[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4822 Introduced in House (IH)]

<DOC>






118th CONGRESS
  1st Session
                                H. R. 4822

   To improve price transparency with respect to certain health care 
                   services, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 24, 2023

Mr. Smith of Missouri introduced the following bill; which was referred 
    to the Committee on Energy and Commerce, and in addition to the 
  Committees on Ways and Means, Education and the Workforce, and the 
 Budget, for a period to be subsequently determined by the Speaker, in 
   each case for consideration of such provisions as fall within the 
                jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
   To improve price transparency with respect to certain health care 
                   services, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Health Care Price 
Transparency Act of 2023''.
    (b) Table of Contents.--The table of contents for this Act is as 
follows:

Sec. 1. Short title; table of contents.
          TITLE I--HEALTH CARE PRICE TRANSPARENCY FOR PATIENTS

Sec. 101. Requiring certain facilities under the Medicare program to 
                            disclose certain information relating to 
                            charges and prices.
Sec. 102. Promoting group health plan price transparency.
Sec. 103. Oversight of pharmacy benefits manager services.
Sec. 104. Reports on health care transparency tools and data 
                            requirements.
Sec. 105. Report on integration in Medicare.
                   TITLE II--FAIR PRICES FOR PATIENTS

Sec. 201. Limitation on cost sharing to net price amount under Medicare 
                            part D.
Sec. 202. Requiring a separate identification number and an attestation 
                            for each off-campus outpatient department 
                            of a provider.
Sec. 203. Parity in Medicare payments for hospital outpatient 
                            department services furnished off-campus.
                 TITLE III--PATIENT-FOCUSED INVESTMENTS

Sec. 301. Establishing requirements with respect to the use of prior 
                            authorization under Medicare Advantage 
                            plans.
Sec. 302. Extension of certain direct spending reductions.

          TITLE I--HEALTH CARE PRICE TRANSPARENCY FOR PATIENTS

SEC. 101. REQUIRING CERTAIN FACILITIES UNDER THE MEDICARE PROGRAM TO 
              DISCLOSE CERTAIN INFORMATION RELATING TO CHARGES AND 
              PRICES.

    (a) In General.--Part E of title XVIII of the Social Security Act 
(42 U.S.C. 1395x et seq.) is amended by adding at the end the following 
new section:

``SEC. 1899C. HEALTH CARE PROVIDER PRICE TRANSPARENCY.

