FEATURED ARTICLE

Transparency in Coverage Final Rules Issued

On October 5, 2026, the Departments of Labor, the Treasury, and Health and Human Services (Departments) finalized the Transparency in Coverage final rules (2026 Final Rules). These rules amend the Departments’ 2020 Transparency in Coverage rules to revise, among other things, the disclosures payors must make regarding in-network rates and out-of-network allowed amounts for covered items and services. The 2026 Final Rules take effect December 7, 2026, although most of the amended requirements apply on later dates, as described below.

Background

On November 12, 2020, the Departments finalized rules (2020 Rules) requiring non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage (Payors) to post machine-readable files to their websites containing data on (1) in-network negotiated rates for covered items and services, (2) out-of-network allowed amounts and the associated billed charges for covered items and services, and (3) negotiated rates and historical net prices for prescription drugs. The 2020 Rules also required Payors to provide cost-sharing information to participants, beneficiaries, and enrollees through an online self-service tool or, upon request, on paper.

On February 25, 2025, President Trump issued Executive Order 14221, which directed the Departments to, among other things, “promote universal access to clear and accurate healthcare prices[;] ... to improve existing price transparency requirements; increase enforcement of price transparency requirements; and identify opportunities to further empower patients with meaningful price information, potentially including through the expansion of existing price transparency requirements.” Consistent with Executive Order 14221, the 2026 Final Rules finalize, with some changes, amendments to the 2020 Rules that the Departments proposed on December 23, 2025.

In-Network Rate File Adjustments

Under the 2020 Rules, Payors were required to prepare one In-network Rate File for each plan or policy. The 2026 Final Rules instead require Payors to prepare one In-network Rate File for each provider network they maintain or contract with. Each file must identify the product type (e.g., HMO, PPO) for each plan or policy it represents, along with the common provider network name and provider network identifier.

Payors must exclude from these files provider-rate combinations for items and services that providers would be unlikely to be reimbursed for, given the provider’s specialty, as determined by the Payors’ internal provider taxonomies or other internal rules used in claims adjudication.

These requirements will apply beginning March 6, 2027. In-network Rate Files must be updated and posted quarterly, rather than monthly, on the first day of each calendar-year quarter beginning with the first calendar-year quarter following that date.

Out-of-Network Allowed Amount File Adjustments

The 2026 Final Rules require Payors to aggregate their Allowed Amount Files by insurance market type (large group, small group, individual, and all self-insured group health plans maintained by the plan sponsor). The 2026 Final Rules also lower the threshold for reporting allowed amounts for certain items or services from 20 to 11 claims, and extend the reporting period from 90 days to six months and the lookback period from 180 days to nine months.

These requirements will also apply beginning March 6, 2027, and Allowed Amount Files are subject to the same quarterly posting schedule as In-network Rate Files.

Addition of New Contextual Files

The 2026 Final Rules will require Payors to post additional contextual files. The first is a “Taxonomy File,” in which Payors must post the internal provider taxonomy mapping or other rules they used to prepare each In-network Rate File; the Taxonomy File must be posted quarterly, even if unchanged. The second is a “Utilization File,” which Payors must prepare for each In-network Rate File and which must identify all providers who have submitted and received reimbursement for at least one claim for a covered item or service for the most recent plan or policy year ending at least six months before the posting of the file. The Utilization File must be posted beginning on July 1, 2028, and updated and posted annually thereafter.

Accessibility and Attestation Adjustments

The 2026 Final Rules also will require Payors to add a link labeled “Price Transparency” or “Transparency in Coverage” in the footer of their website’s home page, and of any other page that includes a footer, that routes directly to the publicly available web page that hosts the machine-readable files, and to post a plain text (.txt) file in the root folder of their website with information on the specific location of the machine-readable files.

The text file must also include contact information, including a monitored email address for an individual or group dedicated to receiving and responding to inquiries and issues related to the machine-readable files. The 2026 Final Rules will also require Payors to use a single, non-proprietary, open-standard file format, which the Departments intend to specify in guidance as JSON, for all machine-readable files other than the text file.

Payors must attest in each In-network Rate, Allowed Amount, Prescription Drug, Taxonomy, and Utilization File that, to the best of the Payor’s knowledge and belief, the file includes all applicable information and the information is true, accurate, and complete as of the date in the file. Each of those files must also name the Payor’s chief executive officer, president, or senior official designated to oversee the encoding of the data. Payors may satisfy these requirements through a written agreement under which another party, such as a third-party administrator, makes the attestation and encodes the name of its own designated official, but only if that party has also agreed to provide the required file information on the Payor’s behalf.

The Taxonomy File, Utilization File, text file, and website footer requirements described above will apply beginning September 6, 2027 (although, as noted, the Utilization File must be posted beginning on July 1, 2028). The attestation and single file format requirements apply beginning March 6, 2027.

Cost-Sharing Disclosures

The 2026 Final Rules also require Payors to provide by phone, upon request, the cost-sharing information they must make available through the internet-based self-service tool or on paper, for plan years (in the individual market, policy years) beginning on or after January 1, 2027. Satisfying this requirement also satisfies section 114 of the No Surprises Act, including for grandfathered group health plans and grandfathered coverage not otherwise subject to the 2026 Final Rules.

The CMS fact sheet on the 2026 Final Rules can be found here, and the 2026 Final Rules can be found here.

Reporter, William Mavity, Los Angeles, CA, +1 213 218 4043, [email protected]

CLIENT ALERT

FTC Warns Healthcare Systems That CMS Price Transparency Compliance Is No Safe Harbor Under the FTC Act

On October 5, 2026, Federal Trade Commission (FTC) Chairman Andrew Ferguson sent warning letters to twenty-four of the nation’s largest health systems. The letters remind recipients that Section 5 of the FTC Act requires timely, accurate, and complete pricing, particularly for non-emergency services scheduled in advance. The FTC has not named the recipients and has said it will not do so. Press reports indicate the letters went to the nation’s largest for-profit hospital groups, representing more than 1,000 locations. Most significantly, the letters take the position that compliance with the Centers for Medicare & Medicaid Services (CMS) price transparency regulations does not create a safe harbor from FTC Act liability. Read the full Client Alert here.

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A keynote session will feature the Honorable Alex M. Azar II, the 24th U.S. Secretary of Health and Human Services (HHS) and a recognized leader in healthcare innovation. During his tenure, he led transformative efforts to modernize the U.S. healthcare system, expanding telehealth, advancing interoperability of health records, increasing healthcare transparency and accelerating the shift to value-based care.

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Editors: Chris Kenny and Ahsin Azim

Issue Editors: Lindsay Greenblatt and Brittany Tandy