The DOL, HHS, and IRS have proposed regulations that would streamline health care pricing disclosures. Transparency in coverage (TiC) regulations that became applicable in 2022 require most group health plans and insurers to disclose certain pricing to the public in machine-readable files updated monthly. The disclosures must show negotiated rates for covered items and services between the plan or insurer and in-network providers, as well as historical payments to, and billed charges from, out-of-network providers. Plans and insurers also must provide individualized cost-sharing information to a participant, beneficiary, or enrollee, via an online self-service tool or in paper format, upon request. Here are highlights of the new proposals:
- Machine-Readable Files: The proposed regulations would require plans and insurers to update and post the in-network rate and out-of-network allowed amount files quarterly rather than monthly (except for prescription drug files, which would remain monthly). To reduce the number and size of the machine-readable files, the proposals would exclude from the files any data for services that providers would be unlikely to perform. And to reduce duplicative data, plans and insurers would be required to prepare one in-network rate file for each provider network they maintain or contract with rather than for each plan or policy they offer, as currently required. Other proposed changes include rules to address insufficient disclosure of out-of-network pricing information. The provisions impacting machine-readable files would apply 12 months following finalization.
- Individualized Disclosures: As suggested in 2021 FAQ guidance, the proposed regulations would align the TiC regulations with subsequently enacted No Surprises Act disclosures, which were largely duplicative but require cost-sharing information to also be provided over the phone. The agencies propose that the TiC disclosures be required to be communicated over the phone, upon request, to satisfy the No Surprises Act cost-sharing tool provision. Other proposed changes would update the regulations to take into account protections against balance billing under the No Surprises Act. These provisions would apply for plan years beginning on or after January 1, 2027.
The proposed rules follow an Executive Order issued in early 2025 directing the agencies to take “all necessary and appropriate action” to implement and increase enforcement of the TiC regulations, along with FAQs (Part 70) describing forthcoming technical implementation guidance for machine-readable files. The agencies advise that they intend to separately consider changes to the currently on-hold prescription drug disclosure requirements.
