[House Report 118-742]
[From the U.S. Government Publishing Office]
118th Congress } { Rept. 118-742
HOUSE OF REPRESENTATIVES
2d Session } { Part 1
======================================================================
TRANSPARENCY IN COVERAGE ACT
_______
November 18, 2024.--Ordered to be printed
_______
Ms. Foxx, from the Committee on Education and the Workforce,
submitted the following
R E P O R T
[To accompany H.R. 4507]
The Committee on Education and the Workforce, to whom was
referred the bill (H.R. 4507) to amend the Employee Retirement
Income Security Act of 1974 to promote transparency in health
coverage and reform pharmacy benefit management services with
respect to group health plans, and for other purposes, having
considered the same, reports favorably thereon with an
amendment and recommends that the bill as amended do pass.
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Transparency in Coverage Act''.
SEC. 2. PROMOTING GROUP HEALTH PLAN AND GROUP HEALTH INSURANCE COVERAGE
PRICE TRANSPARENCY.
(a) In General.--
(1) ERISA.--
(A) In general.--Section 719 of the Employee
Retirement Income Security Act of 1974 (29 U.S.C.
1185h) is amended to read as follows:
``SEC. 719. PRICE TRANSPARENCY REQUIREMENTS.
``(a) In General.--A group health plan, and a health insurance issuer
offering group health insurance coverage, shall make available to the
public accurate and timely disclosures of the following information:
``(1) Claims payment policies and practices.
``(2) Periodic financial disclosures.
``(3) Data on enrollment.
``(4) Data on disenrollment.
``(5) Data on the number of claims that are denied.
``(6) Data on rating practices.
``(7) Information on cost-sharing and payments with respect
to any out-of-network coverage (or with respect to any item and
service furnished under such a plan or such group health
insurance coverage that does not use a network of providers).
``(8) Information on participant and beneficiary rights under
this part.
``(9) Rate and payment information described in subsection
(d).
``(10) Other information as determined appropriate by the
Secretary.
Rate and payment information described in paragraph (9) shall be made
available to the public not later than January 10, 2025, and not later
than the tenth day of every month thereafter, in the manner described
in subsection (d)(2)(A), and, beginning on January 1, 2027, in real-
time through an application program interface (or successor technology)
described in subsection (d)(2)(B).
``(b) Use of Plain Language.--The information required to be
submitted under subsection (a) shall be provided in plain language. The
term `plain language' means language that the intended audience,
including individuals with limited English proficiency, can readily
understand and use because that language is clear, concise, well-
organized, accurately describes the information, and follows other best
practices of plain language writing. The Secretary, jointly with the
Secretary of Health and Human Services and the Secretary of Labor,
shall develop and issue standards for plain language writing for
purposes of this section and shall develop a standardized reporting
template and standardized definitions of terms to allow for comparison
across group health plans and health insurance coverage.
``(c) Cost Sharing Transparency.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance coverage,
shall, upon request of a participant or beneficiary and in a
timely manner, provide to the participant or beneficiary a
statement of the amount of cost-sharing (including deductibles,
copayments, and coinsurance) under the participant's or
beneficiary's plan or coverage that the participant or
beneficiary would be responsible for paying with respect to the
furnishing of a specific item or service by a provider. At a
minimum, such information shall include the information
specified in paragraph (2) and shall be made available at no
cost to the participant or beneficiary through a self-service
tool that meets the requirements of paragraph (3) or through a
paper or phone disclosure, at the option of the 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 (as
applicable) 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 (f)) for such item or
service and for any other item or service that is
inherent in the furnishing of the item or service that
is the subject of such request.
``(B) If such provider is not a participating
provider, the allowed amount, percentage of billed
charges, or other rate 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 billed by such provider.
``(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 amount or rate
described in such subparagraph (or, in the case such
plan or issuer uses a percentage of billed charges to
determined the amount of payment for such provider,
using a reasonable estimate of such percentage of such
charges)).
``(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) Any shared savings or other benefit available
to the participant or beneficiary with respect to such
item or service.
``(F) In the case such plan or coverage imposes any
frequency or volume limitations with respect to such
item or service (excluding medical necessity
determinations), the amount that such participant or
beneficiary has accrued towards such limitation with
respect to such item or service.
``(G) Any prior authorization, concurrent review,
step therapy, fail first, or similar requirements
applicable to coverage of such item or service under
such plan or group health insurance coverage.
``(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, mobile
application, or other platform determined appropriate
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 accurate at the time such
request is made;
``(D) allows such a request to be made with respect
to an item or service furnished by--
``(i) a specific provider that is a
participating provider with respect to such
item or service;
``(ii) all providers that are participating
providers with respect to such plan and such
item or service for purposes of facilitating
price comparisons; or
``(iii) a provider that is not described in
clause (ii); and
``(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.
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 items and
services.
``(4) Provider tool.--A group health plan, and a health
insurance issuer offering group health insurance coverage,
shall permit providers to learn the amount of cost-sharing
(including deductibles, copayments, and coinsurance) that would
apply under an 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 another provider in
a timely manner upon the request of the provider and with the
consent of such individual in the same manner and to the same
extent as if such request has been made by such individual. As
part of any tool used to facilitate such requests from a
provider, such plan or issuer offering health insurance
coverage may include functionality that--
``(A) allows providers to submit the notifications to
such plan or coverage required under section 2799B-6 of
the Public Health Service Act; and
``(B) provides for notifications required under
section 716(f) to such an individual.
``(d) Rate and Payment Information.--
``(1) In general.--For purposes of subsection (a)(9), the
rate and payment information described in this subsection is,
with respect to a group health plan or group health insurance
coverage (as applicable), the following:
``(A) With respect to each item or service (other
than a drug) for which benefits are available under
such plan or coverage, the in-network rate (in a dollar
amount) in effect as of the first day of the plan year
during which such information is submitted with each
provider (identified by national provider identifier)
that is a participating provider with respect to such
item or service (or, in the case such rate is not
available in a dollar amount, such formulae, pricing
methodologies, or other information used to calculate
such rate).
``(B) With respect to each dosage form and indication
of each drug (identified by national drug code) for
which benefits are available under such plan or
coverage--
``(i) the in-network rate (in a dollar
amount) in effect as of the first day of the
plan year during which such information is
submitted with each provider (identified by
national provider identifier) that is a
participating provider with respect to such
drug (or, in the case such rate is not
available in a dollar amount, such formulae,
pricing methodologies, or other information
used to calculate such rate); 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 submission to each
provider that was a participating provider with
respect to such drug, broken down by each such
provider (identified by national provider
identifier), other than such an amount paid to
a provider that, during such period, submitted
fewer than 20 claims for such drug to such plan
or coverage.
``(C) With respect to each item or service for which
benefits are available under such plan or coverage, the
amount billed, and the amount allowed by the plan or
coverage, for each such item or service furnished
during the 90-day period specified in subparagraph (B)
by a provider that was not a participating provider
with respect to such item or service, broken down by
each such provider (identified by national provider
identifier), other than items and services with respect
to which fewer than 20 claims for such item or service
were submitted to such plan or coverage during such
period.
Such rate and payment information shall be made available with
respect to each individual item or service, regardless of
whether such item or service is paid for as part of a bundled
payment, episode of care, value-based payment arrangement, or
otherwise.
``(2) Manner of publication.--
``(A) In general.--Rate and payment information
required to be made available under subsection (a)(9)
shall be so made available in dollar amounts through 3
separate machine-readable files corresponding to the
information described in each of subparagraphs (A)
through (C) of paragraph (1) that meet such
requirements as specified by the Secretary not later
than 180 days after the date of the enactment of this
paragraph through rulemaking. Such requirements shall
ensure that such files are limited to an appropriate
size, do not include information that is duplicative of
information contained in the same file or in other
files made available under such subsection, are made
available in a widely-available format that allows for
information contained in such files to be compared
across group health plans and group health insurance
coverage, and are accessible to individuals at no cost
and without the need to establish a user account or
provide other credentials.
``(B) Real-time provision of information.--
``(i) In general.--Subject to clause (ii),
beginning January 1, 2026, rate and payment
information required to be made available by a
group health plan or health insurance issuer
under subsection (a)(9) shall, in addition to
being made available in the manner described in
subparagraph (A), be made available through an
application program interface (or successor
technology) that provides access to such
information in real time and that meets such
technical standards as may be specified by the
Secretary.
``(ii) Exemption for certain plans or
coverage.--Clause (i) shall not apply with
respect to information described in such clause
required to be made available by a group health
plan or health insurance issuer offering health
insurance coverage if such plan or coverage, as
applicable, provides benefits for fewer than
500 participants and beneficiaries.
``(3) User guide.--The Secretary, Secretary of Health and
Human Services, and Secretary of the Treasury shall jointly
make available to the public instructions written in plain
language explaining how individuals may search for information
described in paragraph (1) in files submitted in accordance
with paragraph (2).
``(4) Annual summary.--For each year (beginning with 2025),
each group health plan and health insurance issuer offering
group health insurance coverage shall make public a machine-
readable file meeting such standards as established by the
Secretary under paragraph (2) 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 year (such as
averages of all such information so made public).
``(e) Attestation.--Each group health plan and health insurance
issuer offering group health insurance coverage shall annually submit
to the Secretary an attestation of such plan's or such coverage's
compliance with the provisions of this section along with a link to
disclosures made in accordance with subsection (a).
``(f) Definitions.--In this subsection:
``(1) Participating provider.--The term `participating
provider' has the meaning given such term in section 716 and
includes a participating facility.
``(2) In-network rate.--The term `in-network rate' means,
with respect to a group health plan or group health insurance
coverage and an item or service furnished by a provider that is
a participating provider with respect to such plan or coverage
and item or service, the contracted rate (reflected as a dollar
amount) in effect between such plan or coverage and such
provider for such item or service.''.
(B) Clerical amendment.--The table of contents in
section 1 of such Act is amended by striking the item
relating to section 719 and inserting the following new
item:
``Sec. 719. Price transparency requirements.''.
(2) IRC.--
(A) In general.--Section 9819 of the Internal Revenue
Code of 1986 is amended to read as follows:
``SEC. 9819. PRICE TRANSPARENCY REQUIREMENTS.
``(a) In General.--A group health plan shall make available to the
public accurate and timely disclosures of the following information:
``(1) Claims payment policies and practices.
``(2) Periodic financial disclosures.
``(3) Data on enrollment.
``(4) Data on disenrollment.
``(5) Data on the number of claims that are denied.
``(6) Data on rating practices.
``(7) Information on cost-sharing and payments with respect
to any out-of-network coverage (or with respect to any item and
service furnished under such a plan that does not use a network
of providers).
``(8) Information on participant and beneficiary rights under
this part.
``(9) Rate and payment information described in subsection
(d).
``(10) Other information as determined appropriate by the
Secretary.
Rate and payment information described in paragraph (9) shall be made
available to the public not later than January 10, 2025, and not later
than the tenth day of every month thereafter, in the manner described
in subsection (d)(2)(A), and, beginning on January 1, 2027, in real-
time through an application program interface (or successor technology)
described in subsection (d)(2)(B).
``(b) Use of Plain Language.--The information required to be
submitted under subsection (a) shall be provided in plain language. The
term `plain language' means language that the intended audience,
including individuals with limited English proficiency, can readily
understand and use because that language is clear, concise, well-
organized, accurately describes the information, and follows other best
practices of plain language writing. The Secretary, jointly with the
Secretary of Health and Human Services and the Secretary of Labor,
shall develop and issue standards for plain language writing for
purposes of this section and shall develop a standardized reporting
template and standardized definitions of terms to allow for comparison
across group health plans and health insurance coverage.
``(c) Cost Sharing Transparency.--
``(1) In general.--A group health plan shall, upon request of
a participant or beneficiary and in a timely manner, provide to
the participant or beneficiary a statement of the amount of
cost-sharing (including deductibles, copayments, and
coinsurance) under the participant's or beneficiary's plan that
the participant or beneficiary would be responsible for paying
with respect to the furnishing of a specific item or service by
a provider. At a minimum, such information shall include the
information specified in paragraph (2) and shall be made
available at no cost to the participant or beneficiary through
a self-service tool that meets the requirements of paragraph
(3) or through a paper or phone disclosure, at the option of
the 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 (f)) for such item or
service and for any other item or service that is
inherent in the furnishing of the item or service that
is the subject of such request.
``(B) If such provider is not a participating
provider, the allowed amount, percentage of billed
charges, or other rate that such plan will recognize as
payment for such item or service, along with a notice
that such individual may be liable for additional
charges billed by such provider.
``(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 amount or rate
described in such subparagraph (or, in the case such
plan uses a percentage of billed charges to determined
the amount of payment for such provider, using a
reasonable estimate of such percentage of such
charges)).
``(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) Any shared savings or other benefit available
to the participant or beneficiary with respect to such
item or service.
``(F) 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.
``(G) Any prior authorization, concurrent review,
step therapy, fail first, or similar requirements
applicable to coverage of such item or service under
such plan.
``(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, mobile
application, or other platform determined appropriate
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 accurate at the time such
request is made;
``(D) allows such a request to be made with respect
to an item or service furnished by--
``(i) a specific provider that is a
participating provider with respect to such
item or service;
``(ii) all providers that are participating
providers with respect to such item or service
for purposes of facilitating price comparisons;
or
``(iii) a provider that is not described in
clause (ii); and
``(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.
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 items and
services.
``(4) Provider tool.--A group health plan shall permit
providers to learn the amount of cost-sharing (including
deductibles, copayments, and coinsurance) that would apply
under an individual's plan that the individual would be
responsible for paying with respect to the furnishing of a
specific item or service by another provider in a timely manner
upon the request of the provider and with the consent of such
individual in the same manner and to the same extent as if such
request has been made by such individual. As part of any tool
used to facilitate such requests from a provider, such plan may
include functionality that--
``(A) allows providers to submit the notifications to
such plan or coverage required under section 2799B-6 of
the Public Health Services Act; and
``(B) provides for notifications required under
section 9816(f) to such an individual.
``(d) Rate and Payment Information.--
``(1) In general.--For purposes of subsection (a)(9), the
rate and payment information described in this subsection is,
with respect to a group health plan, the following:
``(A) With respect to each item or service (other
than a drug) for which benefits are available under
such plan, the in-network rate (in a dollar amount) in
effect as of the first day of the plan year during
which such information is submitted with each provider
(identified by national provider identifier) that is a
participating provider with respect to such item or
service (or, in the case such rate is not available in
a dollar amount, such formulae, pricing methodologies,
or other information used to calculate such rate).
``(B) With respect to each dosage form and indication
of each drug (identified by national drug code) for
which benefits are available under such plan--
``(i) the in-network rate (in a dollar
amount) in effect as of the first day of the
plan year during which such information is
submitted with each provider (identified by
national provider identifier) that is a
participating provider with respect to such
drug (or, in the case such rate is not
available in a dollar amount, such formulae,
pricing methodologies, or other information
used to calculate such rate); 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 submission to each
provider that was a participating provider with
respect to such drug, broken down by each such
provider (identified by national provider
identifier), other than such an amount paid to
a provider that, 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, 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
(identified by national provider identifier), other
than items and services with respect to which fewer
than 20 claims for such item or service were submitted
to such plan or coverage during such period.
Such rate and payment information shall be made available with
respect to each individual item or service, regardless of
whether such item or service is paid for as part of a bundled
payment, episode of care, value-based payment arrangement, or
otherwise.
``(2) Manner of publication.--
``(A) In general.--Rate and payment information
required to be made available under subsection (a)(9)
shall be so made available in dollar amounts through 3
separate machine-readable files corresponding to the
information described in each of subparagraphs (A)
through (C) of paragraph (1) that meet such
requirements as specified by the Secretary not later
than 180 days after the date of the enactment of this
paragraph through rulemaking. Such requirements shall
ensure that such files are limited to an appropriate
size, do not include information that is duplicative of
information contained in other files made available
under such subsection, are made available in a widely-
available format that allows for information contained
in such files to be compared across group health plans,
and are accessible to individuals at no cost and
without the need to establish a user account or provide
other credentials.
``(B) Real-time provision of information.--
``(i) In general.--Subject to clause (ii),
beginning January 1, 2026, rate and payment
information required to be made available by a
group health plan under subsection (a)(9)
shall, in addition to being made available in
the manner described in subparagraph (A), be
made available through an application program
interface (or successor technology) that
provides access to such information in real
time and that meets such technical standards as
may be specified by the Secretary.
``(ii) Exemption for certain plans and
coverage.--Clause (i) shall not apply with
respect to information described in such clause
required to be made available by a group health
plan if such plan provides benefits for fewer
than 500 participants and beneficiaries.
``(3) User guide.--The Secretary, Secretary of Health and
Human Services, and Secretary of Labor shall jointly make
available to the public instructions written in plain language
explaining how individuals may search for information described
in paragraph (1) in files submitted in accordance with
paragraph (2).
``(4) Annual summary.--For each year (beginning with 2025),
each group health plan shall make public a machine-readable
file meeting such standards as established by the Secretary
under paragraph (2) containing a summary of all rate and
payment information made public by such plan with respect to
such plan or coverage during such year (such as averages of all
such information so made public).
``(e) Attestation.--Each group health plan shall annually submit to
the Secretary an attestation of such plan's compliance with the
provisions of this section along with a link to disclosures made in
accordance with subsection (a).
``(f) Definitions.--In this subsection:
``(1) Participating provider.--The term `participating
provider' has the meaning given such term in section 9816 and
includes a participating facility.
``(2) In-network rate.--The term `in-network rate' means,
with respect to a group health plan and an item or service
furnished by a provider that is a participating provider with
respect to such plan and item or service, the contracted rate
(reflected as a dollar amount) in effect between such plan and
such provider for such item or service.''.
(B) Clerical amendment.--The item relating to section
9819 in the table of sections for subchapter B of
chapter 100 of the Internal Revenue Code of 1986 is
amended to read as follows:
``Sec. 9819. Price transparency requirements.''.
(3) PHSA.--Section 2799A-4 of the Public Health Service Act
(42 U.S.C. 300gg-114) is amended to read as follows:
``SEC. 2799A-4. PRICE TRANSPARENCY REQUIREMENTS.
``(a) In General.--A group health plan, and a health insurance issuer
offering group or individual health insurance coverage, shall make
available to the public accurate and timely disclosures of the
following information:
``(1) Claims payment policies and practices.
``(2) Periodic financial disclosures.
``(3) Data on enrollment.
``(4) Data on disenrollment.
``(5) Data on the number of claims that are denied.
``(6) Data on rating practices.
``(7) Information on cost-sharing and payments with respect
to any out-of-network coverage (or with respect to any item and
service furnished under such a plan or such group or individual
health insurance coverage that does not use a network of
providers).
``(8) Information on enrollee rights under this part.
``(9) Rate and payment information described in subsection
(d).
``(10) Other information as determined appropriate by the
Secretary.
Rate and payment information described in paragraph (9) shall be made
available to the public not later than January 10, 2025, and not later
than the tenth day of every month thereafter, in the manner described
in subsection (d)(2)(A), and, beginning on January 1, 2027, in real-
time through an application program interface (or successor technology)
described in subsection (d)(2)(B).
``(b) Use of Plain Language.--The information required to be
submitted under subsection (a) shall be provided in plain language. The
term `plain language' means language that the intended audience,
including individuals with limited English proficiency, can readily
understand and use because that language is clear, concise, well-
organized, accurately describes the information, and follows other best
practices of plain language writing. The Secretary, jointly with the
Secretary of Labor and the Secretary of the Treasury, shall develop and
issue standards for plain language writing for purposes of this section
and shall develop a standardized reporting template and standardized
definitions of terms to allow for comparison across group health plans
and health insurance coverage.
``(c) Cost Sharing Transparency.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group or individual health insurance
coverage, shall, upon request of an enrollee and in a timely
manner, provide to the enrollee a statement of the amount of
cost-sharing (including deductibles, copayments, and
coinsurance) under the enrollee's plan or coverage that the
enrollee would be responsible for paying with respect to the
furnishing of a specific item or service by a provider. At a
minimum, such information shall include the information
specified in paragraph (2) and shall be made available at no
cost to the enrollee through a self-service tool that meets the
requirements of paragraph (3) or through a paper or phone
disclosure, at the option of the enrollee, 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 (as applicable) furnished by a health care provider to
an enrollee 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 (f)) for such item or
service and for any other item or service that is
inherent in the furnishing of the item or service that
is the subject of such request.
``(B) If such provider is not a participating
provider, the allowed amount, percentage of billed
charges, or other rate that such plan or coverage will
recognize as payment for such item or service, along
with a notice that such enrollee may be liable for
additional charges billed by such provider.
``(C) The estimated amount of cost sharing (including
deductibles, copayments, and coinsurance) that the
enrollee 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 amount or rate described in such
subparagraph (or, in the case such plan or issuer uses
a percentage of billed charges to determined the amount
of payment for such provider, using a reasonable
estimate of such percentage of such charges)).
