[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[S. 2355 Reported in Senate (RS)]
<DOC>
Calendar No. 522
119th CONGRESS
2d Session
S. 2355
To amend the Public Health Service Act to provide for hospital and
insurer price transparency.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
July 17, 2025
Mr. Marshall (for himself, Mr. Hickenlooper, Mr. Grassley, Ms. Hassan,
Mr. Sheehy, Ms. Ernst, Ms. Baldwin, Mr. Moreno, Mr. Scott of Florida,
Mr. Kim, Mr. Husted, Ms. Blunt Rochester, Mr. Tuberville, Ms. Lummis,
Mr. Coons, Mr. Mullin, Mr. Booker, Mr. Welch, Mr. Peters, Ms. Warren,
Mr. Armstrong, Mr. Kelly, Mr. Schmitt, Mr. Fetterman, and Mr. Gallego)
introduced the following bill; which was read twice and referred to the
Committee on Health, Education, Labor, and Pensions
July 27, 2026
Reported by Mr. Cassidy, with an amendment
[Strike out all after the enacting clause and insert the part printed
in italic]
_______________________________________________________________________
A BILL
To amend the Public Health Service Act to provide for hospital and
insurer price transparency.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
<DELETED>SECTION 1. SHORT TITLE.</DELETED>
<DELETED> This Act may be cited as the ``Patients Deserve Price Tags
Act''.</DELETED>
<DELETED>SEC. 2. STRENGTHENING HOSPITAL PRICE TRANSPARENCY
REQUIREMENTS.</DELETED>
<DELETED> (a) In General.--Section 2718(e) of the Public Health
Service Act (42 U.S.C. 300gg-18(e)) is amended to read as
follows:</DELETED>
<DELETED> ``(e) Standard Hospital Charges.--</DELETED>
<DELETED> ``(1) In general.--</DELETED>
<DELETED> ``(A) Disclosure of standard charges.--
Each hospital shall, in accordance with a method and
format established by the Secretary under subparagraph
(C), on a monthly basis compile and make public
(without subscription and free of charge)--</DELETED>
<DELETED> ``(i) all of the hospital's
standard charges (including the information
described in subparagraph (B)) for each item
and service furnished by such hospital;
and</DELETED>
<DELETED> ``(ii) hospital standard charge
information, including the information
described in subparagraph (B), in a consumer-
friendly format (as specified by the
Secretary), that includes--</DELETED>
<DELETED> ``(I) 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 through December 31,
2026, after which the hospital's prices
shall include all shoppable services;
and</DELETED>
<DELETED> ``(II) 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.</DELETED>
<DELETED> ``(B) Standard charges described.--For
purposes of subparagraph (A), standard charges
means:</DELETED>
<DELETED> ``(i) A plain language description
of each item or service, accompanied by any
applicable billing codes, including modifiers,
using commonly recognized billing code sets,
including the Current Procedural Terminology
code, the Healthcare Common Procedure Coding
System code, the diagnosis-related group, the
National Drug Code, and other nationally
recognized identifier.</DELETED>
<DELETED> ``(ii) The gross charge, expressed
as a dollar amount, for each such item or
service, when provided in, as applicable, the
inpatient setting and outpatient department
setting.</DELETED>
<DELETED> ``(iii) The discounted cash price
expressed as a dollar amount, for each such
item or service when provided in, as
applicable, the inpatient setting and
outpatient department setting (or, in the case
no discounted cash price is available for an
item or service, the minimum cash price
accepted by the hospital from self-pay
individuals for such item or service, expressed
as a dollar amount, as well as, 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). The hospital shall accept the
discounted cash price as payment in full from
any patient that chooses to pay in cash without
regard to the patient's coverage.</DELETED>
<DELETED> ``(iv) The payer-specific
negotiated charges, expressed as a dollar
amount and clearly associated with the name of
the applicable third party payer and name of
each plan, that apply to each such item or
service when provided in, as applicable, the
inpatient setting and outpatient department
setting. If the charges are based on an
algorithm, percentage of another amount, or
other formula or criteria, the hospital also
shall disclose such algorithm, percentage,
formula, or criteria as set forth in its
contract and any other terms, schedules,
exhibits, data, or other information referenced
in any such contract as shall be required to
determine and disclose the negotiated
charge.</DELETED>
<DELETED> ``(v) The de-identified maximum
and minimum negotiated charges for each such
item or service, expressed as a non-zero dollar
amount.</DELETED>
<DELETED> ``(vi) Any other additional
information the Secretary may require 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.</DELETED>
<DELETED> ``(C) Uniform method and format.--Not
later than January 1, 2026, the Secretary shall
establish a standard, uniform method and format for
hospitals to use in compiling and making public
standard charges pursuant to subparagraph (A)(i) and a
standard, uniform method and format for such hospitals
to use in compiling and making public prices pursuant
to subparagraph (A)(ii). Such methods and formats
shall--</DELETED>
<DELETED> ``(i) in the case of such method
and format for making public standard charges
pursuant to subparagraph (A)(i), ensure that
such charges are made available in a machine-
readable spreadsheet format;</DELETED>
<DELETED> ``(ii) meet such standards as
determined appropriate by the Secretary in
order to ensure the accessibility and usability
of such charges and prices; and</DELETED>
<DELETED> ``(iii) be updated as determined
appropriate by the Secretary, in consultation
with stakeholders.</DELETED>
<DELETED> ``(2) No deemed compliance.--The availability of a
price estimator tool shall not be considered to deem compliance
with or otherwise vitiate the requirements of paragraph
(1)(A)(ii) or any other requirements of this section.
Furthermore, the use of an estimator tool shall not be used for
purposes of compliance with any provisions in this
Section.</DELETED>
<DELETED> ``(3) Monitoring compliance.--The Secretary shall,
in consultation with the Inspector General of the Department of
Health and Human Services, establish a process to monitor
compliance with this subsection. Such process shall ensure that
each hospital's compliance with this subsection is reviewed not
less frequently than once every year.</DELETED>
<DELETED> ``(4) Attestation.--A senior official from each
hospital (the Chief Executive Officer, Chief Financial Officer,
or an official of equivalent seniority) shall attest to the
accuracy and completeness of the disclosures made in accordance
with the hospital price transparency requirements set forth in
this regulation. Such attestation shall be deemed to be
material to payment from the Federal Government to the
hospital.</DELETED>
<DELETED> ``(5) Enforcement.--</DELETED>
<DELETED> ``(A) In general.--In the case of a
hospital that fails to comply with the requirements of
this subsection, 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 shall include
a request for a corrective action plan to comply with
such requirements.</DELETED>
<DELETED> ``(B) Civil monetary penalty.--</DELETED>
<DELETED> ``(i) In general.--In addition to
any other enforcement actions or penalties that
may apply under another provision of law, a
hospital that has received a request for a
corrective action plan under subparagraph (A)
and fails to comply with the requirements of
this subsection by the date that is 45 days
after such request is made 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--
</DELETED>
<DELETED> ``(I) in the case of a
hospital with 30 or fewer beds, $300
per day;</DELETED>
<DELETED> ``(II) in the case of a
hospital with more than 30 beds but
fewer than 101 beds, $12.50 per bed per
day (or, in the case of such a hospital
that has been noncompliant with such
requirements for a 1-year period or
longer, beginning with the first day
following such 1-year period, $15 per
bed per day);</DELETED>
<DELETED> ``(III) in the case of a
hospital with more than 100 beds but
fewer than 301 beds, $17.50 per bed per
day (or, in the case of such a hospital
that has been noncompliant with such
requirements for a 1-year period or
longer, beginning with the first day
following such 1-year period, $20 per
bed per day);</DELETED>
<DELETED> ``(IV) in the case of a
hospital with more than 300 beds but
fewer than 501 beds, $20 per bed per
day (or, in the case of such a hospital
that has been noncompliant with such
requirements for a 1-year period or
longer, beginning with the first day
following such 1-year period, $25 per
bed per day); and</DELETED>
<DELETED> ``(V) in the case of a
hospital with more than 500 beds, $25
per bed per day (or, in the case of
such a hospital that has been
noncompliant with such requirements for
a 1-year period or longer, beginning
with the first day following such 1-
year period, $35 per bed per
day).</DELETED>
<DELETED> ``(ii) Increase authority.--In
applying this subparagraph with respect to
violations occurring in 2027 or a subsequent
year, the Secretary may through notice and
comment rulemaking increase--</DELETED>
<DELETED> ``(I) the limitation on
the per day amount of any penalty
applicable to a hospital under clause
(i)(I);</DELETED>
<DELETED> ``(II) the limitations on
the per bed per day amount of any
penalty applicable under any of
subclauses (II) through (V) of clause
(i); and</DELETED>
<DELETED> ``(III) the limitation on
the increase of any penalty applied
under clause (iii) pursuant to the
amounts specified in subclause (II) of
such clause.</DELETED>
<DELETED> ``(iii) Persistent
noncompliance.--</DELETED>
<DELETED> ``(I) In general.--In the
case of a hospital that the Secretary
has determined to be knowingly and
willfully noncompliant with the
provisions of this subsection two or
more times during a 1-year period, the
Secretary may increase any penalty
otherwise applicable under this
subparagraph by 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.</DELETED>
<DELETED> ``(II) Specified amount.--
For purposes of subclause (I), the
amount specified in this subclause is,
with respect to a hospital--</DELETED>
<DELETED> ``(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;</DELETED>
<DELETED> ``(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;</DELETED>
<DELETED> ``(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</DELETED>
<DELETED> ``(dd) with more
than 500 beds, and amount that
is not less than $5,000,000 and
not more than
$10,000,000.</DELETED>
<DELETED> ``(iv) Provision of technical
assistance.--The Secretary may, to the extent
practicable, provide technical assistance
relating to compliance with the provisions of
this section to hospitals requesting such
assistance.</DELETED>
<DELETED> ``(v) 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.</DELETED>
<DELETED> ``(C) No waiver.--The Secretary shall not
grant or extend any waiver, delay, tolling, or other
mitigation of a civil monetary penalty for violation of
this subsection.</DELETED>
<DELETED> ``(6) Definitions.--For purposes of this
subsection:</DELETED>
<DELETED> ``(A) Discounted cash price.--The term
`discounted cash price' means the minimum charge,
exclusive of any hospital or third-party payer
assistance, that the hospital accepts from an
individual who pays cash, or cash equivalent, for a
hospital-furnished item or service, without regard to
patient coverage, as payment in full.</DELETED>
<DELETED> ``(B) Gross charge.--The term `gross
charge' means the charge for an individual item or
service that is reflected on a hospital's chargemaster,
absent any discounts.</DELETED>
<DELETED> ``(C) Hospital.--The term `hospital' means
a hospital (as defined in section 1861(e) of the Social
Security Act), a critical access hospital (as defined
in section 1861(mmm)(1) of the Social Security Act), or
a rural emergency hospital (as defined in section
1861(kkk) of the Social Security Act), together with
any parent, subsidiary, or other affiliated provider or
supplier of health care items and services without
regard to whether such parent, subsidiary, or other
affiliated provider or supplier operates under separate
licensure, certification, or designation.</DELETED>
<DELETED> ``(D) Payer-specific negotiated charge.--
The term `payer-specific negotiated charge' means the
charge that a hospital has negotiated with a third
party payer for an item or service.</DELETED>
<DELETED> ``(E) 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.</DELETED>
<DELETED> ``(F) Third party payer.--The term `third
party payer' means an entity that is, by statute,
contract, or agreement, legally responsible for payment
of a claim for a health care item or service.</DELETED>
<DELETED> ``(7) Rulemaking.--The Secretary shall implement
this subsection through notice and comment rulemaking in
accordance with section 553 of title 5, United States
Code.''.</DELETED>
<DELETED> (b) Effective Date.--</DELETED>
<DELETED> (1) In general.--The amendment made by subsection
(a) shall apply beginning January 1, 2026.</DELETED>
<DELETED> (2) Continued applicability of rules for previous
years.--Nothing in the amendment made by this section may be
construed as affecting the applicability of the regulations
codified at part 180 of title 45, Code of Federal Regulations,
before January 1, 2025.</DELETED>
<DELETED> (c) Continued Applicability of State Law.--The provisions
of this Act shall not supersede any provision of State law that
establishes, implements, or continues in effect any requirement or
prohibition related to health care price transparency, except to the
extent that such requirement or prohibition prevents the application of
a requirement or prohibition of this Act.</DELETED>
<DELETED>SEC. 3. INCREASING PRICE TRANSPARENCY OF CLINICAL DIAGNOSTIC
LABORATORY TESTS.</DELETED>
<DELETED> Section 2718 of the Public Health Service Act (42 U.S.C.
300gg-18) is amended by adding at the end the following:</DELETED>
<DELETED> ``(f) Clinical Diagnostic Laboratory Price Transparency.--
</DELETED>
<DELETED> ``(1) In general.--Beginning July 1, 2027, an
applicable laboratory shall--</DELETED>
<DELETED> ``(A) make publicly available on an
internet website the information described in paragraph
(2) with respect to each such specified clinical
diagnostic laboratory test that such laboratory so
furnishes; and</DELETED>
<DELETED> ``(B) ensure that such information is
updated not less frequently than monthly, if there have
been any changes to such information.</DELETED>
<DELETED> ``(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 following:</DELETED>
<DELETED> ``(A) A plain language description of each
item or service, accompanied by any applicable billing
codes, including modifiers, using commonly recognized
billing code sets, including the Current Procedural
Terminology code, the Healthcare Common Procedure
Coding System code, the diagnosis-related group, the
National Drug Code, and other nationally recognized
identifier.</DELETED>
<DELETED> ``(B) The gross charge expressed as a
dollar amount, for each such item or service.</DELETED>
<DELETED> ``(C) The discounted cash price expressed
as a dollar amount, for each such item or service (or,
in the case no discounted cash price is available for
an item or service, the minimum cash price accepted by
the laboratory from self-pay individuals for such item
or service when provided in such settings for the
previous three years, expressed as a dollar amount, as
well as, with respect to prices made public pursuant to
subparagraph (A)(ii), a link to a consumer-friendly
document that clearly explains the laboratory's charity
care policy). The laboratory shall accept the
discounted or minimum cash price as payment in full
from any patient that chooses to pay in cash without
regard to the patient's coverage.</DELETED>
<DELETED> ``(D) The payer-specific negotiated
charges, expressed as a dollar amount and clearly
associated with the name of the applicable third party
payer and name of each plan, that apply to each such
item or service when provided in, as applicable, the
inpatient setting and outpatient department setting. If
the charges are based on an algorithm, percentage of
another amount, or other formula or criteria, the
clinical diagnostic laboratory also shall disclose such
algorithm, percentage, formula, or criteria as set
forth in its contract and any other terms, schedules,
exhibits, data, or other information referenced in any
such contract as shall be required to determine and
disclose the negotiated charge.</DELETED>
<DELETED> ``(E) The de-identified maximum and
minimum negotiated charges for each such item or
service, expressed as a non-zero dollar
amount.</DELETED>
<DELETED> ``(F) Any other additional information the
Secretary may require 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.</DELETED>
<DELETED> ``(3) Uniform method and format.--Not later than
January 1, 2027, 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 shall--</DELETED>
<DELETED> ``(A) include a machine-readable
spreadsheet format containing the information described
in paragraph (2) for all items and services furnished
by each laboratory;</DELETED>
<DELETED> ``(B) meet such standards as determined
appropriate by the Secretary in order to ensure the
accessibility and usability of such information;
and</DELETED>
<DELETED> ``(C) be updated as determined appropriate
by the Secretary, in consultation with
stakeholders.</DELETED>
<DELETED> ``(4) Inclusion of ancillary services.--Any price
or rate for a specified clinical diagnostic laboratory test
available to be furnished by an applicable laboratory made
publicly available in accordance with paragraph (1) shall
include the price or rate for any ancillary item or service
(including specimen collection services, specimen transport,
centrifugation, aliquoting, labeling, requisition processing,
and standard result reporting services) that would customarily
and routinely be furnished by such laboratory as part of such
test, as specified by the Secretary.</DELETED>
<DELETED> ``(5) Enforcement.--</DELETED>
<DELETED> ``(A) In general.--In the case that the
Secretary determines that an applicable laboratory is
not in compliance with paragraph (1)--</DELETED>
<DELETED> ``(i) not later than 30 days after
such determination, the Secretary shall notify
such laboratory of such determination;
and</DELETED>
<DELETED> ``(ii) if such laboratory
continues to fail to comply with such paragraph
after the date that is 90 days after such
notification is sent, the Secretary may impose
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 laboratory was failing to comply with
such paragraph) during which such failure is
ongoing.</DELETED>
<DELETED> ``(B) Increase authority.--In applying
this paragraph with respect to violations occurring in
2028 or a subsequent year, the Secretary may through
notice and comment rulemaking increase the per day
limitation on civil monetary penalties under
subparagraph (A)(ii).</DELETED>
<DELETED> ``(C) Application of certain provisions.--
The provisions of section 1128A of the Social Security
Act (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.</DELETED>
<DELETED> ``(6) 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.</DELETED>
<DELETED> ``(7) Definitions.--In this subsection:</DELETED>
<DELETED> ``(A) Applicable laboratory.--The term
`applicable laboratory' means a `laboratory' as such
term is defined in section 493.2, 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 a
hospital pursuant to subsection (e) of this
section.</DELETED>
<DELETED> ``(B) 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.</DELETED>
<DELETED> ``(C) Gross charge.--The term `gross
charge' means the charge for an individual item or
service that is reflected on an applicable laboratory's
chargemaster, absent any discounts.</DELETED>
<DELETED> ``(D) 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.</DELETED>
<DELETED> ``(E) 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 (e) of this section), other than such a test
that is only available to be furnished by a single
provider of services or supplier.</DELETED>
<DELETED> ``(F) Third party payer.--The term `third
party payer' means an entity that is, by statute,
contract, or agreement, legally responsible for payment
of a claim for a health care item or service.</DELETED>
<DELETED> ``(8) Rulemaking.--The Secretary shall implement
this subsection through notice and comment rulemaking in
accordance with section 553 of title 5, United States
Code.''.</DELETED>
<DELETED>SEC. 4. IMAGING TRANSPARENCY.</DELETED>
<DELETED> Section 2718 of the Public Health Service Act (42 U.S.C.
