The Price is Right? Final Transparency Rules Require More Accurate and Reliable Data

The Departments of Labor, Health and Human Services (“HHS”), and the Treasury have finalized a number of updates to the current Transparency in Coverage rules. In summary, plans and issuers will move to quarterly reporting and publish in-network rates as dollar amounts, with a senior official attesting to the accuracy of the data. Here is our take on what changes, what it means for plan sponsors and health insurance issuers, and what to do before the rules take effect, with some provisions coming online as early as January 1, 2027.

Overview

On October 6, 2026, the Departments of Labor, HHS, and the Treasury (collectively, the Departments) published another Transparency in Coverage Final Rule (“final rule”). The final rule implements Executive Order 14221 and largely follows the December 2025 proposal, with notable changes intended to reduce burden. It revises the Transparency in Coverage 2020 Final Rule (“2020 final rule”), including requirements related to the machine-readable files (“MRFs”) that group health plans and issuers have posted since 2022. On October 7, 2026, the Departments also published FAQs About Affordable Care Act Implementation Part 75 addressing implementation.

The new final rule purports to improve the standardization, accuracy, accessibility, and usability of public pricing disclosures under Section 2715A of the Public Health Service Act (PHS Act) and Section 1311(e)(3) of the Patient Protection and Affordable Care Act.  

Groom Insight: The Departments received comments on the 2025 proposed rule from 132 commenters, including a wide variety of stakeholders. Many commenters addressed multiple provisions and provided detailed comments in response to specific requests for feedback in the proposed rule. By comparison, the Departments received more than 25,000 comments on the rules proposed in 2020. Although the number of commenters declined substantially, the breadth and detail of the 2025 submissions suggest that affected stakeholders remained actively engaged and that the lower volume may reflect the rulemaking’s narrower focus on refining an established transparency framework rather than creating a new one.

Key Changes

• Rx reporting expected by 2027
• New quarterly reporting cadence for in-network and allowed amount MRFs
• New contextual files and data elements; threshold reporting changes and certain rate exclusions
• New attestation requirement
• New notice requirements for the cost-sharing tool

Groom Insight: Although this final rule purports to reduce burden, it marches forward with additional prescription drug reporting under the Transparency in Coverage requirement, in addition to the detailed prescription drug reporting already required under the separate RxDC reporting.  In addition, a new attestation requirement appeared in the final rule, a requirement that was not proposed. Plans and issuers must now attest to the accuracy of the MRFs; the attestation is required from a senior officer. As the Departments are aware, most plans do not actually possess this information. Plans and issuers may satisfy this requirement by entering into a written agreement under which another party makes the attestation.

Key Compliance Dates

The overall compliance and posting dates for the required files and data are summarized below.

• January 1, 2027 plan years: Telephone access, revised balance-billing language, and No Surprises Act deemed compliance.
• March 6, 2027: Core MRF changes, attestation, and quarterly reporting applicable.
• April 1, 2027: New In-Network Rate File and Allowed Amount File must be posted. Updated quarterly thereafter.
• May 2027: Rx schema finalized.
• September 6, 2027: Taxonomy file, root-directory text file, and footer link applicable.
• October 1, 2027: New taxonomy file and text file must be posted. The taxonomy file must be updated quarterly thereafter. The text file must be updated within 7 days of any updates thereafter.
• December 2027: Initial Rx disclosure (monthly thereafter).
• July 1, 2028: First utilization file must be posted. The utilization file must be updated annually thereafter.

Machine-Readable Files

The 2020 final rule requires group health plans and health insurance issuers to publicly post MRFs monthly for each plan or coverage they offer. Currently, plans and issuers are required to make available on a public internet website three MRFs that include information for all covered items and services regarding:

• In-network rates (including negotiated rates, derived amounts, and underlying fee schedule rates), for all in-network providers (“In-Network Rate File”).

• Out-of-network allowed amounts and billed charges, including prescription drugs, furnished by out-of-network providers (“Allowed Amount File”).

