[Congressional Record Volume 169, Number 203 (Monday, December 11, 2023)]
[House]
[Pages H6762-H6789]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
LOWER COSTS, MORE TRANSPARENCY ACT
Mrs. RODGERS of Washington. Mr. Speaker, I move to suspend the rules
and pass the bill (H.R. 5378) to promote price transparency in the
health care sector, and for other purposes, as amended.
The Clerk read the title of the bill.
The text of the bill is as follows:
H.R. 5378
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Lower Costs, More
Transparency Act''.
SEC. 2. TABLE OF CONTENTS.
The table of contents of this Act is as follows:
Sec. 1. Short title.
Sec. 2. Table of contents.
TITLE I--IMPROVING HEALTH CARE TRANSPARENCY
Sec. 101. Hospital price transparency.
Sec. 102. Clinical diagnostic laboratory test price transparency.
Sec. 103. Imaging price transparency.
Sec. 104. Ambulatory surgical center price transparency.
Sec. 105. Health coverage price transparency.
Sec. 106. Pharmacy benefits price transparency.
Sec. 107. Reports on health care transparency tools and data.
Sec. 108. Report on integration in Medicare.
Sec. 109. Advisory Committee.
Sec. 110. Report on impact of Medicare regulations on provider and
payer consolidation.
Sec. 111. Implementation funding.
TITLE II--REDUCING HEALTH CARE COSTS FOR PATIENTS
Sec. 201. Increasing transparency in generic drug applications.
Sec. 202. Improving transparency and preventing the use of abusive
spread pricing and related practices in Medicaid.
Sec. 203. Parity in Medicare payments for hospital outpatient
department services furnished off-campus.
Sec. 204. Requiring a separate identification number and an attestation
for each off-campus outpatient department of a provider.
TITLE III--SUPPORTING PATIENTS, HEALTH CARE WORKERS, COMMUNITY HEALTH
CENTERS, AND HOSPITALS
Sec. 301. Extension for community health centers, the national health
service corps, and teaching health centers that operate
GME programs.
Sec. 302. Extension of special diabetes programs.
Sec. 303. Delaying certain disproportionate share payment cuts.
Sec. 304. Medicaid improvement fund.
TITLE IV--INCREASING ACCESS TO QUALITY HEALTH DATA AND LOWERING HIDDEN
FEES
Sec. 401. Increasing Plan Fiduciaries' Access to Health Data.
Sec. 402. Hidden Fees Disclosure Requirements.
Sec. 403. Prescription drug price information requirement.
Sec. 404. Implementation funding.
TITLE I--IMPROVING HEALTH CARE TRANSPARENCY
SEC. 101. HOSPITAL PRICE TRANSPARENCY.
(a) Medicare.--Part E of title XVIII of the Social Security
Act (42 U.S.C. 1395x et seq.) is amended by adding at the end
the following new section:
``SEC. 1899C. HOSPITAL PRICE TRANSPARENCY.
``(a) Transparency Requirement.--
``(1) In general.--Beginning January 1, 2026, each
specified hospital that receives payment under this title for
furnishing items and services shall comply with the price
transparency requirement described in paragraph (2).
``(2) Requirement described.--
``(A) In general.--For purposes of paragraph (1), the price
transparency requirement described in this paragraph is, with
respect to a specified hospital, that such hospital, in
accordance with a method and format established by the
Secretary under subparagraph (C), compile and make public
(without subscription and free of charge) for each year--
``(i) all of the hospital's standard charges (including the
information described in subparagraph (B)) for each item and
service furnished by such hospital;
``(ii) information in a consumer-friendly format (as
specified by the Secretary)--
``(I) on the hospital's prices (including the information
described in subparagraph (B)) for as many of the Centers for
Medicare & Medicaid Services-specified shoppable services
that are furnished by the hospital, and as many additional
hospital-selected shoppable services (or all such additional
services, if such hospital furnishes fewer than 300 shoppable
services) as may be necessary for a combined total of at
least 300 shoppable services; and
``(II) that includes, with respect to each Centers for
Medicare & Medicaid Services-specified shoppable service that
is not furnished by the hospital, an indication that such
service is not so furnished; and
``(iii) an attestation that all information made public
pursuant to this subparagraph is complete and accurate.
``(B) Information described.--For purposes of subparagraph
(A), the information described in this subparagraph is, with
respect to standard charges and prices, as applicable, made
public by a specified hospital, the following:
``(i) A plain language description of each item or service,
accompanied by, as applicable, the Healthcare Common
Procedure Coding System code, the diagnosis-related group,
the national drug code, or other identifier used or approved
by the Centers for Medicare & Medicaid Services.
``(ii) The gross charge, as applicable, expressed as a
dollar amount, for each such item or service, when provided
in, as applicable, the inpatient setting and outpatient
department setting.
``(iii) The discounted cash price, as applicable, expressed
as a dollar amount, for each such item or service when
provided in, as applicable, the inpatient setting and
outpatient department setting (or, in the case no discounted
cash price is available for an item or service, the median
cash price charged by the hospital to 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 hospital's charity care policy that
[[Page H6763]]
includes, if applicable, any sliding scale payment structure
employed for determining charges for a self-pay individual).
``(iv) The payer-specific negotiated charges, as
applicable, clearly associated with the name of the third
party payer and plan and expressed as a dollar amount, that
apply to each such item or service when provided in, as
applicable, the inpatient setting and outpatient department
setting.
``(v) The de-identified maximum and minimum negotiated
charges, as applicable, for each such item or service.
``(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.
``(C) Uniform method and format.--Not later than January 1,
2026, the Secretary shall establish a standard, uniform
method and format for specified hospitals to use in compiling
and making public standard charges pursuant to subparagraph
(A)(i) 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--
``(i) shall, 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 format (or a successor technology specified
by the Secretary);
``(ii) may be similar to any template made available by the
Centers for Medicare & Medicaid Services as of the date of
the enactment of this subparagraph;
``(iii) shall meet such standards as determined appropriate
by the Secretary in order to ensure the accessibility and
usability of such charges and prices; and
``(iv) shall be updated as determined appropriate by the
Secretary, in consultation with stakeholders.
``(3) Monitoring compliance.--The Secretary shall, through
notice and comment rulemaking and in consultation with the
Inspector General of the Department of Health and Human
Services, establish a process to monitor compliance with this
subsection. Such process shall ensure that each specified
hospital's compliance with this subsection is reviewed not
less frequently than once every 3 years.
``(4) Enforcement.--
``(A) In general.--In the case of a specified hospital that
fails to comply with the requirements of this subsection--
``(i) not later than 30 days after the date on which the
Secretary determines such failure exists, the Secretary shall
submit to such hospital a notification of such determination
(which may include, as determined appropriate by the
Secretary, a request for a corrective action plan to comply
with such requirements); and
``(ii) in the case of a hospital that does not receive a
request for a corrective action plan as part of a
notification submitted by the Secretary under clause (i)--
``(I) the Secretary shall, not later than 45 days after
such notification is sent, determine whether such hospital is
in compliance with such requirements; and
``(II) if the Secretary determines under subclause (I) that
such hospital is not in compliance with such requirements,
the Secretary shall either--
``(aa) submit to such hospital a request for a corrective
action plan to comply with such requirements; or
``(bb) if the Secretary determines that such hospital has
not taken meaningful actions to come into compliance since
such notification was sent, impose a civil monetary penalty
in accordance with subparagraph (B).
``(B) Civil monetary penalty.--
``(i) In general.--Subject to clause (vii), in addition to
any other enforcement actions or penalties that may apply
under another provision of law, a specified hospital that has
received a request for a corrective action plan under clause
(i) or (ii) of subparagraph (A) and fails to comply with the
requirements of this subsection by the date that is 45 days
after such request is made, and a specified hospital with
respect to which the Secretary has made a determination
described in clause (ii)(II)(bb) of such subparagraph, shall
be subject to a civil monetary penalty of an amount specified
by the Secretary for each day (beginning with the day on
which the Secretary first determined that such hospital was
not complying with such requirements) during which such
failure was ongoing. Such amount shall not exceed--
``(I) in the case of a specified hospital with 30 or fewer
beds, $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 violations occurring in 2027 or a subsequent
year, the Secretary may through notice and comment rulemaking
increase--
``(I) the limitation on the per day amount of any penalty
applicable to a specified hospital 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 amounts specified in clause (iii)(II).
``(iii) Persistent noncompliance.--
``(I) In general.--In the case of a specified hospital
(other than a specified hospital with 30 or fewer beds) that
the Secretary has determined to be knowingly and willfully
noncompliant with the provisions of this subsection 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.
``(II) Specified amount.--For purposes of subclause (I),
the amount specified in this subclause is, with respect to a
specified hospital--
``(aa) with more than 30 beds but fewer than 101 beds, an
amount that is not less than $500,000 and not more than
$1,000,000;
``(bb) with more than 100 beds but fewer than 301 beds, an
amount that is greater than $1,000,000 and not more than
$2,000,000;
``(cc) with more than 300 beds but fewer than 501 beds, an
amount that is greater than $2,000,000 and not more than
$4,000,000; and
``(dd) with more than 500 beds, and amount that is not less
than $5,000,000 and not more than $10,000,000.
``(iv) Authority to waive or reduce penalty.--
``(I) In general.--Subject to subclause (II), the Secretary
may waive any penalty, or reduce any penalty by not more than
75 percent, otherwise applicable under this subparagraph with
respect to a specified hospital located in a rural or
underserved area if the Secretary certifies that imposition
of such penalty would result in an immediate threat to access
to care for individuals in the service area of such hospital.
``(II) Limitation on application.--The Secretary may not
elect to waive a penalty under subclause (I) with respect to
a specified hospital more than once in a 6-year period and
may not elect to reduce such a penalty with respect to such a
hospital more than once in such a period. Nothing in the
preceding sentence shall be construed as prohibiting the
Secretary from both waiving and reducing a penalty with
respect to a specified hospital during a 6-year period.
``(v) Provision of technical assistance.--The Secretary
shall, to the extent practicable, provide technical
assistance relating to compliance with the provisions of this
subsection to specified hospitals requesting such assistance.
``(vi) 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.
``(vii) Nonduplication of certain penalties.--The Secretary
may not subject a specified hospital to a civil monetary
penalty under this subparagraph with respect to noncompliance
with the provisions of this section for a period if the
Secretary has imposed a civil monetary penalty on such
hospital under section 2718(f) of the Public Health Service
Act for failure to comply with the provisions of such section
for such period.
``(C) Publication of hospital price transparency
information.--Beginning on January 1, 2026, the Secretary
shall make publicly available on the public website of the
Centers for Medicare & Medicaid Services information with
respect to compliance with the requirements of this
subsection and enforcement activities undertaken by the
Secretary under this subsection. Such information shall be
updated in real time and include--
``(i) the number of reviews of compliance with this
subsection undertaken by the Secretary;
``(ii) the number of notifications described in
subparagraph (A)(i) sent by the Secretary;
[[Page H6764]]
``(iii) the identity of each specified hospital that was
sent such a notification and a description of the nature of
such hospital's noncompliance with this subsection;
``(iv) the amount of any civil monetary penalty imposed on
such hospital under subparagraph (B);
``(v) whether such hospital subsequently came into
compliance with this subsection;
``(vi) any waivers or reductions of penalties made pursuant
to a certification by the Secretary under subparagraph
(B)(iv), including--
``(I) the name of any specified hospital that received such
a waiver or reduction;
``(II) the dollar amount of each such penalty so waived or
reduced; and
``(III) the rationale for the granting of each such waiver
or reduction; and
``(vii) any other information as determined by the
Secretary.
``(b) Ensuring Accessibility Through Implementation.--In
implementing the amendments made by this section, the
Secretary of Health and Human Services shall through
rulemaking ensure that a hospital submitting charges and
information pursuant to such amendments takes reasonable
steps (as specified by the Secretary) to ensure the
accessibility of such charges and information to individuals
with limited English proficiency. Such steps may include the
hospital's provision of interpretation services or the
hospital's provision of translations of charges and
information.
``(c) Definitions.--For purposes of this section:
``(1) Discounted cash price.--The term `discounted cash
price' means the charge that applies to an individual who
pays cash, or cash equivalent, for an item or service.
``(2) Federal health care program.--The term `Federal
health care program' has the meaning given such term in
section 1128B.
``(3) Gross charge.--The term `gross charge' means the
charge for an individual item or service that is reflected on
a specified hospital's or provider of service's or
supplier's, as applicable, chargemaster, absent any
discounts.
``(4) 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.
``(5) Payer-specific negotiated charge.--The term `payer-
specific negotiated charge' means the charge that a specified
hospital or provider of services or supplier, as applicable,
has negotiated with a third party payer for an item or
service.
``(6) 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.
``(7) Specified hospital.--The term `specified hospital'
means a hospital (as defined in section 1861(e)), a critical
access hospital (as defined in section 1861(mmm)(1)), or a
rural emergency hospital (as defined in section 1861(kkk)).
``(8) 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) PHSA.--
(1) In general.--Section 2718 of the Public Health Service
Act (42 U.S.C. 300gg-18) is amended by adding at the end the
following new subsection:
``(f) Hospital Transparency Requirement.--
``(1) In general.--Beginning January 1, 2026, each hospital
shall comply with the price transparency requirement
described in paragraph (2).
``(2) Requirement described.--
``(A) In general.--For purposes of paragraph (1), the price
transparency requirement described in this paragraph is, with
respect to a hospital, that such hospital, in accordance with
a method and format established by the Secretary under
subparagraph (C), compile and make public (without
subscription and free of charge) for each year--
``(i) all of the hospital's standard charges (including the
information described in subparagraph (B)) for each item and
service furnished by such hospital;
``(ii) information in a consumer-friendly format (as
specified by the Secretary)--
``(I) on the hospital's prices (including the information
described in subparagraph (B)) for as many of the Centers for
Medicare & Medicaid Services-specified shoppable services
that are furnished by the hospital, and as many additional
hospital-selected shoppable services (or all such additional
services, if such hospital furnishes fewer than 300 shoppable
services) as may be necessary for a combined total of at
least 300 shoppable services; and
``(II) that includes, with respect to each Centers for
Medicare & Medicaid Services-specified shoppable service that
is not furnished by the hospital, an indication that such
service is not so furnished; and
``(iii) an attestation that all information made public
pursuant to this subparagraph is complete and accurate.
``(B) Information described.--For purposes of subparagraph
(A), the information described in this subparagraph is, with
respect to standard charges and prices, as applicable, made
public by a hospital, the following:
``(i) A plain language description of each item or service,
accompanied by, as applicable, the Healthcare Common
Procedure Coding System code, the diagnosis-related group,
the national drug code, current procedure terminology codes,
or other identifier used or approved by the Centers for
Medicare & Medicaid Services.
``(ii) The gross charge, as applicable, expressed as a
dollar amount, for each such item or service, when provided
in, as applicable, the inpatient setting and outpatient
department setting.
``(iii) The discounted cash price, as applicable, expressed
as a dollar amount, for each such item or service when
provided in, as applicable, the inpatient setting and
outpatient department setting (or, in the case no discounted
cash price is available for an item or service, the median
cash price charged by the hospital to 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 hospital's charity care policy that
includes, if applicable, any sliding scale payment structure
employed for determining charges for a self-pay individual).
``(iv) The payer-specific negotiated charges, as
applicable, clearly associated with the name of the third
party payer and plan and expressed as a dollar amount, that
apply to each such item or service when provided in, as
applicable, the inpatient setting and outpatient department
setting.
``(v) The de-identified maximum and minimum negotiated
charges, as applicable, for each such item or service.
``(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.
``(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--
``(i) shall, 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 format (or a successor technology specified
by the Secretary);
``(ii) may be similar to any template made available by the
Centers for Medicare & Medicaid Services as of the date of
the enactment of this subparagraph;
``(iii) shall meet such standards as determined appropriate
by the Secretary in order to ensure the accessibility and
usability of such charges and prices; and
``(iv) shall be updated as determined appropriate by the
Secretary, in consultation with stakeholders.
``(3) Monitoring compliance.--The Secretary shall, through
notice and comment rulemaking and in consultation with the
Inspector General of the Department of Health and Human
Services, establish a process to monitor compliance with this
subsection. Such process shall ensure that each hospital's
compliance with this subsection is reviewed not less
frequently than once every 3 years.
``(4) Enforcement.--
``(A) In general.--In the case of a hospital that fails to
comply with the requirements of this subsection--
``(i) not later than 30 days after the date on which the
Secretary determines such failure exists, the Secretary shall
submit to such hospital a notification of such determination
(which may include, as determined appropriate by the
Secretary, a request for a corrective action plan to comply
with such requirements); and
``(ii) in the case of a hospital that does not receive a
request for a corrective action plan as part of a
notification submitted by the Secretary under clause (i)--
``(I) the Secretary shall, not later than 45 days after
such notification is sent, determine whether such hospital is
in compliance with such requirements; and
``(II) if the Secretary determines under subclause (I) that
such hospital is not in compliance with such requirements,
the Secretary shall either--
``(aa) submit to such hospital a request for a corrective
action plan to comply with such requirements; or
``(bb) if the Secretary determines that such hospital has
not taken meaningful actions to come into compliance since
such notification was sent, impose a civil monetary penalty
in accordance with subparagraph (B).
``(B) Civil monetary penalty.--
``(i) In general.--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 clause (i) or (ii) of
subparagraph (A) and fails to comply with the requirements of
this subsection by the
[[Page H6765]]
date that is 45 days after such request is made, and a
hospital with respect to which the Secretary has made a
determination described in clause (ii)(II)(bb) of such
subparagraph, shall be subject to a civil monetary penalty of
an amount specified by the Secretary for each day (beginning
with the day on which the Secretary first determined that
such hospital was not complying with such requirements)
during which such failure was ongoing. Such amount shall not
exceed--
``(I) in the case of a 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 bed per day);
``(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);
``(III) in the case of a 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 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 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 violations occurring in 2027 or a subsequent
year, the Secretary may through notice and comment rulemaking
increase--
``(I) the limitation on the per day amount of any penalty
applicable to a 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 amounts specified in clause (iii)(II).
``(iii) Persistent noncompliance.--
``(I) In general.--In the case of a hospital (other than a
hospital with 30 or fewer beds) that the Secretary has
determined to be knowingly and willfully noncompliant with
the provisions of this subsection two or more times during a
1-year period, the Secretary may increase any penalty
otherwise applicable under this subparagraph by 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) Authority to waive or reduce penalty.--
``(I) In general.--Subject to subclause (II), the Secretary
may waive any penalty, or reduce any penalty by not more than
75 percent, otherwise applicable under this subparagraph with
respect to a hospital located in a rural or underserved area
if the Secretary certifies that imposition of such penalty
would result in an immediate threat to access to care for
individuals in the service area of such hospital.
``(II) Limitation on application.--The Secretary may not
elect to waive a penalty under subclause (I) with respect to
a hospital more than once in a 6-year period and may not
elect to reduce such a penalty with respect to such a
hospital more than once in such a period. Nothing in the
preceding sentence shall be construed as prohibiting the
Secretary from both waiving and reducing a penalty with
respect to a hospital during a 6-year period.
``(v) Provision of technical assistance.--The Secretary
shall, to the extent practicable, provide technical
assistance relating to compliance with the provisions of this
section to hospitals requesting such assistance.
``(vi) 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.
``(vii) Nonduplication of penalties.--The Secretary may not
subject a hospital to a civil monetary penalty under this
subparagraph with respect to noncompliance with the
provisions of this subsection for a period if the Secretary
has imposed a civil monetary penalty on such hospital under
section 1899C of the Social Security Act for failure to
comply with the provisions of such section for such period.
``(C) Publication of hospital price transparency
information.--Beginning on January 1, 2026, the Secretary
shall make publicly available on the public website of the
Centers for Medicare & Medicaid Services information with
respect to compliance with the requirements of this
subsection and enforcement activities undertaken by the
Secretary under this subsection. Such information shall be
updated in real time and include--
``(i) the number of reviews of compliance with this
subsection undertaken by the Secretary;
``(ii) the number of notifications described in
subparagraph (A)(i) sent by the Secretary;
``(iii) the identity of each hospital that was sent such a
notification and a description of the nature of such
hospital's noncompliance with this subsection;
``(iv) the amount of any civil monetary penalty imposed on
such hospital under subparagraph (B);
``(v) whether such hospital subsequently came into
compliance with this subsection;
``(vi) any waivers or reductions of penalties made pursuant
to a certification by the Secretary under subparagraph
(B)(iv), including--
``(I) the name of any hospital that received such a waiver
or reduction;
``(II) the dollar amount of each such penalty so waived or
reduced; and
``(III) the rationale for the granting of each such waiver
or reduction; and
``(vii) any other information as determined by the
Secretary.
``(5) Ensuring accessibility through implementation.--In
implementing the amendments made by this section, the
Secretary of Health and Human Services shall through
rulemaking ensure that a hospital submitting charges and
information pursuant to such amendments takes reasonable
steps (as specified by the Secretary) to ensure the
accessibility of such charges and information to individuals
with limited English proficiency. Such steps may include the
hospital's provision of interpretation services or the
hospital's provision of translations of charges and
information.
``(6) Definitions.--For purposes of this subsection:
``(A) Discounted cash price.--The term `discounted cash
price' means the charge that applies to an individual who
pays cash, or cash equivalent, for a hospital-furnished item
or service.
``(B) Federal health care program.--The term `Federal
health care program' has the meaning given such term in
section 1128B of the Social Security Act.
``(C) 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.
``(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.
``(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.
``(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.''.
(2) Conforming amendments.--Section 2718 of the Public
Health Service Act (42 U.S.C. 300gg-18) is amended--
(A) in subsection (b)(3), by inserting ``(other than the
provisions of subsection (f))'' after ``this section''; and
(B) in subsection (e), by adding at the end the following
new sentence: ``The preceding provisions of this subsection
shall not apply beginning on January 1, 2026.''.
(3) Effective date.--The amendments made by this subsection
shall apply beginning January 1, 2026.
(c) Accessibility Through Implementation.--In implementing
the amendments made by this section, the Secretary of Health
and Human Services shall through rulemaking ensure that a
hospital submitting charges and information pursuant to such
amendments takes reasonable steps (as specified by the
Secretary) to ensure the accessibility of such charges and
information to individuals with limited English proficiency.
Such steps may include the hospital's provision of
interpretation services or the hospital's provision of
translations of charges and information.
SEC. 102. CLINICAL DIAGNOSTIC LABORATORY TEST PRICE
TRANSPARENCY.
Section 1846 of the Social Security Act (42 U.S.C. 1395w-2)
is amended--
(1) in the header, by inserting ``and additional
requirements'' after ``sanctions''; and
(2) by adding at the end the following new subsection:
``(c) Price Transparency Requirement.--
``(1) In general.--Beginning January 1, 2026, any
applicable laboratory that receives payment under this title
for furnishing any specified clinical diagnostic laboratory
test under this title shall--
``(A) make publicly available on an internet website the
information described in
[[Page H6766]]
paragraph (2) with respect to each such specified clinical
diagnostic laboratory test that such laboratory so furnishes;
and
``(B) ensure that such information is updated not less
frequently than annually.
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph is, with
respect to an applicable laboratory and a specified clinical
diagnostic laboratory test, the following:
``(A) The discounted cash price for such test (or, if no
such price exists, the gross charge for such test).
``(B) The deidentified minimum payer-specific negotiated
charge between such laboratory and any third party payer for
such test.
``(C) The deidentified maximum payer-specific negotiated
charge between such laboratory and any third party payer for
such test.
``(3) Uniform method and format.--Not later than January 1,
2026, the Secretary shall establish a standard, uniform
method and format for applicable laboratories to use in
compiling and making public information pursuant to paragraph
(1). Such method and format--
``(A) may be similar to any template made available by the
Centers for Medicare & Medicaid Services (as described in
section 1899C(a)(2)(C)(ii));
``(B) shall meet such standards as determined appropriate
by the Secretary in order to ensure the accessibility and
usability of such information; and
``(C) shall be updated as determined appropriate by the
Secretary, in consultation with stakeholders.
``(4) Inclusion of ancillary services.--Any price or 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 (as applicable) for any ancillary item or
service (such as specimen collection services) that would
normally be furnished by such laboratory as part of such
test, as specified by the Secretary.
``(5) Enforcement.--
``(A) In general.--In the case that the Secretary
determines that an applicable laboratory is not in compliance
with paragraph (1)--
``(i) not later than 30 days after such determination, the
Secretary shall notify such laboratory of such determination;
and
``(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
(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.
``(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 per day limitation on civil monetary penalties
under subparagraph (A)(ii).
``(C) Application of certain provisions.--The provisions of
section 1128A (other than subsections (a) and (b) of such
section) shall apply to a civil monetary penalty imposed
under this paragraph in the same manner as such provisions
apply to a civil monetary penalty imposed under subsection
(a) of such section.
``(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.
``(7) Definitions.--In this subsection:
``(A) Applicable laboratory.--The term `applicable
laboratory' has the meaning given such term in section
414.502, of title 42, Code of Federal Regulations (or a
successor regulation), except that such term does not include
a laboratory with respect to which standard charges and
prices for specified clinical diagnostic laboratory tests
furnished by such laboratory are made available by a hospital
pursuant to section 1899C or section 2718(f) of the Public
Health Service Act.
``(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.
``(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.
``(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.
``(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 section
1899C(a)(2)(A)(ii)(I)), other than such a test that is only
available to be furnished by a single provider of services or
supplier.
``(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.''.
SEC. 103. IMAGING PRICE TRANSPARENCY.
Section 1899C of the Social Security Act, as added by
section 101, is amended--
(1) by redesignating subsection (b) as subsection (c);
(2) by inserting after subsection (a) the following new
subsection:
``(b) Imaging Services Price Transparency.--
``(1) In general.--Beginning January 1, 2028, each provider
of services and supplier that receives payment under this
title for furnishing a specified imaging service, other than
such a provider or supplier with respect to which standard
charges and prices for such services furnished by such
provider or supplier are made available by a hospital
pursuant to section 1899C or section 2718(f) of the Public
Health Service Act, shall--
``(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
``(B) ensure that such information is updated not less
frequently than annually.
