[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9645 Introduced in House (IH)]
<DOC>
119th CONGRESS
2d Session
H. R. 9645
To promote health care price transparency, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 13, 2026
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, and Education and Workforce, 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 promote health care price transparency, 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.
This Act may be cited as the ``Health Care Price Certainty for All
Americans Act''.
SEC. 2. 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. 1899D. HEALTH CARE PROVIDER PRICE TRANSPARENCY.
``(a) Hospitals.--
``(1) In general.--Beginning January 1, 2027, each
specified hospital 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--
``(i) in accordance with a method and
format established by the Secretary under
subparagraph (C), compile and make public
(without subscription and free of charge), and
update not less frequently than annually (or at
such greater frequency as may be specified by
the Secretary)--
``(I) all of the hospital's
standard charges (including the
information described in subparagraph
(B)) for each item and service
furnished by such hospital;
``(II) information--
``(aa) 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
``(bb) 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;
``(ii) post in a publicly accessible
location of such hospital (in a form and manner
specified by the Secretary) the discounted cash
price, as applicable, expressed as a dollar
amount, for each Centers for Medicare &
Medicaid Services-specified shoppable service
that is furnished by the hospital when provided
in, as applicable, the inpatient setting and
outpatient department setting (or, in the case
no discounted cash price is available for such
service, the median cash price charged by the
hospital to self-pay individuals for such
service when provided in such settings for the
previous three years, expressed as a dollar
amount); and
``(iii) submit to the Secretary (in a form
and manner specified by the Secretary and on an
annual basis) an attestation, signed by the
chief executive officer, chief financial
officer, or other comparable official (as
specified by the Secretary) of such hospital,
that all information made public pursuant to
this subparagraph is complete and accurate.
``(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 plain language description (as
specified by the Secretary) of each item or
service, accompanied by, as applicable,
commonly recognized billing code sets,
including the Healthcare Common Procedure
Coding System code, the diagnosis-related
group, the national drug code, or other
applicable identifier determined appropriate by
the Secretary.
``(ii) For each such item or service when
provided in, as applicable, the inpatient and
outpatient department settings--
``(I) the gross charge, as
applicable, expressed as a dollar
amount;
``(II) each payer-specific
negotiated charge in effect between
such hospital and a third party payer,
expressed as a dollar amount;
``(III) the deidentified maximum
and minimum payer-specific negotiated
charges in effect between such hospital
and any third party payer; and
``(IV) the discounted cash price,
as applicable, expressed as a dollar
amount (or, in the case no discounted
cash price is available for such item
or service, the median cash price
charged by the hospital (not including
charity care) to self-pay individuals
for such item or service when provided
in such settings for the previous three
years, expressed as a dollar amount).
``(iii) With respect to prices made public
pursuant to subparagraph (A)(ii), a link to a
consumer-friendly document that clearly
explains the hospital's charity care policy
that includes, if applicable, any sliding scale
payment structure employed for determining
prices.
``(iv) Any other additional information the
Secretary may require (in consultation with
stakeholders) for the purpose of improving the
accuracy of, or enabling consumers to easily
understand and compare, standard charges and
prices for an item or service (which may
include, in the case that charges described in
clause (iii) for an item or service are unable
to be expressed as a dollar amount, such
information relating to past allowed charges
for such item or service as may be specified by
the Secretary), except information that is
duplicative of any other reporting requirement
under this subsection.
In the case of standard charges and prices for an item
or service included as part of a bundled, per diem,
episodic, or other similar arrangement, the information
described in this subparagraph shall be made available
as determined appropriate by the Secretary.
``(C) Uniform method and format.--Not later than
January 1, 2028, the Secretary shall establish a
standard, uniform method and format for specified
hospitals to use in compiling and making public
standard charges pursuant to subparagraph (A)(i)(I) and
a standard, uniform method and format for such
hospitals to use in compiling and making public prices
pursuant to subparagraph (A)(i)(II). Such methods and
formats--
``(i) shall, in the case of such method and
format for making public--
``(I) standard charges pursuant to
subparagraph (A)(i)(I), ensure that
such charges are made available in a
machine-readable format (or a successor
technology specified by the Secretary);
and
``(II) prices pursuant to
subparagraph (A)(i)(II), ensure that
such prices are made available in a
consumer-friendly format (as specified
by the Secretary);
``(ii) 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;
``(iii) shall meet such standards as
determined appropriate by the Secretary in
order to ensure the accessibility and usability
of such charges and prices; and
``(iv) shall be updated as determined
appropriate by the Secretary, in consultation
with stakeholders.
``(D) Deemed compliance with shoppable services
requirement for hospitals with a price estimator
tool.--
``(i) In general.--Before 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
compiled and made public information described
in subparagraph (A)(i)(II) (relating to
shoppable services) in accordance with a method
and format specified by the Secretary under
subparagraph (C) if such hospital maintains a
price estimator tool described in clause (ii).
``(ii) Price estimator tool described.--For
purposes of clause (i), a 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 subclause (IV)(cc)) 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:
``(aa) The name of such
individual.
``(bb) The date of birth of
such individual.
``(cc) 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.
``(dd) In the case of an
individual described in item
(cc), 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).
``(ee) 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.
``(3) Monitoring compliance.--The Secretary shall establish
processes to monitor and assess specified hospitals' compliance
with this subsection. Such processes shall ensure that each
specified hospital's compliance with this subsection is
reviewed not less frequently than once every 3 years and
include processes relating to the following:
``(A) The evaluation and analysis of complaints
made by individuals or other entities relating to such
hospitals' compliance with this subsection.
``(B) The use of audits to ensure such hospitals'
compliance with this subsection.
``(C) The obtaining of additional information from
such hospitals to determine such hospitals' compliance
with this subsection (as determined appropriate by the
Secretary).
``(4) Enforcement.--
``(A) In general.--In the case of a specified
hospital that fails to comply with the requirements of
this subsection--
``(i) not later than 30 days after the date
on which the Secretary determines such failure
exists, the Secretary shall submit to such
hospital a notification of such determination
(which may include, as determined appropriate
by the Secretary, a request for a corrective
action plan (to be submitted not later than 45
days after such request is made) to comply with
such requirements); and
``(ii) in the case of a hospital that does
not receive a request for a corrective action
plan as part of a notification submitted by the
Secretary under clause (i)--
``(I) the Secretary shall, not
later than 60 days after such
notification is sent, determine whether
such hospital is in compliance with
such requirements; and
``(II) if the Secretary determines
under subclause (I) that such hospital
is not in compliance with such
requirements, the Secretary shall
either--
``(aa) submit to such
hospital a request for a
corrective action plan (to be
submitted not later than 45
days after such request is
made) to comply with such
requirements; or
``(bb) if the Secretary
determines that such hospital
has not taken meaningful
actions to come into compliance
since such notification was
sent, impose a civil monetary
penalty in accordance with
subparagraph (B).
``(B) Civil monetary penalty.--
``(i) In general.--Subject to clause (vii),
in addition to any other enforcement actions or
penalties that may apply under another
provision of Federal law, a specified hospital
that has received a request for a corrective
action plan under clause (i) or (ii) of
subparagraph (A) and fails to comply with the
requirements of this subsection by the date
that is 90 days after such request is made (or,
if such hospital has submitted such a
corrective action plan not later than 45 days
after the date such request was made, by the
date that is 90 days after the date of the
submission of such corrective action plan), and
a specified hospital with respect to which the
Secretary has made a determination described in
clause (ii)(II)(bb) of such subparagraph, shall
be subject to a civil monetary penalty of an
amount specified by the Secretary for each day
(beginning with the day on which the Secretary
first determined that such hospital was not
complying with such requirements) during which
such failure was ongoing. Such amount shall not
exceed--
``(I) in the case of a specified
hospital with 30 or fewer beds, $342
per day;
``(II) in the case of a specified
hospital with more than 30 beds but
fewer than 550 beds, $11 per bed per
day; and
``(III) in the case of a specified
hospital with 550 beds or more, $6,277
per day.
``(ii) Increase authority.--In applying
this subparagraph with respect to failures to
comply occurring in 2029 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 under subclause (I)
or (III) of clause (i);
``(II) the limitations on the per
bed per day amount of any penalty
applicable under clause (i)(II); and
``(III) the amounts specified in
clause (iii)(II).
``(iii) Persistent noncompliance.--
``(I) In general.--In the case of a
specified hospital (other than a
specified hospital with 30 or fewer
beds) that the Secretary has determined
to be knowingly and willfully
noncompliant with the provisions of
this subsection for two or more 6-month
periods during any 3-year period, the
Secretary may increase any penalty
otherwise applicable under this
subparagraph by the amount specified in
subclause (II) with respect to such
hospital and may require such hospital
to complete such additional corrective
actions plans as the Secretary may
specify.
``(II) Specified amount.--For
purposes of subclause (I), the amount
specified in this subclause is, with
respect to a specified hospital--
``(aa) with more than 30
beds but fewer than 101 beds,
an amount that is not less than
$500,000 and not more than
$1,000,000;
``(bb) with more than 100
beds but fewer than 301 beds,
an amount that is greater than
$1,000,000 and not more than
$2,000,000;
``(cc) with more than 300
beds but fewer than 501 beds,
an amount that is greater than
$2,000,000 and not more than
$4,000,000; and
``(dd) with more than 500
beds, and amount that is not
less than $5,000,000 and not
more than $10,000,000.
``(iv) Authority to waive or reduce
penalty.--
``(I) In general.--Subject to
subclause (II), the Secretary may waive
any penalty, or reduce any penalty by
not more than 75 percent, otherwise
applicable under this subparagraph with
respect to a specified hospital located
in a rural area (as defined by the
Federal Office of Rural Health Policy
for the purpose of rural health grant
programs administered by such Office)
or an underserved area if the Secretary
determines that imposition of such
penalty would result in an immediate
threat to access to care for
individuals in the service area of such
hospital.
``(II) Limitation on application.--
The Secretary may not elect to waive a
penalty under subclause (I) with
respect to a specified hospital more
than once in a 6-year period and may
not elect to reduce such a penalty with
respect to such a hospital more than
once in such a period. Nothing in the
preceding sentence shall be construed
as prohibiting the Secretary from both
waiving and reducing a penalty with
respect to a specified hospital during
a 6-year period.
``(v) Hardship exemption.--Notwithstanding
any limit on the waiver or reduction of a
penalty under clause (iv), the Secretary may
waive any penalty with respect to a specified
hospital on a case-by-case basis if the
Secretary determines that a circumstance exists
interfering with such hospital's ability to
comply with the provisions of this subsection
(such as a natural disaster (as defined in
section 602(a) of the Robert T. Stafford
Disaster Relief and Emergency Assistance Act),
a public health emergency, or other unique or
unexpected event).
``(vi) Provision of technical assistance.--
The Secretary shall, to the extent practicable,
provide technical assistance relating to
compliance with the provisions of this
subsection to specified hospitals requesting
such assistance.
``(vii) 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.
``(C) Publication of hospital price transparency
information.--Beginning on January 1, 2028, the
Secretary shall make publicly available on the 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 in real
time (if practicable) and include--
``(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 identity 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;
``(vi) any waivers or reductions of
penalties made pursuant to a certification by
the Secretary under subparagraph (B)(iv),
including--
``(I) the name of any specified
hospital that received such a waiver or
reduction;
``(II) the dollar amount of each
such penalty so waived or reduced; and
``(III) the rationale for the
granting of each such waiver or
reduction, but only to the extent that
such rationale does not make public
commercially sensitive information; and
``(vii) any other information as determined
by the Secretary.