300gg-18), as amended by section 3, is further amended by adding at the
end the following:</DELETED>
<DELETED> ``(g) Imaging Services Price Transparency.--</DELETED>
<DELETED> ``(1) In general.--Beginning July 1, 2027, each
provider of services or supplier that furnishes 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
hospital pursuant to subsection (e), shall--</DELETED>
<DELETED> ``(A) make publicly available (in
accordance with paragraph (3)) on an internet website
the information described in paragraph (2) with respect
to each such service that such provider of services or
supplier furnishes; and</DELETED>
<DELETED> ``(B) ensure that such information is
updated not less frequently than annually.</DELETED>
<DELETED> ``(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 following:</DELETED>
<DELETED> ``(A) A plain language description of each
item or service, accompanied by any applicable billing
codes, including modifiers, using commonly recognized
billing code sets, including the Current Procedural
Terminology code, the Healthcare Common Procedure
Coding System code, the diagnosis-related group, the
National Drug Code, and other nationally recognized
identifier.</DELETED>
<DELETED> ``(B) The gross charge expressed as a
dollar amount, for each such item or service.</DELETED>
<DELETED> ``(C) The discounted cash price expressed
as a dollar amount, for each such item or service (or,
in the case no discounted cash price is available for
an item or service, the minimum cash price accepted by
the provider of services or supplier from self-pay
individuals for such item or service when provided in
such settings for the previous three years, expressed
as a dollar amount, as well as, with respect to prices
made public pursuant to subparagraph (A)(ii), a link to
a consumer-friendly document that clearly explains the
provider of services or supplier's charity care
policy). The provider of services or supplier shall
accept the discounted or minimum cash price as payment
in full from any patient that chooses to pay in cash
without regard to the patient's coverage.</DELETED>
<DELETED> ``(D) The payer-specific negotiated
charges, expressed as a dollar amount and clearly
associated with the name of the applicable third party
payer and name of each plan, that apply to each such
item or service when provided in, as applicable, the
inpatient setting and outpatient department setting. If
the charges are based on an algorithm, percentage of
another amount, or other formula or criteria, the
provider or supplier also shall disclose such
algorithm, percentage, formula, or criteria as set
forth in its contract and any other terms, schedules,
exhibits, data, or other information referenced in any
such contract as shall be required to determine and
disclose the negotiated charge.</DELETED>
<DELETED> ``(E) The de-identified maximum and
minimum negotiated charges for each such item or
service, expressed as a non-zero dollar
amount.</DELETED>
<DELETED> ``(F) Any other additional information the
Secretary may require 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.</DELETED>
<DELETED> ``(3) Uniform method and format.--Not later than
January 1, 2027, 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 shall--</DELETED>
<DELETED> ``(A) include a machine-readable
spreadsheet format containing the information described
in paragraph (2) for all items and services furnished
by each provider of services and supplier described in
paragraph (1);</DELETED>
<DELETED> ``(B) meet such standards as determined
appropriate by the Secretary in order to ensure the
accessibility and usability of such information;
and</DELETED>
<DELETED> ``(C) be updated as determined appropriate
by the Secretary, in consultation with
stakeholders.</DELETED>
<DELETED> ``(4) Monitoring compliance.--The Secretary shall,
through notice and comment rulemaking and in consultation with
the Inspector General of the Department of Health and Human
Services, establish a process to monitor compliance with this
subsection.</DELETED>
<DELETED> ``(5) Enforcement.--</DELETED>
<DELETED> ``(A) In general.--In the case that the
Secretary determines that a provider of services or
supplier is not in compliance with paragraph (1)--
</DELETED>
<DELETED> ``(i) not later than 30 days after
such determination, the Secretary shall notify
such provider or supplier of such
determination;</DELETED>
<DELETED> ``(ii) upon request of the
Secretary, such provider or supplier shall
submit to the Secretary, not later than 45 days
after the date of such request, a corrective
action plan to comply with such paragraph;
and</DELETED>
<DELETED> ``(iii) if such provider or
supplier continues to fail to comply with such
paragraph after the date that is 90 days after
such notification is sent (or, in the case of
such a provider or supplier that has submitted
a corrective action plan described in clause
(ii) in response to a request so described,
after the date that is 90 days after such
submission), the Secretary may impose a civil
monetary penalty in an amount not to exceed
$300 for each day (beginning with the day on
which the Secretary first determined that such
provider or supplier was failing to comply with
such paragraph) during which such failure to
comply or failure to submit is
ongoing.</DELETED>
<DELETED> ``(B) Increase authority.--In applying
this paragraph with respect to violations occurring in
2027 or a subsequent year, the Secretary may through
notice and comment rulemaking increase the amount of
the civil monetary penalty under subparagraph
(A)(iii).</DELETED>
<DELETED> ``(C) Application of certain provisions.--
The provisions of section 1128A of the Social Security
Act (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.</DELETED>
<DELETED> ``(D) No authority to waive or reduce
penalty.--The Secretary shall not grant or extend any
waiver, delay, tolling, or other mitigation of a civil
monetary penalty for violation of this
subsection.</DELETED>
<DELETED> ``(E) 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.</DELETED>
<DELETED> ``(F) Clarification of nonapplicability of
other enforcement provisions.--Notwithstanding any
other provision of this title, this paragraph shall be
the sole means of enforcing the provisions of this
subsection.</DELETED>
<DELETED> ``(6) Specified imaging service defined.--the term
`specified imaging service' means an imaging service that is a
Centers for Medicare & Medicaid Services-specified shoppable
service (as described in subsection (e)).</DELETED>
<DELETED> ``(7) Rulemaking.--The Secretary shall implement
this subsection through notice and comment rulemaking in
accordance with section 553 of title 5, United States
Code.''.</DELETED>
<DELETED>SEC. 5. AMBULATORY SURGICAL CENTER PRICE TRANSPARENCY
REQUIREMENTS.</DELETED>
<DELETED> Section 2718 of the Public Health Service Act (42 U.S.C.
300gg-18), as amended by section 4, is further amended by adding at the
end the following:</DELETED>
<DELETED> ``(h) Ambulatory Surgery Center Transparency.--</DELETED>
<DELETED> ``(1) In general.--Beginning July 1, 2027, each
specified ambulatory surgical center shall comply with the
price transparency requirement described in paragraph
(2).</DELETED>
<DELETED> ``(2) Requirement described.--</DELETED>
<DELETED> ``(A) In general.--A specified ambulatory
surgical center, in accordance with a method and format
established by the Secretary under subparagraph (C),
shall compile and make public (without subscription and
free of charge), for each year--</DELETED>
<DELETED> ``(i) one or more lists, in a
machine-readable format specified by the
Secretary, of the ambulatory surgical center's
standard charges (including the information
described in subparagraph (B)) for each item
and service furnished by such surgical
center;</DELETED>
<DELETED> ``(ii) information in a consumer-
friendly format (as specified by the Secretary)
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 included on the list
described in subsection (e) 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</DELETED>
<DELETED> ``(iii) with respect to each
Centers for Medicare & Medicaid Services-
specified shoppable service (as described in
clause (ii)) that is not furnished by the
ambulatory surgical center, an indication that
such service is not so furnished.</DELETED>
<DELETED> ``(B) Information described.--For purposes
of subparagraph (A), the information described in this
subparagraph is, with respect to standard charges and
prices made public by a specified ambulatory surgical
center, the following:</DELETED>
<DELETED> ``(i) A description of each item
or service, accompanied by the Healthcare
Common Procedure Coding System code, the
national drug code, or other identifier used or
approved by the Centers for Medicare & Medicaid
Services.</DELETED>
<DELETED> ``(ii) The gross charge, expressed
as a dollar amount, for each such item or
service.</DELETED>
<DELETED> ``(iii) The discounted cash price,
expressed as a dollar amount, for each such
item or service (or, in the case no discounted
cash price is available for an item or service,
the minimum cash price accepted by the
specified ambulatory surgical center from self-
pay individuals for such item or service when
provided in such settings for the previous
three years, expressed as a dollar amount, as
well as, with respect to prices made public
pursuant to subparagraph (A)(ii), a link to a
consumer-friendly document that clearly
explains the provider of services or supplier's
charity care policy). The specified ambulatory
surgical center shall accept the discounted
cash price as payment in full from any patient
that chooses to pay in cash without regard to
the patient's coverage.</DELETED>
<DELETED> ``(iv) The payer-specific
negotiated charges, expressed as a dollar
amount and clearly associated with the name of
the applicable third party payer and name of
each plan, that apply to each such item or
service when provided in, as applicable, the
inpatient setting and outpatient department
setting. If the charges are based on an
algorithm, percentage of another amount, or
other formula or criteria, the ambulatory
surgical center also shall disclose such
algorithm, percentage, formula, or criteria as
set forth in its contract and any other terms,
schedules, exhibits, data, or other information
referenced in any such contract as shall be
required to determine and disclose the
negotiated charge.</DELETED>
<DELETED> ``(v) The de-identified maximum
and minimum negotiated charges for each such
item or service, expressed as a non-zero dollar
amount.</DELETED>
<DELETED> ``(vi) Any other additional
information the Secretary may require 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.</DELETED>
<DELETED> ``(C) Uniform method and format.--Not
later than January 1, 2027, the Secretary shall
establish a standard, uniform method and format for
specified 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
shall--</DELETED>
<DELETED> ``(i) in the case of such charges
made public by an ambulatory surgical center,
ensure that such charges are made available in
a machine-readable format;</DELETED>
<DELETED> ``(ii) meet such standards as
determined appropriate by the Secretary in
order to ensure the accessibility and usability
of such charges and prices; and</DELETED>
<DELETED> ``(iii) be updated as determined
appropriate by the Secretary, in consultation
with stakeholders.</DELETED>
<DELETED> ``(3) No deemed compliance.--The availability of a
price estimator tool shall not be considered to deem compliance
with or otherwise vitiate the requirements of this subsection
(aa). Furthermore, the use of an estimator tool shall not be
used for purposes of compliance with any provisions in this
subsection.</DELETED>
<DELETED> ``(4) Monitoring compliance.--The Secretary shall,
in consultation with the Inspector General of the Department of
Health and Human Services, establish a process to monitor
compliance with this subsection. Such process shall ensure that
each specified ambulatory surgical center's compliance with
this subsection is reviewed not less frequently than once every
year.</DELETED>
<DELETED> ``(5) Enforcement.--</DELETED>
<DELETED> ``(A) In general.--In the case of a
specified ambulatory surgical center that fails to
comply with the requirements of this subsection--
</DELETED>
<DELETED> ``(i) the Secretary shall notify
such ambulatory surgical center of such failure
not later than 30 days after the date on which
the Secretary determines such failure exists;
and</DELETED>
<DELETED> ``(ii) upon request of the
Secretary, the ambulatory surgical center shall
submit to the Secretary, not later than 45 days
after the date of such request, a corrective
action plan to comply with such
requirements.</DELETED>
<DELETED> ``(B) Civil monetary penalty.--</DELETED>
<DELETED> ``(i) In general.--A specified
ambulatory surgical center that has received a
notification under subparagraph (A)(i) and
fails to comply with the requirements of this
subsection by the date that is 90 days after
such notification (or, in the case of an
ambulatory surgical center that has submitted a
corrective action plan described in
subparagraph (A)(ii) in response to a request
so described, by the date that is 90 days after
such submission) shall be subject to a civil
monetary penalty of an amount specified by the
Secretary for each day (beginning with the day
on which the Secretary first determined that
such hospital was not complying with such
requirements) during which such failure is
ongoing (not to exceed $300 per day).</DELETED>
<DELETED> ``(ii) Increase authority.--In
applying this subparagraph with respect to
violations occurring in 2027 or a subsequent
year, the Secretary may through notice and
comment rulemaking increase the limitation on
the per day amount of any penalty applicable to
a specified ambulatory surgical center under
clause (i).</DELETED>
<DELETED> ``(iii) Application of certain
provisions.--The provisions of section 1128A of
the Social Security Act (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.</DELETED>
<DELETED> ``(iv) No authority to waive or
reduce penalty.--The Secretary shall not grant
or extend any waiver, delay, tolling, or other
mitigation of a civil monetary penalty for
violation of this subsection.</DELETED>
<DELETED> ``(6) 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 ambulatory surgical centers requesting
such assistance.</DELETED>
<DELETED> ``(7) Definitions.--For purposes of this
section:</DELETED>
<DELETED> ``(A) Discounted cash price.--The term
`discounted cash price' means the charge that applies
to an individual who pays cash, or cash equivalent, for
a item or service furnished by an ambulatory surgical
center.</DELETED>
<DELETED> ``(B) Gross charge.--The term `gross
charge' means the charge for an individual item or
service that is reflected on a specified surgical
center's chargemaster, absent any discounts.</DELETED>
<DELETED> ``(C) Group health plan; group health
insurance coverage; individual health insurance
coverage.--The terms `group health plan', `group health
insurance coverage', and `individual health insurance
coverage' have the meaning given such terms in section
2791 of the Public Health Service Act.</DELETED>
<DELETED> ``(D) Payer-specific negotiated charge.--
The term `payer-specific negotiated charge' means the
charge that a specified surgical center has negotiated
with a third party payer for an item or
service.</DELETED>
<DELETED> ``(E) 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.</DELETED>
<DELETED> ``(F) Specified ambulatory surgical
center.--The term `specified ambulatory surgical
center' means an ambulatory surgical center with
respect to which a hospital (or any person with an
ownership or control interest (as defined in section
1124(a)(3) of the Social Security Act) in a hospital)
is a person with an ownership or control interest (as
so defined).</DELETED>
<DELETED> ``(G) Third party payer.--The term `third
party payer' means an entity that is, by statute,
contract, or agreement, legally responsible for payment
of a claim for a health care item or service.</DELETED>
<DELETED> ``(8) Rulemaking.--The Secretary shall implement
this subsection through notice and comment rulemaking in
accordance with section 553 of title 5, United States
Code.''.</DELETED>
<DELETED>SEC. 6. STRENGTHENING HEALTH COVERAGE TRANSPARENCY
REQUIREMENTS.</DELETED>
<DELETED> (a) Transparency in Coverage.--Section 1311(e)(3)(C) of
the Patient Protection and Affordable Care Act (42 U.S.C.
18031(e)(3)(C)) is amended--</DELETED>
<DELETED> (1) by striking ``The Exchange'' and inserting the
following:</DELETED>
<DELETED> ``(i) In general.--The
Exchange'';</DELETED>
<DELETED> (2) in clause (i), as inserted by paragraph (1)--
</DELETED>
<DELETED> (A) by striking ``participating provider''
and inserting ``provider'';</DELETED>
<DELETED> (B) by inserting ``shall include the
information specified in clause (ii) and'' after ``such
information'';</DELETED>
<DELETED> (C) by striking ``an Internet website''
and inserting ``a self-service tool that meets the
requirements of clause (iii)''; and</DELETED>
<DELETED> (D) by striking ``and such other'' and all
that follows through the period and inserting ``or, at
the option such individual, through a paper or phone
disclosure (as selected by such individual and provided
at no cost to such individual) that meets such
requirements as the Secretary may specify.'';
and</DELETED>
<DELETED> (3) by adding at the end the following new
clauses:</DELETED>
<DELETED> ``(ii) Specified information.--For
purposes of clause (i), the information
specified in this clause is, with respect to
benefits available under a health plan for an
item or service furnished by a health care
provider, the following:</DELETED>
<DELETED> ``(I) If such provider is
a participating provider with respect
to such item or service, the in-network
rate (as defined in subparagraph (F))
for such item or service.</DELETED>
<DELETED> ``(II) If such provider is
not described in subclause (I), the
maximum allowed dollar amount for such
item or service.</DELETED>
<DELETED> ``(III) The 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 subclause (II),
shall be calculated using the maximum
amount described in such
subclause).</DELETED>
<DELETED> ``(IV) The amount the
individual 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 separate
individuals enrolled in the plan, by
such separate deductibles or maximums,
in addition to any cumulative
deductible or maximum).</DELETED>
<DELETED> ``(V) 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.</DELETED>
<DELETED> ``(VI) Any prior
authorization, concurrent review, step
therapy, fail first, or similar
requirements applicable to coverage of
such item or service under such
plan.</DELETED>
<DELETED> ``(iii) Self-service tool.--For
purposes of clause (i), a self-service tool
established by a health plan meets the
requirements of this clause if such tool--
</DELETED>
<DELETED> ``(I) is based on an
internet website;</DELETED>
<DELETED> ``(II) provides for real-
time responses to requests described in
such clause;</DELETED>
<DELETED> ``(III) is updated in a
manner such that information provided
through such tool is timely and
accurate;</DELETED>
<DELETED> ``(IV) allows such a
request to be made with respect to an
item or service furnished by--
</DELETED>
<DELETED> ``(aa) a specific
provider that is a
participating provider with
respect to such item or
service;</DELETED>
<DELETED> ``(bb) all
providers that are
participating providers with
respect to such plan and such
item or service; or</DELETED>
<DELETED> ``(cc) a provider
that is not described in item
(bb);</DELETED>
<DELETED> ``(V) provides that such a
request may be made with respect to an
item or service through use of--
</DELETED>
<DELETED> ``(aa) the billing
code for such item or service;
or</DELETED>
<DELETED> ``(bb) through use
of a descriptive term for such
item or service to produce a
list of billing code options
from which the individual
selects to indicate the subject
matter items or services;
and</DELETED>
<DELETED> ``(VI) holds a member
harmless for the amount of any
difference in excess of the amount of
the individual's responsibility
generated by the self-service tool and
the amount ultimately billed or charged
to the individual.''.</DELETED>
<DELETED> (b) Disclosure of Additional Information.--Section
1311(e)(3) of the Patient Protection and Affordable Care Act (42 U.S.C.
18031(e)(3)) is amended by adding at the end the following new
subparagraphs:</DELETED>
<DELETED> ``(E) Rate and payment information.--
</DELETED>
<DELETED> ``(i) In general.--Not later than
January 1, 2027, and every month thereafter,
each health plan shall submit to the Exchange,
the Secretary, the State insurance
commissioner, and make available to the public,
the rate and payment information described in
clause (ii) in accordance with clause
(iii).</DELETED>
<DELETED> ``(ii) Rate and payment
information described.--For purposes of clause
(i), the rate and payment information described
in this clause is, with respect to a health
plan, the following:</DELETED>
<DELETED> ``(I) With respect to each
item or service for which benefits are
available under such plan (expressed as
a dollar amount), including
prescription drugs, identified by CPT,
HCPCS, DRG, NDC, or other applicable
nationally recognized identifier,
including any applicable code
modifiers, and accompanied by a brief
description of the item or service, the
in-network rate in effect as of the
date of the submission of such
information with each provider
(identified by national provider
identifier) that is a participating
provider with respect to such item or
service, other than such a rate in
effect with a provider--</DELETED>
<DELETED> ``(aa) that has
submitted no claims;
and</DELETED>
<DELETED> ``(bb) expects to
receive no claims in the then
applicable calendar year for
such item or service to such
plan.</DELETED>
<DELETED> ``(II) With respect to
each drug (identified by National Drug
Code, J-code, or other commonly
recognized billing code used for drugs)
for which benefits are available under
such plan:</DELETED>
<DELETED> ``(aa) The in-
network rate (expressed as a
dollar amount), including the
individual and total amounts
for any bundled rates, 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.</DELETED>
<DELETED> ``(bb) The
historical net price paid by
such plan (net of rebates,
discounts, and price
concessions) (expressed as a
dollar amount) for such drug
dispensed or administered
during the 90-day period
beginning 180 days before such
date of submission to each
provider that was a
participating provider with
respect to such drug, broken
down by each such provider
(identified by national
provider identifier), other
than such an amount paid to a
provider that has submitted no
claims for such drug to such
plan.</DELETED>
<DELETED> ``(III) With respect to
each item or service for which benefits
are available under such plan
(expressed as a dollar amount),
identified by CPT, DRG, HCPCS, NDC, or
other applicable nationally recognized
identifier, including any applicable
code modifiers, and accompanied by a
brief description of the item or
service, the amount billed or charged
by the provider, and the amount allowed
by the plan, for each such item or
service furnished during the 90-day
period beginning 180 days before such
date of submission by each provider
that was not a participating provider
with respect to such item or service,
broken down by each such provider
(identified by national provider
identifier), other than items and
services with respect to which no
claims for such item or service were
submitted to such plan during such
period.</DELETED>
<DELETED> ``(iii) Manner of submission.--
Rate and payment information required to be
submitted and made available under this
subparagraph shall be so submitted and so made
available as follows:</DELETED>
<DELETED> ``(I) Information shall be
contained in 3 separate machine-
readable files corresponding to the
information described in each of
subclauses (I) through (III) of clause
(ii) that meet such requirements as
specified by the Secretary through
rulemaking, in consultation with the
Secretaries of Labor and the Treasury
to apply comparable requirements to
group health plans and to entities
providing benefit management or other
third-party administration services on
a contractual basis with a group health
plan.</DELETED>
<DELETED> ``(II) Requirements
specified by the Secretary through
rulemaking shall ensure that:</DELETED>
<DELETED> ``(aa) Such files
are limited to an appropriate
size, are made available in a
widely available format that
allows for information
contained in such files to be
compared across health plans,
and are accessible to
individuals at no cost and
without the need to establish a
user account or provider other
credentials.</DELETED>
<DELETED> ``(bb) The rates,
amounts, and prices to be
disclosed include contractual
terms containing calculation
formulae, pricing
methodologies, and other
information necessary to
determine the dollar value of
reimbursement.</DELETED>
<DELETED> ``(cc) Each such
file includes each of the
following data
elements:</DELETED>
<DELETED> ``(AA) A
numerical identifier
for the group health
plan and/or health
insurance issuer (such
as a Health Insurance
Oversight System
identifier).</DELETED>
<DELETED> ``(BB) A
plain-language
description of the item
or service (including,
for drugs, the
proprietary and
nonproprietary name
assigned).</DELETED>
<DELETED> ``(CC) The
billing code, including
any applicable
modifiers, associated
with such item or
service, including the
Healthcare Common
Procedure Coding System
code, diagnosis-related
group, national drug
code, or other commonly
recognized code
set.</DELETED>
<DELETED> ``(DD) The
place of service
code.</DELETED>
<DELETED> ``(EE) The
National Provider
Identifier or provider
Tax Identification
Number.</DELETED>
<DELETED> ``(III) The rate and
payment information disclosed under
subclauses (I) through (III) of clause
(ii) shall be separately delineated for
each item or service, regardless of
whether such item or service is
reimbursed as a part of a bundle,
episode, or other grouping of items and
services.</DELETED>
<DELETED> ``(IV) An officer or
executive of competent authority shall
attest to the accuracy and completeness
of information submitted and made
available under this subparagraph. Such
attestation shall be subject to
enforcement under subparagraph (H) and,
where applicable, shall be deemed
material to payments from the Federal
Government received by the group health
plan or health insurance
issuer.</DELETED>
<DELETED> ``(V) Regulations
promulgated pursuant to this section
shall provide that:</DELETED>
<DELETED> ``(aa) The
Secretary shall audit the three
machine-readable files required
by subparagraph (E)(ii) posted
by no fewer than 20 group
health plans or health
insurance issuers.</DELETED>
<DELETED> ``(bb) The
Secretary of Labor shall audit
the three machine-readable
files required by subparagraph
(E)(ii) posted by no fewer than
200 group health plans or
service providers furnishing
third-party administrator
services to a group health
plan.</DELETED>
<DELETED> ``(cc) Findings,
conclusions, and enforcement
actions taken based on audits
of the machine-readable files
shall be reported annually to
Congress no later than July 1
of the calendar year during
which the files were audited.