    ``(a) Hospital Price Transparency.--
            ``(1) In general.--Beginning January 1, 2026, each 
        specified hospital (as defined in paragraph (6)) that receives 
        payment under this title for furnishing items and services 
        shall comply with the price transparency requirement described 
        in paragraph (2).
            ``(2) Requirement described.--
                    ``(A) In general.--For purposes of paragraph (1), 
                the price transparency requirement described in this 
                paragraph is, with respect to a specified hospital, 
                that such hospital, in accordance with a method and 
                format established by the Secretary under subparagraph 
                (C), compile and make public (without subscription and 
                free of charge) for each year--
                            ``(i) one or more lists, in a format 
                        specified by the Secretary (which may be a 
                        machine-readable format), of the hospital's 
                        standard charges (including the information 
                        described in subparagraph (B)) for each item 
                        and service furnished by such hospital; and
                            ``(ii) information in a consumer-friendly 
                        format (as specified by the Secretary)--
                                    ``(I) on the hospital's prices 
                                (including the information described in 
                                subparagraph (B)) for as many of the 
                                Centers for Medicare & Medicaid 
                                Services-specified shoppable services 
                                that are furnished by the hospital, and 
                                as many additional hospital-selected 
                                shoppable services (or all such 
                                additional services, if such hospital 
                                furnishes fewer than 300 shoppable 
                                services) as may be necessary for a 
                                combined total of at least 300 
                                shoppable services; and
                                    ``(II) that includes, with respect 
                                to each Centers for Medicare & Medicaid 
                                Services-specified shoppable service 
                                that is not furnished by the hospital, 
                                an indication that such service is not 
                                so furnished.
                    ``(B) Information described.--For purposes of 
                subparagraph (A), the information described in this 
                subparagraph is, with respect to standard charges and 
                prices (as applicable) made public by a specified 
                hospital, the following:
                            ``(i) A description of each item or 
                        service, accompanied by, as applicable, the 
                        Healthcare Common Procedure Coding System code, 
                        the diagnosis-related group, the national drug 
                        code, or other identifier used or approved by 
                        the Centers for Medicare & Medicaid Services.
                            ``(ii) The gross charge, expressed as a 
                        dollar amount, for each such item or service, 
                        when provided in, as applicable, the inpatient 
                        setting and outpatient department setting.
                            ``(iii) The discounted cash price, 
                        expressed as a dollar amount, for each such 
                        item or service when provided in, as 
                        applicable, the inpatient setting and 
                        outpatient department setting (or, in the case 
                        no discounted cash price is available for an 
                        item or service, the median price charged by 
                        the hospital for such item or service when 
                        provided in such settings for the previous 
                        three years, expressed as a dollar amount).
                            ``(iv) Any other information the Secretary 
                        may require for purposes of promoting public 
                        awareness of specified hospital standard 
                        charges or prices in advance of receiving an 
                        item or service from such a hospital, except 
                        information that is duplicative of any other 
                        reporting requirement under this section. Such 
                        information may include any current payer-
                        specific negotiated charges, clearly associated 
                        with the name of the third party payer and plan 
                        and expressed as a dollar amount, that apply to 
                        each such item or service when provided in, as 
                        applicable, the inpatient setting and 
                        outpatient department setting.
                    ``(C) Method and format.--Not later than January 1, 
                2026, the Secretary shall establish one or more methods 
                and formats for specified facilities to use in 
                compiling and making public standard charges and prices 
                (as applicable) pursuant to subparagraph (A). Any such 
                method and format--
                            ``(i) may be similar to any template made 
                        available by the Centers for Medicare & 
                        Medicaid Services as of the date of the 
                        enactment of this subparagraph;
                            ``(ii) shall meet such standards as 
                        determined appropriate by the Secretary in 
                        order to ensure the accessibility and usability 
                        of such charges and prices; and
                            ``(iii) shall be updated as determined 
                        appropriate by the Secretary, in consultation 
                        with stakeholders.
            ``(3) Deemed compliance with shoppable services requirement 
        for hospitals with a price estimator tool.--
                    ``(A) In general.--With respect to each year until 
                the effective date of regulations implementing the 
                provisions of sections 2799A-1(f) and 2799B-6 of the 
                Public Health Service Act (relating to advanced 
                explanations of benefits), including regulations on 
                establishing data transfer standards to effectuate such 
                provisions, a specified hospital shall be deemed to 
                have complied with the requirement described in 
                paragraph (2)(A)(ii)(I) (relating to shoppable 
                services) if such hospital maintains a price estimator 
                tool described in subparagraph (B).
                    ``(B) Price estimator tool described.--For purposes 
                of subparagraph (A), the price estimator tool described 
                in this subparagraph is, with respect to a specified 
                hospital, a tool that meets the following requirements:
                            ``(i) Such tool allows an individual to 
                        immediately obtain a price estimate (taking 
                        into account whether such individual is covered 
                        under any plan, coverage, or program described 
                        in clause (iv)(III)) and the discounted cash 
                        price charged by a specified hospital, for each 
                        Centers for Medicare & Medicaid Services-
                        specified shoppable service that is furnished 
                        by such hospital, and for each additional 
                        shoppable service as such hospital may select, 
                        such that price estimates are available through 
                        such tool for at least 300 shoppable services 
                        (or for all such services, if such hospital 
                        furnishes fewer than 300 shoppable services).
                            ``(ii) Such tool allows an individual to 
                        obtain such an estimate by billing code and by 
                        service description.
                            ``(iii) Such tool is prominently displayed 
                        on the public internet website of such 
                        hospital.
                            ``(iv) Such tool does not require an 
                        individual seeking such an estimate to create 
                        an account or otherwise input personal 
                        information, except that such tool may require 
                        that such individual provide information 
                        specified by the Secretary, which may include 
                        the following:
                                    ``(I) The name of such individual.
                                    ``(II) The date of birth of such 
                                individual.
                                    ``(III) In the case such individual 
                                is covered under a group health plan, 
                                group or individual health insurance 
                                coverage, a Federal health care 
                                program, or the program established 
                                under chapter 89 of title 5, United 
                                States Code, an identifying number 
                                assigned by such plan, coverage, or 
                                program to such individual.
                                    ``(IV) In the case of an individual 
                                described in subclause (III), an 
                                indication as to whether such 
                                individual is the primary insured 
                                individual under such plan, coverage, 
                                or program (and, if such individual is 
                                not the primary insured individual, a 
                                description of the individual's 
                                relationship to such primary insured 
                                individual).
                                    ``(V) Any other information 
                                specified by the Secretary.
                            ``(v) Such tool contains a statement 
                        confirming the accuracy and completeness of 
                        information presented through such tool as of 
                        the date such request is made.
                            ``(vi) Such tool meets any other 
                        requirement specified by the Secretary.
            ``(4) Monitoring compliance.--The Secretary shall, through 
        notice and comment rulemaking and in consultation with the 
        Inspector General of the Department of Health and Human 
        Services, establish a process to monitor compliance with this 
        subsection. Such process shall ensure that each specified 
        hospital's compliance with this subsection is reviewed not less 
        frequently than once every 3 years.
            ``(5) Enforcement.--
                    ``(A) In general.--In the case of a specified 
                hospital that fails to comply with the requirements of 
                this subsection--
                            ``(i) the Secretary shall notify such 
                        hospital of such failure not later than 30 days 
                        after the date on which the Secretary 
                        determines such failure exists; and
                            ``(ii) upon request of the Secretary, the 
                        hospital shall submit to the Secretary, not 
                        later than 45 days after the date of such 
                        request, a corrective action plan to comply 
                        with such requirements.
                    ``(B) Civil monetary penalty.--
                            ``(i) In general.--In addition to any other 
                        enforcement actions or penalties that may apply 
                        under another provision of law, a specified 
                        hospital that has received a notification under 
                        subparagraph (A)(i) and fails to comply with 
                        the requirements of this subsection by the date 
                        that is 90 days after such notification (or, in 
                        the case of such a hospital that has submitted 
                        a corrective action plan described in 
                        subparagraph (A)(ii) in response to a request 
                        so described, by the date that is 90 days after 
                        the Secretary identifies the failure of such 
                        hospital to satisfactorily complete such 
                        corrective action plan) shall be subject to a 
                        civil monetary penalty of an amount specified 
                        by the Secretary for each subsequent day during 
                        which such failure is ongoing. Such amount 
                        shall not exceed--
                                    ``(I) in the case of a specified 
                                hospital that is a hospital or critical 
                                access hospital with 30 or fewer beds, 
                                $300 per day; and
                                    ``(II) in the case of any specified 
                                hospital and except as provided in 
                                clause (iii), $2,000,000 for a 1-year 
                                period.
                            ``(ii) Increase authority.--In applying 
                        this subparagraph with respect to violations 
                        occurring in 2027 or a subsequent year, the 
                        Secretary may through notice and comment 
                        rulemaking increase--
                                    ``(I) the limitation on the per day 
                                amount of any penalty applicable to a 
                                specified hospital that is a hospital 
                                or critical access hospital with 30 or 
                                fewer beds under clause (i)(I);
                                    ``(II) the limitation on the amount 
                                of any penalty applicable for a 1-year 
                                period under clause (i)(II); and
                                    ``(III) the limitation on the 
                                increase of any penalty applied under 
                                clause (iii).
                            ``(iii) Persistent noncompliance.--In the 
                        case of a specified hospital (other than a 
                        specified hospital that is a hospital or 
                        critical access hospital with 30 or fewer beds) 
                        that the Secretary has determined to be 
                        knowingly and willfully noncompliant with the 
                        provisions of this subsection two or more times 
                        during a 1-year period, the Secretary may 
                        increase any penalty otherwise applicable under 
                        this subparagraph by not more than $1,000,000 
                        and may require such hospital to complete such 
                        additional corrective actions plans as the 
                        Secretary may specify.
                            ``(iv) Application of certain provisions.--
                        The provisions of section 1128A (other than 
                        subsections (a) and (b) of such section) shall 
                        apply to a civil monetary penalty imposed under 
                        this subparagraph in the same manner as such 
                        provisions apply to a civil monetary penalty 
                        imposed under subsection (a) of such section.
                            ``(v) Authority to waive or reduce 
                        penalty.--The Secretary may waive or reduce any 
                        penalty otherwise applicable with respect to a 
                        specified hospital under this subparagraph if 
                        the Secretary determines that imposition of 
                        such penalty would result in a significant 
                        hardship for such hospital (such as in the case 
                        of a hospital located in a rural or underserved 
                        area where imposition of such penalty may 
                        result in, or contribute to, a lack of access 
                        to care for individuals in such area).
                    ``(C) Publication of hospital price transparency 
                information.--Beginning on January 1, 2026, the 
                Secretary shall make publicly available on the public 
                website of the Centers for Medicare & Medicaid Services 
                information with respect to compliance with the 
                requirements of this subsection and enforcement 
                activities undertaken by the Secretary under this 
                subsection. Such information shall be updated not less 
                than annually and include, with respect to each year--
                            ``(i) the number of reviews of compliance 
                        with this subsection undertaken by the 
                        Secretary;
                            ``(ii) the number of notifications 
                        described in subparagraph (A)(i) sent by the 
                        Secretary;
                            ``(iii) the identify of each specified 
                        hospital that was sent such a notification and 
                        a description of the nature of such hospital's 
                        noncompliance with this subsection;
                            ``(iv) the amount of any civil monetary 
                        penalty imposed on such hospital under 
                        subparagraph (B);
                            ``(v) whether such hospital subsequently 
                        came into compliance with this subsection; and
                            ``(vi) any other information as determined 
                        by the Secretary.
            ``(6) Definitions.--For purposes of this subsection:
                    ``(A) Discounted cash price.--The term `discounted 
                cash price' means the charge that applies to an 
                individual who pays cash, or cash equivalent, for a 
                specified hospital-furnished item or service.
                    ``(B) Federal health care program.--The term 
                `Federal health care program' has the meaning given 
                such term in section 1128B.
                    ``(C) Gross charge.--The term `gross charge' means 
                the charge for an individual item or service that is 
                reflected on a specified hospital's chargemaster, 
                absent any discounts.
                    ``(D) Group health plan; group health insurance 
                coverage; individual health insurance coverage.--The 
                terms `group health plan', `group health insurance 
                coverage', and `individual health insurance coverage' 
                have the meaning given such terms in section 2791 of 
                the Public Health Service Act.
                    ``(E) Payer-specific negotiated charge.--The term 
                `payer-specific negotiated charge' means the charge 
                that a specified 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 and includes all 
                ancillary items and services customarily furnished as 
                part of such service.
                    ``(G) Specified hospital.--The term `specified 
                hospital' means a hospital (as defined in section 
                1861(e)), a critical access hospital (as defined in 
                section 1861(mmm)(1)), or a rural emergency hospital 
                (as defined in section 1861(kkk)).
                    ``(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.
    ``(b) Ambulatory Surgical Center Price Transparency.--
            ``(1) In general.--Beginning January 1, 2028, each 
        ambulatory surgical center that receives payment under this 
        title for furnishing items and services shall comply with the 
        price transparency requirement described in paragraph (2).
            ``(2) Requirement described.--
                    ``(A) In general.--For purposes of paragraph (1), 
                the price transparency requirement described in this 
                subsection is, with respect to an ambulatory surgical 
                center, that such surgical center in accordance with a 
                method and format established by the Secretary under 
                subparagraph (C)), compile and make public (without 
                subscription and free of charge), for each year--
                            ``(i) one or more lists, in a format 
                        specified by the Secretary, of the ambulatory 
                        surgical center's standard charges (including 
                        the information described in subparagraph (B)) 
                        for each item and service furnished by such 
                        surgical center;
                            ``(ii) information on the ambulatory 
                        surgical center's prices (including the 
                        information described in subparagraph (B)) for 
                        as many of the Centers for Medicare & Medicaid 
                        Services-specified shoppable services that are 
                        furnished by such surgical center, and as many 
                        additional ambulatory surgical center-selected 
                        shoppable services (or all such additional 
                        services, if such surgical center furnishes 
                        fewer than 300 shoppable services) as may be 
                        necessary for a combined total of at least 300 
                        shoppable services;
                            ``(iii) with respect to each Centers for 
                        Medicare & Medicaid Services-specified 
                        shoppable service that is not furnished by the 
                        ambulatory surgical center, an indication that 
                        such service is not so furnished; and
                            ``(iv) any additional information specified 
                        by the Secretary.
                    ``(B) Information described.--For purposes of 
                subparagraph (A), the information described in this 
                subparagraph is, with respect to standard charges and 
                prices (as applicable) made public by an ambulatory 
                surgical center, the following:
                            ``(i) A description of each item or 
                        service, accompanied by, as applicable, the 
                        Healthcare Common Procedure Coding System code, 
                        the diagnosis-related group, the national drug 
                        code, or other identifier used or approved by 
                        the Centers for Medicare & Medicaid Services.
                            ``(ii) The gross charge, expressed as a 
                        dollar amount, for each such item or service.
                            ``(iii) The discounted cash price, 
                        expressed as a dollar amount, for each such 
                        item or service (or, in the case no discounted 
                        cash price is available for an item or service, 
                        the gross charge for such item or service for 
                        the previous three years, expressed as a dollar 
                        amount).
                            ``(iv) Any other information the Secretary 
                        may require that is not duplicative of any 
                        other reporting requirement under this 
                        subsection for purposes of promoting public 
                        awareness of ambulatory surgical center prices 
                        in advance of receiving an item or service from 
                        such an ambulatory surgical center, which may 
                        include any current payer-specific negotiated 
                        charges, clearly associated with the name of 
                        the third party payer and plan and expressed as 
                        a dollar amount, that applies to each such item 
                        or service.
                    ``(C) Method and format.--Not later than January 1, 
                2028, the Secretary shall establish one or more methods 
                and formats for ambulatory surgical centers to use in 
                making public standard charges and prices (as 
                applicable) pursuant to subparagraph (A). Any such 
                method and format--
                            ``(i) may be similar to any template made 
                        available by the Centers for Medicare & 
                        Medicaid Services as of the date of the 
                        enactment of this paragraph;
                            ``(ii) shall meet such standards as 
                        determined appropriate by the Secretary in 
                        order to ensure the accessibility and usability 
                        of such charges and prices; and
                            ``(iii) shall be updated as determined 
                        appropriate by the Secretary, in consultation 
                        with stakeholders.
            ``(3) Deemed compliance with shoppable services requirement 
        for ambulatory surgical centers with a price estimator tool.--
                    ``(A) In general.--An ambulatory surgical center 
                shall be deemed to have complied with the requirement 
                described in subsection (b)(2)(A) (relating to 
                shoppable services) if such surgical center maintains a 
                price estimator tool described in subparagraph (B).
                    ``(B) Price estimator tool described.--For purposes 
                of subparagraph (A), the price estimator tool described 
                in this subparagraph is, with respect to an ambulatory 
                surgical center, a tool that meets the following 
                requirements:
                            ``(i) Such tool allows an individual to 
                        immediately obtain a price estimate (taking 
                        into account whether such individual is covered 
                        under any plan, coverage, or program described 
                        in clause (iv)(III)) for each Centers for 
                        Medicare & Medicaid Services-specified 
                        shoppable service that is furnished by such 
                        surgical center, and for each additional 
                        shoppable service as such surgical center may 
                        select, such that price estimates are available 
                        through such tool for at least 300 shoppable 
                        services (or for all such services, if such 
                        surgical center furnishes fewer than 300 
                        shoppable services).
                            ``(ii) Such tool allows an individual to 
                        obtain such an estimate by billing code and by 
                        service description.
                            ``(iii) Such tool is prominently displayed 
                        on the public internet website of such 
                        ambulatory surgical center.
                            ``(iv) Such tool does not require an 
                        individual seeking such an estimate to create 
                        an account or otherwise input personal 
                        information, except that such tool may require 
                        that such individual provide information 
                        specified by the Secretary, which may include 
                        the following:
                                    ``(I) The name of such individual.
                                    ``(II) The date of birth of such 
                                individual.
                                    ``(III) In the case such individual 
                                is covered under a group health plan, 
                                group or individual health insurance 
                                coverage, a Federal health care 
                                program, or the program established 
                                under chapter 89 of title 5, United 
                                States Code, an identifying number 
                                assigned by such plan, coverage, or 
                                program to such individual.
                                    ``(IV) In the case of an individual 
                                described in subclause (III), an 
                                indication as to whether such 
                                individual is the primary insured 
                                individual under such plan, coverage, 
                                or program (and, if such individual is 
                                not the primary insured individual, a 
                                description of the individual's 
                                relationship to such primary insured 
                                individual).
                                    ``(V) Any other information 
                                specified by the Secretary.
                            ``(v) Such tool contains a statement 
                        confirming the accuracy and completeness of 
                        information presented through such tool as of 
                        the date such request is made.
                            ``(vi) Such tool meets any other 
                        requirement specified by the Secretary.
            ``(4) Monitoring compliance.--The Secretary shall, through 
        notice and comment rulemaking and in consultation with the 
        Inspector General of the Department of Health and Human 
        Services, establish a process to monitor compliance with this 
        subsection. Such process shall ensure that each ambulatory 
        surgical center's compliance with this subsection is reviewed 
        not less frequently than once every 3 years.
            ``(5) Enforcement.--
                    ``(A) In general.--In the case of an ambulatory 
                surgical center that fails to comply with the 
                requirements of this subsection--
                            ``(i) the Secretary shall notify such 
                        ambulatory surgical center of such failure not 
                        later than 30 days after the date on which the 
                        Secretary determines such failure exists; and
                            ``(ii) upon request of the Secretary, the 
                        ambulatory surgical center shall submit to the 
                        Secretary, not later than 45 days after the 
                        date of such request, a corrective action plan 
                        to comply with such requirements.
                    ``(B) Civil monetary penalty.--
                            ``(i) In general.--In addition to any other 
                        enforcement actions or penalties that may apply 
                        under another provision of law, an ambulatory 
                        surgical center that has received a 
                        notification under subparagraph (A)(i) and 
                        fails to comply with the requirements of this 
                        subsection by the date that is 90 days after 
                        such notification (or, in the case of an 
                        ambulatory surgical center that has submitted a 
                        corrective action plan described in 
                        subparagraph (A)(ii) in response to a request 
                        so described, by the date that is 90 days after 
                        such submission) shall be subject to a civil 
                        monetary penalty of an amount specified by the 
                        Secretary for each subsequent day during which 
                        such failure is ongoing (not to exceed $300 per 
                        day).
                            ``(ii) Increase authority.--In applying 
                        this subparagraph with respect to violations 
                        occurring in 2027 or a subsequent year, the 
                        Secretary may through notice and comment 
                        rulemaking increase the limitation on the per 
                        day amount of any penalty applicable to an 
                        ambulatory surgical center under clause (i).
                            ``(iii) Application of certain 
                        provisions.--The provisions of section 1128A 
                        (other than subsections (a) and (b) of such 
                        section) shall apply to a civil monetary 
                        penalty imposed under this subparagraph in the 
                        same manner as such provisions apply to a civil 
                        monetary penalty imposed under subsection (a) 
                        of such section.
                            ``(iv) Authority to waive or reduce 
                        penalty.--The Secretary may waive or reduce any 
                        penalty otherwise applicable with respect to an 
                        ambulatory surgical center under this 
                        subparagraph if the Secretary determines that 
                        imposition of such penalty would result in a 
                        significant hardship for such ambulatory 
                        surgical center (such as in the case of an 
                        ambulatory surgical center located in a rural 
                        or underserved area where imposition of such 
                        penalty may result in, or contribute to, a lack 
                        of access to care for individuals in such 
                        area).
            ``(6) Definitions.--For purposes of this section:
                    ``(A) Discounted cash price.--The term `discounted 
                cash price' means the charge that applies to an 
                individual who pays cash, or cash equivalent, for a 
                item or service furnished by an ambulatory surgical 
                center.
                    ``(B) Federal health care program.--The term 
                `Federal health care program' has the meaning given 
                such term in section 1128B.
                    ``(C) Gross charge.--The term `gross charge' means 
                the charge for an individual item or service that is 
                reflected on a specified surgical center's 
                chargemaster, absent any discounts.
                    ``(D) Group health plan; group health insurance 
                coverage; individual health insurance coverage.--The 
                terms `group health plan', `group health insurance 
                coverage', and `individual health insurance coverage' 
                have the meaning given such terms in section 2791 of 
                the Public Health Service Act.
                    ``(E) Payer-specific negotiated charge.--The term 
                `payer-specific negotiated charge' means the charge 
                that a specified surgical center 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 and includes all 
                ancillary items and services customarily furnished as 
                part of such service.
                    ``(G) 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.
    ``(c) Imaging Services Price Transparency.--
            ``(1) In general.--Beginning January 1, 2025, each provider 
        of services and supplier that receives payment under this title 
        for furnishing a specified imaging service shall--
                    ``(A) make publicly available (in a form and manner 
                specified by the Secretary) on an Internet website the 
                information described in paragraph (2) with respect to 
                each such service that such provider of services or 
                supplier furnishes; and
                    ``(B) ensure that such information is updated not 
                less frequently than annually.
            ``(2) Information described.--For purposes of paragraph 
        (1), the information described in this subsection is, with 
        respect to a provider of services or supplier and a specified 
        imaging service, the following:
                    ``(A) The discounted cash price for such service 
                (or, if no such price exists, the gross charge for such 
                service).
                    ``(B) If required by the Secretary, the 
                deidentified minimum negotiated rate in effect between 
                such provider or supplier and any group health plan or 
                group or individual health insurance coverage for such 
                service and the deidentified maximum negotiated rate in 
                effect between such provider or supplier and any such 
                plan or coverage for such service.
            ``(3) Method and format.--Not later than January 1, 2028, 
        the Secretary shall establish one or more methods and formats 
        for each provider of services and supplier to use in compiling 
        and making public standard charges and prices (as applicable) 
        pursuant to paragraph (1). Any such method and format--
                    ``(A) may be similar to any template made available 
                by the Centers for Medicare & Medicaid Services as of 
                the date of the enactment of this subsection;
                    ``(B) shall meet such standards as determined 
                appropriate by the Secretary in order to ensure the 
                accessibility and usability of such charges and prices; 
                and
                    ``(C) shall be updated as determined appropriate by 
                the Secretary, in consultation with stakeholders.
            ``(4) Monitoring compliance.--The Secretary shall, through 
        notice and comment rulemaking and in consultation with the 
        Inspector General of the Department of Health and Human 
        Services, establish a process to monitor compliance with this 
        subsection.
            ``(5) Specification of services.--Not later than January 1, 
        2025, the Secretary shall publish a list of at least 50 imaging 
        services that the Secretary determines are shoppable (or all 
        such services, if the Secretary determines that fewer than 50 
        such services are shoppable) between providers of services and 
        suppliers of such services. The Secretary shall update such 
        list as determined appropriate by the Secretary.
            ``(6) Enforcement.--
                    ``(A) In general.--In the case that the Secretary 
                determines that a provider of services or supplier is 
                not in compliance with paragraph (1)--
                            ``(i) not later than 30 days after such 
                        determination, the Secretary shall notify such 
                        provider or supplier of such determination;
                            ``(ii) upon request of the Secretary, such 
                        provider or supplier shall submit to the 
                        Secretary, not later than 45 days after the 
                        date of such request, a corrective action plan 
                        to comply with such paragraph; and
                            ``(iii) if such provider or supplier 
                        continues to fail to comply with such paragraph 
                        after the date that is 90 days after such 
                        notification is sent (or, in the case of such a 
                        provider or supplier that has submitted a 
                        corrective action plan described in clause (ii) 
                        in response to a request so described, after 
                        the date that is 90 days after such 
                        submission), the Secretary may impose a civil 
                        monetary penalty in an amount not to exceed 
                        $300 for each subsequent day during which such 
                        failure to comply or failure to submit is 
                        ongoing.
                    ``(B) Increase authority.--In applying this 
                paragraph with respect to violations occurring in 2027 
                or a subsequent year, the Secretary may through notice 
                and comment rulemaking increase the amount of the civil 
                monetary penalty under subparagraph (A)(iii).
                    ``(C) Application of certain provisions.--The 
                provisions of section 1128A (other than subsections (a) 
                and (b) of such section) shall apply to a civil 
                monetary penalty imposed under this paragraph in the 
                same manner as such provisions apply to a civil 
                monetary penalty imposed under subsection (a) of such 
                section.
                    ``(D) Authority to waive or reduce penalty.--The 
                Secretary may waive or reduce any penalty otherwise 
                applicable with respect to a provider of services or 
                supplier under this subparagraph if the Secretary 
                determines that imposition of such penalty would result 
                in a significant hardship for such provider or supplier 
                (such as in the case of a provider or supplier located 
                in a rural or underserved area where imposition of such 
                penalty may result in, or contribute to, a lack of 
                access to care for individuals in such area).
                    ``(E) Clarification of nonapplicability of other 
                enforcement provisions.--Notwithstanding any other 
                provision of this title, this paragraph shall be the 
                sole means of enforcing the provisions of this 
                subsection.
            ``(7) Definitions.--In this subsection:
                    ``(A) Group health plan; group health insurance 
                coverage; individual health insurance coverage.--The 
                terms `group health plan', `group health insurance 
                coverage', and `individual health insurance coverage' 
                have the meaning given such terms in section 2791 of 
                the Public Health Service Act.
                    ``(B) Specified imaging service.--the term 
                `specified imaging service' means an imaging service 
                that is included on the list published by the Secretary 
                under subsection (e).
    ``(d) Clinical Laboratory Price Transparency.--
            ``(1) In general.--Beginning January 1, 2025, each 
        applicable laboratory that receives payment under this title 
        for furnishing a specified clinical diagnostic laboratory test 
        shall--
                    ``(A) make publicly available (in a manner and form 
                specified by the Secretary) on an Internet website the 
                information described in paragraph (2) with respect to 
                each such specified clinical diagnostic laboratory test 
                that such laboratory is so available to furnish; and
                    ``(B) ensure that such information is updated not 
                less frequently than annually.
            ``(2) Information described.--For purposes of paragraph 
        (1), the information described in this subsection is, with 
        respect to an applicable laboratory and a specified clinical 
        diagnostic laboratory test, the following:
                    ``(A) The discounted cash price for such test (or, 
                if no such price exists, the gross charge for such 
                test).
                    ``(B) If required by the Secretary, the 
                deidentified minimum negotiated rate in effect between 
                such laboratory and any group health plan or group or 
                individual health insurance coverage for such test and 
                the deidentified maximum negotiated rate in effect 
                between such laboratory and any such plan or coverage 
                for such test.
            ``(3) Method and format.--Not later than January 1, 2028, 
        the Secretary shall establish one or more methods and formats 
        for each provider of services and supplier to use in compiling 
        and making public standard charges and prices (as applicable) 
        pursuant to paragraph (1). Any such method and format--
                    ``(A) may be similar to any template made available 
                by the Centers for Medicare & Medicaid Services as of 
                the date of the enactment of this subsection;
                    ``(B) shall meet such standards as determined 
                appropriate by the Secretary in order to ensure the 
                accessibility and usability of such charges and prices; 
                and
                    ``(C) shall be updated as determined appropriate by 
                the Secretary, in consultation with stakeholders.
            ``(4) Monitoring compliance.--The Secretary shall, through 
        notice and comment rulemaking and in consultation with the 
        Inspector General of the Department of Health and Human 
        Services, establish a process to monitor compliance with this 
        subsection.
            ``(5) Enforcement.--
                    ``(A) In general.--In the case that the Secretary 
                determines that an applicable laboratory is not in 
                compliance with paragraph (1)--
                            ``(i) not later than 30 days after such 
                        determination, the Secretary shall notify such 
                        laboratory of such determination;
                            ``(ii) upon request of the Secretary, such 
                        laboratory shall submit to the Secretary, not 
                        later than 45 days after such request is sent, 
                        a corrective action plan to comply with such 
                        subsection; and
                            ``(iii) if such laboratory continues to 
                        fail to comply with such paragraph after the 
                        date that is 90 days after such notification is 
                        sent (or, in the case of such a laboratory that 
                        has submitted a corrective action plan 
                        described in clause(ii) in response to a 
                        request so described, after the date that is 90 
                        days after such submission), the Secretary may 
                        impose a civil monetary penalty in an amount 
                        not to exceed $300 for each subsequent day 
                        during which such failure to comply is ongoing.
                    ``(B) Increase authority.--In applying this 
                paragraph with respect to violations occurring in 2027 
                or a subsequent year, the Secretary may through notice 
                and comment rulemaking increase the amount of the civil 
                monetary penalty under subparagraph (A)(iii).
                    ``(C) Application of certain provisions.--The 
                provisions of section 1128A (other than subsections (a) 
                and (b) of such section) shall apply to a civil 
                monetary penalty imposed under this paragraph in the 
                same manner as such provisions apply to a civil 
                monetary penalty imposed under subsection (a) of such 
                section.
                    ``(D) Authority to waive or reduce penalty.--The 
                Secretary may waive or reduce any penalty otherwise 
                applicable with respect to an applicable laboratory 
                under this paragraph if the Secretary determines that 
                imposition of such penalty would result in a 
                significant hardship for such laboratory (such as in 
                the case of an applicable laboratory located in a rural 
                or underserved area where imposition of such penalty 
                may result in, or contribute to, a lack of access to 
                care for individuals in such area).
                    ``(E) Clarification of nonapplicability of other 
                enforcement provisions.--Notwithstanding any other 
                provision of this title, this subsection shall be the 
                sole means of enforcing the provisions of this section.
            ``(6) Definitions.--In this subsection:
                    ``(A) Applicable laboratory.--The term `applicable 
                laboratory' has the meaning given such term in section 
                414.502, of title 42, Code of Federal Regulations (or 
                any successor regulation).
                    ``(B) Group health plan; group health insurance 
                coverage; individual health insurance coverage.--The 
                terms `group health plan', `group health insurance 
                coverage', and `individual health insurance coverage' 
                have the meaning given such terms in section 2791 of 
                the Public Health Service Act.
                    ``(C) Specified clinical diagnostic laboratory 
                test.--The term `specified clinical diagnostic 
                laboratory test' means a clinical diagnostic laboratory 
                test that is included on the list of shoppable services 
                specified by the Centers for Medicare & Medicaid 
                Services pursuant to section 180.60 of title 45, Code 
                of Federal Regulations (or a successor regulation), 
                other than such a test that is an advanced diagnostic 
                laboratory test (as defined in section 1834A(d)(5)).''.
    (b) Publication of Hospital Compliance With Price Transparency 
Requirements.--Section 1886 of the Social Security Act (42 U.S.C. 
1395ww) is amended by adding at the end the following new subsection:
    ``(u) Publication of Hospital Compliance With Price Transparency 
Requirements.--
            ``(1) In general.--Beginning January 1, 2026, the Secretary 
        shall, for each hospital with respect to which the Secretary 
        has conducted a review of such hospital's compliance with the 
        provisions of section 1899C(a) and found such hospital 
        noncompliant with such provisions--
                    ``(A) indicate such noncompliance on such 
                hospital's entry on the Hospital Compare internet 
                website (or a successor website); and
                    ``(B) specify whether such hospital--
                            ``(i) submitted a corrective action plan 
                        described in subsection (a)(5)(A)(ii) of such 
                        section (and, if so, the date such plan was 
                        received by the Secretary); or
                            ``(ii) was subject to a civil monetary 
                        penalty imposed under subsection (a)(5)(B) of 
                        such section (and, if so, the date of the 
                        imposition of such penalty and the amount of 
                        such penalty).
            ``(2) Additions and updates.--The Secretary shall update 
        any specification described in subparagraph (A) or (B) of 
        paragraph (1) with respect to such hospital--
                    ``(A) in the case of the specification described in 
                such paragraph (1)(A), as soon as practicable after 
                sending the notification described in section 
                1899C(a)(5)(A)(i); and
                    ``(B) in the case of the specification described in 
                such paragraph (1)(B)(ii), as soon as practicable after 
                the imposition of a civil monetary penalty described in 
                such paragraph.''.
    (c) Conforming Amendment.--Section 2718(e) of the Public Health 
Service Act (42 U.S.C. 300gg-18(e)) is amended by adding at the end the 
following new sentence: ``The preceding sentence shall not apply 
beginning January 1, 2026.''.
    (d) Funding.--
            (1) In general.--In addition to funds otherwise available, 
        out of any moneys in the Treasury not otherwise appropriated, 
        there are appropriated $10,000,000 for fiscal year 2024, to 
        remain available until expended, for purposes of--
                    (A) implementing the amendment made by this 
                subsection (a); and
                    (B) monitoring the compliance of entities with such 
                amendment.
            (2) Report on expenditures.--Not later than 5 years after 
        the date of the enactment of this Act, the Secretary of Health 
        and Human Services shall submit to the Committee on Ways and 
        Means and the Committee on Energy and Commerce of the House of 
        Representatives and the Committee on Finance of the Senate a 
        report that--
                    (A) describes activities undertaken funded through 
                funds made available under paragraph (1), including a 
                specification of the amount of such funds expended for 
                each such activity; and
                    (B) identifies all entities with which the 
                Secretary has entered into contracts for purposes of 
                implementing the amendment made by this subsection (a), 
                monitoring compliance of entities with such amendment, 
                or providing technical assistance to entities to 
                promote compliance with such amendment.
    (e) Implementation.--
            (1) Accessibility.--In implementing section 
        1899C(a)(2)(A)(ii) of the Social Security Act (as added by 
        subsection (a)), the Secretary of Health and Human Services 
        shall through rulemaking ensure that information made available 
        pursuant to such amendment by an entity is so made available in 
        plain, easily understandable language and that such entity 
        provides access to such interpretation services, translations, 
        and other assistive services to make such information 
        accessible to individuals with limited English proficiency and 
        individuals with disabilities.
            (2) Technical assistance.--The Secretary of Health and 
        Human Services shall, to the extent practicable, provide 
        technical assistance to entities making public standard charges 
        and prices (as applicable) pursuant to the amendment made by 
        subsection (a).