``(b) Clinical Diagnostic Laboratory Services.--
``(1) In general.--Beginning January 1, 2028, any
applicable laboratory that receives payment under this title
for furnishing any specified clinical diagnostic laboratory
test under this title shall--
``(A) make publicly available, in accordance with a
method and format established by the Secretary under
paragraph (3), the information described in paragraph
(2) with respect to each such specified clinical
diagnostic laboratory test that such laboratory so
furnishes;
``(B) update such information not less frequently
than annually (or at such greater frequency as the
Secretary may specify);
``(C) submit to the Secretary on an annual basis an
attestation, signed by the chief executive officer,
chief financial officer, or other comparable official
(as specified by the Secretary) of such laboratory,
that all such information is complete and accurate; and
``(D) post in a publicly accessible location of
such laboratory (in a form and manner specified by the
Secretary) the discounted cash price, as applicable,
expressed as a dollar amount, for each Centers for
Medicare & Medicaid Services-specified shoppable
service that is furnished by the laboratory (or, in the
case no discounted cash price is available for such
service, the median cash price charged by the
laboratory to self-pay individuals for such service for
the previous three years, expressed as a dollar
amount).
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph is, with
respect to an applicable laboratory and a specified clinical
diagnostic laboratory test, the discounted cash price for such
test (or, if no such price exists, the gross charge for such
test).
``(3) Uniform method and format.--Not later than January 1,
2028, the Secretary shall establish a standard, uniform method
and format for applicable laboratories to use in compiling and
making public information pursuant to paragraph (1). Such
method and format--
``(A) may be similar to any template made available
by the Centers for Medicare & Medicaid Services (as
described in subsection (a)(2)(C)(ii));
``(B) shall meet such standards as determined
appropriate by the Secretary in order to ensure the
accessibility and usability of such information; and
``(C) shall be updated as determined appropriate by
the Secretary, in consultation with stakeholders.
``(4) Inclusion of ancillary services.--Any price or charge
for a specified clinical diagnostic laboratory test furnished
by an applicable laboratory made publicly available in
accordance with paragraph (1) shall include the price or charge
(as applicable) for any ancillary item or service (such as
specimen collection services) that would normally be furnished
by such laboratory as part of such test, as specified by the
Secretary.
``(5) Monitoring compliance.--The Secretary shall, through
notice and comment rulemaking, establish a process to monitor
compliance with this subsection.
``(6) Enforcement.--
``(A) In general.--In the case that the Secretary
determines that an applicable laboratory is not in
compliance with the requirements of paragraph (1)--
``(i) not later than 30 days after such
determination, the Secretary shall notify such
laboratory of such determination (which may
include, as determined appropriate by the
Secretary, a request for a corrective action
plan (to be submitted not later than 45 days
after such request is made)); and
``(ii) in the case of a laboratory that
does not receive a request for a corrective
action plan as part of a notification under
clause (i)--
``(I) the Secretary shall, not
later than 90 days after such
notification is sent, determine whether
such laboratory is in compliance with
such requirements; and
``(II) if the Secretary determines
under subclause (I) that such
laboratory is not in compliance with
such requirements, the Secretary shall
either--
``(aa) submit to such
laboratory a request for a
corrective action plan (to be
submitted not later than 45
days after such request is
made) to comply with such
requirements; or
``(bb) if the Secretary
determines that such laboratory
has not taken meaningful
actions to come into compliance
since such notification was
sent, impose a civil monetary
penalty in accordance with
subparagraph (B).
``(B) Civil monetary penalty.--An applicable
laboratory that has received a request for a corrective
action plan under clause (i) or (ii) of subparagraph
(A) and fails to comply with the requirements of
paragraph (1) by the date that is 90 days after such
request is made, and an applicable laboratory with
respect to which the Secretary has made a determination
described in clause (ii)(II)(bb) of such subparagraph,
shall be subject to a civil monetary penalty in an
amount not to exceed $300 for each day (beginning with
the day on which the Secretary first determined that
such hospital was not complying with such requirements)
during which such failure was ongoing.
``(C) Increase authority.--In applying this
paragraph with respect to failures to comply occurring
in 2029 or a subsequent year, the Secretary may through
notice and comment rulemaking increase the per day
limitation on civil monetary penalties under
subparagraph (B).
``(D) 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.
``(E) Authority to waive or reduce penalty.--
``(i) In general.--Subject to clause (ii),
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 an immediate
threat to access to care for individuals in the
service area of such laboratory.
``(ii) Limitation.--The Secretary may not
elect to waive or reduce a penalty under clause
(i) with respect to an applicable laboratory
more than 3 times in a 10 year period.
``(F) Hardship exemption.--Notwithstanding any
limit on the waiver or reduction of a penalty under
subparagraph (E), the Secretary may waive any penalty
with respect to an applicable laboratory on a case-by-
case basis if the Secretary determines that a
circumstance exists interfering with such laboratory's
ability to comply with the provisions of this
subsection (such as a natural disaster (as defined in
section 602(a) of the Robert T. Stafford Disaster
Relief and Emergency Assistance Act), a public health
emergency, or other unique or unexpected event).
``(7) Provision of technical assistance.--The Secretary
shall, to the extent practicable, provide technical assistance
relating to compliance with the provisions of this subsection
to applicable laboratories requesting such assistance.
``(8) 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 a
successor regulation), except that such term does not
include a laboratory with respect to which standard
charges and prices for specified clinical diagnostic
laboratory tests furnished by such laboratory are made
available by--
``(i) a specified hospital pursuant to
subsection (a); or
``(ii) an ambulatory surgical center
pursuant to subsection (d).
``(B) 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 (as described in subsection (a)(2)(A)(i)(II)),
other than an advanced diagnostic laboratory test (as
defined in section 1834A(d)(5)).
``(c) Imaging Services.--
``(1) In general.--Beginning January 1, 2028, each provider
of services and supplier that receives payment under this title
for furnishing a specified imaging service, other than such a
provider or supplier with respect to which standard charges and
prices for such services furnished by such provider or supplier
are made available by a specified hospital pursuant to
subsection (a) or an ambulatory surgical center pursuant to
subsection (d), shall--
``(A) make publicly available, in accordance with a
method and format established by the Secretary under
paragraph (3), the information described in paragraph
(2) with respect to each such service that such
provider of services or supplier furnishes;
``(B) updated such information not less frequently
than annually (or at such greater frequency as the
Secretary may specify);
``(C) submit to the Secretary on an annual basis an
attestation, signed by the chief executive officer,
chief financial officer, or other comparable official
(as specified by the Secretary) of such provider or
supplier, that all such information is complete and
accurate; and
``(D) post in a publicly accessible location of
such provider or supplier (in a form and manner
specified by the Secretary) the discounted cash price,
as applicable, expressed as a dollar amount, for each
Centers for Medicare & Medicaid Services-specified
shoppable service that is furnished by the provider or
supplier (or, in the case no discounted cash price is
available for such service, the median cash price
charged by the provider or supplier to self-pay
individuals for such service for the previous three
years, expressed as a dollar amount).
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph is, with
respect to a provider of services or supplier and a specified
imaging service, the discounted cash price for such service
(or, if no such price exists, the gross charge for such
service).
``(3) Uniform method and format.--Not later than January 1,
2028, the Secretary shall establish a standard, uniform method
and format for providers of services and suppliers to use in
making public information described in paragraph (2). Any such
method and format--
``(A) may be similar to any template made available
by the Centers for Medicare & Medicaid Services (as
described in subsection (a)(2)(C)(ii));
``(B) shall meet such standards as determined
appropriate by the Secretary in order to ensure the
accessibility and usability of such information; 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, establish a process to monitor
compliance with this subsection.
``(5) Enforcement.--
``(A) In general.--In the case that the Secretary
determines that a provider of services or supplier is
not in compliance with the requirements of paragraph
(1)--
``(i) not later than 30 days after such
determination, the Secretary shall notify such
provider or supplier of such determination
(which may include, as determined appropriate
by the Secretary, a request for a corrective
action plan (to be submitted not later than 45
days after such request is made)); and
``(ii) in the case of a provider of
services or supplier that does not receive a
request for a corrective action plan as part of
a notification under clause (i)--
``(I) the Secretary shall, not
later than 90 days after such
notification is sent, determine whether
such provider or supplier is in
compliance with such requirements; and
``(II) if the Secretary determines
under subclause (I) that such provider
or supplier is not in compliance with
such requirements, the Secretary shall
either--
``(aa) submit to such
provider or supplier a request
for a corrective action plan
(to be submitted not later than
45 days after such request is
made) to comply with such
requirements; or
``(bb) if the Secretary
determines that such provider
or supplier has not taken
meaningful actions to come into
compliance since such
notification was sent, impose a
civil monetary penalty in
accordance with subparagraph
(B).
``(B) Civil monetary penalty.--A provider of
services or supplier that has received a request for a
corrective action plan under clause (i) or (ii) of
subparagraph (A) and fails to comply with the
requirements of paragraph (1) by the date that is 90
days after such request is made, and a provider of
services or supplier with respect to which the
Secretary has made a determination described in clause
(ii)(II)(bb) of such subparagraph, shall be subject to
a civil monetary penalty in an amount not to exceed
$300 for each day (beginning with the day on which the
Secretary first determined that such provider or
supplier was not complying with such requirements)
during which such failure was ongoing.
``(C) Increase authority.--In applying this
paragraph with respect to failures to comply occurring
in 2029 or a subsequent year, the Secretary may through
notice and comment rulemaking increase the amount of
the civil monetary penalty under subparagraph (B).
``(D) 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.
``(E) Authority to waive or reduce penalty.--
``(i) In general.--Subject to clause (ii),
the Secretary may waive or reduce any penalty
otherwise applicable with respect to a provider
of services or supplier under this paragraph if
the Secretary determines that imposition of
such penalty would result in an immediate
threat to access to care for individuals in the
service area of such provider or supplier.
``(ii) Limitation.--The Secretary may not
elect to waive or reduce a penalty under clause
(i) with respect to a specific provider of
services or supplier more than 3 times in a 10
year period.
``(F) Hardship exemption.--Notwithstanding any
limit on the waiver or reduction of a penalty under
subpargraph (E), the Secretary may waive any penalty
with respect to a provider of services or supplier on a
case-by-case basis if the Secretary determines that a
circumstance exists interfering with such provider's or
supplier's ability to comply with the provisions of
this subsection (such as a natural disaster (as defined
in section 602(a) of the Robert T. Stafford Disaster
Relief and Emergency Assistance Act), a public health
emergency, or other unique or unexpected event).
``(G) Provision of technical assistance.--The
Secretary shall, to the extent practicable, provide
technical assistance relating to compliance with the
provisions of this subsection to providers of services
and suppliers requesting such assistance.
``(6) Definition.--In this subsection, the term `specified
imaging service' means an imaging service that is included on
the list of Centers for Medicare & Medicaid Services-specified
shoppable services (as described in subsection (a)(i)(II)).