Such report to Congress shall
be accessible to the
public.</DELETED>
<DELETED> ``(iv) User guide.--Each health
plan shall make available to the public
instructions written in plain language
explaining how individuals may search for
information described in clause (ii) in files
submitted in accordance with clause
(iii).</DELETED>
<DELETED> ``(F) Definitions.--In this
paragraph:</DELETED>
<DELETED> ``(i) Participating provider.--The
term `participating provider' has the meaning
given such term in section 2799A-1 of the
Public Health Service Act.</DELETED>
<DELETED> ``(ii) In-network rate.--The term
`in-network rate' means, with respect to a
health plan and an item or service furnished by
a provider that is a participating provider
with respect to such plan and item or service,
the contracted rate in effect between such plan
and such provider for such item or service. If
the rate is based on an algorithm, percentage
of another amount, or other formula or
criteria, the health plan also shall disclose
such algorithm, percentage, formula, or
criteria as set forth in its contract and any
other terms, schedules, exhibits, data, or
other information referenced in any such
contract as shall be required to determine and
disclose the negotiated rate.</DELETED>
<DELETED> ``(G) Applicability to accountable care
organizations.--An applicable ACO participating in the
Medicare Shared Savings Program, as defined in Section
1899 of the Social Security Act (42 U.S.C. 1395jjj),
shall be subject to the requirements of this paragraph
as if such applicable ACO is a group health plan or
health insurance issuer.</DELETED>
<DELETED> ``(H) Enforcement.--</DELETED>
<DELETED> ``(i) In general.--Each year, the
Secretary shall audit the three machine-
readable files required by subparagraph (E)(ii)
posted by no fewer than 20 group health plans
or health insurance issuers.</DELETED>
<DELETED> ``(ii) Notification and request
for corrective action.--In the case of a health
plan that fails to comply with the requirements
of this subsection, not later than 30 days
after the date on which the Secretary
determines such failure exists, the Secretary
shall submit to such health plan a notification
of such determination, which shall include a
request for a corrective action plan to comply
with such requirements.</DELETED>
<DELETED> ``(iii) Civil monetary penalty.--A
health plan that has received a request for a
corrective action plan under clause (ii) and
fails to comply with the requirements of this
subsection by the date that is 90 days after
such request is made 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 laboratory was failing to comply with
such paragraph) during which such failure was
ongoing. Such amount shall not exceed $300 per
member per day or $10,000,000, whichever is
lesser.</DELETED>
<DELETED> ``(I) Rulemaking.--The Secretary shall
implement subparagraphs (E) through (H) through notice
and comment rulemaking in accordance with section 553
of title 5, United States Code.''.</DELETED>
<DELETED> (c) Effective Date.--</DELETED>
<DELETED> (1) In general.--The amendments made by
subsections (a) and (b) shall apply beginning January 1,
2026.</DELETED>
<DELETED> (2) Continued applicability of rules for previous
years.--Nothing in the amendments made by this section 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)
before January 1, 2026.</DELETED>
<DELETED>SEC. 7. INCREASING GROUP HEALTH PLAN ACCESS TO HEALTH
DATA.</DELETED>
<DELETED> (a) Group Health Plan Access to Information.--</DELETED>
<DELETED> (1) In general.--Paragraph (2) of section 408(b)
of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1108(b)) is amended by adding at the end the following
new subparagraphs:</DELETED>
<DELETED> ``(C) No contract or arrangement for
services, and no extension or renewal of such contract
or arrangement, between a group health plan (as that
term is defined in section 733(a) of this title) and
party in interest, including a health care provider
(which for purposes of this subparagraph, includes a
health care facility), network or association of
providers, service provider offering access to a
network of providers, third-party administrator, or
pharmacy benefit manager (collectively referred to as
`Covered Service Providers'), is reasonable within the
meaning of this paragraph unless such contract or
arrangement--</DELETED>
<DELETED> ``(i) allows the responsible plan
fiduciary (as that term is defined in
subparagraph (B)(ii)(I)(ee)) access to all
claims and encounter information or data, and
any documentation supporting claim payments,
including, but not limited to, medical records
and policy documents, or information or data
described in section 724(a)(1)(B) to--
</DELETED>
<DELETED> ``(I) enable such entity
to comply with the terms of the plan
and any applicable law; and</DELETED>
<DELETED> ``(II) determine the
accuracy or reasonableness of payment;
and</DELETED>
<DELETED> ``(ii) does not--</DELETED>
<DELETED> ``(I) unreasonably limit
or delay access, as determined by the
Secretary but in any event not longer
than 15 days, to such information or
data;</DELETED>
<DELETED> ``(II) limit the volume of
claims and encounter information or
data that the group health plan, the
plan sponsor, the plan administrator,
or a business associate of such plan
may access during an audit or pursuant
to any request for such information or
data;</DELETED>
<DELETED> ``(III) limit the
disclosure of pricing terms for value-
based payment arrangements or capitated
payment arrangements, including--
</DELETED>
<DELETED> ``(aa) payment
calculations and
formulas;</DELETED>
<DELETED> ``(bb) quality
measures;</DELETED>
<DELETED> ``(cc) contract
terms;</DELETED>
<DELETED> ``(dd) payment
amounts;</DELETED>
<DELETED> ``(ee) measurement
periods for all incentives;
and</DELETED>
<DELETED> ``(ff) other
payment methodologies used by
an entity, including a health
care provider (including a
health care facility), network
or association of providers,
service provider offering
access to a network of
providers, third-party
administrator, or pharmacy
benefit manager;</DELETED>
<DELETED> ``(IV) limit the
disclosure of overpayments and
overpayment recovery terms;</DELETED>
<DELETED> ``(V) limit the right of
the group health plan, the plan
sponsor, or the plan administrator of
such plan to select an auditor or
define audit scope or
frequency;</DELETED>
<DELETED> ``(VI) otherwise limit or
unduly delay the group health plan, the
plan sponsor, the plan administrator,
or a business associate of such plan
from accessing claims and encounter
information or data in a daily
batch;</DELETED>
<DELETED> ``(VII) limit the
disclosure of fees charged to the group
health plan related to plan
administration and claims processing,
including renegotiation fees, access
fees, repricing fees, or enhanced
review fees;</DELETED>
<DELETED> ``(VIII) limit the right
of the group health plan, the plan
sponsor, or the plan administrator to
request action on any suspect claim
payments; or</DELETED>
<DELETED> ``(IX) limit public
disclosure of de-identified or
aggregate information.</DELETED>
<DELETED> ``(D)(i) Covered Service Providers shall
provide information or data under this paragraph in a
manner consistent with the privacy and security
regulations promulgated under the Health Insurance
Portability and Accountability Act (referred to in this
subparagraph as `HIPAA').</DELETED>
<DELETED> ``(ii) A group health plan that receives a
disclosure from a party in interest pursuant to
subparagraph (B) or (C) shall comply with the privacy
and security regulations promulgated under
HIPAA.</DELETED>
<DELETED> ``(iii) Nothing in this subparagraph shall
be construed to modify the requirements for the
creation, receipt, maintenance, or transmission of
protected health information under the HIPAA privacy
regulation (as defined in section 1180(b)(3) of the
Social Security Act) as they apply directly or
indirectly to an entity pursuant to this
paragraph.</DELETED>
<DELETED> ``(iv) This subparagraph shall not be read
to abridge or limit the disclosure requirements under
this paragraph or to impose additional privacy or
security requirements on Covered Service Providers or
plan sponsors.</DELETED>
<DELETED> ``(E) A group health plan receiving
information or data under this paragraph may disclose
such information only in a manner that is consistent
with the Health Insurance Portability and
Accountability Act (HIPAA) and the privacy and security
regulations promulgated thereunder, regardless of their
direct or indirect applicability to the plan or any
entities that could be or are business
associates.</DELETED>
<DELETED> ``(F) Information made available under
this section shall conform to the following
standards:</DELETED>
<DELETED> ``(i) All claims from a healthcare
provider shall be made to the group health plan
in accordance with transaction standards
adopted by regulation under HIPAA, as
follows:</DELETED>
<DELETED> ``(I) Institutional,
professional, and dental claims shall
be in ASC X12N 837 format or any
subsequent standard.</DELETED>
<DELETED> ``(II) Pharmacy claims
shall be in the National Council for
Prescription Drug Programs (NCPDP)
format or any subsequent
standard.</DELETED>
<DELETED> ``(III) The files shall be
unmodified copies of the files sent
from the provider. In the event that
paper claims are sent by the provider,
they shall be converted to the
appropriate standard electronic format.
Files shall be accessible to the plan
at no cost to the group health
plan.</DELETED>
<DELETED> ``(ii) All claim payment (or EFT,
electronic funds transfer) and electronic
remittance advice (ERA) notices sent by a
Covered Service Provider shall be made
available to the group health plan as ASC X12N
835 files in accordance with standards adopted
by regulation under HIPAA. The files shall be
unmodified copies of the files sent by the
Covered Service Provider to the healthcare
provider. Files shall be accessible at no cost
to the group health plan.</DELETED>
<DELETED> ``(iii) The contractual terms
containing calculation formulae, pricing
methodologies, and other information used to
determine the dollar value of
reimbursement.</DELETED>
<DELETED> ``(iv) All non-claim costs shall
be itemized and made available to the group
health plan in real time through a web-based
portal, through an API, and through a
downloadable CSV file.</DELETED>
<DELETED> ``(G) The Secretary shall implement
subparagraphs (C) through (F) through notice and
comment rulemaking in accordance with section 553 of
title 5, United States Code.''.</DELETED>
<DELETED> (2) Civil enforcement.--Subsection (c) of section
502 of such Act (29 U.S.C. 1132) is amended by adding at the
end the following new paragraph:</DELETED>
<DELETED> ``(13) In the case of an agreement between a group
health plan (as defined in section 733(a)), the plan sponsor of
such plan (as defined in section 3(16)(B)), or the plan
administrator of such plan (as defined in section 3(16)(A)) and
a health care provider (which, for purposes of this paragraph,
includes a health care facility), network or association of
providers, service provider offering access to a network or
association of providers, third-party administrator, or
pharmacy benefit manager, that violates the provisions of
section 724, the Secretary may assess a civil penalty against
such provider, network or association, service provider
offering access to a network or association of providers,
third-party administrator, pharmacy benefit manager, or other
service provider in the amount of $10,000 for each day during
which such violation continues. Such penalty shall be in
addition to other penalties as may be prescribed by
law.''.</DELETED>
<DELETED> (3) Existing provisions void.--Section 410 of such
Act (29 U.S.C. 1110) is amended by adding at the end the
following:</DELETED>
<DELETED> ``(c) Any provision in an agreement or instrument shall be
void as against public policy if such provision--</DELETED>
<DELETED> ``(1) unduly delays or limits a group health plan
(as defined in section 733(a)), the plan sponsor of such plan
(as defined in section 3(16)(B)), or the plan administrator of
such plan (as defined in section 3(16)(A)) from accessing the
claims and encounter information or data described in section
724(a)(1)(B); or</DELETED>
<DELETED> ``(2) violates the requirements of section
408(b)(2)(C).''.</DELETED>
<DELETED> (4) Technical amendment.--Clause (i) of section
408(b)(2)(B) of such Act is amended by striking ``this clause''
and inserting ``this paragraph''.</DELETED>
<DELETED> (b) Updated Attestation for Price and Quality
Information.--Section 724(a)(3) of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1185m(a)(3)) is amended to read as
follows:</DELETED>
<DELETED> ``(3) Attestation.--</DELETED>
<DELETED> ``(A) In general.--Subject to subparagraph
(C), a group health plan or health insurance issuer
offering group health insurance coverage shall annually
submit to the Secretary an attestation that such plan
or issuer of such coverage is in compliance with the
requirements of this subsection. Such attestation shall
also include a statement verifying that--</DELETED>
<DELETED> ``(i) the information or data
described under subparagraphs (A) and (B) of
paragraph (1) is available upon request and
provided to the group health plan, the plan
sponsor, the plan administrator, or the
business associate of such plan, or the issuer
in a timely manner; and</DELETED>
<DELETED> ``(ii) there are no terms in the
agreement under such paragraph (1) that
directly or indirectly restrict or unduly delay
a group health plan, the plan sponsor, the plan
administrator, a business associate of such
plan, or the issuer from auditing, reviewing,
or otherwise accessing such
information.</DELETED>
<DELETED> ``(B) Limitation on submission.--Subject
to clause (ii), a group health plan or issuer offering
group health insurance coverage may not enter into an
agreement with a third-party administrator or other
service provider to submit the attestation required
under subparagraph (A).</DELETED>
<DELETED> ``(C) Exception.--In the case of a group
health plan or issuer offering group health insurance
coverage that is unable to obtain the information or
data needed to submit the attestation required under
subparagraph (A), such plan or issuer may submit a
written statement in lieu of such attestation that
includes--</DELETED>
<DELETED> ``(i) an explanation of why such
plan or issuer was unsuccessful in obtaining
such information or data, including whether
such plan, the plan sponsor, or the plan
administrator or issuer was limited or
prevented from auditing, reviewing, or
otherwise accessing such information or
data;</DELETED>
<DELETED> ``(ii) a description of the
efforts made by the group health plan, the plan
sponsor, or the plan administrator to remove
any gag clause provisions from the agreement
under paragraph (1); and</DELETED>
<DELETED> ``(iii) a description of any
response by the third-party administrator or
other service provider with respect to efforts
to comply with the attestation requirement
under subparagraph (A), including the name of
the third-party administrator or other service
provider.''.</DELETED>
<DELETED> (c) Effective Date.--The amendments made by subsections
(a) and (b) shall apply with respect to a plan beginning with the first
plan year that begins on or after the date that is 1 year after the
date of enactment of this Act.</DELETED>
<DELETED>SEC. 8. OVERSIGHT OF ADMINISTRATIVE SERVICE
PROVIDERS.</DELETED>
<DELETED> (a) ERISA Amendments.--</DELETED>
<DELETED> (1) In general.--Subpart B of part 7 of subtitle B
of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1021 et seq.) is amended by adding at the end the
following:</DELETED>
<DELETED>``SEC. 726. OVERSIGHT OF ADMINISTRATIVE SERVICE
PROVIDERS.</DELETED>
<DELETED> ``(a) In General.--For plan years beginning on or after
the date that is 2 years after the date of enactment of this section,
no agreement between a group health plan (as defined in section
733(a)), the plan sponsor of such plan (as defined in section
3(16)(B)), the plan administrator of such plan (as defined in section
3(16)(A)), or a business associate of such plan (as defined in section
160.103 of title 45, Code of Federal Regulations), (or health insurance
issuer offering group health insurance coverage in connection with such
a plan), and a health care provider, network or association of
providers, third-party administrator, service provider offering access
to a network of providers, pharmacy benefit managers, or any other
third party (each referred to as a `health plan service provider') is
permissible if such agreement limits (or delays beyond the applicable
reporting period described in subsection (b)(1)) the disclosure of
information to group health plans in such a manner that prevents such
plan, issuer, or entity from providing the information described in
subsection (b).</DELETED>
<DELETED> ``(b) Required Disclosures.--</DELETED>
<DELETED> ``(1) Contents and frequency.--With respect to
plan years beginning on or after the date that is 2 years after
the date of enactment of this section, not less frequently than
quarterly, a health plan service provider shall provide to the
group health plan or health insurance issuer the following
information at no cost to the group health plan or health
insurance issuer:</DELETED>
<DELETED> ``(A) The information described in section
724(a)(1)(B).</DELETED>
<DELETED> ``(B) Any contractual and subcontractual
calculation methodologies, pricing or fee schedules, or
other formulae used to determine reimbursement amounts
to providers and subcontractors, including
methodologies, schedules, fee structures, and any
applied adjustments or modifiers, with such information
provided in a manner sufficiently detailed to enable
the group health plan or health insurance issuer to
accurately assess, verify, and ensure compliance with
the terms of any contractual and subcontractual
agreement governing the reimbursement
amounts.</DELETED>
<DELETED> ``(C) The total amount received or
expected to be received by the health plan service
provider or its subcontractors in provider or supplier
rebates, fees, alternative discounts, and all other
remuneration including amounts held in escrow or
variance accounts that has been paid or is to be paid
for claims incurred and administrative services
including data sales or network payments.</DELETED>
<DELETED> ``(D) The total amount paid or expected to
be paid by the health plan service provider or to
subcontractors in rebates, fees, contractual
arrangements, and all other remuneration that has been
paid or is expected to be paid for administrative and
other services.</DELETED>
<DELETED> ``(E) All payment data and reconciliation
information related to alternative compensation
arrangements including accountable care organizations,
value-based programs, shared savings programs,
incentive compensation, bundled payments, capitation
arrangements, performance payments, and any other
reimbursement or payment models, where the group health
plan or health insurance issuer paid fees, incurred
obligations, or made payments in connection with the
group health plan related to such
arrangements.</DELETED>
<DELETED> ``(2) Privacy requirements.--</DELETED>
<DELETED> ``(A) In general.--Health plan service
providers shall provide the information or data under
paragraph (1) consistent with the privacy, security,
and breach notification regulations at parts 160 and
164 of title 45, Code of Federal Regulations,
promulgated under subtitle F of the Health Insurance
Portability and Accountability Act of 1996, subtitle D
of the Health Information Technology for Clinical
Health Act of 2009, and section 1180 of the Social
Security Act, and shall restrict the use and disclosure
of such information according to such privacy,
security, and breach notification regulations. An
entity that receives a disclosure from a party in
interest pursuant to subparagraph (B) or (C) shall
comply with the privacy and security regulations
promulgated under HIPAA.</DELETED>
<DELETED> ``(B) Restrictions.--A group health plan
shall comply with section 164.504(f) of title 45, Code
of Federal Regulations (or a successor regulation), and
a plan sponsor shall act in accordance with the terms
of the agreement described in such section.</DELETED>
<DELETED> ``(C) Rule of construction.--Nothing in
this section shall be construed to modify the
requirements for the creation, receipt, maintenance, or
transmission of protected health information under the
HIPAA privacy regulations (45 C.F.R. parts 160 and 164,
subparts A and E).</DELETED>
<DELETED> ``(3) Disclosure and redisclosure.--</DELETED>
<DELETED> ``(A) In general.--A group health plan
receiving information under paragraph (1) may disclose
such information only--</DELETED>
<DELETED> ``(i) to the entity from which the
information was received or to that entity's
business associates or to the group health
plan's business associates as defined in
section 160.103 of title 45, Code of Federal
Regulations (or successor regulations);
or</DELETED>
<DELETED> ``(ii) as permitted by the HIPAA
Privacy Rule (45 C.F.R. parts 160 and 164,
subparts A and E).</DELETED>
<DELETED> ``(B) Availability of information.--To the
extent the information required by this subsection is
made available to the health insurance issuer offering
