[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 410 Introduced in House (IH)]
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118th CONGRESS
1st Session
H. R. 410
To amend the Public Health Service Act to provide for hospital and
insurer price transparency.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
January 20, 2023
Mr. Davidson introduced the following bill; which was referred to the
Committee on Energy and Commerce
_______________________________________________________________________
A BILL
To amend the Public Health Service Act to provide for hospital and
insurer price transparency.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Health Care Prices Revealed and
Information to Consumers Explained Transparency Act'' or the ``Health
Care PRICE Transparency Act''.
SEC. 2. PRICE TRANSPARENCY REQUIREMENTS.
(a) Hospitals.--Section 2718(e) of the Public Health Service Act
(42 U.S.C. 300gg-18(e)) is amended--
(1) by striking ``Each hospital'' and inserting the
following:
``(1) In general.--Each hospital'';
(2) by inserting ``, in plain language without subscription
and free of charge, in a consumer-friendly, machine-readable
format,'' after ``a list''; and
(3) by adding at the end the following: ``Each hospital
shall include in its list of standard charges, along with such
additional information as the Secretary may require with
respect to such charges for purposes of promoting public
awareness of hospital pricing in advance of receiving a
hospital item or service, as applicable, the following:
``(A) A description of each item or service
provided by the hospital.
``(B) The gross charge.
``(C) Any payer-specific negotiated charge clearly
associated with the name of the third party payer and
plan.
``(D) The de-identified minimum negotiated charge.
``(E) The de-identified maximum negotiated charge.
``(F) The discounted cash price.
``(G) Any code used by the hospital for purposes of
accounting or billing, including Current Procedural
Terminology (CPT) code, the Healthcare Common Procedure
Coding System (HCPCS) code, the Diagnosis Related Group
(DRG), the National Drug Code (NDC), or other common
payer identifier.
``(2) Delivery methods and use.--
``(A) In general.--Each hospital shall make public
the standard charges described in paragraph (1) for as
many of the 70 Centers for Medicaid & Medicare
Services-specified shoppable services that are provided
by the hospital, and as many additional hospital-
selected shoppable services as may be necessary for a
combined total of at least 300 shoppable services,
including the rate at which a hospital provides and
bills for that shoppable service. If a hospital does
not provide 300 shoppable services in accordance with
the previous sentence, the hospital shall make public
the information specified under paragraph (1) for as
many shoppable services as it provides.
``(B) Determination by cms.--A hospital shall be
deemed by the Centers for Medicare & Medicaid Services
to meet the requirements of subparagraph (A) if the
hospital maintains an internet-based price estimator
tool that meets the following requirements:
``(i) The tool provides estimates for as
many of the 70 specified shoppable services
that are provided by the hospital, and as many
additional hospital-selected shoppable services
as may be necessary for a combined total of at
least 300 shoppable services.
``(ii) The tool allows health care
consumers to, at the time they use the tool,
obtain an estimate of the amount they will be
obligated to pay the hospital for the shoppable
service.
``(iii) The tool is prominently displayed
on the hospital's website and easily accessible
to the public, without subscription, fee, or
having to submit personal identifying
information (PII), and searchable by service
description, billing code, and payer.
``(3) Definitions.--Notwithstanding any other provision of
law, for the purpose of paragraphs (1) and (2):
``(A) De-identified maximum negotiated charge.--The
term `de-identified maximum negotiated charge' means
the highest charge that a hospital has negotiated with
all third party payers for an item or service.
``(B) De-identified minimum negotiated charge.--The
term `de-identified minimum negotiated charge' means
the lowest charge that a hospital has negotiated with
all third party payers for an item or service.
``(C) Discounted cash price.--The term `discounted
cash price' means the charge that applies to an
individual who pays cash, or cash equivalent, for a
hospital item or service. Hospitals that do not offer
self-pay discounts may display the hospital's
undiscounted gross charges as found in the hospital
chargemaster.
``(D) Gross charge.--The term `gross charge' means
the charge for an individual item or service that is
reflected on a hospital's chargemaster, absent any
discounts.
``(E) Payer-specific negotiated charge.--The term
`payer-specific negotiated charge' means the charge
that a hospital has negotiated with a third party payer
for an item or service.
