Health Insurers Must Reveal True Costs by 2026 Deadline
Published Date: 12/23/2025
Proposed Rule
Summary
Starting soon, health plans and insurers must share clearer, easier-to-understand price info for medical services. This means better details on what you’ll pay in-network and out-of-network, with more frequent updates and extra info like plan types and provider networks. These changes affect most group and individual health plans and aim to help you shop smarter and save money by December 2026.
Analyzed Economic Effects
7 provisions identified: 6 benefits, 0 costs, 1 mixed.
New Context Files for Price Data
Health plans and insurers would have to publish new contextual machine-readable files alongside in-network rate files, including a change-log, a 12-month utilization file (covering the 12 months that end 6 months before publication), and an internal provider taxonomy file. These files must be posted on public websites and will help users understand the raw price data for each provider network.
More Out-of-Network Historical Data
Out-of-network allowed amount disclosures would be reported at the health insurance market level instead of the plan level, the claims-inclusion threshold per item/service would drop from 20 to 11 distinct claims, the reporting period would increase from 90 days to 6 months, and the lookback period would increase from 180 days to 9 months. These changes mean more historical out-of-network allowed-amount data will be publicly available.
Dollar Rates, Enrollment, and Product Type
In-network rate files would be required to include the common provider network name, the product type for the plan or policy, and current enrollment totals for each plan or coverage option that uses the provider network. In-network rates must be shown as dollar amounts except where contractual percentage-of-billed-charge arrangements prevent assigning a dollar amount in advance.
Allow Aggregated Files for Self-Insured Plans
Under certain agreements, self-insured group health plans could let another party (for example, a service provider) publish a single In-network Rate File and aggregate Allowed Amount Files across multiple self-insured plans, including plans offered by different plan sponsors or across markets. This permits consolidation of disclosures when plans have such agreements.
Less-Frequent File Updates (Quarterly)
The rule would change the reporting cadence for in-network rate files and out-of-network allowed amount files from monthly to quarterly. Prescription drug machine-readable files would remain on a monthly cadence.
Phone Access for Price Estimates
Plans and issuers would be required to make the same cost-sharing estimates and disclosures available by telephone as they provide via internet tools and paper on request. The telephone number must be the same number printed on plan ID cards and providing phone access satisfies the No Surprises Act section 114 price-comparison tool requirement (including for grandfathered plans where that No Surprises Act requirement applies).
Remove Implausible Provider-Rate Pairs
Plans and issuers must exclude any provider-and-rate combination from in-network rate files if, using their internal provider taxonomy, the provider is unlikely to be reimbursed for that item or service given the provider's specialty. This aims to reduce irrelevant or misleading rate entries.
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Key Dates
Department and Agencies
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