The Trump administration on Monday finalized rules that require health insurers and employer health plans to vouch for the accuracy of the prices they publish and to drop rates for services their providers are unlikely to perform. The Department of Health and Human Services, through the Centers for Medicare & Medicaid Services, issued the changes jointly with the Labor and Treasury departments, and the rules were published in the Federal Register on Tuesday and take effect Dec. 7.
The rules rewrite the Transparency in Coverage requirements that took effect in July 2022 and have since obliged most insurers and group plans to post monthly machine-readable files of their in-network rates and the amounts they allowed for out-of-network care. Those requirements date to rules issued during President Trump's first term. Experts say the files have grown so large and cluttered that even experienced researchers find them nearly impossible to navigate. The departments tied the overhaul to Executive Order 14221, the president's directive on clear, accurate and actionable health care pricing.
Regulators said much of the bulk comes from rates for care a provider is unlikely to deliver given its specialty, such as a podiatrist performing heart surgery, because contracts are often negotiated for every clinician in a provider organization. Plans must now strip those pairings from their in-network files, using their own provider taxonomies or claims rules to decide what to cut, and publish the rules they used in a separate file. They will also report rates once for each provider network instead of separately for every plan. Officials said at Monday's HHS event that the changes should shrink pricing files by an estimated 70 percent.
Plans must now attest in their rate files that, to the best of their knowledge, the data are true, accurate and complete, and must name the chief executive, president or a senior official designated to oversee the data. They also have to post a plain text file at the root of their websites that points to the data and lists a monitored email address, and add a homepage footer link labeled Price Transparency or Transparency in Coverage.
For out-of-network care, the claims threshold for reporting allowed amounts drops from 20 to 11, the data must be grouped by market type (large group, small group, individual and self-insured), and the reporting period becomes more than twice as long. The departments said they expect those changes to significantly increase the out-of-network pricing data available to the public.
Insurers get relief on timing, since the in-network and out-of-network files will be updated quarterly instead of monthly. The departments said the slower cadence will cut storage and hosting costs, noting that plans, insurers and researchers told them networks and rates do not change significantly from month to month. They project net savings for plans and insurers of about $174.5 million a year starting in the second year, though the rule's economic analysis also estimates almost $400 million in one-time compliance costs for insurers, Healthcare Dive reported. Plans will also have to give consumers personalized cost-sharing information by phone, in addition to existing online tools.
"Americans should know what their healthcare will cost before they receive it," Health and Human Services Secretary Robert F. Kennedy Jr. said. At the event, Kennedy said the earlier rules had made negotiated prices public but left consumers and employers with files too large and complicated to use. Labor Secretary Keith Sonderling, in his first official remarks in the job, said that in some cases "you practically needed to be a data scientist" to make sense of the pricing data.
Federal Trade Commission Chairman Andrew Ferguson sent letters the same day to 24 of the country's largest health care services companies, reminding them that failing to give patients timely, accurate and complete prices can be an unfair or deceptive practice. The letters say that meeting CMS price transparency rules does not create a safe harbor from liability under the FTC Act, and Ferguson said hospitals that do not comply could face enforcement action and litigation.
Employer groups welcomed the rules. "The first round of price data opened the books. This rule makes the data usable by a general audience," said James Gelfand, president and chief executive of the ERISA Industry Committee, which lobbies on health benefits issues for companies. Elizabeth Mitchell, chief executive of the Purchaser Business Group on Health, which represents large employers, said the rule "has the potential to meaningfully address the affordability crisis in the commercial market."
The final version stops short of what some transparency advocates wanted, including disclosure of out-of-network payments even when only a single claim is involved, and regulators did not finalize a proposal to flag specific rate changes between updates, which insurers had opposed as a massive operational lift. In comments on the proposal, some critics said it would leave significant gaps, others said incomplete, ambiguous and hard-to-use files would remain a problem, and still others warned of higher costs and burdens for group health plans, particularly small and regional ones. AHIP, the dominant insurance industry lobby, did not respond to Healthcare Dive's request for comment.
Price transparency has been central to the health agendas of both Trump administrations, but Healthcare Dive noted that it has produced some localized benefits without yet moving overall U.S. health spending, and that some researchers fear more disclosure could lead providers to raise prices after seeing what competitors charge. CMS pointed to data showing that prices for the most expensive 25 percent of health care services have fallen 6.3 percent a year since disclosure requirements first took effect for hospitals and health plans.
Changes to the existing rate files apply five months after publication, and plans have 11 months to post the new contextual files. Drug prices are on a separate track: the departments plan to begin designing a standard format for prescription drug files in November, finalize it around May 2027 and expect plans to publish drug files using it starting in December 2027.