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph is, with
respect to a provider of services or supplier and a specified
imaging service, the following:
``(A) The discounted cash price for such service (or, if no
such price exists, the gross charge for such service).
``(B) If required by the Secretary, the deidentified
minimum payer-specific negotiated charge for such service and
the deidentified maximum payer-specific negotiated charge for
such service.
``(3) Uniform method and format.--Not later than January 1,
2028, the Secretary shall establish a standard, uniform
method and format for providers of services and suppliers to
use in making public information described in paragraph (2).
Any such method and format--
``(A) may be similar to any template made available by the
Centers for Medicare & Medicaid Services (as described in
section 1899C(a)(2)(C)(ii));
``(B) shall meet such standards as determined appropriate
by the Secretary in order to ensure the accessibility and
usability of such information; and
``(C) shall be updated as determined appropriate by the
Secretary, in consultation with stakeholders.
``(4) Monitoring compliance.--The Secretary shall, through
notice and comment rulemaking and in consultation with the
Inspector General of the Department of Health and Human
Services, establish a process to monitor compliance with this
subsection.
``(5) Enforcement.--
``(A) In general.--In the case that the Secretary
determines that a provider of services or supplier is not in
compliance with paragraph (1)--
``(i) not later than 30 days after such determination, the
Secretary shall notify such provider or supplier of such
determination;
``(ii) upon request of the Secretary, such provider or
supplier shall submit to the Secretary, not later than 45
days after the date of such request, a corrective action plan
to comply with such paragraph; and
``(iii) if such provider or supplier continues to fail to
comply with such paragraph after the date that is 90 days
after such notification is sent (or, in the case of such a
provider or supplier that has submitted a corrective action
plan described in clause (ii) in response to a request so
described, after the date that is 90 days after such
submission), the Secretary may impose a civil monetary
penalty in an amount not to exceed $300 for each 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.
``(B) Increase authority.--In applying this paragraph with
respect to violations occurring in 2029 or a subsequent year,
the Secretary may through notice and comment rulemaking
increase the amount of the civil monetary penalty under
subparagraph (A)(iii).
``(C) Application of certain provisions.--The provisions of
section 1128A (other than subsections (a) and (b) of such
section) shall apply to a civil monetary penalty imposed
under this paragraph in the same manner as such provisions
apply to a civil monetary penalty imposed under subsection
(a) of such section.
``(D) Authority to waive or reduce penalty.--
``(i) In general.--Subject to clause (ii), the Secretary
may waive or reduce any penalty otherwise applicable with
respect to a provider of services or supplier under this
subparagraph if the Secretary certifies that imposition of
such penalty would result in an immediate threat to access to
care for individuals in the service area of such provider or
supplier.
``(ii) Limitation.--The Secretary may not elect to waive or
reduce a penalty under clause (i) with respect to a specific
provider of services or supplier more than 3 times.
``(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.
``(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.''; and
[[Page H6767]]
(3) in subsection (c), as so redesignated by paragraph
(1)--
(A) by redesignating paragraph (8) as paragraph (9); and
(B) by inserting after paragraph (7) the following new
paragraph:
``(8) Specified imaging service.--the term `specified
imaging service' means an imaging service that is a Centers
for Medicare & Medicaid Services-specified shoppable service
(as described in subsection (a)(2)(A)(ii)(I)).''.
SEC. 104. AMBULATORY SURGICAL CENTER PRICE TRANSPARENCY.
Section 1834 of the Social Security Act (42 U.S.C. 1395m)
is amended by adding at the end the following new subsection:
``(aa) Ambulatory Surgical Center Price Transparency.--
``(1) In general.--Beginning January 1, 2026, each
ambulatory surgical center that receives payment under this
title for furnishing items and services shall comply with the
price transparency requirement described in paragraph (2).
``(2) Requirement described.--
``(A) In general.--For purposes of paragraph (1), the price
transparency requirement described in this subsection is,
with respect to an ambulatory surgical center, that such
surgical center in accordance with a method and format
established by the Secretary under subparagraph (C), compile
and make public (without subscription and free of charge),
for each year--
``(i) all of the ambulatory surgical center's standard
charges (including the information described in subparagraph
(B)) for each item and service furnished by such surgical
center;
``(ii) information on the ambulatory surgical center's
prices (including the information described in subparagraph
(B)) for as many of the Centers for Medicare & Medicaid
Services-specified shoppable services that are furnished by
such surgical center, and as many additional ambulatory
surgical center-selected shoppable services (or all such
additional services, if such surgical center furnishes fewer
than 300 shoppable services) as may be necessary for a
combined total of at least 300 shoppable services; and
``(iii) with respect to each Centers for Medicare &
Medicaid Services-specified shoppable service that is not
furnished by the ambulatory surgical center, an indication
that such service is not so furnished.
``(B) Information described.--For purposes of subparagraph
(A), the information described in this subparagraph is, with
respect to standard charges and prices (as applicable) made
public by an ambulatory surgical center, the following:
``(i) A plain language description of each item or service,
accompanied by, as applicable, the Healthcare Common
Procedure Coding System code, the diagnosis-related group,
the national drug code, or other identifier used or approved
by the Centers for Medicare & Medicaid Services.
``(ii) The gross charge, as applicable, expressed as a
dollar amount, for each such item or service.
``(iii) The discounted cash price, as applicable, 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 median cash price charged to self-pay
individuals for such item or service for the previous three
years, expressed as a dollar amount).
``(iv) The current payer-specific negotiated charges,
clearly associated with the name of the third party payer and
plan and expressed as a dollar amount, that applies to each
such item or service.
``(v) The de-identified maximum and minimum negotiated
charges, as applicable, for each such item or service.
``(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.
``(C) Uniform method and format.--Not later than January 1,
2026, the Secretary shall establish a standard, uniform
method and format for ambulatory surgical centers to use in
making public standard charges and a standard, uniform method
and format for such centers to use in making public prices
pursuant to subparagraph (A). Any such method and format--
``(i) shall, 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 (or successor
technology);
``(ii) may be similar to any template made available by the
Centers for Medicare & Medicaid Services as of the date of
the enactment of this paragraph;
``(iii) shall meet such standards as determined appropriate
by the Secretary in order to ensure the accessibility and
usability of such charges and prices; and
``(iv) shall be updated as determined appropriate by the
Secretary, in consultation with stakeholders.
``(3) Monitoring compliance.--The Secretary shall, through
notice and comment rulemaking and in consultation with the
Inspector General of the Department of Health and Human
Services, establish a process to monitor compliance with this
subsection. Such process shall ensure that each ambulatory
surgical center's compliance with this subsection is reviewed
not less frequently than once every 3 years.
``(4) Enforcement.--
``(A) In general.--In the case of an ambulatory surgical
center that fails to comply with the requirements of this
subsection--
``(i) the Secretary shall notify such ambulatory surgical
center of such failure not later than 30 days after the date
on which the Secretary determines such failure exists; and
``(ii) upon request of the Secretary, the ambulatory
surgical center shall submit to the Secretary, not later than
45 days after the date of such request, a corrective action
plan to comply with such requirements.
``(B) Civil monetary penalty.--
``(i) In general.--In addition to any other enforcement
actions or penalties that may apply under another provision
of law, an ambulatory surgical center that has received a
notification under subparagraph (A)(i) and fails to comply
with the requirements of this subsection by the date that is
90 days after such notification (or, in the case of an
ambulatory surgical center that has submitted a corrective
action plan described in subparagraph (A)(ii) in response to
a request so described, by the date that is 90 days after
such submission) shall be subject to a civil monetary penalty
of an amount specified by the Secretary for each subsequent
day during which such failure is ongoing (not to exceed $300
per day).
``(ii) Increase authority.--In applying this subparagraph
with respect to violations occurring in 2027 or a subsequent
year, the Secretary may through notice and comment rulemaking
increase the limitation on the per day amount of any penalty
applicable to an ambulatory surgical center under clause (i).
``(iii) Application of certain provisions.--The provisions
of section 1128A (other than subsections (a) and (b) of such
section) shall apply to a civil monetary penalty imposed
under this subparagraph in the same manner as such provisions
apply to a civil monetary penalty imposed under subsection
(a) of such section.
``(iv) Authority to waive or reduce penalty.--
``(I) In general.--Subject to subclause (II), the Secretary
may waive any penalty, or reduce any penalty by not more than
75 percent, otherwise applicable under this subparagraph with
respect to an ambulatory surgical center located in a rural
or underserved area if the Secretary certifies that
imposition of such penalty would result in an immediate
threat to access to care for individuals in the service area
of such surgical center.
``(II) Limitation on application.--The Secretary may not
elect to waive a penalty under subclause (I) with respect to
an ambulatory surgical center more than once in a 6-year
period and may not elect to reduce such a penalty with
respect to such a surgical center more than once in such a
period. Nothing in the preceding sentence shall be construed
as prohibiting the Secretary from both waiving and reducing a
penalty with respect to an ambulatory surgical center during
a 6-year period.
``(5) Definitions.--For purposes of this section:
``(A) Discounted cash price.--The term `discounted cash
price' means the charge that applies to an individual who
pays cash, or cash equivalent, for a item or service
furnished by an ambulatory surgical center.
``(B) Federal health care program.--The term `Federal
health care program' has the meaning given such term in
section 1128B.
``(C) Gross charge.--The term `gross charge' means the
charge for an individual item or service that is reflected on
an ambulatory surgical center's chargemaster, absent any
discounts.
``(D) Group health plan; group health insurance coverage;
individual health insurance coverage.--The terms `group
health plan', `group health insurance coverage', and
`individual health insurance coverage' have the meaning given
such terms in section 2791 of the Public Health Service Act.
``(E) Payer-specific negotiated charge.--The term `payer-
specific negotiated charge' means the charge that an
ambulatory surgical center has negotiated with a third party
payer for an item or service.
``(F) Shoppable service.--The term `shoppable service'
means a service that can be scheduled by a health care
consumer in advance and includes all ancillary items and
services customarily furnished as part of such service.
``(G) Third party payer.--The term `third party payer'
means an entity that is, by statute, contract, or agreement,
legally responsible for payment of a claim for a health care
item or service.''.
SEC. 105. HEALTH COVERAGE PRICE TRANSPARENCY.
(a) Price Transparency Requirements.--
(1) IRC.--
(A) In general.--Section 9819 of the Internal Revenue Code
of 1986 is amended to read as follows:
``SEC. 9819. TRANSPARENCY IN COVERAGE.
``(a) Cost-sharing Transparency.--
``(1) In general.--For plan years beginning on or after
January 1, 2026, a group health plan shall permit a
participant or beneficiary to learn the amount of cost-
sharing (including deductibles, copayments, and coinsurance)
under the participant or beneficiary's plan that the
participant or beneficiary would be responsible for paying
with respect to the furnishing of a specific item or service
by a provider in a timely manner upon the request of the
participant or beneficiary. At a minimum, such information
[[Page H6768]]
shall include the information specified in paragraph (2) and
shall be made available to such participant or beneficiary
through a self-service tool that meets the requirements of
paragraph (3) or, at the option of such participant or
beneficiary, through a paper disclosure or phone or other
electronic disclosure (as selected by such participant or
beneficiary and provided at no cost to such participant or
beneficiary) that meets such requirements as the Secretary
may specify.
``(2) Specified information.--For purposes of paragraph
(1), the information specified in this paragraph is, with
respect to an item or service for which benefits are
available under a group health plan furnished by a health
care provider to a participant or beneficiary of such plan,
the following:
``(A) If such provider is a participating provider with
respect to such item or service, the in-network rate (as
defined in subsection (c)) for such item or service.
``(B) If such provider is not a participating provider with
respect to such item or service, the maximum allowed amount
or other dollar amount that such plan or coverage will
recognize as payment for such item or service, along with a
notice that such participant or beneficiary may be liable for
additional charges.
``(C) The estimated amount of cost sharing (including
deductibles, copayments, and coinsurance) that the
participant or beneficiary will incur for such item or
service (which, in the case such item or service is to be
furnished by a provider described in subparagraph (B), shall
be calculated using the maximum allowed amount or other
dollar amount described in such subparagraph).
``(D) The amount the participant or beneficiary has already
accumulated with respect to any deductible or out of pocket
maximum under the plan (broken down, in the case separate
deductibles or maximums apply to separate participants and
beneficiaries enrolled in the plan, by such separate
deductibles or maximums, in addition to any cumulative
deductible or maximum).
``(E) In the case such plan imposes any frequency or volume
limitations with respect to such item or service (excluding
medical necessity determinations), the amount that such
participant or beneficiary has accrued towards such
limitation with respect to such item or service.
``(F) Any prior authorization, concurrent review, step
therapy, fail first, or similar requirements applicable to
coverage of such item or service under such plan.
``(G) Any shared savings (such as any credit, payment, or
other benefit provided by such plan) available to the
participant or beneficiary with respect to such item or
service furnished by such provider known at the time such
request is made.
``(3) Self-service tool.--For purposes of paragraph (1), a
self-service tool established by a group health plan meets
the requirements of this paragraph if such tool--
``(A) is based on an Internet website (or successor
technology specified by the Secretary);
``(B) provides for real-time responses to requests
described in paragraph (1);
``(C) is updated in a manner such that information provided
through such tool is timely and accurate at the time such
request is made;
``(D) allows such a request to be made with respect to an
item or service furnished by--
``(i) a specific provider that is a participating provider
with respect to such item or service; or
``(ii) all providers that are participating providers with
respect to such item or service;
``(E) provides that such a request may be made with respect
to an item or service through use of the billing code for
such item or service or through use of a descriptive term for
such item or service; and
``(F) meets any other requirement determined appropriate by
the Secretary to ensure the accessibility and usability of
information provided through such tool.
The Secretary may require such tool, as a condition of
complying with subparagraph (E), to link multiple billing
codes to a single descriptive term if the Secretary
determines that the billing codes to be so linked correspond
to similar items and services.
``(b) Rate and Payment Information.--
``(1) In general.--For plan years beginning on or after
January 1, 2026, each group health plan (other than a
grandfathered health plan (as defined in section 1251(e) of
the Patient Protection and Affordable Care Act)) shall, for
each month, not later than the tenth day of such month, make
available to the public the rate and payment information
described in paragraph (2) in accordance with paragraph (3).
``(2) Rate and payment information described.--For purposes
of paragraph (1), the rate and payment information described
in this paragraph is, with respect to a group health plan,
the following:
``(A) With respect to each item or service (other than a
drug) for which benefits are available under such plan, the
in-network rate (expressed as a dollar amount) in effect as
of the date on which such information is made public with
each provider that is a participating provider with respect
to such item or service.
``(B) With respect to each drug (identified by national
drug code) for which benefits are available under such plan--
``(i) the in-network rate (expressed as a dollar amount) in
effect as of the first day of the month in which such
information is made public with each provider that is a
participating provider with respect to such drug; and
``(ii) the average amount paid by such plan (net of
rebates, discounts, and price concessions) for such drug
dispensed or administered during the 90-day period beginning
180 days before such date of publication to each provider
that was a participating provider with respect to such drug,
broken down by each such provider, other than such an amount
paid to a provider that, during such period, submitted fewer
than 20 claims for such drug to such plan.
``(C) With respect to each item or service for which
benefits are available under such plan, the amount billed,
and the amount allowed by the plan, for each such item or
service furnished during the 90-day period specified in
subparagraph (B) by a provider that was not a participating
provider with respect to such item or service, broken down by
each such provider.
``(3) Manner of publication.--Rate and payment information
required to be made available under this subsection shall be
so made available in dollar amounts through separate machine-
readable files (and any successor technology, such as
application program interface technology, determined
appropriate by the Secretary) corresponding to the
information described in each of subparagraphs (A) through
(C) of paragraph (2) that meet such requirements as specified
by the Secretary through subregulatory guidance. Such
requirements shall ensure that such files are limited to an
appropriate size, do not include disclosure of unnecessary
duplicative information contained in other files made
available under this subsection, are made available in a
widely available format through a publicly available website
that allows for information contained in such files to be
compared across group health plans and group or individual
health insurance coverage, and are accessible to individuals
at no cost and without the need to establish a user account
or provide other credentials.
``(4) User instructions.--Each group health plan shall make
available to the public instructions written in plain
language explaining how individuals may search for
information described in paragraph (2) in files submitted in
accordance with paragraph (3). The Secretary shall develop
and publish through subregulatory guidance a template that
such a plan may use in developing instructions for purposes
of the preceding sentence.
``(5) Summary.--For each plan year beginning on or after
January 1, 2026, each group health plan shall make public a
data file, in a manner that ensures that such file may be
easily downloaded and read by standard spreadsheet software
and that meets such requirements as established by the
Secretary, containing a summary of all rate and payment
information made public by such plan with respect to such
plan during such plan year. Such file shall include the
following:
``(A) The mean, median, and interquartile range of the in-
network rate, and the amount allowed for an item or service
when not furnished by a participating provider, in effect as
of the first day of such plan year for each item or service
(identified by payer identifier approved or used by the
Centers for Medicare & Medicaid Services) for which benefits
are available under the plan, broken down by the type of
provider furnishing the item or service and by the geographic
area in which such item or service is furnished.
``(B) Trends in payment rates for such items and services
over such plan year, including an identification of instances
in which such rates have increased, decreased, or remained
the same.
``(C) The name of such plan, a description of the type of
network of participating providers used by such plan, and a
description of whether such plan is self-insured or fully-
insured.
``(D) For each item or service which is paid as part of a
bundled rate--
``(i) a description of the formulae, pricing methodologies,
or other information used to calculate the payment rate for
such bundle; and
``(ii) a list of the items and services included in such
bundle.
``(E) The percentage of items and services that are paid
for on a fee-for-service basis and the percentage of items
and services that are paid for as part of a bundled rate,
capitated payment rate, or other alternative payment model.
``(6) Attestation.--Each group health plan shall post,
along with rate and payment information made public by such
plan, an attestation that such information is complete and
accurate.
``(c) Accessibility.--A group health plan shall take
reasonable steps (as specified by the Secretary) to ensure
that information provided in response to a request described
in subsection (a), and rate and payment information made
public under subsection (b), is provided in plain, easily
understandable language and that interpretation,
translations, and assistive services are provided to those
with limited English proficiency and those with disabilities.
``(d) Definitions.--In this section:
``(1) Participating provider.--The term `participating
provider' means, with respect to an item or service and a
group health plan, a physician or other health care provider
who is acting within the scope of practice of that provider's
license or certification under applicable State law and who
has a
[[Page H6769]]
contractual relationship with the plan, respectively, for
furnishing such item or service under the plan, and includes
facilities, respectively.
``(2) Provider.--The term `provider' includes a health care
facility.
``(3) In-network rate.--The term `in-network rate' means,
with respect to a group health plan and an item or service
furnished by a provider that is a participating provider with
respect to such plan and item or service, the contracted rate
(reflected as a dollar amount) in effect between such plan
and such provider for such item or service, regardless of
whether such rate is calculated based on a set amount, a fee
schedule, or an amount derived from another amount, or a
formula, or other method.''.
(B) Clerical amendment.--The item relating to section 9819
of the table of sections for subchapter B of chapter 100 of
the Internal Revenue Code of 1986 is amended to read as
follows:
``Sec. 9819. Transparency in coverage.''.
(2) PHSA.--Section 2799A-4 of the Public Health Service Act
(42 U.S.C. 300gg-114) is amended to read as follows:
``SEC. 2799A-4. TRANSPARENCY IN COVERAGE.
``(a) Cost-sharing Transparency.--
``(1) In general.--For plan years beginning on or after
January 1, 2026, a group health plan and a health insurance
issuer offering group or individual health insurance coverage
shall permit an individual enrolled under such plan or
coverage to learn the amount of cost-sharing (including
deductibles, copayments, and coinsurance) under the
individual's plan or coverage that the individual would be
responsible for paying with respect to the furnishing of a
specific item or service by a provider in a timely manner
upon the request of the individual. At a minimum, such
information shall include the information specified in
paragraph (2) and shall be made available to such individual
through a self-service tool that meets the requirements of
paragraph (3) or, at the option of such individual, through a
paper disclosure or phone or other electronic disclosure (as
selected by such individual and provided at no cost to such
individual) that meets such requirements as the Secretary may
specify.
``(2) Specified information.--For purposes of paragraph
(1), the information specified in this paragraph is, with
respect to an item or service for which benefits are
available under a group health plan or group or individual
health insurance coverage furnished by a health care provider
to an individual enrolled under such plan or coverage, the
following:
``(A) If such provider is a participating provider with
respect to such item or service, the in-network rate (as
defined in subsection (c)) for such item or service.
``(B) If such provider is not a participating provider with
respect to such item or service, the maximum allowed amount
or other dollar amount that such plan or coverage will
recognize as payment for such item or service, along with a
notice that such individual may be liable for additional
charges.
``(C) The estimated amount of cost sharing (including
deductibles, copayments, and coinsurance) that the individual
will incur for such item or service (which, in the case such
item or service is to be furnished by a provider described in
subparagraph (B), shall be calculated using the maximum
allowed amount or other dollar amount described in such
subparagraph).
``(D) The amount the individual has already accumulated
with respect to any deductible or out of pocket maximum under
the plan or coverage (broken down, in the case separate
deductibles or maximums apply to separate individuals
enrolled in the plan or coverage, by such separate
deductibles or maximums, in addition to any cumulative
deductible or maximum).
``(E) In the case such plan imposes any frequency or volume
limitations with respect to such item or service (excluding
medical necessity determinations), the amount that such
individual has accrued towards such limitation with respect
to such item or service.
``(F) Any prior authorization, concurrent review, step
therapy, fail first, or similar requirements applicable to
coverage of such item or service under such plan or coverage.
``(G) Any shared savings (such as any credit, payment, or
other benefit provided by such plan or issuer) available to
the individual with respect to such item or service furnished
by such provider known at the time such request is made.
``(3) Self-service tool.--For purposes of paragraph (1), a
self-service tool established by a group health plan or
health insurance issuer offering group or individual health
insurance coverage meets the requirements of this paragraph
if such tool--
``(A) is based on an internet website (or successor
technology specified by the Secretary);
``(B) provides for real-time responses to requests
described in paragraph (1);
``(C) is updated in a manner such that information provided
through such tool is timely and accurate at the time such
request is made;
``(D) allows such a request to be made with respect to an
item or service furnished by--
``(i) a specific provider that is a participating provider
with respect to such item or service; or
``(ii) all providers that are participating providers with
respect to such item or service;
``(E) provides that such a request may be made with respect
to an item or service through use of the billing code for
such item or service or through use of a descriptive term for
such item or service; and
``(F) meets any other requirement determined appropriate by
the Secretary to ensure the accessibility and usability of
information provided through such tool.
The Secretary may require such tool, as a condition of
complying with subparagraph (E), to link multiple billing
codes to a single descriptive term if the Secretary
determines that the billing codes to be so linked correspond
to similar items and services.
``(b) Rate and Payment Information.--
``(1) In general.--For plan years beginning on or after
January 1, 2026, each group health plan and health insurance
issuer offering group or individual health insurance coverage
(other than a grandfathered health plan (as defined in
section 1251(e) of the Patient Protection and Affordable Care
Act)) shall, for each month, not later than the tenth day of
such month, make available to the public the rate and payment
information described in paragraph (2) in accordance with
paragraph (3).
``(2) Rate and payment information described.--For purposes
of paragraph (1), the rate and payment information described
in this paragraph is, with respect to a group health plan or
group or individual health insurance coverage, the following:
``(A) With respect to each item or service (other than a
drug) for which benefits are available under such plan or
coverage, the in-network rate (expressed as a dollar amount)
in effect as of the date on which such information is made
public with each provider that is a participating provider
with respect to such item or service.
``(B) With respect to each drug (identified by national
drug code) for which benefits are available under such plan
or coverage--
``(i) the in-network rate (expressed as a dollar amount) in
effect as of the first day of the month in which such
information is made public with each provider that is a
participating provider with respect to such drug; and
``(ii) the average amount paid by such plan (net of
rebates, discounts, and price concessions) for such drug
dispensed or administered during the 90-day period beginning
180 days before such date of publication to each provider
that was a participating provider with respect to such drug,
broken down by each such provider, other than such an amount
paid to a provider that, during such period, submitted fewer
than 20 claims for such drug to such plan or coverage.
``(C) With respect to each item or service for which
benefits are available under such plan or coverage, the
amount billed, and the amount allowed by the plan, for each
such item or service furnished during the 90-day period
specified in subparagraph (B) by a provider that was not a
participating provider with respect to such item or service,
broken down by each such provider.
``(3) Manner of publication.--Rate and payment information
required to be made available under this subsection shall be
so made available in dollar amounts through separate machine-
readable files (and any successor technology, such as
application program interface technology, determined
appropriate by the Secretary) corresponding to the
information described in each of subparagraphs (A) through
(C) of paragraph (2) that meet such requirements as specified
by the Secretary through subregulatory guidance. Such
requirements shall ensure that such files are limited to an
appropriate size, do not include disclosure of unnecessary
duplicative information contained in other files made
available under this subsection, are made available in a
widely-available format through a publicly-available website
that allows for information contained in such files to be
compared across group health plans and group or individual
health insurance coverage, and are accessible to individuals
at no cost and without the need to establish a user account
or provide other credentials.
``(4) User instructions.--Each group health plan and health
insurance issuer offering group or individual health
insurance coverage shall make available to the public
instructions written in plain language explaining how
individuals may search for information described in paragraph
(2) in files submitted in accordance with paragraph (3). The
Secretary shall develop and publish through subregulatory
guidance a template that such a plan may use in developing
instructions for purposes of the preceding sentence.
