[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9397 Introduced in House (IH)]
<DOC>
119th CONGRESS
2d Session
H. R. 9397
To amend title XXVII of the Public Health Service Act and title XVIII
of the Social Security Act to ensure health insurer accountability
through publishing of overhead costs and claim payments, and to direct
the Secretary of Health and Human Services to issue guidance on the
provision of certain insurance information.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 23, 2026
Mr. Pfluger (for himself and Mr. Moran) introduced the following bill;
which was referred to the Committee on Energy and Commerce, and in
addition to the Committee on Ways and Means, 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 amend title XXVII of the Public Health Service Act and title XVIII
of the Social Security Act to ensure health insurer accountability
through publishing of overhead costs and claim payments, and to direct
the Secretary of Health and Human Services to issue guidance on the
provision of certain insurance information.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Premium Transparency Act''.
SEC. 2. ENSURING HEALTH INSURER ACCOUNTABILITY THROUGH PUBLISHING OF
OVERHEAD COSTS AND CLAIM PAYMENTS.
(a) In General.--Section 2718(a) of the Public Health Service Act
(42 U.S.C. 300gg-18(a)) is amended--
(1) by redesignating paragraphs (1) through (3) as
subparagraphs (A) through (C), and adjusting the margins
accordingly;
(2) by striking ``A health insurance issuer'' and inserting
the following:
``(1) In general.--A health insurance issuer''; and
(3) by adding at the end the following new paragraph:
``(2) Overhead costs and claim payment information.--
``(A) In general.--A health insurance issuer
offering group or individual health insurance coverage
(including a grandfathered health plan) shall, with
respect to each plan year beginning on or after January
1, 2027, submit to the Secretary (and, in the case such
coverage was offered through an Exchange established
under subtitle D of title I of the Patient Protection
and Affordable Care Act, to such Exchange) and publish
on the public website of such issuer the following
information in a consumer-friendly format specified by
the Secretary:
``(i) the percentage of total premium
revenue expended for each category described in
subparagraphs (A) through (C) of paragraph (1);
``(ii) the explanation described in
paragraph (1)(C); and
``(iii) the percentage of total premium
revenue not expended and retained by such
issuer.
``(B) Manner of publication.--Information submitted
and published by a health insurance issuer under
subparagraph (A) shall be so submitted and published at
the coverage level and shall in addition, if determined
appropriate by the Secretary, be so submitted and
published in the aggregate in such manner as specified
by the Secretary (such as across all such coverage
offered by such issuer that are offered within the same
insurance market (as specified in subclause (I), (II),
(III), or (IV) of section 2799A-1(a)(3)(E)(iv))).''.
(b) Medicare Advantage.--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:
``(7) Overhead costs and claim payment information.--
``(A) In general.--Beginning with plan years
beginning on or after January 1, 2027, a contract under
this section with an MA organization shall require the
organization, with respect to each MA plan offered by
such organization during such plan year, to submit to
the Secretary and publish on the public website of such
organization the following information in a consumer-
friendly format specified by the Secretary:
``(i) The amount of total revenue (as
determined under section 422.2420(c) of title
42, Code of Federal Regulations (or a successor
regulation)) collected under such plan.
``(ii) The amount and percentage of such
revenue expended on incurred claims (as
determined in accordance with paragraphs (2)
through (4) of section 422.2420(b) of title 42,
Code of Federal Regulations (or a successor
regulation)).
``(iii) The amount and percentage of such
revenue expended on non-claims costs (as
defined in section 422.2401 of title 42, Code
of Federal Regulations (or a successor
regulation)).
``(iv) The amount of the difference between
the MLR numerator (as determined under
paragraph (b) of section 422.2420 of title 42,
Code of Federal Regulations (or a successor
regulation)) and the MLR denominator (as
determined under paragraph (c) of such section
(or a successor regulation)).
``(v) The amount described in clause (iv),
expressed as a percentage of such revenue.