SEC. 102. PROMOTING GROUP HEALTH PLAN PRICE TRANSPARENCY.

    (a) Price Transparency Requirements.--
            (1) IRC.--
                    (A) In general.--Section 9819 of the Internal 
                Revenue Code of 1986 (26. U.S.C. 9816) is amended to 
                read as follows:

``SEC. 9819. PRICE TRANSPARENCY REQUIREMENTS.

    ``(a) Cost Sharing Transparency.--
            ``(1) In general.--For plan years beginning on or after the 
        date that is 2 years after the date of the enactment of the 
        Health Care Price Transparency Act of 2023, a group health plan 
        shall permit individuals to learn the amount of cost-sharing 
        (including deductibles, copayments, and coinsurance) under the 
        individual's plan or coverage that the individual would be 
        responsible for paying with respect to the furnishing of a 
        specific item or service by a provider in a timely manner upon 
        the request of the individual. At a minimum, such information 
        shall include the information specified in paragraph (2) and 
        shall be made available to such individual through a self-
        service tool that meets the requirements of paragraph (3) or, 
        at the option of such individual, through a paper disclosure or 
        phone or other electronic disclosure (as selected by such 
        individual and provided at no cost to such individual) that 
        meets such requirements as the Secretary may specify.
            ``(2) Specified information.--For purposes of paragraph 
        (1), the information specified in this paragraph is, with 
        respect to an item or service for which benefits are available 
        under a group health plan furnished by a health care provider 
        to a participant or beneficiary of such plan, the following:
                    ``(A) If such provider is a participating provider 
                with respect to such item or service, the in-network 
                rate (as defined in subsection (c)) for such item or 
                service.
                    ``(B) If such provider is not described in 
                subparagraph (A), the maximum allowed amount for such 
                item or service.
                    ``(C) The estimated amount of cost sharing 
                (including deductibles, copayments, and coinsurance) 
                that the participant or beneficiary will incur for such 
                item or service (which, in the case such item or 
                service is to be furnished by a provider described in 
                subparagraph (B), shall be calculated using the maximum 
                amount described in such subparagraph).
                    ``(D) The amount the participant or beneficiary has 
                already accumulated with respect to any deductible or 
                out of pocket maximum, whether for items and services 
                furnished by a participating provider or for items and 
                services furnished by a provider that is not a 
                participating provider, under the plan (broken down, in 
                the case separate deductibles or maximums apply to 
                separate participants and beneficiaries enrolled in the 
                plan, by such separate deductibles or maximums, in 
                addition to any cumulative deductible or maximum).
                    ``(E) In the case such plan imposes any frequency 
                or volume limitations with respect to such item or 
                service (excluding medical necessity determinations), 
                the amount that such participant or beneficiary has 
                accrued towards such limitation with respect to such 
                item or service.
                    ``(F) Any prior authorization, concurrent review, 
                step therapy, fail first, or similar requirements 
                applicable to coverage of such item or service under 
                such plan.
        The Secretary may provide that information described in any of 
        subparagraphs (A) through (F) not be treated as information 
        specified in this paragraph, and specify additional information 
        that shall be treated as information specified in this 
        paragraph, if determined appropriate by the Secretary.
            ``(3) Self-service tool.--For purposes of paragraph (1), a 
        self-service tool established by a group health plan meets the 
        requirements of this paragraph if such tool--
                    ``(A) is based on an Internet website;
                    ``(B) provides for real-time responses to requests 
                described in paragraph (1);
                    ``(C) is updated in a manner such that information 
                provided through such tool is timely and accurate at 
                the time such request is made;
                    ``(D) allows such a request to be made with respect 
                to an item or service furnished by--
                            ``(i) a specific provider that is a 
                        participating provider with respect to such 
                        item or service;
                            ``(ii) all providers that are participating 
                        providers with respect to such item or service; 
                        or
                            ``(iii) a provider that is not described in 
                        clause (ii);
                    ``(E) provides that such a request may be made with 
                respect to an item or service through use of the 
                billing code for such item or service or through use of 
                a descriptive term for such item or service; and
                    ``(F) meets any other requirement determined 
                appropriate by the Secretary.
        The Secretary may require such tool, as a condition of 
        complying with subparagraph (E), to link multiple billing codes 
        to a single descriptive term if the Secretary determines that 
        the billing codes to be so linked correspond to similar items 
        and services.
    ``(b) Rate and Payment Information.--
            ``(1) In general.--For plan years beginning on or after the 
        date that is 2 years after the date of the enactment of the 
        Health Care Price Transparency Act of 2023, each group health 
        plan (other than a grandfathered health plan (as defined in 
        section 1251(e) of the Patient Protection and Affordable Care 
        Act) shall, not less frequently than once every 3 months (or, 
        in the case of information described in paragraph (2)(B), not 
        less frequently than monthly), make available to the public the 
        rate and payment information described in paragraph (2) in 
        accordance with paragraph (3).
            ``(2) Rate and payment information described.--For purposes 
        of paragraph (1), the rate and payment information described in 
        this paragraph is, with respect to a group health plan, the 
        following:
                    ``(A) With respect to each item or service (other 
                than a drug) for which benefits are available under 
                such plan, the in-network rate in effect with each 
                provider that is a participating provider with respect 
                to such item or service, other than such a rate in 
                effect with a provider that, during the 1-year period 
                ending 10 business days before the date of the 
                publication of such information, did not submit any 
                claim for such item or service to such plan.
                    ``(B) With respect to each drug (identified by 
                national drug code) for which benefits are available 
                under such plan, the average amount paid by such plan 
                (net of rebates, discounts, and price concessions) for 
                such drug dispensed or administered during the 90-day 
                period beginning 180 days before such date of 
                publication to each provider that was a participating 
                provider with respect to such drug, broken down by each 
                such provider, other than such an amount paid to a 
                provider that, during such period, submitted fewer than 
                20 claims for such drug to such plan.
                    ``(C) With respect to each item or service for 
                which benefits are available under such plan, the 
                amount billed, and the amount allowed by the plan, for 
                each such item or service furnished during the 90-day 
                period specified in subparagraph (B) by a provider that 
                was not a participating provider with respect to such 
                item or service, broken down by each such provider, 
                other than items and services with respect to which 
                fewer than 20 claims for such item or service were 
                submitted to such plan during such period.
            ``(3) Manner of publication.--Rate and payment information 
        required to be made available under this subsection shall be so 
        made available in dollar amounts through 3 separate machine-
        readable files (or any successor technology, such as 
        application program interface technology, determined 
        appropriate by the Secretary) corresponding to the information 
        described in each of subparagraphs (A) through (C) of paragraph 
        (2) that meet such requirements as specified by the Secretary. 
        Such requirements shall ensure that such files are limited to 
        an appropriate size, do not include disclosure of unnecessary 
        duplicative information contained in other files made available 
        under this subsection, are made available in a widely-available 
        format through a publicly-available website that allows for 
        information contained in such files to be compared across group 
        health plans, and are accessible to individuals at no cost and 
        without the need to establish a user account or provide other 
        credentials.
            ``(4) User instructions.--Each group health plan shall make 
        available to the public instructions written in plain language 
        explaining how individuals may search for information described 
        in paragraph (2) in files submitted in accordance with 
        paragraph (3). The Secretary shall develop and publish a 
        template that such a plan may use in developing instructions 
        for purposes of the preceding sentence.
            ``(5) Attestation.--Each group health plan shall post, 
        along with rate and payment information made public by such 
        plan, an attestation that such information is complete and 
        accurate.
    ``(c) Definitions.--In this section:
            ``(1) Participating provider.--The term `participating 
        provider' has the meaning given such term in section 9816.
            ``(2) In-network rate.--The term `in-network rate' means, 
        with respect to a health plan and an item or service furnished 
        by a provider that is a participating provider with respect to 
        such plan and item or service, the contracted rate in effect 
        between such plan and such provider for such item or 
        service.''.
                    (B) Clerical amendment.--The item relating to 
                section 9819 of the table of sections for subchapter B 
                of chapter 100 of the Internal Revenue Code of 1986 is 
                amended to read as follows:

``Sec. 9819. Price transparency requirements.''.
            (2) PHSA.--Section 2799A-4 of the Public Health Service Act 
        (42 U.S.C. 300gg-114) is amended to read as follows:

``SEC. 2799A-4. PRICE TRANSPARENCY REQUIREMENTS.

    ``(a) Cost Sharing Transparency.--
            ``(1) In general.--For plan years beginning on or after the 
        date that is 2 years after the date of the enactment of the 
        Health Care Price Transparency Act of 2023, a group health plan 
        or a health insurance issuer offering group or individual 
        health insurance coverage shall permit individuals to learn the 
        amount of cost-sharing (including deductibles, copayments, and 
        coinsurance) under the individual's plan or coverage that the 
        individual would be responsible for paying with respect to the 
        furnishing of a specific item or service by a provider in a 
        timely manner upon the request of the individual. At a minimum, 
        such information shall include the information specified in 
        paragraph (2) and shall be made available to such individual 
        through a self-service tool that meets the requirements of 
        paragraph (3) or, at the option of such individual, through a 
        paper disclosure or phone or other electronic disclosure (as 
        selected by such individual and provided at no cost to such 
        individual) that meets such requirements as the Secretary may 
        specify.
            ``(2) Specified information.--For purposes of paragraph 
        (1), the information specified in this paragraph is, with 
        respect to an item or service for which benefits are available 
        under a group health plan or group or individual health 
        insurance coverage furnished by a health care provider to a 
        participant or beneficiary of such plan, or enrollee in such 
        coverage, the following:
                    ``(A) If such provider is a participating provider 
                with respect to such item or service, the in-network 
                rate (as defined in subsection (c)) for such item or 
                service.
                    ``(B) If such provider is not described in 
                subparagraph (A), the maximum allowed amount for such 
                item or service.
                    ``(C) The estimated amount of cost sharing 
                (including deductibles, copayments, and coinsurance) 
                that the participant or beneficiary will incur for such 
                item or service (which, in the case such item or 
                service is to be furnished by a provider described in 
                subparagraph (B), shall be calculated using the maximum 
                amount described in such subparagraph).
                    ``(D) The amount the participant, beneficiary, or 
                enrollee has already accumulated with respect to any 
                deductible or out of pocket maximum, whether for items 
                and services furnished by a participating provider or 
                for items and services furnished by a provider that is 
                not a participating provider, under the plan or 
                coverage (broken down, in the case separate deductibles 
                or maximums apply to separate participants, 
                beneficiaries or enrollees enrolled in the plan or 
                coverage, by such separate deductibles or maximums, in 
                addition to any cumulative deductible or maximum).
                    ``(E) In the case such plan or coverage imposes any 
                frequency or volume limitations with respect to such 
                item or service (excluding medical necessity 
                determinations), the amount that such participant, 
                beneficiary, or enrollee has accrued towards such 
                limitation with respect to such item or service.
                    ``(F) Any prior authorization, concurrent review, 
                step therapy, fail first, or similar requirements 
                applicable to coverage of such item or service under 
                such plan or coverage.
        The Secretary may provide that information described in any of 
        subparagraphs (A) through (F) not be treated as information 
        specified in this paragraph, and specify additional information 
        that shall be treated as information specified in this 
        paragraph, if determined appropriate by the Secretary.
            ``(3) Self-service tool.--For purposes of paragraph (1), a 
        self-service tool established by a group health plan or group 
        or individual health insurance coverage meets the requirements 
        of this paragraph if such tool--
                    ``(A) is based on an Internet website;
                    ``(B) provides for real-time responses to requests 
                described in paragraph (1);
                    ``(C) is updated in a manner such that information 
                provided through such tool is timely and accurate at 
                the time such request is made;
                    ``(D) allows such a request to be made with respect 
                to an item or service furnished by--
                            ``(i) a specific provider that is a 
                        participating provider with respect to such 
                        item or service;
                            ``(ii) all providers that are participating 
                        providers with respect to such item or service; 
                        or
                            ``(iii) a provider that is not described in 
                        clause (ii);
                    ``(E) provides that such a request may be made with 
                respect to an item or service through use of the 
                billing code for such item or service or through use of 
                a descriptive term for such item or service; and
                    ``(F) meets any other requirement determined 
                appropriate by the Secretary.
        The Secretary may require such tool, as a condition of 
        complying with subparagraph (E), to link multiple billing codes 
        to a single descriptive term if the Secretary determines that 
        the billing codes to be so linked correspond to similar items 
        and services.
    ``(b) Rate and Payment Information.--
            ``(1) In general.--For plan years beginning on or after the 
        date that is 2 years after the date of the enactment of the 
        Health Care Price Transparency Act of 2023, each group health 
        plan (other than a grandfathered health plan (as defined in 
        section 1251(e) of the Patient Protection and Affordable Care 
        Act) or group or individual health insurance coverage, shall, 
        not less frequently than once every 3 months (or, in the case 
        of information described in paragraph (2)(B), not less 
        frequently than monthly), make available to the public the rate 
        and payment information described in paragraph (2) in 
        accordance with paragraph (3).
            ``(2) Rate and payment information described.--For purposes 
        of paragraph (1), the rate and payment information described in 
        this paragraph is, with respect to a group health plan or group 
        or individual health insurance coverage, the following:
                    ``(A) With respect to each item or service (other 
                than a drug) for which benefits are available under 
                such plan or coverage, the in-network rate in effect 
                with each provider that is a participating provider 
                with respect to such item or service, other than such a 
                rate in effect with a provider that, during the 1-year 
                period ending 10 business days before the date of the 
                publication of such information, did not submit any 
                claim for such item or service to such plan or 
                coverage.
                    ``(B) With respect to each drug (identified by 
                national drug code) for which benefits are available 
                under such plan, the average amount paid by such plan 
                or coverage (net of rebates, discounts, and price 
                concessions) for such drug dispensed or administered 
                during the 90-day period beginning 180 days before such 
                date of publication to each provider that was a 
                participating provider with respect to such drug, 
                broken down by each such provider, other than such an 
                amount paid to a provider that, during such period, 
                submitted fewer than 20 claims for such drug to such 
                plan or coverage.
                    ``(C) With respect to each item or service for 
                which benefits are available under such plan or 
                coverage, the amount billed, and the amount allowed by 
                the plan or coverage, for each such item or service 
                furnished during the 90-day period specified in 
                subparagraph (B) by a provider that was not a 
                participating provider with respect to such item or 
                service, broken down by each such provider, other than 
                items and services with respect to which fewer than 20 
                claims for such item or service were submitted to such 
                plan or coverage during such period.
            ``(3) Manner of publication.--Rate and payment information 
        required to be made available under this subsection shall be so 
        made available in dollar amounts through 3 separate machine-
        readable files (or any successor technology, such as 
        application program interface technology, determined 
        appropriate by the Secretary) corresponding to the information 
        described in each of subparagraphs (A) through (C) of paragraph 
        (2) that meet such requirements as specified by the Secretary. 
        Such requirements shall ensure that such files are limited to 
        an appropriate size, do not include disclosure of unnecessary 
        duplicative information contained in other files made available 
        under this subsection, are made available in a widely-available 
        format through a publicly-available website that allows for 
        information contained in such files to be compared across group 
        health plans and group and individual health insurance 
        coverage, and are accessible to individuals at no cost and 
        without the need to establish a user account or provide other 
        credentials.
            ``(4) User instructions.--Each group health plan and group 
        or individual health insurance coverage shall make available to 
        the public instructions written in plain language explaining 
        how individuals may search for information described in 
        paragraph (2) in files submitted in accordance with paragraph 
        (3). The Secretary shall develop and publish a template that 
        such a plan or coverage may use in developing instructions for 
        purposes of the preceding sentence.
            ``(5) Attestation.--Each group health plan and group or 
        individual health insurance coverage shall post, along with 
        rate and payment information made public by such plan or 
        coverage, an attestation that such information is complete and 
        accurate.
    ``(c) Definitions.--In this section:
            ``(1) Participating provider.--The term `participating 
        provider' has the meaning given such term in section 2791A-
        1(a)(3)(G)(ii).
            ``(2) In-network rate.--The term `in-network rate' means, 
        with respect to a health plan or coverage and an item or 
        service furnished by a provider that is a participating 
        provider with respect to such plan and item or service, the 
        contracted rate in effect between such plan or coverage and 
        such provider for such item or service.''.
            (3) ERISA.--
                    (A) In general.--Section 719 of the Employee 
                Retirement Income Security Act of 1974 (29 U.S.C. 
                1185h) is amended to read as follows:

``SEC. 719. PRICE TRANSPARENCY REQUIREMENTS.