``(5) Summary.--For each plan year beginning on or after
January 1, 2026, each group health plan and health insurance
issuer offering group or individual health insurance coverage
shall make public a data file, in a manner that ensures that
such file may be easily downloaded and read by standard
spreadsheet software and that meets such requirements as
established by the Secretary, containing a summary of all
rate and payment information made public by such plan or
issuer with respect to such plan or coverage during such plan
year. Such file shall include the following:
``(A) The mean, median, and interquartile range of the in-
network rate, and the amount allowed for an item or service
when not furnished by a participating provider, in effect as
of the first day of such plan year for each item or service
(identified by payer
[[Page H6770]]
identifier approved or used by the Centers for Medicare &
Medicaid Services) for which benefits are available under the
plan or coverage, broken down by the type of provider
furnishing the item or service and by the geographic area in
which such item or service is furnished.
``(B) Trends in payment rates for such items and services
over such plan year, including an identification of instances
in which such rates have increased, decreased, or remained
the same.
``(C) The name of such plan, a description of the type of
network of participating providers used by such plan or
coverage, and, in the case of a group health plan, a
description of whether such plan is self-insured or fully-
insured.
``(D) For each item or service which is paid as part of a
bundled rate--
``(i) a description of the formulae, pricing methodologies,
or other information used to calculate the payment rate for
such bundle; and
``(ii) a list of the items and services included in such
bundle.
``(E) The percentage of items and services that are paid
for on a fee-for-service basis and the percentage of items
and services that are paid for as part of a bundled rate,
capitated payment rate, or other alternative payment model.
``(6) Attestation.--Each group health plan and health
insurance issuer offering group or individual health
insurance coverage shall post, along with rate and payment
information made public by such plan or issuer, an
attestation that such information is complete and accurate.
``(c) Accessibility.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage shall take reasonable steps (as specified
by the Secretary) to ensure that information provided in
response to a request described in subsection (a), and rate
and payment information made public under subsection (b), is
provided in plain, easily understandable language and that
interpretation, translations, and assistive services are
provided to those with limited English proficiency and those
with disabilities.
``(d) Definitions.--In this section:
``(1) Participating provider.--The term `participating
provider' means, with respect to an item or service and a
group health plan or health insurance issuer offering group
or individual health insurance coverage, a physician or other
health care provider who is acting within the scope of
practice of that provider's license or certification under
applicable State law and who has a contractual relationship
with the plan or issuer, respectively, for furnishing such
item or service under the plan or coverage, and includes
facilities, respectively.
``(2) Provider.--The term `provider' includes a health care
facility.
``(3) In-network rate.--The term `in-network rate' means,
with respect to a group health plan or group or individual
health insurance coverage and an item or service furnished by
a provider that is a participating provider with respect to
such plan or coverage and item or service, the contracted
rate (reflected as a dollar amount) in effect between such
plan or coverage and such provider for such item or service,
regardless of whether such rate is calculated based on a set
amount, a fee schedule, or an amount derived from another
amount, or a formula, or other method.''.
(3) ERISA.--
(A) In general.--Section 719 of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1185h) is amended to
read as follows:
``SEC. 719. TRANSPARENCY IN COVERAGE.
``(a) Cost-Sharing Transparency.--
``(1) In general.--For plan years beginning on or after
January 1, 2026, a group health plan and a health insurance
issuer offering group health insurance coverage shall permit
a participant or beneficiary to learn the amount of cost-
sharing (including deductibles, copayments, and coinsurance)
under the participant or beneficiary's plan or coverage that
the participant or beneficiary would be responsible for
paying with respect to the furnishing of a specific item or
service by a provider in a timely manner upon the request of
the participant or beneficiary. At a minimum, such
information shall include the information specified in
paragraph (2) and shall be made available to such participant
or beneficiary through a self-service tool that meets the
requirements of paragraph (3) or, at the option of such
participant or beneficiary, through a paper disclosure or
phone or other electronic disclosure (as selected by such
participant or beneficiary and provided at no cost to such
participant or beneficiary) that meets such requirements as
the Secretary may specify.
``(2) Specified information.--For purposes of paragraph
(1), the information specified in this paragraph is, with
respect to an item or service for which benefits are
available under a group health plan or group health insurance
coverage furnished by a health care provider to a participant
or beneficiary of such plan or coverage, the following:
``(A) If such provider is a participating provider with
respect to such item or service, the in-network rate (as
defined in subsection (c)) for such item or service.
``(B) If such provider is not a participating provider with
respect to such item or service, the maximum allowed amount
or other dollar amount that such plan or coverage will
recognize as payment for such item or service, along with a
notice that such participant or beneficiary may be liable for
additional charges.
``(C) The estimated amount of cost-sharing (including
deductibles, copayments, and coinsurance) that the
participant or beneficiary will incur for such item or
service (which, in the case such item or service is to be
furnished by a provider described in subparagraph (B), shall
be calculated using the maximum allowed amount or other
dollar amount described in such subparagraph).
``(D) The amount the participant or beneficiary has already
accumulated with respect to any deductible or out of pocket
maximum under the plan or coverage (broken down, in the case
separate deductibles or maximums apply to separate
participants and beneficiaries enrolled in the plan or
coverage, by such separate deductibles or maximums, in
addition to any cumulative deductible or maximum).
``(E) In the case such plan imposes any frequency or volume
limitations with respect to such item or service (excluding
medical necessity determinations), the amount that such
participant or beneficiary has accrued towards such
limitation with respect to such item or service.
``(F) Any prior authorization, concurrent review, step
therapy, fail first, or similar requirements applicable to
coverage of such item or service under such plan or coverage.
``(G) Any shared savings (such as any credit, payment, or
other benefit provided by such plan or issuer) available to
the participant or beneficiary with respect to such item or
service furnished by such provider known at the time such
request is made.
``(3) Self-service tool.--For purposes of paragraph (1), a
self-service tool established by a group health plan or
health insurance issuer offering group health insurance
coverage meets the requirements of this paragraph if such
tool--
``(A) is based on an internet website (or successor
technology specified by the Secretary);
``(B) provides for real-time responses to requests
described in paragraph (1);
``(C) is updated in a manner such that information provided
through such tool is timely and accurate at the time such
request is made;
``(D) allows such a request to be made with respect to an
item or service furnished by--
``(i) a specific provider that is a participating provider
with respect to such item or service; or
``(ii) all providers that are participating providers with
respect to such item or service;
``(E) provides that such a request may be made with respect
to an item or service through use of the billing code for
such item or service or through use of a descriptive term for
such item or service; and
``(F) meets any other requirement determined appropriate by
the Secretary to ensure the accessibility and usability of
information provided through such tool.
The Secretary may require such tool, as a condition of
complying with subparagraph (E), to link multiple billing
codes to a single descriptive term if the Secretary
determines that the billing codes to be so linked correspond
to similar items and services.
``(b) Rate and Payment Information.--
``(1) In general.--For plan years beginning on or after
January 1, 2026, each group health plan and health insurance
issuer offering group health insurance coverage (other than a
grandfathered health plan (as defined in section 1251(e) of
the Patient Protection and Affordable Care Act)) shall, for
each month, not later than the tenth day of such month, make
available to the public the rate and payment information
described in paragraph (2) in accordance with paragraph (3).
``(2) Rate and payment information described.--For purposes
of paragraph (1), the rate and payment information described
in this paragraph is, with respect to a group health plan or
group health insurance coverage, the following:
``(A) With respect to each item or service (other than a
drug) for which benefits are available under such plan or
coverage, the in-network rate (expressed as a dollar amount)
in effect as of the date on which such information is made
public with each provider that is a participating provider
with respect to such item or service.
``(B) With respect to each drug (identified by national
drug code) for which benefits are available under such plan
or coverage--
``(i) the in-network rate (expressed as a dollar amount) in
effect as of the first day of the month in which such
information is made public with each provider that is a
participating provider with respect to such drug; and
``(ii) the average amount paid by such plan (net of
rebates, discounts, and price concessions) for such drug
dispensed or administered during the 90-day period beginning
180 days before such date of publication to each provider
that was a participating provider with respect to such drug,
broken down by each such provider, other than such an amount
paid to a provider that, during such period, submitted fewer
than 20 claims for such drug to such plan or coverage.
``(C) With respect to each item or service for which
benefits are available under such plan or coverage, the
amount billed, and the amount allowed by the plan, for each
such item or service furnished during the 90-day period
specified in subparagraph (B) by a provider that was not a
participating provider
[[Page H6771]]
with respect to such item or service, broken down by each
such provider.
``(3) Manner of publication.--Rate and payment information
required to be made available under this subsection shall be
so made available in dollar amounts through separate machine-
readable files (and any successor technology, such as
application program interface technology, determined
appropriate by the Secretary) corresponding to the
information described in each of subparagraphs (A) through
(C) of paragraph (2) that meet such requirements as specified
by the Secretary through subregulatory guidance. Such
requirements shall ensure that such files are limited to an
appropriate size, do not include disclosure of unnecessary
duplicative information contained in other files made
available under this subsection, are made available in a
widely available format through a publicly available website
that allows for information contained in such files to be
compared across group health plans and group or individual
health insurance coverage, and are accessible to individuals
at no cost and without the need to establish a user account
or provide other credentials.
``(4) User instructions.--Each group health plan and health
insurance issuer offering group health insurance coverage
shall make available to the public instructions written in
plain language explaining how individuals may search for
information described in paragraph (2) in files submitted in
accordance with paragraph (3). The Secretary shall develop
and publish through subregulatory guidance a template that
such a plan may use in developing instructions for purposes
of the preceding sentence.
``(5) Summary.--For each plan year beginning on or after
January 1, 2026, each group health plan and health insurance
issuer offering group health insurance coverage shall make
public a data file, in a manner that ensures that such file
may be easily downloaded and read by standard spreadsheet
software and that meets such requirements as established by
the Secretary, containing a summary of all rate and payment
information made public by such plan or issuer with respect
to such plan or coverage during such plan year. Such file
shall include the following:
``(A) The mean, median, and interquartile range of the in-
network rate, and the amount allowed for an item or service
when not furnished by a participating provider, in effect as
of the first day of such plan year for each item or service
(identified by payer identifier approved or used by the
Centers for Medicare & Medicaid Services) for which benefits
are available under the plan or coverage, broken down by the
type of provider furnishing the item or service and by the
geographic area in which such item or service is furnished.
``(B) Trends in payment rates for such items and services
over such plan year, including an identification of instances
in which such rates have increased, decreased, or remained
the same.
``(C) The name of such plan, a description of the type of
network of participating providers used by such plan or
coverage, and, in the case of a group health plan, a
description of whether such plan is self-insured or fully-
insured.
``(D) For each item or service which is paid as part of a
bundled rate--
``(i) a description of the formulae, pricing methodologies,
or other information used to calculate the payment rate for
such bundle; and
``(ii) a list of the items and services included in such
bundle.
``(E) The percentage of items and services that are paid
for on a fee-for-service basis and the percentage of items
and services that are paid for as part of a bundled rate,
capitated payment rate, or other alternative payment model.
``(6) Attestation.--Each group health plan and health
insurance issuer offering group health insurance coverage
shall post, along with rate and payment information made
public by such plan or issuer, an attestation that such
information is complete and accurate.
``(c) Accessibility.--A group health plan and a health
insurance issuer offering group health insurance coverage
shall take reasonable steps (as specified by the Secretary)
to ensure that information provided in response to a request
described in subsection (a), and rate and payment information
made public under subsection (b), is provided in plain,
easily understandable language and that interpretation,
translations, and assistive services are provided to those
with limited English proficiency and those with disabilities.
``(d) Definitions.--In this section:
``(1) Participating provider.--The term `participating
provider' means, with respect to an item or service and a
group health plan or health insurance issuer offering group
or individual health insurance coverage, a physician or other
health care provider who is acting within the scope of
practice of that provider's license or certification under
applicable State law and who has a contractual relationship
with the plan or issuer, respectively, for furnishing such
item or service under the plan or coverage, and includes
facilities, respectively.
``(2) Provider.--The term `provider' includes a health care
facility.
``(3) In-network rate.--The term `in-network rate' means,
with respect to a group health plan or group health insurance
coverage and an item or service furnished by a provider that
is a participating provider with respect to such plan or
coverage and item or service, the contracted rate (reflected
as a dollar amount) in effect between such plan or coverage
and such provider for such item or service, regardless of
whether such rate is calculated based on a set amount, a fee
schedule, or an amount derived from another amount, or a
formula, or other method.''.
(B) Clerical amendment.--The table of contents in section 1
of the Employee Retirement Income Security Act of 1974 is
amended by striking the item relating to section 719 and
inserting the following new item:
``Sec. 719. Transparency in coverage.''.
(b) Application Programming Interface Report.--Not later
than January 1, 2025, and annually thereafter, the Secretary
of Health and Human Services shall, in consultation with the
Office of the National Coordinator for Health Information
Technology, Department of Labor, the Department of the
Treasury, and stakeholders, submit to the House Committees on
Education and the Workforce, Energy and Commerce, and Ways
and Means, and the Senate Committees on Finance and Health,
Education, Labor, and Pensions a report on the use of
standards-based application programming interfaces (in this
subsection referred to as ``APIs'') to facilitate access to
health care price transparency information and the
interoperability of other medical information. Such report
shall include an evaluation of the capacity of the Department
of Health and Human Services, the Department of Labor, and
the Department of the Treasury to regulate and implement
standards related to APIs and recommendations for improving
such capacity. Such report shall include the following:
(1) A description of current use, and proposed use, of APIs
under Federal rules to facilitate interoperability, including
information related to capacity constraints within the
agencies, barriers to adoption, privacy and security,
administrative burdens and efficiencies, care coordination,
and levels of compliance.
(2) A description of the feasibility of agency
participation in the development of APIs to enable
application access to price transparency data under the
amendments made by subsection (a).
(3) A specification of the timeline for which such data
standards can be required to make such data accessible via an
API.
(4) An analysis of the benefits and challenges of
implementing standards-based APIs for price transparency
data, including the ability for consumers to access rate and
payment information and the amount of cost-sharing (including
deductibles, copayments, and coinsurance) under the
consumer's plan through third-party internet-based tools and
applications.
(5) An analysis of the impact that APIs which provide real-
time access to pricing and cost-sharing information may have
in increasing the amount of services shoppable for
individuals, such as by standardizing more health care spend
via episode bundles.
(6) An analysis of which health care items and services may
be useful under API, such as those for which prices change
with the greatest frequency.
(7) An analysis of the cost of API standards implementation
on issuers, employers, and other private-sector entities.
(8) An analysis of the ability of State regulators to
enforce API standards and the costs to the Federal Government
and States to regulate and enforce API standards.
(9) An analysis of the interaction with API standards and
Federal health information privacy standards.
(c) Provider Tool Report.--
(1) In general.--Not later than 1 year after the date of
the enactment of this Act, The Secretary of Health and Human
Services, acting through the Administrator of the Centers for
Medicare & Medicaid Services, shall, in consultation with
stakeholders, conduct a study and submit to the House
Committees on Education and the Workforce, Energy and
Commerce, and Ways and Means, and the Senate Committees on
Finance and Health, Education, Labor, and Pensions a report
on the usefulness and feasibility of the establishment of a
provider tool by a group health plan, or a health insurance
issuer offering group and individual health insurance
coverage, in facilitating the provision of information made
available pursuant to the amendments made by subsection (a).
Such report shall include the following:
(A) A description of the feasibility of establishing a
requirement for the various types of plans and coverage to
offer such a provider tool, including any challenges to
establishing a provider tool using the same technology
platform as the self-service tool described in such
amendments.
(B) An evaluation on the usefulness of a provider tool to
aid patient-decision making and how such tool would
coordinate with other information available to a patient and
their provider under other Federal requirements in place or
under consideration.
(C) An evaluation of whether the information provided by
such tool would be duplicative of the advanced explanation of
benefits required under Federal law or any other existing
requirement.
(D) A description of the usability and expected utilization
of such tool among providers, including among different
provider types.
(E) An analysis of the impact of a provider tool in value-
based care arrangements.
[[Page H6772]]
(F) An analysis on the potential impact of the provider
tool on--
(i) patients' out-of-pocket spending;
(ii) plan design, including impacts on cost-sharing
requirements;
(iii) care coordination and quality;
(iv) plan premiums;
(v) overall health care spending and utilization; and
(vi) health care access in rural areas.
(G) An analysis of the feasibility of a provider tool to
include additional functionality to facilitate and improve
the administration of the requirements on providers to submit
notifications to such plan or coverage under section 2799B-6
of the Public Health Service Act and the requirements on such
plan or coverage to provide an advanced explanation of
benefits to individuals under section 2799A-1(f) of such Act.
(H) An analysis of which health care items and services,
would be most useful for patients utilizing a provider tool.
(I) An analysis of rulemaking required to ensure such a
tool complies with federal health information privacy
standards.
(J) An analysis of the burden and cost of the creation of a
provider tool by plans and coverage on providers, issuers,
employers, and other private-sector entities.
(K) An analysis of the ability of state regulators to
enforce provider tool standards and the costs to the
Department and states to regulate and enforce provider tool
standards.
(2) Definition.--The term ``provider tool'' means a tool
designed to facilitate the provision of information made
available pursuant to the amendments made by subsection (a)
and established by a group health plan or a health insurance
issuer offering group and individual health insurance
coverage that allows providers to access the information such
plan or coverage must provide through the self-service tool
described in such amendments to an individual with whom the
provider is actively treating at the time of such request,
upon the request of the provider, and with the consent of
such individual.
(d) Reports.--
(1) Compliance.--Not later than January 1, 2027, the
Comptroller General of the United States shall submit to
Congress a report containing--
(A) an analysis of compliance with the amendments made by
this section;
(B) an analysis of enforcement of such amendments by the
Secretaries of Health and Human Services, Labor, and the
Treasury;
(C) recommendations relating to improving such enforcement;
and
(D) recommendations relating to improving public
disclosure, and public awareness, of information required to
be made available by group health plans and health insurance
issuers pursuant to such amendments.
(2) Prices.--Not later than January 1, 2028, and biennially
thereafter, the Secretaries of Health and Human Services,
Labor, and the Treasury shall jointly submit to Congress a
report containing an assessment of differences in negotiated
prices (and any trends in such prices) in the private market
between--
(A) rural and urban areas;
(B) the individual, small group, and large group markets;
(C) consolidated and nonconsolidated health care provider
areas (as specified by the Secretary of Health and Human
Services);
(D) nonprofit and for-profit hospitals;
(E) nonprofit and for-profit insurers; and
(F) insurers serving local or regional areas and insurers
serving multistate or national areas.
(e) Quality Report.--Not later than 1 year after the date
of enactment of this subsection, the Secretaries of Health
and Human Services, Labor, and the Treasury shall jointly
submit to Congress a report on the feasibility of including
data relating to the quality of health care items and
services with the price transparency information required to
be made available under the amendments made by subsection
(a). Such report shall include recommendations for
legislative and regulatory actions to identify appropriate
metrics for assessing and comparing quality of care.
(f) Continued Applicability of Rules for Previous Years.--
Nothing in the amendments made by subsection (a) may be
construed as affecting the applicability of the rule entitled
``Transparency in Coverage'' published by the Department of
the Treasury, the Department of Labor, and the Department of
Health and Human Services on November 12, 2020 (85 Fed. Reg.
72158), for any plan year beginning before January 1, 2026.
SEC. 106. PHARMACY BENEFITS PRICE TRANSPARENCY.
(a) PHSA.--Title XXVII of the Public Health Service Act (42
U.S.C. 300gg et seq.) is amended--
(1) in part D (42 U.S.C. 300gg-111 et seq.), by adding at
the end the following new section:
``SEC. 2799A-11. OVERSIGHT OF PHARMACY BENEFITS MANAGER
SERVICES.
``(a) In General.--For plan years beginning on or after the
date that is 2 years after the date of enactment of this
section, a group health plan or a health insurance issuer
offering group health insurance coverage, or an entity or
subsidiary providing pharmacy benefits management services on
behalf of such a plan or issuer, shall not enter into a
contract with a drug manufacturer, distributor, wholesaler,
subcontractor, rebate aggregator, or any other third party
that 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 making the reports described in
subsection (b).
``(b) Reports.--
``(1) In general.--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 every 6 months (or
at the request of a group health plan, not less frequently
than quarterly, but under the same conditions, terms, and
cost of the semiannual report under this subsection), a group
health plan or health insurance issuer offering group health
insurance coverage, or an entity providing pharmacy benefits
management services on behalf of such a plan or issuer, shall
submit to the group health plan a report in accordance with
this section. Each such report shall be made available to
such group health plan in a machine-readable format and shall
include the information described in paragraph (2).
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph is, with
respect to drugs covered by a group health plan or health
insurance issuer offering group health insurance coverage
during each reporting period--
``(A) in the case of such a plan offered by a specified
large employer (or such coverage offered in connection with
such a plan offered by a specified large employer)--
``(i) a list of drugs for which a claim was filed and, with
respect to each such drug on such list--
``(I) the brand name, chemical entity, and National Drug
Code;
``(II) the type of dispensing channel used to furnish such
drug, including retail, mail order, or specialty pharmacy;
``(III) with respect to each drug dispensed under each type
of dispensing channel (including retail, mail order, or
specialty pharmacy)--
``(aa) whether such drug is a brand name drug or a generic
drug, and--
``(AA) in the case of a brand name drug, the wholesale
acquisition cost, listed as cost per days supply and cost per
dosage unit, on the date such drug was dispensed; and
``(BB) in the case of a generic drug, the average wholesale
price, listed as cost per days supply and cost per dosage
unit, on the date such drug was dispensed; and
``(bb) the total number of--
``(AA) prescription claims (including original
prescriptions and refills);
``(BB) participants, beneficiaries, and enrollees for whom
a claim for such drug was filed;
``(CC) dosage units per fill of such drug; and
``(DD) days supply of such drug per fill;
``(IV) the net price per course of treatment or single
fill, such as a 30-day supply or 90-day supply to the plan or
coverage after manufacturer rebates, fees, and other
remuneration or adjustments;
``(V) the total amount of out-of-pocket spending by
participants, beneficiaries, and enrollees on such drug,
including spending through copayments, coinsurance, and
deductibles;
``(VI) the total net spending by the plan or coverage
during the reporting period;
``(VII) the total amount received, or expected to be
received, by the plan or coverage from any entity in drug
manufacturer rebates, fees, alternative discounts, and all
other remuneration received from an entity or any third party
(including group purchasing organizations) other than the
plan sponsor;
``(VIII) the total amount received, or expected to be
received by the plan or issuer, from drug manufacturers in
rebates, fees, alternative discounts, or other remuneration--
``(aa) that has been paid, or is to be paid, by drug
manufacturers for claims incurred during the reporting
period; and
``(bb) that is related to utilization rebates for such
drug; and
``(IX) to the extent feasible, information on the total
amount of remuneration, including copayment assistance
dollars paid, copayment cards applied, or other discounts
provided by each drug manufacturer (or entity administering
copay assistance on behalf of such drug manufacturer) to the
participants, beneficiaries, and enrollees enrolled in such
plan or coverage for such drug;
``(ii) for each category or class of drugs for which a
claim was filed, a breakdown of the total gross spending on
drugs in such category or class before rebates, price
concessions, alternative discounts, or other remuneration
from drug manufacturers, and the net spending after such
rebates, price concessions, alternative discounts, or other
remuneration from drug manufacturers, including--
``(I) the number of participants, beneficiaries, and
enrollees who filled a prescription for a drug in such
category or class, including the National Drug Code for each
such drug;
``(II) if applicable, a description of the formulary tiers
and utilization mechanisms (such as prior authorization or
step therapy) employed for drugs in that category or class;
and
``(III) the total out-of-pocket spending under the plan or
coverage by participants, beneficiaries, and enrollees,
including spending through copayments, coinsurance, and
deductibles;
``(iii) in the case of a drug for which gross spending by
such plan, coverage, or entity
[[Page H6773]]
exceeded $10,000 during the reporting period--
``(I) a list of all other drugs in the same therapeutic
category or class; and
``(II) the rationale for the formulary placement of such
drug in that therapeutic category or class, if applicable;
and
``(iv) in the case such plan or coverage (or an entity
providing pharmacy benefits management services on behalf of
such plan or coverage) has an affiliated pharmacy or pharmacy
under common ownership--
``(I) the percentage of total prescriptions dispensed by
such pharmacies to individuals enrolled in such plan or
coverage;
``(II) a list of all drugs dispensed by such pharmacies to
individuals enrolled in such plan or coverage, and, with
respect to each drug dispensed--
``(aa) the amount charged, per dosage unit, per 30-day
supply, or per 90-day supply (as applicable) to the plan or
issuer, and to participants, beneficiaries, and enrollees
enrolled in such plan or coverage;
``(bb) the median amount charged to such plan or issuer,
and the interquartile range of the costs, per dosage unit,
per 30-day supply, and per 90-day supply, including amounts
paid by the participants, beneficiaries, and enrollees, when
the same drug is dispensed by other pharmacies that are not
affiliated with or under common ownership with the entity and
that are included in the pharmacy network of such plan or
coverage;
``(cc) the lowest cost per dosage unit, per 30-day supply
and per 90-day supply, for each such drug, including amounts
charged to the plan and participants, beneficiaries, and
enrollees, that is available from any pharmacy included in
the network of such plan or coverage; and
``(dd) the net acquisition cost per dosage unit, per 30-day
supply, and per 90-day supply, if such drug is subject to a
maximum price discount;
``(B) in the case of a plan or coverage not described in
subparagraph (A)--
``(i) the total net spending by the plan or coverage for
all drugs covered by such plan or coverage during such
reporting period;
``(ii) the total amount received, or expected to be
received, by the plan or coverage from any entity in drug
manufacturer rebates, fees, alternative discounts, and all
other remuneration received from an entity or any third party
(including group purchasing organizations) other than the
plan sponsor for all such drugs; and
``(iii) to the extent feasible, information on the total
amount of remuneration, including copayment assistance
dollars paid, copayment cards applied, or other discounts
provided by each drug manufacturer (or entity administering
copay assistance on behalf of such drug manufacturer) to the
participants, beneficiaries, and enrollees enrolled in such
plan or coverage for such drugs;
``(C) amounts paid directly or indirectly in rebates, fees,
or any other type of compensation (as defined in section
408(b)(2)(B)(ii)(dd)(AA) of the Employee Retirement Income
Security Act) to brokers, consultants, advisors, or any other
individual or firm, for the referral of the group health
plan's or health insurance issuer's business to an entity
providing pharmacy benefits management services, including
the identity of the recipient of such amounts;
``(D) an explanation of any benefit design parameters that
encourage or require participants, beneficiaries, and
enrollees in such plan or coverage to fill prescriptions at
mail order, specialty, or retail pharmacies that are
affiliated with or under common ownership with the entity
providing pharmacy benefit management services under such
plan or coverage, including mandatory mail and specialty home
delivery programs, retail and mail auto-refill programs, and
cost-sharing assistance incentives directly or indirectly
funded by such entity; and
``(E) total gross spending on all drugs during the
reporting period.