``(D) The amount the enrollee 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
enrollees in the plan or coverage, by such separate
deductibles or maximums, in addition to any cumulative
deductible or maximum).
``(E) Any shared savings or other benefit available
to the enrollee with respect to such item or service.
``(F) In the case such plan or coverage imposes any
frequency or volume limitations with respect to such
item or service (excluding medical necessity
determinations), the amount that such enrollee has
accrued towards such limitation with respect to such
item or service.
``(G) Any prior authorization, concurrent review,
step therapy, fail first, or similar requirements
applicable to coverage of such item or service under
such plan or group or individual health insurance
coverage.
``(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, mobile
application, or other platform determined appropriate
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 accurate at the time such
request is made;
``(D) allows such a request to be made with respect
to an item or service furnished by--
``(i) a specific provider that is a
participating provider with respect to such
item or service;
``(ii) all providers that are participating
providers with respect to such plan and such
item or service for purposes of facilitating
price comparisons; or
``(iii) a provider that is not described in
clause (ii); and
``(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.
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 items and
services.
``(4) Provider tool.--A group health plan, and a health
insurance issuer offering group or individual health insurance
coverage, shall permit providers to learn the amount of cost-
sharing (including deductibles, copayments, and coinsurance)
that would apply under an 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 another
provider in a timely manner upon the request of the provider
and with the consent of such individual in the same manner and
to the same extent as if such request has been made by such
individual. As part of any tool used to facilitate such
requests from a provider, such plan or issuer offering health
insurance coverage may include functionality that--
``(A) allows providers to submit the notifications to
such plan or coverage required under section 2799B-6;
and
``(B) provides for notifications required under
section 2799A-1(f) to such an individual.
``(d) Rate and Payment Information.--
``(1) In general.--For purposes of subsection (a)(9), the
rate and payment information described in this subsection is,
with respect to a group health plan or group or individual
health insurance coverage (as applicable), the following:
``(A) With respect to each item or service (other
than a drug) for which benefits are available under
such plan or coverage, the in-network rate (in a dollar
amount) in effect as of the first day of the plan year
during which such information is submitted with each
provider (identified by national provider identifier)
that is a participating provider with respect to such
item or service (or, in the case such rate is not
available in a dollar amount, such formulae, pricing
methodologies, or other information used to calculate
such rate).
``(B) With respect to each dosage form and indication
of each drug (identified by national drug code) for
which benefits are available under such plan or
coverage--
``(i) the in-network rate (in a dollar
amount) in effect as of the first day of the
plan year during which such information is
submitted with each provider (identified by
national provider identifier) that is a
participating provider with respect to such
drug (or, in the case such rate is not
available in a dollar amount, such formulae,
pricing methodologies, or other information
used to calculate such rate); 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 submission to each
provider that was a participating provider with
respect to such drug, broken down by each such
provider (identified by national provider
identifier), other than such an amount paid to
a provider that, during such period, submitted
fewer than 20 claims for such drug to such plan
or coverage.
``(C) With respect to each item or service for which
benefits are available under such plan or coverage, the
amount billed, and the amount allowed by the plan or
coverage, for each such item or service furnished
during the 90-day period specified in subparagraph (B)
by a provider that was not a participating provider
with respect to such item or service, broken down by
each such provider (identified by national provider
identifier), other than items and services with respect
to which fewer than 20 claims for such item or service
were submitted to such plan or coverage during such
period.
Such rate and payment information shall be made available with
respect to each individual item or service, regardless of
whether such item or service is paid for as part of a bundled
payment, episode of care, value-based payment arrangement, or
otherwise.
``(2) Manner of publication.--
``(A) In general.--Rate and payment information
required to be made available under subsection (a)(9)
shall be so made available in dollar amounts through 3
separate machine-readable files corresponding to the
information described in each of subparagraphs (A)
through (C) of paragraph (1) that meet such
requirements as specified by the Secretary not later
than 180 days after the date of the enactment of this
paragraph through rulemaking. Such requirements shall
ensure that such files are limited to an appropriate
size, do not include information that is duplicative of
information contained in other files made available
under such subsection, are made available in a widely-
available format that allows for information contained
in such files to be compared across group health plans
and group or individual health insurance coverage, and
are accessible to individuals at no cost and without
the need to establish a user account or provide other
credentials.
``(B) Real-time provision of information.--
``(i) In general.--Subject to clause (ii),
beginning January 1, 2026, rate and payment
information required to be made available by a
group health plan or health insurance issuer
under subsection (a)(9) shall, in addition to
being made available in the manner described in
subparagraph (A), be made available through an
application program interface (or successor
technology) that provides access to such
information in real time and that meets such
technical standards as may be specified by the
Secretary.
``(ii) Exemption for certain plans and
coverage.--Clause (i) shall not apply with
respect to information described in such clause
required to be made available by a group health
plan or health insurance issuer offering health
insurance coverage if such plan or coverage, as
applicable, provides benefits for fewer than
500 enrollees.
``(3) User guide.--The Secretary, Secretary of Labor, and
Secretary of the Treasury shall jointly make available to the
public instructions written in plain language explaining how
individuals may search for information described in paragraph
(1) in files submitted in accordance with paragraph (2).
``(4) Annual summary.--For each year (beginning with 2025),
each group health plan and health insurance issuer offering
group or individual health insurance coverage shall make public
a machine-readable file meeting such standards as established
by the Secretary under paragraph (2) 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 year
(such as averages of all such information so made public).
``(e) Attestation.--Each group health plan and health insurance
issuer offering group or individual health insurance coverage shall
annually submit to the Secretary an attestation of such plan's or such
coverage's compliance with the provisions of this section along with a
link to disclosures made in accordance with subsection (a).
``(f) Definitions.--In this subsection:
``(1) Participating provider.--The term `participating
provider' has the meaning given such term in section 2799A-1
and includes a participating facility.
``(2) In-network rate.--The term `in-network rate' means,
with respect to a group health plan or group or individual
health insurance coverage and an item or service furnished by a
provider that is a participating provider with respect to such
plan or coverage and item or service, the contracted rate
(reflected as a dollar amount) in effect between such plan or
coverage and such provider for such item or service.''.
(b) Reports to Congress.--
(1) Quality report.--Not later than 1 year after the date of
enactment of this subsection, the Secretary of Labor shall
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.
(2) Transparency data assessment.--Not later than January 1,
2026, and biannually thereafter through 2032, the Secretary
shall submit to Congress, and make publicly available on a
website of the Department of Labor, a report with respect to
the information described in section 719 of the Employee
Retirement Income Security Act (29 U.S.C. 1185h) (as amended by
the ``Transparency in Coverage Act of 2023''), assessing the
differences in commercial negotiated prices--
(A) between rural and urban markets;
(B) in the individual, small-employer, and large-
employer markets;
(C) in consolidated and non-consolidated provider
markets;
(D) between non-profit and for-profit hospitals; and
(E) between non-profit and for-profit insurers.
(c) Effective Date.--
(1) In general.--The amendments made by subsection (a) shall
apply to plan years beginning on or after January 1, 2025.
(2) 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 plan years beginning before January 1, 2025.
SEC. 3. PHARMACY BENEFIT MANAGER TRANSPARENCY.
(a) ERISA.--
(1) In general.--Subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1021 et seq.)
is amended--
(A) in subpart B of part 7 (29 U.S.C. 1185 et seq.),
by adding at the end the following:
``SEC. 726. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.
``(a) In General.--For plan years beginning on or after January 1,
2025, a group health plan (or health insurance issuer offering group
health insurance coverage in connection with such a plan) or an entity
or subsidiary providing pharmacy benefits management services on behalf
of such a plan or issuer may not enter into a contract with a drug
manufacturer, distributor, wholesaler, switch, patient or copay
assistance program administrator, pharmacy, subcontractor, rebate
aggregator, or any associated third party that limits or delays the
disclosure of information to plan administrators in such a manner that
prevents the plan or issuer, or an entity or subsidiary providing
pharmacy benefits management services on behalf of a plan or issuer,
from making or substantiating the reports described in subsection (b).
``(b) Reports.--
``(1) In general.--For plan years beginning on or after
January 1, 2025, not less frequently than quarterly (and upon
request by the plan administrator), a group health plan or
health insurance issuer offering group health insurance
coverage, or an entity providing pharmacy benefits management
services on behalf of a group health plan or an issuer
providing group health insurance coverage, shall submit to the
plan administrator (as defined in section 3(16)(A)) of such
plan or coverage a report in accordance with this subsection,
and make such report available to the plan administrator in a
machine-readable format (or as may be determined by the
Secretary, other formats). Each such report shall include, with
respect to the applicable group health plan or health insurance
coverage--
``(A) information collected from a patient or copay
assistance program administrator by such entity on the
total amount of copayment assistance dollars paid, or
copayment cards applied, or other discounts that were
funded by the drug manufacturer with respect to the
participants and beneficiaries in such plan or
coverage;
``(B) total gross spending on prescription drugs by
the plan or coverage during the reporting period;
``(C) total amount received, or expected to be
received, by the plan or coverage from any entities, in
rebates, fees, alternative discounts, and all other
remuneration received from the entity or any third
party (including group purchasing organizations) other
than the plan administrator, related to utilization of
drug or drug spending under such plan or coverage
during the reporting period;
``(D) the total net spending on prescription drugs by
the plan or coverage during such reporting period;
``(E) 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
brokerage houses, brokers, consultants, advisors, or
any other individual or firm for the referral of the
group health plan's or health insurance issuer's
business to the pharmacy benefits manager, identified
by the recipient of such amounts;
``(F)(i) an explanation of any benefit design
parameters that encourage or require participants and
beneficiaries in the 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 funded by an entity
providing pharmacy benefit management services;
``(ii) the percentage of total prescriptions
charged to the plan, issuer, or participants
and beneficiaries in such plan or coverage,
that were dispensed by mail order, specialty,
or retail pharmacies that are affiliated with
or under common ownership with the entity
providing pharmacy benefit management services;
and
``(iii) a list of all drugs dispensed by such
affiliated pharmacy or pharmacy under common
ownership and charged to the plan, issuer, or
participants and beneficiaries of the plan,
during the applicable period, and, with respect
to each drug--
``(I)(aa) the amount charged, per
dosage unit, per 30-day supply, and per
90-day supply, with respect to
participants and beneficiaries in the
plan or coverage, to the plan or
issuer; and
``(bb) the amount charged,
per dosage unit, per 30-day
supply, and per 90-day supply,
to participants and
beneficiaries;
``(II) the median amount charged to
the plan or issuer, per dosage unit,
per 30-day supply, and per 90-day
supply, including amounts paid by the
participants and beneficiaries, 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;
``(III) the interquartile range of
the costs, per dosage unit, per 30-day
supply, and per 90-day supply,
including amounts paid by the
participants and beneficiaries, 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 that plan or
coverage;
``(IV) the lowest cost, per dosage
unit, per 30-day supply, and per 90-day
supply, for such drug, including
amounts charged to the plan and
participants and beneficiaries, that is
available from any pharmacy included in
the network of the plan or coverage;
``(V) the net acquisition cost per
dosage unit, per 30-day supply, and per
90-day supply, if the drug is subject
to a maximum price discount; and
``(VI) other information with respect
to the cost of the drug, as determined
by the Secretary, such as average sales
price, wholesale acquisition cost, and
national average drug acquisition cost
per dosage unit or per 30-day supply,
and per 90-day supply, for such drug,
including amounts charged to the plan
or issuer and participants and
beneficiaries among all pharmacies
included in the network of such plan or
coverage; and
``(G) in the case of a large employer--
``(i) a list of each drug covered by such
plan, issuer, or entity providing pharmacy
benefits management services for which a claim
was filed during the reporting period,
including, with respect to each such drug
during the reporting period--
``(I) the brand name, generic or non-
proprietary name, and the National Drug
Code;
``(II)(aa) the number of participants
and beneficiaries for whom a claim for
such drug was filed during the
reporting period, the total number of
prescription claims for such drug
(including original prescriptions and
refills), and the total number of
dosage units and total days supply of
such drug for which a claim was filed
during the reporting period; and
``(bb) with respect to each
claim or dosage unit described
in item (aa), the type of
dispensing channel used, such
as retail, mail order, or
specialty pharmacy;
``(III) the wholesale acquisition
cost, listed as cost per days supply
and cost per dosage unit on date of
dispensing;
``(IV) the total out-of-pocket
spending by participants and
beneficiaries on such drug after
application of any benefits under such
plan or coverage, including participant
and beneficiary spending through
copayments, coinsurance, and
deductibles (but not including any
amounts spent by participants and
beneficiaries on drugs not covered
under such plan or coverage, or for
which no claim was submitted to such
plan or coverage);
``(V) for any drug for which gross
spending of the plan or coverage
exceeded $10,000 during the reporting
period--
``(aa) a list of all other
drugs in the same therapeutic
category or class, including
brand name drugs, biological
products, generic drugs, or
biosimilar biological products
that are in the same
therapeutic category or class
as such drug; and
``(bb) the rationale for
preferred formulary placement
of such drug in that
therapeutic category or class,
if applicable; and
``(ii) a list of each therapeutic category or
class of drugs for which a claim was filed
under the health plan or health insurance
coverage during the reporting period, and, with
respect to each such therapeutic category or
class of drugs during the reporting period--
``(I) total gross spending by the
plan;
``(II) the number of participants and
beneficiaries who filled a prescription
for a drug in that category or class;
``(III) if applicable to that
category or class, a description of the
formulary tiers and utilization
mechanisms (such as prior authorization
or step therapy) employed for drugs in
that category or class;
``(IV) the total out-of-pocket
spending by participants and
beneficiaries, including participant
and beneficiary spending through
copayments, coinsurance, and
deductibles; and
``(V) for each drug--
``(aa) the amount received,
or expected to be received,
from any entity in rebates,
fees, alternative discounts, or
other remuneration--
``(AA) for claims
incurred during the
reporting period; or
``(BB) that is
related to utilization
of drugs or drug
spending;
``(bb) the total net
spending, after deducting
rebates, price concessions,
alternative discounts or other
remuneration from drug
manufacturers, by the health
plan or health insurance
coverage on that category or
class of drugs; and
``(cc) the average net
spending per 30-day supply and
per 90-day supply, incurred by
the health plan or health
insurance coverage and its
participants and beneficiaries,
among all drugs within the
therapeutic class for which a
claim was filed during the
reporting period.
``(2) Privacy requirements.--Health insurance issuers
offering group health insurance coverage and entities providing
pharmacy benefits management services on behalf of a group
health plan shall provide information under paragraph (1) in a
manner consistent with the privacy, security, and breach
notification regulations promulgated under section 264(c) of
the Health Insurance Portability and Accountability Act of
1996, and shall restrict the use and disclosure of such
information according to such privacy regulations.
``(3) Disclosure and redisclosure.--
``(A) Limitation to business associates.--A group
health plan receiving a report under paragraph (1) may
disclose such information only to business associates
of such plan as defined in section 160.103 of title 45,
Code of Federal Regulations (or successor regulations).
``(B) Clarification regarding public disclosure of
information.--Nothing in this section prevents a health
insurance issuer offering group health insurance
coverage or an entity providing pharmacy benefits
management services on behalf of a group health plan
from placing reasonable restrictions on the public
disclosure of the information contained in a report
described in paragraph (1), except that such entity may
not restrict disclosure of such report to the
Department of Health and Human Services, the Department
of Labor, the Department of the Treasury, the
Comptroller General of the United States, or applicable
State agencies.
``(C) Limited form of report.--The Secretary shall
define through rulemaking a limited form of the report
under paragraph (1) required of plan administrators who
are drug manufacturers, drug wholesalers, or other
direct participants in the drug supply chain, in order
to prevent anti-competitive behavior.
``(4) Report to gao.--A health insurance issuer offering
group health insurance coverage or an entity providing pharmacy
benefits management services on behalf of a group health plan
shall submit to the Comptroller General of the United States
each of the first 4 reports submitted to a plan administrator
under paragraph (1) with respect to such coverage or plan, and
other such reports as requested, in accordance with the privacy
requirements under paragraph (2), the disclosure and
redisclosure standards under paragraph (3), the standards
specified pursuant to paragraph (5).
``(5) Standard format.--Not later than 6 months after the
date of enactment of this section, the Secretary shall specify
through rulemaking standards for health insurance issuers and
entities required to submit reports under paragraph (4) to
submit such reports in a standard format.
``(c) Rule of Construction.--Nothing in this section shall be
construed to permit a health insurance issuer, group health plan, or
other entity to restrict disclosure to, or otherwise limit the access
of, the Department of Labor to a report described in subsection (b)(1)
or information related to compliance with subsection (a) by such
issuer, plan, or entity.
``(d) Definitions.--In this section:
``(1) Large employer.--The term `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
(B) in section 502 (29 U.S.C. 1132)--
(i) in subsection (a)--
(I) in paragraph (6), by striking
``or (9)'' and inserting ``(9), or
(13)'';
(II) in paragraph (10), by striking
at the end ``or'';
(III) in paragraph (11), at the end
by striking the period and inserting
``; or''; and
(IV) by adding at the end the
following new paragraph:
``(12) by the Secretary, to enforce section 726.'';
(ii) in subsection (b)(3), by inserting ``and
subsections (a)(12) and (c)(13)'' before ``,
the Secretary is not''; and
(iii) in subsection (c), by adding at the end
the following new paragraph:
``(13) Secretarial enforcement authority relating to
oversight of pharmacy benefits manager services.--
``(A) Failure to provide timely information.--The
Secretary 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.''.
(b) PHSA.--Part D of title XXVII of the Public Health Service Act (42
U.S.C. 300gg-111 et seq.) is amended by adding at the end the following
new section:
``SEC. 2799A-11. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.
``(a) In General.--For plan years beginning on or after January 1,
2025, a group health plan (or health insurance issuer offering group
health insurance coverage in connection with such a plan) or an entity
or subsidiary providing pharmacy benefits management services on behalf
of such a plan or issuer may not enter into a contract with a drug
manufacturer, distributor, wholesaler, switch, patient or copay
assistance program administrator, pharmacy, subcontractor, rebate
aggregator, or any associated third party that limits or delays the
disclosure of information to plan administrators in such a manner that
prevents the plan or issuer, or an entity or subsidiary providing
pharmacy benefits management services on behalf of a plan or issuer,
from making or substantiating the reports described in subsection (b).
