Final Rule on Healthcare Transparency in Coverage

Background on the transparency in coverage requirements

The December 2020 TiC final rule requires non-grandfathered health plans and insurers to disclose healthcare pricing information about their plans and policies to the public and to participants, beneficiaries and enrollees.

Since 2022, the TiC rule has required plans and insurers to post machine-readable files (MRFs) containing certain negotiated rate and out-of-network payment data. Prescription drug disclosure requirements have been on hold while awaiting technical guidance from the Departments.

Since 2023, the TiC rule has also required health plans and insurers to make an online price-comparison tool available that participants, beneficiaries and enrollees can use to search for cost-sharing information for different providers for covered items and services, including prescription drugs. Upon request, plans and insurers must provide this information in paper form. The No Surprises Act expanded transparency requirements, including extending price comparison tool requirements to grandfathered plans and requiring information to be disclosed over the phone. (See our January 14, 2021 insight, “New Law Requires Transparency and Prohibits Surprise Billing.”)

The final rule on Transparency in Coverage

Consistent with the February 2025 Executive Order on healthcare price transparency (discussed in our March 21, 2025 insight, “Executive Order Targets Better Healthcare Price Transparency”) and the No Surprises Act, the Departments updated both the TiC disclosure requirements and the technical file specifications (referred to as “schemas”).

The TiC 2026 final rule, published in the October 6, 2026 Federal Register, largely adopts the changes proposed in the TiC 2026 proposed rule (discussed in our January 23, 2026 insight, “Proposed Rule on Healthcare Price Transparency Disclosures”) with a few notable changes.

Along with the rule, the Departments also issued FAQs About Affordable Care Act Implementation Part 75 | U.S. Department of Labor that provide additional details on implementation timing as well as a resource called Top 5 FAQs about Transparency in Coverage. Simultaneously, the Centers for Medicare & Medicaid Services issued a Fact Sheet that presents an overview of the final rule.

Key changes from the proposed rule include new attestation requirements and an accelerated phased implementation schedule. The final rule does not adopt the proposal to require plans and insurers to report enrollment counts or publish a Change-log File in conjunction with the In-network Rate File.

The TiC 2026 final rule makes several changes to the MRFs that non-grandfathered group health plans and insurers must publish. These changes are intended to streamline the disclosures in a manner aimed to improve access, accuracy and efficiency.

Until April 1, 2027, plans and issuers are expected to continue complying with the requirements of the 2020 TiC final rule for the In-network Rate and Allowed Amount MRFs.

In-network Rate Files

In-network Rate MRFs must be organized by provider network rather than by plan and include a provider network name. The rule also requires disclosure of a provider network identifier and clarifies what constitutes a provider network.

Plans and insurers must report the plan type (e.g., HMO or PPO), which the rule refers to as a “product,” but will not be required to disclose a numeric enrollment total for each plan for which information is provided.

In addition, plans and insurers must exclude from the In-network Rate MRFs negotiated rate and provider combinations for items and services the provider would be unlikely to perform because the item or service is not in the provider’s area of specialty (“ghost rates”: e.g., a plan would exclude rates for podiatrists to perform heart surgery).

Out-of-network Allowed Amount Files

Allowed Amount MRFs must be organized by health insurance market type (i.e., large group, small group, individual and self-insured) rather than at the plan level.

The self-insured group health plan market includes all self-insured group health plans maintained by the plan sponsor. Administrators of self-insured group health plans may aggregate out-of-network allowed amounts for more than one plan, including those offered by different self-insured plan sponsors, into a single Allowed Amount File.

The rule also revises reporting periods, lookback periods and minimum claims thresholds for Allowed Amount MRFs as follows:

New file requirements

Plans and insurers must post three new contextual files:

• A Utilization File published annually that identifies covered items and services with paid claims and the in-network providers that furnished them
• A Taxonomy File that shows the plan’s or issuer’s internal mapping of billing codes to provider specialties that was used to determine which provider-rate combinations to exclude from the In-network Rate MRF
• A Text File in .txt. format with links to the MRFs and contact information for issues or inquiries. Plans and insurers may provide a monitored email address for either an individual or a group dedicated to responding to inquiries and issues related to the files.

The rule does not require publication of a Change-log File which, under the proposed rule, would have required plans and insurers to prepare a file that tracks changes to the In-network Rate MRFs over time.

