The Proposed Transparency in Coverage Regulations Are Finally Here

At long last, the Federal Departments released proposed regulations intended to improve the public disclosure of pricing information for medical items and services covered under a health plan. I say “long last” because we were expecting these proposed regulations¹ back in September 2025, but it took the Federal Departments until December 19th to finally release these proposed changes. 

A Quick Refresher on the TiC Regulations 

In October 2020, the first Trump Administration finalized regulations, known as the Transparency in Coverage or TiC regulations. These regulations require insurance carriers and self-insured plans to publicly disclose – through three distinct machine-readable files (MRFs) – the following: 

• In-network negotiated (INN) rates for covered medical items and services, known as the “INN Rate File”.
• Out-of-network (OON) allowed amounts the carrier or plan paid to out-of-network providers, known as the “OON Allowed Amounts File”.
• INN rates and the historical “net price” for covered prescription drugs, known as the “Prescription Drug File”. 

Problems with the Public Disclosure of Pricing Information 

The MRFs are the means through which medical and prescription drug pricing data must be publicly disclosed. However, over the course of the past four years in which the TiC regulations have been effective, self-insured plan sponsors and their service providers have discovered that the pricing data is not downloadable, understandable or consumable. This is effectively due to the following: 

• Oversized files: The MRFs – in particular, the INN Rate File and the OON Allowed Amounts File – are way too large, which has made it extremely difficult for plan sponsors and their service providers to ingest, analyze and evaluate the publicly disclosed pricing information.
• Poor data quality: The pricing data inputted into the MRFs are incorrect, inaccurate and duplicative, which has made it almost impossible to develop an accurate picture of the pricing information and provider patterns in a particular geographic region.
• Non-compliance: There is a lack of compliance with the TiC regulatory requirements, which many believe is the root-cause for (1) the large-scale size of the INN Rate and OON Allowed Amounts Files and (2) the disclosure of incorrect, inaccurate and duplicative pricing data. Many industry stakeholders actually believe this non-compliance is purposeful and is intended to continue to shroud the full disclosure of pricing information for medial items and services and prescription drugs. 

Efforts to Address These Problems 

Self-insured plan sponsors and their service providers have highlighted the problems noted above and encouraged the Federal Departments to issue new regulations that would improve and strengthen the existing TiC regulations. The Federal Departments listened, and through these proposed regulations, the Departments endeavor to reduce the size of the MRFs, eliminate duplication, and improve the accuracy of the pricing information. 

What Did the Proposed Regulations Actually Say? 

The following highlights what I believe to be the most helpful aspects of these proposed regulations: 

4 New Files to Help Understand the INN Rate File Data 

Over the course of the past four years, the Federal Departments have come to realize that additional information relating to the publicly disclosed pricing data is necessary to promote a fuller understanding of pricing dynamics. In response, the Departments are now proposing to require insurance carriers and self-insured plans to develop and post four new, distinct and separate Files to provide what the Departments are calling “additional context” to the INN Rate File, including the following: 

• Change Log File: The proposed regulations would require carriers and plans to prepare a separate “Change Log File” for each INN Rate File, identifying any updates to pricing information since the last publication. This would effectively eliminate the need to cross-check old INN Rate Files with new INN Rate Files to figure out what pricing data may have changed from update to update.
• Utilization File: Carriers and plans would also be required to develop a “Utilization File,” which would document all items and services covered under the plans or policies represented in the INN Rate File for which a claim has been submitted and reimbursed. This Utilization File would also include each INN provider – identified by the National Provider Identifier (“NPI”), Tax Identification Number (“TIN”) and Place of Service Code – who was reimbursed for a claim for each covered item or service included in the INN Rate File.
• Taxonomy File: These proposed rules would require carriers and plans to make available a Taxonomy File that includes the carrier’s/plan’s “internal provider taxonomy,” which maps items and services to provider specialties. This will help the carrier/plan determine if they should deny reimbursement for an item or service because it was not furnished by a provider in an appropriate specialty.
• Text File: The website of a carrier, a plan or a service provider on behalf of a plan must prominently display a “Text File” with information on the specific location of the INN Rate and OON Allowed Amount Files. This will include contact information for the carrier, plan or service provider so individuals who need help researching and interpreting the Files can reach a point of contact to answer their questions. 

Proposed Changes to the INN Rate and OON Allowed Amount Files 

The Federal Departments have emphasized that the transparency of INN rates and OON payment data is vital for plan sponsors, researchers and policymakers to analyze health care spending, benchmark costs and inform future policy decisions. Based on the Federal Departments’ internal assessments – and in response to external industry stakeholder feedback over the last four years of implementation – the Departments have determined that making the following changes to the INN Rate and OON Allowed Amount Files should help achieve these goals: 

• Inn Rate File Changes
  • Organizing files by provider network: Insurance carriers and self-insured plans often use the same medical provider network for participants covered under their multiple insurance policies and health plans. The proposed regulations would require carriers and plans to prepare one File for the provider network that may then be used by all these different policies and plans, instead of preparing multiple Files for each policy and plan.
  • Aggregating self-insured plan files by provider network at the service provider-level: Self-insured plans may allow their service provider to make available a single INN Rate File for each provider network used by more than one self-insured plan. In other words, the INN Rate File may be made available at the “service provider-level” for each provider network used by a self-insured plan, and could include information for more than one self-insured plan for whom the service provider administers.
  • Including enrollment totals: The proposed regulations would require each INN Rate File to include current numerical enrollment totals of all participants and their dependents – as of the date the File is posted – for each coverage option offered by a carrier or plan that uses the File’s provider network.
  • Eliminating “Ghost Rates” in the files: The proposed regulations would effectively eliminate the public disclosure of “ghost rates”. These are medical prices that are listed for items and services that participants never utilize, and medical providers never furnish, which make the pricing data misleading.
• OON Allowed Amount File Changes
  • Lowering the claims threshold for disclosing OON payments: The proposed regulations would require more disclosures of payments for OON services in the OON Allowed Amount File by lowering the number of claims that must be incurred before the public disclosure requirement is triggered, from the current 20 claims threshold to 11 claims.
  • Extending the reporting and lookback periods for disclosure: The Departments also propose increasing the reporting period from the current 90 days to six months and the lookback period from the current 180 days to nine months. This will increase the universe of OON payments that may be disclosed in the OON Allowed Amount File.
• INN Rate File and OON Allowed Amount File Changes
  • Reporting by product type: The proposed regulations would require carriers and plans to report the product type (e.g., Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO)) associated with the coverage option for which data is being reported in BOTH the INN Rate File and the OON Allowed Amount File, which would effectively reflect the differences between the INN rates and OON payments for each HMO versus PPO coverage option. 

What’s Next for These Proposed TiC Regs? 

Public comments on these proposed regulations are due February 23rd. It will likely take the Federal Departments six months or more (1) to review the comments and then (2) to finalize the proposed changes. So, I would not expect to see final regulations until at least the 3rd Quarter of 2026, but also don’t be surprised if it takes until the end of the year. Stay tuned…