``(b) Reports.--
``(1) In general.--For plan years beginning on or after
January 1, 2025, not less frequently than quarterly (and upon
request by the plan administrator), a group health plan or
health insurance issuer offering group health insurance
coverage, or an entity providing pharmacy benefits management
services on behalf of a group health plan or an issuer
providing group health insurance coverage, shall submit to the
plan administrator (as defined in section 3(16)(A) of the
Employee Retirement Income Security Act of 1974) of such plan
or coverage a report in accordance with this subsection, and
make such report available to the plan administrator in a
machine-readable format (or as may be determined by the
Secretary, other formats). Each such report shall include, with
respect to the applicable group health plan or health insurance
coverage--
``(A) information collected from a patient or copay
assistance program administrator by such entity on the
total amount of copayment assistance dollars paid, or
copayment cards applied, or other discounts that were
funded by the drug manufacturer with respect to the
participants and beneficiaries in such plan or
coverage;
``(B) total gross spending on prescription drugs by
the plan or coverage during the reporting period;
``(C) total amount received, or expected to be
received, by the plan or coverage from any entities, in
rebates, fees, alternative discounts, and all other
remuneration received from the entity or any third
party (including group purchasing organizations) other
than the plan administrator, related to utilization of
drug or drug spending under such plan or coverage
during the reporting period;
``(D) the total net spending on prescription drugs by
the plan or coverage during such reporting period;
``(E) 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 of 1974) to
brokerage houses, brokers, consultants, advisors, or
any other individual or firm for the referral of the
group health plan's or health insurance issuer's
business to the pharmacy benefits manager, identified
by the recipient of such amounts;
``(F)(i) an explanation of any benefit design
parameters that encourage or require participants and
beneficiaries in the 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 funded by an entity
providing pharmacy benefit management services;
``(ii) the percentage of total prescriptions
charged to the plan, issuer, or participants
and beneficiaries in such plan or coverage,
that were dispensed by mail order, specialty,
or retail pharmacies that are affiliated with
or under common ownership with the entity
providing pharmacy benefit management services;
and
``(iii) a list of all drugs dispensed by such
affiliated pharmacy or pharmacy under common
ownership and charged to the plan, issuer, or
participants and beneficiaries of the plan,
during the applicable period, and, with respect
to each drug--
``(I)(aa) the amount charged, per
dosage unit, per 30-day supply, and per
90-day supply, with respect to
participants and beneficiaries in the
plan or coverage, to the plan or
issuer; and
``(bb) the amount charged,
per dosage unit, per 30-day
supply, and per 90-day supply,
to participants and
beneficiaries;
``(II) the median amount charged to
the plan or issuer, per dosage unit,
per 30-day supply, and per 90-day
supply, including amounts paid by the
participants and beneficiaries, 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;
``(III) the interquartile range of
the costs, per dosage unit, per 30-day
supply, and per 90-day supply,
including amounts paid by the
participants and beneficiaries, 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 that plan or
coverage;
``(IV) the lowest cost, per dosage
unit, per 30-day supply, and per 90-day
supply, for such drug, including
amounts charged to the plan and
participants and beneficiaries, that is
available from any pharmacy included in
the network of the plan or coverage;
``(V) the net acquisition cost per
dosage unit, per 30-day supply, and per
90-day supply, if the drug is subject
to a maximum price discount; and
``(VI) other information with respect
to the cost of the drug, as determined
by the Secretary, such as average sales
price, wholesale acquisition cost, and
national average drug acquisition cost
per dosage unit or per 30-day supply,
and per 90-day supply, for such drug,
including amounts charged to the plan
or issuer and participants and
beneficiaries among all pharmacies
included in the network of such plan or
coverage; and
``(G) in the case of a large employer--
``(i) a list of each drug covered by such
plan, issuer, or entity providing pharmacy
benefits management services for which a claim
was filed during the reporting period,
including, with respect to each such drug
during the reporting period--
``(I) the brand name, generic or non-
proprietary name, and the National Drug
Code;
``(II)(aa) the number of participants
and beneficiaries for whom a claim for
such drug was filed during the
reporting period, the total number of
prescription claims for such drug
(including original prescriptions and
refills), and the total number of
dosage units and total days supply of
such drug for which a claim was filed
during the reporting period; and
``(bb) with respect to each
claim or dosage unit described
in item (aa), the type of
dispensing channel used, such
as retail, mail order, or
specialty pharmacy;
``(III) the wholesale acquisition
cost, listed as cost per days supply
and cost per dosage unit on date of
dispensing;
``(IV) the total out-of-pocket
spending by participants and
beneficiaries on such drug after
application of any benefits under such
plan or coverage, including participant
and beneficiary spending through
copayments, coinsurance, and
deductibles (but not including any
amounts spent by participants and
beneficiaries on drugs not covered
under such plan or coverage, or for
which no claim was submitted to such
plan or coverage);
``(V) for any drug for which gross
spending of the plan or coverage
exceeded $10,000 during the reporting
period--
``(aa) a list of all other
drugs in the same therapeutic
category or class, including
brand name drugs, biological
products, generic drugs, or
biosimilar biological products
that are in the same
therapeutic category or class
as such drug; and
``(bb) the rationale for
preferred formulary placement
of such drug in that
therapeutic category or class,
if applicable; and
``(ii) a list of each therapeutic category or
class of drugs for which a claim was filed
under the health plan or health insurance
coverage during the reporting period, and, with
respect to each such therapeutic category or
class of drugs during the reporting period--
``(I) total gross spending by the
plan;
``(II) the number of participants and
beneficiaries who filled a prescription
for a drug in that category or class;
``(III) if applicable to that
category or class, a description of the
formulary tiers and utilization
mechanisms (such as prior authorization
or step therapy) employed for drugs in
that category or class;
``(IV) the total out-of-pocket
spending by participants and
beneficiaries, including participant
and beneficiary spending through
copayments, coinsurance, and
deductibles; and
``(V) for each drug--
``(aa) the amount received,
or expected to be received,
from any entity in rebates,
fees, alternative discounts, or
other remuneration--
``(AA) for claims
incurred during the
reporting period; or
``(BB) that is
related to utilization
of drugs or drug
spending;
``(bb) the total net
spending, after deducting
rebates, price concessions,
alternative discounts or other
remuneration from drug
manufacturers, by the health
plan or health insurance
coverage on that category or
class of drugs; and
``(cc) the average net
spending per 30-day supply and
per 90-day supply, incurred by
the health plan or health
insurance coverage and its
participants and beneficiaries,
among all drugs within the
therapeutic class for which a
claim was filed during the
reporting period.
``(2) Privacy requirements.--Health insurance issuers
offering group health insurance coverage and entities providing
pharmacy benefits management services on behalf of a group
health plan shall provide information under paragraph (1) in a
manner consistent with the privacy, security, and breach
notification regulations promulgated under section 264(c) of
the Health Insurance Portability and Accountability Act of
1996, and shall restrict the use and disclosure of such
information according to such privacy regulations.
``(3) Disclosure and redisclosure.--
``(A) Limitation to business associates.--A group
health plan receiving a report under paragraph (1) may
disclose such information only to business associates
of such plan as defined in section 160.103 of title 45,
Code of Federal Regulations (or successor regulations).
``(B) Clarification regarding public disclosure of
information.--Nothing in this section prevents a health
insurance issuer offering group health insurance
coverage or an entity providing pharmacy benefits
management services on behalf of a group health plan
from placing reasonable restrictions on the public
disclosure of the information contained in a report
described in paragraph (1), except that such issuer or
entity may not restrict disclosure of such report to
the Department of Health and Human Services, the
Department of Labor, the Department of the Treasury,
the Comptroller General of the United States, or
applicable State agencies.
``(C) Limited form of report.--The Secretary shall
define through rulemaking a limited form of the report
under paragraph (1) required of plan administrators who
are drug manufacturers, drug wholesalers, or other
direct participants in the drug supply chain, in order
to prevent anti-competitive behavior.
``(4) Report to gao.--A health insurance issuer offering
group health insurance coverage or an entity providing pharmacy
benefits management services on behalf of a group health plan
shall submit to the Comptroller General of the United States
each of the first 4 reports submitted to a plan administrator
under paragraph (1) with respect to such coverage or plan, and
other such reports as requested, in accordance with the privacy
requirements under paragraph (2), the disclosure and
redisclosure standards under paragraph (3), the standards
specified pursuant to paragraph (5).
``(5) Standard format.--Not later than 6 months after the
date of enactment of this section, the Secretary shall specify
through rulemaking standards for health insurance issuers and
entities required to submit reports under paragraph (4) to
submit such reports in a standard format.
``(c) Enforcement.--
``(1) Failure to provide timely information.--An entity
providing pharmacy benefits management services that violates
subsection (a) or fails to provide information required under
subsection (b) shall be subject to a civil monetary penalty in
the amount of $10,000 for each day during which such violation
continues or such information is not disclosed or reported.
``(2) False information.--An entity providing pharmacy
benefits management services that knowingly provides false
information under this section shall be subject to a civil
money penalty in an amount not to exceed $100,000 for each item
of false information. Such civil money penalty shall be in
addition to other penalties as may be prescribed by law.
``(3) Procedure.--The provisions of section 1128A of the
Social Security Act, other than subsection (a) and (b) and the
first sentence of subsection (c)(1) of such section shall apply
to civil monetary penalties under this subsection in the same
manner as such provisions apply to a penalty or proceeding
under section 1128A of the Social Security Act.
``(4) Waivers.--The Secretary may waive penalties under
paragraph (2), or extend the period of time for compliance with
a requirement of this section, for an entity in violation of
this section that has made a good-faith effort to comply with
this section.
``(d) Rule of Construction.--Nothing in this section shall be
construed to permit a health insurance issuer, group health plan, or
other entity to restrict disclosure to, or otherwise limit the access
of, the Department of Health and Human Services to a report described
in subsection (b)(1) or information related to compliance with
subsection (a) by such issuer, plan, or entity.
``(e) Definitions.--In this section:
``(1) Large employer.--The term `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.''.
(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 new section:
``SEC. 9826. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.
``(a) In General.--For plan years beginning on or after January 1,
2025, a group health plan or an entity or subsidiary providing pharmacy
benefits management services on behalf of such a plan may not enter
into a contract with a drug manufacturer, distributor, wholesaler,
switch, patient or copay assistance program administrator, pharmacy,
subcontractor, rebate aggregator, or any associated third party that
limits or delays the disclosure of information to plan administrators
in such a manner that prevents the plan, or an entity or subsidiary
providing pharmacy benefits management services on behalf of a plan,
from making or substantiating the reports described in subsection (b).
``(b) Reports.--
``(1) In general.--For plan years beginning on or after
January 1, 2025, not less frequently than quarterly (and upon
request by the plan administrator), a group health plan, or an
entity providing pharmacy benefits management services on
behalf of a group health plan, shall submit to the plan
administrator (as defined in section 3(16)(A) of the Employee
Retirement Income Security Act of 1974) of such plan a report
in accordance with this subsection, and make such report
available to the plan administrator in a machine-readable
format (or as may be determined by the Secretary, other
formats). Each such report shall include, with respect to the
applicable group health plan--
``(A) information collected from a patient or copay
assistance program administrator by such entity on the
total amount of copayment assistance dollars paid, or
copayment cards applied, or other discounts that were
funded by the drug manufacturer with respect to the
participants and beneficiaries in such plan;
``(B) total gross spending on prescription drugs by
the plan during the reporting period;
``(C) total amount received, or expected to be
received, by the plan from any entities, in rebates,
fees, alternative discounts, and all other remuneration
received from the entity or any third party (including
group purchasing organizations) other than the plan
administrator, related to utilization of drug or drug
spending under such plan during the reporting period;
``(D) the total net spending on prescription drugs by
the plan during such reporting period;
``(E) 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 of 1974) to
brokerage houses, brokers, consultants, advisors, or
any other individual or firm for the referral of the
group health plan's business to the pharmacy benefits
manager, identified by the recipient of such amounts;
``(F)(i) an explanation of any benefit design
parameters that encourage or require participants and
beneficiaries in the 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 funded
by an entity providing pharmacy benefit management
services;
``(ii) the percentage of total prescriptions
charged to the plan, or participants and
beneficiaries in such plan, that were dispensed
by mail order, specialty, or retail pharmacies
that are affiliated with or under common
ownership with the entity providing pharmacy
benefit management services; and
``(iii) a list of all drugs dispensed by such
affiliated pharmacy or pharmacy under common
ownership and charged to the plan, or
participants and beneficiaries of the plan,
during the applicable period, and, with respect
to each drug--
``(I)(aa) the amount charged, per
dosage unit, per 30-day supply, and per
90-day supply, with respect to
participants and beneficiaries in the
plan, to the plan; and
``(bb) the amount charged,
per dosage unit, per 30-day
supply, and per 90-day supply,
to participants and
beneficiaries;
``(II) the median amount charged to
the plan, per dosage unit, per 30-day
supply, and per 90-day supply,
including amounts paid by the
participants and beneficiaries, 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;
``(III) the interquartile range of
the costs, per dosage unit, per 30-day
supply, and per 90-day supply,
including amounts paid by the
participants and beneficiaries, 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 that plan;
``(IV) the lowest cost, per dosage
unit, per 30-day supply, and per 90-day
supply, for such drug, including
amounts charged to the plan and
participants and beneficiaries, that is
available from any pharmacy included in
the network of the plan;
``(V) the net acquisition cost per
dosage unit, per 30-day supply, and per
90-day supply, if the drug is subject
to a maximum price discount; and
``(VI) other information with respect
to the cost of the drug, as determined
by the Secretary, such as average sales
price, wholesale acquisition cost, and
national average drug acquisition cost
per dosage unit or per 30-day supply,
and per-90 day supply, for such drug,
including amounts charged to the plan
and participants and beneficiaries
among all pharmacies included in the
network of such plan; and
``(G) in the case of a large employer--
``(i) a list of each drug covered by such
plan or entity providing pharmacy benefits
management services for which a claim was filed
during the reporting period, including, with
respect to each such drug during the reporting
period--
``(I) the brand name, generic or non-
proprietary name, and the National Drug
Code;
``(II)(aa) the number of participants
and beneficiaries for whom a claim for
such drug was filed during the
reporting period, the total number of
prescription claims for such drug
(including original prescriptions and
refills), and the total number of
dosage units and total days supply of
such drug for which a claim was filed
during the reporting period; and
``(bb) with respect to each
claim or dosage unit described
in item (aa), the type of
dispensing channel used, such
as retail, mail order, or
specialty pharmacy;
``(III) the wholesale acquisition
cost, listed as cost per days supply
and cost per dosage unit on date of
dispensing;
``(IV) the total out-of-pocket
spending by participants and
beneficiaries on such drug after
application of any benefits under such
plan, including participant and
beneficiary spending through
copayments, coinsurance, and
deductibles (but not including any
amounts spent by participants and
beneficiaries on drugs not covered
under such plan, or for which no claim
was submitted to such plan);
``(V) for any drug for which gross
spending of the plan exceeded $10,000
during the reporting period--
``(aa) a list of all other
drugs in the same therapeutic
category or class, including
brand name drugs, biological
products, generic drugs, or
biosimilar biological products
that are in the same
therapeutic category or class
as such drug; and
``(bb) the rationale for
preferred formulary placement
of such drug in that
therapeutic category or class,
if applicable; and
``(ii) a list of each therapeutic category or
class of drugs for which a claim was filed
under the plan during the reporting period,
and, with respect to each such therapeutic
category or class of drugs during the reporting
period--
``(I) total gross spending by the
plan;
``(II) the number of participants and
beneficiaries who filled a prescription
for a drug in that category or class;
``(III) if applicable to that
category or class, a description of the
formulary tiers and utilization
mechanisms (such as prior authorization
or step therapy) employed for drugs in
that category or class;
``(IV) the total out-of-pocket
spending by participants and
beneficiaries, including participant
and beneficiary spending through
copayments, coinsurance, and
deductibles; and
``(V) for each drug--
``(aa) the amount received,
or expected to be received,
from any entity in rebates,
fees, alternative discounts, or
other remuneration--
``(AA) for claims
incurred during the
reporting period; or
``(BB) that is
related to utilization
of drugs or drug
spending;
``(bb) the total net
spending, after deducting
rebates, price concessions,
alternative discounts or other
remuneration from drug
manufacturers, by the plan on
that category or class of
drugs; and
``(cc) the average net
spending per 30-day supply and
per 90-day supply, incurred by
the plan and its participants
and beneficiaries, among all
drugs within the therapeutic
class for which a claim was
filed during the reporting
period.
``(2) Privacy requirements.--Entities providing pharmacy
benefits management services on behalf of a group health plan
shall provide information under paragraph (1) in a manner
consistent with the privacy, security, and breach notification
regulations promulgated under section 264(c) of the Health
Insurance Portability and Accountability Act of 1996, and shall
restrict the use and disclosure of such information according
to such privacy regulations.
``(3) Disclosure and redisclosure.--
``(A) Limitation to business associates.--A group
health plan receiving a report under paragraph (1) may
disclose such information only to business associates
of such plan as defined in section 160.103 of title 45,
Code of Federal Regulations (or successor regulations).
``(B) Clarification regarding public disclosure of
information.--Nothing in this section prevents an
entity providing pharmacy benefits management services
on behalf of a group health plan from placing
reasonable restrictions on the public disclosure of the
information contained in a report described in
paragraph (1), except that such entity may not restrict
disclosure of such report to the Department of Health
and Human Services, the Department of Labor, the
Department of the Treasury, the Comptroller General of
the United States, or applicable State agencies.
``(C) Limited form of report.--The Secretary shall
define through rulemaking a limited form of the report
under paragraph (1) required of plan administrators who
are drug manufacturers, drug wholesalers, or other
direct participants in the drug supply chain, in order
to prevent anti-competitive behavior.
``(4) Report to gao.--An entity providing pharmacy benefits
management services on behalf of a group health plan shall
submit to the Comptroller General of the United States each of
the first 4 reports submitted to a plan administrator under
paragraph (1) with respect to such plan, and other such reports
as requested, in accordance with the privacy requirements under
paragraph (2), the disclosure and redisclosure standards under
paragraph (3), the standards specified pursuant to paragraph
(5).
``(5) Standard format.--Not later than 6 months after the
date of enactment of this section, the Secretary shall specify
through rulemaking standards for entities required to submit
reports under paragraph (4) to submit such reports in a
standard format.
``(c) Enforcement.--
``(1) Failure to provide timely information.--An entity
providing pharmacy benefits management services that violates
subsection (a) or fails to provide information required under
subsection (b) shall be subject to a civil monetary penalty in
the amount of $10,000 for each day during which such violation
continues or such information is not disclosed or reported.
``(2) False information.--An entity providing pharmacy
benefits management services that knowingly provides false
information under this section shall be subject to a civil
money penalty in an amount not to exceed $100,000 for each item
of false information. Such civil money penalty shall be in
addition to other penalties as may be prescribed by law.
``(3) Procedure.--The provisions of section 1128A of the
Social Security Act, other than subsection (a) and (b) and the
first sentence of subsection (c)(1) of such section shall apply
to civil monetary penalties under this subsection in the same
manner as such provisions apply to a penalty or proceeding
under section 1128A of the Social Security Act.
``(4) Waivers.--The Secretary may waive penalties under
paragraph (2), or extend the period of time for compliance with
a requirement of this section, for an entity in violation of
this section that has made a good-faith effort to comply with
this section.
``(d) Rule of Construction.--Nothing in this section shall be
construed to permit a group health plan, or other entity to restrict
disclosure to, or otherwise limit the access of, the Department of the
Treasury to a report described in subsection (b)(1) or information
related to compliance with subsection (a) by such plan or entity.
``(e) Definitions.--In this section:
``(1) Large employer.--The term `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.''.
(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.''.
SEC. 4. INFORMATION ON PRESCRIPTION DRUGS.
(a) 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 3, 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 of 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 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 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 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.''.
(b) 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 3, is further amended by inserting after
the item relating to section 726 the following new item:
``Sec. 727. Information on prescription drugs.''.
SEC. 5. ADVISORY COMMITTEE ON THE ACCESSIBILITY OF CERTAIN INFORMATION.
(a) In General.--Not later than January 1, 2025, the Secretary of
Labor (in this section referred to as the ``Secretary'') shall convene
an Advisory Committee (in this section referred to as the
``Committee'') consisting of 9 members to advise the Secretary on how
to improve the accessibility and usability of information made
available in accordance the amendments made by section 3 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 such information fully meets the needs of employers, patients,
researchers, regulators, and purchasers.
(b) Membership.--The Secretary shall 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 established under this section shall
terminate on January 1, 2028.
Purpose
H.R. 4507, the Transparency in Coverage Act, amends the
Employee Retirement Income Security Act of 1974 (ERISA)\1\ to
promote group health plan and group health insurance coverage
price transparency. The bill codifies and strengthens the final
rule titled ``Transparency in Coverage'' (TiC),\2\ which
requires plans and issuers to disclose pricing and cost-sharing
information to participants and beneficiaries and to make
payment rate data public. The bill also prevents plans from
contracting with Pharmacy Benefit Managers (PBMs) unless PBMs
report certain information to plan administrators.
---------------------------------------------------------------------------
\1\29 U.S.C. Sec. 1001 et seq.
\2\Transparency in Coverage, 85 Fed. Reg. 72,158 (Nov. 12, 2020).
---------------------------------------------------------------------------
Committee Action
116TH CONGRESS
Subcommittee Hearing on Examining Surprise Billing: Protecting
Patients from Financial Pain
On April 2, 2019, the Subcommittee on Health, Employment,
Labor, and Pensions (HELP) held a hearing entitled ``Examining
Surprise Billing: Protecting Patients from Financial Pain,''
which discussed hospital billing practices, including
unexpected costs to consumers due, in part, to a lack of
transparency in health care. The witnesses were Ms. Ilyse
Schuman, Senior Vice President, Health Policy, American
Benefits Council, Washington, D.C.; Dr. Jack Hoadley, Research
Professor Emeritus, Health Policy Institute, Georgetown
University McCourt School of Public Policy, McLean, Virginia;
Mr. Frederick Isasi, Executive Director, Families USA,
Washington, D.C.; and Ms. Christen Linke Young, Fellow, USC
Brookings Schaeffer Initiative on Health Policy, Washington,
D.C. Members and witnesses discussed the need for more
transparency in hospital billing. Witnesses further discussed
the positive impact that increased transparency will have on
boosting competition in health care.
Subcommittee Hearing on Making Health Care More Affordable:
Lowering Drug Prices and Increasing Transparency
On September 26, 2019, the HELP Subcommittee held a hearing
entitled ``Making Health Care More Affordable: Lowering Drug
Prices and Increasing Transparency,'' which examined the impact
of rising prescription drug prices on workers and businesses,
and the need for greater transparency. Members and witnesses
discussed how information on PBMs' price negotiations with drug
manufacturers is not provided to consumers. The witnesses were
Mr. Frederick Isasi, Executive Director, Families USA,
Washington, D.C.; Mr. David Mitchell, Founder, Patients for
Affordable Drugs, Washington, D.C.; Ms. Bari Talente, Executive
Vice President, National Multiple Sclerosis Society,
Washington, D.C.; Dr. Mariana Socal, Assistant Scientist, Johns
Hopkins University Bloomberg School of Public Health,
Department of Health Policy and Management, Baltimore,
Maryland; Mr. Christopher Holt, Director of Health Care Policy,
American Action Forum, Washington, D.C.; and Dr. Craig
Garthwaite, Associate Professor of Strategy, Northwestern
University Kellogg School of Management, Evanston, Illinois.
