Transparency in Coverage FAQs

Q1: When will CMS post the Transparency in Coverage PY2025 data reported by issuers?

CMS intends to publish the Transparency in Coverage public use file (PUF) in the months following the completion of the PY2025 QHP certification cycle.

Q2: Does the information required in the URL landing page need to be live at the time issuers submit the Transparency in Coverage Template for PY2025 data submission?

Yes. All Transparency in Coverage URLs must be live and in compliance when the template is submitted and remain active for the entire plan year. Please see specific URL requirements listed in the Transparency in Coverage Instructions on the QHP certification website.

Q3: Does a QHP issuer offering a QHP for the first time in PY2025 need to submit a Transparency in Coverage Template?

Yes. An issuer offering a QHP for the first time in PY2025 is required to submit a template that includes all of the required information on the issuer-level tab and that lists each PY2025 plan ID on the plan-level data tab. Issuers should mark "N/A" on the template for the remaining issuer- and plan-level fields referring to 2023 data as the plan was not offering coverage in PY2023.

Q4: Should both on- and off-Exchange plans be included in the Transparency in Coverage Template?

The Transparency in Coverage Template must include all on-Exchange PY2025 plan IDs that are present in the issuer’s PY2025 QHP Application. Do not include plan IDs for off-Exchange-only QHPs or plans not requiring certification. Issuers that have more than one HIOS Issuer ID in the same state must submit a Transparency in Coverage Template for each unique HIOS Issuer ID. Issuers should only report plan-level claims data for plan IDs that were offered on the Exchange in PY2023 and will be offered again in PY2025 under the exact same plan ID.

Although QHPs must be made available both on and off the Exchange, issuers are only required to report claims data to the Exchange for plans sold through the Exchange.

Q5: What are the Transparency in Coverage data requirements, including those for first year issuers?

All issuers applying for PY2025 QHP certification, including issuers applying for Exchange certification for off-Exchange SADPs, must submit a Transparency in Coverage Template by the QHP Application initial submission deadline of June 12, 2024. CMS does not consider an application for QHP certification to be complete without submission of this template.

The Transparency in Coverage Template must include all on-Exchange PY2025 plan IDs that are present in the PY2025 QHP Application. Issuers that have more than one HIOS Issuer ID in the same state must submit a Transparency in Coverage Template for each unique HIOS Issuer ID.

While the template is a required submission for all PY2025 issuers, issuers should only report numerical claims data for plan IDs that were offered on the Exchange in PY2023 if the same plan ID will be offered again in PY2025.

Specifically, issuers will be required to report completed Transparency in Coverage Templates with numerical claims data for QHPs (including SADPs) sold through the Exchange for dates of service from January 1, 2023 through December 31, 2023.
If the PY2025 plan ID was not offered on the Exchange in PY2023, it should be included in the template, but the issuer should indicate that PY2023 claims data is not applicable for that plan ID. Do not include numerical claims data for plans returning to the Exchange if the plan ID was changed after PY2023.
Issuers that did not participate on the Exchange in PY2023 should complete the template indicating reporting requirements are not applicable.

Although QHPs are generally available both on and off the Exchange, issuers are only required to report claims data for QHP coverage sold on the Exchange. Off-Exchange-only PY2025 plan IDs should not be included in the template. Off-Exchange-only SADPs should complete the template indicating reporting requirements are not applicable.

Q6: For Transparency in Coverage reporting, how does CMS define a "claim"?

CMS defines a claim as any individual live of service within a bill for services received from a provider (both medical and pharmacy). For example, if a medical bill contains 10 lines of service, then it will be counted as 10 claims.

Additional information regarding Transparency in Coverage reporting, including instructions, are available on the QHP Certification website.

Q7: Are State-based Exchange (SBE) issuers required to submit a Transparency in Coverage Template?

While Transparency in Coverage regulatory provisions at 45 CFR 156.220 apply to issuers on all Exchanges, issuers in SBE states using their own IT platform are not required to submit transparency data to CMS at this time.

Current Transparency in Coverage reporting requirements are for issuers applying for QHP certification in Federally-facilitated Exchange (FFE) states, states performing plan management functions, and states with State-based Exchanges on the Federal Platform (SBE-FPs). Issuers in states that are in the process of transitioning to SBEs should submit to CMS the transparency data reporting along with all other certification documents in the event that the transition does not happen as scheduled.

This reporting requirement includes all QHPs, including stand-alone dental plans (SADPs) and Small Business Health Options Program (SHOP) QHPs.

Q8: Should issuers report data for plans returning to the Exchange in PY2025 if the plan ID has changed?

Issuers should only report data for a plan ID on the Plan Level tab of the Transparency in Coverage Template when the plan is returning to the Exchange from the year before the prior plan year with the exact same plan ID. For example:

A plan from PY2023 is returning to the Exchange in PY2025, but with a different plan ID. For this plan, the issuer will input "N/A" in all the plan level data fields corresponding to the new PY2025 plan ID.
A plan from PY2023 is returning to the Exchange in PY2025 with the exact same plan ID. For this plan, the issuer will input numerical claims data in all the plan level data fields corresponding to the plan and plan ID combination that is exactly the same between PY2023 and PY2025.