group health insurance in connection with a group
health plan, the health insurance issuer shall make
such information available, at the same time, in the
same format, and at no cost, to the group health
plan.</DELETED>
<DELETED> ``(C) Failure to provide.--The obligation
to provide information pursuant to this subsection
shall exist notwithstanding the presence of any formal
data-sharing agreement between the parties. Failure to
provide the required information as specified shall
constitute a violation of this Act and the Secretary
shall initiate enforcement action under section 502
within 90 days of becoming aware of a violation of this
section, except that nothing in this section shall be
construed to limit the Secretary's existing authority
under the Act.</DELETED>
<DELETED> ``(4) Data format standards.--All data and
information provided pursuant to this subsection shall comply
with the following standards:</DELETED>
<DELETED> ``(A) All claims from a healthcare
provider shall be made to the group health plan in
accordance with transactions standards adopted under
HIPAA, as follows:</DELETED>
<DELETED> ``(i) Institutional, professional,
and dental claims and adjustments to these
claims shall be in ASC X12N 837 format, as
transmitted by the provider, or, in the case of
paper claims, converted to the ASC X12N 837
electronic format.</DELETED>
<DELETED> ``(ii) Prescription drug claims
shall be in the National Council for
Prescription Drug Programs (NCPDP) format, as
transmitted by the provider, or in the case of
paper claims, converted to the NCPDP electronic
format.</DELETED>
<DELETED> ``(iii) Such data shall be
provided at no cost to the group health
plan.</DELETED>
<DELETED> ``(B) All claim payment (or EFT,
electronic funds transfer) and electronic remittance
advice (ERA) information sent by a health plan service
provider shall be provided to the group health plan or
health insurance issuer in the ASC X12N 835 format in
accordance with transaction standards adopted under
HIPAA, unmodified from the form in which it was
transmitted to the healthcare provider. Such
information shall be provided at no cost to the group
health plan or health insurance issuer.</DELETED>
<DELETED> ``(C) The Secretary may modify the
standards set forth in this paragraph as necessary to
align with any changes adopted by the Secretary of
Health and Human Services pursuant to the authority
provided under section 1173 of the Social Security Act
(42 U.S.C. 1320d-2).</DELETED>
<DELETED> ``(c) Prohibited Contractual Provisions.--Any provision in
an agreement between a group health plan, the plan sponsor, the plan
administrator, or a business associate of such plan or a health
insurance issuer and a health plan service provider that unduly delays
or limits a group health plan's or health insurance issuer's access to
information described in this section or that restricts the format or
timing of the provision of such information in a manner that is
inconsistent with the requirements of this section shall be prohibited
and, if a group health plan or health insurance issuer enters into such
agreement, shall be deemed void as against public policy.</DELETED>
<DELETED> ``(d) Penalties for Non-Compliance.--Any failure by a
health plan service provider to comply with the requirements of this
section shall result in the imposition of a civil penalty of $100,000
for each day the violation continues, in addition to any other
penalties prescribed by law.</DELETED>
<DELETED> ``(e) Regulations.--The Secretary shall implement this
section through notice and comment rulemaking in accordance with
section 553 of title 5, United States Code.''.</DELETED>
<DELETED> (2) Penalty.--</DELETED>
<DELETED> (A) In general.--Section 502(a) of the
Employee Retirement Income Security Act of 1974 (29
U.S.C. 1132(a)) is amended by adding at the end the
following new paragraph:</DELETED>
<DELETED> ``(14) The Secretary may assess a civil penalty
against any person of $100,000 per day for each violation by
any person of section 726.''.</DELETED>
<DELETED> (B) Technical amendment.--Paragraph (6) of
section 502(a) of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1132(a)) is amended by
striking ``or (9)'' and inserting it with the phrase
``(9), (13), or (14)''.</DELETED>
<DELETED> (b) PHSA Amendments.--</DELETED>
<DELETED> (1) In general.--Part D of title XXVII of the
Public Health Service Act (42 U.S.C. 300gg-111 et seq.) is
amended by adding at the end the following:</DELETED>
<DELETED>``SEC. 2799A-11. OVERSIGHT OF ADMINISTRATIVE SERVICE
PROVIDERS.</DELETED>
<DELETED> ``(a) In General.--For plan years beginning on or after
the date that is 1 year after the date of enactment of this section, no
agreement between a group health plan that is a self-funded, non-
Federal governmental plan, as defined in section 2791(d)(8)(C) (42
U.S.C. 300gg-91(d)(8)(C)), and a health care provider, network or
association of providers, third-party administrator, service provider
offering access to a network of providers, pharmacy benefit managers,
or any other third party (each referred to in this section as a `health
plan service provider') is permissible if such agreement limits (or
delays beyond the applicable reporting period described in subsection
(b)(1)) the disclosure of information to group health plans in such a
manner that prevents such plan, issuer, or entity from providing the
information described in subsection (b).</DELETED>
<DELETED> ``(b) Required Disclosures.--</DELETED>
<DELETED> ``(1) Contents and frequency.--With respect to
plan years beginning on or after the date that is 1 year after
the date of enactment of this section, not less frequently than
quarterly, a health plan service provider shall provide to the
group health plan that is a self-funded, non-Federal
governmental plan the following information at no cost to the
plan:</DELETED>
<DELETED> ``(A) The information described in section
2799A-9(a)(1)(B) (42 U.S.C. 300gg-
119(a)(1)(B)).</DELETED>
<DELETED> ``(B) Any contractual and subcontractual
calculation methodologies, pricing or fee schedules, or
other formulae used to determine reimbursement amounts
to providers and subcontractors, including
methodologies, schedules, fee structures, and any
applied adjustments or modifiers, with such information
provided in a manner sufficiently detailed to enable
the group health plan to accurately assess, verify, and
ensure compliance with the terms of any contractual and
subcontractual agreement governing the reimbursement
amounts.</DELETED>
<DELETED> ``(C) The total amount received or
expected to be received by the health plan service
provider or its subcontractors in provider or supplier
rebates, fees, alternative discounts, and all other
remuneration including amounts held in escrow or
variance accounts that has been paid or is to be paid
for claims incurred and administrative services
including data sales or network payments.</DELETED>
<DELETED> ``(D) The total amount paid or expected to
be paid by the health plan service provider or to
subcontractors in rebates, fees, contractual
arrangements, and all other remuneration that has been
paid or is expected to be paid for administrative and
other services.</DELETED>
<DELETED> ``(E) All payment data and reconciliation
information related to alternative compensation
arrangements including accountable care organizations,
value-based programs, shared savings programs,
incentive compensation, bundled payments, capitation
arrangements, performance payments, and any other
reimbursement or payment models, where the group health
plan paid fees, incurred obligations, or made payments
in connection with the group health plan related to
such arrangements.</DELETED>
<DELETED> ``(2) Privacy requirements.--</DELETED>
<DELETED> ``(A) In general.--Health plan service
providers shall provide the information or data under
paragraph (1) consistent with the privacy, security,
and breach notification regulations at parts 160 and
164 of title 45, Code of Federal Regulations,
promulgated under subtitle F of the Health Insurance
Portability and Accountability Act of 1996, subtitle D
of the Health Information Technology for Clinical
Health Act of 2009, and section 1180 of the Social
Security Act, and shall restrict the use and disclosure
of such information according to such privacy,
security, and breach notification regulations. An
entity that receives a disclosure from a party in
interest pursuant to subparagraph (B) or (C) shall
comply with the privacy and security regulations
promulgated under HIPAA.</DELETED>
<DELETED> ``(B) Restrictions.--A group health plan
that is a self-funded, non-Federal governmental plan
shall comply with section 164.504(f) of title 45, Code
of Federal Regulations (or a successor regulation), and
a plan sponsor shall act in accordance with the terms
of the agreement described in such section.</DELETED>
<DELETED> ``(C) Rule of construction.--Nothing in
this section shall be construed to modify the
requirements for the creation, receipt, maintenance, or
transmission of protected health information under the
HIPAA privacy regulations (45 C.F.R. parts 160 and 164,
subparts A and E).</DELETED>
<DELETED> ``(3) Disclosure and redisclosure.--</DELETED>
<DELETED> ``(A) In general.--A group health plan
that is a self-funded, non-Federal governmental plan
receiving information under paragraph (1) may disclose
such information only--</DELETED>
<DELETED> ``(i) to the entity from which the
information was received or to that entity's
business associates as defined in section
160.103 of title 45, Code of Federal
Regulations (or successor regulations);
or</DELETED>
<DELETED> ``(ii) as permitted by the HIPAA
Privacy Rule (45 C.F.R. parts 160 and 164,
subparts A and E).</DELETED>
<DELETED> ``(B) Rule of construction.--Nothing in
this section shall be construed to prevent a group
health plan that is a self-funded, non-Federal
governmental plan, or a health plan service provider
providing services with respect to such a plan, from
placing reasonable restrictions on the public
disclosure of the information described in paragraph
(1), except that such plan or entity may not restrict
disclosure of such information to the Department of
Health and Human Services, the Department of Labor, the
Department of the Treasury, or the Comptroller General
of the United States.</DELETED>
<DELETED> ``(C) Failure to provide.--The obligation
to provide information pursuant to this subsection
shall exist notwithstanding the presence of any formal
data-sharing agreement between the parties. Failure to
provide the required information as specified shall
constitute a violation of this Act and the Secretary
shall initiate enforcement action under section 2723(b)
(42 U.S.C. 300gg-22(b)) within 90 days of becoming
aware of a violation of this section, except that
nothing in this section shall be construed to limit the
Secretary's existing authority under this
Act.</DELETED>
<DELETED> ``(4) Data format standards.--All data and
information provided pursuant to this subsection shall comply
with the following standards:</DELETED>
<DELETED> ``(A) All claims from a healthcare
provider shall be made to the group health plan in
accordance with standards adopted under HIPAA at
section 162.1101 of title 45, Code of Federal
Regulations, as follows:</DELETED>
<DELETED> ``(i) Institutional, professional,
and dental claims and adjustments to these
claims shall be provided to the group health
plan that is a self-funded, non-Federal
governmental plan in the ASC X12N 837
format.</DELETED>
<DELETED> ``(ii) Prescription drug claims
shall be in the National Council for
Prescription Drug Programs (NCPDP)
format.</DELETED>
<DELETED> ``(iii) The files shall be
unmodified copies of the files sent from the
provider. In the event that paper claims are
sent by the provider, they shall be converted
to the appropriate standard electronic format.
Such data shall be provided at no cost to the
group health plan.</DELETED>
<DELETED> ``(B) All claim payment (or EFT,
electronic funds transfer) and electronic remittance
advice (ERA) information sent by a health plan service
provider shall be provided to the group health plan or
health insurance issuer in the ASC X12N 835 format, in
accordance with standards adopted under HIPAA at
section 162.1602 of title 45, Code of Federal
Regulations, unmodified from the form in which it was
transmitted to the healthcare provider. Such
information shall be provided at no cost to the group
health plan.</DELETED>
<DELETED> ``(C) The Secretary may modify the
standards set forth in this paragraph as necessary to
align with any changes adopted by the Secretary
pursuant to the authority provided under section 1173
of the Social Security Act (42 U.S.C. 1320d-
2).</DELETED>
<DELETED> ``(c) Prohibited Contractual Provisions.--Any provision in
an agreement that unduly delays or limits a group health plan that is a
self-funded, non-Federal governmental plan's access to information
described in this section or that restricts the format or timing of the
provision of such information in a manner that is inconsistent with the
requirements of this section shall be prohibited and, if a self-funded,
non-Federal governmental plan enters into such agreement, shall be
deemed void as against public policy.</DELETED>
<DELETED> ``(d) Regulations.--The Secretary shall implement this
section through notice and comment rulemaking in accordance with
section 553 of title 5, United States Code.''.</DELETED>
<DELETED> (2) Penalty.--Section 2723(b) of the Public Health
Service Act (42 U.S.C. 300gg-22(b)) is amended by adding at the
end the following:</DELETED>
<DELETED> ``(4) Enforcement authority relating to health
plan service providers.--Notwithstanding any provisions to the
contrary, the Secretary may assess a penalty against a health
plan service provider, as defined in section 2799A-11(a) (42
U.S.C. 300gg-121(a)), of $100,000 per day for each violation of
such section, pursuant to substantially similar processes and
procedures as those set forth in section 2723(b)(2)(D) through
(G) (42 U.S.C. 300gg-121(b)(2)(D) through (G)).''.</DELETED>
<DELETED>SEC. 9. STATE PREEMPTION ONLY IN EVENT OF CONFLICT.</DELETED>
<DELETED> The provisions of sections 2 through 5 (including the
amendments made by such sections) shall not supersede any provision of
State law which establishes, implements, or continues in effect any
requirement or prohibition related to health care price transparency,
including hospital, clinical diagnostic laboratory tests, imaging
services, and ambulatory surgical center, except to the extent that
such requirement or prohibition prevents the application of a
requirement or prohibition of such sections (or amendment). Nothing in
this section shall be construed to affect group health plans
established under the Employee Retirement Income Security Act of 1974,
or alter the application of section 514 of such Act (29 U.S.C.
1144).</DELETED>
<DELETED>SEC. 10. REQUIREMENT FOR EXPLANATION OF BENEFITS.</DELETED>
<DELETED> (a) PHSA Amendments.--</DELETED>
<DELETED> (1) Emergency services.--Section 2799A-1(f)(1)(C)
of the Public Health Service Act (42 U.S.C. 300gg-111(f)(1)(C))
is amended to read as follows:</DELETED>
<DELETED> ``(C) A good faith estimate of the amount
the plan or coverage is responsible for paying for
items and services included in the estimate described
in subparagraph (B), including a plain language
description of each item or service and all applicable
billing codes for each item or service, including
modifiers, using standard and commonly recognized
billing code sets that are clearly
identified.''.</DELETED>
<DELETED> (2) Explanation of benefits.--Section 2799A-1 of
the Public Health Service Act (42 U.S.C. 300gg-111) is amended
by adding at the end the following:</DELETED>
<DELETED> ``(g) Explanation of Benefits.--</DELETED>
<DELETED> ``(1) In general.--For plan years beginning on or
after January 1, 2026, each group health plan, or a health
insurance issuer offering group or individual health insurance
coverage shall, within 45 days of receiving any request for
payment for an item or service under the plan, provide to the
participant, beneficiary, or enrollee (through mail or
electronic means, as requested by the participant, beneficiary,
or enrollee) a notification (in clear and understandable
language and utilizing substantially the same format as the
advanced explanation of benefits required by subsection (f) to
enable comparison) including the following:</DELETED>
<DELETED> ``(A) Whether or not the provider or
facility is a participating provider or a participating
facility with respect to the plan or coverage with
respect to the furnishing of such item or
service.</DELETED>
<DELETED> ``(B) An itemized explanation of benefits
that includes the following:</DELETED>
<DELETED> ``(i) A plain language description
of each item or service.</DELETED>
<DELETED> ``(ii) All applicable billing
codes for each item or service, including
modifiers, using standard and commonly
recognized billing code sets that are clearly
identified.</DELETED>
<DELETED> ``(iii) The amount the plan or
coverage is responsible for paying for each
item or service.</DELETED>
<DELETED> ``(iv) The amount of any cost-
sharing for which the participant, beneficiary,
or enrollee is responsible for each item or
service (as of the date of such
notification).</DELETED>
<DELETED> ``(v) The amount that the
participant, beneficiary, or enrollee has
incurred toward meeting the limit of the
financial responsibility (including with
respect to deductibles and out-of-pocket
maximums) under the plan or coverage (as of the
date of such notification).</DELETED>
<DELETED> ``(vi) The site of each item or
service.</DELETED>
<DELETED> ``(2) Format.--If applicable, the notification
described in paragraph (1) may be provided in conjunction with,
or as part of, a notice of a claim determination or other
communication required by section 2719(a) (42 U.S.C. 300gg-
19(a)), or regulations thereunder.</DELETED>
<DELETED> ``(h) Regulations.--The Secretary shall implement this
section through notice and comment rulemaking in accordance with
section 553 of title 5, United States Code.''.</DELETED>
<DELETED> (b) IRC Amendments.--</DELETED>
<DELETED> (1) Emergency services.--Section 9816(f)(1)(C) of
the Internal Revenue Code of 1986 is amended to read as
follows:</DELETED>
<DELETED> ``(C) A good faith estimate of the amount
the plan is responsible for paying for items and
services included in the estimate described in
subparagraph (B), including a plain language
description of each item or service and all applicable
billing codes for each item or service, including
modifiers, using standard and commonly recognized
billing code sets that are clearly
identified.''.</DELETED>
<DELETED> (2) Explanation of benefits.--Section 9816 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following:</DELETED>
<DELETED> ``(g) Explanation of Benefits.--</DELETED>
<DELETED> ``(1) In general.--For plan years beginning on or
after January 1, 2026, each group health plan shall, within 45
days of receiving any request for payment for an item or
service under the plan, provide to the participant or
beneficiary (through mail or electronic means, as requested by
the participant or beneficiary) a notification (in clear and
understandable language and utilizing substantially the same
format as the advanced explanation of benefits required by
subsection (f) to enable comparison) including the
following:</DELETED>
<DELETED> ``(A) Whether or not the provider or
facility is a participating provider or a participating
facility with respect to the plan with respect to the
furnishing of such item or service.</DELETED>
<DELETED> ``(B) An itemized explanation of benefits
that includes the following:</DELETED>
<DELETED> ``(i) A plain language description
of each item or service.</DELETED>
<DELETED> ``(ii) All applicable billing
codes for each item or service, including
modifiers, using standard and commonly
recognized billing code sets that are clearly
identified.</DELETED>
<DELETED> ``(iii) The amount the plan is
responsible for paying for each item or
service.</DELETED>
<DELETED> ``(iv) The amount of any cost-
sharing for which the participant or
beneficiary is responsible for each item or
service (as of the date of such
notification).</DELETED>
<DELETED> ``(v) The amount that the
participant or beneficiary has incurred toward
meeting the limit of the financial
responsibility (including with respect to
deductibles and out-of-pocket maximums) under
the plan (as of the date of such
notification).</DELETED>
<DELETED> ``(vi) The site of each item or
service.</DELETED>
<DELETED> ``(2) Format.--If applicable, the notification
described in paragraph (1) may be provided in conjunction with,
or as part of, a notice of a claim determination or other
communication required by section 503 of the Employee
Retirement Income Security Act of 1974 or regulations
thereunder.</DELETED>
<DELETED> ``(h) Regulations.--The Secretary shall implement this
section through notice and comment rulemaking in accordance with
section 553 of title 5, United States Code.''.</DELETED>
<DELETED> (c) ERISA Amendments.--</DELETED>
<DELETED> (1) Emergency services.--Section 716(f)(1)(C) of
the Employee Retirement Income Security Act of 1974 (29 U.S.C.
