On May 22, 2025, the DOL, HHS, and Treasury announced important initiatives to enhance and enforce existing healthcare price transparency requirements, particularly with respect to prescription drugs. The release follows President Trump’s February 25, 2025, executive order 14221, which called for rapid action to improve and fully implement health plan and hospital price transparency rules.
Employers – as group health plan sponsors – should be aware of these developments, which may bring additional compliance obligations but are ultimately designed to provide access to healthcare pricing data needed to properly fulfill their fiduciary duties.
Background
The executive order and announcement focus on enforcement of the Transparency in Coverage final rule (TiC final rule) and the Hospital Price Transparency final rule (HPT final rule), which require, among other items, the public disclosure of healthcare prices in machine-readable files (MRFs).
Specifically, the TiC final rule requires non-grandfathered group health plans and insurers to publicly post MRFs monthly with the following information:
- Negotiated rates for in-network (INN) covered items and services.
- Historical out-of-network (OON) allowed amounts and billed charges.
- Prescription drug negotiated rates and historical net prices.
Group health plans and insurers were required to comply with the INN and OON MRF posting requirements beginning in July 2022. However, the departments initially deferred enforcement of the prescription drug MRF posting requirement, in part due to litigation seeking to block its enforcement. The departments rescinded the deferred enforcement policy in September 2023, but did not issue guidance to implement the prescription drug MRF posting requirement.
The HPT final rule requires hospitals to publicly post standard charges, including gross charges, cash prices, payer-specific negotiated rates, and minimum negotiated charges, in an easy-to-understand format for shoppable services.
Both the TiC and HPT final rules are aimed at creating a more competitive healthcare pricing market by providing access to clear, accurate, and actionable pricing data. However, the lack of full enforcement of the TiC and HPT final rule requirements has resulted in the posting of incomplete and inconsistent medical data and limited prescription drug data, thus thwarting efforts to fully achieve the rules’ objectives.
Departments’ New Actions
Against this background, the departments’ newly announced efforts are primarily targeted at advancing prescription drug disclosures and overcoming deficiencies in the current reporting of healthcare pricing data by plans, insurers, and hospitals.
Request for Information on Prescription Drug Disclosures
Most significantly for plan sponsors, in this newest round of guidance, the departments issued a Request for Information (RFI) seeking public comments to inform future rulemaking or guidance regarding the implementation of the TiC final rule prescription drug disclosure requirement, including any changes or additional technical guidance necessary to ensure accurate and timely disclosures. As enacted in 2020, the TiC final rule requires plans and insurers to publicly post MRFs with the negotiated rates and historical net prices (both reflected as dollar amounts) for each covered prescription drug item or service. Notably, the historical net prices must consider rebates, discounts, dispensing fees, administrative fees, and other price concessions.
In the RFI, the departments specifically request feedback related to the required data elements for the prescription drug disclosures, including whether additional or alternative data elements should be required. Among other questions, the RFI inquires as to whether the data would be more useful if reported in a different form or manner or streamlined to reduce redundancies, how remuneration details (e.g., pre-rebate and post-rebate pricing and bundled arrangements) should be disclosed, and whether plans should be required to identify their pharmacy networks, PBMs, and other service providers. The RFI also requests comments regarding general implementation concerns, such as the timeline, operational, formatting, or technical considerations, and challenges and advantages that may result if prescription drug disclosures were required to be delivered in other than MRF format.
ACA FAQs Part 70
Simultaneously, the departments issued FAQs regarding upcoming improvements to the technical data formats for MRFs known as “schemas,” which are intended to reduce file sizes, eliminate redundancies, and better contextualize the data to make it more meaningful. Since most plan sponsors arrange with carriers, TPAs, and other service providers to create the MRFS, these parties will need to prepare to comply with the new schema version by February 2, 2026.
HPT Final Rule Guidance and RFI
Separately, CMS, an agency of HHS, released guidance to strengthen the HPT final rule by requiring hospitals to post actual prices of items and services, not estimates. CMS also issued its own RFI to solicit public comments on how to increase hospital compliance and enforcement to ensure data shared is accurate and complete. Although the HPT final rule does not impose any direct compliance obligations on plans, the data disclosed by hospitals is used in price transparency tools. The tools are then used by plan sponsors to assess their negotiated prices for hospital services.
Employer Takeaway
Clearly, improving healthcare price transparency and lowering prescription drug prices are top priorities for the Trump administration. Employers, in their role as plan sponsors, should take note of the departments’ recent announcements and RFI to implement the TiC final rule prescription drug disclosure requirement.
Although it is expected that comments will largely be submitted by carriers, TPAs, data analytics firms, and other industry stakeholders more directly involved with preparing or using the prescription drug data files, employers wishing to submit comments, whether directly or through an active industry association, may do so in accordance with the RFI instructions. It’s unclear at this time how the parties who originally sought to block enforcement of aspects of the prescription drug MRF posting requirement will react to the RFI, although it is likely they will submit robust comments, and then determine whether they will refile their cases based on the departments’ resulting actions.
In any event, employers should be aware of these developments and anticipate the possible issuance of new rules or guidance from the departments, which may include a prescription drug MRF posting implementation date. Therefore, employers may want to consult with their carriers, TPAs, PBMs, and other service providers to ensure they will timely prepare and post complete and accurate prescription drug information for the employer’s plans, once required.
As a reminder, a fully insured plan can contract with the carrier to fulfill the TiC final rule MRF requirements on the plan’s behalf and assume any related liabilities; a self-insured plan can contract with a TPA or other service provider to assist with the MRF requirements, but the plan remains ultimately responsible for the disclosures.
Moreover, employers should recognize that the TiC and HPT final rules are ultimately intended to help them fulfill their ERISA plan fiduciary obligations to prudently administer their plans and plan assets, select and monitor service providers, and verify their service providers’ compensation is reasonable. Historically, the lack of transparency in healthcare pricing has made it difficult for plan sponsors to obtain accurate information about healthcare costs to make informed decisions about plan benefits. The public disclosure of healthcare pricing mandated by the TiC and HPT final rules allows data analytics experts to compile, consolidate, and present this data in a way that allows plan sponsors to make meaningful comparisons between different coverage options and providers.
Price comparison tools are now available to help plan fiduciaries manage costs and reduce risks, and greater enforcement of transparency laws will only enhance these tools’ capabilities. For further details, please ask your broker or consultant for a copy of our publication ERISA Fiduciary Governance: A Guide for Employers and for information on available price comparison tools.
We will be monitoring this topic closely and will report relevant updates in future editions of Compliance Corner.