• Negotiated rates and historical net prices for prescription drugs furnished by in-network providers (“Prescription Drug File”).[1]

The Departments proposed a number of changes to the MRFs in 2025. See Groom’s prior publication that discusses the proposed changes. The Departments finalized numerous changes in the final rule to the required MRFs.

Groom Insight: By streamlining the MRF requirements, the final rule may make the data more practical for employers and researchers to use while reducing administrative burden on plans and issuers. The Departments acknowledged that the MRFs are not generally used by participants, although the Departments continue to argue that public access to “actionable” information is necessary.

In-Network Rate File

Provider Network-Level Reporting

The 2020 final rule requires plans and issuers to include in-network provider rates for all covered items and services (other than prescription drugs) that are under a fee-for-service arrangement for each coverage option offered by a group health plan. In the 2025 proposed rule, the Departments noted that, when plans and issuers organize the In-Network Rate Files by plan ID, they often repeatedly include the same negotiated rates across multiple plan files (because multiple plans utilize the same network at the same rates), which can lead to significant duplication of data and increased file size.

To address that duplication, the final rule requires a separate In-Network Rate File for each provider network maintained or contracted by the plan or issuer. Network-level reporting should make it easier for employers and plan sponsors to compare negotiated rates across networks.

In addition, the final rule requires each In-Network Rate File to include the common provider network name for which the negotiated rate information is included. The Departments expect plans and issuers to define what constitutes a separate provider network according to their own business practices. In addition, in response to comments, the Departments finalized an additional requirement that plans and issuers disclose a provider network identifier, in addition to the common provider network name. The Departments expect plans and issuers to use the existing network identifier used for internal tracking, which the Departments expect will be minimally burdensome to disclose. Instructions on how a plan or issuer may report the network identifier if no network identifier already exists will be provided through future technical implementation guidance.

Groom Insight: The network-based structure may facilitate more efficient aggregation and analysis and aligns with the approach used under Hospital Price Transparency[2] requirements.

Percentage of Billed Charges

Under the 2020 final rule, plans and issuers must publish all applicable rates, including negotiated rates, underlying fee schedule rates, or derived amounts for all covered items and services in the In-Network Rate File. The Departments provided guidance in FAQs Part 53 and FAQs Part 61, permitting plans or issuers to report a percentage number, in lieu of a dollar amount, in certain instances.

The final rule codifies the FAQ guidance and requires that in-network rates must be reflected as a dollar amount, except for contractual arrangements under which a plan or 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. In those circumstances, plans and issuers are required to report a percentage number, in lieu of a dollar amount, in the form and manner as specified in guidance issued by the Departments.

Excluded Provider Information

Under the 2020 final rule, plans and issuers must include all applicable rates for in-network providers, including negotiated rates, underlying fee schedule rates, or derived amounts, to the extent they may be used for purposes of determining provider reimbursement or cost-sharing for in-network providers. According to the preamble to the 2025 proposed rule, the Departments received feedback that the In-Network Rate File often includes negotiated rates for providers for items and services that such providers would not likely be reimbursed for because the items and services are outside the provider’s specific specialty.

The final rule allows plans and issuers to exclude from the In-Network Rate Files certain data for services that providers are unlikely to perform. The final rule requires plans and issuers to use either their own internal provider taxonomy or other internal rules that are typically used during the claims adjudication process to make these determinations. This policy seeks to respond to stakeholder concerns about the inclusion of these rates, often referred to as ghost rates.

Enrollment Totals

The Departments proposed to require plans and issuers to include in each In-Network Rate File, 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. Specifically, the numerical enrollment totals would have to include the number of participants, beneficiaries, and enrollees (including all dependents) in the coverage option offered by a plan or issuer.

The Departments did not finalize this proposal and enrollment totals are not required for these files. 