Full Committee Markup of H.R. 5800, the Ban Surprise Billing Act
On February 11, 2020, the Committee met to mark up H.R.
5800, the Ban Surprise Billing Act. The legislation included
provisions improving transparency with respect to group health
plan service providers, including those providing brokerage and
consulting services. The Committee favorably reported the bill,
as amended, by a vote of 32 yeas and 13 nays.
117TH CONGRESS
Subcommittee Hearing on Lower Drug Costs Now: Expanding Access
to Affordable Health Care
On May 5, 2021, the HELP Subcommittee held a hearing
entitled ``Lower Drug Costs Now: Expanding Access to Affordable
Health Care.'' The witnesses were Dr. Douglas Holtz-Eakin,
President, American Action Forum, Washington, D.C.; Mr.
Frederick Isasi, Executive Director, Families USA, Washington,
D.C.; Mr. David Mitchell, Founder, Patients for Affordable
Drugs, Washington, D.C.; and Dr. Mariana Socal, Assistant
Scientist, Johns Hopkins University Bloomberg School of Public
Health, Baltimore, Maryland. The hearing included a discussion
regarding how the lack of PBM transparency contributes to
higher costs for plans and consumers.
Full Committee Hearing Examining the President's Fiscal Year
2023 Budget Proposal for the Department of Health and
Human Services
On April 6, 2022, the Committee held a hearing entitled
``Examining the Policies and Priorities of the U.S. Department
of Health and Human Services.'' The sole witness was the
Honorable Xavier Becerra, Secretary of the U.S. Department of
Health and Human Services (HHS), Washington, D.C. The lack of
transparency in PBMs' activities and the impacts on health
plans was discussed at the hearing.
118TH CONGRESS
Subcommittee Hearing on Reducing Health Care Costs for Working
Americans and Their Families
On April 26, 2023, the HELP Subcommittee held a hearing
entitled ``Reducing Health Care Costs for Working Americans and
Their Families,'' which examined the need for increased
transparency in health care and lowering costs by expanding
oversight into PBMs. During the hearing, members and witnesses
discussed how a lack of transparency is associated with PBMs
not passing on savings to employer-provided health plans. The
witnesses were Mr. Joel White, President, Council for
Affordable Health Coverage, Washington, D.C.; Mrs. Tracy Watts,
Senior Partner, Mercer, Washington, D.C.; Ms. Marcie Strouse,
Partner, Capitol Benefits Group, Des Moines, Iowa; and Ms.
Sabrina Corlette, J.D., Research Professor and Co-Director,
Center on Health Insurance Reforms, Georgetown University's
McCourt School of Public Policy, Washington, D.C.
Full Committee Hearing Examining the President's Fiscal Year
2024 Budget Proposal for the Department of Health and
Human Services
On June 13, 2023, the Committee held a hearing entitled
``Examining the Policies and Priorities of the U.S. Department
of Health and Human Services.'' The sole witness was the
Honorable Xavier Becerra, Secretary of HHS, Washington, D.C.
Secretary Becerra spoke to the need for improved transparency
of PBMs' activities.
Subcommittee Hearing on Competition and Transparency: The
Pathway Forward for a Stronger Health Care Market
On June 21, 2023, the HELP Subcommittee held a hearing
entitled ``Competition and Transparency: The Pathway Forward
for a Stronger Health Care Market,'' which examined the need to
improve competition and transparency in health care. The
witnesses were Dr. Gloria Sachdev, President and CEO,
Employers' Forum of Indiana, Carmel, Indiana; Ms. Sophia
Tripoli, Senior Director of Health Policy and Director of the
Center for Affordable Whole-Person Care, Families USA,
Washington, D.C.; Mr. Greg Baker, CEO, AffirmedRx, Louisville,
Kentucky; Ms. Christine Monahan, Assistant Research Professor,
Center on Health Insurance Reforms, Georgetown University
Center McCourt School of Public Policy, Washington, D.C.; and
Mr. Juan Carlos ``JC'' Scott, President and CEO, Pharmaceutical
Care Management Association, Washington, D.C.
Full Committee Markup of H.R. 4507, the Transparency in Coverage
Act
On July 10, 2023, Rep. Bob Good (R-VA-5), Chairman of the
HELP Subcommittee, introduced H.R. 4507, the Transparency in
Coverage Act, with Rep. Mark DeSaulnier (D-CA-10), Ranking
Member of the HELP Subcommittee, as an original cosponsor. On
July 12, 2023, the Committee met to mark up H.R. 4507 and The
Committee adopted an Amendment in the Nature of a Substitute
offered by Rep. Good, which made technical changes to H.R.
4507. Rep. Lori Chavez-DeRemer (R-OR-5) offered an amendment to
add the Safe Step Act (H.R. 2630, 118th), legislation requiring
group health plans to offer exceptions to step-therapy
protocols, to the bill. The amendment was withdrawn. The
Committee reported the bill favorably, as amended, to the House
of Representatives by a vote of 38 yeas and 1 nay.
Committee Views
TRANSPARENCY IN COVERAGE
In 2020, the U.S. Departments of Labor, HHS, and the
Treasury (jointly tri-agencies) published a final rule titled
``Transparency in Coverage''\3\ (TiC) requiring that most
health plans and issuers make available to participants and
beneficiaries personalized, out-of-pocket cost information and
the underlying negotiated rates for all covered health care
items and services (including prescription drugs) through an
internet-based self-service tool and in paper form upon
request. The rule also requires that most health plans and
issuers make available to the public three separate machine-
readable files that include detailed pricing information.
---------------------------------------------------------------------------
\3\Transparency in Coverage, 85 Fed. Reg. 72,158 (Nov. 12, 2020).
---------------------------------------------------------------------------
While parts of the TiC rule were slated to go into effect
on January 1, 2022, the tri-agencies delayed some
implementation deadlines by six months.\4\ On July 1, 2022, the
Centers for Medicare and Medicaid Services (CMS) within HHS
began enforcing the requirement that health plans publicly
disclose the contracted prices they pay their in-network health
care providers and the allowed amounts they will pay out-of-
network providers. Beginning January 1, 2023, health plans were
required to create a tool for their enrollees to receive real-
time, personalized estimates of potential cost-sharing
liability for 500 designated items and services. As of January
1, 2024, the cost-sharing tool must provide the same
information for all covered items and services.\5\ Noncompliant
payers may face fines of up to $100 per day for each violation
and for each individual affected.
---------------------------------------------------------------------------
\4\https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-
activities/resource-center/faqs/aca-part-49.pdf.
\5\Id.
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In August 2021, the U.S. Chamber of Commerce and the
Pharmaceutical Care Management Association (PCMA) filed
lawsuits challenging the requirement that PBMs must report the
historical net price of prescription drugs. The lawsuits argued
that federal officials could not require the disclosure of
historical net price information.\6\ These organizations
withdrew their lawsuits after the tri-agencies issued guidance
deferring enforcement of the drug-price transparency provisions
pending further rulemaking.\7\
---------------------------------------------------------------------------
\6\https://www.healthaffairs.org/content/forefront/two-new-
lawsuits-challenge-insurer-transparency-rule.
\7\https://news.bloomberglaw.com/health-law-and-business/end-delay-
of-drug-price-transparency-rule-employer-group-urges.
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Experts have identified ways to build on the TiC rule to
make data more accessible and user-friendly and to improve
compliance. A recent report found that many of the uploaded
data files are too large to access and the data as presented is
challenging to understand.\8\ The TiC rule preamble discusses
the benefits of standardizing the data for the use of
standards-based application programming interface (API) to
improve access and plan compliance. Access to pricing
information through an API could have a number of benefits for
consumers, employers, and providers, including providing real-
time access to pricing information, providing access to
personalized actionable health care price estimates through an
application of the consumer's choice, and enabling third-party
developers to develop internet-based self-service tools.\9\
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\8\https://georgetown.app.box.com/s/
1ezsggz1c7smsaexkr8rght15sokgusl.
\9\Transparency in Coverage, 85 Fed. Reg. 72,158 (Nov. 12, 2020).
---------------------------------------------------------------------------
TiC reporting requirements are geared towards fee-for-
service reporting and fail to capture prices fully from value-
based arrangements (VBAs). The Transparency in Coverage Act
addresses this shortcoming.
PHARMACY BENEFIT MANAGER REPORTING
PBMs serve as intermediaries between pharmaceutical
manufacturers and health insurers, Medicare Part D drug plans,
employers, and other payers. PBMs create formularies, negotiate
rebates with manufacturers, process claims, create pharmacy
networks, and review drug utilization. The Congressional Budget
Office (CBO) found that PBMs' ability to negotiate larger
rebates from manufacturers has helped lower governmental costs
and copays for plan enrollees.\10\ However, in light of rising
health care costs, PBMs have faced growing scrutiny for their
role in prescription drug costs and spending.
---------------------------------------------------------------------------
\10\https://www.cbo.gov/system/files/2019-05/55151-
SupplementalMaterial.pdf.
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By negotiating with drug manufacturers and pharmacies to
control costs, PBMs have a significant behind-the-scenes impact
in determining total drug costs for insurers, shaping patients'
access to medications, and determining how much pharmacies are
paid. PBMs primarily earn profits through administrative fees
charged for their services, spread pricing, and shared savings,
where the PBM keeps part of the rebates or discounts negotiated
with drug manufacturers. There has been increasing concern that
the current structure creates a perverse incentive as higher
list prices for drugs often translate into higher compensation
for PBMs. Policymakers have also raised concerns that patients
lack adequate line of sight into the financial flows and
incentives that inform pricing.\11\
---------------------------------------------------------------------------
\11\https://oversight.house.gov/wp-content/uploads/2021/12/PBM-
Report-12102021.pdf.
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Three PBMs--CVS Caremark, Express Scripts, and OptumRx--
account for nearly 90 percent of the market.\12\ While some
have argued that this consolidation increases the bargaining
power of PBMs relative to drug manufacturers, others have
raised concerns that less competition among PBMs reduces
competitive pressures and may allow them to earn higher profits
than they would in a more competitive market.
---------------------------------------------------------------------------
\12\https://content.naic.org/cipr-topics/pharmacy-benefit-managers.
---------------------------------------------------------------------------
PBMs have also come under scrutiny for vertically
integrating with health insurers and pharmacies. The three
largest PBMs are each vertically integrated with a major health
insurer--CVS Caremark with Aetna, Express Scripts with Cigna,
and OptumRx with UnitedHealth Group. In its 2023 Report to
Congress, the Medicare Payment Advisory Committee (MedPAC)
warns that these large PBMs may have conflicting interests
among their integrated entities.\13\ The Federal Trade
Commission is currently studying the effects of vertical
integration on access to prescription drugs.\14\
---------------------------------------------------------------------------
\13\https://www.medpac.gov/wp-content/uploads/2023/03/
Mar23_MedPAC_Report_To_
Congress_SEC.pdf.
\14\https://www.ftc.gov/news-events/news/press-releases/2022/06/
ftc-launches-inquiry-prescription-drug-middlemen-industry.
---------------------------------------------------------------------------
PBM reimbursement methods can be complex and unclear. Two
practices of particular concern are rebate pricing models and
spread pricing. For certain prescriptions, PBMs receive rebates
and discounts from pharmaceutical companies in exchange for
formulary placement. One study found a direct correlation
between rebate increases and manufacturer price increases: a $1
increase in rebates corresponds with a $1.17 increase in drug
list price, suggesting that rebates play a role in increasing
list prices.\15\ PBMs may retain manufacturer rebates as
profits rather than passing them through to their health plan
clients. When health plans lack full transparency and cannot
see how much manufacturers paid in rebates, they do not know
how much their PBM retained as profits.
---------------------------------------------------------------------------
\15\https://healthpolicy.usc.edu/research/the-association-between-
drug-rebates-and-list-prices/.
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Spread pricing occurs when PBMs charge health plans and
payers more for a prescription drug than what they reimburse to
the pharmacy and then keep the difference. Because neither the
plan nor the pharmacy knows what the other side was paid or
charged, the practice hides the PBM's margins. State auditors
have found PBMs overcharging Medicaid programs by more than
$415 million in Ohio, Kentucky, Illinois, and Arkansas.
Allegations of overcharging were settled in Kansas for $27.6
million, New Hampshire for $21.2 million, and New Mexico for
$13.7 million.\16\
---------------------------------------------------------------------------
\16\https://oversight.house.gov/wp-content/uploads/2023/03/Letter-
to-CMS.pdf.
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In the 116th Congress, S. 1895, the Lower Health Care Costs
Act of 2019, was a bipartisan bill reported by the Senate
Committee on Health, Education, Labor, and Pensions. It would
have required PBMs to provide quarterly reports to plan
sponsors with detailed data on prescription drug spending,
including the acquisition cost of drugs, total out-of-pocket
spending, a formulary placement rationale, and aggregate rebate
information. CBO estimated that subsequent iterations of this
legislation would save the federal government $2.2 billion over
the 10-year budgetary window.\17\
---------------------------------------------------------------------------
\17\https://www.cbo.gov/system/files/2022-06/hr7666.pdf.
---------------------------------------------------------------------------
During the HELP Subcommittee's June 21, 2023, hearing on
``Competition and Transparency: The Pathway Forward for a
Stronger Health Care Market,'' Ms. Monahan spoke in support of
codifying the Transparency in Coverage rule.\18\ Mr. Baker, Ms.
Monahan, Ms. Tripoli, and Dr. Sachdev each expressed support
for increased PBM transparency.\19\
---------------------------------------------------------------------------
\18\https://www.congress.gov/118/meeting/house/116125/witnesses/
HHRG-118-ED02-Wstate-MonahanC-20230621.pdf.
\19\https://www.congress.gov/118/meeting/house/116125/witnesses/
HHRG-118-ED02-Wstate-MonahanC-20230621.pdf; https://www.congress.gov/
118/meeting/house/116125/witnesses/HHRG-118-ED02-Wstate-SachdevG-
20230621.pdf; https://www.congress.gov/118/meeting/house/116125/
witnesses/HHRG-118-ED02-Wstate-BakerG-20230621.pdf; https://
www.congress.gov/118/meeting/house/116125/witnesses/HHRG-118-ED02-
Wstate-TripoliS-20230621.pdf.
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H.R. 4507, Transparency in Coverage Act
H.R. 4507, the Transparency in Coverage Act, amends ERISA,
the Public Health Service Act (PHSA), and the Internal Revenue
Code (IRC) to promote price transparency in group health plans
and health insurance coverage. The bill codifies the tri-agency
TiC rule, which increased requirements on plans to make pricing
data public and provide information directly to participants
and beneficiaries. The bill also prevents group health plans
from contracting with PBMs unless PBMs report certain payment
information to plan administrators.\20\
---------------------------------------------------------------------------
\20\H.R. 4507 allows for the submission of certain information in
lieu of a dollar amount in limited circumstances. This is intended to
fill gaps in current TiC rule data by addressing value-based payment
models that may not be expressed in a dollar amount. As acknowledged by
the Chairwoman and Ranking Member during a brief colloquy during the
markup, the intent of this provision is not to undermine any existing
requirement of the TiC rule or allow entities to evade transparency
requirements.
---------------------------------------------------------------------------
H.R. 4507 builds off the important work of the TiC rule.
Codifying the rule will give employers, plans, and other health
care stakeholders certainty over their future reporting
obligations. The bill makes improvements to the usability of
the data required to be reported by streamlining the machine-
readable files that plans and issuers must upload to ensure
they are not overwhelmed by duplicative information and
ensuring that data is reported in dollars so that enrollees can
know with certainty the amount they are expected to pay for
services. The bill further requires PBMs to report information
on their prescription drug spending and provide quarterly
reports to plan administrators, giving plan administrators the
information needed to weigh the value that their respective PBM
provides to their plans. Each of these steps will make health
care pricing more transparent, leading to more informed
purchasing choices, better outcomes, and lower spending.
H.R. 4507 Section-by-Section Summary
Section 1. Short title
Section 1 provides that the short title is ``Transparency
in Coverage Act.''
Section 2. Promoting group health plan and group health insurance
coverage price transparency
Section 2 amends ERISA Section 719, IRC Section 9819, and
PHSA Section 2799A-4 to codify the TiC rule. The amendments to
ERISA Section 719 (a)-(c)(1) restate portions of current law
from Section 1311(e)(3) of the Affordable Care Act (ACA) with
respect to requirements to make certain information publicly
available. The TiC rule cites ACA Section 1311(e)(3) as its
statutory authority. By including ACA Section 1311(e)(3) in
ERISA, the Committee continues its efforts to reorganize the
U.S. Code to ensure that ACA provisions governing group health
plans are included in ERISA.
Codification of TiC. Section 2 of H.R. 4507 amends ERISA
Section 719, IRC Section 9819, and PHSA Section 2799A-4 to
codify the TiC rule. Section 2 requires that all plans report
on the following: the in-network rate for all items and
services; the out-of-network maximum allowed amount for all
items and services; the estimated amount of cost-sharing that a
participant or beneficiary will incur for these items and
services; the amount the participant or beneficiary has
accumulated towards his or her out-of-pocket costs; any shared
savings available to the participant or beneficiary; volume
restrictions the plan places on items or services; and any
coverage restrictions the plan places on items or services
(such as prior authorization).
Section 2 codifies TiC's self-service tool, which requires
plans to create a virtual tool that provides real-time
responses to the data requests by a beneficiary. This tool
allows a beneficiary to look up cost information regarding
items and services by billing code or through a description.
Provider Tool. Section 2 creates a provider-facing self-
service tool, which allows a provider (with the permission of
the participant or beneficiary) to look up the cost-sharing for
items and services. The plan and provider may use this tool to
create a good faith estimate or advanced explanation of
benefits.
Rate and Payment Information. Section 2 outlines the
standards by which the rate and payment information must be
reported. It codifies the rate and payment reporting
requirements in the TiC rule, requires plans to report on
prescription drug costs, and ensures improvements to this
reporting. The improvements are as follows:
1. Prices must be reported in dollar amounts. Currently,
plans report prices based on a percentage or use other metrics
for measuring costs, which causes confusion when comparing
costs to other plans. When a dollar amount cannot be used (as
in a value-based arrangement), the plan must include the
formulae, pricing methodology, or other information used to
calculate the rate.
2. Plans must include the dosage form and indication for
each drug reported. This allows data users to measure the costs
of drugs across plans.
3. Plans must report costs for value-based arrangements and
bundled payments.
Machine-Readable Files. Section 2 requires that plans
upload information publicly in three machine-readable files: an
in-network file, an out-of-network file, and a prescription-
drug file. The Secretaries of Labor, Health and Human Services,
and the Treasury (jointly Secretaries) must limit the size of
the file and ensure it does not include duplicative information
and that the data in the files can be compared across health
plans and coverage.
Application Program Interface. Section 2 requires that
plans and issuers make information available via application
program interface (API) beginning January 1, 2026. This will
improve the standardization and usability of the data and will
allow third-party developers instant access to TiC data. Third-
party developers will be able to create cost-comparing tools
for patients, providers, employers, academics, and other
entities, which will improve the shoppability of health care
services and coverage options. Section 2 includes a small-plan
exemption for plans with fewer than 500 beneficiaries.
User Guide and Annual Summary. Section 2 directs the
Secretaries to create standards by which plans must produce
user guides for machine-readable files. The user guides must
explain to individuals how to search for information in the
files. Section 2 also directs plans to create an annual summary
of the machine-readable files.
Attestation. Section 2 requires health plans to submit an
annual attestation to the Secretaries that they are in
compliance with the requirements of the Transparency in
Coverage Act and provide links to machine-readable files.
Report to Congress. Section 2 directs the Secretary of
Labor to submit a report to Congress recommending legislative
and regulatory actions to incorporate metrics for assessing and
comparing quality of care into published data. The Secretary is
also directed to create additional reports assessing the
differences in commercially negotiated prices across different
markets.
Section 3. PBM reports to plan administrators
Oversight of PBMs. Section 3 amends ERISA, the PHSA, and
the IRC to disallow group health plans from contracting with
PBMs and other entities unless the PBMs report the following
information to plan administrators on a quarterly basis:
The total amount of copayment assistance dollars
paid, copayment cards applied, or other discounts applied,
which were funded by drug manufacturers;
Total gross spending on prescription drugs by the
plan;
Total amount received or expected to be received
by the plan in rebates, fees, and alternative discounts, and
all other remuneration received from a third party related to
the utilization of a drug;
Total net spending on prescription drugs;
Amounts paid in rebates, fees, and other types of
compensation to entities for the referral of the group health
plan's business to the PBM; and
An explanation of any benefit design that
encourages or requires a participant to fill prescriptions at
mail-order, specialty, or PBM-owned pharmacies; the percentage
of total prescriptions charged to the plan that were dispensed
by these pharmacies; and a list and cost information with
respect to all drugs dispensed by PBM-owned pharmacies.