    ``(a) Cost Sharing Transparency.--
            ``(1) In general.--For plan years beginning on or after the 
        date that is 2 years after the date of the enactment of the 
        Health Care Price Transparency Act of 2023, a group health plan 
        or a health insurance issuer offering group health insurance 
        coverage shall permit individuals to learn the amount of cost-
        sharing (including deductibles, copayments, and coinsurance) 
        under the individual's plan or coverage that the individual 
        would be responsible for paying with respect to the furnishing 
        of a specific item or service by a provider in a timely manner 
        upon the request of the individual. At a minimum, such 
        information shall include the information specified in 
        paragraph (2) and shall be made available to such individual 
        through a self-service tool that meets the requirements of 
        paragraph (3) or, at the option of such individual, through a 
        paper disclosure or phone or other electronic disclosure (as 
        selected by such individual and provided at no cost to such 
        individual) that meets such requirements as the Secretary may 
        specify.
            ``(2) Specified information.--For purposes of paragraph 
        (1), the information specified in this paragraph is, with 
        respect to an item or service for which benefits are available 
        under a group health plan or group health insurance coverage 
        furnished by a health care provider to a participant or 
        beneficiary of such plan, or enrollee in such coverage, the 
        following:
                    ``(A) If such provider is a participating provider 
                with respect to such item or service, the in-network 
                rate (as defined in subsection (c)) for such item or 
                service.
                    ``(B) If such provider is not described in 
                subparagraph (A), the maximum allowed amount for such 
                item or service.
                    ``(C) The estimated amount of cost sharing 
                (including deductibles, copayments, and coinsurance) 
                that the participant or beneficiary will incur for such 
                item or service (which, in the case such item or 
                service is to be furnished by a provider described in 
                subparagraph (B), shall be calculated using the maximum 
                amount described in such subparagraph).
                    ``(D) The amount the participant, beneficiary, or 
                enrollee has already accumulated with respect to any 
                deductible or out of pocket maximum, whether for items 
                and services furnished by a participating provider or 
                for items and services furnished by a provider that is 
                not a participating provider, under the plan or 
                coverage (broken down, in the case separate deductibles 
                or maximums apply to separate participants, 
                beneficiaries or enrollees enrolled in the plan or 
                coverage, by such separate deductibles or maximums, in 
                addition to any cumulative deductible or maximum).
                    ``(E) In the case such plan or coverage imposes any 
                frequency or volume limitations with respect to such 
                item or service (excluding medical necessity 
                determinations), the amount that such participant, 
                beneficiary, or enrollee has accrued towards such 
                limitation with respect to such item or service.
                    ``(F) Any prior authorization, concurrent review, 
                step therapy, fail first, or similar requirements 
                applicable to coverage of such item or service under 
                such plan or coverage.
        The Secretary may provide that information described in any of 
        subparagraphs (A) through (F) not be treated as information 
        specified in this paragraph, and specify additional information 
        that shall be treated as information specified in this 
        paragraph, if determined appropriate by the Secretary.
            ``(3) Self-service tool.--For purposes of paragraph (1), a 
        self-service tool established by a group health plan or group 
        health insurance coverage meets the requirements of this 
        paragraph if such tool--
                    ``(A) is based on an Internet website;
                    ``(B) provides for real-time responses to requests 
                described in paragraph (1);
                    ``(C) is updated in a manner such that information 
                provided through such tool is timely and accurate at 
                the time such request is made;
                    ``(D) allows such a request to be made with respect 
                to an item or service furnished by--
                            ``(i) a specific provider that is a 
                        participating provider with respect to such 
                        item or service;
                            ``(ii) all providers that are participating 
                        providers with respect to such item or service; 
                        or
                            ``(iii) a provider that is not described in 
                        clause (ii);
                    ``(E) provides that such a request may be made with 
                respect to an item or service through use of the 
                billing code for such item or service or through use of 
                a descriptive term for such item or service; and
                    ``(F) meets any other requirement determined 
                appropriate by the Secretary.
        The Secretary may require such tool, as a condition of 
        complying with subparagraph (E), to link multiple billing codes 
        to a single descriptive term if the Secretary determines that 
        the billing codes to be so linked correspond to similar items 
        and services.
    ``(b) Rate and Payment Information.--
            ``(1) In general.--For plan years beginning on or after the 
        date that is 2 years after the date of the enactment of the 
        Health Care Price Transparency Act of 2023, each group health 
        plan (other than a grandfathered health plan (as defined in 
        section 1251(e) of the Patient Protection and Affordable Care 
        Act) or group health insurance coverage, shall, not less 
        frequently than once every 3 months (or, in the case of 
        information described in paragraph (2)(B), not less frequently 
        than monthly), make available to the public the rate and 
        payment information described in paragraph (2) in accordance 
        with paragraph (3).
            ``(2) Rate and payment information described.--For purposes 
        of paragraph (1), the rate and payment information described in 
        this paragraph is, with respect to a group health plan or group 
        health insurance coverage, the following:
                    ``(A) With respect to each item or service (other 
                than a drug) for which benefits are available under 
                such plan or coverage, the in-network rate in effect 
                with each provider that is a participating provider 
                with respect to such item or service, other than such a 
                rate in effect with a provider that, during the 1-year 
                period ending 10 business days before the date of the 
                publication of such information, did not submit any 
                claim for such item or service to such plan or 
                coverage.
                    ``(B) With respect to each drug (identified by 
                national drug code) for which benefits are available 
                under such plan, the average amount paid by such plan 
                or coverage (net of rebates, discounts, and price 
                concessions) for such drug dispensed or administered 
                during the 90-day period beginning 180 days before such 
                date of publication to each provider that was a 
                participating provider with respect to such drug, 
                broken down by each such provider, other than such an 
                amount paid to a provider that, during such period, 
                submitted fewer than 20 claims for such drug to such 
                plan or coverage.
                    ``(C) With respect to each item or service for 
                which benefits are available under such plan or 
                coverage, the amount billed, and the amount allowed by 
                the plan or coverage, for each such item or service 
                furnished during the 90-day period specified in 
                subparagraph (B) by a provider that was not a 
                participating provider with respect to such item or 
                service, broken down by each such provider, other than 
                items and services with respect to which fewer than 20 
                claims for such item or service were submitted to such 
                plan or coverage during such period.
            ``(3) Manner of publication.--Rate and payment information 
        required to be made available under this subsection shall be so 
        made available in dollar amounts through 3 separate machine-
        readable files (or any successor technology, such as 
        application program interface technology, determined 
        appropriate by the Secretary) corresponding to the information 
        described in each of subparagraphs (A) through (C) of paragraph 
        (2) that meet such requirements as specified by the Secretary. 
        Such requirements shall ensure that such files are limited to 
        an appropriate size, do not include disclosure of unnecessary 
        duplicative information contained in other files made available 
        under this subsection, are made available in a widely-available 
        format through a publicly-available website that allows for 
        information contained in such files to be compared across group 
        health plans and group and individual health insurance 
        coverage, and are accessible to individuals at no cost and 
        without the need to establish a user account or provide other 
        credentials.
            ``(4) User instructions.--Each group health plan and group 
        health insurance coverage shall make available to the public 
        instructions written in plain language explaining how 
        individuals may search for information described in paragraph 
        (2) in files submitted in accordance with paragraph (3). The 
        Secretary shall develop and publish a template that such a plan 
        or coverage may use in developing instructions for purposes of 
        the preceding sentence.
            ``(5) Attestation.--Each group health plan and group health 
        insurance coverage shall post, along with rate and payment 
        information made public by such plan or coverage, an 
        attestation that such information is complete and accurate.
    ``(c) Definitions.--In this section:
            ``(1) Participating provider.--The term `participating 
        provider' has the meaning given such term in section 
        716(a)(3)(G)(ii).
            ``(2) In-network rate.--The term `in-network rate' means, 
        with respect to a health plan or coverage and an item or 
        service furnished by a provider that is a participating 
        provider with respect to such plan and item or service, the 
        contracted rate in effect between such plan or coverage and 
        such provider for such item or service.''.
                    (B) Clerical amendment.--The table of contents in 
                section 1 of the Employee Retirement Income Security 
                Act of 1974 is amended by striking the item relating to 
                section 719 and inserting the following new item:

``Sec. 719. Price transparency requirements.''.
    (b) Accessibility Through Implementation.--In implementing the 
amendments made by subsection (a), the Secretary of the Treasury, the 
Secretary of Health and Human Services, and the Secretary of Labor 
shall take reasonable steps to ensure the accessibility of information 
made available pursuant to such amendments, including reasonable steps 
to ensure that such information is provided in plain, easily 
understandable language and that interpretation, translations, and 
assistive services are provided by group health plans and health 
insurance issuers offering group or individual health insurance 
coverage to make such information accessible to those with limited 
English proficiency and those with disabilities.
    (c) Continued Applicability of Rules for Previous Years.--Nothing 
in the amendments made by subsection (a) may be construed as affecting 
the applicability of the rule entitled ``Transparency in Coverage'' 
published by the Department of the Treasury, the Department of Labor, 
and the Department of Health and Human Services on November 12, 2020 
(85 Fed. Reg. 72158) for any plan year beginning before the date that 
is 2 years after the date of the enactment of this Act.

SEC. 103. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.

    (a) IRC.--
            (1) In general.--Subchapter B of chapter 100 of the 
        Internal Revenue Code of 1986 is amended by adding at the end 
        the following:

``SEC. 9826. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.

    ``(a) In General.--For plan years beginning on or after the date 
that is 3 years after the date of enactment of this section, a group 
health plan, or an entity or subsidiary providing pharmacy benefits 
management services on behalf of such a plan, shall not enter into a 
contract with a drug manufacturer, distributor, wholesaler, 
subcontractor, rebate aggregator, or any associated third party that 
limits the disclosure of information to plan sponsors in such a manner 
that prevents the plan, or an entity or subsidiary providing pharmacy 
benefits management services on behalf of a plan, from making the 
report described in subsection (b).
    ``(b) Annual Report.--
            ``(1) In general.--With respect to plan years beginning on 
        or after the date that is 3 years after the date of enactment 
        of this section, for each such plan year, a group health plan, 
        or an entity providing pharmacy benefits management services on 
        behalf of such a plan, shall submit to the plan sponsor (as 
        defined in section 3(16)(B) of the Employee Retirement Income 
        Security Act of 1974) of such plan a report in a machine-
        readable format. Each such report shall include, with respect 
        to such plan provided for such plan year--
                    ``(A) to the extent feasible, information collected 
                from drug manufacturers (or an entity administering 
                copay assistance on behalf of such manufacturers) by 
                such plan (or entity or subsidiary providing pharmacy 
                benefits management services on behalf of such plan) on 
                the total amount of copayment assistance dollars paid, 
                or copayment cards applied, that were funded by the 
                drug manufacturer with respect to the participants and 
                beneficiaries in such plan;
                    ``(B) a list of each drug covered by such plan that 
                was dispensed during the plan year, including, with 
                respect to each such drug during such plan year--
                            ``(i) the brand name, chemical entity, and 
                        National Drug Code;
                            ``(ii) the number of participants and 
                        beneficiaries for whom the drug was dispensed 
                        during the plan year, the total number of 
                        prescription claims for the drug (including 
                        original prescriptions and refills), and the 
                        total number of dosage units of the drug 
                        dispensed across the plan year, disaggregated 
                        by dispensing channel (such as retail, mail 
                        order, or specialty pharmacy);
                            ``(iii) the wholesale acquisition cost, 
                        listed as cost per days supply and cost per 
                        pill, or in the case of a drug in another form, 
                        per dosage unit;
                            ``(iv) the total out-of-pocket spending by 
                        participants and beneficiaries on such drug, 
                        including participant and beneficiary spending 
                        through copayments, coinsurance, and 
                        deductibles;
                            ``(v) for any drug for which gross spending 
                        of the group health plan exceeded $10,000 
                        during the plan year--
                                    ``(I) a list of all other drugs in 
                                the same therapeutic category or class, 
                                including brand name drugs and 
                                biological products and generic drugs 
                                or biosimilar biological products that 
                                are in the same therapeutic category or 
                                class as such drug; and
                                    ``(II) the rationale for the 
                                formulary placement of such drug in 
                                that therapeutic category or class, if 
                                applicable;
                            ``(vi) the amount received, or expected to 
                        be received, from drug manufacturers in 
                        rebates, fees, alternative discounts, or other 
                        remuneration for claims incurred for such drug 
                        during the plan year;
                            ``(vii) the total net spending, after 
                        deducting rebates, price concessions, 
                        alternative discounts or other remuneration 
                        from drug manufacturers, by the health plan on 
                        such drug; and
                            ``(viii) the net price per course of 
                        treatment or single fill, such as a 30-day 
                        supply or 90-day supply, incurred by the health 
                        plan and its participants and beneficiaries 
                        after manufacturer rebates, fees, and other 
                        remuneration for such drug dispensed during the 
                        plan year;
                    ``(C) a list of each therapeutic category or class 
                of drugs that were dispensed under the health plan 
                during the plan year, and, with respect to each such 
                therapeutic category or class of drugs, during the plan 
                year--
                            ``(i) total gross spending by the plan, 
                        before manufacturer rebates, fees, or other 
                        manufacturer remuneration;
                            ``(ii) the number of participants and 
                        beneficiaries who were dispensed a drug covered 
                        by such plan in that category or class, broken 
                        down by each such drug (identified by National 
                        Drug Code);
                            ``(iii) if applicable to that category or 
                        class, a description of the formulary tiers and 
                        utilization management (such as prior 
                        authorization or step therapy) employed for 
                        drugs in that category or class; and
                            ``(iv) the total out-of-pocket spending by 
                        participants and beneficiaries, including 
                        participant and beneficiary spending through 
                        copayments, coinsurance, and deductibles;
                    ``(D) total gross spending on prescription drugs by 
                the plan during the plan year, before rebates and other 
                manufacturer fees or remuneration;
                    ``(E) total amount received, or expected to be 
                received, by the health plan in drug manufacturer 
                rebates, fees, alternative discounts, and all other 
                remuneration received from the manufacturer or any 
                third party, other than the plan sponsor, related to 
                utilization of drug or drug spending under that health 
                plan during the plan year;
                    ``(F) the total net spending on prescription drugs 
                by the health plan during the plan year; and
                    ``(G) amounts paid directly or indirectly in 
                rebates, fees, or any other type of remuneration to 
                brokers, consultants, advisors, or any other individual 
                or firm for the referral of the group health plan's 
                business to the pharmacy benefits manager.
            ``(2) Privacy requirements.--Entities providing pharmacy 
        benefits management services on behalf of a group health plan 
        shall provide information under paragraph (1) in a manner 
        consistent with the privacy, security, and breach notification 
        regulations promulgated under section 264(c) of the Health 
        Insurance Portability and Accountability Act of 1996, and shall 
        restrict the use and disclosure of such information according 
        to such privacy regulations.
            ``(3) Disclosure and redisclosure.--
                    ``(A) Limitation to business associates.--A group 
                health plan receiving a report under paragraph (1) may 
                disclose such information only to business associates 
                of such plan as defined in section 160.103 of title 45, 
                Code of Federal Regulations (or successor regulations).
                    ``(B) Clarification regarding public disclosure of 
                information.--Nothing in this section prevents an 
                entity providing pharmacy benefits management services 
                on behalf of a group health plan from placing 
                reasonable restrictions on the public disclosure of the 
                information contained in a report described in 
                paragraph (1), except that such entity may not restrict 
                disclosure of such report to the Department of Health 
                and Human Services, the Department of Labor, the 
                Department of the Treasury, the Comptroller General of 
                the United States, or applicable State agencies.
                    ``(C) Limited form of report.--The Secretary shall 
                define through rulemaking a limited form of the report 
                under paragraph (1) required of plan sponsors who are 
                drug manufacturers, drug wholesalers, or other direct 
                participants in the drug supply chain, in order to 
                prevent anti-competitive behavior.
            ``(4) Report to gao.--A group health plan, or an entity 
        providing pharmacy benefits management services on behalf of a 
        group health plan, shall submit to the Comptroller General of 
        the United States each of the first 4 reports submitted to a 
        plan sponsor under paragraph (1) with respect to such plan, and 
        other such reports as requested, in accordance with the privacy 
        requirements under paragraph (2), the disclosure and 
        redisclosure standards under paragraph (3), the standards 
        specified pursuant to paragraph (5), and such other information 
        that the Comptroller General determines necessary to carry out 
        the study under section 103(d) of the Health Care Price 
        Transparency Act of 2023.
            ``(5) Standard format.--Not later than 18 months after the 
        date of enactment of this section, the Secretary shall specify 
        through rulemaking standards for entities required to submit 
        reports under paragraph (4) to submit such reports in a 
        standard format.
    ``(c) Rule of Construction.--Nothing in this section shall be 
construed to permit a group health plan or other entity to restrict 
disclosure to, or otherwise limit the access of, the Secretary of the 
Treasury to a report described in subsection (b)(1) or information 
related to compliance with subsection (a) or (b) by such plan or other 
entity subject to such subsections.
    ``(d) Definition.--In this section, the term `wholesale acquisition 
cost' has the meaning given such term in section 1847A(c)(6)(B) of the 
Social Security Act.''.
            (2) Clerical amendment.--The table of sections for 
        subchapter B of chapter 100 of the Internal Revenue Code of 
        1986 is amended by adding at the end the following new item:

``Sec. 9826. Oversight of pharmacy benefits manager services.''.
    (b) PHSA.--Title XXVII of the Public Health Service Act (42 U.S.C. 
300gg et seq.) is amended--
            (1) in part D (42 U.S.C. 300gg-111 et seq.), by adding at 
        the end the following new section:

``SEC. 2799A-11. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.