``(3) Privacy requirements.--
``(A) In general.--Health insurance issuers offering group
health insurance coverage and entities providing pharmacy
benefits management services on behalf of a group health plan
shall provide information under paragraph (1) in a manner
consistent with the privacy, security, and breach
notification regulations promulgated under section 13402(a)
of the Health Information Technology for Clinical Health Act
and consistent with the HIPAA privacy regulations (as defined
in section 1180(b)(3) of the Social Security Act) and shall
restrict the use and disclosure of such information according
to such privacy, security, and breach notification
regulations and such HIPAA privacy regulations.
``(B) Additional requirements.--
``(i) In general.--An entity providing pharmacy benefits
management services on behalf of a group health plan or
health insurance issuer offering group health insurance
coverage that submits a report under paragraph (1) shall
ensure that such report contains only summary health
information, as defined in section 164.504(a) of title 45,
Code of Federal Regulations (or successor regulations).
``(ii) 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.
``(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 (as defined
in section 1180(b)(3) of the Social Security Act).
``(4) Disclosure and redisclosure.--
``(A) Limitation to business associates.--A group health
plan receiving a report under paragraph (1) may disclose such
information only to the entity from which the report 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 as permitted by the HIPAA
Privacy Rule (45 CFR parts 160 and 164, subparts A and E).
``(B) Clarification regarding public disclosure of
information.--Nothing in this section shall prevent a group
health plan or health insurance issuer offering group health
insurance coverage, or an entity providing pharmacy benefits
management services on behalf of such a plan or coverage,
from placing reasonable restrictions on the public disclosure
of the information contained in a report described in
paragraph (1), except that such plan, issuer, or entity may
not restrict disclosure of such report to the Department of
Health and Human Services, the Department of Labor, the
Department of the Treasury, or the Comptroller General of the
United States.
``(C) Limited form of report.--The Secretary shall define
through rulemaking a limited form of the report under
paragraph (1) required with respect to group health plans
where the plan sponsors of such plans are drug manufacturers,
drug wholesalers, or other direct participants in the drug
supply chain, in order to prevent anti-competitive behavior.
``(5) Report to gao.--A group health plan or health
insurance issuer offering group health insurance coverage, or
an entity providing pharmacy benefits management services on
behalf of such plan or coverage, shall submit to the
Comptroller General of the United States each of the first 4
reports submitted to a group health plan under paragraph (1)
and other such reports as requested, in accordance with the
privacy requirements under paragraph (3), the disclosure and
redisclosure standards under paragraph (4), the standards
specified pursuant to paragraph (6), and such other
information that the Comptroller General determines necessary
to carry out the study under section 106(d) of the Lower
Costs, More Transparency Act.
``(6) Standard format.--Not later than 1 year after the
date of enactment of this section, the Secretary shall
specify through rulemaking standards for group health plans,
health insurance issuers offering group health insurance
coverage, and entities providing pharmacy benefits management
services on behalf of such plans or coverage, required to
submit reports under paragraph (1) to submit such reports in
a standard format.
``(c) Enforcement.--
``(1) In general.--The Secretary shall enforce this
section.
``(2) Failure to provide information.--A health insurance
issuer or an entity providing pharmacy benefits management
services on behalf of such plan or coverage that violates
sub-section (a) or fails to provide the information required
under subsection (b) shall be subject to a civil monetary
penalty in the amount of $10,000 for each day during which
such violation continues or such information is not disclosed
or reported.
``(3) False information.--A health insurance issuer or an
entity providing pharmacy benefits management services on
behalf of such a plan or coverage that knowingly provides
false information under this section shall be subject to a
civil money penalty in an amount not to exceed $100,000 for
each item of false information. Such civil money penalty
shall be in addition to other penalties as may be prescribed
by law.
``(4) Procedure.--The provisions of section 1128A of the
Social Security Act, other than subsections (a) and (b) and
the first sentence of subsection (c)(1) of such section shall
apply to civil monetary penalties under this subsection in
the same manner as such provisions apply to a penalty or
proceeding under such section.
``(5) Waivers.--The Secretary may waive penalties under
paragraph (2), or extend the period of time for compliance
with a requirement of this section, for an entity in
violation of this section that has made a good-faith effort
to comply with the requirements in this section.
``(d) Rule of Construction.--Nothing in this section shall
be construed to permit a group health plan, health insurance
issuer, or entity providing pharmacy benefits management
services on behalf of such plan or coverage, to restrict
disclosure to, or otherwise limit the access of, the
Department of Health and Human Services to a report described
in subsection (b)(1) or information related to compliance
with subsection (a) or (b) by entities subject to such
subsection.
``(e) Definitions.--In this section:
``(1) Specified large employer.--The term `specified large
employer' means, in connection with a group health plan with
respect to a calendar year and a plan year, an employer who
employed an average of at least 50 employees on business days
during the preceding calendar year and who employs at least 1
employee on the first day of the plan year.
``(2) Wholesale acquisition cost.--The term `wholesale
acquisition cost' has the meaning given such term in section
1847A(c)(6)(B) of the Social Security Act.''; and
[[Page H6774]]
(2) in section 2723 (42 U.S.C. 300gg-22)--
(A) in subsection (a)--
(i) in paragraph (1), by inserting ``(other than
subsections (a) and (b) of section 2799A-11)'' after ``part
D''; and
(ii) in paragraph (2), by inserting ``(other than
subsections (a) and (b) of section 2799A-11)'' after ``part
D''; and
(B) in subsection (b)--
(i) in paragraph (1), by inserting ``(other than
subsections (a) and (b) of section 2799A-11)'' after ``part
D'';
(ii) in paragraph (2)(A), by inserting ``(other than
subsections (a) and (b) of section 2799A-11)'' after ``part
D''; and
(iii) in paragraph (2)(C)(ii), by inserting ``(other than
subsections (a) and (b) of section 2799A-11)'' after ``part
D''.
(b) ERISA.--
(1) In general.--Subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1021 et
seq.) is amended--
(A) in subpart B of part 7 (29 U.S.C. 1185 et seq.), by
adding at the end the following:
``SEC. 726. OVERSIGHT OF PHARMACY BENEFIT MANAGER SERVICES.
``(a) In General.--For plan years beginning on or after the
date that is 2 years after the date of enactment of this
section, a group health plan or a health insurance issuer
offering group health insurance coverage, or an entity or
subsidiary providing pharmacy benefits management services on
behalf of such a plan or issuer, shall not enter into a
contract with a drug manufacturer, distributor, wholesaler,
subcontractor, rebate aggregator, or any other third party
that 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 making the reports described in
subsection (b).
``(b) Reports.--
``(1) In general.--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 every 6 months (or
at the request of a group health plan, not less frequently
than quarterly, but under the same conditions, terms, and
cost of the semiannual report under this subsection), a group
health plan or health insurance issuer offering group health
insurance coverage, or an entity providing pharmacy benefits
management services on behalf of such a plan or issuer, shall
submit to the group health plan a report in accordance with
this section. Each such report shall be made available to
such group health plan in a machine-readable format and shall
include the information described in paragraph (2).
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph is, with
respect to drugs covered by a group health plan or health
insurance issuer offering group health insurance coverage
during each reporting period--
``(A) in the case of such a plan offered by a specified
large employer (or such coverage offered in connection with
such a plan offered by a specified large employer)--
``(i) a list of drugs for which a claim was filed and, with
respect to each such drug on such list--
``(I) the brand name, chemical entity, and National Drug
Code;
``(II) the type of dispensing channel used to furnish such
drug, including retail, mail order, or specialty pharmacy;
``(III) with respect to each drug dispensed under each type
of dispensing channel (including retail, mail order, or
specialty pharmacy)--
``(aa) whether such drug is a brand name drug or a generic
drug, and--
``(AA) in the case of a brand name drug, the wholesale
acquisition cost, listed as cost per days supply and cost per
dosage unit, on the date such drug was dispensed; and
``(BB) in the case of a generic drug, the average wholesale
price, listed as cost per days supply and cost per dosage
unit, on the date such drug was dispensed; and
``(bb) the total number of--
``(AA) prescription claims (including original
prescriptions and refills);
``(BB) participants and beneficiaries for whom a claim for
such drug was filed;
``(CC) dosage units per fill of such drug; and
``(DD) days supply of such drug per fill;
``(IV) the net price per course of treatment or single
fill, such as a 30-day supply or 90-day supply to the plan or
coverage after manufacturer rebates, fees, and other
remuneration or adjustments;
``(V) the total amount of out-of-pocket spending by
participants, beneficiaries, and enrollees on such drug,
including spending through copayments, coinsurance, and
deductibles;
``(VI) the total net spending by the plan or coverage
during the reporting period;
``(VII) the total amount received, or expected to be
received, by the plan or coverage from any entity in drug
manufacturer rebates, fees, alternative discounts, and all
other remuneration received from an entity or any third party
(including group purchasing organizations) other than the
plan sponsor;
``(VIII) the total amount received, or expected to be
received by the plan or issuer, from drug manufacturers in
rebates, fees, alternative discounts, or other remuneration--
``(aa) that has been paid, or is to be paid, by drug
manufacturers for claims incurred during the reporting
period; and
``(bb) that is related to utilization rebates for such
drug; and
``(IX) to the extent feasible, information on the total
amount of remuneration, including copayment assistance
dollars paid, copayment cards applied, or other discounts
provided by each drug manufacturer (or entity administering
copay assistance on behalf of such drug manufacturer) to the
participants, beneficiaries, and enrollees enrolled in such
plan or coverage for such drug;
``(ii) for each category or class of drugs for which a
claim was filed, a breakdown of the total gross spending on
drugs in such category or class before rebates, price
concessions, alternative discounts, or other remuneration
from drug manufacturers, and the net spending after such
rebates, price concessions, alternative discounts, or other
remuneration from drug manufacturers, including--
``(I) the number of participants, beneficiaries, and
enrollees who filled a prescription for a drug in such
category or class, including the National Drug Code for each
such drug;
``(II) if applicable, a description of the formulary tiers
and utilization mechanisms (such as prior authorization or
step therapy) employed for drugs in that category or class;
and
``(III) the total out-of-pocket spending under the plan or
coverage by participants, beneficiaries, and enrollees,
including spending through copayments, coinsurance, and
deductibles;
``(iii) in the case of a drug for which gross spending by
such plan, coverage, or entity exceeded $10,000 during the
reporting period--
``(I) a list of all other drugs in the same therapeutic
category or class; and
``(II) the rationale for the formulary placement of such
drug in that therapeutic category or class, if applicable;
and
``(iv) in the case such plan or coverage (or an entity
providing pharmacy benefits management services on behalf of
such plan or coverage) has an affiliated pharmacy or pharmacy
under common ownership--
``(I) the percentage of total prescriptions dispensed by
such pharmacies to individuals enrolled in such plan or
coverage;
``(II) a list of all drugs dispensed by such pharmacies to
individuals enrolled in such plan or coverage, and, with
respect to each drug dispensed--
``(aa) the amount charged, per dosage unit, per 30-day
supply, or per 90-day supply (as applicable) to the plan or
issuer, and to participants, beneficiaries, and enrollees
enrolled in such plan or coverage;
``(bb) the median amount charged to such plan or issuer,
and the interquartile range of the costs, per dosage unit,
per 30-day supply, and per 90-day supply, including amounts
paid by the participants, beneficiaries, and enrollees, when
the same drug is dispensed by other pharmacies that are not
affiliated with or under common ownership with the entity and
that are included in the pharmacy network of such plan or
coverage;
``(cc) the lowest cost per dosage unit, per 30-day supply
and per 90-day supply, for each such drug, including amounts
charged to the plan and participants, beneficiaries, and
enrollees, that is available from any pharmacy included in
the network of such plan or coverage; and
``(dd) the net acquisition cost per dosage unit, per 30-day
supply, and per 90-day supply, if such drug is subject to a
maximum price discount;
``(B) in the case of a plan or coverage not described in
subparagraph (A)--
``(i) the total net spending by the plan or coverage for
all drugs covered by such plan or coverage during such
reporting period;
``(ii) the total amount received, or expected to be
received, by the plan or coverage from any entity in drug
manufacturer rebates, fees, alternative discounts, and all
other remuneration received from an entity or any third party
(including group purchasing organizations) other than the
plan sponsor for all such drugs; and
``(iii) to the extent feasible, information on the total
amount of remuneration, including copayment assistance
dollars paid, copayment cards applied, or other discounts
provided by each drug manufacturer (or entity administering
copay assistance on behalf of such drug manufacturer) to the
participants, beneficiaries, and enrollees enrolled in such
plan or coverage for such drugs;
``(C) amounts paid directly or indirectly in rebates, fees,
or any other type of compensation (as defined in section
408(b)(2)(B)(ii)(dd)(AA)) to brokers, consultants, advisors,
or any other individual or firm, for the referral of the
group health plan's or health insurance issuer's business to
an entity providing pharmacy benefits management services,
including the identity of the recipient of such amounts;
``(D) an explanation of any benefit design parameters that
encourage or require participants, beneficiaries, and
enrollees in such plan or coverage to fill prescriptions at
mail order, specialty, or retail pharmacies that are
affiliated with or under common ownership with the entity
providing pharmacy benefit management services under such
plan or coverage, including mandatory mail and specialty home
delivery programs, retail and mail auto-refill programs, and
cost-sharing assistance incentives directly or indirectly
funded by such entity; and
``(E) total gross spending on all drugs during the
reporting period.
``(3) Privacy requirements.--
``(A) In general.--Health insurance issuers offering group
health insurance coverage and entities providing pharmacy
benefits management services on behalf of a group health
[[Page H6775]]
plan shall provide information under paragraph (1) in a
manner consistent with the privacy, security, and breach
notification regulations promulgated under section 13402(a)
of the Health Information Technology for Clinical Health Act
and consistent with the HIPAA privacy regulations (as defined
in section 1180(b)(3) of the Social Security Act) and shall
restrict the use and disclosure of such information according
to such privacy, security, and breach notification
regulations and such HIPAA privacy regulations.
``(B) Additional requirements.--
``(i) In general.--An entity providing pharmacy benefits
management services on behalf of a group health plan or
health insurance issuer offering group health insurance
coverage that submits a report under paragraph (1) shall
ensure that such report contains only summary health
information, as defined in section 164.504(a) of title 45,
Code of Federal Regulations (or successor regulations).
``(ii) 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.
``(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 (as defined
in section 1180(b)(3) of the Social Security Act).
``(4) Disclosure and redisclosure.--
``(A) Limitation to business associates.--A group health
plan receiving a report under paragraph (1) may disclose such
information only to the entity from which the report 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 as permitted by the HIPAA
Privacy Rule (45 CFR parts 160 and 164, subparts A and E).
``(B) Clarification regarding public disclosure of
information.--Nothing in this section shall prevent a group
health plan or health insurance issuer offering group health
insurance coverage, or an entity providing pharmacy benefits
management services on behalf of such a plan or coverage,
from placing reasonable restrictions on the public disclosure
of the information contained in a report described in
paragraph (1), except that such plan, issuer, or entity may
not restrict disclosure of such report to the Department of
Health and Human Services, the Department of Labor, the
Department of the Treasury, or the Comptroller General of the
United States.
``(C) Limited form of report.--The Secretary shall define
through rulemaking a limited form of the report under
paragraph (1) required with respect to group health plans
where the plan sponsors of such plans are drug manufacturers,
drug wholesalers, or other direct participants in the drug
supply chain, in order to prevent anti-competitive behavior.
``(5) Report to gao.--A group health plan or health
insurance issuer offering group health insurance coverage, or
an entity providing pharmacy benefits management services on
behalf of such plan or coverage, shall submit to the
Comptroller General of the United States each of the first 4
reports submitted to a group health plan under paragraph (1)
and other such reports as requested, in accordance with the
privacy requirements under paragraph (3), the disclosure and
redisclosure standards under paragraph (4), the standards
specified pursuant to paragraph (6), and such other
information that the Comptroller General determines necessary
to carry out the study under section 106(d) of the Lower
Costs, More Transparency Act.
``(6) Standard format.--Not later than 1 year after the
date of enactment of this section, the Secretary shall
specify through rulemaking standards for group health plans,
health insurance issuers offering group health insurance
coverage, and entities providing pharmacy benefits management
services on behalf of such plans or coverage, required to
submit reports under paragraph (1) to submit such reports in
a standard format.
``(c) Rule of Construction.--Nothing in this section shall
be construed to permit a group health plan, health insurance
issuer, or entity providing pharmacy benefits management
services on behalf of such plan or coverage, to restrict
disclosure to, or otherwise limit the access of, the
Secretary of Labor to a report described in subsection (b)(1)
or information related to compliance with subsection (a) or
(b) by entities subject to such subsection.
``(d) Definitions.--In this section:
``(1) Specified large employer.--The term `specified large
employer' means, in connection with a group health plan with
respect to a calendar year and a plan year, an employer who
employed an average of at least 50 employees on business days
during the preceding calendar year and who employs at least 1
employee on the first day of the plan year.
``(2) Wholesale acquisition cost.--The term `wholesale
acquisition cost' has the meaning given such term in section
1847A(c)(6)(B) of the Social Security Act.''.
(B) in section 502 (29 U.S.C. 1132)--
(i) in subsection (b)(3), by striking ``under subsection
(c)(9))'' and inserting ``under paragraphs (9) and (13) of
subsection (c))''; and
(ii) in subsection (c), by adding at the end the following
new paragraph:
``(13) Secretarial enforcement authority relating to
oversight of pharmacy benefits manager services.--
``(A) Failure to provide information.--The Secretary may
impose a penalty against any health insurance issuer or
entity providing pharmacy benefits management services that
violates section 726(a) or fails to provide information
required under section 726(b) in the amount of $10,000 for
each day during which such violation continues or such
information is not disclosed or reported.
``(B) False information.--The Secretary may impose a
penalty against a health insurance issuer or entity providing
pharmacy benefits management services that knowingly provides
false information under section 726 in an amount not to
exceed $100,000 for each item of false information. Such
penalty shall be in addition to other penalties as may be
prescribed by law.
``(C) Waivers.--The Secretary may waive penalties under
subparagraph (A), or extend the period of time for compliance
with a requirement of section 726, for an entity in violation
of such section that has made a good-faith effort to comply
with such section.''.
(2) Clerical amendment.--The table of contents in section 1
of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1001 et seq.) is amended by inserting after the item
relating to section 725 the following new item:
``Sec. 726. Oversight of pharmacy benefits manager services.''.
(c) IRC.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following:
``SEC. 9826. OVERSIGHT OF PHARMACY BENEFIT MANAGER SERVICES.
``(a) In General.--For plan years beginning on or after the
date that is 2 years after the date of enactment of this
section, a group health plan, or an entity or subsidiary
providing pharmacy benefits management services on behalf of
such a plan, shall not enter into a contract with a drug
manufacturer, distributor, wholesaler, subcontractor, rebate
aggregator, or any other third party that 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 or
entity from making the reports described in subsection (b).
``(b) Reports.--
``(1) In general.--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 every 6 months (or
at the request of a group health plan, not less frequently
than quarterly, but under the same conditions, terms, and
cost of the semiannual report under this subsection), a group
health plan, or an entity providing pharmacy benefits
management services on behalf of such a plan, shall submit to
the group health plan a report in accordance with this
section. Each such report shall be made available to such
group health plan in a machine-readable format and shall
include the information described in paragraph (2).
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph is, with
respect to drugs covered by a group health plan during each
reporting period--
``(A) in the case of such a plan offered by a specified
large employer--
``(i) a list of drugs for which a claim was filed and, with
respect to each such drug on such list--
``(I) the brand name, chemical entity, and National Drug
Code;
``(II) the type of dispensing channel used to furnish such
drug, including retail, mail order, or specialty pharmacy;
``(III) with respect to each drug dispensed under each type
of dispensing channel (including retail, mail order, or
specialty pharmacy)--
``(aa) whether such drug is a brand name drug or a generic
drug, and--
``(AA) in the case of a brand name drug, the wholesale
acquisition cost, listed as cost per days supply and cost per
dosage unit, on the date such drug was dispensed; and
``(BB) in the case of a generic drug, the average wholesale
price, listed as cost per days supply and cost per dosage
unit, on the date such drug was dispensed; and
``(bb) the total number of--
``(AA) prescription claims (including original
prescriptions and refills);
``(BB) participants, beneficiaries, and enrollees for whom
a claim for such drug was filed;
``(CC) dosage units per fill of such drug; and
``(DD) days supply of such drug per fill;
``(IV) the net price per course of treatment or single
fill, such as a 30-day supply or 90-day supply to the plan
after manufacturer rebates, fees, and other remuneration or
adjustments;
``(V) the total amount of out-of-pocket spending by
participants, beneficiaries, and enrollees on such drug,
including spending through copayments, coinsurance, and
deductibles;
``(VI) the total net spending by the plan during the
reporting period;
``(VII) the total amount received, or expected to be
received, by the plan from any
[[Page H6776]]
entity in drug manufacturer rebates, fees, alternative
discounts, and all other remuneration received from an entity
or any third party (including group purchasing organizations)
other than the plan sponsor;
``(VIII) the total amount received, or expected to be
received by the plan, from drug manufacturers in rebates,
fees, alternative discounts, or other remuneration--
``(aa) that has been paid, or is to be paid, by drug
manufacturers for claims incurred during the reporting
period; and
``(bb) that is related to utilization rebates for such
drug; and
``(IX) to the extent feasible, information on the total
amount of remuneration, including copayment assistance
dollars paid, copayment cards applied, or other discounts
provided by each drug manufacturer (or entity administering
copay assistance on behalf of such drug manufacturer) to the
participants, beneficiaries, and enrollees enrolled in such
plan for such drug;
``(ii) for each category or class of drugs for which a
claim was filed, a breakdown of the total gross spending on
drugs in such category or class before rebates, price
concessions, alternative discounts, or other remuneration
from drug manufacturers, and the net spending after such
rebates, price concessions, alternative discounts, or other
remuneration from drug manufacturers, including--
``(I) the number of participants, beneficiaries, and
enrollees who filled a prescription for a drug in such
category or class, including the National Drug Code for each
such drug;
``(II) if applicable, a description of the formulary tiers
and utilization mechanisms (such as prior authorization or
step therapy) employed for drugs in that category or class;
``(III) the total out-of-pocket spending under the plan by
participants, beneficiaries, and enrollees, including
spending through copayments, coinsurance, and deductibles;
and
``(iii) in the case of a drug for which gross spending by
such plan or entity exceeded $10,000 during the reporting
period--
``(I) a list of all other drugs in the same therapeutic
category or class; and
``(II) the rationale for the formulary placement of such
drug in that therapeutic category or class, if applicable;
and
``(iv) in the case such plan (or an entity providing
pharmacy benefits management services on behalf of such plan)
that has an affiliated pharmacy or pharmacy under common
ownership--
``(I) the percentage of total prescriptions dispensed by
such pharmacies to individuals enrolled in such plan;
``(II) a list of all drugs dispensed by such pharmacies to
individuals enrolled in such plan, and, with respect to each
drug dispensed--
``(aa) the amount charged, per dosage unit, per 30-day
supply, or per 90-day supply (as applicable) to the plan, and
to participants, beneficiaries, and enrollees enrolled in
such plan;
``(bb) the median amount charged to such plan, and the
interquartile range of the costs, per dosage unit, per 30-day
supply, and per 90-day supply, including amounts paid by the
participants, beneficiaries, and enrollees, when the same
drug is dispensed by other pharmacies that are not affiliated
with or under common ownership with the entity and that are
included in the pharmacy network of such plan;
``(cc) the lowest cost per dosage unit, per 30-day supply
and per 90-day supply, for each such drug, including amounts
charged to the plan and participants, beneficiaries, and
enrollees, that is available from any pharmacy included in
the network of such plan; and
``(dd) the net acquisition cost per dosage unit, per 30-day
supply, and per 90-day supply, if such drug is subject to a
maximum price discount;
``(B) in the case of a plan not described in subparagraph
(A)--
``(i) the total net spending by the plan for all drugs
covered by such plan during such reporting period;
``(ii) the total amount received, or expected to be
received, by the plan from any entity in drug manufacturer
rebates, fees, alternative discounts, and all other
remuneration received from an entity or any third party
(including group purchasing organizations) other than the
plan sponsor for all such drugs; and
``(iii) to the extent feasible, information on the total
amount of remuneration, including copayment assistance
dollars paid, copayment cards applied, or other discounts
provided by each drug manufacturer (or entity administering
copay assistance on behalf of such drug manufacturer) to the
participants, beneficiaries, and enrollees enrolled in such
plan for such drugs;
``(C) amounts paid directly or indirectly in rebates, fees,
or any other type of compensation (as defined in section
408(b)(2)(B)(ii)(dd)(AA) of the Employee Retirement Income
Security Act) to brokers, consultants, advisors, or any other
individual or firm, for the referral of the group health
plan's business to an entity providing pharmacy benefits
management services, including the identity of the recipient
of such amounts;
``(D) an explanation of any benefit design parameters that
encourage or require participants, beneficiaries, and
enrollees in such plan to fill prescriptions at mail order,
specialty, or retail pharmacies that are affiliated with or
under common ownership with the entity providing pharmacy
benefit management services under such plan, including
mandatory mail and specialty home delivery programs, retail
and mail auto-refill programs, and cost-sharing assistance
incentives directly or indirectly funded by such entity; and
``(E) total gross spending on all drugs during the
reporting period.