Timing

In-network Rate and Allowed Amount MRFs must be updated quarterly rather than monthly except for the prescription drug file (Rx File), which once applicable, must be updated monthly.

Website posting requirements

Plans and insurers may contract with a third party to post MRFs on their behalf. Plans with their own public website must provide a link to any MRFs hosted by a service provider.

New attestation requirements

Each MRF must include an attestation that, to the best of the plan’s or insurer’s knowledge, the information being reported is true, accurate and complete, and submitted in accordance with applicable requirements. Each MRF must identify the senior official responsible for overseeing the submission.

A health plan or insurer that has entered into an agreement with a third party for the third party to post files on their behalf may enter into a written agreement under which the third party also makes the attestation on the plan’s behalf.

Preventing duplication

The rule includes provisions aimed at preventing unnecessary duplication. Specifically, insured group health plans can enter into a written agreement under which the health insurance issuer provides the price comparison tool and required public transparency disclosures on its behalf. In this case, if the insurer fails to provide the required information in compliance with the law, the insurer, not the plan, violates the transparency disclosure requirements.

Further, a self-insured plan or insurer may enter into a written agreement under which another party, such as a third-party administrator, will provide the price comparison tool or required public transparency disclosures on behalf of the plan or insurer. In this case, if the party with which the plan or insurer contracts fails to provide the required information in compliance with the law, the plan or insurer violates the transparency disclosure requirements.

Special rules for self-insured plans

Self-insured plans may allow a party acting on their behalf to create a single In-network Rate MRF using provider network information across multiple clients and health insurance markets. The file must meet specified standards, including requiring each In-network Rate MRF to include all covered items and services for every plan using that network and requiring the corresponding Utilization and Taxonomy Files to reflect the same plans represented in the In-network Rate MRF.

Similarly, self-insured plans may permit a party acting on their behalf to create a single Allowed Amount MRF covering multiple self-insured group health plans, including plans sponsored by different employers. However, out-of-network allowed amount and billed charge data for a particular item or service must be omitted if disclosure would require disclosure of out-of-network allowed amounts in connection with fewer than 11 claims across all plans included in the file.

Price comparison tool

Plans and insurers must, upon request, provide by phone the same price comparison information available through the online tool and paper methods. They must also update the required statement regarding balance-billing protections that accompanies cost-sharing information. Grandfathered plans may satisfy No Surprises Act price comparison tool requirements by complying with the updated TiC requirements.

If a participant, beneficiary or enrollee requests price comparison information via an alternative method (such as email) instead of online or via paper or phone, alternative methods continue to be permissible provided the timing requirements are met.

Implementation timeline

The amendments to the internet-based self-service tool provisions apply for plan or policy years beginning on or after January 1, 2027.

The technical file specifications for the new file requirements will be released in two phases:

1. Schema 3.0 for the In-network Rate and Allowed Amount MRFs will be applicable March 6, 2027, with the initial disclosure required on April 1, 2027, and quarterly thereafter.
2. Schema 1.0 for the Text File, the Taxonomy File and the Utilization File will be applicable September 6, 2027, with the initial disclosure required on October 1, 2027 for the Text and Taxonomy Files and July 1, 2028 for the Utilization File. The Text File must be updated within seven days of any change to the information in the file. The Taxonomy File must be updated quarterly, as needed. The Utilization File must be updated annually.

Schema 1.0 for the Rx File is expected to be released by the Departments around May 2027 with plans and insurers expected to publish Rx Files starting in December 2027 and monthly thereafter.

FAQs About Affordable Care Act Implementation Part 75 outline the timeline for the release of technical file specifications for the MRFs and specify the applicability dates for the various new file requirements. Download an implementation timeline graphic.

Implications for sponsors of group health plans

Plan sponsors that rely upon their third-party administrators to comply with the MRF and price comparison tool requirements will need to coordinate to ensure compliant implementation and determine an approach to the newly required attestation. Plan sponsors that directly administer the MRF and price comparison tool should begin compliance efforts and watch for further implementation guidance.

Plans should ensure the price comparison tool is updated so that information is available over the phone, and the required balance-billing statement is updated for the plan year beginning in 2027.

As the new Rx File guidance becomes available in 2027, plans will need to begin compliance efforts directly or coordinate with their Rx administrator to ensure compliance. As implementation progresses, plans can leverage information gained through the new price transparency to help evaluate whether the plan is being provided competitive rates either directly or through contracts managed by the plan’s service providers.