    ``(a) In General.--For plan years beginning on or after the date 
that is 3 years after the date of enactment of this section, a group 
health plan or health insurance issuer offering group health insurance 
coverage, or an entity or subsidiary providing pharmacy benefits 
management services on behalf of such a plan or issuer, shall not enter 
into a contract with a drug manufacturer, distributor, wholesaler, 
subcontractor, rebate aggregator, or any associated third party that 
limits the disclosure of information to plan sponsors in such a manner 
that prevents the plan or issuer, or an entity or subsidiary providing 
pharmacy benefits management services on behalf of a plan or issuer, 
from making the report described in subsection (b).
    ``(b) Annual Report.--
            ``(1) In general.--With respect to plan years beginning on 
        or after the date that is 3 years after the date of enactment 
        of this section, for each such plan year, a group health plan 
        or health insurance issuer offering group health insurance 
        coverage, or an entity providing pharmacy benefits management 
        services on behalf of such a plan or an issuer, shall submit to 
        the plan sponsor (as defined in section 3(16)(B) of the 
        Employee Retirement Income Security Act of 1974) of such plan 
        or coverage a report in a machine-readable format. Each such 
        report shall include, with respect to such plan or coverage 
        provided for such plan year--
                    ``(A) to the extent feasible, information collected 
                from drug manufacturers (or an entity administering 
                copay assistance on behalf of such manufacturers) by 
                such plan or issuer (or entity or subsidiary providing 
                pharmacy benefits management services on behalf of such 
                plan or issuer) on the total amount of copayment 
                assistance dollars paid, or copayment cards applied, 
                that were funded by the drug manufacturer with respect 
                to the participants, beneficiaries, and enrollees in 
                such plan or coverage;
                    ``(B) a list of each drug covered by such plan or 
                coverage that was dispensed during the plan year, 
                including, with respect to each such drug during such 
                plan year--
                            ``(i) the brand name, chemical entity, and 
                        National Drug Code;
                            ``(ii) the number of participants, 
                        beneficiaries, and enrollees for whom the drug 
                        was dispensed during the plan year, the total 
                        number of prescription claims for the drug 
                        (including original prescriptions and refills), 
                        and the total number of dosage units of the 
                        drug dispensed across the plan year, 
                        disaggregated by dispensing channel (such as 
                        retail, mail order, or specialty pharmacy);
                            ``(iii) the wholesale acquisition cost, 
                        listed as cost per days supply and cost per 
                        pill, or in the case of a drug in another form, 
                        per dosage unit;
                            ``(iv) the total out-of-pocket spending by 
                        participants, beneficiaries, and enrollees on 
                        such drug, including participant, beneficiary, 
                        and enrollee spending through copayments, 
                        coinsurance, and deductibles;
                            ``(v) for any drug for which gross spending 
                        of the group health plan or health insurance 
                        coverage exceeded $10,000 during the plan 
                        year--
                                    ``(I) a list of all other drugs in 
                                the same therapeutic category or class, 
                                including brand name drugs and 
                                biological products and generic drugs 
                                or biosimilar biological products that 
                                are in the same therapeutic category or 
                                class as such drug; and
                                    ``(II) the rationale for the 
                                formulary placement of such drug in 
                                that therapeutic category or class, if 
                                applicable;
                            ``(vi) the amount received, or expected to 
                        be received, from drug manufacturers in 
                        rebates, fees, alternative discounts, or other 
                        remuneration for claims incurred for such drug 
                        during the plan year;
                            ``(vii) the total net spending, after 
                        deducting rebates, price concessions, 
                        alternative discounts or other remuneration 
                        from drug manufacturers, by the health plan or 
                        health insurance coverage on such drug; and
                            ``(viii) the net price per course of 
                        treatment or single fill, such as a 30-day 
                        supply or 90-day supply, incurred by the health 
                        plan or health insurance coverage and its 
                        participants, beneficiaries, and enrollees, 
                        after manufacturer rebates, fees, and other 
                        remuneration for such drug dispensed during the 
                        plan year;
                    ``(C) a list of each therapeutic category or class 
                of drugs that were dispensed under the health plan or 
                health insurance coverage during the plan year, and, 
                with respect to each such therapeutic category or class 
                of drugs, during the plan year--
                            ``(i) total gross spending by the plan or 
                        coverage, before manufacturer rebates, fees, or 
                        other manufacturer remuneration;
                            ``(ii) the number of participants, 
                        beneficiaries, and enrollees who were dispensed 
                        a drug covered by such plan or coverage in that 
                        category or class, broken down by each such 
                        drug (identified by National Drug Code);
                            ``(iii) if applicable to that category or 
                        class, a description of the formulary tiers and 
                        utilization management (such as prior 
                        authorization or step therapy) employed for 
                        drugs in that category or class; and
                            ``(iv) the total out-of-pocket spending by 
                        participants, beneficiaries, and enrollees, 
                        including participant, beneficiary, and 
                        enrollee spending through copayments, 
                        coinsurance, and deductibles;
                    ``(D) total gross spending on prescription drugs by 
                the plan or coverage during the plan year, before 
                rebates and other manufacturer fees or remuneration;
                    ``(E) total amount received, or expected to be 
                received, by the health plan or health insurance 
                coverage in drug manufacturer rebates, fees, 
                alternative discounts, and all other remuneration 
                received from the manufacturer or any third party, 
                other than the plan sponsor, related to utilization of 
                drug or drug spending under that health plan or health 
                insurance coverage during the plan year;
                    ``(F) the total net spending on prescription drugs 
                by the health plan or health insurance coverage during 
                the plan year; and
                    ``(G) amounts paid directly or indirectly in 
                rebates, fees, or any other type of remuneration to 
                brokers, consultants, advisors, or any other individual 
                or firm for the referral of the group health plan's or 
                health insurance issuer's business to the pharmacy 
                benefits manager.
            ``(2) Privacy requirements.--Health insurance issuers 
        offering group health insurance coverage and entities providing 
        pharmacy benefits management services on behalf of a group 
        health plan shall provide information under paragraph (1) in a 
        manner consistent with the privacy, security, and breach 
        notification regulations promulgated under section 264(c) of 
        the Health Insurance Portability and Accountability Act of 
        1996, and shall restrict the use and disclosure of such 
        information according to such privacy regulations.
            ``(3) Disclosure and redisclosure.--
                    ``(A) Limitation to business associates.--A group 
                health plan receiving a report under paragraph (1) may 
                disclose such information only to business associates 
                of such plan as defined in section 160.103 of title 45, 
                Code of Federal Regulations (or successor regulations).
                    ``(B) Clarification regarding public disclosure of 
                information.--Nothing in this section prevents a health 
                insurance issuer offering group health insurance 
                coverage or an entity providing pharmacy benefits 
                management services on behalf of a group health plan 
                from placing reasonable restrictions on the public 
                disclosure of the information contained in a report 
                described in paragraph (1), except that such issuer or 
                entity may not restrict disclosure of such report to 
                the Department of Health and Human Services, the 
                Department of Labor, the Department of the Treasury, 
                the Comptroller General of the United States, or 
                applicable State agencies.
                    ``(C) Limited form of report.--The Secretary shall 
                define through rulemaking a limited form of the report 
                under paragraph (1) required of plan sponsors who are 
                drug manufacturers, drug wholesalers, or other direct 
                participants in the drug supply chain, in order to 
                prevent anti-competitive behavior.
            ``(4) Report to gao.--A group health plan or health 
        insurance issuer offering group health insurance coverage, or 
        an entity providing pharmacy benefits management services on 
        behalf of a group health plan shall submit to the Comptroller 
        General of the United States each of the first 4 reports 
        submitted to a plan sponsor under paragraph (1) with respect to 
        such coverage or plan, and other such reports as requested, in 
        accordance with the privacy requirements under paragraph (2), 
        the disclosure and redisclosure standards under paragraph (3), 
        the standards specified pursuant to paragraph (5), and such 
        other information that the Comptroller General determines 
        necessary to carry out the study under section 103(d) of the 
        Health Care Price Transparency Act of 2023.
            ``(5) Standard format.--Not later than 18 months after the 
        date of enactment of this section, the Secretary shall specify 
        through rulemaking standards for health insurance issuers and 
        entities required to submit reports under paragraph (4) to 
        submit such reports in a standard format.
    ``(c) Enforcement.--
            ``(1) In general.--Notwithstanding section 2723, the 
        Secretary, in consultation with the Secretary of Labor and the 
        Secretary of the Treasury, shall enforce this section.
            ``(2) Failure to provide timely information.--A health 
        insurance issuer or an entity providing pharmacy benefits 
        management services that violates subsection (a) or fails to 
        provide information required under subsection (b) shall be 
        subject to a civil monetary penalty in the amount of $10,000 
        for each day during which such violation continues or such 
        information is not disclosed or reported.
            ``(3) False information.--A health insurance issuer or 
        entity providing pharmacy benefits management services that 
        knowingly provides false information under this section shall 
        be subject to a civil money penalty in an amount not to exceed 
        $100,000 for each item of false information. Such civil money 
        penalty shall be in addition to other penalties as may be 
        prescribed by law.
            ``(4) Procedure.--The provisions of section 1128A of the 
        Social Security Act, other than subsection (a) and (b) and the 
        first sentence of subsection (c)(1) of such section shall apply 
        to civil monetary penalties under this subsection in the same 
        manner as such provisions apply to a penalty or proceeding 
        under section 1128A of the Social Security Act.
            ``(5) Waivers.--The Secretary may waive penalties under 
        paragraph (2), or extend the period of time for compliance with 
        a requirement of this section, for an entity in violation of 
        this section that has made a good-faith effort to comply with 
        this section.
    ``(d) Rule of Construction.--Nothing in this section shall be 
construed to permit a health insurance issuer, group health plan, or 
other entity to restrict disclosure to, or otherwise limit the access 
of, the Secretary of Health and Human Services to a report described in 
subsection (b)(1) or information related to compliance with subsection 
(a) or (b) by such issuer, plan, or other entity subject to such 
subsections.
    ``(e) Definition.--In this section, the term `wholesale acquisition 
cost' has the meaning given such term in section 1847A(c)(6)(B) of the 
Social Security Act.''; and
            (2) in section 2723 of such Act (42 U.S.C. 300gg-22)--
                    (A) in subsection (a)--
                            (i) in paragraph (1), by inserting ``(other 
                        than subsections (a) and (b) of section 2799A-
                        11)'' after ``part D''; and
                            (ii) in paragraph (2), by inserting 
                        ``(other than subsections (a) and (b) of 
                        section 2799A-11)'' after ``part D''; and
                    (B) in subsection (b)--
                            (i) in paragraph (1), by inserting ``(other 
                        than subsections (a) and (b) of section 2799A-
                        11)'' after ``part D'';
                            (ii) in paragraph (2)(A), by inserting 
                        ``(other than subsections (a) and (b) of 
                        section 2799A-11)'' after ``part D''; and
                            (iii) in paragraph (2)(C)(ii), by inserting 
                        ``(other than subsections (a) and (b) of 
                        section 2799A-11)'' after ``part D''.
    (c) ERISA.--
            (1) In general.--Subtitle B of title I of the Employee 
        Retirement Income Security Act of 1974 (29 U.S.C. 1021 et seq.) 
        is amended--
                    (A) in subpart B of part 7 (29 U.S.C. 1185 et 
                seq.), by adding at the end the following:

``SEC. 726. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.