``(3) Privacy requirements.--
``(A) In general.--Entities providing pharmacy benefits
management services on behalf of a group health plan shall
provide information under paragraph (1) in a manner
consistent with the privacy, security, and breach
notification regulations promulgated under section 13402(a)
of the Health Information Technology for Clinical Health Act
and consistent with the HIPAA privacy regulations (as defined
in section 1180(b)(3) of the Social Security Act) and shall
restrict the use and disclosure of such information according
to such privacy, security, and breach notification
regulations and such HIPAA privacy regulations.
``(B) Additional requirements.--
``(i) In general.--An entity providing pharmacy benefits
management services on behalf of a group health plan that
submits a report under paragraph (1) shall ensure that such
report contains only summary health information, as defined
in section 164.504(a) of title 45, Code of Federal
Regulations (or successor regulations).
``(ii) 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.
``(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 (as defined
in section 1180(b)(3) of the Social Security Act).
``(4) Disclosure and redisclosure.--
``(A) Limitation to business associates.--A group health
plan receiving a report under paragraph (1) may disclose such
information only to the entity from which the report 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 as permitted by the HIPAA
Privacy Rule (45 CFR parts 160 and 164, subparts A and E).
``(B) Clarification regarding public disclosure of
information.--Nothing in this section shall prevent a group
health plan or health insurance issuer offering group health
insurance coverage, or an entity providing pharmacy benefits
management services on behalf of such a plan or coverage,
from placing reasonable restrictions on the public disclosure
of the information contained in a report described in
paragraph (1), except that such plan, issuer, or entity may
not restrict disclosure of such report to the Department of
Health and Human Services, the Department of Labor, the
Department of the Treasury, or the Comptroller General of the
United States.
``(C) Limited form of report.--The Secretary shall define
through rulemaking a limited form of the report under
paragraph (1) required with respect to group health plans
where the plan sponsors of such plans are drug manufacturers,
drug wholesalers, or other direct participants in the drug
supply chain, in order to prevent anti-competitive behavior.
``(5) Report to gao.--A group health plan, or an entity
providing pharmacy benefits management services on behalf of
such plan, shall submit to the Comptroller General of the
United States each of the first 4 reports submitted to a
group health plan under paragraph (1) and other such reports
as requested, in accordance with the privacy requirements
under paragraph (3), the disclosure and redisclosure
standards under paragraph (4), the standards specified
pursuant to paragraph (6), and such other information that
the Comptroller General determines necessary to carry out the
study under section 106(d) of the Lower Costs, More
Transparency Act.
``(6) Standard format.--Not later than 1 year after the
date of enactment of this section, the Secretary shall
specify through rulemaking standards for group health plans,
and entities providing pharmacy benefits management services
on behalf of such plans, required to submit reports under
paragraph (1) to submit such reports in a standard format.
``(c) Rule of Construction.--Nothing in this section shall
be construed to permit a group health plan or entity
providing pharmacy benefits management services on behalf of
such plan, to restrict disclosure to, or otherwise limit the
access of, the Secretary of Health and Human Services to a
report described in subsection (b)(1) or information related
to compliance with subsections (a) or (b) by entities subject
to such subsection.
``(d) Definitions.--In this section:
``(1) Specified large employer.--The term `specified large
employer' means, in connection with a group health plan with
respect to a calendar year and a plan year, an employer who
employed an average of at least 50 employees on business days
during the preceding calendar year and who employs at least 1
employee on the first day of the plan year.
``(2) Wholesale acquisition cost.--The term `wholesale
acquisition cost' has the meaning given such term in section
1847A(c)(6)(B) of the Social Security Act.''.
[[Page H6777]]
(2) Clerical amendment.--The table of sections for
subchapter B of chapter 100 of the Internal Revenue Code of
1986 is amended by adding at the end the following new item:
``Sec. 9826. Oversight of pharmacy benefits manager services.''.
(d) GAO Reports.--
(1) Report on pharmacy network design.--
(A) In general.--Not later than 3 years after the date of
enactment of this Act, the Comptroller General of the United
States shall submit to Congress a report on--
(i) pharmacy networks that have contracted with group
health plans, health insurance issuers offering group health
insurance coverage, or entities providing pharmacy benefits
management services on behalf of such plans or issuers,
including networks with pharmacies that are under common
ownership (in whole or part) with such plans, issuers, or
entities (including entities that provide pharmacy benefits
administrative services on behalf of such plans or issuers);
(ii) pharmacy network design parameters that encourage
individuals enrolled in such plans or coverage to fill
prescriptions at mail order, specialty, or retail pharmacies
that are wholly or partially owned by a plan, issuer, or
entity;
(iii) whether such plans and issuers have options to elect
different network pricing arrangements in the marketplace
with entities that provide pharmacy benefits management
services and the prevalence of electing such different
network pricing arrangements;
(iv) with respect to pharmacy networks that include
pharmacies under common ownership described in clause (i)--
(I) whether such networks are designed to encourage
individuals enrolled in a group health plan or health
insurance coverage to use such pharmacies over other network
pharmacies for specific services or drugs, and if so, the
reasons the networks give for encouraging use of such
pharmacies; and
(II) whether such pharmacies are used by enrollees
disproportionately more in the aggregate or for specific
services or drugs compared to other network pharmacies;
(v) the degree to which mail order, specialty, or retail
pharmacies that dispense prescription drugs to an enrollee in
a plan or coverage that are under common ownership (in whole
or part) with plans, issuers, or entities providing pharmacy
benefits management services or pharmacy benefits
administrative services on behalf of such plan or coverage
receive reimbursement that is greater than the median price
charged to the plan or issuer when the same drug is dispensed
to enrollees in the plan or coverage by other pharmacies
included in the pharmacy network of that plan, issuer, or
entity that are not wholly or partially owned by the plan or
issuer, or entity providing pharmacy benefits management
services on behalf of such plan or issuer.
(B) Requirement.--The Comptroller General of the United
States shall ensure that the report under subparagraph (A)
does not contain information that would identify a specific
group health plan or health insurance issuer (or an entity
providing pharmacy benefits management services on behalf of
such plan or issuer), or otherwise contain commercial or
financial information that is privileged or confidential.
(C) Definitions.--In this paragraph, the terms ``group
health plan'', ``health insurance coverage'', and ``health
insurance issuer'' have the meanings given such terms in
section 2791 of the Public Health Service Act (42 U.S.C.
300gg-91).
(2) Report on copay assistance programs.--Not later than 18
months after the date of the enactment of this Act, the
Comptroller General of the United States shall submit to
Congress a report on what is known about the role of copay
assistance programs and the impact of such programs on
commercial health insurance, stop loss, and drug prices. Such
report shall include to the extent feasible--
(A) a description of copay assistance programs, including--
(i) the types of programs available and the methods of
providing copay assistance through such programs, including
cash discounts, copay cards, or drugs provided to an
individual at no cost;
(ii) how such programs are funded;
(iii) the types of entities that own, operate, or otherwise
conduct such programs, the types of information such entities
collect, and the direct and indirect contractual
relationships between the entities in the drug supply chain
that interact with such programs, such as a drug
manufacturer, pharmacy, wholesaler, switch, rebate
aggregator, pharmacy benefit manager, and other entities in
the drug supply chain;
(iv) the effect of such programs on patient out-of-pocket
spending, including for stop-loss insurance, and drug
utilization, including drug adherence; and
(v) patient eligibility criteria for such programs; and
(B) an analysis of--
(i) the sources of funding for such programs; and
(ii) the effects of such programs on Federal health care
programs and the individuals enrolled in such Federal health
care programs.
SEC. 107. REPORTS ON HEALTH CARE TRANSPARENCY TOOLS AND DATA.
(a) Initial Report.--Not later than December 31, 2024, the
Comptroller General of the United States shall submit to the
Committees (as defined in subsection (d)) an initial report
that--
(1) identifies and describes health care transparency tools
and Federal health care reporting requirements (as described
in subsection (d)) that are in effect as of the date of the
submission of such initial report, including the frequency of
reports with respect to each such requirement and whether any
such requirements are duplicative;
(2) reviews how such reporting requirements are enforced;
(3) analyzes whether the public availability of health care
transparency tools, and the publication of data pursuant to
such reporting requirements, has--
(A) been utilized and valued by consumers, including
reasons for such utilization (or lack thereof); and
(B) assisted health insurance plan sponsors and fiduciaries
improve benefits, lower health care costs for plan
participants, and meet fiduciary requirements;
(4) includes recommendations to the Committees, the
Secretary of Health and Human Services, the Secretary of
Labor, and the Secretary of the Treasury to--
(A) improve the efficiency, accuracy, and usability of
health care transparency tools;
(B) streamline Federal health care reporting requirements
to eliminate duplicative requirements and reduce the burden
on entities required to submit reports pursuant to such
provisions;
(C) improve the accuracy and efficiency of such reports
while maintaining the integrity and usability of the data
provided by such reports;
(D) address any gaps in data provided by such reports; and
(E) ensure that the data and information reported is
comparable and usable to consumers, including patients, plan
sponsors, and policy makers.
(b) Final Report.--Not later than December 31, 2028, the
Comptroller General of the United States shall submit to the
Committees a report that includes--
(1) the information provided in the initial report, along
with any updates to such information; and
(2) any new information with respect to health care
transparency tools that have been released following the
submission of such initial report, or new reporting
requirements in effect as of the date of the submission of
the final report.
(c) Report on Expanding Price Transparency Requirements.--
Not later than December 31, 2025, the Comptroller General of
the United States, in consultation with the Secretary of
Health and Human Services, health care provider groups, and
patient advocacy groups, shall submit to the Committees a
report that includes recommendations to expand price
transparency reporting requirements to additional care
settings, with an emphasis on settings where shoppable
services (as defined in subsection (d)) are furnished.
(d) Definitions.--In this section:
(1) Committees.--The term ``Committees'' means the
Committee on Ways and Means, the Committee on Energy and
Commerce, and the Committee on Education and the Workforce of
the House of Representatives, and the Committee on Finance
and the Committee on Health, Education, Labor, and Pensions
of the Senate.
(2) Federal health care reporting requirements.--The term
``Federal health care reporting requirements'' includes
regulatory and statutory requirements with respect to the
reporting and publication of health care price, cost access,
and quality data, including requirements established by the
Consolidated Appropriations Act of 2021 (Public Law 116-260),
this Act, and other reporting and publication requirements
with respect to transparency in health care as identified by
the Comptroller General of the United States.
(3) Shoppable service.--The term ``shoppable service''
means a service that can be scheduled by a health care
consumer in advance and includes all ancillary items and
services customarily furnished as part of such service.
SEC. 108. REPORT ON INTEGRATION IN MEDICARE.
(a) Required MA and PDP Reporting.--
(1) MA plans.--Section 1857(e) of the Social Security Act
(42 U.S.C. 1395w-27(e)) is amended by adding at the end the
following new paragraph:
``(6) Required disclosure of certain information relating
to health care provider ownership.--
``(A) In general.--For plan year 2025 and for every third
plan year thereafter, each applicable MA organization
offering an MA plan under this part during such plan year
shall submit to the Secretary, at a time and in a manner
specified by the Secretary--
``(i) the taxpayer identification number for each health
care provider that was a specified health care provider with
respect to such organization during such year;
``(ii) the total amount of incentive-based payments made
to, and the total amount of shared losses recoupments
collected from, such specified health care providers during
such plan year; and
``(iii) the total amount of incentive-based payments made
to, and the total amount of shared losses recoupments
collected from, providers of services and suppliers not
described in clause (ii) during such plan year.
``(B) Definitions.--For purposes of this paragraph:
``(i) Applicable ma organization.--The term `applicable MA
organization' means,
[[Page H6778]]
with respect to a plan year, an MA organization with at least
25,000 individuals enrolled under Medicare Advantage plans
offered by such organization during such plan year.
``(ii) Specified health care provider.--The term `specified
health care provider' means, with respect to an applicable MA
organization and a plan year, a provider of services or
supplier with respect to which such organization (or any
person with an ownership or control interest (as defined in
section 1124(a)(3)) in such organization) is a person with an
ownership or control interest (as so defined).''.
(2) Prescription drug plans.--Section 1860D-12(b) of the
Social Security Act (42 U.S.C. 1395w-112(b)) is amended by
adding at the end the following new paragraph:
``(9) Provision of information relating to pharmacy
ownership.--
``(A) In general.--For plan year 2025 and for every third
plan year thereafter, each PDP sponsor offering a
prescription drug plan under this part during such plan year
shall submit to the Secretary, at a time and in a manner
specified by the Secretary, the taxpayer identification
number and National Provider Identifier for each pharmacy
that was a specified pharmacy with respect to such sponsor
during such year.
``(B) Definition.--For purposes of this paragraph, the term
`specified pharmacy' means, with respect to an PDP sponsor
offering a prescription drug plan and a plan year, a pharmacy
with respect to which--
``(i) such sponsor (or any person with an ownership or
control interest (as defined in section 1124(a)(3)) in such
sponsor) is a person with an ownership or control interest
(as so defined); or
``(ii) a pharmacy benefit manager offering services under
such plan (or any person with an ownership or control
interest (as so defined) in such sponsor) is a person with an
ownership or control interest (as so defined).''.
(b) MedPAC Reports.--Part E of title XVIII of the Social
Security Act (42 U.S.C. 1395x et seq.), as amended by section
101, is further amended by adding at the end the following
new section:
``SEC. 1899D. REPORTS ON VERTICAL INTEGRATION UNDER MEDICARE.
``(a) In General.--Not later than June 15, 2029, and every
3 years thereafter, the Medicare Payment Advisory Commission
shall submit to Congress a report on the state of vertical
integration in the health care sector during the applicable
year with respect to entities participating in the Medicare
program, including health care providers, pharmacies,
prescription drug plan sponsors, Medicare Advantage
organizations, and pharmacy benefit managers. Such report
shall include--
``(1) with respect to Medicare Advantage organizations, the
evaluation described in subsection (b);
``(2) with respect to prescription drug plans, pharmacy
benefit managers, and pharmacies, the comparisons and
evaluations described in subsection (c);
``(3) with respect to Medicare Advantage plans under which
benefits are available for physician-administered drugs, the
information described in subsection (d);
``(4) the identifications described in subsection (e); and
``(5) an analysis of the impact of such integration on
health care access, price, quality, and outcomes.
``(b) Medicare Advantage Organizations.--For purposes of
subsection (a)(1), the evaluation described in this
subsection is, with respect to Medicare Advantage
organizations and an applicable year, an evaluation, taking
into account patient acuity and the types of areas serviced
by such organization, of--
``(1) the average number of qualifying diagnoses made
during such year with respect to enrollees of a Medicare
Advantage plan offered by such organization who, during such
year, received a health risk assessment from a specified
health care provider;
``(2) the average risk score for such enrollees who
received such an assessment during such year;
``(3) any relationship between such risk scores for such
enrollees receiving such an assessment from such a provider
during such year and incentive payments made to such
providers;
``(4) the average risk score for enrollees of such plan who
received any item or service from a specified health care
provider during such year;
``(5) any relationship between the risk scores of enrollees
under such plan and whether the enrollees have received any
item or service from a specified provider; and
``(6) any relationship between the risk scores of enrollees
under such plan that have received any item or service from a
specified provider and incentive payments made under the plan
to specified providers.
``(c) Prescription Drug Plans.--For purposes of subsection
(a)(2), the comparisons and evaluations described in this
subsection are, with respect to prescription drug plans and
an applicable year, the following:
``(1) For each covered part D drug for which benefits are
available under such a plan, a comparison of the average
negotiated rate in effect with specified pharmacies with such
rates in effect for in-network pharmacies that are not
specified pharmacies.
``(2) Comparisons of the following:
``(A) The total amount paid by pharmacy benefit managers to
specified pharmacies for covered part D drugs and the total
amount so paid to pharmacies that are not specified
pharmacies for such drugs.
``(B) The total amount paid by such sponsors to specified
pharmacy benefit managers as reimbursement for covered part D
drugs and the total amount so paid to pharmacy benefit
managers that are not specified pharmacy benefit managers as
such reimbursement.
``(C) Fees paid under by plan to specified pharmacy benefit
managers compared to such fees paid to pharmacy benefit
managers that are not specified pharmacy benefit managers.
``(3) An evaluation of the total amount of direct and
indirect remuneration for covered part D drugs passed through
to prescription drug plan sponsors and the total amount
retained by pharmacy benefit managers (including entities
under contract with such a manager).
``(4) To the extent that the available data permits, an
evaluation of fees charged by rebate aggregators that are
affiliated with plan sponsors.
``(d) Physician-administered Drugs.--For purposes of
subsection (a)(3), the information described in this
subsection is, with respect to physician-administered drugs
for which benefits are available under a Medicare Advantage
plan during an applicable year, the following:
``(1) With respect to each such plan, an identification of
each drug for which benefits were available under such plan
only when administered by a health care provider that
acquired such drug from an affiliated pharmacy.
``(2) An evaluation of the difference between the total
number of drugs administered by a health care provider that
were acquired from affiliated pharmacies compared to the
number of such drugs so administered that were acquired from
pharmacies other than affiliated pharmacies, and an
evaluation of the difference in payments for such drugs so
administered when acquired from a specified pharmacy and when
acquired from a pharmacy that is not a specified pharmacy.
``(3) An evaluation of the dollar value of all such drugs
that were not so administered because of a delay attributable
to an affiliated pharmacy compared to the dollar value of all
such drugs that were not so administered because of a delay
attributable to pharmacy that is not an affiliated pharmacy.
``(4) The number of enrollees administered such a drug that
was acquired from an affiliated pharmacy.
``(5) The number of enrollees furnished such a drug that
was acquired from a pharmacy that is not an affiliated
pharmacy.
``(e) Identifications.--For purposes of subsection (a)(4),
the identifications described in this subsection are, with
respect to an applicable year, identifications of each health
care entity participating under the Medicare program with
respect to which another health care entity so participating
is a person with an ownership or control interest (as defined
in section 1124(a)(3)).
``(f) Definitions.--In this section:
``(1) Affiliated pharmacy.--The term `affiliated pharmacy'
means, with respect to a Medicare Advantage plan offered by a
Medicare Advantage organization, a pharmacy with respect to
which such organization (or any person with an ownership or
control interest (as defined in section 1124(a)(3)) in such
organization) is a person with an ownership or control
interest (as so defined).
``(2) Applicable year.--The term `applicable year' means,
with respect to a report submitted under subsection (a), the
first calendar year beginning at least 4 years prior to the
date of the submission of such report.
``(3) Covered part d drug.--The term `covered part D drug'
has the meaning given such term in section 1860D-2(e).
``(4) Direct and indirect remuneration.--The term `direct
and indirect remuneration' has the meaning given such term in
section 423.308 of title 42, Code of Federal Regulations (or
any successor regulation).
``(5) Qualifying diagnosis.--The term `qualifying
diagnosis' means, with respect to an enrollee of a Medicare
Advantage plan, a diagnosis that is taken into account in
calculating a risk score for such enrollee under the risk
adjustment methodology established by the Secretary pursuant
to section 1853(a)(3).
``(6) Risk score.--The term `risk score' means, with
respect to an enrollee of a Medicare Advantage plan, the
score calculated for such individual using the methodology
described in paragraph (5).
``(7) Physician-administered drug.--The term `physician-
administered drug' means a drug furnished to an individual
that, had such individual been enrolled under part B and not
enrolled under part C, would have been payable under section
1842(o).
``(8) Specified health care provider.--The term `specified
health care provider' means, with respect to a Medicare
Advantage plan offered by a Medicare Advantage organization,
a health care provider with respect to which such
organization (or any person with an ownership or control
interest (as defined in section 1124(a)(3)) in such
organization) is a person with an ownership or control
interest (as so defined).
``(9) Specified pharmacy.--The term `specified pharmacy'
means, with respect to a prescription drug plan offered by a
prescription drug plan sponsor, a pharmacy with respect to
which--
``(A) such sponsor (or any person with an ownership or
control interest (as defined in
[[Page H6779]]
section 1124(a)(3)) in such sponsor) is a person with an
ownership or control interest (as so defined); or
``(B) a pharmacy benefit manager offering services under
such plan (or any person with an ownership or control
interest (as so defined) in such sponsor) is a person with an
ownership or control interest (as so defined).
``(10) Specified pharmacy benefit manager.--The term
`specified pharmacy benefit manager' means, with respect to a
prescription drug plan offered by a prescription drug plan
sponsor, a pharmacy benefit manager with respect to which
such sponsor (or any person with an ownership or control
interest (as defined in section 1124(a)(3)) in such sponsor)
is a person with an ownership or control interest (as so
defined).''.
SEC. 109. ADVISORY COMMITTEE.
(a) In General.--Not later than January 1, 2025, the
Secretary of Labor, the Secretary of Health and Human
Services, and the Secretary of the Treasury shall jointly
convene an advisory committee (in this section referred to as
the ``committee'') consisting of 9 members to advise the
Secretaries on how to improve the usefulness, accessibility,
and usability of information made available in accordance the
amendments made by sections 105 and 106, and by section 204
of division BB of the Consolidated Appropriation Act, 2021
(Public Law 116-260), streamline the reporting of such
information, and ensure that--
(1) such information is accurate, accessible, and is
delivered in a form and manner consistent with the
requirements of such section;
(2) the form and manner in which such information is
delivered is routinely updated in accordance with widely-used
practices in order to ensure accessibility; and
(3) such information is available for audit (including by
making recommendations relating to how Federal and State
actors may conduct such audits).
(b) Membership.--The Secretaries shall jointly appoint
members representing end-users of the information described
in subsection (a). Vacancies on the committee shall be filled
by appointment consistent with this subsection not later than
3 months after the vacancy arises.
(c) Termination.--The committee shall terminate on January
1, 2028.
(d) Nonapplicaiton of FACA.--The Federal Advisory Committee
Act (5 U.S.C. App.) shall not apply to the committee.
SEC. 110. REPORT ON IMPACT OF MEDICARE REGULATIONS ON
PROVIDER AND PAYER CONSOLIDATION.
(a) Annual Report on the Impact of Certain Medicare
Regulations on Provider and Payer Consolidation; Public
Comment on Provider and Payer Consolidation for Certain
Proposed Rules.--
(1) Annual report.--Not later than December 30, 2026, and
annually thereafter, the Secretary of Health and Human
Services (in this section referred to as the ``Secretary'')
shall submit to Congress a report on the impact in the
aggregate on provider and payer consolidation with respect to
regulations for parts A, B, C, and D of title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.) implemented in
the calendar year immediately prior to such report. Such
report shall include regulations that--
(A) implement a change to an applicable payment system, a
rate schedule, or another payment system under part A, B, C,
or D of such title; or
(B) result in a significant rule effecting provider or
payer consolidation.
(2) Public comment on impact to provider and payer
consolidation.--Beginning for 2025, as part of any notice and
comment rulemaking process that will result in a significant
rule effecting provider or payer consolidation with respect
to a proposed rule for parts A, B, C, and D of title XVIII of
the Social Security Act (42 U.S.C. 1395j et seq.), the
Secretary shall seek public comment on the projected impact
of such proposed rule on provider and payer consolidation in
the aggregate.
(3) Definitions.--In this section:
(A) Provider and payer consolidation.--The term ``provider
and payer consolidation'' includes the vertical or horizontal
integration among providers of services (as defined in
subsection (u) of section 1861 of the Social Security Act (42
U.S.C. 1395x)), suppliers (as defined in subsection (d) of
such section), accountable care organizations under section
1899 of the Social Security Act (42 U.S.C. 1395jjj), Medicare
Advantage organizations, PDP sponsors, pharmacy benefit
managers, pharmacies, and integrated delivery systems.
(B) Applicable payment system.--The term ``applicable
payment system'' includes--
(i) with respect to outpatient hospital services, the
prospective payment system for covered OPD services
established under section 1833(t) of such Act (42 U.S.C.
1395(l)); and
(ii) with respect to physicians' services, the physician
fee schedules established under section 1848 of such Act (42
U.S.C. 1395w-4).
(b) Consideration of Effects on Provider and Payer
Consolidation With Respect to CMI Models.--
(1) In general.--Section 1115A(b)(4)(A) of the Social
Security Act (42 U.S.C. 1315a(b)(4)(A)) is amended--
(A) in clause (i), by striking at the end ``and'';
(B) in clause (ii), by striking the period at the end and
inserting ``; and''; and
(C) by adding at the end the following new clause:
``(iii) the extent to which, and how, the model has
effected and could effect provider and payer consolidation,
which includes the vertical or horizontal integration among
providers of services (as defined in subsection (u) of
section 1861), suppliers (as defined in subsection (d) of
such section), and accountable care organizations under
section 1899.''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply with respect to models tested on or after January
1, 2025.
SEC. 111. IMPLEMENTATION FUNDING.
(a) In General.--For the purposes described in subsection
(b), there are appropriated, in addition to amounts otherwise
available, out of amounts in the Treasury not otherwise
appropriated, to the Secretary of Health and Human Services
and the Secretary of the Treasury, $65,000,000 for fiscal
year 2024, to remain available through fiscal year 2029.
(b) Permitted Purposes.--The purposes described in this
subsection are the following purposes, insofar as such
purposes are to carry out the provisions of, including the
amendments made by, this title:
(1) Preparing, drafting, and issuing proposed and final
regulations or interim regulations.
(2) Preparing, drafting, and issuing guidance and public
information.