Groom Insight: The Departments did not finalize this policy in response to commenters’concerns regarding the operational difficulties in reporting enrollment numbers at the plan level. The Departments were also concerned that differences in data systems, reporting methodologies, and reconciliation processes could increase the likelihood of inconsistent or inaccurate reporting across plans and issuers, thereby reducing the reliability and comparability of the data for users.

Allowed Amount Machine-Readable File

Reducing the Claims Threshold

Under the 2020 final rule, plans and issuers are required to disclose on a public website an MRF that includes, among other things, each unique out-of-network allowed amount with respect to covered items or services furnished by a particular out-of-network provider. Currently, plans and issuers must omit such data in relation to a particular item or service and provider when including it would require the plan or issuer to report payment of out-of-network allowed amounts in connection with fewer than 20 different claims for payments for an item or service under a single plan or coverage.

The final rule lowers the minimum claims threshold for a particular item or service under a single plan or coverage to 11 claims. This change is intended to increase the volume of allowed amount data available while still balancing privacy concerns. Lastly, the Departments finalized changes to more clearly specify that the claims threshold pertains to the number of claims for an item or service overall for the file, not the number of claims for an item or service from a particular provider.

Groom Insight: The final 11-claim threshold aligns with the Centers for Medicare and Medicaid Services (CMS) cell suppression policy, which is a safeguard designed to prevent the identification of individual Medicare or Medicaid beneficiary data when shared publicly and ensure compliance with Federal privacy laws, such as the Health Insurance Portability and Accountability Act (HIPAA), by reducing the risk of re-identification of individuals.

Reporting Period

The 2020 final rule requires plans and issuers to disclose on a public website an MRF that includes, among other things, each unique out-of-network allowed amount with respect to covered items or services furnished by a particular out-of-network provider during the 90-day time period that begins 180 days prior to the publication date of the Allowed Amount File.

The final rule modifies this provision and requires that plans and issuers include in the Allowed Amount File the allowed amounts and billed charges with respect to covered items or services furnished by out-of-network providers during the 6-month time period that begins 9 months prior to the publication date of the file. This policy increases the reporting period from 90 days to 6 months and increases the lookback period from 180 days to 9 months.

Aggregated Data by Health Insurance Market

The 2020 final rule permits plans and issuers to make available out-of-network allowed amount data that has been aggregated to include information from more than one plan or policy. Currently, plans and issuers are permitted to satisfy this requirement by contracting with an issuer, service provider, or other party to make available out-of-network allowed amount data that has been aggregated to include information from more than one plan, policy, or contract. Under the current requirement, these plans, policies, or contracts may be across multiple health insurance markets.

The final rule changes the current requirement by requiring plans and issuers to make an out-of-network allowed amount MRF available for each health insurance market (i.e. individual market, large group market, small group market, and self-insured group health plans maintained by the same plan sponsor) in which the plan or issuer offers a plan or coverage. The final rule acknowledges the unique nature of self-insured group health plans and allows self-insured group health plans to permit another party (pursuant to a contract) to make available in a single Allowed Amount File the information required for more than one self-insured group health plan, including those offered by different plan sponsors with which the other party contracts. In order for a self-insured group health plan to take advantage of this special rule, however, the 11-claim threshold noted above must be applied to the aggregated data set. The Departments note that applying the threshold to aggregated data, especially when aggregated across multiple self-insured group health plans offered by different plan sponsors, will likely increase the amount of allowed amount data available because more services will likely exceed the 11-claim threshold.

Both In-Network Rate and Allowed Amount Files

HIOS Identifier and Product Type

The 2020 final rule requires plans and issuers to include their 14-digit Health Insurance Oversight System (“HIOS”) identifier (“ID”) in the In-Network Rate File and Allowed Amount File unless the plan or issuer does not have a 14-digit HIOS ID available, in which case the plan or issuer must include the HIOS ID at the 5-digit issuer level. If a plan or issuer does not have a HIOS ID, it must use its Employer Identification Number (“EIN”).