    ``(a) In General.--For plan years beginning on or after the date 
that is 3 years after the date of enactment of this section, a group 
health plan or health insurance issuer offering group health insurance 
coverage, or an entity or subsidiary providing pharmacy benefits 
management services on behalf of such a plan or issuer, shall not enter 
into a contract with a drug manufacturer, distributor, wholesaler, 
subcontractor, rebate aggregator, or any associated third party that 
limits the disclosure of information to plan sponsors in such a manner 
that prevents the plan or issuer, or an entity or subsidiary providing 
pharmacy benefits management services on behalf of a plan or issuer, 
from making the report described in subsection (b).
    ``(b) Annual Report.--
            ``(1) In general.--With respect to plan years beginning on 
        or after the date that is 3 years after the date of enactment 
        of this section, for each such plan year, a group health plan 
        or health insurance issuer offering group health insurance 
        coverage, or an entity providing pharmacy benefits management 
        services on behalf of such a plan or an issuer, shall submit to 
        the plan sponsor (as defined in section 3(16)(B)) of such plan 
        or coverage a report in a machine-readable format. Each such 
        report shall include, with respect to such plan or coverage 
        provided for such plan year--
                    ``(A) to the extent feasible, information collected 
                from drug manufacturers (or an entity administering 
                copay assistance on behalf of such manufacturers) by 
                such plan or issuer (or entity or subsidiary providing 
                pharmacy benefits management services on behalf of such 
                plan or issuer) on the total amount of copayment 
                assistance dollars paid, or copayment cards applied, 
                that were funded by the drug manufacturer with respect 
                to the participants, beneficiaries, and enrollees in 
                such plan or coverage;
                    ``(B) a list of each drug covered by such plan or 
                coverage that was dispensed during the plan year, 
                including, with respect to each such drug during such 
                plan year--
                            ``(i) the brand name, chemical entity, and 
                        National Drug Code;
                            ``(ii) the number of participants, 
                        beneficiaries, and enrollees for whom the drug 
                        was dispensed during the plan year, the total 
                        number of prescription claims for the drug 
                        (including original prescriptions and refills), 
                        and the total number of dosage units of the 
                        drug dispensed across the plan year, 
                        disaggregated by dispensing channel (such as 
                        retail, mail order, or specialty pharmacy);
                            ``(iii) the wholesale acquisition cost, 
                        listed as cost per days supply and cost per 
                        pill, or in the case of a drug in another form, 
                        per dosage unit;
                            ``(iv) the total out-of-pocket spending by 
                        participants, beneficiaries, and enrollees on 
                        such drug, including participant, beneficiary, 
                        and enrollee spending through copayments, 
                        coinsurance, and deductibles;
                            ``(v) for any drug for which gross spending 
                        of the group health plan or health insurance 
                        coverage exceeded $10,000 during the plan 
                        year--
                                    ``(I) a list of all other drugs in 
                                the same therapeutic category or class, 
                                including brand name drugs and 
                                biological products and generic drugs 
                                or biosimilar biological products that 
                                are in the same therapeutic category or 
                                class as such drug; and
                                    ``(II) the rationale for the 
                                formulary placement of such drug in 
                                that therapeutic category or class, if 
                                applicable;
                            ``(vi) the amount received, or expected to 
                        be received, from drug manufacturers in 
                        rebates, fees, alternative discounts, or other 
                        remuneration for claims incurred for such drug 
                        during the plan year;
                            ``(vii) the total net spending, after 
                        deducting rebates, price concessions, 
                        alternative discounts or other remuneration 
                        from drug manufacturers, by the health plan or 
                        health insurance coverage on such drug; and
                            ``(viii) the net price per course of 
                        treatment or single fill, such as a 30-day 
                        supply or 90-day supply, incurred by the health 
                        plan or health insurance coverage and its 
                        participants, beneficiaries, and enrollees, 
                        after manufacturer rebates, fees, and other 
                        remuneration for such drug dispensed during the 
                        plan year;
                    ``(C) a list of each therapeutic category or class 
                of drugs that were dispensed under the health plan or 
                health insurance coverage during the plan year, and, 
                with respect to each such therapeutic category or class 
                of drugs, during the plan year--
                            ``(i) total gross spending by the plan or 
                        coverage, before manufacturer rebates, fees, or 
                        other manufacturer remuneration;
                            ``(ii) the number of participants, 
                        beneficiaries, and enrollees who were dispensed 
                        a drug covered by such plan or coverage in that 
                        category or class, broken down by each such 
                        drug (identified by National Drug Code);
                            ``(iii) if applicable to that category or 
                        class, a description of the formulary tiers and 
                        utilization management (such as prior 
                        authorization or step therapy) employed for 
                        drugs in that category or class; and
                            ``(iv) the total out-of-pocket spending by 
                        participants, beneficiaries, and enrollees, 
                        including participant, beneficiary, and 
                        enrollee spending through copayments, 
                        coinsurance, and deductibles;
                    ``(D) total gross spending on prescription drugs by 
                the plan or coverage during the plan year, before 
                rebates and other manufacturer fees or remuneration;
                    ``(E) total amount received, or expected to be 
                received, by the health plan or health insurance 
                coverage in drug manufacturer rebates, fees, 
                alternative discounts, and all other remuneration 
                received from the manufacturer or any third party, 
                other than the plan sponsor, related to utilization of 
                drug or drug spending under that health plan or health 
                insurance coverage during the plan year;
                    ``(F) the total net spending on prescription drugs 
                by the health plan or health insurance coverage during 
                the plan year; and
                    ``(G) amounts paid directly or indirectly in 
                rebates, fees, or any other type of remuneration to 
                brokers, consultants, advisors, or any other individual 
                or firm for the referral of the group health plan's or 
                health insurance issuer's business to the pharmacy 
                benefits manager.
            ``(2) Privacy requirements.--Health insurance issuers 
        offering group health insurance coverage and entities providing 
        pharmacy benefits management services on behalf of a group 
        health plan shall provide information under paragraph (1) in a 
        manner consistent with the privacy, security, and breach 
        notification regulations promulgated under section 264(c) of 
        the Health Insurance Portability and Accountability Act of 
        1996, and shall restrict the use and disclosure of such 
        information according to such privacy regulations.
            ``(3) Disclosure and redisclosure.--
                    ``(A) Limitation to business associates.--A group 
                health plan receiving a report under paragraph (1) may 
                disclose such information only to business associates 
                of such plan as defined in section 160.103 of title 45, 
                Code of Federal Regulations (or successor regulations).
                    ``(B) Clarification regarding public disclosure of 
                information.--Nothing in this section prevents a health 
                insurance issuer offering group health insurance 
                coverage or an entity providing pharmacy benefits 
                management services on behalf of a group health plan 
                from placing reasonable restrictions on the public 
                disclosure of the information contained in a report 
                described in paragraph (1), except that such issuer or 
                entity may not restrict disclosure of such report to 
                the Department of Health and Human Services, the 
                Department of Labor, the Department of the Treasury, 
                the Comptroller General of the United States, or 
                applicable State agencies.
                    ``(C) Limited form of report.--The Secretary shall 
                define through rulemaking a limited form of the report 
                under paragraph (1) required of plan sponsors who are 
                drug manufacturers, drug wholesalers, or other direct 
                participants in the drug supply chain, in order to 
                prevent anti-competitive behavior.
            ``(4) Report to gao.--A group health plan or health 
        insurance issuer offering group health insurance coverage, or 
        an entity providing pharmacy benefits management services on 
        behalf of a group health plan shall submit to the Comptroller 
        General of the United States each of the first 4 reports 
        submitted to a plan sponsor under paragraph (1) with respect to 
        such coverage or plan, and other such reports as requested, in 
        accordance with the privacy requirements under paragraph (2), 
        the disclosure and redisclosure standards under paragraph (3), 
        the standards specified pursuant to paragraph (5), and such 
        other information that the Comptroller General determines 
        necessary to carry out the study under section 103(d) of the 
        Health Care Price Transparency Act of 2023.
            ``(5) Standard format.--Not later than 18 months after the 
        date of enactment of this section, the Secretary shall specify 
        through rulemaking standards for health insurance issuers and 
        entities required to submit reports under paragraph (4) to 
        submit such reports in a standard format.
    ``(c) Enforcement.--
            ``(1) In general.--Notwithstanding section 502, the 
        Secretary, in consultation with the Secretary of Health and 
        Human Services and the Secretary of the Treasury, shall enforce 
        this section.
            ``(2) Failure to provide timely information.--A health 
        insurance issuer or an entity providing pharmacy benefits 
        management services that violates subsection (a) or fails to 
        provide information required under subsection (b) shall be 
        subject to a civil monetary penalty in the amount of $10,000 
        for each day during which such violation continues or such 
        information is not disclosed or reported.
            ``(3) False information.--A health insurance issuer or 
        entity providing pharmacy benefits management services that 
        knowingly provides false information under this section shall 
        be subject to a civil money penalty in an amount not to exceed 
        $100,000 for each item of false information. Such civil money 
        penalty shall be in addition to other penalties as may be 
        prescribed by law.
            ``(4) Procedure.--The provisions of section 1128A of the 
        Social Security Act, other than subsection (a) and (b) and the 
        first sentence of subsection (c)(1) of such section shall apply 
        to civil monetary penalties under this subsection in the same 
        manner as such provisions apply to a penalty or proceeding 
        under section 1128A of the Social Security Act.
            ``(5) Waivers.--The Secretary may waive penalties under 
        paragraph (2), or extend the period of time for compliance with 
        a requirement of this section, for an entity in violation of 
        this section that has made a good-faith effort to comply with 
        this section.
    ``(d) Rule of Construction.--Nothing in this section shall be 
construed to permit a health insurance issuer, group health plan, or 
other entity to restrict disclosure to, or otherwise limit the access 
of, the Secretary of Labor to a report described in subsection (b)(1) 
or information related to compliance with subsection (a) or (b) by such 
issuer, plan, or other entity subject to such subsections.
    ``(e) Definition.--In this section, the term `wholesale acquisition 
cost' has the meaning given such term in section 1847A(c)(6)(B) of the 
Social Security Act.''; and
                    (B) in section 502 (29 U.S.C. 1132)--
                            (i) in subsection (a)--
                                    (I) in paragraph (6), by striking 
                                ``or (9)'' and inserting ``(9), or 
                                (13)'';
                                    (II) in paragraph (10), by striking 
                                at the end ``or'';
                                    (III) in paragraph (11), at the end 
                                by striking the period and inserting 
                                ``; or''; and
                                    (IV) by adding at the end the 
                                following new paragraph:
            ``(12) by the Secretary, in consultation with the Secretary 
        of Health and Human Services, and the Secretary of the 
        Treasury, to enforce section 726.'';
                            (ii) in subsection (b)(3), by inserting 
                        ``and subsections (a)(12) and (c)(13)'' before 
                        ``, the Secretary is not''; and
                            (iii) in subsection (c), by adding at the 
                        end the following new paragraph:
            ``(13) Secretarial enforcement authority relating to 
        oversight of pharmacy benefits manager services.--
                    ``(A) Failure to provide timely information.--The 
                Secretary, in consultation with the Secretary of Health 
                and Human Services and the Secretary of the Treasury, 
                may impose a penalty against any group health plan or 
                health insurance issuer offering group health insurance 
                coverage, or entity providing pharmacy benefits 
                management services on behalf of such plan or coverage, 
                that violates section 726(a) or fails to provide 
                information required under section 726(b), in the 
                amount of $10,000 for each day during which such 
                violation continues or such information is not 
                disclosed or reported.
                    ``(B) False information.--The Secretary, in 
                consultation with the Secretary of Health and Human 
                Services and the Secretary of the Treasury, may impose 
                a penalty against a group health plan or health 
                insurance issuer offering group health coverage, or an 
                entity providing pharmacy benefits management services 
                on behalf of such plan or coverage, that knowingly 
                provides false information under section 726 in an 
                amount not to exceed $100,000 for each item of false 
                information. Such penalty shall be in addition to other 
                penalties as may be prescribed by law.
                    ``(C) Waivers.--The Secretary may waive penalties 
                under subparagraph (A), or extend the period of time 
                for compliance with a requirement of section 726, for 
                an entity in violation of such section that has made a 
                good-faith effort to comply with such section.''.
            (2) Clerical amendment.--The table of contents in section 1 
        of the Employee Retirement Income Security Act of 1974 (29 
        U.S.C. 1001 et seq.) is amended by inserting after the item 
        relating to section 725 the following new item:

``Sec. 726. Oversight of pharmacy benefits manager services.''.
    (d) GAO Study.--
            (1) In general.--Not later than 3 years after the date of 
        enactment of this Act, the Comptroller General of the United 
        States shall submit to Congress a report on--
                    (A) pharmacy networks of group health plans, health 
                insurance issuers, and entities providing pharmacy 
                benefits management services under such group health 
                plan or group or individual health insurance coverage, 
                including networks that have pharmacies that are under 
                common ownership (in whole or part) with group health 
                plans, health insurance issuers, or entities providing 
                pharmacy benefits management services or pharmacy 
                benefits administrative services under group health 
                plan or group or individual health insurance coverage;
                    (B) as it relates to pharmacy networks that include 
                pharmacies under common ownership described in 
                subparagraph (A)--
                            (i) whether such networks are designed to 
                        encourage enrollees of a plan or coverage to 
                        use such pharmacies over other network 
                        pharmacies for specific services or drugs, and 
                        if so, the reasons the networks give for 
                        encouraging use of such pharmacies; and
                            (ii) whether such pharmacies are used by 
                        enrollees disproportionately more in the 
                        aggregate or for specific services or drugs 
                        compared to other network pharmacies;
                    (C) whether group health plans and health insurance 
                issuers offering group or individual health insurance 
                coverage have options to elect different network 
                pricing arrangements in the marketplace with entities 
                that provide pharmacy benefits management services, the 
                prevalence of electing such different network pricing 
                arrangements;
                    (D) pharmacy network design parameters that 
                encourage enrollees in the plan or coverage to fill 
                prescriptions at mail order, specialty, or retail 
                pharmacies that are wholly or partially-owned by that 
                issuer or entity; and
                    (E) the degree to which mail order, specialty, or 
                retail pharmacies that dispense prescription drugs to 
                an enrollee in a group health plan or health insurance 
                coverage that are under common ownership (in whole or 
                part) with group health plans, health insurance 
                issuers, or entities providing pharmacy benefits 
                management services or pharmacy benefits administrative 
                services under group health plan or group or individual 
                health insurance coverage receive reimbursement that is 
                greater than the median price charged to the group 
                health plan or health insurance issuer when the same 
                drug is dispensed to enrollees in the plan or coverage 
                by other pharmacies included in the pharmacy network of 
                that plan, issuer, or entity that are not wholly or 
                partially owned by the health insurance issuer or 
                entity providing pharmacy benefits management services.
            (2) Requirement.--The Comptroller General of the United 
        States shall ensure that the report under paragraph (1) does 
        not contain information that would allow a reader to identify a 
        specific plan or entity providing pharmacy benefits management 
        services or otherwise contain commercial or financial 
        information that is privileged or confidential.
            (3) Definitions.--In this subsection, the terms ``group 
        health plan'', ``health insurance coverage'', and ``health 
        insurance issuer'' have the meanings given such terms in 
        section 2791 of the Public Health Service Act (42 U.S.C. 300gg-
        91).

SEC. 104. REPORTS ON HEALTH CARE TRANSPARENCY TOOLS AND DATA 
              REQUIREMENTS.

    (a) Initial Report.--Not later than December 31, 2024, the 
Comptroller General of the United States shall submit to the Committees 
(as defined in subsection (d)) an initial report that--
            (1) identifies and describes health care transparency tools 
        and Federal health care reporting requirements (as described in 
        subsection (d)) that are in effect as of the date of the 
        submission of such initial report, including the frequency of 
        reports with respect to each such requirement and whether any 
        such requirements are duplicative;
            (2) reviews how such reporting requirements are enforced;
            (3) analyzes whether the public availability of health care 
        transparency tools, and the publication of data pursuant to 
        such reporting requirements, has--
                    (A) been utilized and valued by consumers, 
                including reasons for such utilization (or lack 
                thereof); and
                    (B) assisted health insurance plan sponsors and 
                fiduciaries improve benefits, lower health care costs 
                for plan participants, and meet fiduciary requirements;
            (4) includes recommendations to the Committees, the 
        Secretary of Health and Human Services, the Secretary of Labor, 
        and the Secretary of the Treasury to--
                    (A) improve the efficiency, accuracy, and usability 
                of health care transparency tools;
                    (B) streamline Federal health care reporting 
                requirements to eliminate duplicative requirements and 
                reduce the burden on entities required to submit 
                reports pursuant to such provisions;
                    (C) improve the accuracy and efficiency of such 
                reports while maintaining the integrity and usability 
                of the data provided by such reports;
                    (D) address any gaps in data provided by such 
                reports; and
                    (E) ensure that the data and information reported 
                is comparable and usable to consumers, including 
                patients, plan sponsors, and policy makers.
    (b) Final Report.--Not later than December 31, 2028, the 
Comptroller General of the United States shall submit to the Committees 
a report that includes--
            (1) the information provided in the initial report, along 
        with any updates to such information; and
            (2) any new information with respect to health care 
        transparency tools that have been released following the 
        submission of such initial report, or new reporting 
        requirements in effect as of the date of the submission of the 
        final report.
    (c) Report on Expanding Price Transparency Requirements.--Not later 
than December 31, 2025, the Comptroller General of the United States, 
in consultation with the Secretary of Health and Human Services, health 
care provider groups, and patient advocacy groups, shall submit to the 
Committees a report that includes recommendations to expand price 
transparency reporting requirements to additional care settings, with 
an emphasis on settings where shoppable services (as defined in 
subsection (d)) are furnished.
    (d) Definitions.--In this section:
            (1) Committees.--The term ``Committees'' means the 
        Committee on Ways and Means, the Committee on Energy and 
        Commerce, and the Committee on Education and the Workforce of 
        the House of Representatives, and the Committee on Finance and 
        the Committee on Health, Education, Labor, and Pensions of the 
        Senate.
            (2) Federal health care reporting requirements.--The term 
        ``Federal health care reporting requirements'' includes 
        regulatory and statutory requirements with respect to the 
        reporting and publication of health care price, cost access, 
        and quality data, including requirements established by the 
        Consolidated Appropriations Act of 2021 (Public Law 116-260), 
        this Act, and other reporting and publication requirements with 
        respect to transparency in health care as identified by the 
        Comptroller General of the United States.
            (3) Shoppable service.--The term ``shoppable service'' 
        means a service that can be scheduled by a health care consumer 
        in advance and includes all ancillary items and services 
        customarily furnished as part of such service.

SEC. 105. REPORT ON INTEGRATION IN MEDICARE.

    (a) Required MA and PDP Reporting.--
            (1) MA plans.--Section 1857(e) of the Social Security Act 
        (42 U.S.C. 1395w-27(e)) is amended by adding at the end the 
        following new paragraph:
            ``(6) Required disclosure of certain information relating 
        to health care provider ownership.--
                    ``(A) In general.--For plan year 2025 and for every 
                third plan year thereafter, each MA organization 
                offering an MA plan under this part during such plan 
                year shall submit to the Secretary, at a time and in a 
                manner specified by the Secretary--
                            ``(i) the taxpayer identification number 
                        for each health care provider that was a 
                        specified health care provider with respect to 
                        such organization during such year;
                            ``(ii) the total amount of incentive-based 
                        payments made to, and the total amount of 
                        shared losses recoupments collected from, such 
                        specified health care providers during such 
                        plan year; and
                            ``(iii) the total amount of incentive-based 
                        payments made to, and the total amount of 
                        shared losses recoupments collected from, 
                        providers of services and suppliers not 
                        described in clause (ii) during such plan year.
                    ``(B) Definition.--For purposes of this paragraph, 
                the term `specified health care provider' means, with 
                respect to an MA organization and a plan year, a 
                provider of services or supplier with respect to which 
                such organization (or any person with an ownership or 
                control interest (as defined in section 1124(a)(3)) in 
                such organization) is a person with an ownership or 
                control interest (as so defined).''.
            (2) Prescription drug plans.--Section 1860D-12(b) of the 
        Social Security Act (42 U.S.C. 1395w-112(b)) is amended by 
        adding at the end the following new paragraph:
            ``(9) Provision of information relating to pharmacy 
        ownership.--
                    ``(A) In general.--For plan year 2025 and for every 
                third plan year thereafter, each PDP sponsor offering a 
                prescription drug plan under this part during such plan 
                year shall submit to the Secretary, at a time and in a 
                manner specified by the Secretary, the taxpayer 
                identification number and National Provider Identifier 
                for each pharmacy that was a specified pharmacy with 
                respect to such sponsor during such year.
                    ``(B) Definition.--For purposes of this paragraph, 
                the term `specified pharmacy' means, with respect to an 
                PDP sponsor offering a prescription drug plan and a 
                plan year, a pharmacy with respect to which--
                            ``(i) such sponsor (or any person with an 
                        ownership or control interest (as defined in 
                        section 1124(a)(3)) in such sponsor) is a 
                        person with an ownership or control interest 
                        (as so defined); or
                            ``(ii) a pharmacy benefit manager offering 
                        services under such plan (or any person with an 
                        ownership or control interest (as so defined) 
                        in such sponsor) is a person with an ownership 
                        or control interest (as so defined).''.
    (b) MedPAC Reports.--Part E of title XVIII of the Social Security 
Act (42 U.S.C. 1395x et seq.), as amended by section 101, is further 
amended by adding at the end the following new section:

``SEC. 1899D. REPORTS ON VERTICAL INTEGRATION UNDER MEDICARE.

