CMS is arguing for important updates to its Price Transparency rules.
See:
- News at Fierce Healthcare here.
- CMS press release here.
- CMS FAQ here.
- CMS proposed rule here.
- See paginated Fed Reg version Dec 23.
- The work follows Executive Order 14221, “Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information.” (2-25-2025)
Below is a blog-ready review of the Transparency in Coverage Proposed Rule (CMS-9882-P), written with your policy-savvy readership in mind. I focus first on what the actual proposed rule does, then compare it with the press-release framing, and finally flag notable provisions that are largely absent or understated in the press messaging.
CMS Proposes Major Reset of Payer Price Transparency Rules (CMS-9882-P): What Actually Changes
On December 19, 2025, CMS, jointly with DOL and Treasury, released a sweeping proposed update to the 2020 Transparency in Coverage (TiC) rules. While publicly framed as a “burden-reducing” cleanup, the proposed rule is more accurately described as a structural redesign of how payer price data must be generated, organized, contextualized, and consumed .
The core policy diagnosis is blunt: TiC succeeded in forcing disclosure, but failed in usability. CMS identifies three systemic problems—file size, ambiguity, and misalignment with hospital price transparency—and the proposal is aimed squarely at fixing those defects.
1. From “Plan-Level” to “Network-Level” In-Network Rate Files
Perhaps the most consequential change is the requirement that In-Network Rate Files be reported at the provider-network level, not separately for each plan or product. CMS recognizes that dozens (or hundreds) of plans often share identical networks and rates, and current plan-level reporting is massively duplicative.
Why it matters:
This is a fundamental data-model shift, not a formatting tweak. It aligns payer disclosures with hospital price transparency conventions and implicitly treats provider networks—not plans—as the economic unit of price formation.
2. Mandatory Exclusion of “Unlikely Provider–Service” Combinations
Plans would be required to strip out negotiated rates for services a provider would never realistically perform, using the plan’s internal provider taxonomy already used for claims adjudication.
CMS goes further and requires public disclosure of:
The taxonomy mapping file itself
A Utilization File listing providers who actually billed for services over a defined lookback period
A Change-Log File showing what changed quarter-to-quarter
Why it matters:
This quietly moves TiC from a “dump everything” regime to a curated, defensible dataset—and exposes plans’ internal logic for determining who is paid for what.
3. Substantially More Out-of-Network (OON) Data
CMS explicitly acknowledges that Allowed Amount Files have been nearly useless due to the 20-claim threshold and short lookback window. The proposal would:
Aggregate OON data by insurance market type (large group, small group, individual, self-insured)
Lower the threshold from 20 to 11 claims
Extend the reporting window from 90 days to 6 months, with a 9-month lookback
Why it matters:
This is not cosmetic. CMS expects materially more OON pricing data to enter the public domain, enabling analysis of balance-billing exposure and market-type pricing behavior.
4. Quarterly (Not Monthly) Reporting
CMS proposes to move In-Network and Allowed Amount files from monthly to quarterly updates, while keeping prescription drug files monthly.
Why it matters:
This is framed as burden reduction, but it also implicitly acknowledges that rates are sticky, and that analytic value does not increase with frenetic refresh cycles.
5. New Contextual Data Elements
Each file would newly include:
Product type (HMO, PPO, etc.)
Enrollment counts
Common network names
This is CMS conceding that raw prices without context are analytically misleading.
6. “Findability” Requirements
Plans must post:
A plain-text (.txt) file in the website root identifying file locations and contacts
A standardized “Price Transparency” footer link on the homepage
This mirrors hospital transparency enforcement and is clearly designed to support automated crawling and third-party analytics.
7. Single File Format Under Consideration
CMS explicitly floats the idea of mandating a single file format (JSON or CSV) via future technical guidance.
Why it matters:
This is a signal that CMS sees standardization—not flexibility—as the next phase of transparency policy.
8. Phone-Based Price Transparency (No Surprises Act Alignment)
Plans would be required to provide the same price-comparison information by phone as online or in print, and CMS explicitly states that satisfying this requirement also satisfies No Surprises Act §114.