Under the final rule, plans and issuers are still required to report the HIOS ID, if they have one, to identify the plan or coverage. The Departments clarify that the addition of the common provider network name field is a complement to the network-level reporting requirement for the In-network Rate File and does not replace the HIOS ID as the primary identifier for group or individual health insurance coverage. The Departments also finalized the proposal to add a requirement for plans and issuers to report the product type (for example, Health Maintenance Organization or Preferred Provider Organization) associated with the coverage option for which data is being reported.  The Departments clarified that HMO and PPO are examples of product types and not an exhaustive list.

Posting the In-Network Rate and Allowed Amount Files

The final rule changes the update frequency for the In-Network Rate and Allowed Amount Files from monthly to quarterly.

Attestation Requirement

In response to concerns from commenters regarding the validity and accuracy of the data, the Departments finalized an attestation requirement as an additional step to address concerns about the accuracy of the information provided and help ensure its validity. Notably, this was not part of the 2025 proposed rule. Under this requirement, plans and issuers must certify that, to the best of their knowledge and belief, they have included all applicable information in accordance with the final rule and must encode the name of the chief executive officer, president, or senior official designated to oversee the encoding of true, accurate, and complete data. Similar to other transparency requirements, plans and issuers may satisfy this requirement by entering into a written agreement under which another party makes the attestation. However, if the plan is self-insured and the third party fails to attest, the plan is still considered to have violated the transparency requirements (for fully insured plans, the issuer—not the plan—would be considered to have violated the transparency requirements).

Groom Insight: As noted above, this attestation requirement was not part of the 2025 proposed rule and, therefore, raises the question of whether this requirement is a logical outgrowth of the proposed rule. The Departments explain in the preamble that “[i]t is also a logical extension of the proposals related to improving the accuracy of public pricing disclosures, and will help fulfill the objectives of Executive Order 14221.” The Departments assert that “[r]equiring plans and issuers to attest to the accuracy of their MRFs, to the best of their knowledge, is an extension of those proposed rules, and several commenters made it clear that they understood such a requirement would achieve this alignment.” The Departments also note that an attestation requirement is aligned with the Hospital Price Transparency reporting requirements.

New Contextual Files: Change-log, Utilization, Taxonomy, and Text

The final rule adds machine-readable contextual files intended to help users interpret and use the required pricing data. This information is not required under the 2020 final rule.

Groom Insight: The final rule did not finalize the proposed change log file. The Departments noted that this was in response to commenters’concerns that the burden of creating and maintaining this file outweighs the marginal value it would provide to file users.

Utilization File

The final rule requires that plans and issuers make available, in a machine-readable format, a Utilization File for each In-Network Rate File that includes which provider has submitted a claim for covered items and services for the most recent plan year that ends at least 6 months prior to the date each Utilization File is published. The Departments clarified that claims that would be reimbursed but for cost-sharing liability must also be included when accounting for claims that were submitted and reimbursed.

The Utilization File must be updated and posted annually beginning on July 1, 2028. Under the final rule, plans and issuers will not be required to disclose the number of times that any given provider submitted a claim for any particular item or service, but rather only that a given provider submitted and was reimbursed, partially or in whole, for at least one claim for a covered item or service during the reporting period.

Taxonomy File

The final rule requires plans and issuers to make available, in a machine-readable format, a Taxonomy File. This file must include the plan’s or issuer’s internal methodology for mapping items and services (represented by billing codes) to provider specialties (represented by specialty codes derived from the National Uniform Claim Committee (“NUCC”)) to determine whether the plan or issuer should deny reimbursement for an item or service because it was not furnished by a provider in an appropriate specialty. The Departments clarified in the final rule that plans and issuers must base the Taxonomy File on their internal provider taxonomy or other internal rules used during the claims adjudication process to determine whether the plan or issuer should deny reimbursement for an item or service based on the provider’s specialty. In addition, the final rule specifies that the information provided in the Taxonomy File, regardless of whether it is based on an internal taxonomy or other internal rules, must be expressed as pairings of items and services (represented by billing codes) with provider specialties (represented by specialty codes derived from the Health Care Provider Taxonomy code set established by the NUCC). The file is intended to help users understand the rules plans and issuers apply when denying reimbursement for certain items or services based on the provider’s specialty and when excluding provider-rate combinations from the In-Network Rate File. Plans and issuers are required to post a Taxonomy File on a quarterly basis, even if there is no data to be updated from the prior quarter, beginning October 1, 2027.