``(d) Ambulatory Surgical Centers.--
``(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 center--
``(i) in accordance with a method and
format established by the Secretary under
subparagraph (C), compile and make public
(without subscription and free of charge), and
update not less frequently than annually (or at
such greater frequency as may be specified by
the Secretary)--
``(I) all 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
(as specified by the Secretary) 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; and
``(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;
``(ii) submit to the Secretary on an annual
basis an attestation, signed by the chief
executive officer, chief financial officer, or
other comparable official (as specified by the
Secretary) of such center, that all information
made public pursuant to this subparagraph is
complete and accurate; and
``(iii) post in a publicly accessible
location of such center (in a form and manner
specified by the Secretary) the discounted cash
price, as applicable, expressed as a dollar
amount, for each Centers for Medicare &
Medicaid Services-specified shoppable service
that is furnished by the center (or, in the
case no discounted cash price is available for
such service, the median cash price charged by
the center to self-pay individuals for such
service for the previous three years, expressed
as a dollar amount).
``(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 plain language description (as
specified by the Secretary) of each item or
service, accompanied by, as applicable,
commonly recognized billing code sets,
including the Healthcare Common Procedure
Coding System code, the national drug code, or
other applicable identifier determined
appropriate by the Secretary.
``(ii) For each such item or service--
``(I) the gross charge, as
applicable, expressed as a dollar
amount;
``(II) each payer-specific
negotiated charge in effect between
such center and a third party payer,
expressed as a dollar amount;
``(III) the deidentified maximum
and minimum payer-specific negotiated
charges in effect between such center
and any third party payer; and
``(IV) the discounted cash price,
as applicable, expressed as a dollar
amount (or, in the case no discounted
cash price is available for an item or
service, the median cash price charged
to self-pay individuals (not including
charity care) for such item or service
for the previous three years, expressed
as a dollar amount).
``(iii) Any other additional information
the Secretary may require (in consultation with
stakeholders) for the purpose of improving the
accuracy of, or enabling consumers to easily
understand and compare, standard charges and
prices for an item or service, except
information that is duplicative of any other
reporting requirement under this subsection.
In the case of standard charges and prices for an item
or service included as part of a bundled, per diem,
episodic, or other similar arrangement, the information
described in this subparagraph shall be made available
as determined appropriate by the Secretary.
``(C) Uniform method and format.--Not later than
January 1, 2028, the Secretary shall establish a
standard, uniform method and format for ambulatory
surgical centers to use in making public standard
charges pursuant to subparagraph (A)(i) and a standard,
uniform method and format for such centers to use in
making public prices pursuant to subparagraph (A)(ii).
Any such method and format--
``(i) shall, in the case of--
``(I) standard charges made public
by an ambulatory surgical center under
subparagraph (A)(i), ensure that such
charges are made available in a
machine-readable format (or successor
technology); and
``(II) prices made public by an
ambulatory surgical center under
subparagraph (A)(ii), ensure that such
prices are made available in a
consumer-friendly format (as specified
by the Secretary);
``(ii) may be similar to any template made
available by the Centers for Medicare &
Medicaid Services (as described in subsection
(a)(2)(C)(ii));
``(iii) shall meet such standards as
determined appropriate by the Secretary in
order to ensure the accessibility and usability
of such charges and prices; and
``(iv) shall be updated as determined
appropriate by the Secretary, in consultation
with stakeholders.
``(D) Deemed compliance with shoppable services
requirement for centers with a price estimator tool.--
``(i) In general.--Before 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
compiled and made public information described
in subparagraph (A)(i)(II) (relating to
shoppable services) in accordance with a method
and format specified by the Secretary under
subparagraph (C) if such hospital maintains a
price estimator tool described in clause (ii).
``(ii) Price estimator tool described.--For
purposes of clause (i), a 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 subclause (IV)(cc)) and
the discounted cash price charged by an
ambulatory surgical center for each
Centers for Medicare & Medicaid
Services-specified shoppable service
that is furnished by such center, and
for each additional shoppable service
as such 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 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 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:
``(aa) The name of such
individual.
``(bb) The date of birth of
such individual.
``(cc) 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.
``(dd) In the case of an
individual described in item
(cc), 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).
``(ee) 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.
``(3) Monitoring compliance.--The Secretary shall establish
processes to monitor and assess ambulatory surgical centers'
compliance with this subsection. Such processes shall include
processes relating to the following:
``(A) The evaluation and analysis of complaints
made by individuals or other entities relating to such
centers' compliance with this subsection.
``(B) The use of audits to ensure such centers'
compliance with this subsection.
``(C) The obtaining of additional information from
such centers to determine such centers' compliance with
this subsection (as determined appropriate by the
Secretary).
``(4) Enforcement.--
``(A) In general.--In the case that the Secretary
determines that an ambulatory surgical center is not in
compliance with the requirements of paragraph (1)--
``(i) not later than 30 days after such
determination, the Secretary shall notify such
center of such determination (which may
include, as determined appropriate by the
Secretary, a request for a corrective action
plan (to be submitted not later than 45 days
after such request is made)); and
``(ii) in the case of an ambulatory
surgical center that does not receive a request
for a corrective action plan as part of a
notification under clause (i)--
``(I) the Secretary shall, not
later than 90 days after such
notification is sent, determine whether
such center is in compliance with such
requirements; and
``(II) if the Secretary determines
under subclause (I) that such center is
not in compliance with such
requirements, the Secretary shall
either--
``(aa) submit to such
center a request for a
corrective action plan (to be
submitted not later than 45
days after such request is
made) to comply with such
requirements; or
``(bb) if the Secretary
determines that such center has
not taken meaningful actions to
come into compliance since such
notification was sent, impose a
civil monetary penalty in
accordance with subparagraph
(B).
``(B) Civil monetary penalty.--
``(i) In general.--An ambulatory surgical
center that has received a request for a
corrective action plan under clause (i) or (ii)
of subparagraph (A) and fails to comply with
the requirements of paragraph (1) by the date
that is 90 days after such request is made, and
an ambulatory surgical center with respect to
which the Secretary has made a determination
described in clause (ii)(II)(bb) of such
subparagraph, shall be subject to a civil
monetary penalty in an amount not to exceed
$300 for each day (beginning with the day on
which the Secretary first determined that such
center was not complying with such
requirements) during which such failure was
ongoing.
``(ii) Increase authority.--In applying
this subparagraph with respect to failures to
comply occurring in 2029 or a subsequent year,
the Secretary may through notice and comment
rulemaking increase the limitation on the per
day amount of any penalty 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.--
``(I) In general.--Subject to
subclause (II), the Secretary may waive
any penalty, or reduce any penalty by
not more than 75 percent, otherwise
applicable under this subparagraph with
respect to an ambulatory surgical
center located in a rural or
underserved area if the Secretary
certifies that imposition of such
penalty would result in an immediate
threat to access to care for
individuals in the service area of such
surgical center.
``(II) Limitation on application.--
The Secretary may not elect to waive a
penalty under subclause (I) with
respect to an ambulatory surgical
center more than once in a 6-year
period and may not elect to reduce such
a penalty with respect to such a
surgical center more than once in such
a period. Nothing in the preceding
sentence shall be construed as
prohibiting the Secretary from both
waiving and reducing a penalty with
respect to an ambulatory surgical
center during a 6-year period.
``(v) Hardship exemption.--Notwithstanding
any limit on the waiver or reduction of a
penalty under clause (iv), the Secretary may
waive any penalty with respect to an ambulatory
surgical center on a case-by-case basis if the
Secretary determines that a circumstance exists
interfering with such center's ability to
comply with the provisions of this subsection
(such as a natural disaster (as defined in
section 602(a) of the Robert T. Stafford
Disaster Relief and Emergency Assistance Act),
a public health emergency, or other unique or
unexpected event).
``(5) Provision of technical assistance.--The Secretary
shall, to the extent practicable, provide technical assistance
relating to compliance with the provisions of this subsection
to ambulatory surgical centers requesting such assistance.
``(e) Ensuring Accessibility Through Implementation.--In
implementing this section, the Secretary shall through rulemaking
ensure that a provider of services or supplier making public charges
and prices pursuant to this section takes reasonable steps (as
specified by the Secretary) to ensure the accessibility of such charges
and information to individuals with limited English proficiency. Such
steps may include the provision of interpretation services or the
provision of translations of charges and information.
``(f) Definitions.--For purposes of this section:
``(1) Discounted cash price.--The term `discounted cash
price' means the charge that applies to an individual who pays
cash, or cash equivalent, for an item or service.
``(2) Gross charge.--The term `gross charge' means the
charge for an individual item or service that is reflected on a
specified hospital's chargemaster or provider of service or
supplier's, as applicable, chargemaster (or similar list of
prices), absent any discounts.
``(3) Payer-specific negotiated charge.--The term `payer-
specific negotiated charge' means the charge that an applicable
laboratory has negotiated with a third party payer for an item
or service.
``(4) 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.
``(5) 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)).
``(6) 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 an item or
service.''.
(b) 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 provisions of this subsection
shall not apply beginning on January 1, 2028.''.
SEC. 3. HEALTH COVERAGE PRICE TRANSPARENCY.
(a) Price Transparency Requirements.--
(1) IRC.--
(A) In general.--Section 9819 of the Internal
Revenue Code of 1986 is amended--
(i) in the header, by striking
``maintenance of price comparison tool'' and
inserting ``transparency in coverage'';
(ii) by striking ``A group health plan''
and inserting the following:
``(a) Maintenance of Price Comparison Tool for Plan Years Before
2029.--
``(1) In general.--A group health plan'';
(iii) in subsection (a), as inserted by
clause (ii), by adding at the end the following
new paragraph:
``(2) Sunset.--Paragraph (1) shall not apply with respect
to plan years beginning on or after January 1, 2029.''; and
(iv) by adding at the end the following new
subsections:
``(b) Cost-sharing Transparency.--
``(1) In general.--For plan years beginning on or after
January 1, 2029, a group health plan shall provide a
participant or beneficiary, in a timely manner upon request of
the participant or beneficiary, information on the amount of
cost-sharing (including deductibles, copayments, and
coinsurance) under the participant or beneficiary's plan that
the participant or beneficiary would be responsible for paying
with respect to the furnishing of a specific item or service by
a provider. At a minimum, such information shall include the
information specified in paragraph (2) and shall be made
available to such participant or beneficiary through a self-
service tool that meets the requirements of paragraph (3) or,
at the option of such participant or beneficiary, through a
paper disclosure or phone or other electronic disclosure (as
selected by such participant or beneficiary and provided at no
cost to such participant or beneficiary) 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 for such item or service.
``(B) If such provider is not a participating
provider with respect to such item or service, the
maximum allowed amount or other dollar amount that such
plan will recognize as payment for such item or
service, along with a notice that such participant or
beneficiary may be liable for additional charges.
``(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
allowed amount or other dollar 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 under the plan (broken down, in
the case separate deductibles or maximums apply to a
participant and such participant's 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.
``(G) Any financial incentives (such as any credit,
payment, or other benefit provided by such plan)
available to the participant or beneficiary with
respect to such item or service furnished by such
provider known at the time such request is made.
``(H) Other information 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 (or successor
technology specified by the Secretary);
``(B) is made available in plain language at no
cost;
``(C) provides for real-time responses to requests
described in paragraph (1);
``(D) is updated in a manner such that information
provided through such tool is timely and accurate at
the time such request is made;
``(E) 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) nonspecific providers located in a
relevant geographic region that are not
participating providers with respect to such
item or service;
``(F) 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
``(G) meets any other requirement determined
appropriate by the Secretary, including requirements to
ensure the accessibility and usability of information
provided through such tool.
