding the Great Healthcare Plan proposal – a broad healthcare initiative intended to slash prescription drug prices – but also in other regulatory efforts like the potential ERISA section 408(b)(2) prescription drug disclosure requirements and the continued attention to the CAA prescription drug reporting (i.e., RxDC) framework. This pattern suggests that prescription drug reporting will likely remain an active regulatory focus.

B. Consumer Disclosures and Accessibility

1. Balance Billing Disclaimer

In states that permit OON balance billing, required disclaimers must state that cost-sharing estimates may not reflect additional charges.  

2. Telephone Accessibility

Plans and issuers would still provide cost-sharing information through internet-based self-service tools and on paper upon request, but the proposal would also require availability by telephone.  This proposal would align with the NSA’s telephone-based price comparison requirements.

Applicability Dates

• MRFs: 12 months following publication of the final regulations in the Federal Register.
  • Consumer Tools: Plan years beginning on or after January 1, 2027.

Public Comment Deadline: Comments are due February 23, 2026. 

[1] See, for example, new 408(b)(2) rule and PBM reform (here and here).

[2] 90 Fed. Reg. 60432 (Dec. 23, 2025).

[3] Not all proposed MRF changes apply to all MRFs, as explained below.

[4] See generally Medicare and Medicaid Programs: Hospital Price Transparency Requirements, 84 Fed. Reg. 65,524 (Nov. 27, 2019) (establishing initial hospital transparency standards).

[5] See CMS Interoperability and Prior Authorization Final Rule.

[6] See FAQs About Affordable Care Act Implementation Part 53, Q1 (Apr. 19, 2022) (“[P]lans and issuers may report a percentage number, in lieu of a dollar amount… if the plan or issuer is unable to ascertain the dollar amount that will be billed.”).