Transparency in Coverage

Under section 1311(e)(3) of the Patient Protection and Affordable Care Act, as implemented by regulations at 45 CFR 155.1040(a) and 156.220, health insurance issuers seeking certification of a health plan as a QHP must make accurate and timely disclosures of certain information to the appropriate Health Insurance Marketplace (also known as Exchange), the Secretary of HHS, and the state insurance commissioner, and make it available to the public. Section 2715A of the PHS Act, as added by the Patient Protection and Affordable Care Act, extends the transparency reporting provisions under section 1311(e)(3) to non-grandfathered group health plans and health insurance issuers offering group or individual coverage, except that a plan or coverage not offered through an Exchange shall only be required to submit such information to the Secretary of HHS and state insurance commissioner, and make the information public.

Key Changes for PY2025:
  • No changes for the 2025 QHP Application.
Tips for the Transparency in Coverage Section

  • Issuers applying to offer on-Exchange plans for PY2025 that did not offer on-Exchange plans in PY2023 must still submit a Transparency in Coverage Template. 
  • Issuer level data for returning issuers must be non-numeric for in- and out-of-network claims received and denied but can be zero for issuer level in- and out-of-network claims appealed and resubmitted.
  • Do not include off-Exchange–only plans in the Plan Level tab of the Transparency in Coverage Template.
  • Required data elements are identified by an asterisk (*) next to the field name. 
  • Complete a separate template for each unique HIOS Issuer ID.
  • Use only the tabs provided in the Transparency in Coverage Template. Do not add additional tabs, rows, or columns. 
  • Enter all on-Exchange plan level data in the Plan Level Data tab. One plan ID should be captured in each row. Each plan ID listed should be a distinct 14-character ID. 
  • Check the templates for completeness and data validity before submitting by clicking Validate on the Issuer Level Data tab. 
  • For issuers that submit via the System for Electronic Rates & Forms Filing (SERFF), one identical Transparency in Coverage Template containing all plan IDs should be submitted in each submission binder. For example, if an issuer submits an Individual Market binder and a SHOP Market binder, both the Individual Market plan IDs and the SHOP Market plan IDs should be included in one Transparency in Coverage Template and submitted in each binder. Note that this is different from the process used for other templates submitted as part of the QHP Application and certification process, wherein each binder should include a unique template.
Application Resources