Text File

The final rule requires 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: 1) the source page URL for the internet website that hosts the required MRFs; 2) a direct link to the URL for the required MRFs; and 3) point-of-contact information including an up-to-date name, title, and email address for an individual who can address inquiries and issues related to the MRFs.  Under the final rule, plans and issuers may provide a monitored email address for either an individual or a group of individuals dedicated to receiving and responding to inquiries and issues related to the MRFs, in lieu of requiring the point-of-contact information to include a specific named individual with their title.

Plans and issuers are required to post a Text File on October 1, 2027 and update the Text File as soon as practicable but not later than 7 calendar days following a change in any of the required information.

Change-Log File

The Departments proposed to require plans and issuers to make available, in a machine-readable format, a Change-log File for each In-Network Rate File, that identifies any changes made to the required information in the In-Network Rate File since the immediately preceding published In-Network Rate File.

The Departments did not finalize this proposal and there is no requirement for a new change-log file.

Required Disclosures to Participants, Beneficiaries, or Enrollees

The 2020 final rule requires plans and issuers to disclose certain cost-sharing information upon the request of a participant, beneficiary, or enrollee (or his or her authorized representative) for a covered item or service through an internet-based, self-service tool or in paper form.  The tool is often referred to as the “cost share tool” or “self-service tool.” The information provided through the self-service tool is required to be built upon actual negotiated rates, out-of-network allowed amounts, and individual-specific accumulated amounts, which must be accurate at the time the request is made. In addition, the cost-sharing information needs to be disclosed in plain language, meaning it is written and presented in a manner calculated to be understood by the average participant, beneficiary, or enrollee.

Under the 2020 final rule, plans and issuers must also provide a notice in plain language, in connection with a request for cost-sharing liability, informing participants, beneficiaries, and enrollees of certain protections.

Disclosure of Cost-Sharing Information by Telephone

The 2020 final rule requires plans and issuers to provide detailed cost-sharing information online through an internet-based, self-service tool or in paper form upon request and permits offering the information via telephone.

The final rule now requires plans and issuers to provide the same detailed cost-sharing information whether provided online, in print, or by telephone, upon request. This policy change is in response to feedback received by the Departments indicating a limited ability to receive cost-sharing information over the phone when requested. In order to minimize the burden on plans and issuers, the final rule allows plans and issuers to 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 per enrollee per disclosure method. This mirrors the limitations finalized in the 2020 final rule for paper disclosures.

Alignment with the No Surprises Act

Currently, the notice is not required to reflect the existence of the Federal balance billing protections set forth under the No Surprises Act, because it was not yet enacted. The final rule aligns the requirements for the plan or issuer-provided price comparison tool by requiring that the notice include the Federal protections against balance billing under the No Surprises Act. The Departments also finalized a requirement to include a statement that the cost-sharing information provided per the required disclosures does not account for potential additional amounts in situations where applicable State and Federal law allows out-of-network providers to bill enrollees for the difference between a provider’s billed charges and the sum of the amount collected from the plan or issuer and from the enrollee in the form of a copayment, coinsurance, or deductible (also referred to as balance billing). The final rule acknowledges that some States prohibit all balance billing and notes that the statement will not be required in such States.

Lastly, the Departments finalized the proposal that the required disclosures under the 2020 final rule through the self-service tool would satisfy the disclosure requirements of ERISA section 719, as added by section 114 of the No Surprises Act (i.e., Maintenance of Price Comparison Tool), which requires plans and issuers to offer price comparison guidance by telephone and make available on the plan’s or issuer’s website a “price comparison tool” that allows individuals enrolled under such plan or coverage offered by the plan or issuer to compare the amount of cost sharing that the individual would be responsible for paying for an item or service furnished by an in-network provider. This disclosure requirement under the 2020 final rule was applicable with respect to plan years beginning on or after January 1, 2023.

