2025 Transparency in Coverage proposed rule released

Today the Centers for Medicare & Medicaid Services, the Department of Labor, and the Department of the Treasury (the Departments) released a new Transparency in Coverage Proposed Rule, which includes updates to payer machine-readable files (MRF) and internet-based self-service tools.

Payer MRFs

According to the Departments, the rule is focused on three main barriers to the original goals of the 2020 price transparency rules:

• inaccessibility due to MRF size
• ambiguity regarding some of the data disclosures due to a lack of contextual information alongside the raw data
• misalignment with the 2019 Hospital Price Transparency rule that makes comparing data across disclosures challenging

To overcome those barriers, the Departments have proposed a number of changes to payer MRFs. First, payer MRFs must not contain items or services that are unlikely to be furnished by a given provider, such as a reported rate for a gallbladder removal associated with a psychiatrist. The Departments proposed several different approaches to accomplishing this:

1) require group health plans and health insurance issuers to exclude from their In-network Rate Files provider-rate combinations for items and services for providers that would be unlikely to be reimbursed for the item or service given that provider's area of specialty. The proposal would require plans and issuers to determine which providers to exclude by using their internal provider taxonomy mappings used in the claims adjudication process;

2) require payers to post the internal provider taxonomy mapping they used to prepare the In-network Rate File; and

3) require plans and issuers to post a new file called a Utilization File for each In-network Rate File which would include all providers who have submitted and received reimbursement for at least one claim for a covered item or service over the 12-month period ending 6 months before the posting of the file.

Next, the Department focused on minimizing duplicative data by proposing payers report rates at the network level. This proposed change mirrors the way hospitals already report rates in their own MRFs and also highlights the Departments’ intent to harmonize requirements across payers and providers. This change makes it easier to compare hospital and payer files and study them side by side.

Finally, the proposal targets a number of different aspects of data utility and ensures the data is easy to locate. There are specific recommendations for

• Claims thresholds and lookback periods
• Additional data elements - product type, enrollment count, and common network name
• A change-log MRF to reflect changes in the in-network file between one quarter to the next
• Requiring a plain text file located in the root folder of a payer’s website with info on MRF location alongside contact info for a specific point of contact for data clarification or questions. This is another callback to the hospital MRF location and contact info requirements.

Notably, the proposed rule also moves payers from a monthly file refresh requirement to a quarterly file refresh. Hospitals are currently required to update their files annually.

If finalized as written, the MRF changes would go into effect “12 months following the date of publication of the final regulations in the Federal Register.”

These changes, if finalized and implemented, would likely significantly decrease the amount of MRF data users would need to download and parse, thus making the experience more nimble.

This proposed rule does not eliminate the Schema 2.0 requirements that go into effect on February 2, 2026.

Internet-based self-service Tools

The rule also emphasizes the importance of complete and useful data in order to create accurate patient estimates. In a similar approach to the most recent 2026 OPPS Hospital Final Rule, the Departments are seeking to streamline requirements from a number of different relevant rules and laws to minimize competing requirements that aim to accomplish the same goals.

Specifically for internet-based self-service tools, the Departments are proposing that upon request, payers provide the same information to patients as the No Surprises Act requires. The goal remains transparent, plain-language pricing estimates that are able to factor in cost sharing information if and when patients have insurance.

If finalized as written, the changes to internet-based self-service tools would go into effect on January 1, 2027.

More to Come

Overall, these changes could lead to meaningful payer MRF organization and consolidation and a better ability to create accurate upfront patient estimates.

We also remain vigilant for the Departments to issue requirements and an enforcement date for prescription drug MRFs.

Turquoise will be diving into the specifics, sharing our thoughts, and submitting a public comment in the new year.