``(B) Manner of publication.--Information submitted
and published by an MA organization under subparagraph
(A) shall be so submitted and published at the MA plan
level and shall in addition, if determined appropriate
by the Secretary, be so submitted and published in the
aggregate in such manner as specified by the Secretary
(such as across all MA plans offered by such
organization).''.
SEC. 3. PROMOTING COMPARABILITY OF QUALIFIED HEALTH PLANS OFFERED
THROUGH AN EXCHANGE.
Section 1311(d)(4)(C) of the Patient Protection and Affordable Care
Act (42 U.S.C. 18031(d)(4)(C)) is amended--
(1) by striking ``website through which'' and inserting the
following: ``website--
``(i) through which'';
(2) in clause (i), as so inserted, by striking the
semicolon and inserting ``; and''; and
(3) by adding at the end the following new clause:
``(ii) that includes, as part of such
comparative information for enrollments for
plan years beginning on or after January 1,
2029, in the case a qualified health plan
offered through such Exchange for such plan
year was offered through such Exchange for a
previous plan year, the most recent information
submitted to such Exchange with respect to such
plan by the health insurance issuer of such
plan under section 2718(a)(2) of the Public
Health Service Act;''.
SEC. 4. GUIDANCE ON PROVISION OF CERTAIN INSURANCE INFORMATION IN
STANDARDIZED, PLAIN ENGLISH FORMAT.
(a) In General.--Not later than January 1, 2028, the Secretary
shall issue guidance to group health plans, health insurance issuers
offering group or individual health insurance coverage, and Medicare
Advantage organizations offering an MA plan on providing information on
the benefits and coverage available under the applicable plan or
coverage, consistent with the relevant requirements under section 2715
of the Public Health Service Act (42 U.S.C. 300gg-15), section 1851(d)
of the Social Security Act (42 U.S.C. 1395w-21(d)), and section 1852(c)
of such Act (42 U.S.C. 1395w-22(c)). Such guidance shall include
standards for providing information in a standardized, plain English
format with respect to the following aspects of the plan or coverage
(to the extent applicable):
(1) Any monthly premium.
(2) Any annual deductible.
(3) Any maximum limitations on out-of-pocket expenses.
(4) The type of provider network used by the plan or
coverage.
(5) The plan or coverage share of the total allowed costs
of benefits provided under the plan or coverage.
(6) The standard cost-sharing amounts for in-network care,
including for the following types of care:
(A) Primary care.
(B) Specialist care.
(C) Urgent care.
(D) Emergency department care.
(E) Imaging.
(F) Inpatient hospital care.
(G) Outpatient facility care.
(H) Laboratory services.
(I) Preferred brand name drugs.
(J) Generic drugs.
(7) Additional features of the plan or coverage, including
the following:
(A) Specialist referral policies.
(B) The availability of wellness programs.
(C) The availability of disease management
programs.
(D) Whether an individual enrolled in such plan or
coverage is an eligible individual for purposes of
section 223 of the Internal Revenue Code of 1986
(relating to health savings accounts).
(E) Coverage of preventive care services.
(8) Such other aspects of the plan or coverage as the
Secretary may specify.
(b) Consultation.--In developing the guidance under subsection (a),
the Secretary shall consult with the Secretary of Labor and the
Secretary of the Treasury.
(c) Rule of Construction.--Nothing in this section shall be
construed as requiring a group health plan, a health insurance issuer
offering group or individual health insurance coverage, or a Medicare
Advantage organization offering an MA plan to offer any of the plan
features described in subsection (a).
(d) Definitions.--In this section:
(1) Medicare advantage terms.--The terms ``Medicare
Advantage organization'' and ``MA plan'' have the meanings
given each such term for purposes of part C of title XVIII of
the Social Security Act (42 U.S.C. 1395w-21 et seq.).
(2) Private health insurance terms.--The terms ``group
health plan'', ``health insurance coverage'', ``health
insurance issuer'', ``group health insurance coverage'', and
``individual health insurance coverage'' have the meanings
given each such term in section 2791 of the Public Health
Service Act (42 U.S.C. 300gg-91).
(3) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
<all>