Healthcare Price Transparency: 5 Things Employers and Plan Sponsors Need to Know
Monday, Oct. 5th, 2026, was a significant day for healthcare price transparency.
BenefitsDNA Founder and CEO Justin Leader was one of roughly 100 people invited to Washington, D.C. for the federal government’s announcement of major new healthcare price transparency requirements. He attended alongside EOB Podcast co-host, Executive Director, Legal and Compliance at Judi Group and Founder of Health Plan Legal Counsel Julie Selesnick and many of the individuals who have spent years working on healthcare transparency, employer fiduciary responsibility and healthcare policy.
For those who have been pushing for employers and patients to have meaningful access to healthcare pricing and plan data, it was a unique moment to witness firsthand.
We also want to recognize the tremendous amount of work that has happened behind the scenes. Employers, advisors, attorneys, transparency advocates and other stakeholders have consistently provided input, identified shortcomings in the existing transparency framework and pushed for better access to usable data.
Just as importantly, dedicated policymakers have listened, engaged with stakeholders and worked to turn those concerns into policy. That includes Caitlin Soto, Senior Policy Advisor at the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA), Kevin Lyons at EBSA, and many others who have invested significant time and effort in moving this work forward.
Yesterday provided an opportunity to see years of conversations, advocacy, policy development and collaboration take another tangible step forward.
Here’s what employers and plan sponsors need to know.
1. Transparency in Coverage Is Getting a Major Overhaul
The Departments of Labor, Health and Human Services, and Treasury finalized significant changes to the federal Transparency in Coverage requirements.
The original Transparency in Coverage rules resulted in an unprecedented amount of negotiated healthcare pricing becoming publicly available.
There was just one problem: much of the data was extraordinarily difficult to use.
The new rule is intended to move healthcare transparency beyond simply publishing massive files and toward making the information more standardized, accurate, comparable and actionable.
Among the significant changes:
- Machine-readable files will contain better information identifying networks, products, providers and negotiated rates.
- Certain unnecessary provider/service combinations can be eliminated, reducing the enormous size and complexity of today’s files.
- New utilization information will help identify providers and services that are actually being utilized rather than simply showing every theoretical rate contained within a network.
- Plans and insurers will be required to attest to the accuracy and completeness of applicable machine-readable-file information.
- A senior official will be identified as responsible for overseeing the accuracy and completeness of the information.
- Key reporting will move from monthly to quarterly while becoming more standardized and easier to locate and analyze.
For employers, this has the potential to change the conversation from:
“What discount did our network negotiate?”
to:
“Where are our employees actually receiving care, what are we paying those providers, and how competitive are those negotiated rates?”
That’s a much more meaningful question.
2. The FTC Just Put Hospitals and Healthcare Providers on Notice
At the same time, the Federal Trade Commission issued warning letters to 24 large healthcare-services companies concerning healthcare price transparency.
This development should not be overlooked.
The FTC made clear that compliance with CMS Hospital Price Transparency requirements does not necessarily provide a safe harbor from the FTC Act.
Healthcare pricing information that is inaccurate, incomplete, misleading or untimely could potentially raise concerns under federal prohibitions against unfair or deceptive practices.
In other words, simply posting a file may no longer be the end of the conversation.
The accuracy of the information matters.
3. What Happens When the Numbers Don’t Match?
This could ultimately become one of the most consequential aspects of these developments.
As these datasets become more standardized and usable, employers and their advisors should increasingly be able to compare:
Hospital-reported negotiated prices
↕️
Carrier/TPA-reported negotiated rates
↕️
Actual plan claims experience
Those numbers should tell a consistent story.
When they don’t, we should be asking why.
Is the hospital’s information inaccurate?
Is the carrier or administrator reporting something different?
Did the actual claim adjudicate differently from the negotiated rate represented in the transparency data?
For the first time, we’re beginning to develop the infrastructure necessary to independently validate what different participants in the healthcare system are reporting.
That’s where transparency becomes significantly more powerful.
Transparency → Usable Data → Accuracy → Accountability
4. This Matters to Employer Plan Fiduciaries
Employers have spent years hearing that healthcare pricing information is proprietary, unavailable, difficult to obtain or simply too complicated to meaningfully analyze.
That environment continues to change.
For plan sponsors responsible for overseeing millions of dollars in healthcare spending, better pricing, network, utilization and claims information creates opportunities to evaluate network performance, negotiated rates, provider utilization, vendor performance and ultimately whether plan assets are being spent prudently.
There remains an important unresolved issue, however.
Employers must have meaningful access to their own plan data.
A contract stating that there is “no gag clause” means very little if an employer subsequently requests its data and encounters operational restrictions, delays, excessive fees or outright refusal.
As transparency requirements evolve, the distinction between contractual access to data and actual, functional access to data will become increasingly important.
5. Prescription Drugs and PBMs Are Next
The work isn’t finished.
The next major frontier is prescription drug transparency.
The federal government has indicated that development of the Prescription Drug Machine-Readable File schema is expected to begin in November 2026, with the schema anticipated around May 2027 and publication of prescription drug files beginning in December 2027.
That could eventually provide another critical dataset for employers evaluating prescription drug pricing and PBM arrangements.
Given the complexity surrounding rebates, spread pricing, pharmacy networks, drug acquisition costs, administrative fees and other components of the prescription drug supply chain, this next phase will be particularly important for employer plan sponsors.
The Bigger Picture
Yesterday wasn’t simply about another federal regulation.
It represented another step in a much larger transition:
Transparency → Usable Data → Accuracy → Accountability
For years, employers, patients, advisors, attorneys, policymakers and healthcare transparency advocates have been asking for the ability to understand what healthcare actually costs and where the money goes.
There is still considerable work ahead.
But yesterday was a good day.
We are grateful for the people throughout our community who have relentlessly pushed these issues forward and for the policymakers who have listened, engaged with stakeholders and worked to translate those concerns into policy.
Now comes the important part:
Making sure employers can actually use it.
Read the Primary Sources
Transparency in Coverage Final Rule
https://public-inspection.federalregister.gov/2026-20447.pdf
HHS/CMS Fact Sheet
https://www.hhs.gov/press-room/fact-sheet-cms-finalizes-healthcare-price-transparency-rules.html
FTC Hospital Price Transparency Warning Letter
https://www.ftc.gov/legal-library/browse/warning-letters/warning-letter-template-regarding-hospital-price-transparency
BenefitsDNA will continue analyzing these developments and providing updates as implementation guidance and the upcoming prescription drug transparency requirements are released.
We Fix Your Healthcare®. 🧬