Transparency in Coverage: A 5-Minute Briefing for Benefits Leaders

What Is the Transparency in Coverage Rule?

The Transparency in Coverage (TiC) rule, finalized in 2020 and phased into effect from 2022 onward, requires group health plans and health insurance issuers in the individual and group markets to publicly disclose pricing information that was previously confidential.

Who Does It Apply To?

• Payers (health insurers and TPAs): Must publish machine-readable files containing all negotiated rates with in-network providers and all allowed amounts paid to out-of-network providers.
• Self-insured employer plans: Subject to TiC requirements through their insurance carrier or TPA.
• Hospitals (separate rule): Subject to the Hospital Price Transparency rule, which has different requirements and enforcement.

What Data Is Now Public?

Under TiC, payers must publish:

1. In-Network Rate Files: Negotiated rates for every item and service with every in-network provider, organized by billing code (CPT, DRG, etc.)
2. Allowed Amount Files: Historical out-of-network allowed amounts, allowing market comparisons
3. Consumer Cost-Sharing Tool: An online tool allowing members to estimate their cost-sharing for specific services before receiving care

Why Does It Matter?

For the first time, the healthcare market has access to actual negotiated rates — not list prices, not estimates. This enables:

• Employers to audit whether their TPA rates are competitive with the market
• Health tech companies to build consumer-facing price comparison tools
• Providers to benchmark their contracted rates against competitors
• Researchers and policymakers to analyze pricing patterns at population scale

The Catch

The raw data is extraordinarily complex — hundreds of payers publishing enormous volumes of data monthly in inconsistently structured files. Turning TiC data into actionable intelligence requires specialized infrastructure that most organizations don’t have. That’s the problem SumHealth was built to solve.