1185e(f)(1)(C)) is amended to read as follows:</DELETED>
<DELETED> ``(C) A good faith estimate of the amount
the health plan is responsible for paying for items and
services included in the estimate described in
subparagraph (B), including a plain language
description of each item or service and all applicable
billing codes for each item or service, including
modifiers, using standard and commonly recognized
billing code sets that are clearly
identified.''.</DELETED>
<DELETED> (2) Explanation of benefits.--Section 716 of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1185e) is amended by adding at the end the following:</DELETED>
<DELETED> ``(g) Explanation of Benefits.--</DELETED>
<DELETED> ``(1) In general.--For plan years beginning on or
after January 1, 2026, each group health plan or health
insurance issuer offering group health insurance coverage
shall, within 45 days of receiving any request for payment for
an item or service under the plan, provide to the participant
or beneficiary (through mail or electronic means, as requested
by the participant or beneficiary) a notification (in clear and
understandable language and utilizing substantially the same
format as the advanced explanation of benefits required by
subsection (f) to enable comparison) including the
following:</DELETED>
<DELETED> ``(A) Whether or not the provider or
facility is a participating provider or a participating
facility with respect to the plan or coverage with
respect to the furnishing of such item or
service.</DELETED>
<DELETED> ``(B) An itemized explanation of benefits
that includes the following:</DELETED>
<DELETED> ``(i) A plain language description
of each item or service.</DELETED>
<DELETED> ``(ii) All applicable billing
codes for each item or service, including
modifiers, using standard and commonly
recognized billing code sets that are clearly
identified.</DELETED>
<DELETED> ``(iii) The amount the plan or
coverage is responsible for paying for each
item or service.</DELETED>
<DELETED> ``(iv) The amount of any cost-
sharing for which the participant or
beneficiary is responsible for each item or
service (as of the date of such
notification).</DELETED>
<DELETED> ``(v) The amount that the
participant or beneficiary has incurred toward
meeting the limit of the financial
responsibility (including with respect to
deductibles and out-of-pocket maximums) under
the plan or coverage (as of the date of such
notification).</DELETED>
<DELETED> ``(vi) The site of each item or
service.</DELETED>
<DELETED> ``(2) Format.--If applicable, the notification
described in paragraph (1) may be provided in conjunction with,
or as part of, a notice of a claim determination or other
communication required by section 503 or regulations
thereunder.</DELETED>
<DELETED> ``(h) Regulations.--The Secretary shall implement this
section through notice and comment rulemaking in accordance with
section 553 of title 5, United States Code.''.</DELETED>
<DELETED>SEC. 11. PROVISION OF ITEMIZED BILLS.</DELETED>
<DELETED> Part E of title XXVII of the Public Health Service Act (42
U.S.C. 300gg-131 et seq.) is amended by adding at the end the
following:</DELETED>
<DELETED>``SEC. 2799B-10. PROVIDER REQUIREMENTS FOR ITEMIZED
BILLS.</DELETED>
<DELETED> ``(a) Requirements.--</DELETED>
<DELETED> ``(1) Itemized bill and other information
required.--</DELETED>
<DELETED> ``(A) In general.--A health care provider
or health care facility that requests payment from an
individual after providing a health care item or
service to the patient shall include with such request
a written, itemized bill of the cost of each reasonably
expected item or service the health care provider or
health care facility provided to the individual,
including telehealth visits or visits by other
electronic means. The health care provider or health
care facility shall provide the itemized bill not later
than 30 days after the health care provider or health
care facility received a final payment on the provided
service or supply from a third party.</DELETED>
<DELETED> ``(B) Required information.--For each item
or service provided by the health care provider or
facility or for which the health care provider or
facility is billing the individual, the itemized bill
must include--</DELETED>
<DELETED> ``(i) a plain language description
of each distinct health care item or
service;</DELETED>
<DELETED> ``(ii) all applicable billing
codes for each distinct health care item or
service, including modifiers, using standard
and commonly recognized billing code sets that
are clearly identified;</DELETED>
<DELETED> ``(iii) the price and billed
amount, if different, of each distinct health
care item or service or if the provider or
facility is offering binding, all-in prices for
bundled items and services, the total binding
price for bundled items and services and billed
amount;</DELETED>
<DELETED> ``(iv) any payments made to the
health care provider or health care facility by
or on behalf of the individual (including
payments by any health plan or insurance) for
any health care item or service covered in the
itemized bill;</DELETED>
<DELETED> ``(v) information about the
availability of language-assistance services
for individuals with limited English
proficiency (LEP);</DELETED>
<DELETED> ``(vi) the identification of an
office or individual at the health care
provider or health care facility, including
phone number and email address, that shall be
able to discuss the specific details of the
itemized statement and be authorized to make
appropriate changes thereto; and</DELETED>
<DELETED> ``(vii) information about the
health care provider's or health care
facility's charity care policies and
instructions on how to apply for charity
care.</DELETED>
<DELETED> ``(2) Collections actions.--</DELETED>
<DELETED> ``(A) In general.--A health care provider
or health care facility shall not take any collections
actions against an individual--</DELETED>
<DELETED> ``(i) for any provided health care
item or service unless the health care provider
or health care facility has complied with
paragraph (1); or</DELETED>
<DELETED> ``(ii) with respect to any items
or services for which the amount appearing on
an itemized bill described above in paragraph
(1) exceeds the amount disclosed pursuant to
Federal health care price transparency
regulations, including part 180 of title 45,
Code of Federal Regulations, or provided in a
good faith estimate that complies with section
2799B-6 of this Act and section 149.610 of
title 45, Code of Federal Regulations, or
another good faith estimate provided by a
health care entity covered under this section
but not otherwise covered under such section
2799B-6 unless the provider or facility
documents that the additional items or services
were medically necessary due to unforeseen
complications or a patient-initiated change,
and could not reasonably have been
anticipated.</DELETED>
<DELETED> ``(B) Burden of proof.--The burden of
proof under subparagraph (A)(ii) shall rest with the
provider, and absent the documentation described in
such subparagraph, the good faith estimate shall be
binding.</DELETED>
<DELETED> ``(b) Failure To Comply.--</DELETED>
<DELETED> ``(1) Penalties.--The Secretary shall impose
penalties on any health care provider or health care facility
that fails to comply with the requirements of this section in
an amount not to exceed $10,000 for each instance of failure to
comply.</DELETED>
<DELETED> ``(2) Presumption in favor of individual.--If a
health care provider or health care facility fails to comply
with the requirements of this section, the presumption shall be
that charges were substantially in excess of the good faith
estimate (as set forth in section 2799B-6) for the purpose of
any patient-provider dispute, including in accordance with
section 2799B-7 and regulations promulgated
thereunder.</DELETED>
<DELETED> ``(c) Regulations.--The Secretary shall implement this
section through notice and comment rulemaking in accordance with
section 553 of title 5, United States Code.''.</DELETED>
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Patients Deserve Price Tags Act''.
SEC. 2. STRENGTHENING HOSPITAL PRICE TRANSPARENCY.
Title XXVII of the Public Health Service Act is amended by
inserting after section 2718 (42 U.S.C. 300gg-18) the following:
``SEC. 2718A. PROVIDER PRICE TRANSPARENCY.
``(a) Definitions.--In this section:
``(1) Applicable imaging service provider.--The term
`applicable imaging provider' means a provider of services or
supplier who furnishes any imaging services to patients,
including an independent diagnostic testing facility, an
outpatient diagnostic facility, and any other imaging center
designated by the Secretary, except that such term does not
include an imaging service provider with respect to which
standard charges for specified imaging service provider
services furnished by such service provider are made available
by a hospital pursuant to subsection (b) or specified
ambulatory surgical center pursuant to subsection (e).
``(2) Applicable laboratory.--The term `applicable
laboratory' means a `laboratory' as such term is defined in
section 493.2, 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 for specified
clinical diagnostic laboratory tests furnished by such
laboratory are made available by a hospital pursuant to
subsection (b) or specified ambulatory surgical center pursuant
to subsection (e).
``(3) Discounted cash price.--
``(A) In general.--The term `discounted cash price'
means the minimum charge expressed as a dollar amount,
subject to subparagraph (B), that the applicable
service provider subject to this section accepts from
an individual who pays cash, or cash equivalent, for a
furnished item or service, without regard to health
insurance coverage, as payment in full.
``(B) Exclusions.--For purposes of subparagraph
(A), the minimum charge described in such subparagraph,
with respect to a furnished item or service, as
applicable, shall be calculated without taking into
account any financial assistance, including assistance
attributable to charity care (in the case of a
hospital, as such term is used for purposes of hospital
cost reporting under title XVIII of the Social Security
Act), or third-party assistance for such item or
service.
``(4) Extraordinary collection actions.--The term
`extraordinary collection action' has the meaning given such
term for purposes of section 501(r) of the Internal Revenue
Code of 1986.
``(5) Gross charge.--The term `gross charge' means the
charge for an individual item or service that is reflected on a
hospital's chargemaster or similar list of prices facilitated
by any other provider, as defined by the Secretary, absent any
discounts.
``(6) Hospital.--The term `hospital' means an institution
in any State in which State or applicable local law provides
for the licensing of hospitals, that is licensed as a hospital
pursuant to such law or is approved, by the agency of such
State or locality responsible for licensing hospitals, as
meeting the standards established for such licensing. For
purposes of this paragraph, the term `State' includes each of
the several States, the District of Columbia, Puerto Rico, the
Virgin Islands, Guam, American Samoa, and the Northern Mariana
Islands.
``(7) Payer-specific negotiated charge.--The term `payer-
specific negotiated charge' means the charge that a hospital
has negotiated with a third-party payer for an item or service.
``(8) Shoppable service.--The term `shoppable service'
means a service that can be scheduled by a healthcare consumer
in advance. Such services are routinely provided in non-urgent
situations that do not require immediate action or attention to
the patient, thus allowing patients to price shop and schedule
a service at a time that is convenient for them.
``(9) Specified ambulatory surgical center.--The term
`specified ambulatory surgical center' means any distinct
entity that operates exclusively for the purpose of providing
surgical services to patients not requiring hospitalization and
in which the expected duration of services would not exceed 24
hours following an admission, except that such term does not
include a surgical center with respect to which standard
charges for specified ambulatory surgical center services
furnished by such surgical center are made available by a
hospital pursuant to subsection (b).
``(10) Specified clinical diagnostic laboratory test.--The
term `specified clinical diagnostic laboratory test' means any
clinical diagnostic laboratory test or service that is provided
by the applicable laboratory, excluding advanced diagnostic
laboratory tests (as defined in section 1834A(d)(5) of the
Social Security Act).
``(11) Specified imaging service.--The term `specified
imaging service' has the meaning given to the term `radiology
and certain other imaging services' for purposes of section
411.351 of title 42, Code of Federal Regulations (or successor
regulations).
``(12) Third party payer.--The term `third party payer'
means an entity that is, by statute, contract, or agreement,
legally responsible for payment of a claim for a health care
item or service.
``(b) Hospital Price Transparency.--
``(1) In general.--Beginning January 1 of the year that
begins on or after the date that is 1 year after the date of
enactment of the Patients Deserve Price Tags Act, each hospital
shall, in accordance with a method and format established by
the Secretary under paragraph (3), on a quarterly basis (if
there have been any changes to the standard charges described
in subparagraph (2) compile and make publicly available on an
internet website (without subscription and free of charge)--
``(A) all of the hospital's standard charges for
each item and service furnished by such hospital in a
machine-readable format (or a successor technology
specified by the Secretary);
``(B) all of the hospital's standard charges in a
consumer-friendly format (as specified by the
Secretary), that includes--
``(i) 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
through the January 1 described in this
subparagraph, after which the hospital shall
include all shoppable services that the
hospital furnishes; and
``(ii) 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; and
``(C) the name and business address for each person
or entity that, with respect to the hospital--
``(i) has an ownership or investment
interest;
``(ii) has a controlling interest;
``(iii) is a management services
organization; or
``(iv) is a significant equity investor.
``(2) Standard charges defined.--For purposes of paragraph
(1), the term `standard charges' means the following:
``(A) A plain language description of each item and
service, accompanied by any applicable billing codes,
including modifiers, using commonly recognized billing
code sets, including--
``(i) the Diagnosis Related Group;
``(ii) the Healthcare Common Procedure
Coding System code;
``(iii) the National Drug Code; and
``(iv) other applicable identifiers as
determined by the Secretary (or successor code
sets).
``(B) The gross charge, expressed as a dollar
amount, for each such item or service, when provided
in, as applicable, the inpatient setting and outpatient
department setting.
``(C) The discounted cash price.
``(D) The payer-specific negotiated charges,
expressed as a dollar amount and clearly associated
with the name of the applicable third-party payer and
name of each plan, that apply to each such item or
service when provided in, as applicable, the inpatient
setting and outpatient department setting. If the
charges are based on an algorithm, percentage of
another amount, or other formula or criteria, the
hospital shall also disclose such algorithm,
percentage, formula, or criteria as set forth in its
contract and any other information necessary to
determine the negotiated charge as a dollar amount.
``(E) The de-identified maximum and minimum
negotiated charges for each such item or service,
expressed as a non-zero dollar amount.
``(F) The amount of any facility fee, as defined by
the Secretary, or add-on charges that will be part of
the final payment amount, in addition to any
information that might help the patient understand when
a facility fee or add-on charge may apply and how to
avoid such charges.
``(G) Any other additional information the
Secretary may require for the purpose of improving the
accuracy of, or enabling consumers to easily understand
and compare, standard charges for an item or service,
except information that is duplicative of any other
reporting requirement under this subsection. In the
case of standard charges 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.
``(3) Uniform method and format.--The Secretary shall
establish a standard, uniform method and format for hospitals
to use in compiling and making public information described in
paragraph (1). Such method and format shall--
``(A) include a machine-readable format (or
successor technology specified by the Secretary)
containing the information described in paragraph (2)
for all items and services furnished by each hospital;
``(B) meet such standards as determined appropriate
by the Secretary in order to ensure the accessibility
and usability of such charges; and
``(C) be updated as determined appropriate by the
Secretary, in consultation with stakeholders.
``(4) No deemed compliance.--Hospitals may offer a price
estimator tool, but the availability of such a price estimator
tool shall not be considered to deem compliance with or
otherwise vitiate the requirements of paragraph (1)(B) or any
other requirements of this subsection.
``(5) Monitoring compliance.--The Secretary shall, in
consultation with the Inspector General of the Department of
Health and Human Services, establish a process to monitor
compliance with this subsection. Such process shall ensure that
each hospital's compliance with this subsection is reviewed not
less frequently than once every year.
``(6) Attestation.--A senior official from each hospital
(the Chief Executive Officer, Chief Financial Officer, or an
official of equivalent seniority) shall attest to the accuracy
and completeness of the disclosures, and any other attestations
as required by the Secretary, made in accordance with the
hospital price transparency requirements based on criteria
established by the Secretary.
``(7) Enforcement.--
``(A) In general.--In the case of a hospital that
fails to comply with the requirements of this
subsection, not later than 30 days after the date on
which the Secretary determines such failure exists, the
Secretary shall notify such hospital of such
determination, which shall include a request for a
corrective action plan if applicable to comply with
such requirements.
``(B) Civil monetary penalty.--
``(i) In general.--In addition to any other
enforcement actions or penalties that may apply
under another provision of law, a hospital that
has received a request for a corrective action
plan under subparagraph (A) and fails to comply
with the requirements of this subsection by the
date that is 90 days after such request is made
shall be subject to a civil monetary penalty of
an amount specified by the Secretary for each
day (beginning on the day the hospital was
first out of compliance, as determined by the
Secretary) during which such failure was
ongoing. Such amount shall not exceed--
``(I) in the case of a specified
hospital with 30 or fewer beds, $300
per day (or, in the case of such a
hospital that has been noncompliant
with such requirements for a 1-year
period or longer, beginning with the
first day following such 1-year period,
$400 per day);
``(II) in the case of a specified
hospital with more than 30 beds but
fewer than 101 beds, $12.50 per bed per
day (or, in the case of such a hospital
that has been noncompliant with such
requirements for a 1-year period or
longer, beginning with the first day
following such 1-year period, $15 per
bed per day);
``(III) in the case of a specified
hospital with more than 100 beds but
fewer than 201 beds, $17.50 per bed per
day (or, in the case of such a hospital
that has been noncompliant with such
requirements for a 1-year period or
longer, beginning with the first day
following such 1-year period, $20 per
bed per day);
``(IV) in the case of a specified
hospital with more than 200 beds but
fewer than 501 beds, $20 per bed per
day (or, in the case of such a hospital
that has been noncompliant with such
requirements for a 1-year period or
longer, beginning with the first day
following such 1-year period, $25 per
bed per day); and
``(V) in the case of a specified
hospital with more than 500 beds, $25
per bed per day (or, in the case of
such a hospital that has been
noncompliant with such requirements for
a 1-year period or longer, beginning
with the first day following such 1-
year period, $35 per bed per day).
``(ii) Increase authority.--In applying
this subparagraph with respect to hospitals
that fail to comply in 2028 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
hospital under clause (i)(I);
``(II) the limitations on the per
bed per day amount of any penalty
applicable under any of subclauses (II)
through (V) of clause (i); and
``(III) the limitation on the
increase of any penalty applied under
clause (iii) pursuant to the amounts
specified in subclause (II) of such
clause.
``(iii) Persistent noncompliance.--
``(I) In general.--In the case of a
hospital that the Secretary has
determined to be noncompliant with the
provisions of this subsection two or
more times during a 1-year period (as
determined by the Secretary), 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 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) Provision of technical assistance.--
The Secretary may, to the extent practicable,
provide technical assistance relating to
compliance with the provisions of this section
to hospitals requesting such assistance.
``(v) Application of certain provisions.--
The provisions of section 1128A of the Social
Security Act (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) No authority to waive or reduce penalty.--The
Secretary shall not grant or extend any waiver, delay,
tolling, or other mitigation of a civil monetary
penalty for failing to comply with the requirements of
this subsection except where the Secretary determines
that imposing the maximum civil monetary penalty,
including penalties for persistent noncompliance, will
disrupt hospital operations in a manner that impacts
patient care. The Secretary may request documentation
in such form and manner as the Secretary may require in
order to evaluate impact on hospital operations.
``(D) Prohibition on extraordinary collection.--In
addition to civil monetary penalties applicable under
subparagraph (B) and any other enforcement actions or
penalties that may apply under any other provision of
law, for a hospital that has received a request for a
corrective action plan under subparagraph (A) and fails
to comply with the requirements of this subsection by
the date that is 90 days after such request, that
hospital or any other person or entity collecting on
behalf of the hospital shall--
``(i) not take any extraordinary collection
actions against any patient or patient
guarantor for debt incurred by any patient on
the date or dates of service when the hospital
was not in compliance with the requirements of
this subsection;
``(ii) cease any extraordinary collection
actions that have begun against any patient or
patient guarantor for debt incurred by any
patient on the date or dates of service when
the hospital was not in compliance with the
requirements of this subsection; and
``(iii) not take any extraordinary
collection actions against any patient or
patient guarantor for debt incurred by any
patient on the date or dates of service when
the hospital was not in compliance with the
requirements of this subsection after the
hospital comes back into compliance with the
requirements of this subsection.
``(8) Rulemaking.--
``(A) In general.--The Secretary shall implement
this subsection through notice and comment rulemaking
in accordance with section 553 of title 5, United
States Code.
``(B) Ownership information.--In promulgating
regulations under this paragraph, the Secretary shall
define the individuals and organizations that must be
disclosed under paragraph (1)(C) in a manner that
harmonizes disclosure requirements with requirements
established under section 1124 of the Social Security
Act and prioritizes the disclosure of individuals and
organizations who's ownership or management
relationship with a hospital impacts operational,
financial, or clinical decision making for such
hospital.''.
SEC. 3. CLINICAL DIAGNOSTIC LABORATORY PRICE TRANSPARENCY.
Section 2718A of the Public Health Service Act, as added by section
2, is amended by adding at the end the following:
``(c) Clinical Diagnostic Laboratory Price Transparency.--
``(1) In general.--Beginning January 1 of the year that
begins on or after the date that is 1 year after the date of
enactment of the Patients Deserve Price Tags Act, an applicable
laboratory shall, on a quarterly basis (if there have been any
changes to the standard charges described in paragraph (2))
compile and make publicly available on an internet website
(without subscription and free of charge)--
``(A) the standard charges described in paragraph
(2) with respect to each specified clinical diagnostic
laboratory test that such laboratory so furnishes; and
``(B) the name and business address for each person
or entity that, with respect to the laboratory--
``(i) has an ownership or investment
interest;
``(ii) has a controlling interest;
``(iii) is a management services
organization; or
``(iv) is a significant equity investor.
``(2) Standard charges defined.--For purposes of paragraph
(1), the term `standard charges' means, with respect to an
applicable laboratory and a specified clinical diagnostic
laboratory test, the following:
``(A) A plain language description of each item or
service, accompanied by any applicable billing codes
(including modifiers that materially change the price
for insurers or providers, and that materially change
out-of-pocket costs for consumers) using commonly
recognized billing code sets, including--
``(i) the Healthcare Common Procedure
Coding System code;
``(ii) the National Drug Code; or
``(iii) other applicable identifier as
determined by the Secretary (or successor code
sets).
``(B) The gross charge expressed as a dollar
amount, for each such test.
``(C) The discounted cash price.
``(D) The payer-specific negotiated charges,
expressed as a dollar amount and clearly associated
with the name of the applicable third-party payer and
name of each plan, that apply to each such test. If the
charges are based on an algorithm, percentage of
another amount, or other formula or criteria, the
applicable laboratory also shall disclose such
algorithm, percentage, formula, or criteria as set
forth in its contract and any other information
necessary to determine the negotiated charge as a
dollar amount.
``(E) The de-identified maximum and minimum
negotiated charges for each such item or service,
expressed as a non-zero dollar amount.
``(F) Any other additional information the
Secretary may require for the purpose of improving the
accuracy of, or enabling consumers to easily understand
and compare, standard charges for an item or service,
except information that is duplicative of any other
reporting requirement under this section. In the case
of standard charges 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.
``(3) Uniform method and format.--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 shall--
``(A) include a machine-readable format (or a
successor technology specified by the Secretary)
containing the information described in paragraph (2)
for all specified clinical diagnostic laboratory tests
furnished by each laboratory and the ownership
information described in paragraph (1)(B);
``(B) meet such standards as determined appropriate
by the Secretary in order to ensure the accessibility
and usability of such information; and
``(C) be updated as determined appropriate by the
Secretary, in consultation with stakeholders.
``(4) Monitoring compliance.--The Secretary shall, in
consultation with the Inspector General of the Department of
Health and Human Services, establish a process to monitor
compliance with this subsection. Such process shall ensure that
each applicable laboratory's compliance with this subsection is
reviewed not less frequently than once every year.
``(5) Inclusion of ancillary services.--Any charge for a
specified clinical diagnostic laboratory test furnished by an
applicable laboratory made publicly available in accordance
with paragraph (1) shall include the charge for any ancillary
item or service (such as specimen collection services, specimen
transport, centrifugation, aliquoting, labeling, requisition
processing, and standard result reporting services) that would
customarily and routinely be furnished by such laboratory as
part of such test, as specified by the Secretary.
``(6) Attestation.--A senior official from each clinical
diagnostic laboratory (the Chief Executive Officer, Chief
Financial Officer, or an official of equivalent seniority)
shall attest to the accuracy and completeness of the
disclosures, and any other attestations as required by the
Secretary, made in accordance with the clinical laboratory
price transparency requirements based on criteria established
by the Secretary.
``(7) Enforcement.--
``(A) In general.--In the case of an applicable
laboratory that fails to comply with the requirements
of this subsection--
``(i) the Secretary shall notify such
laboratory of such failure not later than 30
days after the date on which the Secretary
determines such failure exists; and
``(ii) upon request of the Secretary, such
laboratory shall submit to the Secretary, not
later than 45 days after the date of such
request, a corrective action plan to comply
with such requirements.