``(F) Shoppable service.--The term `shoppable
service' means a service that can be scheduled by a
health care consumer in advance.
``(G) Standard charges.--The term `standard
charges' means the regular rate established by the
hospital for an item or service, including both
individual items and services and service packages,
provided to a specific group of paying patients,
including the gross charge, the payer-specific
negotiated charge, the discounted cash price, the de-
identified minimum negotiated charge, the de-identified
maximum negotiated charge, and other rates determined
by the Secretary.
``(H) Third party payer.--The term `third party
payer' means an entity that is, by statute, contract,
or agreement, legally responsible for payment of a
claim for a health care item or service.
``(4) Enforcement.--In addition to any other enforcement
actions or penalties that may apply under subsection (b)(3) or
another provision of law, a hospital that fails to provide the
information required by this subsection and has not completed a
corrective action plan to comply with the requirements of such
subsection shall be subject to a civil monetary penalty of an
amount not to exceed $300 per day that the violation is ongoing
as determined by the Secretary. Such penalty shall be imposed
and collected in the same manner as civil money penalties under
subsection (a) of section 1128A of the Social Security Act are
imposed and collected.''.
(b) Transparency in Coverage.--Section 1311(e)(3) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18031(e)(3)) is amended--
(1) in subparagraph (A)--
(A) by redesignating clause (ix) as clause (xii);
and
(B) by inserting after clause (viii), the
following:
``(ix) In-network provider rates for
covered items and services.
``(x) Out-of-network allowed amounts and
billed charges for covered items and services.
``(xi) Negotiated rates and historical net
prices for covered prescription drugs.'';
(2) in subparagraph (B)--
(A) in the heading, by striking ``use'' and
inserting ``delivery methods and use'';
(B) by inserting ``and subparagraph (C)'' after
``subparagraph (A)'';
(C) by inserting ``, as applicable,'' after
``English proficiency''; and
(D) by inserting after the second sentence, the
following: ``The Secretary shall establish standards
for the methods and formats for disclosing information
to individuals. At a minimum, these standards shall
include the following:
``(i) An internet-based self-service tool
to provide information to an individual in
plain language, without subscription and free
of charge, in a machine readable format,
through a self-service tool on an internet
website that provides real-time responses based
on cost-sharing information that is accurate at
the time of the request that allows, at a
minimum, users to--
``(I) search for cost-sharing
information for a covered item or
service provided by a specific in-
network provider or by all in-network
providers;
``(II) search for an out-of-network
allowed amount, percentage of billed
charges, or other rate that provides a
reasonably accurate estimate of the
amount an insurer will pay for a
covered item or service provided by
out-of-network providers; and
``(III) refine and reorder search
results based on geographic proximity
of in-network providers, and the amount
of the individual's cost-sharing
liability for the covered item or
service, to the extent the search for
cost-sharing information for covered
items or services returns multiple
results.
``(ii) In paper form at the request of the
individual that includes no fewer than 20
providers per request with respect to which
cost-sharing information for covered items and
services is provided, and discloses the
applicable provider per-request limit to the
individual, mailed to the individual not later
than 2 business days after receiving an
individual's request.'';
(3) in subparagraph (C)--
(A) in the first sentence--
(i) by striking ``The Exchange'' and
inserting the following:
``(i) In general.--The Exchange'';
(ii) by inserting ``or out-of-network
provider'' after ``item or service by a
participating provider''; and
(iii) by inserting before the period the
following: ``the following information:
``(i) An estimate of an individual's cost-
sharing liability for a requested covered item
or service furnished by a provider, which shall
reflect any cost-sharing reductions the
individual would receive.
``(ii) A description of the accumulated
amounts.
``(iii) The in-network rate, including
negotiated rates and underlying fee schedule
rates.
``(iv) The out-of-network allowed amount or
any other rate that provides a more accurate
estimate of an amount an issuer will pay,
including the percent reimbursed by insurers to
out-of-network providers, for the requested
covered item or service furnished by an out-of-
network provider.
``(v) A list of the items and services
included in bundled payment arrangements for
which cost-sharing information is being
disclosed.
