Final Transparency in Coverage rules aim to ease way to better data 

With the first Machine Readable Files that were required to be posted in 2022 under the original set of Transparency in Coverage rules, we began a journey toward data transparency in healthcare pricing, but the road is a challenging one. Plan sponsors have access to mountains of data intended to enable detailed price comparisons of medical services, but the data is formatted as MRFs that are simply too big to be used easily easily — and and prescription drug MRFs are not yet required. The expectation was that making the data public would empower consumers and employers to shop and compare costs, foster market competition and ultimately slow or reverse the rising cost of healthcare.

While progress has been made, there is still a long way to go to realize those initial expectations. Currently, we use this data to help employers supplement broad network analyses, evaluate narrow networks and point solutions and conduct value and steerage analyses. We are hopeful that the recently released amended final Transparency in Coverage regulations — which we discuss below — further improve data usability for employers and consumers. Additional guidance on prescription drug MRFs is expected. Regulators intend to update and release additional technical implementation guidance on GitHub in 2027 as well. Goals include tackling the large size of the MRFs, reducing data ambiguity and resolving misalignments with the Hospital Price Transparency rule that currently complicate data comparisons. As to the self-service tool, the rules were updated to align with changes introduced by the No Surprises Act. Unfortunately, we were disappointed that quality metrics were not addressed.

What’s in the new TiC rules — and how will they help?

In general, the TiC rules should improve plans’ and issuers’ analyses by:

• Publishing in-network rates at the network level, rather than the plan level, to better align with industry practices for rate negotiation, hospital price transparency and streamlining reporting for payers.
• Removing ghost rates from payer TiC submissions, which should reduce computing barriers for users and limit distortions in aggregated data. “Ghost rates” are rates for combinations of providers and items and services that are unlikely to be reimbursed based on provider specialty, such as rates for podiatrists performing heart surgery.
• Increasing the amount of reported data on out-of-network allowed amounts, which may help shed light on claims subject to the No Surprises Act, an area of concern for many plan sponsors.

In network and out-of-network allowed amount MRFs. Currently, group health plans must post MRFs monthly, disclosing in-network rates for all covered items and services, as well as out-of-network allowed amounts. The changes required by the final regulations will need to be incorporated into the MRFs posted on April 1, 2027 — the first quarter following the applicability date of March 6, 2027 — unless otherwise indicated. Key changes include:

• Requiring plans and issuers to post a single in-network file per provider network and reducing the frequency of postings from monthly to quarterly.
  
  
• Excluding ghost rates and requiring new contextual files — a utilization file and a taxonomy file — to provide clarity as to the services that are typically reimbursed by a plan.
  
  
• Requiring payers to use a single file format.
  
  
• Allowing percentage-of-billed charges reporting when the dollar amount is not known in advance.
  
  
• Addressing limited data in many out-of-network MRFs by requiring files to be aggregated by insurance market type, lowering the claims threshold from 20 to 11 claims and extending the reporting period.
  
  
• Making data easier to find by requiring a plain text file in the root folder of the source page URL for the website hosting the MRFs; a direct link to the URL for the MRFs; and a monitored email address for questions. This change is effective October 1, 2027.
  
  
• Requiring a footer on the home page of the plan’s or issuer’s website that directs users to the webpage hosting links to the MRFs. This change is effective October 1, 2027.

Notably, the new rules require an attestation by the CEO, president or other senior official of the plan or issuer that the data in the MRFs are true, accurate and complete. Self-funded and insured plans may enter into an agreement with their TPA or carrier for this purpose, but self-funded plan sponsors will retain responsibility for any failure.

Prescription drug MRFs. Government officials announced publicly and in FAQs that guidance for the prescription drug MRFs is expected in May 2027, with the aim of having those files posted by the end of 2027. It appears that the prescription drug MRFs will need to be posted monthly. Regulators are considering feedback from the June 2025 request for information on prescription drug MRFs to guide implementation of the TiC prescription drug requirements through technical guidance or future rulemaking.

Self-service tool. The TiC rules require group health plans to provide cost-sharing information to participants through an online self-service tool or on paper upon request, including explanatory notices and disclosures of data limitations. The No Surprises Act further requires plans to make cost-sharing information available over the phone.

Under the new rules, which are effective for plan years beginning on or after January 1, 2027, group health plans must:

• Make the same cost-sharing information that is disclosed under the TiC rules and is accurate at the time of the request available by calling the telephone number on the plan identification card.
  
  
• Amend notice requirements to reflect federal protections against balance billing in certain situations.

Next steps

Challenges remain for plan sponsors. While the changes provide many inherent benefits to plan sponsors, new limitations may also exist in the reported data. For example, out-of-network reimbursement programs maintained by payers may differ by plan sponsor, and aggregated data may mask granular patterns at the plan sponsor level that could help determine appropriate out-of-network reimbursement thresholds. Additionally, plan sponsors may be limited in reconciling carrier revenue obtained from out-of-network reimbursement schemes when data is aggregated.

Likewise, removing ghost rates may offer tangible benefits when summarizing negotiated rate data, but it is a complex exercise that may not follow simple logic. A primary concern is whether relevant negotiated rate data may be removed through the proposed process.

In addition, several important issues were not addressed in the new rules, including variations in in-network rates — such as when a payer publishes multiple rates for the same billing code-provider combination, or rates that differ by the type of provider — as well as conditional clauses and carve-outs that are largely not reported in the current schema. The Departments indicated these areas would be addressed in technical implementation guidance posted to GitHub at a later date.

While awaiting additional guidance for MRFs, plan sponsors should focus on compliance for their plans’ self-service tool as those changes must be implemented by January 1, 2027. Plan sponsors should also seek to ensure that their carriers and TPAs will be ready for the 2027 and 2028 MRF deadlines and confirm that they will provide the required attestation for the MRFs with appropriate contractual language as needed.