``(B) Civil monetary penalty.--
``(i) In general.--An applicable laboratory
that has received a notification under
subparagraph (A)(i) and fails to comply with
the requirements of this subsection by the date
that is 90 days after such notification (or, in
the case of an applicable laboratory that has
submitted a corrective action plan described in
subparagraph (A)(ii) in response to a request
so described, by the date that is 90 days after
such submission) shall be subject to a civil
monetary penalty of an amount specified by the
Secretary for each day (beginning with the day
on which the Secretary first determined that
such laboratory was not complying with such
requirements) during which such failure is
ongoing (not to exceed $300 per day).
``(ii) Increase authority.--In applying
this subparagraph with respect to an applicable
laboratory that fails to comply with the
requirements of this subsection in 2028 or a
subsequent year, the Secretary may through
notice and comment rulemaking increase the
limitation on the per day amount of any penalty
applicable to an applicable laboratory under
clause (i).
``(iii) Application of certain
provisions.--The provisions of section 1128A of
the Social Security Act (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) No authority to waive or reduce
penalty.--The Secretary shall not grant or
extend any waiver, delay, tolling, or other
mitigation of a civil monetary penalty for
failing to comply with the requirements of this
subsection except where the Secretary
determines that imposing the maximum civil
monetary penalty will disrupt applicable
laboratory operations in a manner that impacts
patient care. The Secretary may request
documentation in such form and manner as the
Secretary may require in order to evaluate
impact on applicable laboratory operations.
``(8) 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.
``(9) Rulemaking.--
``(A) In general.--The Secretary shall implement
this subsection through notice and comment rulemaking
in accordance with section 553 of title 5, United
States Code.
``(B) Ownership information.--In promulgating
regulations under this paragraph, the Secretary shall
define the individuals and organizations that must be
disclosed under paragraph (1)(C) in a manner that
harmonizes disclosure requirements with requirements
established under section 1124 of the Social Security
Act and prioritizes the disclosure of individuals and
organizations who's ownership or management
relationship with a hospital impacts operational,
financial, or clinical decision making for such
hospital.''.
SEC. 4. IMAGING SERVICES PRICE TRANSPARENCY.
Section 2718A of the Public Health Service Act, as amended by
section 3, is further amended by adding at the end the following:
``(d) Imaging Services Price Transparency.--
``(1) In general.--Beginning January 1 of the year that
begins on or after the date that is 1 year after the date of
enactment of the Patients Deserve Price Tags Act, each
applicable imaging service provider shall, on a quarterly basis
(if there have been any changes to the standard charges
described in paragraph (2)) compile and make publicly available
on an internet website (without subscription and free of
charge)--
``(A) the standard charges described in paragraph
(2) with respect to each such specified imaging service
provided by such provider; and
``(B) the name and business address for each person
or entity that, with respect to the imaging services
provider--
``(i) has an ownership or investment
interest;
``(ii) has a controlling interest;
``(iii) is a management services
organization; or
``(iv) is a significant equity investor.
``(2) Standard charges defined.--For purposes of paragraph
(1), the term `standard charges', with respect to an applicable
imaging service provider and a specified imaging service, means
the following:
``(A) A plain language description of each item or
service, accompanied by any applicable billing codes
(including modifiers that materially change the price
for insurers or providers, and that materially change
out-of-pocket costs for consumers) using commonly
recognized billing code sets, including--
``(i) the Healthcare Common Procedure
Coding System code;
``(ii) the National Drug Code; or
``(iii) other applicable identifier as
determined by the Secretary (or successor code
sets).
``(B) The gross charge expressed as a dollar
amount, for each such item or service.
``(C) The discounted cash price.
``(D) The payer-specific negotiated charges,
expressed as a dollar amount and clearly associated
with the name of the applicable third-party payer and
name of each plan, that apply to each such service. If
the charges are based on an algorithm, percentage of
another amount, or other formula or criteria, the
provider or supplier also shall disclose such
algorithm, percentage, formula, or criteria as set
forth in its contract and any other information
necessary to determine the negotiated charge as a
dollar amount.
``(E) The de-identified maximum and minimum
negotiated charges for each such item or service,
expressed as a non-zero dollar amount.
``(F) Any other additional information the
Secretary may require 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 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.
``(3) Uniform method and format.--The Secretary shall
establish a standard, uniform method and format for applicable
imaging service providers to use in making public information
described in paragraph (1). Any such method and format shall--
``(A) include a machine-readable format (as
specified by the Secretary) containing the information
described in paragraph (2) for all specified imaging
services furnished by each applicable imaging service
provider and ownership information described in
paragraph (1)(B);
``(B) meet such standards as determined appropriate
by the Secretary in order to ensure the accessibility
and usability of such information; and
``(C) be updated as determined appropriate by the
Secretary, in consultation with stakeholders.
``(4) Monitoring compliance.--The Secretary shall, in
consultation with the Inspector General of the Department of
Health and Human Services, establish a process to monitor
compliance with this subsection.
``(5) Attestation.--A senior official from each specified
imaging service provider (the Chief Executive Officer, Chief
Financial Officer, or an official of equivalent seniority)
shall attest to the accuracy and completeness of the
disclosures, and any other attestations as required by the
Secretary, made in accordance with the imaging service provider
price transparency requirements based on criteria established
by the Secretary.
``(6) Enforcement.--
``(A) In general.--In the case of a specified
imaging service provider that fails to comply with the
requirements of this subsection--
``(i) the Secretary shall notify such
imaging service provider of such failure not
later than 30 days after the date on which the
Secretary determines such failure exists; and
``(ii) upon request of the Secretary, such
imaging service provider shall submit to the
Secretary, not later than 45 days after the
date of such request, a corrective action plan
to comply with such requirements.
``(B) Civil monetary penalty.--
``(i) In general.--A specified imaging
service provider that has received a
notification under subparagraph (A)(i) and
fails to comply with the requirements of this
subsection by the date that is 90 days after
such notification (or, in the case of a
specified imaging service provider that has
submitted a corrective action plan described in
subparagraph (A)(ii) in response to a request
so described, by the date that is 90 days after
such submission) shall be subject to a civil
monetary penalty of an amount specified by the
Secretary for each day (beginning with the day
on which the Secretary first determined that
such imaging service provider was not complying
with such requirements) during which such
failure is ongoing (not to exceed $300 per
day).
``(ii) Increase authority.--In applying
this subparagraph with respect to a specified
imaging service provider that fails to comply
with the requirements of this subsection in
2028 or a subsequent year, the Secretary may
through notice and comment rulemaking increase
the limitation on the per day amount of any
penalty applicable to a specified imaging
service provider under clause (i).
``(iii) Application of certain
provisions.--The provisions of section 1128A of
the Social Security Act (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) No authority to waive or reduce
penalty.--The Secretary shall not grant or
extend any waiver, delay, tolling, or other
mitigation of a civil monetary penalty for
failing to comply with the requirements of this
subsection except where the Secretary
determines that imposing the maximum civil
monetary penalty will disrupt specified imaging
service provider operations in a manner that
impacts patient care. The Secretary may request
documentation in such form and manner as the
Secretary may require in order to evaluate
impact on specified imaging service provider
operations.
``(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 providers of services and suppliers requesting such
assistance.
``(8) Rulemaking.--
``(A) In general.--The Secretary shall implement
this subsection through notice and comment rulemaking
in accordance with section 553 of title 5, United
States Code.
``(B) Ownership information.--In promulgating
regulations under this paragraph, the Secretary shall
define the individuals and organizations that must be
disclosed under paragraph (1)(C) in a manner that
harmonizes disclosure requirements with requirements
established under section 1124 of the Social Security
Act and prioritizes the disclosure of individuals and
organizations who's ownership or management
relationship with a hospital impacts operational,
financial, or clinical decision making for such
hospital.''.
SEC. 5. AMBULATORY SURGICAL CENTER PRICE TRANSPARENCY.
Section 2718A of the Public Health Service Act, as amended by
section 4, is further amended by adding at the end the following:
``(e) Ambulatory Surgical Center Price Transparency.--
``(1) In general.--Beginning January 1 of the year that
begins on or after the date that is 1 year after the date of
enactment of the Patients Deserve Price Tags Act, each
specified ambulatory surgical center shall, on a quarterly
basis (if there have been any changes to the standard charges
described in paragraph (2)), compile and make publicly
available on an internet website (without subscription and free
of charge)--
``(A) the standard charges described in paragraph
(2) with respect to each specified service furnished by
such surgical center; and
``(B) the name and business address for each person
or entity that, with respect to the ambulatory surgical
center--
``(i) has an ownership or investment
interest;
``(ii) has a controlling interest;
``(iii) is a management services
organization; or
``(iv) is a significant equity investor.
``(2) Standard charges defined.--For purposes of paragraph
(1), the term `standard charges' with respect to standard
charges and prices made public by a specified ambulatory
surgical center means the following:
``(A) A plain language description of each item or
service, accompanied by any applicable billing codes
(including modifiers that materially change the price
for insurers or providers, and that materially change
out-of-pocket costs for consumers) using commonly
recognized billing code sets, including--
``(i) the Healthcare Common Procedure
Coding System code;
``(ii) the National Drug Code; or
``(iii) other applicable identifier as
determined by the Secretary (or successor code
sets).
``(B) The gross charge, expressed as a dollar
amount, for each such item or service.
``(C) The discounted cash price.
``(D) The payer-specific negotiated charges,
expressed as a dollar amount and clearly associated
with the name of the applicable third party payer and
name of each plan, that apply to each such item or
service. If the charges are based on an algorithm,
percentage of another amount, or other formula or
criteria, the ambulatory surgical center also shall
disclose such algorithm, percentage, formula, or
criteria as set forth in its contract and any other
information necessary to determine the negotiated
charge as a dollar amount.
``(E) The de-identified maximum and minimum
negotiated charges for each such item or service,
expressed as a non-zero dollar amount.
``(F) Any other additional information the
Secretary may require 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. In the case of standard charges 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.
``(3) Uniform method and format.--The Secretary shall
establish a standard, uniform method and format for specified
ambulatory surgical centers to use in compiling and making
public information pursuant to paragraph (1). Such method and
format shall--
``(A) include a machine-readable format (or a
successor technology specified by the Secretary)
containing the information described in paragraph (2)
for all specified services furnished by each ambulatory
surgical center and for the ownership information
described in paragraph (1)(B);
``(B) meet such standards as determined appropriate
by the Secretary in order to ensure the accessibility
and usability of such charges; and
``(C) be updated as determined appropriate by the
Secretary, in consultation with stakeholders.
``(4) Monitoring compliance.--The Secretary shall, in
consultation with the Inspector General of the Department of
Health and Human Services, establish a process to monitor
compliance with this subsection. Such process shall ensure that
each specified ambulatory surgical center's compliance with
this subsection is reviewed not less frequently than once every
year.
``(5) Attestation.--A senior official from each specified
ambulatory surgical center (the Chief Executive Officer, Chief
Financial Officer, or an official of equivalent seniority)
shall attest to the accuracy and completeness of the
disclosures, and any other attestations as required by the
Secretary, made in accordance with the ambulatory center price
transparency requirements based on criteria established by the
Secretary.
``(6) Enforcement.--
``(A) In general.--In the case of a specified
ambulatory surgical center that fails to comply with
the requirements of this subsection--
``(i) the Secretary shall notify such
ambulatory surgical center of such failure not
later than 30 days after the date on which the
Secretary determines such failure exists; and
``(ii) upon request of the Secretary, such
ambulatory surgical center shall submit to the
Secretary, not later than 45 days after the
date of such request, a corrective action plan
to comply with such requirements.
``(B) Civil monetary penalty.--
``(i) In general.--A specified ambulatory
surgical center that has received a
notification under subparagraph (A)(i) and
fails to comply with the requirements of this
subsection by the date that is 90 days after
such notification (or, in the case of a
specified ambulatory surgical center that has
submitted a corrective action plan described in
subparagraph (A)(ii) in response to a request
so described, by the date that is 90 days after
such submission) shall be subject to a civil
monetary penalty of an amount specified by the
Secretary for each day (beginning with the day
on which the Secretary first determined that
such ambulatory surgical center was not
complying with such requirements) during which
such failure is ongoing (not to exceed $300 per
day).
``(ii) Increase authority.--In applying
this subparagraph with respect to a specified
ambulatory surgical center that fails to comply
with the requirements of this subsection in
2028 or a subsequent year, the Secretary may
through notice and comment rulemaking increase
the limitation on the per day amount of any
penalty applicable to a specified ambulatory
surgical center under clause (i).
``(iii) Application of certain
provisions.--The provisions of section 1128A of
the Social Security Act (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) No authority to waive or reduce
penalty.--The Secretary shall not grant or
extend any waiver, delay, tolling, or other
mitigation of a civil monetary penalty for
failing to comply with the requirements of this
subsection except where the Secretary
determines that imposing the maximum civil
monetary penalty will disrupt specified
ambulatory surgical center operations in a
manner that impacts patient care. The Secretary
may request documentation in such form and
manner as the Secretary may require in order to
evaluate impact on specified ambulatory
surgical center operations.
``(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 specified ambulatory surgical centers requesting such
assistance.
``(8) Rulemaking.--
``(A) In general.--The Secretary shall implement
this subsection through notice and comment rulemaking
in accordance with section 553 of title 5, United
States Code.
``(B) Ownership information.--In promulgating
regulations under this paragraph, the Secretary shall
define the individuals and organizations that must be
disclosed under paragraph (1)(C) in a manner that
harmonizes disclosure requirements with requirements
established under section 1124 of the Social Security
Act and prioritizes the disclosure of individuals and
organizations who's ownership or management
relationship with a hospital impacts operational,
financial, or clinical decision making for such
hospital.
``(f) Continued Applicability of State Law.--The provisions of this
section shall not supersede any provision of State law that
establishes, implements, or continues in effect any requirement or
prohibition related to health care price transparency, except to the
extent that such requirement or prohibition prevents the application of
a requirement or prohibition of this section.''.
SEC. 6. STRENGTHENING HEALTH COVERAGE TRANSPARENCY REQUIREMENTS.
(a) Transparency in Coverage.--Section 2715A of the Public Health
Service Act (42 U.S.C. 300gg-15a) is amended--
(1) by striking ``A Group health'' and inserting the
following:
``(a) In General.--A group health''; and
(2) by ending at the end the following:
``(b) Additional Transparency Requirements.--
``(1) Specified information required.--
``(A) In general.--A group health plan or health
insurance issuer offering coverage in the individual or
group market shall provide to each participant,
beneficiary, or enrollee, at the time of enrollment in
the plan or coverage, the information described in
subparagraph (B).
``(B) Information required.--For purposes of
subparagraph (A), the information specified in this
subparagraph is, with respect to benefits available
under the plan or coverage for an item or service
furnished by a health care provider, the following (or
other information as determined appropriate by the
Secretary):
``(i) If such provider is an in-network
provider with respect to such item or service,
the in-network rate (as defined in paragraph
(5)) for such item or service.
``(ii) If such provider is not described in
clause (i), the out-of-network allowed amount
(as such term is defined for purposes of
section 147.210(a)(2)(xvii) of title 45, Code
of Federal Regulation) for such item or service
that the plan or coverage will pay without
regard to the amount in clause (iii).
``(iii) The amount of cost-sharing
liability (including deductibles, copayments,
and coinsurance) that the individual will incur
for such item or service based on the
information available to the plan or coverage
at the time the request is made (which, in the
case such item or service is to be furnished by
a provider described in clause (ii), shall be
calculated using the maximum amount described
in such clause).
``(iv) The accumulated amounts with respect
to any deductible or out-of-pocket maximum
under the plan or coverage reflected in the
plan's or coverage's records at the time the
request is made (broken down, in the case
separate deductibles or maximums apply to
separate individuals enrolled in the plan or
coverage, by such separate deductibles or
maximums, in addition to any cumulative
deductible or maximum).
``(v) In the case such plan or coverage
imposes any frequency or volume limitations
with respect to such item or service (excluding
medical necessity determinations), the amount
that such individual has accrued towards such
limitation with respect to such item or service
reflected in the plan's or coverage's records
at the time the request is made.
``(vi) Information about any utilization
management requirements, such as prior
authorization, concurrent review, step therapy,
fail first, or similar requirements applicable
to coverage of such item or service under such
plan or coverage, including information
regarding utilization management practices and
determinations, including aggregate information
related to approval and denial rates,
associated timelines, and appeals, as
determined appropriate by the Secretary.
``(C) Self-service tool .--For purposes of
subparagraph (A), a self-service tool established by a
health plan meets the requirements of this subparagraph
if such tool--
``(i) is based on an internet website;
``(ii) provides for real-time responses to
requests described in such subparagraph;
``(iii) is updated in a manner such that
the information is accurate based on the
information available to the plan or coverage
at the time the request is made;
``(iv) allows such a request to be made for
information with respect to an item or service
furnished by--
``(I) a specific provider that is
an in-network provider with respect to
such item or service; or
``(II) all providers that are in-
network providers with respect to such
plan or coverage and such item or
service;
``(v) provides that such a request may be
made for information with respect to an item or
service through use of--
``(I) the billing code for such
item or service; or
``(II) through use of a descriptive
term for such item or service; and
``(vi) is made available in plain language,
without subscription or other fee.
``(D) Nonduplication.--A group health plan or
health insurance issuers shall be deemed to be in
compliance with this paragraph if such plan or issuer
has a tool in place under section 2799A-4.
``(2) Rate and payment information.--
``(A) In general.--Beginning January 1 of the year
that begins on or after the date that is 1 year after
the date of enactment of the Patients Deserve Price
Tags Act, and every quarter thereafter (if there have
been any changes to the rate and payment information
described in subparagraphs (B) and (C), each group
health plan or health insurance issuer offering
coverage in the group or individual market shall make
available to the public, the rate and payment
information described in subparagraph (B) in accordance
with subparagraph (C).
``(B) Rate and payment information described.--For
purposes of subparagraph (A), the rate and payment
information described in this subparagraph is, with
respect to a plan or coverage, the following:
``(i) With respect to each item or service
for which benefits are available under such
plan or coverage, excluding those included in
clause (ii), identified by CPT, HCPCS, DRG, or
other applicable nationally recognized
identifier, including any applicable code
modifiers, and accompanied by a plain language
description of the item or service, the in-
network rate (expressed as a dollar amount or
percentage of charges, unless otherwise
specified by the Secretary), including the
individual and total amounts for any bundled
rates, in effect as of the date of the
submission of such information with each
provider (identified by national provider
identifier) that is an in-network provider with
respect to such item or service, other than
such a rate in effect with a provider that an
issuer has determined based on factors
determined by the Secretary (such as medical
specialty) that it is unlikely that the
provider would be reimbursed for the item or
service.
``(ii) With respect to each drug and
biologic (identified by National Drug Code, J-
code, or other commonly recognized billing code
used for drugs) for which benefits are
available under such plan or coverage, the in-
network rate (expressed as a dollar amount or
percentage of charges, unless otherwise
specified by the Secretary) in effect as of the
first day of the quarter in which such
information is made public with each pharmacy
or other prescription drug dispenser that is an
in-network pharmacy or other prescription drug
dispenser with respect to such drug.
``(iii) With respect to each item or
service for which benefits are available under
such plan or coverage (expressed as a dollar
amount), identified by CPT, DRG, HCPCS, or
other applicable nationally recognized
identifier, including any applicable code
modifiers, and accompanied by a brief
description of the item or service, the amount
billed or charged by the provider, and the
amount allowed by the plan or coverage, for
each such item or service furnished during a
representative lookback window established by
the Secretary by each provider that was an out-
of-network provider with respect to such item
or service, broken down by each such provider
(identified by national provider identifier),
other than items and services with respect to
which not fewer than 11 claims for such item or
service were submitted to such plan during such
period.
``(C) Manner of submission.--Rate and payment
information required to be submitted and made available
under this paragraph shall be so submitted and so made
available as follows:
``(i) Information shall be contained in at
least 3 separate machine-readable files
corresponding to the information described in
each of clauses (i) through (iii) of
subparagraph (B) that meet such requirements as
specified by the Secretary through rulemaking,
in consultation with the Secretaries of Labor
and the Treasury, to apply comparable
requirements to group health plans and health
insurance coverage and to entities providing
benefit management or other third-party
administration services on a contractual basis
with a group health plan or coverage.
``(ii) Requirements specified by the
Secretary through rulemaking (or subregulatory
guidance) shall ensure the following:
``(I) Such files are made available
in a widely available format that
allows for information contained in
such files to be compared across plans
and coverage and are freely accessible
to individuals at no cost and without
the need to establish a user account or
provide other credentials.
