New proposed rule to update price transparency requirements for health plans and issuers: Key changes

The Centers for Medicare and Medicaid Services (CMS), in conjunction with the Departments of Treasury and Labor, published a proposed rule on December 23, 2025 to update the price transparency reporting requirements for non-grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage, including self-insured group health plans.

In amending the existing price transparency regulations issued under the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code, the proposed rule aims to improve the standardization, accuracy, and accessibility of public pricing disclosures.

Comments on the proposed rule are due by February 23, 2026. Our alert provides a summary of key changes included in the proposed rule.

Key changes under the proposed rule

New definition added for “Health Insurance Market”

A newly defined term, “Health Insurance Market,” would be added to the definitions section, defining individual, small, and large group markets along with a special definition for self-insured group health plans. The definitions include express exceptions based on market type, such as short-term, limited-duration plans, excepted benefit plans, and, in the case of self-insured plans, account-based plans (e.g., health reimbursement arrangements).

Revised notice for members regarding balance billing

Aiming to align the existing disclosure related to balance billing with the No Surprises Act requirements, the notice for members would be revised to remove language suggesting that out-of-network providers “may” balance bill members. Instead, the notice would clarify that the cost-sharing information does not account for any balance billing permitted by federal or state law. The notice would not be required if the applicable state law prohibits all out-of-network balance billing.

New method and format for disclosures to members

In addition to the existing required internet-based self-service tools and paper methods, the proposed rule would add a new phone method for disclosures.

New public disclosure requirements for in-network provider rates

Public disclosures of in-network provider rates would need to adopt a revised format and add new data elements, such as:

• Displaying rates based on “provider network” instead of by plan
• Identifying networks by their “common” name and the product type (e.g., health maintenance organization, preferred provider organization)
• Including numerical enrollment totals, current as of the posting date
• Excluding provider rates for items or services “unlikely” to be provided by the provider (e.g., a podiatrist performing heart surgery)

New public disclosure requirements for out-of-network provider rates

CMS observed that plans and issuers were reporting limited or no data in their allowed amount machine-readable files for out-of-network rates. They believe that the lack of data may partly stem from the current reporting standards. To increase data disclosure, the new rules would require that those files:

1. Include aggregated unique allowed amounts and billed charges by each health insurance market (as explained above)
2. Only omit data when fewer than 11 different claims (instead of the existing threshold of 20) exist for payment of a particular item or service in a single health insurance market
3. Increase the period of reporting from 90 days to 6 months, with the lookback period increasing from 180 days to 9 months

New contextual file requirements

Newly added “contextual” file requirements would include obligations to make available a change-log file, a utilization file, and a taxonomy file. Under these requirements:

• The change-log file would reflect changes in data from one in-network rate file to the publishing of the next file, which CMS anticipates would allow users to only need to look at the change-log file to determine which new files they need to examine from one reporting period to the next
• The utilization file would include all providers who have submitted and received reimbursement for at least one claim for a covered item or service over the 12-month period, ending 6 months before the posting of the file
• The taxonomy file would reflect a payer’s internal provider taxonomy mapping that it used to prepare the in-network provider rate file

New website links and information

Plans would need to include a plain text file in the root folder of a payer’s website, including the source page URL hosting the machine-readable files, a direct link to the URL, and a point of contact. Additionally, the payer’s website must include a footer on the home page, labeled as “Price Transparency” or “Transparency in Coverage,” with a link to the publicly available web page hosting the link to the files.

Reduced update frequency

Under the proposed rule, payers will only need to update the files quarterly, instead of the existing monthly requirement. However, the specific terms for timing are laid out in the proposed rules and include a monthly reporting timeframe for the prescription drug machine-readable file.

Special rules for self-insured group health plans

Under the proposed “special rules” that would be added for self-insured group health plans, a plan may fulfill its obligations under the transparency rules by entering into an agreement with a third party to manage the in-network and out-of-network allowed amount machine-readable files, provided that the terms of the special rules are met.

Timeline for finalization

If finalized, the amendments in the proposed rule would become effective 12 months after publication of the final rule. All existing requirements would remain in effect until that date.

Learn more

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