``(c) Rate and Payment Information.--
``(1) In general.--For plan years beginning on or after
January 1, 2029, 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 a church plan
(as defined in section 414(e))) shall 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--
``(i) the in-network rate (expressed as a
dollar amount) in effect as of the date on
which such information is made public with each
provider that is a participating provider with
respect to such item or service (other than, in
the case that such plan provides benefits for
such item or service only when furnished by a
specific type of provider, such a participating
provider who is not such type of provider
(referred to in this subparagraph as an
`excluded provider')); and
``(ii) with respect to each such
participating provider (other than a provider
that is an excluded provider with respect to
such item or service), an indication of
whether, during the 1-year period beginning 18
months before the date such information is made
public, such provider submitted a claim for
such item or service to such plan for which
payment was made (in whole or in part) under
such plan.
``(B) With respect to each drug (identified by
national drug code) for which benefits are available
under such plan--
``(i) the in-network rate (expressed as a
dollar amount) in effect as of the first day of
the month in which such information is made
public with each provider that is a
participating provider with respect to such
drug;
``(ii) the average amount paid by such plan
(accounting for, in a manner determined
appropriate by the Secretary, rebates,
discounts, price concessions, and any other
remuneration specified by the Secretary) 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, unless
fewer than 20 claims for such drug were
submitted to such plan during such period; and
``(iii) in the case such drug is an
applicable spread price drug dispensed by a
pharmacy--
``(I) a specification that such
drug is such an applicable spread price
drug; and
``(II) for each pharmacy that has a
contractual relationship for dispensing
such drug under such plan, a
specification of the difference (if
any) between the specified payment
amount for such drug so dispensed by
such pharmacy and the specified
reimbursement amount for such drug so
dispensed by such pharmacy.
``(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 6-month
period beginning 9 months before the date such
information is made public by a provider that was not a
participating provider with respect to such item or
service, broken down by each such provider, other than
such an amount with respect to an item or service for
which, during such period, fewer than 11 claims were
made under such plan. In determining the number of
claims made under such plan with respect to an item or
service during such period for purposes of the
preceding sentence, such number shall be deemed to
include all claims for such item or service made during
such period under all group health plans offered in the
same insurance market (specified in subclause (I),
(II), (III), of section 9816(a)(3)(E)(iv)) by the
sponsor of the plan at issue.
In the case that a specific dollar amount for an in-network
rate required to be made available pursuant to this subsection
with respect to an item or service cannot be determined
prospectively on the basis that such rate is determined as a
percentage of the billed charges for such item or service, such
percentage and the median amount recognized by such plan as
payment for such item or service with respect to claims for
such item or service submitted by participating providers
during the period described in subparagraph (A)(ii) shall be
reported by such plan in lieu of such rate. Such plan shall
identify that such median amount represents an estimate of such
in-network rate for such item or service.
``(3) Manner of publication.--
``(A) In general.--Rate and payment information
required to be made available under this subsection
shall be so made available in dollar amounts through
separate machine-readable files (and any successor
technology, as applicable, such as application
programming 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 (which may
be so specified through subregulatory guidance),
including requirements relating to whether such
information should be so made available on the plan or
coverage level, with respect to individual provider
networks, or aggregated in such manner 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 or
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 or undertake other steps as may be
specified by the Secretary.
``(B) Timing.--Rate and payment information
described in paragraph (2) shall be made public on a
quarterly basis.
``(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 through
subregulatory guidance a template that such a plan may use in
developing instructions for purposes of the preceding sentence.
``(5) Summary.--For each plan year beginning on or after
January 1, 2029, each group health plan shall make public a
data file, in a manner that ensures that such file may be
easily downloaded and read by standard spreadsheet software and
that meets such requirements as established by the Secretary,
containing a summary of all rate and payment information made
public by such plan with respect to such plan during such plan
year. Such file shall include the following:
``(A) The mean, median, and interquartile range of
the in-network rate, and the amount allowed for an item
or service when not furnished by a participating
provider, in effect as of the first day of such plan
year for each item or service (identified by payer
identifier approved or used by the Centers for Medicare
& Medicaid Services) for which benefits are available
under the plan, broken down by the type of provider
furnishing the item or service and by the geographic
area in which such item or service is furnished.
``(B) Trends in payment rates for such items and
services over such plan year, including an
identification of instances in which such rates have
increased, decreased, or remained the same.
``(C) The name of such plan, a description of the
type of network of participating providers used by such
plan, and a description of whether such plan is self-
insured or fully-insured.
``(D) For each item or service which is paid as
part of a bundled or capitated rate--
``(i) a description of the formulae,
pricing methodologies, or other information
used to calculate the payment rate for such
rate; and
``(ii) a list of the items and services
included in such rate.
``(E) The percentage of items and services that are
paid for on a fee-for-service basis and the percentage
of items and services that are paid for as part of a
bundled rate, capitated payment rate, or other
alternative payment model.
``(d) Attestation.-- A group health plan shall annually submit to
the Secretary an attestation, signed by the chief executive officer,
chief financial officer, or other comparable official (as specified by
the Secretary) of such plan, of such plan's compliance with the
provisions of this section and that information made available under
this section is true, accurate, and complete. Such attestation shall,
except in the case of a grandfathered health plan (as defined in
section 1251(e) of the Patient Protection and Affordable Care Act) or a
church plan (as defined in section 414(e)), include a link to the
website (or other successor technology) where rate and payment
information required to be made public under subsection (c) may be
accessed.
``(e) Accessibility.--A group health plan shall take reasonable
steps (as specified by the Secretary) to ensure that information
provided in response to a request described in subsection (b), and rate
and payment information made public under subsection (c), is provided
in plain, easily understandable language and that interpretation,
translations, and assistive services are provided to those with limited
English proficiency and those with disabilities.
``(f) Definitions.--In this section:
``(1) Applicable spread price drug.--The term `applicable
spread price drug' means, with respect to a group health plan,
a drug for which benefits are available under such plan and
with respect to which, at the time rate and payment information
is made public by such plan under subsection (c)--
``(A) a contract is in effect between an entity
providing pharmacy benefit management services on
behalf of such plan and a pharmacy for the dispensing
of such drug under such plan; and
``(B) the specified payment amount for such drug so
dispensed is less than the specified reimbursement
amount for such drug so dispensed.
``(2) In-network rate.--The term `in-network rate' means,
with respect to a group 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
(reflected as a dollar amount) in effect between such plan and
such provider for such item or service, regardless of whether
such rate is calculated based on a set amount, a fee schedule,
or an amount derived from another amount, or a formula, or
other method.
``(3) Participating provider.--The term `participating
provider' means, with respect to an item or service and a group
health plan, a physician or other health care provider (as
defined in paragraph (4)) who is acting within the scope of
practice of that provider's license or certification under
applicable State law and who has a contractual relationship
with the plan for furnishing such item or service under the
plan.
``(4) Provider.--The term `provider' includes a health care
facility and a pharmacy.
``(5) Specified payment amount.--The term `specified
payment amount' means, with respect to a drug to be dispensed
by a pharmacy to a participant or beneficiary of a group health
plan where such pharmacy has in effect a contract with an
entity providing pharmacy benefit management services on behalf
of such plan for the dispensing of such drug under such plan,
the amount that such entity has agreed to pay such pharmacy for
the ingredient costs and any applicable dispensing fee for such
drug (or the amount that such entity has agreed to pay such
pharmacy for such drug under any other compensation structure
specified by the Secretary) under such contract, taking into
account any cost sharing requirement applicable to such drug
and participant or beneficiary.
``(6) Specified reimbursement amount.--The term `specified
reimbursement amount' means, with respect to a drug to be
dispensed by a pharmacy to a participant or beneficiary of a
group health plan where such pharmacy has in effect a contract
with an entity providing pharmacy benefit management services
on behalf of such plan for the dispensing of such drug under
such plan, the amount that such plan has agreed to pay to such
entity for the ingredient costs and any applicable dispensing
fee for such drug (or the amount that such plan has agreed to
pay such entity for such drug under any other compensation
structure specified by the Secretary), taking into account any
cost sharing requirement applicable to such drug and
participant or beneficiary.''.
(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. Transparency in coverage.''.
(2) PHSA.--Section 2799A-4 of the Public Health Service Act
(42 U.S.C. 300gg-114) is amended--
(A) in the header, by striking ``maintenance of
price comparison tool'' and inserting ``transparency in
coverage'';
(B) by striking ``A group health plan'' and
inserting the following:
``(a) Maintenance of Price Comparison Tool for Plan Years Before
2029.--
``(1) In general.--A group health plan'';
(C) in subsection (a), as inserted by subparagraph
(B), by adding at the end the following new paragraph:
``(2) Sunset.--Paragraph (1) shall not apply with respect
to plan years beginning on or after January 1, 2029.''; and
(D) by adding at the end the following new
subsections:
``(b) Cost-sharing Transparency.--
``(1) In general.--For plan years beginning on or after
January 1, 2029, a group health plan and a health insurance
issuer offering group or individual health insurance coverage
shall provide a participant, beneficiary, or enrollee, in a
timely manner upon request of the participant, beneficiary, or
enrollee, information on the amount of cost-sharing (including
deductibles, copayments, and coinsurance) under the
participant, beneficiary, or enrollee's plan or coverage that
the participant, beneficiary, or enrollee would be responsible
for paying with respect to the furnishing of a specific item or
service by a provider. At a minimum, such information shall
include the information specified in paragraph (2) and shall be
made available to such participant, beneficiary, or enrollee
through a self-service tool that meets the requirements of
paragraph (3) or, at the option of such participant,
beneficiary, or enrollee, 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 an
individual enrolled under such plan or coverage, the following:
``(A) If such provider is a participating provider
with respect to such item or service, the in-network
rate for such item or service.
``(B) If such provider is not a participating
provider with respect to such item or service, the
maximum allowed amount or other dollar amount that such
plan or coverage will recognize as payment for such
item or service, along with a notice that such
individual may be liable for additional charges.
``(C) The estimated amount of cost sharing
(including deductibles, copayments, and coinsurance)
that the individual 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 allowed amount or
other dollar amount described in such subparagraph).
``(D) The amount the individual has already
accumulated with respect to any deductible or out of
pocket maximum under the plan or coverage (broken down,
in the case separate deductibles or maximums apply to
individuals 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 imposes any frequency
or volume limitations with respect to such item or
service (excluding medical necessity determinations),
the amount that such individual 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.
``(G) Any financial incentives (such as any credit,
payment, or other benefit provided by such plan or
issuer) available to the individual with respect to
such item or service furnished by such provider known
at the time such request is made.
``(H) Other information 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 health
insurance issuer offering group or individual health insurance
coverage meets the requirements of this paragraph if such
tool--
``(A) is based on an internet website (or successor
technology specified by the Secretary);
``(B) is made available in plain language at no
cost;
``(C) provides for real-time responses to requests
described in paragraph (1);
``(D) is updated in a manner such that information
provided through such tool is timely and accurate at
the time such request is made;
``(E) 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) nonspecific providers located in a
relevant geographic region that are not
participating providers with respect to such
item or service;
``(F) 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
``(G) meets any other requirement determined
appropriate by the Secretary, including requirements to
ensure the accessibility and usability of information
provided through such tool.
