CMS, IRS, and EBSA Release Transparency in Coverage Final Rule

• On October 5, 2026, the Internal Revenue Service, the Employee Benefits Security Administration, and the Centers for Medicaid and Medicare Services (collectively, the Departments) issued the Transparency in Coverage Final Rule (Final Rule). It is scheduled to be published in the Federal Register on October 6, 2026.
• The Final Rule amends the Transparency in Coverage requirements for non-grandfathered group health plans and issuers in the group and individual markets, to make publicly disclosed pricing data more standardized, accurate, accessible, and useful for consumers, employers, researchers, and developers. Among the Final Rule’s requirements are the following: 
  • Plans and issuers must report in-network rate files at the provider-network level rather than repeating the same information for each plan
    • product type,  
    • provider network name,  
    • provider network identifier, and  
    • contextual information that helps users understand the reported data.
  • The Final Rule excludes provider-rate combinations that are unlikely to result in reimbursement. It also requires information that allows users to identify and interpret changes in the reported data.
  • The reporting period for historical out-of-network data is lengthened, and the minimum claims threshold is lowered so that more usable allowed-amount information is disclosed. The data are also aggregated at a broader market level.
  • The update cadence for the in-network rate and out-of-network allowed amount files is reduced from monthly to quarterly, while retaining requirements designed to keep the data current and reliable.
  • Plans and issuers must make all required machine-readable files, including the prescription drug file, easier to locate by posting standardized website links and a text file containing contact information for questions about the files.
  • Pricing and cost-sharing information must also be available by telephone (in addition to online self-service tools and paper forms). Compliance with this telephone requirement will also satisfy the comparable disclosure obligation under the No Surprises Act.
• The Final Rule is effective 60 days after publication in the Federal Register.  

More on This Topic:

• Final Rule

For questions, please reach out to Geni Tunstall.