The following reporting requirements apply only to plans
serving large employers (over 50 employees):
A list of each covered drug for which a claim was
filed. The list must include the name of the drug, the number
of participants or beneficiaries for whom a claim was filed,
the total number of prescription claims, the total number of
dosage units, and the total days' supply. The list must include
the type of dispensing channel used (e.g., retail, mail, or
specialty), the wholesale acquisition costs, and the total out-
of-pocket spending by participants or beneficiaries on such
drugs.
For any drug where the gross spending of the plan
exceeds $10,000, the following must be reported:
A list of all other drugs in the same
therapeutic category or class and the rationale for the
preferred formulary placement of the drug.
A list of each therapeutic category or
class of drugs for which a claim was filed and the
total gross spending by the plan, the number of
participants or beneficiaries who filled a prescription
for a drug in that category, a description of the
formulary tiers and utilization mechanisms, and the
total out-of-pocket spending by participants or
beneficiaries.
For each drug, the amount received or
expected to be received in rebates, fees, or other
remuneration; the total net spending by the plan on
that category or class of drugs; and the average net
spending per 30-day supply and 90-day supply.
Privacy Requirements. Section 3 reaffirms that all the
information provided in the required reports abides by the
privacy, security, and breach notification regulations under
the Health Insurance Portability and Accountability Act of 1996
(HIPAA).
Disclosure and Redisclosure Requirements. Section 3
includes safeguards to protect against anticompetitive
behavior.
GAO Report. Section 3 requires PBMs to submit their first
four reports to the Government Accountability Office (GAO).
Standard Format. Section 3 requires the Secretaries to
specify reporting standards not later than 6 months after
enactment of the Act.
Enforcement. Section 3 authorizes the Secretaries to levy
civil monetary penalties of up to $10,000 per day for each
violation for each day and of up to $100,000 for each instance
of knowing submission of false information.
Section 4. Information on prescription drugs
Section 4 amends ERISA to prohibit group health plans and
issuers offering group health insurance coverage from entering
into contracts that restrict pharmacies from informing
participants and beneficiaries that out-of-pockets costs may be
lower without using their health plan or coverage. Section 2729
of the PHSA establishes similar requirements with respect to
issuers and state and local government health plans but has not
been enacted in ERISA.
Section 5. Advisory committee on the accessibility of certain
information
Section 5 requires the Secretary of Labor to convene an
Advisory Committee to make recommendations to improve the
accessibility and usability of published information,
streamline reporting, and ensure that such information fully
meets the needs of stakeholders.
The Advisory Committee shall convene not later than January
1, 2025, and terminate on January 1, 2028.
Explanation of Amendments
The amendments, including the amendment in the nature of a
substitute, are explained in the body of this report.
Application of Law to the Legislative Branch
Section 102(b)3 of Public Law 104-1 requires a description
of the application of this bill to the legislative branch. H.R.
4507 takes important steps to increase transparency that will
benefit health care consumers--including access for any
eligible employees of the Legislative Branch--by improving
transparency of coverage and prescription drug spending in
health care plans for which employees of the Legislative Branch
are enrolled.
Statement of General Performance Goals and Objectives
The goal of H.R. 4507 is to codify the Transparency in
Coverage final rule and improve PBM reporting requirements.
This is meant to ensure that plans and plan participants and
beneficiaries have the information necessary to make informed
health care purchasing decisions.
Required Committee Hearing and Related Hearings
In compliance with clause 3(c)(6) of rule XIII of the Rules
of the House of Representatives the following hearings held
during the 118th Congress were used to develop or consider H.R.
4507: on April 26, 2023, the HELP Subcommittee held a hearing
entitled ``Reducing Health Care Costs for Working Americans and
Their Families''; on June 13, 2023, the Committee held a
hearing entitled ``Examining the Policies and Priorities of the
U.S. Department of Health and Human Services''; and on June 21,
2023, the HELP Subcommittee held a hearing entitled
``Competition and Transparency: The Pathway Forward for a
Stronger Health Care Market.''
Unfunded Mandate Statement
Pursuant to Section 423 of the Congressional Budget and
Impoundment Control Act of 1974, Pub. L. No. 93-344 (as amended
by Section 101(a)(2) of the Unfunded Mandates Reform Act of
1995, Pub. L. No. 104-4), the Committee adopts as its own the
cost estimate prepared by the Congressional Budget Office (CBO)
pursuant to section 402 of the Congressional Budget and
Impoundment Control Act of 1974.
Earmark Statement
H.R. 4507 does not contain any congressional earmarks,
limited tax benefits, or limited tariff benefits as defined in
clause 9 of rule XXI of the Rules of the House of
Representatives.
Roll Call Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives requires the Committee Report to include for
each record vote on a motion to report the measure or matter
and on any amendments offered to the measure or matter the
total number of votes for and against and the names of the
Members voting for and against.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Duplication of Federal Programs
No provision of H.R. 4507 establishes or reauthorizes a
program of the Federal Government known to be duplicative of
another Federal program, a program that was included in any
report from the Government Accountability Office to Congress
pursuant to section 21 of Public Law 111-139, or a program
related to a program identified in the most recent Catalog of
Federal Domestic Assistance.
Statement of Oversight Findings and Recommendations of
the Committee
In compliance with clause 3(c)(1) of rule XIII and clause
2(b)(1) of rule X of the Rules of the House of Representatives,
the committee's oversight findings and recommendations are
reflected in the body of this report.
New Budget Authority and CBO Cost Estimate
With respect to the requirements of clause 3(c)(2) of rule
XIII of the Rules of the House of Representatives and section
308(a) of the Congressional Budget Act of 1974 and with respect
to requirements of clause 3(c)(3) of rule XIII of the Rules of
the House of Representatives and section 402 of the
Congressional Budget Act of 1974, the Committee requested a
cost estimate from the Congressional Budget Office. The
Committee adopts the following estimate for H.R. 4507 provided
by the Congressional Budget Office to Majority staff via email
on September 12, 2023: ``We have finished the estimate for H.R.
4507 (timestamp 9:49am on July 11, 2023). Across all sections,
we estimate the bill would reduce the deficit by $2.2 billion
over the 2023-2033 budget window. This includes a $2.5 billion
decrease in the deficit for section 3, a $254 million increase
to the deficit for the API requirements included in section 2,
and a $34 million increase to the deficit for the pharmacy gag
clause ban included in section 4. We do not estimate any
further direct spending or revenue effects from H.R. 4507.''
Committee Cost Estimate
Clause 3(d)(1) of rule XIII of the Rules of the House of
Representatives requires an estimate and a comparison of the
costs that would be incurred in carrying out H.R. 4507.
However, clause 3(d)(2)(B) of that rule provides that this
requirement does not apply when, as with the present report,
the committee adopts as its own the cost estimate of the bill
prepared by the Congressional Budget Office under section 402
of the Congressional Budget Act.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italics, and existing law in which no
change is proposed is shown in roman):
EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974
short title and table of contents
Section 1. This Act may be cited as the ``Employee Retirement
Income Security Act of 1974''.
TABLE OF CONTENTS
* * * * * * *
TITLE I--PROTECTION OF EMPLOYEE BENEFIT RIGHTS
* * * * * * *
Subtitle B--Regulatory Provisions
* * * * * * *
Part 7--Group Health Plan Requirements
* * * * * * *
Subpart B--Other Requirements
* * * * * * *
[Sec. 719. Maintenance of price comparison tool.]
Sec. 719. Price transparency requirements.
* * * * * * *
Sec. 726. Oversight of pharmacy benefits manager services.
Sec. 727. Information on prescription drugs.
* * * * * * *
TITLE I--PROTECTION OF EMPLOYEE BENEFIT RIGHTS
* * * * * * *
Subtitle B--Regulatory Provisions
* * * * * * *
Part 5--Administration and Enforcement
* * * * * * *
civil enforcement
Sec. 502. (a) A civil action may be brought--
(1) by a participant or beneficiary--
(A) for the relief provided for in subsection
(c) of this section, or
(B) to recover benefits due to him under the
terms of his plan, to enforce his rights under
the terms of the plan, or to clarify his rights
to future benefits under the terms of the plan;
(2) by the Secretary, or by a participant,
beneficiary or fiduciary for appropriate relief under
section 409;
(3) by a participant, beneficiary, or fiduciary (A)
to enjoin any act or practice which violates any
provision of this title or the terms of the plan, or
(B) to obtain other appropriate equitable relief (i) to
redress such violations or (ii) to enforce any
provisions of this title or the terms of the plan;
(4) by the Secretary, or by a participant, or
beneficiary for appropriate relief in the case of a
violation of section 105(c) or 113(a);
(5) except as otherwise provided in subsection (b),
by the Secretary (A) to enjoin any act or practice
which violates any provision of this title, or (B) to
obtain other appropriate equitable relief (i) to
redress such violation or (ii) to enforce any provision
of this title;
(6) by the Secretary to collect any civil penalty
under paragraph (2), (4), (5), (6), (7), (8), [or (9)]
(9), or (13) of subsection (c) or under subsection (i)
or (l);
(7) by a State to enforce compliance with a qualified
medical child support order (as defined in section
609(a)(2)(A));
(8) by the Secretary, or by an employer or other
person referred to in section 101(f)(1), (A) to enjoin
any act or practice which violates subsection (f) of
section 101, or (B) to obtain appropriate equitable
relief (i) to redress such violation or (ii) to enforce
such subsection;
(9) in the event that the purchase of an insurance
contract or insurance annuity in connection with
termination of an individual's status as a participant
covered under a pension plan with respect to all or any
portion of the participant's pension benefit under such
plan constitutes a violation of part 4 of this title or
the terms of the plan, by the Secretary, by any
individual who was a participant or beneficiary at the
time of the alleged violation, or by a fiduciary, to
obtain appropriate relief, including the posting of
security if necessary, to assure receipt by the
participant or beneficiary of the amounts provided or
to be provided by such insurance contract or annuity,
plus reasonable prejudgment interest on such amounts;
(10) in the case of a multiemployer plan that has
been certified by the actuary to be in endangered or
critical status under section 305, if the plan
sponsor--
(A) has not adopted a funding improvement or
rehabilitation plan under that section by the
deadline established in such section, or
(B) fails to update or comply with the terms
of the funding improvement or rehabilitation
plan in accordance with the requirements of
such section,
by an employer that has an obligation to contribute
with respect to the multiemployer plan or an employee
organization that represents active participants in the
multiemployer plan, for an order compelling the plan
sponsor to adopt a funding improvement or
rehabilitation plan or to update or comply with the
terms of the funding improvement or rehabilitation plan
in accordance with the requirements of such section and
the funding improvement or rehabilitation plan; [or]
(11) in the case of a multiemployer plan, by an
employee representative, or any employer that has an
obligation to contribute to the plan, (A) to enjoin any
act or practice which violates subsection (k) of
section 101 (or, in the case of an employer, subsection
(l) of such section), or (B) to obtain appropriate
equitable relief (i) to redress such violation or (ii)
to enforce such subsection[.]; or
(12) by the Secretary, to enforce section 726.
(b)(1) In the case of a plan which is qualified under section
401(a), 403(a), or 405(a) of the Internal Revenue Code of 1986
(or with respect to which an application to so qualify has been
filed and has not been finally determined) the Secretary may
exercise his authority under subsection (a)(5) with respect to
a violation of, or the enforcement of, parts 2 and 3 of this
subtitle (relating to participation, vesting, and funding),
only if--
(A) requested by the Secretary of the Treasury, or
(B) one or more participants, beneficiaries, or
fiduciaries, of such plan request in writing (in such
manner as the Secretary shall prescribe by regulation)
that he exercise such authority on their behalf. In the
case of such a request under this paragraph he may
exercise such authority only if he determines that such
violation affects, or such enforcement is necessary to
protect, claims of participants or beneficiaries to
benefits under the plan.
(2) The Secretary shall not initiate an action to enforce
section 515.
(3) Except as provided in subsections (c)(9) and (a)(6) (with
respect to collecting civil penalties under subsection (c)(9))
and subsections (a)(12) and (c)(13), the Secretary is not
authorized to enforce under this part any requirement of part 7
against a health insurance issuer offering health insurance
coverage in connection with a group health plan (as defined in
section 706(a)(1)). Nothing in this paragraph shall affect the
authority of the Secretary to issue regulations to carry out
such part.
(c)(1) Any administrator (A) who fails to meet the
requirements of paragraph (1) or (4) of section 606, section
101(e)(1), section 101(f),, section 105(a), or section 113(a)
with respect to a participant or beneficiary, or (B) who fails
or refuses to comply with a request for any information which
such administrator is required by this title to furnish to a
participant or beneficiary (unless such failure or refusal
results from matters reasonably beyond the control of the
administrator) by mailing the material requested to the last
known address of the requesting participant or beneficiary
within 30 days after such request may in the court's discretion
be personally liable to such participant or beneficiary in the
amount of up to $100 a day from the date of such failure or
refusal, and the court may in its discretion order such other
relief as it deems proper. For purposes of this paragraph, each
violation described in subparagraph (A) with respect to any
single participant, and each violation described in
subparagraph (B) with respect to any single participant or
beneficiary, shall be treated as a separate violation.
(2) The Secretary may assess a civil penalty against any plan
administrator of up to $1,000 a day from the date of such plan
administrator's failure or refusal to file the annual report
required to be filed with the Secretary under section
101(b)(1). For purposes of this paragraph, an annual report
that has been rejected under section 104(a)(4) for failure to
provide material information shall not be treated as having
been filed with the Secretary.
(3) Any employer maintaining a plan who fails to meet the
notice requirement of section 101(d) with respect to any
participant or beneficiary or who fails to meet the
requirements of section 101(e)(2) with respect to any person or
who fails to meet the requirements of section 302(d)(12)(E)
with respect to any person may in the court's discretion be
liable to such participant or beneficiary or to such person in
the amount of up to $100 a day from the date of such failure,
and the court may in its discretion order such other relief as
it deems proper.
(4) The Secretary may assess a civil penalty of not more than
$1,000 a day for each violation by any person of subsection
(j), (k), or (l) of section 101 or section 514(e)(3).
(5) The Secretary may assess a civil penalty against any
person of up to $1,000 a day from the date of the person's
failure or refusal to file the information required to be filed
by such person with the Secretary under regulations prescribed
pursuant to section 101(g).
(6) If, within 30 days of a request by the Secretary to a
plan administrator for documents under section 104(a)(6), the
plan administrator fails to furnish the material requested to
the Secretary, the Secretary may assess a civil penalty against
the plan administrator of up to $100 a day from the date of
such failure (but in no event in excess of $1,000 per request).
No penalty shall be imposed under this paragraph for any
failure resulting from matters reasonably beyond the control of
the plan administrator.
(7) The Secretary may assess a civil penalty against a plan
administrator of up to $100 a day from the date of the plan
administrator's failure or refusal to provide notice to
participants and beneficiaries in accordance with subsection
(i) or (m) of section 101. For purposes of this paragraph, each
violation with respect to any single participant or beneficiary
shall be treated as a separate violation.
(8) The Secretary may assess against any plan sponsor
of a multiemployer plan a civil penalty of not more
than $1,100 per day--
(A) for each violation by such sponsor of the
requirement under section 305 to adopt by the
deadline established in that section a funding
improvement plan or rehabilitation plan with
respect to a multiemployer plan which is in
endangered or critical status, or
(B) in the case of a plan in endangered
status which is not in seriously endangered
status, for failure by the plan to meet the
applicable benchmarks under section 305 by the
end of the funding improvement period with
respect to the plan.
(9)(A) The Secretary may assess a civil penalty against any
employer of up to $100 a day from the date of the employer's
failure to meet the notice requirement of section
701(f)(3)(B)(i)(I). For purposes of this subparagraph, each
violation with respect to any single employee shall be treated
as a separate violation.
(B) The Secretary may assess a civil penalty against any plan
administrator of up to $100 a day from the date of the plan
administrator's failure to timely provide to any State the
information required to be disclosed under section
701(f)(3)(B)(ii). For purposes of this subparagraph, each
violation with respect to any single participant or beneficiary
shall be treated as a separate violation.
(10) Secretarial enforcement authority relating to
use of genetic information.--
(A) General rule.--The Secretary may impose a
penalty against any plan sponsor of a group
health plan, or any health insurance issuer
offering health insurance coverage in
connection with the plan, for any failure by
such sponsor or issuer to meet the requirements
of subsection (a)(1)(F), (b)(3), (c), or (d) of
section 702 or section 701 or 702(b)(1) with
respect to genetic information, in connection
with the plan.
(B) Amount.--
(i) In general.--The amount of the
penalty imposed by subparagraph (A)
shall be $100 for each day in the
noncompliance period with respect to
each participant or beneficiary to whom
such failure relates.
(ii) Noncompliance period.--For
purposes of this paragraph, the term
``noncompliance period'' means, with
respect to any failure, the period--
(I) beginning on the date
such failure first occurs; and
(II) ending on the date the
failure is corrected.
(C) Minimum penalties where failure
discovered.--Notwithstanding clauses (i) and
(ii) of subparagraph (D):
(i) In general.--In the case of 1 or
more failures with respect to a
participant or beneficiary--
(I) which are not corrected
before the date on which the
plan receives a notice from the
Secretary of such violation;
and
(II) which occurred or
continued during the period
involved;
the amount of penalty imposed by
subparagraph (A) by reason of such
failures with respect to such
participant or beneficiary shall not be
less than $2,500.
(ii) Higher minimum penalty where
violations are more than de minimis.--
To the extent violations for which any
person is liable under this paragraph
for any year are more than de minimis,
clause (i) shall be applied by
substituting ``$15,000'' for ``$2,500''
with respect to such person.
(D) Limitations.--
(i) Penalty not to apply where
failure not discovered exercising
reasonable diligence.--No penalty shall
be imposed by subparagraph (A) on any
failure during any period for which it
is established to the satisfaction of
the Secretary that the person otherwise
liable for such penalty did not know,
and exercising reasonable diligence
would not have known, that such failure
existed.
(ii) Penalty not to apply to failures
corrected within certain periods.--No
penalty shall be imposed by
subparagraph (A) on any failure if--
(I) such failure was due to
reasonable cause and not to
willful neglect; and
(II) such failure is
corrected during the 30-day
period beginning on the first
date the person otherwise
liable for such penalty knew,
or exercising reasonable
diligence would have known,
that such failure existed.
(iii) Overall limitation for
unintentional failures.--In the case of
failures which are due to reasonable
cause and not to willful neglect, the
penalty imposed by subparagraph (A) for
failures shall not exceed the amount
equal to the lesser of--
(I) 10 percent of the
aggregate amount paid or
incurred by the plan sponsor
(or predecessor plan sponsor)
during the preceding taxable
year for group health plans; or
(II) $500,000.
(E) Waiver by secretary.--In the case of a
failure which is due to reasonable cause and
not to willful neglect, the Secretary may waive
part or all of the penalty imposed by
subparagraph (A) to the extent that the payment
of such penalty would be excessive relative to
the failure involved.
(F) Definitions.--Terms used in this
paragraph which are defined in section 733
shall have the meanings provided such terms in
such section.
(11) The Secretary and the Secretary of Health and Human
Services shall maintain such ongoing consultation as may be
necessary and appropriate to coordinate enforcement under this
subsection with enforcement under section 1144(c)(8) of the
Social Security Act.
(12) The Secretary may assess a civil penalty against
any sponsor of a CSEC plan of up to $100 a day from the
date of the plan sponsor's failure to comply with the
requirements of section 306(j)(3) to establish or
update a funding restoration plan.
(13) Secretarial enforcement authority relating to
oversight of pharmacy benefits manager services.--
(A) Failure to provide timely 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.
(d)(1) An employee benefit plan may sue or be sued under this
title as an entity. Service of summons, subpena, or other legal
process of a court upon a trustee or an administrator of an
employee benefit plan in his capacity as such shall constitute
service upon the employee benefit plan. In a case where a plan
has not designated in the summary plan description of the plan
an individual as agent for the service of legal process,
service upon the Secretary shall constitute such service. The
Secretary, not later than 15 days after receipt of service
under the preceding sentence, shall notify the administrator or
any trustee of the plan of receipt of such service.
(2) Any money judgment under this title against an employee
benefit plan shall be enforceable only against the plan as an
entity and shall not be enforceable against any other person
unless liability against such person is established in his
individual capacity under this title.
(e)(1) Except for actions under subsection (a)(1)(B) of this
section, the district courts of the United States shall have
exclusive jurisdiction of civil actions under this title
brought by the Secretary or by a participant, beneficiary,
fiduciary, or any person referred to in section 101(f)(1).
State courts of competent jurisdiction and district courts of
the United States shall have concurrent jurisdiction of actions
under paragraphs (1)(B) and (7) of subsection (a) of this
section.