``(c) Rate and Payment Information.--
``(1) In general.--For plan years beginning on or after
January 1, 2029, each group health plan and health insurance
issuer offering group or individual health insurance coverage
(other than a grandfathered health plan (as defined in section
1251(e) of the Patient Protection and Affordable Care Act) and
other than such an issuer offering group health insurance
coverage in connection with a church plan (as defined in
section 414(e) of the Internal Revenue Code of 1986)) shall
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--
``(i) the in-network rate (expressed as a
dollar amount) in effect as of the date on
which such information is made public with each
provider that is a participating provider with
respect to such item or service (other than, in
the case that such plan or coverage provides
benefits for such item or service only when
furnished by a specific type of provider, such
a participating provider who is not such type
of provider (referred to in this subparagraph
as an `excluded provider')); and
``(ii) with respect to each such
participating provider (other than a provider
that is an excluded provider with respect to
such item or service), an indication of
whether, during the 1-year period beginning 18
months before the date such information is made
public, such provider submitted a claim for
such item or service to such plan or coverage
for which payment was made (in whole or in
part) under such plan or coverage.
``(B) With respect to each drug (identified by
national drug code) for which benefits are available
under such plan or coverage--
``(i) the in-network rate (expressed as a
dollar amount) in effect as of the first day of
the month in which such information is made
public with each provider that is a
participating provider with respect to such
drug;
``(ii) the average amount paid by such plan
or coverage (accounting for, in a manner
determined appropriate by the Secretary,
rebates, discounts, price concessions, and any
other remuneration specified by the Secretary)
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,
unless fewer than 20 claims for such drug were
submitted to such plan or coverage during such
period; and
``(iii) in the case such drug is an
applicable spread price drug dispensed by a
pharmacy--
``(I) a specification that such
drug is such an applicable spread price
drug; and
``(II) for each pharmacy that has a
contractual relationship for dispensing
such drug under such plan or coverage,
a specification of the difference (if
any) between the specified payment
amount for such drug so dispensed by
such pharmacy and the specified
reimbursement amount for such drug so
dispensed by such pharmacy.
``(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 6-month period beginning 9 months
before the date such information is made public by a
provider that was not a participating provider with
respect to such item or service, broken down by each
such provider, other than such an amount with respect
to an item or service for which, during such period,
fewer than 11 claims were made under such plan or
coverage. In determining the number of claims made
under such plan or coverage with respect to an item or
service during such period for purposes of the
preceding sentence, such number shall be deemed to
include all claims for such item or service made during
such period under all group health plans and health
insurance coverage offered in the same insurance market
(specified in subclause (I), (II), (III), or (IV) of
section 2799A-1(a)(3)(E)(iv)) by the sponsor or issuer
(as applicable) of the plan or coverage at issue.
In the case that a specific dollar amount for an in-network
rate required to be made available pursuant to this subsection
with respect to an item or service cannot be determined
prospectively on the basis that such rate is determined as a
percentage of the billed charges for such item or service, such
percentage and the median amount recognized by such plan or
coverage as payment for such item or service with respect to
claims for such item or service submitted by participating
providers during the period described in subparagraph (A)(ii)
shall be reported by such plan in lieu of such rate. Such plan
or coverage shall identify that such median amount represents
an estimate of such in-network rate for such item or service.
``(3) Manner of publication.--
``(A) In general.--Rate and payment information
required to be made available under this subsection
shall be so made available in dollar amounts through
separate machine-readable files (and any successor
technology, as applicable, such as application
programming 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 (which may
be so specified through subregulatory guidance),
including requirements relating to whether such
information should be so made available on the plan or
coverage level, with respect to individual provider
networks, or aggregated in such manner 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 or
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.
``(B) Timing.--Rate and payment information
described in paragraph (2) shall be made public on a
quarterly basis.
``(4) User instructions.--Each group health plan and health
insurance issuer offering 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 through subregulatory guidance a template that such
a plan may use in developing instructions for purposes of the
preceding sentence.
``(5) Summary.--For each plan year beginning on or after
January 1, 2029, each group health plan and health insurance
issuer offering group or individual health insurance coverage
shall make public a data file, in a manner that ensures that
such file may be easily downloaded and read by standard
spreadsheet software and that meets such requirements as
established by the Secretary, containing a summary of all rate
and payment information made public by such plan or issuer with
respect to such plan or coverage during such plan year. Such
file shall include the following:
``(A) The mean, median, and interquartile range of
the in-network rate, and the amount allowed for an item
or service when not furnished by a participating
provider, in effect as of the first day of such plan
year for each item or service (identified by payer
identifier approved or used by the Centers for Medicare
& Medicaid Services) for which benefits are available
under the plan or coverage, broken down by the type of
provider furnishing the item or service and by the
geographic area in which such item or service is
furnished.
``(B) Trends in payment rates for such items and
services over such plan year, including an
identification of instances in which such rates have
increased, decreased, or remained the same.
``(C) The name of such plan, a description of the
type of network of participating providers used by such
plan or coverage, and, in the case of a group health
plan, a description of whether such plan is self-
insured or fully-insured.
``(D) For each item or service which is paid as
part of a bundled or capitated rate--
``(i) a description of the formulae,
pricing methodologies, or other information
used to calculate the payment rate for such
rate; and
``(ii) a list of the items and services
included in such rate.
``(E) The percentage of items and services that are
paid for on a fee-for-service basis and the percentage
of items and services that are paid for as part of a
bundled rate, capitated payment rate, or other
alternative payment model.
``(d) Attestation.--Each group health plan and health insurance
issuer offering group or individual health insurance coverage shall
annually submit to the Secretary an attestation, signed by the chief
executive officer, chief financial officer, or other comparable
official (as specified by the Secretary) of such plan or issuer, of
such plan's or coverage's compliance with the provisions of this
section and that information made available under this section is true,
accurate, and complete. Such attestation shall, except in the case of a
grandfathered health plan (as defined in section 1251(e) of the Patient
Protection and Affordable Care Act) or in the case of such an issuer
offering group health insurance coverage in connection with a church
plan (as defined in section 414(e) of the Internal Revenue Code of
1986), include a link to the website (or other successor technology)
where rate and payment information required to be made public under
subsection (c) may be accessed.
``(e) Accessibility.--A group health plan and a health insurance
issuer offering group or individual health insurance coverage shall
take reasonable steps (as specified by the Secretary) to ensure that
information provided in response to a request described in subsection
(b), and rate and payment information made public under subsection (c),
is provided in plain, easily understandable language and that
interpretation, translations, and assistive services are provided to
those with limited English proficiency and those with disabilities.
``(f) Definitions.--In this section:
``(1) Applicable spread price drug.--The term `applicable
spread price drug' means, with respect to a group health plan
or group or individual health insurance coverage, a drug for
which benefits are available under such plan or coverage and
with respect to which, at the time rate and payment information
is made public by such plan under subsection (c)--
``(A) a contract is in effect between an entity
providing pharmacy benefit management services on
behalf of such plan or coverage and a pharmacy for the
dispensing of such drug under such plan or coverage;
and
``(B) the specified payment amount for such drug so
dispensed is less than the specified reimbursement
amount for such drug so dispensed.
``(2) In-network rate.--The term `in-network rate' means,
with respect to a group health plan or group or individual
health insurance coverage and an item or service furnished by a
provider that is a participating provider with respect to such
plan or coverage and item or service, the contracted rate
(reflected as a dollar amount) in effect between such plan or
coverage and such provider for such item or service, regardless
of whether such rate is calculated based on a set amount, a fee
schedule, or an amount derived from another amount, or a
formula, or other method.
``(3) Participating provider.--The term `participating
provider' means, with respect to an item or service and a group
health plan or health insurance issuer offering group or
individual health insurance coverage, a physician or other
health care provider (as defined in paragraph (4)) who is
acting within the scope of practice of that provider's license
or certification under applicable State law and who has a
contractual relationship with the plan or issuer, respectively,
for furnishing such item or service under the plan or coverage,
respectively.
``(4) Provider.--The term `provider' includes a health care
facility and a pharmacy.
``(5) Specified payment amount.--The term `specified
payment amount' means, with respect to a drug to be dispensed
by a pharmacy to a participant, beneficiary, or enrollee of a
group health plan or group or individual health insurance
coverage where such pharmacy has in effect a contract with an
entity providing pharmacy benefit management services on behalf
of such plan or coverage for the dispensing of such drug under
such plan or coverage, the amount that such entity has agreed
to pay such pharmacy for the ingredient costs and any
applicable dispensing fee for such drug (or the amount that
such entity has agreed to pay such pharmacy for such drug under
any other compensation structure specified by the Secretary)
under such contract, taking into account any cost sharing
requirement applicable to such drug and participant,
beneficiary, or enrollee.
``(6) Specified reimbursement amount.--The term `specified
reimbursement amount' means, with respect to a drug to be
dispensed by a pharmacy to a participant, beneficiary, or
enrollee of a group health plan or group or individual health
insurance coverage where such pharmacy has in effect a contract
with an entity providing pharmacy benefit management services
on behalf of such plan or coverage for the dispensing of such
drug under such plan or coverage, the amount that such plan or
coverage has agreed to pay to such entity for the ingredient
costs and any applicable dispensing fee for such drug (or the
amount that such plan or coverage has agreed to pay such entity
for such drug under any other compensation structure specified
by the Secretary), taking into account any cost sharing
requirement applicable to such drug and participant,
beneficiary, or enrollee.''.
(3) ERISA.--
(A) In general.--Section 719 of the Employee
Retirement Income Security Act of 1974 (29 U.S.C.
1185h) is amended--
(i) in the header, by striking
``maintenance of price comparison tool'' and
inserting ``transparency in coverage'';
(ii) by striking ``A group health plan''
and inserting the following:
``(a) Maintenance of Price Comparison Tool for Plan Years Before
2029.--
``(1) In general.--A group health plan'';
(iii) in subsection (a), as inserted by
clause (ii), by adding at the end the following
new paragraph:
``(2) Sunset.--Paragraph (1) shall not apply with respect
to plan years beginning on or after January 1, 2029.''; and
(iv) by adding at the end the following new
subsections:
``(b) Cost-Sharing Transparency.--
``(1) In general.--For plan years beginning on or after
January 1, 2029, a group health plan and a health insurance
issuer offering group health insurance coverage shall provide a
participant or beneficiary, in a timely manner upon request of
the participant or beneficiary, information on the amount of
cost-sharing (including deductibles, copayments, and
coinsurance) under the participant or beneficiary's plan or
coverage that the participant or beneficiary would be
responsible for paying with respect to the furnishing of a
specific item or service by a provider. At a minimum, such
information shall include the information specified in
paragraph (2) and shall be made available to such participant
or beneficiary through a self-service tool that meets the
requirements of paragraph (3) or, at the option of such
participant or beneficiary, through a paper disclosure or phone
or other electronic disclosure (as selected by such participant
or beneficiary and provided at no cost to such participant or
beneficiary) 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 coverage, the following:
``(A) If such provider is a participating provider
with respect to such item or service, the in-network
rate for such item or service.
``(B) If such provider is not a participating
provider with respect to such item or service, the
maximum allowed amount or other dollar amount that such
plan or coverage will recognize as payment for such
item or service, along with a notice that such
participant or beneficiary may be liable for additional
charges.