    ``(a) In General.--Not later than June 15, 2029, and every 3 years 
thereafter, the Medicare Payment Advisory Commission shall submit to 
Congress a report on the state of vertical integration in the health 
care sector during the applicable year with respect to entities 
participating in the Medicare program, including health care providers, 
pharmacies, prescription drug plan sponsors, Medicare Advantage 
organizations, and pharmacy benefit managers. Such report shall 
include--
            ``(1) with respect to Medicare Advantage organizations, the 
        evaluation described in subsection (b);
            ``(2) with respect to prescription drug plans, pharmacy 
        benefit managers, and pharmacies, the comparisons and 
        evaluations described in subsection (c);
            ``(3) with respect to Medicare Advantage plans under which 
        benefits are available for physician-administered drugs, the 
        information described in subsection (d); and
            ``(4) the identifications described in subsection (e); and
            ``(5) an analysis of the impact of such integration on 
        health care access, price, quality, and outcomes.
    ``(b) Medicare Advantage Organizations.--For purposes of subsection 
(a)(1), the evaluation described in this subsection is, with respect to 
Medicare Advantage organizations and an applicable year, an evaluation, 
taking into account patient acuity and the types of areas serviced by 
such organization, of--
            ``(1) the average number of qualifying diagnoses made 
        during such year with respect to enrollees of a Medicare 
        Advantage plan offered by such organization who, during such 
        year, received a health risk assessment from a specified health 
        care provider;
            ``(2) the average risk score for such enrollees who 
        received such an assessment during such year;
            ``(3) any relationship between such risk scores for such 
        enrollees receiving such an assessment from such a provider 
        during such year and incentive payments made to such providers;
            ``(4) the average risk score for enrollees of such plan who 
        received any item or service from a specified health care 
        provider during such year;
            ``(5) any relationship between the risk scores of enrollees 
        under such plan and whether the enrollees have received any 
        item or service from a specified provider; and
            ``(6) any relationship between the risk scores of enrollees 
        under such plan that have received any item or service from a 
        specified provider and incentive payments made under the plan 
        to specified providers.
    ``(c) Prescription Drug Plans.--For purposes of subsection (a)(2), 
the comparisons and evaluations described in this subsection are, with 
respect to prescription drug plans and an applicable year, the 
following:
            ``(1) For each covered part D drug for which benefits are 
        available under such a plan, a comparison of the average 
        negotiated rate in effect with specified pharmacies with such 
        rates in effect for in-network pharmacies that are not 
        specified pharmacies.
            ``(2) Comparisons of the following:
                    ``(A) The total amount paid by pharmacy benefit 
                managers to specified pharmacies for covered part D 
                drugs and the total amount so paid to pharmacies that 
                are not specified pharmacies for such drugs.
                    ``(B) The total amount paid by such sponsors to 
                specified pharmacy benefit managers as reimbursement 
                for covered part D drugs and the total amount so paid 
                to pharmacy benefit managers that are not specified 
                pharmacy benefit managers as such reimbursement.
                    ``(C) Fees paid under by plan to specified pharmacy 
                benefit managers compared to such fees paid to pharmacy 
                benefit managers that are not specified pharmacy 
                benefit managers.
            ``(3) An evaluation of the total amount of direct and 
        indirect remuneration for covered part D drugs passed through 
        to prescription drug plan sponsors and the total amount 
        retained by pharmacy benefit managers (including entities under 
        contract with such a manager).
            ``(4) To the extent that the available data permits, an 
        evaluation of fees charged by rebate aggregators that are 
        affiliated with plan sponsors.
    ``(d) Physician-Administered Drugs.--For purposes of subsection 
(a)(3), the information described in this subsection is, with respect 
to physician-administered drugs for which benefits are available under 
a Medicare Advantage plan during an applicable year, the following:
            ``(1) With respect to each such plan, an identification of 
        each drug for which benefits were available under such plan 
        only when administered by a health care provider that acquired 
        such drug from an affiliated pharmacy.
            ``(2) An evaluation of the difference between the total 
        number of drugs administered by a health care provider that 
        were acquired from affiliated pharmacies compared to the number 
        of such drugs so administered that were acquired from 
        pharmacies other than affiliated pharmacies, and an evaluation 
        of the difference in payments for such drugs so administered 
        when acquired from a specified pharmacy and when acquired from 
        a pharmacy that is not a specified pharmacy.
            ``(3) An evaluation of the dollar value of all such drugs 
        that were not so administered because of a delay attributable 
        to an affiliated pharmacy compared to the dollar value of all 
        such drugs that were not so administered because of a delay 
        attributable to pharmacy that is not an affiliated pharmacy.
            ``(4) The number of enrollees administered such a drug that 
        was acquired from an affiliated pharmacy.
            ``(5) The number of enrollees furnished such a drug that 
        was acquired from a pharmacy that is not an affiliated 
        pharmacy.
    ``(e) Identifications.--For purposes of subsection (a)(4), the 
identifications described in this subsection are, with respect to an 
applicable year, identifications of each health care entity 
participating under the Medicare program with respect to which another 
health care entity so participating is a person with an ownership or 
control interest (as defined in section 1124(a)(3)).
    ``(f) Definitions.--In this section:
            ``(1) Affiliated pharmacy.--The term `affiliated pharmacy' 
        means, with respect to a Medicare Advantage plan offered by a 
        Medicare Advantage organization, a pharmacy with respect to 
        which such organization (or any person with an ownership or 
        control interest (as defined in section 1124(a)(3)) in such 
        organization) is a person with an ownership or control interest 
        (as so defined).
            ``(2) Applicable year.--The term `applicable year' means, 
        with respect to a report submitted under subsection (a), the 
        first calendar year beginning at least 4 years prior to the 
        date of the submission of such report.
            ``(3) Covered part d drug.--The term `covered part D drug' 
        has the meaning given such term in section 1860D-2(e).
            ``(4) Direct and indirect remuneration.--The term `direct 
        and indirect remuneration' has the meaning given such term in 
        section 423.308 of title 42, Code of Federal Regulations (or 
        any successor regulation).
            ``(5) Qualifying diagnosis.--The term `qualifying 
        diagnosis' means, with respect to an enrollee of a Medicare 
        Advantage plan, a diagnosis that is taken into account in 
        calculating a risk score for such enrollee under the risk 
        adjustment methodology established by the Secretary pursuant to 
        section 1853(a)(3).
            ``(6) Risk score.--The term `risk score' means, with 
        respect to an enrollee of a Medicare Advantage plan, the score 
        calculated for such individual using the methodology described 
        in paragraph (5).
            ``(7) Physician-administered drug.--The term `physician-
        administered drug' means a drug furnished to an individual 
        that, had such individual been enrolled under part B and not 
        enrolled under part C, would have been payable under section 
        1842(o).
            ``(8) Specified health care provider.--The term `specified 
        health care provider' means, with respect to a Medicare 
        Advantage plan offered by a Medicare Advantage organization, a 
        health care provider with respect to which such organization 
        (or any person with an ownership or control interest (as 
        defined in section 1124(a)(3)) in such organization) is a 
        person with an ownership or control interest (as so defined).
            ``(9) Specified pharmacy.--The term `specified pharmacy' 
        means, with respect to a prescription drug plan offered by a 
        prescription drug plan sponsor, a pharmacy with respect to 
        which--
                    ``(A) such sponsor (or any person with an ownership 
                or control interest (as defined in section 1124(a)(3)) 
                in such sponsor) is a person with an ownership or 
                control interest (as so defined); or
                    ``(B) a pharmacy benefit manager offering services 
                under such plan (or any person with an ownership or 
                control interest (as so defined) in such sponsor) is a 
                person with an ownership or control interest (as so 
                defined).
            ``(10) Specified pharmacy benefit manager.--The term 
        `specified pharmacy benefit manager' means, with respect to a 
        prescription drug plan offered by a prescription drug plan 
        sponsor, a pharmacy benefit manager with respect to which such 
        sponsor (or any person with an ownership or control interest 
        (as defined in section 1124(a)(3)) in such sponsor) is a person 
        with an ownership or control interest (as so defined).''.

                   TITLE II--FAIR PRICES FOR PATIENTS

SEC. 201. LIMITATION ON COST SHARING TO NET PRICE AMOUNT UNDER MEDICARE 
              PART D.

    (a) In General.--Section 1860D-2 of the Social Security Act (42 
U.S.C. 1395w-102) is amended--
            (1) in subsection (b)--
                    (A) in paragraph (2)(A), by striking ``(8) and 
                (9)'' and inserting ``(8), (9), and (10)'';
                    (B) in paragraph (9)(B)(ii), by striking ``For a 
                plan year'' and inserting ``Subject to paragraph (10), 
                for a plan year''; and
                    (C) by adding at the end the following new 
                paragraph:
            ``(10) Limitation on cost sharing to net price amount.--
                    ``(A) In general.--For a plan year beginning on or 
                after January 1, 2027, the coverage provides benefits 
                for a supply of a covered part D drug dispensed by a 
                pharmacy, for costs in excess of the deductible 
                specified in paragraph (1) and prior to an individual 
                reaching the out-of-pocket threshold under paragraph 
                (4), with cost-sharing for a month's supply that does 
                not exceed the average net price for such a supply of 
                such drug during such plan year (or, if lower, the 
                applicable cash price for such a supply of such drug so 
                dispensed by such pharmacy).
                    ``(B) Definitions.--In this paragraph:
                            ``(i) Applicable cash price.--The term 
                        `applicable cash price' means, with respect to 
                        a supply of a covered part D drug dispensed by 
                        a pharmacy, the price that such pharmacy would 
                        charge for such supply of such drug dispensed 
                        to an individual without benefits for such drug 
                        under any Federal health care program (as 
                        defined in section 1128B), a group health plan 
                        or group or individual health insurance 
                        coverage (as such terms are defined in section 
                        2791 of the Public Health Service Act), or the 
                        program established under chapter 89 of title 
                        5, United States Code.
                            ``(ii) Average net price.--The term 
                        `average net price' means, with respect to a 
                        supply of a covered part D drug, a prescription 
                        drug plan, and a plan year, the average amount 
                        paid under such plan (including any amounts 
                        paid by an individual enrolled under such plan 
                        as cost sharing for such drug) as payment for 
                        such a supply of such drug dispensed during 
                        such year, less any rebates or other forms of 
                        remuneration received under such plan with 
                        respect to such drug.''; and
            (2) in subsection (c), by adding at the end the following 
        new paragraph:
            ``(7) Cost sharing limited to net price.--The coverage is 
        provided in accordance with subsection (b)(10).''.
    (b) Conforming Amendment to Cost-Sharing for Low-Income 
Individuals.--Section 1860D-14(a)(1)(D)(iii) of the Social Security Act 
(42 U.S.C. 1395w-114(a)(1)(D)(iii)) is amended by adding at the end the 
following new sentence: ``For plan year 2027 and subsequent plan years, 
the copayment amount applicable under this clause to a supply of a 
covered part D drug dispensed to the individual may not exceed the 
amount provided under section 1860D-2(b)(10).''.
    (c) GAO Report.--Not later than January 1, 2029, the Comptroller 
General of the United States shall submit to Congress a report 
containing--
            (1) an analysis of compliance with the amendments made by 
        this section;
            (2) an analysis of enforcement of such amendments;
            (3) recommendations with respect to improving such 
        enforcement; and
            (4) recommendations relating to improving public 
        disclosure, and public awareness of, the requirements of such 
        amendments.

SEC. 202. REQUIRING A SEPARATE IDENTIFICATION NUMBER AND AN ATTESTATION 
              FOR EACH OFF-CAMPUS OUTPATIENT DEPARTMENT OF A PROVIDER.

    (a) In General.--Section 1833(t) of the Social Security Act (42 
U.S.C. 1395l(t)) is amended by adding at the end the following new 
paragraph:
            ``(23) Use of unique health identifiers; attestation.--
                    ``(A) In general.--No payment may be made under 
                this subsection (or under an applicable payment system 
                pursuant to paragraph (21)) for items and services 
                furnished on or after January 1, 2026, by an off-campus 
                outpatient department of a provider (as defined in 
                subparagraph (C)) unless--
                            ``(i) such department has obtained, and 
                        such items and services are billed under, a 
                        standard unique health identifier for health 
                        care providers (as described in section 
                        1173(b)) that is separate from such identifier 
                        for such provider; and
                            ``(ii) such provider has submitted to the 
                        Secretary, during the 2-year period ending on 
                        the date such items and services are so 
                        furnished, an attestation that such department 
                        is compliant with the requirements described in 
                        section 413.65 of title 42, Code of Federal 
                        Regulations (or a successor regulation).
                    ``(B) Process for submission and review.--Not later 
                than 1 year after the date of enactment of this 
                paragraph, the Secretary shall, through notice and 
                comment rulemaking, establish a process for each 
                provider with an off-campus outpatient department of a 
                provider to submit an attestation pursuant to 
                subparagraph (A)(ii), and for the Secretary to review 
                each such attestation and determine, through site 
                visits, remote audits, or other means (as determined 
                appropriate by the Secretary), whether such department 
                is compliant with the requirements described in such 
                subparagraph.
                    ``(C) Off-campus outpatient department of a 
                provider defined.--For purposes of this paragraph, the 
                term `off-campus outpatient department of a provider' 
                means a department of a provider (as defined in section 
                413.65 of title 42, Code of Federal Regulations, or any 
                successor regulation) that is not located--
                            ``(i) on the campus (as defined in such 
                        section) of such provider; or
                            ``(ii) within the distance (described in 
                        such definition of campus) from a remote 
                        location of a hospital facility (as defined in 
                        such section).''.
    (b) HHS OIG Analysis.--Not later than January 1, 2030, the 
Inspector General of the Department of Health and Human Services shall 
submit to Congress--
            (1) an analysis of the process established by the Secretary 
        of Health and Human Services to conduct the reviews and 
        determinations described in section 1833(t)(23)(B) of the 
        Social Security Act, as added by subsection (a) of this 
        section; and
            (2) recommendations based on such analysis, as the 
        Inspector General determines appropriate.

SEC. 203. PARITY IN MEDICARE PAYMENTS FOR HOSPITAL OUTPATIENT 
              DEPARTMENT SERVICES FURNISHED OFF-CAMPUS.

    (a) In General.--Section 1833(t)(16) of the Social Security Act (42 
U.S.C. 1395l(t)(16)) is amended by adding at the end the following new 
subparagraph:
                    ``(H) Parity in fee schedule amount for certain 
                services furnished by an off-campus outpatient 
                department of a provider.--
                            ``(i) In general.--Subject to clause (iii), 
                        in the case of specified OPD services (as 
                        defined in clause (v)) that are furnished 
                        during 2025 or a subsequent year by an off-
                        campus outpatient department of a provider (as 
                        defined in clause (iv)) (or, in the case of an 
                        off-campus outpatient department of a provider 
                        that is a hospital described in section 
                        1886(d)(1)(B)(v), or is located in a rural area 
                        or a health professional shortage area, such 
                        services that are furnished during 2026 or a 
                        subsequent year), there shall be substituted 
                        for the amount otherwise determined under this 
                        subsection for such service and year an amount 
                        equal to the payment amount that would have 
                        been payable under the applicable payment 
                        system under this part (other than under this 
                        subsection) had such services been furnished by 
                        such a department subject to such payment 
                        system pursuant to paragraph (21)(C).
                            ``(ii) Not budget neutral implementation.--
                        In making any budget neutrality adjustments 
                        under this subsection for 2025 or a subsequent 
                        year, the Secretary shall not take into account 
                        the reduced expenditures that result from the 
                        application of this subparagraph.
                            ``(iii) Transition.--The Secretary shall 
                        provide for a 4-year phase-in of the 
                        application of clause (i), with clause (i) 
                        being fully applicable for specified OPD 
                        services beginning with 2028 (or in the case of 
                        an off-campus outpatient department of a 
                        provider that is a hospital described in 
                        section 1886(d)(1)(B)(v), or is located in a 
                        rural area or a health professional shortage 
                        area, beginning with 2029).
                            ``(iv) Off-campus department of a 
                        provider.--For purposes of this subparagraph, 
                        the term `off-campus outpatient department of a 
                        provider' means a department of a provider (as 
                        defined in section 413.65(a)(2) of title 42, 
                        Code of Federal Regulations) that is not 
                        located--
                                    ``(I) on the campus (as such term 
                                is defined in such section) of such 
                                provider; or
                                    ``(II) within the distance 
                                (described in such definition of 
                                campus) from a remote location of a 
                                hospital facility (as defined in such 
                                section).
                            ``(v) Other definitions.--For purposes of 
                        this subparagraph:
                                    ``(I) Designated ambulatory payment 
                                classification group.--The term 
                                `designated ambulatory payment 
                                classification group' means an 
                                ambulatory payment classification group 
                                for drug administration services.
                                    ``(II) Health professional shortage 
                                area.--The term `health professional 
                                shortage area' has the meaning given 
                                such term in section 332(a)(1)(A) of 
                                the Public Health Service Act.
                                    ``(III) Rural area.--The term 
                                `rural area' has the meaning given such 
                                term in section 1886(d)(2)(D).
                                    ``(IV) Specified opd services.--The 
                                term `specified OPD services' means 
                                covered OPD services assigned to a 
                                designated ambulatory payment 
                                classification group.''.
    (b) Implementation.--Section 1833(t)(12) of the Social Security Act 
(42 U.S.C. 1395l(t)(12)) is amended--
            (1) in subparagraph (D), by striking ``and'' at the end;
            (2) in subparagraph (E), by striking the period at the end 
        and inserting ``; and''; and
            (3) by adding at the end the following new subparagraph:
                    ``(F) the determination of any payment amount under 
                paragraph (16)(H), including the transition under 
                clause (iii) of such paragraph.''.