Why it matters:
This quietly expands operational obligations and training costs—and pulls grandfathered plans into certain disclosure duties.
How the Press Release Frames It (and What It Downplays)
The CMS press release emphasizes:
Smaller files
Easier consumer use
Empowerment and competition
Burden reduction
Alignment with Trump-era transparency goals
All accurate—but selectively so .
What’s Missing or Underplayed in the Press Messaging
Here are important features in the rule that are largely absent or muted in the press release:
Disclosure of Internal Provider Taxonomy Logic
The rule requires plans to expose how they internally decide which providers can be paid for which services.
- This is new transparency into payer decision-making, not just prices.
Utilization Files as a De-Facto Validation Layer
The Utilization File requirement effectively creates a ground-truth layer against negotiated rates—something the press release barely mentions, despite its analytical importance.Magnitude of New Compliance Costs
The regulatory impact analysis estimates over $900 million in one-time compliance costs, driven largely by Utilization Files and Change-Logs—numbers absent from public messaging .Shift Toward Machine-First, Not Consumer-First, Transparency
Despite consumer-friendly rhetoric, the rule is optimized for developers, researchers, employers, and enforcement, not casual patient shopping.
- May serve as input for AI, other advanced data analyses.
Quiet Expansion of Federal Authority via No Surprises Act Crosswalk
CMS explicitly states that satisfying TiC phone-based disclosure requirements satisfies NSA obligations—even for some grandfathered plans. This is a regulatory consolidation move not highlighted publicly.
Bottom Line for Policy Watchers
This proposed rule is not just a cleanup. It represents CMS’s tacit admission that first-generation transparency failed at usability, and that the second generation will be more structured, more enforceable, and more analytable—even if that means exposing payer logic and imposing nontrivial new compliance costs.
For data users, this is a clear win.
For plans and TPAs, it is a quiet but significant operational escalation.
For CMS, it signals a pivot from “disclosure as ideology” to disclosure as infrastructure.
Comment deadline: February 21, 2026.
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I work in clinical genomics, how do I summarize in 30 seconds for my boss?
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Two bullets for your lab industry boss (executive-level)
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CMS is hardening price-transparency data into infrastructure, not optics.
The TiC rewrite forces payers to publish cleaner, contextualized, machine-usable datasets (networks, utilization, enrollment), signaling that CMS increasingly expects pricing data to support analytics, benchmarking, and enforcement—not just consumer browsing. -
This strengthens payer leverage and normalization pressure—eventually affecting advanced diagnostics pricing.
Better out-of-network and network-level data improves payer ability to benchmark negotiated rates and utilization patterns, which over time increases pressure toward price rationalization even in complex service categories.
Why this matters (if your boss asks “so what?”)
1. It’s upstream of molecular pricing, not adjacent to it
The rule doesn’t touch labs directly—but it improves payer visibility into how prices behave across markets and networks. Once that infrastructure exists, it becomes easier for CMS and commercial payers to ask uncomfortable questions later about:
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why certain services sit outside norms,
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why OON utilization persists,
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why network participation differs by market type.
That matters for molecular labs because complexity has historically protected pricing. CMS is slowly dismantling opacity as a structural defense.
2. It aligns with CMS’s broader “data-first” regulatory arc
This rule fits the same pattern you see in:
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Hospital Price Transparency enforcement tightening
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No Surprises Act operationalization
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CMS interest in AI/analytics using administrative data
For diagnostics companies, the takeaway isn’t “price transparency is coming for us tomorrow,” but rather:
CMS is building the data rails first; policy follows later.
3. It subtly favors scale and sophistication
Smaller plans and TPAs will struggle more with utilization files, taxonomy logic, and change logs. Large payers and integrated systems will adapt faster—and those are the same actors that increasingly shape lab network inclusion and reimbursement terms.
What I would not overstate
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❌ No immediate impact on CPT pricing, PLA rates, or MolDx
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❌ No new disclosure requirements for labs
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❌ No short-term revenue effect
This is strategic weather, not tactical risk.
Draft comment-letter themes for payers, employers, or analytics firms
Compare this rule to hospital price transparency enforcement trajectories
Analyze implications for AI-driven price comparison tools and data licensing