(2) Where an action under this title is brought in a district
court of the United States, it may be brought in the district
where the plan is administered, where the breach took place, or
where a defendant resides or may be found, and process may be
served in any other district where a defendant resides or may
be found.
(f) The district courts of the United States shall have
jurisdiction, without respect to the amount in controversy or
the citizenship of the parties, to grant the relief provided
for in subsection (a) of this section in any action.
(g)(1) In any action under this title (other than an action
described in paragraph (2)) by a participant, beneficiary, or
fiduciary, the court in its discretion may allow a reasonable
attorney's fee and costs of action to either party.
(2) In any action under this title by a fiduciary for or on
behalf of a plan to enforce section 515 in which a judgment in
favor of the plan is awarded, the court shall award the plan--
(A) the unpaid contributions,
(B) interest on the unpaid contributions,
(C) an amount equal to the greater of--
(i) interest on the unpaid contributions, or
(ii) liquidated damages provided for under
the plan in an amount not in excess of 20
percent (or such higher percentage as may be
permitted under Federal or State law) of the
amount determined by the court under
subparagraph (A),
(D) reasonable attorney's fees and costs of the
action, to be paid by the defendant, and
(E) such other legal or equitable relief as the court
deems appropriate.
For purposes of this paragraph, interest on unpaid
contributions shall be determined by using the rate provided
under the plan, or, if none, the rate prescribed under section
6621 of the Internal Revenue Code of 1986.
(h) A copy of the complaint in any action under this title by
a participant, beneficiary, or fiduciary (other than an action
brought by one or more participants or beneficiaries under
subsection (a)(1)(B) which is solely for the purpose of
recovering benefits due such participants under the terms of
the plan) shall be served upon the Secretary and the Secretary
of the Treasury by certified mail. Either Secretary shall have
the right in his discretion to intervene in any action, except
that the Secretary of the Treasury may not intervene in any
action under part 4 of this subtitle. If the Secretary brings
an action under subsection (a) on behalf of a participant or
beneficiary, he shall notify the Secretary of the Treasury.
(i) In the case of a transaction prohibited by section 406 by
a party in interest with respect to a plan to which this part
applies, the Secretary may assess a civil penalty against such
party in interest. The amount of such penalty may not exceed 5
percent of the amount involved in each such transaction (as
defined in section 4975(f)(4) of the Internal Revenue Code of
1986) for each year or part thereof during which the prohibited
transaction continues, except that, if the transaction is not
corrected (in such manner as the Secretary shall prescribe in
regulations which shall be consistent with section 4975(f)(5)
of such Code) within 90 days after notice from the Secretary
(or such longer period as the Secretary may permit), such
penalty may be in an amount not more than 100 percent of the
amount involved. This subsection shall not apply to a
transaction with respect to a plan described in section
4975(e)(1) of such Code.
(j) In all civil actions under this title, attorneys
appointed by the Secretary may represent the Secretary (except
as provided in section 518(a) of title 28, United States Code),
but all such litigation shall be subject to the direction and
control of the Attorney General.
(k) Suits by an administrator, fiduciary, participant, or
beneficiary of an employee benefit plan to review a final order
of the Secretary, to restrain the Secretary from taking any
action contrary to the provisions of this Act, or to compel him
to take action required under this title, may be brought in the
district court of the United States for the district where the
plan has its principal office, or in the United States District
Court for the District of Columbia.
(l)(1) In the case of--
(A) any breach of fiduciary responsibility under (or
other violation of) part 4 by a fiduciary, or
(B) any knowing participation in such a breach or
violation by any other person,
the Secretary shall assess a civil penalty against such
fiduciary or other person in an amount equal to 20 percent of
the applicable recovery amount.
(2) For purposes of paragraph (1), the term ``applicable
recovery amount'' means any amount which is recovered from a
fiduciary or other person with respect to a breach or violation
described in paragraph (1)--
(A) pursuant to any settlement agreement with the
Secretary, or
(B) ordered by a court to be paid by such fiduciary
or other person to a plan or its participants and
beneficiaries in a judicial proceeding instituted by
the Secretary under subsection (a)(2) or (a)(5).
(3) The Secretary may, in the Secretary's sole discretion,
waive or reduce the penalty under paragraph (1) if the
Secretary determines in writing that--
(A) the fiduciary or other person acted reasonably
and in good faith, or
(B) it is reasonable to expect that the fiduciary or
other person will not be able to restore all losses to
the plan (or to provide the relief ordered pursuant to
subsection (a)(9)) without severe financial hardship
unless such waiver or reduction is granted.
(4) The penalty imposed on a fiduciary or other person under
this subsection with respect to any transaction shall be
reduced by the amount of any penalty or tax imposed on such
fiduciary or other person with respect to such transaction
under subsection (i) of this section and section 4975 of the
Internal Revenue Code of 1986.
(m) In the case of a distribution to a pension plan
participant or beneficiary in violation of section 206(e) by a
plan fiduciary, the Secretary shall assess a penalty against
such fiduciary in an amount equal to the value of the
distribution. Such penalty shall not exceed $10,000 for each
such distribution.
* * * * * * *
Part 7--Group Health Plan Requirements
* * * * * * *
Subpart B--Other Requirements
* * * * * * *
[SEC. 719. MAINTENANCE OF PRICE COMPARISON TOOL.
[A group health plan or a health insurance issuer offering
group health insurance coverage shall offer price comparison
guidance by telephone and make available on the Internet
website of the plan or issuer a price comparison tool that (to
the extent practicable) allows an individual enrolled under
such plan or coverage, with respect to such plan year, such
geographic region, and participating providers with respect to
such plan or coverage, to compare the amount of cost-sharing
that the individual would be responsible for paying under such
plan or coverage with respect to the furnishing of a specific
item or service by any such provider.]
SEC. 719. PRICE TRANSPARENCY REQUIREMENTS.
(a) In General.--A group health plan, and a health insurance
issuer offering group health insurance coverage, shall make
available to the public accurate and timely disclosures of the
following information:
(1) Claims payment policies and practices.
(2) Periodic financial disclosures.
(3) Data on enrollment.
(4) Data on disenrollment.
(5) Data on the number of claims that are denied.
(6) Data on rating practices.
(7) Information on cost-sharing and payments with
respect to any out-of-network coverage (or with respect
to any item and service furnished under such a plan or
such group health insurance coverage that does not use
a network of providers).
(8) Information on participant and beneficiary rights
under this part.
(9) Rate and payment information described in
subsection (d).
(10) Other information as determined appropriate by
the Secretary.
Rate and payment information described in paragraph (9) shall
be made available to the public not later than January 10,
2025, and not later than the tenth day of every month
thereafter, in the manner described in subsection (d)(2)(A),
and, beginning on January 1, 2027, in real-time through an
application program interface (or successor technology)
described in subsection (d)(2)(B).
(b) Use of Plain Language.--The information required to be
submitted under subsection (a) shall be provided in plain
language. The term ``plain language'' means language that the
intended audience, including individuals with limited English
proficiency, can readily understand and use because that
language is clear, concise, well-organized, accurately
describes the information, and follows other best practices of
plain language writing. The Secretary, jointly with the
Secretary of Health and Human Services and the Secretary of
Labor, shall develop and issue standards for plain language
writing for purposes of this section and shall develop a
standardized reporting template and standardized definitions of
terms to allow for comparison across group health plans and
health insurance coverage.
(c) Cost Sharing Transparency.--
(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance
coverage, shall, upon request of a participant or
beneficiary and in a timely manner, provide to the
participant or beneficiary a statement of the amount of
cost-sharing (including deductibles, copayments, and
coinsurance) under the participant's or beneficiary's
plan or coverage that the participant or beneficiary
would be responsible for paying with respect to the
furnishing of a specific item or service by a provider.
At a minimum, such information shall include the
information specified in paragraph (2) and shall be
made available at no cost to the participant or
beneficiary through a self-service tool that meets the
requirements of paragraph (3) or through a paper or
phone disclosure, at the option of the 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 (as applicable) 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
(f)) for such item or service and for any other
item or service that is inherent in the
furnishing of the item or service that is the
subject of such request.
(B) If such provider is not a participating
provider, the allowed amount, percentage of
billed charges, or other rate 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
billed by such provider.
(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
amount or rate described in such subparagraph
(or, in the case such plan or issuer uses a
percentage of billed charges to determined the
amount of payment for such provider, using a
reasonable estimate of such percentage of such
charges)).
(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) Any shared savings or other benefit
available to the participant or beneficiary
with respect to such item or service.
(F) In the case such plan or coverage imposes
any frequency or volume limitations with
respect to such item or service (excluding
medical necessity determinations), the amount
that such participant or beneficiary has
accrued towards such limitation with respect to
such item or service.
(G) Any prior authorization, concurrent
review, step therapy, fail first, or similar
requirements applicable to coverage of such
item or service under such plan or group health
insurance coverage.
(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, mobile
application, or other platform determined
appropriate 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
accurate at the time such request is made;
(D) allows such a request to be made with
respect to an item or service furnished by--
(i) a specific provider that is a
participating provider with respect to
such item or service;
(ii) all providers that are
participating providers with respect to
such plan and such item or service for
purposes of facilitating price
comparisons; or
(iii) a provider that is not
described in clause (ii); and
(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.
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 items and services.
(4) Provider tool.--A group health plan, and a health
insurance issuer offering group health insurance
coverage, shall permit providers to learn the amount of
cost-sharing (including deductibles, copayments, and
coinsurance) that would apply under an 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 another provider in a
timely manner upon the request of the provider and with
the consent of such individual in the same manner and
to the same extent as if such request has been made by
such individual. As part of any tool used to facilitate
such requests from a provider, such plan or issuer
offering health insurance coverage may include
functionality that--
(A) allows providers to submit the
notifications to such plan or coverage required
under section 2799B-6 of the Public Health
Service Act; and
(B) provides for notifications required under
section 716(f) to such an individual.
(d) Rate and Payment Information.--
(1) In general.--For purposes of subsection (a)(9),
the rate and payment information described in this
subsection is, with respect to a group health plan or
group health insurance coverage (as applicable), the
following:
(A) With respect to each item or service
(other than a drug) for which benefits are
available under such plan or coverage, the in-
network rate (in a dollar amount) in effect as
of the first day of the plan year during which
such information is submitted with each
provider (identified by national provider
identifier) that is a participating provider
with respect to such item or service (or, in
the case such rate is not available in a dollar
amount, such formulae, pricing methodologies,
or other information used to calculate such
rate).
(B) With respect to each dosage form and
indication of each drug (identified by national
drug code) for which benefits are available
under such plan or coverage--
(i) the in-network rate (in a dollar
amount) in effect as of the first day
of the plan year during which such
information is submitted with each
provider (identified by national
provider identifier) that is a
participating provider with respect to
such drug (or, in the case such rate is
not available in a dollar amount, such
formulae, pricing methodologies, or
other information used to calculate
such rate); 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 submission to each
provider that was a participating
provider with respect to such drug,
broken down by each such provider
(identified by national provider
identifier), other than such an amount
paid to a provider that, during such
period, submitted fewer than 20 claims
for such drug to such plan or coverage.
(C) With respect to each item or service for
which benefits are available under such plan or
coverage, the amount billed, and the amount
allowed by the plan or coverage, for each such
item or service furnished during the 90-day
period specified in subparagraph (B) by a
provider that was not a participating provider
with respect to such item or service, broken
down by each such provider (identified by
national provider identifier), other than items
and services with respect to which fewer than
20 claims for such item or service were
submitted to such plan or coverage during such
period.
Such rate and payment information shall be made
available with respect to each individual item or
service, regardless of whether such item or service is
paid for as part of a bundled payment, episode of care,
value-based payment arrangement, or otherwise.
(2) Manner of publication.--
(A) In general.--Rate and payment information
required to be made available under subsection
(a)(9) shall be so made available in dollar
amounts through 3 separate machine-readable
files corresponding to the information
described in each of subparagraphs (A) through
(C) of paragraph (1) that meet such
requirements as specified by the Secretary not
later than 180 days after the date of the
enactment of this paragraph through rulemaking.
Such requirements shall ensure that such files
are limited to an appropriate size, do not
include information that is duplicative of
information contained in the same file or in
other files made available under such
subsection, are made available in a widely-
available format that allows for information
contained in such files to be compared across
group health plans and group health insurance
coverage, and are accessible to individuals at
no cost and without the need to establish a
user account or provide other credentials.
(B) Real-time provision of information.--
(i) In general.--Subject to clause
(ii), beginning January 1, 2026, rate
and payment information required to be
made available by a group health plan
or health insurance issuer under
subsection (a)(9) shall, in addition to
being made available in the manner
described in subparagraph (A), be made
available through an application
program interface (or successor
technology) that provides access to
such information in real time and that
meets such technical standards as may
be specified by the Secretary.
(ii) Exemption for certain plans or
coverage.--Clause (i) shall not apply
with respect to information described
in such clause required to be made
available by a group health plan or
health insurance issuer offering health
insurance coverage if such plan or
coverage, as applicable, provides
benefits for fewer than 500
participants and beneficiaries.
(3) User guide.--The Secretary, Secretary of Health
and Human Services, and Secretary of the Treasury shall
jointly make available to the public instructions
written in plain language explaining how individuals
may search for information described in paragraph (1)
in files submitted in accordance with paragraph (2).
(4) Annual summary.--For each year (beginning with
2025), each group health plan and health insurance
issuer offering group health insurance coverage shall
make public a machine-readable file meeting such
standards as established by the Secretary under
paragraph (2) 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 year
(such as averages of all such information so made
public).
(e) Attestation.--Each group health plan and health insurance
issuer offering group health insurance coverage shall annually
submit to the Secretary an attestation of such plan's or such
coverage's compliance with the provisions of this section along
with a link to disclosures made in accordance with subsection
(a).
(f) Definitions.--In this subsection:
(1) Participating provider.--The term ``participating
provider'' has the meaning given such term in section
716 and includes a participating facility.
(2) In-network rate.--The term ``in-network rate''
means, with respect to a group health plan or group
health insurance coverage and an item or service
furnished by a provider that is a participating
provider with respect to such plan or coverage and item
or service, the contracted rate (reflected as a dollar
amount) in effect between such plan or coverage and
such provider for such item or service.
* * * * * * *
SEC. 726. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.
(a) In General.--For plan years beginning on or after January
1, 2025, a group health plan (or health insurance issuer
offering group health insurance coverage in connection with
such a plan) or an entity or subsidiary providing pharmacy
benefits management services on behalf of such a plan or issuer
may not enter into a contract with a drug manufacturer,
distributor, wholesaler, switch, patient or copay assistance
program administrator, pharmacy, subcontractor, rebate
aggregator, or any associated third party that limits or delays
the disclosure of information to plan administrators in such a
manner that prevents the plan or issuer, or an entity or
subsidiary providing pharmacy benefits management services on
behalf of a plan or issuer, from making or substantiating the
reports described in subsection (b).
(b) Reports.--
(1) In general.--For plan years beginning on or after
January 1, 2025, not less frequently than quarterly
(and upon request by the plan administrator), a group
health plan or health insurance issuer offering group
health insurance coverage, or an entity providing
pharmacy benefits management services on behalf of a
group health plan or an issuer providing group health
insurance coverage, shall submit to the plan
administrator (as defined in section 3(16)(A)) of such
plan or coverage a report in accordance with this
subsection, and make such report available to the plan
administrator in a machine-readable format (or as may
be determined by the Secretary, other formats). Each
such report shall include, with respect to the
applicable group health plan or health insurance
coverage--
(A) information collected from a patient or
copay assistance program administrator by such
entity on the total amount of copayment
assistance dollars paid, or copayment cards
applied, or other discounts that were funded by
the drug manufacturer with respect to the
participants and beneficiaries in such plan or
coverage;
(B) total gross spending on prescription
drugs by the plan or coverage during the
reporting period;
(C) total amount received, or expected to be
received, by the plan or coverage from any
entities, in rebates, fees, alternative
discounts, and all other remuneration received
from the entity or any third party (including
group purchasing organizations) other than the
plan administrator, related to utilization of
drug or drug spending under such plan or
coverage during the reporting period;
(D) the total net spending on prescription
drugs by the plan or coverage during such
reporting period;
(E) 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 brokerage houses,
brokers, consultants, advisors, or any other
individual or firm for the referral of the
group health plan's or health insurance
issuer's business to the pharmacy benefits
manager, identified by the recipient of such
amounts;
(F)(i) an explanation of any benefit design
parameters that encourage or require
participants and beneficiaries in the 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 funded by an entity
providing pharmacy benefit management services;
(ii) the percentage of total
prescriptions charged to the plan,
issuer, or participants and
beneficiaries in such plan or coverage,
that were dispensed by mail order,
specialty, or retail pharmacies that
are affiliated with or under common
ownership with the entity providing
pharmacy benefit management services;
and
(iii) a list of all drugs dispensed
by such affiliated pharmacy or pharmacy
under common ownership and charged to
the plan, issuer, or participants and
beneficiaries of the plan, during the
applicable period, and, with respect to
each drug--
(I)(aa) the amount charged,
per dosage unit, per 30-day
supply, and per 90-day supply,
with respect to participants
and beneficiaries in the plan
or coverage, to the plan or
issuer; and
(bb) the amount
charged, per dosage
unit, per 30-day
supply, and per 90-day
supply, to participants
and beneficiaries;
(II) the median amount
charged to the plan or issuer,
per dosage unit, per 30-day
supply, and per 90-day supply,
including amounts paid by the
participants and beneficiaries,
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;
(III) the interquartile range
of the costs, per dosage unit,
per 30-day supply, and per 90-
day supply, including amounts
paid by the participants and
beneficiaries, 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 that plan
or coverage;
(IV) the lowest cost, per
dosage unit, per 30-day supply,
and per 90-day supply, for such
drug, including amounts charged
to the plan and participants
and beneficiaries, that is
available from any pharmacy
included in the network of the
plan or coverage;
(V) the net acquisition cost
per dosage unit, per 30-day
supply, and per 90-day supply,
if the drug is subject to a
maximum price discount; and
(VI) other information with
respect to the cost of the
drug, as determined by the
Secretary, such as average
sales price, wholesale
acquisition cost, and national
average drug acquisition cost
per dosage unit or per 30-day
supply, and per 90-day supply,
for such drug, including
amounts charged to the plan or
issuer and participants and
beneficiaries among all
pharmacies included in the
network of such plan or
coverage; and
(G) in the case of a large employer--
(i) a list of each drug covered by
such plan, issuer, or entity providing
pharmacy benefits management services
for which a claim was filed during the
reporting period, including, with
respect to each such drug during the
reporting period--
(I) the brand name, generic
or non-proprietary name, and
the National Drug Code;
(II)(aa) the number of
participants and beneficiaries
for whom a claim for such drug
was filed during the reporting
period, the total number of
prescription claims for such
drug (including original
prescriptions and refills), and
the total number of dosage
units and total days supply of
such drug for which a claim was
filed during the reporting
period; and
(bb) with respect to
each claim or dosage
unit described in item
(aa), the type of
dispensing channel
used, such as retail,
mail order, or
specialty pharmacy;
(III) the wholesale
acquisition cost, listed as
cost per days supply and cost
per dosage unit on date of
dispensing;
(IV) the total out-of-pocket
spending by participants and
beneficiaries on such drug
after application of any
benefits under such plan or
coverage, including participant
and beneficiary spending
through copayments,
coinsurance, and deductibles
(but not including any amounts
spent by participants and
beneficiaries on drugs not
covered under such plan or
coverage, or for which no claim
was submitted to such plan or
coverage);
(V) for any drug for which
gross spending of the plan or
coverage exceeded $10,000
during the reporting period--
(aa) a list of all
other drugs in the same
therapeutic category or
class, including brand
name drugs, biological
products, generic
drugs, or biosimilar
biological products
that are in the same
therapeutic category or
class as such drug; and
(bb) the rationale
for preferred formulary
placement of such drug
in that therapeutic
category or class, if
applicable; and
(ii) a list of each therapeutic
category or class of drugs for which a
claim was filed under the health plan
or health insurance coverage during the
reporting period, and, with respect to
each such therapeutic category or class
of drugs during the reporting period--
(I) total gross spending by
the plan;
(II) the number of
participants and beneficiaries
who filled a prescription for a
drug in that category or class;
(III) if applicable to that
category or class, a
description of the formulary
tiers and utilization
mechanisms (such as prior
authorization or step therapy)
employed for drugs in that
category or class;
(IV) the total out-of-pocket
spending by participants and
beneficiaries, including
participant and beneficiary
spending through copayments,
coinsurance, and deductibles;
and
(V) for each drug--
(aa) the amount
received, or expected
to be received, from
any entity in rebates,
fees, alternative
discounts, or other
remuneration--
(AA) for
claims incurred
during the
reporting
period; or
(BB) that is
related to
utilization of
drugs or drug
spending;
(bb) the total net
spending, after
deducting rebates,
price concessions,
alternative discounts
or other remuneration
from drug
manufacturers, by the
health plan or health
insurance coverage on
that category or class
of drugs; and
(cc) the average net
spending per 30-day
supply and per 90-day
supply, incurred by the
health plan or health
insurance coverage and
its participants and
beneficiaries, among
all drugs within the
therapeutic class for
which a claim was filed
during the reporting
period.