                 TITLE III--PATIENT-FOCUSED INVESTMENTS

SEC. 301. ESTABLISHING REQUIREMENTS WITH RESPECT TO THE USE OF PRIOR 
              AUTHORIZATION UNDER MEDICARE ADVANTAGE PLANS.

    (a) In General.--Section 1852 of the Social Security Act (42 U.S.C. 
1395w-22) is amended by adding at the end the following new subsection:
    ``(o) Prior Authorization Requirements.--
            ``(1) In general.--In the case of a Medicare Advantage plan 
        that imposes any prior authorization requirement with respect 
        to any applicable item or service (as defined in paragraph (5)) 
        during a plan year, such plan shall--
                    ``(A) beginning with the third plan year beginning 
                after the date of the enactment of this subsection--
                            ``(i) establish the electronic prior 
                        authorization program described in paragraph 
                        (2); and
                            ``(ii) meet the enrollee protection 
                        standards specified pursuant to paragraph (4); 
                        and
                    ``(B) beginning with the fourth plan year beginning 
                after the date of the enactment of this subsection, 
                meet the transparency requirements specified in 
                paragraph (3).
            ``(2) Electronic prior authorization program.--
                    ``(A) In general.--For purposes of paragraph 
                (1)(A), the electronic prior authorization program 
                described in this paragraph is a program that provides 
                for the secure electronic transmission of--
                            ``(i) a prior authorization request from a 
                        provider of services or supplier to a Medicare 
                        Advantage plan with respect to an applicable 
                        item or service to be furnished to an 
                        individual and a response, in accordance with 
                        this paragraph, from such plan to such provider 
                        or supplier; and
                            ``(ii) any attachment relating to such 
                        request or response.
                    ``(B) Electronic transmission.--
                            ``(i) Exclusions.--For purposes of this 
                        paragraph, a facsimile, a proprietary payer 
                        portal that does not meet standards specified 
                        by the Secretary, or an electronic form shall 
                        not be treated as an electronic transmission 
                        described in subparagraph (A).
                            ``(ii) Standards.--An electronic 
                        transmission described in subparagraph (A) 
                        shall comply with--
                                    ``(I) applicable technical 
                                standards adopted by the Secretary 
                                pursuant to section 1173; and
                                    ``(II) other requirements to 
                                promote the standardization and 
                                streamlining of electronic transactions 
                                under this part specified by the 
                                Secretary.
                            ``(iii) Deadline for specification of 
                        additional requirements.--Not later than July 
                        1, 2024, the Secretary shall finalize 
                        requirements described in clause (ii)(II).
                    ``(C) Real-time decisions.--
                            ``(i) In general.--Subject to clause (iv), 
                        the program described in subparagraph (A) shall 
                        provide for real-time decisions (as defined by 
                        the Secretary in accordance with clause (v)) by 
                        a Medicare Advantage plan with respect to prior 
                        authorization requests for applicable items and 
                        services identified by the Secretary pursuant 
                        to clause (ii) if such requests are submitted 
                        with all medical or other documentation 
                        required by such plan.
                            ``(ii) Identification of items and 
                        services.--
                                    ``(I) In general.--For purposes of 
                                clause (i), the Secretary shall 
                                identify, not later than the date on 
                                which the initial announcement 
                                described in section 1853(b)(1)(B)(i) 
                                for the third plan year beginning after 
                                the date of the enactment of this 
                                subsection is required to be announced, 
                                applicable items and services for which 
                                prior authorization requests are 
                                routinely approved.
                                    ``(II) Updates.--The Secretary 
                                shall consider updating the applicable 
                                items and services identified under 
                                subclause (I) based on the information 
                                described in paragraph (3)(A)(i) (if 
                                available and determined practicable to 
                                utilize by the Secretary) and any other 
                                information determined appropriate by 
                                the Secretary not less frequently than 
                                biennially. The Secretary shall 
                                announce any such update that is to 
                                apply with respect to a plan year not 
                                later than the date on which the 
                                initial announcement described in 
                                section 1853(b)(1)(B)(i) for such plan 
                                year is required to be announced.
                            ``(iii) Request for information.--The 
                        Secretary shall issue a request for information 
                        for purposes of initially identifying 
                        applicable items and services under clause 
                        (ii)(I).
                            ``(iv) Exception for extenuating 
                        circumstances.--In the case of a prior 
                        authorization request submitted to a Medicare 
                        Advantage plan for an individual enrolled in 
                        such plan during a plan year with respect to an 
                        item or service identified by the Secretary 
                        pursuant to clause (ii) for such plan year, 
                        such plan may, in lieu of providing a real-time 
                        decision with respect to such request in 
                        accordance with clause (i), delay such decision 
                        under extenuating circumstances (as specified 
                        by the Secretary), provided that such decision 
                        is provided no later than 72 hours after 
                        receipt of such request (or, in the case that 
                        the provider of services or supplier submitting 
                        such request has indicated that such delay may 
                        seriously jeopardize such individual's life, 
                        health, or ability to regain maximum function, 
                        no later than 24 hours after receipt of such 
                        request).
                            ``(v) Definition of real-time decision.--In 
                        establishing the definition of a real-time 
                        decision for purposes of clause (i), the 
                        Secretary shall take into account current 
                        medical practice, technology, health care 
                        industry standards, and other relevant 
                        information relating to how quickly a Medicare 
                        Advantage plan may provide responses with 
                        respect to prior authorization requests.
                            ``(vi) Implementation.--The Secretary shall 
                        use notice and comment rulemaking for each of 
                        the following:
                                    ``(I) Establishing the definition 
                                of a `real-time decision' for purposes 
                                of clause (i).
                                    ``(II) Updating such definition.
                                    ``(III) Initially identifying 
                                applicable items or services pursuant 
                                to clause (ii)(I).
                                    ``(IV) Updating applicable items 
                                and services so identified as described 
                                in clause (ii)(II).
            ``(3) Transparency requirements.--
                    ``(A) In general.--For purposes of paragraph 
                (1)(B), the transparency requirements specified in this 
                paragraph are, with respect to a Medicare Advantage 
                plan, the following:
                            ``(i) The plan, annually and in a manner 
                        specified by the Secretary, shall submit to the 
                        Secretary the following information:
                                    ``(I) A list of all applicable 
                                items and services that were subject to 
                                a prior authorization requirement under 
                                the plan during the previous plan year.
                                    ``(II) The percentage and number of 
                                specified requests (as defined in 
                                subparagraph (F)) approved during the 
                                previous plan year by the plan in an 
                                initial determination and the 
                                percentage and number of specified 
                                requests denied during such plan year 
                                by such plan in an initial 
                                determination (both in the aggregate 
                                and categorized by each item and 
                                service).
                                    ``(III) The percentage and number 
                                of specified requests submitted during 
                                the previous plan year that were made 
                                with respect to an item or service 
                                identified by the Secretary pursuant to 
                                paragraph (2)(C)(ii) for such plan 
                                year, and the percentage and number of 
                                such requests that were subject to an 
                                exception under paragraph (2)(C)(iv) 
                                (categorized by each item and service).
                                    ``(IV) The percentage and number of 
                                specified requests submitted during the 
                                previous plan year that were made with 
                                respect to an item or service 
                                identified by the Secretary pursuant to 
                                paragraph (2)(C)(ii) for such plan year 
                                that were approved (categorized by each 
                                item and service).
                                    ``(V) The percentage and number of 
                                specified requests that were denied 
                                during the previous plan year by the 
                                plan in an initial determination and 
                                that were subsequently appealed.
                                    ``(VI) The number of appeals of 
                                specified requests resolved during the 
                                preceding plan year, and the percentage 
                                and number of such resolved appeals 
                                that resulted in approval of the 
                                furnishing of the item or service that 
                                was the subject of such request, 
                                categorized by each applicable item and 
                                service and categorized by each level 
                                of appeal (including judicial review).
                                    ``(VII) The percentage and number 
                                of specified requests that were denied, 
                                and the percentage and number of 
                                specified requests that were approved, 
                                by the plan during the previous plan 
                                year through the utilization of 
                                decision support technology, artificial 
                                intelligence technology, machine-
                                learning technology, clinical decision-
                                making technology, or any other 
                                technology specified by the Secretary.
                                    ``(VIII) The average and the median 
                                amount of time (in hours) that elapsed 
                                during the previous plan year between 
                                the submission of a specified request 
                                to the plan and a determination by the 
                                plan with respect to such request for 
                                each such item and service, excluding 
                                any such requests that were not 
                                submitted with the medical or other 
                                documentation required to be submitted 
                                by the plan.
                                    ``(IX) The percentage and number of 
                                specified requests that were excluded 
                                from the calculation described in 
                                subclause (VIII) based on the plan's 
                                determination that such requests were 
                                not submitted with the medical or other 
                                documentation required to be submitted 
                                by the plan.
                                    ``(X) Information on each 
                                occurrence during the previous plan 
                                year in which, during a surgical or 
                                medical procedure involving the 
                                furnishing of an applicable item or 
                                service with respect to which such plan 
                                had approved a prior authorization 
                                request, the provider of services or 
                                supplier furnishing such item or 
                                service determined that a different or 
                                additional item or service was 
                                medically necessary, including a 
                                specification of whether such plan 
                                subsequently approved the furnishing of 
                                such different or additional item or 
                                service.
                                    ``(XI) A disclosure and description 
                                of any technology described in 
                                subclause (VII) that the plan utilized 
                                during the previous plan year in making 
                                determinations with respect to 
                                specified requests.
                                    ``(XII) The number of grievances 
                                (as described in subsection (f)) 
                                received by such plan during the 
                                previous plan year that were related to 
                                a prior authorization requirement.
                                    ``(XIII) Such other information as 
                                the Secretary determines appropriate.
                            ``(ii) The plan shall provide--
                                    ``(I) to each provider or supplier 
                                who seeks to enter into a contract with 
                                such plan to furnish applicable items 
                                and services under such plan, the list 
                                described in clause (i)(I) and any 
                                policies or procedures used by the plan 
                                for making determinations with respect 
                                to prior authorization requests;
                                    ``(II) to each such provider and 
                                supplier that enters into such a 
                                contract, access to the criteria used 
                                by the plan for making such 
                                determinations and an itemization of 
                                the medical or other documentation 
                                required to be submitted by a provider 
                                or supplier with respect to such a 
                                request; and
                                    ``(III) to an enrollee of the plan, 
                                upon request, access to the criteria 
                                used by the plan for making 
                                determinations with respect to prior 
                                authorization requests for an item or 
                                service.
                    ``(B) Option for plan to provide certain additional 
                information.--As part of the information described in 
                subparagraph (A)(i) provided to the Secretary during a 
                plan year, a Medicare Advantage plan may elect to 
                include information regarding the percentage and number 
                of specified requests made with respect to an 
                individual and an item or service that were denied by 
                the plan during the preceding plan year in an initial 
                determination based on such requests failing to 
                demonstrate that such individuals met the clinical 
                criteria established by such plan to receive such items 
                or services.
                    ``(C) Regulations.--The Secretary shall, through 
                notice and comment rulemaking, establish requirements 
                for Medicare Advantage plans regarding the provision 
                of--
                            ``(i) access to criteria described in 
                        subparagraph (A)(ii)(II) to providers of 
                        services and suppliers in accordance with such 
                        subparagraph; and
                            ``(ii) access to such criteria to enrollees 
                        in accordance with subparagraph (A)(ii)(III).
                    ``(D) Publication of information.--The Secretary 
                shall publish information described in subparagraph 
                (A)(i) and subparagraph (B) on a public website of the 
                Centers for Medicare & Medicaid Services. Such 
                information shall be so published on an individual plan 
                level and may in addition be aggregated in such manner 
                as determined appropriate by the Secretary.
                    ``(E) Medpac report.--Not later than 3 years after 
                the date information is first submitted under 
                subparagraph (A)(i), the Medicare Payment Advisory 
                Commission shall submit to Congress a report on such 
                information that includes a descriptive analysis of the 
                use of prior authorization. As appropriate, the 
                Commission should report on statistics including the 
                frequency of appeals and overturned decisions. The 
                Commission shall provide recommendations, as 
                appropriate, on any improvement that should be made to 
                the electronic prior authorization programs of Medicare 
                Advantage plans.
                    ``(F) Specified request defined.--For purposes of 
                this paragraph, the term `specified request' means a 
                prior authorization request made with respect to an 
                applicable item or service.
            ``(4) Enrollee protection standards.--For purposes of 
        paragraph (1)(A)(ii), with respect to the use of prior 
        authorization by Medicare Advantage plans for applicable items 
        and services, the enrollee protection standards specified in 
        this paragraph are--
                    ``(A) the adoption of transparent prior 
                authorization programs developed in consultation with 
                enrollees and with providers and suppliers with 
                contracts in effect with such plans for furnishing such 
                items and services under such plans;
                    ``(B) allowing for the waiver or modification of 
                prior authorization requirements based on the 
                performance of such providers and suppliers in 
                demonstrating compliance with such requirements, such 
                as adherence to evidence-based medical guidelines and 
                other quality criteria; and
                    ``(C) conducting annual reviews of such items and 
                services for which prior authorization requirements are 
                imposed under such plans through a process that takes 
                into account input from enrollees and from providers 
                and suppliers with such contracts in effect and is 
                based on consideration of prior authorization data from 
                previous plan years and analyses of current coverage 
                criteria.
            ``(5) Applicable item or service defined.--For purposes of 
        this subsection, the term `applicable item or service' means, 
        with respect to a Medicare Advantage plan, any item or service 
        for which benefits are available under such plan, other than a 
        covered part D drug.
            ``(6) Reports to congress.--
                    ``(A) GAO.--Not later than the end of the fourth 
                plan year beginning on or after the date of the 
                enactment of this subsection, the Comptroller General 
                of the United States shall submit to Congress a report 
                containing an evaluation of the implementation of the 
                requirements of this subsection and an analysis of 
                issues in implementing such requirements faced by 
                Medicare Advantage plans.
                    ``(B) HHS.--Not later than the end of the fifth 
                plan year beginning after the date of the enactment of 
                this subsection, and biennially thereafter through the 
                date that is 10 years after such date of enactment, the 
                Secretary shall submit to Congress a report containing 
                a description of the information submitted under 
                paragraph (3)(A)(i) during--
                            ``(i) in the case of the first such report, 
                        the fourth plan year beginning after the date 
                        of the enactment of this subsection; and
                            ``(ii) in the case of a subsequent report, 
                        the 2 plan years preceding the year of the 
                        submission of such report.''.
    (b) Ensuring Timely Responses for All Prior Authorization Requests 
Submitted Under Part C.--Section 1852(g) of the Social Security Act (42 
U.S.C. 1395w-22(g)) is amended--
            (1) in paragraph (1)(A), by inserting ``and in accordance 
        with paragraph (6)'' after ``paragraph (3)'';
            (2) in paragraph (3)(B)(iii), by inserting ``(or, subject 
        to subsection (o), with respect to prior authorization requests 
        submitted on or after the first day of the third plan year 
        beginning after the date of the enactment of the [Improving 
        Seniors' Timely Access to Care Act of 2023], not later than 24 
        hours)'' after ``72 hours''.
            (3) by adding at the end the following new paragraph:
            ``(6) Timeframe for response to prior authorization 
        requests.--Subject to paragraph (3) and subsection (o), in the 
        case of an organization determination made with respect to a 
        prior authorization request for an item or service to be 
        furnished to an individual submitted on or after the first day 
        of the third plan year beginning after the date of the 
        enactment of this paragraph, the organization shall notify the 
        enrollee (and the physician involved, as appropriate) of such 
        determination no later than 7 days (or such shorter timeframe 
        as the Secretary may specify through notice and comment 
        rulemaking, taking into account enrollee and stakeholder 
        feedback) after receipt of such request.''.
    (c) Rule of Construction.--None of the amendments made by this 
section may be construed to affect the finalization of the proposed 
rule entitled ``Medicare and Medicaid Programs; Patient Protection and 
Affordable Care Act; Advancing Interoperability and Improving Prior 
Authorization Processes for Medicare Advantage Organizations, Medicaid 
Managed Care Plans, State Medicaid Agencies, Children's Health 
Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, 
Issuers of Qualified Health Plans on the Federally Facilitated 
Exchanges, Merit-Based Incentive Payment System (MIPS) Eligible 
Clinicians, and Eligible Hospitals and Critical Access Hospitals in the 
Medicare Promoting Interoperability Program'' published on December 13, 
2022 (87 Fed. Reg. 76238), or application of such rule so finalized, 
for plan years before the third plan year beginning on or after the 
date of the enactment of this Act.

SEC. 302. EXTENSION OF CERTAIN DIRECT SPENDING REDUCTIONS.

    Section 251A(6)(D) of the Balanced Budget and Emergency Deficit 
Control Act of 1985 (901a(6)(D)) is amended--
            (1) in clause (i), by striking ``; and'' and inserting a 
        semicolon;
            (2) in clause (ii), by striking ``second 6 months in which 
        such order is effective for such fiscal year, the payment 
        reduction shall be 0 percent.'' and inserting ``2 month period 
        beginning on the day after the last day of the period described 
        in clause (i) in which such order is effective for such fiscal 
        year, the payment reduction shall be 1.5 percent; and''; and
            (3) by adding at the end the following new clause:
                            ``(iii) with respect to the last 4 months 
                        in which such order is effective for such 
                        fiscal year, the payment reduction shall be 0 
                        percent.''.
                                 <all>