``(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
allowed amount or other dollar 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 under the plan or coverage
(broken down, in the case separate deductibles or
maximums apply to a participant and such participant's
beneficiaries 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 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 or coverage.
``(G) Any financial incentives (such as any credit,
payment, or other benefit provided by such plan or
issuer) available to the participant or beneficiary
with respect to such item or service furnished by such
provider known at the time such request is made.
``(H) Other information 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 health
insurance issuer offering group health insurance coverage meets
the requirements of this paragraph if such tool--
``(A) is based on an internet website (or successor
technology specified by the Secretary);
``(B) is made available in plain language at no
cost;
``(C) provides for real-time responses to requests
described in paragraph (1);
``(D) is updated in a manner such that information
provided through such tool is timely and accurate at
the time such request is made;
``(E) 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) nonspecific providers located in a
relevant geographic region that are not
participating providers with respect to such
item or service;
``(F) 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
``(G) meets any other requirement determined
appropriate by the Secretary, including requirements to
ensure the accessibility and usability of information
provided through such tool.
``(c) Rate and Payment Information.--
``(1) In general.--For plan years beginning on or after
January 1, 2029, each group health plan and health insurance
issuer offering group health insurance coverage (other than a
grandfathered health plan (as defined in section 1251(e) of the
Patient Protection and Affordable Care Act)) shall 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--
``(i) the in-network rate (expressed as a
dollar amount) in effect as of the date on
which such information is made public with each
provider that is a participating provider with
respect to such item or service (other than, in
the case that such plan or coverage provides
benefits for such item or service only when
furnished by a specific type of provider, such
a participating provider who is not such type
of provider (referred to in this subparagraph
as an `excluded provider')); and
``(ii) with respect to each such
participating provider (other than a provider
that is an excluded provider with respect to
such item or service), an indication of
whether, during the 1-year period beginning 18
months before the date such information is made
public, such provider submitted a claim for
such item or service to such plan or coverage
for which payment was made (in whole or in
part) under such plan or coverage.
``(B) With respect to each drug (identified by
national drug code) for which benefits are available
under such plan or coverage--
``(i) the in-network rate (expressed as a
dollar amount) in effect as of the first day of
the month in which such information is made
public with each provider that is a
participating provider with respect to such
drug;
``(ii) the average amount paid by such plan
or coverage (accounting for, in a manner
determined appropriate by the Secretary,
rebates, discounts, price concessions, and any
other remuneration specified by the Secretary)
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,
unless fewer than 20 claims for such drug were
submitted to such plan or coverage during such
period; and
``(iii) in the case such drug is an
applicable spread price drug dispensed by a
pharmacy--
``(I) a specification that such
drug is such an applicable spread price
drug; and
``(II) for each pharmacy that has a
contractual relationship for dispensing
such drug under such plan or coverage,
a specification of the difference (if
any) between the specified payment
amount for such drug so dispensed by
such pharmacy and the specified
reimbursement amount for such drug so
dispensed by such pharmacy.
``(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 6-month period beginning 9 months
before the date such information is made public by a
provider that was not a participating provider with
respect to such item or service, broken down by each
such provider, other than such an amount with respect
to an item or service for which, during such period,
fewer than 11 claims were made under such plan or
coverage. In determining the number of claims made
under such plan or coverage with respect to an item or
service during such period for purposes of the
preceding sentence, such number shall be deemed to
include all claims for such item or service made during
such period under all group health plans and health
insurance coverage offered in the same insurance market
(specified in subclause (I), (II), (III), or (IV) of
section 716(a)(3)(E)(iv)) by the sponsor or issuer (as
applicable) of the plan or coverage at issue.
In the case that a specific dollar amount for an in-network
rate required to be made available pursuant to this subsection
with respect to an item or service cannot be determined
prospectively on the basis that such rate is determined as a
percentage of the billed charges for such item or service, such
percentage and the median amount recognized by such plan or
coverage as payment for such item or service with respect to
claims for such item or service submitted by participating
providers during the period described in subparagraph (A)(ii)
shall be reported by such plan or coverage in lieu of such
rate. Such plan or coverage shall identify that such median
amount represents an estimate of such in-network rate for such
item or service.
``(3) Manner of publication.--
``(A) In general.--Rate and payment information
required to be made available under this subsection
shall be so made available in dollar amounts through
separate machine-readable files (and any successor
technology, as applicable, such as application
programming 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 (which may
be so specified through subregulatory guidance),
including requirements relating to whether such
information should be so made available on the plan or
coverage level, with respect to individual provider
networks, or aggregated in such manner 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 or
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.
``(B) Timing.--Rate and payment information
described in paragraph (2) shall be made public on a
quarterly basis.
``(4) User instructions.--Each group health plan and health
insurance issuer offering 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
through subregulatory guidance a template that such a plan may
use in developing instructions for purposes of the preceding
sentence.
``(5) Summary.--For each plan year beginning on or after
January 1, 2029, each group health plan and health insurance
issuer offering group health insurance coverage shall make
public a data file, in a manner that ensures that such file may
be easily downloaded and read by standard spreadsheet software
and that meets such requirements as established by the
Secretary, containing a summary of all rate and payment
information made public by such plan or issuer with respect to
such plan or coverage during such plan year. Such file shall
include the following:
``(A) The mean, median, and interquartile range of
the in-network rate, and the amount allowed for an item
or service when not furnished by a participating
provider, in effect as of the first day of such plan
year for each item or service (identified by payer
identifier approved or used by the Centers for Medicare
& Medicaid Services) for which benefits are available
under the plan or coverage, broken down by the type of
provider furnishing the item or service and by the
geographic area in which such item or service is
furnished.
``(B) Trends in payment rates for such items and
services over such plan year, including an
identification of instances in which such rates have
increased, decreased, or remained the same.
``(C) The name of such plan, a description of the
type of network of participating providers used by such
plan or coverage, and, in the case of a group health
plan, a description of whether such plan is self-
insured or fully-insured.
``(D) For each item or service which is paid as
part of a bundled or capitated rate--
``(i) a description of the formulae,
pricing methodologies, or other information
used to calculate the payment rate for such
rate; and
``(ii) a list of the items and services
included in such rate.
``(E) The percentage of items and services that are
paid for on a fee-for-service basis and the percentage
of items and services that are paid for as part of a
bundled rate, capitated payment rate, or other
alternative payment model.
``(d) Attestation.--Each group health plan and health insurance
issuer offering group health insurance coverage shall annually submit
to the Secretary an attestation, signed by the chief executive officer,
chief financial officer, or other comparable official (as specified by
the Secretary) of such plan or issuer, of such plan's or coverage's
compliance with the provisions of this section and that information
made available under this section is true, accurate, and complete. Such
attestation shall, except in the case of a grandfathered health plan
(as defined in section 1251(e) of the Patient Protection and Affordable
Care Act), include a link to the website (or other successor
technology) where rate and payment information required to be made
public under subsection (c) may be accessed.
``(e) Accessibility.--A group health plan and a health insurance
issuer offering group health insurance coverage shall take reasonable
steps (as specified by the Secretary) to ensure that information
provided in response to a request described in subsection (b), and rate
and payment information made public under subsection (c), is provided
in plain, easily understandable language and that interpretation,
translations, and assistive services are provided to those with limited
English proficiency and those with disabilities.
``(f) Definitions.--In this section:
``(1) Applicable spread price drug.--The term `applicable
spread price drug' means, with respect to a group health plan
or group health insurance coverage, a drug for which benefits
are available under such plan or coverage and with respect to
which, at the time rate and payment information is made public
by such plan under subsection (c)--
``(A) a contract is in effect between an entity
providing pharmacy benefit management services on
behalf of such plan or coverage and a pharmacy for the
dispensing of such drug under such plan or coverage;
and
``(B) the specified payment amount for such drug so
dispensed is less than the specified reimbursement
amount for such drug so dispensed.
``(2) In-network rate.--The term `in-network rate' means,
with respect to a group health plan or group health insurance
coverage and an item or service furnished by a provider that is
a participating provider with respect to such plan or coverage
and item or service, the contracted rate (reflected as a dollar
amount) in effect between such plan or coverage and such
provider for such item or service, regardless of whether such
rate is calculated based on a set amount, a fee schedule, or an
amount derived from another amount, or a formula, or other
method.
``(3) Participating provider.--The term `participating
provider' means, with respect to an item or service and a group
health plan or health insurance issuer offering group health
insurance coverage, a physician or other health care provider
(as defined in paragraph (4)) who is acting within the scope of
practice of that provider's license or certification under
applicable State law and who has a contractual relationship
with the plan or issuer, respectively, for furnishing such item
or service under the plan or coverage, respectively.
``(4) Provider.--The term `provider' includes a health care
facility and a pharmacy.
``(5) Specified payment amount.--The term `specified
payment amount' means, with respect to a drug to be dispensed
by a pharmacy to a participant or beneficiary of a group health
plan or group health insurance coverage where such pharmacy has
in effect a contract with an entity providing pharmacy benefit
management services on behalf of such plan or coverage for the
dispensing of such drug under such plan or coverage, the amount
that such entity has agreed to pay such pharmacy for the
ingredient costs and any applicable dispensing fee for such
drug (or the amount that such entity has agreed to pay such
pharmacy for such drug under any other compensation structure
specified by the Secretary) under such contract, taking into
account any cost sharing requirement applicable to such drug
and participant or beneficiary.
``(6) Specified reimbursement amount.--The term `specified
reimbursement amount' means, with respect to a drug to be
dispensed by a pharmacy to a participant or beneficiary of a
group health plan or group health insurance coverage where such
pharmacy has in effect a contract with an entity providing
pharmacy benefit management services on behalf of such plan or
coverage for the dispensing of such drug under such plan or
coverage, the amount that such plan or coverage has agreed to
pay to such entity for the ingredient costs and any applicable
dispensing fee for such drug (or the amount that such plan or
coverage has agreed to pay such entity for such drug under any
other compensation structure specified by the Secretary),
taking into account any cost sharing requirement applicable to
such drug and participant or beneficiary.''.
(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. Transparency in coverage.''.
(b) Application Programming Interface Report.--Not later than
January 1, 2029, and annually thereafter, the Secretary of Health and
Human Services shall, in consultation with the Office of the National
Coordinator for Health Information Technology, Department of Labor, the
Department of the Treasury, and stakeholders, submit to the House
Committees on Education and the Workforce, Energy and Commerce, and
Ways and Means, and the Senate Committees on Finance and Health,
Education, Labor, and Pensions a report on the use of standards-based
application programming interfaces (in this subsection referred to as
``APIs'') to facilitate access to health care price transparency
information and the interoperability of other medical information. Such
report shall include an evaluation of the capacity of the Department of
Health and Human Services, the Department of Labor, and the Department
of the Treasury to regulate and implement standards related to APIs and
recommendations for improving such capacity. Such report shall include
the following:
(1) A description of current use, and proposed use, of APIs
under Federal rules to facilitate interoperability, including
information related to capacity constraints within the
agencies, barriers to adoption, privacy and security,
administrative burdens and efficiencies, care coordination, and
levels of compliance.
(2) A description of the feasibility of agency
participation in the development of APIs to enable application
access to price transparency data under the amendments made by
subsection (a).
(3) A specification of the timeline for which such data
standards can be required to make such data accessible via an
API.
