Transparency in Coverage proposed rule aims to make price files more usable

HHS’s proposed updates to health plan price transparency files mark a notable step in ensuring the information is useful for providers and other healthcare stakeholders, experts say.

The Transparency in Coverage (TiC) proposed rule issued in December would modify requirements for health plans with an eye toward making the massive machine-readable files (MRFs) more navigable starting in 2027.

One change is a requirement to filter out payment information that does not apply to a given provider (the rule cites the example of a heart surgery payment rate for a podiatrist) and instead list only providers that delivered the item or service at least once over a 12-month period.

Insurers also would generate one rate per provider network, instead of one per health plan or policy. In addition to reducing the volume of the TiC files, the change could better align payer data with the hospital price transparency files.

MRFs also would incorporate sub-files called provider reference files, improving the cohesiveness of the main files by grouping all providers that operate under a single national provider identifier (NPI).

“[Historically] if you have 500 services that are rendered within a group, and then you’ve got another 500 [individual] providers, they’re going to post every rate for every doctor,” said Dilpreet Sahota, co-founder and CEO of Trek Health, a price transparency strategy firm. “It’s really complicated.”

Under the proposed change, “We [would] know this rate is tied to this organization and all the providers that are part of that organization,” Sahota said.

Why the changes matter for payers and providers

While regulations for the hospital transparency files have been updated multiple times, including with new requirements set to be enforced starting April 1, the health plan files have been largely unchanged since their launch, noted Carol Skenes, chief of staff with Turquoise Health.

A goal of the proposed rule is convergence, namely standardizing data elements across hospital and payer files and making it possible to reliably link a payer rate to a corresponding hospital rate, according to a fact sheet.

“The idea is that you have a higher level of confidence [that this] is the source-of-truth rate that exists,” Skenes said.

A proposal to move from monthly to quarterly updates in the TiC files could help reduce timing mismatches where the hospital files show the pre-negotiation rate and the TiC files show the post-negotiation rate, Skenes said. Hospital and payer data thus are more likely to align, improving the opportunity to use the data in negotiations.

Whereas it used to be common for only one side to bring transparency data to contract talks, these days both sides are more likely to walk in with the same data set, Skenes said. But rather than line-item data, hospital executives are more likely to expect analysis and visualization of concepts such as how the hospital’s payment rates match up with its peer organizations.

“It’s the idea that you can use the data in 10 minutes or less to help move the negotiations conversation forward in a more productive way,” Skenes said.

What hospitals face in 2026 enforcement

Looming changes to the hospital price transparency files include posting negotiated amounts with percentile ranges (10^th, median and 90^th percentiles) instead of estimated allowed amounts whenever a negotiated charge is based on a percentage or algorithm. New regulations also mandate including a count of the allowed amounts for each listed rate.

While effective as of Jan. 1, those updates won’t be enforced until April 1.

Thus far the changes appear to be less disruptive than might have been anticipated, Skenes said. Hospitals already did the heavy lifting by complying with a requirement to post estimated allowed amounts starting in 2025, and they most likely can apply the same claims payment data in preparing for the April 1 deadline.

“The foundational work done to showcase the estimated allowed amount should translate well into now creating these percentile fields,” Skenes said.

Hospitals can get a jump on testing their compliance with the new requirements if they upload their files to CMS’s updated validator tool, she added.

Sahota sees an argument for one day phasing out the hospital transparency files as applicable to payer-negotiated prices. He thinks such a step would improve the coherence of healthcare price transparency and would relieve the compliance burden on small hospitals.

“The same data that’s put in the hospital data set is also available in the payer data set, but the difference is that the payer data set has not only got those hospital rates, but they’ve also got all other lines of service,” Sahota said. “They’ve got behavioral health, outpatient surgery, they’ve got every medically reimbursable service. It gives a much broader, 360-degree view.”

Enforcement and accountability outlook for health plans

Enforcement of health plan transparency regulations is patchwork because it mostly takes place at the state level, whereas CMS has regulatory authority to enforce the hospital transparency requirements. No civil monetary penalties are known to have been issued for noncompliance with TiC regulations.

But the proposed schema requires health plan executives to sign off on data accuracy, potentially creating personal liability for intentional obfuscation, Sahota said. And states such as Colorado are becoming more active with their reviews of TiC files and soon could use AI tools to perform quality assurance at scale, Skenes noted.

“That is a part of why it matters that the files are [proposed to be] smaller and only include relevant rates,” Skenes said. “It makes enforcement less of a technical burden.”

Transparency requirements may become more stringent across healthcare if the concepts introduced in President Donald Trump’s recently proposed healthcare plan get implemented in future legislation.

“Even though the specifics have not been fleshed out yet, price transparency is top of mind,” Skenes said. “And I think we’re going to hear a lot about it in 2026.”

Trump called for a hospital’s full set of prices to be posted on-site, which Skenes said could mean offering searchable interfaces, along with plain-language service groupings for consumers instead of information presented as DRGs or CPTs.

Meanwhile, insurers would be required to publish their claim denial and rejection rates. Payers thus could be pressured to find solutions to the denials issue upstream in the contracting phase.

“I’m hopeful that brings more innovative thinkers into the conversations with payers and providers on what it functionally looks like to contract in a way that shrinks those denials,” Skenes said.