Managing healthcare costs requires a clear view of what providers charge and what health plans pay. Plan sponsors, insurers and their benefits partners need that information to evaluate spending and question charges that appear excessive. Federal rules already require many plans and insurers to publish healthcare prices, although large files, repeated entries and missing data can make those disclosures difficult to use.
Updates to the Transparency in Coverage (TiC) rules, finalized in October 2026, aim to make those prices easier to find, compare and check.
aequum helps plans, third-party administrators (TPAs) and insurers address questionable medical charges through technology-supported medical bill defense, overpayment recovery and participant advocacy, with legal representation available through Koehler Fitzgerald LLC.
A More Useful View of Medical and Drug Prices
A heart-surgery rate listed for a foot doctor does little to help a plan compare care costs. The new rules remove these “ghost rates” and group network rates by provider network, reducing irrelevant entries and repeated information.
For most network arrangements, readers should see a dollar price. If a contract pays a percentage of the provider’s bill and a dollar amount cannot be determined in advance, the file must show that percentage.
More out-of-network payment information should become available as reporting expands from 90 days of claims to six months. The minimum claim count for disclosing those prices falls from 20 to 11 and results will be grouped by coverage type, including self-funded plans.
Prescription drug disclosures will also show negotiated rates alongside historical net prices, meaning average past payments that account for rebates, discounts and other price adjustments. Drug and pharmacy identifiers connect those amounts to the product, dispenser and service location. The disclosure requirement dates to 2020 but implementation has been delayed.
Context That Helps Interpret the Rates
Three supporting files will make it easier to understand what a listed network rate represents:
• Utilization: Shows whether a provider was paid for at least one claim for a service, without reporting the total number of claims.
• Taxonomy: Explains how a plan uses provider specialties to decide whether to pay for services and exclude unlikely rates.
• Text: Provides direct links to the files and contact information for an individual who can address inquiries and issues related to the files.
The proposed change-log file, which would have tracked changes between publications, was dropped.
Accountability and the Vendor Relationship
The new rules require plans and insurers to formally confirm or attest that specified files meet disclosure requirements and are accurate and complete to the best of their knowledge and belief. A CEO, president or designated senior official must be identified as overseeing the accuracy and completeness of the required pricing and supporting files.
Plans may arrange for insurers and TPAs to prepare files and make attestations under written agreements. Qualifying arrangements also allow shared network and supporting files and consolidated out-of-network files covering multiple self-funded plans.
A vendor may hold the underlying pricing data but a self-funded plan remains responsible for compliance even when its contract provides financial protection. Contracts should spell out access to source data, who checks accuracy, how quickly errors must be corrected and whether the vendor must reimburse the plan for losses caused by its mistakes.
With a qualifying written agreement, a fully insured plan can satisfy these duties through its insurer, which is responsible if it fails to perform. Existing enforcement powers still apply, including penalties where permitted by law, despite the absence of a new penalty schedule.
Getting Ready for the Rollout
The final rules take effect December 7, 2026, with the new requirements rolling out on different applicability and publication schedules beginning in 2027. Supporting-file requirements apply September 6, 2027.
The publication schedule is phased:
• April 1, 2027- Updated network and out-of-network medical pricing files are due, with quarterly updates replacing monthly reporting.
• October 1, 2027- Taxonomy and text files are due. Taxonomy files follow a quarterly schedule. Text files must be updated within seven calendar days when their information changes.
• December 2027- Files using the new prescription drug format are expected, followed by monthly updates.
• July 1, 2028- Post the first utilization file, then update it annually.
Plan sponsors, administrators and brokers should use these dates to confirm who will prepare, review and publish each file.
For plan years beginning on or after January 1, 2027, plans must provide personalized cost-sharing information by phone upon request, alongside existing online and paper options. Members can use this service to understand their expected costs, so administrators should ensure callers receive answers based on their coverage details.
Putting Transparency to Work with aequum
When a pricing comparison raises concerns about a payment, aequum can review the bill, amount paid and relevant plan or provider terms to determine whether recovery is warranted. aequum works with self-funded plans and insurers, while TPAs and cost containment partners can refer claims needing specialized support.
A member who receives an unreasonable balance bill or collection demand needs support, too. aequum advocates for members and dependents and communicates with providers, payers and collection agencies. When legal representation is needed, Koehler Fitzgerald LLC attorneys can assist with negotiation, litigation and appeals.
aequum’s proprietary relational database supports customizable reports on claim status, disputed amounts, settlements, savings and recoveries, helping plans and partners follow each referral and assess its financial outcome.
Contact aequum to discuss a medical bill dispute, potential overpayment or participant concern affecting your plan or clients.