New year, renewed efforts

2025 was a sprint to the finish as the latest hospital and payer requirements and proposals were individually released in October, November, and December. The Turquoise team has enjoyed some time off, digested our holiday meals and the new policy verbiage, and we’re ready to hit the ground running now that the new year is here. Two inadvertent exercise-related metaphors in one intro paragraph is enough to consider any new year’s resolutions complete, yes? Anyway.

As far as what’s on deck for 2026, we’ve got our eye on two key dates and some open conversations that will continue this year. We also want to keep a spotlight on a few lingering areas that we’re eager for the publication of additional legislation and enforcement plans.

Perhaps most importantly, we’re ready for 2026 to be the year we tackle some of the bigger foundational issues that, even with accurate and complete machine-readable file (MRF) data at our fingertips, continue to weigh down the healthcare transaction with friction and waste.

Let’s jump into the specifics below.

Dates to Keep in Mind

February 2, 2026

In early February, payers must update their MRFs to use the schema 2.0 format, which is the first meaningful change to payer files since they were first published in July of 2022. Notably, the schema 2.0 format and due date is not impacted by December’s proposed rule. Although no payers have been fined for noncompliant files, we’re starting to see glimmers of momentum from states looking to ensure payer MRFs are complete and accurate. The new schema iteration is a good place for parties in charge of compliance to assess MRFs, and the schema modifications should also make MRF parsing incrementally easier for third parties accessing the data.

April 1, 2026

Next up, hospitals are responsible for their own MRF changes. April’s updates are focused on a few core areas:

• Attestation language and hospital executive accountability for accurate files
• New Percentile Allowed Amount Reporting & Count of Allowed Amount
• NPI reporting

You can read more about the specifics of these 4/1 changes in the link above. Hospitals have done many iterations of reporting changes in the past two years, and ideally MRF generation teams can take their approach for creating the soon-to-be-defunct Estimated Allowed Amount field and utilize it for creating the new Percentile Allowed Amount reporting.

Both the February and April changes weave into the broader landscape evolution we’re expecting to see this year, which we’ll tackle next.

Landscape Changes in 2026

Shrinking the Data

The novelty of publicly available negotiated rates has started to wear off since 2021. What started as a field day of interested parties diving into petabytes of data has turned into more thoughtful, strategic approaches to data utility. The 2025 Transparency in Coverage (TiC) proposed rule spends a decent number of paragraphs on not only the specifics of what changes are to come for payer MRFs, but also, a broader story of how and why payer MRFs are best seen as one piece of the puzzle critical to understanding the cost of care.

For example, the industry has come to realize that sometimes less is more if and when less is accurate. The TiC proposed rule summarily points to the idea that in the original final rule, it’s fair to categorize the approach to payer file creation as more is more:

The Departments understand that plans and issuers frequently negotiate applicable rates at the provider organization level (such as large multi-specialty physician groups or integrated health systems) for every provider who is a member of that organization, regardless of whether that provider would be likely to be reimbursed for that item or service.

Under the 2020 final rules, these rates are required to be disclosed. As a result, the Departments and interested parties have observed that there are many provider-rate combinations that are not meaningful for transparency purposes and impose unnecessary burden on both producers and users of the In-network Rate File. This overinclusion leads to significant file sizes, where In-network Rate Files are consistently enlarged by the inclusion of these unlikely provider-rate combinations.

In September 2024, the Departments analyzed a subset of In-network Rate Files and discovered that 73 percent of hematologists' negotiated rates were for 500 billing codes for services for which they would be unlikely to be reimbursed for.

Now, we are older and wiser and realize we no longer benefit from throwing all possible potential rates against the wall to see what sticks. If finalized as written, the proposed rule moves to MRF data consolidation where payers report a rate one time and ensure that rate is tied to only the relevant providers or networks.

A lot of this evolution, according to the TiC proposed rule, came from policy makers watching and learning from the iterations of hospital MRFs and listening to innovators making recommendations on how to improve payer MRFs.

While the machine-readable file requirements of the 2020 final rules and the 2019 Hospital Price Transparency rule do not require the exact same disclosures, they have similar goals and some overlapping data. Therefore, it can be useful to review studies of hospital machine-readable files for lessons learned and outcomes that may translate to the plan and issuer machine-readable file disclosures.

Legislative Convergence

That leads to a second theme of convergence of rules and laws. We’re now firmly in an era where it’s plausible and reasonable to expect that, if the TiC proposed rule is finalized, there will be clear opportunities to join payer and hospital MRFs on common data elements and compare rates. Endeavors to complete an apples-to-apples comparison across MRFs may finally be plausible, and the convergence efforts don’t end there.

The proposed rule also focuses on clarity around defining a health insurance network and creating requirements around price comparison tools, both of which are relevant to the No Surprises Act (NSA): “The Departments intend for these proposed rules to satisfy the requirements of the No Surprises Act.”