``(vi) A notification that coverage of a
specific item or service is subject to a
prerequisite, if applicable.
``(vii) A notice that includes the
following information:
``(I) A statement that out-of-
network providers may bill individuals
for the difference, including the
balance billing, between a provider's
billed charges and the sum of the
amount collected from the insurer in
the form of a copayment or coinsurance
amount and the cost-sharing
information.
``(II) A statement that the actual
charges for an individual's covered
item or service may be different from
an estimate of cost-sharing liability
depending on the actual items or
services the individual receives at the
point of care.
``(III) A statement that the
estimate of cost-sharing liability for
a covered item or service is not a
guarantee that benefits will be
provided for that item or service.
``(IV) A statement disclosing
whether the plan counts copayment
assistance and other third-party
payments in the calculation of the
individual's deductible and out-of-
pocket maximum.
``(V) For items and services that
are recommended preventive services
under section 2713 of the Public Health
Service Act, a statement that an in-
network item or service may not be
subject to cost-sharing if it is billed
as a preventive service in the insurer
cannot determine whether the request is
for a preventive or non-preventive item
or service.
``(VI) Any additional information,
including other disclaimers, that the
insurer determines is appropriate,
provided the additional information
does not conflict with the information
required to be provided by this
subsection.'';
(B) by striking the second sentence; and
(C) by adding at the end the following:
``(ii) Definitions.--Notwithstanding any
other provision of law, for the purpose of this
subparagraph and subparagraphs (A) and (B):
``(I) Accumulated amounts.--The
term `accumulated amounts' means the
amount of financial responsibility an
individual has incurred at the time a
request for cost-sharing information is
made, with respect to a deductible or
out-of-pocket limit, including any
expense that counts toward a deductible
or out-of-pocket limit, but exclude any
expense that does not count toward a
deductible or out-of-pocket limit. To
the extent an insurer imposes a
cumulative treatment limitation on a
particular covered item or service
independent of individual medical
necessity determinations, the amount
that has accrued toward the limit on
the item or service.
``(II) Historical net price.--The
term `historical net price' means the
retrospective average amount an insurer
paid for a prescription drug, inclusive
of any reasonably allocated rebates,
discounts, chargebacks, fees, and any
additional price concessions received
by the insurer with respect to the
prescription drug. The allocation shall
be determined by dollar value for non-
product specific and product-specific
rebates, discounts, chargebacks, fees,
and other price concessions to the
extent that the total amount of any
such price concession is known to the
insurer at the time of publication of
the historical net price.
``(III) Negotiated rate.--The term
`negotiated rate' means the amount a
plan or issuer has contractually agreed
to pay for a covered item or service,
whether directly or indirectly through
a third party administrator or pharmacy
benefit manager, to an in-network
provider, including an in-network
pharmacy or other prescription drug
dispenser, for covered items or
services.
``(IV) Out-of-network allowed
amount.--The term `out-of-network
allowed amount' means the maximum
amount an insurer will pay for a
covered item or service furnished by an
out-of-network provider.
``(V) Out-of-network limit.--The
term `out-of-network limit' means the
maximum amount that an individual is
required to pay during a coverage
period for his or her share of the
costs of covered items and services
under his or her plan or coverage,
including for self-only and other than
self-only coverage, as applicable.
``(VI) Underlying fee schedule
rates.--The term `underlying fee
schedule rates' means the rate for an
item or service that a plan or issuer
uses to determine a participant's,
beneficiary's, or enrollee's cost-
sharing liability from a particular
provider or providers, when the rate is
different from the negotiated rate.'';
(4) in subparagraph (D), by striking ``subparagraph (A)''
and inserting ``subparagraphs (A), (B), and (C)''; and
(5) by adding at the end the following:
``(F) Application of paragraph.--In addition to
qualified health plans (and plans seeking certification
as qualified health plans), this paragraph (as amended
by the Health Care Prices Revealed and Information to
Consumers Explained Transparency Act) shall apply to
group health plans (including self-insured and fully
insured plans) and health insurance coverage (as such
terms are defined in section 2791 of the Public Health
Service Act).''.
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