Price Transparency Rules: Key Updates by CMS

On December 19^th, The Centers for Medicare & Medicaid Services (CMS), in collaboration with other agencies, announced proposed updates to the healthcare price Transparency in Coverage (TiC) rules introduced during President Trump’s first administration. According to CMS, the changes proposed in the rule aim to make health plan and Third-Party Administrator (TPA) pricing data more standardized, accurate, and accessible. It addresses key barriers such as oversized machine-readable files, lack of contextual information, and misalignment with hospital transparency requirements.

Key Proposals

The proposed rule is intended to improve usability and reduce administrative burden through several measures:

Smaller, more efficient files: Health plans would exclude unlikely provider-service combinations and report in-network rates at the network level, aligning with hospital transparency standards.

More usable data: Aggregation by market type, a lower claims threshold (11 claims) and extended reporting periods will enhance data completeness.

Added context: New data elements—such as product type, enrollment counts and network names—will provide greater clarity. A new change-log file will track updates between publications.

Improved accessibility: Health plans must include a plain text file with file locations and contact details, plus a homepage footer link labeled “Price Transparency” or “Transparency in Coverage.”

Reduced burden: Quarterly updates (instead of monthly) will simplify maintenance and reduce costs.

CMS is also seeking feedback on adopting a single file format for machine-readable files. The agency proposes that health plans provide price information over-the-phone and upon request starting January 1, 2027.

Comment Period

These are proposed rules, which means there is a comment period. Public comments are due by February 21, 2026. The Departments will then review public comments and publish a final rule in the Federal Register. The final rule would take effect one year after being published in the Federal Register.

What this means for you

The proposed rules are just that: proposed. Based on comments submitted during the public comment period, the administration may or may not adopt some or all of these proposed requirements. These proposed requirements would have to be “finalized” in a final rule, which is usually published anywhere from six months to a year and a half after the proposed rule. According to CMS, any proposed requirements that are finalized in a future final rule would take effect one year after the final rule, which means any of these requirements that are ultimately finalized are unlikely to take effect before July 2027.

The proposed changes will require large updates to MRFs, both In-network and Allowed Amount. The service taxonomy mapping will also be a big lift as it would require detailed analysis of claim history and understanding of the relationship between specialty and billing code. Furthermore, reduction in MRF update frequency could lead to missing provider rates detail in Transparency tools if new providers are added to networks during that gap.

Zelis is uniquely suited to help
- Data Clean-up – Along with MRF creation, mapping and hosting, Zelis leverages MRF data to power member facing transparency tools and has deep experience in cleaning MRF data to eliminate unlikely services performed by providers based on their specialty. Zelis has built a taxonomy around this which already benefits many of our clients.
- Allowed Amount File – Zelis has expertise in creating and updating Allowed Amount File. This file may replace Out-of-Network Rates files that are created to meet members facing transparency tool requirements.
- In-Network MRF update – Zelis has been a trusted partner for many of our clients to create and update MRF files. We can help you update the MRF files so they are network specific.
- Member Facing Transparency Tool – Most of the changes proposed in In-Network and AAMRF files will impact downstream transparency applications. Zelis’ will continue to monitor regulatory changes and ensure its guidance platform, S365, meets all regulatory requirements.