(2) Privacy requirements.--Health insurance issuers
offering group health insurance coverage and entities
providing pharmacy benefits management services on
behalf of a group health plan shall provide information
under paragraph (1) in a manner consistent with the
privacy, security, and breach notification regulations
promulgated under section 264(c) of the Health
Insurance Portability and Accountability Act of 1996,
and shall restrict the use and disclosure of such
information according to such privacy regulations.
(3) Disclosure and redisclosure.--
(A) Limitation to business associates.--A
group health plan receiving a report under
paragraph (1) may disclose such information
only to business associates of such plan as
defined in section 160.103 of title 45, Code of
Federal Regulations (or successor regulations).
(B) Clarification regarding public disclosure
of information.--Nothing in this section
prevents a health insurance issuer offering
group health insurance coverage or an entity
providing pharmacy benefits management services
on behalf of a group health plan from placing
reasonable restrictions on the public
disclosure of the information contained in a
report described in paragraph (1), except that
such entity may not restrict disclosure of such
report to the Department of Health and Human
Services, the Department of Labor, the
Department of the Treasury, the Comptroller
General of the United States, or applicable
State agencies.
(C) Limited form of report.--The Secretary
shall define through rulemaking a limited form
of the report under paragraph (1) required of
plan administrators who are drug manufacturers,
drug wholesalers, or other direct participants
in the drug supply chain, in order to prevent
anti-competitive behavior.
(4) Report to gao.--A health insurance issuer
offering group health insurance coverage or an entity
providing pharmacy benefits management services on
behalf of a group health plan shall submit to the
Comptroller General of the United States each of the
first 4 reports submitted to a plan administrator under
paragraph (1) with respect to such coverage or plan,
and other such reports as requested, in accordance with
the privacy requirements under paragraph (2), the
disclosure and redisclosure standards under paragraph
(3), the standards specified pursuant to paragraph (5).
(5) Standard format.--Not later than 6 months after
the date of enactment of this section, the Secretary
shall specify through rulemaking standards for health
insurance issuers and entities required to submit
reports under paragraph (4) to submit such reports in a
standard format.
(c) Rule of Construction.--Nothing in this section shall be
construed to permit a health insurance issuer, group health
plan, or other entity to restrict disclosure to, or otherwise
limit the access of, the Department of Labor to a report
described in subsection (b)(1) or information related to
compliance with subsection (a) by such issuer, plan, or entity.
(d) Definitions.--In this section:
(1) Large employer.--The term ``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.
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 of 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 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 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 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.
* * * * * * *
----------
INTERNAL REVENUE CODE OF 1986
TITLE 26--INTERNAL REVENUE CODE
* * * * * * *
Subtitle K--Group Health Plan Requirements
* * * * * * *
CHAPTER 100--GROUP HEALTH PLAN REQUIREMENTS
* * * * * * *
Subchapter B--OTHER REQUIREMENTS
Sec.
* * * * * * *
[9819. Maintenance of price comparison tool.]
9819. Price transparency requirements.
* * * * * * *
9826. Oversight of pharmacy benefits manager services.
* * * * * * *
[SEC. 9819. MAINTENANCE OF PRICE COMPARISON TOOL.
[A group health plan shall offer price comparison guidance by
telephone and make available on the Internet website of the
plan or issuer a price comparison tool that (to the extent
practicable) allows an individual enrolled under such plan,
with respect to such plan year, such geographic region, and
participating providers with respect to such plan or coverage,
to compare the amount of cost-sharing that the individual would
be responsible for paying under such plan with respect to the
furnishing of a specific item or service by any such provider.]
SEC. 9819. PRICE TRANSPARENCY REQUIREMENTS.
(a) In General.--A group health plan shall make available to
the public accurate and timely disclosures of the following
information:
(1) Claims payment policies and practices.
(2) Periodic financial disclosures.
(3) Data on enrollment.
(4) Data on disenrollment.
(5) Data on the number of claims that are denied.
(6) Data on rating practices.
(7) Information on cost-sharing and payments with
respect to any out-of-network coverage (or with respect
to any item and service furnished under such a plan
that does not use a network of providers).
(8) Information on participant and beneficiary rights
under this part.
(9) Rate and payment information described in
subsection (d).
(10) Other information as determined appropriate by
the Secretary.
Rate and payment information described in paragraph (9) shall
be made available to the public not later than January 10,
2025, and not later than the tenth day of every month
thereafter, in the manner described in subsection (d)(2)(A),
and, beginning on January 1, 2027, in real-time through an
application program interface (or successor technology)
described in subsection (d)(2)(B).
(b) Use of Plain Language.--The information required to be
submitted under subsection (a) shall be provided in plain
language. The term ``plain language'' means language that the
intended audience, including individuals with limited English
proficiency, can readily understand and use because that
language is clear, concise, well-organized, accurately
describes the information, and follows other best practices of
plain language writing. The Secretary, jointly with the
Secretary of Health and Human Services and the Secretary of
Labor, shall develop and issue standards for plain language
writing for purposes of this section and shall develop a
standardized reporting template and standardized definitions of
terms to allow for comparison across group health plans and
health insurance coverage.
(c) Cost Sharing Transparency.--
(1) In general.--A group health plan shall, upon
request of a participant or beneficiary and in a timely
manner, provide to the participant or beneficiary a
statement of the amount of cost-sharing (including
deductibles, copayments, and coinsurance) under the
participant's or beneficiary's plan that the
participant or beneficiary would be responsible for
paying with respect to the furnishing of a specific
item or service by a provider. At a minimum, such
information shall include the information specified in
paragraph (2) and shall be made available at no cost to
the participant or beneficiary through a self-service
tool that meets the requirements of paragraph (3) or
through a paper or phone disclosure, at the option of
the 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
(f)) for such item or service and for any other
item or service that is inherent in the
furnishing of the item or service that is the
subject of such request.
(B) If such provider is not a participating
provider, the allowed amount, percentage of
billed charges, or other rate that such plan
will recognize as payment for such item or
service, along with a notice that such
individual may be liable for additional charges
billed by such provider.
(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
amount or rate described in such subparagraph
(or, in the case such plan uses a percentage of
billed charges to determined the amount of
payment for such provider, using a reasonable
estimate of such percentage of such charges)).
(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) Any shared savings or other benefit
available to the participant or beneficiary
with respect to such item or service.
(F) 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.
(G) Any prior authorization, concurrent
review, step therapy, fail first, or similar
requirements applicable to coverage of such
item or service under such plan.
(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, mobile
application, or other platform determined
appropriate 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
accurate at the time such request is made;
(D) allows such a request to be made with
respect to an item or service furnished by--
(i) a specific provider that is a
participating provider with respect to
such item or service;
(ii) all providers that are
participating providers with respect to
such item or service for purposes of
facilitating price comparisons; or
(iii) a provider that is not
described in clause (ii); and
(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.
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 items and services.
(4) Provider tool.--A group health plan shall permit
providers to learn the amount of cost-sharing
(including deductibles, copayments, and coinsurance)
that would apply under an individual's plan that the
individual would be responsible for paying with respect
to the furnishing of a specific item or service by
another provider in a timely manner upon the request of
the provider and with the consent of such individual in
the same manner and to the same extent as if such
request has been made by such individual. As part of
any tool used to facilitate such requests from a
provider, such plan may include functionality that--
(A) allows providers to submit the
notifications to such plan or coverage required
under section 2799B-6 of the Public Health
Services Act; and
(B) provides for notifications required under
section 9816(f) to such an individual.
(d) Rate and Payment Information.--
(1) In general.--For purposes of subsection (a)(9),
the rate and payment information described in this
subsection is, with respect to a group health plan, the
following:
(A) With respect to each item or service
(other than a drug) for which benefits are
available under such plan, the in-network rate
(in a dollar amount) in effect as of the first
day of the plan year during which such
information is submitted with each provider
(identified by national provider identifier)
that is a participating provider with respect
to such item or service (or, in the case such
rate is not available in a dollar amount, such
formulae, pricing methodologies, or other
information used to calculate such rate).
(B) With respect to each dosage form and
indication of each drug (identified by national
drug code) for which benefits are available
under such plan--
(i) the in-network rate (in a dollar
amount) in effect as of the first day
of the plan year during which such
information is submitted with each
provider (identified by national
provider identifier) that is a
participating provider with respect to
such drug (or, in the case such rate is
not available in a dollar amount, such
formulae, pricing methodologies, or
other information used to calculate
such rate); 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 submission to each
provider that was a participating
provider with respect to such drug,
broken down by each such provider
(identified by national provider
identifier), other than such an amount
paid to a provider that, 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,
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 (identified by national provider
identifier), other than items and services with
respect to which fewer than 20 claims for such
item or service were submitted to such plan or
coverage during such period.
Such rate and payment information shall be made
available with respect to each individual item or
service, regardless of whether such item or service is
paid for as part of a bundled payment, episode of care,
value-based payment arrangement, or otherwise.
(2) Manner of publication.--
(A) In general.--Rate and payment information
required to be made available under subsection
(a)(9) shall be so made available in dollar
amounts through 3 separate machine-readable
files corresponding to the information
described in each of subparagraphs (A) through
(C) of paragraph (1) that meet such
requirements as specified by the Secretary not
later than 180 days after the date of the
enactment of this paragraph through rulemaking.
Such requirements shall ensure that such files
are limited to an appropriate size, do not
include information that is duplicative of
information contained in other files made
available under such subsection, are made
available in a widely-available format that
allows for information contained in such files
to be compared across group health plans, and
are accessible to individuals at no cost and
without the need to establish a user account or
provide other credentials.
(B) Real-time provision of information.--
(i) In general.--Subject to clause
(ii), beginning January 1, 2026, rate
and payment information required to be
made available by a group health plan
under subsection (a)(9) shall, in
addition to being made available in the
manner described in subparagraph (A),
be made available through an
application program interface (or
successor technology) that provides
access to such information in real time
and that meets such technical standards
as may be specified by the Secretary.
(ii) Exemption for certain plans and
coverage.--Clause (i) shall not apply
with respect to information described
in such clause required to be made
available by a group health plan if
such plan provides benefits for fewer
than 500 participants and
beneficiaries.
(3) User guide.--The Secretary, Secretary of Health
and Human Services, and Secretary of Labor shall
jointly make available to the public instructions
written in plain language explaining how individuals
may search for information described in paragraph (1)
in files submitted in accordance with paragraph (2).
(4) Annual summary.--For each year (beginning with
2025), each group health plan shall make public a
machine-readable file meeting such standards as
established by the Secretary under paragraph (2)
containing a summary of all rate and payment
information made public by such plan with respect to
such plan or coverage during such year (such as
averages of all such information so made public).
(e) Attestation.--Each group health plan shall annually
submit to the Secretary an attestation of such plan's
compliance with the provisions of this section along with a
link to disclosures made in accordance with subsection (a).
(f) Definitions.--In this subsection:
(1) Participating provider.--The term ``participating
provider'' has the meaning given such term in section
9816 and includes a participating facility.
(2) In-network rate.--The term ``in-network rate''
means, with respect to a group health plan and an item
or service furnished by a provider that is a
participating provider with respect to such plan and
item or service, the contracted rate (reflected as a
dollar amount) in effect between such plan and such
provider for such item or service.
* * * * * * *
SEC. 9826. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.
(a) In General.--For plan years beginning on or after January
1, 2025, a group health plan or an entity or subsidiary
providing pharmacy benefits management services on behalf of
such a plan may not enter into a contract with a drug
manufacturer, distributor, wholesaler, switch, patient or copay
assistance program administrator, pharmacy, subcontractor,
rebate aggregator, or any associated third party that limits or
delays the disclosure of information to plan administrators in
such a manner that prevents the plan, or an entity or
subsidiary providing pharmacy benefits management services on
behalf of a plan, from making or substantiating the reports
described in subsection (b).
(b) Reports.--
(1) In general.--For plan years beginning on or after
January 1, 2025, not less frequently than quarterly
(and upon request by the plan administrator), a group
health plan, or an entity providing pharmacy benefits
management services on behalf of a group health plan,
shall submit to the plan administrator (as defined in
section 3(16)(A) of the Employee Retirement Income
Security Act of 1974) of such plan a report in
accordance with this subsection, and make such report
available to the plan administrator in a machine-
readable format (or as may be determined by the
Secretary, other formats). Each such report shall
include, with respect to the applicable group health
plan--
(A) information collected from a patient or
copay assistance program administrator by such
entity on the total amount of copayment
assistance dollars paid, or copayment cards
applied, or other discounts that were funded by
the drug manufacturer with respect to the
participants and beneficiaries in such plan;
(B) total gross spending on prescription
drugs by the plan during the reporting period;
(C) total amount received, or expected to be
received, by the plan from any entities, in
rebates, fees, alternative discounts, and all
other remuneration received from the entity or
any third party (including group purchasing
organizations) other than the plan
administrator, related to utilization of drug
or drug spending under such plan during the
reporting period;
(D) the total net spending on prescription
drugs by the plan during such reporting period;
(E) 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 of 1974) to
brokerage houses, brokers, consultants,
advisors, or any other individual or firm for
the referral of the group health plan's
business to the pharmacy benefits manager,
identified by the recipient of such amounts;
(F)(i) an explanation of any benefit design
parameters that encourage or require
participants and beneficiaries in the 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 funded by an entity
providing pharmacy benefit management services;
(ii) the percentage of total
prescriptions charged to the plan, or
participants and beneficiaries in such
plan, that were dispensed by mail
order, specialty, or retail pharmacies
that are affiliated with or under
common ownership with the entity
providing pharmacy benefit management
services; and
(iii) a list of all drugs dispensed
by such affiliated pharmacy or pharmacy
under common ownership and charged to
the plan, or participants and
beneficiaries of the plan, during the
applicable period, and, with respect to
each drug--
(I)(aa) the amount charged,
per dosage unit, per 30-day
supply, and per 90-day supply,
with respect to participants
and beneficiaries in the plan,
to the plan; and
(bb) the amount
charged, per dosage
unit, per 30-day
supply, and per 90-day
supply, to participants
and beneficiaries;
(II) the median amount
charged to the plan, per dosage
unit, per 30-day supply, and
per 90-day supply, including
amounts paid by the
participants and beneficiaries,
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;
(III) the interquartile range
of the costs, per dosage unit,
per 30-day supply, and per 90-
day supply, including amounts
paid by the participants and
beneficiaries, 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 that plan;
(IV) the lowest cost, per
dosage unit, per 30-day supply,
and per 90-day supply, for such
drug, including amounts charged
to the plan and participants
and beneficiaries, that is
available from any pharmacy
included in the network of the
plan;
(V) the net acquisition cost
per dosage unit, per 30-day
supply, and per 90-day supply,
if the drug is subject to a
maximum price discount; and
(VI) other information with
respect to the cost of the
drug, as determined by the
Secretary, such as average
sales price, wholesale
acquisition cost, and national
average drug acquisition cost
per dosage unit or per 30-day
supply, and per-90 day supply,
for such drug, including
amounts charged to the plan and
participants and beneficiaries
among all pharmacies included
in the network of such plan;
and
(G) in the case of a large employer--
(i) a list of each drug covered by
such plan or entity providing pharmacy
benefits management services for which
a claim was filed during the reporting
period, including, with respect to each
such drug during the reporting period--
(I) the brand name, generic
or non-proprietary name, and
the National Drug Code;
(II)(aa) the number of
participants and beneficiaries
for whom a claim for such drug
was filed during the reporting
period, the total number of
prescription claims for such
drug (including original
prescriptions and refills), and
the total number of dosage
units and total days supply of
such drug for which a claim was
filed during the reporting
period; and
(bb) with respect to
each claim or dosage
unit described in item
(aa), the type of
dispensing channel
used, such as retail,
mail order, or
specialty pharmacy;
(III) the wholesale
acquisition cost, listed as
cost per days supply and cost
per dosage unit on date of
dispensing;
(IV) the total out-of-pocket
spending by participants and
beneficiaries on such drug
after application of any
benefits under such plan,
including participant and
beneficiary spending through
copayments, coinsurance, and
deductibles (but not including
any amounts spent by
participants and beneficiaries
on drugs not covered under such
plan, or for which no claim was
submitted to such plan);
(V) for any drug for which
gross spending of the plan
exceeded $10,000 during the
reporting period--
(aa) a list of all
other drugs in the same
therapeutic category or
class, including brand
name drugs, biological
products, generic
drugs, or biosimilar
biological products
that are in the same
therapeutic category or
class as such drug; and
(bb) the rationale
for preferred formulary
placement of such drug
in that therapeutic
category or class, if
applicable; and
(ii) a list of each therapeutic
category or class of drugs for which a
claim was filed under the plan during
the reporting period, and, with respect
to each such therapeutic category or
class of drugs during the reporting
period--
(I) total gross spending by
the plan;
(II) the number of
participants and beneficiaries
who filled a prescription for a
drug in that category or class;
(III) if applicable to that
category or class, a
description of the formulary
tiers and utilization
mechanisms (such as prior
authorization or step therapy)
employed for drugs in that
category or class;
(IV) the total out-of-pocket
spending by participants and
beneficiaries, including
participant and beneficiary
spending through copayments,
coinsurance, and deductibles;
and
(V) for each drug--
(aa) the amount
received, or expected
to be received, from
any entity in rebates,
fees, alternative
discounts, or other
remuneration--
(AA) for
claims incurred
during the
reporting
period; or
(BB) that is
related to
utilization of
drugs or drug
spending;
(bb) the total net
spending, after
deducting rebates,
price concessions,
alternative discounts
or other remuneration
from drug
manufacturers, by the
plan on that category
or class of drugs; and
(cc) the average net
spending per 30-day
supply and per 90-day
supply, incurred by the
plan and its
participants and
beneficiaries, among
all drugs within the
therapeutic class for
which a claim was filed
during the reporting
period.
(2) Privacy requirements.--Entities providing
pharmacy benefits management services on behalf of a
group health plan shall provide information under
paragraph (1) in a manner consistent with the privacy,
security, and breach notification regulations
promulgated under section 264(c) of the Health
Insurance Portability and Accountability Act of 1996,
and shall restrict the use and disclosure of such
information according to such privacy regulations.
(3) Disclosure and redisclosure.--
(A) Limitation to business associates.--A
group health plan receiving a report under
paragraph (1) may disclose such information
only to business associates of such plan as
defined in section 160.103 of title 45, Code of
Federal Regulations (or successor regulations).
(B) Clarification regarding public disclosure
of information.--Nothing in this section
prevents an entity providing pharmacy benefits
management services on behalf of a group health
plan from placing reasonable restrictions on
the public disclosure of the information
contained in a report described in paragraph
(1), except that such entity may not restrict
disclosure of such report to the Department of
Health and Human Services, the Department of
Labor, the Department of the Treasury, the
Comptroller General of the United States, or
applicable State agencies.
(C) Limited form of report.--The Secretary
shall define through rulemaking a limited form
of the report under paragraph (1) required of
plan administrators who are drug manufacturers,
drug wholesalers, or other direct participants
in the drug supply chain, in order to prevent
anti-competitive behavior.
(4) Report to gao.--An entity providing pharmacy
benefits management services on behalf of a group
health plan shall submit to the Comptroller General of
the United States each of the first 4 reports submitted
to a plan administrator under paragraph (1) with
respect to such plan, and other such reports as
requested, in accordance with the privacy requirements
under paragraph (2), the disclosure and redisclosure
standards under paragraph (3), the standards specified
pursuant to paragraph (5).
(5) Standard format.--Not later than 6 months after
the date of enactment of this section, the Secretary
shall specify through rulemaking standards for entities
required to submit reports under paragraph (4) to
submit such reports in a standard format.
(c) Enforcement.--
(1) Failure to provide timely information.--An entity
providing pharmacy benefits management services that
violates subsection (a) or fails to provide information
required under subsection (b) shall be subject to a
civil monetary penalty in the amount of $10,000 for
each day during which such violation continues or such
information is not disclosed or reported.
(2) False information.--An entity providing pharmacy
benefits management services that knowingly provides
false information under this section shall be subject
to a civil money penalty in an amount not to exceed
$100,000 for each item of false information. Such civil
money penalty shall be in addition to other penalties
as may be prescribed by law.
(3) Procedure.--The provisions of section 1128A of
the Social Security Act, other than subsection (a) and
(b) and the first sentence of subsection (c)(1) of such
section shall apply to civil monetary penalties under
this subsection in the same manner as such provisions
apply to a penalty or proceeding under section 1128A of
the Social Security Act.