``(II) Each such file includes each
of the following data elements:
``(aa) A numerical
identifier for the group health
plan or health insurance issuer
(such as a Health Insurance
Oversight System identifier).
``(bb) A plain-language
description of the item or
service (including, for drugs,
the proprietary and
nonproprietary name assigned).
``(cc) The billing code,
including any applicable
modifiers, associated with such
item or service, including the
Healthcare Common Procedure
Coding System code, diagnosis-
related group, national drug
code, or other commonly
recognized code set.
``(dd) The place of service
code.
``(ee) The National
Provider Identifier and
provider Tax Identification
Number.
``(iii) The rate and payment information
disclosed under clauses (i) through (iii) of
subparagraph (B) shall be separately delineated
for each item or service, regardless of whether
such item or service is reimbursed as a part of
a bundle, episode, or other grouping of items
and services.
``(iv) An officer or executive of competent
authority shall attest to the accuracy and
completeness of information submitted and made
available under this subparagraph. In the case
of a plan or coverage that relies on a third-
party administrator or other service provider
to compile the information submitted and made
available under this subparagraph, such plan or
coverage may satisfy the requirement under this
clause by obtaining such an attestation from
the third-party administrator or other service
provider. Such attestation shall be subject to
enforcement under paragraph (6).
``(3) Ownership information.--Beginning January 1 of the
year that begins on or after the date that is 1 year after the
date of enactment of the Patients Deserve Price Tags Act, and
every quarter thereafter (if there have been any changes in the
required information), each group health plan or health
insurance issuer offering coverage in the individual or group
market shall submit to the Secretary, the applicable State
authority, and make available to the public, the name and
business address of each person or entity that, with respect to
such plan or coverage--
``(A) has an ownership or investment interest;
``(B) has a controlling interest;
``(C) is a management services organization; or
``(D) is a significant equity investor.
``(4) Enforcement.--
``(A) In general.--Each year, the Secretary shall
audit the machine-readable files required by paragraph
(2)(B) posted by not fewer than 50 group health plans
or health insurance issuers for compliance with format
and accessibility standards.
``(B) Notification and request for corrective
action.--In the case of a group health plan or health
insurance issuer that fails to comply with the
requirements of this paragraph, not later than 30 days
after the date on which the Secretary determines such
failure exists, the Secretary shall submit to such plan
or issuer a notification of such determination, which
shall include a request for a corrective action plan to
comply with such requirements.
``(C) Civil monetary penalty.--A plan or issuer
that has received a request for a corrective action
plan under subparagraph (B) and fails to comply with
the requirements of this paragraph by the date that is
30 days after such request is made shall be subject to
a civil monetary penalty of an amount specified by the
Secretary for each day (beginning with the day on which
such health plan or health insurance issuer was failing
to comply with such paragraph) during which such
failure was ongoing. Such amount shall not exceed $300
per participant, beneficiary, or covered individual per
day or $10,000,000, whichever is lesser.
``(5) Definitions.--In this subsection:
``(A) In-network provider.--The term `in-network
provider' has the meaning given such term in section
54.9815-2715A1(a)(2)(xii) of title 26, Code of Federal
Regulations.
``(B) In-network rate.--The term `in-network rate'
means, with respect to a health plan and an item or
service furnished by a provider that is a participating
provider with respect to such plan and item or service,
the contracted rate in effect between such plan and
such provider for such item or service. If the rate is
based on an algorithm, percentage of another amount, or
other formula or criteria, the health plan also shall
disclose such algorithm, percentage, formula, or
criteria as set forth in its contract and any other
terms, schedules, exhibits, data, or other information
referenced in any such contract as shall be required to
determine and disclose the negotiated rate.
``(6) Rulemaking.--
``(A) In general.--The Secretary shall implement
this subsection through notice and comment rulemaking
in accordance with section 553 of title 5, United
States Code. The Secretary may implement the manner of
submission of data described in paragraph (2)(C)
through subregulatory guidance.
``(B) Regulations.--Regulations promulgated
pursuant to this subsection shall provide the
following:
``(i) The Secretary shall annually audit
the machine-readable files required by
paragraph (2)(B) posted by not fewer than 50
group health plans or health insurance issuers
for compliance with format and accessibility
standards.
``(ii) The Secretary of Labor shall
annually audit the machine-readable files
required by paragraph (2)(B) posted by not
fewer than 250 group health plans or service
providers furnishing third-party administrator
services to a group health plan for compliance
with format and accessibility standards.
``(iii) The Secretary of Health and Human
Services, in conjunction with the Secretary of
Labor and the Secretary of the Treasury, shall
annually issue a report to Congress that
includes findings, conclusions, and enforcement
actions taken based on audits of the machine-
readable files. Such report shall be provided
no later than July 1 following the calendar
year during which the audits were completed.
The Secretary of Health and Human Services
shall make such report to Congress accessible
to the public.''.
(b) Effective Date.--
(1) In general.--The amendments made by subsections (a) and
(b) shall apply beginning January 1 of the year that begins on
or after the date that is 1 year after the date of enactment of
the Patients Deserve Price Tags Act.
(2) Continued applicability of rules for previous years.--
Nothing in the amendments made by this section 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),
or amendments made to such rule that are applicable before the
date of enactment of the Patients Deserve Price Tags Act.
SEC. 7. INCREASING GROUP HEALTH PLAN ACCESS TO HEALTH DATA.
(a) Group Health Plan Access to Information.--
(1) In general.--Section 2799A-9 of the Public Health
Service Act (42 U.S.C. 300gg-119) is amended by adding at the
end the following:
``(1) Group health plan access to information.--
``(A) In general.--No contract or arrangement for
services, and no extension or renewal of such contract
or arrangement, between a group health plan that is
offered by a specified large employer or that is a
specified large plan (as such terms are defined in
subparagraph (F)) and a health care provider (which for
purposes of this subparagraph, includes a health care
facility), network or association of providers, service
provider offering access to a network of providers,
third-party administrator, health insurance issuer
offering group or individual health insurance coverage,
or pharmacy benefit manager, or any entity acting as an
intermediary between the group health plan and the
health care provider, network association of providers,
service provider offering access to a network or
association of providers (including a licensed health
insurance issuer or third-party administrator), or
pharmacy benefit manager (collectively referred to in
this subsection as `Covered Service Providers'), is
reasonable within the meaning of this subsection unless
such contract or arrangement--
``(i) allows the responsible plan fiduciary
(as that term is defined in section
408(b)(2)(B)(ii)(I)(ee)) access to all claims
and encounter information or data, and any
documentation supporting claim payments,
including, but not limited to, medical records
and policy documents, or information or data
described in subsection (a)(1)(B) to--
``(I) comply with applicable law;
and
``(II) determine the accuracy or
reasonableness of claims payment; and
``(ii) does not--
``(I) unreasonably limit or delay
access, as determined by the Secretary
but in any event not longer than 15
days, after a request for access by a
plan fiduciary to such information or
data;
``(II) limit the volume of claims
and encounter information or data that
the group health plan, the plan
sponsor, the plan administrator, or a
business associate of such plan may
access during an audit or pursuant to
any request for such information or
data;
``(III) limit the disclosure of
pricing terms for value-based payment
arrangements or capitated payment
arrangements, including--
``(aa) payment calculations
and formulas;
``(bb) quality measures;
``(cc) contract terms;
``(dd) payment amounts;
``(ee) measurement periods
for all incentives; and
``(ff) other payment
methodologies used by an
entity, including a health care
provider (including a health
care facility), network or
association of providers,
service provider offering
access to a network of
providers, third-party
administrator, or pharmacy
benefit manager;
``(IV) limit the disclosure of
overpayments and overpayment recovery
terms;
``(V) limit the right of the group
health plan, the plan sponsor, or the
plan administrator of such plan to
select an auditor or define audit scope
or frequency;
``(VI) otherwise limit or unduly
delay the group health plan, the plan
sponsor, the plan administrator, or a
business associate of such plan from
accessing claims and encounter
information or data;
``(VII) limit the disclosure of
fees charged to the group health plan
related to plan administration and
claims processing, including
renegotiation fees, access fees,
repricing fees, or enhanced review
fees;
``(VIII) limit the right of the
group health plan, the plan sponsor, or
the plan administrator to request
action on any suspect claim payments;
``(IX) limit public disclosure of
de-identified or aggregate information;
``(X) limit the disclosure of, with
respect to a provider that files claims
under such plan, whether a Covered
Service Provider--
``(aa) has an ownership or
investment interest;
``(bb) has a controlling
interest;
``(cc) is a management
services organization; or
``(dd) is a significant
equity investor; or
``(XI) limit the disclosure of the
name and address of each person or
entity that, with respect to the health
plan service provider--
``(aa) has an ownership or
investment interest;
``(bb) has a controlling
interest; or
``(cc) is a significant
equity investor.
``(B) Manner of providing information or data.--
``(i) In general.--A Covered Service
Provider shall provide information or data
under this subsection in a manner consistent
with the privacy regulations promulgated under
section 13402(a) of the Health Information
Technology for Economic and Clinical Health Act
(42 U.S.C. 17932(a)) and consistent with the
privacy regulations promulgated under the
Health Insurance Portability and Accountability
Act of 1996 in part 160 and subparts A and E of
part 164 of title 45, Code of Federal
Regulations (or successor regulations)
(referred to in this paragraph as the `HIPAA
privacy regulations') and shall restrict the
use and disclosure of such information
according to such privacy regulations and such
HIPAA privacy regulations. A Covered Service
Provider shall not be required to disclose
information or data under this subsection that
could reasonably identify a participant or
beneficiary through individually identifiable
health information (as such term is defined
under HIPAA privacy regulations).
``(ii) Additional requirements.--In
carrying out this subsection, a Covered Service
Provider shall comply with section 164.504(f)
of title 45, Code of Federal Regulations (or a
successor regulation).
``(iii) Rule of construction.--
``(I) In general.--Nothing in this
subsection shall be construed to modify
the requirements for the creation,
receipt, maintenance, or transmission
of protected health information under
the HIPAA privacy regulations.
``(II) Civil rights laws.--Nothing
in this subsection shall be construed
to affect the application of any
Federal or State privacy or civil
rights law, including the HIPAA privacy
regulations, the Genetic Information
Nondiscrimination Act of 2008 (Public
Law 110-233) (including the amendments
made by such Act), the Americans with
Disabilities Act of 1990 (42 U.S.C.
12101 et seq.), section 504 of the
Rehabilitation Act of 1973 (29 U.S.C.
794), section 1557 of the Patient
Protection and Affordable Care Act (42
U.S.C. 18116), title VI of the Civil
Rights Act of 1964 (42 U.S.C. 2000d),
and title VII of the Civil Rights Act
of 1964 (42 U.S.C. 2000e).
``(iv) Written notice.--Each plan year, a
Covered Service Provider shall provide to each
participant or beneficiary written notice
informing the participant or beneficiary of the
requirement that Covered Service Providers
respond to requests to submit information or
data under paragraph (1), as applicable, which
may include incorporating such notification in
plan documents provided to the participant or
beneficiary, or providing individual
notification.
``(v) Clarification regarding public
disclosure of information.--Nothing in this
subsection shall prevent a Covered Service
Provider from placing reasonable restrictions
on the public disclosure of the information or
data described in paragraph (1), except that
such Provider may not restrict disclosure of
such report to the Department of Health and
Human Services, the Department of Labor, or the
Department of the Treasury.
``(vi) Limitation.--This paragraph shall
not be construed to abridge or limit the
disclosure requirements under this subsection
or to impose additional privacy or security
requirements on Covered Service Providers or
plan sponsors.
``(C) Limitation on disclosure.--A group health
plan receiving information or data under this
subsection may disclose such information only in a
manner that is consistent with HIPAA and the privacy
and security regulations promulgated thereunder,
regardless of their direct or indirect applicability to
the plan or any entities that could be or are business
associates. A group health plan (and any business
associate or other entity acting on behalf of such
plan) may use such information or data only for
purposes of plan administration and may not sell,
license, or otherwise commercially exploit such
information or data or provide such information or data
to any third party that may take such action.
``(D) Requirements of information.--Information
made available under this subsection shall conform to
the following standards:
``(i) All claims from a healthcare provider
shall be made to the group health plan in
accordance with transaction standards adopted
by regulation under HIPAA, as follows:
``(I) Institutional, professional,
and dental claims shall be in ASC X12N
837D format or any subsequent standard
as established by the Secretary.
``(II) Pharmacy claims shall be in
the National Council for Prescription
Drug Programs (NCPDP) format or any
subsequent standard as established by
the Secretary.
``(III) The files shall be
unmodified copies of the files sent
from the provider, or, upon request,
delivered in a machine readable format.
In the event that paper claims are sent
by the provider, they shall be
converted to the appropriate standard
electronic format. Files shall be
accessible to the plan at no cost to
the group health plan.
``(ii) All claim payment (or EFT,
electronic funds transfer) and electronic
remittance advice (ERA) notices sent by a
Covered Service Provider shall be made
available to the group health plan as ASC X12N
835 files (or any other format as identified by
the Secretary) in accordance with standards
adopted by regulation under HIPAA. The files
shall be unmodified copies of the files sent by
the Covered Service Provider to the healthcare
provider. Files shall be accessible at no cost
to the group health plan.
``(iii) The contractual terms containing
payment calculations and formulas, pricing
methodologies, and other information used to
determine the dollar value of reimbursement, in
a format as specified by the Secretary.
``(iv) All non-claim costs shall be
itemized and made available to the group health
plan as requested through a web-based portal,
through an application program interface (API),
through a downloadable Comma-Separated Value
(CSV) file, and, as appropriate, through other
downloadable machine-readable file types.
``(E) Implementation.--The Secretary shall
implement this subsection through notice and comment
rulemaking in accordance with section 553 of title 5,
United States Code.
``(F) Definitions.--
``(i) In general.--The provisions of
sections 408 and 410 of the Employee Retirement
Income Security Act of 1974 shall apply with
respect to terms used under this subsection.
``(ii) Specified large employer.--In this
subsection, the term `specified large employer'
means, in connection with a group health plan
(including group health insurance coverage
offered in connection with such a plan)
established or maintained by a single employer,
with respect to a calendar year or a plan year,
as applicable, an employer who employed an
average of at least 50 employees on business
days during the preceding calendar year or plan
year and who employs at least 1 employee on the
first day of the calendar year or plan year.
``(iii) Specified large plan.--In this
subsection, the term `specified large plan'
means a group health plan (including group
health insurance coverage offered in connection
with such a plan) established or maintained by
a plan sponsor described in clause (ii) or
(iii) of section 3(16)(B) of the Employee
Retirement Income Security Act of 1974 that had
an average of at least 50 participants on
business days during the preceding calendar
year or plan year, as applicable.''.
(2) Civil enforcement.--
(A) Civil enforcement.--Subsection (c) of section
502 of such Act (29 U.S.C. 1132) is amended by adding
at the end the following new paragraph:
``(13)(A) In the case of an agreement between a group
health plan (as defined in section 733(a)), the plan sponsor of
such plan (as defined in section 3(16)(B)), or the plan
administrator of such plan (as defined in section 3(16)(A)) and
a health care provider (which, for purposes of this paragraph,
includes a health care facility), network or association of
providers, service provider offering access to a network or
association of providers, third-party administrator, or
pharmacy benefit manager, that violates the provisions of
section 724(b), the Secretary may assess a civil penalty
against such provider, network or association, service provider
offering access to a network or association of providers,
third-party administrator, pharmacy benefit manager, or other
service provider in the amount of up to $10,000 for each day
during which such violation continues. Such penalty shall be in
addition to other penalties as may be prescribed by law.
``(B) Nothing in subparagraph (A) shall be construed to
permit the Secretary to regulate health care providers acting
in their capacity as medical organizations furnishing items and
services to patients.''.
(B) Existing provisions void.--Section 410 of such
Act (29 U.S.C. 1110) is amended by adding at the end
the following:
``(c) Any provision in an agreement or instrument shall be void as
against public policy if such provision--
``(1) unduly delays or limits a group health plan (as
defined in section 733(a)), the plan sponsor of such plan (as
defined in section 3(16)(B)), or the plan administrator of such
plan (as defined in section 3(16)(A)) from accessing the claims
and encounter information or data described in section
724(b)(1)(B); or
``(2) violates the requirements of section 408(b)(2)(C).''.
(C) Technical amendments.--Section 408(b)(2)(B) of
such Act (29 U.S.C. 1108(b)(2)) is amended--
(i) in clause (i), by striking ``this
clause'' and inserting ``this paragraph''; and
(ii) by adding at the end the following:
``(xi) A contract or arrangement shall not
be reasonable under this subparagraph if it
fails to comply with section 724(b).''.
(b) Updated Attestation for Price and Quality Information.--Section
2799A-9(a)(4) of the Public Health Service Act (42 U.S.C. 300gg-
119(a)(4)) is amended to read as follows:
``(4) Attestation.--
``(A) In general.--Subject to subparagraph (C), a
group health plan or health insurance issuer offering
group health insurance coverage shall annually submit
to the Secretary an attestation that such plan or
issuer of such coverage is in compliance with the
requirements of this subsection. Such attestation shall
also include a statement verifying that--
``(i) the information or data described
under subparagraphs (A) and (B) of paragraph
(1) is available upon request and provided to
the group health plan, the plan sponsor, the
plan administrator, or the business associate
of such plan, or the issuer, as applicable, in
a timely manner; and
``(ii) there are no terms in the agreement
under such paragraph (1) that directly or
indirectly restrict or unduly delay a group
health plan, the plan sponsor, the plan
administrator, a business associate of such
plan, or the issuer from auditing, reviewing,
or otherwise accessing such information.
``(B) Limitation on submission.--A group health
plan or issuer offering group health insurance coverage
may not enter into an agreement with a third-party
administrator or other service provider to submit the
attestation required under subparagraph (A).
``(C) Exception.--In the case of a group health
plan or health insurance issuer offering group health
insurance coverage that is unable to obtain the
information or data needed to submit the attestation
required under subparagraph (A), such plan or issuer
may submit a written statement in lieu of such
attestation that includes--
``(i) an explanation of why such plan or
issuer was unsuccessful in obtaining such
information or data, including whether such
plan, the plan sponsor, or the plan
administrator or issuer was limited or
prevented from auditing, reviewing, or
otherwise accessing such information or data;
``(ii) a description of the efforts made by
the group health plan, the plan sponsor, or the
plan administrator to remove any gag clause
provisions from the agreement under paragraph
(1); and
``(iii) a description of any response by
the third-party administrator or other service
provider with respect to efforts to comply with
the attestation requirement under subparagraph
(A), including the name of the third-party
administrator or other service provider.''.
(c) Effective Date.--The amendments made by subsections (a) and (b)
shall apply with respect to a plan beginning with the first plan year
that begins on or after the date that is 1 year after the date of
enactment of this Act.
SEC. 8. OVERSIGHT OF ADMINISTRATIVE SERVICE PROVIDERS.
(a) PHSA Amendment.--Part D of title XXVII of the Public Health
Service Act (42 U.S.C. 300gg-111 et seq.), as amended by section
6701(a) of the Consolidated Appropriations Act, 2026, is amended by
adding at the end the following:
``SEC. 2799A-12. OVERSIGHT OF ADMINISTRATIVE SERVICE PROVIDERS.
``(a) In General.--For plan years beginning on or after January 1
of the year that begins on or after the date that is 1 year after the
date of enactment of the Patients Deserve Price Tags Act, no agreement
between a group health plan that is offered by a specified large
employer or that is a specified large plan (as such terms are defined
in section 2799A-11(f)) or a health insurance issuer offering
individual or group health coverage (that makes an election subject to
subsection (b)(5)) and a health insurance issuer that is operating as a
third-party administrator, a health care provider, network or
association of providers, third-party administrator, service provider
offering access to a network of providers, pharmacy benefit managers,
or any other third party (each referred to in this section as a `health
plan service provider') is permissible if such agreement limits (or
delays beyond the applicable reporting period described in subsection
(b)(1)) the disclosure of information to such group health plans and
health insurance issuers in a manner that prevents any health plan
service provider from providing the information described in subsection
(b)).
``(b) Required Disclosures.--
``(1) Contents and frequency.--With respect to plan years
beginning on or after the date that is 1 year after the date of
enactment of this section, not less frequently than quarterly,
a health plan service provider shall provide to the group
health or the health insurance issuer offering individual or
group health insurance coverage the following information at no
cost to the plan or issuer:
``(A) The information described in section 2799A-
9(a)(1)(B) (42 U.S.C. 300gg-119(a)(1)(B)).