(4) An analysis of the benefits and challenges of
implementing standards-based APIs for price transparency data,
including the ability for consumers to access rate and payment
information and the amount of cost-sharing (including
deductibles, copayments, and coinsurance) under the consumer's
plan through third-party internet-based tools and applications.
(5) An analysis of the impact that APIs which provide real-
time access to pricing and cost-sharing information may have in
increasing the amount of services shoppable for individuals,
such as by standardizing more health care spend via episode
bundles.
(6) An analysis of which health care items and services may
be useful under API, such as those for which prices change with
the greatest frequency.
(7) An analysis of the cost of API standards implementation
on issuers, employers, and other private-sector entities.
(8) An analysis of the ability of State regulators to
enforce API standards and the costs to the Federal Government
and States to regulate and enforce API standards.
(9) An analysis of the interaction with API standards and
Federal health information privacy standards.
(c) Provider Tool Report.--
(1) In general.--Not later than 1 year after the date of
the enactment of this Act, The Secretary of Health and Human
Services, acting through the Administrator of the Centers for
Medicare & Medicaid Services, shall, in consultation with
stakeholders, conduct a study and submit to the House
Committees on Education and the Workforce, Energy and Commerce,
and Ways and Means, and the Senate Committees on Finance and
Health, Education, Labor, and Pensions a report on the
usefulness and feasibility of the establishment of a provider
tool by a group health plan, or a health insurance issuer
offering group or individual health insurance coverage, in
facilitating the provision of information made available
pursuant to the amendments made by subsection (a). Such report
shall include the following:
(A) A description of the feasibility of
establishing a requirement for the various types of
plans and coverage to offer such a provider tool,
including any challenges to establishing a provider
tool using the same technology platform as the self-
service tool described in such amendments.
(B) An evaluation on the usefulness of a provider
tool to aid patient-decision making and how such tool
would coordinate with other information available to a
patient and their provider under other Federal
requirements in place or under consideration.
(C) An evaluation of whether the information
provided by such tool would be duplicative of the
advanced explanation of benefits required under Federal
law or any other existing requirement.
(D) A description of the usability and expected
utilization of such tool among providers, including
among different provider types.
(E) An analysis of the impact of a provider tool in
value-based care arrangements.
(F) An analysis on the potential impact of the
provider tool on--
(i) patients' out-of-pocket spending;
(ii) plan design, including impacts on
cost-sharing requirements;
(iii) care coordination and quality;
(iv) plan premiums;
(v) overall health care spending and
utilization; and
(vi) health care access in rural areas.
(G) An analysis of the feasibility of a provider
tool to include additional functionality to facilitate
and improve the administration of the requirements on
providers to submit notifications to such plan or
coverage under section 2799B-6 of the Public Health
Service Act and the requirements on such plan or
coverage to provide an advanced explanation of benefits
to individuals under section 2799A-1(f) of such Act.
(H) An analysis of which health care items and
services, would be most useful for providers utilizing
a provider tool.
(I) An analysis of rulemaking required to ensure
such a tool complies with federal health information
privacy standards.
(J) An analysis of the burden and cost of the
creation of a provider tool by plans and coverage on
providers, issuers, employers, and other private-sector
entities.
(K) An analysis of the ability of state regulators
to enforce provider tool standards and the costs to the
Department and states to regulate and enforce provider
tool standards.
(2) Definition.--The term ``provider tool'' means a tool
designed to facilitate the provision of information made
available pursuant to the amendments made by subsection (a) and
established by a group health plan or a health insurance issuer
offering group or individual health insurance coverage that
allows providers to access the information such plan or
coverage must provide through the self-service tool described
in such amendments to an individual with whom the provider is
actively treating at the time of such request, upon the request
of the provider, and with the consent of such individual.
(d) Reports.--
(1) Compliance.--Not later than January 1, 2029, the
Comptroller General of the United States shall submit to
Congress a report containing--
(A) an analysis of compliance with the amendments
made by this section;
(B) an analysis of enforcement of such amendments
by the Secretaries of Health and Human Services, Labor,
and the Treasury;
(C) recommendations relating to improving such
enforcement; and
(D) recommendations relating to improving public
disclosure, and public awareness, of information
required to be made available by group health plans and
health insurance issuers pursuant to such amendments.
(2) Prices.--Not later than January 1, 2029, and biennially
thereafter, the Secretaries of Health and Human Services,
Labor, and the Treasury shall jointly submit to Congress a
report containing an assessment of differences in negotiated
prices (and any trends in such prices) in the private market
between--
(A) rural and urban areas;
(B) the individual, small group, and large group
markets;
(C) consolidated and nonconsolidated health care
provider areas (as specified by the Secretary of Health
and Human Services);
(D) nonprofit and for-profit hospitals;
(E) nonprofit and for-profit insurers; and
(F) insurers serving local or regional areas and
insurers serving multistate or national areas.
(e) Quality Report.--Not later than 1 year after the date of
enactment of this subsection, the Secretaries of Health and Human
Services, Labor, and the Treasury shall jointly submit to Congress a
report on the feasibility of including data relating to the quality of
health care items and services with the price transparency information
required to be made available under the amendments made by subsection
(a). Such report shall include recommendations for legislative and
regulatory actions to identify appropriate metrics for assessing and
comparing quality of care.
(f) 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 January 1,
2029.
SEC. 4. INFORMATION ON PRESCRIPTION DRUGS.
(a) PHSA.--
(1) In general.--Part D of title XXVII of the Public Health
Service Act is amended by adding at the end the following new
section:
``SEC. 2799A-12. INFORMATION ON PRESCRIPTION DRUGS.
``(a) In General.--A group health plan or a health insurance issuer
offering group or individual health insurance coverage shall--
``(1) not restrict, directly or indirectly, any pharmacy
that dispenses a prescription drug to an enrollee in the plan
or coverage from informing (or penalize such pharmacy for
informing) an enrollee of any differential between the
enrollee's out-of-pocket cost under the plan or coverage with
respect to acquisition of the drug and the amount an individual
would pay for acquisition of the drug without using any group
health plan or health insurance coverage; and
``(2) ensure that any entity that provides pharmacy
benefits management services under a contract with any such
health plan or health insurance coverage does not, with respect
to such plan or coverage, restrict, directly or indirectly, a
pharmacy that dispenses a prescription drug from informing (or
penalize such pharmacy for informing) an enrollee of any
differential between the enrollee's out-of-pocket cost under
such plan or coverage with respect to acquisition of the drug
and the amount an individual would pay for acquisition of the
drug without using any group health plan or health insurance
coverage.
``(b) Definition.--For purposes of this section, the term `out-of-
pocket cost', with respect to acquisition of a drug, means the amount
to be paid by the enrollee under the plan or coverage, including any
cost-sharing (including any deductible, copayment, or coinsurance) and,
as determined by the Secretary, any other expenditure.''.
(2) Conforming amendment.--Section 2729 of the Public
Health Service Act (42 U.S.C. 300gg-29) is amended by adding at
the end the following new subsection:
``(c) Sunset.--The preceding provisions of this section shall not
apply beginning on the date of the enactment of this subsection.''.
(b) ERISA.--
(1) In general.--Subpart B of part 7 of Subtitle B of title
I of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185 et seq.) is amended by adding at the end the
following new section:
``SEC. 727. INFORMATION ON PRESCRIPTION DRUGS.
``(a) In General.--A group health plan or a health insurance issuer
offering group health insurance coverage shall--
``(1) not restrict, directly or indirectly, any pharmacy
that dispenses a prescription drug to a participant or
beneficiary in the plan or coverage from informing (or penalize
such pharmacy for informing) a participant or beneficiary of
any differential between the participant's or beneficiary's
out-of-pocket cost under the plan or coverage with respect to
acquisition of the drug and the amount an individual would pay
for acquisition of the drug without using any group health plan
or health insurance coverage; and
``(2) ensure that any entity that provides pharmacy
benefits management services under a contract with any such
health plan or health insurance coverage does not, with respect
to such plan or coverage, restrict, directly or indirectly, a
pharmacy that dispenses a prescription drug from informing (or
penalize such pharmacy for informing) a participant or
beneficiary of any differential between the participant's or
beneficiary's out-of-pocket cost under such plan or coverage
with respect to acquisition of the drug and the amount an
individual would pay for acquisition of the drug without using
any group health plan or health insurance coverage.
``(b) Definition.--For purposes of this section, the term `out-of-
pocket cost', with respect to acquisition of a drug, means the amount
to be paid by the participant or beneficiary under the plan or
coverage, including any cost-sharing (including any deductible,
copayment, or coinsurance) and, as determined by the Secretary, any
other expenditure.''.
(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 726 the following new item:
``Sec. 727. Information on prescription drugs.''.
(c) 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. 9827. INFORMATION ON PRESCRIPTION DRUGS.
``(a) In General.--A group health plan shall--
``(1) not restrict, directly or indirectly, any pharmacy
that dispenses a prescription drug to a participant or
beneficiary in the plan from informing (or penalize such
pharmacy for informing) a participant or beneficiary of any
differential between the participant's or beneficiary's out-of-
pocket cost under the plan with respect to acquisition of the
drug and the amount an individual would pay for acquisition of
the drug without using any group health plan or health
insurance coverage; and
``(2) ensure that any entity that provides pharmacy
benefits management services under a contract with any such
plan does not, with respect to such plan or coverage, restrict,
directly or indirectly, a pharmacy that dispenses a
prescription drug from informing (or penalize such pharmacy for
informing) a participant or beneficiary of any differential
between the participant's or beneficiary's out-of-pocket cost
under the plan with respect to acquisition of the drug and the
amount an individual would pay for acquisition of the drug
without using any group health plan or health insurance
coverage.
``(b) Definition.--For purposes of this section, the term `out-of-
pocket cost', with respect to acquisition of a drug, means the amount
to be paid by the participant or beneficiary under the plan, including
any cost-sharing (including any deductible, copayment, or coinsurance)
and, as determined by the Secretary, any other expenditure.''.
(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. 9827. Information on prescription drugs.''.
SEC. 5. VERTICAL INTEGRATION ACCOUNTABILITY.
(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 2028 and for every
third plan year thereafter, each applicable 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 with respect to such plan year to
such specified health care providers that have
in effect a financial risk arrangement with
respect to such plan year;
``(iii) the total amount of recoupments
collected with respect to such plan year from
such specified health care providers that have
in effect a financial risk arrangement with
respect to such plan year;
``(iv) the total amount of incentive-based
payments made with respect to such plan year to
providers of services and suppliers not that
are not specified health care providers and
that have in effect a financial risk
arrangement with respect to such plan year; and
``(v) the total amount of recoupments
collected with respect to such plan year from
such providers of services and suppliers that
have in effect a financial risk arrangement
with respect to such plan year.
``(B) Definitions.--For purposes of this paragraph:
``(i) Applicable ma organization.--The term
`applicable MA organization' means, with
respect to a plan year, an MA organization with
at least 25,000 individuals enrolled across all
Medicare Advantage plans offered by such
organization during such plan year.