The idea of a clearly defined health insurance network is tied to clarity around calculating a qualifying payment amount (QPA) for out-of-network visits, and the goal of the updates to price comparison tool requirements is to create a singular list of requirements for all types of estimate tools, regardless of if they are required by the hospital final rule, a future TiC final rule, or the NSA.

That level of detail may seem uninteresting or even off-topic, but the goal is clear: regardless of which final rule or law a specific requirement stems from originally, there should be uniformity and congruence between each requirement to publish negotiated rates and create standardized, accurate pricing estimates. For years the Turquoise team has referred to these final rules and laws as The Triumvirate, but the more The Convergence occurs, the less we’ll need to focus on specific elements of The Triumvirate and the more we can focus on the broader tactics of creating a more frictionless healthcare transaction.

Relatedly, there are a number of different federal bills that have the potential to codify price transparency requirements as law this year. Our hope is that if this occurs, any federal law would continue to streamline the requirements and maintain uniformity.

Getting Accurate Costs in Front of Patients

The TiC proposed rule addresses yet another area of feedback that’s been common these last few years: MRF data is not meant to be the primary source of information for patients to understand their cost of care. Patient estimate tools (PETs) must be user-friendly and accurate enough for patients to understand costs, starting with elective or shoppable services, but reliable MRF data still matters in how quickly those PETs can develop.

The Departments expect that continued analyses and development of consumer-facing tools and services will result in similar savings opportunities achieved from studying the hospital machine-readable files. However, the success of these analyses and the effectiveness of consumer-facing tools depend on the usability of the machine-readable files. Large file sizes, lack of clarity, and data of limited use hamper efforts to build tools that can be brought to market. These proposed changes, if finalized, would contribute to making the files easier to digest and analyze, reduce challenges for existing tool developers, and open the market to additional tool and app developers.

MRF data can and should be a means to an end when it comes to the NSA requirements as well, which moves us into the open requests we still have headed into the year.

Open Requests

Enforcement Dates for Advanced EOBs

A major element of the rules and laws converging will occur when AEOBs get an enforcement date. The idea that a price comparison tool can and should factor in patient cost sharing calculations is pivotal for insured patients looking to understand their costs. The updated comparison tool requirements within this TiC proposed rule, which would go into effect on 1/1/2027 if finalized as written, could serve as an opportunity for the Departments to consider an enforcement date for AEOBs too. Doing so would bolster the convergence of rules and laws and solidify the expectations that patients can and should receive reliable and transparent cost estimates in plain language.

Outlier/Stop Loss Reporting

We wrote extensively about outlier and stop loss reporting in our Q4 2025 Impact Report, but neither the most recent hospital final rule nor the TiC proposed rule included additional reporting fields to capture stop loss scenarios. Cost of high-acuity care is often a blind spot within MRFs, and we look to the Departments to remedy that in 2026.

Drug Data

We’d be remiss to go through this year’s outlook without addressing the lack of pharmacy data. TiC originally required a third prescription drug file, which has been indefinitely delayed for years. The proposed rule notes that but ultimately does not give any concrete plans or requirement dates:

The Departments considered all public input received as they developed the policies in these proposed rules, with the exception of prescription drug RFI comments. However, the Departments received these prescription drug RFI comments and are separately taking them into consideration to evaluate how to implement the Transparency in Coverage prescription drug disclosure requirements in technical implementation guidance or future rulemaking.

Thousands of words have already been written on the topic, but we’ll be keeping a close eye out for the future rulemaking the Departments mention.

The Turquoise Takeaways & Moving Beyond MRFs

We’re encouraged by the common refrain that MRF data must feed accurate, upfront PETs to meaningfully impact patients’ ability to understand the cost of their care. But if we step back and look at the entire healthcare transaction comprehensively, there’s even more we must do to challenge an opaque, proprietary, friction-laden, and often wasteful status quo. Healthcare is at an inflection point like we’ve never seen before and we can’t ignore it. The TiC proposed rule seems to agree with this sentiment:

The disclosure requirements under the Transparency in Coverage rules represent just one prong in a multipronged approach to promote greater transparency and understanding of costs and pricing in the health care and the health insurance market.

The negotiated rates, negotiated rate types, and contract structures that are now available thanks to price transparency rules and laws serve as a starting point for creating transaction efficiency. The Turquoise team believes that modularizing those rate types and contract structures helps providers and payers implement better agreements, set simplified and transparent billing and payment terms, and streamline authorizations.

This year we’ll be dialed in on our PATIENTS framework and publicly developing the core tenets we believe are foundational to the transaction efficiency mentioned above:

1. Consider the patient first
2. Strive for a perfectly efficient, payer-provider integrated transaction
3. Ensure backwards compatibility to existing transaction rails and payment systems
4. Set open license standards for interoperability
5. Maintain transparent documentation that anyone can understand.
   

The results from that work can reduce claims denials and appeals, and create an entirely reenvisioned patient financial experience.

Cheers to you, 2026

Happy new year from your friends at Turquoise Health! If there’s anything on your newly-created 2026 vision board we can be a part of, drop us a line here.