Navigating the American healthcare system has long felt like shopping in a store with no price tags, where the final bill arrives weeks later, often bearing staggering and unpredictable costs. In an effort to demystify this process, the 2020 Transparency in Coverage regulations mandated that health insurers publish their pricing data, but the result was a deluge of information so complex and unwieldy it proved virtually useless for the average consumer. Now, federal regulators are making a second, more targeted attempt to fulfill the promise of true price transparency. The Centers for Medicare and Medicaid Services (CMS), in partnership with the Department of Labor and the Department of the Treasury, has unveiled a proposed rule designed to transform these massive, disorganized data sets into a functional resource. This new initiative, released in late 2025, acknowledges the practical failures of its predecessor and aims to standardize data formats, enhance usability, and empower patients and third-party developers to finally make sense of healthcare costs before a bill is ever issued.
Restructuring the Data Foundation
A central pillar of the proposed overhaul involves a fundamental reorganization of the machine-readable files that form the bedrock of price transparency. Under the original 2020 rule, insurers were required to create separate files for each of their health plans, a methodology that resulted in an astronomical amount of redundant information and file sizes that were often too large to download or process. The new proposal seeks to rectify this by requiring insurers to structure their In-network Rate Files by provider network instead of by individual plan. This seemingly technical shift has profound implications; it not only aligns the reporting standard with the existing Hospital Price Transparency regulations, creating a more cohesive data ecosystem, but it also drastically reduces data duplication. By consolidating the rates for a given network into a single, more manageable file, regulators hope to make the information far more accessible to researchers and app developers who can build the user-friendly tools that consumers need to compare costs effectively across different providers.
Further refining the data’s utility, the proposal introduces several key measures aimed at improving clarity and reducing the administrative burden on insurers without sacrificing the quality of information. A significant addition is the requirement for “Change-log” files, which would allow users to easily track updates and modifications to pricing data over time, providing a clear history of rate changes. Alongside this, new “Utilization Files” would offer insights into how frequently certain services are used, adding a crucial layer of context to the raw pricing data. In a nod to the operational challenges faced by insurers, the rule also proposes to change the reporting cadence for In-network and Allowed Amount files from monthly to quarterly. This adjustment is designed to ease the compliance effort for health plans while still ensuring that the pricing information available to the public remains reasonably current and relevant for making informed healthcare decisions. This balanced approach seeks to make the entire transparency system more sustainable and practical for all parties involved.
Expanding Access and Empowering Consumers
Beyond restructuring the core data, the proposed regulations aim to cast a wider net over pricing information, particularly in the often-opaque realm of out-of-network care. The initial rules left significant gaps in this area, but the new proposal introduces changes to broaden the scope of available data. It mandates that Allowed Amount files, which detail payments to out-of-network providers, be organized by health insurance market type, making it easier to analyze pricing trends within specific segments like the individual or group markets. More critically, the proposal lowers the reporting threshold for a provider’s services, requiring disclosure if there have been 11 or more claims for a service, down from the previous threshold of 20. In conjunction with this, the lookback period for capturing this claims data is extended from 180 days to a more comprehensive nine months. Together, these changes are designed to bring a much larger volume of out-of-network pricing data into the public domain, offering consumers a clearer picture of potential costs when they seek care outside their plan’s network.
Ultimately, the success of any transparency initiative hinges on whether consumers can easily access and understand the information. The proposed rule directly addresses this by strengthening the requirements for the price comparison tools that insurers must provide to their members. These enhancements are designed to align with the consumer protections established under the No Surprises Act, creating a more unified and predictable experience for patients. A key mandate is that the cost-sharing information a consumer receives must be consistent, regardless of how they access it—whether through an online portal, a printed document, or a phone call with a customer service representative. This provision is a crucial step toward health equity, ensuring that price transparency is not a privilege reserved for the digitally savvy. By guaranteeing access to clear and reliable cost estimates across multiple platforms, the rule aims to empower all individuals to make informed financial decisions about their healthcare, fostering a more competitive and patient-centric market.
A Measured Step Forward
The regulatory effort to refine price transparency was a clear acknowledgment that the initial 2020 rules, while ambitious, had fallen short of their intended goal. The administration, through Health and Human Services Secretary Robert F. Kennedy, Jr., framed the new proposal as a critical step toward providing families with “clear, usable information,” reflecting a continued federal priority established under Executive Order 14221. This move was not without its historical friction; when the original rule was released, industry groups like AHIP had voiced strong objections, arguing that it overstepped statutory authority by forcing the disclosure of privately negotiated rates. The new proposal attempted to address the practical, rather than ideological, failings of the first attempt. Notably, the proposal carved out major changes to prescription drug disclosures, which CMS indicated would be addressed in a separate future rulemaking. As the 60-day comment period concluded on February 21, 2026, stakeholders across the healthcare industry submitted feedback, marking the next phase in a long and complex journey toward a truly transparent healthcare marketplace.