(3) Preparing, drafting, and publishing reports.
(4) Enforcement of such provisions.
(5) Reporting, collection, and analysis of data.
(6) Other administrative duties necessary for
implementation of such provisions.
(c) Transparency of Implementation Funds.--Each Secretary
described in subsection (a) shall annually submit, no later
than September 1st of each year, to the Committees on Energy
and Commerce, on Ways and Means, on Education and Workforce,
and on Appropriations of the House of Representatives and on
the Committees on Health, Education, Labor, and Pensions and
on Appropriations of the Senate a report on funds expended
pursuant to funds appropriated under this section.
TITLE II--REDUCING HEALTH CARE COSTS FOR PATIENTS
SEC. 201. INCREASING TRANSPARENCY IN GENERIC DRUG
APPLICATIONS.
(a) In General.--Section 505(j)(3) of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 355(j)(3)) is amended by
adding at the end the following:
``(H)(i) Upon request (in controlled correspondence or an
analogous process) by a person that has submitted or intends
to submit an abbreviated application under this subsection
for a drug that is required by regulation to contain one or
more of the same inactive ingredients in the same
concentrations as the listed drug referred to, or for which
the Secretary determines there is a scientific justification
for an approach that is in vitro in whole or in part to be
used to demonstrate bioequivalence for a drug if such a drug
contains one or more of the same inactive ingredients in the
same concentrations as the listed drug, the Secretary shall
inform the person whether such drug is qualitatively and
quantitatively the same as the listed drug. The Secretary may
also provide such information to such a person on the
Secretary's own initiative during the review of an
abbreviated application under this subsection for such drug.
``(ii) Notwithstanding section 301(j), if the Secretary
determines that such drug is not qualitatively or
quantitatively the same as the listed drug, the Secretary
shall identify and disclose to the person--
``(I) the ingredient or ingredients that cause such drug
not to be qualitatively or quantitatively the same as the
listed drug; and
``(II) for any ingredient for which there is an identified
quantitative deviation, the amount of such deviation.
``(iii) If the Secretary determines that such drug is
qualitatively and quantitatively the same as the listed drug,
the Secretary shall not change or rescind such determination
after the submission of an abbreviated application for such
drug under this subsection unless--
``(I) the formulation of the listed drug has been changed
and the Secretary has determined that the prior listed drug
formulation was withdrawn for reasons of safety or
effectiveness; or
``(II) the Secretary makes a written determination that the
prior determination must be changed because an error has been
identified.
``(iv) If the Secretary makes a written determination
described in clause (iii)(II), the Secretary shall provide
notice and a copy of the written determination to the person
making the request under clause (i).
``(v) The disclosures required by this subparagraph are
disclosures authorized by law, including for purposes of
section 1905 of title 18, United States Code.''.
(b) Guidance.--
(1) In general.--Not later than one year after the date of
enactment of this Act, the Secretary of Health and Human
Services shall issue draft guidance, or update guidance,
describing how the Secretary will determine whether a drug is
qualitatively and quantitatively the same as the listed drug
(as such terms are used in section 505(j)(3)(H) of the
Federal Food, Drug, and Cosmetic Act, as added by subsection
(a)), including with respect to assessing pH adjusters.
[[Page H6780]]
(2) Process.--In issuing guidance under this subsection,
the Secretary of Health and Human Services shall--
(A) publish draft guidance;
(B) provide a period of at least 60 days for comment on the
draft guidance; and
(C) after considering any comments received and not later
than one year after the close of the comment period on the
draft guidance, publish final guidance.
(c) Applicability.--Section 505(j)(3)(H) of the Federal
Food, Drug, and Cosmetic Act, as added by subsection (a),
applies beginning on the date of enactment of this Act,
irrespective of the date on which the guidance required by
subsection (b) is finalized.
SEC. 202. IMPROVING TRANSPARENCY AND PREVENTING THE USE OF
ABUSIVE SPREAD PRICING AND RELATED PRACTICES IN
MEDICAID.
(a) Spread Pricing.--
(1) In general.--Section 1927(e) of the Social Security Act
(42 U.S.C. 1396r-8(e)) is amended by adding at the end the
following:
``(6) Pharmacy price reimbursement required.--
``(A) In general.--A contract between the State and a
pharmacy benefit manager (in this paragraph referred to as a
`PBM'), or a contract between the State and a designated
entity (as defined in subparagraph (C)) that includes
provisions making the designated entity responsible for the
administration of medical assistance consisting of covered
outpatient drugs for individuals enrolled with the designated
entity, shall require that payment for such drugs and related
administrative services (as applicable), including payments
made by a PBM on behalf of the State or designated entity, is
based on a pharmacy price reimbursement model under which--
``(i) any payment made by the designated entity or the PBM
(as applicable) for such a drug--
``(I) is limited to--
``(aa) ingredient cost; and
``(bb) a professional dispensing fee that is not less than
the professional dispensing fee that the State plan or waiver
would pay if the plan or waiver was making the payment
directly;
``(II) is passed through in its entirety by the designated
entity or PBM to the pharmacy or provider that dispenses the
drug and is not retroactively denied or reduced except as
permitted or required under Federal or State law or
regulation; and
``(III) is made in a manner that is consistent with
sections 447.502, 447.512, 447.514, and 447.518 of title 42,
Code of Federal Regulations (or any successor regulation) as
if such requirements applied directly to the designated
entity or the PBM, except that any payment by the designated
entity or the PBM for the ingredient cost of such a drug
purchased by a covered entity (as defined in subsection
(a)(5)(B)) may exceed the actual acquisition cost (as defined
in section 447.502 of title 42, Code of Federal Regulations
(or any successor regulation)) for such drug if--
``(aa) such drug was subject to an agreement under section
340B of the Public Health Service Act;
``(bb) such payment for such cost of such drug does not
exceed the maximum payment that would have been made by the
designated entity or the PBM for the ingredient cost of such
drug had such drug not been purchased by such a covered
entity; and
``(cc) such covered entity reports to the Secretary, on an
annual basis (in a form and manner specified by the
Secretary) and with respect to payments for such costs of
such drugs so purchased by such covered entity that are in
excess of the actual acquisition costs for such drugs, the
aggregate amount of such excess;
``(ii) payment to the designated entity or the PBM (as
applicable) for administrative services performed by the
designated entity or PBM is limited to an administrative fee
that reflects the fair market value of providing such
services;
``(iii) the designated entity or the PBM (as applicable)
makes available to the State, and the Secretary upon request,
all costs and payments related to covered outpatient drugs
and accompanying administrative services incurred, received,
or made by the designated entity or the PBM, including
ingredient costs, professional dispensing fees,
administrative fees, post-sale and post-invoice fees,
discounts, or related adjustments such as direct and indirect
remuneration fees, and any and all other remuneration; and
``(iv) any form of spread pricing whereby any amount
charged or claimed by the designated entity or the PBM (as
applicable) is in excess of the amount paid to the pharmacies
by the designated entity or the PBM, including any post-sale
or post-invoice fees, discounts, or related adjustments such
as direct and indirect remuneration fees or assessments
(after allowing for a fair market administrative fee as
described in clause (ii)), is not allowable for purposes of
claiming Federal matching payments under this title.
``(B) Making certain information available.--The Secretary
shall publish, not less frequently than on an annual basis,
information received by the Secretary pursuant to
subparagraph (A)(i)(III)(cc). Such information shall be so
published in an electronic and searchable format, such as
through the 340B Office of Pharmacy Affairs Information
System (or a successor system).
``(C) Definitions.--In this paragraph:
``(i) Designated entity.--The term `designated entity'
means a managed care entity or other specified entity.
``(ii) Managed care entity; other specified entity.--The
terms `managed care entity' and `other specified entity' have
the meaning given such terms in section 1903(m)(9)(D).''.
(2) Conforming amendments.--Section 1903(m) of such Act (42
U.S.C. 1396b(m)) is amended--
(A) in paragraph (2)(A)(xiii)--
(i) by striking ``and (III)'' and inserting ``(III)'';
(ii) by inserting before the period at the end the
following: ``, and (IV) with respect to covered outpatient
drugs and related administrative services (as applicable)
provided by the entity (or by a pharmacy benefit manager on
behalf of the entity under a contract or other arrangement
with the entity), that payment for such drugs and related
administrative services is based on a pharmacy price
reimbursement model described in section 1927(e)(6)(A)''; and
(iii) by moving the margin 2 ems to the left; and
(B) by adding at the end the following new paragraph:
``(10) No payment shall be made under this title to a State
with respect to expenditures incurred by it for payment for
services provided by an other specified entity (as defined in
paragraph (9)(D)) unless the contract between the State and
the entity for the provision of such services provides, with
respect to covered outpatient drugs and related
administrative services (as applicable) provided by the
entity (or by a pharmacy benefit manager on behalf of the
entity under a contract or other arrangement with the
entity), that payment for such drugs and related
administrative services is based on a pharmacy price
reimbursement model described in section 1927(e)(6)(A).''.
(3) Effective date.--The amendments made by this subsection
apply to contracts between States and pharmacy benefit
managers and designated entities (as defined in section
1927(e)(6) of the Social Security Act, as added by paragraph
(1)) that have an effective date beginning on or after the
date that is 18 months after the date of enactment of this
Act.
(b) Ensuring Accurate Payments to Pharmacies Under
Medicaid.--
(1) In general.--Section 1927(f) of the Social Security Act
(42 U.S.C. 1396r-8(f)) is amended--
(A) by striking ``and'' after the semicolon at the end of
paragraph (1)(A)(i) and all that precedes it through ``(1)''
and inserting the following:
``(1) Determining pharmacy actual acquisition costs.--The
Secretary shall conduct a survey of retail community pharmacy
drug prices to determine the national average drug
acquisition cost as follows:
``(A) Use of vendor.--The Secretary may contract services
for--
``(i) with respect to retail community pharmacies, the
determination of retail survey prices of the national average
drug acquisition cost for covered outpatient drugs based on a
monthly survey of such pharmacies; and'';
(B) by adding at the end of paragraph (1) the following:
``(F) Survey reporting.--A State shall require that any
retail community pharmacy in the State that receives any
payment, reimbursement, administrative fee, discount, or
rebate related to the dispensing of covered outpatient drugs
to individuals receiving benefits under this title,
regardless of whether such payment, reimbursement,
administrative fee, discount, or rebate is received from the
State or a designated entity (as defined in subsection
(e)(6)(C)) directly or from a pharmacy benefit manager that
has a contract with the State or a designated entity, shall
respond to surveys of retail prices conducted under this
subsection.
``(G) Survey information.--Information on national drug
acquisition prices obtained under this paragraph shall be
made publicly available in a timely manner following the
collection of such information and shall include at least the
following:
``(i) The monthly response rate to the survey including a
list of pharmacies not in compliance with subparagraph (F).
``(ii) The sampling frame and number of pharmacies sampled
monthly.
``(iii) Information on price concessions to the pharmacy,
including discounts, rebates, and other price concessions, to
the extent that such information may be publicly released and
is available during the survey period.
``(H) Report on specialty pharmacies.--Not later than 1
year after the date that this subparagraph takes effect, the
Secretary shall submit to Congress a report examining
specialty drug coverage and reimbursement under this title,
including--
``(i) a description of how State Medicaid programs define
specialty drugs and specialty pharmacies;
``(ii) the amount State Medicaid programs pay for specialty
drugs;
``(iii) how States and designated entities (as defined in
subsection (e)(6)(C)) determine payment for specialty drugs;
``(iv) the settings in which specialty drugs are dispensed
to individuals receiving benefits under this title (such as
retail community pharmacies or specialty pharmacies);
``(v) the extent to which specialty drugs (as defined by
the respective States) are captured in the national average
drug acquisition cost survey (or through another process);
[[Page H6781]]
``(vi) examples of specialty drug dispensing fees to
support the services associated with dispensing such
specialty drugs; and
``(vii) recommendations as to whether specialty pharmacies
should be included in the survey of retail prices to ensure
national average drug acquisition costs capture drugs sold at
specialty pharmacies, and how such specialty pharmacies
should be defined.
``(I) Enforcement.--At the discretion of the Secretary, the
Secretary (acting through the Inspector General and in
collaboration with the Administrator of the Centers for
Medicare & Medicaid Services) may enforce non-compliance with
this paragraph by a pharmacy through the establishment of
penalties until compliance with this paragraph has been
completed.''; and
(C) in paragraph (2)--
(i) in subparagraph (A), by inserting ``(including payment
rates under managed care organization as defined in section
1932(a)(1)(B)(i) and PIHPs and PAHPs as defined in section
1903(m)(9)(D)(iii)(I) and (II), respectively)'' after ``under
this title''; and
(ii) in subparagraph (B), by inserting ``, and the basis
for such dispensing fees'' before the semicolon at the end.
(2) Effective date.--The amendments made by this subsection
shall take effect on the first day of the first quarter that
begins on or after the date that is 18 months after the date
of enactment of this Act.
SEC. 203. PARITY IN MEDICARE PAYMENTS FOR HOSPITAL OUTPATIENT
DEPARTMENT SERVICES FURNISHED OFF-CAMPUS.
(a) In General.--Section 1833(t)(16) of the Social Security
Act (42 U.S.C. 1395l(t)(16)) is amended by adding at the end
the following new subparagraph:
``(H) Parity in fee schedule amount for certain services
furnished by an off-campus outpatient department of a
provider.--
``(i) In general.--Subject to clause (iii), in the case of
specified OPD services (as defined in clause (v)) that are
furnished during 2025 or a subsequent year by an off-campus
outpatient department of a provider (as defined in clause
(iv)) (or, in the case of an off-campus outpatient department
of a provider that is a hospital described in section
1886(d)(1)(B)(v), or is located in a rural area or a health
professional shortage area, such services that are furnished
during 2026 or a subsequent year), there shall be substituted
for the amount otherwise determined under this subsection for
such service and year an amount equal to the payment amount
that would have been payable under the applicable payment
system under this part (other than under this subsection) had
such services been furnished by such a department subject to
such payment system pursuant to paragraph (21)(C).
``(ii) Not budget neutral implementation.--In making any
budget neutrality adjustments under this subsection for 2025
or a subsequent year, the Secretary shall not take into
account the reduced expenditures that result from the
application of this subparagraph.
``(iii) Transition.--The Secretary shall provide for a 4-
year phase-in of the application of clause (i), with clause
(i) being fully applicable for specified OPD services
beginning with 2028 (or in the case of an off-campus
outpatient department of a provider that is a hospital
described in section 1886(d)(1)(B)(v), or is located in a
rural area or a health professional shortage area, beginning
with 2029).
``(iv) Off-campus department of a provider.--For purposes
of this subparagraph, the term `off-campus outpatient
department of a provider' means a department of a provider
(as defined in section 413.65(a)(2) of title 42, Code of
Federal Regulations) that is not located--
``(I) on the campus (as such term is defined in such
section) of such provider; or
``(II) within the distance (described in such definition of
campus) from a remote location of a hospital facility (as
defined in such section).
``(v) Other definitions.--For purposes of this
subparagraph:
``(I) Designated ambulatory payment classification group.--
The term `designated ambulatory payment classification group'
means an ambulatory payment classification group for drug
administration services.
``(II) Health professional shortage area.--The term `health
professional shortage area' has the meaning given such term
in section 332(a)(1)(A) of the Public Health Service Act.
``(III) Rural area.--The term `rural area' has the meaning
given such term in section 1886(d)(2)(D).
``(IV) Specified opd services.--The term `specified OPD
services' means covered OPD services assigned to a designated
ambulatory payment classification group.''.
(b) Implementation.--Section 1833(t)(12) of the Social
Security Act (42 U.S.C. 1395l(t)(12)) is amended--
(1) in subparagraph (D), by striking ``and'' at the end;
(2) in subparagraph (E), by striking the period at the end
and inserting ``; and''; and
(3) by adding at the end the following new subparagraph:
``(F) the determination of any payment amount under
paragraph (16)(H), including the transition under clause
(iii) of such paragraph.''.
SEC. 204. REQUIRING A SEPARATE IDENTIFICATION NUMBER AND AN
ATTESTATION FOR EACH OFF-CAMPUS OUTPATIENT
DEPARTMENT OF A PROVIDER.
(a) In General.--Section 1833(t) of the Social Security Act
(42 U.S.C. 1395l(t)) is amended by adding at the end the
following new paragraph:
``(23) Use of unique health identifiers; attestation.--
``(A) In general.--No payment may be made under this
subsection (or under an applicable payment system pursuant to
paragraph (21)) for items and services furnished on or after
January 1, 2026, by an off-campus outpatient department of a
provider (as defined in subparagraph (C)) unless--
``(i) such department has obtained, and such items and
services are billed under, a standard unique health
identifier for health care providers (as described in section
1173(b)) that is separate from such identifier for such
provider; and
``(ii) such provider has submitted to the Secretary, during
the 2-year period ending on the date such items and services
are so furnished, an attestation that such department is
compliant with the requirements described in section 413.65
of title 42, Code of Federal Regulations (or a successor
regulation).
``(B) Process for submission and review.--Not later than 1
year after the date of enactment of this paragraph, the
Secretary shall, through notice and comment rulemaking,
establish a process for each provider with an off-campus
outpatient department of a provider to submit an attestation
pursuant to subparagraph (A)(ii), and for the Secretary to
review each such attestation and determine, through site
visits, remote audits, or other means (as determined
appropriate by the Secretary), whether such department is
compliant with the requirements described in such
subparagraph.
``(C) Off-campus outpatient department of a provider
defined.--For purposes of this paragraph, the term `off-
campus outpatient department of a provider' means a
department of a provider (as defined in section 413.65 of
title 42, Code of Federal Regulations, or any successor
regulation) that is not located--
``(i) on the campus (as defined in such section) of such
provider; or
``(ii) within the distance (described in such definition of
campus) from a remote location of a hospital facility (as
defined in such section).''.
(b) HHS OIG Analysis.--Not later than January 1, 2030, the
Inspector General of the Department of Health and Human
Services shall submit to Congress--
(1) an analysis of the process established by the Secretary
of Health and Human Services to conduct the reviews and
determinations described in section 1833(t)(23)(B) of the
Social Security Act, as added by subsection (a) of this
section; and
(2) recommendations based on such analysis, as the
Inspector General determines appropriate.
TITLE III--SUPPORTING PATIENTS, HEALTH CARE WORKERS, COMMUNITY HEALTH
CENTERS, AND HOSPITALS
SEC. 301. EXTENSION FOR COMMUNITY HEALTH CENTERS, THE
NATIONAL HEALTH SERVICE CORPS, AND TEACHING
HEALTH CENTERS THAT OPERATE GME PROGRAMS.
(a) Teaching Health Centers That Operate Graduate Medical
Education Programs.--
(1) Addition to capped amounts for fiscal years 2024 and
2025.--Paragraph (2) of section 340H(b) of the Public Health
Service Act (42 U.S.C. 256h(b)) is amended by adding at the
end the following:
``(C) Addition.--Notwithstanding any provision of this
section, for each of fiscal years 2024 and 2025, the
Secretary may use any amounts made available in any fiscal
year to carry out this section (including amounts recouped
under subsection (f)) to make payments described in
paragraphs (1)(A) and (1)(B), in addition to the total amount
of funds appropriated under subsection (g).''.
(2) Reconciliation.--Section 340H(f) of the Public Health
Service Act (42 U.S.C. 256h(f)) is amended--
(A) by striking ``The Secretary shall determine'' and
inserting the following:
``(1) Determination.--The Secretary shall determine''; and
(B) by adding at the end the following:
``(2) Annual report to congress.--For each fiscal year, the
Secretary shall submit to the Committee on Energy and
Commerce of the House of Representatives and the Committee on
Health, Education, Labor, and Pensions of the Senate a report
specifying--
``(A) the total amount of funds recouped under paragraph
(1);
``(B) the rationale for the funds being recouped; and
``(C) in the case of the reports for each of fiscal years
2024 and 2025, the total amount of funds recouped under
paragraph (1) that were used pursuant to subsection (b)(2)(C)
to adjust total payment amounts above the total amounts
appropriated under subsection (g).''.
(3) Funding.--Section 340H(g) of the Public Health Service
Act (42 U.S.C. 256h(g)) is amended--
(A) by amending paragraph (1) to read as follows:
``(1) In general.--To carry out this section, there are
appropriated such sums as may be necessary, not to exceed--
``(A) $230,000,000, for the period of fiscal years 2011
through 2015;
``(B) $60,000,000 for each of fiscal years 2016 and 2017;
[[Page H6782]]
``(C) $126,500,000 for each of fiscal years 2018 through
2023;
``(D) $16,635,616 for the period beginning on October 1,
2023, and ending on November 17, 2023;
``(E) $21,834,247 for the period beginning on November 18,
2023, and ending on January 19, 2024;
``(F) $136,530,137 for the period beginning on January 20,
2024, and ending on September 30, 2024;
``(G) $175,000,000 for fiscal year 2025;
``(H) $225,000,000 for each of fiscal years 2026 and 2027;
and
``(I) $300,000,000 for each of fiscal years 2028, 2029, and
2030.''; and
(B) by adding at the end the following:
``(3) Availability.--The amounts made available under
paragraph (1) shall remain available until expended.''.
(b) Extension for Community Health Centers.--Section
10503(b)(1)(F) of the Patient Protection and Affordable Care
Act (42 U.S.C. 254b-2(b)(1)(F)) is amended--
(1) by striking ``and'' before ``$690,410,959''; and
(2) by inserting ``, $3,183,561,644 for the period
beginning on January 20, 2024, and ending on September 30,
2024, $4,400,000,000 for fiscal year 2025, and $1,109,000,000
for the period beginning October 1, 2025, and ending December
31, 2025'' before the semicolon at the end.
(c) Extension for the National Health Service Corps.--
Section 10503(b)(2) of the Patient Protection and Affordable
Care Act (42 U.S.C. 254b-2(b)(2)) is amended--
(1) in subparagraph (H), by striking ``and'' at the end;
(2) in subparagraph (I), by striking the period at the end
and inserting ``; and''; and
(3) by adding at the end the following:
``(J) $255,726,028 for the period beginning on January 20,
2024, and ending on September 30, 2024, $350,000,000 for
fiscal year 2025, and $88,219,178 for the period beginning
October 1, 2025, and ending December 31, 2025.''.
(d) Government Accountability Office Report.--
(1) In general.--Not later than one year after the date of
enactment of this Act, the Comptroller General of the United
States shall submit to the Committee on Energy and Commerce
of the House of Representatives and the Committee on Health,
Education, Labor, and Pensions of the Senate a report
assessing the effectiveness of the National Health Service
Corps at attracting health care professionals to HPSAs,
including by--
(A) assessing the metrics used by the Health Resources and
Services Administration in evaluating the program;
(B) comparing the retention rates of NHSC participants in
the HPSAs where they completed their period of obligated
service to the retention rate of non-NHSC participants in the
corresponding HPSAs;
(C) comparing the retention rates of NHSC participants in
the HPSAs where they completed their period of obligated
service to the retention rates of NHSC participants in HPSAs
other than those where they completed their period of
obligated service;
(D) identifying factors that influence a NHSC participant's
decision to practice in a HPSA other than the HPSA where they
completed their period of obligated service;
(E) identifying factors other than participation in the
National Health Service Corps Scholarship and Loan Repayment
Programs that attract health care professionals to a HPSA;
(F) assessing the impact the National Health Service Corps
has on wages for health care professionals in a HPSA; and
(G) comparing the distribution of NHSC participants across
HPSAs, including a comparison of rural versus non-rural
HPSAs.
(2) Definition.--In this section:
(A) The term ``HPSA'' means a health professional shortage
area designated under section 332 of the Public Health
Service Act (42 U.S.C. 254e).
(B) The term ``NHSC participant'' means a National Health
Service Corps member participating in the National Health
Service Corps Scholarship or Loan Repayment Program.
(e) Application of Provisions.--Amounts appropriated
pursuant to the amendments made by this section shall be
subject to the requirements contained in Public Law 117-328
for funds for programs authorized under sections 330 through
340 of the Public Health Service Act.
(f) Conforming Amendment.--Paragraph (4) of section 3014(h)
of title 18, United States Code, is amended by striking ``and
section 2321(d) of the Continuing Appropriations Act, 2024
and Other Extensions Act'' and inserting ``section 2321(d) of
the Continuing Appropriations Act, 2024 and Other Extensions
Act, and section 301(e) of the Lower Costs, More Transparency
Act''.
SEC. 302. EXTENSION OF SPECIAL DIABETES PROGRAMS.
(a) Extension of Special Diabetes Programs for Type I
Diabetes.--Section 330B(b)(2) of the Public Health Service
Act (42 U.S.C. 254c-2(b)(2)) is amended--
(1) in subparagraph (D), by striking ``and'' at the end;
(2) in subparagraph (E), by striking the period at the end
and inserting a semicolon; and
(3) by adding at the end the following:
``(F) $124,383,562 for the period beginning on January 20,
2024, and ending on September 30, 2024, to remain available
until expended;
``(G) $170,000,000 for fiscal year 2025, to remain
available until expended; and
``(H) $42,849,315 for the period beginning October 1, 2025,
and ending December 31, 2025, to remain available until
expended.''.
(b) Extending Funding for Special Diabetes Programs for
Indians.--Section 330C(c)(2) of the Public Health Service Act
(42 U.S.C. 254c-3(c)(2)) is amended--
(1) in subparagraph (D), by striking ``and'' at the end;
(2) in subparagraph (E), by striking the period at the end
and inserting a semicolon; and
(3) by adding at the end the following:
``(F) $124,383,562 for the period beginning on January 20,
2024, and ending on September 30, 2024, to remain available
until expended;
``(G) $170,000,000 for fiscal year 2025, to remain
available until expended; and
``(H) $42,849,315 for the period beginning October 1, 2025,
and ending December 31, 2025, to remain available until
expended.''.
SEC. 303. DELAYING CERTAIN DISPROPORTIONATE SHARE PAYMENT
CUTS.