``(B) Any contractual and subcontractual
calculation methodologies, pricing or fee schedules, or
other formulae used to determine reimbursement amounts
to providers and subcontractors, including
methodologies, schedules, fee structures, and any
applied adjustments or modifiers, with such information
provided in a manner sufficiently detailed to enable
the group health plan or issuer to accurately assess,
verify, and ensure compliance with the terms of any
contractual and subcontractual agreement governing the
reimbursement amounts.
``(C) The total amount received or expected to be
received by the health plan service provider or its
subcontractors in provider or supplier rebates, fees,
alternative discounts, and all other remuneration
including amounts held in escrow or variance accounts
that has been paid or is to be paid for claims incurred
and administrative services including data sales or
network payments.
``(D) The total amount paid or expected to be paid
by the health plan service provider to its
subcontractors in rebates, fees, contractual
arrangements, and all other remuneration for
administrative and other services.
``(E) All payment data, calculation methodologies,
and reconciliation information related to alternative
compensation arrangements, including accountable care
organizations, value-based programs, shared savings
programs, incentive compensation, bundled payments,
capitation arrangements, performance payments, and any
other reimbursement or payment models, where the group
health plan paid fees, incurred obligations, or made
payments in connection with the group health plan or
issuer related to such arrangements.
``(F) Whether, with respect to a provider that
files claims under such plan or coverage, the health
plan service provider--
``(i) has an ownership or investment
interest;
``(ii) has a controlling interest;
``(iii) is a management services
organization; or
``(iv) is a significant equity investor.
``(G) The name and business address for each person
or entity that, with respect to the health plan service
provider--
``(i) has an ownership or investment
interest;
``(ii) has a controlling interest; or
``(iii) is a significant equity investor.
``(2) Manner of providing information or data.--
``(A) In general.--A health plan service provider
shall provide information or data under paragraph (1)
in a manner consistent with the privacy regulations
promulgated under section 13402(a) of the Health
Information Technology for Economic and Clinical Health
Act (42 U.S.C. 17932(a)) and consistent with the
privacy regulations promulgated under the Health
Insurance Portability and Accountability Act of 1996 in
part 160 and subparts A and E of part 164 of title 45,
Code of Federal Regulations (or successor regulations)
(referred to in this paragraph as the `HIPAA privacy
regulations') and shall restrict the use and disclosure
of such information according to such privacy
regulations and such HIPAA privacy regulations.
``(B) Additional requirements.--In carrying out
this subsection, a health plan service provider shall
comply with section 164.504(f) of title 45, Code of
Federal Regulations (or a successor regulation).
``(C) Rule of construction.--
``(i) In general.--Nothing in this
subsection shall be construed to modify the
requirements for the creation, receipt,
maintenance, or transmission of protected
health information under the HIPAA privacy
regulations.
``(ii) Civil rights laws.--Nothing in this
subsection shall be construed to affect the
application of any Federal or State privacy or
civil rights law, including the HIPAA privacy
regulations, the Genetic Information
Nondiscrimination Act of 2008 (Public Law 110-
233) (including the amendments made by such
Act), the Americans with Disabilities Act of
1990 (42 U.S.C. 12101 et seq.), section 504 of
the Rehabilitation Act of 1973 (29 U.S.C. 794),
section 1557 of the Patient Protection and
Affordable Care Act (42 U.S.C. 18116), title VI
of the Civil Rights Act of 1964 (42 U.S.C.
2000d), and title VII of the Civil Rights Act
of 1964 (42 U.S.C. 2000e).
``(D) Written notice.--Each plan year, a health
plan service provider shall provide to each participant
or beneficiary written notice informing the participant
or beneficiary of the requirement for health plan
service providers to submit information or data under
paragraph (1), as applicable, which may include
incorporating such notification in plan documents
provided to the participant or beneficiary, or
providing individual notification.
``(E) Clarification regarding public disclosure of
information.--Nothing in this subsection shall prevent
a health plan service provider from placing reasonable
restrictions on the public disclosure of the
information or data described in paragraph (1), except
that such provider may not restrict disclosures under
subsection (b)(1) to the Department of Health and Human
Services, the Department of Labor, or the Department of
the Treasury.
``(F) Limitation.--This paragraph shall not be
construed to abridge or limit the disclosure
requirements under this subsection or to impose
additional privacy or security requirements on health
plan service providers or plan sponsors.
``(3) Disclosure and redisclosure.--
``(A) In general.--A group health plan or health
insurance issuer offering individual or group coverage
receiving information under paragraph (1) may disclose
such information only--
``(i) to the entity from which the
information was received or to that entity's
business associates as defined in section
160.103 of title 45, Code of Federal
Regulations (or successor regulations); or
``(ii) as permitted by the HIPAA Privacy
Rule (45 C.F.R. part 160 and subparts A and E
of part 164).
``(B) Availability of information.--To the extent
the information required by this subsection is made
available to the health insurance issuer offering group
health insurance coverage, the health insurance issuer
shall make such information available, at the same
time, in the same format, and at no cost, to the group
health plan.
``(C) Limitation on use of information.--A group
health plan or health insurance issuer (and any
business associate or other entity acting on behalf of
such plan) may use information or data under this
paragraph only for purposes of plan administration and
may not sell, license, or otherwise commercially
exploit such information or data or provide such
information or data to any third party that may take
such action.
``(D) Rule of construction.--Nothing in this
section shall be construed to prevent a group health
plan, a health insurance issuer, or a health plan
service provider providing services with respect to
such a plan, from placing reasonable restrictions on
the public disclosure of the information described in
paragraph (1), except that such plan or entity may not
restrict disclosure of such information to the
Department of Health and Human Services, the Department
of Labor, the Department of the Treasury, or the
Comptroller General of the United States.
``(E) Failure to provide.--The obligation to
provide information pursuant to this subsection shall
exist notwithstanding the presence of any formal data-
sharing agreement between the parties. Failure to
provide the required information as specified shall
constitute a violation of this Act and the Secretary
shall initiate enforcement action under section 2723(b)
(42 U.S.C. 300gg-22(b)) within 90 days of becoming
aware of a violation of this section, except that
nothing in this section shall be construed to limit the
Secretary's existing authority under this Act.
``(4) Data format standards.--All data and information
provided pursuant to this subsection shall comply with the
following standards:
``(A) All claims from a healthcare provider shall
be made to the group health plan in accordance with
standards adopted under HIPAA as described in subpart K
of part 162 of title 45, Code of Federal Regulations,
as follows:
``(i) Institutional, professional, and
dental claims and adjustments to these claims
shall be provided to the group health plan or
health insurance issuer in the ASC X12N 837
format.
``(ii) Prescription drug claims shall be in
the National Council for Prescription Drug
Programs (NCPDP) format.
``(iii) The files shall be unmodified
copies of the files sent from the provider. In
the event that paper claims are sent by the
provider, they shall be converted to the
appropriate standard electronic format. Such
data shall be provided at no cost to the group
health plan.
``(B) All claim payment (or EFT, electronic funds
transfer) and electronic remittance advice (ERA)
information sent by a health plan service provider
shall be provided to the group health plan or health
insurance issuer in the ASC X12N 835 format, in
accordance with standards and operating rules adopted
under HIPAA at subpart P of part 162 of title 45, Code
of Federal Regulations, unmodified from the form in
which it was transmitted to the healthcare provider.
Such information shall be provided at no cost to the
group health plan.
``(C) The Secretary may modify the standards set
forth in this paragraph as necessary to align with any
changes adopted by the Secretary pursuant to the
authority provided under section 1173 of the Social
Security Act ( 42 U.S.C. 1320d-2).
``(5) Opt-in for health insurance coverage.--In the case of
a health insurance issuer offering coverage in the individual
or group market, such issuer may, on an annual basis, for plan
years beginning on or after the effective date of this section,
elect to require a health plan service provider to submit to
such issuer a report that includes all of the information
described in paragraph (1).
``(c) Prohibited Contractual Provisions.--Any provision in an
agreement that unduly delays or limits a group health plan or issuer's
access to information described in this section or that restricts the
format or timing of the provision of such information in a manner that
is inconsistent with the requirements of this section shall be
prohibited and, if a group health plan or issuer enters into such
agreement, shall be deemed void as against public policy.
``(d) Regulations.--The Secretary shall implement this section
through notice and comment rulemaking in accordance with section 553 of
title 5, United States Code.''.
(b) Penalty.--Section 2723(b) of the Public Health Service Act (42
U.S.C. 300gg-22(b)) is amended by adding at the end the following:
``(4) Enforcement authority relating to health plan service
providers.--Notwithstanding any provisions to the contrary, the
Secretary may assess a penalty against a health plan service
provider, as defined in section 2799A-12(a) (42 U.S.C. 300gg-
121(a)), of $100,000 per day for each violation of such
section, pursuant to substantially similar processes and
procedures as those set forth in section 2723(b)(2)(D) through
(G) (42 U.S.C. 300gg-121(b)(2)(D) through (G)).''.
(c) ERISA Amendments.--
(1) In general.--Section 502(c) of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1132(c)) is amended by
adding at the end the following new paragraph:
``(14) The Secretary may assess a civil penalty against any
person of $100,000 per day for each violation by any person of
section 727.''.
(2) Technical amendment.--Paragraph (6) of section 502(a)
of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1132(a)) is amended by striking ``or (9)'' and inserting
``(9), (13), or (14)''.
SEC. 9. STATE PREEMPTION ONLY IN EVENT OF CONFLICT.
The provisions of section 2718A of the Public Health Service Act
(as added and amended by this Act) shall not be construed to supersede
any provision of State law which establishes, implements, or continues
in effect any requirement or prohibition related to health care price
transparency, including for hospitals, clinical diagnostic
laboratories, provider of specified imaging services, and ambulatory
surgical centers (as such terms are defined in section 2718A(a) of the
Public Health Service Act), except to the extent that such requirement
or prohibition prevents the application of a requirement or prohibition
of such sections (or such amendments). Nothing in this section shall be
construed to affect group health plans established under the Employee
Retirement Income Security Act of 1974, or alter the application of
section 514 of such Act (29 U.S.C. 1144).
SEC. 10. REQUIREMENT FOR EXPLANATION OF BENEFITS.
(a) Advanced Explanation of Benefits.--Section 2799A-1(f) of the
Public Health Service Act (42 U.S.C. 300gg-111(f)) is amended--
(1) in paragraph (1)--
(A) by striking subparagraph (C) and inserting the
following:
``(C) A good faith estimate of the amount the plan
or coverage is responsible for paying for items and
services included in the estimate described in
subparagraph (B), including a plain language
description of each item or service and all applicable
billing codes for each item or service, including
modifiers, using standard and commonly recognized
billing code sets that are clearly identified.''; and
(B) by adding at the end the following
``(I) A notification that the recipient may be held
harmless, in certain circumstances, if the information
in the advanced explanation of benefits does not match
the amount the recipient is billed.''; and
(2) by adding at the end the following
``(3) Hold harmless.--
``(A) In general.--For plan years beginning on or
after the date that is 1 year after the date on which
the Secretary implements this section, a participant,
beneficiary, or enrollee shall be held harmless for any
amount that is substantially in excess (as defined by
the Secretary in a manner consistent with the process
described in section 2799B-7) of the estimate generated
by the advanced explanation of benefits.
``(B) No patient responsibility for excess
charges.--A group health plan or a health insurance
issuer in the group or individual market shall not hold
a participant, beneficiary, or enrollee responsible for
excess charges described in this paragraph if such
excess is the result of coverage or payment
determinations that differ from projections made in the
advanced explanation of benefits at the time such
explanation was generated.
``(C) Substantial excess.--A participant,
beneficiary, or enrollee shall not be held harmless for
excess amounts if such amounts reflect the cost of
medically necessary items or services furnished based
on unforeseen circumstances that could not have
reasonably been anticipated by the provider or facility
at the time the good faith estimate was generated or by
the plan or issuer at the time the advanced explanation
of benefits was generated.''.
(b) Good Faith Estimates.--Section 2799B-6 of the Public Health
Service Act (42 U.S.C. 300gg-136) is amended--
(1) by striking ``Each health care'' and inserting the
following:
``(a) In General.--Each health care''; and
(2) by adding at the end the following:
``(b) Hold Harmless.--
``(1) In general.--For plan years beginning on or after the
date that is 1 year after the date on which the Secretary
implements section 2799A-1(f), if an individual enrolled in a
group health plan or health insurance coverage (and seeks to
have a claim for an item or service submitted to such plan or
coverage) is responsible for any amount that is substantially
in excess (as defined by the Secretary in a manner consistent
the process described in section 2799B-7) of the estimate
generated in the advanced explanation of benefits described in
section 2799A-1(f) because the final charges for items and
services were substantially in excess of the good faith
estimate provided to the plan or coverage under this section, a
provider shall not bill the patient for amounts substantially
in excess of the advanced explanation of benefits.
``(2) Substantial excess.--An individual seeking to have a
claim for an item or service covered by a group health plan or
health insurance coverage shall not be held harmless for excess
amounts if such amounts reflect the cost of medically necessary
items or services furnished based on unforeseen circumstances
that could not have reasonably been anticipated by the provider
or facility at the time the good faith estimate was generated
or by the plan or issuer at the time the advanced explanation
of benefits was generated.''.
(c) Explanation of Benefits.--Section 2799A-1 of the Public Health
Service Act (42 U.S.C. 300gg-111) is amended by adding at the end the
following:
``(g) Explanation of Benefits.--
``(1) In general.--For plan years beginning on January 1 of
the year that begins on or after the date that is 1 year after
the date of enactment of the Patients Deserve Price Tags Act,
each group health plan, or a health insurance issuer offering
group or individual health insurance coverage shall, within 45
days of receiving the information necessary to decide a claim
for payment (as defined by the Secretary) for an item or
service under the plan or coverage for which liability under
the plan or coverage has been determined, provide to the
participant, beneficiary, or enrollee (through mail or
electronic means, as requested by the participant, beneficiary,
or enrollee) a notification (in clear and understandable
language and utilizing substantially the same format as the
advanced explanation of benefits required by subsection (f) to
enable comparison when an advanced explanation of benefits is
provided) including the following:
``(A) Whether or not the provider or facility is a
participating provider or a participating facility with
respect to the plan or coverage with respect to the
furnishing of such item or service.
``(B) An itemized explanation of benefits that
includes the following:
``(i) A plain language description of each
item or service.
``(ii) All applicable billing codes for
each item or service, including modifiers,
using standard and commonly recognized billing
code sets that are clearly identified.
``(iii) The amount the plan or coverage is
responsible for paying for each item or
service.
``(iv) The amount of any cost-sharing for
which the participant, beneficiary, or enrollee
is responsible for each item or service (as of
the date of such notification).
``(v) The amount that the participant,
beneficiary, or enrollee has incurred toward
meeting the limit of the financial
responsibility (including with respect to
deductibles and out-of-pocket maximums) under
the plan or coverage (as of the date of such
notification).
``(vi) The type of site of each item or
service, including office, facility, or
emergency room.
``(vii) If applicable, a description of any
discrepancies that exist between the services
outlined in a patient's advanced explanation of
benefits and the explanation of benefits.
``(viii) The amount of any facility fee or
other patient charges that were added to the
final payment amount, together with a plain
language explanation of the fee, if applicable.
``(C) If the provider or facility is a
participating provider or facility with respect to the
plan or coverage with respect to the furnishing of such
item or service, the contracted rate under such plan or
coverage for such item or service.
``(D) The charges submitted by the provider or
facility for each item or service.
``(E) Information pertaining to plan type, as
defined the Secretary.
``(2) Format.--If applicable, the notification described in
paragraph (1) may be provided in conjunction with, or as part
of, a notice of a claim determination or other communication
required by section 2719(a) (42 U.S.C. 300gg-19(a)), or
regulations thereunder.
``(h) Regulations.--The Secretary shall implement this section
through notice and comment rulemaking in accordance with section 553 of
title 5, United States Code.''.
SEC. 11. TRANSPARENCY IN BILLING.
(a) In General.--Part E of title XXVII of the Public Health Service
Act (42 U.S.C. 300gg-131 et seq.) is amended by adding at the end the
following:
``SEC. 2799B-10. PATIENT ACCESS TO COMPLETE BILLING INFORMATION.
``(a) Requirements.--
``(1) Notice of right of access to itemized bills; in
general.--A health care provider or health care facility that
requests payment from an individual for providing a health care
item or service to the patient shall include with such request
a written notice of the individual's right to request an
itemized bill as part of the individual's designated record set
under section 164,524 of title 45, Code of Federal Regulations
(or a successor regulation).
``(2) Required information.--A notice under paragraph (1)
shall provide--
``(A) a phone number and internet website where an
individual can make a request for access to their
itemized bill;
``(B) information about the availability of
language-assistance services for individuals with
limited English proficiency (LEP); and
``(C) information about the health care provider's
or health care facility's charity care policies and
instructions on how to apply for charity care.
``(3) Collections actions.--
``(A) In general.--A health care provider or health
care facility shall not bill or take any collections
actions against an individual--
``(i) for any provided health care item or
service unless the health care provider or
health care facility has complied with
paragraph (1) or section 13405(e)(4) of the
HITECH Act; or
``(ii) with respect to any items or
services for which the amount appearing on an
itemized bill described above in paragraph (1)
exceeds the amount disclosed pursuant to
Federal health care price transparency
regulations, including part 180 of title 45,
Code of Federal Regulations, or provided in a
good faith estimate that complies with section
2799B-6 of this Act and section 149.610 of
title 45, Code of Federal Regulations, or
another good faith estimate provided by a
health care entity covered under this section
but not otherwise covered under such section
2799B-6, unless the provider or facility
documents that the additional items or services
were medically necessary due to unforeseen
complications or a patient-initiated change,
and could not reasonably have been anticipated.
``(B) Provider requirement.--If a provider fails to
provide a documentation as required under subparagraph
(A)(ii) in the case of items or services, the good
faith estimate described in such subparagraph with
respect to such items or services shall be binding.
``(b) Failure To Comply.--
``(1) Penalties.--The Secretary shall impose penalties on
any health care provider or health care facility that fails to
comply with the requirements of this section in an amount not
to exceed $10,000 for each instance of failure to comply.
``(2) Presumption in favor of individual.--If a health care
provider or health care facility fails to comply with the
requirements of this section, the presumption shall be that
charges were substantially in excess of the good faith
estimate, as set forth in section 2799B-6, for the purpose of
any patient-provider dispute, including in accordance with
section 2799B-7 and regulations promulgated thereunder.
``(c) Regulations.--The Secretary shall implement this section
through notice and comment rulemaking in accordance with section 553 of
title 5, United States Code.''.
(b) Standards for Accessing Itemized Bills.--Section 13405(e) of
the HITECH Act (42 U.S.C. 17935(e)) is amended--
(1) in paragraph (2), by striking ``and'' at the end;
(2) in paragraph (3), by striking the period and inserting
``; and''; and
(3) by adding at the end, the following:
``(4) if the individual makes a request only for an
itemized copy of a bill for services provided, the covered
entity or business associate shall--
``(A) make such protected health information
available within 30 days of such request;
``(B) not impose any fee for providing such
individual a copy of their information; and
``(C) include in such itemized bill, a plain
language description of each distinct health care item
or service, all applicable billing codes for each
distinct item or service, including modifiers, using
standard and commonly recognized billing code sets, the
price and billed amount, if different, of each distinct
item or service.''.
SEC. 12. TECHNICAL AMENDMENTS.
(a) ERISA.--Section 715(a)(1) of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1185d(a)(1)) is amended by inserting
``and parts D and E of the Public Health Service Act (as amended by the
Patients Deserve Price Tags Act)'' after ``Affordable Care Act)''.
(b) Internal Revenue Code.--Section 9815(a)(1) of the Internal
Revenue Code of 1986 is amended by inserting ``and parts D and E of the
Public Health Service Act (as amended by the Patients Deserve Price
Tags Act)'' after ``Affordable Care Act)''.
SEC. 13. IMPLEMENTATION AND ENFORCEMENT FUNDING.
(a) Appropriation for Secretary of Labor.--There are authorized to
be appropriated, such sums as may be necessary for fiscal year 2026,
and each subsequent fiscal year, to enable the Secretary of Labor to
carry out this Act and the amendments made by this Act, including
enforcement activities.
(b) Appropriation for the Secretary of Health and Human Services.--
There are authorized to be appropriated, such sums as may be necessary
for fiscal year 2026, and each subsequent fiscal year, to enable the
Secretary of Health and Human Services to carry out the amendments made
by this Act, including implementation and enforcement activities.
Calendar No. 522
119th CONGRESS
2d Session
S. 2355
_______________________________________________________________________
A BILL
To amend the Public Health Service Act to provide for hospital and
insurer price transparency.
_______________________________________________________________________
July 27, 2026
Reported with an amendment