“People should know what their health insurance will cover and what they will need to pay before receiving medical care, not after the bill arrives.” That is how the Centers for Medicare & Medicaid Services described the goal of new Transparency in Coverage rules in an Oct. 5 announcement.
The rules, finalized Oct. 5, require group health plans and health insurance issuers to give members personalized cost-sharing information by phone, in addition to existing online tools. Cost-sharing means the part of a bill the member pays, such as a deductible, copay or coinsurance.
The change reaches anyone with job-based coverage or an individual policy who wants a price before scheduling a test, a surgery or a specialist visit. Under the rules, a member who would rather talk to a person than use a website can call the plan and ask. The question to put to the plan is simple: what will this specific service cost me, given my deductible and what I have already paid this year?
An estimate shows what a plan will pass on, but it does not show whether a benefit program could lower the bill. The Benefits Checklist covers 11 benefit programs and lists the 2026 income limits for them.
Get the 2026 income limits for 11 benefit programs →
When the phone requirement starts
The CMS fact sheet on the final rules says the phone and online cost-sharing requirements apply for “plan years (in the individual market, policy years) beginning on or after Jan. 1, 2027.” For a calendar-year plan, that means the first day of 2027. For a plan whose year starts in July, the requirement arrives with the plan year that begins in July 2027.
The rules themselves take effect 60 days after publication in the Federal Register, according to the fact sheet. Plans get time to build the phone service before the plan-year date arrives.
Online tools already exist
The rules did not invent online cost estimates. CMS describes the phone requirement as an addition to online tools plans already have to offer. The change is for members who do not use the internet, or who want to confirm a figure with a person.
Drug price files and quarterly reporting
The rules do more than add a phone line. According to the HHS announcement, plans will publish Prescription Drug Files starting in December 2027, and the reporting that plans do moves from monthly to quarterly. CMS says plans will publish the files “using this schema starting in December 2027 and monthly thereafter,” with the data format due on or around May 2027.
HHS quoted Secretary Robert F. Kennedy Jr.: “Americans should know what their healthcare will cost before they receive it.” The department also said the top 25 percent of the most expensive healthcare service prices have dropped by 6.3 percent per year.
What the rule costs and saves
The fact sheet estimates a net cost savings to plans and issuers of about $174.5 million a year. That figure is about plans’ costs, not members’ bills. The rules do not promise a lower price on any procedure. They promise a quoted price before it is performed.
The limits of an estimate
A personalized estimate is built from a member’s own plan terms, so it covers the services asked about and can miss anything added during care, such as a second procedure. The rules do not change what a plan pays. They change when members can find out.
Asking a plan for a price before a procedure
Until the phone requirement starts, members can still call the number on the insurance card and ask for member services. For a planned procedure, gather the billing code if the doctor’s office has one, the name of the facility, and the name of every provider involved. Ask the plan for the cost under the member’s plan for each, and write down the date, the representative’s name and the figure quoted.
Then compare that quote with what the plan has applied to the deductible so far this year. A member who is close to the out-of-pocket limit will see a very different number from one who has just started a new plan year. After the procedure, the explanation of benefits from the plan should match the quote, and a gap is worth a call.
The CMS fact sheet is the document to cite when a plan says it is not yet required to offer the service: it sets the first plan year for the phone requirement as one beginning on or after Jan. 1, 2027.
For the phone calls that follow a quote, The Benefits Checklist includes a 50-state phone directory, and a printable tracker comes with the download.
Get the phone directory and printable tracker from The Benefits Checklist →
This article was produced with AI assistance and edited for accuracy against the CMS and HHS pages linked above.