``(ii) Specified health care provider.--The
term `specified health care provider' means,
with respect to an applicable MA organization
and a plan year, a provider of services or
supplier that--
``(I) is owned by, controlled by,
or related under a common ownership
structure with such MA organization;
``(II) has in effect a contract
solely with such organization (or with
an entity owned by, controlled by, or
related under a common ownership
structure with such organization (or
that has in effect any comparable
arrangement with such organization))
for furnishing items and services;
``(III) is a partner under a
partnership (as defined in section
7701(a)(2) of the Internal Revenue Code
of 1986) with such organization (or
with any an entity owned by, controlled
by, or related under a common ownership
structure with such organization); or
``(IV) through contract, ownership,
or otherwise--
``(aa) directly or
indirectly controls, is
controlled by, or is under
common ownership with such
organization (or with an entity
owned by, controlled by, or
related under a common
ownership structure with such
organization);
``(bb) is part of a
controlled group of
corporations under section 1563
of the Internal Revenue Code of
1986 with such organization (or
with any such entity);
``(cc) is a participant in
a lawful combination under
which such provider or supplier
shares substantial financial
risk in connection with such
organization's operations (or
with the operations of any such
entity); or
``(dd) part of an
affiliated service group under
section 414 of such Code with
such organization (or with any
such entity).''.
(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 2028 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 plan during such year.
``(B) Definition.--For purposes of this paragraph,
the term `specified pharmacy' means, with respect to a
prescription drug plan offered by a PDP sponsor and a
plan year, a pharmacy that--
``(i) is owned by, controlled by, or
related under a common ownership structure with
such sponsor;
``(ii) has in effect a contract solely with
such sponsor (or with an entity owned by,
controlled by, or related under a common
ownership structure with such sponsor (or that
has in effect any comparable arrangement with
such sponsor)) for dispensing covered part D
drugs;
``(iii) is a partner under a partnership
(as defined in section 7701(a)(2) of the
Internal Revenue Code of 1986) with such
sponsor (or with any an entity owned by,
controlled by, or related under a common
ownership structure with such sponsor); or
``(iv) through contract, ownership, or
otherwise--
``(I) directly or indirectly
controls, is controlled by, or is under
common ownership with such sponsor (or
with an entity owned by, controlled by,
or related under a common ownership
structure with such sponsor);
``(II) is part of a controlled
group of corporations under section
1563 of the Internal Revenue Code of
1986 with such sponsor (or with any
such entity);
``(III) is a participant in a
lawful combination under which such
provider or supplier shares substantial
financial risk in connection with such
sponsor's operations (or with the
operations of any such sponsor); or
``(IV) part of an affiliated
service group under section 414 of such
Code with such sponsor (or with any
such entity).''.
(b) Reports on Vertical Integration Under Medicare.--
(1) In general.--Not later than the first June 15 occurring
on or after the date that is 2 years after the Secretary of
Health and Human Services first makes available information
submitted under sections 1857(e)(6) and 1860D-12(b)(9) of the
Social Security Act (as added by paragraphs (1) and (2),
respectively, of subsection (a)) to the Medicare Payment
Advisory Commission, and again not later than 4 years after the
first report is submitted under this paragraph, 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 under part C of title
XVIII of the Social Security Act (42 U.S.C. 1395w-21 et seq.)
or part D of such title (42 U.S.C. 1395w-101 et seq.),
including health care providers, pharmacies, prescription drug
plan sponsors, Medicare Advantage organizations, and pharmacy
benefit managers. Such report shall include, to the extent
practicable--
(A) with respect to Medicare Advantage
organizations, the evaluation described in paragraph
(2);
(B) with respect to prescription drug plans,
pharmacy benefit managers, and pharmacies, the
comparisons and summary described in paragraph (3);
(C) an assessment of the Medicare Advantage
organization and PDP sponsor integration information
described in paragraph (4); and
(D) an analysis of the impact of such integration
on health care access, price, quality, and outcomes.
(2) Medicare advantage organizations.--For purposes of
paragraph (1)(A), the evaluation described in this paragraph
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--
(A) 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,
compared to the average number of such diagnoses made
during such year with respect to enrollees of such plan
who, during such year, did not receive such an
assessment from such a provider;
(B) the average risk score for enrollees of a
Medicare Advantage plan who received such an assessment
from a specified health care provider during such year
compared to the average risk score for enrollees of
such plan who did not receive such an assessment from
such a provider during such year;
(C) any relationship between risk scores for such
enrollees receiving such an assessment from such a
provider during such year and incentive-based payments
made to such providers;
(D) the average risk score for enrollees of such
plan who received any item or service from a specified
health care provider during such year compared to the
average risk score for enrollees of such plan who did
not receive any item or service from such a provider
during such year;
(E) 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
(F) any relationship between the risk scores of
enrollees under such plan that have received any item
or service from a specified provider and incentive-
based payments made under the plan to specified
providers.
(3) Prescription drug plans.--For purposes of paragraph
(1)(B), the comparisons and summary described in this paragraph
are, with respect to prescription drug plans and an applicable
year, the following:
(A) For each covered part D drug for which benefits
are available under such a plan, a comparison of
information about payments submitted with respect to
such plan under section 1860D-12(h)(1)(C)(i)(I) of the
Social Security Act (42 U.S.C. 1395w-
112(h)(1)(C)(i)(I)) with respect to specified
pharmacies with the same such information about
payments submitted by such plan with respect to in-
network pharmacies that are not specified pharmacies.
(B) Comparisons of the following:
(i) 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.
(ii) 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) A summary of the total manufacturer-derived
revenue retained by pharmacy benefit managers and any
affiliates of such pharmacy benefit managers (as
reported under section 1860D-12(h)(1)(C)(i)(I)(kk) of
the Social Security Act (42 U.S.C. 1395w-
112(h)(1)(C)(i)(I)(kk)).
(4) Medicare advantage organization and pdp sponsor
integration information.--For purposes of paragraph (1)(C), the
Medicare Advantage organization and PDP sponsor integration
information described in this paragraph is information
submitted under sections 1857(e)(6) and 1860D-12(b)(9) of the
Social Security Act (as added by paragraphs (1) and (2),
respectively, of subsection (a)) and section1860D-12(h) of such
Act (42 U.S.C. 1395w-112(h)).
(5) Definitions.--In this subsection:
(A) Applicable year.--The term ``applicable year''
means--
(i) with respect to the first report
submitted under paragraph (1), plan year 2028;
and
(ii) with respect to the second report
submitted under paragraph (1), plan year 2031.
(B) Covered part d drug.--The term ``covered part D
drug'' has the meaning given such term in section
1860D-2(e) of the Social Security Act (42 U.S.C. 1395w-
102(e)).
(C) 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) of the
Social Security Act (42 U.S.C. 1305w-23(a)(3)).
(D) 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 subparagraph (E).
(E) 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 that--
(i) is owned by, controlled by, or related
under a common ownership structure with such
organization;
(ii) has in effect a contract solely with
such organization (or with an entity owned by,
controlled by, or related under a common
ownership structure with such organization (or
that has in effect any comparable arrangement
with such organization)) for furnishing items
and services;
(iii) is a partner under a partnership (as
defined in section 7701(a)(2) of the Internal
Revenue Code of 1986) with such organization
(or with any an entity owned by, controlled by,
or related under a common ownership structure
with such organization); or
(iv) through contract, ownership, or
otherwise--
(I) directly or indirectly
controls, is controlled by, or is under
common ownership with such organization
(or with an entity owned by, controlled
by, or related under a common ownership
structure with such organization);
(II) is part of a controlled group
of corporations under section 1563 of
the Internal Revenue Code of 1986 with
such organization (or with any such
entity);
(III) is a participant in a lawful
combination under which such provider
or supplier shares substantial
financial risk in connection with such
organization's operations (or with the
operations of any such entity); or
(IV) part of an affiliated service
group under section 414 of such Code
with such organization (or with any
such entity).
(F) Specified pharmacy.--The term ``specified
pharmacy'' means, with respect to a prescription drug
plan offered by a prescription drug plan sponsor, a
pharmacy that--
(i) is owned by, controlled by, or related
under a common ownership structure with such
sponsor;
(ii) has in effect a contract solely with
such sponsor (or with an entity owned by,
controlled by, or related under a common
ownership structure with such sponsor (or that
has in effect any comparable arrangement with
such sponsor)) for dispensing covered part D
drugs;
(iii) is a partner under a partnership (as
defined in section 7701(a)(2) of the Internal
Revenue Code of 1986) with such sponsor (or
with any an entity owned by, controlled by, or
related under a common ownership structure with
such sponsor); or
(iv) through contract, ownership, or
otherwise--
(I) directly or indirectly
controls, is controlled by, or is under
common ownership with such sponsor (or
with an entity owned by, controlled by,
or related under a common ownership
structure with such sponsor);
(II) is part of a controlled group
of corporations under section 1563 of
the Internal Revenue Code of 1986 with
such sponsor (or with any such entity);
(III) is a participant in a lawful
combination under which such provider
or supplier shares substantial
financial risk in connection with such
sponsor's operations (or with the
operations of any such entity); or
(IV) part of an affiliated service
group under section 414 of such Code
with such sponsor (or with any such
entity).
(G) 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 that--
(i) is owned by, controlled by, or related
under a common ownership structure with such
sponsor;
(ii) has in effect a contract solely with
such sponsor (or with an entity owned by,
controlled by, or related under a common
ownership structure with such sponsor (or that
has in effect any comparable arrangement with
such sponsor)) for furnishing pharmacy benefit
management services;
(iii) is a partner under a partnership (as
defined in section 7701(a)(2) of the Internal
Revenue Code of 1986) with such sponsor (or
with any an entity owned by, controlled by, or
related under a common ownership structure with
such sponsor); or
(iv) through contract, ownership, or
otherwise--
(I) directly or indirectly
controls, is controlled by, or is under
common ownership with such sponsor (or
with an entity owned by, controlled by,
or related under a common ownership
structure with such sponsor);
(II) is part of a controlled group
of corporations under section 1563 of
the Internal Revenue Code of 1986 with
such sponsor (or with any such entity);
(III) is a participant in a lawful
combination under which such provider
or supplier shares substantial
financial risk in connection with such
sponsor's operations (or with the
operations of any such entity); or
(IV) part of an affiliated service
group under section 414 of such Code
with such sponsor (or with any such
entity).
SEC. 6. IMPLEMENTATION FUNDING.
(a) In General.--For the purposes described in subsection (b),
there are appropriated, in addition to amounts otherwise available, out
of amounts in the Treasury not otherwise appropriated--
(1) to the Secretary of Health and Human Services and the
Secretary of the Treasury, $65,000,000 for fiscal year 2027, to
remain available through fiscal year 2032; and
(2) to the Secretary of Labor, $35,000,000 for fiscal year
2027, to remain available through fiscal year 2032.
(b) Permitted Purposes.--The purposes described in this subsection
are the following purposes, insofar as such purposes are to carry out
the provisions of, including the amendments made by, this title:
(1) Preparing, drafting, and issuing proposed and final
regulations or interim regulations.
(2) Preparing, drafting, and issuing guidance and public
information.
(3) Preparing, drafting, and publishing reports.
(4) Enforcement of such provisions.
(5) Reporting, collection, and analysis of data.
(6) Other administrative duties necessary for
implementation of such provisions.
(c) Transparency of Implementation Funds.--Each Secretary described
in subsection (a) shall annually submit, not later than September 1st
of each year, to the Committees on Energy and Commerce, on Ways and
Means, on Education and the Workforce, and on Appropriations of the
House of Representatives and the Committees on Health, Education,
Labor, and Pensions, on Finance, and on Appropriations of the Senate a
report on funds expended pursuant to funds appropriated under this
section.
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