Required Method and Format for Disclosing Information to the Public

The Departments intend to specify that JSON is the required format for the MRF files; previously, plans and issuers had flexibility in the format used for MRFs. The newly required Text File must be published in .txt format. In the past, the Departments have considered requiring the use of Application Programming Interfaces (“APIs”) to access MRFs. However, the Departments did not finalize a requirement to use APIs at this time due to the substantial new development costs it would impose on plans and issuers and the effectiveness of delivering the required information through the modified and redesignated file format.

The final rule requires plans and issuers to place a footer link labeled either “Price Transparency” or “Transparency in Coverage” on the homepage and any other webpage with a footer. The link must lead directly to the public page hosting the MRFs. The two label options provide organizational flexibility while creating a predictable navigation path for users and automated retrieval tools. The 2020 final rule does not include a comparable footer requirement.

The files must also be available free of charge to individuals, automated scripts, and web crawlers without conditions such as an account, password, submission of personally identifiable information or other credentials, or access restrictions imposed through server configurations or firewalls.

The Departments also finalized the proposal to codify the guidance issued as part of FAQs Part 55 that any plan or issuer could 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. The Departments determined that, for a plan or issuer that does not have a public website, it would be overly burdensome to require such plan or issuer to create and maintain a website to satisfy this requirement. Additionally, the Departments finalized that if the files are hosted on a service provider’s website, and the plan or issuer does maintain a public website and chooses not to also post the files separately on its own public website, the plan or issuer is required to provide a link on its own public website to the location where the files are made publicly available. This requirement applies to a public website maintained by the plan or issuer and does not apply to a public website maintained by an employer or plan sponsor.

Enforcement

Commenters urged the Departments to increase enforcement through audits, warning letters, corrective action plans, and monetary penalties. The Departments agreed that enforcement is critical to the continued usefulness of the published data and acknowledged public interest in greater transparency regarding compliance and enforcement actions.

In response to commenters, the Departments reiterated their existing enforcement efforts and authorities. They explained that they have been engaged in compliance and enforcement efforts since the 2020 final rule requirements became effective. They noted that with the new final rule, the Departments will prioritize compliance and enforcement through existing authorities and will work to ensure that any enforcement actions will be transparent to the public. Under chapter 100 of the Code, Part 7 of ERISA, and title XXVII of the PHS Act, as applicable, the Departments may require corrective actions and impose civil monetary penalties, or seek equitable or other forms of remedial relief through voluntary compliance or otherwise, to the extent permitted under applicable law, when the Departments find violations through market conduct examinations and investigations of plans and issuers within their jurisdiction.

New FAQs Part 75

FAQs Part 75 provide a phased schema-release schedule. The Departments plan to release version 3.0 of the In-Network Rate and Allowed Amount File schemas around February 1, 2027 (Phase 1), followed by version 1.0 of the Utilization, Taxonomy, and Text File schemas around June 1, 2027 (Phase 2). Plans and issuers may continue using version 2.0 under the 2020 final rule through March 31, 2027. As noted above, development of the Prescription Drug File schema is expected to begin in November 2026, with initial publication anticipated in December 2027.

[1] In the December 2025 proposed rule, the Departments did not propose any changes to the Prescription Drug File requirements. The Departments note that they have received prescription drug RFI comments and 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. The Departments plan to finalize technical implementation guidance for the prescription drug MRF on or around May 2027. Plans and issuers will be expected to publish the file starting in December 2027, and monthly thereafter.

[2] 45 CFR 180.50. Available online: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-E/part-180/subpart-B/section-180.50

[3] Transparency in Coverage, final rule, 91 Fed. Reg. 63748 at 63773 (Oct. 6, 2026).

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