Section 1923(f)(7)(A) of the Social Security Act (42 U.S.C.
1396r-4(f)(7)(A)) is amended--
(1) in clause (i)--
(A) by striking ``For the period beginning January 20,
2024, and ending September 30, 2024, and for each of fiscal
years 2025'' and inserting ``For each of fiscal years 2026'';
and
(B) by striking ``or period'' each place such term appears;
and
(2) in clause (ii), by striking ``for the period beginning
January 20, 2024, and ending September 30, 2024, and for each
of fiscal years 2025'' and inserting ``for each of fiscal
years 2026''.
SEC. 304. MEDICAID IMPROVEMENT FUND.
Section 1941(b)(3)(A) of the Social Security Act (42 U.S.C.
1396w-1(b)(3)(A)) is amended by striking `` $6,357,117,810''
and inserting ``$0''.
TITLE IV--INCREASING ACCESS TO QUALITY HEALTH DATA AND LOWERING HIDDEN
FEES
SEC. 401. INCREASING PLAN FIDUCIARIES' ACCESS TO HEALTH DATA.
(a) Plan Fiduciary Access to Information.--
(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
subparagraph:
``(C) No contract or arrangement for services between a
group health plan and any other 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, is reasonable within the meaning of
this paragraph unless such contract or arrangement--
``(i) allows the responsible plan fiduciary (as defined in
subparagraph (B)(ii)(I)(ee)) to audit or review all de-
identified claims and encounter information or data described
in section 724(a)(1)(B) to--
``(I) ensure that such entity complies with the terms of
the plan and any applicable law; and
``(II) determine the reasonableness of compensation
received by such entity; and
``(ii) does not--
``(I) unreasonably limit the number of audits permitted
during a given period of time;
``(II) limit the number of de-identified claims and
encounter information or data that the responsible plan
fiduciary may access during an audit;
``(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 responsible plan fiduciary to
select an auditor;
``(VI) otherwise limit or unduly delay by greater than 60
calendar days after the date of request the responsible plan
fiduciary from auditing all de-identified claims and
encounter information or data; or
``(VII) permit the entity to charge a fee beyond the
reasonable direct costs to provide the required information
and otherwise comply and assist with an audit request.''.
(2) Civil enforcement.--
(A) In general.--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) In the case of an agreement between a group health
plan and 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, 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 of
providers, third-party administrator, pharmacy benefit
manager, or other service provider in the
[[Page H6783]]
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.''.
(B) Conforming amendment.--Paragraph (6) of section 502(a)
of such Act is amended by striking ``or (9)'' and inserting
``(9), or (13)''.
(3) Existing provisions void.--Section 410 of such Act is
amended by adding at the end the following new subsection:
``(c) Any provision in an agreement or instrument shall be
void as against public policy if such provision--
``(1) unduly delays or limits a plan fiduciary from
accessing the de-identified claims and encounter information
or data described in section 724(a)(1)(B); or
``(2) violates the requirements of section 408(b)(2)(C).''.
(b) Updated Attestation for Price and Quality
Information.--Section 724(a)(3) of the Employee Retirement
Income Security Act (29 U.S.C. 1185m(a)(3)) is amended to
read as follows:
``(3) Attestation.--
``(A) In general.--Subject to subparagraph (C), the plan
fiduciary of 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 plan fiduciary, the plan administrator, or
the issuer 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 plan fiduciary, the plan administrator, or the issuer
from auditing, reviewing, or otherwise accessing such
information, except as permitted under section 408(b)(2)(C).
``(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).
``(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--
``(i) an explanation of why such plan or issuer was
unsuccessful in obtaining such information or data, including
whether such plan 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 plan
fiduciary 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).''.
(c) Report on Plan Assets.--Not later than 1 year after the
date of enactment of this Act, the Secretary of Labor shall
submit to the Committee on Education and the Workforce of the
House of Representatives and the Committee on Health,
Education, Labor, and Pensions of the Senate a report on the
status of de-identified claims and encounter information or
data described in section 724(a)(1)(B) of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1185m),
including information on the following:
(1) Whether changes to regulations or guidance would permit
such information or data to be deemed a group health plan
asset (as defined under section 3(42) of such Act).
(2) Whether restrictions on the ability of a plan fiduciary
to access such information or data violates a requirement of
current law.
(3) The existing regulatory authority of the Secretary to
clarify whether such information or data is the property of a
group health plan, rather than a service provider.
(4) Legislative recommendations to establish that such
information or data related to a plan belongs to a group
health plan and is handled in the best interests of plan
participants and beneficiaries.
(d) 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. 402. HIDDEN FEES DISCLOSURE REQUIREMENTS.
(a) Clarification of the Application of Fee Disclosure
Requirements to Covered Service Providers.--
(1) Services.--Clause (ii)(I)(bb) of section 408(b)(2)(B)
of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1108(b)(2)(B)) is amended--
(A) in subitem (AA) by striking ``Brokerage services,'' and
inserting ``Services (including brokerage services),''; and
(B) in subitem (BB)--
(i) by striking ``Consulting,'' and inserting ``Other
services,''; and
(ii) by inserting ``any of the following:'' before ``plan
design''.
(2) Disclosures.--Clause (iii)(III) of section 408(b)(2)(B)
of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1108(b)(2)(B)) is amended by striking ``, either in
the aggregate or by service,'' and inserting ``by service''.
(b) Strengthening Disclosure Requirements With Respect to
Pharmacy Benefit Managers and Third Party Administrators for
Group Health Plans.--
(1) Certain arrangements for pharmacy benefit manager
services considered as indirect.--
(A) In general.--Clause (i) of section 408(b)(2)(B) of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1108(b)(2)(B)) is amended--
(i) by striking ``requirements of this clause'' and
inserting ``requirements of this subparagraph''; and
(ii) by adding at the end the following: ``For purposes of
applying section 406(a)(1)(C) with respect to a transaction
described under this subparagraph, a contract or arrangement
for services between a covered plan and a health insurance
issuer providing health insurance coverage in connection with
the covered plan in which the health insurance issuer
contracts, in connection with such plan, with a service
provider for pharmacy benefit management services shall be
considered to constitute an indirect furnishing of goods,
services, or facilities between the plan and the service
provider acting as the party in interest.''.
(B) Health insurance issuer and health insurance coverage
defined.--Clause (ii)(I)(aa) of section 408(b)(2)(B) of such
Act (29 U.S.C. 1108(b)(2)(B)) is amended by inserting before
the period at the end ``and the terms `health insurance
coverage' and `health insurance issuer' have the meanings
given such terms in section 733(b)''.
(C) Technical amendment.--Clause (ii)(I)(aa) of section
408(b)(2)(B) of the Employee Retirement Income Security Act
of 1974 (29 U.S.C. 1108(b)(2)(B)) is further amended by
inserting ``in'' after ``defined''.
(2) Specific disclosure requirements with respect to
pharmacy benefit management services.--
(A) In general.--Clause (iii) of section 408(b)(2)(B) of
such Act (29 U.S.C. 1108(b)(2)(B)) is amended by adding at
the end the following:
``(VII) With respect to a contract or arrangement with the
covered plan in connection with the provision of pharmacy
benefit management services, as part of the description
required under subclauses (III) and (IV)--
``(aa) all compensation described in clause
(ii)(I)(dd)(AA), including fees, rebates, alternative
discounts, co-payment offsets, and other remuneration
expected to be received by the covered service provider, an
affiliate, or a subcontractor from a pharmaceutical
manufacturer, distributor, rebate aggregator, accumulator,
and maximizer, group purchasing organization, or any other
third party;
``(bb) the amount and form of any rebates, discounts, or
price concessions, including the amount expected to be passed
through to the plan sponsor or the participants and
beneficiaries under the covered plan;
``(cc) all compensation expected to be received by the
covered service provider, an affiliate, or a subcontractor as
a result of paying a lower amount for the drug than the
amount charged as a copayment, coinsurance amount, or
deductible;
``(dd) all compensation expected to be received by the
covered service provider, an affiliate, or a subcontractor as
a result of paying pharmacies less than what is charged the
health plan, plan sponsor, or participants and beneficiaries
under the covered plan; and
``(ee) all compensation expected to be received by the
covered service provider, an affiliate, or a subcontractor
from drug manufacturers and any other third party in exchange
for--
``(AA) administering, invoicing, allocating, or collecting
rebates related to the covered plan;
``(BB) providing business services and activities,
including providing access to drug utilization data;
``(CC) keeping a percentage of the list price of a drug; or
``(DD) any other reason related to the role of a covered
service provider as a conduit between the drug manufacturers
or any other third party and the covered plan.''.
(B) Annual disclosure.--Clause (v) of section 408(b)(2)(B)
of such Act (29 U.S.C. 1108(b)(2)(B)) is amended by adding at
the end the following:
``(III) A covered service provider, with respect to a
contract or arrangement with the covered plan in connection
with providing pharmacy benefit management services, shall
disclose, on an annual basis not later than 60 days after the
beginning of the current plan year, to a responsible plan
fiduciary, in writing, the following with respect to the
twelve months preceding the current plan year:
``(aa) All direct compensation described in subclause (III)
of clause (iii) and indirect compensation described in
subclause (IV) of clause (iii) received by the covered
service provider (including such compensation described in
subclause (VII) of clause (iii)).
``(bb) The total gross spending by the covered plan on
drugs (excluding rebates, discounts, or other price
concessions).
``(cc) The total net spending by the covered plan on drugs.
``(dd) The total gross spending at all pharmacies wholly or
partially owned by the covered service provider or any entity
affiliated with the covered service provider, including
[[Page H6784]]
mail-order, specialty and retail pharmacies, with a breakdown
by individual pharmacy location.
``(ee) The aggregate amount of clawback from such
pharmacies, including mail-order, specialty, and retail
pharmacies.
``(AA) categorical explanations (grouped by the reason for
clawback, such as contractual true-up provisions,
overpayments, or non-covered medication dispensed, and
including information on the amount in each category that was
passed through to the covered plan and to participants and
beneficiaries of the covered plan); or
``(BB) individual explanations for such clawbacks.
``(ff) Total aggregate amounts of fees collected by the
covered service provider, an affiliate, or a subcontractor in
connection with the provision of pharmacy benefit management
services to the covered plan.
``(gg) Any other information specified by the Secretary
through regulations or guidance that may be necessary for a
responsible plan fiduciary to consider the merits of the
contract or arrangement with the covered service provider and
any conflicts of interest that may exist.''.
(C) Pharmacy benefit management services defined.--Clause
(ii)(I) of section 408(b)(2)(B) of such Act (29 U.S.C.
1108(b)(2)(B)) is amended by adding at the end the following:
``(gg) The term `pharmacy benefit management services'
includes any services provided by a covered service provider
to a covered plan with respect to the administration of
prescription drug benefits under the covered plan,
including--
``(AA) processing and payment of claims;
``(BB) design of pharmacy networks;
``(CC) negotiation, aggregation, and distribution of
rebates, discounts, and other price concessions;
``(DD) formulary design and maintenance;
``(EE) operation of pharmacies (whether retail, mail order,
specialty drug, or otherwise);
``(FF) recordkeeping;
``(GG) utilization review;
``(HH) adjudication of claims; and
``(II) any other services specified by the Secretary
through guidance or rulemaking.''.
(D) Clawback defined.--Clause (ii)(I) of section
408(b)(2)(B) of such Act (29 U.S.C. 1108(b)(2)(B)), as
amended by subparagraph (C), is amended by adding at the end
the following:
``(hh) The term `clawback' means amounts collected by a
provider of pharmacy benefit management services from a
pharmacy for copayments collected from a participant or
beneficiary in excess of the contracted rate.''.
(3) Specific disclosure requirements with respect to third
party administration services for group health plans.--
(A) In general.--Clause (iii) of section 408(b)(2)(B) of
such Act (29 U.S.C. 1108(b)(2)(B)), as amended by paragraph
(2)(A), is further amended by adding at the end the
following:
``(VIII) With respect to a contract or arrangement with the
covered plan in connection with the provision of third party
administration services for group health plans, as part of
the description required under subclauses (III) and (IV)--
``(aa) the amount and form of any rebates, discounts,
savings fees, refunds, or amounts received from providers and
facilities, including the amounts that will be retained by
the covered service provider as a fee;
``(bb) the amount and form of fees expected to be received
from other service providers in relation to the covered plan,
including the amounts that will be retained by the covered
service provider as a fee; and
``(cc) the amount and form of expected recoveries by the
covered service provider, including the amounts that will be
retained by the covered service provider as a fee
(disaggregated by category), as a result of--
``(AA) overpayments;
``(BB) erroneous payments;
``(CC) uncashed checks or incomplete payments;
``(DD) billing errors;
``(EE) subrogation;
``(FF) fraud; or
``(GG) any other reason on behalf of the covered plan.''.
(B) Annual disclosure.--Clause (v) of section 408(b)(2)(B)
of such Act (29 U.S.C. 1108(b)(2)(B)), as amended by
paragraph (2)(B), is amended by adding at the end the
following:
``(IV) A covered service provider, with respect to a
contract or arrangement with the covered plan in connection
with providing third party administration services for group
health plans, shall disclose, on an annual basis not later
than 60 days after the beginning of the current plan year, to
a responsible plan fiduciary, in writing, the following with
respect to the twelve months preceding the current plan year:
``(aa) All direct compensation described in subclause (III)
of clause (iii).
``(bb) All indirect compensation described in subclause
(IV) of clause (iii) received by the covered service
provider, an affiliate, or a subcontractor (including such
compensation described in subclause (VIII) of clause (iii)).
``(cc) The aggregate amount for which the covered service
provider, an affiliate, or a subcontractor received indirect
compensation and the estimated amount of cost-sharing
incurred by plan participants and beneficiaries as a result.
``(dd) The total gross spending by the covered plan on all
costs and fees arising under or paid under the administrative
services agreement with the covered service provider (not
including any amounts described in items (aa) through (cc) of
clause (iii)(VIII)).
``(ee) The total net spending by the covered plan on all
costs and fees arising under or paid under the administrative
services agreement with the covered service provider.
``(ff) The aggregate fees collected by the covered service
provider, an affiliate, or a subcontractor.
``(gg) Any other information specified by the Secretary
through regulations or guidance that may be necessary for a
responsible plan fiduciary to consider the merits of the
contract or arrangement with the covered service provider and
any conflicts of interest that may exist.''.
(C) Third party administration services for group health
plans defined.--Clause (ii)(I) of section 408(b)(2)(B) of
such Act (29 U.S.C. 1108(b)(2)(B)), as amended by paragraph
(2)(C), is amended by adding at the end the following:
``(ii) The term `third party administration services for
group health plans' includes any services provided by a
covered service provider, an affiliate, or a subcontractor to
a covered plan with respect to the administration of health
benefits under the covered plan, including--
``(AA) the processing, repricing, and payment of claims;
``(BB) design, creation, and maintenance of provider
networks;
``(CC) negotiation of discounts off gross rates;
``(DD) benefit and plan design;
``(EE) negotiation of payment rates;
``(FF) recordkeeping;
``(GG) utilization review;
``(HH) adjudication of claims;
``(II) regulatory compliance; and
``(JJ) any other services set forth in an administrative
services agreement or similar agreement or specified by the
Secretary through rulemaking.''.
(4) Rule of construction.--Nothing in the amendments made
by this section shall be construed to imply that a practice
in relation to which a covered service provider is required
to provide information as a result of such amendments is
permissible under Federal law.
(5) Effective date.--No contract or arrangement entered
into prior to January 1, 2025, shall be subject to the
requirements of subsection (b).
(c) Privacy Requirements.--Section 408(b)(2) of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.
1108(b)(2)), as amended by section 401, is further amended by
adding at the end the following:
``(D) Privacy requirements.--Covered service providers
shall provide information under subparagraph (B) in a manner
consistent with the privacy, security, and breach
notification regulations promulgated under section 13402(a)
of the Health Information Technology for Clinical Health Act
(42 U.S.C. 17932(a)), and consistent with the HIPAA privacy
regulations (as defined in section 1180(b)(3) of the Social
Security Act) and shall restrict the use and disclosure of
such information according to such privacy, security, and
breach notification regulations and such HIPAA privacy
regulations.
``(E) Disclosure and redisclosure.--
``(i) Limitation to business associates.--A responsible
plan fiduciary receiving information disclosed under
subparagraph (B) may disclose such information only to the
entity from which the information was received, the group
health plan for which the information pertains, or to that
entity's business associates as defined in section 160.103 of
title 45, Code of Federal Regulations (or successor
regulations) or as permitted by the HIPAA Privacy Rule (45
CFR parts 160 and 164, subparts A and E).
``(ii) Clarification regarding public disclosure of
information.--Nothing in this section shall prevent a group
health plan or health insurance issuer offering group health
insurance coverage, or a covered service provider, from
placing reasonable restrictions on the public disclosure of
the information described in this subparagraph, except that
such plan, issuer, or entity may not restrict disclosure of
such information to the Department of Labor.
``(F) Additional privacy requirements.--
``(i) In general.--Covered service providers shall ensure
that information provided under subparagraph (B) contains
only summary health information, as defined in section
164.504(a) of title 45, Code of Federal Regulations (or
successor regulations).
``(ii) Restrictions.--A group health plan must comply with
section 164.504(f) of title 45, Code of Federal Regulations
and a responsible plan administrator who is a plan sponsor
must act in accordance with the terms of the agreement
described in such section.
``(G) 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 (as defined
in section 1180(b)(3) of the Social Security Act).''.
(d) Implementation.--Not later than 1 year after the date
of enactment of this Act, the Secretary of Labor shall issue
notice and comment rulemaking as necessary to implement the
provisions of this section. The Secretary shall ensure that
such rulemaking--
[[Page H6785]]
(1) accounts for the varied compensation practices of
covered service providers (as defined under section
408(b)(2)(B); and
(2) establishes standards for the disclosure of expected
compensation by such covered service providers.
SEC. 403. PRESCRIPTION DRUG PRICE INFORMATION REQUIREMENT.
(a) PHSA.--
(1) In general.--Part D of title XXVII of the Public Health
Service Act, as amended by section 106, is further amended by
adding at the end the following new section:
``SEC. 2799A-12. INFORMATION ON PRESCRIPTION DRUGS.
``(a) In General.--A group health plan or a health
insurance issuer offering group or individual health
insurance coverage shall--
``(1) not restrict, directly or indirectly, any pharmacy
that dispenses a prescription drug to an enrollee in the plan
or coverage from informing (or penalize such pharmacy for
informing) an enrollee of any differential between the
enrollee's out-of-pocket cost under the plan or coverage with
respect to acquisition of the drug and the amount an
individual would pay for acquisition of the drug without
using any group health plan or health insurance coverage; and
``(2) ensure that any entity that provides pharmacy
benefits management services under a contract with any such
health plan or health insurance coverage does not, with
respect to such plan or coverage, restrict, directly or
indirectly, a pharmacy that dispenses a prescription drug
from informing (or penalize such pharmacy for informing) an
enrollee of any differential between the enrollee's out-of-
pocket cost under such plan or coverage with respect to
acquisition of the drug and the amount an individual would
pay for acquisition of the drug without using any group
health plan or health insurance coverage.
``(b) Definition.--For purposes of this section, the term
`out-of-pocket cost', with respect to acquisition of a drug,
means the amount to be paid by the enrollee under the plan or
coverage, including any cost-sharing (including any
deductible, copayment, or coinsurance) and, as determined by
the Secretary, any other expenditure.''.
(2) Conforming amendment.--Section 2729 of the Public
Health Service Act (42 U.S.C. 300gg-29) is amended by adding
at the end the following new subsection:
``(c) Sunset.--The preceding provisions of this section
shall not apply beginning on the date of the enactment of
this subsection.''.
(b) ERISA.--
(1) In general.--Subpart B of part 7 of Subtitle B of title
I of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185 et seq.), as amended by section 106, is further
amended by adding at the end the following new section:
``SEC. 727. INFORMATION ON PRESCRIPTION DRUGS.
``(a) In General.--A group health plan or a health
insurance issuer offering group health insurance coverage
shall--
``(1) not restrict, directly or indirectly, any pharmacy
that dispenses a prescription drug to a participant or
beneficiary in the plan or coverage from informing (or
penalize such pharmacy for informing) a participant or
beneficiary of any differential between the participant's or
beneficiary's out-of-pocket cost under the plan or coverage
with respect to acquisition of the drug and the amount an
individual would pay for acquisition of the drug without
using any group health plan or health insurance coverage; and
``(2) ensure that any entity that provides pharmacy
benefits management services under a contract with any such
health plan or health insurance coverage does not, with
respect to such plan or coverage, restrict, directly or
indirectly, a pharmacy that dispenses a prescription drug
from informing (or penalize such pharmacy for informing) a
participant or beneficiary of any differential between the
participant's or beneficiary's out-of-pocket cost under such
plan or coverage with respect to acquisition of the drug and
the amount an individual would pay for acquisition of the
drug without using any group health plan or health insurance
coverage.
``(b) Definition.--For purposes of this section, the term
`out-of-pocket cost', with respect to acquisition of a drug,
means the amount to be paid by the participant or beneficiary
under the plan or coverage, including any cost-sharing
(including any deductible, copayment, or coinsurance) and, as
determined by the Secretary, any other expenditure.''.
(2) Clerical amendment.--The table of contents in section 1
of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1001 et seq.), as amended by section 106, is further
amended by inserting after the item relating to section 726
the following new item:
``Sec. 727. Information on prescription drugs.''.
(c) IRC.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986, as amended by section 106, is
further amended by adding at the end the following:
``SEC. 9827. INFORMATION ON PRESCRIPTION DRUGS.
``(a) In General.--A group health plan shall--
``(1) not restrict, directly or indirectly, any pharmacy
that dispenses a prescription drug to a participant or
beneficiary in the plan from informing (or penalize such
pharmacy for informing) a participant or beneficiary of any
differential between the participant's or beneficiary's out-
of-pocket cost under the plan with respect to acquisition of
the drug and the amount an individual would pay for
acquisition of the drug without using any group health plan
or health insurance coverage; and
``(2) ensure that any entity that provides pharmacy
benefits management services under a contract with any such
plan does not, with respect to such plan or coverage,
restrict, directly or indirectly, a pharmacy that dispenses a
prescription drug from informing (or penalize such pharmacy
for informing) a participant or beneficiary of any
differential between the participant's or beneficiary's out-
of-pocket cost under the plan with respect to acquisition of
the drug and the amount an individual would pay for
acquisition of the drug without using any group health plan
or health insurance coverage.
``(b) Definition.--For purposes of this section, the term
`out-of-pocket cost', with respect to acquisition of a drug,
means the amount to be paid by the participant or beneficiary
under the plan, including any cost-sharing (including any
deductible, copayment, or coinsurance) and, as determined by
the Secretary, any other expenditure.''.
(2) Clerical amendment.--The table of sections for
subchapter B of chapter 100 of the Internal Revenue Code of
1986, as amended by section 106, is further amended by adding
at the end the following new item:
``Sec. 9827. Information on prescription drugs.''.
SEC. 404. IMPLEMENTATION FUNDING.
(a) In General.--For the purposes described in subsection
(b), and in addition to amounts otherwise available for such
purposes there are appropriated, out of amounts in the
Treasury not otherwise appropriated, to the Secretary of
Labor $35,000,000, for fiscal year 2024, to remain available
through fiscal year 2029.
(b) Permitted Purposes.--The purposes described in this
subsection are limited to the following purposes, insofar as
such purposes are to carry out the provisions of, including
the amendments made by, title I and IV:
(1) Preparing, drafting, and issuing proposed and final
regulations or interim regulations.
(2) Preparing, drafting, and issuing guidance and public
information.
(3) Preparing, drafting, and publishing reports.
(4) Enforcement of such provisions.
(5) Reporting, collection, and analysis of data.
(6) Other administrative duties necessary for
implementation of such provisions.
(c) Transparency of Implementation Funds.--The Secretary of
Labor shall annually submit, no later than September 1st of
each year, to the Committees on Education and Workforce and
on Appropriations of the House of Representatives and the
Committees on Health, Education, Labor, and Pensions and on
Appropriations of the Senate a report on funds expended
pursuant to funds appropriated under this section.
The SPEAKER pro tempore. Pursuant to the rule, the gentlewoman from
Washington (Mrs. Rodgers) and the gentleman from New Jersey (Mr.
Pallone) each will control 20 minutes.
The Chair recognizes the gentlewoman from Washington.
General Leave
Mrs. RODGERS of Washington. Mr. Speaker, I ask unanimous consent that
all Members may have 5 legislative days in which to revise and extend
their remarks and include extraneous material in the Record on the
bill.
The SPEAKER pro tempore. Is there objection to the request of the
gentlewoman from Washington?
There was no objection.
Mrs. RODGERS of Washington. Mr. Speaker, I yield myself such time as
I may consume.
I rise in support of the Lower Cost, More Transparency Act. We all
know that healthcare is too expensive, and the system is far too
complicated. In the Committee on Energy and Commerce, we have heard
countless stories about real patients who were victims of an opaque
system and were on the hook for staggering amounts of money for seeing
a doctor, going to a hospital, or getting medicine.
We heard about a patient who tried to shop for her care and was
billed thousands of dollars more than what she was quoted. We heard
about a patient who was overcharged $11,000 by a hospital for services
she didn't receive. We heard moving testimony from cancer patient
advocates about policies we can enact right now to lower their drug
costs.
The Lower Costs, More Transparency Act includes these and other
policies that would directly help all these patients. It lowers costs
for Americans through increased healthcare price transparency. It
ensures that senior citizens on Medicare never pay more for a drug
because of where it is administered, and it makes drug prices
transparent to help patients and employers
[[Page H6786]]
get the best deals possible on medicines.
Over 90 percent of Americans support increased price transparency in
healthcare. By passing this bill, we will be delivering results people
are counting on. Further, CBO confirms that the bill would save
taxpayers more than $700 million over the next decade.
