Price transparency has long been a federal policy priority but most of the policymaking has been focused on hospitals, not payers. That changed last week, when the Department of Health and Human Services (HHS) finalized its Transparency in Coverage (TiC) rule updating requirements for insurers and group health plans. On the same day, the Federal Trade Commission (FTC) sent warning letters to health systems reminding them to comply with the current federal price transparency requirements and warning them that failure to provide comprehensive pricing information (e.g., omitting certain physician fees or facility fees) could also constitute a deceptive practice under Section 5 of the FTC Act – increasing hospital liability for the price transparency requirements.    

Price Transparency in Coverage Rule Finalized 

The TiC rule governs how non-grandfathered health plans provide rate data. The goal of the rule is to make the data shared by payers similar to the one provided by hospitals, making it more comparable. This can make discrepancies between hospital and payor disclosures easier to identify for CMS. The finalized changes to the TiC rule include:  

  • Moving to one in-network rate file for insurer data, hoping this will reduce duplication; 
  • Requiring the removal of “ghost rates,” which are rates for services the provider is unlikely to furnish;  
  • Reducing reporting frequency from monthly to quarterly; 
  • Requiring payors to disclose the in-network rate file for each provider network instead of the in-network rate file for each plan or policy offered by the payor; 
  • Requiring insurers to attest to the accuracy of the data and identify a responsible senior official. 
  • Like hospitals, requiring plans and issuers to add a link in the footer of their website titled “Price Transparency” or “Transparency in Coverage.” 
  • For the first time, requiring payers to offer personalized pricing information by phone, in addition to online and on paper. 

The final rule takes effect December 7, 2026, with phased in adoption throughout early 2027. Hospitals are already required to provide machine-readable files and consumer-facing, shoppable service information to patients.  

FTC issues Transparency Warnings to Hospital Systems 

The FTC sent warning letters to more than 20 large hospital systems in regard to CMS’ price transparency requirements. Although the Agency did not publicly release which systems have received warnings or accused the systems of violating the law, they did share the practices that could be viewed as deceptive:  

  • Incomplete Price Estimates: Disclosures that only provide part of the expected cost or cover only a portion of the anticipated service, since patients might incorrectly assume the quoted amount is their total cost. 
  • Relevant Fees Omitted: Quoted prices that do not include physician charges or facility fees that patients can “reasonably expect” as a part of their care. 
  • Inaccurate Pricing Information: Prices that are provided but are inaccurate enough to be misleading under the FTC Act. 
  • Untimely Data: Prices that are provided too late to be useful for comparison shopping for routine, nonemergency healthcare.

The FTC emphasizes that CMS’ requirements provide a baseline but should not be taken as a “safe harbor” from Section 5 of the FTC Act. This means that meeting CMS’ checklist might not necessarily be enough when the Agency believes consumer-facing pricing is incomplete, inaccurate or potentially misleading. This poses a challenge – the regulations requiring payers to share an Advanced Explanation of Benefits with patients and providers have not yet been implemented by CMS. This means that hospitals don’t have a seamless, electronic way to access a patient’s health coverage information and develop comprehensive price estimates. Until those regulations are implemented, price estimates only capture one piece of the pie – with payers holding the rest of the information (e.g., coverage limits and deductibles) that impact pricing.

Topics: CMS, Payment Policy: Price Transparency