The Trump administration is overhauling federal price transparency rules for payers and self-insured employers, including cutting so-called “ghost rates,” expanding out-of-network price disclosures and requiring executives to vouch for the accuracy of the data.
The final rule, released Oct. 5 by CMS and the Labor and Treasury departments, revises the price transparency regulations first finalized in 2020 during President Trump’s first term, which have required payers to post their negotiated rates since 2022. Hospitals have been required to post their prices under separate federal rules since 2021. The new rule takes effect Dec. 5, though most of the data requirements will be phased in across 2027.
The change follows a CMS proposal and an executive order from the president last year that directed federal agencies to step up price transparency enforcement.
Since the original rules took effect, research has questioned whether insurers have been publishing complete data, though none have ever been publicly fined. In comparison, CMS has fined 28 hospitals for violating transparency rules, which as of this year require hospitals to publish actual dollar amounts charged for services rather than estimates. In the new rule, the government said it will prioritize enforcement and work to make those actions public.
Critics have also long said the currently published price transparency data is hard for consumers to use given the sheer size and ambiguity of the files. In the final rule, the government declined to require consumer-friendly cost summaries in the files, saying the data cannot reflect an individual’s deductible or other personal cost-sharing requirements.
Six things to know about the final rule:
- Payers will be required to post one in-network rate file for each provider network instead of one for each plan, and each in-network file must also include a network name and network identifier. Because many plans share the same networks and rates, the change is meant to cut down on duplicate data being published, and it matches how hospitals typically report their own pricing files. Payers must also remove “ghost rates,” or rates for services a provider is unlikely to be paid for given its specialty (such as heart surgery rates listed for podiatrists). CMS noted those published rates are a major reason the files have grown so large. Payers will use their own internal rules to decide which rates to drop, but must publish those rules in a new taxonomy file. Payers will also have to post a utilization file listing providers that were paid for at least one claim.
- Out-of-network data should become more plentiful, as payers currently report an out-of-network allowed amount only after at least 20 claims. That threshold will drop to 11, and each file will cover six months of claims instead of 90 days. Files will need to be grouped by market type (large group, small group, individual and self-insured) and list each plan’s product type, such as HMO or PPO.
- In-network and out-of-network files must be updated quarterly instead of monthly. The departments expect that change and the smaller file sizes to save plans and issuers about $174.5 million a year starting in the second year. Payers must use a single file format, post a plain text file on their website showing where the files are, add a monitored contact email, and include a “Price Transparency” or “Transparency in Coverage” link on their homepage.
- Each file must include an attestation that the data is accurate and complete, along with the name of the plan CEO, president or senior executive that oversees it. Hospitals faced a similar attestation requirement that CMS began enforcing in April.
- Starting with plans beginning on or after Jan. 1, 2027, members will be able to get personalized cost-sharing estimates by phone, in addition to the online and paper options already required.
- Payers must post their first revised in-network and out-of-network files April 1, 2027, and their first taxonomy and text files Oct. 1, 2027, while the utilization file won’t be due until July 1, 2028. The rule does not change the prescription drug file, which would show what plans pay for drugs, including prices after rebates and discounts. The government said it will finalize a format for that data around May 2027, and plans will have to begin posting the information in December 2027. Regulators did not finalize two proposals, one requiring a file showing what changed between postings and another requiring enrollment totals for plans.