I thank Chairman Jason Smith, Chairwoman Virginia Foxx, and Ranking
Member Frank Pallone for their leadership. I thank Majority Leader
Steve Scalise for working with us to bring this bill to the floor
today.
Also, a special thank you to Ranking Member Pallone's team, notably
Tiffany Guarascio, Waverly Gordon, Una Lee, and Saha Khaterzai for
working with us to find this bipartisan agreement.
Finally, I thank my own staff, especially Grace Graham, Corey
Ensslin, and Kristin Flukey for their tireless efforts that will make a
meaningful difference for patients all across this Nation.
In sum, this bill is a legislative opportunity, bipartisan, regular
order, and fully paid for. It advances foundational healthcare reforms
for patients, lowers healthcare costs, and reduces the deficit.
Mr. Speaker, I urge all my colleagues to support the Lower Costs,
More Transparency Act, and I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, I rise in strong support of H.R. 5378, the Lower Costs,
More Transparency Act. This bipartisan bill does exactly what it says
it does: It delivers lower healthcare costs for the American people and
brings much-needed transparency to our Nation's healthcare system.
Access to affordable healthcare remains a major challenge for many
American families. More than 40 percent of adults say they have either
delayed or forgone medical care because of high costs. Prices for
healthcare services also vary widely. Consumers often have difficulty
obtaining price information to begin with. Another problem is that the
information can be misleading or inaccurate, making it difficult for
consumers to compare prices across healthcare providers before
receiving care. Too many patients are forced to wait until after they
receive care and receive their medical bill to see what they actually
owe.
H.R. 5378 brings some much-needed transparency to the healthcare
system by codifying and strengthening important price transparency
protections. It is a victory for everyone who has ever struggled to
navigate and understand the cost of a healthcare procedure or a
prescription drug at the pharmacy counter. These measures will empower
consumers and employers with data on the prices hospitals charge and
the rates insurers pay so that they can compare prices and save money.
It also increases transparency of how pharmacy benefit managers, or
PBMs, affect drug prices at the pharmacy counter. This will also help
increase competition and lower healthcare costs for Americans. We have
added new language in the bill to enhance the privacy protections for
consumers' health information and to ensure that the full protection of
the HIPAA privacy rule is applicable.
I also want to mention, Mr. Speaker, the bill reduces costs for
patients by ensuring Medicare beneficiaries are not paying more for the
exact same drug because it was administered in a hospital outpatient
department instead of a physician's office. It will also build on
Democrats' work to rein in the soaring cost of prescription drugs by
requiring the FDA to provide more information to generic drug
manufacturers during the development process. This will help speed up
the path to market and increase competition sooner to lower drug prices
faster. All of these provisions in this bill will help make healthcare
and prescription drugs more affordable for the American people.
I also want to mention, Mr. Speaker, that H.R. 5378 will also make
healthcare more accessible to American families thanks to critical
investments in our Nation's public health programs that serve low-
income and uninsured patients. The bill includes increased funding for
community health centers at $4.4 billion per year, an unprecedented 10
percent increase over current funding levels.
Community health centers are a critical source of primary healthcare
for more than 30 million patients, 1 in every 11 Americans. These
centers deliver high-quality, affordable healthcare to some of our most
vulnerable communities, and this increased funding will allow these
centers to continue providing this critical care.
The bill increases funding for the National Health Service Corps,
which places doctors in high-need communities. It also includes an
unprecedented 7 years of funding, more than double the funding under
current law, for the Teaching Health Center Graduate Medical Education
program to support the training of primary care physicians in
community-based settings. This program helps address doctor shortages
in underserved areas as graduates of the program are likely to practice
close to their training sites and to care for underserved patients.
This long-term funding will help bring more certainty to the program to
ensure that teaching health centers can plan and recruit for their
residency programs.
Finally, the bill also reauthorizes and increases funding for both
the Special Diabetes Program and Special Diabetes Program for Indians.
These programs provide critical investments in diabetes research and
care.
I will also mention that H.R. 5378 eliminates looming cuts to
Medicaid Disproportionate Share Hospitals to support these high-need
hospitals that provide care for large numbers of Medicaid and uninsured
patients.
The increased funding for each of these public health and workforce
programs is essential to ensuring access to care for our constituents
across the country. All of this funding is fully offset with policies
that will further strengthen our healthcare system and help reduce
costs for American families.
Mr. Speaker, when a version of this bill came before the Committee on
Energy and Commerce, it passed unanimously with bipartisan support.
Chair Rodgers and I have been working on this bill all year, and I
commend her for her ongoing commitment to get it across the finish
line. It is an important bill that delivers meaningful results.
I will also take an opportunity to thank some of the staff who have
worked on this. From my committee staff, I thank Tiffany Guarascio,
Waverly Gordon, Una Lee, Saha Khaterzai, Rick Van Buren, Stephen
Holland, and Lydia Abma. From the Republican staff, I thank Nate
Hodson, Sarah Burke, Grace Graham, and Corey Ensslin.
Floor action today simply would not have been possible without months
of long-term commitment by the staff on both sides of the aisle to get
this done. I think you can tell that I really think this is probably
one of the most important bills that will come out of the Committee on
Energy and Commerce this session. It is truly bipartisan, which is
another thing I think is very important right now.
I strongly urge my colleagues to join me in supporting the bill to
lower healthcare costs for the American people and to make healthcare
more accessible.
Mr. Speaker, I reserve the balance of my time.
Mrs. RODGERS of Washington. Mr. Speaker, I would like to engage in a
colloquy with Ranking Member Pallone.
This bill codifies and strengthens healthcare price transparency
requirements. Congress asserting itself to declare price transparency
the law of the land is critical, but Congress can't account for every
specificity and eventuality that is needed to ensure price transparency
policies established by the Trump and Biden administrations are set in
stone. We have to allow implementing agencies discretion to update
regulations that reflect changes in terminology and technology over
time.
For example, with respect to health insurance price transparency, it
is the intent of this House that this law shall be implemented to
ensure that health plans report the prices that they have negotiated
with the hospitals, other providers, and drug manufacturers to allow
patients and employers purchasing coverage to use these data to drive
down healthcare prices through open competition.
Under existing regulations, health plans and insurers must disclose
very specific price information for all
[[Page H6787]]
healthcare items and services. This bill codifies the authority holding
up those regulations to ensure that such robust data continues to be
disclosed. These data include all billing codes and modifiers, using
industry-standard, government-recognized, commonly used code sets used
by all medical providers to define specific healthcare items and
services. We ensure the data are accurate by requiring providers' ID
codes, place of service codes, and health plan identifiers assigned to
the group health plan and insurer, all critical information that makes
price disclosures comparable across different health plans.
It is our intent that the requirements for transparency in coverage
should be as comprehensive as possible, without limitations. I yield to
the gentleman from New Jersey (Mr. Pallone), the ranking member for the
purpose of a colloquy.
Mr. PALLONE. Mr. Speaker, let me say that I concur with my colleagues
and partners in crafting this important bipartisan piece of legislation
that is intended to codify and improve upon the robust requirements
that exist in the regulations that have been implemented by both the
Trump and Biden administrations. With this bill, we seek to bring true
health price transparency to lower costs for patients, employers, and
unions purchasing health coverage.
This bill is a floor, not a ceiling, and I intend that the
implementing agencies will use the discretion left to them to ensure
that health plans and insurers disclose the detailed price information
and necessary data on reimbursement rates for healthcare items and
services. We intend to follow this colloquy with a bipartisan letter to
the agencies reiterating our expectations in greater detail.
In addition, in further colloquy with Chair Rodgers, I address a
technical change that needs to be made to the bill in negotiations with
the Senate. In the new version of the bill, we have limited the drug
price data flowing to small employers in order to strengthen health
privacy protections for their employees. However, I want to make clear
that we did not intend to exclude multiemployer, public sector, or
retiree-only and union health plans under this new provision, and we
are committed to fixing this issue before the bill becomes law. Ranking
Member Bobby Scott also agrees with this perspective.
I ask Chair Rodgers if she would concur with me that we make sure
this issue is addressed in our negotiation with the Senate and before
the bill becomes law.
Mrs. RODGERS of Washington. Mr. Speaker, I thank Ranking Member
Pallone for his ongoing leadership, and I agree it is critical that the
legislation meets our intent when it comes to ensuring that the PBMs
must be transparent with multiemployer, public sector, and retiree-only
health plans along with all other employer health plans. I do concur
that we will address this issue in negotiations with the Senate, and I
look forward to working to make sure this bill becomes law.
Mr. Speaker, I reserve the balance of my time.
Mr. PALLONE. Mr. Speaker, I yield 2 minutes to the gentleman from
Texas (Mr. Doggett), a member of the Ways and Means Committee.
{time} 1615
Mr. DOGGETT. Mr. Speaker, this transparency bill lacks transparency
on two of the major problems that are impacting soaring healthcare
costs. The only reason to reject transparency for, first, private
equity and, second, Medicare Advantage is that they have got more to
hide and apparently more lobbying power.
A growing private equity takeover of healthcare has already
undermined care in nursing homes and now threatens hospitals and
medical specialty practices across the United States with higher
prices, higher cost to taxpayers, and less quality.
A Senate committee has just launched a major investigation into the
impact of private equity on hospital costs and lower quality care.
Having failed to save taxpayers a dime that was promised--of the many
millions that was promised--Medicare Advantage costs $1,500 per person
each year over the cost of traditional Medicare. That is billions in
wasted taxpayer dollars.
The best way to fund much-needed services at community health centers
and to expand and improve and strengthen Medicare with services such as
dental, hearing, and vision is to take it right out of Medicare
Advantage.
This bill, I believe, should be rejected until these issues are
addressed by permitting the very amendments that we offered in the
House Ways and Means Committee that rejected them, as usual, to address
private equity and Medicare Advantage.
Mr. Speaker, with all respect to the bipartisan efforts and hard work
in the Energy and Commerce Committee, I believe there is a better way
to finance needs, and a very important need, to address the issues of
transparency on Medicare Advantage and private equity. Therefore, I
oppose the bill.
Mrs. RODGERS of Washington. Mr. Speaker, I yield 2 minutes to the
gentlewoman from North Carolina (Ms. Foxx), the chairwoman of the
Education and the Workforce Committee. I appreciate her partnership on
this legislation.
Ms. FOXX. Mr. Speaker, the American healthcare system is a complex,
expensive maze fueled by heavyhanded regulation, consolidation, and
lack of transparency. Growth in health spending is rising at
unsustainable rates, forcing insurance premiums and out-of-pocket costs
higher and remaining too expensive for working families.
The bill before us is a bipartisan solution to help lower costs by
pulling the curtain back on healthcare and revealing anticompetitive
industry practices that are stifling the free market.
Included in this bill is the Hidden Fee Disclosure Act, authored by
Representatives Joe Courtney and Erin Houchin, which requires
pharmacy benefit managers, PBMs, and third-party administrators to
disclose hidden compensation to plan sponsors.
The Health DATA Act, authored by Representative Lori Chavez-DeRemer,
is also included in this legislation. It prohibits gag clauses between
health plans and third-party entities, which restricts a plan sponsor's
access to its own data.
Additionally, the bill includes the Transparency in Coverage Act,
authored by Representative Bob Good. It builds on the general
principles of transparency and accountability enshrined in the No
Surprises Act by requiring health plans to disclose their prices
publicly.
Patients have been left in the dark. Because of opaque rules and
industry practices, patients are often left paying higher costs. This
is why we are taking action and shining a light on these issues.
Increasing transparency has been proven to root out waste successfully
and save healthcare dollars.
Bottom line, we want to provide workers and their families with more
options at lower prices. The Lower Costs, More Transparency Act does
just that while also reducing the deficit by $800 million.
Mr. Speaker, I encourage my colleagues to support its passage.
Mr. PALLONE. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, I thank my friend, Representative Doggett, for his hard
work on the important issues that he raised and that have been raised
today. I should mention that he is the ranking member of the Ways and
Means Health Subcommittee, so he is very familiar with these issues.
I know he thinks that certain things should have been added to this
bill, but I want to stress that I think we have to support this bill
based on the important policies that we have in the bill. It is not
always easy to get consensus between Democrats and Republicans. This is
one of those rare examples, unfortunately, where we have come to a
consensus, which our committee often does. That is why I do stress the
important policies that are in it.
I think the legislation is a victory for the American people. It
addresses a lot of obvious failings in our health system. The bill
brings some much-needed price transparency to the healthcare system and
will help lower healthcare costs for patients.
Americans have been struggling for years to obtain accurate price
information before going in for a healthcare procedure. It is difficult
for patients to know how much a hospital or their insurance company
will charge them for the care that they receive.
[[Page H6788]]
All this information should be readily available to the public. This
bill requires hospitals and insurance companies to list prices in an
easy to understand format for patients.
The bill also prevents hospital outpatient facilities from unfairly
overcharging seniors. This policy will save Medicare beneficiaries $1.4
billion in lower premiums.
The bill helps further rein in the cost of prescription drugs by
cracking down on price gouging by pharmacy benefit managers and
requires the PBMs to be transparent about their price information.
This is going to help lower healthcare costs for both employers and
patients and bring needed oversight to the PBM industry.
In addition to these patient protection provisions, the legislation
includes a historic $15 billion in investments in safety net and
workforce programs and programs to address physician shortages around
the country.
The legislation essentially lowers healthcare costs for the American
people and makes healthcare more accessible to American families. I
think this delivers meaningful results to the American people on a
bipartisan basis.
Mr. Speaker, I reserve the balance of my time.
Mrs. RODGERS of Washington. Mr. Speaker, I yield 2 minutes to the
gentleman from Kentucky (Mr. Guthrie), the chairman of the Health
Subcommittee.
Mr. GUTHRIE. Mr. Speaker, I rise today to speak in support of H.R.
5378, the Lower Costs, More Transparency Act.
Over the past several years, I have heard from countless Kentuckians
about the challenges they face and the pain they are feeling due to
rising healthcare costs. This bipartisan, landmark legislation marks
the first step in driving transformational change across our healthcare
system.
The Lower Costs, More Transparency Act incorporates transparency
requirements in nearly every aspect of the healthcare system. We are
building on the Trump-era price transparency rules for hospitals and
insurance plans. We are requiring pharmacy benefit managers to disclose
prices and fees to lower costs for patients and employers. We are even
requiring transparency for clinical labs.
We have countless testimonials and data to show that transparency
lowers costs. Recently, a multinational equipment manufacturer fired
their PBM and started managing their own prescription drug benefits for
its employees because they finally understood what they were being
charged.
The most important part about this bill is that, for once, it is not
a top-down, Washington-knows-best approach to the cost of healthcare.
The American people have given Congress this mandate, with over 95
percent of surveyed voters supporting healthcare price transparency to
reduce healthcare costs, according to a 2022 KFF poll.
The Lower Costs, More Transparency Act directly lowers costs that
seniors are paying out of pocket for certain drugs like cancer drugs
and other medicines administered in doctors' offices that are owned by
hospitals.
Seniors receiving Medicare should not be paying more for a drug based
solely off the location of where they receive the drug. We are fixing
this.
I should note that we are able to get major policy changes in this
legislation while making sure the bill saves the American people money,
an estimated $700 million. This is an objective that Congress very
rarely prioritizes.
Mr. Speaker, I thank Chair Rodgers for her vision and steadfast
leadership on this bill. I will proudly be casting a ``yes'' vote on
H.R. 5378, and I urge my House colleagues to do the same.
Mr. PALLONE. Mr. Speaker, I have no additional speakers. If the chair
needs time for people who will support the bill, I will yield to them.
Mr. Speaker, I reserve the balance of my time.
Mrs. RODGERS of Washington. Mr. Speaker, I yield 2 minutes to the
gentleman from Missouri (Mr. Smith), the chairman of the House Ways and
Means Committee.
Mr. SMITH of Missouri. Mr. Speaker, the Lower Costs, More
Transparency Act empowers patients and will lower healthcare costs for
millions of Americans.
This bipartisan bill has been a collaborative effort, and I thank my
colleagues on the Energy and Commerce Committee and the Education and
the Workforce Committee for their partnership.
American families have struggled for far too long to afford the cost
of their healthcare. What is worse is they have been unable to
anticipate those costs because our current system makes it nearly
impossible to figure out the actual price for almost any type of
treatment, medicine, drug, or procedure.
The legislation before us would ensure timely and accurate details
about the cost of care, treatments, and services are available and
accessible before a patient goes into the doctor's office or hospital.
Hospitals, insurance companies, labs, imaging providers, and others
would be required to publicly disclose their prices, creating
incentives to lower prices across the board. This bill would increase
access to care by combating healthcare consolidation, which reduces
options and drives up costs.
It also would take an important step to address the soaring costs of
prescription drugs by requiring health insurers and PBM middlemen to
disclose negotiated drug rebates and discounts. It would ease the
financial burden on our seniors, widen access to more affordable
generic drugs, and arm employers with vital drug price information.
This bill would make important investments in training programs for
new doctors to help address the healthcare workforce shortage and
further invest in hospitals that serve high Medicaid populations.
Mr. Speaker, I urge my colleagues to support this bill to deliver a
healthcare system that is more accessible and affordable for the
American people.
Mr. PALLONE. Mr. Speaker, I reserve the balance of my time.
Mrs. RODGERS of Washington. Mr. Speaker, I yield 1 minute to the
gentleman from Florida (Mr. Bilirakis), a subcommittee chair.
Mr. BILIRAKIS. Mr. Speaker, I rise in strong support of H.R. 5378,
the Lower Costs, More Transparency Act.
I hear from my constituents on a regular basis that the cost of
healthcare is too high, and it remains a burden for everyday Americans
who are struggling to get by.
This bipartisan package led by Chair Rodgers, who I appreciate so
much, finally looks to turn the tide of these high costs by injecting
much-needed transparency and accountability into our healthcare system.
This includes updating CMS' price transparency rules so they actually
work effectively for patients. It ensures we better understand and
reduce consolidation among hospitals, insurers, and PBMs alike.
This also includes my bill with Representative DeGette to reauthorize
the Special Diabetes Program for 2 years with increased funding, all
while reducing the deficit by $750 million.
Mr. Speaker, I urge my colleagues to support this transformative
package.
Mr. PALLONE. Mr. Speaker, I reserve the balance of my time.
Mrs. RODGERS of Washington. Mr. Speaker, I yield 2 minutes to the
gentleman from Indiana (Mr. Bucshon), the vice chair of the Health
Subcommittee.
Mr. BUCSHON. Mr. Speaker, I rise today in strong support of H.R.
5378, the Lower Costs, More Transparency Act.
This bill, which was a product of thorough bipartisan work across
three committees, is one of the strongest healthcare bills I can
remember voting on since coming to Congress in 2011. Honestly, it
really is. I want to say that again: It is one of the strongest
healthcare bills I can remember voting on since coming to Congress.
I thank Chair Rodgers, Ranking Member Pallone, and the members of the
other two committees for their hard work on getting this bill to the
floor.
At nearly $13,000 per person, or about 18 percent of the GDP, U.S.
national health expenditures far exceed other high-income countries,
and they continue to rise at unsustainable rates.
Congress must enact serious reforms that spur competition and show
taxpayers where all of these healthcare dollars are going. They are
certainly not always going to them.
{time} 1630
The problem is not limited to one part of our healthcare system, and
so
[[Page H6789]]
the solution must also reach across the entire system. This legislation
seeks to increase transparency and lower costs related to hospital
care, outpatient services, and prescription drugs, among other things.
It also reauthorizes community health centers and supports
disproportionate share hospitals.
Finally, we cannot get control of our national debt and deficit
unless we first have transparency in our healthcare system, one of the
largest expenditures that the Federal Government has. This bill is a
tremendous step in that direction.
Mr. Speaker, I am proud to support this legislation, and I urge all
my colleagues to support it.
Mr. PALLONE. Mr. Speaker, I continue to reserve the balance of my
time.
Mrs. RODGERS of Washington. Mr. Speaker, I yield 1 minute to the
gentleman from Georgia (Mr. Carter).
Mr. CARTER of Georgia. Mr. Speaker, I thank the gentlewoman for
yielding.
Mr. Speaker, I rise today in strong support of H.R. 5378, the Lower
Costs, More Transparency Act.
As a pharmacist for over four decades, I have seen firsthand how our
healthcare system treats patients with unaffordable prices and
inaccessible care.
Under the leadership of Chairwoman Rodgers and Health Subcommittee
Chairman Guthrie, we can do something about it by reining in the PBMs
and putting patients before profits.
Included in this bill is my Drug Price Transparency in Medicaid Act
which puts an end to the PBM games by prohibiting spread pricing in
Medicaid and increasing transparency and fairness to community
pharmacies by allowing them to be reimbursed at an appropriate rate for
dispensing medications to Medicaid patients.
I am also pleased to see my PBM Accountability Act is also included
in this bill.
The Lower Costs, More Transparency Act is such an important first
step towards bringing down prescription drug prices by addressing the
root cause: the middlemen who prey on patients for profits.
Mr. Speaker, I urge my colleagues to support the Lower Costs, More
Transparency Act.
Mrs. RODGERS of Washington. Mr. Speaker, I yield 1 minute to the
gentleman from Pennsylvania (Mr. Joyce).
Mr. JOYCE of Pennsylvania. Mr. Speaker, I thank the gentlewoman for
yielding.
The Lower Costs, More Transparency Act is part of our commitment to
supporting our patients, creating access to affordable medications, and
making the healthcare process easier to access for literally all
Americans.
Included in this legislation is my bill, the Strengthening Community
Care Act, which would reauthorize support for community health centers.
These centers are a vital source of care for over 30 million Americans
and nearly 240,000 individuals in Pennsylvania's 13th Congressional
District.
By reducing barriers like cost, lack of insurance, or distance,
community health centers are able to provide high-quality treatment to
the patients who need it the most: the patients who are underinsured or
not insured at all.
Mr. Speaker, I urge all of my colleagues to support the Lower Costs,
More Transparency Act, and I will be voting ``yes'' for this important
piece of legislation.
Mr. PALLONE. Mr. Speaker, I yield myself the balance of my time.
Mr. Speaker, I cannot emphasize the importance of this bill. I think
that in terms of the overall effort to increase affordability, to
increase access to healthcare, and to make sure that there is
competition, if you will, within the hospital industry and within the
insurance industry, this bill does all of those things.
It is really amazing, in my opinion, that we are able to do this on a
bipartisan basis. It came out of committee, I believe, unanimously. I
think it will go far towards increasing affordability, accessibility,
and competition, which also lowers prices.
For all those reasons, Mr. Speaker, I urge support for the
legislation, and I yield back the balance of my time.
Mrs. RODGERS of Washington. Mr. Speaker, I, too, want to urge support
for this major bipartisan legislation. It is very important healthcare
legislation. We are concerned about consolidation within healthcare and
the rising costs within healthcare.
The first way we are going to address that is by demanding
transparency. We have to know what the prices actually are so that we
can empower patients and we can get some more competition within our
healthcare system.
I thank everyone who has worked together. This was a priority we laid
out at the very beginning of this Congress. It has been months' worth
of work.
A big thank you, again, to the ranking member of the Energy and
Commerce Committee, as well as the other committees, the chairmanship
of Virginia Foxx and the chairman of the Ways and Means Committee,
Jason Smith, for working together. We have all contributed, and we have
a better product because of it.
I definitely urge support by my colleagues both Republicans and
Democrats. This is one that we need to get on the President's desk with
a big vote today.
Mr. Speaker, I yield back the balance of my time.
Mr. SCOTT of Virginia. Mr. Speaker, one of the reasons health care
costs are so high is that consumers and employers often do not have
enough information about what they are paying for.
This makes it hard for patients to find affordable, high-quality
health care providers. And it prevents employers from spending workers'
premium dollars carefully. It also hinders competition, which keeps
health care costs in check. And finally, it limits our ability as
policymakers to improve the health care system.
Americans deserve to know what they are being asked to pay. The Lower
Costs, More Transparency Act helps ensure health care costs are driven
by those who provide the highest quality services, not those with the
most market power.
This bill includes several bipartisan priorities for our Committee
Members, and I thank my colleagues on both sides of the aisle for
working together on this package.
I am especially pleased that it strengthens oversight of the direct
and indirect compensation earned by health plan service providers. This
includes not only pharmacy benefit managers but also--critically--
insurance companies serving as third-party administrators for self-
funded plans.
I was also pleased to work with my colleagues to ensure strong
privacy protections for workers.
Finally, I appreciate my colleagues' bipartisan commitment to
incorporating technical corrections to ensure that the reporting
requirements for pharmacy benefit managers apply fully to multiemployer
plans, state and local government plans, and retiree-only plans--
consistent with the intent of the legislation.
Moving forward, we must continue to promote transparency and
competition and take direct action to lower health care costs for
workers and their families.
Ms. FOXX. Mr. Speaker, the goal of the Lower Costs, More Transparency
Act is to allow a wide range of employers, workers, and health plans to
benefit from increased transparency of pharmacy benefit managers so
they can make more informed, cost-conscious health care decisions.
It has come to our attention that the definition of large employer in
this bill, as written, may have inadvertently left out certain types of
non-employer plans, such as multiemployer, union, governmental, and
retiree plans.
I rise today to affirm that my colleagues and I never intended for
this bill to exclude these plans from leveraging the transparency tools
included in this bill.
We remain committed to addressing this technical issue as we work
with our Senate colleagues to expand transparency in health care
following passage of the Lower Costs, More Transparency Act today.
The SPEAKER pro tempore. The question is on the motion offered by the
gentlewoman from Washington (Mrs. Rodgers) that the House suspend the
rules and pass the bill, H.R. 5378, as amended.
The question was taken.
The SPEAKER pro tempore. In the opinion of the Chair, two-thirds
being in the affirmative, the ayes have it.
Mrs. RODGERS of Washington. Mr. Speaker, on that I demand the yeas
and nays.
The yeas and nays were ordered.
The SPEAKER pro tempore. Pursuant to clause 8 of rule XX, further
proceedings on this motion will be postponed.
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