Transparency in Coverage

The Transparency in Coverage rules require health plans and issuers to publicly share the prices they pay providers and give their participants and beneficiaries upfront cost estimates. The updated rules are designed to help people locate, analyze, and compare costs before getting care, while also reducing the reporting burden on plans and issuers.

Top 5 FAQs about Transparency in Coverage

1. What do the rules do?

   Health plans and insurers are already required to publish machine-readable data files online showing the prices they've negotiated with in-network doctors, hospitals, and other providers, as well as historical out-of-network allowed amounts, and drug pricing information. These files are meant to help researchers, employers, and software developers understand and compare healthcare prices — but these files, with millions of entries, are too large and complex for consumer use.

   The new rules standardize how pricing information is published, cut down on unnecessary or irrelevant data, and organize information in a more logical way. The rules also lessen the reporting frequency from monthly to quarterly, which lowers the administrative burden while maintaining meaningful transparency. 

2. How do the rules help workers?

   Workers and consumers will have an easier way to know what they'll likely owe before they receive care, rather than being surprised by a bill afterward. Plans and issuers must provide their participants and beneficiaries with personalized cost-sharing estimates through an easy-to-use online tool, or on paper upon request, and that same information must now also be available by phone, so people without internet access can get an estimate in real time, too.

   The new rules also amend the public machine-readable files requirements to ensure that reported information can ultimately be provided to consumers in a clear, concise, and usable manner.

3. How do the rules help employers that sponsor group health plans?

   Employers will be able to see negotiated rates organized by provider network, making it easier to compare networks and judge which ones offer more competitive pricing. With clearer data in hand, employers are better positioned to make informed decisions about which plans to offer their employees. The new rules also increase the amount of data produced in the historical out-of-network allowed amount files, which will benefit employers and plan sponsors by empowering them to benchmark costs, refine benefit designs, and negotiate more effectively with administrators.

4. Who do these final rules apply to?

   The rules apply to non-grandfathered group health plans and health insurance issuers, with some exceptions (account-based plans, short-term limited-duration insurance, excepted benefit plans). Grandfathered plans are also covered by the online tool and phone price comparison provisions, per the No Surprises Act.

5. How do I know the pricing information is accurate?

   Plans and issuers are required to stand behind the data. They must attest, in each data file they publish, that the information is true, accurate, and complete to the best of their knowledge. Each file must also name the CEO, president, or a senior official responsible for overseeing that accuracy.

Tools and Resources

Transparency in Coverage Final Rules Fact Sheet

This fact sheet explains the 2026 changes that build on the 2020 Transparency in Coverage final rules to improve access to healthcare pricing information.

Learn more about the fact sheet

Affordable Care Act Implementation FAQs Part 70

These FAQs discuss the machine-readable file schemas under the 2020 Transparency in Coverage final rules.

Learn more about ACA FAQs Part 70

Affordable Care Act Implementation FAQs Part 65

This FAQ addresses cost-sharing disclosure requirements when utilization of an item or service is very low.

Learn more about ACA FAQs Part 65

Affordable Care Act Implementation FAQs Part 61

These FAQs address the enforcement approach to the prescription drug machine-readable file requirement and the reporting safe harbor.

Learn more about ACA FAQs Part 61

Affordable Care Act Implementation FAQs Part 55

These FAQs primarily address balance billing and cost-sharing protections under the No Surprises Act and clarify how plans can satisfy Transparency in Coverage requirements when using a third-party website.

Learn more about ACA FAQs Part 55

Affordable Care Act Implementation FAQs Part 53

These FAQs address an enforcement safe harbor for plans and issuers unable to report specific dollar amounts in their machine-readable files due to certain reimbursement arrangements.

Learn more about ACA FAQs Part 53

Affordable Care Act Implementation FAQs Part 49

These FAQs address enforcement for the Transparency in Coverage machine-readable file requirement and explain more about the TiC price comparison tool.

Learn more about ACA FAQs Part 49

Transparency in Coverage Proposed Rule Fact Sheet | CMS

This fact sheet describes the Transparency in Coverage rules as proposed in December 2025, before they were finalized.

Learn more about the fact sheet

Transparency in Coverage Model Notice

Learn more about draft model disclosure

Negotiated Rate File - Data Elements

Learn more about negotiated rate file

Allowed Amounts File - Data Elements

Learn more about allowed amount