Transparency in Coverage Rule

On 11/12/2020, the Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury published the Transparency in Coverage Final Rule (85 FR 72158-01). The first phase of the Transparency in Coverage Rule requires group health plans and health insurance issuers to provide pricing information for covered items and services as follows:

  • In-network provider negotiated rates
  • Historical out-of-network provider allowed amounts

The above pricing information, provided in machine-readable files, is now available to the public and can be used by third parties, such as researchers and application developers, to help a member better understand the costs associated with their healthcare. This is not, however, an estimate of the cost patients will be responsible for paying for such item or service. Coverage of any item or service in the files is subject to the terms, limitations and conditions of the member’s contract. Always check the member’s benefits for coverage information and limitations.

Access the Table of Contents for the Transparency in Coverage Rule machine-readable pricing files.

Note: Group-specific pricing files will be made available effective on a group’s renewal date beginning on and after 7/1/2022. Therefore, groups with renewal dates from 1/1/2022 – 7/1/2022 will be included in the pricing files that are available beginning 7/1/2022.