Overview

In 2019, the Centers for Medicare and Medicaid Services (CMS) introduced price transparency requirements for hospitals. The price transparency landscape as we know it today began on 1/1/2021, when hospitals were first required to publish machine-readable files (MRFs) containing (among other required fields) five types of standard charges: gross charge, discounted cash price, payer-specific negotiated charge, de-identified minimum negotiated charge, and de-identified maximum negotiated charge.

As of 1/1/2024, CMS strengthened access requirements: hospitals must make the MRF easy to find via a “Price Transparency” footer link on the hospital website, and CMS also added a requirement to support automated access via a standardized text file in the website root folder.

CMS also moved toward greater standardization of MRF structure by requiring hospitals (as of 7/1/2024) to encode data using the CMS template—first for a subset of required data elements by 7/1/2024, and then for all required data elements by 1/1/2025. CMS began maintaining templates and full specifications (including required columns and definitions) in its public GitHub documentation.

Beginning 1/1/2025, one notable addition was the requirement to calculate an Estimated Allowed Amount for payer-specific negotiated charges that are not a fixed dollar amount (for example, percentage-based or algorithmic rates).

Effective 1/1/2026 (with enforcement beginning 4/1/2026), CMS replaced the Estimated Allowed Amount with Percentile Allowed Amounts: hospitals must instead report the 10th percentile, median, and 90th percentile allowed amounts, plus a count of allowed amounts, using historical remittance-derived allowed amounts. Additional changes include a modification to the affirmation statement, the inclusion of NPIs in the file, and a requirement to include the name of a hospital official designated to oversee file compliation. A more detailed summary of the changes can be found on the CMS GitHub page here

This repository contains documentation of Turquoise's understanding of and approach to MRF generation. Although CMS has been actively responding to clarifying questions on github, a number of nuanced rate types and contract provisions remain open to interpretation. By publishing our rationale and decision-making processes, we hope to encourage further clarification around murky requirements to ensure all hospitals have a comprehensive tool kit to achieve full compliance.

External Resources

CMS Hospital Price Transparency Resources

2020 Hospital Final Rule - full text

2024 Hospital Price Transparency Final Rule - full text

2026 Hospital Price Transparency Final Rule - full text

CMS Hospital Price Transparency github

Turquoise Health TQU Hospital Price Transparency Hub

Questions? Reach out to the Turquoise team!