(4) Waivers.--The Secretary may waive penalties under
paragraph (2), or extend the period of time for
compliance with a requirement of this section, for an
entity in violation of this section that has made a
good-faith effort to comply with this section.
(d) Rule of Construction.--Nothing in this section shall be
construed to permit a group health plan, or other entity to
restrict disclosure to, or otherwise limit the access of, the
Department of the Treasury to a report described in subsection
(b)(1) or information related to compliance with subsection (a)
by such plan or entity.
(e) Definitions.--In this section:
(1) Large employer.--The term ``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.
* * * * * * *
----------
PUBLIC HEALTH SERVICE ACT
TITLE XXVII--REQUIREMENTS RELATING TO HEALTH
INSURANCE COVERAGE
* * * * * * *
PART D--ADDITIONAL COVERAGE PROVISIONS
* * * * * * *
[SEC. 2799A-4. MAINTENANCE OF PRICE COMPARISON TOOL.
[A group health plan or a health insurance issuer offering
group or individual health insurance coverage shall offer price
comparison guidance by telephone and make available on the
Internet website of the plan or issuer a price comparison tool
that (to the extent practicable) allows an individual enrolled
under such plan or coverage, with respect to such plan year,
such geographic region, and participating providers with
respect to such plan or coverage, to compare the amount of
cost-sharing that the individual would be responsible for
paying under such plan or coverage with respect to the
furnishing of a specific item or service by any such provider.]
SEC. 2799A-4. PRICE TRANSPARENCY REQUIREMENTS.
(a) In General.--A group health plan, and a health insurance
issuer offering group or individual health insurance coverage,
shall make available to the public accurate and timely
disclosures of the following information:
(1) Claims payment policies and practices.
(2) Periodic financial disclosures.
(3) Data on enrollment.
(4) Data on disenrollment.
(5) Data on the number of claims that are denied.
(6) Data on rating practices.
(7) Information on cost-sharing and payments with
respect to any out-of-network coverage (or with respect
to any item and service furnished under such a plan or
such group or individual health insurance coverage that
does not use a network of providers).
(8) Information on enrollee rights under this part.
(9) Rate and payment information described in
subsection (d).
(10) Other information as determined appropriate by
the Secretary.
Rate and payment information described in paragraph (9) shall
be made available to the public not later than January 10,
2025, and not later than the tenth day of every month
thereafter, in the manner described in subsection (d)(2)(A),
and, beginning on January 1, 2027, in real-time through an
application program interface (or successor technology)
described in subsection (d)(2)(B).
(b) Use of Plain Language.--The information required to be
submitted under subsection (a) shall be provided in plain
language. The term ``plain language'' means language that the
intended audience, including individuals with limited English
proficiency, can readily understand and use because that
language is clear, concise, well-organized, accurately
describes the information, and follows other best practices of
plain language writing. The Secretary, jointly with the
Secretary of Labor and the Secretary of the Treasury, shall
develop and issue standards for plain language writing for
purposes of this section and shall develop a standardized
reporting template and standardized definitions of terms to
allow for comparison across group health plans and health
insurance coverage.
(c) Cost Sharing Transparency.--
(1) In general.--A group health plan, and a health
insurance issuer offering group or individual health
insurance coverage, shall, upon request of an enrollee
and in a timely manner, provide to the enrollee a
statement of the amount of cost-sharing (including
deductibles, copayments, and coinsurance) under the
enrollee's plan or coverage that the enrollee would be
responsible for paying with respect to the furnishing
of a specific item or service by a provider. At a
minimum, such information shall include the information
specified in paragraph (2) and shall be made available
at no cost to the enrollee through a self-service tool
that meets the requirements of paragraph (3) or through
a paper or phone disclosure, at the option of the
enrollee, 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 (as applicable)
furnished by a health care provider to an enrollee 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
(f)) for such item or service and for any other
item or service that is inherent in the
furnishing of the item or service that is the
subject of such request.
(B) If such provider is not a participating
provider, the allowed amount, percentage of
billed charges, or other rate that such plan or
coverage will recognize as payment for such
item or service, along with a notice that such
enrollee may be liable for additional charges
billed by such provider.
(C) The estimated amount of cost sharing
(including deductibles, copayments, and
coinsurance) that the enrollee 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 amount or rate
described in such subparagraph (or, in the case
such plan or issuer uses a percentage of billed
charges to determined the amount of payment for
such provider, using a reasonable estimate of
such percentage of such charges)).
(D) The amount the enrollee 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
enrollees in the plan or coverage, by such
separate deductibles or maximums, in addition
to any cumulative deductible or maximum).
(E) Any shared savings or other benefit
available to the enrollee with respect to such
item or service.
(F) In the case such plan or coverage imposes
any frequency or volume limitations with
respect to such item or service (excluding
medical necessity determinations), the amount
that such enrollee has accrued towards such
limitation with respect to such item or
service.
(G) Any prior authorization, concurrent
review, step therapy, fail first, or similar
requirements applicable to coverage of such
item or service under such plan or group or
individual health insurance coverage.
(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, mobile
application, or other platform determined
appropriate 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
accurate at the time such request is made;
(D) allows such a request to be made with
respect to an item or service furnished by--
(i) a specific provider that is a
participating provider with respect to
such item or service;
(ii) all providers that are
participating providers with respect to
such plan and such item or service for
purposes of facilitating price
comparisons; or
(iii) a provider that is not
described in clause (ii); and
(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.
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 items and services.
(4) Provider tool.--A group health plan, and a health
insurance issuer offering group or individual health
insurance coverage, shall permit providers to learn the
amount of cost-sharing (including deductibles,
copayments, and coinsurance) that would apply under an
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 another
provider in a timely manner upon the request of the
provider and with the consent of such individual in the
same manner and to the same extent as if such request
has been made by such individual. As part of any tool
used to facilitate such requests from a provider, such
plan or issuer offering health insurance coverage may
include functionality that--
(A) allows providers to submit the
notifications to such plan or coverage required
under section 2799B-6; and
(B) provides for notifications required under
section 2799A-1(f) to such an individual.
(d) Rate and Payment Information.--
(1) In general.--For purposes of subsection (a)(9),
the rate and payment information described in this
subsection is, with respect to a group health plan or
group or individual health insurance coverage (as
applicable), the following:
(A) With respect to each item or service
(other than a drug) for which benefits are
available under such plan or coverage, the in-
network rate (in a dollar amount) in effect as
of the first day of the plan year during which
such information is submitted with each
provider (identified by national provider
identifier) that is a participating provider
with respect to such item or service (or, in
the case such rate is not available in a dollar
amount, such formulae, pricing methodologies,
or other information used to calculate such
rate).
(B) With respect to each dosage form and
indication of each drug (identified by national
drug code) for which benefits are available
under such plan or coverage--
(i) the in-network rate (in a dollar
amount) in effect as of the first day
of the plan year during which such
information is submitted with each
provider (identified by national
provider identifier) that is a
participating provider with respect to
such drug (or, in the case such rate is
not available in a dollar amount, such
formulae, pricing methodologies, or
other information used to calculate
such rate); 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 submission to each
provider that was a participating
provider with respect to such drug,
broken down by each such provider
(identified by national provider
identifier), other than such an amount
paid to a provider that, during such
period, submitted fewer than 20 claims
for such drug to such plan or coverage.
(C) With respect to each item or service for
which benefits are available under such plan or
coverage, the amount billed, and the amount
allowed by the plan or coverage, for each such
item or service furnished during the 90-day
period specified in subparagraph (B) by a
provider that was not a participating provider
with respect to such item or service, broken
down by each such provider (identified by
national provider identifier), other than items
and services with respect to which fewer than
20 claims for such item or service were
submitted to such plan or coverage during such
period.
Such rate and payment information shall be made
available with respect to each individual item or
service, regardless of whether such item or service is
paid for as part of a bundled payment, episode of care,
value-based payment arrangement, or otherwise.
(2) Manner of publication.--
(A) In general.--Rate and payment information
required to be made available under subsection
(a)(9) shall be so made available in dollar
amounts through 3 separate machine-readable
files corresponding to the information
described in each of subparagraphs (A) through
(C) of paragraph (1) that meet such
requirements as specified by the Secretary not
later than 180 days after the date of the
enactment of this paragraph through rulemaking.
Such requirements shall ensure that such files
are limited to an appropriate size, do not
include information that is duplicative of
information contained in other files made
available under such subsection, are made
available in a widely-available format that
allows for information contained in such files
to be compared across group health plans and
group or individual health insurance coverage,
and are accessible to individuals at no cost
and without the need to establish a user
account or provide other credentials.
(B) Real-time provision of information.--
(i) In general.--Subject to clause
(ii), beginning January 1, 2026, rate
and payment information required to be
made available by a group health plan
or health insurance issuer under
subsection (a)(9) shall, in addition to
being made available in the manner
described in subparagraph (A), be made
available through an application
program interface (or successor
technology) that provides access to
such information in real time and that
meets such technical standards as may
be specified by the Secretary.
(ii) Exemption for certain plans and
coverage.--Clause (i) shall not apply
with respect to information described
in such clause required to be made
available by a group health plan or
health insurance issuer offering health
insurance coverage if such plan or
coverage, as applicable, provides
benefits for fewer than 500 enrollees.
(3) User guide.--The Secretary, Secretary of Labor,
and Secretary of the Treasury shall jointly make
available to the public instructions written in plain
language explaining how individuals may search for
information described in paragraph (1) in files
submitted in accordance with paragraph (2).
(4) Annual summary.--For each year (beginning with
2025), each group health plan and health insurance
issuer offering group or individual health insurance
coverage shall make public a machine-readable file
meeting such standards as established by the Secretary
under paragraph (2) 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 year (such as averages of all such information so
made public).
(e) Attestation.--Each group health plan and health insurance
issuer offering group or individual health insurance coverage
shall annually submit to the Secretary an attestation of such
plan's or such coverage's compliance with the provisions of
this section along with a link to disclosures made in
accordance with subsection (a).
(f) Definitions.--In this subsection:
(1) Participating provider.--The term ``participating
provider'' has the meaning given such term in section
2799A-1 and includes a participating facility.
(2) In-network rate.--The term ``in-network rate''
means, with respect to a group health plan or group or
individual health insurance coverage and an item or
service furnished by a provider that is a participating
provider with respect to such plan or coverage and item
or service, the contracted rate (reflected as a dollar
amount) in effect between such plan or coverage and
such provider for such item or service.
* * * * * * *
SEC. 2799A-11. OVERSIGHT OF PHARMACY BENEFITS MANAGER SERVICES.
(a) In general For plan years beginning on or after January
1, 2025, a group health plan (or health insurance issuer
offering group health insurance coverage in connection with
such a plan) or an entity or subsidiary providing pharmacy
benefits management services on behalf of such a plan or issuer
may not enter into a contract with a drug manufacturer,
distributor, wholesaler, switch, patient or copay assistance
program administrator, pharmacy, subcontractor, rebate
aggregator, or any associated third party that limits or delays
the disclosure of information to plan administrators in such a
manner that prevents the plan or issuer, or an entity or
subsidiary providing pharmacy benefits management services on
behalf of a plan or issuer, from making or substantiating the
reports described in subsection (b).
(b) Reports
(1) In general For plan years beginning on or after
January 1, 2025, not less frequently than quarterly
(and upon request by the plan administrator), a group
health plan or health insurance issuer offering group
health insurance coverage, or an entity providing
pharmacy benefits management services on behalf of a
group health plan or an issuer providing group health
insurance coverage, shall submit to the plan
administrator (as defined in section 3(16)(A) of the
Employee Retirement Income Security Act of 1974) of
such plan or coverage a report in accordance with this
subsection, and make such report available to the plan
administrator in a machine-readable format (or as may
be determined by the Secretary, other formats). Each
such report shall include, with respect to the
applicable group health plan or health insurance
coverage--
(A) information collected from a patient or
copay assistance program administrator by such
entity on the total amount of copayment
assistance dollars paid, or copayment cards
applied, or other discounts that were funded by
the drug manufacturer with respect to the
participants and beneficiaries in such plan or
coverage;
(B) total gross spending on prescription
drugs by the plan or coverage during the
reporting period;
(C) total amount received, or expected to be
received, by the plan or coverage from any
entities, in rebates, fees, alternative
discounts, and all other remuneration received
from the entity or any third party (including
group purchasing organizations) other than the
plan administrator, related to utilization of
drug or drug spending under such plan or
coverage during the reporting period;
(D) the total net spending on prescription
drugs by the plan or coverage during such
reporting period;
(E) 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 of 1974) to
brokerage houses, brokers, consultants,
advisors, or any other individual or firm for
the referral of the group health plan's or
health insurance issuer's business to the
pharmacy benefits manager, identified by the
recipient of such amounts;
(F)(i) an explanation of any benefit design
parameters that encourage or require
participants and beneficiaries in the 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 funded by an entity
providing pharmacy benefit management services;
(ii) the percentage of total
prescriptions charged to the plan,
issuer, or participants and
beneficiaries in such plan or coverage,
that were dispensed by mail order,
specialty, or retail pharmacies that
are affiliated with or under common
ownership with the entity providing
pharmacy benefit management services;
and
(iii) a list of all drugs dispensed
by such affiliated pharmacy or pharmacy
under common ownership and charged to
the plan, issuer, or participants and
beneficiaries of the plan, during the
applicable period, and, with respect to
each drug--
(I)(aa) the amount charged,
per dosage unit, per 30-day
supply, and per 90-day supply,
with respect to participants
and beneficiaries in the plan
or coverage, to the plan or
issuer; and
(bb) the amount
charged, per dosage
unit, per 30-day
supply, and per 90-day
supply, to participants
and beneficiaries;
(II) the median amount
charged to the plan or issuer,
per dosage unit, per 30-day
supply, and per 90-day supply,
including amounts paid by the
participants and beneficiaries,
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;
(III) the interquartile range
of the costs, per dosage unit,
per 30-day supply, and per 90-
day supply, including amounts
paid by the participants and
beneficiaries, 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 that plan
or coverage;
(IV) the lowest cost, per
dosage unit, per 30-day supply,
and per 90-day supply, for such
drug, including amounts charged
to the plan and participants
and beneficiaries, that is
available from any pharmacy
included in the network of the
plan or coverage;
(V) the net acquisition cost
per dosage unit, per 30-day
supply, and per 90-day supply,
if the drug is subject to a
maximum price discount; and
(VI) other information with
respect to the cost of the
drug, as determined by the
Secretary, such as average
sales price, wholesale
acquisition cost, and national
average drug acquisition cost
per dosage unit or per 30-day
supply, and per 90-day supply,
for such drug, including
amounts charged to the plan or
issuer and participants and
beneficiaries among all
pharmacies included in the
network of such plan or
coverage; and
(G) in the case of a large employer--
(i) a list of each drug covered by
such plan, issuer, or entity providing
pharmacy benefits management services
for which a claim was filed during the
reporting period, including, with
respect to each such drug during the
reporting period--
(I) the brand name, generic
or non-proprietary name, and
the National Drug Code;
(II)(aa) the number of
participants and beneficiaries
for whom a claim for such drug
was filed during the reporting
period, the total number of
prescription claims for such
drug (including original
prescriptions and refills), and
the total number of dosage
units and total days supply of
such drug for which a claim was
filed during the reporting
period; and
(bb) with respect to
each claim or dosage
unit described in item
(aa), the type of
dispensing channel
used, such as retail,
mail order, or
specialty pharmacy;
(III) the wholesale
acquisition cost, listed as
cost per days supply and cost
per dosage unit on date of
dispensing;
(IV) the total out-of-pocket
spending by participants and
beneficiaries on such drug
after application of any
benefits under such plan or
coverage, including participant
and beneficiary spending
through copayments,
coinsurance, and deductibles
(but not including any amounts
spent by participants and
beneficiaries on drugs not
covered under such plan or
coverage, or for which no claim
was submitted to such plan or
coverage);
(V) for any drug for which
gross spending of the plan or
coverage exceeded $10,000
during the reporting period--
(aa) a list of all
other drugs in the same
therapeutic category or
class, including brand
name drugs, biological
products, generic
drugs, or biosimilar
biological products
that are in the same
therapeutic category or
class as such drug; and
(bb) the rationale
for preferred formulary
placement of such drug
in that therapeutic
category or class, if
applicable; and
(ii) a list of each therapeutic
category or class of drugs for which a
claim was filed under the health plan
or health insurance coverage during the
reporting period, and, with respect to
each such therapeutic category or class
of drugs during the reporting period--
(I) total gross spending by
the plan;
(II) the number of
participants and beneficiaries
who filled a prescription for a
drug in that category or class;
(III) if applicable to that
category or class, a
description of the formulary
tiers and utilization
mechanisms (such as prior
authorization or step therapy)
employed for drugs in that
category or class;
(IV) the total out-of-pocket
spending by participants and
beneficiaries, including
participant and beneficiary
spending through copayments,
coinsurance, and deductibles;
and
(V) for each drug--
(aa) the amount
received, or expected
to be received, from
any entity in rebates,
fees, alternative
discounts, or other
remuneration--
(AA) for
claims incurred
during the
reporting
period; or
(BB) that is
related to
utilization of
drugs or drug
spending;
(bb) the total net
spending, after
deducting rebates,
price concessions,
alternative discounts
or other remuneration
from drug
manufacturers, by the
health plan or health
insurance coverage on
that category or class
of drugs; and
(cc) the average net
spending per 30-day
supply and per 90-day
supply, incurred by the
health plan or health
insurance coverage and
its participants and
beneficiaries, among
all drugs within the
therapeutic class for
which a claim was filed
during the reporting
period.
(2) Privacy requirements Health insurance issuers
offering group health insurance coverage and entities
providing pharmacy benefits management services on
behalf of a group health plan shall provide information
under paragraph (1) in a manner consistent with the
privacy, security, and breach notification regulations
promulgated under section 264(c) of the Health
Insurance Portability and Accountability Act of 1996,
and shall restrict the use and disclosure of such
information according to such privacy regulations.
(3) Disclosure and redisclosure
(A) Limitation to business associates A group
health plan receiving a report under paragraph
(1) may disclose such information only to
business associates of such plan as defined in
section 160.103 of title 45, Code of Federal
Regulations (or successor regulations).
(B) Clarification regarding public disclosure
of information Nothing in this section prevents
a health insurance issuer offering group health
insurance coverage or an entity providing
pharmacy benefits management services on behalf
of a group health plan from placing reasonable
restrictions on the public disclosure of the
information contained in a report described in
paragraph (1), except that such issuer or
entity may not restrict disclosure of such
report to the Department of Health and Human
Services, the Department of Labor, the
Department of the Treasury, the Comptroller
General of the United States, or applicable
State agencies.
(C) Limited form of report The Secretary
shall define through rulemaking a limited form
of the report under paragraph (1) required of
plan administrators who are drug manufacturers,
drug wholesalers, or other direct participants
in the drug supply chain, in order to prevent
anti-competitive behavior.
(4) Report to GAO A health insurance issuer offering
group health insurance coverage or an entity providing
pharmacy benefits management services on behalf of a
group health plan shall submit to the Comptroller
General of the United States each of the first 4
reports submitted to a plan administrator under
paragraph (1) with respect to such coverage or plan,
and other such reports as requested, in accordance with
the privacy requirements under paragraph (2), the
disclosure and redisclosure standards under paragraph
(3), the standards specified pursuant to paragraph (5).
(5) Standard format Not later than 6 months after the
date of enactment of this section, the Secretary shall
specify through rulemaking standards for health
insurance issuers and entities required to submit
reports under paragraph (4) to submit such reports in a
standard format.
(c) Enforcement
(1) Failure to provide timely information An entity
providing pharmacy benefits management services that
violates subsection (a) or fails to provide information
required under subsection (b) shall be subject to a
civil monetary penalty in the amount of $10,000 for
each day during which such violation continues or such
information is not disclosed or reported.
(2) False information An entity providing pharmacy
benefits management services that knowingly provides
false information under this section shall be subject
to a civil money penalty in an amount not to exceed
$100,000 for each item of false information. Such civil
money penalty shall be in addition to other penalties
as may be prescribed by law.
(3) Procedure The provisions of section 1128A of the
Social Security Act, other than subsection (a) and (b)
and the first sentence of subsection (c)(1) of such
section shall apply to civil monetary penalties under
this subsection in the same manner as such provisions
apply to a penalty or proceeding under section 1128A of
the Social Security Act.
(4) Waivers The Secretary may waive penalties under
paragraph (2), or extend the period of time for
compliance with a requirement of this section, for an
entity in violation of this section that has made a
good-faith effort to comply with this section.
(d) Rule of construction Nothing in this section shall be
construed to permit a health insurance issuer, group health
plan, or other entity to restrict disclosure to, or otherwise
limit the access of, the Department of Health and Human
Services to a report described in subsection (b)(1) or
information related to compliance with subsection (a) by such
issuer, plan, or entity.
(e) Definitions In this section:
(1) Large employer The term ``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.
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